Postoperative Pain Management in Spanish Hospitals: A Cohort Study Using the PAIN-OUT Registry

Local anesthetic delivery systems for the management of postoperative pain

Postoperative pain (POP) is a major clinical challenge. Local anesthetics (LAs), including amide-type LAs, ester-type LAs, and other potential ion-channel blockers, are emerging as drugs for POP management because of their effectiveness and affordability. However, LAs typically exhibit short durations of action and prolonging the duration by increasing their dosage or concentration may increase the risk of motor block or systemic local anesthetic toxicity. In addition, techniques using LAs, such as intrathecal infusion, require professional operation and are prone to catheter displacement, dislodgement, infection, and nerve damage. With the development of materials science and nanotechnology, various LAs delivery systems have been developed to compensate for these disadvantages. Numerous delivery systems have been designed to continuously release a safe dose in a single administration to ensure minimal systemic toxicity and prolong pain relief. LAs delivery systems can also be designed to control the duration and intensity of analgesia according to changes in the external trigger conditions, achieve on-demand analgesia, and significantly improve pain relief and patient satisfaction. In this review, we summarize POP pathways, animal models and methods for POP testing, and highlight LAs delivery systems for POP management. STATEMENT OF SIGNIFICANCE: Postoperative pain (POP) is a major clinical challenge. Local anesthetics (LAs) are emerging as drugs for POP management because of their effectiveness and affordability. However, they exhibit short durations and toxicity. Various LAs delivery systems have been developed to compensate for these disadvantages. They have been designed to continuously release a safe dose in a single administration to ensure minimal toxicity and prolong pain relief. LAs delivery systems can also be designed to control the duration and intensity of analgesia to achieve on-demand analgesia, and significantly improve pain relief and patient satisfaction. In this paper, we summarize POP pathways, animal models, and methods for POP testing and highlight LAs delivery systems for POP management.

Efficacy and safety of patient-controlled intravenous analgesia after APS team standardized postoperative pain management: A 6-year experience of an acute pain service in 107802 Chinese patients

There are few studies on the impact of postoperative pain management (such as Acute Pain Service, APS) on the prognosis of patients, especially the research on large samples, even less data on Chinese patients. It is reported that only 25.12 % of hospitals in China have established APS or similar teams, and less than 10 % of them are responsible for the whole process of postoperative analgesia services. Tongji Hospital affiliated to Tongji Medical College of Huazhong University of Science and Technology has established a professional APS team led by anesthesiologists (TJ-APS), and has a standardized workflow and management system. Based on the TJ-APS standardized postoperative pain management, the incidence and adverse effects of postoperative pain in different types of surgical patients were analyzed. In total, 107,802 patients receiving intravenous PCA from the Tongji Hospital affiliated to Tongji Medical College of Huazhong University of Science and Technology were selected between January 2016 and December 2021, which were under TJ-APS standardized postoperative analgesia process, postoperative analgesia strategy based on the principle of "low opioid, multimodal, specialization and individualization", as well as regular ward rounds and 24-h on call on-duty system. We assessed the incidence and adverse effects of postoperative pain in different types of surgical patients. Based on the TJ-APS standardized postoperative pain management, the incidence of poor postoperative analgesia in patients with intravenous PCA is significantly lower than that reported in the current literature (20 %), and mainly occurs in biliary-pancreatic surgery, extrahepatic surgery and gastrointestinal surgery. The overall incidence of adverse effects was 5.52 %, of which nausea and vomiting was the highest, especially among gynecological tumors and gynecological patients, which were 10.75 % and 8.68 % respectively, but both were lower than the level reported in the current literature (20 %). This APS multimodal management and analgesia process can provide reference and guidance for PCA management of postoperative acute pain.

Do we really know if they are in pain? A cross-sectional study in hospitalised adult patients in Spain

AIMS

To describe the prevalence and characteristics of pain in adult hospitalised patients, as well as to analyse the concordance between patient-reported and recorded pain and its impact on analgesic management.

DESIGN

A cross sectional study.

METHODS

The study was performed on a sample of 611 patients, from October to December 2017. Data were obtained from patient interviews, review of medical and nursing records and review of electronic prescribing.

