Management of acute pain in the postoperative setting: the importance of quality indicators

Comparison of Pain Assessment Tools and Numeric Rating Scale Thresholds for Analgesic Administration in the Postanaesthetic Care Unit

PURPOSE

The aim of this study was to assess the correlation between the Visual Analog Scale (VAS), Numeric Rating Scale (NRS), and Verbal Rating Scale (VRS). Additionally, the study aimed to determine NRS threshold values for both mild analgesic administration (= without risk of nausea and vomiting [NV] side effects) and strong analgesic administration (= with risk of NV side effects) in the postanaesthetic care unit (PACU).

DESIGN

Prospective, observational study design.

METHODS

The study was conducted between August 2019 and April 2022. Patients scheduled for elective surgery under general anesthesia were included. The primary outcome was the correlation between the VAS, NRS, and VRS, assessed at PACU admission and discharge. Secondary outcomes included pain evolution, desire for analgesic administration with or without risk of NV side effects, and preferred tool for pain assessment.

FINDINGS

VAS, NRS, and VRS were significantly correlated (r = 0.82 to 0.94, P < .001) at both PACU admission and discharge. The median VAS scores significantly improved from 32 (interquartile range [IQR]: 9 to 22) at PACU admission to 27 (IQR: 8 to 39) at PACU discharge (P < .001), while the median NRS scores significantly improved from 3 (IQR: 1 to 6) at PACU admission to 3 (IQR: 1 to 4) at PACU discharge (P < .001). At PACU admission, receiver-operating characteristics curve analysis indicated that an optimal NRS threshold value for the administration of a mild analgesic (= without risk of NV side effects) was greater than 2, and greater than 5 for the administration of a strong analgesic (= with risk of NV side effects). At PACU discharge, patients reported a preferred median NRS score of 5 to be treated with a mild analgesic (= without risk of NV side effects), and a preferred median NRS score of 8 to be treated with a strong analgesic (= with risk of NV side effects).

CONCLUSIONS

All three pain assessment tools can be used to evaluate postoperative pain in the PACU setting during the recovery from general anesthesia.

Acute postoperative pain management after living donor hepatectomy during the transition from an open to minimally invasive surgical approach

Background

Acute post-surgical pain is a common concern for patients undergoing living donor hepatectomy (LDH), potentially leading to unfavorable outcomes if not treated adequately. This study aimed to evaluate the impact of the transition of surgical techniques from open and laparoscopic to robot-assisted minimally invasive surgical (MIS) approach, and the different types of graft resection, including right, left, and left lateral partial lobectomy (LL), on analgesia requirements during the first two postoperative days.

Methods

A single-center retrospective electronic chart review of all patients who underwent LDH procedures between 2018 and 2020 was performed.

Results

Patients underwent LDH procedure (n = 414) through open (n = 93, 22%), laparoscopic (n = 68, 16%), or robot-assisted MIS (n = 253, 61%) approaches; and had right lobectomy (n = 215, 52%), left lobectomy (n = 121, 29%), or LL (n = 78, 19%). Postoperatively within the first 48 h, the pain reported on a 3-point Visual Analogue Scale (VAS), was mild 77%, moderate 21%, or severe only 2%. The laparoscopic approach and LL resection were associated with higher pain scores, whereas the robotic approach was the least painful overall.

Conclusions

Robot-assisted MIS approach for LDH procedure resulted in lower acute pain scores when compared with other surgical approaches, obviating the need for intravenous (IV) patient-controlled analgesia (PCA).

Development of a set of indicators for the quality of chronic pain management in Chinese community-dwelling older adults: a Delphi study

BACKGROUND

Standardized and systematic quality assessments of chronic pain management, particularly among older adult populations, are lacking in resource-limited community settings. A specific set of indicators to evaluate the quality of chronic pain management in this population has yet to be developed. Therefore, the present study constructed a set of indicators to assess the quality of chronic pain management in Chinese community-dwelling older adults, providing a standardized reference and guidance for community health centers to manage chronic pain in this population.

METHODS

The indicator set was developed in three steps. Step 1 involved preparation by forming a research team and establishing the guiding theory. Step 2 included developing an expert inquiry questionnaire based on a literature review and semi-structured interviews. Step 3 completed the construction of the indicator set through the Delphi method and hierarchical analysis to quantify the relative importance of each indicator and ensure the development of a scientifically validated and practically applicable evaluation model.

RESULTS

The final set of indicators for evaluating the quality of chronic pain management among community-dwelling older adults in China comprised three primary indicators: structural quality indicator, process quality indicator, and outcome quality indicator. Structural quality indicators included 3 secondary and 11 tertiary indicators; process quality indicators included 4 secondary and 21 tertiary indicators; and outcome quality indicators included 2 secondary and 4 tertiary indicators. Across two rounds of questionnaires, the response rate was 100%, with expert authority coefficients of 0.924 and 0.938, coefficients of variation ranging from 0 to 0.32 and 0 to 0.20, and Kendall's concordance coefficients of 0.302 and 0.220, respectively. Hierarchical analysis showed that the consistency ratios of all indicators were < 0.1000, indicating a balanced distribution of indicator weights.

CONCLUSIONS

This study introduces a preliminary framework, based on the "Structure-Process-Outcome" theory, to evaluate chronic pain management in Chinese community-dwelling older adults. Its reliance on expert opinions without empirical validation, exclusion of patient perspectives, and focus on Chinese communities limit its applicability and generalizability. Future research should address these limitations by incorporating patient feedback, empirically validating indicators, and evaluating their applicability across diverse populations.

Quality of nursing care in pain management in orthopedic surgical patients: a scoping review

OBJECTIVE

To map the evidence on quality nursing care practices in pain management in orthopedic surgical patients.

METHOD

Scoping review, as per the JBI Manual recommendations. Searches were performed in the MEDLINE (PubMed), LILACS (Regional VHL), Scopus, Embase, Web of Science, Cochrane, Cinahl databases, and gray literature, regardless of language and period. Selection and extraction were performed by two independent reviewers, using inclusion/exclusion criteria, and the extracted data were organized to reflect key themes or recurring patterns related to the purpose of the review.

RESULTS

A total of 94 studies were included, most from the United States, corresponding to 34% of the sample, and published between 1997 and 2022. The findings were categorized into: nursing quality practices in pain management related to the organization and monitoring of units, and pre- and post-operative period.

CONCLUSION

The research revealed that quality nursing care practices in pain management in orthopedic surgical patients encompass a variety of approaches, from the use of nonpharmacological practices and patient education to the use of pain assessment scales, staff training, to innovative pharmacological procedures.

Strategies for Health Professionals in Managing Patients and Families in Critical Care Units

The primary objective of this article is to share effective strategies for integrating patients and their families into the critical care setting. Additionally, it aims to address lack of pain management knowledge, burnout syndrome, and stress management tactics tailored for practicing critical care registered nurses.

Employing the Artificial Intelligence Object Detection Tool YOLOv8 for Real-Time Pain Detection: A Feasibility Study

Introduction

Effective pain management is crucial for patient care, impacting comfort, recovery, and overall well-being. Traditional subjective pain assessment methods can be challenging, particularly in specific patient populations. This research explores an alternative approach using computer vision (CV) to detect pain through facial expressions.

