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La evidencia sobre la gestión del dolor postoperatorio presenta un grado de calidad bajo o insuficiente. El Grupo de Trabajo del Dolor Agudo SEDAR ha elaborado este documento-guía para aplicar la mejor evidencia científica disponible a la práctica clínica habitual, individualizándolo en función de factores propios del paciente y del procedimiento, y englobando las distintas opciones organizativas del control de dolor.El documento profundiza y actualiza conceptos y requisitos mínimos necesarios para una analgesia óptima postoperatoria, el abordaje multidisciplinar y la gestión del dolor agudo postoperatorio. Se definen y se describen líneas estratégicas y los distintos modelos de gestión. Se establece un plan de actuación general perioperatoria basado en la colaboración con los servicios quirúrgicos implicados, en la revisión conjunta de la evidencia y en la elaboración de protocolos por procedimiento. Finalmente, se presenta un plan de seguimiento y los indicadores mínimos necesarios para un control de calidad del dolor postoperatorio. (AU)

The evidence on postoperative pain management is of low or insufficient quality. The SEDAR Acute Pain Working Group has prepared this guideline-document to apply the best available scientific evidence to clinical practice, individualizing it based on factors specific to the patient and the procedure, and encompassing different organizational options, attempting to individualize it based on specific factors of the patient and the procedure, and encompassing the different organizational options for pain control.The document updates concepts and minimum requirements necessary for optimal postoperative analgesia, a multidisciplinary approach and the management of acute postoperative pain. Strategic lines and different management models are defined. A general perioperative action plan is established based on collaboration with the surgical departments involved, on the joint review of the evidence and on preparation of protocols by the procedure. Finally, a follow-up plan and a series of minimum indicators necessary for quality control of postoperative pain are presented. (AU)

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The evidence on postoperative pain management is of low or insufficient quality. The SEDAR Acute Pain Working Group has prepared this guideline-document to apply the best available scientific evidence to clinical practice, individualizing it based on factors specific to the patient and the procedure, and encompassing different organizational options, attempting to individualize it based on specific factors of the patient and the procedure, and encompassing the different organizational options for pain control. The document updates concepts and minimum requirements necessary for optimal postoperative analgesia, a multidisciplinary approach and the management of Acute Postoperative Pain. Strategic lines and different management models are defined. A general perioperative action plan is established based on collaboration with the surgical departments involved, on the joint review of the evidence and on preparation of protocols by the procedure. Finally, a follow-up plan and a series of minimum indicators necessary for quality control of postoperative pain are presented.

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Anualmente se ha observado un ascenso del 5 % en la intervenciones quirúrgicas realizadas mundialmente, junto con un incremento en la complejidad de las mismas, así como en la comorbilidades de los pacientes. No obstante, entre el 30-80 % de los pacientes experimentan dolor agudo postoperatorio (DAP) mode­rado-intenso tras las primeras 24 horas de postoperatorio, a pesar de un mejor conocimiento fisiopatológico, el empleo de nuevas técnicas y fármacos analgésicos, la publicación de nuevas guías y la creación de las Unidades de Dolor Agudo (UDA). Además, hemos de tener presente a los pacientes vulnerables (población pediátrica, gestantes, ancianos, etc.) y a los consumidores crónicos de opioides, que habitualmente son desviaciones de los protocolos analgésicos y, por tanto, nos sitúan en un escenario en el que el manejo del dolor postoperatorio es más difícil y obliga al diseño de estrategias personalizadas a cada paciente. Se ha de tener también presente que un inadecuado control del DAP puede dar lugar a una cronificación del dolor postoperatorio, suponiendo un auténtico reto te­rapéutico para las unidades de dolor crónico, junto con un deterioro de la calidad de vida del paciente debido a sus repercusiones físicas, psicológicas y económicas. A través de este manuscrito, pretendemos realizar un análisis crítico y proponer puntos de mejora en la forma en la que gestionamos actualmente el DAP, basándonos en la evidencia científica para la obtención de mejores resultados postoperatorios en los próximos años.(AU)

