Quality of Postoperative Pain Management after Midfacial Fracture Repair—An Outcome-oriented Study

Objectives There is a lack of literature regarding the procedure-specific quality of acute postoperative pain management after midfacial fracture repair. The purpose of the presented prospective clinical study was to evaluate postoperative pain management after surgical repair of midfacial fractures. Materials and methods Eighty-five adults were evaluated on the first postoperative day following midfacial repair using the questionnaire of the Quality Improvement in Postoperative Pain Management (QUIPS) project. The main outcome measures were patients’ characteristics and clinical- and patient-reported outcome parameters. Results Overall, pain on the first postoperative day was moderate. A significant correlation between process and outcome parameters could be shown. Duration of surgery above the calculated median was significantly associated with higher maximum pain intensity (p = 0.017). Patients requiring opioids in the recovery room presented significantly higher pain on activity (p = 0.029) and maximum pain (p = 0.035). Sleeping impairment (p = 0.001) and mood disturbance (p = 0.008) were significantly more prevalent in patients undergoing repair of a centrolateral midfacial fracture. Conclusions QUIPS is a simple and qualified tool to evaluate the procedure specific quality of acute postoperative pain management. Pain on the first postoperative day following midfacial fracture repair seems overall to be moderate. Nearly a third of the patients showed inadequate postoperative pain management. To prevent inadequate postoperative pain management, it is necessary to establish a continued procedure-specific outcome measurement

Clinical and Genetic Evaluation of Patients with KATP Channel Mutations from the German Registry for Congenital Hyperinsulinism

Congenital hyperinsulinism (CHI) causes hypoglycemia due to irregular insulin secretion. In infants, a rapid diagnosis and appropriate management to avoid severe hypoglycemia is mandatory. CHI is a heterogeneous condition at the clinical and genetic level, and disease-causing genes have been identified in about half of the patients. The majority of mutations have been identified in the ABCC8 and KCNJ11 genes encoding subunits of the KATP channel responsible for two distinct histological forms. The diffuse form is caused by autosomal recessive or dominant inherited mutations, whereas the focal form is caused by a paternally transmitted recessive mutation and a second somatic event. We report on an unselected cohort of 136 unrelated patients from the German CHI registry. Mutations in either the ABCC8 or KCNJ11 gene were identified in 61 of these patients (45%). In total, 64 different mutations including 38 novel ones were detected in this cohort. We observed biparental (recessive) inheritance in 34% of mutation-positive patients, dominant inheritance in 11% and paternal transmission of a mutation associated with a focal CHI type in 38%. In addition, we observed inheritance patterns that do not exactly follow the classical recessive or dominant mode, further adding to the genetic complexity of this disease

Quality of Postoperative Pain Management After Maxillofacial Fracture Repair

Background: Effective pain management is an essential component in the perioperative care of surgical patients. However, post-operative pain after maxillofacial fracture repair and its optimal therapy has not been described in detail. Materials and Methods: In a prospective cohort study, 95 adults rated their pain on the first postoperative day after maxillofacial fracture repair using the questionnaire of the Quality Improvement in Postoperative Pain Management (QUIPS) project. Quality Improvement in Postoperative Pain Management allowed for a standardized assessment of patients’ characteristics and pain- related parameters. Results: Overall, the mean maximal pain and pain on activity (numeric rating scales) were significantly higher in patients with mandibular fractures than in patients with midface fractures (P = 0.002 and P = 0.045, respectively). In patients with mandibular fractures, a longer duration of surgery was significantly associated with higher satisfaction with pain intensity (P = 0.015), but was more frequently associated with postoperative vomiting (P = 0.023). A shorter duration of surgery and an absence of preoperative pain counseling in these patients were significantly correlated to desire for more pain medication (P = 0.049 and P = 0.004, respectively). Patients with mandibular fractures that received opioids in the recovery room had significantly higher strain-related pain (P = 0.017). In patients with midface fractures, a longer duration of surgery showed significantly higher levels of decreased mobility (P = 0.003). Patients receiving midazolam for premedication had significantly less minimal pain (P = 0.021). Conclusions: Patients with mandibular fractures seem to have more postoperative pain than patients with midface fractures. Monitoring of postsurgical pain and a procedure-specific pain-treatment protocol should be performed in clinical routine

