Preoperative Pain Management Research Articles

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

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

The effects of early femoral nerve block intervention on preoperative pain management and incidence of postoperative delirium geriatric patients undergoing trochanteric femur fracture surgery: A randomized controlled trial.

Hip fracture is a common clinical problem which causes severe pain in geriatric patients. However, severe pain following fracture may bring on mental disorders and delirium. A neuroinflammatory response with IL-6 and IL-8 has been shown to be associated with the pathophysiology of delirium. In this study, our primary hypothesis is that preoperative femoral nerve block (FNB) intervention in geriatric patients will more effectively attenuate pain following trochanteric femur fracture than the preoperative paracetamol application. Our secondary hypothesis is that interleukin levels (IL-6, IL-8) in cerebrospinal fluid (CSF) will be lower in the femoral nerve block group than the paracetamol group. Our tertiary hypothesis is that the incidence of postoperative delirium will be lower in the femoral nerve block group. The patients over 65 years of age with ASA status II-IV and admitted to the Emergency Service for femur fracture were included in this study. Recommendations of the 'delirium prevention table' were applied to all of the patients at arrival. In the first group, 15 mg/kg paracetamol was administered intravenously every eight hours. In the second group, femoral nerve blockage was performed, and a catheter was placed. Then, 0.5 mL/kg bupivacaine 0.25% was applied every eight hours. In both groups, pain scores four hours after interventions were recorded. All patients were operated within 48 hours under spinal anesthesia. During spinal anesthesia, 2 mL of CSF samples were taken from all patients for analysis of IL-6 and IL-8 cytokines, and pain scores during positioning were recorded. VAS scores four hours after the first preoperative pain treatment and during the positioning for regional anesthesia were significantly lower in the femoral nerve block group. IL-8 levels are significantly lower in the femoral nerve block group but not in IL-6 levels. The incidence of delirium was less in the femoral nerve block group, but the difference was not statistically significant. The femoral nerve block was more effective in preoperative pain management of trochanteric femur fracture and preventing pain during regional anesthesia application. The mean IL-8 level was lower in the femoral nerve block group when compared to the paracetamol group. There is no difference in the postoperative delirium incidence between groups.

Pre-operative pain management with nerve block in patients with hip fractures: a randomized, controlled trial

IntroductionPain management in patients with hip fractures is a major challenge for emergency care. The objective of this study was to evaluate whether the supplementation of pre-operative analgesia with low-dose fascia iliaca compartment block (FICB) compared with placebo would improve pain relief in patients with hip fractures. MethodsA double-blind, randomized, controlled trial was conducted on 127 patients. At hospital admission, a low-dose FICB was administered to patients with hip fractures as a supplement to regular pre-operative analgesia. Patients with and without cognitive impairment were included. The instruments used were a visual analogue scale (VAS), a numerical rating scale and a tool for behavior related pain assessment. The primary endpoint was the change in reported pain on movement from hospital admission to two hours after FICB. ResultsThe intervention group showed improved pain management by mean VAS score for pain on movement compared with the control group (p = 0.002). ConclusionsOur results support the use of low-dose FICB as a pain-relieving adjuvant to other analgesics when administered to patients with a hip fracture.

Incidence and influence factors analysis of chronic postoperative inguinal pain after tension-free repair for inguinal hernia

