[Show abstract][Hide abstract] ABSTRACT: Background
Increase in the diagnosis of prostate cancer has increased the incidence of radical prostatectomy. However, the literature assessing pain therapy for this procedure has not been systematically evaluated. Thus, optimal pain therapy for patients undergoing radical prostatectomy remains controversial.
Medline, Embase, and Cochrane Central Register of Controlled Trials were searched for studies assessing the effects of analgesic and anesthetic interventions on pain after radical prostatectomy. All searches were conducted in October 2012 and updated in June 2015.
Most treatments studied improved pain relief and/or reduced opioid requirements. However, there were significant differences in the study designs and the variables evaluated, precluding quantitative analysis and consensus recommendations.
This systematic review reveals that there is a lack of evidence to develop an optimal pain management protocol in patients undergoing radical prostatectomy. Most studies assessed unimodal analgesic approaches rather than a multimodal technique. There is a need for more procedure-specific studies comparing pain and analgesic requirements for open and minimally invasive surgical procedures. Finally, while we wait for appropriate procedure specific evidence from publication of adequate studies assessing optimal pain management after radical prostatectomy, we propose a basic analgesic guideline.
[Show abstract][Hide abstract] ABSTRACT: Objectives:
To provide a short overview of fast-track VATS and to identify areas requiring further research.
A literature search was made using key words including: fast-track, enhanced recovery, video-assisted thoracoscopic surgery (VATS), robot-assisted thoracoscopic surgery (RATS), robotic, thoracotomy, single-incision, uniportal, natural orifice transluminal endoscopic surgery (NOTES), chest tube, air-leak, digital drainage, pain management, analgesia, perioperative management, anaesthesia and nonintubated. References from articles were screened for further articles. Using abstracts, areas of interest for developing a fast-track protocol were selected.
Minimally invasive approach can be divided into several surgical methods, which need further research to establish superiority. The role of intubation has to be further examined, as well as the role of chest drains. Multimodal analgesic treatment including preoperative methylprednisolone seems promising and requires further research.
The fast track data from other procedures may support future development and improvement of fast track VATS.
[Show abstract][Hide abstract] ABSTRACT: Background:
Early postoperative mobilization is essential for rapid recovery but may be impaired by orthostatic intolerance (OI) and orthostatic hypotension (OH), which are highly prevalent after major surgery. Pathogenic mechanisms include an insufficient postoperative vasopressor response. The oral α-1 agonist midodrine hydrochloride increases vascular resistance, and the authors hypothesized that midodrine would reduce the prevalence of OH during mobilization 6 h after total hip arthroplasty relative to placebo.
This double-blind, randomized trial allocated 120 patients 18 yr or older and scheduled for total hip arthroplasty under spinal anesthesia to either 5 mg midodrine hydrochloride or placebo orally 1 h before mobilization at 6 and 24 h postoperatively. The primary outcome was the prevalence of OH (decrease in systolic or diastolic arterial pressures of > 20 or 10 mmHg, respectively) during mobilization 6 h after surgery. Secondary outcomes were OI and hemodynamic responses to mobilization at 6 and 24 h.
At 6 h, 14 (25%; 95% CI, 14 to 38%) versus 23 (39.7%; 95% CI, 27 to 53%) patients had OH in the midodrine and placebo group, respectively, relative risk 0.63 (0.36 to 1.10; P = 0.095), whereas OI was present in 15 (25.0%; 15 to 38%) versus 22 (37.3%; 25 to 51%) patients, relative risk 0.68 (0.39 to 1.18; P = 0.165). At 24 h, OI and OH prevalence did not differ between groups.
Preemptive use of oral 5 mg midodrine did not significantly reduce the prevalence of OH during early postoperative mobilization compared with placebo. However, further studies on dose and timing are warranted since midodrine is effective in chronic OH conditions.
[Show abstract][Hide abstract] ABSTRACT: Background:
Breast cancer patients treated with axillary lymph node dissection (ALND) have a higher risk of both acute and persistent pain than those treated with sentinel lymph node biopsy (SLNB). This could be attributed to a higher risk of nerve injury with ALND. We hypothesized that (1) pain patients have more pronounced sensory dysfunction than pain-free patients, (2) ALND have more sensory dysfunction and pain than SLNB patients and (3) patients with preserved intercostobrachial nerve (ICBN) preservation have less sensory dysfunction compared to a sectioned ICBN.
