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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 8  |  Issue : 14  |  Page : 104-108

A 5-year prospective review of postoperative pain management in Ahmadu Bello University Teaching Hospital Zaria: Challenges and way forward


1 Department of Anesthesia, College of Health Sciences, Ahmadu Bello University Teaching Hospital, Kaduna State, Nigeria
2 Department of Orthopaedic, College of Health Sciences, Ahmadu Bello University Teaching Hospital, Kaduna State, Nigeria
3 Department of Maxillofacial Surgery, College of Health Sciences, Ahmadu Bello University Teaching Hospital, Kaduna State, Nigeria
4 Department of Anaesthesia, College of Health Sciences, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
5 Department of Obstetrics and Gynaecology, College of Health Sciences, Ahmadu Bello University Teaching Hospital, Kaduna State, Nigeria

Date of Submission01-Aug-2018
Date of Acceptance01-Jul-2019
Date of Web Publication04-Oct-2019

Correspondence Address:
Dr. Yunus Adeniyi Abdulghaffar
Department of Anesthesia, College of Health Sciences, Ahmadu Bello University Teaching Hospital, Shika-Zaria, Kaduna State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/nnjcr.nnjcr_32_18

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  Abstract 


Background: Perception of postoperative pain varies. It depends on the type of surgery and the individual involved, which is influenced by race. Postoperative pain, in general, is inadequately managed in developing countries. This study prospectively reviewed the challenges of postoperative pain management in our center, the incidences and other options available for effective postoperative pain management. Methods: Following hospital ethics approval and informed consent, a 5-year prospective review of postoperative pain management was carried out on 3623 patients operated in Ahmadu Bello University Teaching Hospital under subspecialty of general, maxillofacial, orthopedic, and obstetrics and gynecology surgeries, from January 2013 to December 2017. Following the enlightenment of patients about numeric pain score scale, pain scores of the patients that met the inclusion criteria were determined 24 h postoperatively through a predesigned questionnaire. Numeric pain scale was used to ascertain pain intensity and the level of satisfaction following postoperative pain management. The surgeons' and the anesthetic review, as well as the anesthetic chart of the 3623 patients managed, were studied. The incidence of the degree of pain scores was calculated for the different patient's populations. Techniques of anesthesia were also computed. Data were analyzed using Chi-square statistical package. Results: High rate of severe pain incidences was observed. Out of the overall 3623 patients managed within the study period, 42.1% (1525) of the patients reported severe pain. About 43.8% (1587) of patients had moderate pain and only 14.1% (511) of the patients recorded mild pain. Most of the patients [56.1% (2033)] had general anesthesia, while 41.5% (1503) had regional anesthesia. Around 2.4% (87) of the patients had both general and regional anesthesia. Conclusion: Postoperative pain is inadequately managed. There is need for the policymakers to provide intensive intervention on postoperative pain management by considering adequate supply of strong opioids regularly. More so, knowledge of the anesthetists and physicians involved in postoperative pain management need to be improved and updated, especially on the techniques for managing postoperative pain.

Keywords: Anesthesia, current management trends, developing country, opioids, postoperative pain


How to cite this article:
Abdulghaffar YA, Ejagwulu F S, Fomete B, Obidike A B, Abdullahi S O, Akande T S. A 5-year prospective review of postoperative pain management in Ahmadu Bello University Teaching Hospital Zaria: Challenges and way forward. N Niger J Clin Res 2019;8:104-8

How to cite this URL:
Abdulghaffar YA, Ejagwulu F S, Fomete B, Obidike A B, Abdullahi S O, Akande T S. A 5-year prospective review of postoperative pain management in Ahmadu Bello University Teaching Hospital Zaria: Challenges and way forward. N Niger J Clin Res [serial online] 2019 [cited 2019 Dec 5];8:104-8. Available from: http://www.mdcan-uath.org/text.asp?2019/8/14/104/268532




  Introduction Top


Surgical pain management is inadequate worldwide, and this adversely affects patient surgical experience and outcome.[1],[2],[3],[4] In a setting with an expected high incidence of postoperative pain, it is necessary to know and fully utilize basic analgesic modalities and other options in pain management. Advanced methods for postoperative pain management have evolved in the developed health institutions around the world, but such is not obtainable in low-resource settings. For this reason, the incidence and challenges associated with postoperative pain need to be identified and addressed utilizing other available, yet effective options.

