Rate Of Severe Pain Research Articles

Impact of preoperative anxiety on postoperative outcomes in patients undergoing minimally invasive thoracoscopic surgery: A prospective cohort study

BackgroundPreoperative anxiety is a common preoperative psychological state in patients with cancer and associated with worsening perioperative outcomes. However, high-quality prospective studies on preoperative anxiety in patients undergoing lung surgery are scarce. MethodsWe conducted a prospective cohort study, enrolling a total of 540 patients. Preoperative anxiety in patients undergoing thoracic surgery was measured using the Hospitalization Anxiety Scale. Patients were grouped according to the Hospitalization Anxiety Scale scores as follows: no anxiety (score <8) and anxiety (score ≥8). The association of preoperative anxiety with postoperative complications and non-complicated adverse events was determined by univariate regression and polynomial regression analyses. ResultsA total of 121 patients (22.4 %) experienced preoperative anxiety. The anxiety group had a longer average hospital stay (4.33 vs. 3.85 days). Postoperative complications were similar between groups, but the anxiety group reported worse sleep quality (measured by the Athens Insomnia Scale). Regarding postoperative pain, both groups had comparable rates of mild and severe pain on postoperative day 1. However, the anxiety group experienced significantly higher rates of severe pain on postoperative day 2 and mild pain on postoperative day 3. Additionally, the incidence of postoperative nausea and vomiting was significantly higher in the anxiety group on postoperative day 1. ConclusionsPreoperative anxiety may not increase the rates of postoperative complications in patients undergoing lung surgery. However, it may be associated with postoperative sleep disturbances, pain, nausea, and vomiting, as well as prolong the length of postoperative hospitalization.

Retrospective Review of Intrathecal Hydromorphone Dose Range and Complications

BACKGROUND: Optimal intrathecal dosing regimens for hydromorphone are not well established for analgesia after abdominal surgery. OBJECTIVES: We reviewed intrathecal hydromorphone doses and complications because dosing variability has been observed among anesthesiologists. We hypothesized that increasing doses of intrathecal hydromorphone would be associated with improved postoperative analgesia, but with increased rates of opioid-related adverse events. STUDY DESIGN: Retrospective analysis. SETTING: A high-volume academic referral center in the United States. METHODS: A retrospective study was conducted of adults undergoing abdominal surgery under general anesthesia supplemented preoperatively with intrathecal hydromorphone for postoperative analgesia from May 5, 2018, through May 31, 2021. Patients were categorized into 3 hydromorphone dosing groups: low-dose (50-100 µg), middle-dose (101-199 µg), and high-dose (200-300 µg). Multivariable logistic regression models were used to assess rates of severe postoperative pain, severe opioid-related adverse events, oversedation, and pruritus in the postanesthesia care unit (PACU) and within 24 hours after PACU discharge. RESULTS: Of 1,846 patients identified, 1,235 (66.9%) were in the low-dose group; 321 (17.3%), middle-dose group; and 290 (15.7%), high-dose group. Patients receiving the 2 higher doses had more extensive procedures. An unadjusted analysis showed differing rates of severe pain in the PACU by group: 306 (24.8%) in the low-dose, 73 (22.7%) middle-dose, and 45 (15.5%) in the high-dose group (P = 0.003); these differences, however, were no longer significant after an adjusted analysis (P = 0.34). Ten severe opioid-related events occurred; all were recognized in the PACU. Five events each occurred in the low-dose and high-dose groups versus none in the middle-dose group (P = 0.02). No other differences were identified with adjusted analyses. LIMITATIONS: Limitations of our study include its retrospective design and its conduct at a single center, along with the apparent, but difficult to characterize, treatment biases in hydromorphone dosing. CONCLUSIONS: No dose response was observed between intrathecal hydromorphone dose and postoperative analgesia, a finding that may reflect treatment bias. Higher rates of severe opioid-related events were detected for patients receiving high-dose hydromorphone in the PACU, but all other safety outcomes were similar between dosing regimens. KEY WORDS: Drug-related side effects, opioid analgesics, outcome assessment, postoperative pain, spinal injections

Effect of Dexamethasone in Management of Postoperative Nausea, Vomiting and Pain After Tonsillectomy in Paediatric Patients

Introduction: The effectiveness of dexamethasone (DEX) in reducing complication rates following paediatric tonsillectomy is still up for debate. The incidence of postoperative nausea and vomiting (PONV) and the severity of pain following paediatric tonsillectomy were examined by comparing concentrations of DEX 0.15 and DEX 0.5 mg/kg, respectively. Aim of the study: The aim of the study is to assess the effect of Dexamethasone in management of postoperative nausea, vomiting and pain after tonsillectomy where the targeted patients are of 3 to 10 years children. Methods: This prospective cross sectional study was conducted in the Department of Paediatric Anaesthesiology and Surgical ICU in Bangladesh Shishu Hospital and Institute, Dhaka, Bangladesh during July 2019 to June 2022. This study included 123 children undergoing elective tonsillectomy. The Institutional Ethics Committee approved this study and informed parental written consent was obtained from the parents before collecting the patients’ information. Results: The prevalence of early PONV was lower in both DEX groups (DEX 0.15: 22%; DEX 0.5: 26%; placebo: 48%; P=0.001). On the second day after surgery, the DEX groups had a lower rate of severe pain (DEX 0.15: 20%; DEX 0.5: 5%; placebo: 47%; P&lt;0.001). The study was not conducted to assess a difference between the two dose groups of Dexamethasone. Conclusions: The frequency of early and late PONV and the level of pain on the second postoperative day were both reduced by an i.v injection of DEX during the induction of anesthesia. To reduce the incidence of PONV, it appeared that a dose of DEX 0.15 mg/kg was just as effective as a dose of DEX 0.5 mg/kg.

