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analgesia on postoperative pain and analgesic use following total knee replacement
Abstracts
F19 Perioperative Analgesia (452) The effect of regional versus general intraoperative anesthesia/analgesia on postoperative pain and analgesic use following total knee replacement J Bussler, C O-Sullivan, K Sluka, K Herr, S Booker, C Clark, N Noiseux, J Callaghan, B Rakel, and M Zimmerman; The University of Iowa, Iowa City, IA Total Knee Replacement (TKR) is a common procedure for older individuals and is often associated with severe postoperative pain. Both regional and general intraoperative anesthesia/analgesia (IAA) are used but evidence of their effect on postoperative pain and analgesic use is inconsistent and little is known about factors that influence the choice of IAA for TKR. The purpose of this study was to compare characteristics of patients receiving regional versus general IAA and determine if patients receiving regional IAA experience significantly less postoperative pain and analgesic intake than patients receiving general IAA. The current study is part of a large randomized, placebocontrolled trial evaluating the effect of TENS on rehabilitation pain following TKR. Data were collected from 297 participants undergoing TKR, of whom 52% received general and 48% received regional IAA. Participants were 50% female with a mean age of 62.3 years (SD=9.5). Preoperative demographic, medical, and psychological characteristics were collected, along with pain and analgesic intake from surgery to postoperative day 2. Participants receiving regional IAA were significantly more likely to be female (p=0.010), have longer pain duration prior to surgery (p=0.002), take more pain medication preoperatively (p=0.021), and have specific surgeons perform their surgery (p=0.0001). Veteran participants having surgery at the VAMC were significantly less likely to receive regional IAA (p=0.0001). Participants receiving regional IAA did not have significantly less pain (at rest or with knee ROM) or analgesic intake (opioid or non-opioid) during the immediate postoperative period compared to those receiving general IAA. These results did not change when controlling for sex, pain duration, preop pain medication, or surgeon/site. While there are factors that influence who will receive regional versus general IAA, pain and analgesic intake during the immediate postoperative period are not impacted by the type of IAA received. This work was supported by NIH grant R01NR009844.
F21 Sympathetic Blocks (453) Ganglion impar block for chronic vulvar pain syndrome J Park; Kyungpook National University Medical Center, Daegu, South Korea Although chronic vulvar pain syndrome or vulvodynia is not rare, it has no known effective treatment. Vulvodynia may be a common pathway in or the ultimate outcome of several pathological processes; therefore, given the heterogeneous etiology of the disorder, one management strategy may not be adequate for all women with vulvar pain. Although the role of the sympathetic nervous system (SNS) in neuropathic pain is a controversial issue, selective sympathetic nerve blocks have been a standard treatment for chronic pain. Efferent sympathetic nerve activity is functionally separate from that of primary afferent neurons under normal physiologic conditions, but nerve injury or tissue inflammation may result in chemical and anatomical coupling of sympathetic postganglionic and primary sensory neurons. In this case, the SNS may mediate pain via abnormal activation of the a-adrenergic receptors of primary afferents, direct interaction between efferent sympathetic fibers and primary afferent neurons during regeneration and sprouting, or indirect coupling through neurovascular transmission-mediated effects. Four patients who had experienced vulvar pain for 3 months to more than 10 years were treated with ganglion impar block under C-arm guidance with a mixture of 0.5% lidocaine (4 cc), 0.2% ropivacaine (5 cc), and triamcinolone (20 mg). Ganglion impar block was performed once in 2 patients, twice in 1 patient, and four times in 1 patient (including neurolysis with alcohol). The initial visual analogue scale scores ranged from 6 to 9, but decreased to less than 4 in all patients after the procedure. The symptom completely improved and no further treatment was necessary in 1 patient; the other 3 patients received medication (opioid + serotonin-norepinephrine reuptake inhibitor + pregabalin). The follow-up period was 3 months to 2 years. In conclusion, chronic vulvar pain syndrome can be effectively managed with ganglion impar block, and a multimodal and multidisciplinary team approach is essential.
The Journal of Pain
S89
(454) Cervical sympathetic blockade for the management of electrical storm R Ali, J Ciccone, and V Tseng; Mount Sinai Medical Center, New York, NY A 75 year old male with a past medical history of ischemic cardiomyopathy, coronary artery disease, 5 vessel coronary artery bypass graft, multiple percutaneous coronary interventions, and atrial fibrillation presented with dizziness and fatigue secondary to ventricular and supraventricular arrhythmias. He underwent an elective ablation but continued to have ventricular tachycardia (VT) with cardiovascular instability despite antiarrhythmic therapy with multiple agents. The patient continued to develop episodes of VT and an episode of ventricular fibrillation (VF). Electrical storm (ES) encompasses a situation of cardiac instability which may present as several episodes of ventricular tachycardia or ventricular fibrillation in a short period of time. We performed an ultrasound guided left stellate ganglion block at the bedside which resulted in sinus rhythm with episodes of sinus tachycardia and abolition of electrical storm. Left stellate ganglion block has proven to be a successful mode of treatment for patients with ventricular tachyarrhythmia resistant to medical management or those who fail atrioventricular node ablation. Ultrasound guided LSGB is a valuable and effective means to providing sympathectomy in the management of electrical storm or ventricular tachyarrhythmias.
