Yanagimoto, Y., Takiguchi, S., Miyazaki, Y., Mikami, J., Makino, T., Takahashi, T., . . . Doki, Y. (2016). Comparison of pain management after laparoscopic distal gastrectomy with and without epidural analgesia. Surgery Today, 46, 229–234.
To evaluate the effectiveness of epidural analgesia after LDG
Patients received either combined thoracic epidural and general analgesia or general anesthesia alone.
PHASE OF CARE: Active anti-tumor treatment
Retrospective study of 84 patients with previously untreated gastric cancer who underwent LDG; received either combined thoracic epidural and general anesthesia or general anesthesia alone. Data was recorded on the patients, surgery, postoperative outcomes, and anesthesia-related complications.
The following data was collected: sex, age, body mass index, American Society of Anesthesiologists (ASA) anesthetic risk classification, previous laparotomy, tumor stage, lymph node dissection, reconstructive procedure, length of surgery, blood loss, postoperative complications above grade 2 in Clavien-Dindo classification, number of additional doses of analgesics required during the first three days after surgery, first day of oral intake, first day of flatus, first day of ambulation, length of hospital stay, and incidence of anesthesia-related complications such as nausea, vomiting, hypotension, bradycardia, and urinary retention.
The two groups were not significantly different with regard to the first day of ambulation, first day of oral intak,e or length of hospital stay. The epidural group experienced a significantly earlier first day of flatus and required significantly fewer additional postoperative analgesic doses compared to the non-epidural group. One patient in the epidural group experienced a urinary tract infection, which was cured with antibiotics; nevertheless, the groups did not have significantly different rates of urinary tract infection.
There was no significant differences between the epidural group and the non-epidural group in the degree of nausea, vomiting, hypotension, or bradycardia. However, significantly more (20.6%) cases of postoperative urinary retention were observed in the epidural group than the non-epidural group. Adverse events related to epidural anesthesia, such as nausea, hypotension, and bradycardia, resolved after a brief interruption or dose reduction of the epidural anesthesia.
The optimal postoperative analgesic regimens for laparoscopic gastrectomy have not yet been determined. Our findings suggest that epidural anesthesia could lead to a decreased use of additional analgesics after LDG. However, as found in previous reports, epidural anesthesia was associated with a higher risk of urinary retention.
None included
Oh, T.K., Lim, M.C., Lee, Y., Yun, J.Y., Yeon, S., & Park, S.Y. (2016). Improved postoperative pain control for cytoreductive surgery in women with ovarian cancer using patient-controlled epidural analgesia. International Journal of Gynecological Cancer, 26, 588–593.
To compare the pain scores and complications of patients who underwent cytoreductive surgery for ovarian cancer and used either patient-controlled epidural analgesia (PCEA) or patient-controlled IV analgesia (PCA) for postoperative pain management
Use of either patient-controlled epidural analgesia (PCEA) or patient-controlled IV analgesia (PCA) for postoperative pain management in ovarian cancer surgery
PHASE OF CARE: Active anti-tumor treatment
Retrospective review of pain scores for postoperative days (POD) 0-5 and the incidence of complications were examined and compared in patients receiving PCEA and PCA.
Numeric rating scale was used to measure differences in intensity of pain
Of 105 patients, 38 received PCEA and 67 received PCA. Pain scores were significantly lower in the PCEA group than the PCA group at POD 0, 1, and 3 and tended to be lower in the PCEA group at PODs 2, 4, and 5. PCEA provided significantly better pain relief as analyzed by a mixed-effect model.
PCEA was more effective for postoperative pain management compared with PCA from POD 1 to POD 3 in patients with ovarian cancer who underwent cytoreductive surgery, without increased morbidity.
None included
Serce, S., Ovayolu, O., Pirbudak, L., & Ovayolu, N. (2018). The effect of acupressure on pain in cancer patients with bone metastasis: A nonrandomized controlled trial. Integrative Cancer Therapies, 17, 728–736.
To evaluate the effect of acupressure in managing pain experienced by patients with cancer with bone metastases
Study participants received a 10 minute acupressure session prior to each radiotherapy treatment for a total of eight sessions. Acupressure was applied for up to 10 seconds to 31 points on the body surface for approximately 5 minutes total. Acupressure is delivered by applying physical pressure and is believed to provide energy circulation and balance in the body.
