Acute Pain SIG Newsletter - February 2018

SIG’s Chair Report
Acute Pain after Surgery: Lessons from the Last Decade
Minutes of the Acute Pain SIG Meeting, September 5, 2017
From Within to Without—Time to Move from the Center to the Periphery
Pain Education in India: If it Is Hatched from a Swan's Egg
A Single-Center Experience of a Perioperative Pain Management Improvement Program in a Developing Country: An IASP-Funded Study

SIG’s Chair Report

Following up on the excellent report that Immediate Past Chair Dan Carr provided in the August 2017 newsletter, this is a further report on most recent and future activities of the SIG on Acute Pain.

In the context of the 2017 Global Year Against Pain After Surgery, the most outstanding event hosted by our SIG was the IASP-EFIC preconference Satellite Symposium, which took place on September 5 in Copenhagen, just before the EFIC meeting. The satellite was a great event with excellent attendance, superb presentations, and enthusiastic discussions. A detailed description of the preconference satellite and brief summaries of the lectures is provided in this newsletter courtesy of Dan Carr and the presenters.

In addition, on the day before the satellite, another small EFIC preconference on preventing chronic postsurgical pain discussed new clinical trial results for a novel therapeutic, an oligonucleide inhibitor targeting the upregulation of the transcription factor EGR1.

At the satellite, there was also a meeting of the SIG, attended by 13 members; the detailed minutes can be found in this newsletter.

With these satellites just behind us, planning for the SIG activities in 2018 is rapidly advancing. Here the focus is on two specific issues, the World Congress on Pain in Boston in September and the 2018 Global Year for Excellence in Pain Education.

Concerning the World Congress, the SIG has already registered a satellite symposium for Tuesday, September 11, 2018, in Boston. This symposium is titled “The cascade from tissue injury to CRPS: beyond ‘chronification’?” and is jointly organized by our SIG and the SIG on Complex Regional Pain Syndrome.

This symposium will review what is known about the inciting factors for CRPS and the distinctive biology that is emerging from research. It will help participants develop a clearer picture of the distinctive pathophysiology of the evolution of CRPS after acute injury and its implications for the prevention and treatment of CRPS. The afternoon sessions will separate into two streams specific to the respective SIGs. We hope this satellite symposium will find the interest of members of both SIGs.

For the World Congress itself, the executive has decided to sponsor two topical workshops proposed by members of the SIG and related to acute pain. One has been proposed by Eske Aasvang from Copenhagen, titled “Clinical relevance of multifactorial prediction models for post-operative pain: an integrated

Approach.” The second comes from Esther Pogatzki-Zahn in Münster, Germany, and will address “Outcome in acute postoperative pain: past, current and the future.”

With regard to the Global Year for Excellence in Pain Education, we are currently planning a webinar on pain education focused on acute pain. All members are invited to make suggestions for how the SIG can contribute to this important topic!

I close this report with my heartfelt thanks to Dan Carr for his preceding chairmanship and his ongoing input into many aspects of the SIG – and with best wishes for 2018.

-- Stephan Schug
Chair, Acute Pain SIG


Acute Pain after Surgery: Lessons from the Last Decade

A summary of the Acute Pain SIG satellite meeting during the recent EFIC Congress, compiled by Dan Carr, Acute Pain SIG immediate past chair

In conjunction with the 2017 Global Year Against Pain After Surgery, IASP’s Acute Pain SIG collaborated with the European Pain Federation (EFIC) to organize and bring to fruition a number of activities and publications. These activities have ranged from Fact Sheets, to publication of the proceedings of a symposium in PAIN Reports, to the upcoming book Pain After Surgery (an updated IASP Press monograph on this topic), to formal endorsement of the Global Year effort by numerous professional organizations.  

