CLINICAL GUIDELINES ID TAG Title: Acute pain strategy for adult day surgery Author: Speciality / Division: Directorate: Dr Jeffrey Brown Anaesthetics/ATICS Acute Date Uploaded: March 2018 Review Date Clinical Guideline ID 2021 CG0541
Acute pain strategy for adult day surgery. Ensuring comfort after day surgery. There are an increasing number of operations that are deemed suitable for day case surgery. 1 The procedures are becoming more complex but it should be remembered that relatively minor procedures can be associated with an inordinate amount of pain. A recent survey has shown that patients are most worried about post-operative vomiting followed by post-operative pain. 2 Uncontrolled pain has several adverse reactions that include, in the short term, emotional and physical suffering, sleep disturbance, cardiovascular effects, and decreased mobility which promotes thromboembolism. 3 In the longer term, post-operative pain can lead to chronic pain and in children behavioural changes are sometimes seen that can last up to a year. 3 It is imperative that we give adequate pain relief to assure patients that going home after surgery is a safe and comfortable postoperative pathway. In the past, patient satisfaction surveys have noted that patients preferred day case surgery but felt that post-operative instruction was often inadequate. 4 Ensuring optimal analgesia and comfort after day surgery is a key element to ensuring the best longterm outcome for the patient. 5 In addition, effective management of acute pain has long been recognised as important in improving the post-operative experience, reducing complications and promoting early discharge from hospital. 6 Pain problems and associated complications escalate if patients are discharged with insufficient pain relief medications. 7 Chronic pain can develop if pain is not treated effectively at the time of surgery. 8,9 Despite this understanding, a large gap exists between the evidence available to guide practitioners and current practice. 7 10 Pain which is poorly managed in the post-operative period is the main cause of delayed discharge after day-case surgery. 11 Failure of pain management after day surgery clearly results in increased patient suffering. Control of pain following surgery continues to present a challenge in many healthcare systems. 3 <5% of patients experiencing severe pain in the 48 hours post-operatively is a generally accepted standard of care. There is evidence that some services have further reduced this to 1% or 2%. This more challenging target may serve to drive improvement towards excellence. Pain following surgery may be predicted by factors such as pre-operative pain, type of surgery. anticipated postoperative pain by the clinician, pre-operative high expectations of the patient, younger age and fear of shortterm consequences of the operation. 12 Good quality pain relief will result in earlier mobilisation, reducing the social cost in terms of returning to work and reduce the requirement for intervention by primary care.
Optimising pain management Optimising pain management in day surgery involves measuring a range of process and outcome indicators. The Royal College of Anaesthetists have updated their guidance on the provision of acute pain management and have produced clear statements about requirements for optimal pain relief in the perioperative period. 13 Pain should be recorded as the 5th vital sign, and evaluated, treated and re-evaluated frequently. Pain should be measured on movement (dynamic pain assessment). Optimal postoperative pain relief is considered to be <4 on a 0 to 10 scale or at a level acceptable to the patient. A score of 4 or more on an 11 point (0 10) verbal numerical rating scale(vnrs) is considered a threshold for intervention. 11 Elderly patients are more likely to under-report pain and have difficulty in quantifying pain. In most patients pain control plans should result in good pain control. Identifying patients in whom that plan has not been entirely effective should lead to improved methods. Pain can also be assessed using the ubiquitous verbal descriptor scale (VDS) as none, mild, moderate(a score of 4 or more on VNRS described above) or severe. The quality of post-operative pain control for individual patients and for institutions can then be assessed as follows; all pain assessments none or mild GOOD control isolated instance(s) of moderate or severe pain BORDERLINE control two or more consecutive instances of moderate or severe pain POOR control Institutional standards to aspire to in the control of post-operative pain; 100% patients discharged with written and oral instructions regarding pain relief. <5% reporting severe pain on verbal pain score in the first 48 hours after discharge. >85% reporting none or mild pain after discharge. >85% satisfied with management of their pain at home. Procedure specific approaches to pain relief, modified to the needs of individual patients, such as those included in the Southern Trust adult day surgery acute pain algorithm below are widely recommended. 14
