Magnifying endoscopic observation of the gastric mucosa, particularly in patients with atrophic gastritis

Time perspective as a predictor of acute postsurgical pain and coping with pain following abdominal surgery

BACKGROUND

The aim of this study was to predict acute postsurgical pain and coping with pain following surgery based on preoperative time perspectives. Time perspective is a basic dimension of psychological time. It is a tendency to focus on a particular time area: the past, the present and the future.

METHOD

Seventy-six patients completed measures of time perspective and pain 24 h before abdominal surgery. During the 3 days after surgery, measures of pain and coping with pain were completed.

RESULTS

We performed hierarchical regression analyses to identify predictors of acute postsurgical pain and how patients cope with it. These analyses suggested that a preoperative past-negative time perspective can be a predictor of postoperative pain level and catastrophizing after surgery.

CONCLUSION

The findings of our study indicate the importance of time perspective, especially the past perspective, in dealing with postoperative pain.

SIGNIFICANCE

Our research indicates that a preoperative past-negative time perspective is a significant predictor of acute postsurgical pain intensity and the strongest predictor of pain catastrophizing.

Frequency, impact, and predictors of persistent pain after root canal treatment: a national dental PBRN study

Root canal treatment (RCT) is commonly performed surgery and persistent pain is known to occur, but little is known about how these patients are affected by this pain. Although biopsychosocial mechanisms are thought to be associated with the development of such pain, similar to persistent pain after surgery in other body sites, little is known about the baseline predictors for persistent pain. We assessed the frequency of persistent pain 6 months after RCT, measured the impact this pain had on patients, and determined predictive factors for persistent tooth pain in a multicenter prospective cohort study conducted within the National Dental Practice-Based Research Network. Of 708 patients enrolled, 651 (91.9%) provided follow-up data, with 65 (10.0%) meeting criteria for pain 6 months after RCT. On average, these patients reported their pain as mild to moderate in intensity, present for approximately 10 days in the preceding month, and minimally interfered with daily activities. After adjusting for the type of dental practitioner and patient age, gender, and household income, pain duration over the week before RCT significantly increased the risk of developing persistent pain (odds ratio = 1.19 per 1 day increase in pain duration, 95% confidence interval: 1.07-1.33), whereas optimism about the procedure reduced the risk (odds ratio = 0.39, 95% confidence interval: 0.22-0.67). Our data suggest that persistent pain 6 months after RCT is fairly common, but generally does not have a large impact on those experiencing it. Furthermore, patient age and gender did not predict persistent pain, whereas preoperative pain duration and the patient's expectation did.

Risk Assessment for Chronic Pain and Patient Satisfaction After Total Knee Arthroplasty

The estimated prevalence of patients who report minor or no improvement of their symptoms and pain after total knee arthroplasty (TKA) remains high, ranging from 5% to 40%. The authors sought to determine whether chronic pain and functional health are related to specific variations in demographic data, surgical techniques, or radiographic pre- and postoperative findings. They also sought to identify independent risk factors for persistent moderate-to-severe chronic pain after TKA. A total of 273 patients who underwent primary TKA from October 2007 to March 2010 with a minimum follow-up of 1 year were identified from electronic medical records. A questionnaire to identify persistent postoperative pain (36-item Short Form Health Survey [SF-36]) was mailed to these patients. Linear regression and logistic regression were used to identify predictors for SF-36 and chronic pain, respectively. Thirty-nine percent of patients reported persistent pain after TKA, with a median average pain score of 3 out of 10 and worst pain score of 5 out of 10. Independent risk factors for persistent pain are the length of the operative procedure (odds ratio [OR]=1.013), medical history of diabetes mellitus (OR=0.430), presence of preoperative flexion contracture (OR=1.089), and patellofemoral joint overstuffing (OR=0.915). Persistent postoperative pain is a common finding after TKA. Nonmodifiable risk factors could be used for risk stratification, whereas modifiable risk factors could be used as a clinical guidance for modification of some aspects of existing surgical techniques.

Laparoscopic surgery: a narrative review of pharmacotherapy in pain management

Laparoscopic surgery is widespread, and an increasing number of surgeries are performed laparoscopically. Early pain after laparoscopy can be similar or even more severe than that after open surgery. Thus, proactive pain management should be provided. Pain after laparoscopic surgery is derived from multiple origins; therefore, a single agent is seldom sufficient. Pain is most effectively controlled by a multimodal, preventive analgesia approach, such as combining opioids with non-opioid analgesics and local anaesthetics. Wound and port site local anaesthetic injections decrease abdominal wall pain by 1-1.5 units on a 0-10 pain scale. Inflammatory pain and shoulder pain can be controlled by NSAIDs or corticosteroids. In some patient groups, adjuvant drugs, ketamine and α2-adrenergic agonists can be helpful, but evidence on gabapentinoids is conflicting. In the present review, the types of pain that need to be taken into account while planning pain management protocols and the wide range of analgesic options that have been assessed in laparoscopic surgery are critically assessed. Recommendations to the clinician will be made regarding how to manage acute pain and how to prevent persistent postoperative pain. It is important to identify patients at the highest risk for severe and prolonged post-operative pain, and to have a proactive strategy in place for these individuals.

Factors Associated with Acute Postoperative Pain Following Breast Reconstruction

INTRODUCTION

Post-mastectomy breast reconstruction has become an increasingly important component of breast cancer treatment. Unfortunately, some patients experience severe postoperative pain, placing them at risk for increased clinical morbidity and the development of disabling chronic pain. In an attempt to identify at-risk patients, we prospectively evaluated patient characteristics and medical/surgical variables associated with more severe acute post-reconstruction pain.

METHODS

Women (N = 2207; one-week 82.8% response rate) undergoing breast reconstruction were assessed for pain experience, anxiety, depression, and sociodemographic characteristics prior to surgery. Pain assessments were made preoperatively and postoperative at 1-week using validated survey instruments including the McGill Pain Questionnaire-Short Form (MPQ-SF), Numerical Pain Rating Scale (NPRS), and BREAST-Q Chest and Upper Body scale. Depressive symptoms and anxiety severity were assessed by the Patient Health Questionnaire and Generalized Anxiety Disorders Scale, respectively. Mixed-effects regression modeling was used to examine the relationships between patient characteristics and medical/surgical factors and 1-week postoperative pain.

