Severe Acute Postoperative Pain Research Articles

Postoperative pain management using multimodal analgesia

Perry and postoperative pain management remain an acute problem to this day. The intensity of pain depends on various objective and subjective factors, on the individual characteristics of the patient. The course and severity of acute postoperative pain determine the likelihood of developing chronic postoperative pain.Then. Multimodal analgesia is the effect on the peripheral and / or central nervous system, acting on drugs and techniques with different mechanisms of action (including non-pharmacological techniques), with synergistic and additive effects that can achieve higher quality analgesia than using these methods alone. Use low-dose medications to avoid dose-dependent side effects. Fractionation of analgesics at all stages of the perioperative period.Postoperative pain prevention should begin as soon as surgical treatment is planned. The multidisciplinary team of physicians, based on the conclusion made after assessing the patient's condition and risk factors, develops a perioperative plan for pain relief. Multimodal analgesia is unequivocally a priority and most effective in the world literature today.

How Much Pain Will I Have After Surgery? A Preoperative Nomogram to Predict Acute Pain Following Mastectomy.

IntroductionAcute postoperative pain affects time to opioid cessation and quality of life, and is associated with chronic pain. Effective screening tools are needed to identify patients at increased risk of experiencing more severe acute postoperative pain, and who may benefit from multimodal analgesia and early pain management referral. In this study, we develop a nomogram to preoperatively identify patients at high risk of moderate–severe pain following mastectomy.MethodsDemographic, psychosocial, and clinical variables were retrospectively assessed in 1195 consecutive patients who underwent mastectomy from January 2019 to December 2020 and had pain scores available from a post-discharge questionnaire. We examined pain severity on postoperative days 1–5, with moderate–severe pain as the outcome of interest. Multivariable logistic regression was performed to identify variables associated with moderate–severe pain in a training cohort of 956 patients. The final model was determined using the Akaike information criterion. A nomogram was constructed using this model, which also included a priori selected clinically relevant variables. Internal validation was performed in the remaining cohort of 239 patients.ResultsIn the training cohort, 297 patients reported no–mild pain and 659 reported moderate–severe pain. High body mass index (p = 0.042), preoperative Distress Thermometer score ≥4 (p = 0.012), and bilateral surgery (p = 0.003) predicted moderate–severe pain. The resulting nomogram accurately predicted moderate–severe pain in the validation cohort (AUC = 0.735).ConclusionsThis nomogram incorporates eight preoperative variables to provide a risk estimate of acute moderate–severe pain following mastectomy. Preoperative risk stratification can identify patients who may benefit from individually tailored perioperative pain management strategies and early postoperative interventions to treat pain and assist with opioid tapering.Supplementary InformationThe online version contains supplementary material available at 10.1245/s10434-022-11976-5.

A Multimodal Analgesic Protocol with Gabapentin-dexmedetomidine for Post-operative Pain Management after Modified Radical Mastectomy Surgery: A Randomized Placebo-Controlled Study

Background and Aim: Modified radical mastectomy (MRM) is accompanied by severe acute postoperative pain. This study evaluated the safety and efficacy of oral gabapentin plus dexmedetomidine infusion as an analgesic multimodal protocol in patients undergoing MRM.
 Methods: This prospective randomized, double-blind placebo-controlled study included 30 females scheduled for MRM from June 2021 to December 2021. They were randomly divided into two groups. GD Group (n=15) received oral gabapentin 400 mg and IV infusion of Dexmedetomidine 0.4 µg/kg/h over 10 min after a bolus of 0.5 µg/kg before induction of general anesthesia. Placebo Group (n=15) received a placebo capsule and saline infusion identical to the GD Group. The primary outcome measure was total morphine consumption, and secondary outcomes were pain and sedation scores and intraoperative fentanyl consumption.
 Results: Pain score was significantly lower in the GD Group than the Placebo group, starting immediately postoperative up to 24 hours except after 18 hours. The total intraoperative fentanyl consumption and postoperative morphine consumption were significantly lower in the GD Group. The sedation score was significantly higher in the GD Group compared to the Placebo group immediately postoperative and after 2 hours. The heart rate and mean arterial pressure were within the clinically accepted ranges intra- and postoperatively in the two groups.
 Conclusion: Preemptive oral gabapentin plus dexmedetomidine IV infusion is a safe and effective analgesic alternative for patients undergoing MRM.

