[Implementation of a standardized perioperative pain management concept in three hospitals of a consortium]

The effectiveness of an oral opioid rescue medication algorithm for postoperative pain management compared to PCIA : A cohort analysis

Background

Standard protocols or algorithms are considered essential to ensure adequate analgesia. Germany has widely adopted postoperative protocols for pain management including oral opioids for rescue medication, but the effectiveness of such protocols has only been evaluated longitudinally in a before and after setting. The aim of this cohort analysis was to compare the effectiveness of an oral opioid rescue medication algorithm for postoperative management of pain to the gold standard of patient-controlled intravenous analgesia (PCIA).

Material and methods

This study compared cohorts of patients of two prospective observational studies undergoing elective total hip replacement. After surgery patients received piritramide to achieve a pain score of ≤3 on the numeric rating scale (NRS 0–10). A protocol was started consisting of oral long-acting oxycodone and ibuprofen (basic analgesia). Cohort 1 (C1, 126 patients) additionally received an oral opioid rescue medication (hydromorphone) when reporting pain >3 on the NRS. Cohort 2 (C2, 88 patients) was provided with an opioid by PCIA (piritramide) for opioid rescue medication. Primary endpoints were pain intensity at rest, during movement, and maximum pain intensity within the first 24 h postoperative. Secondary endpoints were opioid consumption, functional outcome and patient satisfaction with pain management.

Results

Pain during movement and maximum pain intensity were higher in C1 compared to C2: pain on movement median 1st–3rd quartile: 6 (3.75–8) vs. 5 (3–7), p = 0.023; maximum pain intensity: 7 (5–9) vs. 5 (3–8), p = 0.008. There were no differences in pain intensity at rest or between women and men in either group. The mean opioid consumption in all patients (combined PACU, baseline, and rescue medication; mean ± SD mg ME) was 126.6 ± 51.8 mg oral ME (median 120 (87.47–154.25) mg ME). Total opioid consumption was lower in C1 than C2 (117 ± 46 mg vs 140 ± 56 mg, p = 0.002) due to differences in rescue opioids (C1: 57 ± 37 mg ME, C2: 73 ± 43 mg ME, p = 0.006, Z = −2.730). Basic analgesia opioid use was comparable (C1: 54 ± 31 mg ME, C2: 60 ± 36 mg ME, p = 0.288, Z = −1.063). There were no differences in respect to the addition of non-opioids and reported quality of mobilization, sleep, frequency of nausea and vomiting, or general satisfaction with pain management.

Conclusion

In this study PCIA provided a better reduction of pain intensity, when compared to a standardized protocol with oral opioid rescue medication. This effect was associated with increased opioid consumption. There were no differences in frequencies of opioid side effects. This study was a retrospective analysis of two cohorts of a major project. As with all retrospective studies, our analysis has several limitations to consider. Data can only represent the observation of clinical practice. It cannot reflect the quality of a statement of a randomized controlled trial. Observational studies do not permit conclusions on causal relationships.

[Standardized treatment protocols in acute postoperative pain therapy: analysis of contents of standardized medicinal concepts]

BACKGROUND

Standardized treatment approaches can improve the quality of the management of acute postoperative pain.

AIM

The purpose of this study was to describe the content and structure of currently implemented standards for the management of acute postoperative pain in German hospitals and to better define the concept of a treatment standard for acute pain.

MATERIAL AND METHODS

Written standardized treatment protocols from 68 hospitals for the management of acute postoperative pain were analyzed. The evaluation was based on the layout of processes, the baseline and rescue or on-demand analgesic medication and safety mechanisms.

RESULTS

A treatment standard per hospital separated for adults (68 standards) and children (27 standards) was identified and analyzed. A baseline medication was provided in all standards for adults and in 89% for children. Of the 95 standards 68% routinely combined opioids and non-opioids as a basis (78% for adults and 42% for children). A way to adapt the baseline medication was described more often in standards for adults. Of the standards for adults 91% (85% for children) contained provisions for rescue or on-demand analgesia and half of them (both adults and children) included an immediate-release opioid formulation, which was readily available. For adults the availability was regulated by a predefined process in 29% of the standards (8% for children). In cases of persisting pain, repetition of the rescue medication was generally possible in 63% of adult standards (54% for children) but within 1 h after the first dose in only 43% (30% for children). Intervention limitations for application of the rescue medication (e.g., a defined score on the numeric rating scale) were set in 63% of adult standards (54% for children). A follow-up assessment of the pain intensity after a rescue medication was only required in approximately half of the standards and safety information or mechanisms were only rarely included.

CONCLUSION

Content, structure and type of the evaluated treatment standards showed a considerable heterogeneity with respect to the availability of rescue and baseline medication. Safety aspects were not addressed in many cases. These findings show that despite the requirements of the German guidelines for treatment of perioperative and posttraumatic pain for treatment standards, there are still no practical recommendations with respect to contents and structure of such standards.

Opioid analgesia for acute abdominal pain in children: A systematic review and meta-analysis

OBJECTIVES

There are long-held concerns that analgesia in patients with acute abdominal pain may obscure the physical examination and lead to missing a diagnosis of appendicitis. Despite evidence to the contrary, analgesia continues to be underutilized and suboptimally dosed in children with acute abdominal pain. The objective of this systematic review and meta-analysis was to determine if opioids provide analgesia without an increase in side effects and appendicitis-related complications.

METHODS

Trials were identified through electronic searches of MEDLINE (1946-2013), EMBASE (1980-2013), Cochrane Central Register of Controlled Trials (2013), CINAHL (1981-2013), and Google Scholar (2013). All randomized controlled trials (RCTs) of children aged 0-18 years with acute abdominal pain that compared any opioid analgesic to placebo were included. The methodologic qualities of studies and the overall quality of evidence were evaluated using the Cochrane Collaboration's Risk of Bias tool and the Grading of Recommendations Assessment, Development, and Evaluation system, respectively.

