Thirty-five Years of Acute Pain Services: Where Do We Go From Here?

Management of acute postoperative pain: Conditions to guarantee the safety and effectiveness of analgesic treatments

The evidence on postoperative pain management is of low or insufficient quality. The SEDAR Acute Pain Working Group has prepared this guideline-document to apply the best available scientific evidence to clinical practice, individualizing it based on factors specific to the patient and the procedure, and encompassing different organizational options, attempting to individualize it based on specific factors of the patient and the procedure, and encompassing the different organizational options for pain control. The document updates concepts and minimum requirements necessary for optimal postoperative analgesia, a multidisciplinary approach and the management of Acute Postoperative Pain. Strategic lines and different management models are defined. A general perioperative action plan is established based on collaboration with the surgical departments involved, on the joint review of the evidence and on preparation of protocols by the procedure. Finally, a follow-up plan and a series of minimum indicators necessary for quality control of postoperative pain are presented.

Perioperative Pain Management for Thoracic Surgery: A Multi-Layered Approach

Cardiothoracic surgeries frequently pose unique challenges in the management of perioperative acute pain that require a multifaceted and personalized approach in order to optimize patient outcomes. This article discusses various analgesic strategies including regional anesthesia techniques such as thoracic epidurals, erector spinae plane blocks, and serratus anterior plane blocks and underscores the significance of perioperative multimodal medications, while providing nuanced recommendations for their use. This article further attempts to provide evidence for the efficacy of the different modalities and compares the effectiveness of the choice of analgesia. The roles of Acute Pain Services (APS) and Transitional Pain Services (TPS) in mitigating opioid dependence and chronic postsurgical pain are also discussed. Precision medicine is also presented as a potential way to offer a patient tailored analgesic strategy. Supported by various randomized controlled trials and meta-analyses, the article concludes that an integrated, patient-specific approach encompassing regional anesthesia and multimodal medications, while also utilizing the services of the Acute Pain Service can help to enhance pain management outcomes in cardiothoracic surgery.

Acute Pain Services and pain-related patient-reported outcomes in Hungarian hospitals

BACKGROUND

Postoperative pain management is an important part of surgical care, where Acute Pain Service offers added value in terms of patient outcomes and costs. The technology, however, has hardly been adopted in Hungary, with only two hospitals operating Acute Pain Service and whose performance has not been evaluated yet. This research compared pain management outcomes of surgical, orthopedic, and traumatology patients in Hungarian hospitals with and without Acute Pain Service.

METHODS

We recruited 348 patients, 120 in the APS group and 228 in the control group, whose experience was surveyed with an adapted version of the American Pain Society Patient Outcome Questionnaire. The questionnaire covered pain intensity, pain interference with physical and emotional functions, side effects, patient satisfaction, information received, and participation in treatment decisions. The differences were analyzed by Fisher's exact test and Mann-Whitney U test.

RESULTS

The APS group showed better results with lower pain intensity scores regarding worst postoperative pain (χ2 = 18.919, p = 0.0043). They reported less pain interference with activities in bed (χ2 = 21.978, p = 0.0006) and out of bed (χ2 = 14.341, p = 0.0129). Furthermore, patients in the APS group experienced fewer pain-management-related side effects, like nausea (χ2 = 15.240, p = 0.0101), drowsiness (χ2 = 26.965, p = 0.0001), and dizziness (χ2 = 13.980, p = 0.0124). However, patient information (χ2 = 3.480, p = 0.0945) and patient satisfaction (χ2 = 5.781, p = 0.2127) did not differ significantly between the two groups.

CONCLUSIONS

Our findings confirm earlier international evidence on the benefits of Acute Pain Service in postoperative pain management and support the wider adoption of the technology in Hungarian hospitals. Nevertheless, close attention should be paid to patient information and involvement as better outcomes alone do not necessarily increase patient satisfaction.

