Predictors for Early Physical Recovery for General and Orthopedic Patients after Major Surgery: Structural Equational Model Analyses

BackgroundAttention to factors that may affect patients’ ability to experience enhanced recovery after surgery is essential in planning for postoperative care.AimsTo create models of predefined pre,- peri-, and postoperative variables in order to analyze their impact on patients’ physical recovery on postoperative days 1 and 2 after major orthopedic and general surgery.DesignAn exploratory design with repeated measures was used, including 479 patients who had undergone orthopedic (289) or general surgery (190) at three hospitals.MethodsPain, nausea, and level of physical ability were measured preoperatively and on postoperative days 1 and 2 by using the Numerical Rating Scale and items from the Postoperative Recovery Profile. Structural equation modeling was used to explore the impact of the predefined variables on patients’ physical recovery.ResultsThe orthopedic group contained significantly more women and significantly more patients with pain and opioid use. Although the models showed good fit, “traditional” preoperative (pain, nausea, physical abilities, chronic pain, opioid use) and perioperative variables (anesthesia, length of surgery) constituted few (orthopedic) or no (general surgery) predictive properties for physical recovery. Postoperative average pain intensity, average nausea intensity, and physical ability explained physical recovery on day 1, and physical recovery on day 1 predicted physical recovery on day 2.Conclusions“Traditional” predictors had little effect on patients’ postoperative physical recovery, while associations with common postoperative symptoms were shown. Further research is needed to explore additional variables affecting early physical recovery and to understand how soon patients are physically ready to return home.     

School-aged children's interpretation of their experience with acute surgical pain.

This study examined the intensity of pain children experience following surgical procedures, the relationship between analgesic administration patterns and perceived level of pain, and children's affective, cognitive, and sensory interpretation of their experiences with pain. The sample included 24 children between 7 and 11 years of age who were hospitalized after abdominal, orthopedic, or urologic surgery. Children rated the intensity of their pain on a visual analog scale three times on the day after surgery. A chart review examined analgesic administration. On the third day after surgery, children were interviewed about their experiences with pain. The findings provide insight into the content of children's fears and concerns when they have postoperative pain, and how they interpret their responses and the responses of others in the management of their pain experience.     

A qualitative study of the operating room experience of patients who underwent surgery under spinal anesthesia: “It was like an adventure”

This study aimed to explore the experiences of the people who underwent orthopedic surgery under spinal anesthesia and to report their feelings and thoughts. The study was carried out using a qualitative approach. Twenty‐one patients were interviewed who underwent orthopedic surgery on the first or second postoperative day. Content analysis was performed after the collection of raw data. NVIVO 12 Pro software was used for data analysis. The frequency count (f) and participant codes (P) were used for the presentation of the findings. The themes and frequency counts obtained by analyzing the interviews with the patients were as follows: “Time passed like watching a movie” (f = 213), “Like an adventure” (f = 587), and “See, feel, look” (f = 405). Five of 21 participants (23.8%) stated that they would not recommend spinal anesthesia. The findings generally indicated the anxiety caused by the unknown, fear in the preanesthetic period, operation experienced like an adventure, and a process generally completed with satisfaction.     

Colorectal Surgery Patients’ Pain Status,Activities, Satisfaction,and Beliefs about Pain and Pain Management

This study describes surgical colorectal cancer patients’ pain levels, recovery activities, beliefs and expectations about pain, and satisfaction with pain management. A convenience sample of 50 adult inpatients who underwent colorectal surgery for cancer participated. Patients were administered the modified American Pain Society Patient Outcome Questionnaire on postoperative day 2 and asked to report on their status in the preceding 24 hours. Patients reported low current (mean 1.70) and average (mean 2.96) pain scores but had higher scores and greater variation for worst pain (mean 5.48). Worst pain occurred mainly while turning in bed or mobilizing, and 25% of patients experienced their worst pain at rest. Overall, patients expected to have pain after surgery and were very satisfied with pain management. Patients with worst pain scores >7 reported interference with recovery activities, mainly general activity (mean 5.67) and walking ability (mean 5.15). These patients were likely to believe that “people can get addicted to pain medication easily” (mean 3.39 out of 5) and that “pain medication should be saved for cases where pain gets worse” (mean 3.20 out of 5). These beliefs could deter patients from seeking pain relief and may need to be identified and addressed along with expectations about pain in the preoperative nursing assessment.     

