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Acute Pain Management Following Laryngectomy
Richard Orgill, MD;
Greg A. Krempl, MD;
Jesus E. Medina, MD
Arch Otolaryngol Head Neck Surg. 2002;128:829-832.
ABSTRACT
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Objectives To evaluate the adequacy of as-needed (prn) dosing of narcotics during
the acute postoperative period following laryngectomy and to evaluate the
role of nurses' interpretation and implementation of narcotic orders in postoperative
pain management.
Study Design A retrospective review of the medical records of 37 patients who underwent
laryngectomy at the University of Oklahoma. The postoperative care was standardized
through a clinical pathway to provide a uniform level of care.
Methods The parameters reviewed include (1) the type and dose of analgesic prescribed,
(2) the quantity and frequency of analgesic administered to each patient,
and (3) the adequacy of the initial pain-control prescription.
Results All physician orders for narcotics were at or above the minimum dosing
guidelines; 68% met a recommended adequate postoperative prescription for
moderate pain. However, none of the patients actually received the intended
dose during a 24-hour period while hospitalized. Physicians were contacted
about 13 patients (35%) because of inadequate pain relief, but only 8 patients
(22%) had their narcotic dose increased appropriately. Patients were dosed
below the minimum prescribed dose 19 times (2.8%), and in 24 instances (3.6%)
the backup analgesic, designated as "prn breakthrough pain," was given as
the primary analgesic.
Conclusions As-needed dosing of analgesia resulted in suboptimal pain control for
at least 35% of patients undergoing laryngectomy. Inadequate prescription
and variable implementation of prn orders contributed to this.
INTRODUCTION
PAIN IS one of the most feared consequences of cancer, and as many as
72% of patients who die of cancer die with pain.1
Many patients with head and neck cancer do not present until they develop
intolerable pain.2 The treatment of head and
neck cancer often includes ablative surgery, which can be a source of both
acute and chronic pain. In a study of 93 patients with head and neck cancer,
Chaplin and Morton3 found that 48% of the patients
had pain at the time of diagnosis. Following surgery, 25% of these patients
had chronic pain after 12 months, and 26% after 24 months. Adequate pain control
is an important factor in preserving quality of life for patients with head
and neck cancer, particularly during the acute treatment phase.
Despite the association of pain with cancer, pain management is not
emphasized appropriately in medical training and is infrequently discussed
in cancer literature. As little as 0.1% of the cancer literature addresses
the diagnosis of pain or its management.1 As
a result, shortfalls in the administration of analgesics are common. In 1973,
Marks and Sachar4 analyzed the pain management
of 37 patients admitted to a medical ward. They reported that despite physician
orders for narcotics, 32% of patients suffered severe distress, 41% moderate
distress, and 27% minimal distress from pain. They found that the analgesic
amount actually administered was "less-than-optimal dosing" in 65% of their
study population, concluding that health care professionals undertreat pain.
One criticism of this study is the sample population: most of the patients
were admitted for chest pain, and none were recovering from surgery. No study
to date has evaluated the adequacy of acute pain management in patients recovering
from ablative surgery for head and neck cancer.
Frenette5 suggests that 30% to 70% of
patients who have undergone major surgery experience severe postoperative
pain. The main reason cited for insufficient postoperative pain control is
inadequate application of available information and therapies. It has been
debated whether patient-controlled analgesia is superior to nurse-administered
intermittent intravenous boluses or intramuscular injections. Similar controversy
is found when comparing routine scheduled administration with doses given
on an as-needed (prn) basis. When pain medication is ordered prn, the amount
administered and the dosing frequency are subject to the nurses' discretion,
which may result in unpredictable dosing of analgesics.
Until recently, our department has managed postoperative pain following
ablative head and neck cancer surgery with prn dosing of intravenous and oral
narcotics. We hypothesize that the practice of prescribing analgesic pain
medications with a dosage range and on a prn basis results in variable narcotic
dosing, with potential undertreatment of postoperative pain. We believe that
the amounts ordered by the physician and the role of the administering nurse
are critical components in postoperative pain management. With this in mind,
we analyzed our pain management strategy to provide the basis for a prospective
study of patient satisfaction with postoperative pain management following
ablative head and neck cancer surgery. The objectives of this study were (1)
to evaluate the adequacy of the narcotic doses prescribed for hospitalized
patients following ablative head and neck cancer surgery and (2) to evaluate
the role of the nursing staff in the implementation of physicians' analgesic
orders for postoperative pain management.
MATERIALS AND METHODS
A retrospective review was performed of the medical records of patients
who underwent either a total laryngectomy or laryngopharyngectomy at the University
of Oklahoma Health Sciences Center, Oklahoma City, from February 1, 1998,
to December 30, 2000. Beginning in February 1998, all patients undergoing
a laryngectomy at the University of Oklahoma Health Sciences Center have been
enrolled in a clinical pathway designed to standardize postoperative care.
Uniform levels of postoperative nursing care, patient education, and rehabilitation
implemented in the pathway provide the population with similar surgical intervention,
postoperative pain management, and hospital stay. Since one goal of the pathway
is to provide teaching to allow discharge on postoperative day 7, the medical
records were reviewed only through the seventh postoperative day.
