Satisfaction and efficacy of epidural analgesia after surgery at the department of required services treatment in the national hospital of obstetrics and gynecology – Nguyen Thi Bich Van

68 JMR 116 E3 (7) - 2018 JOURNAL OF MEDICAL RESEARCH SATISFACTION AND EFFICACY OF EPIDURAL ANALGESIA AFTER SURGERY AT THE DEPARTMENT OF REQUIRED SERVICES TREATMENT IN THE NATIONAL HOSPITAL OF OBSTETRICS AND GYNECOLOGY Nguyen Thi Bich Van, Nguyen Thi Phuong Thao, Phan Thi Anh National Hospital of Obstetrics and Gynecology This cross-sectional descriptive study was conducted to monitor the analgesic effects of epidural analge- sia in postoperative patients and to evaluate the satisfaction of patients using epidural anesthesia for the purpose of postoperative pain management at the Department of required services treatment in the National Hospital of Obstetrics and Gynecology from 01/08/2018 to 31/10/2018. 34 patients with postmenopausal and gynecologic problems were enrolled and applied with epidural analgesia to release pain after the operation. Results showed that the mean age of subjects was 34.3 ± 4.2 years. The mean VAS score at 12 hours was highest at 3.76 ± 2.64. The percentage of patients who were satisfied with the epidural analgesia was 73.5%, and the dissatisfaction rate was 26.5%. The proportion of patients treated with other pain management measures was 64.7%. The incidence of patients with undesirable effects was 2.9%. The proportion of pa- tients who agreed to use the epidural anesthesia, if indicated for another procedure, was 50%. It could be concluded that postoperative pain relief by epidural anesthesia is a safe and effective method of pain relief. Key words: epidural anesthesia. Satisfaction, efficacy I. INTRODUCTION Pain relief is always a matter of concern for patients and physicians, particularly in the field of obstetrics and gynecology, due to its tre- mendous effects on physiology and recovery of the patient. More specifically, obstetric pa- tients have different characteristics than those of general surgical patients. There is the expo- sure of infants to pain relief medication through breast milk to contend with, and pa- tients should soon regain their self-control and self-care to take care of their baby . When investigating what women fear and want after caesarean section, pain is the most relevant factor [1]. Postoperative pain can cause the patient to lose the ability to take care of the baby, affecting the newly established mother- child relationship [2]. Thus, pain relief is a nec- essary medical intervention, helping patients rapidly balance physiology, reducing hospital stay, strengthening maternal and neonatal relationships, and thus helping them to return to the daily life as quickly as possible. Up until now, there have been many au- thors who have investigated various pain relief methods for postoperative patients. Epidural analgesia is considered to be the optimal method for postoperative pain relief, severe surgery, and especially in patients with comor- bidities. Understanding the importance of post- operative analgesia, from the beginning of 2018, the National hospital of Obstetrics and Gynecology has implemented epidural analge- Corresponding author: Nguyen Thi Phuong Thao, National Hospital of Obstetrics and Gynecology Email: [email protected] Received: 03/10/2018 Accepted: 26/11/2018 JMR 116 E3 (7) - 2018 69 JOURNAL OF MEDICAL RESEARCH sia to relieve pain after surgery. So we con- ducted this study with the following aims: 1. To monitor the pain relief effects of epi- dural analgesia for postoperative patients. 2. To assess of patients' satisfaction with the use of epidural analgesia for postoperative patients II. METHODS 1. Subjects The research was conducted with the pain relief by epidural analgesia for postoperative patients at the Required services treatment Department, The National hospital of Obstet- rics and Gynecology from August 2018 to Oc- tober 2018. Inclusion criteria - Patients undergoing cesarean section and gynecological surgery at the National Hospital of Obstetrics and Gynecology who underwent epidural analgesia therapy for post- operative surgical pain. - Patients with normal mental health and willing to participate in the study. Exclusion criteria - Patients with neurological and psychiatric conditions, patients with communication diffi- culties. - Patients not willing to participate in the study 2. Study design A cross sectional study was used for this study. 