Prevalence of acute post-operative pain in patients in adult age-group undergoing inpatient abdominal surgery and correlation of intensity of pain and satisfaction with analgesic management: A cross-sectional single institute-based study

Effect of Ondansetron on Postoperative Pain and Vomiting after Acute Appendicitis Surgery: A Placebo-Controlled Double-Blinded Randomized Clinical Trial

Background

Common postoperative complications following surgery, particularly acute appendicitis surgery, include postoperative pain and vomiting, which can cause discomfort and delay recovery time.

Methods

A randomized double-blinded placebo-controlled clinical trial was conducted with 80 cases of acute appendicitis of American Society of Anesthesiologists (ASA) physical status I or II and aged 18-60 y/o scheduled for appendectomy under general anesthesia. Patients were randomly divided into two equal groups: group A received 4 mg of ondansetron IV (2 ml) and group B received 2 ml of normal slain IV (placebo). Pain according to VAS, nausea and vomiting according to clinical symptoms, shivering and sedation according to the Bedside Shivering Assessment Scale (BSAS), and the Ramsay Sedation Scale (RSS) at 2, 6, 12, and 24 hours after surgery were evaluated and compared between the groups.

Results

There was a significant decline in the severity of pain only at 2 hours after surgery between the ondansetron and control groups (5.3 ± 1.0 vs. 6.0 ± 1.0; p=0.01), not showing a difference between the groups at 6, 12, and 24 hours after appendectomy. Postoperative nausea and vomiting at 2 (5% vs. 25%; p=0.03) and 6 (7.5% vs. 27.5%; p=0.04) hours after appendectomy in the ondansetron group. At different times, the ondansetron and control groups did not differ in terms of pethidine consumption or sedation.

Conclusions

In conclusion, our study found that ondansetron was effective in reducing postoperative vomiting after acute appendicitis surgery. However, it did not show a clinically significant effect on postoperative pain. This trial is registered with IRCT20230722058883N1.

Therapeutic efficacy of intravenous lidocaine infusion compared with thoracic epidural analgesia in major abdominal surgery: a noninferiority randomised clinical trial

BACKGROUND

Open major abdominal surgery is one of the most risky surgical procedures for acute postoperative pain. Thoracic epidural analgesia (TEA) has been considered the standard analgesic approach. In different reports, lidocaine i.v. has been shown to have an analgesic efficacy comparable with TEA. We compared the analgesic efficacy of i.v. lidocaine with thoracic epidural analgesia using bupivacaine in patients undergoing major abdominal surgery.

METHODS

In this noninferiority clinical trial, 210 patients were randomised to thoracic epidural bupivacaine with morphine or i.v. lidocaine. Dynamic pain at 24 h after surgery was measured using a numerical pain rating scale (NPR), and morphine consumption was also measured. A difference in i.v. the lidocaine-epidural bupivacaine NPR of ≤1 for dynamic pain was considered a noninferiority margin.

RESULTS

The NPR for dynamic pain in the lidocaine group at 24 h was between 5.7 (1.8) and 5.2 (1.9) in the epidural group, with a difference of 0.53 (95% confidence interval 0.0-1.0). In the first 24 h, the average difference in morphine consumption was 1.8 mg between the i.v. lidocaine and epidural groups (95% confidence interval 1-3 mg). No differences were found in adverse events or complications associated with the procedures.

CONCLUSIONS

Intravenous lidocaine is noninferior to thoracic epidural analgesia for acute postoperative pain control in major abdomial surgery at 24 h postoperatively.

CLINICAL TRIALS REGISTRATION

NCT04017013.

The Effect of Aromatherapy with Citrus aurantium Aroma on Pain after Orthopedic Surgery: A Randomized Clinical Trial

Introduction

Postoperative pain is one of the most common physiological and psychological stress in patients that disrupts body function and can endanger patients' health. This study aims to determine the effect of aromatherapy with Citrus aurantium essential on pain after orthopedic surgery.

Methods

This randomized clinical trial was performed on 60 candidates for orthopedic surgery. Patients were selected through convenience sampling and divided into intervention and control groups through randomized block allocation. If the visual analogue scale (VAS) score was above 3, patients in the intervention group received aromatherapy with C. aurantium essential and the patients in the control group received a placebo (almond oil). VAS was used to measure pain. Data analysis was performed using independent t test, paired t test, and analysis of variance with repeated measures using SPSS software version 13.

