Philip Peng

Predictors of postoperative pain and analgesic consumption: a qualitative systematic review.

Pain is a subjective and multidimensional experience that is often inadequately managed in clinical practice. Effective control of postoperative pain is important after anesthesia and surgery. A systematic review was conducted to identify the independent predictive factors for postoperative pain and analgesic consumption. The authors identified 48 eligible studies with 23,037 patients included in the final analysis. Preoperative pain, anxiety, age, and type of surgery were four significant predictors for postoperative pain. Type of surgery, age, and psychological distress were the significant predictors for analgesic consumption. Gender was not found to be a consistent predictor as traditionally believed. Early identification of the predictors in patients at risk of postoperative pain will allow more effective intervention and better management. The coefficient of determination of the predictive models was less than 54%. More vigorous studies with robust statistics and validated designs are needed to investigate this field of interest.

A systematic review of the effect of waiting for treatment for chronic pain.

&NA; In many countries timely access to care is a growing problem. As medical costs escalate health care resources must be prioritized. In this context there is an increasing need for benchmarks and best practices in wait‐time management. The Canadian Pain Society struck a Task Force in December 2005 to identify benchmarks for acceptable wait‐times for treatment of chronic pain. As part of the mandate a systematic review of the literature regarding the relationship between waiting times, health status and health outcomes for patients awaiting treatment for chronic pain was undertaken. Twenty‐four studies met the inclusion criteria for the review. The current review supports that patients experience a significant deterioration in health related quality of life and psychological well being while waiting for treatment for chronic pain during the 6 months from the time of referral to treatment. It is unknown at what point this deterioration begins as results from the 14 trials involving wait‐times of 10 weeks or less yielded mixed results with wait‐times amounting to as little as 5 weeks, associated with deterioration. It was concluded that wait‐times for chronic pain treatment of 6 months or longer are medically unacceptable. Further study is necessary to determine at what stage the deterioration begins from the onset of pain to treatment and the impact of waiting on treatment outcomes. Most important is the need to improve access to appropriate care for patients with chronic pain, an escalating public health care problem with significant human and economic costs.

A Comparative Study of General Anesthesia, Intravenous Regional Anesthesia, and Axillary Block for Outpatient Hand Surgery: Clinical Outcome and Cost Analysis

IV regional anesthesia can offer a more favorable patient recovery profile and shorter postoperative nursing care time and hospital discharge time than an isoflurane-based general anesthetic or brachial plexus block technique for hand surgery.

Ultrasound-guided interventional procedures in pain medicine: a review of anatomy, sonoanatomy, and procedures: part I: nonaxial structures.

Application of ultrasound in pain medicine is a rapidly growing medical field in interventional pain management. Ultrasound provides direct visualization of various soft tissues and real-time needle advancement and avoids exposing both the health care provider and the patient to the risks of radiation. The machine itself is more affordable than a fluoroscope, computed tomography scan, or magnetic resonance imaging machine. In the present review, we discuss the challenges and limitations of ultrasound-guided procedures for pain management, anatomy, and sonoanatomy of selected pain management procedures and the literature on those selected procedures.

Analgesic effect of interscalene block using low-dose bupivacaine for outpatient arthroscopic shoulder surgery.

Background and Objectives. Although interscalene brachial plexus block (ISBPB) is often used to provide anesthesia for arthroscopic shoulder surgery, its selective analgesic effect, provided by low‐dose local anesthetic, has not been studied. We hypothesized that ISBPB using a low volume and low concentration of bupivacaine can provide effective postoperative analgesia for shoulder surgery without producing significant sensory or motor block elsewhere. Methods. In this double‐blind study, 30 outpatients scheduled to undergo shoulder arthroscopy were randomly assigned to receive either an ISBPB with 10 mL 0.125% bupivacaine with epinephrine 1:400,000 (n = 15) or 10 mL of normal saline (n = 15). The block was performed preoperative, prior to a standardized general anesthetic. Postoperative pain scores, morphine and oral analgesic consumption, recovery profile, and patient satisfaction were recorded. Results. In the ISBPB group, verbal analog pain scores within 120 minutes after surgery were lower, morphine consumption in the postanesthesia care unit was significantly lower (2.7 ± 2.6 mg vs 9.5 ± 5.2 mg), the time to postoperative administration of the first systemic or oral analgesic was significantly longer (141 ± 182 minutes vs 13 ± 10 minutes), the degree of motor and sensory block 120 minutes after surgery was minimal, time to reach hospital discharge criteria was earlier, and patient satisfaction with postoperative analgesia at 24‐hour follow‐up was greater. Thirty‐three percent of the patients receiving ISBPB did not require any analgesic prior to hospital discharge. Conclusions. Interscalene brachial plexus block with low‐dose bupivacaine is a useful and selective analgesic technique for outpatient shoulder arthroscopic surgery.