RESULTS

The prevalence of pain at the time of the interview was 36.7%. The median VAS score was 4. 90% of the patients had their pain assessed within the last 24 h; however, concordance between patient-reported pain and recorded pain in the nursing record was slight.

CONCLUSION

Pain is still often documented inadequately. Despite the wide use of analgesics, half of the patients with moderate to severe pain do not have adequate pain management. A systematic assessment and recording of pain promotes appropriate analgesic prescription.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

The findings of our study provide insight into the main gaps in the correct management of pain in hospitalised patients. A systematic assessment and recording of the pain suffered by the patient facilitates its control and allows a better management of the analgesic prescription by the physician. This information could help hospital managers to develop training programmes on pain assessment and on the importance of doctor-nurse collaboration to improve pain management, increasing the quality of care and reducing hospital costs.

REPORTING METHOD

The study has adhered to the relevant EQUATOR guidelines, according to The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.

[Identifying patients with risk for severe pain after ophthalmological surgery]

Modern ophthalmology includes a wide range of surgical options and, accordingly, also requires appropriate pain management. There are established risk factors for severe postoperative pain that should be identified and considered in the perioperative management. The main risk factors and existing recommendations are presented in this article. Patients at risk should be identified before surgery. It is important that perioperative pain management is implemented in the treatment plan as part of an interdisciplinary cooperation to identify and address the risks as early as possible.

The First Comprehensive Survey of the Practice of Postoperative Pain Management in Hungarian Hospitals - a Descriptive Study

BACKGROUND

Pain management is a key issue in health care. Providers adopt promising technological developments, like Acute Pain Service, at differing speeds, with countries, such as the USA and Germany taking the lead. Where Hungary stands is unknown, as the practice of pain management has not yet been comprehensively reviewed in that country.

AIM

To explore the practice of postoperative pain management in Hungarian hospitals by addressing the questions of who is responsible for it, who measures pain and how, what kind of pain relief technologies are used, and who takes care of patients during duty hours.

METHODS

We carried out a survey covering Hungarian hospitals with operational license for surgery, traumatology, orthopedics and anesthesiology between December 2019 and March 2020. The response rate was 72%, and we analyzed 135 questionnaires.

RESULTS

We identified only 2 hospitals with an Acute Pain Service. In the majority of hospitals, the attending physician orders pain relief therapy. During duty hours the surgeon on duty takes care of pain management in 52.1% of the cases. Among pain relief therapies, intravenous infusions (74.1%) and oral medication (67.4%) are the most frequent. Ward nurses measure postoperative pain (77.8%) with unidimensional scales. According to 59.7% of the respondents, pain is not measured and documented at rest. Written protocols are available in 34.4% of the departments.

CONCLUSIONS

Compared with other countries, pain management in Hungary lags behind with significant room for improvement. Development and implementation of pain management protocols with appropriate education is the key intervention point.

Postoperative Pain Management Outcomes at a Chinese Hospital: A Cross-Sectional Survey

PURPOSE

Postoperative pain is one of the most common postoperative complications, and improper management not only adds to patient suffering but also affects patients' recovery. In this study, we measured patients' postoperative pain to understand the status of patients after surgery and to identify factors influencing postoperative pain.

DESIGN

A descriptive and cross-sectional study METHODS: This survey was conducted at a large tertiary hospital in Chengdu, Sichuan Province. A total of 655 postoperative inpatients were included. The survey was conducted using the Chinese version of the Houston Pain Outcome Instrument. General patient data, pain management-related factors, and the pain management index were used to survey risk factors. We used t-tests and ANOVA for univariate analysis of each pain outcome category to explore the association with the predictor variables. Then, those variables with a significance level of 0.05 on univariate analysis were entered into multivariable regression analysis to identify parsimonious subsets of independent risk factors.

FINDINGS

In this survey, 58.7% of patients experienced moderate to severe pain in the 24-hour postoperative period, and 33.6% of patients had moderate to severe average pain over the 24-hour postoperative period. The postoperative pain impact scores on patient mood, somatic function, patient satisfaction with postoperative pain management, and pain education were 3.5 ± 2.1, 4.3 ± 3.1, 8.9 ± 1.4 and 8.2 ± 1.8, respectively. The pain management index, surgery type, insurance, and pain assessment of nurse were influential factors of postoperative pain intensity. Age, ethnicity, insurance, surgery type, patents' knowledge of pain, and pain assessment of the nurse affected the patients' postoperative physiological function (F = 3.822, R² = 0.065, P = .000). In addition, area of residence and physician attitudes affected the outcomes of patient satisfaction with pain management (F = 26.652, R² = 0.259, P = .000).

