Pain Management In Surgical Patients Research Articles

Trends of Opioid Usage in Surgical Patients in a Small Community Hospital: Analysis of Patient Data Between 2017 and 2021.

Purpose: The purpose of our study was to quantify and analyze the annual opioid usage in surgical patients at Wood County Hospital (WCH) between 2017 and 2021. Methods: In this retrospective study, patient data between 2017 and 2021 was analyzed to determine the oral morphine milligram equivalent (MME) of opioids used in surgical patients at WCH. Annual MME prescribed per admission was compared each year using one-way ANOVA followed by Tukey post hoc test. Similarly, the annual use of intravenous (IV) acetaminophen for surgical patients per admission was also calculated and analyzed using the one-way ANOVA followed by Tukey post hoc test. Results: Compared to the year 2017 (42.0 ± 3.6), a statistically significant decrease in opioid usage per surgical admission (mean±SEM of MME) was observed during the years 2018 (32.6 ± 1.4; P = .04), 2019 (30.4 ± 1.2; P = .01), and 2021 (30.8 ± 1.9; P = .01). An analysis of individual opioid use revealed a trend toward lower fentanyl and hydromorphone usage each year since 2017. A significant decrease in the annual morphine usage (mean±SEM of MME) for surgical patients was observed during both 2020 (14.4 ± 0.9; P = .05) and 2021 (14.0 ± 0.7; P = .05) compared to the year 2017 (22.1 ± 2.4). Finally, compared to the year 2017, a statistically significant decrease (P < .05) in the annual use of oxycodone (MME) and IV acetaminophen (mg) for pain management in surgical patients was observed from 2018 to 2021. Conclusion: Our analysis reveals a significant decrease in opioid usage per surgical admission at WCH over 2017 to 2021 indicating a positive impact of the various opioid stewardship measures implemented at the hospital.

Perioperative Pain Management for Surgical Patients with Opioid Use Disorder: A Program Development Initiative

PurposeOver the last decade an increased number of individuals have been diagnosed with Opioid Use Disorder (OUD) and state-level regulatory pressure has mounted to develop the capability to provide opioid-free anesthesia (OFA) on clinical indication or at patient request. DesignA program initiative for OUD patients who require OFA was developed and implemented in two phases. MethodPhase I assessed the needs and knowledge of licensed nurse anesthetists in the state of Florida. Phase II recruited volunteers for a day-long event which involved both didactic and simulation training. Data collection for phase II included: demographics, knowledge, evidence-based practice belief scale (EBPBS), and evidence-based practice implementation scale (EBPIS) which measures the perceived ability to implement those beliefs. Phase II training was divided into three domains: Preoperative, Intraoperative and Postoperative with didactic and simulation experiences for each domain. FindingsThe phase II participants pre-simulation median total knowledge assessment score was 9 with median scores of 5 for questions 1 to 6 and 4 for questions 7 to 12. After participating in simulation, median knowledge assessment scores increased to 11, with median scores of 6 for questions 1 to 6 and 5 for questions 7 to 12. Before simulation training, median scores for the EBPBS and EBPIS were 66 (IQR 8) and 22 (IQR 24) respectively. After simulation, the median EBPBS score increased to 76 (IQR 7.5), a significant improvement from pre-simulation (P = .002). ConclusionThere is a lack of knowledge and training of anesthesia providers on how to manage the growing population of patients with OUD. This program initiative increased perceived ability to provide OFA care to patients with OUD presenting for surgery.

An interdisciplinary approach to safe opioid prescribing and administration for surgical patients at an academic medical center.

