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Periañez CAH, Castillo-Diaz MA, Barbosa MH, De Mattia AL. Pain Predictors in Patients in the Postanesthesia Care Unit. J Perianesth Nurs 2024; 39:652-658. [PMID: 38310508 DOI: 10.1016/j.jopan.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 11/07/2023] [Accepted: 11/13/2023] [Indexed: 02/05/2024]
Abstract
PURPOSE To analyze the effects of pain-predicting factors on patients in the postanesthesia care unit (PACU). DESIGN This is an observational and prospective study. METHODS This study was conducted at a University Hospital in the state of Minas Gerais (Brazil). To collect data on demographic, clinical, and surgical factors, a collection instrument was devised. The verbal numerical scale was employed to measure pain levels before and after surgery in the PACU. A path analysis was used to assess a predictive model. FINDINGS A total of 226 patients were included in this study. The incidence of pain in the PACU was 31.9%. A model with demographic, clinical, and surgical variables was tested. The final model, after including modification indices, obtained results that indicated an acceptable data fit (comparative fit index = 0.996; root mean square error of approximation = 0.08). Age (being young), sex (being a woman), oncological diagnosis as an indication for the surgical procedure, type of surgery (surgery of the digestive system), duration of surgery (longer surgeries), and high intraoperative doses of opioids were predictive variables for pain in the PACU. CONCLUSIONS This study's findings provide support for pain management in the PACU. Furthermore, the results of this research can be used to anticipate the occurrence of acute postoperative pain and personalized perioperative analgesia needs.
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Affiliation(s)
| | - Marcio Alexander Castillo-Diaz
- Universidad Nacional Autónoma de Honduras, Vicerrectoría de Orientación y Asuntos Estudiantiles. Tegucigalpa, Francisco Morazán, Honduras
| | - Maria Helena Barbosa
- Universidade Federal do Triângulo Mineiro, Departamento de Enfermagem na Assistência Hospitalar. Uberaba, Minas Gerias, Brasil
| | - Ana Lúcia De Mattia
- Universidade Federal de Minas Gerais, Escola de Enfermagem, Departamento de Enfermagem Básica, Belo Horizonte, Minas Gerais, Brasil
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Sakai N, Wu JM, Willis-Gray M. Preoperative Activity Level and Postoperative Pain After Pelvic Reconstructive Surgery. UROGYNECOLOGY (PHILADELPHIA, PA.) 2023; 29:807-813. [PMID: 37093570 DOI: 10.1097/spv.0000000000001349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
IMPORTANCE Higher preoperative activity level is associated with improved postoperative outcomes, but its impact on postoperative pain after urogynecologic surgery is unknown. OBJECTIVE The aim of the study was to assess the relationship between preoperative activity level and postoperative pain. STUDY DESIGN In this prospective cohort study, we evaluated women undergoing pelvic reconstructive surgery from April 2019 through September 2021. We used the Activity Assessment Survey (AAS) to create cohorts of high (AAS = 100) and low (AAS < 100) baseline activity (BA). Our primary outcome was postoperative pain scores. Our secondary outcome was postoperative opioid use. RESULTS Of 132 patients, 90 (68%) were in the low BA group and 42 (32%) were in the high BA group. The groups were similar in age (mean 59 ± 12 years for high BA vs 60 ± 12 for low BA, P = 0.70), body mass index, and surgical procedures performed; however, the high BA group had lower preoperative pain scores (2 ± 6 vs 11 ± 9, P ≤ 0.01). For the primary outcome, the high BA group reported lower postoperative pain scores (16 ± 8 vs 20 ± 9, P = 0.02) and less opioid use (19 ± 32 vs 52 ± 70 morphine milliequivalents, P = 0.01) than the low BA group. However, when adjusting for age, baseline pain, hysterectomy, baseline opioid use, and Charlson Comorbidity Index, high BA did not remain associated with lower postoperative pain scores and less opioid use. CONCLUSION A higher preoperative activity level among patients undergoing urogynecologic surgery was not associated with lower pain scores nor decreased opioid use.