Objective To investigate the incidence and influence factors of chronic postoperative inguinal pain (CPIP) after tension-free repair for inguinal hernia. Methods The retrospective case-control study was conducted. The clinicopathological data of 1 188 patients who underwent tension-free repair for inguinal hernia in the People′s Hospital of Xinjiang Uygur Autonomous Region between January 2011 and August 2017 were collected. Observation indicators: (1) surgical and postoperative situations; (2) follow-up; (3) influence factors analysis of CPIP. Follow-up using outpatient examination and telephone interview was performed to detect inguinal pain and complications at 1, 3, 6 months and 1 year postoperatively up to August 2018. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distrubution were described as M (range). The univariate and multivariate analysis were done using the chi-square test and Logistic regression model. Results (1) Surgical and postoperative situations: 1 188 patients underwent successful tension-free repair for inguinal hernia. Eighty-five patients (7.155%, 85/1 188) had CPIP, including 76 (8.370%, 76/908) undergoing open surgery and 9 (3.214%, 9/280) undergoing laparoscopic surgery. (2) Follow-up: 1 188 patients were followed up for 12-36 months, with a median time of 19 months. Incidence rates of CPIP with visual analogue score > 3 were 11.785%(140/1 188), 7.155%(85/1 188), 5.808%(69/1 188), 3.199%(38/1 188) at 1, 3, 6 months and 1 year postoperatively. Patients were given individualized and reasonable treatment according to their own conditions and CPIP was relieved after conservative treatment including drug treatment, physiotherapy such as acupuncture, nerve block and psychotherapy. Of 5 patients with CPIP after tension-free repair for inguinal hernia undergoing surgeries, 1 was relieved nerve ligation by surgery, 3 with mesh related pain were removed meshes, 1 was taken the fixed stiches out. They were relieved CPIP after above treatments. During the follow-up, 161 patients with incisional seroma, 75 with incisional infection and 5 with disruption of wound were cured by symptomatic treatments including reinforced incision management, dressing change and physiotherapy. Seven patients with mesh infection were removed meshes. Of 68 patients with hernia recurrence, 53 had reoperation, 18 complicated with diseases induced severe increased intra-abdominal pressure were suggested to undergo surgeries after treatment of complications. (3) Influence factors analysis of CPIP: ① results of univariate analysis showed that sex, age, body mass index, surgical method, degree of preoperative pain, intraoperative nerve stretching or injury and incisional infection were related factors affecting CPIP after tension-free repair for inguinal hernia (χ2=21.002, 6.715, 6.012, 8.563, 11.887, 49.447, 10.025, P<0.05). ② Results of multivariate analysis showed that sex, body mass index, surgical method, degree of preoperative pain, intraoperative nerve stretching or injury and incisional infection were independent related factors affecting CPIP after tension-free repair for inguinal hernia (odds ratio=1.267, 2.986, 1.661, 3.208, 2.034, 1.871, 95% confidence interval: 1.042-1.392, 1.372-4.901, 0.998-2.758, 1.933-6.013, 1.556-3.118, 1.095-3.534, P<0.05). Conclusions Sex, body mass index, surgical method, degree of preoperative pain, intraoperative nerve stretching or injury and incisional infection are independent related factors affecting CPIP after tension-free repair for inguinal hernia. Preoperative pain management and psychological counseling, intraoperative refine performance, inguinal nerve protection and postoperative incisional management should be reinforced to prevent and reduce incidence of CPIP. Key words: Hernia, inguinal; Tension-free hernia repair; Mesh repair; Laparoscopy; Chronic pain; Complications; Risk factors

Anesthesia for awake craniotomy

The current review reports on current trends in the anesthetic management of awake craniotomy, including preoperative preparation, sedation schemes, pain management, and prevention of intraoperative complications. Both approaches for anesthesia for awake craniotomy, asleep-awake-asleep and monitored anesthesia care (MAC), have shown equal efficacy for performing intraoperative brain mapping. Choice of the appropriate scheme is currently based mainly on the preferences of the particular anesthesiologist. Dexmedetomidine has demonstrated high efficacy and safety in MAC for awake craniotomy and has become a rational alternative to propofol. Despite the high efficacy of scalp block and opioids, pain remains a common compliant in awake craniotomy. Appropriate surgical tactics can reduce pain and even prevent postoperative neurological complications. Although the efficacy of prophylaxis of intraoperative seizures with anticonvulsants remains doubtful, levetiracetam can be superior to other drugs for this purpose. Following a great deal of progress in anesthetic management, awake craniotomy, which had been a relatively rare approach, is now a commonly performed procedure for neurosurgical intervention. Modern anesthesia techniques can provide for successful brain mapping in almost any patient. Management of awake craniotomy in high-risk patients is a central task for future research.

