Inadequate Pain Control Research Articles

Opioid-Sparing Pain Control After Rhinoplasty: Updated Review of the Literature.

Rhinoplasty is one of the most performed elective surgeries, and given the opioid crisis, increasing research and studies are focused on successful pain control with multimodality opioid-sparing techniques, such as acetaminophen, non-steroidal anti-inflammatory drugs, and gabapentin. Although limiting overuse of opioids is critical, this cannot be at the expense of inadequate pain control, particularly as insufficient pain control can be correlated with patient dissatisfaction and the postoperative experience in elective surgery. There is likely significant opioid overprescription, as patients often report taking less than 50% of their prescribed opioids. Furthermore, excess opioids provide opportunities for misuse and opioid diversion if not disposed of properly. To optimize postoperative pain control and minimize opioid requirements, interventions must occur at the preoperative, intraoperative, and postoperative timepoints. Preoperative counseling is imperative to set expectations for pain and to screen for predisposing factors for opioid misuse. Use of local nerve blocks and long-acting analgesia in conjunction with modified surgical techniques can lead to prolonged pain control. Postoperatively, pain should be managed with a multimodal approach, incorporating acetaminophen, NSAIDs, and potentially gabapentin with opioids reserved for rescue analgesia. Rhinoplasty represents a category of short-stay, low/medium pain, and elective procedures highly susceptible to overprescription and consequently, are readily amenable to opioid minimization through standardized perioperative interventions. Recent literature on regimens and interventions to help limit opioids after rhinoplasty are reviewed and discussed here.

F.4 Relationship between poor postoperative pain control and surgical outcomes after elective spine surgery

Background: Inadequate pain control after spine surgery is common, but its impact on long-term surgical outcomes has not been studied. Accordingly, this study aimed to investigate the relationship between poor postoperative pain control and surgical outcomes. Methods: Consecutive adult patients undergoing elective spine surgery were enrolled. Poor surgical outcome was defined as failure to achieve a minimal clinically important difference (MCID) of 30% improvement on the Oswestry Disability Index or Neck Disability Index at follow-up (3-months, 1-year, 2-years). Poor pain control was defined as a mean numeric rating scale score of >4 within 24-hours postoperatively. Univariable analyses followed by multivariable random-effects models were used, after adjusting for known risk factors that impact surgical outcomes. Results: 42.8% of 1305 patients failed to achieve MCID at follow-up. 56.9% had poor postoperative pain control. Poor pain control was independently associated with failure to achieve MCID (OR 2.15 [95%CI=1.42-3.25], p<0.001), after adjusting for age (p=0.15), sex (p=0.59), PHQ-9 score (p=0.030), ASA physical status >2 (p<0.001), ≥3 motion segment surgery (p=0.003), revision surgery (p=0.032), and follow-up time (p<0.001). Conclusions: Poor pain control 24-hours after elective spine surgery was an independent risk factor for poor surgical outcome. Perioperative strategies to improve pain control may lead to improved outcomes.

Therapy of chronic pain in cancer patients: Tafalgin use experience. Case report

Background. Chronic pain is the most common and severe condition associated with cancer, causing peripheral and central nervous system disorders Inadequate pain control can be destructive and negatively affect patients' quality of life and daily activity. Therefore, developing new drugs for complete pain control during antitumor therapy and palliative care is an urgent problem in modern oncology. One of these directions is the search for selective molecules that interact with 1-opioid receptors without many side effects of opioids.
 Aim. To evaluate the effectiveness of a new selective 1-opioid analgesic, Tafalgin, in treating chronic pain in a patient with pancreatic cancer.
 Materials and methods. Tafalgin was used to control chronic pain in a 60-year-old patient with stage IV pancreatic cancer, pT2 N0M1, with liver metastases, state after 10 cycles of polychemotherapy, and distal subtotal resection of the pancreas with splenectomy, progression in October 2022, liver metastases; state after 4 cycles of polychemotherapy, severe chronic pain.
 Results. The initial pain severity was evaluated using a visual analog scale: 7 points at rest and 9 points on exertion. The patient developed pain during FOLFIRINOX polychemotherapy, for which he received tramadol at a daily dose of 400 mg in combination with paracetamol, with an effect for 1.5 months. The pain severity increased with breakthrough pain. The patient was prescribed long-acting morphine at 60 mg/day, with good effect. However, the patient experienced nausea and vomiting. The morphine dose was reduced to 20 mg, thus resolving side effects and decreasing the effectiveness. Tafalgin was administered at a dose of 4 mg TID. The pain severity decreased to 11.2 points. No adverse events were reported. The patient has been receiving the drug for 52 days. His sleep and appetite have improved, physical activity has increased, and no weight loss has been reported.
 Conclusion. When switching a patient to Tafalgin, continuous adequate pain control is maintained, not inferior to morphine. Tafalgin is associated with a favorable safety profile.

