Management Of Acute Postsurgical Pain Research Articles

Leveraging the functionality of Research Electronic Data Capture (REDCap) to enhance data collection and quality in the Opioid Analgesic Reduction Study.

The Opioid Analgesic Reduction Study is a double-blind, prospective, clinical trial investigating analgesic effectiveness in the management of acute post-surgical pain after impacted third molar extraction across five clinical sites. Specifically, Opioid Analgesic Reduction Study examines a commonly prescribed opioid combination (hydrocodone/acetaminophen) against a non-opioid combination (ibuprofen/acetaminophen). The Opioid Analgesic Reduction Study employs a novel, electronic infrastructure, leveraging the functionality of its data management system, Research Electronic Data Capture, to not only serve as its data reservoir but also provide the framework for its quality management program. Within the Opioid Analgesic Reduction Study, Research Electronic Data Capture is expanded into a multi-function management tool, serving as the hub for its clinical data management, project management and credentialing, materials management, and quality management. Research Electronic Data Capture effectively captures data, displays/tracks study progress, triggers follow-up, and supports quality management processes. At 72% study completion, over 12,000 subject data forms have been executed in Research Electronic Data Capture with minimal missing (0.15%) or incomplete or erroneous forms (0.06%). Five hundred, twenty-three queries were initiated to request clarifications and/or address missing data and data discrepancies. Research Electronic Data Capture is an effective digital health technology that can be maximized to contribute to the success of a clinical trial. The Research Electronic Data Capture infrastructure and enhanced functionality used in Opioid Analgesic Reduction Study provides the framework and the logic that ensures complete, accurate, data while guiding an effective, efficient workflow that can be followed by team members across sites. This enhanced data reliability and comprehensive quality management processes allow for better preparedness and readiness for clinical monitoring and regulatory reporting.

Pregabalin for Postoperative pain in patients undergoing spinal surgery: A Dose ranging randomized clinical study

Background: The efficacy of pregabalin in acute post-surgical pain management is well demonstrated. As, the use of pregabalin is officially not approved and hence, there is no dosing guideline as well. Aim: To determine whether single preoperative administration of different doses of pregabalin (150 mg to 300mg) could decrease postoperative pain intensity following spinal surgery. Materials and Method: In this prospective, randomized double-blinded study, a total 60 patients undergoing spinal surgery were selected and randomly assigned any of these four groups of 15 each; group A (received placebo drug), group B (received pregabalin 150mg), group C (received pregabalin 200mg) and group D (received pregabalin 300mg). All the groups received the said drugs (coded as it was double-blinded study) in the same manner and two hours prior to operation. The patients were followed for pain scores on visual analogue scale (VAS), time to rescue analgesia and side effects as secondary outcomes. Results: Patients in pregabalin dose ranging group had lower pain in the initial hour of recovery. However, the pain scores subsequently decreased and became similar in all groups. Time for the requirement for analgesic was longer in pregabalin 300mg group when compared with other study groups. Conclusion: A single dose of 300 mg pregabalin given 1–2 hours prior to surgery is superior to placebo after spinal surgery.

Advances in the Management of Acute Postsurgical Pain: A Review.

Despite the millions of surgeries performed every year around the world, postoperative pain remains prevalent and is often addressed with inadequate or suboptimal treatments. Chronic postsurgical pain is surprisingly prevalent, and its rate varies with the type of surgery, as well as with certain patient characteristics. Thus, better clinical training is needed as well as patient education. As pain can be caused by more than one mechanism, multimodal or balanced postsurgical analgesia is appropriate. Pharmacological agents such as opioid and nonopioid pain relievers, as well as adjuvants and nonpharmacologic approaches, can be combined to provide better and opioid-sparing pain relief. Many specialty societies have guidelines for postoperative pain management that emphasize multimodal postoperative analgesia. These guidelines are particularly helpful when dealing with special populations such as pregnant patients or infants and children. Pediatric pain control, in particular, can be challenging as patients may be unable to communicate their pain levels. A variety of validated assessment tools are available for diagnosis. Related to therapy, most guidelines agree on the fact that codeine should be used with extreme caution in pediatric patients as some may be "rapid metabolizers" and its use may be life-threatening. Prehabilitation is a preoperative approach that prepares patients in advance of elective surgery with conditioning exercises and other interventions to optimize their health. Prehabilitation may have aerobic, strength-training, nutritional, and counseling components. Logistical considerations and degree of patient adherence represent barriers to effective prehabilitation programs. Notwithstanding all this, acute postoperative pain represents a clinical challenge that has not yet been well addressed.

