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Patel MK, Ekka M, Ekka S, Dalai H, Pujahari PS. A COMPARATIVE STUDY OF PREEMPTIVE ANALGESIC PROPERTY OF INTRAVENOUS PARACETAMOL AND DICLOFENAC SODIUM. ACTA ACUST UNITED AC 2018. [DOI: 10.18410/jebmh/2018/97] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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52
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Zhu A, Benzon HA, Anderson TA. Evidence for the Efficacy of Systemic Opioid-Sparing Analgesics in Pediatric Surgical Populations. Anesth Analg 2017; 125:1569-1587. [DOI: 10.1213/ane.0000000000002434] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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53
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Hah JM, Bateman BT, Ratliff J, Curtin C, Sun E. Chronic Opioid Use After Surgery: Implications for Perioperative Management in the Face of the Opioid Epidemic. Anesth Analg 2017; 125:1733-1740. [PMID: 29049117 PMCID: PMC6119469 DOI: 10.1213/ane.0000000000002458] [Citation(s) in RCA: 457] [Impact Index Per Article: 65.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Physicians, policymakers, and researchers are increasingly focused on finding ways to decrease opioid use and overdose in the United States both of which have sharply increased over the past decade. While many efforts are focused on the management of chronic pain, the use of opioids in surgical patients presents a particularly challenging problem requiring clinicians to balance 2 competing interests: managing acute pain in the immediate postoperative period and minimizing the risks of persistent opioid use after the surgery. Finding ways to minimize this risk is particularly salient in light of a growing literature suggesting that postsurgical patients are at increased risk for chronic opioid use. The perioperative care team, including surgeons and anesthesiologists, is poised to develop clinical- and systems-based interventions aimed at providing pain relief in the immediate postoperative period while also reducing the risks of opioid use longer term. In this paper, we discuss the consequences of chronic opioid use after surgery and present an analysis of the extent to which surgery has been associated with chronic opioid use. We follow with a discussion of the risk factors that are associated with chronic opioid use after surgery and proceed with an analysis of the extent to which opioid-sparing perioperative interventions (eg, nerve blockade) have been shown to reduce the risk of chronic opioid use after surgery. We then conclude with a discussion of future research directions.
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Affiliation(s)
- Jennifer M Hah
- From the *Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, California; †Department of Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; and ‡Department of Neurosurgery, §Department of Orthopaedic Surgery (by courtesy), ‖Division of Hand and Plastic Surgery, Department of Orthopaedic Surgery, ¶Department of Anesthesiology, Perioperative, and Pain Medicine, and #Department of Health Research and Policy (by courtesy), Stanford University, Stanford, California
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55
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Combined intraoperative paracetamol and preoperative dexamethasone reduces postoperative sore throat: a prospective randomized study. J Anesth 2017; 31:869-877. [PMID: 28980140 DOI: 10.1007/s00540-017-2411-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 09/17/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Postoperative sore throat (POST) after general anesthesia with endotracheal intubation is a common and undesirable complication. In this study, we evaluated the combined effects of paracetamol and dexamethasone on the prevention of POST in patients after general anesthesia. METHODS A total of 226 patients scheduled for urologic surgery under general anesthesia were randomly assigned to one of two groups. In the DexaPara group (n = 113), dexamethasone (10 mg) and paracetamol (1000 mg) was infused. In the Dexa group (n = 113), dexamethasone (10 mg) alone was given. POST, hoarseness, and dysphagia were monitored. The postoperative wound pain score and perioperative opioid requirements were compared. In addition, complications related to opioids were compared between the groups. RESULTS The overall incidence of POST was lower in the DexaPara group than in the Dexa group [42 (37%) vs. 72 (64%), p < 0.001]. The incidence of POST while resting at postoperative 1 and 6 h was lower in the DexaPara group than in the Dexa group (p = 0.008 and p = 0.004, respectively). The incidence of postoperative nausea, vomiting, drowsiness, shivering, and headache was comparable between the groups. CONCLUSIONS Paracetamol and dexamethasone infusion reduced the incidence of POST without serious complications in patients for urologic surgery under general anesthesia.
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56
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Ketheeswaran A, Morrisey J, Abbott J, Bennett M, Dudley J, Deans R. Intensive vaginal dilation using adjuvant treatments in women with Mayer-Rokitansky-Kuster-Hauser syndrome: retrospective cohort study. Aust N Z J Obstet Gynaecol 2017; 58:108-113. [PMID: 28960241 DOI: 10.1111/ajo.12715] [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: 04/05/2017] [Accepted: 08/15/2017] [Indexed: 01/09/2023]
Abstract
AIMS To evaluate the effect of adjuvants during intensive vaginal dilator therapy for functional and anatomical neovagina creation in women with Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH). METHODS This retrospective cohort study included 75 women with MRKH undergoing intensive vaginal dilator treatment between 2000 and 2014. One specialist nurse performed non-surgical vaginal dilation aided by adjuvants, during inpatient admissions for several dilation sessions per day. Following discharge, women continued dilation at home and were advised to attend fortnightly follow-up appointments. RESULTS Outcomes from 68 women were analysed. The median age of starting treatment was 18 years (range: 13-36). There was a mean of 3 days per admission (range 1-5) with a median of 10 dilation sessions per admission. Adjuvant treatment was used by 48/68 (71%) women: oestriol cream 29/68 (43%), 50:50 nitrous oxide and oxygen 44/68 (65%), diazepam 8/68 (12%), lidocaine ointment 26/68 (39%), paracetamol 35/68 (51%) and naproxen 2/68 (3%). There were no statistically significant differences for changes in vaginal parameters. Women receiving adjuvants had a median increase of 4.5 cm (0.5-7 cm) in neovaginal length compared with women not receiving adjuvants who had a median increase of 3.25 cm (0-7 cm) during intensive treatment. Women who received adjuvants tolerated more dilation sessions per day (10 vs 6.5 median sessions respectively) than those who did not (P < 0.001). Of those with documented length at discharge, 42/56 (75%) women had an anatomical neovagina of 7 cm or greater length. CONCLUSIONS Vaginal dilation delivered by intensive treatment and supplemented by adjuvant treatments in a multi-disciplinary centre is a rapid and effective method for creation of a neovagina in women with MRKH.
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Affiliation(s)
| | - Jennifer Morrisey
- Paediatric and Adolescent Gynaecology, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Jason Abbott
- University of New South Wales, Sydney, New South Wales, Australia.,Paediatric and Adolescent Gynaecology, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Michael Bennett
- University of New South Wales, Sydney, New South Wales, Australia
| | - Jan Dudley
- Paediatric and Adolescent Gynaecology, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Rebecca Deans
- University of New South Wales, Sydney, New South Wales, Australia.,Paediatric and Adolescent Gynaecology, Royal Hospital for Women, Sydney, New South Wales, Australia
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Roberts CA, Shah-Becker S, O’Connell Ferster A, Baker A, Stahl LE, Sedeek K, Carr MM. Randomized Prospective Evaluation of Intraoperative Intravenous Acetaminophen in Pediatric Adenotonsillectomy. Otolaryngol Head Neck Surg 2017; 158:368-374. [PMID: 28873028 DOI: 10.1177/0194599817728911] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Objective To establish the safety and efficacy of single-dose intraoperative intravenous (IV) acetaminophen in postoperative pain management following adenotonsillectomy in addition to a standardized regimen of oral pain medication. Study Design Randomized, controlled prospective clinical trial. Setting Single academic medical center. Subjects and Methods Patients between the ages of 3 and 17 years scheduled for tonsillectomy or adenotonsillectomy by a single surgeon between December 2014 and November 2016 were recruited. Patients were randomly assigned to 1 of 2 groups; group 1 received a single intraoperative dose of IV acetaminophen, and group 2 did not. Induction and maintenance of anesthesia, as well as operative technique, were standardized. Nursing pain scores, pain medications administered, and recovery times were reviewed during the 24-hour postoperative period. Postoperative pain regimen included standing alternating oral acetaminophen and ibuprofen. Results In total, 260 patients were included in the study, and 131 (50.4%) received a single intraoperative dose of IV acetaminophen. Patients receiving IV acetaminophen were more likely to experience postoperative nausea and vomiting than patients who did not receive IV acetaminophen (1.53% vs 0.00%, P = .016). There were no significant differences noted for postoperative pain scores, requirements for breakthrough pain medications, time to discharge from the recovery room or hospital, or postoperative complications. Conclusion The use of a single intraoperative dose of IV acetaminophen was associated with minimal additional adverse effects. However, a single intraoperative IV dose of acetaminophen added to standard narcotic and nonnarcotic pain medication does not provide a statistically significant improvement in pain control.
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Affiliation(s)
- Christopher A. Roberts
- Department of Otolaryngology–Head and Neck Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Shivani Shah-Becker
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
| | - Ashley O’Connell Ferster
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
| | - Aaron Baker
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
| | - Lauren E. Stahl
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
| | - Khaled Sedeek
- Department of Anesthesiology, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
| | - Michele M. Carr
- Department of Otolaryngology–Head and Neck Surgery, West Virginia University, Morgantown, West Virginia, USA
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Boric K, Dosenovic S, Jelicic Kadic A, Batinic M, Cavar M, Urlic M, Markovina N, Puljak L. Interventions for postoperative pain in children: An overview of systematic reviews. Paediatr Anaesth 2017; 27:893-904. [PMID: 28707454 DOI: 10.1111/pan.13203] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2017] [Indexed: 01/08/2023]
Abstract
The aim of this study was to conduct an overview of systematic reviews that summarizes the results about efficacy and safety from randomized controlled trials involving the various strategies used for postoperative pain management in children. We searched the Cochrane Database of Systematic Reviews, CINAHL, Database of Reviews of Effect, Embase, MEDLINE, and PsycINFO from the earliest date to January 24, 2016. This overview included 45 systematic reviews that evaluated interventions for postoperative pain in children. Out of 45 systematic reviews that investigated various interventions for postoperative pain in children, 19 systematic reviews (42%) presented conclusive evidence of efficacy. Positive conclusive evidence was reported in 18 systematic reviews (40%) for the efficacy of diclofenac, ketamine, caudal analgesia, dexmedetomidine, music therapy, corticosteroid, epidural analgesia, paracetamol, and/or nonsteroidal anti-inflammatory drugs and transversus abdominis plane block. Only one systematic review reported conclusive evidence of equal efficacy that involved a comparison of dexmedetomidine vs morphine and fentanyl. Safety of interventions was reported as conclusive in 14 systematic reviews (31%), with positive conclusive evidence for dexmedetomidine, corticosteroid, epidural analgesia, transversus abdominis plane block, and clonidine. Seven systematic reviews reported equal conclusive safety for epidural infusion, diclofenac intravenous vs ketamine added to opioid analgesia, bupivacaine, ketamine, paracetamol, and dexmedetomidine vs intravenous infusions of various opioid analgesics, oral suspension and suppository of diclofenac, only opioid, normal saline, no treatment, placebo, and midazolam. Negative conclusive statement for safety was reported in one systematic review for caudal analgesia vs noncaudal regional analgesia. More than half of systematic reviews included in this overview were rated as having medium methodological quality. Of 45 included systematic reviews, 10 were Cochrane reviews and they had higher methodological quality than non-Cochrane reviews. As evidence concerning efficacy and safety is inconclusive for most of the analyzed interventions, our review points out the need for more rigorous trials concerning pain management in children.
