Scott A. Strassels

Management of postoperative pain: A clinical practice guideline from the American pain society, the American society of regional anesthesia and pain medicine, and the American society of anesthesiologists' committee on regional anesthesia, executive committee, and administrative council

UNLABELLEDnMost patients who undergo surgical procedures experience acute postoperative pain, but evidence suggests that less than half report adequate postoperative pain relief. Many preoperative, intraoperative, and postoperative interventions and management strategies are available for reducing and managing postoperative pain. The American Pain Society, with input from the American Society of Anesthesiologists, commissioned an interdisciplinary expert panel to develop a clinical practice guideline to promote evidence-based, effective, and safer postoperative pain management in children and adults. The guideline was subsequently approved by the American Society for Regional Anesthesia. As part of the guideline development process, a systematic review was commissioned on various aspects related to various interventions and management strategies for postoperative pain. After a review of the evidence, the expert panel formulated recommendations that addressed various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care. The recommendations are based on the underlying premise that optimal management begins in the preoperative period with an assessment of the patient and development of a plan of care tailored to the individual and the surgical procedure involved. The panel found that evidence supports the use of multimodal regimens in many situations, although the exact components of effective multimodal care will vary depending on the patient, setting, and surgical procedure. Although these guidelines are based on a systematic review of the evidence on management of postoperative pain, the panel identified numerous research gaps. Of 32xa0recommendations, 4 were assessed as being supported by high-quality evidence, and 11 (in the areas of patient education and perioperative planning, patient assessment, organizational structures and policies, and transitioning to outpatient care) were made on the basis of low-quality evidence.nnnPERSPECTIVEnThis guideline, on the basis of a systematic review of the evidence on postoperative pain management, provides recommendations developed by a multidisciplinary expert panel. Safe and effective postoperative pain management should be on the basis of a plan of care tailored to the individual and the surgical procedure involved, and multimodal regimens are recommended in many situations.

Impact of Irritable Bowel Syndrome on Quality of Life and Resource Use in the United States and United Kingdom

Background: Although irritable bowel syndrome (IBS) is not a life-threatening condition, it can have a serious impact on a patient’s daily activities and quality of life. This effect on quality of life has not been compared previously across different cultures. Methods: We compared measures of health-related quality of life and health care resource utilization using a cross-sectional point-in-time postal survey of a random sample of 500 members of the International Foundation for Functional Gastrointestinal Disorders in the US and 500 members of the IBS Network support group in the UK. The analysis was limited to persons who reported that a physician had told them they had IBS. A general health status questionnaire, the SF-36, and a disease-specific questionnaire, the Irritable Bowel Syndrome Quality of Life questionnaire (IBSQOL), were self-administered as part of the survey to measure health-related quality of life. Results on the SF-36 were compared with published normative data for adults in the US and UK with and without chronic diseases. Results: The UK group (n = 343) reported significantly poorer quality of life on the SF-36 and on four parameters of the IBSQOL than did the US group (n = 287). The general health status of persons with IBS in either country was much poorer compared with that of general populations in the respective countries. Health care resource utilization (i.e. emergency room, doctor and hospital outpatient visits) of persons with IBS was similar in the two countries, as was the direct effect of IBS on employment. Nearly one third of those surveyed missed at least 1 day of work due to IBS in the previous 4 weeks, and a greater percentage cut back in their work or activites due to IBS. Taken together, average time lost or cut back amounted to nearly 5 days or 1 work-week. Conclusion: IBS has a significant impact on quality of life and resource use in both the US and UK. The effect on quality of life, however, appears to be greater in the UK than in the US.

