Optimal Postoperative Pain Management Research Articles

Current status and progress of research on analgesia after laparoscopic surgery

Background With the development of minimally invasive surgical techniques, laparoscopy used in various clinical surgery can accelerate the rehabilitation of patients to a certain extent, but the main factor postoperative wound pain is still affecting the rapid recovery. Therefore, it is of great significance for the management of pain after laparoscopic surgery. Objective This paper summarized the methods of pain management after laparoscopic surgery to provide a basis for more reasonable and effective management. Content Discussing the effect of laparoscopic surgery on the rapid recovery and the common methods of clinical analgesia after laparoscopic surgery. Trend The optimal management of postoperative pain has a positive impact on postoperative accelerated rehabilitation, which can reduce the number of days of hospitalization and reduce the complications of laparoscopic surgery. Key words: Enhanced recovery after surgery; Therapeutic laparoscopy; Postoperative pain

Role of Multimodal Analgesia in the Evolving Enhanced Recovery after Surgery Pathways.

Enhanced recovery after surgery (ERAS) are specially designed multimodal perioperative care pathways which are intended to attain and improve rapid recovery after surgical interventions by supporting preoperative organ function and attenuating the stress response caused by surgical trauma, allowing patients to get back to normal activities as soon as possible. Evidence-based protocols are prepared and published to implement the conception of ERAS. Although they vary amongst health care institutions, the main three elements (preoperative, perioperative, and postoperative components) remain the cornerstones. Postoperative pain influences the quality and length of the postoperative recovery period, and later, the quality of life. Therefore, the optimal postoperative pain management (PPM) applying multimodal analgesia (MA) is one of the most important components of ERAS. The main purpose of this article is to discuss the concept of MA in PPM, particularly reviewing the use of opioid-sparing measures such as paracetamol, nonsteroid anti-inflammatory drugs (NSAIDs), other adjuvants, and regional techniques.

CE: Managing Postoperative Pain.

: Acute postoperative pain remains undertreated despite the dramatic increase in opioid prescribing in the United States over the past 20 years. Inadequately relieved postoperative pain may be a risk factor for persistent postoperative pain, chronic pain, and disability. In an effort to promote evidence-based strategies for optimal postoperative pain management, the American Pain Society published a new postoperative pain management guideline in 2016. Its 32 recommendations for interdisciplinary and multimodal postoperative pain management are stratified according to risks and benefits, based on varying levels of evidence. This article aims to help nurses translate the recommendations into clinical practice, while providing the historical context in which the guidelines emerged and describing current events that may affect guideline implementation.

A prospective randomized controlled trial to identify the optimal postoperative pain management in shoulder arthroplasty: liposomal bupivacaine versus continuous interscalene catheter

Shoulder arthroplasty is the fastest growing joint replacement surgery in the United States, and optimal postoperative pain management is critical to optimize outcomes for these surgeries. Liposomal bupivacaine (LB) has gained popularity for its potential to provide extended postoperative pain relief with possibly fewer side effects. The goal of this study was to assess the impact of LB compared with continuous interscalene nerve block (CISB) in terms of postoperative pain control, outpatient pain scores, and patient-reported and functional outcomes after shoulder arthroplasty surgery. A prospective randomized controlled clinical trial compared consecutive patients undergoing shoulder arthroplasty treated with CISB vs. LB with a single bolus interscalene block. The primary outcome measures included pain assessment up to 24 hours after surgery; in addition, all doses and times of narcotics administered during the inpatient stay were recorded. Patient-reported outcome measures for pain, satisfaction, and functional outcomes were recorded postoperatively. A total of 70 of 74 consecutive patients who underwent shoulder arthroplasty were included in the study. The LB group had equivalent narcotic use, pain scores, and time to first narcotic rescue compared with the CISB group within the first 24 hours (P > .05). The LB group had higher American Shoulder and Elbow Surgeons score and Penn Shoulder Score at final follow-up. There was an increased number of complications and cost for the CISB group. This prospective randomized controlled trial demonstrated that LB provides excellent postoperative pain relief for shoulder arthroplasty patients. In addition, LB had fewer complications and lower cost, making it a promising addition to a multimodal pain regimen for shoulder arthroplasty.

