Improvements and Difficulties in Postoperative Pain Management

A Systematic Review of Race, Sex, and Socioeconomic Status Differences in Postoperative Pain and Pain Management

1.1. Background: Postoperative pain remains one of the greatest burdens for patients following surgery. Nurses play a vital role in postoperative pain assessment and management following surgery. Therefore, nurses should have adequate knowledge about to carry out such responsibilities. 1.2. Methods: A descriptive cross-sectional study was conducted to assess the nurse’s knowledge regarding postoperative pain assessment and management among 50 respondents in NCMH, Nepal. Non –probability convenience sampling technique was used to select subject of the study. A self-prepared structured interview questionnaire was used to collect needed data. Ethical consideration was maintained to reduce biasness. Statistical Package of Social Science (SPSS) 21 was applied for data analysis. 1.3. Results: The study showed that majority of participants, twenty-six (52%) of respondents were the aged group of 20-24 year. It reported that 17.6% of the participants had low level of knowledge regarding postoperative pain management while 17.6% had medium level of knowledge, 64.7% had high level of knowledge. It was seen that knowledge regarding pain assessment was significantly higher than knowledge regarding management of pain (P=0.04). 1.4. Conclusion: However, majority of participants had high level of knowledge regarding postoperative pain management, nurse’s professional development, training, or in service education should be arranged to enhance knowledge of nurse regarding postoperative pain management

Objectives The aim of this systematic review is to identify the most effective interventions used by nurses in the relief/reduction of post-operative pain. Question What are the most effective nursing interventions in the management of surgical pain? Criteria for considering studies for this review Types of participants Adults (18 years and above) experiencing acute pain following surgery in acute care hospitals. Types of interventions Interventions related to management of post-operative pain by nurses. These include: • Administration of analgesia: including oral, IMI, PCA, Epidural; • Assessment and documentation of intensity of pain at regular intervals; • Protocols, clinical pathways or flow-sheet used in the management of pain; • Preoperative patient education; • Non-pharmacological interventions such as massage and relaxation. Types of outcome measures • Relief or reduction of post-operative pain of pain • Patient satisfaction • Length of hospital stay

The COVID-19 pandemic has significantly affected healthcare, particularly surgical care. Although short-term effects on surgical outcomes have been examined, understanding of long-term postoperative prognosis and pain management in COVID-19 patients remains limited. This knowledge gap is critical as the pandemic evolves and the need for optimized postoperative care becomes increasingly important. The primary objective of this study was to evaluate the impact of COVID-19 infection on postoperative outcomes and pain management in surgical patients. We aimed to assess surgical mortality, complication rates, and postoperative pain levels in COVID-19-positive patients relative to a closely matched control group. We conducted a retrospective cohort study of COVID-19 patients admitted to the ICU following surgery. Data were collected on baseline characteristics, postoperative complications, mortality and pain scores. Univariate and multivariate linear regression models were used to evaluate the impact of COVID-19 infection on postoperative pain. Stratified and interaction analyses were additionally performed to examine the robustness of these associations across subgroups. Mortality rates and the incidence of sepsis were significantly higher in the COVID-19 cohort. Patients with COVID-19 also experienced longer duration of mechanical ventilation in the ICU and prolonged ICU stays. In the fully adjusted multivariate linear regression model, COVID-19 infection was positively associated with higher postoperative visual analog scale pain scores (β = 1.51; 95% CI: 1.03-1.98; p < 0.001), corresponding to an average increase of 1.51 units in postoperative pain. Stratified analysis largely corroborated these findings across subgroups. Surgical intervention in patients with COVID-19 was associated with higher mortality and sepsis rates, longer ICU stays, and increased postoperative pain scores. These findings highlight the need for continued research to optimize surgical care and improve patient outcomes in the evolving post-pandemic era.

A prospective randomized study to analyze the efficacy of balanced pre-emptive analgesia in spine surgery

Parental involvement in their school-aged childrenʼs post operative pain management in the hospital setting: a systematic review

Ropivacaine is a long-acting amide local anaesthetic agent and first produced as a pure enantiomer. It produces effects similar to other local anaesthetics via reversible inhibition of sodium ion influx in nerve fibres. Ropivacaine is less lipophilic than bupivacaine and is less likely to penetrate large myelinated motor fibres, resulting in a relatively reduced motor blockade. Thus, ropivacaine has a greater degree of motor sensory differentiation, which could be useful when motor blockade is undesirable. The reduced lipophilicity is also associated with decreased potential for central nervous system toxicity and cardiotoxicity. The drug displays linear and dose proportional pharmacokinetics (up to 80 mg administered intravenously). It is metabolised extensively in the liver and excreted in urine. The present article details the clinical applications of ropivacaine and its current place as a local anaesthetic in the group.

