A procedure-specific systematic review and consensus recommendations for postoperative analgesia following total knee arthroplasty

The PROSPECT Working Group, a collaboration of anaesthetists and surgeons, conducts systematic reviews of postoperative pain management for different surgical procedures (http://www.postoppain.org). Evidence-based consensus recommendations for the effective management of postoperative pain are then developed from these systematic reviews, incorporating clinical practice observations, and transferable evidence from other relevant procedures. We present the results of a systematic review of pain and other outcomes following analgesic, anaesthetic and surgical interventions for total knee arthroplasty (TKA). The evidence from this review supports the use of general anaesthesia combined with a femoral nerve block for surgery and postoperative analgesia, or alternatively spinal anaesthesia with local anaesthetic plus spinal morphine. The primary technique, together with cooling and compression techniques, should be supplemented with paracetamol and conventional non-steroidal anti-inflammatory drugs or COX-2-selective inhibitors, plus intravenous strong opioids (high-intensity pain) or weak opioids (moderate- to low-intensity pain).

A procedure-specific systematic review and consensus recommendations for analgesia after total hip replacement

Total hip replacement is a major surgical procedure usually associated with significant pain in the early postoperative period. Several anaesthetic and analgesic techniques are in common clinical use for this procedure but, to date, clinical studies of pain after total hip replacement have not been systematically assessed. Using the Cochrane protocol, we have conducted a systematic review of analgesic, anaesthetic and surgical interventions affecting postoperative pain after total hip replacement. In addition to the review, transferable evidence from other relevant procedures and clinical practice observations collated by the Delphi method were used to develop evidence-based recommendations for the treatment of postoperative pain. For primary total hip replacement, PROSPECT recommends either general anaesthesia combined with a peripheral nerve block that is continued after surgery or an intrathecal (spinal) injection of local anaesthetic and opioid. The primary analgesic technique should be combined with a step-down approach using paracetamol plus conventional non-steroidal anti-inflammatory drugs, with strong or weak opioids as required.

A procedure-specific systematic review and consensus recommendations for postoperative analgesia following laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy has advantages over the open procedure for postoperative pain. However, a systematic review of postoperative pain management in this procedure has not been conducted.

METHODS

A systematic review was conducted according to the guidelines of the Cochrane Collaboration. Randomized studies examining the effect of medical or surgical interventions on linear pain scores in patients undergoing laparoscopic cholecystectomy were included. Qualitative and quantitative analyses were performed. Recommendations for patient care were derived from review of these data, evidence from other relevant procedures, and clinical practice observations collated by the Delphi method among the authors.

RESULTS

Sixty-nine randomized trials were included and 77 reports were excluded. Recommendations are provided for preoperative analgesia, anesthetic and operative techniques, and intraoperative and postoperative analgesia.

CONCLUSIONS

A step-up approach to the management of postoperative pain following laparoscopic cholecystectomy is recommended. This approach has been designed to provide adequate analgesia while minimizing exposure to adverse events.

[Surgical pain management. A Germany-wide survey including the effect of clinical guidelines]

INTRODUCTION

Over the last few years, various studies have aimed at improving the diagnosis and therapy of perioperative and posttraumatic pain.

METHODS

In an anonymous postal survey, 2,393 German surgical clinics were asked to describe several aspects of their clinical pain treatment. In order to assess the influence of interdisciplinary guidelines on surgical pain therapy, the results of this survey were compared to a survey from 1997.

RESULTS

The response rate was 30.8% ( n=738). Pain was measured quantitatively in 11.4% ( n=80) of hospitals, a figure which is unchanged since 1997. In pain treatment,however, some changes were discernible: while 46.6% of all hospitals in 1997 used patient-controlled analgesia often or occasionally, this proportion has risen to 64.5%.Both, the national acute pain guidelines and the WHO chronic pain guidelines were well known (71.3% and 74.7%) and accepted (98.8% and 98.5%, respectively). Among those surgeons who knew the national guidelines,93.7% reported that they used them clinically. In 149 hospitals (20.2%), local guidelines have been developed either anew or from existing guidelines.

CONCLUSIONS

Although clinical guidelines are widely used, pain therapy in surgical patients has improved only marginally.

