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Huang L, Zhang T, Wang K, Chang B, Fu D, Chen X. Postoperative Multimodal Analgesia Strategy for Enhanced Recovery After Surgery in Elderly Colorectal Cancer Patients. Pain Ther 2024; 13:745-766. [PMID: 38836984 PMCID: PMC11254899 DOI: 10.1007/s40122-024-00619-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 05/21/2024] [Indexed: 06/06/2024] Open
Abstract
Enhanced Recovery After Surgery (ERAS) protocols have substantially proven their merit in diminishing recuperation durations and mitigating postoperative adverse events in geriatric populations undergoing colorectal cancer procedures. Despite this, the pivotal aspect of postoperative pain control has not garnered the commensurate attention it deserves. Typically, employing a multimodal analgesia regimen that weaves together nonsteroidal anti-inflammatory drugs, opioids, local anesthetics, and nerve blocks stands paramount in curtailing surgical complications and facilitating reduced convalescence within hospital confines. Nevertheless, this integrative pain strategy is not devoid of pitfalls; the specter of organ dysfunction looms over the geriatric cohort, rooted in the abuse of analgesics or the complex interplay of polypharmacy. Revolutionary research is delving into alternative delivery and release modalities, seeking to allay the inadvertent consequences of analgesia and thereby potentially elevating postoperative outcomes for the elderly post-colorectal cancer surgery populace. This review examines the dual aspects of multimodal analgesia regimens by comparing their established benefits with potential limitations and offers insight into the evolving strategies of drug administration and release.
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Affiliation(s)
- Li Huang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Tianhao Zhang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Kaixin Wang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Bingcheng Chang
- The Second Affiliated Hospital of Guizhou, University of Traditional Chinese Medicine, Guiyang, 550003, China
| | - Daan Fu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China.
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Ministry of Education, Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Wuhan, China.
| | - Xiangdong Chen
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China.
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Ministry of Education, Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Wuhan, China.
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Helden EV, Kranendonk J, Vermulst A, Boer AD, Reuver PD, Rosman C, Wilt JD, Laarhoven KV, Scheffer GJ, Keijzer C, Warlé M. Early postoperative pain and 30-day complications following major abdominal surgery: a retrospective cohort study. Reg Anesth Pain Med 2024:rapm-2024-105277. [PMID: 38839084 DOI: 10.1136/rapm-2024-105277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 05/15/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Increasing evidence supports a positive relationship between the intensity of early postoperative pain, and the risk of 30-day postoperative complications. Higher pain levels may hamper recovery and contribute to immunosuppression after surgery. This leaves patients at risk of postoperative complications. METHODS One thousand patients who underwent major abdominal surgery (cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, esophageal, liver, or pancreas surgery) at the Radboud university medical center were randomly selected from eligible patients between 2014 and 2020. Pain scores on day 1, the independent variable of interest, were extracted from the electronic patient files. Outcome measures were 30-day postoperative complications (infectious, non-infectious, total complications and classification according to Clavien-Dindo). RESULTS Seven hundred ninety complications occurred in 572 patients within 30 days after surgery, of which 289 (36.7%) were of infectious origin, and 501 (63.4%) complications were non-infectious. The mean duration from the end of surgery to the occurrence of infectious complications was 6.5 days (SD 5.6) and 4.1 days (SD 4.7) for non-infectious complications (p<0.001). Logistic regression analysis revealed that pain scores on postoperative day 1 (POD1) were significantly positively associated with 30-day total complications after surgery (OR=1.132, 95% CI (1.076 to 1.190)), Clavien-Dindo classification (OR=1.131, 95% CI (1.071 to 1.193)), infectious complications (OR=1.126, 95% CI (1.059 to 1.196)), and non-infectious complications (OR=1.079, 95% CI (1.022 to 1.140)). CONCLUSIONS After major abdominal surgery, higher postoperative pain scores on day 1 are associated with an increased risk of 30-day postoperative complications. Further studies should pursue whether optimization of perioperative analgesia can improve immune homeostasis, reduce complications after surgery and enhance postoperative recovery.
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Affiliation(s)
| | | | - Ad Vermulst
- Mental Healthcare East-Brabant Region Helmond-Peelland, Boekel, Oost-Brabant, The Netherlands
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Yang R, Wang J, Shi DW, Niu Y, Zhou XD, Liu Y, Xu GH. The Efficiency of Multipoint Rectus Sheath Block Based on Incision Location in Laparoscopic-Assisted Colorectal Surgery: A Randomized Clinical Trial. Dis Colon Rectum 2023; 66:1578-1586. [PMID: 37379171 DOI: 10.1097/dcr.0000000000002895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
BACKGROUND Laparoscopic-assisted colorectal surgery is an effective surgery to treat colorectal cancer. During the laparoscopic-assisted colorectal surgery, a midline incision and several trocar insertions are required during the surgery. OBJECTIVE To observe whether the rectus sheath block based on the locations of the surgical incision and trocars can significantly reduce the pain score on the first day after surgery. DESIGN This study was a prospective, double-blinded, randomized controlled trial approved by the Ethics Committee of First Affiliated Hospital of Anhui Medical University (registration number: ChiCTR2100044684). SETTINGS All patients were recruited from 1 hospital. PATIENTS Forty-six patients aged 18 to 75 years undergoing elective laparoscopic-assisted colorectal surgery were successfully recruited, and 44 patients completed the trial. INTERVENTIONS Patients in the experimental group received rectus sheath block, with 0.4% ropivacaine 40 to 50 mL, whereas the control group received an equal volume of normal saline. MAIN OUTCOME MEASURES The primary outcome was pain score on postoperative day 1. Secondary outcomes included patient-controlled analgesia use at 24 and 48 hours after surgery and pain score at 6, 12, and 48 hours after surgery. RESULTS Pain scores at rest and during activity at 6, 12, 24, and 48 hours after surgery and patient-controlled analgesia consumption of patients on the first day after surgery were significantly lower in the experimental group than those in the control group (all p < 0.05). LIMITATIONS We did not separate pain into visceral and somatic pain because patients often had difficulty differentiating the source of pain. CONCLUSIONS Our research indicates that in the context of multimodal analgesia, the rectus sheath block according to the midline incision and the positions of the trocars can reduce the pain scores and consumption of