a review of the acute pain service in hospital kuala lumpur · original article a review of the...

ORIGINAL ARTICLE

A Review of the Acute Pain Service in HospitalKuala Lumpur

G Neelima, MAnaes*, D C Chieng, BMedSc*, T A Linl, FRCA*, K Inbasegaran, FANZCA**

-Anaesthesiology Unit, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, --Department ofAnaesthesiology and Intensive Care, Hospital Kuala Lumpur

Introduction

Post-operative pain is the most common form ofacute pain and is either the result of surgicalprocedures or the underlying pathologicalcondition' . It is not a separate phenomenon butone of the body's responses to surgery and isintegrated with several other complex networkssuch as autonomic response, protein catabolism,hypercoagulobility, increased vascular demandand immunosuppression 2.

Most patients expect to experience pain after asurgical operation but are willing to suffer the painrather than complain about it, even though theyexpect their pain to be promptly treated 2,3, Nursesand other medical staff may also have

misperceptions about post-operative pain relief.Due to fear of side effects and narcotic addiction,nurses give less than sufficient analgesia to thepatients 4. Some nurses will only provide analgesiawhen the patient requests it, unaware that manypatients are reluctant to request for analgesia 3.

Underestimation of the amount of analgesiarequired by the patient to maintain pain relief alsooccurs 5,6. Physicians tend to overestimate the painrelief while underestimating the pain itself 7.

The advantages of a service catering specificallyfor post-operative pain relief had been shown 20years ago 8. Today, such services have been set upin many countries to facilitate post-operative care8,9,10.11 • The role of the Acute Pain Service CAPS) is to

This article was accepted: 10 November 2002 . . . .Corresponding Author: TA Lim, Anaethesiology Unit, Fakulti Perubatan dan Sains Kesihatan, Umversltl Putra Malays/Q, HKL, Ja/anMasiid 50586 Kuala Lumpur

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ORIGINAL ARTICLE

improve the pain relief of patients through bettermanagement, quality control, and choice ofanalgesia in terms of drugs and methods ofadministration. Better pain relief will lead toreduced post-operative complications, hospitalstay and costs 1.9,12. The APS can provide postoperative pain relief using a wide range ofanalgesic techniques without endangering patientsafety 13.

An Acute Pain Service requires a well-organisedset-up. This includes the training of nurses anddoctors, familiarity with the available equipment,together with the use of guidelines and protocolsfor safe operation. The effectiveness of the APSneeds to be regularly evaluated in order toimprove the service.

In Hospital Kuala Lumpur (HKL), an APS has beenproviding post-operative pain management since1993. The aim of this study is to review theeffectiveness and safety of the analgesic modalitiesmanaged by the APS in HKL.

Materials and Methods

The study is a retrospective review of patientsunder the care of the Acute Pain Service ofHospital Kuala Lumpur from 1998 to 2001.Records of post-operative surgical, gynaecologyand orthopaedic patients were included in thestudy. Data from patients below the age of 12years and records with missing vital informationwere excluded.

Data Collection

The data used was obtained from the APS recordsheets (appendix n, which were completed by theAPS staff during their twice-daily ward round. Painscores were recorded hourly for the first 4 hours,and were subsequently recorded 4 hourly. From

, 1999 to 2001, the pain score (0 to 10) was obtainedusing the visual analogue scale (VAS). Pain scoreswere taken using the verbal descriptor scale in1998, and were excluded from the analysis.

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The period during which the patient was under thecare of the APS was recorded as the duration ofanalgesia. Side effects such as pruritis, nausea andvomiting, respiratory depression, numbness andurinary retention were noted.

The analgesic techniques were grouped in thefollowing fashion:PCAM: Patient controlled analgesia with either

morphine or pethidineEPIDC: Epidural infusion of a mixture of

bupivacaine and fentanyl.EPIDP: Epidural infusion of morphine or

pethidine either by continuous or patientcontrolled infusion

Others: Includes all other modalities not includedin the above categories.

The data collected was entered into a computerusing Microsoft® Access 2000 (9.0.2720). All VASpain scores in the APS record sheets were roundedto the nearest whole number to facilitate dataanalysis. For each patient, the followingparameters were derived:

Lowest pain score at rest:Score at rest taken on the first visit by the APS staff,at least 6 hours after the analgesic technique wasstarted.

