Preemptive Pain Management Research Articles

Local anaesthetic efficacy provided by lidocaine or lidocaine-tramadol in dogs undergoing maxillary fourth premolar extraction.

Oral nerve blocks are an indispensable technique for pre-emptive pain management in various veterinary procedures, including tooth extractions. Local anaesthetic drugs are considered the safest and the most effective agents to inhibit oral pain. Recently, tramadol was used as an adjuvant to local anaesthetics to increase the duration of analgesia. The aim of this study was to compare the effect of maxillary nerve block induced by lidocaine or lidocaine-tramadol on perioperative pain in dogs undergoing upper fourth premolar extraction. A randomized blinded clinical study was conducted over five months involving sixteen animals divided into two groups, Group L (8 animals, Group Lidocaine) and Group LT (8 animals, Group Lidocaine-Tramadol). Both drugs provided effective pain control during and after surgical intervention, but lidocaine-tramadol resulted in longer analgesia than lidocaine alone. These findings suggest that the maxillary nerve block with lidocaine-tramadol can ensure adequate and prolonged pain control in dogs undergoing dental extraction. Although these are preliminary results, tramadol showed promising effects as a potential drug to use during oral surgery in association to local anaesthetics.

Comparison of the effects of pregabalin and famotidine with pregabalin and diphenhydramine on postoperative abdominal pain

ObjectivesPain is one of the most significant problems, and its uncontrolled management can lead to complications such as increased blood pressure, myocardial ischemia, etc. An effective approach to control postoperative pain is preemptive pain management with a combination of drugs prior to surgery. The present study aims to compare the level of postoperative abdominal pain in patients receiving pregabalin and famotidine versus pregabalin and diphenhydramine. Materials and methodsIn this double-blind clinical trial, a total of 34 candidates for abdominal surgery (laparotomy) with ASA physical status classification of 1 or 2 were enrolled from the patients referring to (XXX). They were divided into two groups of 17 (Group A: pregabalin and famotidine, Group B: pregabalin and diphenhydramine). The drugs were administered to the patients 2 h before the surgery. The patients' pain levels were measured using the Visual Analog Scale (VAS) at the recovery stage after complete consciousness and at 6, 12, and 24 h postoperatively. Additionally, the amount of analgesic consumed within the first 24 h after the surgery was recorded and compared between the two groups. ResultsThe average pain intensity score at 6 h postoperatively was (6 ± 0.2) in patients who received pregabalin and diphenhydramine, and (7.1 ± 0.1) in patients who received pregabalin and famotidine (p = 0.002). The average pain intensity score at 12 h postoperatively was (6.1 ± 0.3) in patients who received pregabalin and famotidine, and (5.6 ± 0.2) in patients who received pregabalin and diphenhydramine (p = 0.021). Furthermore, the average pain intensity score at 24 h postoperatively was (5.2 ± 0.2) in patients who received pregabalin and famotidine, and (4.2 ± 0.2) in patients who received pregabalin and diphenhydramine (p = 0.014). The results demonstrated that the pain intensity score decreased in all four measured time intervals in the overall patient population (p < 0.001), and this reduction was significantly different between the two groups (p = 0.002), with the final average pain score being lower in the group receiving pregabalin and diphenhydramine compared to the other group. ConclusionThe results of this study indicate that the use of drugs such as diphenhydramine and pregabalin as preemptive medications can be effective in controlling postoperative abdominal pain and reducing the consumption of analgesics in patients after abdominal surgery.

2022 AAHA Pain Management Guidelines for Dogs and Cats.

These updated guidelines present a practical and logical approach to the assessment and management of acute and chronic pain in canine and feline patients. Recognizing pain is fundamental to successful treatment, and diagnostic guides and algorithms are included for assessment of both acute and chronic pain. Particularly for chronic pain, capturing owner evaluation is important, and pain-assessment instruments for pet owners are described. Expert consensus emphasizes proactive, preemptive pain management rather than a reactive, "damage control" approach. The guidelines discuss treatment options centered on preemptive, multimodal analgesic therapies. There is an extensive variety of pharmacologic and nonpharmacologic therapeutic options for the management of acute and chronic pain in cats and dogs. The guidelines include a tiered decision tree that prioritizes the use of the most efficacious therapeutic modalities for the treatment of acute and chronic pain.

