Salima Ladak

The Toronto General Hospital Transitional Pain Service: development and implementation of a multidisciplinary program to prevent chronic postsurgical pain.

Chronic postsurgical pain (CPSP), an often unanticipated result of necessary and even life-saving procedures, develops in 5–10% of patients one-year after major surgery. Substantial advances have been made in identifying patients at elevated risk of developing CPSP based on perioperative pain, opioid use, and negative affect, including depression, anxiety, pain catastrophizing, and posttraumatic stress disorder-like symptoms. The Transitional Pain Service (TPS) at Toronto General Hospital (TGH) is the first to comprehensively address the problem of CPSP at three stages: 1) preoperatively, 2) postoperatively in hospital, and 3) postoperatively in an outpatient setting for up to 6 months after surgery. Patients at high risk for CPSP are identified early and offered coordinated and comprehensive care by the multidisciplinary team consisting of pain physicians, advanced practice nurses, psychologists, and physiotherapists. Access to expert intervention through the Transitional Pain Service bypasses typically long wait times for surgical patients to be referred and seen in chronic pain clinics. This affords the opportunity to impact patients’ pain trajectories, preventing the transition from acute to chronic pain, and reducing suffering, disability, and health care costs. In this report, we describe the workings of the Transitional Pain Service at Toronto General Hospital, including the clinical algorithm used to identify patients, and clinical services offered to patients as they transition through the stages of surgical recovery. We describe the role of the psychological treatment, which draws on innovations in Acceptance and Commitment Therapy that allow for brief and effective behavioral interventions to be applied transdiagnostically and preventatively. Finally, we describe our vision for future growth.

Chronic postsurgical pain and persistent opioid use following surgery: the need for a transitional pain service

AIM To identify the 3-month incidence of chronic postsurgical pain and long-term opioid use in patients at the Toronto General Hospital. METHODS 200 consecutive patients presenting for elective major surgery completed standardized questionnaires by telephone at 3 months after surgery. RESULTS 51 patients reported a preoperative chronic pain condition, with 12 taking opioids preoperatively. 3 months after surgery 35% of patients reported having surgical site pain and 13.5% continued to use opioids for postsurgical pain relief. Postoperative opioid use was associated with interference with walking and work, and lower mood. CONCLUSION Chronic postsurgical pain and ongoing opioid use are concerns that warrant the implementation of a Transitional Pain Service to modify the pain trajectories and enable effective opioid weaning following major surgery.

The Journey of the Pain Resource Nurse in Improving Pain Management Practices: Understanding Role Implementation

Pain assessment and management continues to be challenging for many nurses. Single educational interventions have proven to be unsuccessful in knowledge retention. This study will assist leaders in nursing in understanding how a 4-day educational program delivered to self-selected pain resource nurses (PRNs) could improve pain assessment and management practices. A focus group study was undertaken at a trisite academic health science center to understand the role implementation of the PRNs and required resources to sustain the role at a unit level. To evaluate the PRN role, a qualitative descriptive study design using focus group interviews was used to answer the following questions: What was the experience of the PRN during role implementation? What barriers and enablers affected the implementation of this role? Organizational support, integration within the interdisciplinary team, and organizational role awareness were key themes highlighted in the focus group results. This article will describe how the three-site academic health science center used the PRN role to foster practice-related change and enhance current knowledge of evidence-based pain management.

A case report on the treatment of complex chronic pain and opioid dependence by a multidisciplinary transitional pain service using the ACT Matrix and buprenorphine/naloxone

In an era of growing concern about opioid prescribing, the postsurgical period remains a critical window with the risk of significant opioid dose escalation, particularly in patients with a history of chronic pain and presurgical opioid use. The purpose of this case report is to describe the multidisciplinary care of a complex, postsurgical pain patient by an innovative transitional pain service (TPS). A 59-year-old male with complex chronic pain, as well as escalating long-term opioid use, presented with a bleeding duodenal ulcer requiring emergency surgery. After surgery, the TPS provided integrated pharmacological and behavioral treatment, including buprenorphine combined with naloxone and acceptance and commitment therapy (ACT) using the ACT Matrix. The result was dramatic pain reduction and improved functioning and quality of life after 40+ years of chronic pain, thus changing the pain trajectory of a chronic, complex, opioid-dependent patient.

