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Coccolini F, Corradi F, Sartelli M, Coimbra R, Kryvoruchko IA, Leppaniemi A, Doklestic K, Bignami E, Biancofiore G, Bala M, Marco C, Damaskos D, Biffl WL, Fugazzola P, Santonastaso D, Agnoletti V, Sbarbaro C, Nacoti M, Hardcastle TC, Mariani D, De Simone B, Tolonen M, Ball C, Podda M, Di Carlo I, Di Saverio S, Navsaria P, Bonavina L, Abu-Zidan F, Soreide K, Fraga GP, Carvalho VH, Batista SF, Hecker A, Cucchetti A, Ercolani G, Tartaglia D, Galante JM, Wani I, Kurihara H, Tan E, Litvin A, Melotti RM, Sganga G, Zoro T, Isirdi A, De'Angelis N, Weber DG, Hodonou AM, tenBroek R, Parini D, Khan J, Sbrana G, Coniglio C, Giarratano A, Gratarola A, Zaghi C, Romeo O, Kelly M, Forfori F, Chiarugi M, Moore EE, Catena F, Malbrain MLNG. Postoperative pain management in non-traumatic emergency general surgery: WSES-GAIS-SIAARTI-AAST guidelines. World J Emerg Surg 2022; 17:50. [PMID: 36131311 PMCID: PMC9494880 DOI: 10.1186/s13017-022-00455-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/16/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Non-traumatic emergency general surgery involves a heterogeneous population that may present with several underlying diseases. Timeous emergency surgical treatment should be supplemented with high-quality perioperative care, ideally performed by multidisciplinary teams trained to identify and handle complex postoperative courses. Uncontrolled or poorly controlled acute postoperative pain may result in significant complications. While pain management after elective surgery has been standardized in perioperative pathways, the traditional perioperative treatment of patients undergoing emergency surgery is often a haphazard practice. The present recommended pain management guidelines are for pain management after non-traumatic emergency surgical intervention. It is meant to provide clinicians a list of indications to prescribe the optimal analgesics even in the absence of a multidisciplinary pain team. MATERIAL AND METHODS An international expert panel discussed the different issues in subsequent rounds. Four international recognized scientific societies: World Society of Emergency Surgery (WSES), Global Alliance for Infection in Surgery (GAIS), Italian Society of Anesthesia, Analgesia Intensive Care (SIAARTI), and American Association for the Surgery of Trauma (AAST), endorsed the project and approved the final manuscript. CONCLUSION Dealing with acute postoperative pain in the emergency abdominal surgery setting is complex, requires special attention, and should be multidisciplinary. Several tools are available, and their combination is mandatory whenever is possible. Analgesic approach to the various situations and conditions should be patient based and tailored according to procedure, pathology, age, response, and available expertise. A better understanding of the patho-mechanisms of postoperative pain for short- and long-term outcomes is necessary to improve prophylactic and treatment strategies.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124, Pisa, Italy.
| | | | | | - Raul Coimbra
- Trauma Surgery Department, Riverside University Health System Medical Center, Loma Linda, CA, USA
| | - Igor A Kryvoruchko
- Department of Surgery No2, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Ari Leppaniemi
- General Surgery Department, Helsinki University Hospital, Helsinki, Finland
| | - Krstina Doklestic
- Clinic of Emergency Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Elena Bignami
- ICU Department, Parma University Hospital, Parma, Italy
| | | | - Miklosh Bala
- Trauma and Acute Care Surgery Unit Hadassah, Hebrew University Medical Center, Jerusalem, Israel
| | - Ceresoli Marco
- General Surgery Department, Monza University Hospital, Monza, Italy
| | - Dimitris Damaskos
- General and Emergency Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Walt L Biffl
- Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Paola Fugazzola
- General Surgery Department, Pavia University Hospital, Pavia, Italy
| | | | | | | | - Mirco Nacoti
- ICU Department Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Timothy C Hardcastle
- Trauma and Burn Service, Inkosi Albert Luthuli Central Hospital, Mayville, Durban, South Africa
| | - Diego Mariani
- General Surgery Department, Legnano Hospital, Legnano, Milano, Italy
| | - Belinda De Simone
- Emergency and Colorectal Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy, France
| | - Matti Tolonen
- Emergency Surgery, HUS Helsinki University Hospital, Meilahti Tower Hospital, Helsinki, Finland
| | - Chad Ball
- Trauma and Acute Care Surgery, Foothills Medical Center, Calgary, AB, Canada
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | | | - Salomone Di Saverio
- General Surgery Department, San Benedetto del Tronto Hospital, San Benedetto del Tronto, Italy