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Affiliation(s)
- Nozomi Sakai
- From the Department of Obstetrics and Gynecology
| | - Jennifer M Wu
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Marcella Willis-Gray
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Cummings S, Scime NV, Brennand EA. Age and postoperative opioid use in women undergoing pelvic organ prolapse surgery. Acta Obstet Gynecol Scand 2023; 102:1371-1377. [PMID: 37587619 PMCID: PMC10540930 DOI: 10.1111/aogs.14638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/08/2023] [Accepted: 06/30/2023] [Indexed: 08/18/2023]
Abstract
INTRODUCTION Our objective was to explore the relation between patient age and postoperative opioid use up to 24 hours following pelvic organ prolapse (POP) surgery. MATERIAL AND METHODS We conducted a prospective cohort study following 335 women ranging in age from 26 to 82 years who underwent surgery for multi-compartment POP at a tertiary center in Alberta, Canada. Patient characteristics were measured using baseline questionnaires. Perioperative data were collected from medical chart review during and up to 24 hours following surgery. We used logistic regression to analyze the odds of being opioid-free and linear regression to analyze mean differences in opioid dose, measured as total morphine equivalent daily dose, exploring for a potential non-linear effect of age. Adjusted models controlled for preoperative pain, surgical characteristics and patient health factors. RESULTS Overall, age was positively associated with greater odds of being opioid-free in the first 24 hours after surgery (adjusted odds ratio per increasing year of age = 1.07, 95% confidence interval [CI] 1.04-1.09, n = 332 women). Among opioid users, age was inversely associated with total opioid dose (adjusted mean difference per increasing year of age = 0.71 mg morphine equivalent daily dose, 95% CI -0.99 to -0.44, n = 204 women). There was no evidence of a non-linear relation between age and postoperative opioid use or dose. CONCLUSIONS In the context of POP surgery, we found that younger women were more likely to use opioids after surgery and to use a higher dose in the first 24 hours when compared with older women. These findings support physicians to consider age when counseling POP patients regarding pain management after surgery, and to direct resources aimed at opioid-free pain control towards younger patients.
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Affiliation(s)
- Shannon Cummings
- Department of Obstetrics and Gynecology, Cumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | - Natalie V. Scime
- Department of Health and SocietyUniversity of Toronto ScarboroughScarboroughOntarioCanada
| | - Erin A. Brennand
- Department of Obstetrics and Gynecology, Cumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
- Department of Community Health Sciences, Cumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
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Examining Age and Postoperative Opioid Use in the Urogynecology Population: A Prospective Study. UROGYNECOLOGY (HAGERSTOWN, MD.) 2022; 28:872-878. [PMID: 36409645 DOI: 10.1097/spv.0000000000001251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
IMPORTANCE Surgeons must individualize postoperative pain management while also reducing the amount of unused prescribed opioids. OBJECTIVES This study compared postoperative opioid use in younger versus older women following urogynecologic surgery. We also assessed the likelihood of women returning unused opioids for safe disposal. STUDY DESIGN This was a prospective study of women undergoing pelvic reconstructive surgery divided into 2 cohorts: younger (<65 years) and older (≥65 years). Our primary outcome was total opioid use, measured in morphine milligram equivalents (MME). We also assessed the average pain score during the first week after surgery measured by a numerical pain scale (range, 0-10). Our secondary outcome was the rate of return of unused prescribed opioids at the 6-week postoperative visit utilizing a disposable drug deactivation system. RESULTS From April 2019 to September 2021, 152 participants were enrolled: 92 (61%) in the younger cohort (mean age, 51 ± 8 years) and 60 (39%) in the older cohort (mean age, 72 ± 6 years). For our primary outcome, younger women used significantly more opioids during the first postoperative week compared with older women (49 ± 71 vs 28 ± 40 MME, respectively, P = 0.04), despite no difference in average pain scores (4 ± 2 younger vs 3 ± 2 older, P = 0.05). For our secondary outcome, 23% of participants returned their opioids for disposal with the drug deactivation system. CONCLUSIONS Younger women had higher postoperative opioid use despite similar pain scores after urogynecologic surgery. Among those prescribed opioids, a quarter of participants returned their opioids for disposal at their postoperative visit.
