What Pain Levels Do TSA Patients Experience When Given a Long-acting Nerve Block and Multimodal Analgesia?

BACKGROUND: The pain experience for total shoulder arthroplasty (TSA) patients in the first 2 weeks after surgery has not been well described. Many approaches to pain management have been used, with none emerging as clearly superior; it is important that any approach minimizes postoperative opioid use. QUESTIONS/PURPOSES: (1) With a long-acting nerve block and comprehensive multimodal analgesia, what are the pain levels after TSA from day of surgery until postoperative day (POD) 14? (2) How many opioids do TSA patients take from the day of surgery until POD 14? (3) What are the PainOUT responses at POD 1 and POD 14, focusing on side effects from opioids usage? METHODS: From January 27, 2017 to December 6, 2017, 154 TSA patients were identified as potentially eligible for this prospective, institutional review board-approved observational study. Of those, 46 patients (30%) were excluded (either because they were deemed not appropriate for the study, research staff were not available, patients were not eligible, or they declined to participate), and another six (4%) had incomplete followup data and could not be studied, leaving 102 patients (66%) for analysis here. Median preoperative pain with movement was 7 (interquartile range [IQR], 5-9) and 13 of 102 patients used preoperative opioids. All patients received a single-injection bupivacaine interscalene block with adjuvant clonidine, dexamethasone, and buprenorphine. Multimodal analgesia included acetaminophen, NSAIDs, and opioids. The primary outcome was the Numerical Rating Scale (NRS) pain score with movement on POD 14. The NRS pain score ranges from 0 (no pain) to 10 (worst pain possible). Secondary outcomes included NRS pain scores at rest and with movement (day of surgery, and PODs 1, 3, 7 and 14), daily analgesic use from day of surgery to POD 14 (both oral and intravenous), Opioid-Related Symptom Distress Scale (which assesses 12 symptoms ranging from 0 to 4, with 4 being the most distressing; the composite score is the mean of the 12 symptom-specific scores) on POD 1, and the PainOut questionnaire on POD 1 and POD 14. The PainOut questionnaire includes questions rating nausea, drowsiness, itching from 0 (none) to 10 (severe), as well as rating difficulty staying asleep from 0 (does not interfere) to 10 (completely interferes). RESULTS: The median NRS pain scores with movement were 2 (IQR, 0-5) on POD 1, 5 (IQR, 3-6) on POD 3, and the pain score was 3 (IQR, 1-5) on POD 14. Median total opioid use (converted to oral morphine equivalents) was 16 mg (4-50 mg) for the first 24 hours, 30 mg (8-63 mg) for the third, and 0 mg (0-20 mg) by the eighth 24-hour period, while the most frequent number of activations of the intravenous patient-controlled analgesia device was 0. Median PainOut scores on POD 1 and POD 14 for sleep interference, nausea, drowsiness and itching were 0, and the median composite Opioid-Related Symptom Distress Scale score on day 1 was 0.3 (IQR, 0.1-0.5). CONCLUSIONS: Clinicians using this protocol, which combines a long-acting, single-injection nerve block with multimodal analgesia, can inform TSA patients that their postoperative pain will likely be less than their preoperative pain, and that on average they will stop using opioids after 7 days. Future research could investigate what the individual components of this protocol contribute. Larger cohort studies or registries would document the incidence of rare complications. Randomized controlled trials could directly compare analgesic effectiveness and cost-benefits for this protocol versus alternative strategies, such as perineural catheters or liposomal bupivacaine. Perhaps most importantly, future studies could seek ways to further reduce peak pain and opioid usage on POD 2 and POD 3. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Association of obesity with inflammation and pain after total hip arthroplasty.