Abstract P6-05-57: Developing and feasibility testing a web-based intervention (ePainQ) to support post-operative pain and symptom self-management following surgery for breast cancer

Abstract Background: Breast cancer is the most commonly diagnosed women’s cancer with 2.3 million new global cases diagnosed in 2020. The global rise in survivorship has resulted in a significant health and economic burden on society. Breast cancer survivors report being overwhelmed physically and emotionally with treatment adverse effects. Recommendations include self-management support and personalised follow-up to meet patient needs. Persistent post-surgical pain (PPSP) is the most common negative consequence of breast surgery, often relating to inadequate acute post-surgical pain management. An unintended consequence of day surgery is reduced post-operative pain monitoring. There is a need to ensure appropriate support and pain monitoring alongside preparation, behavioural change and expectation management. Web-based interventions (WBI) could be a potential solution. A mixed-methods approach was used to develop a WBI to capture patient self-reported post-operative symptoms and provide individualised self-management advice. Methods: An audit and service evaluation revealed a 46% PPSP rate and identified opportunities where advice could support improved self-management. Developing the WBI (ePainQ) comprised a scoping review, systematic review, and development study with all results informing the development of ePainQ. ePainQ comprised two parts; a website containing supportive information and a post-operative symptom questionnaire. Intervention questions included pain, swelling, infection, functionality and QoL. Advice was generated for each question with different levels, based on CTCAE grading agreed with clinicians. A feasibility study prospectively tested ePainQ for acceptability, usability and perceived usefulness. Feasibility study aims were assessing uptake, retention, follow up and completion rates and acceptability of ePainQ. Study arms: usual care (cohort) or intervention (ePainQ). Intervention: daily online symptom questionnaire for 2 weeks commencing the day after surgery. Participants received immediate advice based on the severity of the reported symptoms, either self-management advice or in cases of clinical concern, advice to contact the hospital team. Reports were immediately available to HCPs as ePainQ was linked to the electronic patient record. Data collection: baseline, 2 weeks, 3 and 9 months post-operatively. Outcome measures: EORTC C30, and BR23, EQ-5D, HADS and BPI. Patient Activation was measured at baseline and 9 months. Results: 69 patients recruited over 8 months; 60 intervention and 9 cohort. Mean age: 57.7yrs (SD 9.8; range 38-82). Recruitment rate was 63%. IT issues prevented 12/60 using ePainQ but engagement of the 48/60 active participants was 89.6%. 40/48 completed a usability scale in which • 97.5% highlighted ePainQ as easy to use • 95% reported not needing any technical support • 90% felt very confident using ePainQ Outcome measures: 69/69 (100%) completion at baseline and 2 weeks. No active withdrawals with 13/69 passive withdrawals by 9 months. 67 participants (97.1%) consented to an interview invite with 14/67 interviews conducted. Participants were a mix of compliance rates to be reflective of the study and capture both positive and negative feedback. Feasibility study results demonstrated that ePainQ was perceived to be simple, easy to use and not requiring much learning to use effectively. All pre-set criteria for progression to a phase III RCT were met. Conclusion: ePainQ was designed in response to patient identified needs. The feasibility study established that ePainQ was accepted, used, and liked by participants who interacted with it. Even participants with limited use felt they had benefited from the advice. Results demonstrated patient positivity towards ePainQ suggesting recruitment rates could be increased if research capacity was improved and higher retention rates if IT issues were resolved and daily reporting duration was slightly reduced. Citation Format: Sue M. Hartup, Laura Ashley, Michelle Briggs, Galina Velikova, Mark Johnson. Developing and feasibility testing a web-based intervention (ePainQ) to support post-operative pain and symptom self-management following surgery for breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-05-57.

