Division of Cardiac Surgery, Yale School of Medicine, New Haven, CT (M.M., C.B., P.D., A.G.), Yale School of Medicine, New Haven, CT.
Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (M.M., Y.L., E.S.S., H.M.K.).
Circ Cardiovasc Qual Outcomes. 2021 Aug;14(8):e007781. doi: 10.1161/CIRCOUTCOMES.120.007781. Epub 2021 Jul 26.
BACKGROUND: Postoperative pain after cardiac surgery is a significant problem, but studies often report pain value as an average of the study cohort, obscuring clinically meaningful differences in pain trajectories. We sought to characterize heterogeneity in postoperative pain experiences. METHODS: We enrolled patients undergoing a cardiac surgery at a tertiary care center between January 2019 and February 2020. Participants received an electronically-delivered questionnaire every 3 days for 30 days to assess incision site pain level. We evaluated the variability in pain trajectories over 30 days by the cohort-level mean with confidence band and latent classes identified by group-based trajectory model. Group-based trajectory model estimated the probability of belonging to a specific trajectory of pain. RESULTS: Of 92 patients enrolled, 75 provided ≥3 questionnaire responses. The cohort-level mean showed a gradual and consistent decline in the mean pain level, but the confidence bands covered most of the pain score range. The individual-level trajectories varied substantially across patients. Group-based trajectory model identified 4 pain trajectories: persistently low (n=9, 12%), moderate declining (initially mid-level, followed by decline; n=26, 35%), high declining (initially high-level, followed by decline; n=33, 44%), and persistently high pain (n=7, 9%). Persistently high pain and high declining groups did not seem to be clearly distinguishable until approximately postoperative day 10. Patients in persistently low pain trajectory class had a numerically lower median age than the other 3 classes and were below the lower confidence band of the cohort-level approach. Patients in the persistently high pain trajectory class had a longer median length of hospital stay than the other 3 classes and were often higher than the upper confidence band of the cohort-level approach. CONCLUSIONS: We identified 4 trajectories of postoperative pain that were not evident from a cohort-level mean, which has been a common way of reporting pain level. This study provides key information about the patient experience and indicates the need to understand variation among sites and surgeons and to investigate determinants of different experience and interventions to mitigate persistently high pain.
背景:心脏手术后的疼痛是一个严重的问题,但研究通常报告研究队列的平均疼痛值,掩盖了疼痛轨迹的临床有意义的差异。我们试图描述术后疼痛体验的异质性。
方法:我们招募了 2019 年 1 月至 2020 年 2 月期间在一家三级保健中心接受心脏手术的患者。参与者在术后 30 天内每隔 3 天接受一次电子问卷调查,以评估切口疼痛程度。我们通过队列水平均值的置信带和基于群组的轨迹模型确定的潜在类别来评估 30 天内疼痛轨迹的变异性。基于群组的轨迹模型估计属于特定疼痛轨迹的概率。
结果:在 92 名入组患者中,75 名患者提供了≥3 次问卷回复。队列水平均值显示疼痛水平逐渐持续下降,但置信带涵盖了大部分疼痛评分范围。个体水平的轨迹在患者之间差异很大。基于群组的轨迹模型确定了 4 种疼痛轨迹:持续低水平(n=9,12%)、逐渐下降(初始中等水平,随后下降;n=26,35%)、高水平下降(初始高水平,随后下降;n=33,44%)和持续高水平疼痛(n=7,9%)。直到术后大约第 10 天,持续高水平疼痛和高水平下降组似乎还没有明显区分开来。持续低水平疼痛轨迹类别的患者年龄中位数明显低于其他 3 个类别,且低于队列水平方法的置信带下限。持续高水平疼痛轨迹类别的患者住院时间中位数明显长于其他 3 个类别,且经常高于队列水平方法的置信带上限。
结论:我们发现了 4 种术后疼痛轨迹,这在队列水平平均值中并不明显,这是一种常见的报告疼痛水平的方法。本研究提供了关于患者体验的关键信息,并表明需要了解不同部位和外科医生之间的差异,并研究不同体验的决定因素和缓解持续高水平疼痛的干预措施。
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