Évaluation des pratiques professionnelles de la prise en charge de la douleur postopératoire à court,moyen et long terme

Objectives

To evaluate the short medium and long-term impact of a quality-improvement program (QIP) in a university hospital using a validated reference tool.

Methods

Seven surgical departments were audited before and after implementation of a QIP in postoperative pain management. Audits were conducted in 2005, 2007, 2009 and 2012. In each audit, 10 medical charts from each surgical department were analyzed for 9 quality criteria. A surgical department score (SDS) was calculated for each department (maximum score = 90). The surgical departments with a SDS < 45 received targeted training sessions.

Results

In 2005, three surgical departments had a SDS < 45. After the first audit, a targeted training sessions was conducted in the three surgical departments, all seven departments improved their scores with a SDS > 45 in 2007. Between 2007 and 2009, all seven departments improved their scores. Conversely, between 2009 and 2012, the SDS diminished in six of the seven surgical departments and four of the nine evaluated quality criteria decreased significantly: right detailed order for postoperative pain analgesia (prescriber identifier, agent used, unit doses, mode of administration; 100% versus 53; P = 0.027), appropriate dosing of steps I and II analgesics (96% versus 80%; P = 0.041), morphine (90% versus 76%; P = 0.039), based on corresponding physician orders and monitor morphine side effects (87% versus 29; P = 0.027).

Conclusion

Audits should be performed regularly (at least every two years) for detecting postoperative pain management degradation. Lack of targeted training sessions can explain partially this degradation.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

Infiltration de ropivacaïne en chirurgie carcinologique du sein : effet sur la douleur postopératoire aiguë et chronique

Objectives

Decrease acute pain after breast cancer surgery by an infiltration of ropivacaine. Analyse effect on chronic pain.

Study design

Prospective randomised double blind versus placebo study.

Patients and methods

Eighty-one patients randomised between two groups received wound infiltration with 40 ml of ropivacaine 4.75 mg/ml or placebo. Acute pain was assessed during 24 h with analogical visual scale and antalgic consumption. One year later, telephonic interviews looked for chronic pain and evaluate it with McGill Pain Questionnaire.

Results

Analogical visual scale pain score, antalgic consumption and chronic pain incidence were similar between groups.

Conclusion

Ropivacaine scar infiltration provided no acute or chronic pain relief after breast cancer surgery.     

Stratégie de réhabilitation postopératoire de la fracture du col fémoral

The femoral neck fracture in elderly patient is an entity that is within the scope of “disease causing a femoral neck fracture”. The specific factors for successful management of these elderly patients are centered around patient's comorbidities, specific management in a clinical pathway, and more or less early rehabilitation after surgery. The type of fracture, surgery, specific treatment, early active recovery for the patients lying in bed after surgery optimize the functional outcome at mean term. The improvement of nutritional status, equilibrium for comorbidities and early rehabilitation with walking activities and physiotherapy significantly improve functional outcome at short and medium terms and postoperative mortality. The use of multimodal analgesia and regional analgesia primarily by perioperative continuous femoral nerve blocks also improve the medical prognosis and functional outcome of the patient.     

Comparaison prospective et randomisée de la morphine nébulisée versus la péridurale thoracique dans la prise en charge de la douleur des traumatisés thoraciques

Introduction

Successful management of pain reduces morbidity and improves patient satisfaction of patient after a chest trauma. The purpose of the study was to evaluate the efficacy of the respiratory administration of nebulized morphine in such patients.

Patients and methods

Patients were included in this prospective and randomized study patients to receive either nebulized morphine in group M or a mixture of bupivacaine-fentanyl by epidural route. In group M, patients received nebulized morphine every 30 minutes until the second hour then every 4 hours during 48 hours. In the thoracic epidural analgesia group (group P) they received a mixture of 0.125% bupivacaine and 0.115% of fentanyl continuously infused at the rate of 7 ml/h during 48 hours. The main criterion of judgment was the analgesic effects of analgesic regimen with EVA < 4. Sedation, haemodynamic and respiratory parameters were continuously recorded, as adverse side effects were they occurred. Statistical comparisons were performed with Chi², Fisher or Student t-test when appropriate (p < 0.05).

Results

Forty patients were randomized in two groups. Groups were not different regarding the demographic parameters. Analgesia was effective in both groups (NS). Sedation, hemodynamic and respiratory parameters were not different between groups. No side effect was noted in groups.

Conclusion

Nebulized morphine was an analgesic technique as effective as epidural bupivacaine-fentanyl in our series. This non-invasive route of administration of morphine appears to be useful to treat pain after a chest trauma.     

Enquête sur les pratiques françaises d’analgésie en chirurgie thoracique (réalisée avec le concours de l’ARCOTHOVA)

Objective

To assess the current practice of analgesia after thoracotomy and thoracoscopy in France.

Study design

Cross-sectional practice survey.

Material

Anaesthetist physicians, each referent for one of the French centres practicing thoracic surgery, during year 2012.

Methods

Electronic questionnaire about the activity of the centre in thoracic surgery, and modalities and estimated frequencies of different analgesic techniques. Primary assessment was the estimated percentage of acts, after imputation from original data.

Results

Eighty-four centres out of 103 (82 %) answered the questionnaire. Coupling locoregional to general anaesthesia involved 74 % of thoracotomies and 35 % of thoracoscopies. A practice (i.e. for more than 5 % of patients) of epidural analgesia was declared by 68 centres (81 %), and by 27 centres (32 %) for paravertebral block. The most current practices for epidural analgesia were: thoracic puncture, intraoperative initiation, ropivacaïne 0.2 % plus sufentanil, patient-controlled administration with infusion plus bolus, application more than 48 hrs post surgery. The practice rates for technique of paravertebral block were: Eason & Wyatt 34 %, ultrasound-guided 24 %, internal 42 %. The most frequent systemic analgesia was patient-controlled intravenous morphine. Ketamine was used in 60 % of the cases.

Conclusions

French practice of analgesia after thoracic surgery improved quality during the last decade, but more than one patient on four (compared to 8 % in UK) may have neither epidural nor paravertebral block, while such techniques are nowadays considered as standard.