The paper reports the results of the evidence search conducted by using two databases: EBSCO/CINAHL and Medline/Pubmed. The purposes of the assignment, as well as search criteria, are briefly stated in the introduction. The following section, Methods, and Results, describes the tools and approaches used during the search and analyzes the quality of each selected source separately. Lastly, a concise explanation of how the evidence may be utilized in the suggested PICOTS research project is given in the conclusion.
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The purpose of the assignment is to locate high-quality evidence for the research project aimed to answer the following PICOTS question: In adults patients following ORIF surgery for a hip fracture (P) in an acute care setting (S), how effective is PCA pain medication compared to PRN intramuscular pain medication (I) in controlling postoperative pain (O) during the postoperative period (T)? To locate relevant articles, two databases were used: EBSCO/CINAHL and Medline/Pubmed.
The objective was to find level I-IV evidence and, thus, the search targeted only primary studies (randomized control trials, descriptive studies, quantitative studies, and so forth), as well as secondary literature, including systematic reviews, and evidence-based clinical practice guidelines. Another important eligibility criterion was the publication within the last five years. Qualitative studies were considered ineligible for the present research project as they fall under the category of level VI-VII evidence.
Methods and Results
Four articles suitable for answering the formulated PICOTS question were found by using various combinations of keywords. They included such terms as postoperative pain, patient-controlled analgesia, intramuscular analgesia, ORIF pain management, hip fracture, and so forth. It was observed that the combinations of two and three terms (for instance, patient-controlled analgesia, and postoperative pain management) were the most effective in locating articles linked to the topic of current interest. At the same time, most of the found materials did not cover the selected issue directly and entirely, while those that did address the problem comprehensively were dated.
First, a Japan-based, randomized study by Nishio et al. (2014) was located through EBSCO/CINAHL. The keywords used during the search were as follows: PCA versus intramuscular analgesia, hip fracture. The researchers aimed to evaluate and compare the effectiveness of different pain management methods, including “continuous femoral nerve block (FNB group), single-shot caudal epidural block with morphine (EB group), intravenous patient-controlled analgesia with fentanyl (IV-PCA group), and systemic administration of nonsteroidal anti-inflammatory drugs (NSAIDs group)” (Nishio et al., 2014, p. 15).
Thus, although it did not investigate the PRN intramuscular pain medication method, it provided a substantial pool of information regarding one variable in the PICOTS question. For instance, it was revealed that, compared to other pain management procedures assessed by Nishio et al. (2014), PCA is associated with a higher rate of postoperative complications, including delays in functional recovery, drowsiness, and nausea. At the same time, it leads to a higher degree of pain relief within twelve hours after the operation.
The study provides Level III evidence since a control group was not included in the comparison. Some research design weaknesses are observed, including a limited time for evaluation of analgesic effects (12 hours) and a small sample size (8-10 participants in each of the four groups). Secondly, the researchers focused on the assessment of patients who underwent unilateral total hip arthroplasty and, as a result, the findings maybe not applicable to individuals who had ORIF surgery. Considering all these limitations, it is possible to say that the level of evidence is not exceptionally high and is not enough to obtain a credible answer to the formulated PICOTS question.
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The second international study by Luiten et al. (2014) was located through EBSCO/CINAHL as well. The following keywords were used during the search: ORIF, postoperative pain management, PRN intramuscular, PCA. The research design employed by Luiten et al. (2014) was a retrospective comparative study, and thus it provides Level III evidence. The main independent variables included in the analysis were such pain control methods as continuous peripheral nerve block (CPNB) and PCA with morphine. The dependent variables were patients’ pain scores, recovery, and length of hospital stay.
Similar to the article by Nishio et al. (2014), the study by Luiten et al. (2014) addresses the PICOTS question only partially, yet their findings are more relevant because the researchers analyzed the sample of patients who underwent ORIF (for ankle fractures). The number of participants in both involved study populations was sufficiently large but non-randomized. It means that some confounding variables could bias the results and negatively affect their reliability and validity.
Another article was located through the MEDLINE database with the help of such keywords as pain management, PRN analgesia, and ORIF. It comprises expert opinion/practical guidelines developed by Drew et al. (2014) and published in a nursing journal, Pain Management Nursing. Considering that the practical recommendations outlined in the source are supported by high-quality academic and professional research findings, it provides Level I evidence.
The main focus of the article is patient safety during the administration of PRN range opioids by nurses. The guidelines are general in nature and not centered on any specific health condition. It means that they may be primarily used for researching the background of the “as-needed” pain medication administration and identification of factors of this method’s efficacy.
The last US article by Bijur et al. (2017) was located by using the following keywords: PCA, acute care, postoperative pain management. The study provides Level I evidence since the randomized control trial design was implemented by the researchers. The researchers compared the intervention group (exposed to PCA) and control group (exposed to usual pain management care, namely, the intravenous opioid dose). The study employed a large sample of 636 patients, which significantly increased the validity of the findings.
Nevertheless, the evaluation period was too short and equated to two hours for each intervention. Thus, the results do not mirror the potential long-term effects of the PCA method. However, the observations made by Bijur et al. (2017) regarding a high frequency of PCA-related adverse incidents can still be taken into account during the research of the formulated PICOTS question as they demonstrate possible drawbacks of the given pain control method and, thus, can be useful in its comparison with the intramuscular PRN drugs administration.
The evidence of different quality levels is retrieved from the selected articles yet since none of the sources addresses the PICOTS question directly, they may be primarily used for the review of the topic background and the analysis of some aspects of the PCA pain control method. Notably, two studies (Bijur et al., 2017; Nishio et al., 2014) reported a high rate of PCA-associated complications, and in spite of the finding that it may lead to a significant reduction in pain rate over time, the researchers recommend using alternative pain control methods, such as CPNB, instead (Luiten et al., 2014). However, these data are not enough to define the comparative effectiveness of intramuscular PRN drug administration, and additional evidence on this topic is required.
Bijur, P., Mills, A., Chang, A., White, D., Restivo, A., Persaud, S.,… Birnbaum, A., Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY. (2017). Comparative effectiveness of patient-controlled analgesia for treating acute pain in the emergency department. Annals of Emergency Medicine, 70(6), 809-818.
Drew, D., Gordon, D., Renner, L., Morgan, B., Swensen, H., Manworren, R.,… American Pain Society. (2014). The use of “as-needed” range orders for opioid analgesics in the management of pain: A consensus statement of the American Society of Pain Management Nurses and the American Pain Society. Pain Management Nursing: Official Journal of the American Society of Pain Management Nurses, 15(2), 551-4.
Luiten, W., Hermanides, J., Stevens, M., Hollmann, M., Van, S., Schepers, T.,… Carel, G. (2014). Comparison of continuous nerve block versus patient-controlled analgesia for postoperative pain and outcome after talar and calcaneal fractures. Foot and Ankle International, 35(11), 1116-1121.
Nishio, S., Fukunishi, S., Juichi, M., Sahoko, K., Fujihara, Y., Fukui, T., & Yoshiya, S. (2014). Comparison of continuous femoral nerve block, caudal epidural block, and intravenous patient-controlled analgesia in pain control after total hip arthroplasty: A prospective randomized study. Orthopedic Reviews, 6(1), 15-19.