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Original Report| Volume 18, ISSUE 10, P1237-1252, October 2017

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Postoperative Pain Management in Spanish Hospitals: A Cohort Study Using the PAIN-OUT Registry

      Highlights

      • Postoperative outcomes in Spanish hospitals were obtained using a multidimensional scale.
      • Spanish pain outcomes were similar to those reported in Europe and the United States.
      • Patient's participation in pain management was poor.
      • Presurgical chronic pain (numeric rating scale score >7) was associated with worsened pain outcomes.
      • Adequate control of chronic pain might improve postoperative outcomes.

      Abstract

      Pain after surgery remains a problem worldwide, although there are no published data on postoperative outcomes in Spain. We evaluated 2,922 patients on the first day after surgery in 13 tertiary care Spanish hospitals, using the PAIN-OUT questionnaire. The aims were to: assess postoperative outcomes and anesthetic/analgesic management in Orthopedics (ORT) and General Surgery (GEN) patients; explore the influence of the analgesic therapy on outcomes and opioid requirements; evaluate and compare outcomes and analgesic management according to surgical procedure. Mean worst pain and percentage of patients in severe pain were 5.6 (on a numeric rating scale of 0–10) and 39.4%, respectively, slightly lower than those reported in Western countries (range, 5.0–8.4 and 33–55%). Patients’ pain assessment (83.1%) and information were high (63.3%), but participation in decision-making (4.8) was lower than in the United States (7.0) and Europe (Germany, France, Norway, and Denmark; mean, 5.9). Patients after orthopedic surgery had the worst outcomes. General anesthesia was more frequent in GEN patients, whereas regional (central and peripheral) was more frequent in ORT surgery patients. Mean opioid consumption (20.2 mg per patient per 24 hours, oral morphine equivalents), was lower than reported and decreased >50% after regional analgesia. Intravenous morphine patient-controlled analgesia was seldom used (6.2%). Acute opioid treatments were associated with worsened outcomes whereas multimodal analgesia (mainly antipyretic analgesics–nonsteroidal anti-inflammatory drugs–opioids) were associated with improved results. Epidurals in abdominal surgery (16.7%) were also associated with better outcomes. Presurgical chronic pain (>7) and/or chronic opioid consumption, were associated with worsened pain outcomes; the latter with a 50% increase in postoperative opioid requirements. Tibia/fibula and foot surgeries (ORT), and gastric, small intestine, and anterior abdominal wall procedures (GEN) were the most painful. Rigorous control of chronic pain before surgery, and combining opioids with adjuvants and other analgesics perioperatively, might improve postoperative outcomes.

      Perspective

      We analyzed postoperative outcomes and analgesic management in patients from tertiary care Spanish hospitals. The study serves as a point of comparison with other Western countries and shows that pain intensity outcomes and opioid consumption were slightly better in the Spanish population. Chronic pain before surgery (numeric rating scale score >7) and/or chronic opioid consumption, were associated with worsened pain outcomes, suggesting that rigorous control of chronic pain before surgery, and combining opioids with adjuvants and other analgesics perioperatively, might improve outcomes. Patients’ pain participation in decision-making was inadequate and should be improved in Spanish hospitals.

