|Year : 2020 | Volume
| Issue : 1 | Page : 54-57
An audit of pain management at a tertiary care center
Dhananjay Kumar1, Bhinyaram Jat2, Shuchita Singh Pachaury1, Hitesh Verma1
1 Department of Otorhinolaryngology-Head and Neck Surgery, AIIMS, New Delhi, India
2 Department of Otorhinolaryngology.Head and Neck Surgery, AIIMS, Rishikesh, Uttarakhand, India
|Date of Submission||11-Oct-2020|
|Date of Acceptance||16-Dec-2020|
|Date of Web Publication||19-Jan-2021|
Dr. Hitesh Verma
Department of Otorhinolaryngology-Head and Neck Surgery, AIIMS, New Delhi
Source of Support: None, Conflict of Interest: None
Introduction: Pain management is a vital part of postoperative treatment. Pain management in the postoperative period is based on a number of factors such as the extent of surgery, patient profile and surgeon experience, etc. The numbers of subjective scoring system were proposed to scale the severity of pain.
Materials and Methods: This prospective audit was performed between November 2015 to January 2016. Pain scores were recorded in all patients underwent surgery for initial three days by numerical rating scale (NRS).
Results: A total of 92 patients were included in this audit. The patients were broadly divided into the two groups: non-malignancy group and malignancy group. Pain scores were found higher in adult patients, in malignancy patients, and in patients who require wide excision. The scores were found on the lower side in the ear and throat surgery group in comparison to the nose surgery group.
Discussion: Postoperative pain is an individual multi-factorial experience. Poor management is likely to increases the chances of local and systemic complications and delays in the recovery of the patients. Appropriate selection of analgesics would reduce hospital financial burden to a great extent but the side effect profile of each drug should be kept in mind.
Keywords: Analgesic, drug, malignancy, nonmalignancy, pain, side effect
|How to cite this article:|
Kumar D, Jat B, Pachaury SS, Verma H. An audit of pain management at a tertiary care center. Saudi Surg J 2020;8:54-7
| Introduction|| |
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. The various factors that determine the severity of postoperative pain are gender, age, amount of preoperative pain, operation site, duration of surgery, and psychological factors., Prevalence of pain is highest in head-and-neck cancer patients in comparison to other cancer patients. Effective pain control is an essential part of patient care. Poorly controlled postoperative pain may result in prolonged hospital stay and delayed inpatient recovery and affects the patient's experience with the healthcare system also. Adequate pain control consists of proper assessment of pain status and good use of appropriate analgesics. The numerical rating scale (NRS), verbal rating scale, and visual analog scale are the common self-reporting methods used for pain assessment in the literature. NRS is a simple tool and easy to follow for an educated or uneducated person.,,,
In this prospective audit, we had used the NRS scoring system to evaluate our protocol for postoperative pain management at the Otorhinolaryngyology and Head and Neck Surgery Department of AIIMS, New Delhi.
| Material and Methods|| |
The existing pain protocol for the major surgeries who received intensive care unit (ICU) care was intravenous (IV) opioids for the 1st day and IV paracetamol TDS or QID for the subsequent period. It was followed in patients with extensive head-and-neck surgical resection, presence of significant comorbidities, and reconstructive surgery. The patients who were shifted directly to the high-dependency unit (HDU) of the ward; the usual protocol was IV paracetamol TDS or QID for a couple of days. The selection of other Non steroid anti-inflammatory drugs or a combination of drugs was depending on the patient's status in the postoperative period, performed surgery, and patient profile. Oral analgesics were used in minor surgeries (tympanoplasy, foreign body removal, endoscopic procedures, etc.).
This prospective, observational study was performed between November 2015 and January 2016. All the subjects were asked to rate their pain on a daily basis by NRS in the first 3 postoperative days. In this study, patients were asked to rate their pain between zero (no pain) and ten (very severe pain). Score range from 1 to 3 is mild, 4 to 6 is moderate, and 7 to 10 is severe pain. The scores on the 3rd day or score on the day of discharge (if patient is discharged early) was considered as the final score and the patients were categorized according to that patients were broadly divided into two surgical groups (malignancy and nonmalignancy group). Nonmalignancy group was further divided into three subgroups (ear, nose, and throat surgery group). Separate categorization of adults and pediatric patients was also done for evaluation.
| Results|| |
A total of 92 patients were recruited in this study. The demographic details are mentioned in [Table 1]. In head-and-neck malignancy group, the patients belonged to adulthood and a total of 32 in number. Reconstructive surgeries were performed in 27 out of 32 patients who had moderate-to-severe pain on the 1st postoperative day. Median score was 5.5, 4, and 3.5 on postoperative day 1, 2, and 3, respectively [Table 2]. Out of 32 patients, 19 patients had required soft tissue excision and 13 patients had required soft tissue and bony excision. The pain scores were higher in patients who required both bone and soft tissue work. The scores were found on the lower side in patients who received ICU care as compared to patients who received HDU care. In comparison with the nonmalignancy group, the pain scores were found on the higher side in the malignancy group [Table 2], and it was statistically significant.
