Goals and Objectives to Optimize the Value of an Acute Pain Service in Perioperative Pain Management

Novel Techniques for Musculoskeletal Pain Management after Orthopedic Surgical Procedures: A Systematic Review

Effective postoperative pain management is critical for recovery after orthopedic surgery, but often remains inadequate despite multimodal analgesia. This systematic review synthesizes evidence on innovative modalities for enhancing pain control following major orthopedic procedures. Fifteen randomized controlled trials and comparative studies evaluating peripheral nerve blocks, local anesthetic infiltration, cryotherapy, transcutaneous electrical stimulation, adjunct medications, and other techniques are included. Thematic analysis reveals that peripheral nerve blocks and local anesthetic infiltration consistently demonstrate reduced pain scores, opioid consumption, and side effects versus conventional analgesia alone. Oral multimodal medications also show promise as part of opioid-sparing regimens. Adjunctive approaches like cryotherapy, music, and dexmedetomidine require further research to optimize protocols. Despite promising innovations, critical knowledge gaps persist regarding comparative effectiveness, optimal interventions and dosing, combination strategies, cost-effectiveness, and implementation. High-quality randomized controlled trials using standardized protocols are essential to guide the translation of enhanced multimodal regimens into clinical practice. This review provides a framework for pursuing research priorities and advancing evidence-based postoperative pain management across orthopedic surgeries.

Quantifying the impact of reduced opioid use in patients after emergency laparotomy

BACKGROUND

Emergency laparotomies have high rates of morbidity and mortality. The evaluation and management of pain are crucial, as poorly managed pain may contribute to postoperative complications and increase the risk of mortality. This study aims to describe the relationship between opioid use and opioid-related adverse effects and identify what constitutes appropriate dose reductions to elicit clinically relevant benefits.

METHODS

This was a retrospective, observational study of patients presenting for emergency laparotomy due to trauma from 2014 to 2018. The primary objective was to define clinical outcomes that may be significantly affected by changes in milligrams of morphine equivalent during the first 72 hours postoperatively; additionally, we sought to quantify the approximate differences in morphine equivalent that correlate with clinically meaningful outcomes such as hospital length of stay, pain scores, and time to first bowel movement. For descriptive summaries, patients were categorized into low, moderate, and high groups based on morphine equivalent requirements of 0 to 25, 25 to 50, and >50, respectively.

RESULTS

A total of 102 (35%), 84 (29%), and 105 (36%) patients were stratified into the low, moderate, and high groups, respectively. Mean pain scores for postoperative days 0 to 3 (P = .034), time to first bowel movement (P = .002), and nasogastric tube duration (P = .003) were the clinical outcomes found to be significantly associated with morphine equivalent. Estimated clinically significant reductions in morphine equivalent for these outcomes ranged from 194 to 464.

CONCLUSION

Clinical outcomes, such as pain scores, and opioid-related adverse effects, such as time to first bowel movement and nasogastric tube duration, may be linked with the amount of opioids used.

Addition of infiltration between the popliteal artery and the capsule of the posterior knee (IPACK) to local infiltration analgesia for total knee arthroplasty: a prospective randomized controlled trial

BACKGROUND

Local infiltration analgesia (LIA) is a popular analgesic technique commonly administered during total knee arthroplasty (TKA). Recent studies have demonstrated that the infiltration between the popliteal artery and the capsule of the posterior knee (IPACK) can be complementary to analgesic modalities. However, the combined and relative efficacy of LIA and IPACK is unclear. We aimed to evaluate the analgesic and functional outcomes among LIA, IPACK, and LIA+IPACK.

MATERIALS AND METHODS

A total of 120 patients undergoing primary TKA were randomly allocated to 1 of 3 groups: LIA (50 mL of 0.25% ropivacaine and 2.0 μg/mL epinephrine); IPACK (20 mL of 0.25% ropivacaine and 2.0 μg/mL epinephrine); and LIA+IPACK. The primary outcome was the visual analog scale (VAS) pain score. Secondary outcomes were opioid use, knee range of motion (ROM), quadriceps muscle strength, mobilization distance, timed up and go (TUG) test, and postoperative complications.

RESULTS

The mean VAS pain scores were significantly higher after using IPACK alone than after using LIA+IPACK and LIA within 24 hours (all p＜0.05). LIA+IPACK had lower mean VAS pain scores than LIA when the knees were at rest (within 12 hours, p < 0.05) and flexion (within 8 hours, p＜0.05). Patients receiving LIA+IPACK and LIA had significantly lower morphine equivalents (ME) than those receiving IPACK alone within 24 hours (26.3, 28.9 versus 47.8, both p＜0.05) and during hospitalization (98, 101.6, versus 128.4 both p＜0.05). Both LIA+IPACK and LIA had higher ROM (within two days), higher level of muscle strength (within 12 hours), longer mobilization distances (within one day), and shorter TUG time (till discharge) compared with IPACK alone (all p＜0.05), while LIA+IPACK only had a higher knee ROM than LIA on the first postoperative day (p＜0.05). There was no significant difference in any other outcomes.

CONCLUSIONS

This randomized controlled trial demonstrated that there were significantly lower pain scores, less opioid consumption, and better functional results with LIA+IPACK and LIA when compared with IPACK alone, suggesting that IPACK alone was inferior for pain control.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Acute Pain Service in Hungarian hospitals

Background

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Why Unidimensional Pain Measurement Prevails in the Pediatric Acute Pain Context and What Multidimensional Self-Report Methods Can Offer

Although pain is widely recognized to be a multidimensional experience and defined as such, unidimensional pain measurement focusing on pain intensity prevails in the pediatric acute pain context. Unidimensional assessments fail to provide a comprehensive picture of a child's pain experience and commonly do little to shape clinical interventions. The current review paper overviews the theoretical and empirical literature supporting the multidimensional nature of pediatric acute pain. Literature reporting concordance data for children's self-reported sensory, affective and evaluative pain scores in the acute pain context has been reviewed and supports the distinct nature of these dimensions. Multidimensional acute pain measurement holds particular promise for identifying predictive markers of chronicity and may provide the basis for tailoring clinical management. The current paper has described key reasons contributing to the widespread use of unidimensional, rather than multidimensional, acute pediatric pain assessment protocols. Implications for clinical practice, education and future research are considered.

Evolving the management of acute perioperative pain towards opioid free protocols: a narrative review

Objective: Identification of pain as the fifth vital sign has resulted in over-prescription and overuse of opioids in the US, with addiction reaching epidemic proportions. In Europe, and more recently in the US, a shift has occurred with the global adoption of multimodal analgesia (MMA), which seeks to minimize perioperative opioid use. Improved functional outcomes and reduced healthcare utilization costs have been demonstrated with MMA, but wide scale use of opioids in pain management protocols continues. As a next step in the pain management evolution, opioid-free analgesia (OFA) MMA strategies have emerged as feasible in many surgical settings.Methods: Articles were limited to clinical studies and meta-analyses focusing on comparisons between opioid-intensive and opioid-free/opioid-sparing strategies published in English.Results: In this review, elimination or substantial reduction in opioid use with OFA strategies for perioperative acute pain are discussed, with an emphasis on improved pain control and patient satisfaction. Improved functional outcomes and patient recovery, as well as reduced healthcare utilization costs, are also discussed, along with challenges facing the implementation of such strategies.Conclusions: Effective MMA strategies have paved the way for OFA approaches to postoperative pain management, with goals to reduce opioid prescriptions, improve patient recovery, and reduce overall healthcare resource utilization and costs. However, institution-wide deployment and adoption of OFA is still in early stages and will require personalization and better management of patient expectations.