The duration of chronic low back pain is associated with acute postoperative pain intensity in lumbar fusion surgery: a prospective observational study

BackgroundPre-existing chronic pain has been associated with severe postoperative pain. In this study, we sought to prospectively analyse the association between the duration of chronic low back pain and the intensity of acute postoperative pain after lumbar fusion surgery.MethodsA total of 330 patients who underwent lumbar fusion surgery were divided into three groups (chronic low back pain less than 1 year, one to 5 years, and more than 5 years) based on the duration of chronic pain. On the first postoperative day, the maximum pain scores of each patient were recorded during the day and at night. Bivariate correlation and logistic regression were performed to identify relationships between acute postoperative pain and related variables (age, sex, smoking history, body mass index, operation history, duration of surgery, level of preoperative pain, aetiology of back pain, Self-rating Anxiety Scale, Self-rating Depression Scale, FRAIL scale, and duration of chronic low back pain). If the postoperative pain score was > 3 when the patient reported was at rest, the patients were treated with postoperative intravenous self-controlled analgesia or rescue analgesics if necessary.ResultsThere was an association between severe acute postoperative pain and the duration of chronic low back pain. In terms of VAS day, multivariable logistic regression showed the duration of chronic low back pain was not statistically significant (OR = 2.48, 95% CI: 0.900 to 6.828, p = 0.0789). The result is uncertain because the confidence interval included the null after controlling for SAS, SDS, BMI, and aetiology of back pain. In terms of VAS night, patients with a duration of chronic low back pain of more than 5 years were more likely having moderate to severe acute postoperative pain (VAS > 3) compared to patients with a duration of chronic low back pain less than 1 year (OR = 3.546, 95% CI: 1.405 to 8.95, p = 0.0074). Hospital stay, the pain score on the day of discharge and the pain score after 3 months displayed no significant difference among the three groups (P > 0.05). However, the need for postoperative rescue analgesics was different among the three groups (P < 0.05).ConclusionThe longer the duration of chronic pain was, the higher the incidence of moderate to severe acute postoperative pain was and the greater the amount of analgesics required after surgery.Trial registrationThis study was registered at the Chinese Clinical Trial Registration Center (http://www.chictr.org.cn/index.aspx, clinical trial number: ChiECRCT20200165, date of registration: July 6, 2020).

Acute postoperative pain after orthognathic surgery can be predicted by the preoperative evaluation of conditioned pain modulation and pain catastrophizing.

The incidence and severity of chronic postoperative pain (POP) are major clinical challenges, and presurgical conditioned pain modulation (CPM) and pain catastrophizing scale (PCS) assessments have exhibited predictive values for POP. However, whether CPM and PCS assessments are also predictive of acute POP is unknown. We aimed to investigate the relationship between preoperative CPM and PCS and acute POP severity after orthognathic surgery by assessing preoperative CPM and PCS in 43 patients. The pressure pain threshold and tonic painful cold-heat pulse stimulation (applied with a pain intensity score of 70 on a visual analogue scale [VAS 0-100]) were used as the test and conditioning stimuli, respectively. The pain area under the postoperative VAS area under the curve (VASAUC) was estimated. The associations between CPM, PCS, and VASAUC were also analyzed. No patient experienced chronic POP after 1 month. Negative and positive CPM effects (test stimulus threshold was 0% > and 0% ≤ during conditioning stimulation, respectively) were detected in 36 and 7 patients, respectively. For patients with negative CPM effects (CPM responders), multiple regression analysis revealed a prediction formula of log (VASAUC) = (-0.02 × CPM effect) + (0.13 × PCS-magnification) + 5.10 (adjusted R 2 = 0.4578, P = 0.00002, CPM effect; P = 0.002, PCS-magnification; P = 0.0004), indicating that a weaker CPM and higher PCS scores were associated with more acute POP after surgery. CPM and PCS can predict acute POP after orthognathic surgery.