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Affiliation(s)
- Krste Boric
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia
| | - Svjetlana Dosenovic
- Department of Anesthesiology and Intensive Care, University Hospital Center Split, Split, Croatia
| | | | - Marijan Batinic
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia
| | - Marija Cavar
- Department of Radiology, University Hospital Center Split, Split, Croatia
| | - Marjan Urlic
- Department of Thoracic Surgery, University Hospital Center Split, Split, Croatia
| | - Nikolina Markovina
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia
| | - Livia Puljak
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia
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Consensus Review of Optimal Perioperative Care in Breast Reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations. Plast Reconstr Surg 2017; 139:1056e-1071e. [PMID: 28445352 DOI: 10.1097/prs.0000000000003242] [Citation(s) in RCA: 202] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Enhanced recovery following surgery can be achieved through the introduction of evidence-based perioperative maneuvers. This review aims to present a consensus for optimal perioperative management of patients undergoing breast reconstructive surgery and to provide evidence-based recommendations for an enhanced perioperative protocol. METHODS A systematic review of meta-analyses, randomized controlled trials, and large prospective cohorts was conducted for each protocol element. Smaller prospective cohorts and retrospective cohorts were considered only when higher level evidence was unavailable. The available literature was graded by an international panel of experts in breast reconstructive surgery and used to form consensus recommendations for each topic. Each recommendation was graded following a consensus discussion among the expert panel. Development of these recommendations was endorsed by the Enhanced Recovery after Surgery Society. RESULTS High-quality randomized controlled trial data in patients undergoing breast reconstruction informed some of the recommendations; however, for most items, data from lower level studies in the population of interest were considered along with extrapolated data from high-quality studies in non-breast reconstruction populations. Recommendations were developed for a total of 18 unique enhanced recovery after surgery items and are discussed in the article. Key recommendations support use of opioid-sparing perioperative medications, minimal preoperative fasting and early feeding, use of anesthetic techniques that decrease postoperative nausea and vomiting and pain, use of measures to prevent intraoperative hypothermia, and support of early mobilization after surgery. CONCLUSION Based on the best available evidence for each topic, a consensus review of optimal perioperative care for patients undergoing breast reconstruction is presented. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
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Kaye AD, Cornett EM, Helander E, Menard B, Hsu E, Hart B, Brunk A. An Update on Nonopioids: Intravenous or Oral Analgesics for Perioperative Pain Management. Anesthesiol Clin 2017; 35:e55-e71. [PMID: 28526161 DOI: 10.1016/j.anclin.2017.01.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Despite an appreciation for many unwanted physiologic effects from inadequate postoperative pain relief, moderate to severe postoperative pain remains commonplace. Although treatment options have evolved in recent years, the use of nonopioid analgesics agents can reduce acute pain-associated morbidity and mortality. This review focuses on the importance of effective postoperative nonopioid analgesic agents, such as acetaminophen, nonsteroidal anti-inflammatory agents, gabapentinoid agents, NMDA antagonists, alpha 2 agonists, and steroids, in opioid sparing and enhancing recovery. A careful literature review focusing on these treatment options, potential benefits, and side effects associated with these strategies is emphasized in this review.
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Affiliation(s)
- Alan D Kaye
- Department of Anesthesiology, LSU School of Medicine, 1542 Tulane Avenue, New Orleans, LA 70112, USA; Department of Pharmacology, Louisiana State University School of Medicine, Louisiana State University Health Science Center, 1542 Tulane Avenue, New Orleans, LA 70112, USA.
| | - Elyse M Cornett
- Department of Anesthesiology, LSU School of Medicine, 1501 Kings Highway, Shreveport, LA 71130, USA
| | - Erik Helander
- Department of Anesthesiology, LSU School of Medicine, 1542 Tulane Avenue, New Orleans, LA 70112, USA
| | - Bethany Menard
- Department of Anesthesiology, LSU School of Medicine, 1542 Tulane Avenue, New Orleans, LA 70112, USA
| | - Eric Hsu
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, UCLA School of Medicine, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095-7403, USA
| | - Brendon Hart
- Department of Anesthesiology, LSU School of Medicine, 1501 Kings Highway, Shreveport, LA 71130, USA
| | - Andrew Brunk
- Department of Anesthesiology, LSU School of Medicine, 1542 Tulane Avenue, New Orleans, LA 70112, USA
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McEvoy MD, Scott MJ, Gordon DB, Grant SA, Thacker JKM, Wu CL, Gan TJ, Mythen MG, Shaw AD, Miller TE. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on optimal analgesia within an enhanced recovery pathway for colorectal surgery: part 1-from the preoperative period to PACU. Perioper Med (Lond) 2017; 6:8. [PMID: 28413629 PMCID: PMC5390366 DOI: 10.1186/s13741-017-0064-5] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 03/14/2017] [Indexed: 01/01/2023] Open
Abstract
Background Within an enhanced recovery pathway (ERP), the approach to treating pain should be multifaceted and the goal should be to deliver “optimal analgesia,” which we define in this paper as a technique that optimizes patient comfort and facilitates functional recovery with the fewest medication side effects. Methods With input from a multi-disciplinary, international group of clinicians, and through a structured review of the literature and use of a modified Delphi method, we achieved consensus surrounding the topic of optimal analgesia in the perioperative period for colorectal surgery patients. Discussion As a part of the first Perioperative Quality Improvement (POQI) workgroup meeting, we sought to develop a consensus document describing a comprehensive, yet rational and practical, approach for developing an evidence-based plan for achieving optimal analgesia, specifically for a colorectal surgery ERP. The goal was two-fold: (a) that application of this process would lead to improved patient outcomes and (b) that investigation of the questions raised would identify knowledge gaps to aid the direction for research into analgesia within ERPs in the years to come. This document details the evidence for a wide range of analgesic components, with particular focus from the preoperative period to the post-anesthesia care unit. The overall conclusion is that the combination of analgesic techniques employed in the perioperative period is not important as long as it is effective in delivering the goal of optimal analgesia as set forth in this document.
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Affiliation(s)
- Matthew D McEvoy
- Department of Anesthesiology, CIPHER (Center for Innovation in Perioperative Health, Education, and Research) Vanderbilt University Medical Center, 2301VUH, Nashville, TN 37232 USA
| | - Michael J Scott
- Anaesthesia & Intensive Care Medicine, Royal Surrey County NHS Foundation Hospital, Surrey, UK.,Department of Anaesthesia, University of Surrey, Surrey, UK.,University College London, London, UK
| | - Debra B Gordon
- Harborview Integrated Pain Care Program, Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, USA
| | - Stuart A Grant
- Division of Regional Division, Department of Anesthesiology, Duke University Medical Center, Durham, USA
| | - Julie K M Thacker
- Division of Advanced Oncologic and GI Surgery, Department of Surgery, Duke University Medical Center, Durham, USA
| | - Christopher L Wu
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University School of Medicine, Suffolk, USA
| | - Monty G Mythen
- UCL/UCLH National Institute of Health Research Biomedical Research Centre, London, UK
| | - Andrew D Shaw
- Department of Anesthesiology, Vanderbilt University, Nashville, USA
| | - Timothy E Miller
- Division of General, Vascular and Transplant Anesthesia, Duke University Medical Center, Durham, USA
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Abstract
Perioperative lidocaine infusion improves analgesia and recovery after some surgical procedures, possibly through systemic antiinflammatory effects. This commentary provides the clinician with evidence for rational use of perioperative lidocaine infusion in procedures where it is of demonstrated benefit.
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Abstract
PURPOSE OF REVIEW Management of acute pain following surgery using a multimodal approach is recommended by the American Society of Anesthesiologists whenever possible. In addition to opioids, drugs with differing mechanisms of actions target pain pathways resulting in additive and/or synergistic effects. Some of these agents include alpha 2 agonists, NMDA receptor antagonists, gabapentinoids, dexamethasone, NSAIDs, acetaminophen, and duloxetine. RECENT FINDINGS Alpha 2 agonists have been shown to have opioid-sparing effects, but can cause hypotension and bradycardia and must be taken into consideration when administered. Acetaminophen is commonly used in a multimodal approach, with recent evidence lacking for the use of IV over oral formulations in patients able to take medications by mouth. Studies involving gabapentinoids have been mixed with some showing benefit; however, future large randomized controlled trials are needed. Ketamine is known to have powerful analgesic effects and, when combined with magnesium and other agents, may have a synergistic effect. Dexamethasone reduces postoperative nausea and vomiting and has been demonstrated to be an effective adjunct in multimodal analgesia. The serotonin-norepinephrine reuptake inhibitor, duloxetine, is a novel agent, but studies are limited and further evidence is needed. Overall, a multimodal analgesic approach should be used when treating postoperative pain, as it can potentially reduce side effects and provide the benefit of treating pain through different cellular pathways.