Highest pain score:Highest pain score during the whole postoperative period, including the first day.

Day of the highest pain:Day the highest pain score was recorded.

Data Analysis

Data analysis was done using SPSS version 9.05database software. Differences betweenproportions were compared using the X' test.Differences between means were compared usingStudent's t-test and Analysis of variance asappropriate. When the distribution was, notnormal, Mann-Whitney U-test was used in place ofthe Student's t-test. Analysis of covariance and

Med J Malaysia Vol 58 No 2 June 2003

logistic regression was used when severalcovariates and factors influenced the outcome. Avalue of p < 0.05 was considered significant.

Results

Patient data

The APS managed 5189 patients from 1998 to 2001.One hundred and forty-seven children below theage of 12 were excluded from the study. Nopatient was excluded due to incomplete or missingvital data.

Distribution of patients' age, weight and gender isshown in Table 1. The APS managed more femalethan male patients in all of the 4 years reviewed.However, the male to female ratio was notsignificantly different between years (X2 = 356, df= 3, p = 0.32). There was no significant differencebetween the mean ages of the patients in the fouryears under review (F = 0.35, p = 0.79). Meanweight was also not significantly different (F =

1.77, P = 0.15).

Analgesic technique

Most patients (61.3%) received PCAM for postoperative analgesia, followed by EPIDC (29.1%),EPIDP (9.2%) and others (0.4%). The proportionof techniques used were significantly differentbetween the years (X2 = 248, df = 6, p < O.OD. Theproportion of patients managed with EPIDCincreased while the proportion of patients havingEPIDP declined.

Within the PCAM group, 22 patients (0.72%) hadpethidine instead of morphine. All patients in theEPIDC group had a mixture of bupivacaine andfentanyl. In the EPIDP group, 4 patients (0.95%)had epidural morphine instead of pethidine. Asless than 1% of patients were given PCA pethidineor epidural morphine, these patients were notanalysed as separate groups.

Thirty-eight patients (8.2%) received patientcontrolled epidural analgesia (PCEA) with


A Review of the Acute Pain Service in Hospital Kuala Lumpur

pethidine instead of a continuous epiduralinfusion. Of these patients, only 10 had painscores which could be used in the analysis. Assuch, patients who received PCEA pethidine wereconsidered a sub-group of EPIDP and whereappropriate, further analysis was done withpatients who received PCEA pethidine being aseparate group.

The majority of the patients treated by the APSwere from general surgery (39.7%) andgynaecology (26.7%), followed by orthopaedics(17.6%), urology (13.7%) and plastic & ENTsurgery (2.3%). Most of the general surgicalpatients had abdominal or thoracic surgery. TableII shows the distribution of patients by techniqueand surgical discipline.

Pain Score

Pain scores in 1998 were obtained using a mixtureof visual analogue and verbal descriptor scales.Thus, the pain scores for that year were excludedfrom the analysis. A total of 3333 (88.4%) recordswere complete with the highest pain score, ofwhich 3266 (86.6%) recorded the day the highestpain score occurred. There were 3181 (84.4%)records available for analysis of the lowest painscore at rest.

A highest pain score of 6 or less during the entirepost-operative stay was recorded in 81.8% of thepatients. The highest pain score occurred on thefirst post-operative day in 68.3% of the patients.Resting pain score on the first post-operative daywas 3 or less in 82.1% of the patients. Distributionof highest pain scores, day the highest pain scoreoccurred and lowest pain scores at rest, in patientswho had patient controlled or epidural analgesia,are shown in Figures 1 to 4.

Using univariate analysis, age, gender, analgesictechnique and surgical discipline significantlyinfluenced the highest pain score (Table III).Using analysis of covariance, age, analgesictechnique and surgical discipline were found to beindependent predictors. There were' no

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ORIGINAL ARTICLE

interactions between factors. The result of theanalysis was not different when PCEA pethidinewas considered as a separate analgesic technique.

Side Effects

The incidence of side effects attributed to patientcontrolled and epidural analgesia is shown inTable IV. Respiratory depression was a rareoccurrence. There were only 8 cases reported outof 5021 patients.

