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The Post-Operative Pain Experience and an Assessment of Analgesic Administration in elective surgical patients at a teaching hospital in Kingston, Jamaica


Ingrid Tennant1, Richard Augier1, Annette Crawford-Sykes1, Doreen Ferron-Boothe1, Nicola Meeks-Aitken1, Karen Jones1, Georgiana Gordon-Strachan2, Hyacinth Harding-Goldson1.

 

Institutional Affiliation of Authors:
(1) Department of Surgery, Radiology and Anaesthesia and Intensive Care,
(2) Health Research Resource Unit, Dean’s Office, Faculty of Medical Sciences, University of the West Indies.

Corresponding Author:
Ingrid A. Tennant
Department of Surgery, Radiology, Anaesthesia and Intensive Care
University of the West Indies
Mona, Kingston 7.

Key Words:
Postoperative pain
Postoperative analgesia
Patient satisfaction

SUMMARY


Postoperative pain continues to be inadequately managed leading to patient discomfort and an increased incidence of a multitude of complications. The objectives of this study were to assess postoperative pain scores, analgesia prescriptions and their implementation and patient satisfaction with their pain control.

A prospective, descriptive cohort study was undertaken at the University Hospital of the West Indies (UHWI), Kingston, Jamaica. Data was collected by trained personnel via a postoperative interview and review of in-patient charts 24 to 48 hours after anaesthesia. A verbal numerical rating scale (VNRS) of 0 to 10 was used to assess pain severity. Data were analysed using SPSS version 12.

A total of 499 patients participated, 290 gynaecological and 209 orthopaedic. There were 368 females (73.7%) and the mean age was 44.7 ± 15.6 years. The majority of patients had general anaesthesia (80.5%). No pain was reported by 10.6% of patients, 20.8% had mild pain (scores of 1-3), 26.3% had moderate pain (4-6), and 42.3% experienced severe pain (7-10). Younger patients (<60 years) and those having undergone orthopaedic procedures reported more severe postoperative pain (p<0.001 and p=0.001 respectively). Opioid analgesics were administered as ordered in only 33.9% of patients and gynaecological patients were less likely to receive opioids at the prescribed dosing intervals (p<0.001). NSAIDs were given as ordered in 80.3% of patients. The majority of patients thought that their pain management was either excellent (43.6%) or very good (25.3%) and only 3.4% assessed their pain control as poor. Gynaecological patients gave better assessments of their pain management (p<0.001).

Most patients at this institution still experience moderate to severe pain postoperatively, and provision of analgesia is suboptimal. Despite this, satisfaction with pain management was high. Our observations highlight the need for dedication of greater resources to acute pain control in the peri-operative period.

INTRODUCTION


Effective postoperative pain management continues to be a challenging clinical problem, as evidenced by several studies from the United States and Europe which have reported that postoperative pain management remains poor and that up to 80% of patients experience pain post surgery (Apfelbaum et al., 2003, Benhamou et al., 2008). Inadequate management of postoperative pain can have profound implications, and has been shown to increase morbidity and mortality as well as costs (Carr and Goudas, 1999). Some of the negative clinical outcomes increased by inadequate post-operative analgesia include deep vein thrombosis, pulmonary embolism, coronary ischemia, myocardial infarction, pneumonia, poor wound healing, insomnia, chronic pain syndromes and demoralization (Breivik, 1998, Carr and Goudas, 1999). The implications of these complications include prolonged hospital stay, readmissions and patient dissatisfaction with medical care (Apfelbaum et al., 2003, Twersky et al., 1997). The failure to provide good postoperative analgesia is multifactorial. Among its causes are insufficient education, fear of complications associated with analgesic drugs, poor pain assessment and inadequate staffing (Ramsay, 2000).

The objective of postoperative pain management is to relieve pain while keeping side effects to a minimum. A multimodal approach using different drugs and techniques can achieve both these goals (Kehlet and Dahl, 1993). Coordinated collaboration between anaesthesia, surgery, acute pain management teams and the postsurgical nursing staff is necessary to achieve the full benefits of improved analgesic regimes (White and Kehlet, 2010).

An understanding of the postoperative pain experience from a patient’s perspective is important if health care professionals are to identify ways to improve care. The objective of this study was to characterize the postoperative pain experience, assess analgesia prescriptions and their implementation and assess patient satisfaction with postoperative pain management.