Perioperative pain management models in four European countries: A narrative review of differences, similarities and future directions

There is general agreement that acute pain management is an important component of perioperative medicine. However, there is no consensus on the best model of care for perioperative pain management, mainly because evidence is missing in many aspects. Comparing the similarities and differences between countries might reveal some insights into different organisational models and how they work. Here, we performed a narrative review to describe and compare the structures, processes and outcomes of perioperative pain management in the healthcare systems of four European countries using Donabedian's framework as a guide. Our comparison revealed many similarities, differences and gaps. Different structures of acute pain services in the four countries with no common definition and standards of care were found. Protocols have been implemented in all countries and guidelines in some. If outcome is assessed, it is mainly pain intensity, and many patients experiencing more intense pain than others have common risk factors (e.g. preoperative pain, preoperative opioid intake, female sex and young age). Outcome assessment beyond pain intensity (such as pain-related physical function, which is important for early rehabilitation and recovery) is currently not well implemented. Developing common quality indicators, a European guideline for perioperative pain management (e.g. for patients at high risk for experiencing severe pain and other outcome parameters) and common criteria for acute pain services might pave the way forward for improving acute pain management in Europe. Finally, the education of general and specialist staff should be aligned in Europe, for example, by using the curricula of the European Pain Federation (EFIC).

Perioperative quality indicators specific to the practice of anesthesia in noncardiac surgery: an umbrella review

PURPOSE

Improvement in delivery of perioperative care depends on the ability to measure outcomes that can direct meaningful changes in practice. We sought to identify and provide an overview of perioperative quality indicators specific to the practice of anesthesia in noncardiac surgery.

SOURCE

We conducted an umbrella review (a systematic review of systematic reviews) according to Joanna Briggs Institute methodology. We included systematic reviews examining perioperative indicators in patients ≥ 18 yr of age undergoing noncardiac surgery. Our primary outcome was any quality indicator specific to anesthesia. Indicators were classified by the Donabedian system and perioperative phase of care. The quality of systematic reviews was assessed using AMSTAR 2 criteria. Level of evidence of quality indicators was stratified by the Oxford Centre for Evidence-Based Medicine Classification.

PRINCIPAL FINDINGS

Our search returned 1,475 studies. After removing duplicates and screening of abstracts and full texts, 23 systematic reviews encompassing 3,164 primary studies met our inclusion criteria. There were 330 unique quality indicators. Process indicators were most common (n = 169), followed by outcome (n = 114) and structure indicators (n = 47). Few identified indicators were supported by high-level evidence (45/330, 14%). Level 1 evidence supported indicators of antibiotic prophylaxis (1a), venous thromboembolism prophylaxis (1a), postoperative nausea/vomiting prophylaxis (1b), maintenance of normothermia (1a), and goal-directed fluid therapy (1b).

CONCLUSION

This umbrella review highlights the scarcity of perioperative quality indicators that are supported by high quality evidence. Future development of quality indicators and recommendations for outcome measurement should focus on metrics that are supported by level 1 evidence. Potential targets for evidence-based quality-improvement programs in anesthesia are identified herein.

STUDY REGISTRATION

PROSPERO (CRD42020164691); first registered 28 April 2020.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Current Approaches to Four Challenging Pain Syndromes

During a conference of pain specialists, some of the experts addressed the potential management of four prevalent but difficult painful conditions, namely, chronic postsurgical pain (CPSP), knee osteoarthritis, chest trauma, and facet joint arthropathy. In all cases, the conditions posed challenges in accurate diagnoses as well as safe, effective treatments, especially using locoregional blocks. It is not clear why some surgical patients develop CPSP and others do not, although some risk factors have been identified. More importantly, the transitional phase of pain from acute to chronic deserves greater scrutiny. It appears as if more aggressive and more effective perioperative and postoperative analgesia could help mitigate or possibly prevent CPSP. Knee osteoarthritis is prevalent but is often managed pharmacologically and then with joint replacement; many patients simply live with the condition which can be viewed as a disease of the entire joint. New approaches with intra-articular injections of hyaluronic acid, platelet-rich plasma, and botulinum toxin may provide safe, effective, and durable pain control. Chest trauma can be extremely painful and a source of morbidity, but its management tends to rely on watchful waiting and drug therapy. New approaches to regional nerve blocks can be beneficial and may reduce troublesome symptoms such as the inability to cough or clear the lungs. Facet joint arthropathy is very prevalent among older people but is not completely clarified. It may be the source of intense pain with limited management strategies. The role of nerve blocks in facet joint arthropathy is an important new addition to the armamentarium of pain management, particularly for geriatric patients.