CONCLUSIONS

The incidence of moderate to severe pain in post-surgical patients remains high, and postoperative pain affects patients physically and psychologically. Special attention should be given to patients with lower income and literacy levels.

Postoperative pain management in non-traumatic emergency general surgery: WSES-GAIS-SIAARTI-AAST guidelines

BACKGROUND

Non-traumatic emergency general surgery involves a heterogeneous population that may present with several underlying diseases. Timeous emergency surgical treatment should be supplemented with high-quality perioperative care, ideally performed by multidisciplinary teams trained to identify and handle complex postoperative courses. Uncontrolled or poorly controlled acute postoperative pain may result in significant complications. While pain management after elective surgery has been standardized in perioperative pathways, the traditional perioperative treatment of patients undergoing emergency surgery is often a haphazard practice. The present recommended pain management guidelines are for pain management after non-traumatic emergency surgical intervention. It is meant to provide clinicians a list of indications to prescribe the optimal analgesics even in the absence of a multidisciplinary pain team.

MATERIAL AND METHODS

An international expert panel discussed the different issues in subsequent rounds. Four international recognized scientific societies: World Society of Emergency Surgery (WSES), Global Alliance for Infection in Surgery (GAIS), Italian Society of Anesthesia, Analgesia Intensive Care (SIAARTI), and American Association for the Surgery of Trauma (AAST), endorsed the project and approved the final manuscript.

CONCLUSION

Dealing with acute postoperative pain in the emergency abdominal surgery setting is complex, requires special attention, and should be multidisciplinary. Several tools are available, and their combination is mandatory whenever is possible. Analgesic approach to the various situations and conditions should be patient based and tailored according to procedure, pathology, age, response, and available expertise. A better understanding of the patho-mechanisms of postoperative pain for short- and long-term outcomes is necessary to improve prophylactic and treatment strategies.

Robust gelatin hydrogels for local sustained release of bupivacaine following spinal surgery

Adequate treatment of pain arising from spinal surgery is a major clinical challenge. Opioids are the mainstay of current treatment methods, but the frequency and severity of their side effects display a clear need for opioid-free analgesia. Local anesthetics have been encapsulated into sustained-release drug delivery systems to provide postoperative pain relief. However, these formulations are limited by rapid diffusion out of the surgical site. To overcome this limitation, we synthesized ring-shaped hydrogels incorporating bupivacaine, designed to be co-implanted with pedicle screws during spinal surgery. Hydrogels were prepared by riboflavin-mediated crosslinking of gelatin functionalized with tyramine moieties. Additionally, oxidized β-cyclodextrin was introduced into the hydrogel formulation to form dynamic bonds with tyramine functionalities, which enables self-healing behavior and resistance to shear. Feasibility of hydrogel implantation combined with pedicle screws was qualitatively assessed in cadaveric sheep as a model for instrumented spinal surgery. The in-situ crystallization of bupivacaine within the hydrogel matrix provided a moderate burst decrease and sustained release that exceeded 72 hours in vitro. The use of bupivacaine crystals decreased drug-induced cytotoxicity in vitro compared to bupivacaine HCl. Thus, the presented robust hydrogel formulation provides promising properties to enable the stationary release of non-opioid analgesics following spinal surgery. STATEMENT OF SIGNIFICANCE: Currently, postoperative pain following spinal surgery is mainly treated with opioids. However, the use of opioids is associated with several side effects including addiction. Here we developed robust and cytocompatible gelatin hydrogels, prepared via riboflavin-mediated photocrosslinking, that can withstand orthopedic implantation. The implantability was confirmed in cadaveric instrumented spinal surgery. Further, hydrogels were loaded with bupivacaine crystals to provide sustained release beyond 72 hours in vitro. The use of crystallized bupivacaine decreased cytotoxicity compared to bupivacaine HCl. The present formulation can aid in enabling opioid-free analgesia following instrumented spinal surgery.

