Samina Ismail  ( Department of Anaesthesia, Aga Khan University Hospital, Karachi )
Aziza M. Hussain   ( Department of Anaesthesia, Aga Khan University Hospital, Karachi. )

Day care surgery has shown a remarkable development over the last two decades, comprising approximately 60-70% of all surgical procedures. Therefore major proportions of surgical patients are recovering at home and have little or no assessment of the adequacy oftheir pain relief. The aim of our audit was to compare suggested postoperative pain indicators with targets for best practice. This audit was done at the Aga Khan UniversityHospital day care unit for a period of three months. On theday of surgery patients having the contact numbers wereinformed about the telephone call 24 hrs after the surgery inquiring about their pain relief. Patients were shown and explained the visual analogue score from 0 to 10. The data was collected by one of the investigators on the day of surgery. We could assess 63.3% of day care patients. All patients were discharged with analgesia. Only three percentreported severe pain after 24 hrs which is according to the proposed standard for best practice that is < 5 %. Sixtypercent of patients had mild or no pain which is less than the proposed standard (>85%) and 84.2% were satisfied whichis almost borderline (>85%) according to the standard ofbest practice.

 The practice of day care surgery dates back more than 90 years, although it has only been over the last two decades that dramatic development is seen with marked increase in the number and complexity of procedures,comprising approximately 60-70% of all procedures.Therefore a major proportion of surgical patients will be recovering at home and have little or no assessment of their pain relief.1Some studies estimate that up to 75% of postsurgical patients experience pain because of under medication.2Patient's low expectation may well contribute to this problem .Studies3 have shown that 48% of patients take it is a part of healing and 39% see it as something to been dured. This may reduce the number of patients actually using the analgesics prescribed to them.Despite many tools for providing analgesia, pain isstill a common reason for delay in discharge, for contact with the family doctor 4 and for unanticipated hospital admissions.5Pain ranks in the top three undesirable postoperative outcomes6and among the most common symptom of greatest concern for patients and their families.7To treat pain effectively, it is important to understandthe pattern of pain and define any predictive factors forsevere postoperative pain. Chung and Mezei8in their study identified risk factors for severe postoperative pain. They found that type and length of surgical procedures influence the incidence of postoperative symptoms.8Given thesefactors, modifying the anaesthetic care to a protocoldesigned to reduce postoperative pain achieved measurable improvement in reducing pain.9Developments in ourunderstanding of the pathophysiology of acute pain have ledto the concept of preventive analgesia (inhibition ofphysiological and pathophysiological secondaryinflammatory pain). Therefore postoperative pain control should be started intraoperatively or, ideally, preoperativelyto ensure a pain free recovery. The approach should bemultimodal, using non-steroidal anti-inflammatory drugs(NSAIDs), opioids, and local anaesthetic techniques.10NSAIDs in addition to providing effective analgesiaprovide their anti-inflammatory effects which may helpreduce local oedema and minimize the use of opioids andtheir accompanying side effects. Consideration should be

Before 24 No. of Pts	hours	24 hours No. of Pts	onward
Mild (1 - 3)	45	59.2	46	60.5
Moderate (4 - 7)	23	30	27	35.5
Severe (8 - 10)	8	10.5	3	3.9

