Higher Postoperative Pain Scores Research Articles

Preoperative Psychological Factors, Postoperative Pain Scores, and Development of Posttraumatic Stress Disorder Symptoms After Pediatric Anterior Cruciate Ligament Reconstruction.

Acute orthopedic injuries and subsequent surgical repair can be challenging for children and adolescents and result in posttraumatic stress reactions that can be problematic after the acute perioperative period. In a cohort of patients undergoing anterior cruciate ligament reconstruction (ACLR), we investigated the incidence and explored risk factors associated with the development of posttraumatic stress disorder (PTSD) symptoms after surgery. We analyzed data from a multicenter, prospective, observational registry of pediatric patients undergoing ACLR. Patient data included demographic, psychological assessments, postoperative pain measures, and a posttraumatic stress disorder assessment (Child PTSD Symptom Scale [CPSS]) collected after the operation. An analysis of patients who provided survey data at 6 months was used to determine the incidence of posttraumatic stress reactions and to explore associated risk factors. A total of 519 patients were enrolled in a prospective observational study of outcomes after ACLR. A cohort of 226 patients (44%) provided completed data collection and CPSS follow-up surveys at 6 months. We found that 17 of the patients (7.5%) met the criteria for PTSD at 6 months which represents 3.3% of our total study population (17/519). A univariate analysis suggested that a negative (P = .017), excitable (P = .039), or inhibitory (P = .043) temperament compared to a positive temperament, high preoperative scores for anxiety (P = .001) or depression (P = .019) and high pain scores on postoperative day (POD)1 (P = .02) increased the odds of PTSD at 6 months. A multivariable model revealed that patients self-reporting symptoms consistent with clinical anxiety/depression preoperatively and patients with a max pain score ≥7 on POD1 were 29 times (P = .018) and 9.8 times (P = .018) more likely to develop PTSD at 6 months. A portion of patients undergoing ACLR are at risk for the development of symptoms consistent with PTSD. Risk factors include preoperative anxiety or depression and high postoperative pain scores. Interventions designed to address preoperative risk factors and optimization of postoperative pain may represent opportunities to improve outcomes in this patient population.

Sleep quality after autologous breast reconstruction

BackgroundSleep is a fundamental aspect of human health and well-being, but is often interrupted in a hospital setting. Especially after surgery, poor sleep quality can negatively affect postoperative recovery and quality of life. Therefore the aim of this study is to gain insight in the quality of sleep in patients after autologous breast reconstruction and evaluate factors associated with quality of sleep. Materials and methodsIn this single-center observational cohort study, participants completed a sleep diary, including the Pittsburgh Sleep Quality Index (PSQI) and the EQ-5D-5L quality of life questionnaire, before surgery, during hospital admission and two weeks and three months postoperative. Additional variables such as pain, and anesthesia time were collected. ResultsTwenty-nine patients were included. Before surgery, 58% of them experienced poor quality of sleep, with a median PSQI score of 5.0. During hospital admission, 83% of the patients had a poor quality of sleep, with a PSQI score of 6.0. The PSQI score two weeks postoperative increased to 7.0 and was decreased three months postoperative to 5.0. Patients with a pain score >4 (‘pain’ group), had a higher median PSQI score than patients with a pain score ≤4 (‘no pain’ group) at all postoperative time points previously mentioned. No correlation was observed between anesthesia time or quality of life. ConclusionPoor sleep quality is experienced by most women after autologous breast reconstruction, especially in those with higher postoperative pain scores. This knowledge offers an opportunity to improve the postoperative care for these patients.

Early postoperative pain and 30-day complications following major abdominal surgery: a retrospective cohort study

BackgroundIncreasing evidence supports a positive relationship between the intensity of early postoperative pain, and the risk of 30-day postoperative complications. Higher pain levels may hamper recovery and contribute to immunosuppression...