Nausea and vomiting was common with 23.2% ofthe patients complaining of at least one episode.The incidence of nausea and vomiting betweentechniques was significantly different with patientsmanaged with EPIDC having the lowest (20.0%).Nausea and vomiting was more commonly seen inwomen. The incidence was highest amonggynaecology patients and lowest among generalsurgical patients. Age, duration of analgesia andpain scores were also significantly differentbetween patients who complained of nausea andvomiting, and patients who did not. Whensubjected to logistic regression, gender, analgesictechnique, surgical discipline, duration ofanalgesia .and resting pain score were found tosignificantly affect the incidence of nausea andvomiting. The result of the analysis was notdifferent when PCEA pethidine was considered asa separate analgesic technique.

Seventy-eight cases of pruritis were recorded and58 cases involved patients using PCAM. However,

170

the proportion of pruritis between PCAM, EPIDCand EPIDP was not significantly different (X 2 =

5.54, df = 2, P = 0.063). Paraesthesia occured in10.6% of patients who received EPIDC.

Other problems related to the APS are shown inTable VI. 194 patients had their analgesictechnique changed at least once during theirtreatment period. Out of these, 122 patientsstarted off with EPIDC while 56 EPIDP patientsrequired a change of technique. Patients managedwith PCAM required significantly less change oftechnique when compared with EPIDC and EPIDP(X2 = 255, df = 2, P < 0.01).

The most common catheter related problem wascatheter slippage. Other catheter problems wereblockage (6 cases), disconnection from bacteriafilter (18 cases) and catheter contamination (1case). Nine of the catheter related probleminvolved usage of PCAM, the most common beingdisconnection of the intravenous infusion in 5cases. The other four cases were due to blockageand contamination. Catheter insertion siteproblems include bleeding or purulent discharge,inflammation and leakage of infusion fluid.

Twelve patient were either disoriented, confusedor both and could not score their pain when askedby the nurse. Another 62 patients either refused touse the analgesic or ask' to be taken off themachine. The 17 cases of machine error includepower failure, programming error, syringe pumpproblem and other malfunction.



Table I: Distribution of Patients by Gender, Age and Weight

Year

1998 1999 2000 2001 Total

Number of Patients 1271 1166 1402 1203 5042Sex

Male 546 523 602 554 2225Female 725 643 800 649 2817

Age (years)

Mean (SD) 47.0 (16.9) 46.6 (16.7) 47.1 (17.1) fi6.6 (17.2) 46.8 (7.0)Range 12 - 95 12 - 90 12 - 89 12 - 88 12 - 95

Weight (kg)

Mean (SD) 59.5 (15.0) 59.6 (13.3) 60.1 (13.2) 60.9 (16.2) 60.0 (14.4)

Range 16 - 160 20 - 155 17 - 120 23 - 270 16 - 270

Technique

PCAM 776 725 893 694 3088

EPIDC 300 266 418 484 1468

EPIDP 188 172 89 16 465

Others 7 3 2 9 21

Table II: Distribution of Patients by Surgical Discipline

Discipline

Orthopaedics General Surgery Gynaecology Urology Plastic &

ENT Surgery

Number of Patients 889 2000 1344 692 117

Year

1998 201 554 351 140 25

1999 168 519 284 175 20

2000 271 532 392 181 26

2001 249 395 317 196 46

Technique

PCAM 556 1289 790 377 76

EPIDC 279 513 390 252 34

EPIDP 50 189 160 61 5

Others 4 9 4 2 2


ORIGINAL ARTiClE

Table III: Factors and covariates influencing the highest pain score

Factor / Covariate Pain score Significance(mean ± SD) Univariate Analysis of

Analysis CovarianceGender

Male 4.48 ± 2.44 t= 2.84, F= 0.01,Female 4.25 ± 2.26 p < 0.01 p = 0.92

TechniquePCAM 4.54 ±2.25 F = 18.8, F= 5.06,EPIDC 3.99 ± 2.51 p < 0.01 p < 0.01EPIDP 4.19 ± 2.31

Surgical DisciplineOrthopaedics 4.28 ± 2.49Gen Surgery 4.62 ± 2.37 F= 13.3 F= 3.46Gynaecology 4.05 ± 2.15 p < 0.01 P < 0.01Urology 4.50 ± 2.33Plastic & ENT 3.18 ± 2.39

