Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, California.
Stanford Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California.
JAMA Netw Open. 2019 Mar 1;2(3):e190168. doi: 10.1001/jamanetworkopen.2019.0168.
Acute postoperative pain is associated with the development of persistent postsurgical pain, but it is unclear which aspect is most estimable.
To identify patient clusters based on acute pain trajectories, preoperative psychosocial characteristics associated with the high-risk cluster, and the best acute pain predictor of remote outcomes.
DESIGN, SETTING, AND PARTICIPANTS: A secondary analysis of the Stanford Accelerated Recovery Trial randomized, double-blind clinical trial was conducted at a single-center, tertiary, referral teaching hospital. A total of 422 participants scheduled for thoracotomy, video-assisted thoracoscopic surgery, total hip replacement, total knee replacement, mastectomy, breast lumpectomy, hand surgery, carpal tunnel surgery, knee arthroscopy, shoulder arthroplasty, or shoulder arthroscopy were enrolled between May 25, 2010, and July 25, 2014. Data analysis was performed from January 1 to August 1, 2018.
Patients were randomized to receive gabapentin (1200 mg, preoperatively, and 600 mg, 3 times a day postoperatively) or active placebo (lorazepam, 0.5 mg preoperatively, inactive placebo postoperatively) for 72 hours.
A modified Brief Pain Inventory prospectively captured 3 surgical site pain outcomes: average pain and worst pain intensity over the past 24 hours, and current pain intensity. Within each category, acute pain trajectories (first 10 postoperative pain scores) were compared using a k-means clustering algorithm. Fifteen descriptors of acute pain were compared as predictors of remote postoperative pain resolution, opioid cessation, and full recovery.
Of the 422 patients enrolled, 371 patients (≤10% missing pain scores) were included in the analysis. Of these, 146 (39.4%) were men; mean (SD) age was 56.67 (11.70) years. Two clusters were identified within each trajectory category. The high pain cluster of the average pain trajectory significantly predicted prolonged pain (hazard ratio [HR], 0.63; 95% CI, 0.50-0.80; P < .001) and delayed opioid cessation (HR, 0.52; 95% CI, 0.41-0.67; P < .001) but was not a predictor of time to recovery in Cox proportional hazards regression (HR, 0.89; 95% CI, 0.69-1.14; P = .89). Preoperative risk factors for categorization to the high average pain cluster included female sex (adjusted relative risk [ARR], 1.36; 95% CI, 1.08-1.70; P = .008), elevated preoperative pain (ARR, 1.11; 95% CI, 1.07-1.15; P < .001), a history of alcohol or drug abuse treatment (ARR, 1.90; 95% CI, 1.42-2.53; P < .001), and receiving active placebo (ARR, 1.27; 95% CI, 1.03-1.56; P = .03). Worst pain reported on postoperative day 10 was the best predictor of time to pain resolution (HR, 0.83; 95% CI, 0.78-0.87; P < .001), opioid cessation (HR, 0.84; 95% CI, 0.80-0.89; P < .001), and complete surgical recovery (HR, 0.91; 95% CI, 0.86-0.96; P < .001).
This study has shown a possible uniform predictor of remote postoperative pain, opioid use, and recovery that can be easily assessed. Future work is needed to replicate these findings.
ClinicalTrials.gov Identifier: NCT01067144.
急性术后疼痛与持续性术后疼痛的发展有关，但尚不清楚哪个方面更具评估价值。
根据急性疼痛轨迹、术前与高危集群相关的社会心理特征，以及远程结局的最佳急性疼痛预测因子，确定患者集群。
设计、地点和参与者：对单中心三级转诊教学医院的斯坦福加速康复试验随机、双盲临床试验进行二次分析。2010 年 5 月 25 日至 2014 年 7 月 25 日期间共纳入 422 名计划接受剖胸术、电视辅助胸腔镜手术、全髋关节置换术、全膝关节置换术、乳房切除术、乳房肿块切除术、手部手术、腕管松解术、膝关节镜检查、肩关节置换术或肩关节镜检查的患者。数据分析于 2018 年 1 月 1 日至 8 月 1 日进行。
患者被随机分配接受加巴喷丁（术前 1200mg，术后每天 3 次 600mg）或活性安慰剂（劳拉西泮，术前 0.5mg，术后无效安慰剂）72 小时。
改良的简短疼痛量表前瞻性地捕获了 3 个手术部位疼痛结果：过去 24 小时的平均疼痛和最严重疼痛强度，以及当前疼痛强度。在每个类别中，使用 k-均值聚类算法比较急性疼痛轨迹（前 10 个术后疼痛评分）。将 15 个急性疼痛描述符作为远程术后疼痛缓解、阿片类药物停药和完全恢复的预测因子进行比较。
在纳入的 422 名患者中，有 371 名（≤10%缺失疼痛评分）患者纳入分析。其中，146 名（39.4%）为男性；平均（SD）年龄为 56.67（11.70）岁。在每个轨迹类别中都确定了两个集群。平均疼痛轨迹的高疼痛集群显著预测了疼痛的持续时间（风险比[HR]，0.63；95%置信区间[CI]，0.50-0.80；P<0.001）和阿片类药物停药的延迟（HR，0.52；95% CI，0.41-0.67；P<0.001），但在 Cox 比例风险回归中不是恢复时间的预测因子（HR，0.89；95% CI，0.69-1.14；P=0.89）。分类到高平均疼痛集群的术前危险因素包括女性（调整相对风险[ARR]，1.36；95% CI，1.08-1.70；P=0.008）、术前疼痛升高（ARR，1.11；95% CI，1.07-1.15；P<0.001）、酒精或药物滥用治疗史（ARR，1.90；95% CI，1.42-2.53；P<0.001）和接受活性安慰剂（ARR，1.27；95% CI，1.03-1.56；P=0.03）。术后第 10 天报告的最严重疼痛是疼痛缓解时间（HR，0.83；95% CI，0.78-0.87；P<0.001）、阿片类药物停药（HR，0.84；95% CI，0.80-0.89；P<0.001）和完全手术恢复（HR，0.91；95% CI，0.86-0.96；P<0.001）的最佳预测因子。
本研究显示了一种可能的远程术后疼痛、阿片类药物使用和恢复的统一预测因子，易于评估。未来需要进一步研究以复制这些发现。
ClinicalTrials.gov 标识符：NCT01067144。
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