Percutaneous nephrolithotomy or flexible ureteral lithotripsy, which one is better for patients with upper ureteral calculi of 1.5–2.0 cm in diameter

PurposeFirst research to evaluate the clinical efficacy and safety of flexible ureteral lithotripsy (FURSL) and percutaneous nephrolithotomy (PCNL) in the treatment of the upper ureteral stone is between 1.5 cm and 2.0 cm in diameter since there is no consensus with such ureteral stone yet.MethodsFrom December 2018 to October 2022, 104 patients with calculi in the upper ureter received percutaneous nephrolithotomy (PCNL)or flexible ureteroscopic lithotripsy (FURSL) in our institution. The clinical data of the patients in the two groups were retrospectively searched. Stone removal rate, operation time, blood loss, postoperative pain score, postoperative inflammatory factor, postoperative complication rates and ureteral obstruction three months after the operation were compared between the two groups.ResultsA total of 104 patients were included in the study. The stone clearance rate and the secondary surgery rate were 88.89% and 7.41% in the FURSL group, the figures were 97.96% and 2.0% in the PCNL group (p = 0.067, 0.497). Regarding ureteral obstruction three months after the operation, there were 2 patients in FURSL group and 0 patients in PCNL group(p = 0.497).Compared to patients in FURSL group, patients in the PCNL group had shorter operation time(PCNL 71.81 ± 18.94 min vs. FURSL 86.80 ± 22.49 min, p = 0.0004), fewer complications(PCNL 20.37% vs. FURSL 6.12%), and lower postoperative inflammatory factor(p = 0.0004), yet they got more hemoglobin drop (PCNL 13.14 ± 9.81 g/L vs. FURSL 4.77 ± 3.55 g/L, p < 0.0001), higher postoperative pain scores(p = 0.0017) in the first three postoperative days and longer hospital stay (PCNL 4.96 ± 1.21 days vs. FURSL 3.60 ± 0.83 days).ConclusionBoth FURSL and PCNL were effective methods for treating upper ureteral stones of 1.5–2.0 cm in diameter given the extremely high stone clearance rate and a very low secondary surgery rate, as long as rare ureteral obstruction in medium-long term observation. Additionally, FURSL can effectively reduce surgical bleeding, postoperative pain, and hospital stay, while PCNL can decrease operation time, the risk of infection, and complications. Therefore, doctors could select suitable surgical treatment for those patients depending on their different clinical situations based on these findings.

Validation of the Portuguese Version of the Short-Form Glasgow Composite Measure Pain Scale (CMPS-SF) According to COSMIN and GRADE Guidelines.

We aimed to validate the CMPS-SF according to COSMIN and GRADE guidelines. Four trained evaluators assessed 208 videos (pre-operative-M1, peak of pain-M2, 1 h after the peak of pain and analgesia (rescue)-M3, and 24 h post-extubation-M4) of 52 dogs, divided into negative controls (n = 10), soft tissue surgeries (n = 22), and orthopedic surgeries (n = 20). The videos were randomized and blinded as to when they were filmed, and were evaluated in two stages, 21 days apart. According to confirmatory analysis, the CMPS-SF is a unidimensional scale. Intra-observer reliability was between 0.80 and 0.99 and inter-observer reliability between 0.73 and 0.86. Criterion validity was confirmed by the correlation between the CMPS-SF and other unidimensional scales (≥0.7). The differences between the scores were M2 ≥ M3 > M4 > M1 (responsiveness), and the scale presented construct validity (higher postoperative pain scores in dogs undergoing surgery versus control). Internal consistency was 0.7 (Cronbach's α) and 0.77 (McDonald's ω), and the item-total correlation was between 0.3 and 0.7, except for "A(ii)-Attention to wound". Specificity and sensitivity were 78-87% and 74-83%, respectively. The cut-off point for rescue analgesia was ≥5 or ≥4 excluding item B(iii) mobility, and the GRADE classification was high, confirming the validity of the scale.

Development of a nomogram to predict negative postoperative behavioral changes based on a prospective cohort