Bilateral Sagittal Split Osteotomy-parameters and Correlations of Postoperative Pain Management

Objectives Postoperative pain management is of utmost interest for patients undergoing orthognathic surgery. Currently, there is a lack of information regarding process and outcome parameters of postoperative pain management after bilateral sagittal split osteotomy. Materials and methods In a prospective clinical study, 31 adults were evaluated on the first postoperative day following bilateral sagittal split osteotomy using the standardized questionnaire of the Germany-wide project Quality Improvement in Postoperative Pain Management (QUIPS). It allows a standardized assessment of patients’ characteristics, pain parameters, outcome, and pain therapy process parameters. Results Pain management consisted mainly of premedication with midazolam, sufentanil, and metamizol intraoperatively; piritramide in the recovery room; and metamizol and tramadol on ward. Twenty patients (64.5%) showed inadequate pain management with pain levels ≥4. Patients receiving tramadol as opioid on ward presented significantly higher maximum pain levels (p = .037). Significantly lower satisfaction with postoperative pain intensity (p \u3e .001) and significantly higher desire for additional pain medication (p = .023) were detected, when duration of surgery was above the median of 107.5 min. Conclusions Inadequate pain management on the first postoperative day following bilateral sagittal split osteotomy was widespread on our ward. QUIPS helped us to identify it and thereby gave us the possibility to improve the situation. Prolonged duration of surgery seems to be a predictor of an elevated postoperative pain medication demand. Clinical relevance Only the establishment of an ongoing monitoring of postoperative pain management can help to reduce or even avoid inadequate postoperative pain management. In accordance to the existing literature, we found inadequate postoperative pain management more widespread than thought

Rapid functional plasticity in the primary somatomotor cortex and perceptual changes after nerve block

Abstract The mature human primary somatosensory cortex displays a striking plastic capacity to reorganize itself in response to changes in sensory input. Following the elimination of afferent return, produced by either amputation, deafferentation by dorsal rhizotomy, or nerve block, there is a well-known but little-understood 'invasion' of the deafferented region of the brain by the cortical representation zones of still-intact portions of the brain adjacent to it. We report here that within an hour of abolishing sensation from the radial and medial three-quarters of the hand by pharmacological blockade of the radial and median nerves, magnetic source imaging showed that the cortical representation of the little finger and the skin beneath the lower lip, whose intact cortical representation zones are adjacent to the deafferented region, had moved closer together, presumably because of their expansion across the deafferented area. A paired-pulse transcranial magnetic stimulation procedure revealed a motor cortex disinhibition for two muscles supplied by the unaffected ulnar nerve. In addition, two notable perceptual changes were observed: increased two-point discrimination ability near the lip and mislocalization of touch of the intact ulnar portion of the fourth finger to the neighbouring third finger whose nerve supply was blocked. We suggest that disinhibition within the somatosensory system as a functional correlate for the known enlargement of cortical representation zones might account for not only the 'invasion' phenomenon, but also for the observed behavioural correlates of the nerve block