The latest effort affirming this theme took place in September at EFIC’s 10th Congress, during which a full day was devoted to a preconference satellite organized by IASP AP SIG Chair Stephan Schug and Vice Chair Esther Pogatzki-Zahn. The carefully selected expert presenters were grouped into four topics:

  1. Acute Pain after Surgery: Lessons Learned from the Last Decade (chairs: Esther Pogatzki-Zahn and Daniel B. Carr)
  2. Acute Pain Management: Change the Vision (chairs: Winfried Meissner and Stephan Schug)
  3. Transition from Acute to Chronic Pain After Surgery (chairs: Jane Quinlan, Esther Pogatzki-Zahn)
  4. Treatment of Chronic Pain After Surgery: New Approaches (chairs: Stephan Schug, Dominique Fletcher)

The individual talks, along with a brief precis of each talk provided by its presenter, follow at the end of this article.

Many aspects of the broader EFIC Congress addressed pain after surgery or related topics. AP SIG officers as well as world-renowned leaders in the field of postoperative pain control, such as Henrik Kehlet from Denmark, presented plenary or refresher course lectures.

Another EFIC preconference on preventing chronic postsurgical pain discussed new clinical trial results for a novel therapeutic, an oligonucleide inhibitor targeting the upregulation of the transcription factor EGR1. As described by Donald Manning, who chaired the workshop, EGR1 induction is known to regulate a variety of inflammatory and pain-inducing pathways whose activation after trauma contribute to sensitization and chronification.

Dan Carr, Oscar de Leon-Casasola, Henrik Kehlet, and Stephan Schug, along with Julien Mamet discussed findings of persistent decreases in pain at rest and during walking for at least six weeks following a single perioperative administration to patients undergoing knee replacement.

The conference center and organizers were excellent, and the weather cooperated by raining at times when it served the conference well to have people not off sightseeing. The conference banquet dinner took place at the Danish National Museum amid remarkable archaeological finds and cultural artifacts. The last evening of the EFIC Congress welcomed attendees to an unusual and memorable dinner experience in a spectacular venue featuring “Copenhagen street food” and other international fare. Luckily, this venue was mere steps away from the canals, which offered picturesque views as twilight proceeded into night.

Following are summaries of the presentations from each speaker in order of their presentations:

Daniel Segelcke, “Lessons learned from animal studies”: Clinical pain management after surgery is far from being successful despite dramatically increased scientific evidence in this area. The under-treatment of postoperative pain has many reasons; one of the more important is the limited translation of basic and clinical findings into clinical practice. Postoperative pain models characterize by showing resting pain, mechanical/heat hyperalgesia, movement-evoked pain, and anxiety/depression behavior and thus simulate pain after surgery in patients. Postoperative pain represents a unique pain entity in spinal and supraspinal structures and molecular pathways.

Dominic Aldington, “Lessons learned from Cochrane Reviews”: The Cochrane database is a valuable resource for clinicians, but it does not, on its own, constitute evidence-based medicine; this is instead a fusion of clinical experience with “external” evidence. We must consider the wider aspects of the health-care service and the system we use; we must not expect a “magic bullet” to do everything for our patients and us.

Stephan Schug, “Lessons learned from analysis of scientific evidence”: From scientific evidence, we have learned primarily that pain relief after surgery should be multimodal and procedure-specific. Multimodal analgesia ideally should have an opioid-sparing effect, thereby reducing adverse effects of opioids while improving pain control. This approach is governed by the use of regional analgesia whenever possible and a concept of maximizing non-opioids and minimizing opioids. In parallel, as analgesic medications and techniques have different effects in different surgical settings, provision of postoperative analgesia should be procedure-specific.

Winfried Meissner, “Lessons Learned from Big Data”: Big data is often defined as data too big, too complex, too weakly structured, or too speedy to process with conventional computing resources. In clinical acute pain research, large registries or routine data (e.g., EMR) do not always fulfill “Big Data” definitions but challenge researchers by complexity. [Next sentence requires clarification] In contrast to RCTs, registries, and routine data often include patients with rare conditions, may detect infrequent complications, mirror “real life,” and create new hypotheses. Known and unknown confounders may bias findings of registry data; therefore, associations are not necessarily of causal relationship.