RESULTS

Younger age, bilateral reconstruction, and severity of preoperative pain, anxiety and depression were all associated with more severe acute postoperative pain on all the pain measures and BREAST-Q. Comparison of surgical procedure type indicated less severe postoperative pain for PTRAM, DIEP and SIEA reconstructive surgery compared to tissue expander/implant reconstruction.

CONCLUSIONS

This study identified patients at risk for greater acute postoperative pain following breast reconstruction. These findings will allow plastic surgeons to better tailor postoperative care to improve patient comfort, reduce clinical morbidity, and further enhance patient satisfaction with their surgical outcome.

Relationship between self-reported pain sensitivity and pain after total knee arthroplasty: a prospective study of 71 patients 8 weeks after a standardized fast-track program

Background and purpose

This was a prospective cohort study assessing data from 71 adult patients undergoing total knee arthroplasty (TKA) following a standardized fast-track program between January and July 2013. The objective was to examine the relationship between self-rated pain sensitivity, as measured by the Pain Sensitivity Questionnaire (PSQ), and postoperative pain after TKA.

Methods

The baseline questionnaires, PSQ and Brief Pain Inventory, were given to the patients for self-administration at the presurgical evaluation (1–2 weeks prior to surgery). The follow-up questionnaire, Brief Pain Inventory, was administered at the first follow-up, 8 weeks after surgery.

Results

A statistically significant association was found between average preoperative pain and average pain 8 weeks after surgery (P=0.001). The PSQ-minor was statistically significantly associated with average pain only for patients younger than 70 years (P=0.03).

Interpretation

This is the first study to examine the relationship between pain sensitivity measured by PSQ and postoperative pain in patients after TKA. We found that a lower score on the PSQ-minor was statistically significantly associated with patients’ pain 8 weeks after TKA surgery, but only for younger patients. Further research is needed to explore whether the PSQ could be a useful screening tool for patients’ pain sensitivity in clinical settings.

Preoperative Pain, Symptoms, and Psychological Factors related to Higher Acute Pain Trajectories during Hospitalization for Total Knee Arthroplasty

OBJECTIVES

Unrelieved postoperative pain after total knee arthroplasty (TKA) is a significant problem. This longitudinal study investigated how preoperative pain intensity, as well as a comprehensive list of preoperative and perioperative factors, influenced the severity of acute average and worst pain after TKA.

METHODS

Prior to surgery, 203 patients completed a demographic questionnaire, Lee Fatigue Scale, Fatigue Severity Scale, Hospital Anxiety and Depression Scale, and Brief Illness Perception Questionnaire. Brief Pain Inventory was completed prior to surgery as well as through postoperative days (POD) 0 to 4. Clinical data were extracted from medical records.

RESULTS

Several factors were associated with higher levels of preoperative and postoperative pain. Lower preoperative average and worst pain intensity scores were associated with increases in average and worst postoperative pain from POD1 to POD4. A higher number of comorbidities, higher C-reactive protein values, and higher pain interference with function were associated with higher preoperative levels of average pain. Older age, higher fatigue levels, and higher scores on identity and emotional responses to osteoarthritis (OA) were associated with higher preoperative levels of worst pain. Lower perceived consequences of OA were associated with higher pain from POD1 to POD4. Males and patients with lower preoperative scores for average pain had higher worst pain following surgery.

DISCUSSION

Patients at higher risk for more severe postoperative pain can be identified through an assessment of pain and other risk factors identified in this study. Future research needs to test the efficacy of interventions that modify patients' perceptions of living with OA and pain intensity before surgery on short and long term postoperative outcomes.

The optimal dose of dexmedetomidine added to an sufentanil-based analgesic regimen for postoperative pain control in spine surgery: A probit analysis study

Postoperative spinal patients remain a challenge for provision of postoperative analgesia. Patient-controlled intravenous analgesia (PCIA) is a major method in reducing the severe pain after the surgery in our institution, but some adverse effects prevent the use of adequate dosage opioids.This study was determined using the probit analysis to investigate the optimal dose of dexmedetomidine (DEX) infusion for postoperative analgesia combined with sufentanil (SUF) in spine surgery.The dose of DEX needed to produce satisfactory analgesia conditions following combination of 3.0 μg/kg SUF in PCIA pump, which was diluted to 250 mL with a 4 mL/h as background infusion. Patients were recruited with age 35 to 65 years. The satisfactory criteria of postoperative analgesia were determined with a average satisfaction level of pain control, sedation, self-satisfaction, and adverse effects, among others. The dose of DEX was determined using the modified Dixon's up-and-down method (0.5 μg/kg as a step size). The first patient was test at 3.0 μg/kg DEX. The patient was assessed at 6, 12, 36 hours, and termination of PCIA following the continuous infusion of DEX-SUF mixture in PCIA after surgery.Twenty-five patients were enrolled by predetermined criteria. The optimal dose of DEX required for satisfactory analgesic was 4.33 (SD, 0.38) μg/kg combined with 3.0 μg/kg SUF via a PCIA volume of 250 mL by background infusion of 4 mL/h. Using probit analysis, the ED50 of DEX was 4.12 μg/kg (95% confidence limits 3.74-4.52 μg/kg) for satisfactory postoperative analgesic in spine surgery, the ED95 of DEX was 4.85 μg/kg (95% confidence limits 4.48-7.13 μg/kg). There was no report of somnolence or respiratory depression, relevant bradycardia or hypotension, or over sedation in this study.The optimal dose of DEX was 4.33 (0.38) μg/kg combined with 3.0 μg/kg SUF diluted to 250 mL with a background infusion of 4 mL/h for satisfactory analgesic after spine surgery. From probit analysis, ED50 and ED95 of DEX were 4.12 μg/kg (95% confidence limits 3.74-4.52 μg/kg) and 4.85 μg.kg (95% confidence limits 4.48-7.13 μg/kg), respectively.

Smoking history, nicotine dependence and opioid use in patients with chronic non-malignant pain

BACKGROUND

Previous studies have demonstrated a positive association between smoking and addiction to opioids in patients with chronic non-malignant pain. This could be explained by a susceptibility in some patients to develop addiction. Another explanation could be that nicotine influences both pain and the opioid system. The objective of the study was to investigate whether smoking, former smoking ± nicotine use and nicotine dependence in patients with chronic non-malignant pain were associated with opioid use and addiction to opioids.

METHODS

The study was a cross-sectional study carried out at a multidisciplinary Danish pain centre. All patients aged 18 or more in treatment at the pain centre on the 1st of September 2013 were invited to participate in the study.

