Prevalence of postoperative pain after hospital discharge: systematic review and meta-analysis

The effect of adductor canal block on outcomes of total knee arthroplasty: A single centre, historical cohort study

Background

Adductor canal blocks (ACBs) have been associated with reduced pain following total knee arthroplasty (TKA). There is a paucity of evidence regarding whether these early differences impact longer term outcomes. This study aimed to identify whether using ACB in TKA was associated with improvements in both early and late outcomes.

Methods

Patients who underwent a unilateral TKA between 2021 and 2022 were retrospectively assessed for pain scores, time to first mobilization and opioid use over the first 72 h. At 6 weeks, complications, pain scores and opioid use were assessed. At 12 months validated patient reported outcome measures (PROMs) and patient satisfaction with their surgery were assessed.

Results

262 unilateral TKA, of whom 129 received ACB (ACB group) and 133 did not (control group) were assessed. The ACB group had significantly lower median day 1 pain (median difference -0.44 (-0.09 to -0.79), p = 0.015). There was no significant difference between groups for pain after 24 h, time to mobilization or opioid use over 72 h. There was no significant difference in pain (p = 0.892), opioid use (p = 0.913) or complications (p = 0.348) at 6 weeks, or median change in PROMs (p = 0.436 and p = 0.307), opioid use (p = 0.187), or satisfaction with surgery (p = 0.262) at 12 months.

Conclusion

ACBs were associated with a clinically insignificant difference in median pain on day 1. there was no association with pain after 24 h, opioid use, time to mobilization or longer term outcomes. Our findings do not support the use of routine ACB during TKA.

Impacts of opioid stewardship in surgical settings: a scoping review

ABSTRACT

Opioid stewardship programs have been implemented in many countries to reduce harms related to prescription opioid use. Yet, there is an evidence gap on the impact of these programs in surgical settings. This systematic scoping review aimed to examine the impact of opioid stewardship on opioid use and clinical outcomes, alongside assessing adherence, and barriers to its implementation in surgical settings. A systematic search strategy was developed and applied among 7 electronic databases for published literature. In total, 100 eligible articles were included in the review. Most studies showed that opioid stewardship reduced the quantity of opioid use (in 83/88 studies; 94%) and the number of days of opioid supplied (15/18; 83%). No effect was seen on the rate of opioid refills (34/44; 78%), postoperative pain scores (22/23; 96%), and length of hospital stay (12/15; 80%). The adherence rates ranged from 32% to 100%, with considerable heterogeneity in the indicators used to measure the quality use of opioids. Logistical issues, patients' demand for analgesics, clinicians' uncertainty regarding the efficacy of nonopioid analgesics, and a lack of role allocation were reported as major barriers to implementation. Opioid stewardship can improve the quality use of opioids without adversely affecting clinical outcomes. The variety of opioid stewardship types, measurement metrics, study designs, and different surgeries pose challenges in determining causal relationships. Future prospective studies using standardized approaches are needed to develop more robust evidence.

Factors influencing surgical anxiety and postoperative pain: a comprehensive evaluation of psychological and gynecological determinants

BACKGROUND

Postoperative pain is a persistent challenge in gynecological surgery, influenced by psychological and clinical factors. Surgical anxiety, a critical preoperative psychological state, is shaped by underlying psychological conditions that can affect pain experiences during recovery. This study aimed to explore the psychological factors contributing to surgical anxiety and their interaction with postoperative pain outcomes, focusing on anxiety, psychological distress, and general gynecological status.

METHODS

A cross-sectional study was conducted with 114 women undergoing gynecological surgery at a tertiary care hospital. Data collection included demographic and clinical characteristics, along with psychological assessments using the surgical anxiety questionnaire, Kessler psychological distress scale, and general health questionnaire-12. Postoperative pain was evaluated using the American Pain Society Patient Outcome Questionnaire-Revised and the Postoperative Pain Assessment Tool-Day 1/7. Statistical analyses involved correlation tests, group comparisons, and structural equation modeling (SEM).

