Postoperative pain trajectory and opioid requirements after laparoscopic bariatric surgery: a single-centre historical cohort study.

PURPOSE: Concerns around delayed emergence and opioid-induced ventilatory impairment in bariatric surgery can lead to intraoperative reliance on short-acting opioids and avoidance of long-acting analgesics with potential sedative effects. Nevertheless, an overly-conservative intraoperative analgesic strategy may result in significant pain at emergence and higher opioid requirements in later phases of care. We sought to establish the pattern of intraoperative analgesic use in bariatric surgical patients as well as their postoperative pain trajectory and opioid requirements. METHODS: We undertook a single-centre historical cohort study. We explored associations between intraoperative analgesic interventions and pain scores and opioid requirements in postanesthesia care units (PACUs), and associations between the quality of analgesia at emergence and subsequent pain and patient-centred recovery outcomes. RESULTS: We extracted perioperative data for 939 patients who underwent bariatric metabolic surgery between January 2018 and October 2019. Only 39% of patients received long-acting opioids intraoperatively and there was minimal use of nonopioid analgesic adjuncts. Nearly 80% of patients reported moderate-to-severe pain on PACU arrival; 97% of patients received intravenous opioids for rescue analgesia (mean dose, 31 mg oral morphine equivalents). Lower pain scores at PACU admission and discharge were associated with subsequent lower inpatient pain scores, lower opioid requirements, shorter time to ambulation, and shorter length of hospital stay. CONCLUSION: In bariatric surgical patients, effective intraoperative analgesic strategies that improve early pain control may have an impact on recovery and pain experience. Judicious use of intraoperative opioids coupled with opioid-sparing multimodal analgesic techniques should be considered and balanced against concerns regarding opioid-related adverse effects in this patient population.

RéSUMé: OBJECTIF: Les préoccupations concernant l'émergence retardée et l'insuffisance ventilatoire induite par les opioïdes en chirurgie bariatrique peuvent conduire à une dépendance peropératoire aux opioïdes à courte durée d'action et à l'évitement des analgésiques à action prolongée ayant des effets sédatifs potentiels. Néanmoins, une stratégie analgésique peropératoire trop conservatrice peut entraîner une douleur importante à l'émergence et des besoins en opioïdes plus élevés dans les phases ultérieures des soins. Nous avons cherché à établir le profil d'utilisation des analgésiques peropératoires chez les patient·es en chirurgie bariatrique ainsi que leur trajectoire de douleur postopératoire et leurs besoins en opioïdes. MéTHODE: Nous avons mené une étude de cohorte historique monocentrique. Nous avons exploré les associations entre les interventions analgésiques peropératoires et les scores de douleur et les besoins en opioïdes dans les salles de réveil, ainsi que les associations entre la qualité de l'analgésie à l'émergence et la douleur ultérieure et les résultats de récupération centrés sur les patient·es. RéSULTATS: Nous avons extrait les données périopératoires de 939 patient·es ayant bénéficié d'une chirurgie métabolique bariatrique entre janvier 2018 et octobre 2019. Seulement 39 % des patient·es ont reçu des opioïdes à action prolongée en peropératoire et l'utilisation d'analgésiques auxiliaires non opioïdes a été minimale. Près de 80 % des patient·es ont signalé une douleur modérée à sévère à leur arrivée en salle de réveil; 97 % des patient·es ont reçu des opioïdes par voie intraveineuse pour une analgésie de secours (dose moyenne, équivalents de morphine orale de 31 mg). Des scores de douleur plus faibles à l'admission et à la sortie de la salle de réveil ont été associés à des scores de douleur plus faibles en milieu hospitalier, à des besoins en opioïdes plus faibles, à un délai avant l'ambulation plus court et à une durée d'hospitalisation plus courte. CONCLUSION: Chez la patientèle de chirurgie bariatrique, des stratégies analgésiques peropératoires efficaces qui améliorent le contrôle précoce de la douleur peuvent avoir un impact sur la récupération et l'expérience de la douleur. L'utilisation judicieuse d'opioïdes peropératoires associée à des techniques analgésiques multimodales d'épargne opioïde doit être envisagée et mise en balance avec les préoccupations concernant les effets indésirables liés aux opioïdes dans cette population de patient·es.

Predictors of Chronic Pain 6 Months and 1 Year After Bariatric Surgery.

