Dor crônica persistente pós‐operatória: o que sabemos sobre prevenção, fatores de risco e tratamento?

Assessment of Chronic Postsurgical Pain Knowledge Among Surgical Nurses in a Turkish University Hospital

Objective: Chronic postsurgical pain (CPSP) is a significant yet often underrecognized complication following surgical procedures, impacting patients' quality of life. Surgical nurses play a crucial role in postoperative care and pain management, making their knowledge of CPSP essential for improving patient outcomes. The aim of the study was to assess CPSP knowledge among surgical nurses in a Turkish University Hospital. Methods: This descriptive cross-sectional study included a total of 175 nurses. Data were collected from nurses employed in the surgical units of İnönü University hospital between May 15 and June 15, 2023. Personal information and knowledge-level forms created by the researchers were used for data collection. IBM SPSS Statistics v.25 was used for the statistical analysis. Results: The mean CPSP knowledge score of the nurses working in surgical clinics was 9.26 ± 1.40 (min. = 0, max. = 12) and 75.4% of them had sufficient knowledge. Surgical nurses' knowledge level of CPSP was influenced by their education level (p ≤ 0.001) and total duration of employment in the surgical department (p=0.002). Conclusions: Although most surgical nurses had sufficient CPSP knowledge, gaps remained, particularly among those with lower education levels and less experience. Targeted training programs and continuous professional development initiatives are recommended to enhance CPSP awareness and improve postoperative pain management practices.

[Translated article] Vertebral metastases. En bloc treatment

En bloc resection of vertebral metastases has been the subject of study in medical literature due to its impact on patients' quality of life and effectiveness in local disease control. This bibliographic analysis examines the findings and perspectives of published studies concerning en bloc resection of oligometastases in the spine. The technique, which involves the complete removal of the tumour along with a portion of the surrounding bone, has been shown to improve local tumour control, reduce recurrence, and potentially prolong patient survival compared to conventional decompression and stabilisation techniques. However, en bloc resection also presents risks and complications, such as surgical morbidity and extended recovery time. Appropriate patient selection, preoperative planning, and a multidisciplinary approach are essential to optimise outcomes. As new techniques and advances in adjuvant treatment develop, en bloc resection of oligometastases in the spine remains an area of interest in oncological research.

Vertebral metastases. En bloc treatment

En bloc resection of vertebral metastases has been the subject of study in medical literature due to its impact on patients' quality of life and effectiveness in local disease control. This bibliographic analysis examines the findings and perspectives of published studies concerning en bloc resection of oligometastases in the spine. The technique, which involves the complete removal of the tumour along with a portion of the surrounding bone, has been shown to improve local tumour control, reduce recurrence, and potentially prolong patient survival compared to conventional decompression and stabilization techniques. However, en bloc resection also presents risks and complications, such as surgical morbidity and extended recovery time. Appropriate patient selection, preoperative planning, and a multidisciplinary approach are essential to optimize outcomes. As new techniques and advances in adjuvant treatment develop, en bloc resection of oligometastases in the spine remains an area of interest in oncological research.

"Persistent Post-Operative Pain in Children - An Argument for a Transitional Pain Service in Pediatrics"

BACKGROUND

Persistent post-operative pain continues to occur in pediatric patients. Despite the growing amount of literature on causes, there is little discussion on treatment and prevention with a majority of studies focusing on specific surgeries.

AIM

The aim of this retrospective chart study is to identify risk factors and clinical features of persistent post-operative pain after any surgery in a pediatric quaternary complex pain service, describe the pharmacologic and non-pharmacologic management in children, and explore options to improve outcomes, in particular, the introduction of a transitional pain service.

METHODS

A retrospective chart review recorded demographics, gender, age, pain location and surgery type, treatment, and outcomes of 31 children identified through relevant registers over a 2-year period.

RESULTS

A total of 31 children were positively identified as having persistent post-operative pain and were seen in the complex pain clinic. Consistent with the literature, most cases represented neuropathic pain and persistent post-operative pain was most commonly seen after orthopedic surgery. All but four children had resolution of their pain after implementing the pain management plan. Management was characterized by early intervention, emphasis on non-pharmacologic strategies, and conservative use of opioids.

