Factors affecting the incidence of chronic pain following breast cancer surgery: Preoperative history, anesthetic management, and surgical technique.

BACKGROUND OR OBJECTIVES: Breast cancer is the most frequent cancer in women. Chronic pain following mastectomy remains a significant problem. This study aimed to evaluate risk factors associated with postoperative chronic pain. METHODS: Medical records were analyzed retrospectively for 147 consecutive patients with breast cancer who underwent mastectomy between July 2016 and February 2018 with one-year follow-up. All patients received a paravertebral block pre-operatively and then general anesthesia for the surgery. RESULTS: The median postoperative pain score was 1.3 on the verbal analgesic score. The average total dose of opioids administered postoperatively was 10.4 mg, expressed in morphine milligram equivalents. The incidence of chronic pain after mastectomy was 16.7% at 6 months and 13.3% at 1 year. The satisfaction rate for anesthesia and surgery was 95.7%. CONCLUSIONS: The data suggested that preoperative paravertebral nerve blocks, appropriate adjuvants, and a balanced general anesthetic may contribute to better postoperative pain control and decreased the incidence of chronic pain. A history of preoperative use of opioids and/or a history of alcohol consumption were both associated with significant increased levels of postoperative pain, and this subgroup warrants attention to diminish the risk of developing chronic pain.

The utility of abnormal initial arterial blood gas values in determining clinical futility of trauma cases with severe hemorrhage.

BACKGROUND: Patients who experience trauma with severe hemorrhage requiring immediate surgery and massive blood transfusion often present with markedly abnormal laboratory values. These cases require valuable resources; however, little is known regarding prognostic factors that correlate with mortality. The purpose of this study was to determine whether abnormal initial arterial blood gas (ABG) pH, a marker for severe blood loss, could serve as a prognostic indicator for these patients. METHODS: An IRB approved retrospective study was performed at LAC+USC Medical Center Level I Trauma Center. Data was collected from trauma patients with severe hemorrhage admitted between June 2015 and April 2016 who were immediately admitted to the OR following entry into the ER. Baseline variables of age, sex and mechanism of trauma were collected. The pH readings from the initial three ABG data were obtained, and mortality was determined for each patient. RESULTS: We identified 247 patients, 84.2% of which were male. Ages ranged from 1 to 91years (average=38.4). Overall mortality was 13.8%. The average initial pH value for non-survivors (7.10±0.13) was significantly lower than for survivors (7.34±0.07) [p<0.001]. Among patients whose initial three ABG pH values averaged ≤7.15, the survival rate was 8.7%. Ten patients had any single recorded pH value≤6.91. The mortality rate among these patients was 90%. CONCLUSIONS: Consideration should be given to initial pH values when resuscitating "red blanket" patients. However, the pH values alone cannot reliably be used to determine clinical futility in individual patients in the early period after injury.

Challenges of pain control and the role of the ambulatory pain specialist in the outpatient surgery setting.

Ambulatory surgery is on the rise, with an unmet need for optimum pain control in ambulatory surgery centers worldwide. It is important that there is a proportionate increase in the availability of acute pain-management services to match the rapid rise of clinical patient load with pain issues in the ambulatory surgery setting. Focus on ambulatory pain control with its special challenges is vital to achieve optimum pain control and prevent morbidity and mortality. Management of perioperative pain in the ambulatory surgery setting is becoming increasingly complex, and requires the employment of a multimodal approach and interventions facilitated by ambulatory surgery pain specialists, which is a new concept. A focused ambulatory pain specialist on site at each ambulatory surgery center, in addition to providing safe anesthesia, could intervene early once problematic pain issues are recognized, thus preventing emergency room visits, as well as readmissions for uncontrolled pain. This paper reviews methods of acute-pain management in the ambulatory setting with risk stratification, the utilization of multimodal interventions, including pharmacological and nonpharmacological options, opioids, nonopioids, and various routes with the goal of preventing delayed discharge and unexpected hospital admissions after ambulatory surgery. Continued research and investigation in the area of pain management with outcome studies in acute surgically inflicted pain in patients with underlying chronic pain treated with opioids and the pattern and predictive factors for pain in the ambulatory surgical setting is needed.

The Clinical Applications of Extended-Release Abuse-Deterrent Opioids.

Opioids are the mainstay for treatment of acute pain and cancer pain, and also have a role in the treatment of chronic non-malignant pain. There has been, however, a growing public health problem stemming from the misuse of opioid analgesics leading to serious consequences. To deter abuse, new formulations of extended-release opioid analgesics and tamper-resistant opioids have recently been developed. The concept of abuse-deterrent extended-release opioids is relatively new and, although abuse may not be completely prevented, the utilization of such abuse-deterrent extended-release opioids could reduce this risk. Extended-release abuse-deterrent opioids have been found to have important clinical applications in cancer, acute pain, and chronic non-malignant pain for analgesia control with decreased incidence of tampering and abuse. In this review, different extended-release formulations of opioids available for clinical applications are presented with descriptions of the formulations, their physical properties, and the clinical studies performed to provide physicians with a better understanding of their uses.

Tapentadol extended release in the management of peripheral diabetic neuropathic pain.

Tapentadol, a µ-opioid agonist and norepinephrine reuptake inhibitor, has been found to be an effective medication for a wide variety of chronic pain conditions, including back pain, cancer-related pain, and arthritic pain. It has also been found to have fewer gastrointestinal side effects than more traditional opioid-based therapies. More recently, tapentadol extended release has been demonstrated to be effective in the management of painful diabetic neuropathy, an often debilitating condition affecting approximately one-third of all patients with diabetes. This review highlights the most up-to-date basic and clinical studies by focusing on the mechanisms of action of tapentadol and its clinical efficacy, especially with regard to painful diabetic neuropathy.