Acute Postsurgical Pain Research Articles

Commentary on the "Co-Crystal of Tramadol-Celecoxib in Patients with Moderate to Severe Acute Post-Surgical Oral Pain: A Dose-Finding, Randomised, Double-Blind, Placebo- and Active-Controlled, Multicentre Phase II Trial". Implications for Cardiovascular Safety

Commentary on the "Co-Crystal of Tramadol-Celecoxib in Patients with Moderate to Severe Acute Post-Surgical Oral Pain: A Dose-Finding, Randomised, Double-Blind, Placebo- and Active-Controlled, Multicentre Phase II Trial". Implications for Cardiovascular Safety

Commentary on the "Co-Crystal of Tramadol-Celecoxib in Patients with Moderate to Severe Acute Post-Surgical Oral Pain: A Dose-Finding, Randomised, Double-Blind, Placebo- and Active-Controlled, Multicentre Phase II Trial". Implications for Cardiovascular Safety

Pain is the most common symptom for which patients seek medical attention and represents a major clinical, social, and economic problem across all ages, with estimates of the monthly prevalence ranging from 1.0% to over 60.0%

Ultrarestrictive Opioid Prescription Protocol for Pain Management After Gynecologic and Abdominal Surgery

ImportanceOpioids are routinely prescribed for postoperative home pain management for most patients in the United States, with limited evidence of the amount needed to be dispensed. Opioid-based treatment often adversely affects recovery. Prescribed opioids increase the risk of chronic opioid use, abuse, and diversion and contribute to the current opioid epidemic.ObjectiveTo evaluate whether after hospital discharge, postsurgical acute pain can be effectively managed with a markedly reduced number of opioid doses.Design, Setting, and ParticipantsIn this case-control cohort study, an ultrarestrictive opioid prescription protocol (UROPP) was designed and implemented from June 26, 2017, through June 30, 2018, at a single tertiary-care comprehensive cancer center. All patients undergoing gynecologic oncology surgery were included. Patients undergoing ambulatory or minimally invasive surgery (laparoscopic or robotic approach) were not prescribed opioids at discharge unless they required more than 5 doses of oral or intravenous opioids while in the hospital. Patients who underwent a laparotomy were provided a 3-day opioid pain medication supply at discharge.Main Outcomes and MeasuresTotal number of opioid pain medications prescribed in the 60-day perioperative period, requests for opioid prescription refills, and postoperative pain scores and complications were evaluated. Factors associated with increased postoperative pain, preoperative and postoperative pain scores, inpatient status, prior opioid use, and all opioid prescriptions within the 60-day perioperative window were monitored among the case patients and compared with those from consecutive control patients treated at the center in the 12 months before the UROPP was implemented.ResultsPatient demographics and procedure characteristics were not statistically different between the 2 cohorts of women (605 cases: mean [SD] age, 56.3 [14.5] years; 626 controls: mean [SD] age, 55.5 [13.9] years). The mean (SD) number of opioid tablets given at discharge after a laparotomy was 43.6 (17.0) before implementation of the UROPP and 12.1 (8.9) after implementation (P < .001). For patients who underwent laparoscopic or robotic surgery, the mean (SD) number of opioid tablets given at discharge was 38.4 (17.4) before implementation of the UROPP and 1.3 (3.7) after implementation (P < .001). After ambulatory surgery, the mean (SD) number of opioid tablets given at discharge was 13.9 (16.6) before implementation of the UROPP and 0.2 (2.1) after implementation (P < .001). The mean (SD) perioperative oral morphine equivalent dose was reduced to 64.3 (207.2) mg from 339.4 (674.4) mg the year prior for all opioid-naive patients (P < .001). The significant reduction in the number of dispensed opioids was not associated with an increase the number of refill requests (104 patients [16.6%] in the pre-UROPP group vs 100 patients [16.5%] in the post-UROPP group; P = .99), the mean (SD) postoperative visit pain scores (1.1 [2.2] for the post-UROPP group vs 1.4 [2.3] for pre-UROPP group; P = .06), or the number of complications (29 cases [4.8%] in the post-UROPP group vs 42 cases [6.7%] in the pre-UROPP group; P = .15).Conclusions and RelevanceImplementation of a UROPP was associated with a significant decrease in the overall amount of opioids prescribed to patients after gynecologic and abdominal surgery at the time of discharge for all patients, and for the entire perioperative time for opioid-naive patients without changes in pain scores, complications, or medication refill requests.

