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Lim KI, Liu CK, Chen CL, Wang CH, Huang CJ, Cheng KW, Wu SC, Shih TH, Yang SC, Lee YE, Jawan B, Juang SE. Transitional Study of Patient-Controlled Analgesia Morphine With Ketorolac to Patient-Controlled Analgesia Morphine With Parecoxib Among Donors in Adult Living Donor Liver Transplantation: A Single-Center Experience. Transplant Proc 2016; 48:1074-6. [DOI: 10.1016/j.transproceed.2015.11.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 11/06/2015] [Indexed: 12/26/2022]
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Abstract
OBJECTIVE To study the association between ketorolac use and postoperative complications. BACKGROUND Nonsteroidal anti-inflammatory drugs may impair wound healing and increase the risk of anastomotic leak in colon surgery. Studies to date have been limited by sample size, inability to identify confounding, and a focus limited to colon surgery. METHODS Ketorolac use, reinterventions, emergency department (ED) visits, and readmissions in adults (≥ 18 years) undergoing gastrointestinal (GI) operations was assessed in a nationwide cohort using the MarketScan Database (2008-2012). RESULTS Among 398,752 patients (median age 52, 45% male), 55% underwent colorectal surgery, whereas 45% had noncolorectal GI surgery. Five percent of patients received ketorolac. Adjusting for demographic characteristics, comorbidities, surgery type/indication, and preoperative medications, patients receiving ketorolac had higher odds of reintervention (odds ratio [OR] 1.20, 95% confidence interval [CI] 1.08-1.32), ED visit (OR 1.44, 95% CI 1.37-1.51), and readmission within 30 days (OR 1.11, 95% CI 1.05-1.18) compared to those who did not receive ketorolac. Ketorolac use was associated with readmissions related to anastomotic complications (OR 1.20, 95% CI 1.06-1.36). Evaluating only admissions with ≤ 3 days duration to exclude cases where ketorolac might have been used for complication-related pain relief, the odds of complications associated with ketorolac were even greater. CONCLUSIONS Use of intravenous ketorolac was associated with greater odds of reintervention, ED visit, and readmission in both colorectal and noncolorectal GI surgery. Given this confirmatory evaluation of other reports of a negative association and the large size of this cohort, clinicians should exercise caution when using ketorolac in patients undergoing GI surgery.
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The Effect of Early Postoperative Non-Steroidal Anti-Inflammatory Drugs on Pancreatic Fistula Following Pancreaticoduodenectomy. J Gastrointest Surg 2015; 19:1632-9. [PMID: 26123102 DOI: 10.1007/s11605-015-2874-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 06/08/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) are used commonly for postoperative analgesia but can potentially impair healing. Their effect on pancreaticoduodenectomy (PD) outcomes is unknown. We sought to examine the impact of early postoperative NSAIDs on pancreatic fistula (PF) after PD. METHODS We reviewed our prospective pancreatectomy database supplemented by medication administration records, including all PDs from 2002 to 2012. Primary outcome was occurrence of clinically significant (grade B-C) PF. Secondary outcomes included major morbidity (Clavien grade III-V) and 90-day mortality. Patients were compared based on early postoperative NSAID use (first 3 days following surgery) using univariate and multivariate analyses. Subgroup analyses were conducted based on NSAID type (COX-2 inhibitors and non-selective inhibitors). RESULTS We included 251 PDs, of whom 127 (50.6%) patients received NSAIDs postoperatively (35.5% COX-2 inhibitors, 18.3% non-selective inhibitors, and 4.4% both). Use of any NSAIDs was associated with a non-significant increase in PF (16.5 vs 11.3%%; p = 0.23), and no difference in major morbidity and mortality. Use of non-selective inhibitors was not associated with an increase in PF (8.7 vs 15.1%; p = 0.256). COX-2 inhibitors were associated with increased PF (20.2 vs 10.5 %; p = 0.033), but no difference in major morbidity or mortality. After adjusting for Charlson comorbidity and estimated blood loss, use of COX-2 inhibitors was independently associated with PF (odds ratio 2.12; p = 0.044). CONCLUSIONS COX-2 inhibitors are associated with PF in the early postoperative period. While non-selective inhibitors appear safe in this setting, caution is warranted with the use of COX-2 inhibitors.