analgesic drugs on the first day after surgery for patients undergoing laparoscopic-assisted colorectal surgery. LA EFICIENCIA DEL BLOQUEO DE LA VAINA DEL RECTO DE VARIOS PUNTOS SEGN LA UBICACIN DE LA INCISIN EN LA CIRUGA COLORRECTAL ASISTIDA POR LAPAROSCOPIA UN ENSAYO CLNICO ALEATORIZADO ANTECEDENTES:La cirugía colorrectal asistida por laparoscopia es una cirugía eficaz para tratar el cáncer colorrectal. Durante la cirugía colorrectal asistida por laparoscopia, se requiere una incisión en la línea media y varias inserciones de trócaresOBJETIVO:El propósito de nuestro estudio fue observar si el bloqueo de la vaina del recto basado en las ubicaciones de la incisión quirúrgica y los trocares puede reducir significativamente la puntuación del dolor en el primer día después de la cirugía.DISEÑO:Este estudio fue un ensayo controlado aleatorio prospectivo, doble ciego, aprobado por el Comité de Ética del Primer Hospital Afiliado de la Universidad Médica de Anhui (número de registro: ChiCTR2100044684).ESCENARIO:Todos los pacientes fueron reclutados en un hospital.PACIENTES:Cuarenta y seis pacientes de 18 a 75 años de edad que se sometieron a cirugía colorrectal electiva asistida por laparoscopía fueron reclutados con éxito y cuarenta y cuatro pacientes completaron el ensayo.INTERVENCIONES:Los pacientes del grupo experimental recibieron bloqueo de la vaina del recto con 40-50 ml de ropivacaína al 0.4%, mientras que el grupo de control recibió el mismo volumen de solución salina normal.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la puntuación del dolor en el día 1 postoperatorio. Los resultados secundarios incluyeron el uso de analgesia controlada por el paciente a las 24 y 48 horas después de la cirugía y la puntuación del dolor a las 6, 12, y 48 horas después de la cirugía.RESULTADOS:Las puntuaciones de dolor en reposo y durante la actividad a las 6, 12, 24, y 48 horas después de la cirugía, y el consumo de PCA de los pacientes el primer día después de la cirugía fueron significativamente más bajos en el grupo experimental que en el grupo control (todos p < 0.05).LIMITACIONES:No separamos el dolor en dolor visceral y somático porque los pacientes a menudo tenían dificultades para diferenciar la fuente del dolor.CONCLUSIONES:Nuestra investigación indica que, en el contexto de la analgesia multimodal, el bloqueo de la vaina del recto de acuerdo con la incisión de la línea media y las posiciones de los trócares pueden reducir los puntajes de dolor y el consumo de analgésicos en el primer día después de la cirugía para pacientes sometidos a cirugía colorrectal laparoscópica. (Traducción-Dr. Jorge Silva Velazco ).
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Affiliation(s)
- Rui Yang
- Department of Anesthesiology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Jing Wang
- Department of Anesthesiology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - De-Wen Shi
- Department of Anesthesiology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Yong Niu
- Department of Anesthesiology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Xiao-Dan Zhou
- Department of Anesthesiology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Yang Liu
- Department of Anesthesiology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Guang-Hong Xu
- Department of Anesthesiology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Department of Neurology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
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Zhou Y, Cao L, Yang Y, Gao Y, Li Y, Wang B, Pan B, Huang J, Guo W. Is OPRM1 genotype a valuable predictor of VAS in patients undergoing laparoscopic radical resection of colorectal cancer with fentanyl? BMC Anesthesiol 2023; 23:173. [PMID: 37217861 DOI: 10.1186/s12871-023-02120-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 04/30/2023] [Indexed: 05/24/2023] Open
Abstract
OBJECTIVE This study was conducted to examine the association between the A118G polymorphism of the OPRM1 gene and the risk of increased VAS scores in patients with colorectal cancer who underwent laparoscopic radical resection for which fentanyl was used. METHODS The OPRM1 A118G genotype in subjects were detected. The relationship between the A118G polymorphism of the OPRM1 gene and increased Visual Analogue Scale (VAS) scores throughout the perioperative period was explored. A total of 101 patients receiving fentanyl anesthesia undergoing laparoscopic radical resection of colon tumors at Zhongshan Hospital, Fudan University between July 2018 and December 2020 were investigated in the present study. The relative risk between the A118G polymorphism of the OPRM1 gene and VAS ≥ 4 in the PACU was estimated using the adjusted effect relationship diagram, baseline characteristic analysis, and multiple logistic regression analysis. The relationship between the A118G polymorphism of the OPRM1 gene and VAS in the PACU, as well as perioperative fentanyl usage, was examined after confounders were adjusted. RESULTS Subjects with OPRM1 A118G wild gene A were less sensitive to fentanyl, which was a risk factor for PACU VAS ≥ 4. Before the model was adjusted, the odds ratio (OR) was 14.73 (P = 0.001). After adjusting for age, sex, weight, height, and the duration of surgery, the OR increased to 16.55 (P = 0.001). When adjusting for age, sex, weight, height, surgery duration, COMT Val158Met gene polymorphism, CYP3A4 *1G gene polymorphism, and CYP3A5 *3gene polymorphism, the OR was 19.94 (P = 0.002). Moreover, OPRM1 A118G wild type gene A was found to be a risk factor for increased dosage of fentanyl in the PACU. Before the model was adjusted, the OR reached 16.90 (P = 0.0132). After adjusting for age, sex, body weight, intraoperative fentanyl dosage, surgery duration, and height, the OR was 13.81, (P = 0.0438). When adjusting for age, sex, weight, height, intraoperative fentanyl dosage, surgery duration, COMT Val158Met gene polymorphism, CYP3A4 *1G gene polymorphism, and CYP3A5 *3 gene polymorphism, the OR reached 15.23, (P = 0.0205). CONCLUSION The A118G polymorphism of the OPRM1 gene carrying wild gene A was a risk factor for VAS ≥ 4 in the PACU. Moreover, it is a risk factor for increased dosage of fentanyl in the PACU.
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Affiliation(s)
- Yan Zhou
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, 111 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China
| | - Lei Cao
- Department of Pharmacy, Zhongshan Hospital, Fudan University, 111 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China
| | - Yihui Yang
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, 111 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China
| | - Yaoyi Gao
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, 111 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China
| | - Yihao Li
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, 111 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China
| | - Beili Wang
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, 111 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China
| | - Baishen Pan
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, 111 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China
| | - Jian Huang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, 111 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China.
| | - Wei Guo
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, 111 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China.
