Prolonged Opioid Use and Pain Outcome and Associated Factors after Surgery under General Anesthesia: A Prospective Cohort Association Multicenter Study.

BACKGROUND: There is insufficient prospective evidence regarding the relationship between surgical experience and prolonged opioid use and pain. The authors investigated the association of patient characteristics, surgical procedure, and perioperative anesthetic course with postoperative opioid consumption and pain 3 months postsurgery. The authors hypothesized that patient characteristics and intraoperative factors predict opioid consumption and pain 3 months postsurgery. METHODS: Eleven U.S. and one European institution enrolled patients scheduled for spine, open thoracic, knee, hip, or abdominal surgery, or mastectomy, in this multicenter, prospective observational study. Preoperative and postoperative data were collected using patient surveys and electronic medical records. Intraoperative data were collected from the Multicenter Perioperative Outcomes Group database. The association between postoperative opioid consumption and surgical site pain at 3 months, elicited from a telephone survey conducted at 3 months postoperatively, and demographics, psychosocial scores, pain scores, pain management, and case characteristics, was analyzed. RESULTS: Between September and October 2017, 3,505 surgical procedures met inclusion criteria. A total of 1,093 cases were included; 413 patients were lost to follow-up, leaving 680 (64%) for outcome analysis. Preoperatively, 135 (20%) patients were taking opioids. Three months postsurgery, 96 (14%) patients were taking opioids, including 23 patients (4%) who had not taken opioids preoperatively. A total of 177 patients (27%) reported surgical site pain, including 45 (13%) patients who had not reported pain preoperatively. The adjusted odds ratio for 3-month opioid use was 18.6 (credible interval, 10.3 to 34.5) for patients who had taken opioids preoperatively. The adjusted odds ratio for 3-month surgical site pain was 2.58 (1.45 to 4.4), 4.1 (1.73 to 8.9), and 2.75 (1.39 to 5.0) for patients who had site pain preoperatively, knee replacement, or spine surgery, respectively. CONCLUSIONS: Preoperative opioid use was the strongest predictor of opioid use 3 months postsurgery. None of the other variables showed clinically significant association with opioid use at 3 months after surgery.

The effect of audiovisual distraction on patient-controlled sedation under spinal anesthesia: a prospective, randomized trial.

Audiovisual distraction (AVD) has been used to augment or replace procedural sedation. We investigated whether AVD in patients having total hip (THA) or total knee arthroplasty (TKA) under spinal anesthesia would reduce self-administered propofol consumption during surgery. 50 participants were randomized equally into a patient-controlled sedation (PCS) group or AVD group. All participants were given a spinal block and a propofol PCS device prior to surgery. In addition, Group AVD participants selected and watched a movie or documentary film on a tablet device with noise-cancelling headphones during surgery. The primary outcome of this study was total propofol consumption standardized as mcg/kg/min. Secondary outcomes evaluated increased supplemental oxygen use, rescue airway interventions, hypotension, disruptive movement events during surgery, sedation, and satisfaction with anesthesia scores. Historical clinician-controlled propofol usage at our institution over the previous 2 years were recorded. There was no significant difference in median propofol consumption between Groups PCS and AVD, 8.4 mcg/kg/min (1.6-18.9) vs 4 mcg/kg/min (0-9) (P = 0.29), respectively. Historical clinician-controlled usage of propofol demonstrated a median of 39.3 mcg/kg/min (29.2-51.2). There were few differences in the secondary outcome measures. The use of AVD did not reduce patient-controlled propofol consumption in patients having a THA or TKA surgery under spinal anesthesia.

Observation of Complement Protein Gene Expression Before and After Surgery in Opioid-Consuming and Opioid-Naive Patients.

Opioids may influence inflammation. We compared genes associated with pain and inflammation in patients who consumed opioids (3-120 mg of oral morphine equivalents per day) with those who did not for differential expression. White blood cells were assayed in 20 patients presenting for total lower extremity joint replacement. We focused on messenger ribonucleic acid expression of complement proteins. We report that the expression of a complement inhibitor, complement 4 binding protein A, was reduced, and the expression of a complement activator, complement factor D, was increased in opioid-consuming patients. We conclude that opioid consumption may influence expression of complement activators and inhibitors.

A Comparison of the Open Semi-extended Parapatellar Versus Standard Entry Tibial Nailing Techniques and Knee Pain: A Randomized Controlled Trial.

OBJECTIVE: To determine if an open, semi-extended, parapatellar tibial nailing technique (SEK) imparts any undue knee symptoms/pain compared with the traditional infrapatellar tibial nailing technique (FK). DESIGN: Randomized controlled trial. SETTING: Level 1 trauma center. PATIENTS: Forty-seven patients with OTA/AO 42A-C tibial shaft fractures were included in the study. INTERVENTION: Patients were randomized to treatment with either a SEK or an FK technique. MAIN OUTCOME: The main outcome was a symptoms subset of the International Knee Documentation Committee (SS-IKDC) pertaining to knee symptoms/pain. RESULTS: Final follow-up was collected at 1 year for 24 SEK and 23 FK patients. No significant differences were found between the groups in regards to demographics, injury, or surgery-related variables. The 2 techniques did have equivalent symptoms scores [mean for the difference (SEK - FK): 0.29, 90% confidence interval: -4.16 to 4.75] but did not have equivalent pain scores [mean for the difference (SEK - FK): 0.2, 90% confidence interval: -3.18 to 3.59]. When comparing demographic and injury-related variables to the SS-IKDC, only Kellgren-Lawrence classification was statistically significant (P = 0.026), where increasing presence of osteoarthritis was associated with lower scores. CONCLUSIONS: The results of this single-center randomized controlled trial show that SEK and FK techniques for tibial nailing are equivalent in regards to knee symptoms (defined as ±5 points on the SS-IKDC) but not specifically pain that showed trends toward decreasing knee pain with the open SEK technique. This randomized controlled trial demonstrates that the use of the open semi-extended, parapatellar technique for tibial nailing should not be associated with any higher likelihood of knee pain/symptoms than the traditional flexed knee, infrapatellar technique. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.