Finding the vulnerable postoperative population: A two-step cluster analysis of the PAIN-OUT registry

BACKGROUND

Identifying predictors of poor postoperative outcomes is crucial for planning personalized pain treatments. The aim of this study was to examine pain outcomes using cluster analysis in N=2,678 patients from the PAIN-OUT registry at first postoperative day.

METHODS

Indicator variables of the clustering analysis assessed multiple domains, such as clinical and surgical conditions, analgesic-anesthetic variables, desire for more pain treatment and outcome variables of the International Pain Outcome Questionnaire (IPO) summarized as factor scores.

RESULTS

Two-step cluster identified the three-cluster solution as the optimal. Two empirical groups (C1 and C2) included patients with good postoperative outcomes discriminated by peripheral nerve block use, while the other cluster (C3) grouped patients with the worst outcomes, where all patients desired more pain treatment. C3 comprised about 20% of the participants, mostly lower limb, abdominal and spine procedures. The best predictors of belonging to C3 included younger age, being male, preoperative opioid use, bone and fracture reduction procedures, institution, number of comorbidities and morphine equivalents in the recovery room.

CONCLUSIONS

IPO factor scores can be used to select pain outcomes phenotypes in large clinical databases. Most of the predictors were present before the recovery period so perioperative planning should focus in the preoperative and intraoperative periods.

The Effect of Reducing the Fasting Time on Postoperative Pain in Orthopaedic Patients: A Randomized Controlled Trial

Background

Patients undergoing orthopedics surgery experience the most severe postoperative pain. The fasting time is a factor that affects this complication. The aim of this study was to investigate the impact of fasting time reduction by using oral carbohydrate on postoperative pain and analgesic consumption in orthopedic patients.

Materials and Methods

This randomized control trial was conducted between November 2017 and December 2018. Sixty-four patients were randomly assigned into the intervention (which consumed 200 mL of the 12.50% carbohydrate, 2 h before the surgery) and the control group (which was fasted from midnight). Postoperative pain was measured by visual analog scale; the amount of the consumed analgesics was also recorded. The data were analyzed by using Chi-square and t-test.

Results

The mean (SD) of the pain scores in the control group immediately and 2, 4, 6, 12 and 24 h after consciousness were 7.19 (2.64), 6.69 (2.17), 6.31 (2.05), 6.16 (2.08), 6.06 (2.24), and 5.38 (1.86), respectively. These scores for the intervention group were 7.44 (1.48), 6.31 (1.25), 5.72 (1.17), 5.59 (1.43), 5.25 (1.13), and 4.97 (1.57). The mean of the pain scores between two groups was not different (p > 0.05). The amount of the consumed morphine (t ₆₁= -2.10, p = 0.039), pethidine (t ₆₂= -2.25, p = 0.028), and diclofenac (t ₆₂= -2.51, p = 0.015) were significantly different between the two groups.

Conclusions

The pain intensity in the patients with shortened fasting time was lower, but it was not statistically significant. Moreover, reducing fasting time by using carbohydrate significantly reduced the use of analgesics.

Confirmatory factor analysis of the International Pain Outcome questionnaire in surgery

Supplemental Digital Content is Available in the Text.

The reliability and validity of International Pain Outcome questionnaire Spanish adaptation is confirmed in a large heterogeneous sample. Factor scores can be used as a global outcome analysis tool.

Background:

Choosing perioperative suitable treatments requires reliable and valid outcome measurements. The International Pain Outcome (IPO) questionnaire has been widely used for quality improvement and research purposes within the PAIN-OUT network that has collected more than 550,000 data sets of postoperative patients in 200 hospitals worldwide. Our aim is to confirm psychometric properties of the Spanish version of the IPO questionnaire and its invariance by pain predictors.

Method:

Sample included 4014 participants within a large age range, who underwent different surgical procedures. Confirmatory factor analysis (CFA) assessed internal structure, considering invariance by sex, age, procedure, smoking, obesity, affective disorder, and chronic pain. Incremental predictive validity of factor scores on question would have liked more pain treatment and opioid requirement was also estimated with logistic binary regression.

Results:

Confirmatory factor analysis verified original structure in 3 factors measuring pain intensity and interference (F1), adverse effects (F2), and perceptions of care (F3), with good internal consistency. Multigroup CFA analysis confirmed invariance by assessed pain predictors. Good incremental predictive capacity to identify would have liked more pain treatment was achieved.

