This study determined preoperative predictors of movement and resting pain following total knee replacement (TKR). We hypothesized that younger patients with higher preoperative pain intensity, pain sensitivity, trait anxiety, pain catastrophizing, and depression would be more likely to experience higher postoperative movement pain than older patients with lower scores on these variables prior to surgery and that predictors would be similar for resting pain. Demographics, analgesic intake, anxiety, depression, pain catastrophizing, resting pain, movement pain (i.e., during active knee range of motion), and quantitative sensory tests, were performed pre-operatively on 215 participants scheduled for a unilateral TKR. On postoperative day 2 (POD2), analgesic intake, resting pain, and movement pain were again assessed. Significant predictors of moderate or severe movement pain were higher preoperative movement pain, von Frey pain intensity (VFPI) and heat pain threshold (HPT). People with severe movement pain preoperatively were 20 times more likely to have severe movement pain postoperatively. When the influence of preoperative movement pain was removed, depression became a predictor. Significant predictors of moderate to severe resting pain were higher preoperative resting pain, depression, and younger age. These results suggest that patients with higher preoperative pain and depression are more likely to have higher pain following TKR and younger patients may have higher resting pain. Cutaneous pain sensitivity predicted movement pain but not resting pain, suggesting that mechanisms underlying movement pain are different from resting pain. Aggressive management of preoperative pain, pain sensitivity, and depression prior to surgery may facilitate postoperative recovery.
Postoperative Pain; Movement Pain; Total Knee Replacement; Pain Sensitivity
Effective postoperative pain management is important for older surgical patients since pain affects perioperative outcomes. A prospective cohort study was conducted to describe the direct and indirect effects of patient risk factors and pain treatment in explaining levels of postoperative pain in older surgical patients.
We studied patients who were 65 years of age or older and were scheduled for major non-cardiac surgery with a postoperative hospital stay of at least 2 days. The numeric rating scale (0 = no pain, 10 = worst possible pain) was used to measure pain levels before surgery and once daily for 2 days after surgery. Path analysis was performed to examine the association between predictive variables and postoperative pain levels.
Three hundred fifty patients were studied. The results reveal that preoperative pain level, use of preoperative opioids, female gender, higher ASA physical status, and postoperative pain control methods were the strongest predictors of postoperative pain as measured the first day after surgery. Younger age, greater preoperative symptoms of depression and lower cognitive function also contributed to higher postoperative pain levels. Pain levels on the second day after surgery were strongly predicted by preoperative pain level, use of preoperative opioids, surgical risk, and pain and opioid dose on postoperative day 1. However, younger age, female gender, higher ASA physical status, greater preoperative symptoms of depression, lower cognitive function and postoperative pain control methods indirectly contributed to pain levels on the second day after surgery.
Although preoperative pain and use of preoperative opioids have the strongest effects on postoperative pain, clinicians should be aware that other factors such as age, gender, surgical risk, preoperative cognitive impairment and depression also contribute to reported postoperative pain. Based on significant statistical correlations, these study results can contribute to more effective postoperative care for those patients having the risk factors studied here. Preoperative treatment/intervention based in part on factors such as preoperative pain, use of preoperative opioids and depression may improve postoperative pain management.
aged; 80 and over; aging; pain; postoperative
The ability to identify and focus care to patients at higher risk of moderate to severe postoperative pain should improve analgesia and patient satisfaction, and may affect reimbursement. We undertook this multi-centre cross-sectional study to identify preoperative risk factors for moderate to severe pain after total hip (THR) and knee (TKR) replacement.
A total of 897 patients were identified from electronic medical records. Preoperative information and anaesthetic technique was gained by retrospective chart review. The primary outcomes were moderate to severe pain (pain score ≥ 4/10) at rest and with activity on postoperative day one. Logistic regression was performed to identify predictors for moderate to severe pain.
Moderate to severe pain was reported by 20 % at rest and 33 % with activity. Predictors for pain at rest were female gender (OR 1.10 with 95 % CI 1.01–1.20), younger age (0.96, 0.94–0.99), increased BMI (1.02, 1.01–1.03), TKR vs. THR (3.21, 2.73–3.78), increased severity of preoperative pain at the surgical site (1.15, 1.03–1.30), preoperative use of opioids (1.63, 1.32–2.01), and general anaesthesia (8.51, 2.13–33.98). Predictors for pain with activity were TKR vs. THR (1.42, 1.28–1.57), increased severity of preoperative pain at the surgical site (1.11, 1.04–1.19), general anaesthesia (9.02, 3.68–22.07), preoperative use of anti-convulsants (1.78, 1.32–2.40) and anti-depressants (1.50, 1.08–2.80), and prior surgery at the surgical site (1.28, 1.05–1.57).
Our findings provide clinical guidance for preoperative stratification of patients for more intensive management potentially including education, nursing staffing, and referral to specialised pain management.
Inadequate management of postoperative pain is common, and postoperative pain is a risk factor for prolonged pain. In addition to medical and technical factors, psychological factors may also influence the experience of postoperative pain.
Pain was measured postoperatively at 24, 48, and 72 hr in hospital and after 3 months at home in 140 patients undergoing radical prostatectomy (RP). Patients answered questionnaires about anxiety and depression (HAD scale) and health-related quality of life (SF-36) at baseline and 3 months after surgery.
