Acute pain medicine in anesthesiology

The First Comprehensive Survey of the Practice of Postoperative Pain Management in Hungarian Hospitals - a Descriptive Study

BACKGROUND

Pain management is a key issue in health care. Providers adopt promising technological developments, like Acute Pain Service, at differing speeds, with countries, such as the USA and Germany taking the lead. Where Hungary stands is unknown, as the practice of pain management has not yet been comprehensively reviewed in that country.

AIM

To explore the practice of postoperative pain management in Hungarian hospitals by addressing the questions of who is responsible for it, who measures pain and how, what kind of pain relief technologies are used, and who takes care of patients during duty hours.

METHODS

We carried out a survey covering Hungarian hospitals with operational license for surgery, traumatology, orthopedics and anesthesiology between December 2019 and March 2020. The response rate was 72%, and we analyzed 135 questionnaires.

RESULTS

We identified only 2 hospitals with an Acute Pain Service. In the majority of hospitals, the attending physician orders pain relief therapy. During duty hours the surgeon on duty takes care of pain management in 52.1% of the cases. Among pain relief therapies, intravenous infusions (74.1%) and oral medication (67.4%) are the most frequent. Ward nurses measure postoperative pain (77.8%) with unidimensional scales. According to 59.7% of the respondents, pain is not measured and documented at rest. Written protocols are available in 34.4% of the departments.

CONCLUSIONS

Compared with other countries, pain management in Hungary lags behind with significant room for improvement. Development and implementation of pain management protocols with appropriate education is the key intervention point.

Are the Placement, Maintenance, and Removal of Femoral and Sciatic Catheters Associated With Bleeding Complications in Vascular Patients on Antithrombotics? A Single-Center, Retrospective Cohort Study

BACKGROUND

Information on the safety of placement, maintenance, and removal of peripheral nerve blocks in the presence of therapeutic or prophylactic antithrombotics is limited to case reports.

METHODS

In this retrospective, descriptive study, we examined the use of femoral and gluteal or subgluteal sciatic perineural catheters in 146 patients on antithrombotics who received lower limb amputation (LLA) above or below the knee at the University of Florida Health Shands Hospital between January 2015 and December 2019. We searched patient surgical records for complications such as bleeding, nerve damage, infection, and hematoma during placement, maintenance, and removal of the perineural catheters.

RESULTS

In this cohort of 146 patients on antithrombotics, there was 1 episode of hematoma with an estimated incidence of 1 of 146 (0.68%, 95% confidence interval [CI], 0.02-3.76). This patient developed a hematoma at the location of the femoral catheter and required a blood transfusion. This patient was on aspirin daily and subcutaneous heparin 3 times per day and had a normal coagulation profile during their hospital stay.

CONCLUSIONS

This report investigates bleeding complications of femoral and sciatic perineural catheters in patients undergoing LLA on antithrombotics. We found that, except for 1 patient, most patients on varying combinations of antithrombotics did not experience bleeding complications related to the femoral and sciatic perineural catheters.

Acute Pain Service in Hungarian hospitals

Background

Surgical procedures play an increasing role among health technologies to treat diseases. Pain often accompanies such diseases, both as a result of their pathology, but also as the side-effect of the intervention itself, and it is not only a burdensome subjective feeling, but adversely affects the recovery process, can induce complications and increases treatment costs. Acute Pain Service Teams are becoming increasingly widespread in hospitals to address post-operative pain, yet we have so far no data on how many hospitals have actually adopted this technology in Hungary.

Objectives

The main objectives of our study were to assess the prevalence of Acute Pain Service Teams, map their structure and operation, as well as to understand the barriers and conducive factors of their establishment in Hungarian hospitals.

Methods

We carried out a survey among the 72 hospitals with surgical departments. The questionnaire was filled in by 52 providers, which gave us a response rate of 72.2%.

Results

Our results show, that only two of the responding hospitals have Acute Pain Service Teams albeit their structure and operation are in line with the literature. In the 50 hospitals without such teams, financing difficulties and human resources shortages are mentioned to be the most important obstacles of their establishment, but the lack of initiative and interest on the part of the specialities concerned are also an important barrier.

