Acute Postoperative Pain Management Research Articles

The Medicines Company Strengthens its Perioperative Care Franchise via Deals with Incline Therapeutics and BMS

The Medicines Company (TMC) has agreed to acquire Incline Therapeutics, which is pursuing the development of Ionsys® (fentanyl iontophoretic transdermal system), a needleless, patient-controlled analgesia device for the short-term management of acute postoperative pain. Cadence Pharmaceuticals obtained an exclusive option to acquire Incline in 2010 but this will be terminated on completion of the purchase of Incline by TMC. On the same day as the Incline deal, TMC also announced a 2-year global licence and collaboration agreement for Bristol-Myers Squibb’s Recothrom®, a US FDA approved topical recombinant thrombin to control non-arterial bleeding during surgery.

Postoperative pain is undertreated: results from a local survey at Jordan university hospital

Postoperative pain management is nowadays considered an integral part of modern surgical practice. An audit was made in 2010 to assess the status of acute postoperative pain management at Jordan University Hospital. Data were collected from patients' files and through face-to-face interviews of all patients aged over 16 years who underwent general, gynaecological, ear-nose-throat and orthopaedic surgery. Of 275 patients, 72.0% experienced moderate to severe pain postoperatively at rest and 89.3% on movement. No analgesics were prescribed to 4.7% of the patients and of the remainder, a single analgesic was prescribed to 51.5%. Pethidine and paracetamol were the drugs most commonly prescribed (to 66.9% and 42.5% of patients respectively), most often on a regular schedule rather than on-demand. Despite improvements in pain management worldwide, patients at this hospital were still suffering from postoperative pain. Awareness among professionals and the public is needed and a structured acute pain management programme is essential.

Optimizing the Dose of Preemptive Oral Pregabalin for Postoperative Pain Control after Abdominal Hysterectomy under Spinal Anaesthesia

Objectives: Acute postoperative pain is a challenge to all clinicians which has prompted many authors to study the effect of neuropathic pain killers like gabapentin and pregabalin as preemptive drugs for management of acute postoperative pain. The dose of preemptive oral pregabalin though studied by few authors has not yet been optimized. Hence the present study has been undertaken to arrive at optimal dose of preemptive oral pregabalin. Methods :This was a randomized double blind prospective study with 90 patients of American society of anesthesiology (ASA) Grade I and II aged between 35 to 60 years divided into 3 groups with Group I receiving placebo, Group II receiving 150mg oral pregabalin and Group III receiving 225mg oral Pregabalin. Statistical tools: Statistical analysis was done by using averages, means and percentages. Results: The time to visual analogue scale (VAS) > 3 was significantly increased in group III and group II than group I. The total dose of tramadol consumed in 24 hours duration was significantly less in group III and group II than group I. Sedation scores were more in patients of group III. Side effects like dizziness were more in Group III than in Group II. Patient satisfaction score was more in Group II than in Group III. Conclusion: Preemptive oral pregabalin 150mg is very effective in providing good postoperative analgesia with better patient satisfaction. Keywords: Preemptive analgesia, Pregabalin, Spinal Anaesthesia

The efficacy of the time-scheduled decremental continuous infusion of fentanyl for postoperative patient-controlled analgesia after total intravenous anesthesia

BackgroundIntravenous fentanyl has been used for acute postoperative pain management, but has not always provided reliable adequate analgesia, including patient-controlled analgesia (PCA). The purpose of this study was to investigate the efficacy of time-scheduled decremental infusion of fentanyl for postoperative analgesia.MethodsNinety-nine patients, aged 20-65 years, undergoing laparoscopic-assisted hysterectomy using total intravenous anesthesia (TIVA) were randomly assigned into one of the three groups. Their background infusions of fentanyl diluent (2 ml/hr of diluent was equivalent with 0.5 µg/kg/hr of fentanyl) with PCA were maintained at the fixed-rate of 2 ml/hr until the postoperative 24 hr (FX2-2-2), or at the decremental rates of 6.0, 4.0, 2.0 ml/hr (D6-4-2) and 8.0, 4.0, 2.0 ml/hr (D8-4-2). The visual analogue score (VAS), incidence of inadequate analgesia, frequency of PCA intervention, and side effects were evaluated.ResultsVAS was significantly higher in FX2-2-2 than in D6-4-2 and D8-4-2 until postoperative 3 hr (P < 0.05). After postoperative 4 hr, VAS was significantly higher in FX2-2-2 than D8-4-2 (P < 0.05). The incidence of inadequate analgesia of FX2-2-2 was significantly greater than D6-4-2 (P = 0.038) and D8-4-2 (P < 0.001) until postoperative 1 hr. None of the patients had ventilatory depression, and postoperative nausea and vomiting were not significant among the groups.ConclusionsThe time-scheduled decremental background infusion regimens of fentanyl, based on the pharmacokinetic model, could provide more effective postoperative pain management after TIVA, and the side effects and the risk for morbidity were not different from the fixed-rate infusion regimen.

