Effective Management Of Acute Pain Research Articles

Comparison of Postoperative Opioid Consumption of Paravertebral Block and Erector Spinae Plane Block After Thoracotomy: A Randomized Controlled Trial.

Background Thoracotomy is associated with severe postoperative pain. Pain developing after thoracotomy causes lung infections, inability to expel secretions, and atelectasis as a result of deep breathing. Effective management of acute pain after thoracotomy may prevent these complications. A multimodal approach to analgesia is widely employed by thoracic anesthetists using a combination of regional anesthetic blockade and systemic analgesia, with both non-opioid and opioid medications and local anesthesia blockade. Nowadays, regional anesthesia techniques such as thoracic epidural paravertebral block (PVB), erector spinae plane block (ESPB), and serratus plane block are frequently used to prevent pain after thoracotomy. In this study, we compared paravertebral block with erector spinae block for pain relief after thoracotomy. Our primary aim was to determine whether there was a difference between postoperative opioid consumption and pain scores. We also compared the two regional anesthesia techniques in terms of intraoperative hemodynamic data and postoperative complications. Methodology Patients aged between 18 and 75 years with an American Society of Anesthesiology (ASA) physical status I-III and scheduled for elective thoracotomy were included in the study. Using www.randomizer.org, patients were divided into two different groups, namely, ESPB and PVB.All patients were provided with a patient-controlled analgesia device preloaded with morphine. Postoperative 24-hour morphine consumptions were recorded. Results Data from 45 patients were used in the final analyses. Morphine consumption was higher in the ESPB group than in the PVB group at 24 hours postoperatively (19.2 ± 4.26 mg and 16.2 ± 2.64 mg, respectively; p < 0.05).There was no significant difference in numerical rating scale scores both at rest and with coughing (p > 0.05). Intraoperative heart rates were similar between groups. However, mean intraoperative blood pressure was significantly lower in the PVB group at 30 minutes (p < 0.05). Nausea and vomiting were observed in two patients in the ESPB group and one patient in the PVB group. The complication of nausea and vomiting was not statistically significant between the two groups (p > 0.05). Catastrophic complications such as hematoma, pneumothorax, and local anesthetic systemic toxicity were not observed in either group. Conclusions We found that patients who underwent PVB consumed less morphine postoperatively than patients who underwent ESPB. However, we did not observe any difference in pain scores between both groups. We think that ESPB can be considered a reliable method in thoracotomy surgery due to its ease of application and the fact that the place where the block is technically performed is farther from the central structures compared to PVB.In light of the results of our study, ESPB can be used as an alternative to PVB, which has been proven as postoperative analgesia in thoracic surgery.

Severe pain management in the emergency department: patient pathway as a new factor associated with IV morphine prescription.

Across the world, 25-29% of the population suffer from pain. Pain is the most frequent reason for an emergency department (ED) visit. This symptom is involved in approximately 70% of all ED visits. The effective management of acute pain with adequate analgesia remains a challenge, especially for severe pain. Intravenous (IV) morphine protocols are currently indicated. These protocols are based on patient-reported scores, most often after an immediate evaluation of pain intensity at triage. However, they are not systematically prescribed. This aspect could be explained by the fact that physicians individualize opioid pain management for each patient and each care pathway to determine the best benefit-risk balance. Few data are available regarding bedside organizational factors involved in this phenomenon. This study aimed to analyze the organizational factors associated with no IV morphine prescription in a standardized context of opioid management in a tertiary-care ED. A 3-month prospective study with a case-control design was conducted in a French university hospital ED. This study focused on factors associated with protocol avoidance despite a visual analog scale (VAS) ≥60 or a numeric rating scale (NRS) ≥6 at triage. Pain components, physician characteristics, patient epidemiologic characteristics, and care pathways were considered. Qualitative variables (percentages) were compared using Fisher's exact test or the chi-squared tests. Student's t-test was used to compare continuous variables. The results were expressed as means with their standard deviation (SD). Factors associated with morphine avoidance were identified by logistic regression. A total of 204 patients were included in this study. A total of 46 cases (IV morphine) and 158 controls (IV morphine avoidance) were compared (3:1 ratio). Pain patterns and patient's epidemiologic characteristics were not associated with an IV morphine prescription. Regarding NRS intervals, the results suggest a practice disconnected from the patient's initial self-report. IV morphine avoidance was significantly associated with care pathways. A significant difference between the IV morphine group and the IV morphine avoidance group was observed for "self-referral" [adjusted odds ratio (aOR): 5.11, 95% CIs: 2.32-12.18, p < 0.0001] and patients' trajectories (Fisher's exact test; p < 0.0001), suggesting IV morphine avoidance in ambulatory pathways. In addition, "junior physician grade" was associated with IV morphine avoidance (aOR: 2.35, 95% CIs: 1.09-5.25, p = 0.03), but physician gender was not. This bedside case-control study highlights that IV morphine avoidance in the ED could be associated with ambulatory pathways. It confirms the decreased choice of "NRS-only" IV morphine protocols for all patients, including non-trauma patterns. Modern pain education should propose new tools for pain evaluation that integrate the heterogeneity of ED pathways.

