Department of Anesthesiology and Intensive Care.
University of Defence, Medical Faculty of the Military Medical Academy.
Clin J Pain. 2023 Oct 1;39(10):537-545. doi: 10.1097/AJP.0000000000001153.
The quality of postoperative pain management is often poor. A "bundle," a small set of evidence-based interventions, is associated with improved outcomes in different settings. We assessed whether staff caring for surgical patients could implement a "Perioperative Pain Management Bundle" and whether this would be associated with improved multidimensional pain-related patient-reported outcomes (PROs).
"PAIN OUT," a perioperative pain registry, offers tools for auditing pain-related PROs and obtaining information about perioperative pain management during the first 24 hours after surgery. Staff from 10 hospitals in Serbia used this methodology to collect data at baseline. They then implemented the "Perioperative Pain Management Bundle" into the clinical routine and collected another round of data. The bundle consists of 4 treatment elements: (1) a full daily dose of 1 to 2 nonopioid analgesics (eg, paracetamol and/or nonsteroidal anti-inflammatory drugs), (2) at least 1 type of local/regional anesthesia, (3) pain assessment by staff, and (4) offering patients information about pain management. The primary endpoint was a multidimensional pain composite score (PCS), evaluating pain intensity, interference, and side effects that was compared between patients who received the full bundle versus not.
Implementation of the complete bundle was associated with a significant reduction in the PCS ( P < 0.001, small-medium effect size [ES]). When each treatment element was evaluated independently, nonopioid analgesics were associated with a higher PCS (ie, poorer outcome, and negligible ES), and the other elements were associated with a lower PCS (all negligible small ES). Individual PROs were consistently better in patients receiving the full bundle compared with 0 to 3 elements. The PCS was not associated with the surgical discipline.
We report findings from using a bundle approach for perioperative pain management in patients undergoing mixed surgical procedures. Future work will seek strategies to improve the effect.
术后疼痛管理的质量往往较差。在不同环境中，一组小的基于证据的干预措施（即“套件”）与改善结果相关。我们评估了照顾手术患者的医护人员是否能够实施“围手术期疼痛管理套件”，以及这是否与改善多维与疼痛相关的患者报告结局（PRO）相关。
“疼痛评估”（PAIN OUT）是一个围手术期疼痛登记处，提供审核与疼痛相关的 PRO 并获取术后 24 小时内围手术期疼痛管理相关信息的工具。塞尔维亚 10 家医院的工作人员使用这种方法在基线时收集数据。然后，他们将“围手术期疼痛管理套件”纳入临床常规，并收集了另一轮数据。该套件由 4 种治疗元素组成：（1）1 至 2 种非甾体类抗炎药（如扑热息痛和/或非甾体抗炎药）的每日全剂量；（2）至少 1 种局部/区域麻醉；（3）工作人员进行疼痛评估；（4）向患者提供有关疼痛管理的信息。主要终点是多维疼痛综合评分（PCS），比较接受完整套件的患者与未接受完整套件的患者的疼痛强度、干扰和副作用。
实施完整套件与 PCS 显著降低相关（P<0.001，小到中效应大小[ES]）。当评估每个治疗元素的独立性时，非甾体类抗炎药与更高的 PCS 相关（即更差的结果和可忽略不计的 ES），而其他元素与更低的 PCS 相关（所有可忽略不计的小 ES）。接受完整套件的患者的个体 PRO 始终优于接受 0 至 3 个元素的患者。PCS 与手术学科无关。
我们报告了在接受混合手术的患者中使用围手术期疼痛管理套件方法的结果。未来的工作将寻求改善效果的策略。
