Effectiveness of Epidural Analgesia, Continuous Surgical Site Analgesia, and Patient-Controlled Analgesic Morphine for Postoperative Pain Management and Hyperalgesia, Rehabilitation, and Health-Related Quality of Life After Open Nephrectomy: A Prospective, Randomized, Controlled Study

Perioperative Regional Anesthesia on Persistent Opioid Use and Chronic Pain after Noncardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Whether regional anesthesia impacts the development of chronic postsurgical pain is currently debateable, and few studies have evaluated an effect on prolonged opioid use. We sought to systematically review the effect of regional anesthesia for adults undergoing noncardiac elective surgery on these outcomes.

METHODS

A systematic search was conducted in MEDLINE, EMBASE, CENTRAL, and CINHAL for randomized controlled trials (from inception to April 2022) of adult patients undergoing elective noncardiac surgeries that evaluated any regional technique and included one of our primary outcomes: (1) prolonged opioid use after surgery (continued opioid use ≥2 months postsurgery) and (2) chronic postsurgical pain (pain ≥3 months postsurgery). We conducted a random-effects meta-analysis on the specified outcomes and used the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach to rate the quality of evidence.

RESULTS

Thirty-seven studies were included in the review. Pooled estimates indicated that regional anesthesia had a significant effect on reducing prolonged opioid use (relative risk [RR] 0.48, 95% CI, 0.24-0.96, P = .04, I 2 0%, 5 trials, n = 348 patients, GRADE low quality). Pooled estimates for chronic pain also indicated a significant effect favoring regional anesthesia at 3 (RR, 0.74, 95% CI, 0.59-0.93, P = .01, I 2 77%, 15 trials, n = 1489 patients, GRADE moderate quality) and 6 months (RR, 0.72, 95% CI, 0.61-0.85, P < .001, I 2 54%, 19 trials, n = 3457 patients, GRADE moderate quality) after surgery. No effect was found in the pooled analysis at 12 months postsurgery (RR, 0.44, 95% CI, 0.16-1.17, P = .10).

CONCLUSIONS

The results of this study suggest that regional anesthesia potentially reduces chronic postsurgical pain up to 6 months after surgery. Our findings also suggest a potential decrease in the development of persistent opioid use.

Comparison of dexmedetomidine and opioids as local anesthetic adjuvants in patient controlled epidural analgesia: a meta-analysis

BACKGROUND

Data on the efficacy and incidence of adverse effects associated with dexmedetomidine (DEX) as a local anesthetic adjuvant for patient-controlled epidural analgesia (PCEA) are inconclusive. This meta-analysis assessed the efficacy and risks of DEX for PCEA using opioids as a reference.

METHODS

Two researchers independently searched PubMed, Embase, Cochrane Library, and China Biology Medicine for randomized controlled trials comparing DEX and opioids as local anesthetic adjuvants in PCEA.

RESULTS

In total, 636 patients from seven studies were included in this meta-analysis. Postoperative patients who received DEX had lower visual analog scale (VAS) scores than those who received opioids at 4-8 h (mean difference [MD]: 0.61, 95% CI [0.45, 0.76], P < 0.001, I2 = 0%), 12 h (MD: 0.85, 95% CI [0.61, 1.09], P < 0.001, I2 = 0%), 24 h (MD: 0.59, 95% CI [0.06, 1.12], P = 0.030, I2 = 82%), and 48 h (MD: 0.54, 95% CI [0.05, 1.02], P = 0.030, I2 = 91%). Additionally, patients who received DEX had a lower incidence of itching (odds ratio [OR]: 2.86, 95% CI [1.18, 6.95], P = 0.020, I2 = 0%) and nausea and vomiting (OR: 6.83, 95% CI [3.63, 12.84], P < 0.001, I2 = 24%). In labor analgesia, no significant differences in neonatal (pH and PaO2 of cord blood, fetal heart rate) or maternal outcomes (duration of labor stage, mode of delivery) were found between the DEX and opioid groups.

CONCLUSIONS

Compared with opioids, using DEX as a local anesthetic adjuvant in PCEA improved postoperative analgesia and reduced the incidence of itching and nausea and vomiting without increasing the incidence of adverse events.

Assessment of Continuous Epidural Analgesia Versus Continuous Surgical Transverse Abdominis Plane Block for Postoperative Analgesia in Gynecological Surgeries

Background Surgical transverse abdominis plane (TAP) block has been studied in various surgeries. However, its role particularly in the form of continuous infusion in comparison to epidural infusion in open gynecological surgeries remains unknown. Hence, this study was taken up. Methodology Sixty patients were assigned to either of the two groups: continuous epidural (Group E) or continuous infusion in the surgical TAP (Group S). The primary outcomes were visual analog scale (VAS) pain scores and rescue analgesic requirements. Postoperative complications such as nausea/vomiting, hypotension, and bradycardia were also assessed. Results Mean pain scores were significantly lesser in Group E. However, 80% (24) of Group E and 50% (15) of Group S did not require rescue analgesia, which was not statistically significant. Adverse effects did not differ significantly between the two groups. Conclusions The efficacy of the continuous surgical TAP block is similar to a continuous epidural. Therefore, it can be considered in settings with limited resources and expertise or in cases of contraindications for an epidural.

Efficacy of epidural analgesia for intractable cancer pain: A systematic review

BACKGROUND

Epidural analgesia is a common technique for managing perioperative and obstetric pain. Patients with cancer who cannot tolerate opioids or not responding to conventional treatment may benefit from epidural analgesia. Therefore, this systematic review aimed to analyze the efficacy and safety of epidural analgesia in patients with intractable cancer pain.

METHODS

We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials to identify studies on patients with cancer who received epidural analgesia. We assessed the quality of all included studies using the risk-of-bias tool or Newcastle-Ottawa scale. The primary outcome was pain relief after epidural analgesia, and the secondary outcome was quality of life, analgesic consumption, and adverse events. The studies were grouped based on the medications used for epidural analgesia. A descriptive synthesis was performed following the Synthesis Without Meta-analysis reporting guideline.

