Procedure-specific risk factor analysis for the development of severe postoperative pain

Effect of individualized anesthesia and analgesia on postoperative pain in patients stratified for pain sensitivity: A study protocol for the PeriOPerative individualization trial randomized controlled trial

BACKGROUND

Despite advancements in surgical and anesthesia techniques, acute and persistent postoperative pain are still a common challenge. Postoperative pain has direct effects on individual patient care and outcome, as well as putting strain on limited health care resources. Several prediction methods for postoperative pain have been described. One such method is the assessment of pain during peripheral venous cannulation (VCP). It is not known if different approaches to anesthesia and analgesia, depending on the evaluation of risk for postoperative pain, can improve outcome. The aim of this study is to evaluate if individualized anesthesia and analgesia can affect postoperative pain and recovery after surgery, in patients stratified by VCP.

METHODS

Adult patients scheduled for laparoscopic surgery undergo pain-sensitivity stratification using VCP on the day of surgery. Patients scoring VCP ≥2.0 on the visual analogue scale (pain-sensitive) are randomized to multimodal anaesthesia and analgesia with opioids or standard of care. Patients scoring VCP ≤1.9 (pain-tolerant) are randomized to opioid-free anaesthesia or standard of care. The primary outcome is acute postoperative pain measured with numeric rating scale in the postoperative care unit. Secondary outcomes include analysis of pain after 24 h, persistent postoperative pain and quality of recovery.

DISCUSSION

Individualized perioperative pain management has the potential to improve patient care. This study will examine the impact of different anesthesia and analgesia regimes, in patients with differing pain sensitivity, on postoperative pain.

TRIAL REGISTRATION

Prospectively posted at ClinicalTrials.gov, identifier NCT04751812.

Multiorganizational consensus to define guiding principles for perioperative pain management in patients with chronic pain, preoperative opioid tolerance, or substance use disorder

Significant knowledge gaps exist in the perioperative pain management of patients with a history of chronic pain, substance use disorder, and/or opioid tolerance as highlighted in the US Health and Human Services Pain Management Best Practices Inter-Agency Task Force 2019 report. The report emphasized the challenges of caring for these populations and the need for multidisciplinary care and a comprehensive approach. Such care requires stakeholder alignment across multiple specialties and care settings. With the intention of codifying this alignment into a reliable and efficient processes, a consortium of 15 professional healthcare societies was convened in a year-long modified Delphi consensus process and summit. This process produced seven guiding principles for the perioperative care of patients with chronic pain, substance use disorder, and/or preoperative opioid tolerance. These principles provide a framework and direction for future improvement in the optimization and care of 'complex' patients as they undergo surgical procedures.

Comparison of nerve block and spinal anesthesia in second toe pulp free flap surgery for fingertip reconstruction

Toe pulp flap surgery is a viable option for soft tissue defects of the fingertips, effectively addressing patient needs and fingertip characteristics. The preferred anesthesia for lower-extremity surgery includes spinal and regional anesthesia. However, the choice between these methods depends on patient safety and surgical efficacy. In this retrospective study, we aimed to ascertain the optimal anesthetic technique by examining the efficacy, safety, pain control, and potential side effects of spinal and peripheral nerve block anesthetics. We included 40 patients aged 18-60 years who underwent partial second toe pulp free flap surgery for fingertip reconstruction. Twenty patients received spinal anesthesia (SA), while the remaining 20 received peripheral nerve block anesthesia. We conducted a comparative analysis of postoperative pain scores, adverse effects, analgesic usage, and patient satisfaction scores associated with each anesthesia method. Independent t-test, Mann-Whitney U test, and chi-squared test were performed. The SA group exhibited hypotension, bradycardia, urinary retention, and postdural puncture headache rates of 10%, 10%, 5%, and 5%, respectively. A significant difference in the timing of first analgesic use was observed (spinal, 3.7 ± 0.8 vs. peripheral nerve block, 13.2 ± 6.6; P = 0.006). Visual analog scale (VAS) scores of the patients at the 2nd, 4th, and 6th h were significantly lower in the peripheral nerve block group (P < 0.001, P < 0.001, P < 0.001, respectively). VAS scores at 12 and 24 h were similar between the groups (P = 0.07, P = 0.135, respectively). Peripheral nerve block anesthesia is superior to SA for partial second toe pulp free flap surgery, offering lower complication rates, reduced postoperative pain, and improved patient comfort.

Prospective Study of Preoperative Negative Affect and Postoperative Pain in Patients Undergoing Thoracic Surgery: The Moderating Role of Sex

Objective: Preoperative negative affect is a risk factor for worse postoperative pain, but research investigating this association among patients undergoing thoracic surgery is inconsistent. Additionally, female patients often report greater negative affect and postoperative pain than males. This prospective observational study investigated the association between preoperative negative affect and postoperative pain after thoracic surgery and whether this association differed by sex. Methods: Patients (n = 105) undergoing thoracic surgery completed preoperative assessments of pain and negative affect (PROMIS anxiety and depression short forms). Patients reported their daily worst pain over the first 7 postoperative days, and an index score of acute postoperative pain was created. Six months after surgery, a subsample of patients (n = 60) reported their worst pain. Results: Higher levels of preoperative anxiety (r = 0.25, p = 0.011) and depression (r = 0.20, p = 0.042) were associated with greater acute postoperative pain, but preoperative negative affect was not related to chronic postsurgical pain (anxiety: r = 0.19, p = 0.16; depression: r = -0.01, p = 0.94). Moderation analyses revealed that the associations between both preoperative anxiety (b = 0.12, 95% CI [0.04, 0.21], p = 0.004) and depression (b = 0.15, 95% CI [0.04, 0.26], p = 0.008) with acute postoperative pain were stronger among females than males. Similarly, the association between preoperative anxiety and chronic postsurgical pain was stronger among females (b = 0.11, 95% CI [0.02, 0.20], p = 0.022), but the association between preoperative depression and chronic pain did not differ based on sex (b = 0.13, 95% CI [-0.07, 0.34], p = 0.201]). Conclusions: Our findings suggest that negative affect may be especially important to the experience of pain following thoracic surgery among female patients, whose degree of preoperative anxiety may indicate vulnerability to progress to a chronic pain state. Preoperative interventions aimed at reducing negative affect and pain may be particularly useful among females with high negative affect before thoracic surgery.

Predicting risk factors for acute pain after hepatobiliary and pancreatic surgery: an observational case control study

BACKGROUND

Inadequate postoperative analgesia is associated with increased risks of various postoperative complications, longer hospital stay, decreased quality of life and higher costs.

OBJECTIVES

This study aimed to investigate the risk factors for moderate-to-severe postoperative pain within the first 24 hours and 24-48 hours after major hepatobiliary pancreatic surgery.

METHODS

Data of patients who underwent surgery at the Department of Hepatobiliary Surgery in Henan Provincial People's Hospital were collected from January 2018 to August 2020. Univariate and multivariate logistic regression analyses were used to identify the risk factors of postoperative pain.

RESULTS

In total, 2180 patients were included in the final analysis. 183 patients (8.4%) suffered moderate-to-severe pain within 24 hours after operation. The independent risk factors associated with moderate-to-severe pain 24 hours after procedures were younger age (OR, 0.97; 95% CI 0.95 to 0.98, p<0.001), lower body mass index (BMI) (OR, 0.94; 95% CI 0.89 to 0.98, p=0.018), open surgery (OR, 0.34; 95% CI 0.22 to 0.52, p<0.001), and postoperative analgesia protocol with sufentanil (OR, 4.38; 95% CI 3.2 to 5.99, p<0.001). Postoperative hospital stay was longer in patients with inadequate analgesia (p<0.05).

CONCLUSION

Age, BMI, laparoscopic surgery, and different analgesic drugs were significant predictors of postoperative pain after major hepatobiliary and pancreatic surgery.

TRIAL REGISTRATION

ChiCTR2100049726.

Effect of age on postoperative 24-hour moderate-to-severe pain after radical resection of lung cancer-specific pain in the post-anaesthesia care unit: a single-centre retrospective cohort study

OBJECTIVES

To explore the relationship between age and postoperative 24-hour moderate-to-severe pain after radical resection of lung cancer and the specific effect of moderate-to-severe pain in the post-anaesthesia care unit (PACU) on this relationship.

DESIGN

Retrospective cohort study.

SETTING

Single medical centre.

PARTICIPANTS

Patients ≥18 years having radical resection of lung cancer between 2018 and 2020.

MEASUREMENTS

Postoperative 24-hour moderate-to-severe pain.

RESULTS

A total of 3764 patients were included in the analysis. The incidence of postoperative 24-hour moderate-to-severe pain was 28.3%. Age had a significant effect on the prediction model of postoperative 24-hour moderate-to-severe pain. Among the whole population and those without moderate-to-severe pain in the PACU, those who were younger than 58.5 years were prone to experience moderate-to-severe pain 24 hours after surgery, and in patients with moderate-to-severe pain in the PACU, the age threshold was 62.5 years.

CONCLUSION

For patients who underwent elective radical resection for lung cancer, age was related to postoperative 24-hour moderate-to-severe pain, and moderate-to-severe pain in the PACU had a specific effect on this relationship. Patients among the whole population and those patients without moderate-to-severe pain in the PACU were more likely to experience postoperative 24-hour moderate-to-severe pain when they were younger than 58.5 years old, and in patients with moderate-to-severe pain in the PACU, the age threshold was 62.5 years old.

Prospective cohort study investigating frequency and risk factors for acute pain 1 day after refractive surgery

BACKGROUND/AIMS

To examine demographic and clinical factors associated with ocular pain 1 day after refractive surgery.