Methods

The study implements the YOLOv8 real-time object detection model to analyze facial expressions indicative of pain. Given four pain datasets, a dataset of pain-expressing faces was compiled, and each image was carefully labeled based on the presence of pain-associated Action Units (AUs). The labeling distinguished between two classes: pain and no pain. The pain category included specific AUs (AU4, AU6, AU7, AU9, AU10, and AU43) following the Prkachin and Solomon Pain Intensity (PSPI) scoring method. Images showing these AUs with a PSPI score above 2 were labeled as expressing pain. The manual labeling process utilized an open-source tool, makesense.ai, to ensure precise annotation. The dataset was then split into training and testing subsets, each containing a mix of pain and no-pain images. The YOLOv8 model underwent iterative training over 10 epochs. The model's performance was validated using precision, recall, and mean Average Precision (mAP) metrics, and F1 score.

Results

When considering all classes collectively, our model attained a mAP of 0.893 at a threshold of 0.5. The precision for "pain" and "nopain" detection was 0.868 and 0.919, respectively. F1 scores for the classes "pain", "nopain", and "all classes" reached a peak value of 0.80. Finally, the model was tested on the Delaware dataset and in a real-world scenario.

Discussion

Despite limitations, this study highlights the promise of using real-time computer vision models for pain detection, with potential applications in clinical settings. Future research will focus on evaluating the model's generalizability across diverse clinical scenarios and its integration into clinical workflows to improve patient care.

Postoperative pain management practice and associated factors among nurses working at public hospitals, in Oromia region, Ethiopia, 2021: an institution-based cross-sectional study

BACKGROUND

Management of postoperative pain leads to positive patient progress and shortens the duration of hospital stay. There is a lack of information on nurse's postoperative pain management practice and its associated factors.

OBJECTIVE

To assess postoperative pain management practice and associated factors among nurses working in public hospitals of West Shoa Zone, Oromia, Ethiopia, 2021.

DESIGN

An institutional-based cross-sectional study was employed.

SETTING

Study was conducted among eight public hospitals (two tertiary hospitals and six secondary hospitals), which were located in West Shoa Zone in Oromia, Ethiopia.

PARTICIPANTS

Totally 377 participants were selected by using simple random sampling. From this, 277 were men and 100 participants were women. All nurses who were worked in surgical ward, medical wards, minor operation room and major operation room, recovery rooms, emergency, obstetrics and gynaecology wards were included.

METHODS

Data were collected by distributing structured self-administered questionnaires that adapted from different literatures and were entered into Epi data V.3.1 and exported to SPSS V.22 for analysis. Variables with significant association in the bivariate analyses were entered into a multivariable regression analysis to identify the independent factors associated with nurses' postoperative pain management practice. Significant factors were declared at p<0.05.

RESULT

The result showed that 66% of nurses had good pain management practice. Nurses favourable attitude towards postoperative pain management (adjusted OR (AOR): 4.698, 95% CI (2.725 to 8.100)), having access to read pain management guideline (AOR: 3.112, 95% CI (1.652 to 5.862)), adequate knowledge of postoperative pain management (AOR: 2.939, 95% CI (1.652 to 5.227)), working at operation room (AOR: 2.934, 95% CI (1.27 to 6.795)) and received training on pain management (AOR: 3.289, 95% CI (1.461 to 7.403)) were significantly associated with the practices of postoperative pain management.

CONCLUSION AND RECOMMENDATION

65% of participants (nurses) have a good level of practice of postoperative pain management. Training, access to pain management guidelines, knowledge and attitude are significant factors in postoperative pain management practice. Governmental and other bodies concerned to postoperative care quality needs to show commitment on availing needed training and infrastructures.

Incidence and risk factors of post-operative delirium in glioma patients: A prospective cohort study in general wards

AIMS

Glioma patients are at high risk for postoperative delirium (POD), yet studies focusing on this population in general neurosurgical ward settings are limited. This paper investigates the incidence of POD and related risk factors in glioma patients hospitalized in general wards.

DESIGN

Prospective observational study.

METHODS

This prospective study included 133 adult glioma patients hospitalized in the general neurosurgery ward. In addition to collecting routine perioperative general clinical data, patients' psychological status was assessed preoperatively using the Hospital Anxiety and Depression Scale (HADS). POD was assessed within 3 days postoperatively using the Confusion of Consciousness Assessment method, twice daily. The incidence of POD was calculated, and risk factors were identified using logistic regression analysis.

RESULTS

The incidence of POD in glioma patients admitted to the general ward was 31.6% (40/133). Multivariate regression revealed advanced age (age > 50 years), frontal lobe tumour, presence of preoperative anxiety or depression, retention of a luminal drain, postoperative pain, indwelling catheter these six factors were independent risk factors for the development of delirium in patients after surgery.

CONCLUSION

In general ward settings, supratentorial glioma patients exhibit a high risk of POD. Critical risk factors include preoperative psychological conditions, as well as postoperative pain, drainage and catheterization. Rigorous preoperative evaluations, effective pain management strategies and the integration of humanistic care principles are essential in mitigating the risk of POD for glioma patients.

RELEVANCE TO CLINICAL PRACTICE

In general ward settings, this study reveals the high occurrence of POD in glioma patients and identifies preoperative psychological states, age, tumour location and several postoperative factors as significant risk factors for POD, which provides a framework for targeted interventions. By integrating these insights into clinical practice, healthcare teams can better identify glioma patients at risk for POD and implement preventive measures, thereby enhancing recovery and overall care quality for glioma patients in general neurosurgical wards.

REPORTING METHOD

This study adheres to the STROBE guidelines, ensuring a transparent and comprehensive reporting of the observational research methodology and results.

PATIENT OR PUBLIC CONTRIBUTION

Patients involvement was limited to the provision of data through their participation in the study's assessments and the collection of clinical information. The study did not involve a direct patient or public contribution in the design, conduct, analysis, or interpretation of the data, nor in the preparation of the manuscript.

Perspectives and Practice in Eastern and Western Medicine for Pain Management in Rehabilitation Training after Orthopedic Trauma Surgery: A Qualitative Study

BACKGROUND

Despite the increasing emphasis on rehabilitation training after orthopedic surgery, little is known about the pain caused by the procedure itself. Clinical practice is driven by beliefs in pain management.

AIMS

This study aimed to explore the perspective of pain management during rehabilitation training after orthopedic trauma in China and its influencing factors from different perspectives in traditional Chinese medicine and Western medicine, respectively.

DESIGN

A phenomenological qualitative study involving semi-structured interviews.

SETTINGS

  METHODS: A qualitative study was conducted with 16 medical workers working in the Rehabilitation Medicine Department in eastern China from July 2022-February 2023. A directed method to thematic analysis was used to code the transcribed data and identify themes.

RESULTS

Four main themes emerged. (1) Inconsistent perspectives and practice: Chinese doctors majoring in Western medicine felt sympathy, helpless, and had a lack of knowledge and misconception about pain. Traditional Chinese medicine deemed that pain is a protective mechanism and attached importance to holism and unique means. (2) Consistent outcome: Insufficient pain management will have a series of negative consequences for patients' recovery, forming a vicious cycle. (3) Expectations: Though they are not optimistic about traditional analgesics, enhancement, cooperation and ideal analgesic methods still be expressed, and (4) Concept transformation: Conducting nitrous oxide is a process not only to promote analgesic technology but also to promote the awareness and concept of pain management.