Acute Pain Management: Change the Vision

Ulrike Stamer, “Too much pain after C-Section?”: Data from scientific studies/RCTs provide evidence that good pain control after Cesarean section is possible; however, these settings do not reflect everyday clinical practice. The UK Royal College of Anaesthetists suggested several quality indicators aimed at pain management after Cesarean section, which are not met, if analyzing data of the international acute pain registry PAIN OUT. Pain scores are too high, time in severe pain too long, and non-opioid analgesics not used on a regular basis in daily clinical routine. There is a need for meaningful but realistic quality criteria reflecting pain-related short-term and long-term outcomes and functional impairment after Cesarean section.

Madelon Peters, “Psychological Aspects: How important are they and how can we target them perioperatively?”: There is now a large evidence base showing that psychological distress factors are associated with elevated levels of acute postsurgical pain and a higher incidence of persistent postsurgical pain. The most prominent factors appear to be pain catastrophizing and anxiety, explaining around 10 percent to 15 percent of variance in acute pain intensity. Perioperative psychological interventions targeting catastrophizing and anxiety with the aim of decreasing postoperative pain appear to be promising, but the evidence for their efficacy is still limited. Interventions should be brief, and mode of delivery should be practical, so that they can be implemented in clinical practice.

Esther Pogatzki-Zahn, “Can we predict pain outcome after surgery?”: Although many therapeutic methods and drugs are available, pain after surgery is not sufficiently managed. One reason might be the different responses of individual patients to surgery and analgesics. Some patients are more susceptible than others for developing severe pain and pain-related functional impairment. A preoperative identification of patients at high risk for “poor” pain outcome would help decide which patients might be placed on more intensive treatment options. By using data from acute pain registry projects, we were able to identify easy-to-assess risk factors; by using these factors in clinical practice, further studies are warranted to show an improvement by using these risk factors—for instance to identify the ideal pain-management strategies in these patients to reduce pain and pain-related impairment.

Babita Ghai, “Postoperative pain (POP) management in older persons”: With rapid growth of the aging population, large numbers of elderly individuals will require surgery and perioperative care. The magnitude and challenges of POP management in this special population were discussed, and recent evidence was presented for pain management with a focus on the concept of multimodal analgesia and “start slow and go slow” in this population.

Transition from Acute to Chronic Pain After Surgery

Patricia Lavand’homme, “Prolonged pain after surgery: hype or real problem?”: Prolonged pain after surgery is a socioeconomic problem. From multiple retrospective and prospective studies, estimates are that one patient out of 10 will develop long-lasting pain after surgery, and one patient out of 100 will suffer severe prolonged pain affecting rehabilitation and quality of life, particularly when the pain involves a neuropathic component (35 percent to 57 percent of the cases). The incidence unfortunately has not changed over the last 20 years and is similar in ambulatory and pediatric patients. Reports from the recently developed “Transitional Pain Clinics” (also called “APS Out-Patient Clinic”) support observations from the literature. Even more, they highlight the humanistic and economic burden of the problem. These reports also underline the difficulty to relieve the neuropathic pain component, which is extremely frequent in severe prolonged postsurgical pain as well as the risk of dependence to prescribed postoperative painkillers (mostly opioids and gabapentinoids).

Dominique Fletcher, “Prediction of prolonged pain after surgery”: The risk of chronic postsurgical pain (CPSP) should be part of preoperative determinants of surgical indication, surgical technique, surgeon, and institution choice. Nerve lesion is an important factor but is not always responsible for CPSP. Partial nerve lesion should be avoided. The most significant patient-related predictive factors of CPSP are young age, preoperative pain, preoperative opioid use, and psychological factors. Early postoperative warnings of CPSP are intensity and neuropathic characteristics of postoperative pain and hyperalgesia. We should organize early detection (specific follow up; dedicated consultation) and try to define validated predictive scores for the preoperative or postoperative period.