Results

Mean (SD) of pain intensity after intervention in experimental and control groups within 4, 8, and 12 hours after surgery was 7.30 (1.23) vs. 7.90 (0.99), 5.30 (0.98) versus 5.53 (0.68) and 2.53 (0.9) vs. 3.60 (0.77) respectively. The findings indicated that there was a significant difference in mean pain intensity between the experimental and control groups at 4 and 12 hours after surgery. Use of analysis of variance with repeated measures test with taking into account the interaction of time and group also showed a significant difference in mean pain intensity between the two experimental and control groups.

Conclusion

Aromatherapy with Citrus aurantium essential can be effective in reducing mild to moderate pain after orthopedic surgery. Further studies are recommended to confirm this finding.

Review of the Current Situation of Postoperative Pain and Causes of Inadequate Pain Management in Africa

Postoperative pain is one of the most prevalent complications following surgery, and more than 47% of surgical patients endure postoperative discomfort worldwide. In Africa, due to resource shortages and other issues, postoperative pain is substantially more common when compared to developed countries. Severe postoperative pain has many negative effects, including possibly death, which can burden both individuals and society as a whole. Therefore, effectively controlling postoperative pain is becoming increasingly important. To enhance the effectiveness of future pain management, a thorough analysis of the current reasons for inadequate postoperative pain management is necessary. In this article, the present situations of occurring postoperative pain, children's postoperative pain, and pain management in Africa are reviewed, based on relevant and recent literature. In particular, the reasons for inadequate postoperative pain management in Africa are detailed in this article from five perspectives: the inadequate assessment of postoperative pain, the knowledge gap among medical professionals, the patients' misconceptions, the scarcity of resources, and the lack of medications. Additionally, we offer appropriate solutions following various factors.

Predicting factors that determine patients' satisfaction with post-operative pain management following abdominal surgeries at Komfo Anokye Teaching Hospital, Kumasi, Ghana

Introduction

Poorly controlled postoperative pain has been known to be characterized by longer post-operative care, longer hospital stays with increased readmission rates, and decreased patient satisfaction. Post-operative pain has been continuously addressed in the past three (3) to four (4) decades and has been shown that 20 to 80% of post-operative patients suffer ineffective pain management.

Objective

The study was aimed at assessing the factors that may predict the satisfaction of patients with early postoperative pain management following abdominal surgeries at the Komfo Anokye Teaching Hospital, Kumasi.

Methodology

A descriptive cross-sectional study was conducted among patients who had undergone abdominal surgeries between October 2019 and December 2019 at the Komfo Anokye Teaching Hospital. Structured questionnaires based on the IPO-Q were used to obtain responses from the patients. Descriptive and Inferential statistical analysis were employed in analyzing the data obtained from the respondents of the study.

Results

138 patients were involved in this study. The mean age of patients in the study was 45.81 (±16.81) years. A higher percentage, 58.7% of the patients were males. 39.1% had completed their tertiary level of education. The majority (50.7%) of the patients had had persistent pain for more than three (3) months. The satisfaction of the patients with the post-operative pain management received was generally high among a significant majority of the patients. Meanwhile, among the factors that influence the satisfaction of the patients with the post-operative pain management received, type of analgesia and pain relief methods (Pearson Coefficient = 0.523, p-value <0.05), patient’s ability to request more pain relief, (Pearson Coefficient = 0.29, p-value <0.05), patient’s access to information about their pain treatment options from the Nurses (Pearson coefficient = -0.22, p<0.05), were the only predictors of satisfaction in patients.

Conclusion

This study found out that patients were generally satisfied with the post-operative pain management offered by their healthcare providers although the degree of satisfaction depended largely on the type of analgesia and pain relief methods, the ability to request for more pain relief, and access to information on pain treatment.

The Effects of Inhalation Aromatherapy on Postoperative Abdominal Pain: A Three-Arm Randomized Controlled Clinical Trial

PURPOSE

This study compares the effects of inhalation aromatherapy using essential oils of sweet orange and damask rose on postoperative abdominal pain.

DESIGN

A randomized three-arm controlled trial.

METHODS

In this randomized double-blinded, and parallel-group controlled trial, a total of 120 patients who underwent open abdominal surgeries were enrolled using a sequential sampling method. Participants were then randomly assigned to three groups of sweet orange, damask rose, and placebo (distilled water) using the permuted block randomization. When the patients regained full consciousness, a clean gauze impregnated with four drops of either distilled water or essential oils of sweet orange or damask rose were attached to the collar of the patients, and they were asked to inhale the aroma through normal breathing for 30 minutes. Abdominal pain severity was recorded using the visual analog scale at four time points including before the intervention (baseline) and 4, 8, and 12 hours after the intervention.