CONCLUSIONS

Identifying risk factors is useful, however putting strategies into place for prevention is necessary. Early intervention and the implementation of strategies before and immediately after are best provided by a transitional pain service.

Benzodiazepines safeguards nerve cells from the toxicity of lidocaine via miR-133a-3p/EGFR pathway

BACKGROUND

Lidocaine was an anesthetic commonly used for analgesia, but the neurotoxicity could not be ignored. However, benzodiazepines could alleviate the toxicity when combined with other drugs.

PURPOSE

To explore the molecular mechanism of benzodiazepines in protecting nerve cells after the induction of lidocaine.

METHODS

PC12 cells were induced by lidocaine (0 mM, 0.1 mM, 0.5 mM and 1 mM) first and then treated by benzodiazepines (0 μM-200 μM). RT-qPCR assays measured RNA expressions of epidermal growth factor receptor (EGFR) and microRNA-133a-3p (miR-133a-3p) in PC12 cell line, respectively. Western blot was for protein detections of EGFR and caspase-3. Flow cytometry assay assessed apoptosis and cellular viability was validated via Cell Counting Kit-8 (CCK-8) test. Bioinformatics analysis predicted the potential link between miR-133a-3p and EGFR and the binding was verified using the Dual luciferase reporter experiment.

RESULTS

Benzodiazepines increased cellular viability of PC12 cells up to 100 μM while suppressed viability between 100 and 200 μM. Benzodiazepines (0 μM, 10 μM, 50 μM and 100 μM) did not regulate PC12 cell viability but promoted the viability of lidocaine-treated PC12 cells. Lidocaine downregulated miR-133a-3p RNA expression but facilitated EGFR mRNA expression, which was reversed after treated by benzodiazepines. MiR-133a-3p targeted and negatively regulated EGFR expressions in mRNA and protein levels. Furthermore, miR-133a-3p inhibitor and overexpressed EGFR transfection both restrained the decreased PC12 cell viability and prompted cell apoptosis caused by benzodiazepines.

CONCLUSION

Benzodiazepines restrained lidocaine-induced toxicity in PC12 cells which secured viability and reduced apoptosis via miR-133a-3p/EGFR pathway.

Chronic postoperative pain: ubiquitous and scarcely appraised: narrative review

The International Association for the Study of Pain chose pain prevention as the theme for the 2020 Global Year. Chronic postoperative pain is one the many types of pain that can be potentially prevented. It develops or increases in severity after a surgery, persists for at least three months, even after ruling out all other possible causes of pain. To perform the present narrative review, the authors searched the PubMed database using the following keywords "postoperative pain" OR "postsurgical pain" AND "chronic" OR "persistent". The present review focused on the incidence, pain development and chronification, and predisposing factors. It also discusses prevention, diagnosis, and treatment of chronic postoperative pain. Awareness of occurrence of chronic postoperative pain and recognizing risk factors is crucial for the day-to-day practice of the anesthesiologist. Hence, numerous surgical patients can have their outcome improved by preventing chronic postoperative pain, a condition scarcely identified and without a well-established treatment.

Regional anesthetics versus analgesia for stopping the persistent postsurgical pain: A meta-analysis

INTRODUCTION

Regional anesthesia might moderate the risk of persistent postsurgical pain, but its effect compared to systemic analgesia is still conflicting. This meta-analysis study was performed to assess the relationship between the efficiency of regional anesthesia versus systemic analgesia in reducing pain persisting longer than 3 months after surgery.

METHODS

Through a systematic literature search up to August 2020, 31 studies included 2975 subjects who underwent surgery at baseline and reported a total of 1471 subjects using regional anesthesia and 1319 subjects using conventional anesthesia were found recording relationships between efficiency of regional anesthesia versus systemic analgesia in reducing pain persisting longer than 3 months after surgery. Odds ratio (OR) with 95% confidence intervals (CIs) was calculated between regional anesthesia versus systemic analgesia in reducing pain persisting longer than 3 months after surgery using the dichotomous methods with a random or fixed-effect model.