Previous studies have revealed a high incidence (41%–61%) of moderate or severe postoperative pain in developed countries.[4] Most studies only reported on the overall incidence of postoperative pain or compared different methods of analgesia.[1],[2],[4],[5],[6] Few studies that aimed at identifying high-risk groups for practical clinical use were found.[5],[7]

The aim of this study was to explore the incidence of moderate and severe pain during the first 24 h postoperatively and to identify specific groups of patients that would require adequate analgesia. The outcome of this study will help in projection and prompt requisition of opioids and utilization of other modalities of pain management, thereby improving the postoperative patient care.


  Methods Top


After obtaining ethical clearance from the hospital ethical committee, a prospective study was carried out on 3623 patients operated at Ahmadu Bello University Teaching Hospital (ABUTH) Zaria. The patients were hospitalized for at least 24 h, met the inclusion criteria, and had surgeries in the modular theaters of the hospital in five selected subspecialties of general surgery, maxillofacial surgery, orthopedic surgery and obstetrics, and gynecology surgery from January 2013 to December 2017. Interaction with patients was on the first postoperative day and was anchored by an experienced physician. Patients with the American Society of Anesthesiologist (ASA) Class of I and II were included. Patients that were under the age of 18 years, patients who do not want to take part in the study, and those who were admitted to intensive care unit after surgery were excluded. Furthermore, those with a history of allergy to analgesics, ASA physical status III and IV, epilepsy, and other psychiatric patients were also excluded. During the patient's interaction, informed consent was obtained, and the patients were educated on numeric pain scale (NPS): zero means no pain, 1–3 means mild pain, 4–7 means moderate pain, and 8–10 means the severest pain anybody could ever experience. Patients were asked to complete a questionnaire on numeric pain score scales, as shown in the appendix. Patients who could not speak English and those who could not fill the questionnaire were assisted by the resident doctors and language translators. In addition, the following data were obtained from the anesthetic record: age, gender, surgical specialties, and technique of anesthesia. The incidences of moderate and severe pain were recorded at time of the interaction. Patient groups, according to the collected data, were compared with regard to the maximum pain recorded.

Chi-square test was used to evaluate the significance of difference, and P < 0.05 depicts a statistically significant difference.


  Results Top


[Table 1] presents the result of the patients that underwent general surgery. For 5 years, 756 patients comprising 378 males and 378 females were managed in our center. About 64.6% (488) of the patients had general anesthesia, whereas 32.9% (249) of the patients had regional anesthesia. Only 2.5% (19) of the patients had combined (general and regional) anesthesia. Most of the patients [61.8% (467)] recorded moderate pain, followed by the 30.3% (229) that reported severe pain. Only 7.9% (60) of the patients experienced mild pain. As shown in [Table 2], of the 394 patients for maxillofacial surgeries, a high incidence rate of severe pain was observed in most of the patients [56.6% (223)]. Moderate pain was observed in 40.4% (159) of the patients and a mild pain in 3% (12 patients). Among these patients, 57.1% (225) were male patients, while 42.9% (196) were female patients. A higher rate of severe pain incidence was recorded in the patients for orthopedic surgery, as seen in the 56.2% (521) of the patients, 36.5% (339) of the patients had moderate pain, while only 7.3% (68) had mild pain. Of the 928 patients seen within the 5-year duration, most of them were males 66.9% (621), while 33.1% (307) of them were females as shown in [Table 3]. In [Table 4], which was exclusively for female patients, 1545 patients were seen between 2013 and 207. Only 24% (371) patients had mild pain, 40.3% (622) patients had moderate pain, while 35.7% (552) of the patients reported severe pain postoperatively. On the technique of anesthesia, majority 51.9% (802) of the patients had general anesthesia and 46% (710) had regional anesthesia. Only 2.1% (33) patients had both general and regional anesthesia. Summarily, from the overall total of 3623 patients managed from 2013 to 2017, 42.1% (1525) of the patients had severe pain and 43.8% (1587) of the patients had moderate pain. Insignificant number [14.1% (511)] of the patients reported mild pain as shown in [Table 5]. Taken together, most of the patients [56.1% (2033)] had general anesthesia, while 41.5% (1503) had regional anesthesia, 2.4% (87) patients were given both general and regional anesthesia.
Table 1: Result of the general surgery over the period of 5 years

