the surgeon 8 (2010) 151158

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The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland
www.thesurgeon.net

Review

Factors contributing to poor post-operative abdominal pain management in adult patients: a review
Ahmad Al Samaraee*, Gill Rhind, Usama Saleh, Vish Bhattacharya
Department of General Surgery, Doctors Ofce-Ward 10, Queen Elizabeth Hospital, Sheriff hill, Gateshead NE9 6SX, UK

article info
Article history: Received 29 October 2009 Accepted 29 October 2009 Keywords: Acute abdominal pain Post-operative pain Pain Pain management Pain intensity Analgesia Pain killers

abstract
Post-operative abdominal pain management can be a major issue facing medical and nursing staff in daily clinical practice. Effective pain control reduces post-operative morbidity as well as facilitates rehabilitation and accelerates recovery from surgery. In turn, poor pain control has been shown to alter body metabolic response that can lead to delayed recovery, with subsequent prolonged hospital stay and increased morbidity, and can lead to the development of a chronic pain state. Despite the signicant developments in anaesthesia, delivery techniques and analgesia, post-operative abdominal pain management in adult patients remains suboptimal. Achieving effective pain management needs the implementation of an active approach in practice. This approach includes the provision of information and appropriate education tailored to the patients needs and level of understanding, with the aim of reducing patient anxiety and avoiding unrealistic expectations. In addition, medical and nursing staff should continuously use the appropriate pain assessment tools to evaluate of postoperative pain in the surgical wards. Pain assessment needs to be regarded as the fth vital sign and recorded on the patients observation chart. Analgesia should be used in a multimodal fashion and by the clock according to the patients needs. Moreover, governmental and professional guidelines need to be implemented to establish continuity of care, improve the quality of decision making and reduce unnecessary variations in practice Overall, there is a need for improved post-operative abdominal pain management in adults to enhance recovery, patient safety and reduce morbidity. This can be achieved with the appropriate education backed up with robust policies and guidelines, supported by up to date evidence. 2009 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Introduction
Acute pain has frequently been reported as undertreated, in 1994 it was revealed that 87% of 3000 patients in 36 NHS

hospitals reported moderate or severe pain,1 then in 2000 it was concluded that despite major improvements in pain assessment and management, post-operative patients continued to experience moderate to severe pain.2 More

* Corresponding author. Tel.: 44 191 4820000x2670; fax: 44 191 4456187. E-mail address: ahmadas@doctors.org.uk (A. Al Samaraee). 1479-666X/$ see front matter 2009 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.surge.2009.10.039

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recently, Sommer et al. stated in 2008, that 41% of 1490 surgical patients reported moderate to severe pain despite an acute pain protocol.3 In 1997, the UK Audit Commission proposed a standard that after 1997 fewer than 20% of patients should experience severe pain after surgery, and that by 2002 it should ideally be fewer than 5%.4 Pain is a highly subjective complex experience with multiple dimensions that are emphasised by the denition published in 1979 by the International Association for the Study of Pain (IASP); Pain is dened as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage5 and McCaffery in 1983; Pain is whatever the experiencing person says it is, existing whenever they say it does.6 Despite these denitions, there continues to be barriers to effective post-operative pain management with many personnel believing that pain is a natural, inevitable, acceptable and harmless consequence of surgery.7 It is now known that inadequate pain control coupled with the physiological stress of surgery can alter the metabolic response to trauma and increase sympathetic outow which can lead to increased heart rate, vasoconstriction and higher oxygen demands.8 These consequently can lead to a delayed recovery, with associated pulmonary dysfunction or infection and hypoxia; this can develop into cardiac ischaemia with restrictions on mobility and consequently higher risks of thromboembolism.9 Therefore a reduction in the surgical stress responses (endocrine, metabolic and inammatory) has been shown to reduce the incidence of post-operative organ dysfunction and hence, improves outcome.10 Recently there has been recognition of the interrelationship between acute pain, the injury response that initiated the pain and the effects of physical, psychological and social factors associated with the injury. The provision of multimodal analgesia together with intravenous nutrition and early mobilisation is capable of preventing the possible catabolism that is associated with major abdominal and thoracic surgery.11 In addition to this, there is a body of clinical evidence stating that acute pain can progress into a chronic pain state following surgery or trauma.12,13 This is thought to be due to the patho-physiological processes that occur after tissue and nerve damage. It is thought that changes occur in the peripheral nerves, spinal cord and higher central pathways following a barrage of afferent nociceptive activity. This is know as wind up and central sensitisation. It is thought that effective acute pain management may decrease the likelihood of this progression.14 Multiple factors have been identied as contributing to poor post-operative pain management, including insufcient education and training of doctors and nursing staff and poor communication at various levels. There is a lack of awareness of the availability and importance of clear systems and guidelines for recording the intensity of pain and efcacy of analgesia and a lack of patient education.15 The aim of this review is to explore the factors that could contribute to poor pain management in adult patients following abdominal surgery. This was achieved by examining the available literature and reviewing the evidence in order to identify the relevant issues.

