Incidences et causes d’insatisfaction des patients vis-à-vis de la prise en charge de la douleur postopératoire

Introduction

Patient satisfaction regarding postoperative pain management (POPM) is not always correlated with pain level relief.

Objective

To evaluate the percentage of satisfied patients while splitting satisfaction related with nurses, anaesthesiologists and surgeons during 48 h postoperative period.

Patients and methods

The study was performed in 2007 by two investigators in six different surgical suites in a university hospital. Approximatively 15 patients have been randomly selected in each surgical ward. Each patient received during the first or second postoperative day an anonymous questionnaire and was required to complete it with the investigator assistance if necessary. Questions requiring a yes-or-no reply assessed the patient's satisfaction with POPM performed by nurses, surgeons, and anaesthesiologists. In case of dissatisfaction, patients were invited to explain the reasons.

Results

Ninety-two patients were included, 5% of the patients were not satisfied with nurse POPM and nearly 15% were not satisfied with anaesthesiologist or surgeon POPM. The main reasons of dissatisfaction with nurses were the excessive delays between requesting and receiving an analgesic and because of the significant discrepancies in POPM between nurses. Patient discontent regarding surgeons was explained by the lack of interest of the latter for POPM. Patient discontent regarding anaesthesiologists was explained by the lack of anaesthesiologist visit in the postoperative period.

Conclusion

There is a relationship between patient dissatisfaction and the lack of attention for POPM by surgeons and the lack of postoperative visit by the anaesthesiologist. A postoperative visit by a team of anaesthesia nurses should improve patient satisfaction with POPM.     

Enquête nationale sur la prise en charge de la douleur aiguë postopératoire dans les hôpitaux libanais

Introduction

Postoperative pain relief in Lebanon is a public health problem because its coverage is insufficient.

Study design

A survey was performed with a questionnaire distributed to anaesthesiologists during the Lebanese national meeting of anaesthesia in May 2006.

Results

A total of 106 out of the 230 distributed questionnaires were collected. The coverage of the postoperative pain is different in the university hospitals and others. A preoperative information and postoperative evaluation of pain are only performed by 26% of anesthesiologists. A multimodal analgesia is begun in the operative room or in postanaesthesist care unit for 92% of the patients. Only 71% of the anaesthesiologists have pumps for patient-controlled analgesia. Written protocols for postoperative analgesia are available in only 58% of the centres. Among anaesthesiologists, only 36% have an initial and/or continuous formation to treat the postoperative pain. The major obstacle for improvement of postoperative pain is the cost of such treatments, which must be supported by the patients.

Conclusion

Even if there is a good awareness of the importance to relieve the postoperative pain, important efforts must be done in this domain in Lebanon.     

Analgésie postopératoire à domicile : évaluation de la douleur par les parents,information

Postoperative analgesia at home induces necessarily pain assessment by self-report or observational measure. A special scale has been validated for day-case surgery: the PPMP. Nevertheless, children's and parents’ information and education are essential.     

Efficacité de l’infiltration cicatricielle subfasciale par la bupivacaïne dans la réduction de la douleur postopératoire des hernies inguinales

Introduction

The reduction of postoperative pain after surgery of inguinal hernia is an objective of lot of studies. The subfasciale infiltration of the wound may be an efficient technique.

Methods

This study was designed as a randomized, double blind, prospective study, comparing two treatment groups: a group infiltrated by bupivacaine (Gr B), and second one infiltrated by a placebo (Gr P). A part of demographic parameters and ASA class, the postoperative pain intensity at rest and at coughing, the morphine consumption and the secondary effects were compared. Patient's satisfaction and postoperative chronic pain at 3 and 6 months were also analyzed.

Results

Concerning demographic parameters, ASA class and secondary effects, we didn’t find any meaningful difference between the two groups. However, there was a significant reduction of postoperative pain in the bupivacaine group as well at rest as coughing. Gr P patients have more morphine consumption and they were unsatisfied and accused more chronic pain.

Discussion

Wound infiltration is still a simple and efficient technique in postoperative pain reduction. With this technique, hernia surgery may become ambulatory.     

Évaluation des pratiques de prise en charge analgésique en postopératoire de césarienne avant et après mesures d’amélioration

Objective

To assess the improvement of practices in postoperative analgesia after a cesarean section post implementation of a corrective program.

