Audit of Pain Management After Colorectal Surgeries in a Tertiary Care Cancer Hospital

Abstract

Surgery for gastrointestinal malignancy is associated with severe post-operative pain, which if inadequately treated, can lead to pulmonary complications and, in addition, delayed mobilization leading to delayed recovery and discharge. We audited our practices looking at the various pain modalities used and their effects on the post-operative recovery in colorectal surgeries, in a tertiary care cancer centre during the era of ERAS. The primary aim of the study was to assess the average pain score on movement in the first 72 h of post-operative period among patients. The secondary aim was to study the various modalities of pain management used and complications, perioperative vasopressor requirement, post-operative resumption of enteral feeding, ambulation, duration of hospital stay, duration of ICU/HDU stay, and worst pain scores in the first 72 h. We analyzed a total of 174 patients who underwent colorectal surgeries for the period of 1 year from 1^st January 2018 till 31^st December 2018. Out of the 174 patients, 86 (49.4%) patients received epidural analgesia and 88 (50.6%) patients who did not receive epidural analgesia, belong to the non-epidural group. Average pain scores on movement at 72 h in the epidural group was 2 [2, 3] and 2 [1, 2] in the non-epidural group (p < 0.001). Worst pain score at post-operative 72 h in epidural group was 3 [3, 4] and 3 [2, 4] in the non-epidural group (p = 0.016). In conclusion, we conclude, that the analgesic efficacy of epidural analgesia was not found to be superior in our study in patients undergoing major colorectal surgeries.

Introduction

Colorectal cancer contributes to more than 1.8 million new cancer cases every year and is the fourth most common cancer worldwide [1]. At our tertiary care cancer centre, 1100 new cases of colorectal cancer are registered every year. Open laparotomy for colorectal malignancy is associated with severe post-operative pain, which if inadequately treated, can cause shallow breathing, atelectasis, retention of secretions leading to pulmonary complications and, in addition, delayed mobilization leading to delayed recovery and discharge [2].

Enhanced Recovery After Surgery (ERAS) is a paradigm shift in today’s perioperative care and emphasizes on the post-operative pain management for early post-operative recovery to reduce respiratory complications, early return of functional status and thus early discharge [3]. Various modalities for the post-operative pain management for major abdominal surgeries according to the type and extent of surgery are possible including epidural analgesia, truncal blocks, intravenous opioids and non-opioid analgesics. We audited our practices looking at the various pain modalities used and their effects on the post-operative recovery in colorectal surgeries in a tertiary care cancer centre during the era of ERAS. In addition, we wish to highlight the importance of a dedicated APS in achieving hospital wide practice change and improving quality of postoperative pain management.

Methodology

The primary aim of the study was to assess the average pain score on movement in the first 72 h of post-operative period among patients. The secondary aim was to study the various modalities of pain management used and complications, perioperative vasopressor requirement, post-operative resumption of enteral feeding, ambulation, duration of hospital stay, duration of ICU/HDU stay, and worst pain scores in the first 72 h. After IEC approval (28/12/2020) and CTRI registration (CTRI/2021/01/030425), records of patients who underwent elective colorectal surgeries from 1^st January 2018 to 31^st December 2018 were collected from our ERAS database and from acute pain service database. The pain score was recorded at 3 time points(consultant-based APS round, evening round and night round) till postoperative day 3 (POD 3). The average pain score and worst pain score in postoperative 72 h was then compared between the 2 mentioned groups.

Categorical data was reported as frequencies and percentages, and continuous data as mean (standard deviation), and median [interquartile range]. Data was analysed using SPSS 25 software. Comparison between epidural and non-epidural group was done using Mann-Whitney U test and continuous data was compared using Kruskal-Wallis test. Various modalities of analgesia were analysed using chi-squares test for association.

Results

We analyzed a total of 174 patients who underwent colorectal surgeries for the period of 1 year from 1^st January 2018 till 31^st December 2018. Out of the 174 patients, 86 (49.4%) patients received epidural analgesia and 88 (50.6%) patients who did not receive epidural analgesia belong to the non-epidural group. Average pain scores on movement at 72 h, in the epidural group was 2 [2, 3] and 2 [1, 2] in the non-epidural group (p < 0.001). Worst pain score at post-operative 72 h, in the epidural group was 3 [3, 4] and 3 [2, 4] in the non-epidural group (p = 0.016). All patients received Paracetamol, whereas, diclofenac (NSAIDs) was used in 35 (40.7%) patients in the epidural group and in 69 (78.4%) in the non-epidural group (p < 0.001). Use of tramadol was higher in the non-epidural group in 60 patients (68.2%) as compared to 12 (14%) (p < 0.001) in the epidural group. Our study showed an incidence of failed epidural in 2 (2.3%); epidural site infection in 3(3.5%); motor weakness in 3(3.5%); hypotension in 21(24.4%) requiring vasopressors, but no incidence of PDPH or epidural hematoma. Out of these 174 patients, 18 cases were supra-major surgeries {(Cytoreductive surgeries with Hyperthermic intraperitoneal chemotherapy (CRS HIPEC)} and all these cases were in the epidural group. The results for first ambulation and feeding in the epidural when compared to the non-epidural group was statistically not significant when CRS HIPEC patients were excluded. The overall mean post-operative day of discharge from hospital (9 [6.2, 15] vs 7 [6, 10] (P = 0.001)) and ICU/HDU were statistically significant. Out of 68 patients who received epidural, 9 where on vasopressor support till POD 1; this could be the reason for a longer HDU/ICU stay (Table 1). Another important factor was that among the patients in the non-epidural group, 66(75%) out of 88 patients underwent minimally invasive surgery (MIS), whereas only 8(9.3%) out of 86 patients underwent MIS in the epidural group which could be the reason for a longer hospital stay.