RESULTS

Psychological distress and general health were significant predictors of surgical anxiety. Higher levels of surgical anxiety were associated with increased psychosocial impacts on postoperative pain, particularly in activity interference and self-care. SEM analysis revealed moderate indirect effects of surgical anxiety on pain outcomes through psychological distress, while direct effects on pain were minimal.

CONCLUSIONS

Preoperative assessments of psychological distress and general health are essential for understanding surgical anxiety and its nuanced impact on postoperative pain. Tailored pain management strategies that address both psychological and clinical factors may enhance recovery and patient satisfaction following gynecological surgery.

Voices of surgical wards nurses on barriers hindering acute post-operative pain management at Tshwane municipality, South Africa

INTRODUCTION AND BACKGROUND

Acute pain is expected following a surgery, but it is often inadequately managed by health care providers. However, little is known about the barriers that hinder acute post-operative pain management among surgical wards nurses.

OBJECTIVE

Uncovering barriers that hinder the surgical wards nurses to manage acute post-operative pain at the selected public hospital in Tshwane municipality, Gauteng Province, South Africa.

METHODS

This study utilized a qualitative explorative, descriptive, and contextual research design. Individual semi-structured interviews were conducted from a purposive sampling of 13 professional nurses. Data collected were audio recorded and transcribed verbatim by the first author. Data were analysed using thematic data analysis, which led to the emergence of themes and sub-themes. An independent co-coder assisted with data analysis.

FINDINGS

The barriers described by the participants include: 1) Organisational/ management related barriers; 2) Personnel related barriers, which were discussed as shortage of nurses, inadequate skill competency to manage acute post-operative pain, and interprofessional communication; and 3) Patient related barriers.

CONCLUSION

This paper comes to the conclusion that, due to a number of stated barriers or obstacles, the nurses employed in the surgical wards of the selected hospital in South Africa are not adequately managing the acute post-operative pain. As a result, hospital management must devise practical solutions to the stated obstacles.

Risk factors for persistent postoperative opioid use: an entity distinct from chronic postsurgical pain

Despite a decline in opioid prescriptions over the past decade, patients commonly receive opioid analgesics as a treatment for postoperative pain in the USA. One complication that patients may experience after surgery is persistent postoperative opioid use (PPOU), or opioid use beyond the typical recovery period. Often defined as beyond 3 months postsurgery, PPOU is frequently conflated with chronic postsurgical pain (CPSP), where pain persists well after the expected healing time following surgery. This narrative review explores the distinct risk factors for each condition, their interrelation, and potential future research directions.For PPOU, major risk factors include the risky use of substances including misuse and use disorders; depression and other mental health disorders; a history of chronic pain before surgery including back pain; and certain surgical types (ie, total knee arthropathy, open cholecystectomy, total hip arthropathy). Conversely, CPSP risk factors include the type of surgery (ie, thoracic and breast surgeries), mental health conditions (particularly catastrophizing), and pain in both the preoperative and postoperative phases. Despite the overlap of some factors, studies typically employ different frameworks when examining PPOU and CPSP, with a biopsychosocial model applied for CPSP and little emphasis on an individual's social environment employed for PPOU. Additionally, existing studies predominantly rely on retrospective insurance claims data, which may not capture the full scope of risk factors.To fill gaps in understanding, investigations may prospectively assess and analyze patient-reported outcomes, implement similar frameworks, and concurrently measure both conditions to advance the scientific understanding of PPOU and CPSP.

Effects of Repeated Feedback on Pain Documentation: A Cluster Randomized Trial

PURPOSE

The study aimed to determine how pain documentation audits and repeated feedback (REFPAD intervention) affect registered nurses' pain documentation and knowledge, and to discover how background variables relate to such documentation and knowledge.

DESIGN

A cluster randomized trial.

