51
|
Zhu Q, Li L, Yang Z, Shen J, Zhu R, Wen Y, Cai W, Liu L. Ultrasound guided continuous Quadratus Lumborum block hastened recovery in patients undergoing open liver resection: a randomized controlled, open-label trial. BMC Anesthesiol 2019; 19:23. [PMID: 30777027 PMCID: PMC6380018 DOI: 10.1186/s12871-019-0692-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 02/06/2019] [Indexed: 12/22/2022] Open
Abstract
Background Quadratus lumborum (QL) block is increasingly being used as a new abdominal nerve block technique. In some studies of mid and lower abdominal and hip analgesia, continuous QL block achieved favorable outcomes as an alternative to continuous intravenous analgesia with opioids. However, the use of continuous QL block for upper abdominal pain is less well characterized. This study aimed to investigate the effects of continuous anterior QL block (CQLB) on postoperative pain and recovery in patients undergoing open liver resection. Methods Sixty-three patients underwent elective open liver resection were randomly divided into continuous anterior QL block (CQLB, n = 32) group and patient-controlled intravenous analgesia (PCIA, n = 31) group. Patients in CQLB group underwent ultrasound-guided anterior QL block at the second lumbar vertebral transverse processes before general anesthesia, followed by postoperative CQLB analgesia. Patients in PCIA group underwent continuous intravenous analgesia postoperatively. Postoperative numerical rating scale (NRS) pain scores upon coughing and at rest, self-administered analgesic counts, rate of rescue analgesic use, time to first out-of-bed activity and anal flatus after surgery, and incidences of analgesic-related adverse effects were recorded. Results Postoperative NRS pain scores on coughing in CQLB group at different time points and NRS pain score at rest 48 h after surgery were significantly lower than those in PCIA group (P < 0.05). Time to first out-of-bed activity and anal flatus after surgery in CQLB group were significantly earlier than those in PCIA group (P < 0.05). No significant differences of postoperative self-administered analgesic counts, rate of postoperative rescue analgesic usage, or incidences of analgesic-related adverse effects were found between the two groups (P > 0.05). Conclusions Ultrasound-guided anterior QL block significantly alleviated the pain during coughing after surgery, shortened the time to first out-of-bed activity and anal flatus, promoting postoperative recovery of the patients undergoing open liver resection. Trial registration This study has been registered in April 1, 2018 on Chinese Clinical Trail Registry, the registration number is ChiCTR1800015454.
Collapse
Affiliation(s)
- Qiang Zhu
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Hunan, China
| | - Li Li
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Hunan, China
| | - Zhaoyun Yang
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Hunan, China
| | - Jinmei Shen
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Hunan, China
| | - Rong Zhu
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Hunan, China
| | - Yu Wen
- Department of Hepatobiliary Surgery, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Hunan, China
| | - Wenwu Cai
- Department of Hepatobiliary Surgery, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Hunan, China
| | - Lei Liu
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Hunan, China.
| |
Collapse
|
52
|
Bello M, Oger S, Bedon-Carte S, Vielstadte C, Leo F, Zaouter C, Ouattara A. Effect of opioid-free anaesthesia on postoperative epidural ropivacaine requirement after thoracic surgery: A retrospective unmatched case-control study. Anaesth Crit Care Pain Med 2019; 38:499-505. [PMID: 30731138 DOI: 10.1016/j.accpm.2019.01.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 12/16/2018] [Accepted: 01/25/2019] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Patients undergoing thoracic surgery are at risk of severe postoperative pain. Post-thoracotomy pain relief is usually provided with thoracic epidural analgesia (TEA). Intraoperative use of opioids may result in hyperalgesia and increase analgesics consumption. We investigated the effect of opioid-free anaesthesia (OFA) on epidural ropivacaine requirement after thoracotomy. METHODS This retrospective study compared postoperative epidural ropivacaine requirement of patients undergoing open thoracotomy and receiving either opioid-based anaesthesia (OBA group) or a non-opioid regimen including clonidine, ketamine and lidocaine (OFA group). All patients received postoperative multimodal analgesia including both epidural analgesia and intravenous analgesics. The primary outcome was the cumulative first 48 postoperative hours epidural ropivacaine consumption. Secondary outcomes included postoperative pain scores, requirement for postoperative morphine titration, total opioid analgesics consumption within the first 48 postoperative hours, incidence of nausea and vomiting, intraoperative haemodynamic. RESULTS From January 2015 to February 2018, 50 patients received an OBA and 25 received an OFA. The cumulative first 48 postoperative hours epidural ropivacaine consumption was significantly higher in the OBA-group (919 ± 311 mg versus 693 ± 270 mg, P = 0.002). Numerical Rating Scale at 6 and 24 h were significantly lower in the OFA-group (1[0-2] versus 3 [1-5], P = 0.0005 and 1[0-2] versus 3.5 [1-5], P = 0.001). In post-anaesthesia care unit, the proportion of patients requiring morphine was significantly higher in the OBA-group (42% versus 4%, P < 0.001). During anaesthesia, the OBA-group required more vasopressor support, while there were more hypertensive events in the OFA-group. CONCLUSION OFA might reduce ropivacaine consumption, early postoperative pain scores and requirement for morphine titration after thoracotomy.
Collapse
Affiliation(s)
- Maeva Bello
- CH Périgueux, Department of Anaesthesia, 24000 Périgueux, France; Université Bordeaux, Inserm, UMR 1034, Biology of cardiovascular diseases, 33600 Pessac, France
| | - Sébastien Oger
- CH Périgueux, Department of Anaesthesia, 24000 Périgueux, France
| | | | | | - Francesco Leo
- CH Périgueux, Department of thoracic surgery, 24000 Périgueux, France
| | - Cédrick Zaouter
- CHU Bordeaux, Department of Anaesthesia and critical care, Magellan medico-surgical center, 33000 Bordeaux, France
| | - Alexandre Ouattara
- Université Bordeaux, Inserm, UMR 1034, Biology of cardiovascular diseases, 33600 Pessac, France; CHU Bordeaux, Department of Anaesthesia and critical care, Magellan medico-surgical center, 33000 Bordeaux, France.
| |
Collapse
|
53
|
Preperitoneal or Subcutaneous Wound Catheters as Alternative for Epidural Analgesia in Abdominal Surgery. Ann Surg 2019; 269:252-260. [DOI: 10.1097/sla.0000000000002817] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
54
|
Mungroop TH, Geerts BF, Veelo DP, Pawlik TM, Bonnet A, Lesurtel M, Reyntjens KM, Noji T, Liu C, Jonas E, Wu CL, de Santibañes E, Abu Hilal M, Hollmann MW, Besselink MG, van Gulik TM. Fluid and pain management in liver surgery (MILESTONE): A worldwide study among surgeons and anesthesiologists. Surgery 2019; 165:337-344. [DOI: 10.1016/j.surg.2018.08.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/17/2018] [Accepted: 08/12/2018] [Indexed: 02/07/2023]
|
55
|
Grandhi RK, Abd-Elsayed A. Post-operative Pain Management in Spine Surgery. TEXTBOOK OF NEUROANESTHESIA AND NEUROCRITICAL CARE 2019:447-455. [DOI: 10.1007/978-981-13-3387-3_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
|
56
|
Dunkman WJ, Manning MW. Enhanced Recovery After Surgery and Multimodal Strategies for Analgesia. Surg Clin North Am 2018; 98:1171-1184. [DOI: 10.1016/j.suc.2018.07.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
|
57
|
Rana M, Yusuff H, Zochios V. The Right Ventricle During Selective Lung Ventilation for Thoracic Surgery. J Cardiothorac Vasc Anesth 2018; 33:2007-2016. [PMID: 30595486 DOI: 10.1053/j.jvca.2018.11.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Indexed: 12/25/2022]
Abstract
The right ventricle (RV) has been an area of evolving interest after decades of being ignored and considered less important than the left ventricle. Right ventricular dysfunction/failure is an independent predictor of mortality and morbidity in cardiac surgery; however, very little is known about the incidence or impact of RV dysfunction/failure in thoracic surgery. The pathophysiology of RV dysfunction/failure has been studied in the context of acute respiratory distress syndrome (ARDS), cardiac surgery, pulmonary hypertension, and left ventricular failure, but limited data exist in literature addressing the issue of RV dysfunction/failure in the context of thoracic surgery and one-lung ventilation (OLV). Thoracic surgery and OLV present as a unique situation where the RV is faced with sudden changes in afterload, preload, and contractility throughout the perioperative period. The authors discuss the possible pathophysiologic mechanisms that can affect adversely the RV during OLV and introduce the term RV injury to the myocardium that is affected adversely by the various intraoperative factors, which then makes it predisposed to acute dysfunction. The most important of these mechanisms seems to be the role of intraoperative mechanical ventilation, which potentially could cause both ventilator-induced lung injury leading to ARDS and RV injury. Identification of at-risk patients in the perioperative period using focused imaging, particularly echocardiography, is paramount. The authors also discuss the various RV-protective strategies required to prevent RV dysfunction and management of established RV failure.
Collapse
Affiliation(s)
- Meenal Rana
- University Hospitals of Leicester National Health Service Trust, Department of Cardiothoracic Anesthesia and Critical Care Medicine, Glenfield Hospital, Leicester, UK; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, Centre of Translational Inflammation Research, University of Birmingham, Birmingham, UK
| | - Hakeem Yusuff
- University Hospitals of Leicester National Health Service Trust, Department of Cardiothoracic Anesthesia and Critical Care Medicine, Glenfield Hospital, Leicester, UK; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, Centre of Translational Inflammation Research, University of Birmingham, Birmingham, UK.
| | - Vasileios Zochios
- University Hospitals Birmingham National Health Service Foundation Trust, Department of Critical Care Medicine, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, Centre of Translational Inflammation Research, University of Birmingham, Birmingham, UK
| |
Collapse
|
58
|
Mullins C, O'Loughlin L, Albus U, Skelly JR, Smith J. Managing epidural catheters in critical care beds: An observation analysis in the Republic of Ireland. J Perioper Pract 2018; 29:228-236. [PMID: 30372362 DOI: 10.1177/1750458918808153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In certain hospitals, epidural analgesia is restricted to critical care beds. Due to critical care bed strain, it is likely that many patients are unable to avail of epidural analgesia. The aims of the study were to retrospectively review the number of patients admitted to critical care beds for epidural analgesia over a two-year period 2015–16, to determine the duration of epidural analgesia, to identify the average critical care bed occupancy during this period, to get updated information on the implementation of acute pain service in the Republic of Ireland and the availability of ward-based epidural analgesia. One hundred and sixty patients had a midline laparotomy, 40 of which had an epidural (25%). Forty-two patients were admitted to a critical care bed for epidural analgesia. Aside from epidural analgesia, 12% had other indications for ICU admission. Median duration epidural analgesia was 1.64 days (IQR 0.98–2.14 days). ICU bed occupancy rates were 88.7% in 2015 and 85.1% in 2016. Acute pain service and ward-based epidural analgesia were available in 46 and 42% of hospitals, respectively. Restricting epidural use to a critical care setting is likely to result in reduced access to epidural analgesia. The implementation of acute pain service and availability of ward-based epidural analgesia in the Republic of Ireland are suboptimal.