In the ear surgery subgroup, the total number of patients was 18 (ten adult and three pediatric). Median scores were 4.5, 2, and 2 on postoperative day 1, 2, and 3, respectively [Table 3]. On the 1st postoperative day, the average score was 4 in patients who were on injectable analgesics and score was 4.7 in patients who were oral analgesics. Only five patients out of total of 18 patients were admitted till postoperative day 3 in the ear surgery group. The higher score was seen in extensive cholesteatoma removal, glomus tumor surgery, etc.
|Table 3: Comparison of pain score in ear, nose, and throat surgery group|
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In the nose surgery subgroup, a total of 13 patients (ten adult and three pediatric) were recruited. As shown in [Table 3], the median score on the first 3 postoperative days was 5, 4, and 2, respectively. The average score was lower in adult patients than pediatric patients in contrast to other subgroups. This group has a higher score on postoperative day 1 and 2 as compared to the ear surgery and the throat surgery group [Table 3]. The average score on the postoperative day 1 was 5.6 in patients who were on injectable analgesics and the score was 4 in patients who received oral analgesics. Minor surgery and soft tissue work (nasal tip surgery, nasal polyp removal, etc.) had low scores.
In the throat surgery subgroup, out of 29 patients, 15 were adults and 14 were pediatric patients. As shown in [Table 3], the median score on the first 3 postoperative days was 4, 3, and 2, respectively. The scores were on the higher side in the patients who required extensive surgeries, i.e., sleep surgery, palatal surgery.
Overall, the adult patients had high pain scores on all assessment days as compared to pediatric patients and it was found statistically significant [Table 4].
| Discussion|| |
Postoperative pain management plays an utmost important role in timely recovery, and it has a significant impact on the quality of life. Postoperative pain is an individual multifactorial experience. Ineffectively managed postoperative pain can lead to poor healing and increase wound infection by activation of pituitary–adrenal link.,, The risk of systemic complications such as deep vein thrombosis, pulmonary embolism, pneumonia, and cardiac complications is increased by many folds by delay in mobilization due to persistent postoperative pain.,, Studies showed a direct relationship between persistent acute postoperative pain and chronic pain. Appropriate selection of analgesics would reduce the postoperative expenditure on health by reducing hospital stay and cost of management, and it also increases patient's satisfaction level.
IV paracetamol alone or in combination with other NSAIDs have considerable control over postoperative pain.,,,,, This is also seen in our study. As shown in our result, within nonmalignancy surgery (ear/nose/throat) groups, the pain score was higher in nose surgery patients as compared to other subgroups. Overall pediatric patients had low scores compared to adult patients (except nose surgery groups). Hence, we can recommend for one to two day's use of IV paracetamol alone for pediatric patients, i.e., ear and throat surgery patients. A combination of IV paracetamol with NSAIDs for 1–2 days followed by oral paracetamol is recommended in adult patients, nose surgery patients, and patients who underwent extensive ear or throat resection surgeries.
Narcotics are major analgesics used for postoperative pain management in head-and-neck cancer patients. At our center, the anesthetist used it on the 1st postoperative day followed by nonnarcotic analgesics in the ward HDU. Nonnarcotic analgesics such as paracetamol and other NSAIDS were used in patients who shifted directly in the ward HDU. The literature suggests the use of IV narcotic/opioid analgesics in the head-and-neck cancer surgery patients for the first 5 days usually which is in contrast with our usual practice, but Indian patients' profile is also different. In our head-and-neck cancer patients, the average score was above 3 for the first 3 postoperative days. The higher pain score of the malignancy group as compared to nonmalignancy group may be due to extensive dissection and prolonged duration of surgery. In the Indian scenario, we may use IV narcotic analgesics or its combination with NSAIDS/paracetamol for the first 2–3 postoperative days depending on surgical extent and surgeon expensive followed by nonnarcotic analgesics (paracetamol alone or combination with NSAIDs) depending on the pain score. Surgeon should keep in mind the adverse effects associated with narcotic analgesics such as nausea, vomiting, constipation, urinary retention, and respiratory depression and drug dependence before prescribing it for a longer period. The prescription should also be based on patient profile and surgeon experience.
| Conclusion|| |
To get conclusive evidence for postoperative analgesia practice in ear-nose-throat and head-and-neck cancer patients in the Indian population, further multi-institutional, large-scale, and randomized control trials are required.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]