Advances in the Management of Acute Postsurgical Pain: A Review

Despite the millions of surgeries performed every year around the world, postoperative pain remains prevalent and is often addressed with inadequate or suboptimal treatments. Chronic postsurgical pain is surprisingly prevalent, and its rate varies with the type of surgery, as well as with certain patient characteristics. Thus, better clinical training is needed as well as patient education. As pain can be caused by more than one mechanism, multimodal or balanced postsurgical analgesia is appropriate. Pharmacological agents such as opioid and nonopioid pain relievers, as well as adjuvants and nonpharmacologic approaches, can be combined to provide better and opioid-sparing pain relief. Many specialty societies have guidelines for postoperative pain management that emphasize multimodal postoperative analgesia. These guidelines are particularly helpful when dealing with special populations such as pregnant patients or infants and children. Pediatric pain control, in particular, can be challenging as patients may be unable to communicate their pain levels. A variety of validated assessment tools are available for diagnosis. Related to therapy, most guidelines agree on the fact that codeine should be used with extreme caution in pediatric patients as some may be "rapid metabolizers" and its use may be life-threatening. Prehabilitation is a preoperative approach that prepares patients in advance of elective surgery with conditioning exercises and other interventions to optimize their health. Prehabilitation may have aerobic, strength-training, nutritional, and counseling components. Logistical considerations and degree of patient adherence represent barriers to effective prehabilitation programs. Notwithstanding all this, acute postoperative pain represents a clinical challenge that has not yet been well addressed.

Virtual Pain Unit Is Associated with Improvement of Postoperative Analgesia Quality: A Retrospective Single-Center Clinical Study

INTRODUCTION

Acute postoperative pain is a major concern among surgical patients. Thus, this study established a new acute pain management model and compared the effects of the acute pain service (APS) model in 2020 and the virtual pain unit (VPU) model in 2021 on postoperative analgesia quality.

METHODS

This retrospective, single-center clinical study involved 21,281 patients from 2020 to 2021. First, the patients were grouped on the basis of their pain management model (APS and VPU). The incidence of moderate to severe postoperative pain (MSPP) [numeric rating scale (NRS) score ≥ 5], postoperative nausea and vomiting (PONV), and postoperative dizziness were recorded.

RESULTS

The VPU group recorded significantly lower MSPP incidence (1-12 months), PONV, and postoperative dizziness (1-10 months and 12 months) compared with the APS group. In addition, the annual average incidence of MSPP, PONV, and postoperative dizziness in the VPU group was significantly lower than in the APS group.

CONCLUSIONS

The VPU model reduces the incidence of moderate to severe postoperative pain, nausea, vomiting, and dizziness; hence, it is a promising acute pain management model.

Electroacupuncture for Pain Outcomes in a Trauma Center's Acute Pain Service: A Retrospective Observational Study

Background

Evidence for acupuncture to treat pain is growing. Electrostimulation of acupuncture needles (electroacupuncture) is common for pain and is thought to augment the therapeutic effect.

Objectives

To examine the association of pain outcomes after a single acupuncture session with electrostimulation included (EA) compared with no electrostimulation included (NEA).

Methods

A retrospective observational study was conducted using electronic health records of acupuncture sessions for adults with acute pain under the care of an acute pain service. Paired t-test and linear regression were used to report pain intensity changes after a single acupuncture session and by including EA. Ordered logistic regression was used to report categorical pain relief. Logistic regression was used to explore the odds of adding EA and the patient's age, gender, and pretreatment pain.

Results

From July 24, 2017, through November 9, 2020, 465 acupuncture sessions recorded EA (n = 194), or NEA (n = 271). Acupuncture, independent of EA status, reduced pain intensity by a mean 2.5 points. EA was associated with a mean 0.38-point reduction in pain intensity more than NEA (confidence interval [95% CI]: -0.75 to -0.01). Among sessions reporting categorical pain relief (n = 415), higher relief was more likely with EA (odds ratio = 2.16, 95% CI: 1.52-3.08). There was no association between EA and the patient's age, gender, and pretreatment pain intensity.

Conclusions

After a single acupuncture session, both EA and NEA reduced pain intensity. Higher categorical pain relief was reported with EA, though the clinical meaning is uncertain. Future research should focus on well-defined populations for electroacupuncture and factors for including electrostimulation.

Shared Decision-Making in Acute Pain Services

PURPOSE OF REVIEW

The implementation of shared decision-making (SDM) in acute pain services (APS) is still in its infancies especially when compared to other medical fields.