Annually, a 5 % rise has been observed in surgical interventions performed worldwide, together with an increase in their complexity as well as in patient comorbidities. However, between 30-80 % of patients experience moderate-intense acute postoperative pain (APD) after the first 24 postoperative hours, despite better pathophysiological knowledge, use of new techniques and analgesic drugs, publication of new guidelines and the creation of the Acute Pain Units (UDA). In addition, we must bear in mind vulnerable patients (pediatric population, pregnant women, the elderly, ...) and chronic opioid users who are usually deviations from analgesic protocols and, therefore, place us in a scenario in which the management of Postoperative pain is more difficult and requires the design of personalized strategies for each patient. It must also be borne in mind that inadequate PDA control can lead to chronic postoperative pain, posing a real therapeutic challenge for Chronic Pain Units, toge­ther with a deterioration in the patient's quality of life due to its physical repercussions, psychological and economic. Through this manuscript, we intend to carry out a critical analysis and propose points for improvement in the way we currently manage DAP based on scientific evidence to obtain better postoperative results in the coming years.(AU)

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Objetivo: conocer la prevalencia de dolor y su enfoque terapéutico en un servicio de urgencias. Material y métodos: estudio transversal llevado a cabo en el Servicio de Urgencias de un hospital universitario durante 7 días consecutivos. El médico de triaje interrogó sobre la presencia de dolor a los pacientes mayores de 15 años que acudían a urgencias. Se excluyeron los pacientes atendidos en el Servicio de Psiquiatría, Obstetricia-Ginecología y aquellos cuya gravedad no permitía la valoración del dolor en el triaje. Se revisó posteriormente el tratamiento analgésico previo a la visita, la evaluación del dolor, el tratamiento analgésico aplicado durante su estancia en urgencias y el tratamiento pautado al alta. Resultados: se analizaron 668 de los 2.287 pacientes que acudieron a urgencias durante el periodo del estudio. Presentaron dolor 501 pacientes (75 %), de los que 45 ingresaron y 456 fueron dados de alta a domicilio (240 pacientes procedentes de nivel 1 y 216 de nivel 2). El 24,5 % de los 501 pacientes que manifestaron tener dolor realizaba tratamiento analgésico previo. De los 216 pacientes atendidos en el nivel 2, el 41,7 % recibió tratamiento analgésico durante su estancia [paracetamol (80,2 %), antiinflamatorios no esteroideos (AINE) (50 %), coanalgésicos (1 %), opioides débiles (20,8 %), opioides fuertes (3,1 %)]. El 32,7 % de los 196 pacientes sin registro de evaluación del dolor recibió tratamiento analgésico a demanda. En un 69,4 % de los 456 pacientes que no precisaron ingreso, al alta se pautó analgesia o se modificó el tratamiento analgésico previo [paracetamol (55 %), AINE (67 %), co-analgésicos (10 %), opioides débiles (10 %), opioides fuertes (1,1 %)]. Conclusiones: se evidencia una elevada prevalencia de dolor (75 %) en los pacientes que acuden al servicio de urgencias. El 41,7 % de los pacientes que presentaban dolor recibió tratamiento analgésico durante su estancia y en el 69,4 % de los pacientes que no precisaron ingreso se pautó analgesia al alta. Destaca la baja prescripción de opioides (AU)

Aim: To know the prevalence of pain and the therapeutic approach in an emergency department (ED). Material and methods: Cross-sectional study in the ED of a university hospital during 7 consecutive days was performed. The presence of pain was asked by a physician to patients older than 15 years admitted at ED. Patients admitted at Psychiatry, Obstetrics-Gynecology Emergency Department and those whose serious condition would not allow pain assessment in triage were excluded. The previous analgesic treatment, pain assessment, analgesic treatment in the ED and also scheduled treatment at discharge were later reviewed. Results: Six hundred and sixty-eight from 2,287 patients who were admitted at ED were analyzed. Five hundred and one patients reported pain (75 %), of which 45 were admitted and 456 were discharged at home (240 patients in level 1, 216 at level 2). The 24.5 % of the 501 patients who reported pain at admission were previously treated with analgesics. The 41.7 % of the 216 patients treated at level 2 received analgesic treatment during their stay [paracetamol (80.2 %), nonsteroidal antiinflammatory drugs (NSAIDs) (50.0 %), co-analgesics (1.0 %), weak opioids (20.8 %), strong opioids (3.1 %)]. The 32.7 % of the 196 patients without documented pain assessment received analgesic treatment as required. In 69.4 % of the 456 patients who did not require hospitalization, analgesic treatment was prescribed or modified at discharge [paracetamol (55 %), nonsteroidal anti-inflammatory drugs (NSAIDs) (67 %), co-analgesics (10 %), weak opioids (10 %), strong opioids (1.1 %)]. Conclusions: A high prevalence of pain (75 %) was found in patients admitted at ED. The 41.7 % received analgesic treatment during their stay and in 69.4 % of patients analgesia was prescribed at discharge. Low opioid prescription was detected (AU)