Comparison of Efficacy of Erector Spinae Plane Block with Paravertebral Block for Postoperative Analgesia in Patients Undergoing Breast Cancer Surgery

Background: Patients undergoing modified radical mastectomy (MRM) experience acute pain. Inadequate acute postoperative pain control may lead to anxiety, hemodynamic imbalance and development of chronic pain syndrome. Hence analgesia is extremely important for favourable outcome. This study was undertaken to compare the efficacy of ultrasound guided thoracic paravertebral block (TPVB) versus ultrasound guided thoracic erector spinae plane block (ESPB) with clonidine as an adjuvant to local anaesthetic for post-operative analgesia in modified radical mastectomy. Method: This prospective randomized interventional comparative trial, involving 60 patients were undergoing modified radical mastectomy for breast cancer surgery, was conducted in a tertiary care teaching hospital over 18 months. Sixty patients undergoing MRM for breast cancer under general anaesthesia were enrolled. The patients were randomly allocated into one of the two groups. Group E received ultrasound guided erector spinae block and Group P received Paravertebral block at the level of 4th thoracic vertebra (T4). Both the groups were given 21 mL of 0.5% ropivacaine and 1 μg/kg of clonidine diluted in 1 mL of saline (making total volume of up to 22 mL). Primary outcome measure was to compare duration of analgesia, that is from the time of block administration till the time to first rescue analgesia demanded by the patients. Secondary outcome measures were mean visual analogue scale (VAS) score at rest as well as during abduction of ipsilateral arm at various time points, total intraoperative fentanyl and tramadol requirement up to 24 hours postoperatively; postoperative nausea and vomiting; patients satisfaction at the end of 24 hours postoperatively. Statistical method used: Quantitative variables were compared using Independent t-test/Mann-Whitney Test (when the data sets were not normally distributed). Qualitative variables were compared using Chi-Square test /Fisher’s exact test. A p value of <0.05 was considered statistically significant. Results: Duration of analgesi, that is, time of first rescue analgesia from the administration of the block was comparable between the two study groups. The mean (SD) duration of analgesia in group E was 22.78 (3.31) hours and in group P was 22.88 (3.34) hours (P = 0.914). Both the groups were comparable in terms of fentanyl requirement and total 24 hours tramadol requirement Other parameters like postoperative nausea vomiting, effect on hemodynamic and overall patient satisfaction were also comparable between the two groups. Conclusions: Both ultrasound guided ESPB and TPVB are equally efficacious in providing postoperative analgesia in patients undergoing modified radical mastectomy.

Sustained release of levobupivacaine from temperature-sensitive injectable hydrogel for long-term local anesthesia in postoperative pain management

Postoperative pain is a major concern for most of the surgical patients, and an inadequate postoperative pain control may cause a series of complications. With an effective pain control and lesser side effects, local anesthetics are preferred for use in postoperative pain management. However, the action duration of current local anesthetics is too short to meet the requirements of postoperative analgesia. In this study, an injectable levobupivacaine (LB)-loaded thermo-sensitive hydrogel system based on biodegradable poly(D,L-lactide)-poly(ethylene glycol)-poly(D,L-lactide) (PLEL) was developed for long-acting local anesthetic, in which the soluble charged cation form of LB (LB HCl) was partly alkalified to the poorly soluble base form (LB base). This hybrid LB loaded PLEL system (hLB/PLEL) is a free flowable liquid at room temperature and changes into a semi-solid hydrogel once injection in response to the physiological temperature. Then, the dissolved LB HCl could release firstly from the hydrogel contributing to a quick work, and the insoluble LB base dissolved and released gradually as the decrease of the pH during the biodegradation of PLEL hydrogel, resulting in a long-term LB release in local. The drug release behavior, pharmacokinetic, and biocompatibility of the thermo-sensitive hLB/PLEL were studied in vitro and in vivo. The anesthetic effects of hLB/PLEL system were evaluated in the rat models of sciatic nerve block, subcutaneous infiltration anesthesia and postoperative pain as well. This hLB/PLEL system generated a significantly prolonged analgesic effect in rat models, which produced approximately 7 times longer duration than 0.75% LB HCl and effectively relieved the spontaneous pain for 3 days. In general, the presented hLB/PLEL system can not only achieve a fast-acting but also sustainably release LB to block the nerve and significantly extend the effect of local analgesia, which means a promising candidate for long-acting postoperative pain management.

