Postoperative Pain Management Protocol Research Articles

Feasibility and Analgesic Efficacy of Thoracolumbar Dorsal Ramus Nerve Block Using Multiorifice Pain Catheters for Scoliosis Surgery: A Prospective Cohort Study.

Approximately 38,000 scoliosis surgery correction operations are performed annually in the United States; these operations are associated with considerable postoperative pain which can be difficult to manage. This is largely attributed to an incision spanning multiple vertebral segments with paraspinal muscle dissection and retraction to facilitate the implantation of segmental hardware and rods. Frequently utilized analgesic modalities include intravenous patient-controlled analgesia and epidural analgesia, often in combination. We sought to ascertain the feasibility and analgesic efficacy of continuous thoracolumbar dorsal ramus nerve (TDRN) block using surgically placed multiorifice catheters. Forty-two patients diagnosed with idiopathic scoliosis who underwent a posterior spinal fusion (PSF) were enrolled after consent was obtained. Patients were managed utilizing a standardized Enhanced Recovery After Surgery) protocol including a perioperative opioid-sparing regimen. Data were collected at specified time intervals during the recovery period. These data points included pain scores using the Numeric Rating Scale. Parenteral or both oral and parenteral opioid consumption doses were also collected every 4 hours. Any significant postoperative adverse events were recorded as well. A total of 42 patients had surgically placed TDRN catheters, and 40 patients were included in this study. The patients all reported low to moderate pain scores with low opioid consumption postoperatively, while the TDRN catheter delivery of local anesthetic analgesics did not result in significant complications. A regional technique utilizing TDRN catheters could be a valuable component of the postoperative pain management protocols for PSF surgery, and additional studies are warranted. This study evaluated the feasibility and analgesic efficacy of TDRN catheters for postoperative pain control following multilevel PSF for idiopathic scoliosis. Continuous local anesthetic delivery through TDRN catheters is a feasible and safe technique for postoperative pain control in these patients. Selective blockade of the dorsal rami might have benefits over epidural analgesia or other regional techniques.

The Efficacy of the Combination of Continuous Femoral Nerve Block and Intravenous Parecoxib on Rehabilitation in Patients Undergoing Total Knee Arthroplasty: A Double-Blind, Randomized Clinical Trial.

The optimal strategy for the management of postoperative pain after total knee arthroplasty (TKA) remains challenging, while its treatment is crucial to increase patients' outcomes. This study aimed to investigate the effects of parecoxib as add-on therapy, in a standard postoperative pain management protocol, represented by the continuous femoral nervous block. We studied its influence on rehabilitation indices and pain scoresin patients undergoing TKA. This is a single-center, prospective, double-blind, randomized, placebo-controlled trial. All patients were operated with the use of subarachnoid anesthesia, and divided into two groups for postoperative analgesia. Both groups received a continuous femoral nerve block. One of the groups received intravenous parecoxib, while the other received a placebo. The primary investigated outcome was the range of motion (ROM). Recordings were noted at different times postoperatively. Bromage score (BS), visual analogscale (VAS), and the State-Trait Anxiety Inventory (STAI) were also studied. A total of 90 patients were included and analyzed. ROM was significantly better (p<0.001) and pain scores were significantly lower (p=0.007) in the parecoxib group. No statistically significant difference was found with regardto BS between the two groups. A significant correlation was found between ROM and VAS pain scores at 12 hours (p=0.02), while ROM was inversely correlated with STAI postoperatively. The use of intravenous parecoxib is effective in improving rehabilitation indices and provides decreased postoperative pain scores after TKA.