METHODS

Prospective study of individuals undergoing refractive surgery. Participants rated their ocular pain on a 0-10 numerical rating scale (NRS) presurgery and 1 day after surgery. Presurgery, participants completed questionnaires on demographics, comorbidities, medications and dry eye and ocular pain symptoms; and an anaesthetised Schirmer test was performed. Acute ocular pain 1 day after surgery was defined as an NRS score of worst pain since surgery ≥3 and this group was compared with individuals with NRS scores<3.

RESULTS

251 individuals underwent refractive surgery (89% laser-assisted in situ keratomileusis, n=222; 11% PRK, n=29). Mean age was 35±8 years (range 19 to 60); 60% (n=150) self-identified as female, 80% (n=203) as White, and 36% (n=89) as Hispanic. Thirteen (5%) individuals reported ocular pain (NRS ≥3) prior to surgery and 67% (n=168) reported ocular pain 1 day after surgery (nine individuals had pain at both time points). Factors that were associated with pain 1 day after surgery included Hispanic ethnicity (adjusted relative risk (aRR) 1.42, 95% CI 1.21 to 1.68, p<0.001) and the presence of eye pain presurgery (aRR 1.10, 95% CI 1.02 to 1.18, p=0.02).

CONCLUSION

A majority of individuals report moderate or greater pain within 24 hours of refractive surgery. Hispanic ethnicity and eye pain prior to surgery were associated with self-reported acute postsurgical pain.

The Relationship Between Preoperative Anxiety Level and Postoperative Pain Outcomes in Total Hip and Knee Replacement Surgery: A Cross-sectional Study

PURPOSE

Preoperative anxiety is considered a common part of the surgerical experience and can be associated with serious postoperative side effects. This study aims to determine the relationship between preoperative anxiety level and postoperative pain outcomes in patients undergoing total hip replacement (THR) and total knee replacement (TKR).

DESIGN

The study used a cross-sectional and correlational research method.

METHODS

The study was conducted with a total of 104 participants, who underwent 17 THR and 87 TKR, at the Orthopedic Clinic of a state hospital in southern Turkey between June 2021 and June 2022. The State-Trait Anxiety Inventory (STAI) was used to determine preoperative anxiety level, and the Visual Analog Scale (VAS) and the Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) were used to assess postoperative pain level.

FINDINGS

The mean preoperative STAI-I and STAI-II scores of the participants who underwent THR and TKR were 53.95 ± 10.51 and 44.20 ± 10.55, respectively. There was a moderate positive correlation between STAI-I scores and VAS pain scores at preoperative and postoperative 6th, 12th, 24th, and 36th hours. There was a moderate positive correlation between STAI-I scores and affective subdimension scores, a moderate positive correlation with pain severity and sleep interference and activity interference, and a weak positive correlation between STAI-II scores and pain severity and sleep interference, activity interference and affective. The factors independently affecting the 6th-hour VAS pain score were determined as male gender, THR procedure, and increasing STAI score.

CONCLUSIONS

We found that high preoperative state anxiety was associated with early postoperative pain outcomes. State anxiety was associated with pain in the 6th postoperative hour. Considering the multidimensional nature of anxiety, further research is recommended to understand the anxiety domain in surgical patients.

Chronic Postsurgical Pain in Children and Adolescents: A Call for Action

Chronic postsurgical pain (CPSP) affects a significant proportion of children and adolescents after major surgery and is a detriment to both short- and long-term recovery outcomes. While clinical characteristics and psychosocial risk factors for developing CPSP in children and adults are well established in the literature, there has been little progress on the prevention and management of CPSP after pediatric surgery. Limited evidence to support current pharmacologic approaches suggests a fundamentally new paradigm must be considered by clinicians to both conceptualize and address this adverse complication. This narrative review provides a comprehensive evaluation of both the known and emerging mechanisms that support our current understanding of CPSP. Additionally, we discuss the importance of optimizing perioperative analgesic strategies to mitigate CPSP based on individual patient risks. We highlight the importance of postoperative pain trajectories to identify those most at risk for developing CPSP, the early referral to multi-disciplinary pain clinics for comprehensive evaluation and treatment of CPSP, and additional work needed to differentiate CPSP characteristics from other chronic pain syndromes in children. Finally, we recognize ongoing challenges associated with the universal implementation of available knowledge about pediatric CPSP into practically useful care plans for clinicians.

Risk Factors for Acute Postsurgical Pain: A Narrative Review

Acute postsurgical pain (APSP) has received growing attention as a surgical outcome. When poorly controlled, APSP can affect short- and long-term outcomes in patients. Despite the steady increase in awareness about postoperative pain and standardization of pain prevention and treatment strategies, moderate-to-severe APSP is frequently reported in clinical practice. This is possibly because pain varies widely among individuals and is influenced by distinct factors, such as demographic, perioperative, psychological, and genetic factors. This review investigates the risk factors for APSP, including gender, age, obesity, smoking history, preoperative pain history, pain sensitivity, preoperative anxiety, depression, pain catastrophizing, expected postoperative pain, surgical fear, and genetic polymorphisms. By identifying patients having an increased risk of moderate-to-severe APSP at an early stage, clinicians can more effectively manage individualized analgesic treatment protocols with a combination of pharmacological and non-pharmacological interventions. This would alleviate the transition from APSP to chronic pain and reduce the severity of APSP-induced chronic physical disability and social psychological distress.

Long-term postoperative opioid use in orthopaedic patients

BACKGROUND

The prevalence of long-term opioid use after orthopaedic surgery varies from 1.4% to 24% and has mostly been studied with prescription data, making it difficult to estimate the size and impact of the problem. This study aims to assess the prevalence and predictors of long-term postoperative opioid use in a high volume and tertiary orthopaedic centre by using online patient reported measures.

METHODS

This Dutch prospective cohort study was conducted among adult patients who underwent any type of orthopaedic surgery from June to August 2021. Six months after surgery patients were invited to complete an online survey on current opioid use and patients' willingness to taper opioids. The demographics, clinical factors and preoperative opioid use were extracted from the patient file.

RESULTS

In total, 607 patients (mean age 61.2 years, 63.4% female) completed the survey. Seventy-six patients (12.5%) used opioids 6 months after surgery of which 20 (3.3%) did not use opioids before surgery. The median (Q1-Q3) postoperative daily dose after 6 months was 29.9 mg (10.0-76.1) morphine equivalents. Most of them (88.2%) wanted to taper opioids. Affected body region (OR's: 6.84-12.75) and pre-operative opioid use (OR = 35.33) were significant predictors of long-term opioid use.

CONCLUSION

The prevalence of long-term postoperative opioid use was 12.5%; one in thirty patients became a new long-term opioid user. Pre-operative opioid use and affected body region were predictive for long-term opioid use. These findings, together with the observation that long-term opioid users want to taper opioids, emphasize the relevance of prevention, recognition and tapering support in the perioperative setting.

LEVEL OF EVIDENCE

Level II.

SIGNIFICANCE

Short-term opioid use can unintentionally progress to long-term opioid use. The prevalence of long-term opioid use after orthopaedic surgery varies widely and is mostly prescription-based, making it difficult to estimate the magnitude of the problem. This study assessed long-term postoperative opioid use in a full breadth orthopaedic population using patient reported measures, making conclusions much more robust. The prevalence of long-term postoperative opioid use in this study was 12.5%.

Postoperative Opioid Consumption is Greater after Simultaneous versus Staged Bilateral Total Knee Arthroplasty

Increased exposure to opioids around total knee arthroplasty (TKA) can lead to a risk of long-term dependence. We hypothesized that performing simultaneous bilateral total knee arthroplasty (simBTKA) over staged surgery (staged bilateral total knee arthroplasty [stgBTKA]) may decrease the total amount of opiates used. We retrospectively reviewed 29 patients who underwent simBTKAs performed between February 2015 and November 2020 and identified 23 that did not use opioids ≤90 days prior to surgery. These were frequency matched for gender and body mass index to 50 stgBTKAs completed within 6 months who also were opioid-free ≤90 days prior to their first surgery. Using our state's prescription database, we reviewed postsurgery opioid refills and morphine milligram equivalents (MMEs) for the two groups and compared their initial MME prescription at discharge and their total MME consumption 6 months postoperatively. Total MME consumption for the stgBTKA group included all prescriptions following the first and 6 months after the second surgery, whereas for the simBTKA group, total consumption included the 6 months after their two same-day surgeries. The simBTKA group had more MMEs prescribed initially (median = 375) than did the stgBTKA group after second surgery (median = 300; p < 0.007), larger postoperative-refill MMEs in the first 30 days (median = 300) than stgBTKA (median = 0; p = 0.221) and increased total MME consumption 6 months after surgery (median = 675) compared with stgBTKA after second surgery (median = 450; p = 0.077). However, both groups had similar monthly consumptions rates, with medians I MMEs/month of 112 for simBTKA versus 96 for stgBTKA (p = 0.585). Our results suggest there is no significant difference in opioid consumption between simBTKA and stgBTKA. In fact, we found that simBTKA patients received larger opioid amounts in the immediate postoperative period as well as slightly larger amounts at 30 days.

Ambulatory Robotic Colectomy: Factors Affecting and Affected by Postoperative Opioid Use

BACKGROUND

The ongoing opioid crisis demands an investigation into the factors driving postoperative opioid use. Ambulatory robotic colectomies are an emerging concept in colorectal surgery, but concerns persist surrounding adequate pain control for these patients who are discharged very early. We sought to identify key factors affecting recovery room opioid use (ROU) and additional outpatient opioid prescriptions (AOP) after ambulatory robotic colectomies.

