Assessment of main complications of regional anesthesia recorded in an acute pain unit in a tertiary care university hospital: a retrospective cohort

Abstract Background Regional anesthesia has been increasingly used. Despite its low number of complications, they are associated with relevant morbidity. This study aims to evaluate the incidence of complications after neuraxial block and peripheral nerve block. Methods A retrospective cohort study was conducted, and data related to patients submitted to neuraxial block and peripheral nerve block at a tertiary university hospital from January 1, 2011 to December 31, 2017 were analyzed. Results From 10,838 patients referred to Acute Pain Unit, 1093(10.1%) had side effects or complications: 1039 (11.4%) submitted to neuraxial block and 54 (5.2%) to peripheral nerve block. The most common side effects after neuraxial block were sensory (48.5%) or motor deficits (11.8%), nausea or vomiting (17.5%) and pruritus (8.0%); The most common complications: 3 (0.03%) subcutaneous cell tissue hematoma, 3 (0.03%) epidural abscesses and 1 (0.01%) arachnoiditis. 204 of these patients presented sensory or motor deficits at hospital discharge and needed follow-up. Permanent peripheral nerve injury after neuraxial block had an incidence of 7.7:10,000 (0.08%). The most common side effects after peripheral nerve block were sensory deficits (52%) and 21 patients maintained follow-up due to symptoms persistence after hospital discharge. Conclusion Although we found similar incidences of side effects or even lower than those described, major complications after neuraxial block had a higher incidence, particularly epidural abscesses. Despite this, other serious complications, such as spinal hematoma and permanent peripheral nerve injury, are still rare.

The Value Proposition of Observation Medicine in Managing Acute Oncologic Pain.

PURPOSE OF REVIEW: Despite recommended best practice guidelines, pain remains an ongoing but undertreated symptom in patients with cancer, many of whom require emergency department evaluation for acute oncologic pain. A significant proportion of these patients are hospitalized for pain management, which increases healthcare costs and exposes patients to the risks of hospitalization. We reviewed the literature on observation medicine: an emerging mode of healthcare delivery which can offer patients with acute pain access to a hospital's pain management solutions and specialists without an inpatient hospitalization. Specifically, we appraised the role of observation medicine in acute pain management and its financial implications in order to consider its potential impact on the management of acute oncologic pain. RECENT FINDINGS: Recent evidence shows that observation medicine has the potential to decrease short-stay hospitalizations in cancer patients presenting with various concerns, including pain. Observation medicine is reported to be successful in providing comprehensive and cost-effective care for non-cancer patients with acute pain, making it a promising alternative to short-stay hospitalizations for cancer patients with acute oncologic pain.

Assessment of main complications of regional anesthesia recorded in an acute pain unit in a tertiary care university hospital: a retrospective cohort.

BACKGROUND: Regional anesthesia has been increasingly used. Despite its low number of complications, they are associated with relevant morbidity. This study aims to evaluate the incidence of complications after neuraxial block and peripheral nerve block. METHODS: A retrospective cohort study was conducted, and data related to patients submitted to neuraxial block and peripheral nerve block at a tertiary university hospital from January 1, 2011 to December 31, 2017 were analyzed. RESULTS: From 10,838 patients referred to Acute Pain Unit, 1093(10.1%) had side effects or complications: 1039 (11.4%) submitted to neuraxial block and 54 (5.2%) to peripheral nerve block. The most common side effects after neuraxial block were sensory (48.5%) or motor deficits (11.8%), nausea or vomiting (17.5%) and pruritus (8.0%); The most common complications: 3 (0.03%) subcutaneous cell tissue hematoma, 3 (0.03%) epidural abscesses and 1 (0.01%) arachnoiditis. 204 of these patients presented sensory or motor deficits at hospital discharge and needed follow-up. Permanent peripheral nerve injury after neuraxial block had an incidence of 7.7:10,000 (0.08%). The most common side effects after peripheral nerve block were sensory deficits (52%) and 21 patients maintained follow-up due to symptoms persistence after hospital discharge. CONCLUSION: Although we found similar incidences of side effects or even lower than those described, major complications after neuraxial block had a higher incidence, particularly epidural abscesses. Despite this, other serious complications, such as spinal hematoma and permanent peripheral nerve injury, are still rare.