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Long JB, Morgan BM, Boyd SS, Davies MF, Kunselman AR, Stetter CM, Andreae MH. A randomized trial of standard vs restricted opioid prescribing following midurethral sling. Am J Obstet Gynecol 2022; 227:313.e1-313.e9. [PMID: 35550371 DOI: 10.1016/j.ajog.2022.05.010] [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: 01/03/2022] [Revised: 04/29/2022] [Accepted: 05/02/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Postoperative opioid prescribing has historically lacked information crucial to balancing the pain control needs of the individual patient with our professional responsibility to judiciously prescribe these high-risk medications. OBJECTIVE This study aimed to evaluate pain control, satisfaction with pain control, and opioid use among patients undergoing isolated midurethral sling randomized to 1 of 2 different opioid-prescribing regimens. STUDY DESIGN Patients who underwent isolated midurethral sling placement from June 1, 2020, to November 22, 2021, were offered enrollment into this prospective, randomized, open-label, noninferiority clinical trial. Participants were randomized to receive either a standard prescription of ten 5-mg oxycodone tablets provided preoperatively (standard) or an opioid prescription provided only during patient request postoperatively (restricted). Preoperatively, all participants completed baseline demographic and pain surveys, including the 9-Question Central Sensitization Index, Pain Catastrophizing Scale, and Likert pain score (scale 0-10). The participants completed daily surveys for 1 week after surgery to determine the average daily pain score, number of opioids used, other forms of pain management, satisfaction with pain control, perception of the number of opioids prescribed, and need to return to care for pain management. The online Prescription Drug Monitoring Program was used to determine opioid filling in the postoperative period. The primary outcome was average postoperative day 1 pain score, and an a priori determined margin of noninferiority was set at 2 points. RESULTS Overall, 82 patients underwent isolated midurethral sling placement and met the inclusion criteria: 40 were randomized to the standard arm, and 42 were randomized to the restricted group. Concerning the primary outcome of average postoperative day 1 pain score, the restricted arm (mean pain score, 3.9±2.4) was noninferior to the standard arm (mean pain score, 3.7±2.7; difference in means, 0.23; 95% confidence interval, -∞ to 1.34). Of note, 23 participants (57.5%) in the standard arm vs 8 participants (19.0%) in the restricted arm filled an opioid prescription (P<.001). Moreover, 18 of 82 participants (22.0%) used opioids during the 7-day postoperative period, with 10 (25.0%) in the standard arm and 8 (19.0%) in the restricted arm using opioids (P=.52). Of participants using opioids, the average number of tablets used was 3.4±2.3, and only 3 participants used ≥5 tablets. On a scale of 1="prescribed far more opioids than needed" to 5="prescribed far less opioids than needed," the means were 1.9±1.0 in the standard arm and 2.7±1.0 in the restricted arm (P<.001). CONCLUSION Restricted opioid prescription was noninferior to standard opioid prescription in the setting of pain control and satisfaction with pain control after isolated midurethral placement. Participants in the restricted arm filled fewer opioid prescriptions than participants in the standard arm. On average, only 3.4 tablets were used by those that filled prescriptions in both groups. Restrictive opioid-prescribing practices may reduce unused opioids in the community while achieving similar pain control.
