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Patient and Procedural Determinants of Postoperative Pain Trajectories
术后疼痛轨迹的患者和程序决定因素
全文翻译：Riozhou
EDITOR’S PERSPECTIVE
What We Already Know about This Topic
· The resolution of pain after surgery is highly variable, and the factors contributing to these differences are poorly described
· Identifying groups of patients sharing similar pain trajectories may help us predict and optimize recovery from surgery
关于这个话题我们已经知道的
· 手术后疼痛的解决是高度可变的，而导致这些差异的因素并未得到很好的描述
· 确定具有相似疼痛轨迹的患者类型可能有助于我们预测和优化手术后的恢复
What This Article Tells Us That Is New
· Monitoring postoperative pain for 7 days in 360 patients recovering from surgery allowed the identification of five distinct pain
trajectories
· Patient-specific factors such as age, sex, and psychologic features
were the predominant determinants of trajectory group membership
这篇文章告诉我们的是新的
· 对360名术后恢复期患者进行7天的术后疼痛监测，可以确定5种不同的疼痛轨迹
· 患者的具体因素，如年龄、性别和心理特征是轨迹组成员的主要决定因素
The primary goal of this study was to evaluate patterns in acute postoperative pain in a mixed surgical patient cohort with the hypothesis that there would be heterogeneity in these patterns.
本研究的主要目的是评估混合手术患者队列中急性术后疼痛的模式，假设这些模式存在异质性。
This study included 360 patients from a mixed surgical cohort whose pain was measured across postoperative days 1 through 7. Pain was characterized using the Brief Pain Inventory. Primary analysis used groupbased trajectory modeling to estimate trajectories/patterns of postoperative pain. Secondary analysis examined associations between sociodemographic, clinical, and behavioral patient factors and pain trajectories.
这项研究包括了来自一个混合手术队列的360名患者，他们的疼痛是在术后1到7天测量的。疼痛的特征是使用简短的疼痛量表。初步分析使用基于组的轨迹模型来估计术后疼痛的轨迹/模式。二次分析检查了社会人口学、临床和行为患者因素与疼痛轨迹之间的关联。
Five distinct postoperative pain trajectories were identified. Many patients (167 of 360, 46%) were in the moderate-to-high pain group, followed by the moderate-to-low (88 of 360, 24%), high (58 of 360, 17%), low (25 of 360, 7%), and decreasing (21 of 360, 6%) pain groups. Lower age (odds ratio, 0.94; 95% CI, 0.91 to 0.99), female sex (odds ratio, 6.5; 95% CI, 1.49 to 15.6), higher anxiety (odds ratio, 1.08; 95% CI, 1.01 to 1.14), and more pain behaviors (odds ratio, 1.10; 95% CI, 1.02 to 1.18) were related to increased likelihood of being in the high pain trajectory in multivariable analysis. Preoperative and intraoperative opioids were not associated with postoperative pain trajectories. Pain trajectory group was, however, associated with postoperative opioid use (P < 0.001), with the high pain group (249.5 oral morphine milligram equivalents) requiring four times more opioids than the low pain group (60.0 oral morphine milligram equivalents).
确定了五种不同的术后疼痛轨迹。许多患者（167/360，46%）属于中重度疼痛组，其次是中度至轻度疼痛组（88/360，24%）、重度疼痛组（58/360，17%）、轻度疼痛组（25/360，7%）和逐渐减轻的疼痛组（21/360，6%）。年龄较低（优势比0.94；95%可信区间，0.91～0.99），女性（优势比6.5；95%可信区间为1.49～15.6），焦虑程度较高（优势比为1.08；95%可信区间1.01～1.14）。在多变量分析中，更多的疼痛行为（优势比1.10；95%可信区间1.02~1.18）与处于更高的疼痛轨迹的可能性增加有关。术前和术中阿片类药物与术后疼痛轨迹无关。然而，疼痛轨迹组与术后阿片类药物的使用有关（P<0.001），高疼痛组（249.5口服吗啡毫克当量）需要的阿片类药物是低疼痛组（60.0口服吗啡毫克当量）的4倍。
There are multiple distinct acute postoperative pain intensity trajectories, with 63% of patients reporting stable and sustained high or moderate-to-high pain over the first 7 days after surgery. These postoperative pain trajectories were predominantly defined by patient factors and not surgical factors.
