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The scope of anesthesiology has expanded to encompass
areas outside the operating room, including such other
aspects of patient care as preoperative evaluation,
postanesthetic care, critical care and pain management,
just to mention a few. The anesthesiologist has truly
become a perioperative physician.
At the 31st Emery A. Rovenstine Memorial Lecture (1993),
Nicholas M. Greene, M.D., proposed a change in the name
of our specialty.* Not only
is practice so different from when the term “anesthesia”
was first coined by Oliver Wendell Holmes in 1846, but
also because the horizons of “anesthesia practice”
have expanded beyond the provision of surgical anesthesia.1
One of the clinical areas in which anesthesiologists
are increasingly involved is postoperative pain management.
In 1995, Warfield and Kahn2
assessed “the state of acute pain management”
in American hospitals. Of the 300 hospitals surveyed,
46 percent had established a pain management program
with “acute postoperative pain management”
as a component in 42 percent of all hospitals. At that
time, another 13 percent of hospitals surveyed had planned
to establish a formal “acute pain management program.”
Eighty percent of the acute pain management programs
were headed by anesthesiologists, and 94 percent had
an anesthesiologist as a member of the acute pain management
team.
Despite attempts to improve pain management, a significant
number of patients continue to experience inadequate
postoperative analgesia. The formation of an acute postoperative
pain service leads to establishing standards of care
with resultant improvement in patient satisfaction.3-5
Pain management is intimately related to the practice
of anesthesiology.
Holmes used the word “anesthesia” to describe
the state of “painless surgery” achieved
by dentist William T.G. Morton with the use of ether.
The word “anesthesia” is derived from the
Greek prefix “an-” meaning “without”
and the Greek word “esthesia,” which means
“sensation.” Thus a fundamental aspect of
the practice of anesthesiology is to prevent sensation,
to prevent pain. Several factors contribute to the increasing
involvement of the anesthesiologist in acute pain management.
Profound knowledge of anatomy (more specifically neuroanatomy),
understanding of pain pathways and the mechanisms and
physiology of pain, knowledge of pharmacology, pharmacodynamics
and pharmacokinetics of analgesic drugs all add to our
role in managing these patients postoperatively. To
these we must add the anesthesiologist’s expertise
in regional anesthesia.
The Agency for Healthcare Research and Quality issued
guidelines for acute pain management in 1992. The guidelines
emphasized the need for adequate acute pain management,
stating that “postoperative pain leads to patient
discomfort, which in turn leads to longer recovery period
and higher health care costs.”
The Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) created standards requiring that
hospitals assess, treat and document patients’
pain. JCAHO’s 2001 accreditation of health care
organizations was partly determined by how these organizations
adhered to the standards. Hence, an organized acute
pain management service is mandatory to fulfill JCAHO
requirements.
| “The
anesthesiologist participating in an
acute pain service must be committed
to patient care, specifically to improving
the quality of postoperative analgesia.”
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Intraoperative anesthesia technique as well as postoperative
analgesic techniques may significantly affect perioperative
morbidity. Morbidity leads to increased cost and hospital
stay. Some studies have demonstrated the benefits and
efficacy of epidural anesthesia/analgesia in reducing
morbidity for some procedures, especially in high-risk
patient populations.6-7
Epidural analgesia is just one modality of pain control.
The anesthesiologist’s training and expertise
should lead to the appropriate decision when choosing
treatment modalities for each individual patient.
The anesthesiologist participating in an acute pain
service must be committed to patient care, specifically
to improving the quality of postoperative analgesia.
Improved analgesia is associated in many cases with
decreased morbidity and shortened hospital stay.8
For an anesthesiology-based acute pain service to succeed,
it is tremendously important that we maintain open communication
with surgeons as well as with other members of the team
involved in each patient’s care. We must develop
protocols for pain management that can be individualized
easily to each patient’s needs. Integration of
effective analgesia into surgical care must be mandatory
to improve outcome.
As Myer H. Rosenthal, M.D., stated: “We must accept
the fact that for the anesthesiologist, perioperative
involvement is as important as intraoperative practice.”
9 Becoming a perioperative
physician is an opportunity for our specialty to become
more visible within the hospital community and to patients
and their families. This will increase the patient’s
understanding of the role of the anesthesiologist as
a member of his/her care team.
| * In that year, Dr. Greene
proposed changing the specialty’s name to
“metesthesiology” because that word,
he felt, better described the vast changes that
the specialty had undergone. |
References:
1. Greene NM. The 31st Rovenstine Lecture. The
changing horizons in anesthesiology. Anesthesiology.
1993; 79:164-170.
2. Warfield CA, Kahn CH. Acute pain management
programs in U.S. hospitals and experiences and
attitudes among U.S. adults. Anesthesiology.
1995; 83:1090-1094.
3. Schug SA, Torrie JJ. Safety assessment of postoperative
pain management by an acute pain service. Pain.
1993; 55:387-391.
4. Ready LB, Oden R, et al. Development of anesthesiology-based
postoperative pain management service. Anesthesiology.
1988; 68:100-106.
5. Miaskowski C, Crews J, et al. Anesthesia-based
pain services improve the quality of postoperative
pain management. Pain. 1999; 80:23-29.
6. Liu SS, Carpenter RL, et al. Effects of perioperative
analgesic techniques on role of recovery after
colon surgery. Anesthesiology. 1995;
83:757-765.
7. Liu SS, Carpenter RL, et al. Epidural anesthesia
and analgesia: Their role in postoperative outcome.
Anesthesiology. 1995; 82:1474-1506.
8. Rawal N. Acute pain services revisited. Good
from far, far from good? (editorial) Reg Anesth
Pain Med. 2002; 27:117-121.
9. Rosenthal MH. Critical care medicine: At the
cross roads (editorial). Anesth Analg.
1995; 81:439-440.  |
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Mercedes
Concepcion, M.D., is Staff Anesthesiologist, Brigham
and Women’s Hospital, and Associate Professor
of Anesthesia, Harvard Medical School, Boston,
Massachusetts. |
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Sunil
Eappen, M.D., is Staff Anesthesiologist, Brigham
and Women’s Hospital, and Assistant Professor
of Anesthesia, Harvard Medical School, Boston,
Massachusetts. |
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The views expressed herein are those of the authors and
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