Methods
Electronic search of databases (English language only): Pubmed-Medline, Ovid, Blackwell Synergy, Also Google Scholar and hand search. The keywords were acute abdominal pain, post-operative pain, pain, pain management, pain intensity, analgesia, pain killers. Searches were screened and those studies thought to be relevant had full text versions retrieved. The references of all retrieved texts were searched for further relevant studies.

Patient information
Patients expectations regarding pain and its management can be inuenced by information provided through the media, and/or through direct education messages provided by health professionals.16 Teaching adults pain communication skills and providing pain management information before surgery has been shown to result in greater pain relief during the early postoperative period.17 Psychoeducational care provided to adult surgical patients was shown to reduce pain and anxiety and have a positive effect on length of hospital stay and patient satisfaction.18 Patients also reported a signicant reduction in fear levels when given written information about postoperative pain and access to analgesia.19 In contrast, Chumbley et al. stated that the detailed provision of preoperative information had no signicant effect on pain relief.20 Other studies reported that the expectation of pain might give rise to anticipatory anxiety or even cause patients to delay or avoid seeking treatment. They reached the conclusion that memory for pain intensity appeared to be more accurate than for pain quality; however, they also conrmed the importance of reducing patients anxiety and avoiding unrealistic expectations of post-operative pain.21 All these studies suggest that patients need to be taught how to assess their pain so that they can communicate their pain and be made aware that they should ask for pain relief when needed. Patients should be assured that every attempt will be made to make them as comfortable as possible but that a pain score of zero may not be achievable. Patients should be informed about the surgical procedure, anticipated sensory experiences, analgesic treatment and the recovery period. Information and appropriate education should be given to each patient, tailored to their needs and level of understanding.22 This information should be given verbally but it could be reinforced with written information that patients can re-read at home. It is important to encourage patients to record their pain experience and/or discuss them with their clinicians (i.e. patients feedback).23

Pain assessment
Pain is a very individual and subjective experience with levels of pain threshold varying from one patient to another. Previous pain experiences, culture and background, as well as physical, psychological and biological factors all contribute to pain experience; therefore, pain should be reported according to the individual subjective response and documented as

