The Transition Process from Patient-Controlled Intravenous Analgesia to As-Needed Analgesia in Postoperative Situations – A Preliminary Look at the Issue

摘要

Purpose: Several studies have shown that patients often receive inadequate treatment for postoperative pain. However, there is little literature focusing on the transition process from patient-controlled intravenous analgesia (IV-PCA) and systematic (regular or as needed [PRN]) analgesia in the postoperative context. The purpose of this descriptive study is to describe the types of medication received by postoperative patients during the transition between IV-PCA and PRN analgesia, and to describe the pain assessments performed by nurses during this transition (n=36). Method: A retrospective analysis of participants' patient records by checking their medical history, analgesics prescribed and administered, and nurses' pain assessments.Results: When IV-PCA was discontinued, 52.8% of participants had no documented pain assessment and 75.0% received no PRN medication. Only 5 participants (24.8%) received analgesia. A double-entry table of the data indicates no significant relationship between the presence of a pain assessment and the presence of PRN analgesia when IV-PCA was stopped. Conclusion: This study confirms the need to review postoperative pain assessment and management procedures. Nurses must receive training in pain assessment and management. Introduction Postoperative pain is an important issue. Non-relieved pain is a major physiological stress (1) that may increase heart rate and blood pressure, slow gastric emptying, provoke endocrine imbalances and reduce breathing capacity, among other problems (2). Immobility due to pain in turn promotes deep vein thrombosis and pulmonary embolism (1,3-5). It also has psychological effects, such as increased anxiety, sleep disorders, fatigue, agitation, irritability, aggressiveness, and above all emotional suffering and distress (2,6,7). People with a high level of postoperative pain are also more likely to develop delirium (8). Ultimately, these complications will unnecessarily prolong the patient's hospital stay (7), increasing health care costs, and can even turn regular pain into chronic pain (3,7,9,10). Considering all the implications of poorly-relieved postoperative pain, it is essential to ensure that relief is provided successfully.To this end, several therapeutic alternatives are available, such as nurse-controlled systematic (regular or as needed [PRN]) analgesia, ongoing (intravenous, epidural) analgesia, and patient-controlled (intravenous or transdermal) analgesia (7,11). In recent decades, patient-controlled intravenous analgesia (IV-PCA) has emerged as the preferred therapeutic drug-administration method to efficiently manage postoperative pain (11). With IV-PCA, the patient self-injects a dose of analgesic, usually morphine or hydromorphone, administered parenterally via a pump that has been pre-programmed to the patient's clinical parameters by the anesthesia department (12,13). Although IV-PCA remains the preferred therapeutic method of postoperative pain management, several studies have reported mixed results concerning its effectiveness, particularly as regards the reduction and alleviation of postoperative pain (12,14,15). Nonetheless, IV-PCA improves patient satisfaction (11,13-16), outcome (11,16,17), feelings of control (4,12,15,18) and engagement (4). It also helps reduce analgesic gaps (13), anxiety (18) and feelings of helplessness (4). Nursing staff also acknowledge the benefits of IV-PCA for patients (18), since it permits greater flexibility in the administration of analgesics (11) and decreases patients' use of nursing staff (12), which in turn decreases the nurses’ workload (13,19). However, IV-PCA does not fit all patients (4,11), particularly those with cognitive disabilities, psychological disorders, a decreased level of consciousness (13) or a significant mobility impairment (11). It is therefore essential to carefully select patients eligible for IV-PCA (4,11-13,17,18). Usually, IV-PCA is used in the first 24-48 hours after surgery. Subsequent