ACUTE PAIN CONTROL AND ACCELERATED POSTOPERATIVE SURGICAL RECOVERY

doi:10.1016/S0039-6109(05)70390-X

Surgical Clinics of North America

Volume 79, Issue 2, 1 April 1999, Pages 431-443

https://doi.org/10.1016/S0039-6109(05)70390-X Get rights and content

The alleviation of postoperative pain is primarily provided for humanitarian reasons but also to reduce nociception-induced responses, which may adversely influence organ functioning and contribute to morbidity.¹⁴ As discussed in this issue, much progress has been made in our understanding of pain physiology and the effectiveness and side effects of various analgesics and techniques of administration. Based on this knowledge, optimal pain relief allowing normal function can usually be obtained following most surgical procedures, especially when using multimodal or balanced analgesia. This approach provides sufficient pain relief through additive or synergistic effects by different analgesics and with a concomitant reduction of side effects because of the requirement of lower doses of individual drugs and differences in side-effect profiles.¹³

In recent years, awareness of pain relief and pain education has been introduced in the surgical literature.¹⁵ The introduction of acute pain services has increased the quality of postoperative pain relief; however, further improvements in perioperative care and outcome require increased attention among surgeons to choices and availability of different analgesics and techniques in different operations because pain relief is a prerequisite to improved outcome.

This article provides an updated review of the differential effects of different analgesics on perioperative pathophysiologic responses and organ dysfunctions, hospital stay, and convalescence. Furthermore, updated knowledge is provided on the integration of postoperative pain relief in a multimodal approach to hasten recovery, based on recent reviews.16, 17

Section snippets

PAIN CONTROL AND THE SURGICAL STRESS RESPONSE

A common feature shared by all surgical patients is the widespread changes in several biologic cascade systems, including a predominance of catabolic hormones, activation of cytokines, complement, arachidonic acid metabolites, nitric oxide, and free oxygen radicals, all of which secondarily may lead to organ dysfunction and morbidity. Pain may obviously be considered as another neurophysiologic response to surgery but with its own secondary effects on biologic functions. Effective treatment of

PAIN CONTROL AND SURGICAL OUTCOME

Despite extensive data to demonstrate beneficial physiologic effects in specific organ dysfunctions and outcomes (Table 1) by efficient analgesia, the anesthetic and surgical literature has shown inconsistent results on overall postoperative morbidity.

THE MULTIMODAL APPROACH TO ACCELERATE POSTOPERATIVE RECOVERY

The pathogenesis to postoperative morbidity, need for hospitalization, and convalescence involves several factors (Fig. 1).¹⁶ Pain relief per se has not represented a major breakthrough to improve surgical outcome, as discussed earlier. Nevertheless, effective functional postoperative pain relief has a great potential to improve postoperative outcome, because pain-relieving techniques have beneficial physiologic effects on different organ systems in the postoperative period. To enhance progress

SUMMARY

Postoperative pain relief continues to demand our awareness, and surgeons should be fully aware of the potential physiologic benefits of effective dynamic pain relief regimens and the great potential to improve postoperative outcome if such analgesia is used for rehabilitation. To achieve advantageous effects, accelerated multimodal postoperative recovery programs should be developed as a multidisciplinary effort, with integration of postoperative pain management into a postoperative

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Cited by (156)

