Effectiveness and safety of postoperative pain management: a survey of 18 925 consecutive patients between 1998 and 2006 (2nd revision): a database analysis of prospectively raised data

Treatment of pain in children after limb-sparing surgery: an institution's 26-year experience

A significant proportion of patients report long-term pain that is ≥5 on a 0-10 intensity scale after limb-sparing surgery for malignancies of the long bones. Patients experience several distinct types of pain after limb-sparing surgery which constitute a complex clinical entity. This retrospective study examined 26 years of experience in a pediatric institution (1981-2007) in pain management as long as 6 months after limb-sparing surgery and reviewed the historical evolution of pain interventions. One hundred fifty patients underwent 151 limb-salvage surgeries for bone cancer of the extremities in this series. Pain treatment increased progressively in complexity. Therapies included opioids, nonsteroidal antiinflammatory drugs, acetaminophen-opioid combinations, postoperative continuous epidural infusion, anticonvulsants and tricyclic antidepressants for neuropathic pain, local anesthetic wound catheters, and continuous peripheral nerve block catheters. Management of pain after limb-sparing surgery has evolved over the 26 years of this review. It currently relies on multiple "layers" of pharmacologic and nonpharmacologic strategies to address the complex mixed nociceptive and neuropathic mechanisms of pain in this patient population.

Adding regional analgesia to general anaesthesia: increase of risk or improved outcome?

Although it is clear that regional analgesia in association with general anaesthesia substantially reduces postoperative pain, the benefits in terms of overall perioperative outcome are less evident. The aim of this nonsystematic review was to evaluate the effect on middle and long-term postoperative outcomes of adding regional perioperative analgesia to general anaesthesia. This study is based mostly on systematic reviews, large epidemiological studies and large or high-quality randomized controlled trials that were selected and evaluated by the author. The endpoints that are discussed are perioperative morbidity, cancer recurrence, chronic postoperative pain, postoperative rehabilitation and risk of neurologic damage. Epidural analgesia may have a favourable but very small effect on perioperative morbidity. The influence of other regional anaesthetic techniques on perioperative morbidity is unclear. Preliminary data suggest that regional analgesia might reduce the incidence of cancer recurrence. However, adequately powered randomized controlled trials are lacking. The sparse literature available suggests that regional analgesia may prevent the development of chronic postoperative pain. Rehabilitation in the immediate postoperative period is possibly improved, but the advantages in the long term remain unclear. Permanent neurological damage is extremely rare. In conclusion, while the risk of permanent neurologic damage remains extremely low, evidence suggests that regional analgesia may improve relevant outcomes in the long term. The effect size is mostly small or the number-needed-to-treat is high. However, considering the importance of the outcomes of interest, even minor improvement probably has substantial clinical relevance.

The quality of pain management in German hospitals

BACKGROUND

The Pain-Free Hospital Project was initiated in 2003 with the aim of improving pain management throughout Germany. We assessed the current state of pain management in German hospitals.

METHODS

From 2004 to 2006, data were obtained anonymously from 2252 patients who had undergone surgery, and 999 who had been treated non-surgically, in a total of 25 hospitals. They were interviewed about the intensity of pain they had experienced and about the effectiveness of its treatment.

RESULTS

No pain at all was reported by 12.4% of patients who had undergone surgery and by 16.7% of the non-surgically treated patients. Moderate to severe pain at rest was reported by 29.5% of the surgical group and 36.8% of the non-surgical group. More than 50% of the overall group reported pain on movement. 55% of the surgical group, and 57% of the non-surgical group, were dissatisfied with their pain management. Peak pain tended to occur outside normal working hours. No analgesic treatment at all was given to 39% of patients in the non-surgical group, even though they were in pain; the corresponding figure for the surgical group was 15% (a significant difference, p<0.001). Inadequately effective pain management was reported by 45.6% of patients in the non-surgical group and 29.6% in the operative group (again, a significant difference. Cancer patients were treated more often with potent opioids.

