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      Prevalence and Risk Factors for Acute Postoperative Pain After Elective Orthopedic and General Surgery at a Tertiary Referral Hospital in Tanzania

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          Abstract

          Background

          In Africa, postoperative pain management is still a major problem with a prevalence of postoperative pain in up to 95.2% of the patients. There are little data on the prevalence and potential risk factors for postoperative pain in Tanzania. Therefore, we aimed to investigate these at Kilimanjaro Christian Medical Centre in Northern Tanzania. Our goal is to optimize pain management.

          Methods

          A prospective cohort study was carried out from December 2016 to April 2017. Patients ≥18 years admitted for elective general or orthopedic surgery were included in the study. Demographic data were collected during a pre-operative visit, and pain was assessed with a numerical rating scale (NRS 0–10) at 4, 24, 36 and 48 hours postoperatively. A NRS >3 was considered as moderate to severe postoperative pain. Potential risk factors for postoperative pain were identified using univariate and multivariable binary logistic regression analyses.

          Results

          A total of 281 patients were included in the study. The prevalence of postoperative pain was 61%, 73%, 67% and 58% at 4, 24, 36 and 48 hours after surgery, respectively. Pethidine was the most frequently prescribed analgesic for postoperative pain management (85.1%) in the first 24 hours postoperatively; only 1% received paracetamol or diclofenac, and 13% received tramadol. In the multivariable model, general anesthesia and intra-operative analgesia (OR = 3.70, 95% CI 1.70–8.04) were significant risk factors for postoperative pain.

          Conclusion

          Pain is still inadequately managed at Kilimanjaro Christian Medical Centre leading to a high prevalence (73% on the first day after surgery) of reported postoperative pain in this study. It reflects the need for adequate postoperative analgesia, especially in low- and middle-income countries. Further research identifying risk factors in larger cohorts can be performed if adequate analgesia is given.

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          Most cited references 23

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          Predictors of postoperative pain and analgesic consumption: a qualitative systematic review.

          Pain is a subjective and multidimensional experience that is often inadequately managed in clinical practice. Effective control of postoperative pain is important after anesthesia and surgery. A systematic review was conducted to identify the independent predictive factors for postoperative pain and analgesic consumption. The authors identified 48 eligible studies with 23,037 patients included in the final analysis. Preoperative pain, anxiety, age, and type of surgery were four significant predictors for postoperative pain. Type of surgery, age, and psychological distress were the significant predictors for analgesic consumption. Gender was not found to be a consistent predictor as traditionally believed. Early identification of the predictors in patients at risk of postoperative pain will allow more effective intervention and better management. The coefficient of determination of the predictive models was less than 54%. More vigorous studies with robust statistics and validated designs are needed to investigate this field of interest.
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            Effectiveness of acute postoperative pain management: I. Evidence from published data.

            This review examines the evidence from published data concerning the incidence of moderate-severe and of severe pain after major surgery, with three analgesic techniques; intramuscular (i.m.) analgesia, patient controlled analgesia (PCA), and epidural analgesia. A MEDLINE search of the literature was conducted for publications concerned with the management of postoperative pain. Over 800 original papers and reviews were identified. Of these 212 papers fulfilled the inclusion criteria but only 165 provided usable data on pain intensity and pain relief. Pooled data on pain scores obtained from these studies, which represent the experience of a total of nearly 20,000 patients, form the basis of this review. Different pain measurement tools provided comparable data. When considering a mixture of three analgesic techniques, the overall mean (95% CI) incidence of moderate-severe pain and of severe pain was 29.7 (26.4-33.0)% and 10.9 (8.4-13.4)%, respectively. The overall mean (95% CI) incidence of poor pain relief and of fair-to-poor pain relief was 3.5 (2.4-4.6)% and 19.4 (16.4-22.3)%, respectively. For i.m. analgesia the incidence of moderate-severe pain was 67.2 (58.1-76.2)% and that of severe pain was 29.1 (18.8-39.4)%. For PCA, the incidence of moderate-severe pain was 35.8 (31.4-40.2)% and that of severe pain was 10.4 (8.0-12.8)%. For epidural analgesia the incidence of moderate-severe pain was 20.9 (17.8-24.0)% and that of severe pain was 7.8 (6.1-9.5)%. The incidence of premature catheter dislodgement was 5.7 (4.0-7.4)%. Over the period 1973-1999 there has been a highly significant (P < 0.0001) reduction in the incidence of moderate-severe pain of 1.9 (1.1-2.7)% per year. These results suggest that the UK Audit Commission (1997) proposed standards of care might be unachievable using current analgesic techniques. The data may be useful in setting standards of care for Acute Pain Services.
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              The prevalence of postoperative pain in a sample of 1490 surgical inpatients.

              To measure the prevalence of postoperative pain, an assessment was made of 1490 surgical inpatients who were receiving postoperative pain treatment according to an acute pain protocol. Measurements of pain (scores from 0 to 100 on a visual analogue scale) were obtained three times a day on the day before surgery and on days 0-4 postoperatively; mean pain intensity scores were calculated. Patients were classified as having no pain (score 0-5), mild pain (score 6-40), moderate pain (score 41-74) or severe pain (score 75-100). Moderate or severe pain was reported by 41% of the patients on day 0, 30% on days 1 and 19%, 16% and 14% on days 2, 3 and 4. The prevalence of moderate or severe pain in the abdominal surgery group was high on postoperative days 0-1 (30-55%). A high prevalence of moderate or severe pain was found during the whole of days 1-4 in the extremity surgery group (20-71%) and in the back/spinal surgery group (30-64%). We conclude that despite an acute pain protocol, postoperative pain treatment was unsatisfactory, especially after intermediate and major surgical procedures on an extremity or on the spine.
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                Author and article information

                Journal
                J Pain Res
                J Pain Res
                jpr
                jpainres
                Journal of Pain Research
                Dove
                1178-7090
                19 November 2020
                2020
                : 13
                : 3005-3011
                Affiliations
                [1 ]Department of Anesthesiology, Kilimanjaro Christian Medical Centre , Kilimanjaro, Tanzania
                [2 ]Department of Anesthesiology and Pain and Palliative Medicine, Radboud University Medical Centre , Nijmegen, the Netherlands
                [3 ]Department of Orthopedic and Trauma, Kilimanjaro Christian Medical Centre , Kilimanjaro, Tanzania
                [4 ]Department of Anesthesiology, Amsterdam University Medical Center Location VU , Amsterdam, the Netherlands
                Author notes
                Correspondence: Ansbert S Ndebea Department of Anesthesiology, Kilimanjaro Christian Medical Centre , PO Box 3010, Moshi, Tanzania Email sweetbert19@gmail.com
                Article
                258954
                10.2147/JPR.S258954
                7684026
                © 2020 Ndebea et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                Page count
                Figures: 2, Tables: 2, References: 23, Pages: 7
                Categories
                Original Research

                Anesthesiology & Pain management

                tanzania, postoperative pain, risk factors, prevalence

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