CONCLUSIONS

Our study emphasized that medical workers should be aware of the importance of pain management at the same time while treating the disability. The study provides insight into pain management experiences within different educational backgrounds. The findings enable professionals to recognize the importance of pain management and its influencing factors to provide feasible and effective pain management strategies.

Perioperative pain management models in four European countries: A narrative review of differences, similarities and future directions

There is general agreement that acute pain management is an important component of perioperative medicine. However, there is no consensus on the best model of care for perioperative pain management, mainly because evidence is missing in many aspects. Comparing the similarities and differences between countries might reveal some insights into different organisational models and how they work. Here, we performed a narrative review to describe and compare the structures, processes and outcomes of perioperative pain management in the healthcare systems of four European countries using Donabedian's framework as a guide. Our comparison revealed many similarities, differences and gaps. Different structures of acute pain services in the four countries with no common definition and standards of care were found. Protocols have been implemented in all countries and guidelines in some. If outcome is assessed, it is mainly pain intensity, and many patients experiencing more intense pain than others have common risk factors (e.g. preoperative pain, preoperative opioid intake, female sex and young age). Outcome assessment beyond pain intensity (such as pain-related physical function, which is important for early rehabilitation and recovery) is currently not well implemented. Developing common quality indicators, a European guideline for perioperative pain management (e.g. for patients at high risk for experiencing severe pain and other outcome parameters) and common criteria for acute pain services might pave the way forward for improving acute pain management in Europe. Finally, the education of general and specialist staff should be aligned in Europe, for example, by using the curricula of the European Pain Federation (EFIC).

Post-operative pain management by nurses in an intensive care unit: a best practice implementation project

INTRODUCTION

Post-operative pain is the most prevalent type of acute pain. Nurses are the health care professionals who most frequently assess pain, as well as evaluating the patient's response to pain management treatment and monitoring for the occurrence of adverse events. Thus, to improve outcomes and quality of care, the interventions used by nurses should be based on best practices.

OBJECTIVES

The aim of this project was to implement best practices in post-operative pain management in an intensive care unit.

METHODS

This evidence implementation project was conducted in a hospital for the surgical treatment of orthopedic diseases and trauma. The project followed the JBI evidence implementation framework. The project used JBI PACES software as well as JBI's Getting Research into Practice (GRiP) audit and feedback tools to develop eight audit criteria for the baseline and follow-up audits.

RESULTS

The baseline audit showed that criteria 3 and 6 had low compliance, with few patients having documented plans and goals, and receiving multimodal analgesia in the ICU, respectively. Criteria 7 and 8, which assessed the use of opioids and follow-up by a pain specialist, revealed compliance of 60% and 50%, respectively. Criterion 3 improved from 0% to 20%. Criteria 6, 7, and 8 also improved, rising to 30%, 22.8%, and 50%, respectively.

CONCLUSION

The project improved compliance with best practices in post-operative pain management. Further studies are needed to ensure the project's long-term sustainability.

Surgery patients' perspectives of their role in postoperative pain: A scoping review

Background

Post-operative pain is a major factor in surgical recovery. There is evidence that pain remains undermanaged. Complications related to the undermanagement of acute pain can increase length of stay and contribute to readmission and the development of chronic pain. It is well acknowledged that pain assessment is critical to pain management and that self-report of pain is the gold standard. As a result, patients play a central role in their own pain management. A preliminary review of the literature failed to provide a clear or consistent description of this key patient role.

Objective

A scoping review was conducted with the objective of reviewing literature that described adult patients' perspectives or highlighted the adult patient's role in post-operative pain management, including assessment. Understanding patients' attitudes toward their roles in pain management through a scoping review of the current literature is critical for informing research and improvements in post-operative pain management.

Design

Scoping review.

Methods

The databases searched for the review included CINAHL, MEDLINE, PubMed, and SCOPUS (ending May 2022). Thematic analysis, using the methodology of Arksey and O'Malley, was applied to the records identified.

Results

Of the 106 abstracts initially identified, 26 papers were included in the final analysis. Two major themes identified through thematic analysis were attitudes toward pain and pain management, with the subthemes of patient expectations and beliefs and desire to treat; and care and communication, with the subthemes of pain assessment and education.

Conclusions

This paper provides one of the first known comprehensive scoping reviews of surgical patients' perspectives of their role in pain management, including assessment, and offers an important global awareness of this patient role. The findings suggest that improved understanding of patients' perspectives of their roles in pain assessment and treatment is critical to improving post-operative pain management. Engaging patients as partners in their care can facilitate enhanced communication and improving congruence in pain assessment and treatment decisions. The complex nature of patients' beliefs, expectations, and subjective experiences of pain present challenges for health care practitioners. These challenges can be met with enhanced education for patients, respect for patients' beliefs and expectations, and the provision of dignified care.

Development of care quality indicators for palliative care in China: A modified Delphi method study

Objective

While there are limited studies addressing palliative care quality in China, the availability of an effective set of care quality indicators is scarce. This study aimed to develop a comprehensive set of quality indicators for palliative care in China.

Methods

Conducting a systematic literature search across databases and guideline websites from inception to October 2020, combined with qualitative interviews, we established a preliminary pool of indicators. Subsequently, two rounds of Delphi expert consultation surveys were administered to 19 multidisciplinary experts (specializing in clinical nursing/medicine, nursing/medicine management, and health care administration, as well as those engaged in teaching and research) from 12 provinces in Mainland China (three each from North, East, and South China, and four from Central China) via email from March to June 2021. The analytic hierarchy process was employed to determine indicator weights.

Results

Both rounds of expert consultation yielded a 100% positive coefficient, with expert authority coefficient values of 0.91 and 0.93, respectively. Kendall coefficient of concordance values for the two rounds were 0.148 and 0.253 (P < 0.001), indicating consensus among experts. Consequently, 71 quality indicators deemed important in the Chinese palliative care setting were identified, comprising 22 structure indicators, 35 process indicators, and 14 outcome indicators.

Conclusions

This study established an evidence-based set of quality indicators, addressing previously unmet needs and providing a novel approach to assessing and monitoring palliative care quality. Furthermore, ongoing refinement and integration with the evolving social context are warranted.

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.

Educational needs and preferences of adult patients with acute or chronic pain: a mixed methods systematic review protocol

OBJECTIVES

This review will aim to synthesize the available quantitative and qualitative evidence on the educational needs and preferences of adult patients with acute or chronic pain.

INTRODUCTION

Acute and chronic pain are prevalent problems and are associated with significant individual and societal consequences. Education is a critical component of pain management. However, the impact of educational interventions on pain outcomes remains limited. The lack of patient input--what patients want to know and how they want to be informed--is one of the main issues underlying intervention design.

INCLUSION CRITERIA

We will include qualitative, quantitative, and mixed methods studies describing the educational needs and preferences of adult patients with acute or chronic pain.

METHODS

This review will follow the JBI guidelines for mixed methods systematic reviews. We will search MEDLINE (PubMed), Embase (Ovid), PsycINFO (Ovid), CINAHL (EBSCO), the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and ProQuest Dissertations and Theses. The search strategy will commence from the year 1990 onward and there will be no language restrictions. The retrieved titles, abstracts, and full-text reports will be screened by pairs of independent reviewers. These pairs of reviewers will also independently extract data using the JBI tools for mixed methods systematic reviews. Methodological quality will be assessed using the mixed methods appraisal tool. A convergent integrated approach to synthesis and integration of the quantitative and qualitative data will be used.

