Current practices for postoperative pain management in Europe and the potential role of the fentanyl HCl iontophoretic transdermal system

Postoperative analgesia by adding acupuncture to conventional therapy, a non-randomized controlled trial

Background Postoperative pain is common in patients hospitalized in surgical departments, yet it is currently not sufficiently controlled by analgesics. Acupuncture, a complementary medical practice, has been evaluated for its benefits in postoperative pain with heterogeneous results. We tested the feasibility of a controlled study comparing the postoperative analgesic effect of acupuncture together with standard-of-care to standard-of-care only. Methods In this pilot non-randomized controlled study conducted at a tertiary medical center in Israel, patients received either acupuncture with standard-of-care pain treatment (acupuncture group) or standard-of-care treatment only (control group) following surgery. Visual Analogue Scale (VAS) ratings for pain level at rest and in motion were evaluated both at recruitment and two hours after treatment. Acupuncture-related side effects were reported as well. Results We recruited 425 patients; 336 were assigned to the acupuncture group and 89 to the control group. The acupuncture group exhibited a decrease of at least 40% in average level of pain both at rest (1.8±2.4, p<0.0001) and in motion (2.1±2.8, p<0.0001) following acupuncture, whereas the control group exhibited no significant decrease (p=0.92 at rest, p=0.98 in motion). Acupuncture's analgesic effect was even more prominent in reducing moderate to severe pain at baseline (VAS ≥4), with a decrease of 49% and 45% of pain level at rest and in motion respectively (p<0.001), compared with no significant amelioration in the control group (p=0.20 at rest, p=0.12 in motion). No major side effects were reported. Conclusion Integrating acupuncture with standard care may improve pain control in the postoperative setting.

Recent advances in the pharmaceutical management of pain

Pain is an unpleasant sensory and emotional experience for patients. Management of pain is the most frequent issue encountered by clinicians and treatment is usually with pharmacological therapy. This review discusses recent pharmaceutical advances in pain management with respect to new modes of analgesic delivery, as well as new analgesic agents and adjuvants that are currently being investigated for their analgesic properties. New modes of administration include transdermal delivery in the form of skin patches, transmucosal delivery, inhalational administration, various patient-controlled devices and extended-release analgesic formulations. Up-to-date research is presented on classical analgesics, such as opioids, anti-inflammatory agents, including cyclo-oxygenase-2 inhibitors and paracetamol (acetaminophen), local anesthetics and ketamine. In addition, newer agents such as antidepressants and antiepileptic drugs as well as medicinal cannabinoids are discussed. As our understanding of the multiple pain pathways involved in the pathogenesis of pain expands, further compounds with analgesic properties will be developed.

The Postoperative Recovery Profile (PRP) - a multidimensional questionnaire for evaluation of recovery profiles

AIMS AND OBJECTIVES

The previously developed Postoperative Recovery Profile (PRP) questionnaire is intended for self-assessment of general recovery after surgery. The aim of this study was to further evaluate the questionnaire regarding the construct validity and ability to discriminate recovery profiles between groups. Furthermore, the item variables of greatest importance during the progress of recovery were investigated.

METHODS

Post-operative recovery was assessed during the period from discharge to 12 months after lower abdominal and orthopaedic surgery. Construct validity was evaluated by comparing the assessments from the PRP questionnaire and a global recovery scale. Recovery profiles of the diagnose groups were displayed by the cumulative proportion recovered participants over time. The importance of item variables was investigated by ranking ordering.

RESULTS

A total of 158 patients were included. Support was given for good construct validity. The result showed that 7.6% of all possible pairs were disordered when comparing the assessments from the PRP questionnaire and the global recovery scale. Twelve months after discharge the PRP assessments discriminated significantly the recovery profiles of the abdominal and orthopaedic groups. The variable pain was one of the top five most important issues at each follow-up occasion in both study groups. The importance of the item variables was thereby emphasized.