Real-World Evidence on the Efficacy and Tolerability of Tramadol/Dexketoprofen (TRAM/DKP) Fixed-Dose Combination for the Management of Acute Non-surgical Pain in Asian Patients: A Multicentre Retrospective Case Series.

Multimodal analgesia is key in the effective management of acute pain. Previous clinical trials have demonstrated good results with the use of a fixed-dose combination (FDC) of tramadol 75 mg and dexketoprofen 25 mg (TRAM/DKP) in acute pain management. However, there is a dearth of real-world evidence on the efficacy and safety of this combination in the management of acute non-surgical pain, especially among Asian patients. The case series reported herein investigates the real-world experiences of physicians and Asian patients with the use of TRAM/DKP FDC in the management of acute non-surgical pain. Data were collected retrospectively on 11 Asian patients across multiple hospitals who had received a short course of TRAM/DKP FDC for acute non-surgical orthopaedic and non-orthopaedic pain. Data on baseline characteristics, medical history, treatment regimen, clinical outcomes, and patient satisfaction were compiled and shared at a peer-to-peer expert meeting in October 2022. All patients experienced a reduction in pain intensity and were very satisfied with pain management, with a mean satisfaction score of 4.3/5. Five patients (range: 63-74 years) experienced mild adverse events, including nausea, vomiting, and dizziness, which resolved with no need for additional treatment in the majority of cases. No serious adverse events were recorded. Asian patients with acute non-surgical orthopaedic and non-orthopaedic pain achieved good pain control with TRAM/DKP FDC. The regimen was well tolerated, and patients reported high levels of satisfaction with the outcomes, indicating that TRAM/DKP FDC is an effective choice for the control of acute non-surgical pain in Asian patients.

Comparison of Intercostal Block and Epidural Analgesia for Post-thoracotomy: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND: Thoracotomy is associated with severe postoperative pain. Effective management of acute pain after thoracotomy may reduce complications and chronic pain. Epidural analgesia (EPI) is considered the gold standard for postthoracotomy analgesia; however, it is associated with complications and limitations. Emerging evidence suggests that an intercostal nerve block (ICB) has a low risk of severe complications. Anesthetists will benefit from a review that assesses the advantages and disadvantages associated with ICB and EPI in thoracotomy. OBJECTIVES: This meta-analysis aimed to evaluate the analgesic efficacy and adverse effects of ICB and EPI for pain treatment after thoracotomy. STUDY DESIGN: Systematic review. METHODS: This study was registered in the International Prospective Register of Systematic Reviews (CRD42021255127). Relevant studies were searched for in PubMed, Embase, Cochrane, and Ovid databases. Primary (postoperative pain at rest and during cough) and secondary (nausea and vomiting, morphine consumption, and length of hospital stay) outcomes were analyzed. The standard mean difference for continuous variables and the risk ratio for dichotomous variables were calculated. RESULTS: Nine randomized controlled studies with a total of 498 patients who underwent thoracotomy were included. The results of the meta-analysis demonstrated no statistically significant differences between the 2 methods in terms of the Visual Analog Scale scores for pain at 6-8, 12-15, 24-25, and 48-50 hours at rest and at 24 hours during coughing after surgery. There were no significant differences in nausea and vomiting, morphine consumption, or length of hospital stay between the ICB and EPI groups. LIMITATIONS: The number of included studies was small, and the quality of evidence was low. CONCLUSIONS: ICB may be as effective as EPI for pain relief after thoracotomy. KEY WORDS: Thoracic surgery, intercostal nerve block, epidural analgesia, postthoracotomy pain, postoperative pain, randomized controlled trial, meta-analysis, systematic review

