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
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.
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
Gray A, Kehlet H*, Bonnet F, Rawal N.
*Section for Surgical Pathophysiology, The Juliane Marie Centre 4074, Rigshospitalet Blegdamsvej 9, 2100 Copenhagen, Denmark
Predicting postoperative analgesia outcomes: NNT league tables or procedure-specific evidence?
Number needed to treat (NNT) values have been recommended and used to assess efficacy of analgesics for acute pain management. However, the data analysed come from a variety of procedures, which may potentially hinder the interpretation of the NNT value for specific procedures. We reanalysed available NNT data with acetaminophen in relation to the magnitude of surgical injury. Acetaminophen was less effective for pain relief after orthopaedic procedures than after dental procedures. The relative risk ratio for more than 50% pain relief, compared with placebo, was only 1.87 compared with 3.77 (P<0.05). Although NNT can give a valuable overview of efficacy, this concept is not necessarily applicable to all types of surgery. We suggest that estimates of NNT should be related to specific surgical procedures.
Br J Anaesth. 2005; 94 (6):710–714. http://www.ncbi.nlm.nih.gov/pubmed/15833778
Kehlet, H*.
*Section for Surgical Pathophysiology 4074, The Juliane Marie Centre, Rigshospitalet, Copenhagen, Denmark
Procedure-specific postoperative pain management.
Procedure-specific postoperative pain management guidelines arguably are more helpful to the clinician than general pain guidelines or guidelines based on the use of the Oxford League Tables. Two sources, the United States Veteran’s Health Administration and the European Prospect Working Group, offer websites that include surgical procedure-specific postoperative pain management guidelines, which are available and currently updated.
Anesthesiol Clin North America. 2005 Mar;23(1):203–210. http://www.ncbi.nlm.nih.gov/pubmed/15763419