Cost-effectiveness of the Perioperative Pain Management Bundle a registry-based study.

INTRODUCTION The Perioperative Pain Management Bundle was introduced in 10 Serbian PAIN OUT network hospitals to improve the quality of postoperative pain management. The Bundle consists of 4 elements: informing patients about postoperative pain treatment options; administering a full daily dose of 1-2 non-opioid analgesics; administering regional blocks and/or surgical wound infiltration; and assessing pain after surgery. In this study, we aimed to assess the cost-effectiveness of the Bundle during the initial 24 h after surgery. MATERIALS AND METHODS The assessment of cost-effectiveness was carried out by comparing patients before and after Bundle implementation and by comparing patients who received all Bundle elements to those with no Bundle element. Costs of postoperative pain management included costs of the analgesic medications, costs of labor for administering these medications, and related disposable materials. A multidimensional Pain Composite Score (PCS), the effectiveness measurement, was obtained by averaging variables from the International Pain Outcomes questionnaire evaluating pain intensity, interference of pain with activities and emotions, and side effects of analgesic medications. The incremental cost-effectiveness ratio (ICER) was calculated as the incremental change in costs divided by the incremental change in PCS and plotted on the cost-effectiveness plane along with the economic preference analysis. RESULTS The ICER value calculated when comparing patients before and after Bundle implementation was 181.89 RSD (1.55 EUR) with plotted ICERs located in the northeast and southeast quadrants of the cost-effectiveness plane. However, when comparing patients with no Bundle elements and those with all four Bundle elements, the calculated ICER was -800.63 RSD (-6.82 EUR) with plotted ICERs located in the southeast quadrant of the cost-effectiveness plane. ICER values differ across surgical disciplines. CONCLUSION The proposed perioperative pain management Bundle is cost-effective. The cost-effectiveness varies depending on the number of implemented Bundle elements and fluctuates across surgical disciplines

Updates on Wound Infiltration Use for Postoperative Pain Management: A Narrative Review

Local anesthetic wound infiltration (WI) provides anesthesia for minor surgical procedures and improves postoperative analgesia as part of multimodal analgesia after general or regional anesthesia. Although pre-incisional block is preferable, in practice WI is usually done at the end of surgery. WI performed as a continuous modality reduces analgesics, prolongs the duration of analgesia, and enhances the patient’s mobilization in some cases. WI benefits are documented in open abdominal surgeries (Caesarean section, colorectal surgery, abdominal hysterectomy, herniorrhaphy), laparoscopic cholecystectomy, oncological breast surgeries, laminectomy, hallux valgus surgery, and radical prostatectomy. Surgical site infiltration requires knowledge of anatomy and the pain origin for a procedure, systematic extensive infiltration of local anesthetic in various tissue planes under direct visualization before wound closure or subcutaneously along the incision. Because the incidence of local anesthetic systemic toxicity is 11% after subcutaneous WI, appropriate local anesthetic dosing is crucial. The risk of wound infection is related to the infection incidence after each particular surgery. For WI to fully meet patient and physician expectations, mastery of the technique, patient education, appropriate local anesthetic dosing and management of the surgical wound with “aseptic, non-touch” technique are needed

The Perioperative Pain Management Bundle is Feasible: Findings from the PAIN OUT Registry.

OBJECTIVES The quality of postoperative pain management is often poor. A 'bundle', a small set of evidence-based interventions, is associated with improved outcomes in different settings. We assessed whether staff caring for surgical patients could implement a 'Perioperative Pain Management Bundle' and whether this would be associated with improved multi-dimensional pain-related Patient-Reported-Outcomes (PROs). METHODS PAIN OUT, a perioperative pain registry, offers tools for auditing pain-related PROs and obtaining information about perioperative pain management during the first 24 hours after surgery. Staff from 10 hospitals in Serbia used this methodology to collect data at baseline. They then implemented the 'perioperative pain management bundle' into the clinical routine and collected another round of data. The bundle consists of four treatment elements: (1) a full daily dose of 1-2 non-opioid analgesics (e.g. paracetamol, NSAIDs); (2) at least one type of local/regional anesthesia; (3) pain assessment by staff; (4) offering patients information about pain management. The primary endpoint was a multi-dimensional pain composite score (PCS), evaluating pain intensity, interference and side-effects: It was compared between patients who received the full bundlevs.not. RESULTS Implementation of the complete bundle was associated with a significant reduction in the PCS (P<0.001, small-medium effect size [ES]). When each treatment element was evaluated independently, non-opioid analgesics were associated with a higher PCS (i.e. poorer outcome; negligible ES); the other elements were associated with a lower PCS (all negligible-small ES). Individual PROs were consistently better in patients receiving the full bundle compared to 0-3 elements. The PCS was not associated with surgical discipline. DISCUSSION We report findings from using a bundle approach for perioperative pain management in patients undergoing mixed surgical procedures. Future work will seek strategies to improve the effect. TRIAL REGISTRATION ClinicalTrials.gov identified NCT02083835

Status quo of pain-related patient reported outcomes and perioperative pain management in 10 415 patients from 10 countries: analysis of registry data

Postoperative pain is common at the global level, despite considerable attempts for improvement, reflecting the complexity of offering effective pain relief. In this study, clinicians from Mexico, China, and eight European countries evaluated perioperative pain practices and patient-reported outcomes (PROs) in their hospitals as a basis for carrying out quality improvement (QI) projects in each country