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Year : 2007  |  Volume : 51  |  Issue : 5  |  Page : 441 Table of Contents     

Postoperative Pain Management : Organisation and Audits

M.D, FICS, FAMS, Senior Prof. & Head, Department of Anaesthesiology, R.N.T.Medical College, Udaipur (Raj.), India

Date of Web Publication20-Mar-2010

Correspondence Address:
Pramila Bajaj
25, Polo Ground, Udaipur (Raj.)
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Source of Support: None, Conflict of Interest: None

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How to cite this article:
Bajaj P. Postoperative Pain Management : Organisation and Audits. Indian J Anaesth 2007;51:441

How to cite this URL:
Bajaj P. Postoperative Pain Management : Organisation and Audits. Indian J Anaesth [serial online] 2007 [cited 2021 May 11];51:441. Available from: https://www.ijaweb.org/text.asp?2007/51/5/441/61180

Pain relief after surgical procedures continues to be a major medical challenge. The alleviation of pain is given a high priority by the medical profession and health authorities, who recognize that improvements in perioperative analgesia are not only desirable for humani­tarian reasons, but essential for reducing postoperative morbidity and mortality [1],[2] . The guidelines for acute pain management established by the Agency for Health Care Policy and Research highlight the fact that appropriate pain management in postoperative patients contributes to earlier mobilisation, shorter hospital stay and lower costs. Pain relief per se does not significantly improve the postoperative outcome, with the exception of patient satisfaction and pulmonary complications. Postoperative morbidity and the length of hospital stay are dependent on many factors, including preoperative information, qual­ity of analgesia and existing programs for postoperative care and rehabilitation, including orders for mobilisation, oral nutrition and discharge criteria [3] . In recent years, the techniques for pain management in patients under­going surgery have substantially improved. The choice of analgesic and the route and technique of administra­tion can be tailored to individual need to optimize pain control and to avoid postoperative discomfort and suf­fering. However, although there is no reason why a pa­tient should not receive appropriate analgesia, recent sur­veys have revealed that the incidence of moderate or even severe postoperative pain may be as high as 30­-70% [4],[5] . Most patients, physicians, surgeons and nurses still consider moderate-to-severe pain an acceptable con­sequence of surgical interventions. Undertreatment of pain has been determined to have a negative impact on short-term recovery and may even have a detrimental long-term effect on health. Three reasons for the undertreatment of pain relate to fear of narcotic addic­tion, poor communication among staff and perceptions by patients that medications for pain are neither neces­sary nor good. The recognition that unrelieved pain con­tributes to preoperative morbidity and mortality has in­spired many institutions to develop an Acute Pain Ser­vice (APS) in an attempt to provide effective postop­erative relief. Immediate and sustained formal support, as well as authoritative recommendations from various medical and health care organisations, have promoted the widespread introduction of APS [6],[7],[8],[9],[10],[11],[12] . This in turn has led to the successful and safe implementation of multi­modal pain management strategies in surgical wards [13] . It has also led to an increase in the use of specialised pain relief methods, such as Patient Controlled Analge­sia (PCA) and epidural infusions of local anaesthetics/opioid mixtures. Implementation of these methods may represent real advances both in improving patient well­being and in reducing postoperative morbidity [14] .

Studies have shown that pain is a particularly im­portant determinant of patient satisfaction. It is now rec­ognized that many patients have been greatly under­treated for their postoperative pain in the past. In spite of this fact, however, studies that include the assess­ment of patient satisfaction with postoperative pain man­agement have repeatedly indicated that most patients seem satisfied with their postoperative care. Satisfac­tion is a subjective appraisal of personal care, and a num­ber of factors seem to influence satisfaction with hospi­tal care. Thorough information about the predictability and controllability of the painful stimulus is a major influ­ence in pain expectation; however, most patients do not receive any information on pain and its possible methods of treatment. Providing patients with accurate prepara­tory information regarding the onset, duration, intensity and sensory qualities of the stressful events has been shown to minimise the distress of patients undergoing invasive medical procedures [15],[16] . To ensure that patients have all the information they need, it is important to have annual audits of the postoperative pain unit; the audits should include an investigation of the quality of analge­sia (the efficacy and safety of pain management), the amount and quality of patient information, patient satis­faction and the cost of treatment.

   Cost of pain management Top

Studies of healthcare cost attempt to analyse the benefit of intervention and to provide well defined and relevant outcome measurements [17],[18] . Cost analysis of acute pain management is impeded by the lack of a well­ defined baseline or outcome assessment. There is no valid method for assigning financial cost to differing lev­els of analgesia. Attempts at cost-benefit analyses that incorporate complication and outcome measures have been advocated, but a few studies involving APS have been conducted. It is important that cost-efficacy analy­ses consider the costs of analgesics, devices and nurs­ing time, as well as the duration of stay in PACU/ICU/ surgical wards. The survival of APS may be threatened because of the present economic constraints in health-care and the requirements for cost-effective thera­peutic interventions. This makes it especially important in the context of improved pain relief and outcome that there be well-defined quality criteria for provided ser­vice and an APS that is integrated in the multimodal re­habilitation program.