METHODS

This was a single-institution retrospective review of ambulatory robotic colon resections performed between 2019 and 2022. Patients were included if they discharged on the same day (SDD) or postoperative day 1 (POD1). Outcomes of interest included ROU [measured in parenteral morphine milligram equivalents (MMEs)], AOP (written between PODs 2 to 7), postoperative emergency department presentations, and readmissions.

RESULTS

Two hundred nineteen cases were examined, 48 of which underwent SDD. The mean ROU was 29.4 MME, and 8.7% of patients required AOP. Between SDD and POD1 patients, there were no differences in postoperative emergency department presentations, readmissions, recovery opioid use, or additional outpatient opioid scripts. Older age was associated with a lower ROU (-0.54 MME for each additional year). Older age, a higher body mass index, and right-sided colectomies were also more likely to use zero ROU. Readmissions were strongly associated with lower ROU. Among SDD patients, lower ROU was also associated with higher rates of AOP.

CONCLUSION

Ambulatory robotic colectomies and SDD can be performed with low opioid use and readmission rates. Notably, we found an association between low ROU and more readmission, and, in some cases, higher AOP. This suggests that adequate pain control during the postoperative recovery phase is a crucial component of reducing these negative outcomes.

Evaluating a targeted person-centred pain management intervention programme in lumbar spine surgery - a controlled segment-specific before-and-after interventional design

BACKGROUND

Postoperative pain management in lumbar spine surgery care remains a challenge. The aim of this study was to evaluate the impact of a person-centred postoperative pain management intervention programme on lumbar spine surgery patients on postoperative pain, shared decision-making, and satisfaction with postoperative pain management.

METHODS

The study was performed with a controlled before-and-after interventional design in an orthopaedic unit at a university hospital. Person-centred pain management for patients undergoing spine surgery was developed in co-creation by a multi-professional team and implemented throughout the care pathway. The usual care group (pre-intervention) served as a comparison to the intervention group. Pain intensity, shared decision-making in pain management, and patient satisfaction with results of pain management, served as patient-reported measures, collected using the International Pain Outcomes questionnaire and analysed using descriptive statistics.

RESULTS

The intervention showed no benefit for patients' pain and satisfaction, while shared decision-making in pain management was significant lower in the intervention group than in the conventional group. The per-protocol analysis showed no significant differences between groups.

CONCLUSION

The initial assumption of the study, that the implementation of a co-created structured person-centred care pathway would improve patient-reported outcomes, was not confirmed. The periodically low fidelity to the intervention due to organizational constraints (due to sub-optimal organizational conditions and managerial support) may have affected the results.

Objectively measured activity is not associated with average pain intensity 1 week after surgery: A cross-sectional study

BACKGROUND

Measures of physical activity and pain-related patient-reported outcomes are important components of patient recovery after surgery. However, little is known about their association in the early post-operative period. This study aims to increase this knowledge. Our primary objective was to determine the association between average pain intensity and activity (in steps) 1 week after surgery. Secondary objectives were the association of activity with other patient-reported outcomes, age, sex, comorbidities and body mass index.

METHODS

Data were obtained from the PROMPT sub-project of IMI-PainCare. Patients after breast and endometriosis-related surgery, sternotomy and total knee arthroplasty completed pain-related outcomes questionnaires and wore an ActiGraph activity-tracking device. We correlated steps with average pain intensity on post-operative days 6 and 7. Secondary analyses were done using correlations and t-tests.

RESULTS

In 284 cases, there was no statistically significant correlation between steps and average pain intensity. In addition, none of the 28 secondary analyses showed a statistically significant result.

CONCLUSIONS

Pain-related patient-reported outcome measures and physical activity are separate entities. Both should be measured after surgery to assess patient recovery and to identify treatment deficiencies.

SIGNIFICANCE STATEMENT

Measuring recovery is a multi-dimensional challenge. After surgery, clinicians need to be aware that neither pain intensity nor activity levels tell the whole story. Each can hint to problems and treatment requirements.

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).

Effect of Remifentanil on Acute and Chronic Postsurgical Pain in Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-analysis

OBJECTIVES

Our purpose was to explore the effect of remifentanil on acute and chronic postsurgical pain after cardiac surgery.

MATERIALS AND METHODS

Randomized controlled trials were retrieved from electronic databases, such as PubMed, Cochrane Library, China National Knowledge Internet databases, Scopus, and Web of Science. A systematic review, meta-analysis, and trial sequential analysis (TSA) were performed. Basic information and outcomes were extracted from the included studies. The primary outcome was chronic postsurgical pain. Secondary outcomes were scores of postsurgical pain and morphine consumption within 24 hours after cardiac surgery. Risk of bias (ROB) assessment was based on the Cochrane ROB tool version 2. The overall quality of the evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

RESULTS

Seven studies consisting of 658 patients were enrolled in the meta-analysis. A single study had a high ROB and 2 studies had a moderate ROB. The incidence of chronic postsurgical pain (4 studies [415 patients]; risk ratio: 1.02 [95% CI: 0.53 to 1.95]; P = 0.95; I2 = 59%; TSA-adjusted CI: 0.78 to 1.20) and the postsurgical pain score (2 studies [196 patients]; mean difference: 0.09 [95% CI: -0.36 to 0.55]; P = 0.69; I2 = 0%; TSA-adjusted CI: -0.36 to 0.55) were not statistically different between the 2 groups. However, morphine consumption (6 studies [569 patients]; mean difference: 6.94 [95% CI: 3.65 to 10.22]; P < 0.01; I2 = 0%; TSA-adjusted CI: 0.00 to 0.49) was higher in the remifentanil group than in the control group.

CONCLUSION

There was not enough evidence to prove that remifentanil can increase the incidence of chronic postsurgical pain after cardiac surgery, but interestingly, the results tended to support a trend toward increased complications in the intervention group. However, there was moderate certainty evidence that the use of remifentanil increases the consumption of morphine for analgesia, and more direct comparison trials are needed to inform clinical decision-making with greater confidence.

The association of intraoperative opioid dose with postanesthesia care unit outcomes in children: a retrospective study

PURPOSE

In children, the relationship between the dose of intraoperative opioid and postoperative outcomes is unclear. We examined the relationship between intraoperative opioid dose and postanesthesia care unit (PACU) pain scores and opioid and antiemetic administrations.

METHODS

We performed a single-institution retrospective cohort study. Patients who were aged < 19 yr, had an American Society of Anesthesiologists Physical Status of I-III, were undergoing one of 11 procedures under general anesthesia and without regional anesthesia, and who were admitted to the PACU were included. Patients were analyzed by quartiles of total intraoperative opioid dose using multivariable regression, adjusting for confounders including procedure. An exploratory analysis of opioid-free anesthetics was also performed.

RESULTS

Three thousand, seven hundred and thirty-three cases were included, and the mean age of included patients was 8.3 yr. After adjustment, there were no significant differences between the lowest and higher quartiles for first conscious pain score, mean pain score, PACU opioid dose, or PACU length of stay; in addition, estimated differences were small. Patients in higher quartiles were estimated to be more likely to receive antiemetics, significantly so for those in the second quartile. Patients in the lowest quartile received significantly more intraoperative nonopioid analgesics. In the exploratory analysis, no significant difference in PACU pain scores was found in cases without intraoperative opioids.

CONCLUSIONS

Children who received lower doses of intraoperative opioids did not have worse PACU pain outcomes but required fewer antiemetics and received greater numbers of nonopioid analgesics intraoperatively. These findings suggest that lower doses of intraoperative opioids may be administered to children as long as other analgesics are used.

Responsiveness of multiple patient-reported outcome measures for acute postsurgical pain: primary results from the international multi-centre PROMPT NIT-1 study

BACKGROUND

Postsurgical outcome measures are crucial to define the efficacy of perioperative pain management; however, it is unclear which are most appropriate. We conducted a prospective study aiming to assess sensitivity-to-change of patient-reported outcome measures assessing the core outcome set of domains pain intensity (at rest/during activity), physical function, adverse events, and self-efficacy.

METHODS

Patient-reported outcome measures were assessed preoperatively, on day 1 (d1), d3, and d7 after four surgical procedures (total knee replacement, breast surgery, endometriosis-related surgery, and sternotomy). Primary outcomes were sensitivity-to-change of patient-reported outcome measures analysed by correlating their changes (d1-d3) with patients' global impression of change and patients' specific impression of change items as anchor criteria. Secondary outcomes included identification of baseline and patient characteristic variables explaining variance in change for each of the scales and descriptive analysis of various patient-reported outcome measures from different domains and after different surgeries.

RESULTS

Of 3322 patients included (18 hospitals, 10 countries), data from 2661 patients were analysed. All patient-reported outcome measures improved on average over time; the median calculated sensitivity-to-change for all patient-reported outcome measures (overall surgeries) was 0.22 (range: 0.07-0.31, scale: 0-10); all changes were independent of baseline data or patient characteristics and similar between different procedures.

CONCLUSIONS

Pain-related patient-reported outcome measures have low to moderate sensitivity-to-change; those showing higher sensitivity-to-change from the same domain should be considered for inclusion in a core outcome set of patient-reported outcome measures to assess the effectiveness and efficacy of perioperative pain management.

