Clinical Practice of Deliberate Postoperative Analgesia in Paediatric Patients

  Deliberate postoperative analgesia (DPA) has four essential elements: methodical prescription of the necessary analgesics, systematic assessment of the analgesic demand, planned preventive or therapeutic intervention according to the pain assessments and systematic documentation of the whole process. It is still unclear in which of these elements clinically relevant shortcomings or mistakes appear and what are the consequences. Thus by using a representative sample we studied which mistakes within the DPA influence the effectiveness of the postoperative analgesia in paediatric patients. Methods  As of March 2001 the DPA was introduced into clinical practice at the University Clinic for Paediatric Surgery, Ruhr University Bochum. It consists of a methodical prescription following a fixed scheme on the use of basic analgesics (Paracetemol, Metamizol and Diclofenac) and rescue analgesics (Ketamine, Talvosilen and Piritramide), a systematic age‐related assessment of the analgesic demand at fixed time intervals (CHIPPS, Bieri scale, VAS)(1,2), application of the analgesics by the nursing staff on the wards according to the prescriptions and to the pain assessments and a systematic formal documentation of all data of the whole process. In a prospective study of all 351 children aged between 1 day and 16 years, who were treated consecutively in a period of 6 weeks at the Clinic for Paediatric Surgery of the Ruhr University Bochum, the documentation of the postoperative analgesic treatment was collected. The following problems were investigated:•  whether the age‐related systems for the assessment of pain were correctly selected and applied, •  whether the analgesic demand was completely documented on the ward, •  whether the prescription of basic and rescue analgesics complied with the proposals of the fixed scheme, •  whether the applications on the wards conformed with the prescriptions •  which deviation from the standardised process had an influence on the effectiveness of the DPA.DPA was defined as effective if the children had no analgesic demand postoperatively or if an existing analgesic demand was recognised and successfully treated by the application of the rescue analgesic. Results  15 anaesthetists gave the anaesthetics. The patients were treated on 2 wards. The surgical procedures comprised the whole spectrum of paediatric surgery with the exception of open heart surgery. 28 patients required postoperative intensive care, one patient followed a special nurse‐controlled analgesia. All DPA documents on 285 patients could be collected (return rate 82%). In 68.4% the basic analgesic was sufficient, in additional 23.2% the rescue medication was effective. In 4.2% the DPA was ineffective and in another 4.2% it was not possible to assess the effectiveness of the DPA because of insufficient documentation. The following proportional deviations from the standardised procedures occurred ( Table 1). 1MetNot metInfluence on
effectiveness
of the DPASignificancePain scale correctly selected: 97.5 2.5 No Not significant Prescription according to scheme: 80.4 19.6 Impairment P < 0.001 Application according to prescriptions: 63.5 36.5 Impairment P < 0.001 Systematic documentation 84.5 15.5 Impairment P < 0.001Discussion  Deviations from the fixed scheme impair the effectiveness of the DPA. Thus it cannot be claimed that the deviations were always targeted and occurred according to the demands of the individual case. Lack of documentation is due to an irregular survey of the patient. If an analgesic demand is not identified and/or documented, a therapeutic consequence or intervention will be missed. This influences the effectiveness of the DPA. Conclusion  To ensure the success rate of the DPA in paediatric patients, systematic, complete documentation is just as necessary as the systematism of the preventive and therapeutic treatment.