Postoperative Analgesia: Economics, Resource Use, and Patient Satisfaction in an Urban Teaching Hospital

We sought to describe the economic and humanistic burden after total abdominal hysterectomy (TAH), total hip replacement (THR), or total knee replacement (TKR) surgery. Resource use and costs were estimated from the hospital perspective. The mean worst pain severity was 8.9, 8.1, and 7.6 on a 0- to 10-point scale after TAH, THR, and TKR, respectively. Postoperative pain was worst on postoperative day 1 after TAH or THR, and on postoperative day 2 after TKR. Analgesic medications relieved from 60% to nearly 78% of postoperative pain, but participants re- ported moderate-to-high levels of interference with general activity, walking ability, and sleep because of postoperative pain. Most costs were attributed to the hospital admission and operating room. The average length of hospitalization was 2.8 days after TAH, and 3.9 days after THR or TKR. This study provides insight into patients’ experience with pain after common surgeries, perioperative costs, and medical resource use.

Diagnoses and factors associated with medical evacuation and return to duty for service members participating in Operation Iraqi Freedom or Operation Enduring Freedom: a prospective cohort study

BACKGROUNDnAnticipation of the types of injuries that occur in modern warfare is essential to plan operations and maintain a healthy military. We aimed to identify the diagnoses that result in most medical evacuations, and ascertain which demographic and clinical variables were associated with return to duty.nnnMETHODSnDemographic and clinical data were prospectively obtained for US military personnel who had been medically evacuated from Operation Iraqi Freedom or Operation Enduring Freedom (January, 2004-December, 2007). Diagnoses were categorised post hoc according to the International Classification of Diseases codes that were recorded at the time of transfer. The primary outcome measure was return to duty within 2 weeks.nnnFINDINGSn34 006 personnel were medically evacuated, of whom 89% were men, 91% were enlisted, 82% were in the army, and 86% sustained an injury in Iraq. The most common reasons for medical evacuation were: musculoskeletal and connective tissue disorders (n=8104 service members, 24%), combat injuries (n=4713, 14%), neurological disorders (n=3502, 10%), psychiatric diagnoses (n=3108, 9%), and spinal pain (n=2445, 7%). The factors most strongly associated with return to duty were being a senior officer (adjusted OR 2.01, 95% CI 1.71-2.35, p<0.0001), having a non-battle-related injury or disease (3.18, 2.77-3.67, p<0.0001), and presenting with chest or abdominal pain (2.48, 1.61-3.81, p<0.0001), a gastrointestinal disorder (non-surgical 2.32, 1.51-3.56, p=0.0001; surgical 2.62, 1.69-4.06, p<0.0001), or a genitourinary disorder (2.19, 1.43-3.36, p=0.0003). Covariates associated with a decreased probability of return to duty were serving in the navy or coast guard (0.59, 0.45-0.78, p=0.0002), or marines (0.86, 0.77-0.96, p=0.0083); and presenting with a combat injury (0.27, 0.17-0.44, p<0.0001), a psychiatric disorder (0.28, 0.18-0.43, p<0.0001), musculoskeletal or connective tissue disorder (0.46, 0.30-0.71, p=0.0004), spinal pain (0.41, 0.26-0.63, p=0.0001), or other wound (0.54, 0.34-0.84, p=0.0069).nnnINTERPRETATIONnImplementation of preventive measures for service members who are at highest risk of evacuation, forward-deployed treatment, and therapeutic interventions could reduce the effect of non-battle-related injuries and disease on military readiness.nnnFUNDINGnJohn P Murtha Neuroscience and Pain Institute, and US Army Regional Anesthesia and Pain Management Initiative.

Core competencies for pain management: Results of an interprofessional consensus summit

Objective The objective of this project was to develop core competencies in pain assessment and management for prelicensure health professional education. Such core pain competencies common to all prelicensure health professionals have not been previously reported. Methods An interprofessional executive committee led a consensus-building process to develop the core competencies. An in-depth literature review was conducted followed by engagement of an interprofessional Competency Advisory Committee to critique competencies through an iterative process. A 2-day summit was held so that consensus could be reached. Results The consensus-derived competencies were categorized within four domains: multidimensional nature of pain, pain assessment and measurement, management of pain, and context of pain management. These domains address the fundamental concepts and complexity of pain; how pain is observed and assessed; collaborative approaches to treatment options; and application of competencies across the life span in the context of various settings, populations, and care team models. A set of values and guiding principles are embedded within each domain. Conclusions These competencies can serve as a foundation for developing, defining, and revising curricula and as a resource for the creation of learning activities across health professions designed to advance care that effectively responds to pain.