Age (years) r = -0.04, F= 5.68p = 0.02 p =0.02

Weight (kg) r = 0.013,p = 0.53 -

Table IV: Incidence of side effects

Side Effect: TechniquePCAM EPIDC EPIDP Total

n = 3088 n = 1468 n = 465 n = 5021Respiratory Depression 5 1 2 8Pruritis 58 15 5 78Nausea and Vomiting 756 294 116 1166Urinary Retention 2734 1335 426 4495Hypotension - 5 1 6Death 8 3 3 14Giddiness 125 30 23 178Numbness 1 156 3 160Sedated 19 3 3 25Headache 5 4 2 11Other 4 1 - 5

172 Med J Malaysia Vol 58 No 2 June 2003


Table V: Factors and covariates influencing the incidence of nausea and I or vomiting

Factor / Covariate Patients with Patients with Sianificance

nausea / vomiting no nausea / vomiting Univariate Logistic

Analysis Regression

Gender

Male 326 1899 X2 = 162, P < 0.01

Female 842 1975 p < 0.01

Technique

PCAM 756 2332 X2 =14.2,

EPIDC 294 1174 p < 0.01 p < 0.01

EPIDP 116 349

Others 2 19

Surgical Discipline

Orthopaedics 189 700

Gen Surgery 309 1691 X2 = 180, p < 0.01

Gynaecology 474 870 p < 0.01

Urology 167 525

Plastic & ENT 29 88

Age (yr) (mean ± SD) 44.5 ± 15.6 47.5 ± 17.3 t = 5.27, p < 0.01 p = 0.063

Weight (kg) (mean ± SD) 60.0 ± 14.4 60.0 ± 14.4 1=-0.11, P = 0.91 -

Duration of analgesia (hr) 2 [1 - 9] 2 [1 - 13] U = 2004976,

(median [range]) p < 0.01 p = 0.011

Pain score at rest 2 [0 - 10] 1 [0 - 10] U = 853065,

(median [range]) p < 0.01 p < 0.01

Highest pain score 4.5 [0 - 10] 4.3 [0 - 10] t=-2.01,

(mean [range]) p = 0.045 p = 0.13

Day of highest pain 1 [0 - 5] 1 [0 - 17] U = 1696455,

(median [range]) p < 0.01 P = 0.64

Med J Malaysia Vol 58 No 2June 2003 173

ORIGINAL ARTiClE

Table VI: Other problems encountered by the APSProblem: Number of Cases

Scoring Related Problem

Catheter Related Problem

Catheter Insertion Site Problem

Machine Error

Patient Changing Analgesic Technique

Usage Related Problem

88152

52

17

194

77

25

10

20

9 10

0-

Rl PCAM

8XJ EPIDC

!ilim EPIDP

Analgesia Technique

2804 1227 405N = 2693 1174385

~ 6

'"c:

~ 4

Score at rest Highest scoreHighest Pain Score

Fig. 1: Box and whicker plot showingdistribution of lowest pain scores atrest and highest pain scores. The darkline represents the median while thebox represents the inter-quartilerange.Number of records analysed =3757

Fig. 2: Distribution of highest pain scoresNumber of records analysed = 3326

80-60

70

60·

jgi 50-

~ 40

~~ 30cr

20

10

3 4 5 6 7 9 >10

Day highest pain score occurred

50

~ 40

[

~ 30

'".l!lg

~ 20

10

9 10

Resting Pain Score

Fig. 3: Day on which the highest pain scoreoccurredNumber of records analysed =3260

Fig. 4: Distribution of the lowest pain score atrestNumber of records analysed = 3174

174 Med J Malaysia Vol 58 No 2 June 2003

Discussion

Pain Assessment

Pain is a subjective experience and it is difficult toobjectively quantify it. Assessment of a patient'spain depends on the patient's overtcommunication, both verbal and behavioural 14.

As pain assessment requires translation of asubjective quality into an objective one, the painscores commonly in use may not necessarilyreflect the patient's pain. In spite of this, the VisualAnalogue Scale (VAS) is a useful tool for thestatistical study of pain. The VAS is useful inassessing both pain intensity and pain relief 7.

During the APS rounds in HKL, patients wereasked to indicate their level of pain along a scale ofo to 100 mm. However, most values recorded bythe APS team was in whole numbers and in orderto standardise the reported values, the VAS wasconverted to a discontinuous numerical ratingscale for the purpose of this review. Each numberof the numerical scale is assumed to represent aproportional increase in pain intensity. We thencorrelated the numerical scale to the verbaldescriptor scale in the following manner 15:


episode of severe pain (VAS 7 - 10) and another31.2% had at least one episode of moderate pain(VAS 4 - 6) during the post-operative period. Thehigh percentage of patients reporting moderate tosevere pain might be misleading because it isbased on a single highest pain experienced by thepatient during the whole post-operative period.Such episodes of moderate or severe pain couldhave occurred once or a few times.

