Special Issue "Management of Perioperative Pain in the 21st Century – Lessons Learned and How to Move On?"

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Anesthesiology".

Deadline for manuscript submissions: closed (16 April 2021).

Special Issue Editors

Prof. Winfried Meissner
E-Mail Website
Guest Editor
Department of Anaesthesiology and Intensive Care Medicine, Friedrich Schiller University, Jena, Thuringia, Germany
Interests: acute pain; chronic pain; patient reported outcomes; quality, palliative care; observational studies
Dr. Ruth Zaslansky
E-Mail Website
Co-Guest Editor
Department of Anaesthesiology and Intensive Care Medicine, Friedrich Schiller University, Jena, Thuringia, Germany
Interests: acute pain; registry; quality; observational studies; pain measurement; patient reported outcomes

Special Issue Information

Dear Colleagues,

This Special Issue will focus on management of perioperative pain. Perioperative pain is an important issue in global health-care policy as it affects a large population of people worldwide, during different phases of life from childhood to adulthood to old age, in a multitude of settings, in hospital or during ambulatory care. Surgery can reduce the risk of death and improve patient’s quality of life, yet, it frequently includes pain which can last for days, weeks, and months following the procedure. This pain is associated with short- and long-term harms. Perioperative pain medicine is multi-disciplinary, involving anesthesiologists, surgeons, nurses, pharmacists, psychologists and physiotherapists, in different phases of care.  The literature describes considerable variability in care, at the local, national and international levels.

Twenty years into the 21st century, we have an opportunity to appraise how this type of pain is being managed.  Such a process could contribute towards shaping progress in this field over the coming years.

We invite healthcare professionals and researchers involved in the care of surgical patients to address topics such as the ones listed below and to contribute an original research article, meta-analysis, review, or observational study for this Special Issue.

  1. Are opioids over- or under-prescribed to patients undergoing surgery?
  2. Opioid-free anesthesia and opioid-free analgesia – what is the evidence? Does it work in practice?
  3. Is it possible to use precision medicine for management of acute pain?
  4. Acute pain management of pediatric/adult/older adults [when resources are limited].
  5. Pros and cons of Enhanced Recovery After Surgery (ERAS) for optimizing outcomes such as pain.  
  6. Integrating a perioperative pain service into the Perioperative Surgical Home - are outcomes improved? Is this a viable approach?
  7. Big data methods in studying acute pain - is this is a useful approach for creating knowledge?
  8. Is there evidence that multi-disciplinary perioperative pain management works in the real world?
  9. What is quality acute pain management? How can it be provided in countries with limited resources/in high resource countries?
  10. Psychologists have a role in management of acute post-operative pain - pros and cons.
  11. Techniques for wound infiltration for abdominal/orthopedic/obstetric & gynecologic surgery.
  12. Do NSAIDs really prevent bone healing after surgery?  What is the evidence?

Prof. Winfried Meissner
Dr. Ruth Zaslansky
Guest Editors

Manuscript Submission Information

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Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2400 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • perioperative pain
  • management techniques
  • pediatric
  • adult
  • older adult
  • high – low resource countries
  • analgesics
  • patient reported outcomes
  • outcomes
  • precision medicine
  • guidelines
  • enhanced recovery after surgery (ERAS)
  • big data
  • quality

Published Papers (12 papers)