In the first 3 postoperative days, mild pain was reported by 45 patients (32%), moderate pain by 64 (45%), and severe pain by 31 (22%) on one or more days. High postoperative pain scores were correlated with length of hospital stay and with high pain scores at home. Forty patients (29%) reported moderate (n = 35) or severe (n = 5) pain after discharge from hospital. Patients who experienced anxiety and depression preoperatively had higher postoperative pain scores and remained anxious and depressed 3 months after surgery. The scores for the physical domains in the SF-36 were decreased, while the mental health scores were increased at 3 months. Anxiety and depression were negatively correlated with all domains of the SF-36.
There is a need for nurses to be aware of the psychological status of RP patients and its impact upon patients' experience of postoperative pain and recovery. The ability to identify patients with psychological distress and to target interventions is an important goal for future research.
To manage intractable cancer pain, an alternative to systemic analgesics is neuraxial analgesia. In long-term treatment, intrathecal administration could provide a more satisfactory pain relief with lower doses of analgesics and fewer side-effects than that of epidural administration. However, implantable drug delivery systems using intrathecal pumps in Korea are very expensive. Considering cost-effectiveness, we performed epidural analgesia as an alternative to intrathecal analgesia.
We retrospectively investigated the efficacy, side effects, and complications of epidural morphine and local anesthetic administration through epidural catheters connected to a subcutaneous injection port in 29 Korean terminal cancer patients. Patient demographic data, the duration of epidural administration, preoperative numerical pain rating scales (NRS), side effects and complications related to the epidural catheterization and the drugs, and the numerical pain rating scales on the 1st, 3rd, 7th and 30th postoperative days were determined from the medical records.
The average score for the numerical pain rating scales for the 29 patients decreased from 7 ± 1.0 at baseline to 3.6 ± 1.4 on postoperative day 1 (P < 0.001). A similar decrease in pain intensity was maintained for 30 days (P < 0.001). Nausea and vomiting were the most frequently reported side effects of the epidural analgesia and two patients (6.9%) experienced paresthesia.
Epidural morphine and local anesthetic infusion with a subcutaneous pump seems to have an acceptable risk-benefit ratio and allows a high degree of autonomy to patients with cancer pain.
cancer pain; efficacy; epidural catheter; port; side effects
Orthopaedic procedures have been reported to have the highest incidence of pain compared to other types of operations. There are limited studies in the literature that investigate postoperative pain.
Materials and Methods
A prospective study of 98 patients undergoing orthopedic foot and ankle operations was undertaken to evaluate their pain experience. A Short-Form McGill Pain Questionnaire (SF-MPQ) was administered preoperatively and postoperatively.
The results showed that patients who experienced pain before the operation anticipated feeling higher pain intensity immediately postoperatively. Patients, on average, experienced higher pain intensity 3 days after the operation than anticipated. The postoperative pain intensity at 3 days was the most severe, while postoperative pain intensity at 6 weeks was the least severe. Age, gender and preoperative diagnosis (acute versus chronic) did not have a significant effect on the severity of pain that patients experienced. Six weeks following the operation, the majority of patients felt no pain. In addition, the severity of preoperative pain was highly predictive of their anticipated postoperative pain and 6-week postoperative pain, and both preoperative pain and anticipated pain predict higher immediate postoperative pain.
The intensity of patients' preoperative pain was predictive of the anticipated postoperative pain. Patients' preoperative pain and anticipated postoperative pain were independently predictive of the 3-day postoperative pain. The higher pain intensity a patient experienced preoperatively suggested that their postoperative pain severity would be greater. Therefore, surgeons should be aware of these findings when treating postoperative pain after orthopaedic foot and ankle operations.
Postoperative Pain; Pain Expectations; Foot and Ankle Surgery; SF-MPQ; Short-Form McGill Pain Questionnaire; Longitudinal Pain Study
Variability in patients' postoperative pain experience and response to treatment challenges effective pain management. Variability in pain reflects individual differences in inhibitory pain modulation and psychological sensitivity, which in turn may be clinically relevant for the disposition to acquire pain. The aim of this study was to investigate the effects of conditioned pain modulation and situational pain catastrophizing on postoperative pain and pain persistency.
Preoperatively, 42 healthy males undergoing funnel chest surgery completed the Spielberger's State-Trait Anxiety Inventory and Beck's Depression Inventory before undergoing a sequential conditioned pain modulation paradigm. Subsequently, the Pain Catastrophizing Scale was introduced and patients were instructed to reference the conditioning pain while answering. Ratings of movement-evoked pain and consumption of morphine equivalents were obtained during postoperative days 2–5. Pain was reevaluated at six months postoperatively.
Patients reporting persistent pain at six months follow-up (n = 15) were not significantly different from pain-free patients (n = 16) concerning preoperative conditioned pain modulation response (Z = 1.0, P = 0.3) or level of catastrophizing (Z = 0.4, P = 1.0). In the acute postoperative phase, situational pain catastrophizing predicted movement-evoked pain, independently of anxiety and depression (β = 1.0, P = 0.007) whereas conditioned pain modulation predicted morphine consumption (β = −0.005, P = 0.001).
Preoperative conditioned pain modulation and situational pain catastrophizing were not associated with the development of persistent postoperative pain following funnel chest repair. Secondary outcome analyses indicated that conditioned pain modulation predicted morphine consumption and situational pain catastrophizing predicted movement-evoked pain intensity in the acute postoperative phase. These findings may have important implications for developing strategies to treat or prevent acute postoperative pain in selected patients. Pain may be predicted and the malfunctioning pain inhibition mechanism as tested with CPM may be treated with suitable drugs augmenting descending inhibition.
