Fischer HB,* Simanski CJ, Sharp C, et al.
*Anaesthesia and Pain Management, Department of Anaesthesia, Alexandra Hospital, Redditch, Worcester

A procedure-specific systematic review and consensus recommendations for postoperative analgesia following total knee arthroplasty.

The PROSPECT Working Group, a collaboration of anaesthetists and surgeons, conducts systematic reviews of postoperative pain management for different surgical procedures (http://archive.postoppain.org). Evidence-based consensus recommendations for the effective management of postoperative pain are then developed from these systematic reviews, incorporating clinical practice observations, and transferable evidence from other relevant procedures. We present the results of a systematic review of pain and other outcomes following analgesic, anaesthetic and surgical interventions for total knee arthroplasty (TKA). The evidence from this review supports the use of general anaesthesia combined with a femoral nerve block for surgery and postoperative analgesia, or alternatively spinal anaesthesia with local anaesthetic plus spinal morphine. The primary technique, together with cooling and compression techniques, should be supplemented with paracetamol and conventional non-steroidal anti-inflammatory drugs or COX-2-selective inhibitors, plus intravenous strong opioids (high-intensity pain) or weak opioids (moderate- to low-intensity pain).

Anaesthesia. 2008;63(10):1105-1123.
http://www.ncbi.nlm.nih.gov/pubmed/18627367

Neugebauer E*, Wilkinson R, Kehlet H, Schug S, on behalf of the PROSPECT Working Group.
*Institute for Research in Operative Medicine, University of Witten/Herdecke, Cologne, Germany

PROSPECT: a practical method for formulating evidence-based expert recommendations for the management of postoperative pain.

BACKGROUND: Many patients still suffer severe acute pain in the postoperative period. Although guidelines for treating acute pain are widely published and promoted, most do not consider procedure-specific differences in pain experienced or in techniques that may be most effective and appropriate for different surgical settings. The procedure-specific postoperative pain management (PROSPECT) Working Group provides procedure-specific recommendations for postoperative pain management together with supporting evidence from systematic literature reviews and related procedures at http://archive.postoppain.org METHODS: The methodology for PROSPECT reviews was developed and refined by discussion of the Working Group, and it adapts existing methods for formulation of consensus recommendations to the specific requirements of PROSPECT. RESULTS: To formulate PROSPECT recommendations, we use a methodology that takes into account study quality and source and level of evidence, and we use recognized methods for achieving group consensus, thus reducing potential bias. The new methodology is first applied in full for the 2006 update of the PROSPECT review of postoperative pain management for laparoscopic cholecystectomy. CONCLUSIONS: Transparency in PROSPECT processes allows the users to be fully aware of any limitations of the evidence and recommendations, thereby allowing for appropriate decisions in their own practice setting.

Surgical Endoscopy. 2007 Jul;21(7):1047–1053.
http://www.ncbi.nlm.nih.gov/pubmed/17294309

Kehlet H,* Wilkinson R, Fischer HBJ, Camu F, on behalf of the PROSPECT Working Group.
*Section for Surgical Pathophysiology 4074, The Juliane Marie Centre, Rigshospitalet, Copenhagen, Denmark

PROSPECT: Evidence-based, procedure-specific postoperative pain management.

Summary: Existing general guidelines for perioperative pain management do not consider procedure-specific differences in analgesic efficacy or applicability of a given analgesic technique. For the clinician, an evidence-based, procedure-specific guideline for perioperative pain management is therefore desirable. This chapter reviews the methodology and results of PROSPECT: a public web site (www.postoppain.org) which provides information and recommendations for evidence-based procedure-specific postoperative pain management.

Best Practice and Research: Clinical Anaesthesiology. 2007;21(1):149–159.
http://www.ncbi.nlm.nih.gov/pubmed/17489225

Girish P Joshi, Kehlet H, Rawal N; PROSPECT Working Group.

Evidence-based guidelines for postoperative pain management.

Comment in:
Reply to Drs. Joshi, Kehlet, and Rawal. Acute postsurgical pain management: a critical appraisal of current practice. Rathmell JP. Reg Anesth Pain Med. 2007 Nov-Dec;32(6):545.