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64
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Medina-Vera AJ, Novoa LM. Reduced anaesthetic requirements and postoperative analgesics in patients undergoing laparoscopic cholecystectomy: premedication with intravenous paracetamol versus ketorolac, a double blind and randomised clinical trial. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2017; 64:64-70. [PMID: 27370941 DOI: 10.1016/j.redar.2016.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 05/17/2016] [Accepted: 05/19/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To compare the effects of premedication with intravenous paracetamol versus ketorolac, in decreasing intraoperative anaesthetic and postoperative opioid analgesics requirements in patients undergoing laparoscopic cholecystectomy. METHOD An experimental, prospective, comparative, double blind, and randomised clinical trial was conducted to determine intraoperative opioid requirements, and pain and analgesic requirements in the postoperative period in 100 healthy patients undergoing laparoscopic cholecystectomy. They were randomised into 2 groups: Group 1: pre-medicated with paracetamol 1g, and Group 2: with ketorolac 30mg (both administered intravenously 30minutes prior to surgery). RESULTS There were no statistically significant differences between groups as regards intraoperative remifentanil use (Group 1: 0.0739±0.016μg/kg/min, Group 2: 0.0741±0.018μg/kg/min). The number of patients in Group 2 that had values of VAS>4 points (22.4%) was lower than in Group 1 (28.6%), but with no statistically significant difference. Of the patients who needed postoperative opioid rescue, most required a single rescue and application of analgesics during hospitalisation, that prevailed between 3 and 12hours, without any significant differences between groups. No adverse effects were observed in the study sample. CONCLUSION Paracetamol 1g IV given preoperatively decreased anaesthetic requirements and the need for postoperative analgesics similar to the preoperative administration of ketorolac 30mg IV.
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MESH Headings
- Acetaminophen/administration & dosage
- Acetaminophen/therapeutic use
- Adult
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/therapeutic use
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/therapeutic use
- Anesthetics, Inhalation/administration & dosage
- Anesthetics, Intravenous/administration & dosage
- Cholecystectomy, Laparoscopic
- Dose-Response Relationship, Drug
- Double-Blind Method
- Female
- Humans
- Infusions, Intravenous
- Intraoperative Complications/drug therapy
- Isoflurane/administration & dosage
- Ketorolac/administration & dosage
- Ketorolac/therapeutic use
- Male
- Middle Aged
- Morphine/administration & dosage
- Morphine/therapeutic use
- Pain, Postoperative/drug therapy
- Pain, Postoperative/prevention & control
- Piperidines/administration & dosage
- Postoperative Period
- Preanesthetic Medication
- Prospective Studies
- Remifentanil
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Affiliation(s)
- A J Medina-Vera
- Servicio de Anestesiología, Hospital General del Este Dr. Domingo Luciani, Caracas, Venezuela.
| | - L M Novoa
- Servicio de Anestesiología, Hospital General del Este Dr. Domingo Luciani, Caracas, Venezuela
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Lee HY, Ban GY, Jeong CG, Lee JH, Park SH, Kim SH, Lee YH, Ye YM. Propacetamol poses a potential harm of adverse hypotension in male and older patients. Pharmacoepidemiol Drug Saf 2017; 26:256-264. [DOI: 10.1002/pds.4159] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 12/02/2016] [Indexed: 12/17/2022]
Affiliation(s)
- Hyun-Young Lee
- Department of Statistics, Clinical Trial Center; Ajou University Medical Center; Korea
| | - Ga-Young Ban
- Department of Allergy and Clinical Immunology; Ajou University School of Medicine; Korea
- Regional Pharmacovigilance Center; Ajou University Medical Center; Suwon Korea
| | - Chang-Gyu Jeong
- Department of Allergy and Clinical Immunology; Ajou University School of Medicine; Korea
- Regional Pharmacovigilance Center; Ajou University Medical Center; Suwon Korea
| | - Ji-Ho Lee
- Department of Allergy and Clinical Immunology; Ajou University School of Medicine; Korea
- Regional Pharmacovigilance Center; Ajou University Medical Center; Suwon Korea
| | - Seung-Hee Park
- Regional Pharmacovigilance Center; Ajou University Medical Center; Suwon Korea
| | - Sang-Hee Kim
- Regional Pharmacovigilance Center; Ajou University Medical Center; Suwon Korea
| | - Young-Hee Lee
- Regional Pharmacovigilance Center; Ajou University Medical Center; Suwon Korea
| | - Young-Min Ye
- Department of Allergy and Clinical Immunology; Ajou University School of Medicine; Korea
- Regional Pharmacovigilance Center; Ajou University Medical Center; Suwon Korea
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Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. THE JOURNAL OF PAIN 2016; 17:131-57. [PMID: 26827847 DOI: 10.1016/j.jpain.2015.12.008] [Citation(s) in RCA: 1572] [Impact Index Per Article: 196.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 12/11/2015] [Accepted: 12/14/2015] [Indexed: 12/11/2022]
Abstract
UNLABELLED Most patients who undergo surgical procedures experience acute postoperative pain, but evidence suggests that less than half report adequate postoperative pain relief. Many preoperative, intraoperative, and postoperative interventions and management strategies are available for reducing and managing postoperative pain. The American Pain Society, with input from the American Society of Anesthesiologists, commissioned an interdisciplinary expert panel to develop a clinical practice guideline to promote evidence-based, effective, and safer postoperative pain management in children and adults. The guideline was subsequently approved by the American Society for Regional Anesthesia. As part of the guideline development process, a systematic review was commissioned on various aspects related to various interventions and management strategies for postoperative pain. After a review of the evidence, the expert panel formulated recommendations that addressed various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care. The recommendations are based on the underlying premise that optimal management begins in the preoperative period with an assessment of the patient and development of a plan of care tailored to the individual and the surgical procedure involved. The panel found that evidence supports the use of multimodal regimens in many situations, although the exact components of effective multimodal care will vary depending on the patient, setting, and surgical procedure. Although these guidelines are based on a systematic review of the evidence on management of postoperative pain, the panel identified numerous research gaps. Of 32 recommendations, 4 were assessed as being supported by high-quality evidence, and 11 (in the areas of patient education and perioperative planning, patient assessment, organizational structures and policies, and transitioning to outpatient care) were made on the basis of low-quality evidence. PERSPECTIVE This guideline, on the basis of a systematic review of the evidence on postoperative pain management, provides recommendations developed by a multidisciplinary expert panel. Safe and effective postoperative pain management should be on the basis of a plan of care tailored to the individual and the surgical procedure involved, and multimodal regimens are recommended in many situations.
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Apfel CC, Souza K, Portillo J, Dalal P, Bergese SD. Patient satisfaction with intravenous acetaminophen: a pooled analysis of five randomized, placebo-controlled studies in the acute postoperative setting. J Healthc Qual 2016; 37:155-62. [PMID: 24433365 DOI: 10.1111/jhq.12062] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Intravenous (IV) acetaminophen has been shown to reduce postoperative pain and opioid consumption, which may lead to increased patient satisfaction. To determine the effect IV acetaminophen has on patient satisfaction, a pooled analysis from methodologically homogenous studies was conducted. We obtained patient-level data from five randomized, placebo-controlled studies in adults undergoing elective surgery in which patient satisfaction was measured using a 4-point categorical rating scale. The primary endpoint was "excellent" satisfaction and the secondary endpoint was "good" or "excellent" satisfaction at 24 hr after first study drug administration. Bivariate analyses were conducted using the chi-square test and Student's t-test and multivariable analyses were conducted using logistic regression analysis. Patients receiving IV acetaminophen were more than twice as likely as those who received placebo to report "excellent" patient satisfaction ratings (32.3% vs. 15.9%, respectively). Of all variables that remained statistically significant in the multivariable analysis (i.e., type of surgery, duration of anesthesia, last pain rating, and opioid consumption), IV acetaminophen had the strongest positive effect on "excellent" patient satisfaction with an odds ratio of 2.76 (95% CI 1.81-4.23). Results for "excellent" or "good" satisfaction were similar. When given as part of a perioperative analgesic regimen, IV acetaminophen was associated with significantly improved patient satisfaction.
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Ehieli E, Yalamuri S, Brudney CS, Pyati S. Analgesia in the surgical intensive care unit. Postgrad Med J 2016; 93:38-45. [PMID: 27777355 DOI: 10.1136/postgradmedj-2016-134047] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 07/10/2016] [Accepted: 08/27/2016] [Indexed: 01/30/2023]
Abstract
Critically ill patients are a heterogeneous group with diverse comorbidities and physiological derangements. The management of pain in the critically ill population is emerging as a standard of care in the intensive care unit (ICU). Pain control of critically ill patients in the ICU presents numerous challenges to intensivists. Inconsistencies in pain assessment, analgesic prescription and variation in monitoring sedation and analgesia result in suboptimal pain management. Inadequate pain control can have deleterious effects on several organ systems in critically ill patients. Therefore, it becomes incumbent on physicians and nurses caring for these patients to carefully evaluate their practice on pain management and adopt an optimal pain management strategy that includes a reduction in noxious stimuli, adequate analgesia and promoting education regarding sedation and analgesia to the ICU staff. Mechanistic approaches and multimodal analgesic techniques have been clearly demonstrated to be the most effective pain management strategy to improve outcomes. For example, recent evidence suggests that the use of short acting analgesics and analgesic adjuncts for sedation is superior to hypnotic based sedation in intubated patients. This review will address analgesia in the ICU, including opioid therapy, adjuncts, regional anaesthesia and non-pharmacological options that can provide a multimodal approach to treating pain.
