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

Relembrar o sindrome de realimentação

The Refeeding Syndrome was described in adult survivors of concentration camps in 1945, and regained attention following introduction of total parenteral nutrition in the 1970s. Refeeding syndrome is characterized by severe fluid and electrolytes shifts especially phosphate), associated with metabolic abnormalities in malnourished patients undergoing refeeding, whether orally, enterally, or parenterally. Clinical features involve cardiac, neurologic, hematologic events and even sudden death. It is not an uncommon entity and may be seen in 0,8 % of all hospitalized adult patients. It is very important to be aware of the syndrome to prevent this potentially lethal condition: recognize those at risk; laboratory data must be monitored and abnormal values corrected accordingly; and finally, a slow increase in caloric delivery is recommended. Not all clinics and institutions have nutritional support teams. So it is important to educate heath care practitioners to the potential danger of too aggressively refeeding a chronically malnourished patient – and so remember Refeeding Syndrome. A síndrome de Realimentação foi descrita em adultos sobreviventes dos campos de concentração em 1945 e voltou a ganhar a atenção da comunidade médica após a introdução da alimentação parentérica total na década de 1970. Esta síndrome é caracterizada por alterações de fluidos e electrólitos (especialmente fósforo) associada a alterações metabólicas em doentes desnutridos, nos quais se inicia suporte nutricional por via oral, entérica ou parentérica. A clínica inclui manifestações cardíacas, neurológicas, hematológicas e mesmo morte súbita. Ocorre em 0,8 % dos adultos hospitalizados. É fundamental conhecer esta síndrome de forma a prevenir uma condição potencialmente letal: reconhecer doentes em risco; proceder à monitorização laboratorial e à correcção de anomalias e, finalmente, recomenda-se um aumento progressivo do aporte calórico. Nem todos os hospitais têm grupos de suporte nutricional, pelo que é importante relembrar a Síndrome de Realimentação para que os profissionais de saúde conheçam o perigo potencial de realimentar de forma agressiva um doente desnutrido.