Pain treatment presentation and manual have not changed the prescription of analgesics in the postoperative period of gynecological surgeries*

of a postoperative pain treatment manual to assistant physicians, residents and intern physicians of the Gynecology Clinic of a medium-sized teaching hospital. RESULTS : Pain intensity in the first postoperative hour was 3.62 ± 2.48 for group 1; 3.62 ± 3.65 for group 2; 2.58 ± 1.93 for group 3 (p = 0.33). In the 12 th hour, pain intensity was 3.62 ± 2.28, for group 1; 3.91 ± 3.26, for group 2; 3.50 ± 2.14, for group 3 (p = 0.85). In the 24 th hour, mean pain intensity was 2.35 ± 1.98, for group 1; 3.70 ± 2.75, for group 2; 2.95 ± 1.65, for group 3 (p = 0.12). In the 48 th hour, mean intensity has varied from 3.00 ± 1.82, for group 1; 3.44 ± 1.81, for group 2; 3.33 ± 1.36, for group 3 (p = 0.90). As observed, there have been no statistically significant differences between stages in the 1 st , 12 th , 24 th e 48 th postoperative hour. CONCLUSION : Proposed intervention has not brought statistically significant changes, however the multimodal analgesic combination used has provided adequate analgesia.


INTRODUCTION
Planning of analgesia to treat acute postoperative pain is critical for its effective control. In addition to improving patients' assistance, it has the advantage of accelerating their recovery, being advisable an analgesia planning tailored for each patient. It should always be multimodal, with the association of two or more peripheral or central analgesic agents or techniques, including non-pharmacological methods because the synergism between drugs and analgesic techniques decreases the use of drugs, thus minimizing their side effects and improving their analgesic activity 1,2 . Postoperative pain treatment is neglected and very often insufficient. Major causes of insufficient analgesia are: belief that postoperative pain is not harmful to patients or is a normal surgical consequence; fear that pain relief may mask diagnosis or signs of an adverse event; trend to underestimate and not recognize the variability of pain awareness by patients; lack of knowledge of the huge variability of analgesic needs among patients; lack of regular and frequent pain evaluation; incorrect use of relief measures; unawareness of different analgesic techniques; unawareness of analgesics pharmacokinetics and pharmacodynamics; unawareness that age and weight should be considered when deciding dose, administration route and analgesic drug; fear of opioid dependence; inadequate orientation of patients about analgesia and fear of patients to request analgesia; lack of financial resources and difficulties to supply opioid analgesics 3 .
Gynecologists should understand the psychosocial aspects of gynecological diseases, acknowledging the importance women give to their organic, sexual and reproductive functions. They should spend time to adequately evaluate patients and select for surgery only those nee-ding it, to choose surgeries that would more adequately meet the needs of each patient, to learn how to preserve functions and to offer alternatives to surgical treatment, when possible. One should also stress the importance of a good dialogue with patients and their families. These aspects also reflect postoperative pain intensity, being necessary individually adequate analgesia because every patient has a type of anxiety interfering with prognosis and, as a consequence, with the effectiveness of postoperative analgesia 4 . Surgery-related pain is widely investigated in Brazil, however it is necessary to analyze whether the analgesic therapy applied by anesthesiologists and surgeons to their patients is being successful, since studies on this subject are scarse 5 . This study aimed at evaluating the effectiveness and type of analgesia used in the postoperative period of gynecological surgeries in the Teaching Hospital of Taubaté (HUT) before and after a presentation and the distribution of a manual on postoperative pain for physicians, residents and internists.

METHOD
This was a prospective and controlled study with random sampling, including 72 female patients aged between 18 and 80 years, submitted to gynecological surgeries in the HUT Operating Center, who were divided in three groups of 24 patients. Pain intensity was evaluated by the pain numerical scale (PNS), according to which zero means no pain and 10 the most severe pain ever experienced by the patient. Group 1 -Pain intensity was evaluated in the 1 st , 12 th , 24 th and 48 th hour after surgery and analgesic prescription was evaluated in the same moments. Group 2 -A presentation was made about postoperative pain pathophysiology and treatment, followed by the distribution of a pocket manual about postoperative pain pathophysiology and treatment for physicians, residents and internists and then pain intensity and prescriptions were evaluated at the same moments as group 1. Group 3 -Three months after the presentation about postoperative pain pathophysiology and treatment and distribution of pocket manuals about postoperative pain pathophysiology and treatment to physicians, residents and internists, pain intensity and prescriptions were evaluated in the same moments as group 1. Group 3 aimed at analyzing whether changes after postoperative pain pathophysiology and treatment presentation and distribution of the pocket manual about postoperative pain pathophysiology and treatment were maintained.
The software JMP ® from SAS (Statistical Analysis System) Institute was used for statistical analysis of results obtained after orientations and Analysis of Variance followed by Dunnett's test was applied with significance level < 5% (p < 0.5%). This study was approved by the Research Ethics Committee, University of Taubaté, under protocol CEP/UNI-TAU 033/2011.