To explore and understand the current practice, perceptions, and knowledge of general surgery trainees, advanced practice providers, and surgical nurses regarding opioid prescribing and administration. To this end, a novel opioid education and training was introduced to educate these practitioners on safe opioid practices in surgical patients. National awareness of the opioid epidemic has increased significantly in the last several years. However, there remain a disturbingly high number of opioid prescriptions written in the US indicating a need for improved provider and nurse education. This involves increasing awareness and understanding of national guidelines as well as implementing multi-modal therapy to treat pain. Pre-post-intervention quality improvement project. An opioid education and training involving a morphine equivalent daily dosing calculator in the electronic medical record was provided to 26 surgical trainees, eight advanced practice providers and 97 surgical nurses in November 2019. Perceptions, current practice and knowledge were measured using a pre- and post-intervention survey (SQUIRE checklist). The survey results showed a positive clinical change in perception of opioid use in surgical patients following the intervention and a modest decrease in the average morphine equivalent daily dosing at discharge in general and transplant surgery patients. Effective pain management for surgical patients must be individualised. Safe opioid prescribing should involve an interdisciplinary approach with all members of the team undergoing assessment of their opioid knowledge and prescribing habits, easily accessible training tools and opioid calculators in the electronic medical record. Our initiative may provide useful information to settings that replicate use of a morphine equivalent daily dosing calculator in the electronic medical record. Utilisation of safe opioid prescribing tools in the electronic medical record and continuing education for providers and nurses can help ensure the safety of surgical patients.

Trends in Pain Medication Prescriptions and Satisfaction Scores in Spine Surgery Patients at a Single Institution.

As the opioid crisis has gained national attention, there have been increasing efforts to decrease opioid usage. Simultaneously, patient satisfaction has been a crucial metric in the American health care system and has been closely linked to effective pain management in surgical patients. The purpose of this study was to examine rates of pain medication prescription and concurrent patient satisfaction in spine surgery patients. A total of 1729 patients undergoing spine surgery between June 25, 2017, and June 30, 2018, at a single institution by surgeons performing ≥20 surgeries per quarter, with medication data during hospitalization available, were assessed. Patients were evaluated for nonopioid pain medication prescription rates and morphine milligram equivalents (MME) of opioids used during hospitalization. Of the total cohort, 198 patients were evaluated for Press Ganey Satisfaction Survey responses. A χ2 test of independence was used to compare percentages, and 1-way analysis of variance was used to compare means across quarters. The mean total MME per patient hospitalization was 574.46, with no difference between quarters. However, mean MME per day decreased over time (P = .048), with highest mean 91.84 in Quarter 2 and lowest 77.50 in Quarter 4. Among all procedures, acetaminophen, nonsteroidal anti-inflammatory drugs, and steroid prescription rates increased, whereas benzodiazepine and γ-aminobutyric acid-analog prescriptions decreased. There were no significant differences between quarters for mean hospital ratings (P = .521) nor for responses to questions from the Press Ganey Satisfaction Survey regarding how often staff talk about pain (P = .164), how often staff talk about pain treatment (P = .595), or whether patients recommended the hospital (P = .096). There were also no differences between quarters for responses in all other patient satisfaction questions (P value range, .359-.988). Over the studied time period, opioid use decreased and nonopioid prescriptions increased during hospitalization, whereas satisfaction scores remained unchanged. These findings indicate an increasing effort in reducing opioid use among providers and suggest the ability to do so without affecting overall satisfaction rates. 4. The opioid epidemic has highlighted the need to reduce opioid usage in orthopedic spine surgery. This study reviews the trends for inpatient management of post-op pain in orthopedic spine surgery patients in relation to patient satisfaction. There was a significant increase in non-opioid analgesic pain medications, and a reduction in opioids during the study period. During this time, patient satisfaction as measured by Press-Ganey surveys did not show a decrease. This demonstrates that treatment of post-operative pain in orthopedic spine surgery patients can be managed with less opioids, more multimodal analgesia, and patient satisfaction will not be affected.