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Research

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Article
Subcutaneous Bupivacaine Infiltration Is Not Effective to Support Control of Postoperative Pain in Paediatric Patients Undergoing Spinal Surgery
J. Clin. Med. 2021, 10(11), 2407; https://doi.org/10.3390/jcm10112407 - 29 May 2021
Viewed by 777
Abstract
Spinal deformity corrections in paediatric patients are long-lasting procedures involving damage to many tissues and long pain exposure; therefore, effective pain management after surgical treatment is an important issue. In this study, the effect of inclusion of local infiltration analgesia, as an integral [...] Read more.
Spinal deformity corrections in paediatric patients are long-lasting procedures involving damage to many tissues and long pain exposure; therefore, effective pain management after surgical treatment is an important issue. In this study, the effect of inclusion of local infiltration analgesia, as an integral part of the scheme in postoperative pain control, in children and adolescents, subjected to the spinal deformity correction procedure, was assessed. Thirty patients, aged 8 to 17 years, undergoing spinal deformity correction were divided into a study group, receiving a 0.25% bupivacaine solution before wound closure, and a control group (no local analgesic agent). Morphine, at the doses of 0.10 mg/kg of body weight, was administered to the patients when pain occurred. Pain scores, morphine administration, and bleeding were observed during 48 postoperative hours. The pain scores were slightly lower in a 0–4 h period in patients who received bupivacaine compared with those in the control group. However, no differences were observed in a longer period of time and in the total opioid consumption. Moreover, increasing bleeding was observed in the bupivacaine-treated patients (study group) vs. the control. Bupivacaine only modestly affects analgesia and, due to the increased bleeding observed, it should not to be part of pain control management in young patients after spinal deformity correction. Full article
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Article
Association of Perioperative Regional Analgesia with Postoperative Patient-Reported Pain Outcomes and Opioid Requirements: Comparing 22 Different Surgical Groups in 23,911 Patients from the QUIPS Registry
J. Clin. Med. 2021, 10(10), 2194; https://doi.org/10.3390/jcm10102194 - 19 May 2021
Viewed by 719
Abstract
(1) Background: In many surgical procedures, regional analgesia (RA) techniques are associated with improved postoperative analgesia compared to systemic pain treatment. As continuous RA requires time and experienced staff, it would be helpful to identify settings in which continuous RA has the largest [...] Read more.
(1) Background: In many surgical procedures, regional analgesia (RA) techniques are associated with improved postoperative analgesia compared to systemic pain treatment. As continuous RA requires time and experienced staff, it would be helpful to identify settings in which continuous RA has the largest benefit. (2) Methods: On the basis of 23,911 data sets from 179 German and Austrian hospitals, we analyzed the association of perioperative RA with patient-reported pain intensity, functional impairment of movement, nausea and opioid use for different surgeries. Regression analyses adjusted for age, sex and preoperative pain were performed for each surgery and the following groups: patients receiving continuous RA (surgery and ward; RA++), RA for surgery only (RA+−) and patients receiving no RA (RA−−). (3) Results: Lower pain scores in the RA++ compared to the RA−− group were observed in 13 out of 22 surgeries. There was no surgery where pain scores for RA++ were higher than for RA−−. If maximal pain, function and side effects were combined, the largest benefit of continuous RA (RA++) was observed in laparoscopic colon and sigmoid surgery, ankle joint arthrodesis, revision (but not primary) surgery of hip replacement, open nephrectomy and shoulder surgery. The benefit of RA+− was lower than that of RA++. (4) Discussion: The additional benefit of RA for the mentioned surgeries is larger than in many other surgeries in clinical routine. The decision to use RA in a given surgery should be based on the expected pain intensity without RA and its additional benefits. Full article
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Article
The Short-Term Kinetics of sICAM-1 after Induction of Acute Experimental Pain in Healthy Volunteers
J. Clin. Med. 2021, 10(9), 2021; https://doi.org/10.3390/jcm10092021 - 09 May 2021
Viewed by 631
Abstract
Intercellular adhesion molecule-1 (ICAM-1) mediates extravasation of leukocytes, releasing proinflammatory cytokines or endogenous opioids in the inflamed tissue. Thus, ICAM-1 is a crucial component of peripheral antinociception. Previously, we demonstrated a significant correlation between the soluble form of ICAM (sICAM-1) in serum and [...] Read more.
