Acute pain trajectory after elective total hip arthroplasty: a systematic review and data synthesis

Classic high-scoring literature reading·Acute pain trajectory after elective total hip arthroplasty: systematic review and data synthesisPXL/Riozhou/LYEditor's key pointsØ Understanding when acute pain is likely to be problematic after surgery allows targeted management.
Ø Understanding postoperative acute pain The timing of when the pain may be problematic facilitates targeted treatment
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Ø Acute pain trajectories after total hip replacement were calculated from published literature, which displayed significant heterogeneity in analgesic approaches.
Heterogeneity
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Ø With a basic analgesic approach, pain peaked up to 2 h after surgery, and declined thereafter.
By identifying the acute pain trajectory, a range of additional analgesic approaches may be planned to minimise pain peaks.
Ø With a basic analgesic approach, Pain peaked at 2 hours postoperatively and then gradually decreased
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By identifying acute pain trajectories, a range of additional analgesic approaches can be planned to minimize pain peaks
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Ø There are very limited data on postoperative analgesia for chronic pain patients or those on long-term opioids, with a need for further research in this area.
limited, and further research is needed in this area
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Ø AbstractØ Background: For most procedures, there is insufficient evidence to guide clinicians in the optimal timing of advanced analgesic methods, which should be based on the expected time course of acute postoperative pain severity and aimed at time points where basic analgesia has proven insufficient.
Ø Background: For most procedures, there is insufficient evidence to guide clinicians in selecting the optimal timing of advanced analgesia approaches based on the expected time course of acute postoperative pain severity and targeting the inefficiency of primary analgesia.
sufficient time
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Ø Methods: We conducted a systematic search of the literature of analgesic trials for total hip arthroplasty (THA), extracting and pooling pain scores across studies, weighted for study size.
Patients were grouped according to basic anaesthetic method used (general, spinal), and adjuvant analgesic interventions such as nerve blocks, local infiltration analgesia, and multimodal analgesia.
Special consideration was given to high-risk populations such as chronic pain or opioid-dependent patients.
A systematic search of the literature on pain trials was performed, and pain scores from different studies were extracted and aggregated, weighted according to study size
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Patients were grouped according to the primary anesthesia method used (general anesthesia, spinal anesthesia) and adjunctive analgesic interventions (eg, nerve blocks, local infiltration, and multimodal analgesia)
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Special consideration is given to high-risk groups such as patients with chronic pain or opioid dependence
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Ø Results: We identified and analysed 71 trials with 5973 patients and constructed pain trajectories from the available pain scores.
In most patients undergoing THA under general anaesthesia on a basic analgesic regimen, postoperative acute pain recedes to a mild level (<4/10) by 4 h after surgery.
We note substantial variability in pain intensity even in patients subjected to similar analgesic regimens.
Chronic pain or opioid-dependent patients were most often actively excluded from studies, and never analysed separately.
Ø Results: We identified and analysed 71 trials with a total of 5973 patients and constructed pain trajectories based on available pain scores
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In most patients undergoing total hip arthroplasty under general anesthesia-based analgesia regimens, acute postoperative pain was reduced to mild (<4/10) 4 hours after surgery
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We noted significant differences in pain intensity even among patients receiving similar analgesic regimens
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Patients with chronic pain or opioid dependence were generally excluded from studies and were never analyzed separately
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Ø Conclusions: We have demonstrated that it is feasible to construct procedure-specific pain curves to guide clinicians on the timing of advanced analgesic measures.
Acute intense postoperative pain after THA should have resolved by 4-6 h after surgery in most patients.
However, There is a substantial gap in knowledge on the management of patients with chronic pain and opioid-dependent patients.
Ø Conclusion: We have demonstrated that it is feasible to construct procedure-specific pain profiles to guide clinicians in the timing of advanced analgesic measures
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In most patients, acute severe pain should disappear within 4-6 hours after total hip arthroplasty
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However, there are large gaps in knowledge about the management of patients with chronic pain and those with opioid dependence
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(1) Research background For most procedures, there is insufficient evidence to guide clinicians in the optimal timing of advanced analgesic methods, which should be based on the expected time course of acute postoperative pain severity and aimed at time points where basic analgesia has proven insufficient .
When is the best time to choose further pain relief methods? Basic analgesia has been shown to be insufficient; (2) Study protocol 1) Inclusion criteria: (1) Published clinical randomized controlled trials and non-randomized controlled trials; (2) Any age undergoing elective unilateral total hip arthroplasty of patients; (3) spinal or general anesthesia was reported as the primary type of anesthesia used; (4) the type and duration of postoperative pain management were reported (5) the primary outcome included postoperative pain at rest within 5 days postoperatively Scoring, secondary outcomes included hourly and cumulative postoperative opioid consumption
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2) Exclusion criteria: (1) studies, review articles, and case reports with unclear data were excluded; (2) studies that did not describe pain scores in sufficient detail to be included in weighted data summaries were excluded
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3) Specific process Our two literature searches identified 1631 potentially relevant studies, of which 793 duplicates were removed.