Acute pain after total hip and knee arthroplasty does not affect chronic pain during the first postoperative year: observational cohort study of 389 patients

Chronic pain is frequently reported after total hip and knee arthroplasties (THA/TKA) in osteoarthritis (OA) patients. We investigated if severity of acute postoperative pain following THA/TKA in OA patients was associated with pain during the first postoperative year. From an observational study, OA patients scheduled for primary THA/TKA (June 2012–December 2017) were included from two hospitals in the Netherlands. Acute postoperative pain scores were collected within 72 h postoperatively and categorized as no/mild (NRS ≤ 4) or moderate/severe (NRS > 4). Pain was assessed preoperatively, 3, 6 and 12 months postoperatively using the HOOS/KOOS subscale pain. With Multilevel Mixed-effects-analyses, we estimated associations between acute and chronic pain until one year postoperative, adjusted for confounders and including an interaction term (Time*Acute pain). 193 THA and 196 TKA patients were included, 29% of THA and 51% of TKA patients reported moderate/severe pain acutely after surgery. In the THA group, the difference in pain at 3 months between the no/mild and moderate/severe groups, was approximately six points, in favor of the no/mild group (95% CI [−12.4 to 0.9]) this difference became smaller over time. In the TKA group we found similar differences, with approximately four points (95% CI [−9.6 to 1.3]) difference between the no/mild and moderate/severe group at 6 months, this difference attenuated at 12 months. No association between severity of acute postoperative pain and pain during the first postoperative year was found. These findings suggest that measures to limit acute postoperative pain will likely not impact development of chronic pain.

Association between aesthetic satisfaction and chronic postsurgical pain in breast cancer patients treated with one stage prosthesis implantation

This study retrospectively studied the incidence of chronic post-surgical pain (CPSP) following single-stage implant-based breast reconstruction (IBBR) and evaluated the possible risk factors. This was a retrospective cohort study, involving all patients undergoing single-stage IBBR between January and December 2019. The follow-up was completed between January and March 2021. The scores for satisfaction (SS) were based on the BREAST-Q, while the pain burden index (PBI) was used to assess the degree of CPSP. The questionnaires were completed by 159 patients. CPSP occurred in 48.43% of the patients, 2.52% of them being severe cases. Significant predictors for the development of CPSP in the univariate analysis included severe acute postoperative pain (PP), a history of preoperative chronic pain, psychological disorders, SS with the reconstructed breasts, and whether there were any regrets about having had the reconstruction. Multivariate analysis identified severe acute PP (odds ratio (OR) = 2.80, 95% confidence interval (CI) = 1.16–6.79, p = 0.023), a history of preoperative chronic pain (OR = 3.39, 95% CI = 1.42–8.10, p = 0.006), and the SS (OR = 0.86, 95% CI = 0.75–0.99, p = 0.034) as being independently associated with the development of CPSP. In subgroup analysis, the PBI of the patients in the SS < 12 group (p < 0.001), the bilateral group (p < 0.01), and the severe acute PP group (p < 0.005) was significantly higher than the PBI of those in the control groups. This study demonstrated a significant incidence of CPSP following single-stage IBBR, and the patients with lower SS of their reconstructed breasts developed more CPSP. Lower SS, bilateral procedures, and severe acute PP were predictors of higher PBI.Trial registration: Registered in Chictr.org.cn registry system on 24 February 2020 (ChiCTR2000030139).

