Multimodal Pain Strategies and Clinical Significant Improvements in Postoperative Quality of Recovery

Dear Editor, I read with great interest the article by Elkassabany et al. in a recent issue of the Journal [1]. The authors performed a before and after study on 252 patients undergoing ambulatory shoulder surgery and concluded that the implementation of a multimodal pain strategy improved the overall quality of recovery (QoR) and many aspects of postoperative pain relief while reducing total opioid consumption in patients undergoing ambulatory shoulder surgery. The authors should be congratulated for performing a well-designed study on an important topic (e.g., acute pain) in patients undergoing surgery [2,3]. In addition, the current emphasis on the need to improve postoperative recovery and patient satisfaction makes the topic very relevant in perioperative medicine [4,5]. Although the study of Elkassabany et al. was well conducted, there are some questions regarding the study that need to be clarified to determine the validity of the results. First, the authors did not control the use of intraoperative analgesics, which are known to affect postoperative pain and subsequently patient recovery. Second, the authors found only a one-point difference in the quality of recovery scores, which does not imply improvement or deterioration in postoperative recovery. For example, it has been reported that a five-point difference in the QoR score is clinically significant [6]. Finally, it is unclear how the authors assessed postoperative pain in the recovery period. It is well known that the use of nurses’ evaluation through chart review is not a reliable method. I would welcome comments to address these issues, as they might help to further substantiate the findings of this important study. Funding sources: None/departmental. Conflict of interest: None.