Background & Aims

The role of Acute Pain Service( APS) in management of post-operative pain is well established. Though the concept was introduced four decades earlier, APS is not well established globally, and in many countries the service is in the initial developmental stages(1). In our hospital, the Acute Pain Service was started back in 2002(2). We are a Government run tertiary Cancer center, with more than three thousand major surgeries and at least a thousand epidural catheter insertion annually(3). We have grown from a team of two members to a strong force manned by anesthesiologists and nurses. We share our experience over the last twenty years and hope this would provide immense insight and solutions to other centers with limited resources.

Methods

In this descriptive review the hurdles and home grown solution adapted has been enumerated. The challenges faced have been presented with relevant details; and supported with our publications, for better credibility. As this is a review of our experiences, Ethics permission has not been sought. No new patient data has been shared except from our pervious audits and publications which have been conducted after due ethical permission and necessary patient consent as applicable.

Results

After acceptance of the need and concept of APS by the head of department and Institute, a formal APS team was formed comprising of a consultant and trainee Anesthesiologists. The initial protocols for the APS were laid down (2). Regular audits(3-11) and lessons learnt from patients and our trials(12-20) helped us carve a robust plan for the team. Training of junior anesthesiologists about principles of acute pain management was essential to ensure smooth functioning of the service . We started our asynchronistic teaching program for students training using WhatsApp(21,22). In addition, we initiated our annual teaching program with the aim to increase awareness under the banner of ECAP- Education in Cancer and Acute Pain.(23) New modalities of pain relief for onco-surgeries were explored and adapted. (24-28) Nurse’s education and inclusion has been one of the new initiatives. Disease management protocols have been adapted for more inclusive participation from our surgical colleagues.

Conclusions

Our model has survived the challenges which were encountered in the initial years of APS building. The key problems include and are not limited to development of a pragmatic patient centric pain protocol, training of juniors and manpower issues. A strong teaching program and nurses inclusive approach is strongly recommended.