David Yarnitsky, “Prevention of chronic postsurgical pain, how can we tailor the correct mechanisms?”: David Yarnitsky reviewed pronociception, as evaluated by conditioned pain modulation and temporal summation and its influence in postoperative pain. He elaborated on “fix the dysfunction” principle in tailoring pain therapy; drugs that augment pain inhibition, i.e. SNRIs, should best help patients with dysfunctional, reduced pain inhibition, while drugs that reduce pain facilitation, i.e. gabaoentinoids, should best help patients with dysfunctional, augmented pain facilitation.

Eske Aasvang, “The role of surgical factors”: Any surgical procedure will result in injury to nerves (cutaneous, deeper, visceral) resulting in acute pain resolving within weeks or months in the majority of cases but progressing to moderate or severe persistent pain in 5 percent to 15 percent of cases, depending on the procedure. Likewise, inflammation from the surgical injury is increased with the magnitude of trauma and together with the nerve injury may play a crucial role in the transition to chronic postsurgical pain. As such, future investigation on the transition from acute to chronic pain should focus on the interaction between the two nociceptive pathways and guide interventional studies. Furthermore, studies need to recognize the importance of details in the surgical procedure as differences in the size of trauma (laparoscopic versus open), nerve handling (transection versus preservation), implantation (mesh versus no mesh), tourniquet use, etc., all may be relevant factors for acute and persistent pain.

Treatment of Chronic Pain After Surgery: New Approaches

Hanse Clark, “Do we need a new organizational approach for the treatment of persistent postsurgical pain in outpatient clinics?” With the current concern about opioid prescribing, the postsurgical period remains a critical window with the risk of significant opioid dose escalation, particularly in patients with a history of chronic pain and presurgical opioid use. Hanse Clarke discussed the development and implementation of a Transitional Pain Program at the Toronto General Hospital that enables close monitoring of pain, opioid medications, and mental health vulnerabilities that place certain patients at a higher risk of developing chronic postsurgical pain. The economic cost to society for the development of chronic postsurgical pain was discussed in detail. Beyond in-hospital interventions, he is working to scale the Transitional Pain Program post-discharge, involving community partners, to tackle the current public health crisis of pain and opioid addiction.

Audun Stubhaug, “Pharmacological management of chronic pain after surgery: Is it special?”: A large proportion of chronic postsurgical pain can be classified as neuropathic, with differences between different surgical procedures. A careful examination of pain history and patient may identify different pain components with different mechanisms. Peripherally driven pain can be treated with peripheral approaches such as topicals and peripherally acting drugs. Identified neuropathic, nociceptive, and inflammatory pain components should be treated according to general guidelines for chronic pain.

Ralf Baron, “QST—predictor of treatment outcome?”: Patients with peripheral neuropathic pain are heterogeneous in etiology, pathophysiology, and clinical appearance. We examined more than 1,100 patients with quantitative sensory testing and classified the patients into three subtypes with distinct sensory profiles. These profiles reflect neurobiological mechanisms and are independent of the underlying etiology. Recent clinical trials with oxcarbazapine or botulinum toxin using a phenotype-stratified approach demonstrated that subgroups of patients respond better than others. Consequently, cohorts in clinical trials should be stratified and potentially enriched with patients who likely respond to the study drug based on the sensory profile rather than on the underlying etiology. This approach has the potential to minimize pathophysiological heterogeneity within the groups under study and to increase the power to detect a positive treatment result. In clinical proof-of-concept trials, the study population can be enriched prospectively on the basis of “a priori” defined entry criteria.