FINDINGS

Pain reduction after sweet orange inhalation was significantly greater than placebo (at 8 and 12 hours after the intervention) and damask rose (at 12 hours after the intervention). The differences in the mean score of pain severity between all before-and-after observations were statistically significant in the three groups, except in the placebo group between the baseline score of pain severity and the pain severity score at 4 hours after the intervention.

CONCLUSIONS

Inhalation aromatherapy using sweet orange seems to be more effective than the damask rose in reducing pain severity after open abdominal surgeries.

Comparison of preemptive paracetamol, paracetamol-diclofenac & paracetamol-tramadol combination on postoperative pain after elective abdominal surgery under general anesthesia, Ethiopia: a randomized control trial study, 2018

Background

In the practice of postoperative pain management, pain is still poorly managed in low resource setting where the practice of epidural and opioid free analgesia is impractical. There has been a recent trend of combining different drugs and concept of preemptive analgesia but the therapeutic superiority remains understudied for postoperative pain management. The aim of this study is to assess postoperative analgesic effect of preemptive Paracetamol, Paracetamol-diclofenac and Paracetamol-tramadol combination in patients undergoing laparotomy surgery.

Methods

Three-arm, randomized control trial study conducted on 63 patients undergone laparotomy surgery; group-P (paracetamol 1 g), group-PD (1 g + diclofenac 75 mg) and group-PT (paracetamol 1 g + tramadol 100 mg). The Numerical Rating Scale (NRS) pain rating system was used for this study. The primary endpoint of the study was total amount of analgesia consumption. Post-operative analgesic therapy [intravenous tramadol, 50 mg] were provided when patients complain of pain (request medication) or a numeric rating scale ≥4 was recorded. Secondary endpoint of the study were the time of first analgesic request and the intensity of the pain during 24 h post-op follow up period. Parametric data were analyzed using (ANOVA) and nonparametric data analyzed by Kuruska-Wallis H rank test. Chi-square test used for categorical variable. Statistical significance were sated at p value < 0.05 with a power of 80%.

Results

The mean total tramadol consumption was significant higher in paracetamol group 250 ± 79.06 mg compared to paracetamol-diclofenac (173.81 ± 87.49 mg p = 0. 008) and paracetamol-tramadol (154.76 ± 70.54 mg p = 0. 001) group. Time to first analgesic request was significantly shorter within paracetamol group (87.62 ± 20.95 min) compared to paracetamol-diclofenac (103.01 ± 23.53 min p = 0.029) and paracetamol-tramadol (144.05 ± 14.72 min p < 0.001) group. There was statistically significant difference at 4th, 6th and 8th hour showing lower median pain score in paracetamol-tramadol group compared to paracetamol group.

Conclusion

Preemptive combination of paracetamol-tramadol and paracetamol-diclofenac reduce total tramadol consumption and prolongs time to first analgesic request compared to paracetamol alone in patients undergoing laparotomy surgery.

Trial registration

The study was retrospectively registered on 07 July 2019 at Pan African Clinical Trial Registry with the identification number of PACTR201908890749145. It was accepted on 14 August 2019.

The Effect of Preoperative Pentoxifylline on Postoperative Pain and Development of Secondary Hyperalgesia in Patients Undergoing Laparoscopic Appendectomy: A Randomized, Double-Blind, Placebo-Controlled Trial Study

BACKGROUND

After surgery and loss of anesthetic effect, postoperative pain can annoy the patient and affect patient satisfaction with treatment. This study was aimed at evaluating the effect of preoperative pentoxifylline (PTX) on postoperative pain and development of secondary hyperalgesia in patients undergoing laparoscopic appendectomy (LA).

METHODS

This randomized, double-blind, placebo-controlled clinical trial study was conducted on 91 eligible subjects with acute appendicitis referred to Shahid Beheshti hospital of Sabzevar, Iran, in 2018. The intervention and control groups were administered with a single oral dose of PTX (10 mg/kg) and placebo an hour before surgery, respectively. Postoperative pain was measured within 24 hours after surgery using a VAS, and the area of secondary hyperalgesia was measured 24 hours after surgery using the Stubhaug et al. method.

RESULTS

The mean age of the subjects was 26.74 ± 9.99 years, and 57.14% were female. Pain intensity during rest was significantly greater in the control group as compared to the PTX group 24 hours after surgery (VAS scores 2.19 ± 0.49 and 3.13 ± 0.66, respectively; P < 0.001). Moreover, pain intensity during cough was substantially lower in the PTX group compared with the control group 24 hours after surgery (VAS scores 2.65 ± 1.90 and 4.10 ± 2.60, respectively; P = 0.003 in turn). The dynamic hyperalgesia was significantly greater in the control group as compared with the PTX group (3.80 ± 1.82 and 7.43 ± 2.38, respectively; P < 0.001).