Methadone rotation versus other opioid rotation for refractory cancer induced bone pain: protocol of an exploratory randomised controlled open-label study

BackgroundA third of patients with advanced cancer and bone metastasis suffer from cancer induced bone pain (CIBP), impeding quality of life, psychological distress, depression and anxiety. This study will evaluate the impact of an opioid rotation, comparing methadone rotation with other opioid rotation in patients with refractory CIBP.MethodsThis open-label randomised controlled trial will recruit cancer patients with CIBP and inadequate pain control despite established baseline opioid and/or intolerable opioid side effects from cancer and palliative care services. Participants will be at least 18 years old, with a predicted prognosis of greater than 8 weeks, meet the core diagnostic criteria for CIBP, have a worst pain score of ≥ 4 of 10 from CIBP and/ or have opioid toxicity (graded ≥ 2 on Common Terminology Criteria for Adverse Events). Participants will have sufficiently proficient English to complete questionnaires and provide informed consent.Participants will be randomised 1:1 to be rotated to methadone to another opioid. The primary objective is to examine the impact of opioid rotation in improving CIBP by comparing analgesic efficacy, safety and tolerability in the two arms. Secondary objectives will assess changes in the intensity, duration and frequency of breakthrough pain, requirement of breakthrough analgesia, overall opioid escalation index, and time taken to observe improvement in pain reduction, pain interference and quality of life.DiscussionLaboratory studies suggest the involvement of neuropathic involvement in the mechanism of CIBP, though there remains no clear evidence of the routine use of neuropathic agents. Methadone as an analgesic agent may have a role to play in this cohort of patients, thus warranting further exploratory studies.Trial RegistrationAustralian New Zealand Clinical Trials Registry No: ACTRN12621000141842. Registered 11 February 2021.

Bones, groans and sending patients home: Perioperative opioid-related harm reduction strategy utilisation in a regional New South Wales (NSW) hospital.

Perioperative initiation of opioids continues to be a major contributor to chronic use, misuse and diversion in regional areas. There is considerable effort to mitigate harm through avoiding excessive prescribing and reducing the risk of persistent postoperative opioid use. Improving perioperative documentation practices has been reported to ensure appropriate opioid initiation and de-escalation. It has not been established whether these strategies are utilised in regional hospitals. A retrospective observational study of perioperative opioid prescribing and documentation practices in Goulburn Base Hospital, a regional centre in the Southern New South Wales (NSW) Local Health District. Data were collected from 110 records and validated for adult patients undergoing elective total knee replacement (TKR) or total hip replacement (THR) from 12 January 2020 to 13 January 2021. To observe perioperative opioid prescribing and utilisation of harm reduction strategies in a regional hospital. 65% of patients were opioid naïve (ON). Preoperative pain assessments and patient education were completed in 23% and 15% of records, respectively. Postoperative opioids were prescribed for 99% of patients, with 74% prescribed a slow-release (SR) formulation. 50% of patients were discharged with an SR prescription. Inadequate postoperative pain control was reported in 21% of patients. Of the 103 patients prescribed opioids on discharge, only 20% included a de-escalation plan and only 35% of discharge summaries included dose and quantity of opioids supplies. This study has identified underutilisation of perioperative harm reduction strategies despite the potential to improve appropriate initiation and de-escalation of opioids. These findings highlight opportunities for improvement in regional hospitals.

Pro: Regional Anesthesia for Cardiac Surgery With Sternotomy

With the growing prevalence of cardiovascular disease worldwide, over 2 million patients undergo median sternotomy for cardiac surgery annually.1 The incidence of severe acute postoperative pain after sternotomy is as high as 49%, and appropriate management of this pain has important implications for short- and long-term recovery.2 Inadequate post-surgical pain control following sternotomy in cardiac surgery has profound negative consequences on pulmonary function, hemodynamics, myocardial oxygen demand, postoperative delirium, and ICU and hospital length of stay.3 Severe pain has also been shown to harm long-term outcomes such as quality of life4,5 and is associated with the development of persistent post-sternotomy pain with an incidence as high as 35% at 1-year follow-up.1,6

Patients’ and prescribers’ experiences of managing neuropathic pain with medication: a scoping review