An allometric pharmacokinetic model and minimum effective analgesic concentration of fentanyl in patients undergoing major abdominal surgery

BackgroundWe aimed to characterise the population pharmacokinetics of fentanyl in adults and to determine the minimum effective concentration (MEC) and minimum effective analgesic concentration (MEAC) of i.v. fentanyl in patients after major abdominal open surgery. MethodsIn the pharmacokinetic study, subjects received an intravenous bolus of fentanyl 100 μg during operation, and arterial blood was sampled at pre-set intervals. In addition, data from previously published fentanyl pharmacokinetic studies were incorporated to build a pharmacokinetic model. In the MEAC study, subjects were asked to rate their pain every 10 min using a VAS (0=no pain, 10=most severe pain) in the PACU. The first blood sample was obtained when wound pain was rated as ≥3 at rest or ≥5 during compression. Then, fentanyl 50 μg was administered every 10 min until the pain intensity had decreased to <3 at rest and <5 during compression, at which point the second blood was sampled and the first MEAC of fentanyl was measured. The same procedure was repeated to obtain a third sample (MEC) and a fourth sample (second MEAC). ResultsIn the population pharmacokinetic study (n=95), the plasma concentration of fentanyl over time was well-described by the three-compartment mammillary model using an allometric expression. The V1, V2, V3, Cl, Q1, and Q2 of a 70 kg subject were 10.1, 26.5, 206 L, 0.704, 2.38, and 1.49 L min−1, respectively. In the MEAC study (n=30), the median (inter-quartile range) MEC and MEAC were 0.72 (0.58–1.05) ng ml−1, and 0.99 (0.76–1.28) ng ml−1, respectively. ConclusionThese results provide a scientific basis for the use of fentanyl for acute postoperative pain management in surgical patients. Clinical trial registrationKCT0003273 (http://cris.nih.go.kr).

A comprehensive model for pain management in patients undergoing pelvic reconstructive surgery: a prospective clinical practice study

Postoperative opioid prescription patterns play a key role in driving the opioid epidemic. A comprehensive system toward pain management in surgical patients is necessary to minimize overall opioid consumption. This study aimed to evaluate the efficacy of a pain management model in patients undergoing pelvic reconstructive surgery by measuring postdischarge narcotic use in morphine milligram equivalents. This is a prospective clinical practice study that included women undergoing inpatient pelvic reconstructive surgery from December 2018 to June 2019 with overnight stay after surgery. As a routine protocol, all the patients followed an enhanced recovery after surgery protocol that included a preoperative multimodal pain regimen. Brief Pain Inventory surveys were collected preoperatively and on postoperative day 1. Brief pain inventory and activities assessment scale scores were collected at postoperative week 1 and postoperative weeks 4-6 after surgery. Patients were discharged with 15 tablets of an oral narcotic using an electronic prescription for controlled substances software platform, which is mandated in the state of Connecticut for all controlled substances, prescriptions, and refills. Patients were called at postoperative week 1 and postoperative weeks 4-6 to answer questions regarding their pain, the number of remaining narcotic tablets, and patient satisfaction regarding pain management. Patient electronic medical records and the Connecticut Prescription Monitoring and Reporting System were reviewed to determine whether patients received narcotic refills. Primary outcome was postdischarge narcotic use measured in morphine milligram equivalents. Secondary outcomes evaluated refill rate, brief pain inventory and activities assessment scale scores, and patient satisfaction with pain management. Descriptive statistics were described as mean and standard deviation and median and interquartile range. Bivariate comparisons used Spearman's rho (ρ) with α=0.05. A total 113 patients were enrolled; the median (interquartile range) morphine milligram equivalent prescribed (including refills) was 112.5 (112.5-112.5). The median postdischarge narcotic use was 24.0 (0-82.5) morphine milligram equivalent, which is equivalent to fewer than 4 oxycodone (5 mg) tablets. About 75% of our participants required fewer than 11 oxycodone tablets. The median unused morphine milligram equivalent was 90.0 (45-112.5). 81.4% (92/113), and 83.2% (94/113) of patients at postoperative week 1 and postoperative weeks 4-6, respectively, reported being satisfied or extremely satisfied with their postdischarge pain control. About 88.5% (100/113) of patients felt that the number of opioids they were discharged with was sufficient for their pain needs at the postoperative 1 and postoperative weeks 4-6 time points. At postoperative weeks 4-6, 19.5% of patients said that they filled the narcotic prescription but did not use any of the pills. The overall refill rate was 10.6% (12/113). All patients who needed a refill described the refill process as easy. In-hospital narcotic use was not predictive of postdischarge narcotic use (ρ0.065, P=.495). Patients reported median brief pain inventory scores for "average pain" of 0 (no pain) at postoperative week 1 and postoperative weeks 4-6; however, the scores did not clinically correlate with postdischarge narcotic use. Activities assessment scale scores were not correlated with postdischarge narcotic use. Most patients after pelvic reconstructive surgery used fewer than 11 oxycodone (5 mg) tablets, averaging less than 4 tablets, with a third of patients not requiring any opioids. Pain and activities scores did not correlate with narcotic use. A minimal number of opioids can be prescribed because the secure electronic prescribing system allows for convenient electronic refill if required. Our practical and comprehensive pre- and postoperative protocol for pain management minimizes opioid consumption in addition to maximizing patient satisfaction.