Minutes of the Acute Pain SIG Meeting, September 5, 2017

Held at the Pre-Congress “Pain after Surgery” Satellite Symposium, Bella Center, Copenhagen

Attending:
Jill Treby (JT) IASP Liaison
Stephan Schug (SS) Australia
Dan Carr (DC) USA
Esther Pogatzki-Zahn (EP-Z) Germany
Winfried Meissner (WM) Germany
Jane Quinlan (JQ) UK
Audan Stubhaug (AS) Norway
Babita Ghai (BG) India
Patricia Lavand'Homme (PL-H) Belgium
Hance Clark (HC) Canada
Eske Aasvang (EA) Denmark
Brigitte Brandsborg (BB) Denmark
Norbert Schmitter (NS) Switzerland

Discussion:

  1. APSIG Satellite Meeting Proposals
    APSIG would like to hold a pre-Congress satellite meeting at the World Congress on Pain in Boston. We may do a joint meeting with the CRPS SIG (chair-elect Andreas Goebel) as there are commonalities between CRPS and CPSP (chronic post-surgical pain). DC highlighted that some acute pains become CRPS while most do not progress. The difference between CRPS and CPSP is that the latter is triggered by minor trauma with no acute severe pain or significant inflammatory insult so differs from post-traumatic or CPSP.

    Need to develop program and then Andreas will submit brief outline (with DC's input). It was suggested that the joint meeting could also link with Dom Aldington to look at veterans, but this was felt too complicated to consider for now. DC has already sketched out two thirds of the program.

    The group felt that there should be a joint half-day session then split into the SIG groups in the afternoon. PLH suggested having the morning as acute and chronic pain after trauma including CRPS, then concentrating on pain after surgery in the afternoon. All agreed on having a joint meeting in the morning then two streams in the afternoon.

    *The joint satellite APSIG and CRPS SIG meeting has now been approved by IASP*

  2. Social after the Satellite Meeting

    DC knows of an excellent Chinese restaurant in Boston that may be suitable for an evening dinner reception.  After some discussion, it was decided to keep a cocktail reception at the venue immediately after the satellite so that everyone stays and invite those who would like to come to dinner to join us at the Chinese restaurant. DC will contact the restaurant for prices and this could be included in the registration documents.

  3. Topical Workshops for the World Congress

    We shall aim to have two dedicated SIG sessions during the Congress. EP-Z invited everyone to send suggestions to SS and EP-Z for workshop topics and/or speakers by early November, even if they are just rough ideas. We shall also send an email to the whole SIG asking for ideas.

  4. Pain Education

    2018 will be the IASP Global Year for Excellence in Pain Education.  EP-Z spoke about using apps and videos for patients (e.g., Beth Darnell’s internet-based intervention for pre op catastrophizing)

    IASP’s Pain Reports will want articles on patient pain education, so APSIG could contribute to those.

    EA spoke about using technology to help people adhere to advice.

  5. APSIG Newsletter

    BG is now the new editor for the newsletter. SS and DC called for a co-editor to help her. We could send out a mailing to the whole SIG to ask for volunteers. JQ to prepare draft email to be sent to the whole SIG membership with all the above information.

Minutes completed by Jane Quinlan (APSIG Secretary) on September 21, 1917, based on contemporaneous notes taken on September 5, 2017.


From Within to Without—Time to Move from the Center to the Periphery

Peripheral nerve blocks as a part of postoperative analgesia regimen

Acute postoperative pain is experienced by 80-86% patients, of whom less than half report adequate analgesia. Of these patients in pain, nearly 70-75% report moderate to extreme pain after surgery, and around 60-74% report moderate to extreme pain during the first two weeks following hospital discharge.1, 2 Despite comprehensive multimodal analgesic regimens, this problem has not been successfully addressed and remains a major challenge for perioperative physicians. Inadequately managed postoperative pain has significant functional, cognitive, emotional, and societal consequences and increases the risk of chronic postsurgical pain.

An ideal multimodal pathway should provide adequate pain relief with minimal opioid con­sumption, preserve motor strength to prevent postoperative complications, promote rehabilitation, and decrease venous stasis.