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Affiliation(s)
- Eric Ehieli
- Department of Anesthesiology, Duke University Medical Center, Surgical Intensive Care Unit, Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Suraj Yalamuri
- Department of Anesthesiology, Duke University Medical Center, Surgical Intensive Care Unit, Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Charles S Brudney
- Department of Anesthesiology, Duke University Medical Center, Surgical Intensive Care Unit, Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Srinivas Pyati
- Department of Anesthesiology, Duke University Medical Center, Surgical Intensive Care Unit, Veterans Affairs Medical Center, Durham, North Carolina, USA
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Hedin RJ, Umberham BA, Detweiler BN, Kollmorgen L, Vassar M. Publication Bias and Nonreporting Found in Majority of Systematic Reviews and Meta-analyses in Anesthesiology Journals. Anesth Analg 2016; 123:1018-25. [DOI: 10.1213/ane.0000000000001452] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Mahshidfar B, Sameti A, Abbasi S, Farsi D, Mofidi M, Hafezimoghadam P, Rahimzadeh P, Rezai M. Can intravenous acetaminophen reduce the needs to more opioids to control pain in intubated patients? Indian J Crit Care Med 2016; 20:465-8. [PMID: 27630458 PMCID: PMC4994126 DOI: 10.4103/0972-5229.188197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
AIMS To evaluate the effect of intravenous (IV) acetaminophen on reducing the need for morphine sulfate in intubated patients admitted to the Intensive Care Unit (ICU). SETTINGS AND DESIGN Current study was done as a clinical trial on the patients supported by mechanical ventilator. SUBJECTS AND METHODS Behavioral pain scale (BPS) scoring system was used to measure pain in the patients. All of the patients received 1 g, IV acetaminophen, every 6 h during the 1(st) and 3(rd) days of admission and placebo during the 2(nd) and 4(th) days. Total dose of morphine sulfate needed, its complications, and the BPS scores at the end of every 6 h interval were compared. RESULTS Totally forty patients were enrolled. The mean pain scores were significantly lower in the 2(nd) and 4(th) days (4.33 and 3.66, respectively; mean: 4.0) in which the patients had received just morphine sulfate compared to the 1(st) and 3(rd) days (7.36 and 3.93, respectively; mean: 5.65) in which the patients had received acetaminophen in addition to morphine sulfate too (P < 0.001). Cumulative dose of morphine sulfate used, was significantly higher in the 1(st) and 3(rd) days (8.92 and 3.15 mg, respectively; 12.07 mg in total) compared to the 2(nd) and 4(th) days (6.47 mg and 3.22 mg, respectively; 9.7 mg in total) (P = 0.035). CONCLUSION In our study, IV acetaminophen had no effect on decreasing the BPSs and need of morphine sulfate in intubated patients admitted to ICU.
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Affiliation(s)
- Babak Mahshidfar
- Emergency Medicine Management Research Center, Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Azadeh Sameti
- Emergency Medicine Management Research Center, Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Saeed Abbasi
- Emergency Medicine Management Research Center, Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Davood Farsi
- Emergency Medicine Management Research Center, Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mani Mofidi
- Emergency Medicine Management Research Center, Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Peyman Hafezimoghadam
- Emergency Medicine Management Research Center, Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Popak Rahimzadeh
- Department of Anesthesiology, Rasoul-e-Akram Hospital, Iran university of Medical Sciences, Tehran, Iran
| | - Mahdi Rezai
- Emergency Medicine Management Research Center, Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
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Schillers F, Eberhardt E, Leffler A, Eberhardt M. Propacetamol-Induced Injection Pain Is Associated with Activation of Transient Receptor Potential Vanilloid 1 Channels. J Pharmacol Exp Ther 2016; 359:18-25. [PMID: 27457427 DOI: 10.1124/jpet.116.233452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 07/22/2016] [Indexed: 01/16/2023] Open
Abstract
Propacetamol (PPCM) is a prodrug of paracetamol (PCM), which was generated to increase water solubility of PCM for intravenous delivery. PPCM is rapidly hydrolyzed by plasma esterases to PCM and diethylglycine and shares some structural and metabolic properties with lidocaine. Although PPCM is considered to be comparable to PCM regarding its analgesic properties, injection pain is a common side effect described for PPCM but not PCM. Injection pain is a frequent and unpleasant side effect of numerous drugs in clinical use, and previous reports have indicated that the ligand gated ion channels transient receptor potential ankyrin 1 (TRPA1) and transient receptor potential vanilloid 1 (TRPV1) can mediate this effect on sensory neurons. This study aimed to investigate molecular mechanisms by which PPCM, in contrast to PCM, causes injection pain. Therefore, human TRPV1 and TRPA1 receptors were expressed in human embryonic kidney 293 cells and investigated by means of whole-cell patch clamp and ratiometric calcium imaging. PPCM (but not PCM) activated TRPV1, sensitized heat-induced currents, and caused an increase in intracellular calcium. In TRPA1-expressing cells however, both PPCM and PCM evoked calcium responses but failed to induce inward currents. Intracutaneous injection of PPCM, but not of PCM, in human volunteers induced an intense and short-lasting pain and an increase in superficial blood flow, indicating activation of nociceptive C fibers and subsequent neuropeptide release. In conclusion, activation of human TRPV1 by PPCM seems to be a relevant mechanism for induction of pain upon intracutaneous injection and thus also for pain reported as an adverse side effect upon intravenous administration.
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Affiliation(s)
- Florian Schillers
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany (F.S., A.L., M.E.); and Department of Anaesthesiology, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany (E.E.)
| | - Esther Eberhardt
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany (F.S., A.L., M.E.); and Department of Anaesthesiology, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany (E.E.)
| | - Andreas Leffler
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany (F.S., A.L., M.E.); and Department of Anaesthesiology, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany (E.E.)
| | - Mirjam Eberhardt
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany (F.S., A.L., M.E.); and Department of Anaesthesiology, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany (E.E.)
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Detweiler BN, Kollmorgen LE, Umberham BA, Hedin RJ, Vassar BM. Risk of bias and methodological appraisal practices in systematic reviews published in anaesthetic journals: a meta-epidemiological study. Anaesthesia 2016; 71:955-68. [DOI: 10.1111/anae.13520] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2016] [Indexed: 11/28/2022]
Affiliation(s)
- B. N. Detweiler
- Institutional Research and Analytics; Oklahoma State University Center for Health Sciences; Tulsa Oklahoma USA
| | - L. E. Kollmorgen
- Institutional Research and Analytics; Oklahoma State University Center for Health Sciences; Tulsa Oklahoma USA
| | - B. A. Umberham
- Institutional Research and Analytics; Oklahoma State University Center for Health Sciences; Tulsa Oklahoma USA
| | - R. J. Hedin
- Institutional Research and Analytics; Oklahoma State University Center for Health Sciences; Tulsa Oklahoma USA
| | - B. M. Vassar
- Institutional Research and Analytics; Oklahoma State University Center for Health Sciences; Tulsa Oklahoma USA
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George JA, Park PS, Hunsberger J, Shay JE, Lehmann CU, White ED, Lee BH, Yaster M. An Analysis of 34,218 Pediatric Outpatient Controlled Substance Prescriptions. Anesth Analg 2016; 122:807-813. [PMID: 26579844 DOI: 10.1213/ane.0000000000001081] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Prescription errors are among the most common types of iatrogenic errors. Because of a previously reported 82% error rate in handwritten discharge narcotic prescriptions, we developed a computerized, web-based, controlled substance prescription writer that includes weight-based dosing logic and alerts to reduce the error rate to (virtually) zero. Over the past 7 years, >34,000 prescriptions have been created by hospital providers using this platform. We sought to determine the ongoing efficacy of the program in prescription error reduction and the patterns with which providers prescribe controlled substances for children and young adults (ages 0-21 years) at hospital discharge. METHODS We examined a database of 34,218 controlled substance discharge prescriptions written by our institutional providers from January 1, 2007 to February 14, 2014, for demographic information, including age and weight, type of medication prescribed based on patient age, formulation of dispensed medication, and amount of drug to be dispensed at hospital discharge. In addition, we randomly regenerated 2% (700) of prescriptions based on stored data and analyzed them for errors using previously established error criteria. Weights that were manually entered into the prescription writer by the prescriber were compared with the patient's weight in the hospital's electronic medical record. RESULTS Patients in the database averaged 9 ± 6.1 (range, 0-21) years of age and 36.7 ± 24.9 (1-195) kg. Regardless of age, the most commonly prescribed opioid was oxycodone (73%), which was prescribed as a single agent uncombined with acetaminophen. Codeine was prescribed to 7% of patients and always in a formulation containing acetaminophen. Liquid formulations were prescribed to 98% of children <6 years of age and to 16% of children >12 years of age (the remaining 84% received tablet formulations). Regardless of opioid prescribed, the amount of liquid dispensed averaged 106 ± 125 (range, 2-3240) mL, and the number of tablets dispensed averaged 51 ± 51 (range, 1-1080). Of the subset of 700 regenerated prescriptions, all were legible (drug, amount dispensed, dose, patient demographics, and provider name) and used best prescribing practice (e.g., no trailing zero after a decimal point, leading zero for doses <1). Twenty-five of the 700 (3.6%) had incorrectly entered weights compared with the most recent weight in the chart. Of these, 14 varied by 10% or less and only 2 varied by >15%. Of these, 1 resulted in underdosing (true weight 80 kg prescribed for a weight of 50 kg) and the other in overdosing (true weight 10 kg prescribed for a weight of 30 kg). CONCLUSIONS A computerized prescription writer eliminated most but not all the errors common to handwritten prescriptions. Oxycodone has supplanted codeine as the most commonly prescribed oral opioid in current pediatric pain practice and, independent of formulation, is dispensed in large quantities. This study underscores the need for liquid opioid formulations in the pediatric population and, because of their abuse potential, the urgent need to determine how much of the prescribed medication is actually used by patients.