Procedure-Specific Pain Intensity Four Days After Day Surgery and the Relationship with Preoperative Pain: A Prospective Cohort Study.

BackgroundIdentification of painful procedures is essential for the development of procedure-specific pain-treatment schedules. The aim of this study was firstly, to analyze the prevalence of acute postsurgical pain (APSP) after various types of day surgery on the fourth postoperative day, and secondly, to assess the predictive value of preoperative pain for the development of APSP after different types of surgical procedures. MethodsFrom November 2008 to April 2010, patients scheduled for elective day surgery were enrolled in this prospective cohort study. Data were collected one week preoperatively and four days postoperatively. The 11-point Numeric Rating Scale (NRS) was used for pain measurement. Moderate pain was defined as an NRS 4 to 5, and severe pain as an NRS > 5. The predictive value of preoperative pain for development of APSP was analyzed using a univariate logistic regression, stratified for the surgical procedure.ResultsFrom a total of 1123 included patients, 182 patients experienced moderate pain (16.3%) and 136 patients experienced severe pain (12.1%) on the fourth postoperative day. A large procedure-specific variability in APSP was observed, with shoulder, anal and dental surgery associated with the highest pain levels. Overall, preoperative pain significantly predicted postoperative pain on the fourth day (OR 4.45). This predictive value showed a procedure-specific variation and was not noted after various well-defined procedures. ConclusionsThe prevalence of moderate to severe APSP was high four days after day surgery and showed a significant procedure-specific variation. Furthermore, there was a strong relationship between preoperative and postoperative pain, likewise characterized by a significant procedure-specific variation.

A good beginning makes a good ending: association between acute pain trajectory and chronic postsurgical pain

A good beginning makes a good ending: association between acute pain trajectory and chronic postsurgical pain

Chronic Pain, Quality of Life and Functional Impairment After Emergency Laparotomy.

Emergency laparotomy is a high-risk procedure with increased morbidity and mortality rates. The long-term outcomes are poorly investigated.The aim was to describe the frequency of chronic postsurgical pain (CPSP), pain-related functional impairment, to evaluate the gastrointestinal quality of life (QoL) and identify risk factors for CPSP after emergency laparotomy. A questionnaire study was conducted from Copenhagen University Hospital Herlev. Population area: 435.000. Patients undergoing emergency midline laparotomy from May 2009-May 2013 and June 2014-November 2015 were included. The survey consisted of five parts exploring the extent of acute and chronic postsurgical pain. Pain-related functional impairment and quality of life were measured using the activity assessment scale and the gastrointestinal quality of life questionnaire, respectively. Primary outcomes were rates of CPSP and pain-related functional impairment. Gastrointestinal QoL was compared between patients with or without CPSP. Multivariate regression analysis was performed to estimate risk factors for CPSP. The primary emergency laparotomy population consisted of 1573 patients. A total of 605 patients were eligible for inclusion, and 440 patients completed the survey. Response rate: 73%. Median age was 69years (range 18-95), 56.4% female. Median follow-up was 60months (IQR 47). 19% (85/440) experienced CPSP and had low gastrointestinal QoL. We identified APSP OR 5.0 95%CI (2.4-10.5), p < 0.01 and age < 60 OR 2.1 95%CI (1.2-3.8), p = 0.01 as independent risk factors for CPSP. 45% (199/440) of all patients experienced moderate-severe functional impairment. CPSP (19%) and low gastrointestinal QoL were common after emergency laparotomy and almost every second patient had moderate-severe functional impairment on long-term follow-up.

Comparison of Incidence and Severity of Chronic Postsurgical Pain Following Ear Surgery.