Impact of preoperative insomnia on poor postoperative pain control after elective spine surgery and the modified Calgary postoperative pain after spine surgery (MCAPPS) score

Background

Approximately 30% to 64% of patients experience inadequate pain control following spine surgery. The Calgary postoperative pain after spine surgery (CAPPS) score was developed to identify this subset of patients. The impact of preoperative insomnia on postoperative pain control is unknown. This study aimed to investigate the relationship between preoperative insomnia and poor pain control after spine surgery, as well as improve the predictive accuracy of the CAPPS score.

Methods

A prospective cohort study was conducted in patients undergoing elective spine surgery. Poor pain control was defined as a mean numeric rating scale pain score >4 at rest within the first 24-hours after surgery. Patients were evaluated using the CAPPS score, which included 7 prognostic factors. A multivariable logistic regression model was used to examine the association between preoperative insomnia severity index (ISI) and poor pain control, adjusting for the CAPPS score. The Modified CAPPS score was derived from this model.

Results

Of 219 patients, 49.7% experienced poorly controlled pain. Prevalence of clinical insomnia (ISI≥15) was 26.9%. Preoperative ISI was independently associated with poor pain control (odds ratio [OR] 1.09, [95%CI=1.03-1.16], p=.004), after adjusting for the CAPPS score (OR 1.61, [95%CI=1.38-1.89], p<.001). The model exhibited good discrimination (c-statistics 0.80, [95%CI=0.74-0.86]) and calibration (Hosmer-Lemeshow chi-square=8.95, p=.35). The Modified CAPPS score also demonstrated good discrimination (c-statistic 0.78, [95%CI=0.72-0.84]) and calibration (Hosmer-Lemeshow chi-square=2.92, p=.57). Low-, high-, and extreme-risk groups stratified by the Modified CAPPS score had 17.3%, 49.1%, and 80.7% predicted probability of experiencing inadequate pain control compared to 32.0%, 64.0%, and 85.1% in the CAPPS score.

Conclusions

Preoperative insomnia is prevalent and is a modifiable risk factor for poor pain control following spine surgery. Early identification and management of preoperative insomnia may lead to improved postoperative pain outcomes. Future external validation is needed to confirm the accuracy of the Modified CAPPS score.

Ultrasound-guided external oblique and rectus abdominis plane "EXORA" block for postoperative pain after laparoscopic cholecystectomy: a propensity-matched study

BACKGROUND

Various types of plane blocks are used for analgesia in the upper abdomen. The purpose of this study was to evaluate the efficacy of the external oblique and rectus abdominis plane (EXORA) block for antero-lateral upper abdominal analgesia.

METHODS

This study included 60 patients undergoing laparoscopic cholecystectomy. Patients were divided into control group, intravenous patient-controlled analgesia (IV.PCA) (N.=30) and EXORA group (block with 25 mL 0.25% bupivacaine + IV.PCA [N.=30]). Postoperative pain (at rest) was evaluated at 30 minutes, two, four, six, 12 and 24 hours using Visual Analogue Scale (VAS) scores. Postoperative activity pain at two, four, six, 12 and 24 hours was also assessed using VAS. Secondary outcomes included tramadol use at 12 and 24 hours after surgery, side effect profile, dermatomal spread, and additional analgesic use.

RESULTS

The VAS scores were statistically significantly lower in the EXORA group compared to the other groups (P<0.001). In addition, mean tramadol consumption at 12 and 24 hours was statistically significantly lower in the EXORA group (P<0.001). Sensory block was recorded in the lateral and anterior abdomen at T6 to T11 after EXORA block application.

CONCLUSIONS

The EXORA block used to provide analgesia after laparoscopic cholecystectomy provides analgesia to the upper abdominal wall. Further data may be obtained from cadaveric studies and other studies.

[Dealing with "complex" pain patients in eye surgery : Perioperative management of patients with pre-existing chronic pain, opioid consumption and opioid use disorder]

The quality of postoperative pain management is still considered insufficient in many cases, also in surgical ophthalmology. Complex constellations and comorbidities, such as pre-existing chronic pain, opioid consumption and opioid use disorders represent a special challenge due to psychosocial influencing factors and sometimes psychological and psychiatric comorbidities but also due to pharmacological effects, such as the development of opioid tolerance, the opioid-induced hyperalgesia. This review article aims to impart knowledge on aspects of these comorbidities and the perioperative management to improve the treatment skills of ophthalmologists in the management of pain in these complex patients.

Risk Factors for Severe Pain and Impairment of Daily Life Activities after Cesarean Section-A Prospective Multi-Center Study of 11,932 Patients

Cesarean section (CS) is the most widely performed and one of the most painful surgeries. This study investigated postoperative pain after CS using patient-related outcomes (PROs) to identify risk factors for severe pain. The secondary outcome was to evaluate the influence of surgery indication (primary CS (PCS) vs. urgent CS (UCS)). This multi-center, prospective cohort study included data submitted to the pain registry "quality improvement in postoperative pain treatment" (QUIPS) between 2010 and 2020. In total, 11,932 patients were evaluated. Median of maximal pain was 7.0 (numeric rating scale (NRS) 0 to 10); 53.9% suffered from severe pain (NRS ≥ 7), this being related to impairment of mood, ambulation, deep breathing and sleep, as well as more vertigo, nausea and tiredness (p < 0.001). Distraction, relaxation, mobilization, having conversations, patient-controlled analgesia (PCA) and pain monitoring were shown to be protective for severe pain (p < 0.001). Maximal pain in PCS and UCS was similar, but UCS obtained more analgesics (p < 0.001), and experienced more impairment of ambulation (p < 0.001) and deep breathing (p < 0.05). Severe pain has a major effect on daily-life activities and recovery after CS, and depends on modifiable factors. More effort is needed to improve the quality of care after CS.

Chronic pain patients and time to sustained acceptable pain scores after major surgery - A retrospective registry analysis

STUDY OBJECTIVE

We tested the hypothesis that pre-existing chronic pain is associated with prolonged time to reach sustained acceptable pain scores after major surgery.

DESIGN

Retrospective study using the German Network for Safety in Regional Anaesthesia and Acute Pain Therapy registry.

SETTING

Operating rooms and surgical wards.

PATIENTS

107,412 patients recovering from major surgery who were cared for by an acute pain service. 3.3% of the treatments were in patients who reported chronic pain with functional or psychological impairment.

INTERVENTIONS AND MEASUREMENT

We compared time to sustained adequacy of postoperative pain control defined by numeric rating scores <4 at rest and with movement in patients with and without chronic pain using an adjusted cox proportional hazard regression model and Kaplan-Meier analysis. The observation period was censored at 10 days and propensity score matching was used as a sensitivity analysis.

MAIN RESULTS

Postoperative pain at rest took significantly longer to resolve in patients with chronic pain than in those without (adjusted hazard ratio HR 1.42, 95% CI 1.36-1.49, P < 0.001). Postoperative pain with movement took even longer to resolve in patients with chronic pain (adjusted HR 1.65, 95%CI 1.56-1.75, P < 0.001).

CONCLUSIONS

Patients with chronic pain sustain more surgical pain than those without, and the pain takes longer to resolve. Clinicians providing postoperative pain management should consider the special needs of chronic pain patients.

Prognostic models for chronic postsurgical pain-Current developments, trends, and challenges

PURPOSE OF REVIEW

Prognostic models for chronic postsurgical pain (CPSP) aim to predict the likelihood for development and severity of CPSP in individual patients undergoing surgical procedures. Such models might provide valuable information for healthcare providers, allowing them to identify patients at higher risk and implement targeted interventions to prevent or manage CPSP effectively. This review discusses the latest developments of prognostic models for CPSP, their challenges, limitations, and future directions.

RECENT FINDINGS

Numerous studies have been conducted aiming to develop prognostic models for CPSP using various perioperative factors. These include patient-related factors like demographic variables, preexisting pain conditions, psychosocial aspects, procedure-specific characteristics, perioperative analgesic strategies, postoperative complications and, as indicated most recently, biomarkers. Model generation, however, varies and performance and accuracy differ between prognostic models for several reasons and validation of models is rather scarce.

SUMMARY

Precise methodology of prognostic model development needs advancements in the field of CPSP. Development of more accurate, validated and refined models in large-scale cohorts is needed to improve reliability and applicability in clinical practice and validation studies are necessary to further refine and improve the performance of prognostic models for CPSP.

Development and Internal Validation of the Postoperative Analgesic Intake Needs Score: A Predictive Model for Post-Operative Narcotic Requirement after Spine Surgery

STUDY DESIGN

Retrospective Cohort.

OBJECTIVE

The aim of this study was to develop a clinical tool to pre-operatively risk-stratify patients undergoing spine surgery based on their likelihood to have high postoperative analgesic requirements.

METHODS

A total of 1199 consecutive patients undergoing elective spine surgery over a 2-year period at a single center were included. Patients not requiring inpatient admission, those who received epidural analgesia, those who had two surgeries at separate sites under one anesthesia event, and those with a length of stay greater than 10 days were excluded. The remaining 860 patients were divided into a derivation and validation cohort. Pre-operative factors were collected by review of the electronic medical record. Total postoperative inpatient opioid intake requirements were converted into morphine milligram equivalents to standardize postoperative analgesic requirements.

RESULTS

The postoperative analgesic intake needs (PAIN) score was developed after the following predictor variables were identified: age, race, history of depression/anxiety, smoking status, active pre-operative benzodiazepine use and pre-operative opioid use, and surgical type. Patients were risk-stratified based on their score with the high-risk group being more likely to have high opioid consumption postoperatively compared to the moderate and low-risk groups in both the derivation and validation cohorts.

CONCLUSION

The PAIN Score is a pre-operative clinical tool for patients undergoing spine surgery to risk stratify them based on their likelihood for high analgesic requirements. The information can be used to individualize a multi-modal analgesic regimen rather than utilizing a "one-size fits all" approach.