Conclusions

Lagging behind the more affluent EU member states, but similarly to other Central and Eastern European countries, Acute Pain Service has been hardly adopted by Hungarian hospitals. Hungarian health professionals know the technology and would support its wider introduction, if the technical feasibility barriers could be overcome. Health policy should play a more active role to facilitate change in this area, the investment in which promises a substantial return in terms of health gains and cost savings.

Influence of infiltration anaesthesia on perioperative outcomes following lumbar discectomy under surgical pleth index-guided general anaesthesia: A preliminary report from a randomised controlled prospective trial

PURPOSE

Severe postoperative pain (SPP) may occur after lumbar discectomy. To prevent SPP and reduce rescue opioid consumption, infiltration anaesthesia (IA) has been combined with general anaesthesia (GA). This study verified how GA combined with IA facilitated intra- and postoperative demand for opioids and affected the incidence of SPP in patients subjected to open lumbar discectomy.

MATERIALS/METHODS

Ninety-nine patients undergoing lumbar discectomy under GA with Surgical Pleth Index (SPI)-guided fentanyl (FNT) administration were randomly assigned to receive IA combined with either 0.2% bupivacaine (BPV) or 0.2% ropivacaine (RPV) with FNT 50 μg and compared with controls (BF, RF, and C groups, respectively).

RESULTS

Ninety-four patients were included in the final analysis. Adjusted according to SPI, total intraoperative FNT dosages did not differ between the study groups (p = 0.23). The proportion of patients who reported SPP was the highest in group C (41.9%) than in the RF (12.9%) and BF groups (31.3%) (p < 0.05). Mild pain was experienced by 67.7%, 53.1% and 32.3% of patients from the RF, BF and C groups, respectively (p < 0.01). Morphine requirement was the highest in the control group (7.1 ± 5.9 mg), followed by the RF (2.7 ± 5.3 mg) and BF groups (4 ± 4.9 mg) (p < 0.05).

CONCLUSIONS

IA using RPV/FNT mixture significantly reduced SPP and postoperative demand for morphine in patients subjected to lumbar discectomy under GA.

Managing epidural catheters in critical care beds: An observation analysis in the Republic of Ireland

In certain hospitals, epidural analgesia is restricted to critical care beds. Due to critical care bed strain, it is likely that many patients are unable to avail of epidural analgesia. The aims of the study were to retrospectively review the number of patients admitted to critical care beds for epidural analgesia over a two-year period 2015–16, to determine the duration of epidural analgesia, to identify the average critical care bed occupancy during this period, to get updated information on the implementation of acute pain service in the Republic of Ireland and the availability of ward-based epidural analgesia. One hundred and sixty patients had a midline laparotomy, 40 of which had an epidural (25%). Forty-two patients were admitted to a critical care bed for epidural analgesia. Aside from epidural analgesia, 12% had other indications for ICU admission. Median duration epidural analgesia was 1.64 days (IQR 0.98–2.14 days). ICU bed occupancy rates were 88.7% in 2015 and 85.1% in 2016. Acute pain service and ward-based epidural analgesia were available in 46 and 42% of hospitals, respectively. Restricting epidural use to a critical care setting is likely to result in reduced access to epidural analgesia. The implementation of acute pain service and availability of ward-based epidural analgesia in the Republic of Ireland are suboptimal.

Economic Considerations of Acute Pain Medicine Programs

Acute pain medicine services influence many different aspects of postoperative recovery and function. Here, we discuss the various stakeholders of an acute pain medicine service, review the direct and indirect impact on said stakeholders, review the shared and competing interests between acute pain medicine programs and various payer systems, and discuss how APM services can help service lines align with the interests of the recent CMS Innovations Comprehensive Care for Joint Replacement Model.

Comparison of Bupivacaine Plus Magnesium Sulfate and Ropivacaine Plus Magnesium Sulfate Infiltration for Postoperative Analgesia in Patients Undergoing Lumbar Laminectomy: A Randomized Double-blinded Study

Aim:

The objective of this study was to assess and compare the analgesic duration of local infiltration of bupivacaine plus magnesium sulfate and ropivacaine plus magnesium sulfate for postoperative analgesia in patients undergoing lumbar laminectomy.

