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The national discussion forum and community for UK Healthcare Professionals with an interest in acute, chronic, or palliative Pain Management.
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This page was last updated: November 19, 2007
prospect: procedure-specific postoperative pain management
On behalf of the prospect Working Group
Introduction
Inadequate pain management following a surgical procedure is a frequent problem. Approximately 70% of patients experience pain that is moderate, severe or extreme after surgery, a problem which may be due to the use of generalised guidelines that do not consider the effect of varying analgesic efficacy between different operative procedures. As analgesic and technical advances are made in acute pain management, it is increasingly important to evaluate the options, considering the operative procedure as well as patient risk factors to determine the most favourable regimen for patient recovery.
The prospect initiative (www.postoppain.org) presents evidence-based guidelines for postoperative pain management, formulated by consensus opinion of an international Working Group of surgeons and anaesthesiologists. Recommendations are based on evidence from procedure-specific systematic reviews, and consider the balance of risks and benefits for each intervention in the context of clinical practice. The prospect Working Group formulates recommendations for the use of analgesic, anaesthetic and surgical techniques in different operative procedures. The prospect web site is used internationally, and provides clinicians with the evidence to make informed decisions about pain therapy. Building on experience from previous prospect reviews, prospect methodology has recently been refined to take greater account of the quality of available evidence, to increase accuracy and reduce ambiguity, to reduce potential bias, and to enable the user to better judge the strength of the recommendations.
Methodology
The prospect review process begins with a systematic review of the literature, based on the protocol of the Cochrane Collaboration. The specific inclusion criteria for the review require randomised studies reporting pain scores on a visual analogue or verbal/numerical rating scale. Two or three prospect Working Group members (and usually an expert clinician external to the prospect group) with particular interest and expertise in the operative procedure to be reviewed, are closely involved in designing the review strategy, together with a medical writing team. Where there is limited procedure-specific evidence regarding the analgesic effects of a particular intervention, the group may agree to include supplementary “transferable” evidence from other procedures with a comparable pain profile. Transferable evidence regarding adverse effects may be extracted from a variety of other surgical procedures. Members of the prospect Working Group first comment on the review using the Delphi Method, and thereafter collated comments are shared and discussed until a group consensus is achieved.
How are the recommendations developed?
prospect online
The final version of the review is presented on the prospect web site (www.postoppain.org). Evidence and graded recommendations for peri-operative interventions are contained within folders in a tree structure, with procedure-specific evidence, transferable evidence, clinical practice information and recommendations clearly separated, allowing quick and easy access to the relevant information. A summary of the recommendations and details of the systematic literature review are also presented, and overall recommendations are included as a flow diagram showing a pathway for the continuity of the pre-, intra-, and post-operative pain management. Lists of included and excluded studies, links to abstracts, and qualitative and quantitative (meta-analysis, where possible) analyses may also be found on the web site.
The web-based format offers a user-friendly way to present the large amount of information contained within each review, and encourages users to submit feedback to the Working Group via the web site. Every 2–3 years following a procedure review, the prospect group performs an assessment of newly published trials in that procedure to determine whether a change to the recommendations is warranted – if so, the review is updated accordingly.
Summary: advantages of the prospect process
•Procedure-specific recommendations take into consideration the differences in character, location and severity of pain associated with different surgical procedures
Procedure-specific recommendations take into consideration the differences in character, location and severity of pain associated with different surgical procedures•Evidence from a systematic review is supplemented with transferable evidence and expert knowledge from a Working Group of surgeons and anaesthesiologists
Evidence from a systematic review is supplemented with transferable evidence and expert knowledge from a Working Group of surgeons and anaesthesiologists•Consensus recommendations are formulated by the Working Group, using established methods for group decision-making (Delphi method, Nominal Group Process)
Consensus recommendations are formulated by the Working Group, using established methods for group decision-making (Delphi method, Nominal Group Process)•Recommendations are graded to indicate the strength of recommendations (A–D), and are provided with an explanation of the evidence on which they are based, including the level (LoE 1–4) and source (procedure-specific or transferable) of evidence, with study design, quality, consistency and directness being taken into consideration
Recommendations are graded to indicate the strength of recommendations (A–D), and are provided with an explanation of the evidence on which they are based, including the level (LoE 1–4) and source (procedure-specific or transferable) of evidence, with study design, quality, consistency and directness being taken into consideration•All procedure-specific evidence from the systematic review, as well as transferable evidence, is summarised and abstracts of all references are provided; clinical practice information (expert opinion) is also presented in a clearly separate section
All procedure-specific evidence from the systematic review, as well as transferable evidence, is summarised and abstracts of all references are provided; clinical practice information (expert opinion) is also presented in a clearly separate section•Benefits and disadvantages of different interventions are indicated with a system of √ and X , and the balance of benefits and disadvantages is considered in formulating the recommendations
Benefits and disadvantages of different interventions are indicated with a system of √ and X , and the balance of benefits and disadvantages is considered in formulating the recommendationsCurrent reviews of postoperative pain management
Currently prospect recommendations are available for the following procedures:
There is also a link to the detailed methodology employed by the prospect Working Group during the review process.
