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      Protocols for treating the postoperative pain of fractures in Dutch hospitals

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          Every year, over 260,000 patients in the Netherlands are diagnosed with a traumatic fracture. Many patients are treated surgically and need postoperative treatment of pain. Research suggests postoperative pain is often under-treated, leaving a significant proportion of patients in moderate to severe postoperative pain. Specialized, evidence-based pain-management protocols offer patients the best possible pain management, and significantly reduce the risk of pain-related health complications.


          Our objective was to review the range of postoperative pain protocols that are currently being used to treat postoperative fracture pain within the Netherlands, and investigate whether a specialized, evidence-based protocol for treating postoperative fracture pain exists within this sample.


          A written request for the protocol currently being used for the treatment of postoperative pain following the surgical treatment of a fracture was sent to 101 Dutch hospital departments. The administration and dosage of pain medications used during postoperative pain management were then identified and summarized.


          Of the contacted hospitals, 57% sent in protocols; 45% of these were eligible for analysis. All of the departments sent a general or acute pain protocol rather than a specialized protocol for the treatment of postoperative pain associated with the surgical treatment of fractures. A total of 22 different analgesics were used for pain management in 135 different administration schemes. Paracetamol, diclofenac, and morphine were used in the majority of protocols. Medication was given via oral, rectal, intravenous, subcutaneous, intramuscular, and epidural routes, amongst others.


          No specialized, evidence-based protocols for the treatment of postoperative fracture pain were found in this Dutch sample. A wide variety of medications, dosages, and administration schemes were used to manage postoperative pain following the surgical treatment of a fracture. The importance of developing a clear, specialized, evidence-based protocol for the treatment of postoperative pain following fracture surgery is discussed.

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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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            Chronic pain following total hip arthroplasty: a nationwide questionnaire study.

            Chronic post-operative pain is a well-recognized problem after various types of surgery, but little is known about chronic pain after orthopedic surgery. Severe pre-operative pain is the primary indication for total hip arthroplasty (THA). Therefore, we examined the prevalence of chronic pain after THA in relation to pre-operative pain and early post-operative pain. A questionnaire was sent to 1231 consecutive patients who had undergone THA 12-18 months previously, and whose operations had been reported to the Danish Hip Arthroplasty Registry. The response rate was 93.6%. Two hundred and ninety-four patients (28.1%) had chronic ipsilateral hip pain at the time of completion of the questionnaire, and pain limited daily activities to a moderate, severe or very severe degree in 12.1%. The chronic pain state was related to the recalled intensity of early post-operative pain [95% confidence interval (CI), 20.4-33.4%] and pain complaints from other sites of the body (95% CI, 20.7-32.1%), but not to the pre-operative intensity of pain. Chronic pain after THA seems to be a significant problem in at least 12.1% of patients. Our results suggest that genetic and psychosocial factors are important for the development of chronic post-THA pain.
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              Thirty percent of patients have moderate to severe pain 24 hr after ambulatory surgery: a survey of 5,703 patients.

              Postoperative pain is the commonest reason for delayed discharge and unanticipated hospital admission after ambulatory surgery. We investigated the severity of pain at 24 hr postoperatively and determined the most painful procedures. The need for further medical advice and clarity of postoperative analgesia instructions were also studied. Five thousand seven hundred and three ambulatory surgical patients were telephoned 24 hr postoperatively. Patients graded their pain using the ten-point self-assessing verbal scale (0 = no pain, 10 = worst pain). Data were analyzed in two groups, those with moderate to severe pain (pain score 4-10) and those with no or mild pain (0-3). Thirty percent of patients (1,495/5,703) had moderate to severe pain. Microdiscectomy, laparoscopic cholecystectomy, shoulder surgery, elbow/hand surgery, ankle surgery, inguinal hernia repair, and knee surgery were identified as the procedures causing most pain at 24 hr. 13.2% of patients needed medical advice by telephone, 1.4% made an unplanned visit to a doctor while the rate of readmission to the hospital was 0.08%. Ninety-eight percent found postoperative instruction sheets and advice helpful. Eighty-eight percent of patients indicated that analgesic instructions were absolutely clear. This study has identified the more painful common ambulatory surgical procedures which will allow take home analgesia to be tailored according to individual procedures. Further improvement in analgesic instructions may help in better pain management of ambulatory surgery patients.

                Author and article information

                J Pain Res
                J Pain Res
                Journal of Pain Research
                Dove Medical Press
                13 August 2013
                : 6
                : 635-639
                [1 ]Department of surgery, VU University Medical Center, The Netherlands
                [2 ]Department of Oral and Maxillofacial Surgery, VU University Medical Center, The Netherlands
                [3 ]Department of social and Organizational Psychology, VU University, Amsterdam, The Netherlands
                Author notes
                Correspondence: FW Bloemers, Department of Surgery, VU University Medical center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands, Tel +31 20 444 1150, Fax +31 20 444 1024, Email fw.bloemers@ 123456vumc.nl
                © 2013 Ossendorp et al. This work is published by Dove Medical Press Ltd, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License.

                The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Ltd, provided the work is properly attributed.

                Original Research

                Anesthesiology & Pain management

                protocol, fracture, postoperative pain, pain management


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