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Affiliation(s)
- Jessica A George
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Departments of Pediatrics and Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee; and Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Mamoun NF, Lin P, Zimmerman NM, Mascha EJ, Mick SL, Insler SR, Sessler DI, Duncan AE. Intravenous acetaminophen analgesia after cardiac surgery: A randomized, blinded, controlled superiority trial. J Thorac Cardiovasc Surg 2016; 152:881-889.e1. [PMID: 27236864 DOI: 10.1016/j.jtcvs.2016.04.078] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 03/14/2016] [Accepted: 04/23/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pain after cardiac surgery traditionally has been controlled by intravenous opioids and nonsteroidal antiinflammatory drugs. An intravenous analgesic with fewer adverse effects is needed. Therefore, we tested the primary hypothesis that intravenous acetaminophen is more effective than placebo for pain management, which was defined a priori as superior on either pain intensity score and/or opioid consumption and not worse on either. METHODS In this single-center, double-blind trial, 147 patients having cardiac surgery via median sternotomy were randomized to receive either 1 g of intravenous acetaminophen (73 patients) every 6 hours for 24 hours or comparable placebo (74 patients) starting in the operating room after sternal closure. Cumulative opioid consumption (in morphine equivalents) and pain intensity scores (on a 0-10 Numeric Rating Scale) were measured at 4, 6, 8, 12, 16, 20, and 24 hours after surgery. We estimated ratio of mean opioid consumption by using multivariable linear regression (noninferiority delta = 1.15) and pain score difference by using repeated measures regression (noninferiority delta = 1). RESULTS Acetaminophen was superior to placebo on mean pain intensity scores and noninferior on opioid consumption, with estimated difference in mean pain (95% confidence interval) of -0.90 (-1.39, -0.42), P < .001 (superior), and estimated ratio of means in opioid consumption (90% confidence interval) of 0.89 (0.73-1.10), P = .28 (noninferior; not superior). CONCLUSIONS Intravenous acetaminophen reduced pain after cardiac surgery, but not opioid consumption. Intravenous acetaminophen can be an effective analgesic adjunct in patients recovering from median sternotomy.
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Affiliation(s)
- Negmeldeen F Mamoun
- Department of Cardiothoracic Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Peirong Lin
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nicole M Zimmerman
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Edward J Mascha
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Stephanie L Mick
- Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Steven R Insler
- Department of Cardiothoracic Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Andra E Duncan
- Department of Cardiothoracic Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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Mischkowski D, Crocker J, Way BM. From painkiller to empathy killer: acetaminophen (paracetamol) reduces empathy for pain. Soc Cogn Affect Neurosci 2016; 11:1345-53. [PMID: 27217114 DOI: 10.1093/scan/nsw057] [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: 10/28/2015] [Accepted: 04/19/2016] [Indexed: 01/09/2023] Open
Abstract
Simulation theories of empathy hypothesize that empathizing with others' pain shares some common psychological computations with the processing of one's own pain. Support for this perspective has largely relied on functional neuroimaging evidence of an overlap between activations during the experience of physical pain and empathy for other people's pain. Here, we extend the functional overlap perspective to the neurochemical level and test whether a common physical painkiller, acetaminophen (paracetamol), can reduce empathy for another's pain. In two double-blind placebo-controlled experiments, participants rated perceived pain, personal distress and empathic concern in response to reading scenarios about another's physical or social pain, witnessing ostracism in the lab, or visualizing another study participant receiving painful noise blasts. As hypothesized, acetaminophen reduced empathy in response to others' pain. Acetaminophen also reduced the unpleasantness of noise blasts delivered to the participant, which mediated acetaminophen's effects on empathy. Together, these findings suggest that the physical painkiller acetaminophen reduces empathy for pain and provide a new perspective on the neurochemical bases of empathy. Because empathy regulates prosocial and antisocial behavior, these drug-induced reductions in empathy raise concerns about the broader social side effects of acetaminophen, which is taken by almost a quarter of adults in the United States each week.
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Affiliation(s)
- Dominik Mischkowski
- National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, MD, USA
| | - Jennifer Crocker
- Department of Psychology, The Ohio State University, Columbus, OH, USA
| | - Baldwin M Way
- Department of Psychology, The Ohio State University, Columbus, OH, USA Institute for Behavioral Medicine Research, The Ohio State Wexner Medical Center, Columbus, OH, USA
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Putting it all together: recommendations for improving pain management in plastic surgical procedures. Plast Reconstr Surg 2016; 134:94S-100S. [PMID: 25255014 DOI: 10.1097/prs.0000000000000677] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
SUMMARY The benefits of optimal pain management are well recognized. Nevertheless, treatment of postoperative pain continues to be a major challenge, and inadequate postoperative pain relief remains disturbingly high. One of the reasons for suboptimal pain management may be related to inadequate or improper application of available analgesic therapies. Use of patient-specific and procedure-specific pain management strategies should improve pain control and consequently improve perioperative outcome, including early ambulation, ability to perform rehabilitation activities, and return to activities of daily living. This article discusses the current evidence that should allow improved postoperative pain control with emphasis on the use of procedure-specific pain management.
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Acetaminophen, nonsteroidal anti-inflammatory drugs, and cyclooxygenase-2 selective inhibitors: an update. Plast Reconstr Surg 2016; 134:24S-31S. [PMID: 25255003 DOI: 10.1097/prs.0000000000000672] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
SUMMARY Plastic and cosmetic surgery is often performed as an ambulatory procedure, and pain is often mild to moderate. Good pain relief is central to patient comfort and satisfaction. Analgesics used should ensure rapid onset and adequate pain relief lasting a sufficiently long duration with minimal or no side effects. Acetaminophen is well tolerated by patients, efficacious, and associated with only minor side effects, when used in the minimal effective doses. Nonsteroidal anti-inflammatory drugs (NSAIDs) are more efficacious, having lower numbers needed to treat compared with acetaminophen, but have several side effects and contraindications. However, when used in the correct doses in healthy patients, NSAIDs are excellent for pain management with one caveat that there is an increased risk for oozing or bleeding. In contrast, cyclooxygenase inhibitors (Coxibs) are equally efficacious as NSAIDs but have the added advantage that they have minimal or no effect on platelet function, and therefore, the risk for bleeding complications is minimal. However, there has been some concern about the risk of vascular events in patients with ischemic heart disease, specifically when using Coxibs, but even some NSAIDs, for example, diclofenac. In conclusion, acetaminophen should be given postoperatively to all patients undergoing plastic surgical procedures. For patients undergoing moderately invasive surgery, the addition of Coxibs to acetaminophen would be an advantage except in the patient with ischemic heart disease where NSAIDs could have a place in management of pain. Side effects and contraindications of NSAIDs, however, restrict their use to the healthy patient with mild comorbidities.
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Abstract
SUMMARY To improve postoperative pain management, several concepts have been developed, including preemptive analgesia, preventive analgesia, and multimodal analgesia. This article will discuss the role of these concepts in improving perioperative pain management. Preemptive analgesia refers to the administration of an analgesic treatment before the surgical insult or tissue injury. Several randomized clinical trials have, however, provided equivocal evidence regarding the benefits of preincisional compared with postincisional analgesic administration. Current general consensus, therefore, indicates that use of preemptive analgesia does not translate into consistent clinical benefits after surgery. Preventive analgesia is a wider concept where the timing of analgesic administration in relation to the surgical incision is not critical. The aim of preventive analgesia is to minimize sensitization induced by noxious stimuli arising throughout the perioperative period. Multimodal analgesia consists of the administration of 2 or more drugs that act by different mechanisms for providing analgesia. These drugs may be administered via the same route or by different routes. Thus, the aim of multimodal analgesia is to improve pain relief while reducing opioid requirements and opioid-related adverse effects. Analgesic modalities currently available for postoperative pain control include opioids, local anesthetic techniques [local anesthetic infiltration, peripheral nerve blocks, and neuraxial blocks (epidural and paravertebral)], acetaminophen, nonsteroidal anti-inflammatory drugs, and cyclooxygenase-2-specific inhibitors as well as analgesic adjuncts such as steroids, ketamine, α-2 agonists, and anticonvulsants.
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Luiz T, Scherer G, Wickenkamp A, Blaschke F, Hoffmann W, Schiffer M, Zimmer J, Schaefer S, Voigt C. [Prehospital analgesia by paramedics in Rhineland-Palatinate : Feasability, analgesic effectiveness and safety of intravenous paracetamol]. Anaesthesist 2015; 64:927-936. [PMID: 26497656 DOI: 10.1007/s00101-015-0089-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 06/05/2015] [Accepted: 08/20/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND In contrast to the widespread practice in life-threatening emergencies, delegation of medical pain therapy to paramedics by the medical director of Emergency Medical Services, EMS, are still the exception in Germany. This is due to the fact that in non-life-threatening situations, the expected benefit and potential side effects of drug therapy have to be carefully weighed. In addition, in Germany federal law generally restricts the administration of opiates to physicians. METHODS In 2011 the medical directors of EMS in the German state of Rhineland- Palatinate (4 million inhabitants) developed and implemented a standard operating procedure (SOP) for paramedics related to the prehospital parenteral administration of paracetamol for patients with isolated limb trauma. After a 2 h training session and examination, paramedics were authorized to administer 1 g of paracetamol to patients with a pain score > 5 points on an 11-point numerical rating scale (NRS). For purposes of quality management, every administration of paracetamol had to be prospectively documented on a specific electronic mission form. RESULTS A total of 416 mission forms could be analyzed. After administration of paracetamol the median NRS score decreased from 8 points (interquartile range: 6; 8) to 4 points (interquartile range: 3; 7). In 51.2 % of the patients the pain intensity was reduced by at least 3 NRS points and in 50.5 % of the patients the NRS was less than 5 points after treatment. The extent of pain reduction was positively correlated with the initial NRS value (r = 0.31, p < 0.0001). No serious side effects were noted. The percentage of patients with an initial heart rate > 100/min declined from 14.6 % to 5.2 % after the administration of paracetamol (p < 0.0001), 18.7 % of the patients received paracetamol for trauma not related to the extremities and 7 % of the patients for nontraumatic pain. An emergency physician was involved in 50 % of the EMS missions and 98.6 % of the patients were transported to a hospital for further diagnostics and treatment. CONCLUSION The prehospital intravenous administration of paracetamol by paramedics to patients with limb trauma is simple, safe and in 50 % of the patients effective in achieving a NRS value < 5; however, further improvements in prehospital pain therapy initiated by paramedics are desirable, especially in patients with an initial NRS value > 7.