Conclusion:

Our study confirms the factor structure, supports reliability, and adds some evidence of convergent validity of the Spanish adaptation of the IPO questionnaire. The sum of scores in its main factors serves a global outcome analysis tool. Low scores in F1 and F2 with high scores in F3 would indicate optimal quality of care.

Assessment of Patient's Satisfaction and Associated Factors regarding Postoperative Pain Management at the University of Gondar Compressive Specialized Hospital, Northwest Ethiopia

Objective

We aimed to assess the level of patient's satisfaction and associated factors regarding postoperative pain management.

Methods

An institution-based cross-sectional study was conducted from April to May 2018 at the University of Gondar, and comprehensive specialized hospital data were collected through semistructured questionnaire and chart review. Level of satisfaction was measured using five-point Likert scale. Statistical analysis was done using SPSS software version 23. Both bivariable and multivariable logistic regression analyses were done. Variables of P value ≤0.2 in the bivariable analysis were a candidate for multivariable logistic regression. A P value ≤0.05 was considered as significantly associated with patient's level of satisfaction at 95% CI.

Results

A total of 418 patients were included in this study with a response rate of 98.58%. The overall proportion of patients who were satisfied with pain management services was 72.2% (95% CI: 67.7-76.6). ASA1 (AOR = 3.55: 95% CI = 1.20-10.55) and ASA2 patients (AOR = 3.72: 95% CI = 1.04-13.28), absence of postoperative pain (AOR = 1.86: 95% CI = 1.02-3.39), peripheral nerve block done (AOR = 9.14: 95% CI = 3.93 20.86), received analgesic before request (AOR = 6.90: 95% CI = 3.72-12.83), and received systemic analgesics (AOR = 6.10: 95% CI = 1.17-33.91) were significantly associated with the level of satisfaction.

Conclusion

The level of patient satisfaction with postoperative pain management was considerably low. Hence, it is vital to implement time-interval pain assessment method during the first 24 hours of postoperative period and treat accordingly based on the WHO pain ladder. Moreover, we suggested that all patients who underwent major surgery should receive peripheral nerve block as part of multimodal analgesia to decrease the incidence and severity of post op pain.

Regional Catheters for Postoperative Pain Control: Review and Observational Data

Context

Perioperative analgesia is an essential but frequently underrated component of medical care. The purpose of this work is to describe the actual situation of surgical patients focusing on effective pain control by discarding prejudice against ‘aggressive’ measures.

Evidence Acquisition

This is a narrative review about continuous regional pain therapy with catheters in the postoperative period. Included are the most-relevant literature as well as own experiences.

Results

As evidenced by an abundance of studies, continuous regional/neuraxial blocks are the most effective approach for relief of severe postoperative pain. Catheters have to be placed in adequate anatomical positions and meticulously maintained as long as they remain in situ. Peripheral catheters in interscalene, femoral, and sciatic positions are effective in patients with surgery of upper and lower limbs. Epidural catheters are effective in abdominal and thoracic surgery, birth pain, and artery occlusive disease, whereas paravertebral analgesia may be beneficial in patients with unilateral approach of the truncus. However, failure rates are high, especially for epidural catheter analgesia. Unfortunately, many reports lack a comprehensive description of catheter application, management, failure rates and complications and thus cannot be compared with each other.

Conclusions

Effective control of postoperative pain is possible by the application of regional/neuraxial catheters, measures requiring dedication, skill, effort, and funds. Standard operating procedures contribute to minimizing complications and adverse side effects. Nevertheless, these methods are still not widely accepted by therapists, although more than 50% of postoperative patients suffer from ‘moderate, severe or worst’ pain.

L4 erector spinal plane block after lumbar spine arthrodesi: A case-series

INTRODUCTION

Thoracic erector spinae plane block is now performed in many different surgical procedures, including lumbar spinal fusion. We evaluated the analgesic effect of lumbar ESP performed at L4 after lumbar spinal fusion surgery.

METHODS AND CASE SERIES

Eight patients scheduled for lumbar spinal fusion were included in the case series. Erector spinae plane block was performed at L4 preoperatively, administering 20ml of 0.2% ropivacaine on each side. We recorded patient-reported pain intensity during the first 48 postoperative hours using a visual analogue scale (VAS) and rescue analgesia requirements. Pain at rest was controlled in all patients (VAS 0 to 3), although pain on movement ranged from mild to severe (VAS 0 to 8). Rescue analgesia consumption ranged from 1 to 22mg morphine.