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such. There are times when it may not be possible to obtain such self-reports of pain, for example in unconscious or confused patients, the elderly, and children and in situations where language is a barrier. In these conditions it can be possible to monitor associated factors like mechanical withdrawal threshold, plasma cortisol for stress response, coughing and ambulation for functional impairment, changes in heart rate, blood pressure, respiration rates and analgesic requirements.14 However, absence of specic pain behavior or absence of physiological indicators of pain does not mean absence of pain,24 since other pathologies like diabetes, and/or pharmacological mechanisms, such as beta blockers, could alter these responses. At other times there are discrepancies between a patients behavior and their self-report of pain. For the elderly it has been shown that there is a good correlation between unidimensional tools and behavioral measures in those who are cognitively intact, however for those with cognitive impairment, despite there being several assessment tools available, there is insufcient evidence of reliability or validity.25 The most reliable method to assess acute pain experience and intensity in adult patients is by patients self-report.14 There are several scales available; the visual analogue scale (VAS) is a clear, highly subjective scale that is of most value when looking at change within individuals.26 In addition it is easily understood and used by patients. Bijur et al. showed that the reliability of the VAS for acute pain measurement appeared to be high, the data from this study suggested that the VAS is sufciently reliable to be used to assess acute pain.27 The verbal numerical rating scale (VNRS-11) where the pain is rated on a scale between 0 and 10 is another way to measure pain intensity. It is the most commonly used tool in the post-operative period and performs as well as the VAS in assessing changes in pain intensity.28 Hartrick et al. noted that there was a linear relationship between the pain assessments of post-operative patients with thoracic or abdominal incisions during cough, but that there was no such correlation between the same post-operative patients at rest. In addition they also concluded that VNRS-11 should not be considered to be interchangeable with the VAS.29 The short form McGill Pain Questionnaire (SFMPQ) is generally used for research purposes or to assess chronic pain as it has been shown to express clear distinctions in pain qualities.30Despite this, some have shown it to be a valid and sensitive assessment tool for post-operative pain.31 Others, however, have pointed out that this method fails to assess the intensity of pain expressed verbally by patients32 and it can take a longer time to be completed by the patient when compared to the Verbal Numerical Rating Scale (VNRS-11). In practice verbal pain behavior is the main indicator of the patients need for analgesia. Patients are frequently asked to rate their pain whilst resting, whereas a better indicator of pain management would be the assessment of pain caused by physical activity such as coughing, deep breathing or moving. Pain assessment should be an ongoing process, being reassessed regularly during the treatment period, even if the patient appears pain free. The frequency of this assessment should be increased if there is poor pain control or if the pain stimulus or treatment interventions change such as before and after physiotherapy.33

Staff approach
Pain is a subjective phenomenon which clinicians consistently fail to identify as a priority.34 It is often thought to be an inescapable consequence of abdominal surgery. Several reports have shown a constant need to improve the quality of postoperative pain management35,14 and have provided clinical guidelines and quality programs in order to do so. The assessment of pain and response to pain relief in various situations like rest, cough, mobility and globally (i.e., overall evaluation from the end of surgery till discharge from the hospital), is inadequate and done differently by doctors and nursing staff.15

Nurses
Nurses play a major role in the treatment of post-operative pain management, due to the fact that although drugs are prescribed by doctors, they are administered by nurses. It has been found that the nursing staff had the theoretical knowledge about pain management but they lacked the ability to transfer it into action; the reasons were that nurses have either supercial knowledge or their knowledge was not well integrated or they follow the usual traditional habits of the ward rather than reecting on their own knowledge and experience in clinical practice. It was also found that nurses were relying heavily on their own judgement of patients pain levels instead of asking a direct question and using an assessment tool or were inadequately using the available pain assessment tools.36,37 This was conrmed by a recent study, when 40% of nurses said that they did not use VAS and did not assess pain at both rest and activity.38 Schafheutle et al. stated that nurses reported that analgesic prescribing was sometimes inadequate, or that doctors or the pain team were not always available. Another interesting fact from this study was that nurses did not ask patients a pain-related question during drug rounds, though this would be the optimum time for pain questioning, as it usually involves verbal communication with the patients more than one time per day.39 The most commonly mentioned reasons given were that patients were asleep, on epidural or patient controlled analgesia (PCA), or had recently had an analgesic; therefore the staff automatically assumed that the patient was either pain free or having maximum available analgesia. In some areas the pain score is included on the observation chart along with temperature, blood pressure, pulse, O2 saturations, respiratory rate and VNRS-11 as the fth vital sign,40 however, it is generally not checked regularly by nurses or doctors, especially in stable patients or patients who look pain free. The reasons expressed were work overload, absence of pain behavior or underestimation of the signicance of the fth vital sign.41 Nurses need to inform patients pre-operatively about likely post-operative pain, how it is going to be assessed and the importance of communicating their pain. Nursing education, in contrast, needs to educate nurses on the need to measure pain and the different approaches in assessing that pain, as well as empathy and empathic communication in relation to pain.42