Opioid-Induced Constipation and Bowel Dysfunction:A Clinical Guideline

OBJECTIVE:  To formulate timely evidence-based guidelines for the management of opioid-induced bowel dysfunction. SETTING:  Constipation is a major untoward effect of opioids. Increasing prescription of opioids has correlated to increased incidence of opioid-induced constipation. However, the inhibitory effects of opioids are not confined to the colon, but also affect higher segments of the gastrointestinal tract, leading to the coining of the term "opioid-induced bowel dysfunction." METHODS:  A literature search was conducted using Medline, EMBASE, and EMBASE Classic, and the Cochrane Central Register of Controlled Trials. Predefined search terms and inclusion/exclusion criteria were used to identify and categorize relevant papers. A series of statements were formulated and justified by a comment, then labeled with the degree of agreement and their level of evidence as judged by the Strength of Recommendation Taxonomy (SORT) system. RESULTS:  From a list of 10,832 potentially relevant studies, 33 citations were identified for review. Screening the reference lists of the pertinent papers identified additional publications. Current definitions, prevalence, and mechanism of opioid-induced bowel dysfunction were reviewed, and a treatment algorithm and statements regarding patient management were developed to provide guidance on clinical best practice in the management of patients with opioid-induced constipation and opioid-induced bowel dysfunction. CONCLUSIONS:  In recent years, more insight has been gained in the pathophysiology of this "entity"; new treatment approaches have been developed, but guidelines on clinical best practice are still lacking. Current knowledge is insufficient regarding management of the opioid side effects on the upper gastrointestinal tract, but recommendations can be derived from what we know at present

Cranio-Maxillofacial Reconstruction with Microvascular Radialis Flaps—Parameters and Correlations of Postoperative Pain Management

Objectives Postoperative pain management is of highest interest for patients undergoing maxillofacial surgery including microvascular reconstructive surgery. Currently, there is a lack of information regarding process and outcome of postoperative pain management after microvascular reconstruction. Materials and methods In a prospective clinical study, 31 adults were evaluated on the first postoperative day following microvascular reconstruction with a radial forearm flap using the standardized questionnaire of the Germany-wide project Quality Improvement in Postoperative Pain Management (QUIPS). It enables a standardized assessment of patients’ characteristics, pain parameters, outcome and pain therapy process parameters. Results Pain management consisted predominately of premedication with midazolam, sufentanil and metamizol intraoperatively, piritramid in the intensive care unit and metamizol, tramadol and fentanyl patches on ward. Nineteen patients (61.3 %) showed inadequate pain management with pain levels ≥4. Among other significant relations, patients exhibiting an age below the median presented significant higher levels of pain under strain (p = .041) and maximum pain (p = .006) as well as rate of breathing (p = .009) and mood (p = .006) disturbance. Performance of pain counselling showed specific impact on pain under strain (p = .008), maximum pain (p = .004) and satisfaction with pain intensity (p = .001). Whether microvascular reconstruction was performed with primary or secondary intention or performance of a neck dissection did not show significant influence. Conclusions QUIPS helped us to adequately evaluate the procedure-specific quality of postoperative management following microvascular reconstruction with a radial forearm flap. It helped us to identify a surprisingly high amount of inadequate pain management. Postoperative pain levels seem to be primarily influenced by the performed reconstruction. Clinical relevance Establishment of a continuous and procedure-specific evaluation of postoperative pain levels should help to avoid inadequate pain management, which is widely prevalent according to the literature and our study. Preoperative pain counselling is essential and should be procedure specific to be its best

Cost-effectiveness of the Perioperative Pain Management Bundle a registry-based study.

INTRODUCTION The Perioperative Pain Management Bundle was introduced in 10 Serbian PAIN OUT network hospitals to improve the quality of postoperative pain management. The Bundle consists of 4 elements: informing patients about postoperative pain treatment options; administering a full daily dose of 1-2 non-opioid analgesics; administering regional blocks and/or surgical wound infiltration; and assessing pain after surgery. In this study, we aimed to assess the cost-effectiveness of the Bundle during the initial 24 h after surgery. MATERIALS AND METHODS The assessment of cost-effectiveness was carried out by comparing patients before and after Bundle implementation and by comparing patients who received all Bundle elements to those with no Bundle element. Costs of postoperative pain management included costs of the analgesic medications, costs of labor for administering these medications, and related disposable materials. A multidimensional Pain Composite Score (PCS), the effectiveness measurement, was obtained by averaging variables from the International Pain Outcomes questionnaire evaluating pain intensity, interference of pain with activities and emotions, and side effects of analgesic medications. The incremental cost-effectiveness ratio (ICER) was calculated as the incremental change in costs divided by the incremental change in PCS and plotted on the cost-effectiveness plane along with the economic preference analysis. RESULTS The ICER value calculated when comparing patients before and after Bundle implementation was 181.89 RSD (1.55 EUR) with plotted ICERs located in the northeast and southeast quadrants of the cost-effectiveness plane. However, when comparing patients with no Bundle elements and those with all four Bundle elements, the calculated ICER was -800.63 RSD (-6.82 EUR) with plotted ICERs located in the southeast quadrant of the cost-effectiveness plane. ICER values differ across surgical disciplines. CONCLUSION The proposed perioperative pain management Bundle is cost-effective. The cost-effectiveness varies depending on the number of implemented Bundle elements and fluctuates across surgical disciplines