      Key words

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      References

        • Anderson R.
        • Saiers J.H.
        • Abram S.
        • Schlicht C.
        Accuracy in equianalgesic dosing: Conversion dilemmas.
        J Pain Symptom Manage. 2001; 21: 397-406
        • Benhamou D.
        • Berti M.
        • Brodner G.
        • De Andres J.
        • Draisci G.
        • Moreno-Azcoita M.
        • Neugebauer E.A.
        • Schwenk W.
        • Torres L.M.
        • Viel E.
        Postoperative Analgesic THerapy Observational Survey (PATHOS): A practice pattern study in 7 central/southern European countries.
        Pain. 2008; 136: 134-141
        • Breivik H.
        Postoperative pain management: Why is it difficult to show that it improves outcome?.
        Eur J Anaesthesiol. 1998; 15: 748-751
        • Breivik H.
        • Collett B.
        • Ventafridda V.
        • Cohen R.
        • Gallacher D.
        Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment.
        Eur J Pain. 2006; 10: 287-333
        • Cabañero D.
        • Campillo A.
        • Célérier E.
        • Romero A.
        • Puig M.M.
        Pronociceptive effects of remifentanil in a mouse model of postsurgical pain: Effect of a second surgery.
        Anesthesiology. 2009; 111: 1334-1345
        • Campillo A.
        • Cabañero D.
        • Romero A.
        • García-Nogales P.
        • Puig M.M.
        Delayed postoperative latent pain sensitization revealed by the systemic administration of opioid antagonists in mice.
        Eur J Pharmacol. 2011; 657: 89-96
        • Célérier E.
        • González J.R.
        • Maldonado R.
        • Cabañero D.
        • Puig M.M.
        Opioid-induced hyperalgesia in a murine model of postoperative pain: Role of nitric oxide generated from the inducible nitric oxide synthase.
        Anesthesiology. 2006; 104: 546-555
        • Chou R.
        • Gordon D.B.
        • de Leon-Casasola O.A.
        • Rosenberg J.M.
        • Bickler S.
        • Brennan T.
        • Carter T.
        • Cassidy C.L.
        • Chittenden H.
        • Degenhardt E.
        • Griffith S.
        • Manworren R.
        • Mccarberg B.
        • Montgomery R.
        • Murphy J.
        • Perkal M.F.
        • Suresh S.
        • Sluka K.
        • Strassels S.
        • Thirlby R.
        • Viscusi E.
        • Walco G.A.
        • Warner L.
        • Weisman S.J.
        • Wu C.L.
        Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council [erratum in: 17:508–510, 2016].
        J Pain. 2016; 17: 131-157
        • Cohen J.
        A power primer.
        Psychol Bull. 1992; 112: 155-159
        • Cohen S.P.
        • Christo P.J.
        • Wang S.
        • Chen L.
        • Stojanovic M.P.
        • Shields C.H.
        • Brummett C.
        • Mao J.
        The effect of opioid dose and treatment duration on the perception of a painful standardized clinical stimulus.
        Reg Anesth Pain Med. 2008; 33: 199-206
        • Correll D.J.
        • Vlassakov K.V.
        • Kissin I.
        No evidence of real progress in treatment of acute pain, 1993-2012: Scientometric analysis.
        J Pain Res. 2014; 7: 199-210
        • Curatolo M.
        • Sveticic G.
        Drug combinations in pain treatment: A review of the published evidence and a method for finding the optimal combination.
        Best Pract Res Clin Anaesthesiol. 2002; 16: 507-519
        • Dihle A.
        • Helseth S.
        • Kongsgaard U.E.
        • Paul S.M.
        • Miaskowski C.
        Using the American Pain Society’s patient outcome questionnaire to evaluate the quality of postoperative pain management in a sample of Norwegian patients.
        J Pain. 2006; 7: 272-280
        • Dolin S.J.
        • Cashman J.N.
        • Bland J.M.
        • Clinic P.
        • Richard S.
        • Po C.
        Effectiveness of acute postoperative pain management: I. Evidence from published data.
        Br J Anaesth. 2002; 89: 409-423
        • Fletcher D.
        • Fermanian C.
        • Mardaye A.
        • Aegerter P.
        A patient-based national survey on postoperative pain management in France reveals significant achievements and persistent challenges.
        Pain. 2008; 137: 441-451
        • Fleurence R.L.
        • Naci H.
        • Jansen J.P.
        The critical role of observational evidence in comparative effectiveness research.
        Health Aff (Millwood). 2010; 29: 1826-1833
        • Gan T.J.
        • Habib A.S.
        • Miller T.E.
        • White W.
        • Apfelbaum J.L.
        Incidence, patient satisfaction, and perceptions of post-surgical pain: Results from a US national survey.
        Curr Med Res Opin. 2014; 30: 149-160
        • García-López J.
        • Domingo Vicent F.