There is increasing interest in peripheral nerve blocks (PNB), single or continuous, to be part of multimodal postoperative analgesic regimens.3, 4 Advantages of PNBs include fewer collateral effects when compared to systemic opioids or central neuraxial blockade (epidural analgesia). PNB is reported to reduce opioid consumption and hence the opioid-related adverse effects such as nausea, vomiting, pruritus, and post-operative delerium.5, 6

PNB can avoid the adverse effects associated with epidural blockade such as hypotension, urinary retention, and pruritus. Moreover, the advantage of targeting a specific analgesic area allows early mobilization and earlier hospital discharge, together with reduced anesthetic requirements, and thus betters postoperative recovery, if the blocks are sited preoperatively. PNB can be particularly valuable in elderly patients or those with significant comorbidities where either central neuraxial block or opioids may risk unacceptable side effects.

[Edited properly?] The wide variety of PNBs encompass those for surgery on the lower limb (lumbar plexus, fascia iliaca compartment, femoral, sciatic, adductor canal, tibial and popliteal blocks); upper limb (brachial plexus, median, ulnar, and radial nerve blocks); breast surgery (thoracic paravertebral, pectoral nerve blocks type 1 and 2 and the serratus plane block); as well as those for minimally invasive cardiac surgery (thoracic paravertebral block); among others.

A skilled and knowledgeable anesthesiologist will find most PNBs technically easy to perform. However, with adequate training, they can also be performed in resource-poor settings, providing a valuable tool for postoperative analgesia provision.

Technical advancements include the use of ultrasound guidance for successful localization of nerves; progression from single-shot peripheral nerve blocks to continuous infusions using a perineural catheter; and liposomal preparations of local anesthetic, allowing prolonged analgesia. Other advances include fine-tuning appropriate positions of PNB to maximize the analgesia, preserve muscle strength, and minimize the complications, such as the lower approach for an interscalene block and the mid-adductor canal approach for adductor canal block.

As we enter IASP’s Global Year for Excellence in Pain Education, let us not forget the importance of training in regional anesthetic techniques, and peripheral nerve blocks in particular. Just as we are moving from the center to the periphery in local anesthetic blocks, the same is true for pain education. It is time to move from the center to the periphery.

There is an urgent need to decentralize the pain curriculum and training—we should move from centric (tertiary and secondary care center-specific) pain education to a peripheral (primary care and community-level) education model. This shift is particularly pertinent to low-resource countries where pain management education is not yet established as a discipline.

References

  1. Gan TJ, Habib AS, Miller TE, White W, Apfelbaum JL. Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey. Curr Med Res Opin 2014; 30: 149–60.
  2. Buvanendran A, Fiala J, Patel KA, et al: The incidence and severity of postoperative pain following inpatient surgery. Pain Med 2015; 16: 2277-2283
  3. Joshi G, Gandhi K, Shah N, Gadsden J, Corman SL. Peripheral nerve blocks in the management of postoperative pain: challenges and opportunities. J Clin Anesth 2016; 35: 524-529.
  4. Kessler J, Marhofer P, Hopkins PM, Hollmann MW. Peripheral regional anaesthesia and outcome: lessons learned from the last 10 years. Br J Anaesth. 2015; 114: 728-45.
  5. Scurrah, A., Shiner, C. T., Stevens, J. A. and Faux, S. G. Regional nerve blockade for early analgesic management of elderly patients with hip fracture – a narrative review. Anaesthesia 2017; doi:10.1111/anae.14178
  6. Guay J, Johnson RL, Kopp S. Nerve blocks or no nerve blocks for pain control after elective hip replacement (arthroplasty) surgery in adults. Cochrane Database Syst Rev. 2017;10: CD011608.

-- Babita Ghai, MD, DNB, FAMS
Editor, Acute Pain SIG Newsletter


Pain Education in India: If it Is Hatched from a Swan's Egg

An appropriate way to describe pain education in India for the past half-decade would be to use the swan metaphor. For the neutral observer, it is the graceful aquatic bird that moves with elegance but, perhaps, a bit too slow for their liking. Making it look elegant and graceful are the pain educators, the frantic underwater paddlers, with the enduring belief that a bit more of a push and the swan would move faster. The pain education cygnet has not only grown faster but also has been moving faster.