RESULTS

A total of 98 patients (65%) participated in the study. The prevalence of current smokers was twice as high as in the general population. The prevalence of patients using opioids was 54% and the prevalence of addiction to opioids was 6%. No significant differences in addiction were found between the different smoking groups, but smokers and former smokers using nicotine tended to use opioids more frequently and at higher doses than never smokers and former smokers not using nicotine.

CONCLUSIONS

The study supports previous evidence that smoking is associated with chronic pain. Our data suggest that information about use of nicotine substitution in chronic non-malignant patients are relevant both in a clinical setting, but also in future studies of the association between smoking habits, pain and opioid use.

Prediction of postoperative opioid analgesia using clinical-experimental parameters and electroencephalography

BACKGROUND

Opioids are often used for pain treatment, but the response is often insufficient and dependent on e.g. the pain condition, genetic factors and drug class. Thus, there is an urgent need to identify biomarkers to enable selection of the appropriate drug for the individual patient, a concept known as personalized medicine. Quantitative sensory testing (QST) and clinical parameters can provide some guidance for response, but better and more objective biomarkers are urgently warranted. Electroencephalography (EEG) may be suitable since it assesses the central nervous system where opioids mediate their effects.

METHODS

Clinical parameters, QST and EEG (during rest and tonic pain) was recorded from patients the day prior to total hip replacement surgery. Postoperative pain treatment was performed using oxycodone and piritramide as patient-controlled analgesia. Patients were stratified into responders and non-responders based on pain ratings 24 h post-surgery. Parameters were analysed using conventional group-wise statistical methods. Furthermore, EEG was analysed by machine learning to predict individual response.

RESULTS

Eighty-one patients were included, of which 51 responded to postoperative opioid treatment (30 non-responders). Conventional statistics showed that more severe pre-existing chronic pain was prevalent among non-responders to opioid treatment (p = 0.04). Preoperative EEG analysis was able to predict responders with an accuracy of 65% (p = 0.009), but only during tonic pain.

CONCLUSIONS

Chronic pain grade before surgery is associated with the outcome of postoperative pain treatment. Furthermore, EEG shows potential as an objective biomarker and might be used to predict postoperative opioid analgesia.

SIGNIFICANCE

The current clinical study demonstrates the viability of EEG as a biomarker and with results consistent with previous experimental results. The combined method of machine learning and electroencephalography offers promising results for future developments of personalized pain treatment.

Postoperative persistent chronic pain: what do we know about prevention, risk factors, and treatment

BACKGROUND AND OBJECTIVES

Postoperative persistent chronic pain (POCP) is a serious health problem, disabling, undermining the quality of life of affected patients. Although more studies and research have addressed the possible mechanisms of the evolution from acute pain to chronic postoperatively, there are still no consistent data about the risk factors and prevention. This article aims to bring what is in the panorama of the current literature available.

CONTENT

This review describes the definition, risk factors, and mechanisms of POCD, its prevention and treatment. The main drugs and techniques are exposed comprehensively.

CONCLUSION

Postoperative persistent chronic pain is a complex and still unclear etiology entity, which interferes heavily in the life of the subject. Neuropathic pain resulting from surgical trauma is still the most common expression of this entity. Techniques to prevent nerve injury are recommended and should be used whenever possible. Despite efforts to understand and select risk patients, the management and prevention of this syndrome remain challenging and inappropriate.

Postoperative paediatric pain prevalence: A retrospective analysis in a university teaching hospital

BACKGROUND

Overall pain prevalence in paediatric patients is well documented, but relatively little attention has been paid to pain prevalence and intensity on specific postoperative days within the first week following an operation.

OBJECTIVES

To evaluate reported pain prevalence on the day of surgery and each day during the following week and to analyse pain trajectories.

DESIGN

Retrospective study.

SETTING

Single centre university hospital.

PARTICIPANTS

815 postoperative children and adolescents (age≤18 years) were included (female: 36%, age 9.8±5.8). Children with ear, nose, throat (e.g. tonsillectomy), eye (e.g. strabismus repair) or dental surgery (e.g. dental extraction) were treated at other departments and therefore were not included in this study.

METHODS

Retrospective analysis of the overall and clinically relevant (pain score ≥4/10) postoperative pain prevalence in children and adolescents during the first week after surgery. Possible influencing factors (age, sex, body mass index, type of anaesthesia, type of surgery and duration of surgery) on pain trajectories are analysed using mixed model techniques.

RESULTS

Overall, 36% of 815 analysed children and adolescents suffered from pain ≥4 during their entire hospital stay. Compared to the day of surgery, the number of patients with pain ≥4 was slightly higher on day 1 after surgery (21% vs. 25%, respectively). In self-reported pain intensity rating (done for patients age≥4 years) the type of surgery (p<.001) was the only significant variable influencing pain intensity. In observational pain assessment (age<4 years) pain scores increased with patient's age (p=.004). In this patient group, pain intensity ratings did not differ between types of surgery (p=.278).

CONCLUSION

Type of surgery is an important predictor for self-reported pain intensity ratings in children but not for observational pain assessment in younger children. In younger children observational pain assessment ratings increase with age.

An Evaluation of the Effect of Hypnosis on Postoperative Analgesia following Laparoscopic Cholecystectomy

Little attention has been paid to the effectiveness of hypnosis in improving the results of surgery in Iran. One hundred and twenty patients scheduled for laparoscopic cholecystectomy were randomly divided into either control (standard care) or experimental (hypnosis) groups. Prior to surgery and again after surgery, abdominal pain, nausea, and vomiting were assessed. The results suggest that hypnosis could effectively reduce pain after laparoscopic cholecystectomy and significantly reduce hospitalization time.

