Anesthesia Experts

Understanding the Pain Scale

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Author: Dr Nikesh Seth

Feedspot Weekly

Effective communication about pain is crucial in healthcare. Understanding and articulating your pain accurately to your healthcare provider can significantly enhance the management and treatment of your condition. The pain scale, a common tool used in clinical settings, helps in quantifying pain, providing a more objective measure of something inherently subjective. This guide explores how to use the pain scale to communicate your pain effectively.

What is the Pain Scale?

The pain scale is a tool designed to help patients and healthcare providers gauge the intensity of pain. It provides a quantitative measure that helps in assessing the severity of pain, facilitating more accurate treatment decisions. Historically developed for better pain management, these scales are simple yet powerful tools for describing an individual’s pain experience.

Types of Pain Scales

There are several types of pain scales used in medical practice:

  • Numeric Rating Scale (NRS): This scale ranges from 0 (no pain) to 10 (the worst possible pain). It is straightforward and widely used for adults.
  • Visual Analog Scale (VAS): This scale features a line, usually 10 centimeters long, where patients mark their pain level along the continuum from ‘no pain’ to ‘worst pain imaginable.’
  • Faces Pain Scale-Revised (FPS-R): Particularly useful for children, this scale uses faces with varying expressions from no pain to very much pain to help describe pain levels.

Each type of scale may be more suitable depending on the patient’s age, cognitive abilities, and specific medical conditions.

How to Use the Pain Scale

Using the pain scale involves several steps:

  1. Select the appropriate scale: Choose a scale that you understand and feel comfortable using.
  2. Consider the type of your pain: Reflect on whether your pain is acute or chronic, as this might affect your perception of pain intensity.
  3. Evaluate the impact on activities: Think about how your pain affects your daily activities and overall quality of life.
  4. Incorporate emotional aspects: Recognize any emotional or psychological components to your pain, as these can amplify the physical sensation of pain.

Challenges in Using Pain Scales

While pain scales are incredibly useful, they are not without challenges. Pain is subjective, and individual tolerance varies significantly. Some patients may find it difficult to quantify their pain, while others might underestimate or exaggerate their pain unintentionally. Healthcare providers can aid in this process by offering clear explanations and ensuring the patient feels comfortable expressing their pain accurately.

Enhancing Pain Communication with Your Doctor

When discussing your pain with your doctor:

  • Be descriptive: Use the scale to provide a baseline, but also describe the nature of your pain (e.g., stabbing, burning, throbbing).
  • Update regularly: Communicate any changes in your pain or its characteristics.
  • Discuss the effectiveness of treatments: Share what has or hasn’t worked in managing your pain.

Key Takeaways

Accurately communicating pain using the pain scale is integral to effective pain management. It helps your healthcare provider understand your pain better, leading to more tailored and effective treatment strategies.

FAQs

1. What does a pain scale score really tell my doctor?

A pain scale score provides your doctor with a quantitative measure of your pain, which can help in assessing the severity and nature of your pain. It’s a crucial part of your medical history and treatment plan, aiding in decisions about diagnostics, treatment adjustments, and monitoring of your condition over time.

2. How do I choose which pain scale to use?

The choice of a pain scale often depends on the clinical setting and your personal comfort with the scale. Adults typically use the Numeric Rating Scale (NRS) for its simplicity. For children or individuals who might struggle with abstract numerical concepts, the Faces Pain Scale-Revised (FPS-R) is often more appropriate. Discuss with your healthcare provider which scale would be best suited for your needs.

3. Can I use the pain scale for chronic pain, or is it only for acute pain?

Pain scales are useful for both acute and chronic pain. Chronic pain, however, may require additional considerations, such as the pain’s impact on daily activities and emotional well-being. It’s important to communicate the persistent nature of your pain and any variations in its intensity over time when using the scale.

4. What if my pain changes during the day? Should I average my pain score when reporting it?

Instead of averaging your pain scores, it’s more helpful to note the range of pain you experience throughout the day and the circumstances under which it changes. This information can give your healthcare provider a clearer picture of your pain’s dynamics and help tailor your treatment plan.

