Background & Aims

The choice of route for postoperative analgesia administration affects efficacy and cost-effectiveness of postoperative pain management strategies, as well as patient comfort. Following surgery, when patients can ingest liquids again, current guidelines prioritize the oral route (PO) over intravenous (IV), citing its convenience, non-invasiveness, and cost-effectiveness while maintaining comparable efficacy. The intramuscular route (IM) is discouraged for causing discomfort and unreliable absorption, resulting in inconsistent pain relief. Furthermore, immediate-release opioids are favored over modified-release formulations for easier titration [1-4]. We aimed to evaluate whether clinical practice aligns with current guidelines and to explore the economic implications of any potential misalignment.

Methods

We conducted a secondary analysis of data collected using the PAIN OUT methodology in 10 Serbian hospitals [5]. This involved 2,354 adult patients who underwent various surgical procedures. They were followed-up during their stay in surgical wards for the initial 24 hours after surgery. We analyzed the proportion of patients receiving non-opioid and opioid analgesics via the PO, IV, and IM routes in the entire cohort and in a subgroup of patients in whom administration of analgesics via PO route was regarded feasible. The PO route was not considered feasible in patients undergoing gastrointestinal, pancreatic and hepatobiliary surgery except for laparoscopic cholecystectomy. In this subgroup, we estimated the projected savings if the PO route was utilized instead of the IV or IM. Costs of analgesic therapy accounted for the medications, related disposables and staff labor.

Results

The IV route was utilized for administering non-opioids in 2,043 (87%) patients and opioids in 917 (39%) patients. The IM route was employed in 156 (7%) patients for non-opioids and 91 (4%) patients for opioids. Ten (1%) patients received oral analgesics, all as immediate-release formulations. Within the subgroup of 1,759 patients in whom the PO route was deemed feasible, the IV route was employed in 1,512 (86%) patients for non-opioids and 649 (37%) patients for opioids. In the same subgroup, 129 (7%) patients received IM injections of non-opioids and 86 (5%) of opioids. Costs of parenteral analgesics averaged at 822.3 RSD (7.94 USD) per patient, while projected costs of oral analgesics were significantly lower, at 124.5 RSD (1.19 USD) per patient, resulting in an average projected savings of 85%.

Conclusions

Our findings reveal a widespread reliance on IV administration for postoperative analgesics. The limited use of oral analgesics, especially in patients regarded as eligible, underscores a notable disparity between practice and guidelines. The prevalence of the IM route is cause for concern. Moreover, the substantial projected cost savings associated with oral analgesics highlights the importance of aligning practice with evidence-based recommendations. As a next step, we plan to expand the analysis to include data from multiple countries within the international perioperative PAIN OUT registry. This could provide crucial insights into international adherence to postoperative pain management guidelines and enable future improvement.

References

1. Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain 2016; 17: 131-57.
2. (NICE) NIfHaCE. Perioperative care in adults [N1] Evidence reviews for managing acute postoperative pain [ NG180]. , 2020.
3.Aubrun F, Nouette-Gaulain K, Fletcher D, et al. Revision of expert panel’s guidelines on postoperative pain management. Anaesth Crit Care Pain Med 2019; 38: 405-11.
4.Schug SA, Palmer GM, Scott DA, Alcock M HR, Mott JF, College WGotAaNZ. Acute Pain Management: Scientific Evidence. Melbourne: ANZCA & FPM, 2020.
5.Stamenkovic D, Baumbach P, Radovanovic D, et al. The Perioperative Pain Management Bundle is Feasible: Findings From the PAIN OUT Registry. Clin J Pain 2023; 39: 537-45.

Presenting Author

Ruth Zaslansky

Poster Authors

Suzana Bojic

MD

University Clinical Hospital Centre “Dr. Dragisa Misovic – Dedinje“, Belgrade, Serbia

Lead Author

Ruth Zaslansky

DSc

Jena University Hospital

Lead Author

Winfried Meissner

Jena University Hospital, Friedrich Schiller University, Jena, Germany

Lead Author

Ulrike Stamer

MD

Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

Lead Author

Philipp Baumbach

PhD

Jena University Hospital, Friedrich Schiller University, Jena, Germany

Lead Author

Dusica Stamenkovic

Medical Faculty of Military Medical Academy, University of Defense Belgrade, SERBIA

Lead Author

Topics

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