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NG Tube Pain Avoidable but Not Avoided

Bukata, W. Richard MD

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Dr. Bukata is the medical director of the emergency department at San Gabriel Valley Medical Center in San Gabriel, CA, a clinical professor in the department of emergency medicine at Los Angeles County/USC Medical Center, and the editor of Emergency Medical Abstracts

I've read a number of studies that suggest that patients rank the insertion of a nasogastric tube as the most noxious routine experience in the ED. I personally can't remember the last NG tube that I requested because there aren't many indications for them, and I know from secondhand experience how nasty the procedure can be.

In fact, when I visited medical schools trying to convince them that I would be a decent selection, I was told at one, Jefferson Medical College in Philadelphia, that students routinely performed procedures on each other (including passing NG tubes). I quickly decided — sight unseen — that Temple University (which was up the road a piece) was clearly the superior place to go.

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In any case, studies also have demonstrated that passing an NG tube can be made much more tolerable if clinicians are willing to take the time to prepare the patient appropriately with anesthetics. Normally, when we order an NG tube on the chart, we quickly leave the area so we don't have to be confronted by the nurse who has to do the dastardly deed. Then, left to their own devices, the nurses use their own special tricks to accomplish the task. Some like the tube hardened and put it in ice water; others prefer the wet noodle technique and put the tube in hot water to soften it.

All talk in a much louder voice as they overcome the patient's protestations by shouting “swallow, swallow, swallow.” It seems this encouragement always comes in threes.

Now to the point. Given that it has been demonstrated unequivocally in other studies that inhalation of nebulized lidocaine and other similar techniques are more humane than placing a glob of lidocaine gel on the tube, why do we not incorporate these techniques into our practice? The patients say it is noxious and painful, and the literature says we can fix that, but we choose not to. That's the thrust of the first paper this month. Only a quarter of surveyed doctors said they used the methods they believed were most effective in reducing the pain of NG tube insertion. And, in reality, was it really a quarter or were they saying what they believed the surveyors wanted to hear?

Emergency Physicians' Practices and Attitudes Regarding Procedural Anaesthesia for Nasogastric Tube Insertion, Juhl GA, et al, Emerg Med J, 2005;22:243

BACKGROUND: Nasogastric tube insertion is believed to be the most painful of routinely performed procedures in the ED, but measures to minimize this pain are reportedly underused.

METHODS: The authors from the University of Rochester (NY) surveyed 38 emergency medicine residents and 30 attending physicians concerning their beliefs about and practices in measures to relieve the discomfort of NG tube insertion.

RESULTS: The survey response rate was 68 percent. Nearly all the respondents felt that NG tube insertion was uncomfortable or painful for awake and alert patients (98%). Although 93 percent reported use of some measure to reduce this discomfort, only 28 percent felt what they do is adequate and only 39 percent expressed satisfaction with their current practice. Most (91%) stated they would change their practices if new literature reported on convenient and effective measures. The most commonly used measures included lubricant gel (78%), topical anesthetic spray (65%), lidocaine gel (54%), and distraction (17%). Although there were variable beliefs among respondents about the relative value of these and other methods employed, only 24 percent of respondents said they use those methods they believe are most effective in reducing pain.

CONCLUSIONS: There appears to be a need to improve the use of effective methods to relieve pain associated with NG tube insertion in the ED.

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Oxycodone or Hydrocodone?

Speaking of pain relief, here's a study that has everyday applicability to the ED. Which narcotic is better: oxycodone or hydrocodone? Because I have been surveying the literature religiously since 1977, I can tell you there are not a lot of papers on this important subject. In fact, of the 36 references listed in the following study, only a few suggest prior comparisons (and even then it is unclear because specific drugs are not mentioned in the title).

Techniques for easing the pain of NG tube placement exist, so why don't clinicians incorporate them into practice?

Given that, hopefully most emergency physicians recognize that codeine is not worth the powder to blow it up. The literature on this topic is compelling: the addition of codeine adds about five percent effectiveness to the analgesia of acetaminophen and markedly increases side effects. So which narcotic combination should we choose? Is there a difference?

The following paper, not paid for by any drug company, suggests that oxycodone would be a better choice than hydrocodone. Congratulations to the authors for focusing on this important topic. Studies such as these indicate that there are still plenty of opportunities for useful clinical research that has practical applicability.