Collapse
Affiliation(s)
- Cormac Mullins
- Department of Anaesthesia, Sligo University Hospital, Sligo, Ireland
| | - Lauren O'Loughlin
- Department of Anaesthesia, Sligo University Hospital, Sligo, Ireland
| | - Ulrich Albus
- Department of Anaesthesia, Sligo University Hospital, Sligo, Ireland
| | - J R Skelly
- Department of Anaesthesia, Sligo University Hospital, Sligo, Ireland
| | - Jeremy Smith
- Department of Anaesthesia, Sligo University Hospital, Sligo, Ireland
| |
Collapse
|
59
|
Is epidural analgesia still a viable option for enhanced recovery after abdominal surgery. Curr Opin Anaesthesiol 2018; 31:622-629. [DOI: 10.1097/aco.0000000000000640] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
|
60
|
Abstract
BACKGROUND AND OBJECTIVES Psoas blocks are an alternative to femoral nerve blocks and have the potential advantage of blocking the entire lumbar plexus. However, the psoas muscle is located deeply, making psoas blocks more difficult than femoral blocks. In contrast, while femoral blocks are generally easy to perform, the inguinal region is prone to infection. We thus tested the hypothesis that psoas blocks are associated with more insertion-related complications than femoral blocks but have fewer catheter-related infections. METHODS We extracted 22,434 surgical cases from the German Network for Regional Anesthesia registry (2007-2014) and grouped cases as psoas (n = 7593) and femoral (n = 14,841) blocks. Insertion-related complications (including single-shot blocks and catheter) and infectious complications (including only catheter) in each group were compared with χ tests. The groups were compared with multivariable logistic models, adjusted for potential confounding factors. RESULTS After adjustment for potential confounding factors, psoas blocks were associated with more complications than femoral blocks including vascular puncture 6.3% versus 1.1%, with an adjusted odds ratio (aOR) of 3.6 (95% confidence interval [CI], 2.9-4.6; P < 0.001), and multiple skin punctures 12.6% versus 7.7%, with an aOR of 2.6 (95% CI, 2.1-3.3; P <0.001). Psoas blocks were also associated with fewer catheter-related infections: 0.3% versus 0.9% (aOR of 0.4; 95% CI, 0.2-0.8; P = 0.016), and with improved patient satisfaction (mean ± SD 0- to 10-point scale score, 9.6 ± 1.2 vs 8.4 ± 2.9; P < 0.001). Results from a propensity-matched sensitivity analysis were similar. CONCLUSIONS Psoas blocks are associated with more insertion-related complications but fewer infectious complications. CLINICAL TRIAL REGISTRATION ID NCT02846610.
Collapse
|
61
|
Berninger MT, Friederichs J, Leidinger W, Augat P, Bühren V, Fulghum C, Reng W. Effect of local infiltration analgesia, peripheral nerve blocks, general and spinal anesthesia on early functional recovery and pain control in total knee arthroplasty. BMC Musculoskelet Disord 2018; 19:232. [PMID: 30021587 PMCID: PMC6052689 DOI: 10.1186/s12891-018-2154-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 06/24/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Postoperative pain control and enhanced mobilization, muscle strength and range of motion following total knee arthroplasty (TKA) are pivotal requisites to optimize rehabilitation and early recovery. The aim of the study was to analyze the effect of local infiltration analgesia (LIA), peripheral nerve blocks, general and spinal anesthesia on early functional recovery and pain control in primary total knee arthroplasty. METHODS Between January 2016 until August 2016, 280 patients underwent primary TKA and were subdivided into four groups according to their concomitant pain and anesthetic procedure with catheter-based techniques of femoral and sciatic nerve block (group GA&FNB, n = 81) or epidural catheter (group SP&EPI, n = 51) in combination with general anesthesia or spinal anesthesia, respectively, and LIA combined with general anesthesia (group GA&LIA, n = 86) or spinal anesthesia (group SP&LIA, n = 61). Outcome parameters focused on the evaluation of pain (NRS scores), mobilization, muscle strength and range of motion up to 7 days postoperatively. The cumulative consumption of (rescue) pain medication was analyzed. RESULTS Pain relief was similar in all groups, while the use of opioid medication was significantly lower (up to 58%) in combination with spinal anesthesia, especially in SP&EPI. The LIA groups, in contrast, revealed significant higher mobilization (up to 26%) and muscle strength (up to 20%) in the early postoperative period. No analgesic technique-related or surgery-related complications occurred within the first 7 days. Due to insufficient pain relief, 8.4% of the patients in the catheter-based groups and 12.2% in the LIA groups resulted in a change of the anesthetics pain management. CONCLUSIONS The LIA technique offers a safe and effective treatment option concerning early functional recovery and pain control in TKA. Significant advantages were shown for mobilization and muscle strength in the early postoperative period while pain relief was comparable within the groups.
Collapse
Affiliation(s)
- M T Berninger
- endogap, Joint Replacement Institute, Garmisch-Partenkirchen Medical Center, Auenstr. 6, 82467, Garmisch-Partenkirchen, Germany. .,Department of Trauma Surgery, BG Trauma Center Murnau, Prof.-Küntscher Str. 8, 82418, Murnau, Germany.
| | - J Friederichs
- Department of Trauma Surgery, BG Trauma Center Murnau, Prof.-Küntscher Str. 8, 82418, Murnau, Germany
| | - W Leidinger
- Department of Anesthesiology and Intensive Care, Garmisch-Partenkirchen Medical Center, Auenstr. 6, 82467, Garmisch-Partenkirchen, Germany
| | - P Augat
- Institute of Biomechanics, BG Trauma Center Murnau, Prof.-Küntscher Str. 8, 82418, Murnau, Germany.,Institute of Biomechanics, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria
| | - V Bühren
- Department of Trauma Surgery, BG Trauma Center Murnau, Prof.-Küntscher Str. 8, 82418, Murnau, Germany
| | - C Fulghum
- endogap, Joint Replacement Institute, Garmisch-Partenkirchen Medical Center, Auenstr. 6, 82467, Garmisch-Partenkirchen, Germany
| | - W Reng
- endogap, Joint Replacement Institute, Garmisch-Partenkirchen Medical Center, Auenstr. 6, 82467, Garmisch-Partenkirchen, Germany
| |
Collapse
|
62
|
Staudt MD, Pasternak SH, Sharma M, Pandey SK, Arango MF, Pelz DM, Lownie SP. Multilevel, ultra-large-volume epidural blood patch for the treatment of neurocognitive decline associated with spontaneous intracranial hypotension: case report. J Neurosurg 2018; 129:205-210. [DOI: 10.3171/2017.5.jns17249] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spontaneous intracranial hypotension (SIH) is a progressive clinical syndrome characterized by orthostatic headaches, nausea, emesis, and occasionally focal neurological deficits. Rarely, SIH is associated with neurocognitive changes. An epidural blood patch (EBP) is commonly used to treat SIH when conservative measures are inadequate, although some patients require multiple EBP procedures or do not respond at all. Recently, the use of a large-volume (LV) EBP has been described to treat occult leak sites in treatment-refractory SIH. This article describes the management of a patient with profound neurocognitive decline associated with SIH, who was refractory to conservative management and multiple interventions. The authors describe the successful use of an ultra-LV-EBP of 120 ml across multiple levels, the largest volume reported in the literature, and describe the technical aspects of the procedure. This procedure has resulted in dramatic and sustained symptom resolution.
Collapse
Affiliation(s)
| | - Stephen H. Pasternak
- Departments of 1Clinical Neurological Sciences,
- 2Robarts Research Institute, Western University, London, Ontario, Canada
| | | | | | - Miguel F. Arango
- 4Anesthesia and Perioperative Medicine, London Health Sciences Centre, and
| | | | - Stephen P. Lownie
- Departments of 1Clinical Neurological Sciences,
- 3Medical Imaging, and
| |
Collapse
|
63
|
Weibel S, Jelting Y, Pace NL, Helf A, Eberhart LHJ, Hahnenkamp K, Hollmann MW, Poepping DM, Schnabel A, Kranke P. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults. Cochrane Database Syst Rev 2018; 6:CD009642. [PMID: 29864216 PMCID: PMC6513586 DOI: 10.1002/14651858.cd009642.pub3] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The management of postoperative pain and recovery is still unsatisfactory in a number of cases in clinical practice. Opioids used for postoperative analgesia are frequently associated with adverse effects, including nausea and constipation, preventing smooth postoperative recovery. Not all patients are suitable for, and benefit from, epidural analgesia that is used to improve postoperative recovery. The non-opioid, lidocaine, was investigated in several studies for its use in multimodal management strategies to reduce postoperative pain and enhance recovery. This review was published in 2015 and updated in January 2017. OBJECTIVES To assess the effects (benefits and risks) of perioperative intravenous (IV) lidocaine infusion compared to placebo/no treatment or compared to epidural analgesia on postoperative pain and recovery in adults undergoing various surgical procedures. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, and reference lists of articles in January 2017. We searched one trial registry contacted researchers in the field, and handsearched journals and congress proceedings. We updated this search in February 2018, but have not yet incorporated these results into the review. SELECTION CRITERIA We included randomized controlled trials comparing the effect of continuous perioperative IV lidocaine infusion either with placebo, or no treatment, or with thoracic epidural analgesia (TEA) in adults undergoing elective or urgent surgery under general anaesthesia. The IV lidocaine infusion must have been started intraoperatively, prior to incision, and continued at least until the end of surgery. DATA COLLECTION AND ANALYSIS We used Cochrane's standard methodological procedures. Our primary outcomes were: pain score at rest; gastrointestinal recovery and adverse events. Secondary outcomes included: postoperative nausea and postoperative opioid consumption. We used GRADE to assess the quality of evidence for each outcome. MAIN RESULTS We included 23 new trials in the update. In total, the review included 68 trials (4525 randomized participants). Two trials compared IV lidocaine with TEA. In all remaining trials, placebo or no treatment was used as a comparator. Trials involved participants undergoing open abdominal (22), laparoscopic abdominal (20), or various other surgical procedures (26). The application scheme of systemic lidocaine strongly varies between the studies related to both dose (1 mg/kg/h to 5 mg/kg/h) and termination of the infusion (from the end of surgery until several days after).The risk of bias was low with respect to selection bias (random sequence generation), performance bias, attrition bias, and detection bias in more than 50% of the included studies. For allocation concealment and selective reporting, the quality assessment yielded low risk of bias for only approximately 20% of the included studies.IV Lidocaine compared to placebo or no treatment We are uncertain whether IV lidocaine improves postoperative pain compared to placebo or no treatment at early time points (1 to 4 hours) (standardized mean difference (SMD) -0.50, 95% confidence interval (CI) -0.72 to -0.28; 29 studies, 1656 participants; very low-quality evidence) after surgery. Due to variation in the standard deviation (SD) in the studies, this would equate to an average pain reduction of between 0.37 cm and 2.48 cm on a 0 to 10 cm visual analogue scale . Assuming approximately 1 cm on a 0 to 10 cm pain scale is clinically meaningful, we ruled out a clinically relevant reduction in pain with lidocaine at intermediate (24 hours) (SMD -0.14, 95% CI -0.25 to -0.04; 33 studies, 1847 participants; moderate-quality evidence), and at late time points (48 hours) (SMD -0.11, 95% CI -0.25 to 0.04; 24 studies, 1404 participants; moderate-quality evidence). Due to variation in the SD in the studies, this would equate to an average pain reduction of between 0.10 cm to 0.48 cm at 24 hours and 0.08 cm to 0.42 cm at 48 hours. In contrast to the original review in 2015, we did not find any significant subgroup differences for different surgical procedures.We are uncertain whether lidocaine reduces the risk of ileus (risk ratio (RR) 0.37, 95% CI 0.15 to 0.87; 4 studies, 273 participants), time to first defaecation/bowel movement (mean difference (MD) -7.92 hours, 95% CI -12.71 to -3.13; 12 studies, 684 participants), risk of postoperative nausea (overall, i.e. 0 up to 72 hours) (RR 0.78, 95% CI 0.67 to 0.91; 35 studies, 1903 participants), and opioid consumption (overall) (MD -4.52 mg morphine equivalents , 95% CI -6.25 to -2.79; 40 studies, 2201 participants); quality of evidence was very low for all these outcomes.The effect of IV lidocaine on adverse effects compared to placebo treatment is uncertain, as only a small number of studies systematically analysed the occurrence of adverse effects (very low-quality evidence).IV Lidocaine compared to TEAThe effects of IV lidocaine compared with TEA are unclear (pain at 24 hours (MD 1.51, 95% CI -0.29 to 3.32; 2 studies, 102 participants), pain at 48 hours (MD 0.98, 95% CI -1.19 to 3.16; 2 studies, 102 participants), time to first bowel movement (MD -1.66, 95% CI -10.88 to 7.56; 2 studies, 102 participants); all very low-quality evidence). The risk for ileus and for postoperative nausea (overall) is also unclear, as only one small trial assessed these outcomes (very low-quality evidence). No trial assessed the outcomes, 'pain at early time points' and 'opioid consumption (overall)'. The effect of IV lidocaine on adverse effects compared to TEA is uncertain (very low-quality evidence). AUTHORS' CONCLUSIONS We are uncertain whether IV perioperative lidocaine, when compared to placebo or no treatment, has a beneficial impact on pain scores in the early postoperative phase, and on gastrointestinal recovery, postoperative nausea, and opioid consumption. The quality of evidence was limited due to inconsistency, imprecision, and study quality. Lidocaine probably has no clinically relevant effect on pain scores later than 24 hours. Few studies have systematically assessed the incidence of adverse effects. There is a lack of evidence about the effects of IV lidocaine compared with epidural anaesthesia in terms of the optimal dose and timing (including the duration) of the administration. We identified three ongoing studies, and 18 studies are awaiting classification; the results of the review may change when these studies are published and included in the review.
