Postoperative pain management in Chinese hospitals: a national survey

Editor—Postoperative pain is common among patients who have undergone surgery. Based on a US national survey, most of the pain was described as moderate to severe,1Gan T.J. Habib A.S. Miller T.E. White W. Apfelbaum J.L. Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey.Curr Med Res Opin. 2014; 30: 149-160Crossref PubMed Scopus (431) Google Scholar with ∼75% of patients suffering intense pain and 10% transitioning to persistent pain with neuropathic features.2Glare P. Aubrey K.R. Myles P.S. Transition from acute to chronic pain after surgery.Lancet. 2019; 393: 1537-1546Abstract Full Text Full Text PDF PubMed Scopus (235) Google Scholar This implies that postoperative pain is undermanaged and may lead to functional and quality-of-life impairment, delayed recovery time, and higher healthcare costs.3Suksompong S. von Bormann S. von Bormann B. Regional catheters for postoperative pain control: review and observational data.Anesth Pain Med. 2020; 10e99745Crossref PubMed Scopus (25) Google Scholar However, information on the status of pain management processes, analgesic methods, and drugs used for postoperative pain in Chinese hospitals is scarce. We conducted a national survey to investigate the current status of postoperative pain management in Chinese hospitals, identify challenges, and propose potential strategies for improvement in postoperative pain management. A total of 4996 hospitals above Grade II across mainland China were identified from the National Health Commission of the People's Republic of China. Grade II hospitals are defined as regional medical and technical centres, whereas Grade III hospitals are defined as medical prevention technology centres with comprehensive medical, teaching, and scientific research capacities. A group of 43 members of the Pain Group of the Chinese Society of Anesthesiology established and reviewed the questionnaire on postoperative pain management. The questionnaire was distributed to the chief anaesthesiologist or a member of the Pain Group of the Chinese Society of Anesthesiology in mainland China through WeChat (Tencent, Shenzhen, China), which is a free application that provides instant messaging services for smart terminals. Data collection was completed from March 1 to November 1, 2019. Statistical analyses were performed using SPSS 24.0 (IBM, Armonk, NY, USA). P<0.05 was considered a statistically significant difference. A total of 2198 (2198/4996; 48.9%) valid questionnaires from 29 provinces and municipalities and autonomous regions were included. The hospitals responding to our survey were mainly Grade III hospitals (1418/2198; 64.5%), and 780 (780/2198; 35.5%) were Grade II class hospitals. The median (inter-quartile range [range]) number of surgical cases per year was 7000 (12 000 [100–350 000]). Among 2798 non-responding hospitals, 38.4% (1075/2798) were Grade III hospitals, and 61.6% (1723/2798) were Grade II hospitals. Most Chinese hospitals performed preoperative visits (2177/2198; 99.0%) and pain evaluations via validated pain intensity assessment scales, such as the VAS, numerical rating scale, verbal rating scale, and Wong–Baker face pain rating scale (2115/2198; 96.2%).4Chou R. Gordon D.B. de Leon-Casasola O.A. 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: 131-157Abstract Full Text Full Text PDF PubMed Scopus (1497) Google Scholar A total of 1682 (1682/2198; 76.5%) hospitals performed operations with preoperative education, which included negative effects of pain (1054/1682; 62.7%), pain controllability (1067/1682; 63.4%), common analgesia modalities (1315/1682; 78.2%), instructions for patient-controlled analgesia (PCA) (1353/1682; 80.4%), self-assessment of postoperative pain (885/1682; 52.6%), and adverse reactions to analgesia (1368/1682; 81.3%). For postoperative analgesia, we found that the personnel for pain management differed between the operating theatre and the surgical ward (Fig. 1a and b). In the operating theatre, analgesic strategy was determined by attending anaesthesiologists (which means senior anaesthesiologists compared with anaesthesia residents) (1809/2198; 82.3%) and anaesthesia residents (681/2198; 31.0%). The number of surgeons who decided on treatment of pain increased from 365 (365/2198; 16.6%) in the operating theatre to 1072 (1072/2198; 48.8%) in the postoperative wards. We subsequently evaluated whether these changes were related to hospital grade. As a result, we found a reduction of attending anaesthetists formulating postoperative pain treatments both in the operating theatre and wards in Grade II