Pub Date : 2025-12-01DOI: 10.1016/j.bjao.2025.100509
Thuy Bui , Michael J. Dooley , J. Simon Bell , Paul S. Myles
Up to one-third of patients are discharged with opioids after surgery, and up to one-half after traumatic injury, with usage typically intended for the short term. Evidence on persistent opioid use predominantly originates from North America, particularly the USA, and focuses on the elective surgical population. Definitions of new persistent opioid use vary widely, particularly in how opioid-naïve patients are classified and continued use is measured. The reported incidence of new persistent opioid use after surgery and trauma ranges from <1% to 41%, depending on the population, setting, and definition used. Although patient characteristics and factors related to surgery and trauma care are key risk factors, many of which are not readily modifiable, opioid prescribing practices represent a modifiable and actionable target for intervention. Understanding these risks can assist healthcare providers in implementing alternative management strategies to promote judicious opioid prescribing and reduce persistent opioid use. High-income countries with substantial opioid-related harms have implemented various strategies, ranging from national to hospital-level initiatives, to reduce prescribing and limit opioid exposure after hospital discharge. A priority is the development and adoption of standardised definitions, which consider the various opioid medications, incorporate different data sources, and clearly define thresholds for duration and quantity of use. Further research on new persistent opioid use in more regions, after trauma, targeted interventions, and their impact on patient-centred outcomes is needed.
{"title":"New persistent opioid use after surgery and traumatic injury: a narrative review of global rates, risk factors, and healthcare interventions","authors":"Thuy Bui , Michael J. Dooley , J. Simon Bell , Paul S. Myles","doi":"10.1016/j.bjao.2025.100509","DOIUrl":"10.1016/j.bjao.2025.100509","url":null,"abstract":"<div><div>Up to one-third of patients are discharged with opioids after surgery, and up to one-half after traumatic injury, with usage typically intended for the short term. Evidence on persistent opioid use predominantly originates from North America, particularly the USA, and focuses on the elective surgical population. Definitions of new persistent opioid use vary widely, particularly in how opioid-naïve patients are classified and continued use is measured. The reported incidence of new persistent opioid use after surgery and trauma ranges from <1% to 41%, depending on the population, setting, and definition used. Although patient characteristics and factors related to surgery and trauma care are key risk factors, many of which are not readily modifiable, opioid prescribing practices represent a modifiable and actionable target for intervention. Understanding these risks can assist healthcare providers in implementing alternative management strategies to promote judicious opioid prescribing and reduce persistent opioid use. High-income countries with substantial opioid-related harms have implemented various strategies, ranging from national to hospital-level initiatives, to reduce prescribing and limit opioid exposure after hospital discharge. A priority is the development and adoption of standardised definitions, which consider the various opioid medications, incorporate different data sources, and clearly define thresholds for duration and quantity of use. Further research on new persistent opioid use in more regions, after trauma, targeted interventions, and their impact on patient-centred outcomes is needed.</div></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"16 ","pages":"Article 100509"},"PeriodicalIF":0.0,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145694170","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-01DOI: 10.1016/j.bjao.2025.100512
Thomas Giral , Olivier Maupain , Yoann Elmaleh , Davy Huynh , Floriane Ciceron , Kilian Yao , Pablo Devidas , Albert El Metni , Johannes Kutter
Background
Haemorrhoid surgery is often associated with severe postoperative pain. Bilateral transperineal pudendal nerve block, performed using anatomical landmarks or nerve stimulation, is effective and currently recommended for postoperative analgesia. However, these blind techniques carry risks such as pudendal artery puncture or rectal injury and are not always routinely performed. The ultrasound-guided transperineal pudendal nerve block has shown promise in paediatric urological surgery, appearing both effective and well tolerated, but has not yet been evaluated in proctological procedures.
Methods
This multicentre, prospective, randomised, double-blind trial aims to compare the analgesic efficacy, adverse effects, and safety of ultrasound-guided vs nerve stimulator-guided bilateral transperineal pudendal nerve block in patients undergoing haemorrhoid surgery. The primary endpoint is the maximum pain score (0–10 numerical rating scale) in the post-anaesthesia care unit. Secondary outcomes include length of stay in post-anaesthesia care unit and hospital, quality of recovery score (QoR-15 score), pain and analgesic medication consumption during the first 7 days, and treatment-related adverse effects and safety. A total of 202 patients are required to test non-inferiority, based on a predefined margin of 0.7. The study received ethical approval from the Comité de Protection des Personnes Ouest IV in May 2025.
Conclusions
Recruitment is expected to begin in September 2025. Results will be submitted for peer-reviewed publication and conference presentation.