Literature review shows a limited number of studies investigating chronic pain following ear surgeries. The effect of mastoidectomy on chronic postsurgical pain, however, has never been investigated. The present study investigates not only the incidence and severity of chronic pain following ear surgeries with and without mastoidectomy, but also predisposing diseases for pain. The study was performed in a total of 150 patients who underwent tympanoplasty or tympanomastoidectomy through a retroauricular incision in a single tertiary health care center. During the routine postoperative 3rd-month examination, the patients were questioned for the presence and severity of chronic pain, as well as the diseases that might predispose the pain. The difference between the visual analog scale scores of the groups was not statistically significant. Comparison of pain character revealed that neuropathic pain is more prevalent in both the groups. Evaluating the relationship between concomitant diseases and chronic pain, it was observed that migraine, cervical pathology, and acute postsurgical pain were closely associated with chronic pain. It was demonstrated that mastoidectomy does not pose an additional risk for chronic postsurgical pain. However, patients with migraine, cervical pathology, and acute postsurgical pain are at risk for chronic postsurgical pain.

Effect of Intrasocket Application of Manuka Honey on Postsurgical Pain of Impacted Mandibular Third Molars Surgery: Split-Mouth Randomized Controlled Trial.

Sufficient evidence exists recommending the use of honey in the management of wounds. Studies revealed that the healing effect of honey could be classified by its antibacterial and anti-inflammatory properties of its components. Since surgical extraction of impacted molars is one of the most common operations in the oral cavity and the postoperative pain disturbing the patient may reduce the quality of health service, this study aimed to assess the analgesic potential of Manuka honey application into the extraction socket of impacted mandibular third molars. This randomized split-mouth controlled study included 33 patients undergoing impacted bilateral lower third molars surgery under local anesthesia (n = 66). Randomization was carried out by coin flipping. One of the two impacted third molars was assigned to treatment group (Manuka honey applied just before suturing), other side to control group (nothing applied). Postsurgical pain was evaluated using visual analogue scale (VAS) of faces 7days after extraction. The total analgesic dose used was also evaluated. In treatment group, postoperative VAS scores were significantly lower compared to that in control group regarding first and second days postoperatively (P < 0.05). Total analgesic intake in the control group was significantly higher (P = 0.0001). This study demonstrated that intrasocket application of Manuka honey after surgical extraction of impacted lower third molar is an effective method for reducing acute postsurgical pain.

C-reactive Protein Level on Postoperative Day One is Associated with Chronic Postsurgical Pain After Mastectomy.

BackgroundC-reactive protein (CRP) is an acute phase reactant released in response to inflammation or tissue injury. Inflammation is one of the pathogenic factors related to transition from acute postsurgical pain (APSP) to chronic postsurgical pain (CPSP). Although several risk factors are reportedly associated with CPSP, the effects of CRP levels on CPSP have not been examined.ObjectivesThe present study investigated the relationship between perioperative risk factors, including CRP levels on postoperative day one and CPSP, in patients undergoing mastectomy.MethodsPreoperative anxiety and depression levels were evaluated in female patients undergoing mastectomy under general anesthesia, with or without peripheral nerve block. Patients with chronic preoperative pain and/or preoperative breast pain were excluded. The intensity of postoperative pain was prospectively examined one and six days, and three and twelve months after surgery using a numerical rating scale (NRS).ResultsThe current researchers conducted univariate and multivariate linear regression analyses to explore risk factors for CPSP in 36 patients. Patient demographics, preoperative psychological states, and anesthetic managements showed no relationship with CPSP. On the other hand, pain intensity of APSP and CRP levels on postoperative day one was significantly associated with the pain intensity of CPSP.ConclusionsPostoperative CRP level is likely to be associated with the development of CPSP after mastectomy.

Analysis of predictors of opioid-free analgesia for management of acute post-surgical pain in the United States

Objectives: Utilization of opioid-free analgesia (OFA) for post-surgical pain is a growing trend to counter the risks of opioid abuse and opioid-related adverse drug events (ORADEs). However, utilization patterns of OFA have not been examined. In this study, we investigated the utilization patterns and predictors of OFA in a surgical population in the United States.Methods: Analysis of the Cerner Health Facts database (January 2011 to December 2015) was conducted to describe hospital and patient characteristics associated with OFA. Baseline characteristics, such as age, gender, race, discharge status, year of admission and chronic comorbidities at index admission were collected. Hospital characteristics and payer type at index admission were collected as reported in the electronic health record database. Descriptive statistics and logistic regression were used to identify statistically significant predictors of OFA on patient and institutional levels.Results: The study identified 10,219 patients, from 187 hospitals, who received post-surgical OFA and 255,196 patients who received post-surgical opioids. OFA rates varied considerably by hospital. Patients more likely to receive OFA were older (OR = 1.06, 95% CI [1.03, 1.10]; p < .001), or had neurological disorders (OR = 1.24, 95% CI [1.10, 1.39]; p < .001), diabetes (OR = 1.20, 95% CI [1.08, 1.33]; p = .001) or psychosis (OR = 1.18, 95% CI [1.01, 1.37]; p = .030). Patients with obesity and depression were less likely to receive OFA (OR = 0.80, 95% CI [0.67, 0.95]; p = .010 OR = 0.85, 95% CI [0.73, 0.98]; p = .030, respectively).Conclusions: Use of post-surgical OFA was limited overall and was not favored in some patient groups prone to ORADEs, indicating missed opportunities to reduce opioid use and ORADE incidence. A substantial proportion of OFA patients was contributed by a few hospitals with especially high rates of OFA, suggesting that hospital policies, institutional structure and cross-functional departmental commitment to reducing opioid use may play a large role in the implementation of OFA.