The efficacy of preoperative versus postoperative rofecoxib for preventing acute postoperative dental pain: a prospective randomized crossover study using bilateral symmetrical oral surgery

BACKGROUND: Previous data have demonstrated that rofecoxib has good analgesic efficacy for acute postoperative dental pain. However, up to half of these patients require rescue analgesics within the first 24 hours. As the timing of analgesic interventions may be an important factor in pain control, the present study tested the hypothesis that rofecoxib administered preoperatively would improve the analgesic efficacy and reduce rescue analgesic requirements within the first 24 hours compared with postoperative administration. METHODS: This was a double-blind, randomized, crossover study where 45 patients had each of their identical impacted mandibular third molars removed under local anesthesia on 2 separate occasions. Patients acted as their own control; one side was pretreated with rofecoxib 50 mg, 2 hours before surgery, followed by placebo 15 minutes after surgery, and the contralateral side was pretreated with placebo 2 hours before surgery and posttreated with rofecoxib 50 mg 15 minutes after surgery. The difference in postoperative pain between 2 sides was assessed by 4 primary end-points: pain intensity as measured by a 100-mm visual analogue scale hourly for 12 hours, time to rescue analgesic, postoperative analgesic consumption, and patient's global assessment. RESULTS: Patients reported significantly lower pain scores (P = 0.04), longer time to rescue analgesic (P = 0.02), lesser postoperative analgesic consumption (P = 0.008), and better global assessment (P = 0.01) in the pretreated compared with the posttreated sides. There were significantly more patients in the pretreated group who did not required rescue analgesic within the first 24 hours (80% vs. 58%, P = 0.01), and the pain scores were extremely low in both groups during the 12 hours postoperative period (9.8 +/- 5.0 mm vs. 14.3 +/- 7.4 mm). CONCLUSION: Rofecoxib is an excellent analgesic for preventing postoperative dental pain and when given 2 hours preoperatively rendered most patients relatively pain free, requiring no rescue analgesics on the first postoperative day.     

The prevalence of postoperative pain in a cross-sectional group of patients after day-case surgery in a university hospital

OBJECTIVES: Although a great variety of surgical procedures are performed on an ambulatory basis, little is known about postoperative pain experience at home after ambulatory surgery. This study was performed to assess the prevalence and course of postoperative pain in the early postoperative period after ambulatory surgery. METHODS: Over a period of 4 months, 648 patients who underwent day-case surgery were included in our study. Data were collected with interviews and questionnaires. Pain intensity was measured using a visual analog scale (VAS) during 4 days after surgery. Side effects of anesthesia and analgesia techniques were also recorded. RESULTS: On the day of the operation, 26% of the patients had moderate to severe pain (defined as mean VAS >40 mm). Mean VAS-scores were greater than 40 mm in 21% on postoperative day (POD) 1, in 13% on POD 2, in 10% on POD 3, and in 9% on POD 4. Operations of nose and pharynx, abdominal operations, plastic surgery of the breasts, and orthopedic operations were the most painful procedures during the first 48 hours. DISCUSSION: This study showed that an important number of patients still experience moderate to severe pain in the postoperative period after day-case surgery even after a 4-day period. Furthermore, the type of operation should be considered when planning postoperative analgesia for ambulatory surgery.     

QUIPSambulant

Background and objectives

Up until recently no tool for quality assurance (QA) of outpatient pain therapy after outpatient surgery, which currently constitutes one third of all operations, was available with benchmarking capacity. The QUIPS (German abbreviation for quality assurance in postoperative pain therapy) questionnaire, that had primarily been developed and established for inpatient postoperative pain therapy, was to be optimized to not only incorporate the issues with regard to outpatient operations but also a revision for use in the clinical routine.

Material and methods

An interdisciplinary task force reviewed and optimized the QUIPS questionnaire. The optimized questionnaire was then used within the scope of outpatient surgery in their clinics. A total of 121 patients and 12 surgeons received a questionnaire on the first postoperative day containing questions on acceptance and understandability of the QUIPS patient outcome questionnaire.