CONCLUSIONS

Lumbar ESP appears to contribute to pain control during the first 48hours after lumbar spinal fusion.

A Patient-Based National Survey and Prospective Evaluation of Postoperative Pain Management in Spain: Prevalent but Possibly Preventable

Objective

To evaluate the national general prevalence of postoperative pain and the associated organizational/structural factors related to the provision of health care services.

Design and Setting

Observational prospective cohort study performed in 46 tertiary hospitals that were randomly selected from the Spanish National Inventory of Hospitals through a two-stage balanced and stratified procedure.

Subjects and Methods

Nine-hundred surgical patients representing a wide spectrum of surgical procedures and anesthetic methods were recruited. Those suffering moderate or worse pain while in the postanesthesia care unit/surgery ward (PACU/SW) were followed for 72 hours. Site characteristics were also surveyed. Multilevel models were used to evaluate center- and patient-level factors associated with pain and quality of recovery (QoR). Weighted generalized estimating equations were used to analyze the evolution of pain intensity.

Results

The prevalence while in and at discharge from the PACU/SW was 48.7% (cluster-adjusted 95% confidence interval [CI] = 38.1–59.2%) and 21.6% (95% CI = 15.4–27.8%), respectively. Pain intensity decreased significantly over time. Less than 20% of the patients received systemic patient-controlled analgesia (PCA) or regional analgesic techniques. Age, preexisting pain, type of surgery, use of general anesthesia, and postoperative potent opioids were associated with pain risk and intensity, as were center-level factors such as patient information, protocol availability, and coordination of care. In turn, QoR was related to pain intensity and patient satisfaction with analgesia and side effects.

Conclusions

Compared with previous reports, the prevalence of moderate/severe postoperative pain has decreased but remains excessive. Organizational improvements to deploy procedure-specific, opioid-sparing analgesic strategies including regional techniques are recommended.

Diverse characters of Brennan's paw incision model regarding certain parameters in the rat

Background

Brennan’s rodent paw incision model has been extensively used for understanding mechanisms underlying postoperative pain in humans. However, alterations of physiological parameters like blood pressure and heart rate, or even feeding and drinking patterns after the incision have not been documented as yet. Moreover, though eicosanoids like prostaglandins and leukotrienes contribute to inflammation, tissue levels of these inflammatory mediators have never been studied. This work further investigates the antinociceptive effect of protein C after intra-wound administration.

Methods

Separate groups of Sprague–Dawley rats were used for quantitation of cyclooxygenase (COX) activity and leukotriene B4 level by enzyme-linked immunosorbent assay, as well as estimation of cardiovascular parameters and feeding and drinking behavior after paw incision. In the next part, rats were subjected to incision and 10 μg of protein C was locally administered by a micropipette. Both evoked and non-evoked pain parameters were then estimated.

Results

COX, particularly COX-2 activity and leukotriene B4 levels increased after incision. Hemodynamic parameters were normal. Feeding and drinking were affected on days 1 and 3, and on day 1, respectively. Protein C attenuated non-evoked pain behavior alone up to day 2.

Conclusions

Based upon current observations, Brennan’s rodent paw incision model appears to exhibit a prolonged period of nociception similar to that after surgery, with minimal interference of physiological parameters. Protein C, which is likely converted to activated protein C in the wound, attenuated the guarding score, which probably represents pain at rest after surgery in humans.

Effect of Ketorolac on the Prevention of Postoperative Catheter-Related Bladder Discomfort in Patients Undergoing Robot-Assisted Laparoscopic Radical Prostatectomy: A Randomized, Double-Blinded, Placebo-Controlled Study