Prolonged-release Oxycodone/Naloxone in Postoperative Pain Management: From a Randomized Clinical Trial to Usual Clinical Practice

These studies evaluated the feasibility of using oral prolonged-release oxycodone/naloxone (OXN PR) for the management of acute postoperative pain. Three studies were undertaken: (i) the analgesic efficacy of OXN PR was compared with prolonged-release oxycodone (OXY PR) in patients with knee arthroplasty in an immediate postoperative period (IPOP) study; (ii) OXN PR treatment was compared with other opioids during rehabilitation after knee arthroplasty in a noninterventional study (NIS); and (iii) surgical patients on other opioids were switched to OXN PR postoperatively during a quality improvement programme (QIP). In the IPOP study, the pain intensity at rest score decreased by a similar amount in the OXN PR and OXY PR groups, indicating similar analgesic efficacies. In the NIS, patient assessments indicated enhanced efficacy and tolerability for OXN PR compared with other opioids. The QIP indicated significant improvements in bowel function and less difficulty passing urine at the end of OXN PR treatment compared with baseline. No safety concerns were raised. The analgesic efficacies of OXN PR and OXY PR were similar in postoperative pain settings. OXN PR reduced the degree of restriction in relation to patients carrying out physiotherapy compared with other opioids, and improved bowel and bladder function.

Pain management and satisfaction in postsurgical patients

To examine the relationship between patient satisfaction and the incidence of severe and enduring pain through a health board wide hospital satisfaction questionnaire. The incidence and management of acute postoperative pain and its relationship to patient satisfaction have been of great interest to clinicians over the last 20 years. Evidence suggests that despite many moves to address this problem with the advent of acute pain nurse specialists and dedicated pain teams, severe and enduring pain continues to be a problem. However, patients appear to report high satisfaction levels. The study design was a postal questionnaire the results of which were analysed statistically. The postal questionnaire was sent to patients who had been discharged from acute hospitals in one health board in the previous two weeks. A total of three large acute hospitals were included. The data were analysed to produce descriptive statistics for all patients on the pain questions and then for patients with severe and enduring pain on the variables of age, gender, ethnic group, responses to pain questions and type of admission. Twenty-six percent of patients reported having pain all or most of the time. Patients suffering from severe and enduring pain were younger females. Acute postoperative pain continues to be a problem, although patients continue reporting moderate satisfaction levels. Acute postoperative pain is an ongoing issue for postsurgical patients. It is crucial to understand and recognise issues that can adversely contribute to increased pain severity.

Postoperative Pain: Nurses’ Knowledge and Patients’ Experiences

The aim of this study was to determine nurses’ knowledge and attitudes regarding postoperative pain and identify postoperative patients’ pain intensity experiences. The assessment and management of acute postoperative pain is important in the care of postoperative surgical patients. Inadequate relief of postoperative pain can contribute to postoperative complications such as atelectasis, deep vein thrombosis, and delayed wound healing. A pilot study with an exploratory design was conducted at a large teaching hospital in the eastern United States. The convenience samples included 31 nurses from the gastrointestinal and urologic surgical units and 14 first- and second-day adult postoperative open and laparoscopic gastrointestinal and urologic patients who received patient-controlled analgesia (PCA). The Knowledge and Attitudes Survey Regarding Pain was used to measure nurses’ knowledge about pain management. The Short-Form McGill Pain Questionnaire (SF-MPQ) was used to measure patients’ pain intensity. The nurses’ mean score on the Knowledge and Attitudes Survey Regarding Pain was 69.3%. Patients experienced moderate pain, as indicated by the score on the SF-MPQ. There is a need to increase nurses’ knowledge of pain management.

