Procedure Related Pain and Anxiety during Bone Marrow Aspiration

Bone marrow aspiration/biopsy (BMA) is a common procedure used to diagnose and follow up treatment in patients with haematological disorders. Procedures in these patients are often associated with some pain, discomfort and anxiety. However, there is only sparse data on the characteristics and determinants of procedural pain during BMA. In addition, little is known concerning the level of agreement between patients’ and health care professionals’ ratings of the formers’ experienced pain and anxiety. The overall aim of this study was to increase knowledge about pain and anxiety in adult haematological patients undergoing BMA, and about how health care professionals estimate patients’ pain and anxiety during BMA. Two-hundred-and-thirty-five adult patients (109 female and 126 male, median age 62 years, range 20-89) scheduled consecutively for BMA at the Division of Haematology, Karolinska University Hospital Solna, (Study I and II) were included, Nine attending haematologists and seven haematology fellows who performed the BMA, and nine registered nurses (RNs) who assisted the physicians (Study II) were also included. Selfadministered questionnaires with questions regarding patient characteristics such as age, gender, pain in daily life, pre-existing pain, anxiety, employment status, previous BMA, pain during and after BMA) were used to assess patients before-, 10 minutes post and 1-7 days post BMA. The RNs and physicians filled in questionnaires regarding patients’ pain and anxiety immediately after each BMA. Factors associated with BMA-related pain and anxiety was examined using univariate and multivariate logistic regression analysis. Seventy percent of haematological patients undergoing BMA reported procedure related pain, one-third of them severe. Pre-existing pain OR 2.60, anxiety about diagnostic outcome OR 3.17 or needle-insertion OR 2.49, and low employment status OR 3.14 were independent risk factors (Study I). The level of agreement between patients and health-care professionals (Study II) was evaluated by calculating proportions of agreement, Cohen’s unweighted kappa coefficient (к) and intra class correlations (ICC). The results showed fair agreement regarding the occurrence of pain between RNs and patients and physicians (к 0.33 and 0.37), and moderate agreement for intensity of pain (ICC 0.42 and 0.44). RNs and physicians underestimated severe pain and overestimated mild pain. There was slight agreement between patients and RNs and physicians regarding occurrence of anxiety about BMA outcome and needle-insertion (к 0.14-0.21). The ICC showed poor agreement between patients and RNs and physicians for anxiety about BMA outcome and needle-insertion (ICC 0.13-0.36). In conclusion, procedure related pain was common in these adult patients undergoing BMA, and was often accompanied with pre procedural anxiety and pain. Health-care professionals underestimated patients’ pain and anxiety during BMA. LIST OF PUBLICATIONS I. Lidén Y, Landgren O, Arnér S, Sjölund KF, Johansson E. Procedure related pain among adult patients with haematologic malignancies. Acta Anaesthesiol Scand. 2009 Mar; 53 (3): 354-63. II. Lidén Y, Olofsson N, Landgren O, Johansson E. Poor congruence between hematologic cancer patients and health-care professionals’ ratings of patients’ pain and anxiety during bone marrow aspiration. Manuscript. CONTENTS BACKGROUND 1 Haematopoiesis and haematological disorders 1 Malignant haematological disorders 1 Bone marrow aspiration/biopsy (BMA) 1 Pain 2 Pain in patients with haematological disorders 3 Procedure related pain 3 Assessment of pain 3 Patients’ satisfaction with pain management 4 Anxiety 4 Assessment of anxiety 5 Health-care professionals` opinions of patients` experience of pain & anxiety 6 AIM OF THE STUDY 7 MATERIALS AND METHODS 8 Patients 8 Health-care professionals 8 Instruments 10 Statistics and data analysis 11 ETHICAL CONSIDERATIONS 15 RESULTS 16 RESULT DISCUSSION 22 METHODOLOGICAL DISCUSSION 23 Study I 21 Study II 22 CONCLUSIONS AND CLINICAL IMPLICATIONS 26 FUTURE RESEARCH 27 ACKNOWLEDGEMENTS 28 REFERENCES 31 Studies I-II LIST OF ABBREVIATIONS BMA Bone marrow aspiration/biopsy CI Confidence interval ICC Intra class correlation mm Millimetre κ Cohen ́s unweighted kappa coefficient NRS Numeric Rating Scale OR Odds ratio P(A) Proportion of agreement RN(s) Registered nurse(s) STAI-S Stait trait anxiety scale-state STAI-T Stait trait anxiety scale-trait VAS Visual Analogue Scale VRS Verbal Rating Scale