Enhancing the Use of Opioid Sparing Protocol in the PACU

IntroductionOpioids serve as the cornerstone for severe acute post-operative pain management in the PACU. Opioids have been used for their quick onset and efficacy without analgesic ceiling yet have significant side effects. Identification of the problemAcute post-operative pain remains a major problem, resulting in the multiple undesirable outcomes if inadequately controlled. In the PACU setting, opioid use is common as the primary treatment for post-operative pain. Purpose of the studyThe purpose of the study is to assess the impact of the Opioid Sparing Protocol on opioid-naive patients in the PACU post knee and hip arthroplasty. MethodsRetrospective analysis by chart review of 200 comparable cases, from each period, for implementation of the Opioid Sparing Protocol pre-intervention (Q2, 2018) and post-intervention (Q2, 2019). Outcomes/ResultsSignificant increase in the use of Tramadol (+242.86%), along with reduction in the use of Percocet (-44.44%) and Oxycodone (-56.52%) have shown to be effective in providing analgesia and improved patient outcomes. DiscussionThere is an ongoing effort to develop strategies for safe and effective alleviation of post-operative pain. This analysis of comparable cases shows that changes in pain management methodologies can lead to positive results for the patient's surgical experience and post-operative clinical outcome. ConclusionUtilizing the multimodal approach outlined in the Opioid Sparing Protocol provides pain relief while reducing opioid requirements and opioid related events. Effective management of acute pain in the PACU results in reduced PACU length of stay and improved patient outcomes. Implications for peri-anesthesia nurses and future researchAs health care professionals, it is our responsibility to provide safe and effective pain management. Considering the heavy societal cost of the opioid crisis, enhanced pain management addresses opioid misuse. The challenge for the healthcare workforce is to develop new, effective and non-addictive approaches to pain management.

Implementing an intravenous ketamine protocol for acute pain in the medical-surgical setting.

A subanesthetic intravenous ketamine infusion is a safe and effective acute pain management modality for moderate to severely painful surgical procedures and may be useful in patients who are at increased risk for opioid-related adverse events. Despite its safety profile, intravenous ketamine is often restricted to the intensive care unit, which results in decreased patient access to this effective therapy. For clinicians who wish to implement an intravenous ketamine protocol in the medical-surgical setting, there are few resources available. In this brief report, we present our ketamine infusion protocol for acute pain and the clinical and financial outcomes 1 year after implementation. In our experience, ketamine infusions on the medical-surgical ward are safe and cost-effective when an established acute pain service protocol is followed. Nurse practitioners play an essential role in increasing patient access to intravenous ketamine infusions and leading change by collaborating with stakeholders to develop a protocol, training nurses and interdisciplinary team members, and providing ongoing support to nursing staff.

Transforming acute pain management in children: A concept analysis to develop a new model of nurse, child and parent partnership.

To identify the core components of acute pain management in children, re-conceptualise the process and update the existing model to inform nursing research and clinical practice. Acute pain in hospitalised children remains suboptimal, despite extensive nursing research and education. Improvements require a patient-centred approach and a conceptual model which includes the role of parents and partnership. Using Rodgers' Evolutionary method, a concept analysis was conducted to define the core components for effective acute pain management in children. A scoping review of peer-reviewed literature from 1990 through 2020 was conducted using the terms "pain management," "pain control," "pain treatment," "multi modal," and "concept*". Abstracts from 85 articles were initially reviewed with 30 articles retained for analysis. Core concepts were identified, defined and synthesised. The PRISMA 2020 checklist was used. A new model was developed from a synthesis of past work which incorporates the role of parents, the complexity of the process and definitions for shared decision-making. Trust, safety, collaborative communication and genuine partnership were identified as the core components for effective pain management in children, with the triadic relationship of nurses, patients and parents in genuine partnership foundational to the nursing process. The new model for acute pain management in children transforms the nurse's role from gatekeeper to facilitator, shifting the process from nurse driven to patient-centred. The new collaborative model will promote shared decision-making for individualised pain assessments, interventions and evaluations. Establishing the nurse, child, parent partnership as an essential foundation to pain management has the potential to expand pain assessments, optimise treatment selections, advancing clinical practice, patient outcomes and nursing science. No Patient or Public Contributions were included in this paper as this was a concept analysis pulling from past works.