Intercellular adhesion molecule-1 (ICAM-1) mediates extravasation of leukocytes, releasing proinflammatory cytokines or endogenous opioids in the inflamed tissue. Thus, ICAM-1 is a crucial component of peripheral antinociception. Previously, we demonstrated a significant correlation between the soluble form of ICAM (sICAM-1) in serum and pain intensity reported by chronic pain patients. The present study examines the role and kinetics of sICAM-1 in experimentally induced acute pain. Three groups of 10 subjects were exposed to 10 min of high (capsaicin-enhanced) or low-intensity heat pain or cold pain, respectively. Thermal stimuli were induced using a device for quantitative sensory testing. Topical capsaicin significantly increased heat pain intensity without the risk of thermal tissue damage. Pain intensity was recorded every minute during testing. sICAM-1 concentrations in serum were determined by ELISA before, immediately after, and 60 min after test termination. Among all experimental groups, sICAM-1 significantly decreased immediately after pain induction. After 60 min, sICAM-1 concentrations returned towards initial values. Interestingly, a linear correlation was found between the extent of sICAM-1 changes and the initial concentrations. Whereas high initial values led to a distinct decrease of sICAM-1, low concentrations tended to increase. There was no statistically significant correlation between levels or alterations of serum sICAM-1 and pain intensity reported by the test subjects. In contrast to our previous findings in chronic pain patients, the present results show that sICAM-1 values do not correlate with the intensity of acute experimental pain. However, we were able to detect short-term changes of sICAM-1 after induction of nociceptive thermal stimuli, suggesting that this marker is part of a demand-oriented homeostatically controlled system. Full article
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Article
Development and Validation of the Pain and State of Health Inventory (PHI): Application for the Perioperative Setting
J. Clin. Med. 2021, 10(9), 1965; https://doi.org/10.3390/jcm10091965 - 03 May 2021
Cited by 1 | Viewed by 539
Abstract
Currently, general measurements and evaluations of the quality of recovery are difficult because no adequate measuring tools are available. Therefore, there is an urgent need for a universal tool that assesses patient-relevant criteria—postoperative pain, state of health, and somatic parameters. For this purpose, [...] Read more.
Currently, general measurements and evaluations of the quality of recovery are difficult because no adequate measuring tools are available. Therefore, there is an urgent need for a universal tool that assesses patient-relevant criteria—postoperative pain, state of health, and somatic parameters. For this purpose, a pain and state of health inventory (PHI, Schmerz- und Befindlichkeitsinventar (SBI) in German) has been developed. In this study, we describe its development and validation. The development phase was led by an expert panel and was divided into three subphases: determining the conceptual structure, testing the first editions, and adjusting the inventory for a finalized edition. For the purpose of validation, the PHI was filled in by 132 patients who have undergone total knee replacement and was analyzed using principal component analysis. Construct validity was tested by correlating the items with validated questionnaires. The results showed that the inventory can test pain, state of health, and somatic parameters with great construct validity. Furthermore, the inventory is accepted by patients, map changes, and supports to initiate adequate treatment. In conclusion, the PHI is a universal tool that can be used to assess the quality of recovery in the perioperative setting and allow immediate intervention. Full article
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Article
Chronic Breast Pain Prior to Breast Cancer Surgery Is Associated with Worse Acute Postoperative Pain Outcomes
J. Clin. Med. 2021, 10(9), 1887; https://doi.org/10.3390/jcm10091887 - 27 Apr 2021
Viewed by 574
Abstract
Acute postoperative pain is associated with adverse short and long-term outcomes among women undergoing surgery for breast cancer. Previous studies identified preexisting pain as a predictor of postoperative pain, but rarely accounted for pain location or chronicity. This study leveraged a multinational pain [...] Read more.
Acute postoperative pain is associated with adverse short and long-term outcomes among women undergoing surgery for breast cancer. Previous studies identified preexisting pain as a predictor of postoperative pain, but rarely accounted for pain location or chronicity. This study leveraged a multinational pain registry, PAIN OUT, to: (1) characterize patient subgroups based on preexisting chronic breast pain status and (2) determine the association of preexisting chronic pain with acute postoperative pain-related patient-reported outcomes and opioid consumption following breast cancer surgery. The primary outcome was a composite score comprising the mean of pain intensity and pain interference items from the International Pain Outcomes Questionnaire. The secondary outcome was opioid consumption in the recovery room and ward. Among 1889 patients, we characterized three subgroups: no preexisting chronic pain (n = 1600); chronic preexisting pain elsewhere (n = 128) and; chronic preexisting pain in the breast with/without pain elsewhere (n = 161). Controlling for covariates, women with preexisting chronic breast pain experienced more severe acute postoperative pain and pain interference (β = 1.0, 95% CI = 0.7-1.3, p < 0.001), and required higher doses of opioids postoperatively (β = 2.7, 95% CI = 0.6–4.8, p = 0.013). Preexisting chronic breast pain may be an important risk factor for poor pain-related postoperative outcomes. Targeted intervention of this subgroup may improve recovery. Full article
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Review