Addition of Surgeon-Administered Adductor Canal Infiltration to the Periarticular Infiltration in Total Knee Arthroplasty: Effect on Pain and Early Outcomes

BackgroundOur aim was to study the additive effect of surgeon-administered adductor canal infiltration (SACI) over routine periarticular infiltration (PAI) on pain control [morphine consumption and pain score by the visual analog scale (VAS)] and early function [flexion and Timed Up and Go (TUG) test] post–total knee arthroplasty (TKA). MethodsWe prospectively randomized 60 patients into 2 groups. Group I patients received the standard PAI, whereas in Group II, the patients received a SACI in addition to the PAI. The total volume of the injected drug and the postoperative pain management protocol were the same for all. The number of doses of patient-controlled analgesia (PCA) used for breakthrough pain was recorded as PCA consumption. For early function, flexion and the TUG test were used. The VAS score and PCA consumption were compared between the 2 groups by using analyses of variance with post hoc tests as indicated. The TUG test and flexion were compared using Student t tests. The level of significance was set at 0.05. ResultsThe PCA consumption in the first 6 hours was significantly higher in Group I (P = .04). The VAS at 6 hours was significantly lower in Group II (P = .042). The TUG test was comparable between the 2 groups preoperatively (P = .72) at 24 hours (P = .60) and 48 hours (P = .60) post-TKA. The flexion was comparable between the 2 groups preoperatively (P = .85) at 24 hours (P = .48) and 48 hours (P = .79) post-TKA. ConclusionsAdding a SACI to PAI provides improved pain relief and reduces opioid consumption without affecting early function post-TKA. A SACI avoids the need for an anesthesiologist or specialized equipment with no added operating time and minimal added cost. We recommend routine use of SACI for all patients undergoing TKA.

The Effect of Postoperative Naloxone in Certain Otolaryngologic Surgeries.

To evaluate the association of postoperative naloxone with the development of new substance use disorder (SUD), overdose, and death within 6 months of otolaryngologic surgery. Retrospective cohort database study on TriNetX. Adult patients who underwent tonsil surgery (noncancerous), thyroid/parathyroid, septorhinoplasty, otology/neurotology, sinus/anterior skull base, and head and neckcancer surgeries between January 2003 and April 2023. Patients were excluded if they had an instance of SUD or overdose recorded in their charts prior to surgery, or had undergone another surgery within that 6-month time frame. We hypothesized that patients prescribed naloxone postoperatively would have decreased odds for experiencing new SUD, overdose, and/or death within 6months of surgery compared to patients who did not receive naloxone. P < .01 was considered statistically significant. There were 2,305,655 patients in this study. The average age was 36.7 ± 19.5 years old, with 46% female patients. Before matching, cohorts showed equivocal odds for developing new SUD, increased odds for overdose, and mixed odds for dying. After matching for demographic variables and comorbidities such as other substance use, opioid use for other pathologies, and psychiatric conditions, these effects diminished (P > .01). Our results suggest that postoperative naloxone may not significantly affect development of new SUD and incident overdose and death in certain otolaryngologic surgeries after controlling for prior SUD and psychiatric conditions. Clinicians should be aware of these comorbidities when considering their postoperative pain management protocol, which may or may not include naloxone.

Bupivacaine liposomal injectable suspension does not provide improved pain control in dogs undergoing abdominal surgery.

To evaluate the difference in postoperative pain scores of dogs undergoing abdominal surgery receiving surgical incision infiltration of saline or bupivacaine liposomal injectable suspension (BLIS). 40 dogs undergoing exploratory laparotomy. Dogs were prospectively enrolled and randomized to receive either BLIS or saline surgical incision infiltration. All dogs received 5.3 mg of BLIS/kg or an equal volume of saline infiltrated in the muscle/fascia, subcutaneous tissue, and intradermal layer during closure. All dogs received a standardized postoperative pain management protocol. Pain assessment was performed at select time points postoperatively by blinded observers with an electronic algometer, short version of the Glasgow Composite Measure Pain Scale (GCMPS), and indirect measures of pain, including systolic blood pressure, heart rate, and serum cortisol levels. At day 0, blood pressure was higher in the saline group (149.6 vs 125.8 mm Hg; P = .006). At day 3, GCMPS was lower in the BLIS group (BLIS = 1, saline = 2, P = .027), though both average GCMPS scores were low and only 10 dogs were available for day 3 assessments (6 BLIS and 4 saline). No other differences in algometer readings, GCMPS scores, other measured parameters, or need for rescue analgesia were present between BLIS and saline groups at any time point. There was no difference in postoperative incisional infection rate or complications. Use of BLIS for exploratory laparotomy did not provide improved pain control over postoperative opioid administration alone. Patients that received BLIS had no increase in short-term complications.

