Patient and Procedural Determinants of Postoperative Pain Trajectories

Abstract

Background The primary goal of this study was to evaluate patterns in acute postoperative pain in a mixed surgical patient cohort with the hypothesis that there would be heterogeneity in these patterns. Methods This study included 360 patients from a mixed surgical cohort whose pain was measured across postoperative days 1 through 7. Pain was characterized using the Brief Pain Inventory. Primary analysis used group-based trajectory modeling to estimate trajectories/patterns of postoperative pain. Secondary analysis examined associations between sociodemographic, clinical, and behavioral patient factors and pain trajectories. Results Five distinct postoperative pain trajectories were identified. Many patients (167 of 360, 46%) were in the moderate-to-high pain group, followed by the moderate-to-low (88 of 360, 24%), high (58 of 360, 17%), low (25 of 360, 7%), and decreasing (21 of 360, 6%) pain groups. Lower age (odds ratio, 0.94; 95% CI, 0.91 to 0.99), female sex (odds ratio, 6.5; 95% CI, 1.49 to 15.6), higher anxiety (odds ratio, 1.08; 95% CI, 1.01 to 1.14), and more pain behaviors (odds ratio, 1.10; 95% CI, 1.02 to 1.18) were related to increased likelihood of being in the high pain trajectory in multivariable analysis. Preoperative and intraoperative opioids were not associated with postoperative pain trajectories. Pain trajectory group was, however, associated with postoperative opioid use (P < 0.001), with the high pain group (249.5 oral morphine milligram equivalents) requiring four times more opioids than the low pain group (60.0 oral morphine milligram equivalents). Conclusions There are multiple distinct acute postoperative pain intensity trajectories, with 63% of patients reporting stable and sustained high or moderate-to-high pain over the first 7 days after surgery. These postoperative pain trajectories were predominantly defined by patient factors and not surgical factors. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Trajectories of opioid consumption from day of surgery to 28 days postoperatively: a prospective cohort study in patients undergoing abdominal, joint, or spine surgery

“…We chose K=5 classes initially as this had been shown to be the number of pain trajectory classes during the first 7 days following similar surgeries. 14 Evaluating the number of latent classes from 1 to 7 in the working model was then performed and the favored number of latent classes chosen based on the lowest Bayesian information criteria. The optimal structure of the model from fixed to unrestricted random effects was then determined.…”

“…In a study using similar methods to the current study, Vasilopoulos et al evaluated pain trajectories in a mixed surgical cohort across days 1-7 following surgery. 14 Five distinct trajectories of pain were identified: low, moderate-to-low, moderate-to-high, and high pain over time. A fifth trajectory identified dramatically decreasing pain over time.…”

The Future of Pain Medicine

“… the case of PPSP, the combination of certain gene polymorphisms and phenotypic factors has been associated with an increased risk. 17,[19][20][21] Additional opportunities related to a better understanding of genetics include evaluating the metabolism and action of opioids, 22 risk of substance use disorder, 3 and potentially advanced interventional therapies for common chronic diseases such as intervertebral disc pathologies. 24 We are also learning that treatment decisions related to pain management may have previously unrecognized and unanticipated long-term consequences.…”

Personalization over Protocolization

“…Previous larger studies (22,000 patients) suggest that 28% of patients still experience moderate-to-severe acute pain after surgery, 3 and higher pain trajectories have been associated with more frequent returns to the emergency department and readmission. 4 In this issue of Anesthesiology, Vasilopoulos et al 5 report their empiric discrimination of the postoperative pain trajectories of patients in the 7 days after undergoing major elective noncardiac surgery. The importance of looking at pain trajectory versus a single point in time or an average of pain scores over time (area under the curve) is that it represents a patient's pain experience over the duration of their care, graphically visualizing the time course of pain, including a sense of its stability and resolution, and allowing a more complete overall picture of analgesic benefit.…”

“…The prospective and iterative approach taken by Vasilopoulos et al 5 aimed to cluster patients with similar patterns and identified five unique postoperative trajectories, which is distinct from most previous descriptions, which typically have discerned only two or three trajectories. Their concise, clinically relevant descriptions of each of these groups revealed that, similar to previous trajectory work, most of the groups were primarily defined by the pain intensity/severity (high, moderate-to-high, moderate-to-low, and low), with the exception of a single group with a vastly different temporal pattern (descending pain group).…”