RESULTS

Our systematic review included nine randomized controlled trials (n = 340) and 15 observational studies (n = 926). Two randomized controlled trials suggested that epidural opioids were not superior to systemic opioids in relieving pain. Epidural opioids combined with local anesthetics or adjuvants, including calcitonin, clonidine, ketamine, neostigmine, methadone, and dexamethasone, offered better analgesic effects. No significant difference in pain relief between an intermittent bolus and a continuous infusion of epidural morphine was observed. Epidural opioids had more analgesic effects on nociceptive pain than neuropathic pain. The methods used to evaluate the quality of life and the corresponding results were heterogeneous among studies. Six observational studies demonstrated that some patients could have decreased opioid consumption after epidural analgesia. Adverse events, including complications and drug-related side effects, were reported in 23 studies. Five serious complications, such as epidural abscess and hematoma, required surgical management. The heterogeneity and methodological limitations of the studies hindered meta-analysis and evidence-level determination.

CONCLUSION

Coadministration of epidural opioids, local anesthetics, and adjuvants may provide better pain relief for intractable cancer pain. However, we must assess the patients to ensure that the benefits outweigh the risks before epidural analgesia. Therefore, further high-quality studies are required.

Use of local wound infiltration in open hepatectomy to reduce wound pain: A systematic review and meta-analysis

The aim of this study was to assess the effects of local wound infiltration anaesthesia on postoperative wound pain in patients undergoing open liver resection. The Cochrane Library, PubMed, EMBASE, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM) and Wanfang databases were searched. The search period spanned from database creation to December 2022. All relevant studies on local wound infiltration anaesthesia for analgesia after hepatectomy were included. Two investigators independently screened the literature, extracted data and evaluated the quality of each study. Review Manager (RevMan) 5.4 software (Cochrane Collaboration) was used for the meta-analysis, in which 12 studies with 986 patients were included. The results show that local wound infiltration anaesthesia effectively reduced surgical site wound pain at 4 h (mean difference [MD]: -1.26, 95% confidence intervals [CIs]: -2.15 to -0.37, P = .005), 12 h (MD: -0.84, 95% CIs: -1.26 to -0.42, P < .001), 24 h (MD: -0.57, 95% CIs: -1.01 to -0.14, P = .009) and 48 h (MD: -0.54, 95% CIs: -0.81 to -0.26, P < .001) postoperatively; however, there was no significant difference in analgesia at 72 h postoperatively (MD: -0.10, 95% CIs: -0.80 to 0.59, P = .77). These findings suggest that local wound infiltration anaesthesia administered to patients undergoing open liver resection provides good postoperative wound analgesia at the surgical site.

Therapeutic efficacy of intravenous lidocaine infusion compared with thoracic epidural analgesia in major abdominal surgery: a noninferiority randomised clinical trial

BACKGROUND

Open major abdominal surgery is one of the most risky surgical procedures for acute postoperative pain. Thoracic epidural analgesia (TEA) has been considered the standard analgesic approach. In different reports, lidocaine i.v. has been shown to have an analgesic efficacy comparable with TEA. We compared the analgesic efficacy of i.v. lidocaine with thoracic epidural analgesia using bupivacaine in patients undergoing major abdominal surgery.

METHODS

In this noninferiority clinical trial, 210 patients were randomised to thoracic epidural bupivacaine with morphine or i.v. lidocaine. Dynamic pain at 24 h after surgery was measured using a numerical pain rating scale (NPR), and morphine consumption was also measured. A difference in i.v. the lidocaine-epidural bupivacaine NPR of ≤1 for dynamic pain was considered a noninferiority margin.

RESULTS

The NPR for dynamic pain in the lidocaine group at 24 h was between 5.7 (1.8) and 5.2 (1.9) in the epidural group, with a difference of 0.53 (95% confidence interval 0.0-1.0). In the first 24 h, the average difference in morphine consumption was 1.8 mg between the i.v. lidocaine and epidural groups (95% confidence interval 1-3 mg). No differences were found in adverse events or complications associated with the procedures.

CONCLUSIONS

Intravenous lidocaine is noninferior to thoracic epidural analgesia for acute postoperative pain control in major abdomial surgery at 24 h postoperatively.

CLINICAL TRIALS REGISTRATION

NCT04017013.

Comment on Crettenand et al. Is Continuous Wound Infiltration a Better Option for Postoperative Pain Management after Open Nephrectomy Compared to Thoracic Epidural Analgesia? J. Clin. Med. 2023, 12, 2974

We have read with great interest the retrospective study recently published by Crettenand et al. in this journal [...].

Patient Controlled Analgesia and its effect on postoperative outcomes in an older cohort of patients undergoing orthopaedic procedures: A retrospective observational study

BACKGROUND

Patient Controlled Analgesia is a popular technique used to manage postoperative pain. The suitability of Patient Controlled Analgesia in older patients after surgical procedures and its effect on postoperative outcomes are not clear.

METHOD

The records of 305 older patients undergoing orthopaedic surgeries in a single tertiary centre were reviewed. Postoperative outcomes were compared between those given Patient Controlled Analgesia and those who were not, using multinomial logistic regression adjusted by propensity scores.

RESULTS

Physical function on day 3 after surgery is worse, and risk of requiring personal assistance is higher if the patient had Patient Controlled Analgesia (p = 0.01). Length of stay in patients using patient-controlled analgesia was longer than patients not using patient-controlled analgesia (p = 0.002), and patients given Patient Controlled Analgesia had higher odds of needing support on discharge (p = 0.01). Surprisingly, pain control is poor in the Patient Controlled Analgesia group (p = 0.009).

CONCLUSION

In this review, Patient Controlled Analgesia use was common (40% of our sample), and postoperative outcomes such as physical function on day 3, length of stay and discharge destination were unfavourable in patients who had Patient Controlled Analgesia.

Study of the effect of pain on postoperative rehabilitation of patients with uterine malignant tumor

Objective

The relationship between acute postoperative pain (APSP) and health-related quality of life (HRQoL) in patients with uterine malignant tumor after operation was evaluated with self-rating scales, and the influencing factors of postoperative rehabilitation were screened.

Methods

A total of 102 patients undergoing elective surgery for Gynecology in the First Affiliated Hospital of Guangxi Medical University were included in this study. PCS, SAS, NRS and EQ-5D scales were evaluated 1 day before surgery, and NRS and EQ-5D scales were evaluated 1,3,7,14, and 30 days after surgery. In addition, the general and perioperative information of patients was collected from the medical record system of the hospital.