Total knee arthroplasty is the most recent procedure to be added (May 2007), and reviews of pain management after breast surgery and haemorrhoidectomy are currently in development.
The prospect Working Group
Professor Henrik Kehlet (Chairman)
Professor Francis Bonnet
Professor Frederic Camu
Dr Barrie Fischer
Professor Girish Joshi
Professor Edmund Neugebauer
Professor Narinder Rawal
Professor Stephan Schug
Dr Christian Simanski
prospect publications
1.Fischer B, Simanski C, on behalf of the PROSPECT Working Group. A procedure-specific systematic review and consensus recommendations for analgesia after total hip replacement. Anaesthesia 2005; 60: 1189–1202.
Fischer B, Simanski C, on behalf of the PROSPECT Working Group. A procedure-specific systematic review and consensus recommendations for analgesia after total hip replacement. Anaesthesia 2005; 60: 1189–1202. 2.Gray A, Kehlet H, Bonnet F, Rawal N. Predicting postoperative analgesic outcomes: NNT league tables or procedure-specific evidence? Br J Anaesth 2005; 94 (6): 710–14.
Gray A, Kehlet H, Bonnet F, Rawal N. Predicting postoperative analgesic outcomes: NNT league tables or procedure-specific evidence? Br J Anaesth 2005; 94 (6): 710–14.3.Kehlet H, Gray A, Bonnet F, Camu F, Fischer BJ, McCloy RF, Neugebauer EAM, Puig MM, Rawal N, Simanski CJP. A procedure-specific systematic review and consensus recommendations for postoperative analgesia following laparoscopic cholecystectomy. Surgical Endoscopy 2005; 19 (10): 1396–415.
Kehlet H, Gray A, Bonnet F, Camu F, Fischer BJ, McCloy RF, Neugebauer EAM, Puig MM, Rawal N, Simanski CJP. A procedure-specific systematic review and consensus recommendations for postoperative analgesia following laparoscopic cholecystectomy. Surgical Endoscopy 2005; 19 (10): 1396–415.4.Kehlet H, Wilkinson R, Fischer HBJ, Camu F, on behalf of the PROSPECT Working Group. PROSPECT: Evidence-based, procedure-specific postoperative pain management. Best Practice and Research: Clinical Anaesthesiology 2007; 21 (1):149–59.
Kehlet H, Wilkinson R, Fischer HBJ, Camu F, on behalf of the PROSPECT Working Group. PROSPECT: Evidence-based, procedure-specific postoperative pain management. Best Practice and Research: Clinical Anaesthesiology 2007; 21 (1):149–59.5.Neugebauer E, Wilkinson R, Kehlet H, on behalf of the PROSPECT Working Group. Transferable Evidence in Support of Reaching a Consensus. German Journal for Evidence and Quality in Healthcare Special issue: ‘Guidelines and Consensus' [Z.ärztl. Fortbild. Qual.Gesundh.wes. (ZaeFQ) 101 (2007) 103–107]
Neugebauer E, Wilkinson R, Kehlet H, on behalf of the PROSPECT Working Group. Transferable Evidence in Support of Reaching a Consensus. German Journal for Evidence and Quality in Healthcare Special issue: ‘Guidelines and Consensus' [Z.ärztl. Fortbild. Qual.Gesundh.wes. (ZaeFQ) 101 (2007) 103–107]6.Neugebauer E, Wilkinson R, Kehlet H, Schug S, on behalf of the PROSPECT Working Group. PROSPECT: a practical method for formulating evidence-based expert recommendations for the management of postoperative pain. Surgical Endoscopy 2007; 21 (7): 1047–53.
Neugebauer E, Wilkinson R, Kehlet H, Schug S, on behalf of the PROSPECT Working Group. PROSPECT: a practical method for formulating evidence-based expert recommendations for the management of postoperative pain. Surgical Endoscopy 2007; 21 (7): 1047–53.7.Stephan A. Schug, Henrik Kehlet, Francis Bonnet, Frederic Camu, Barrie Fischer, Girish Joshi, Edmund A.M. Neugebauer, Narinder Rawal and Christian Simanski. Procedure specific pain management after surgery—“PROSPECT”. Acute Pain 2007, 9 (2): 55–57.
Stephan A. Schug, Henrik Kehlet, Francis Bonnet, Frederic Camu, Barrie Fischer, Girish Joshi, Edmund A.M. Neugebauer, Narinder Rawal and Christian Simanski. Procedure specific pain management after surgery—“PROSPECT”. Acute Pain 2007, 9 (2): 55–57.
Feedback from prospect users:
“Congratulations on a fabulous site – great synthesis of the evidence and very easy to navigate!!” prospect user, Canada.
“I love the site. It is easy to navigate, and contains concise and precise information with references so that the evidence may be gathered oneself.” prospect user, Wales, UK
“I am enjoying reading your recommendations and find the format very easy to use.” prospect user, Australia