Bilateral Erector Spinae Plane Block for Acute Post-Surgical Pain in Adult Cardiac Surgical Patients: A Randomized Controlled Trial

To examine the analgesic efficacy of bilateral erector spinae plane (ESP) block compared with conventional treatment for pain after cardiac surgery in adult patients. A prospective, randomized, controlled, single-blinded study. Single-center tertiary teaching hospital. One hundred and six adult patients undergoing elective cardiac surgery with cardiopulmonary bypass. Patients were randomized into 2 groups. Patients in group 1 (ESP block group, n = 53) received ultrasound-guided bilateral ESP block with 3mg/kg of 0.375% ropivacaine before anesthesia induction at the T6 transverse process level. Patients in group 2 (paracetamol and tramadol group, n = 53) received paracetamol (1 gm every 6 hours) and tramadol (50mg every 8 hours) intravenously in the postoperative period. The primary study outcome was to evaluate pain at rest using an 11-point numeric rating scale (NRS). Mann-Whitney U test was used for comparing NRS scores. The postoperative pain level after extubation and duration of analgesia during which NRS was <4 of 10 was compared between the groups. The median pain score at rest after extubation in group 1 was 0 of 10 until hour 6, 3 of 10 at hour 8, and 4 of 10 at hours 10 and 12 postextubation. These were significantly less in comparison with group 2 (p = 0.0001). Patients in group 1 had a significantly higher mean duration of analgesia (8.98 ± 0.14 hours), during which NRS was < 4 of 10, compared with group 2 (4.60 ± 0.12 hours) (p = 0.0001). ESP block safely provided significantly better pain relief at rest for longer duration as compared to intravenous paracetamol and tramadol.

2428 Obstructive sleep apnea as an independent predictor of postoperative delirium and pain: An observational study of a surgical cohort

OBJECTIVES/SPECIFIC AIMS: To study the role of OSA as an independent predictor of perioperative outcomes. METHODS/STUDY POPULATION: For this single-institution cohort study, we included data from patients who were enrolled into 1 of 3 prospective parent studies. All participants underwent in-patient surgeries, excluding neurosurgeries, which required general anesthesia and a postoperative stay of at least 1 day. Patients included in this study were assessed daily for postoperative delirium and pain severity as part of the parent studies. In the current study, determination of delirium diagnosis was based on the 3-minute Diagnostic Confusion Assessment Method (3D-CAM), and the Visual Analogue Pain Scale (VAS) was used for pain severity. Data on OSA diagnosis (determined by sleep study); OSA risk (determined by the STOP-Bang tool; snoring, tiredness, observed apnea, high blood pressure, body mass index&gt;35 kg/m2, age&gt;50, neck circumference, male gender); and compliance with treatment were obtained from the preoperative assessment record. Participants were grouped into 1 of 3 categories: high risk of OSA (HR-OSA; including patients with a previous positive sleep study or STOP-Bang score ≥5); intermediate risk of OSA (IR-OSA; including patients with a STOP-Bang score of 3 or 4); and low risk of OSA (LR-OSA; including patients with a previous negative sleep study or STOP-Bang score &lt;3). Candidate risk factors for delirium and pain were also extracted from this record. RESULTS/ANTICIPATED RESULTS: Logistic regression will be used to test whether OSA independently predicts postoperative delirium and linear regression to assess OSAs relationship to acute pain severity. We hypothesize that patients in the HR-OSA category will experience a higher incidence of postoperative delirium and greater postoperative pain severity. We also predict a step-wise increase in risk of these adverse outcomes when analyzing patients stratified by OSA risk (HR-OSA vs. IR-OSA vs. LR-OSA). For our secondary analyses, we anticipate these outcomes are modified by compliance with CPAP treatment. We believe patients with OSA who do not use prescribed CPAP will experience a higher incidence of postoperative delirium as well as increased pain severity. DISCUSSION/SIGNIFICANCE OF IMPACT: OSA is a common and frequently undiagnosed perioperative problem associated with altered pain processing and a high incidence of postoperative delirium. While likely providing stronger evidence of OSA’s reported impact on postoperative delirium and pain, our findings might also help discern points of intervention for treatment and prevention. Since OSA’s presumed impact poses challenges to clinicians and patients, prospective, randomized trials testing preventative or mitigating interventions are necessary. We hope to use these results to design such trials and clinical plans, with the goal of reducing postoperative delirium and acute postsurgical pain severity for the large number of patients at risk due to OSA.