Background: Post-operative surgical pain of at least 2- month duration in absence of clear causes was defined as Chronic Post-operative Surgical Pain syndrome (CPSP). Transversus Abdominis Plane (TAP) block is a new imple-mented regional anaesthetic technique included in the analgesic regimen for many abdominal surgeries to reduce immediate post-operative pain and opioid requirements. Aim of Study: To assess the feasibility and efficacy of US guided TAP block in the management of chronic post-operative surgical pain. Patients and Methods: US-guided TAB block done for 20 patients complaining of chronic lower abdominal pain around 3-months to one-year duration after surgical operation with injection of 20ml of bupivacaine 0.25% and 2ml of methyl prednisolone (40mg/ml). Unilateral injection done for 12 patients & bilateral injections done for 8 patients. Second injection done for 6 patients after 3 months (three unilateral & three bilateral). Patient's pain intensity was assessed by Visual Analogue Score (VAS) before procedure & during follow-up visits for the next six months. Results: Three months after US-guided TAP block; 5 patients with mild degree of pain & 2 out of 10 patients with moderate degree of pain became completely pain free, while other 13 patients acquired relative improvement (5 patients with mild degree of pain and 8 patients with moderate degree of pain). Six months after US-guided TAP block; 6 patients (accepted second injection) improved with mild degree of pain while other 2 patients showed little improvement with still moderate degree of pain. Conclusion: Ultrasound guided TAP block is safe and effective method in management of chronic post-operative surgical pain.

Background: Active participation in pain management is vital to improve postoperative pain outcomes. However, this issue has not been fully examined in Vietnam. This study aimed to examine the active participation of patients in pain management after surgery, as well as explore its effect on acute postoperative pain. Methods: A hospital-based survey on 245 patients after surgery was conducted. Information about demographic and clinical characteristics, pain intensity and active participation in pain management was collected. Multivariate regression models were utilized to determine the associations. Results: 53.9% of patients reported that they were informed about the postoperative pain relief method before surgery. One-third (33.5%) of patients selected preferred pain relief methods; 46.1% reported that they asked physicians when feeling pain immediately after surgery; 49.8% asked physicians when pain was not relieved after taking medications, and 52.2% asked physicians for their current pain in the time of interview. Age and occupation were found to be positively associated with active participation score. Patients being informed about the postoperative pain relief method before surgery had 0.87 points higher than those not receiving explanation (Coef. = 0.87; 95%CI = 0.49–1.26). Patients with high active participation scores were more likely to have pain improvement (OR = 3.41, 95%CI = 2.37–4.92). Conclusion: This study highlights a low level of active participation in postoperative pain management among Vietnamese patients. Routinely providing information about pain control before surgery, and encouraging patients to actively participate in pain management are essential to improve postoperative pain outcomes.

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. 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. 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. 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. 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.

Purpose This study aims to assess the effect of the implementation of the Six Sigma approach to improve the quality of post-operative pain management in patients attending Alexandria University Student Hospital. Design/methodology/approach A pre-post interventional study involving patients over the age of 16 years old who were proposed and planned for any surgical operation at Alexandria University Student Hospital. We used Six Sigma’s define, measure, analyze, improve and control (DMAIC) improvement process. Data were gathered from samples evaluated six months before the Six Sigma project’s implementation and seven months after the project’s implementation. The areas selected for improvement were using postoperative pain assessment and reducing postoperative pain management POPM defects. Findings There was a significant decrease in the overall mean (SD) of the worst pain score between the pre-intervention 7.5 (±2.4) and post-intervention 2.7 (±1.9) phases (p < 0.001). A significant decrease (p < 0.001) in the DPMO between pre-and post-intervention phases (580773.4, 78678.2 respectively). That decrease was followed by an improvement in the sigma level of the POPM process (from 1.375 to 3 sigma level). Practical implications This research underscores the efficacy of ongoing quality improvement initiatives, particularly through the Six Sigma DMAIC methodology, in enhancing surgical care by optimizing postoperative pain management. Implementing Six Sigma can significantly increase patient satisfaction by reducing discomfort and improve recovery outcomes by minimizing complications like blood clots, infections and chronic pain. Additionally, it promotes optimal resource utilization and cost efficiency in health-care systems by streamlining pain management procedures. Overall, the study confirms that Six Sigma effectively improves postoperative outcomes and reduces process defects in pain management. However, the research contains a few pitfalls which may be the exclusion of cancer patients, children under 16 years old and intensive care patients. These excluded groups might have different pain management needs and responses and different pain assessment tools, so the results may not apply to these populations. Besides, the research considered mainly general surgery and orthopedic operations for improvement. As they were the most prevalent types of surgeries in the research setting. Originality/value Health-care organizations can improve postoperative pain treatment by implementing the Six Sigma strategy, which incorporates technical integration, patient-centric measurements, customized programs and ongoing improvement. To the best of our knowledge, this is the first study in Egypt and worldwide to investigate the implementation of the Six Sigma strategy in post-operative pain management.