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Postoperative Opioid Prescribing After Female Pelvic Medicine and Reconstructive Surgery. Female Pelvic Med Reconstr Surg 2021; 27:643-653. [PMID: 34669653 DOI: 10.1097/spv.0000000000001113] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE This study aimed to provide female pelvic medicine and reconstructive surgery (FPMRS) providers with evidence-based guidance on opioid prescribing following surgery. METHODS A literature search of English language publications between January 1, 2000, and March 31, 2021, was conducted. Search terms identified reports on opioid prescribing, perioperative opioid use, and postoperative pain after FPMRS procedures. Publications were screened, those meeting inclusion criteria were reviewed, and data were abstracted. Data regarding the primary objective included the oral morphine milligram equivalents of opioid prescribed and used after discharge. Information meeting criteria for the secondary objectives was collected, and qualitative data synthesis was performed to generate evidence-based practice guidelines for prescription of opioids after FPMRS procedures. RESULTS A total of 6,028 unique abstracts were identified, 452 were screened, and 198 full-text articles were assessed for eligibility. Fifteen articles informed the primary outcome, and 32 informed secondary outcomes. CONCLUSIONS For opioid-naive patients undergoing pelvic reconstructive surgery, we strongly recommend surgeons to provide no more than 15 tablets of opioids (roughly 112.5 morphine milligram equivalents) on hospital discharge. In cases where patients use no or little opioids in the hospital, patients may be safely discharged without postoperative opioids. Second, patient and surgical factors that may have an impact on opioid use should be assessed before surgery. Third, enhanced recovery pathways should be used to improve perioperative care, optimize pain control, and minimize opioid use. Fourth, systemic issues that lead to opioid overprescribing should be addressed. Female pelvic medicine and reconstructive surgery surgeons must aim to balance adequate postoperative pain control with individual and societal risks associated with excess opioid prescribing.
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Oxycodone Use During the Postoperative Period After Hysterectomy for Benign Indications. Female Pelvic Med Reconstr Surg 2021; 28:90-95. [PMID: 34264895 DOI: 10.1097/spv.0000000000001084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objective of this study was to estimate the amount of oxycodone tablets required for pain control in the 2-week postoperative period after laparoscopic hysterectomy (LH) and vaginal hysterectomy (VH) for benign disease. METHODS We conducted a prospective cohort study of English-speaking women 18 years or older undergoing hysterectomy for benign indications. Participants completed a pain survey at baseline and daily for 2 weeks postoperatively. In addition, they recorded the number of oxycodone tablets and other pain medications taken daily for 2 weeks. The primary outcome was the median number of oxycodone tablets (5 mg) consumed after LH or VH during 2 weeks postoperative. RESULTS Eighty-one women underwent VH and 82 underwent LH. Women who underwent VH were older (mean ± SD, 64.2 ± 10.3 years vs 47.5 ± 7.7 years), more parous (2 [interquartile range (IQR), 2-3] vs 2 [IQR, 1-2]), and less likely to be sexually active (51.9% vs 79.3%, P < 0.02). Women in the VH group also had significantly lower baseline pain levels (0 [IQR, 0-1] vs 1 [IQR, 0-4], P < 0.001). All VH participants had surgery for prolapse, whereas only 12.2% in the LH group had surgery for this indication (P < 0.001). Most in the LH group had surgery for fibroids (61%) or abnormal uterine bleeding (15.9%). Women in the VH group consumed significantly less oxycodone tablets postoperatively (median, 4.5 [IQR, 1-9] vs 7 [IQR, 2-18]; P = 0.047) and took oxycodone for less days after discharge (median, 1 [IQR, 0-3] vs 3 [IQR, 1-6]; P < 0.001). CONCLUSIONS Women consume less oxycodone after minimally invasive hysterectomy than previously thought. Those who undergo VH may consume less oxycodone than those who undergo LH.