METHODS

Thirty work units in a university hospital were randomized into intervention (n = 15) and control (n = 15) groups. The intervention group received monthly pain documentation audits and feedback, while the control group received no feedback. A pain knowledge test was conducted in three phases. Data were collected from February to November 2022. A linear mixed model was used to detect the effects of the REFPAD intervention.

RESULTS

The REFPAD intervention positively affected pain documentation quality, but its statistical significance was lost because of substantial within-unit variation. At baseline, pain documentation quality scores were in intervention 35% and control 38%. After 8 months of feedback, the quality scores were 44% and 43%. The number of pain assessments per patient per day was the only factor that affected pain documentation quality. The REFPAD intervention had no effect on pain knowledge.

CONCLUSIONS

The REFPAD intervention may improve pain documentation quality. A more comprehensive analysis of implementation barriers and facilitators is needed to reduce variations between and within work units.

CLINICAL IMPLICATIONS

More focus should be paid to feedback implementation and continuous monitoring of the quality of pain care is recommended.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05373641. Registration date: February 22, 2022.

Efficacy of Duloxetine for Postspine Surgery Pain: A Systematic Review and Meta-Analysis

BACKGROUND

Duloxetine, a serotonin and norepinephrine reuptake inhibitor (SNRI), is used to treat various health conditions, including major depressive disorder, generalized anxiety disorder, fibromyalgia, and off-label for chemotherapy-induced pain. We conducted this systematic review and meta-analysis aiming to test the current evidence regarding effectiveness and safety of duloxetine for postspine surgeries pain.

METHODS

We searched the Cochrane Central Register of Controlled Trials, PubMed, Scopus and Web of science databases for relevant articles up to March 2024. The following search terms were Used in combination using the Boolean operators ((Duloxetine Hydrochloride) AND ((Pain, Postoperative) OR (Postoperative Period) OR (Postoperative Cognitive Complications) OR (Delayed Emergence from Anesthesia) OR (Postoperative Care) OR (spine surgery)) without time constrain for the search. Meta-analysis was performed using Review Manager (RevMan version 5.4) on the extracted outcome data that present in at least 3 of the included studies. Mean difference (MD) was used as the effect size for continuous outcomes with a 95% confidence interval (CI) or standardized mean difference (SMD) in case of different outcome reporting scales.

RESULTS

Pooled analysis showed that duloxetine significantly reduces pain intensity after 24 h from the operation compared to placebo (SMD = -1.11, 95% CI [-2.16 to -0.07], p = 0.04) with no significant difference in pain after 2 and 48 h. Meta-analysis revealed that duloxetine shows a significant reduction in the amount of analgesic consumption after 24 h postoperative; (MD = -3.33, 95% CI [-5.53 to -1.13], p = 0.003). The analysis did not show any statistically significant difference between duloxetine and placebo in patients experiencing nausea or vomiting (RR = 1.37, 95% CI [0.62 to 3.00] CONCLUSION: The findings of this study suggest that duloxetine may be effective in reducing pain 24 h after spine surgery. Furthermore, there is a promising effect of duloxetine in treating chronic postoperative pain. However, it is important to acknowledge that further research is warranted to thoroughly evaluate the efficacy and safety of duloxetine for relieving chronic postoperative pain.

Incidence and Risk Factors for Moderate to Severe Pain After Foot and Ankle Surgery: A Retrospective Study

BACKGROUND

Severe pain after foot/ankle surgeries is often underestimated because these procedures are perceived as less extensive than other orthopedic surgeries. However, surgeries involving the bones and joints in the foot and ankle can result in intense pain.

AIMS

This study aimed to identify the incidence and risk factors associated with postoperative moderate to severe pain.

DESIGN

We reviewed the medical records of 334 patients undergoing foot/ankle surgery under spinal anesthesia. The maximum numeric rating scale (NRS) pain scores were recorded at 12-hour intervals for 48 hours postsurgery, and the incidence of postoperative pain was calculated. Patients were then classified into two groups based on their maximum NRS score from the first postoperative day: those with no or mild pain (NRS score of 0-3) and those with moderate to severe pain (NRS score of 4-10). We collected variables related to the patient, surgery, and anesthesia and used logistic regression analysis to identify the factors associated with moderate to severe pain.

