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Biomedical Research

A prospective drug utilization evaluation of analgesics and pain assessment in postoperative urological patients in a Tertiary care hospital

Author(s): Swamy RM, Venkatesh G, Nagaraj HK

Vol. 21, No. 4 (2010-10 - 2010-12)

Swamy RM٭, Venkatesh G٭٭, Nagaraj HK٭٭٭

٭Department of Pharmacology, Sri Siddhartha Medical College, Tumkur, India
٭٭Department of Physiology, Sri Siddhartha Medical College, Tumkur, India
٭٭٭ Department of Urology, M.S.Ramaiah Medical College, Bangalore, India

Study conducted in, Department of pharmacology, M.S.Ramaiah Medical College, Bangalore.

Abstract

Drug utilization evaluation is a one time study to assess appropriateness of drug therapy. Pain is the most frequent cause of suffering and disability and impairs quality life. The management of post operative pain has long been recognized to be inadequate. Our study aims to evaluate drug utilization pattern and proper usage of analgesic to reduce the post operative pain in patients undergoing urological surgeries. A total of 208 patients underwent urological surgeries aged above 20 years were selected of which 168 were males and 40 were females. The study details were explained to the participants about the importance of pain management and also use of Visual Analog Scale (VAS). The post operative pain of the patient was assessed by VAS every 2hours on the Operative day, Post operative day 1 and Post operative day 2. We studied the analgesic utilization pattern in these patients and the intensity of pain relief with the analgesic prescribed on the Operative day, Post-operative day 1 and Post-operative day 2. The Mean pain scores were 4.29, 3.00 and 1.98 on Operative day, Post operative day 1 and Post operative day 2 respectively. Mean reduction in pain scores between males and females were almost similar. Though there was a slight higher pain scores in females on Operative day and Postoperative day 1 and slight decrease in pain scores on Postoperative day 2 compared to males. In our study, there is significant reduction in pain scores from operative day to postoperative day 2, implying that proper utilization of prescribed drugs can bring about a positive outcome.

Key words: Drug utilization evaluation, visual analog scale, surgery, post operative pain
Accepted June 17 2010

Introduction

Drug utilization evaluation is a structural process used to assess the quality of drug therapy by engaging in the evaluation of the data on prescribing, dispensing and/or patient used in a given health care environment against predetermined, agreed upon criteria and standards. Drug utilization evaluation is a one time study to assess appro-priateness of drug therapy. The purpose is to identify if current patterns of prescribing, dispensing and use of drug therapy are consistent with criteria and standards. These criteria and standards demonstrate the drug therapy is effective, safe, appropriate, and cost effective and support optimal patient outcome [1]. In 1964 World Health Or-ganization (WHO) organized a symposium on drug toxicology in Moscow, that serious considerations was first given to major public study in drug utilization [2]. Dr. P Siderius of Netherland and Dr.A Engel of Sweden col-lected data from various countries [3] and their findings laid before Oslo meeting on 1969 and lead to the formation of WHO Drug consumption group, later become the WHO Utilization Research group. This venture has been serving the interests of efficient, effective and safe medicine [2].

Pain is the most frequent cause of suffering and disability and impairs quality life of millions of people throughout the world. Studies shows that annually in the United States and in many other industrialized nations, 15-20% of populations have acute pain and 25-30% has chronic pain. In most instances acute painful disorders are cor-rectly diagnosed and effectively treated, but there is evi-dence that many patients with severe or very severe post operative and post operative traumatic pain and severe visceral pain are not effectively relieved. Pain assessment is the corner stone to optimal pain management. Pain assessment moves away from pure physical estimation of pain and includes psychological, social, spiritual and cul-tural dimensions [4]. Many people experience sub opti-mally managed post operative pain [5]. Despite many studies of post operative pain and its effects information is scanty about the severity, frequency and duration of pain that patients experience after common operations [6]. Improving postoperative pain control thought to result most efficient use of health resources and patient satisfac-tions with care and quality given [7]. Patient satisfaction is an important guide to success of post operative care. It includes post surgical costs, kinds of analgesics and medications used from admissions to discharge from the hospital [8]. The management of post operative pain has long been recognized to be inadequate Joint report from Royal College of Surgeons and College of Anaesthetists [9] recommended for the development of Acute Pain Ser-vice (APS) in all the hospitals undertaking surgery. A formal APS is an organization dedicated to the management of acute pain in surgical patients and other patients with acute pain. The APS has the responsibility for day today management of post operative pain and should pro-vide an organizational framework for an appropriate level of care and monitoring adjusted to the clinical condition of the patient and the technique used. The introduction of APS has led to an increase in the use of specialized pain relief methods, such as Patient Controlled Anaelgesia such as local Anaesthetics /opiod mixtures in surgical wards. Implementation of this methods may represent real advances in improving patients well being and in reduc-ing post operative morbidity [10]. There is a range of methods available, but the frequency and timing of pain assessment vary considerably. Multidimensional assess-ment, for example Chronic Pain Acceptance Question-naire (CPAQ) [11], The Stanford Health Assessment Questionnaire [12] and McGills pain questionnaires has been shown to produce consistent results but these are too complicated to use in immediate post operative period. In contrast, Visual Analog Scale (VAS) is easy to use and have been utilized widely by the investigators to quantify acute pain in post operative period. Moreover the reliabil-ity and reproducibility of the VAS have been studied ex-tensively [13]. For the interpretation of anesthetic, surgi-cal, or pain studies that use the VAS score as an assess-ment of outcome. VAS score represents a relative change in the magnitude of pain sensation. This enhances its clinical application [14].

