Pain management is an essential part of postoperative care. Epidural and intravenous (i.v.) analgesia are now commonly used for the management of postoperative pain after major surgery. However, particular challenges for improved pain control postoperatively remain the evaluation of pain intensity both at rest and on movement and the accurate predetermination of the analgesic effect of opioids due to, for instance, individual variability in pharmacodynamics .
Current practices show large intra- and inter-hospital differences in the choice of techniques, drugs and dosage schemes. This variability is due, in part, to differences in hospital structures and resources and also to the level of experience, expertise and knowledge of healthcare providers. The widespread use of epidural analgesia and i.v. patient-controlled analgesia (PCA) carries a finite risk of complications that may be minor (nausea, vomiting, pruritus) or potentially serious (epidural haematoma, respiratory depression) [2,3]. Thus, adequate monitoring of patients is required for timely diagnosis and treatment.
The constitution of an acute pain service (APS) has proven an efficacious way of dealing with the problems related to postoperative analgesia . However, the organization of APS is still open to debate [5,6]. We studied the terms of application and monitoring of epidural and i.v. analgesia by anaesthetic departments in public and university hospitals with or without an APS in Greece. As this was the first attempt to document postoperative pain management practices within the Greek hospitals, we intended to classify the quality of services and to explore whether establishment of an APS assures higher quality postoperative pain management.
Following approval by the Ethics Committee, a questionnaire was designed. Three anaesthetic departments were consulted to improve reliability of answers, readability and ease of completion, balancing between thoroughness and possible response rate. Following approval by the Hellenic Society of Anaesthesiologists, the questionnaire was sent to the directors of the anaesthetic departments of all 110 Greek hospitals, to be completed anonymously without identifying the hospital, until November 2004. Questions (see Appendix) focussed on departmental policies on the use of i.v. and epidural analgesia, postoperative patient monitoring, organization and procedures regarding postoperative pain management, and proposals for the improvement of pain management. We made no distinction between teaching, university or district hospitals, as in Greece, almost all hospitals offer some resident training, and there is no official functional designation of what a district hospital is.
Postoperative pain services were classified according to the following quality criteria [7-9]: regular assessment during working days and non-working days, constitution of an APS and assignment of personnel, use of a pain scale, evaluation of dynamic analgesia (i.e. pain on movement), documentation of pain intensity and written protocols for postoperative pain management.
Returned questionnaires were evaluated for consistency within each section. Descriptive statistics were used to summarize answers and Fisher's exact test was used to compare hospitals with an APS with those without an APS. Data were analysed using SPSS.
Anaesthetic departments of 51 of 110 (46.4%) Greek hospitals responded to our questionnaire (Table 1).
Epidural analgesia was used in 49 (96%) hospitals; 29 used both intermittent and continuous or patient-controlled epidural analgesia (PCEA), 10 used exclusively intermittent boluses and 10 used only continuous and/or PCEA (Table 2). Of the 39 hospitals that were using intermittent epidural analgesia, 24 provided no more than two boluses daily. The most frequently used drug regimen was the combination of an opioid with a local anaesthetic. Fentanyl was used in combination with a local anaesthetic only, usually as a continuous epidural infusion and/or PCEA. Ropivacaine 0.2% was usually administered as a continuous epidural analgesia or PCEA, followed by levo-bupivacaine. Twenty-seven of the 39 anaesthetic departments administered a volume of 6-15 mL h−1, while the others administered 2-5 mL h−1.
Proposals with the highest priority for an improvement of epidural analgesia included improved patient monitoring (15 departments), further education of anaesthesiologists (9 departments) and better co-operation between physicians and nurses on the surgical ward (8 departments).
I.v. analgesia was used in 42 of the 51 (82%) anaesthetic departments (Table 3). In those that used a PCA device, lockout times less than 12 min were used in 7 (23%). In some departments, lockout times ranged from 30 to 240 min. Two-thirds of the departments applied i.v. analgesia until the second postoperative day only. Twenty-one of the 38 (56%) anaesthetic departments that were using PCA, with or without background infusion, informed patients preoperatively about the use of the device. Choice of patients suitable for PCA was based on criteria such as age or American Society of Anesthesiologists (ASA) status in 28 of the 38 (74%) departments, while 10 (26%) departments considered patients' preferences and ability to co-operate.