Algorithm It is intended that the acute pain algorithm below should be used by the anaesthetist caring for any given day surgery patient to indicate and recommend to the surgical team the optimal analgesic regimen to be prescribed by the surgical team on their discharge letter. Acute Pain Strategy Adult (>50kg) Day Surgery Pain category (circle one only) To be prescribed on the discharge letter by the discharging clinician/team (after Anaesthetist s recommendation) Pain intensity Discharge medication (to be prescribed by the discharging clinician) Length of course A None None B Mild C1 Moderate C1N(Nausea poss) Moderate C2 Moderate Codeine phosphate 30mg 6hrly prn C2N(Nausea poss) Moderate Codeine phosphate 30mg 6hrly prn C3 C3N(Nausea poss) Moderate Moderate D1 Severe Codeine Phosphate 60mg 6hrly prn D2N(Nausea poss) Severe Lactulose 15ml 12 hrly D3(exceptional) Severe Sevredol 10(ten)mg 6hrly prn D3(exceptional) Severe Continued overleaf. Operation (Nurse to complete) Sevredol 10(ten)mg 6hrly prn Addressograph 3 day (Total12tabs) 3 day (Total12tabs) Anaes signature (sign/date 1 box only)
Below are suggested pain categories for common procedures in the day surgery unit, to be used in conjunction with the above. Please circle a category even if the exact operation performed is not listed below. Patient factors and procedural factors may demand alteration of pain category/analgesia prescription. A B C C/D EuA ears Cataract surgery Anal surgery ACL reconstruction Cystoscopy Grommets/T-tubes Arthroscopy Circumcision Restorative dentistry Prostate biopsy Axillary clearance Endometrial ablation Sebaceous cyst surgery Breast lumps Laparoscopy Sigmoidoscopy Dupuytren s contracture Haemorrhoidectomy Skin lesion surgery Carpal tunnel decompression Hernia repair Urethral surgery Cervical/vulval surgery Joint fusion/osteotomy Hysteroscopy/D&C Shoulder surgery Middle ear surgery Testicular surgery Vaginal sling Tonsillectomy Varicose vein surgery Wisdom tooth extraction Vasectomy Dental clearance Non-wisdom tooth extraction Quality improvement A quality improvement proforma will permit analysis of unit performance toward the national standards described on page 2 of this document. It will also serve to guide the re-categorisation of procedures in the algorithm if required. 1 BADS directory 3rd Edition. British Association of Day Surgery, London June 2009 (http://www.bads.co.uk). 2 Eberhart LHJ et al. Patient preferences for immediate postoperative recovery. Br J Anaesth2002;89(5):760 761. 3 Post Operative Pain Management Good Clinical Practice. European Society of Regional Anaesthesia and Pain Therapy (http://www.esraeurope.org/postoperativepainmanagement.pdf). 4 Mooney G, Symonds A. They just said come in for a day : patients experiences of day case surgery. Primary Health Care Research and Development 2001;2:55 56. 5 White P, Kehlet H. Improving post-operative pain management. Anesthesiology 2010;112(1):220 225. 6 Commission on the provision of surgical services. Reports of the working party on pain after surgery. RCS and RCoA, London 1990. 7 Niraj G, Rowbotham J. Persistent post-operative pain: where are we now? Br J Anaesth 2011;107(1):25 29. 8 Macrae W. Chronic postsurgical pain: 10 years on Br J Anaesth 2008;101(1):77 86. 9 Global Year against Acute Pain campaign. International Association for the Study of Pain, 2010 (http://www.iasppain.org/content/navigationmenu/globalyearagainstpain/globalyearagainstacutepain/default.htm). 10 Australia and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute Pain Management: scientific evidence (3rd Edn). ANZCA, Melbourne 2010 (http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp104_3.pdf). 11 Royal College of Anaesthetists. Raising the Standard: a compendium of audit recipes. 3rd Edition 2012. 12 Gramke et al. Predictive factors of postoperative pain after day-case surgery. Clin J Pain 13 Guidance on the provision of anaesthesia services for acute pain management. RCoA, London 2010 (http://www.rcoa.ac.uk/node/712). 2009;25(6):455 460. 14 Guideline. Day case and short stay surgery: 2 Working party of Association of Anaesthetists of Great Britain and Ireland/British Association of Day Surgery. Anaesthesia, 2011;66:417-434.