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

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

Ultrasound-guided erector spinae plane catheter versus video-assisted paravertebral catheter placement in minimally invasive thoracic surgery: comparing continuous infusion analgesic techniques on early quality of recovery, respiratory function and chronic persistent surgical pain: study protocol for a double-blinded randomised controlled trial

BackgroundCompared to conventional thoracotomy, minimally invasive thoracic surgery (MITS) can reduce postoperative pain, reduce tissue trauma and contribute to better recovery. However, it still causes significant acute postoperative pain. Truncal regional anaesthesia techniques such as paravertebral and erector spinae blocks have shown to contribute to postoperative analgesia after MITS. Satisfactory placement of an ultrasound-guided thoracic paravertebral catheter can be technically challenging compared to an ultrasound-guided erector spinae catheter. However, in MITS, an opportunity arises for directly visualised placement of a paravertebral catheter by the surgeon under thoracoscopic guidance. Alongside with thoracic epidural, a paravertebral block is considered the “gold standard” of thoracic regional analgesic techniques. To the best of our knowledge, there are no randomised controlled trials comparing surgeon-administered paravertebral catheter and anaesthesiologist-assisted erector spinae catheter for MITS in terms of patient-centred outcomes such as quality of recovery.MethodsThis trial will be a prospective, double-blinded randomised controlled trial. A total of 80 eligible patients will be randomly assigned to receive either an anaesthesiologist-assisted ultrasound-guided erector spinae catheter or a surgeon-assisted video-assisted paravertebral catheter, in a 1:1 ratio following induction of general anaesthesia for minimally assisted thoracic surgery. Both groups will receive the same standardised analgesia protocol for both intra- and postoperative periods. The primary outcome is defined as Quality of Recovery (QoR-15) score between the two groups at 24 h postoperative. Secondary outcomes include assessment of chronic persistent surgical pain (CPSP) at 3 months postoperative using the Brief Pain Inventory (BPI) Short Form and Short Form McGill (SF-15) questionnaires, assessment of postoperative pulmonary function, area under the curve for Verbal Rating Score for pain at rest and on deep inspiration versus time over 48 h, total opioid consumption over 48 h, QoR-15 at 48 h, and postoperative complications and morbidity as measured by the Comprehensive Complication Index.DiscussionDespite surgical advancements in thoracic surgery, severe acute postoperative pain following MITS is still prevailing. This study will provide recommendations about the efficacy of an anaesthesia-administered ultrasound-guided erector spinae catheter or surgeon-administered, video-assisted paravertebral catheter techniques for early quality of recovery following MITS.Trial registrationClinicalTrials.govNCT04729712. Registered on 28 January 2021. All items from the World Health Organization Trial Registration Data Set have been included.

Evaluating oliceridine as a treatment option for moderate to severe acute post-operative pain in adults

ABSTRACT Introduction Despite the advances in regional anesthesia and non-opioid systemic analgesia, opioids remain the primary rescue analgesic for moderate to severe pain. However, the risks and side effects of opioid medications are well documented. Oliceridine is a novel opioid receptor agonist which is thought to have less risk of adverse events, such as postoperative nausea and vomiting (PONV) and respiratory depression. Areas Covered In this review, the authors discuss the limitations of the current opioid and non-opioid analgesic options. They also review the pharmacokinetics of oliceridine, its analgesic efficacy, and risk of adverse events; and its added clinical value in managing moderate to severe pain. Expert opinion Despite the advances in regional anesthesia and multimodal systemic analgesia, opioid free analgesia is only feasible in selected procedures and patients. Oliceridine is effective in the management of moderate to severe pain and appears to be associated with lower risk of nausea and vomiting. The risk of sedation and respiratory depression associated with oliceridine will require further study. The availability of an opioid agonist with a better side effect profile could potentially change the current paradigm of opioid avoidance in postoperative pain management.

Acute Pain Burden and Opioid Dose Requirements after Cesarean Delivery in Parturients with Preexisting Chronic Back Pain and Migraine.