Patients’ attitudes, experience and satisfaction with acute postoperative pain management: A multicentre survey of 15 tertiary hospitals in Maharashtra.

Background and aims: Optimal postoperative pain management leads to improved patient related outcomes (PROs),and satisfactionin the patients. It is important to understand the patients’ perspective as it helps in developing strategies for improvement. Attitudes and beliefs of patients are important because wrong attitudes and misconceptions can act as barriers in providing pain relief.Hence, a multicentre survey was carried out in the tertiary hospitals of Maharashtrato understand the attitudes,beliefs,experiences and satisfaction levels of patients with acute postoperative pain management. Also,comparison of responses was done to evaluate if Acutepain service (APS) leads to better patient outcomes and satisfaction.Materials and methods: A 13-item questionnaire for patients, adapted from previous studies was used to collect data on patients’ experience of postoperative pain management.The responses of 179 patients were included in the study.Results:The incidence of postoperative pain was 91.6% with 75.5% having moderate to severe pain.Despite this, 91.06% of patients were satisfied. Patients in APS set up had lower incidence of moderate –severe pain (44.23%) and higher satisfaction rates (100%).Although, 35.2% of patients pronounced that postoperative pain management should be done in best possible way, they also had many misconceptions, which were possibly reinforced by counselling done by health providers.Conclusions:The findings suggest that the postoperative pain management is far from adequate even with an APS in place. Patient and health provider education needs to be stressed for better pain management and improved outcomes.

Paper #14 - A prospective randomized trial to identify the optimal postoperative pain management in shoulder arthroplasty: liposomal bupivacaine vs. continuous peripheral nerve block

Paper #14 - A prospective randomized trial to identify the optimal postoperative pain management in shoulder arthroplasty: liposomal bupivacaine vs. continuous peripheral nerve block

Neglect of Postoperative Pain Management in Children: A Qualitative Study Based on the Experiences of Parents

Identifying parents' experiences of barriers to optimal postoperative pain management in children. This qualitative-content analysis study was conducted with 16 parents whose school-age children had undergone emergency abdominal surgery in university hospitals of Ahvaz, southern Iran. A purposive sampling method was used to select the participants. The semi-structured interviews with all of the participants were recorded, transcribed, and analysed. After data analysis, neglect emerged as the main theme. This neglect consisted of three categories including the healthcare system's disregard, insufficient sensitivity of the healthcare providers, and hesitance or delays of parents and children in asking for care. The optimal management of children's postoperative pain requires the provision of relevant infrastructures by the healthcare system, responsible performance of the health professionals beyond the routine, and active and informed participation of both parents and children.

Efficacy of multimodal drug injection after supramalleolar osteotomy for varus ankle osteoarthritis: A prospective randomized study.

Optimal management of postoperative pain is important to ensure patient comfort and functional improvement. Despite the frequent use of multimodal drug injection for pain control after orthopedic surgery, few studies have evaluated its use after supramalleolar osteotomy. Supramalleolar osteotomy was performed in 62 patients (65 ankles). Thirty patients (31 ankles) were randomly assigned to receive multimodal drug injection (injection group) and 32 patients (34 ankles) were assigned to receive no multimodal drug injection (control group). The two groups were compared with regard to the degree of postoperative pain, the number of times patients pushed the patient-controlled analgesia (PCA) button, the total amount of fentanyl administered, and the frequency of additional diclofenac sodium injections. The injection group had significant pain reduction during the first 36 postoperative hours compared to the control group. There were significant differences between the groups in the number of times that patients pushed the PCA button as well as the total amount of fentanyl administered up to 24h postoperatively. The mean frequency of additional diclofenac sodium injections in the first 12 postoperative hours was significantly less in the injection group compared to that in the control group. Multimodal drug injection was effective in reducing pain and decreasing both fentanyl and diclofenac sodium usage in patients undergoing supramalleolar osteotomy. Therefore, multimodal drug injection should be considered for improved pain control and patient comfort in the early postoperative period after supramalleolar osteotomy.