Incidence of opioid use and early postoperative pain intensity after primary unilateral inguinal hernia repair at a single-center specialty hospital

PURPOSE

This research examined opioid use, pain intensity, and pain management after primary unilateral inguinal hernia repair (PUIHR) at a single-center specialty hospital.

METHODS

After research, ethics board approval, and informed consent, pain scores (0-10 numerical rating scale [NRS]) were obtained from survey-based questionnaires administered at the pre- and 3-day postoperative timepoints. Descriptive results are presented as frequency, mean, standard deviation, range, median, and interquartile ranges, as appropriate. Significance tests were conducted to compare participants who did and did not receive opioids after surgery. p-value <0.05 is considered statistically significant. As the standard of care, participants received nonopioid multimodal analgesia (acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs)) and opioids, when necessary.

RESULTS

A total of 414 and 331 participants completed the pre- and 3-day postoperative questionnaires, respectively. Out of the 414 participants, 38 (9.2%) received opioids during the postoperative stay. There was no significant difference between pain frequency or mean preoperative NRS pain intensity scores of those who did and did not receive opioids. Mean NRS pain intensity scores on day 3 after surgery were significantly higher for participants who received opioids (3.15±2.08) than those who did not (2.19±1.95), p=0.005.

CONCLUSION

Most participants did not receive opioids after PUIHR and had lower mean postoperative NRS pain intensity scores compared to those who did, most likely reflecting the need for opioids among the latter. Opioids were discontinued by day 3 for all participants who received them. Therefore, for most patients undergoing PUIHR, effective pain control can be achieved with nonopioid multimodal analgesia in the early postoperative period.

The Acute Perioperative Pain Service: Impact, Organization, and Future Directions

PURPOSE OF REVIEW

The Acute Perioperative Pain Service has been established as a relatively new but important concept and service in clinical patient care. Many surgical institutions have dedicated inpatient acute pain services with variable compositions. This review aims to investigate the purpose, clinical and economic implications, and future direction of the Acute Perioperative Pain Service (APPS).

RECENT FINDINGS

There is growing evidence of the multiple benefits of a dedicated APPS, especially pertaining to patients at higher risk of poorly controlled postoperative pain. Healthcare providers furthermore realize the importance of the perioperative pain management continuity of care, consisting of preoperative pain evaluations and post-discharge follow-up in an outpatient pain management setting, in coordination with the primary teams. The Transitional Pain Service (TPS) has emerged as the next step in this evolution and has been successfully implemented at various medical centers. With the growing number of surgical procedures and the increasing complexity of the patient population, effective management of acute postoperative pain continues to be challenging, despite ongoing advances in clinical care, analgesic modalities, and research. The APPS is becoming the clinical standard of care for managing postoperative pain, and its role continues to expand worldwide.

Validation of the Calgary Postoperative Pain after Spine Surgery Score for Poor Postoperative Pain Control after Spine Surgery

OBJECTIVE

The Calgary Postoperative Pain after Spine Surgery (CAPPS) score was developed to identify patients at risk of experiencing poorly controlled pain after spine surgery. The goal of this study was to independently validate the CAPPS score on a prospectively collected patient sample.

METHODS

Poor postoperative pain control was defined as a mean numeric rating scale (NRS) for pain >4 at rest in the first 24 hours after surgery. Baseline characteristics in this study (validation cohort) were compared to those of the development cohort used to create the CAPPS score. Predictive performance of the CAPPS score was assessed by the area under the curve (AUC) and percentage misclassification for discrimination. A graphical comparison between predicted probability vs. observed incidence of poorly controlled pain was performed for calibration.

RESULTS

Fifty-two percent of 201 patients experienced poorly controlled pain. The validation cohort exhibited lower depression scores and a higher proportion using daily opioid medications compared to the development cohort. The AUC was 0.74 [95%CI = 0.68-0.81] in the validation cohort compared to 0.73 [95%CI = 0.69-0.76] in the development cohort for the eight-tier CAPPS score. When stratified between the low- vs. extreme-risk and low- vs. high-risk groups, the percentage misclassification was 21.2% and 30.7% in the validation cohort, compared to 29.9% and 38.0% in the development cohort, respectively. The predicted probability closely mirrored the observed incidence of poor pain control across all scores.

CONCLUSIONS

The CAPPS score, based on seven easily obtained and reliable prognostic variables, was validated using a prospectively collected, independent sample of patients.

Postoperative Rebound Pain: Our Current Understanding About the Role of Regional Anesthesia and Multimodal Approaches in Prevention and Treatment

PURPOSE OF REVIEW

Rebound pain (RP) is a common occurrence after peripheral nerve block placement, especially when blocks are used for orthopedic surgery. This literature review focuses on the incidence and risk factors for RP as well as preventative and treatment strategies.

RECENT FINDINGS

The addition of adjuvants to a block, when appropriate, and starting patients on oral analgesics prior to sensory resolution are reasonable approaches. Using continuous nerve block techniques can provide extended analgesia through the immediate postoperative phase when pain is the most intense. Peripheral nerve blocks (PNBs) are associated with RP, a frequent phenomenon that must be recognized and addressed to prevent short-term pain and patient dissatisfaction, as well as long-term complications and avoidable hospital resource utilization. Knowledge about the advantages and limitations of PNBs allows the anesthesiologists to anticipate, intervene, and hopefully mitigate or avoid the phenomenon of RP.

Different Gabapentin and Pregabalin Dosages for Perioperative Pain Control in Patients Undergoing Spine Surgery: A Systematic Review and Network Meta-Analysis

IMPORTANCE

Patients undergoing spine surgery often experience severe pain. The optimal dosage of pregabalin and gabapentin for pain control and safety in these patients has not been well established.

OBJECTIVE

To evaluate the associations of pain, opioid consumption, and adverse events with different dosages of pregabalin and gabapentin in patients undergoing spine surgery.

DATA SOURCES

PubMed/MEDLINE, Embase, Web of Science, Cochrane library, and Scopus databases were searched for articles until August 7, 2021.

STUDY SELECTION

Randomized clinical trials conducted among patients who received pregabalin or gabapentin while undergoing spine surgery were included.

DATA EXTRACTION AND SYNTHESIS

Two investigators independently performed data extraction following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) reporting guideline. The network meta-analysis was conducted from August 2022 to February 2023 using a random-effects model.

MAIN OUTCOMES AND MEASURES

The primary outcome was pain intensity measured using the Visual Analog Scale (VAS), and secondary outcomes included opioid consumption and adverse events.

RESULTS

Twenty-seven randomized clinical trials with 1861 patients (median age, 45.99 years [range, 20.00-70.00 years]; 759 women [40.8%]) were included in the systematic review and network meta-analysis. Compared with placebo, the VAS pain score was lowest with gabapentin 900 mg per day, followed by gabapentin 1200 mg per day, gabapentin 600 mg per day, gabapentin 300 mg per day, pregabalin 300 mg per day, pregabalin 150 mg per day, and pregabalin 75 mg per day. Additionally, gabapentin 900 mg per day was found to be associated with the lowest opioid consumption among all dosages of gabapentin and pregabalin, with a mean difference of -22.07% (95% CI, -33.22% to -10.92%) for the surface under the cumulative ranking curve compared with placebo. There was no statistically significant difference in adverse events (nausea, vomiting, and dizziness) among all treatments. No substantial inconsistency between direct and indirect evidence was detected for all outcomes.

CONCLUSIONS AND RELEVANCE

These findings suggest that gabapentin 900 mg per day before spine surgery is associated with the lowest VAS pain score among all dosages. In addition, no differences in adverse events were noted among all treatments.

No Success without Effort: Follow-Up at Six Years after Implementing a Benchmarking and Feedback Concept for Postoperative Pain after Total Hip Arthroplasty

BACKGROUND

Total hip arthroplasty (THA) is still ranked among the operations with the highest postoperative pain scores. Uncontrolled postsurgical pain leads to prolongated hospital stays, causes more frequent adverse reactions and can induce chronical pain syndromes. In 2014, we implemented a standardized, multidisciplinary pain management concept with continuous benchmarking at our tertiary referral center by using the "Quality Improvement in Postoperative Pain Management" (QUIPS) program with excellent results over a period of two years. The initial study ended in 2016 and we aimed to evaluate if it was possible to obtain the excellent short-term results over a period of six years without any extra effort within the daily clinical routine.

MATERIALS AND METHODS

In a retrospective study design, we compared postoperative pain, side effects and functional outcome after primary THA for 2015 and 2021, using validated questionnaires from the QUIPS project. In contrast to the implementation of the pain management concept in 2014, the weekly meetings of the multidisciplinary health care team and special education for nurses were stopped in 2021. Data assessment was performed by an independent pain nurse who was not involved in pain management.

RESULTS

Altogether, 491 patients received primary THA in 2015 and 2021 at our tertiary referral center. Collected data revealed significantly worse maximum and activity-related pain (both p < 0.001) in combination with significantly higher opioid consumption in comparison to implementation in 2015. Though the patients reported to be less involved in pain management (p < 0.001), the worse pain scores were not reflected by patient satisfaction which remained high. While the participation rate in this benchmarking program dropped, we still fell behind in terms of maximum and activity-related pain in comparison to 24 clinics.

CONCLUSION

Significantly worse pain scores in combination with higher opioid usage and a lower hospital participation rate resemble a reduced awareness in postoperative pain management. The significantly lower patient participation in pain management is in line with the worse pain scores and indirectly highlights the need for special education in pain management. The fact patient satisfaction appeared to remain high and did not differ significantly from 2015, as well as the fact we still achieved an acceptable ranking in comparison to other clinics, highlight the value of the implemented multidisciplinary pain management concept.