EFFICACY OF PLATELET-RICH PLASMA INTRA-ARTICULAR INJECTION IN ADJUNCTION TO CONVENTIONAL THERAPY FOR ASEPTIC NECROSIS OF FEMORAL HEAD

Objectives: To evaluate the results of autologous platelet-rich plasma (PRP) intra-articular injection combined with medical therapy in treating aseptic necrosis of the femoral head (ANFH) after 5 months. Subjects and methods: Non-control interventional study, comparing before and after treatment for 30 patients (47 sterile necrotic femoral heads) who received 2 injections of PRP one month apart. Evaluation of clinical symptoms and images of necrosis on magnetic resonance imaging of the hip joint after 5 months. Results: The mean Visual Analogue Scale (VAS) decreased from 7.03 ± 1.90 to 3.77 ± 2.64, and the rate of severe pain decreased from 63.3% to 23.3%. The average range of motion of the hip joint increased (flexion from 87.17 ± 13.69 to 101.50 ± 14.69; abduction from 21.50 ± 5.89 to 28.50 ± 7.09; external rotation from 28.33 ± 4.01 to 34.00 ± 5.15; internal rotation from 30.33 ± 4.90 to 34.17 ± 4.93 degrees) with p &lt; 0.001. According to Merle D'Aubigné, the ability to walk score increased from 4.05 ± 0.83 to 4.95 ± 0.76 (p &lt; 0.001). Magnetic resonance imaging showed the rate of bone marrow edema decreased from 66.7% to 40.0% (p &lt; 0.05), four sterile necrotic femoral heads from stage III to stage IV. Conclusion: The results of autologous PRP intra-articular injection combined with medical therapy in treating ANFH have markedly improved analgesia and motor function.

Assessment of Pain Management in Patients Referred to Radiation Oncology for Palliation of Acute Pain Symptoms

<h3>Purpose/Objective(s)</h3> More than half of cancer patients experience pain during their disease course. The three-step analgesic ladder developed by the World Health Organization promotes appropriate escalation from non-opioid analgesics to increased strength opioids. Despite these established guidelines, patients are often under-treated for their intensity of pain. The aim of this study is to investigate whether patients sent to a tertiary center Radiation Oncology department for acute pain symptoms are appropriately pharmacologically managed before and after presenting for a consultation. <h3>Materials/Methods</h3> This retrospective review of cancer patients seen in consultation for palliative radiation analyzed patients seen in consultation for acute pain management between July 23, 2020, and July 23, 2021. Clinical data including patient and treatment characteristics, cancer type, pain scores and medication lists were abstracted for all identified patients. Statistical analysis was performed using univariate and multivariate logistic regression models to assess patient characteristics associated with severe pain. <h3>Results</h3> The mean overall pain score was 5.95 (SD 2.53). Patients were stratified into mild to moderate pain (pain score 1-6) or severe pain (pain score 7-10). Among 137 patients, 54.7% (n=75) presented with mild to moderate pain and 45.3% (n=62) presented with severe pain. In patients presenting with severe pain, 67% had been prescribed morphine milligram equivalents (MME) of less than 50, and 35% had been prescribed MME of less than 25. Patients who identified as African American (OR 3.35, p=0.008) were more likely to present with severe pain compared to Caucasian patients, and patients insured by Medicaid (OR 3.61, p=0.018) were more likely to present with severe pain compared to patients with private insurance. Age, gender, marital status, and establishment of medical oncology care prior to consultation did not predict severe pain. <h3>Conclusion</h3> Patients presenting for a consultation to receive palliative radiotherapy for acute pain management are often not on adequate pain medications and have not been provided with pain/palliative care referrals. Patients who are African American present at higher rates of severe pain in comparison to Caucasian patients. Patients insured with Medicaid present at higher rates of severe pain than patients with private insurance. Our findings add to a body of literature, highlighting the inequities in providing adequate pain management to all populations. The findings of this study should promote the development of standardized protocols for cancer patients receiving palliative care for pain.

Effects of dezocine combined with dexmedetomidine on adverse reactions and inflammatory factors in patients undergoing HIPEC after intestinal surgery and its protective effect on the heart in the perioperative period.