Background: Neuropathic pain (NP) is a chronic condition that affects patients’ quality of life. Prescribing for NP within primary care is variable. There is a need to understand NP medicine management from both patient and prescribers’ perspectives. This scoping review aimed to identify, synthesise and identify gaps in the literature on the experiences of: i) prescribers in prescribing medicines to manage the symptoms of NP and ii) people with NP who use prescribed medicines to manage their symptoms. Methods: Four electronic bibliographic databases (Medline, CINAHL, Embase and PsycInfo) were searched from inception to the end of October 2022 using a structured search strategy. The findings were synthesised and presented using a modified framework for monitoring opioid prescribing called the 5 A’s framework. The 5 A’s are Analgesia, Activities of daily living, Adverse effects, Aberrant behaviour, and Activities and actions of healthcare professionals. Results: From the 10,995 records identified, 11 studies were included in the review. All the studies focused on patients' experiences, with no studies about the experiences of prescribers in managing NP. Patients reported that medicines seem to work at the outset but, over time, are less effective in relieving their pain. Patients took less than the prescribed dose of their medicine, depending on their pain level on the day. Taking medication allowed patients to participate in activities they would not otherwise have been able to do, often resulting in less isolation and loneliness. Conclusions: This scoping review has highlighted patients' experiences of using medicines to manage NP. Results provide insight into how patients cope with inadequate pain control and the impact this has on patients’ lives. More research is required to explore the experiences of people living with non-specific types of NP as well as the experiences of prescribers who prescribe medicines to manage NP.

Schedule II Narcotics are often Unnecessary for Pain Control in Patients with Pelvic or Acetabular Fractures

Objectives: Determine if patients with pelvic and acetabular fractures require scheduled II narcotics after discharge. Design: Retrospective case series. Setting: Level I Trauma Center Patients: 124 consecutive patients with operatively managed pelvic (OTA 61B or C) and acetabular fractures (OTA 62A, 62B or C) Intervention: A multimodal oral pain regimen was prescribed at discharge with schedule II narcotic only if needed for pain control. Main Outcome: Primary outcomes were defined as the need for schedule II narcotic at discharge or in follow up. Measurements: Prescription of narcotic on follow up or return to ER for inadequate pain control. Visual Analog Pain Scale score. Results: Ninety-two patients (74%) with adequate follow-up were included for the final analysis, including patients with 25 acetabular fractures, 50 pelvic fractures, and 17 combined injuries. Sixty-four patients (69.6%) were multiply-injured patients. Four (4.3%) patients were discharged with a Schedule II narcotic. Of the remaining patients (n=88), two (2.2%) required delayed prescription of a Schedule II narcotic after discharge and 5 (5.4%) presented to the ED for pain control. There were no readmissions for pain. Overall 81 of 92 (88.0%) patients had pain controlled without schedule II narcotics or ED presentation. The mean VAS pain score for all patients was 4.1±3.6 from 5 to 21 days, 3.2±3.4 at 22 to 60 days, and 2.7±3.3 at greater than 60 to 180 days after discharge, there was no significant difference between groups Conclusion: Multimodal pain control regimens without schedule II narcotics in the immediate postoperative follow-up period can be effective in managing pain in the majority of patients with pelvic or acetabular fractures. Level of Evidence: IV; case series Keywords: narcotics, pain control, acetabular fractures, pelvic fractures

Analgesic outcomes of tramadol alone and in combination with Butorphanol or Flurbiprofen Axetil after cesarean section: a retrospective study with propensity score matching analysis

BackgroundThe Society for Obstetric Anesthesia and Perinatology recommends a multimodal analgesia regimen for cesarean delivery analgesia. This study aimed to compare the analgesic effects of tramadol alone and combined with butorphanol or flurbiprofen axetil after a cesarean section.MethodsWe performed a retrospective analysis based on the electronic medical records of a teaching hospital in China from January 2018 to January 2020. We collected data on demographic characteristics, anesthesia, analgesia strategy, and pain intensity postoperatively during the first 48 hours. Inadequate postoperative analgesia during this period was defined as an NRS score ≥ 4. We also collected data regarding off-bed activity and intestinal function recovery. Participants were classified into three groups according to analgesia regimens. Groups T, TF, and TB received tramadol, a mixture of tramadol and flurbiprofen axetil, and a combination of tramadol and butorphanol, respectively. Analgesic outcomes were compared using propensity score matching analysis.ResultsData from 2323 cases of caesarean section were included in the analysis, and 521 pairs were matched in each group according to their propensity score. Compared with group T, The inadequate analgesia on pain at rest and pain at movement was lower in group TF (RR: 0.42, 95% CI: 0.36–0.49, P = 0.001 and RR: 0.58, 95% CI: 0.48–0.69, P < 0.001, respectively),and the incidence of inadequate control of pain at movement was higher in group TB (RR: 1.38, 95% CI: 1.22–1.55, P < 0.001).Additionally, the percentage of off-bed activity at 2 days postoperatively was higher in group TB than in groups TF and T (78.7% vs. 68.5 and 78.7% vs. 64.9%, respectively, P < 0.001). The incidence of intestinal function recovery 2 days after cesarean delivery in group TB was higher than that in group TF (73.3% vs. 66.2%, P = 0.013).ConclusionsCombining tramadol and flurbiprofen axetil could enhance the analgesic effect and be safely used for analgesia after a cesarean section. However, combining tramadol and butorphanol may produce an antagonistic effect.

