Regional anaesthesia and quality of recovery after surgery

Abstract

Recovery from surgery is a complex process dependent on surgical, anaesthetic and patient factors, among others. Traditionally, recovery has been measured primarily by physiological parameters and adverse events such as morbidity and mortality 1. More recently, there has been a shift of emphasis towards defining recovery from a patient's perspective, with self-reported measures of recovery incorporating multiple postoperative domains 2. This reflects both a decrease in overall surgical morbidity and mortality due to surgical and anaesthetic advances as well as an increased focus on factors of importance to the patient 3. In this issue of Anaesthesia, Koning et al. report on the impact of an anaesthetic intervention (intrathecal bupivacaine and morphine added to general anaesthesia) on the quality of recovery after robot-assisted radical prostatectomy 4. The primary outcome was the 15-item Quality of Recovery (QoR-15) score and a statistically significant improvement was reported in this study 5. The QoR-15 is a patient-reported outcome measurement of postoperative quality of recovery, published and available on a free-to-access basis 5. This tool was developed by the same group that produced the nine-item ‘QoR’ score in 1999 6, and expanded on it with the longer and more comprehensive QoR-40 in 2000, which demonstrated superior validity and reliability 7. Quality of Recovery-40 has been extensively used and validated in the intervening period 8. Five dimensions are included in QoR-40: pain; physical comfort and physical independence (grouped as physical well-being); and psychological support and emotional state (grouped as mental well-being). Quality of Recovery-15 was in turn derived from QoR-40 as a simplified, shorter version limited to one page which enhances its feasibility and likelihood of completion. Quality of Recovery-15 has equivalent psychometric properties to QoR-40 with an estimated time to completion of 2.5 min vs. 10 min for QoR-40 5. Each of the 15 questions included in this questionnaire is answered on an 11-point numerical rating scale (0–10). The resulting composite score (scaled from 0 to 150) is attained by summing the values from each question to produce a single number. The maximum score of 150 would represent a ‘perfect’ condition with no pain, no nausea or vomiting, no sleep disruption, feeling of well-being, able to perform own hygiene and no anxiety or sadness. Quality of Recovery-15 has been validated in patients undergoing surgery and general anaesthesia across a range of minor, intermediate and major surgical procedures, thus it represents an appropriate measure for quality of recovery in the surgical context of robot-assisted radical prostatectomy. This scoring system has been shown to be reliable, consistent, responsive and clinically acceptable 5, with translation and validation into multiple languages and has undergone systematic review 9. The QoR-15 score (alongside the nine-item QoR score) has recently been recommended by the standardised endpoints in peri-operative medicine initiative as one of six endpoints which should be considered for inclusion in clinical trials assessing patient comfort and pain after surgery 10. Furthermore, the European Society of Anaesthesia (ESA) – European Society of Intensive Care Medicine joint taskforce has recommended QoR-15 as the standardised outcome measure for quality of recovery 11. The use of such validated, standardised measures in clinical trials is deemed necessary to enable accurate comparison of results across studies. A limitation of composite scoring is that it assigns equal value to different recovery parameters, so that, for example, severe pain produces equal weighting to the inability to look after personal hygiene 12. The score is intended for use in clinical trials and in quality assurance, but not at the individual level to determine adequacy of recovery. Several alternative multidimensional quality of recovery assessment scores are avail