1304 Feasibility of Day-Case Laparoscopic Cholecystectomy in Paediatric Patients

Abstract Aim Standard approach for treatment of cholecystolithiasis is laparoscopic cholecystectomy (LC), however day-case laparoscopic cholecystectomy (DCLC) has not been established as standard procedure in paediatric population. This is to assess the feasibility and safety of DCLC in paediatric population focusing on post-operative outcomes as a measure of success and using a protocolised post-operative pain management approach. Method Data, which include demographics, surgeon (trainee/consultant), admission mode, length of stay, complications, and post-operative pain management as per hospital protocol were collected from the hospital database from 2016 to 2022. Patients who underwent DCLS were discharged within 23 hours. Telephone survey was conducted to investigate type and length of analgesia administered at home. Results 31 patients underwent LC with a day-case rate of 77%. 63% were female. Mean age was 11 years (3 - 16). Obesity and haemolytic disorders were present in 29% and 8%, respectively. 96% were elective admissions. 20% had ASA I, 48% ASA II and 32% ASA III. Post-operatively, opioids with paracetamol/ibuprofen were administered in 96%, and in 80% as post-discharge analgesia. Post-discharge analgesia was administered 1 - 7 days, and 28% used oral opioid analgesia at home up to 3 days. Post-operative complications were present in 2 patients - 1 infected umbilical wound and 1 persistent dyspepsia. Six months readmission rate was 8% due to hypogastric pain treated conservatively. After a 3-month follow-up, all the patients were discharged. Conclusions LC can be performed safely as a day case procedure with excellent outcomes using a standardised post-operative and post-discharge pain management protocol.

The Role of Liposomal Bupivacaine in Multimodal Pain Management following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis: Faster and Farther with Less Opioids.

Retrospective controlled cohort. To evaluate the effect of intraoperative liposomal bupivacaine (LB) infiltration on post-surgical pain management in adolescent idiopathic scoliosis (AIS) patients by analyzing postoperative opioid consumption, ambulation, and length of stay (LOS). Optimal postoperative pain control for AIS patients undergoing posterior spinal fusion (PSF) is challenging. Multimodal pain management protocols provide adequate analgesia while decreasing opioid consumption. LB was recently approved for pediatric patients; however, use in AIS patients is understudied. 119 consecutive patients with AIS who underwent PSF were included. Patients were divided into 2 groups: patients who received LB as erector spinae block in addition to the standard postoperative pain management protocol (Group A), and patients who received only the standard postoperative pain protocol (Group B). Oral morphine equivalents, intravenous opioid and valium consumption, pain scores (VAS), nausea/vomiting, ambulation distance and LOS were assessed. Group A experienced significantly lower total opioid consumption compared to Group B (44.5mg vs. 70.2mg). Morphine use was lower in Group A on post operative day (POD) 0, and oxycodone use was lower in Group A on PODs 1 and 2. There was a higher proportion of patients who used only oral opioids in Group A (81% vs. 41%). Of patients requiring any intravenous opioids, 79% did not receive LB. A significantly higher proportion of LB patients were discharged on POD 2 (55% vs. 27%); therefore, LOS was shorter for Group A. Group A ambulated further postoperatively. There were no differences in pain scores, valium requirements or nausea/vomiting. LB was associated with decreased total opioid use, shorter LOS, and improved ambulation in AIS patients undergoing PSF. Including LB in multimodal pain management protocols proved effective in reducing opioid use while increasing mobilization in the immediate postoperative period. III Retrospective controlled cohort.

Nurses’ Assessments Versus Patients’ Self-Assessments of Postoperative Pain: Knowledge and Skills of Nurses for Effective Pain Management