Fascia-iliaca compartment block vs intra-articular hip injection for preoperative pain management in intracapsular hip fractures: A blind, randomized, controlled trial

BackgroundThe aim of this study was to compare the fascia-iliaca compartment block and the intra-articular hip injection in terms of pain management and the need for additional systemic analgesia in the preoperative phase of intracapsular hip fractures. MethodsPatients >65 years old with an intracapsular hip fracture were randomized in this prospective, blind, controlled, parallel trial in a Level-I trauma center. Patients were randomly assigned to receive either the fascia-iliaca compartment block (cohort FICB) or the intra-articular hip injection (cohort IAHI) upon admission to the emergency department. The primary outcome was pain relief at 20 min, 12 h, 24 h and 48 h after the regional anesthesia, both at rest and during internal rotation of the fractured limb. The Numeric Rating Scale was used. Residual pain was managed with the same protocol in all patients. Additional analgesic drug administration during the 48 h from admission was recorded. ResultsA total of 120 patients with comparable baseline characteristics were analyzed in this study: the FICB group consisted of 70 subjects, while the IAHI group consisted of 50 subjects.Pain was significantly lower in the IAHI group during movement of the fractured limb at 20 min (p < 0.05), 12 h (p < 0.05), 24 h (p < 0.05) and 48 h (p < 0.05).In the FICB cohort 72.9% of patients needed to take oxycodone, in contrast to 28.6% of the IAHI cohort (p < 0.05). In the FICB cohort 14.09 ± 11.57 mg of oxycodone was administered, while in the IAHI cohort 4.38 ± 7.63 mg (p < 0.05). No adverse events related to either technique were recorded. ConclusionsIntra-articular hip injection provides better pre-operatory pain management in elder patients with intracapsular hip fractures compared to the fascia-iliaca compartment block. It also reduced the need for supplementary systemic analgesia. Level of EvidenceTherapeutic Level I.

Protocols for Management of Underserved Patients Undergoing Arthroplasty: A National Survey of Safety Net Hospitals.

Although it has been shown that perioperative protocols enhance arthroplasty care and safety, it is not known how prevalent their use is in safety net hospitals, which operate with a mandate to treat the poor and underserved. Understanding the elements currently included in standard perioperative arthroplasty protocols at various institutions may help guide future interventions and policy aimed at improving underserved patients' outcomes. In this cross-sectional study, safety net hospitals were asked to complete a survey over the phone, via email or in person regarding existence and elements of perioperative management protocols for total hip arthroplasty (THA) and total knee arthroplasty (TKA). Implementation barriers were also addressed. Specifically, survey questions sought to determine the total yearly number of arthroplasty procedures performed at each institution and better understand, among other elements, the following: presence of preoperative pain management protocols, inpatient care pathways, use of social workers and involvement of physical therapy services. Descriptive statistics were calculated and reported. Over 90% of safety net hospitals performing arthroplasty utilized regional anesthetic techniques, inpatient clinical care pathways and inpatient physical therapy. However, 16.7%, 20.0%, 23.3% and 73% lacked social services, anesthesia preoperative clinics, inpatient pain management protocols and preoperative sobriety pathways, respectively. Barriers to receiving arthroplasty care included lack of qualified surgical personnel and concerns about surgical risk in vulnerable patient populations. These findings suggest that further effort is warranted to expand and improve arthroplasty care for the underserved to ensure safety and high quality outcomes.