CONCLUSIONS

The PRP questionnaire allows for evaluation of the progress of post-operative recovery, and can be useful to assess patient-reported recovery after surgical treatment both on individual and group levels. Knowledge about recovery profiles can assist clinicians in determining the critical time points for measuring change.

Improvements and difficulties in postoperative pain management

BACKGROUND

This review examines postoperative pain (POP) management from the perspectives of healthcare providers, patients, and institutions. It summarizes current thought about POP, including difficulties and recent improvements in the field.

METHODS

Studies were identified from PubMed, MEDLINE, and the search engine Google Scholar and by hand-searching reference lists from review articles and research papers (1998-2009). The search was limited to articles published in the English language. Given the broad review of POP, a complete review of all the potential articles was not possible. Thus, an inclusion criterion was defined, and we retrieved only those studies that included the term postoperative pain treatment, together with 1 or more of the following terms: adult patients, education, interdisciplinary teams, attitudes, physicians, and nurses. Two hundred twenty studies were retrieved, and 93 studies were sufficiently close to the topic of this review. They were organized according to the following themes: POP management as it relates to healthcare providers, patients, and institutions; changing trends in healthcare education in relation to various POP interventions; and the role of policy makers concerning improvements and challenges in the management of POP.

RESULTS

Interdisciplinary teams are needed to implement multimodal methods to treat POP in ways that will provide patients with interventions that will improve their ability to cope with the physical and psychosocial aspects of POP. This is hindered by a lack of hospital financial resources, a lack of educational programs, a lack of knowledge regarding diverse pharmacological options, and lingering negative attitudes toward certain treatments, especially opioids.

CONCLUSIONS

Successful POP management depends on providers' receiving education and information. Policy makers and organizations are called upon to actively intervene by formulating programs and promoting a feedback system, or else POP will remain a neglected issue.

[New substances and applications for postoperative pain therapy]

The onset of postoperative pain is the result of various pathophysiological mechanisms and depends on the type of surgery performed. Therefore, any adequate postoperative pain treatment requires multimodal and procedure-specific analgesia. In addition to reducing perioperative complications and improving patient comfort, optimal postoperative pain management also represents an important quality characteristic which can influence the patient in their choice of hospital. In the past 1-2 years, known groups of substances have been rediscovered for postoperative pain therapy (e.g., Gabapentin and Pregabalin, i.v. Lidocaine, Ketamine or glucocorticoids), while new substances (coxibe, oral oxycodone+naloxone) and applications have been developed. The present overview article discusses the advantages and disadvantages of these substances and analgesic methods, as well as their specific areas of application.

A survey of postoperative epidural and intravenous analgesia in Greece

BACKGROUND AND OBJECTIVE

Epidural and intravenous analgesia are widely used for postoperative pain management. Efficacy and safety is enhanced with the establishment of acute pain services. We studied the terms of application of these techniques in Greek hospitals and compared practices between anaesthetic departments with or without acute pain services.

METHODS

We performed a postal survey regarding departmental policy on the application of epidural and intravenous analgesia, patient monitoring, audit and educational activities, acute pain service teams and proposals for improvement. Pain services were classified according to predetermined quality criteria. Hospitals with or without acute pain services were compared.

RESULTS

Response rate was 46.3% (51 of 110 departments). Epidural analgesia was used in 49 departments, equally applied as intermittent boluses or continuous infusion. Twenty-two of the 39 departments that were using continuous infusion, used exclusively a lumbar approach. Intravenous analgesia was used by 42 (82%) departments; 13 used exclusively continuous infusion. All eight departments that had an established acute pain service fulfilled the predefined quality criteria compared with only ten of the remaining 43 (P < 0.001).

CONCLUSION

Our study discloses important issues regarding the use of intravenous and epidural analgesia and postoperative patient monitoring in Greek hospitals. Implementation of acute pain services that are satisfying the quality criteria may help to improve patient care.