BACKGROUND: The prevalence of obesity is increasing, and obesity often leads to degenerative joint disease requiring total hip arthroplasty (THA). Obesity is a proinflammatory state associated with an increase in chronic, low-grade inflammatory response. As such, it may augment the postoperative inflammatory response, which has been associated with postoperative pain and complications. QUESTIONS/PURPOSES: We determined whether severity of obesity was associated with (1) severity of inflammatory response, as measured by the in vivo circulating levels of cytokines and ex vivo functional reactivity of mononuclear blood cells, and (2) severity of pain, as measured by verbal pain scores and analgesic consumption, in the first 24 hours after THA. METHODS: We studied 60 patients (20 normal weight, 20 overweight, 20 obese) undergoing elective primary unilateral THA in this prospective cross-sectional study. Blood samples were collected for C-reactive protein and cytokine levels, including IL-1ß, IL-2, IL-6, IL-8, and tumor necrosis factor α (TNF-α), from patients before and 24 hours after surgery. Cytokine response of whole blood was evaluated ex vivo with or without two standard activators, phorbol-12-myristate-13-acetate and lipopolysaccharide, using standardized blood sample from patients at 24 hours. These standard immune activators are implicated in the inflammatory response to gram-negative infection, translocation of microbial products, pathophysiology of septic shock syndrome in human, and tumor promotion. Pain response was gauged using verbal pain scores (on a 0- to 10-point scale, where 0 = no pain and 10 = worst pain) at rest and with activity at 24 hours after surgery and analgesic consumption of volume of epidural analgesic solution for the first 24 hours after surgery. RESULTS: No correlation was found between BMI and postoperative spontaneous circulating cytokine levels. However, after activation of blood leukocytes with lipopolysaccharide, there was a significant positive correlation between the BMI and IL-1ß, IL-6, and TNF-α levels (r = 0.26-0.32; p = 0.03, p = 0.03, and p = 0.01, respectively), suggesting priming of the innate immune system in obesity and potential for excessive postoperative inflammatory response. Obesity was not associated with increased pain or analgesic consumption in the first 24 hours after surgery. CONCLUSIONS: Obesity is associated with a proinflammatory state after THA as demonstrated by enhanced cytokine reactivity. Larger studies exploring the specific impact of obesity and inflammation on surgical outcomes, including pain, are warranted. LEVEL OF EVIDENCE: Level II, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Perioperative comparative effectiveness of anesthetic technique in orthopedic patients.

BACKGROUND: The impact of anesthetic technique on perioperative outcomes remains controversial. We studied a large national sample of primary joint arthroplasty recipients and hypothesized that neuraxial anesthesia favorably influences perioperative outcomes. METHODS: Data from approximately 400 hospitals between 2006 and 2010 were accessed. Patients who underwent primary hip or knee arthroplasty were identified and subgrouped by anesthesia technique: general, neuraxial, and combined neuraxial-general. Demographics, postoperative complications, 30-day mortality, length of stay, and patient cost were analyzed and compared. Multivariable analyses were conducted to identify the independent impact of choice of anesthetic on outcomes. RESULTS: Of 528,495 entries of patients undergoing primary hip or knee arthroplasty, information on anesthesia type was available for 382,236 (71.4%) records. Eleven percent were performed under neuraxial, 14.2% under combined neuraxial-general, and 74.8% under general anesthesia. Average age and comorbidity burden differed modestly between groups. When neuraxial anesthesia was used, 30-day mortality was significantly lower (0.10, 0.10, and 0.18%; P < 0.001), as was the incidence of prolonged (>75th percentile) length of stay, increased cost, and in-hospital complications. In the multivariable regression, neuraxial anesthesia was associated with the most favorable complication risk profile. Thirty-day mortality remained significantly higher in the general compared with the neuraxial or neuraxial-general group for total knee arthroplasty (adjusted odds ratio [OR] of 1.83, 95% CI 1.08-3.1, P = 0.02; OR of 1.70, 95% CI 1.06-2.74, P = 0.02, respectively). CONCLUSIONS: The utilization of neuraxial versus general anesthesia for primary joint arthroplasty is associated with superior perioperative outcomes. More research is needed to study potential mechanisms for these findings.

Predictors for moderate to severe acute postoperative pain after total hip and knee replacement.