METHODS


A prospective, descriptive cohort study was undertaken between June 2009 and September 2010 at the University Hospital of the West Indies (UHWI), Kingston, Jamaica. This is a 500-bed, multidisciplinary, tertiary referral centre and teaching hospital affiliated to the University of the West Indies (UWI). Ethical approval was obtained from the UWI Faculty of Medical Sciences Ethics Committee and informed consent procured from each patient. Elective orthopaedic and gynaecological patients receiving either a general or regional anaesthetic were included. The following groups of patients were excluded:
1. Patients under 16 years;
2. Patients with a diagnosis of mental retardation or senile dementia;
3. Patients who were hearing impaired;
4. Day-case patients (discharged within 24 hours post anaesthesia);
5. Patients who refused or were unable to participate in the study.

Data collected included the patient’s age, gender, American Society of Anesthesiologists (ASA) physical status score, preoperative medical conditions, anaesthetic technique and length of anaesthesia. Surgical procedures were graded according to perceived associated risk into major (such as Wertheim’s hysterectomies, total knee replacements), intermediate (hysterectomies, open reduction and internal fixation of fractures) and minor (biopsies, or incision and drainage of abscesses). A postoperative interview and review of in-patient charts was conducted 24 to 48 hours after anaesthesia by trained research nurses or one of the research anaesthetists. A verbal numerical rating scale (VNRS) of 0 to 10 was used to assess pain severity, where 0 represented “not present” and 10 represented “the worst pain one could imagine”. The level of patient satisfaction with their pain management and anaesthesia care were assessed via a 5-point and 7-point Likert scale respectively.

Data were analysed using SPSS version 12. Potential risk factors for inadequate postoperative analgesia were assessed using bivariate analysis and the chi-square test. A p-value of less than 0.05 was accepted as statistically significant.

RESULTS


A total of 499 patients participated in this study, 290 were post gynaecological and 209 post orthopaedic surgery. There were 368 females (73.7%) and 131 males (26.3%). The mean age was 44.7 ± 15.6, ranging between 16 and 88 years with a median of 43 years. The orthopaedic patients were slightly younger than the gynaecological patients (42.8 ± 18.2 vs. 46.1 ± 13.2 p=0.02). Most patients were assessed as either ASA 1 (55.3%) or 2 (37.9%) [Table 1]. Medium risk surgeries accounted for the majority overall (83.2%), but orthopaedic patients had a higher number of high risk surgeries (32.1% vs. 1%, p<0.001). Most gynaecological procedures lasted between 1 and 2 hours (50%), while about 60% of orthopaedic surgeries were over 2 hours (p<0.001) [Table 2].

Overall, 30.5% of patients had one comorbidity and 16.8% had two or more (Table 1). The most common were hypertension (25.9%) and diabetes mellitus (9.4%), with there being a significantly higher incidence of hypertension in the gynaecological patients (31.4% vs. 18.2%, p=0.001). The majority of patients had general anaesthesia (80.5%), with the remainder having either a central neuraxial block (17.7%), or peripheral nerve block (1.4%). Regional techniques were more commonly used in orthopaedic patients (38.1% vs 6.2%, p<0.001) [Table 2].

Table 1: Patient demographics/ characteristics

Variable

Gynaecology patients

n=290

Orthopaedic patients

n=209

Total

n=499

p-value

Age

46.1 ± 13.2

42.8 ± 18.2

44.7 ± 15.6

0.02

Sex

     Male

     Female

 

0

290 (100%)

 

131 (62.7%)

78 (37.8%)

 

131 (26.3%)

368 (73.7%)

 

0.163

ASA 1

ASA 2

ASA 3

ASA 4

146 (50.3%)

130 (44.8%)

14 (4.8%)

0

130 (62.2%)

59 (28.2%)

19 (9.1%)

1 (0.5%)

276 (55.3%)

189 (37.9%)

33 (6.6%)

1 (0.2%)

0.001

Comorbidities:

None

One

≥ 2

 

157 (54.1%)

96 (33.1%)

37 (12.8%)

 

106 (50.7%)

56 (26.8%)

47 (22.5%)

 

263 (52.7%)

152 (30.5 %)

84 (16.8%)

 

0.013

 

 

 

 

 

 

 

Table 2: Characteristics of surgery and anaesthesia by specialty

Variable

Gynaecology pts

(n=290)

Orthopaedic pts

(n=209)

Total

(n=499)

p-value

Surgical risk category:

1

2

3

 

5 (1.7%)

282 (97.2%)

3 (1%)

 

9 (4.3%)

133 (63.6%)

67 (32.1%)

 

14 (2.8%)

415 (83.2%)

70 (14%)

 

<0.001

Anaesthetic technique:

General

Spinal/ epidural

PN block

Combined

 

272 (93.8%)

18 (6.2%)

0

0

 

129 (62.1%)

70 (33.7%)

7 (3.4%)

2 (1%)

 