Postoperative Pain Trajectories and Pain Chronification-an Empirical Typology of Pain Patients.

High intensity of acute postsurgical pain is one of the strongest predictors of chronic postsurgical pain (CPSP). We investigated if different types of patients with distinct combinations of initial pain intensity and rate of pain resolution exhibit different risks for increased pain intensity six months after surgery. Data from 174 patients were examined using growth mixture analysis by means of structural equation modeling. Three types of patients were distinguished on the basis of acute pain trajectories. The majority of patients (57%) showed an unproblematic pattern of little initial pain on the first postoperative day, combined with further pain resolution over the four subsequent days. There also was a substantial group of patients (30%) who started out with severe pain but exhibited a high rate of pain resolution. Finally, we found a problematic group of patients (13%) who reported high pain intensities throughout all five postoperative measurements, with no signs of pain resolution. Even after controlling for preoperative pain intensity, these patients exhibited significantly higher pain intensities six months after surgery than the remaining patient groups. In this study, we demonstrated that there is substantial variation in postsurgical pain trajectories, not only with regard to postsurgical initial pain intensity, but also with regard to individual rates of pain resolution. Successful pain resolution appeared to be a better predictor of absence of increased pain intensities six months after surgery than initial pain immediately after surgery. Hence, attention should be given to appropriate pain treatment in order to minimize the risk of CPSP.

Research Agenda for the Prevention of Pain and Its Impact: Report of the Work Group on the Prevention of Acute and Chronic Pain of the Federal Pain Research Strategy

After the 2011 Institute of Medicine report on chronic pain, the Interagency Pain Research Coordinating Committee (IPRCC) was created to enhance research efforts among federal agencies. The IPRCC and Office of Pain Policy at the National Institutes of Health collaborated to identify gaps in knowledge and address them via a Federal Pain Research Strategy (FPRS). Interdisciplinary work groups (WGs) were established to make research recommendations in 5 areas: prevention of acute and chronic pain, acute pain and acute pain management, transition from acute to chronic pain, chronic pain and chronic pain management, and disparities in pain and pain care; cross-cutting issues were also considered. The objective was to provide guidance on current research and to make recommendations about addressing identified gaps. Findings from the Prevention of Acute and Chronic Pain WG are summarized in this article. The WG created subgroups to develop recommendations on specific aspects of prevention of acute and chronic pain, including: public education, primary prevention, secondary prevention, tertiary prevention, transition from acute to chronic pain, and cross-cutting mediators. No formal literature review was conducted; however, external advisors were available and consulted as needed. Seven key research priorities were identified. The one deemed “greatest near-term value” was to optimize public health strategies to educate patients on managing pain; that deemed “most impactful” was to determine an association between patient and intervention factors. Other recommendations were related to the epidemiology of acute pain from health care procedures, the epidemiology of acute pain from work-related injuries, safety and effectiveness of management of pain associated with health care procedures, optimizing approaches to acute postsurgical pain, and safety and effectiveness of early interventions for tertiary prevention. Stakeholders, including federally sponsored research programs, researchers, health care providers, policy makers, patients, and others should work together to implement recommendations and address important gaps. PerspectiveThe FPRS Steering Committee created 5 WGs to identify research needs and make recommendations in key areas of research. This article reports the results of one—the Prevention of Acute and Chronic Pain group. Several research priorities emerged, and recommendations made to fill existing knowledge gaps.