RESULTS

Number of subjects reporting persistent pain 3 months postsurgery was significantly lower in regional anesthesia compared to systemic analgesia in thoracotomy (OR, 0.44; 95% CI, 0.29-0.65, P < .001); breast surgery (OR, 0.46; 95% CI, 0.29-0.72, P < .001); and cesarean section (OR, 0.44; 95% CI, 0.27-0.72, P < .001).

CONCLUSIONS

Regional anesthesia might have an independent relationship with lower pain persisting longer than 3 months after thoracotomy, breast surgery, and cesarean section. Further studies are required to validate these findings.

Inflammatory and healing environment in synovial fluid after anterior cruciate ligament reconstruction: Granulocytes and endogenous opioids as new targets of postoperative pain

Background

Biological processes after anterior cruciate ligament reconstruction (ACLR) is crucial for recovery. However, alterations in the of synovial fluid cell population during the acute phase following ACLR and the relationship between these cells and postoperative pain is unclear. The goal of this study was to reveal alterations in synovial fluid cell population during the acute phase following ACLR and relationship between postoperative pain and proportion of synovial fluid cells.

Methods

Synovial fluids were obtained from all patients (n = 50) before surgery and from patients who showed hydrarthrosis at days 4 (n = 25), and 21 (n = 42) post-surgery. The cell population was analyzed by flow cytometry. IL1β, IL8, and met-enkephalin in synovial fluid were quantitated by enzyme-linked immunosorbent assay. Patients answered numerical rating scale (NRS) questionnaire at 4 days and approximately 4 weeks postoperatively.

Results

The granulocyte population was significantly higher at 4 days after surgery than at any other time points. The population of macrophages was 3.2 times and 7.7 times as high as at surgery on days 4 and 21, respectively. T cell population was significantly higher 21 days after surgery compared to 4 days after surgery. All NRS 4 weeks after surgery showed a significant negative correlation with the granulocyte population in synovial fluid 4 days after surgery. Granulocyte population in synovial fluid significantly correlated with the levels of IL1β and IL8. Postoperative pain at rest tended to decrease with an increase in met-enkephalin concentration 4 days after ACLR.

Conclusions

Synovial fluid after ACLR had an inflammatory environment at early time points and a healing environment in the subsequent phase about concerning to the cellular composition. A proportion of synovial fluid cells and endogenous opioids affected postoperative pain.

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Granulocyte population was higher at 4 days after ACLR than at other time points.

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Postoperative pain negatively correlated with the granulocyte in synovial fluid.

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Granulocyte population in synovial fluid correlate with IL1β and IL8 concentration.

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Postoperative pain tended to decrease with an increase in met-enkephalin.

Evaluation of the Efficacy of Prolonged Pregabalin Administration Before and After Surgery in Patients Undergoing Arthroscopic Anterior Cruciate Ligament Repair: A Prospective, Randomized, Double-blind Study

CONTEXT AND OBJECTIVE

Reconstruction of the knee ligament causes postoperative pain and delayed rehabilitation.

OBJECTIVE

The primary objective of this study was to evaluate the effect of a prolonged preoperative and postoperative pregabalin use for arthroscopic anterior cruciate ligament repair.

MATERIALS AND METHODS

Group 1 (N=25) patients received pregabalin 75 mg/d, and group 2 (N=25) received placebo, 7 days before and 7 days after surgery. Spinal anesthesia was performed using 0.5% hyperbaric bupivacaine (15 mg). The following were evaluated: pain intensity immediately after the surgery, and 12 hours, 24 hours, 1 week, 2 weeks, 1 month, and 2 months after the surgery using a Numerical Rating Scale; dose of postoperative supplementary analgesic for 2 months; time to first analgesic requirement; and side effects during 2 months. For supplementation, the participants received 1 g dipyrone; if there was no pain control, 100 mg ketoprofen was administered; if there was no effect, 100 mg tramadol was administered; and if there was no pain control, 5 mg intravenous morphine was administered until pain control.

RESULTS

There was no difference between the groups with regard to pain intensity (P=0.077). In the pregabalin group, morphine consumption was lower at 12 hours (P=0.039) and 24 hours (P=0.044) after surgery, and the consumption of tramadol and ketoprofen was lower 24 hours after surgery. There was no significant difference in the incidence of nausea and vomiting. Dizziness was higher in the pregabalin group (group 1=12 patients; group 2=3 patients; P=0.005).

