Évaluation de la douleur postopératoire

Pain is a subjective feeling; its assessment is therefore difficult, and no “gold standard” method exists for humans. Major improvements have, however, been made in the last decade by widespread acceptation of the concept of pain evaluation and widespread use on surgical wards. Evaluation by the patient himself is the rule (unless communication is impaired), as assessment of pain by nurses or doctors systematically leads to underestimation (which also occurs with observational scales). Theoretically, pain should be evaluated in its multiple dimensions such as intensity, location, emotional consequences and sémiologic correlates. Scales which have been developed to evaluate these dimensions are, however, too complex for widespread and repetitive use in surgical patients. The Mac Gill Pain Questionnaire is therefore only used in the surgical setting for research purposes. Moreover, its scientific accuracy, although often accepted, is poor and in our opinion cannot be accepted as a reference method. Only methods assessing pain intensity can be used in the clinical setting because of their simplicity. The verbal rating scale (VRS), the numerical rating scale (NRS) and the visual analogue scale (VAS) are preferred by an increasing number of groups. Although scientific validation is difficult, VAS seems the most accurate and reproducible scale. Post-operative pain should be assessed several times a day in every patient, at rest and in dynamic conditions (cough, movement) and should focus on present pain rather than on pain in the previous hours. Assessment of pain is essential before quality-assurance programmes can be implemented.     

Prévention de la douleur postopératoire

The pre-emptive analgesia concept suggests that pre-administration of analgesics may enhance the efficacy of these drugs. This review has selected the data from the literature according to two types of methodological criteria: Sackett's criteria, and those specific of pre-emptive analgesia studies. Infiltration, spinal and peripheral nerve blocks using local anaesthetic drugs do not seem to produce pre-emptive analgesia. The few positive results have limited clinical significance. The results concerning opioids are contradictory and the clinical significance is limited. Preoperative oral administration of non steroidal anti-inflammatory drugs (NSAIDs) offers no benefit. Intravenous pre-administration has a limited advantage, but enhances perioperative bleeding. Kétamine, an NMDA receptor antagonist, may have some pre-emptive analgesic properties according to the few studies available. In conclusion, pre-administration of analgesic drugs represents the usual strategy for the anaesthesiologist (spinal or peripheral block, infiltration, opioids). In other cases (NSAIDs, kétamine), pre-administration represents a change in usual practice. This is not justified for NSAIDs; NMDA receptor antagonists may offer an interesting research area. Data concerning pre-emptive analgesia for chronic pain syndrome such as phantom limb pain are quite limited.     

Épidémiologie de la douleur postopératoire

Postoperative pain, as all types of pain, is a complex phenomenon including sensory, emotional and behavioural factors. The incidence and severity of postoperative pain is very variable between patients and is rather unpredictable. Patients characteristics as well as the types of surgery and anaesthesia will be of importance. Health professionnals have a major role to play for improving effectiveness of pain management as well as safety.     

Gestion de la douleur postopératoire dans une unité de soins

In order to improve the management of postoperative pain many publications insist on progressive changes in care organization. The following list outlines steps to be taken for implementation of these changes: 1) an initial analysis of management of post-operative pain allows awareness of reforms to be proposed; 2) participation of health teams in special training in order to use evaluation tools and collect data (use of analgesics, adverse effects); 3) establishing policies and procedures: recovery room, guidelines for analgesic use and adverse effects; 4) notifying patient about the various procedures to be used in postoperative period -discussion with the patient during the preoperative interview; 5) current use of standard patient-controlled analgesia (PCA) and locoregional analgesia; 6) use of combined techniques in order to achieve a balanced analgesia; 7) implementing a quality assurance programme which should include analgesic effectiveness, patient satisfaction and prevention of complications; and 8) planning of an Acute Pain Service based on a clinical nurse co-ordinator which offers highly effective forms of postsurgical analgesia.     

Comment organiser la prise en charge de la douleur postopératoire dans les services de chirurgie ?

Many studies have demonstrated that the management of pain after surgery was unsatisfactory. New pain management techniques have been developed in recent years (patient-controlled analgesia, epidural analgesia). To extend the number of patients who may benefit from these recent techniques and/or to obtain the best efficacy from existing methods of pain relief, re-organisation should take place on surgical wards. For example, protocols describing pain management strategies should be written. Surveys and audits should be carried out regularly to check their efficacy. Moreover, patients should be fully informed of the range of treatments available and their adverse effects. Finally, all staff involved in providing acute pain relief should undergo training.     