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Avrahami N, Betesh-Abay B, Azab AN, Nisimov T, Abu Tailakh M. The Association Between Pain and In-Hospital Complications and Duration of Stay After Colorectal Surgery. Pain Manag Nurs 2022; 23:848-854. [PMID: 35140054 DOI: 10.1016/j.pmn.2022.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 12/19/2021] [Accepted: 01/02/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pain is a subjective and multidimensional experience often inadequately managed following surgery. Postoperative pain has been shown to correlate with hospital length of stay (HLOS) and hospital complications. Given advancements in preemptive pain management approaches, reevaluation is necessary. AIMS The purpose of this study was to examine the association between postoperative pain intensity and HLOS and in-hospital complications among patients who underwent colorectal surgery, adjusted by sociodemographic and underlying medical variables. SETTING AND PATIENTS We used electronic medical records. Data were collected from patients who underwent colorectal surgery at a large general hospital in Israel from January 2012 to December 2018. DESIGN AND METHODS This is a retrospective cohort study. Information on HLOS, medical diagnoses, pain intensity, use of analgesics, postoperative infections, patient sociodemographic data, chronic diseases, functionality status, and source of admission were extracted from medical records. Logistic regression analysis was used for the final model, and HLOS and in-hospital complications were the major outcomes. RESULTS We enrolled 1,073 patients. Of them, 554 males (51.6%) with a mean age of 62.54 ± 16.55 years. The median postoperative pain score was 1.54 (interquartile range, 0.84; 2.16), and an in-hospital complication rate of 1.3% (n = 14). Postoperative pain was not associated with prolonged HLOS with adjustment to relevant independent variables (odds ratio, 1.399; 95% confidence interval, 0.759-2.578; p = .282). Contrarily, age, malignancy, assistance needed in activities of daily living, use of analgesic agents, and postoperative infection were risk factors for prolonged HLOS. Additionally, postoperative pain was not related to a higher risk of in-hospital complications. CONCLUSIONS Pain intensity post colorectal surgery was not a risk factor for extended HLOS or in-hospital complications. In contradistinction, tending to patient needs, adequate analgesic use, and reducing infection rates can shorten HLOS, improve health outcomes, and economize health care resources.
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Affiliation(s)
- Noga Avrahami
- Recanati School for Community Health Professions, Department of Nursing, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel and Soroka University Medical Center, Beer-Sheva, Israel; High Risk Pregnancy Department, Baruch Padeh Medical Center, Poriya, Tiberias, Israel
| | - Batya Betesh-Abay
- Recanati School for Community Health Professions, Department of Nursing, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel and Soroka University Medical Center, Beer-Sheva, Israel
| | - Abed N Azab
- Recanati School for Community Health Professions, Department of Nursing, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel and Soroka University Medical Center, Beer-Sheva, Israel; Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Tatiana Nisimov
- Division of Surgery, Soroka University Medical Center, Beer-Sheva, Israel
| | - Muhammad Abu Tailakh
- Recanati School for Community Health Professions, Department of Nursing, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel and Soroka University Medical Center, Beer-Sheva, Israel.
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Li S, van Boekel RLM, van den Heuvel SAS, Coenen MJH, Vissers KCP. Pain predict genetics: protocol for a prospective observational study of clinical and genetic factors to predict the development of postoperative pain. BMJ Open 2022; 12:e066134. [PMID: 36446453 PMCID: PMC9710368 DOI: 10.1136/bmjopen-2022-066134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Postoperative pain remains a challenging medical condition impacting the quality of life of every patient. Although several predictive factors for postoperative pain have been identified, an adequate prediction of postoperative pain in patients at risk has not been achieved yet.The primary objective of this study is to identify specific genetic risk factors for the development of acute and chronic postoperative pain to construct a prediction model facilitating a more personalised postoperative pain management for each individual. The secondary objectives are to build a databank enabling researchers to identify other risk factors for postoperative pain, for instance, demographic and clinical outcome indicators; provide insight into (genetic) factors that predict pharmacological pain relief; investigate the relationship between acute and chronic postoperative pain. METHODS AND ANALYSIS In this prospective, observational study, patients who undergo elective surgery will be recruited to a sample size of approximately 10 000 patients. Postoperative acute and chronic pain outcomes will be collected through questionnaires at different time points after surgery in the follow-up of 6 months. Potential genetic, demographic and clinical risk factors for prediction model construction will be collected through blood, questionnaires and electronic health records, respectively.Genetic factors associated with acute and/or chronic postoperative pain will be identified using a genome-wide association analysis. Clinical risk factors as stated in the secondary objectives will be assessed by multivariable regression. A clinical easy-to-use prediction model will be created for postoperative pain to allow clinical use for the stratification of patients. ETHICS AND DISSEMINATION The Institutional Review Board of the Radboud university medical centre approved the study (authorisation number: 2012/117). The results of this study will be made available through peer-reviewed scientific journals and presentations at relevant conferences, which will finally contribute to personalised postoperative pain management. TRIAL REGISTRATION NUMBER NCT02383342.