BackgroundIt is believed that negative postoperative behavioral changes (NPOBC) is associated with negative perioperative outcomes in children. The importance of development of a predictive model of NPOBC was noted. This study aims to identify potential risk factors develop a nomogram to predict NPOBC on postoperative day 3 based on a prospective cohort.MethodsA prospective observational study was conducted on children(American Society of Anesthesiologists I ~ III) aged 2 ~ 12 years who underwent selective surgery under general anesthesia between September 2022 and February 2023. The patient’s clinical data were analyzed. The method of measuring NPOBC is with the The Posthospital Behaviour Questionnaire (PHBQ), and all of children remained hospitalized at the time of assessment. The enrolled patients were categorized into the NPOBC group and the non-NPOBC group according to if children developed NPOBC on postoperative day 3. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors and develop the nomogram to predict NPOBC. Internal validation was performed using the parametric bootstrapping method.ResultsOne hundred ninety-two patients were enrolled in the study, 44.8% (86/192 patients) of children developed NPOBC on postoperative day 3. Univariate and multivariate logistic regression analysis demonstrated that the Pediatric Anesthesia Behavior (PAB) score (OR: 1.23, 95%CI: 1.14–1.33), cerebral desaturation (OR: 1.16, 95%CI: 1.02–1.32), and postoperative pain score (OR: 1.07, 95%CI: 1.02–1.13) were independent predictors for NPOBC on postoperative day 3 (P < 0.05). They were used to develop the prediction model. The calibration curve demonstrated satisfied discrimination and calibration of the prediction model. The model presented with good discriminative ability (area under the receiver operating characteristic curve: 0.762 [95%CI: 0.691—0.833]). The decision curve analysis also revealed the great clinical utility of the nomogram.ConclusionBased on our prospective observational study, pre-anesthesia patients with higher PAB scores, presence of cerebral desaturation, and higher postoperative pain score were more likely to develop NPOBC on postoperative day 3. We established and validated a nomogram for predicting NPOBC, which could help assess patients individually, identify high-risk groups of NPOBC and improve patient prognosis.Trial registrationChinese Clinical Trial Registry, ChiCTR‐2,200,059,776. Registered 11 May 2022.

Perioperative Management and Outcomes in Patients With Autism Spectrum Disorder: A Retrospective Cohort Study.

Autism spectrum disorder (ASD) is a neurocognitive disorder characterized by impairments in communication and socialization. There are little data comparing the differences in perioperative outcomes in children with and without ASD. We hypothesized that children with ASD would have higher postoperative pain scores than those without ASD. Pediatric patients undergoing ambulatory tonsillectomy/adenoidectomy, ophthalmological surgery, general surgery, and urologic procedures between 2016 and 2021 were included in this retrospective cohort study. ASD patients, defined by International Classification of Diseases-9/10 codes, were compared to controls utilizing inverse probability of treatment weighting based on surgical category/duration, age, sex, race and ethnicity, anesthetizing location, American Society of Anesthesiology physical status, intraoperative opioid dose, and intraoperative dexmedetomidine dose. The primary outcome was the maximum postanesthesia care unit (PACU) pain score, and secondary outcomes included premedication administration, behavior at induction, PACU opioid administration, postoperative vomiting, emergence delirium, and PACU length of stay. Three hundred thirty-five children with ASD and 11,551 non-ASD controls were included. Maximum PACU pain scores in the ASD group were not significantly higher than controls (median, 5; interquartile range [IQR], 0-8; ASD versus median, 5; IQR, 0-8 controls; median difference [95% confidence interval {CI}] of 0 [-1.1 to 1.1]; P = .66). There was no significant difference in the use of premedication (96% ASD versus 95% controls; odds ratio [OR], 1.5; [95% CI, 0.9-2.7]; P = .12), but the ASD cohort had significantly higher odds of receiving an intranasal premedication (4.2% ASD versus 1.2% controls; OR, 3.5 [95% CI, 1.8-6.8]; P < .001) and received ketamine significantly more frequently (0.3% ASD versus <0.1% controls; P < .001). Children with ASD were more likely to have parental (4.9% ASD versus 1.0% controls; OR, 5 [95% CI, 2.1-12]; P < .001) and child life specialist (1.3% ASD versus 0.1% controls; OR, 9.9 [95% CI, 2.3-43]; P < .001) presence at induction, but were more likely to have a difficult induction (11% ASD versus 3.4% controls; OR, 3.42 [95% CI, 1.7-6.7]; P < .001). There were no significant differences in postoperative opioid administration, emergence delirium, vomiting, or PACU length of stay between cohorts. We found no difference in maximum PACU pain scores in children with ASD compared to a similarly weighted cohort without ASD. Children with ASD had higher odds of a difficult induction despite similar rates of premedication administration, and significantly higher parental and child life specialist presence at induction. These findings highlight the need for future research to develop evidence-based interventions to optimize the perioperative care of this population.