Fréquence,intensité, évolution et retentissements de la douleur postopératoire en fonction du type de chirurgie

Type of surgery is the most important factor conditionning intensity and duration of postoperative pain. Thoracic and spinal surgery are the most painfull procedures. Abdominal, urologic and orthopedic surgery lead to severe postoperative pain. Duration of severe pain rarely exceeds 72 hours. Mobilization increases pain intensity after abdominal, thoracic and orthopaedic surgery. Pain could occur after day-case minor surgical procedures and is often underestimated. Postoperative complications related to pain are difficult to disclose because of the interposition of the direct effects of analgesic treatments. Respiratory and cardiovascular postoperative complications are unrelated to postoperative pain in healthy subjects. This could be different in high risk patients. The surgical procedure is the major determinant of metabolic and psychologic postoperative deterioration. Adequate pain relief allows postoperative rehabilitation and physiotherapy programmes after abdominal and orthopaedic surgery. This could be expected to reduce hospital stay and improve convalescence.     

Douleur postopératoire. Spécificités de l'enfant de moins de 5 ans,néonatologie exclue

For many years, postoperative pain has been undertreated in children less than 5 years old in comparison to adults. The assessment of pain is indeed difficult in this range of age, and only the scales of hetero-evaluation are used. The guidelines for treatment are similar as in adults: systematic administration, balanced analgesia, evaluation of pain and potential adverse effects. Non opioid analgesics used are mainly paracetamol, niflumic acid and ibuprofen. Morphine remains the drug of choice among opioids; however the risk of respiratory depression in higher in infants less than 3 months old. Nalbuphine is also widely used in paediatrics. In addition, regional anaesthesia, either in single shot for minor surgery, or in continuous administration through epidural catheter for major surgery, has changed the management of postoperative pain in paediatrics.     

Validation francophone de la grille d’évaluation de la douleur-déficience intellectuelle – version postopératoire

Purpose

The aim of the study was to test the validity of a French language version of the Non-Communicating Children’s Pain Checklist - Postoperative Version (NCCPC-PV): grille d’évaluation de la douleur-déficience intellectuelle (GED-DI).

Methods

We assessed the intensity of pain in 87 intellectually disabled surgical patients recruited in four Canadian and French hospitals in the pre- and post-operative settings using the GED-DI, a 100-mm visual analogue pain scale (VAS) and the Rosen sedation scale. The validity of the GED-DI was measured by the difference in scores between pre- and postoperative conditions. The checklist was made up of 30 items divided into seven subgroups. Items were rated from 0 to 3 for a total score ranging from 0 to 90 points.

Results

The mean (standard deviation) age of the patients was 17 (11) yr and the mean mental age 24.5 (24) months. The total GED-DI score was 6.1 (4.9) pre- and 13.4 (11.2) post-surgery (P < 0.001). All subgroups had a higher score after surgery (P < 0.001). The receiver operating characteristic (ROC) curves, comparing the absence of pain to mild pain scores and moderate to severe pain scores, showed a cutoff at 6 (mild pain) and 11 (moderate to severe pain).

Conclusion

The French version of the NCCPC-PV can be used to assess pain in non-communicating patients with intellectual disabilities in a postoperative setting. It has good content validity, as the total pre-surgery score for the GED-DI was significantly lower than the postoperative score, and showed a good concurrent validity when compared to the VAS.     

Indications et place de l'albumine, à l'exclusion du remplissage vasculaire,dans la prise en charge préopératoire ou postopératoire de l'hypertension portale

Low serum albumin levels are common in patients with cirrhosis and liver failure. Decreased synthesis is the main but not the only mechanism leading to decreased serum levels. The consequences of low albumin concentrations are a decreased plasma colloid osmotic pressure and a decreased binding of liposoluble xenobiotics and endogenous substances. Besides the fluid accumulation in pleura and peritoneum, the complications directly related to low serum albumin levels have been only poorly assessed. An increase in serum albumin levels (by a few g·L⁻¹) for a few days can be achieved by the infusion of large amounts of human albumin (approximately 120 g over 3 days). The efficacy of this treatment has been only tested in association with large paracentesis: albumin infusion, which induces volume expansion, reduced the incidence of hyponatremia and functional renal failure. No significant effect on ascites production rate or survival has been observed. Similar results were achieved through polygelin or dextran-70 infusions. No well-conducted controlled study on the value of albumin infusion in other circumstances apart from cirrhotic patients is available. In conclusion, albumin infusion should be reserved to the treatment of hyponatraemia or functional renal failure complicating cirrhosis with severe liver failure and marked hypoalbuminaemia, when the infusion of colloids failed to correct these anomalies.     