{"title":"Ultrasound-guided versus neurostimulation-guided bilateral transperineal pudendal nerve block for analgesia in outpatient haemorrhoid surgery: protocol for a multicentre, randomised, double-blind, non-inferiority trial","authors":"Thomas Giral , Olivier Maupain , Yoann Elmaleh , Davy Huynh , Floriane Ciceron , Kilian Yao , Pablo Devidas , Albert El Metni , Johannes Kutter","doi":"10.1016/j.bjao.2025.100512","DOIUrl":"10.1016/j.bjao.2025.100512","url":null,"abstract":"<div><h3>Background</h3><div>Haemorrhoid surgery is often associated with severe postoperative pain. Bilateral transperineal pudendal nerve block, performed using anatomical landmarks or nerve stimulation, is effective and currently recommended for postoperative analgesia. However, these blind techniques carry risks such as pudendal artery puncture or rectal injury and are not always routinely performed. The ultrasound-guided transperineal pudendal nerve block has shown promise in paediatric urological surgery, appearing both effective and well tolerated, but has not yet been evaluated in proctological procedures.</div></div><div><h3>Methods</h3><div>This multicentre, prospective, randomised, double-blind trial aims to compare the analgesic efficacy, adverse effects, and safety of ultrasound-guided <em>vs</em> nerve stimulator-guided bilateral transperineal pudendal nerve block in patients undergoing haemorrhoid surgery. The primary endpoint is the maximum pain score (0–10 numerical rating scale) in the post-anaesthesia care unit. Secondary outcomes include length of stay in post-anaesthesia care unit and hospital, quality of recovery score (QoR-15 score), pain and analgesic medication consumption during the first 7 days, and treatment-related adverse effects and safety. A total of 202 patients are required to test non-inferiority, based on a predefined margin of 0.7. The study received ethical approval from the Comité de Protection des Personnes Ouest IV in May 2025.</div></div><div><h3>Conclusions</h3><div>Recruitment is expected to begin in September 2025. Results will be submitted for peer-reviewed publication and conference presentation.</div></div><div><h3>Clinical trial registration</h3><div>NCT07015775.</div></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"16 ","pages":"Article 100512"},"PeriodicalIF":0.0,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145746876","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-01DOI: 10.1016/j.bjao.2025.100506
Sune Bille , Rasmus B. Lindhardt , Lars P. Riber , Peter Juhl-Olsen , Hanne B. Ravn , Sebastian B. Rasmussen
Background
Chronic kidney disease (CKD) is a well-established risk factor for adverse outcomes after cardiac surgery. However, the long-term trajectory of kidney function in this high-risk group remains poorly characterised. This study’s primary aim was to describe CKD progression and kidney failure in patients with kidney impairment before cardiac surgery. The secondary aim was to evaluate the impact of preexisting CKD in association with known risk factors (age, sex, and postoperative acute kidney injury) on CKD disease progression after cardiac surgery.
Methods
This retrospective observational multicentre study included adult patients who underwent cardiac surgery at the Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, between 2000 and 2022, and the Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, between 2008 and 2024. Three outcomes were assessed, according to Kidney Disease: Improving Global Outcomes (KDIGO): rapid progression (confirmed estimated glomerular filtration rate [eGFR] decline ≥5 ml min−1 1.73 m2 per year), CKD stage progression (confirmed decline in eGFR ≥25% with CKD stage advancement), and kidney failure (confirmed eGFR <15 ml min−1 1.73 m2). Competing risk analysis accounted for mortality during median 7-yr follow-up.
Results
Among 27 483 adult cardiac surgery patients, 3512 patients (12.8%) had preexisting CKD (KDIGO stages G3a–G5), based on preoperative eGFR levels. Five-year survival decreased with worsening baseline kidney function: 86.1% in stages G1–2, 70.6% in stage G3a, 61.4% in stage G3b, 45.7% in stage G4, and 51.9% in stage G5. Cumulative 5-yr incidence was 38.7% for rapid progression, 23.8% for CKD stage progression, and 5.5% for kidney failure. Events clustered early post discharge, with 43% of rapid progression, 26% of kidney failure, and 18% of CKD progression events occurring within the first year. Males aged ≤70 yr with stage G4 CKD who developed postoperative acute kidney injury faced highest risks across all outcomes.
Conclusions
Cardiac surgery patients with preexisting CKD face substantial kidney disease progression, especially early after discharge. These findings highlight the need for research into structured follow-up programmes and kidney-preventive interventions.
背景：慢性肾脏疾病（CKD）是心脏手术后不良后果的一个公认的危险因素。然而，在这一高危人群中，肾功能的长期发展轨迹仍然不明确。本研究的主要目的是描述心脏手术前肾脏损害患者的CKD进展和肾衰竭。次要目的是评估先前存在的CKD与已知危险因素（年龄、性别和术后急性肾损伤）对心脏手术后CKD疾病进展的影响。方法本回顾性观察性多中心研究纳入2000年至2022年在欧登塞大学医院心胸血管外科和2008年至2024年在奥胡斯大学医院心胸血管外科接受心脏手术的成年患者。根据肾脏疾病：改善总体结果（KDIGO）评估了三个结果：快速进展（确认估计肾小球滤过率[eGFR]下降≥5 ml min - 1 1.73 m2 /年），CKD阶段进展（确认eGFR下降≥25%，CKD阶段进展）和肾衰竭（确认eGFR下降15 ml min - 1 1.73 m2）。竞争风险分析计算了中位7年随访期间的死亡率。结果在27483例成人心脏手术患者中，根据术前eGFR水平，3512例（12.8%）患者既往存在CKD （KDIGO分期G3a-G5）。5年生存率随着基线肾功能的恶化而下降：G1-2期为86.1%，G3a期为70.6%，G3b期为61.4%，G4期为45.7%，G5期为51.9%。快速进展的5年累积发病率为38.7%，CKD阶段进展为23.8%，肾衰竭为5.5%。事件集中在出院后早期，43%的快速进展，26%的肾衰竭和18%的CKD进展事件发生在第一年。年龄≤70岁的男性G4期CKD术后发生急性肾损伤的风险最高。结论既往存在CKD的心脏手术患者面临严重的肾脏疾病进展，特别是出院后早期。这些发现强调了对结构化随访规划和肾脏预防干预进行研究的必要性。