DISCUSSION
PNS used in this study is a very useful method to evaluate pain because it is a simple, sensitive and reproducible tool. Unidimensional tools are designed to quantify only pain severity or intensity and have been often used in hospitals and clinics to obtain fast, noninvasive and valid information about pain and analgesia 6 . However, this is a scale seldom used in the daily practice by health professionals of the studied hospital. Final PNS scores analysis in the first postoperative hour in the three studied groups has shown mean pain intensity of 3.62 in groups 1 and 2, and of 2.58 in group 3, with predominance of no pain reported by patients. The evaluation of this hour has shown that anesthesia has induced satisfactory intra and perioperative analgesia. One may stress here the importance of regional anesthesia, since 80.55% of patients were submitted to spinal block, which provided good analgesia. In addition, lower abdomen and gynecological tract are knowingly regions causing less postoperative pain 7 . As to analgesic choice, it has been observed in the prescriptions of the HUT gynecology team, both in the 12 th and in the 24 th and 48 th postoperative hours, the preference for the association of dipirone and NSAIDs (Graph 1). The difference between medical prescription stages was related to the administration route; up to the 24 th hour, patients received intravenous drugs and after the 24 th hour they received oral drugs. As observed from results, there has been no statistically significant difference among groups in the 12 th , 24 th and 48 th postoperative hours and mean pain intensity was low, showing that, in general, prescription was satisfactory, however most studied patients were discharged within 24 hours, which has impaired our evaluation, being possible that these patients will have pain when returning to daily activities. Treatment is prescribed by scholars and supervised by residents and many times they simply follow an analgesic prescription pattern without valuing individual complaints, since there were patients with more severe pain who were medicated similarly to those without pain, which shows lack of dynamics and standardization of postoperative pain treatment in the sector, which has not changed even after the symposium intervention. This result confirms a previous study which showed lower quality of analgesic prescription in this sector as compared to other surgical clinics 5 . In the hospital, pain is a common and clinically relevant experience, but in spite of advances in the understanding of its mechanisms and treatment, studies have shown that it has not been recognized and adequately treated in admitted patients 8 . The low opioid use rate in studied patients (2.77%) may be due to its side effects and to the need for a trained nursing team to early recognize possible complications and be able to promptly act when facing life threatening conditions. However, the prejudice with regard to this analgesic class should be overcome because multimodal analgesia is indicated for moderate pain. Gynecological patients should be uniquely treated, considering their preoperative clinical condition, pain expectation, previous painful experiences and anxieties with regard to surgery. Gender-related differences in pain awareness may be associated to hyperalgesia in females, but also to the hypoactivity of females' pain inhibitory system 9 . Mean age of evaluated patients was 45 years, age of female hormonal changes, and with this they present several complaints very often neglected by health professionals. Postoperative pain is a major clinical problem deserving higher attention and dedication of the whole surgical team, taking into consideration an adequate intraoperative anesthesia and an effective postoperative treatment. It is not enough to evaluate pain as the fifth vital sign; it is critical that health institution chiefs feel the real need to adequately control pain, with adherence of the clinical staff, to improve patients' assistance and walk toward the objective of the "pain-free hospital" 10,11 . This study has shown that there were no statistically significant changes after the intervention, but in general, most patients had pain intensity mean below 5 by PNS, which has allowed an effective treatment with the association of NSAIDs and common analgesics, which was the scheme adopted by the team of this sector.

CONCLUSION
Data have shown that the proposed intervention has not generated significant changes in postoperative analgesic prescriptions, however, the multimodal analgesic combination used has provided adequate postoperative analgesia for most patients.