Collapse
Affiliation(s)
- Stephanie Weibel
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
| | - Yvonne Jelting
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
| | - Nathan L Pace
- University of UtahDepartment of Anesthesiology3C444 SOM30 North 1900 EastSalt Lake CityUTUSA84132‐2304
| | - Antonia Helf
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
| | - Leopold HJ Eberhart
- Philipps‐University MarburgDepartment of Anaesthesiology & Intensive Care MedicineBaldingerstrasse 1MarburgGermany35043
| | - Klaus Hahnenkamp
- University HospitalDepartment of AnesthesiologyGreifswaldGermany17475
| | - Markus W Hollmann
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 DD
| | - Daniel M Poepping
- University Hospital MünsterDepartment of Anesthesiology and Intensive CareAlbert Schweitzer Str. 33MünsterGermany48149
| | - Alexander Schnabel
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
| | - Peter Kranke
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
| | | |
Collapse
|
64
|
Patients' Experiences of Pain Have an Impact on Their Pain Management Attitudes and Strategies. Pain Manag Nurs 2018; 19:464-473. [PMID: 29776871 DOI: 10.1016/j.pmn.2018.02.067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 01/13/2018] [Accepted: 02/17/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Postoperative pain remains undermanaged in orthopedic surgery. To identify areas of improvement for future structural changes in pain management, patients' experiences of pain and pain management when undergoing elective lumbar spine surgery were explored, using a qualitative method with focus group interviews. SETTING The study setting was an orthopedic spine surgery department at a University Hospital in Sweden. METHODS This study consisted of two focus group interviews with patients (n = 6/group, a total of 12 patients) who had undergone lumbar spine surgery 4 days to 5 weeks prior to the focus group interviews. The interviews were semi-structured, and the analysis was performed using qualitative content analysis. RESULTS The main result of this study revealed that patients' experiences of pain influenced their attitudes and strategies for pain management. Three main categories emerged from the focus group interviews: I. Coping with pain while waiting for surgery; II. Using different pain-relieving strategies after surgery; and III. How organizational structures influence the pain experiences. CONCLUSIONS In conclusion the results from this study acknowledge that postoperative pain experiences and coping strategies after spine surgery are highly diverse and individual. This calls for staff having a more personalized approach to pain management in order to optimize pain relief, which was stressed as highly valued by the patients.
Collapse
|
65
|
Li MH, Xu ZZ, Huang SM, Li T, Li XY, Wang DX. Effect of combined epidural anaesthesia on tumor-infiltrating lymphocytes in lung adenocarcinoma: a prospective exploratory sub-analysis. Acta Anaesthesiol Scand 2018; 62:687-700. [PMID: 29363103 DOI: 10.1111/aas.13068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 12/05/2017] [Accepted: 12/12/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Regional anaesthesia may have advantages in preserving immune function. Tumor-infiltrating lymphocytes (TILs) are considered indicators of immune response in the tumor microenvironment and used as a prognostic marker in patients after cancer surgery. This study investigated the effects of combined epidural anaesthesia on the number of TILs in patients undergoing surgery for lung adenocarcinoma. METHODS Patients undergoing radical resection for primary lung cancer were randomized to receive either combined epidural-general anaesthesia (Epi-GA) or general anaesthesia (GA) in an ongoing randomized controlled trial (ChiCTR-TRC-14004136). Excised adenocarcinoma specimens from patients enrolled between 1 June 2015 and 30 November 2015 were selected for immunohistochemical staining of CD8 and FOXP3 molecules. The numbers of positive lymphocytes were counted and expressed as the number of cells per mm2 tumor area. RESULTS One hundred and twenty-eight patients were recruited and randomized; 64 patients were included in immunohistochemistry analysis (37 received Epi-GA vs. 27 received GA). The number of CD8+ T cells was higher in the Epi-GA group than in the GA group (median [interquartile range]: 292.8 [198.0-418.3] vs. 204.7 [131.1-305.8], P = 0.036); whereas the number of FOXP3+ T cells was less in the Epi-GA group than in the GA group (37.6 [14.7-92.3] vs. 99.8 [68.9-168.3], P < 0.001). CONCLUSIONS For patients undergoing surgery for lung adenocarcinoma under general anesthesia, use of epidural anaesthesia increased CD8+ T cells infiltration but decreased FOXP3+ T cells accumulation in tumor tissues. Epidural anaesthesia may affect TILs in a manner that preserves immune function.
Collapse
Affiliation(s)
- M.-H. Li
- Departments of Anaesthesiology and Critical Care Medicine; Peking University First Hospital; Beijing China
| | - Z.-Z. Xu
- Departments of Anaesthesiology and Critical Care Medicine; Peking University First Hospital; Beijing China
| | - S.-M. Huang
- Departments of Anaesthesiology and Critical Care Medicine; Peking University First Hospital; Beijing China
| | - T. Li
- Department of Pathology; Peking University First Hospital; Beijing China
| | - X.-Y. Li
- Department of Biostatistics; Peking University First Hospital; Beijing China
| | - D.-X. Wang
- Departments of Anaesthesiology and Critical Care Medicine; Peking University First Hospital; Beijing China
| |
Collapse
|
66
|
Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy. Reg Anesth Pain Med 2018; 43:263-309. [DOI: 10.1097/aap.0000000000000763] [Citation(s) in RCA: 442] [Impact Index Per Article: 73.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
67
|
Leffert L, Butwick A, Carvalho B, Arendt K, Bates SM, Friedman A, Horlocker T, Houle T, Landau R, Dubois H, Fernando R, Houle T, Kopp S, Montgomery D, Pellegrini J, Smiley R, Toledo P. The Society for Obstetric Anesthesia and Perinatology Consensus Statement on the Anesthetic Management of Pregnant and Postpartum Women Receiving Thromboprophylaxis or Higher Dose Anticoagulants. Anesth Analg 2018; 126:928-944. [DOI: 10.1213/ane.0000000000002530] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
68
|
|
69
|
Meissner W, Huygen F, Neugebauer EAM, Osterbrink J, Benhamou D, Betteridge N, Coluzzi F, De Andres J, Fawcett W, Fletcher D, Kalso E, Kehlet H, Morlion B, Montes Pérez A, Pergolizzi J, Schäfer M. Management of acute pain in the postoperative setting: the importance of quality indicators. Curr Med Res Opin 2018; 34:187-196. [PMID: 29019421 DOI: 10.1080/03007995.2017.1391081] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Despite the introduction of evidence-based recommendations for postoperative pain management (POPM), the consensus is that pain control remains suboptimal. Barriers to achieving patient-satisfactory analgesia include deficient knowledge regarding POPM among staff, lack of instructions, insufficient pain assessments and sub-optimal treatment. Effective monitoring of POPM is essential to enable policy makers and healthcare providers to improve the quality of care. Quality indicators (QIs) are quantitative measures of clinical practice that can monitor, evaluate and guide the quality of care provided to patients. QIs can be used to assess various aspects relating to the care process and they have proven useful in improving health outcomes in diseases such as myocardial infarction. In this commentary we critically analyze the evidence regarding the use of QIs in acute POPM based upon the experience of pain specialists from Europe and the USA who are members of the Change Pain Advisory Board. We also undertook a literature review to see what has been published on QIs in acute pain with the goal of assessing which QIs have been developed and used, and which ones have been successful/unsuccessful. In the hospital sector the development and implementation of QIs is complex. The nature of POPM requires a highly trained, multidisciplinary team and it is at this level that major improvements can be made. Greater involvement of patients regarding pain management is also seen as a priority area for improving clinical outcomes. Changes in structure and processes to deliver high-level quality care need to be regularly audited to ensure translation into better outcomes. QIs can help drive this process by providing an indicator of current levels of performance. In addition, outcomes QIs can be used to benchmark levels of performance between different healthcare providers.