Can Consistent Benchmarking within a Standardized Pain Management Concept Decrease Postoperative Pain after Total Hip Arthroplasty? A Prospective Cohort Study including 367 Patients

Background: The number of total hip replacement surgeries has steadily increased over recent years. Reduction in postoperative pain increases patient satisfaction and enables better mobilization. Thus, pain management needs to be continuously improved. Problems are often caused not only by medical issues but also by organization and hospital structure. The present study shows how the quality of pain management can be increased by implementing a standardized pain concept and simple, consistent, benchmarking. Methods: All patients included in the study had undergone total hip arthroplasty (THA). Outcome parameters were analyzed 24 hours after surgery by means of the questionnaires from the German-wide project "Quality Improvement in Postoperative Pain Management" (QUIPS). A pain nurse interviewed patients and continuously assessed outcome quality parameters. A multidisciplinary team of anesthetists, orthopedic surgeons, and nurses implemented a regular procedure of data analysis and internal benchmarking. The health care team was informed of any results, and suggested improvements. Every staff member involved in pain management participated in educational lessons, and a special pain nurse was trained in each ward. Results: From 2014 to 2015, 367 patients were included. The mean maximal pain score 24 hours after surgery was 4.0 (+/- 3.0) on an 11-point numeric rating scale, and patient satisfaction was 9.0 (+/- 1.2). Over time, the maximum pain score decreased (mean 3.0, +/- 2.0), whereas patient satisfaction significantly increased (mean 9.8, +/- 0.4; p<0.05). Among 49 anonymized hospitals, our clinic stayed on first rank in terms of lowest maximum pain and patient satisfaction over the period. Conclusion: Results were already acceptable at the beginning of benchmarking a standardized pain management concept. But regular benchmarking, implementation of feedback mechanisms, and staff education made the pain management concept even more successful. Multidisciplinary teamwork and flexibility in adapting processes seem to be highly important for successful pain management

Implications of Placebo and Nocebo Effects for Clinical Practice: Expert Consensus

Background: Placebo and nocebo effects occur in clinical or laboratory medical contexts after administration of an inert treatment or as part of active treatments and are due to psychobiological mechanisms such as expectancies of the patient. Placebo and nocebo studies have evolved from predominantly methodological research into a far-reaching interdisciplinary field that is unravelling the neurobiological, behavioural and clinical underpinnings of these phenomena in a broad variety of medical conditions. As a consequence, there is an increasing demand from health professionals to develop expert recommendations about evidence-based and ethical use of placebo and nocebo effects for clinical practice. Methods: A survey and interdisciplinary expert meeting by invitation was organized as part of the 1st Society for Interdisciplinary Placebo Studies (SIPS) conference in 2017. Twenty-nine internationally recognized placebo researchers participated. Results: There was consensus that maximizing placebo effects and minimizing nocebo effects should lead to better treatment outcomes with fewer side effects. Experts particularly agreed on the importance of informing patients about placebo and nocebo effects and training health professionals in patient-clinician communication to maximize placebo and minimize nocebo effects. Conclusions: The current paper forms a first step towards developing evidence-based and ethical recommendations about the implications of placebo and nocebo research for medical practice, based on the current state of evidence and the consensus of experts. Future research might focus on how to implement these recommendations, including how to optimize conditions for educating patients about placebo and nocebo effects and providing training for the implementation in clinical practice. (C) 2018 S. Karger AG, Base