[A multimodal and multidisciplinary postoperative pain management concept]

Quality of nursing care in pain management in orthopedic surgical patients: a scoping review

OBJECTIVE

To map the evidence on quality nursing care practices in pain management in orthopedic surgical patients.

METHOD

Scoping review, as per the JBI Manual recommendations. Searches were performed in the MEDLINE (PubMed), LILACS (Regional VHL), Scopus, Embase, Web of Science, Cochrane, Cinahl databases, and gray literature, regardless of language and period. Selection and extraction were performed by two independent reviewers, using inclusion/exclusion criteria, and the extracted data were organized to reflect key themes or recurring patterns related to the purpose of the review.

RESULTS

A total of 94 studies were included, most from the United States, corresponding to 34% of the sample, and published between 1997 and 2022. The findings were categorized into: nursing quality practices in pain management related to the organization and monitoring of units, and pre- and post-operative period.

CONCLUSION

The research revealed that quality nursing care practices in pain management in orthopedic surgical patients encompass a variety of approaches, from the use of nonpharmacological practices and patient education to the use of pain assessment scales, staff training, to innovative pharmacological procedures.

Challenges and opportunities of pharmaceutical cocrystals: a focused review on non-steroidal anti-inflammatory drugs

The focus of the review is to discuss the relevant and essential aspects of pharmaceutical cocrystals in both academia and industry with an emphasis on non-steroidal anti-inflammatory drugs (NSAIDs). Although cocrystals have been prepared for a plethora of drugs, NSAID cocrystals are focused due to their humongous application in different fields of medication such as antipyretic, anti-inflammatory, analgesic, antiplatelet, antitumor, and anti-carcinogenic drugs. The highlights of the review are (a) background of cocrystals and other solid forms of an active pharmaceutical ingredient (API) based on the principles of crystal engineering, (b) why cocrystals are an excellent opportunity in the pharma industry, (c) common methods of preparation of cocrystals from the lab scale to bulk quantity, (d) some latest case studies of NSAIDs which have shown better physicochemical properties for example; mechanical properties (tabletability), hydration, solubility, bioavailability, and permeability, and (e) latest guidelines of the US FDA and EMA opening new opportunities and challenges.

Cranio-maxillofacial reconstruction with microvascular radialis flaps-parameters and correlations of postoperative pain management

OBJECTIVES

Postoperative pain management is of highest interest for patients undergoing maxillofacial surgery including microvascular reconstructive surgery. Currently, there is a lack of information regarding process and outcome of postoperative pain management after microvascular reconstruction.

MATERIALS AND METHODS

In a prospective clinical study, 31 adults were evaluated on the first postoperative day following microvascular reconstruction with a radial forearm flap using the standardized questionnaire of the Germany-wide project Quality Improvement in Postoperative Pain Management (QUIPS). It enables a standardized assessment of patients' characteristics, pain parameters, outcome and pain therapy process parameters.

RESULTS

Pain management consisted predominately of premedication with midazolam, sufentanil and metamizol intraoperatively, piritramid in the intensive care unit and metamizol, tramadol and fentanyl patches on ward. Nineteen patients (61.3 %) showed inadequate pain management with pain levels ≥4. Among other significant relations, patients exhibiting an age below the median presented significant higher levels of pain under strain (p = .041) and maximum pain (p = .006) as well as rate of breathing (p = .009) and mood (p = .006) disturbance. Performance of pain counselling showed specific impact on pain under strain (p = .008), maximum pain (p = .004) and satisfaction with pain intensity (p = .001). Whether microvascular reconstruction was performed with primary or secondary intention or performance of a neck dissection did not show significant influence.

CONCLUSIONS

QUIPS helped us to adequately evaluate the procedure-specific quality of postoperative management following microvascular reconstruction with a radial forearm flap. It helped us to identify a surprisingly high amount of inadequate pain management. Postoperative pain levels seem to be primarily influenced by the performed reconstruction.

CLINICAL RELEVANCE

Establishment of a continuous and procedure-specific evaluation of postoperative pain levels should help to avoid inadequate pain management, which is widely prevalent according to the literature and our study. Preoperative pain counselling is essential and should be procedure specific to be its best.

Trend of analgesic consumption and pain scores in the post anesthetic care unit (A 9-year survey in surgical cancer patients)

As part of a quality assurance program, we assessed the trend of our analgesic consumption using our anesthesia database which include anesthesia and postanesthetic care records for all patients. In recent years, emphasis was made on anesthesia personnel to decrease postoperative opioid analgesic at the expense of non-opioid analgesics in order to decrease opioid related side effects. The following items were recorded: intraoperative opioid consumption, total morphine consumption, non-opioid analgesic consumption pain and sedation scores in the postoperative care unit (PACU). The database consisted of 57,967 patients for 9 consecutive years from 2002 to 2010, mean data exhaustivity was of 95%. Total morphine consumption per patient in the operative room and in the PACU decreased significantly from 11 ± 4 mg in year 2002 to 7 ± 3 mg in 2010, P < 0.05. In the intraoperative period, remifentanil/sufentanil ratio increased significantly from 33/67 to 87/13% of patients (P < 0.05) without affecting pain scores in the PACU. This multi-year trend shows a significant decrease in overall postoperative morphine consumption, in addition we showed that computerized database can easily follow the trend of analgesic consumption and can be used therefore as a powerful tool with easy access as part of a quality assurance program.

[New and evidence-based aspects of postoperative pain therapy]

Poorly managed postoperative pain has been recognised to delay patient recovery and hospital discharge. Recent metaanalyses support a multimodal approach with combinations of analgesics from different classes. The pharmacological options of commonly used opioids, nonsteroidal anti-inflammatory drugs, and other nonopioid analgesics in combination have been shown to provide effective pain relief and to reduce opioid consumption. Local, intraarticular, epidural, and, more importantly, modern peripheral regional techniques can be used successfully to enhance perioperative analgesia. The use of continuous perineural techniques with local anaesthetic infusion has been extended beyond hospital discharge in many European countries.

[Implementation of a standardized perioperative pain management concept in three hospitals of a consortium]

BACKGROUND

Provision of sufficient perioperative pain therapy is an obligation in the clinical management of patients suffering from pain. The implementation of a standardized pain management concept was planned to be introduced in the clinical routine. The results of three hospitals are shown.

MATERIAL AND METHODS

The concept included tools which gave information about legal aspects and basic fundamentals of pain relief, management modules regarding agreements on the implementation of perioperative pain therapy, instruments to measure pain intensity, assigning accountability and documentation modules. Questionnaires were carried out according to Picker.

RESULTS

The project revealed that, according to the Picker questionnaire, about 50% of the patients treated in the hospitals had pain, 30-40% still had intensive pain during the stay in hospital and 90% of the patients received pain relief medication within 10 min of the request. More than 78% of the patients thought the hospital staff did their best to relieve the pain and over 92% found the pain treatment adequate.

CONCLUSION

It was possible to implement a standardized perioperative pain therapy concept in three hospitals of a consortium. Whether an adequate pain relief can be improved with the help of standard measurements and documentation, could not be evaluated in this study.