Not Satisfied   12   15.7

given to the timing of NSAIDs. Orally they should be given preoperatively when the patient is awake. Even intravenously, NSAIDs take at least 30 minutes to beeffective. Local anaesthetic wound infiltration and peripheral nerve block are simple, safe and an important part of the multimodal approach. Intracavity instillation oflocal anaesthetic is another simple and effective means of providing analgesics after laparoscopic and arthroscopic procedures.10Opioids still remain the primary perioperativeanalgesic despite the association with nausea, vomiting and sedation, which may delay discharge. Postoperative pain in the PACU should be treated promptly with small doses of potent rapidly acting opioid analgesics. Claxton et al11found that equipotent doses of fentanyl and morphine provided a more sustained analgesic effect but caused of more nausea and vomiting after discharge as fentanyl is ashort acting opioid and its use in the PACU should be accompanied by an oral drug to provide more prolonged pain relief. The aim of our audit was to find the adequacy ofpostoperative pain relief after discharge. Our suggestedindicators were:Percentage of *Patients discharged with analgesics.*Patients with verbal pain score of severe in the first 48hours after discharge.*Patients achieving a verbal pain score of mild or nonewith medication after discharge.*Patients satisfied with management of their pain whileat home.Our targets for best practice were1:*100% patients discharged with analgesics.*< 5% reporting 'severe' pain on verbal pain score in thefirst 48 hours after discharge.*>85% reporting no pain or mild pain after discharge(with medication)*>85% satisfied with management of their pain while athome.

On the day of surgery, patients contactable on telephone were informed about the telephone call that oneof the investigators would make 24 hours after the surgery asking questions about their postoperative pain. Patients were shown and explained the visual analogue score from 0to 10. They were explained that 0 meant no pain and 10meant worst possible pain and they were told to grade their level of pain from 0 to 10 depending upon the severity. We have taken the pain score 1-3 as mild, 4-7 as moderate and7-10 as severe.We included all patients above 14 years of age undergoing day care surgery. We excluded all patients whowere admitted after surgery, patients who refused to participate, not having telephone access, mentally not capable to understand and having a language barrier.Data for the day of surgery was collected by one ofthe investigators. Patients were called 24 hours after the surgery by one of the investigators and data was collected.Data collected on the day care surgery included contact number, age, sex, name and M.R #, surgery performed,ASAgrading, type of anaesthesia (general anaesthesia,regional or monitored anaesthesia care), type of analgesia(narcotic, non narcotic or multimodal). Data collected after24 hours included whether patients were discharged withanalgesics or not, verbal pain score, whether using medication, reasons for not taking medication, and satisfaction with management of pain. This audit was done for a period of three months atthe surgical day care unit of Aga Khan University Hospital.Total numbers of cases done as day care during the timewere 120. Out of these eleven patients did not have telephone access and eleven patients were admitted. None of the patients refused to participate. Out of these 98patients only 76 could be contacted and assessed for adequacy of postoperative pain relief after discharge.All of the cases were discharged with analgesics.Nine (11.8%) patients did not take analgesics. Of these eightpatients did not have pain and one could not take it becauseof excessive vomiting.Pain and Satisfaction Scores are presented in table 1and 2. Eight patients (10.5%) had severe pain after goinghome upto 24 hours. Out of these eight patients three (3.9%)continued to have severe pain even after 24hrs, one had mild and four had moderate pain after 24 hours.One patient who continued to have severe pain hadarthroscopy and was given general anaesthesia andnarcotics were used for analgesia and was taking paracetomol postoperatively. Second patient had inguinalhernia repair under general anaesthesia with narcotics and NSAIDS and postoperatively was taking calpol. Third patient had haemorriodectomy under general anaesthesiawith narcotics. Postoperatively she was on paracetamol anddiclophenac .She had to go to the hospital for pain relief.Twelve patients (15.7%) were not satisfied with pain management. Amongst them three patients had pain score ofsevere even after 24 hours, eight patients had moderate painwith score of 6-7 and one had mild with score of three after24 hours .

We could only assess 63.3% of surgical day care patients, as others could not be contacted.  All patients were discharged with analgesics. Only three percent reported severe pain after 24 hours which is comparable with the proposed standard for best practice which is < 5%. Sixty percent of patients had mild or no pain which is less than the proposed standard (>85%) and 84.2% were satisfied which is almost borderline (>85%) according to the bench mark ofbest practice. We recommend the need to educate patients so that they communicate to the care giver that they are experiencing pain so that it can be treated. All health care workers should be familiar with appropriate pain management modalities and the practice of prevention andmultimodal analgesia should be implemented to obtainoptimum pain management in ambulatory surgical patients.