CONCLUSION

Severe postoperative pain is still too common among hospitalized patients, particularly pain that is induced by movement. Patients being treated on non-surgical wards also often suffer severe pain needlessly. Pain management seems to be worse for non-surgical patients (cancer patients excepted) than for surgical patients: waiting times for medication are longer, and ineffective medications are given more often. On the other hand, a number of hospitals provide positive examples of the potential effectiveness of pain management for both surgical and non-surgical patients.

Implementation of a standardized pain management in a pediatric surgery unit

Postoperative pain is still a major complication causing discomfort and significant suffering, especially for children. Therefore, every effort should be made to prevent pain and treat it effectively once it arises. Under-treatment of pediatric pain is often due to a lack of both knowledge about age-specific aspects of physiology and pharmacology and routine pain assessment. Factors for long term success require regularly assessing pain, as routinely as the other vital signs together with documentation of side effects. The fear of side effects mostly prevents the adequate usage of analgesics. Essential is selecting and establishing a simple concept for clinical routine involving a combination of non-pharmacological treatment strategies, non-opioid drugs, opioids and regional anesthesia.

[Interest of evaluation of professional practice for the improvement of the management of postoperative pain with patient controlled analgesia (PCA)]

OBJECTIVES

To evaluate the daily practice of postoperative PCA in Nancy University Hospital, in continuity with a quality program of postoperative pain (POP) care conducted in 2003.

TYPE OF STUDY

A retrospective audit of patient medical records.

MATERIAL AND METHODS

A review of all the medical records of consecutive surgical patients managed by PCA over a 5-week period in six surgical services. Criteria studied: Evaluation of hospital means (eight criteria) and of medical and nursing staff practice (16 criteria). A second audit was conducted 6 months after the implementation of quality improvement measures.

RESULTS

Assessment of the hospital means: temperature chart including pain scores and PCA drug consumption, patient information leaflet, PCA protocol, postoperative pre-filled prescription form (PFPF) for post-anaesthesia care including PCA, and optional training of nurses in postoperative pain management. EVALUATION OF PRACTICES: One hundred and fifty-nine files of a total of 176 patients were analyzed (88%). Improvements noted after 6 months: trace of POP evaluation progressed from 73 to 87%, advance prescription of PCA adjustment increased from 56 to 68% and of the treatment of adverse effects from 54 to 68%, trace of PCA adaptation by attending nurse from 15 to 43%, trace of the administration of the treatment of adverse effects by attending nurse from 24% to 64%, as did the use of PFPF from 59 to 70%.

CONCLUSIONS

The usefulness of a pre-filled prescription form for post-anaesthesia care including PCA prescription is demonstrated. Quality improvement measures include: poster information and pocket guides on PCA for nurses, training of 3 nurses per service to act as "PCA advisers" who will in turn train their ward colleagues in PCA management and the use of equipment until an acute pain team is established.

Epidural hematoma after neuraxial blockade: a retrospective report from China

We conducted a detailed 54-year retrospective review of patients who developed epidural hematoma after neuraxial blockade in a university hospital and throughout Mainland China. Incidence, risk factors, and outcomes in the Chinese population were identified. The incidence of epidural hematoma after neuraxial blockade was 2.14 of 100,000 (95% confidence interval: 0.44-6.25 of 100,000). Patients who had a bacterial infection and required emergency surgery were at increased risk of developing epidural hematoma. There is a significant correlation between good neurologic recovery and short interval to decompressive surgery.

Prevention of acute hematoma after face-lifts

Acute hematoma remains one of the most frequently encountered complications after face-lift surgery. Several risk factors inherent to the patient and omission of certain intraoperative regimens are considered to cause hematoma. Significant risk factors include high blood pressure and male gender. Possible intraoperative regimens for the prevention of hematoma include tumescence infiltration without adrenaline, clotting of raw surfaces with fibrin glue, usage of drains, and application of compression bandages. However, little attention has been paid to postoperative measures. To examine whether different regimens in the postoperative phase can influence the incidence of hematoma, all face-lift patients who underwent surgery by a single surgeon in two different clinics (n = 376) with two different postoperative regimens were evaluated over the course of 3 years. In group 1 (n = 308), all postoperative medication was administered on request including medication for pain control, blood pressure stabilization, and prevention of nausea and vomiting as well as postoperative restlessness and agitation. In group 2 (n = 68), this medication was administered prophylactically at the end of the operation before extubation. The hematoma rate was 7% in group 1 and 0% in group 2. This study showed that the prophylactic use of medications (e.g., analgesics, antihypertonics, antiemetics, and sedatives) during the postoperative phase is superior to making drugs available to patients on request and can decrease the occurrence of acute hematoma in face-lift patients.