Towards an improved pain assessment in castrated horses using facial expressions (HGS) and circulating miRNAs.

BACKGROUND: Pain in horses is an emergent welfare concern, and its assessment represents a challenge for equine clinicians. This study aimed at improving pain assessment in horses through a convergent validation of existing tools: we investigated whether an effective analgesic treatment influences the horse grimace scale (HGS) and the concentration of specific circulating microRNAs (miRNAs). METHODS: Eleven stallions underwent routine surgical castration under general anaesthesia. They were divided into two analgesic treatment groups: castration with the administration of preoperative flunixin and castration with preoperative flunixin plus a local injection of mepivacaine into the spermatic cords. HGS and levels of seven circulating miRNAs were evaluated pre-, 8 and 20 hours post-procedure. RESULTS: Compared to pre-castration, HGS, miR-126-5p, miR-145 and miR-let7e increased significantly in horses receiving flunixin at 8 hours post-castration (Friedman test, p < 0.05). Both behavioural and molecular changes occurred in horses receiving flunixin only, confirming that the addition of local mepivacaine is an effective analgesic treatment. CONCLUSIONS: Combining the use of HGS and circulating miRNAs, particularly miR-145, could be meaningful to monitor acute pain conditions in horses. Our results further validate the HGS as a method to assess acute pain in horses and point out miR-145 as a promising biomarker to identify pain.

Impact of sickle cell disease on patients' daily lives, symptoms reported, and disease management strategies: Results from the international Sickle Cell World Assessment Survey (SWAY).

Sickle cell disease (SCD) is a genetic disorder, characterized by hemolytic anemia and vaso-occlusive crises (VOCs). Data on the global SCD impact on quality of life (QoL) from the patient viewpoint are limited. The international Sickle Cell World Assessment Survey (SWAY) aimed to provide insights into patient-reported impact of SCD on QoL. This cross-sectional survey of SCD patients enrolled by healthcare professionals and advocacy groups assessed disease impact on daily life, education and work, symptoms, treatment goals, and disease management. Opinions were captured using a Likert scale of 1-7 for some questions; 5-7 indicated "high severity/impact." Two thousand one hundred and forty five patients (mean age 24.7 years [standard deviation (SD) = 13.1], 39% ≤18 years, 52% female) were surveyed from 16 countries (six geographical regions). A substantial proportion of patients reported that SCD caused a high negative impact on emotions (60%) and school achievement (51%) and a reduction in work hours (53%). A mean of 5.3 VOCs (SD = 6.8) was reported over the 12 months prior to survey (median 3.0 [interquartile range 2.0-6.0]); 24% were managed at home and 76% required healthcare services. Other than VOCs, fatigue was the most commonly reported symptom in the month before survey (65%), graded "high severity" by 67% of patients. Depression and anxiety were reported by 39% and 38% of patients, respectively. The most common patient treatment goal was improving QoL (55%). Findings from SWAY reaffirm that SCD confers a significant burden on patients, epitomized by the high impact on patients' QoL and emotional wellbeing, and the high prevalence of self-reported VOCs and other symptoms.

Pediatric Dental Procedure-Related Pain Assessment Practices in A Rural Alaskan Health Care Organization: A Qualitative Study.

Purpose: Acute pain experienced during dental procedures can lead to distress, difficulty with behavior guidance, and dental fear/avoidance. The purpose of this study was to explore dental providers' perceptions of pediatric procedure-related pain and acute pain assessment practices. Methods: Fifteen dental providers (53 percent female; nine dentists, three dental therapists, three dental hygienists) currently/formerly employed by a single rural Alaskan health care organization were interviewed using a semi-structured guide. Recorded interviews were transcribed, verified, and coded using inductive qualitative analytic methods. Results: Six providers suggested that pediatric procedure-related pain is rarely encountered. Providers who reported encountering it rely on observation of body language, facial expression, behavior, crying, and verbalization to know whether a child is experiencing procedural pain. Even when available, only four interviewees reported using standardized pain scales. Conclusions: Dental providers have mixed perceptions about whether they encounter pediatric procedure-related pain. There is high variability in how providersassess procedural pain, and approaches often are nonstandardized.