Results

From the 1st to the 30th day after operation, the NRS and EQ-5D-5L scores of patients decreased gradually, and EQ-VAS scores increased gradually. NRS score was correlated with EQ-5D score (P < 0.01). Postoperative hospital stay, Education level, PCS score and NRS score (Overall state and Active state) were the principal influencing factors of EQ-5D score (P < 0.05). Patients in the pain group had a later time to get out of bed and eat, a higher incidence of postoperative complications, and a longer postoperative hospital stay (P < 0.05). Endoscopic surgery can reduce postoperative pain and promote postoperative rehabilitation (χ ²= 37.631, P < 0.001).

Conclusions

The postoperative rehabilitation of patients in the pain group was poor. Minimally invasive surgery can reduce postoperative pain and promote postoperative rehabilitation. EQ-5D score can be used as a subjective index to evaluate postoperative rehabilitation.

Trial Registration

Chinese Clinical Trial Registry (identifier: ChiCTR2000032759).

Postoperative analgesia efficacy of erector spinae plane block in adult abdominal surgery: A systematic review and meta-analysis of randomized trials

Objectives

Erector spinae plane block (ESPB) has been used for many thoracic and abdominal surgeries. However, evidence of its analgesic efficacy following abdominal surgery, compared with that of thoracic analgesia, is insufficient. Our study explored the analgesic effect of ESPB after abdominal surgery.

Methods

We searched PubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. Primary outcomes were pain scores at 6, 12 and 24 h and 24-h opioid consumption. Secondary outcomes included time to first rescue analgesia, length of hospital stay, and incidence of postoperative nausea and vomiting (PONV). We calculated standardized mean differences (SMDs) with 95% confidence intervals (CIs) for primary outcomes and mean differences (MDs) and risk ratios (RRs) with 95% CIs for secondary outcomes.

Results

We systematically included 1,502 cases in 24 trials. Compared with placebo, ESPB significantly reduced pain scores at 6 h (SMD -1.25; 95% CI -1.79 to -0.71), 12 h (SMD -0.85; 95% CI -1.33 to -0.37) and 24 h (SMD -0.84; 95% CI -1.30 to -0.37) and 24-h opioid consumption (SMD -0.62; 95% CI -1.19 to -0.06) post-surgery. ESPB prolonged the time to first rescue analgesia and decreased the incidence of PONV. Compared with transversus abdominal plane block (TAPB), ESPB significantly reduced pain scores at 6, 12, and 24 h and 24-h opioid consumption and prolonged the time to first rescue analgesia postsurgically. Furthermore, subgroup analysis showed that ESPB significantly reduced pain scores at various time points and opioid consumption within 24 h after laparoscopic cholecystectomy, percutaneous nephrolithotomy and bariatric surgery.

Conclusion

Compared with placebo, ESPB improves the postoperative analgesic efficacy after abdominal surgery. Furthermore, our meta-analysis confirmed that ESPB provides more beneficial analgesic efficacy than TAPB.

Systematic review registration

[https://www.crd.york.ac.uk/PROSPEROFILES/301491_STRATEGY_20220104.pdf], identifier [CRD42022301491].

Anaesthetic Approach to Enhanced Recovery after Surgery for Kidney Transplantation: A Narrative Review

Enhanced recovery after surgery (ERAS) protocols are designed to reduce medical complications, the length of hospital stays (LoS), and healthcare costs. ERAS is considered safe and effective for kidney transplant (KTx) surgery. KTx recipients are often frail with multiple comorbidities. As these patients follow an extensive diagnostic pathway preoperatively, the ERAS protocol can ideally be implemented at this stage. Small singular changes in a long perioperative pathway can result in significant positive outcomes. We have investigated the current evidence for an ERAS pathway related to anaesthetic considerations in renal transplant surgery for adult recipients.

Effect of ultrasound-guided erector spinae plane block on post-surgical pain in patients undergoing nephrectomy: a single-center, randomized, double-blind, controlled trial

OBJECTIVE

Erector spinae plane (ESP) block is an alternative to neuraxial block for post-surgical pain in nephrectomy patients. However, no clinical trial has directly compared ESP block with a control group.

METHODS

In a single-center, double-blind randomized comparative trial, patients undergoing nephrectomy with a subcostal flank incision under general anesthesia were divided into the following two groups: ESP block group (ESP block before anesthesia) and non-ESP (control) group (no intervention). The primary outcome measure was pain score (Numeric Rating Scale [NRS] 0 to 10). Secondary outcomes were postoperative opiate use, anesthetic and surgical complications, length of hospital stay, and patient-reported outcomes.

RESULTS

Postoperatively (0 to 24 hours), the ESP block group experienced less pain and had lower NRS pain scores 0 to 24 hours postoperatively than the non-ESP group. Opioid consumption and the number of rescue analgesic doses decreased significantly in the ESP group compared with the non-ESP group. Patient-Reported Outcomes Information System (Quality of Recovery-15) scores significantly improved in the ESP group compared with the non-ESP block group.

CONCLUSIONS

Patients receiving an ESP block for intraoperative and postoperative analgesia during radical nephrectomies experienced less postoperative pain 0 to 24 hours compared with the non-ESP group.

Effectiveness of the Tailored, Early Comprehensive Rehabilitation Program (t-ECRP) based on ERAS in improving the physical function recovery for patients following minimally invasive esophagectomy: a prospective randomized controlled trial

BACKGROUND

Perioperative rehabilitation management is essential to enhanced recovery after surgery (ERAS). Limited reports, however, have focused on quantitative, detailed early activity plans for patients receiving minimally invasive esophagectomy (MIE). The purpose of this research was to estimate the effectiveness of the Tailored, Early Comprehensive Rehabilitation Program (t-ECRP) based on ERAS in the recovery of bowel and physical functions for patients undergoing MIE.

METHODS

In this single-blind, 2-arm, parallel-group, randomized pilot clinical trial, patients admitted to the Affiliated Cancer Hospital of Zhengzhou University from June 2019 to February 2020 were selected and randomly assigned to an intervention group (IG) or a control group (CG). The participants in the IG received medical care based on the t-ECRP strategy during perioperative period, and participants in the CG received routine care. The recovery of bowel and physical functions, readiness for hospital discharge (RHD), and postoperative hospital stay were evaluated on the day of discharge.