Five-year experience of critical incidents associated with patient-controlled analgesia in an Irish University Hospital

BACKGROUND

Patient-controlled analgesia (PCA) is a common and effective means of managing post-operative pain. We sought to identify factors that may lead to critical incidents (CIs) in patient safety when using PCA in our institution.

METHODS

An observational study of prospectively collected data of patients who received PCA from 2002 to 2006 was performed. All CIs were documented and analysed by staff members of the acute pain service (APS). Cause analysis of CIs was undertaken to determine if measures can be instituted to prevent recurrence of similar events.

RESULTS

Over eight thousand patients (8,240) received PCA. Twenty-seven CIs were identified. Eighteen were due to programming errors. Other CIs included co-administration of opioids and oversedation.

CONCLUSION

In our institution, the largest contributory factor to CIs with PCAs was programming error. Strategies to minimize this problem include better education and surveillance.

Interscalene brachial plexus block for open-shoulder surgery: a randomized, double-blind, placebo-controlled trial between single-shot anesthesia and patient-controlled catheter system

INTRODUCTION

Interscalene brachial plexus block (ISB) is widely used as an adjuvant regional pain therapy in patients undergoing major shoulder surgery and has proved its effectiveness on postoperative pain reduction and opioid-sparing effect.

METHOD

This single-center, prospective, double-blind, randomized and placebo-controlled study was to compare the effectiveness of a single-shot and a patient-controlled catheter insertion ISB system after major open-shoulder surgeries. Seventy patients were entered to receive an ISB and a patient-controlled interscalene catheter. The catheter was inserted under ultrasound guidance. Patients were then assigned to receive one of two different postoperative infusions, either 0.2% ropivacaine (catheter group) or normal saline solution (single-shot group) via a disposable patient-controlled infusion pump.

RESULTS

The study variables were amount of rescue medication, pain at rest and during physiotherapy, patient satisfaction and incidence of unwanted side effects. The ropivacaine group revealed significantly less consumption of rescue medication within the first 24 h after surgery. Incidence of side effects did not differ between the two groups.

CONCLUSION

Based on our results, we recommend the use of interscalene plexus block in combination with a patient-controlled catheter system under ultrasound guidance only for the first 24 h after major open-shoulder surgery.

Complications in colorectal surgery: risk factors and preventive strategies

BACKGROUND

Open or laparoscopic colorectal surgery comprises of many different types of procedures for various diseases. Depending upon the operation and modifiable and non-modifiable risk factors the intra- and postoperative morbidity and mortality rate vary. In general, surgical complications can be divided into intraoperative and postoperative complications and usually occur while the patient is still in the hospital.

METHODS

A literature search (1980-2009) was carried out, using MEDLINE, PubMed and the Cochrane library.

RESULTS

This review provides an overview how to identify and minimize intra- and postoperative complications. The improvement of different treatment strategies and technical inventions in the recent decade has been enormous. This is mainly attributable to the increase in the laparoscopic approach, which is now well accepted for many procedures. Training of the surgeon, hospital volume and learning curves are becoming increasingly more important to maximize patient safety, surgeon expertise and cost effectiveness. In addition, standardization of perioperative care is essential to minimize postoperative complications.

CONCLUSION

This review summarizes the main perioperative complications of colorectal surgery and influencable and non-influencable risk factors which are important to the general surgeon and the relevant specialist as well. In order to minimize or even avoid complications it is crucial to know these risk factors and strategies to prevent, treat or reduce intra- and postoperative complications.