The Association Between Pain and In-Hospital Complications and Duration of Stay After Colorectal Surgery

BackgroundPain is a subjective and multidimensional experience often inadequately managed following surgery. Postoperative pain has been shown to correlate with hospital length of stay (HLOS) and hospital complications. Given advancements in preemptive pain management approaches, reevaluation is necessary. AimsThe purpose of this study was to examine the association between postoperative pain intensity and HLOS and in-hospital complications among patients who underwent colorectal surgery, adjusted by sociodemographic and underlying medical variables. Setting and PatientsWe used electronic medical records. Data were collected from patients who underwent colorectal surgery at a large general hospital in Israel from January 2012 to December 2018. Design and MethodsThis is a retrospective cohort study. Information on HLOS, medical diagnoses, pain intensity, use of analgesics, postoperative infections, patient sociodemographic data, chronic diseases, functionality status, and source of admission were extracted from medical records. Logistic regression analysis was used for the final model, and HLOS and in-hospital complications were the major outcomes. ResultsWe enrolled 1,073 patients. Of them, 554 males (51.6%) with a mean age of 62.54 ± 16.55 years. The median postoperative pain score was 1.54 (interquartile range, 0.84; 2.16), and an in-hospital complication rate of 1.3% (n = 14). Postoperative pain was not associated with prolonged HLOS with adjustment to relevant independent variables (odds ratio, 1.399; 95% confidence interval, 0.759-2.578; p = .282). Contrarily, age, malignancy, assistance needed in activities of daily living, use of analgesic agents, and postoperative infection were risk factors for prolonged HLOS. Additionally, postoperative pain was not related to a higher risk of in-hospital complications. ConclusionsPain intensity post colorectal surgery was not a risk factor for extended HLOS or in-hospital complications. In contradistinction, tending to patient needs, adequate analgesic use, and reducing infection rates can shorten HLOS, improve health outcomes, and economize health care resources.

The Effect of Perioperative Ketorolac Administration on Opioid Use After Hip Arthroscopy.

Patients undergoing hip arthroscopy often have postoperative pain that is managed in part with opioids. The hypothesis of this study was that administration of ketorolac at the conclusion of the case may improve postoperative pain control and reduce opioid use. This investigation was a retrospective, observational study of opioid use, pain, and time spent in the postanesthesia care unit (PACU) among opioid-naïve patients undergoing primary hip arthroscopy (Current Procedural Terminology code 29914 or 29916) for femoroacetabular impingement syndrome before and after the institution of a surgeon-driven policy to administer ketorolac at the end of the case. Baseline characteristics and perioperative ketorolac administration were recorded. Outcomes included opioids used in the PACU through discharge measured in oral morphine equivalents, time spent in the PACU, and pain reported by the patient in the PACU. Comparative statistics, including multivariable main effects linear regression modeling, were performed to determine the effect of ketorolac administration on outcomes. Patients who did not receive ketorolac consumed a median of 22.5 oral morphine equivalents in the PACU through discharge, whereas patients who received ketorolac consumed a median of 17.5 oral morphine equivalents. No significant difference was found in pain reported or time spent in the PACU through discharge, although the results favored ketorolac administration. This study showed a modest but statistically significant reduction in early postoperative opioid use among patients receiving ketorolac at closure. Ketorolac could be part of a multimodal preemptive pain management strategy to help to reduce postoperative opioid use. [Orthopedics. 2021;44(3):e417-e421.].

Factors associated with home opioid use after thoracic surgery

ObjectiveEnhanced recovery after surgery (ERAS) with a pre-emptive pain management program has been shown to decrease opioid prescriptions after thoracic surgery. We sought to determine which patient or procedural factors were associated with the need for prescription opioid medications after thoracic surgical procedures. MethodsWe performed a retrospective analysis of a postoperative pain survey at the time of follow-up in combination with procedural and patient characteristic data. We then performed univariate and multivariate logistic regression to determine factors associated with prescription opioids use. ResultsTwo hundred twenty-eight patients completed questionnaires at a median of 37 days after surgery. Most patients received minimally invasive surgery (n = 213, 93%) with the 2 most common types of operations being foregut (n = 92, 40%) and pulmonary resection (n = 80, 35%). Thirty-nine percent of patients (n = 89) were taking chronic pain medications preoperatively, with 15% on chronic opioids medication (n = 33). After surgery, 166 patients (72%) did not take opioids at home. Multivariate analysis showed any chronic opioid medications before surgery (odds ratio, 28.8; 95% confidence interval, 9.13-90.8, P < .001) were associated with opioid use postoperatively. In contrast, increase in age was associated with a decrease in opioid use (odds ratio, 0.96; 95% confidence interval, 0.93-0.99, P = .01). ConclusionsERAS with pre-emptive pain management was associated with patients avoiding opioid prescriptions during recovery. The patient factor of preoperative opioid pain medication(s) and younger age is a significant factor for the patient needing opioids at home after surgery instead of procedural factors. Patient characteristics should be considered when tailoring the patient's pain management after thoracic surgical procedures.

