Current issues in postoperative pain management

Rawal, Narinder. European Journal of Anaesthesiology: March 2016 – Volume 33 – Issue 3 – p 160–171


Postoperative pain has been poorly managed for decades. Recent surveys from USA and Europe do not show any major improvement. Persistent postoperative pain is common after most surgical procedures, and after thoracotomy and mastectomy, about 50% of patients may experience it. Opioids remain the mainstay of postoperative pain treatment in spite of strong evidence of their drawbacks. Multimodal analgesic techniques are widely used but new evidence is disappointing. Regional anaesthetic techniques are the most effective methods to treat postoperative pain.

Current evidence suggests that epidural analgesia can no longer be considered the ‘gold standard’. Perineural techniques are good alternatives for major orthopaedic surgery but remain underused. Infiltrative techniques with or without catheters are useful for almost all types of surgery. Simple surgeon-delivered local anaesthetic techniques such as wound infiltration, preperitoneal/intraperitoneal administration, transversus abdominis plane block and local infiltration analgesia can play a significant role in improvement of postoperative care, and the last of these has changed orthopaedic practice in many institutions.

Current postoperative pain management guidelines are generally ‘one size fits all’. It is well known that pain characteristics such as type, location, intensity and duration vary considerably after different surgical procedures. Procedure-specific postoperative pain management recommendations are evidence based, and also take into consideration the role of anaesthetic and surgical techniques, clinical routines and risk–benefit aspects. The role of acute pain services to improve pain management and outcome is well accepted but implementation seems challenging.

The need for upgrading the role of surgical ward nurses and collaboration with surgeons to implement enhanced recovery after surgery protocols with regular audits to improve postoperative outcome cannot be overstated.

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Psychological distress, burnout and personality traits in Dutch anaesthesiologists: A survey

van der Wal, R. et al. European Journal of Anaesthesiology: March 2016 – Volume 33 – Issue 3 – p 179–186

Background: The practice of anaesthesia comes with stress. If the demands of a stressful job exceed the resources of an individual, that person may develop burnout. Burnout poses a threat to the mental and physical health of the anaesthesiologist and therefore also to patient safety.

Objectives: Individual differences in stress appraisal (perceived demands) are an important factor in the risk of developing burnout. To explore this possible relationship, we assessed the prevalence of psychological distress and burnout in the Dutch anaesthesiologist population and investigated the influence of personality traits.

Results: Respectively, psychological distress and burnout were prevalent in 39.4 and 18% of all respondents. The prevalence of burnout was significantly different in resident and consultant anaesthesiologists: 11.3% vs. 19.8% (χ2 5.4; P < 0.02). The most important personality trait influencing psychological distress and burnout was neuroticism: adjusted odds ratio 6.22 (95% confidence interval 4.35 to 8.90) and 6.40 (95% confidence interval 3.98 to 10.3), respectively.

Conclusion: The results of this study show that psychological distress and burnout have a high prevalence in residents and consultant anaesthesiologists and that both are strongly related to personality traits, especially the trait of neuroticism. This suggests that strategies to address the problem of burnout would do well to focus on competence in coping skills and staying resilient. Personality traits could be taken into consideration during the selection of residents. In future longitudinal studies the question of how personal and situational factors interact in the development of burnout should be addressed.

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The effect of a standardised source of divided attention in airway management: A randomised, crossover, interventional manikin study

Prottengeier, J. European Journal of Anaesthesiology: March 2016 – Volume 33 – Issue 3 – p 195–203

Background: Dual-tasking, the need to divide attention between concurrent tasks, causes a severe increase in workload in emergency situations and yet there is no standardised training simulation scenario for this key difficulty.

Objectives: We introduced and validated a quantifiable source of divided attention and investigated its effects on performance and workload in airway management.

Participant: One hundred and fifty volunteer medical students, paramedics and anaesthesiologists of all levels of training.

Interventions: Participants secured the airway of a manikin using a supraglottic airway, conventional endotracheal intubation and video-assisted endotracheal intubation with and without the Paced Auditory Serial Addition Test (PASAT), which served as a quantifiable source of divided attention.

Results: All 150 participants completed the tests. Volunteers perceived our test to be challenging (99%) and the experience of stress and distraction true to an emergency situation (80%), but still fair (98%) and entertaining (95%). The negative effects of divided attention were reproducible in participants of all levels of expertise. Time consumption and perceived workload increased and almost half the participants make procedural mistakes under divided attention. The supraglottic airway technique was least affected by divided attention.

Conclusion: The scenario was effective for simulation training involving divided attention in acute care medicine. The significant effects on performance and perceived workload demonstrate the validity of the model, which was also characterised by high acceptability, technical simplicity and a novel degree of standardisation.

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Rota gaps causing ‘significant problems for patient safety’

Anaesthesia UK: 2nd February 2016

The latest census of consultant physicians and higher specialty trainees in the UK (2014/15) produced by the Royal College of Physicians, Royal College of Physicians of Edinburgh and the Royal College of Physicians and Surgeons of Glasgow, highlights significant concerns around filling gaps in trainee rotas.

Published in full today, the annual census measures the number of UK consultants and higher specialty trainees in all medical specialties, as well as capturing the views of those in the profession.

As part of the census, consultant physicians were asked about the gaps they face in their trainees’ rotas and their concerns. The findings from the consultant census show that trainee rota gaps were reported by 21% of respondents as, ‘frequent, such that they cause significant problems for patient safety’. This problem is reported more among consultants who have an acute or general medical commitment (28%). A further 48% stated rota gaps happened ‘often, but usually with a workaround solution such that patient safety is not compromised’.

The consultant census also notes, along with previous years, the growing need for consultants who can meet the needs of frail older patients. Following trends noted in last year’s census, the greatest increase in consultant jobs advertised have been in acute medicine and geriatric medicine, suggesting a move away from specialist working to more generalist roles treating acutely ill patients.

The nature of patients coming to hospital is changing. Sixty-five per cent of people admitted to hospital are over 65 years old and many have multiple complex conditions – often such patients require increased generalist input, as highlighted by the RCP’s Future Hospital Commission report.