CONCLUSIONS

Findings suggest that oral administration of PTX 1 hour before surgery in patients undergoing LA can reduce postoperative pain in patients and prevent secondary hyperalgesia at a surgical site.

Tramadol/Diclofenac Fixed-Dose Combination: A Review of Its Use in Severe Acute Pain

Pain is a health issue affecting all populations, regardless of age, gender, economic status, race, or geography. Acute pain is the most common type of pain, with a complex aetiology. Inadequately managed acute pain adversely affects quality of life and imposes significant economic burden. The majority of the available pain-relieving drugs have monomodal mechanisms of analgesia, which necessitates combining drugs with non-redundant mechanisms of action in order to provide adequate pain relief and reduce the side effects from higher doses of individual drugs. In this regard, combining an oral opioid (such as codeine or tramadol) and a non-opioid (such as paracetamol or non-steroidal anti-inflammatory drug) offers a plausible option. Tramadol/diclofenac fixed-dose combination (FDC) is one such analgesic combination which has demonstrated promising clinical activity via its multimodal mechanisms of action. This review seeks to provide an up-to-date narrative on the current scientific literature regarding the pharmacological properties, clinical efficacy, and tolerability of tramadol/diclofenac FDC in the treatment of acute severe pain. A comprehensive, qualitative review of the literature was conducted using a structured search strategy in Medline/PubMed and additional Internet-based sources to identify relevant studies. Based on the available scientific literature, evidence of the efficacy and safety of tramadol/diclofenac FDC for treatment of patients with acute severe pain, including musculoskeletal pain, postoperative pain, and acute flare-up of osteoarthritis or rheumatoid arthritis, appears to be substantial. Although additional comparative studies would be required to definitively position tramadol/diclofenac FDC with respect to other analgesic combinations, the available data suggest that tramadol/diclofenac FDC is a valuable treatment option for patients with acute severe pain.

Audit of pain management following emergency laparotomies in cancer patients: A prospective observational study from an Indian tertiary care hospital

Background:

Emergency laparotomies present a challenge in pain management given sick patients, odd timings and poor outcomes. Current recommendations favour multimodal opioid-sparing analgesia following elective laparotomies. No recommendation exists for emergency surgeries.

Methodology:

After approval and registration of the trial, adult patients posted for emergency laparotomy in the hospital (tertiary centre for cancer care) starting August 2015, for 6 months, were included in this prospective study. Patients' details including indication for emergency surgery, preoperative haemodynamic parameters, baseline coagulation status were captured. Patients were followed for pain scores, satisfaction with pain management and outcome. The number of anaesthesiologists present and their experience concerning regional techniques were noted.

Results:

Intestinal obstruction was the commonest cause of emergency laparotomy. Most patients belonged to the ASA IE/IIE class (91%). Intraoperatively, opioids were the mainstay of pain management with an epidural catheter inserted in only 9% of cases even though most cases were conducted by anaesthesiologists confident/expert in thoracic epidural insertion. There was no correlation of choice of pain management technique with the time of surgery (P = 0.22), ASA grading (P = 0.28), predicted mortality by p-Possum scores (P = 0.24). Pain at movement was moderate-severe in more than 50% of patients within the first 24 h. The regional group had better satisfaction when compared to opioid and non-opioid based management. (P < 0.001).

Conclusion:

Regional techniques for pain management in emergency laparotomies are less preferred, therefore, opioids are the mainstay. Lack of experience is essentially not the primary reason for regional techniques not gaining popularity. Pain management in this group needs a thorough re-evaluation.

Postoperative Patients in Jordan: Pain Prevalence, Characteristics, Beliefs, and Satisfaction

BACKGROUND

Unrelieved postoperative pain contributes to soaring medical costs and poor quality of life. Whilst much has been written about postoperative pain prevalence in the literature, few empirical studies have explored pain care in Middle Eastern countries.

AIMS

This study aimed to determine pain prevalence, its characteristics, beliefs and satisfaction among postoperative patients in Jordan.

DESIGN

This is a descriptive survey design.

SETTINGS

This study was conducted in a 200-bed Jordanian public hospital located in the southern province of Jordan.

PARTICIPANTS

A convenient sample of 143 surgical patients was selected.

METHODS

Data were collected by the American Pain Society Patient Outcomes questionnaire, Brief Pain Inventory scale and beliefs towards pain scale. Data were analyzed using SPSS version 21.