5. Is the pain scale used the same way in every medical situation?

While the basic use of the pain scale is consistent, its application can vary based on the medical setting and the specific condition being treated. For instance, in post-operative care, frequent pain assessments are crucial to managing acute pain, whereas, in chronic pain management, longer intervals between assessments may be appropriate. Always discuss with your healthcare provider how to use the pain scale effectively in your specific situation.

Regional Analgesia and Cancer Recurrence: Comment

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Authors: Philip J. Peyton, M.D., Ph.D., M.B.B.S.; Simon W. Chong, M.B.B.S., B.Med.Sci., D.med.Sc.
Anesthesiology October 2024, Vol. 141, 797–798.

We wish to thank Dr. Cata and Dr. Sessler for their carefully considered review of factors contributing to the failure of promising preclinical study findings to be confirmed in subsequent large clinical trials of the effects of anesthetic technique on cancer surgery outcomes.  Their forensic analysis of the reasons focused on experimental methodology in animal research, and the mechanistic drivers and reductionist approach that characterize preclinical science. Their explanation also included “often unjustified” small sample sizes and “unsophisticated” statistical analysis. (A common example might be failure to correct for multiplicity in experimental comparisons when determining statistical significance, for instance.) They pointed to the “huge effort and the expense” of the clinical trials prompted by this preclinical work, but ultimately with negative findings.

However, the authors did not mention the likely contribution of positive publication bias to this failure in research translation. The damaging effect of publication bias on evidence quality in medicine has been lamented for many years by experts who estimate half of research activity goes unpublished.  In the field of anesthesiology, we and other authors have confirmed this.  We found that, among more than 1,000 abstracts of clinical trials presented at the annual American Society of Anesthesiologists (ASA; Schaumburg, Illinois) meeting from 2001 to 2004, those with positive findings were twice as likely (odds ratio 2.01) to proceed to eventual peer-reviewed journal publication as those with negative findings.  The hallmarks of clinical research that promote publication bias are single center, small trial design, and lack of transparency in prospective hypothesis formation with potential for selective outcome reporting.  These features can all be shared by animal laboratory research, and there is certainly no reason to believe that it is any less prone to publication bias than clinical trials.

With a view to future solutions, we repeated our analysis by using ASA abstracts from 2010 to 2016, following the implementation by the International Committee of Medical Journal Editors (ICMJE) of mandatory prospective clinical trial registration for publication after 2005. We found that the magnitude of imbalance in publication outcome had significantly reduced (odds ratio 1.3), suggesting that this policy successfully limits the influence of publication bias in clinical anesthesiology.  However, mandatory prospective trial registration does not extend to preclinical trials and animal studies, nor to the publication policies of journals in other fields of the biologic sciences. Leaders in preclinical science have recently called for integration of trial registration into the animal ethics review process.  Animal research registries have been established, but with only sporadic use. 

We fear therefore that, in combination with the factors which Dr. Cata and Dr. Sessler have described, the persistence of publication bias offers little prospect that the problem of false promises by preclinical research will be solved any time soon. We can thus expect much wasted cost and effort in subsequent clinical trials to continue into the future.

Hypertension and Kidney Function After Living Kidney Donation

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Authors: Amit X Garg et al
JAMA . 2024 Jul 23;332(4):287-299

Importance: Recent guidelines call for better evidence on health outcomes after living kidney donation.

Objective: To determine the risk of hypertension in normotensive adults who donated a kidney compared with nondonors of similar baseline health. Their rates of estimated glomerular filtration rate (eGFR) decline and risk of albuminuria were also compared.

Design, setting, and participants: Prospective cohort study of 924 standard-criteria living kidney donors enrolled before surgery and a concurrent sample of 396 nondonors. Recruitment occurred from 2004 to 2014 from 17 transplant centers (12 in Canada and 5 in Australia); follow-up occurred until November 2021. Donors and nondonors had the same annual schedule of follow-up assessments. Inverse probability of treatment weighting on a propensity score was used to balance donors and nondonors on baseline characteristics.

Exposure: Living kidney donation.

Main outcomes and measures: Hypertension (systolic blood pressure [SBP] ≥140 mm Hg, diastolic blood pressure [DBP] ≥90 mm Hg, or antihypertensive medication), annualized change in eGFR (starting 12 months after donation/simulated donation date in nondonors), and albuminuria (albumin to creatinine ratio ≥3 mg/mmol [≥30 mg/g]).

