Opioid-Induced Hyperalgesia, Tolerance, and Chronic Postsurgical Pain: A Dilemma Complicating Postoperative Pain Management

2018 ◽  
Author(s):  
Dalia H. Elmofty
Keyword(s):  
Pain Management ◽  
Postoperative Pain ◽  
Surgical Techniques ◽  
Cyclooxygenase Inhibitors ◽  
Opioid Tolerance ◽  
Postsurgical Pain ◽  
Perioperative Pain ◽  
Chronic Postsurgical Pain ◽  
Opioid Induced Hyperalgesia ◽  
Perioperative Pain Management

Perioperative pain management continues to be a challenge for physicians. Postoperative pain can compromise patient progress and lead to poor outcomes or chronic pain. Opioid medications, the mainstay of treatment for perioperative pain, can cause opioid-induced hyperalgesia and opioid tolerance. Attempts should be made to modify factors that increase the risk for chronic postsurgical pain. Certain patient factors and anesthetic and surgical techniques have been implicated. Incorporating multimodal methods for perioperative pain management using nonconventional opioids, such as methadone, cyclooxygenase inhibitors, NMDA antagonists, and regional techniques can improve outcomes and prevent opioid-induced hyperalgesia, opioid tolerance, and chronic postsurgical pain in patients on long-term opioid therapy.

scholarly journals Audit of perioperative pain management in paediatric patients following tonsillectomy at a tertiary hospital in Johannesburg

2019 ◽  
pp. 30-36
Author(s):  
PM Mogane ◽  
M Mashinini ◽  
C Lundgren
Keyword(s):  
Pain Management ◽  
Postoperative Pain ◽  
Surgical Technique ◽  
Surgical Techniques ◽  
Optimal Care ◽  
Perioperative Pain ◽  
Pain Scores ◽  
Paediatric Patients ◽  
Analgesic Regimen ◽  
Perioperative Pain Management

Background: Adenotonsillectomy remains one of the most frequently performed surgical procedures in children. Despite improvements in anaesthetic and surgical techniques, severe pain is reported in as many as 25–50% of children. Pain assessment and knowledge of drug pharmacodynamics and pharmacokinetics in the paediatric patient, is a prerequisite for optimal care. Much has been written on perioperative pain management following tonsillectomy. However, no consensus has been reached on what the ideal analgesic regimen should be. This audit is a review of current practice at Chris Hani Baragwanath Academic Hospital. It aims to identify problems and develop possible solutions to improve anaesthetic practice. Methods: A prospective, contextual, descriptive study design using a data collection sheet was used on paediatric patients presenting for tonsillectomy. Results: Eighty-five patients aged three to 12 years of age, with ASA grading I or II, were enrolled in the study. The choice of anaesthetic was variable with a combination of simple analgesics, opioids and adjuvants. This affected postoperative pain scores. Snare dissection and monopolar cautery haemostasis, was the standard surgical technique. Surgical seniority influenced the duration of tonsillectomy, with an effect on postoperative pain scores. Conclusions: Audits are necessary to evaluate what resources are needed to optimise care. The occurrence of pain after tonsillectomy continues to be poorly managed. Appropriate premedication and fasting of clear fluids for no more than two hours, needs to be introduced. Where possible surgical technique should involve bipolar cautery and be limited to less than 45 minutes. A preemptive, multimodal, opioid-sparing anaesthetic should be routinely practised.

Implementation of a Standardized Perioperative Pain Management Protocol to Reduce Opioid Prescriptions in Otolaryngologic Surgery

2022 ◽  
pp. 019459982110711
Author(s):  
Michael T. Chang ◽  
M. Lauren Lalakea ◽  
Kimberly Shepard ◽  
Micah Saste ◽  
Amanda Munoz ◽  
...  
Keyword(s):  
Pain Management ◽  
Postoperative Pain ◽  
Lower Amount ◽  
Opioid Use ◽  
Protocol Implementation ◽  
Perioperative Pain ◽  
Management Protocol ◽  
Before And After ◽  
Perioperative Pain Management ◽  
Low Levels