In the United Kingdom, it was proposed in 1997that less than 20% of patients should experiencesevere pain following surgery 15. While theincidence of severe pain in our study is high, it isstill within the above limit.

In this review, patients treated with PCAM hadhigher pain scores than patients given EPIDC orEPIDP. While it is likely that the epiduraltechniques are more effective than intravenousPCA, the difference in pain scores, thoughsignificant, were not very great (Table III).Similarly, while there was significant correlationbetween age and highest pain scores, the variationwith age was small. Mean pain score for patientsaged 20 to 30 years was 4.57 while patients aged60 to 70 years scored 4.36.

However, in post-operative patients, it is a better tomeasure pain on movement rather than pain at rest". We found that 18.3% of patients had at least one

The highest pain score occurred mostly on the firstpost-operative day. This indicates that mostpatients felt that the pain on the first post-operativeday was most painful regardless of the magnitudeof the pain. In spite of this, the first day restingpain scores were low and are comparable to otherstudies 10.16,17,18,19,20,21.

Numerical RatingPain Score

o1 - 34-67-9

10

Verbal DescriptorScale

No painMild pain

Moderate PainSevere Pain

Worst Possible Pain

General surgical and urology patients generallyhad higher pain scores. This can be expectedfrom the site and nature of the operations. Gynaecologypatients, whose procedures were confined mainlyto the lower abdominal region, had slightly lowerpain scores. Patients who underwent spinesurgery generally had higher pain scores, thusincreasing the mean score in orthopaedic patientsas a whole. Again, while the mean pain scoreswere statistically different, the mean highest painscores for these four groups fell within the 4.0 to4.7 range.

The only group with significantly lower painscores than all others were patients who hadplastic & ENT surgery. Most of these patients hadhead and neck surgery.


ORIGINAL ARTICLE

Analgesic techniques

In our study, we found PCAM was more often usedthan the epidural techniques. This could bebecause of the simplicity of an intravenous PCAsystem. In addition, epidural analgesia is notsuitable for operations involving the head, neckand upper limbs.

We also found a decline in the use of epiduralpethidine during the period covered by thisreview. During this period, the pethidine solutionused for epidural infusion could only be kept forthree days, after which it needed to be discarded.This meant that when it was planned to start apatient on an epidural pethidine infusion postoperatively, the APS needed to be informed a dayearlier. Very often, it was not easy to do so, as thetime of the pre-operative visit by the anaesthetistwas very variable. This led to patients being givenlocal anaesthetics rather than pethidine foranalgesia.

The proportion of patients changing analgesictechniques differed significantly betweentechniques. Patients on epidural analgesia (eitherEPIDC or EPIDP) were changed to PCAM for avariety of reasons, including inadequate analgesiaand problems related to the epidural catheter.

Side effects and other problems

In this review, only two of the reported side effectshad an incidence of over 5%. The incidence ofrespiratory depression, sedation, hypotension andpruritis were lower than the corresponding valuesreported in other studies 10,13,16,18,23,24,25.

There was a high incidence of nausea andvomiting in the patients managed by the APS,comparable to the results of other studies 10,25.

Logistic regression revealed that gender, analgesictechnique, surgical discipline, duration ofanalgesia and resting pain score significantlyinfluenced the incidence of nausea and vomiting.However, there were interactions between gender,analgesic technique and surgical discipline.

176

It was found that female patients were twice aslikely to have nausea and vomiting than malepatients (30% vs. 15%), Patients treated usingEPIDC, and patients with lower pain scores had alower incidence of nausea and vomiting. Thiscould be because these two groups of patientsreceived less opioids for analgesia. On the otherhand a lower duration of analgesia was associatedwith 'a higher incidence of nausea and vomiting.These patients were likely to be those who werenot as ill, and were able to ambulate early. Femalegender, opioid analgesics and movement areknown factors associated with post-operativenausea and vomiting 26.

Most patients were catheterised in the postoperative period. Whether the catheterisation wasbecause of the analgesic technique or theoperation is not certain.