RESULTS

Six RCTs met inclusion criteria, and each compared a single-dose parenteral opioid to a placebo, providing data on 342 children aged 5 to 18 years. The pooled mean pre/post difference in self-reported pain scores was 19.61 mm (95% confidence interval [CI] = -1.16 to 40.37 mm) lower in those receiving opioid analgesia. There was no significant increase in the risk of perforation or abscess associated with opioids in cases of appendicitis (relative risk [RR] = 1.03, 95% CI = 0.55 to 1.93). The risk of side effects was significantly greater in patients who received opioids (RR = 6.06, 95% CI = 1.10 to 33.49). Subtherapeutic dosing of opioids was detected in all six trials.

CONCLUSIONS

The use of opioids in undifferentiated acute abdominal pain in children is associated with no difference in pain scores and an increased risk of mild side effects. However, there is no increased risk of perforation or abscess. The overall quality of evidence is low, suggesting the need for larger, high-quality trials that are powered to detect both serious complications of appendicitis and determine the most efficacious opioid dosing for children.

[Organization of pediatric pain management: Austrian interdisciplinary recommendations for pediatric perioperative pain management]

BACKGROUND

Postoperative pain management is still in need of vast improvement, especially for children. The aim of this article is to demonstrate which structures and processes must be optimized to ultimately improve patient satisfaction and safety.

RESPONSIBILITIES

Basic prerequisites are among others personnel continuity and good cooperation in a multiprofessional team. A clear assignment of responsibilities is also of essential importance.

PATIENT HISTORY AND INFORMED CONSENT

On admission every patient should be questioned on the currently existing pain. Patients or the parents must be informed about the pain therapy in a comprehensible manner. Possible complications, chances of success, advantages and disadvantages of the planned procedure and alternative forms of treatment must be discussed.

IMPLEMENTATION

The implementation needs a great deal of consideration. The introduction of clearly defined pathways and thorough schooling contribute more to successful pain management than the establishment of pain measurement or the use of special techniques alone.

EVALUATION AND DOCUMENTATION

Because pain intensity can only be described indirectly it is difficult to assess in children. Assessment is made by another person until children are 5 years old. The gold standard in pain measurement is, however, self-estimation using appropriate scales which is possible for older children. The routinely carried out representation of pain values and prompt documentation of all pain therapeutic measures are indispensible for the control and optimization of pain therapy.

QUALITY OF RESULTS

Whether improvements in acute pediatric pain therapy will actually be achieved can only be realized by standardized compilation and analysis of the quality of therapy. For this purpose QUIPSInfant was developed.

Treatment of acute abdominal pain in the emergency room: a systematic review of the literature

Appropriate pain therapy prior to diagnosis in patients with acute abdominal pain remains controversial. Several recent studies have demonstrated that pain therapy does not negatively influence either the diagnosis or subsequent treatment of these patients; however, current practice patterns continue to favour withholding pain medication prior to diagnosis and surgical treatment decision. A systematic review of PubMed, Web-of-Science and The-Cochrane-Library from 1929 to 2011 was carried out using the key words of 'acute', 'abdomen', 'pain', 'emergency' as well as different pain drugs in use, revealed 84 papers. The results of the literature review were incorporated into six sections to describe management of acute abdominal pain: (1) Physiology of Pain; (2) Common Aetiologies of Abdominal Pain; (3) Pre-diagnostic Analgesia; (4) Pain Therapy for Acute Abdominal Pain; (5) Analgesia for Acute Abdominal Pain in Special Patient Populations; and (6) Ethical and Medico-legal Considerations in Current Analgesia Practices. A comprehensive algorithm for analgesia for acute abdominal pain in the general adult population was developed. A review of the literature of common aetiologies and management of acute abdominal pain in the general adult population and special patient populations seen in the emergency room revealed that intravenous administration of paracetamol, dipyrone or piritramide are currently the analgesics of choice in this clinical setting. Combinations of non-opioids and opioids should be administered in patients with moderate, severe or extreme pain, adjusting the treatment on the basis of repeated pain assessment, which improves overall pain management.

[Quality management in acute pain therapy: results from a survey of certified hospitals]

AIM

Systems for and methods of quality management are increasingly being implemented in public health services. The aim of our study was to analyze the current state of the integrated quality management concept "quality management acute pain therapy" of the TÜV Rheinland® (TÜV) after a 5-year project period.

MATERIAL AND METHODS

General characteristics of the participating hospitals, number of departments certified by the TÜV and implementation of structures and processes according to the TÜV guidelines were evaluated by a mail questionnaire. Furthermore, positive and negative aspects concerning the effects of certification were evaluated by the hospitals' representatives of certification.

RESULTS

A total of 36 questionnaires were returned. Since 2006 the number of certified hospitals (2011: n = 48) and surgical departments (2011: n = 202) has increased continuously. The number of certified medical departments is low (2011: n = 39); however, in the last 3 years, it has increased by about 200-300% annually. Standard operative procedures for pain therapy and measurement of pain intensity at regular intervals were implemented in all certified clinics (100%). Although 41% take part in the benchmarking project QUIPS (Quality Improvement in Postoperative Pain Therapy), 24% do not systematically check the quality of the outcome of pain management. Acceptance of the new pain therapy concepts among nursing staff was rated positively (ratio positive:negative 16:1); however, acceptance among physicians was rated negatively (1:15).

CONCLUSION

Certification by the TÜV leads to sustainable implementation of quality management principles. Future efforts should focus on better integration of physicians in acute pain therapy and the development of an integrated tool to measure patients' outcome.

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.