Assessment, Quantification, and Management of Fracture Pain: from Animals to the Clinic.

PURPOSE OF REVIEW: Fractures are painful and disabling injuries that can occur due to trauma, especially when compounded with pathologic conditions, such as osteoporosis in older adults. It is well documented that acute pain management plays an integral role in the treatment of orthopedic patients. There is no current therapy available to completely control post-fracture pain that does not interfere with bone healing or have major adverse effects. In this review, we focus on recent advances in the understanding of pain behaviors post-fracture. RECENT FINDINGS: We review animal models of bone fracture and the assays that have been developed to assess and quantify spontaneous and evoked pain behaviors, including the two most commonly used assays: dynamic weight bearing and von Frey testing to assess withdrawal from a cutaneous (hindpaw) stimulus. Additionally, we discuss the assessment and quantification of fracture pain in the clinical setting, including the use of numeric pain rating scales, satisfaction with pain relief, and other biopsychosocial factor measurements. We review how pain behaviors in animal models and clinical cases can change with the use of current pain management therapies. We conclude by discussing the use of pain behavioral analyses in assessing potential therapeutic treatment options for addressing acute and chronic fracture pain without compromising fracture healing. There currently is a lack of effective treatment options for fracture pain that reliably relieve pain without potentially interfering with bone healing. Continued development and verification of reliable measurements of fracture pain in both pre-clinical and clinical settings is an essential aspect of continued research into novel analgesic treatments for fracture pain.

Multiple criteria decision analysis approach to consider therapeutic innovations in the emergency department: The methoxyflurane organizational impact in acute trauma pain.

BACKGROUND: Acute trauma pain is poorly managed in the emergency department (ED). The reasons are partly organizational: ED crowding and rare trauma care pathways contribute to oligoanalgesia. Anticipating the organizational impact of an innovative care procedure might facilitate the decision-making process and help to optimize pain management. METHODS: We used a multiple criteria decision analysis (MCDA) approach to consider the organizational impact of methoxyflurane (self-administered) in the ED, introduced alone or supported by a trauma care pathway. A MCDA experiment was designed for this specific context, 8 experts in emergency trauma care pathways (leading physicians and pharmacists working in French urban tertiary hospitals) were recruited. The study involved four steps: (i) Selection of organizational criteria for evaluating the innovation's impact; (ii) assessment of the relative weight of each criterion; (iii) choice of appropriate scenarios for exploring the organizational impact of MEOX under various contexts; and (iv) software-assisted simulation based on pairwise comparisons of the scenarios. The final outcome measure was the expected overall organizational impact of methoxyflurane on a 0-to-100 scale (score >50: positive impact). RESULTS: Nine organizational criteria were selected. "Mean length of stay in the ED" was the most weighted. Methoxyflurane alone obtained 59 as a total score, with a putative positive impact for eight criteria, and a neutral effect on one. When a trauma care pathway was introduced concomitantly, the impact of methoxyflurane was greater overall (score: 75) and for each individual criterion. CONCLUSIONS: Our model highlighted the putative positive organizational impact of methoxyflurane in the ED-particularly when supported by a trauma care pathway-and the relevance of expert consensus in this particular pharmacoeconomic context. The MCDA approach could be extended to other research fields and healthcare challenges in emergency medicine.

In-Hospital Cost Comparison of Triple-Rule-Out Computed Tomography Angiography Versus Standard of Care in Patients With Acute Chest Pain.