Health disparities in regional anesthesia and analgesia for the management of acute pain in trauma patients.

Health disparities in regional anesthesia and analgesia for the management of acute pain in trauma patients.

The Ramifications of Opioid Utilization and Outcomes of Alternative Pain Control Strategies for Total Knee Arthroplasties.

Morbidity and mortality related to opioid use has generated a public health crisis in the United States. Total knee arthroplasty (TKA) is an increasingly common procedure and is often accompanied by post-operative opioid utilization. Unfortunately, post-operative opioid usage after TKA has been shown to lead to higher rates of complications, longer hospital stays, increased costs, and more frequent need for revision surgery. Pre-operative opioid utilization has been shown to be one of the most important predictors of post-operative opioid usage. Additional risk factors for continued post-operative opioid utilization after TKA include pre-operative substance and tobacco use as well as higher post-operative prescription dosages, younger age, female gender, and Medicaid insurance. One method for mitigating excessive post-operative opioid utilization are Enhanced Recovery After Surgery (ERAS) protocols, which include a multidisciplinary approach that focuses on perioperative factors to optimize patient recovery and function after surgery. Additional strategies include multimodal pain regimens with epidural anesthetics, extended duration local anesthetics and adjuvants, and ultrasound guided peripheral nerve blocks. In recent years, opioid prescribing duration limitations have also been put into place by state and federal government, hospital systems, and ambulatory surgery centers making effective acute pain management imperative for all stakeholders. In this regard, as rates of TKA continue to increase across the United States, multidisciplinary efforts by all stakeholders are needed to ensure adequate pain control while preventing the negative sequalae of opioid medications.

Error traps in acute pain management in children.

Providing effective acute pain management to hospitalized children can help improve outcomes, decrease length of stay, and increase patient and parental satisfaction. Error traps (circumstances that lead to erroneous actions or undesirable consequences) can result in inadequately controlled pain, unnecessary side effects, and adverse events. This article highlights five error traps encountered when managing acute pain in children. They include failure to appropriately assess pain, optimally utilize regional anesthesia, select suitable systemic analgesics, identify and treat medication-related side effects, and consider patient characteristics when choosing medication or dosing route. These issues are easily addressed when the clinician is cognizant of ways to anticipate, identify, and mitigate or avoid these errors.

Enhancing the Use of Opioid Sparing Protocol in the PACU

<h3>Introduction</h3> Opioids serve as the cornerstone for severe acute post-operative pain management in the PACU. Opioids have been used for their quick onset and efficacy without analgesic ceiling yet have significant side effects. The Opioid Sparing Protocol was developed to provide pain relief to post knee and hip arthroplasty while minimizing narcotics and allowing rapid rehabilitation and faster discharge. <h3>Identification of the problem</h3> Acute post-operative pain remains a major problem, resulting in the multiple undesirable outcomes if inadequately controlled. In the PACU setting, opioid use is common as the primary treatment for post-operative pain. <h3>Purpose of the study</h3> The purpose of the study is to assess the impact of the Opioid Sparing Protocol on opioid-naive patients in the PACU post knee and hip arthroplasty. <h3>Methods</h3> Retrospective analysis by chart review of 200 comparable cases, from each period, for implementation of the Opioid Sparing Protocol pre-intervention (Q2, 2018) and post-intervention (Q2, 2019). <h3>Outcomes/Results</h3> Significant increase in the use of Tramadol (+242.86%), along with reduction in the use of Percocet (-44.44%) and Oxycodone (-56.52%) have shown to be effective in providing analgesia and improved patient outcomes. <h3>Discussion</h3> There is an ongoing effort to develop strategies for safe and effective alleviation of post-operative pain. This analysis of comparable cases shows that changes in pain management methodologies can lead to positive results for the patient's surgical experience and post-operative clinical outcome. <h3>Conclusion</h3> Utilizing the multimodal approach outlined in the Opioid Sparing Protocol provides consistent pain relief while reducing opioid requirements and opioid related events. Effective management of acute pain in the PACU results in reduced PACU length of stay and improved patient outcomes. <h3>Implications for perianesthesia nurses and future research</h3> As health care professionals, it is our responsibility to provide safe and effective pain management. Considering the heavy societal cost of the opioid crisis, enhanced pain management addresses opioid misuse. The challenge for the healthcare workforce is to develop new, effective and non-addictive approaches to pain management.

