Management Of Acute Postoperative Pain: Experience With 11,937 Patients Managed With Epidural Catheters

摘要

Introduction The management of postoperative acute pain has become one of the principal missions of the anesthesiologist. The establishment and organization of an Acute Pain Management Service is essential for the delivery of high quality acute pain management, but it is a complicated process. In this article, we will first present a brief history of the formation of the Acute Pain Management Service at the Methodist Hospital and then our experience with epidural analgesia in more than 11,000 cases. We hope that our experience will be of help to those seeking to establish an acute pain management service. Historical background In 1985, we began to use postoperative epidural analgesia in orthopedic surgery patients at the Methodist Hospital. Various research protocols, such as intrathecal and epidural Duramorph, fentanyl, sufentanyl and alfentanyl were used initially. All of these patients were assigned to an orthopedic research intermediate care unit for the duration of their epidural infusion. The nurses in this area were specially trained to assess for analgesia, side effects and complications. When epidural pain management was extended to other surgical services in 1991, patients with epidurals were still required to be admitted to the orthopedic intermediate care. This not only created a problem of availability of intermediate care beds but also problems between the orthopedic service and other surgical services who wanted to use “the orthopedic unit” for their patients.In order to correct this situation and to provide quality postoperative pain management for all surgical services, the decision to create a hospital-wide acute pain management service was made in August, 1991, and an anesthesiologist Medical Director and a R.N. Clinical Coordinator were appointed to head the service. A multidisciplinary committee was formed to deal with the many details of establishing a pain service. The formation and operation of this committee, which met every two weeks initially and thereafter monthly, was essential for the establishment of an efficient service. Aside from the medical director and clinical coordinator, it included hospital and nursing administration, nursing, and pharmacy personnel. Using a program based upon one developed by Dr. Lex Hubbard and Chris Pasero, R.N. at Schumpert Medical Center, Shreveport, Louisiana, we developed standing orders, a pain management flow sheet, a daily rounding progress note, policies and procedures, and a continuous quality improvement program.We gather patient data daily and use it for generating statistics, rounding sheets, and billing information. Gathering of outcome and complication data is essential for our quality improvement program.Pharmacologically, we decided to base our epidural service on a fentanyl/bupivacaine combination. In order to avoid confusion, because of the potential size of the pain service and the number of anesthesiology staff involved, we initially used only one standard infusion (Fentanyl 20 mcg/ml and bupivacaine 0.125%). However, because most of the anesthesiologists were placing their catheters in the lumbar area, and thus the need for higher infusion rates, we decreased the concentration of fentanyl to10 mcg/ml and of bupivacaine to 0.1%. We now offer three standard solutions of fentanyl/bupivacaine, and the pharmacy can make custom solutions on request. Also, after much discussion and teaching, most anesthesiologists are now using a thoracic epidural approach. The quality improvement program serves as our tool to modify our procedures, such as the use of different epidural infusion solutions as more experience is gained.We initiated the program in the OB and GYN units because their nursing staff were generally more familiar with the concept of epidurals. Initially, nurses were given a two hour inservice by the pain service nurse that included anatomy, physiology, pharmacology, side effects, titration of the infusion and troubleshooting the pump. There is no