Patients’ recovery after surgery is one of the most important health processes in planned hospital healthcare and has a direct impact on welfare and welfare systems. Therefore, what nurses do in the im­mediate postoperative period is of vital importance. This thesis addresses the question of understanding how nurses work in managing post-operative pain by exploring their daily nursing practices and experiences in responding to the patient in pain within a Thai cultural context. The project applied a qualitative methodology where the local culture and its day-to-day practices of pain management were studied by using observations, focus groups, in-depth interviews and a critical incident interview approach with nurses. Informants were recruited at a public hospital in Bangkok in a surgical ward. In all, 100 hours of observations, 39 interviews and 69 descriptions of critical incidents related to nurse’s pain management were gathered. The data analysis followed the principles of qualitative research. The findings showed that, although there is a clearly defined approach to pain management, the response system followed by the nurses to address patients’ pain is complex and includes much lead time between assessing patients’ pain and the nurses responding to the pain. Furthermore, nurses are caught in what is labeled a patient pa­radigm, where evidence of pain often is double- and triple-checked by scoring and recording signs that are then subject to confirmation by a third party. Underpinning this is a culture of pain management cultivated between the nurses that rests first and foremost on their own experiences and a working/professional culture where nurses offer each other practical help in urgent situations, but seldom discuss event-based strategies together. Nevertheless, when nurses described situations when they were successful in practicing pain management, they considered their own engagement and their availability of time, space and therapeutic options to be important. Keywords: Culture of nursing, Nursing in pain management, Pain assessment, Perception of pain, Pain management, Pain post-operative

Introdução: a analgesia multimodal é amplamente usada para o controle da dor perioperatória em um esforço para reduzir o uso de opioides. A duloxetina é um inibidor seletivo da recaptação da serotonina e noradrenalina com eficácia para estados de dor crônica. O objetivo principal deste estudo foi avaliar a eficácia de duas doses orais de 60 mg de duloxetina em termos de consumo de fentanil durante o período pós-operatório em pacientes submetidos à cirurgia eletiva de artrodese de coluna lombar. Método: este estudo foi um ensaio clínico prospectivo, duplo encoberto, aleatório e controlado com placebo. Os pacientes receberam 60 mg de duloxetina ou placebo idêntico uma hora antes da cirurgia e 24 horas depois. Os sujeitos do estudo foram divididos em dois grupos: grupo C (controle) de indivíduos que receberam o placebo; e grupo D (duloxetina) de indivíduos que receberam 60 mg de duloxetina. O consumo total de fentanil administrado pelo próprio paciente em 24 e 48 horas após a cirurgia foi mensurado. Os desfechos secundários foram os escores de dor e a presença ou ausência de efeitos adversos, tais como cefaleia, náuseas, vômitos, prurido, tonturas e sonolência. Resultados: as características demográficas não diferiram entre os grupos. Houve uma diferença significativa no consumo de fentanil nas primeiras 24 horas entre os grupos C e D (diferença média, 223,11 ± 39,32 ?g; p < 0,001). O consumo de fentanil também diferiu entre os grupos C e D após 48 horas (diferença média, 179,35 ± 32,55 ug; p < 0,00). Os escores de dor em mais de 48 horas não diferiram significativamente entre os grupos. A incidência de efeitos colaterais foi semelhante nos dois grupos. Conclusão: a duloxetina foi associada à redução do consumo de fentanil no pós-operatório de cirurgias sobre a coluna lombar, portanto, sendo eficaz como adjuvante para a analgesia pós-operatória e redução do consumo de opioides / Background: Multimodal analgesia is widely advocated for the control of perioperative pain in an effort to reduce the use of opioids. Duloxetine is a selective serotonin and noradrenaline reuptake inhibitor with efficacy for chronic pain states. The main objective of this study was to evaluate the efficacy of two oral doses of 60 mg duloxetine in terms of fentanyl submitted to elective lumbar spine arthrodesis surgery. Method: This study was prospective, double blind, randomized, and placebo controlled clinical trial. Patients received duloxetine 60 mg or identical placebo one hour before surgery and 24 hours later. The study subjects were divided into two groups: group C (control) of subjects who received placebo; and group D (duloxetine) from subjects received 60 mg. The total fentanyl consumption by the patient himself at 24 and 48 hours after surgery was measured. Secondary outcomes were pain scores and the presence or absence of adverse effects such as headache, nausea, vomiting, pruritus, dizziness and drowsiness. Results: Demographic characteristics did not differ between groups. There was a significant difference in fentanyl consumption in the first 24 hours between groups C and D (mean difference, 223.11 ± 39.32 ?g; p < 0.001). Fentanyl consumption also differed between groups C and D after 48 hours (mean difference, 179.35 ± 32.55 ?g; p < 0.00). Pain scores in more than 48 hours did not differ significantly between groups. The incidence of side effects was similar in both groups. Conclusion: Duloxetine was associated with reduction of fentanyl consumption in the postoperative period of surgeries on the lumbar spine, therefore, it was effective as adjuvant for postoperative analgesia and reduction of opioid consumption

Introdução: a analgesia multimodal é amplamente usada para o controle da dor perioperatória em um esforço para reduzir o uso de opioides. A duloxetina é um inibidor seletivo da recaptação da serotonina e noradrenalina com eficácia para estados de dor crônica. O objetivo principal deste estudo foi avaliar a eficácia de duas doses orais de 60 mg de duloxetina em termos de consumo de fentanil durante o período pós-operatório em pacientes submetidos à cirurgia eletiva de artrodese de coluna lombar. Método: este estudo foi um ensaio clínico prospectivo, duplo encoberto, aleatório e controlado com placebo. Os pacientes receberam 60 mg de duloxetina ou placebo idêntico uma hora antes da cirurgia e 24 horas depois. Os sujeitos do estudo foram divididos em dois grupos: grupo C (controle) de indivíduos que receberam o placebo; e grupo D (duloxetina) de indivíduos que receberam 60 mg de duloxetina. O consumo total de fentanil administrado pelo próprio paciente em 24 e 48 horas após a cirurgia foi mensurado. Os desfechos secundários foram os escores de dor e a presença ou ausência de efeitos adversos, tais como cefaleia, náuseas, vômitos, prurido, tonturas e sonolência. Resultados: as características demográficas não diferiram entre os grupos. Houve uma diferença significativa no consumo de fentanil nas primeiras 24 horas entre os grupos C e D (diferença média, 223,11 ± 39,32 ?g; p < 0,001). O consumo de fentanil também diferiu entre os grupos C e D após 48 horas (diferença média, 179,35 ± 32,55 ug; p < 0,00). Os escores de dor em mais de 48 horas não diferiram significativamente entre os grupos. A incidência de efeitos colaterais foi semelhante nos dois grupos. Conclusão: a duloxetina foi associada à redução do consumo de fentanil no pós-operatório de cirurgias sobre a coluna lombar, portanto, sendo eficaz como adjuvante para a analgesia pós-operatória e redução do consumo de opioides / Background: Multimodal analgesia is widely advocated for the control of perioperative pain in an effort to reduce the use of opioids. Duloxetine is a selective serotonin and noradrenaline reuptake inhibitor with efficacy for chronic pain states. The main objective of this study was to evaluate the efficacy of two oral doses of 60 mg duloxetine in terms of fentanyl submitted to elective lumbar spine arthrodesis surgery. Method: This study was prospective, double blind, randomized, and placebo controlled clinical trial. Patients received duloxetine 60 mg or identical placebo one hour before surgery and 24 hours later. The study subjects were divided into two groups: group C (control) of subjects who received placebo; and group D (duloxetine) from subjects received 60 mg. The total fentanyl consumption by the patient himself at 24 and 48 hours after surgery was measured. Secondary outcomes were pain scores and the presence or absence of adverse effects such as headache, nausea, vomiting, pruritus, dizziness and drowsiness. Results: Demographic characteristics did not differ between groups. There was a significant difference in fentanyl consumption in the first 24 hours between groups C and D (mean difference, 223.11 ± 39.32 ?g; p < 0.001). Fentanyl consumption also differed between groups C and D after 48 hours (mean difference, 179.35 ± 32.55 ?g; p < 0.00). Pain scores in more than 48 hours did not differ significantly between groups. The incidence of side effects was similar in both groups. Conclusion: Duloxetine was associated with reduction of fentanyl consumption in the postoperative period of surgeries on the lumbar spine, therefore, it was effective as adjuvant for postoperative analgesia and reduction of opioid consumption