Comment on:
Acute post-surgical pain management: a critical appraisal of current practice, December 2-4, 2005. Rathmell JP, Wu CL, Sinatra RS, Ballantyne JC, Ginsberg B, Gordon DB, Liu SS, Perkins FM, Reuben SS, Rosenquist RW, et al. Reg Anesth Pain Med. 2006 Jul-Aug; 31(4 Suppl 1):1–42.

Reg Anesth Pain Med. 2007 Mar-Apr;32(2):173. http://www.ncbi.nlm.nih.gov/pubmed/17350537

Neugebauer E,* Wilkinson R, Kehlet H, on behalf of the PROSPECT Working Group.
*Institute for Research in Operative Medicine, Faculty of Medicine, University of Witten/Herdecke, Cologne, Germany

Transferable Evidence in Support of Reaching a Consensus

The value of consensus recommendations for improving clinical practice may be restricted by the limitations of the evidence on which they are based. When few high quality studies are identified for evaluation from the specific field of interest, selected ‘transferable’ evidence from comparable clinical situations may add important information. Such transferable evidence must be critically assessed for relevance to the objective of the recommendations, and must be clearly differentiated from specific evidence. In particular, systems for grading of recommendations must take into account the different types of evidence used, so as not to give equivalent weight to transferable and specific evidence without justification. In this article, we discuss the use of transferable evidence by the PROSPECT Working Group, which has developed a clinical decision support programme (www.postoppain.org) to provide evidence and recommendations for procedure-specific postoperative pain management.

German Journal for Evidence and Quality in Healthcare Special issue: ‘Guidelines and Consensus’ . Z.ärztl.Fortbild.Qual.Gesundh. 2007;101:103–107.
http://www.ncbi.nlm.nih.gov/pubmed/17458355

Abstract

Total hip replacement is a major surgical procedure usually associated with significant pain in the early postoperative period.Several anaesthetic and analgesic techniques are in common clinical use for this procedure but, to date, clinical studies of pain after total hip replacement have not been systematically assessed. Using the Cochrane protocol, we have conducted a systematic review of analgesic, anaesthetic and surgical interventions affecting postoperative pain after total hip replacement. In addition to the review, transferable evidence from other relevant procedures and clinical practice observations collated by the Delphi method were used to develop evidence-based recommendations for the treatment of postoperative pain. For primary total hip replacement, PROSPECT recommends either general anaesthesia combined with a peripheral nerve block that is continued after surgery or an intrathecal (spinal) injection of local anaesthetic and opioid. The primary analgesic technique should be combined with a step-down approach using paracetamol plus conventional non-steroidal anti-inflammatory drugs, with strong or weak opioids as required.

Abstract and Data Tables [PDF]

Kehlet H*, Gray AW, Bonnet F, Camu F, et al.
*Section for Surgical Pathophysiology, The Juliane Marie Centre 4074, Rigshospitalet Blegdamsvej 9, 2100 Copenhagen, Denmark

A procedure-specific systematic review and consensus recommendations for postoperative analgesia following laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy has advantages over the open procedure for postoperative pain. However, a systematic review of postoperative pain management in this procedure has not been conducted. METHODS: A systematic review was conducted according to the guidelines of the Cochrane Collaboration. Randomized studies examining the effect of medical or surgical interventions on linear pain scores in patients undergoing laparoscopic cholecystectomy were included. Qualitative and quantitative analyses were performed. Recommendations for patient care were derived from review of these data, evidence from other relevant procedures, and clinical practice observations collated by the Delphi method among the authors. RESULTS: Sixty-nine randomized trials were included and 77 reports were excluded. Recommendations are provided for preoperative analgesia, anesthetic and operative techniques, and intraoperative and postoperative analgesia. CONCLUSIONS: A step-up approach to the management of postoperative pain following laparoscopic cholecystectomy is recommended. This approach has been designed to provide adequate analgesia while minimizing exposure to adverse events.
Surg Endosc. 2005;19 (10):1396–1415. http://www.ncbi.nlm.nih.gov/pubmed/16151686