REVIEW REGISTRATION

PROSPERO CRD42022303834.

The effect of pharmacist-initiated perioperative multidisciplinary pharmaceutical care model and clinical pathway on pain management in patients undergoing orthopedic surgery: a before-after study

BACKGROUND

Poor pain control is common in perioperative orthopedic surgeries. However, there is a lack of exploration of the clinical pharmacy practice model for this population.

AIM

To construct a perioperative pharmaceutical care model and clinical pathway for patients undergoing orthopedic surgeries and assess their impact on pain management.

METHOD

This historical before-and-after study was conducted in the Department of Orthopedics of a tertiary hospital in Guangdong Province, China. The control group was surgical patients who received routine diagnosis and treatment. The intervention group received pain management from a multidisciplinary team based on a pharmacist-initiated pharmaceutical care practice model and clinical pathways for medication management. The primary outcome measures were postoperative pain at rest (PAR) and movement-evoked pain (MEP) scores, number of breakthrough pains, and length of hospital stay.

RESULTS

A total of 320 orthopedic surgery patients were included. Among patients with expected moderate or severe postoperative pain (82.5%), significantly lower PAR and MEP scores were observed in the intervention group 24 h after surgeries compared to the control group (p < 0.05). Compared to the control group, hospital stay in the intervention group was shortened by 2.3 days (p < 0.001). However, there were no significant differences in the control of breakthrough pain and the incidence of adverse drug reactions (p > 0.05).

CONCLUSION

Multidisciplinary perioperative pain management practice models and clinical pathways initiated by pharmacists could improve outcome indicators related to pain management and support the role and value of pharmacists.

Analgesic efficacy of bupivacaine with or without magnesium adjunct in bilateral ilioinguinal and iliohypogastric nerve blocks following cesarean section under subarachnoid block: A randomized controlled trial

Background

Pain relief is a basic aspect of anesthesia care. Optimal post-cesarean section analgesia should minimize postoperative complications, facilitate infant care, and prevent postoperative morbidity. Bilateral ilioinguinal-iliohypogastric (IIIH) nerve block has been considered as a part of the multimodal approach. This study was designed to explore the efficacy of adding magnesium sulfate as an adjunct to bupivacaine to provide analgesia following cesarean delivery, using bilateral IIIH nerve block.

Materials And Methods

Seventy-two parturients who were scheduled for elective cesarean section were randomized into two groups of 36 patients each. Group MB patients were given bilateral IIIH nerve block with 250 mg of magnesium sulfate and 95 mg of 0.25% plain bupivacaine. Group B patients were given bilateral IIIH nerve block with 0.9% normal saline and 95 mg of 0.25% plain bupivacaine. Postoperative visual analog scale (VAS) pain scores at post-anesthesia care unit (PACU), 2, 4, 6, 12, and 24 h, both at rest and with activity were measured. Rescue doses of opioid (intravenous [IV] tramadol 50 mg) at each time point of assessment, total tramadol consumption, time to patients' first request for rescue analgesic agent, and patients' satisfaction score were recorded.

Results

The demographic and social parameters of patients in both the groups were comparable. The mean postoperative VAS pain score in group MB was significantly lesser both at rest and with movement than in group B at 12 and 24 h after surgery (P < 0.05). Total postoperative tramadol consumed over 24 h was significantly lesser in the magnesium group than in the control group (125.55 ± 20.76 vs. 160.24 ± 25.82 mg), with a P value of 0.026. The time to patient's first analgesic request was significantly prolonged in group MB compared to group B (505.2 ± 41.4 vs. 372.6 ± 88.8 min, respectively), with a P value of 0.040. However, patients in both groups expressed good satisfaction scores.

Conclusion

Magnesium sulfate as an adjunct to bupivacaine in bilateral IIIH nerve block reduced VAS pain scores, total tramadol consumption, and prolonged post-cesarean section analgesia.

Predicting postoperative pain by using preoperative pain threshold in response to electrical stimulus in women undergoing gynaecological cancer surgery - Single-arm, prospective, observational study

Background and Aims

Individual variability leading to different pain experiences makes pain prediction challenging. This study aimed to evaluate whether preoperative electrical pain threshold testing is predictive of postoperative pain.

Methods

Following ethics committee approval and registration of the trial, 40 consenting patients undergoing open laparotomy (interval debulking surgery) for ovarian cancer were included in the study. Electrical stimulus (maximum of 256 μA) was used preoperatively to determine the current perception threshold (CPT) and pain equivalent current (PEC). A numerical rating scale (NRS; 0-10, with 0 indicating no pain and 10 indicating severe pain) was used to assess pain. All patients received intravenous paracetamol in accordance to body weight, diclofenac (1 mg/kg, maximum 50 mg), and tramadol (1 mg/kg, maximum 50 mg) eight hourly for 24 hours. The preoperative PEC was compared with worst pain score (PS) at movement at the end of 24 hours. PEC was also compared with average PS at rest, at movement, and with opioid requirement (24 hours).

Results

The median values of CPT and PEC were 12.51 (45 [10.1-14.6]) μA and 94.75 (174 [48.8-94.7]) μA, respectively. A moderate correlation was observed between PEC and worst PS (P = 0.01, r = -0.402), with patients having PEC less than 60 μA being associated with moderate-to-severe PS. There was no correlation between PEC and average PS at rest (P = 0.16, r = 0.225), at movement (P = 0.46, r = 0.119), and the postoperative opioid consumption in the first 24 hours (P = 0.50, r = -0.110).

Conclusion

There is a moderate association between preoperative pain threshold in response to electrical stimulus and worst PS in the postoperative period following interval debulking surgery for ovarian cancer.

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.

Examining the adaptability and validity of interRAI acute care quality indicators in a surgical context

Background:

Currently, the use of quality indicators in the surgical setting may be challenged by diverse patient needs, clinical complexity, and health trajectories. Therefore, the objective of this study was to examine the adaptability of existing quality indicators to a surgical context and propose new time points.

Methods:

A multi-method approach included an environmental scan of the literature, consultation with multinational experts, and analysis of surgical patient data. Quality indicators from the nurse-administered interRAI Acute Care instrument were examined within a surgical context using secondary data from a hospital in Brisbane, Australia (N = 1006 surgical cases).

Results:

A lack of relevancy of existing time points can preclude meaningful quality indicator measurement. Definitions of some quality indicators were adapted to ensure relevancy for the surgical population. As well, a surgical baseline (measured preoperative and post-injury) and a 48-h postoperative time point were added to the existing measurement timeline.

Conclusion:

Distinct measurement timelines were created for elective and non-elective surgical patients. The use of surgery-specific time points that can be embedded into an existing Acute Care measurement framework supports consistent quality indicator reporting. This study represents the first steps towards standardized quality reporting for health information systems across different care settings.