Chronic pain has been traditionally defined by pain duration, but this approach has limited empirical support; and does not account for chronic pain’s multidimensionality. This study compared duration-based and prospective approaches to defining chronic pain in terms of their ability to predict future pain course and outcomes for primary care patients with three common pain conditions: back pain (n = 971), headache (n = 1078), or orofacial pain (n = 455). At baseline, their chronic pain was classified retrospectively based on Pain Days in the prior six months and prospectively with a prognostic Risk Score identifying patients with “possible” or “probable” chronic pain. The 0–28 Risk Score was based on pain intensity, pain-related activity limitations, depressive symptoms, number of pain sites, and Pain Days. Pain and behavioral outcomes were assessed at six-month follow-up, and long-term opioid use was assessed two to five years after baseline. Risk Score consistently predicted clinically significant pain at six months better than did Pain Days alone (Area under the Curve of 0.74–0.78 for Risk Score vs. 0.63–0.73 for Pain Days). Risk Score was a stronger predictor of future SF-36 Physical Function, pain-related worry, unemployment, and long-term opioid use than Pain Days alone. Thus, for these three common pain conditions, a prognostic Risk Score had better predictive validity for pain outcomes than did pain duration alone. However, chronic pain appears to be a continuum rather than a distinct class, because long-term pain outcomes are highly variable and inherently uncertain.
chronic pain; back pain; headache; orofacial pain; classification; epidemiology
Ideally, the intensity of postoperative pain should be predicted so as to customize analgesia. The objective of this study was to investigate whether preoperative electrical and pressure pain assessment can predict post-caesarean section pain and analgesic requirement.
Materials and Methods:
A total of 65 subjects scheduled for elective caesarean section, who gave written informed consent, were studied. Preoperatively, PainMatcher® was used to evaluate electrical pain threshold, while manual PainTest™ FPN 100 Algometer and digital PainTest™ FPX 25 Algometer determined pressure pain threshold and tolerance. Postoperatively, numerical rating scales were used to assess pain at regular time intervals. Patients received intramuscular pethidine (100mg, 6 hourly), rectal diclofenac (100mg, 12 hourly), and oral paracetamol (1g, p.r.n.) for pain relief. Statistical analysis was conducted using PASW Statistics 18 software.
Preoperative electrical pain threshold correlated significantly with post-caesarean pain scores at 6 and 24 hours (r = –0.26, P < 0.02; r = –0.23, P < 0.04, respectively), and with the quantity of paracetamol consumed by the patient within 48 hours of surgery (r = –0.33, P < 0.005). Preoperative pressure pain tolerance measured by PainTest™ FPX 25 Algometer was significantly correlated with pain scores 6 hours postsurgery (r = –0.21, P < 0.05). Pain scores 6 hours post-caesarean section correlated significantly with anesthesia—general or spinal (F = 4.22, v1 = 1, v2 = 63, P < 0.05).
The predictive methods proposed may aid in identifying patients at greater risk for postoperative pain. Electrical pain threshold could be useful in personalizing the postoperative analgesic protocol.
Analgesia; caesarean section; general anesthesia; postoperative pain; pain threshold; spinal anesthesia
Persistent postoperative pain continues to be an underrecognized complication. We examined the prevalence of and risk factors for this type of pain after cardiac surgery.
We enrolled patients scheduled for coronary artery bypass grafting or valve replacement, or both, from Feb. 8, 2005, to Sept. 1, 2009. Validated measures were used to assess (a) preoperative anxiety and depression, tendency to catastrophize in the face of pain, health-related quality of life and presence of persistent pain; (b) pain intensity and interference in the first postoperative week; and (c) presence and intensity of persistent postoperative pain at 3, 6, 12 and 24 months after surgery. The primary outcome was the presence of persistent postoperative pain during 24 months of follow-up.
A total of 1247 patients completed the preoperative assessment. Follow-up retention rates at 3 and 24 months were 84% and 78%, respectively. The prevalence of persistent postoperative pain decreased significantly over time, from 40.1% at 3 months to 22.1% at 6 months, 16.5% at 12 months and 9.5% at 24 months; the pain was rated as moderate to severe in 3.6% at 24 months. Acute postoperative pain predicted both the presence and severity of persistent postoperative pain. The more intense the pain during the first week after surgery and the more it interfered with functioning, the more likely the patients were to report persistent postoperative pain. Pre-existing persistent pain and increased preoperative anxiety also predicted the presence of persistent postoperative pain.
Persistent postoperative pain of nonanginal origin after cardiac surgery affected a substantial proportion of the study population. Future research is needed to determine whether interventions to modify certain risk factors, such as preoperative anxiety and the severity of pain before and immediately after surgery, may help to minimize or prevent persistent postoperative pain.
The role of preoperative gabapentin in postoperative pain management is not clear, particularly in patients receiving regional blockade. Patients undergoing thoracotomy benefit from epidural analgesia but still may experience significant postoperative pain. We examined the effect of preoperative gabapentin in thoracotomy patients.
Adults undergoing elective thoracotomy were enrolled in this prospective, randomized, double-blinded, placebo-controlled study, and randomly assigned to receive 600 mg gabapentin or active placebo (12.5 mg diphenhydramine) orally within 2 hours preoperatively. Standardized management included thoracic epidural infusion, intravenous patient-controlled opioid analgesia, acetaminophen and ketorolac. Pain scores, opioid use and side effects were recorded for 48 hours. Pain was also assessed at 3 months.