401 (80.5%)

88 (17.7%)

7 (1.4%)

2 (0.4%)

 

<0.001

Duration of procedure:

<60 mins

60-119mins

120-179 mins

≥180 mins

 

31 (10.7%)

145 (50%)

83 (28.6%)

31 (10.7%)

 

27 (12.9%)

59 (28.2%)

60 (28.7%)

63 (30.1%)

 

58 (11.6%)

204 (40.9%)

143 (28.7%)

94 (18.8%)

 

<0.001

 

 

 

 

 

Table 3: Factors contributing to pain severity

 

No pain

 

n (%)

Mild pain

 

n (%)

Moderate pain

n (%)

Severe pain

n (%)

p-value

Specialty

Gynaecology

Orthopaedics

 

25 (8.6)

28 (13.4)

 

75 (25.9)

29 (13.9)

 

86 (29.7)

45 (21.5)

 

104 (35.7)

107 (51.2)

 

<0.001

Gender

     Male

     Female

 

14 (10.7)

39 (10.6)

 

15 (11.5)

89 (24.1)

 

32 (24.4)

99 (26.9)

 

70 (53.4)

141 (38.0)

 

0.005

Age

     <60 yrs

     ≥60 yrs    

 

39 (9.4)

14 (16.9)

 

77 (18.5)

27 (32.5)

 

109 (26.2)

22 (26.5)

 

191 (45.9)

20 (24.1)

 

0.001

Anaesthetic technique

     General

     Spinal/ Epidural

     PN block

     Combined

 

41 (10.2)

9 (10.2)

2 (28.6)

1 (50)

 

90 (22.4)

13 (14.8)

1 (14.3)

0

 

113 (28.2)

18 (20.5)

0

0

 

157 (39.2)

48 (54.5)

4 (57.1)

1 (50)

 

0.056

Surgical risk grade

      1

      2

      3

 

2 (14.3)

41 (9.9)

10 (14.3)

 

1 (7.1)

88 (21.2)

15 (21.4)

 

3 (21.4)

116 (28.0)

12 (17.1)

 

8 (57.1)

170 (41.0)

33 (47.1)

 

0.346

Comorbidities

     None

     ≥ 1

 

28 (10.6)

25 (10.6)

 

61 (23.2)

43 (18.2)

 

59 (22.4)

72 (30.5)

 

115 (43.7)

96 (40.7)

 

0.184

 

 

 

 

 

 

 

Table 4: Patient Satisfaction with Postoperative Pain management

Pain control

Gynaecological patients

n (%)

Orthopaedic patients

n (%)

Total

n (%)

Excellent

151 (58.1)

66 (31.7)

217 (43.6)

Very good

77 (26.6)

49 (23.6)

126 (25.3)

Good

41 (14.1)

64 (30.8)

105 (21.1)

Adequate

14 (4.8)

19 (9.1)

33 (6.6)

Poor

7 (2.4)

10 (4.8)

17 (3.4)

 

Postoperatively, the reported worst pain experienced (VNRS) was a median score of 5, but a mode of 10. A VNRS of 10 was reported in 14.8% of patients, followed by a score of 8 in 13.2%. Approximately eleven percent of patients (10.6%) reported having no pain at all, 20.8% had mild pain (scores of 1-3), 26.3% had moderate pain (4-6), and 42.3% experienced severe pain (7-10). Orthopaedic patients reported more severe postoperative pain (51.2% vs 35.9%, p<0.001) [Table 3]. The median VNRS in gynaecological patients was 5 with modes of 5 and 8, and in orthopaedic patients was 7, with a mode of 10. Older patients (≥60 years) reported milder pain than their younger counterparts (p=0.001) with a median VNRS of 4 in comparison to 6 in patients less than 60 years. Severe pain (VNRS 7-10) was reported in 46% of patients < 60 years compared to 24% in those ≥ 60 years. Females also reported less pain in comparison to males (p=0.005) [Table 3]. However, when adjusted for specialty, gender was no longer a significant predictor of postoperative pain (p=0.163). The procedure risk (p=0.346), duration of procedure (p=0.218), anaesthetic technique (p=0.055) and the presence of comorbidities (p=0.178) were not significant predictors of postoperative pain.

Analgesia prescribed was most commonly an intramuscular opioid, usually Pethidine (Meperidine) and a rectal or oral non-steroidal anti-inflammatory drug (NSAID), usually Diclofenac. Approximately 75% of patients were prescribed 100mg Pethidine every six hours. The remainder were prescribed either 75mg (16.2%) or 50mg (6.8%) and these were mainly orthopaedic patients (p<0.001). Opioid analgesics were administered as ordered in only 33.9% of patients and gynaecological patients were less likely to receive opioids at the prescribed dosing intervals (p<0.001). NSAIDs were given as ordered in 80.3% of patients, with no difference between specialties (p=0.395).

