Multimodality Approaches to Improving Post-operative Pain and Outcomes

Multimodality Approaches to Improving Post-operative Pain and Outcomes

Blackshear Robert H , Chamberlain Ronald S
US ONCOLOGY - VOLUME 5 ISSUE 1
Published: July 2009
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Abstract
Pain is an inevitable complication of surgery. It not only impedes healing and recovery in the surgical patient, but also imposes a great deal of strain on healthcare resources. Post-operative ileus (POI), a frequent complication following surgery (especially of the abdomen), is intimately related to modes of pain control. Important aspects of effective pain control measures include improvement in quality of life and patient satisfaction as well as the prevention or limitation of post-operative complications, particularly POI. A comprehensive review of numerous peri-operative management methods reveals only limited benefit, if any, when employed individually. Strategies incorporating various preventive–therapeutic approaches devised to manage surgical patients in a ‘fast-track’ manner peri-operatively may provide better outcomes.

Keywords
Pain management, ileus, fast-track, multimodality approaches

Disclosure: Ronald S Chamberlain, MD, MPA, FACS, is a consultant for Ethicon, Inc., and is on the speaker’s bureau of Merck, Wyeth, and sanofi-aventis. Robert H Blackshear, MD, is a member of the speaker’s bureau of Entoria, Inc (Chlorapep), on the speaker’s bureau of and a consultant for EKR Therapeutics, Inc., and on the speaker’s bureau of and a consultant for Flynn Pharma, Inc.
Received: February 12, 2009 Accepted: April 8, 2009
Correspondence: Ronald S Chamberlain, MD, Chairman and Surgeon in Chief, Department of Surgery, Saint Barnabas Medical Center, 94 Old Short Hills Road, Livingstone, NJ 07039. E: rchamberlain@sbhcs.com

Approximately 72 million surgeries are performed in the US every year,1 with over 20 million involving major inpatient procedures.2 Despite the proliferation of new pain-management modalities, over 75% of all surgical patients experience moderate to severe post-operative pain.3 Higher post-operative pain scores alone have been documented to be associated with longer length of hospital stay (LOS), increased postoperative medical complications, and inadequate or delayed rehabilitation.4 The Joint Commission on Accreditation of Health Care Organizations (JCAHO) stated that “pain is the fifth vital sign” and has established new guidelines for the assessment and management of pain. These guidelines recognize the right of patients to appropriate assessment and treatment of pain, ensure staff competency in pain assessment and management, support appropriate use of effective pain medications, and establish quality measures for the management of pain. Consequently, healthcare providers are encouraged to continuously assess and actively treat a patient’s pain.5,6 Post-operative ileus (POI), a frequent complication following surgery, is intimately related to methods of post-operative pain management. It is the most common complication leading to prolonged LOS following abdominal surgery,7 thereby overtaxing healthcare resources.8

POI contributes towards post-operative complications, including delayed wound healing and ambulation, atelectasis, pneumonia, and deep vein thrombosis (DVT). The relationship between POI and DVT was demonstrated in a clinical review of 2,949 patients who underwent 3,364 consecutive primary and revision orthopaedic surgeries.9 The incidence of symptomatic DVT was 1.7%, and was higher (8.1%) in patients with POI (odds ratio [OR] 5.5; p=0.0036). Furthermore, the incidence of pulmonary embolism (PE) was 3.2% in patients with POI versus 0.24% in those without POI (OR 19.6; p< 0.0082). In addition, the in-hospital mortality rate is reportedly higher in patients with POI than in those without it (6.5 versus 2.3%; p< 0.01).10 An analysis of 161,000 major bowel resections found that in patients with POI the LOS increased by five days and the re-admission rate was higher (3.6%) compared with that of all other patients (0.2%).7,10 Similarly, 17.4% of the 17,896 partial colectomy patients reviewed by Iyer and Saunders had a secondary diagnosis of POI and a significantly longer average LOS (13.75±13.33 days with POI versus 8.85±9.49 days without POI; p< 0.001).11 Furthermore, the hospitalization costs attributed to POI are $1.14 billion/annum, and the expenses per patient are significantly higher ($16,000/patient with POI versus $10,000/patient without POI; p< 0.01).7 The fiscal benefit that can accrue from decreasing LOS by even a day is substantial, and warrants disciplined management of POI.11

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Keywords:
Pain management, ileus, fast-track, multimodality approaches, chronic cancer pain, treatment cancer pain, pain control, management cancer pain, postoperative ileus, ileus information, meconium ileus, treatmen ileus, cancer pain management, acute pain management, pain mangement techniques,

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