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Review
Updates on Wound Infiltration Use for Postoperative Pain Management: A Narrative Review
J. Clin. Med. 2021, 10(20), 4659; https://doi.org/10.3390/jcm10204659 - 11 Oct 2021
Viewed by 606
Abstract
Local anesthetic wound infiltration (WI) provides anesthesia for minor surgical procedures and improves postoperative analgesia as part of multimodal analgesia after general or regional anesthesia. Although pre-incisional block is preferable, in practice WI is usually done at the end of surgery. WI performed [...] Read more.
Local anesthetic wound infiltration (WI) provides anesthesia for minor surgical procedures and improves postoperative analgesia as part of multimodal analgesia after general or regional anesthesia. Although pre-incisional block is preferable, in practice WI is usually done at the end of surgery. WI performed as a continuous modality reduces analgesics, prolongs the duration of analgesia, and enhances the patient’s mobilization in some cases. WI benefits are documented in open abdominal surgeries (Caesarean section, colorectal surgery, abdominal hysterectomy, herniorrhaphy), laparoscopic cholecystectomy, oncological breast surgeries, laminectomy, hallux valgus surgery, and radical prostatectomy. Surgical site infiltration requires knowledge of anatomy and the pain origin for a procedure, systematic extensive infiltration of local anesthetic in various tissue planes under direct visualization before wound closure or subcutaneously along the incision. Because the incidence of local anesthetic systemic toxicity is 11% after subcutaneous WI, appropriate local anesthetic dosing is crucial. The risk of wound infection is related to the infection incidence after each particular surgery. For WI to fully meet patient and physician expectations, mastery of the technique, patient education, appropriate local anesthetic dosing and management of the surgical wound with “aseptic, non-touch” technique are needed. Full article
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Review
A Narrative Review on Perioperative Pain Management Strategies in Enhanced Recovery Pathways—The Past, Present and Future
J. Clin. Med. 2021, 10(12), 2568; https://doi.org/10.3390/jcm10122568 - 10 Jun 2021
Cited by 1 | Viewed by 770
Abstract
Effective pain management is a key component in the continuum of perioperative care to ensure optimal outcomes for surgical patients. The overutilization of opioids in the past few decades for postoperative pain control has been a major contributor to the current opioid epidemic. [...] Read more.
Effective pain management is a key component in the continuum of perioperative care to ensure optimal outcomes for surgical patients. The overutilization of opioids in the past few decades for postoperative pain control has been a major contributor to the current opioid epidemic. Multimodal analgesia (MMA) and enhanced recovery after surgery (ERAS) pathways have been repeatedly shown to significantly improve postoperative outcomes such as pain, function and satisfaction. The current review aims to examine the history of perioperative MMA strategies in ERAS and provide an update with recent evidence. Furthermore, this review details recent advancements in personalized pain medicine. We speculate that the next important step for improving perioperative pain management could be through incorporating these personalized metrics, such as clinical pharmacogenomic testing and patient-reported outcome measurements, into ERAS program. Full article
Review
Do NSAIDs Really Interfere with Healing after Surgery?
J. Clin. Med. 2021, 10(11), 2359; https://doi.org/10.3390/jcm10112359 - 27 May 2021
Cited by 3 | Viewed by 676
Abstract
Perioperative analgesia should be multimodal to improve pain relief, reduce opioid use and thereby adverse effects impairing recovery. Non-steroidal anti-inflammatory drugs (NSAIDs) are an important non-opioid component of this approach. However, besides potential other adverse effects, there has been a longstanding discussion on [...] Read more.