PURPOSE: The ability to identify and focus care to patients at higher risk of moderate to severe postoperative pain should improve analgesia and patient satisfaction, and may affect reimbursement. We undertook this multi-centre cross-sectional study to identify preoperative risk factors for moderate to severe pain after total hip (THR) and knee (TKR) replacement. METHODS: A total of 897 patients were identified from electronic medical records. Preoperative information and anaesthetic technique was gained by retrospective chart review. The primary outcomes were moderate to severe pain (pain score ≥ 4/10) at rest and with activity on postoperative day one. Logistic regression was performed to identify predictors for moderate to severe pain. RESULTS: Moderate to severe pain was reported by 20 % at rest and 33 % with activity. Predictors for pain at rest were female gender (OR 1.10 with 95 % CI 1.01-1.20), younger age (0.96, 0.94-0.99), increased BMI (1.02, 1.01-1.03), TKR vs. THR (3.21, 2.73-3.78), increased severity of preoperative pain at the surgical site (1.15, 1.03-1.30), preoperative use of opioids (1.63, 1.32-2.01), and general anaesthesia (8.51, 2.13-33.98). Predictors for pain with activity were TKR vs. THR (1.42, 1.28-1.57), increased severity of preoperative pain at the surgical site (1.11, 1.04-1.19), general anaesthesia (9.02, 3.68-22.07), preoperative use of anti-convulsants (1.78, 1.32-2.40) and anti-depressants (1.50, 1.08-2.80), and prior surgery at the surgical site (1.28, 1.05-1.57). CONCLUSIONS: Our findings provide clinical guidance for preoperative stratification of patients for more intensive management potentially including education, nursing staffing, and referral to specialised pain management.

Performance characteristics and validation of the Opioid-Related Symptom Distress Scale for evaluation of analgesic side effects after orthopedic surgery.

BACKGROUND: The Opioid-Related Symptom Distress Scale (ORSDS) is a 4-point scale that evaluates 3 symptom distress dimensions (frequency, severity, bothersomeness) for 12 symptoms. The symptom-specific ORSDS is the average of the 3 symptom distress dimensions. The composite ORSDS is the average of 12 symptom-specific scores. The ORSDS was validated for outpatient laparoscopic cholecystectomy (under general anesthesia) by assessment of internal consistency, content validity, construct validity, principal components analysis, known group validity, responsiveness, and opioid dose dependency. Additional validation studies were suggested. We investigated performance characteristics and validity of the ORSDS for postoperative analgesia after 4 types of anesthetic and analgesic regimens. METHODS: The ORSDS and validation questions were administered to 4 groups of 50 orthopedic patients. Peripheral nerve blockade (Peripheral) was performed for distal upper extremity surgery; neuraxial anesthesia (Neuraxial) was performed for anterior cruciate ligament reconstruction; combined spinal-epidural anesthesia/femoral nerve block/epidural analgesia (Regional) was performed for total knee arthroplasty; and general anesthesia/IV opioids (GA) was performed for posterior lumbar spine fusion. All patients also received oral opioid analgesics. RESULTS: Median composite ORSDS scores on postoperative day 1 were 0.19 (Peripheral), 0.52 (Neuraxial), 0.51 (Regional), and 0.94 (GA). The following symptoms had median symptom-specific ORSDS scores >0: Neuraxial = drowsiness, dry mouth; Regional = dizziness, dry mouth; GA = nausea, fatigue, dizziness, drowsiness, dry mouth. Problematic symptoms (symptoms for which at least 25%of patients reported symptom-specific ORSDS scores >1) were: all groups = drowsiness, dry mouth, fatigue; Neuraxial = nausea, dizziness, itchiness; Regional = nausea, dizziness, itchiness; GA = difficulty concentrating, headache, nausea, dizziness, itchiness. High symptom-specific ORSDS scores were associated with clinically meaningful adverse events. In some cases, relevant ORSDS scores were related to activity level, patient satisfaction, and nausea and vomiting measures. Many components occurred in correlated clusters. Responsiveness statistics (the ability of an instrument to detect changes once they have occurred) were high for nausea and vomiting. Linear regression analysis indicated that opioid use was associated with composite ORSDS scores for Peripheral, Regional, and GA. CONCLUSIONS: Validity of the ORSDS was supported by predetermined validation criteria, including measures of internal consistency, content validity, construct validity, principal components analysis, known group validity, responsiveness, and correlation with opioid intake. The ORSDS is a valid tool for assessment of opioid side effects after orthopedic surgery, and can be used in clinical trials involving a wide variety of anesthetic and analgesic regimens.