Buprenorphine for acute post-surgical pain: A systematic review and meta-analysis.

Our study was designed to evaluate the efficacy of buprenorphine for the management of acute post-surgical pain reported in published studies in the years 2015-2022. Comprehensive research was performed by using online resources like PUBMED and the Wiley Library database to gather the relevant literature. Two authors were assigned to independently collect the information. Cochran's Q-test and I square statistic were used to determine the heterogeneity across the studies. Publication bias was estimated by using the Egger regression analysis and found to be significantly present once the P value <0.05. In this review, 15 studies were included. The pooled ratio of pain reduction after 12 hours of surgery was reported as 11.2% with 97% heterogeneity. Day one shows 5.9 reductions in pain with 98% heterogeneity. The 3% more pain was reduced on day 2. The day 3 pooled pain reduction score was observed as 1.9%. The overall pool prevalence of pain reduction was noted as 6.2% at different time duration with significant heterogeneity of 100%. Buprenorphine transdermal and sublingual both have significant pain relief scores. The analgesic drug consumption was reduced at the end of the follow-up duration.

A triple-blind randomized clinical trial of different associations between dexamethasone and non-steroids anti-inflammatories for preemptive action in third molar extractions

The aim of this study is to evaluate the preemptive analgesic effects of dexamethasone (DEX) alone or combined with non-steroidal anti-inflammatory drugs (NSAIDs) in third molar surgeries. The subjects were divided into five groups (n = 20 teeth/group); subjects received only 8 mg of dexamethasone 1 h before the surgical procedure (DEX group), or in combination with etodolac (DEX + ETO), ketorolac (DEX + KET), ibuprofen (DEX + IBU), loxoprofen (DEX + LOX). Paracetamol 750 mg was provided as the number of rescue analgesics (NRA). Salivary PGE2 expression was measured preoperatively and at 48 h. Edema and Maximum mouth opening (MMO) were measured postoperatively at 48 h and 7 days. A visual analog scale (VAS) was performed postoperatively at 6, 12, 24, 48, 72 h, and 7 days. Salivary expression of PGE2 showed a decrease only for the DEX group. Edema and MMO and NRA consumption showed no significant differences among the groups (P > 0.05). The VAS showed a significantly lower pain perception at 6 h after the surgery for the DEX + ETO and DEX + KET groups (P < 0.05). The combination of DEX and NSAIDS should be considered for preemptive acute postsurgical pain management in third molar surgery. In some drug associations such as dexamethasone 8 mg + NSAIDS (ETO and KET) in the pre-operative time, only a few rescue analgesics are necessary.

Minimizing the Risk of Opioid Misuse and Abuse in the Surgical Setting

The misuse of opioids continues to be a public health problem. Acute post-surgical pain management requires a careful balance between the benefits and risks of opioids. Opioids should be part of a multimodal treatment plan, including the use of nonopioid and nonpharmacologic treatment options. Multimodal pain management allows for individualized treatment and improved patient satisfaction while limiting the risks inherent to opioids, including diversion. Surgeons should avoid overprescribing opioids and have a plan for decreasing the use of opioids in the postsurgical time frame. With careful consideration of the risks, opioids can be prescribed to treat acute postsurgical pain effectively. [Orthopedics. 2021;44(6):353-359.].

Effectiveness of Transcutaneous Electrical Nerve Stimulation on Pain and Disability Among Patients with Hip Arthroplasty: A Randomized Control Study

Background: Pain after surgery is highly inevitable, and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) has been reported with side effects. Objectives: This study evaluated the effectiveness of transcutaneous electrical nerve stimulation (TENS) on pain intensity and disability of patients who underwent hip arthroplasty. Methods: A purposive sampling technique was used to recruit 56 subjects that underwent hip arthroplasty. They were randomly allocated to the TENS group (TG) and control group (CG) equally. The subjects in the TG group were treated with conventional TENS twice a day for three weeks, but the CG group was treated with normal drugs only. Pain intensity and hip disability were measured in both groups with the Visual Analogue scale (VAS) and Oxford hip score before the treatment and after the intervention, respectively. Results: The results showed that there was a significant reduction between the pre-treatment and post-treatment pain intensity (t = 3.83, P = 0.003) and hip disability (t = -4.45, P &lt; 0.001) in the TG group. A significant reduction was also observed in pain intensity (t = 3.16, P = 0.01) and hip disability (t = -6.71, P = 0.000) between the pre-treatment and post-treatment periods in the CG group. There was a significant reduction in post-treatment pain intensity (t = 10, P = 0.000) and hip disability (t = -3.51, P = 0.006) when the TG group was compared with the CG group. Conclusions: TENS was effective in the management of acute post-surgical pain and disability of patients with hip arthroplasty.