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Table 2: Summary of maxillofacial surgeries

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Table 3: Result of orthopaedic surgeries

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Table 4: Obstetric and gynecological surgeries

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Table 5: Summary of the subspecialty with numeric pain scores

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  Discussion Top


This prospective review considered how postoperative pain has been managed in ABUTH Zaria, with the view to identifying the group of patients with severe and moderate postoperative pain, the challenges associated with postoperative pain management, and the way forward.

Our findings indicated that postoperative pain is inadequately managed, as large percentages of the patients suffer from severe and moderate pain; the same is presented in the summary of subspecialties on [Table 5]. The way forward is that the policymakers need to imbibe the culture of supplying strong opioids at all times. There is need to improve on the knowledge of anesthetists and physicians involved in postoperative pain management regarding the techniques for postoperative pain management.

In the developed health institutions such as the Netherlands hospital, moderate or severe pain was reported by 41% of patients on the day of surgery and 30% on the following day.[2] A meta-analysis of 165 studies (20,000 patients) revealed that 30% and 11% of patients suffered moderate-to-severe and severe postoperative pain, respectively.[3] In the United Kingdom, a study was conducted in 2012 and revealed that 68% of postoperative patients experienced pain, of which 38% reported severe pain and 52% moderate pain.[4]

The incidence of acute postoperative pain in our center ABUTH Zaria, a tertiary health institution, was high (85.9%) in comparison to developed countries even though patients from lower-income groups have a tendency to underreport their pain.[5] Reasons that could have contributed are infrequent administration of analgesic and limited access to advanced modalities of acute postoperative pain management. In our study, we observed that factors that determine the pain intensity included patient's age, gender, and subspecialties (anatomical site), with orthopedic and maxillofacial surgery patients suffering the most [Table 5]. Maxillofacial patients experience the highest pain, probably due to the fact that the closer the operation field to the brain, the higher the pain experienced.

Moderate-to-severe postoperative pain is far higher in our study, and the underlying cause is lack of constant supply of strong opioids for inadequate analgesia. The issue is. Are our patients getting their opioids as prescribed or are the opioids readily available? The answer is not far-fetched. Strong opioids are not readily available. The less potent analgesics like pentazocine are usually prescribed. Therefore, other adjunct and modalities of acute pain management should be the way forward to achieve adequate postoperative pain management and to minimize the wide gap between the developing and the developed worlds. At this point, all stakeholders involved in postoperative pain management should be more proactive in the requisition, procurement, and administration and monitoring of the opioids, so that the desired outcome of excellent postoperative pain management is achieved.

Another possible contributing factor could be that the attending anesthetists and physicians may not be aware of the magnitude of the postoperative pain experienced by the patients. Studies have revealed that health-care providers underestimate patients' pain, and their desire for analgesia, but pain monitoring programs, consisting of staff education and pain documentation with NPSs, have been shown to improve the compliance with the administration of analgesia.[1],[7],[8],[9] In the Europe, it is now becoming common practice to document pain scores as part of the routine postoperative observations.[5] This could provide a way to make nursing staff more aware of the problem as patients tend to underreport their pain until it becomes unbearable.[6] An excessive nursing workload due to low staff numbers in addition to the paperwork needed for scheduled drug administration and the fear of opiate abuse may also have contributed.[10]

In our study, patients who had the same procedures differed widely in the degree of pain they experienced postoperatively. This may be due to sociocultural background of the individuals coupled with the site of the surgery. Intravenous paracetamol, nonsteroidal anti-inflammatory drugs, and intrathecal opioids which necessitate a higher level of postoperative care are used with good effect in other institutions.[9],[10] This is not the case in our institution due to the erratic supply.