Innovation in Hospital Quality Improvement Activities—Acute Postoperative Pain Management (APOP) Self-Help Toolkit Audits as an Example

It is often difficult to maintain quality improvement change. Many behavioral strategies have been used to improve uptake of new practices and knowledge. One effective way of changing medication prescribing is audit and feedback with specific educational feedback. The challenge however is to maintain ongoing quality improvement activities. In Australia, unique downloadable "toolkits" are now available to assist hospitals to maintain prescribing quality improvement activities. The first designed to improve the management of acute postoperative pain (APOP toolkit) has been piloted. The toolkit includes data collection and educational tools, an automated feedback report on key indicators, with complete instructions for use. The APOP toolkit has been used in 73 hospitals, in two facilitated "snapshot" audits. There was continued improvement in performance, assessed by increases in the percentage of patients with measured pain and sedation scores and in those with documented pain management plans at discharge, compared with earlier APOP project audits. Using this example of the APOP toolkit and "snapshot" audits, we have now demonstrated that hospitals nationwide are able to undertake quality improvement activities voluntarily to maintain optimal performance. Encouragement, guidance, and availability of ready-made tools developed by a national team facilitate opportunities for ongoing quality improvements.

The impact of intravenous clonidine on management of acute postoperative pain following colorectal surgery

The impact of intravenous clonidine on management of acute postoperative pain following colorectal surgery

Intravenous ketamine compared with diclofenac suppository in suppressing acute postoperative pain in women undergoing gynecologic laparoscopy

We aimed to compare the analgesic effects of low-dose intravenous ketamine with the effects of diclofenac suppositories in acute postoperative pain management in women undergoing gynecologic laparoscopic surgery under general anesthesia. In a double-blind, randomized clinical trial, 80 patients were selected and entered the study. After the induction of general anesthesia, one group received 0.15 mg/kg intravenous ketamine and the other group received a 100-mg rectal diclofenac suppository. The two groups were compared regarding acute pain scores, postoperative morphine requirements, and untoward complications. Pain scores and morphine requirements were lower in the rectal diclofenac suppository group at the 1st, 3rd, and 6th postoperative hours. Higher incidences of postoperative nausea and vomiting (PONV), delusions, and oral secretions were observed in the ketamine group. Diclofenac 100-mg suppositories were more effective in suppressing acute pain than 0.15 mg/kg intravenous ketamine in women undergoing elective gynecologic laparoscopy, with fewer untoward complications.

Patient centred approach to acute post-operative pain management

The Sri Lankan Journal of Anaesthesiology is the official journal of the College of Anaesthesiologists of Sri Lanka. It publishes clinical investigations, research articles, audits, case reports, review articles and CME articles relating to anaesthesiology, critical care and pain. It is published bi annually in January and June. Sri Lankan Journal of Anaesthesiology is included on DOAJ and Scopus.

Non-Stimulation Needle with External Indwelling Cannula for Brachial Plexus Block and Pain Management in 62 Patients Undergoing Upper-Limb Surgery

Objective: To investigate the feasibility of a non-stimulation needle with an external indwelling cannula for upper-limb surgery and acute postoperative pain management. Methods: 62 patients undergoing either scheduled or emergency upper-limb surgery received brachial plexus block of modified interscalene or axillary brachial and then postoperative patient-controlled analgesia (PCA) with local analgesics using a specially designed non-stimulation needle with an external indwelling cannula. The outcome measurements included anesthetic effect, acute or chronic complications, postoperative analgesic effect and patient's satisfaction. Results: The success rate of anesthesia was 96.8%. The single attempt placement with the external indwelling cannula was achieved in 85.2% of patients with axillary brachial plexus block and 78.8% with modified interscalene brachial plexus block. The incidence of severe intoxication was 3.7% with axillary brachial plexus block and 3.0% with modified interscalene brachial plexus block. No hematoma at the injection site, Horner's syndrome, hoarseness or dyspnea was observed. Postoperative analgesic effect was achieved in 100% and activities were slightly lowered in 91.7%. The incidence of nausea and vomit was 8.3%; patient's satisfaction was 9.1 on a 10-point scale system. Infection, nerve injury and respiratory depression were absent during the catheter indwelling. The indwelling time of external indwelling cannula was 30.5 h on average. There was no nerve injury related complication after withdrawing the external indwelling catheter. Conclusions: Brachial plexus block using a non-stimulation needle with an external indwelling cannula has favorable intra-operative anesthetic benefit and provides an excellent postoperative analgesic outcome. The low incidence of complications and favorable patient's satisfaction suggest that non-stimulation needle with an external indwelling cannula is a useful and safe anesthetic tool in brachial nerve block and acute postoperative pain management.