Collapse
Affiliation(s)
- Winfried Meissner
- a Dept. of Anesthesiology and Intensive Care , Jena University Hospital , Jena , Germany
| | - Frank Huygen
- b University Hospital , Rotterdam , The Netherlands
| | - Edmund A M Neugebauer
- c Brandenburg Medical School - Theodor Fontane , Neuruppin , Germany
- d Faculty of Health - School of Medicine , Witten/Herdecke University , Witten , Germany
| | - Jürgen Osterbrink
- e Institute of Nursing Science and Practice, WHO Collaborating Centre for Nursing Research and Education, Paracelsus Medical University , Salzburg , Austria
- f Brooks College of Health , University of North Florida, Jacksonville , Florida , USA
| | - Dan Benhamou
- g Département d'Anesthésie-Réanimation, Groupe Hospitalier Paris Sud , Hôpital Bicêtre , Le Kremlin-Bicêtre , France
- h SOS Regional Anaesthesia (SOS-RA) Service , Le Kremlin-Bicêtre , France
| | | | - Flaminia Coluzzi
- j Dept. Medical and Surgical Sciences and Biotechnologies, Unit of Anaesthesia, Intensive Care and Pain Medicine , Sapienza University of Rome - Polo Pontino , Latina , Italy
| | - José De Andres
- k Anesthesia Critical Care and Pain Management Department , General University Hospital , Valencia , Spain
| | - William Fawcett
- l Department of Anaesthesia , Royal Surrey County Hospital , Guildford , UK
- m Faculty of Health and Medical Sciences , University of Surrey , Guildford , UK
| | - Dominique Fletcher
- n Department of Anesthesiology and Critical Care , Hôpital Raymond-Poincaré , Garches , France
| | - Eija Kalso
- o Pain Clinic, Department of Anaesthesiology, Intensive Care, and Pain Medicine , Helsinki University Hospital and University of Helsinki , Helsinki , Finland
| | - Henrik Kehlet
- p Section for Surgical Pathophysiology, Rigshospitalet , Copenhagen , Denmark
| | - Bart Morlion
- q The Leuven Centre for Algology & Pain Management , University of Leuven , Leuven , Belgium
| | - Antonio Montes Pérez
- r Department of Anesthesiology , Hospitales Mar-Esperanza, Universitat Autònoma Barcelona , Barcelona , Spain
| | | | | |
Collapse
|
70
|
Li X, He W, Chen Y, Yang G, Wan H, Zhang L, Hu Q, Feng J, Zhang Z, He F, Bai C, Zhang L, You L, Tao W. Discovery of SHR9352: A Highly Potent G Protein-Biased μ-Opioid Receptor Agonist. ACS OMEGA 2017; 2:9261-9267. [PMID: 31457439 PMCID: PMC6645658 DOI: 10.1021/acsomega.7b01452] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Accepted: 12/18/2017] [Indexed: 06/10/2023]
Abstract
Recently, targeting the G protein-biased signaling has emerged as an attractive therapeutic strategy for treating severe acute pain with the potential to reduce the side effect of the traditional opioid drug. Herein, we describe the discovery of a highly potent G protein-biased μ-opioid receptor (MOR) agonist, SHR9352. This novel molecule exhibited excellent MOR activity and limited β-arrestin recruitment, as well as a high selectivity over κ-opioid receptor and δ-opioid receptor demonstrated robust in vivo efficacy and displayed favorable pharmacokinetic properties across species.
Collapse
Affiliation(s)
- Xin Li
- Shanghai
Hengrui Pharmaceutical Co., Ltd., 279 Wenjing Road, Shanghai 200245, China
| | - Wei He
- Shanghai
Hengrui Pharmaceutical Co., Ltd., 279 Wenjing Road, Shanghai 200245, China
| | - Yang Chen
- Shanghai
Hengrui Pharmaceutical Co., Ltd., 279 Wenjing Road, Shanghai 200245, China
| | - Guimei Yang
- Shanghai
Hengrui Pharmaceutical Co., Ltd., 279 Wenjing Road, Shanghai 200245, China
| | - Hong Wan
- Shanghai
Hengrui Pharmaceutical Co., Ltd., 279 Wenjing Road, Shanghai 200245, China
| | - Lei Zhang
- Shanghai
Hengrui Pharmaceutical Co., Ltd., 279 Wenjing Road, Shanghai 200245, China
| | - Qiyue Hu
- Shanghai
Hengrui Pharmaceutical Co., Ltd., 279 Wenjing Road, Shanghai 200245, China
| | - Jun Feng
- Shanghai
Hengrui Pharmaceutical Co., Ltd., 279 Wenjing Road, Shanghai 200245, China
| | - Zhigao Zhang
- Shanghai
Hengrui Pharmaceutical Co., Ltd., 279 Wenjing Road, Shanghai 200245, China
| | - Feng He
- Shanghai
Hengrui Pharmaceutical Co., Ltd., 279 Wenjing Road, Shanghai 200245, China
| | - Chang Bai
- Shanghai
Hengrui Pharmaceutical Co., Ltd., 279 Wenjing Road, Shanghai 200245, China
| | - Lianshan Zhang
- Jiangsu
Hengrui Medicine Co., Ltd., Lianyungang, Jiangsu 222047, China
| | - Li You
- Department
of Anaesthesiology, Fudan University Shanghai
Cancer Center, 270 Dongan
Road, Shanghai 200032, China
| | - Weikang Tao
- Shanghai
Hengrui Pharmaceutical Co., Ltd., 279 Wenjing Road, Shanghai 200245, China
| |
Collapse
|
71
|
Comparison of Epidural or Regional Analgesia and Patient-controlled Analgesia: A Critical Analysis of Patient Data by the Acute Pain Service in a University Hospital. Clin J Pain 2017; 32:681-8. [PMID: 26528866 DOI: 10.1097/ajp.0000000000000315] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES A large number of patients still experience pain after surgery. This study investigates if epidural or regional analgesia (continuous infusion peripheral nerve blocks [CPNB]) provide superior pain relief compared with patient-controlled analgesia (PCIA) and identifies the incidence of minor and major adverse effects or complications of these techniques. MATERIALS AND METHODS Prospectively collected data of postoperative patients from an online data registration system of a special dedicated nurse-based acute pain service were analyzed. The acute pain service consultations were documented from January 2008 to August 2013 in a university hospital in The Netherlands. RESULTS An analysis was applied on data of 12,399 consecutive patients. Results showed that patients who received epidural analgesia and CPNB reported lower pain scores than those who received PCIA, after undergoing the same procedures. In addition, pain scores at rest were significantly lower than movement-evoked pain scores, in abdominal surgery. Severe nausea was mostly observed in patients with PCIA and itching was most common in patients with epidural analgesia. Opioid-induced respiratory depression was found in 5 patients with PCIA. DISCUSSION Epidural analgesia and CPNB provide better pain relief to patients than PCIA, especially in dynamic pain scores of patients. Evaluating real patient data on every patient visit is important for further improvement of the quality of postoperative pain management. Pain scores may vary widely between patients with similar surgical procedures. Therefore, we recommend that future research focuses on personalized pain measurement and pain management, to improve clinical practice more intensely.
Collapse
|
72
|
|
73
|
Asgar Pour H. Association Between Acute Pain and Hemodynamic Parameters in a Postoperative Surgical Intensive Care Unit. AORN J 2017; 105:571-578. [PMID: 28554354 DOI: 10.1016/j.aorn.2017.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 10/18/2016] [Accepted: 04/13/2017] [Indexed: 11/26/2022]
Abstract
I conducted a prospective repeated-measure study in the general surgery intensive care unit to investigate the associations among acute postoperative pain, analgesic therapy, and hemodynamic parameters. I selected 33 patients and recorded 84 episodes of pain. I measured intensity of pain and hemodynamic parameters after patients were transferred from the postanesthesia care unit to the general surgery intensive care unit, immediately before analgesic therapy and at 15, 30, and 45 minutes after analgesic therapy. Acute pain increased systolic (SBP), diastolic (DBP), and mean arterial blood pressure (MAP); pulse rate (PR); and arterial oxygen saturation. Fifteen minutes after analgesic therapy, SBP and PR decreased, and DBP, MAP, and oxygen saturation increased. Thirty minutes after therapy, SBP, MAP, and PR decreased, and DBP and oxygen saturation increased. Forty-five minutes after therapy, SBP, MAP, and PR decreased, and DBP and oxygen saturation increased. I saw no significant hemodynamic parameter changes during postoperative episodes of pain.
Collapse
|
74
|
van Samkar G, Hermanns H, Lirk P, Hollmann MW, Stevens MF. Influence on number of top-ups after implementing patient controlled epidural analgesia: A cohort study. PLoS One 2017; 12:e0186225. [PMID: 29045482 PMCID: PMC5646815 DOI: 10.1371/journal.pone.0186225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 09/27/2017] [Indexed: 11/18/2022] Open
Abstract
Postoperative epidural analgesia often needs rate readjustment using top-ups. Patient-controlled epidural analgesia (PCEA) is said to reduce the requirement of epidural top-ups when compared to continuous epidural analgesia (CEA). We compared CEA and PCEA in major thoracic and abdominal surgery, in a cohort study. The primary endpoint was the required number of epidural top-ups. Secondary endpoints were pain scores, side effects and workload differences. We analysed 199 patients with CEA and 187 with PCEA. Both groups had similar pain scores. The total number of top-ups was 75 in 57 patients (CEA) versus 20 top-ups in 18 patients (PCEA). (p = 0.0001) Sedation tended to occur more frequently in patients with CEA versus PCEA, 5.5% vs 1.6% (p = 0.05). Implementation of PCEA led to a decreased number of top-ups, fewer side-effects and decreased use of the postoperative care unit.
Collapse
Affiliation(s)
- Ganapathy van Samkar
- Department of Anaesthesiology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Henning Hermanns
- Department of Anaesthesiology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Philipp Lirk
- Department of Anaesthesiology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Markus W. Hollmann
- Department of Anaesthesiology, Academic Medical Centre, Amsterdam, the Netherlands
- * E-mail:
| | - Markus F. Stevens
- Department of Anaesthesiology, Academic Medical Centre, Amsterdam, the Netherlands
| |
Collapse
|
75
|
Lee EK, Ahn HJ, Zo JI, Kim K, Jung DM, Park JH. Paravertebral Block Does Not Reduce Cancer Recurrence, but Is Related to Higher Overall Survival in Lung Cancer Surgery. Anesth Analg 2017; 125:1322-1328. [DOI: 10.1213/ane.0000000000002342] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
76
|
Abstract
Postoperative pain control is a highly studied topic because of its significant effect on costs, hospital course, and, most importantly, patient satisfaction. Opioid use has been the "status quo" of postoperative pain management but prolongs hospital stays and increases complications. Optimizing acute pain management in patients with orthopedic trauma is important and can translate into significant positive physiologic and financial outcomes. Although multiple viable examples of optimizing acute pain management in the literature demonstrate outcome improvements, implementation has not been widespread. Significant outcome success will depend more on systemwide implementation than a specific regimen for postoperative pain control.
Collapse
|
77
|
Abstract
Progress in surgical acute pain management has allowed most foot and ankle surgery to be performed in ambulatory outpatient surgical centers. Multimodal analgesia focuses on improving postoperative pain by combining pharmacologic and other modalities, addressing multiple pain mechanisms and receptor pathways while reducing adverse effects through lower doses of oral medications. Local anesthesia techniques provide excellent pain relief with few adverse events. Multimodal analgesia in foot and ankle surgery provides superior pain relief, and reduced opioid dependence and opioid-related side effects, improving patient satisfaction, safety, and timely return to function.
Collapse
Affiliation(s)
- Jessica M Kohring
- Department of Orthopaedics, The University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA.
| | - Nathan G Orgain
- Department of Anesthesiology, The University of Utah, SOM 3C444, 30 North 1900 East, Salt Lake City, UT 84132, USA
| |
Collapse
|
78
|
Huang BWY, Kuo BIT, Chen CC, Chang WH, Sun FJ, Yen DHT. Comparative Analysis of Different Methods of Pain Management for Elderly Patients in the Surgical Intensive Care Unit. INT J GERONTOL 2017. [DOI: 10.1016/j.ijge.2017.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
|
79
|
Andrés JD, Pogatzki-Zahn E, Huygen F, Neugebauer E, Fawcett W. Controlling acute pain to improve the quality of postoperative pain management: an update from the European Society of Regional Anesthesia meeting held in Maastricht (September 2016). Pain Manag 2017; 7:513-522. [PMID: 28793825 DOI: 10.2217/pmt-2017-0026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Improvement in postoperative pain management remains a global concern with a significant unmet need for patients. This was the focus of a 'Change Pain' session at the 35th European Society of Regional Anesthesia meeting (Maastricht, September 2016). Awareness of the size and nature of the problem is important to improve postoperative pain management strategies. Optimal treatment of acute pain should aim to avoid long-term sequelae such as the development of chronic pain disorders (e.g., phantom limb pain). Cases highlighting unsuccessful and successful strategies to manage individuals undergoing surgery were presented. The benefits of personalized care, encouraging patients to be more involved in decisions regarding their treatment and their preferred clinical outcomes were discussed and considered to be a step forward in acute pain management.
