E Gora, A Spacek, FX Neiger, J Jarosz, HG Kress
Depts of Anaesthesiology (B) University of Vienna, A-1090 Vienna, Waehringer Guertel 18-20, Austria and Anaesthesiology of Institute of Oncology in Warsaw, Poland

Aim of Investigation: A prospective, randomised, double-blind comparison of the infusion of tramadol combined with dipyrone (an i.v. non-opioid drug) versus tramadol alone or placebo in postoperative pain management.

Methods: Ninety patients were allocated to three groups. In group 1 patients received continuously over 24 postoperative hours the 500 ml infusion contained 2.5 mg DHB (dehydrobenzperidol) as an antiemetic and 600 mg tramadol, in group 2, 2.5 mg DHB, 600 mg tramadol and 4 g dipyrone, in group 3 only 2.5 mg DHB. For all patients a PCA device was setted with 1 mg morphine per demand and a lock-out interval of 6 mm as a rescue. Pain in rest and during the movement was measured with visual analogue scale (VAS) for 24 hours

Results: A significant pain relief occurred in all three groups dunng the 24 hour study period, both in rest and during the movement (due to the availability of the PCA regime).
The consumption of morphine was significantly lower in patients in group 2 (tramadol and dipyrone) than in the groups 1 and 3, but also in group 1 (tramadol) than group 3 (placebo).

Conclusions: The combination of the two drugs (the non-opioid and the weak opioid) with their different analgesic properties and mechanisms provides better analgesic effect than tramadol alone or placebo, and has no severe or threatening side effects when combined with DHB. Because of its safety and simple dosage, it can be recommended on peripheral wards as well as in POCR.

QUALITY CIRCLES - A MODEL FOR ORGANISATION
Susanne Pedersen, secretary & Gitte Handberg. Department of Anaesthesia, Odense University Hospital, 5000-Denmark.

Introduction: This paper introduces a method for quality development. With 1200 beds, 27.000 operations a year, 10% of which need epidural block in the postoperative period it takes a relatively firm organisation plan to secure quality - quality plans.

Method: In co-operation with surgeons and anaesthetists -the audit group - plans for the pain treatment and rehabilitation for a group of patients is elaborated. The goal is to mobilise and exercise as expected. The nurses are trained by the acute pain service (APS) to implement basic pain treatment principles and to compile data in the wards. Collected data is gathered in APS and periodically presented for the audit group. After analysing and adjusting a new quality circle is started.

Results: The model has so fare involved 1000 patients per year. The patients are once a day checked for level of the epidural block and are asked about pain, using VAS-scores 4-6 times a day. Example 1: It was registered that 80% of the patients undergoing knee alloplasty had a misplaced epidural block. After analysing and implementation of new treatment this was reduced to 10%. Example 2: Patients undergoing back stabilising operations had a similar rate for misplacement but after several rounds in the quality circle treatment is not radically improved.

Conclusion: This organisation model makes it possible to handle and estimate quality development in the postoperative period. By handling patients in diagnostic groups, identifying problems in the treatment, analyse and evidence based improve the treatment it is possible with few resources to handle many patients.

QUALITY IN THE POSTOPERATIVE PAIN TREATMENT - A TOOL
Inger Skaarup, R.N. & Gitte Handberg. Acute Pain Unit, Department of Anaesthesia, Odense University Hospital, DK-5000 Denmark.

Aim of study: We present a tool for quality development in the postoperative pain treatment and rehabilitation of patients with epidural block. Clinically there is a need for quality development in the postoperative pain treatment and especially in the patients treated with epidural regional block.

Method: A pain chart was created for data registration. We isolated a set of data to describe 3 phases: 1) Pain treatment in the peroperative, 2) early postoperative period and 3) later postoperative period. The pain chart was introduced to the operation units concerned, to the recovery room and finally to the surgical wards and concurrently a database for storing and handling data was built up. Periodically, each unit and ward receives a report as a feedback on the quality of treatment.

Results: The peroperative registration has guided the clinicians in placing the epidural catheters correctly in relation to the cicatrix and has led to the suggestion that the surgeon preoperatively on the pain chart note the coming incision. In phase 2 the pain sheet functions as a filter to ensure that patients leave the anaesthesiology area with sufficient pain treatment. The third is correlated to rehabilitation plans in the surgical wards.

Conclusion: The pain chart brought into focus the quality of the postoperative treatment. The costs of time spend on data registration is positively balanced with the benefits in form of a quality lift and more transparency in decision making.

FACTORS INFLUENCING PATIENT SATIS-FACTION WITH POSTOPERATIVE PAIN MANAGEMENT
Hengo Haljamae. Ingrid Svensson, Bjom Sjostrom, Departments of Anaesthesiology and Intensive Care, Sahlgrenska University Hospital, and Health Care Pedagogics, Goteborg University, Goteborg, Sweden

Aim of investigation: To describe pain experiences of surgical patients after elective procedures and to assess the association between patient related variables, the actual clinical pain management and patient satisfaction.

Methods: Pain was assessed (VAS) for patients (n=200) at 4, 24, 48, and 72 h after elective surgery. The occurrence of intermittent worst pain episodes and possible evoking factors were documented for each 24-h period. From individual regression curves the over all probability of pain was calculated. Within 1 week of surgery patient satisfaction was assessed and factors of import-ance for satisfaction^ dissatisfaction were analysed.