Influence of depression, catastrophizing, anxiety, and resilience on postoperative pain at the first day after otolaryngological surgery: A prospective single center cohort observational study

The aim was to assess the association between objectified preoperative psychological factors and postoperative pain at the first day after otolaryngological surgery in accordance with other predictors of postoperative pain. Eighty-two (82) patients (59% male, median age 56 years) were included between January and May 2015. The psychological assessment the day before surgery included the Patient Health Questionnaire (PHQ-9), pain catastrophizing scale (PCS), State-Trait Operation Anxiety (STOA) inventory, and the resilience scale (RS-13). On first postoperative day, patients were rated their pain using the questionnaires of the German-wide project Quality Improvement in Postoperative Pain Treatment (QUIPS) including a numeric rating scale (NRS, 0-10) for determination of patient's maximal pain. QUIPS allowed standardized assessment of patients' characteristics, pain parameters, and outcome. The influence of preoperative and postoperative parameters on patients' maximal postoperative pain was estimated by univariate and multivariate statistical analysis. The mean maximal pain was 3.2 ± 2.9. In univariate analysis, higher PHQ-9 score more than 4 (P = 0.010), higher STOA trait anxiety (P = 0.044), and higher STOA total score (P = 0.043) were associated to more postoperative pain. In multivariate analysis higher PHQ-9 score remained an independent predictor for severe pain (beta = 0.302; 95% confidence interval [CI]: 0.054-0.473; P = 0.014). When all parameters were included into multivariate analysis, 2 of all somatic, psychological, and treatment factors were associated with severe maximal pain: more depression (PHQ-9; beta = 0.256; 95% CI: 0.042-0.404; P = 0.017), and use of opioids in the recovery room (beta = 0.371; 95% CI: 0.108-0.481; P = 0.002). Otolaryngological surgery covers the spectrum from low to severe postoperative pain and is therefore a good model for pain management studies. A set of somatic and psychological parameters seems to allow the identification of patients with higher risk for more postoperative pain. This should help to individualize and improve the perioperative pain management.

Females report higher postoperative pain scores than males after ankle surgery

OBJECTIVES

The majority of patients experience moderate-to-intense pain following ankle surgery. Early, adequate treatment of postoperative pain is desirable for optimal pain relief, which in turn may facilitate optimal pulmonary function, normal respiration pattern, rehabilitation and prevention of a chronic pain condition. In this retrospective study, we aimed to identify possible predictors of moderate-to-intense postoperative pain while in the Post Anaesthesia Care Unit (PACU) in patients operated for ankle fractures.

MATERIALS AND METHODS

Social demographics and clinical characteristics from admission throughout the stay in the PACU were collected from the hospital patient record system in retrospect. Pain was assessed using a Visual Analogue Scale (VAS) or a verbal Numeric Rating Scale (vNRS). A VAS/vNRS score 4-6 was classified as moderate and 7-10 as intense pain. Other factors which were investigated were time from ankle fracture to surgery, anaesthetic procedure, pre-, per- and postoperative medical treatment, radiological classification, complexity of fracture, operative technique, and time using tourniquet procedure.

RESULTS

Data from 336 patients who underwent surgery to repair an ankle fracture between January 2009 and December 2010 were analysed. None of the following variables had a statistically significant effect on pain; age, weight, smoking, timeframe from fracture to operation, type of anaesthesia, opioids given peroperatively, complexity of the fracture, operation technique or tourniquet inflation procedure. Female sex predicted moderate-to-intense postoperative pain in the PACU with odds ratio 2.31 (95% confidence interval 1.39-3.86), P=0.001. As far as we know, this is the first study to show a sex difference in reporting pain in the first hours after surgery for ankle fracture.

CONCLUSION

Female patients operated for ankle fracture report higher pain-intensity-score than male patients while in the PACU.

IMPLICATIONS

Our findings suggest that treatment strategies to prevent high peaks of pain should particularly target women operated for an ankle fracture.

Relationships among pain intensity, pain-related distress, and psychological distress in pre-surgical total knee arthroplasty patients: a secondary analysis

The current study aimed to examine the relationships between movement and resting pain intensity, pain-related distress, and psychological distress in participants scheduled for total knee arthroplasty (TKA). This study examined the impact of anxiety, depression, and pain catastrophizing on the relationship between pain intensity and pain-related distress. Data analyzed for the current study (N = 346) were collected at baseline as part of a larger Randomized Controlled Trial investigating the efficacy of TENS for TKA (TANK Study). Participants provided demographic information, pain intensity and pain-related distress, and completed validated measures of depression, anxiety, and pain catastrophizing. Only 58% of the sample reported resting pain >0 while 92% of the sample reported movement pain >0. Both movement and resting pain intensity correlated significantly with distress (r_s = .86, p < .01 and .79, p < .01, respectively). About three quarters to two thirds of the sample (78% for resting pain and 65% for movement pain) reported different pain intensity and pain-related distress. Both pain intensity and pain-related distress demonstrated significant relationships with anxiety, depression, and catastrophizing. Of participants reporting pain, those reporting higher anxiety reported higher levels of distress compared to pain intensity. These findings suggest that anxious patients may be particularly distressed by movement pain preceding TKA. Future research is needed to investigate the utility of brief psychological interventions for pre-surgical TKA patients.

Preoperative cognitive-behavioural intervention improves in-hospital mobilisation and analgesic use for lumbar spinal fusion patients

BACKGROUND

Catastrophic thinking and fear-avoidance belief are negatively influencing severe acute pain following surgery causing delayed ambulation and discharge. We aimed to examine if a preoperative intervention of cognitive-behavioural therapy (CBT) could influence the early postsurgical outcome following lumbar spinal fusion surgery (LSF).

METHODS

Ninety patients undergoing LSF due to degenerative spinal disorders were randomly allocated to either the CBT group or the control group. Both groups received surgery and postoperative rehabilitation. In addition, the CBT group received a preoperative intervention focussed on pain coping using a CBT approach. Primary outcome was back pain during the first week (0-10 scale). Secondary outcomes were mobility, analgesic consumption, and length of hospitalisation. Data were retrieved using self-report questionnaires, assessments made by physical therapists and from medical records.

RESULTS

No difference between the groups' self-reported back pain (p = 0.76) was detected. Independent mobility was reached by a significantly larger number of patients in the CBT group than the control group during the first three postoperative days. Analgesic consumption tended to be lower in the CBT group, whereas length of hospitalisation was unaffected by the CBT intervention.

CONCLUSION

Participation in a preoperative CBT intervention appeared to facilitate mobility in the acute postoperative phase, despite equally high levels of self-reported acute postsurgical pain in the two groups, and a slightly lower intake of rescue analgesics in the CBT group. This may reflect an overall improved ability to cope with pain following participation in the preoperative CBT intervention.

TRIAL REGISTRATION

The study was approved by the Danish Protection Agency (2011-41-5899) and the Ethics Committee of the Central Denmark Region (M-20110047). The trial was registered in Current Controlled Trials ( ISRCTN42281022 ).

Inter-Hospital Variability of Postoperative Pain after Tonsillectomy: Prospective Registry-Based Multicentre Cohort Study

Objectives

Although tonsillectomy is one of the most frequent and painful surgeries, the association between baseline and process parameters and postoperative pain are not fully understood.