Clinical Evaluation for Effectiveness and Safety of Lidocaine and Bupivacaine Combination Epidural Infusion for the Management of Post-Total Hip Replacement Pain

Background The management of post-operative pain is critical for both the patient and the surgical outcome. Although epidural analgesia is valuable method, optimal local anesthetic selection and combination could improve its effectiveness. To determine the effectiveness and safety of bupivacaine and lidocaine bolus epidural analgesia in the management of post-total hip arthroplasty. Methods          65 Records of patients who underwent total hip arthroplasty and received bolus epidural analgesia with bupivacaine and lidocaine were evaluated retrospectively. The numerical pain score for 48 hours, drug adverse effects, hospital stay, and opioid intake were analyzed statistically to determine the effectiveness and safety of epidural analgesia. Results The numerical pain score showed mild pain perception through the first 48 hours post operatively. There was no significant difference (p≥ 0.005) between the first score data collected at 6 hours and the last score at 48 hours. Post-operatively, patients had lower incidence of hypotension and headache with acceptable mobility. Opioid rescue analgesia was used for 11(16.9%) of patients. Conclusions For patients who have undergone total hip replacement surgery, epidural analgesia with a bolus epidural infusion of lidocaine and bupivacaine delivers an effective and safe pain control method for 48 hours. This method was effective in opioid sparing.  

Gaps in standardized postoperative pain management quality measures: A systematic review

BACKGROUND

The goal of this study was an assessment of availability postoperative pain management quality measures and National Quality Forum-endorsed measures. Postoperative pain is an important clinical timepoint because poor pain control can lead to patient suffering, chronic opiate use, and/or chronic pain. Quality measures can guide best practices, but it is unclear whether there are measures for managing pain after surgery.

METHODS

The National Quality Forum Quality Positioning System, Agency for Healthcare Research and Quality Indicators, and Centers for Medicare and Medicaid Services Measures Inventory Tool databases were searched in November 2019. We conducted a systematic literature review to further identify quality measures in research publications, clinical practice guidelines, and gray literature for the period between March 11, 2015 and March 11, 2020.

RESULTS

Our systematic review yielded 1,328 publications, of which 206 were pertinent. Nineteen pain management quality measures were identified from the quality measure databases, and 5 were endorsed by National Quality Forum. The National Quality Forum measures were not specific to postoperative pain management. Three of the non-endorsed measures were specific to postoperative pain.

CONCLUSION

The dearth of published postoperative pain management quality measures, especially National Quality Forum-endorsed measures, highlights the need for more rigorous evidence and widely endorsed postoperative pain quality measures to guide best practices.

Relationship Between Quality of Care and Patient Care Outcomes for Postoperative Pain in Major Orthopedic Surgery: Analytical and Cross-Sectional Study

The quality of care provided for the management of postoperative pain and patient outcomes are key criteria for healthcare institutions. This study aimed to determine the relationship between the quality of care provided for the alleviation of postoperative pain experienced among patients undergoing major orthopedic surgery and the patient care outcomes. The study was designed as an analytical and cross-sectional study. The rates of pain severity and sleep interference, activity interference, affective experiences, and adverse effects due to postoperative pain were higher in female patients than in male patients. A significant positive correlation was identified between the quality of postoperative pain care and the perception of care (p < .05). Implementing nursing interventions to improve pain management and increase the quality of care appears to be vital elements for reducing adverse effects caused by pain and increasing the satisfaction with postoperative pain care.

Acute Pain Service in Hungarian hospitals

Background

Surgical procedures play an increasing role among health technologies to treat diseases. Pain often accompanies such diseases, both as a result of their pathology, but also as the side-effect of the intervention itself, and it is not only a burdensome subjective feeling, but adversely affects the recovery process, can induce complications and increases treatment costs. Acute Pain Service Teams are becoming increasingly widespread in hospitals to address post-operative pain, yet we have so far no data on how many hospitals have actually adopted this technology in Hungary.

Objectives

The main objectives of our study were to assess the prevalence of Acute Pain Service Teams, map their structure and operation, as well as to understand the barriers and conducive factors of their establishment in Hungarian hospitals.

Methods

We carried out a survey among the 72 hospitals with surgical departments. The questionnaire was filled in by 52 providers, which gave us a response rate of 72.2%.

Results

Our results show, that only two of the responding hospitals have Acute Pain Service Teams albeit their structure and operation are in line with the literature. In the 50 hospitals without such teams, financing difficulties and human resources shortages are mentioned to be the most important obstacles of their establishment, but the lack of initiative and interest on the part of the specialities concerned are also an important barrier.

Conclusions

Lagging behind the more affluent EU member states, but similarly to other Central and Eastern European countries, Acute Pain Service has been hardly adopted by Hungarian hospitals. Hungarian health professionals know the technology and would support its wider introduction, if the technical feasibility barriers could be overcome. Health policy should play a more active role to facilitate change in this area, the investment in which promises a substantial return in terms of health gains and cost savings.

Identification of preoperative predictors for acute postsurgical pain and for pain at three months after surgery: a prospective observational study

Identifying patients at risk is the start of adequate perioperative pain management. We aimed to identify preoperative predictors for acute postsurgical pain (APSP) and for pain at 3 months after surgery to develop prediction models. In a prospective observational study, we collected preoperative predictors and the movement-evoked numerical rating scale (NRS-MEP) of postoperative pain at day 1, 2, 3, 7, week 1, 6 and 3 months after surgery from patients with a range of surgical procedures. Regression analyses of data of 2258 surgical in- and outpatients showed that independent predictors for APSP using the mean NRS-MEP over the first three days after surgery were hospital admittance, female sex, higher preoperative pain, younger age, pain catastrophizing, anxiety, higher score on functional disability, highest categories of expected pain, medical specialty, unknown wound size, and wound size > 10 cm compared to wound size ≤ 10 cm (RMSE = 2.11). For pain at three months, the only predictors were preoperative pain and a higher score on functional disability (RMSE = 1.69). Adding pain trajectories improved the prediction of pain at three months (RMSE = 1.37). Our clinically applicable prediction models can be used preoperatively to identify patients at risk, as well as in the direct postoperative period.

Comparison of Feature Extraction Methods for Physiological Signals for Heat-Based Pain Recognition

While even the most common definition of pain is under debate, pain assessment has remained the same for decades. But the paramount importance of precise pain management for successful healthcare has encouraged initiatives to improve the way pain is assessed. Recent approaches have proposed automatic pain evaluation systems using machine learning models trained with data coming from behavioural or physiological sensors. Although yielding promising results, machine learning studies for sensor-based pain recognition remain scattered and not necessarily easy to compare to each other. In particular, the important process of extracting features is usually optimised towards specific datasets. We thus introduce a comparison of feature extraction methods for pain recognition based on physiological sensors in this paper. In addition, the PainMonit Database (PMDB), a new dataset including both objective and subjective annotations for heat-induced pain in 52 subjects, is introduced. In total, five different approaches including techniques based on feature engineering and feature learning with deep learning are evaluated on the BioVid and PMDB datasets. Our studies highlight the following insights: (1) Simple feature engineering approaches can still compete with deep learning approaches in terms of performance. (2) More complex deep learning architectures do not yield better performance compared to simpler ones. (3) Subjective self-reports by subjects can be used instead of objective temperature-based annotations to build a robust pain recognition system.

The opioid overdose crisis as a global health challenge

PURPOSE OF REVIEW

To assess the current state of the opioid overdose crisis along three major axes: drug markets and patterns of use, the effectiveness of systems of care, and international developments.