{"title":"Chronic kidney disease progression after cardiac surgery: a retrospective multicentre study","authors":"Sune Bille , Rasmus B. Lindhardt , Lars P. Riber , Peter Juhl-Olsen , Hanne B. Ravn , Sebastian B. Rasmussen","doi":"10.1016/j.bjao.2025.100506","DOIUrl":"10.1016/j.bjao.2025.100506","url":null,"abstract":"<div><h3>Background</h3><div>Chronic kidney disease (CKD) is a well-established risk factor for adverse outcomes after cardiac surgery. However, the long-term trajectory of kidney function in this high-risk group remains poorly characterised. This study’s primary aim was to describe CKD progression and kidney failure in patients with kidney impairment before cardiac surgery. The secondary aim was to evaluate the impact of preexisting CKD in association with known risk factors (age, sex, and postoperative acute kidney injury) on CKD disease progression after cardiac surgery.</div></div><div><h3>Methods</h3><div>This retrospective observational multicentre study included adult patients who underwent cardiac surgery at the Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, between 2000 and 2022, and the Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, between 2008 and 2024. Three outcomes were assessed, according to Kidney Disease: Improving Global Outcomes (KDIGO): rapid progression (confirmed estimated glomerular filtration rate [eGFR] decline ≥5 ml min<sup>−1</sup> 1.73 m<sup>2</sup> per year), CKD stage progression (confirmed decline in eGFR ≥25% with CKD stage advancement), and kidney failure (confirmed eGFR <15 ml min<sup>−1</sup> 1.73 m<sup>2</sup>). Competing risk analysis accounted for mortality during median 7-yr follow-up.</div></div><div><h3>Results</h3><div>Among 27 483 adult cardiac surgery patients, 3512 patients (12.8%) had preexisting CKD (KDIGO stages G3a–G5), based on preoperative eGFR levels. Five-year survival decreased with worsening baseline kidney function: 86.1% in stages G1–2, 70.6% in stage G3a, 61.4% in stage G3b, 45.7% in stage G4, and 51.9% in stage G5. Cumulative 5-yr incidence was 38.7% for rapid progression, 23.8% for CKD stage progression, and 5.5% for kidney failure. Events clustered early post discharge, with 43% of rapid progression, 26% of kidney failure, and 18% of CKD progression events occurring within the first year. Males aged ≤70 yr with stage G4 CKD who developed postoperative acute kidney injury faced highest risks across all outcomes.</div></div><div><h3>Conclusions</h3><div>Cardiac surgery patients with preexisting CKD face substantial kidney disease progression, especially early after discharge. These findings highlight the need for research into structured follow-up programmes and kidney-preventive interventions.</div></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"16 ","pages":"Article 100506"},"PeriodicalIF":0.0,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145746874","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The incidence of chronic postsurgical pain (CPSP) is relatively high after breast cancer surgery. Psychological factors, especially high pain catastrophising, are predictive of CPSP. Cognitive behavioural therapy (CBT) can reduce anxiety and depression and help emotional self-regulation. We tested the hypothesis that perioperative CBT is more effective than a pain education and mindfulness (PEM) programme at reducing CPSP intensity at 3 months after breast cancer surgery in high pain catastrophising patients.
Methods
Women having primary breast cancer surgery were screened (n=208) for pain catastrophising characteristics using the pain catastrophising scale (PCS). A total of 45 patients scoring ≥24 received four 1-h sessions with the same psychologist, randomised 1:1 to receive either CBT or PEM during the perioperative period. The primary outcome was Brief Pain Inventory (BPI) average pain severity measured at 3 months. Secondary outcomes included BPI composite pain interference scores, PCS scores, and Hospital Anxiety and Depression Scale (HADS) score.
Results
There were no significant between group differences at 3 months with regard to the primary outcome, BPI average pain intensity score difference (median 25–75%) PEM vs CBT, 0 (0–1) vs 0 (0–1). P=0.45. Similarly, there were no significant between group differences at 3 months in relation to the study’s secondary outcomes: quality of recovery score at 24 h after surgery, pain interference, pain catastrophising, anxiety levels, and mood. There were within group improvements over the 3 months observation period in pain interference (PEM: P=0.05, CBT: P=0.01), catastrophising (PEM: P<0.01, CBT: P<0.01), anxiety (PEM: P<0.01, CBT: P<0.01) and mood (PEM: P=0.03, CBT: P=0.01) scores in both study arms after 3 months when compared with preoperative baseline values.
Conclusions
Delivery of four one-to-one, perioperative CBT or PEM sessions to patients with high pain catastrophising characteristics achieved similar reductions in pain intensity at 3 months after breast cancer surgery. Perioperative psychology might potentially help reduce the incidence of CPSP after breast cancer surgery.
