An audit of acute pain service in Central, Saudi Arabia

OBJECTIVE: A retrospective analysis of acute pain service (APS) was performed to look at the epidural and patient-controlled analgesia (PCA) with respect to their indications, duration and quality of pain control, dosage regimen and common side effects.

METHODS: This study was conducted in the Armed Forces Hospital, Riyadh, Kingdom of Saudi Arabia. All APS monitoring forms, from the year 1994 to 2003 were collected. Every tenth PCA and epidural form was then randomly taken out and reviewed. From each sample form information concerning operation, analgesic modality (epidural or PCA), its duration, side effects and non-steroidal anti-inflammatory drug (NSAID) use was collected. Postoperative pain and sedation were monitored as 0=none, 1=mild, 2=moderate and 3=severe. For the first 24 hour of APS period, information was also gathered concerning duration of each pain score, highest pain score, sedation score and lowest respiratory rate. Informations of PCA (incremental dose, lock-out interval, back ground infusion, number of hours PCA not activated and total morphine consumed) and epidural infusion (concentration of mixture of local anesthetic with opioid and its volume consumed during first 24 hours) were also collected.

RESULTS: A total of 10002 patients aged 16-74 years received APS; one third of them receiving epidural and two thirds receiving PCA. Eighty-five percent of patients received APS after cesarean section and 7.8% received APS after abdominal hysterectomy. Acute pain service served 77% of total APS patients for 24-48 hours. The average duration of APS was 44.2 hours. For the first 24 hours, PCA and epidural was compared for severity and duration of pain. A pain score of zero was found for a longer period (average 19.6 hours) with epidural whilst; a pain score of 1 and 2 was observed for a longer period (average 11.4 and 4.0) with PCA. The mean highest pain score was 0.7 for epidural and 1.7 for PCA. Patients having no postoperative pain included 35.7% of the epidural analgesia group and 0.5% of the PCA group. The highest sedation score of one was found more often in the epidural group and a score of 2 was found more often in the PCA group. No case was documented where the respiratory rate was <12/minute. Most (51%) PCA patients were prescribed an incremental dose of 1.5mg of morphine with a lock-out interval of 10 minutes. Basal morphine infusion was used in 96% of PCA patients. Patient-controlled analgesia was not activated for the mean period of 13.2 hours in the first 24 hours postoperative period. Average total amount of morphine consumed by patients was 76.8 mg during the average total duration of 42.9 hours of PCA. Amongst patients who received epidural analgesia, 93.6% received the mixture of fentanyl (4 microgram/ml) and Bupivacaine (0.03%). On average, 194 mls of epidural infusion was used in the first 24 postoperative hours. Overall, 35% of patients received NSAIDs along with APS and 12.6% of patients developed complications during APS. Complications were recorded in 25.6% of epidural patients and 4.4% of PCA patients. The most common complication was pruritis.

CONCLUSION: In the past decade, APS has provided a safe and efficient service to over 10 thousand postoperative obstetric and gynecology patients. Epidural analgesia as compared to PCA provided superior analgesia but caused more frequent minor side effects. More resources are required to provide good quality APS to all eligible postoperative patients for the desirable period.