Pain management in ambulatory surgery

Preoperative analgesic instruction and prescription reduces early home pain after outpatient surgery: a randomized controlled trial

BACKGROUND

Home pain remains the most common complication in outpatient surgery. Optimal management requires good information and early availability of analgesics. The main objective of this randomized controlled trial was to compare the effects of pre- vs postoperative analgesic instruction and prescription on postoperative home pain.

METHODS

Patients were randomized into an anesthesia consultation group (AC group) and a standard postoperative group (POP group). The AC group and the POP group received analgesic prescription and instruction during the anesthesia consultation and after surgery, respectively. The primary outcome was the incidence of home pain on postopertive day one (D1). Home pain was defined by at least one episode with a numeric rating scale score > 3/10 at rest. Treatment compliance and postoperative nausea and vomiting (PONV) were also assessed on D1 and postoperative day 7 (D7).

RESULTS

One hundred and eighty-six patients were included between May 2017 and May 2018 at Rouen University Hospital, France. Ninety-four patients were randomized to the AC group and 92 to the POP group. On D1, the incidence of pain was 23/94 (24%) in the AC group and 44/92 (48%) in the POP group (P < 0.001). On D1, the rate of treatment compliance was significantly higher in the AC group than in the POP group (85% vs 69%; P = 0.02). There was no statistically significant difference in the incidence of pain or treatment compliance between groups on D7 or in PONV on D1 and on D7.

CONCLUSIONS

Preoperative analgesic instruction and prescription during anesthesia consultation reduces the incidence of early postoperative home pain in outpatient surgery.

TRIAL REGISTRATION

www.clinicaltrialsgov (NCT03205189); registered 2 July 2017.

The Effect of Text Messaging on Medication Adherence After Outpatient Knee Arthroscopy: A Randomized Controlled Trial

PURPOSE

The purpose of this project was to examine if text message reminders can increase postoperative adherence to treatment with acetaminophen among outpatients undergoing arthroscopic knee surgery.

DESIGN

A nonblinded randomized control trial.

METHODS

In this study, 187 patients were randomized to either an intervention group (text message reminders) or a control group (no text message reminders). On the fourth postoperative day, all patients received an electronic questionnaire concerning (1) adherence to treatment with acetaminophen (main outcome), (2) pain intensity, and (3) unscheduled health care contacts.

FINDINGS

Data were available from 134 patients (intervention group, n = 70; control group, n = 64). No significant differences between groups were found regarding the median number of missed acetaminophen doses (1 vs 2.5; P = .06), pain intensity at rest and during walking, or the number of unscheduled health care contacts (7 vs 4; P = .35).

CONCLUSIONS

A nonsignificant trend toward an increased medication adherence of acetaminophen was found.

Effectiveness of postoperative analgesia in the management of acute pain in day-case surgeries

Background:

Surgery is the most common source of acute pain.

Aim:

To determine the intensity of acute pain following day case surgery and evaluate the effectiveness of the prescribed analgesics.

Methods:

A descriptive observational study carried out at the main operating and the Urology Outpatient theatre suites of the University College Hospital, Ibadan. Seventy consecutive adult patients presenting for day case surgeries between July and September 2013 were recruited. The procedures were stratified as follows: peripheral, groin/perineal, urologic/endoscopy or orthopedic/plastic surgeries. The prescribed postoperative oral analgesics were paracetamol alone or in combination with diclofenac, tramadol or both. Postoperative pain intensity was assessed on arrival in the recovery room and at 6, 12, 24, 48, & 72 hours using the Verbal Intensity Pain Scale (VIPS). The pain scores were presented as mean±SD at different time intervals for each stratified surgical procedures and analgesics using tables and frequency bar charts. A mean pain score of less than 2 for each category of surgical procedures or analgesics group was considered as satisfactory pain control and thus effective analgesia.

Result:

The overall prevalence of moderate to worst possible pain after surgery in this study was 54.3% on arrival in the recovery room. The mean pain score was greater than 2 at 6 hours postoperative in all surgical categories except in patients who had peripheral surgeries irrespective of single or combination analgesic therapy.

Conclusion:

A high proportion of patients arrived in the recovery room with a high pain score; measures to improve intraoperative analgesia should be employed.

Predicting recovery at home after ambulatory surgery

The correct implementation of Ambulatory Surgery must be accompanied by an accurate monitoring of the patient post-discharge state. We fit different statistical models to predict the first hours postoperative status of a discharged patient. We will also be able to predict, for any discharged patient, the probability of needing a closer follow-up, or of having a normal progress at home.

BACKGROUND

The status of a discharged patient is predicted during the first 48 hours after discharge by using variables routinely used in Ambulatory Surgery. The models fitted will provide the physician with an insight into the post-discharge progress. These models will provide valuable information to assist in educating the patient and their carers about what to expect after discharge as well as to improve their overall level of satisfaction.