Twenty-seven patients treated with ALND and 27 with SLNB examined with a standardized Quantitative Sensory Testing (QST) protocol, including sensory mapping, mechanical and thermal thresholds, as well as recording intraoperative ICBN handling and pain status 1 week post-operative.
The area of cold hypoaesthesia was significantly associated with movement-related pain (P = 0.004), with a similar tendency for warmth (P = 0.018) and brush (P = 0.030) hypoaesthesia areas. 14 (26%) of the patients had moderate/severe pain at rest and 13 (24%) during movement without differences between ALND and SLNB, but ALND was associated with more sensory dysfunction than SLNB. Patients with sectioned ICBN reported lower pain intensity than those with preserved ICBN (P = 0.005), but without differences in sensory dysfunction.
Pain was increased in patients having larger areas of hypoaesthesia and reduced in patients where ICBN-section was done. Sensory dysfunction was related to extent of axillary surgery, but not with ICBN handling. Our data suggest that acute pain after breast cancer surgery may be related to nerve injury.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Intact orthostatic blood pressure regulation is essential for early mobilization after surgery. However, postoperative orthostatic hypotension and intolerance (OI) may delay early ambulation. The mechanisms of postoperative OI include impaired vasopressor responses relating to postoperative autonomic dysfunction. Thus, based on a previous study on haemodynamic responses during mobilization before and after elective total hip arthroplasty (THA), we performed secondary analyses of heart rate variability (HRV) and aimed to identify possible abnormal postoperative autonomic responses in relation to postural change.
METHODS: A standardized mobilization protocol before, 6 and 24 h after surgery was performed in 23 patients scheduled for elective THA. Beat-to-beat arterial blood pressure was measured by photoplethysmography and HRV was derived from pulse wave interbeat intervals and analysed in the time and frequency domain as well as by non-linear analysis using sample entropy
RESULTS: Before surgery, arterial pressures and HR increased upon standing, while HRV low (LF) and high frequency (HF) components remained unchanged. At 6 and 24 h after surgery, resting total HRV power, sample entropy and postural responses in arterial pressures decreased compared to preoperative conditions. During standing HF variation increased by 16.7 (95 % CI 8.0-25.0) normalized units (nu) at 6 h and 10.7 (2.0-19.4) nu at 24 h compared to the preoperative evaluation. At 24 h the LF/HF ratio decreased from 1.8 (1.2-2.6) nu when supine to 1.2 (0.8-1.8) nu when standing.
CONCLUSIONS: This study observed postoperative autonomic cardiovascular dysregulation that may contribute to limited HRV responses during early postoperative mobilization.
TRIAL REGISTRATION: ClinicalTrials.gov NCT01089946.
[Show abstract][Hide abstract] ABSTRACT: Gabapentin has shown acute postoperative analgesic effects, but the optimal dose and procedure-specific benefits vs. harm have not been clarified. In this randomized, double-blind, placebo-controlled, dose-finding study, 300 opioid-naive patients scheduled for total knee arthroplasty were randomized (1:1:1) to either gabapentin 1300 mg/day (group A), gabapentin 900mg/day (group B) or placebo (group C) daily from 2 hours preoperatively to postoperative day 6 in addition to a standardized multimodal analgesic regime. The primary outcome was pain upon ambulation 24 hours after surgery, the secondary outcome sedation6 hours after surgery. Other outcomes were overall pain during well-defined mobilizations and at rest, and sedation during the first 48hours and from day2-6, morphine use, anxiety, depression, sleep quality, and nausea, vomiting, dizziness, concentration difficulty, head-ache, visual disturbances, and adverse reactions. Pain upon ambulation [VAS, mean (95% CI)] 24hours after surgery in group A vs. B vs. C was: 41(37-46) vs.41(36-45) vs.42(37-47), p=0.93. Sedation [NRS, median (range)] 6hours after surgery was: 3.2(0-10) vs.2.6 (0-9) vs.2.3 (0-9), the mean difference Avs.C being 0.9(0.2-1.7),p=0.046. No between-group differences were observed in overall pain or morphine use the first 48hours and from day2-6. Sleep quality was better during the first 2 nights in group A and Bvs.C. Dizziness was more pronounced from day2-6 in Avs. C. More severe adverse reactions were observed in group Avs.B and C. In conclusion, gabapentin may have limited if any role in acute postoperative pain management of opioid-naive patients undergoing total knee arthroplasty and should not be recommended as standard of care.