Introduction Preexisting chronic pain has been reported to be a consistent risk factor for severe acute postoperative pain. However, each specific chronic pain condition has unique pathophysiology, and it is possible that the effect of each condition on postoperative pain is different. Methods This is a retrospective cohort study of pregnant women with preexisting chronic pain conditions (i.e., migraine, chronic back pain, and the combination of migraine + chronic back pain), who underwent cesarean delivery. The effects of the three chronic pain conditions on time-weighted average (TWA) pain score (primary outcome) and opioid dose requirements in morphine milligram equivalents (MME) during postoperative 48 hours were compared. Results The TWA pain score was similar in preexisting migraine and chronic back pain. Chronic back pain was associated with significantly greater opioid dose requirements than migraine (12.92 MME, 95% CI: 0.41 to 25.43, P=0.041). Preoperative opioid use (P < 0.001) was associated with a greater TWA pain score. Preoperative opioid use (P < 0.001), smoking (P=0.004), and lower postoperative ibuprofen dose (P=0.002) were associated with greater opioid dose requirements. Conclusions Findings suggest women with chronic back pain and migraine do not report different postpartum pain intensities; however, women with preexisting chronic back pain required 13 MME greater opioid dose than those with migraine during 48 hours after cesarean delivery.

Enhancing the Use of Opioid Sparing Protocol in the PACU

<h3>Introduction</h3> Opioids serve as the cornerstone for severe acute post-operative pain management in the PACU. Opioids have been used for their quick onset and efficacy without analgesic ceiling yet have significant side effects. The Opioid Sparing Protocol was developed to provide pain relief to post knee and hip arthroplasty while minimizing narcotics and allowing rapid rehabilitation and faster discharge. <h3>Identification of the problem</h3> Acute post-operative pain remains a major problem, resulting in the multiple undesirable outcomes if inadequately controlled. In the PACU setting, opioid use is common as the primary treatment for post-operative pain. <h3>Purpose of the study</h3> The purpose of the study is to assess the impact of the Opioid Sparing Protocol on opioid-naive patients in the PACU post knee and hip arthroplasty. <h3>Methods</h3> Retrospective analysis by chart review of 200 comparable cases, from each period, for implementation of the Opioid Sparing Protocol pre-intervention (Q2, 2018) and post-intervention (Q2, 2019). <h3>Outcomes/Results</h3> Significant increase in the use of Tramadol (+242.86%), along with reduction in the use of Percocet (-44.44%) and Oxycodone (-56.52%) have shown to be effective in providing analgesia and improved patient outcomes. <h3>Discussion</h3> There is an ongoing effort to develop strategies for safe and effective alleviation of post-operative pain. This analysis of comparable cases shows that changes in pain management methodologies can lead to positive results for the patient's surgical experience and post-operative clinical outcome. <h3>Conclusion</h3> Utilizing the multimodal approach outlined in the Opioid Sparing Protocol provides consistent pain relief while reducing opioid requirements and opioid related events. Effective management of acute pain in the PACU results in reduced PACU length of stay and improved patient outcomes. <h3>Implications for perianesthesia nurses and future research</h3> As health care professionals, it is our responsibility to provide safe and effective pain management. Considering the heavy societal cost of the opioid crisis, enhanced pain management addresses opioid misuse. The challenge for the healthcare workforce is to develop new, effective and non-addictive approaches to pain management.

Buprenorphine blood concentrations: A biomarker for analgesia.

Opioids, the frontline drugs for postsurgical analgesia, have been linked to diversion and abuse with lethal consequences. The search for safe analgesics with less harm potential has been decades long. However, clinical trials for safe opioid and nonopioid analgesics have relied on subjective pain reports, which are biased by placebo effects that increase the complexity of trials to develop new therapies to manage pain. Research in opioid naïve animals and humans demonstrates that blood concentrations of opioids that effectively saturate the morphine opioid receptor are tightly linked with patient reports and quantitative sensory tests for analgesia. Opioid drug concentrations can predict clinical responses. This report reviews preclinical and clinical evidence correlating buprenorphine pharmacokinetics with analgesia. More than 30 years of data confirm buprenorphine blood concentrations can be an objective biomarker of analgesia for moderate to severe acute postoperative pain.