| | - Pradeep Navsaria
- Trauma Center, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Luigi Bonavina
- General Surgery Department, San Donato Hospital, Milan, Italy
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, University of Bergen, Bergen, Norway
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | | | | | - Andreas Hecker
- General Surgery, Giessen University Hospital, Giessen, Germany
| | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences - DIMEC, Alma Mater Studiorum - University of Bologna, General Surgery of the Morgagni - Pierantoni Hospital, Forlì, Italy
| | - Giorgio Ercolani
- Department of Medical and Surgical Sciences - DIMEC, Alma Mater Studiorum - University of Bologna, General Surgery of the Morgagni - Pierantoni Hospital, Forlì, Italy
| | - Dario Tartaglia
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124, Pisa, Italy
| | - Joseph M Galante
- General Surgery Department, UCLA Davis University Hospital, Los Angeles, CA, USA
| | - Imtiaz Wani
- General Surgery Department, Government Gousiua Hospital, Srinagar, India
| | - Hayato Kurihara
- Emergency and Trauma Surgery Department, Milano University Hospital, Milan, Italy
| | - Edward Tan
- Emergency Department, Nijmegen Hospital, Nijmegen, The Netherlands
| | - Andrey Litvin
- Department of Surgical Disciplines, Immanuel Kant Baltic Federal University, Regional Clinical Hospital, Kaliningrad, Russia
| | | | - Gabriele Sganga
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Tamara Zoro
- ICU Department, Pisa University Hospital, Pisa, Italy
| | | | - Nicola De'Angelis
- Service de Chirurgie Digestive Et Hépato-Bilio-Pancréatique, Hôpital Henri Mondor, Université Paris Est, Créteil, France
| | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Adrien M Hodonou
- Faculty of Medicine of Parakou, University of Parakou, Parakou, Benin
| | - Richard tenBroek
- General Surgery Department, Nijmegen Hospital, Nijmegen, The Netherlands
| | - Dario Parini
- General Surgery Department, Santa Maria Della Misericordia Hospital, Rovigo, Italy
| | - Jim Khan
- University of Portsmouth, Portsmouth Hospitals University NHS Trust UK, Portsmouth, UK
| | | | | | | | | | - Claudia Zaghi
- General, Emergency and Trauma Surgery Department, Vicenza Hospital, Vicenza, Italy
| | - Oreste Romeo
- Trauma and Surgical Critical Care, East Medical Center Drive, University of Michigan Health System, Ann Arbor, MI, USA
| | - Michael Kelly
- Department of General Surgery, Albury Hospital, Albury, Australia
| | | | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124, Pisa, Italy
| | | | - Fausto Catena
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Manu L N G Malbrain
- First Department Anaesthesiology Intensive Therapy, Medical University Lublin, Lublin, Poland.,International Fluid Academy, Lovenjoel, Belgium
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Salicath JH, Yeoh ECY, Bennett MH. Epidural analgesia versus patient-controlled intravenous analgesia for pain following intra-abdominal surgery in adults. Cochrane Database Syst Rev 2018; 8:CD010434. [PMID: 30161292 PMCID: PMC6513588 DOI: 10.1002/14651858.cd010434.pub2] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Intravenous patient-controlled analgesia (IVPCA) with opioids and epidural analgesia (EA) using either continuous epidural administration (CEA) or patient-controlled (PCEA) techniques are popular approaches for analgesia following intra-abdominal surgery. Despite several attempts to compare the risks and benefits, the optimal form of analgesia for these procedures remains the subject of debate. OBJECTIVES The objective of this review was to update and expand a previously published Cochrane Review on IVPCA versus CEA for pain after intra-abdominal surgery with the addition of the comparator PCEA. We have compared both forms of EA to IVPCA. Where appropriate we have performed subgroup analysis for CEA versus PCEA. SEARCH METHODS We searched the following electronic databases for relevant studies: Cochrane Central Register of Controlled Trials (CENTRAL) (2017; Issue 8), MEDLINE (OvidSP) (1966 to September 2017), and Embase (OvidSP) (1988 to September 2017) using a combination of MeSH and text words. We searched the following trial registries: Australian New Zealand Clinical Trials Registry, ClinicalTrials.gov, and the EU Clinical Trials Register in September 2017, together with reference checking and citation searching to identify additional studies.We included only randomized controlled trials and used no language restrictions. SELECTION CRITERIA We included all parallel and cross-over randomized controlled trials (RCTs) comparing CEA or PCEA (or both) with IVPCA for postoperative pain relief in adults following intra-abdominal surgery. DATA COLLECTION AND ANALYSIS Two review authors (JS and EY) independently identified studies