Literature Review of Post Operative Pain Management

1. INTRODUCTION

The aim of the project will be to provide a critical review for the improvement of clinical and medicinal management of post operative pain. If the points put forward are taken into consideration then the dissertation will not only prove beneficial if the reader is a clinician as it can also can be read and understood by a patient or a student for literary purposes or wants to find ways to improve their treatment before they undergo surgery.

Project Question – The primary research question of the dissertation is: “How, if possible, can post operative care measures be improved to help the patient overcome pain, whilst maintaining standards of NICE (National Institute for Health and Clinical Excellence) guidelines.

2. LITERATURE REVIEW

This section would be dedicated to the background of the dissertation. The reader should gain an understanding behind the physiology of acute pain. The delivery of drugs is also an important factor as different procedures for their delivery depend on the patient’s condition and requirements. Quality measures must also be taken into consideration as each patient should be attended to as a unique case no matter how similar the requirement.

The following must also be taken into consideration when presenting background information:

NICE Guidelines for assessment of changes in post operative pain management strategies over the last 3 years (to base the project on current information)

Evidence (tabular, graphical or statistical) to support different efficacies between drug modalities.

Most commonly used drugs, further pinpointing the use of specific drugs for patient’s suffering from different conditions.

2.1. Importance of post operative pain management

This section should elaborate on why this kind of care is necessary. One good scenario based example can involve a busy surgical ward:

Using journal literature, one good example can be given where short supplies of patient controlled analgesic pumps (PCA pumps) are present. In such a scenario, post-operative ward patients may be required to be earlier withdrawn from the equipment to make this treatment available for the next patients leaving the theatres. Therefore, once these pumps are removed, analgesic drug therapy is required to treat pain.

Successful implementation of pain management can result in patience comfort and satisfaction; therefore reputation of the hospital is well preserved.

2.1.1 Effect on Patients and families

Ethical/Cultural issues which surround post operative pain management, especially in patient groups including:

– Children

– Elderly

– Pregnant Women

– Cancer/Terminal Patients

– Patients administered with high drug dosage during operation

– Those with high risk due to drug allergies

2.1.2 Effect on Health Costs

Little data is available addressing the costs of post operative pain management. Such knowledge can help the reader’s understanding of caregiver choices related to direct medical costs, i.e. route of medication, type and required frequency. Therefore this can be a good idea to help improve pain strategy.

2.2 WHY SHOULD POST OPERATIVE MANAGEMENT OF PAIN BE IMPROVED?

2.2.1. How current post-operative pain management strategies work

Sedation Scores: The scores test whether a patient is easily aroused and to help prevent them from overdosing. There are 3 important factors which make up the sedation scoring system:

(i) It should cause minimal disturbance to the patient

(ii) be simple to use

(iii) be incorporated as a part of the patient’s routine assessment

Sedation scores create an impact on patient safety as respiratory depression may occur as a result from use strong drugs, such as narcotics. Identification or tracing these forms of drugs may be difficult and therefore lead to respiratory depression unnoticed.

Therapeutic Modalities: Opioids, Non-Steroidal Anti-Inflammatory (NSAID), COX-2 Inhibitors

Regional Techniques: Epidural, spinal analgesia contribute towards successful surgical outcome through progressive decrease in intra-operative blood loss, incidence of thromboembolic events, post operative catabolism, improvement of vascular graft blood flow and post operative pulmonary function.

Non-pharmacological techniques: Electrical-stimulation of peripheral nerves

2.2.2 Ineffective Drugs and Procedures

Choice of drug may have little or effect on pain

Method of Drug delivery may not allow the drug to work at its optimum efficacy

3. UNRESOLVED ISSUES

3.1 Multimodal Analgesia

The concept comes with the aim to combine analgesics with additive or synergistic effects.

However, combinational use of drug classes can pose as a risk to patients due to differing mechanism of drug action, side-effect profile of individual drugs and efficacies.