OGC P26 The role of inadequate analgesia in care escalation after oesophagectomy

Abstract Background There is a paucity of data describing the incidence and causes of escalation in level of care after oesophagectomy for cancer. This study aimed to address this, including the description of baseline predisposing variables, and contrasting the profile of care escalation among different surgical approaches to oesophagectomy. Methods This was a retrospective analysis of a prospectively maintained database (‘CODA’) at a UK tertiary centre. CODA is a bespoke, high-quality resource, based on senior clinician and data scientist data entry at every stage of the care of the patient's pathway. Complications are updated weekly using the Esophageal Complications Consensus group definition-set. The inclusion criteria were anyone undergoing cancer oesophagectomy between 01/06/2015 and 31/05/2021. Exclusion criteria included patients not on the ‘Enhanced Recovery after Surgery’ pathway and patients with delayed extubation (&amp;gt;2 days post-operatively). Escalation of care was defined as re-admission to the intensive care unit (ICU) or re-intubation on ICU. Standard care at our centre is to maintain epidural analgesia for four days after surgery. Inadequate analgesia was defined as more than one reference to inadequate pain control in the first four days after surgery when the patient deteriorated and required care escalation. Characteristics were compared between patients with and without care escalation, and between patients with and without respiratory failure related to inadequate analgesia. Results From 448 oesophagectomys, 42 patients had escalation in their level of care (9.38%). Baseline characteristics between oesophagectomy patients with and without escalation in care were similar, except for escalated patients more likely to have squamous cell carcinoma histology (28.6% vs 14.3%, P = 0.02). 20.0% of 3-phase oesophagectomy patients required care escalation but this just failed to achieve significance when compared with other oesophagectomy approaches (9.6%, P = 0.06). Of escalated patients, 35.7% had respiratory failure related to inadequate analgesia, 33.3% had respiratory failure not related to inadequate analgesia and 31.0% did not have respiratory failure as the reason for care escalation. The major cause of respiratory failure not related to analgesia was pneumonia (6 of 14, 42.9%) and the most frequent cause of non-respiratory failure associated escalation in care was re-operation (5 of 13, 38.5%). Inadequate analgesia was more commonly a contributing factor to escalation in care after left thoracoabdominal oesophagectomy compared to all other approaches (11 of 18 [61.1%] vs 4 of 24 [16.7%], P = 0.003). Conclusions The overall rate for escalation in care in this centre was low at 9.38%. This figure may be useful for benchmarking and ongoing research into morbidity after oesophagectomy. There was no clear influence from baseline characteristics or surgical approach on the rate of escalation in care. Respiratory failure contributed to escalation in care for the majority of patients. Our data indicates that left thoraco-abdominal incisions are particularly sensitive to inadequate analgesia, which suggests that effective analgesic rescue plans are especially critical after this type of oesophagectomy.

Cerebrospinal Fluid Leak Following Explantation of Percutaneous Spinal Cord Stimulator Device: A Case Report

BACKGROUND: While spinal cord stimulation (SCS) is a safe and effective treatment for chronic pain, some patients require explantation of their devices due to complications or inadequate pain control. The rate of SCS implantation has steadily increased over the years; however, the complications of percutaneous lead extraction have not been well-documented in the scientific literature. CASE REPORT: We present an 86-year-old patient at our institution who developed an intraoperative cerebrospinal fluid (CSF) leak during SCS explantation. The leak was conservatively managed with tight surgical closure and placement of an abdominal binder. The patient tolerated the procedure well and only developed a minor headache which self-resolved. CONCLUSION: Although rare, SCS lead extraction can cause CSF leakage from unintentional intraoperative dural tear. While most CSF leaks can be managed conservatively and do not require surgical repair, pain physicians need to be well-informed on how to manage CSF leaks that occur during SCS explantation. KEY WORDS: Case report, cerebrospinal fluid leak, chronic pain, explantation, spinal cord stimulation

Postoperative Pain in Patients Undergoing Cancer Surgery and Intravenous Patient-Controlled Analgesia Use: The First and Second 24h Experiences.

