Acute pain management: analysis, implications and consequences after prospective experience with 6349 surgical patients

Abstract

An acute pain service (APS) was set up to improve pain management after operation. We attempted to reduce the length of stay in the intensive care unit (ICU) of patients undergoing major surgery and to improve their homeostasis and rehabilitation using a multimodal approach (pain relief, stress reduction, early extubation). Patient-controlled epidural analgesia (PCEA) was a keystone of this approach. If PCEA was not applicable, patients received patient-controlled intravenous analgesia (PCIA) instead. Brachial plexus blockade (BPB) was used for surgery of the upper limbs. A computer based documentation system was used to help evaluate prospectively (a) the quality of analgesia, (b) adverse effects and risks of the special pain management techniques, and (c) cost-effectiveness. Patients receiving PCEA (n = 5.602) received a patient-titrated continuous infusion into the epidural space of either bupivacaine 0.175% or ropivacaine 0.2%, with 1 microg sufentanil mL(-1) added, followed by patient-controlled boluses of 2 mL (lockout time 20 min). For patients receiving PCIA (n = 634) an initial bolus of 7.5-15 mg piritramide was given, and the subsequent bolus was 2 mg (lockout time 10 min). A continuous infusion of bupivacaine 0.25% was administered to patients receiving BPB (n = 113). The dose was titrated to a dynamic visual analogue scale (VAS) scores < 40. The mean treatment periods were: BPB = 4.33 days, PCEA = 5.6 days, PCIA = 5.0 days. In the case of PCEA, the quality of pain relief, vigilance and satisfaction were superior compared with the PCIA method, which resulted in greater sedation and nausea. Although personal supervision was higher for the PCEA-treated patients, cost analysis revealed final savings of Euro 91,620 for the year 1998 obviating the need for an ICU stay totalling 433 days. Provided that PCEA is part of a fast-track protocol employing early tracheal extubation and optimal perioperative management, the associated initial higher costs will be recouped by the benefits to patients of better pain relief after surgery and fewer days subsequently spent in the ITU.

Key Performance Indicators in Intensive Care Medicine. A Retrospective Matched Cohort Study

“…In a study by Tsui et al, 31 adequate post-operative analgesia was able to reduce overall mortality and hospital mortality, as well as mean hospital stay, in patients after oesophagectomy (n = 578). A study by Brodner et al 32 confirmed these data by demonstrating that the intervention of an acute pain management service was able to reduce the length of ICU stay in surgical patients (n = 5602); regular assessment of pain formed part of this intervention.…”

Назальна форма кеторолаку трометаміну Аsprix як аналгетичний препарат вибору в ортопедичних пацієнтів у ранньому післяопераційному періоді

“…За даними літератури, від значного та помірного больового синдрому в післяопераційному періоді страждають майже 75 % усіх прооперованих пацієнтів [2,6]. При цьому біль після оперативних втручань на кістках та суглобах за інтенсивністю по-сідає друге місце після операцій на органах черевної порожнини, а неадекватна аналгезія спостерігається в 30-50 % пацієнтів [1,6].…”

Organisationsmodell der postoperativen Schmerztherapie am Beispiel eines Krankenhauses der Regelversorgung

“…Analgetisch wirksamere, aus diesem Grund aber aufwändigere Verfahren werden im Rahmen eines ASD häufiger praktiziert und kommen auch öfter Patienten auf allgemeinen Pflegestationen zugute [35]. Nur so lassen sich die bei Risikopatienten und nach großen operativen Eingriffen unbestrittenen Vorteile der "epidural analgesia" (EDA) auch nutzen [9,20]. [17,25,29].…”

“…Einem relativ geringen Aufwand sollten hierbei Kriterien, wie Patientenkomfort und -zufriedenheit und eine mögliche Verkürzung der Hospitalisationszeit, als Erfolgsfaktoren gegenübergestellt werden. Daten zeigen, dass v. a. PCEA die Frühmobilisation und damit einen verkürzten Krankenhausaufenthalt ermöglicht; dies führt letztendlich zu einer Kosteneinsparung [9,20]. Miaskowski et al fanden eine durchschnittliche Reduktion der Hospitalisationszeit um ca.…”