Proposals to improve the efficacy of the method included education and co-operation with physicians and nurses on the surgical ward (20 departments), education of anaesthesiologists (10 departments), improvement in patient monitoring (8 departments), availability of PCA pumps (5 departments), improving selection of patients and patient education during the preoperative visit (2 departments) and using of PCA instead of continuous infusion (2 departments). Fourteen anaesthetic departments agreed that surgeons may use PCA devices, while 23 responded negatively.
Forty-eight of the 49 (98%) departments applying epidural analgesia and 38 of the 42 (90.4%) departments applying i.v. analgesia treated their patients on a general surgical ward. Twenty-four departments (47%) assessed patients once or twice daily, and 19 (37.3%) more than twice; 8 (15.7%) did not have a departmental policy. In 45 of the 51 (88%) responding anaesthetic departments, patients were visited during non-working days. Participation of surgical departments in the management of i.v. or epidural analgesia was limited to six of the 51 (11.8%) hospitals.
Eight anaesthetic departments had an APS and all of them fulfilled the predefined quality criteria (Table 4). Ten departments without APS (of 43) met all the rest of the quality criteria for postoperative patient monitoring (P < 0.001, Fisher's exact test for the comparison between departments with or without APS). Eighteen of the 43 non-APS anaesthetic departments were in the process of implementing an APS. All APSs included specialist and resident anaesthesiologists performing two to four daily patient visits. In four of eight APS, and in one of the 43 non-APS hospitals, pain nurses were also involved in patient monitoring. In six APS teams, a specialist anaesthesiologist was available around the clock. Considering educational activities on postoperative pain management, in 21 of the 51 departments (40.1%), there was an audit procedure; in 23 (45%), continuing education was provided within the anaesthetic department; and in 21 (40.1%), there were common educational activities involving surgical and nursing staff. All these activities were provided by seven of the 43 non-APS departments and in six of the APS departments (P = 0.002, for the comparison between departments with or without APS).
This questionnaire study is the first attempt to record postoperative pain management practices in the anaesthetic departments in Greek hospitals. Surgical departments have been traditionally dealing with postoperative pain, with anaesthetic involvement reserved for selected patients. During the last decade, an increasing number of anaesthetic departments in Greece have started to deal with postoperative analgesia in an attempt to improve patient satisfaction and, possibly, outcome. We surveyed the extent and modes of application of i.v. and epidural analgesia, as well as the quality of patient monitoring. The low response rate, especially from small-sized hospitals, probably led to considerable positive bias, assuming that anaesthetic departments with no particular interest in postoperative analgesia were less likely to respond to our questionnaire.
Forty-nine of the 51 responding anaesthetic departments reported on the use of the epidural route for postoperative analgesia, either as intermittent boluses or as a continuous infusion. Administration of local anaesthetics in combination with opioids offers better dynamic analgesia, with smaller total doses of both drugs due to synergism, and fewer adverse effects . Twenty-eight of the 39 departments applying intermittent boluses were using an opioid-local anaesthetic combination. However, in some, only two daily doses were used; this may provide inadequate analgesia as to the duration of action of the local anaesthetic.
Continuous infusion was considerably underused in comparison with reports from the UK  and Sweden . Possible reasons mentioned by the responders included inadequate postoperative around the clock monitoring, doubts about the advantages and safety of continuous infusion, lack of explicit departmental policy and lack of training. Congruency of the catheter insertion site with the surgical incision and the volume of the local anaesthetic are of primary importance for synergism. Although an opioid-local anaesthetic combination was used by 34 (87.2%) of the anaesthetic departments that were using continuous epidural infusion, congruency of the catheter insertion site with the surgical incision was considered in only 44% of the departments, while the others always chose the lumbar approach. This also falls short compared with 65% and 75% reported in the UK  and in a European study , respectively.