RESULTS

Two hundred and fifteen cases with esophageal cancer (EC) were enrolled and randomized to the IG (n = 107) or CG (n = 108). The mean age was 62.58 years (SD 9.07) and 71.16% were male. For EC, 53.49% were mid-location cancers and 79.07% were classified as pathological stage II and III cancers. There were no significant differences between the two groups in terms of demographic and clinical characteristics and baseline physical functions. Participants in the IG group presented significantly shorter lengths of time to first flatus (P < 0.001), first postoperative bowel movement (P = 0.024), and for up and go test (P < 0.001), and lower scores of frailty (P < 0.001). The analysis also showed that participants in the IG had higher scores of RHD and shorter lengths of postoperative stay than in the CG (P < 0.05).

CONCLUSIONS

The t-ECRP appears to improve bowel and physical function recovery, ameliorate RHD, and shorten postoperative hospital stay for patients undergoing MIE. Clinicians should consider prescribing quantitative, detailed, and individualized early activity plans for these patients.

TRIAL REGISTRATION

ClinicalTrials.gov (Identifier: NCT01998230).

Predictors of Chronic Postsurgical Pain in Elderly Patients Undergoing Hip Arthroplasty: A Multi-Center Retrospective Cohort Study

Background

Identifying patients at high risk of developing chronic postsurgical pain (CPSP) is of extreme importance in order to help launch appropriate therapeutic strategies and intensive initiation of pain management.

Aim

In this study, we aimed to conduct a multi-center retrospective cohort study to establish a prognostic model and a nomogram to predict the risks of CPSP in elderly patients who underwent hip arthroplasty at 6 months postoperatively.

Methods

We collected data from 736 patients aged >65 years who had undergone hip arthroplasty from October 1, 2016 to September, 30, 2018 at multiple tertiary referral centers in Guangzhou, China. All data were randomly stratified into a training set and a testing set at a ratio of 8:2. Data were analyzed via multiple logistic regression analysis with receiver operating characteristic (ROC) curves and areas under the curve. This model was further validated by estimating calibration and discrimination. A nomogram was ultimately developed.

Results

A total of 736 eligible patients were enrolled, 27.20% of whom developed CPSP within 6 months postoperatively. Preoperative pain in the surgical area (OR=2.456, 95% CI:1.814–3.327, P<0.001), preoperative depression state (OR=1.256, 95% CI:1.146–1.378, P<0.001), surgical type (OR=7.138, 95% CI:3.548–14.364, P<0.001), acute postoperative numerical rating scale score (OR=5.537, 95% CI:3.607–8.499, P<0.001) and analgesic type (patient-controlled epidural analgesia: OR=0.129, 95% CI:0.055–0.299, P<0.001; patient-controlled intravenous analgesia: OR=0.033, 95% CI:0.011–0.097, P<0.001) were identified as independent significant factors associated with CPSP. A prognostic model was established and further validated. An ROC curve confirmed the predictive ability of this model with a high sensitivity value of 92.12% (95% CI:86.90–95.74) and specificity value of 91.72% (95% CI:88.77–94.11). A nomogram was developed to simplify the use of the predictive model in clinical practice.

Conclusion

This prognostic model could be of great value in clinical practice, serving as the basis for early personalized analgesic management of elderly patients undergoing hip arthroplasty.

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The Role of Regional Anesthesia During the SARS-CoV2 Pandemic: Appraisal of Clinical, Pharmacological and Organizational Aspects

The severe acute respiratory syndrome coronavirus SARS-CoV2 is spreading over millions of people worldwide, leading to thousands of deaths, even among the healthcare providers. Italy has registered the deaths of 337 physicians and more than 200 nurses as of March 14, 2021. Anesthesiologists are at higher risk as they are the care providers in both ICU and operating rooms.Although the vaccination of healthcare providers has been the prioirity, physicians are still continually exposed to the virus and potentially risk contagion and must thus protect themselves and their patients from the risks of infection while providing the best care to their surgical patients.Regional anesthesia allows for a reduction in airway manipulation, reducing environmental contamination as a result. Furthermore, regional anesthesia reduces the opioid requirements as well as the muscle paralysis due to muscle-relaxants and should be recommended whenever possible in COVID-19 patients. Our aim is to evaluate the advantages and criticisms of regional anesthesia in the management of surgical patients in the pandemic age.

Mechanisms, diagnosis, prevention and management of perioperative opioid-induced hyperalgesia

Opioid-induced hyperalgesia (OIH) occurs when opioids paradoxically enhance the pain they are prescribed to ameliorate. To address a lack of perioperative awareness, we present an educational review of clinically relevant aspects of the disorder. Although the mechanisms of OIH are thought to primarily involve medullary descending pathways, it is likely multifactorial with several relevant therapeutic targets. We provide a suggested clinical definition and directions for clinical differentiation of OIH from other diagnoses, as this may be confusing but is germane to appropriate management. Finally, we discuss prevention including patient education and analgesic management choices. As prevention may serve as the best treatment, patient risk factors, opioid mitigation, and both pharmacologic and non-pharmacologic strategies are discussed.

The Effects of Add-On Self-Care Therapy on Epidural Catheter Analgesia and Pain in Patients after Surgical Stabilization of Multiple Rib Fractures

BACKGROUND

Epidural (EPI) catheter analgesia is frequently prescribed as a regional analgesic technique to patients with multiple rib fractures (MRF) following surgical stabilization of rib fractures (SSRF).

AIMS

We aimed to study the effect of add-on self-care therapy on recovery and quality of life (QoL) in patients on EPI analgesia after surgical stabilization of rib fractures (SSRF).

DESIGN/SETTINGS/PARTICIPANTS/SUBJECTS

A total of 267 eligible patients with MRF who received EPI catheter analgesia after SSRF were recruited, and assigned to one of two groups in a random fashion: intervention group received education on self-care therapy, while the control group did not.

METHODS

Pain scores, incentive spirometry (IS) volumes, oxygen saturation (SpO2), respiratory rate, hospital length of stay (LoS) and QoL were evaluated.

RESULTS

Compared with control group, the intervention group showed significantly improved pain scores, IS volume, respiratory rate, and SpO2. Hospital LoS was shorter for the intervention group than the control group. Overall QoL scores in the intervention group were also significantly better than control patients.