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Guidance for Improving Surgical Care and Recovery in Urogynecologic Surgery. Female Pelvic Med Reconstr Surg 2021; 27:223-224. [PMID: 33770804 DOI: 10.1097/spv.0000000000001004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Willis-Gray MG, Young JC, Pate V, Jonsson Funk M, Wu JM. Perioperative opioid prescriptions associated with stress incontinence and pelvic organ prolapse surgery. Am J Obstet Gynecol 2020; 223:894.e1-894.e9. [PMID: 32653459 PMCID: PMC7704807 DOI: 10.1016/j.ajog.2020.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/12/2020] [Accepted: 07/07/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is an opioid epidemic in the United States with a contributing factor of opioids being prescribed for postoperative pain after surgery. OBJECTIVE Among women who underwent stress urinary incontinence and pelvic organ prolapse surgeries, our primary objective was to determine the proportion of women who filled perioperative opioid prescriptions and to compare factors associated with these opioid prescriptions. We also sought to assess the risk of prolonged opioid use through 1 year after stress urinary incontinence and pelvic organ prolapse surgeries. STUDY DESIGN Using a population-based cohort of commercially insured individuals in the 2005-2015 IBM MarketScan databases, we identified opioid-naive women ≥18 years who underwent stress urinary incontinence and/or pelvic organ prolapse procedures based on Current Procedural Terminology codes. We defined the perioperative period as the window beginning 30 days before surgery extending until 7 days after surgery. Any filled opioid prescription in this window was considered a perioperative prescription. For our primary outcome, we reported the proportion of opioid-naive women who filled a perioperative opioid prescription and reported the median quantity dispensed in the perioperative period. We also assessed demographic and perioperative factors associated with perioperative opioid prescription fills. Previous studies have defined prolonged use as the proportion of women who fill an opioid prescription between 90 and 180 days after surgery. We report this estimate as well as continuous opioid use, defined as the proportion of women with ongoing monthly opioid prescriptions filled through 1 year after stress urinary incontinence and/or pelvic organ prolapse surgery. RESULTS Among the 217,460 opioid-naive women who underwent urogynecologic surgery, 61,025 (28.1%) had pelvic organ prolapse and stress urinary incontinence surgeries, 85,575 (39.4%) had stress urinary incontinence surgery without pelvic organ prolapse surgery, and 70,860 (32.6%) had pelvic organ prolapse surgery without stress urinary incontinence surgery. Overall, 167,354 (77.0%) filled a perioperative opioid prescription, and the median quantity was 30 pills (interquartile range, 20-30). In a multivariate regression model, younger age, pelvic organ prolapse surgery with or without stress urinary incontinence surgery, abdominal route, hysterectomy, and mesh use remained significantly associated with opioid prescriptions filled. Among those with a filled perioperative opioid prescription, the risk of prolonged use defined as an opioid prescription filled between 90 and 180 days was 7.5% (95% confidence interval, 7.3-7.6). However, the risk of prolonged use defined as continuous use with at least 1 monthly opioid prescription filled after surgery was significantly lower: 1.2% (1.13-1.24), 0.32% (0.29-0.35), 0.06% (0.05-0.08), and 0.04% (0.02-0.05) at 60, 90, 180, and 360 days after surgery, respectively. CONCLUSION Among privately insured, opioid-naive women undergoing stress urinary incontinence and/or pelvic organ prolapse surgery, 77% of women filled an opioid prescription with a median of 30 opioid pills prescribed. For prolonged use, 7.5% (95% confidence interval, 7.3-7.6) filled an opioid prescription within 90 to 180 days after surgery, but the rates of continuously filled opioid prescriptions were significantly lower at 0.06% (95% confidence interval, 0.05-0.08) at 180 days and 0.04% (95% confidence interval, 0.02-0.05) at 1 year after surgery.
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Affiliation(s)
- Marcella G Willis-Gray
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Jessica C Young
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Virginia Pate
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michele Jonsson Funk
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC; Center for Women's Health Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jennifer M Wu
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Center for Women's Health Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
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