Urinary catheterization can cause catheter-related bladder discomfort (CRBD). Ketorolac is widely used for pain control. Therefore, we evaluated the effect of ketorolac on the prevention of CRBD in patients undergoing robot-assisted laparoscopic radical prostatectomy (RALP). All patients were randomly allocated to the ketorolac group or the control group. The primary outcome was CRBD above a moderate grade at 0 h postoperatively. CRBD above a moderate grade at 1, 2, and 6 h was also assessed. Postoperative pain, opioid requirement, ketorolac-related complications, patient satisfaction, and hospitalization duration were also assessed. The incidence of CRBD above a moderate grade at 0 h postoperatively was significantly lower in the ketorolac group (21.5% vs. 50.8%, p = 0.001) as were those at 1, 2, and 6 h. Pain scores at 0 and 1 h and opioid requirement over 24 h were significantly lower in the ketorolac group, while patient satisfaction scores were significantly higher in the ketorolac group. Ketorolac-related complications and hospitalization duration were not significantly different between the two groups. This study shows ketorolac can reduce postoperative CRBD above a moderate grade and increase patient satisfaction in patients undergoing RALP, suggesting it is a useful option to prevent postoperative CRBD.

[Consensus statement on the use of acetaminophen/tramadol in patients with moderate-severe pain]

OBJECTIVES

To present recommendations on the use of the paracetamol/tramadol (P/T) combination in patients with moderate-intense pain based on best evidence and experience.

METHODS

The method of nominal groups and Delphi was followed, and supported by a systematic literature review (SLR). A multidisciplinary panel of 12 experts in pain management was selected. In the first nominal group meeting, the aim, scope, users, and sections of the consensus document, were defined, along with the preliminary general recommendations. For the SLR, the inclusion and exclusion criteria, as well as the search strategies, were defined. Two reviewers selected and analysed the articles. This evidence was discussed in a second nominal group meeting, and definitive recommendations were developed. For each recommendation, the evidence levels and grade of recommendation grades were classified according to the Oxford model, and the grade according to the Delphi technique. It was defined as an agreement if at least 70% of the participants scored ≥7 for each recommendation (1=total disagreement to 10=total agreement).

RESULTS

A total of 20 recommendations were produced, which covered general aspects, such as the assessment of pain, and those specific to P/T management. These latter included the indications of the P/T combination (patient profile, dosing, prescription, formulations), risk management (contraindications, precautions, interactions, concomitant use with other medications, follow-up, special situations), and patient education.

CONCLUSIONS

These recommendations attempt to resolve any of the routine clinical questions, and help in the making of decisions on the use of the P/T combination in patients with moderate-intense pain.

Disability after major abdominal surgery: determinants of recovery of walking ability in elderly patients

BACKGROUND

Increased life expectancy and improved surgical techniques have led to a sharp rise in healthcare resource consumption by older patients. In these patients early recovery of walking ability after abdominal surgery may shorten length of hospital stay and reduce overall healthcare costs, but it is important to understand what factors determine this recovery.

AIM

To assess preoperative and postoperative determinants of walking ability recovery after major abdominal surgery in older patients.

DESIGN

Prospective observational study.

SETTING

General Surgery Unit.

POPULATION

The study included 327 consecutive older inpatients who underwent major acute-care abdominal surgery.

METHODS

Data on demographic characteristics, diagnosis, comorbidities defined by Charlson Comorbidity Index (CCI), preoperative walking ability, and early postoperative physical deconditioning (PPDS) were gathered. All patients underwent an individually-tailored rehabilitation program. At discharge, pain (by a Visual Analogue Scale, VAS-pain, 0-10), transfers and walking ability were assessed. Number of rehabilitation sessions attended and discharge setting were recorded.

RESULTS

Of 320 patients included in the analysis (7 died), 72% had CCI>5, signifying presence of >1 comorbidities. Before hospitalization, 79% of patients were completely independent in walking at home, 12% needed assistive devices or direct assistance from the caregiver, and 9% were unable to walk. Complex postoperative physical deconditioning was detected in 25%. At discharge, most patients (87%) had achieved their rehabilitative goal and returned home. Only PPDS and VAS-pain were able to predict both walking ability and the discharge setting, PPDS alone showing adequate sensitivity (82%) and specificity (70%).

CONCLUSIONS

PPDS was the sole early postoperative predictor of recovery of walking ability and the discharge setting. Pain therapy might be a key factor influencing the postoperative functional decline. Age and severity of preoperative comorbidities seem not important determinants of functional decline in older surgical patients.

CLINICAL REHABILITATION IMPACT

An early postoperative assessment of physical deconditioning might be able to predict the walking ability at discharge (hence, the discharge setting), in older patients undergoing major surgery.