One hundred twenty patients (63 placebo and 57 gabapentin) were studied. Pain scores did not significantly differ at any time point (p=0.53). Parenteral and oral opioid consumption was not significantly different between groups on postoperative day 1 or 2 (p>0.05 in both cases). The frequency of side effects such as nausea and vomiting or respiratory depression was not significantly different between groups, but gabapentin was associated with decreased frequency of pruritus requiring nalbuphine (14% gabapentin vs. 43% control group, p<0.001). The frequency of patients experiencing pain at 3 months post-thoracotomy was also comparable between groups (70% gabapentin vs. 66% placebo group, p=0.72).
A single preoperative oral dose of gabapentin (600 mg) did not reduce pain scores or opioid consumption following elective thoracotomy, and did not confer any analgesic benefit in the setting of effective multimodal analgesia that included thoracic epidural infusion.
Pain; Postoperative; post-thoracotomy pain; Preanesthetic Medication; Acute Pain Service; Patient-Controlled Epidural Analgesia; gabapentin
Lumbar total disc arthroplasty is often performed in patients with axial back pain. There are multiple etiologies for axial back pain, including disc degeneration and annular tears. The location of these annular tears can vary, producing differing preoperative symptomatology. Intraoperatively, disruptions in the annulus are identifiable, and it has been suggested that patients with discrete annular tears may have better clinical outcomes after surgery. The purpose of this study was to investigate whether the presence and location of annular tears have an effect on clinical outcomes after lumbar total disc arthroplasty.
Patients undergoing a single-level anterior disc replacement from L3-S1 at a single site by a single surgeon were evaluated preoperatively for the presence or absence of annular tears with magnetic resonance imaging. All patients were part of either the ProDisc (n = 41) (Synthes, Paoli, Pennsylvania) or Activ-L (n = 19) (Aesculap [B. Braun Melsungen AG], Tuttlingen, Germany) lumbar prospective clinical trials. In those patients with annular tears, the location of the tear (central, paracentral, or lateral) was documented. Patients were assessed at 6 and 12 months after lumbar total disc arthroplasty with the Oswestry Disability Index (ODI), visual analog scale (VAS) score for back pain, VAS score for leg pain, and radiographic imaging. All radiographic evaluations were conducted by an attending neuroradiologist and an attending spinal surgeon, and reliability testing was performed. An analysis of variance was performed among the 3 anatomic locations of annular tears.
A total of 60 patients were included and had complete 12-month follow-up. The prevalence of annular tears among all patients was 42% (n = 25). Outcome data in patients without annular tears were as follows: ODI, 66% preoperatively and 26% postoperatively; VAS score for back pain, 8.0 preoperatively and 2.6 postoperatively; and VAS score for leg pain, 2.9 preoperatively and 1.2 postoperatively. Among those patients with tears, the prevalence of central tears was 80%, the prevalence of paracentral tears was 12%, and the prevalence of lateral tears was 8%. Outcome data in patients with central tears were as follows: ODI, 66% preoperatively and 26% postoperatively; VAS score for back pain, 7.8 preoperatively and 2.6 postoperatively; and VAS score for leg pain, 5.2 preoperatively and 0.5 postoperatively. Outcome data in patients with paracentral tears were as follows: ODI, 86% preoperatively and 59% postoperatively; VAS score for back pain, 8.8 preoperatively and 3.3 postoperatively; and VAS score for leg pain, 5.0 preoperatively and 5.4 postoperatively. Outcome data in patients with lateral tears were as follows: ODI, 6.5 preoperatively and 2.6 postoperatively; VAS score for back pain, 9.2 preoperatively and 0.2 postoperatively; and VAS score for leg pain, 1.4 preoperatively and 0.7 postoperatively. In those patients with paracentral tears, there was a significantly higher incidence of postoperative radicular symptoms both from an intensity standpoint and from a duration standpoint. Other complications did not vary among those patients with or without annular tears.
Although patients with annular tears and patients without annular tears improve after lumbar artificial disc replacement, those with central annular tears or without tears have significantly lower disability scores than those with paracentral tears or lateral tears, whose outcome scores showed significantly less improvement (P ≤ .03). In particular, patients with central tears have less postoperative leg pain than those with paracentral annular tears. In this study the presence or absence of an annular tear on magnetic resonance imaging was not a significant predictive factor for clinical outcome. Further investigation regarding the effects of paracentral annular tears and surgical techniques should be explored.
Lumbar disc arthroplasty; Annular tear; High intensity zone (HIZ)
Epidural analgesia has been the preferred analgesic technique after major abdominal surgery. On the other hand, the combined use of intrathecal morphine (ITM) and intravenous patient controlled analgesia (IVPCA) has been shown to be a viable alternative approach for analgesia. We hypothesized that ITM combined with IVPCA is as effective as patient controlled thoracic epidural analgesia (PCTEA) with respect to postoperative pain control after conventional open gastrectomy.
Materials and Methods
Sixty-four patients undergoing conventional open gastrectomy due to gastric cancer were randomly allocated into the intrathecal morphine combined with intravenous patient-controlled analgesia (IT) group or patient-controlled thoracic epidural analgesia (EP) group. The IT group received preoperative 0.3 mg of ITM, followed by postoperative IVPCA. The EP group preoperatively underwent epidural catheterization, followed by postoperative PCTEA. Visual analog scale (VAS) scores were assessed until 48 hrs after surgery. Adverse effects related to analgesia, profiles associated with recovery from surgery, and postoperative complications within 30 days after surgery were also evaluated.