Early Postoperative Opioid Requirement Is Associated With Later Pain Control Needs After Supratentorial Craniotomies

BACKGROUND

Despite a renewed focus in recent years on pain management in the inpatient hospital setting, postoperative pain after elective craniotomy remains under investigated. This study aims to identify which perioperative factors associate most strongly with postoperative pain and opioid medication requirements after inpatient craniotomy.

MATERIALS AND METHODS

Using an existing dataset, we selected a restricted cohort of patients who underwent elective craniotomy surgery requiring an inpatient postoperative stay during a 7-year period at our institution (n=1832). We examined pain scores and opioid medication usage and analyzed the relative contribution of specific perioperative risk factors to postoperative pain and opioid medication intake (morphine milligram equivalents).

RESULTS

Postoperative pain was found to be highest on postoperative day 1 and decreased thereafter (up to day 5). Factors associated with greater postoperative opioid medication requirement were preoperative opioid medication use, duration of anesthesia, degree of pain in the preoperative setting, and patient age. Notably, the most significant factor associated with a higher postoperative pain score and Morphine milligram equivalents requirement was the time elapsed between the end of general anesthesia and a patient's first intravenous opioid medication.

CONCLUSION

Postcraniotomy patients are at higher risk for requiring opioid pain medications if they have a history of preoperative opioid use, are of younger age, or undergo a longer surgery. Moreover, early requirement of intravenous opioid medications in the postoperative period should alert treating physicians that a patient's pain may require additional or alternative methods of pain control than routinely administered, to avoid over-reliance on opioid medications.

Risk factors and protective factors of acute postoperative pain: an observational study at a German university hospital with cross-sectional and longitudinal inpatient data

OBJECTIVES

Surgical fear is one of the most important psychological risk factors for postoperative pain, but less is known about the contribution of protective factors. This study investigated somatic and psychological risk and resilience factors of postoperative pain and validated the German version of the Surgical Fear Questionnaire (SFQ).

SETTING

University Hospital of Marburg, Germany.

DESIGN

Single-centre observational study and cross-sectional validation study.

PARTICIPANTS

Data for validating the SFQ were obtained from a cross-sectional observational study (N=198, mean age 43.6 years, 58.8% female) with persons undergoing different kinds of elective surgery. A sample of N=196 (mean age 43.0 years, 45.4% female) undergoing elective (orthopaedic) surgery was analysed to investigate somatic and psychological predictors of relevant acute postsurgical pain (APSP).

OUTCOME MEASURES

Participants completed preoperative and postoperative assessments at postoperative days 1, 2 and 7. Presurgical pain, age, gender, pain expectation, surgical setting, physical status, anaesthesia, surgical fear, pain catastrophising, depression, optimism and self-efficacy were examined as predictors.

RESULTS

Confirmatory factor analysis confirmed the original two-factor structure of the SFQ. Correlation analyses indicated good convergent and divergent validity. Internal consistency (Cronbach's α) was between 0.85 and 0.89. Blockwise logistic regression analyses for the risk of APSP revealed outpatient setting, higher preoperative pain, younger age, more surgical fear and low dispositional optimism as significant predictors.

CONCLUSIONS

The German SFQ is a valid, reliable and economical instrument with which the important psychological predictor surgical fear can be assessed. Modifiable factors that increase the risk of postoperative pain were higher pain intensity before surgery and being fearful about negative consequences of the surgery whereas positive expectations seem to buffer against postsurgical pain.

TRIAL REGISTRATION NUMBERS

DRKS00021764 and DRKS00021766.

Effects of oxycodone pharmacogenetics on postoperative analgesia and related clinical outcomes in children: a pilot prospective study

Background: Variability in the pharmacokinetics and pharmacodynamics of oxycodone in children undergoing surgery could be due to genetic polymorphisms. Materials & methods: The authors studied the association between clinical outcomes and pharmacogenes in children undergoing major surgery. A total of 89 children (35 undergoing pectus excavatum repair and 54 undergoing spinal fusion) were recruited. Results: OPRM1 SNP rs6902403 showed an association with maximum pain score and total morphine equivalent dose (p < 0.05). Other polymorphisms in OPRM1 SNP, PXR, COMT and ABCB1 were also shown to be associated with average morphine equivalent dose, length of hospital stay and maximum surgical pain (p < 0.05). Conclusion: This study demonstrates novel associations between the above pharmacogenes and oxycodone's pharmacokinetics as well as postoperative outcomes in children. Clinical trial registration: NCT03495388 (ClinicalTrials.gov).

Artificial intelligence algorithms predict the efficacy of analgesic cocktails prescribed after orthopedic surgery

BACKGROUND

Mixtures ('cocktails') of various analgesics are more effective in controlling post-operative pain because of potential synergetic effects. Few studies have investigated such effects in large combinations of analgesics and no studies have determined the probabilities of effectiveness.

METHODS

We used one-hot encoding of the categorical variables reported pain levels and the administered cocktails (from a total of eight analgesics) and then applied an unsupervised neural network and then the unsupervised DBSCAN algorithm to detect clusters of cocktails. We used Bayesian statistics to classify the effectiveness of these cocktails.

RESULTS

Of the 61 different cocktails administered to 750 patients, we found that four combinations of three to four analgesics were by far the most effective. All these cocktails contained Metamizole and Paracetamol; three contained Hydromorphone and two contained Diclofenac and one Diclofenac-Orphenadrine. The ML probability that these cocktails decreased pain levels ranged from 0.965 to 0.981. Choice of a most effective cocktail involves choosing the optimum in a 4-dimensional parameter space: maximum probability of efficacy, confidence interval about maximum probability, fraction of patients with increase in pain levels, relative number of patients with successful pain level decrease.

CONCLUSIONS

We observed that administering one analgesic or at most two is not effective. We found no statistical indicators that interactions between analgesics in the most effective cocktails decreased their effectiveness. Pairs of most effective cocktails differed by the addition of only one analgesic (Diclofenac-Orphenadrine for one pair and Hydromorphone for the other). We conclude that the listed cocktails are to be recommended.

Intraoperative local instillation anesthesia using injection technique from J-VACTM drain for postoperative pain relief in male-type chest wall contouring surgery

For postoperative acute pain during mastectomy, a few studies have reported the usefulness of an intraoperative local anesthesia instillation technique in which analgesics are injected through a drain placed under the skin, intraoperatively. This study presented a novel administration method, and the efficacy of local instillation anesthesia in male-type chest wall contouring surgery was assessed. Fifty-four patients underwent chest wall contouring surgery under general anesthesia. The 27 patients in each of the study and control groups, with our instillation technique and without the technique were compared, in terms of the maximum numerical rating scale (NRS) score within 24 h after surgery, the postoperative analgesic use frequency, and dosage until 6 d. The analgesic used was a mixture of 5 ml 1% lidocaine hydrochloride, epinephrine (0.05 mg), 10 ml 0.75% bupivacaine, and 10 ml saline. Thereon, 25 ml analgesia was administered from the left and right drain (15-Fr J-VACTM) and infiltrated for 15 min. Both NRS scores of postanesthesia care unit (PACU) discharge and the maximum NRS score within 24 h after PACU discharge were significantly lower in the study group than in the control group (p < 0.001, p = 0.048). The frequency of analgesics administered within 24 h after surgery was significantly lower in the study group than in the control group (p = 0.025). Our anesthesia instillation method for chest wall contouring surgery was effective in relieving acute pain occurring within 24 h after surgery and can be a useful analgesic administration method.

Lung cancer patients with positive programmed death-ligand 1 expression endure graver postoperative pain

BACKGROUND

Postoperative pain after video-assisted thoracoscopic surgery (VATS) is common in lung cancer patients, and it is unclear whether cancer itself participates in pain regulation. Programmed cell death ligand-1 (PD-L1) expressed by tumours may be analgesic. Our study aimed to detect the association between PD-L1 and acute postoperative pain.

METHODS

We reviewed patients who underwent VATS for lung cancer with tumour PD-L1 expression analysed in our centre from Jan 2017 to Jul 2020. They were divided into PD-L1 (-) group and PD-L1 (+) group and were further divided into four subgroups according to opioids for postoperative analgesia: sufentanil PD-L1 (-), sufentanil PD-L1 (+), oxycodone PD-L1 (-), and oxycodone PD-L1 (+). We compared the numeric rating scale (NRS) for the first three postoperative days at rest or cough between groups.

RESULTS

A total of 369 patients (167 in PD-L1 (-) vs. 202 in PD-L1 (+)) were included. On the first postoperative day, NRS at cough in the PD-L1 (+) patients were higher than those in the PD-L1 (-) patients (2.91 ± 1.07 vs. 2.66 ± 1.01, p = 0.018). On the third day, NRS at cough in PD-L1 (+) patients was higher (2.50 ± 1.02 vs. 2.26 ± 1.09, p = 0.043). For patients with oxycodone, NRS was higher in PD-L1 (+) than in PD-L1 (-) (p = 0.041) at cough after surgery. In contrast, those with sufentanil did not significantly differ in NRS between groups.

CONCLUSIONS

Patients with PD-L1 (+) suffered graver pain in the early postoperative period after VATS for lung cancer compared with PD-L1 (-) on tumours. Analgesia with sufentanil seemed to overcome this effect better than oxycodone.