The Assessment of Pain and the Quality of Postoperative Pain Management in Surgical Patients

The aim of the study was to investigate surgical patients’ pain experience and the quality of nursing care in managing acute postoperative pain. A descriptive cross-sectional study using a Strategic and Clinical Quality Indicators in Postoperative Pain Management Questionnaire collected data of 247 patients who underwent surgery in the surgical clinics of a state hospital. Data of 141 patients were included in the analysis. The mean scores for the scale items indicated that the quality of care was acceptable or low. The level of postoperative care, nursing interventions, and environmental subscales of the questionnaire were at an acceptable level, but pain management subscales of the questionnaire were low. These results suggest that health care, including measurable, applicable quality indicators, should be planned and evaluated to maintain professional nursing services, to achieve postoperative pain management and to relieve pain.

P47. Trends in pain medication prescriptions and satisfaction scores in spine surgery patients at a single institution

BACKGROUND CONTEXT As the opioid crisis has gained national attention, there has been an increasing effort to decrease opioid usage. Simultaneously, patient satisfaction is a crucial metric in the American health care system, and has been closely linked to effective pain management in surgical patients. PURPOSE Examine rates of pain medication prescription and concurrent patient satisfaction in spine surgery patients. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE A total of 1,729 patients undergoing any spine surgery. OUTCOME MEASURES Rates of non-opioid pain medication prescriptions during hospitalization as part of a multimodal analgesia regimen, morphine milligram equivalents (MME) of opioids used during hospitalization, Press Ganey Satisfaction Survey data. METHODS Patients ≥18yo undergoing spine surgery between 6/25/2017-6/30/2018 at a single institution by spine surgeons performing ≥20 surgeries/quarter and who had medication data during hospitalization available included. Additional data collected included physician and procedure type. All data analyzed by quarter. Chi-squared test to compare percentages and ANOVA to compare means across quarters. Multivariate regression used to compare procedure-specific trends, controlling for age, revision and level of pain. Significance set at p RESULTS A total of 1,759 patients were included, 427 in Quarter 1 (Q1), 439 in Q2, 453 in Q3 and 440 in Q4. Mean total MME per patient hospitalization was 574.46, no significant difference between quarters (p=0.116). Mean MME/day per patient decreased between quarters (p=0.048), with highest mean 91.84 in Q2 and lowest 77.50 in Q4. From Q1 to Q4, three physicians had decreased mean MME/day (75.47→50.92, p=0.023; 115.70→46.05, p=0.013; 92.89→69.53, p=0.42, respectively) and two physicians had decreased total MME (815.88→243.15, p=0.004; 706.79→451.72, p=0.014, respectively). MME/day decreased (74.78→52.37, p=0.046) for discectomy cases. Controlling for age, revision and level of pain, total MME decreased for discectomies (p=0.006). Among all procedures, acetaminophen, NSAID and steroid prescription rates increased (9.13%→17.05%, p=0.001; 6.32%→9.77%, p=0.048; 9.13%→17.05%, p=0.001, respectively). This was also the case in fusion patients specifically (9.09%→17.99%, p=0.002; 2.77%→5.76%, p=0.024; 9.09%→17.99%, p=0.002, respectively). NSAID prescription in laminectomy patients also increased (3.23%→4.89%, p=0.041). Concurrently, benzodiazepine and GABA analog prescriptions decreased among all procedures (19.20%→10.68%, p CONCLUSIONS Over the studied time period, opioid use decreased and nonopioid prescriptions increased during hospitalization, while satisfaction scores remained unchanged. These findings indicate an increasing effort in reducing opioid use amongst providers, and suggest the ability to do so without impacting overall satisfaction rates. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Oxycodone/naloxone in postoperative pain management of surgical patients.