Challenges in accessing multidisciplinary pain treatment facilities in Canada.

Purpose: The objective of this survey was to examine the services offered by multidisciplinary pain treatment facilities (MPTFs) across Canada and to compare access to care at these MPTFs.Methods: A MPTF was defined as a clinic that advertised specialized multidisciplinary services for the diagnosis and management of patients with chronic pain, having a minimum of three different health care disciplines (including at least one medical speciality) available and integrated within the facility. The search method included approaching all hospital and rehabilitation centre administrators in Canada, the Insurance Bureau of Canada, the Workplace Safety and Insurance Board or similar body in each province. Designated investigators were responsible for confirming and supplementing MPTFs from the preliminary list for each province. Administrative leads at each eligible MPTF were asked to complete a detailed questionnaire regarding their MPTF infrastructure, clinical, research, teaching and administrative activities.Results: Completed survey forms were received from 102 MPTFs (response rate 85%) with 80% concentrated in major cities, and none in Prince Edward Island and the Territories. The MPTFs offer a wide variety of treatments including non-pharmacological modalities such as interventional, physical and psychological therapy. The median wait time for a first appointment in public MPTFs is six months, which is approximately 12 times longer than non-public MPTFs. Eighteen pain fellowship programs exist in Canadian MPTFs and 64% engage in some form of research activitiesConclusion: Canadian MPTFs are unable to meet clinical demands of patients suffering from chronic pain, both in terms of regional accessibility and reasonable wait time for patients’ first appointment.RésuméObjectif: L’objectif de ce sondage était d’examiner les services offerts par les établissements pluridisciplinaires de traitement de la douleur (MPTF — multidisciplinary pain treatment facility) au Canada et de comparer l’accès aux soins dans ces MPTF.Méthode: Un MPTF a été défini comme une clinique affichant des services pluridisciplinaires spécialisés pour le diagnostic et la prise en charge des patients souffrant de douleurs chroniques, et possédant au moins trois disciplines différentes de soins de santé (y compris au moins une spécialité médicale) à disposition et intégrées dans l’établissement. La méthode de recherche comprenait la prise de contact avec tous les administrateurs d’hôpitaux et de centres de réhabilitation canadiens, le Bureau d’assurance du Canada, la Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail ou avec d’autres organismes similaires dans chaque province. Des chercheurs désignés étaient responsables pour la confirmation et l’ajout de MPTF à la liste préliminaire dans chaque province. On a demandé à la direction administrative de chaque MPTF éligible de remplir un questionnaire détaillé concernant l’infrastructure de son MPTF ainsi que ses activités de soins, de recherche, d’enseignement et de gestion.Résultats: Des formulaires de sondage complétés ont été reçus de 102 MPTF (taux de réponse de 85 %), dont 80 % sont situés dans des grandes villes, et aucun sur l’Ile du Prince Edouard et les Territoires. Les MPTF offrent une grande diversité de traitements, y compris des modalités non pharmacologiques, comme par exemple les traitements interventionnels, physiques et psychologiques. Le temps d’attente médian pour un premier rendez-vous dans un MPTF public est de six mois, ce qui est environ 12 fois plus long que dans un MPTF non public. Dix-huit programmes de fellowship en douleur existent dans les MPTF canadiens, et 64 % de ces établissements ont des activités de recherche.Conclusion: Les établissements pluridisciplinaires de traitement de la douleur canadiens ne peuvent répondre aux demandes cliniques de patients souffrant de douleurs chroniques, que ce soit en termes d’accessibilité régionale ou de temps d’attente raisonnable pour le premier rendez-vous d’un patient.

Ultrasound-guided interventional procedures in pain medicine: a review of anatomy, sonoanatomy, and procedures. Part III: shoulder.

Abstract Ultrasound-guided injection in pain medicine is emerging as a popular technique for pain intervention. It can be applied for the intervention procedures in the hip region. The objectives of this review article were to review the relevant anatomy and sonoanatomy of the hip joint and the trochanteric bursae, to describe the techniques for ultrasound-guided injections, and to examine the efficacy and accuracy of such injections.

Suprascapular Nerve Block A Narrative Review

Suprascapular nerve blockade (SSNB) is a simple and safe technique for providing relief from various types of shoulder pain, including rheumatologic disorders, cancer, and trauma pain, and postoperative pain due to shoulder arthroscopy. Posterior, superior, and anterior approaches may be used, the most common being the posterior. Recently, an ultrasound-guided approach has been described. In this review, the basic anatomy of the suprascapular nerve will be described. The different techniques of SSNB and indications for SSNB will be discussed. The complications of SSNB and outcomes of SSNB on the management of acute and chronic shoulder pain will be reviewed.

Dedicated multidisciplinary pain management centres for children in Canada: the current status.

