Improving perisurgical pain control

Ten Mistakes to be avoided

Editor,

‘Pain is a more terrible lord of mankind than even death itself’ said the doctor and philosopher Albert Schweitzer, and nothing could be truer than that.

Postoperative pain is an undermanaged condition. Over the last two decades, there have been many studies showing that more than 70% of surgical patients reported moderate to severe pain in the days following surgery.¹ These numbers are relevant, because despite significant developments in pain medicine, there is still room for improvement. What are we missing? Could this be about human factors? If yes, what kind of human factors? These questions must be addressed. There is evidence of efficacious drugs from many studies. In addition, there are many guidelines in this field. So, what else is needed to improve pain control in surgical patients?

Here, we present the results of a survey that was sent to 30 anaesthetists from one of three main hospitals of Oradea in Romania. They were asked to write down 10 mistakes in the praxis of peri-operative analgesia with which they had been confronted. We received 19 answers, ranking the 10 major mistakes in the order of prevalence. We present these answers from the least to the most significant.

Answer 10. There are deficiencies in the assessment of pain. A careful history and a complete physical examination should be supported by the use of validated assessment tools for pain, sleep, function and mood. Often, staff members assess pain without referring to its dynamic process and most of the time, practitioners are omitting surveying pain on movement, that should be used to prescribe breakthrough analgesia.

Answer 9. There are wrong beliefs about pain. One of the interviewed doctors gave an example from his daily practice: ‘In the hospital where I am working, I heard one of the nurses telling the patient: ‘It's normal to experience that pain considering what surgery you had’. To note that the patient had a hernia repair!’ This is not acceptable. There are other wrong beliefs we might face, like ‘pain is useful to diagnose the acute abdomen or to point out progression throughout condition’.

Answer 8. Pain outside the surgical site may be missed or triggers may be ignored. Precautions of safety have to be taken when transferring unconscious patients. There is a high incidence of peripheral nerve injuries during anaesthesia, representing 12% of general anaesthesia malpractice claims since 1990.² Peripheral nerve injuries are preventable.

Answer 7. The patient's sleep deprivation is overlooked. Sleep deprivation increases the experience of pain, interfering with treatments involving opioidergic and serotoninergic mechanisms of action.³ More recently it has been shown that sleep deprivation may amplify pain reactivity within the primary cortex and may blunt pain reactivity decisions in the striatum and insula.⁴ Thus, sleep deprivation is involved in central sensitisation, basically turning up the intensity of pain. Consequently, insomnia should not be ignored.

Answer 6. The patient's emotional and psychological support is overlooked. The importance of empathy was recognised back in ancient times when Hippocrates said: ‘Cure sometimes, treat often, comfort always!’ Talk and listen to your patient! Offer patients the feeling that they are well understood and you care about them!

Answer 5. Consider adjuvant medication. It is well known that adjuvant drugs may reduce acute perisurgical pain while limiting opioid consumption and opioid-related adverse effects. In addition, nonopioid analgesics may decrease the risk of neuropathic pain.

Answer 4. Do not overuse opioids. There is not yet an opioids crisis in Europe. But we have to take an active role to prevent such a crisis. Various studies have looked into how many patients continue to take opioids after surgery. For example, of almost 400 000 patients undergoing low-risk procedures, 7% continued to take opioids 12 months postoperatively.⁵ It remains unknown how many of those were already on chronic opioid analgesia before surgery. In a recent large-scale study, one million opioid-naive patients undergoing surgery were followed up and it was found that 0.6% had developed misuse, leading to opioid dependence.⁶ The risk of misuse was increased by repeated prescriptions, each additional week of prescription increasing the risk by 20%. However, the risk of misuse was not affected by the dose prescribed.

Answer 3. Traditional practices are maintained despite evidence-based guidelines. Despite the presence of multiple evidence-based guidelines on analgesia, there still remain inconsistencies in how patients are treated. Greater adherence to protocols and guidelines is needed as they have shown real benefits in decreasing morbidity and the length of hospital stay and in increased quality of life.

Answer 2. Medication errors must be avoided. We are all vulnerable to medication errors. In one survey, 91.8% of interviewed anaesthetists reported they had committed administration medication errors in the past.⁷ In 87% of the cases, the errors were immediately identified and corrected, but in 1.8%, consequences of the errors were morbidity and irreversible damage.

Answer 1. Patients should be involved in defining realistic goals for pain control. Peri-operative pain evaluation is needed to correct any underlying misperceptions concerning pain and analgesics. It is important to reconsider diagnoses, to discuss alternative options, to treat physical and emotional elements and finally to tailor pain management to each individual patient.

In summary, it is important that clinicians consider their patients’ pain in the context of biological, social and psychological factors. This concept has been known as a biopsychosocial model for pain control. Analgesia strategies should be multimodal within a multidimensional system. Anaesthesia and analgesia is a holistic discipline, where the clinician should perform as a provider of common sense ensuring a continuous connection between medicine, practice and philosophy.