Acceptance and Commitment Therapy for Prevention of Chronic Postsurgical Pain and Opioid Use in At-Risk Veterans: A Pilot Randomized Controlled Study

High levels of pain, significant anxiety, or depressive symptoms before surgery put patients at elevated risk for chronic pain and prolonged opioid use following surgery. The purpose of this preliminary study was to assess the efficacy of a 1-day Acceptance and Commitment Therapy (ACT) workshop in “at-risk” veterans for the prevention of chronic pain and opioid use following orthopedic surgery. In a randomized controlled trial, 88 at-risk veterans undergoing orthopedic surgery were assigned to treatment as usual (TAU; n = 44) or TAU plus a 1-day ACT workshop (n = 44). Pain levels and opioid use were assessed up to 3 months following surgery. Pain acceptance and values-based behavior were assessed at baseline and 3-month follow-up. Participants who completed the ACT workshop reached pain and opioid cessation sooner than those in TAU. Postoperative complications exhibited a moderating effect on these outcomes, such that the effects of ACT were greater in patients without complications. Increases in pain acceptance and values-based behavior, processes targeted in ACT, were related to better outcomes. These promising results merit further investigation in a larger clinical trial. Providing an intervention before surgery for at-risk veterans has the potential to change clinical practice from a focus on management of postoperative pain to prevention of chronic pain in at-risk individuals. PerspectiveThis pilot study compared the effects of a 1-day preventive behavioral intervention (ACT) to TAU in at-risk veterans undergoing orthopedic surgery. Three months following the intervention, veterans receiving ACT exhibited quicker cessation of pain and opioid use. Focusing on preoperative pain management may help prevent chronic postsurgical pain.

A Robust Approach to Implementing Fascia Iliaca Compartment Nerve Blocks in Hip Fracture Patients.

A clear imperative exists to optimize the preoperative pain management of hip fracture patients. Increasingly, fascia iliaca compartment blocks (FICBs) are being effectively utilized as an adjunct to oral analgesia in the emergency department. We investigated the feasibility, safety, and delivery rate when junior doctors and specialist nurses are trained in FICBs delivery, alongside the introduction of a step-by-step proforma. We conducted a retrospective study of hip fractures patients presenting preinterventions (n = 138) between October and December 2014 and postinterventions (n = 246) between April and August 2015. Outcomes analyzed included delivery frequency, anesthetic dosages used, and procedure documentation. Preintervention, FICB was performed in 40% (n = 51) of eligible patients, with an improvement to 72% (n = 160) postintervention. Postinterventions, 98% of FICBs were performed with the anesthetic dose recommended-a prescription between 75 and 100 mg of 0.25% levobupivacaine. No adverse patient outcomes, relating to the interventions implemented, were noted during the study period. Delivery of FICB by junior doctors and specialist nurses in the emergency department is feasible, safe, and improves the proportion of patients receiving blocks.

Preoperative Pain Management Education: An Evidence-Based Practice Project

The purpose of this evidence-based practice project was to evaluate the effectiveness of a preoperative pain management patient education intervention on improving patients' pain management outcomes. The project was conducted in an outpatient general surgery service at a teaching institution for patients undergoing same-day surgery. Intervention patients received one-on-one education on postoperative pain management including how to take medications, managing medication side effects, using nonpharmacologic methods, and reporting inadequate postoperative pain control. Comparison patients received general education from multiple health care providers, and this information may not have been consistent. Intervention patients received education at the first preoperative clinic visit. Patients in the intervention and comparison groups completed the Revised American Pain Society Patient Outcome Questionnaire during their first postoperative clinic visit. Results were analyzed by the Mann-Whitney U test/Wilcoxon rank sum test. A 12-month project (N = 99) showed statistically significant results (P = .020 and P=.001, respectively) in questions about side effects and whether the patient was encouraged to use nonpharmacologic methods to reduce pain. The intervention group reported the effects of pain on mood (P = .067) and use of nonpharmacologic methods (P=.052); however, these results were not statistically significant. More intervention patients than comparison patients reported medication side effects and were encouraged to use nonpharmacologic methods for reducing postoperative pain. Intervention patients also reported the effects of pain on mood and the use of nonpharmacologic methods more frequently than comparison patients. Preoperative pain management education may increase patients' knowledge in key areas of postoperative pain management to prevent negative outcomes.