Multicenter, Randomized, Comparative Cost-effectiveness Study Comparing 0, 1, and 2 Diagnostic Medial Branch (Facet Joint Nerve) Block Treatment Paradigms before Lumbar Facet Radiofrequency Denervation

Background:Among patients presenting with axial low back pain, facet arthropathy accounts for approximately 10–15% of cases. Facet interventions are the second most frequently performed procedures in pain clinics across the United States. Currently, there are no uniformly accepted criteria regarding how best to select patients for radiofrequency denervation. Methods:A randomized, multicenter study was performed in 151 subjects with suspected lumbar facetogenic pain comparing three treatment paradigms. Group 0 received radiofrequency denervation based solely on clinical findings; group 1 underwent denervation contingent on a positive response to a single diagnostic block; and group 2 proceeded to denervation only if they obtained a positive response to comparative blocks done with lidocaine and bupivacaine. A positive outcome was predesignated as ≥50% pain relief coupled with a positive global perceived effect persisting for 3 months. Results:In group 0, 17 patients (33%) obtained a successful outcome at 3 months versus eight patients (16%) in group 1 and 11 (22%) patients in group 2. Denervation success rates in groups 0, 1, and 2 were 33, 39, and 64%, respectively. Pain scores and functional capacity were significantly lower at 3 months but not at 1 month in group 2 subjects who proceeded to denervation compared with patients in groups 0 and 1. The costs per successful treatment in groups 0, 1, and 2 were

Nonsteroidal Anti-Inflammatory Drugs, Alone or Combined With Opioids, for Cancer Pain A Systematic Review

6,286,

Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) for Quality Improvement of Pain Management in Hospitalized Adults: Preliminary Psychometric Evaluation

17,142, and

Outcome predictors for sacroiliac joint (lateral branch) radiofrequency denervation.

15,241, respectively. Conclusions:Using current reimbursement scales, these findings suggest that proceeding to radiofrequency denervation without a diagnostic block is the most cost-effective treatment paradigm.

Comparison of fluoroscopically guided and blind corticosteroid injections for greater trochanteric pain syndrome: multicentre randomised controlled trial

PURPOSEnTo assess the safety and efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs), alone or combined with opioids, for the treatment of cancer pain.nnnPATIENTS AND METHODSnForty-two trials involving 3,084 patients met inclusion criteria: eight compared NSAID with placebo; 13 compared one NSAID with another; 23 compared NSAID with opioid, NSAID or opioid versus NSAID plus opioid combinations, or NSAID plus opioid combinations versus NSAID plus opioid combinations; and nine studies assessed the effect of increasing NSAID dose.nnnRESULTSnSixteen studies lasted 1 week or longer and 11 evaluated a single dose. Seven of eight trials demonstrated superior efficacy of single doses of NSAID compared with placebo. Only four of 13 studies reported increased efficacy of one NSAID compared with another; four other studies found that one NSAID had fewer side effects than one or more others. Thirteen of 14 studies found no difference, or minimal clinical difference, when comparing an NSAID plus opioid combination versus either drug alone. Comparisons between various NSAID plus opioid combinations were inconclusive. Four studies demonstrated increased efficacy with increased NSAID dose, without dose-dependent increases in side effects.nnnCONCLUSIONnHeterogeneity of study methods and outcomes precluded meta-analyses. Short duration of studies undermines generalization of findings on efficacy and safety. On the basis of limited data, NSAIDs appear to be more effective than placebo for cancer pain; clear evidence to support superior safety or efficacy of one NSAID compared with another is lacking; and trials of combinations of an NSAID with an opioid have disclosed either no significant difference, or at most a slight but statistically significant advantage, compared with either single entity.