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5 Articles in Volume 4, Issue #1
Complications of Uncontrolled, Persistent Pain
Improving Postoperative Pain Outcomes
Peripheral Nerve Catheters for Acute Pain Control
The ABC's of Pain Clinic Referrals
Treatment-resistant Migraines

Improving Postoperative Pain Outcomes

Multimodal pain management approaches — implemented perioperatively — may improve post-operative outcomes and improve overall patient satisfaction.

Over 23 million surgical procedures are performed in the United States each year and are often associated with pain. Surgical pain is often inadequately treated and may persist long after the tissue heals.1 In certain cases the presence of intolerance to opioid analgesics, sedatives and non-steroidal anti-inflammatory drugs (NSAIDs) can limit the options for perioperative pain management, increasing the role of regional and local anesthesia. Understanding perioperative pathophysiology and planning the care of patients in order to reduce the associated stress can help to accelerate rehabilitation and contribute to decreased length of stays and increased patient satisfaction and safety after discharge.2

Consequences of poor planning for pain management perioperatively may not only affect the immediate well-being of the patient but also have negative socioeconomic implications.3 An aggressive approach to assessment and management of pain leads to increased patient comfort and satisfaction. Rigidity in this aspect, however, is inappropriate as patients differ in level of tolerance and perception of pain. Contributing factors include underlying conditions, social circumstances and personal preferences. Surgical stress can lead to a variety of responses including increase in catabolism, glycogenolysis, gluconeogenesis and lipolysis. Inadequate blunting of these responses can lead to tachycardia, hypertension, respiratory compromise and intraventricular hemorrhage. Increase in myocardial oxygen consumption and myocardial ischemia may also result.

Pre-emptive analgesia is an evolving clinical concept that specifies that an analgesic regimen be administered before the onset of noxious stimuli. This prevents the development of central sensitization caused by incisional and inflammatory injuries during both the surgical and initial postoperative periods.4 Though there has been conflicting trial results since the latter half of the 1990s, there is evidence that the use of non-opioids could play a role and — through this mechanism — reduce postoperative opioid requirements. The uniqueness of patients presenting for surgery also requires optimizing patients on an individual basis to improve their postoperative outcome. Examples of a unique patient group include sickle cell patients presenting for surgery. Hydrating such patients, transfusing to hemoglobin> 9g/dl perioperatively, intraoperative body temperature conservation and monitoring for early recognition of ventilation to perfusion mismatch or acid base balance will help reduce incidents of acute painful vaso-occlusive crisis and acute chest syndromes5 and hence contribute to better postoperative conditions.

Regional analgesia and anesthesia are increasing in popularity for perioperative management. Epidural catheters are now being placed for pain management prior to surgical procedures and continued intraoperatively — either as total epidural anesthesia or as supplementation for general anesthesia. Peripheral nerve blocks and wound infiltrations are commonly used as adjuvant to monitored anesthesia care and general anesthetic techniques because they can provide intra- and postoperative analgesia.6

Postoperative pain is often under-treated with routine orders of intramuscular ‘as needed’ medications failing to relieve pain in about half of postoperative patients. Aside from potential side effects, factors such as timing of onset of action, duration of action, maximum pain relief, use of rescue medication, as well as other factors relevant to a given pain model, are important in determining overall analgesic efficacy.7 Post-operative patients in pain manifest shallow breathing and decreased cough with the potential for pulmonary atelectasis. These patients may also experience delayed return of bowel function. Inability to provide adequate analgesia after many of these surgical procedures impedes effective physical therapy and rehabilitation. In cases of procedures like joint or lower extremity surgery, proper pain management is critical to achieving acceptable joint range of motion. Under-treatment of postoperative pain potentially delays discharges and adversely affects quality of life.

Methods

The authors have reviewed literature examining all stages of perioperative care, including the various modalities that have been shown to improve patient outcome postoperatively. The literature search was conducted of applicable studies and trials over a five-year period 1997-2002. Resources searched included the National Library of Medicine (PubMed), Medscape, and popular Internet search engines such as Yahoo and Google. Searches utilized terms such as “perioperative analgesia”, “pain management”, “regional anesthesia”, “perioperative outcome” — alone or in combination. Materials analyzed included abstracts, full-length articles, systematic reviews, meta-analyses randomized controlled trials, controlled trials, cohort, case-control analytic studies, descriptive case series, and narrative reviews. Preference was given to studies comparing at least two modes of administering perioperative pain management with at least one of them being a regional anesthetic or analgesic technique. Articles analyzing patient outcome and satisfaction with perioperative care, as well as placebo-controlled studies involving one modality, were included in this study.

Results

Most studies in this review involved a small number of patients ranging from 30 to 112. Table 1 shows results from 11 studies examining some of the established techniques and methods such as regional blocks, subarachnoid blocks, and epidural analgesia/anesthesia employed at different times during the perioperative period.