Effect of preoperative intravenous vs oral acetaminophen on postoperative opioid consumption in an enhanced recovery after surgery (ERAS) program in patients undergoing open gynecologic oncology surgery

ObjectiveBoth intravenous (IV) and oral acetaminophen provide effective opioid-sparing analgesia after surgery when used as part of a multimodal preemptive pain management strategy. The purpose of this study was to compare postoperative opioid consumption in patients undergoing open gynecologic oncology surgery who received preoperative IV vs oral acetaminophen within an enhanced recovery after surgery (ERAS) program. MethodsRetrospective data were collected on consecutive patients undergoing open gynecologic oncology surgery from May 1, 2016 to February 28, 2018 in patients receiving either 1 g IV or oral acetaminophen preoperatively. Patients were given a preoperative multimodal analgesia regimen including acetaminophen, celecoxib, pregabalin and tramadol. The primary outcomes were morphine equivalent daily doses (MEDD) on postoperative days (POD) 0 and 1. Secondary outcomes included highest patient-reported pain score in the post-anesthesia care unit (PACU) and intraoperative MEDD. Regression models adjusted by matched pairs were fit to estimate the average treatment effect of IV vs oral acetaminophen on MEDD. ResultsOf 353 patients, 178 (50.4%) received IV acetaminophen and 175 (49.6%) received oral acetaminophen. When balancing across the matched samples, there was no difference in postoperative MEDD for POD 0 between the IV and oral acetaminophen groups (Beta = −1.11; 95% CI: −4.83 to 2.60; p = 0.56). On POD 1, there was no difference between the IV and oral groups (Beta = 2.24; 95% CI: −2.76 to 7.25; p = 0.38). ConclusionsThere was no difference in postoperative opioid consumption between patients receiving preoperative IV or oral acetaminophen within an ERAS program for patients undergoing open gynecologic oncology surgery.

Pre-emptive pain management program is associated with reduction of opioid prescription after minimally invasive pulmonary resection.

BackgroundWe developed and implemented a pre-emptive pain management program wherein providers agreed to have non-opioid pain medication as a standard pain management strategy at discharge accompanied by patient education about the program.MethodsA retrospective case-control study of prospectively collected data of patients who underwent minimally invasive pulmonary resection. We compared the outcomes among patients who were managed with pre-emptive pain management program with enhanced recovery after surgery (Pre-emptive), enhanced recovery program after surgery alone (ERAS) and standard care (control).ResultsOf the 443 patients, 132 patients (30%) were in the pre-emptive pain management group, 90 (20%) patients were in the ERAS only group and 221 (50%) in the control group. There were significantly fewer complications (15.9% vs. 23.3% vs. 38%, P<0.001), shorter median length of hospital stay (2 vs. 3 vs. 3 days, P<0.001), lower 30-day readmission rates (2.3% vs. 3.3% vs. 11.3%, P=0.002), and fewer opioid prescriptions at discharge (17.4% vs. 76.7% vs. 83.7%, P<0.001) in the pre-emptive pain management group compared to the ERAS and control groups. Multivariate logistic regression analyses showed that the pre-emptive pain management program (OR 0.06; 95% CI, 0.03, 0.11, P<0.001) and robotic surgery (OR 0.52; 95% CI, 0.3, 0.88, P=0.02) were associated with lower odds of patients being discharged to home with opioid prescriptions. The median pain score in the pre-emptive pain group at 30 days after surgery was 1.5 on a pain scale of 1–10.ConclusionsThe pre-emptive pain management program was associated with a decrease in opioid prescriptions after elective pulmonary resections. Successful implementation of this program can lead to significant decreases in the amount of prescription opioids in the community.