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Affiliation(s)
- Song Li
- Department of Human Genetics, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Regina L M van Boekel
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, Nijmegen, The Netherlands
| | - Sandra A S van den Heuvel
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, Nijmegen, The Netherlands
| | - Marieke J H Coenen
- Department of Human Genetics, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Kris C P Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, Nijmegen, The Netherlands
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Coccolini F, Corradi F, Sartelli M, Coimbra R, Kryvoruchko IA, Leppaniemi A, Doklestic K, Bignami E, Biancofiore G, Bala M, Marco C, Damaskos D, Biffl WL, Fugazzola P, Santonastaso D, Agnoletti V, Sbarbaro C, Nacoti M, Hardcastle TC, Mariani D, De Simone B, Tolonen M, Ball C, Podda M, Di Carlo I, Di Saverio S, Navsaria P, Bonavina L, Abu-Zidan F, Soreide K, Fraga GP, Carvalho VH, Batista SF, Hecker A, Cucchetti A, Ercolani G, Tartaglia D, Galante JM, Wani I, Kurihara H, Tan E, Litvin A, Melotti RM, Sganga G, Zoro T, Isirdi A, De’Angelis N, Weber DG, Hodonou AM, tenBroek R, Parini D, Khan J, Sbrana G, Coniglio C, Giarratano A, Gratarola A, Zaghi C, Romeo O, Kelly M, Forfori F, Chiarugi M, Moore EE, Catena F, Malbrain MLNG. Postoperative pain management in non-traumatic emergency general surgery: WSES-GAIS-SIAARTI-AAST guidelines. World J Emerg Surg 2022; 17:50. [PMID: 36131311 PMCID: PMC9494880 DOI: 10.1186/s13017-022-00455-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/16/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Non-traumatic emergency general surgery involves a heterogeneous population that may present with several underlying diseases. Timeous emergency surgical treatment should be supplemented with high-quality perioperative care, ideally performed by multidisciplinary teams trained to identify and handle complex postoperative courses. Uncontrolled or poorly controlled acute postoperative pain may result in significant complications. While pain management after elective surgery has been standardized in perioperative pathways, the traditional perioperative treatment of patients undergoing emergency surgery is often a haphazard practice. The present recommended pain management guidelines are for pain management after non-traumatic emergency surgical intervention. It is meant to provide clinicians a list of indications to prescribe the optimal analgesics even in the absence of a multidisciplinary pain team. MATERIAL AND METHODS An international expert panel discussed the different issues in subsequent rounds. Four international recognized scientific societies: World Society of Emergency Surgery (WSES), Global Alliance for Infection in Surgery (GAIS), Italian Society of Anesthesia, Analgesia Intensive Care (SIAARTI), and American Association for the Surgery of Trauma (AAST), endorsed the project and approved the final manuscript. CONCLUSION Dealing with acute postoperative pain in the emergency abdominal surgery setting is complex, requires special attention, and should be multidisciplinary. Several tools are available, and their combination is mandatory whenever is possible. Analgesic approach to the various situations and conditions should be patient based and tailored according to procedure, pathology, age, response, and available expertise. A better understanding of the patho-mechanisms of postoperative pain for short- and long-term outcomes is necessary to improve prophylactic and treatment strategies.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | | | | | - Raul Coimbra
- Trauma Surgery Department, Riverside University Health System Medical Center, Loma Linda, CA USA
| | - Igor A. Kryvoruchko
- Department of Surgery No2, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Ari Leppaniemi
- General Surgery Department, Helsinki University Hospital, Helsinki, Finland
| | - Krstina Doklestic
- Clinic of Emergency Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Elena Bignami
- ICU Department, Parma University Hospital, Parma, Italy
| | | | - Miklosh Bala
- Trauma and Acute Care Surgery Unit Hadassah, Hebrew University Medical Center, Jerusalem, Israel
| | - Ceresoli Marco
- General Surgery Department, Monza University Hospital, Monza, Italy
| | - Dimitris Damaskos
- General and Emergency Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Walt L. Biffl
- Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA USA
| | - Paola Fugazzola
- General Surgery Department, Pavia University Hospital, Pavia, Italy
| | | | | | | | - Mirco Nacoti
- ICU Department Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Timothy C. Hardcastle
- Trauma and Burn Service, Inkosi Albert Luthuli Central Hospital, Mayville, Durban, South Africa
| | - Diego Mariani
- General Surgery Department, Legnano Hospital, Legnano, Milano, Italy
| | - Belinda De Simone
- Emergency and Colorectal Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy, France
| | - Matti Tolonen
- Emergency Surgery, HUS Helsinki University Hospital, Meilahti Tower Hospital, Helsinki, Finland
| | - Chad Ball
- Trauma and Acute Care Surgery, Foothills Medical Center, Calgary, AB Canada
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | | | - Salomone Di Saverio
- General Surgery Department, San Benedetto del Tronto Hospital, San Benedetto del Tronto, Italy
| | - Pradeep Navsaria
- Trauma Center, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Luigi Bonavina
- General Surgery Department, San Donato Hospital, Milan, Italy
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, University of Bergen, Bergen, Norway
| | - Gustavo P. Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | | | | | - Andreas Hecker
- General Surgery, Giessen University Hospital, Giessen, Germany
| | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences – DIMEC, Alma Mater Studiorum - University of Bologna, General Surgery of the Morgagni - Pierantoni Hospital, Forlì, Italy
| | - Giorgio Ercolani
- Department of Medical and Surgical Sciences – DIMEC, Alma Mater Studiorum - University of Bologna, General Surgery of the Morgagni - Pierantoni Hospital, Forlì, Italy
| | - Dario Tartaglia
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Joseph M. Galante
- General Surgery Department, UCLA Davis University Hospital, Los Angeles, CA USA
| | - Imtiaz Wani
- General Surgery Department, Government Gousiua Hospital, Srinagar, India
| | - Hayato Kurihara
- Emergency and Trauma Surgery Department, Milano University Hospital, Milan, Italy
| | - Edward Tan
- Emergency Department, Nijmegen Hospital, Nijmegen, The Netherlands
| | - Andrey Litvin
- Department of Surgical Disciplines, Immanuel Kant Baltic Federal University, Regional Clinical Hospital, Kaliningrad, Russia
| | | | - Gabriele Sganga
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Tamara Zoro
- ICU Department, Pisa University Hospital, Pisa, Italy
| | | | - Nicola De’Angelis
- Service de Chirurgie Digestive Et Hépato-Bilio-Pancréatique, Hôpital Henri Mondor, Université Paris Est, Créteil, France
| | - Dieter G. Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Adrien M. Hodonou
- Faculty of Medicine of Parakou, University of Parakou, Parakou, Benin
| | - Richard tenBroek
- General Surgery Department, Nijmegen Hospital, Nijmegen, The Netherlands
| | - Dario Parini
- General Surgery Department, Santa Maria Della Misericordia Hospital, Rovigo, Italy
| | - Jim Khan
- University of Portsmouth, Portsmouth Hospitals University NHS Trust UK, Portsmouth, UK
| | | | | | | | | | - Claudia Zaghi
- General, Emergency and Trauma Surgery Department, Vicenza Hospital, Vicenza, Italy
| | - Oreste Romeo
- Trauma and Surgical Critical Care, East Medical Center Drive, University of Michigan Health System, Ann Arbor, MI USA
| | - Michael Kelly
- Department of General Surgery, Albury Hospital, Albury, Australia
| | | | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | | | - Fausto Catena
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Manu L. N. G. Malbrain
- First Department Anaesthesiology Intensive Therapy, Medical University Lublin, Lublin, Poland
- International Fluid Academy, Lovenjoel, Belgium
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8
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Rama NJG, Lages MCC, Guarino MPS, Lourenço Ó, Motta Lima PC, Parente D, Silva CSG, Castro R, Bento A, Rocha A, Castro-Pocas F, Pimentel J. Usefulness of serum C-reactive protein and calprotectin for the early detection of colorectal anastomotic leakage: A prospective observational study. World J Gastroenterol 2022; 28:2758-2774. [PMID: 35979163 PMCID: PMC9260864 DOI: 10.3748/wjg.v28.i24.2758] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/22/2022] [Accepted: 05/14/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Colorectal anastomotic leakage (CAL) is one of the most dreaded complications after colorectal surgery, with an incidence that can be as high as 27%. This event is associated with increased morbidity and mortality; therefore, its early diagnosis is crucial to reduce clinical consequences and costs. Some biomarkers have been suggested as laboratory tools for the diagnosis of CAL.