[Are computer assisted total knee replacements more accurately placed? A meta-analysis of comparative studies]

Computer-assisted surgery (CAS) has become established in many hospitals throughout the world, especially in the form of computer navigation for total knee replacement (TKR). Analysis of the studies available revealed 18 comparative studies examining the precision of implantation of knee endoprostheses following CAS and after implantation by the conventional technique. In a meta-analysis of 13 studies in which the same safe zone of +/-3 from neutral alignment was defined for the leg axis, a total of 1,784 TKR were performed. In the group of patients in whom the conventional technique was used, 75.6% (654/865) of TKR were implanted within the safe zone. In the CAS group 93.9% (863/919) of the prostheses were implanted within the safe zone (p<0.0001). The differences between the groups were statistically significant in 11 of the 13 studies, and the difference between groups for the entire patient population is highly significant. Only limited clinical results were ascertained in these comparative studies; there were no great differences between the treatment groups in clinical course.

[Postoperative pain relief is an important factor for the patients' selection of a clinic. Results of an anonymous survey]

AIM

The aim of the survey was to elucidate the significance of postoperative pain therapy for the patient and its influence on the choice of hospital.

METHODS

This prospective, anonymous survey of consecutive patients in a general surgical clinic was performed by an independent study nurse.

RESULTS

A total of 161 patients were included; 90% of the surgical patients considered "good pain therapy" as a highly important factor, and three of four patients would admit themselves more likely to a clinic well known for "good pain therapy." If the patients could choose their hospital, factors such as "medical care by the physicians" are most important (rank 1; rank 1 most important, rank 10 most unimportant) followed by quality of "nursing care" (mean rank 2.6) and "good pain therapy" (mean rank 3.6). Older patients (> or = 60 years) preferred a hospital with known "good pain therapy" more often for surgical therapy than younger patients (< 60 years).

CONCLUSION

It can be concluded that postoperative pain relief is an important factor for the patients' selection of a clinic and is influenced by an age of > or = 60 years.

[What prognostic factors correlate with activities of daily living (Barthel Index) 1 year after para-articular hip fracture? A prospective observational study]

The aim of this prospective study was to identify prognostic factors predicting post-operative outcome in patients one year after their hip fracture.

METHODS

From October 1996 until September 1997 all patients (n = 98) treated for a hip fracture in our hospital were prospectively included into the study. Follow up was performed at three, six and twelve months after the injury. The main outcome variable was the activity of daily living measured by the Barthel-Index. An univariate analysis of the variables age, gender, ASA-classification, type of fracture and treatment, length of stay and rehabilitation was performed and all these variables were correlated with the Barthel-Index. A multiple logistic regression was performed for identification of prognostic factors predicting outcome.

RESULTS

The one year lethality was 33% (n = 31). All patients younger than 75 years reached their preoperative activity level at one year follow up. Patients with age of 75 years or more experienced a reduction of their activities of daily living of 20%. The ADL-differences of both groups at the follow up after 3, 6 and 12 months showed a significant p-value (p < 0.001). The ADL-differences between the group of patients with or without a transfer to a specialized rehabilitation center were not significant. The multivariate analysis showed that the preoperative use of the Barthel-Index was the best prognostic factor for outcome until one year after the injury.

CONCLUSION

The preoperative Barthel-Index should be seriously considered for therapeutic decision making in patients with hip fractures.

The Langerhans' cell histiocytosis (eosinophilic granuloma) of the cervical spine: a rare diagnosis of cervical pain

We present the case of a 44-year-old man who complained of cervical pain. He was treated with physiotherapy and analgetics. Because of persistent pain, computed tomography (CT) scan and MRI were performed. They revealed an osteolytic destruction of the fourth cervical vertebra. The patient was treated surgically for removal of the tumor and stabilization of his cervical spine. Histology of the osteolytic material led to the diagnosis of an eosinophilic granuloma of the cervical spine. This case report describes the incidence, clinical significance, background and therapy of an eosinophilic granuloma of the spine.