This study failed to demonstrate the non-inferiority of ITM-IVPCA (n=29) to PCTEA (n=30) with respect to VAS 24 hrs after surgery. Furthermore, the IT group consumed more fentanyl than the EP group did (1247.2±263.7 µg vs. 1048.9±71.7 µg, p<0.001). The IT group took a longer time to ambulate than the EP group (p=0.021) and had higher incidences of postoperative ileus (p=0.012) and pulmonary complications (p=0.05) compared with the EP group.
ITM-IVPCA is not as effective as PCTEA in patients undergoing gastrectomy, with respect to pain control, ambulation, postoperative ileus and pulmonary complications.
Analgesia; epidural; gastrectomy; intrathecal; opioid; postoperative pain
As the North American population ages, the prevalence of knee osteoarthritis and the surgical interventions (ie, total knee arthroplasty [TKA]) aimed at correcting pain and disability will also rise proportionally. Therefore, efforts to better understand the factors associated with surgical outcomes are warranted. To date, no studies have examined the impact of psychosocial factors on acute postoperative TKA pain.
The primary objective was to examine the associations among catastrophizing, negative mood, demographics and acute postoperative pain following TKA. Ancillary analyses examined the association of preoperative psychological variables with postoperative pain.
Patients completed questionnaire packages 2 h before their surgery and on three consecutive postoperative days while in the hospital. The questionnaire packages included the Short Form –McGill Pain Questionnaire, the Pain Catastrophizing Scale and the Shortened Version of Profile of Mood States. The Mini-Mental State Examination was also administered. Demographic data were extracted from patients’ medical charts.
Associations among catastrophizing, negative mood and pain were established. Regressions showed that younger age predicted greater preoperative and postoperative day 1 pain; catastrophizing predicted preoperative and postoperative day 2 pain; and negative mood predicted postoperative day 3 pain. Catastrophizing and negative mood were highly correlated at several assessment points. Preoperative variables did not predict postoperative pain.
These results have postoperative pain management implications. Heightened attention to psychosocial variables, such as postoperative catastrophizing and negative mood, may be useful in identifying patients at risk for greater postoperative pain.
Acute postoperative pain; Older adults; Osteoarthritis; Total knee arthroplasty
To determine the relationship between opioid consumption and cognitive impairment following hip fracture repair.
Prospective study of consecutive patients.
Johns Hopkins Bayview Medical Center; Baltimore, Maryland.
Two hundred thirty-six patients ≥65 years old undergoing hip fracture repair.
Elderly patients without preoperative delirium who underwent hip fracture repair between April 2005 and July 2009 were followed for pain, opioid consumption, and postoperative delirium. Patients were tested for delirium with the confusion assessment method preoperatively and mid-morning on postoperative day 2. Pain was assessed by the nursing staff with a numeric 0–10 verbal scale. Opioid analgesia was provided in response to pain at rest to achieve scores of ≤3. Opioid consumption was analyzed with respect to the occurrence of incident postoperative delirium, presence of dementia, and other demographic variables.
Of the 236 patients, 66 (28%) had dementia with 213 (90%) receiving opioids postoperatively; including 55 (83%) demented patients and 158 (93%) non-demented patients. There was no association between the use of any postoperative opioid and incident delirium (P=0.615) in both demented (p=0.333) and non-demented patients (P=0.398). Dementia, but not postoperative delirium, was associated with less opioid use (P<0.001 for dementia; P=0.120 for delirium; P=0.038, for their interaction; Wald χ2 =142.8 with 7 d.o.f.). Furthermore, opioid dose (P≥0.591) on postoperative days 1 and 2 was not predictive of incident delirium. Dementia (P<0.001) and intensive care unit admission (P=0.006), not opioid consumption, were the most important predictors of incident postoperative delirium.
Concern for postoperative delirium should not prevent the use of opioid analgesic therapy sufficient to achieve a generally accepted level of comfort in patients with or without preexisting cognitive impairment.
delirium; hip fracture; opioids; surgery (complications)
Our objectives were to analyze the effectiveness of epidural anesthesia in patients who underwent open retropubic radical prostatectomy (RRP) at our institution over the past decade, and to examine subsequent oncologic outcomes, comparing those receiving with those not receiving epidural anesthesia.
A comprehensive database of all patients undergoing RRP from November 1996 to December 2006 was analyzed; 354 patients underwent RRP at our institution and were divided into those receiving or not receiving an epidural. An independent pain management team scoring technical success found epidural technique to be consistent. Oncological outcome was an endpoint of our study, comparing both analysis groups. We classed prostate-specific antigen (PSA) recurrence after RRP as a serum PSA ≥ 0.2 ng/mL at any stage of postoperative follow-up. Complications were recorded to 30 days using the modified Clavien system, and full statistical analyses were undertaken.
Records were available for 239 men; we observed a decreased trend in the use of epidural for pain management, along with a decrease in average hospital stay and an overall epidural success rate of 64%. When dividing data into RRP with and without epidural, we found a median hospital stay of 7 days for patients receiving an epidural compared with 6 days for those not receiving an epidural. The differences were statistically significant (P < 0.048) and remained so after adjusting for complications (P < 0.0001). Regarding oncological outcome, PSA recurrence was further analyzed in this cohort. Percentage of recurrence was higher (14.8%) for patients receiving an epidural than for the non-epidural group (4.8%). The differences were statistically significant (P = 0.012).