{"title":"Perioperative cognitive behavioural therapy compared with pain education and mindfulness for chronic postsurgical pain in breast cancer patients with high pain catastrophising characteristics: a randomised, controlled, parallel group clinical trial","authors":"Aneurin Moorthy , Damien Lowry , Carla Edgely , Margarita Blajeva , Máire-Bríd Casey , Donal J. Buggy","doi":"10.1016/j.bjao.2025.100499","DOIUrl":"10.1016/j.bjao.2025.100499","url":null,"abstract":"<div><h3>Background</h3><div>The incidence of chronic postsurgical pain (CPSP) is relatively high after breast cancer surgery. Psychological factors, especially high pain catastrophising, are predictive of CPSP. Cognitive behavioural therapy (CBT) can reduce anxiety and depression and help emotional self-regulation. We tested the hypothesis that perioperative CBT is more effective than a pain education and mindfulness (PEM) programme at reducing CPSP intensity at 3 months after breast cancer surgery in high pain catastrophising patients.</div></div><div><h3>Methods</h3><div>Women having primary breast cancer surgery were screened (<em>n</em>=208) for pain catastrophising characteristics using the pain catastrophising scale (PCS). A total of 45 patients scoring ≥24 received four 1-h sessions with the same psychologist, randomised 1:1 to receive either CBT or PEM during the perioperative period. The primary outcome was Brief Pain Inventory (BPI) average pain severity measured at 3 months. Secondary outcomes included BPI composite pain interference scores, PCS scores, and Hospital Anxiety and Depression Scale (HADS) score.</div></div><div><h3>Results</h3><div>There were no significant between group differences at 3 months with regard to the primary outcome, BPI average pain intensity score difference (median 25–75%) PEM <em>vs</em> CBT, 0 (0–1) <em>vs</em> 0 (0–1). <em>P</em>=0.45. Similarly, there were no significant between group differences at 3 months in relation to the study’s secondary outcomes: quality of recovery score at 24 h after surgery, pain interference, pain catastrophising, anxiety levels, and mood. There were within group improvements over the 3 months observation period in pain interference (PEM: <em>P</em>=0.05, CBT: <em>P</em>=0.01), catastrophising (PEM: <em>P</em><0.01, CBT: <em>P</em><0.01), anxiety (PEM: <em>P</em><0.01, CBT: <em>P</em><0.01) and mood (PEM: <em>P</em>=0.03, CBT: <em>P</em>=0.01) scores in both study arms after 3 months when compared with preoperative baseline values.</div></div><div><h3>Conclusions</h3><div>Delivery of four one-to-one, perioperative CBT or PEM sessions to patients with high pain catastrophising characteristics achieved similar reductions in pain intensity at 3 months after breast cancer surgery. Perioperative psychology might potentially help reduce the incidence of CPSP after breast cancer surgery.</div></div><div><h3>Clinical trial registration</h3><div>NCT04924010.</div></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"16 ","pages":"Article 100499"},"PeriodicalIF":0.0,"publicationDate":"2025-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145417566","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Emergency laparotomy is a high-risk surgery, and postoperative functional decline contributes to the 1-yr mortality of 25%. However, there is no established guidance around postoperative interventions to restore functional capacity, including early mobilisation. This scoping review synthesised current evidence on the definition of early mobilisation, delivery of interventions, barriers, and outcomes reported for postoperative mobilisation interventions.
The review followed a structured methodological framework and was registered with Open Science Framework. Studies were identified through MEDLINE, Embase, and CINAHL. Eligible studies described an early mobilisation protocol (in isolation or as a bundled intervention) after emergency laparotomy. Data were extracted and analysed descriptively.
Fourteen studies (2783 participants) were included, with all but one published since 2018. Mobilisation out of bed within 24 h of surgery was the most frequently used definition of early mobilisation. Adherence rates ranged from 31% to 96%. Interventions were heterogeneous, ranging from encouragement to achieve mobilisation targets through to comprehensive multidisciplinary programmes. Intervention groups tended to achieve earlier and greater mobilisation. Key modifiable barriers were pain, fatigue, and limited physiotherapy staffing. All studies reported physical performance outcomes; only one reported quality of life outcomes.
This scoping review found heterogeneity in the delivery, dose, timing, and adherence to mobility interventions. Barriers to mobilisation after emergency laparotomy mirror those described after elective surgery. We suggest alignment in reporting the impact of individual factors (such as frailty and socioeconomic context) and core outcomes (including patient-centred measures) to standardise early postoperative mobilisation interventions and allow for synthesis of the evidence base.
Scoping review protocol
Open Science Framework (https://doi.org/10.17605/OSF.IO/R63CP).
{"title":"Characterisation and evaluation of early mobilisation interventions after emergency laparotomy surgery: a scoping review","authors":"Leonie Murphy , Todd Leckie , Stefanie Harding , Ana-Carolina Gonçalves , Luke Hodgson","doi":"10.1016/j.bjao.2025.100501","DOIUrl":"10.1016/j.bjao.2025.100501","url":null,"abstract":"<div><div>Emergency laparotomy is a high-risk surgery, and postoperative functional decline contributes to the 1-yr mortality of 25%. However, there is no established guidance around postoperative interventions to restore functional capacity, including early mobilisation. This scoping review synthesised current evidence on the definition of early mobilisation, delivery of interventions, barriers, and outcomes reported for postoperative mobilisation interventions.</div><div>The review followed a structured methodological framework and was registered with Open Science Framework. Studies were identified through MEDLINE, Embase, and CINAHL. Eligible studies described an early mobilisation protocol (in isolation or as a bundled intervention) after emergency laparotomy. Data were extracted and analysed descriptively.</div><div>Fourteen studies (2783 participants) were included, with all but one published since 2018. Mobilisation out of bed within 24 h of surgery was the most frequently used definition of early mobilisation. Adherence rates ranged from 31% to 96%. Interventions were heterogeneous, ranging from encouragement to achieve mobilisation targets through to comprehensive multidisciplinary programmes. Intervention groups tended to achieve earlier and greater mobilisation. Key modifiable barriers were pain, fatigue, and limited physiotherapy staffing. All studies reported physical performance outcomes; only one reported quality of life outcomes.</div><div>This scoping review found heterogeneity in the delivery, dose, timing, and adherence to mobility interventions. Barriers to mobilisation after emergency laparotomy mirror those described after elective surgery. We suggest alignment in reporting the impact of individual factors (such as frailty and socioeconomic context) and core outcomes (including patient-centred measures) to standardise early postoperative mobilisation interventions and allow for synthesis of the evidence base.</div></div><div><h3>Scoping review protocol</h3><div>Open Science Framework (https://doi.org/10.17605/OSF.IO/R63CP).</div></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"16 ","pages":"Article 100501"},"PeriodicalIF":0.0,"publicationDate":"2025-10-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145417565","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-10-17DOI: 10.1016/j.bjao.2025.100497
Elis Liblik , Urs Pietsch , Anne-Katrin Hickmann
Background
Perioperative pain management is a key concern amid the growing opioid pandemic, particularly for opioid-experienced patients. This retrospective single-centre cohort study aimed to compare morphine milligram equivalents (MME) at hospital discharge between opioid-naive and opioid-experienced adults undergoing surgery with postoperative patient-controlled analgesia (PCA). We hypothesised that opioid-experienced patients would require higher MME at discharge, and greater intraoperative remifentanil and postoperative PCA use.