        • Montes P.A.
        • Dürsteler C.
        Puig Riera de Conías MM: Comparison of 2 methods of clinical data collection, one using the PAINOUT questionnaire (a European database for the management of postoperative pain).
        Rev Esp Anestesiol Reanim. 2011; 58 ([in Spanish]): 273-278
        • Gerbershagen H.J.
        • Aduckathil S.
        • van Wijck A.J.
        • Peelen L.M.
        • Kalkman C.J.
        • Meissner W.
        • Kalkman C.J.
        • Meissner W.
        Pain intensity on the first day after surgery: A prospective cohort study comparing 179 surgical procedures.
        Anesthesiology. 2013; 118: 934-944
        • Gerbershagen H.J.
        • Pogatzki-Zahn E.
        • Aduckathil S.
        • Peelen L.M.
        • Kappen T.H.
        • van Wijck A.J.
        • Kalkman C.J.
        • Meissner W.
        • Kappen T.H.
        • Van Wijck A.J.
        • Kalkman C.J.
        • Meissner W.
        Procedure-specific risk factor analysis for the development of severe postoperative pain.
        Anesthesiology. 2014; 120: 1237-1245
        • Gordon D.B.
        • Pellino T.A.
        • Miaskowski C.
        • McNeill J.A.
        • Paice J.A.
        • Laferriere D.
        • Bookbinder M.
        A 10-year review of quality improvement monitoring in pain management: Recommendations for standardized outcome measures.
        Pain Manag Nurs. 2002; 3: 116-130
        • Gordon D.B.
        • Polomano R.C.
        • Pellino T.A.
        • Turk D.C.
        • Mccracken L.M.
        • Sherwood G.
        • Paice J.A.
        • Wallace M.S.
        • Strassels S.A.
        • Farrar J.T.
        Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) for quality improvement of pain management in hospitalized adults: Preliminary psychometric evaluation.
        J Pain. 2010; 11: 1172-1186
        • Hayhurst C.J.
        • Durieux M.E.
        Differential opioid tolerance and opioid-induced hyperalgesia: A clinical reality.
        Anesthesiology. 2016; 124: 483-488
        • Hibbard J.H.
        Engaging health care consumers to improve the quality of care.
        Med Care. 2003; 41: I61-I70
        • Ip H.Y.
        • Abrishami A.
        • Peng P.W.
        • Wong J.
        • Chung F.
        Predictors of postoperative pain and analgesic consumption: A qualitative systematic review.
        Anesthesiology. 2009; 111: 657-677
        • Joshi G.P.
        • Kehlet H.
        Procedure-specific pain management: the road to improve postsurgical pain management?.
        Anesthesiology. 2013; 118: 780-782
        • Kairaluoma P.M.
        • Bachmann M.S.
        • Rosenberg P.H.
        • Pere P.J.
        Preincisional paravertebral block reduces the prevalence of chronic pain after breast surgery.
        Anesth Analg. 2006; 103: 703-708
        • Kehlet H.
        Multimodal approach to control postoperative pathophysiology and rehabilitation.
        Br J Anaesth. 1997; 78: 606-617
        • Kehlet H.
        Updated pain guidelines: What is new?.
        Anesthesiology. 2012; 117 (author reply: 1398): 1397-1398
        • Kehlet H.
        • Jensen T.S.
        • Woolf C.J.
        Persistent postsurgical pain: Risk factors and prevention.
        Lancet. 2006; 367: 1618-1625
        • Larue F.
        • Lehete P.
        • Lejus C.
        • Macaire P.
        • Marret E.
        • Richebé P.
        Expert panel guidelines (2008). Postoperative pain management in adults and children. SFAR Committees on Pain and Local Regional Anaesthesia and on Standards.
        Ann Fr Anesth Reanim. 2009; 28: 403-409
        • Leslie T.A.
        • Greaves M.W.
        • Yosipovitch G.
        Current topical and systemic therapies for itch.
        Handb Exp Pharmacol. 2015; 226: 337-356
        • Lorentzen V.
        • Hermansen I.L.
        • Botti M.
        A prospective analysis of pain experience, beliefs and attitudes, and pain management of a cohort of Danish surgical patients.
        Eur J Pain. 2012; 16: 278-288
        • Macrae W.A.
        Chronic post-surgical pain: 10 Years on.
        Br J Anaesth. 2008; 101: 77-86
        • Maier C.
        • Nestler N.
        • Richter H.
        • Hardinghaus W.
        • Pogatzki-Zahn E.
        • Zenz M.
        • Osterbrink J.
        The quality of pain management in German hospitals.
        Dtsch Arztebl Int. 2010; 107: 607-614
        • McDonald S.
        • Page M.J.
        • Beringer K.
        • Wasiak J.
        • Sprowson A.
        Preoperative education for hip or knee replacement.
        Cochrane Database Syst Rev. 2014; : CD003526
        • Patanwala A.E.
        • Jarzyna D.L.
        • Miller M.D.
        • Erstad B.L.
        Comparison of opioid requirements and analgesic response in opioid-tolerant versus opioid-naive patients after total knee arthroplasty.
