[Postoperative pain management on surgical wards-organization of an anaesthesiology-based acute pain service.].
There have been major advances in knowledge and efficient techniques for pain relief have been developed during recent years. Nevertheless, many patients on surgical wards still suffer from severe pain following surgery or trauma. Therefore, in the University hospital of Kiel (Germany) an anaesthesiology-based acute pain service (APS) was established in 1985 to improve this situation.
The anaesthesiologist in training, who is in overall charge of the recovery unit, serves as an APS for surgical wards and is supervised by a consultant. The anaesthesiologists on duty are on call after regular working hours. The activities of the APS are as follows: induction of adequate postoperative analgesia in the recovery unit for all patients and selection of patients for further special analgesic treatment; clinical rounds including all patients receiving regional analgesia or patient-controlled analgesia (PCA) every morning and throughout the day if necessary; additional consultations on postoperative pain management for other patients on request; assessment and documentation of the clinical status of each patient, the quality of analgesia and side effects; written orders for further treatment (Fig. 1); continuing consultations and informal education for ward nurses, physiotherapists and surgical staff, and formal medical training in postoperative pain management for ward sisters/ charge nurses ACTIVITY OF THE APS: A total of 1947 patients were treated on normal wards from 1985 to 1992. Epidural analgesia was performed using a standard protocol with bupivacaine 0.175-0.25% continuously with top-ups if needed. Since the introduction of an APS, complications of epidural analgesia such as hypotension and insufficient analgesia due to dislocation or other technical complications, have declined significantly in recent years (Fig. 3). Epidural opioids were used in only 46 selected cases on surgical wards. Nevertheless, there were two cases of marked respiratory depression. PCA was performed according to a standard protocol with tramadol or piritramide without background infusion. The loading dose was titrated in the recovery unit. The median duration of PCA was 4 days (range 1-23 days), and the median dose of piritramide was 45 mg/day (range 3-226 mg). There were two cases of somnolence and respiratory depression.


CONCLUSIONS
Since the majority of patients used patient-controlled or epidural analgesia for more than 48 h (Fig. 2), it is emphasized again that these techniques should not be restricted to high-dependency areas such as ICU or recovery units. The introduction of an APS is an adequate approach towards more efficient and safer pain management on surgical wards. This requires standard protocols, standard monitoring and trained ward nurses.
Wulf
H
H
Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum der Chirstian-Albrechts-Universität zu Kiel, Schwanenweg 21, D-24105, Kiel.
Maier
C
C