Postoperative cancer pain imposes severe physical and psychological problems. We aimed to investigate the pain experiences of patients with cancer after surgery, analyze the impact of infusion volume by patient-controlled analgesia (PCA), and explore the variations between day1 and day2. Data were retrospectively extracted from a large health data platform. Descriptive statistics were presented for the demographic and clinical profiles of patients. Multiple logistic regression analyses were performed to evaluate associations between intensity of pain and PCA use after adjustment for risk factors. Among 11,383 patients with cancer, the incidence of pain (moderate to severe pain) was 93.3% (18.3%) at the first 24h after operation, while the respect values decreased to 91.1% and 9.5% at the second 24h. Further, female patients consistently experienced higher risk of pain over the whole 48h postoperatively. Surgical sites were related to pain risk, with the highest risk among the respiratory system (OR 2.077, 95%CI 1.392-3.100). High doses of continuous volume (OR 2.453, 95%CI 1.742-3.456) and total volume (OR 2.830, 95%CI 2.037-3.934) of infusions were related to 1-3-fold elevated pain risk. Additionally, the observed associations were mostly repeated and could be up to over 10 times when pain was evaluated with number of PCA pump compressions instead of Numerical Rating Scale (NRS). High risk of postoperative cancer pain, particularly among the high PCA dose group, could possibly indicate inadequate pain control, and presence of modifiable risk factors warrants more aggressive pain management strategies perioperatively.

Postsurgical pain management among obstetrics and gynecology patients in a teaching hospital in Tabriz, Iran: a best practices implementation project.

The purpose of this project was to improve the compliance of patients' pain management process after surgery using evidence-based criteria at the Al-Zahra Educational Hospital in Tabriz. Reducing and relieving pain are among the basic rights of patients, and the management of this component should be one of the basic goals of the patient care team. Inadequate pain control can have many unpleasant consequences for the patient and increase hospital costs. Due to the importance of pain control and a gap in this area, it was decided to implement a project to improve pain control in postoperative patients grounded in evidence-based recommendations. This project was carried out at a Level III hospital in Iran from December 2019 to June 2020. A baseline audit, based on the JBI Practical Application of Clinical Evidence-Based System (JBI PACES) and Getting Research into Practice (GRiP) audit and feedback tool was conducted with 40 patients in the surgery ward of the hospital. After developing the GRiP table (barriers, strategy, resources and outcome), a follow-up audit was done three times. The different stages of the audit were centered in evidence-based criteria. At each stage of follow-up, 40 patients were randomly selected in the postoperative stage. At the baseline audit, out of a total of eight criteria, only criterion 2 corresponded to the audit criteria where there was no pain assessment tool or protocol for pain or for training patients and nurses. Over the three follow-up audits, 100% improvement was achieved in half of the criteria through preparing visual analogue scale pain instruments, and development of a pain protocol and a pain self-care protocol, and a 63% improvement was observed in one of the criteria. Patients' pain decreased from very severe to mild/moderate in the first few hours in 70% of patients after surgery. The use of this best practices implementation project led to the improvement of the postoperative pain management process of patients and the improvement of patient care quality. The use of the JBI Method is recommended to address other current or defective hospital processes.

A Quality Improvement Effort to Reduce Inpatient Opioid Consumption following Cesarean Delivery.