Methods

A multicentre prospective cohort study using a web-based registry enrolled 1,527 women and 1,008 men aged 4 to 85 years from 52 German hospitals between 2006 and 2015. Maximal pain (MP) score the first day after surgery on a numeric rating scale (NRS) from 0 (no pain) to 10 (MP) was the main outcome parameter.

Results

The mean maximal pain score was 5.8±2.2 (median 6). Multivariable analysis revealed that female gender (Odds ratio [OR] = 1.33; 95% confidence interval [CI] = 1.12 to 1.56; p = 0.001), age <20 years (OR = 1.56; CI = 1.27 to 1.91; p<0.0001), no pain counselling (OR = 1.78; CI = 1.370 to 2.316; p<0.001), chronic pain (OR = 1.34; CI = 1.107 to 1.64; p = 0.004), and receiving opioids in recovery room (OR = 1.89; CI = 1.55 to 2.325; p<0.001) or on ward (OR = 1.79; CI = 1.42 to 2.27; p<0.001) were independently associated with higher experienced maximal postoperative pain (greater the median of 6). The effect of age on pain was not linear. Maximal pain increased in underage patients to a peak at the age of 18 to 20 years. From the age of ≥20 years on, maximal pain after tonsillectomy continuously decreased. Even after adjustment to all statistically important baseline and process parameters, there was substantial variability of maximal pain between hospitals with a heterogeneity variance of 0.31.

Conclusion

Many patients seem to receive insufficient or ineffective analgesia after tonsillectomy. Further research should address if populations at risk of higher postoperative pain such as females, younger patients or those with preexisting pain might profit from a special pain management protocol. Beyond classical demographical and process parameters the large variability between different hospitals is striking and indicates the existence of other unknown factors influencing postoperative pain after tonsillectomy.

A Prospective Cohort Study Evaluating the Ability of Anticipated Pain, Perceived Analgesic Needs, and Psychological Traits to Predict Pain and Analgesic Usage following Cesarean Delivery

Introduction. This study aimed to determine if preoperative psychological tests combined with simple pain prediction ratings could predict pain intensity and analgesic usage following cesarean delivery (CD). Methods. 50 healthy women undergoing scheduled CD with spinal anesthesia comprised the prospective study cohort. Preoperative predictors included 4 validated psychological questionnaires (Anxiety Sensitivity Index (ASI), Fear of Pain (FPQ), Pain Catastrophizing Scale, and Eysenck Personality Questionnaire) and 3 simple ratings: expected postoperative pain (0–10), anticipated analgesic threshold (0–10), and perceived analgesic needs (0–10). Postoperative outcome measures included post-CD pain (combined rest and movement) and opioid used for the 48-hour study period. Results. Bivariate correlations were significant with expected pain and opioid usage (r = 0.349), anticipated analgesic threshold and post-CD pain (r = −0.349), and perceived analgesic needs and post-CD pain (r = 0.313). Multiple linear regression analysis found that expected postoperative pain and anticipated analgesic needs contributed to post-CD pain prediction modeling (R² = 0.443, p < 0.0001); expected postoperative pain, ASI, and FPQ were associated with opioid usage (R² = 0.421, p < 0.0001). Conclusion. Preoperative psychological tests combined with simple pain prediction ratings accounted for 44% and 42% of pain and analgesic use variance, respectively. Preoperatively determined expected postoperative pain and perceived analgesic needs appear to be useful predictors for post-CD pain and analgesic requirements.

Psychiatric Disorders and Psychopharmacologic Treatment as Risk Factors in Elective Fast-track Total Hip and Knee Arthroplasty

BACKGROUND

Psychiatric disorder (PsD) is rarely considered when evaluating perioperative risk factors. Studies on PsD are often limited by use of administrative coding, incomplete follow-up, and lack of preoperative data on psychopharmacological treatment.

METHODS

A multicenter study with prospective registration on preoperative comorbidity, complete 90-day follow-up, and information on dispensed prescriptions on psychopharmacological treatment (excluding benzodiazepines). All departments used similar fast-track approaches and discharge to home. Evaluation of postoperative morbidity was based on discharge records. Odds ratios for length of stay (LOS) more than 4 days and surgery-related readmissions were calculated using multiple logistic regression adjusting for potential confounders.

RESULTS

Of 8,757 procedures, 1,001 (11.4%) were in PsD patients. Of these, 43.4% used selective serotonin inhibitors (SSRIs), 31.6% used other antidepressants, 8.5% used a combination, and 16.5% used antipsychotics. PsD was associated with increased risk of LOS more than 4 days (16.5 vs. 7.3%; odds ratio, 1.90; 95% CI, 1.52 to 2.37), regardless of treatment with SSRIs (2.19; 1.62 to 2.97), other antidepressants (1.81; 1.25 to 2.61), or antipsychotics (1.90; 1.62 to 3.16). PsD was associated with increased 30- (9.9 vs. 5.1%; 1.93; 1.49 to 2.49) and 90-day surgery-related readmissions (12.8 vs. 7.4%; 1.68; 1.34 to 2.10), significant for SSRIs (1.97; 1.38 to 2.82 and 1.77; 1.29 to 2.43), other antidepressants (2.24; 1.51 to 3.32 and 1.82; 1.27 to 2.61), and antipsychotics (1.85; 1.03 to 3.31, 30 days only). In PsD patients, pain (1.4%), postoperative anemia (1.1%), and pulmonary complications (1.1%) were the most frequent causes of LOS more than 4 days. Hip displacements (2.8%) and falls (1.9%) were the most frequent readmissions, and 90-day surgery-related mortality was 0.7% with and 0.2% without PsD.

CONCLUSIONS

Psychopharmacologically treated PsD is a risk factor for postoperative morbidity after fast-track arthroplasty, regardless of treatment type. This may be due to PsD per se and/or drug-related side effects.

Assessment of post-operative pain management among acutely and electively admitted patients - a Swedish ward perspective

RATIONALE, AIMS AND OBJECTIVES

Swedish health care is regulated to involve the patient in every intervention process. In the area of post-operative pain, it is therefore important to evaluate patient experience of the quality of pain management. Previous research has focused on mapping this area but not on comparing experiences between acutely and electively admitted patients. Hence, the aim of this study was to investigate the experiences of post-operative pain management quality among acutely and electively admitted patients at a Swedish surgical department performing soft-tissue surgery.