The aim of this study was to explore the effects of dezocine combined with dexmedetomidine on adverse reactions and inflammatory factors in patients undergoing hyperthermic intraperitoneal chemotherapy (HIPEC) after intestinal surgery and its protective effect on the heart in the perioperative period. A total of 80 patients treated with HIPEC after intestinal surgery in our hospital from September 2018 to December 2019 were enrolled as research subjects. All patients were evenly divided into two groups using a random number table. As to analgesia and sedation during treatment, dezocine was injected intramuscularly at 30 min before treatment in the control group. Meanwhile, dezocine combined with dexmedetomidine was given in the same way in the observation group. Adverse reactions and changes in numeric rating scale (NRS) pain score during intervention were compared between the two groups. The changes in the levels of inflammatory and myocardial injury-related factors, and vascular endothelial function and regeneration ability among cardiovascular indicators at 12 h after intervention were compared as well. Additionally, the correlations of left ventricular mass index (LVMI) with the changes in the levels of inflammatory factor high-sensitivity C-reactive protein (hs-CRP), myocardial injury-related factor lactic dehydrogenase (LDH), vascular endothelial function indicator endothelin-1 (ET-1) and cardiovascular regeneration ability index vascular endothelial growth factor (VEGF) were analyzed. Compared with control group, the total prevalence rate of severe pain, respiratory depression, nausea and vomiting, diarrhea, and muscle rigidity during intervention was significantly reduced in the observation group (p<0.05). NRS pain score at 1, 4, 8 and 12 h after intervention decreased remarkably in the observation group compared with the control group (p<0.05). Meanwhile, the levels of inflammatory factors tumor necrosis factor-α (TNF-α) and hs-CRP, and myocardial injury-related factors LDH and creatine kinase MB (CKMB) as well as ET-1 at 12 h after intervention declined remarkably in observation group compared with control group (p<0.05). However, the levels of nitric oxide (NO), VEGF and basic fibroblast growth factor (bFGF) rose significantly in the observation group (p<0.05). Besides, LVMI was positively correlated with hs-CRP and LDH, whereas was negatively associated with ET-1 and VEGF (p<0.05). In HIPEC, dezocine combined with dexmedetomidine used for sedation and analgesia is able to effectively reduce adverse reactions and relieve inflammatory responses in vivo, exerting a cardio-protective effect.

Water immersion sigmoidoscopy versus standard insufflation for colorectal cancer screening: A cohort study.

Background:Although the efficacy of water-assisted colonoscopy is well established, the role of water immersion sigmoidoscopy (WIS) remains unclear. We compared WIS with carbon dioxide insufflation sigmoidoscopy (CO2S) on patient outcomes.Methods:We conducted an analysis of prospectively collected data from a single-center quality improvement program about patients undergoing unsedated screening sigmoidoscopy (WIS and CO2S) between May 2019 and January 2020. Outcomes studied included the following: Rates of severe pain <17% (score of ≥7 on a numeric rating scale of 0–10, and on a Likert scale), willingness to repeat the procedure without sedation, adequate bowel cleanliness >75% (proportion of Boston Bowel Preparation Scale score: 2–3) and adenoma detection rate (ADR).Results:In total, 234 patients (111 WIS; 123 CO2S) were included. All patients were aged 58 years and 58.9% were female; baseline characteristics were comparable between groups. There were no significant differences in rates of severe pain (WIS: 16.5%, CO2S: 13.8%; P = 0.586), willingness to repeat the unsedated procedure (WIS: 82.3%, CO2S: 84.5%; P = 0.713), adequate bowel cleanliness (WIS: 78.4%, CO2S: 78%, P = 0.999) or ADR (WIS: 25.2%, CO2S: 16.3%; P = 0.106) between groups. However, average procedure times were longer with WIS (9.06 min) compared to CO2S (6.45 min; P < 0.001). Overall, 29.6% of women reported that they would repeat sigmoidoscopy only if sedated.Conclusions:WIS does not ameliorate tolerance to and quality of sigmoidoscopy screening measured by several scores. When offered a choice, the women's willingness to repeat WIS or CO2S without sedation was poor and raises concern on the opportunity of screening sigmoidoscopy without sedation in these subjects.

Comparison of the efficacy and safety of two combined misoprostol regimens for second trimester medical abortion

Objective The aim of the study was to compare the efficacy and safety of two combined misoprostol regimens for second trimester medical abortion. Methods This was a retrospective cohort study examining data on singleton pregnancies that underwent second trimester medical abortion between November 2011 and November 2019 in a tertiary care centre in northern Greece. In the first study period (November 2011 to August 2015), the management protocol (protocol 1) consisted of 800 μg vaginal misoprostol followed by 400 μg oral misoprostol, every 3 h, for up to five doses. In the second study period (September 2015 to November 2019), a new protocol (protocol 2) was introduced, where the oral route was changed to sublingual, using the same dosage. The two routes were compared in terms of efficacy and safety. Results The study comprised 85 women: 43 (50.6%) received the protocol 1 regimen (vaginal-oral), while 42 (49.4%) received the protocol 2 regimen (vaginal-sublingual). The groups did not differ in terms of maternal age, gestational age and parity. Sublingual misoprostol was more effective than oral misoprostol, both in terms of dose needed (median 1600 μg vs 2000 μg; p = 0.031) and induction-to-abortion interval (8 h vs 11 h; p = 0.001). Surgical evacuation due to incomplete abortion was necessary in 11.9% of women in the sublingual group vs 18.6% in the oral group (p = 0.394). Women in the sublingual group reported a higher rate of severe pain (odds ratio [OR] 6.061; 95% confidence interval [95% CI] 1.240, 29.619) and shivering (OR 4.632; 95% CI 1.788, 11.995). Conclusion The administration of vaginal-sublingual misoprostol, when compared with the vaginal-oral regimen, was associated with a shorter induction-to-abortion interval but a higher incidence of severe pain and shivering.