The use of ketamine for perioperative pain management

Ketamine is a phencyclidine derivative that was introduced into clinical use in 1965. It is a noncompetitive N-methyl-Daspartate (NMDA) receptor antagonist, and has analgesic and antihyperalgesic properties. Today, it is unusual to use ketamine as the first-line drug in general anesthesia and the role of ketamine is changing in clinical practice. Ketamine may be a useful adjunct to improve the management of perioperative pain, because the mechanism of action differs from that of opioids. The antihyperalgesic mechanism of ketamine is not fully understood. Opioid-induced hyper algesia may be associated with the influence of excitatory neuro transmission [1]. Therefore, ketamine can prevent the develop ment of tolerance and hyperalgesia by inhibition of the NMDA receptors [2,3]. Various studies have reported on the potentiation of opioidinduced analgesia and the opioid-sparing effect of ketamine [4-6]. However, the results from several clinical trials are controversial. A subanesthetic dose, intravenous intraoperative ketamine reduced mechanical hyperalgesia and improved postoperative analgesia [7], and a small dose of ketamine given before skin incision decreased postoperative pain and reduced morphine consumption after open renal surgery [8]. A small intravenous dose of ketamine before the first incision followed by a 24-h infusion had a morphine-sparing effect after total hip arthroplasty and decreased postoperative chronic pain up to 6 months after surgery [9]. Intravenous patient-controlled analgesia (PCA) with a subanesthetic ketamine and morphine following transthoracic lung and heart surgery resulted in lower pain scores, reduced morphine consumption and shorter postoperative IV-PCA dependence, associated with cardiovascular stability and better respiratory parameters [10]. The potentiation of opioid-induced analgesia and the opioid-sparing effect of ketamine were observed in pediatric patients [6,11]. In this issue of the Korean Journal of Anesthesiology [12], the authors assessed the effectiveness of ketamine, when given intravenously via a PCA pump, as an alternative to nonsteroidal anti-inflammatory drugs towards the management of acute postoperative pain. The authors concluded that a small dose of ketamine (0.5-2.5 μg/kg/min) proportional to fentanyl was not only safe, but also lowered postoperative pain intensity in patients undergoing spinal fusion; however, the opioidsparing effects of ketamine were not demonstrated. However, there was no benefit provided to patients with either small-dose ketamine combined with morphine for PCA after major orthopedic surgery [13] or the addition of a low dose of ketamine to a multimodal analgesic regimen after gynecolo

Ultrasound-Guided Nerve Block for Inguinal Hernia Repair

Open inguinal hernia repair in adults is considered a minor surgical procedure but can be associated with significant pain. We aimed to evaluate acute postoperative pain management in male adults randomized to receive an ultrasound-guided ilioinguinal and iliohypogastric nerve block administered before surgery, in addition to a standard analgesic regimen. Sixty patients were included in this randomized, controlled, and double-blind study. Patients were randomized to the administration of a block with 20 mL bupivacaine 0.5% or a placebo block with 20 mL saline. The primary outcome measure was pain at mobilization in the postanesthesia care unit (PACU). Pain at rest, dermatomal anesthesia, time spent in the PACU/ward, opioid consumption, postoperative vomiting and nausea, ability to perform activities of daily living, and perceived ill health status were secondary outcomes. A significant reduction in pain scores at mobilization (P<0.001) and rest (P < 0.005) was recorded in the bupivacaine group upon arrival in the PACU and again after 30 minutes. Pain at rest was similarly reduced in the bupivacaine group at the time of discharge (P < 0.017). There were significantly fewer patients (P < 0.05) with severe (numerical rating scale >5) and moderate (numerical rating scale >3) pain at mobilization and rest, respectively. Opioid consumption and time spent in the PACU were not significantly different between groups. Ultrasound-guided blocks of the ilioinguinal and iliohypogastric nerves resulted in a statistically significant and clinically relevant reduction in postoperative pain in the PACU both at mobilization and at rest.