Epidural analgesia increased length of hospital stay and technical problems related to the epidural. Furthermore, men receiving an epidural showed an increased recurrence of PSA. In light of our findings, epidurals are probably not indicated for men undergoing RRP. However, as minimally invasive techniques are becoming more widespread, and epidural analgesia is being used less frequently, large randomized controlled trials to definitively support our hypotheses are unlikely to be undertaken.
prostate neoplasm; surgery; prostatectomy; analgesia; epidural
Previous research has shown an association between preoperative depressive symptoms and a poorer surgery outcome in lumbar spinal stenosis (LSS). It is not known whether depressive symptoms throughout the recovery period are relevant to the outcome of surgery in LSS. In this prospective clinical study the predictive value of preoperative and postoperative depressive symptoms with respect to the surgery outcome is reported.
96 patients (mean age 62 years) with symptomatic lumbar spinal stenosis underwent decompressive surgery. They completed the same set of questionnaires preoperatively and 3 months, 6 months, 1 year and 2 years postoperatively. Depressive symptoms were assessed with the 21-item Beck Depression Inventory. Physical functioning and pain were assessed with the Oswestry Disability Index, the Stucki Questionnaire, self-reported walking ability and VAS rating. Logistic regression analyses were used to examine the predictive value of preoperative and postoperative depressive symptoms regarding the surgery outcome. A "good" outcome was defined in two ways: first, by gaining a 30% improvement in relation to the preoperative disability and pain, and second, by having a score at or below the median value for disability and pain on 2-year follow-up.
Having elevated depressive symptoms particularly on 3-month follow-up was predictive of a poorer surgery outcome regarding pain and disability: when the outcome was defined as less than 30% improvement from the baseline, the OR's (with 95% confidence intervals) were 2.94 (1.06-8.12), <0.05 for Oswestry and 3.33 (1.13-9.79), <0.05 for VAS. In median split approach the OR was 4.11 (1.27-13.32), <0.05 for Oswestry. Predictive associations also emerged between having depressive symptoms on 6-month and 1-year follow-ups and a poorer outcome regarding disability. The predictive value of elevated depressive symptoms particularly with respect to 2-yeard disability was evident whether the outcome was defined as a 30% improvement compared to the preoperative status or as belonging to the better scoring half of the study population on 2-year follow-up.
Preoperative and postoperative depressive symptoms may indicate those patients at greater risk of a poorer postoperative functional ability. For these patients, further clinical evaluation should be carried out, especially during postoperative stages.
Background: Arthroscopic shoulder surgery is increasingly performed as a day case procedure. Optimal post-operative pain relief remains a challenge due to considerable variations in the level of pain experienced between individuals. Our aim was to examine whether the preoperative electrical pain threshold was a strong predictor of elevated postoperative pain levels following arthroscopic subacromial decompression (ASD) surgery.
Methods: Forty consenting patients with American Society of Anesthesiologists (ASA) grade 1-2 presenting for elective ASD surgery were recruited. Patients’ electrical pain thresholds were measured preoperatively using a PainMatcher® (Cefar Medical AB, Lund, Sweden) device. Following surgery under general anaesthesia, the maximum pain experienced at rest and movement was recorded using a visual analogue scale until the end of postoperative day four.
Results: In univariate analyses (t-test), the postoperative pain experienced (Area Under Curve) was significantly greater in patients with a low pain threshold as compared with a high pain threshold at both rest (mean 12.5, S.E. 1.7 v mean 6.5, S.E.1.2. P=0.008) and on movement (mean 18.7, S.E. 1.5 v mean 14.1, S.E.1.4. P=0.031). In multivariate analyses, adjusting for additional extra analgesia, the pain experienced postoperatively was significantly greater in the low pain threshold group both at rest (mean difference 4.9, 95% CI 1.5 to 8.4, P=0.007) and on movement (mean difference 4.1, 95%CI 0.03 to 8.2, P=0.049).
Conclusions: Preoperative pain threshold can predict postoperative pain level following ASD of the shoulder.
Trial registration: Clinicaltrials.gov identifier: NCT01351363
Level of Evidence: II
Acute and severe pain is common in patients postoperatively and should be correctly managed. In the past years studies on preparing better postoperative pain control have resulted in development of postoperative pain management guidelines. Perhaps, one of the major improvements in managing postoperative pain is the development of the patient-controlled analgesia systems (PCA), especially through intra venous (IV), extradural and transdermal routes, which has resulted in marked improvements in acute postoperative pain management. Physicians administrate potent opioids for moderate to severe post-surgical pains. Morphine is the most commonly IV-PCA administrated analgesic. The fentanyl iontophoretic transdermal system (fentanyl ITS) is also another efficient option for pain management.
The aim of this study was to compare the analgesic effects of these two routine postoperative pain control systems.
Patients and Methods:
We enrolled 281 patients (224 males, 57 females) in this blind randomized controlled clinical trial, who had undergone an orthopedic surgery, with the mean age of 33.91 ± 14.45 years. Patients were randomly divided into two groups; in group A patients received IV-morphine PCA pump and in group B fentanyl transdermal patches were attached on patients’ arms. The severity of the pain was registered according to Visual Analogue Scale in specially designed forms by pain-trained nurses in two steps; first after the surgery and next before the beginning of analgesic effects. After 24 hours, the pain score was assessed again.