Results

Of the patients 12 (9.9?%) did not understand the original question on special pain therapy procedures stated during the preoperative counseling. For 15 patients (12.4?%) the original questions on chronic or pre-existing pain were misleading and 4 out of the 12 surgeons (33?%) did not conclusively understand these questions. The optimized questionnaire modified the questions in the preoperative counseling in the segment of postoperative pain as follows: question E1 was changed to a yes/no answer. Question E13 was modified to “how content were you with respect to your post-operative pain therapy?” Question E14 was modified to “did you suffer from other pain prior to the operation, hence pain that continued in addition to the postoperative pain?” These changes improved the understandability of the QUIPS patient outcome questionnaire. Surgeons required on average 9.7 min (SD ±3.2 min) to complete the QUIPS documentation sheets and 83?% of the surgeons rated the optimized QUIPS module as usable in the daily routine. The new module QUIPSambulant will soon be available for download on the QUIPS internet website.

Discussion

By reducing items on the QUIPS documentation sheets with respect to items relevant for outpatient surgery and redesigning three questions in the patient outcome questionnaire, a new QUIPS module for the QA of postoperative pain in an ambulatory setting is now available for both patients and surgeons. The necessity for quality management (QM) with regard to postoperative pain therapy after outpatient surgery can be considered assured. To what extentthe newly adapted QM tool QUIPSambulant will be deemed suitable in a routine hospital setting remains to be seen and requires ongoing investigation.

     

Using the American Pain Society's patient outcome questionnaire to evaluate the quality of postoperative pain management in a sample of Norwegian patients.

In the United States, quality improvement (QI) approaches have been used to evaluate pain management. However, the use of QI approaches to evaluate the quality of patient care is just emerging in many European countries. The purposes of this study, using the American Pain Society's QI Standards, were: to describe changes over time, in pain severity, in pain interference with function, and in the doses of analgesics administered; to describe patients' level of satisfaction with postoperative pain management; and to determine the relationships between pain severity and patient outcomes. Results from a sample of patients who underwent orthopedic surgery suggest that undertreatment of pain persists across the first 5 postoperative days and that pain's level of interference with function decreases significantly between the third and fifth postoperative days. As in other studies, despite high pain intensity scores, patients reported high levels of satisfaction with postoperative pain management. PERSPECTIVE: Findings suggest that the undertreatment of pain results in significant decrements in function over the first 5 postoperative days. Future studies designed to improve the quality of postoperative pain management need to use multimodal approaches and evaluate not only pain intensity, but improvements in function as critical outcome measures.     

Acceptance and Commitment Therapy for Prevention of Chronic Postsurgical Pain and Opioid Use in At-Risk Veterans: A Pilot Randomized Controlled Study

High levels of pain, significant anxiety, or depressive symptoms before surgery put patients at elevated risk for chronic pain and prolonged opioid use following surgery. The purpose of this preliminary study was to assess the efficacy of a 1-day Acceptance and Commitment Therapy (ACT) workshop in “at-risk” veterans for the prevention of chronic pain and opioid use following orthopedic surgery. In a randomized controlled trial, 88 at-risk veterans undergoing orthopedic surgery were assigned to treatment as usual (TAU; n?=?44) or TAU plus a 1-day ACT workshop (n?=?44). Pain levels and opioid use were assessed up to 3 months following surgery. Pain acceptance and values-based behavior were assessed at baseline and 3-month follow-up. Participants who completed the ACT workshop reached pain and opioid cessation sooner than those in TAU. Postoperative complications exhibited a moderating effect on these outcomes, such that the effects of ACT were greater in patients without complications. Increases in pain acceptance and values-based behavior, processes targeted in ACT, were related to better outcomes. These promising results merit further investigation in a larger clinical trial. Providing an intervention before surgery for at-risk veterans has the potential to change clinical practice from a focus on management of postoperative pain to prevention of chronic pain in at-risk individuals.

How Many Steps Per Day During the Early Postoperative Period are Associated With Patient-Reported Outcomes of Disability,Pain, and Opioid Use After Lumbar Spine Surgery?