Assessment of preoperative anxiety and depression in patients with pulmonary ground-glass opacities: Risk factors and postoperative outcomes.

A large number of patients with pulmonary ground-glass opacities (GGOs) have anxiety and depression. However, the contributing factors and effects of anxiety and depression on postoperative outcomes are still unclear. Clinical data for patients undergoing surgical resection for pulmonary GGOs were collected. We prospectively evaluated levels and risk factors for anxiety and depression in patients with GGOs before surgery. The relationship between psychological disorders and postoperative morbidity was evaluated. Quality of life (QoL) was also assessed. A total of 133 patients were enrolled. Prevalence rates of preoperative anxiety and depression were 26.3% (n = 35) and 18% (n = 24), respectively. Multivariate analysis revealed depression [odds ratio(OR) = 16.27, p < 0.001] and multiple GGOs (OR = 3.146, p = 0.033) to be risk factors for preoperative anxiety. Anxiety (OR = 52.166, p < 0.001), age > 60 (OR = 3.601, p = 0.036), and unemployment (OR = 8.248, p = 0.006) were identified as risk factors for preoperative depression. Preoperative anxiety and depression were associated with lower QoL and higher postoperative pain scores. Our results also revealed that the incidence of postoperative atrial fibrillation was higher in patients with than in those without anxiety. In patients with pulmonary GGOs, comprehensive psychological assessment and appropriate management are required before surgery to improve QoL and reduce postoperative morbidity.

Risk factors for delirium in elderly patients after lumbar spinal fusion

ObjectiveTo identify perioperative risk factors for postoperative delirium (POD) in patients aged 65 or older undergoing lumbar spinal fusion procedures. Patients and MethodsA retrospective cohort analysis was performed on patients undergoing lumbar spinal fusion over an approximately three-year period at a single institution. Demographic and perioperative data were obtained from electronic medical records. The primary outcome was the presence of postoperative delirium assayed by the Delirium Observation Screening Scale (DOSS) and Confusion Assessment Method for the ICU (CAM-ICU). Univariate and multivariate analyses were performed on the data. ResultsOf the 702 patients included in the study, 173 (24.6%) developed POD. Our analysis revealed that older age (p < 0.001), lower preoperative hemoglobin (p < 0.001), and higher ASA status (p < 0.001), were significant preoperative risk factors for developing POD. The only significant intraoperative risk factor was a higher number of spinal levels that were instrumented (p < 0.001). Higher pain scores on postoperative day 1 (p < 0.001), and lower postoperative hemoglobin (p < 0.001) were associated with increased POD; as were ICU admission (p < 0.001) and increased length of ICU stay (p < 0.001). Patients who developed POD had a longer hospital stay (p < 0.001) with lower rates of discharge to home as opposed to an inpatient facility (p < 0.001). ConclusionRisk factors for POD in older adults undergoing lumbar spinal fusion surgery include advanced age, diabetes, lower preoperative and postoperative hemoglobin, higher ASA grade, greater extent of surgery, and higher postoperative pain scores. Patients with delirium had a higher incidence of postoperative ICU admission, increased length of stay, decreased likelihood of discharge to home and increased mortality, all consistent with prior studies. Further studies may determine whether adequate management of anemia and pain lead to a reduction in the incidence of postoperative delirium in these patients.

Early Postoperative Opioid Requirement Is Associated With Later Pain Control Needs After Supratentorial Craniotomies.

Despite a renewed focus in recent years on pain management in the inpatient hospital setting, postoperative pain after elective craniotomy remains under investigated. This study aims to identify which perioperative factors associate most strongly with postoperative pain and opioid medication requirements after inpatient craniotomy. Using an existing dataset, we selected a restricted cohort of patients who underwent elective craniotomy surgery requiring an inpatient postoperative stay during a 7-year period at our institution (n=1832). We examined pain scores and opioid medication usage and analyzed the relative contribution of specific perioperative risk factors to postoperative pain and opioid medication intake (morphine milligram equivalents). Postoperative pain was found to be highest on postoperative day 1 and decreased thereafter (up to day 5). Factors associated with greater postoperative opioid medication requirement were preoperative opioid medication use, duration of anesthesia, degree of pain in the preoperative setting, and patient age. Notably, the most significant factor associated with a higher postoperative pain score and Morphine milligram equivalents requirement was the time elapsed between the end of general anesthesia and a patient's first intravenous opioid medication. Postcraniotomy patients are at higher risk for requiring opioid pain medications if they have a history of preoperative opioid use, are of younger age, or undergo a longer surgery. Moreover, early requirement of intravenous opioid medications in the postoperative period should alert treating physicians that a patient's pain may require additional or alternative methods of pain control than routinely administered, to avoid over-reliance on opioid medications.