Pain relief after surgical procedures continues to be a major medical challenge. The introduction of the Acute Pain Services has led to a successful and safe implementation of multi-modal pain management strate­gies and an increase in the use of specialised pain relief methods. The APS has the responsibility for day-to-day postoperative pain, and it plays an important role in en­suring safe treatment and improving the knowledge and understanding of pain assessment in staff and patients. A key point in improving postoperative pain management is the regular assessment and documentation of pain. The 'golden rule' of pain assessment is : ' Do not forget to ask the patient!' Self-assessment, in fact, is the single most reliable indicator of the existence and the intensity of pain and the efficacy of pain treatment.

There has been growing interest in the assessment of patient satisfaction with healthcare. Studies have shown that pain is a particularly important determinant of pa­tient satisfaction low pain intensity might be a good pre­dictor of patient satisfaction. An awareness of the im­portance of controlling postoperative pain and the aware­ness of the options for effective postoperative pain re­lief (due to accurate preoperative information regarding the strategies presently available) should have a positive influence on patient satisfaction, despite postoperative experience with pain severity Good communication be­tween APS staff and patients appears to be as impor­tant as analgesic efficacy in determining patient satis­faction. Furthermore, the exchange of information be­tween patients and hospital staff members seems es­sential for a more individualised and optimal pain relief treatment plan. An APS in the hospital can improve both the knowledge of pain treatment and patient satisfaction; indeed, despite the fact that they may experience high levels of pain, most patients are satisfied with the efforts that nurses and physicians make to manage pain.

A satisfaction questionnaire provides useful baseline data for evaluating the quality of an institution's overall pain management program, and, furthermore, that the information it provides can be used to develop a plan for improving pain management. However, by itself, a satis­faction questionnaire is not the solution, even when re­peated at regular intervals to determine APS progress. Indeed, if used in isolation from other data, satisfaction ratings can lead to the erroneous belief that pain man­agement practices are optimal.

   References Top

1.Rodgers A, Walker N, Shung S, et al. Reduction of postopera­tive mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomized trials. BMJ 2000;321:1-12.  Back to cited text no. 1      
2.Kehlet H, Holte K. Effect of postoperative analgesia on surgi­cal outcome. Br J Anaesth 2001;87:62-72  Back to cited text no. 2      
3.Kehlet H.Multi-modal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1977;78:606­667.  Back to cited text no. 3      
4.Smith G. Pain after surgery. Br J Anaesth 1991;67:232-233.   Back to cited text no. 4      
5.Donovan M, Dillon P, Mc Guire L. Incidence and characteris­tics of pain in a sample of medical surgical patients. Pain 1983; 30:69-78.  Back to cited text no. 5      
6.Anonymous National Health & Medical Research Council of Australia :Acute pain management scientific evidence. Ausinfo, Canberra 1990.  Back to cited text no. 6      
7.Anonymous Americal Pain Society. Quality assurance stan­dards for relief of acute pain and cancer pain. In : Bond MR, Charlton JE, Woolf CJ (eds) Proceedings of the VIth World Congress on Pain. Elsevier, Amstermdam, pp 1991;185-189  Back to cited text no. 7      
8.Ready LB, Edwards WTY. Management of acute pain : a prac­tical guide, IASP Publications, Seattle 1992.   Back to cited text no. 8      
9.Anonymous US Department of Health and Human Services, Agency for Health Care Policy and Research. Acute pain man­agement : operative or medical procedures and trauma. AHCP Publications, Rockville, Publication no 1992;92-0032.  Back to cited text no. 9      
10.Anonymous Practice guidelines for acute pain management in the perioperative setting : a report by the American Society of Anesthesiologists TaskForceon Pain Management,Acute Pain Section. Anesthesiology 1995;82:1071-1081.  Back to cited text no. 10      
11.Zimmerman DL, Stewart J. Postoperative pain management and acute pain service activity in Canada. Can J Anaesth 1993;40:568-575  Back to cited text no. 11      
12.Rawal N. Organization of Acute Pain Services. Pain 1994;57:117-123.  Back to cited text no. 12      
13.Gould TH, Crosby DL, Harmer M. Policy for controlling pain after surgery : effect of sequential changes in management. Brit Med J 1992;305:1187-1193.  Back to cited text no. 13      
14.Werner Mu, Soholm L, Rotholl-Nielsen P. Does acute pain service improve postoperative outcome. Anesth Analg 2002;95:1361-1372.  Back to cited text no. 14      
15.Sjoling M, Nordahl G, Olofsson N. The impact of preoperative information on state anxiety, postoperative pain and satisfaction with pain management. Patient Educ Couns 2003;51:169-176.  Back to cited text no. 15      
16.Lee A, Gin T. Educating patients about anaesthesia: effect of various modes on patient's knowledge, anxiety and satisfac­tion. Curr Opin Anaesthesiol 2005;18:205-208.  Back to cited text no. 16      
17.Chestnut DH. How do we measure the cost of pain relief. Anesthesiology 2000;92:643-645.  Back to cited text no. 17      
18.Ward SE, Gordon DB. Patient satisfaction and pain severity as outcomes in pain management: a longitudinal view of one setting's experience. J Pain Symptom Manage 1996;11:242-251.  Back to cited text no. 18      


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