Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Use of early pulse oximetry in the detection of cardiac lesions among asymptomatic term newborns

Background and objectives: Cardiovascular malformations are the commonest form of congenital defects and could result in significant morbidity. Antenatal and early postnatal detection is still unreliable, especially in developing countries and low-income communities. The aim of the study was to assess the value of early pulse oximetry in the detection of cardiac lesions among asymptomatic term newborns with subnormal oxygen saturation. Patients and methods: A cross-sectional study was conducted at the well-baby nursery of a community hospital, between March and August 2013. A total of 120 asymptomatic, apparently healthy term newborns who had persistent postductal SpO2 < 95% in the initial and repeat tests within the first 24 h after birth were consecutively enrolled. Pulse oximetry testing was performed after the age of 2 h and confirmed 2 h later. Cases with persistent saturation below 95% underwent echocardiography. Results: Significant cardiac lesions were detected in 38 newborns (31.6%); they had significantly lower oxygen saturation compared to those with insignificant lesions (n = 41, 34.2%) and normal hearts (n = 41, 34.2%). Repeat testing after 2 h was more reliable. Using cut-offs lower than 95% missed a significant number of lesions. Conclusion: Pulse oximetry can be used as a tool in apparently healthy term newborns for the early detection of cardiac lesions that might necessitate specialized follow-up and care. An initial test after the age of 2 h followed by a confirmatory test 2 h later, with a cut-off value of <95% is proposed. A comprehensive study is necessary to validate the results of this study. This might be of significant importance in low-income communities

Effect of early procedural pain experience on subsequent pain responses among premature infants

Background and objectives: Preterm newborns are exposed to repeated procedural pain during their NICU stay. Acute pain has negative short-term effects and may have adverse neurodevelopmental sequelae. Disagreement among researchers exists in the direction of pain responses. We aimed at evaluating the short-term effects of early procedural pain exposure on subsequent behavioral and physiological responses among preterm infants; and to define possible contributing factors. Patients and methods: A prospective study included 203 preterm newborns recruited from 2 community centers, excluding cases having conditions that may affect pain responses. They were categorized into: group I including cases who were exposed to painful procedures; and group II were not exposed. Pain response to heel-stick procedure was assessed by Neonatal Infant Pain Scale to measure behavioral response, and changes in heart rate and oxygen saturation to evaluate physiological responses. Results: History of pain exposure and number of procedures were the only independent variables that predicted subsequent pain responses while other contextual factors had no significant impact. The behavioral pain responses were blunted in group I with lower pain scores during and after the heel-stick test, while physiological responses were exaggerated with a higher heart rate and oxygen saturation variability. Conclusion: On studying the physiological and behavioral responses to pain in the premature infants, it was found that prior pain exposure and the number of procedures predict dampened behavioral and exaggerated physiologic subsequent pain responses. Protocols for minimization of pain exposure and pain control need to be implemented to avoid infant distress and long-term neurodevelopmental sequelae