PURPOSE: The purpose of this study was to evaluate the utilization of invasive and noninvasive tests and compare cost in patients presenting with chest pain to the emergency department (ED) who underwent either triple-rule-out computed tomography angiography (TRO-CTA) or standard of care. MATERIALS AND METHODS: We performed a retrospective single-center analysis of 2156 ED patients who presented with acute chest pain with a negative initial troponin and electrocardiogram for myocardial injury. Patient cohorts matched by patient characteristics who had undergone TRO-CTA as a primary imaging test (n=1139) or standard of care without initial CTA imaging (n=1017) were included in the study. ED visits, utilization of tests, and costs during the initial episode of hospital care were compared. RESULTS: No significant differences in the diagnosis of coronary artery disease, pulmonary embolism, or aortic dissection were observed. Median ED waiting time (4.5 vs. 7.0 h, P<0.001), median total length of hospital stay (5.0 vs. 32.0 h, P<0.001), hospital admission rate (12.6% vs. 54.2%, P<0.001), and ED return rate to our hospital within 30 days (3.5% vs. 14.6%, P<0.001) were significantly lower in the TRO-CTA group. Moreover, reduced rates of additional testing and invasive coronary angiography (4.9% vs. 22.7%, P<0.001), and ultimately lower total cost per patient (11,783$ vs. 19,073$, P<0.001) were observed in the TRO-CTA group. CONCLUSIONS: TRO-CTA as an initial imaging test in ED patients presenting with acute chest pain was associated with shorter ED and hospital length of stay, fewer return visits within 30 days, and ultimately lower ED and hospitalization costs.

Pulse article: opioid prescription for pain after spinal cord damage (SCD), differences from recommended guidelines, and a proposed algorithm for the use of opioids for pain after SCD.

Study design: Online questionnaire of spinal cord injury (SCI) physicians. Objectives: The objective of this study is to characterize the approach to opioid prescription for persons with spinal cord damage (SCD). Setting: An international online questionnaire. Methods: A survey was posted online and circulated among international societies within the field of SCI medicine from August to November 2018. Results: One hundred and twenty-three physicians responded to the survey. Of these, 107 (92%) managed pain for persons with SCD. Most (82%) felt that opioid prescription was appropriate for uncontrolled acute pain, but fewer (67%) felt it was appropriate for chronic pain. Of those who felt opioids had a role in the treatment of neuropathic pain, 46% did not think there should be a specific upper limit of opioid dose. The majority (85%) would continue prescribing high doses (250 morphine milligram equivalent (MME) doses/day) if that dose were effective. Tramadol was the most common opioid prescribed first line. Conclusion: Most physicians who responded to this survey prescribe opioids for intractable pain after SCD. A significant proportion of respondents believed that there should not be a specific upper limit of opioid dose prescribed if the drug is tolerated; this does not align with current recommendations. Most physicians do not feel influenced in their prescribing habits by regulatory bodies. If physicians decide to taper an opioid that is being tolerated well, it is most commonly related to a fear of the patient developing an opioid-use disorder. The authors propose an algorithm that may help align practice patterns with current recommended practice guidelines.

Opioid prescriptions for acute pain after outpatient surgery at a large public university-affiliated hospital: Impact of state legislation in Florida.

BACKGROUND: In response to the growing opioid crisis, Florida recently implemented a law restricting the duration of opioid prescriptions for acute pain. Little is known about the impact of such legislation on opioid prescription practices at the time of discharge after surgery. The objective of this study was to determine whether Florida's new legislation changed opioid prescription practices for analgesia after surgery. METHODS: Adults 18 years of age and older undergoing cholecystectomy, appendectomy, hernia repair, hysterectomy, mastectomy, or lymph node dissection were included in this retrospective cohort study at a large public university-affiliated hospital. We analyzed opioid prescriptions on discharge after these common outpatient surgical procedures between June 1, 2017, and December 31, 2018. Florida House Bill 21 was passed on March 2, 2018, and subsequent implementation of this law took place on July 1, 2018. The law restricts the duration of opioid prescriptions for acute pain to 3 days, which can be extended up to a maximum of 7 days with additional documentation. The outcomes studied included the following: the proportion of patients receiving opioid prescriptions on discharge, total opioid dose prescribed, daily opioid dose prescribed, and the proportion of patients receiving more than a 3-day supply of opioids. We colledted data on emergency department cumulative visits within 7 and 30 days after discharge. Drug doses were converted to morphine milligram equivalents and calculated for each selected procedure. RESULTS: A total of 1,467 surgical encounters were included. The cohort was predominantly female (963 [65.6%]) with a mean (SD) age of 49.6 (14.4) years. At 6 months after implementation of HB 21, the proportion of patients receiving opioid prescriptions decreased by 21% (95% CI 16.8% to 25.3%, P < .001), mean total opioid dose prescribed decreased by 64.2 morphine milligram equivalents (95% CI 54.7 to 73.7, P < .001) from a baseline mean (SD) of 172.5 (78.9) morphine milligram equivalents. The mean daily opioid dose prescribed increased by 3.5 morphine milligram equivalents (95% CI 1.8 to 5.1, P < .001) from a baseline mean (SD) of 30.5 (9.4) morphine milligram equivalents. The proportion of patients receiving opioid prescriptions for longer than a 3-day supply decreased by 68% (95% CI 63.4% to 72.7%, P < .001). We observed no change in the number of postoperative emergency department visits before and after implementation of the law. CONCLUSION: Opioid prescriptions for patients undergoing common outpatient surgical procedures at a large public university-affiliated hospital in Florida were substantially reduced within 6 months after implementation of state legislation limiting the duration of opioid prescriptions. This reduction was not associated with an increase in the number of postoperative emergency department visits. The legislation should significantly decrease the amount of unused opioid pills potentially available for diversion and abuse. Secondary effects from the enactment of this law remain to be evaluated.