RECENT FINDINGS

Overdose is a major contributor to mortality and disability among people who use drugs. The increasing number of opioid overdoses in North America especially is an indication of changing drug markets and failing regional systems of care. Globally, we see three clusters of overdose prevalence: (1) a group of countries led by the United States with historically high rates of opioid overdose, (2) a group of countries with increasing rates within a concerning range, (3) a group with very low rates. The contamination of street drugs, the quality and accessibility of treatment, and the overall system of care all contribute to the prevalence of overdose.

SUMMARY

Drug markets and pattern of consumption in parts of the world are shifting towards contamination and opioids like fentanyl as the drug of choice, which dismantles insufficient and largely ineffective systems of care. Furthermore, outside of North America, more countries like Estonia, Lithuania, Sweden, Finland, and Norway show very concerning numbers. Without a consistent system response, effects will be devastating.

An Assessment of Patient, Caregiver, and Clinician Perspectives on the Post-discharge Phase of Care

OBJECTIVE

We sought to elicit patients', caregivers', and health care providers' perceptions of home recovery to inform care personalization in the learning health system.

SUMMARY BACKGROUND DATA

Postsurgical care has shifted from the hospital into the home. Daily care responsibilities fall to patients and their caregivers, yet stakeholder concerns in these heterogeneous environments, especially as they relate to racial inequities, are poorly understood.

METHODS

Surgical oncology patients, caregivers, and clinicians participated in freelisting; an open-ended interviewing technique used to identify essential elements of a domain. Within 2 weeks after discharge, participants were queried on 5 domains: home independence, social support, pain control, immediate, and overall surgical impact. Salience indices, measures of the most important words of interest, were calculated using Anthropac by domain and group.

RESULTS

Forty patients [20 whites and 20 African-Americans (AAs)], 30 caregivers (17 whites and 13 AAs), and 20 providers (8 residents, 4 nurses, 4 nurse practitioners, and 4 attending surgeons) were interviewed. Patients and caregivers attended to the personal recovery experience, whereas providers described activities and individuals associated with recovery. All groups defined surgery as life-changing, with providers and caregivers discussing financial and mortality concerns. Patients shared similar thoughts about social support and self-care ability by race, whereas AA patients described heterogeneous pain management and more hopeful recovery perceptions. AA caregivers expressed more positive responses than white caregivers.

CONCLUSIONS

Patients live the day-to-day of recovery, whereas caregivers and clinicians also contemplate more expansive concerns. Incorporating relevant perceptions into traditional clinical outcomes and concepts could enhance the surgical experience for all stakeholders.

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.

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.

Modeling for Change of Daily Nurse Calls After Surgery in an Orthopedics Ward Using Bayesian Statistics

Nurse call data may be used to evaluate the quality of nursing. However, traditional frequency-based statistics may not easily apply to nurse calls due to the large individual variability and daily call changes. We intended to propose a probabilistic modeling of nurse calls based on Bayesian statistics. We constructed the model including nurse call daily changes, individual variability, and adjustment according to characteristics (age and sex). Nurse call differences after surgery were analyzed based on data from the orthopedic ward from April 2014 to October 2017. Results show that there were differences in nurse calls from day 1 to day 10 after surgery between patients who had undergone orthopedic surgery and those who had undergone other surgeries such as tumor surgery. Furthermore, there were differences in nurse calls from day 1 to day 8 after surgery between patients who used extra pain relief medicine and those who did not. Although the analysis required multiple comparisons regarding daily nurse call changes and fixed data samples per day, our approach using Bayesian statistics could detect the periods and significant differences. This indicates that our nurse call modeling based on Bayesian statistics may be used to analyze nurse call changes.

Establishment and Empirical Evaluation of a Quality Indicator System for Postoperative Pain Management

OBJECTIVES

This study aimed to establish a quality indicator system for postoperative pain management and test its reliability, validity, and discrimination in China.

METHODS

We established a quality indicator system using the Delphi method. Further, we designed and administered a survey questionnaire in the orthopedic departments of nine hospitals, located in the Zhejiang and Jiangsu Provinces, through purposive and convenience sampling methods to examine the reliability, validity, and discrimination of the quality indicator system.

RESULTS

We established a quality indicator system to assess structure, process, and outcome measures of postoperative pain management using three first-level, eight subordinate second-level, and 32 subordinate third-level quality indicators. The scale-level content validity indexes of the three sections of the questionnaire, assessing structure, process, and outcomes measures, were 0.99, 0.98, and 0.98, respectively. We identified two common factors from the third section that demonstrated a cumulative variance contribution rate of 80.38% and a Cronbach's α coefficient of 0.95. The total scores and scores of the structure, process, and outcome quality indicators demonstrated statistically significant differences (P < 0.05) between the wards (N = 4) that participated in the "Painless Orthopedics Ward" quality improvement program and those (N = 5) that did not.

CONCLUSIONS

This quality indicator system highlights the need for multidisciplinary cooperation and process characteristics of postoperative pain management, along with interdepartmental quality comparisons. And it demonstrates acceptable reliability, validity, and discrimination; thus it may be completely or partially employed in Chinese hospitals.

Characterisation of pragmatic postoperative PAin Trajectories over seven days and their association with CHronicity after 3 months: a prospective, pilot cohort study (PATCH study)

BACKGROUND

Reliable outcome measurement providing information both on early and late postoperative pain outcomes are still lacking. The purpose of this study was: 1) to characterise postoperative pain trajectories according to an innovative pragmatic concept: ideal pain trajectory (rapid and sustained pain relief) vs non-ideal pain trajectories (late, transient, or no pain relief); and 2) to assess the incidence of persistent post-surgical pain (PPSP) and the potential association between non-ideal pain trajectories and PPSP.

METHODS

This prospective observational pilot cohort study was performed from March until June 2016. A total of 344 patients undergoing major general surgery were invited to complete a self-assessment of pain intensity using numerical rating scale (NRS; 0 = no pain to 10 = worst pain) from day 1 until day 7 after surgery, in order to establish their pain trajectory. Three months after surgery, patients were screened for PPSP.

RESULTS

Rest pain score was analysed in 308 participants. Among them, 210 (68% - 95% CI: 63-73) had an "ideal" pain trajectory, while 98 (32% - 95% CI: 27-37) had "non-ideal" pain trajectories. Three months after surgery, 31% (95% CI: 26-37) reported PPSP. Multivariable analysis showed that "non-ideal" pain trajectories [OR 2.25; (95% CI: 1.26-4.01) P =  0.006] were significantly associated with PPSP.

CONCLUSIONS

The present study proposes an innovative pragmatic concept of postoperative pain trajectories: ideal vs non-ideal pain trajectories, providing information both on acute postoperative pain resolution and early identification patients at risk for developing PPSP.

TRIAL REGISTRATION

NCT02599233; November, 6, 2015, with clinicaltrials.gov.

Impact of Check of Medication Appropriateness (CMA) in optimizing analgesic prescribing: An interrupted time series analysis

BACKGROUND

Pain therapy in inpatients is regularly suboptimal and might be improved by clinical pharmacy services. In our hospital, we have implemented a software-supported 'Check of Medication Appropriateness' (CMA), which is a centralized pharmacist-led service consisting of a clinical rule-based screening for potentially inappropriate prescriptions (PIPs), and a subsequent medication review by pharmacists. We aimed to investigate the impact of the CMA on pain-related prescribing.

