Pain severity and pain control following intracranial surgery
Keywords:
pain severity, pain control, tramadol, intracranial surgeryAbstract
Objective To explore the incidence and severity of acute post-craniotomy pain in Maharaj Nakorn Chiang Mai Hospital, including the adequacy of routine pain relief practices.
Methods Postoperative analgesia prescribed for patients undergoing elective intracranial surgery was classified into two surgical groups: the supratentorial and the infratentorial approaches. Demographic and perioperative clinical data, including the use of a scalp block and the dosage of fentanyl, were collected and analysed. Postoperative pain was assessed for three days following surgery using a numeric rating scale (NRS) or a revised non-verbal pain scale (NVPS-R). Pain medication treatment and side effects were recorded.
Results Of 251 patients, 190 underwent a supratentorial craniotomy, while 61 were treated with an infratentorial approach. On the first postoperative day, the incidence of a NRS score ≥4 (moderate to severe pain) was 18.2-31.8% with NRS versus 6.4-11.1% for NVPS-R. The incidence of a pain score of zero gradually increased over time, reaching 100% in patients assessed with NVPS-R and 87% in those with NRS on day three. In the infratentorial group, a pre-incisional scalp block decreased pain scores upon arrival at the ward and for the first four-hour period after surgery (p=0.05 and 0.042, respectively). Over 90% of patients were prescribed intravenous tramadol every six hours on postoperative day one, but only 60% were given tramadol during the first 8-16 hours in the supratentorial group, while 75% of the infratentorial group received tramadol (p=0.021).
Conclusion Pain after intracranial surgery was effectively relieved with tramadol. NVPS-R should be investigated further to confirm its reliability as a tool for non-verbally communicating patients.
References
2. De Benedittis G, Lorenzetti A, Migliore M, Spagnoli D, Tiberio F, Villani RM. Postoperative pain in neurosurgery : a pilot study in brain. Neurosurgery. 1996;38: 466-70.
3. Dunbar PJ, Visco E, Lam AM. Craniotomy procedures are associated with less analgesic requirements than other surgical procedures. Anesth Analg. 1999;88:335-40.
4. Gottschalk A, Yaster M. The perioperative management of pain from intracranial surgery. Neurocrit Care. 2009; 10:387-402.
5. Hansen MS, Brennum J, Moltke FB, Dahl JB. Suboptimal pain treatment after craniotomy. Dan Med J. 2013; 60: A4569.
6. Gottschalk A, Berkow LC, Stevens RD, Mirski M, Thompson RE, White ED, et al. Prospective evaluation
of pain and analgesic use following major elective intracranial surgery. J Neurosurg. 2007;106:210-6.
7. Mordhorst C, Latz B, Kerz T, Wisser G, Schmidt A, Schneider A, et al. Prospective assessment of postoperative pain after craniotomy. J Neurosurg Anesth. 2010; 22: 202-6.
8. Morad AH, Winters BD, Yaster M, Stevens RD, White ED, Thompson RE, et al. Efficacy of intravenous patient-controlled analgesia after supratentorial intracranial surgery: a prospective randomized controlled trial. J Neurosurg. 2009;111:343-50.
9. Cold GE, Felding M. Even small doses of morphine might provoke “luxury perfusion” in the postoperative period after craniotomy. Neurosurgery. 1993;32:327.
10. Ostermann ME, Keenan SP, Seiferling RA, Sibbald WJ. Sedation in the intensive care unit: a systematic review. JAMA. 2000;283:1451-9.
11. Nemergut EC, Durieux ME, Missaghi NB, Himmelseher S. Pain management after craniotomy. Best Pr Res Clin Anaesthesiol. 2007;21:557-73.
12. Zacko C, LeRoux P. Perioperative neurosurgical critical care. Neurocritical Care Society Practice Update. 2013.
13. Jeffrey HM, Charlton P, Mellor DJ, Moss E, Vucevic M. Analgesia after intracranial surgery: a double-blind, prospective comparison of codeine and tramadol. Br J Anaesth. 1999;83:245-9.
14. Rahimi SY, Alleyne CH, Vernier E, Witcher MR, Vender JR. Postoperative pain management with tramadol after craniotomy: evaluation and cost analysis. J Neurosurg. 2010;112:268-72.
15. Haldar R, Kaushal A, Gupta D, Srivastava S, Singh PK. Pain following craniotomy: reassessment of the available options. Biomed Res Int. 2015;2015:1-8.
16. Vickers M, O’Flaherty D, Szekely SM, Read M, Yoshizumi J. Tramadol: pain relief by an opioid without
depression of respiration. Anaesthesia. 1992;47:291-6.