Results: Among the 924 donors, 66% were female; they had a mean age of 47 years and a mean eGFR of 100 mL/min/1.73 m2. Donors were more likely than nondonors to have a family history of kidney failure (464/922 [50%] vs 89/394 [23%], respectively). After statistical weighting, the sample of nondonors increased to 928 and baseline characteristics were similar between the 2 groups. During a median follow-up of 7.3 years (IQR, 6.0-9.0), in weighted analysis, hypertension occurred in 161 of 924 donors (17%) and 158 of 928 nondonors (17%) (weighted hazard ratio, 1.11 [95% CI, 0.75-1.66]). The longitudinal change in mean blood pressure was similar in donors and nondonors. After the initial drop in donors’ eGFR after nephrectomy (mean, 32 mL/min/1.73 m2), donors had a 1.4-mL/min/1.73 m2 (95% CI, 1.2-1.5) per year lesser decline in eGFR than nondonors. However, more donors than nondonors had an eGFR between 30 and 60 mL/min/1.73 m2 at least once in follow-up (438/924 [47%] vs 49/928 [5%]). Albuminuria occurred in 132 of 905 donors (15%) and 95 of 904 nondonors (11%) (weighted hazard ratio, 1.46 [95% CI, 0.97-2.21]); the weighted between-group difference in the albumin to creatinine ratio was 1.02 (95% CI, 0.88-1.19).

Conclusions and relevance: In this cohort study of living kidney donors and nondonors with the same follow-up schedule, the risks of hypertension and albuminuria were not significantly different. After the initial drop in eGFR from nephrectomy, donors had a slower mean rate of eGFR decline than nondonors but were more likely to have an eGFR between 30 and 60 mL/min/1.73 m2 at least once in follow-up.

US hospitals face IV fluid shortage

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Author: Erica Carbajal
Becker’s Hospital Review

Hospitals across the nation are conserving IV fluids amid a new shortage of supplies — the latest example of fallout from Hurricane Helene.

Somerville, Mass.-based Mass General Brigham held a press call Oct. 3, saying Baxter International, the nation’s largest supplier of IV solutions, sent a letter to the health system and other customers stating it would be receiving 40% of the level of supply it typically receives.

“We have been informed that due to the devastating effects of Hurricane Helene, we will be receiving a reduced supply of IV fluids from Baxter International as they work to mitigate disruptions in their manufacturing operations,” Paul Biddinger, MD, chief preparedness and continuity officer, said in a statement to Becker’s. “Having experienced similar challenges in the wake of Hurricane Maria in 2017, we continue to be mindful of how we manage the supply of these medications to ensure minimal impact on our patients. Hospital operations continue as normal and patient care remains unaffected.”

The supply disruptions affect hospitals across the country and stem from the closure of a Baxter International plant in North Carolina, which suffered significant damage during the storm. The company supplies about 60% of IV solutions used in the U.S., manufacturing around 1.5 million bags per day. The company is assessing the extent of the damage and communicating with customers about actions it is taking to minimize potential disruptions.

In a Sept. 30 statement, Baxter said product allocations will help prevent stockpiling and “increases the likelihood of equitable access to available products.”

It’s unclear when the facility will be able to resume operations

In the meantime, hospitals have put conservation measures into action. At Mass General Brigham, which consumes more than 100,000 liters of IV fluid each month, is giving patients who are healthy enough Gatorade or water instead of IVs. The hospital has also temporarily halted the practice of discarding IV units, regardless of their current volume, and replacing them with new units when patients are transferred from one unit to another. In an email to staff obtained by The Boston Globe, the health system called the shortage as “serious and immediate.”

Cedars-Sinai in Los Angeles remains fully operational, though the hospital has implemented contingency plans.

“We are utilizing alternative solutions based on guidelines from national medical associations and exploring other ways to source IV fluids,” a Cedars-Sinai spokesperson said in a statement to Becker’s. “We are closely monitoring the situation, which is evolving quickly, and will keep our community and patients informed.”

Chicago-based Northwestern Medicine told NBC News it anticipates IV fluid supply disruptions to be a “long-term issue.”