The role of analgesia is crucial in the management of postoperative pain. Different combinations of oral analgesics have been proposed in the past. The oxycodone/naloxone (OXN) combination is a recent addition and is being used by different surgical specialties. The aim of our study was to clarify the possible role, advantages, and disadvantages of OXN in the pain management of surgical patients. The authors retrieved the included studies after performing a systematic search in PubMed and Scopus. Ten studies (six randomized controlled trials, three retrospective studies, and a prospective study) were eligible for inclusion in this review. In total, 1,996 patients were included. Six studies reported on orthopedic procedures while four studies referred to colorectal, gynecologic, cardiac, and thoracic surgery procedures, respectively. The analgesic effect of OXN was evaluated in nine out of 10 studies, where OXN showed superiority only in two out of nine studies. Postoperative bowel function was evaluated in seven out of 10 studies. Patients treated with OXN did not show any significant differences in bowel function when compared to control groups. No superiority was found regarding the possible adverse events. Analgesia is crucial to postoperative recovery. Pain control can be achieved a combination of different analgesics, including OXN. This oral analgesic combination can have the potential to minimize side effects, such as opioid-induced constipation and optimize the recovery period.

The American Opioid Epidemic: Population Health Implications and Potential Solutions. Report from the National Stakeholder Panel.

The American Opioid Epidemic: Population Health Implications and Potential Solutions. Report from the National Stakeholder Panel Janice L. Clarke, RN, Alexis Skoufalos, EdD, and Richard Scranton, MD, MPH Editorial: David B. Nash, MD, MBA S-1 Introduction S-1 The Evolution of Opioid Use in the United States S-2 Unintended Consequences of Postsurgical Pain Management S-2 Pivotal Role of Postsurgical Prescribing Practices S-3 • Population health and societal implications S-4 The Case for Multimodal Pain Management for Surgical Patients S-4 Optimizing Health Outcomes S-4 • Emerging profile of opioids: pros and cons S-5 • Planning for perioperative pain S-5 • Minimizing risk of postsurgical overuse and misuse of opioids S-5 Optimizing Economic Outcomes by Managing Pain Differently S-6 Expert Panel Insights S-7 Conclusion S-7

Impact of beliefs about pain control on perceptions of illness in surgical patients.

Adequacy of pain management in surgical patients is a major contributor to overall treatment outcomes and positive illness perceptions. However, it may be subjectively predetermined by a patient's beliefs about pain control. This study assesses the relationships between beliefs about pain control and perceptions of illness in thoracic surgical patients. A total of 135 patients (72 women and 63 men; mean age 58.4±14.25y) were enrolled in the questionnaire study based on the Beliefs about Pain Control Questionnaire (BPCQ) by S. Skevington and the Multidimensional Essence of Disease and Illness Scale (MEDIS) by J. Sak. Analyses were conducted with use of the k-means clustering technique and one-way ANOVA. Applied classification revealed 3 different clusters of patients with regard to their beliefs about pain control: 1) weak, undifferentiated pain control; 2) intensified influence of chance pain control; 3) strong undifferentiated pain control. Significant differences in illness perceptions between clusters were disclosed in 3 MEDIS dimensions: self-realization constraints (F=4.70; p=0.01; 1 vs. 3), mental dysfunction (F=3.44, p=0.04; 1 vs. 3) and physical dysfunction (F=3.10, p=0.05; 1 vs 2). Patients in cluster 3 demonstrated a greater feeling of self-realization constraints and mental dysfunction than in cluster 1, whereas patients in cluster 2 perceived physical dysfunction as a greater distress than those in cluster 1. Beliefs about pain control significantly influence illness perceptions, and thus may affect the results of treatment in surgical patients. Psychological modelling of beliefs about pain control may offer a valuable way to improve overall clinical outcomes.