RESULTS

Pain prevalence following surgery during the first 24 hours was 87%. The overall Mean of satisfaction of all participants was moderate (66.6%). The analysis found that the greatest interference of pain was with activity (Mean ± SD = 6.27 ± 3.30). The belief "people get addicted to pain medicine easily" was the most common misunderstanding (Mean ± SD = 3.48 ± 1.71). Male participants had worse average pain experience but were more satisfied with pain management than females (ps = .012, .017, respectively). Participants aged 30 or more had better pain management experience and satisfaction than those aged under 30 (p = .021).

CONCLUSIONS

The study revealed high pain prevalence among surgical patients that remains undertreated. If patients' postoperative environment is to be a "Pain Free Zone", nurses' training programs and the application of various screening tools in the postoperative context taking into account the role of gender and culture are urgently needed.

Psychometric evaluation of the Danish version of a modified Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R-D) for patients hospitalized with acute abdominal pain

Background and aims This paper forms part of a study evaluating the effect of patient-controlled oral analgesia for patients admitted to hospital with acute abdominal pain. Pain is a subjective experience, and a multifaceted evaluation tool concerning patient-reported outcome measures is needed to monitor, evaluate, and guide health care professionals in the quality of pain management. The Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) is a validated multifaceted evaluation tool for measuring patient-reported pain experiences to evaluate different pain management interventions. The aim of this study was to evaluate the psychometric properties of a modified Danish version of the Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R-D) used during and after hospitalization for patients with acute abdominal pain. Methods The APS-POQ-R was translated into Danish and two slightly different questionnaires were formed. Questionnaire one had 39 items and the six subscales pain severity (pain), perception of care (satisfaction), pain interference with function (activity) and emotions (emotion), side effects of treatment (safety), and patient-related barriers to pain management. The questionnaire focused on time during hospital stay and was to be completed at discharge. Questionnaire two included 25 items and the five subscales pain, satisfaction, activity, emotion, and safety and focused on time at home and was to be completed daily 1 week after discharge. The questionnaires were tested on 156 patients with acute abdominal pain. Internal consistency reliability and construct validity was examined. Results In both questionnaires, the results of correlations and tests for internal consistency reliability showed a Cronbach's alpha of >0.7 for the pain, activity, and emotion subscales, but the value was ≥0.69 for the satisfaction subscale. In questionnaire one, Cronbach's alpha was ≤0.64 for the safety subscale, but this was 0.73 when the item "itching" was deleted. In questionnaire two, Cronbach's alpha was ≤0.51 for the safety subscale. For the patient-barrier subscale in questionnaire one, Cronbach's alpha was ≤0.62 for any combination of the items in the subscale. The results of the construct validity and factor analysis showed a five-factor structure in questionnaire one and a three-factor structure in questionnaire two. In questionnaire one, items from the pain, activity, emotion, and safety subscales, except for the items "least pain" and "itching," loaded on factor one. In questionnaire two, all items from the pain, activity, and emotion subscales loaded on factor one. Conclusions The modified APS-POQ-R-D demonstrated adequate psychometric properties for the five subscales pain severity (pain), perception of care (satisfaction), pain interference with function (activity) and emotions (emotion), side effects of treatment (safety), but not for the patient-barrier subscale for patients hospitalized with acute abdominal pain. Consequently, the APS-POQ-R-D may be used without the patient-barrier subscale. Implications The clinical implications of this study may help clinicians with investigating how acute patients manage pain during and after hospital admission.

Using Opioids With Surgical Patients: Nurses' Attitudes and Experiences

Opioids such as morphine are effective analgesics and have been recognized worldwide for many years; yet, they are underutilized. The study explores the attitudes and experiences relating to opioids, in general, and morphine, in particular, among Jordanian surgical nurses. The Opioids Attitudes Scale was used. A total of 123 questionnaires were distributed, and 120 were returned, achieving a response rate of 96%. Focus group discussions (n = 4) were conducted with surgical nurses (n = 34). The majority of nurses believe that the addiction is the most serious side effects of opioids. Qualitative analysis revealed 2 major themes. The first theme was referred to as "not being in the same boat," highlighting a lack of teamwork, and comprised 2 subthemes: blame culture and physicians versus nurses. The second "morphine as the last on the list" was also made up of 2 subthemes: the lack of confidence and the fear of legal persecution. Nurses showed negative attitudes and misconceptions about opioids and morphine use within a fragmented surgical unit culture. Therefore, serious efforts must be made to create and sustain an effective unit culture reform and communications path from patient to nurse and doctor.