Postoperative pain is common in hospital-admitted patients. Its management is determined by different therapeutic traditions and by the attitudes of health professionals in each hospital. The aim of this study was to describe the patterns of prescription and administration of analgesic drugs used for postoperative pain after abdominal surgery in Spanish hospitals, to know the prevalence and the severity of postoperative pain, and to determine the extent of variability in the management of postoperative pain among the participating centres. The study was a multicentre descriptive cross-sectional drug utilization study in 12 Spanish hospitals. The subjects were an unselected sample of consecutive patients undergoing abdominal surgery, admitted between October 1994 and January 1995. For each patient, information about the surgical procedure and the use of analgesics was prospectively collected. The severity of postoperative pain was assessed during the first day after surgery by means of a six-category (none, mild, moderate, severe, very severe, and unbearable) rating scale and a visual analogue scale (VAS). Nine hundred and ninety-three patients (547 men) were included. The most common surgical procedures were inguinal hernia repair (315, 32%), cholecystectomy (268, 27%), appendectomy (140, 14%), bowel resection (137, 14%), and gastric surgery (58, 6%). Fifty-nine percent of patients (587) received nonopioid analgesics only, 9% (89) received opioid analgesics only, and 27% (263) received both opioid and nonopioid analgesics. The most frequently administered drugs were metamizole (667 patients) and pethidine (213 patients). Although in the majority of medical orders the administration of analgesics was scheduled at regular time intervals, the majority of actual doses were given 'as-needed'. The average administered daily doses of all analgesics were lower than those prescribed. Thirty-eight percent (371/967) of patients rated their maximum pain on the first day as severe to unbearable. Wide interhospital variability was recorded in the surgical procedures which had been performed, in the analgesics used, and also in the pain scores referred by patients. The percentage of patients in each centre who suffered severe to unbearable pain varied from 22 to 67%. In Spain many patients still suffer severe pain after abdominal surgery, and this seems to be due to an inadequate use of analgesics. Wide interhospital variability in the management of postoperative pain and in its prevalence was also recorded.

This narrative review explores the crucial aspects of postoperative pain management within the framework of Enhanced Recovery After Surgery (ERAS). It emphasizes the significance of effective and secure pain management, highlighting its impact on patient well-being, surgical outcomes, and hospital stays. The inadequacy of perioperative pain relief increases the risk of persistent postoperative pain, emphasizing the need to challenge the notion that pain is expected after surgery. The goals of postoperative pain management extend beyond mere relief, encompassing comfortable sleep, pain-free rest, and liberation from pain during initial recovery. Inadequate pain management can lead to complications such as heightened postoperative bleeding and an increased risk of thrombosis. The review delves into various analgesic methods, their complications, and safety measures.ERASprograms, focused on reducing complications and medical costs, emphasize the importance of judicious postoperative pain management and active rehabilitation. The review discusses complications associated with analgesic methods like opioids, epidural analgesia, and adjuvant analgesics. Collaboration within the perioperative management team is crucial for effective postoperative pain relief. Interdepartmental collaboration is essential for evaluating surgical procedures, analgesic methods, and crisis management strategies. The review concludes by integrating precision medicine into postoperative pain management, emphasizing the potential of genetic information in assessing pain sensitivity. It underscores the importance of inter-departmental collaboration and information gathering for the successful implementation of precision medicine tailored to each facility's perioperative management systems. Additionally, the impact of artificial intelligence (AI) on preoperative risk assessment and innovative monitoring techniques is discussed, paving the way for the advancement of precision medicine in postoperative pain management.

What's New in Spine Surgery.

ObjectiveThe goal of this study was to compare postoperative surgical site pain in gynecologic cancer patients who underwent elective extended lower midline laparotomy and managed their pain with either the ON-Q pain management system (surgical incision site pain relief system, ON-Q pump) or an intravenous patient-controlled analgesia pump (IV PCA).MethodsTwenty gynecologic cancer patients who underwent elective extended lower midline laparotomy were divided into two groups. One group received a 72-hour continuous wound perfusion of the local anesthetic ropivacaine (0.5%, study group) into the supraperitoneal layer of the abdominal incision through the ON-Q pump. The other group received intravenous infusion pump of patient-controlled analgesia (fentanyl citrate 20 mg/mL · kg+ondansetron hydrochloride 16 mg/8 mL+normal saline). Postoperative pain was assessed immediately and at 6, 24, 48, 72, and 96 hours after surgery using the visual analogue scale.ResultsPostoperative surgical site pain scores at 24, 48, and 72 hours after surgery were lower in the ON-Q group than the IV PCA group. Pain scores at 24 hours and 48 hours after surgery were significantly different between the two groups (P=0.023, P<0.001). Overall painkiller administration was higher in the ON-Q group but this difference was not statistically significant (5.1 vs. 4.3, P=0.481).ConclusionThis study revealed that the ON-Q pain management system is a more effective approach than IV PCA for acute postoperative surgical site pain relief after extended lower midline laparotomy in gynecologic cancer patients.