Methods
We retrospectively analysed 406 patients from 2016 to 2023 who received intravenous PCA for acute postoperative pain management. Trauma and neuraxial/regional block cases were excluded; emergency non-trauma cases included. Opioid-experienced patients were defined as chronic use of opioids for ≥3 months before surgery. The primary outcome was opioid dose at discharge in MME. Secondary outcomes were total intraoperative remifentanil dose and total PCA use in MME, analysed using multiple linear regression with permutation testing.
Results
Opioid-experienced patients had a 15.4 MME day−1 higher discharge opioid dose (95% confidence interval [CI] 7.4–23.4 MME day−1; P<0.001), received 6.7× more opioids at discharge than opioid-naive patients (63.5 vs 9.4 MME day−1; P<0.001) and nearly doubled their own preoperative use (63.5 vs 30 MME day−1). Opioid-experienced patients also required 52.0 MME day−1 more via PCA (95% CI 13.1–90.8 MME day−1; P=0.009). Each additional preoperative MME was associated with a 0.9 MME day−1 increase in PCA use during the hospitalisation (95% CI 0.2–1.6 MME day−1; P=0.017).
Conclusions
Preoperative opioid experience strongly predicted postoperative opioid requirements and discharge prescribing. Early identification of opioid-experienced patients and tailored multimodal strategies may improve individualised pain management. However, the retrospective single-centre design and lack of non-opioid analgesia data limit generalisability.
背景：在阿片类药物日益流行的情况下，围手术期疼痛管理是一个关键问题，特别是对于有阿片类药物经历的患者。这项回顾性单中心队列研究旨在比较阿片类药物新手和有阿片类药物经验的接受术后患者自控镇痛（PCA）手术的成人出院时吗啡毫克当量（MME）。我们假设有阿片类药物经历的患者在出院时需要更高的MME，术中和术后使用更多的瑞芬太尼和PCA。方法回顾性分析2016年至2023年406例接受静脉PCA治疗急性术后疼痛的患者。排除创伤和神经轴/区域阻滞病例；包括紧急非创伤病例。有阿片类药物经验的患者被定义为术前慢性使用阿片类药物≥3个月。主要终点是MME患者出院时阿片类药物剂量，次要终点是MME患者术中瑞芬太尼总剂量和PCA总使用，采用多元线性回归和置换检验进行分析。结果阿片类药物经验患者的出院阿片类药物剂量高出15.4 MME day - 1(95%可信区间[CI] 7.4-23.4 MME day - 1; P<0.001)，出院时使用的阿片类药物是阿片类药物新手患者的6.7倍（63.5 vs 9.4 MME day - 1; P<0.001），几乎是其术前使用阿片类药物的两倍（63.5 vs 30 MME day - 1）。有阿片类药物经历的患者通过PCA也需要52.0 MME天−1 （95% CI 13.1-90.8 MME天−1；P=0.009）。术前每增加一个MME，住院期间PCA使用增加0.9 MME天−1 （95% CI 0.2-1.6 MME天−1；P=0.017）。结论术前阿片类药物经验对术后阿片类药物需求和出院处方有较强的预测作用。早期识别有阿片类药物经验的患者和量身定制的多模式策略可能会改善个体化疼痛管理。然而，回顾性单中心设计和缺乏非阿片类镇痛数据限制了通用性。
{"title":"Comparison of total morphine milligram equivalents at hospital discharge between opioid-naive and opioid-experienced surgical patients: a single-centre retrospective cohort study","authors":"Elis Liblik , Urs Pietsch , Anne-Katrin Hickmann","doi":"10.1016/j.bjao.2025.100497","DOIUrl":"10.1016/j.bjao.2025.100497","url":null,"abstract":"<div><h3>Background</h3><div>Perioperative pain management is a key concern amid the growing opioid pandemic, particularly for opioid-experienced patients. This retrospective single-centre cohort study aimed to compare morphine milligram equivalents (MME) at hospital discharge between opioid-naive and opioid-experienced adults undergoing surgery with postoperative patient-controlled analgesia (PCA). We hypothesised that opioid-experienced patients would require higher MME at discharge, and greater intraoperative remifentanil and postoperative PCA use.</div></div><div><h3>Methods</h3><div>We retrospectively analysed 406 patients from 2016 to 2023 who received intravenous PCA for acute postoperative pain management. Trauma and neuraxial/regional block cases were excluded; emergency non-trauma cases included. Opioid-experienced patients were defined as chronic use of opioids for ≥3 months before surgery. The primary outcome was opioid dose at discharge in MME. Secondary outcomes were total intraoperative remifentanil dose and total PCA use in MME, analysed using multiple linear regression with permutation testing.</div></div><div><h3>Results</h3><div>Opioid-experienced patients had a 15.4 MME day<sup>−1</sup> higher discharge opioid dose (95% confidence interval [CI] 7.4–23.4 MME day<sup>−1</sup>; <em>P</em><0.001), received 6.7× more opioids at discharge than opioid-naive patients (63.5 <em>vs</em> 9.4 MME day<sup>−1</sup>; <em>P</em><0.001) and nearly doubled their own preoperative use (63.5 <em>vs</em> 30 MME day<sup>−1</sup>). Opioid-experienced patients also required 52.0 MME day<sup>−1</sup> more via PCA (95% CI 13.1–90.8 MME day<sup>−1</sup>; <em>P</em>=0.009). Each additional preoperative MME was associated with a 0.9 MME day<sup>−1</sup> increase in PCA use during the hospitalisation (95% CI 0.2–1.6 MME day<sup>−1</sup>; <em>P</em>=0.017).</div></div><div><h3>Conclusions</h3><div>Preoperative opioid experience strongly predicted postoperative opioid requirements and discharge prescribing. Early identification of opioid-experienced patients and tailored multimodal strategies may improve individualised pain management. However, the retrospective single-centre design and lack of non-opioid analgesia data limit generalisability.</div></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"16 ","pages":"Article 100497"},"PeriodicalIF":0.0,"publicationDate":"2025-10-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145321228","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-10-15DOI: 10.1016/j.bjao.2025.100496
Tori N. Sutherland , Scott E. Hadland , Jiwon Moon , Joana Fardad , Elizabeth Ramsay , Michael J. Kallan , Mark D. Neuman