Perioperative analgesia should be multimodal to improve pain relief, reduce opioid use and thereby adverse effects impairing recovery. Non-steroidal anti-inflammatory drugs (NSAIDs) are an important non-opioid component of this approach. However, besides potential other adverse effects, there has been a longstanding discussion on the potentially harmful effects of NSAIDs on healing after surgery and trauma. This review describes current knowledge of the effects of NSAIDs on healing of bones, cartilage, soft tissue, wounds, flaps and enteral anastomoses. Overall, animal data suggest some potentially harmful effects, but are contradictory in most areas studied. Human data are limited and of poor quality; in particular, there are only very few good randomized controlled trials (RCTs), but many cohort studies with potential for significant confounding factors influencing the results. The limited human data available are not precluding the use of NSAIDs postoperatively, in particular, short-term for less than 2 weeks. However, well-designed and large RCTs are required to permit definitive answers. Full article
Review
A Bibliometric Analysis of Published Literature in Postoperative Pain in Elderly Patients in Low- and Middle-Income Countries
J. Clin. Med. 2021, 10(11), 2334; https://doi.org/10.3390/jcm10112334 - 27 May 2021
Cited by 1 | Viewed by 903
Abstract
Postoperative pain (POP) remains a major challenge for surgeons and anesthesiologists worldwide, especially in low- and middle-income countries. Elderly patients are at higher risk for undertreatment of pain. Despite that, there is a paucity of papers addressing POP among this population in developing [...] Read more.
Postoperative pain (POP) remains a major challenge for surgeons and anesthesiologists worldwide, especially in low- and middle-income countries. Elderly patients are at higher risk for undertreatment of pain. Despite that, there is a paucity of papers addressing POP among this population in developing countries. This study aimed to provide a bibliometric analysis of the literature concerning postoperative pain in elderly patients from low- and middle-income countries. It was performed an extensive search of papers on this subject through the Web of Science and Scopus database using a series of uniterms and, including publications from 2001 to 2021. Publication quality was assessed by using total citation frequency, average citations per item and other citation indexes. Citation indexes were low, with the highest reaching 15 citations. In conclusion, few studies of postoperative pain in the elderly in countries with medium and low income, indicating a need that has not yet been met for this population and in these areas of the world. The published studies were not specifically aimed at the elderly, had limited impact, low international visibility. They were not epidemiological studies and are not robust, weakening knowledge and decision-making towards policies directed at this vulnerable population. Full article
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Review
Opioid-Free Anesthesia Benefit–Risk Balance: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
J. Clin. Med. 2021, 10(10), 2069; https://doi.org/10.3390/jcm10102069 - 12 May 2021
Cited by 4 | Viewed by 990
Abstract
Opioid-free anesthesia (OFA) is used in surgery to avoid opioid-related side effects. However, uncertainty exists in the balance between OFA benefits and risks. We searched for randomized controlled trials (RCTs) comparing OFA to opioid-based anesthesia (OBA) in five international databases. The co-primary outcomes [...] Read more.
Opioid-free anesthesia (OFA) is used in surgery to avoid opioid-related side effects. However, uncertainty exists in the balance between OFA benefits and risks. We searched for randomized controlled trials (RCTs) comparing OFA to opioid-based anesthesia (OBA) in five international databases. The co-primary outcomes were postoperative acute pain and morphine consumption at 2, 24, and 48 h. The secondary outcomes were the incidence of postoperative chronic pain, hemodynamic tolerance, severe adverse effects, opioid-related adverse effects, and specific adverse effects related to substitution drugs. Overall, 33 RCTs including 2209 participants were assessed. At 2 h, the OFA groups had lower pain scores at rest MD (0.75 (−1.18; −0.32)), which did not definitively reach MCID. Less morphine was required in the OFA groups