DISCUSSION

A prolonged preoperative and postoperative pregabalin prescription for anterior cruciate ligament repair decreased the need for supplementary analgesics during the first 24 postoperative hours but increased dizziness.

Comparison of general anesthesia with endotracheal intubation, combined spinal-epidural anesthesia, and general anesthesia with laryngeal mask airway and nerve block for intertrochanteric fracture surgeries in elderly patients: a retrospective cohort study

BACKGROUND

There is no consensus on the optimal anesthesia method for intertrochanteric fracture surgeries in elderly patients. Our study aimed to compare the hemodynamics and perioperative outcomes of general anesthesia with endotracheal intubation, combined spinal-epidural anesthesia, and general anesthesia with laryngeal mask airway (LMA) and nerve block for intertrochanteric fracture surgeries in elderly patients.

METHODS

This is a retrospective study of 75 patients aged > 60 years scheduled for intertrochanteric fracture surgeries with general anesthesia with intubation (n = 25), combined spinal-epidural anesthesia (n = 25), and general anesthesia with LMA and nerve block (n = 25). The intraoperative hemodynamics were recorded, and the maximum variation rate was calculated. Postoperative analgesic effect was evaluated using the visual analog scale (VAS). Postoperative cognitive status was assessed using the Mini-Mental State Exam (MMSE).

RESULTS

The maximum variation rate of intraoperative heart rate, systolic blood pressure, diastolic blood pressure differed significantly between the three groups (general anesthesia with intubation > combined spinal-epidural anesthesia > general anesthesia with LMA and nerve block). The VAS scores postoperative 2 h, 4 h, 6 h, and 8 h also differed significantly between the three groups (general anesthesia with intubation > combined spinal-epidural anesthesia > general anesthesia with LMA and nerve block). The VAS scores postoperative 24 h were significantly lower in the general anesthesia with LMA/nerve block group than the general anesthesia with intubation group and the combined spinal-epidural anesthesia group. The MMSE scores postoperative 15 min and 45 min differed significantly between the three groups (general anesthesia with intubation < combined spinal-epidural anesthesia < general anesthesia with LMA and nerve block). The MMSE scores postoperative 120 min in the general anesthesia with intubation group were the lowest among the three groups. There was no significant difference in the incidence of respiratory infection postoperative 24 h, 48 h, and 72 h between the three groups.

CONCLUSION

Compared to general anesthesia with intubation and combined spinal-epidural anesthesia, general anesthesia with LMA and nerve block had better postoperative analgesic effect and less disturbances on intraoperative hemodynamics and postoperative cognition for elderly patients undergoing intertrochanteric fracture surgeries.

Poor preoperative sleep quality is a risk factor for severe postoperative pain after breast cancer surgery: A prospective cohort study

The aim of this study was to assess the effect of preoperative sleep quality on acute postoperative pain in breast cancer patients.The Pittsburgh Sleep Quality Index questionnaire (PSQI) was used to assess the overall sleep status of women scheduled for unilateral modified radical mastectomy in the past month. Based on the responses, patients were allocated to good sleep group or poor sleep group. Postoperatively, acute pain was assessed using the numerical rating score in the first 24 hours; in addition, the requirement of analgesics and the incidence of postoperative complications were recorded.A total of 108 breast surgery patients were enrolled. Based on the PSQI results, 55 (51%) patients were allocated to poor sleep group and 53 (49%) to good sleep group. Pain scores were similar in the 2 groups at the end of surgery (P = .589); however, poor sleep group reported higher postoperative pain scores than the good sleep group at 2 (P = .002), 6 (P < .001), 12 (P < .001), and 24 (P = .002) hours after surgery. The incidence of severe pain in the poor sleep group was higher than that in the good sleep group (27% vs 8%, P = .018), and the ratio of participants who required rescued analgesics was greater in the poor sleep group (52% vs 22%, P = .002). In addition, patients with poor sleep quality had more postoperative complications and longer hospital stay.In this study, breast cancer patients with poor preoperative sleep quality reported more severe postoperative pain, required more analgesics, experienced more complications, and had longer hospital stay.