Physician orders were reviewed to determine the narcotics prescribed,
dosing guidelines, and any changes made because of inadequate pain control.
Nurses' notes were reviewed to determine the analgesic doses administered
to each patient and the frequency of dosing. Prescribed and administered doses
were compared between hospital locations (intensive care unit [ICU] vs regular
hospital floor). Adequacy of pain control was assessed using 2 end points:
(1) were analgesic doses increased during the postoperative stay? and (2)
were physicians called because of inadequate pain control?
On completion of data collection, all analgesic doses were standardized
to equivalent doses of parenteral morphine sulfate6
(Table 1). Descriptive statistics
were used to analyze the results. Paired t tests
were used to evaluate differences between the analgesic amounts prescribed
and the amounts administered.
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Table 1. Equianalgesic Doses Adapted From Acute Pain
Management in Adults: Operative Procedures6
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RESULTS
A total of 44 patients were enrolled in the laryngectomy clinical pathway.
Four patients were excluded from the study because of variations in the extent
of the ablative surgery: 3 underwent a total or near-total glossectomy, and
1 had a hemilaryngectomy. Also excluded were 2 patients whose medical records
were not available and 1 patient with chronic paranoid schizophrenia who required
treatment with large doses of antipsychotic agents in the perioperative period.
Thus, the study cohort consisted of 37 patients, 34 men and 3 women. The mean
age was 59 years, with a range from 37 to 79 years.
The primary tumor sites were supraglottic (65%), glottic (22%), base
of the tongue (8%), and hypopharyngeal (5%). Thirty-four patients underwent
a total laryngectomy, and 3 underwent a laryngopharyngectomy. Neck dissections
were performed in 35 patients (95%). Eight patients (22%) had reconstruction
of the pharynx with a pectoralis flap and 1 (3%) with a free radial forearm
flap. Six patients (16%) had complications: 5 fistulas and 1 hematoma. The
median hospital stay was 8 days (mean, 9 days), with the shortest stay being
4 days.
The most commonly prescribed analgesic during the period of this study
was morphine sulfate, which accounted for 87% of hospital days and was the
only analgesic given in 39% of hospital days. Combined narcotic and acetaminophen
preparations containing hydrocodone, oxycodone, and codeine were also prescribed.
Hydrocodone was the most frequently prescribed drug and was ordered in 30%
of total hospital days and was the sole analgesic in 10% of hospital days
(Table 2). In addition to narcotics,
26 patients (70%) were prescribed an anxiolytic during their hospital stay,
22 on a prn basis and 4 as scheduled medicines. Eleven patients (30%) received
at least 1 anxiolytic dose.
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Table 2. Principal Analgesics Prescribed for Postoperative Pain and
Their Respective Frequencies
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In the ICU, the average minimum daily order for analgesia was 29.9 mg/d
of morphine sulfate, but the average daily dose administered was 20.0 mg/d.
The difference between the minimum amount prescribed to ICU patients and the
mean dose received was statistically significant (P
= .005). On the regular hospital floor, the average minimum daily order of
morphine sulfate was 31.4 mg/d, but the average amount received was only 11.5
mg/d (P = .001). The mean dose administered in the
ICU (20.0 mg/d) was greater than the mean dose administered on the regular
hospital floor (11.5 mg/d) (P<.001). The mean
maximum dose available differed also between hospital wards: 79.08 mg/d in
the ICU; 67.95 mg/d on the regular floor (P = .01).
For the purpose of the analysis, 12 mg/d was selected as the minimum
recommended dose of morphine sulfate (this is the lowest dose recommended
by the Physicians' Desk Reference for a 70-kg patient7). This dose was prescribed for all the patients in
the study and on all hospital days. The US Department of Health and Human
Services (USDHHS) recommendations were used to select a dose considered adequate
for moderate postsurgical pain (60 mg/d).6, 8
All patients studied received less than this recommended dose, even though
this dose was prescribed during 68.6% of hospital days. The maximum daily
dose received by any patient in 1 day was 50 mg. The mean dose received was
12.9 mg/d but differed between hospital wards. Patients in the ICU received
an average of 20.0 mg/d, while those on the floor averaged 11.5 mg/d. When
the patient's weight was factored in, the adequate dose for moderate postoperative
pain (0.857 mg/kg per day) was prescribed in 61.7% of physicians' orders.
The mean dose received per day was 0.181 mg/kg, with the maximum being 0.800
mg/kg. Again, there was a difference between doses administered between hospital
wards (ICU, 0.277 mg/kg per day; regular floor, 0.162 mg/kg per day), which
was statistically significant (P = .002). The distribution
of the amount received per hospital day was fairly uniform except for a large
group with almost no narcotic (Figure 1).