47 Systematic review and meta-analysis of analgesic efficacy and safety profile of single injection fascia iliaca compartment blocks in the acute pre-operative pain management of hip fractures

BackgroundIt is hypothesised that a single injection fascia iliaca compartment block (FICB) administered in the pre-operative setting provides better analgesic control for traumatic hip fractures and is not associated with...

Persistent postsurgical pain in children and young people: prediction, prevention, and management.

Ensuring optimum preoperative and postoperative pain management should always be a priority in children.

The Impact of Scripted Pain Education on Patient Satisfaction in Outpatient Abdominal Surgery Patients

Practice guidelines for acute pain management in perioperative patients recommend providing consistent perioperative pain education that includes medication and behavioral techniques to control pain. However, literature indicates that most nurses deliver patient education based on personal preferences, time limitations, and availability of teaching aids. The purpose of this study was to evaluate patient satisfaction with scripted preoperative pain management education for patients undergoing outpatient abdominal surgery. A pretest and posttest design compared patient perceptions of and satisfaction with pain management education before and after the introduction of scripted education. An independent t test was applied to measure differences between groups. The postscripting group responses indicated that pain education was helpful in managing postoperative pain at a significant (P = 0.03) level. Use of scripted dialog, along with specific written patient education, has a positive impact on postoperative patient satisfaction with pain management.

Receipt of Pain Management Information Preoperatively Is Associated With Improved Functional Gain After Elective Total Joint Arthroplasty

BackgroundPoorly controlled postoperative pain may adversely affect total joint arthroplasty (TJA) patients' outcomes and associated healthcare cost. Understanding effective pain management after surgery is important to patients, surgeons, and hospitals. We evaluated patient-reported receipt of preoperative pain management information in a national prospective cohort evaluating postoperative pain and function following elective TJA. MethodsPreoperative and 2-week and 6-month postoperative survey data of 1609 TJA patients collected between June 2013 and December 2014 were analyzed. Data included demographics, medical and musculoskeletal comorbidity, operative joint pain, physical function, and mental health. At 2 weeks postoperative, patients were asked if they had received pain management information prior to surgery, the content of that education, and pain management strategies. Descriptive statistics were performed. ResultsAt 2 weeks post-TJA, one-third of patients reported not receiving information about pain management; an additional 11% did not find the information helpful. There were no differences preoperatively in demographics or clinical profiles between those who received pain information and those who did not. Patients who received pain information reported less pain 2 weeks postoperatively, greater use of non-narcotic pain care strategies, and better physical function scores at 6 months postoperatively. No differences in operative joint pain were identified at 6 months between education and noneducation groups. ConclusionForty-four percent of the patients reported that they did not receive/received unhelpful information regarding postoperative pain management, highlighting a need for improved patient education. In this sample, the lack of pain management information was associated with poorer 6-month postoperative function.

Improving patients’ experience and outcome of total joint replacement: the RESTORE programme