Study design

Prospective impact study.

Patients and methods

After obtaining ethics approval, we included all patients undergoing a cesarean section at Montpellier University Hospital during February 2011 (PRE group) and March 2012 (POST group). The patients were interviewed on the fourth day postpartum about pain management and related data was collected from the chart. From March 2011 to February 2012, training sessions were held for the paramedical and medical teams.

Results

Sixty patients were included in each group. The two groups were not significantly different. The mean overall numeric rating scale worst pain score between Day 0 and Day 4 in POST group was lower (5.5 ± 2.5 vs. 6.5 ± 2.4 p < 0.01) and impairment during mobilization decreased significantly. Compliance with protocols improved in the POST group: the number of women receiving full analgesia regiment increased from 12% to 68% between PRE and POST period.

Conclusion

After an awareness campaign of the paramedical and medical staff, we succeeded in improving significantly the routine use of analgesics regardless of their level. Nevertheless healthcare professionals still seem reluctant to administer opioids.     

Place de l’anesthésie locorégionale dans l’analgésie postopératoire à domicile chez l’enfant

Hospitalization at home has known for the past few years a growing interest in care of patients. It has shown its advantages in children in terms of reducing the stress of parental separation, postoperative infections and the cost of hospitalization. But, pain remains the most common complaint in the postoperative follow-up of patients. As in adults, regional anesthesia has also shown interest in children in terms of morphine consumption and quality of postoperative analgesia. However, the use of single shot regional anesthesia seems to induce an exacerbation of pain upon returning home. For management of prolonged postoperative pain at home, continuous peripheral nerve blocks are then presented as the best options. This type of analgesia is mainly reserved for major orthopedic surgery in children. The quality of analgesia obtained in different pediatric studies is excellent with a low rate of adverse events. L-enantiomer local anesthetics are predominantly used at low concentrations for the systemic safety provided. The use of elastomeric disposable pumps for LA infusion allows early and easy ambulation with a simplified management, bringing great satisfaction to parents and children.     

Effet des anesthésiques locaux sur la réponse inflammatoire postopératoire

Current knowledge suggests that peripheral inflammation following surgery activates and sensitizes both peripheral and central nervous system. These phenomena involved in the maintenance of the inflammatory response lead to hypersensibility, hyperalgesia and allodynia. Hyperalgesia participates in the general experience of postoperative pain and ALo in the development of chronic pain. A correlation between the ability of treatments to reduce areas of hypersensitivity surrounding the wound after surgery and their ability to reduce the incidence of chronic pain has been shown. For a long time, local anaesthetics have been used for their capacity to block nociceptive input. They can ALo modulate the inflammatory response following a surgical trauma. By inhibiting the nervous conductivity at the site of the trauma, local anesthetics attenuate the sensitization of the nervous system and therefore the inflammatory phenomena. They ALo exert intrinsic anti-inflammatory properties by modulating the local and systemic liberation of inflammatory mediators. The mechanisms involved are not clearly elucidated. Local, systemic, and spinal inflammatory mechanisms may be influenced by local anesthetics through multiple different mechanisms. The therapeutic implications of effects of local anesthetics on local, systemic, and spinal inflammatory responses merit further study.     

Stratégie de prise en charge préopératoire visant à diminuer la morbidité et la mortalité de la fracture du col fémoral

Hip femur is extremely common in the elderly and is one of the most common reasons for admission in trauma care. The main reported causes of death after hip fracture were cardiovascular (29%), neurological (20%) and pulmonary. Large epidemiological studies have shown a relatively small decrease in mortality for 20 years despite an active approach to medical and surgical management. Yet 57% of deaths occurring within 30 days post-surgery are preventable because they are not related to a pre-existing disease. Preoperative management to optimize these patients could help to reduce morbidity and mortality and is thus a crucial issue. The anesthesia consultation is used to evaluate the perioperative risk, treat pain, manage treatment and stabilize the patient. An operative delay of more than 48 hours after admission increases mortality. This period should not be prolonged by unnecessary investigations that will not change the perioperative management. The preoperative period is a key moment because it allows to choose the anesthetic technique. Even if this choice is controversial, continuous spinal anesthesia (titrated) do not modify the cardiovascular and neurological physiological balance of these precarious patients.     