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Affiliation(s)
- T Luiz
- Deutsches Zentrum für Notfallmedizin & Informationstechnologie, Fraunhofer IESE, Fraunhofer-Platz 1, 67663, Kaiserslautern, Deutschland. .,Klinik für Anästhesie, Intensiv- und Notfallmedizin 1, Westpfalz-Klinikum GmbH, Kaiserslautern, Deutschland.
| | - G Scherer
- Rettungsdienstbereiche Rheinhessen & Bad Kreuznach, Ingelheim am Rhein, Deutschland
| | - A Wickenkamp
- Deutsches Zentrum für Notfallmedizin & Informationstechnologie, Fraunhofer IESE, Fraunhofer-Platz 1, 67663, Kaiserslautern, Deutschland
| | - F Blaschke
- Rettungsdienstbereiche Ludwigshafen & Südpfalz, Ludwigshafen, Deutschland
| | - W Hoffmann
- Rettungsdienstbereich Kaiserslautern, Kaiserslautern, Deutschland
| | - M Schiffer
- Rettungsdienstbereich Trier, Trier, Deutschland
| | - J Zimmer
- Rettungsdienstbereich Trier, Trier, Deutschland
| | - S Schaefer
- Rettungsdienstbereiche Koblenz & Montabaur, Koblenz, Deutschland
| | - C Voigt
- Rettungsdienstbereiche Koblenz & Montabaur, Koblenz, Deutschland
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81
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Hagan KB, Bhavsar S, Raza SM, Arnold B, Arunkumar R, Dang A, Gottumukkala V, Popat K, Pratt G, Rahlfs T, Cata JP. Enhanced recovery after surgery for oncological craniotomies. J Clin Neurosci 2015; 24:10-6. [PMID: 26474504 DOI: 10.1016/j.jocn.2015.08.013] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 08/02/2015] [Indexed: 01/12/2023]
Abstract
Enhanced recovery after surgery (ERAS) initiatives in the fields of gastrointestinal and pelvic surgery have contributed to improved postoperative functional status for patients and decreased length of stay. A similar comprehensive protocol is lacking for patients undergoing craniotomy for tumor resection. A literature search was performed using PubMed. These references were reviewed with a preference for recent high quality studies. Cohort and retrospective studies were also included if higher levels of evidence were lacking. A literature search was conducted for scalp blocks and minimally invasive craniotomies. Papers were scored using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria for evidence level and recommendation grade. Seventeen ERAS items were reviewed and recommendations made. The current body of evidence is insufficient to create a standardized protocol for craniotomy and tumor resection. However, this initial review of the literature supports pursuing future research initiatives that explore modalities to improve functional recovery and decrease length of stay in craniotomy patients.
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Affiliation(s)
- Katherine B Hagan
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Shreyas Bhavsar
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Shaan M Raza
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Benjamin Arnold
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Radha Arunkumar
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Anh Dang
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Vijay Gottumukkala
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Keyuri Popat
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Greg Pratt
- Systems Analyst, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thomas Rahlfs
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Juan P Cata
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA; Anesthesia and Surgical Oncology Research Group, Houston, TX, USA.
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82
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Single-dose systemic acetaminophen to prevent postoperative pain: a meta-analysis of randomized controlled trials. Clin J Pain 2015; 31:86-93. [PMID: 25485955 DOI: 10.1097/ajp.0000000000000081] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The effect of a single-dose systemic acetaminophen to treat postoperative pain has been previously quantified, but the effect of systemic acetaminophen to prevent postoperative pain is currently not well defined. The preventive analgesic effect of acetaminophen has yet to be quantified in a meta-analysis. The objective of the current investigation was to evaluate the effect of a single preventive dose of systemic acetaminophen on postoperative pain outcomes. MATERIALS AND METHODS A wide search was performed to identify randomized controlled trials that evaluated the effects of a single dose of systemic acetaminophen on pain outcomes in a large variety of surgical procedures. Meta-analysis was performed using a random-effect model. RESULTS Eleven randomized clinical trials evaluating 740 patients were included in the analysis. The weighted mean difference (95% confidence interval [CI]) of the combined effects favored acetaminophen over control for early pain at rest (≤4 h, -1.1 (-2.0 to -0.2)) and early pain at movement (24 h, -1.9 (-2.8 to -1.0)) Postoperative opioid consumption was decreased in the systemic acetaminophen group compared with control. Weighted mean difference (95% CI) of -9.7 (-13.0 to -6.4) mg morphine intravenous equivalents systemic acetaminophen also reduced postoperative nausea and vomiting compared with control, odds ratio (95% CI) of 0.25 (0.13 to 0.47), numbers needed to treat (95% CI)=3.3 (2.3 to 5.9). DISCUSSION Systemic acetaminophen, when used as a single-dose preventive regimen, is an effective intervention to reduce postoperative pain. It also reduces postoperative nausea and/or vomiting. Doses >1 g were not associated with greater reduction in pain outcomes.
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83
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Eftekharian H, Tabrizi R, Kazemi H, Nili M. Evaluation of a Single Dose Intravenous Paracetamol for Pain Relief After Maxillofacial Surgery: A Randomized Clinical Trial Study. J Maxillofac Oral Surg 2015. [PMID: 26225014 DOI: 10.1007/s12663-013-0557-9] [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: 10/26/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate, using a single dose of intravenous paracetamol, pain relief after maxillofacial surgery. MATERIALS AND METHODS This is a controlled, randomized, uni- blind, clinical trial study to evaluate using a single dose of IV paracetamol for pain relief after maxillofacial surgery. The subjects were randomly divided into two groups with 40 subjects in each: group I received paracetamol (Apotel)* as a single dose and group II received placebo. Subjects were randomly allocated according to randomization lists. Paracetamol was used as a single dose (20 mg/kg in 100 cc of normal saline which was infused for 10 min after surgery in recovery room just before discharging). We used a visual analogue scale to investigate pain relief at various times. RESULTS Analysis of the data, did not show any significant difference for age, sex and weight between the treatment group and the control group. Pain decreased 6 h after paracetamol infusion; then it increased mildly. In the control group, pain severity increased after operation, then it decreased mildly. Results showed a correlation between duration of surgery and pain severity in both the groups. CONCLUSION Paracetamol is effective on pain relief after maxillofacial surgeries. Operation time may be an important factor for induction of pain after the surgeries.
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Affiliation(s)
- Hamidreza Eftekharian
- Department of Maxillofacial Surgery, Shiraz University of Medical Science, Shiraz, Iran
| | - Reza Tabrizi
- Department of Maxillofacial Surgery, Shiraz University of Medical Science, Shiraz, Iran ; Chamran Hospital, CMF Ward, Chamran Avenue, Shiraz, Fars Iran
| | - Hamidreza Kazemi
- Department of Maxillofacial Surgery, Shiraz University of Medical Science, Shiraz, Iran
| | - Mahsa Nili
- Shiraz University of Medical Science, Shiraz, Iran
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84
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Jibril F, Sharaby S, Mohamed A, Wilby KJ. Intravenous versus Oral Acetaminophen for Pain: Systematic Review of Current Evidence to Support Clinical Decision-Making. Can J Hosp Pharm 2015; 68:238-47. [PMID: 26157186 DOI: 10.4212/cjhp.v68i3.1458] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Intravenous (IV) acetaminophen is increasingly used around the world for pain control for a variety of indications. However, it is unclear whether IV administration offers advantages over oral administration. OBJECTIVE To identify, summarize, and critically evaluate the literature comparing analgesic efficacy, safety, and pharmacokinetics for IV and oral dosage forms of acetaminophen. DATA SOURCES A literature search of the PubMed, Embase, and International Pharmaceutical Abstracts databases was supplemented with keyword searches of Science Direct, Wiley Library Online, and Springer Link databases for the period 1948 to November 2014. The reference lists of identified studies were searched manually. STUDY SELECTION AND DATA EXTRACTION Randomized controlled trials comparing IV and oral dosage forms of acetaminophen were included if they assessed an efficacy, safety, or pharmacokinetic outcome. For each study, 2 investigators independently extracted data (study design, population, interventions, follow-up, efficacy outcomes, safety outcomes, pharmacokinetic outcomes, and any other pertinent information) and completed risk-of-bias assessments. DATA SYNTHESIS Six randomized clinical trials were included. Three of the studies reported outcomes pertaining to efficacy, 4 to safety, and 4 to pharmacokinetics. No clinically significant differences in efficacy were found between the 2 dosage forms. Safety outcomes were not reported consistently enough to allow adequate assessment. No evidence was found to suggest that increased bioavailability of the IV formulation enhances efficacy outcomes. For studies reporting clinical outcomes, the results of risk-of-bias assessments were largely unclear. CONCLUSIONS For patients who can take an oral dosage form, no clear indication exists for preferential prescribing of IV acetaminophen. Decision-making must take into account the known adverse effects of each dosage form and other considerations such as convenience and cost. Future studies should assess multiple-dose regimens over longer periods for patients with common pain indications such as cancer, trauma, and surgery.
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Affiliation(s)
- Farah Jibril
- BSc(Pharm), PharmD, is a Clinical Pharmacist at the National Center for Cancer Care and Research, Doha, Qatar
| | - Sherif Sharaby
- Sherif Sharaby, BSc(Pharm), is a Pharmacist with the San Joaquin Valley Rehabilitation Hospital, Fresno, California
| | - Ahmed Mohamed
- BSc(Pharm), PhD, is an Assistant Professor with the College of Pharmacy, Qatar University, Doha, Qatar
| | - Kyle J Wilby
- BSP, ACPR, PharmD, is an Assistant Professor - Clinical Pharmacy and Practice, College of Pharmacy, Qatar University, Doha, Qatar
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85
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Cata JP, Lasala J, Bugada D. Best practice in the administration of analgesia in postoncological surgery. Pain Manag 2015; 5:273-84. [PMID: 26072922 DOI: 10.2217/pmt.15.21] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The rationale for using multimodal analgesia after any major surgery is achievement of adequate analgesia while avoiding the unwanted effects of large doses of any analgesic, in particular opioids. There are two reasons why we can hypothesize that multimodal analgesia might have a significant impact on cancer-related outcomes in the context of oncological orthopedic surgery. First, because multimodal analgesia is a key component of enhanced-recovery pathways and can accelerate return to intended oncological therapy. And second, because some of the analgesic used in multimodal analgesia (i.e., COX inhibitors, local analgesics and dexamethasone) can induce apoptosis in cancer cells and/or diminish the inflammatory response during surgery which itself can facilitate tumor growth.