[Regional analgesia--risks and benefits]

BACKGROUND

Local anaesthetics may alleviate pain more effectively than any other anaesthetic method. In regional anaesthesia/analgesia, rare but serious complications make it necessary to always consider the risk-benefit ratio. The article discusses these issues and gives advice on effective and safe conduct.

MATERIAL AND METHODS

The article is based on non-systematic literature searches in the PubMed and Cochrane databases and our own experience from research and clinical work.

RESULTS

Regional anaesthesia is obtained by administering local anaesthetics near the spinal cord and nerve roots (spinal, epidural), spinal nerves (paravertebral), or close to peripheral nerves. Parts of the body will then become numb and paralysed. The same techniques are used for regional analgesia, but this is obtained by using more dilute solutions of local anaesthetics, and other analgesic drugs are often added. Pain impulses are inhibited, but sensation of touch and muscle functions are intact. Regional analgesia gives superior relief of pain provoked by movement. This facilitates early postoperative mobilization of patients, even after major surgery in weak patients. For these patients optimally performed regional analgesia may reduce postoperative morbidity and mortality better than general anaesthesia and opioid and non-opioid analgesics administered postoperatively. Infiltration of the wound with local anaesthetics followed by optimally dosed non-opioid and opioid analgesics is a good alternative for some types of surgery. The risk of spinal bleeding has increased due to increased patient age, routine thromboprophylaxis and frequent use of antihaemostatic drugs, including platelet inhibitors. Infections in the spinal cord are caused by insufficient hygiene. Selection of patients who are likely to benefit from regional anaesthesia/analgesia, strict hygienic precautions, optimal technique, close monitoring, and assistance from an acute pain team, as well as hospital protocols for handling rare but serious complications, have reduced the occurrence and consequences of serious complications.

INTERPRETATION

Optimal regional anaesthesia/analgesia may improve the postoperative result.

Intestinal effects of thoracic epidural anesthesia

PURPOSE OF REVIEW

Thoracic epidural anesthesia (TEA) is most frequently used after major surgery. However, despite ongoing research, the influence of TEA on the intestinal perioperative pathophysiology is not fully understood.

RECENT FINDINGS

According to recent results, the splanchnic sympathetic activity is reduced during TEA both in animal models and in clinical TEA. The splanchnic sympathetic activity during high TEA is still unknown. Intestinal perfusion effects of TEA are still unclear as the technique and extent of TEA, hemodynamic alteration and size of measurement result in--seemingly--conflicting reports. Postoperative ileus after laparotomy is ameliorated by TEA. Recent findings suggest beneficial effects also after major laparoscopic procedures. Finally, the impact of TEA on the intestinal pathophysiology in critical illness is an area of growing clinical and scientific interest, although this knowledge is just at its beginning.

SUMMARY

Further research concerning the use of TEA in major laparoscopic procedures and its potential to improve or endanger anastomotic healing is warranted. The experimental studies of TEA in critical illness should be expanded.

[Concepts for perioperative pain therapy. A critical stocktaking]

Despite numerous publications, new guidelines for the treatment of acute pain and efforts from a number of initiatives, there is still a tremendous need for improvement in postoperative pain therapy. One of the reasons for the shortcomings in the care of patients with postoperative pain is the lack of applicability of guidelines in daily clinical practice. Therefore, simple but effective and easy to implement concepts need to be developed. In the following review, different concepts that have been developed over recent years are presented and evaluated for their effectiveness. One of these is the notion of balanced analgesia, currently probably one of the most widely used perioperative therapy concepts. The idea of this concept is to reduce the doses of analgesics, e.g. opioids, through combinations of different classes of analgesics, thereby reducing their side effects. However, recent studies and essential meta-analyses indicate pitfalls using this concept. The pros and cons will be discussed and ideas on how to deal with balanced analgesia in daily practice will be given. Another pain concept of "procedure-specific postoperative pain therapy", is an appealing idea of an international initiative from surgeons and anaesthesiologists and an essential part of the German S3 guidelines for acute pain released last year. Critical evaluation of the available recommendations for procedure-specific analgesia together with the presentation of relatively simple but evidence-based algorithms for specific procedures may help to implement this concept in clinical routine.