Aside from conservation efforts, hospitals have few options to bolster supplies, an official from Premier, a group purchasing organization for hospitals, told The Wall Street Journal. For example, the U.S. can’t rely on European manufacturers due to existing global shorages.

Meanwhile, other U.S. suppliers are stepping in to try and fill supply gaps. B. Braun Medical, a manufacturer that makes around 23% of supplies used in the U.S., told NBC it is hiring new employees as it works to build up to 24/7 operations at two of its facilities in the coming weeks.

“It’s too early to say what would happen if this [shortage] continues for many weeks or months,” Dr. Biddinger said.

Discover The Best Anesthesiologist Opportunity in New Mexico

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We are seeking a dedicated anesthesiologist to join our all-anesthesiologist group. Our team will consist of 4 full-time providers and 1 for vacation relief, managing 3 operating rooms.

Position Highlights:

  • Zero call for 3 weeks, followed by 1 week of call without daytime work only call after 7 PM therefore you may not work the entire week.
  • Competitive salary of $500,000 plus benefits.
  • 8 weeks of vacation.

This is the best job on GasWork #370670

Interested? Please contact me at 660-596-2224 or drrob@anesthesiaexperts.com if you or anyone you know would like to apply.

Note: Agencies, please do not contact us as we do not use your service

Electroencephalographic Features of Elderly Patients during Anesthesia Induction with Remimazolam

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Authors: Hyoungkyu Kim, Ph.D. et al 
Anesthesiology October 2024, Vol. 141, 681–692.
Background

Although remimazolam is used as a general anesthetic in elderly patients due to its hemodynamic stability, the electroencephalogram characteristics of remimazolam are not well known. The purpose of this study was to identify the electroencephalographic features of remimazolam-induced unconsciousness in elderly patients and compare them with propofol.

Methods

Remimazolam (n = 26) or propofol (n = 26) were randomly administered for anesthesia induction in surgical patients. The hypnotic agent was blinded only to the patients. During the induction of anesthesia, remimazolam was administered at a rate of 6 mg · kg−1 · h−1, and propofol was administered at a target effect-site concentration of 3.5 μg/ml. The electroencephalogram signals from eight channels (Fp1, Fp2, Fz, F3, F4, Pz, P3, and P4, referenced to A2, using the 10 to 20 system) were acquired during the induction of anesthesia and in the postoperative care unit. Power spectrum analysis was performed, and directed functional connectivity between frontal and parietal regions was evaluated using normalized symbolic transfer entropy. Functional connectivity in unconscious processes induced by remimazolam or propofol was compared with baseline. To compare each power of frequency over time of the two hypnotic agents, a permutation test with t statistic was conducted.

Results

Compared to the baseline in the alpha band, the feedback connectivity decreased by averages of 46% and 43%, respectively, after the loss of consciousness induced by remimazolam and propofol (95% CI for the mean difference: −0.073 to −0.044 for remimazolam [P < 0.001] and −0.068 to −0.042 for propofol [P < 0.001]). Asymmetry in the feedback and feedforward connectivity in the alpha band was suppressed after the loss of consciousness induced by remimazolam and propofol. There were no significant differences in the power of each frequency over time between the two hypnotic agents (minimum q value = 0.4235).

Conclusions

Both regimens showed a greater decrease in feedback connectivity compared to a decrease in feedforward connectivity after loss of consciousness, leading to a disruption of asymmetry between the frontoparietal connectivity.

Editor’s Perspective
What We Already Know about This Topic
  • Because of its superior cardiovascular stability, remimazolam may have advantages over propofol as an induction agent in elderly patients
  • The electroencephalographic features of remimazolam in elderly patients have not been well characterized
What This Article Tells Us That Is New
  • During induction of anesthesia, remimazolam caused patterns in electroencephalographic spectral power similar to those seen with propofol
  • Remimazolam nearly halved the directed electroencephalogram alpha-band connectivity from the frontal to the parietal lobes of the brain—again almost identical to the propofol effects on functional connectivity

A Randomized Trial of Intravenous Amino Acids for Kidney Protection

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Authors: Giovanni Landoni et al 
N Engl J Med . 2024 Aug 22;391(8):687-698.