        Pharmacotherapy. 2008; 28: 1453-1460
        • Pereira J.
        • Lawlor P.
        • Vigano A.
        • Dorgan M.
        • Bruera E.
        • Chb M.B.
        Equianalgesic dose ratios for opioids. A critical review and proposals for long-term dosing.
        J Pain Symptom Manage. 2001; 22: 672-687
        • Phillips S.
        • Gift M.
        • Gelot S.
        • Duong M.
        • Tapp H.
        Assessing the relationship between the level of pain control and patient satisfaction.
        J Pain Res. 2013; 6: 683-689
        • Puig M.M.
        • Montes A.
        • Marrugat J.
        Management of postoperative pain in Spain.
        Acta Anaesthesiol Scand. 2001; 45: 465-470
        • Ren Z.Y.
        • Xu X.Q.
        • Bao Y.P.
        • He J.
        • Shi L.
        • Deng J.H.
        • Gao X.J.
        • Tang H.L.
        • Wang Y.M.
        • Lu L.
        The impact of genetic variation on sensitivity to opioid analgesics in patients with postoperative pain: A systematic review and meta-analysis.
        Pain Physician. 2015; 18: 131-152
        • Roeb M.M.
        • Wolf A.
        • Gräber S.S.
        • Meiner W.
        • Volk T.
        Epidural against systemic analgesia: An international registry analysis on postoperative pain and related perceptions after abdominal surgery.
        Clin J Pain. 2017; 3: 189-197
        • Rothaug J.
        • Zaslansky R.
        • Schwenkglenks M.
        • Komann M.
        • Allvin R.
        • Backström R.
        • Brill S.
        • Buchholz I.
        • Engel C.
        • Fletcher D.
        • Fodor L.
        • Funk P.
        • Gerbershagen H.J.
        • Gordon D.B.
        • Konrad C.
        • Kopf A.
        • Leykin Y.
        • Pogatzki-Zahn E.
        • Puig M.
        • Rawal N.
        • Taylor R.S.
        • Ullrich K.
        • Volk T.
        • Yahiaoui-Doktor M.
        • Meissner W.
        Patients’ perception of postoperative pain management: Validation of the International Pain Outcomes (IPO) questionnaire.
        J Pain. 2013; 14: 1361-1370
        • Sabaté S.
        • Canet J.
        • Muñoz S.
        • Castillo J.
        • Lucas M.
        • Mayoral V.
        Epidemiology of anesthesia in Catalonia, Spain, in 2003.
        Med Clin (Barc). 2006; 126 ([in Spanish]): 13-18
        • Schug S.A.
        • Palmer G.M.
        • Scott D.A.
        • Halliwell R.
        • Trinca J.
        Acute pain management: Scientific evidence, fourth edition, 2015.
        Med J Aust. 2016; 204: 315-317
        • Schwenkglenks M.
        • Gerbershagen H.J.
        • Taylor R.S.
        • Pogatzki-Zahn E.
        • Komann M.
        • Rothaug J.
        • Volk T.
        • Yahiaoui-Doktor M.
        • Zaslansky R.
        • Brill S.
        • Ullrich K.
        • Gordon D.B.
        • Meissner W.
        Correlates of satisfaction with pain treatment in the acute postoperative period: Results from the international PAIN OUT registry.
        Pain. 2014; 155: 1401-1411
        • Schwingshackl L.
        • Hoffmann G.
        Mediterranean dietary pattern, inflammation and endothelial function: A systematic review and meta-analysis of intervention trials.
        Nutr Metab Cardiovasc Dis. 2014; 24: 929-939
        • Sentürk M.
        • Ozcan P.E.
        • Talu G.K.
        • Kiyan E.
        • Camci E.
        • Ozyalçin S.
        • Dilege S.
        • Pembeci K.
        The effects of three different analgesia techniques on long-term postthoracotomy pain.
        Anesth Analg. 2002; 94: 11-15
        • Shah S.
        • Kapoor S.
        • Durkin B.
        Analgesic management of acute pain in the opioid-tolerant patient.
        Curr Opin Anaesthesiol. 2015; 28: 398-402
        • Zaslansky R.
        • Chapman C.R.
        • Rothaug J.
        • Bäckström R.
        • Brill S.
        • Davidson E.
        • Elessi K.
        • Fletcher D.
        • Fodor L.
        • Karanja E.
        • Konrad C.
        • Kopf A.
        • Leykin Y.
        • Lipman A.
        • Puig M.
        • Rawal N.
        • Schug S.
        • Ullrich K.
        • Volk T.
        • Meissner W.
        Feasibility of international data collection and feedback on post-operative pain data: Proof of concept.
        Eur J Pain. 2012; 16: 430-438
        • Zaslansky R.
        • Rothaug J.
        • Chapman C.R.
        • Bäckström R.
        • Brill S.
        • Fletcher D.
        • Fodor L.
        • Gordon D.B.
        • Komann M.
        • Konrad C.
        • Leykin Y.
        • Pogatski-Zahn E.
        • Puig M.M.
        • Rawal N.
        • Ullrich K.
        • Volk T.
        • Meissner W.
        PAIN OUT: The making of an international acute pain registry.
        Eur J Pain. 2014; 19: 490-502