Our study aims to evaluate drug utilization pattern and proper usage of analgesic to reduce the post operative pain in patients undergoing urological surgeries.

Material and Methods

The study was conducted in M S Ramaiah Hospital, a tertiary care hospital, Bangalore. For the study 208 pa-tients who underwent urological surgeries were selected. Patients aged >20 years of which 168 were males and 40 were females. Details collected from their inpatient files which included Name, age, sex, Inpatient number. De-tailed data like diagnosis, date of surgery, time of surgery, duration of surgery, pre anesthetic medication details of anesthesia including type of anesthesia, drugs used were noted. Ethical clearance obtained from M S Ramaiah medical college ethical committee. The study details were explained to the participants about the importance of pain management and also use of Visual Analog Scale (VAS). VAS is used commonly to quantify pain in clinical inves-tigation. The principle of VAS was too explained to all the patients on the day before surgery. The VAS consisted of a hundred millimeter line on aA4 paper. It contain reading from 0 to 10, where 0 indicated ‘No pain at all’ which is printed on the extreme left of the line and 10 indicated ‘severe uncontrollable’ pain on the right. Measurement of pain intensity is of vital concern to researchers and clinicians. Since it is a subjective experience only those experiencing pain can determine it s severity and adequacy of its relief. Subjective method of relief is there for VAS most valid and is particularly widely employed [15].

Before surgery the patients were explained about use of VAS. The post operative pain of the patient was assessed by VAS every 2hours on the Operative day, Post opera-tive day 1 and Post operative day 2. A new VAS sheet was used for each time for assessment of pain so that pa-tients were unable to refer to their previous scores. The study was conducted on analgesic utilization pattern in the patient and the intensity of pain relief with the analgesic prescribed on the Operative day, Post operative day 1 and Post operative day 2. For the adequate post operative pain relief appropriate analgesic used. This can be done based on the type of surgery patient undergone. Both males and females were prescribed the same analgesic. On the day of surgery 167 patients were prescribed single drug, 39 prescribed two drug combination and 2 pre-scribed three drug combination. In our study of patients were prescribed single drug and Non-opiods were most commonly prescribed. Addition of an Opiod with a Non-opiod offers additional helping to control patient suffer-ing. The commonest combination was Non-opiod (Di-clofenac sodium) along with an Opiod (Tramadol). Prescription pattern was same between males and females. Analgesics prescribe by the doctors were cross checked with nurses file to confirm the proper utilization of pre-scribed drugs. We studied the analgesic utilization pat-tern in these patients and the intensity of pain relief with the analgesic prescribed. Readings were recorded and results were drawn. Statistical Analysis was by Chi-square test for categorical analysis and student ‘t’ test for comparison. A p value of 0.05 is less (p < 0.05) was con-sidered for statistical significance.

Results

We studied the analgesic utilization pattern in these pa-tients and the intensity of pain relief with the analgesic prescribed on the Operative day, Post-operative day 1 and Post-operative day 2. Readings were recorded and results were drawn.

Table 1 Pain scores

 
TOTAL No. of Patients (N=208)
Observation Mean Standard
Deviation
1 Operative day 4.29 0.93
2 I post operative day 3.00 0.99
3 II post operative day 1.98 1.12

Paired ‘t’ test
Between 1 & 2
2 & 3
2 & 3
t = 21.31٭٭
t = 17.31٭٭
t = 30.14٭٭

٭٭ Statistically Significant

Table 2 Sex wise Impact on Pain Analysis

Observation Males(N=178) Females(30) Students ‘t’ test
Mean Standard
Deviation
Mean Standard
Deviation
1 Operative day 4.25 0.95 4.30 1.12 0.23 NS
2 Post operative day 1 3.02 1.01 3.10 1.24 0.34 NS
3 Post operative day 2 2.00 1.11 1.97 1.38 0.11 NS