CONCLUSIONS

Education on self-care therapy significantly benefited pain management, recovery, and QoL for patients with MRF who received EPI catheter analgesia after SSRF operation.

Effectiveness of Intramuscular Electrical Stimulation on Postsurgical Nociceptive Pain for Patients Undergoing Open Pancreaticoduodenectomy: A Randomized Clinical Trial

BACKGROUND

After pylorus-preserving pancreaticoduodenectomy (PPPD), incision and suture of the abdominal muscles cause inflammatory changes and elicit somatic pain that deteriorates the quality of life. There have been no previous reports on needle electrical twitch obtaining intramuscular stimulation (NETOIMS) in abdominal open operation; this study aimed to apply NETOIMS for postoperative somatic pain in patients undergoing PPPD as a new treatment modality for pain control.

METHODS

Between June 2018 and January 2019, 44 patients who underwent PPPD were randomly assigned to a control group and the NETOIMS group. The NETOIMS group received NETOIMS in the transverse abdominis muscle under ultrasound guidance right after operation under general anesthesia. The pain score (visual analog scale), peak cough flow (PCF), and gait speed were repetitively measured from 1 day before operation to 2 weeks after discharge as scheduled. Data were analyzed by the linear mixed model and repeated-measures analysis of variance.

RESULTS

Of the 44 patients recruited, data from 38 patients were finally analyzed. The pain scores were significantly lower in the NETOIMS group after PPPD (p = 0.01). Although the PCF at each measuring time point did not show inter-group difference (p = 0.20), improvement of PCF from the second day after operation to discharge was greater (p = 0.02) and gait speed improved significantly faster (p < 0.01) in the NETOIMS group than in the control group.

CONCLUSIONS

NETOIMS helps in rapid reduction of postoperative somatic pain developed after PPPD and in improvement of PCF and gait speed.

Dynamic analysis of variations in postoperative pain trajectories over time in patients receiving epidural analgesia using latent curve models

BACKGROUND

Although epidural analgesia (EA) provides reliable pain relief after major operations, few studies have explored how postoperative pain trajectories change over time in patients receiving EA and the associated factors. This study aimed to model the dynamic features of pain trajectories after surgery and investigate factors associated with their variations using latent curve analysis.

METHODS

This retrospective study was conducted at a single medical center in Taiwan, and data were obtained from patients receiving perioperative EA by electronic chart review. Mean numeric rating pain scores were recorded daily in the first five postoperative days. Patient demographics, surgical sites, and infusion pump settings were also collected. Latent curve models using two latent variables, intercept and slope, were developed to explain the variations in postoperative pain scores over time. The influences of potential predictors of postoperative pain trajectories were further evaluated for the final model determination.

RESULTS

Of the 1294 collected patients, the daily pain scores averaged 2.0 to 2.9 for different surgical sites. Among the nine significant factors influencing pain trajectories, chest and lower extremity surgery tended to induce less and more baseline pain, respectively, than those with abdomen surgery (both p < 0.001). In addition, male patients and those with a shorter anesthesia time had less baseline pain (p < 0.001 and p = 0.016, respectively). The older and lighter patients and those with chest surgery or American Society of Anesthesiologists class ≥ 3 tended to have milder decreasing trends in pain trajectories. A higher infusion rate was associated with an elevated baseline level and smoother decreasing trend in pain trajectory. The final model fit our data acceptably (root mean square error of approximation = 0.05, comparative fit index = 0.97).

CONCLUSION

Latent curve analysis provided insights into the dynamic nature of variations in postoperative pain trajectories. Further studies investigating more factors associated with pain trajectories are warranted to elucidate the mechanisms behind the transitions of pain scores over time after surgery.

A randomized controlled trial on analgesic effect of repeated Quadratus Lumborum block versus continuous epidural analgesia following laparoscopic nephrectomy

BACKGROUND

Epidural analgesia as the effective pain management for abdominal surgery has side effects such as paresthesia, hypotension, hematomas, and impaired motoric of lower limbs. The quadratus lumborum block (QLB) has potential as an abdominal truncal block, however, its analgesic efficacy has never been compared to epidural analgesia on laparoscopic nephrectomy. This prospective randomized controlled study compared the effectiveness of QLB with the epidural analgesia technique in relieving postoperative pain following transperitoneal laparoscopic nephrectomy.

METHODS

Sixty-two patients underwent laparoscopic donor nephrectomy and were randomized to receive QLB (n = 31) or continuous epidural (n = 31). The QLB group received bilateral QLB using 0.25% bupivacaine and the epidural group received 6 ml/h of 0.25% bupivacaine for intraoperative analgesia. As postoperative analgesia, the QLB group received repeated bilateral QLB with the same dose and the epidural group received 6 ml/h of 0.125% bupivacaine for 24 h after surgery completion. The primary outcome was the 24-h cumulative morphine requirement after surgery. The secondary outcome was the postoperative pain scores. Sensory block coverage, hemodynamic changes, Bromage score, postoperative nausea-vomiting (PONV), paresthesia, and duration of urinary catheter usage were recorded and analyzed.

RESULT

The 24-h cumulative morphine requirement and pain scores after surgery were comparable between the QLB and epidural groups. The coverage of QLB was extended from T9 to L2 and the continuous epidural block was extended from T8 to L3 dermatomes. The mean arterial pressure (MAP) measured at 24 h after surgery was lower in the epidural group (p = 0.001). Bromage score, incidence of PONV, and paresthesia were not significantly different between the two groups. Duration of urinary catheter usage was shorter (p < 0.001) in the QLB group.

CONCLUSION

The repeated QLB had a similar 24-h cumulative morphine requirement, comparable postoperative pain scores and sensory blockade, higher postoperative MAP, a similar degree of motoric block, no difference in the incidence of PONV and paresthesia, and shorter urinary catheter usage, compared to the continuous epidural analgesia following transperitoneal laparoscopic nephrectomy.

TRIAL REGISTRATION

ClinicalTrial.gov NCT03520205 retrospectively registered on May 9th 2018.

Improved Outcomes of Enhanced Recovery After Surgery (ERAS) Protocol for Radical Cystectomy with Addition of a Multidisciplinary Care Process in a US Comprehensive Cancer Care Center

INTRODUCTION

Although enhanced recovery after surgery (ERAS) components include both anesthesia and surgical care processes, it is unclear whether a multidisciplinary approach to implementing ERAS care processes improves clinical outcomes. The addition of multidisciplinary care with anesthesiology-related components to an existing ERAS protocol for radical cystectomy at a US comprehensive cancer center provided an opportunity to compare short- and long-term outcomes.