PECS II block is associated with lower incidence of chronic pain after breast surgery

Background

Breast cancer is complicated by a high incidence of chronic postoperative pain (25%–60%). Regional anesthesia might play an important role in lowering the incidence of chronic pain; however it is not known if the pectoral nerve block (PECS block), which is commonly used for breast surgery, is able to prevent this complication. Our main objective was therefore to detect any association between the PECS block and chronic pain at 3, 6, 9, and 12 months in patients undergoing breast surgery.

Methods

We conducted a prospective, monocentric, observational study. We enrolled 140 consecutive patients undergoing breast surgery and divided them in patients receiving a PECS block and general anesthesia (PECS group) and patients receiving only general anesthesia (GA group). Then we considered both intraoperative variables (intravenous opioids administration), postoperative data (pain suffered by the patients during the first 24 postoperative hours and the need for additional analgesic administration) and development and persistence of chronic pain (at 3, 6, 9, and 12 mo).

Results

The PECS group had a lower incidence of chronic pain at 3 months (14.9% vs. 31.8%, P = 0.039), needed less intraoperative opioids (fentanyl 1.61 μg/kg/hr vs. 3.3 μg/kg/hr, P < 0.001) and had less postoperative pain (3 vs. 4, P = 0.017).

Conclusions

The PECS block might play an important role in lowering incidence of chronic pain, but further studies are needed.

[Research progress of the role of postoperative pain in the development of postoperative cognitive dysfunction in geriatric patients]

Previous studies have shown that postoperative cognitive dysfunction (POCD) is related to multiple factors including age, postoperative trauma, inflammation, postoperative pain, and anesthesia, among which postoperative pain is thought to play an important role in the development of POCD. This review summarizes the recent findings in the study of the role of postoperative pain in the pathogenesis of POCD in light of nerve injuries, neural remodeling and stress, and the progress in the prevention and treatment of POCD in elderly patients. It is of vital important to assess the postoperative pain and formulate adequate analgesic regimens for effective prevention and management of POCD to protect the brain functions of elderly patients.

The Influence of Race, Ethnicity and Genetic Variants on Postoperative Pain Intensity: An Integrative Literature Review

OBJECTIVES

Chronic postsurgical pain is pain that develops and persists for at least 3 months after a surgical procedure. The purpose of this review was to discover what evidence exists regarding the influence of race and ethnicity on postoperative pain intensity and what evidence exists regarding the influence of genetic polymorphisms on postoperative pain intensity.

DESIGN

Integrative literature review.

DATA SOURCES

CINAHL, PsychInfo, SCOPUS, and PubMed/Medline databases were searched for entries within the last 10 years. Sources included primary research investigating the relationship among race, ethnicity, and genetics in postoperative pain outcomes.

REVIEW/ANALYSIS METHODS

Studies adhered to a strict inclusion and exclusion criteria. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized to evaluate and assess manuscripts for inclusion.

RESULTS

Twelve manuscripts were included for final review. There are significantly higher preoperative and postoperative pain intensity scores reported between African American and Hispanic individuals compared with non-Hispanic whites. Although some studies identified that non-Hispanic whites consumed more opioids and reported increased pain, there were no significant differences in opioid requirements in Hispanic and non-Hispanic individuals. COMT and OPRM1 were the most identified genetic polymorphisms associated with postoperative pain intensity.

CONCLUSIONS

The literature varies with respect to race, ethnicity, and postoperative pain perception. Perioperative pain intensity has been suggested as a significant predictor of chronic postsurgical pain. COMT and OPRM1 may be associated with higher pain perception after surgical procedures.

Persistent breast pain in post-surgery breast cancer survivors and women with no history of breast surgery or cancer: associations with pain catastrophizing, perceived breast cancer risk, breast cancer worry, and emotional distress