Role of Physical Therapy in Reducing Postoperative Musculoskeletal Pain In-Lieu of Opioid Pain Medications

To evaluatephysical Therapy as an alternative to opioids in Acute Postsurgical Pain Management.

(140) The Effect of Multimodal Preoperative Pain Management on Post-Operative Anesthesia Care Unit Opioid Requirements in Laparoscopic Cholecystectomies

Non-opioid medications as a part of multimodal analgesia have been increasingly suggested in the management of acute post-surgical pain. Multimodal protocols have been gaining attention worldwide and have shown to reduce the length of postoperative hospital stay without adversely affecting morbidity. By combining preoperative medications in a multimodal fashion we believe that we can maintain postoperative physiological function and accelerate recovery in patients undergoing routine surgeries such as the laparoscopic cholecystectomy. The present study was planned to compare the opioid consumptions between two groups, those who were pre-medicated with multimodal analgesia in the preoperative setting versus those who were not pre-medicated in the preoperative setting. We hypothesize that the application of a multimodal approach may even reduce or prevent the development of significant postoperative pain in patients undergoing elective laparoscopic cholecystectomy, thereby facilitating same-day surgery in this patient population. In this prospective study patients who met the inclusion criteria, were allocated into two groups: Group A patients received Tylenol 650mg, Pregabalin 75mg, and Oxycodone 10mg in the preoperative setting just prior to induction and Group B, no medication. All patients were assessed in the postoperative setting for both pain scores as well as opioid requirements throughout their PACU stay. Postoperatively, significantly more patients in the premedication group were without pain on arrival in the post-anesthesia care unit (PACU). There was a statistical difference observed between Group A (premedication group) vs. Group B (control, no premedication) in regard to PACU opioid requirements; Group A requested pain medication less frequently in the PACU. All in all, the concomitant use of acetaminophen, opioids, and neuropathic adjuvants such as pregabalin is an effective strategy to decrease postoperative opioid requirements, in turn reducing opioid-related adverse effects and ultimately leading to faster recovery and discharge.

Analysis of predictors of opioid-free analgesia for management of acute post-surgical pain in the United States

Objectives: Utilization of opioid-free analgesia (OFA) for post-surgical pain is a growing trend to counter the risks of opioid abuse and opioid-related adverse drug events (ORADEs). However, utilization patterns of OFA have not been examined. In this study, we investigated the utilization patterns and predictors of OFA in a surgical population in the United States.Methods: Analysis of the Cerner Health Facts database (January 2011 to December 2015) was conducted to describe hospital and patient characteristics associated with OFA. Baseline characteristics, such as age, gender, race, discharge status, year of admission and chronic comorbidities at index admission were collected. Hospital characteristics and payer type at index admission were collected as reported in the electronic health record database. Descriptive statistics and logistic regression were used to identify statistically significant predictors of OFA on patient and institutional levels.Results: The study identified 10,219 patients, from 187 hospitals, who received post-surgical OFA and 255,196 patients who received post-surgical opioids. OFA rates varied considerably by hospital. Patients more likely to receive OFA were older (OR = 1.06, 95% CI [1.03, 1.10]; p < .001), or had neurological disorders (OR = 1.24, 95% CI [1.10, 1.39]; p < .001), diabetes (OR = 1.20, 95% CI [1.08, 1.33]; p = .001) or psychosis (OR = 1.18, 95% CI [1.01, 1.37]; p = .030). Patients with obesity and depression were less likely to receive OFA (OR = 0.80, 95% CI [0.67, 0.95]; p = .010 OR = 0.85, 95% CI [0.73, 0.98]; p = .030, respectively).Conclusions: Use of post-surgical OFA was limited overall and was not favored in some patient groups prone to ORADEs, indicating missed opportunities to reduce opioid use and ORADE incidence. A substantial proportion of OFA patients was contributed by a few hospitals with especially high rates of OFA, suggesting that hospital policies, institutional structure and cross-functional departmental commitment to reducing opioid use may play a large role in the implementation of OFA.