A prospective survey of patient-controlled epidural analgesia with bupivacaine and clonidine after total hip replacement: a pre- and postchange comparison with bupivacaine and hydromorphone in 1,000 patients.

BACKGROUND AND OBJECTIVES: Patient-controlled epidural analgesia (PCEA) with bupivacaine and hydromorphone provides high quality analgesia after orthopedic surgery but is associated with a frequent incidence of opioid-related side effects (15%-30%). Epidural clonidine has a different side effect profile, but there are no large surveys documenting its use. We performed this prospective survey to evaluate analgesia and the side effect profile in total hip replacement patients before and after a systematic change from PCEA with bupivacaine/hydromorphone to bupivacaine/clonidine. METHODS: Five hundred consecutive patients received PCEA with 0.06% bupivacaine and hydromorphone (10 mcg/mL) as a previously described prechange control group. The standard analgesic regimen was then systematically changed to 0.06% bupivacaine and clonidine (1 mcg/mL) without changing the PCEA settings or other aspects of perioperative care, and 500 consecutive patients were included as a postchange group. All data were prospectively entered and then abstracted from the electronic medical record. Data collection included daily verbal pain scores (VPS), pruritus, nausea, hypotension, need for IV fluid boluses, sedation, and respiratory depression. An online survey to measure staff satisfaction with the changeover was sent to all participating surgeons, anesthesiologists, physical therapists, and physician's assistants. RESULTS: Patient characteristics were similar between groups. Most patients received central neuraxial anesthesia (99%). The clonidine group had lower VPS at rest (2.3 vs 3.7, P<0.001 with 95% confidence interval [CI] of difference of 1.4 [1.1, 1.7]) on POD0. The incidence of nausea was 10%-11% for clonidine and 13%-15% for hydromorphone. The incidence of pruritus was less with clonidine (1 vs 10%, P<0.01 with 95% CI of difference of 9% [6, 12]). However, the incidence of hypotension (20 vs 11%, P<0.001 with 95% CI of differences 9% [5, 14]) and IV fluid boluses was more frequent with clonidine (36 vs 19%, P<0.001 with 95% CI of differences of 16 [11, 12]). Sixty-five percent of staff completed the online survey, and 70% considered clonidine worse than hydromorphone. CONCLUSION: The systematic changeover from epidural hydromorphone to clonidine produced mixed results without obvious superiority. The VPS at rest was reduced only on postoperative day 0; pruritus was reduced, but hypotension was increased. On the basis of medical staff preference, we discontinued the systematic change and returned to our previous standard solution of bupivacaine and hydromorphone for PCEA after total hip replacement.

Perioperative pulmonary outcomes in patients with sleep apnea after noncardiac surgery.