Doctors
Doctors have less opportunity than nurses to assess pain as they only visit the patients for a short period of time, as a result,

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they do not witness the patients daily activity (like mobility, coughing and bathing) which is when pain usually occurs.15 Junior doctors; who were more ward based, lacked both knowledge and condence in prescribing analgesia for acute conditions, and that they responded differently to certain scenarios.43 Furthermore, it seemed that the junior doctors felt inadequate when they prescribed analgesia for acute onset pain.44 Many of the doctors surveyed felt that their undergraduate training in acute pain was insufcient and turned to seniors, nurses and drug formularies for help. Other factors reported to contribute signicantly to doctors underestimation of acute pain were work overload, making it harder for them to provide time to assess acute pain properly. This meant that they depended on communication with nurses for feedback,44 poor knowledge regarding various analgesics like maximum dosages, interactions and mechanisms of action; misconceptions and the persistence of some myths all continue to result in inadequate pain management. Fear of causing harm is a potent cause of under-treatment of pain, but is often overestimated by junior doctors leading to a hesitation in prescribing larger doses of opioids because of potential side-effects, particularly respiratory depression.45 As a consequence, junior doctors seek advice from their anaesthetic colleagues to optimise or change analgesia for acute uncontrolled pain or post-operative pain, which can lead to delays in pain control. One of the most documented reasons for deciencies in pain management is inadequate education of medical, nursing and allied health care staff. Education of junior medical staff should include all aspects of the management of pain, particularly the detrimental effects of unrelieved pain on the patients physiological outcomes following trauma or surgery, in addition to as patient wellbeing.7 The provision of guidelines and standardisations for simple as well as more advanced analgesic techniques would help to make pain relief safer and more effective by aiming to improve the quality of clinical decision making and reduce unnecessary variations in clinical practice.14,40

Fig. 1 WHO pain ladder.46

Analgesia
The management of acute abdominal pain continues to be unsatisfactory and problematic despite the introduction of novel drugs and analgesic techniques. According to the World Health Organization; If pain occurs, there should be prompt oral administration of drugs in the following order: nonopioids (aspirin and paracetamol); then, as necessary, mild opioids (codeine); then strong opioids such as morphine, until the patient is free of pain. To calm fears and anxiety, additional drugs adjuvants should be used. To maintain freedom from pain, drugs should be given by the clock, that is every 36 h, rather than on demand. This three-step approach of administering the right drug in the right dose at the right time is inexpensive and 8090% effective.46 This is known as the WHOs Pain Ladder (Fig. 1). It was originally developed for use in the eld of palliative care for pain experienced in cancer but is now widely used in the acute pain setting.47 Rhaman et al. stated that in the post-operative period or in acute severe abdominal pain, stronger parenteral analgesics (like Opioids) should be used as rst line then stepped down. In addition, adjuvant therapy (NSAIDs, NMDA (N-Methyl-D-Aspartate)-receptor agonist and Tricyclic antidepressants) can be used in all three steps.48

Although drugs are prescribed by doctors, they are administered by nurses and studies have shown that, in some cases, nurses tend to under administer analgesics.37 Ene and colleagues concluded that this was related to the discrepancies between patients and nurses assessment of pain and that active treatment was, related to nurses documentation rather than to patients scoring.38 The timing of administration is also an important factor with the WHO stating that analgesics be given regularly rather than PRN.46 During the peri-operative period analgesic therapy should be started in sufcient time as to be effective at the point of emergence from anaesthesia.49