Comparison of Oxycodone and Hydrocodone for the Treatment of Acute Pain Associated with Fractures, Marco CA, et al, Acad Emerg Med, 2005;12(4):282

METHODS: In this prospective, double-blind study from St. Vincent Mercy Medical Center in Toledo, OH, a convenience sample of 73 patients aged 12 or older with “severe” pain (a score of 5 or higher on a scale of 0–10) due to acute fractures were randomized to a single oral dose of oxycodone (5 mg) plus acetaminophen (325 mg) (Percocet, Roxicet, etc.) or hydrocodone (5 mg) plus acetaminophen (325 mg) (Vicodin, Lortab, etc.). Pain was assessed at baseline and at 30 and 60 minutes after treatment. The patients were discharged with sufficient medication for three days of treatment, and were contacted by telephone three to five days after presentation.

RESULTS: In the 67 patients completing the ED study phase, the mean baseline pain score was 7.7 in the oxycodone group and 7.1 in the hydrocodone group. The mean decrease in pain was greater with the oxycodone than with the hydrocodone preparation at 30 minutes (mean decrease 3.7 vs. 2.5 points) and 60 minutes (mean decrease 4.4 vs. 3.0 points), although these differences were not statistically significant. There were no differences in post-treatment vital signs, the use of additional pain medication, or adverse effects with the exception of constipation, which was more common in patients treated with the hydrocodone formulation (21% vs. 0% in the comparison group).

CONCLUSIONS: When combined with acetaminophen, oxycodone may have benefits over hydrocodone in pain relief and a lower incidence of constipation, although it is possible that the differences seen in this small study were due to chance.

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Consoling Statements May Increase Anxiety

And speaking of pain, it is taken for granted that physicians should warn patients what to expect of a painful procedure and console them when pain is experienced. Everybody knows this.

The following article is absolutely fascinating. It demonstrated that negative warning statements such as, “You're going to feel a little stinging sensation,” actually increased patients' pain and anxiety by statistically (and probably clinically) significant amounts.

Sympathy statements, although not increasing pain, did substantially increase anxiety. The authors conclude that our conventional understanding of compassionate behavior may be based more on beliefs than scientific evidence, and suggest further controlled studies to determine more accurately the effect of specific word-sets on patients' perceptions. Unfortunately, at this point, what are the alternatives?

Can Words Hurt? Patient-Provider Interactions During Invasive Procedures, Lang EV, et al, Pain, 2005;114:303

BACKGROUND: It is commonly believed that warning patients of impending discomfort and sympathizing with them following an uncomfortable action is a helpful expression of compassion.

METHODS: The authors from Beth Israel Deaconess Medical Center in Boston analyzed videotapes of 159 patients 18 to 92 (mean age, 57) undergoing interventional radiology procedures who had participated in a prior study on the effects of self-hypnotic relaxation techniques to determine the effects of negative warnings or sympathy statements on patient-reported pain and anxiety assessed on a scale of 0–10. All of the patients were managed with patient-controlled analgesia during the procedures.

RESULTS: The majority of the patients (94%) were Caucasian, and 52 percent were female. The authors observed exposure of 33 of the 159 patients to 86 negative warnings or sympathy statements. All but two of the 41 warnings and at least 18 of the 45 sympathizing statements were made in the absence of patient behavior that would appear to solicit such remarks.

Patients receiving negative warnings recorded higher pain scores at the time of the event than those not receiving such remarks (mean, 3.9 vs. 2.8, p=0.0261) as well as higher anxiety scores (mean, 4.4 vs. 3.2, p=0.0007). Patients receiving negative statements after an event recorded similar pain scores as those not receiving such statements but higher anxiety scores (mean 3.7 vs. 2.9, p=0.0339). Negative statements had no significant effect on the amount of self-administered pain medication.

Negative warning statements actually increase patients' pain and anxiety by statistically significant amounts

CONCLUSIONS: Warnings and commiserations produced a “nocebo” effect, increasing the pain and anxiety of patients undergoing interventional radiology procedures.

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Vitamin E Decreases Menstrual Pain

Again speaking of pain, what about menstrual cramps? I've seen young women brought in by their mothers for nasty menstrual cramps. Most people by now know how effective NSAIDs can be in this setting, but what if they are inadequate? Time for hydrocodone?