Improved Outcomes Associated With the Use of Intravenous Acetaminophen for Management of Acute Post-Surgical Pain in Cesarean Sections and Hysterectomies.

BackgroundPost-surgical pain impacts many patient outcomes. Effective pain management increasingly relies on multimodal analgesia regimens in which acetaminophen (APAP) is a key component. The aim of our study was to examine the impact of oral APAP versus intravenous (IV) APAP as a component of post-surgical pain management after Cesarean sections and hysterectomies.MethodsA retrospective analysis of the Cerner HealthFacts® database (from January, 2011 to December, 2015) was conducted to compare outcomes of Cesarean section and hysterectomy surgery patients who received oral APAP to those who received IV APAP post-surgically. Length of stay (LOS), daily morphine milligram equivalent (MME) consumption, the presence of potential opioid-related adverse events (ORADEs), and total pharmacy costs were assessed. Adjusted results were derived using inverse probability weighted regression adjustment (IPW-RA) estimators based on covariates that included demographics, comorbidities, patient clinical characteristics, and hospital characteristics.ResultsThe study identified 29,124 Cesarean section patients (24,612 oral APAP; 4,512 IV APAP) and 9,767 hysterectomy surgery patients (5,586 oral APAP; 4,181 IV APAP). Compared to the oral APAP group, the IV APAP group had reductions in adjusted LOS (Cesarean section: -11.7% days (P < 0.001), hysterectomy: -11.8% days (P = 0.005)), lowered adjusted daily MME consumption from day 0 to day 3 (Cesarean section: -1.6 mg (P < 0.001), hysterectomy: -1.7 mg (P = 0.014)), and reduced risk of ORADEs for Cesarean sections (relative risk of 0.45, P < 0.001). Total pharmacy costs were not significantly different between the two APAP groups.ConclusionsPost-surgical pain managed with IV APAP in patients undergoing Cesarean section or hysterectomy was associated with shorter LOS, reduced risk of ORADEs, and lower opioid consumption compared to patients managed with oral APAP, without adversely impacting total pharmacy costs.

Effects of Single-Dose Preemptive Pregabalin and Intravenous Ibuprofen on Postoperative Opioid Consumption and Acute Pain after Laparoscopic Cholecystectomy

ABSTRACTPurpose: Non-opioid medications as a part of multimodal analgesia has been increasingly suggested in the management of acute post-surgical pain. The present study was planned to compare the efficacy of the combination of pregabalin plus ıv ibuprofen. Methods: 58 patients were included in this prospective, randomized, double-blinded study. The pregabalin group (Group P, n = 29) received 150 mg pregabalin, the pregabalin plus ibuprofen group (Gropu PI, n = 29) received 150 mg pregabalin and 400mg ıv ibuprofen before surgery. Postoperative fentanyl consumption, additional analgesia requirements and PACU stay were recorded. Postoperative analgesia was performed with patient-controlled IV fentanyl. Results: VAS scores in the group PI were statistically lower at PACU, 1and 2 hours at rest, at PACU, 1, 2, 4, 12 and 24 hours on movement compared to the group P (P < 0.05). Opioid consumption was statistically significantly higher in the group P compared to the group PI (130.17 ± 60.27 vs 78.45 ± 60.40 μq, respectively, P < 0.001) and reduced in the 4th 24 hours by 55% in group PI. Rescue analgesia usage was statistically significantly higher in the group P than in the group PI (16/29 vs 7/29, respectively, P < 0.001). Four patient in the group PI did not need any opioid drug. Besides, PACU stay was shorter in the group PI than the group P (10.62 ± 2.38 vs 15.59 ± 2.11 min, respectively, P < 0.001). Conclusion: Preemptive pregabalin plus ıv ibuprofen in laparoscopic cholecystectomy reduced postoperative opioid consumption. This multimodal analgesic aproach generated lower pain scores in the postoperative period.

