Acute Postoperative Pain Control Research Articles

Atención del dolor agudo postoperatorio: evaluación de resultados en las salas de hospitalización quirúrgicas

ObjectiveTo describe management of acute postoperative pain on the surgical ward. To study the relationship between pain and a variety of surgical procedures and approaches. To determine the level of information patients received, their expectations, and their satisfaction with treatment of postoperative pain. Patients and methodsCross-sectional observational study by survey and review of patient records. We studied 234 patients, including all who were hospitalized for more than 24 hours after scheduled or emergency operations. The main variables recorded were pain intensity at rest and during movement, including on the day after surgery, and the surgical procedure and approach. ResultsThe prevalence of pain (>3 on a numerical scale) on the surgical ward was 33% at rest and 66% during movement. The prevalence of intense pain (>6 on the numerical scale) was 1.7% at rest and 7.3% during movement. Factors related to greater pain intensity were timing, that is, the first day after surgery, when 74.4% of patients experienced their most intense pain; type of surgery and approach (P<.004); and expecting to experience moderate or intense pain (P<.001). ConclusionsRecording the prevalence of postoperative pain on a surgical ward provides information about the real situation of acute postoperative pain control. Pain on movement is a principal indicator for detecting groups of patients for whom analgesic protocols could be improved. Type of surgery and approach is a fundamental factor to consider when comparing the results of analgesic protocols.

Comparing etoricoxib and celecoxib for preemptive analgesia for acute postoperative pain in patients undergoing arthroscopic anterior cruciate ligament reconstruction: a randomized controlled trial

BackgroundThe efficacy of selective cox-2 inhibitors in postoperative pain reduction were usually compared with conventional non-selective conventional NSAIDs or other types of medicine. Previous studies also used selective cox-2 inhibitors as single postoperative dose, in continued mode, or in combination with other modalities. The purpose of this study was to compare analgesic efficacy of single preoperative administration of etoricoxib versus celecoxib for post-operative pain relief after arthroscopic anterior cruciate ligament reconstruction.MethodsOne hundred and two patients diagnosed as anterior cruciate ligament injury were randomized into 3 groups using opaque envelope. Both patients and surgeon were blinded to the allocation. All of the patients were operated by one orthopaedic surgeon under regional anesthesia. Each group was given either etoricoxib 120 mg., celecoxib 400 mg., or placebo 1 hour prior to operative incision. Post-operative pain intensity, time to first dose of analgesic requirement and numbers of analgesic used for pain control and adverse events were recorded periodically to 48 hours after surgery. We analyzed the data according to intention to treat principle.ResultsAmong 102 patients, 35 were in etoricoxib, 35 in celecoxib and 32 in placebo group. The mean age of the patients was 30 years and most of the injury came from sports injury. There were no significant differences in all demographic characteristics among groups. The etoricoxib group had significantly less pain intensity than the other two groups at recovery room and up to 8 hours period but no significance difference in all other evaluation point, while celecoxib showed no significantly difference from placebo at any time points. The time to first dose of analgesic medication, amount of analgesic used, patient's satisfaction with pain control and incidence of adverse events were also no significantly difference among three groups.ConclusionsEtoricoxib is more effective than celecoxib and placebo for using as preemptive analgesia for acute postoperative pain control in patients underwent arthroscopic anterior cruciate ligament reconstruction.Trial registration numberNCT01017380