Pre-surgery beliefs about pain and surgery as predictors of acute and chronic post-surgical pain: A prospective cohort study

BackgroundChronic pain post-surgical pain (CPSP) is common and has far-reaching negative consequences for patients, yet relatively few studies have evaluated the impact of both deficit- and resource-based beliefs about pain and surgery on subjective intensities of acute and chronic post-surgical pain. To address this issue a prospective cohort study was performed. Method259 consecutive surgery patients from general surgery, gynecology, and thoracic departments completed a self-report battery of demographics, pain experiences, and psychological factors 24 h before surgery (T1) and provided follow-up pain intensity ratings 48 h–72 h after surgery (T2), and at a 4-month follow-up (T3). ResultsIn the hierarchical regression model for acute post-operative pain intensity, pre-surgery pain self-efficacy beliefs made a significant unique contribution independent of all other pre-surgery and surgery-related factors (i.e., age, presence of pre-surgical pain, type of anesthesia, surgery duration). In the prediction model for intensity of chronic post-surgical pain, beliefs about long-term effects of surgery had a unique impact after controlling other significant pre-surgery and surgery influences (gender, education, surgery time). ConclusionResults underscored the potential utility of considering specific pre-surgery pain- and surgery-related beliefs as factors that predict patient experiences of acute and chronic post-operative pain.

Identifying At-Risk Subgroups for Acute Postsurgical Pain: A Classification Tree Analysis.

Acute postsurgical pain is common and has potentially negative long-term consequences for patients. In this study, we evaluated effects of presurgery sociodemographics, pain experiences, psychological influences, and surgery-related variables on acute postsurgical pain using logistic regression vs classification tree analysis (CTA). The study design was prospective. This study was carried out at Chongqing No. 9 hospital, Chongqing, China. Patients (175 women, 84 men) completed a self-report battery 24 hours before surgery (T1) and pain intensity ratings 48-72 hours after surgery (T2). An initial logistic regression analysis identified pain self-efficacy as the only presurgery predictor of postoperative pain intensity. Subsequently, a classification tree analysis (CTA) indicated that lower vs higher acute postoperative pain intensity levels were predicted not only by pain self-efficacy but also by its interaction with disease onset, pain catastrophizing, and body mass index. CTA results were replicated within a revised logistic regression model. Together, these findings underscored the potential utility of CTA as a means of identifying patient subgroups with higher and lower risk for severe acute postoperative pain based on interacting characteristics.

Erector spinae plane block as an alternative to epidural analgesia for post-operative analgesia following video-assisted thoracoscopic surgery: A case study and a literature review on the spread of local anaesthetic in the erector spinae plane.

Post-operative pain after minimally invasive video-assisted thoracoscopic surgery (VATS) in adults is commonly managed with oral and parenteral opioids and invasive regional techniques such as thoracic epidural blockade. Emerging research has shown that the novel erector spinae plane (ESP) block, can be employed as a simple and safe alternative analgesic technique for acute post-surgical, post-traumatic and chronic neuropathic thoracic pain in adults. We illustrate this by presenting a paediatric case of VATS, in which an ESP block provided better analgesia, due to greater dermatomal coverage, as well as reduced side-effects when compared with a thoracic epidural that had previously been employed on the same patient for a similar procedure on the opposite side.

Erector spinae plane block for perioperative analgesia in cardiac surgery. Case report

ABSTRACT BACKGROUND AND OBJECTIVES: The anesthetic management has evolved with the use of alternative techniques that promote greater safety, quick recovery and comfort in the perioperative period. The erector spinae plane block emerges as a promising alternative that can be employed as a simple analgesic technique for thoracic analgesia, acute post-surgical, post-traumatic and chronic neuropathic thoracic pain. CASE REPORT: Female patient, 72-year-old, undergoing aortic valve replacement surgery under general anesthesia associated with an erector spinae plane block as a technique for perioperative pain management. CONCLUSION: We demonstrate with this case report that the erector spinae plane block can be a suitable option as a regional analgesia technique for cardiac surgery, used perioperatively as a regional block for multimodal analgesia. Further research and studies are needed to address its efficacy and safety for multiple cardiac and aortic surgery techniques.