Results: At 4, 24, 48, 72 h after surgery, 39%, 43%, 27%, and 16%, respectively, of the patients experienced moderate or even severe pain (VAS >40 mm) at rest. During the first three 24 h periods after surgery 88%, 81% and 72%, respectively, of the patients had at any time moderate or severe pain (VAS S40 mm). Spontaneous pain breakthrough and movement/ mobilization were identified as reasons for the worst pain episodes during the first 72-h period after surgery. The probability of pain intensity of VAS >40 mm was higher for patients receiving parenteral analgesics than for patients having prolonged epidural analgesia. It was found that 81% of the patients claimed to be satisfied or even very satisfied with the pain management while only 8% were dissatisfied or very dissatisfied. Main characteristics of the dissatisfied patient were younger age and female sex.

Conclusions: In spite of major improvements in pain assessment and management, postoperative pain remains a clinical problem. Patient satisfaction does not seem the optimal outcome variable in quality assurance processes.

Acknowledgements: Supported with grants from Vastra Gotalandsregionen and Vardalstiftelsen, Sweden.

THE EVALUATION OF A POSTOPERATIVE PAIN PROTOCOL
M. Judong. I. Schroyen, K. Vissers, M. Puylaert, J. Van Canneyt, J. Froyen, R. Heylen Eastern Limbourg General Hospital, Genk, Belgium

Introduction: In 1997 we implemented a postopera-tive pain protocol in our hospital. In this protocol, we used a multimodal analgesics scheme, which is based on the WHO analgesic stepwise approach. On a regular base, a peripheral acting analgesic (proparacetamol and/or NSAID) is administered. Further using an algorithm, that includes the regular evalutation of the pain score, the degree of sedation, the respiratory function and the circulatory state, the ward nurse can decide independently to administer an opioid if the pain scores remain to high.

Aim of the investigation: We analysed the process of implementation and the efficacy and impact of the protocol three years after implementation in medical and nursing decision making.

Methods: Methodological triangulation : we analysed 39 postoperative patient files and used descriptive questionnaires. These questionnaires were sent to 125 "at random" selected nurses, 26 anesthetists and 27 surgeons (March 2000) all working in the same hospital.

Results: 89% of the anesthetists filled in properly the analgesic medication of the postoperative files. About 80% of the respondents understood the protocol and found it useful four their daily clinical practice. 95% of the nurses systematically asked for postoperative pain, but less than 10% used a numerical pain rating score that was registered in the patient files.

Conclusion: The successful implementation of a protocol, based on a multimodal pain algorithm, is dependent on the involvement of all participants. Regular multidisciplinary meetings and teaching about the protocol is therefore necessary. Since most of the basic medical data for the save application of the protocol were not recorded properly, further research on nursing registration of medical data must be supported.

EXPERIENCE OF MANAGING PCA IV AND EPIDURAL POSTOPERAVELY IN A CENTRAL HOSPITAL OF NORWAY
Pain nurse E Undall. MD. P. Engstrand
Dept ofAnesth, Telemark Central Hospital, N-3710 Skien,
Norway

Aim of Investigation: The aim of this survey was to document the routine management of PCA epidural and iv administration postoperativly (po.) in a central hospital of Norway (9000 anaest/y) with a full time pain nurse.

Methods: The use of epi. and iv. PCA was registrated for a year with focus on indications, side-effects, failure and duration of treatment. Portable pumps, CADD™ "were used, for epi administration of bupivacain 1 mg/ml + fentanyl 2 ug/ml + adr. 2 ug/ml., and Infusor" for iv administration of ketobemidon, Img pr dose with no background infusion.

Results:

Surgery	Gltom	Thortorny	Hipplartic	Kneeplutic	Gyn. lapr	Tot
PCA-epi,noofpat	80	17	95	46	3	463
Duration ofepi.adm (d)	4,7	6,6	4,1	3,9	5.2
Consumed l.day, ml/h	6,9	9,3	6,1	8.4	9,7
Cons. next days ml/h	6,0	7,9	4,0	5,1	8,4
Failed, no (%)	22 (27)	3 (17)	15 (16)	17 (37)	2 (67)	129 (28)
Due to: - dislodged motor block not epidural - leak one-side block cutaneus inflam other	0 1 3 1 0 3 14	0 0 1 1 1 0 0	5 0 1 1 1 0 7	3 1 1 2 2 2 6	0 0 0 0 0 1 1	13 11 10 11 7 15 62
Epi-cath reinstalled	5	2	1	7	0	37
PCA-iv, no of patients	6	1	0	1	92	109
Dur. PCA-iv.adm (d)	2,8	3,9		2,8	2,8
Consumed l.day, mg	21	34		30	30
Cons. next days, mg/d	29	37		34	20
Failed, no (%)	4 (67)	0		0	20 (22)	26 (24)
Due to: - nausea - resp. depression other	0 0 4	0 0 0		0 0 0	11 2 7	11 2 13

Conclusions: Strict routines for use of epi and iv PCA po. organized with a full time pain nurse and systematic documentation make it possible to analyze and optimize the pain treatment. The staff's competence in pain management is strengthened.

Pain in Europe III. EFIC 2000, Nice, France, September 26-29, 2000. Abstracts book, p. 167, 251, 252, 253, 351, 352.