BACKGROUND: Obesity and chronic pain (CP) represent serious, interrelated global public health concerns that have a profound impact on individuals and society. Bariatric surgery is increasing in popularity and has been proven safe and efficacious, providing long-term weight loss and improvements in many obesity-related co-morbidities. A decrease in CP is often a motivation for bariatric surgery. The purpose of this study was to investigate the changes in CP postoperatively and to examine the relationship between psychosocial measures and pain. METHODS: A total of 155 adult bariatric surgery patients were recruited and completed self-report measures for CP severity and interference, neuropathic pain, anxiety, depression, emotion regulation and perceived social support at three timepoints preoperative and 6 and 12 months postoperative. RESULTS: Pain significantly decreased between preoperative and postoperative timepoints, and preoperative pain was the most significant predictor of postoperative pain. Preoperative CP was correlated with anxiety (p < 0.05) and depression (p < 0.01) at 6 months postoperatively and perceived social support (p < 0.01) at 1 year postoperatively. However, regression analyses with psychological variables were not significant. CONCLUSION: CP decreases after bariatric surgery, but further research with larger sample sizes is needed to establish whether psychosocial characteristics impact this outcome.

E-Survey of Stressors and Protective Factors in Practicing Medical Assistance in Dying.

Objective: To better identify, quantify, and understand the current stressors and protective factors reported by Canadian medical assistance in dying (MAiD) assessors and providers to inform policy, education, and supports. Methods: E-survey of MAiD stressors (n = 33) and protective factors (n = 27); resilience measurement and comments relating to practice involving physicians and nurse practitioners who provide MAiD services and belong to the Canadian Association of MAiD Assessors and Providers or a francophone equivalent. The survey was conducted, while Parliament was considering changes to MAiD eligibility criteria, which occurred during COVID-19 pandemic restrictions. Results: In total, there were 131 respondents (response rate 35.8%). Two possible changes to future eligibility (mental disorders as the sole reason for MAiD and mature minors) were highly scored as were extra clinical load and patients' family conflict over MAiD. Twenty percent of respondents considered stopping MAiD work. The CD Resilience Scale-2 mean score was 6.90. Highly scored protective factors included compassionate care, relief of suffering, patient autonomy, patient gratitude, feelings of honor, privilege, and professionally satisfying work. Discussion: The identified stressors and reasons for considering stopping MAiD work indicate needs for policy, education, and supports to be optimized or developed. Respondents showed high resilience and highly scored protective factors, which should be optimized. This survey should be repeated in countries where MAiD is legal to determine stressors and protective factors in MAiD practice, stressors addressed, and protective factors enhanced where feasible in the local context for optimal care.

What Do Adult Surgical Patients Speaking Primarily Cantonese, Italian, or Portuguese Really Want to Know About Pain and Pain Management?

BACKGROUND: Surgical patients consider information about pain and pain management to be highly important (Apfelbaum, 2003). At the same time, evidence indicates that members of racial and ethnic minorities are more likely to experience inadequate pain management (Green, Anderson, Baker, Campbell, Decker, Fillingim, & Todd, 2003; Mossey, 2011). AIMS: This study investigated the needs of general day surgery patients who spoke primarily Cantonese, Italian, or Portuguese at home for information about postoperative pain. DESIGN: This was a mixed methods, descriptive study. SETTING: The day surgery unit of a large, quaternary care hospital in downtown Toronto. PARTIPANTS/SUBJECTS: Inclusion criteria were day patients who were at least 18 years of age or older and spoke primariy Cantonese, Italian or Portugues at home. and were able to read and write in their primary language. METHODS: Participants who had undergone a day surgery procedure completed a telephone information needs survey in their primary language (Cantonese, Italian, Portuguese) within 72 hours after discharge. Composite mean scores were calculated for each item. Chi-squared analyses were used to probe for intergroup differences and compare with English-fluent participants from phase 1 of this study (Kastanias, Denny, Robinson, Sabo, & Snaith, 2009). RESULTS: Sixty-three participants in total completed the survey: 21% Cantonese, 41% Italian, and 38% Portuguese. The mean age of the sample was 70 years old; 89% were born outside of Canada, and 52% were male. For the combined group, the average importance rating score range for the information items was 6.2-8.9 out of a possible score of 10. All items were rated as moderate (5-6 out of 10) to high (≥7out of 10) importance. Surgical subtype, health status, and age had no effect on the importance of any information item. There were no significant differences between the three language groups on any of the information items. This lack of difference may have been a result of a lack of power due to the small sample size of the individual language groupings. Overall, the top-ranked information items were "the plan for which drugs to take and when," "what I can do if I still have pain or side effects," and "side effects I was most likely to get." CONCLUSIONS: Similar to English-fluent participants (Kastanias et al., 2009), participants who primarily spoke either Cantonese, Italian, or Portuguese at home placed moderate to high importance on all of the information items. and neither surgical subtype, health status nor age had any effect on the importance of any item. The multilingual sample in this study placed more importance than English-fluent participants on information regarding help with paying for pain medication (p = .001) and the side effects they were most likely to experience (p < .05). Due to a paucity of literature in this area, further research is warranted. Results may assist with evaluating and improving current approaches to surgical patient pain management education.