Collapse
Affiliation(s)
- Jose De Andrés
- Departments of Anesthesia & Surgery, Critical Care & Multidisciplinary Pain Management, Valencia University General Hospital, Anesthesia Division, Valencia School of Medicine, Valencia, Spain
| | - Esther Pogatzki-Zahn
- Department of Anaesthesiology, Intensive Care & Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Frank Huygen
- Erasmus MC, University Hospital, Rotterdam, The Netherlands
| | - Edmund Neugebauer
- Brandenburg Medical School Theodor Fontane & Health Services Research, Witten/Herdecke University, Campus Neuruppin, Neuruppin, Germany
| | - William Fawcett
- Department of Anesthesia, Royal Surrey County Hospital, Egerton Road, Royal Surrey, Guildford, UK.,Faculty of Health & Medical Sciences, Duke of Kent Building, University of Surrey, Guildford, UK
| |
Collapse
|
80
|
Haeseler G, Schaefers D, Prison N, Ahrens J, Liu X, Karch A. Combatting pain after orthopedic/trauma surgery- perioperative oral extended-release tapentadol vs. extended-release oxycodone/naloxone. BMC Anesthesiol 2017; 17:91. [PMID: 28693439 PMCID: PMC5504600 DOI: 10.1186/s12871-017-0383-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 06/30/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND High post-operative pain scores after "minor" orthopedic/trauma surgery are in part attributed to inadequate prescription of opioid analgesics. Novel concepts aiming to achieve sufficient analgesia while minimizing opioid-related side effects by avoiding fluctuating plasma levels are based on perioperative oral administration of extended-release opioids beginning with the first dose pre-operatively. This is the first study to evaluate analgesic efficacy and side effect rates of extended-release tapentadol compared to oxycodone/naloxone following orthopedic/trauma surgery. METHODS This randomized, observer-blinded, active-controlled prospective clinical trial had 2 co-primary endpoints: (1) Analgesic efficacy: Mean pain level on a numeric rating scale (NRS) from 0 to 10 during exercise over 5 days. (2) Safety: Side effect sum score of the following events: Nausea, vomiting, constipation, sedation, vertigo, somnolence. The study was powered to detect superiority of tapentadol for at least one endpoint pending statistical proof of non-inferiority for both endpoints in a first step. RESULTS Two hundred sixty-six trauma patients were randomized to receive either tapentadol (n = 133) or oxycodone/naloxone (n = 133). Analgesic efficacy: Mean (±SD) daily pain levels in the first five post-operative days were 2.8 ± 1.3 in both groups. Mean maximum pain intensity during exercise in the first 24 h after surgery was 3.8 ± 1.9 (tapentadol) and 3.8 ± 2.1 (oxycodone/naloxone). Statistically tapentadol was non-inferior but not superior to oxycodone/naloxone. SAFETY Vomiting on day 1 occurred in 11%, constipation in 35% of the tapentadol patients and in 16% and 30% of the oxycodone/naloxone patients (p = 0.60 and 0.33), respectively. The incidence of sedation/ vertigo was <10%, that of somnolence <2% in both groups (p > 0.3, respectively). The sum score of side effect events was 51% in the tapentadol vs. 49% in the oxycodone/naloxone group; risk difference 3% [95% CI, -8 to 14%]; p = 0.6). Non-inferiority of tapentadol could not be concluded as the pre-defined non-inferiority margin was exceeded. CONCLUSIONS With both concepts, mean maximum pain intensity during exercise within the first 24 h after orthopedic/trauma surgery was reduced to a score of <4. This analgesic efficacy came at the cost of mainly gastro-intestinal side effects. Thus, we now use a prophylaxis against nausea and vomiting and pre-emptive laxatives as part of these concepts. TRIAL REGISTRATION https://eudract.ema.europa.eu (EudraCT- Nr. 2011-003238-15 ); October 24th, 2012.
Collapse
Affiliation(s)
- Gertrud Haeseler
- Department of Anesthesia, Katholisches Klinikum Ruhrgebiet Nord (KKRN) GmbH, Hervester Str. 57, D-45768, Marl, Germany.
| | - Dirk Schaefers
- Department of orthopedic and trauma surgery, KKRN, Hervester Str. 57, D-45768, Marl, Germany
| | - Natalie Prison
- Department of anesthesia, KKRN, Hervester Str. 57, D-45768, Marl, Germany
| | - Jörg Ahrens
- Department of Anesthesia, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
| | - Xiaofei Liu
- Institute for Biostatistics, Hannover Medical School, Carl-Neuberg-Str. 1, D-30652, Hannover, Germany
| | - Annika Karch
- Institute for Biostatistics, Hannover Medical School, Carl-Neuberg-Str. 1, D-30652, Hannover, Germany
| |
Collapse
|
81
|
Shweikeh F, Hussain M, Sangtani A, Issa H, Bashir A, Johnson JP, Markarian GZ. Cervical spine epidural abscess: a single center analytical comparison to the literature. Spinal Cord Ser Cases 2017; 3:17036. [PMID: 28690871 PMCID: PMC5498827 DOI: 10.1038/scsandc.2017.36] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 05/16/2017] [Accepted: 05/20/2017] [Indexed: 11/09/2022] Open
Abstract
STUDY DESIGN Retrospective review of patient charts. OBJECTIVES Cervical spine epidural abscess (CSEA) is uncommon. In this study, characteristics of CSEA patients are described through an institutional analysis and literature review. SETTING University-affiliated city hospital. METHODS The electronic medical record was searched from 01/2001 to 01/2012. Data on presentation, comorbidities, diagnostic modalities, pathogens, treatments, and neurological recovery were collected. RESULTS Sixteen patients were identified with a mean age of 57.9 years (33-83). Nine were females. Common symptoms were neck/back pain (62.5%), neurological deficits (62.5%), and fever (31.3%). Comorbidities included cardiovascular disease (56.3%), renal disease (37.5%), and diabetes mellitus (37.5%). Lower levels were more likely afflicted (C5-C7). Microorganisms were commonly Staphylococcus and Streptococcus (68.8%). Eight (50.0%) received surgery (anterior [87.5%] and posterior [12.5%] cervical fusion and corpectomy [37.5%]) plus antibiotics and 8 (50.0%) were treated with antibiotics only. Patients with less comorbidities were more likely to receive surgery; more comorbidities were was associated with a poor prognosis. Eight patients (50%) made had full neurological recovery, 2 (12.5%) with had minimal recovery, 2 deaths died, and the remaining (25%) 1 was were sent to a skilled facility and 1or lost to follow-up. CONCLUSIONS Cervical SEA can be problematic. The vast majority do not present classically and treatment does vary. It occurs more frequently in the lower cervical levels. Though antibiotics alone may suffice, surgery is frequently employed and a multitude of techniques are at the utility of the spine surgeon. Cardiovascular comorbidities are associated with a poorer outcome. In order to improve prognosis, management considerations should include both patient factors and multidisciplinary efforts.
Collapse
Affiliation(s)
- Faris Shweikeh
- Summa Health System, College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
- Department of Neurosurgery, Cedars-Sinai Medical Center, Maxine Dunitz Neurosurgical Institute, Los Angeles, CA, USA
| | - Mohammed Hussain
- New Jersey Neuroscience Institute, JFK Medical Center, Edison, NJ, USA
| | - Ajleeta Sangtani
- Summa Health System, College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Husam Issa
- Memorial Hermann Hospital, University of Texas Health Science Center, Houston, TX, USA
| | - Asif Bashir
- New Jersey Neuroscience Institute, JFK Medical Center, Edison, NJ, USA
| | - J Patrick Johnson
- Department of Neurosurgery, Cedars-Sinai Medical Center, Maxine Dunitz Neurosurgical Institute, Los Angeles, CA, USA
| | - Georges Z Markarian
- Summa Health System, College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| |
Collapse
|
82
|
Mungroop TH, van Samkar G, Geerts BF, van Dieren S, Besselink MG, Veelo DP, Lirk P. Serum levels of bupivacaine after pre-peritoneal bolus vs. epidural bolus injection for analgesia in abdominal surgery: A safety study within a randomized controlled trial. PLoS One 2017; 12:e0178917. [PMID: 28614364 PMCID: PMC5470670 DOI: 10.1371/journal.pone.0178917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 05/22/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Continuous wound infiltration (CWI) has become increasingly popular in recent years as an alternative to epidural analgesia. As catheters are not placed until the end of surgery, more intraoperative opioid analgesics might be needed. We, therefore, added a single pre-peritoneal bolus of bupivacaine at the start of laparotomy, similar to the bolus given with epidural analgesia. METHODS This was a comparative study within a randomized controlled trial (NTR4948). Patients undergoing hepato-pancreato-biliary surgery received either a pre-peritoneal bolus of 30ml bupivacaine 0.25%, or an epidural bolus of 10ml bupivacaine 0.25% at the start of laparotomy. In a subgroup of patients, we sampled blood and determined bupivacaine serum levels 20, 40, 60 and 80 minutes after bolus injection. We assumed toxicity of bupivacaine to be >1000 ng/ml. RESULTS A total of 20 patients participated in this sub-study. All plasma levels measured as well as the upper limit of the predicted 99% confidence intervals per time point were well below the toxicity limit. In a mixed linear-effect model both groups did not differ statistically significant (p = 0.131). The intra-operative use of opioids was higher with CWI as compared to epidural (86 (SD 73) μg sufentanil vs. 50 (SD 32). CONCLUSIONS In this exploratory study, the pre-peritoneal bolus using bupivacaine resulted in serum bupivacaine concentrations well below the commonly accepted toxic threshold. With CWI more additional analgesics are needed intraoperatively as compared to epidural analgesia, although this is compensated by a reduction in use of vasopressors with CWI. TRIAL REGISTRATION Netherlands Trial Register NTR4948.
Collapse
Affiliation(s)
- Timothy H. Mungroop
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
- Department of Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Ganapathy van Samkar
- Department of Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Bart F. Geerts
- Department of Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Susan van Dieren
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Marc G. Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Denise P. Veelo
- Department of Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands
- * E-mail:
| | - Philipp Lirk
- Department of Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands
| | | |
Collapse
|
83
|
Predictors of In-hospital Postoperative Opioid Overdose After Major Elective Operations: A Nationally Representative Cohort Study. Ann Surg 2017; 265:702-708. [PMID: 28267693 DOI: 10.1097/sla.0000000000001945] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The aim of this study was to describe national trends and outcomes of in-hospital postoperative opioid overdose (OD) and identify predictors of postoperative OD. SUMMARY OF BACKGROUND DATA In 2000, the Joint Commission recommended making pain the 5th vital sign, increasing the focus on postoperative pain control. However, the benefits of pain management must be weighed against the potentially lethal risk of opioid OD. METHODS This is a retrospective multi-institutional cohort study of patients undergoing 1 of 6 major elective inpatient operation from 2002 to 2011 using the Nationwide Inpatient Sample, an approximately 20% representative sample of all United States hospital admissions. Patients with postoperative OD were identified using ICD-9 codes for poisoning from opioids or adverse effects from opioids. Multivariate logistic regression was used to identify independent predictors. RESULTS Among 11,317,958 patients, 9458 (0.1%) had a postoperative OD; this frequency doubled over the study period from 0.6 to 1.1 overdoses per 1000 cases. Patients with postoperative OD died more frequently during their hospitalization (1.7% vs 0.4%, P < 0.001). Substance abuse history was the strongest predictor of OD (odds ratio = 14.8; 95% confidence interval: 12.7-17.2). Gender, age, income, geographic location, operation type, and certain comorbid diseases also predicted OD (P < 0.05). Hospital variables, including teaching status, size, and urban/rural location, did not predict postoperative OD. CONCLUSIONS Postoperative OD is a rare, but potentially lethal complication, with increasing incidence. Postoperative monitoring and treatment safety interventions should be thoughtfully employed to target high-risk patients and avoid this potentially fatal complication.