METHODS

A survey study design was used as a method based on a multidimensional instrument to assess post-operative pain management: Strategic and Clinical Quality Indicators in Postoperative Pain Management (SCQIPP). Consecutive patients at all wards of a university hospital's surgical department were included. Data collection was performed at hospital discharge.

RESULTS

In total, 160 patients participated, of whom 40 patients were acutely admitted. A significant difference between acutely and electively admitted patients was observed in the SCQIPP area of environment, whereas acute patients rated the post-operative pain management quality lower compared with those who were electively admitted.

CONCLUSIONS

There may be a need for improvement in the areas of post-operative pain management in Sweden, both specifically and generally. There may also be a difference in the experience of post-operative pain quality between acutely and electively admitted patients in this study, specifically in the area of environment. In addition, low levels of the perceived quality of post-operative pain management among the patients were consistent, but satisfaction with analgesic treatment was rated as good.

Efficacy of totally laparoscopic distal gastrectomy for gastric cancer in elderly patients

Elderly patients are often considered as high-risk for major abdominal surgery due to reduced functional reserve and increased comorbidities. We herein evaluated the efficacy of totally laparoscopic distal gastrectomy (TLDG) in elderly patients with gastric cancer by measuring the postoperative systemic responses and postoperative analgesic consumption. A total of 102 patients with gastric cancer [57 who underwent TLDG and 45 who underwent laparoscopy-assisted distal gastrectomy (LADG)] were enrolled in this study. The patients were classified as elderly (aged ≥75 years) and non-elderly (aged <75 years) groups. The surgical outcome and postoperative analgesic consumption were evaluated. The elderly group exhibited a higher incidence of comorbidities and a longer postoperative hospital stay compared with those of younger patients, although there was no difference in the incidence of postoperative complications. In addition, the total consumption of additional analgesics until postoperative day 5 in patients who underwent TLDG was significantly lower compared with that in patients who underwent LADG in the elderly group; there was no such difference in the non-elderly group. The results suggested that TLDG was better for the management of postoperative pain in elderly patients with gastric cancer, who exhibit the highest mortality rates in the adult surgical population.

Persistent Postoperative Pain after Cardiac Surgery: Incidence, Characterization, Associated Factors and its impact in Quality of Life

BACKGROUND

Cardiac surgery (CS) ranks among the most frequently performed interventions worldwide and persistent postoperative pain (PPP) has been recognized as a relevant clinical outcome in this context. We aimed to evaluate its incidence, characteristics, associated factors and patient's quality of life (QoL).

METHODS

Observational prospective study conducted in patients undergoing CS in a tertiary university hospital. PPP was defined as persistent pain after surgery with higher than 3 months' duration, after excluding other causes of pain. We used a set of questionnaires for data collection: Pain Catastrophizing Scale, Duke Health Profile, Brief Pain Inventory Short Form, McGill Pain Questionnaire Short Form, Douleur Neuropathique en 4 Questions and standardized questions regarding pain periodicity.

RESULTS

A total of 288 patients have completed the study and 43% presented PPP assessed at 3 months (PPP3M); out of which 84% were not under any treatment. PPP patients reported significantly lower QoL, and a neuropathic pain (NP) component was present in 50% of them. Younger age, female gender, higher body mass index, catastrophizing, coronary artery bypass graft, osteoarthritis, history of previous surgery (excluding sternotomy) and moderate to severe acute postoperative pain were independent predictors of PPP3M.

CONCLUSION

This is the first study comprehensively describing PPP after CS and identifying NP in half of them. Our results support the important role that PPP plays after CS in considering its interference in patients' daily life and their lower QoL, which deserves the attention of health care professionals in order to improve prevention, assessment and treatment of these patients. WHAT DOES THIS STUDY ADD?: This study comprehensively describes persistent postoperative pain (PPP) after cardiac surgery (CS) and identifies neuropathic pain (NP) in half of them. Our results support the important role that PPP plays after CS in considering its interference in patients' daily life and their lower quality of life.

Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice

Background

The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme.

Methods

Studies were selected with particular attention being paid to meta‐analyses, randomized controlled trials and large prospective cohort studies. For each item of the perioperative treatment pathway, available English‐language literature was examined and reviewed. The group reached a consensus recommendation after critical appraisal of the literature.

Results

This consensus statement demonstrates that anaesthesiologists control several preoperative, intraoperative and postoperative ERAS elements. Further research is needed to verify the strength of these recommendations.

Conclusions

Based on the evidence available for each element of perioperative care pathways, the Enhanced Recovery After Surgery (ERAS ^®) Society presents a comprehensive consensus review, clinical considerations and recommendations for anaesthesia care in patients undergoing gastrointestinal surgery within an ERAS programme. This unified protocol facilitates involvement of anaesthesiologists in the implementation of the ERAS programmes and allows for comparison between centres and it eventually might facilitate the design of multi‐institutional prospective and adequately powered randomized trials.

Evaluation of Intravenous Acetaminophen on Length of Stay in Abdominal Surgery Patients

Purpose

The objective of this study is to evaluate the effect of intravenous acetaminophen on length of stay (LOS) in abdominal surgery patients.

Methods

This retrospective, cohort chart review evaluated patients who underwent colon resection or pancreaticoduodenectomy between January 1, 2010 and August 31, 2013. The primary outcome is postoperative LOS. Secondary outcomes include opioid use, pain scores, and naloxone or laxative use. Patients who received intravenous acetaminophen were compared to patients who did not.

Results

A total of 329 patients were included, with 269 in the non-acetaminophen group compared to 60 patients in the acetaminophen group. There was no difference in postoperative LOS (9.2 s vs 9.1 days; P = .90). Postoperative LOS was also similar when controlling for surgery type. The acetaminophen group had reduced opioid consumption in the first 24 hours postoperatively (P = .02). However, pain scores were higher in the acetaminophen group, both in the first 24 hours (P = .007) and throughout the hospital stay (P < .001). Other clinical outcomes were similar between groups.

Conclusion

Intravenous acetaminophen was not associated with a decreased postoperative LOS at our institution.

Stress symptoms among adolescents before and after scoliosis surgery: correlations with postoperative pain

AIMS AND OBJECTIVES

The aim of this study was to describe stress symptoms among adolescents before and after scoliosis surgery and to explore correlations with postoperative pain.

BACKGROUND

Scoliosis surgery is a major surgical procedure. Adolescent patients suffer from preoperative stress and severe postoperative pain. Previous studies indicate that there is a risk of traumatisation and psychological complications during the recovery period.