BACKGROUND: Although patients with sleep apnea (SA) are considered to be at increased risk for postoperative complications, evidence supporting increased risk of perioperative pulmonary morbidity is limited. The objective of this study, therefore, was to analyze perioperative demographics and pulmonary outcomes of patients with SA after orthopedic and general surgical procedures using a population-based sample. We hypothesized that SA is an independent risk factor for perioperative pulmonary complications, thus providing a basis for an increase in the utilization of resources, including intensive monitoring and development of strategies to prevent and treat these events. METHODS: National Inpatient Sample data for each year between 1998 and 2007 were accessed. Orthopedic and general surgical procedures were included and discharges with a diagnosis code for SA were identified. Patients with the diagnosis of SA were matched to those without the disease based on demographic variables using the propensity scoring method. Aspiration pneumonia, adult respiratory distress syndrome (ARDS), pulmonary embolism (PE), and the need for intubation and mechanical ventilation were the primary outcomes. Odds ratio (OR) and absolute risk reduction along with 95% confidence interval were reported. RESULTS: We identified 2,610,441 entries for orthopedic and 3,441,262 for general surgical procedures performed between 1998 and 2007. Of those, 2.52% and 1.40%, respectively, carried a diagnosis of SA. Patients with SA developed pulmonary complications more frequently than their matched controls after both orthopedic and general surgical procedures, respectively (i.e., aspiration pneumonia: 1.18% vs 0.84% and 2.79% vs 2.05%; ARDS: 1.06% vs 0.45% and 3.79% vs 2.44%; intubation/mechanical ventilation: 3.99% vs 0.79% and 10.8% vs 5.94%, all P values <0.0001). Comparatively, PE was more frequent in SA patients after orthopedic procedures (0.51% vs 0.42%, P = 0.0038) but not after general surgical procedures (0.45% vs 0.49%, P = 0.22). SA was associated with a significantly higher adjusted OR of developing pulmonary complications after both orthopedic and general surgical procedures, respectively, with the exception of PE (OR for aspiration pneumonia: 1.41 [1.35, 1.47] and 1.37 [1.33, 1.41]; for ARDS: 2.39 [2.28, 2.51] and 1.58 [1.54, 1.62]; for PE: OR 1.22 [1.15, 1.29] and 0.90 [0.84, 0.97]; for intubation/mechanical ventilation: 5.20 [5.05, 5.37] and 1.95 [1.91, 1.98]). CONCLUSION: SA is an independent risk factor for perioperative pulmonary complications. Our results may be used for hypothesis generation for clinical studies targeted to improve perioperative outcomes in this patient population.

Cerebral oximetry desaturation during shoulder surgery performed in a sitting position under regional anesthesia.

PURPOSE: Hypotension in the sitting position may reduce cerebral perfusion and oxygenation. We prospectively determined the incidence of cerebral oximetry (rSO2) desaturation in seated patients undergoing ambulatory shoulder arthroscopy. METHODS: A cohort of 99 patients received regional anesthesia and intravenous sedation, and their blood pressure was recorded every five minutes. Hypotension was defined as the occurrence of any of the following: > 30% decline in mean arterial pressure (MAP), systolic blood pressure < 90 mmHg, or MAP <66 mmHg. Cerebral desaturation was defined as a > 20% decrease in rSO2 from baseline. The association of rSO2 desaturation with potential risk factors was examined by the generalized estimating equation to account for within patient correlation and multiple observations per patient. We fitted desaturation with three models: 1) unadjusted (i.e., hypotension as sole regressor); 2) time-trend adjusted; and 3) baseline-factors adjusted model. RESULTS: Hypotension occurred in 76% of observations (mean duration 4,261 sec), but cerebral desaturation was seen in only 0.77% of observations (mean duration 426 sec). Ninety-nine percent of patients experienced hypotension, but cerebral desaturation occurred in only 10%. By unadjusted modelling, hypotension was associated with cerebral desaturation (odds ratio = 3.21; P = 0.02). Once time-trend adjusted, cerebral desaturation was associated with time from baseline but not with hypotension (P = 0.14). When adjusted for baseline factors, the analysis demonstrated a non-significant association with hypotension (P = 0.34) but a significant association with the presence of risk factors for cerebrovascular disease (P = 0.01). CONCLUSIONS: Despite frequent hypotension in the sitting position, rSO2 desaturation was uncommon during shoulder arthroscopy performed in the sitting position with regional anesthesia.

A prospective clinical registry of ultrasound-guided regional anesthesia for ambulatory shoulder surgery.