[Show abstract][Hide abstract] ABSTRACT: Previous studies have reported that 15-25% of patients treated for breast cancer experience long term moderate to severe pain in the area of surgery, potentially lasting for several years. Few prospective studies have included all potential risk factors for the development of persistent pain after breast cancer surgery (PPBCS). The aim of the present prospective cohort study was to comprehensively identify factors predicting PPBCS. Patients scheduled for primary breast cancer surgery were recruited. Assessments were conducted preoperatively, the first 3 days postoperatively and 1 week, 6 months and 1 year after surgery. A comprehensive validated questionnaire was used. Handling of the intercostobrachial nerve (ICBN) was registered by the surgeon. Factors known by the first 3 weeks after surgery were modelled in ordinal logistic regression analyses. 537 patients with baseline data were included and 475 (88%) were available for analysis at 1 year. At 1 year follow up, the prevalence of moderate to severe pain at rest was 14% and during movement was 7%. Factors associated with pain atrest was age <65 years (OR: 1.8, p=0.02), breast conserving surgery (OR: 2.0, p=0.006), axillary lymph node dissection with preservation of the ICBN (OR: 3.1, p=0.0005), moderate to severe preoperative pain (OR: 5.7, p=0.0002), acute postoperative pain (OR: 2.8, p= 0.0018) and signs of neuropathic pain at 1 week OR: 2.1, p=0.01. Higher preoperative diastolic blood pressure was associated with reduced risk of PPBCS (OR 0.98 per mmHg, p=0.01). Both patient and treatment related risk factors predicted PPBCS. Identifying patients at risk may facilitate targeted intervention.
[Show abstract][Hide abstract] ABSTRACT: Background and purpose — Patient satisfaction is important in fast-track total hip and knee replacement (THR, TKR). We assessed: (1) how satisfied patients were with the treatment; (2) factors related to overall satisfaction; and (3) whether there was a difference between THR and TKR regarding length of stay (LOS) and patient satisfaction.
Patients and methods — In this follow-up study, a consecutive series of 445 patients undergoing THR and TKR completed a questionnaire 2 weeks after discharge. LOS and short-term patient satisfaction with the fast-track management were measured. Patient satisfaction was measured using a numerical rating scale (NRS; 0–10).
Results — For THR, the median satisfaction score was 9–10 and for TKR it was 8.5–10 in all parameters. Older THR patients had higher overall satisfaction. No association was found between overall satisfaction following THR or TKR and sex comorbidity, or LOS. THR patients had shorter mean LOS than TKR patients, even though the median LOS was 2 days for both groups. THR patients were more satisfied than TKR patients in the first weeks after discharge.
Interpretation — Patient satisfaction is high following fast-track THR and TKR, with scores ranging from 8.5 to 10 on the NRS. A qualitative investigation of the first weeks after discharge is required to learn more about how to improve the experience of recovery.