Background: Acute kidney injury (AKI) is a serious and common complication of cardiac surgery, for which reduced kidney perfusion is a key contributing factor. Intravenous amino acids increase kidney perfusion and recruit renal functional reserve. However, the efficacy of amino acids in reducing the occurrence of AKI after cardiac surgery is uncertain.

Methods: In a multinational, double-blind trial, we randomly assigned adult patients who were scheduled to undergo cardiac surgery with cardiopulmonary bypass to receive an intravenous infusion of either a balanced mixture of amino acids, at a dose of 2 g per kilogram of ideal body weight per day, or placebo (Ringer’s solution) for up to 3 days. The primary outcome was the occurrence of AKI, defined according to the Kidney Disease: Improving Global Outcomes creatinine criteria. Secondary outcomes included the severity of AKI, the use and duration of kidney-replacement therapy, and all-cause 30-day mortality.

Results: We recruited 3511 patients at 22 centers in three countries and assigned 1759 patients to the amino acid group and 1752 to the placebo group. AKI occurred in 474 patients (26.9%) in the amino acid group and in 555 (31.7%) in the placebo group (relative risk, 0.85; 95% confidence interval [CI], 0.77 to 0.94; P = 0.002). Stage 3 AKI occurred in 29 patients (1.6%) and 52 patients (3.0%), respectively (relative risk, 0.56; 95% CI, 0.35 to 0.87). Kidney-replacement therapy was used in 24 patients (1.4%) in the amino acid group and in 33 patients (1.9%) in the placebo group. There were no substantial differences between the two groups in other secondary outcomes or in adverse events.

Conclusions: Among adult patients undergoing cardiac surgery, infusion of amino acids reduced the occurrence of AKI.

The Child Opportunity Index: Another Dimension of Addressing Perioperative Disparities in Anesthesiology

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Authors: Jonathan M. Tan, M.D., M.P.H., M.B.I. et al 
Anesthesiology October 2024, Vol. 141, 629–631.

“As an ever-evolving medical discipline, addressing disparities in healthcare delivery should be an important priority in anesthesiology.”

On a busy day in the operating rooms of a pediatric hospital, a surgical cancellation or patient no-show can seem like an inconsequential occurrence. However, surgical cancellations might have negative repercussions for all involved parties. For a child, a delay in surgical care could lead to poorer outcomes. Parents and guardians who have taken time off from work to bring their child in for a procedure may have lost a day of income.  An unplanned gap in operating room time can be costly for the healthcare system, and case cancellations have been associated with longer wait times, higher complication rates, and increased costs of care.  Thus, we should endeavor to identify any addressable contributing factors and address them, particularly if we can identify the highest risk populations.

Disparities in perioperative medicine have previously focused primarily on race and ethnicity.  However, other key factors have been demonstrated to affect the health of individuals and populations. Social determinants of health are the conditions in the environment of individuals that affect aspects of health. These factors may include where people live, learn, work, and play. Housing conditions, environmental exposures, access to transportation, and economic instability are some of the key elements of social determinants of health. As anesthesiologists, we may interact with patients daily who have their health negatively affected because of social determinants of health risk factors.

In this issue of Anesthesiology, Willer et al.  conducted a retrospective cohort study of children scheduled for ambulatory surgery at a tertiary pediatric hospital between 2017 and 2022. They aimed to determine the association of day-of-surgery cancellation with neighborhood opportunity (as measured by the Child Opportunity Index 2.0) and evaluate the interaction of neighborhood opportunity with race and ethnicity on the risk of day-of-surgery cancellation.  Willer et al. used the patient’s primary address to geographically link the patient to their respective Child Opportunity Index 2.0 value.  They observed a strong relationship between pediatric day-of-surgery cancellation and neighborhood opportunity and reported evidence of an interaction of Child Opportunity Index with race and ethnicity. The authors concluded that Black children at every level of opportunity had the highest risk of cancellation, suggesting that there are additional factors that render them more vulnerable to neighborhood disadvantage. 