[Pain therapy for the lower extremities]

Pain therapy after surgical procedures of the lower extremity is an important goal, whereas insufficient analgesia leads to an essential reduction of the patient's mobility and convalescence. If possible, regional anaesthetic and intrathecal procedures for pre-, intra- and postoperative analgesia should be used. Systemic analgesics should not be used preoperatively, whereas non-opioids and opioids are recommended postoperatively. Surgical options that adequately reduce pain are intra-articular injection of local anaesthetics alone or in combination with opioids and cooling and physiotherapeutic treatment regimens after joint procedures. There is no scientific rationale as an argument for inserting drains. The surgical approach depends more on the individual patient's anatomical characteristics. Whereas the regional analgesic regimen is more effective than systemic therapy, sufficient tools for pain reduction during surgical procedures of the lower extremity are at the orthopaedic surgeon's disposal, too.

[Therapy of phantom pain with salmon calcitonin and effect on postoperative patient satisfaction]

In this prospective clinical study we examined the intravenous application of salmon-calcitonin in eight patients with severe phantom limb pain (Visual Analogue Scale = 50-100). The patients presented at the Acute Pain Service (APS) section of the Second Department of Surgery, University of Cologne. Six of eight patients (75%) had no phantom limb pain after 10 days of intravenous treatment with salmon-calcitonin (maximum of five cycles of calcitonin infusion). Systematic follow-up examinations after 3, 6 and 12 months showed long-term success. Patient satisfaction was examined with a numeric rating scale (NRS 1-6) between the single infusion cycles. When patient satisfaction was low, the physician modified the time period or drug dosage between infusions. This study shows good or excellent results in patient satisfaction for six of eight patients (75%). A prospective randomized trial is required to verify the excellent results of intravenous salmon-calcitonin in a larger population. Alternative pharmacological and operative treatments of phantom limb pain are critically reviewed and assessed.

[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.

[Therapeutic concept for preventing chronic phantom pain after traumatic brachial plexus lesion]

We report on a 29-year-old motorcyclist, who had suffered a traumatic right side arm plexus lesion. The myelo-CT image showed a avulsion of the cervical roots C7/C8. Five days after the accident the patient complained of phantom pain in the right plegic arm and was presented to our acute pain service (APS). The patient complained of lancinating attacks of severe phantom pain in the right arm (visual analogue scale intensity of 80-100 pts.). The initial pain treatment was performed with PCA (piritramide), and because of the lancinating pain character carbamazepine treatment was introduced. The pain intensity increased under carbamazepine (VAS = 100 pts.), and after treatment with five cycles of salmon-calcitonin infusion the pain intensity decreased (VAS = 10 pts). After withdrawal of the infusion therapy with salmon calcitonin the pain intensity increased up to VAS = 70 pts. TENS therapy five times per day showed no analgetic effect. We repeated the calcitonin-infusion therapy and after five i.v. cycles we continued with 200 I.U. salmon calcitonin intranasal per day. The initial phantompain intensity decreased (VAS = 40 pts.), but showed no long term analgesia. The additional psychological treatment with relaxation techniques (Jacobson/Bensen) showed the desired phantom pain relief. An interdisciplinary and multimodal cooperation between anesthesiologists, trauma surgeons, neurosurgeons and psychologists is needed for successful phantom pain treatment after traumatic brachial plexus lesion. Intravenous salmon calcitonin showed only short-term analgetic effect.

[Postoperative nausea and vomiting (PONV). Clinical significance, basic principles, prevention and therapy]

INTRODUCTION

The incidence of postoperative nausea and vomiting (PONV) of in- and outpatient surgical patients is about 30% (range 2-45%).

METHODS

Based on etiology, anatomy and physiology, this review article provides a critical evaluation of the present PONV literature with the aim of outlining current prophylaxis and treatment strategies.

RESULTS

PONV is often associated with postoperative pain and its treatment. Patients are often more compromised by PONV than by postoperative pain. Surveys demonstrate that 78% of the surgeons consider PONV to be a relevant problem in clinical practice; 82% argue for better management of PONV. However, only 28% of the general surgical patients with PONV received sufficient antiemetic therapy. Studies demonstrate that the prophylactic use of antiemetics in patients at risk can lead to complete symptom control in 85% of the cases. Combination therapy of different antiemetic strategies can further increase the rate up to 96%.