A new method for pain management in total knee arthroplasty: Intraoperative local anesthetic application in addition to one-shot femoral block

Background and Aim: Total knee arthroplasty (TKA) is an effective treatment for end-stage knee arthritis, but the optimal management of postoperative pain remains controversial. Therefore, this study investigated the efficacy of different local anesthetic application methods on early, 1 st day pain control after TKA. Methods: A total of 200 patients who underwent unilateral TKA surgery with spinal anesthesia were randomly assigned into four different groups (50 in each) and were administered pain control by different peri-and post-operative regimens. Group A was the control group wherein no postsurgical analgesia was administered to assess spinal anesthesia efficacy; in Group B, only postsurgical one-shot femoral block was applied; in Group C, intraoperative periarticular local anesthetic was applied; in Group D, a combination of the one-shot femoral block and intraoperative periarticular local anesthetics were applied. Results: Group D patients experienced significantly better postoperative pain relief ( P Conclusion: The intraoperative periarticular application of local anesthetics in addition to one-shot femoral block is an efficient way of controlling postsurgical pain after TKA.

Epidural versus Intravenous Patient Controlled Analgesia after Laparoscopic Gastric Bypass Surgery

Introduction: There is no clear consensus about the optimal postoperative pain management in morbidly obese patients undergoing bariatric surgery. The aim of this study was to evaluate the effects of Patient-Controlled- Epidural-Analgesia (PCEA) compared to Intravenous-Patient-Controlled-Analgesia (IV-PCA) in patients undergoing laparoscopic gastric bypass surgery. Methods: Between January 2013 and December 2014, 154 obese patients underwent laparoscopic gastric bypass surgery. Included in our analyses were all patients receiving either IV-PCA or PCEA in their postoperative course. Group comparison with respect to patient demographics, co-morbidities, details of surgical procedure, details of postoperative course, NRS-scores at rest, and medical follow-ups were performed. Results: Overall 63 (44.4%) patients were treated by PCEA, 79 (55.6%) patients by IV-PCA. We observed no differences across the groups with respect to sex, age, ASA-score, co-morbidities, postoperative BMI, body height, pre- and postoperative weight, ideal weight, weight loss, duration of surgery and postoperative ward. Patient´s BMI (p=0.025) and excess weight before surgery (p=0.029) were significantly higher in the IV-PCA-group. Surgical complications occurred significantly more often in the IV-PCA group (p=0.045). Concerning the postoperative pain management there was no statistically significant difference between different NRS-scores throughout the study period. However, individuals in the IV-PCA-group received significantly more paracetamol (p<0.0001) and diclofenac combined with orphenadrine (p=0.003). Duration of PCA was longer in the PCEA-group compared to patients treated with IV-PCA (p<0.01). Conclusions: Particularly for obese patients, PCEA is more beneficial than IV-PCA, which is borne out by a significantly lower incidence of surgical complications observed in patients receiving PCEA.

Factors affecting recovery of postoperative bowel function after pediatric laparoscopic surgery.

Background and Aims:Laparoscopic pediatric surgery allows a rapid postoperative rehabilitation and hospital discharge. However, the optimal postoperative pain management preserving advantages of this surgical technique remains to be determined. This study aimed to identify factors affecting the postoperative recovery of bowel function after laparoscopic surgery in children.Material and Methods:A retrospective analysis of factors affecting recovery of bowel function in children and infants undergoing laparoscopic surgery between January 1, 2009 and September 30, 2009, was performed. Factors included were: Age, weight, extent of surgery (extensive, regional or local), chronic pain (sickle cell disease or chronic intestinal inflammatory disease), American Society of Anaesthesiologists status, postoperative analgesia (ketamine, morphine, nalbuphine, paracetamol, nonsteroidal anti-inflammatory drugs [NSAIDs], nefopam, regional analgesia) both in the Postanesthesia Care Unit and in the surgical ward; and surgical complications. Data analysis used classification and regression tree analysis (CART) with a 10-fold cross validation.Results:One hundred and sixty six patients were included in the analysis. Recovery of bowel function depended upon: The extent of surgery, the occurrence of postoperative surgical complications, the administration of postoperative morphine in the surgical ward, the coadministration of paracetamol and NSAIDs and/or nefopam in the surgical ward and the emergency character of the surgery. The CART method generated a decision tree with eight terminal nodes. The percentage of explained variability of the model and the cross validation were 58% and 49%, respectively.Conclusion:Multimodal analgesia using nonopioid analgesia that allows decreasing postoperative morphine consumption should be considered for the speed of bowel function recovery after laparoscopic pediatric surgery.