Objective To evaluate the efficacy of implementing a standardized multimodal perioperative pain management protocol in reducing opioid prescriptions following otolaryngologic surgery. Study Design Retrospective cohort study. Setting County hospital otolaryngology practice. Methods A perioperative pain management protocol was implemented in adults undergoing otolaryngologic surgery. This protocol included preoperative patient education and a postoperative multimodal pain regimen stratified by pain level: mild, intermediate, and high. Opioid prescriptions were compared between patient cohorts before and after protocol implementation. Patients in the pain protocol were surveyed regarding pain levels and opioid use. Results We analyzed 210 patients (105 preprotocol and 105 postprotocol). Mean ± SD morphine milligram equivalents (MMEs) prescribed decreased from 132.5 ± 117.8 to 53.6 ± 63.9 ( P < .05) following protocol implementation. Mean MMEs prescribed significantly decreased ( P < .05) for each procedure pain tier: mild (107.4 to 40.5), intermediate (112.8 to 48.1), and high (240.4 to 105.0). Mean MMEs prescribed significantly decreased ( P < .05) for each procedure type: endocrine (105.6 to 44.4), facial plastics (225.0 to 50.0), general (160.9 to 105.7), head and neck oncology (138.6 to 77.1), laryngology (53.8 to 12.5), otology (77.5 to 42.9), rhinology (142.2 to 44.4), and trauma (288.0 to 24.5). Protocol patients reported a mean 1-week postoperative pain score of 3.4, used opioids for a mean 3.1 days, and used only 39% of their prescribed opioids. Conclusion Preoperative counseling and standardization of a multimodal perioperative pain regimen for otolaryngology procedures can effectively lower amount of opioid prescriptions while maintaining low levels of postoperative pain.

Opioid-Tolerant Patient

2013 ◽  
Author(s):  
Alexandra Szabova ◽  
Kenneth R Goldschneider
Keyword(s):  
Pain Management ◽  
Operating Room ◽  
Postoperative Period ◽  
Perioperative Pain ◽  
Opioid Induced Hyperalgesia ◽  
Perioperative Pain Management

Caring for patients who are taking chronic opioids may present several challenges for clinicians in the operating room and in the immediate postoperative period. Factors such as tolerance and opioid-induced hyperalgesia can complicate perioperative pain management.

scholarly journals Multimodal analgesia in primary bone tumors

2021 ◽  
Vol 4 (1) ◽  
pp. 30-37
Author(s):  
Angelica Bratu ◽  
Adrian Cursaru ◽  
Adina Comanelea ◽  
Bogdan Şerban ◽  
Cătălin Cîrstoiu
Keyword(s):  
Pain Management ◽  
Postoperative Pain ◽  
Epidural Analgesia ◽  
General Anesthesia ◽  
Bone Tumors ◽  
Multimodal Analgesia ◽  
Mean Value ◽  
Perioperative Pain ◽  
Continuous Epidural Analgesia ◽  
Perioperative Pain Management

Abstract Introduction: A worrying increase in the number of bone tumors that appear at younger ages justifies the efforts aimed at optimizing perioperative management practices in orthopedic tumor surgery. Pain control is critical in the prognosis and postoperative outcome of these procedures. Material and methods: Our study included a group of 11 patients diagnosed with bone malignancies. These patients were hospitalized in the Orthopedic Clinic of the University Emergency Hospital Bucharest. Under our supervision, they underwent surgical treatment of the tumor under combined general anesthesia and epidural anesthesia for the pelvic limb, and general anesthesia only for the upper limb. We performed perioperative pain management with multimodal analgesia (continuous epidural analgesia with ropivacaine 0,2% and fentanyl 2 mcg/ml in association with systemic analgesics). Following this procedure, we measured the intensity of the postoperative pain at intervals of 48 hours and one week after surgery and compared with preoperative pain intensity using the visual analogue pain scale (VAS). Results: Multimodal analgesia (epidural analgesia associated with systemic analgesics – paracetamol, COX2 inhibitor, gabapentinoids) was performed well in the postoperative pain of the tumor prosthesis, with a significant decrease in VAS from a mean value of 7.63 preoperatively to an average of 3 in the first 48 hours postoperatively. After the removal of the epidural catheter, which also coincided with patient mobilization, the level of pain registered a slight increase to a mean value of 3.23. Conclusions: Multimodal analgesia is currently considered the gold standard in perioperative pain management. The use of multimodal analgesia during perioperative period in patients with bone tumors has been shown to decrease the length of hospital stay, improve surgical outcome, reduce the number of systemic complications, and improve the long-term prognosis of the patient. Efficacy of analgesia correlates with tumor site and vascularization.