Local anaesthetic
Local anaesthetic inltration when used in the incision, blocks the generation and conduction of nerve impulses within the peripheral and central nervous systems. Hence they are highly effective in alleviating post-operative pain when administered using either a peripheral nerve block technique and/or wound inltration resulting in a quicker post-operative recovery.50 More recently, the use of continuous delivery of local anaesthetic using various devices such as the Elastomeric infusion pumps has been investigated. These are being used in conjunction with a variety of catheters, usually with multiple openings so that the drug seeps into the tissues along the length of the wound. These catheters are designed to deliver drugs for up to ve days. The results of studies into continuous analgesic inltration for abdominal surgery are mixed, with some concluding that this technique is a useful, practical, and safe method for the management of postoperative pain after appendicectomy,51 while others concluded that it did not demonstrate any signicant clinical advantage over current best practice.52

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Enteral analgesia
It has been recommended that analgesia is used in a multimodal fashion in the post-operative period; this approach involves the combination of various analgesics such as paracetamol, NSAIDs, opioids and local anaesthetics, used in smaller doses to provide a better pain relief with fewer side effects and less need for opioids9,14,53. The role of oral route analgesia in acute abdominal pain or post-operative abdominal pain is variable. Oral analgesics are usually used when the patients condition is improved and oral intake recommenced. The rectal route requires patient consent but in most cases can be used immediately after some abdominal surgical procedures, such as rectal NSAIDs in groin hernia repair as a single dose in consented patients. In addition, rectal paracetamol or NSAIDs can be used on the surgical wards in some patients who are not allowed to eat or drink or are experiencing nausea and vomiting.54,55 Opioids alter smooth muscle activity leading to inhibition of bowel motility, constipation and delayed gastric emptying. This inhibition is both locally (due to effect on the opioid receptors in the bowel wall) and centrally mediated. Despite some decrease in bowel motility, it is not usually necessary or appropriate to withhold opioids to facilitate the return of bowel function after surgery as long as adequate uid intake, stool softeners and mobilisation is encouraged. Oral naloxone, or newer antagonists have been shown to reduce the effects of opioids on the bowel when titrated to still retain reasonable analgesia.14

Epidural analgesia
The epidural route of analgesia administration can result in equivalent or improved analgesia at doses lower than those required by a systemic delivery.60 The use of peri-operative epidural analgesia in vascular patients has been shown to attenuate hypercoagulability through a mechanism linked to cortisol levels.61 Evidence showed that epidural analgesia decreased the incidence of atelectasis and pulmonary infections in patients undergoing major abdominal procedures.62 Several studies have revealed that thoracic epidural local anaesthetic decreased recovery of GI activity by 2 or 3 days. This combined with early removal of nasogastric tubes, early oral feeding and early mobilisation has reduced post-operative ileus to less than 48 h in colorectal resection with primary anastomosis with subsequent early discharge.12,63

Transversus abdominis plane block

A substantial proportion of the pain experienced during both laparoscopic and abdominal surgery is from the nerve afferents that course through the transversus abdominus neurofascial plane.64,65 The Transversus Abdominis Plane (TAP) Block was developed to block the sensory nerves of the anterior abdominal wall before they pierce the musculature that innervates the abdomen.66 It has been shown to signicantly reduce the need for peri-and post-operative analgesia, therefore reducing the potential for side effects of drowsiness and post-operative nausea and vomiting. In addition, it was shown to demonstrate clinically useful levels of analgesia for at least 48hrs post-operatively.67 More recently this technique has been rened with the use of ultrasound which enables exact placement of the local anaesthetic between the internal oblique abdominal muscle and the transverse abdominal muscle leading to a signicant decrease in systemic analgesics when compared to standard general anaesthetic.68