The study by Willer et al.  is a fine example of the power of using data to answer clinically and socially relevant questions in anesthesiology and perioperative medicine. Although Child Opportunity Index 2.0 as a geographically based social determinant of health measure has been applied extensively in public health and pediatrics for many years, this article is unique in bringing Child Opportunity Index 2.0 to perioperative medicine.  Studying disparities using geographically based indices for social determinants of health has many advantages, including the opportunity to identify more vulnerable populations that need targeted assistance and to enable a more comprehensive assessment of resources and challenges that exist in the environment that affect childhood opportunity.  Furthermore, geographically based indices can enable an additional level of comparison of populations across different health systems.

However, adopting geographically based measures and applying them to individual perioperative patients requires further work to be conducted in collaboration with spatial scientists, geographers, and public health scientists to ensure that the use of geographically based measures of health is statistically valid and scientifically sound and discussed in the proper context. Some critical areas of using geographically based measures for individual patient analysis include ensuring that every patient’s privacy is protected, demonstrating that Health Insurance Portability and Accountability Act (HIPAA)–compliant methods were used in the geocoding process, and ensuring that maps adhere to well-established scientific standards in cartography. Furthermore, the relationship between geographic indices and the individual patient must be examined carefully over both space and time. Two well-studied statistical concerns in the geographic sciences include considerations of how space and time data are aggregated. Known as the “Modifiable Areal Unit Problem” and the “Modifiable Temporal Unit Problem,” these issues highlight how the analysis and subsequent results can be problematic if a suboptimal scale of geography (census tract vs. ZIP code) is selected to conduct the analysis. Similarly, the statistical implications of time segmentation and aggregation can also significantly affect the analysis. Willer et al.  performed their analysis using the preferrable the geographic granularity (census tract), yet they included the use of Child Opportunity Index 2.0 data from 2015 for analysis in a data set with patients from 2017 to 2022. Many of these areas of concern are inevitable and may be limited by the available data, methods employed, and technology used. Future researchers should address these same limitations while advancing the study of disparities in anesthesiology and perioperative medicine by harnessing the power of multidisciplinary methods and teams.

As an ever-evolving medical discipline, addressing disparities in healthcare delivery should be an important priority in anesthesiology.  Clinicians may read the findings reported by Willer et al.  agree with the results, and nod familiarly to their own practice experience. Some readers may further state that disparities in race, ethnicity, and socioeconomic status, including in perioperative medicine, have already been documented in the literature for years—if not decades. For both types of readers, Willer et al.  provide additional insight toward understanding health disparities in perioperative medicine. The next crucial step is the development of interventions and perioperative policies that address these disparities. Through effective, equitable, and efficient local, regional, and national policy interventions, healthcare professionals and health systems can ensure that every child, regardless of race, ethnicity, socioeconomic status, or where they are living, can receive the care they deserve.

Willer et al.  should be commended for advancing the study of health disparities in perioperative medicine through the study of race, ethnicity, and childhood opportunity. Each study of disparities in health and healthcare delivery enables a better understanding of the areas where our care can improve individually and systematically. This study and others like it serve as an important starting point for developing evidence-based interventions and scientifically demonstrating reductions in health disparities. 

Discover The Best Anesthesiologist Opportunity in New Mexico

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We are seeking a dedicated anesthesiologist to join our all-anesthesiologist group. Our team will consist of 4 full-time providers and 1 for vacation relief, managing 3 operating rooms.

Position Highlights:

  • Zero call for 3 weeks, followed by 1 week of call without daytime work only call after 7 PM therefore you may not work the entire week.
  • Competitive salary of $500,000 plus benefits.
  • 8 weeks of vacation.

This is the best job on GasWork #370670

Interested? Please contact me at 660-596-2224 or drrob@anesthesiaexperts.com if you or anyone you know would like to apply.

Note: Agencies, please do not contact us as we do not use your service

Discover A Great CRNA and Anesthesiologist Opportunity in Lubbock TX

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We are seeking a dedicated anesthesia care team to join our new anesthesia care team contract at Lubbock Heart and Surgery Hospital in Lubbock TX.

Position Highlights:

  • Anesthesiologist call is 1:3
  • Competitive salary of $575,000 plus benefits.
  • 8 weeks of vacation.
  • CRNA no call
  • Competitive salary of $280,000 plus benefits.
  • 8 weeks of vacation.

Interested? Please contact me at 660-596-2224 or drrob@anesthesiaexperts.com if you or anyone you know would like to apply.

Note: Agencies, please do not contact us as we do not use your service

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