Analyse de la douleur postopératoire et des résultats fonctionnels précoces dans le traitement de la rhizarthrose. Étude prospective comparative de 74 patientes trapézectomie-interposition vs prothèse MAIA®

Trapeziectomy has been the basis of basal thumb arthritis surgical treatment since the 1950s. This resection arthroplasty has been continuously refined (soft-tissue interposition, ligament reconstruction, spacer implantation, etc.) without leading to a dramatic outcome improvement. Pain decrease is often satisfying in the long-term, but comfort during the early postoperative period may vary. Those disadvantages of trapeziectomy led to the emergence of total trapeziometacarpal prostheses in the 1970s, with a constant improvement of implant design. Few series have compared those two surgical techniques side by side, and prospective ones are even rarer. We compared total trapeziometacarpal prosthesis and trapeziectomy-interposition in the very short term in two similar groups of female patients, to determine whether prosthesis led to faster recovery or not. We compared a total trapeziometacarpal prosthesis (MAIA^®) and trapeziectomy-interposition in the immediate and short-term (6 months), for objective, subjective, functional criteria, as well as short-term comfort or discomfort. We prospectively followed two comparable cohorts of 47 and 27 female patients above 50 years of age, treated for basal joint arthritis with a constrained trapeziometacarpal joint prosthesis or trapeziectomy-interposition, respectively, between April 2009 and February 2010. The patients were followed postoperatively for 6 months. Mobility, pain reduction, satisfaction, strength and functional scores were better in the prosthesis group. The pinch strength improved by 30%, the length of the thumb column was maintained, and better correction of the subluxation was obtained in this group. There were six cases of De Quervain's tenosynovitis and one case of loosening due to trauma. In the short-term, the MAIA^® trapeziometacarpal prosthesis gives better outcome than trapeziectomy with interposition. This has to be confirmed in the long-term and after revision surgery that will be likely to occur.Clinical relevanceTherapeuthic 3.     

Effets de l'anesthésie sur la miction et rétention aiguë d'urine postopératoire

Postoperative micturition difficulties, considered as minor complications, have a high incidence. Acute urinary retention can follow all types of anaesthetics or operations. Surgical trauma to the pelvic nerves or to the bladder, postoperative oedema around the bladder neck, and pain-induced reflex spasm of the external and internal urethral sphincters may play a role in the development of urinary retention. Acute urinary retention is the most common complication of surgery for benign anorectal disease. The incidence of urinary retention is more likely to occur in old male patients. Preoperative urinary symptoms are not a prerequisite for developing postoperative urinary retention, although they are considered to be a risk factor. The type of anaesthetic, postoperative pain and its management may have little effect on the occurrence of postoperative urinary dysfunction. Studies on the urodynamic effects of various anaesthetic agents are rare. The parasympatholytic drugs increase bladder capacity, decrease the rate of bladder contractions and cause downward trends in urethral resistance. The barbiturates and halothane produce similar effects on urethral resistance. The anaesthetic agents decrease the intrabladder pressure and inhibit the micturition reflex. Halothane decreases bladder contractions and increases its capacity measured by the cystometrogram. Urinary retention is a side effect of opioids, particularly after intrathecal or epidural administration. Epidural morphine relaxes the detrusor muscle with a corresponding increase in the maximal bladder capacity. Spinal opioids influence the function of the lower urinary tract, by direct spinal action on the sacral nociceptive neurons and autonomic fibres, as well as by an effect on supraspinal centres. Naloxone increases detrusor pressure, decreases bladder capacity, and causes a need to void. Urinary retention is less common after a short-acting (lidocaine 5 %) than after a long-acting agent (bupivacaine 0.5 %). After spinal anaesthesia, detrusor strength and the ability to void restarts with the return of sacral sensation to pinprick. A single episode of bladder overdistention can result in significant morbidity. Overfilling of the bladder can stretch and damage the detrusor muscle, leading to atony of the bladder wall, so that recovery of micturition may not occur when the bladder is emptied. On the other hand, the excessive use of an indwelling catheter can lead to urinary tract infection, urethral stricture and prolonged hospital stay. Short-term prophylactic catheterisation is recommended in patients with obstructive symptoms. Patients at risk for urinary retention should be stimulated to void and provided a quiet environment in which to do so. They should be encouraged to seat, stand or ambulate as early as possible. The alpha₁ adrenergic receptor blocking agents have been used for treatment of organic or functional urinary retention. It is essential to make sure the bladder empties regularly in the postoperative period, especially in day-case surgery or in patients receiving opioid analgesia or after epidural anaesthesia.     

Chirurgie pariétale de la douleur

Sans résuméRapport du Congrès Européen de Neuro-chirurgie de Zurich, Juillet 1959.