for eligibility and performed data extraction using a data extraction form. In cases of disagreement (three occasions) a third review author (MB) was consulted. We appraised each included study to assess the risk of bias as outlined in Section 8.5 of the Cochrane Handbook for Systematic Reviews of Interventions. We used GRADE to assess the quality of the evidence. MAIN RESULTS We included 32 studies (1716 participants) in our review. There are 10 studies awaiting classification and one ongoing study. A total of 869 participants (51%) received EA and 847 (49%) received IVPCA. The EA trials included 16 trials with CEA (418 participants) and 16 trials with PCEA (451 participants). The studies included a broad range of surgical procedures (including hysterectomies, radical prostatectomies, Caesarean sections, colorectal and upper gastrointestinal procedures), a wide range of adult ages, and were performed in several different countries.Our pooled analyses suggested a benefit with regard to pain scores (using a visual analogue scale between 0 and 100) in favour of EA techniques at rest. The mean pain reduction at rest from waking to six hours after operation was 5.7 points (95% confidence interval (CI) 1.9 to 9.5; 7 trials, 384 participants; moderate-quality evidence). From seven to 24 hours, the mean pain reduction was 9.0 points (95% CI 4.6 to 13.4; 11 trials, 558 participants; moderate-quality evidence). From 24 hours the mean pain reduction was 5.1 points (95% CI 0.9 to 9.4; 7 trials, 393 participants; moderate-quality evidence). Due to high statistical heterogeneity, no pooled analysis was possible for the estimation of pain on movement at any time. Two single studies (one using CEA and one PCEA) reported lower pain scores with EA compared to IVPCA at 0 to 6 hours and 7 to 24 hours. At > 24 hours the results from 2 studies (both CEA) were conflicting.We found no difference in mortality between EA and IVPCA, although the only deaths reported were in the EA group (5/287, 1.7%). The risk ratio (RR) of death with EA compared to using IVPCA was 3.37 (95% CI 0.72 to 15.88; 9 trials, 560 participants; low-quality evidence).A single study suggested that the use of EA may result in fewer episodes of respiratory depression, with an RR of 0.47 (95% CI 0.04 to 5.69; 1 trial; low-quality evidence). The successful placement of an epidural catheter can be technically challenging. The improvements in pain scores above were accompanied by an increase in the risk of failure of the analgesic technique with EA (RR 2.48, 95% CI 1.13 to 5.45; 10 trials, 678 participants; moderate-quality evidence); the occurrence of pruritus (RR 2.36, 95% CI 1.67 to 3.35; 8 trials, 492 participants; moderate-quality evidence); and episodes of hypotension requiring intervention (RR 7.13, 95% CI 2.87 to 17.75; 6 trials, 479 participants; moderate-quality evidence). There was no clear evidence of an advantage of one technique over another for other adverse effects considered in this review (Venous thromboembolism with EA (RR 0.32, 95% CI 0.03 to 2.95; 2 trials, 101 participants; low-quality evidence); nausea and vomiting (RR 0.94, 95% CI 0.69 to 1.27; 10 trials, 645 participants; moderate-quality evidence); sedation requiring intervention (RR 0.87, 95% CI 0.40 to 1.87; 4 trials, 223 participants; moderate-quality evidence); or episodes of desaturation to less than 90% (RR 1.29, 95% CI 0.71 to 2.37; 5 trials, 328 participants; moderate-quality evidence)). AUTHORS' CONCLUSIONS The additional pain reduction at rest associated with the use of EA rather than IVPCA is modest and unlikely to be clinically important. Single-trial estimates provide low-quality evidence that there may be an additional reduction in pain on movement, which is clinically important. Any improvement needs to be interpreted with the understanding that the use of EA is also associated with an increased chance of failure to successfully institute analgesia, and an increased likelihood of episodes of hypotension requiring intervention and pruritus. We have rated the evidence as of moderate quality given study limitations in most of the contributing studies. Further large RCTs are required to determine the ideal analgesic technique. The 10 studies awaiting classification may alter the conclusions of the review once assessed.
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Affiliation(s)
- Jon H Salicath
- Royal Victoria Infirmary/Great North Children’s HospitalDepartment of AnaesthesiaSir James Spence Institute5th floor, Royal Victoria InfirmaryNewcastle Upon TyneUKNE1 4LP
| | - Emily CY Yeoh
- Prince of Wales HospitalDepartment of AnaesthesiaBarker StreetRandwickNSWAustralia2031
| | - Michael H Bennett
- Prince of Wales Clinical School, University of NSWDepartment of AnaesthesiaSydneyNSWAustralia
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