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Affiliation(s)
- Juan P Cata
- Department of Anesthesiology & Perioperative Medicine, The University of Texas-MD Anderson Cancer Center, Houston, TX 77030, USA.,Anesthesia & Surgical Oncology Research Group
| | - Javier Lasala
- Department of Anesthesiology & Perioperative Medicine, The University of Texas-MD Anderson Cancer Center, Houston, TX 77030, USA.,Anesthesia & Surgical Oncology Research Group
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Abstract
Acetaminophen is a commonly used pediatric medication that has recently been approved for intravenous use in the United States. The purpose of this article was to review the pharmacodynamics, indications, contraindications, and precautions for the use of intravenous acetaminophen in pediatrics.
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87
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Kang JE, Park SK, Song IK, Lee JH, Kim JT, Kim HS. Comparison of the Efficacy and Safety of Different Doses of Propacetamol for Postoperative Pain Control after Breast Surgery. Pain Manag Nurs 2015; 16:367-71. [DOI: 10.1016/j.pmn.2014.08.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 08/28/2014] [Accepted: 08/29/2014] [Indexed: 11/28/2022]
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88
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Pal A, Biswas J, Mukhopadhyay P, Sanyal P, Dasgupta S, Das S. Diclofenac is more effective for post-operative analgesia in patients undergoing lower abdominal gynecological surgeries: A comparative study. Anesth Essays Res 2015; 8:192-6. [PMID: 25886225 PMCID: PMC4173621 DOI: 10.4103/0259-1162.134502] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Aim: The present study aimed to compare the efficacy of injectable diclofenac intramuscularly (IM), injection paracetamol intravenously (IV), or a combination of both to provide post-operative analgesia in patients undergoing lower abdominal gynecological surgeries. Materials and Methods: A total of 90 female patients (American Society of Anesthesiologists I and II), aged 20-50 years, scheduled for elective total abdominal hysterectomy with or without bilateral salpingo-oophorectomy were randomized to receive 75 mg diclofenac IM 8 hourly (Group D) or 1 g paracetamol IV 8 hourly (Group P) or a combination of both 8 hourly (Group PD) for 24 h post-operative period from the start of surgery. The primary outcome measured was the requirement of rescue analgesic (tramadol), the secondary outcomes measured included visual analog score (VAS) for pain, time until first rescue analgesic administration, patient satisfaction score and any side effects. Results: The requirement of rescue analgesic was significantly lower in Groups D and PD compared to Group P. Mean (standard deviation) tramadol requirement during 24 h was 56.67 (62.60) mg, 20.00 (40.68) mg and 20.00 (40.68) mg in the Groups P, D and PD respectively. Less number of patients in Groups D and PD (20% in both the groups) required rescue analgesic compared to Group P (50%). The VAS showed a significant decrease in Groups D and PD compared to Group P between 4 and 12 h post-operatively. However, Group PD showed no significant difference when compared to Group D alone. Conclusion: Injection diclofenac IM is more effective than paracetamol IV in terms of rescue analgesic requirement, but the combination of diclofenac IM and paracetamol IV provides no added advantage over diclofenac IM alone.
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Affiliation(s)
- Anirban Pal
- Department of Anaesthesiology, Calcutta National Medical College and Hospital, Kolkatta, West Bengal, India
| | - Jhuma Biswas
- Department of Obstetrics and Gynecology, Bankura Sammilani Medical College and Hospital, Bankura, West Bengal, India
| | - Purnava Mukhopadhyay
- Department of Anaesthesiology, Calcutta National Medical College and Hospital, Kolkatta, West Bengal, India
| | - Poushali Sanyal
- Department of Obstetrics and Gynecology, Institute of Postgraduate Medical Education and Research, Kolkatta, West Bengal, India
| | - Shyamal Dasgupta
- Department of Obstetrics and Gynecology, North Bengal Medical College and Hospital, Darjeeling, West Bengal, India
| | - Shyamashis Das
- Department of Rheumatology, North Bengal Medical College and Hospital, Darjeeling, West Bengal, India
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89
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Koh W, Nguyen KP, Jahr JS. Intravenous non-opioid analgesia for peri- and postoperative pain management: a scientific review of intravenous acetaminophen and ibuprofen. Korean J Anesthesiol 2015; 68:3-12. [PMID: 25664148 PMCID: PMC4318862 DOI: 10.4097/kjae.2015.68.1.3] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 07/11/2014] [Accepted: 07/15/2014] [Indexed: 11/25/2022] Open
Abstract
Pain is a predictable consequence following operations, but the management of postoperative pain is another challenge for anesthesiologists and inappropriately controlled pain may lead to unwanted outcomes in the postoperative period. Opioids are indeed still at the mainstream of postoperative pain control, but solely using only opioids for postoperative pain management may be connected with risks of complications and adverse effects. As a consequence, the concept of multimodal analgesia has been proposed and is recommended whenever possible. Acetaminophen is one of the most commonly used analgesic and antipyretic drug for its good tolerance and high safety profiles. The introduction of intravenous form of acetaminophen has led to a wider flexibility of its use during peri- and postoperative periods, allowing the early initiation of multimodal analgesia. Many studies have revealed the efficacy, safety and opioid sparing effects of intravenous acetaminophen. Intravenous ibuprofen has also shown to be well tolerated and demonstrated to have significant opioid sparing effects during the postoperative period. However, the number of randomized controlled trials confirming the efficacy and safety is small and should be used in caution in certain group of patients. Intravenous acetaminophen and ibuprofen are important options for multimodal postoperative analgesia, improving pain and patient satisfaction.
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Affiliation(s)
- Wonuk Koh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kimngan Pham Nguyen
- Department of Anesthesiology and Perioperative Medicine, UCLA College of Arts and Letters, CA, USA
| | - Jonathan S Jahr
- David Geffen School of Medicine at UCLA Ronald Regan UCLA Medical Center, CA, USA
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90
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Gonzalez AM, Romero RJ, Ojeda-Vaz MM, Rabaza JR. Intravenous acetaminophen in bariatric surgery: effects on opioid requirements. J Surg Res 2015; 195:99-104. [PMID: 25680474 DOI: 10.1016/j.jss.2015.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 12/29/2014] [Accepted: 01/07/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Opioids are commonly used after bariatric surgery for pain control because of their potent analgesic effects. Nevertheless, the morbidly obese patient has increased risk for developing adverse effects produced by opioids (such as sedation, apnea, hypoxemia, ileus, and vomiting). Intravenous acetaminophen (IVA) has been evaluated in some specialties showing a reduction in opioid consumption. The purpose of this study was to evaluate the effect on opioid consumption when IVA is administered in bariatric surgery patients. MATERIAL AND METHODS A retrospective study was performed in patients who underwent bariatric surgery. Group A included those patients who received IVA perioperatively and group B those who did not. The amount of opioids administered was calculated and compared for each group. RESULTS Group A included 38 cases (44.7%) and group B included 47 cases (55.3%). A comparison was performed in terms of age (P = 0.349), body mass index (P = 0.311), gender (P = 0.890), American Society of Anesthesiologist score (P = 0.438), total surgical time (P = 0.497), perioperative complications (P = 0.786), number of procedures per surgeon (P = 0.08), and type of surgical procedure (P ≤ 0.01). Group A had a mean 24-h total opioid dose of 99.5 mg, whereas group B of 164.6 mg (P = 0.018). Group A received 39.5% less opioids than group B. A post hoc analysis determined a statistical power of 0.74. CONCLUSIONS IVA used perioperatively can decrease opioid consumption in patients after bariatric surgery. Randomized trials are needed to corroborate these results.
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Affiliation(s)
| | - Rey Jesús Romero
- Department of General and Bariatric Surgery, Baptist Health South Florida, Miami, Florida
| | - Maria M Ojeda-Vaz
- Nursing & Allied Health Sciences Research, Baptist Health South Florida, Miami, Florida
| | - Jorge Rafael Rabaza
- Department of General and Bariatric Surgery, Baptist Health South Florida, Miami, Florida
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91
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Preventive Acetaminophen Reduces Postoperative Opioid Consumption, Vomiting, and Pain Scores After Surgery. Reg Anesth Pain Med 2015; 40:706-12. [DOI: 10.1097/aap.0000000000000311] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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92
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Abstract
Studies on enhanced recovery after gynecological surgery are limited but seem to report outcome benefits similar to those reported after colorectal surgery. Regional anesthesia is recommended in enhanced recovery protocols. Effective regional anesthetic techniques in gynecologic surgery include spinal anesthesia, epidural analgesia, transversus abdominis plane blocks, local anesthetic wound infusions and intraperitoneal instillation catheters. Non-opioid analgesics including pregabalin, gabapentin, NSAIDs, COX-2 inhibitors, and paracetamol reduce opioid consumption after surgery. This population is at high risk for PONV, thus, a multimodal anti-emetic strategy must be employed, including strategies to reduce the baseline risk of PONV in conjunction with combination antiemetic therapy.
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Affiliation(s)
- Jeanette R Bauchat
- Northwestern University, Feinberg School of Medicine, 250 East Huron Street, F5-704, Chicago, IL 60611, USA
| | - Ashraf S Habib
- Duke University Medical Center, Box 3094, Durham, NC 27710, USA.
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93
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Optimizing pain management to facilitate Enhanced Recovery After Surgery pathways. Can J Anaesth 2014; 62:203-18. [DOI: 10.1007/s12630-014-0275-x] [Citation(s) in RCA: 145] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 11/10/2014] [Indexed: 01/30/2023] Open
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94
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Abstract
This was judged to be the first place winning submission for the American Dental Society of Anesthesiology Student Essay Award. Acetaminophen is an old drug that is now available in an intravenous formulation. Its advantages and disadvantages are reviewed, including its potential role in multimodal postoperative pain therapy.