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The daily dose of narcotic (morphine sulfate equivalent) administered
over the number of hospital days in this study. The limit at 60 mg/d represents
the US Department of Health and Human Services recommendation for a dose adequate
to treat moderate postsurgical pain.6 The limit
at 12 mg/d is the lowest dose recommended by the Physicians'
Desk Reference for a 70-kg patient.7
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While all patients were prescribed the minimum Physicians'
Desk Reference recommended dose,7 analgesic
prescriptions for less than the USDHHS recommended 0.857 mg/kg per day were
ordered during 38.3% of all hospital days, which affected 57% of the patients
for at least 1 day during the first 7 postoperative days. As one might expect,
this was more frequent on the floor (48.6%) than in the ICU (29.7%). The average
amount of drug administered to patients was 18% of the maximum dose available
or 41% of the minimum value prescribed. Interestingly, physicians were contacted
regarding additional pain needs for 13 patients (35%), but only 8 patients
(22%) received an order to increase or augment the narcotic dose.
COMMENT
Despite the effort to ensure adequate pain control by federal and world
health care organizations,8-9
pain control continues to receive little attention in the literature and in
medical training.1 Inadequate prescribing patterns
persist and may adversely affect patients in the hospital. In our study, 38.3%
of physician orders prescribed analgesic levels below the USDHHS recommended
dose for moderate postoperative pain. This could have resulted from inadequate
knowledge of appropriate narcotic dosages or from reluctance to aggressively
treat postoperative pain. Many factors have been suggested as explanations
for physician reluctance to treat pain aggressively. These include concerns
about adverse effects, the potential for addiction, lack of knowledge of appropriate
dosing, and inadequate use of appropriate therapies.5, 10
Physician perception of increased amounts of pain in the immediate postoperative
period may explain higher narcotic doses available in the ICU than on the
regular hospital floor.
It is possible that the level of pain experienced by patients after
undergoing laryngectomy was controlled by lower than the USDHHS recommended
narcotic doses. In this series, we attempted to measure the adequacy of narcotic
prescriptions by physician contact for additional pain medicine or increase
in the amount available. Thirteen patients (35%) had inadequate pain control
by this measure. This finding must be interpreted cautiously because it may
not reflect patient satisfaction with the regimen or the nature of the complaint.
Since only 8 of these 13 patients had additional pain medication ordered,
it is possible that there were other issues that prompted the call as well.
For a true assessment of adequacy of pain control, a prospective assessment
of pain levels must be performed.
Prescribing prn analgesia introduces potential error and bias into pain
management. In this review, significant differences were found between physician
analgesic orders and nurse administration of analgesics in the ICU and on
the floor. One possible explanation is that the patients did not request pain
medication as often as it was available. A second explanation is that when
narcotics were administered, nurses underestimated the severity of postoperative
pain, and therefore minimal amounts were given.5
This bias can affect the amount or frequency of nurse-administered prn analgesics
more than any other dosing method or route. Interestingly, nurses who have
personally experienced postoperative pain are inclined to more freely administer
analgesia,11 while nurses with more clinical
experience administer less.5 The impact of
a nurse's interpretation of orders was clearly demonstrated in 19 instances
(2.8%) where the amount given to a patient was less than the minimum prescribed
dose. The differences seen between the ICU and the floor in our study may
reflect nursing bias in the estimation of the degree of pain, actual differences
in the degree of pain (which may have lessened with time), variability in
comfort level of different nursing units with administration of narcotics,
or nursing availability for assessment of pain and administration of analgesics.
The route of administration did not seem to affect narcotic administration.
On 83 (29%) of 287 hospital days, enteral and parenteral preparations were
ordered. Despite both being available, during 21 (25%) of these days no narcotic
analgesic was administered, and in most instances there was a preferred drug:
only 1of the 2 medicines was administered to patients on 43 days (77%). In
24 doses (3.6%), the analgesia designated as "prn breakthrough pain" or "prn
severe pain" was given as the primary analgesic.
To overcome these pain management shortcomings, several measures should
be taken: (1) educate physicians on adequate dosing of narcotics in the postoperative
setting; (2) educate nursing staff10; (3) prescribe
a single dose rather than a range; (4) use scheduled narcotic dosing7; and/or (5) use different methods of delivery including
patient-controlled anesthesia.5, 10
A prospective trial comparing patient-controlled anesthesia with nurse-administered
prn analgesics in the management of pain is currently under way to further
study this issue.
In conclusion, in our group of postlaryngectomy patients, physicians'
narcotic orders always met minimum dosing guidelines. However, 38.3% of orders
failed to meet USDHHS recommended doses for treating moderate postoperative
pain. Implementation of prn narcotic orders by nurses varied significantly
between the ICU and the floor, and all patients received less than the USDHHS
recommended doses. In 35% of cases, physicians were contacted because of inadequate
pain control. Both the range available and the bias of the administering nurses
may have contributed to this occurrence.
AUTHOR INFORMATION
Accepted for publication November 30, 2001.
Corresponding author: Greg A. Krempl, MD, University of Oklahoma
Health Sciences Center, Department of Otorhinolaryngology, PO Box 26901, WP1360,
Oklahoma City, OK 73190 (e-mail: greg-krempl{at}ouhsc.edu).
From the Department of Otorhinolaryngology, University of Oklahoma
Health Sciences Center, Oklahoma City.
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