The Indian Academy of Pain Medicine (IAPM), the academic wing of the Indian Society for the Study of Pain (ISSP), has come to fruition in the past couple of years. It now has an established governing council and is responsible for advanced pain training of 12 months duration in close to a dozen centers across India. It conducts the entrance and exit exams, has program heads to guide trainees locally, and has a clearly laid-out monitoring system.

IASP, in association with the ISSP, held the Multidisciplinary Evidence-Based Pain Management Program in 2017 in Mumbai and Delhi, which was spread out over six months. This program had experts from India and abroad teaching around 50 candidates state-of-the-art pain management. The ISSP, moreover, offers a well sought-after four-week ISSP-IASP observership for physicians interested in pain management.

India has benefited from the many Developing Countries Education grants from IASP. These grants have helped improve pain education in India significantly, and we are thankful for IASP’s continuing support. One other learned society that is keenly invested in pain education in India is the World Federation of Societies of Anaesthesiologists (WFSA). In 2018, the WFSA-Massimo Essential Pain Management (EPM) project starts in Telangana, where three “Train-the-trainers” workshops at Nizamabad, Warangal, and Hyderabad plan to train 60 pain educators and close to 200 delegates.

There has been a flurry of pain education activities in India on the voluntary front. Traveling Pain School (TPS), a voluntary organization of health-care professionals, has collaborated with many learned societies to educate more than 20,000 doctors, nurses, and physiotherapists over the past five years on the effective management of pain. It has a group of 200 trainers who travel and teach voluntarily, sometimes in the remotest corners of the country. TPS conducts a one-day course for specialists, the contents of which are based on the IASP curriculum.

Furthermore, it has collaborated with WFSA and the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists to introduce EPM in India. The members of TPS, in addition, assist with the workshops in countries such as Bhutan and Sri Lanka, and receive trainees from the neighboring countries. In an ongoing project called UPFRONT (Updates in Pain for the Frontline practitioner), TPS has collaborated with the Association of Physicians of India and the Indian College of Physicians to conduct workshops for internal medicine physicians and general practitioners. More than 40 UPFRONT workshops were held across India in 2016-17.

In India, with regard to pain education, the impossible is often the untried, and many have attempted it with great success. There are many yearlong fellowships with a stipend as well as short-term, advanced pain-management courses offered by public and private institutions. Pallium India, a charitable institution, has been utilizing the Project ECHO (Extension for Community Healthcare Outcomes) platform for online teaching among palliative care physicians.

The underwater paddlers have made pain education move forward with grace, without the fierce anserine temperament. Their collaborative efforts with experts from across the globe have resulted not just in improving pain education but also in building long-term associations—very swan-like. The valuable feedback and auditing systems, reminiscent of the mythological swan that could separate milk from water, are what allows us to filter the good from the bad and optimize practices in pain education, and they eventually will help usher in the metamorphosis into that of a Great Swan, or Paramahamsa, one with great capabilities. The pro bono nature of these pain education endeavors, and the benevolent folk who have helped accomplish it, have ensured that the next swan’s egg—recognition of pain medicine as a specialty—would not be hatched in a duck’s nest.

-- Palanisamy Vijayanand
MBBS, FCARCSI, DPainMed (RCSI), MSc (Pain), FFPMCAI, FFPMANZCA


A Single-Center Experience of a Perioperative Pain Management Improvement Program in a Developing Country: An IASP-Funded Study

Background and aims: Perioperative pain management in low-resource countries is unsatisfactory, just as it is in high-resource countries. The aim of this study was to assess changes in perioperative pain management practices and patient-reported outcomes (PROs) after introducing a change-management program in two surgical wards (orthopedics and urology) in one hospital. Findings here focus mainly on changes in interventions used during surgery, under the responsibility of anesthesiologists and surgeons, and how these were associated with the PROs.