Prediction of Acute Postoperative Pain from Assessment of Pain Associated With Venous Cannulation.

BACKGROUND: It has previously been reported that venous cannulation-induced pain (VCP) can be used to predict acute postoperative pain after laparoscopic cholecystectomy. Patients rating VCP at ≥2.0 VAS units had 3.4 times higher risk for moderate or severe pain. The purpose of this study was to evaluate if VCP scores of ≥2.0 VAS units are associated with higher risk for acute postoperative pain after various common surgical procedures. METHODS: In a prospective clinical observational study, 600 male and female 18- to 80-year-old patients scheduled for elective surgery were included. The primary outcome measure was the difference in maximum postoperative pain intensity between low responders (VCP < 2.0) and high responders (VCP ≥ 2.0) to VCP. Secondary outcome measures were the difference in proportion of patients with moderate or severe postoperative pain between low and high responders, and potential influence of age, gender, and preoperative habitual pain. RESULTS: Patients scoring VCP ≥2.0 VAS units reported higher acute postoperative pain intensity levels than those scoring VCP <2.0 VAS units (median 3.0 [interquartile range 0.0 to 5.0] vs. 0.2 [interquartile range 0.0 to 4.0], P = 0.001), and also had 1.7 times higher risk for moderate or severe postoperative pain (P = 0.005). Moderate or severe postoperative pain was reported by 38% of patients with VCP scores of ≥2.0 VAS units and by 26% with VCP scores of <2.0 VAS units (P = 0.005). CONCLUSION: Scoring of VCP intensity before surgery, requiring no specific equipment or training, is useful to predict individual risks for moderate or severe postoperative pain, regardless of patient age or gender, in a setting involving different kinds of surgery.

Comparison of Risk Factors in Patients With Acute and Chronic Orofacial Pain.

Management of patients with orofacial pain may benefit from a better understanding about patient factors that may lead pain chronicity. In this study, we retrospectively compared physical and psychological factors in patients with acute and chronic orofacial pain. We analyzed data from 854 patients presenting to the Orofacial Pain Center, Department of Dental Anesthesiology, Tokyo Dental College, Suidobashi Hospital between April 2010 and March 2014. We categorized patients into the acute group if their condition had persisted <6 months and the chronic group if their condition had lasted 6 months or longer, based on the classification by the International Association for the Study of Pain. The retrospective data were analyzed by using univariate analysis on background factors from a health questionnaire, pain evaluation sheet, and psychological test completed at the time of presentation. Multiple logistic regression was applied on these factors. Our results suggest that female gender and high trait anxiety may be involved in orofacial pain becoming chronic.

Optimising pain management in children with acute otitis media through a primary care-based multifaceted educational intervention: study protocol for a cluster randomised controlled trial.

