Time to Onset of Sustained Postoperative Pain Relief (SuPPR): Evaluation of a New Systems-Level Metric for Acute Pain Management.

In Reply: The article by Tighe et al,1 entitled “Time to onset of sustained postoperative pain relief (SuPPR): evaluation of a new systems-level metric for acute pain management,” published on line on August 5, 2015 in The Clinical Journal of Pain is both informative and interesting. Tighe and colleagues conducted a retrospective cohort study of surgical case data from 7293 adult patients to examine the impact of age, sex, and the type of surgery on the time to sustained postoperative pain relief (SuPPR), which the authors defined, as the time required until a patient reports the first of multiple (2, 3, 4, or 5 sequential measurements; eg, SuPPR2, SuPPR-3), uninterrupted, mild pain scores (r4/10). The authors found statistically different differences across SuPPR-2 through SuPPR-5 definitions by age, sex, and type of surgery. Tighe et al1 concluded that SuPPR may represent a novel method for evaluating acute pain service performance. However, we would like to point out that the clinical utility of SuPPR may be limited. Such measurement may be more useful in clinical research relative to clinical practice, while taking care of patients with postoperative pain. When used in a hospital setting during the management of acute pain, those patients who report pain scores over 4/10 will not be included, as SuPPR can only document postoperative pain of r4/10. A postoperative pain score of 5/10 of a patient may need slight medication titration, whereas that of 9/10 warrants much more aggressive workup and therapeutic interventions. Unfortunately, none of these typical situations will be relevant when using SuPPR. Thus, the SuPPR metric will not be able to include those complicated and challenging postoperative pain cases. Therefore, it is obvious that SuPPR cannot be used alone as a postoperative pain control metric in acute pain care management because of its intrinsic limitations. In addition, the statement that, “Overall, SuPPR times ranged from 3 minutes for SuPPR-2 and 9 minutes for SuPPR-5 to 160.1 hours for SuPPR-2 and 183.1 hours for SuPPR5,” begs the question as to how valid the reported pain score was, considering it was taken just 3 minutes after surgery. Pain assessment in the immediate postoperative time is often a very difficult task, and the currently available assessment scales are not always reliable during this specific period.2 Most patients are unable to clearly express their pain level in the immediate postoperative period related to multiple factors, making it difficult to use the routinely used numerical rating pain scale. These factors include residual sedation, blurred vision, nausea and/or vomiting, confusion, and postoperative surgical considerations.3 As a result, Aissou et al3 have recommended utilizing pupillary dilatation reflex via a pupilometer to estimate immediate postoperative pain levels and to guide opioid administration, especially in patients with communication impairments. Therefore, the reported findings of “SuPPR times ranged from 3 minutes for SuPPR-2 and 9 minutes for SuPPR-5 to 160.1 hours for SuPPR-2 and 183.1 hours for SuPPR5” might be invalid, in light of the lack of reliability of reported pain scores in the immediate postoperative period.