ObjectiveTo investigate whether early postoperative walking is associated with “best outcome” and no opioid use at 1 year after lumbar spine surgery and establish a threshold for steps/day to inform clinical practice.DesignSecondary analysis from randomized controlled trial.SettingTwo academic medical centers in the United States.ParticipantsWe enrolled 248 participants undergoing surgery for a degenerative lumbar spine condition (N=248). A total of 212 participants (mean age, 62.8±11.4y, 53.3% female) had valid walking data at baseline.InterventionsNot applicable.Main Outcome MeasuresDisability (Oswestry Disability Index), back and leg pain (Brief Pain Inventory), and opioid use (yes vs no) were assessed at baseline and 1 year after surgery. “Best outcome” was defined as Oswestry Disability Index ≤20, back pain ≤2, and leg pain ≤2. Steps/day (walking) was assessed with an accelerometer worn for at least 3 days and 10 h/d at 6 weeks after spine surgery, which was considered as study baseline. Separate multivariable logistic regression analyses were conducted to determine the association between steps/day at 6 weeks and “best outcome” and no opioid use at 1-year. Receiver operating characteristic curves identified a steps/day threshold for achieving outcomes.ResultsEach additional 1000 steps/d at 6 weeks after spine surgery was associated with 41% higher odds of achieving “best outcome” (95% confidence interval [CI], 1.15-1.74) and 38% higher odds of no opioid use (95% CI, 1.09-1.76) at 1 year. Walking ≥3500 steps/d was associated with 3.75 times the odds (95% CI, 1.56-9.02) of achieving “best outcome” and 2.37 times the odds (95% CI, 1.07-5.24) of not using opioids.ConclusionsWalking early after surgery may optimize patient-reported outcomes after lumbar spine surgery. A 3500 steps/d threshold may serve as an initial recommendation during early postoperative counseling.     

Postsurgical pain relief: Patients' status and nurses' medication choices

This study consisted of two interrelated parts. In the first part, the adequacy of pain relief in hospitalized post-surgical patients was assessed and described and in the second part ways in which nurses on the same units chose analgesic medications were examined and analyzed. Pain was considered a subjective experience. Patients were interviewed, and their charts reviewed on the third postoperative day. The sample included 109 patients in 5 central Illinois hospitals. After all patient interviews were completed, 121 nurses on the same units responded to a questionnaire which included clinical vignettes. Results of the patient interviews indicated that 75.2% of these patients were in moderate or marked pain distress and that a general question did not adequately assess pain. Chart review indicated that these patients were actually receiving less narcotic analgesics than they could receive. Nurses were overly concerned about the possibility of addiction; choices of analgesic medications seemed irrational; and knowledge of the drugs was inadequate. Moreover, these nurses indicated that complete pain relief after surgery was not their major goal. In 2 sets of identical vignettes where the only difference was the sex of the patient, nurses selected less medication for pain for female patients (P < 0.001 and P < 0.025 respectively). Factors that nurses consider in administering and choosing postoperative analgesia are described.     

Valdecoxib, a COX-2-specific inhibitor, is an efficacious, opioid-sparing analgesic in patients undergoing hip arthroplasty.

Opioid agents are highly effective analgesics after orthopedic surgery but are associated with several adverse effects. Valdecoxib is a new, highly selective cyclooxygenase (COX)-2-specific inhibitor with a rapid onset of action and significant analgesic properties that is being developed for the management of acute pain. The objective of this study was to demonstrate the opioid-sparing efficacy of valdecoxib as part of a multimodal treatment of pain associated with hip arthroplasty. This multicenter, multiple-dose, double-blind, parallel-group study compared the opioid-sparing effects, analgesic efficacy, and safety of 20- and 40-mg doses of valdecoxib twice daily with placebo in patients receiving morphine by patient-controlled analgesia after hip arthroplasty. Study medication was first administered 1 to 3 hours preoperatively. The total amount of morphine administered, pain intensity, and patient's global evaluation of study medication were assessed over a period of 48 hours. Patients receiving 20 or 40 mg valdecoxib twice daily required on average 40% less morphine than those receiving placebo after hip arthroplasty. Pain intensity levels and patient satisfaction were significantly improved in both valdecoxib groups compared with placebo. Valdecoxib and placebo were equally well tolerated. Pre- and postoperative administration of valdecoxib reduces the amount of morphine required for postoperative pain relief and provides greater analgesic efficacy compared with morphine alone. Thus, valdecoxib has significant clinical utility for acute pain management in orthopedic surgery patients.     