The majority of patients thought that their pain management was either excellent (43.6%), very good (25.3%) or good (21.1%). Only 3.4% assessed their pain control as poor. Gynaecological patients were more likely to give a better assessment of their pain management (58.1% vs 31.7%, p<0.001) [Table 4].There was a positive correlation between patient’s assessment of their pain control and their overall anaesthetic experience (p=0.014).

DISCUSSION


Despite an increased emphasis on postoperative pain management over the last several years, a significant number of patients continue to experience moderate to severe pain after surgery (Apfelbaum et al., 2003, Benhamou et al., 2008). In 2004, the American Society of Anesthesiologists published guidelines for acute pain management in the perioperative setting (ASA, 2004). These guidelines highlight the need for prompt recognition and treatment of pain, as well as use of modern analgesic technologies. However, in this study, postoperative analgesia was found to be inadequate in approximately 69% of our elective patients, who reported a VNRS of 4 or greater. This is similar to results in the literature from the United States, where significant postoperative pain has been reported in up to 75% of patients (Apfelbaum et al., 2003).

PCA has been shown to improve pain scores postoperatively and to increase patient comfort and satisfaction (Kehlet and Holte, 2001, Walder et al., 2001). Continuous epidural local anaesthetic techniques are the most effective method of providing dynamic pain relief after major procedures especially post orthopaedic surgery (Rodgers et al., 2000). Unfortunately, at our hospital such newer modalities of pain management are not consistently used because of the high cost attached and the unavailability of suitable staff for their management. In this study, regional or combined techniques were not used to a great extent in the orthopaedic patients. Where regional techniques were used intra-operatively their use was not continued post-operatively for analgesia. This very likely contributed to the poor analgesia achieved in this group of patients.

Although we were hampered by lack of modern technologies, this study highlighted the fact that we were also not optimizing standard analgesic regimes. Intramuscular opioids may not be ideal, but can be efficacious if administered appropriately, both in terms of actual dose as well as dosing interval. Pethidine (Meperidine) has a half-life of 3 to 4 hours, with peak plasma concentrations being reached in 15-60 minutes after intramuscular injection (Clark et al., 1995). Therefore, a dosing interval of four hours is recommended. In this study, the observed analgesia prescriptions were not patient-specific, but generic and the dosing interval of 6 hours was too long, predisposing to breakthrough pain. In addition, the interval between opioid doses was longer than that prescribed in most (66%) instances. The reasons for this were not explored, but possible explanations could include staffing challenges that result in a delayed response to requests for analgesia, and a belief that analgesics should only be administered when pain is severe. NSAIDs were routinely used to supplement opioid analgesia, and both the dosage and dosing interval was much more appropriate, probably reflecting a feeling of a greater “safety margin” with its use. It is well established that NSAIDs provide moderate postoperative analgesia and thereby an opioid-sparing effect of 20–30% (Power and Barratt, 1999).

Interestingly, despite dismal results in reported pain scores, patients’ satisfaction with pain control was surprisingly very good. Almost all of the patients (90%) gave a positive response regarding their pain management, which is similar to other studies (Donovan, 1983, Nimmaanrat et al., 2007, Rocchi et al., 2002). This could be related to an expectation of pain as an unavoidable sequelae of a surgical procedure and little awareness of the efficacy of current analgesics (Chung and Lui, 2003, Svensson et al., 2001). In addition, patients’ responses are influenced by the level of empathy and friendliness demonstrated by the staff rather than the outcomes of pain relief (Svensson et al., 2001). In one study by Nimmaanrat et al in postoperative gynaecological patients, 71% believed that postoperative pain was inevitable, 50% expected postoperative pain would be more severe than what was actually experienced and 7% wanted to please health care providers (Nimmaanrat et al., 2007). Clinicians should be wary of the subjective nature of reported patient satisfaction scores, which can result in an inflated positive assessment of pain control and mask the need for implementation of improvements (Chung and Lui, 2003).

In summary, among this population most patients still experience moderate to severe pain postoperatively and provision of analgesia is suboptimal. Our observations highlight the need for the inclusion of pain as the fifth vital sign and the dedication of greater resources to acute pain control in the peri-operative period. Major challenges include the patient specific prescribing of analgesic therapies and the timing of dosing. Further work needs to be done to tease out the nuances of the relationship between analgesia and patient satisfaction.

REFERENCES


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First Published February 2012

Copyright Priory Lodge Education Limited 2012 -

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