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Objective: To determine the epidemiology and management of acute pain in the emergency services (ES) of Spanish hospitals. Method: Survey "on line" to doctors responsible for the ES from a sample of different types of hospital across the country. Aspects of pain epidemiology, assessment, institutional resources, types of treatments and specific training aspects in pain practitioners in the field of ES are investigated. Results: With a response rate of 37 % is estimated that 42.8 % of patients come to the ES with pain as the main reason. Musculoskeletal pain is the most represented and more intense. Is usually assessed by scales in 58.3 % of hospitals, although only 23.9 % have specific documentation to do so. Major opioids are used in 16.9 % of patients with pain, weak opioids in 25.4 % and acetaminofen/NSAID 72.3 %. Possess analgesic protocols refer 46.3 %, and acute pain services or institutional pain programs (APS-IPP) 13.4 %. Only 20.9 % of the hospitals have specific training activity in this area. With few differences between them, hospitals with APS-IPP tend to evaluate and document the pain, using more opioids and protocols, while providing more training. Conclusion: Pain is still present and is underevaluated in the ES. At the institutional and individual level there is ample room for improvement in this field must consider new strategies, attitudes and organizational solutions (AU)

Objetivo: Conocer aspectos epidemiológicos y del manejo del dolor agudo en los servicios de urgencia (SU) de los hospitales españoles. Método: Encuesta on line a los responsables médicos de los SU de una muestra de diferentes tipos de hospitales de todo el territorio nacional. Se investigan aspectos relativos a la epidemiología del dolor, evaluación, recursos institucionales, tipos de tratamientos y aspectos formativos específicos en dolor de los profesionales en el ámbito de los SU.Resultados: Con una tasa de respuesta del 37 % se estima que el 42,8 % de los pacientes acuden a los SU con dolor como principal motivo. El dolor músculo-esquelético es el más representado y de mayor intensidad. Se evalúa habitualmente mediante escalas en el 58,3 % de los hospitales, aunque sólo el 23,9 % tienen documentación específica para hacerlo. Opioides mayores se utilizan en el 16,9 % de los pacientes con dolor, opioides débiles en el 25,4 % y paracetamol/AINE en el 72,3 %. Refieren poseer protocolos analgésicos el 46,3 % y unidades de dolor agudo o programas institucionales de dolor (UDA-PID) el 13,4 %. Sólo el 20,9 % de los hospitales realiza actividad formativa específica en este ámbito. Con escasas diferencias entre centros, los hospitales con UDA-PID tienden a evaluar y documentar más el dolor, utilizan más los opioides mayores, los protocolos y facilitan más la formación. Conclusión: El dolor sigue estando presente y es infravalorado en los SU. A nivel institucional e individual existe un amplio margen de mejora en este campo que habrá de contemplar estrategias, actitudes y soluciones organizativas (AU)

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OBJECTIVE: To compare postoperative pain intensity and incidence of adverse events when the evaluation is performed by a visual numerical scale completed by the patient (PAINOUT), or using a verbal numerical scale completed by ward nurses or the staff of the acute pain unit. METHODS: Fifty-two postsurgical patients of both sexes (age range 31-80 years) admitted to the general surgery ward were sequentially recruited and evaluated on postoperative day 1. All patients were assessed using both questionnaires, which measure postoperative outcomes using scales of 0 to 10; values > or =4 were considered clinically relevant. The test and Cohen coefficient were used for statistical analysis. RESULTS: Using the PAINOUT questionnaire, the mean maximum intensity of referred pain was 5.40 (range, 0-10) and the minimum intensity was 1.83 (range, 0-5). Mean values obtained with the verbal numerical scales used by staff on the ward and in the pain clinic were 3.76 (range, 0-10) and 0.97 (range, 0-5), respectively. The differences between the 2 methods of pain assessment were statistically (P = .006) and clinically significant. When evaluating nausea with PAINOUT questionnaire, all patients provided a response; in 88.5% the intensity was less than 4. Six patients reported nausea on the PAINOUT but not in the UDA questionnaire. Moreover, 61% of patients reported drowsiness/sedation in PAINOUT instrument, whereas none reported that effect on the verbal scale. CONCLUSIONS: The intensity of pain and adverse events is significantly higher when the patient evaluates and records its intensity on visual numerical scales compared with verbal numerical scales.

