The purpose of this audit was to find out the efficiencyof our system in providing premedication to surgical daycare patients. This audit was conducted in the Surgical DayCare (SDC) Unit of a University Hospital. All patientsanaesthetised in the SDC unit on day care basis were includedin this audit. Nursing notes and preoperative orders of allpatients to be anaesthetised were checked to see whetherpremedication was given or not and was the timing accordingto the orders written. The result showed that out of 205patients scheduled, twenty (9.7%) patients did not receivepremedication. Only 37.2% of our patients were receivingpremedication according to the orders. The majority of theerrors noted in our audit were system errors related to cancellation,rescheduling and admitting the outpatient in theinpatient ward

Ahmed, Aliya

Ismail, Saminal

Khan, Fauzia A

Shah, Khalid A

eCommons@AKU

eCommons@AKUDepartment of Anaesthesia Medical College, PakistanJanuary 2007Premedication in Surgical Day Care PatientsSaminal IsmailAga Khan UniversityFauzia A. KhanAga Khan UniversityAliya AhmedAga Khan UniversityKhalid A. ShahAga Khan UniversityFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_anaesthPart of the Anesthesiology CommonsRecommended CitationIsmail, S., Khan, F. A., Ahmed, A., Shah, K. A. (2007). Premedication in Surgical Day Care Patients. JPMA. The Journal of the PakistanMedical Association, 57(1), 37-38.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_anaesth/73Short ReportAdequacy of postoperative pain relief after dischargeSamina Ismail, Aziza M. HussainDepartment of Anaesthesia, Aga Khan University Hospital, Karachi.AbstractDay care surgery has shown a remarkabledevelopment over the last two decades, comprisingapproximately 60-70% of all surgical procedures. Thereforemajor proportions of surgical patients are recovering athome and have little or no assessment of the adequacy oftheir pain relief. The aim of our audit was to comparesuggested postoperative pain indicators with targets for bestpractice. This audit was done at the Aga Khan UniversityHospital day care unit for a period of three months. On theday of surgery patients having the contact numbers wereinformed about the telephone call 24 hrs after the surgeryinquiring about their pain relief. Patients were shown andexplained the visual analogue score from 0 to 10. The datawas collected by one of the investigators on the day ofsurgery. We could assess 63.3% of day care patients. Allpatients were discharged with analgesia. Only three percentreported severe pain after 24 hrs which is according to theproposed standard for best practice that is < 5 %. Sixtypercent of patients had mild or no pain which is less than theproposed standard (>85%) and 84.2% were satisfied whichis almost borderline (>85%) according to the standard ofbest practice.IntroductionThe practice of day care surgery dates back morethan 90 years, although it has only been over the last twodecades that dramatic development is seen with markedincrease in the number and complexity of procedures,comprising approximately 60-70% of all procedures.Therefore a major proportion of surgical patients will berecovering at home and have little or no assessment of theirpain relief.1Some studies estimate that up to 75% of postsurgical patients experience pain because of undermedication.2 Patient's low expectation may well contributeto this problem .Studies3 have shown that 48% of patientstake it is a part of healing and 39% see it as something to beendured. This may reduce the number of patients actuallyusing the analgesics prescribed to them.Despite many tools for providing analgesia, pain isstill a common reason for delay in discharge, for contactwith the family doctor4 and for unanticipated hospitaladmissions.5 Pain ranks in the top three undesirablepostoperative outcomes6 and among the most commonsymptom of greatest concern for patients and theirfamilies.7To treat pain effectively, it is important to understandthe pattern of pain and define any predictive factors forsevere postoperative pain. Chung and Mezei8 in their studyidentified risk factors for severe postoperative pain. Theyfound that type and length of surgical procedures influencethe incidence of postoperative