at 2 and 24 h, but with very small reductions: 1.61 mg (−2.69; −0.53) and −1.73 mg (p < 0.05), respectively, both not reaching MCID. The reduction in PONV in the OFA group in the PACU presented an RR of 0.46 (0.38, 0.56) and an RR of 0.34 (0.21; 0.56), respectively. Less sedation and shivering were observed in the OFA groups with an SMD of −0.81 (−1.05; −0.58) and an RR of 0.48 (0.33; 0.70), respectively. Quantitative analysis did not reveal differences between the hemodynamic outcomes, although severe side effects have been identified in the literature. No clinically significant benefits were observed with OFA in terms of pain and opioid use after surgery. A clear benefit of OFA use was observed with respect to a reduction in PONV. However, more data on the safe use of OFAs should be collected and caution should be taken in the development of OFA. Full article
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Review
Sleep Well and Recover Faster with Less Pain—A Narrative Review on Sleep in the Perioperative Period
J. Clin. Med. 2021, 10(9), 2000; https://doi.org/10.3390/jcm10092000 - 07 May 2021
Cited by 1 | Viewed by 894
Abstract
Sleep disturbance, pain, and having a surgical procedure of some kind are all very likely to occur during the average lifespan. Postoperative pain continues to be a prevalent problem and growing evidence supports the association between pain and sleep disturbances. The bidirectional nature [...] Read more.
Sleep disturbance, pain, and having a surgical procedure of some kind are all very likely to occur during the average lifespan. Postoperative pain continues to be a prevalent problem and growing evidence supports the association between pain and sleep disturbances. The bidirectional nature of sleep and pain is widely acknowledged. A decline in sleep quality adds a risk for the onset of pain and also exacerbates existing pain. The risk factors for developing insomnia and experiencing severe pain after surgery are quite similar. The main aim of this narrative review is to discuss why it is important to be aware of sleep disturbances both before and after surgery, to know how sleep disturbances should be assessed and monitored, and to understand how better sleep can be supported by both pharmacological and non-pharmacological interventions. Full article
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Review
Big Data in Studying Acute Pain and Regional Anesthesia
J. Clin. Med. 2021, 10(7), 1425; https://doi.org/10.3390/jcm10071425 - 01 Apr 2021
Cited by 1 | Viewed by 681
Abstract
The digital transformation of healthcare is advancing, leading to an increasing availability of clinical data for research. Perioperative big data initiatives were established to monitor treatment quality and benchmark outcomes. However, big data analyses have long exceeded the status of pure quality surveillance [...] Read more.
The digital transformation of healthcare is advancing, leading to an increasing availability of clinical data for research. Perioperative big data initiatives were established to monitor treatment quality and benchmark outcomes. However, big data analyses have long exceeded the status of pure quality surveillance instruments. Large retrospective studies nowadays often represent the first approach to new questions in clinical research and pave the way for more expensive and resource intensive prospective trials. As a consequence, the utilization of big data in acute pain and regional anesthesia research has considerably increased over the last decade. Multicentric clinical registries and administrative databases (e.g., healthcare claims databases) have collected millions of cases until today, on which basis several important research questions were approached. In acute pain research, big data was used to assess postoperative pain outcomes, opioid utilization, and the efficiency of multimodal pain management strategies. In regional anesthesia, adverse events and potential benefits of regional anesthesia on postoperative morbidity and mortality were evaluated. This article provides a narrative review on the growing importance of big data for research in acute postoperative pain and regional anesthesia. Full article
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