A total of 513 trials were excluded after screening their titles and abstracts because they did not meet the inclusion criteria.
We assessed the full-text articles of the remaining 325 studies, and an additional 20 studies were identified by reviewing references.
We excluded 274 studies where postoperative pain was not reported on a 10- or 100-point scale or that did not fulfil the inclusion criteria.
At the end of the selection period, a total of 71 studies were included in our analysis.
These studies had a total of 5973 patients, of whom 2327 underwent neuraxial block and 3646 underwent GA.
The time window during which reproducible data could be aggregated and which, in our view ,well reflects the clinical course after hip surgery, was 72 h Two literature searches identified 1631 potentially relevant studies, of which 793 duplicates were deleted
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After screening titles and abstracts, a total of 513 trials were excluded because they did not meet the inclusion criteria
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The full text of the remaining 325 studies was assessed and an additional 20 studies were identified by reviewing references
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274 studies that did not report postoperative pain on a 10 or 100 subscale or did not meet the inclusion criteria were excluded
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At the end of the selection period, a total of 71 studies were included in the analysis.
A total of 5973 patients were included in the studies, of which 2327 received axonal block and 3646 received GA for a time window of 72 hours
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(3) Research steps 1) Flowchart: 2) Interventions: • There was considerable heterogeneity in the way analgesic interventions were performed, we grouped them into five broad categories of interventions, which had been investigated in a sufficient number of studies to allow for the creation of pain trajectories:(1) LIA (1209 patients); (2) single shot nerve block (S-block, 515 patients);(3) continuous nerve block (C-block, 1430 patients);( 4) multimodal drug therapy (1198 patients); and (5) a primarily opioid-focused analgesic regimen representing the control group (C, 1621 patients).
• The authors group it into five broad categories of interventions that are already in sufficient numbers investigated to allow the creation of pain trajectories: (1) local infiltration block (LIA) (1209 patients); (2) single nerve block (S-block, 515 patients); (3) continuous Nerve block (C-block, 1430 patients); (4) multimodal drug therapy (1198 patients); and (5) control group (C, 1621 patients): analgesic regimen primarily focused on opioid
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Partial definitions of interventions supplemented • (1) LIA: The optimal technique and location of LIA is a subject of debate, with surgical practice varying widely, reflected also in the broad spectrum of different approaches among the 23 analysed studies.
The LIA interventions differed in respect to the infiltration site, the type of the local anaesthetic and other adjuvant drugs, the timing of infiltration, and the accompanying systemic analgesic regimen.
(2) Peripheral nerve blocks (including single shot nerve block and continuous nerve block ): there was heterogeneity of regional anaes-thetic technique, including the type of block, the timing, the local anaesthetic used, and the means of needle guidance (ultrasound[US], landmarks, or nerve stimulation).
Different peripheral nerve blocks re currently used for perioperative management in hipsurgery.
Seven types were included in this study: psoas compartment block, fascia iliaca block, femoral nerve sheath block, lumbar plexus block, subcostal nerve block, lateral femoral cutaneous nerve (LFCN) block , and the three-in-one block.
(There is also heterogeneity in regional anaesthesia techniques, including block type, timing, local anaesthetic used, and needle guidance (ultrasound, landmarks, or nerve stimulation)
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Different peripheral nerve blocks are currently used in the perioperative management of hip surgery
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Seven types were included in this study: psoas major compartment block, fascia iliaca block, femoral nerve sheath block, lumbar plexus block, subcostal nerve block, lateral femoral cutaneous nerve (LFCN) block, and three (3) multimodal drug therapy: The multimodal drug therapy group was defined by absence of use of LIA or peripheral nerve blocks.
The drug regimens and the dosages varied between studies but consisted mainly of NSAIDs, ketamine, gabapentin, COX-2 in-hibitors, pregabalin, glucocorticoids, and clonidine.
(The multimodal drug therapy group was defined as not using LIA or peripheral nerve blocks
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Drug regimens and doses varied by study, but consisted primarily of NSAIDs, ketamine, gabapentin, cyclooxygenase-2 inhibitors, pregabalin, glucocorticoids, and clonidine) 3) Data extraction: ü The first outcome: the patient's postoperative pain scores immediately after THA and up to 120 h postoperatively, both at rest and during activity, when available.
ü Main extracted data: the patient's postoperative pain scores immediately after THA and up to 120 h postoperatively, both at rest and during activity, when available.
Postoperative pain scores, including at rest and during activity; ü Secondary outcome: hourly and cumulative opioid consumption measured in milligrams of intravenous morphine equivalents according to the equianalgesic chart provided by the Pain Assessment and Management Initiative.
ü Secondary data extraction: Intravenous Hourly and cumulative opioid consumption measured in milligrams of morphine equivalents, thereby drawing a graph of equivalent analgesia; 4) Statistical analysis: Mean pain scores and standard deviation of pain scores were extracted from each study.
(From each item The mean pain scores and standard deviation of pain scores were extracted in the studies) (1) For studies that reported median pain scores with inter-quartile ranges or ranges, an approximate mean value and standard deviation were calculated.