O84: OPIOID PRESCRIPTION AT OPERATIVE DISCHARGE (OPIOID STUDY)

Abstract Presenting Author Email: etheophilidou@gmail.com Research Question Opioid misuse is a major health epidemic. Surveys in the US have shown that over 130 patients die daily due to opioid related drug overdose with 10.3 million patients misused prescription opioids in 2018. This is the first study in the UK to explore the magnitude of the opioid crisis in our country. The opioid crisis was identified first in the US after life expectancy reduced dramatically in 2015. One of the main reasons attributed to this was the increase in the number of overdoses and suicides, both linked with the use of opioid drugs. Between 1999 and 2017 the number of deaths from opioid overdoses increased almost six fold. The 2019 National Survey on Drug use and Health in the US showed that 10.3 million patients misused prescription opioids in 2018 and 2 million patients with an opioid use disorder. Factors contributing to opioid dependence were identified as the use of modified release formulations, the use of repeat opioid prescriptions and the treatment of acute pain. Background and Aim The aim of the study is to explore the magnitude of the opioid crisis in the UK, by identifying risk factors for persistent opioid use following major general surgical intervention. Design Phase 1 of the OPiOiD study is a national retrospective audit. We are aiming to identify risk factors for persistent opioid use in patients undergoing major general surgical interventions. Specifically we will be assessing the number of patients given a duration or point of review when opioids should be stopped and whether any written information has been given to these patients on discharge regarding safe use of opioids and de-prescribing advice. 23 hospitals across the UK have registered so far. Data are collected using the electronic discharge summaries send to the GPs and copies given to patients. Phase 2 of the study will be to proceed with a national observational study with the aim to develop strategies to promote safe and effective management of acute pain. Team and infrastructure The East Midlands Surgical Academic Network (EMSAN) leads the study, supervised by Dr Roger Knaggs, Associate Professor School of Pharmacy University of Nottingham, Dr Nicholas Levy, Department of Anaesthesia and peri-operative Medicine West Suffolk NHS Foundation Trust and Professor Dileep Lobo, Nottingham Digestive Diseases Centre National Institute for Health Research.

Development of a mobile application for acute pain management in U.S. military healthcare

One of the most significant challenges faced by the U.S. military health system is effective pain management. In resource-denied environments such as En Route Care (ERC), patient care begins with effective acute pain management and is vital to ensure optimal long-term patient outcomes. An electronic, mobile pain management application (app) called the Bee Better app was developed to address the gaps in acute pain management for patients transported throughout the ERC system. The app enables patients to track self-reported acute pain data, provides education and evidenced-based non-pharmacologic interventions during transport. The Delphi method was used as a novel approach to solicit feedback from subject matter experts to systematically enhance the app development process. In its current state, the app tracks patients' reported pain data and information regarding medication intake and provides educational resources about medications and the flight environment. Optimally in the future, the app will deliver real-time therapeutic pain interventions, integrate with the electronic health record and communicate with providers in real-time during care, enabling better patient-centered pain management in the austere ERC environment. Initial usability scores were above industry standards indicating a potential benefit in using a rigorous process for healthcare app development. These mobile apps may enable increased self-management and autonomy in resource-limited environments and optimize outcomes of acute pain management.

Pain management in the surgical ICU patient.

Acute pain management in the surgical ICU is imperative. Effective acute pain management hastens a patient's return to normal function and avoid the negative sequelae of untreated acute pain. Traditionally, opioids have been the mainstay of acute pain management strategies in the surgical ICU, but alternative medications and management strategies are increasingly being utilized. Extrapolating from lessons learned from enhanced recovery after surgery protocols, surgical intensivists are increasingly utilizing multimodal pain regimens (MMPRs) in critically ill surgical patients recovering from major surgical procedures and injuries. MMPRs incorporate both oral medications from several drug classes and regional blocks when feasible. In addition, although MMPRs may include opioids as needed, they are able to achieve effective pain control while minimizing opioid exposure. Even after major elective surgery or significant injury, opioid-minimizing MMPRs can effectively treat acute pain.

