Background & Aims

Chronic post-surgical pain (CPSP) has a prevalence of 20-30% with higher values following chest incisions. [1,2] A “transitional pain service” (TPS) is a multidisciplinary perioperative approach to bridge the gap between inpatient pain services and outpatient chronic pain pathways in order to improve recovery trajectories for patients with the hope of preventing the transition from acute to chronic pain states. [3]

This is a service evaluation of the first “TPS” in the UK: at St Bartholomew’s Hospital, a specialist centre for cardiothoracic surgery. Our objectives were to describe patient demographics for those treated by the dedicated Persistent Perioperative Pain (PPP) team at Barts and understand referral processes for this service. Additionally, we aimed to identify any potential risk factors for CPSP among these patients. Our follow-up tracked patients from hospital discharge to postoperative clinic reviews, with a specific focus on assessing neuropathic pain and opioid use.

Methods

A service evaluation was conducted of all patients seen by the PPP team from its inception in March 2022 over a 20 month period until October 2023.

Results

46 patients were studied of whom 41% were male, with a mean age of 50. Surgical categories were as follows: 63% thoracic surgery, 28% cardiac surgery, and 9% cardiology interventions. Specific surgical incisions included: 30% sternotomy, 20% robotic-assisted thoracoscopy, 17% video-assisted thoracoscopy. The primary reason for referral to the pain team was postoperative acute severe pain (70%). 46% of patients had a history of chronic pain and 43% had a history of mental health disorders. Preoperatively 15% of patients were on strong opioids. Upon discharge, 96% of patients were on opioids, with 37% initiated on new long-acting strong opioids. In terms of clinic encounters with the PPP service, 65% of patients were reviewed on a single occasion only. Opioid stewardship was noted for all patients discharged from hospital on opioids. Neuropathic pain was documented in 35% of patients upon discharge. At follow-up by the PPP service, 30% of patients reported ongoing neuropathic symptoms.

Conclusions

The PPP service at Barts attempts to establish a connection between inpatient and outpatient pain management services for individuals recovering from surgery. The clinical trajectory of 46 patients undergoing this novel approach has been documented. Our findings show that patients are predominantly referred to this service postoperatively and due to acute severe pain. These patients are more likely to have a history of chronic pain, opioid tolerance, or mental health conditions compared to the broader surgical population. The existing literature suggests these factors pose an increased risk for the development of CPSP. Future work could be directed toward pre-emptively identifying such patients early during the preoperative period. This project lays the foundation for developing the PPP service with the goal of improving access to pain management services for surgical patients in a timely manner and during their entire perioperative journey.

References

1 – Rosenberger, D.C., and E.M. Pogatzki-Zahn. ‘Chronic Post-Surgical Pain – Update on Incidence, Risk Factors and Preventive Treatment Options’. BJA Education 22, no. 5 (May 2022): 190–96. https://doi.org/10.1016/j.bjae.2021.11.008.

2 – Xiao, Maggie Z. X., James S. Khan, Elad Dana, Vivek Rao, George Djaiani, Philippe Richebé, Joel Katz, Dorothy Wong, and Hance Clarke. ‘Prevalence and Risk Factors for Chronic Postsurgical Pain after Cardiac Surgery: A Single-Center Prospective Cohort Study’. Anesthesiology 139, no. 3 (1 September 2023): 309–20. https://doi.org/10.1097/ALN.0000000000004621.

3 – Katz, Joel, Aliza Weinrib, Samantha Fashler, Rita Katznelson, Bansi Shah, Salima Ladak, Jiao Jiang, et al. ‘The Toronto General Hospital Transitional Pain Service: Development and Implementation of a Multidisciplinary Program to Prevent Chronic Postsurgical Pain’. Journal of Pain Research, October 2015, 695. https://doi.org/10.2147/JPR.S91924.

Presenting Author

Masseh Yakubi

Poster Authors

Masseh Yakubi

MBBS, FRCA

St Bartholomew's Hospital

Lead Author

Fiona Cameron

St Bartholomew's Hospital

Lead Author

Sally Hetherington

St Bartholomew's Hospital

Lead Author

Sibs Anwar

St Bartholomew's Hospital

Lead Author

Topics

  • Specific Pain Conditions/Pain in Specific Populations: Post-surgical/Post-traumatic Chronic Pain