Quantifying postoperative sleep loss associated with increased pain in children undergoing a modified Nuss operation
2020, Journal of Pediatric Surgery
The presence of pain may interrupt sleep and impede normal postoperative recovery; however, no prior studies have quantified sleep loss due to pain in children undergoing inpatient surgery. Wearable accelerometers objectively measure sleep patterns in children. We aimed to quantify sleep loss associated with patient reported pain scores after a Modified Nuss operation.
Ten patients undergoing Modified Nuss operations were recruited during their inpatient stay. Children wore an Actigraph GT3X-BT accelerometer postoperatively during their hospital stay. Hourly sleep minutes were recorded using the Actigraph between 10 pm and 6 am. Patient reported pain scores were abstracted from patient charts. Mixed linear regression models, adjusting for within-subject random effects, were estimated to quantify the association between hourly sleep minutes and patient reported pain scores.
Patients were 30% female, with an average age of 15.7 years (range 13–22). The majority (70%) of patients were white non-Hispanic. All patients received a patient controlled analgesic pump. Average postoperative length of stay was 4.8 days (range 4.0–6.0; SD = 0.8). A total of 240 sleep hours and associated pain scores were analyzed. Patients slept on average 48 min per hour. Mixed model analysis predicted that a 1-point increase in pain score was associated with 2.5 min per hour less sleep time.
Increases in patient-reported pain scores are associated with sleep loss after a Modified Nuss operation. Objectively quantifying sleep loss associated with postoperative pain using accelerometer data may help clinicians better understand their patient's level of pain control. Our findings provide the basis for future studies aimed at more accurately titrating pain medication to optimize sleep and speed up recovery.
Case Series Without Comparison Group, Level IV.
Statewide Utilization of Multimodal Analgesia and Length of Stay After Colectomy
2020, Journal of Surgical Research
Both enhanced recovery and anesthesia literature recommend multimodal perioperative analgesia to hasten recovery, prevent adverse events, and reduce opioid use after surgery. However, adherence to, and outcomes of, these recommendations are unknown. We sought to characterize use of multimodal analgesia and its association with length of stay after colectomy.
Within a statewide, 72-hospital collaborative quality initiative, we evaluated postoperative analgesia regimens among adult patients undergoing elective colectomy between 2012 and 2015. We used logistic regression to identify factors associated with the use of multimodal analgesia and performed multivariable linear regression to evaluate its association with postoperative length of stay (LOS).
Among 7265 patients who underwent elective colectomy in the study period, 4660 (64.1%) received multimodal analgesia, 2405 (33.1%) received opioids alone, and 200 (2.8%) received one nonopioid pain medication alone. Multimodal analgesia was independently associated with shorter adjusted postoperative LOS, compared with opioids alone (5.60 d [95% CI 5.38–5.81] versus 5.96 d [5.68-6.24], P = 0.016).
Multimodal analgesia is associated with shorter LOS, yet one-third of patients statewide received opioids alone after colectomy. As surgeons increasingly focus on our role in the opioid crisis, particularly in postdischarge opioid prescribing, we must also focus on inpatient postoperative pain management to limit opioid exposure. At the hospital level, this may have the added benefit of decreasing LOS and hastening recovery.
Does continuous infusion of local anaesthesia improve pain control and walking distance after coronary artery bypass graft surgery? A randomised controlled trial
2017, Physiotherapy (United Kingdom)
Citation Excerpt :
Inadequate pain relief may result in reduced chest wall expansion, shallow breathing, ineffective cough, retained secretions, atelectasis and pneumonia [8,12,30,31]. Physiotherapists use interventions such as walking, deep breathing exercises, and coughing, in post cardiac surgery patients to prevent and treat postoperative pulmonary complications [5,10] and to commence early rehabilitation [11]. Milgrom et al. [8] found that in the early post-operative cardiac surgery period, coughing elicited the highest pain, followed by movements such as walking or getting up from a chair; deep breathing exercise and incentive spirometry, with lowest pain occurring when resting in the chair or in the bed.
To evaluate the effects of continuous infusion of ropivacaine compared to sham infusion or usual care on pain scores before and after physiotherapy treatment, distance walked and time to discharge from physiotherapy, after coronary artery bypass graft (CABG) surgery.
Prospective, randomised, double blind controlled trial.
Seventy-five participants who underwent CABG surgery with left internal mammary artery grafts were allocated, to the ropivacaine group (n = 26), the sham group (n = 25), or usual care group (n = 24). Participants in the ropivacaine group received 0.5% ropivacaine and participants in the sham group received normal saline, both as continuous infusions via two parasternally tunnelled catheters for 96 hours continuously. The usual care group did not receive a device. All groups had patient-controlled analgesia and/or oral analgesia.
Seventy-two participants completed the study. There was no significant between-group differences in pain scores, distance walked on any post operative day (POD) or number of participants discharged from physiotherapy by POD 4. For the group as a whole there was a significant linear decrease in pain score from mean (SD) 42 (24) mm on POD1 to 15 (16) mm on POD4 (p < 0.001), (MD 27 mm, 95% CI 22 to 32) and walking distance increased from 1 (5) m on POD1 to 183 (239) m on POD4 (p < 0.001) MD 181 m, 95% CI 126 to 236).
Infusion of ropivacaine post CABG surgery was unable to reduce pain, increase distance walked or reduce time to physiotherapy discharge compared to sham or usual care.
Trial registration number ACTRN12612001243808.
Outpatient thoracic surgery: Evolution of the indications, current applications and limits
2016, Revue des Maladies Respiratoires