RESULTS

Approximately 67% of patients experienced moderate to severe pain on the first day after foot/ankle surgery, with the peak severity occurring during the initial 12 hours. Performing spinal anesthesia alone (adjusted risk ratio [ARR], 1.44; 95% confidence interval [CI], 1.21-1.71; p < .001) and hindfoot/ankle surgery (ARR, 1.22; 95% CI, 1.03-1.44; p = .020) were identified as independent risk factors for moderate to severe pain.

CONCLUSIONS

Due to the high incidence of severe pain following foot/ankle surgery, patients who had spinal anesthetic alone or underwent hindfoot/ankle surgery are more likely to experience moderate to severe pain. Improved pain management measures are crucial for these patients to achieve better outcomes.

Evaluating quality of life changes in patients with cleft lip or palate: a mixed method pre- and postsurgical analysis in Karachi

BACKGROUND

Cleft lip and/or palate (CLP) is the most common orofacial congenital disability, presenting significant medical, psychological, and social challenges. In Pakistan, the incidence of CLP is high, estimated at one in 523 live births, but accurate data are lacking due to the absence of a birth registry. Early diagnosis and intervention are crucial for improving outcomes. This study evaluated the impact of CLP on patients' quality of life in Karachi, comparing pre- and post-surgical phases.

METHODS

A sequential exploratory quantitative-qualitative mixed-methods study was conducted at two tertiary care hospitals in Karachi. In the quantitative phase, 280 patients with CLP, either awaiting or post-surgery, completed the Oral Health Impact Profile (OHIP-14) questionnaire to assess oral health-related quality of life (OHRQoL). Based on questionnaire responses, 30 participants were purposively selected for in-depth, semi-structured interviews exploring their experiences. Quantitative data were analyzed using SPSS version 25; qualitative data were analyzed thematically.

RESULTS

Quantitative findings revealed significant gender disparities in cleft types and correction status; females had a higher prevalence of unilateral cleft lip, while males had more cleft palate cases. Dental and oral health issues significantly affected daily activities, with higher impacts in cleft palate patients. OHRQoL varied by gender, cleft type, and correction status, with those post-surgery reporting poorer OHRQoL. Qualitative analysis identified six themes: Diagnosis and Early Treatment, Challenges and Impact, Postsurgical Experiences, Support Systems, Healthcare Experiences, and Future Perspectives. Inconsistencies in psychological support, accessibility and financial burdens were presented as significant issues. Sentiment analysis highlighted varied emotions, from despair to hope and gratitude.

CONCLUSIONS

CLP significantly affects patients' quality of life in Karachi across multiple dimensions. Early diagnosis and surgical intervention are essential but often hindered by financial and accessibility issues. Psychological effects, including low self-esteem and social isolation, highlight the need for integrated mental health support. Family and community support are critical for patient resilience. A comprehensive approach addressing medical, psychological, social, and systemic factors is necessary to improve outcomes for individuals with CLP.

Educational needs and preferences of adult patients with acute pain: a mixed-methods systematic review

ABSTRACT

Many patients experience acute pain, which has been associated with numerous negative consequences. Pain education has been proposed as a strategy to improve acute pain management. However, studies report limited effects with educational interventions for acute pain in adults, which can be explained by the underuse of the person-centered approach. Thus, we aimed to systematically review and synthetize current evidence from quantitative, qualitative and mixed-methods studies describing patients' needs and preferences for acute pain education in adults. We searched original studies and gray literature in 7 databases, from January 1990 to October 2023. Methodological quality was assessed with the Mixed Methods Appraisal Tool. A total of 32 studies were included (n = 1847 patients), two-thirds of which were qualitative studies of high methodological quality. Most of the studies were conducted over the last 15 years in patients with postsurgical and posttraumatic pain, identified as White, with a low level of education. Patients expressed the greatest need for education when it came to what to expect in pain intensity and duration, as well how to take the medication and its associated adverse effects. The most frequently reported educational preferences were for in-person education while involving caregivers and to obtain information first from physicians, then by other professionals. This review has highlighted the needs and preferences to be considered in pain education interventions, which should be embedded in an approach cultivating communication and partnership with patients and their caregivers. The results still need to be confirmed with different patient populations.