AIM To assess the usefulness of plasma C-reactive protein (CRP) and calprotectin (CLP) as early predictors of CAL.
METHODS A prospective monocentric observational study was conducted including patients who underwent colorectal resection with anastomosis, from March 2017 to August 2019. Patients were divided into three groups: G1 – no complications; G2 – complications not related to CAL; and G3 – CAL. Five biomarkers were measured and analyzed in the first 5 postoperative days (PODs), namely white blood cell (WBC) count, eosinophil cell count (ECC), CRP, CLP, and procalcitonin (PCT). Clinical criteria, such as abdominal pain and clinical condition, were also assessed. The correlation between biomarkers and CAL was evaluated. Receiver operating characteristic (ROC) curve analysis was used to compare the accuracy of these biomarkers as predictors of CAL, and the area under the ROC curve (AUROC), specificity, sensitivity, positive predictive value, and negative predictive value (NPV) during this period were estimated.
RESULTS In total, 25 of 396 patients developed CAL (6.3%), and the mean time for this diagnosis was 9.0 ± 6.8 d. Some operative characteristics, such as surgical approach, blood loss, intraoperative complications, and duration of the procedure, were notably related to the development of CAL. The length of hospital stay was markedly higher in the group that developed CAL compared with the group with complications other than CAL and the group with no complications (median of 21 d vs 13 d and 7 d respectively; P < 0.001). For abdominal pain, the best predictive performance was on POD4 and POD5, with the largest AUROC of 0.84 on POD4. Worsening of the clinical condition was associated with the diagnosis of CAL, presenting a higher predictive effect on POD5, with an AUROC of 0.9. WBC and ECC showed better predictive effects on POD5 (AUROC = 0.62 and 0.7, respectively). Those markers also presented a high NPV (94%-98%). PCT had the best predictive effect on POD5 (AUROC = 0.61), although it presented low accuracy. However, this biomarker revealed a high NPV on POD3, POD4, and POD5 (96%, 95%, and 96%, respectively). The mean CRP value on POD5 was significantly higher in the group that developed CAL compared with the group without complications (195.5 ± 139.9 mg/L vs 59.5 ± 43.4 mg/L; P < 0.00001). On POD5, CRP had a NPV of 98%. The mean CLP value on POD3 was significantly higher in G3 compared with G1 (5.26 ± 3.58 μg/mL vs 11.52 ± 6.81 μg/mL; P < 0.00005). On POD3, the combination of CLP and CRP values showed a high diagnostic accuracy (AUROC = 0.82), providing a 5.2 d reduction in the time to CAL diagnosis.
CONCLUSION CRP and CLP are moderate predictors of CAL. However, the combination of these biomarkers presents an increased diagnostic accuracy, potentially decreasing the time to CAL diagnosis.
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Affiliation(s)
- Nuno J G Rama
- Colorectal Surgical Division, Leiria Hospital Centre, Leiria 2410-021, Portugal
- Abel Salazar Biomedical Institute (ICBAS), University of Oporto, Oporto 4099-002, Portugal
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, Leiria 2410-541, Portugal
| | - Marlene C C Lages
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, Leiria 2410-541, Portugal
| | - Maria Pedro S Guarino
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, Leiria 2410-541, Portugal
| | - Óscar Lourenço
- Faculty of Economics, CeBER, University of Coimbra, Coimbra 3000-137, Portugal
| | | | - Diana Parente
- Colorectal Surgical Division, Leiria Hospital Centre, Leiria 2410-021, Portugal
| | - Cândida S G Silva
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, Leiria 2410-541, Portugal
| | - Ricardo Castro
- Clinical Pathology Division, Leiria Hospital Centre, Leiria 2410-541, Portugal
| | - Ana Bento
- Clinical Pathology Division, Leiria Hospital Centre, Leiria 2410-541, Portugal
| | - Anabela Rocha
- Abel Salazar Biomedical Institute (ICBAS), University of Oporto, Oporto 4099-002, Portugal
- Surgical Division, Oporto Hospital Centre, Oporto 4099-001, Portugal
| | - Fernando Castro-Pocas
- Abel Salazar Biomedical Institute (ICBAS), University of Oporto, Oporto 4099-002, Portugal
- Department of Gastroenterology, Santo António Hospital, Porto Hospital Center, Porto 4099-001, Portugal
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto 4099-001, Portugal
| | - João Pimentel
- Faculty of Medicine, University of Coimbra, Coimbra 3004-531, Portugal
- Surgical Division, Montes Claros Hospital, Coimbra 3030-320, Portugal
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9
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Rivas E, Cohen B, Pu X, Xiang L, Saasouh W, Mao G, Minko P, Mosteller L, Volio A, Maheshwari K, Sessler DI, Turan A. Pain and Opioid Consumption and Mobilization after Surgery: Post Hoc Analysis of Two Randomized Trials. Anesthesiology 2022; 136:115-126. [PMID: 34780602 DOI: 10.1097/aln.0000000000004037] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Early mobilization is incorporated into many enhanced recovery pathways. Inadequate analgesia or excessive opioids may restrict postoperative mobilization. The authors tested the hypotheses that in adults recovering from abdominal surgery, postoperative pain and opioid consumption are inversely related to postoperative mobilization, and that postoperative mobilization is associated with fewer potentially related complications. METHODS The authors conducted a subanalysis of two trials that enrolled adults recovering from abdominal surgery. Posture and movement were continuously monitored for 48 postoperative hours using noninvasive untethered monitors. Mobilization was defined as the fraction of monitored time spent sitting or standing. RESULTS A total of 673 patients spent a median [interquartile range] of 7% [3 to 13%] of monitored time sitting or standing. Mobilization time was 1.9 [1.0 to 3.6] h/day for patients with average pain scores 3 or lower, but only 1.2 [0.5 to 2.6] h/day in those with average scores 6 or greater. Each unit increase in average pain score was associated with a decrease in mobilization time of 0.12 (97.5% CI, 0.02 to 0.24; P = 0.009) h/day. In contrast, there was no association between postoperative opioid consumption and mobilization time. The incidence of the composite of postoperative complications was 6.0% (10 of 168) in the lower mobilization quartile, 4.2% (7 of 168) in the second quartile, and 0% among 337 patients in the highest two quartiles (P = 0.009). CONCLUSIONS Patients recovering from abdominal surgery spent only 7% of their time mobilized, which is considerably less than recommended. Lower pain scores are associated with increased mobility, independently of opioid consumption. Complications were more common in patients who mobilized poorly. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Eva Rivas
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Department of Anesthesia, Hospital Clinic of Barcelona, August Pi i Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain
| | - Barak Cohen
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Division of Anesthesia, Critical Care and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Xuan Pu