Mindful Self-Compassion (MSC) with Veterans: a Program Evaluation

This pilot study explores the impact of Mindful Self-Compassion (MSC) in veterans. Self-compassion, the capacity to hold one’s suffering with kindness and a wish to alleviate it, is associated with improvements in well-being. Veterans have more medical conditions than non-veterans and higher prevalence rates of severe pain. Acceptability of the intervention with veterans is assessed along with the impact of MSC on the physical, mental, and social health of the participants. A racially diverse, predominantly male group of veterans (n = 80) were assessed pre- and post-MSC group with the Patient-Reported Outcomes Measurement Information System (PROMIS) to evaluate physical, mental, and social health. Measures of self-compassion, happiness, self-report medication usage, and a global assessment of improvement measure were also included. Qualitative responses to the MSC program were also solicited and reviewed. Engagement with MSC was high (74% completion rate) and 96% of treatment completers rated their participation in the intervention as positive. Completers demonstrated small to medium effect size increases in self-compassion, happiness, and social role satisfaction, 95% CIs (− 6.13, − 2.65), (− 2.62, − 1.06), and (− 4.28, − 1.05), and decreases in depression, anxiety, fatigue, and pain interference, 95% CIs (0.44, 4.13), (0.57, 4.84), (0.43, 3.71), and (0.13, 2.70). In exploratory analyses related to pain, veterans taking pain medication reported a significant decrease in use (χ2(2, N = 47) = 24.30, p < .001). These results are suggestive of the positive effects of the MSC intervention to veterans, but await a randomized controlled trial to establish its effectiveness in this population.

A Prospective Study of Factors Associated with Abdominal Pain in Patients during Unsedated Colonoscopy Using a Magnifying Endoscope.

Objective With the advent of endoscopic treatment, the detailed diagnosis of colorectal neoplasms made using magnifying colonoscopy has become increasingly important. However, insertion difficulty causes pain in unsedated colonoscopy. The aim of this prospective observational study was to clarify the factors associated with a patient's pain in unsedated colonoscopy using a magnifying endoscope. Methods Patient pain was assessed using a numerical rating scale (0-10) immediately after the procedure. We defined 5 as mild enough pain that patients would not be reluctant to undergo another colonoscopy. Acceptable pain was defined as 5 or less and severe pain was defined as 8 to 10. Univariate and multivariate linear regression analyses were performed using the pain scale score as a dependent variable. Results A total of consecutive 600 patients undergoing unsedated colonoscopies were evaluated to assess their abdominal pain. The completion rate was 99.5% (597/600). The mean pain scale score was 3.88±2.38. The rate of acceptable pain was 80.5% (483/600). The rate of severe pain was 6.7% (40/600) including the incomplete cases. A comparison of polyp-positive and polyp-negative cases revealed no marked difference in patient pain (3.82±2.24 vs. 3.94±2.49, respectively; p=0.590) or insertion time (6.62±3.98 vs. 6.29±4.21, p=0.090), while more observation time was needed in polyp-positive cases than in polyp-negative ones (16.30±4.95 vs. 13.08±4.69, p<0.01). Univariate and multivariate linear regression analyses revealed that an older age, colectomy, antispasmodic agent use, and a small-diameter endoscope were significant factors associated with less patient pain. In particular, a small-diameter endoscope induces significantly more acceptable pain than a non-small diameter endoscope [85.63% (274/320) vs. 73.93% (207/280), p=0.00003]. Conclusion Unsedated colonoscopy using a magnifying endoscope by an expert may result in acceptable pain levels. The use of an antispasmodic agent, particularly hyoscine N-butyl bromide, and a small-diameter endoscope are recommended for reducing abdominal pain during unsedated colonoscopy.

COMPARISON OF MINI CHOLECYSTECTOMY VERSUS OPEN CHOLECYSTECTOMY IN PATIENTS WITH CHOLELITHIASIS

ABSTRACT&#x0D; Objectives: The objective of this study is to compare the outcome of mini cholecystectomy with open conventional cholecystectomy in the management of cholelithiasis.&#x0D; Study Design: This was a randomized controlled trial.&#x0D; Study Period: Study was conducted in Department Of Surgery, Teaching Hospital Dera Ghazi Khan, from June 2017 to Dec 2017 for a period of six month.&#x0D; &#x0D; Patients and Methods: A total of 100 cases; 50 cases in each group was included in the study. 100 patients were admitted from OPD of Teaching Hospital Dera Ghazi Khan fulfilling inclusion criteria. Demographic information was recorded. All admitted patients were diagnosed on the basis of history, clinical examination and relevant investigations. Written consent was obtained. Data entry and analysis&#x0D; was done by using SPSS 11. Data was analyzed according to the proposed analysis plan.&#x0D; &#x0D; Results: Mean age of all patients was 39.96±3.84 years. Age range of patients was 30-48 years. In Group-A mean hospital stay was 5.38±1.15 and in Group-B mean hospital stay was 3.02±0.58 days respectively. At 1st visit 14(28%) patients in Group-B and only 1(2%) patient in Group-A had wound infection. According to p-value wound infection was significantly associated with treatment group. Patients in Group-A had less infection rate as compared to Group-B patients. i.e. (p-value=0.000) Whereas at 2nd visit 8(16%) patients in Group-B and 3 patients in Group-A suffered from wound infection. At 2nd visit wound infection was statistically same in both treatment groups. i.e. (p-value=0.110). It was observed that in Group-B only 44(88%) of the patients had severe pain whereas only 12(24%) of the patients in Group-A had severe pain. Keeping in mind this results rate of severe pain at 12th hour was high in Group-B patients as compared to Group-A patients. i.e. (p-value=0.000).&#x0D; &#x0D; Conclusion: Mini cholecystectomy is effective and associated with less patients discomfort in terms of post operative pain and infection as well as with less hospital stay.