F23 Other Interventional Techniques (455) How long does it last? Sustaining improved pain practices in pediatric hospitals following implementation of a knowledge translation intervention and pain practice booster B Stevens, J Yamada, and S Promislow C, TEAM IN CHILDREN’S PAIN; The Hospital for Sick Children, Toronto, Ontario, Canada Despite substantial pediatric pain research, pain assessment and management practices for hospitalized children remain sub-optimal. To address this research to practice gap, a multidimensional knowledge translation (KT) intervention, Evidence-based Practice for Improving Quality (EPIQ), was implemented. EPIQ significantly improved pain assessment and management from baseline to EPIQ completion; however, the sustainability of these improvements over time and the introduction of a pain practice change booster intervention (Booster) to sustain improved pain practices requires further study. The objectives of the study were to determine (1) the sustainability of EPIQ on pain practices 12 months post EPIQ and (2) the effectiveness of the Booster at 24 and 36 months post EPIQ compared to baseline. A repeated measures cohort comparative design study was conducted in 16 units at 8 Canadian pediatric hospitals. Following EPIQ completion, a repeated measures cluster RCT was conducted; 8 units randomized to the Booster and 8 to standard care. Pain practices were compared to baseline at EPIQ completion and 12, 24 and 36 months postEPIQ completion. Statistically significant differences were found over time in the proportion of children whose pain was assessed using any pain assessment tool (P=0.017) and a validated pain assessment tool (P=0.023). At 36 months, a significantly higher proportion of patients had their pain assessed using validated tools (P=0.022) compared to baseline. Statistically significant improvements were associated with pain management interventions; however, results were variable over time. There were no significant group by time interactions for pain practices following the Booster implementation. Improved pain assessment practices were sustained and enhanced over time, post EPIQ. However, the Booster did not appear to provide any additional impact on pain practices. A more effective strategy to promote sustained improvements in pediatric pain practices over time is needed. Supported by the Canadian Institutes for Health Research (CTP-79854, MOP-86605 and MOP-231330).
F19 Perioperative Analgesia (452) The effect of regional versus general intraoperative anesthesia/analgesia on postoperative pain and analgesic use following total knee replacement J Bussler, C O-Sullivan, K Sluka, K Herr, S Booker, C Clark, N Noiseux, J Callaghan, B Rakel, and M Zimmerman; The University of Iowa, Iowa City, IA Total Knee Replacement (TKR) is a common procedure for older individuals and is often associated with severe postoperative pain. Both regional and general intraoperative anesthesia/analgesia (IAA) are used but evidence of their effect on postoperative pain and analgesic use is inconsistent and little is known about factors that influence the choice of IAA for TKR. The purpose of this study was to compare characteristics of patients receiving regional versus general IAA and determine if patients receiving regional IAA experience significantly less postoperative pain and analgesic intake than patients receiving general IAA. The current study is part of a large randomized, placebocontrolled trial evaluating the effect of TENS on rehabilitation pain following TKR. Data were collected from 297 participants undergoing TKR, of whom 52% received general and 48% received regional IAA. Participants were 50% female with a mean age of 62.3 years (SD=9.5). Preoperative demographic, medical, and psychological characteristics were collected, along with pain and analgesic intake from surgery to postoperative day 2. Participants receiving regional IAA were significantly more likely to be female (p=0.010), have longer pain duration prior to surgery (p=0.002), take more pain medication preoperatively (p=0.021), and have specific surgeons perform their surgery (p=0.0001). Veteran participants having surgery at the VAMC were significantly less likely to receive regional IAA (p=0.0001). Participants receiving regional IAA did not have significantly less pain (at rest or with knee ROM) or analgesic intake (opioid or non-opioid) during the immediate postoperative period compared to those receiving general IAA. These results did not change when controlling for sex, pain duration, preop pain medication, or surgeon/site. While there are factors that influence who will receive regional versus general IAA, pain and analgesic intake during the immediate postoperative period are not impacted by the type of IAA received. This work was supported by NIH grant R01NR009844.