Alpha-2 agonists in acute pain management

Importance of the field: This review explores the significance of alpha-2 agonists used clinically in acute pain management.Areas covered in this review: Although alpha-2 agonists have been reported to have an analgesic effect, they are not commonly used clinically for acute pain management. Clinical studies on use of alpha-2 agonists for acute pain management are reviewed and discussed. A literature search was done using Medline with the keywords ‘alpha-2 agonist’, ‘clonidine’, ‘dexmedetomidine’, ‘fadolmidine’, ‘pharmacokinetics’, ‘pharmacodynamics’, ‘postoperative analgesia’, ‘epidural’, ‘intrathecal’, ‘peripheral nerve block’ and various combinations with these keywords. The years 1977 – 2009 have been included, with particular focus on clinical studies from between 1990 and 2009.What the reader will gain: This article helps to clarify the clinical use of alpha-2 agonists in acute pain management according to current, up-to-date evidence. Clinically, available alpha-2 agonists, including clonidine and dexmedetomidine, are discussed in detail.Take home message: Alpha-2 agonists, especially clonidine, seem to be promising with regard to acute postoperative pain management. However, more clinical evidence on dexmedetomidine is necessary to confirm its definite role in acute postoperative pain control.

Using acupuncture for acute pain in hospitalized children

Clinical study to determine the acceptability and feasibility of acupuncture for acute postoperative pain control in hospitalized children. Nonrandomized clinical trial. A single, tertiary referral pediatric intensive care unit. A total of 20 patients aged 7 months to 18 years. Eleven of the patients had posterior spinal fusion surgery and the remaining nine patients had other surgical diagnoses. Two 10- to 15-minute sessions of acupuncture 24-48 hours apart. The treatment was highly accepted (27 patients were approached and 4 patients refused; of the 23 patients enrolled, 20 patients completed the study). Acupuncture was well tolerated by patients without adverse events related to treatment. In follow-up interviews, 70% of both parents and patients believed acupuncture helped the child's pain. Eighty-five percent of the parents said they would pay out of pocket for acupuncture if not covered by insurance. The pain scores, vital signs, and narcotic usage were recorded before and several times after acupuncture. In posterior spinal fusion patients, the mean pain scores (0-10) immediately before and 4 and 24 hours after acupuncture were: 3.7, 1.7, and 3.1, respectively, after the first acupuncture session and 3.7, 2.2, and 3.1, respectively, after the second session. In the other surgical cohort, the mean pain scores immediately before and 4 and 24 hours after the first session of acupuncture were 2.5, 0.3, and 1.6, respectively. Our results support that acupuncture is highly accepted and feasible in critically ill, postoperative pediatric patients with acute pain. Our findings suggest that acupuncture may be a potentially useful adjunctive tool for acute pediatric postoperative pain management. A randomized, controlled clinical trial is warranted to confirm these findings.

Control of Acute Postoperative Pain by Transcutaneous Electrical Nerve Stimulation after Open Cardiac Operations: A Randomized Placebo-Controlled Prospective Study

We investigated the effectiveness of transcutaneous electrical nerve stimulation (TENS) therapy on pain during the first 24 hours after a cardiac surgical procedure. A total of 60 patients who had undergone median sternotomy (MS) for coronary artery bypass graft (n = 55) or valve repair surgery (n = 5) were randomized to receive TENS and pharmacologic analgesia, placebo TENS and pharmacologic analgesia, or pharmacologic analgesia alone (control group). For each group we recorded severity of pain, analgesic intake, and pulmonary complications. Pethidine HCL and metamizol sodium were administered for postsurgical analgesia. Pain after MS was measured on a 10-point visual analogue scale (VAS). Mean scores in the TENS, placebo TENS, and control groups, respectively, were 5.70 +/- 1.78, 5.75 +/- 1.83, and 5.95 +/- 1.63 before treatment (P >.05); 2.40 +/- 1.18, 3.90 +/- 1.48, and 3.55 +/- 1.60 on the 12th hour of the intervention (P < .05); and 1.25 +/- 0.91, 2.30 +/- 1.34, and 2.15 +/- 1.13 on the 24th hour of the intervention (P < .05). The mean VAS scores decreased within each group (P < .05). However, the mean VAS scores decreased much more significantly in the TENS group (P < .05). Metamizol sodium intake was 1.05 +/- 0.39 g, 2.30 +/- 1.08 g, and 2.90 +/- 1.20 g and pethidine HCL intake was 17 +/- 16.25 mg, 57 +/- 21.54 mg, and 51.50 +/- 18.99 mg, respectively, in the TENS, placebo TENS, and control groups. Metamizol sodium and pethidine HCL intake was least in the TENS group (P < .05). Postoperative complications were observed in 6 (10%) of patients. The most frequent complication was atelectasia. TENS was more effective than placebo TENS or control treatments in decreasing pain and limiting opioid and nonopioid medication intake during the first 24-hour period following MS.