术后有多种不同的急性术后疼痛强度轨迹，63%的患者在术后的前7天报告稳定和持续的高或中到高疼痛。这些术后疼痛轨迹主要由患者因素而非手术因素决定。
Increased acute postoperative pain intensity is associated with the development of persistent postsurgical pain, which is defined by the International Classification of Diseases-11 as pain persisting more than 3 months after surgery.
Epidemiologic work suggests that for every 10% increase in the patient estimate of the percentage of time spent in severe postoperative pain, there is a 24% increase in pain intensity at 6 months after surgery .
To personalize postoperative analgesia to these anticipated temporal profiles of acute and persistent postoperative pain, we must first develop better models of postoperative pain trajectories.
The primary goal was to use group-based trajectory modeling to characterize unique groups of postoperative pain trajectories for postoperative days 1 through 7 across a mixed surgical cohort. We hypothesized that we would identify more than two groups of pain trajectories. The secondary goal was to examine sociodemographic, clinical, and behavioral factors in relation to pain trajectories. We hypothesized that these factors would differ across the identified trajectory groups.
术后急性疼痛强度增加与术后持续性疼痛的发生有关，国际疾病分类-11将其定义为术后持续3个月以上的疼痛。
流行病学研究表明，患者估计的术后疼痛时间百分比每增加10%，术后6个月疼痛强度就增加24%。
为了将术后镇痛个性化，使之符合急性和持续性术后疼痛的预期时间特征，我们必须首先建立更好的术后疼痛轨迹模型。
主要目的是使用基于组的轨迹建模来描述混合手术队列中术后第1天至第7天的独特组术后疼痛轨迹。我们假设我们将确定两组以上的疼痛轨迹。第二个目标是研究与疼痛轨迹相关的社会人口统计学、临床和行为因素。我们假设这些因素在确定的轨迹组中是不同的。
This study was a prospective cohort using a mixed surgical sample that aimed to investigate how group-based trajectory modeling was associated with acute postoperative pain trajectories.
Study Participants:
The study included patients undergoing elective, major orthopedic, urologic, colorectal, pancreatic/biliary , thoracic, or spine surgery with anticipated postoperative admission of at least 48 h.
Inclusion criteria was age greater than 18 yr, anticipated length of stay 72 h or longer, and expected survival of longer than 6 months after surgery .
Exclusion criteria included anticipated need for postoperative intubation greater than 24 h, urgent or emergent surgery , or the inability to understand or participate in data collection instruments.
这项研究是一项前瞻性队列研究，采用混合手术样本，旨在研究基于组的轨迹建模与急性术后疼痛轨迹的关系。
研究参与者：
这项研究包括接受择期、大型骨科、泌尿科、结直肠、胰腺/胆道、胸科或脊柱手术的患者，预计术后住院时间至少为48小时。
纳入标准为年龄大于18岁，预期住院时间为72小时或更长，术后预期生存期为6个月以上。
排除标准包括术后插管超过24小时的预期需要，紧急或紧急手术，或无法理解或参与。
Data collection:
Sociodemographic variables. Age, sex, race, ethnicity, and preoperative body mass index.
Clinical measures. The preoperative and postoperative use of pain medication were recorded and the intraoperative consumption of opioid administration was calculated as oral morphine milligram equivalents.
Pain Assessment. The perioperative pain experience was characterized using the average pain severity item from the Brief Pain Inventory , which asks subjects to indicate the number (0, which indicates “no pain, ” to 10, which indicates “pain as bad as you can imagine”) that best describes their pain on average, as well as worst and least pain in the last 24 h. Patients were assessed with the Brief Pain Inventory before surgery and then each day after surgery through post-operative day 7.
Preoperative Mental Health and Behavioral Factors. PROMIS. Three measures were developed and validated as a part of the Patient-Reported Outcomes Measurement Information System (PROMIS), including adult measures of PROMIS Anxiety , PROMIS Depression, and PROMIS Pain Behavior (i.e., behaviors that would indicate to others that an individual is experience pain, such as grimacing or sighing).