Twelve of the 39 anaesthetic departments administered ropivacaine 0.2% or an equivalent dose of a local anaesthetic at a rate up to 5 mL h−1. Even though an estimation of the analgesic spread of a dose of a local anaesthetic is not available, Bromage  has shown the dose-dependent relationship of anaesthetic spread. Current practice and experience [15,16], as well as recent guidelines of the European Society of Regional Anaesthesia  recommending a local anaesthetic-opioid infusion rate of 6-12 mL h−1, suggest that many hospitals were using inadequate infusion rates. This is even more probable in the case of 10 of these departments that used exclusively the lumbar approach, irrespectively of the level of the surgical incision. Nine of those administered morphine with ropivacaine and one was using ropivacaine alone. We may assume that with these regimens, the analgesic effect after, for instance, upper abdominal or thoracic operations, is due solely to the epidural spread of morphine. In addition, in all these 10 departments, a sympathetic blockade of the lower extremities was induced, which may contribute to adverse effects, but not to an improvement of the upper abdominal or thoracic analgesia. For thoracic or upper abdominal surgery, thoracic epidural analgesia provides better dynamic analgesia compared to lumbar , and also improves gastrointestinal, respiratory and cardiac function [19,20], and decreases the risk of hypotension, urinary retention and limb weakness [21-23].
Administration of i.v. opioids with a pump has been considered superior to intramuscular injections, offering better and more consistent analgesia . Twenty-five departments reported on the use of i.v. continuous opioid infusion. This is in contrast with current international practice, as it cannot be tailored to individual patient needs, while increasing the risk of respiratory depression. Eighteen of the 38 departments that were using PCA used it with a background infusion. Continuous infusion added to patient-controlled boluses is not superior to on-demand boluses alone, regarding opioid requirements and quality of sleep, while the incidence of respiratory depression may increase [25-27]. Increased patient monitoring requirements imposed by the use of a background infusion may be among the reasons why in the US, only 10.6% of hospitals without an APS are using this technique compared with 89.4% of the hospitals with an APS . Adding a continuous infusion to PCA may be best reserved for patients with high opioid requirements due to tolerance or idiosyncrasy [26,27].
An appropriate lockout time is essential for the safety of the PCA method. Pharmacokinetic and clinical data indicate that a lockout period of 5-12 min is appropriate for the majority of the opioids used . Twenty-four (77%) anaesthetic departments used a lockout period greater than 12 min, with cases in the range of 30-240 min seriously undermining the effectiveness of the method. This was due in part to misconceptions regarding the safety of PCA, opioid pharmacodynamics and patient monitoring requirements. Meperidine and nalbuphine, despite a rather unfavourable profile for use in PCA [29,30], were employed by 11 departments. Most departments selected patients to receive PCA primarily on criteria as age and ASA status, paying little attention to patients' preferences or ability to co-operate . Furthermore, in 19 of the 38 (50%) departments using PCA, information and education of the patient about the use of the PCA device was taking place postoperatively only. These practices will almost certainly compromise the efficacious and safe use of the method, indicating that there is room for improvement .
Systemic non-steroidal anti-inflammatory drugs were administered by most of the anaesthetic departments concomitantly with i.v. and epidural analgesia. These patients may benefit from an opioid-sparing effect and a reduced complication rate due to multimodal analgesia [32,33]. The majority of anaesthetic departments were also systematically administering antiemetic drugs, a practice that has been advocated considering the high prevalence of nausea and vomiting in postoperative patients receiving opioid analgesia [2,34].
The reported application of PCA and epidural analgesia in the surgical ward is in accordance with practices in Germany , the United Kingdom , Australia , Spain  and Canada . These techniques have been considered safe practice, provided there are adequate patient monitoring and supporting structures. They are more widely applied in hospitals with an APS . Pertinent to safety issues are the frequency of patient visits and the involvement of the surgical department in pain management. It has been recommended that epidural analgesia is checked hourly on the first postoperative day and 4-hourly thereafter . Others have reached similar conclusions [41,42]. The limited participation of surgical departments in the management of analgesia, with more than half of the anaesthetic departments performing no more than two visits daily, suggests that minimal safety requirements were not met in a substantial number of hospitals. One-third of the anaesthetic departments had a protocol for the diagnosis and treatment of respiratory depression and epidural haematoma and had relevant educational activities involving the surgical team. Checking for clinical signs of complications within the usual nursing care of the surgical departments was considered the most appropriate solution to improve safety of i.v. and epidural analgesia. Making analgesia efficacious and safe in the surgical ward allows its application to all patients who may benefit and for the extent of time required .
