Procedural pain requires a multidisciplinary approach to pain management so both pharmacological and medication-free interventions must be utilised to reflect the multidimensional nature of pain.
2.4.1 Procedural pain assessed by nurses, patients and physicians
It seems that both physicians and nurses (Klopfenstein et al. 2000, Heins et al. 2006, Jacobsen et al. 2007, Lauzon Clabo 2008, Wilson 2009, van Herk 2009) assess and manage pain inadequately. Nurses’ assessment and response to patients’ pain is insufficient when patients for example, describe it verbally or use a pain scale (Heikkinen et al. 2005, Brown & McCormack 2006, McDonald et al. 2007). Regardless they seem to be able to assess the effect of pain management satisfactorily (Idvall et al.
2005, Sloman et al. 2005).
According to Sloman et al. (2005), nursing education was found not to influence their pain assessment which is in contrast to Hansson et al’s (2006) and Layman Young et al’s (2006) findings which highlighted that nurses with training beyond basic nursing education tend to assess patients’ pain more accurately (Sloman et al. 2005, Hansson et al. 2006, Layman Young et al. 2006). It is also supposed that nurses’ knowledge has critical deficits and misbeliefs about pain management (Watt-Watson et al. 2001).
Therefore it is important to emphasise better training to reach systematic pain assessment and pain management (Klopfenstein et al. 2000).
2.4.2 Pharmacological pain management
In most European countries and in the United States (Appendix 3) sedatives and pain medication are in common use and administered by physicians, nurses or patients themselves during medical procedures e.g. colonoscopy (Stermer et al. 2000, Vicari 2002, Bright et al. 2003, Kulling et al. 2004, Heuss et al. 2004, Bowles et al. 2004,
Faulx et al. 2005, Cohen et al. 2006). Sedation has four stages, ranging from minimal (anxiolysis) to moderate (conscious sedation) to deep and finally general anaesthesia (Gross et al. 2002). Opiates are often given in combination with benzodiazepines to induce sedation and analgesia e.g. meperidine (a fast-acting opioid) and midatzolam, (an ultra short-acting benzodiazepine) can increase the tolerance during the procedure (Terruzzi et al. 2001, Rex et al. 1999) but may cause cardiorespiratory problems (Ristikankare 2000). Remifentanil (an ultra short-acting synthetic opioid) can be considered safe during short radiology and palliative procedures. Patients are capable of moving after the procedure without medication for pain and nausea. (Moser et al. 2005.) It can also be an appropriate analgesic choice for stapedotomy (Mesolella et al. 2004) and extracorporeal shock wave lithotripsy patients (Medina et al. 2005) as well as for older patients undergoing medical procedures (Greilich et al. 2001). Patient controlled anaesthesia (PCA) is supposed to be safe and satisfactory for patients (Kulling et al.
2004, Stermer et al. 2000). It is known that midazolam and/or fentanyl (synthetic opioid) and propofol (a short-acting hypnotic agent) alone or together may cause significant cognitive impairment at discharge from elective colonoscopy (Padmanabhan et al.2009). It is still worth bearing in mind that routine sedation practices are time-consuming for patients and staff, not to mention the financial costs involved (Aisenberg et al. 2005, Jonas et al. 2007), as well as the adverse events and complications attributable to use of medication (Sieg et al. 2001, Levin et al. 2006, Ko et al. 2007).
Nitrous oxide (an inhaled anaesthetic agent) combined with oxygen can increase patients’ willingness to attend the procedure because of fast recovery and discharge without diminishing driving capability (Martin et al. 2000, Castera et al. 2001).
Pharyngeal anaesthesia in both non sedated and sedated oesophagogastroduodenoscopy is known to increase procedural completion rate, ease of intubation and patient and endoscopist satisfaction (Evans et al. 2006, Amornyotin et al. 2009).
Pain management must also be taken into account for minor procedures. Tissue adhesives are suitable for traumatic lacerations as they are quicker and cause less pain than suturation (Farion et al. 2002). Lidocaine/prilocaine mixture cream is an effective and well tolerated local anaesthetic when applied to intact skin as a cream (Zilbert 2002). Lidocaine, dosed with facemask and combined with nebulisator before
nasogastric tube insertion can reduce patient discomfort but may increase the risk of nasal bleeding (Schmidt 2005).
2.4.3 Non-drug interventions
Non-drug interventions in pain relief can be defined as a variety of methods designed to relieve pain without medication (e.g. distraction, relaxation, imagery, listening to music, patient education and guidance) and has been used to treat procedure pain (c.f. Lee et al.
2002, Schaffer & Yucha 2004, Olney 2005). Non- drug interventions can reduce the emotional components of pain, give patients a sense of control over the situation and make pain more tolerable. (McCaffery & Pasero 1999, Richardson & Mustard 2009).
The use of these interventions has its basis in pain mechanism and they are thought to be explained through the gate control theory of pain (Melzack & Wall 1993) and spinal inhibition’s role in endogenous pain control. According to this theory the interpretation of pain includes the existence of sensory, affective and cognitive dimensions. It is proposed that information coming from the periphery of the body may transmit directly to the brain through the spinal cord. The stimulation of the thin nociceptive nerve fibres (A-delta () and C) “opens the gate”. Regardless, as a result of e.g. cognitive factors the perception of pain is modulated by the interaction between pain-transmitting and non-pain transmitting neurons so spinal inhibition is dynamically regulated. (Price et al.
2009.) The activation of nerves or neurons that do not transmit pain signals (A-beta () fibres) indirectly inhibits or modulates signals from pain fibres, “closing the gate”.
Stimulus that activates only non-nociceptive nerves can inhibit pain e. g. when the injured area is rubbed, touched or massaged the pain seems to be lessened. The “gate”
can also be closed by activating the inhibitory system by the use of non-drug interventions e.g. distraction and relaxation. (Kalso 2002b, Weng et al. 2006, Salanterä et al. 2006, Kawasaki et al. 2008, Youn et al. 2008, Price et al. 2009.)
There is some research on non-drug interventions for adults undergoing medical procedures. Nurses can teach muscle relaxation, breathing techniques and relaxed posture to patients (Schaffer & Yucha 2004). Massage may lower blood pressure and
pulse during ambulatory operations (Olney 2005). Listening to music can reduce the patients’ anxiety, decrease blood pressure and pulse and minimise sedation (Salmore &
Nelson 2000, Allen et al. 2001, Lee et al. 2002, Hayes et al. 2003, Cooke et al. 2005) and can relieve tension and make the procedure more pleasant (Chlan et al. 2000). Some patients may consider it disturbing (Kwekkeboom 2003), which is why it is not suitable for all procedures (Domar et al. 2005). Patient education and guidance can decrease patients’ anxiety and depression before procedures (Andrewes et al. 1999, Bytzer &
Lindeberg 2007), if expressions which reflect negative experiences increase patients’
pain experiences, fear and anxiety are excluded (Lang et al. 2005). Stimulation of sense of seeing and hearing can decrease unpleasant feelings in the abdomen (Lembo et al.
1998) but TENS (transcutaneus electrical nerve stimulation) does not relieve colonoscopy pain (Robinson et al. 2001). Regardless, there is only a limited amount of studies of non-drug interventions available designed as intervention studies (Lee et al.
2002, Bytzer & Lindeberg 2007) depicting the effectiveness of non-pharmacological methods in colonoscopies.