With the epidural technique, numbness andcatheter slippage were common problems.Numbness over the lower limbs occurred almostexclusively in patients given EPIDC. Epiduralcatheter slippage occurred in 6,1% of patients. Theincidence of these two problems was similar toother studies 10,16.

We also noted 62 patients either refused to use theanalgesic technique prescribed, or asked to betaken off the infusion pump, This could bebecause of the patients' fear of a high blood levelof opioid, as well as insufficient information on thecorrect usage of the PCA device 27. Another patientperceived disadvantage is the fear that too muchanalgesia will lead to loss of contact with thenurses 28.

Comparison with previous reports from 1995to 1997

Results from this study were compared with' dataobtained from the annual reports of the APS in1995 to 1997. During that period, subcutaneousmorphine was the technique managed by the APSin 14.9% of patients, However, the individualsurgical units now manage patients onsubcutaneous morphine. Between 1995 to 1997,


62.1% of patients had PCAM while 22.6% had.epidural analgesia. While the proportion ofpatients receiving PCAM did not differ greatlybetween 1995-1997 and 1998-2001, the differencein usage of epidural techniques between the twoperiods was about 15%. This reflects an increasedtendency to use regional analgesia in the currentpractice.

Sixty-eight percent of patients reported no or mildpain on the first postoperative day in 1996 and1997. This is lower than the current percentage,and reflects an improvement in the service. Theincidence of nausea and vomiting has notchanged, with 23.4% of patients in 1996 and 1997complaining of this side effect.

Conclusions

From this review, we conclude that:1. The pain relief achieved in post-operative

patients managed by the APS in HKL iscomparable to that reported by otherinvestigators.

2. Patient controlled intravenous analgesiaremains the most popular choice of analgesictechnique.

3. The low incidence of side effects and problemsrelated to the APS reflects the safety of theservice.

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A Review of the Acute Pain Service in Hospital Kuala lumpur

Areas of improvement include:1. Better patient education to reduce the

incidence of severe pain, and reduce patientrefusal of the prescribed analgesic technique.

2. Adaptation of anaesthetic techniques and useof antiematics to decrease the incidence ofnausea and vomiting.

3. The analgesic techniques in use could beimproved. This includes:

a. Proper siting of the epidural catheter to ensurethe correct spinal segments and nerve roots areblocked. This would improve the efficiency ofthe technique and at the same time reduce thedosage and adverse effects.

b. The use of combination techniques where onetechnique can supplement another without aconcomitant increase in side effects.

Acknowledgements

The authors would like to thank Dr. Azian SyedOthman, staff nurse Rosemary Kinajil and staffnurse Annusuey Mariappan for their help andadvice with the collection of data for this review.The authors would also like to thank the DirectorGeneral of Health of Malaysia for permission topublish this article.

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Appendix 1

HOSPITAL KUAlA LUMPUR ACUTE PAIN SERVICE RECORD SHEET

Name: .RN: .Ie No: .Age: Sex: .Diagnosis/Operation: .

APS Technique: .Date started : ..Date end: ..

APS Record No : .Ward: .Weight: kgUnit: ..Incision : .

APS Technique: .Date started : .Date end : .

Epidural Level : . Skin Marking: cm Inserted by : Dr .

Oral Analgesic: Drug : Dose:............................. Date started: .

Date

Time

Seen by

Technique -

Total drug used sincelast review (mg or ml)

Pain* (rest)

Pain* (movement/cough)

Complications**

- respiratory

- pruritus

- nausea/vomiting

- urinary retenion***

- epid cath/cannula site

- giddiness

- others

Technique- SCM =Subcutaneous MorphinePCAM =PCA MorphineEPIOC =Epidural Cocktail

SCP =Subcutaneous PethidinePCAP = PCA PethidineEPIOP =Epidural Pethidine

*Pain Score: 0 =no pain, 1 =Slight pain, 2 =moderate pain, 3 =severe pain, 4 =worst pain imaginable(Record pain score at time of review)

**Complications score: 0 =mild, no treatment needed, 2 =moderate. helped by treatment3 =severe, despite treatment

***Urinary retention, 3 =needed to be catheterised, "CBO" if catheter in situ

Level of Satisfaction (tick one)Excellent 0 Good 0 Satisfactory 0 Poor 0


a review of the acute pain service in hospital kuala lumpur · original article a review of the...

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