Postoperative pain is the most common form of acute pain. Nurses contribute to effective pain management with their knowledge and skills. The aims of this research were to examine differences between nurses' assessments and patients' self-assessments of postoperative pain, differences in the mentioned (self) assessments with respect to characteristics of both groups of respondents, and the correlation between the NRS and the VRS scale. The study included 103 nurses employed at a hospital and 103 patients treated in the surgical departments after the surgical procedures. Data were collected using the standardized Numerical rating scale (NRS) and Verbal rating score (VRS). The median of patients' self-assessments of pain intensity on the NRS scale was 4, while the nursing assessment of patients' pain was 3, with no significant difference (p = 0.083). No significant differences were found on the VRS scale between nurse assessments and patient self-assessments of current pain intensity. The pain was described as moderate by 35% of participants, including 35.9% nurses and 35% patients. Significant positive correlations were recorded between values on the VRS and NRS scales for nurses (Rho = 0.812; p < 0.001) and patients (Rho = 0.830; p < 0.001). The results of this study may have implications for the improvement of postoperative pain management protocols, with regular use of pain assessment scales and individualization of analgesic prescriptions.

Superior Transverse Atraumatic Reconstruction (STAR) approach provides a better-compared outcome to standard Direct Superior Approach (DSA): a matched, prospective comparative single-surgeon study

The Direct Superior Approach (DSA) is a muscle-sparing hip approach that does not protect the piriformis and the other short external rotators. We present a DSA modification we named STAR (Superior Transverse Atraumatic Reconstruction), which has DSA advantages but always preserves piriformis. Our study compared the early postoperative, radiological, and functional results of patients undergoing primary total hip arthroplasty (THA) through the STAR approach with a matched DSA group performed by a senior surgeon. Each group, DSA, and STAR included 200 elective primary unilateral THAs performed by the surgeon between 2016-2017 and 2020-2021, respectively. Patients were included in both groups using the same inclusion criteria. Both groups were matched for age and sex. The same postoperative pain management, chemoprophylaxis, and physiotherapy protocols were followed in both groups. Two independent orthopaedic surgeons performed the clinical and radiological follow-up. The STAR group had significantly lower mean incision length (p=0.042) and hospital stay (p=0.002) than the DSA group. The mean intraoperative blood loss (p=0.085) and the need for blood transfusion (p=0.228) were less for the STAR than the DSA group. The mean postoperative functional scores improvement was significantly higher for the STAR than the DSA group at the end of the first and third postoperative months. The STAR approach offers earlier functional improvement, shorter hospital stay and less transfusion need than DSA for patients undergoing primary THA. Both approaches showed a limited complication risk and an outstanding acetabular and femoral access enabling the procedure.

Postoperative Pain Management and Patient Satisfaction in an Indian Tertiary Care Centre-A Prospective Observational Study

Introduction: Despite various advancements over last two decades in pain medicine, post-operative pain remains inadequately addressed, even in a tertiary medical center. There are very limited studies addressing post-operative pain management in India. Few published studies have assessed post-operative pain, but only at 24 hours intervals, and utilising tools focusing on any one parameter of pain. Hence, a holistic assessment using four different pain assessment tools should be done to get a wider overview of the condition. Aim: To assess the intensity and severity of post-operative pain at 6, 12, 24 &amp; 48 hours postoperatively for patients undergoing surgery for orthopaedics, gastrointestinal, general surgery, obstetrics &amp; gynaecological ailments and patient satisfaction at 24 hours postoperatively. Materials and Methods: A prospective observational survey was conducted at a tertiary care centre of New Delhi from October 2020 to October 2021. Three scales were used to determine the status of post-operative pain at 6,12,24 and 48 hours followup. The three different pain scales were Numerical Pain Rating Scale (NRS-pain) static and dynamic, Global Perceived Effect (GPE) and Neuropathic Pain System Inventory (NPSI). Results: Total of 400 patients, with mean age of the study population was 43.26±4.98 years. Majority were males, 250 (60%) and of ASA Grade I, 208 (52%). Significant improvement was observed in the NRS pain score at each follow-up among those undergoing orthopaedic surgery, general surgery, and gynaecological procedures. Improvement in the mean GPE scale was only seen for orthopaedic surgeries. There was a significant neuropathic pain component observed in all the surgeries except gynaecological surgeries. Majority 321 (80.25%) had received information about their pain treatment but only 174 (43.5%) were satisfied with their pain treatment. Conclusion: A majority of the patients undergoing orthopaedic or general surgery, and gynaecological procedures had improvement in pain. This survey highlights the need for investigating future post-operative pain management protocols so that the intensity of post-operative pain, incidence of chronic persistent pain &amp; resulting suffering, as well as disability, can be minimised to a large extent.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