Background
Increasing data suggest adolescents have elevated risk of persistent postsurgical pain and opioid use, but their recovery experience remains poorly characterised.
Methods
This prospective cohort study enrolled opioid-naive adolescents without chronic pain between June 2022 and May 2023 before undergoing procedures with anticipated mild, moderate, or severe postoperative pain. Participants completed eight surveys during recovery. We measured characteristics associated with persistent opioid use, including non-surgical site pain, difficulty sleeping, depression (Patient Health Questionnaire-9 [PHQ-9]), and anxiety (General Anxiety Disorder [GAD-7]) over 5 months after surgery.
Results
Five hundred adolescents (median age: 15 yr (inter-quartile range 13–17 yr]) completed the baseline survey. Overall, 47.4% were female, 69.6% identified as White, 22.4% as Black/African American, and 10.8% as Hispanic/Latino. Overall, one in five (21.1%) reported depression, approximately two in five reported anxiety (37.4%), and one in six (16.6%) reported prior-year substance use. Among those undergoing procedures associated with severe pain, 93.4% received an outpatient opioid prescription (median 18 doses [inter-quartile range 12–25 doses]). At the end of the study, 16.7% (n=47) reported regular non-surgical site pain, 20.6% (n=58) had difficulty sleeping, and 15.7% and 15.3% had persistent depression and anxiety symptoms, respectively.
Conclusion
A high proportion of adolescents endorsed preoperative anxiety, depression, and substance use, which, in combination with prescription opioids, are known risk factors for postoperative opioid use disorder. Over time, postoperative non-surgical site pain, difficulty sleeping, depression, and anxiety declined but remained common. Additional research is needed to understand the relationship between pre- and postoperative risk factors and adverse outcomes during surgical recovery.
{"title":"The Adolescent Surgery Experience (ASE): a survey-based prospective cohort study to measure risk factors for persistent opioid use","authors":"Tori N. Sutherland , Scott E. Hadland , Jiwon Moon , Joana Fardad , Elizabeth Ramsay , Michael J. Kallan , Mark D. Neuman","doi":"10.1016/j.bjao.2025.100496","DOIUrl":"10.1016/j.bjao.2025.100496","url":null,"abstract":"<div><h3>Background</h3><div>Increasing data suggest adolescents have elevated risk of persistent postsurgical pain and opioid use, but their recovery experience remains poorly characterised.</div></div><div><h3>Methods</h3><div>This prospective cohort study enrolled opioid-naive adolescents without chronic pain between June 2022 and May 2023 before undergoing procedures with anticipated mild, moderate, or severe postoperative pain. Participants completed eight surveys during recovery. We measured characteristics associated with persistent opioid use, including non-surgical site pain, difficulty sleeping, depression (Patient Health Questionnaire-9 [PHQ-9]), and anxiety (General Anxiety Disorder [GAD-7]) over 5 months after surgery.</div></div><div><h3>Results</h3><div>Five hundred adolescents (median age: 15 yr (inter-quartile range 13–17 yr]) completed the baseline survey. Overall, 47.4% were female, 69.6% identified as White, 22.4% as Black/African American, and 10.8% as Hispanic/Latino. Overall, one in five (21.1%) reported depression, approximately two in five reported anxiety (37.4%), and one in six (16.6%) reported prior-year substance use. Among those undergoing procedures associated with severe pain, 93.4% received an outpatient opioid prescription (median 18 doses [inter-quartile range 12–25 doses]). At the end of the study, 16.7% (<em>n</em>=47) reported regular non-surgical site pain, 20.6% (<em>n</em>=58) had difficulty sleeping, and 15.7% and 15.3% had persistent depression and anxiety symptoms, respectively.</div></div><div><h3>Conclusion</h3><div>A high proportion of adolescents endorsed preoperative anxiety, depression, and substance use, which, in combination with prescription opioids, are known risk factors for postoperative opioid use disorder. Over time, postoperative non-surgical site pain, difficulty sleeping, depression, and anxiety declined but remained common. Additional research is needed to understand the relationship between pre- and postoperative risk factors and adverse outcomes during surgical recovery.</div></div><div><h3>Clinical trial registration</h3><div>NCT05482919.</div></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"16 ","pages":"Article 100496"},"PeriodicalIF":0.0,"publicationDate":"2025-10-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145321230","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-10-15DOI: 10.1016/j.bjao.2025.100500
Inaame Ettoumi , Daniel Pearce , Theodora Wingert , Amelie Delaporte , Brenton Alexander , Ravi Pal , Jason Tang , Nancy M. Boulos , Yann Gricourt , Janice Boktor , Maziar M. Nourian , Tristan Grogan , Cecila Canales , Dan Cole , Robert A. Whittington , Maxime Cannesson , Alexandre Joosten
Background
Intraoperative hypotension has been associated with postoperative complications, but its relationship with postoperative delirium remains debated.