Medial open transversus abdominis plane (MOTAP) catheters for analgesia following open liver resection: study protocol for a randomized controlled trial

BackgroundThe current standard for pain control following liver surgery is intravenous, patient-controlled analgesia (IV PCA) or epidural analgesia. We have developed a modification of a regional technique called medial open transversus abdominis plane (MOTAP) catheter analgesia. The MOTAP technique involves surgically placed catheters through the open surgical site into a plane between the internal oblique muscle and the transverse abdominis muscle superiorly. The objective of this trial is to assess the efficacy of this technique.Methods/designThis protocol describes a multicentre, prospective, blinded, randomized controlled trial. One hundred and twenty patients scheduled for open liver resection through a subcostal incision will be enrolled. All patients will have two MOTAP catheters placed at the conclusion of surgery. Patients will be randomized to one of two parallel groups: experimental (local anaesthetic through MOTAP catheters) or placebo (normal saline through MOTAP catheters). Both groups will also receive IV PCA. The primary endpoint is mean cumulative postoperative opioid consumption over the first 2 postoperative days (48 hours). Secondary outcomes include pain intensity, patient functional outcomes, and the incidence of complications.DiscussionThis trial has been approved by the ethics boards at participating centres and is currently enrolling patients. Data collection will be completed by the end of 2014 with analysis mid-2015 and publication by the end of 2015.Trial registrationThe study is registered withhttp://clinicaltrials.gov (NCT01960049; 23 September 2013)

Review: compression plus pharmacological prophylaxis reduces VTE more than monotherapy in high-risk patients.

S K Kakkos Dr S K Kakkos, Henry Ford Hospital, Detroit, MI, USA; kakkosstavros@gmail.com; s.kakkos@imperial.ac.uk How does intermittent pneumatic leg compression (IPC) plus pharmacological prophylaxis compare with either monotherapy for preventing venous thromboembolism in high-risk patients? Included studies compared ICP plus pharmacological prophylaxis with either therapy alone in patients at high risk of developing venous thromboembolism (including surgery and trauma patients). Studies evaluating intraoperative IPC were excluded. Outcomes were pulmonary embolism (PE) and deep venous thrombosis (DVT). Medline, CINAHL, EMBASE/Excerpta Medica (all to present); Cochrane Peripheral Vascular …

Transversus Abdominis Plane Blocks: An Overview of Indication and Nursing Care

Transversus abdominis plane (TAP) blocks are an evolving regional anesthesia technique used as part of postoperative pain management regimens after major abdominal surgery. This article reviews TAP block insertion techniques, commonly used local anesthetics, and recommends nursing care related to TAP blocks.

Smoking, pain intensity, and opioid consumption one to three months after major surgery: A retrospective study in a hospital-based Transitional Pain Service.

Introduction The present study investigated the associations between smoking, pain, and opioid consumption in the 3 months after major surgery in patients seen by the Transitional Pain Service. Current smoking status and lifetime pack-years were expected to be related to higher pain intensity, more opioid use, and poorer opioid weaning after surgery. Methods A total of 239 patients reported smoking status in their presurgical assessment (62 smokers, 92 past smokers, and 85 never smokers). Pain and daily opioid use were assessed in hospital before postsurgical discharge, at first outpatient visit (median of 1 month postsurgery), and at last outpatient visit (median of 3 months postsurgery). Pain was measured using numeric rating scale. Morphine equivalent daily opioid doses were calculated for each patient. Results Current smokers reported significantly higher pain intensity (p < .05) at 1 month postsurgery than never smokers and past smokers. Decline in opioid consumption differed significantly by smoking status, with both current and past smokers reporting a less than expected decline in daily opioid consumption (p < .05) at 3 months. Decline in opioid consumption was also related to pack-years, with those reporting higher pack-years having a less than expected decline in daily opioid consumption at 3 months (p < .05). Conclusions Smoking status may be an important modifiable risk factor for pain intensity and opioid use after surgery. Implications In a population with complex postsurgical pain, smoking was associated with greater pain intensity at 1 month after major surgery and less opioid weaning 3 months after surgery. Smoking may be an important modifiable risk factor for pain intensity and opioid use after surgery.

Entrapped Epidural Catheter Case

An 81 year old male underwent lung and liver resection for cancer and was unable to have his epidural catheter removed on post-operative day 5. Following passing an 18” mandrill wire under fluoroscopy, the epidural catheter was successfully extracted.

Review: early feeding after major gynaecological surgery is safe except for an increase in nausea.

K Charoenkwan Dr K Charoenkwan, Chiang Mai University, Chiang Mai, Thailand; kicharoe@mail.med.cmu.ac.th In women having major abdominal gynaecological surgery, does early initiation of oral intake of food and fluids increase postoperative complications more than delayed initiation? ### Data sources: Cochrane Menstrual Disorders and Subfertility Group’s specialised register of controlled trials, Medline, CINAHL, EMBASE/Excerpta Medica, and Cochrane Central Register of Controlled Trials (to April 2007); reference lists; and experts. ### Study selection and assessment: randomised controlled trials (RCTs) that compared early ( 24 h, after resolution of postoperative ileus) initiation of oral intake of food and fluids after major open gynaecological surgery. Excluded were trials that were quasi-randomised or had no clear random allocation criteria; had important violations of the randomisation procedure or exclusions …