No significant difference was observed in mean pain intensity score at the first patient assessment. Mean pain intensity scores were also similar in both groups at the last measured time point (P > 0.05). Differential pain intensity scores, showing the impacts of analgesic system on the pain experience of the patients was also similar between fentanyl patches (6.48 ± 2.20) and morphine PCIA (6.40 ± 1.80). (P > 0.05) Mean patient satisfactory score (scale: 0–100) was also similar in both groups (P > 0.05). The percentage of patients, whose differential pain intensity scores at 24 hours reached our pain management goal was similar between fentanyl and morphine groups (P > 0.05). The percentage of patients with at least one adverse event was significantly higher in fentanyl group (P < 0.05). The most frequent adverse events were nausea, vomiting and itching. In none of the groups, no patient experienced serious adverse events related to the studied medications.
Although both pain killing therapeutic regimens are safe and effective for postoperative pain management, regarding the easy usage of the patches, lower risk of abuse and cost-effectiveness in the Iranian market, it is recommended for use in Iranian hospitals and trauma centers and in countries with similar socioeconomic situations.
Fentanyl; Morphine; Analgesia; Patients; Pain Management; Postoperative Period
To investigate whether preoperative risk for delirium moderates the effect of postoperative pain and opioids on the development of postoperative delirium.
Prospective cohort study
University medical center
Patients ≥ 65 years of age scheduled for major noncardiac surgery
A structured interview was conducted pre- and post-operatively to determine the presence of delirium, defined using the Confusion Assessment Method. We first developed a prediction model to determine which patients were at high vs. low risk for the development of delirium based on preoperative patient data. We then computed a logistic regression model to determine whether preoperative risk for delirium moderates the effect of postoperative pain and opioids on incident delirium.
Of 581 patients, 40% developed delirium on days 1 or 2 after surgery. Independent preoperative predictors of postoperative delirium included lower cognitive status, a history of central nervous system disease, high surgical risk, and major spine and joint arthroplasty surgery. Compared to the patients at low preoperative risk for developing delirium, the relative risk for postoperative delirium for those in the high preoperative risk group was 2.38 (95% CI = 1.67–3.40). A significant three-way interaction indicates that preoperative risk for delirium significantly moderated the effect of postoperative pain and opioid use on the development of delirium. Among patients at high preoperative risk for development of delirium who also had high postoperative pain and received high opioid doses, the incidence of delirium was 72%, compared to 20% among patients with low preoperative risk, low postoperative pain and received low opioid doses.
High levels of postoperative pain and using high opioid doses increased risk for postoperative delirium for all patients. However, the highest incidence of delirium was among patients who had high preoperative risk for delirium and also had high postoperative pain and used high opioid doses.
The authors studied preoperative pain intensity and chronicity and the amount of postoperative analgesia as a marker of length of stay (LOS) in patients undergoing spinal fusion, cervical or lumbar. Regression analysis revealed statistical significance only between LOS and surgical site. It showed no significance between LOS as the dependent variable and preoperative pain parameter, postoperative morphine per kilogram, sex, or age as predictors
Pain medication use is enormous in those looking for relief of chronic back pain. The impact of long-term analgesia use might serve as a marker for prolonged hospitalization due to undertreating postoperative pain, which could ultimately result in higher health care costs.
We studied preoperative pain intensity and chronicity and the amount of postoperative analgesia as a marker of length of stay (LOS) in patients undergoing spinal fusion. The charts of patients undergoing cervical or lumbar spinal fusion were reviewed, and data on their intensity of pain at admission and length of pain was documented, as was the amount of morphine used.
Regression analysis revealed statistical significance only between LOS and surgical site (neck or lumbar spine). It showed no significance between LOS as the dependent variable and preoperative pain parameter, postoperative morphine per kilogram, sex, or age as predictors.
Postoperative pain management continues to be a challenge because of the need to balance satisfactory analgesia in patients with the fear of adverse effects due to overdosing. This challenge is even greater in patients with long-term narcotic use. Anecdotally, patients undergoing spinal fusion show an inverse relationship between LOS and amount of use of postoperative pain medication. A more extensive scientific review of current postoperative pain control protocols is warranted in patients undergoing spinal fusion.
Opioids are considered a “gold standard” in clinical practice for the treatment of postoperative pain. The spinal administration of an opioid drug does not guarantee selective action and segmental analgesia in the spine. Evidence from experimental studies in animals indicates that bioavailability in the spinal cord biophase is negatively correlated with liposolubility, and is higher for hydrophilic opioids, such as morphine, than lipophilic opioids, such as fentanyl, sufentanil and alfentanil.
Epidural morphine sulphate has proven analgesic efficacy and superiority over systemically administered morphine for improving postoperative pain. However, pain relief after a single epidural injection of morphine could last less than 24 hours. Techniques used to administered and prolong opioid epidural analgesia, can be costly and inconvenient. Moreover, complications can arise from indwelling epidural catheterization, particularly in patients receiving anticoagulants. Clinical trials have shown that epidural morphine in the form of extended-release liposome injections (EREM) gives good analgesia for a period of 48 hours, with no need for epidural catheterisation. Intrathecal morphine produces intense analgesia for up to 24 hours with a single shot, and clinical recommendation is to choose the minimum effective dose and do not exceed 300 μg to prevent the delay respiratory depression.
To assess prospectively the incidence of chronic and neuropathic pain in patients undergoing anteroaxillary thoracotomy with postoperative epidural analgesia or controlled-release oxycodone pain regimen.