Incidence of Acute and Chronic Post-Thoracotomy Pain in Pediatric Patients

We studied acute and chronic pain in pediatric patients who underwent thoracotomy for benign disease with a follow-up of at least three months. A telephone interview investigated about the presence of pain and the analgesic therapy in progress. The results were compared with the anesthetic technique, postoperative pain and the adequacy of pain therapy, both during the first week after surgery and at the time of interview. Fifty-six families consented to the study. The mean age of the children at surgery was 2.9 ± 4.5 years, while at the time of the interview was 6.5 ± 4.4 years. We performed different anesthetic strategies: Group A: general anesthesia (36 pts); Group B: general anesthesia and thoracic epidural (10 pts); Group C: general anesthesia and intercostal nerve block (10 pts). During the immediate postoperative period, 21 patients (37.5%) had at least one painful episode. At the time of interview, 3 children (5.3%) had moderate chronic neuropathic (burning) pain on surgical scar. There was no statistically significant difference between the type of anesthesia and the incidence and severity of acute post-operative pain. Despite its limitations, this study confirms the low incidence of chronic post-thoracotomy pain syndrome in children.

PDG6 Budget Impact Analysis for Oliceridine in the Management of Moderate to Severe Acute Postoperative Pain

Use of conventional opioids for postoperative pain are associated with adverse events (ORAEs) that can affect health outcomes, compromising analgesia. Oliceridine, a new class of μ-opioid receptor IV agonist , is selective for G-protein signaling (achieving analgesia) with limited recruitment of β-arrestin (associated with ORAEs). Here we estimate the budget impact of oliceridine vs morphine for postoperative pain. We compared costs & outcomes of patients managed with demand dosing (DD) of oliceridine (0.35mg and 0.5mg) to those with morphine (1mg), using a decision tree with a 24-hour time horizon and sample population of 1,000 surgeries for each arm. Three common and costly ORAEs; respiratory depression (SpO2<90%, RD), vomiting, and somnolence were utilized. Costs were enumerated as differences in cost of analgesics and resources utilized to manage the 3 ORAEs within 24 hours post-surgery. Risk ratios (RR) were based on AE rates observed in two controlled Phase-3 studies. RRs were then applied to AE rates observed in an open-label Phase-3 study of oliceridine to estimate AE incidence in real-world sample. Costs of all analgesics and antiemetics were tabulated based on rates observed in Phase-3 studies. Standard cost weights from national discharge data and literature-sources were used to estimate hospital budget impact & costs for each AE. Average price was set to $100/day for oliceridine and $15/day for morphine. Incremental cost of RD, vomiting and somnolence was estimated at $3,975, $1,035 and $991, respectively. Use of oliceridine resulted in greater medication expenditures vs. morphine ($127,181 vs $30,558). However, overall hospital costs resulting from resources for managing AEs were lower for oliceridine vs morphine ($528,424 vs $852, 429), with net savings of $324,005 for each 1,000 treated patients. Use of oliceridine vs morphine for postoperative pain is expected to increase pharmacy costs but have a favorable overall budget impact.

Chronic Breast Pain Prior to Breast Cancer Surgery Is Associated with Worse Acute Postoperative Pain Outcomes.