METHODS

A quasi-experimental study was performed in a large teaching hospital, using an interrupted time series design. Pre-implementation, patients were exposed to standard of care. Afterwards, a pain-focused CMA comprising 12 specific clinical rules pertaining to analgesic prescribing were implemented in the post-implementation period. A regression model was used to assess the impact of the intervention on the number of pain-related residual PIPs between both periods. The total number of recommendations and acceptance rate was recorded for the post-implementation period.

RESULTS

At baseline, a median number of 13.1 (range: 9.5-15.8) residual PIPs per day was observed. After the CMA intervention, the number was reduced to 2.2 (range: 0-9.5) per day. Clinical rules showed an immediate relative reduction of 66% (p < .0001) in pain-related residual PIPs. A significant decreasing time trend was observed during the post-implementation period. Post-implementation, 1683 recommendations were given over 1 year with an acceptance rate of 74.3%.

CONCLUSIONS

We proved that the CMA approach reduced the number of pain-related residual PIPs. More pharmacist involvement and the use of clinical rules during hospital stay should be further promoted to optimize appropriate prescribing of analgesics.

SIGNIFICANCE

Prescribing of analgesics should be improved in inpatients to optimize pain control and to reduce iatrogenic harm. The Check of Medication Appropriateness (CMA) approach, comprising a clinical rule-based screening for patients at risk and a targeted medication review by pharmacists, reduced the number of pain-related potentially inappropriate prescriptions in a highly significant and sustained manner. This study presents the opportunities of a centralized clinical pharmacy service to help clinicians to further improve analgesic prescribing.

Transversus Abdominis Plane Block Appears to Be Effective and Safe as a Part of Multimodal Analgesia in Bariatric Surgery: a Meta-analysis and Systematic Review of Randomized Controlled Trials

Purpose

Pain after bariatric surgery can prolong recovery. This patient group is highly susceptible to opioid-related side effects. Enhanced Recovery After Surgery guidelines strongly recommend the administration of multimodal medications to reduce narcotic consumption. However, the role of ultrasound-guided transversus abdominis plane (USG-TAP) block in multimodal analgesia of weight loss surgeries remains controversial.

Materials and Methods

A systematic search was performed in four databases for studies published up to September 2019. We considered randomized controlled trials that assessed the efficacy of perioperative USG-TAP block as a part of multimodal analgesia in patients with laparoscopic bariatric surgery.

Results

Eight studies (525 patients) were included in the meta-analysis. Pooled analysis showed lower pain scores with USG-TAP block at every evaluated time point and lower opioid requirement in the USG-TAP block group (weighted mean difference (WMD) = − 7.59 mg; 95% CI − 9.86, − 5.39; p < 0.001). Time to ambulate was shorter with USG-TAP block (WMD = − 2.22 h; 95% CI − 3.89, − 0.56; p = 0.009). This intervention also seemed to be safe: only three non-severe complications with USG-TAP block were reported in the included studies.

Conclusion

Our results may support the incorporation of USG-TAP block into multimodal analgesia regimens of ERAS protocols for bariatric surgery.

Electronic supplementary material

The online version of this article (10.1007/s11695-020-04973-8) contains supplementary material, which is available to authorized users.

The Effectiveness of Using a Nurse-Led Pain Relief Model for Pain Management among Abdominal Surgical Patients: A Single-Center, Controlled before-after Study in China

BACKGROUND

Effective pain management is closely related to the prognosis of patients after surgery. Setting up acute pain service is among the effective strategies to control pain. The operation of acute pain service is mostly dominated by anesthesiologists; however, control of postsurgical pain is still unsatisfactory. Nurses are the main force for providing postoperative care of patients, and their role in acute pain service is crucial. Therefore, in the current study, we have developed a nurse-led pain relief model that emphasizes the central role of nurses during the entire surgical procedure. However, the effect of using this model for pain management among abdominal surgical patients remains unknown.

AIMS

The current study was conducted to investigate the effect of using a nurse-led pain relief model for pain management among abdominal surgical patients.

DESIGN

A single-center, propensity score-matched, controlled before-after study.

METHODS

The patients, hospitalized for abdominal surgery in a university-affiliated hospital from January 2015 to December 2017, were enrolled and divided into group A (hospitalized before nurse-led pain relief model implementation, from January, 2015 to October, 2016) and group B (hospitalized after nurse-led pain relief model implementation, from October, 2016, to December, 2017) using propensity score match assay. The researchers compared the quality of acute pain management, the main side effects of pain management, and nurses' pain knowledge and attitude between group A and group B.

RESULTS

A total of 2851 patients undergoing nonemergency abdominal surgery were enrolled in the current study and were propensity matched 1:1 into two groups with 1,127 subjects in each group. The quality of acute pain management postsurgery was better after implementation of the nurse-led pain relief model. More patients received higher numerical rating scales cores (≥4 points) at indicated time points after surgery in group A compared with group B (14.20% vs. 12.24% 6 hours postsurgery, p = .001; 12.33% vs. 8.52% 12 hours postsurgery, p = .004; 12.95% vs. 3.99% 24 hours postsurgery, p = .036; 16.06% vs. 7.19% 48 hours postsurgery, p = .001). Furthermore, the occurrence of nausea and vomiting during pain management were significantly decreased in patients from group B (nausea: X² = 38.926, p < .05; vomit: X² = 39.302, p < .05). Additionally, after using the nurse-led pain relief model, nurses were more open to improving their knowledge and attitudes to pain management (p < .05).

CONCLUSION

Our study demonstrated that a nurse-led pain relief model can enhance the quality of acute pain management among post-abdominal surgical patients, suggesting that such a model can be an effective intervention for providing a better pain control among postsurgical patients.

Bayesian statistic model for nurse call data considering time-series, individual patient variabilities and massive zero-count call data

Analysis of nurse call data is important to evaluate nursing management, because nurse calls reflect the fundamental demand of patients. However, the nurse call data include time-series properties and individual patient variabilities. In addition, the calls do not necessarily follow the common single distributions such as normal and Poisson distribution. These characteristics of the nurse call data cause the difficulty of applying traditional frequent statistics. To resolve this problem, we introduced Bayesian statistics and proposed a model including three elements: 1) transition, which represents time-series change of nurse calls, 2) random effect, which handles individual patient variabilities, and 3) zero inflated Poisson distribution, which is suitable for nurse call data including massive zero data. To evaluate the model, nurse call dataset containing total 3324 patients in orthopedics ward was used and the differences of nurse calls between the patients who had undergone orthopedics surgery and those who had undergone other surgeries were analyzed. The result in comparing all combinations of elements suggested that our model including all elements was the most fitting model to the dataset. In addition, the model could detect longer duration of nurse call difference existence than the other models. These results indicated that our proposed model based on Bayesian statistics may contribute to analyzing nurse call dataset.

Role of the anaesthetist in postoperative care

Teamwork

Moderate to severe acute pain disturbs motor cortex intracortical inhibition and facilitation in orthopedic trauma patients: A TMS study

OBJECTIVE

Primary motor (M1) cortical excitability alterations are involved in the development and maintenance of chronic pain. Less is known about M1-cortical excitability implications in the acute phase of an orthopedic trauma. This study aims to assess acute M1-cortical excitability in patients with an isolated upper limb fracture (IULF) in relation to pain intensity.