Purpose: The objective of this study was to examine the services currently offered by multidisciplinary pain treatment facilities (MPTFs) dedicated for pediatric chronic pain management across Canada.Methods: A MPTF was defined as a clinic that advertised specialized multidisciplinary services for the diagnosis and management of chronic pain and had a minimum of three different health care disciplines (including at least one medical speciality) available and integrated within the facility. The search method was previously described in an accompanying article. Designated investigators were responsible for confirming and supplementing MPTFs from the preliminary list in their respective provinces. Administrative leads at each eligible MPTF were asked to complete a detailed questionnaire on their infrastructure, clinical, research, teaching and administrative activities. Only MPTFs dedicated to pediatric populations were included.Results: Only five centres surveyed had dedicated pediatric MPTFs, all located in major cities in five different provinces. While the median wait time was four weeks, it could be as long as nine months in one MPTF. Headache and neuropathic pain were the most commonly treated pain syndromes. All MPTFs included physicians, nurses and psychologists, and used a rehabilitation model that incorporated a wide variety of pharmacological, psychological and physical therapies. All centres provided training for medical and other healthcare professionals, and three of the five centres conducted research. Government funding was the major source of funding for patient services and overhead costs.Conclusions: There are very few pediatric MPTFs in Canada. These facilities exist in five of ten provinces, each within large urban centres. Limited accessibility leads to variable and prolonged wait times for pediatric patients suffering from chronic pain.RésuméObjectif: L’objectif de cette étude était d’examiner les services actuellement offerts par les établissements pluridisciplinaires de traitement de la douleur (MPTF — multidisciplinary pain treatment facility) spécialisés dans la prise en charge des douleurs chroniques chez les enfants au Canada.Méthode: Un MPTF a été défini comme une clinique affichant des services pluridisciplinaires spécialisés pour le diagnostic et la prise en charge des patients souffrant de douleurs chroniques, et possédant au moins trois disciplines différentes de soins de santé (y compris au moins une spécialité médicale) à disposition et intégrées dans l’établissement. La méthode de recherche a été précédemment décrite dans un article concomitant. Des chercheurs désignés étaient responsables de la confirmation et de l’ajout de MPTF à la liste préliminaire dans leur province respective. On a demandé à la direction administrative de chaque MPTF éligible de remplir un questionnaire détaillé concernant l’infrastructure de son MPTF ainsi que ses activités de soins, de recherche, d’enseignement et de gestion. Seuls les MPTF se consacrant aux enfants ont été inclus.Résultats: Seulement cinq des centres contactés offraient des MPTF pédiatriques spécialisés, tous situés dans des grandes villes de cinq provinces différentes. Bien que le temps d’attente médian soit de quatre semaines, il pouvait aller jusqu’à neuf mois dans un des établissements. Les maux de tête et les douleurs neuropathiques constituaient les syndromes de la douleur les plus fréquemment soignés. Tous les MPTF comptaient des médecins, des infirmiers, infirmières et psychologues, et utilisaient un modèle de réhabilitation qui comprenait une grande diversité de traitements pharmacologiques, psychologiques et physiques. Tous ces centres fournissent une formation pour les professionnels médicaux et de la santé, et il existait de la recherche dans trois des cinq établissements. Le financement public constituait la source la plus importante de financement pour les services aux patients et pour les frais généraux.Conclusion: Il n’existe que très peu d’établissements pluridisciplinaires de traitement de la douleur spécialisés en pédiatrie au Canada. Ces centres existent dans cinq des dix provinces, et tous se trouvent dans des centres urbains d’envergure. Un accès limité engendre des temps d’attente variables et prolongés pour les enfants souffrant de douleurs chroniques.

The American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, and the Asian Australasian Federation of Pain Societies Joint Committee recommendations for education and training in ultrasound-guided interventional pain procedures.

Abstract The use of ultrasound in pain medicine for interventional axial, nonaxial, and musculoskeletal pain procedures is rapidly evolving and growing. Because of the lack of specialty-specific guidelines for ultrasonography in pain medicine, an international collaborative effort consisting of members of the Special Interest Group on Ultrasonography in Pain Medicine from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, and the Asian Australasian Federation of Pain Societies developed the following recommendations for education and training in ultrasound-guided interventional pain procedures. The purpose of these recommendations is to define the required skills for performing ultrasound-guided pain procedures, the processes for appropriate education, and training and quality improvement. Training algorithms are outlined for practice- and fellowship-based pathways. The previously published American Society of Regional Anesthesia and Pain Medicine and European Society of Regional Anaesthesia and Pain Therapy education and teaching recommendations for ultrasound-guided regional anesthesia served as a foundation for the pain medicine recommendations. Although the decision to grant ultrasound privileges occurs at the institutional level, the committee recommends that the training guidelines outlined in this document serve as the foundation for educational training and the advancement of the practice of ultrasonography in pain medicine.