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95
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96
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Allegaert K, Olkkola KT, Owens KH, Van de Velde M, de Maat MM, Anderson BJ. Covariates of intravenous paracetamol pharmacokinetics in adults. BMC Anesthesiol 2014; 14:77. [PMID: 25342929 PMCID: PMC4165439 DOI: 10.1186/1471-2253-14-77] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Accepted: 09/11/2014] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Pharmacokinetic estimates for intravenous paracetamol in individual adult cohorts are different to a certain extent, and understanding the covariates of these differences may guide dose individualization. In order to assess covariate effects of intravenous paracetamol disposition in adults, pharmacokinetic data on discrete studies were pooled. METHODS This pooled analysis was based on 7 studies, resulting in 2755 time-concentration observations in 189 adults (mean age 46 SD 23 years; weight 73 SD 13 kg) given intravenous paracetamol. The effects of size, age, pregnancy and other clinical settings (intensive care, high dependency, orthopaedic or abdominal surgery) on clearance and volume of distribution were explored using non-linear mixed effects models. RESULTS Paracetamol disposition was best described using normal fat mass (NFM) with allometric scaling as a size descriptor. A three-compartment linear disposition model revealed that the population parameter estimates (between subject variability,%) were central volume (V1) 24.6 (55.5%) L/70 kg with peripheral volumes of distribution V2 23.1 (49.6%) L/70 kg and V3 30.6 (78.9%) L/70 kg. Clearance (CL) was 16.7 (24.6%) L/h/70 kg and inter-compartment clearances were Q2 67.3 (25.7%) L/h/70 kg and Q3 2.04 (71.3%) L/h/70 kg. Clearance and V2 decreased only slightly with age. Sex differences in clearance were minor and of no significance. Clearance, relative to median values, was increased during pregnancy (F(PREG) = 1.14) and decreased during abdominal surgery (F(ABDCL) = 0.715). Patients undergoing orthopaedic surgery had a reduced V2 (F(ORTHOV) = 0.649), while those in intensive care had increased V2 (F(ICV) = 1.51). CONCLUSIONS Size and age are important covariates for paracetamol pharmacokinetics explaining approximately 40% of clearance and V2 variability. Dose individualization in adult subpopulations would achieve little benefit in the scenarios explored.
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Affiliation(s)
- Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Neonatal Intensive Care Unit, University Hospitals Leuven, Herestraat 49, Leuven, Belgium
| | - Klaus T Olkkola
- Department of Anaesthesiology, Intensive Care, Emergency Care and Pain Medicine University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Katie H Owens
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Marc Van de Velde
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
- Department of Anaesthesiology, University Hospital Leuven, Leuven, Belgium
| | - Monique M de Maat
- Department of Clinical Pharmacy, Rijnstate Hospital Arnhem, Arnhem, The Netherlands
| | - Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
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97
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Singh S, Maldonado Y, Taylor MA. Optimal perioperative medical management of the vascular surgery patient. Anesthesiol Clin 2014; 32:615-637. [PMID: 25113724 DOI: 10.1016/j.anclin.2014.05.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Perioperative medical management of patients undergoing vascular surgery can be challenging because they represent the surgical population at highest risk. β-Blockers should be continued perioperatively in patients already taking them preoperatively. Statins may be used in the perioperative period in patients who are not on statin therapy preoperatively. Institutional guidelines should be used to guide insulin replacement. Recent research suggests that measurement of troponins may provide some risk stratification in clinically stable patients following vascular surgery. Multimodal pain therapy including nonopioid strategies is necessary to improve the efficacy of pain relief and decrease the risk of side effects and complications.
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Affiliation(s)
- Saket Singh
- Department of Anesthesiology, Allegheny Health Network, Temple University School of Medicine, 2570 Haymaker Road, Pittsburgh, PA 15146, USA.
| | - Yasdet Maldonado
- Department of Anesthesiology, Allegheny Health Network, Temple University School of Medicine, 2570 Haymaker Road, Pittsburgh, PA 15146, USA
| | - Mark A Taylor
- Department of Anesthesiology, Allegheny Health Network, Temple University School of Medicine, 2570 Haymaker Road, Pittsburgh, PA 15146, USA
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98
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Jakobsson JG. Pain management in ambulatory surgery-a review. Pharmaceuticals (Basel) 2014; 7:850-65. [PMID: 25061796 PMCID: PMC4167203 DOI: 10.3390/ph7080850] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 06/27/2014] [Accepted: 07/09/2014] [Indexed: 02/07/2023] Open
Abstract
Day surgery, coming to and leaving the hospital on the same day as surgery as well as ambulatory surgery, leaving hospital within twenty-three hours is increasingly being adopted. There are several potential benefits associated with the avoidance of in-hospital care. Early discharge demands a rapid recovery and low incidence and intensity of surgery and anaesthesia related side-effects; such as pain, nausea and fatigue. Patients must be fit enough and symptom intensity so low that self-care is feasible in order to secure quality of care. Preventive multi-modal analgesia has become the gold standard. Administering paracetamol, NSIADs prior to start of surgery and decreasing the noxious influx by the use of local anaesthetics by peripheral block or infiltration in surgical field prior to incision and at wound closure in combination with intra-operative fast acting opioid analgesics, e.g., remifentanil, have become standard of care. Single preoperative 0.1 mg/kg dose dexamethasone has a combined action, anti-emetic and provides enhanced analgesia. Additional α-2-agonists and/or gabapentin or pregabalin may be used in addition to facilitate the pain management if patients are at risk for more pronounced pain. Paracetamol, NSAIDs and rescue oral opioid is the basic concept for self-care during the first 3–5 days after common day/ambulatory surgical procedures.
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Affiliation(s)
- Jan G Jakobsson
- Department of Anaesthesia & Intensive Care, Institution for Clinical Science, Karolinska Institutet, Danderyds Hospital, 182 88 Stockholm, Sweden.
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Wang J, Liu GT, Mayo HG, Joshi GP. Pain Management for Elective Foot and Ankle Surgery: A Systematic Review of Randomized Controlled Trials. J Foot Ankle Surg 2014; 54:625-35. [PMID: 24954920 DOI: 10.1053/j.jfas.2014.05.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Indexed: 02/03/2023]
Abstract
Pain after foot and ankle surgery can significantly affect the postoperative outcomes. We performed a systematic review of randomized controlled trials assessing postoperative pain after foot and ankle surgery, because the surgery will lead to moderate-to-severe postoperative pain, but the optimal pain therapy has been controversial. A systematic review of randomized controlled trials in English reporting on pain after foot and ankle surgery in adults published from January 1946 to February 2013 was performed. The primary outcome measure was the postoperative pain scores. The secondary outcome measures included supplemental analgesic requirements and other recovery outcomes. With 953 studies identified, 45 met the inclusion criteria. The approaches improving pain relief (reduced pain scores or opioid requirements) included peripheral nerve blocks, wound infiltration, intravenous dexamethasone, acetaminophen, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 selective inhibitors, and opioids. Wound instillation, intra-articular injection, and intravenous regional analgesia had variable analgesia. The lack of homogeneous study design precluded quantitative analyses. Optimal pain management strategies included locoregional analgesic techniques plus acetaminophen and nonsteroidal anti-inflammatory drugs or cyclooxygenase-2 selective inhibitors, with opioids used for "rescue," and 1 intraoperative dose of parenteral dexamethasone. Popliteal sciatic nerve blocks would be appropriate when expecting severe postoperative pain (extensive surgical procedure), and ankle blocks and surgical incision infiltration would be appropriate when expecting moderate postoperative pain (less extensive and minimally invasive surgical procedures). Additional studies are needed to assess multimodal analgesia techniques.
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Affiliation(s)
- Jia Wang
- Resident, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX
| | - George T Liu
- Assistant Professor, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Helen G Mayo
- Research and Liaison Librarian, University of Texas Southwestern Health Sciences Digital Library and Learning Center, University of Texas Southwestern Medical Center, Dallas, TX
| | - Girish P Joshi
- Professor, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX.
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Nour C, Ratsiu J, Singh N, Mason L, Ray A, Martin M, Hassanian M, Uhler J, Applegate RL. Analgesic effectiveness of acetaminophen for primary cleft palate repair in young children: a randomized placebo controlled trial. Paediatr Anaesth 2014; 24:574-81. [PMID: 24697925 DOI: 10.1111/pan.12393] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/26/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND Clefting of the lip, palate, or both is a common congenital abnormality. Inadequate treatment for pain in children may result from concerns over opioid-related adverse effects. Providing adequate pain control with minimal adverse effects remains challenging in children. OBJECTIVES To assess opioid-sparing effects of oral or intravenous acetaminophen following primary cleft palate repair in children. METHODS Prospective randomized controlled trial in 45 healthy children, ages 5 months to 5 years, using standardized general anesthesia and lidocaine infiltration of the operative field. Patients were allocated to groups: intravenous acetaminophen/oral placebo (intravenous), oral acetaminophen/intravenous placebo (oral), or intravenous/oral placebo (control). Groups were compared for differences in opioid administration during the 24-h study period (morphine equivalents µg·kg(-1) ; 95% confidence interval). RESULTS Intravenous acetaminophen decreased opioid requirement after surgery (P = 0.003). Patients in the intravenous group received less opioid (272.9; 202.9-342.8 µg·kg(-1) ) than control patients (454.2; 384.3-524.2 µg·kg(-1) ; P < 0.002). Opioid requirement in oral patients (376.5; 304.1-448.9 µg·kg(-1) ) was intermediate and not significantly different from either intravenous (P = 0.11) or control (P = 0.27). During the ward phase of care, intravenous had better analgesia than control (P = 0.002), and both intravenous and oral group patients received less opioid than control (P = 0.01). CONCLUSION Intravenous acetaminophen given to young children undergoing primary cleft palate repair was associated with opioid-sparing effects compared to placebo. The fewer morphine doses during ward stay in both intravenous and oral may be important clinically in some settings.
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Affiliation(s)
- Chelan Nour
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, CA, USA
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