Effet de la kétamine dans la prévention des douleurs chroniques post-mastectomies. Étude pilote

Objective

This pilot study was designed to evaluate the feasibility of a trial to estimate the preventive effect of ketamine on postmastectomy pain syndrome (PMPS).

Study design

Double-blind, randomized, placebo-controlled pilot trial.

Patients and method

Thirty six patients scheduled for a radical mastectomy with axillary lymph node dissection were randomized in two groups (n = 18 per group). Before skin incision, a bolus (0.5 mg/kg of ketamine or placebo) followed by a continuous infusion (0.25 mg/kg per hour of ketamine or placebo) was administered and discontinued at the end of surgical procedure. We studied the incidence and characteristics of PMPS three months after surgery as well as the feasibility of chosen methods.

Results

Thirty patients were followed for three months (group ketamine n = 12; group placebo n = 18). At three months, there was no significant difference in the incidence of chronic pain, but a tendency to a decrease of hyperalgesia near the scar. There was no repercussion on the quality of life. The characteristics of the PMPS are similar to those described in the recent literature (intercostobrachial neuralgia 33%, neuroma pain 39%, and phantom breast pain 22%). The feasibility of the experimental study is established by the absence of difficulty during the clinical investigation period.

Conclusion

We found no preventive effect of ketamine on the development of PMPS. However, the non-statistically significant effect of ketamine on hyperalgesia three months after surgery could justify a larger study with the same methodology.     

Apport de la saturation veineuse centrale en oxygène dans la décision transfusionnelle postopératoire

Objective

The aim of this study was to assess the value of central venous oxygen saturation (ScvO₂) for the decision of blood transfusion in comparison with the criteria of the French guidelines for blood transfusion (2003).

Study design

Prospective, observational.

Patients and methods

Sixty patients, haemodynamically stable, for whom a blood transfusion (BT) was discussed in the postoperative course of general surgery, were included. ScvO₂ (%) and haemoglobin (g/dl) were measured before and after BT. Patients were retrospectively divided into two groups according to ScvO₂ measured before BT (< or ≥ 70%). Results are expressed as median.

Results

The ScvO₂ before transfusion was greater or equal to 70% in 25 (47.2%) patients. Following BT, the ScvO₂ increased significantly (from 57.8 to 68.5%) in the group with initial ScvO₂ less than 70% whereas it was unchanged in patients with initial ScvO₂ greater or equal 70% (from 76.8 to 76.5%). Twenty patients (37.7%) did not meet the French guidelines for BT criteria. Eighteen patients out of 33 that met the criteria had ScvO₂ greater or equal 70% before BT while 13 patients with ScvO₂ less than 70% were not detected by these same criteria.

Conclusion

ScvO₂ could be a relevant biological parameter to complete the current guidelines for BT in stable patient with a central venous catheter during the postoperative period.     

Cécité bilatérale en postopératoire d’une chirurgie du rachis

We report the case of a 36-year-old man who underwent neurosurgery for a T9 spine fracture consecutive to a fall. The patient had complete postoperative blindness which did not totally recover during the hospital stay. Decreased visual acuity and postoperative vision loss are not uncommon in spine surgery. Such postoperative complications in spine surgery are severe. To avoid them, it is mandatory to identify the contributing factors and set up a preventive strategy.     

Dysfonctions cognitives postopératoires : stratégie de prévention, de dépistage et de prise en charge

The femoral neck fracture is a major cause of morbidity and mortality in the elderly. The etiology of cognitive impairment observed in this population of aged patient seems to be multifactorial. In the strategy of prevention, elderly patient must have the clearer information dealing with the postoperative cognitive dysfunction. This would reduce the incidence of POCD and some cognitive complaints, which often reflect the anxiety of the elderly patient facing the possibility of cognitive impairment. During the anaesthesia consultation, it seems important to assess the cognitive function of this elderly patient (like using neuropsycholgical scale as the MMSE) and to identify associated risk factors of cognitive dysfunction. The management of cognitive disorders should be multidisciplinary, the anesthesiologist being the main referent, in collaboration with the geriatrician and the surgeon. In the clinical setting of femoral neck fracture in the elderly, this multimodal management (pain, nutrition, functional rehabilitation to make these patients autonomous as quickly as possible), seems to improve the functional prognosis and to have the observed POCD decreased.