The Effect of Preoperative Cannabis Use on Postoperative Pain Following Gynaecologic Oncology Surgery

ObjectiveTo determine whether cannabis users have different pain scores after gynaecologic oncology surgery than non-cannabis users. MethodsA retrospective chart review was completed for 654 patients who underwent gynaecologic oncology surgery during a 2-year period. The primary outcome was postoperative pain at 12 and 36 hours after surgery using an 11-point pain scale. Secondary outcomes included opioid consumption, length of hospital stay, opioid side effects, and sleep disturbance. ResultsOf all patients included in this study, 64 used cannabis and 590 did not. Propensity score matching and list-wise deletion identified 57 matched pairs. Pain scores were significantly higher at 12 hours (P < 0.001) and 36 hours (P =0.002) after surgery in cannabis users (median pain scores 6 [IQR 5–7]) and 5 [IQR 4–7], respectively) than non-users (median pain scores 4 [IQR 3–6] and 4 ([IQR 2–5], respectively). Median opioid consumption was significantly higher at 12 hours (P = 0.039) and 36 hours (P = 0.044) after surgery in cannabis users (oral morphine equivalent [OME] 20 [IQR 10–40] mg and OME 40 [IQR 10–100] mg, respectively) than non-users (OME 10 [IQR 5–20] mg and OME 30 mg [IQR 7.5–50] mg, respectively]. Sleep disturbance was significantly higher in cannabis users (odds ratio 3.31; P = 0.009). ConclusionsAfter gynaecologic oncology surgery, patients who used cannabis preoperatively had higher postoperative pain scores, higher opioid use, and more sleep disturbance than non-users. This suggests that preoperative cannabis use is a risk factor for postoperative pain.

Perirenal Extravasation After Retrograde Intrarenal Surgery for Renal Stones: A Prospective Study.

BackgroundThe incidence and consequences of the perirenal extravasation of the irrigation fluid during retrograde intrarenal surgery (RIRS) are not fully elucidated. The objective of this study was to assess the incidence, risk factors, and complications of perirenal extravasation of irrigation fluid during RIRS.MethodsThis prospective observational study was conducted in the Department of Urology, Bir Hospital, Kathmandu, Nepal, from January 2020 to March 2021. Patients undergoing RIRS for renal stones less than 2 cm in diameter were included in the study. Irrigation during the procedure was performed using isotonic normal saline under gravity at 50 cm from the symphysis pubis of patients with intermittent manual compression if required. Lithotripsy was performed with 120-Watt Ho:YAG laser using 200-micron laser fiber. Retrograde pyelogram was performed after the completion of lithotripsy to document the presence or absence of extravasation on fluoroscopic images. A double-J stent was placed at the end in all patients. Patients were observed for systemic inflammatory response syndrome (SIRS) features. Postoperative abdominal ultrasonography was performed on the first postoperative day to assess the perirenal collection together with complete blood count. The visual analogue scale (VAS) was used to assess pain in postoperative period. The preoperative patient’s and stone characteristics, hydronephrosis, intraoperative characteristics, and postoperative findings were analyzed.ResultsA total of 71 patients who underwent RIRS during the study period were analyzed. The mean (SD) stone size was 13.19 (3.12) mm. Intraoperative perirenal extravasation of contrast was noted in eight (11.26%) patients; however, no patient had ipsilateral perirenal collection on ultrasonography obtained on the first postoperative day. No significant differences were observed among patients with or without perirenal extravasation in terms of mean stone size, laser settings, operative duration, and lasing duration. Use of ureteral access sheath (UAS) was associated with lower incidence of extravasation; however, it was not significant. SIRS was documented in eight patients overall, with none of the patients with extravasation having features of SIRS. Patients with extravasation experienced more postoperative flank pain (p<0.05).ConclusionPerirenal extravasation was common during RIRS and was associated with higher postoperative pain scores. Stone size, use of UAS, laser settings, operative duration, and lasing duration were not associated with an increased risk of extravasation. Extravasation was not associated with increased postoperative complications.