DESIGN

A prospective quantitative cohort study with consecutive inclusion of participants.

METHODS

A cohort of 37 adolescent patients aged 13-18. To assess the adolescents' experiences before surgery and at six to eight months after surgery, the Trauma Symptom Checklist for Children - Alternative version, Youth Self-Report and Kiddie Schedule for Affective Disorder and Schizophrenia for children 12-18 were used. The Visual Analogue Scale was used for self-report of postoperative pain on day three.

RESULTS

Rates of anxiety/depression and internalising behaviour were significantly higher before surgery than six months after. Preoperative anger, social problems and attention problems correlated significantly with postoperative pain on day three. At follow-up, postoperative pain correlated significantly with anxiety, social problems and attention problems.

CONCLUSIONS

The results of this study indicate a need for interventions to reduce perioperative stress and postoperative pain to improve the quality of nursing care.

RELEVANCE TO CLINICAL PRACTICE

Attention to preoperative stress and implementation of interventions to decrease stress symptoms could ameliorate the perioperative process by reducing levels of postoperative pain, anxiety, social and attention problems in the recovery period.

Predictors of postoperative pain and analgesic requirements following abdominal hysterectomy: an observational study

PURPOSE

A prospective observational study is conducted to identify independent predictors of pain and morphine consumption following abdominal hysterectomy.

METHODS

Preoperative State Trait Anxiety Inventory (STAI), Numerical Rating Scales (NRS) for anxiety and pain expectations, thermal pain thresholds and pain scores at forearm and incision site, and pain scores generated from the insertion of an intravenous catheter were measured in female patients undergoing abdominal hysterectomy. Pearson correlations between the predictors and the two outcome measures postoperative pain scores and morphine consumption were studied and multiple regression analysis was conducted to identify independent predictors (primary outcome). Secondary outcomes included cut-off values of predictive tools for morphine consumption.

RESULTS

Data from 60 patients were analyzed. STAI state anxiety, NRS pain expectations, and NRS anxiety scores were identified as independent predictors of postoperative morphine consumption. We identified a cut-off value of 4.5 (sensitivity 90 %, specificity of 60 %) for the NRS anxiety and a cut-off of 42.5 (sensitivity 70 %, specificity 70 %) for the state anxiety STAI score for increased postoperative morphine consumption.

CONCLUSIONS

Preoperative STAI state anxiety scores and NRS pain expectations are independent predictors for increased morphine consumption following hysterectomy. The STAI state anxiety tool and NRS 0-10 anxiety tool can be used interchangeably. The NRS 0-10 anxiety is a much simpler tool than STAI state anxiety and is associated with a higher sensitivity for high morphine consumption. Thermal pain thresholds and IV pain scores were not predictive of postoperative morphine consumption.

Differential predictors of acute post-surgical pain intensity after abdominal hysterectomy and major joint arthroplasty

BACKGROUND

Psychological factors have a significant role in post-surgical pain, and their study can inform pain management.

PURPOSE

The aims of this study are to identify psychological predictors of post-surgical pain following abdominal hysterectomy (AH) and major joint arthroplasty (MJA) and to investigate differential predictors by type of surgery.

METHOD

One hundred forty-two women undergoing AH and 110 patients undergoing MJA were assessed 24 h before (T1) and 48 h after (T2) surgery.

RESULTS

A predictive post-surgical pain model was found for AH and MJA yielding pre-surgical pain experience and pain catastrophizing as significant predictors and a significant interaction of pre-surgical optimism and surgery type. Separate regression models by surgery type showed that pre-surgical optimism was the best predictor of post-surgical pain after MJA, but not after AH.

CONCLUSIONS

Findings highlight the relevance of psychological predictors for both surgeries and the value of targeting specific psychological factors by surgery type in order to effectively manage acute post-surgical pain.

Risk factors associated with postoperative pain after ophthalmic surgery: a prospective study

BACKGROUND

Risk factors associated with postoperative pain intensity and duration, as well as consumption of analgesics after ophthalmic surgery are poorly understood.

METHODS

A prospective study was conducted among adults (N=226) who underwent eye surgery at the University Hospital Split, Croatia. A day before the surgery, the patients filled out questionnaires assessing personality, anxiety, pain catastrophizing, sociodemographics and were given details about the procedure, anesthesia, and analgesia for each postoperative day. All scales were previously used for the Croatian population. The intensity of pain was measured using a numerical rating scale from 0 to 10, where 0 was no pain and 10 was the worst imaginable pain. The intensity of pain was measured before the surgery and then 1 hour, 3 hours, 6 hours, and 24 hours after surgery, and then once a day until discharge from the hospital. Univariate and multivariate analyses were performed.

RESULTS

A multivariate analysis indicated that independent predictors of average pain intensity after the surgery were: absence of premedication before surgery, surgery in general anesthesia, higher pain intensity before surgery and pain catastrophizing level. Independent predictors of postoperative pain duration were intensity of pain before surgery, type of anesthesia, and self-assessment of health. Independent predictors of pain intensity ≥5 during the first 6 hours after the procedure were the type of procedure, self-assessment of health, premedication, and the level of pain catastrophizing.

CONCLUSION

Awareness about independent predictors associated with average postoperative pain intensity, postoperative pain duration, and occurrence of intensive pain after surgery may help health workers to improve postoperative pain management in ophthalmic surgery.

Factors Related to Postoperative Pain Trajectories following Total Knee Arthroplasty: A Longitudinal Study of Patients Admitted to a Russian Orthopaedic Clinic

This study explores sociodemographic, clinical, and surgical factors in relation to pain trajectories during the first 3 days following total knee arthroplasty (TKA). 100 patients (mean age 63.5 ± 7.8 years and 93% female) consecutively admitted for uncomplicated primary TKA were prospectively included. Postoperative pain was assessed using pain diaries. Measures of preoperative pain, symptoms, daily functioning, quality of life, comorbidities, knee function, perioperative characteristics, and physical/biochemical parameters were also evaluated. All pain ratings decreased in the three days following surgery (p < .001) as well as the reported number of daily hours in moderate/severe pain (p < .001). Women reported more pain than men (p = .009). Pain trajectories did not differ by education, employment, cohabitation, or any patient clinical and biochemical characteristics but were significantly related to preoperative anxiety (p = .029). Patients reporting moderate/severe pain prior to surgery also reported more hours in moderate/severe pain on days 0–3 postoperatively (p = .029). Patients with surgeries longer than 90 min reported more hours of moderate/severe pain compared with patients who had shorter surgeries (p = .008), and similar results were observed for ratings of pain with activity (p = .012). In this sample, only female gender, higher levels of preoperative pain and anxiety, and longer surgical duration were associated with increased pain after TKA.