RECENT FINDINGS

Emerging evidence fosters the value of SDM in various acute care settings. We provide an overview of general SDM practices and possible advantages of incorporating such concepts in APS, point out barriers to SDM in this setting, present common patient decisions aids developed for APS and discuss opportunities for further development. Especially in the APS setting, patient-centred care is a key component for optimal patient outcome. SDM could be included into everyday clinical practice by using structured approaches such as the "seek, help, assess, reach, evaluate" (SHARE) approach, the 3 "MAking Good decisions In Collaboration"(MAGIC) questions, the "Benefits, Risks, Alternatives and doing Nothing"(BRAN) tool or the "the multifocal approach to sharing in shared decision-making"(MAPPIN'SDM) as guidance for participatory decision-making. Such tools aid in the development of a patient-clinician relationship beyond discharge after immediate relief of acute pain has been accomplished. Research addressing patient decision aids and their impact on patient-reported outcomes regarding shared decision-making, organizational barriers and new developments such as remote shared decision-making is needed to advance participatory decision-making in acute pain services.

Status quo of pain-related patient reported outcomes and perioperative pain management in 10 415 patients from 10 countries: analysis of registry data

BACKGROUND

Postoperative pain is common at the global level, despite considerable attempts for improvement, reflecting the complexity of offering effective pain relief. In this study, clinicians from Mexico, China, and eight European countries evaluated perioperative pain practices and patient-reported outcomes (PROs) in their hospitals as a basis for carrying out quality improvement (QI) projects in each country.

METHODS

PAIN OUT, an international perioperative pain registry, provided standardized methodology for assessing management and multi-dimensional PROs on the first postoperative day, in patients undergoing orthopedic, general surgery, obstetric & gynecology or urological procedures.

RESULTS

Between 2017-2019, data obtained from 10,415 adult patients in 105 wards, qualified for analysis. At the ward level: 50% (median) of patients reported worst pain intensities ≥7/10 NRS, 25% spent ≥50% of the time in severe pain and 20-34% reported severe ratings for pain-related functional and emotional interference. Demographic variables, country and surgical discipline explained a small proportion of the variation in the PROs, leaving about 88% unexplained. Most treatment processes varied considerably between wards. Ward effects accounted for about 7% and 32% of variation in PROs and treatment processes, respectively.

CONCLUSIONS

This comprehensive evaluation demonstrates that many patients in this international cohort reported poor pain-related PROs on the first postoperative day. PROs and treatments varied greatly. Most of the variance of the PROs could not be explained. The findings served as a basis for devising and implementing QI programs in participating hospitals.

[The guidelines of the Federal Joint Committee on acute pain management : Background and consequences for the practice in hospitals]

The quality of postoperative pain therapy in Germany shows a heterogeneous treatment practice and large differences in quality between individual institutions, The patient representatives in the Federal Joint Committee (G-BA) have therefore decisively campaigned for many years that instruments of non-legislative standards are employed in order to noticeably improve the quality of perioperative pain therapy for patients in Germany. As a result of these efforts, in October 2020 a binding specification for internal quality management was included in the quality management guidelines (QM-RL) by the G‑BA. This describes in concrete terms the structural and procedural requirements for an internal quality management of acute pain for all institutions in which operations and comparable potentially painful interventions are carried out. This article describes the content of this regulation and the resulting consequences for the institutions, the medical and administrative management and especially the role of anesthesia.

Finding the vulnerable postoperative population: A two-step cluster analysis of the PAIN-OUT registry

BACKGROUND

Identifying predictors of poor postoperative outcomes is crucial for planning personalized pain treatments. The aim of this study was to examine pain outcomes using cluster analysis in N=2,678 patients from the PAIN-OUT registry at first postoperative day.

METHODS

Indicator variables of the clustering analysis assessed multiple domains, such as clinical and surgical conditions, analgesic-anesthetic variables, desire for more pain treatment and outcome variables of the International Pain Outcome Questionnaire (IPO) summarized as factor scores.

RESULTS

Two-step cluster identified the three-cluster solution as the optimal. Two empirical groups (C1 and C2) included patients with good postoperative outcomes discriminated by peripheral nerve block use, while the other cluster (C3) grouped patients with the worst outcomes, where all patients desired more pain treatment. C3 comprised about 20% of the participants, mostly lower limb, abdominal and spine procedures. The best predictors of belonging to C3 included younger age, being male, preoperative opioid use, bone and fracture reduction procedures, institution, number of comorbidities and morphine equivalents in the recovery room.