Approaching acute pain in emergency settings: European Society for Emergency Medicine (EUSEM) guidelines-part 1: assessment.

Pain management is a vital component of patient care, particularly in the emergency setting. Pain can hinder the opportunities to treat and manage pain-causing conditions and remains one of the primary reasons patients seek emergency medical care, yet despite this, pain often remains under-acknowledged, under-assessed and undertreated. Despite the importance of effective management of acute pain, there are currently no well-defined emergency medicine guidelines at a European level to support healthcare professionals in achieving this goal. The European Society for Emergency Medicine (EUSEM) identified this as a significant unmet requirement, for improving day-to-day patient management and for providing guidance to trainees and non-emergency medicine physicians. Under the auspices of EUSEM, a programme-the European Pain Initiative-was launched with the aim of providing information, advice and guidance on pain management in pre-hospital and emergency department settings. Search terms were developed to search MEDLINE, Cochrane database, Google Scholar and EMBASE online databases to return English language articles published in the last 10years. A working package of reference materials was evaluated against inclusion and exclusion criteria and levels of evidence ascribed. A short survey was developed by the European Pain Initiative Steering Committee for completion by EUSEM members to evaluate actual clinical practice. A working document of > 800 publications was identified for further review and evaluation against agreed criteria. Some further publications were included by the Steering Committee to explore older literature for long-established analgesics, or newly emergent literature that was considered important for inclusion but was identified as the guideline development was underway. This article provides the methodology used to inform the guidelines, including survey results of EUSEM members on assessment and treatment of acute pain. A companion manuscript in this issue presents an evidence-based review and recommendations for individualised evaluation of acute pain in patients in emergency settings.

Post-Thoracotomy Pain: Current Strategies for Prevention and Treatment.

Treating acute pain after thoracotomy surgery and preventing the development of chronic post-thoracotomy pain syndrome (PTPS) remain significant challenges in this surgical population. While appropriately treated acute thoracotomy pain often resolves, a significant number of patients develop PTPS, with up to 65% of patients experiencing some pain and 10% suffering life-altering, debilitating pain. Currently, there is very little known about specific molecular targets or novel therapeutic combinations that effectively prevent PTPS. Identifying modifiable clinical risk factors (procedure, physical and mental health, preoperative pain in the surgical area and another regions) seems to the most pragmatic approach for prevention for now. Effective acute pain management adopting a multimodal approach can result in a decreased incidence of PTPS. Interventional techniques such as paraverterbral blocks, intercostal blocks, and erector spinae blocks show some promise as well. Future research should be focused on minimally invasive surgeries and also the effect of ERAS protocols, including early mobilization, nutrition, and early removal of drains, on the development of PTPS.

The predictors, barriers and facilitators to effective management of acute pain in children by emergency medical services: A systematic mixed studies review.

We aimed to identify predictors, barriers and facilitators to effective pre-hospital pain management in children. A segregated systematic mixed studies review was performed. We searched from inception to 30-June-2020: MEDLINE, CINAHL Complete, PsycINFO, EMBASE, Web of Science Core Collection and Scopus. Empirical quantitative, qualitative and multi-method studies of children under 18 years, their relatives or emergency medical service staff were eligible. Two authors independently performed screening and selection, quality assessment, data extraction and quantitative synthesis. Three authors performed thematic synthesis. Grading of Recommendations Assessment, Development and Evaluation and Confidence in the Evidence from Reviews of Qualitative Research were used to determine the confidence in cumulative evidence. From 4030 articles screened, 78 were selected for full text review, with eight quantitative and five qualitative studies included. Substantial heterogeneity precluded meta-analysis. Predictors of effective pain management included: ‘child sex (male)’, ‘child age (younger)’, ‘type of pain (traumatic)’ and ‘analgesic administration’. Barriers and facilitators included internal (fear, clinical experience, education and training) and external (relatives and colleagues) influences on the clinician along with child factors (child’s experience of event, pain assessment and management). Confidence in the cumulative evidence was deemed low. Efforts to facilitate analgesic administration should take priority, perhaps utilising the intranasal route. Further research is recommended to explore the experience of the child. Registration: PROSPERO CRD42017058960

Treating Perioperative and Acute Pain in Patients on Buprenorphine: Narrative Literature Review and Practice Recommendations.

