Criticare - A special feature on Anaesthesiology

Minimising post operative pain through ‘Acute Pain Services’

Dr S Gajendragadkar and Dr J D’Mello

“An hour of pain is as long as a day of pleasure” Proverb

A priority for any anaesthesiologist is to achieve the best possible patient care. After a surgery, the focus of the anaesthesiologist is to provide effective pain relief and maximum comfort to the patient. As rightly said by Armitage, ‘Slapping the patient on the face and telling him or her it is all over, is the complete inversion of the truth. As far as the patient is concerned, it is often the beginning.’

The International Association for Study of Pain and the American Pain Society defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

The word pain comes from the Greek “poin” meaning penalty or Latin “poena” meaning punishment. Pain was often thought to be punishment from the Gods. Sadly, till today, the post operative pain continues to be under managed largely due to apathy of medical professionals, risk of respiratory depression and the attitude of patient and his relatives towards pain.

Unrelieved post operative pain can lead to delayed discharge and recovery and inability to participate in rehabilitation programmes. So significant are the benefits of treating pain effectively that the Joint Commission on Accreditation of Healthcare Organisations commanded that all institutions should develop pain management programmes as a criterion for regaining certification. This changed the emphasis to patient satisfaction as an essential element that drives the clinical activity of healthcare professionals.

Many modalities of pain relief are available which include oral / IV analgesics, non steroidal anti-inflammatory drugs (NSAIDs), epidural blocks, peripheral nerve blocks etc. Multimodal therapy is optimal and effective as it can tackle various aspects of pain. The acute pain ladder is depicted below.

Post-operative pain relief continues to be a medical challenge. In spite of the documentation of benefits of pain relief, pain continues to be under treated. Solution to the problem of inadequate pain relief lies not in the development of new analgesic drugs and technologies, but development of organised approach to utilise existing expertise.

The concept of an Acute Pain Service (APS) was introduced in the US in late 1980s and then gradually spread to the UK in 1990s. Most major institutes in the US have anaesthetist-based APS. The APS team typically consists of anaesthesiologists, specially trained nurses, physiotherapists and biomedical personnel.

This type of APS gives better results but is more expensive. Some institutions follow anaesthesiologist supervised nurse based APS.

Components of APS include

• Designated personnel who are responsible for providing 24 hours APS
• Regular pain assessment at rest and movement, and assessment of pain scores
• Standardisation of equipment, assessment charts and prescription guidelines
• Active co-operation with surgeons and ward nurses
• Patient education about pain monitoring and treatment options, goals, benefits and adverse effects
• Audit for effective use of pain management tools and research Service satisfaction.

PD Hinduja National Hospital has been a pioneer in establishing APS in Mumbai since 1996. The hospital provides 24-hour APS. Our APS is anaesthesiologist-based. The team consists of six consultant anaesthesiologists, twelve resident anaesthesiologists and three biomedical personnel (for maintenance of PCA pumps).

Every patient undergoing major orthopaedic, oncosurgery, spine surgery, general surgery (laparotomies, APR etc) is given patient controlled analgesia (PCA) for post operative pain relief. PCA pumps are specially designed for this purpose. They give continuous background infusion superimposed on patient controlled boluses. This maintains serum drug levels with improved analgesia, decreased side effects, less total drug use, more rapid return to physical activity. Moreover, the patient feels in control.

Pain relief is provided via intravenous (IV) PCA, epidural PCA, or combination of IV PCA and peripheral nerve blocks. All patients receive non steroidal anti inflammatory drugs unless contraindicated. We have standard protocols for the use of drugs. Opioids are used for IV PCA and local anaesthetics with or without opioids are used for epidurals.

Assessment of pain scores is done by visual analog scales (VAS). Pain is assessed one hourly for first three hours and three hourly thereafter. It is scored from 0 to 10 where 0 is ‘no pain’ and 10 is the ‘maximum pain’. The aim of APS is to keep the pain scores below three at all points.

The recovery room nurses are trained to monitor pain. Regular lectures are taken for the ward nurses (every three months) by one of the APS consultants.

Pain is now widely accepted to be the ‘fifth vital sign’ that needs monitoring after temperature, pulse, respiration and blood pressure. The patient’s vital parameters, pain scores, sensory level/motor power (for epidural PCA), side effects like nausea, vomiting, itching, urinary retention, and thrombophlebitis are monitored at regular intervals by APS members. Protocols to identify and treat complications (respiratory depression, hypotension) are available on each floor. IV Naloxone and all emergency drugs are also available on each floor.

Every patient enrolled in APS is assessed at least once a day by a consultant anaesthesiologist. ‘Pain rounds’ are taken by resident anaesthesiologists at least twice a day and as and when required. Any problems/queries are sorted out on the rounds. It is the duty of the APS team and the floor nurse to educate the patient regarding the use of PCA pump and the potential benefits of effective pain relief. Records are maintained on a standardised PCA form. Patient satisfaction is noted at the time of discontinuation of the service. The PCA records are regularly audited.

All PCA pumps are regularly checked and serviced by our colleagues in the biomedical department.

With such a multidisciplinary team approach, post-operative patients can look forward to a painless recovery without stress and anxiety.

The writers are consultant anaesthesiologists with PD Hinduja National Hospital & Medical Research Centre, Mumbai