F21 Sympathetic Blocks (453) Ganglion impar block for chronic vulvar pain syndrome J Park; Kyungpook National University Medical Center, Daegu, South Korea Although chronic vulvar pain syndrome or vulvodynia is not rare, it has no known effective treatment. Vulvodynia may be a common pathway in or the ultimate outcome of several pathological processes; therefore, given the heterogeneous etiology of the disorder, one management strategy may not be adequate for all women with vulvar pain. Although the role of the sympathetic nervous system (SNS) in neuropathic pain is a controversial issue, selective sympathetic nerve blocks have been a standard treatment for chronic pain. Efferent sympathetic nerve activity is functionally separate from that of primary afferent neurons under normal physiologic conditions, but nerve injury or tissue inflammation may result in chemical and anatomical coupling of sympathetic postganglionic and primary sensory neurons. In this case, the SNS may mediate pain via abnormal activation of the a-adrenergic receptors of primary afferents, direct interaction between efferent sympathetic fibers and primary afferent neurons during regeneration and sprouting, or indirect coupling through neurovascular transmission-mediated effects. Four patients who had experienced vulvar pain for 3 months to more than 10 years were treated with ganglion impar block under C-arm guidance with a mixture of 0.5% lidocaine (4 cc), 0.2% ropivacaine (5 cc), and triamcinolone (20 mg). Ganglion impar block was performed once in 2 patients, twice in 1 patient, and four times in 1 patient (including neurolysis with alcohol). The initial visual analogue scale scores ranged from 6 to 9, but decreased to less than 4 in all patients after the procedure. The symptom completely improved and no further treatment was necessary in 1 patient; the other 3 patients received medication (opioid + serotonin-norepinephrine reuptake inhibitor + pregabalin). The follow-up period was 3 months to 2 years. In conclusion, chronic vulvar pain syndrome can be effectively managed with ganglion impar block, and a multimodal and multidisciplinary team approach is essential.
The Journal of Pain
S89
(454) Cervical sympathetic blockade for the management of electrical storm R Ali, J Ciccone, and V Tseng; Mount Sinai Medical Center, New York, NY A 75 year old male with a past medical history of ischemic cardiomyopathy, coronary artery disease, 5 vessel coronary artery bypass graft, multiple percutaneous coronary interventions, and atrial fibrillation presented with dizziness and fatigue secondary to ventricular and supraventricular arrhythmias. He underwent an elective ablation but continued to have ventricular tachycardia (VT) with cardiovascular instability despite antiarrhythmic therapy with multiple agents. The patient continued to develop episodes of VT and an episode of ventricular fibrillation (VF). Electrical storm (ES) encompasses a situation of cardiac instability which may present as several episodes of ventricular tachycardia or ventricular fibrillation in a short period of time. We performed an ultrasound guided left stellate ganglion block at the bedside which resulted in sinus rhythm with episodes of sinus tachycardia and abolition of electrical storm. Left stellate ganglion block has proven to be a successful mode of treatment for patients with ventricular tachyarrhythmia resistant to medical management or those who fail atrioventricular node ablation. Ultrasound guided LSGB is a valuable and effective means to providing sympathectomy in the management of electrical storm or ventricular tachyarrhythmias.
F23 Other Interventional Techniques (455) How long does it last? Sustaining improved pain practices in pediatric hospitals following implementation of a knowledge translation intervention and pain practice booster B Stevens, J Yamada, and S Promislow C, TEAM IN CHILDREN’S PAIN; The Hospital for Sick Children, Toronto, Ontario, Canada Despite substantial pediatric pain research, pain assessment and management practices for hospitalized children remain sub-optimal. To address this research to practice gap, a multidimensional knowledge translation (KT) intervention, Evidence-based Practice for Improving Quality (EPIQ), was implemented. EPIQ significantly improved pain assessment and management from baseline to EPIQ completion; however, the sustainability of these improvements over time and the introduction of a pain practice change booster intervention (Booster) to sustain improved pain practices requires further study. The objectives of the study were to determine (1) the sustainability of EPIQ on pain practices 12 months post EPIQ and (2) the effectiveness of the Booster at 24 and 36 months post EPIQ compared to baseline. A repeated measures cohort comparative design study was conducted in 16 units at 8 Canadian pediatric hospitals. Following EPIQ completion, a repeated measures cluster RCT was conducted; 8 units randomized to the Booster and 8 to standard care. Pain practices were compared to baseline at EPIQ completion and 12, 24 and 36 months postEPIQ completion. Statistically significant differences were found over time in the proportion of children whose pain was assessed using any pain assessment tool (P=0.017) and a validated pain assessment tool (P=0.023). At 36 months, a significantly higher proportion of patients had their pain assessed using validated tools (P=0.022) compared to baseline. Statistically significant improvements were associated with pain management interventions; however, results were variable over time. There were no significant group by time interactions for pain practices following the Booster implementation. Improved pain assessment practices were sustained and enhanced over time, post EPIQ. However, the Booster did not appear to provide any additional impact on pain practices. A more effective strategy to promote sustained improvements in pediatric pain practices over time is needed. Supported by the Canadian Institutes for Health Research (CTP-79854, MOP-86605 and MOP-231330).