The amount of opioid prescribed following cesarean delivery (CD) is commonly in excess of patients' needs. An additional concern in a breastfeeding mother is neonatal opioid exposure. A maximum daily dose of 30 mg of oxycodone is recommended in breastfeeding women. Inadequate pain control can inhibit breastfeeding, as well as other negative consequences. We aimed to evaluate the effect of reducing the as-needed opioid ordered following CD on inpatient opioid consumption and analgesia. At our tertiary-care institution, our standard as-needed opioid order was reduced from oxycodone 5 to 10 mg every 4 hours to oxycodone 5 mg every 6 hours, in May 2019. Orders for scheduled acetaminophen and nonsteroidal anti-inflammatory drugs were unchanged. We compared opioid use and pain scores before (February 2019-April 2019) and after (May 2019-July 2019) the order modification. Our primary outcome was the proportion of patients using >30 mg of oxycodone in the 24 hours prior to hospital discharge. We further assessed 48-hour opioid consumption and patient-reported verbal pain scores. There were 559 patients who met inclusion criteria; 241 preintervention patients and 318 postintervention patients. In the preintervention group, 14.5% (35/241) used >30-mg oxycodone in the 24 hours before discharge, compared with 5.0% (16/318) after the order set change (relative risk [RR] = 0.34, 95% confidence interval [CI]: 0.19, 0.61; number needed to treat [NNT] = 10.5). There was no change in the proportion of women with one or more pain score >7 (preintervention: 44.4% [107/241], postintervention: 43.1% [137/318], p = 0.756) or >4 and ≤7 (preintervention: 36.9% [89/241], postintervention: 36.9% [125/318], p = 0.567), nor was there a change in mean pain score (mean ± standard deviation [SD]: preintervention = 2.8 ± 1.6 and postintervention = 2.7 ± 1.4, p = 0.464). Reducing the amount of opioid ordered after CD reduced the proportion of post-CD patients exceeding the maximum recommended daily oxycodone dose for breastfeeding women. · Inpatient opioid prescribing influences usage.. · Opioid orders influence consumption.. · Reducing opioids may not increase pain..

Opioid Free Anesthesia (OFA) for Laparoscopic Cholecystectomy in Low Resource Settings

Laparoscopic Cholecystectomy is a common minimally invasive surgical procedure done under general anesthesia using an opioid-based regimen. Although laparoscopic cholecystectomy is a minimally invasive surgical procedure, some patients may have significant discomfort in the postoperative period in the first 24 to 72 hours. Inadequate pain control, PONV, and delayed recovery are common postoperative issues. This case report shows that OFA is a safe, opioid‑sparing, and feasible option that provide stable perioperative hemodynamics, good analgesia, and an uneventful recovery profile to patients undergoing laparoscopic cholecystectomy.

Cultivating the ideal obstetrical patient: How physicians-in-training describe pain associated with childbirth

We explore the work labor pain does in cultivating obstetrics and gynecology (OB/GYN) resident physicians’ conceptualization of the “ideal” obstetrical patient – replete with moral, pharmacological, classed, and racialized dimensions. Our data is derived from a single-site, qualitative study conducted at an urban academic OB/GYN residency program in the midwestern U.S. between 2018 and 2019. 36 residents, 9 from each post-graduate year, were randomly selected to complete a semi-structured interview on their perceptions of patient pain surrounding OB/GYN procedures.Grounded theory analysis of the OB/GYN residents' interviews revealed the idealized obstetrical patient is quiet and easily controlled. Residents praised women whom they believed were suppressing their labor pain, a racialized and classed concept that furthers misconceptions about the “obstetric hardiness” of Black women and the hypersensitivity of wealthy White women. Participants' conceptions of “bad” patients included those with less cultural health capital due to low health literacy and socioeconomic status, which impeded the patients’ ability to participate in shared decision-making.Despite acknowledging the importance of patient autonomy regarding pain control during labor, the interviewed residents positioned themselves as the ultimate authority. Their subjective assessment of patients’ pain inherently invoked their personal biases, such as conflating low socioeconomic status and race. Some participants posited an inverse relationship between hardship and pain, while others questioned whether those with low health literacy exaggerate their pain due to fear of the clinical encounter or to secure medical attention. Both framings have concerning implications for inadequate pain control and the unintentional perpetuation of obstetric violence and obstetric racism within the profession.

Median sternotomy pain after cardiac surgery: To block, or not? A systematic review and meta-analysis.