PHASE OF CARE: Active anti-tumor treatment
Non-randomized controlled trial
Pain level was measured using a visual analog scale at baseline and after the 8 acupressure sessions. In addition, participants completed a questionnaire at baseline which collected sociodemographic and disease-related information.
The difference in the intervention group’s mean pain score from baseline (7.6, SD = 1.9) and after acupressure (6.8, SD = 1.9) was statistically significant (p = 0.004) compared to the control group’s pain level (baseline = 8.2, SD = 1.7; after acupressure = 7.7, SD = 2.1; p = 0.056).
Although a statistically significant difference in pain level was found for the intervention group, it cannot be concluded that acupressure is effective in reducing pain in patients with cancer with bone metastases. Due to the limitations identified below and since only 31 of the 60 study participants had metastatic cancer, rigorous testing of this intervention needs to be conducted before acupressure can be recommended for practice in patients with bone metastases.
Although this study did not provide scientific evidence for the use of acupressure in managing bone metastases, side effects are rare and the benefits of acupressure outweigh harms. If both the clinician and patient agree that this is an appropriate intervention for managing pain, nurses should know who to refer the patient to for acupressure treatment. In addition, acupressure appears to be an intervention which nurses could learn with brief training.
Shapiro, A.C., Adlis, S.A., Robien, K., Kirstein, M.N., Liang, S., Richter, S.A., & Lerner, R.E. (2016). Randomized, blinded trial of vitamin D3 for treating aromatase inhibitor-associated musculoskeletal symptoms (AIMSS). Breast Cancer Research and Treatment, 155, 501–512.
To compare outcomes between women receiving the tolerable upper limit intake of vitamin D3 to those receiving recommended dietary allowances.
Patients were randomized to receive either usual recommended dose or 4,000 IU vitamin D3 and 1,000 mg calcium carbonate. Participants had a four-week run-in period with 600 IU to normalize serum levels, and then received treatment according to random assignment. Treatment was given for six months. Adherence was determined by pill counts at study visits and symptoms were monitored through weekly diaries.
PHASE OF CARE: Late effects and survivorship
Double-blind RCT
In the intervention group, serum total and free 25(OH)D levels increased (p < 0.0001). After six months, there were no differences in outcome measurement scores between groups.
High-dose vitamin D3 did not results in improvement in AI-related musculoskeletal symptoms.
No information on use of analgesics is provided
This study did not show an effect of high-dose vitamin D3 for musculoskeletal side effects associated with AI treatment.
Zecca, E., Brunelli, C., Centurioni, F., Manzoni, A., Pigni, A., & Caraceni, A. (2017). Fentanyl sublingual tablets versus subcutaneous morphine for the management of severe cancer pain episodes in patients receiving opioid treatment: A double-blind, randomized, noninferiority trial. Journal of Clinical Oncology, 35, 759–765.
To directly compare fentanyl sublingual tablets (FST) and subcutaneous morphine (SCM) in the first 30 minutes of a severe breakthrough pain episode.
Patients were randomly assigned to receive FST or SCM. Placebo was saline solution or a sublingual tablet reproducing the fentanyl preparation. Re-medication was available after 30 minutes for patients who did not achieve at least a 2-point reduction in pain. Average pain scores were obtained at baseline, 10, 20, 30, and 60 minutes. SCM was given at a 5 mg dose, and the dose for FST was 100 mcg. A non-inferiority margin of 1 point on the pain scale was used.
Double-blind, double dummy, noninferiority RCT
Numeric rating scale
Overall there was no significant difference in change of pain intensity between groups; however, non-inferiority of FST was not shown because the difference between groups was less than the margin established for testing. Patients tended to prefer the tablet rather than subcutaneous injection.
Subcutaneous morphine showed slightly better efficacy than the fentanyl tablet for reducing breakthrough pain intensity. Both approaches were effective.
Risk of bias (no blinding)
This study showed that both fentanyl sublingual tablets and subcutaneous morphine were effective in reducing the intensity of breakthrough pain. Findings here showed slightly better efficacy of the subcutaneous morphine, though patients preferred the tablet.
Rogriguez, D., Urrutia, G., Escobar, Y., Moya, J., & Murillo, M. (2015). Efficacy and safety of oral or nasal fentanyl for treatment of breakthrough pain in cancer patients: A systematic review. Journal of Pain and Palliative Care Pharmacotherapy, 29, 228–246.