3.2 Pre-operative Analgesia leading to post-operative outcomes

Clinicians assume post-operative pain relief can lead to better clinical outcomes to benefit the patient and hospital finances. A few named examples of improved clinical outcomes include the following:

– Reduced organ dysfunction

– Decreased Morbidity

– Shorter hospital stay

Problems are associated with these assumptions as attention should be shifted to effects which are clinically meaningful for example:

– Resumption of dietary intake

– Recovery of bowel and bladder function

– Resumption of normal lifestyle and physical activity

– Long term recovery (i.e. less chronic pain)

4. NEW FINDINGS

.This section should elaborate on any novel discoveries made in the following:

4.1 PROCEDURES

4.1.1 DRUG DELIVERY

– Intravenous Patient-Controlled Analgesia (IV PCA)

– Patient-Controlled Epidural Analgesia (PCEA)

– Patient-Controlled Regional Analgesia (PCRA)

– Patient-Controlled Intranasal Analgesia (PCINA)

– Fentanyl Iontophoretic Transdermal System (ITS)

Post-operative pain has shown significant improvement through the introduction of patient-controlled analgesia (PCA) delivery. Current PCA procedures (including intravenous or epidural routes) show limitations where requirement for indwelling catheter remains and time is also needed for system set up and use.

New PCA technology have addressed drawbacks to existing equipment, however using complex new and improved technology can be an issue as training is required. An example of new technology includes “smart” intravenous PCA infusion pumps – to help make the delivery of analgesic drugs safer. Another example includes needle free options such as intranasal delivery and fentanyl HCl iontophoretic transdermal system for transdermal delivery

4.2 DRUGS

Analogues or isoforms of current effective drugs, which show more potential in phase II or III clinical trials. Diagrams of these isoforms can be provided with a brief description on its mechanism of action and use.

Pre-emptive analgesia: The drug is administered before the painful stimulus occurs to substantially reduce or prevent pain and any further analgesic requirement. This hypothesis of protecting the nervous system pre-emptively has provoked numerous clinical studies to take place; therefore it is an attractive area worth looking into. For example, administration of epidural fentanyl or bupivacaine prior to surgical incision in male patients that went through radical prostatectomy.

Dexmedetomidin: A centrally active alpha- 2-adrenergic agonist that is highly selective to provide both sedation and analgesia without significant ventilatory depression.

Regional anaesthesia and local anaesthetics: Adjuvants, Gabapentin, Ketamine

5. IMPACT OF IMPROVING POST OPERATIVE PAIN MANAGEMENT

Consistent efficacy across a number of hospital/surgeries

Right kind of treatment received at the right time means less complication or risk of clinical malpractice

Improvement of pain management strengthens our knowledgebase of drugs in the market

Space can be given to perform clinical trials where drugs may potentially be administered without the use of equipment, therefore reducing costs

6. DISCUSSION / CONCLUSION

The discussion of the project should draw upon the various criticisms made towards drugs and procedures in order to provide a rational argument for a route for improvement.

For example in terms of procedures, there remains an important need for clinicians to implement evidence-based, procedure specific protocols for new drugs, especially those which are shown to have high efficacy in clinical trials. Additionally, drug profiles should be modified to meet the need of individual patients and therefore enhancing the quality of post operative pain management.

A combined education/training approach amongst healthcare providers (i.e. anaesthesiologists, surgeons, nurses and physiotherapists) has been shown to improve quality of a patient’s recover process, reducing hospital stay or morbidity. The importance of assessing pain in different patient groups is a vital point. For example, an adult would react differently to pain than a child would. Furthermore being able to segregate patient groups can further aid provision of the right kind of drug rather than using generic treatment to expect optimal recovery.

Once these arguments are compared and discussed, it would be worth having the final conclusion to mention the impact of improvement (linking section 5) taking into consideration the budget cuts within the NHS as a result of the economical downturn (recession) and how making services more efficient would bring more benefits than drawbacks to the NHS as a whole.