GEDOS-SECOT consensus on the care process of patients with knee osteoarthritis and arthoplasty

ObjectiveTo develop recommendations on the evaluation and management procedure in patients undergoing total knee replacement based on best evidence and the experience of a panel of experts. MethodsA multidisciplinary group of 12 experts was selected that defined the scope, users and the document parts. Three systematic reviews were performed in patients undergoing knee replacement: (i) efficacy and safety of fast-tracks; (ii) efficacy and safety of cognitive interventions in patients with catastrophic pain, and (iii) efficacy and safety of acute post-surgical pain management on post-surgical outcomes. A narrative review was conducted on the evaluation and management of pain sensitisation, and about the efficacy and safety of pre-surgical physiotherapy. The experts generated the recommendations and explicative text. The level of agreement was evaluated in a multidisciplinary group of 85 experts with the Delphi technique. The level of evidence was established as well for each recommendation. ResultsA total of 20 recommendations were produced. An agreement higher than 80% was reached in all of them. We found the highest agreement on the need for a full discharge report, on providing proper information about the process and on following available guidelines. ConclusionsThere is consensus among professionals involved in the management of patients undergoing total knee replacement, in that it is important to protocolize the replacement process, performing a proper, integrated and coordinated patient evaluation and follow-up, paying special attention to the surgical procedure and postoperative period.

Consenso GEDOS-SECOT sobre el proceso de atención a pacientes con artrosis de rodilla e indicación de artroplastia

ObjectiveTo develop recommendations on the evaluation and management procedure in patients undergoing total knee replacement based on best evidence and the experience of a panel of experts. MethodsA multidisciplinary group of 12 experts was selected that defined the scope, users and the document parts. Three systematic reviews were performed in patients undergoing knee replacement: (i)efficacy and safety of fast-tracks; (ii)efficacy and safety of cognitive interventions in patients with catastrophic pain, and (iii) efficacy and safety of acute post-surgical pain management on post-surgical outcomes. A narrative review was conducted on the evaluation and management of pain sensitization, and about the efficacy and safety of pre-surgical physiotherapy. The experts generated the recommendations and explicative text. The level of agreement was evaluated in a multidisciplinary group of 85 experts with the Delphi technique. The level of evidence was established as well for each recommendation. ResultsA total of 20 recommendations were produced. An agreement higher than 80% was reached in all of them. We found the highest agreement on the need for a full discharge report, on providing proper information about the process and on following available guidelines. ConclusionsThere is consensus among professionals involved in the management of patients undergoing total knee replacement, in that it is important to protocolize the replacement process, performing a proper, integrated and coordinated patient evaluation and follow-up, paying special attention to the surgical procedure and postoperative period.

A comparison of predictors and intensity of acute postsurgical pain in patients undergoing total hip and knee arthroplasty.

BackgroundAcute pain is an expected result after surgery. Nevertheless, when not appropriately controlled, acute pain has a very negative impact on individual clinical outcomes, impairing healing and recovery, and has clear consequences on health care system costs. Augmenting knowledge on predictors and potentially modifiable determinants of acute postsurgical pain can facilitate early identification of and intervention in patients at risk. However, only a few studies have examined and compared acute pain after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The aim of this study was to compare THA and TKA in acute postsurgical pain intensity and its predictors.MethodsA consecutive sample of 124 patients with osteoarthritis (64 undergoing THA and 60 TKA) was assessed 24 hours before (T1) and 48 hours after (T2) surgery. Demographic, clinical, and psychological factors were assessed at T1, and acute postsurgical pain experience was examined at T2. Additionally, the same hierarchical regression analysis was performed separately for each arthroplasty type.ResultsTKA patients reported higher levels of acute postsurgical pain compared with THA (t=8.490, p=0.004, d=0.527, 95% confidence interval, 0.196–0.878). In the final THA predictive model, presurgical pain was the only variable approaching significant results (t[57]=1.746, β=0.254, p=0.086). In the final TKA predictive model, optimism was the only predictor of pain (t[51]=−2.518, β=−0.339, p=0.015), with emotional representation (t[51]=1.895, β=0.254, p=0.064) presenting a trend toward significance.ConclusionThe current study is the first examining THA and TKA differences on acute postsurgical pain intensity and its predictors using a multivariate approach. Results from this study could prove useful for the design of distinct interventions targeting acute postsurgical pain management depending on whether the site of arthroplasty is the hip or the knee. Finally, the current results also support the argument that these two surgeries, at least with regard to acute pain, should be approached separately.