STUDY PURPOSE: To evaluate different oral or transmucosal fentanyl formulations for breatkthrough pain
TYPE OF STUDY: Systematic review
DATABASES USED: MEDLINE, EMBASE, Cochrane Collaboration through June 2012
INCLUSION CRITERIA: Not specified
EXCLUSION CRITERIA: Not specified
TOTAL REFERENCES RETRIEVED: 414
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Risk of bias assessment based on Cochrane, approach GRADE system classification. Lack of detail in some studies did not allow for risk of bias determination.
FINAL NUMBER STUDIES INCLUDED: 11
TOTAL PATIENTS INCLUDED IN REVIEW: 1,121
SAMPLE RANGE ACROSS STUDIES: 25 to 139
PHASE OF CARE: Late effects and survivorship
Fentanyl buccal tablets: 2 studies
Oral transmucosal fentanyl citrate: 5 studies
Sublingual fentanyl citrate tablets: 2 studies
Fentanyl buccal soluble film: 1 study
Intranasal fentanyl spray: 2 studies
Fentanyl pectin nasal spray: 4 studies
All oral and intranasal formulations seem to be effective treatment for breakthrough episodes and it is not possible to conclude that any formulation is superior to others. There is limited information regarding long-term safety. Transmucosal opioids appear to be superior to immediate-release morphine.
Transmucosal opioids are effective for managing breakthrough pain and appear to be superior to immediate-release opioid.
Transmucosal opioids are effective for management of breakthrough pain. Nurses can advocate for use of these formulations which appear to be superior to immediate-release morphine. Transmucosal opioids have more rapid onset, which is important for breakthrough pain. There are varied methods for establishing dosages to be used and further work to identify most effective methods for dose determination would be helpful.
Fiorelli, A., Izzo, A.C., Frongillo, E.M., Del Prete, A., Liguori, G., Di Costanzo, E., . . . Santini, M. (2016). Efficacy of wound analgesia for controlling post-thoracotomy pain: A randomized double-blind study. European Journal of Cardio-Thoracic Surgery, 49, 339–347.
To investigate the effectiveness of wound analgesia for pain in patients undergoing lung cancer resection
Patients were randomly allocated to receive either continuous surgical wound site infusion of bupivacaine or normal saline as a placebo control. All patients use PCA postoperatively. All patients received a standardized anesthetic management. After surgery, all had IV PCA of 5 mg bolus morphine followed by 1.2 mg per hour with a 5-10 minutes lockout for the first 48 hours postoperatively. Additional morphine or ketorolac was given if needed due to a pain score greater than 4, at 15 mg, every 6 to 8 hours. No oral pain medications were used. Cytokine levels were measured before surgery and at 6, 12, 24, 48, and 72 hours postoperatively.
PHASE OF CARE: Active anti-tumor treatment
Double-blind, placebo-controlled RCT
Cytokines IL6, IL10, and TNF alpha were significantly lower in the wound analgesia group (p < 0.001). Pain scores were consistently lower in the wound analgesia group at all time points in the study at rest (p < 0.001) and after coughing (p = 0.01). Those in the wound analgesia group required less additional morphine (p = 0.03) or ketorolac (p = 0.01) compared to the placebo group. The wound analgesia group had faster recovery of FEV1 (p = 0.01) and FVC (p = 0.02). There were no adverse events associated with the analgesia.
Wound analgesia infusion was effective for postoperative pain control, reduction in cytokine levels, and faster recovery of pulmonary function after lung resection.
Small sample (< 100)
This study adds to a growing body of evidence showing effectiveness of wound analgesia for management of postoperative pain. Nurses can advocate for consideration of this type of approach for postoperative pain management in their patients.
Nguyen, L.T., Alexander, K., & Yates, P. (2018). Psychoeducational intervention for symptom management of fatigue, pain and sleep disturbance cluster among cancer patients: A pilot quasi-experimental study. Journal of Pain and Symptom Management, 55, 1459–1472.
To assess the feasibility of conducting a trial of a psycho-educational intervention involving the provision of tailored information and coaching to improve management of a cancer-related symptom cluster (fatigue, pain, and sleep disturbance) and reduce symptom cluster effects on patient health outcomes in the Vietnamese context, and to undertake a preliminary evaluation of the intervention.