BACKGROUND: There is a lack of clinical registries to document efficacy and safety of ultrasound-guided regional anesthesia. Interscalene blocks are effective for shoulder arthroscopy, and ultrasound guidance may reduce risk. Furthermore, ultrasound-guided supraclavicular block is a novel approach for shoulder anesthesia that may have less risk for neurological symptoms than interscalene block. METHODS: One thousand one hundred sixty-nine patients undergoing ultrasound-guided regional anesthesia for ambulatory shoulder arthroscopy were enrolled in our prospective registry. Standardized perioperative data were collected including a preoperative neurological screening tool. Either interscalene or supraclavicular block was performed at the discretion of the clinical team. Standardized follow-up was performed in the postanesthesia care unit and at 1 week. Postoperative neurological symptoms (PONS) were assessed at the 1-week follow-up with the same screening tool by a blinded neurologist. RESULTS: Ultrasound-guided interscalene (n = 515) and supraclavicular (n = 654) blocks had excellent anesthetic success (99.8%; 95% confidence interval [CI], 99.4%-99.9%) with 0% (95% CI, 0%-0.3%) incidence of vascular puncture or intravascular injection. The incidence of hoarseness in the postanesthesia care unit was significantly less with supraclavicular (22% with 95% CI, 19%-26%) than interscalene block (31% with 95% CI, 27%-35%). The incidence of dyspnea was similar (7% for supraclavicular vs 10% with interscalene). No patient had a clinically apparent pneumothorax. The incidence of PONS was very low (0.4% with 95% CI, 0.1%-1%), and there was a 0% (95% CI, 0%-0.3%) incidence of permanent nerve injury. CONCLUSIONS: Ultrasound-guided interscalene and supraclavicular blocks are effective and safe for shoulder arthroscopy. Temporary and permanent PONS is uncommon.

A prospective, randomized, controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory shoulder surgery for postoperative neurological symptoms.

BACKGROUND: Visualization with ultrasound during regional anesthesia may reduce the risk of intraneural injection and subsequent neurological symptoms but has not been formally assessed. Thus, we performed this randomized clinical trial comparing ultrasound versus nerve stimulator-guided interscalene blocks for shoulder arthroscopy to determine whether ultrasound could reduce the incidence of postoperative neurological symptoms. METHODS: Two hundred thirty patients were randomized to a standardized interscalene block with either ultrasound or nerve stimulator with a 5 cm, 22 g Stimuplex insulated needle with 1.5% mepivacaine with 1:300,000 epinephrine and NaCO3 (1 meq/10 mL). A standardized neurological assessment tool (questionnaire and physical examination) designed by a neurologist was administered before surgery (both components), at approximately 1 wk after surgery (questionnaire), and at approximately 4-6 weeks after surgery (both components). Diagnosis of postoperative neurological symptoms was determined by a neurologist blinded to block technique. RESULTS: Two hundred nineteen patients were evaluated. Use of ultrasound decreased the number of needle passes for block performance (1 vs 3, median, P < 0.001), enhanced motor block at the 5-min assessment (P = 0.04) but did not decrease block performance time (5 min for both). No patient required conversion to general anesthesia for failed block, and patient satisfaction was similar in both groups (96% nerve stimulator and 92% ultrasound). The incidence of postoperative neurological symptoms was similar at 1 wk follow-up with 11% (95% CI of 5%-17%) for nerve stimulator and 8% (95% CI of 3%-13%) for ultrasound and was similar at late follow-up with 7% (95% CI of 3%-12%) for nerve stimulator and 6% (95% CI of 2%-11%) for ultrasound. The severity of postoperative neurological symptoms was similar between groups with a median patient rating of moderate. Symptoms were primarily sensory and consisted of pain, tingling, or paresthesias. CONCLUSIONS: Ultrasound reduced the number of needle passes needed to perform interscalene block and enhanced motor block at the 5 min assessment; however, we did not observe significant differences in block failures, patient satisfaction or incidence, and severity of postoperative neurological symptoms.