Inadequate pain control after median sternotomy leads to reduced mobilization, increased respiratory complications, and longer hospital stays. Typically, postoperative pain is controlled by opioid analgesics that may have several adverse effects. Parasternal intercostal block (PSB) has emerged as part of a multimodal strategy to control pain after median sternotomy. However, the effectiveness of this intervention on postoperative pain control and analgesic use has not been fully established. We conducted a meta-analysis to assess the effect of PSB on postoperative pain and analgesic use in adult cardiac surgery patients undergoing median sternotomy. PubMed, Embase, Google Scholar, and the Cochrane database were searched with the following search strategy: ([postoperative pain]or [pain relief]OR[analgesics]or [analgesia]or [nerve block]or [regional block]or [local block]or [regional anesthesia]or [local anesthetic]or [parasternal block]and [sternotomy]) and (humans [filter]). Inclusion criteria were: patients who underwent cardiac surgery via median sternotomy, age >18 and parasternal block (continuous and single dose). Exclusion criteria were: noncardiac surgery, nonparasternal nerve blocks, and the use of NSAIDS in parasternal block. Quality assessment was performed by threeindependent reviewers via the Cochrane risk of bias assessment tool. Of 1165 total citations, 18 were found to be relevant. Of these 18 citations, 7 citations (N = 2223 patients) reported postoperative pain scores in an extractable format and 11 citations (N = 2155 patients) reported postoperative opioid use in an extractable format. For postoperative opioid use, morphine equivalent doses were calculated for all studies and postoperative pain scores were standardized to a 10-point visual analog scale for comparison between studies; both these were reported as total opioid use or cumulative score ranging from 24to 72 h postoperative. All data analyses were run using a random effects model, using a restricted maximum likelihood estimator, to obtain summary standardized mean differences with 95% confidence interval (CI's). For studies which only reported median and interquatile range (IQR), the median was standard deviation was estimated by IQR/1.35. Following median sternotomy both postoperative pain (SMD [95% CI] -0.49 [-0.92 to -0.06]) and postoperative morphine equivalent use (SMD [95% CI] -1.68 [-3.11 to-0.25]) were significantly less in the PSB group. Our meta-analysis suggests that parasternal nerve block significantly reduces postoperative pain and opioid use.

151. Factors causing delay in discharge in patients eligible for ambulatory lumbar fusion surgery

<h3>BACKGROUND CONTEXT</h3> Assessing postoperative system inefficiencies and implementing process-improvement measures are vital to increase the feasibility of ambulatory lumbar fusion. <h3>PURPOSE</h3> Primary objective was to identify patients who would have been eligible for same-day discharge following minimally invasive elective lumbar fusion and then analyze the limiting factors in their postoperative pathway that led to a delay in discharge. Secondary objective was to assess if patient characteristics and operative variables had an impact on postoperative parameters influencing discharge. <h3>STUDY DESIGN/SETTING</h3> Retrospective review of prospectively collected data. <h3>PATIENT SAMPLE</h3> Consecutive patients undergoing primary single-level minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for degenerative conditions of the lumbar spine who would have been eligible for ambulatory lumbar fusion. <h3>OUTCOME MEASURES</h3> Postoperative in-hospital variables including 1) length of stay (LOS), 2) time in post-anesthesia recovery unit (PACU), 3) alertness check, neurological exam and pain scores at 3 hours and 6 hours, 4) type of analgesia, 5) time to physical therapy (PT) visit and clearance, 6) reasons for PT non-clearance, 7) time to per-oral (PO) intake, 8) time to voiding, 9) time to readiness for discharge, and 10) complications. <h3>METHODS</h3> Eligibility criteria for ambulatory lumbar fusion and discharge criteria were determined a priori based on a review of the literature and the authors' experience. Preoperative, surgical and postoperative in-hospital data were analyzed. Time taken to meet each discharge criterion was calculated. Time of discharge readiness was taken as the point when the patient had fulfilled all the criteria. The percentage of patients meeting each discharge criterion at 3 hours and 6 hours post-surgery was calculated. Correlation and regression analyses were performed to study the effect of postoperative variables on LOS. Multiple linear and logistic regression analyses were performed to study the effect of preoperative and operative variables on postoperative parameters influencing discharge. <h3>RESULTS</h3> A total of 71 patients were included of which only 4% were discharged on the same day. Most (69%) patients were discharged on postoperative day one. PT clearance, voiding and PO intake were the last-met discharge criterion in 93%, 6% and 1% of patients respectively. A total of 66% of patients did not get a PT evaluation on the day of surgery. Intravenous (IV) opioids for pain control (average of 2 doses) were required for 76% of patients. Less than 60% of patients had adequate pain control at 3 hours and 6 hours after the surgery. Orthostatic intolerance was seen in 27% of patients. The median postoperative LOS was 26.9 hours, time in PACU was 4.2 hours, time to PO intake was 6.5 hours, time to first void was 6.3 hours, time to first PT visit was 17.7 hours, time to PT clearance was 21.8 hours, and time to discharge readiness was 21.9 hours. Regression analyses showed that postoperative variables (time to PT clearance, time to PO intake, time to voiding, time in PACU, and pain score at 3 hours) had a significant effect on LOS. There was no effect of preoperative and operative variables on postoperative parameters influencing discharge. <h3>CONCLUSIONS</h3> Unavailability of PT, orthostatic intolerance, inadequate pain control, prolonged PACU stay, and long feeding and voiding times were identified as modifiable factors preventing same-day discharge in patients eligible for ambulatory lumbar fusion. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.