The Use of Liposomal Bupivacaine Intraoperatively Through a Superficial Cervical Plexus Blockade for Postoperative Pain Management for Carotid Endarterectomy: a Case Report

Abstract Currently, bupivacaine liposome injectable suspension (Exparel™, PACIRA BIOSCIENCES, INC., Tampa, Florida, USA) has approval by the Food and Drug Administration for the management of postoperative pain in various surgical patients. In this case report, we suggest the addition of introducing its use in surgical procedures involving the neck, specifically, patients undergoing carotid endarterectomy. The infiltration of liposomal bupivacaine into the superficial cervical plexus has proved to provide adequate pain relief for approximately 72 hours postoperatively discarding the use of other analgesics. Despite the findings, this calls for a larger study comparing the efficacy of different postoperative pain management protocols. Keywords: Liposomal Bupivacaine, Regional Anesthesia, Endarterectomy, Pain Management.

Effect of a Postoperative Multimodal Opioid-Sparing Protocol vs Standard Opioid Prescribing on Postoperative Opioid Consumption After Knee or Shoulder Arthroscopy

In arthroscopic knee and shoulder surgery, there is growing evidence that opioid-sparing protocols may reduce postoperative opioid consumption while adequately addressing patients' pain. However, there are a lack of prospective, comparative trials evaluating their effectiveness. To evaluate the effect of a multimodal, opioid-sparing approach to postoperative pain management compared with the current standard of care in patients undergoing arthroscopic shoulder or knee surgery. This randomized clinical trial was performed at 3 clinical sites in Ontario, Canada, and enrolled 200 patients from March 2021 to March 2022 with final follow-up completed in April 2022. Adult patients undergoing outpatient arthroscopic shoulder or knee surgery were followed up for 6 weeks postoperatively. The opioid-sparing group (100 participants randomized) received a prescription of naproxen, acetaminophen (paracetamol), and pantoprazole; a limited rescue prescription of hydromorphone; and a patient educational infographic. The control group (100 participants randomized) received the current standard of care determined by the treating surgeon, which consisted of an opioid analgesic. The primary outcome was postoperative oral morphine equivalent (OME) consumption at 6 weeks after surgery. There were 5 secondary outcomes, including pain, patient satisfaction, opioid refills, quantity of OMEs prescribed at the time of hospital discharge, and adverse events at 6 weeks all reported at 6 weeks after surgery. Among the 200 patients who were randomized (mean age, 43 years; 73 women [38%]), 193 patients (97%) completed the trial; 98 of whom were randomized to receive standard care and 95 the opioid-sparing protocol. Patients in the opioid-sparing protocol consumed significantly fewer opioids (median, 0 mg; IQR, 0-8.0 mg) than patients in the control group (median, 40.0 mg; IQR, 7.5-105.0; z = -6.55; P < .001). Of the 5 prespecified secondary end points, 4 showed no significant difference. The mean amount of OMEs prescribed was 341.2 mg (95% CI, 310.2-372.2) in the standard care group and 40.4 mg (95% CI, 39.6-41.2) in the opioid-sparing group (mean difference, 300.8 mg; 95% CI, 269.4-332.3; P < .001). There was no significant difference in adverse events at 6 weeks (2 events [2.1%] in the standard care group vs 3 events [3.2%] in the opioid-sparing group), but more patients reported medication-related adverse effects in the standard care group (32% vs 19%, P = .048). Among patients who underwent arthroscopic knee or shoulder surgery, a multimodal opioid-sparing postoperative pain management protocol, compared with standard opioid prescribing, significantly reduced postoperative opioid consumption over 6 weeks. ClinicalTrials.gov Identifier: NCT04566250.

Prospective Randomized Study Using Pharmacogenetics to Customize Postoperative Pain Medication Following Hip and Knee Arthroplasty.