Analgesic Concentrations of Oxycodone – A Prospective Clinical PK/PD Study in Patients with Laparoscopic Cholecystectomy

The analgesic concentrations of oxycodone in acute post-operative pain management have not been established. Here, we have evaluated the minimum effective concentration (MEC) and the minimum effective analgesic concentration (MEAC) of oxycodone in pain after laparoscopic cholecystectomy (LCC) in 23 adult patients. The patients were provided with 0.1 mg/kg of oxycodone i.v. 10-15 min. before the end of surgery. After surgery, when the wound pain at rest was ≥3/10 and/or ≥5/10 during wound compression, a first blood sample was obtained (MEC). A second blood sample was obtained after titration with 2 mg i.v. of oxycodone to wound pain <3/10 at rest and <5/10 during wound compression (MEAC). A third blood sample was obtained at the recurrence of the wound pain (the second MEC), and the final blood sample when pain relief was obtained a second time (the second MEAC). At the first onset of pain (MEC), mean P-oxycodone was 21 ng/mL (95% CI 13-29 ng/mL). At the first pain relief (MEAC), P-oxycodone was 55 ng/mL (19-91 ng/mL). The second MEC was 34 ng/mL (11-57 ng/mL), and the second MEAC was 47 ng/mL (14-80 ng/mL). In conclusion, the estimated MEC, 20-35 ng/mL, and MEAC, 45-50 ng/mL, values of P-oxycodone in patients after LLC were significantly higher than those proposed previously. Early pain after LCC appeared to be a feasible method to estimate the analgesic efficacy of oxycodone in acute pain management.

Multimodal therapies for postoperative nausea and vomiting, and pain

Postoperative nausea and vomiting (PONV) and pain are two of the major concerns for patients presenting for surgery. The causes of PONV are multifactorial and can largely be categorized as patient risk factors, anaesthetic technique, and surgical procedure. Antiemetics work on several different receptor sites to prevent or treat PONV. This is probably why numerous studies have now demonstrated that using more than one antiemetic is usually more effective and results in fewer side-effects than simply increasing the dose of a single antiemetic. A multimodal approach to PONV should not be limited to drug therapy alone but should involve a holistic approach starting before operation and continuing intraoperatively with risk reduction strategies to which are added prophylactic antiemetics according to the assessed patient risk for PONV. With the increasing understanding of the pathophysiology of acute pain, especially the occurrence of peripheral and central hypersensitization, it is unlikely that a single drug or intervention is sufficiently broad in its action to be adequately effective, especially with moderate or greater pain. Although morphine and its congeners are usually the foundation of pain management regimens, as their dose increases so does the incidence of side-effects. Thus, the approach for the management of acute postoperative pain is to use multiple drugs or modalities (e.g. regional anaesthesia) to maximize pain relief and reduce side-effects.

Acute Postoperative Pain Management in the Older Patient

Acute pain management in the older adult is both challenging and rewarding. This review addresses the difficulty with assessment of pain in the older adult, variations in the pain experience of older adults, physiological differences between the young and old, changes in pharmacokinetics and pharmacodynamics with age, and useful pharmacological treatments for acute pain in older adults. It then presents a few representative cases of pain management in older adults. The goal of this review is to provide relevant information that can be used to manage acute postoperative pain in the older adult.