A Qualitative Study of Young Adult Experiences in the Bariatric Healthcare System: Psychosocial Challenges and Developmental Difficulties.

OBJECTIVES: Bariatric surgery is an evidence-based treatment for severe obesity; however, the unique developmental and psychosocial needs of young adults often complicate care and, as yet, are not well understood. We sought to identify themes in young adult patients undergoing bariatric surgery regarding: 1) the psychosocial experiences of obese young adults (18 to 24) seeking bariatric surgery; 2) the experiences during the preoperative bariatric surgery process and 3) the postoperative experiences of young adult patients. METHODS: In-depth, semistructured individual interviews were conducted with 13 young adult bariatric patients who were seeking or had undergone bariatric surgery within the past 5 years. Interviews were analyzed using a qualitative methodology. RESULTS: We found the following themes in our analyses: 1) the impact of relationships (with families and healthcare providers) on the bariatric healthcare experience; 2) preoperative experiences by young adults prior to undergoing surgery and 3) postoperative reflections and challenges experienced by young adult patients. CONCLUSIONS: Results revealed that patients' experiences appear to encompass impact on familial relationships, needs sought to be fulfilled by healthcare providers, and various preoperative and postoperative psychosocial concerns. By understanding the experiences of young adults, healthcare providers might be able to provide better care for these patients.

Factors Leading to Self-Removal from the Bariatric Surgery Program After Attending the Orientation Session.

BACKGROUND: Bariatric surgery orientation sessions are often the first point of contact and a recommended component of pre-bariatric surgery assessment. Self-removal rates after bariatric program orientation are as high as 25 % despite the proven efficacy of this procedure. The objective of this study was to identify factors contributing to patient self-removal after orientation using a mixed method approach. METHODS: Patients who attended the Toronto Western Hospital Bariatric Surgery Program orientation between 2012 and 2013 and then self-removed from the program (N = 216) were included in the study. Subjects were interviewed via telephone using a semi-structured interview guide, generating both quantitative and qualitative data. Factors leading to discontinuation were rated on a five-point Likert scale. Qualitative data was analyzed using constant comparative methodology. RESULTS: The response rate was 59 % with a 40.7 % completion rate (N = 88). Concerns about potential surgical risks and complications and the ability to adapt to changes in eating and drinking post-operatively were identified as the top two factors for patients' self-removal from the program. Thematic analysis uncovered 11 major themes related to patient self-removal. Unexpected themes include perceived personal suitability for the surgery, family impact of surgery, miscommunication with the family physician, and fears related to the orientation information. CONCLUSIONS: This is one of the first studies examining barriers to bariatric surgery in the pre-operative setting and offers new insights into the reasons patients self-remove from bariatric surgery programs. This study may inform bariatric orientation program changes resulting in improved access to this effective surgical intervention.

The journey of the pain resource nurse in improving pain management practices: understanding role implementation.

Pain assessment and management continues to be challenging for many nurses. Single educational interventions have proven to be unsuccessful in knowledge retention. This study will assist leaders in nursing in understanding how a 4-day educational program delivered to self-selected pain resource nurses (PRNs) could improve pain assessment and management practices. A focus group study was undertaken at a trisite academic health science center to understand the role implementation of the PRNs and required resources to sustain the role at a unit level. To evaluate the PRN role, a qualitative descriptive study design using focus group interviews was used to answer the following questions: What was the experience of the PRN during role implementation? What barriers and enablers affected the implementation of this role? Organizational support, integration within the interdisciplinary team, and organizational role awareness were key themes highlighted in the focus group results. This article will describe how the three-site academic health science center used the PRN role to foster practice-related change and enhance current knowledge of evidence-based pain management.