[Show abstract][Hide abstract] ABSTRACT: Although certain risk factors can identify individuals who are most likely to develop chronic pain, few interventions to prevent chronic pain have been identified. To facilitate the identification of preventive interventions, an IMMPACT meeting was convened to discuss research design considerations for clinical trials investigating the prevention of chronic pain. We present general design considerations for prevention trials in populations that are at relatively high risk for developing chronic pain. Specific design considerations included subject identification, timing and duration of treatment, outcomes, timing of assessment, and adjusting for risk factors in the analyses. We provide a detailed examination of 4 models of chronic pain prevention (i.e., chronic post-surgical pain, postherpetic neuralgia, chronic low back pain, and painful chemotherapy-induced peripheral neuropathy). The issues discussed can, in many instances, be extrapolated to other chronic pain conditions. These examples were selected because they are representative models of primary and secondary prevention, reflect persistent pain resulting from multiple insults (i.e., surgery, viral infection, injury, and toxic/noxious element exposure), and are chronically painful conditions that are treated with a range of interventions. Improvements in the design of chronic pain prevention trials could improve assay sensitivity and thus accelerate the identification of efficacious interventions. Such interventions would have the potential to reduce the prevalence of chronic pain in the population. Additionally, standardization of outcomes in prevention clinical trials will facilitate meta-analyses and systematic reviews and improve detection of preventive strategies emerging from clinical trials.
[Show abstract][Hide abstract] ABSTRACT: Patients who are surgically treated for an acute hip fracture in Denmark commence early in-hospital physical rehabilitation (PR) with more than 95% of patients referred to further PR following discharge. However, the specifics of the PR services after discharge are unknown. Thus, the aim of the present paper was to describe the specifics of PR provided to patients following discharge after hip fracture (HF) surgery in Denmark to evaluate the need for future interventions or guidelines.
This was a national, cross-sectional questionnaire survey including 56 randomly selected municipalities out of 98. Information was gathered on PR and categorised into outpatient PR (including one-to-one and group), home-based PR, 24-hour in-patient PR units and nursing homes.
Sixty PR centres (97%) within 51 municipalities (91%) participated. The PR was initiated within 1-2 weeks after the municipality had received a referral from the hospital in 97% of the participating centres. The duration of PR was 8-12 weeks or 4-7 weeks in 85% of the centres, and most often comprised 1-2 training sessions per week. In all, 72% out of 56 municipalities returned a specific PR programme of which only 14% provided specific information regarding the intensity and the progression of training.
PR after hip fracture in Denmark is initiated shortly after referral, for a variable duration of time and with poorly described exercise intensity and progression. This calls for a national description and implementation of an optimised PR programme according to the best available evidence.
The study was supported by grants from The IMK Foundation, The Research Foundation of the Capital Region, The Research Foundation of the Danish Physical Therapy Organization, The Research Foundation of Hvidovre Hospital and The UCSF Lundbeck Foundation. The funding agencies had no influence on the study design, methods, subjects, data collection, analyses or on the manuscript.
Danish Medical Journal 04/2015; 62(4):A5023. · 1.07 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Sufficient pain treatment remains a challenge after total knee arthroplasty (TKA), especially in high pain catastrophizing patients. Serotonergic signaling may be involved in pain processing, but the effect of selective serotonin reuptake inhibitors on well-defined postoperative pain has not previously been investigated. The authors hypothesized that perioperative escitalopram would reduce pain after TKA in high pain catastrophizing patients.
A total of 120 pain catastrophizing patients (selected using the pain catastrophizing scale as preoperative screening tool) scheduled for TKA were randomized in a double-blind manner to either 10 mg escitalopram or placebo daily from preanesthesia to postoperative day 6 in addition to a standardized analgesic regime. The primary outcome was pain upon ambulation 24 h after surgery. Secondary outcomes were overall pain during well-defined mobilizations and at rest from 2 to 48 h and from days 2 to 6, morphine equivalents, anxiety, depression, and side effects.
Pain upon ambulation (mean [95% CI]) 24 h after surgery in the escitalopram versus placebo group was 58 (53 to 64) versus 64 (58 to 69), the mean difference being -5 (-13 to 3), P = 0.20. Overall pain upon ambulation and at rest from days 2 to 6 was lower in the escitalopram versus placebo group, as was depression score at day 6 (all P ≤ 0.01 in analyses uncorrected for multiple tests). Side effects were nonsignificant except for reduced tendency to sweat and prolonged sleep in the escitalopram group. No other between-group differences were observed.
Escitalopram did not reduce pain upon ambulation 24 h after TKA in high pain catastrophizing patients. Future studies on optimal timing, dose, and duration of selective serotonin reuptake inhibitor treatment might be warranted.