Organising acute pain management: a shared responsibility

Prof. Gabriel M. Gurman
Professor Emeritus, Anesthesiology and Critical Care
Ben Gurion University of the Negev, Beer Sheva, Israel

The idea of touching on this topic jumped into my mind after two lectures I delivered at the recent CEEA course in Tbilisi, Georgia. 

The more I worked to put together relevant stuff, the more it became clear that in many parts of our continent, the gap between recognising the need to take pain management into our own hands and today’s reality is still large and deep. 

Once more, I must remind our readers that a  good part of our routine activity is outside the operating room (OR). 

According to my own experience, as of today, one-third of the anaesthesia workforce is involved in daily procedures done outside the OR. 

This fact is well known to everybody, including our patients. In a study done many years ago (1), in which data were collected from Swiss patients at the end of the preoperative visit, 75% of the responders declared that the anaesthesiologist was also engaged in activities outside the OR. 

This activity covers work in the intensive care units, procedures done under anaesthesia outside the OR, and anaesthesia outpatient clinics, including chronic pain clinics. 

But what about the acute pain management? 

In most of our hospitals, the anaesthesia department takes care of the immediate postoperative pain in PACU (post-anesthesia care units). However, what happens once the patient is transferred back to their department? Is this a necessary part of the anaesthesia staff’s daily activity?  

And if the answer is yes, how is it done? In other words, how is this field organised to ensure the 24/7 coverage of as many patients as possible in acute pain? 

Needless to say, the situation is far from being uniform, and it varies from one country to another and from one hospital to another. 

The idea of an acute pain service (APS) is old. It started in the USA in 1988 by Ready (2), who wrote: “What is different and exciting is that a cadre of experts, based in a department of anesthesiology, are committed and available 24 hours a day to manage pain following surgery”. 

Later on, the idea reached the UK and then, little by little, almost every single country on the European continent. 

Lovasi et al. (3) recently described three types of APS: the first one, introduced by Ready, in which the team is headed by an anaesthesiologist; the second one, developed in Sweden, according to which the team management is in the hands of trained nurses, supervised by anaesthesiologists and, finally, the third one, proposed by Borracci et al. (4), which offers the lead to young anaesthesia residents.  

Whatever the type of service is in function, some general rules apply to all of them. It starts with the need for proper pain care in PACU for each patient.  

Then, there is a need to establish a plan for the continuation of the treatment for every patient, which is passed to the ward team and, at the same time, to the APS team. The ward team will inform the APS team about the patient’s response to the treatment and their vital signs situation. A special form will be filled out by one of the APS team members, the APS physician in charge will be continuously informed about the patient’s condition, and they will intervene anytime there is a need for an MD presence near the patient’s bed.  

But, despite the clear evidence about the necessity to organise such a service in each hospital, the reality is far from satisfactory. 

A search in the literature provided the following partial, data regarding the percentage of European hospitals in which an APS is active 24 hours a day. 

Examples: Germany 81% (2015), Italy 59% (2012), Austria 39% (2011). 

In Hungary, only two hospitals, out of 50 all over the country, have an organised service, functioning on a 24/7 basis (3). 

Besides, one cannot forget the fact that acute pain is not only related to the immediate postoperative period but many other conditions (acute pancreatitis, trigeminal neuralgia, acute myocardial infarction, etc.) are accompanied by various degrees of acute pain.  

If so, the next question would be: why is it so difficult to organise such a service in all the hospitals? In other words, how come that in the last one hundred years, for too many professionals, analgesia is considered crucial for any simple surgical procedure, but only some are convinced that any acute pain must be treated as seriously as during surgery? 

The answer is not that simple. 

It seems that three main obstacles are to be confronted in the way of creation and function of an active APS: 

• educational aspects. This applies to patients and staff, too. The old and wrong saying that “pain does not kill” is to be opposed by an explanation regarding the negative effects of pain in its acute phase as well as in the long term. 
• the logistic difficulties. The need for personnel will be evident from the very first moment. Our daily reality shows that an anaesthesia department will never have a reserve of physicians, 24 hours a day, to cover the needs of an APS, and this obstacle is not so easy to overcome. Besides, there is a need for continuous cooperation with other clinical departments (first of all the surgical, but not only) since the supervision of the patient is their own task. 
• Finally, the financial obstacles. In many countries, insurance companies do not recognise the necessity of an active APS functioning around the clock. The workforce is expensive, and in most cases, the cost burden is to be covered by hospitals themselves. 

The positive effects of an efficient APS represent the answer to the above problems. Govind and al (5) compared the period without an APS and the immediate one after the institution of such a service. The results showed a significant increase in the number of patients who benefited from acute pain management, a significant decrease in the mean VAS (Visual Analogue Scale) for all treated patients, in comparison with the previous period, as well as a reduction in the length of stay in hospital, e.g. money saving. 

So, this task of instituting an active and efficient APS is ours. 

We are those who must convince our peers and leaders that: 

• acute pain is not only a problem for the surgical patient but also for many others who come for treatment and badly need pain alleviation besides the treatment for the specific disease 
• pain is dangerous because it may result in rapid neuronal sensitisation and chronic pain 
• patient satisfaction is important for any medical institution name and fame 
• a well-built APS could solve most of the problems related to acute pain and avoid futile complications. 

I will end by quoting Ken Hubbard, a preacher and Christian leader (1933-2010): “There is no failure except no longer trying. There is no defeat except from within, and no really insurmountable barrier save our inherent weakness of purpose”. 

Good luck! 

References 

1. Kindler CH et al. Anaesthetist 2002;51:890 
2. Ready LB et al. Anesthesiology 1988;68:100 
3. Lovasi O et al. PLOS ONE | https://doi.org/10.1371/journal.pone.0257585 September 22, 2021 
4. Borracci T et al. BMC Anesthesiol 2016;16:14