Effect of Dexamethasone on Postoperative Analgesia Following the Transversus Abdominis Plane Block in Gynecological Laparotomies

PURPOSE

Postoperative pain is an acute pain that begins with surgical trauma and decreases as the tissue heals. The transversus abdominis plane (TAP) block is one of the abdominal field blocks used in the treatment of acute postoperative pain after lower abdominal surgery. This study aims to investigate the effects of dexamethasone added to a local anesthetic solution on postoperative analgesia in ultrasonography-guided TAP block.

MATERIALS AND METHODS

Our study included female patients aged 18-80 with American Society of Anesthesiology (ASA) I-II status who had undergone gynecological laparotomy (total abdominal hysterectomy (TAH), total abdominal hysterectomy + bilateral salpingoophorectomy (TAH+BSO), myomectomy). The patients were examined in two groups, each consisting of 30 people. Patients in whom dexamethasone was added to the analgesic solution while applying the TAP block were classified as Group D and patients without dexamethasone were classified as Group B. The patients' Visual Analog Scale (VAS) scores at the 2nd, 4th, 8th, 12th, and 24th hours postoperatively; their painkiller needs in the first 24 hours postoperatively; their first mobilization time; and their total analgesic requirements in the first 24 hours postoperatively were examined.

RESULTS

When postoperative 2, 4, 8, and 12 hours VAS scores were compared, no significant difference was found between the groups (p>0.05). Postoperative 24th-hour VAS scores were significantly lower in Group D (p<0.001). No statistically significant difference was found when additional analgesic demands were compared between the groups at 2, 4, 8, and 12 hours postoperatively (p>0.05). Additional analgesic demand at the 24th postoperative hour was significantly lower in Group D (p=0.020). When the 24-hour additional IV analgesic demands of the patients were compared, the additional analgesic demand in Group B was found to be significantly higher than in Group D (p=0.038). When postoperative mobilization hours were compared between the groups, no statistically significant difference was found between the two groups (p=0.617). When the patient's first analgesic request times were compared, no significant difference was found between the groups (p=0.617).

CONCLUSION

It was determined that dexamethasone added to bupivacaine in USG-guided TAP block reduced the amount of additional analgesic consumed in the first 24 hours postoperatively and reduced VAS scores. We think that adding dexamethasone to local anesthetics in the TAP block will benefit multimodal analgesia.

A prospective cohort study of chronic postsurgical pain after ambulatory surgeries

OBJECTIVE

The incidence and factors associated with chronic postsurgical pain (CPSP) after ambulatory surgeries have not been well studied. Our primary objective was to determine the incidence of CPSP and secondary objectives included assessment of intensity of CPSP, incidence of moderate-to-severe CPSP, and exploration of factors associated with CPSP.

METHODS

This is a prospective cohort study of ambulatory surgery patients having procedures with a potential to cause moderate-to-severe postoperative pain. All patients had participated in a randomized controlled trial (RCT) showing no difference in achieving satisfactory analgesia in a recovery unit with either morphine or hydromorphone. CPSP was defined as chronic pain that developed or increased in intensity after the surgical procedure and is localized to the surgical field or within the innervation territory of a nerve in the surgical field, and has persisted for 3 months post-surgery, with the exclusion of other causes of pain. Incidences of CPSP were reported as rate (%) with 95% CI, and intensity using a 0-10 numerical rating scale (95% CI). We used logistic regression to explore factors associated with CPSP adjusting for baseline catastrophizing and depression.