Anesthesia Management and Postanesthetic Recovery Following Endoscopic Sinus Surgery.

Delayed anesthesia recovery following endoscopic sinus surgery (ESS) can be an indicator of immediate complications and negatively impact healthcare efficiency. This study aims to examine clinical factors with a focus on improving clinical practice. Medical records of patients undergoing ESS under general anesthesia from 2014 to 2018 were reviewed. Based on the interquartile range of anesthesia recovery for the cohort, patients in the upper quartile were categorized as "prolonged" and the lowest three quartiles as "goal" recovery. Patient and surgical characteristics were investigated. Analyzing 416 patients who underwent ESS, the median anesthesia recovery time was 48 [35-66] minutes. Prolonged recovery was associated with higher body mass index (odds ratio 1.50 [95% confidence interval 1.03-2.18] per 10 kg/m2 , P = .03) and surgical duration (1.37 [1.10-1.72] per hour, P < .01). Inversely, goal recovery was associated with preoperative acetaminophen (0.61 [0.38-0.98], P = .04) and intraoperative remifentanil (0.55 [0.32-0.93], P = .03). Patients with prolonged recovery had higher rates of severe pain (33 (31.7%) vs. 25 (8.0%), P < .01), respiratory depression (7 [6.7] vs. 2 [0.6], P < .01), oversedation (39 [37.5] vs. 39 [12.5], P < .01), and the need for rescue opioids (52 [50] vs. 71 [22.8], P < .01). In addition to reduced postanesthesia recovery time, patients who were administered preemptive acetaminophen had lower rates of severe pain (OR 0.55 [0.31-0.98], P = .04) and nausea and vomiting (0.39 [0.17-0.87], P = .02). Our findings substantiate the use of acetaminophen and remifentanil in ESS, facilitating anesthesia recovery. Broadly consideration of preemptive acetaminophen could further increase postoperative comfort in ESS. 4 - Retrospective. Laryngoscope, 131:E815-E820, 2021.

Postoperative Nausea and Vomiting and Pain After Robotic-Assisted Mitral Valve Repair

To determine the rate and clinical factors associated with postoperative nausea and vomiting (PONV) and severe pain after robotic-assisted mitral valve repair. Retrospective chart review. Major quaternary academic medical center. Adult patients undergoing robotic-assisted mitral valve repair from May 5, 2018 through September 13, 2019. Participant electronic medical records were abstracted for clinical characteristics, PONV within the first 72 postoperative hours, episodes of severe pain (defined as pain score ≥7 using an 11-point numerical pain rating scale), and opioid use within the first 24 postoperative hours. Multivariate analyses were performed. Of 124 participants, PONV was noted in 83 (67%; 95% confidence interval [CI] 58%-75%) patients and severe pain in 96 (77%, 95% CI 69%-84%) patients. The median (interquartile range) time to PONV was 6.1 (3.7-14.7) hours. After adjusting for age, sex, and duration of surgery, pre-incisional use of methadone was associated with reduced risk for severe pain (odds ratio 0.40 [95% CI 0.16-0.99]; p = 0.048) and a lower 24-postoperative hour opioid requirement (estimate -29.0 mg intravenous morphine equivalents [95% CI -46.7 to -11.3]; p = 0.006). However, methadone was not associated with a reduction of the cumulative opioid dose (intraoperative and 24-hour postoperative opioid dose; p = 0.248). Both severe pain and PONV were associated with longer hospital stay. PONV and severe pain are common after robotic-assisted mitral valve repair. Peri-incisional methadone is associated with a modest decrease in the severe pain rate but without a reduction in opioid dose or hospital stay.

High Levels of Peripheral Vasoconstriction Detected By Polysomnography Predict More Acute Severe Pain Episodes in Children with Sickle Cell Anemia