Ultrasound-Guided Paravertebral Catheter Versus Intercostal Blocks for Postoperative Pain Control in Video-Assisted Thoracoscopic Surgery: A Prospective Randomized Trial

The use of continuous paravertebral (PV) catheters for management of acute postsurgical pain after video-assisted thoracoscopic surgery (VATS) has not been investigated previously as a randomized controlled trial. The purpose of this study was to compare the efficacy of an ultrasound-guided continuous PV catheter catheter infusion for postoperative pain control with single-shot intercostal blocks (ICB). A prospective, randomized, controlled trial. An academic university hospital. Patients (≥18 years of age) who underwent a VATS procedure. Patients were randomized into 2 groups. Group 1 received single-shot ICB. Group 2 received an ultrasound-guided PV catheter with a continuous infusion of 0.2% ropivacaine. There were 25 patients in group 1 and 23 patients in group 2. The maximum pain score was significantly lower in the group that received the PV catheter compared with those who received ICB during 24 to 48 hours (3.65 v 6.44, p<0.001). Seventeen patients (74%) who received PV catheters reported satisfaction with a pain control regimen compared to the 11 (44%) who received ICB (p = 0.036). In addition, during 24 to 48 hours after surgery the mean opioid use decreased significantly in the PV catheter group (14.39 v 30.50 mg morphine equivalents, p = 0.046). Ultrasound-guided continuous PV catheter infusions provided prolonged pain control and superior patient satisfaction compared with single-shot ICB after video-assisted thoracoscopic surgery.

Cardiovascular safety of hydroxypropyl-β-cyclodextrin–diclofenac in the management of acute postsurgical pain: a pooled analysis of 2 randomized, double-blind, placebo- and active comparator–controlled phase III clinical trials

Study ObjectiveLong-term use of nonsteroidal anti-inflammatory drugs, including selective and nonselective cyclooxygenase inhibitors, has been suggested to be associated with cardiovascular (CV) safety risks. Data are limited regarding CV risks associated with short-term nonsteroidal anti-inflammatory drug use, including injectable formulations, although it has been suggested that even a single dose may increase CV adverse event (AE) risk. The objective of this study was to examine the CV safety of an injectable diclofenac formulation solubilized with hydroxypropyl-β-cyclodextrin (HPβCD) when given for ≤5days postoperatively. DesignA pooled analysis of CV AEs from 2 pivotal phase III clinical trials examining the efficacy and safety of intravenous (IV) HPβCD-diclofenac vs placebo and the active comparator ketorolac was conducted. SettingPostoperative, with treatment initiated in the postanesthesia care unit ≤6hours postsurgery. PatientsOverall, 608 abdominal/pelvic and orthopedic surgery patients met inclusion criteria and received ≥1 study medication dose. InterventionsPatients received either HPβCD-diclofenac, ketorolac, or placebo via IV bolus injection every 6hours, for ≤5days postsurgery. MeasurementsCV AEs, reported by study investigators, were evaluated through the treatment period and follow-up (≤37days after last study medication dose), and relative CV AE risks were estimated. Main ResultsIV HPβCD-diclofenac was not associated with increased treatment-emergent CV AE incidence vs placebo (11.6% vs 12.2%; relative risk, 0.96 [95% confidence interval, 0.56-1.62]). Serious CV AEs as well as treatment-related AEs were uncommon, and there were no reports of myocardial infarction or cerebrovascular accident. CV AEs were uncommon during the follow-up period, occurring in 1.3%, 0%, and 1.4% of patients in the HPβCD-diclofenac, ketorolac, and placebo groups, respectively. ConclusionsAlthough a longer duration follow-up study in a larger patient population would expand our understanding of potential CV risks, the present analysis suggests that postoperative use of HPβCD-diclofenac does not present an added CV safety risk over placebo.