Implementation and evaluation of a multisite drug usage evaluation program across Australian hospitals - a quality improvement initiative

BackgroundWith the use of medicines being a broad and extensive part of health management, mechanisms to ensure quality use of medicines are essential. Drug usage evaluation (DUE) is an evidence-based quality improvement methodology, designed to improve the quality, safety and cost-effectiveness of drug use. The purpose of this paper is to describe a national DUE methodology used to improve health care delivery across the continuum through multi-faceted intervention involving audit and feedback, academic detailing and system change, and a qualitative assessment of the methodology, as illustrated by the Acute Postoperative Pain Management (APOP) project.MethodsAn established methodology, consisting of a baseline audit of inpatient medical records, structured patient interviews and general practitioner surveys, followed by an educational intervention and follow-up audit, is used. Australian hospitals, including private, public, metropolitan and regional, are invited to participate on a voluntary basis. De-identified data collected by hospitals are collated and evaluated nationally to provide descriptive comparative analyses. Hospitals benchmark their practices against state and national results to facilitate change. The educational intervention consists of academic detailing, group education, audit and feedback, point-of-prescribing prompts and system changes. A repeat data collection is undertaken to assess changes in practice.An online qualitative survey was undertaken to evaluate the APOP program. Qualitative assessment of hospitals' perceptions of the effectiveness of the overall DUE methodology and changes in procedure/prescribing/policy/clinical practice which resulted from participation were elicited.Results62 hospitals participated in the APOP project. Among 23 respondents to the evaluation survey, 18 (78%) reported improvements in the documentation of pain scores at their hospital. 15 (65%) strongly agreed or agreed that participation in APOP directly resulted in increased prescribing of multimodal analgesia for pain relief in postoperative patients.ConclusionsThis national DUE program has facilitated the engagement and participation of a number of acute health care facilities to address issues relating to quality use of medicine. This approach has been perceived to be effective in helping them achieve improvements in patient care.

Douleurs postopératoires de repos après prothèse de hanche ou de genou : intensité, particularités sensorielles et retentissement sur le sommeil

Summary Introduction The management of acute postoperative pain poses a significant challenge in surgical specialities. Despite the prevalence and impact of acute postoperative pain, there is a paucity of published data regarding its occurrence and sensory qualities after joint replacement. Hypothesis That a proportion of patients would experience severe acute postoperative pain at rest after Total Hip Replacement (THR) and Total Knee Replacement (TKR). Materials and methods Pain was assessed preoperatively, and then five times daily for the first three postoperative days in 105 THR and TKR patients. Pain severity was assessed using a pain Visual Analogue Scale and the sensory qualities of pain were assessed using the pain descriptors from the Short-Form McGill Pain Questionnaire. Results Median acute pain scores peaked on the first postoperative day, with 58 % of TKR patients and 47 % of THR patients reporting moderate-severe pain. Preoperative pain was most frequently described as aching, stabbing and sharp, whereas acute postoperative pain was described as aching, heavy and tender. Night pain disturbed between 44–57 % of TKR patients and 21–52 % of THR patients on postoperative nights 1–3. Discussion These findings demonstrate that acute postoperative pain at rest after joint replacement, particularly TKR, is poorly managed, although it does not reach the severity of preoperative pain. Level of evidence Level IV (observational cohort study).

Acute postoperative pain at rest after hip and knee arthroplasty: Severity, sensory qualities and impact on sleep

The management of acute postoperative pain poses a significant challenge in surgical specialities. Despite the prevalence and impact of acute postoperative pain, there is a paucity of published data regarding its occurrence and sensory qualities after joint replacement. That a proportion of patients would experience severe acute postoperative pain at rest after total hip replacement (THR) and total knee replacement (TKR). Pain was assessed preoperatively, and then five times daily for the first three postoperative days in 105 THR and TKR patients. Pain severity was assessed using a pain Visual Analogue Scale and the sensory qualities of pain were assessed using the pain descriptors from the Short-Form McGill Pain Questionnaire. Median acute pain scores peaked on the first postoperative day, with 58% of TKR patients and 47% of THR patients reporting moderate-severe pain. Preoperative pain was most frequently described as aching, stabbing and sharp, whereas acute postoperative pain was described as aching, heavy and tender. Night pain disturbed between 44-57% of TKR patients and 21-52% of THR patients on postoperative nights 1-3. These findings demonstrate that acute postoperative pain at rest after joint replacement, particularly TKR, is poorly managed, although it does not reach the severity of preoperative pain. Level IV (observational cohort study).