References

1.Jain PN, Bakshi SG, Thota RS. Acute Pain Service in India: A glimpse of the current scenario. J Anaesthesiol Clin Pharmacol 2015;31: 554-7
2.Jain PN, Chatterjee A. Development of acute pain service in an Indian Cancer Hospital. Journal of Pain & Palliative Care Pharmacotherapy.2010;24:129-135.
3.Bakshi SG, Jain PN, Sareen R. Audit of Complications of Postoperative epidural analgesia from an Indian Cancer Centre. Journal of Pain & Palliative Care Pharmacotherapy.2013; 27:35-38.
4.Jain PN, Behere A, Chatterjee A. ‘Potentiation of Postoperative Epidural Analgesia with the addition of epinephrine to bupivacaine and fentanyl mixture after major cavity surgery’. Ind J of Pain 2008; 22: 137-140
5.Bakshi SG, Jain PN, Sareen R. Patient Controlled Analgesia: redefining its role in an Indian cancer hospital. Journal of Pain and Palliative care pharmacotherapy. 2010;24: 213-218
6.Jain PN, Padole D, Bakshi S. Prevalence of acute neuropathic pain after cancer surgery: A prospective study. Indian J Anaesth 2014; 58: 36-42
7.Solanki SL, Katwale B, Jain AA, Chatterjee A, Gehdoo RP. Comparison of Continuous Epidural Analgesia and Intravenous Patient-Controlled Analgesia with Opioids in Terms of Postoperative Pain and Their Complications in Mega-Prosthesis Total Knee Arthroplasty for Bone Cancers. Indian J Surg Oncol. 2019 Sep;10(3):567-569. doi: 10.1007/s13193-019-00940-7. Epub 2019 May 23
8.Bakshi SG, Gehdoo RS. Incidence and management of post-dural puncture headache following spinal anaesthesia and accidental dural puncture from a non-obstetric hospital: A retrospective analysis. Indian J Anaesth 2018; 62:881-6.
9.Karkhanis DR, Bakshi SG, Divatia JV, Kannan S. Role of gabapentinoids in post operative pain management in thoracic surgeries: A single centre propensity score matched audit. Indian J Anaesth 2023;67: S35-40.
10.Bakshi SG, Gawri A, Panigrahi AR. Audit of pain management following emergency laparotomies in cancer patients: A prospective observational study from an Indian tertiary care hospital. Indian J Anaesth 2020; 64:470-6.
11.Gotur AJ, Chatterjee A,. Pain Severity and Quality of Life Following Major Mandibular Reconstructive Surgery in Head Neck Cancer. Indian Journal of Pain 37(1):p 20-26, Jan–Apr 2023. | DOI: 10.4103/ijpn.ijpn_80_22
12.V.S. Paulin, S.G. Bakshi, P.C. Hegde et al., Inkk Trial — Intraoperative ketamine for perioperativepain management following total knee endoprosthetic replacement in oncology: a double-blinded randomized trial, Brazilian Journal of Anesthesiology https://doi.org/10.1016/j.bjane.2021.07.014
13.Bakshi SG, Rathod A, Salunkhe S. Influence of interpretation of pain scores on patients’ perception of pain: A prospective study. Indian J Anaesth 2021; 65:216-20.
14.Bakshi SG, Paulin SV, Bhawalkar P.A randomised controlled trial to evaluate the peri-operative role of intraoperative dexmedetomidine infusion in robotic-assisted laparoscopic oncosurgeries. Indian J Anaesth 2020;64:784-9.
15.Kanaparthi AA, Raghunathan P, Chatterjee A. Successful management of an epidural abscess without surgical drainage at a tertiary care cancer centre. Indian J Anaesth 2019;63:594-6
16.Karan N, Bakshi SG, Patil V, Sayed A. Use of Thromboelastography for Solving Neuraxial Blockade Dilemma. Turk J Anaesthesiol Reanim 2019; DOI: 10.5152/ TJAR.2019.05695
17.Bakshi SG, Rajan G, Jain PN. Epidural analgesia information card averted permanent neurological sequelae. Indian J Anaesth 2017; 61: 597-8
18.Yadav A, Chatterjee AS, Gehdoo RP. Pregabalin for refractory postdural puncture headache. Journal of Anaesth Clinical Pharmacology 2015; 31 (2):258-60
19.Bakshi SG, Shetmahajan M, Dhurwe B. Ultrasound-aided thoracic epidural catheter insertion: Description of a feasible technique. J Anaesthesiol Clin Pharmacol 2023;39:659-60.
20.Bakshi, Sumitra G.; Kadam, Sonal; Shylasree, T. S.1. Predicting postoperative pain by using preoperative pain threshold in response to electrical stimulus in women undergoing gynaecological cancer surgery – Single-arm, prospective, observational study. Indian Journal of Anaesthesia 67(6):p 497-502, June 2023. | DOI: 10.4103/ija.ija_503_22
21.Bakshi SG, Bhawalkar P. Role of WhatsApp-based discussions in improving residents’ knowledge of post-operative pain management: a pilot study. Korean J Anesthesiol 2017; pISSN 2005-6419 • eISSN 2005-7563
22.Bakshi SG, Doctor JR, Trivedi B, Chatterjee AS, Thota RS, Jain PN. WhatsApp-based teaching module for acute pain management: a prospective educational project Can J Anesth/J Can Anesth 2019; 66:736–737
23.Bakshi SG, Jain PN, Kannan S. An assessment of basic pain knowledge and impact of pain education on Indian Anaesthesiologists- a pre and post questionnaire study. Indian J Anaesth 2014; 58:127-31
24.Bakshi SG, Mapari A, ShylasreeTS. Rectus Sheath block for post-operative analgesia in gynecological Oncology Surgery(RESONS): a randomized- controlled trial. Can J Anesth 2016; 63: 1335-44.
25.Bakshi SG, Awaskar S, Qureshi SS, Gala K. Continuous erector spinae plane block in pediatric patients with intraspinal tumors – Case reports. J Anaesthesiol Clin Pharmacol 2020; 36:558-60.
26.Bakshi SG, Doctor JR, Trivedi BD, Qureshi SS. Transversus abdominis plane catheters for postoperative pain relief in pediatric patients. J Anaesthesiol Clin Pharmacol 2017; 33: 121-2.
27.Bakshi SG, Pokhale S, Sharma S. Role of regional catheters for postoperative analgesia following reconstructive surgeries for breast cancer. Indian J Cancer 2016; 53: 243.
28.Bakshi S, Mapari A, Paliwal R. Ultrasound-guided rectus sheath catheters: A feasible and effective, opioid-sparing, post-operative pain management technique: A case series. Indian J Anaesth 2015; 59: 118-20.

Presenting Author

Sumitra Bakshi

Poster Authors

Sumitra Bakshi

MD; DNB( Anesthesia)

Tata Memorial Hospital, Mumbai, INDIA

Lead Author

Aparna Chatterjee

Tata Memorial Hospital and Homi Bhabha National Institute , Mumbai, INDIA

Lead Author

Parmanand Jain

Tata Memorial Hospital and Homi Bhabha National Institute , Mumbai, INDIA

Lead Author

Topics

  • Evidence, Clinical Trials, Systematic Review, Guidelines, and Implementation Science