Preemptive pain-management program is associated with reduction of opioid prescriptions after benign minimally invasive foregut surgery

ObjectiveThe opioid crisis is partly due to opioids prescribed after elective surgery. We sought to determine if a preemptive pain-management program would be associated with opioid-free discharge after benign foregut surgery. MethodsA retrospective case-control study of prospectively collected data was conducted at a single institution of patients who underwent elective minimally invasive benign foregut surgery. We compared the outcomes among patients who were managed with standard care (control), enhanced recovery after surgery alone, or a preemptive pain-management program with enhanced recovery after surgery. ResultsAmong 414 patients, there were significantly fewer opioid medication prescriptions at discharge (9.6% vs 85.2% vs 87%, P < .001) and fewer postoperative complications (3.2% vs 14.8% vs 15.1%, P = .004) in the preemptive pain-management group (n = 94), enhanced recovery after surgery alone (n = 81), and the control group (n = 239), respectively. Multivariable logistic regression analysis showed that the preemptive pain-management program was a factor associated with a decrease in opioid medication prescriptions at discharge (odds ratio, 0.01; 95% confidence interval, 0.01-0.03; P < .001), as well as a decrease in complications after surgery (odds ratio, 0.22; 95% confidence interval, 0.06-0.79; P = .02). Moreover, in the preemptive pain-management group, average self-reported pain level in a subset of patients at 30 days after surgery was 0.9 ± 1.4 on a 0- to 10-point pain scale. ConclusionsThe preemptive pain-management program was associated with opioid-free discharge after minimally invasive foregut surgery. This study provides a strategy to reduce opioid prescriptions after foregut surgery and, if implemented nationally, could decrease the amount of opioids used in the community.

Clinicopathological characteristics of patients with pain after endoscopic submucosal dissection for gastric epithelial neoplasm.

Endoscopic submucosal dissection (ESD) is widely used for large superficial gastrointestinal tumors. Epigastric pain is a frequent complication of ESD. However, little is known about its incidence and associated factors. This study evaluated pain incidence and characteristics of patients with pain after gastric ESD. We retrospectively analyzed a prospectively collected registry of clinical, endoscopic, and pathologic results of patients who underwent ESD for gastric adenoma or cancer from January 2010 to December 2015. A Visual Analogue Scale (VAS) was used to assess pain immediately after, and 2, 12, and 24h after ESD. The primary outcome was the use of painkillers (VAS score > 4). Analyzed data included age, sex, pathology, specimen and tumor size, procedure time, and tumor location. Of 1226 patients, 461 (36.4%) needed a painkiller at least once after ESD (pain group). Compared with the no pain group, the pain group had more females, less alcohol consumption, larger tumor and specimen size, and more antral lesions. In multivariate analysis, female sex (OR 1.559, 95% CI 1.217-1.996, p < 0.001), antral tumor location (OR 1.780, 95% CI 1.398-2.265, p < 0.001), and procedure time over 30min (OR 1.443, 95% CI 1.130-1.842, p = 0.003) were predictive factors for pain. This study showed that a considerable number of patients needed one or more painkiller doses after gastric ESD. The factors affecting pain included sex, procedure time, and lesion location. Endoscopists should use preemptive or aggressive pain management in high-risk patients after ESD.

Evaluation of preemptive dexketoprofen trometamol effect on blood chemistry, vital signs and postoperative pain in dogs undergoing ovariohysterectomy.

To investigate the postoperative analgesic effects of preemptive dexketoprofen trometamol in dogs subjected to ovariohysterectomy (OHE). Seventeen adult bitches of various breeds were used in this study. The dogs were randomly allocated into of two groups. Subjects in the dexketoprofen trometamol (DEX) group (n=10), received intravenous (i.v.) dexketoprofen trometamol, 1 mg/kg, 15 minutes before premedication, while those assigned to the control (C) group (n=7) were given no analgesics prior to premedication. Pain level was assessed by two researchers before the administration of anaesthesia (15 minutes before start) and 0, 1, 2, 4 and 6 hours after surgery. A modified University of Melbourne Pain Scale (UMPS) was used to evaluate pain in both groups. Serum cortisol level changed from 0 to 1 h and from 0 to 1 to 4 h were compared between the groups; the increase in the C group was statistically significant. The modified UMPS was applied to both groups at baseline and postoperative 1, 2, 4 and 6 h. According to this test, the values for DEX were significantly lower than controls at 4 and 6 h (p<0.001). Stable vital signs with unchanged biochemical parameters on dexketoprofen administration are a promising finding. The clinical advantage shown by the pain scale difference and the low serum cortisol levels should qualify dexketoprofen for preemptive pain management in dogs (Tab. 5, Fig. 2, Ref. 30).