METHODS

We retrospectively compared the outcomes of 116 consecutive patients who underwent cystectomy after implementation of a multidisciplinary ERAS protocol with those of a historical control group of 143 consecutive patients who had been treated with a surgical ERAS protocol. Length of stay, return of bowel function, rate of blood transfusion, nausea, pain, and readmission rates were examined.

RESULTS

Implementation of a multidisciplinary ERAS protocol was associated with better postsurgical symptom control, as indicated by lower rates of patient-reported nausea (P < .05). Multivariate Poisson regression analysis showed a decrease in estimated intraoperative transfusions (P ≤ .001) after adjusting for the effects of potential confounding variables. There were no statistically significant differences noted in length of stay, return of bowel function, 30- and 90-day complications, or readmissions.

CONCLUSION

This is the first study to investigate the effects of adding anesthesia ERAS components to an existing surgical ERAS protocol for radical cystectomy. We found that with the addition of anesthesia-related interventions, there was a decrease in transfusions and nausea.

Chronified Pain Following Operative Procedures

BACKGROUND

Over 18 million operative procedures are performed each year in Germany alone. Approximately 10% of surgical patients develop moderate to severe chronic post-surgical pain (CPSP), which can severely impair their quality of life. The pain must persist for at least three months to be called chronic; pain that arises after a symptom-free interval is not excluded. The perioperative use of local anesthetic agents may lessen the incidence of CPSP.

METHODS

We selectively reviewed the pertinent literature, including two current Cochrane Reviews. Local and regional anesthetic techniques are discussed, as is the intravenous administration of lidocaine.

RESULTS

The main risk factors for CPSP are pre-existing (preoperative) chronic pain, opioid intake, a pain-related catastrophizing tendency, intraoperative nerve injury, and severe acute postoperative pain. CPSP is reported to be especially common after thoracic surgery, breast surgery, amputations, and orthopedic procedures. Local and regional anesthetic techniques have been shown to significantly lower the incidence of CPSP after thoracotomy (number needed to treat for an additional beneficial outcome [NNTB] = 7), breast cancer surgery (NNTB = 7), and cesarean section (NNTB = 19). Intravenous lidocaine also lowers the incidence of CPSP after various types of procedures.

CONCLUSION

Local and regional anesthetic techniques and intravenous lidocaine lower the incidence of CPSP after certain types of operative procedures. The intravenous administration of lidocaine to prevent CPSP is off label and requires the patient's informed consent. The evidence for the measures presented here is of low to medium quality.

Prevention and Treatment of Chronic Postsurgical Pain: A Narrative Review

Chronic postsurgical pain affects between 5 and 75% of patients, often with an adverse impact on quality of life. While the transition of acute to chronic pain is a complex process-involving multiple mechanisms at different levels-the current strategies for prevention have primarily been restricted to perioperative pharmacological interventions. In the present paper, we first present an up-to-date narrative literature review of these interventions. In the second section, we develop several ways by which we could overcome the limitations of the current approaches and enhance the outcome of our surgical patients, including the better identification of individual risk factors, tailoring treatment to individual patients, and improved acute and subacute pain evaluation and management. The third and final section covers the treatment of established CPSP. Given that evidence for the current therapeutic options is limited, we need high-quality trials studying multimodal interventions matched to pain characteristics.

Regional analgesia techniques for pain management in patients admitted to the intensive care unit

Controlling pain should be a priority in the clinical practice of intensive care units (ICUs). Monomodal analgesic approaches, such as the administration of opioids, are widely employed; however, the widespread use of opioids has catastrophic consequences, given their multiple side effects and the development of dependence. Regional analgesia (RA), with single or continuous dosing using neuraxial and peripheral catheters, can play an important role in multimodal analgesia for management of pain in critical care patients. RA provides superior pain control, as compared to systemic treatments, and is associated with a lower rate of side effects. Nevertheless, RA remains underused in ICUs. Many critically ill, post-surgical or traumatically injured patients would benefit from these techniques. For these reasons, we aim to establish a set of potential indications integrating the use of RA in analgesia protocols routinely used in ICUs. We performed a review of literature sources with contrasted evidence levels to present RA techniques and their potential applications in ICU patients.

Persistent Postsurgical Pain

The development of chronic pain is considered a major complication after surgery. Basic science research in animal models helps us understand the transition from acute to chronic pain by identifying the numerous molecular and cellular changes that occur in the peripheral and central nervous systems. It is now well recognized that inflammation and nerve injury lead to long-term synaptic plasticity that amplifies and also maintains pain signaling, a phenomenon referred to as pain sensitization. In the context of surgery in humans, pain sensitization is both responsible for an increase in postoperative pain via the expression of wound hyperalgesia and considered a critical factor for the development of persistent postsurgical pain. Using specific drugs that block the processes of pain sensitization reduces postoperative pain and prevents the development of persistent postoperative pain. This narrative review of the literature describes clinical investigations evaluating different preventative pharmacologic strategies that are routinely used by anesthesiologists in their daily clinical practices for preventing persistent postoperative pain. Nevertheless, further efforts are needed in both basic and clinical science research to identify preclinical models and novel therapeutics targets. There remains a need for more patient numbers in clinical research, for more reliable data, and for the development of the safest and the most effective strategies to limit the incidence of persistent postoperative pain.

Comparison of patient-controlled epidural analgesia with patient-controlled intravenous analgesia for laparoscopic radical prostatectomy

Background

Patient-controlled epidural analgesia (PCEA) is known to provide good postoperative analgesia in many types of surgery including laparoscopic surgery. However, no study has compared PCEA with patient-controlled intravascular analgesia (PCIA) in laparoscopic radical prostatectomy (LARP). In this study, the efficacy and side effects of PCEA and PCIA after LARP were compared.

Methods

Forty patients undergoing LARP were randomly divided into two groups: 1) a PCEA group, treated with 0.2% ropivacaine 3 ml and 0.1 mg morphine in the bolus; and 2) a PCIA group, treated with oxycodone 1 mg and nefopam 1 mg in the bolus. After the operation, a blinded observer assessed estimated blood loss (EBL), added a dose of rocuronium, performed transfusion, and added analgesics. The numeric rating scale (NRS), infused PCA dose, and side effects were assessed at 1, 6, 24, and 48 h.