Collapse
|
84
|
Koh JC, Song Y, Kim SY, Park S, Ko SH, Han DW. Postoperative pain and patient-controlled epidural analgesia-related adverse effects in young and elderly patients: a retrospective analysis of 2,435 patients. J Pain Res 2017; 10:897-904. [PMID: 28442931 PMCID: PMC5396922 DOI: 10.2147/jpr.s133235] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
In this retrospective study, data of 2,435 patients who received fentanyl and ropivacaine-based patient-controlled epidural analgesia (PCEA) for pain relief after elective surgery under general or spinal anesthesia were reviewed. Differences in postoperative pain, incidence of patient-controlled analgesia (PCA)-related adverse effects, and risk factors for the need for rescue analgesics for 48 hours postsurgery in young (age 20–39 years) and elderly (age ≥70 years) patients were evaluated. Although there were no significant differences in postoperative pain intensity between the two groups until 6 hours postsurgery, younger patients experienced greater postoperative pain intensity compared with older patients 6–48 hours postsurgery. While younger patients exhibited greater incidence of numbness, motor weakness, and discontinuation of PCA postsurgery, elderly patients exhibited greater incidence of hypotension, nausea/vomiting, rescue analgesia, and antiemetic administration. Upon multivariate analysis, low fentanyl dosage and history of smoking were found to be associated with an increased need for rescue analgesia among younger patients, while physical status classification III/IV and thoracic surgery were associated with a decreased need for rescue analgesia among the elderly. Discontinuation of PCA was more frequent among younger patients than the elderly (18.5% vs 13.5%, P=0.001). Reasons for discontinuation of PCA among young and elderly patients, respectively, were nausea and vomiting (6.8% vs 26.6%), numbness or motor weakness (67.8% vs 11.5%), urinary retention (7.4% vs 8.7%), dizziness (2.2% vs 5.2%), and hypotension (3.1% vs 20.3%). In conclusion, PCEA was more frequently associated with numbness, motor weakness, and discontinuation of PCA in younger patients and with hypotension, nausea/vomiting, and a greater need for rescue analgesics/antiemetics among elderly patients. Therefore, in order to minimize the adverse effects of PCEA and enhance pain relief, different PCEA regimens and administration/prevention strategies should be considered for young and elderly patients.
Collapse
Affiliation(s)
- Jae Chul Koh
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Song
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - So Yeon Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Sooyeun Park
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Seo Hee Ko
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Dong Woo Han
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| |
Collapse
|
85
|
Mohamad MF, Mohammad MA, Hetta DF, Ahmed EH, Obiedallah AA, Elzohry AAM. Thoracic epidural analgesia reduces myocardial injury in ischemic patients undergoing major abdominal cancer surgery. J Pain Res 2017; 10:887-895. [PMID: 28442930 PMCID: PMC5396972 DOI: 10.2147/jpr.s122918] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background and objectives Major abdominal cancer surgeries are associated with significant perioperative mortality and morbidity due to myocardial ischemia and infarction. This study examined the effect of perioperative patient controlled epidural analgesia (PCEA) on occurrence of ischemic cardiac injury in ischemic patients undergoing major abdominal cancer surgery. Patients and methods One hundred and twenty patients (American Society of Anesthesiologists grade II and III) of either sex were scheduled for elective upper gastrointestinal cancer surgeries. Patients were allocated randomly into two groups (60 patients each) to receive, besides general anesthesia: continuous intra and postoperative intravenous (IV) infusion with fentanyl for 72 h postoperatively (patient controlled intravenous analgesia [PCIA] group) or continuous intra and postoperative epidural infusion with bupivacaine 0.125% and fentanyl (PCEA group) for 72 h postoperatively. Perioperative hemodynamics were recorded. Postoperative pain was assessed over 72 h using visual analog scale (VAS). All patients were screened for occurrence of myocardial injury (MI) by electrocardiography, echocardiography, and cardiac troponin I serum level. Other postoperative complications as arrhythmia, deep venous thrombosis (DVT), pulmonary embolism, pneumonia, and death were recorded. Results There was a significant reduction in overall adverse cardiac events (myocardial injury, arrhythmias, angina, heart failure and nonfatal cardiac arrest) in PCEA group in comparison to PCIA group. Also, there was a significant reduction in dynamic VAS pain score in group PCEA in comparison to PCIA at all measured time points. Regarding perioperative hemodynamics, there was a significant reduction in intra-operative mean arterial pressure (MAP); and heart rate in PCEA group in comparison to PCIA group at most of measured time points while there was not a significant reduction in postoperative MAP and heart rate in the second and third postoperative days. The incidence of other postoperative complications such as DVT, pneumonia and in hospital mortality were decreased in PCEA group. Conclusion Perioperative thoracic epidural analgesia in patients suffering from coronary artery disease subjected to major abdominal cancer surgery reduced significantly postoperative major adverse cardiac events with better pain control in comparison with perioperative IV analgesia.
Collapse
Affiliation(s)
| | | | | | | | - Ahmed A Obiedallah
- Department of Internal Medicine, Faculty of Medicine, Assiut University, Arab Republic of Egypt
| | | |
Collapse
|
86
|
Rwei AY, Zhan C, Wang B, Kohane DS. Multiply repeatable and adjustable on-demand phototriggered local anesthesia. J Control Release 2017; 251:68-74. [PMID: 28153763 PMCID: PMC5394744 DOI: 10.1016/j.jconrel.2017.01.031] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 11/29/2016] [Accepted: 01/26/2017] [Indexed: 11/18/2022]
Abstract
A phototriggerable system whereby patients could repeatedly and non-invasively control the timing and dosage of local anesthesia according to their needs would be beneficial for perioperative pain and perhaps obviate the need for oral narcotics. However, clinical application of phototriggerable systems have been limited by concerns over phototoxicity of lasers and limited tissue penetration of light. To address these limitations, we increased the devices' effective sensitivity to light by co-delivering a second compound, dexmedetomidine, that potentiates the effect of delivered local anesthetics. The concurrent release of dexmedetomidine enhanced the efficacy of released local anesthetics, greatly increasing the number of triggerable nerve blocks (up to nine triggerable events upon a single injection) and reducing the irradiance needed to induce nerve block by 94%. The intensity and duration of on-demand analgesia could be adjusted by varying the intensity and duration of irradiance, which could not only be delivered by lasers, but also by light-emitting diodes, which are less expensive, safer, and more portable.
Collapse
Affiliation(s)
- Alina Y Rwei
- Laboratory for Biomaterials and Drug Delivery, Department of Anesthesiology, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA; Department of Materials Science and Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Changyou Zhan
- Laboratory for Biomaterials and Drug Delivery, Department of Anesthesiology, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Bruce Wang
- Laboratory for Biomaterials and Drug Delivery, Department of Anesthesiology, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Daniel S Kohane
- Laboratory for Biomaterials and Drug Delivery, Department of Anesthesiology, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| |
Collapse
|
87
|
Lagerkranser M. Neuraxial blocks and spinal haematoma: Review of 166 case reports published 1994–2015. Part 1: Demographics and risk-factors. Scand J Pain 2017; 15:118-129. [DOI: 10.1016/j.sjpain.2016.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Abstract
Background
Bleeding into the vertebral canal causing a spinal haematoma (SH) is a rare but serious complication to central neuraxial blocks (CNB). Of all serious complications to CNBs such as meningitis, abscess, cardiovascular collapse, and nerve injury, neurological injury associated with SH has the worst prognosis for permanent harm. Around the turn of the millennium, the first guidelines were published that aimed to reduce the risk of this complication. These guidelines are based on known risk factors for SH, rather than evidence from randomised, controlled trials (RCTs). RCTs, and therefore meta-analysis of RCTs, are not appropriate for identifying rare events. Analysing published case reports of rare complications may at least reveal risk factors and can thereby improve management of CNBs. The aims of the present review were to analyse case reports of SH after CNBs published between 1994 and 2015, and compare these with previous reviews of case reports.
Methods
MEDLINE and EMBASE were used for identifying case reports published in English, German, or Scandinavian languages, using appropriate search terms. Reference lists were also scrutinised for case reports. Twenty different variables from each case were specifically searched for and filled out on an Excel spreadsheet, and incidences were calculated using the number of informative reports as denominator for each variable.
Results
Altogether 166 case reports on spinal haematoma after CNB published during the years between 1994 and 2015 were collected. The annual number of case reports published during this period almost trebled compared with the two preceding decades. This trend continued even after the first guidelines on safe practice of CNBs appeared around year 2000, although more cases complied with such guidelines during the second half of the observation period (2005–2015) than during the first half. Three types of risk factors dominated:(1)Patient-related risk factors such as haemostatic and spinal disorders, (2) CNB-procedure-related risks such as complicated block, (3) Drug-related risks, i.e. medication with antihaemostatic drugs.
Conclusions and implications
The annual number of published cases of spinal haematoma after central neuraxial blocks increased during the last two decades (1994–2015) compared to previous decades. Case reports on elderly women account for this increase.Antihaemostatic drugs, heparins in particular, are still major risk factors for developing post-CNB spinal bleedings. Other risk factors are haemostatic and spinal disorders and complicated blocks, especially “bloody taps”, whereas multiple attempts do not seem to increase the risk of bleeding. In a large number of cases, no risk factor was reported. Guidelines issued around the turn of the century do not seem to have affected the number of published reports. In most cases, guidelines were followed, especially during the second half of the study period. Thus, although guidelines reduce the risk of a post-CNB spinal haematoma, and should be strictly adhered to in every single case, they are no guarantee against such bleedings to occur.
Collapse
Affiliation(s)
- Michael Lagerkranser
- Section for Anaesthesiology and Intensive Care Medicine , Department of Physiology and Pharmacology , Karolinska Institutet , 171 77 Stockholm Stockholm , Sweden
| |
Collapse
|
88
|
Forest DJ, Segal S. Update on Thrombocytopenia in Pregnancy and Neuraxial Anesthesia. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0204-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
89
|
Okkerse P, Hay JL, Sitsen E, Dahan A, Klaassen E, Houghton W, Groeneveld GJ. Pharmacokinetics and pharmacodynamics of intrathecally administered Xen2174, a synthetic conopeptide with norepinephrine reuptake inhibitor and analgesic properties. Br J Clin Pharmacol 2016; 83:751-763. [PMID: 27987228 DOI: 10.1111/bcp.13176] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 10/12/2016] [Accepted: 10/23/2016] [Indexed: 01/01/2023] Open
Abstract
AIM Xen2174 is a synthetic 13-amino acid peptide that binds specifically to the norepinephrine transporter, which results in inhibition of norepinephrine uptake. It is being developed as a possible treatment for moderate to severe pain and is delivered intrathecally. The current study was performed to assess the pharmacodynamics (PD) and the cerebrospinal fluid (CSF) pharmacokinetics (PK) of Xen2174 in healthy subjects. METHODS This was a randomized, blinded, placebo-controlled study in healthy subjects. The study was divided into three treatment arms. Each group consisted of eight subjects on active treatment and two or three subjects on placebo. The CSF was sampled for 32 h using an intrathecal catheter. PD assessments were performed using a battery of nociceptive tasks (electrical pain, pressure pain and cold pressor tasks). RESULTS Twenty-five subjects were administered Xen2174. CSF PK analysis showed a higher area under the CSF concentration-time curve of Xen2174 in the highest dose group than allowed by the predefined safety margin based on nonclinical data. The most common adverse event was post-lumbar puncture syndrome, with no difference in incidence between treatment groups. Although no statistically significant differences were observed in the PD assessments between the different dosages of Xen2174 and placebo, pain tolerability in the highest dose group was higher than in the placebo group [contrast least squares mean pressure pain tolerance threshold of Xen2174 2.5 mg-placebo (95% confidence interval), 22.2% (-5.0%, 57.1%); P = 0.1131]. CONCLUSIONS At the Xen2174 dose level of 2.5 mg, CSF concentrations exceeded the prespecified exposure limit based on the nonclinical safety margin. No statistically significant effects on evoked pain tests were observed.
