Acute postoperative pain (APOP) is often evaluated through granular parameters, though
monitoring postoperative pain using trends may better describe pain state. We investigated
acute postoperative pain trajectories in cardiac surgical patients to identify subpopulations
of pain resolution and elucidate predictors of problematic pain courses. We examined
retrospective data from 2810 cardiac surgical patients at a single center. The k-means
algorithm for longitudinal data was used to generate clusters of pain trajectories
over the first 5 postoperative days. Patient characteristics were examined for association
with cluster membership using ordinal and multinomial logistic regression. We identified
3 subgroups of pain resolution after cardiac surgery: 37.7% with good resolution,
44.2% with moderate resolution, and 18.2% exhibiting poor resolution. Type I diabetes
(2.04 [1.00–4.16], p = 0.05), preoperative opioid use (1.65 [1.23–2.22], p = 0.001), and illicit drug use (1.89 [1.26–2.83], p = 0.002) elevated risk of membership into worse pain trajectory clusters. Female
gender (1.72 [1.30–2.27], p < 0.001), depression (1.60 [1.03–2.50], p = 0.04) and chronic pain (3.28 [1.79–5.99], p < 0.001) increased risk of membership in the worst pain resolution cluster. This
study defined 3 APOP resolution subgroups based on pain score trend after cardiac
surgery and identified factors that predisposed patients to worse resolution. Patients
with moderate or poor pain trajectory consumed more opioids and received them for
longer before discharge. Future studies are warranted to determine if altering postoperative
pain monitoring and management improve postoperative course of patients at risk of
moderate or poor pain resolution.
Graphical Abstract
Graphical Abstract
Keywords
Abbreviations:
APOP (Acute postoperative pain), ICD-10-CM (International Classification of Disease 10, Clinical Modification), OME (Oral Morphine Equivalents), CABG (Coronary Artery Bypass Grafting), CPT (Current Procedural Terminology), OR (Odds Ratio), BMI (Body Mass Index), NRS (Numeric Rating Scale)To read this article in full you will need to make a payment
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References
- Incidence, patient satisfaction, and perceptions of post-surgical pain: Results from a US national survey.Curr Med Res Opin. 2014; 30: 149-160
- Postoperative pain experience: Results from a national survey suggest postoperative pain continues to be undermanaged.Anesth Analg. 2003; 97: 534-540
- Risk factors and prevention strategies for postoperative opioid abuse.Pain Res Manag. 2019; 20197490801
- Professionals underestimate patients' pain: a comprehensive review.Pain. 2018; 159: 811-818
- Assessment of pain.Br J Anaesth. 2008; 101: 17-24
- Postoperative pain assessment based on numeric ratings is not the same for patients and professionals: A cross-sectional study.Int J Nurs Stud. 2012; 49: 65-71
- Improving individual measurement of postoperative pain: The pain trajectory.J Pain. 2011; 12: 257-262
- Acute pain Factors predictive of post-operative pain and opioid requirement in multimodal analgesia following knee replacement.Eur J Pain. 2016; 20: 822-832
- Prevalence of and risk factors for persistent postoperative nonanginal pain after cardiac surgery: a 2-year prospective multicentre study.CMAJ. 2014; 186: E213-E223
- Distinguishing between pain intensity and pain resolution: using acute post-surgical pain trajectories to predict chronic post-surgical pain.Eur J Pain. 2014; 18: 513-521
- Postoperative pain trajectories and pain chronification-an empirical typology of pain patients.Pain Med. 2018; 19: 2536-2545
- Factors associated with acute pain estimation, postoperative pain resolution, opioid cessation, and recovery: secondary analysis of a randomized clinical trial.JAMA Netw Open. 2019; 2e190168
- Preventive analgesia and novel strategies for the prevention of chronic post-surgical pain.Drugs. 2015; 75: 339-351