Pre-Emptive and Multi-Modal Perioperative Pain Management May Improve Quality of Life in Patients Undergoing Spinal Surgery

Background: Compared to an abundance of data on surgical techniques for degenerative spine conditions and the outcomes thereof, little is available to guide optimal perioperative pain management after spinal surgery. The aim of this study was to survey patterns of perioperative pain management after spinal surgery and to investigate the effects of perioperative pain management, such as pre-emptive analgesia and multi-modal postoperative pain management, on acute postoperative satisfaction, pain reduction, and health-related quality of life in patients undergoing spinal surgery. Study design: Non-blind multicenter prospective observational clinical series. Setting: Seventeen tertiary hospitals (14 hospitals attached to medical colleges and 3 general hospitals). Methods: Pain management protocols of 393 patients (153 men, 240 women; mean age of 67 years, ranging from 21 to 91 years) from 17 tertiary hospitals after spinal surgery for degenerative spine disease were evaluated using a self-administered questionnaire. Results: A total of 79 (20%) patients received pre-emptive analgesics, which included cyclooxygenase-2 (COX-2) inhibitors, with or without administration of anticonvulsants, immediately before surgery at the time of antibiotic prophylaxis. Postoperative pain was managed mainly by multi-modal therapy (363 cases, 92%), along with various combinations of patient controlled anesthesia (PCA), conventional nonsteroidal anti-inflammatory drugs (NSAIDs), COX2 inhibitors, and narcotics. Self-reported levels of pain were not significantly different among postoperative multiple modalities of pain management, but were different significantly for preemptive pain management regimens (P &lt; 0.05, independent t-test). The number of patients that reported the self-administrative use of PCA was higher in the no pre-emptive pain management group compared to the pre-emptive group (P &lt; 0.05). In regards to EQ-5D usual activity, depression/ anxiety and self-care improved significantly in the pre-emptive pain management group when measured at 2 weeks postoperative (P &lt; 0.05). Limitations: The limitation of our study is that it is not a randomized controlled observational study. Conclusions: Pre-emptive analgesia and multi-modal pain management after spinal surgery may lead to better health-related quality of life, greater patient satisfaction, and less postoperative pain. Key words: Degenerative spine, surgery, pre-emptive, pain, management

A Multimodal Clinical Pathway Can Reduce Length of Stay After Total Knee Arthroplasty

Clinical pathways reduce length of stay which is critical for hospitals to remain financially sound. We sought to determine if a multimodal pathway focusing on pre-op discharge planning and pre-emptive pain and nausea management lead to reduced length of stay, better pain management, and more rapid functional gains without an increase in post-op complications. A multimodal pathway incorporating pre-op discharge planning and pre-emptive pain and nausea management was initiated in August of 2007. Physical therapy began the day of surgery. Two hundred eleven patients treated over a 3-month period with the new pathway were compared to 192 patients treated in the last 3months of an older pathway. Length of stay, VAS scores for pain, and the incidence of nausea were compared. Length of time to achieve functional milestones while in hospital and the incidence of complications out to 6months were compared. Average length of stay was reduced by 0.26days. VAS scores for pain were lower. Several functional milestones were achieved earlier and complications were not increased. Efforts to control nausea were not successful and severe nausea was experienced in 40% of patients in both groups. This enhanced pathway can lead to an important reduction in length of stay. Although this reduction seems small, it can significantly increase patient throughput and increase hospital capacity. Post-op nausea continues to be an impediment in patient care after TKR.