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Objetivo: Comparar la intensidad del dolor postoperatorio y la incidencia de efectos adversos cuando la evaluación se realiza mediante una escala numérica visual completada por el propio paciente (PAINOUT) y una escala numérica verbal utilizada por el personal de la unidad de hospitalización/unidad de dolor agudo (UH/UDA). Métodos: Participaron 52 pacientes postquirúrgicos de ambos sexos, rango de edad 31-80 años, reclutados secuencialmente en la UH de cirugía general y evaluados durante las primeras 24 horas del postoperatorio utilizando los dos cuestionarios. Ambos tienen un rango del 0- 10 y valores >=4 fueron considerados clínicamente relevantes. Resultados: En PAINOUT, la media de la intensidad máxima de dolor referido fue de 5,40 (rango 0-10) y la de la intensidad mínima de 1,83 (0-5); en la escala verbal numérica UH/UDA los valores fueron 3,76 (rango 0-10) y 0,97 (0-5), respectivamente. Las diferencias entre los dos métodos de evaluación del dolor fueron estadísticamente (p = 0,006) y clínicamente significativas. Al evaluar las náuseas mediante el PAINOUT, todos los pacientes registraron una respuesta por escrito y en el 88,5% de los pacientes la intensidad fue < 4; seis pacientes refirieron náuseas en el PAINOUT, pero no en el cuestionario UH/UDA. Además, un 61% de pacientes registró cansancio/sedación >= 4 en PAINOUT y ninguno en la evaluación UH/UDA. Conclusiones: La intensidad del dolor y los EA son significativamente mayores cuando el propio paciente evalúa y registra su intensidad mediante escalas numéricas visuales comparadas con las escalas numéricas verbales(AU)

Objetive: To compare postoperative pain intensity and incidence of adverse events when the evaluation is performed by a visual numerical scale completed by the patient (PAINOUT), or using a verbal numerical scale completed by ward nurses or the staff of the acute pain unit. Methods: Fifty-two postsurgical patients of both sexes (age range 31-80 years) admitted to the general surgery ward were sequentially recruited and evaluated on postoperative day 1. All patients were assessed using both questionnaires, which measure postoperative outcomes using scales of 0 to 10; values >= 4 were considered clinically relevant. The test and Cohen coefficient were used for statistical analysis. Results: Using the PAINOUT questionnaire, the mean maximum intensity of referred pain was 5.40 (range, 0-10) and the minimum intensity was 1.83 (range, 0-5). Mean values obtained with the verbal numerical scales used by staff on the ward and in the pain clinic were 3.76 (range, 0-10) and 0.97 (range, 0-5), respectively. The differences between the 2 methods of pain assessment were statistically (P = .006) and clinically significant. When evaluating nausea with PAINOUT questionnaire, all patients provided a response; in 88.5% the intensity was less than 4. Six patients reported nausea on the PAINOUT but not in the UDA questionnaire. Moreover, 61% of patients reported drowsiness/sedation in PAINOUT instrument, whereas none reported that effect on the verbal scale. Conclusions: The intensity of pain and adverse events is significantly higher when the patient evaluates and records its intensity on visual numerical scales compared with verbal numerical scales(AU)

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Se revisan las hernias de disco cervical, su prevalencia, el dolor, el diagnóstico clínico y las pruebas complementarias necesarias para realizar el tratamiento más adecuado. La historia natural de las hernias de disco cervicales es benigna, con una buena respuesta al tratamiento conservador. La indicación de cirugía es el fracaso tratamiento conservador y la lesión de primera o segunda motoneurona. La cirugía presenta buenos resultados con una escasa tasa de complicaciones, no existiendo una evidencia que demuestre mejores resultados con ninguna de las opciones disponibles (AU)

Cervical disc hernias are reviewed, their prevalence, pain, clinical diagnosis and further tests required to give the most appropriate treatment. The natural history of cervical disc herniation is benign, with a good response to conservative treatment. The surgical indication is conservative treatment failure and a primary or secondary motor neuron lesion. Surgery has good results with a low complications rate, there being no evidence that it gives better results than any of the available options (AU)