More specifically,suppose the reported median and inter-quartile ranges were m and q1to q3, the approximate mean value would be mean =(q1+m+q3)/3, and the standard deviation would be S=(q3-q1)/(2φ‾ 1)x(0.
75n—0.
125)/(n+0.
25)
.

For studies reporting median pain scores with interquartile ranges, approximate means and standard deviations were calculated
.

More specifically, assuming the reported median and interquartile range are m and q1 to q3, the approximate mean is mean=(q1+m+q3)/3, and the standard deviation is S=(q3-q1)/ (2φ‾1)x(0.
75n-0.
125)/(n+0.
25) (2) For studies that reported median and mini-mum to maximum ranges (a to b, where a is the minimum and b is the maximum), the approximate mean would be mean=(a+2m+b)/4, and the standard deviation would be S=(ba)/(2φ‾1)x(n—0.
375)/(n+0.
25).
For the report in A study of the number of digits and the minimum to maximum range (a to b, where a is the minimum value and b is the maximum value), the approximate mean is mean=(a+2m+b)/4, and the standard deviation is S=(ba )/(2φ‾1)x(n-0.
375)/(n+0.
25)
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(3) In addition, for studies that reported mean values ​​and the range between minimum and maximum values, the approximate standard deviation would be S=(ba)/4.
, the approximate standard deviation is S=(ba)/4
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(IV) Research results Figure 2: Patients with general anesthesia received only the most basic analgesia, and the acute postoperative pain peak appeared at 0-2 hours after the operation, and then the pain intensity gradually decreased at 4-8 hours after the operation
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Patients with neuraxial anesthesia had significantly less pain at rest 2 h after surgery, and most patients reported only mild pain with basic perioperative analgesics
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Figure 3: Immediately after surgery, the cumulative opioid consumption in the GA group was higher, and at 48 h after surgery, the opioid consumption in the SA group was significantly higher than that in the GA group Figure 4: Patients receiving artificial hip replacement under multimodal analgesia The average patient will still experience an immediate postoperative pain peak! For patients receiving (a) general anesthesia-based analgesia, (b) general anesthesia multimodal analgesia, (c) general anesthesia LIA, or (d) general anesthesia single-injection block, the three main interventions were compared with the control group.
Side-by-side pain trajectories at rest to 72 hours post-surgery
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Figure 5: The pain curves of general anesthesia and spinal anesthesia during exercise were similar to rest pain, and the exercise pain in the GA group was significantly higher than that in the SA group in the acute postoperative period.
Constructed in patients undergoing total hip arthroplasty and receiving opioid-only therapy, it has an initial peak and the most severe pain subsides within 4-8 hours even with basic analgesia
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• There were significant differences in pain response even among patients undergoing the same type of surgery under the same analgesic regimen
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Patients receiving THA under SA appeared to be completely immune to this early peak
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However, this may be achieved at the expense of higher opioid consumption, as spinal anesthetics wear off and patients are titrated with opioid analgesics during and after PACU
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• The 'basic mean pain curve' may be another way of designing and evaluating analgesic interventions that can be used to anticipate postoperative pain intensity and time course, in a procedure-specific manner
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The potential value is to inform whether a given intervention can "flatten" the pain curve without making the intervention less effective until the pain subsides
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Often, guiding a patient through perioperative stress in a rapid manner means administering, for example, a single nerve block to the patient to facilitate discharge
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However, the advantages of immediate postoperative pain relief may be offset by the onset of pain because the block is terminated abruptly, often in settings where immediate analgesic use is not appropriate (eg, at home after outpatient surgery, in general after inpatient surgery surgical ward)
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• Most studies assessed pain at time points such as 12 and 24 hours postoperatively, but acute pain peaks have been reduced after hip replacement
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Therefore, in studies of analgesia in elective total hip arthroplasty, it may be helpful to look at the 0-8 hour postoperative time point to ensure that severe pain in the early postoperative period is accounted for
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• After total hip arthroplasty, local anesthetic infiltration and single-shot nerve blocks were effective in relieving postoperative pain when used in combination with artificial hip arthroplasty, whereas the general patient who underwent artificial hip arthroplasty under multimodal analgesia There is still an immediate postoperative pain peak, and excellent pain relief and functional recovery can be achieved with multimodal analgesia alone or in combination with LIA
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(VI) Conclusions • The pain trajectories after a single surgical intervention provides a new way of defining the time period when directed pain management would actually make the most clinically significant difference for the patient.
• our analysis suggests that the period of intense postoperative pain after elective unilateral THA spans the first 0-4h, after which between 4 and 8 h, most patients' pain shoul d have receded to acceptable levels even on a basic analgesic regimen.
• Pain curves provide a new way to define The time period in pain management that is most clinically meaningful to the patient
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• The time span of severe pain after elective unilateral THA is the initial 0-4 hours; after 4 to 8 hours, pain should have resolved to an acceptable level in most patients, even under basic analgesia regimens
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