The Efficacy of Continuous Local Anesthetic Infiltration in Breast Surgery: Reduction Mammaplasty and Reconstruction

Pain control after reduction mammaplasty and breast reconstruction with tissue expanders often requires intravenous narcotic analgesia and inpatient hospitalization. Regional and local anesthetic techniques are increasing in popularity because they decrease the use of intravenous analgesic medications and offer comparable pain relief without the systemic side effects. This study examined the use of indwelling catheters for the continuous infiltration of local anesthetic (bupivacaine) in 74 consecutive breast reduction and 74 consecutive tissue expander breast reconstruction patients. Patients entering the study before February of 2003 had conventional methods of analgesia (39 patients for each group), whereas those entering afterwards received the infusion pumps (35 patients for each group). The number of hospital admissions among the breast reduction patients with infusion pumps was significantly less than that for those without pumps (p < 0.01). Pain, measured on a verbal response scale of 0 to 10, while in the recovery room was significantly less in the pain pump group than in the comparison group (p < 0.01), as were cumulative amounts of pain medications (p < 0.01). There were no statistically significant differences in the number of complications or in the rate of nausea or vomiting. The number of inpatient days among the tissue expander reconstruction patients with infusion pumps was not significantly different from that for those without pumps; the average pain score was significantly lower (p < 0.01). The cumulative amounts of pain medication in patients receiving the infusion pump were significantly lower than those in patients without the pumps (p < 0.01). There were no statistically significant differences in the number of complications or in the rate of nausea or vomiting. There were no tissue expander infections in patients with the indwelling catheters adjacent to the implant. The continuous infiltration of local anesthetic with an infusion pump represents another tool for pain management in surgical patients.

Pain management—Continuum of care for surgical patients

A pain management process improvement team was created to develop a unified and consistent way to address pain management for surgical patients. Team members evaluated patient satisfaction ratings, patient and family member education, use of specific pain scales, patient comfort function goals, staff member education, and use of physician standing orders and protocols. Team members were proactive in their efforts to improve pain management outcomes for surgical patients and to improve patient satisfaction. They also integrated protocols to comply with pain management standards established by the Joint Commission on Accreditation of Healthcare Organizations.

Changing Acute Pain Management Outcomes in Surgical Patients

Patient outcome studies indicate that patients accept pain as part of hospitalization. The majority of hospitalized patients who report experiencing pain are recovering from surgical intervention. To achieve successful outcomes, a comprehensive multidisciplinary effort must begin preoperatively and continue through discharge. The perioperative period is an essential link in effective pain management, and perioperative nurses are key in helping direct the care of surgical patients before, during, and after surgical procedures. Pain relief and the patients satisfaction with care frequently are used to measure pain management outcomes. This article examines the results of a secondary analysis of a subset of surgical patients drawn from a larger data set that was collected during two studies in urban and rural hospitals. It focuses on two outcomes, namely characteristics of pain and patient satisfaction with pain management after surgery. These outcomes were measured using the American Pain Society patient outcome questionnaire and the pain management index. Correlational, descriptive, and regression analyses indicate that postoperative management of patients' pain in these studies was less than optimal. From this new understanding, strategies for effective pain management of surgical patients are recommended.