Pharmacotherapy for Acute Pain: Implications for Practice

Effective treatment of perioperative acute pain requires that information about the patient’s goals for pain relief, previous history with analgesics, and type of surgical procedure is used to guide decisions about analgesic regimens. Analgesics are selected based on the location of surgery, degree of anticipated pain, and patient characteristics (such as comorbidities), and routes of administration and dosing schedules are determined to maximize the effectiveness and safety of analgesia while minimizing the potential for adverse events. Pain management therapy is then extended into the postsurgical phase of recovery. To accomplish this, nurses must have a thorough understanding of the pharmacology of analgesics. This article provides useful information for commonly used analgesics, primarily nonsteroidal antiinflammatory drugs (NSAIDs), opioids, and local anesthetics for control of acute postoperative pain.

Pharmacotherapy for Acute Pain: Implications for Practice

Effective treatment of perioperative acute pain requires that information about the patient's goals for pain relief, previous history with analgesics, and type of surgical procedure is used to guide decisions about analgesic regimens. Analgesics are selected based on the location of surgery, degree of anticipated pain, and patient characteristics such as comorbidities, and routes of administration and dosing schedules are determined to maximize the effectiveness and safety of analgesia, while minimizing the potential for adverse events. Pain management therapy is then extended into the postsurgical phase of recovery. To accomplish this, nurses must have a thorough understanding of the pharmacology of analgesics. This article provides useful information for commonly used analgesics, primarily nonsteroidal antiinflammatory drugs (NSAIDs), opioids, and local anesthetics for control of acute postoperative pain.

Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery: A case study of 325 patients

Background We have developed a multimodal technique for the control of pain following knee and hip surgery, called "local infiltration analgesia" (LIA). It is based on systematic infiltration of a mixture of ropiva-caine, ketorolac, and adrenaline into the tissues around the surgical field to achieve satisfactory pain control with little physiological disturbance. The technique allows virtually immediate mobilization and earlier discharge from hospital.Patients and methods In this open, nonrandomized case series, we used LIA to manage postoperative pain in all 325 patients presenting to our service from Jan 1, 2005 to Dec 31,2006 for elective hip resurfacing (HRA), primary total hip replacement (THR), or primary total knee replacement arthroplasty (TKR). We recorded pain scores, mobilization times, and morphine usage for the entire group.Results Pain control was generally satisfactory (numerical rating scale pain score range 0–3). No morphine was required for postoperative pain control in two-thirds of the patients. Most patients were able to walk with assistance between 5 and 6 h after surgery and independent mobility was achieved 13–22 h after surgery. Orthostatic hypotension, nausea, and vomiting were occasionally associated with standing for the first time, but other side effects were unremarkable. 230 (71%) of the 325 patients were discharged directly home after a single overnight stay in hospital.Interpretation Local infiltration analgesia is simple, practical, safe, and effective for pain management after knee and hip surgery.