Les objectifs de la chirurgie ambulatoire sont de réduire les risques liés à l’hospitalisation, d’améliorer la récupération postopératoire et de diminuer les dépenses de santé. Peu d’études ont été réalisées dans le domaine de la chirurgie thoracique et il persiste une grande marge de progression en chirurgie pleuropulmonaire ambulatoire. Le but de cet article est de présenter un état des lieux et les perspectives d’évolution de la chirurgie thoracique ambulatoire.
The objectives of outpatient surgery are to reduce the risks connected to hospitalization, to improve postoperative recovery and to decrease the health costs. Few studies have been performed in the field of thoracic surgery and there remains great scope for progress in outpatient lung surgery. The purpose of this article is to present a revue of the current situation and the prospects for the development of out patient thoracic surgery.
Résection thoracoscopique ambulatoire de nodules pulmonaires dans le cadre de la réhabilitation précoce
2016, Revue des Maladies Respiratoires
Les objectifs de la chirurgie ambulatoire sont de réduire les risques liés à l’hospitalisation, d’améliorer la réhabilitation précoce postopératoire et d’optimiser les contacts avec la médecine extrahospitalière. L’objectif de ce travail est de présenter la première unité de chirurgie pulmonaire ambulatoire et de rapporter les résultats des résections de nodules pulmonaires en chirurgie ambulatoire dans le cadre de la réhabilitation précoce.
L’indication de la résection de nodules était portée en réunion de concertation pluridisciplinaire d’oncologie thoracique. Après avoir vérifié que les patients respectaient les critères anesthésiques et chirurgicaux d’une chirurgie ambulatoire, ils bénéficiaient d’une résection d’un ou de plusieurs nodules pulmonaires par thoracoscopie. Nous avons analysé les caractéristiques de la population, la durée opératoire, l’heure d’ablation du drain thoracique, le type de résection et le suivi à distance.
Entre novembre 2013 et décembre 2014, 51 patients ont bénéficié d’une résection infra-lobaires. Parmi eux, 7 patients d’âge moyen 57,6 ans (extrêmes : 39–64) avec antécédents personnels de cancer ont bénéficié de 7 résections atypiques et de 2 segmentectomies pulmonaires ambulatoires (3 patients bénéficiaient de deux résections). La durée opératoire était de 53,75 min en moyenne (extrêmes : 30–90). L’ablation du drain était pratiquée avant la troisième heure dans 8 cas et le troisième jour dans un cas. Le diamètre moyen des tumeurs était de 10,375 mm (extrêmes : 6–23). En postopératoire, l’histologie révélait une métastase de carcinome colorectal dans 4 cas, une métastase d’un carcinome rénal dans un cas, un adénocarcinome in situ dans un cas et une tumeur bénigne dans 3 cas. Avec un suivi moyen de 6 mois, aucune complication ni récidive n’a été observée.
Grâce à un protocole de réhabilitation précoce inscrit dans un chemin clinique bien établi, la résection de nodules pulmonaires par thoracoscopie est réalisable en chirurgie ambulatoire avec sécurité chez des patients bien sélectionnés et bien préparés.
The objectives of outpatient surgery are to reduce the risks related to the hospitalization, to improve the postoperative recovery and to optimize contact with family physicians. The objective of this work is to present the first unit of outpatient pulmonary surgery and to report the results of the resections of pulmonary nodules in outpatient surgery in the setting of early discharge.
The indications for the resection of nodules were discussed in a multidisciplinary thoracic oncology meeting. The patients underwent resection of one or more lung nodules by thoracoscopy after verification that they met the anaesthetic and surgical criteria for ambulatory surgery. We analyzed the characteristics of the population, the duration of surgery, the type of resection, the time of the chest drain removal and the postoperative follow-up.
Between November 2013 and December 2014, 51 patients underwent sub-lobar pulmonary resections. Among them 7 patients (4 men and 3 women), with an average age of 57.6 years (39–64) and histories of malignant tumor, underwent 7 atypical resections and two segmentectomies in outpatient surgery (3 patients had two resections). The average operating time was 53.75 min (30–90). The chest drain was removed before the third hour in 8 cases and on the third day in one case. The average tumor diameter was 10.375 mm (6–23). The histology revealed a metastasis of colorectal carcinoma in 4 cases, a metastasis of a renal carcinoma in 1 case, an in situ adenocarcinoma in 1 case and a benign tumor in 3 cases. Neither recurrence nor complication was observed during an average follow-up of 6 months.
Thanks to a protocol of early mobilisation and discharge included in a well established clinical care pathway, thoracoscopic resection of lung nodules is feasible, with safety in properly selected and prepared patients in outpatient surgery.
Management of Acute Postoperative Pain in Hand Surgery: A Systematic Review
2015, Journal of Hand Surgery
To conduct a systematic review to guide hand surgeons in an evidenced-based approach in managing postoperative pain.
We performed a literature review for primary research articles on management of postoperative pain in hand surgery patients using Medical Literature Analysis and Retrieval System Online (MEDLINE; PubMed), Excerpta Medica database (EMBASE), and the Cochrane Collaboration Library. Inclusion criteria were primary journal articles examining treatment of acute postoperative pain based on any modality. Data related to pain assessment, postoperative recovery, and total postoperative analgesic consumption were extracted.
A total of 903 publications were reviewed; 184 publications underwent abstract review. After applying inclusion and exclusion criteria, 10 primary articles were selected for inclusion in this review. Data were noted to be heterogeneous and findings were compiled. Results were divided into groups evaluating postoperative pain medications or pain infusion catheters.
Although this review did not demonstrate a best practices model for postoperative pain management, it provides evidence for alternative medications and treatment strategies. The evidence available suggests that postoperative pain control should begin before surgery and that combining multiple strategies for pain treatment is beneficial. Given the increasing attention paid to narcotic prescriptions and the potential for abuse, surgeons should adopt evidence-based pain management practices. We provide an example algorithm for pain treatment in hand surgery based on available data and the authors’ experience.
Therapeutic III.