Assessment, Physiological Monitoring, and Consequences of Inadequately Treated Acute Pain

Postoperative pain is a major health care issue. Several factors have contributed to inadequate postoperative pain control, including a lack of understanding of preemptive pain management strategies, mistaken beliefs and expectations of patients, inconsistencies in pain assessment practices, use of as-needed analgesics that patients must request, and lack of analgesic regimens that account for interindividual differences and requirements. Untreated acute pain has the potential to produce acute neurohumoral changes, neuronal remodeling, and long-lasting psychologic and emotional distress and may lead to prolonged chronic pain states. To effectively manage postoperative pain, nurses must be able to adequately assess pain severity in diverse patient populations, understand how to monitor physiologic changes associated with pain and its treatment, be prepared to address the psychosocial experiences accompanying pain, and know the consequences of inadequate analgesia. It is important for nurses to be aware of relevant research and evidence-based guidelines that are available to guide pain assessments and patient monitoring practices.

Assessment, Physiological Monitoring, and Consequences of Inadequately Treated Acute Pain

Postoperative pain is a major health care issue. Several factors have contributed to inadequate postoperative pain control, including a lack of understanding of preemptive pain management strategies, mistaken beliefs and expectations of patients, inconsistencies in pain assessment practices, use of as-needed analgesics that patients must request, and lack of analgesic regimens that account for inter-individual differences and requirements. Untreated acute pain has the potential to produce acute neurohumoral changes, neuronal remodeling, and long-lasting psychological and emotional distress, and may lead to prolonged chronic pain states. To effectively manage postoperative pain, nurses must be able to adequately assess pain severity in diverse patient populations, understand how to monitor physiological changes associated with pain and its treatment, be prepared to address the psychosocial experiences accompanying pain, and know the consequences of inadequate analgesia. It is important for nurses to be aware of relevant research and evidence-based guidelines that are available to guide pain assessments and patient-monitoring practices.

The Effect of Preemptive Analgesics on Third Molar Outcomes

Control of pain following elective but necessary surgical removal of third molars for many is an afterthought, or managed with a “cookbook” management scheme of simply writing a prescription for a large number of combination analgesic tablets or capsules (acetaminophen plus an opioid). This approach spawns multiple concerns and problems including opioid overdose, dependency and addiction, liver failure, and bleeding disorders. There has been significant research addressing preemptive pain management to minimize post operative pain. Reducing or preventing pain however with current pharmacologic agents and accepted technique may have some adverse impact on the healing process. A consistent yet alterable pain management technique is obtainable for improvement of patient satisfaction with the procedure experience. Recent research regarding timing of analgesic dosing, use of modalities that effect pain control during sedation or general anesthesia, and efficacy associated with the use of local anesthesia agents will be presented.

Pathophysiology and Management of Surgical and Chronic Oral Pain in Dogs and Cats

Pain involves a myriad of physiochemical responses leading to the perception of an unpleasant sensation arising from tissue damage. An understanding of the terminology and basic neurophysiology involved with the pain process is helpful in preventing and treating discomfort in our patients. A general understanding of the concepts of nociception, peripheral sensitization, and central sensitization will allow decisions to be made on the choices of analgesic agents in each individual patient based upon the type, duration, and severity of the pain. Using preemptive pain management with a multimodal approach provides the most consistent and predictable results. Analgesic protocols should be closely scrutinized on an individual basis with careful patient pain assessment during the postoperative period. Chronic pain mechanisms, particularly significant in cancer pain and stomatitis, require aggressive and perhaps unique approaches to ensure maximum patient comfort.

COX-2 inhibition and pain management: a review summary

Cyclooxygenase-2 selective inhibitors have long been regarded as potent anti-inflammatory drugs for the treatment of arthritis, osteoarthritis and dysmenorrhea. The reports of cardiovascular risk and the subsequent withdrawal of rofecoxib, and recently valdecoxib, has called the therapeutic potential of coxibs into question. Currently, according to the latest decisions of the US Food and Drug Administration and European Medicines Agency, the approval of valdecoxib has been refused for 1 year due to an increased rate of cardiovascular risks and serious skin reactions. There are restrictions concerning the use of all other coxibs. The short-time use of coxibs, however, in anti-inflammatory treatment and in perioperative settings may become important in the future. Exact insights into the processes of pain modulation explain the benefit of coxibs in reducing peripheral and central nociception, and their use in pre-emptive and multimodal pain management. In the future, coxibs could be established into a personalized therapy in patients with a low cardiovascular risk, but with increased risk of gastrointestinal complications.