Collapse
Affiliation(s)
- Pieter Okkerse
- Centre for Human Drug Research (CHDR), Leiden, The Netherlands
| | - Justin L Hay
- Centre for Human Drug Research (CHDR), Leiden, The Netherlands
| | - Elske Sitsen
- Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Albert Dahan
- Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Erica Klaassen
- Centre for Human Drug Research (CHDR), Leiden, The Netherlands
| | | | | |
Collapse
|
90
|
Hoogervorst-Schilp J, van Boekel R, de Blok C, Steegers M, Spreeuwenberg P, Wagner C. Postoperative pain assessment in hospitalised patients: National survey and secondary data analysis. Int J Nurs Stud 2016; 63:124-131. [DOI: 10.1016/j.ijnurstu.2016.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 08/29/2016] [Accepted: 09/01/2016] [Indexed: 12/13/2022]
|
91
|
Abstract
The authors present 25 cases and an in-depth 4-minute video of fully awake aesthetic breast reduction, which was made possible by thoracic epidural anesthesia. There are obvious and important advantages to this technique. Not only does this allow for intraoperative patient cooperation (i.e., patient self-positioning and opinion for comparison of breasts), meaning a shorter and more efficient intraoperative time, there also is a reduction in postoperative pain, complications, recovery, and discharge times. The authors have also enjoyed great success and no complications with this technique in over 150 awake abdominoplasty/total body lift patients. The authors feel that the elimination of the need for general anesthesia by thoracic epidural sensorial-only anesthesia is a highly effective and efficient technique, with very few disadvantages/complications, providing advantages to both patients and surgeons. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
Collapse
|
92
|
van Rooijen SJ, Huisman D, Stuijvenberg M, Stens J, Roumen RMH, Daams F, Slooter GD. Intraoperative modifiable risk factors of colorectal anastomotic leakage: Why surgeons and anesthesiologists should act together. Int J Surg 2016; 36:183-200. [PMID: 27756644 DOI: 10.1016/j.ijsu.2016.09.098] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 09/12/2016] [Accepted: 09/26/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Colorectal anastomotic leakage (CAL) is a major surgical complication in intestinal surgery. Despite many optimizations in patient care, the incidence of CAL is stable (3-19%) [1]. Previous research mainly focused on determining patient and surgery related risk factors. Intraoperative non-surgery related risk factors for anastomotic healing also contribute to surgical outcome. This review offers an overview of potential modifiable risk factors that may play a role during the operation. METHODS Two independent literature searches were performed using EMBASE, Pubmed and Cochrane databases. Both clinical and experimental studies published in English from 1985 to August 2015 were included. The main outcome measure was the risk of anastomotic leakage and other postoperative complications during colorectal surgery. Determined risk factors of CAL were stated as strong evidence (level I and II high quality studies), and potential risk factors as either moderate evidence (experimental studies level III), or weak evidence (level IV or V studies). RESULTS The final analysis included 117 articles. Independent factors of CAL are diabetes mellitus, hyperglycemia and a high HbA1c, anemia, blood loss, blood transfusions, prolonged operating time, intraoperative events and contamination and a lack of antibiotics. Unequivocal are data on blood pressure, the use of inotropes/vasopressors, oxygen suppletion, type of analgesia and goal directed fluid therapy. No studies could be found identifying the impact of body core temperature or mean arterial pressure on CAL. Subjective factors such as the surgeons' own assessment of local perfusion and visibility of the operating field have not been the subject of relevant studies for occurrence in patients with CAL. CONCLUSION Both surgery related and non-surgery related risk factors that can be modified must be identified to improve colorectal care. Surgeons and anesthesiologists should cooperate on these items in their continuous effort to reduce the number of CAL. A registration study determining individual intraoperative risk factors of CAL is currently performed as a multicenter cohort study in the Netherlands.
Collapse
Affiliation(s)
- S J van Rooijen
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands.
| | - D Huisman
- VU Medical Center, Department of Surgery, Amsterdam, The Netherlands
| | - M Stuijvenberg
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands
| | - J Stens
- VU Medical Center, Department of Surgery, Amsterdam, The Netherlands
| | - R M H Roumen
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands
| | - F Daams
- VU Medical Center, Department of Surgery, Amsterdam, The Netherlands
| | - G D Slooter
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands
| |
Collapse
|
93
|
Olsson LE, Hansson E, Ekman I. Evaluation of person-centred care after hip replacement-a controlled before and after study on the effects of fear of movement and self-efficacy compared to standard care. BMC Nurs 2016; 15:53. [PMID: 27616936 PMCID: PMC5017008 DOI: 10.1186/s12912-016-0173-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 08/30/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The goal of total hip arthroplasty (THA) is optimal pain relief and a normalized health-related quality of life. Anxious patients describe more pain and more difficulties than non-anxious patients during rehabilitation after THA. The aims of the present study were twofold: (1) to identify vulnerable patients using the general self-efficacy scale (GSES) and the Tampa scale for Kinesiophobia (TSK), and (2) to evaluate if person-centred care including the responses of the instruments made rehabilitation more effective in terms of shortening hospital length of stay. METHODS The design of the study was quasi-experimental. Patients scheduled for THA, a control group (n = 138) and an intervention group (n = 128) were consecutively recruited. The intervention was the provision of person-centred care which was designed to reduce the negative effects of low self-efficacy and high levels of pain-related fear of movement. RESULTS Patients with low GSES in the intervention group had shorter length of stay (LoS) by 1.6 days (95 % CI 0.16-3.15) p-value 0.03. Patients with high TSK in the intervention group had shorter LoS by 2.43 days (95 % CI 0.76-4.12) p-value 0.005. For patients who had both, the reduction of LoS was 2.15 days (95 % CI 0.24-4.04) p-value 0.028. CONCLUSIONS The GSES and the TSK instrument were found useful as tools to provide information to support patients which reduced the LoS by 1.67 days in the whole intervention group (95 % CI 0.72-2.62) p-value 0.001. More importantly, vulnerable patients such as ASA group 3 probably gained the most from the extra support, they had a reduction with 6.78 days (95 % CI 2.94-10.62) p-value 0.001.
Collapse
Affiliation(s)
- Lars-Eric Olsson
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Box 457, SE 405 30 Gothenburg, Sweden ; Gothenburg Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden ; Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Elisabeth Hansson
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Box 457, SE 405 30 Gothenburg, Sweden ; Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Inger Ekman
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Box 457, SE 405 30 Gothenburg, Sweden ; Gothenburg Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
94
|
Abstract
Abstract
Background
Catheter-related infection is a serious complication of continuous regional anesthesia. The authors tested the hypothesis that single-dose antibiotic prophylaxis is associated with a lower incidence of catheter-related infections.
Methods
Our analysis was based on cases in the 25-center German Network for Regional Anesthesia database recorded between 2007 and 2014. Forty thousand three hundred sixty-two surgical patients who had continuous regional anesthesia were grouped into no antibiotic prophylaxis (n = 15,965) and single-dose antibiotic prophylaxis (n = 24,397). Catheter-related infections in each group were compared with chi-square test after 1:1 propensity-score matching. Odds ratios (ORs [95% CI]) were calculated with logistic regression and adjusted for imbalanced variables (standardized difference more than 0.1).
Results
Propensity matching successfully paired 11,307 patients with single-dose antibiotic prophylaxis (46% of 24,397 patients) and with 11,307 controls (71% of 15,965 patients). For peripheral catheters, the incidence without antibiotics (2.4%) was greater than with antibiotic prophylaxis (1.1%, P < 0.001; adjusted OR, 2.02; 95% CI, 1.49 to 2.75, P < 0.001). Infections of epidural catheters were also more common without antibiotics (5.2%) than with antibiotics (3.1%, P < 0.001; adjusted OR, 1.94; 95% CI, 1.55 to 2.43, P < 0.001).
Conclusions
Single-dose antibiotic prophylaxis was associated with fewer peripheral and epidural catheter infections.
Collapse
|
95
|
Bomberg H, Kubulus C, Herberger S, Wagenpfeil S, Kessler P, Steinfeldt T, Standl T, Gottschalk A, Stork J, Meissner W, Birnbaum J, Koch T, Sessler DI, Volk T, Raddatz A. Tunnelling of thoracic epidural catheters is associated with fewer catheter-related infections: a retrospective registry analysis. Br J Anaesth 2016; 116:546-53. [PMID: 26994232 DOI: 10.1093/bja/aew026] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Catheter-related infections are a serious complication of continuous thoracic epidural analgesia. Tunnelling catheters subcutaneously may reduce infection risk. We thus tested the hypothesis that tunnelling of thoracic epidural catheters is associated with a lower risk of catheter-related infections. METHODS Twenty-two thousand, four hundred and eleven surgical patients with continuous thoracic epidural analgesia included in the German Network for Regional Anaesthesia registry between 2007 and 2014 were grouped by whether their catheters were tunnelled (n=12 870) or not (n=9541). Catheter-related infections in each group were compared with Student's unpaired t and χ(2) tests. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated with logistic regression, adjusting for potential confounding factors, including age, ASA physical status score, use of catheter for ≥4 days, multiple skin puncture, hospital, and surgical department. RESULTS There were fewer catheter-related infections in patients with tunnelled catheters (4.5 vs 5.5%, P<0.001). Mild infections were also less common (4.0 vs 4.6%, P=0.009), as were moderate infections (0.4 vs 0.8%, P<0.001). After adjustment for potential confounding factors, tunnelling remained an independent prevention for any grade of infection (adjusted OR 0.51, 95% CI 0.42-0.61, P<0.001) and for mild infections (adjusted OR 0.54, 95% CI 0.43-0.66, P<0.001) and moderate and severe infections (adjusted OR 0.44, 95% CI 0.28-0.70, P=0.001). CONCLUSION Tunnelling was associated with a lower risk of thoracic epidural catheter-related infections.