symptoms.8 Given thesefactors, modifying the anaesthetic care to a protocoldesigned to reduce postoperative pain achieved measurableimprovement in reducing pain.9 Developments in ourunderstanding of the pathophysiology of acute pain have ledto the concept of preventive analgesia (inhibition ofphysiological and pathophysiological secondaryinflammatory pain). Therefore postoperative pain controlshould be started intraoperatively or, ideally, preoperativelyto ensure a pain free recovery. The approach should bemultimodal, using non-steroidal anti-inflammatory drugs(NSAIDs), opioids, and local anaesthetic techniques.10NSAIDs in addition to providing effective analgesiaprovide their anti-inflammatory effects which may helpreduce local oedema and minimize the use of opioids andtheir accompanying side effects. Consideration should beVol. 57, No. 7, July 2007 371given to the timing of NSAIDs. Orally they should be givenpreoperatively when the patient is awake. Evenintravenously, NSAIDs take at least 30 minutes to beeffective. Local anaesthetic wound infiltration andperipheral nerve block are simple, safe and an importantpart of the multimodal approach. Intracavity instillation oflocal anaesthetic is another simple and effective means ofproviding analgesics after laparoscopic and arthroscopicprocedures.10 Opioids still remain the primary perioperativeanalgesic despite the association with nausea, vomiting andsedation, which may delay discharge. Postoperative pain inthe PACU should be treated promptly with small doses ofpotent rapidly acting opioid analgesics. Claxton et al11found that equipotent doses of fentanyl and morphineprovided a more sustained analgesic effect but caused ofmore nausea and vomiting after discharge as fentanyl is ashort acting opioid and its use in the PACU should beaccompanied by an oral drug to provide more prolongedpain relief.The aim of our audit was to find the adequacy ofpostoperative pain relief after discharge. Our suggestedindicators were:Percentage of * Patients discharged with analgesics.* Patients with verbal pain score of severe in the first 48hours after discharge.* Patients achieving a verbal pain score of mild or nonewith medication after discharge.* Patients satisfied with management of their pain whileat home.Our targets for best practice were1:* 100% patients discharged with analgesics.* < 5% reporting 'severe' pain on verbal pain score in thefirst 48 hours after discharge.* >85% reporting no pain or mild pain after discharge(with medication)* >85% satisfied with management of their pain while athome.Methods and ResultsOn the day of surgery, patients contactable ontelephone were informed about the telephone call that oneof the investigators would make 24 hours after the surgeryasking questions about their postoperative pain. Patientswere shown and explained the visual analogue score from 0to 10. They were explained that 0 meant no pain and 10meant worst possible pain and they were told to grade theirlevel of pain from 0 to 10 depending upon the severity. Wehave taken the pain score 1-3 as mild, 4-7 as moderate and7-10 as severe.We included all patients above 14 years of ageundergoing day care surgery. We excluded all patients whowere admitted after surgery, patients who refused toparticipate, not having telephone access, mentally notcapable to understand and having a language barrier.Data for the day of surgery was collected by one ofthe investigators. Patients were called 24 hours after thesurgery by one of the investigators and data was collected.Data collected on the day care surgery included contactnumber, age, sex, name and M.R #, surgery performed,ASA grading, type of anaesthesia (general anaesthesia,regional or monitored anaesthesia care), type of analgesia(narcotic, non narcotic or multimodal). Data collected after24 hours included whether patients were discharged withanalgesics or not, verbal pain score, whether usingmedication, reasons for not taking medication, andsatisfaction with management of pain. This audit was done for a period of three months atthe surgical day care unit of Aga Khan University Hospital.Total numbers of cases done as day care during the timewere 120. Out of these eleven patients did not havetelephone access and