Follow-up of post-bunionectomy pain in two in- and outpatient cohorts: interest in patient analgesic education

Dear Editor,
In day-case surgery, discharge on oral medication is at risk of inadequate analgesia and side effects in ambulatory patients [1–3]. To be efficient, analgesia has to provide long-lasting pain relief with minimal side effects including sedation, dizziness, nausea, or psychomotor impairment [4]. Bunionectomy is usually considered as painful surgery and continuous popliteal sciatic nerve block for postoperative pain control at home has been described [5]. However, such a sophisticated technique remains expensive, underused and moreover neurological complications have been described [6]. After agreement of appropriate boards and signed consent, this prospective, mono-centric, single-operator study evaluated the analgesic efficacy of oral medication and preoperative advice to treat pain after discharge in two cohorts of in- and outpatients scheduled for bunionectomy from April 2015 to April 2016. Seventy-three patients were included and operated on under combined ultrasonic popliteal sciatic and saphenous blocks with 1.5% lidocaine at the dose of 4 mg kg-1 and use of a tourniquet. Before surgery, each patient had a preoperative anesthetic consultation and received analgesic prescription and advice with a visual analogic scale (VAS) to take medicine at home and when using rescue doses. From discharge from the post-anesthesia care unit (PACU) on the first day, the analgesic oral protocol consisted of paracetamol (4 × 1 g) and ketoprofen (2 × 100 mg) for seven days. When VAS > 4, rescue was tramadol (50 mg 1 to 4 doses per day) in outpatient or immediate release morphine 10 mg – 1 to 3 doses in the group hospitalized on the first night. Figure 1 highlights the flow of patients throughout the study.
Mean daily pain as the main criterion was evaluated with the VAS at rest and walking, analgesic use and rescue treatment from day (D) 1 to day 7. Patient adherence to the protocol was assessed with a personal diary and phone interview. Fatigue at D2 and D7 was assessed using a Pichot scale from 0 to 32 with severe fatigue if > 22, measuring respectively depressive mood, fatigue and anxiety dimensions [7]. Quality of sleep and life was monitored through the EQ-5D questionnaire with eight items (pain, mobility, mood, self-care, activities, sleep, sex, and need for analgesic) [8]. Sixteen patients were excluded from the study. Demographic data are summarized in Table 1.
VAS values (0–100 mm) from D1 to D7 in both groups are presented...


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