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OBJECTIVE: Pain after total knee replacement surgery is intense. The aim of this study was to compare 3 techniques for providing postoperative analgesia (epidural analgesia, femoral nerve block, and a combined femoral-sciatic nerve block) in total knee arthroplasty. MATERIAL AND METHODS: Observational study of 1550 elective primary unilateral total knee replacement operations. The safety and efficacy of the following 3 techniques were compared: epidural analgesia, femoral nerve block, and femoral-sciatic nerve block. Demographic, anesthetic, and surgical data were recorded. Study variables included pain intensity on a visual analog scale every 4 hours, need for rescue analgesia (morphine), complications and adverse events within 5 postoperative days. RESULTS: No significant differences were found in demographic, anesthetic, or surgical variables. In the first 24 hours after surgery, pain intensity was significantly less for patients who received a femoral-sciatic nerve block. The mean levels of morphine consumption in the first 96 hours after surgery were similar in the femoral-sciatic nerve block group (3.18 mg) and the epidural analgesia group (3.19 mg); morphine consumption in the femoral block group was significantly higher (4.51 mg). Epidural analgesia was associated with the highest rate of complications (17%). CONCLUSIONS: A sciatic nerve block combined with a femoral nerve block attenuates pain more effectively and is associated with less postoperative morphine consumption in comparison with a femoral nerve block alone. Peripheral nerve block techniques have fewer adverse side effects than epidural analgesia.

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OBJETIVOS: El dolor postoperatorio de la prótesis totalde rodilla es de una gran intensidad. El objetivo fuecomparar tres técnicas de analgesia postoperatoria (epidural,bloqueo del nervio femoral y bloqueo de los nerviosfemoral y ciático combinados) después de intervenciónde prótesis total de rodilla.MATERIAL Y MÉTODOS: Estudio observacional de 1.550intervenciones de prótesis de rodilla unilateral primariaselectivas. Se compararon tres técnicas de analgesia postoperatoria(epidural, bloqueo femoral y bloqueo femoralciático)para valorar eficacia y seguridad. Se recogierondatos demográficos, anestésicos y quirúrgicos, intensidaddel dolor según escala visual analógica cada 4 horas,rescate analgésico con morfina, complicaciones e incidenciasdurante los 5 primeros días del postoperatorio.RESULTADOS: No hallamos diferencias en las variablesdemográficas, anestésicas y quirúrgicas. La intensidad deldolor fue significativamente menor en el grupo bloqueofemoral y ciático respecto a los grupos epidural y bloqueofemoral durante las primeras 24 horas del postoperatorio.El consumo medio de morfina a las 96 horas tras la intervenciónfue similar en el grupo con bloqueo femoral y ciático(3,18 mg) y epidural (3,19 mg), y significativamentemayor con el bloqueo femoral (4,51 mg). La analgesia epiduralpresento el mayor índice de complicaciones (17%).CONCLUSIONES: Asociar un bloqueo ciático al bloqueofemoral disminuye el dolor y el consumo de morfina postoperatoriorespecto al bloqueo femoral aislado. Las técnicasanalgésicas de bloqueo periférico presentan menosefectos indeseables que la analgesia epidural (AU)

OBJECTIVE: Pain after total knee replacement surgeryis intense. The aim of this study was to compare 3techniques for providing postoperative analgesia(epidural analgesia, femoral nerve block, and acombined femoral-sciatic nerve block) in total kneearthroplasty.MATERIAL AND METHODS: Observational study of 1550elective primary unilateral total knee replacementoperations. The safety and efficacy of the following 3techniques were compared: epidural analgesia, femoralnerve block, and femoral-sciatic nerve block.Demographic, anesthetic, and surgical data wererecorded. Study variables included pain intensity on avisual analog scale every 4 hours, need for rescueanalgesia (morphine), complications and adverse eventswithin 5 postoperative days.RESULTS: No significant differences were found indemographic, anesthetic, or surgical variables. In thefirst 24 hours after surgery, pain intensity wassignificantly less for patients who received a femoralsciaticnerve block. The mean levels of morphineconsumption in the first 96 hours after surgery weresimilar in the femoral-sciatic nerve block group(3.18 mg) and the epidural analgesia group (3.19 mg);morphine consumption in the femoral block group wassignificantly higher (4.51 mg). Epidural analgesia wasassociated with the highest rate of complications (17%).CONCLUSIONS: A sciatic nerve block combined with afemoral nerve block attenuates pain more effectively andis associated with less postoperative morphineconsumption in comparison with a femoral nerve blockalone. Peripheral nerve block techniques have feweradverse side effects than epidural analgesia (AU)

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