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Nonsteroidal Anti-inflammatory Drugs: Do They Increase the Risk of Anastomotic Leaks Following Colorectal Operations? Dis Colon Rectum 2015; 58:870-7. [PMID: 26252849 DOI: 10.1097/dcr.0000000000000430] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs have become an important component of narcotic-sparing postoperative pain management protocols. However, conflicting evidence exists regarding the adverse association of nonsteroidal anti-inflammatory drug use with intestinal anastomotic healing in colorectal surgery. OBJECTIVE This study compares patients receiving nonsteroidal anti-inflammatory drugs on postoperative day 1 with patients who did not receive nonsteroidal anti-inflammatory drugs with regard to the occurrence of anastomotic leaks. DESIGN This is a retrospective study from a protocol-driven prospectively collected statewide database. A propensity score model was used to adjust for differences between the groups in patient demographics, characteristics, comorbidities, and laboratory values. SETTINGS The multicenter data set used in this analysis represents a variety of academic and community hospitals within the state of Michigan from July 2012 through February 2014. PATIENTS Nonpregnant patients over the age of 18 who underwent colon and rectal surgery with bowel anastomosis were selected. MAIN OUTCOME MEASURES Occurrence of anastomotic leak, composite surgical site infection, sepsis, and death within 30 days of surgery were the primary outcomes measured. RESULTS A total of 4360 patients met inclusion criteria, of which 1297 (29.7%) received nonsteroidal anti-inflammatory drugs and 3063 (70.3%) did not receive nonsteroidal anti-inflammatory drugs. There was no statistically significant difference between the 2 groups in the proportion of cases with anastomotic leak (OR, 1.33; CI, 0.86-2.05; p = 0.20), composite surgical site infection (OR, 1.26; CI, 0.96-1.66; p = 0.09), or death within 30 days (OR, 0.58; CI, 0.28-1.19; p = 0.14). There was a significantly greater risk of sepsis for patients given nonsteroidal anti-inflammatory drugs than for those patients not given nonsteroidal anti-inflammatory drugs (OR, 1.47; CI, 1.05-2.06; p = 0.03). LIMITATIONS This is a nonrandomized study performed retrospectively, and it is based on data collected only within a subset of hospitals in the state of Michigan. CONCLUSIONS No statistically significant increase in the proportion of patients with anastomotic leak was observed when prescribing nonsteroidal anti-inflammatory drugs for analgesia in the early postoperative period for patients undergoing elective colorectal surgery. Unexpectedly, there was an increased risk of sepsis that warrants further investigation (see video, Supplemental Digital Content 1, http://links.lww.com/DCR/A192, for a synopsis of this study).
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Bhangu A, Singh P, Fitzgerald JEF, Slesser A, Tekkis P. Postoperative nonsteroidal anti-inflammatory drugs and risk of anastomotic leak: meta-analysis of clinical and experimental studies. World J Surg 2015; 38:2247-57. [PMID: 24682313 DOI: 10.1007/s00268-014-2531-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Enhanced recovery programs following colorectal resection recommend the use of nonsteroidal anti-inflammatory drugs (NSAIDs) as part of multimodal analgesia. The present study aimed to assess whether postoperative NSAID use increased the risk of anastomotic leak. METHODS A systematic review of published literature was performed for studies comparing anastomotic leak following NSAID administration versus control. Meta-analysis was conducted for studies in human patients and experimental animal models. The primary endpoint was anastomotic leak. RESULTS The final analysis included 8 studies in humans and 12 experimental animal studies. Use of NSAIDs was significantly associated with anastomotic leak in humans (8 studies, 4,464 patients, odds ratio [OR] 2.14; p < 0.001). This effect was seen with nonselective NSAIDs (6 studies, 3,074 patients, OR 2.37; p < 0.001), but not with selective NSAIDs (4 studies, 1,223 patients, OR 2.32; p = 0.170). There was strong evidence of selection bias from all clinical studies, with additional inconsistent definitions and outcomes assessment. From experimental animal models, anastomotic leak was more likely with NSAID use (ten studies, 575 animals, OR 9.51; p < 0.001). Bursting pressures at day 7 were significantly lower in NSAID versus controls (7 studies, 168 animals, weighted mean difference -35.7 mmHg; p < 0.001). CONCLUSIONS Emerging data strongly suggest that postoperative NSAIDs are linked to anastomotic leak, although most studies are flawed and may be describing pre-existing selection bias. However, when combined with experimental data, these increasing concerns suggest caution is needed when prescribing NSAIDs to patients with pre-existing risk factors for leak, until more definitive evidence emerges.