Pain outcomes after intestinal surgery

Pain sensation and distress in 38 intestinal surgical patients were moderate to severe on postoperative day 1, ranging from 34 to 49 mm and 33 to 45 mm, respectively, on 100-mm scales. During ambulation, both increased from baseline to post-ambulation, P < 0.01. Half of the patients reported severe pain not relieved by analgesics, and although 44% learned a relaxation technique in the past, only 8% used one for pain after this surgery. Pain disturbed the sleep of 34% of the patients, and pain was related to respiratory, intestinal, febrile, and other complications in 18 (47%) subjects. Attentive analgesic use and nonpharmacologic therapies are recommended.     

Postoperative Pain Management and Patient Evaluations After Five Different Surgical Procedures. A Prospective Cohort Study

BackgroundSufficient pain management is a necessity and can play an important role in patients’ contentment.AimsTo investigate the instituted postoperative pain treatment, patients’ levels of pain, opioid consumption, and patient contentment, supplemented with a questionnaire based on the International Pain Outcome (IPO).MethodsThis prospective observational cohort study was conducted at Zealand University Hospital Køge, Denmark (ZUHK) from March 8, 2017, to January 7, 2019, aiming for a consecutive inclusion of 200 patients, 40 from five major surgical procedures. The study was approved by the Danish Data Protection Agency (REG-121-2016) and registered at ClinicalTrials.gov (NCT03080272). The Research Ethics Committee of the Zealand Region was consulted, but approval was not needed according to Danish law (J.nr. 16-000014).ResultsWe included 189 patients in total. We found a significant number of patients that did not achieve “no worse than mild pain” (Numeric Rating Scale ≤3) across surgical procedures. The provided pain treatment was heterogenic and inconsistent even among individuals who underwent similar surgical procedures. Although patients did not achieve “no worse than mild pain” (Numeric Rating Scale ≤3), the majority stated that they were content with their pain treatment.ConclusionsThe analgesic treatment varied between procedures and patients and a significant number of patients did not achieve “no worse than mild pain” (Numeric Rating Scale ≤3). A significant association between patient contentment and experience of severe pain, pain relief, and involvement in own pain treatment, was found.     

The use of a questionnaire for improvement of postoperative analgesia after transurethral resection of the prostate

Background: Postoperative analgesic studies with methods like i.v. patient controlled analgesia (i.v. PCA) or epidural analgesia have reported effective pain relief after major surgery, also after urologic cancer surgery. In contrast, systematic results after minor urologic surgery are widely unknown, although the pain intensities may be high for a short time. The aim of the study was to evaluate the usefulness of a pain questionnaire as a measurement tool of postoperative analgesic quality after transurethral resection of the prostate (TUR-P). Methods: A questionnaire of the American Pain Society (APS) for quality assurance of postoperative pain therapy was adapted to estimate the pain profile, analgesic demand, satisfaction and side effects of analgesic therapy at the morning of the first postoperative day in two groups after TUR-P. In one group (group 1; n=50) the efficacy of a routinely used (but non-standardized) analgesic regimen with different analgesics administered only on demand was estimated with the questionnaire. These results were compared with a new and standardized analgesic approach (group 2; n=50), designed as a follow-up study. These patients received an intravenous infusion of the weak opioid tramadol (500 mg) in combination with the spasmolytic butylscopolamine (50 mg) immediately after the surgery until the morning of first postoperative day. Also the effectivity of this standardized regimen was estimated with the questionnaire. Results: In group 1, an evident analgesic undersupply with high pain intensities as well as frequent and long lasting breakthrough pain was documented. In contrast, in group 2 with a standardized approach the questionnaire did indicate impressing clinical improvement. In addition, patient satisfaction was significantly higher, despite some typical side effects of tramadol, such as drowsiness and dizziness. Conclusions: The modified questionnaire of the American Pain Society allows important insights into the analgesic quality after defined surgery without special methods of an Acute Pain Service. The questionnaire is easy to handle and takes only a few minutes. The presented data after TUR-P can not substitute randomized controlled trials.