eleven patients were admitted. Noneof the patients refused to participate. Out of these 98patients only 76 could be contacted and assessed foradequacy of postoperative pain relief after discharge.All of the cases were discharged with analgesics.Nine (11.8%) patients did not take analgesics. Of these eightpatients did not have pain and one could not take it becauseof excessive vomiting.Pain and Satisfaction Scores are presented in table 1and 2. Eight patients (10.5%) had severe pain after goinghome upto 24 hours. Out of these eight patients three (3.9%)continued to have severe pain even after 24hrs, one hadmild and four had moderate pain after 24 hours.One patient who continued to have severe pain hadarthroscopy and was given general anaesthesia andnarcotics were used for analgesia and was takingTable 1. Pain Score.Before 24 hours 24 hours onwardNo. of Pts % No. of Pts %Mild (1 - 3)Moderate (4 - 7)Severe (8 - 10)4523859.23010.54627360.535.53.9Table 2. Satisfaction ScoreNo. of Patients %Not SatisfiedSatisfied126415.784.2372 J Pak Med Assocparacetomol postoperatively. Second patient had inguinalhernia repair under general anaesthesia with narcotics andNSAIDS and postoperatively was taking calpol. Thirdpatient had haemorriodectomy under general anaesthesiawith narcotics. Postoperatively she was on paracetamol anddiclophenac .She had to go to the hospital for pain relief.Twelve patients (15.7%) were not satisfied with painmanagement. Amongst them three patients had pain score ofsevere even after 24 hours, eight patients had moderate painwith score of 6-7 and one had mild with score of three after24 hours .ConclusionWe could only assess 63.3% of surgical day carepatients, as others could not be contacted.  All patients weredischarged with analgesics. Only three percent reportedsevere pain after 24 hours which is comparable with theproposed standard for best practice which is < 5%. Sixtypercent of patients had mild or no pain which is less than theproposed standard (>85%) and 84.2% were satisfied whichis almost borderline (>85%) according to the bench mark ofbest practice. We recommend the need to educate patients so thatthey communicate to the care giver that they areexperiencing pain so that it can be treated. All health careworkers should be familiar with appropriate painmanagement modalities and the practice of prevention andmultimodal analgesia should be implemented to obtainoptimum pain management in ambulatory surgical patients. References1. IJB Jackson. Adequacy of postoperative pain relief after discharge. The RoyalCollege of Anaesthetist / raising the standards 2000. 2. Redmond M, Florence B, Glass PS. Effective analgesic modalities forambulatory patients. Anesthesiology Clin N Am 2003; 21: 329-46.3. Hume MA, Kennedy B, Asbury AJ. Patient knowledge of anaesthesia andPerioperative care. Anaesthesia 1994; 49:715-8.4. Ghosh S, Sallam S. Patient satisfaction and postoperative demands on hospitaland community services after day surgery. Br J Surg 1994; 81:1635-8.5. Fortier J, Chung F, Su J. Predictive factors of unanticipated admission inambulatory surgery: a prospective study. Anesthesiology 1996; 85:A27.6. Jenkins K, Grady D, Wong J, Armanious S, Chung F. Post-operative recovery:day surgery patients' preferences. Br J Anaesth 2001; 86:272-4.7. Jauraz G, Cullinane CA, Borneman T, Falabella A, Ferell BR, Wagman LD, etal. Management of pain and nausea in outpatient surgery. Pain manag Nurs,2005, 6:175-81.8. Chung F, Ritchie E, Su J. Postoperative pain ambulatory surgery. AnesthAnalg 1997; 85:808-16.9. Ewah BN, Robb PJ, Raw M. Postoperative pain, nausea and vomitingfollowing paediatric day care tonsillectomy Anaesthesia 2006;61:116-22.10. McGrath B, Chung F. Postoperative recovery and discharge. AnesthesiologyClin N Am  2003; 21: 367-86.11. Claxton AR, McGuire G, Chung F, Cruise C. Evaluation of morphine versusfentanyl for postoperative analgesia after ambulatory surgical procedures.Anesth Analg 1997; 84:509-14.Vol. 57, No. 7, July 2007 373

Premedication in Surgical Day Care Patients

http://ecommons.aku.edu/cgi/viewcontent.cgi?article=1073&context=pakistan_fhs_mc_anaesth

Premedication in Surgical Day Care Patients

Abstract

Similar works

Full text

Available Versions

eCommons@AKU