Pain Catastrophizing Scale. magnification, rumination, and helplessness
数据收集：
社会人口变量：年龄、性别、种族、民族和术前体重指数。
临床措施： 记录术前和术后疼痛药物的使用情况，术中阿片类药物的消耗量按口服吗啡毫克当量计算。
疼痛评估： 围手术期疼痛体验的特点是使用简明疼痛量表中的平均疼痛严重程度项，要求受试者指出最能描述其平均疼痛程度的数字（0表示“无疼痛”，10表示“疼痛程度如你所能想象的那么严重”），以及过去24小时最严重和最轻的疼痛。在术前和术后第7天对患者进行简短的疼痛评估。
术前心理健康与行为因素： PROMIS。作为患者报告结果测量信息系统（PROMIS）的一部分，开发并验证了三种测量方法，包括成人测量的PROMIS焦虑、PROMIS抑郁和PROMIS疼痛行为（即，向他人表明个人经历疼痛的行为，如鬼脸或叹息）。
疼痛灾难化量表PCS：反复思虑、夸大和无助三个方面
患者特征
共有363名患者被纳入该样本(图1 ).表1总结患者的人口统计和其他术前临床措施。患者平均年龄近60岁，男女比例均匀，14%（51/362，14%）为非白人，4%（14/363）为西班牙裔。结直肠手术是最常见的外科手术，其次是胸/心血管手术和泌尿外科手术(表1 ).
图1：流程图
表1：病人信息
日常疼痛与基于群体的轨迹分析
对于基于组的轨迹分析，n=3没有足够的术后疼痛数据，随后的分析有n=360名患者（图1）。对于整个样本，术后第一天的平均每日疼痛为中度（5.1%）± 2.6），术后7天略有下降（3.5%）± 2.4; 图2）。尽管91%（n=326）有术后至少5天的完整疼痛数据，但每个时间点（术后第1天至第7天）的丢失率在6%至18%之间。表2报告了基于组的轨迹分析的模型拟合。最佳拟合模型包括五个轨迹组，分别为线性和二次轨迹组。图3以图形方式表示这些轨迹组，图4显示了每个轨迹中患者的单独曲线图。轨迹分析的数据和SAS代码见补充数字内容1(http://links.lww.com/ALN/C535). 近一半的患者（360例中167例，46%）属于中度至重度疼痛组。四分之一的患者（360例中的88例，24%）属于中度至轻度疼痛组。总的来说，7%（25/360）的患者属于低疼痛组，而16.9%（58/360）的患者属于高疼痛组。还有一组患者（360人中的22人）在术后7天内疼痛急剧减轻。表3显示了按轨迹组划分的患者特征，图4描述了手术服务和轨迹组之间的轨迹图。以下是每个疼痛轨迹组的主要人口统计学和临床特征总结：
图2。术后前7天平均每日疼痛。整个样本的总体轨迹。误差线表示95%CI。
图3：术后7天的疼痛轨迹误差线表示95%CI
图4：每个疼痛轨迹组内的个体轨迹的轨迹图
High (58 of 360, 16.9%) . Youngest group (54 ± 12 yr), female(2/3) , the largest proportion of Hispanics (4 of 58, 7%), higher opioid use.
Moderate-to-High(167 of 360, 46%). Average age(58 ± 12 yr), female(>50% (89 of 167) ) , Black(>10% (20 of 167)), Hispanic(4% (6 of 167)), colorectal service(1/3), higher need for opioids.
Moderate-to-Low(88 of 360, 24%). Average age(61 ± 13 yr), male(>50%), white(> 90% (81 of 88) ), Hispanic（5% (4 of 88)） reported being . Nearly all patients in this group were evenly distributed across four surgical services: colorectal, orthopedics, thoracic/cardio-vascular, and urology.
Low( 25 of 360, 7%). The oldest (66 ± 13 yr), male(3/4 (19 of 25) ), non-Hispanic, colorectal surgical service(40% (9 of 25)), the lowest opioid requirement.
Decreasing (22 of 360, 6%) . similar to the low pain group, average age(63 ± 10 yr), male(70% (15 of 22) ), no Hispanic, urology service(1/3(6 of 22)).
高(58 of 360, 16.9%)：这是最年轻的一组（54± 12岁），三分之二的患者是女性。这一组的西班牙裔人口比例也最高（58人中有4人，占7%），术中对阿片类药物的需求量更大。
中到高(167 of 360, 46%)：这组患者的平均年龄为58± 12岁，超过50%（167例中89例）为女性。在这个组中，超过10%（20/167）的病人是黑人，4%（6/167）是西班牙裔。其中近三分之一（167人中有46人）接受了结直肠手术。这一组在术后后期对阿片类药物的需求也较高。
中低档(88 of 360, 24%)：这组人的平均年龄是61± 13岁，半数以上为男性。超过90%（81/88）的病人是白人，5%（4/88）是西班牙裔。这一组中几乎所有的患者平均分布在四种外科服务中：结直肠、骨科、胸/心血管和泌尿外科。
低( 25 of 360, 7%)：这组患者年龄最大（66岁± 与其他疼痛轨迹组相比。男性占该组患者的四分之三（25人中的19人），所有患者都报告说他们是非西班牙裔。近40%（9/25）的患者接受了结直肠外科手术。在术后7天，阿片类药物需求量最低。
减少(22 of 360, 6%)：这个组与低痛组相似，平均年龄63± 10岁。本组患者中有近70%（15/22）为男性，无一人报告为西班牙裔。这组病人中有近三分之一（22人中有6人）在泌尿外科服务。
Trajectory groups were statistically significantly associated with age, sex and postoperative opioid requirement.