Acute postoperative pain is associated with adverse short and long-term outcomes among women undergoing surgery for breast cancer. Previous studies identified preexisting pain as a predictor of postoperative pain, but rarely accounted for pain location or chronicity. This study leveraged a multinational pain registry, PAIN OUT, to: (1) characterize patient subgroups based on preexisting chronic breast pain status and (2) determine the association of preexisting chronic pain with acute postoperative pain-related patient-reported outcomes and opioid consumption following breast cancer surgery. The primary outcome was a composite score comprising the mean of pain intensity and pain interference items from the International Pain Outcomes Questionnaire. The secondary outcome was opioid consumption in the recovery room and ward. Among 1889 patients, we characterized three subgroups: no preexisting chronic pain (n = 1600); chronic preexisting pain elsewhere (n = 128) and; chronic preexisting pain in the breast with/without pain elsewhere (n = 161). Controlling for covariates, women with preexisting chronic breast pain experienced more severe acute postoperative pain and pain interference (β = 1.0, 95% CI = 0.7-1.3, p < 0.001), and required higher doses of opioids postoperatively (β = 2.7, 95% CI = 0.6–4.8, p = 0.013). Preexisting chronic breast pain may be an important risk factor for poor pain-related postoperative outcomes. Targeted intervention of this subgroup may improve recovery.

Factors Contributing to Lingering Pain after Surgery: The Role of Patient Expectations.

Pain that lingers beyond the early weeks after the acute postoperative period is an important risk factor for chronic postsurgical pain. This study examined the hypothesis that patients' expectations about their postsurgical pain would be independently associated with lingering postsurgical pain. The study included 3,628 patients who underwent diverse surgeries between February 2015 and October 2016 in a single U.S. tertiary hospital and participated in the Systematic Assessment and Targeted Improvement of Services Following Yearlong Surgical Outcomes Surveys (SATISFY-SOS) observational study. Preoperatively, patients were asked about their expectations about pain 1 month after surgery. Patients were considered to have lingering postsurgical pain if they endorsed having pain in the area related to their surgeries during a follow-up survey obtained 1 to 3 months postoperatively. The independent associations between preselected perioperative variables and lingering postsurgical pain were evaluated. Of the cohort, 36% (1,308 of 3,628) experienced lingering postsurgical pain. Overall, two thirds (2,414 of 3,628) expected their postsurgical pain to be absent or improved from baseline, and 73% of these had their positive expectations fulfilled. A total of 19% (686 of 3,628) expected new, unabated, or worsened pain, and only 39% (257 of 661) of these had their negative expectations fulfilled. Negative expectations were most common in patients with presurgical pain unrelated to the reason for surgery, undergoing surgeries not typically performed to help alleviate pain. Endorsing negative expectations was independently associated with lingering postsurgical pain (odds ratio, 1.56; 95% CI, 1.23 to 1.98; P < 0.001). Additional major factors associated with lingering postsurgical pain included recollection of severe acute postoperative pain (odds ratio, 3.13; 95% CI, 2.58 to 3.78; P < 0.001), undergoing a procedure typically performed to help alleviate pain (odds ratio, 2.18; 95% CI, 1.73 to 2.75; P < 0.001), and preoperative pain related to surgery (odds ratio, 1.91; 95% CI, 1.52 to 2.40; P < 0.001). Lingering postsurgical pain is relatively common after diverse surgeries and is associated with both fixed surgical characteristics and potentially modifiable factors like pain expectations and severe acute postoperative pain.

Risk factors for persistent pain after breast and thoracic surgeries: a systematic literature review and meta-analysis.

Persistent postsurgical pain (PPSP) is common after breast and thoracic surgeries. Understanding which risk factors consistently contribute to PPSP will allow clinicians to apply preventive strategies, as they emerge, to high-risk patients. The objective of this work was to systematically review and meta-analyze the literature on risk factors of PPSP after breast and thoracic surgeries. A systematic literature search using Ovid Medline, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Embase, PsycINFO, and Scopus databases was conducted. Study screening with inclusion and exclusion criteria, data extraction, and risk of bias assessment was performed independently by 2 authors. The data for each surgical group were analyzed separately and meta-analyzed where possible. The literature search yielded 5584 articles, and data from 126 breast surgery and 143 thoracic surgery articles were considered for meta-analysis. In breast surgery, younger age, higher body mass index, anxiety, depression, diabetes, smoking, preoperative pain, moderate to severe acute postoperative pain, reoperation, radiotherapy, and axillary lymph node dissection were the main factors associated with higher risk of PPSP. In thoracic surgery, younger age, female sex, hypertension, preoperative pain, moderate to severe acute postoperative pain, surgical approach, major procedure, and wound complications were associated with PPSP. This systematic review demonstrated certain consistent risk factors of PPSP after breast and thoracic surgeries, as well as identified research gaps. Understanding the factors that increase susceptibility to PPSP can help selectively allocate resources to optimize perioperative care in high-risk patients and help develop targeted, risk-stratified interventions for PPSP prevention.