The purpose of this study is to determine whether pharmacogenetic testing could be used to effectively customize postoperative pain medicine following total joint replacement. Buccal swabs were collected preoperatively from 107 patients. Pharmacogenetic testing was performed for genetic variants on a panel of 16 genes, including CYP2D6, CYP2C9, OPRM1, and CYP1A2, which affect the pharmacodynamics and pharmacokinetics of non-steroidal anti-inflammatory drugs and many opioids. Patients were randomized to a control group or custom group and blinded to their group. The control group was prescribed oxycodone, tramadol, and celecoxib for postoperative pain management. If any of those were not normally metabolized, they were not prescribed to the patients in the custom group, who were given an alternative drug (hydromorphone for narcotics, meloxicam for non-steroidal anti-inflammatory drugs). Patients recorded their pain level (0-10 numeric scale) and all medications taken daily for the first 10 days following surgery. Medication was converted to milligram morphine equivalents (MMEs). Genetic variations to medications in our standard postoperative pain management protocol occurred in 24 of the 107 patients (22.4%). The 10-day MME consumed by patients in the control group with genetic variants was 162.6 mg. Patients with variants who had custom postoperative medication consumed only 86.7 MME in the same timeframe (P= .126). The control group demonstrated a higher 10-day average pain level of 4.2 vs the custom group pain level of only 3.1 (P < .05). With custom postoperative pain prescriptions based on pharmacogenetic testing, patients were able to achieve lower pain levels while reducing the consumption of pain medication.

What's New in Spine Surgery.

What's New in Spine Surgery.

Acute postoperative pain management protocols in podiatric surgery within Australia: a Delphi study

BackgroundThere is limited evidence in the literature to describe an analgesic protocol that takes into consideration the extent of foot and ankle surgery. The aim of this study was to develop a guide for acute postoperative pain management for podiatric surgery in Australia, and to identify opportunities to improve the current list of scheduled medicines available to podiatric surgeons.MethodsA Delphi method involving 3 survey rounds was employed for this study. Twelve expert panellists in the field of podiatric surgery and anaesthesiology were invited to participate, and 10 panellists remained by the end of the study. Round 1 involved 15 open-ended questions. These answers formed the basis of the 55 statements that were developed for the following 2 survey rounds, where panellists rated the appropriateness of each statement on a 9-point Likert scale. The third survey round was an opportunity for panellists to revise their answers to each statement in light of the majority response.ResultsFor mild acute postoperative pain, non-opioid oral analgesics were recommended as an appropriate management option. For moderate and severe acute postoperative pain, both non-opioid and opioid products were found to be appropriate by the majority. It was agreed that oral opioids be reserved for breakthrough pain at all severity levels. All other statements in the Delphi study pertaining to drug hypersensitivities or allergies, stratification of pain management, opioid prescription concerns, and access to pain medications were accepted as appropriate by the majority of panellists.ConclusionThe agreed approach to acute postoperative pain management for podiatric surgeons in Australia was with a stepwise approach, utilising multimodal therapy, and reserving oral opioids for breakthrough pain. Additionally, there was consensus for podiatric surgeons in Australia to have wider access to alternative analgesics and anti-emetics that have similar or improved efficacies with better safety profiles.

Diffusion of Successful Same Day Discharge Practice for Total Joint Arthroplasty Patients to a Select Population of Mastectomy Patients

<h3>Background Information</h3> Reimbursement guided by the Centers for Medicare & Medicaid Services (CMS) inpatient-only list continues to evolve with advancements in technology, care and coordination. Hospitals face business and quality imperatives of adjusting care pathways to allow for safe, high quality discharge of surgical patients earlier than ever. A 171-bed community teaching hospital in the northeast United States wanted to develop a novel care pathway to discharge patients undergoing mastectomy without reconstruction from the post anesthesia care unit (PACU) on the day of surgery. Current practice was to discharge them from the post-op floor. With the recent success of a novel pathway for same day discharge of joint replacement patients developed on this unit, staff were quickly able to translate effective practices to this new population. <h3>Objectives of Project</h3> To develop and implement a novel care pathway to discharge same day mastectomy without reconstruction patients from the PACU while maintaining high quality and patient satisfaction. <h3>Process of Implementation</h3> Following the leadership decision to initiate PACU discharge of select mastectomy patients, a PACU nurse champion was named. She identified needed changes and collaborated with multiple members of the interdisciplinary team to create a novel care pathway. Enhancements put in place included a new standard order set developed in collaboration with the surgical Advanced Practice Provider (APP) to support top of license nursing practice, customization within the electronic health record to clarify discharge materials for patients, collaborating with the Chief of Anesthesia to develop and disseminate a post-operative pain management protocol and a dedicated physical therapy pager and space to facilitate the most efficient care. <h3>Statement of Successful Practice</h3> Since June 2020, 3 patients have been discharged via the PACU pathway. None have required change to the traditional pathway. Mean length of stay has decreased for this population from overnight stay to approximately 6 hours. Patient and surgeon satisfaction for this group is high and there has been no impact to quality metrics. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> The successful implementation of PACU discharge of mastectomy patients is a result of PACU nurses leading collaborative innovation. As organizations across the country explore options to decrease length of stay, PACU nurses will play an important role in addressing strategic initiatives by embracing novel care pathways.