SIGNIFICANCE

We demonstrated that patients with positive programmed cell death ligand-1 (PD-L1) on tumours suffered graver pain in the early postoperative period after video-assisted thoracoscopic surgery for lung cancer and reacted differently with opioids. It might be beneficial to adjust analgesic protocols according to tumour PD-L1 expression for individualized postoperative pain management.

Fairness in the prediction of acute postoperative pain using machine learning models

Introduction

Overall performance of machine learning-based prediction models is promising; however, their generalizability and fairness must be vigorously investigated to ensure they perform sufficiently well for all patients.

Objective

This study aimed to evaluate prediction bias in machine learning models used for predicting acute postoperative pain.

Method

We conducted a retrospective review of electronic health records for patients undergoing orthopedic surgery from June 1, 2011, to June 30, 2019, at the University of Florida Health system/Shands Hospital. CatBoost machine learning models were trained for predicting the binary outcome of low (≤4) and high pain (>4). Model biases were assessed against seven protected attributes of age, sex, race, area deprivation index (ADI), speaking language, health literacy, and insurance type. Reweighing of protected attributes was investigated for reducing model bias compared with base models. Fairness metrics of equal opportunity, predictive parity, predictive equality, statistical parity, and overall accuracy equality were examined.

Results

The final dataset included 14,263 patients [age: 60.72 (16.03) years, 53.87% female, 39.13% low acute postoperative pain]. The machine learning model (area under the curve, 0.71) was biased in terms of age, race, ADI, and insurance type, but not in terms of sex, language, and health literacy. Despite promising overall performance in predicting acute postoperative pain, machine learning-based prediction models may be biased with respect to protected attributes.

Conclusion

These findings show the need to evaluate fairness in machine learning models involved in perioperative pain before they are implemented as clinical decision support tools.

Multimodal analgesia practices for knee and hip arthroplasties in the Netherlands. A prospective observational study from the PAIN OUT registry

INTRODUCTION

Different multimodal pain management strategies following total hip arthroplasty(THA) and total knee arthroplasty (TKA) surgery are used in clinical practice. The optimal pain management strategy, however, remains unclear. This study aims to evaluate the differences in perioperative multimodal pain management strategies for THA and TKA in the Netherlands, and studies the associations between patient- and therapy related factors and pain outcomes.

METHODS

Data from the Dutch hospitals in the PAIN OUT network were used in this study. Demographic data, pain management strategy including perioperative medication use and anesthetic techniques were recorded and used in a multivariable regression analysis to study the association with maximum pain intensity, the duration of severe pain, pain interference in bed and postoperative nausea.

RESULTS

In 343 hip arthroplasty patients and 301 knee arthroplasty patients in seven hospitals, respectively 28 and 35 different combinations of analgesic regimens were used. The number of different drugs prescribed was not related to postoperative pain intensity. Female sex, younger age and spinal anesthesia were associated with higher postoperative maximum pain scores (Numeric Rating Scale (NRS) > 5). Hip surgery and ketamine use were associated with lower postoperative pain scores. The use of non-steroidal anti-inflammatory drugs (NSAIDs) and gabapentinoids, higher age, higher body mass index (BMI) and male gender were associated with less postoperative nausea (NRS < 3).

CONCLUSION

In conclusion, our study demonstrated a large diversity of analgesic strategies following total joint arthroplasties in the Netherlands. Although no ideal strategy was identified, the use of NSAIDs, ketamine and dexamethasone were associated with less pain and less side effects.

Incidence and risk factors for acute shoulder pain after hepatectomy: a nested case-control study

BACKGROUND

Shoulder pain is commonly reported after hepatic surgery; however, the factors affecting post-hepatectomy shoulder pain remain unclear. This study aimed to determine the incidence and risk factors of shoulder pain after hepatectomy.

METHODS

This prospective cohort study recruited 218 patients who underwent hepatic resection at our hospital from June to September 2022. Data were obtained from electronic medical records and follow-up assessments on the second postoperative day. All patients denied chronic pain before surgery. In this cohort study, patients were grouped according to the appearance of shoulder pain. Demographic information and perioperative data were compared between the two groups. The relationship between shoulder pain and independent variables was assessed using univariate binary logistic regression analysis. The potential risk factors were analyzed using multivariable binary logistic regression.

RESULTS

Of the 218 patients enrolled in this cohort study, 91 (41.7%) reported shoulder pain. Patients in the case group were significantly younger than those in the control group (P = 0.001). Epidural anesthesia was used more frequently in the case group (P = 0.012). Patients over 60 years of age showed a lower incidence of shoulder pain than younger patients (P = 0.028). According to multivariable binary logistic regression analysis, advanced age and epidural anesthesia were associated with risk of shoulder pain (advanced age: odds ratio [OR] [95% confidence interval (CI)]: 0.96 [0.94, 0.99], P = 0.002; epidural anesthesia: OR [95% CI]: 2.08 [1.18, 3.69], P = 0.012).

CONCLUSIONS

The incidence of acute shoulder pain after hepatectomy is 41.7%. The application of epidural anesthesia is an independent risk factor for shoulder pain after hepatectomy, whereas advanced age is a protective factor.

Risk of serious adverse events associated with non-steroidal anti-inflammatory drugs in orthopaedic surgery. A protocol for a systematic review

BACKGROUND

Postoperative pain is a common condition following orthopaedic surgeries and causes prolonged hospitalisation, delayed rehabilitation and hamper the quality of life. Non-steroidal anti-inflammatory drugs (NSAIDs) are effective analgesics and anti-inflammatory mediators in the treatment of postoperative pain. The association of NSAIDs with serious adverse events may however keep some clinicians and clinical decision makers from using NSAIDs perioperatively. The evidence regarding the risks of serious adverse events following perioperative use of NSAIDs in orthopaedic surgery is sparse and needs to be assessed in a systematic review. This is a protocol for a systematic review that aims to identify the risks of serious adverse events from perioperative use of NSAIDs in orthopaedic patients.

METHODS

Our methodology is based on the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols and the eight-step assessment procedure suggested by Jakobsen and colleagues. We wish to assess if NSAIDs versus placebo, usual care or no intervention, will influence the risks of serious adverse events in patients undergoing orthopaedic surgery. We will include all randomised trials assessing the use of NSAIDs perioperatively. To identify trials we will search the Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Cochrane Central Register, Science Citation Index Expanded on Web of Science and BIOSIS. Two authors will screen the literature and extract data. We will use the 'Risk of Bias 2 tool' to assess trials. Extracted data will be analysed using RStudio and Trial Sequential Analysis. We will create a 'Summary of Findings' table in which we will present our primary and secondary outcomes. We will assess the quality of evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE).

DISCUSSION

This systematic review can potentially aid clinicians and clinical decision makers in the use of NSAIDs for treatment of postoperative pain following orthopaedic surgeries.

Selected Factors Influencing the Intensity of Postoperative Pain in Patients after Orthopedic and Gynecological Surgeries

Currently, pain is considered the fifth vital sign, and its effective relief is a priority in many surgical departments. The aim of this study was to determine the influence of selected factors on the intensity of postoperative pain after orthopedic and gynecological procedures. The study was conducted in a group of 200 patients undergoing orthopedic and gynecological procedures at the County Hospital in Nisko between August 2017 and January 2018. The method of estimation and document analysis was applied in the course of the study. A standardized tool was used—Polish adaptation of the Melzack Pain Questionnaire (MPQ), an individual documentation of patients and a scientific and research questionnaire developed by the authors. The tests were conducted for three consecutive days from the day of the operation. The strongest pain immediately after surgery was experienced by the patients after general endotracheal anesthesia, and the mildest after full intravenous short-term anesthesia (p < 0.05). Procedures lasting more than 60 min were associated with greater pain intensity on all tested days. The sex of the patient did not significantly affect the level of the perceived intensity of postoperative pain (p > 0.05). The highest intensity of pain occurred on day 0 after surgery, with a declining trend in the following days (p < 0.001). The highest intensity of postoperative pain was caused by gynecological procedures as well as laparotomy and arthroplasty (p < 0.001). The variability of the results indicates the need for an individual approach to each patient, both in pain assessment and treatment. Therefore, continuous improvement of the quality of health services provided in accordance with the guidelines for pain relief is necessary.

Efficacy and Safety of Lidocaine Patch in the Management of Acute Postoperative Wound Pain: A Comprehensive Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

This study sought to quantify the pooled effects of lidocaine patch (LP) on postoperative pain and side-effects through a comprehensive review and meta-analysis.

APPROACH

The study followed PRISMA, AMSTAR and the Cochrane Collaboration. Randomized controlled trials s comparing LP with placebo were retrieved from five electronic databases. Primary outcome in the study was cumulative intravenous morphine equivalent consumption (mg) within 24 hours postoperatively.

RESULTS

Twelve trials comprising 617 patients were included in the final analysis. Primary result indicated that the analgesic effects LP were only statistical but not clinically significant of postoperative intravenous morphine consumption within 24 hours (mean difference, -4.61 mg; 95% CI, -8.09, -1.14). Interestingly, the results of subgroup and meta-regression analysis indicated that preoperative administration of LP had potential advantages in postoperative wound pain management. It is also worthwhile to mention that LP provided a clinically important benefit in rest pain scores within 24-hour postoperatively. Apart from these, other secondary outcome analysis did not uncover any particularly significant analgesic or safety advantages to LP. Finally, LP also does not increase the risk of any local anesthetic-related side effects.

INNOVATION

This systematic review and meta-analysis provides moderate-to-high quality evidence undermining the role of LP for management of acute postoperative wound pain following surgical procedures and the justification for the associated extra costs.