The following paper suggests that there is a miracle drug for menstrual cramps: vitamin E. In recent months, vitamin E has had a rough spell. All sorts of studies have concluded that it doesn't make you live longer or prevent your heart attacks or dementia or cancer or pretty much anything else. But maybe there is some redeeming value for this fallen vitamin. The only problem with the following study is that the results seem unbelievable. But it's cheap and won't hurt you, and if it is even half as good as claimed, it would still be terrific.

A Randomised Controlled Trial of Vitamin E in the Treatment of Primary Dysmenorrhea, Ziaei S, et al, Br J Obstet Gynecol, 2005;112:466

BACKGROUND: The pain of primary dysmenorrhea is believed to be prostaglandin-mediated. Vitamin E inhibits arachidonic acid release and conversion to prostaglandin, and in a prior study, was found to reduce the severity of pain in primary dysmenorrhea at a daily dose of 500 IU.

METHODS: In this double-blind, controlled Iranian study, 278 girls ages 15 to 17 with primary dysmenorrhea were randomized to a four-month course of vitamin E (total daily dose, 400 IU) or placebo with instructions to take study tablets twice daily for two days before and three days after the beginning of menstruation.

RESULTS: The mean dysmenorrhea pain score at baseline on a scale of 0–10 was 6 in both groups. The mean pain score decreased in both groups at two months, but the decrease in the vitamin E group was significantly greater than the decrease in controls. Mean scores were 3 vs. 5 at two months, and 0.5 vs. 6 at four months. The mean duration of pain at four months was 1.6 hours in the vitamin E group compared with 16.7 hours in controls (p<0.001), and the percentage of patients taking rescue ibuprofen was 4.3 percent vs. 89.4 percent (p<0.001). Both groups exhibited a statistically significant reduction in menstrual blood loss, but the decrease was significantly greater in the vitamin E group.

CONCLUSIONS: At a daily dose of 400 IU, vitamin E reduced the severity and duration of pain associated with primary dysmenorrhea as well as the amount of menstrual blood loss.

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Do High BP Symptoms Exist?

How many times has a patient said, “Doc, would you check my pressure? I just don't feel good.” Despite the fact that blood pressure shouldn't affect how we feel unless we are having a hypertensive emergency, it appears that both physicians and laymen are willing to ascribe all manner of symptoms to elevated blood pressure, despite the fact that when this is looked at in clinical studies, it is very difficult to show a relationship between symptoms and blood pressure.

Here's another paper that makes this conclusion. It demonstrates that there was no relationship between the degree of elevated blood pressure and self-reported or solicited symptoms often ascribed to high blood pressure. I only wish they had included people with normal blood pressure.

Lack of Relationship between Hypertension-Associated Symptoms and Blood Pressure in Hypertensive ED Patients, Karras DJ, et al, Am J Emerg Med, 2005;23(2):106

BACKGROUND: Various symptoms are considered to be related to blood pressure elevation, and when present in patients with hypertension, are considered markers of hypertensive emergency requiring immediate treatment.

No relationship exists between the degree of elevated blood pressure and self-reported or solicited symptoms

METHODS: This observational study from Temple University in Philadelphia examined the relationship between blood pressure elevation and seven symptoms considered suggestive of hypertension-related end-organ damage in 529 emergency department patients noted to have blood pressures above 140/90 mmHg. Interviews were conducted with 294 of these patients to characterize this relationship further.

RESULTS: The mean age of the study cohort was 51 years, 54 percent were female and 78 percent were African-American. Stage 1 hypertension (140–159 mmHg /90–99 mmHg) was present in 57 percent, stage 2 (160–179 mmHg /100–109 mmHg) in 24 percent, and stage 3 (at least 180/110 mmHg) in 19 percent. At least one of the seven complaints was spontaneously reported without prompting by 26 percent of the study group (shortness of breath in 11%, chest pain in 12%, focal neurologic deficits, epistaxis, dizziness, or headache in 1% to 5%, blurred vision 0%), including 25 percent of patients with stage 1 hypertension and 28 percent in both the stage 2 and stage 3 groups.

Among the interviewed patients, 63 percent reported at least one of these symptoms when specifically asked (63% to 67% in the three blood pressure subgroups), most commonly dyspnea (36%), headache (32%), chest pain and dizziness (26% each). There were no differences among the three blood pressure groups in the prevalence of symptoms occurring during the 24 hours or week prior to presentation.

CONCLUSIONS: These findings suggest that clinicians should be cautious in ascribing characteristic symptoms to BP elevation and hypertensive emergency.

© 2005 Lippincott Williams & Wilkins, Inc.

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