Evaluation of an opioid restrictive pain management initiative in adult kidney transplant recipients.

Evidence to guide opioid utilization following kidney transplantation is lacking. The purpose of this study is to evaluate the implementation of an opioid restrictive post-operative pain management protocol in adult kidney transplant recipients. We analyzed patients who underwent kidney transplant between 1/1/2017 to 8/15/2018. A standardized, opioid restrictive pain management protocol was implemented in February 2018. The primary outcome was quantity of opioid tablets prescribed at discharge. Secondary outcomes included amount of opioid prescribed within first 30days, number of patient calls for pain, and opioid prescription in electronic medical record (EMR) at 90days and 1year. After implementation, significantly fewer opioid tablets were prescribed at discharge (4 vs. 60 tablets, p<.001) and less oral morphine milligram equivalence (OME) were prescribed within 30days of transplant (38 vs. 300, p<.001). In cohort 2, fewer patients received more than one opioid prescription, more patients received truncal block and only 5 patients received patient controlled analgesia compared to all in cohort 1. A standardized, patient-centered pain management strategy after kidney transplantation reduced opioid prescribing without increasing readmissions or clinic calls. This data may be used to inform guidelines for appropriate OME prescribing at discharge after kidney transplantation.

Cryoneurolysis before Total Knee Arthroplasty in Patients With Severe Osteoarthritis for Reduction of Postoperative Pain and Opioid Use in a Single-Center Randomized Controlled Trial

BackgroundWe hypothesized that preoperative cryoneurolysis of the superficial genicular nerves in patients with osteoarthritis would decrease postoperative opioid use relative to standard of care (SOC) treatment in patients undergoing total knee arthroplasty (TKA). MethodsPatients received either cryoneurolysis (intent-to-treat [ITT]: n = 62) or SOC (ITT: n = 62). The cryoneurolysis group received cryoneurolysis of the superficial genicular nerves 3–7 days before surgery plus a similar preoperative, intraoperative, and postoperative pain management protocol as the SOC group. The primary end point was cumulative opioid consumption in total daily morphine equivalents from discharge to the 6-week study follow-up assessment. Secondary end points included changes in pain and functional scores. Primary and secondary end points were assessed using ITT and per-protocol (PP) analyses. ResultsThe primary end point was not met in the ITT analysis (4.8 [cryoneurolysis] vs 6.1 [SOC] mg; P = .0841) but was met in the PP analysis (4.2 vs 5.9 mg; P = .0186) after excluding patients with medication deviations or missing follow-up data. Compared with the SOC group, the cryoneurolysis group had improved functional scores and numerical improvements in pain scores across all follow-up assessments, with significant improvements observed in current pain from baseline to the 72-hour and 2-week follow-up assessments and pain in the past week from baseline to the 12-week follow-up assessment. ConclusionFindings from the PP analysis suggest that preoperative cryoneurolysis in patients with knee osteoarthritis can reduce opioid consumption and improve functional outcomes after TKA.