Collapse
Affiliation(s)
- H Bomberg
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine
| | - C Kubulus
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine
| | - S Herberger
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine
| | - S Wagenpfeil
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University, University Medical Centre, Homburg/Saar, Germany
| | - P Kessler
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Orthopaedic University Hospital, Frankfurt, Germany
| | - T Steinfeldt
- Department of Anaesthesiology and Intensive Care Therapy, Philipps University Marburg, Marburg, Germany
| | - T Standl
- Department of Anaesthesia, Intensive and Palliative Care Medicine, Academic Hospital Solingen, Solingen, Germany
| | - A Gottschalk
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Friederikenstift Hannover, Hannover, Germany
| | - J Stork
- Centre for Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, Hamburg D-20246, Germany
| | - W Meissner
- Department of Anaesthesiology and Intensive Care, Jena University Hospital, Jena, Germany
| | - J Birnbaum
- Department of Anaesthesiology and Operative Intensive Care Medicine, Charité Campus Virchow Klinikum and Campus Mitte, Charité University Medicine Berlin, Berlin, Germany
| | - T Koch
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
| | - D I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue P77, Cleveland, OH 44195, USA
| | - T Volk
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine
| | - A Raddatz
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine
| |
Collapse
|
96
|
Kupersztych-Hagege E, Dubuisson E, Szekely B, Michel-Cherqui M, François Dreyfus J, Fischler M, Le Guen M. Epidural Hematoma and Abscess Related to Thoracic Epidural Analgesia: A Single-Center Study of 2,907 Patients Who Underwent Lung Surgery. J Cardiothorac Vasc Anesth 2016; 31:446-452. [PMID: 27720493 DOI: 10.1053/j.jvca.2016.07.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To report the major complications (epidural hematoma and abscess) of postoperative thoracic epidural analgesia in patients who underwent lung surgery. DESIGN Prospective, monocentric study. SETTING A university hospital. PARTICIPANTS All lung surgical patients who received postoperative thoracic epidural analgesia between November 2007 and November 2015. INTERVENTIONS Thoracic epidural analgesia for patients who underwent lung surgery. MEASUREMENTS AND MAIN RESULTS During the study period, data for 2,907 patients were recorded. The following 3 major complications were encountered: 1 case of epidural hematoma (0.34 case/1,000; 95% confidence interval 0.061-1.946), for which surgery was performed, and 2 cases of epidural abscesses (0.68 case/1,000; 95% confidence interval 0.189-2.505), which were treated medically. CONCLUSIONS The risk range of serious complications was moderate; only the patient who experienced an epidural hematoma also experienced permanent sequelae.
Collapse
Affiliation(s)
| | - Etienne Dubuisson
- Department of Anesthesiology, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Barbara Szekely
- Department of Anesthesiology, Hôpital Foch, Suresnes, France; Université Versailles Saint-Quenti- en-Yvelines, Versailles, France
| | - Mireille Michel-Cherqui
- Department of Anesthesiology, Hôpital Foch, Suresnes, France; Université Versailles Saint-Quenti- en-Yvelines, Versailles, France
| | | | - Marc Fischler
- Department of Anesthesiology, Hôpital Foch, Suresnes, France; Université Versailles Saint-Quenti- en-Yvelines, Versailles, France.
| | - Morgan Le Guen
- Department of Anesthesiology, Hôpital Foch, Suresnes, France; Université Versailles Saint-Quenti- en-Yvelines, Versailles, France
| |
Collapse
|
97
|
Comparison of continuous femoral nerve block (CFNB/SA) and continuous femoral nerve block with mini-dose spinal morphine (CFNB/SAMO) for postoperative analgesia after total knee arthroplasty (TKA): a randomized controlled study. BMC Anesthesiol 2016; 16:38. [PMID: 27422406 PMCID: PMC4947328 DOI: 10.1186/s12871-016-0205-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 06/01/2016] [Indexed: 11/15/2022] Open
Abstract
Background Unsatisfactory analgesia for major knee surgery with femoral nerve block (FNB) alone was reported and the additional benefit of sciatic block to continuous femoral nerve block (CFNB) was not conclusive. The aim of the present study was to find the benefit of the additional mini-dose spinal morphine (0.035 mg) to CFNB for postoperative pain control and to compare their associated side effects after total knee arthroplasty (TKA). Methods After written informed consent and with Institutional Ethics Committee approval, 68 American Society of Anesthesiologists (ASA) Physical Status I-III patients scheduled for elective unilateral TKA under spinal anesthesia (SA) were included in the present prospective, randomized controlled study. The patients were allocated into two groups. CFNB was placed in all patients by the inguinal paravascular approach with 20 ml of 0.25 % levobupivacaine. Group I (named CFNB/SA group), SA was administered with 2.8 ml levobupivacaine and Group II (named CFNB/SAMO group), SA with 2.8 ml levobupivacaine plus morphine 0.035 mg. At Post Anesthesia Care Unit (PACU), pain and other adverse effects were recorded. Pain was assessed by visual analog scale (VAS) 0-10. Tramadol 50 mg intravenous (IV) was given if the VAS > 4. In the ward, all patients were maintained by continuous femoral infusion of 0.125 % levobupivacaine rate 7 ml/hr and then reduced to 5 ml/hr if VAS ≤3. Results Patient’s demographics data in each group were not different. At post-operative (PO) 12-24 h, the VAS scores were significantly lesser in the CFNB/SAMO group. Cumulative tramadol IV requirement for PO48h were also significantly lesser in the CFNB/SAMO group. Nausea, vomiting and numbness were significantly greater in the CFNB/SAMO group during early postoperative period (PO1-6 h). Conclusion Though in some patients CFNB was inadequate, a mini-dose of intrathecal morphine (0.035 mg) in addition to CFNB was found to be effective with minimal side effects. Trial registration Thai Clinical Trial Registry (identifier: TCTR20150609003, date of registration: 6 June 2015).
Collapse
|
98
|
Mungroop TH, Veelo DP, Busch OR, van Dieren S, van Gulik TM, Karsten TM, de Castro SM, Godfried MB, Thiel B, Hollmann MW, Lirk P, Besselink MG. Continuous wound infiltration versus epidural analgesia after hepato-pancreato-biliary surgery (POP-UP): a randomised controlled, open-label, non-inferiority trial. Lancet Gastroenterol Hepatol 2016; 1:105-113. [PMID: 28404067 DOI: 10.1016/s2468-1253(16)30012-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 05/17/2016] [Accepted: 05/18/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Epidural analgesia is the international standard for pain treatment in abdominal surgery. Although some studies have advocated continuous wound infiltration with local anaesthetics, robust evidence is lacking, especially on patient-reported outcome measures. We aimed to determine the effectiveness of continuous wound infiltration in hepato-pancreato-biliary surgery. METHODS In this randomised controlled, open label, non-inferiority trial (POP-UP), we enrolled adult patients undergoing hepato-pancreato-biliary surgery by subcostal or midline laparotomy in two Dutch hospitals. Patients were centrally randomised (1:1) to receive either pain treatment with continuous wound infiltration using bupivacaine plus patient-controlled analgesia with morphine or to receive (patient-controlled) epidural analgesia with bupivacaine and sufentanil. All patients were treated within an enhanced recovery setting. Randomisation was stratified by centre and type of incision. The primary outcome was the mean Overall Benefit of Analgesic Score (OBAS) from day 1-5, a validated composite endpoint of pain scores, opioid side-effects, and patient satisfaction (range 0 [best] to 28 [worst]). Analysis was per-protocol. The non-inferiority limit of the mean difference was + 3·0. This trial is registered with the Netherlands Trial Registry, number NTR4948. FINDINGS Between Jan 20, 2015, and Sept 16, 2015, we randomly assigned 105 eligible patients: 53 to receive continuous wound infiltration and 52 to receive epidural analgesia. One patient in the continuous wound infiltration group discontinued treatment, as did five in the epidural analgesia group; of these five patients, preoperative placement failed in three (these patients were treated with continuous wound infiltration instead), one patient refused an epidural, and data for the primary endpoint was lost for one. Thus, 55 patients were included in the continuous wound infiltration group and 47 in the epidural analgesia group for the per-protocol analyses. Mean OBAS was 3·8 (SD 2·4) in the continuous wound infiltration group versus 4·4 (2·2) in the epidural group (mean difference -0·62, 95% CI -1·54 to 0·30). Because the upper bound of the one-sided 95% CI did not exceed +3·0, non-inferiority was shown. Four (7%) patients in the continuous wound infiltration group and five (11%) of those in the epidural group had an adverse event. One patient in the continuous wound infiltration group had a serious adverse event (temporary hypotension and arrhythmia after bolus injection); no serious adverse events were noted in the epidural group. INTERPRETATION These data suggest that continuous wound infiltration is non-inferior to epidural analgesia in hepato-pancreato-biliary surgery within an enhanced recovery setting. Further large-scale trials are required to make a definitive assessment of non-inferiority. FUNDING Academic Medical Centre, Amsterdam, Netherlands.
Collapse
Affiliation(s)
- Timothy H Mungroop
- Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands; Department of Anaesthesiology, Academic Medical Centre, Amsterdam, Netherlands
| | - Denise P Veelo
- Department of Anaesthesiology, Academic Medical Centre, Amsterdam, Netherlands
| | - Olivier R Busch
- Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands
| | - Susan van Dieren
- Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands; Department of Anaesthesiology, Academic Medical Centre, Amsterdam, Netherlands
| | | | - Tom M Karsten
- Department of Surgery, OLVG Oost, Amsterdam, Netherlands
| | | | - Marc B Godfried
- Department of Anaesthesiology, OLVG Oost, Amsterdam, Netherlands
| | - Bram Thiel
- Department of Anaesthesiology, OLVG Oost, Amsterdam, Netherlands
| | - Markus W Hollmann
- Department of Anaesthesiology, Academic Medical Centre, Amsterdam, Netherlands
| | - Philipp Lirk
- Department of Anaesthesiology, Academic Medical Centre, Amsterdam, Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands.
| |
Collapse
|
99
|
Rosero EB, Joshi GP. Nationwide incidence of serious complications of epidural analgesia in the United States. Acta Anaesthesiol Scand 2016; 60:810-20. [PMID: 26876878 DOI: 10.1111/aas.12702] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 12/01/2015] [Accepted: 01/15/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND This study aimed to describe the incidence and risk factors of in-hospital spinal hematoma and abscess associated with epidural analgesia in adult obstetric and non-obstetric populations in the United States. METHODS The Nationwide Inpatient Sample was analyzed to identify patients receiving epidural analgesia from 1998 to 2010. Primary outcomes were incidence of spinal hematoma and epidural abscess. Use of decompressive laminectomy was also investigated. Regression analyses were conducted to assess predictors of epidural analgesia complications. Differences in mortality and disposition of patients at discharge were compared in patients with and without neuraxial complications. Obstetric and non-obstetric patients were studied separately. RESULTS A total of 3,703,755 epidural analgesia procedures (2,320,950 obstetric and 1,382,805 non-obstetric) were identified. In obstetric patients, the incidence of spinal hematoma was 0.6 per 100,000 epidural catheterizations (95% CI, 0.3 to 1.0 × 10(-5) ). The incidence of epidural abscess was zero. In non-obstetric patients, the incidence of spinal hematoma and epidural abscess were, respectively, 18.5 per 100,000 (95% CI, 16.3 to 20.9 × 10(-5) ) and 7.2 per 100,000 (95% CI, 5.8 to 8.7 × 10(-5) ) catheterizations. Predictors of spinal hematoma included type of surgical procedure (higher in vascular surgery), teaching status of hospital, and comorbidity score. Patients with spinal complications had higher in-hospital mortality (12.2% vs. 1.1%, P < 0.0001) and were significantly less likely to be discharged to home. CONCLUSIONS This large nationwide data analysis reveals that the incidence of epidural analgesia-related complications is very low in obstetric population epidural analgesia and much higher in patients having vascular surgery.
Collapse
Affiliation(s)
- E B Rosero
- Department of Anesthesiology & Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - G P Joshi
- Department of Anesthesiology & Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| |
Collapse
|
100
|
|