Effectiveness of acute postoperative pain management: I' Evidence from published data

1
Effectiveness of acute postoperative pain
managementI. Evidence from published data

• R4???
• British Journal of Anaesthesia 89(3)409-23(2002)

2
Context

• Introduction
• Method
• Result
• Discussion
• How much pain is acceptable after surgery?
• Adequate analgesia?
• Satisfaction good analgesia?
• Restoration of bowl function?
• Does morphine effect the bowel function?

3
Introduction I

• Royal colleges of surgeons and anesthetists
• 1994 73 had pain service
• 1999 88 established pain service
• Severe pain experience
• 1997 -- 20 patients ? experience severe pain
• 2002 less than 5

4
(No Transcript)
5
Introduction II

• Pain relief method
• Intramuscular (IM)
• Intravenous patient-controlled analgesia (IVPCA)
• Epidural analgesia

6
Introduction III

• Three broad areas of outcome
• Effectiveness
• Pain scores
• Safety
• Respiratory depression
• Hypotension
• Tolerability
• Nausea vomiting
• Sedation
• Itching
• The need for urinary catheterization

7
Methods
8
Method

• Keywords pain, pain therapy, IV PCA,
• Epidural analgesia
• English language journals Anaesthesia, British
  Journal of Anaesthesia, Acta Anesthesiologica
  Scandinavica, Anesthesiology
• 1980-1999
• Task force levels of evidence level 2-3

9
United states preventive task force levels of
evidence

• Level 1
• Systematic review of relevant randomized
  controlled trials with meta-analysis
• Level 2
• One or more well-designed randomized clinical
  trial
• Level 3
• Well-designed, non-controlled studies
  (prospective longitudinal study with/without
  specific intervention) or from well-designed
  case-controlled studies

10
(No Transcript)
11
Definition

• Analgesic failure
• Who experienced moderate-severe pain
• Who experienced severe pain
• At some time during the first 24h
• Pain scale
• VAS (visual analogue scale)0-100mm
• NRS (Numerical rating scale)0-10
• Verbal rating scale (mild/moderate/severe)

12
Results
13
Pain intensity
14
(No Transcript)
15
(No Transcript)
16
(No Transcript)
17
(No Transcript)
18
Discussion
19

• How much pain is acceptable after surgery?
• Adequate analgesia?
• Satisfaction good analgesia?
• Restoration of bowl function?
• Does morphine effect the bowel function?

20
How much pain is acceptable after surgery?

• The evidence from this review ? severe pain 11
• Pain evaluation is complex
• Pain at rest or movement?
• Cough, physiotherapy, dressing change

21
Adequate analgesia

• IM? the highest percentage of inadequate
  analgesia (mod-severe severe6730)
• Epidural analgesia gt PCA
• Scott report epidural analgesic failure 17.4
• Stenseth report PCA failure 24-37
• The total review
• EA suffered severe mod-severe 7.820.9
• PCA10.435.8
• EA technical failure 5.7

22
Satisfaction good analgesia?

• Satisfaction is complex
• Effectiveness of analgesia
• Analgesic technique
• Side-effects of treatment
• Patient satisfaction still high even presence of
  mod-severe pain
• Pre-OP psychological support
• Carer
• ?1. satisfaction does not actually measure what
  happened after surgery
• 2. pain relief teaching

23

• Severe pain experience
• 1997 -- 20 patients ? experience severe pain
• 2002 less than 5? may not be achievable

24
Restoration of bowl function

• EA gt PCA
• Surgical endoscopy 2007 21247-252
• Postoperative ileus
• Surgical stress
• Pain
• Inflammatory mediators
• Mechanical handling
• Delay feeding
• ?parasympathetic tone ?

25
Does morphine affect the bowel function?
Colon rectum 200043163-168

• Narcotics affect bowel function
• Morphine? delay transit in small bowel and left
  colon
• Myoelectric complexes? non-propulsive movement
• May be useful to replace by Keto
• 45 reduction of opioid usage

26
Thanks for your attention