3. Sample size and Sampling - Sample size: After select all patient who were given epidural analgesia from August 1st 2018 to October 31st 2018 at the National Hospital of Obstetrics and Gynecology, we had a total of 34 patients for this study. - Sampling: convenience sampling epidural analgesia in postoperative patients at the De- partment of requires services treatment, the National Hospital of Obstetrics and Gynecol- ogy. Step 1: Develop research tool to collect study data. Step 2: Select postoperative patients who were given epidural analgesia and were willing to participate in the study. Step 3: Instruct the patient to use the Vis- ual Analogue Scale (VAS) to assess pain with 10 points equivalent to 10 scores from Astra Zeneca Brand . Step 4: Interview and monitor the patients to collect information according to the data collection tool. The patients were transferred from the De- partment of Anesthesiology & Recovery to Department of Required Services Treatment. Informed consent was obtained from the pa- tients; if patients refused to be excluded in the study, only follow up steps with the consent of the patient . After instructing patients to use the VAS pain scale, patients recorded their own VAS pain score on the follow-up sheet. 4. Data analysis and processing Data after collecting was cleaned, entered and processed by SPSS 16.0. We also ap- plied descriptive analyze statistics for this study. 5. Research ethics The research only aimed to evaluate the postoperative pain relief efficacy of epidural 70 JMR 116 E3 (7) - 2018 JOURNAL OF MEDICAL RESEARCH analgesia and patient satisfaction with this method. Research subjects were provided with sufficient information and agreed to participate in the study. All information related to research objects is encrypted and confidential. Every subject has the right to refuse to participate in the research. III. RESULTS 1. General characteristics of subjects 1.1. Age of patients Figure 3.1. Distribution of patients by age The mean age of the patients was 34.3 ± 4.2 (years old), the highest age was 47 and the low- est was 23 years old. Those aged 25 to 35 accounted for 50%, aged over 35 years old accounted for 41.2%, and only 8.8% patients were under 25 years old. 1.2. Surgery type In 34 patients who participated in the study, there were 30 cesarean patients which were 88.2%, and the remaining four patients underwent hysterectomy, which accounted for 11.8%. 2. Degree of pain at the time of the study Table 1. Mean of VAS score at the time of the study VAS score after surgery Mean of VAS score VAS score after surgery 3 hours 2.68 ± 2.37 VAS score after surgery 6 hours 3.62 ± 2.55 VAS score after surgery 12 hours 3.76 ± 2.64 VAS score after surgery 18 hours 3.18 ± 2.39 VAS score after surgery 24 hours 3.32 ± 2.57 VAS score after surgery 36 hours 2.91 ± 1.99 VAS score after surgery 48 hours 3.15 ± 2.20 JMR 116 E3 (7) - 2018 71 JOURNAL OF MEDICAL RESEARCH The highest mean of postoperative VAS score at postoperative 12 hours was 3.76 ± 2.64, after that it tended to decrease. At the time of 24-hour after surgery VAS score was 3.32 ± 2.57 and after 36 hours surgery was 2.91 ± 1.99. 3. Combination with other pain relief therapies Table 2. Combination with other pain relief therapies Combination with other pain relief therapies N Rate (%) Yes 22 64,7% No 12 35, 3% Total 34 100% There were 22 patients in combination with other analgesics such as paracetamol, suppository and morphine which account for 64.7%. 4. Side effects Table 3. Side effects Adverse effects n Rate (%) Itching, urticarial 0 0 Nausea, vomiting 0 0 Headache 0 0 Scabies, weak in the lower limbs 1 2,9 % Total 1 2,9 % Side effects were recorded in 34 patients who had pain relief therapy postoperative. Only one patient had scabies and lower extremity weakness, both accounting for 2.9% of patients each. 5. Satisfaction of patients Figure 2. Satisfaction of patients after surgery 72 JMR 116 E3 (7) - 2018 JOURNAL OF MEDICAL RESEARCH Of the 34 patients who used postoperative analgesia, there were 25 patients were satisfied with 73.5%, 9 patients (26.5%) were dissatisfied with this therapy. .6. Reusing this therapy in the next surgery Table 3. Percentage rate of reusing epidural analgesia Reusing Level of satisfaction Yes No N Rate (%) n Rate (%) Satisfaction 17 50% 8 23,5% Dissatisfaction 0 0% 9 26,5% In 25 satisfied patients with the use of epidural analgesia, 17 patients agreed to use this ther- apy again if undergoing another procedure, accounted for 50%. There were 8 patients who was not going to reuse the epidural analgesia, account for 23% 5%. Of the 9 patients who were dissat- isfaction, no patients wanted to use the therapy again. IV. DISCUSSION Results in the Figure 3.1 show that the mean age of the patients was 34.3 ± 4.2 years old, in which the proportion of patients in the age group from 25 to 35 accounted for the highest rate of 50%. Patients in the age group of over 35 years old accounted for 41.2% and only 8.8% of were aged < 25 years. This is considered to be the age of reproduction; the patient is stable both in health status, fertility as well as physiology. According to the study, we found that the group