Acute Pain Medicine

Acute Pain Medicine is a book with an innovative goal to apply case-based learning to acute pain medicine. This is a very readable book, in which leading physicians in pain medicine communicate their lifetime professional experience and knowledge, to give the reader the impression of having learned a valid clinical approach by being with them for years. The book is organized into 3 sections with chapters that treat several topics related to perioperative and nonperioperative pain conditions. Section I (The Practice of Acute Pain Medicine, Chapters 1–2) details the economic problem of implementing acute pain medicine services. This section underlines the value of pain management as a service and the centrality of acute pain services in the integration between multimodal analgesia, regional analgesia, protocols of enhanced recovery after surgery (ERAS), and the use of procedure-specific postoperative pain management (PROSPECT) protocols. Section II (Case-Based Acute Pain Medicine, Chapters 3–25) constitutes the most interesting part of the book. It offers a variety of scenarios in acute pain medicine that can be encountered in practice. The range of topics is wide and includes orthopedic, thoracic, abdominal, and pediatric surgery, as well as some nonperioperative pain conditions and polytrauma. The structure of the case-based chapters is exceptional and represents an excellent method of clinical thinking. The authors start with questions that arise daily in clinical practice. At the beginning of each chapter, the authors put forward a case-based pain problem (in Greek πρό [pró, “before”] + βάλλω [bállō, “throw, cast”] mean, “to put forward”). The authors advance their reasoning through the problem’s fundamental expression, “the question,” spanning clinical, diagnostic, and therapeutic considerations. All chapters contain a special focus on pharmacology. Up-to-date references and guidelines support each section. This is a book made of many good questions with corresponding concise but sufficiently detailed answers. Readers will find an immediate response to all aspects of the proposed pain problem. They will also appreciate the fact that questions and answers cover all aspects of each single case in a truly holistic fashion. For future editions, we expect that clinical cases will be organized into a more defined etiological classification and also include obstetrical pain syndromes and more nonorthopedic pain conditions. The third section of the book (Advanced Regional Anesthesia and Analgesia, Chapters 26–60) is an updated version of the Military Advanced Regional Anesthesia and Analgesia Handbook (MARAA II) where almost every type of regional block can be found. Image quality of regional procedures for specific areas of the body is good; the text is simple but complete and includes basic pediatric regional anesthesia, acupuncture treatments on the battlefield, acute pain nursing, acute pain treatment in the battlefield, and air transport of the critically injured patient. With this text, the authors underline the problem of experience and its transmission into medical education in the 21st century. Dealing with pain clinics requires a skilled use of intelligence. In its Latin origin (intus/inter + legere) the word “intelligence” means literally “to read through, read inside.” However, who can help us to read reality and increase our clinical experience? In this unique era of the history of medicine, we have plenty of readily available information supported by improved scientific methodology, but we again need to “read through” and to pick what is more adapted to the individual clinical situation, because every patient is unique. “Experience, as development of the person, connotes the fact of becoming aware of one’s growth in the understanding of reality.”1 As opposed to what happens in the scientific field, where we can add today’s advances to those of the past, experience in its basic form is not simply an additional process.2 Experience needs to be transmitted by someone who has gained it through intelligence and needs to be renewed during a lifetime’s work for knowledge. The clinical eye of a good mentor on the treatment of a patient can be learned only from the mentor himself (Figure 1).3 That is why mentorship and case-based learning are the original and fundamental methods of learning in medicine. The Acute Pain Medicine book is unique, and it attempts to bridge the gap by transmitting the experience of great mentors. For these reasons, fellows and residents should have this book, and the book is also recommended to those physicians who know that the long journey to knowledge never ends.Figure.: André Brouillet. Un Leçon Clinique à la Salpêtrière (Jean-Martin Charcot demonstrating in a clinical lecture to his colleagues). 1887. Université Paris Descartes, Paris. From Wikipedia; available at: https://www.google.com/search?q=andre+brouillet+salpetriere&client=ms-android-huawei&prmd=nimv&sxsrf=ALeKk02q9w_Ks2S-6pf45k2zrdUDNk86Ug:1591737381299&source=lnms&tbm=isch&sa=X&ved=2ahUKEwjt_L_p0_XpAhW1WxUIHfM1DK0Q_AUoAnoECBUQAg&biw=480&bih=656#imgrc=wEDppSZRfwtxvM.Zhirajr Mokini, MDDhurata Vrenozi, MDDepartment of AnesthesiologyClinique Saint FrançoisChâteauroux, France[email protected]