Abstract
Inadequately managed post-operative pain is a significant driver of patient morbidity and healthcare costs. In Bangladesh, current practices are often reactive, inconsistent, and overly reliant on intravenous (IV) routes. The Optima Pain Consensus brought together sixteen senior surgical and pain management experts to address these gaps. The panel recommends a paradigm shift from reactive “SOS” dosing to proactive “By the Clock” multimodal analgesia, the implementation of objective pain assessment tools, and standardized discharge protocols to reduce the 38% rate of pain-related hospital readmissions.
1. Introduction: The Burden of Post-operative Pain
Post-operative pain remains a critical challenge, with over 80% of surgical patients experiencing pain and approximately 75% reporting it as moderate-to-severe. Beyond patient discomfort, uncontrolled pain has severe clinical consequences:
- Recovery Speed: Delayed ambulation leads to increased risk of Deep Vein Thrombosis (DVT), muscle loss, and prolonged hospital stays.
- Surgical Outcomes: Poor pain control can lead to atelectasis, pneumonia, and unplanned ICU admissions.
- Economic Impact: Inadequate analgesia adds an estimated 1.7–3.2 extra hospital days, significantly increasing costs.
- Patient Experience: Pain is the primary driver of patient dissatisfaction and the leading cause (38%) of unplanned hospital readmissions.
2. Current Landscape and Practice Gaps in Bangladesh
Insights gathered from healthcare professionals prior to the consensus meeting revealed significant systemic challenges:
- Inconsistency: Pain control varies widely between institutions and clinicians due to a lack of a simple, Bangladesh-specific protocol.
- Reactive Dosing: Reliance on “SOS” (as needed) orders leads to “catch-up” pain cycles where medication is given only after pain has peaked.
- Subjective Assessment: Clinicians often rely on subjective complaints rather than validated tools like the Numeric Rating Scale (NRS) or Visual Analogue Scale (VAS).
- Route Selection: There is a high dependence on the IV route (91.6% in some studies), with switches to oral or suppository routes often delayed until the 4th or 5th post-operative day.
3. Consensus Recommendations for Standardized Care
3.1 Proactive Assessment Tools The panel agreed that objective pain assessment is essential. While multiple scales exist (NRS, VAS, Oucher scale), a simplified model for busy wards is recommended: “Pain out of 10” combined with assessment during movement and vital sign monitoring.
3.2 The Multimodal Analgesia Framework Experts endorsed a multimodal approach combining pharmacological and non-pharmacological methods to achieve better relief with a lower drug burden. This includes:
- Rational Combination: Using different mechanisms (e.g., paracetamol, one NSAID, and local infiltration) rather than multiple drugs from the same class.
- Procedure-Specific Plans: Higher-trauma surgeries (e.g., laparotomy, thoracic surgery) require more structured, proactive plans than low-intensity procedures.
3.3 Definite Dosing (“By the Clock”) vs. SOS A central recommendation is the adoption of definite dosing in the first 24–48 hours.
- SOS Dosing (Suboptimal): Creates a “sawtooth effect” in plasma concentration, leading to analgesic gaps, patient anxiety, and slower recovery.
- Definite Dosing (Preferred): Administering medication at fixed intervals (e.g., every 8 or 12 hours) prevents pain escalation before it starts, allows the physician to control timing, and facilitates faster mobilization.
3.4 Role of Suppositories in Post-operative Care Rectal Diclofenac was identified as a practical tool, particularly for patients who are NPO (nothing by mouth), vomiting, or requiring night-time coverage.
- Duration: Diclofenac suppository provides 8–12 hours of action, significantly longer than IV Ketorolac (approx. 6 hours).
- Safety: Evidence suggests Diclofenac may be gentler on the kidneys and GI tract than other common NSAIDs for short-term use.
4. Risk Stratification and Safety
Analgesic selection must be patient-specific, considering age, weight, and comorbidities.
- Renal/GI Risk: Combining two or more NSAIDs must be avoided, as it can double the risk of Acute Kidney Injury (AKI).
- High-Risk Patients: Those with cardiovascular risks or undergoing CABG surgery require alternatives to NSAIDs.
5. Discharge and Follow-up
Discharge planning is often neglected, leading to readmissions. The panel recommends:
- Step-down Regimens: Shifting from parenteral to oral or suppository routes before hospital release.
- Clear Documentation: Prescriptions must define dose, timing, duration, and a clear rescue plan for breakthrough pain.
- Patient Education: Overcoming cultural taboos regarding certain routes (e.g., suppositories) through proactive counseling.
5. Conclusion and Future Directions
The Optima Pain Consensus emphasizes that a simple, procedure-aware, and safety-focused protocol is essential for Bangladesh. The proposed next actions include:
- Formation of a Steering Committee to guide the consensus document.
- Development of a Bangladesh-specific draft protocol focusing on assessment, scheduled dosing, and multimodal care.
- Implementation training for junior doctors, nurses, and ward staff to ensure standardized delivery of care.
By moving from a reactive to a proactive pain management model, healthcare providers in Bangladesh can significantly enhance surgical recovery and patient satisfaction.
Authors:
Expert Panel of the Optima Pain Consensus (Chair: Prof. M A Majid)