BACKGROUND: Whilst current guidelines highlight the importance of pain management for children with acute otitis media (AOM), there is evidence to suggest that this is not implemented in everyday practice. We have developed a primary care-based multifaceted educational intervention to optimise pain management in children with AOM, and we trial its clinical and cost effectiveness. METHODS: This cluster randomised controlled trial aims to recruit 250 children aged 6 months to 10 years presenting with AOM to general practitioners (GPs) in 30 primary care centres (PCCs) across the Netherlands. GPs in the PCCs allocated to the intervention group receive a blended GP educational programme (online and face-to-face training). The intervention asks GPs to proactively discuss pain management with parents using an information leaflet, and to prescribe paracetamol and ibuprofen according to current guidelines. GPs in both groups complete an online module illustrating various otoscopic images to standardise AOM diagnosis. GPs in the PCCs allocated to the control group do not receive any further training and provide 'care as usual'. During the 4-week follow-up, parents complete a symptom diary. The primary outcome is the difference in parent-reported mean earache scores over the first 3 days. Secondary outcomes include both number of days with earache and fever, GP re-consultations for AOM, antibiotic prescriptions, and costs. Analysis will be by intention-to-treat. DISCUSSION: The optimal use of analgesics through the multifaceted intervention may provide symptom relief and thereby reduce re-consultations and antibiotic prescriptions in children with AOM. TRIAL REGISTRATION: Netherlands Trial Register, NTR4920 . Registered on 19 December 2014.

[Detection and assessment of acute and chronic pain in Meat Merino ewes using ethological parameters]. / Erfassung und Bewertung von akutem und chronischem Schmerz anhand ethologischer Merkmale bei weiblichen Merinofleischschafen.

OBJECTIVE: The assessment of pain in sheep is a clinical challenge, because being a prey species, they tend to mask it. Since pain in animals cannot be measured directly, various methods are applicable to detect its effects on physiological, biochemical and ethological processes. Clinicians experienced in behavioural assessment are able to reliably determine the level of pain endured by an animal. The objective of this study was to identify behaviours that reflect acute and chronic pain as well as stress in sheep. METHODS: The behaviour of 36 Meat Merino ewes with contagious footrot (contagious interdigital dermatitis) was analysed during normal activities in the flock and during footrot treatment, which included claw trimming to remove abnormal horn. The behaviour during treatment was compared with that of 12 healthy control sheep of the same breed during routine foot trimming. Grading of the observed behaviours was made using a numerical score. The occurrence of footrot was defined as, and equated with, chronic pain, and treatment was equated with acute pain. For the assessment of stress induced by the manipulative treatment, the data of the healthy sheep were taken as a comparison. RESULTS: The strongest indications of chronic pain were non-weight bearing lameness of an affected limb, shifting of weight and abnormal gait patterns. Additionally, sheep with footrot urinated more frequently than healthy animals. Stress-related bruxism occurred in healthy and ill sheep during foot trimming, but not during normal activities in the flock. Tail wagging and strong defensive movements of all limbs commonly occurred during footrot treatment. Head shaking appeared to be primarily stress-related in association with dorsal recumbency on the tilt table, but was exacerbated by pain elicited by hoof trimming. CONCLUSION: The behaviours selected in this study were useful for the identification of chronic and acute pain in sheep; however, correct interpretation of behavioural changes requires an experienced individual.

Early health technology assessment of future clinical decision rule aided triage of patients presenting with acute chest pain in primary care.

The objective of the paper is to estimate the number of patients presenting with chest pain suspected of acute coronary syndrome (ACS) in primary care and to calculate possible cost effects of a future clinical decision rule (CDR) incorporating a point-of-care test (PoCT) as compared with current practice. The annual incidence of chest pain, referrals and ACS in primary care was estimated based on a literature review and on a Dutch and Belgian registration study. A health economic model was developed to calculate the potential impact of a future CDR on costs and effects (ie, correct referral decisions), in several scenarios with varying correct referral decisions. One-way, two-way, and probabilistic sensitivity analyses were performed to test robustness of the model outcome to changes in input parameters. Annually, over one million patient contacts in primary care in the Netherlands concern chest pain. Currently, referral of eventual ACS negative patients (false positives, FPs) is estimated to cost €1,448 per FP patient, with total annual cost exceeding 165 million Euros in the Netherlands. Based on 'international data', at least a 29% reduction in FPs is required for the addition of a PoCT as part of a CDR to become cost-saving, and an additional €16 per chest pain patient (ie, 16.4 million Euros annually in the Netherlands) is saved for every further 10% relative decrease in FPs. Sensitivity analyses revealed that the model outcome was robust to changes in model inputs, with costs outcomes mainly driven by costs of FPs and costs of PoCT. If PoCT-aided triage of patients with chest pain in primary care could improve exclusion of ACS, this CDR could lead to a considerable reduction in annual healthcare costs as compared with current practice.