Trends in mortality, complications, and demographics for primary hip arthroplasty in the United States.

To determine trends in characteristics of total hip arthroplasty (THA) in the United States, the National Hospital Discharge Survey (NHDS) was analyzed from 1990 to 2004 for trends in in-hospital mortality and complications, length of hospital stay, demographics, and comorbidities. The number of THAs performed increased by 158%, whereas mortality rates remained low and slightly decreased (from 0.32% to 0.29%). Prevalence of procedure-related complications decreased over time, and length of stay decreased from an average of 8.7 days to 4.5 days. These improvements occurred despite an increase in comorbidities in patients. An increase in both the proportion of discharges to long- and short-term care facilities and in the proportion of procedures performed in smaller hospitals was noted. Multiple temporal changes in outcomes and demographics for THA were found. These changes have implications for clinical care and allocation of health resources.

The effect of analgesic technique on postoperative patient-reported outcomes including analgesia: a systematic review.

BACKGROUND: The effect of postoperative analgesia on patient-reported outcomes, such as quality of life, quality of recovery, and patient satisfaction, has not been systematically examined. These outcomes are assessed from the patient's perspective and are recognized as valid and important end-points in clinical medicine and research. We performed a systematic review to examine the effect of postoperative analgesia on patient-reported outcomes. METHODS: The National Library of Medicine's Medline and the Cochrane Library databases were searched for the past decade (Jan, 1996 to Jun 1, 2006). Additional Medline searches for specific outcomes (i.e., satisfaction, quality of life, and quality of recovery) were also conducted. RESULTS: Regional analgesic techniques provide statistically superior analgesia compared with systemic opioids. There are insufficient data to determine if the type of analgesic technique, degree of analgesia, and presence of side effects may influence quality of life, quality of recovery, satisfaction, and length of stay, due in part to some significant methodologic issues. CONCLUSIONS: Although there are data suggesting that improved postoperative analgesia leads to better patient outcomes, there is insufficient evidence to support subsequent improvements inpatient-centered outcomes such as quality of life and quality of recovery. Modest reductions in pain scores do not necessarily equate to clinically meaningful improved pain relief for the patient. Further studies are needed to develop validated patient-reported instruments and to assess the effect of analgesic techniques on patient-reported outcomes in the perioperative period.

Effect of postoperative analgesia on major postoperative complications: a systematic update of the evidence.

BACKGROUND: Few individual clinical trials have had sufficient subject numbers to definitively determine the effects of postoperative analgesia on major outcomes. METHODS: We systematically searched the Medline and the Cochrane Library databases for the past decade and focused on meta-analyses and large, randomized, controlled trials. RESULTS: Eighteen meta-analyses, 10 systematic reviews, 8 additional randomized, controlled trials, and 2 observational database articles were identified for review or comment. Epidural analgesia with local anesthetics has the greatest theoretical potential to affect major outcomes and has been the most thoroughly investigated technique. The majority of evidence favors an ability of epidural analgesia to reduce postoperative cardiovascular and pulmonary complications only after major vascular surgery or in high-risk patients. This finding may become irrelevant because of rapid conversion of major surgery to minimally invasive techniques (e.g., endoluminal abdominal aortic repair) that carry less risk of complications. There is also consistent evidence that epidural analgesia with local anesthetics is associated with faster resolution of postoperative ileus after major abdominal surgery. Again, this finding may also become irrelevant with the adoption of laparoscopic techniques and multimodal fast-track programs for abdominal surgery. There is no current evidence that perineural analgesia, continuous wound catheters using local anesthetics, IV patient-controlled analgesia with opioids, or addition of multimodal systemic analgesics have any clinically significant beneficial effect on postoperative complications. CONCLUSIONS: Overall, there is insufficient evidence to confirm or deny the ability of postoperative analgesic techniques to affect major postoperative mortality or morbidity. This is primarily due to typically insufficient subject numbers to detect differences in currently low incidences of postoperative complications.