European approaches to postoperative pain management

Abstract

Recent surveys show that a large proportion of patients still receive inadequate postsurgical analgesia, this problem is international in character. Although the general principles of postoperative pain management in Europe are similar to those in North America, individual European patients may receive treatments that may vary considerably between countries. This may depend on treatment traditions such as frequent use of regional techniques in Scandinavian countries, it may also depend on nursing regulations regarding analgesic techniques such as injection of drugs in epidural catheters or intravenous lines. The different health care systems, allocation of funds, and acute pain service (APS) organization models can also be expected to affect pain management. The proportion of surgery performed on a day care basis is considerably higher in the United States, this has implications for delivery of analgesia in the home environment. There is increasing evidence that many day surgery patients have moderate to severe pain lasting 2 to 3 days, it is also clear that pain management in this group has been generally neglected. This article discusses certain aspects of postoperative pain from a European perspective. Data from a 17 nation, 105 hospital, European survey has shown that approximately 7% of 1.2 million patients who underwent surgery during 1 year received spinal opioid analgesia. Interestingly, 12 different opioids and 8 nonopioids were used routinely for epidural analgesia. Monitoring routines for patients receiving spinal opioids varied greatly, this is consistent with the general international uncertainty regarding where and how to monitor these patients. The technique of intravenous patient controlled analgesia (IV PCA) for post-operative pain was routinely used in 67% of the participating hospitals in the European survey. About 11% of the surgical population received patient controlled analgesia (PCA) for postoperative analgesia, eight different opioids were used. Respiratory depression was noted in 17 out of 89,000 patients (0.02%) who received PCA. The use of regional techniques varied considerably between European countries. In Scandinavian countries regional techniques such as epidural and spinal were commonly used even for ambulatory surgery. The concept of skilled pain therapists collaborating to provide improved post-operative analgesia within the framework of an organized APS appears to be universally applicable. APS models have been described from the United States, United Kingdom, Germany, Switzerland, and Sweden. The United States' model which consists of anesthesiologist-based comprehensive pain management teams is quite effective but because it is too selective and too expensive, it is not transferable to Europe. A nurse-based anesthesiologist-supervised APS in which pain is evaluated in every patient who undergoes surgery has been developed in Sweden. Pain above 3 on the 10 grade visual analog scale is promptly treated. In this low-cost model the anesthesiologists' role is teaching and training ward nurses, supervising the acute pain nurse, and selecting patients for special pain therapies such as epidural, PCA, and peripheral nerve blocks. All senior anesthesiologists (section chiefs) working in the operating room are part of this APS.