Patient controlled analgesia

Morphine Patient Controlled Analgesia (PCA) is one of the common methods for pain control in the post-operative period following major abdominal surgery. There is evidence of a decreased risk of post-operative pulmonary complications, as well as improved patient satisfaction and a decrease in nursing time.56,10 Macintyre reported that PCA does not always provide optimal pain relief due to inadequate analgesia prior to commencement of the PCA and a lack of individualisation of PCA prescription to provide maximum benet for the patient.57 In addition, several studies have revealed a consistent lack of effect of PCA on surgical stress responses and organ dysfunction when compared with epidural analgesia techniques.58,59

Organisation
The NHS Constitution has established a right to choice regarding treatment; therefore patients require education and information in order to support that choice. Governmental and professional guidelines are available and should be implemented to establish continuity of care, improve the

Table 1 Main messages.

1. Patients need to be taught, to a level of their understanding, how to assess their pain and be made aware that they should ask for pain relief when needed with an assurance that every attempt will be made to make them as comfortable as possible but that a pain score of zero may not be achievable. 2. Pain assessment, using an appropriate assessment tool, should be an ongoing process, being reassessed regularly, even if the patient appears pain free. The frequency of this assessment should be increased if there is poor pain control or if the pain stimulus or treatment interventions change such as before and after physiotherapy. 3. Pain assessment should be included on the observation charts as the 5th vital sign. 4. Nursing education needs to emphasise on the need to measure pain and the different approaches in assessing that pain, as well as empathy and empathic communication in relation to pain. 5. Medical staff need to be educated on all aspects of the management of pain, particularly the detrimental effects of unrelieved pain on the patients physiological outcomes following trauma or surgery as well as patient wellbeing. 6. Analgesics need to be used in a multimodal fashion, combining analgesics by the clock rather than on demand. 7. Governmental and professional guidelines should be implemented to establish continuity of care, improve the quality of decision making and reduce unnecessary variations in practice.

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quality of decision making and reduce unnecessary variations in practice. The development of an Acute Pain Service within hospitals, as recommended by the Royal College of Surgeons of England and College of Anaesthetists in 1990,35 can lead to standardisation of pain treatments and equipment, develop medical and nursing practice and provide regular feedback of performance. Guidelines developed to enhance patient outcome and standardise analgesic techniques may lead to consistency of practice potentially improving patient safety and analgesic efcacy.14,69

Discussion and conclusion

Pain is a highly subjective complex experience with multiple dimensions which have been shown to be consistently undertreated. Acute abdominal pain can be a major issue facing medical and nursing staff as it has been shown to alter metabolic response, leading to delayed recovery with subsequent prolonged stay and increased morbidity. In addition it has been suggested that poor post-operative pain management can lead to the development of a chronic pain state through the process of wind up and central sensitisation. Many factors could contribute to poor post-operative pain management. These include insufcient pre-operative education for patients and carers. Nurses need to be aware of the important role they play in the assessment, treatment and evaluation of post-operative pain in the surgical ward using the appropriate tool for the individual patient. Assessment should be an ongoing process to ensure continuity and comparability over time, being performed during activity as well as at rest. Pain assessment needs to be regarded as the fth vital sign and recorded on the patients observation chart. Medical staff needs to develop both knowledge in the detrimental effects of unrelieved pain and the condence to prescribe analgesics in a multimodal fashion, combining analgesics by the clock rather than on demand. Even simple techniques for acute abdominal pain management can be more effective if attention is given to education, documentation, patient assessment and provision of appropriate guidelines and policies. In conclusion, post-operative abdominal pain management in adults continues to be a signicant problem in daily clinical practice; however, this problem can be addressed through the appropriate assessment, documentation and education of staff and patient in the effective use of the available analgesics and different modes of delivery (Table 1). These need to be backed up with robust policies and guidelines supported by up-to date-evidence.

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