Patients who had regional techniques with opioids added to the local anesthetics tend to have better postoperative pain management due to prolonged duration of action. All the four subspecialties in our center had pain incidence far above the developed world, this is partly due to regional blocks without opioids. Therefore, regional anesthesia may wear off over a short period, and severe pain may follow if alternative analgesia of steady supply of strong opioids is not established and adhered to in good time.


  Conclusion Top


Postoperative pain is inadequately managed in our health facilities, with maxillofacial and orthopedic patients most critical. There is a need for the policymakers to provide intensive intervention on postoperative pain management by considering adequate supply of strong opioids regularly. More so, knowledge of the anesthetists and physicians involved in postoperative pain management needs to be improved and updated, especially on the techniques for managing postoperative pain. If this is addressed, excellent postoperative pain management and improved patient's life quality would be the outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Murthy S, Antwi Kusi A, Jabir AR, Ofori-Amanfo G. Patient and practitioner perspectives on postoperative pain control in Kumasi, Ghana. S Afr J Anesth Analg 2013;19:102-7.  Back to cited text no. 1
    
2.
Sommer M, de Rijke JM, van Kleef M, Kessels AG, Peters ML, Geurts JW, et al. The prevalence of postoperative pain in a sample of 1490 surgical inpatients. Eur J Anaesthesiol 2008;25:267-74.  Back to cited text no. 2
    
3.
Dolin SJ, Cashman JN, Bland JM. Effectiveness of acute postoperative pain management: I. Evidence from published data. Br J Anaesth 2002;89:409-23.  Back to cited text no. 3
    
4.
Tocher J, Rodgers S, Smith MA, Watt D, Dickson L. Pain management and satisfaction in postsurgical patients. J Clin Nurs 2012;21:3361-71.  Back to cited text no. 4
    
5.
Mwaka G, Thikra S, Mung'ayi V. The prevalence of postoperative pain in the first 48 hours following day surgery at a tertiary hospital in Nairobi. Afr Health Sci 2013;13:768-76.  Back to cited text no. 5
    
6.
Pöpping DM, Zahn PK, Van Aken HK, Dasch B, Boche R, Pogatzki-Zahn EM, et al. Effectiveness and safety of postoperative pain management: A survey of 18 925 consecutive patients between 1998 and 2006 (2nd revision): A database analysis of prospectively raised data. Br J Anaesth 2008;101:832-40.  Back to cited text no. 6
    
7.
Baratta JL, Schwenk ES, Viscusi ER. Clinical consequences of inadequate pain relief: Barriers to optimal pain management. Plast Reconstr Surg 2014;134:15S-21S.  Back to cited text no. 7
    
8.
Sommer M, de Rijke JM, van Kleef M, Kessels AG, Peters ML, Geurts JW, et al. Predictors of acute postoperative pain after elective surgery. Clin J Pain 2010;26:87-94.  Back to cited text no. 8
    
9.
Hauser ND, Dyer RA. An observational audit of pain scores post orthopaedic surgery at a level two state hospital in Cape Town. S Afr J Anesth Analg 2014;20:110-6.  Back to cited text no. 9
    
10.
Fletcher D, Fermanian C, Mardaye A, Aegerter P; Pain and Regional Anesthesia Committee of the French Anesthesia and Intensive Care Society (SFAR). A patient-based national survey on postoperative pain management in France reveals significant achievements and persistent challenges. Pain 2008;137:441-51.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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