METHODS

Eighty-four (56 IULF patients <14 days post-trauma and 28 healthy controls). IULF patients were divided into two subgroups according to pain intensity (mild versus moderate to severe pain). A single transcranial magnetic stimulation (TMS) session was performed over M1 to compare groups on resting motor threshold (rMT), short-intracortical inhibition (SICI), intracortical facilitation (ICF), and long-interval cortical inhibition (LICI).

RESULTS

Reduced SICI and ICF were found in IULF patients with moderate to severe pain, whereas mild pain was not associated with M1 alterations. Age, sex, and time since the accident had no influence on TMS measures.

DISCUSSION

These findings show altered M1 in the context of acute moderate to severe pain, suggesting early signs of altered GABAergic inhibitory and glutamatergic facilitatory activities.

Factors Influencing Satisfaction with Patient-Controlled Analgesia Among Postoperative Patients Using a Generalized Ordinal Logistic Regression Model

PURPOSE

The purpose of this study was to identify the factors affecting the satisfaction with patient-controlled analgesia (PCA) of patients using a generalized ordinal logistic regression model and to evaluate the difference in results of the ordinal regression from those of binary regression.

METHODS

The study design involved secondary analysis of electronic medical records from a single tertiary care hospital in Seoul, Korea. It included 2,409 patients treated with PCA for postoperative pain management after open or laparoscopic abdominal surgery. Binary logistic regression and generalized ordinal logistic regression were used to identify factors affecting satisfaction.

RESULTS

Binary logistic regression analysis showed that there was insufficient information for analysis. Generalized ordinal logistic regression revealed that sex, age, pain, PCA usage, and side-effects were common factors affecting PCA satisfaction. However, the effect of some factors affecting PCA satisfaction differed with the level of satisfaction. In open surgery patients, the effect of pain at 6 hours after surgery was significantly greater in the group with lower satisfaction. While, in the laparoscopic surgery patients, the effect of pain at 6-24 hours after surgery was significantly greater in the group with lower satisfaction.

CONCLUSION

Generalized logistic regression may be an appropriate statistical method for analyzing ordinal data. Degree of postoperative pain and assessment interval are the most important factors associated with PCA satisfaction. Because the factors affecting PCA satisfaction were different for the two types of abdominal surgeries, customizing PCA to individual patients may potentially improve pain management and consequently increase PCA satisfaction.

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.

American Society for Enhanced Recovery and Perioperative Quality Initiative-4 Joint Consensus Statement on Persistent Postoperative Opioid Use: Definition, Incidence, Risk Factors, and Health Care System Initiatives

Persistent postoperative opioid use is thought to contribute to the ongoing opioid epidemic in the United States. However, efforts to study and address the issue have been stymied by the lack of a standard definition, which has also hampered efforts to measure the incidence of and risk factors for persistent postoperative opioid use. The objective of this systematic review is to (1) determine a clinically relevant definition of persistent postoperative opioid use, and (2) characterize its incidence and risk factors for several common surgeries. Our approach leveraged a group of international experts from the Perioperative Quality Initiative-4, a consensus-building conference that included representation from anesthesiology, surgery, and nursing. A search of the medical literature yielded 46 articles addressing persistent postoperative opioid use in adults after arthroplasty, abdominopelvic surgery, spine surgery, thoracic surgery, mastectomy, and thoracic surgery. In opioid-naïve patients, the overall incidence ranged from 2% to 6% based on moderate-level evidence. However, patients who use opioids preoperatively had an incidence of >30%. Preoperative opioid use, depression, factors associated with the diagnosis of substance use disorder, preoperative pain, and tobacco use were reported risk factors. In addition, while anxiety, sex, and psychotropic prescription are associated with persistent postoperative opioid use, these reports are based on lower level evidence. While few articles addressed the health policy or prescriber characteristics that influence persistent postoperative opioid use, efforts to modify prescriber behaviors and health system characteristics are likely to have success in reducing persistent postoperative opioid use.

Educational interventions to improve medical students’ knowledge of acute pain management: a randomized study

It has been consistently documented that the treatment of acute pain is inadequate. Education of medical students is an obvious strategy to improve this. We therefore conducted a study in which 217 medical students were randomized into one of three groups: a control group (no intervention) and two intervention groups (education with e-learning alone or e-learning combined with simulation-based training). We hypothesized that the combined intervention would be superior to no intervention and e-learning alone. All students completed the same multiple choice questionnaire twice with an interval of approximately 1 week. During this 1-week interval, students in the two intervention groups completed either an 45-min interactive case-based e-learning program, or the e-learning program and a simulation-based training. We showed that the theoretical knowledge about treatment of acute pain increased in both intervention groups but students who received the combined intervention felt more confident in the future handling of patients.

Psychometric evaluation of the Danish version of a modified Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R-D) for patients hospitalized with acute abdominal pain

Background and aims This paper forms part of a study evaluating the effect of patient-controlled oral analgesia for patients admitted to hospital with acute abdominal pain. Pain is a subjective experience, and a multifaceted evaluation tool concerning patient-reported outcome measures is needed to monitor, evaluate, and guide health care professionals in the quality of pain management. The Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) is a validated multifaceted evaluation tool for measuring patient-reported pain experiences to evaluate different pain management interventions. The aim of this study was to evaluate the psychometric properties of a modified Danish version of the Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R-D) used during and after hospitalization for patients with acute abdominal pain. Methods The APS-POQ-R was translated into Danish and two slightly different questionnaires were formed. Questionnaire one had 39 items and the six subscales pain severity (pain), perception of care (satisfaction), pain interference with function (activity) and emotions (emotion), side effects of treatment (safety), and patient-related barriers to pain management. The questionnaire focused on time during hospital stay and was to be completed at discharge. Questionnaire two included 25 items and the five subscales pain, satisfaction, activity, emotion, and safety and focused on time at home and was to be completed daily 1 week after discharge. The questionnaires were tested on 156 patients with acute abdominal pain. Internal consistency reliability and construct validity was examined. Results In both questionnaires, the results of correlations and tests for internal consistency reliability showed a Cronbach's alpha of >0.7 for the pain, activity, and emotion subscales, but the value was ≥0.69 for the satisfaction subscale. In questionnaire one, Cronbach's alpha was ≤0.64 for the safety subscale, but this was 0.73 when the item "itching" was deleted. In questionnaire two, Cronbach's alpha was ≤0.51 for the safety subscale. For the patient-barrier subscale in questionnaire one, Cronbach's alpha was ≤0.62 for any combination of the items in the subscale. The results of the construct validity and factor analysis showed a five-factor structure in questionnaire one and a three-factor structure in questionnaire two. In questionnaire one, items from the pain, activity, emotion, and safety subscales, except for the items "least pain" and "itching," loaded on factor one. In questionnaire two, all items from the pain, activity, and emotion subscales loaded on factor one. Conclusions The modified APS-POQ-R-D demonstrated adequate psychometric properties for the five subscales pain severity (pain), perception of care (satisfaction), pain interference with function (activity) and emotions (emotion), side effects of treatment (safety), but not for the patient-barrier subscale for patients hospitalized with acute abdominal pain. Consequently, the APS-POQ-R-D may be used without the patient-barrier subscale. Implications The clinical implications of this study may help clinicians with investigating how acute patients manage pain during and after hospital admission.