Preparing Your Pediatric Patients and Their Families for the Operating Room: Reducing Fear of the Unknown.

1. Adam C. Adler, MS, MD*,‡ 2. Stephanie Leung, BS, CCLS† 3. Benjamin H. Lee, MD*,‡ 4. Scott R. Dubow, MD§ 1. *Department of Anesthesiology, Perioperative and Pain Medicine and 2. †Department of Child Life, Texas Children’s Hospital, Houston, TX 3. ‡Baylor College of Medicine, Houston, TX 4. §Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA * Abbreviations: BiPAP: : bilevel positive airway pressure CLS: : child life specialist CPAP: : continuous positive airway pressure DEA: : Drug Enforcement Administration IV: : intravenous MRI: : magnetic resonance imaging OSA: : obstructive sleep apnea Clinicians should: identify the resources available to patients and families to allow for a smooth perioperative experience; understand the long-term effects and potential maladaptive changes associated with an anxiety-provoking perioperative period; understand the most common parental and patient concerns and misconceptions regarding surgery; understand the most common and up-to-date perioperative anesthesia practices; understand the indication for referral to the preoperative anesthesia clinic for patient evaluation to avoid unnecessary cancellation. Pediatricians are often tasked with preparing children and their families for the preoperative period and dealing with questions related to postoperative issues and concerns. Instruction based on current practice and new research and techniques may help patients and families cope with the stressors of surgery. Determining which patients may benefit from a medical or child life preoperative visit is of crucial importance. After completing this article, the reader should be able to: 1. Describe common preoperative anesthesia practice. 2. Recognize the role of a child life specialist in preparing children for surgery. 3. Differentiate children who would benefit from a preoperative anesthesia and/or child life evaluation. 4. Instruct patients and families on issues related to the perioperative period. 5. Address a wide array of parental concerns regarding surgery, anesthesia, and postoperative pain management. The period of time surrounding a planned surgical procedure can be tumultuous and anxiety provoking for both pediatric patients and their parents. The “mysterious place” that is the operating room often remains a mystery to many health care providers, including those tasked with caring for patients both before and after a procedure. As the health care provider most familiar to patients and their families, the pediatrician is in a …

Improved Outcomes Associated With the Use of Intravenous Acetaminophen for Management of Acute Post-Surgical Pain in Cesarean Sections and Hysterectomies.

BackgroundPost-surgical pain impacts many patient outcomes. Effective pain management increasingly relies on multimodal analgesia regimens in which acetaminophen (APAP) is a key component. The aim of our study was to examine the impact of oral APAP versus intravenous (IV) APAP as a component of post-surgical pain management after Cesarean sections and hysterectomies.MethodsA retrospective analysis of the Cerner HealthFacts® database (from January, 2011 to December, 2015) was conducted to compare outcomes of Cesarean section and hysterectomy surgery patients who received oral APAP to those who received IV APAP post-surgically. Length of stay (LOS), daily morphine milligram equivalent (MME) consumption, the presence of potential opioid-related adverse events (ORADEs), and total pharmacy costs were assessed. Adjusted results were derived using inverse probability weighted regression adjustment (IPW-RA) estimators based on covariates that included demographics, comorbidities, patient clinical characteristics, and hospital characteristics.ResultsThe study identified 29,124 Cesarean section patients (24,612 oral APAP; 4,512 IV APAP) and 9,767 hysterectomy surgery patients (5,586 oral APAP; 4,181 IV APAP). Compared to the oral APAP group, the IV APAP group had reductions in adjusted LOS (Cesarean section: -11.7% days (P < 0.001), hysterectomy: -11.8% days (P = 0.005)), lowered adjusted daily MME consumption from day 0 to day 3 (Cesarean section: -1.6 mg (P < 0.001), hysterectomy: -1.7 mg (P = 0.014)), and reduced risk of ORADEs for Cesarean sections (relative risk of 0.45, P < 0.001). Total pharmacy costs were not significantly different between the two APAP groups.ConclusionsPost-surgical pain managed with IV APAP in patients undergoing Cesarean section or hysterectomy was associated with shorter LOS, reduced risk of ORADEs, and lower opioid consumption compared to patients managed with oral APAP, without adversely impacting total pharmacy costs.