Paired ‘t’ test
Between 1 & 2
2 & 3
2 & 3
t = 16.58٭٭
t = 14.95٭٭
t = 25.44٭٭
t = 5.43٭٭
t = 7.20٭٭
t = 9.67٭٭
NS : Not significant ٭٭ : Statistically Significant

Figure 1

Figure 1 Pain scores

Table 1 and Figure-1 shows that total mean reduction in pain scores was seen on the Operative day, Post operative day 1 and Post operative day 2.Our study showed the mean pain scores on the day of surgery was 4.29 that reduced to 3.00 on the Post operative day 1 and to 1.98 on Post operative day 2 which is statistically significant. When Chi—square test is applied findings reveals the significant difference in the pain scores between Operative day and Post operative day 1 (21.31), Post operative day 1 to Post operative day 2 (17.31) and Operative day to Post operative day 2 (30.14).

Figure 2

Figure 2 Sex wise Impact on Pain Analysis

Table 2 and Figure-2 shows sex wise impact on pain analysis. There is Mean reduction in pain scores between males and females were almost similar. Though there was a slight higher pain scores in females on Operative day and Postoperative day 1 and slight decrease in pain scores on Postoperative day 2 compared to males. Student ‘t’ test on pain analysis between males and females on operative day, postoperative day 1and postoperative day 2 were found to be non significant.

Paired ‘t’ test on analysis among males on operative day and postoperative day 1, and postoperative day 2, and also between operative day and postoperative day 2 was found to be highly significant. (p < 0.01) Paired ‘t’ test on pain analysis among females on operative day and postoperative day 1 and postoperative day 1 and postoperative day 2, was found to be highly significant. (p < 0.01)

Discussion

Pain assessment moves away from pure physical estima-tion of pain and includes psychological, social, spiritual and cultural dimensions [4]. Many people experience sub optimally managed post operative pain5. The introduction of APS has led to an increase in the use of specialized pain relief methods, such as Patient Controlled Anaelgesia such as local Anaesthetics /opiod mixtures in surgical wards. Implementation of this methods may represent real advances in improving patients well being and in reducing post operative morbidity10. We studied about the analgesic utilization pattern in these patients and the intensity of pain relief with the analgesic prescribed on the Operative day, Post-operative day 1 and Post-operative day 2.

Gould [16] in his study show that the introduction of an APS in all general wards led to considerable improvement in the level of post operative pain relief. Introduction of an Acute Pain Service (APS) led to considerable reductions in the level of post operative pain [16,17]. In our study there is mean reduction in pain scores was seen on the Operative day, Post operative day 1 and Post operative day 2 in both male and females.

Research showed sex-based differences in pain perception and treatment. There are complex factors contributing to differences in pain and analgesic responses between males and females. Gear RW, Gordon NC et al [18] showed definite gender difference in analgesic response. Paller CJ, Claudia M, Dobs AS. et al [19] reported that women experience greater clinical pain, suffer greater pain-related distress, and show heightened sensitivity to experimentally induced pain compared with men.

In our study there is mean reduction in pain scores between males and females were almost similar. Though there was a slight higher pain scores in females on Operative day and Postoperative day 1 and slight decrease in pain scores on Postoperative day 2 compared to males.

Summary and conclusion

Pain is an important dimension of post operative experience for most people and many patients continue to experience moderate to severe pain after surgery. Proper management of pain remains one of the most pressing issues of society in general and Health professionals in particular.

Pain is subjective sensation and difficult to measure. Nevertheless it is important to quantify it as reproducibly as possible. it has been stressed again recently that pain should be assessed routinely in post operative period.

In our study, we observed that there was proper utilization of prescribed analgesics. Also there was a statistically significant reduction in pain scores from operative day to postoperative day 2, implying that proper utilization of prescribed drugs can bring about a positive outcome.

Pain analysis should be done routinely for post operative patients undergoing surgeries.

1. Acute pain service clinics should be established in all major hospitals undertaking surgeries. There is also scope in this setting to educate staff and patients regarding pain and its management.
2. Drug utilization evaluation studies should be done on large a scale which provides information about recent trends in drug usage, factors that influence the prescribing patterns of Health Professionals. They also give information whether clinical trails have had an influence on day-to-day practice of prescribing doctors.

Limitations

It is a short term study and requires follow up studies. Patients respond differently to different pain medications which require further study.

References

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  17. Wheatley RG, Madej TH, Jackson JB and Hunter D et al. The first five years experience of an Acute Pain Service. British Journal of Anaesthesia.1991; 67: 353-359.
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Correspondence:
Swamy R.M.

Department of Pharmacology
Sri Siddhartha Medical College
Tumkur-572106, India
E-mail: dr.swamyrm(at)gmail.com

Biomedical Research Volume 21 Issue 4
Biomedical Research 2010; 21 (4): 401-405

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