Preoperative paravertebral blocks for the management of acute pain following mastectomy: a cost-effectiveness analysis.

PURPOSE: Preoperative paravertebral blocks (PPVBs) are routinely used for treating post-mastectomy pain, yet uncertainties remain about the cost-effectiveness of this modality. We aim to evaluate the cost-effectiveness of PPVBs at common willingness-to-pay (WTP) thresholds. METHODS: A decision analytic model compared two strategies: general anesthesia (GA) alone versus GA with multilevel PPVB. For the GA plus PPVB limb, patients were subjected to successful block placement versus varying severity of complications based on literature-derived probabilities. The need for rescue pain medication was the terminal node for all postoperative scenarios. Patient-reported pain scores sourced from published meta-analyses measured treatment effectiveness. Costing was derived from wholesale acquisition costs, the Medicare fee schedule, and publicly available hospital charge masters. Charges were converted to costs and adjusted for 2016 US dollars. A commercial payer perspective was adopted. Incremental cost-effectiveness ratios (ICERs) were evaluated against WTP thresholds of $500 and $50,000 for postoperative pain control. RESULTS: The ICER for preoperative paravertebral blocks was $154.49 per point reduction in pain score. 15% variation in inpatient costs resulted in ICER values ranging from $124.40-$180.66 per pain point score reduction. Altering the probability of block success by 5% generated ICER values of $144.71-$163.81 per pain score reduction. Probabilistic sensitivity analysis yielded cost-effective trials 69.43% of the time at $500 WTP thresholds. CONCLUSION: Over a broad range of probabilities, PPVB in mastectomy reduces postoperative pain at an acceptable incremental cost compared to GA. Commercial payers should be persuaded to reimburse this technique based on convincing evidence of cost-effectiveness.

Monitoring equine head-related pain with the Equine Utrecht University scale for facial assessment of pain (EQUUS-FAP).

This study validates a recently described pain scale, the Equine Utrecht University scale for facial assessment of pain (EQUUS-FAP), in horses with acute or postoperative pain originating from the head, including dental pain, ocular pain, or trauma to the skull. This cohort study of 23 horses with head-related pain and 23 normal, healthy controls revealed significant differences in EQUUS-FAP scores between control horses and horses with acute or postoperative pain (P <0.001). Moreover, pain scores after surgery decreased significantly over time (P <0.001). The scale showed good inter-observer reliability (intra-class correlation coefficient = 0.92), sensitivity (80%), specificity (78%), and positive (80%) and negative predictive values (78%).

Pain Assessment and Control in the Injured Elderly.

Elderly trauma patients may be at increased risk for underassessment and inadequate pain control in the emergency department (ED). We sought to characterize risk factors for oligoanalgesia in the ED in elderly trauma patients and determine whether it impacts outcomes in elderly trauma patients. We included elderly patients (age ≥55 years) with Glasgow Coma Scale scores 13 to 15 and Injury Severity Score (ISS) ≥9 admitted through the ED at a Level I trauma center. Patient characteristics and outcomes were compared between those who reported pain and received analgesics medication in the ED (MED) and those who did not (NO MED). A total of 183 elderly trauma patients were identified over a three-year study period, of whom 63 per cent had pain assessed via verbal pain score; of those who reported pain, 73 per cent received analgesics in the ED. The MED and NO MED groups were similar in gender, race, ED vitals, ISS, and hospital length of stay. However, NO MED was older, with higher head Abbreviated Injury Scale score and longer intensive care unit length of stay. Importantly, as patients aged they reported lower pain and were less likely to receive analgesics at similar ISS. Risk factors for oligoanalgesia may include advanced age and head injury.