Sickle cell anemia (SCA) is genetic disease associated with chronic hemolysis and severe vaso-occlusive pain. Triggers for vaso-occlusive pain include both extreme temperatures (hot and cold), and stress. Our prior work demonstrates that anticipatory pain, experimental pain, experimental mental stress, and cold exposure cause significant global vasoconstriction in SCA and vasoconstriction responses differ among subjects.Anything that decreases microvascular flow will increase the likelihood that the red blood cells will not escape the microvasculature before deoxyhemoglobin S (HbS) polymerizes, leading to vaso-occlusion. However, this theoretical model has not been proven at a macro scale in patients. We showed that hypoxia induced in SCA subjects causes loss of parasympathetic modulation of heart rate but not decreased microvascular flow. Consistent with this, a prospective cohort study of SCA subjects showed no significant association between low mean nocturnal SpO2 and the incidence of VOC. However, surges in sympathetic activity accompany transient arousals and respiratory events during sleep, and lead to varying levels of peripheral vasoconstriction. In a prospective NIH funded cohort study of children with SCA, we tested the hypothesis that children with SCA and high levels when compared to low levels of intrinsic microvascular vasoreactivity (based on vasoconstriction events detected by polysomnography (PSG)) have a higher incidence rate of severe vaso-occlusive pain that requires hospitalization within 6 months of the PSG. We analyzed the time-series of R-R intervals (RRI) derived from the electrocardiogram and beat-to-beat amplitudes of finger photoplethysmography reflecting peripheral blood flow (PPGa) derived from the scored PSGs and clinical records of 212 children, who participated in the multi-center prospective SCA cohort study reported by Willen et al. (Am J Hematol 2018; 93:478-485). Vasoconstriction events were detected by applying an algorithm that found reductions in PPGa from local baseline that exceeded a threshold level of change. The changes in RRI from the pre-vasoconstriction baseline were also computed (Fig 1). The duration, average magnitude (Mvasoc) and area under the curve of PPGa were extracted from each significant vasoconstriction. The median values of these compact descriptors were taken to represent the nocturnal vasoconstriction characteristics of each participant. A participant was classified to be in the high- or low-pain event category if they were hospitalized for severe pain at least two times or less than 2 times within a 1-year window from 6 months before to 6 months after the PSG, respectively. Multiple logistic regression analysis was applied, using pain category as the outcome variable, and vasoconstriction descriptors, arousal index, obstructive apnea-hypopnea index, age, sex and hemoglobin level as predictor variables. Pain category was strongly associated with magnitude of vasoconstriction (Mvasoc; p=0.0058), with larger Mvasoc predicting high-pain, after accounting for age, sex and hemoglobin level (Hgb). Figure 2 displays the adjusted Mvasoc (mean ± SE) in the high-pain and low/no-pain groups. Mvasoc was strongly correlated with arousal index (p=0.0073). However, none of the traditional measures of sleep-disordered breathing, including arousal index, were associated with pain category. Age was the only other predictor of severe pain. These findings, showing that propensity for a high degree of microvascular vasoconstriction is associated with the temporal relationship of severe pain requiring hospitalization, validate on a macro scale the model that increased microvascular transit time promotes entrapment of sickled red blood cells, elevating the risk of severe vaso-occlusive pain. Our data reveals for the first time, a mechanistic link between the patient's symptoms and the triggering of transition from steady state to acute severe pain. The fact that individuals have intrinsic vasoreactivity phenotypes, that can be identified by analysis of the photoplethysmogram, provides yet another factor in acute vaso-occlusive pain. Autonomic balance and vasoreactivity likely contribute to known variability of the incidence rate of severe pain and represent another plausible target for therapeutic intervention. Disclosures Coates: apo pharma: Consultancy, Honoraria, Speakers Bureau; vifor: Consultancy, Honoraria; agios pharma: Consultancy, Honoraria; celgene: Consultancy, Honoraria, Other: steering committee of clinical study.

The impact of a quality improvement project to standardize pain, agitation, and withdrawal assessments on the use of morphine and midazolam in the Pediatric Intensive Care Unit.

This study aims to assess the impact of a quality improvement initiative to increase assessments of pain, agitation, and iatrogenic withdrawal syndrome, on the use of sedative and analgesic medication in a pediatric intensive care unit. This is a retrospective pre and post, observational, quality improvement study conducted in an 18-bed medical-surgical-cardiac, tertiary intensive care unit. We included patients consecutively admitted from October 1 to March 31 (pre-period 2015-2016, post-period 2016-2017) who were mechanically ventilated beyond 48hours. A multidisciplinary team, including a family advisor, implemented the following interventions using rapid "Plan-Do-Study-Act cycles:" (a) standardized pain and sedation assessments, (b) standardized sedation goal setting, and (c) non-pharmacological strategies to manage pain and agitation. We did not implement any specific sedation protocol. We used audit and feedback to reinforce change. The post-intervention phase started once sedation scores were documented q12h for >60% of patients. The groups (n=45 per group) were similar regarding demographics, severity of illness, and mechanical ventilation duration, but different in length of intensive care stay. The cumulative dose of midazolam equivalent was significantly lower in the post-intervention period (3.71 vs 2.65mg/kg/mechanical ventilation day, P=0.009, 95% CI: -1.12 (-1.89, -0.31)). Morphine equivalent usage went from 3.51 to 2.57mg/kg/mechanical ventilation day (P=0.066, 95% CI: -0.67 [-1.44, 0.05]). There were no significant pre-post-differences in the use of other sedative agents, rates of iatrogenic withdrawal syndrome or severe pain, nor medication cost. Implementation of a multifaceted QI project was successful at increasing standardized assessments of pain and agitation, and was associated with a significant reduction in midazolam use. We also observed a decrease in morphine use without increasing rates of severe pain. Incidence of iatrogenic withdrawal syndrome and cost were unchanged.

