Acute pain management: analysis, implications and consequences after prospective experience with 6349 surgical patients

An acute pain service (APS) was set up to improve pain management after ope ration. We attempted to reduce the length of stay in the intensive care uni t (ICU) of patients undergoing major surgery and to improve their homeostas is and rehabilitation using a multimodal approach (pain relief, stress redu ction, early extubation). Patient-controlled epidural analgesia (PCEA) was a keystone of this approach. If PCEA was not applicable, patients received patient-controlled intravenous analgesia (PCIA) instead. Brachial plexus bl ockade (BPB) was used for surgery of the upper limbs. A computer based docu mentation system was used to help evaluate prospectively (a) the quality of analgesia, (b) adverse effects and risks of the special pain management te chniques, and (c) cost-effectiveness. Patients receiving PCEA (n = 5.602) received a patient-titrated continuous infusion into the epidural space of either bupivacaine 0.175% or ropivacain e 0.2%, with 1 mu g sufentanil mL(-1) added, followed by patient-controlled boluses of 2 mL (lockout time 20 min). For patients receiving PCIA (n = 63 4) an initial bolus of 7.5-15 mg piritramide was given, and the subsequent bolus was 2 mg (lockout time 10 min). A continuous infusion of bupivacaine 0.25% was administered to patients receiving BPB (n = 113). The dose was ti trated to a dynamic visual analogue scale (VAS) scores < 40. The mean treatment periods were: BPB = 4.33 days, PCEA = 5.6 days, PCIA = 5 .0 days. In the case of PCEA, the quality of pain relief, vigilance and sat isfaction were superior compared with the PCIA method, which resulted in gr eater sedation and nausea. Although personal supervision was higher for the PCEA-treated patients, cost analysis revealed final savings of C91620 for the year 1998 obviating the need for an ICU stay totalling 433 days. Provided that PCEA is part of a fast-track protocol employing early trachea l extubation and optimal perioperative management, the associated initial h igher costs will be recouped by the benefits to patients of better pain rel ief after surgery and fewer days subsequently spent in the ITU.