Methods: Surveyors collected PROs and management practices using methodology developed by PAIN OUT on the first postoperative day from patients undergoing orthopedic and urological surgical procedures. Most PROs used 11-point numerical rating scales (0=null, 10=worst possible). Data was collected at two points: “baseline” and “post-intervention.” 

The change-management program included: (1) surveying medical and nursing staff about the topics of interest and optimal format for teaching, (2) using these findings to develop a teaching program and local treatment protocols, and (3) providing patients with information about pain management options.

Results: The program was carried out from December 2014 to November 2015 at the Military Hospital in Belgrade, Serbia. The survey included anesthesiologists, surgeons and residents, and nurses in recovery and ward settings. The teaching program for the operating room staff consisted of mini-lectures, lasting 15 minutes each, to accommodate time limitations. Nurses participated in workshops. Teaching focused on topics relevant to each discipline. Regional anesthesia for anesthesiologists; wound infiltration for surgeons; pain assessment for nurses. Three anesthesiologists (DS, AJ, MI), directing the pain change management program, provided the teaching.

Surveyors collected data from 101 orthopedic and 100 urology patients at baseline (four month’s duration) and post-intervention (eight months duration) from 97 orthopedic and 129 urology patients. After introducing the interventions, the proportion of patients receiving regional anesthesia and wound infiltration increased for patients on both wards. Urology surgeons followed a wound infiltration protocol; orthopedic surgeons did not. For orthopedic patients, anesthesiologists administered fewer non-opioids (see Table 1).

Overall, PROs remained unchanged on both wards (see Figure 1). Assessments of “Allowed to participate in decisions about pain treatment as much as you wanted” increased on both wards; in orthopedics (mean [SD]) from 0.84 [± 2.1] to 5.3 [± 2.6], in urology from 3.5 [± 3.4] to 6.3 [± 4.2]. Satisfaction with pain management did not change on either ward: orthopedics 8.6 [± 1.3] to 8.7 [1.2] and urology 8.0 [2.1] to 8.2 [2.3].  

Summary: Introducing a change-management program in two surgical wards in one hospital over a period of 12 months involved physicians and nurses, with the focus, here, on interventions provided intra-operatively. The mini-lectures were successful in promoting changes in practices in the operating room. Anesthesiologists increased the proportion of regional anesthesia for patients of both wards; however, in orthopedics it was at the expense of administering non-opioids. Surgeons in both wards were enthusiastic to use wound infiltration, as it is simple and safe to administer and relies on available medications and equipment.

Overall, PROs did not improve, on either ward. However, the extent patients felt involved in their care did increase on both wards; interestingly, this was not associated with a change in satisfaction with pain management.

While the study was taking place, the numbers of anesthesiologists and nurses working in the hospital were considerably reduced, leading to increased workloads for those remaining and to reduced motivation for implementing change in clinical practice.

The program will continue to provide teaching to all staff and with developing clinical treatment guidelines. Over time, should reduce both variability in care and the effort individual providers need to expend in providing treatment for pain.

Conclusions: Introducing change in management of perioperative pain is a complex process. The methodology employed here indicates it is possible to introduce change in the clinical routine of a hospital in a developing country.

References

Royal College of Anaesthetists a compendium of audit recipes. 2012. Dusica Stamenkovic1,3, Aleksandar Jordanov1, Marko Ilic1, Vojislava Neskovic1,3 Srdjan Starcevic2,3, Barjaktarevic R2,3, Nemanja Rancic3,   Winfried Meissner 4 Ruth Zaslansky 4

1Department of Anesthesiology and Intensive care, Military Medical Academy, 2 Department of Ortopedic and Trauma surgery, 3Medical School University of Defense Belgrade, Serbia, 4Dept. of Anesthesiology and Intensive Care, Jena University Hospital, Jena, Germany