BackgroundTotal hip replacements (THRs) and total knee replacements (TKRs) are common elective procedures. In the REsearch STudies into the ORthopaedic Experience (RESTORE) programme, we explored the care and experiences of patients with osteoarthritis after being listed for THR and TKR up to the time when an optimal outcome should be expected.ObjectiveTo undertake a programme of research studies to work towards improving patient outcomes after THR and TKR.MethodsWe used methodologies appropriate to research questions: systematic reviews, qualitative studies, randomised controlled trials (RCTs), feasibility studies, cohort studies and a survey. Research was supported by patient and public involvement.ResultsSystematic review of longitudinal studies showed that moderate to severe long-term pain affects about 7–23% of patients after THR and 10–34% after TKR. In our cohort study, 10% of patients with hip replacement and 30% with knee replacement showed no clinically or statistically significant functional improvement. In our review of pain assessment few research studies used measures to capture the incidence, character and impact of long-term pain. Qualitative studies highlighted the importance of support by health and social professionals for patients at different stages of the joint replacement pathway. Our review of longitudinal studies suggested that patients with poorer psychological health, physical function or pain before surgery had poorer long-term outcomes and may benefit from pre-surgical interventions. However, uptake of a pre-operative pain management intervention was low. Although evidence relating to patient outcomes was limited, comorbidities are common and may lead to an increased risk of adverse events, suggesting the possible value of optimising pre-operative management. The evidence base on clinical effectiveness of pre-surgical interventions, occupational therapy and physiotherapy-based rehabilitation relied on small RCTs but suggested short-term benefit. Our feasibility studies showed that definitive trials of occupational therapy before surgery and post-discharge group-based physiotherapy exercise are feasible and acceptable to patients. Randomised trial results and systematic review suggest that patients with THR should receive local anaesthetic infiltration for the management of long-term pain, but in patients receiving TKR it may not provide additional benefit to femoral nerve block. From a NHS and Personal Social Services perspective, local anaesthetic infiltration was a cost-effective treatment in primary THR. In qualitative interviews, patients and health-care professionals recognised the importance of participating in the RCTs. To support future interventions and their evaluation, we conducted a study comparing outcome measures and analysed the RCTs as cohort studies. Analyses highlighted the importance of different methods in treating and assessing hip and knee osteoarthritis. There was an inverse association between radiographic severity of osteoarthritis and pain and function in patients waiting for TKR but no association in THR. Different pain characteristics predicted long-term pain in THR and TKR. Outcomes after joint replacement should be assessed with a patient-reported outcome and a functional test.ConclusionsThe RESTORE programme provides important information to guide the development of interventions to improve long-term outcomes for patients with osteoarthritis receiving THR and TKR. Issues relating to their evaluation and the assessment of patient outcomes are highlighted. Potential interventions at key times in the patient pathway were identified and deserve further study, ultimately in the context of a complex intervention.Study registrationCurrent Controlled Trials ISRCTN52305381.FundingThis project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 12. See the NIHR Journals Library website for further project information.

Higher Dose of Opioids in the Emergency Department and Earlier Initiation of Oral Opioids after Hospitalization Are Associated with Shorter Length of Stay in Children with Sickle Cell Disease Treated for Acute Pain