After adjustment for multiple comparisons, the trajectory group was not statistically significantly associated with race, ethnicity, body mass index, intraoperative medications, preoperative block, or preoperative opioid use.
Association between service and pain trajectory group did not reach statistical significance. Similar results were found for surgical procedure.
轨迹组与年龄、性别和术后阿片类药物需求量显著相关。
调整多重比较后，轨迹组与种族、民族、体重指数、术中用药、术前阻滞或术前阿片类药物使用无统计学显著相关。
服务和疼痛轨迹组之间的关联没有达到统计学意义。在外科手术中也发现了类似的结果。
Pain Trajectory Groups and Preoperative Mental Health
Trajectory groups were statistically significantly associated with each preoperative mental health and behavior measure.
üHigher patient anxiety, depression, pain behaviors and pain catastrophizing were associated with trajectories with higher pain.
üInterestingly , for all measures, patients in the decreasing pain group had similar scores to patients in the low and moderate-to-low groups.
Multivariable Analyses
ülower age, female sex, higher anxiety and more pain behaviors were related to increased likelihood of being in high pain trajectory.
疼痛轨迹组与术前心理健康
轨迹组与每个术前心理健康和行为测量有统计学显著相关。
较高的病人焦虑、抑郁、疼痛行为和疼痛灾变与较高疼痛的轨迹相关。
有趣的是，在所有测量中，疼痛减轻组的患者与低、中、低组的患者得分相似。
多变量分析
较低的年龄、女性、较高的焦虑和更多的疼痛行为与处于高疼痛轨迹的可能性增加有关。
It was thought in the past that approaches to perioperative pain control largely center on surgical procedure type, and most were concerned about the relationship between the type of operations and the acute postoperative pain.
以往认为围手术期疼痛控制的方法主要集中在手术方式上，大多关注手术方式与术后急性疼痛的关系。
Sociodemographic and behavioral factors have been strongly associated with acute postoperative pain intensity over the last few decades. However, much of this early work on preoperative predictors of acute postoperative pain used pain intensity assessments on a single day after surgery or aggregates over the first few days after surgery.
在过去的几十年里，社会人口和行为因素与急性术后疼痛强度密切相关。然而，这项关于术前急性术后疼痛预测因子的早期研究大多采用术后一天的疼痛强度评估或术后最初几天的疼痛强度评估。
The results do not suggest that surgical procedure type, regional anesthesia, or multimodal analgesia are not associated with greater or lesser postoperative pain but rather that these factors were not key differentiators of trajectory group assignments for acute postoperative pain.
结果并不表明外科手术类型、区域麻醉或多模式镇痛与术后疼痛的大小无关，而是这些因素并不是术后急性疼痛轨迹分组的关键因素。
Multivariable modeling showed that sex, anxiety, and pain behaviors were independently associated with group trajectory assignment. Female sex has previously shown a strong association with increased postoperative pain intensity across a variety of surgical procedures.
多变量模型显示，性别、焦虑和疼痛行为与群体轨迹分配独立相关。女性先前在各种外科手术中表现出与术后疼痛强度增加密切相关。
By contrast, despite the strong associations reported between catastrophizing and postoperative pain intensity , catastrophizing was not associated with group trajectory assignment.
相比之下，尽管灾难化与术后疼痛强度之间有很强的相关性，灾难化与分组轨迹分配无关。
In summary, the results demonstrate the existence of at least five categories of acute postoperative pain trajectories defined predominantly by patient factors rather than type of surgery and intraoperative medications.
总之，研究结果表明至少存在五种类型的急性术后疼痛轨迹，主要由患者因素而不是手术类型和术中药物决定。
文献网址：https://pubs.asahq.org/anesthesiology/article/134/3/421/115078/Patient-and-Procedural-Determinants-of
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