METHODS

A total of 922 patients from the Ambulatory Surgery Unit of the Dr. Peset University Hospital (Valencia, Spain) were selected for this study. Their post-discharge status was evaluated through a phone questionnaire. We pretend to predict four variables which were self-reported via phone interviews with the discharged patient: sleep, pain, oral tolerance of fluid/food and bleeding status. A fifth variable called phone score will be built as the sum of these four ordinal variables. The number of phone interviews varies between patients, depending on the evolution. The proportional odds model was used. The predictors were age, sex, ASA status, surgical time, discharge time, type of anaesthesia, surgical specialty and ambulatory surgical incapacity (ASI). This last variable reflects, before the operation, the state of incapacity and severity of symptoms in the discharged patient.

RESULTS

Age, ambulatory surgical incapacity and the surgical specialty are significant to explain the level of pain at the first call. For the first two phone calls, ambulatory surgical incapacity is significant as a predictor for all responses except for sleep at the first call.

CONCLUSIONS

The variable ambulatory surgical incapacity proved to be a good predictor of the patient's status at home. These predictions could be used to assist in educating patients and their carers about what to expect after discharge, as well as to improve their overall level of satisfaction.

Avaliação da dor em criocirurgia de ceratoses actínicas

FUNDAMENTOS: a ceratose actínica é lesão pré-maligna frequente, que ocorre em áreas expostas à luz solar, em pessoas idosas ou adultas de meia-idade e pele clara. A criocirurgia com nitrogênio líquido é a modalidade mais comum para o tratamento de ceratoses actínicas. OBJETIVOS: o objetivo primário deste estudo foi medir a intensidade da dor durante a criocirurgia, por meio da Escala Visual Análoga. Também buscou-se identificar o nível de dor considerado adequado pelo paciente, avaliar a proporção de pacientes que consideram necessária a diminuição da dor sentida e verificar a necessidade ou não de analgesia suplementar. MÉTODOS: Estudo transversal com pacientes encaminhados para terapêutica criocirúrgica de ceratoses actínicas no Ambulatório de Dermatologia Sanitária. Foram avaliados 112 pacientes, após tratamento de ceratoses actínicas, aplicando-se um questionário com perguntas sobre a intensidade da dor sentida durante o procedimento cirúrgico, assim como a dor considerada confortável ou adequada ao procedimento. RESULTADOS: participaram 48 homens (42,8%) e 64 mulheres (57,2%). A média da dor referida durante o procedimento cirúrgico, medida em milímetros na Escala Visual Análoga, foi de 32,85 mm; a média da dor considerada adequada pelos pacientes foi de 23,01 mm. A diferença entre as duas médias foi estatisticamente significativa (p<0,05). Em questionário objetivo e direto, a percentagem de pacientes que referiu ser necessária a diminuição da dor foi 30,4%. CONCLUSÕES: embora a dor considerada adequada seja menor estatisticamente do que a sentida, não alcança níveis suficientes para que seja atribuída a necessidade de método de analgesia suplementar neste tipo de intervenção

Clinical practice and routines for day surgery in Sweden: implications for improvement in nursing interventions

The purpose of this study was to examine nursing practice in day surgery settings in Sweden. A questionnaire focusing on the routines of the day surgery process of patients in Sweden was administered. Based on these findings, appropriate nursing interventions are outlined and discussed. Day surgery routines were in accordance with general worldwide practice. The study revealed that nursing involvement was rare in the preoperative routine. In addition, the major part of the recovery process, including assessments of discharge eligibility and information about pain management, was managed by PACU nurses. The nurse follow-up revealed a number of subjective queries and symptoms that, in a seemingly easy way, could have been prevented by further perianesthesia/perioperative patient education. There is an obvious place for nursing interventions when the decision for day surgery is taken. These interventions should focus on providing the patient with information before surgery, preoperative patient health screening, and information/education at discharge. Furthermore, nursing interventions should include quality assurance, such as follow-up calls for the evaluation of care, as well as providing information and coaching for the patient at home.

Etoricoxib, paracetamol, and dextropropoxyphene for postoperative pain management: a questionnaire survey of consumption of take-home medication after elective hallux valgus surgery

In this study, patients were presented with a questionnaire-based survey about the consumption of analgesics and pain ratings up to the third postoperative day following elective hallux valgus surgery. The aim was to study the consumption of analgesics and to look for factors influencing the need for rescue analgesia. All patients were provided with take-home oral medication, with etoricoxib 120 mg once daily, paracetamol 1 to 4 g daily, and dextropropoxyphene 100 mg provided as add-on rescue analgesics in a stepwise fashion. Thirty-five of the 102 patients responding (response rate 91%) did not take any further analgesics during the entire 4-day follow-up period than the recommended coxib, 67 patients took at least 1 tablet of rescue analgesic, 41 took only paracetamol, and 26 patients (25%) took paracetamol plus at least 1 dextropropoxyphene. There was a significant association between the subjective experience of pain and consumption of analgesics. Female gender and low age were significantly associated with the consumption of analgesics. A stepwise approach based on etoricoxib, paracetamol, and a small number of opioid tablets seems to be a rational approach for take-home medication following a standardized hallux valgus surgery. Female gender and lower age comprise a group that warrants special atten group that warrants special attention.

