Derek Dillane1, Ailar Ramadi2, Stephanie Nathanail3, Bruce D Dick1, Geoff Bostick2, Kitty Chan3, Chris Douglas1, Gordon Goplen3, James Green1, Susan Halliday1, Braiden Hellec4, Saifee Rashiq1, Angela Scharfenberger3, Guy Woolsey3, Lauren A Beaupre5,6,7, M Elizabeth Pedersen3. 1. Department of Anesthesia and Pain Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada. 2. Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada. 3. Collaborative Orthopaedic REsearch (CORe), University of Alberta, Edmonton, AB, Canada. 4. Pharmacy, Alberta Health Services, Edmonton, AB, Canada. 5. Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada. lauren.beaupre@ualberta.ca. 6. Collaborative Orthopaedic REsearch (CORe), University of Alberta, Edmonton, AB, Canada. lauren.beaupre@ualberta.ca. 7. Departments of Physical Therapy and Surgery, University of Alberta, 6-110B Clinical Sciences Building, 8440-112 St., Edmonton, AB, Canada. lauren.beaupre@ualberta.ca.
Abstract
PURPOSE: Complex elective foot and ankle surgeries are often associated with severe pain pre- and postoperatively. When inadequately managed, chronic postsurgical pain and long-term opioid use can result. As no standards currently exist, we aimed to develop best practice pain management guidelines. METHODS: A local steering committee (n = 16) surveyed 116 North American foot and ankle surgeons to understand the "current state" of practice. A multidisciplinary expert panel (n = 35) was then formed consisting of orthopedic surgeons, anesthesiologists, chronic pain physicians, primary care physicians, pharmacists, registered nurses, physiotherapists, and clinical psychologists. Each expert provided up to three pain management recommendations for each of the presurgery, intraoperative, inpatient postoperative, and postdischarge periods. These preliminary recommendations were reduced, refined, and sent to the expert panel and "current state" survey respondents to create a consensus document using a Delphi process conducted from September to December 2020. RESULTS: One thousand four hundred and five preliminary statements were summarized into 51 statements. Strong consensus (≥ 80% respondent agreement) was achieved in 53% of statements including the following: postsurgical opioid use risk should be assessed preoperatively; opioid-naïve patients should not start opioids preoperatively unless non-opioid multimodal analgesia fails; and if opioids are prescribed at discharge, patients should receive education regarding importance of tapering opioid use. There was no consensus regarding opioid weaning preoperatively. CONCLUSIONS: Using multidisciplinary experts and a Delphi process, strong consensus was achieved in many areas, showing considerable agreement despite limited evidence for standardized pain management in patients undergoing complex elective foot and ankle surgery. No consensus on important issues related to opioid prescribing and cessation highlights the need for research to determine best practice.
PURPOSE: Complex elective foot and ankle surgeries are often associated with severe pain pre- and postoperatively. When inadequately managed, chronic postsurgical pain and long-term opioid use can result. As no standards currently exist, we aimed to develop best practice pain management guidelines. METHODS: A local steering committee (n = 16) surveyed 116 North American foot and ankle surgeons to understand the "current state" of practice. A multidisciplinary expert panel (n = 35) was then formed consisting of orthopedic surgeons, anesthesiologists, chronic pain physicians, primary care physicians, pharmacists, registered nurses, physiotherapists, and clinical psychologists. Each expert provided up to three pain management recommendations for each of the presurgery, intraoperative, inpatient postoperative, and postdischarge periods. These preliminary recommendations were reduced, refined, and sent to the expert panel and "current state" survey respondents to create a consensus document using a Delphi process conducted from September to December 2020. RESULTS: One thousand four hundred and five preliminary statements were summarized into 51 statements. Strong consensus (≥ 80% respondent agreement) was achieved in 53% of statements including the following: postsurgical opioid use risk should be assessed preoperatively; opioid-naïve patients should not start opioids preoperatively unless non-opioid multimodal analgesia fails; and if opioids are prescribed at discharge, patients should receive education regarding importance of tapering opioid use. There was no consensus regarding opioid weaning preoperatively. CONCLUSIONS: Using multidisciplinary experts and a Delphi process, strong consensus was achieved in many areas, showing considerable agreement despite limited evidence for standardized pain management in patients undergoing complex elective foot and ankle surgery. No consensus on important issues related to opioid prescribing and cessation highlights the need for research to determine best practice.
Authors: Elina Cv Brinck; Elina Tiippana; Michael Heesen; Rae Frances Bell; Sebastian Straube; R Andrew Moore; Vesa Kontinen Journal: Cochrane Database Syst Rev Date: 2018-12-20
Authors: Muhammad Ali Chaudhary; Nizar Bhulani; Elzerie C de Jager; Stuart Lipsitz; Nicollette K Kwon; Daniel J Sturgeon; Quoc-Dien Trinh; Tracey Koehlmoos; Adil H Haider; Andrew J Schoenfeld Journal: JAMA Netw Open Date: 2019-07-03
Authors: Breda H Eubank; Nicholas G Mohtadi; Mark R Lafave; J Preston Wiley; Aaron J Bois; Richard S Boorman; David M Sheps Journal: BMC Med Res Methodol Date: 2016-05-20 Impact factor: 4.615