17. Sudheer PS, Logan SW, Terblanche C, Ateleanu B, Hall JE. Comparison of the analgesic efficacy and respiratory effects of morphine, tramadol and codeine after craniotomy. Anaesthesia. 2007;62:555-60.
18. Breivik H, Borchgrevink PC, Allen SM, Rosseland LA, Romundstad L, Breivik Hals EK, et al. Assessment of pain. Br J Anaesth. 2008;101:17-24.
19. Kabes AM, Graves JK, Norris J. Further validation of the nonverbal pain scale in intensive care patients. Crit Care Nurse. 2009;29:59-66.
20. Odhner M, Wegman D, Freeland N, Steinmetz A, Ingersoll GL. Assessing pain control in nonverbal critically ill adults. Dimens Crit Care Nurs. 2003;22:260-7.
21. Wegman DA. Tool for pain assessment. Crit Care Nurse. 2005;25:14-5.
22. Verchère E, Grenier B, Mesli A, Siao D, Sesay M, Maurette P. Postoperative pain management after supra-
tentorial craniotomy. J Neurosurg Anesth. 2002;14:96-101.
23. Hansen MS, Brennum J, Moltke FB, Dahl JB. Pain treatment after craniotomy : where is the (procedure-specific) evidence ? A qualitative systematic review. Eur J Anaesthesiol. 2011;28:821-9.
24. Kim YD, Park JH, Yang S, Kim IS, Hong JT, Sung JH, et al. Pain assessment in brain tumor patients after elective craniotomy. Brain Tumor Res Treat. 2013;1:24-7.
25. Klimek M, Ubben JFH, Ammann J, Borner U, Klein J, Verbrugge S. Pain in neurosurgically treated patients: a prospective observational study. J Neurosurg. 2006; 104:350-9.
26. Quiney N, Cooper R, Stoneham M, Walters F. Pain after craniotomy. A time for reappraisal? Br J Neurosurg.
1996;10:295-9.
27. Flexman AM, Ng JL, Gelb AW. Acute and chronic pain following craniotomy. Curr Opin Anaesthesiol. 2010; 23:551-7.
28. Talke PO, Gelb AW. Postcraniotomy pain remains a real headache! Eur J Anaesthesiol. 2005;22:325-7.
29. Thibault M, Girard F, Moumdjian R, Chouinard P, Boudreault D, Ruel M. Craniotomy site influences
postoperative pain following neurosurgical procedures: a retrospective study. Can J Anesth. 2007;54:544-8.
30. Ortiz-Cardona JR, Bendo AA. Perioperative pain management in the neurosurgical patient. Anesthesiol Clin. 2012;30:655-74.
31. Ayoub C, Pharm B, Boudreault D, Chouinard P, Ruel M, Moumdjian R, et al. A Comparison between scalp nerve Block and morphine for transitional analgesia after remifentanil-based anesthesia in neurosurgery. Anesth Analg. 2006;103:1237-40.
32. Tuchinda L, Somboonviboon W, Supbornsug K, Worathongchai S, Limutaitip S. Bupivacaine scalp nerve block: Hemodynamic response during craniotomy, intraoperative and post-operative analgesia. Asian
Biomed. 2010;4:243-51.
33. Vadivelu N, Kai AM, Tran D, Kodumudi G, Legler A, Ayrian E. Options for perioperative pain management in neurosurgery. J Pain Res. 2016;9:37-47.
34. Topolovec-Vranic J, Gélinas C, Li Y, Pollmann-Mudryj MA, Innis J, McFarlan A, et al. Validation and evaluation of two observational pain assessment tools in a trauma and neurosurgical intensive care unit. Pain Res Manag. 2013;18:107-14.
35. Wibbenmeyer L, Sevier A, Liao J, Williams I, Latenser B, Lewis R, et al. Evaluation of the usefulness of two established pain assessment tools in a burn population. J Burn Care Res. 2011;32:52-60.
36. Herr K, Coyne PJ, McCaffery M, Manworren R, Merkel S. Pain assessment in the patient unable to self-report: position statement with clinical practice recommendations. Pain Manag Nurs. 2011;12:230-50.
37. Stites M. Observational pain scales in critically ill adults. Crit Care Nurse. 2013;33:68-78.
38. Rhen T, Cidlowski J a. Antiinflammatory action of glucocorticoids--new mechanisms for old drugs. N Engl J Med. 2005;353:1711-23.
39. Scott LE, Clum GA, Peoples JB. Preoperative predictors of postoperative pain. Pain. 1983;15:283-93.
40. Morin C, Lund JP, Villarroel T, Clokie CM, Feine JS. Differences between the sexes in post-surgical pain. Pain. 2000;85:79-85.
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