A properly timed perioperative medicine consultation by an anesthesiologist can reduce postoperative pain and increase overall patient satisfaction. Indeed, nearly 60% of anticipated pain cases could have been averted with adequate preoperative preparation with adjuvant analgesics, a study suggests.
“Opioid use and psychological illness were the biggest predictors of anticipated postoperative pain,” said Janora M. Payne, MD, an anesthesiology resident at Thomas Jefferson University Hospital, in Philadelphia. “However, only 41% of patients in the anticipated group were provided sufficient pain relief. This shows that we have an unmet need. Better preoperative planning is needed before patients proceed to surgery in this patient population.”
Perioperative medicine and the perioperative surgical home are emerging patterns of surgical care, yet few studies have been conducted to examine their potential to improve pain outcomes.
“Anesthesiologists are uniquely qualified to practice the scope and breadth of perioperative medicine, including preoperative preparation, tailored anesthetic management and postoperative care including pain management,” Dr. Payne noted. “It’s important to determine incidence of severe and unrelieved postoperative pain that may be preventable with this type of consultation.”
Study Design and Results
Researchers reviewed 333 acute pain consults from March 1 to Aug. 31, 2015. The timing of the consult relative to the surgical procedure; history of chronic pain and chronic opioid use; presence of psychological illness including substance abuse and dependence, depression, anxiety and bipolar disorder; medical comorbidities; surgical procedure; and the type and timing of multimodal analgesics were examined.
Dr. Payne and colleagues, who presented their findings at the 2015 annual meeting of the American Society of Anesthesiologists (abstract A1286), divided patients into two categories: unanticipated and uncontrolled pain versus anticipated but uncontrolled pain.
“The likelihood of anticipated pain was determined by what kind of surgery the patient had, the patient’s history of chronic pain and opioid use, and whether the patient had a psychological illness,” Dr. Payne explained. “Depression, anxiety, and substance abuse and dependence were included in the category of psychological illness.”
If patients met the criteria of anticipated pain, researchers assessed whether appropriate analgesic techniques were used during surgery. “At our hospital, for example, we perform a lot of spine surgery,” she said. “It’s a very painful procedure. … If the patient is likely to have anticipated pain, we then looked to see what type of analgesic we used during that procedure.”
Of the 333 pain consults that were initially reviewed, researchers selected 235 cases pertaining only to surgical patients. Of these 235 cases, 215 (91%) were anticipated to have significant postoperative pain.
As Dr. Payne reported, only two factors—opioid use and psychological illness—were found to be associated with anticipated pain. Diabetes, cardiovascular disease, age and sex were not associated with anticipated pain.
“At our institution, we see patients that are on very high doses of pain medication having painful surgeries without certain steps being taken, like giving ketamine in the operating room,” Dr. Payne said. “The issue with preoperative planning is that we can do certain things, like administer intraoperative ketamine or even provide Tylenol [acetaminophen], before the procedure.”
Of the 215 patients who were anticipated to experience postoperative pain, 87 (40.5%) were given ketamine. However, 128 patients (59.5%) who could have been given ketamine, based on their anticipated pain, were not.
“Giving this medication in the operating room, preoperatively, would decrease postoperative pain, but we see that 128 patients from this study did not receive it. … Clearly, there’s room for improvement,” Dr. Payne concluded.
Jaime Barrata, MD, an anesthesiologist at Thomas Jefferson University Hospital, said this study underscored the need for earlier intervention with certain patient populations.
“Patients who are opioid tolerant and undergoing extensive surgery will have anticipated pain that is going to be moderate to severe,” Dr. Barrata said. “We really need to be more proactive in intervening. If we wait until the pain becomes severe, it’s harder to treat, and this can lead to bad outcomes—from uncontrolled pain and worsening of chronic pain to increased morbidity and mortality.”