Proper Postsurgical Pain Management in Orthopaedics: Reviewing the Efficacy of Wound Infiltration with Liposomal Bupivacaine (EXPAREL)

ABSTRACT Adequate postoperative pain management after an orthopaedic procedure is critical for patient well-being, acceptable clinical outcomes and patient satisfaction. Current literature suggests over 80% of surgical patients’ state they have moderate to severe pain within 24 hours postoperatively. The standard in pain management for more than 40 years has been opioids, medications known for their many adverse effects and limited efficacy. Recently, a multimodal approach to pain control has been sought after for optimal postoperative pain management. This approach utilizes multiple methods of pain management, such as nerve blocks, wound infiltration with local anesthetics and oral analgesics, to concomitantly reduce postoperative pain. Liposomal bupivacaine, EXPAREL, has been shown to reduce pain for as long as 96 hours postoperatively in select studies. These studies have included both hard and soft-tissue procedures. The goal of this review is to examine the literature on EXPAREL and provide a comprehensive presentation for orthopaedic surgeons to apply to their practices. Sabesan V, Jelsema TR, Lombardo DJ. Proper Postsurgical Pain Management in Orthopaedics: Reviewing the Efficacy of Wound Infiltration with Liposomal Bupivacaine (EXPAREL). The Duke Orthop J 2015;5(1):6-9.

Optimizing pain management to facilitate Enhanced Recovery After Surgery pathways.

The optimal management of postoperative pain using multimodal analgesia is a key component of Enhanced Recovery After Surgery (ERAS). Pain has adverse clinical implications on postoperative recovery, including prolonging the time to recovery milestones and length of hospital stay. Moreover, the ubiquity of opioids in postoperative analgesic regimens results in adverse effects, such as sedation, postoperative nausea and vomiting, urinary retention, ileus, and respiratory depression, which can delay discharge. Thus, multimodal analgesia, i.e., the use of more than one analgesic modality to achieve effective pain control while reducing opioid-related side effects, has become the cornerstone of enhanced recovery. The purpose of this review is to address the analgesic techniques used as part of multimodal analgesic regimens to optimize postoperative pain control and to summarize the evidence for their use in reducing opioid requirements and side effects. There is a wide variety of analgesic techniques available for multimodal postoperative analgesia. These modalities are divided into pharmacological and non-pharmacological techniques. Systemic pharmacological modalities involve opioids and non-opioids such as acetaminophen, non-steroidal anti-inflammatory drugs, N-methyl-D-aspartate receptor antagonists, anticonvulsants (e.g., gamma-aminobutyric acid analogues), beta-blockers, alpha-2 agonists, transient receptor potential vanilloid receptor agonists (capsaicin), and glucocorticoids. Other pharmacological modalities include central neuraxial techniques, surgical-site infiltration, and regional anesthesia. Evidence supports the use of these pharmacological techniques as part of multimodal analgesia, but each has its own advantages and specific safety profile, which highlights the importance of selecting the appropriate analgesics for each patient. Adjunctive non-pharmacological techniques include acupuncture, music therapy, transcutaneous electrical nerve stimulation, and hypnosis. There is mixed evidence regarding such techniques, although a lack of harm is associated with their use. There are continuing advancements in multimodal analgesic techniques; however, postoperative pain in general continues to be undermanaged. Furthermore, a continuing challenge in multimodal pain research related to ERAS is the difficulty in carrying out randomized trials to determine the relative importance of any one component, including analgesia.