RESULTS

Among 402 RCT patients, 208 provided data for the 3-month outcome. Incidence of CPSP was 18.8% (39/208), 95% CI = 13.7%-24.7% and 78% (28/39) of them had moderate-to-severe CPSP. Average CPSP intensity was 5.5, 95% CI = 4.7-6.4. Every unit increase in pain over the first 24 h was significantly associated with increased odds of moderate-to-severe CPSP at 3 months; odds ratio = 1.28, 95% CI = 1.04-1.58.

CONCLUSIONS

Nearly one in five patients develop CPSP after ambulatory surgeries with the majority of them having moderate-to-severe pain. Considering that acute pain after discharge is associated with CPSP and that there are no formal care pathways to address this need, studies need to focus on evaluating feasible strategies to provide continuing care.

Ultrasound-guided medial branch of the superior laryngeal nerve block to reduce peri-operative opioids dosage and accelerate patient recovery

BACKGROUND

To explore whether the medial branch block of superior laryngeal nerve can reduce the stress response of patients undergoing intubation and further reduce the dosage of opioids.

METHODS

80 patients undergoing gynecological laparoscopic surgery were selected, and randomly divided into 4 groups. All patients in the experimental groups received bilateral internal branch of superior laryngeal nerve block and transversus abdominis plane block. But the dosage of sufentanil used for anesthesia induction in the group A, B, and C was 0.4, 0.2, and 0μg/kg, respectively. Group D do not underwent supralaryngeal nerve block and the dosage of sufentanil was 0.4μg/kg. The heart rate (HR) and mean arterial pressure(MAP) were recorded at the time of entering the operating room(T1), before intubation after induction(T2), immediately after intubation(T3), 5min after intubation(T4), before extubation(T5), immediately after extubation(T6), 5min after extubation(T7). We also recorded the stay time in the recovery room, the number of cases of postoperative sore throat, the number of cases of nausea and vomiting, the first intestinal exhaust time, the length of hospital stay after operation.

RESULTS

The HR of group A, C and D at T3 was significantly higher than that at T2(P < 0.01), while the HR of group B had no significant change. The HR of group A, C and D at T4 was lower than that at T3(P < 0.01), while the HR of group B had no obvious change. The HR of group C and D at T3 was significantly higher than that at T1 (P < 0.01). The MAP of group A and D at T4 was significantly lower than that at T1 (P<0.001). The first postoperative intestinal exhaust time in group A, B and C was significantly shorter than that in group D. The length of hospital stay after operation in group B and C was shorter than that in group D.

CONCLUSIONS

Ultrasound-guided superior laryngeal nerve block combined with 0.2μg/kg sufentanil can reduce the intubation reaction, have better hemodynamic stability, reduce the first postoperative intestinal exhaust time and postoperative hospital stay, thereby accelerating the postoperative recovery of patients.

Post-Operative Thoracic Epidural Analgesia and Incidence of Major Complications according to Specific Safety Standardized Documentation: A Large Retrospective Dual Center Experience

(1) Background: Thoracic epidural analgesia is considered the gold standard in post-operative pain management following thoracic surgery. This study was designed to explore the safety of thoracic epidural analgesia and to quantify the incidence of its post-operative complications and side effects in patients undergoing thoracotomy for major surgery, such as resection of lung malignancies and lung transplantation. (2) Methods: This is a retrospective, dual-center observational study including patients that underwent major thoracic surgery including lung transplantation and received concurrent placement of thoracic epidural catheters for post-operative analgesia. An electronic system of referral and documentation of complications was used, and information was retrieved from our electronic critical care charting system. (3) Results: In total, 1145 patients were included in the study. None of the patients suffered any major complication, including hematoma, abscess, or permanent nerve damage. (4) Conclusions: the present study showed that in experienced centers, post-operative epidural analgesia in patients with thoracotomy is a safe technique, manifesting minimal, none-serious complications.