CO2 Laser Haemorrhoidectomy for Treatment of Grade IV Haemorrhoids

Background: symptomatic haemorrhoids are a common problem. While many treatment options areavailable, none have shown clear superior results. Pain, recurrence rates and potential complicationsare the main considerations when choosing the optimal treatment for haemorrhoids. Methods: Weevaluated post operative pain using a visual analogue at one and four weeks post operatively in patientsundergoing Milligan-Morgan haemorrhoidectomy using CO2 laser. We also recorded any unplannedre-presentations and complications during a 24 months study period. Results: There were 77 patientwho underwent CO2 laser haemorrhoidectomy during the study period. Post operative pain was low(mode=1, mean=3) in the majority of patients. Those who developed a complication had higher postoperative pain scores at one week compared to those who did not. All patients were pain free at fourweek follow up. Conclusion: Overall we found CO2 haemorrhoidectomy to be a safe procedure whichis well tolerated in the vast majority of patients.

Depression and female gender associated with higher postoperative pain scores after sinonasal surgery

Background Although it is extremely necessary to reduce the number of opioids taken postoperatively after sinonasal surgery, this is the subject of controversial discussion. Objectives The objective of this study was to identify factors that predict higher postoperative pain scores (PPS) and the need for opioid analgesics after sinonasal surgery. Material and methods This was a retrospective study of n = 492 patients who underwent functional endoscopic sinus surgery (FESS), septoplasty or a combination of both in the Otolaryngology Department in Erlangen between January and December 2018. Postoperative pain using the numeric rating scale and the postoperative need for non-opioid and opioid analgesics in relation to demographic and surgical parameters were evaluated. Results Significant predictors for a higher pain score were depression (p = .009) and female gender (p < .001). A significant predictor of the need for postoperative opioids was the female gender (p < .001), whereas FESS alone showed a significantly lower need for opioids (p = .035) and a significantly lower PPS compared to septoplasty (p < .001). Conclusions and significance The study identified risk factors for a higher PPS and the need for opioids. The results indicated that reducing postoperative opioids might be possible in patients without these risk factors and might help guide individualized postoperative therapy.

Endoscopic transcanal attico-antrostomy versus endoscopic-assisted canal wall up mastoidectomy in management of localized cholesteatoma: a randomized clinical trial.

This study aims to compare results of endoscopic transcanal tympanoplasty with attico-antrostomy with endoscopic-assisted canal wall up mastoidectomy in treatment of cases of limited attic cholesteatoma. A prospective randomized single-blinded study involving 40 patients with limited attic cholesteatoma was conducted. Randomization of the patients into two groups was done; 20 patients are managed by endoscopic transcanal tympanoplasty with attico-antrostomy, while the other 20 patients are managed by endoscopic-assisted canal wall up mastoidectomy. Primary outcome is recidivism, while secondary outcomes include hearing results, operative time, pain score and associated complications. Comparable recidivism rate was found in the two groups. The endoscopic-assisted canal wall up mastoidectomy group was associated with significantly longer duration of surgery and higher postoperative pain score. There was no significant difference between both the groups regarding hearing results and associated complications. In localized attic cholesteatoma cases, endoscopic transcanal tympanoplasty with attico-antrostomy is a time-saving less-invasive reliable technique with good eradication results. ClinicalTrials.gov (NCT04959539) "retrospectively registered" at 12/7/2021.

Patient-Reported Opioid Analgesic Use After Discharge from Surgical Procedures: A Systematic Review.