hospitals, and the proportion of Grade II hospitals with no clinicians dealing with pain management was higher. During most out-of-hours periods, analgesia services (1672/2198; 76.1% on weekends and 1680/2198; 76.4% during nights) were performed by the anaesthesiologist on duty, and ∼10% (264/2198; 12.0% on weekends and 207/2198; 9.4% during nights) were performed by a dedicated anaesthesiologist (Fig. 1c and d). There was almost no difference between hospital grade; Grade III hospitals were supposed to have more dedicated anaesthesiologists responsible for postoperative analgesia, possibly because of a shortage of anaesthesiologists in China. Postoperative analgesia methods are variable based on the operative method and site. Among surveyed hospitals, the most frequent postoperative analgesia method was PCA (1593/2198; 72.5%); other treatment types are shown in Figure 1e. A lower proportion of Grade II hospitals used PCA (62.9% vs 75.9%), nerve blocks (18.8% vs 40.0%), pre-emptive analgesia (13.8% vs 27.3%), oral medication (12.4% vs 19.6%), local infiltration (10.3% vs 18.8%), and intra-articular administration (4.0% vs 11.6%) compared with the use of these methods in Grade III hospitals. The opioids used for PCA are shown in Figure 1f. Data on the level of postoperative pain relief achieved are lacking. Based on our results, most pain management during nights and weekends was performed by anaesthesiologists on duty, conceivably resulting in pain relief dissatisfaction. Considering the shortage of more than 200 000 anaesthesiologists in China,5Du Y.J. Zhang X.Q. Liu L.D. Zhang J.Y. Han N. Wang G.Y. Overfatigue amongst Chinese anaesthesiologists from 2017 to 2019.Br J Anaesth. 2021; 126: E17-E19Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar this status may be maintained for a long time because of the long training cycle of anaesthesiologists. A previous survey of postoperative pain management in Shandong Province in China in 2016 showed that 51% of hospitals performed operations with preoperative education, whereas the proportion in our survey was 76%, and the ratio of hospitals that performed pain evaluations was 47% and 96% in our survey.6Liu D. Ma J. Zhang Z. et al.Management of postoperative pain in medical institutions in Shandong Province in China.Medicine (Baltimore). 2016; 95e2690Crossref PubMed Scopus (13) Google Scholar The proportion of hospitals that adopted PCA (72% vs 43%), i.v. analgesia (60% vs 43%), and i.m. injection (18% vs 10%) also shows upward trends.6Liu D. Ma J. Zhang Z. et al.Management of postoperative pain in medical institutions in Shandong Province in China.Medicine (Baltimore). 2016; 95e2690Crossref PubMed Scopus (13) Google Scholar Considering that the proportion of Grade III hospitals was quite different between these two surveys, we compared the Grade II hospital data with the previous survey, and the upward trend was still found. Although opioids are associated with hyperalgesia, respiratory depression, nausea and vomiting, and drug addiction, opioid-based PCA plays an important role in postoperative analgesia among Chinese hospitals because of its simplicity and efficacy. Ultrasound-guided nerve blocks and local wound infiltration, important components of multimodal analgesia, are advantageous in Enhanced Recovery After Surgery programmes and help reduce opioid use.7Barr L.F. Boss M.J. Mazzeffi M.A. Taylor B.S. Salenger R. Postoperative multimodal analgesia in cardiac surgery.Crit Care Clin. 2020; 36: 631-651Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar,8Tang J. Churilov L. Tan C.O. et al.Intrathecal morphine is associated with reduction in postoperative opioid requirements and improvement in postoperative analgesia in patients undergoing open liver resection.BMC Anesthesiol. 2020; 20: 207Crossref PubMed Scopus (10) Google Scholar With advancements in visualisation technology in anaesthesiology and ageing surgical patients with multiple comorbidities, nerve block anaesthesia and analgesia are increasingly used in Chinese hospitals. According to our results, Grade III hospitals have more use of nerve blocks than Grade II hospitals. However, nerve block analgesia is limited by surgical sites, and implementable guidelines and standardised management for multimodal analgesia are not available. In conclusion, Chinese hospitals have made substantial progress in postoperative pain management, evident in the use of a variety of analgesic techniques and drugs. However, the lack of available anaesthesiologists remains the main barrier to optimal postoperative pain management. The authors declare that they have no conflicts of interest.