There is currently no standardized approach to emergency department (ED) and inpatient treatment of an acute pain event for patients with sickle cell disease (SCD). In addition, how the initial treatment of a pain event influences the outcome of that pain event is not well described. In surgical patients, aggressive pre-operative and peri-operative pain management is associated with improved pain outcomes post-operatively. Furthermore, in post-operative patients, using oral opioids alone or in combination with intravenous (IV) opioids is shown to provide better pain control, decreased IV opioid consumption, less side effects and higher patient satisfaction. In SCD, it is not known whether more aggressive opioid treatment at presentation to ED care or earlier initiation of oral opioids after hospitalization is associated with improved outcomes. Thus, we sought to determine the impact of the following treatment-related aspects of acute pain events on length of hospital stay: 1) total opioid dose at presentation, 2) time to initiation of first IV opioid at presentation, and 3) time to initiation of first oral opioid after hospitalization. We hypothesized that increased total initial dose of opioids, more rapid initiation of IV opioids in the ED, and earlier initiation of oral opioids after hospitalization would be associated with shorter length of hospital stay.We conducted a secondary analysis of data from the randomized controlled Magnesium for children in Crisis (MAGiC) trial. The MAGiC trial was a double-blind randomized controlled trial of IV magnesium versus saline placebo added to standard treatment for pediatric pain events. All patients had HbSS or HbSβ0 thalassemia to be eligible. The primary outcome, length of stay, was a composite endpoint of actual discharge or 12 hours after administration of last IV opioid, whichever came first. Patients were defined as having severe disease if a history of acute chest syndrome and/or 3 or more pain hospitalizations in the prior 3 years existed. A priori, all pain events were considered severe as the need for hospitalization indicated failure of outpatient therapy. Our primary variables of interest were: 1) Total initial opioid dose: total mg/kg/hr of morphine equivalents administered between first opioid in ED through start of study drug, 2) Time to first IV opioid: total hours between ED arrival and first IV opioid, 3) Time to first oral opioid: total hours between ED arrival and start of first oral opioid after hospitalization. Spearman correlations were used to determine the association between the above variables and length of stay and between length of stay and rehospitalization within 7 days to determine the consequence of earlier discharge.A total of 204 patients were enrolled at 8 sites. Mean (SD) age was 13.6 (4.7) years, 51.5% were female, 88.2% had severe disease and 60.3% were taking hydroxyurea. The primary MAGiC trial analysis found IV magnesium had no impact on length of stay. The mean total initial dose of opioid was 0.043 (0.029) mg/kg/hr that was administered over a median of 8.5 (IQR 6.4-13.1) hours. Higher total initial opioid dose was correlated with shorter length of stay (r=0.34, p<0.01). The median time to first IV opioid was 1.02 (IQR 0.65-1.33) hours. There was no association between the time to first IV opioid and length of stay (r=0.006, p=0.93). The median time to time to first oral opioid was 28.3 (IQR 12.2-61.1) hours. Earlier initiation of oral opioids was strongly associated with shorter length of stay (r=0.61, p<0.01). Neither shorter length of stay (r=-0.08, p=0.28) nor earlier initiation of oral opioids (r=-0.02, p=0.82) was associated with rehospitalization within 7 days.Earlier initiation of oral opioids was strongly associated with shorter length of stay without associated increased rehospitalizations. Higher doses of opioids during the initial management of a pain event also contributed to shorter length of stay, however, more rapid initiation of IV opioids did not alter length of stay. These data suggest that higher initial doses of opioids in the ED and earlier introduction of oral opioids after hospitalization may improve outcomes of pain events. Prospective trials designed to evaluate the impact of initial ED care on outcomes of hospitalizations for pain events and trials aimed at standardizing inpatient treatment for pain events are needed and could ultimately lead to improved outcomes for pain in children with SCD. DisclosuresBrandow:NIH, ASH: Research Funding. Panepinto:NKT Therapeutics, Inc: Consultancy; HRSA, NIH: Research Funding. Brousseau:NIH: Research Funding.

Preoperative pain management education: a quality improvement project.

The management of pain is one of the greatest clinical challenges for nurses who care for patients during the postoperative period. It can be even more challenging for patients who must manage their own pain after discharge from the health care facility. Research shows that postoperative pain continues to be undermanaged despite decades of education and evidence-based guidelines. Ineffective management of postoperative pain can negatively impact multiple patient outcomes. The purpose of this quality improvement project was to evaluate the effectiveness of a preoperative pain management patient education intervention on improving patients' postoperative pain management outcomes. The project was conducted with patients undergoing same-day laparoscopic cholecystectomy in an outpatient general surgery service at a teaching institution. Patients in the intervention and comparison groups completed the American Pain Society Patient Outcome Questionnaire-Revised during their first postoperative clinic visit 2weeks after surgery. Results showed that patients who received the preoperative education intervention reported less severe pain during the first 24hours postoperatively, experienced fewer and less severe pain medication side effects, returned to normal activities sooner, and used more nonpharmacologic pain management methods postoperatively compared with those who did not receive the education.