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Department Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Li Xiang
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Department Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Wael Saasouh
- Department of Anesthesiology, Henry Ford Health System, Detroit, Michigan
| | - Guangmei Mao
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Department Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Paul Minko
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | | | - Andrew Volio
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Kamal Maheshwari
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Department of General Anesthesia, Cleveland Clinic, Cleveland, Ohio
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Department of General Anesthesia, Cleveland Clinic, Cleveland, Ohio
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Starr MR, Patel LG, Ammar M, Yonekawa Y. Opioids and ophthalmology: review of the current literature. Curr Opin Ophthalmol 2021; 32:209-213. [PMID: 33710008 DOI: 10.1097/icu.0000000000000753] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE OF REVIEW The number of opioid-related overdose deaths has rapidly increased since 2000, increasing more than five-fold from 1999 to 2016. Although surgeons only write 10% of opioid prescriptions annually, with ophthalmologists writing only a fraction of this amount, all physicians need to be cognizant of the current opioid epidemic and ways to decrease unnecessary opioid prescriptions. RECENT FINDINGS Previous work within ophthalmology has shown that retrobulbar anesthesia along with peri-operative intravenous or oral nonopioid analgesics can lead to decreased postoperative opioid use following ophthalmic surgery. Recent literature has shifted focus towards the use of opioid prescription guidelines in managing postoperative pain and decreasing the number of unnecessary opioids being prescribed by ophthalmologists. Overall, the frequency of opioid prescriptions may have gradually declined the past few years with such efforts, increased awareness, and new healthcare policies to monitor opioid prescriptions. However, ophthalmologists still continue to prescribe a substantial number of opioid medications, much of which may not be necessary. SUMMARY This review serves as a tool to aid all ophthalmologists in managing postoperative pain. There is a recent trend in addressing the opioid epidemic and efforts are being made to limit the overprescribing of opioids. Continued efforts are still required by all ophthalmologists to address the current opioid epidemic.
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Affiliation(s)
- Matthew R Starr
- Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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11
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Smith SA, Ghabra H, Dhaifallah DG, Rahnema A, Evans BM, Nossaman BD, Sumrall WD, Bardot SF, Canter DJ. Novel Opiate-Free Anesthetic Technique for Major Urologic Procedures. South Med J 2021; 113:499-504. [PMID: 33005965 DOI: 10.14423/smj.0000000000001159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES We postulated that an opiate-free (OF) general anesthesia (GA) technique could adequately control a patient's pain without adversely affecting recovery. We compared patients undergoing major urologic procedures with and without opiate-based GA. METHODS A propensity-matched analysis was performed comparing hospital length of stay, postoperative nausea and vomiting, ileus occurrence, postanesthesia care unit, and total opiate consumption, as well as sedation and hemodynamic variables. The data are expressed as medians and were analyzed with the Wilcoxon rank-sum test. P < 0.05 indicate statistical significance. RESULTS In total, 166 patients were evaluated in both the OF group and the opiate-based treatment group. American Society of Anesthesiologists classification and age were comparable, with most surgeries being laparoscopic and confined to the bladder, kidney, and prostate gland. The median opiate consumption in morphine equivalents in the postanesthesia care unit was 7.7 mg (range 5-11.7 mg) for the OF cohort versus 11.7 mg (range 5-17.3 mg) for the control group (P < 0.001). Similarly, the median total postoperative opiate consumption in morphine equivalents was 23.9 mg (range 13.8-42.4 mg) for the OF group compared with 32.1 mg (range 17.38-57.51 mg) for the control group (P = 0.0081). The median hospital length of stay for the OF group was 1.4 days (range 1.2-2.3 days) versus 1.3 days (range 1.2-2.4 days) for the control group (P = 0.8466). CONCLUSIONS There was a statistically significant difference in opiate consumption postoperatively for patients who underwent an OF technique compared with a conventional opiate-based technique. This technique appears to be a possible alternative approach, without any apparent untoward consequences during admission.
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Affiliation(s)
- Susan A Smith
- From the Department of Anesthesiology, Emory University, Atlanta, Georgia, the Departments of Anesthesiology and Urology, Ochsner Clinic Foundation, New Orleans, Louisiana, the Department of Anesthesiology, Critical Care, & Pain Medicine, St Elizabeth's Medical Center, Brighton, Massachusetts, and the Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock
| | - Hussam Ghabra
- From the Department of Anesthesiology, Emory University, Atlanta, Georgia, the Departments of Anesthesiology and Urology, Ochsner Clinic Foundation, New Orleans, Louisiana, the Department of Anesthesiology, Critical Care, & Pain Medicine, St Elizabeth's Medical Center, Brighton, Massachusetts, and the Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock
| | - Daniah G Dhaifallah
- From the Department of Anesthesiology, Emory University, Atlanta, Georgia, the Departments of Anesthesiology and Urology, Ochsner Clinic Foundation, New Orleans, Louisiana, the Department of Anesthesiology, Critical Care, & Pain Medicine, St Elizabeth's Medical Center, Brighton, Massachusetts, and the Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock
| | - Alexander Rahnema
- From the Department of Anesthesiology, Emory University, Atlanta, Georgia, the Departments of Anesthesiology and Urology, Ochsner Clinic Foundation, New Orleans, Louisiana, the Department of Anesthesiology, Critical Care, & Pain Medicine, St Elizabeth's Medical Center, Brighton, Massachusetts, and the Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock
| | - Bryan M Evans
- From the Department of Anesthesiology, Emory University, Atlanta, Georgia, the Departments of Anesthesiology and Urology, Ochsner Clinic Foundation, New Orleans, Louisiana, the Department of Anesthesiology, Critical Care, & Pain Medicine, St Elizabeth's Medical Center, Brighton, Massachusetts, and the Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock
| | - Bobby D Nossaman
- From the Department of Anesthesiology, Emory University, Atlanta, Georgia, the Departments of Anesthesiology and Urology, Ochsner Clinic Foundation, New Orleans, Louisiana, the Department of Anesthesiology, Critical Care, & Pain Medicine, St Elizabeth's Medical Center, Brighton, Massachusetts, and the Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock
| | - William D Sumrall
- From the Department of Anesthesiology, Emory University, Atlanta, Georgia, the Departments of Anesthesiology and Urology, Ochsner Clinic Foundation, New Orleans, Louisiana, the Department of Anesthesiology, Critical Care, & Pain Medicine, St Elizabeth's Medical Center, Brighton, Massachusetts, and the Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock
| | - Stephen F Bardot
- From the Department of Anesthesiology, Emory University, Atlanta, Georgia, the Departments of Anesthesiology and Urology, Ochsner Clinic Foundation, New Orleans, Louisiana, the Department of Anesthesiology, Critical Care, & Pain Medicine, St Elizabeth's Medical Center, Brighton, Massachusetts, and the Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock
| | - Daniel J Canter
- From the Department of Anesthesiology, Emory University, Atlanta, Georgia, the Departments of Anesthesiology and Urology, Ochsner Clinic Foundation, New Orleans, Louisiana, the Department of Anesthesiology, Critical Care, & Pain Medicine, St Elizabeth's Medical Center, Brighton, Massachusetts, and the Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock
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12
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Boström P, Svensson J, Brorsson C, Rutegård M. Early postoperative pain as a marker of anastomotic leakage in colorectal cancer surgery. Int J Colorectal Dis 2021; 36:1955-1963. [PMID: 34272996 PMCID: PMC8346442 DOI: 10.1007/s00384-021-03984-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Even though anastomotic leakage after colorectal surgery is a major clinical problem in need of a timely diagnosis, early indicators of leakage have been insufficiently studied. We therefore conducted a population-based observational study to determine whether the patient's early postoperative pain is an independent marker of anastomotic leakage. METHODS By combining the Swedish Colorectal Cancer Registry and the Swedish Perioperative Registry, we retrieved prospectively collected data on 3084 patients who underwent anastomotic colorectal surgery for cancer in 2014-2017. Postoperative pain, measured with the numerical rating scale (NRS), was considered exposure, while anastomotic leakage and reoperation due to leakage were outcomes. We performed logistic regression to evaluate associations, estimating odds ratios (ORs) and 95% confidence intervals (CIs), while multiple imputation was used to handle missing data. RESULTS In total, 189 patients suffered from anastomotic leakage, of whom 121 patients also needed a reoperation due to leakage. Moderate or severe postoperative pain (NRS 4-10) was associated with an increased risk of anastomotic leakage (OR 1.69, 95% CI 1.21-2.38), as well as reoperation (OR 2.17, 95% CI 1.41-3.32). Severe pain (NRS 8-10) was more strongly related to leakage (OR 2.38, 95% CI 1.44-3.93). These associations were confirmed in multivariable analyses and when reoperation due to leakage was used as an outcome. CONCLUSION In this population-based retrospective study on prospectively collected data, increased pain in the post-anaesthesia care unit is an independent marker of anastomotic leakage, possibly indicating a need for further diagnostic measures.
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Affiliation(s)
- Petrus Boström
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umea, Sweden
| | - Johan Svensson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umea, Sweden ,Department of Statistics, Umeå School of Business and Economics, Umeå University, Umea, Sweden
| | - Camilla Brorsson
- Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine, Umeå University, Umea, Sweden
| | - Martin Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umea, Sweden ,Wallenberg Centre for Molecular Medicine, Umeå University, Umea, Sweden
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13
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Rivard SJ, Byrn JC, Campbell DS, Hendren S. Colorectal surgery collaboratives: The Michigan experience. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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14
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Starr MR, Patel SV, Bartley GB, Bothun ED. Impact of Standardized Prescribing Guidelines on Postoperative Opioid Prescriptions after Ophthalmic Surgery. Ophthalmology 2020; 127:1454-1459. [PMID: 32654758 DOI: 10.1016/j.ophtha.2020.04.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/20/2020] [Accepted: 04/08/2020] [Indexed: 10/24/2022] Open
Abstract
PURPOSE To determine the effect of implementing standardized opioid prescribing guidelines on prescription patterns for acute pain after ophthalmic surgery in opioid-naïve patients. DESIGN Quality improvement study. PARTICIPANTS Ophthalmic surgeons in an academic department of ophthalmology. METHODS Postoperative opioid prescribing patterns were compared before and after the implementation of standardized opioid prescribing guidelines for ophthalmic surgery at an academic institution. Only prescriptions provided to opioid-naïve patients 18 years of age or older were included. Surgeons reached a consensus for standardized prescribing guidelines appropriate for the type of surgery within their subspecialty. Guidelines were disseminated in conjunction with postsurgical pain management education to all ophthalmologists in the department, including trainees. The frequency of opioid prescriptions, the quantity of opioid prescribed (converted to oral morphine equivalent [OME]), and opioid prescription refill rates were compared before and after intervention. MAIN OUTCOME MEASURES Prescriptions with more than 80 OME, frequency of opioid prescriptions, mean OME, and refill rates. RESULTS Of 5349 ophthalmic surgeries performed during the 2 assessment periods, 196 (3.7%) were associated with opioid prescriptions for acute postoperative pain. The frequency of opioid prescriptions decreased to 3.0% (81/2736) after intervention compared with 4.4% (115/2613) before intervention (P = 0.005). When opioids were prescribed, the mean OME decreased from 93 (range, 27-500) before intervention to 42 (range, 14-100) after intervention (P = 0.003). The number of prescriptions for more than 80 OME decreased from 56 (2.1%) before intervention to 4 (0.1%) after intervention (P < 0.001). Based on the standardized guidelines, 103 of the 115 (89.6%) preintervention opioid prescriptions would not have adhered to the guidelines, whereas 39 of the 81 (48.1%) postintervention prescriptions did not adhere to the guidelines (P < 0.001). The proportion of refill prescriptions did not differ before and after intervention (P = 0.44). CONCLUSIONS The process of discussing postsurgical pain management and developing standardized opioid prescribing guidelines reduces overprescribing of opioids after ophthalmic surgery without increasing refill rates. Continued education is required to improve adherence to the prescribing guidelines further.
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Affiliation(s)
- Matthew R Starr
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
| | - Sanjay V Patel
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
| | | | - Erick D Bothun
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota.