Evaluation of Nursing Facility Resident Safety During Implementation of the INTERACT Quality Improvement Program

BackgroundMedicare incentivizes the reduction of hospitalizations of nursing facility (NF) residents. The effects of these incentives on resident safety have not been examined. ObjectiveExamine safety indicators in NFs participating in a randomized, controlled trial of the INTERACT Quality Improvement Program. DesignSecondary analysis of a randomized trial in which intervention NFs exhibited a statistically nonsignificant reduction in hospitalizations. SettingNFs with adequate on-site medical, radiography, laboratory, and pharmacy services, and capability for online training and data input were eligible. Participants264 NFs randomized into intervention and comparison groups stratified by previous INTERACT use and self-reported hospital readmission rates. InterventionNFs randomized to the intervention group received INTERACT materials, access to online training and a series of training webinars, feedback on hospitalization rates and root-cause analysis data, and monthly telephonic support. MeasuresMinimum data set (MDS) data for unintentional weight loss, malnutrition, hip fracture, pneumonia, wound infection, septicemia, urinary tract infection, and falls with injury for the intervention year and the year prior; unintentional weight loss, dehydration, changes in rates of falls, pressure ulcers, severe pain, and unexpected deaths obtained from the NFs participating in the intervention through monthly telephone calls. ResultsNo adverse effects on resident safety, and no significant differences in safety indicators between intervention and comparison group NFs were identified, with 1 exception. Intervention NFs with high levels of INTERACT tool use reported significantly lower rates of severe pain. Conclusions/ImplicationsResident safety was not compromised during implementation of a quality improvement program designed to reduce unnecessary hospitalization of NF residents.

Safety and patients’ satisfaction after hysteroscopic sterilisation

The aim of this study was to understand the potential complications of the Essure® device as well as the factors influencing its onset and patient satisfaction. We present a 9-year descriptive prospective study that included 1068 patients. The device was placed in 1056 of them (98.8%); 894 had no pain or mild pain during the insertion and only 12 patients experienced pain greater than menstrual pain. The proportion of patients without pain was greater in the group that took NSAIDs or NSAIDs and BZD and the unmedicated group had the highest rate of severe pain (p = .00). In all, 161 of the 1064 patients who had the Essure® inserted reported having an adverse effect during the 3-months post-insertion (pelvic pain or discomfort). The mean score out of 10 attributed to this method was 9.06 (S = 1.11). We concluded that the Essure® shows a low rate of complications and users showed a high degree of satisfaction.Impact statementWhat is already known on this subject: There are few international publications on Essure®. When we conducted a search in PubMed for the term ‘Essure’, we obtained 221 publications. When we added the terms ‘Essure and complications’, we obtained 20 publications, and when we increased the restriction including ‘satisfaction’, we obtained seven; thus, the uniqueness of our study.What the results of this study add: We present a 9-year descriptive prospective study that included 1068 patients. The aim of this study was to understand the potential complications of the Essure® device (Bayer, Whippany, NJ), as well as factors that can influence its onset and the patient satisfaction. The device was placed in 1056 of the patients (98.8%); 894 had no pain or mild pain during the insertion and only 12 patients experienced pain greater than menstrual pain. The proportion of patients without pain was greater in the group that took NSAIDs or NSAIDs and BZD and the unmedicated group had the highest rate of severe pain (p=.00).What the implications are of these findings for clinical practice and/or further research: Our study shows a low rate of complications with Essure®, mild and transient in most cases, as well as a high degree satisfaction. Nevertheless, given the few published studies on this device, we believe that long-term follow-up is needed.

The prevalence of pain and its relationship to falls, fatigue, and depression in a cohort of older people living in the community.

To examine the relationship of the pain severity scores with demographic variables (age, gender, and ethnicity) and with the frequency of falls, fatigue, and depression in a very large New Zealand sample of people over 65years assessed using the Home Care International Residential Assessment Instrument. Pain is reported to be highly prevalent in older people yet it is poorly correlated with tissue damage. There is convincing evidence that it is related to depression and some evidence of its relationship with fatigue and falls. This is a cross-sectional study examining a national cohort assessed on referral for a needs assessment for access to publicly funded service provision or support. Participants were 45,418 adults aged over 65years referred for a mandatory needs assessment between 2012-2014. All variables analysed were drawn from the Home Care International Residential Assessment Instrument. Univariate descriptive statistics were used to characterize the sample in relation to the association of severe pain with age, gender, and ethnicity and with the key variables of interest: falls, fatigue, and depression. Logistic regression models were used to examine the relationship of the presence or not of severe pain with the other key health-related variables: falls, fatigue, and depression, respectively, after controlling for the presence of age, gender, and ethnicity. Odds ratios are reported to quantify the difference in risk with increasing severity of falls, fatigue, and depression. The mean age of the cohort was 82.48years (SD 7.48) and 48.5% of the sample reported experiencing daily pain. The rates of severe daily pain were 12%-18% with those in the 65-74years group having the highest reported rate of severe pain (18%) and a gradual decrease in severe pain with age. After co-varying for age, ethnicity, and gender, the presence of severe daily pain was predicted by increasing frequency of falls and fatigue and having current depression. While two-thirds reported their pain control was adequate, a third reported that their pain control was not adequate despite adhering to a therapeutic regime. The study highlights how pervasive pain is in this group and its correlation with falls, fatigue, and depression. While the effect sizes were relatively small the results may be clinically significant and it may be clinically important that the presence of pain in older people could indicate the need for further nursing assessment in relation to falls, fatigue, and depression.

