Acute pain management following laryngectomy

To evaluate the adequacy of as-needed (prn) dosing of narcotics during the acute postoperative period following laryngectomy and to evaluate the role of nurses' interpretation and implementation of narcotic orders in postoperative pain management.

A retrospective review of the medical records of 37 patients who underwent laryngectomy at the University of Oklahoma. The postoperative care was standardized through a clinical pathway to provide a uniform level of care.

The parameters reviewed include (1) the type and dose of analgesic prescribed, (2) the quantity and frequency of analgesic administered to each patient, and (3) the adequacy of the initial pain-control prescription.

All physician orders for narcotics were at or above the minimum dosing guidelines; 68% met a recommended adequate postoperative prescription for moderate pain. However, none of the patients actually received the intended dose during a 24-hour period while hospitalized. Physicians were contacted about 13 patients (35%) because of inadequate pain relief, but only 8 patients (22%) had their narcotic dose increased appropriately. Patients were dosed below the minimum prescribed dose 19 times (2.8%), and in 24 instances (3.6%) the backup analgesic, designated as "prn breakthrough pain," was given as the primary analgesic.

As-needed dosing of analgesia resulted in suboptimal pain control for at least 35% of patients undergoing laryngectomy. Inadequate prescription and variable implementation of prn orders contributed to this.