Gabapentin and postoperative pain—a systematic review of randomized controlled trials

Abstract The objective of this systematic review was to evaluate the efficacy and tolerability of perioperative gabapentin administration for the control of acute postoperative pain. We searched Medline (1966–2006), the Cochrane Library (2006), Scopus, CINAHL and bibliographies from clinical trials and review articles. We included randomized controlled trials (RCTs) comparing gabapentin with inactive controls in surgical patients. Sixteen valid RCTs were included. Weighted mean difference (WMD) for postoperative pain intensity (0–100 mm visual analogue scale) was −16.55 mm at 6 h and −10.87 mm at 24 h for treatment with a single preoperative dose of gabapentin 1200 mg. Cumulative opioid consumption at 24 h was also significantly decreased with gabapentin (WMD, −27.90 mg). When gabapentin was administered at doses less than 1200 mg, pain intensity was also lower at 6 h (WMD, −22.43 mm) and 24 h (WMD, −13.18 mm). Cumulative 24 h opioid consumption was also lower (WMD, −7.25 mg). Gabapentin was associated with an increased risk of sedation (Peto OR 3.86; 95% CI 2.50–5.94) but less opioid-related side effects such as vomiting (Peto OR 0.58; 95% CI 0.39–0.86) and pruritus (Peto OR 0.27; 95% CI 0.10–0.74). In conclusion, gabapentin has an analgesic and opioid-sparing effect in acute postoperative pain management when used in conjunction with opioids.

Gabapentin and postoperative pain – a systematic review of randomized controlled trials

The objective of this systematic review was to evaluate the efficacy and tolerability of perioperative gabapentin administration for the control of acute postoperative pain. We searched Medline (1966–2006), the Cochrane Library (2006), Scopus, CINAHL and bibliographies from clinical trials and review articles. We included randomized controlled trials (RCTs) comparing gabapentin with inactive controls in surgical patients. Sixteen valid RCTs were included. Weighted mean difference (WMD) for postoperative pain intensity (0–100 mm visual analogue scale) was −16.55 mm at 6 h and −10.87 mm at 24 h for treatment with a single preoperative dose of gabapentin 1200 mg. Cumulative opioid consumption at 24 h was also significantly decreased with gabapentin (WMD, −27.90 mg). When gabapentin was administered at doses less than 1200 mg, pain intensity was also lower at 6 h (WMD, −22.43 mm) and 24 h (WMD, −13.18 mm). Cumulative 24 h opioid consumption was also lower (WMD, −7.25 mg). Gabapentin was associated with an increased risk of sedation (Peto OR 3.86; 95% CI 2.50–5.94) but less opioid-related side effects such as vomiting (Peto OR 0.58; 95% CI 0.39–0.86) and pruritus (Peto OR 0.27; 95% CI 0.10–0.74). In conclusion, gabapentin has an analgesic and opioid-sparing effect in acute postoperative pain management when used in conjunction with opioids.

A comparison of three techniques for acute postoperative pain control following major abdominal surgery

Study objectives To compare the analgesic efficacy of a nonsteroidal antiinflammatory drug (NSAID) alone (basic pain treatment) with that of NSAID in conjunction with either intravenous (IV) patient-controlled analgesia (IV-PCA) or intermittent epidural morphine (epidural morphine), among patients recovering from major intraabdominal surgery; and to assess the fixed and variable costs of providing the respective acute pain treatment modalities. Design Prospective, nonrandomized study. Setting Postanesthesia care unit (PACU) and surgical departments of a large referral hospital. Patients All patients (n = 358) treated by our Acute Pain Service (APS) who were recovering from major intraabdominal surgery (colectomy, cholecystectomy, colostomy, gastrectomy, splenectomy). Measurements and main results The structure of our APS, analgesic regimens, and the associated patient monitoring and event-response algorithms are detailed. Data of 358 patients recovering from major intraabdominal surgery and treated according to one of the three treatment protocols were collected and analyzed. The cost of providing our APS and the nursing time required to monitor and treat patients in each treatment group were also calculated. The median visual analog scale (VAS) scores were low in all three treatment groups (23.5 mm vs. 6 mm vs. 4, for the basic pain treatment, IV-PCA, and epidural morphine groups, respectively). However, the median VAS was significantly ( p < 0.04) lower among patients who received epidural morphine than either the IV-PCA or basic pain treatment groups. Similarly, the number of patients who had at least one episode of a pain VAS >30 mm was significantly ( p < 0.04) lower in the epidural morphine group than either of the other two groups. The frequency of nausea and vomiting was similar among the groups. However, the frequency of postoperative pruritus was significantly ( p < 0.001) higher in the epidural morphine group than the other two groups. Patient satisfaction was unaffected by group allocation. Institutional costs per patient and the nursing time required to provide the APS were lowest in the basic pain treatment group. Conclusion Considering the respective pain profiles, complication rates, and institutional costs associated with the three analgesic regimens analyzed, the basic pain Treatment alone constitutes a useful alternative to the other two analgesic regimens assessed.