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Affiliation(s)
- Aneel Bhangu
- Department of Colorectal Surgery, Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK,
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Youssef N, Orlov D, Alie T, Chong M, Cheng J, Thabane L, Paul J. What Epidural Opioid Results in the Best Analgesia Outcomes and Fewest Side Effects After Surgery? Anesth Analg 2014; 119:965-977. [DOI: 10.1213/ane.0000000000000377] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Koo KC, Yoon YE, Chung BH, Hong SJ, Rha KH. Analgesic opioid dose is an important indicator of postoperative ileus following radical cystectomy with ileal conduit: experience in the robotic surgery era. Yonsei Med J 2014; 55:1359-65. [PMID: 25048497 PMCID: PMC4108824 DOI: 10.3349/ymj.2014.55.5.1359] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Postoperative ileus (POI) is common following bowel resection for radical cystectomy with ileal conduit (RCIC). We investigated perioperative factors associated with prolonged POI following RCIC, with specific focus on opioid-based analgesic dosage. MATERIALS AND METHODS From March 2007 to January 2013, 78 open RCICs and 26 robot-assisted RCICs performed for bladder carcinoma were identified with adjustment for age, gender, American Society of Anesthesiologists grade, and body mass index (BMI). Perioperative records including operative time, intraoperative fluid excess, estimated blood loss, lymph node yield, and opioid analgesic dose were obtained to assess their associations with time to passage of flatus, tolerable oral diet, and length of hospital stay (LOS). Prior to general anaesthesia, patients received epidural patient-controlled analgesia (PCA) consisted of fentanyl with its dose adjusted for BMI. Postoperatively, single intravenous injections of tramadol were applied according to patient desire. RESULTS Multivariate analyses revealed cumulative dosages of both PCA fentanyl and tramadol injections as independent predictors of POI. According to surgical modality, linear regression analyses revealed cumulative dosages of PCA fentanyl and tramadol injections to be positively associated with time to first passage of flatus, tolerable diet, and LOS in the open RCIC group. In the robot-assisted RCIC group, only tramadol dose was associated with time to flatus and tolerable diet. Compared to open RCIC, robot-assisted RCIC yielded shorter days to diet and LOS; however, it failed to shorten days to first flatus. CONCLUSION Reducing opioid-based analgesics shortens the duration of POI. The utilization of the robotic system may confer additional benefit.
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Affiliation(s)
- Kyo Chul Koo
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Young Eun Yoon
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Ha Chung
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Joon Hong
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Koon Ho Rha
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea.
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Saleh F, Jackson TD, Ambrosini L, Gnanasegaram JJ, Kwong J, Quereshy F, Okrainec A. Perioperative nonselective non-steroidal anti-inflammatory drugs are not associated with anastomotic leakage after colorectal surgery. J Gastrointest Surg 2014; 18:1398-404. [PMID: 24912914 DOI: 10.1007/s11605-014-2486-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 02/13/2014] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Recent evidence raises concern about the use of perioperative non-steroidal anti-inflammatory drug (NSAID) use after colorectal resection. The purpose of this retrospective cohort study was to investigate the relationship between perioperative ketorolac use and anastomotic leakage after colorectal surgery. METHODS A retrospective review (2004-2011) was performed on patients who underwent elective colorectal surgery. Univariate analysis and multivariate logistic regression were used to evaluate the association between patients who did not receive any NSAIDs and those who received ketorolac within the first 5 days perioperatively and leak rate. RESULTS A total of 731 patients were identified as having resection with primary anastomosis: 376 (51.4 %) received no NSAIDs and 355 (48.6 %) received ketorolac perioperatively within 5 days after their surgery. There were 24 (3.3 %) leaks, with 12 in both the no NSAIDs (3.2 %) and ketorolac (3.4 %) groups, odds ratio (OR) 1.06 (0.43, 2.62; p = 0.886). Adjusting for smoking, steroid use, and age, there remained no significant difference between ketorolac use and leakage, OR 1.21 (0.52, 2.84; p = 0.660). In our multivariate model, only smoking was a significant predictor of postoperative leak, OR 3.34 (1.30, 8.62; p = 0.021). CONCLUSIONS There does not appear to be a significant association between perioperative ketorolac use and anastomotic leakage after colorectal surgery. However, further prospective studies are needed to confirm our findings before definitive guidelines on NSAID use perioperatively can be recommended.