Background: Persistent breast pain (PBP) is prevalent among breast cancer survivors and has powerful negative psychological consequences. The present study provided a first test of the hypothesis that: (a) pain catastrophizing, (b) heightened perceived risk of cancer, and (c) worry that pain indicates cancer may be independent mediating links between breast cancer survivors' experiences of PBP and heightened emotional distress. Methodology: We assessed levels of PBP and psychological factors in breast cancer survivors (Survivor Group: n = 417; Stages I-IIIA; White = 88.7%; Age M = 59.4 years) at their first surveillance mammogram post-surgery (6-15 months). A comparison group of women without histories of breast surgery or cancer (Non-cancer Group: n = 587; White = 78.7%; Age M = 57.4 years) was similarly assessed at the time of a routine screening mammogram. All women completed measures of breast pain, pain catastrophizing, perceived breast cancer risk, and worry that breast pain indicates cancer, as well as measures of emotional distress (symptoms of anxiety, symptoms of depression, and mammography-specific distress). Analyses included race, age, BMI, education, and menopausal status as covariates, with significance set at 0.05. Results: As expected, PBP prevalence was significantly higher in the Survivor Group than in the Non-cancer Group (50.6% vs. 17.5%). PBP+ survivors also had significantly higher levels of emotional distress, pain catastrophizing, mammography-specific distress, and worry that breast pain indicates cancer, compared to PBP- survivors. Structural equation modeling results were significant for all hypothesized mediational pathways. Interestingly, comparisons of PBP+ to PBP- women in the Non-cancer Group showed similar results. Conclusion: These findings suggest the importance of (a) pain catastrophizing, (b) perceived breast cancer risk and, (c) worry that breast pain may indicate cancer, as potential targets for interventions aimed at reducing the negative psychological impact of PBP in post-surgery breast cancer survivors, as well as in unaffected women with PBP due to unknown reasons.

Epidemiology of Persistent Postsurgical Pain Manifesting as Dry Eye-Like Symptoms After Cataract Surgery

PURPOSE

To evaluate the epidemiology of persistent postsurgical pain (PPP) manifesting as dry eye (DE)-like symptoms 6 months after surgery.

METHODS

This single-center study included 119 individuals whose cataract surgeries were performed by a single surgeon at the Bascom Palmer Eye Institute and who agreed to participate in a phone survey 6 months after surgery. Patients were divided into 2 groups: the PPP group was defined as those with a Dry Eye Questionnaire-5 score ≥6 and without PPP as those with a Dry Eye Questionnaire-5 score <6 at 6 months after cataract surgery.

RESULTS

Mean age of the study population was 73 ± 8.0 years; 55% (n = 66) were female. PPP was present in 34% (n = 41) of individuals 6 months after surgery. Factors associated with an increased risk of PPP were female sex [odds ratio (OR) = 2.68, 95% confidence interval (CI) = 1.20-6.00, P = 0.01], autoimmune disorder (OR = 13.2, CI = 1.53-114, P = 0.007), nonocular chronic pain disorder (OR = 4.29, CI = 1.01-18.1, P = 0.06), antihistamine use (OR = 6.22, CI = 2.17-17.8, P = 0.0003), antireflux medication use (OR = 2.42, CI = 1.04-5.66, P = 0.04), antidepressant use (OR = 3.17, CI = 1.31-7.68, P = 0.01), anxiolytic use (OR = 3.38, CI = 1.11-10.3, P = 0.03), and antiinsomnia medication use (OR = 5.28, CI = 0.98-28.5, P = 0.047). PPP patients also reported more frequent use of artificial tears (P < 0.0001), higher ocular pain levels (P < 0.0001), and greater neuropathic ocular pain symptoms, including burning (P = 0.001), wind sensitivity (P = 0.001), and light sensitivity (P < 0.0001).

CONCLUSIONS

PPP in the form of persistent DE-like symptoms is present in approximately 34% of individuals 6 months after cataract surgery. The frequency of PPP after cataract surgery is comparable to that of other surgeries including laser refractive surgery, dental implants, and genitourinary procedures.

Epidemiology of Persistent Dry Eye-Like Symptoms After Cataract Surgery

PURPOSE

To evaluate the frequency and risk factors for persistent postsurgical pain (PPP) after cataract surgery, defined as mild or greater dry eye (DE)-like symptoms 6 months after surgery.

METHODS

This single-center study included 86 individuals who underwent cataract surgery between June and October 2016 and had DE symptom information available 6 months after surgery. Patients were divided into 2 groups: controls were defined as those without DE symptoms 6 months after surgery (defined by a Dry Eye Questionnaire 5 (DEQ5) score <6), cases were defined as those with mild or greater DE-like symptoms 6 months after surgery (DEQ5 ≥6).