Postoperative pain management

This article provides an overview of current methods used in acute pain management and explains why effective analgesia is crucial in the early postoperative period. It describes the pharmacology of both common and specialist analgesics, as well as explaining the role and uses of regional and neuraxial analgesia, for the non-anaesthetist.

What factors are associated with a second opioid prescription after treatment of distal radius fractures with a volar locking plate?

PURPOSE

Knowledge of factors associated with patient's requests for a second opioid prescription after volar plate fixation of a fracture of the distal radius might inform better pain management protocols and encourage decreased and safer use of opioids. This study tested the primary null hypothesis that there is no difference in demographics, prior opioid prescriptions, injury characteristics, and psychological factors between patients that do and do not receive a second opioid prescription following treatment volar locking plate after distal radius fracture.

PATIENTS AND METHODS

We used data on 206 patients enrolled in one of two prospective studies. Their mean age was 53 years ± SD 15, and 60 (30 %) were men. Forty-seven (23 %) patients received a second opioid prescription. We recorded additional demographics, AO fracture type, American Society for Anesthesiologists (ASA) classification, radiographic parameters at the time of injury prior to reduction and after surgery, and catastrophic thinking.

RESULTS

Male sex (odds ratio [OR] 2.2, 95 % confidence interval [CI] 1.0-4.6, partial pseudo R (2) = 0.018, P = 0.044) and greater dorsal angulation of the articular surface on the lateral post injury radiograph (OR 0.98, 95 % CI 0.96 to 1.0, partial pseudo R (2) = 0.033, P = 0.040) were associated with a second opioid prescription after surgery (pseudo R (2) 0.12, P = 0.0071).

CONCLUSIONS

One measure of fracture severity (dorsal displacement) was independently associated with a second opioid prescription, but alone it accounted for 3.3 % of the variation. Other factors such as the patient's expectation prior to surgery, in particular the realization that injury and surgery hurt, might be addressed in future research.

LEVEL OF EVIDENCE

Prognostic II.

Characteristics of Patients with Lower Extremity Trauma with Improved and Not Improved Pain During Hospitalization: A Pilot Study

Up to 62% of patients report chronic pain at the injury site 6-12 months after blunt trauma, with pain from lower extremity fractures exceeding that from other sites. High pain intensity at time of injury is a risk factor for chronic pain, but it is not clear what patient characteristics influence the pain intensity level during the immediate hospitalization following injury. The purpose of this pilot study was to determine the feasibility of collecting pain scores from medical records to calculate pain trajectories and to determine whether it is possible to examine patient characteristics by classifying them into those whose pain improved and those whose pain did not improve. This descriptive study retrospectively reviewed medical records of 18 randomly chosen patients admitted to an academic trauma center. Patient characteristics and pain scores were collected form electronic and handwritten medical records. The pain trajectories calculated from routinely collected pain scores during the inpatient stay showed that for 44% of patients the pain improved during the hospitalization, for 39% the pain remained the same, and for 17% the pain worsened. The variables age, smoking, weight, abbreviated injury scores, length of hospital stay, mean pain score, and opioid equianalgesic dose differed based on pain trajectory. While patient characteristics differed based on pain trajectory, any significant effects seen from individual tests should be considered tentative, given the number of analyses conducted on this data set. However, feasibility and significance of conducting a larger study has been established.

The Toronto General Hospital Transitional Pain Service: development and implementation of a multidisciplinary program to prevent chronic postsurgical pain

Chronic postsurgical pain (CPSP), an often unanticipated result of necessary and even life-saving procedures, develops in 5-10% of patients one-year after major surgery. Substantial advances have been made in identifying patients at elevated risk of developing CPSP based on perioperative pain, opioid use, and negative affect, including depression, anxiety, pain catastrophizing, and posttraumatic stress disorder-like symptoms. The Transitional Pain Service (TPS) at Toronto General Hospital (TGH) is the first to comprehensively address the problem of CPSP at three stages: 1) preoperatively, 2) postoperatively in hospital, and 3) postoperatively in an outpatient setting for up to 6 months after surgery. Patients at high risk for CPSP are identified early and offered coordinated and comprehensive care by the multidisciplinary team consisting of pain physicians, advanced practice nurses, psychologists, and physiotherapists. Access to expert intervention through the Transitional Pain Service bypasses typically long wait times for surgical patients to be referred and seen in chronic pain clinics. This affords the opportunity to impact patients' pain trajectories, preventing the transition from acute to chronic pain, and reducing suffering, disability, and health care costs. In this report, we describe the workings of the Transitional Pain Service at Toronto General Hospital, including the clinical algorithm used to identify patients, and clinical services offered to patients as they transition through the stages of surgical recovery. We describe the role of the psychological treatment, which draws on innovations in Acceptance and Commitment Therapy that allow for brief and effective behavioral interventions to be applied transdiagnostically and preventatively. Finally, we describe our vision for future growth.

The Impact of Educational Status on the Postoperative Perception of Pain

Background

Postoperative (PO) pain interferes with the recovery and mobilization of the surgical patients. The impact of the educational status has not been studied adequately up to now.

Methods

This prospective study involved 400 consecutive general surgery patients. Various factors known to be associated with the perception of pain including the educational status were recorded as was the preoperative and postoperative pain and the analgesia requirements for the 1^st PO week. Based on the educational status, we classified the patients in 3 groups and we compared these groups for the main outcomes: i.e. PO pain and PO analgesia.

Results

There were 145 patients of lower education (junior school), 150 patients of high education (high school) and 101 of higher education (university). Patients of lower education were found to experience more pain than patients of higher education in all postoperative days (from the 2^nd to the 6^th). No difference was identified in the type and quantity of the analgesia used. The subgroup analysis showed that patients with depression and young patients (< 40 years) had the maximum effect.

Conclusions

The educational status may be a significant predictor of postoperative pain due to various reasons, including the poor understanding of the preoperative information, the level of anxiety and depression caused by that and the suboptimal request and use of analgesia. Younger patients (< 40), and patients with subclinical depression are mostly affected while there is no impact on patients over 60 years old.