CONCLUSION

There is a need for surgeons to pay more attention to patient-related symptoms.

[Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy for Surgical Patients (revised version 2019)]

The treatment of any causal, procedure-specific and/or concomitant acute pain is an essential quality feature in any surgical subspecialty. An interdisciplinary and interprofessional pain therapy aims for an immediate improvement of the patients' quality of life, a reduction of the risk of postoperative morbidity and mortality in the medium term, prevention of any pain chronification in the long run as well as a reduction of hospitalization and sick leave. The "Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy" exists since 1992. In view of the continuously developing scientific evidence, updated guideline recommendations and interprofessionally designed treatment pathways, these agreements have been adapted to the current requirements and structural conditions of the German healthcare system. Thus, both aforementioned professional associations promote an up to date version of an "Agreement for the Organization of Pain Therapy for Surgical Patients", a precise recommendation and a manual for the acting partners in order to realize the abovementioned goals.

[Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy for Surgical Patients (revised version 2019)]

The treatment of any causal, procedure-specific and/or concomitant acute pain is an essential quality feature in any surgical subspecialty. An interdisciplinary and interprofessional pain therapy aims for an immediate improvement of the patients' quality of life, a reduction of the risk of postoperative morbidity and mortality in the medium term, prevention of any pain chronification in the long run as well as a reduction of hospitalization and sick leave. The "Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy" exists since 1992. In view of the continuously developing scientific evidence, updated guideline recommendations and interprofessionally designed treatment pathways, these agreements have been adapted to the current requirements and structural conditions of the German healthcare system. Thus, both aforementioned professional associations promote an up to date version of an "Agreement for the Organization of Pain Therapy for Surgical Patients", a precise recommendation and a manual for the acting partners in order to realize the abovementioned goals.

[Transfer managment of postoperative acute pain therapy to outpatient aftercare]

The significance of postoperative pain management for patients in the hospital is well known and has been a focus of research for several years. The ambulatory care after hospital discharge, however, is not well investigated. A prospective observational study was therefore conducted to study the transfer management from in-hospital patients to ambulatory care. A patient questionnaire was developed and patients were asked to fill it out at different time points after the operation: during the time in the hospital, then at 2 weeks and 6 months after hospital discharge. In addition, the responsible family doctor was approached and interviewed. The main focus of the questionnaire was the measurement of post-surgical pain (numeric rating scale NRS), patient satisfaction (Cologne patient questionnaire), and quality of life (SF 12). Of a total of 128 patients 72.9% described moderate to severe pain after the orthopaedic operations in the hospital. 90.8% of the patients had pain directly after discharge from the hospital; in 67.4% of the cases pain was ≥3 and in 23.4% of the cases pain was ≥6. Six months after discharge pain was significant in 29.4% of the patients, 60.8% of the patients were satisfied with the transfer to the home setting. 16% were not satisfied at all and 23.2% were neutral. Important factors for dissatisfaction with the transfer management were, according to stepwise logistic regeression analysis, sex (female patients), young age, a poor bodily constitution at the hospital and thereafter, and the pain management in the hospital and after discharge. The study shows the significance of the acute pain therapy not only during the hospital stay but also after discharge. There are very few data on pain therapy after discharge from the hospital. Based on the significance of the chronification of acute pain it is of the utmost importance to close this gap.

[Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy for Surgical Patients (revised version 2019)]

The treatment of any causal, procedure-specific and/or concomitant acute pain is an essential quality feature in any surgical subspecialty. An interdisciplinary and interprofessional pain therapy aims for an immediate improvement of the patients' quality of life, a reduction of the risk of postoperative morbidity and mortality in the medium term, prevention of any pain chronification in the long run as well as a reduction of hospitalization and sick leave. The "Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy" exists since 1992. In view of the continuously developing scientific evidence, updated guideline recommendations and interprofessionally designed treatment pathways, these agreements have been adapted to the current requirements and structural conditions of the German healthcare system. Thus, both aforementioned professional associations promote an up to date version of an "Agreement for the Organization of Pain Therapy for Surgical Patients", a precise recommendation and a manual for the acting partners in order to realize the abovementioned goals.