RESULTS

Mean age of the study population was 71 ± 8.6 years; 95% (n = 82) were men. DE-like symptoms were reported in 32% (n = 27) of individuals 6 months after cataract surgery; 10% (n = 8) reported severe symptoms (DEQ5 ≥12). Patients with DE-like symptoms after cataract extraction also had higher ocular pain scores and specific ocular complaints (ocular burning, sensitivity to wind and light) compared with controls with no symptoms. A diagnosis of nonocular pain increased the risk of DE-like symptoms after cataract surgery (odds ratio 4.4, 95% confidence interval 1.58-12.1, P = 0.005).

CONCLUSIONS

Mild or greater PPP occurred in approximately 1/3 of individuals after cataract surgery. Prevalence of severe PPP is in line with that of refractive surgery, dental implants, and genitourinary procedures.

Chronic postsurgical pain: current evidence for prevention and management

Chronic postsurgical pain (CPSP) is an unwanted adverse event in any operation. It leads to functional limitations and psychological trauma for patients, and leaves the operative team with feelings of failure and humiliation. Therefore, it is crucial that preventive strategies for CPSP are considered in high-risk operations. Various techniques have been implemented to reduce the risk with variable success. Identifying the risk factors for each patient and applying a timely preventive strategy may help patients avoid the distress of chronic pain. The preventive strategies include modification of the surgical technique, good pain control throughout the perioperative period, and preoperative psychological intervention focusing on the psychosocial and cognitive risk factors. Appropriate management of CPSP patients is also necessary to reduce their suffering. CPSP usually has a neuropathic pain component; therefore, the current recommendations are based on data on chronic neuropathic pain. Hence, voltage-dependent calcium channel antagonists, antidepressants, topical lidocaine and topical capsaicin are the main pharmacological treatments. Paracetamol, NSAIDs and weak opioids can be used according to symptom severity, but strong opioids should be used with great caution and are not recommended. Other drugs that may be helpful are ketamine, clonidine, and intravenous lidocaine infusion. For patients with failed pharmacological treatment, consideration should be given to pain interventions; examples include transcutaneous electrical nerve stimulation, botulinum toxin injections, pulsed radiofrequency, nerve blocks, nerve ablation, neuromodulation and surgical management. Physical therapy, cognitive behavioral therapy and lifestyle modifications are also useful for relieving the pain and distress experienced by CPSP patients.

Consensus Statement for Clinical Pathway Development for Perioperative Pain Management and Care Transitions

The perioperative surgical home (PSH) model has been created with the intention to reduce costs and to improve efficiency of care and patient experience in the perioperative period. The PSH is a comprehensive model of care that is team-based and patient-centric. The team in each facility should be multidisciplinary and include the input of perioperative services leadership, surgical services, and support personnel in order to provide seamless care for the patient from the preoperative period when decision to undergo surgery is initially made to discharge and, if needed after discharge from the hospital, until full recovery is achieved. PSH is discussed in this consensus article with the emphasis on perioperative care coordination of patients with chronic pain conditions. Preoperative optimization can be successfully undertaken through patient evaluation, screening, and education. Many important positive implications in the PSH model, in particular for those patients with increased potential morbidity, mortality, and high-risk populations, including those with a history of substance abuse or anxiety, reflect a more modern approach to health care. Newer strategies, such as preemptive and multimodal analgesic techniques, have been demonstrated to reduce opioid consumption and to improve pain relief. Continuous catheters, ketamine, methadone, buprenorphine, and other modalities can be best delivered with the expertise of an anesthesiologist and a support team, such as an acute pain care coordinator. A physician-led PSH is a model of care that is patient-centered with the integration of care from multiple disciplines and is ideally suited for leadership from the anesthesia team. Optimum pain control will have a significant positive impact on the measures of the PSH, including lowering of complication rates, lowering of readmissions, improved patient satisfaction, reduced morbidity and mortality, and shortening of hospital stays. All stakeholders should work together and consider the PSH model to ensure the best quality of health care for patients undergoing surgery in the future. The pain management physician's role in the postoperative period should be focused on providing optimal analgesia associated with improved patient satisfaction and outcomes that result in reduced health care costs.