scholarly journals Major lower limb amputation audit – introduction and implementation of a multimodal perioperative pain management guideline

2018 ◽  
Vol 12 (4) ◽  
pp. 230-237 ◽  
Author(s):  
Hafiz Aladin ◽  
Adrian Jennings ◽  
Max Hodges ◽  
Alifia Tameem
Keyword(s):  
Pain Management ◽  
Postoperative Pain ◽  
Lower Limb ◽  
Lower Limb Amputation ◽  
Limb Amputation ◽  
National Guidelines ◽  
Management Guideline ◽  
Perioperative Pain ◽  
Pain Scores ◽  
Perioperative Pain Management

Lower limb amputation is a frequent surgical intervention. It is well known to be associated with postoperative pain. Optimisation of perioperative pain has been shown to reduce the risk of chronic pain. There are no national guidelines for the perioperative pain management of lower limb amputations. Following a baseline audit, we devised a multimodal perioperative pain management guideline, which included the insertion of a local anaesthetic perineural catheter. All patients undergoing an elective or emergency above, through and below knee amputation were reviewed prior and following the implementation of this guideline. Patient postoperative pain scores and opiate usage were analysed. One hundred and twenty-four patients were reviewed (68 patients prior to the implementation of the guideline and 56 patients following the guideline introduction). Following the implementation of the guideline, a greater proportion of patient’s pain scores were reported as 0 (i.e. no pain) compared to patients prior to its implementation (78% vs 61%). Pain scores were lower at all time intervals 6 days postoperatively following the guideline introduction. Statistically significant (Kendall’s tau-b analysis) (p < 0.05) reduction in pain scores was found upon admission to the ward, 6, 12, 24 hours and 2 days postoperatively. Fewer patients required the use of opioid patient controlled of analgesia after the guideline was introduced (26% vs 4%). The implementation of a perioperative pain management guideline improved pain scores and reduced opioid consumption in patients undergoing lower limb amputations. We suggest a holistic and collaborative, multimodal pathway towards the perioperative pain management of lower limb amputations.

scholarly journals Pre-Emptive and Multi-Modal Perioperative Pain Management May Improve Quality of Life in Patients Undergoing Spinal Surgery

2013 ◽  
Vol 3;16 (3;5) ◽  
pp. E217-E226
Author(s):  
Seong-Hwan Moon
Keyword(s):  
Quality Of Life ◽  
Pain Management ◽  
Postoperative Pain ◽  
Spinal Surgery ◽  
Degenerative Spine ◽  
Perioperative Pain ◽  
Related Quality ◽  
Tertiary Hospitals ◽  
Perioperative Pain Management

Background: Compared to an abundance of data on surgical techniques for degenerative spine conditions and the outcomes thereof, little is available to guide optimal perioperative pain management after spinal surgery. The aim of this study was to survey patterns of perioperative pain management after spinal surgery and to investigate the effects of perioperative pain management, such as pre-emptive analgesia and multi-modal postoperative pain management, on acute postoperative satisfaction, pain reduction, and health-related quality of life in patients undergoing spinal surgery. Study design: Non-blind multicenter prospective observational clinical series. Setting: Seventeen tertiary hospitals (14 hospitals attached to medical colleges and 3 general hospitals). Methods: Pain management protocols of 393 patients (153 men, 240 women; mean age of 67 years, ranging from 21 to 91 years) from 17 tertiary hospitals after spinal surgery for degenerative spine disease were evaluated using a self-administered questionnaire. Results: A total of 79 (20%) patients received pre-emptive analgesics, which included cyclooxygenase-2 (COX-2) inhibitors, with or without administration of anticonvulsants, immediately before surgery at the time of antibiotic prophylaxis. Postoperative pain was managed mainly by multi-modal therapy (363 cases, 92%), along with various combinations of patient controlled anesthesia (PCA), conventional nonsteroidal anti-inflammatory drugs (NSAIDs), COX2 inhibitors, and narcotics. Self-reported levels of pain were not significantly different among postoperative multiple modalities of pain management, but were different significantly for preemptive pain management regimens (P < 0.05, independent t-test). The number of patients that reported the self-administrative use of PCA was higher in the no pre-emptive pain management group compared to the pre-emptive group (P < 0.05). In regards to EQ-5D usual activity, depression/ anxiety and self-care improved significantly in the pre-emptive pain management group when measured at 2 weeks postoperative (P < 0.05). Limitations: The limitation of our study is that it is not a randomized controlled observational study. Conclusions: Pre-emptive analgesia and multi-modal pain management after spinal surgery may lead to better health-related quality of life, greater patient satisfaction, and less postoperative pain. Key words: Degenerative spine, surgery, pre-emptive, pain, management