Results

EBL, added rocuronium, and added analgesics in the PCEA group were less than those in the PCIA group. There were no significant differences in side-effects after the operation between the two groups. Patients were more satisfied with PCEA than with PCIA. The NRS and accumulated PCA count were lower in PCEA group.

Conclusions

Combined thoracic epidural anesthesia could induce less blood loss during operations. PCEA showed better postoperative analgesia and greater patient satisfaction than PCIA. Thus, PCEA may be a more useful analgesic method than PICA after LARP.

Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children

BACKGROUND

Regional anaesthesia may reduce the rate of persistent postoperative pain (PPP), a frequent and debilitating condition. This review was originally published in 2012 and updated in 2017.

OBJECTIVES

To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of PPP beyond three months in adults and children undergoing elective surgery.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase to December 2016 without any language restriction. We used a combination of free text search and controlled vocabulary search. We limited results to randomized controlled trials (RCTs). We updated this search in December 2017, but these results have not yet been incorporated in the review. We conducted a handsearch in reference lists of included studies, review articles and conference abstracts. We searched the PROSPERO systematic review registry for related systematic reviews.

SELECTION CRITERIA

We included RCTs comparing local or regional anaesthesia versus conventional analgesia with a pain outcome beyond three months after elective, non-orthopaedic surgery.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trial quality and extracted data and adverse events. We contacted study authors for additional information. We presented outcomes as pooled odds ratios (OR) with 95% confidence intervals (95% CI), based on random-effects models (inverse variance method). We analysed studies separately by surgical intervention, but pooled outcomes reported at different follow-up intervals. We compared our results to Bayesian and classical (frequentist) models. We investigated heterogeneity. We assessed the quality of evidence with GRADE.

MAIN RESULTS

In this updated review, we identified 40 new RCTs and seven ongoing studies. In total, we included 63 RCTs in the review, but we were only able to synthesize data on regional anaesthesia for the prevention of PPP beyond three months after surgery from 39 studies, enrolling a total of 3027 participants in our inclusive analysis.Evidence synthesis of seven RCTs favoured epidural anaesthesia for thoracotomy, suggesting the odds of having PPP three to 18 months following an epidural for thoracotomy were 0.52 compared to not having an epidural (OR 0.52 (95% CI 0.32 to 0.84, 499 participants, moderate-quality evidence). Simlarly, evidence synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low-quality evidence). Pooling data at three to 8 months after surgery from four RCTs favoured regional anaesthesia after caesarean section with an OR of 0.46, (95% CI 0.28 to 0.78; 551 participants, moderate-quality evidence). Evidence synthesis of three RCTs investigating continuous infusion with local anaesthetic for the prevention of PPP three to 55 months after iliac crest bone graft harvesting (ICBG) was inconclusive (OR 0.20, 95% CI 0.04 to 1.09; 123 participants, low-quality evidence). However, evidence synthesis of two RCTs also favoured the infusion of intravenous local anaesthetics for the prevention of PPP three to six months after breast cancer surgery with an OR of 0.24 (95% CI 0.08 to 0.69, 97 participants, moderate-quality evidence).We did not synthesize evidence for the surgical subgroups of limb amputation, hernia repair, cardiac surgery and laparotomy. We could not pool evidence for adverse effects because the included studies did not examine them systematically, and reported them sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered evidence synthesis. High risk of bias from missing data and lack of blinding across a number of included studies reduced our confidence in the findings. Thus results must be interpreted with caution.

AUTHORS' CONCLUSIONS

We conclude that there is moderate-quality evidence that regional anaesthesia may reduce the risk of developing PPP after three to 18 months after thoracotomy and three to 12 months after caesarean section. There is low-quality evidence that regional anaesthesia may reduce the risk of developing PPP three to 12 months after breast cancer surgery. There is moderate evidence that intravenous infusion of local anaesthetics may reduce the risk of developing PPP three to six months after breast cancer surgery.Our conclusions are considerably weakened by the small size and number of studies, by performance bias, null bias, attrition and missing data. Larger, high-quality studies, including children, are needed. We caution that except for breast surgery, our evidence synthesis is based on only a few small studies. On a cautionary note, we cannot extend our conclusions to other surgical interventions or regional anaesthesia techniques, for example we cannot conclude that paravertebral block reduces the risk of PPP after thoracotomy. There are seven ongoing studies and 12 studies awaiting classification that may change the conclusions of the current review once they are published and incorporated.

Psychological factors as predictors of early postoperative pain after open nephrectomy

Purpose

There is an increasing interest in the identification of predictors for individual responses to analgesics and surgical pain. In this study, we aimed to determine psychological factors that might contribute to this response. We hence investigated patients undergoing a standardized surgical intervention (open nephrectomy).

Patients and methods

Between May 2014 and April 2015, we conducted a prospective observational cohort study. The following psychological tests were administered preoperatively: Mini-Mental State Examination, Amsterdam Preoperative Anxiety and Information Scale (APAIS), Hamilton Anxiety Rating Scale, Hamilton Depression Rating Scale, and Pain Catastrophizing Scale. The primary outcome, postoperative pain intensity (11-point numerical rating scale, [NRS]), was assessed in the “immediate early” (first 8 hours), “early” (12 and 24 hours), and “late early” periods (48 and 72 hours).

Results

A total of 196 patients were assessed, and 150 were finally included in the study. NRS scores improved from 4.9 (95% confidence interval [CI]: 4.7–5.1) in the “immediate early” to 3.1 (95% CI: 2.9–3.3) in the “early” and 2.3 (95% CI: 2.1–2.5) in the “late early” postoperative period. Most (87%) patients received intravenous opioids, while 13% received analgesics epidurally. Repeated measures analysis of variance indicated better pain management with epidural analgesia in the first two postoperative periods (F=15.01, p<0.00). Postoperative pain correlated strongly with analgesic strategy and preoperative psychological assessment. Multiple linear regression analysis showed “expected pain” was the only predictor in the “immediate early” phase, and “anxiety” was most important in the “early” postoperative period. In the “late early” phase, catastrophizing was the predominant predictor, alongside “preoperative analgesic usage” and “APAIS anxiety”.