Study Design:

A randomized, prospective, double-blinded single hospital, comparative study.

Methods:

Sixty adult patients of the American Society of Anesthesiologists physical Status I and II were randomly allocated into two Groups BM and RM, comprising 30 and 31 patients. Postlumbar laminectomy, the study drug was locally infiltrated into the paravertebral muscles on either side before skin closure. Group BM was given 20 ml of 0.25% bupivacaine combined with 500 mg of magnesium sulfate (constituted with normal saline [NS]), and Group RM was given 20 ml of 0.25% ropivacaine combined with 500 mg of magnesium sulfate (constituted with NS). Postoperative visual analog scale pain score was assessed hourly for the first 24 h postoperatively. Duration of postoperative analgesia, rescue analgesia consumption and side effects were also recorded.

Statistical Analysis:

Comparison of data between the groups was done with SPSS 21.0© using independent t-test, Chi-square test, and Mann–Whitney U-test accordingly. P<0.05 was considered statistically significant.

Results:

Time to first analgesic consumption was significantly longer in Group BM (7.3 ± 0.46 h) compared to Group RM (6.6 ± 0.69 h) (P < 0.05). The consumption of nalbuphine rescue analgesic was significantly higher in Group RM (15.33 ± 5.07 mg) compared to Group BM (12 ± 4.07 mg) (P < 0.05).

Conclusion:

Wound infiltration with bupivacaine and magnesium sulfate compared to ropivacaine and magnesium sulfate provided longer duration of postoperative analgesia and significantly reduced postoperative opioid consumption in patients undergoing lumbar laminectomy.

Toward Better Pain Management: The Development of a "Pain Stewardship Program" in a Tertiary Children's Hospital

OBJECTIVE

Despite increased focus on pediatric pain, uncontrolled pain is still a problem for hospitalized pediatric inpatients. A program was designed to find patients with uncontrolled pain and develop a framework to oversee their pain management. This report details the development of a pain stewardship program with data from the first year of its activity.

METHODS

Hospitalized inpatients in a tertiary care pediatric center in the mid-Atlantic region were included in the study. Pain scores are recorded every 4 hours in the hospital electronic health record. A report was constructed to find all patients with an average pain score ≥7 in the preceding 12 hours. The charts of these patients were reviewed by our anesthesia pain service, and all patients were grouped into 1 of the following action categories: (1) no action required; (2) telephone call to the patient's attending physician; (3) one-time consultation; (4) consultation with ongoing management; or (5) patient was already on the anesthesia pain service. Demographic data, pain regimens, and outcomes were recorded in a prospectively collected database.

RESULTS

There were 843 records on 441 unique patients. Only 22% required action to be taken by the anesthesia pain service. The pain stewardship database revealed that patients with sickle cell disease or abdominal pain required more frequent attention.

CONCLUSIONS

An electronic health record-based pain stewardship program is an important step in identifying all children in the hospital with undermanaged pain, and it provides a warning system that may improve patient care, outcomes, and satisfaction.

Acute Pain Management/Regional Anesthesia

Effective and efficient acute pain management strategies have the potential to improve medical outcomes, enhance patient satisfaction, and reduce costs. Pain management records are having an increasing influence on patient choice of health care providers and will affect future financial reimbursement. Dedicated acute pain and regional anesthesia services are invaluable in improving acute pain management. In addition, nonpharmacologic and alternative therapies, as well as information technology, should be viewed as complimentary to traditional pharmacologic treatments commonly used in the management of acute pain. The use of innovative technologies to improve acute pain management may be worthwhile for health care institutions.

Which outcomes related to regional anesthesia are most important for orthopedic surgery patients?

An increasing body of evidence supports the benefits of regional anesthesia in orthopedic surgery. Compared with systemic anesthetic and analgesic approaches, these benefits include more focused and sustained pain control, less systemic side effects, improved patient comfort, earlier mobilization and hospital discharge, lower rates of advanced service requirements, and lower perioperative morbidity and mortality. However, there is discussion about the various outcomes as judged by patients and heath care practitioners. This article recapitulates the literature and presents an overview of endpoints.