scholarly journals General, regional and combination anesthesia in knee arthroplasty: A multicenter cohort-study of 15326 cases analyzing patient satisfaction and perioperative pain management

2019 ◽  
Vol 7 (6_suppl4) ◽  
pp. 2325967119S0024
Author(s):  
Felix Greimel ◽  
Günther Maderbach ◽  
Clemens Baier ◽  
Armin Keshmiri ◽  
Timo Schwarz ◽  
...  
Keyword(s):  
Cohort Study ◽  
Patient Satisfaction ◽  
Pain Management ◽  
Postoperative Pain ◽  
Spinal Anesthesia ◽  
Knee Arthroplasty ◽  
Anesthetic Techniques ◽  
Perioperative Pain ◽  
Positive Tendency ◽  
Perioperative Pain Management

Aims and Objectives: In recent years, a steadily increasing number of total knee arthroplasty implants have been reported. After having ameliorated operation techniques and material, pain management and anesthetic methods have come into focus. Various anesthesia procedures for the surgical procedure itself as well as pain management programs have been developed. One of the main goals is to reduce postoperative pain and enable better and faster mobilization in the postoperative period. The present study aims to compare the use of general and regional anesthesia and their combination in terms of perioperative pain management and patient satisfaction. Materials and Methods: In the present cohort study, 15.326 patients were examined in 46 orthopedic departments after knee replacement surgery from 2009-2015. The parameters were analyzed on the first postoperative day as part of the project “QUIPS - Quality Improvement in Postoperative Pain Management”, an initiative to compare the outcome parameters in participating hospitals. Primary outcome values were pain levels (activity, minimum and maximum pain, and pain management satisfaction) on a NRS scale. Pain medication necessity was analyzed using the WHO pain ladder classification. Parameters were compared between the types of anesthesia used: general, regional and combination anesthesia. Results: Pain scores and pain management satisfaction were significantly better in the groups of either spinal or peripheral anesthesia combined with general anesthesia (p0.001, respectively). Patients who received the combination of general and spinal anesthesia were associated with the lowest need for opioids (p0.001). Conclusion: The use of a combined general and spinal anesthesia as well as using a combination of general and peripheral anesthesia in knee arthroplasty was associated with a highly significant advantage to other anesthetic techniques regarding perioperative pain management in daily clinical practice, but maybe below clinical relevance. Furthermore they were associated with positive tendency considering side effects and subjective well-being parameters.

Prevention of Adverse Effects in Perioperative Pain Management for General and Plastic Surgeons

2018 ◽  
Author(s):  
Daniel Krashin ◽  
Natalia Murinova ◽  
Alan D. Kaye
Keyword(s):  
Pain Management ◽  
Postoperative Pain ◽  
Pain Treatment ◽  
Postoperative Pain Management ◽  
Opioid Therapy ◽  
Perioperative Pain ◽  
Perioperative Pain Management ◽  
Complicating Factors ◽  
Multimodal Pain Treatment ◽  
Poor Outcomes

Postoperative pain management is a key part of perioperative care. Inadequately controlled pain contributes to poor outcomes and patient satisfaction. Overmedication with opioids for postoperative pain also leads to complications and slows recovery. Perioperative pain care starts with thorough evaluation at the preoperative visit. Multimodal pain treatment reduces the reliance on opioids and tends to improve outcomes. Many complicating factors, including pregnancy, comorbid psychological and medical conditions, addiction, and chronic opioid therapy need to be identified and addressed in a personalized pain plan. Complications including delirium and opioid-induced respiratory suppression are also discussed.

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