Impact of postsurgical opioid use and ileus on economic outcomes in gastrointestinal surgeries

Objectives:To assess the incidence and economic impact of postoperative ileus (POI) following laparotomy (open) and laparoscopic procedures for colectomies and cholecystectomies in patients receiving postoperative pain management with opioids.Methods:Using the Premier research database, we retrospectively identified adult inpatients discharged between 2008 and 2010 receiving postsurgical opioids following laparotomy and laparoscopic colectomy and cholecystectomy. POI was identified through ICD-9 diagnosis codes and postsurgical morphine equivalent dose (MED) determined.Results:A total of 138,068 patients met criteria, and 10.3% had an ileus. Ileus occurred more frequently in colectomy than cholecystectomy and more often when performed by laparotomy. Ileus patients receiving opioids had an increased length of stay (LOS) ranging from 4.8 to 5.7 days, total cost from $9945 to $13,055 and 30 day all-cause readmission rate of 2.3 to 5.3% higher compared to patients without ileus. Patients with ileus received significantly greater MED than those without (median: 285 vs. 95 mg, p < 0.0001) and were twice as likely to have POI. MED above the median in ileus patients was associated with an increase in LOS (3.8 to 7.1 days), total cost ($8458 to $19,562), and readmission in laparoscopic surgeries (4.8 to 5.2%). Readmission rates were similar in ileus patients undergoing open procedures regardless of MED.Conclusions:Use of opioids in patients who develop ileus following abdominal surgeries is associated with prolonged hospitalization, greater costs, and increased readmissions. Furthermore, higher doses of opioids are associated with higher incidence of POI. Limitations are related to the retrospective design and the use of administrative data (including reliance on ICD-9 coding). Yet POI may not be coded and therefore underestimated in our study. Assessment of pre-existing disease and preoperative pain management was not assessed. Despite these limitations, strategies to reduce opioid consumption may improve healthcare outcomes and reduce the associated economic impact.

Preoperative Opioid Use as a Predictor of Adverse Postoperative Self-Reported Outcomes in Patients Undergoing Spine Surgery.

Opioids are commonly used for preoperative pain management in patients undergoing spine surgery. The objective of this investigation was to assess whether preoperative opioid use predicts worse self-reported outcomes in patients undergoing spine surgery. Five hundred and eighty-three patients undergoing lumbar, thoracolumbar, or cervical spine surgery to treat a structural lesion were included in this prospective cohort study. Self-reported preoperative opioid consumption data were obtained at the preoperative visit and were converted to the corresponding daily morphine equivalent amount. Patient-reported outcome measures were assessed at three and twelve months postoperatively via the 12-Item Short-Form Health Survey and the EuroQol-5D questionnaire, as well as, when appropriate, the Oswestry Disability Index and the Neck Disability Index. Separate multivariable linear regression analyses were then performed. At the preoperative evaluation, of the 583 patients, 56% (326 patients) reported some degree of opioid use. Multivariable analyses controlling for age, sex, diabetes, smoking, surgery invasiveness, revision surgery, preoperative Modified Somatic Perception Questionnaire score, preoperative Zung Depression Scale score, and baseline outcome score found that increased preoperative opioid use was a significant predictor (p < 0.05) of decreased 12-Item Short-Form Health Survey and EuroQol-5D scores, as well as of increased Oswestry Disability Index and Neck Disability Index scores at three and twelve months postoperatively. Every 10-mg increase in daily morphine equivalent amount taken preoperatively was associated with a 0.03 decrease in the 12-Item Short-Form Health Survey physical component summary and mental component summary scores, a 0.01 decrease in the EuroQol-5D score, and a 0.5 increase in the Oswestry Disability Index and Neck Disability Index score at twelve months postoperatively. Higher preoperative Modified Somatic Perception Questionnaire and Zung Depression Scale scores were also significant negative predictors (p < 0.05). Increased preoperative opioid consumption, Modified Somatic Perception Questionnaire score, and Zung Depression Scale score prior to undergoing spine surgery predicted worse patient-reported outcomes. This suggests the potential benefit of psychological and opioid screening with a multidisciplinary approach that includes weaning of opioid use in the preoperative period and close opioid monitoring postoperatively. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

SAT0433 Consensus Statement on the Management of Preoperative Pain in Patients with Total Knee And/Or Hip Replacement

BackgroundTotal knee replacement (TKR) and total hip replacement (THR) are performed to provide pain relief and restore physical functioning. Several preoperative factors have been associated with poor postoperative pain including...