of cesarean section surgery is significant, accounting for 88.2%, 4 patients with gynecological surgery accounted for 11.8%. This may be due to anxiety, fear of postoperative pain and neonatal care and breast feeding of the mothers. In addition, due to increasing living conditions, access to re- productive health services is becoming easier, which influences the choices patients make in order to be comfortable and in less pain, with- out maternal or neonatal effects. There is in- creasing concern about the need for postpar- tum analgesia. In Table 1, we found that the mean VAS score at the 12 hours postoperative was 3.76 ± 2.64, which then tended to decrease gradu- ally. At 24 hours postop, mean VAS score was 3.32 ± 2.57, and after 36 hours the mean VAS score was 2.91 ± 1.99. The results in Table 3.2 show that the number of patients requiring combination therapy with other pain relievers such as paracetamol, suppository, and mor- phine were 22 patients, accounting for 64.7%, only 35.3% of patients did not have any other combination therapy of pain relief . The re- sults of our study differ from those of some authors. Tran Do Anh Vu, Nguyen Van Chung (2014) showed that epidural analgesia had a significant effect of pain relief, which was 62.2% and good effect was 21.6%. 83.8% of patients were satisfied with the level of analge- sia alone, without other pain relief therapies [3]. Nguyen Trung Kien, Nguyen Huu Tu, Cong Quyet Thang (2012) recorded that after epidural analgesia from 1 hour onwards, 100% of participants had mild pain or no pain (VAS < 2) [4]. Block et al. (2003) performed a meta- JMR 116 E3 (7) - 2018 73 JOURNAL OF MEDICAL RESEARCH analysis of 1404 scientific articles with 100 article selection criteria, comparing the pain relief quality of epidural analgesia with the use of bodily opioids. The authors concluded that pain relief by epidural analgesia has better quality than using bodily opioids and was effective until the 4th day postoperatively [5]. This difference may be due to the fact that our hospital recently began implementing postoperative anesthesia with epidural analgesia, so the number of patients in our study was low and the dosage may not be appropriate for each patient. Our records indicate that none of the pa- tients had symptoms of vomiting or headache, and only one patient had lower extremity weakness, and rehabilitation after 2 hours of stop using drug and continue to use lower doses . Our results are similar to those of other authors, Phan Ton Ngoc Vu, Nguyen Van Chung (2011) who reported the number of patients with lower extremity weakness after receiving epidural analgesia was 2.8% and improved after 2 hours of using lower doses. Hoang Xuan Quan, Nguyen Quoc Kinh (2014) reported nausea and vomiting side effects in the group of patients with epidural analgesia were 9% versus 28% in the intravenous mor- phine group [7]. The results in Figure 3.2 and Table 3.4 show that 73.5% of patients were satisfied with epidural analgesia therapy. The remaining 9 patients accounted for 26.5% were not happy about this therapy. Nine pa- tients were not satisfied with this method be- cause postoperative pain remained severe according to their VAS scores, and so patients had to use other pain management methods such as suppository combination with the high cost of pain relief with epidural analgesia ther- apy but the quality of the pain is not adequate, so patients do not intend to use the method again next time . In the 25 patients who were satisfied with this method, there were 17 pa- tients who would undergo this therapy again (68%), and eight patients who would not use the method again (32%). Of the 8 patients who were satisfied with this method but did not plan to use it next time, two patients under- went sterilization and so did not intend to have another baby and two patients underwent hys- terectomy. In addition, four patients found that the cost of the epidural analgesia therapy to be quite high (3,000,000 VND) compared with other pain relief therapies and they could not tolerate that the injection site felt irritated for 3 days. V. CONCLUSION Postoperative pain relief with epidural anal- gesia is a safe technique with a significant effective on pain relief, but initial implementa- tion has not reached the expected results. The optimal analgesic effect should be combined with other analgesic therapies, which do not achieve the desired results and need to con- duct large scale studies, with strict designa- tion, reasonable doses. ACKNOWLEDGEMENTS We would like to give many thanks to the patients and staff members at the Department of Required services Treatment, the National hospital of Obstetrics and Gynecology for their assistance during this study. REFERENCES 1. Lavand’homme P (2006). 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