A Study on Post Operative Pain Assesment on Arrival Using Vas Score among Urological Procedures after general Anaesthesia vs. Regional Anaesthesia

Background: A Visual Analogue Scale (VAS) is a measurement that tries to measure a characteristic or attitude that is believed to range across a continuum of values and cannot easily be directly measured [1]. The 100 mm visual analogue scale (VAS) score is widely used to measure pain intensity after surgery. The main objective here is to compare the effectiveness and safety of general anaesthesia (GA) vs. regional anaesthesia (RA) in urological procedures with the help of VAS. Methods: We enrolled a sequential, unselected cohort of fifty-two patients on arrival from surgery and used a VAS to quantify pain intensity. We compared changes in the VAS among patients who received either GA or RA for urological procedures. Patient’s comorbidities, vitals, pain visual analogue scale (VAS) are evaluated. Intraoperative and post-operative complications were recorded. Results: Vital parameters were maintained at safe values throughout the procedure in both groups. Visual analogue pain score was lower in regional anaesthesia till one hour mark of post-operative period as compared with GA cluster (P <0.05). Patients in regional anaesthesia recorded lower Study Protocol Madhumithra and Priya; JPRI, 33(47B): 630-635, 2021; Article no.JPRI.75028 631 consumption of analgesics during the post-operative day-0 as compared with GA cluster (P < 0.05). Post-operative shivering was higher in RA cluster than GA cluster (8% vs. 2%) whereas nausea and fever was higher in GA cluster than RA cluster (5% vs. 2% and 4% vs. 1% respectively). However, Patients in GA cluster recorded higher overall satisfaction scores than RA cluster. Conclusion: Both GA and RA were effective and safe in Percutaneous Nephrolithotomy. It is observed that PCNL under RA was associated with significantly shorter operative time and hospital stay. Furthermore, postoperative pain scores were low, lower nausea and/or vomiting, and reduced analgesic requirements were noted in the RA group. However, GA provides heaps of satisfaction for patients.


INTRODUCTION
Pain is generally considered as an important postsurgical complication, which may result in serious morbidities if left unaddressed [2].
Postoperative pain management remains a obvious challenge after urological surgery.
Adult patients requiring anaesthesia for renal and genitourinary surgery are often very old, and they may have a host of comorbidities, which pose serious problems before, during, and after surgery and anaesthesia. The choice of anaesthetic technique depends on a myriad of factors, including the patient's pre-existing conditions; type, site, and length of surgery to be performed; skill of the urologist and anaesthesiologist and their intimate knowledge of potential surgical and anaesthetic complications; and predictability and limitations of the surgical and anaesthesia procedures. Based on all of these factors, the ultimate decision of anaesthesia method needs to be the product of a well-informed discussion between the surgeon and the anaesthesiologist [3].
The modern ASA classification system [4], in conjunction with the full preoperative workup data of the patient, provides a degree of perioperative risk stratification that is very useful in choosing the optimal anaesthetic technique for a given patient undergoing a particular surgery.
Medical literature review denoted that there are still controversies whether RA or GA offers better advantages for urological/lower abdominal surgery. Although regarding postoperative pain scores and other complications needs further study, before final conclusion is elucidated. [5,6,7,8,9,10,11] Other medical literature added that in terms of acceptability and satisfaction level of patients, G.A is considered superior to that of R.A .In accordance to complications, R.A had fewer complications and good post-operative analgesic effect when compared to G.A .In view of acceptance, R.A is accepted more by anaesthesiologists when compared to G.A since it possess less morbid complications in comparison [12,13,14].

METHODOLOGY
The study protocol was conducted at SAVEETHA MEDICAL COLLEGE & HOSPITALS was approved by ICMR, between January 2021 and March 2021, fifty-two patients of either sex, aged from twenty to sixty years underwent urological procedures. This prospective study evaluated adult patients recovering from surgery, using the 10 cm VAS to measure pain. Also, all the pre-surgical analysis as well as careful history taking, physical examination, urine analysis, stool culture, complete blood count (CBC) and liver function tests, ECG and plain chest X-rays of individual patients were studied to exclude patients with any comorbidities. For general anaesthesia, drugs used are Midazolam, Propofol, Fentanyl, Morphine, inhalational isoflurane along with muscle relaxant atracurium. Drugs were chosen/added in accordance with intraoperative findings and complications of individual patients. For spinal anaesthesia, hyperbaric bupivacaine was used.
Patients under chronic treatment with analgesics or corticosteroids, patients with contraindications to regional anaesthesia (coagulopathy, chronic infection), hypersensitivity reaction to topical anaesthetic solutions or opioids, psychiatric disorders were excluded from the study.
Once consent is obtained, patients are carefully selected and listed to receive either general anaesthesia or regional anaesthesia with twenty-six patients in each group. Patients with history of chronic illness and prior urologic surgery were excluded subsequently. Parameters such as 10 cm Pain Visual Analogue score , any analgesic intake, side effects like fever, shivering, nausea & vomiting, Patient's satisfaction scores were taken into account on arrival till 24 hr mark.

RESULTS
Fifty-two patients were listed during this study with 50% males and 50% females in GA cluster and 61% males and 39% females in RA cluster [ Fig. 1 Fig.2]. After 2hr mark, the VAS score becomes insignificant since most of the patients received analgesics. Patients in regional anaesthesia recorded lower consumption of analgesics during the post-operative day-0 as compared with GA cluster (P < 0.05).
Post-operative shivering was higher in RA cluster than GA cluster (8% vs. 2%) whereas nausea and fever was higher in GA cluster than RA cluster (5% vs. 2% and 4% vs. 1% respectively) [ Fig.3]. However, Patients in GA cluster recorded higher overall satisfaction scores than RA cluster.

DISCUSSION
We studied the post-operative pain VAS in a group of 52 patients undergoing urological surgeries in separate clusters of R.A & G.A. In this study we have found out that R.A is more efficient in postoperative period in terms of analgesic requirement, VAS score and less side effects when compared to G.A. And Patients' satisfactory score is more in favour of G.A. and may found to be decisive. Despite all that, most of the anaesthesiologists prefer regional anaesthesia for urological surgeries (say PNCL) due to its lesser complications and good analgesic effect.

*each cluster has 26 patients, with remaining patients not developing any complications within 2hrs of surgery
Though it is noted that patient in G.A cluster recorded much better satisfaction score, anaesthesiologists have to consider post operative complications of the patient and consider R.A especially in geriatric age group.
However, Massicotte and his co-worker used intrathecal analgesic with topical anaesthetic which might cause completely different result on operative pain than our study. [16] In spite of all these literatures we still need lot of research and studies in the areas of pain management and scales/scores measuring it to improve patients' comfort and usage of scores in practice.

CONCLUSION
In conclusion, both GA and RA were effective and safe in Percutaneous Nephrolithotomy. It is observed that PCNL under RA was associated with significantly shorter operative time and hospital stay. Furthermore, postoperative pain scores were low, lower nausea and/or vomiting, and reduced analgesic requirements were noted in the RA group. However, GA provides heaps of satisfaction for patients. Further literature and studies should be carried out in mass population with multi-factor parameters taken into account to support the same.

CONSENT
As per international standard or university standard, patient's written consent has been collected and preserved by the author(s).

ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the author(s).