77 patients who underwent anteroaxillary thoracotomy were enrolled in our observational study. 40 patients received postoperatively a standardized oral analgesic protocol with controlled-release oxycodone and IV non opioid (CRO Group), and 37 patients received epidural analgesia with ropivacaine 0.1% + 1 μg/ml sufentanil (EDA Group) and IV non opioid. The painDETECT questionnaire was completed from the patients with one of the authors (JL) on the 7th postoperative day and six months postoperatively.
The data of 60 patients were eligible for statistical analysis, 28 patients in the CRO Group and 32 patients in the EDA Group. 17 patients did not reach the 6-months follow-up interval (12 drop outs in the CRO Group and 5 drop outs in the EDA Group). 79% percent of patients in the CRO Group and 74% percent of patients in the EDA Group had a numeric rating scale score (NRS) = 0 after 6 months. 22% percent of patients in the CRO Group and 16% percent of patients in the EDA Group experienced a NRS 1–3 6-months postoperatively. No patient in the CRO Group and 9% percent of patients in the EDA Group had 6-months postoperatively a NRS 4–6. Neither in the CRO Group nor in the EDA Group we could detect a neuropathic pain 6 months postoperatively corresponding to a painDETECT score > 18. Overall, with regard to NRS, there was no statistical difference between the two groups (p = 0.13). 90% percent of patients in the CRO Group and 90% percent of patients in the EDA Group showed 6-months postoperatively a painDETECT score < 13 (definitely no neuropathic pain), and 9% percent in the EDA Group and 11% in the CRO Group had a 6-months painDETECt score 13–18 (p = not significant).
These pilot data indicate that epidural analgesia is not superior to systemic postoperative analgesia with regard to preventing chronic or neuropathic pain after thoracotomy.
The effectiveness of intrathecal opioids (ITOs) for postoperative analgesia has been limited by reduced opioid dosing because of opioid-related side effects, most importantly respiratory depression. To overcome these limitations, high-dose intrathecal morphine was combined with a continuous intravenous (IV) postoperative naloxone infusion. The aim of the present chart analysis was to investigate the safety and efficacy of high-dose ITOs combined with IV naloxone compared with IV opioid analgesia alone.
A retrospective chart analysis was performed on 121 female patients requiring major pelvic surgery. Ninety-eight patients received a single injection of high-dose ITOs before administration of typical general anesthesia, followed by an IV naloxone infusion at 5 μg/kg/h started post-ITO and continued for 22 h postoperatively. Twenty-three patients were given IV morphine (IVM) for postoperative analgesia and served as a reference group. Postoperative pain relief, analgesic consumption and ability to ambulate were assessed for 48 h postoperatively. Treatment safety was assessed by monitoring opioid-related side effects and vital signs. Data are presented as mean ± SD.
Mean ITOs given were morphine 1.1±0.2 mg combined with fentanyl 49±6 μg. The mean worst pain visual analogue scale score in the first 12 h postoperatively was 0.2±0.90 in the ITO group versus 4.3±3.0 in the IVM group (P<0.05). On postoperative day 2, the mean worst pain visual analogue scale score was only 1±1.8 in the ITO group versus 4.1±2.6 in the IVM group (P<0.05). Analgesic requirements were reduced in the ITO group. In the first 24 h, the ITO group used 6.8±10.2 morphine equivalents (mg IV) versus 76.1±44.4 in the IVM group (P<0.05). All patients in the ITO group were able to ambulate in the first 12 h postoperatively compared with 17/23 in the IVM group. There was a higher incidence of opioid-related sedation in the IVM group. Other opioid-related side effects were infrequent and minor in both groups.
High-dose ITOs combined with a postoperative IV naloxone infusion provided excellent analgesia for major pelvic surgery. The IV naloxone infusion combined with high-dose ITOs appeared to control opioid side effects without affecting analgesia.
Intrathecal opioids; Morphine; Naloxone; Spinal analgesia
Until recently, the clinical significance of post-surgical pain and its undertreatment were for the most part unappreciated. Recognition that inadequate analgesia adversely affects the patient's cardiovascular, pulmonary, and emotional status has spurred development of new and highly effective methods of controlling pain. With the introduction of spinal opioid and patient-controlled analgesia (PCA) came the realization that, while such forms of therapy provided superior pain relief, they were not without their own unique and occasionally serious side effects. For this reason, both techniques are more safely provided by highly trained members of a dedicated acute/post-surgical pain service. Although spinal opioid (epidural, intrathecal) techniques are invasive and require patient cooperation, they have a high degree of safety in low-risk populations (ASA 1 and 2). The major therapeutic advantage of spinal opioids is their ability to prevent pain from being perceived. PCA permits patients to titrate intravenous opioids in proportion to their particular level of pain intensity. Although PCA provides effective pain "relief," the technique is incapable of preventing pain from being appreciated. A number of studies have observed that pain scores in patients successfully employing PCA were significantly higher than those noted in individuals treated with epidural opioids. Nevertheless, the control gained by self-administration, uniformity of analgesia, and low level of adverse results associated with PCA provides higher patient satisfaction and decreased sedation when compared with traditional intramuscular dosing. The effectiveness of PCA may be improved by adjusting for patient variables, utilizing opioids having rapid onset, the addition of a basal infusion, and supplementation with non-steroidal anti-inflammatory agents. Interpleural analgesia represents an important therapeutic option in patients sensitive to opioid-induced respiratory depression. The technique is more effective when local anesthetic solutions are continually infused. Analgesic efficacy may be further enhanced by the addition of "low-dose" PCA.