Factors Associated With the Risk of Developing Moderate to Severe Acute Postoperative Pain After Primary Total Knee Arthroplasty: Results From the PAIN OUT Registry

BackgroundTotal knee arthroplasty (TKA) is one of the most common procedures in orthopedic surgery and not always matches with patient’s expectations of pain relief and function improvement. The aim of this study was to assess risk factors for developing moderate to severe acute postoperative pain (APOP) after TKA using the PAIN OUT questionnaire. MethodsProspective, multicentre, international cohort study within the PAIN OUT project. Patients’ outcomes were measured with 11-point numerical rating scales (0 = null, 10 = worst possible). Patient and analgesic/anesthetic treatment were assessed. Odds ratio for moderate-severe pain was calculated for each variable and if they were statistically significant in the univariate logistic model, variables were fitted into a multivariate logistic regression model. The effect size was assessed by Cohen’s d coefficient. ResultsIn total, 968 patients were evaluated. The multivariate model identified chronic preoperative pain (P < .001), general anesthesia (P = .020), and receiving chronic opioids before (P = .020) or after the surgery (P < .001) as factors associated with moderate-severe APOP. No protective factors were observed. ConclusionsOur model identified several risk factors for APOP. From our results, preoperative chronic pain, general anesthesia and the use of opioid analgesics could be predictors for higher APOP. These findings may help establish new strategies for the treatment of pain in TKR. More studies should be carried out to identify acute pain predictors and to develop better strategies of pain management for risk patients.

Comparative study of postoperative analgesia and opioid requirement using pectoral nerve blocks with general analgesia

Breast cancer, which is the most common cancer in women, results to moderate to severe acute postoperative pain. Pectoral nerve block I and II, relatively new regional techniques, were introduced for perioperative and postoperative postmastectomy pain by Blanco in 2011 and 2012, respectively. The aim of this study is to evaluate the efficacy of combined pectoral nerve block I and pectoral nerve block II blocks for perioperative opioid consumption and postoperative analgesia and also contribute to new topic in anaesthesia: “Opioid-free anaesthesia is possible with combination of pectoral blocks in breast cancer surgery”. Sixty women patients of American Society of Anesthesiologists status I–III, aged ≥ 18 years undergoing breast surgeries, were included to study. Cases were randomly allocated to two groups: Group I, opioid-based general anaesthesia, and Group II, non-opioid general anaesthesia except induction of anaesthesia with pectoral nerve block I and pectoral nerve block II blocks. Patients demographic characteristics, intraoperative total remifentanil consumption, duration of surgery, first analgesic demand after surgery, nausea and vomiting, surgeon and patient satisfaction were recorded. Two groups were similar in terms of demographic features, surgery time, surgery type and vomiting. The mean remifentanil consumption in Group I was 8.63 mL (SD = 3.18) compared to mean = 1.73 mL (SD = 1.04) in Group II. Statistically lower remifentanil consumption was recorded in Group II than Group I. No patient developed nausea after surgery in Group II. Time for first analgesic demand after surgery for Group I and II were 35.00 (SD = 19.60) and 124.5 (SD = 99.00) minutes respectively. Time for first analgesic demand after surgery was statistically significant between the groups. Satisfaction scores were higher in Group II for both surgeon and patient. General anaesthesia combined with pectoral nerve block I and pectoral nerve block II blocks which is gaining acceptance over the world is safe and effective for breast surgery. We thought that further studies are necessary to investigate timing of blocks and combinations of blocks.