Methods
This single-centre retrospective cohort study included adults (≥60 yr) with ASA physical status score of 3 or 4 undergoing major noncardiac surgery, with documented Confusion Assessment Method assessments. Patients with a history of neurosurgery, stroke, dementia, or neurocognitive disorders were excluded. The primary exposure was the cumulative duration of a mean arterial pressure <65 mm Hg (minutes). The primary outcome was postoperative delirium within 7 days, diagnosed via Confusion Assessment Method. Multivariable logistic regression was used to assess the association between intraoperative hypotension and delirium, adjusting for confounders.
Results
Among 5171 patients included from 2013–2024, 632 (11.8%) developed delirium. The median (Q1–Q3) duration of surgery and time with mean arterial pressure <65 mm Hg were 281 (199–430) min and 28 (9–61) min, respectively. In models adjusted for patient characteristics and perioperative factors, intraoperative hypotension was associated with increased odds of delirium (odds ratio per 60 min, 1.12; 95% confidence interval, 1.01–1.24; P=0.038). However, after adjusting for year of surgery, the association was attenuated and no longer statistically significant (odds ratio, 1.06; 95% confidence interval, 0.95–1.18; P=0.320). Both intraoperative hypotension exposure and delirium incidence declined significantly over the study period.
Conclusions
Although intraoperative hypotension initially appeared to be associated with postoperative delirium, this association was no longer significant when accounting for temporal improvements in perioperative care. Intraoperative hypotension may represent a marker of historical practice patterns rather than an independent causal driver of delirium.
{"title":"Intraoperative hypotension and postoperative delirium among older high-risk patients undergoing major noncardiac surgery: a retrospective single-centre cohort study","authors":"Inaame Ettoumi , Daniel Pearce , Theodora Wingert , Amelie Delaporte , Brenton Alexander , Ravi Pal , Jason Tang , Nancy M. Boulos , Yann Gricourt , Janice Boktor , Maziar M. Nourian , Tristan Grogan , Cecila Canales , Dan Cole , Robert A. Whittington , Maxime Cannesson , Alexandre Joosten","doi":"10.1016/j.bjao.2025.100500","DOIUrl":"10.1016/j.bjao.2025.100500","url":null,"abstract":"<div><h3>Background</h3><div>Intraoperative hypotension has been associated with postoperative complications, but its relationship with postoperative delirium remains debated.</div></div><div><h3>Methods</h3><div>This single-centre retrospective cohort study included adults (≥60 yr) with ASA physical status score of 3 or 4 undergoing major noncardiac surgery, with documented Confusion Assessment Method assessments. Patients with a history of neurosurgery, stroke, dementia, or neurocognitive disorders were excluded. The primary exposure was the cumulative duration of a mean arterial pressure <65 mm Hg (minutes). The primary outcome was postoperative delirium within 7 days, diagnosed via Confusion Assessment Method. Multivariable logistic regression was used to assess the association between intraoperative hypotension and delirium, adjusting for confounders.</div></div><div><h3>Results</h3><div>Among 5171 patients included from 2013–2024, 632 (11.8%) developed delirium. The median (Q1–Q3) duration of surgery and time with mean arterial pressure <65 mm Hg were 281 (199–430) min and 28 (9–61) min, respectively. In models adjusted for patient characteristics and perioperative factors, intraoperative hypotension was associated with increased odds of delirium (odds ratio per 60 min, 1.12; 95% confidence interval, 1.01–1.24; <em>P</em>=0.038). However, after adjusting for year of surgery, the association was attenuated and no longer statistically significant (odds ratio, 1.06; 95% confidence interval, 0.95–1.18; <em>P</em>=0.320). Both intraoperative hypotension exposure and delirium incidence declined significantly over the study period.</div></div><div><h3>Conclusions</h3><div>Although intraoperative hypotension initially appeared to be associated with postoperative delirium, this association was no longer significant when accounting for temporal improvements in perioperative care. Intraoperative hypotension may represent a marker of historical practice patterns rather than an independent causal driver of delirium.</div></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"16 ","pages":"Article 100500"},"PeriodicalIF":0.0,"publicationDate":"2025-10-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145321227","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-10-13DOI: 10.1016/j.bjao.2025.100498
David W. Hewson , Jessica Nightingale , Reuben Ogollah , Adam Brooks , Lauren Blackburn , Benjamin J. Ollivere , Matthew L. Costa , Tim Egan , Peter Bates , Ian Tyrrell-Marsh , Nigel M. Bedforth
Background
Traumatic rib fractures cause significant acute pain. Patients are at risk of hypoventilation, atelectasis, hypoxia, retained secretions, pneumonia, respiratory failure, and death. Effective analgesia is thought to reduce these adverse outcomes. There is widespread variation in analgesic treatments given to patients including oral, intravenous, and epidural routes of administration. Erector spinae plane (ESP) block, a novel regional analgesic technique, may be effective, but high-quality evidence is lacking.