Continuous lateral sciatic blocks for acute postoperative pain management after major ankle and foot surgery.

We developed a continuous lateral sciatic nerve infusion technique for postoperative analgesia. A 10-cm insulated Tuohy needle connected to a nerve stimulator was introduced posteriorly between the biceps femoris and vastus lateralis groove 10 cm cephalad from the tip of the patella. After proper positioning of the insulated needle, a 20-gauge catheter was placed in proximity to the sciatic nerve. Continuous lateral sciatic infusion of 0.2% ropivacaine was associated with a significant reduction of morphine consumption by 29% and 62% during postoperative days one and two, respectively, in patients who underwent open reduction and internal fixation of the ankle. Continuous lateral sciatic infusion of 0.2% ropivacaine represents an alternative for acute postoperative pain control after major ankle and foot surgery.

Acute postoperative pain control for children with chronic disabilities.

Children have historically been undertreated for pain. Children with chronic disabilities may face multiple, complex surgeries that cause severe postoperative pain. In addition, underlying problems with increased muscle tone can cause painful postoperative spasms. Gillette Children's Specialty Healthcare treats children with chronic disabilities. Our orthopaedic surgeons have developed a single surgical approach referred to as "multiple lower extremity procedures" (MLEPs) to correct the patient's primary, underlying orthopaedic deformities all under one anesthesia. Because of the intensity of postoperative pain caused by this approach, Gillette Children's uses epidural analgesia or patient-controlled/nurse-controlled analgesia to manage postoperative pain.

Low-dose amitriptyline as an adjunct to opioids for postoperative orthopedic pain: A placebo-controlled trial

Tricyclic antidepressants (TCAs) have been found to be useful in the management of a variety of chronic pain conditions, although there is little published regarding the potential efficacy of this class of drug as an adjunct for the control of acute postoperative pain and related symptoms. Twenty-eight patients undergoing total hip or knee arthroplasty completed a randomized, placebo-controlled, double-blinded trial of 50 mg of amitriptyline p.O. HS on postoperative days 1, 2 and 3 while using patient-controlled morphine or meperidine analgesia (PCA). Visual analog (VAS) and numerical verbal (NVS) pain ratings, sedation scores, sleep quantity/quality scores, and sense of well-being scores were assessed twice daily on each of the days succeeding amitriptyline/placebo use. Hourly opioid use was recorded and transcribed from the memory of the PCA devices in use. Mean scores in the amitriptyline group for pain NVS were greater ( P < 0.05) (higher score = greater pain) on day 1 and greater on day 2 for the pain VAS. Mean scores for sense of well-being were greater ( P < 0.05) (higher score = better sense of well-being) for the placebo group on days 1 and 2. On days 2 and 3, sleep scale variable mean scores were worse in the placebo group ( P < 0.025). There were no other statistically significant differences between the control and active drug groups for any of the outcome variables measured. We conclude that amitriptyline at the dose prescribed is no different than placebo in altering the majority of postoperative symptom variables studied in the sample study population but caused no significant adverse effects. There does not appear to be an opioid-sparing effect nor an improvement in general well-being. Although this specific drug (or other TCAs) may be indicated for symptom management in selected postoperative patients, the results of this study do not support general use as a co-analgesic.

Urinary tract infection in patients with rheumatoid arthritis.

Urinary tract infection in patients with rheumatoid arthritis.