- Identifying increased risk of readmission and in-hospital mortality using hospital administrative data: The AHRQ elixhauser comorbidity index.Med Care. 2017; 55: 698-705
- Differences in characteristics and downstream drug use among opioid-naive and prior opioid users with low back pain.Pain Pract. 2019; 19: 149-157
- Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period.JAMA Intern Med. 2016; 176: 1286-1293
- A synthesis of oral morphine equivalents (OME) for opioid utilisation studies.Pharmacoepidemiol Drug Saf. 2016; 25: 733-737
- Missing data and multiple imputation in clinical epidemiological research.Clin Epidemiol. 2017; 9: 157-166
- KmL: a package to cluster longitudinal data.Comput Methods Programs Biomed. 2011; 104: e112-e121
- K. mice: Multivariate imputation by chained equations in R.J Stat Software. 2011; 45: 67
- nnet: Feed-Forward Neural Networks and Multinomial Log-Linear Models.7.3-12 ed. The Comprehensive R Archive Network, Oxford, UK2019
- Modern Applied Statistics With S.4th ed. Springer, New York: NY2002
- Fast-track surgery: Toward comprehensive peri-operative care.Anesth Essays Res. 2014; 8: 127-133
- Acute opioid tolerance: intraoperative remifentanil increases postoperative pain and morphine requirement.Anesthesiology. 2000; 93: 409-417
- Prediction of future chronic opioid use among hospitalized patients.J Gen Intern Med. 2018; 33: 898-905
- Association between preoperative opioid and benzodiazepine prescription patterns and mortality after noncardiac surgery.JAMA Surg. 2019; 154: e191652https://doi.org/10.1001/jamasurg.2019.1652
- A review of potential adverse effects of long-term opioid therapy: a practitioner's guide.Prim Care Companion CNS Disord. 2012; 14 (Epub 2012 Jun 14)PCC.11m01326https://doi.org/10.4088/PCC.11m01326
- Association of multimodal pain management strategies with perioperative outcomes and resource utilization: a population-based study.Anesthesiology. 2018; 128: 891-902
- Acute pain medicine in the United States: a status report.Pain Med. 2015; 16: 1806-1826
- New approach for treatment of prolonged postoperative pain: APS out-patient clinic.Scand J Pain. 2016; 12: 19-24
- Clinically derived early postoperative pain trajectories differ by age, sex, and type of surgery.Pain. 2015; 156: 609-617
- Approach to pain management in chronic opioid users undergoing orthopaedic surgery.J Am Acad Orthop Surg. 2014; 22: 614-622
- Predicting the pain continuum after adolescent idiopathic scoliosis surgery: A prospective cohort study.Eur J Pain. 2017; 21: 1252-1265
- Multimodal strategies to improve surgical outcome.Am J Surg. 2002; 183: 630-641
- A systematic review of intravenous ketamine for postoperative analgesia.Can J Anaesth. 2011; 58: 911-923
- A meta-analysis of the preoperative use of gabapentinoids for the treatment of acute postoperative pain following spinal surgery.Medicine (Baltimore). 2017; 96: e8031
Article info
Publication history
Published online: September 06, 2022
Publication stage
In Press Journal Pre-ProofFootnotes
Funding: Support was provided solely from institutional and/or departmental sources.
Conflicts of Interest: Drs. Muehlschlegel, Body, and Fox have received NIH grants within the past 36 months. Dr. Fox is the current Secretary/Treasurer for the Society of Cardiovascular Anesthesiologists and spoke at the annual American Congress Osteopathic Anesthesiologists meeting at the University of Kansas. Dr. Shernan is the immediate past President of the Society of Cardiovascular Anesthesiologists. The authors declare no other competing interests.
IRB Protocol #: 2018P002320. Approved 10/22/2018, renewed 6/27/2022
The Institutional Review Board (IRB) of Brigham & Women's Hospital approved the study protocol and publication of data. Patient written consent for the publication of the study data was waived by the IRB given the retrospective design with minimal risk to the patients.
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