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15
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Relationship Between Postoperative Pain and Overall 30-Day Complications in a Broad Surgical Population: An Observational Study. Ann Surg 2020; 269:856-865. [PMID: 29135493 DOI: 10.1097/sla.0000000000002583] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The aim of this study was to establish the relationship between postoperative pain and 30-day postoperative complications. BACKGROUND Only scarce data are available on the association between postoperative pain and a broad range of postoperative complications in a large heterogeneous surgical population. METHODS Having postoperative pain was assessed in 2 ways: the movement-evoked pain score on the Numerical Rating Scale (NRS-MEP) and the patients' opinion whether the pain was acceptable or not. Outcome was the presence of a complication within 30 days after surgery. We used binary logistic regression for the total population and homogeneous subgroups to control for case complexity. Results for homogeneous subgroups were summarized in a meta-analysis using inverse variance weighting. RESULTS In 1014 patients, 55% experienced moderate-to-severe pain on the first postoperative day. The overall complication rate was 34%. The proportion of patients experiencing postoperative complications increased from 0.25 [95% confidence interval (CI) = 0.21-0.31] for NRS-MEP = 0 to 0.45 (95% CI = 0.36-0.55) for NRS-MEP = 10. Patients who found their pain unacceptable had more complications (adjusted odds ratio = 2.17 (95% CI = 1.51-3.10; P < 0.001)). Summary effect sizes obtained with homogeneous groups were similar to those obtained from the total population who underwent very different types of surgery. CONCLUSIONS Higher actual postoperative pain scores and unacceptable pain, even on the first postoperative day, are associated with more postoperative complications. Our findings provide important support for the centrality of personalized analgesia in modern perioperative care.
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16
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Freys SM, Pogatzki-Zahn E. Pain therapy to reduce perioperative complications. Innov Surg Sci 2019; 4:158-166. [PMID: 33977126 PMCID: PMC8059349 DOI: 10.1515/iss-2019-0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 09/16/2019] [Indexed: 12/19/2022] Open
Abstract
The incidence rates of adverse events secondary to any operation are a well-known problem in any surgical field. One outstanding example of such adverse events is postoperative pain. Thus, the incidence of acute postoperative pain following any surgical procedure and its treatment are central issues for every surgeon. In the times of Enhanced Recovery After Surgery (ERAS) programs, acute pain therapy became an increasingly well investigated and accepted aspect in almost all surgical subspecialties. However, if it comes to the reduction of postoperative complications, in the actual context of postoperative pain, surgeons tend to focus on the operative process rather than on the perioperative procedures. Undoubtedly, postoperative pain became an important factor with regard to the quality of surgical care: both, the extent and the quality of the surgical procedure and the extent and the quality of the analgesic technique are decisive issues for a successful pain management. There is growing evidence that supports the role of acute pain therapy in reducing postoperative morbidity, and it has been demonstrated that high pain scores postoperatively may contribute to a complicated postoperative course. This overview comprises the current knowledge on the role of acute pain therapy with regard to the occurrence of postoperative complications. Most of the knowledge is derived from studies that primarily focus on the type and quality of postoperative pain therapy in relation to specific surgical procedures and only secondary on complications. As far as existent, data that report on the recovery period after surgery, on the rehabilitation status, on perioperative morbidity, on the development of chronic pain after surgery, and on possible solutions of the latter problem with the institution of transitional pain services will be presented.
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Affiliation(s)
- Stephan M. Freys
- Chirurgische Klinik, DIAKO Ev. Diakonie-Krankenhaus, Gröpelinger Heerstr. 406-408, 28239 Bremen, Germany
| | - Esther Pogatzki-Zahn
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Münster, Germany
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Nikolian VC, Regenbogen SE. Statewide Clinic Registries: The Michigan Surgical Quality Collaborative. Clin Colon Rectal Surg 2019; 32:16-24. [PMID: 30647542 PMCID: PMC6327739 DOI: 10.1055/s-0038-1673350] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Regional clinical registries provide a unique opportunity for shared learning and population-based analyses of the quality of surgical care. Through the "Michigan Model" of pay for participation in strategic Value Partnerships, exemplified by the Michigan Surgical Quality Collaborative (MSQC), the state's dominant private insurer, Blue Cross Blue Shield of Michigan, has sponsored 20 statewide clinical quality improvement collaboratives. MSQC represents a partnership among 73 Michigan hospitals with a robust data infrastructure and flexible platform for the promulgation of best practices in surgical quality improvement. This article will describe the organizational structure of the MSQC, the contributions the registry has made to quality improvement in colorectal surgery, and how future work will align to improve the reliability of improvement-relevant registry data.
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Grass F, Cachemaille M, Martin D, Fournier N, Hahnloser D, Blanc C, Demartines N, Hübner M. Pain perception after colorectal surgery: A propensity score matched prospective cohort study. Biosci Trends 2018; 12:47-53. [DOI: 10.5582/bst.2017.01312] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Fabian Grass
- Department of Visceral Surgery, University Hospital CHUV
| | | | - David Martin
- Department of Visceral Surgery, University Hospital CHUV
| | - Nicolas Fournier
- Institute for Social and Preventive Medicine, University Hospital CHUV
| | | | | | | | - Martin Hübner
- Department of Visceral Surgery, University Hospital CHUV
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Predictors of In-hospital Postoperative Opioid Overdose After Major Elective Operations: A Nationally Representative Cohort Study. Ann Surg 2017; 265:702-708. [PMID: 28267693 DOI: 10.1097/sla.0000000000001945] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The aim of this study was to describe national trends and outcomes of in-hospital postoperative opioid overdose (OD) and identify predictors of postoperative OD. SUMMARY OF BACKGROUND DATA In 2000, the Joint Commission recommended making pain the 5th vital sign, increasing the focus on postoperative pain control. However, the benefits of pain management must be weighed against the potentially lethal risk of opioid OD. METHODS This is a retrospective multi-institutional cohort study of patients undergoing 1 of 6 major elective inpatient operation from 2002 to 2011 using the Nationwide Inpatient Sample, an approximately 20% representative sample of all United States hospital admissions. Patients with postoperative OD were identified using ICD-9 codes for poisoning from opioids or adverse effects from opioids. Multivariate logistic regression was used to identify independent predictors. RESULTS Among 11,317,958 patients, 9458 (0.1%) had a postoperative OD; this frequency doubled over the study period from 0.6 to 1.1 overdoses per 1000 cases. Patients with postoperative OD died more frequently during their hospitalization (1.7% vs 0.4%, P < 0.001). Substance abuse history was the strongest predictor of OD (odds ratio = 14.8; 95% confidence interval: 12.7-17.2). Gender, age, income, geographic location, operation type, and certain comorbid diseases also predicted OD (P < 0.05). Hospital variables, including teaching status, size, and urban/rural location, did not predict postoperative OD. CONCLUSIONS Postoperative OD is a rare, but potentially lethal complication, with increasing incidence. Postoperative monitoring and treatment safety interventions should be thoughtfully employed to target high-risk patients and avoid this potentially fatal complication.
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