2 Safe and effective post-operative pain relief: introduction and continuous quality-improvement of comprehensive post-operative pain management programmes

Abstract

Listen

Translate article

Planning and implementing a comprehensive, hospital-wide post-operative pain management programme in two university hospitals started in 1992 with emphasis on patient safety and implementing patient-controlled intravenous morphine analgesia and epidural analgesia with a low dose bupivacaine, fentanyl and adrenaline analgesic mixture on ordinary wards as focus for improving quality of post-operative pain management. A major educational programme for all personnel involved in the care of surgical patients aimed at improving understanding of post-operative pain, the consequences of unrelieved pain and increased general knowledge of pain relieving drugs and methods. Gradual, ward-by-ward introduction of PCA and epidural analgesia, with individual follow-up of nurses and patients by the specially assigned anaesthesiologist and nurse, selection of electromechanically very safe pain pumps, standardized prescription and monitoring regimen, has resulted in good to excellent patient satisfaction in 90% of 5749 patients. Side effects reduced quality of pain relief or caused early discontinuation of PCA and epidural analgesia in 25% of patients during the early phase of the programme, later 10–15%. Nausea, dizziness, sedation, confusion, pruritus, and urinary retention were the most frequent adverse effects during PCA. These were infrequent or mild during epidural analgesia, but epidural catheter-problems occurred in 15–20% of patients. Epidural catheter problems have improved, but continue to cause failure or premature discontinuation in 10–15% of epidural analgesia patients. No serious complications with permanent adverse outcome occurred. Four patients had potentially serious respiratory depression in 2922 PCA patients during 11 380 PCA-patient-days due to human error, three potentially serious complications in 2827 epidural patients during 14 870 epidural-patient-days, all were discovered early and treated successfully. These results demonstrate clearly that the infrastructure, the educational and quality assurance programmes of our post-operative pain management concept, are both effective and safe. The economic cost of equipment, medication, and wages for the personnel assigned to the programme are modest when we consider that most surgical patients benefit from the comprehensive post-operative pain management programme. Although we have not attempted to document reductions in post-operative complications or in duration of post-operative course, it is plausible that there is an overall net saving in health care cost from the post-operative pain management programme.