This systematic review synthesizes evidence on patient-reported outpatient opioid analgesic use after surgery. We searched PubMed (February 2019) and Web of Science and Embase (June 2019) for U.S. studies describing patient-reported outpatient opioid analgesic use. Two reviewers extracted data on opioid analgesic use, standardized the data on use , and performed independent quality appraisals based on the Cochrane Risk of Bias Tool and an adapted Newcastle-Ottawa scale. Ninety-six studies met the eligibility criteria; 56 had sufficient information to standardize use in oxycodone 5-mg tablets. Patient-reported opioid analgesic use varied widely by procedure type; knee and hip arthroplasty had the highest postoperative opioid use, and use after many procedures was reported as <5 tablets. In studies that examined excess tablets, 25-98% of the total tablets prescribed were reported to be excess, with most studies reporting that 50-70% of tablets went unused. Factors commonly associated with higher opioid analgesic use included preoperative opioid analgesic use, higher inpatient opioid analgesic use, higher postoperative pain scores, and chronic medical conditions, among others. Estimates also varied across studies because of heterogeneity in study design, including length of follow-up and inclusion/exclusion criteria. Self-reported postsurgery outpatient opioid analgesic use varies widely both across procedures and within a given procedure type. Contributors to within-procedure variation included patient characteristics, prior opioid use, intraoperative and perioperative factors, and differences in the timing of opioid use data collection. We provide recommendations to help minimize variation caused by study design factors and maximize interpretability of forthcoming studies for use in clinical guidelines and decision-making.

Labor prior to cesarean delivery associated with higher post-discharge opioid consumption

Severe acute post-cesarean delivery (CD) pain has been associated with an increased risk for persistent pain and postpartum depression. Identification of women at increased risk for pain can be used to optimize post-cesarean analgesia. The impact of labor prior to CD (intrapartum CD) on acute post-operative pain and opioid use is unclear. We hypothesized that intrapartum CD, which has been associated with both increased inflammation and affective distress related to an unexpected surgical procedure, would result in higher postoperative pain scores and increased opioid intake. This is a secondary analysis of a prospective cohort study examining opioid use up to 2 weeks following CD. Women undergoing CD at six academic medical centers in the United States 9/2014-3/2016 were contacted by phone two weeks following discharge. Participants completed a structured interview that included questions about postoperative pain scores and opioid utilization. They were asked to retrospectively estimate their maximal pain score on an 11-point numeric rating scale at multiple time points, including day of surgery, during hospitalization, immediately after discharge, 1st week, and 2nd week following discharge. Pain scores over time were assessed utilizing a generalized linear mixed-effects model with the patient identifier being a random effect, adjusting for an a priori defined set of confounders. A multivariate negative binomial model was utilized to assess the association between intrapartum CD and opioid utilization after discharge, also adjusting for the same confounders. In the context of non-random prescription distribution, this model was constructed with an offset for the number of tablets dispensed. A total of 720 women were enrolled, 392 with and 328 without labor prior to CD. Patients with intrapartum CD were younger, less likely to undergo repeat CD or additional surgical procedures, and more likely to experience a complication of CD. Women with intrapartum CD consumed more opioid tablets following discharge than women without labor (median 20, IQR 10-30 versus 17, IQR 6-30; p = 0.005). This association persisted after adjustment for confounders (incidence rate ratio 1.16, 95% CI 1.05-1.29; p = 0.004). Pain scores on the day of surgery were higher in women with intrapartum CD (difference 0.91, 95% CI 0.52-1.30; adj. p = <0.001) even after adjustment for confounders. Pain scores at other time points were not meaningfully different between the two groups. Intrapartum CD is associated with worse pain on the day of surgery but not other time points. Opioid requirements following discharge were modestly increased following intrapartum CD.

Association between Postoperative Opioid Requirements and the Duration of Smoking Cessation in Male Smokers after Laparoscopic Distal Gastrectomy with Gastroduodenostomy.