Patient-controlled oral analgesia for postoperative pain management following total knee replacement.

PURPOSE: To investigate whether patient-controlled oral analgesia (PCOA) used by individuals receiving a total knee replacement could reduce pain, increase patient satisfaction, reduce opioid use and/or reduce opioid side effects when compared with traditional nurse (RN)-administered oral analgesia. METHODS: Patients who underwent an elective total knee replacement at a quaternary care centre (Toronto Western Hospital, Toronto, Ontario) were randomly assigned to either PCOA or RN-administered short-acting oral opioids on postoperative day 2. Subjects in the RN group called the RN to receive their prescribed short-acting opioid. Subjects in the PCOA group kept a single dose of their prescribed oral opioid at their bedside and took this dose when they felt they needed it, to a maximum of one dose every 2 h. Study outcomes, collected on postoperative day 2, included pain (measured by the Brief Pain Inventory - Short Form), patient satisfaction (measured by the Pain Outcome Questionnaire Satisfaction subscale - component II), opioid use (oral morphine equivalents), opioid side effects (nausea, pruritus and/or constipation) and knee measures (maximum passive knee flexion and pain at maximum passive knee flexion, performed on the operative knee). RESULTS: Study outcomes were analyzed twice. First, for a subset of 73 subjects who remained in their randomly assigned group (PCOA group, n=36; RN group, n=37), randomized analyses were performed. Second, for the larger sample of 88 subjects who were categorized by their actual method of receiving oral opioids (PCOA group, n=41; RN group, n=47), as-treated analyses were performed. There were no differences in study outcomes between the PCOA and RN groups in either analysis. CONCLUSION: PCOA was not superior to RN administration on study outcomes. However, PCOA did not increase opioid use or pain. PCOA remains an important element in the patient-centred care facility.

What do adult surgical patients really want to know about pain and pain management?

This study investigates the informational content about postoperative pain and pain management that patients identify as being most important. In a descriptive quantitative study design, a convenience sample of 150 general day surgery patients were surveyed by telephone within 72 h after discharge from a hospital day surgery unit. The survey consisted of 19 items rated on a 10-point Likert scale of importance. Composite mean scores were calculated for each item. Chi-squared analyses were used to probe for intergroup differences. Mean information item importance scores ranged from 5.9/10 to 8.7/10. The top three were discharge-related items. The majority of the lowest ratings were for general pain management information items. "If I can get addicted to drugs used to treat my pain" was rated the fourth lowest in importance. "I would have liked to have known other ways of dealing with my pain in addition to pain medicine" was significantly associated with duration of pain preoperatively (chi-squared = 0.010). None of the other information items were associated with preoperative pain duration. All of the pain and pain management survey information items were of moderate (5-6/10) to high (>7/10) importance to the general day surgery patient participants. Of prime importance was information related to what to do about pain and side effects after discharge. Because patients place high importance on information about the pain experience, the pain management plan after discharge, and side effect management, health care professionals need to focus their pain management counseling in these areas.

Patient-controlled oral analgesia: a low-tech solution in a high-tech world.

The primary concern of surgical patients is the expected experience of pain. Presently, the standard for acute postoperative pain management is intravenous patient-controlled analgesia (PCA). Many authors have reported that patients prefer intravenous PCA to nurse-administered analgesia because it affords them greater control and optimizes their pain relief. However, when the patient strengthens and is able to resume enteral sustenance, intravenous PCA is routinely discontinued and replaced with nurse-administered oral analgesia. This eliminates much of the patients' control over managing their pain and results in patients waiting, in pain, for a nurse to bring their pain tablets. When PCA is administered in the hospital setting, it is most often administered by intravenous, subcutaneous, or epidural routes. This article describes the implementation of a successful inpatient program that offers patient-controlled oral analgesia (PCOA). Patient-centered care is "an approach that consciously adopts the patient's perspective...about what matters." Patient-centered care is the practice philosophy of the University Health Network, a large tri-site teaching hospital in downtown Toronto, Ontario, Canada, affiliated with the University of Toronto. This philosophy underpins the concept of PCOA as it has been successfully operationalized in a unique PCOA program at the Toronto Western Hospital, one of the three sites comprising the University Health Network.