A parallel-group, single-blind, pilot, quasiexperimental trial with pre-/post-test follow up was conducted in a cancer department of a general public hospital in Hanoi, Vietnam. Participants in the control group received standard treatment. Patient assigned to the intervention group received the psycho-educational program which consisted of three individualized psychoeducational sessions of up to one hour, tailored to meet patient’s major symptom concerns. Strategies such as energy conservation and restorative activities for fatigue management, sleep hygiene for sleep disturbance, and adherence to prescribed therapy for pain management were explored. A patient self-management booklet was provided at the first session to facilitate education and support.
Single-blind, pilot, quasi-experimental trial with pre-/post-test follow up.
The intervention group demonstrated a significant reduction in symptom cluster severity (p < 0.0001), fatigue severity, fatigue interference (p = 0.03), sleep disturbance (p < 0.0001), depression, and anxiety when compared to the control group. For fatigue severity, while the intervention group witnessed no change in fatigue severity (p = 0.4), the control group observed a significant increase (p = 0.01). Depression (p = 0.004) and anxiety (p < 0.0001) decreased significantly in the intervention group, there was significant increase in depression (p = 0.04) and no change in anxiety (p = 0.08) in the control group. There were no significant differences in pain severity, pain interference, functional status, or health-related quality of life.
Psychoeducational interventions may help to achieve improvement in some symptoms such as fatigue and sleep disturbances, but future RCTs are needed to test the effectiveness of a symptom cluster intervention in Vietnam.
Study provides preliminary evidence to support potential efficacy of a psycho-education intervention in improving symptom cluster severity, fatigue burden, sleep disturbance, and psychological distress.
Fernandez-Feito, A., Lana, A., Cabello-Gutierrez, L., Franco-Correia, S., Baldonedo-Cernuda, R., & Mosteiro-Diaz, P. (2015). Face-to-face information and emotional support from trained nurses reduce pain during screening mammography: Results from a randomized controlled trial. Pain Management Nursing, 16, 862–870.
To determine if an educational and support intervention could reduce pain during mammography
The day before mammography, women were randomized to a usual care control group or the experimental group. The experimental group received a standardized nursing intervention consisting of 10 minutes of face-to-face education about the procedure and accompanying the women during the procedure to provide support and answer questions. Pain was assessed in all women immediately after the test and 10 minutes later. Anxiety was measured prior to the procedure.
PHASE OF CARE: Diagnostic
RCT
State anxiety prior to the mammography was higher in the control group (p = 0.03). In the control group, 26.3% experienced pain, compared to 19% of the experimental group (OR = 0.44, 95% CI [0.24, 0.81]). The intervention was only shown to be effective in women who did not expect pain and did not fear outcomes of the screening.
The education and support intervention provided appeared to reduce pain associated with mammography, particularly for women who had an expectation of pain or feared screening outcomes.
A psychoeducational intervention by nurses was helpful to reduce post-mammography pain among women undergoing screening mammography.
Mohta, M., Kalra, B., Sethi, A.K., & Kaur, N. (2016). Efficacy of dexmedetomidine as an adjuvant in paravertebral block in breast cancer surgery. Journal of Anesthesia, 30, 252–260.
To evaluate the efficacy of dexmedetomidine in combination with bupivacaine for analgesia with paravertebral block
Women undergoing breast cancer surgery receiving a paravertebral block were randomized to receive only bupivacaine, the combination of bupivacaine and dexmetedomidine in the block, or a sham block. All had the same general anesthesia and received IV PCA with morphine for postoperative pain management. All were premedicated with oral diazepam two hours prior to surgery. Vital signs, pain scores, and sedation scores were recorded every 30 minutes for the first two hours, and then at 4, 8, and 24 hours after surgery. Morphine 1.5 mg was given every five minutes until pain level was 3 or less, when pain score was 3 or greater.
Double-blind, sham, controlled RCT
There were no significant differences across groups in duration of surgery or duration of anesthesia. Total morphine consumption was significantly lower in the group who received the combination of dexmetedomidine and bupivacaine compared to the other groups (p < 0.001). Pain intensity scores were significantly lower in this group compared to the others at all time points both at rest and on movement (p < 0.001).
Paravertebral block with the cominbation of dexedetomidine and bupivacaine was associated with better postoperative pain control in this group of patients.
Small sample (< 100)
Use of dexmedetomidine as an adjunct to bupivacaine in paravertebral block was effective for reduction in postoperative pain and overall opioid consumption in this study. This study was limited by its small sample size. Additional research in this approach is warranted.