The effect of anesthesia choice on post-operative outcomes in women undergoing exploratory laparotomy for a suspected gynecologic malignancy

ObjectiveTo determine how anesthesia choice in women undergoing laparotomy for gynecologic malignancy affects pain control and narcotic use. MethodsThis is a retrospective study of women who underwent laparotomy for suspected gynecologic malignancy from May 2012 to January 2013. Patients were categorized into one of three groups: 1) patient controlled analgesia (PCA); 2) PCA+transversus abdominis plane block (TAP); and 3) patient-controlled epidural analgesia (PCEA). Mean narcotic use and patient reported pain scores were compared. ResultsThe analysis includes 112 women (44 PCA, 30 TAP, 38 PCEA). Intraoperative factors were not different between groups with the exception of a significant difference in the rate of intra-operative complications (p=0.020), with lower rates in the PCEA group. The groups differed in intravenous narcotic use in each of the first three postoperative days (day 0: p=0.014; day 1: p<0.0001; day 2: p=0.048), with patients in the TAP group using the least on day 0 and those in the PCEA group using less on postoperative days 1 and 2. In addition, the PCEA group reported lower pain scores on postoperative days 1 and 2 (day 1: p=0.046; day 2: p=0.008). ConclusionsThe use of patient controlled epidural anesthesia after laparotomy for gynecologic malignancy is associated with decreased IV and PO narcotic use and improved pain control without increasing complications or length of hospital stay. Further investigation with prospective randomized trials is warranted to elucidate the optimal post-operative pain management technique.

Postoperative Pain Management in Children and Infants: An Update

Many factors contribute to suboptimal pain management in children. Current evidence suggests that severe pain in children has significant long-lasting effects, even more so than in adults. In particular, recent evidence suggests a lack of optimal postoperative pain management in children, especially following ambulatory surgery. This review provides simple guidelines for the management of postoperative pain in children. It discusses the long-term effects of severe pain and how to evaluate pain in both healthy and neurologically impaired children, including neonates. Currently available treatment options are discussed with reference to the efficacy and side effects of opioid and non-opioid and regional analgesic techniques. The impact of preoperative anxiety on postoperative pain, and the efficacy of some nonpharmacological techniques such as hypnosis or distraction, are also discussed. Finally, basic organizational strategies are described, aiming to promote safer and more efficient postoperative pain management in children.

Evaluation of etoricoxib in patients undergoing total knee replacement surgery in a double-blind, randomized controlled trial

BackgroundOptimal postoperative pain management is important to ensure patient comfort and early mobilization.MethodsIn this double-blind, placebo- and active-controlled, randomized clinical trial, we evaluated postoperative pain following knee replacement in patients receiving placebo, etoricoxib (90 or 120 mg), or ibuprofen 1800 mg daily for 7 days. Patients ≥18 years of age who had pain at rest ≥5 (0–10 Numerical Rating Scale [NRS]) after unilateral total knee replacement were randomly assigned to placebo (N = 98), etoricoxib 90 mg (N = 224), etoricoxib 120 mg (N = 230), or ibuprofen 1800 mg (N = 224) postoperatively. Co-primary endpoints included Average Pain Intensity Difference at Rest over Days 1–3 (0- to 10-point NRS) and Average Total Daily Dose of Morphine over Days 1–3. Pain upon movement was evaluated using Average Pain Intensity Difference upon Knee Flexion (0- to 10-point NRS). The primary objective was to demonstrate analgesic superiority for the etoricoxib doses vs. placebo; the secondary objective was to demonstrate that the analgesic effect of the etoricoxib doses was non-inferior to ibuprofen. Adverse experiences (AEs) including opioid-related AEs were evaluated.ResultsThe least squares (LS) mean (95% CI) differences from placebo for Pain Intensity Difference at Rest over Days 1–3 were -0.54 (-0.95, -0.14); -0.49 (-0.89, -0.08); and -0.45 (-0.85, -0.04) for etoricoxib 90 mg, etoricoxib 120 mg, and ibuprofen, respectively (p < 0.05 for etoricoxib vs. placebo). Differences in LS Geometric Mean Ratio morphine use over Days 1–3 from placebo were 0.66 (0.54, 0.82); 0.69 (0.56, 0.85); and 0.66 (0.53, 0.81) for etoricoxib 90 mg, etoricoxib 120 mg, and ibuprofen, respectively (p < 0.001 for etoricoxib vs. placebo). Differences in LS Mean Pain Intensity upon Knee Flexion were -0.37 (-0.85, 0.11); -0.46 (-0.94, 0.01); and -0.42 (-0.90, 0.06) for etoricoxib 90 mg, etoricoxib 120 mg, and ibuprofen, respectively. Opioid-related AEs occurred in 41.8%, 34.7%, 36.5%, and 36.3% of patients on placebo, etoricoxib 90 mg, etoricoxib 120 mg, and ibuprofen, respectively.ConclusionsPostoperative use of etoricoxib 90 and 120 mg in patients undergoing total knee replacement is both superior to placebo and non-inferior to ibuprofen in reducing pain at rest and also reduces opioid (morphine) consumption.Clinical trial registrationNCT00820027