View all citing articles on Scopus

: Address reprint requests to Henrik Kehlet, MD, PhD, Department of Surgical Gastroenterology, Hvidovre University Hospital, University of Copenhagen, Kettegård Allé 30, 2650 Hvidovre, Denmark

^*: From the Department of Surgical Gastroenterology, Hvidovre University Hospital, University of Copenhagen, Denmark

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ACUTE PAIN CONTROL AND ACCELERATED POSTOPERATIVE SURGICAL RECOVERY

Section snippets

PAIN CONTROL AND THE SURGICAL STRESS RESPONSE

PAIN CONTROL AND SURGICAL OUTCOME

THE MULTIMODAL APPROACH TO ACCELERATE POSTOPERATIVE RECOVERY

SUMMARY

J Clin Anesth

Lancet

Am J Surg

J Am Coll Surg

Br J Anaesth

J Clin Anesth

Anesthesiology

Pain

Ann Thorac Surg

Br J Anaesth

Am J Med

The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials

Anesth Analg

Epidural analgesia and intravenous patient-controlled analgesia result in similar rates of postoperative myocardial ischemia after aortic surgery

Anesth Analg

Infiltration anaesthesia for hernia repair: Feasibility and cost considerations

Anaesthesia

Postoperative fatigue

World J Surg

Use of paravertebral block anesthesia in the surgical treatment of breast cancer

Ann Surg