 
Study # of patients Study design Methods Study conclusions
Laparoscopic urologic surgery8 65 Prospective double-blind randomized study Perioperative ketorolac vs. placebo perioperatively 1. Mean amount of postoperative morphine - placebo > ketorolac
2. Decreased perception of pain in ketorolac group
Otolaryngologic surgery9 112 Randomized double blind placebo controlled Comparing placebo (a), acetaminophen (b), celecoxib (c) and celecoxib combined with acetaminophen (d). 1. (d) group was highly effective in decreasing pain postoperatively.
2. Patient satisfaction was improved when celecoxib was used either alone or in combination
Total knee arthroplasty11 100 Randomized placebo controlled Rofecoxib vs. placebo both started 10 days prior to surgery after discontinuing NSAIDs No significant increase in bleeding or INR in rofecoxib group
Laparoscopic cholecystectomy and inguinal hernioraphy12 30 Randomized case control Perioperative dextromethorphan (DM) vs. placebo 1. Decreased postoperative analgesic consumption, pain intensity and less primary and secondary hyperalgesia in DM group. Also
2. Improved feeling of well-being and decreased sedation.
Abdominal hysterectomy10 45 Randomized case control Perioperative IV flurbiprofen vs. postoperative IV flurbiprofen 1. Decreased postoperative analgesic requirements
2. Perioperative group with less analgesic requirements than postoperative group.
Major amputation14 30 Randomized prospective Perioperative epidural analgesia vs. intraoperative perineural analgesia 1. Improved pain relief with perioperative epidural analgesia
Ambulatory knee arthroscopy18 84 Randomized prospective Subarachnoid block (SAB) vs. GA 1. Postoperative pain GA>SAB
2. PACU analgesic requirement GA>SAB
3. Oral intake was earlier with SAB
Lumbar disc surgery17 44 Prospective controlled 0.9% normal saline (NS) vs. 0.25% bupivacaine and methylprednisone in wound / paravertebral muscle 1. Bupivacaine and corticosteroids maintained adequate postoperatively. analgesia, also
2. Decreased opioid usage
Modified radical mastectomy21 60 Randomized prospective Total epidural anesthesia (TEA) vs. General anesthesia (GA) with opioids 1. Ready for discharge 1 Hour postoperatively - TEA>GA
2. More significant pain days 1,2&3 postoperatively - GA>TEA
3. Patient satisfaction TEA>GA
Thoraco-abdominal esophagectomy19 33 Randomized prospective Continuous thoracic epidural vs. IV PCA morphine 1. No significant difference in pain at rest.
2.Lower pain scores in patients with epidural
Elective colonic resection20 64 Randomized prospective IV PCA morphine vs. Epidural anesthesia with fentanyl and bupivacaine 1. Lower postoperatively pain scores in epidural group.
2. Lower fatigue scores in epidural group

In a study investigating ketorolac compared to placebo perioperatively, there was a decreased perception of pain in the ketorolac group and these patients required a decreased mean amount of narcotics postoperatively.8 Celecoxib compared to placebo, alone and in combination with acetaminophen was shown to cause improved patient satisfaction.9 An NSAID available in intravenous form in Europe also decreased analgesic requirements postoperatively when used either perioperatively or postoperatively.10 However, it had more impact on outcomes when used perioperatively. One of the concerns of using NSAIDs in the perioperative period is the effect on platelets and possible bleeding problems. Rofecoxib however showed no increase in bleeding or in the International Normalized Ratio (INR) when substituted for non-selective NSAIDs 10 days before total knee arthroplasty.11 An interesting finding is the effect of dextromethorphan which, when administered perioperatively, not only decreased pain perception after surgery but also increased the patients’ feeling of well being.12

An interesting finding is the effect of dextromethorphan which, when administered perioperatively, not only decreased pain perception after surgery but also increased the patients’ feeling of well being.12

Approximately 60% to 70% of amputees suffer from phantom pain in the first year after amputation.13 The use of perioperative epidural analgesia placed 24 hours perioperatively compared to intraoperative perineural analgesia did not offer significant difference in postoperative phantom limb pain. The perioperative epidural analgesia did, however, confer significant improvement in long-term pain relief.14 The mechanism for this difference is not currently known.