CONCLUSION

Taken together, the current evidence does not support LP as part of a routine multimodal analgesia strategy to alleviate early postoperative acute pain. However, further studies should explore the clinical value of preoperative administration and the long-term effect of LP.

Early Postoperative Pain Trajectories after Posterolateral and Axillary Approaches to Thoracic Surgery: A Prospective Monocentric Observational Study

Less-invasive thoracotomies may reduce early postoperative pain. The aims of this study were to identify pain trajectories from postoperative days 0–5 after posterolateral and axillary thoracotomies and to identify potential factors related to the worst trajectory. Patients undergoing a posterolateral (92 patients) or axillary (89 patients) thoracotomy between July 2014 and November 2015 were analyzed in this prospective monocentric cohort study. The best-fitting model resulted in four pain trajectory groups: trajectory 1, the “worst”, with 29.8% of the patients with permanent significant pain; trajectory 2 with patients with low pain (32.6%); trajectory 3 with patients with a steep decrease in pain (22.7%); and trajectory 4 with patients with a steep increase (14.9%). According to a multinomial logistic model multivariable analysis, some predictive factors allow for differentiation between trajectory groups 1 and 2. Risk factors for permanent pain are the existence of preoperative pain (OR = 6.94, CI 95% (1.54–31.27)) and scar length (OR = 1.20 (1.05–1.38)). In contrast, ASA class III is a protective factor in group 1 (OR = 0.02 (0.001–0.52)). In conclusion, early postoperative pain can be characterized by four trajectories and preoperative pain is a major factor for the worst trajectory of early postoperative pain.

Group-based trajectory analysis of acute pain after spine surgery and risk factors for rebound pain

Background

This retrospective study was designed to explore the types of postoperative pain trajectories and their associated factors after spine surgery.

Materials and methods

This study was conducted in a single medical center, and patients undergoing spine surgery with intravenous patient-controlled analgesia (IVPCA) for postoperative pain control between 2016 and 2018 were included in the analysis. Maximal pain scores were recorded daily in the first postoperative week, and group-based trajectory analysis was used to classify the variations in pain intensity over time and investigate predictors of rebound pain after the end of IVPCA. The relationships between the postoperative pain trajectories and the amount of morphine consumption or length of hospital stay (LOS) after surgery were also evaluated.

Results

A total of 3761 pain scores among 547 patients were included in the analyses and two major patterns of postoperative pain trajectories were identified: Group 1 with mild pain trajectory (87.39%) and Group 2 with rebound pain trajectory (12.61%). The identified risk factors of the rebound pain trajectory were age less than 65 years (odds ratio [OR]: 1.89; 95% CI: 1.12–3.20), female sex (OR: 2.28; 95% CI: 1.24–4.19), and moderate to severe pain noted immediately after surgery (OR: 3.44; 95% CI: 1.65–7.15). Group 2 also tended to have more morphine consumption (p < 0.001) and a longer length of hospital stay (p < 0.001) than Group 1.

Conclusion

The group-based trajectory analysis of postoperative pain provides insight into the patterns of pain resolution and helps to identify unusual courses. More aggressive pain management should be considered in patients with a higher risk for rebound pain after the end of IVPCA for spine surgery.

Relationship between Preoperative Lower Back Pain and Severe Postoperative Pain after Gynecologic Laparoscopy: A Prospective Observational Study

We hypothesized that preoperative lower back pain (LBP) may be associated with the severity of postoperative pain after gynecologic laparoscopy. This prospective observational study aimed to investigate the association between preoperative LBP and postoperative pain. We assessed the intensity of LBP before surgery and the postoperative pain after surgery. The abilities of preoperative LBP intensity, age, body mass index, and anesthetic duration time to predict moderate-to-severe postoperative pain were measured using receiver operating characteristic analysis. The data of 148 patients were analyzed. Only preoperative LBP intensity showed a significant association with moderate-to-severe postoperative pain (area under the curve, 0.71; 95% confidence interval, 0.63−0.79; p < 0.001). Preoperative LBP rated three on a numeric rating scale (NRS) had the highest combined sensitivity (75.3%) and specificity (58.3%). Patients with LBP above NRS 3 had more severe postoperative pain than those who did not (pain score 5.3 ± 2.2 vs. 3.9 ± 1.9, p < 0.001), leading to more opioid requirement in the recovery room (48.5% vs. 27.5%, p = 0.014). Preoperative LBP intensity is a useful factor for identifying patients at risk for pain after gynecologic laparoscopy.

Measuring Individual Benefits of Medical Treatments Using Longitudinal Hospital Data with Non-Ignorable Missing Responses Caused by Patient Discharge: Application to the Study of Benefits of Pain Management Post Spinal Fusion

Electronic health records (EHR) provide valuable resources for longitudinal studies and understanding risk factors associated with poor clinical outcomes. However, they may not contain complete follow-ups, and the missing data may not be at random since hospital discharge may depend in part on expected but unrecorded clinical outcomes that occur after patient discharge. These non-ignorable missing data requires appropriate analysis methods. Here, we are interested in measuring and analyzing individual treatment benefits of medical treatments in patients recorded in EHR databases. We present a method for predicting individual benefits that handles non-ignorable missingness due to hospital discharge. The longitudinal clinical outcome of interest is modeled simultaneously with the hospital length of stay using a joint mixed-effects model, and individual benefits are predicted through a frequentist approach: the empirical Bayesian approach. We illustrate our approach by assessing individual pain management benefits to patients who underwent spinal fusion surgery. By calculating sample percentiles of empirical Bayes predictors of individual benefits, we examine the evolution of individual benefits over time. We additionally compare these percentiles with percentiles calculated with a Monte Carlo approach. We showed that empirical Bayes predictors of individual benefits do not only allow examining benefits in specific patients but also reflect overall population trends reliably.

Sex Differences in the Mediating Effect of Kinesiophobia on Chronic Pain, Dysesthesia, and Health-Related Quality of Life in Japanese Individuals Aged 65 Years Old and Older Treated with Surgery for Lumbar Spinal Stenosis

Purpose

This study aimed to determine whether kinesiophobia mediates the relationship between low back pain (LBP), leg pain (LP), and leg dysesthesia (LD) and health-related quality of life (HRQOL) among Japanese individuals aged 65 years old and older treated with surgery for lumbar spinal stenosis (LSS).

Patients and Methods

Data collection for this study took place between October 2019 and August 2020 at two Japanese medical facilities. Eligibility criteria for participants in this study were individuals aged 65 years or older and those who had undergone surgery for LSS at least more than one year ago. A self-administered questionnaire assessed the intensity of LBP, LP, and LD (numerical rating scale: NRS), HRQOL (EuroQol-5 Dimension-5 Levels: EQ-5D-5L), and kinesiophobia (Tampa Scale for Kinesiophobia-17 items: TSK-17). Mediation analysis using sex as a control variable was conducted.

Results

Complete responses were obtained from 238 of 431 individuals (73.1 ± 5.1 years; 135 males and 103 females). The mediating effect of NRS scores for LBP, LP, and LD to EQ-5D-5L index on TSK-17 score was significant, respectively (LBP: -0.007 [95% confidence interval -0.012, -0.004], p = 0.000; LP and LD: -0.007 [-0.011, -0.004], p = 0.000). The strength of the association between NRS scores and EQ-5D-5L index decreased when the mediating effect of TSK-17 score (LBP: β = -0.698 [-0.792, -0.603], p = 0.000 to β = -0.616 [-0.707, -0.524], p = 0.000; LP: β = -0.629 [-0.729, -0.529], p = 0.000 to β = -0.539 [-0.638, -0.440], p = 0.000; LD: β = -0.568 [-0.675, -0.460], p = 0.000 to β = -0.482 [-0.586, -0.378], p = 0.000). The mediating effect of TSK score was greater in females than males.

Conclusion

Kinophobia partially mediated the relationship between LBP, LP and LD, and HRQOL in Japanese aged 65 years and older after lumbar surgery. The mediating effect differed by sex.

Effects of Continuous Fascia Iliaca Compartment Block on Early Quality of Recovery After Total Hip Arthroplasty in Elderly Patients: A Randomized Controlled Trial

Purpose

In recent years, patient-centered postoperative quality of recovery has gained attention. This study aimed to assess the influence of ultrasound-guided continuous fascia iliaca compartment block (CFICB) on early quality of recovery in elderly patients after total hip arthroplasty (THA) using the QoR-15 score.

Patients and Methods

In this single-center, randomized, prospective study, 60 patients scheduled for unilateral THA were randomized to the CFICB or patient-controlled intravenous analgesia (PCIA) group. The primary outcome was the QoR-15 score. The secondary outcomes were pain score, number of patients requiring rescue analgesics, time of first postoperative ambulation, incidence of postoperative complications, Bromage score, and length of hospital stay.

Results

The QoR-15 score was significantly higher in the CFICB group than in the PCIA group at 24 h (P < 0.001) after surgery. However, the QoR-15 score was not significantly different at 48 h (P = 0.074) between the two groups. Pain scores at rest and during movement were lower in the CFICB group than in the PCIA group at 12, 24, and 48 h postoperatively (P < 0.05). There was no difference in the number of patients requiring rescue analgesics, time of first postoperative ambulation, incidence of postoperative complications apart from dizziness, or length of hospital stay between the two groups. In addition, Bromage score of 1 point was reported by four patients in the CFICB group at 24 h (P = 0.048) after THA.

Conclusion

In elderly patients following THA, CFICB improved the quality of recovery at 24 h and reduced pain scores compared with PCIA. The time of first postoperative ambulation and length of hospital stay were not significantly affected.