Use of a suitable pain scale and documentation of the findings are essential for the continuity of care, as recommended by the ASA . This was a basic criterion for the evaluation of APS in a relevant German study . Thirty-five of 51 (68%) departments, with or without APS, used a pain scale, whereas fewer (47%) applied appropriate documentation, which is within the range that was reported from other countries [7,37,44-46] (Table 5). The value of comparisons is limited though, since these data have been collected during various times in the last decade, evaluation of pain and documentation and APS definitions may vary between studies, and practices are evolving in each country. The quality criteria for patient monitoring that were used in our and similar studies should be regarded as minimum requirements for an APS. Once implemented, they enable further goal-oriented studies of pain management, including analgesic efficacy and adverse effects that are based on actual large-scale data from reliably documented and standardized practice.
The constitution of a team of specialist anaesthesiologists that are responsible for postoperative pain management and that are actively participating in patient care is an important quality criterion in evaluating pain services . Only 16% of the hospitals had an APS team. This percentage is small, even more so when considering the potential response bias, compared with 30% in Spain , and up to 89.4% in the UK . However, ten of the non-APS hospitals fulfilled all quality criteria for patient follow-up, and 18 further anaesthetic departments were in the process of implementing an APS. The definition and function of APS vary throughout the literature . Studies from the UK  and from Australia and New Zealand  have reported that 37% and 43.2% of APS, respectively, did not require senior anaesthesiologists to be directly involved in patient care. In Germany, 31.3% of APS did not involve permanent physician care .
The participation of acute pain nurses in the APS is commonly recommended in the APS proposed models [40,47]. The acute pain nurse carries the crucial task of implementing and co-ordinating patient care, effectively communicating with nursing staff, the patients' physician and APS anaesthesiologists. Four of the eight APS hospitals included a pain nurse in their team, while only one of the 43 non-APS hospitals did so. Pain nurses were included in 91% of APS hospitals in the UK , but only in 23.6% of APS hospitals in Germany , and in 32% of teaching and 22% of non-teaching hospitals in Spain .
Our survey has revealed many areas of concern. Proposals for enhancing the benefits of epidural and i.v. analgesia mainly raise the issues of patient monitoring and safety, better training of the anaesthetic, surgical and nursing staff, as well as the availability of resources. Constitution of APS teams would ensure a higher quality postoperative pain management, and enforce appropriate evaluation and documentation of analgesia and adverse effects. Also, continuity and coherence in patient care and collaboration with the surgical department would be improved, so that important feedback is offered in audit and educational procedures. These structures and policies shift the emphasis on postoperative care rather than mere analgesia [5,43].
Extensive assignment of anaesthesiologists to the APS is almost impossible in small hospitals and understaffed anaesthetic departments. Interim development of an operational framework, with a leading role assumed by trained and interested individuals, through establishing analgesic protocols, use of pain scales and documentation, adequate and appropriate patient monitoring and established educational activities involving the surgical staff, will greatly contribute to better and safer postoperative analgesia. Alternative APS models with an enhanced role of acute pain nurses acting within this framework  may prove functional and efficacious in most of the small- to medium-sized Greek hospitals.
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Questions were grouped into the following categories:
- Application of intravenous and epidural analgesia:
- Mode of drug administration, techniques used.
- Drugs administered, dosing schemes.
- Postoperative patient monitoring:
- Regular assessment during working days and non-working days
- Evaluation of analgesia.
- Use of a pain scale.
- Documentation of pain.
- Organization and procedures supporting pain management:
- Written protocols for postoperative pain and adverse effects management.
- Constitution of an acute pain service and assignment of personnel (specialist anaesthetists, pain nurses, residents).
- Continuing education (involving anaesthetists, surgeons, nurses).
- Proposals for improving postoperative pain management.