Effects of diclofenac and tenoxicam on distraction osteogenesis

INTRODUCTION

In the management of bone defects, pseudoarthrosis, deformities, chronic osteomyelitis and in extremity lengthening procedures, the technique of distraction osteogenesis (DO) has been frequently used. In this experimental animal study, the effects of two non-steroidal anti-inflammatory drugs, i.e., diclofenac and tenoxicam, on the outcomes of distraction osteogenesis are investigated.

MATERIALS AND METHODS

In this study, 30 mature New Zealand-type male rabbits (2.5-4.5 kg) were used. The rabbits were randomized into three groups, each consisting of ten animals. Under optimal operating conditions, a pre-reconstructed circular external fixator was applied on the right tibias of rabbits, and osteotomy was performed with a Gigli saw just below the tibial tuberosity. After seven postoperative days, distraction was initiated at a rhythm of 2 x 0.5 mm/day. During the 10 days of distraction, adjunctive therapy was not instituted for group I (control group). For 10 days, group II received i.m. diclofenac sodium (0.5 mg/kg per day) and group III was treated with tenoxicam (8 mg/kg per day i.m.). At the end of 3 weeks postoperatively, five rabbits from each group were killed for histologic examinations. The remaining rabbits were killed at the end of eight postoperative weeks for biomechanical and histological analysis. Besides, radiological examinations were performed at the end of 3, 6 and 8 weeks postoperatively for the radiologic evaluation of calluses. For statistical evaluations between groups, Kruskal-Wallis variance analysis, and for intergroup assessments, Mann-Whitney test were performed.

RESULTS

For radiological evaluations, the scoring system developed by Lane and Sandhu, and for histopathological assessments, the grading system of Huddlestone et al. were used. Biomechanical tests were realized using torsional loading. During the first 3 weeks, the groups did not differ much in the radiological parameters. However, in the diclofenac group and in especially the tenoxicam group, the histological scores were lower than in the control group. Radiological images obtained at the end of 6 weeks demonstrated inadequate consolidation in the diclofenac and tenoxicam groups when compared with the control group. At the end of 8 weeks postoperatively, in consideration of biomechanical, radiological and histological tests, significantly worse regenerates were obtained in the diclofenac and tenoxicam groups.

CONCLUSIONS

During the distraction osteogenesis period, diclofenac and tenoxicam affected the quality of regenerate unfavorably. This effect is sustained during all periods of bone healing. However, this finding should be supported by experimental and human studies.

Efficacy and safety of oxymorphone immediate release for the treatment of mild to moderate pain after ambulatory orthopedic surgery: results of a randomized, double-blind, placebo-controlled trial

OBJECTIVE

To assess the analgesic efficacy and safety of 5 mg of oxymorphone immediate release (IR) for mild to moderate pain.

DESIGN

Multicenter, double-blind, randomized, placebo-controlled study.

SETTING

Ambulatory surgical centers.

PARTICIPANTS

Outpatients (age, > or = 18 y) undergoing knee arthroscopy.

INTERVENTION

Randomization to 5 mg of oxymorphone IR or placebo hourly as needed for up to 8 hours.

MAIN OUTCOME MEASURE

Sum of pain intensity difference (SPID) from baseline to 8 hours.

RESULTS

Among 122 patients randomized, 70.5% and 28.7% had moderate or mild postsurgical pain at baseline, respectively. The mean SPID score was significantly greater in the oxymorphone IR group, showing greater pain relief, compared with the placebo group (least squares mean difference +/- standard error, 76.9+/-28.09; 95% confidence interval, 21.26-132.59; P=.007). More placebo patients (48.4%) required rescue medication than oxymorphone IR patients (16.7%), with median times to use of rescue medication of 6 hours 54 minutes and more than 8 hours, respectively (P<.001). More patients (47.4%) rated oxymorphone IR "very good" or "excellent" for pain relief versus placebo (25.0%). No oxymorphone IR-treated patients discontinued because of adverse events (AEs) or experienced serious AEs.

CONCLUSIONS

Five milligrams of oxymorphone IR was well tolerated and effective at relieving mild or moderate postsurgical pain after outpatient knee surgery.

Flagging the pain

Chronic pain represents a major public health problem that impacts negatively on quality-of-life issues and healthcare costs. Unrelieved acute post-traumatic and postoperative pains are risk factors in the development of chronic pain, although psychological and environmental factors are at work as well. Flagging pain (blue, yellow and red flags) helps to identify risk factors in acute pain that need attention to avoid the transition from acute postoperative pain to acute persistent and then on to chronic pain. This offers a unique opportunity for preventative medicine.