Opioid use disorder (OUD), a leading cause of morbidity and mortality in the USA, can be effectively treated with buprenorphine. However, the same pharmacologic properties (e.g., high affinity, partial agonism, long half-life) that make it ideal as a treatment for OUD often cause concern among clinicians that buprenorphine will prevent effective management of acute pain with full agonist opioid analgesics. Because of this concern, many patients are asked to stop buprenorphine preoperatively or at the onset of acute pain, placing them at high risk for both relapse and a difficult transition back to buprenorphine after acute pain has resolved. The purpose of this review is to summarize the existing literature for acute pain and perioperative management in patients treated with buprenorphine for OUD and to provide practical management recommendations for generalist practitioners based on evidence and clinical experience. In short, evidence suggests that sufficient analgesia can be achieved with maintenance of buprenorphine and use of both opioid and non-opioid analgesic options for breakthrough pain. We recommend that clinicians (1) continue buprenorphine in the perioperative or acute pain period for patients with OUD; (2) use a multi-modal analgesic approach; (3) pay attention to care coordination and discharge planning when making an analgesic plan for patients with OUD treated with buprenorphine; and (4) use an individualized approach founded upon shared decision-making. Clinical examples involving mild and severe pain are discussed to highlight important management principles.

Dexmedetomidine in Enhanced Recovery After Surgery (ERAS) Protocols for Postoperative Pain.

Purpose of ReviewEffective acute pain management has evolved considerably in recent years and is a primary area of focus in attempts to defend against the opioid epidemic. Persistent postsurgical pain (PPP) has an incidence of up to 30–50% and has negative outcome of quality of life and negative burden on individuals, family, and society. The 2016 American Society of Anesthesiologists (ASA) guidelines states that enhanced recovery after surgery (ERAS) forms an integral part of Perioperative Surgical Home (PSH) and is now recommended to use a multimodal opioid-sparing approach for management of postoperative pain. As such, dexmedetomidine is now being used as part of ERAS protocols along with regional nerve blocks and other medications, to create a satisfactory postoperative outcome with reduced opioid consumption in the Post anesthesia care unit (PACU).Recent FindingsDexmedetomidine, a selective alpha2 agonist, possesses analgesic effects and has a different mechanism of action when compared with opioids. When dexmedetomidine is initiated at the end of a procedure, it has a better hemodynamic stability and pain response than ropivacaine. Dexmedetomidine can be used as an adjuvant in epidurals with local anesthetic sparing effects. Its use during nerve blocks results in reduced postoperative pain. Also, local infiltration of IV dexmedetomidine is associated with earlier discharge from PACU.SummaryPerioperative use of dexmedetomidine has significantly improved postoperative outcomes when used as part of ERAS protocols. An in-depth review of the use of dexmedetomidine in ERAS protocols is presented for clinical anesthesiologists.

Predictors of effective management of acute pain in children within a UK ambulance service: A cross-sectional study

ObjectiveWe aimed to identify predictors of effective management of acute pain in children in the pre-hospital setting. MethodsA retrospective cross-sectional study using electronic clinical records from one large UK ambulance service during 01-Oct-2017 to 30-Sep-2018 was performed using multivariable logistic regression. We included all children <18 years suffering acute pain. Children with a Glasgow Coma Scale score of <15, no documented pain or without a second pain score were excluded. The outcome measure was effective pain management (abolition or reduction of pain by ≥2 out of 10 using the numeric pain rating scale, Wong-Baker FACES® scale or FLACC [face, legs, activity, crying and consolability] scale). Results2312 patients were included for analysis. Median (IQR) age was 13 (9–16), 54% were male and the cause of pain was trauma in 66% of cases. Predictors of effective pain management include children who were younger (0–5 years) compared to older (12–17 years) (adjusted odds ratio [AOR] 1.53; 95% confidence interval [CI] 1.18–1.97), administered analgesia (AOR 2.26; CI 1.87–2.73), attended by a paramedic (AOR 1.46; CI 1.19–1.79) or living in an area of low deprivation (index of multiple deprivation [IMD] 8–10) compared to children in an area of high deprivation (IMD 1–3) (AOR 1.37; CI 1.04–1.80). Child sex, type of pain, transport time, non-pharmacological treatments and clinician experience were not significant. ConclusionThese predictors highlight disparity in effective pre-hospital management of acute pain in children. Qualitative research is needed to help explain these findings.