Table 1.

Colorectal cases including CRS surgeries and colorectal cases excluding CRS HIPEC surgeries

	Colorectal cases including CRS surgeries			Colorectal cases excluding CRS HIPEC surgeries
Post-operative details	Epidural group (n = 86) Median [IQR]	Non-epidural (n = 88)	P-value	Epidural (n = 68)	Non-epidural (n = 88)	p-value
Average pain scores on movement at 72 h	2 [2, 3]	2 [1, 2]	<0.001	2 [2, 3]	2 [1, 2]	<0.001
Worst pain score on movement at 72 h	3 [3, 4]	3 [2, 4]	0.016	3 [2, 3]	2 [2, 3]	0.191
Feeding resumed on POD	1 [1, 2]	1 [1, 1]	0.015	1 [1, 2]	1 [1, 1]	0.158
First ambulation day	2 [1,2]	1 [1, 2]	<0.001	1 [1, 2]	1 [1, 2]	0.061
Post-operative day of discharge	10 [7, 15]	7 [6, 10]	0.002	9 [ 6.2, 15.0]	7 [ 6, 10]	0.001
Days in ICU/HDU	1.5 [1, 3]	1 [1, 1]	<0.001	1 [1, 2]	1 [1, 1]	<0.001

Discussion

Postoperative analgesia following major colorectal surgeries is an important element of ERAS program, as it directly affects outcomes including early mobilization, feeding, respiratory physiotherapy, shorter recovery and hospital stay [2]. In our audit of postoperative pain relief following colorectal cancers, we recorded lower average and worst pain score in the first 72 h postoperative period in the non-epidural group compared to that in the epidural group. In contrast, in a meta-analysis by Marett et al., assessing epidural analgesia versus parenteral opioid analgesia after colorectal surgery demonstrated lower pain scores in the epidural group [4].

The difference in the results in our study is due to the fact that we have majority of minimally invasive surgeries in non-epidural group compared to majority of open surgeries in the epidural group. Another reason could be active involvement of the acute pain service (APS), a consultant-led service with a dedicated pain nurse, which is responsible for the follow-up of all postoperative patients, assessment of their pain, management and optimisation of inadequate pain relief during (APS) rounds. This could have resulted in lower pain scores in the non-epidural group as the inadequate pain relief was immediately addressed by the APS team. The other important contributing factor might be the use of multimodal analgesia for pain control in all the patients according to the APS protocols at our institution. There was early ambulation and start of enteral feeding in the non-epidural group. In comparison, studies conducted by Steinberg et al. and Mann et al. also showed no difference in time to ambulation in postoperative period between the epidural group and IV PCA group [5, 6]. In 18 patients who underwent CRS HIPEC, all received epidural analgesia as the main modality of pain control. When major resections CRS –HIPEC were analysed as a separate group, as expected, the postoperative feeding, ambulation, ICU/HDU stay and hospital discharge were all prolonged in the CRS HIPEC group and after excluding these cases from the epidural group, the day of ambulation was similar in both the groups. Another factor attributing to the above findings could be that the majority of patients in the non-epidural group underwent MIS compared to those in the epidural group. The overall complication rates (failure, site infection, motor blockade) associated with epidurals are comparable or lower in our patients as compared to those seen in other studies [4, 7, 8]. Our institution being a tertiary care cancer centre, epidural insertion and its management is closely supervised by consultants and this could be an important difference in lowering the rates of epidural failure or epidural site infections. APS services represent a necessary tool to improve acute pain management and decrease the rate of complications. Introduction of APS in our hospital in 2002 has led to a decrease in pain intensity, improved patient satisfaction scores, and fewer adverse events [9]. This service is a dedicated consultant anaesthetist-driven service which assesses, monitors and treats pain and side effects of pain medications, on a 24 h basis with ward rounds at least twice daily. This service precisely adapts to patients’ individual needs, using a multimodal approach resulting in fewer side effects and much more daily patient interaction. The implementation of ERAS increased the role of APS at our centre. These services have been responsible for improving the quality and safety of post-operative pain management by implementing protocols for pain management, and improving documentation related to pain management which has resulted in a high level of satisfaction among our patients [9, 10]. APS services, a necessary service in today’s setting should be viewed as quality improvement service as it improves pain management and patient satisfaction. This is especially true in resource-limited settings where addition of any service is judged by the money it can generate and not by improving of patient care. There could be local adaptation to this service depending on the volume of surgical cases and the resources available. Low cost system with a pain nurse and back-up anaesthetist to trouble shoot can be a starting point of such a service to review its effectiveness and usefulness in a given set-up. Regular APS rounds by the nurse, protocols for pain management, and assessment and documentation of pain can be implemented in low-resource and developing countries that can optimize multimodal treatment regimens and improve pain management.

The retrospective study design is a major limitation of our study. Even the severity of surgical procedures in both groups were not comparable, as most of the procedures in the non-epidural group were minimally invasive compared to extensive surgeries in majority of the epidural group patients.

In conclusion, we conclude that the analgesic efficacy of epidural analgesia was not found to be superior in our study in patients undergoing major colorectal surgeries. This could be because of adaptation of a multimodal analgesic by our APS team and timely interventions leading to an overall improvement in pain relief in the non-epidural group. The establishment of APS has revolutionized postoperative pain management on the wards at our centre. It is not new analgesics or new techniques but a dedicated APS team which has made a difference in acute pain management at our institution addressing the 5^th vital sign.

Declarations

Conflict of Interest

The authors declare no competing interests.