Smoking is clinically associated with high postoperative pain scores and increased perioperative analgesic requirements. However, the association between the duration of smoking cessation and postoperative opioid requirements remains unclear. Therefore, this study aimed to evaluate the association between the duration of smoking cessation and postoperative opioid requirements. We retrospectively analyzed the data of 144 male patients who received intravenous patient-controlled analgesia (IV PCA) after laparoscopic distal gastrectomy with gastroduodenostomy. All patients were divided into three groups: G0, nonsmoker; G1, smoker who quit smoking within 1 month preoperatively; G2, smoker who quit smoking over 1 month preoperatively. Analgesic use, pain intensity, and IV PCA side effects were assessed up to postoperative day 2. As the duration of smoking cessation increased, the amount of postoperative opioid consumption decreased (β = −0.08; 95% confidence interval (CI), −0.11 to −0.04; P < 0.001). The total postoperative opioid requirements in G1 were significantly higher than those in G0 and G2 (G0, 75.5 ± 15.9 mg; G1, 94.6 ± 20.5 mg; and G2, 79.9 ± 19.4 mg (P < 0.001)). A multivariate regression analysis revealed that G1 was independently associated with increased postoperative opioid requirements (β = 12.80; 95% CI, 5.81–19.80; P < 0.001). Consequently, male patients who had ceased smoking within 1 month of undergoing a laparoscopic distal gastrectomy with gastroduodenostomy had higher postoperative opioid use than patients who had ceased smoking for more than 1 month and nonsmokers.

Factors Associated with Prolonged Ambulatory Surgery Stay for Major Gynecologic Surgery

Study Objective To identify factors associated with overnight admission after major minimally invasive gynecologic surgery, and create a prediction model. Design Retrospective cohort study. Setting Academic Medical Center. Patients or Participants Patients undergoing major minimally invasive surgery by a single surgeon between 2018 and 2020. Interventions Pre-operative patient characteristic data and peri-operative data were collected retrospectively. Logistic regression analysis of factors associated with same-day discharge versus overnight admission was performed. Measurements and Main Results 461 major minimally invasive cases were identified, of which 425 cases were considered eligible for ambulatory surgery discharge and were included in the analysis. 279 (65.6%) patients were discharged same-day, and 146 (34.4%) were admitted.Patients with later procedure start times (OR 0.9), cancer pathology (OR 0.4), high four-hour postoperative pain scores (OR 0.8), and presence of urinary catheter in the recovery room (OR 0.1) had significantly decreased likelihood of same-day discharge. A prediction model including nineteen patient characteristic and peri-operative variables explained 57.8% of the variability of whether or not patients were admitted after surgery. The model correctly predicted 69.3% of admissions and 90.1% of same-day discharges, giving an overall prediction rate of 82.4%. 7 (2.5%) patients discharged same-day and 4 (2.7%) patients admitted returned to the emergency room within 30 days; 1 (0.4%) patient discharged same-day and 4 (2.7%) patients admitted had a readmission within 30 days. Conclusion Peri-operative factors such as surgery start time, postoperative pain level, presence of urinary catheter in the recovery room as well as diagnosis of malignancy are predictive of overnight admission. Postoperative hospital stay does not improve 30-day readmission rates or the number of ER visits after the discharge. Knowledge of factors associated with prolonged stay after major ambulatory surgery can aid in counseling and peri-operative planning.

Efeitos da ansiedade pré‐operatória na recuperação anestésica e na dor pós‐operatória em pacientes submetidos a nefrectomia para doação

Background and objectivesIt is suggested that 38‐45% of patients experience preoperative anxiety. We observe that patients undergoing living donor nephrectomy suffer from anxiety. Preoperative anxiety may complicate a patient's recovery from anesthesia and postoperative pain control. This study investigates the preoperative anxiety rate and its effect on anesthetic recovery and postoperative pain in patients undergoing donor nephrectomy. MethodsForty‐eight individuals undergoing living‐related renal donor nephrectomy were included in this analytic prospective observational cohort study. Their preoperative anxiety was measured with the STAI‐I and STAI‐II inventories. The relationships between anxiety scores with data regarding demographics, recovery from anesthesia, and postoperative pain scores were investigated. ResultsThe findings were remarkable in that the anxiety scores of living renal donors were significantly correlated with their recovery variables, which are spontaneous respiration time, sufficient respiration time, extubation time, and PACU discharge time (p<0.01). Anxiety scores were significantly positively correlated with the pain scores of the 30th minute, 1st, 2nd, 4th, 8th, 12th, 24th hours, and the total amounts of analgesic administered in 24hours (p<0.05). A significantly negative correlation was also determined between anxiety scores and patients’ satisfaction. ConclusionOur study showed that patients undergoing living‐related donor nephrectomy with high anxiety levels had late recovery times and high postoperative pain scores. Thus, determining those patients with high preoperative anxiety level is crucial to providing patients with satisfactory emerging from anesthesia and the control of their postoperative pain during donor nephrectomy.