Methods
To determine if a definitive trial of ESP block and catheter in rib fractures is possible, we conducted a multicentre, randomised, controlled pilot study with feasibility assessment. Adults with rib fractures were randomised in a 1:1 ratio to either (i) ESP blockade and catheter, or (ii) placebo ESP blockade and catheter, both for 72 h. In addition, all participants received multimodal analgesia. Participants and outcome assessors were blinded. The primary feasibility outcomes were recruitment rate (target: ≥1.11 participants/site/month), retention rate (target: ≥80%), and trial acceptability assessed by staff interview. Pre-specified red–amber–green criteria were agreed to determine feasibility of a future definitive clinical trial on this topic.
Results
Twenty-five participants (mean [standard deviation] age 57 [16] yr, number of rib fractures 5 [3]) were recruited from three UK major trauma centres at a rate of 0.69 participants per site per month. Retention to 6-week follow-up was 80%. Based on our criteria, the current study design is not feasible for adoption into a definitive trial. For future research in this area, we recommend substantial modification to (i) the intervention, (ii) means of bias reduction, and (iii) timing and nature of outcome measure assessments.
Conclusions
Based on pre-specified criteria, a definitive examination of the clinical effectiveness of ESP block in the analgesic management of adults after blunt force chest wall injury is only feasible if substantial amendments to trial processes piloted in this study are undertaken. An open-label assessment of single-shot ESP block, applying patient-reported average pain intensity of the first 24 h as the primary outcome, and conducted at sites with established ESP analgesic pathways, may overcome the most significant feasibility barriers identified by the present study.
{"title":"Erector Spinae Plane block with fascial plane catheter for the Early Analgesia of Rib fractures in trauma (ESPEAR): a multicentre feasibility randomised trial","authors":"David W. Hewson , Jessica Nightingale , Reuben Ogollah , Adam Brooks , Lauren Blackburn , Benjamin J. Ollivere , Matthew L. Costa , Tim Egan , Peter Bates , Ian Tyrrell-Marsh , Nigel M. Bedforth","doi":"10.1016/j.bjao.2025.100498","DOIUrl":"10.1016/j.bjao.2025.100498","url":null,"abstract":"<div><h3>Background</h3><div>Traumatic rib fractures cause significant acute pain. Patients are at risk of hypoventilation, atelectasis, hypoxia, retained secretions, pneumonia, respiratory failure, and death. Effective analgesia is thought to reduce these adverse outcomes. There is widespread variation in analgesic treatments given to patients including oral, intravenous, and epidural routes of administration. Erector spinae plane (ESP) block, a novel regional analgesic technique, may be effective, but high-quality evidence is lacking.</div></div><div><h3>Methods</h3><div>To determine if a definitive trial of ESP block and catheter in rib fractures is possible, we conducted a multicentre, randomised, controlled pilot study with feasibility assessment. Adults with rib fractures were randomised in a 1:1 ratio to either (i) ESP blockade and catheter, or (ii) placebo ESP blockade and catheter, both for 72 h. In addition, all participants received multimodal analgesia. Participants and outcome assessors were blinded. The primary feasibility outcomes were recruitment rate (target: ≥1.11 participants/site/month), retention rate (target: ≥80%), and trial acceptability assessed by staff interview. Pre-specified red–amber–green criteria were agreed to determine feasibility of a future definitive clinical trial on this topic.</div></div><div><h3>Results</h3><div>Twenty-five participants (mean [standard deviation] age 57 [16] yr, number of rib fractures 5 [3]) were recruited from three UK major trauma centres at a rate of 0.69 participants per site per month. Retention to 6-week follow-up was 80%. Based on our criteria, the current study design is not feasible for adoption into a definitive trial. For future research in this area, we recommend substantial modification to (i) the intervention, (ii) means of bias reduction, and (iii) timing and nature of outcome measure assessments.</div></div><div><h3>Conclusions</h3><div>Based on pre-specified criteria, a definitive examination of the clinical effectiveness of ESP block in the analgesic management of adults after blunt force chest wall injury is only feasible if substantial amendments to trial processes piloted in this study are undertaken. An open-label assessment of single-shot ESP block, applying patient-reported average pain intensity of the first 24 h as the primary outcome, and conducted at sites with established ESP analgesic pathways, may overcome the most significant feasibility barriers identified by the present study.</div></div><div><h3>Clinical trial registration</h3><div>ISRCTN49307616.</div></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"16 ","pages":"Article 100498"},"PeriodicalIF":0.0,"publicationDate":"2025-10-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145321229","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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