Caesarean section wound infiltration with ropivacaine versus placebo: Survey of chronic pelvic pain after 4 years' follow-up

Objective. To test the hypothesis that optimal management of postoperative pain may reduce the risk of developing chronic pelvic pain in women who undergo caesarean section. Methods. In a randomised trial in 2006/2007, ropivacaine was infiltrated through all the layers of the anterior abdominal wound in patients undergoing caesarean section. The outcome was a reduction in severe pain or the need for rescue narcotic analgesia within 1 hour after the operation in the ropivacaine group compared with a placebo group (relative risk 0.51; 95% confidence interval 0.38 - 0.69). A follow-up study 4 years later was designed to assess the prevalence of chronic pelvic pain by carrying out telephonic interviews with these women, of whom 77 were contactable and 75 were analysed. Data and statistical analysis were done using Microsoft Excel (2007), Epi Info (version 343) statistical and Review Manager 5 software. Results. Three out of 40 women in the ropivacaine group and 3/35 in the placebo group had persistent pelvic pain (total rate of chronic pelvic pain 8.1%). Conclusion. There was no significant difference in the prevalence of chronic pelvic pain between the ropivacaine wound infiltration group (7.5%) and the placebo group (8.6%) after 4 years’ follow-up.

The effect of anesthesia choice on post-operative outcomes in women undergoing exploratory laparotomy for gynecologic malignancy.

e20571 Background: The goal of this study is to examine how regional anesthesia choice in women undergoing laparotomy for gynecologic malignancy affects their pain and hospital stay. Methods: This single-institution retrospective review studied women undergoing exploratory laparotomy for suspected gynecologic malignancy from May to January 2013. Patients were in 1 of 3 groups: patient controlled analgesia (PCA), transversus abdominis plane (TAP) blocks with PCA or transthoracic epidural. Narcotic use and pain scale during the first 3 days after surgery, length of surgery, complications and length of postoperative stay were compared. P-values of &lt;0.05 are considered significant. Results: One hundred twelve women were included (44 PCA, 30 TAP + PCA, 38 epidural). Those receiving TAP or epidural tended not to use narcotic prior to surgery, though not a statistically significant result. The length of surgery and estimated blood loss were not different between groups; however, the rate of intra-operative complications differed by pain management method (p=0.020), with those who received an epidural had the lowest rate. In the epidural group, median IV narcotic use (mg) was significantly decreased for the first three post-surgical days (day 1 p =0.014; day 2 p &lt;0.0001; day 3 p = 0.048). Those with epidurals also had significantly lower pain scales on the second and third post-operative days compared to those with TAP or PCA alone (day 2: p=0.046; day 3: p =0.008). After adjusting for age and complications arising both during and after surgery, TAP placement increased the length of hospital stay slightly by 0.35 days (95% CI: 0.07-0.62 days, p=0.014). Conclusions: The use of epidural anesthesia for post-operative pain management in surgery for gynecologic malignancy decreases narcotic analgesia use and improves pain scale measurements without increasing complications or length of hospital stay. Further investigation with prospective randomized trials is warranted to elucidate the optimal post-operative pain management technique.

Exploring influencing factors of postoperative pain in school‐age children undergoing elective surgery

The purpose of this study was to examine the influencing factors of postoperative pain among children undergoing elective surgery. A survey was conducted in 2011 with a convenience sample of 66 children, 6 to 14 years old, in a tertiary hospital in Singapore. Children experienced moderate preoperative anxiety and postoperative pain. Gender, preoperative anxiety, and negative emotional behaviors were significant influencing factors for postoperative pain. Boys reported less postoperative pain than girls. Effective strategies for assessing and managing children's preoperative anxiety are needed to achieve an optimal postoperative pain management outcome.

Procedure-specific Pain Management

Procedure-specific Pain Management