Conclusion

After open nephrectomy, epidural analgesia conveys a clear advantage for pain management only within the first 24 hours. Moreover, as the psychological phenotype of patients changes distinctively in the first 72 postoperative hours, psychological variables increasingly determine pain intensity, even surpassing employed analgesic strategy as its main predictor.

Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children

BACKGROUND

Regional anaesthesia may reduce the rate of persistent postoperative pain (PPP), a frequent and debilitating condition. This review was originally published in 2012 and updated in 2017.

OBJECTIVES

To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of PPP beyond three months in adults and children undergoing elective surgery.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase to December 2016 without any language restriction. We used a combination of free text search and controlled vocabulary search. We limited results to randomized controlled trials (RCTs). We updated this search in December 2017, but these results have not yet been incorporated in the review. We conducted a handsearch in reference lists of included studies, review articles and conference abstracts. We searched the PROSPERO systematic review registry for related systematic reviews.

SELECTION CRITERIA

We included RCTs comparing local or regional anaesthesia versus conventional analgesia with a pain outcome beyond three months after elective, non-orthopaedic surgery.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trial quality and extracted data and adverse events. We contacted study authors for additional information. We presented outcomes as pooled odds ratios (OR) with 95% confidence intervals (95% CI), based on random-effects models (inverse variance method). We analysed studies separately by surgical intervention, but pooled outcomes reported at different follow-up intervals. We compared our results to Bayesian and classical (frequentist) models. We investigated heterogeneity. We assessed the quality of evidence with GRADE.

MAIN RESULTS

In this updated review, we identified 40 new RCTs and seven ongoing studies. In total, we included 63 RCTs in the review, but we were only able to synthesize data on regional anaesthesia for the prevention of PPP beyond three months after surgery from 41 studies, enrolling a total of 3143 participants in our inclusive analysis.Evidence synthesis of seven RCTs favoured epidural anaesthesia for thoracotomy, suggesting the odds of having PPP three to 18 months following an epidural for thoracotomy were 0.52 compared to not having an epidural (OR 0.52 (95% CI 0.32 to 0.84, 499 participants, moderate-quality evidence). Simlarly, evidence synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low-quality evidence). Pooling data at three to 8 months after surgery from four RCTs favoured regional anaesthesia after caesarean section with an OR of 0.46, (95% CI 0.28 to 0.78; 551 participants, moderate-quality evidence). Evidence synthesis of three RCTs investigating continuous infusion with local anaesthetic for the prevention of PPP three to 55 months after iliac crest bone graft harvesting (ICBG) was inconclusive (OR 0.20, 95% CI 0.04 to 1.09; 123 participants, low-quality evidence). However, evidence synthesis of two RCTs also favoured the infusion of intravenous local anaesthetics for the prevention of PPP three to six months after breast cancer surgery with an OR of 0.24 (95% CI 0.08 to 0.69, 97 participants, moderate-quality evidence).We did not synthesize evidence for the surgical subgroups of limb amputation, hernia repair, cardiac surgery and laparotomy. We could not pool evidence for adverse effects because the included studies did not examine them systematically, and reported them sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered evidence synthesis. High risk of bias from missing data and lack of blinding across a number of included studies reduced our confidence in the findings. Thus results must be interpreted with caution.

AUTHORS' CONCLUSIONS

We conclude that there is moderate-quality evidence that regional anaesthesia may reduce the risk of developing PPP after three to 18 months after thoracotomy and three to 12 months after caesarean section. There is low-quality evidence that regional anaesthesia may reduce the risk of developing PPP three to 12 months after breast cancer surgery. There is moderate evidence that intravenous infusion of local anaesthetics may reduce the risk of developing PPP three to six months after breast cancer surgery.Our conclusions are considerably weakened by the small size and number of studies, by performance bias, null bias, attrition and missing data. Larger, high-quality studies, including children, are needed. We caution that except for breast surgery, our evidence synthesis is based on only a few small studies. On a cautionary note, we cannot extend our conclusions to other surgical interventions or regional anaesthesia techniques, for example we cannot conclude that paravertebral block reduces the risk of PPP after thoracotomy. There are seven ongoing studies and 12 studies awaiting classification that may change the conclusions of the current review once they are published and incorporated.

Magic Mirror, on the Wall-Which Is the Right Study Design of Them All?-Part I

The assessment of a new or existing treatment or intervention typically answers 1 of 3 research-related questions: (1) "Can it work?" (efficacy); (2) "Does it work?" (effectiveness); and (3) "Is it worth it?" (efficiency or cost-effectiveness). There are a number of study designs that on a situational basis are appropriate to apply in conducting research. These study designs are classified as experimental, quasi-experimental, or observational, with observational studies being further divided into descriptive and analytic categories. This first of a 2-part statistical tutorial reviews these 3 salient research questions and describes a subset of the most common types of experimental and quasi-experimental study design. Attention is focused on the strengths and weaknesses of each study design to assist in choosing which is appropriate for a given study objective and hypothesis as well as the particular study setting and available resources and data. Specific studies and papers are highlighted as examples of a well-chosen, clearly stated, and properly executed study design type.

Chronic postoperative pain: recent findings in understanding and management

Chronic postoperative pain is a poorly recognized potential outcome from surgery. It affects millions of patients every year, with pain lasting for months to years, resulting in patient suffering and ensuing economic consequences. The operations with the highest incidence of chronic postoperative pain are amputations, thoracotomies, cardiac surgery, and breast surgery. Other risk factors include preoperative pain, psychological factors, demographics, and the intensity of acute postoperative pain. Attempts to prevent chronic postoperative pain have often led to debatable results. This article presents data from recently published studies examining the incidence, risk factors, mechanisms, treatment options, and preventive strategies for chronic postoperative pain in adults. In summary, many of the previously identified risk factors for chronic postoperative pain have been confirmed and some novel ones discovered, such as the importance of the trajectory of acute pain and the fact that catastrophizing may not always be predictive. The incidence of chronic postoperative pain hasn’t changed over time, and there is limited new information regarding an effective preventive therapy. For example, pregabalin may actually cause more harm in certain surgeries. Further research is needed to demonstrate whether multimodal analgesic techniques have the best chance of significantly reducing the incidence of chronic postoperative pain and to determine which combination of agents is best for given surgical types and different patient populations.