In a study by Kountakis (2002), no significant difference was found when comparing local infiltration of bupivacaine with normal saline perioperatively during tonsillectomy in either pain intensity over a ten-day period, oral analgesic use after surgery and oral intake after surgery.15 Using local anesthesia at the trocar sites of laparoscopic cholecystectomy was shown to decrease pain after surgery, reduce opioid requirements and use of antiemetics.16 Comparable findings regarding opioid use were found when methylprednisolone and bupivacaine were injected into the wound and paravertebral muscle in patients undergoing lumbar disc surgery.17 When compared to general anesthesia, neural blockades facilitated patients tolerating oral feeding earlier in the postoperative period.18

Despite the effectiveness of intravenous patient controlled analgesia (IV PCA) as a means of pain control in the postoperative period, a few comparative studies found instead that postoperative epidural analgesia resulted in lower pain scores,19,20,21 lower fatigue scores,20 earlier discharge times as well as improved patient satisfaction.21 Flisberg et al (1995) could not establish a significant difference in pain at rest in patients after thoraco-abdominal esophagectomy between management with continuous thoracic epidural or IV PCA morphine.19

A meta-analysis of randomized controlled trials to assess the effects of seven analgesic therapies on postoperative pulmonary function after various procedures showed that postoperative epidural pain control could significantly decrease the incidence of pulmonary morbidity.22 Using a suprascapular nerve block with general anesthesia was shown to reduce opioid demand in the immediate postoperative period by 51% together with a fivefold reduction in the incidence of nausea as well as visual analog and verbal pain scores.23 Duration of hospital stay was also reduced by 24%. This is similar to the findings using ilioinguinal hypogastic nerve block with monitored anesthesia care for unilateral inguinal hernia repair where patients had shorter time to home readiness, lower pain scores at discharge and lowest cost compared to general anesthesia and spinal anesthesia.24

Discussion

Patient satisfaction has become an important endpoint in outcomes research.25 Preemptive analgesia has been shown to improve patient satisfaction9 following surgery and opioid requirements have also been shown to be decreased.8 One of the potential side effects of NSAIDs is the effect on platelet function with possible perioperative bleeding. The authors found that the use of a cyclooxygenase-2 (COX-2) selective inhibitor rofecoxib does not increase INR or bleeding postoperatively. A significant number of patients in the elderly age group — especially those presenting for joint surgery — have to alter their palliation for arthritis perioperatively by discontinuing NSAIDs. The study by Reuben et al (2002) indicates that we can safely convert these patients to a COX-2 inhibitor prior to surgery without significant affectation of their coagulation profile.

The use of regional anesthesia perioperatively can act not only as preemptive analgesia but serve as an invaluable adjunct to general anesthesia. This can reduce the intraoperative anesthetic requirements and is also useful as a postoperative pain modality as well. Intraoperative infiltration of incision by surgeons has been shown to be beneficial for postoperative pain. This has been proven in lumbar disc surgey17 and laparoscopic surgery.16 Nerve blocks23,24 and subarachnoid blocks18 are other modalities that have been proven beneficial in improving patient outcomes. Adequate perioperative sedation may be an important factor for patient satisfaction with — and acceptance of — regional anesthesia, in part by attenuating intraoperative anxiety.26

While postoperative pain can be managed exceptionally well with regional anesthesia and analgesia, not all procedures are amenable to regional techniques so that, for these conditions, the appropriate use of analgesics, both opioid and non-opioid will provide the optimum improvement in patient well being. Concerns of respiratory depression are the most common reason for withholding the administration of narcotics postoperatively, especially in pediatric, elderly and non-intubated patients. Studies have shown that IV PCA is cost effective and, apart from being a very good analgesic modality, is associated with very high patient satisfaction.

The authors found that good planning and execution of perioperative pain management contributes to reduced intraoperative anesthetic requirements. For example, following thoracic and abdominal surgeries, patients can be extubated easier since there is less splinting due to pain. Adequate pain management using either IV PCA or epidural analgesia leads to improvement in pulmonary function even after thoraco-abdominal esophagectomy by postoperative day six, with thoracic epidural being associated with early mobilization and reduced pain.19 Regional anesthesia is usually associated with less sedation and contributes to patient satisfaction since patients can interact with family members soon after surgery. Modalities that reduce opioid requirements as outlined above also reduce potential opioid-related side effects such as respiratory depression, sedation, nausea, vomiting, pruritus, and orthostatic hypotension. Local anesthetic and regional analgesia techniques, while not without side effects themselves, are often associated with reduced cost to the institution along with better patient satisfaction.18, 24,26

Preemptive analgesia has been shown to improve patient satisfaction9 following surgery and opioid requirements have also been shown to be decreased.8

Several other reviews and meta-analysis have provided a comprehensive overview of the factors believed to influence patient satisfaction.27 These factors include patient-related determinants (socio-demographic factors, physical and psychological health and expectations), provider-related determinants (provider interactions and competence), and process-related (accessibility and convenience, ancillary services, bureaucratic factors, cost environmental factors and organization of healthcare).

Conclusion

This study has reviewed perioperative techniques that have the potential to reduce side effects, improve postoperative outcomes, and improve overall patient satisfaction for patients undergoing surgical procedures. While many of the studies reviewed had relatively small numbers of participating patients, the perioperative modalities presented provide useful techniques that can be adapted to each unique patient need.

Last updated on: May 16, 2011
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