The effect of pregabalin and celecoxib on the analgesic requirements after laparoscopic cholecystectomy: a randomized controlled trial.

Early postoperative pain is a common complaint after elective laparoscopic cholecystectomy. The use of non-opioid medications as a part of multimodal analgesia has been increasingly advocated in the management of acute post-surgical pain. This randomized, double-blinded, placebo-controlled study evaluated the efficacy of pregabalin, celecoxib, and their combination in the management of acute postoperative pain in patients undergoing elective laparoscopic cholecystectomy. One hundred ASA I/II patients scheduled to undergo elective laparoscopic cholecystectomy were assigned to receive two perioperative doses, 12 h apart, of either pregabalin alone, celecoxib alone, their combination, or a placebo. Standard anesthetic protocol was followed. The primary outcomes were postoperative pain at rest and with movement. Secondary outcomes were fentanyl requirements and side effects, which were assessed at 1, 2, 4, 8, 12, and 24h following surgery. Patient satisfaction with pain relief was recorded at discharge. Differences in main outcomes were analyzed using an intention-to-treat approach. There was no statistically significant difference (p>0.05) between the four groups in terms of outcomes such as rest pain, movement pain, postoperative fentanyl requirements, or changes in anxiety scores. Patients who had only celecoxib had significantly higher satisfaction with pain management (p=0.013). Patients who had only pregabalin were at three-times-higher odds of having drowsiness (p=0.040) and four-times-higher odds of having lightheadedness (p=0.019) when compared with the placebo group. Pregabalin, celecoxib alone, or in combination offers no analgesic superiority over standard opioid care in the treatment of postoperative pain following laparoscopic cholecystectomy.

The Role of Pain Catastrophizing in the Provision of Rescue Analgesia by Health Care Providers Following Major Joint Arthroplasty

Background: After surgery, patient reports or health care professional evaluations of heightened acute pain intensity should lead to extra analgesia provision, which is designated by rescue analgesia (RA). Whether RA is administered or not, it is not directly dependent on the patient but rather on clinical decisions, which should be based on pain management guidelines. There is a general lack of studies focusing on pain-related decision-making regarding RA provision. Objectives: This study aimed to examine which pre and post-surgical factors, beyond acute postsurgical pain intensity, might influence clinical decisions on RA administration after major joint arthroplasties (MJA). Methods: A consecutive sample of 110 patients undergoing MJA was fully assessed 24 hours before (T1) and 48 hours after (T2) surgery. Before surgery, baseline demographic, clinical, and psychological variables were evaluated and after surgery the main outcome was RA provision, with acute post-surgical pain intensity being also registered. Study Design: Prospective observational cohort study. Setting: Central hospital in northern Portugal. Results: Logistic regression analysis revealed that RA provision, after MJA, is influenced by a patient-related psychological factor, pain catastrophizing (OR = 1.143; 95% CI 1.044 – 1.253, P = 0.004), above and beyond acute post-surgical pain intensity. Additionally, the type of arthroplasty (OR = 2.806; 95% CI 1.002 – 7.857, P = 0.050) also affected RA provision. Other patient-related factors such as gender, previous pain states, pre-surgical optimism, and post-surgical anxiety did not reveal any predictive role in RA administration. Limitations: This is a single-site study, only confined to MJA patients. Conclusions: The findings of this study shed light on the importance of psychological factors in determining RA provision following MJA. This encourages further reflection on acute postsurgical pain management by health care providers, namely by raising clinicians’ awareness about the factors that influence patient-provider interactions, as well as their impact on decision-making regarding RA provision. A global assessment of patients, wherein psychological variables are taken into account, is warranted in order to improve the quality of surgical pain management. Finally, these findings provide support for the design of acute post-surgical pain management interventions directed at clinicians, in order to augment professionals’ awareness about the potential influence of patient-related psychological factors on RA decisions. Key words: Rescue analgesia, major joint arthroplasty, post-surgical pain intensity, psychological factors, pre-surgical pain catastrophizing, patient-provider interactions, pain-related decisionmaking, predictive analysis