CONCLUSIONS

IPO factor scores can be used to select pain outcomes phenotypes in large clinical databases. Most of the predictors were present before the recovery period so perioperative planning should focus in the preoperative and intraoperative periods.

Regional anesthesia and the acute pain service: compliance and controversies

PURPOSE OF REVIEW

The aims of this article are three-fold: first, to describe the necessary elements that result in accurate and compliant billing practice; second, to discuss billing in the context of new blocks and liposomal bupivacaine; and third, to gain a better understanding of compliance law.

RECENT FINDINGS

Regional anesthesia techniques provide an appealing alternative to opioid medication for pain management. However, these techniques also increase the cost of care. As new peripheral and fascial plane blocks emerge, proper coding has become more complex.

SUMMARY

Familiarity with documentation, billing, and compliance requirements can help maintain proper reimbursement rates, as well as limit potential downstream consequences. Most importantly this can help increase the viability and success of an acute pain service.

Patient Satisfaction With a Nurse-Led Pain Management Program: A Quasi-Experimental Study in Ethiopia

Introduction

Patient satisfaction is one of the important indicators of quality care.

Objective

To examine patient ratings of pain management satisfaction before and after introducing a nurse-led management program.

Methods

A quasi-experimental design with three cross-sectional surveys between October 1, 2016 and June 15, 2017. A total of 845 patients admitted to the four inpatient departments (medicine, surgery, maternity, and gynecology) of Jimma University Medical Centre were invited to participate in the study. A questionnaire adapted from the American Pain Society Patient Outcome Questionnaire, Pain Treatment Satisfaction Scale, and related literature was used for the survey. Data were analyzed using the chi-square test (categorical variables), t-tests for continuous variables, and robust regression to determine the effect of nurse-led management program on patient satisfaction. For all tests, p-values <.05 were considered statistically significant.

Results

Of the 845 patients invited, 782 (92.5%) participated in the surveys—Survey 1: N = 256; Survey 2: N = 259; Survey 3: N = 267. The proportion of patients who perceived that staff responded within 30 min increased from 67.8% in Survey 1 to 71.1% in Survey 2 and 74.2% in Survey 3. On a scale of 1 to 5 (1 = strongly dissatisfied and 5 = strongly satisfied), the overall mean patient satisfaction with pain management was 3.61 (SD 0.80) in Survey 1, 3.81 (SD 0.86) in Survey 2, and 4.10 (SD 0.64) in Survey 3. Moreover, the patients scored significantly higher on all satisfaction items in Survey 2 (B ranged between 0.12 and 0.41) and Survey 3 (B ranged between 0.24 and 0.74) compared to Survey 1.

Conclusion

The patients’ ratings of their satisfaction and staff nurse responsiveness following the nurse-led pain management program have increased compared to the levels before the intervention. However, further studies, including those with a control group, are warranted to confirm the results.

The opioid epidemic from the acute care hospital front line

Prescription opioid use has risen steeply for over two decades, driven primarily by advocacy for better management of chronic non-cancer pain, but also by poor opioid stewardship in the management of acute pain. Inappropriate prescribing, among other things, contributed to the opioid 'epidemic' and striking increases in patient harm. It has also seen a greater proportion of opioid-tolerant patients presenting to acute care hospitals. Effective and safe management of acute pain in opioid-tolerant patients can be challenging, with higher risks of opioid-induced ventilatory impairment and persistent post-discharge opioid use compared with opioid-naive patients. There are also increased risks of some less well known adverse postoperative outcomes including infection, earlier revision rates after major joint arthroplasty and spinal fusion, longer hospital stays, higher re-admission rates and increased healthcare costs. Increasingly, opioid-free/opioid-sparing techniques have been advocated as ways to reduce patient harm. However, good evidence for these remains lacking and opioids will continue to play an important role in the management of acute pain in many patients.Better opioid stewardship with consideration of preoperative opioid weaning in some patients, assessment of patient function rather than relying on pain scores alone to assess adequacy of analgesia, prescription of immediate release opioids only and evidence-based use of analgesic adjuvants are important. Post-discharge opioid prescribing should be contingent on an assessment of patient risk, with short-term only use of opioids. In partnership with pharmacists, nursing staff, other medical specialists, general practitioners and patients, anaesthetists remain ideally positioned to be involved in opioid stewardship in the acute care setting.