Low Nocturnal Hemoglobin Oxygen Saturation Does Not Predict Pain or Acute Chest Syndrome Episodes in Children with Sickle Cell Anemia

Background: Previous evidence has shown that low mean nocturnal oxyhemoglobin saturation is significantly associated with a higher number of pain days per year Hargrave et al. (Blood. 2003; 101(3)846-8). We tested the primary hypothesis that sleep disordered breathing, described by low mean nocturnal oxygen saturation (SpO2), is associated with increased rates of severe vaso-occlusive pain and acute chest syndrome (ACS). Our secondary hypothesis investigated the association between high obstructive apnea hypopnea index (OAHI; the number of obstructive apneas and hypopneas with >3% SpO2desaturations or arousals per hour of sleep) with increased incidence of severe pain requiring hospitalization and ACS episodes.Study design: A prospective cohort study of children and adolescents from the Sleep and Asthma Cohort (SAC) was assembled. Children with sickle cell anemia (SCA), defined as HgbSS or Hb Sβ°, were enrolled from 4 to 18 years of age at three clinical centers, Washington University School of Medicine in St. Louis, Missouri; Case Western Reserve University in Cleveland, Ohio; and University College London in London, UK (which recruited from three London hospitals). At each site, SAC study-certified technicians performed full 12 channel in-laboratory research polysomnography (PSG) including continuous measurements of nocturnal oxygen saturation using standardized protocols according to American Academy of Sleep Medicine guidelines for data acquisition and scoring. All PSGs were read centrally at Vanderbilt University School of Medicine. Negative binomial regression was used to test the association between nocturnal SpO2 and the incidence rate of severe pain requiring hospitalization and ACS episodes. Covariates in the primary models for pain and ACS included: age at polysomnography, sex, hemoglobin, white blood cell count (WBC), OAHI, and mean nocturnal SpO2. All covariates meeting a significance criteria of p<0.20 were subsequently included in the final model for pain or ACS. Pain rate was defined as number of vaso-occlusive pain events that required hospitalization per year. ACS event was defined as an episode of acute respiratory distress associated with a new radiodensity on chest roentgenogram and at least one of the following: temperature greater than 38° Celsius, increased respiratory effort, decreased oxygen saturation, or increased respiratory rate documented in the medical record. A diagnosis of pneumonia was considered an ACS episode. If a pain event occurred with an ACS episode, the participant was counted as having an ACS event.Results: A total of 252 participants with SCA underwent polysomnography and after quality control, 243 were included; of these 223 had values for pain and ACS after polysomnography; missing data were due to lack of follow-up. Of the 223 participants, 18 on hydroxyurea therapy at the time of PSG and one with missing hydroxyurea status were excluded in primary analyses as hydroxyurea treatment is known to significantly influence pain incidence. The final sample included 204 participants, median age 10.4 years (interquartile range 7.3). Participants were followed for median 5.0 years (interquartile range 1.8 after PSG). After adjusting for age, sex, WBC, and hemoglobin, higher nocturnal SpO2 was associated with increased incidence of pain, which is in the opposite direction of our hypothesis (incidence rate ratio 1.11, 95% CI 1.06-1.17, p<0.001). Mean nocturnal SpO2 was not associated with ACS (incidence rate ratio 1.02, CI 0.96-1.09, p=0.500). In separate models, adjusting for age, sex, WBC, and hemoglobin, OAHI was not associated with future pain using either the log OAHI (IRR 0.99, CI 0.88-1.10, p=0.805) or with OAHI ≥2 (IRR 0.87, CI 0.55-1.41, p=0.569). After adjustment for covariates, OAHI was not associated with ACS using either the log OAHI (IRR 1.06, CI 0.92-1.21, p=0.450) or with OAHI ≥2 (IRR 0.86, CI 0.53-1.39, p=0.541). In an attempt to replicate the Hargrave analysis (Blood. 2003; 101(3)846-8), we investigated whether pain days per year was associated with nocturnal SpO2. Nocturnal SpO2was associated with pain days per year, but in the opposite direction of our hypothesis (IRR 1.12, 95% CI 1.05-1.20, p= 0.001).Conclusion: In an unselected group of children with SCA, low mean nocturnal SpO2 and elevated OAHI are not associated with clinically relevant increased incidence rates of vaso-occlusive pain or ACS. DisclosuresNo relevant conflicts of interest to declare.

Vascular Surgery Pain Outcomes Improved by Implementing Hospitalist Comanagement Service

Introduction and Objective: This preliminary study aims to investigate the impact of introducing a hospitalist comanagement service on inpatient vascular surgery pain outcomes. Methods: A total of 2110 consecutive patients were studied: 717 patients who were managed before the comanagement system was implemented (May 2011 to December 2012) and 1393 who were comanaged (January 2013 to December 2014). The visual analog pain (VAP) scores (ranging from no pain to severe pain) of each patient were analyzed. In addition, two questions from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey were additionally analyzed. Results: The comanaged cohort experienced significantly higher rates of patients reporting no pain (Comanaged: 82.97% Not comanaged: 71.97%, p=<0.001) and significantly lower rates of mild pain (Comanaged: 7.39% Not comanaged: 12.55%, p=<0.001) and moderate pain (Comanaged: 7.68% Not comanaged: 13.11%, p=<0.001). The rates of severe pain were similar between groups (Comanaged: 1.93% Not comanaged: 2.37%, p=0.51). HCAHPS results showed increased rates of patients reporting that their pain was always well managed, as well as increased rates of patients reporting that the hospital staff always tried their best to manage their pain. Conclusion: The implementation of a vascular co-management service resulted in significantly improved pain scores and improved HCAHPS scores.