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Affiliation(s)
- Fady Saleh
- Division of General Surgery, University Health Network, 399 Bathurst St, 8-MP 325A, Toronto, ON, M5T 2S8, Canada
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59
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Abstract
The effective relief of pain is of the utmost importance to anyone treating patients undergoing surgery. Pain relief has significant physiological benefits; hence, monitoring of pain relief is increasingly becoming an important postoperative quality measure. The goal for postoperative pain management is to reduce or eliminate pain and discomfort with a minimum of side effects. Various agents (opioid vs. nonopioid), routes (oral, intravenous, neuraxial, regional) and modes (patient controlled vs. "as needed") for the treatment of postoperative pain exist. Although traditionally the mainstay of postoperative analgesia is opioid based, increasingly more evidence exists to support a multimodal approach with the intent to reduce opioid side effects (such as nausea and ileus) and improve pain scores. Enhanced recovery protocols to reduce length of stay in colorectal surgery are becoming more prevalent and include multimodal opioid sparing regimens as a critical component. Familiarity with the efficacy of available agents and routes of administration is important to tailor the postoperative regimen to the needs of the individual patient.
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Affiliation(s)
- Veerabhadram Garimella
- Division of Colorectal Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Christina Cellini
- Division of Colorectal Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
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60
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Pergolizzi JV, Pappagallo M, LeQuang J, Labhsetwar S, Taylor R. New health care measures: emphasis on better management of postsurgical pain and postoperative nausea and vomiting. Hosp Pract (1995) 2014; 42:65-74. [PMID: 24566598 DOI: 10.3810/hp.2014.02.1093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Value-based purchasing and the Hospital Consumer Assessment of Healthcare Providers and Systems are tying patient-centric measures to reimbursements. Hospitals should be particularly concerned about management of postoperative pain and control of postoperative nausea and vomiting (PONV), known to adversely impact overall patient satisfaction. Anesthesiologists are likely to be on the frontlines of these transitions. Although postoperative pain is not always effectively managed, clinicians have the pharmacological tools and guidelines for better pain control. Considerable work has been done in PONV to better identify high-risk patients and effective prophylactic agents. Postoperative pain control and preventing PONV are two relatively straightforward ways to respond to new quality metrics. The aim of this review is to raise practitioner awareness of these new quality metrics and provide an overview of the current tools and methods used to improve postoperative pain control and PONV.
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Affiliation(s)
- Joseph V Pergolizzi
- Adjunct Professor of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Associate Professor of Pharmacology, TemplenUniversity School of Medicine, Philadelphia, PA
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Vadivelu N, Gowda AM, Urman RD, Jolly S, Kodumudi V, Maria M, Taylor R, Pergolizzi JV. Ketorolac tromethamine - routes and clinical implications. Pain Pract 2014; 15:175-93. [PMID: 24738596 DOI: 10.1111/papr.12198] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 01/27/2014] [Indexed: 11/29/2022]
Abstract
Opioids have long been used for analgesic purposes for a wide range of procedures. However, the binding of these drugs to opiate receptors has created various challenges to the clinician due to unfavorable side effect profiles and the potential for tolerance and abuse. In 1989, ketorolac became an approved nonsteroidal inflammatory drug (NSAID) for injectable use as an analgesic. Over the last 20 years, numerous studies have been conducted involving ketorolac. These studies have provided additional information about various routes of administration and their effect on the efficacy and the side effect profile of ketorolac. Moreover, ketorolac has been compared with several widely used analgesics. This review evaluates both the potential benefits and potential drawbacks of ketorolac generally, and specifically discusses routes of administration, including their advantages and disadvantages when compared to several traditional analgesics in both inpatient and outpatient settings.
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Affiliation(s)
- Nalini Vadivelu
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
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62
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Barletta JF, Senagore AJ. Reducing the Burden of Postoperative ileus: Evaluating and Implementing an Evidence-based Strategy. World J Surg 2014; 38:1966-77. [DOI: 10.1007/s00268-014-2506-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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63
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Gritsenko K, Khelemsky Y, Kaye AD, Vadivelu N, Urman RD. Multimodal therapy in perioperative analgesia. Best Pract Res Clin Anaesthesiol 2014; 28:59-79. [PMID: 24815967 DOI: 10.1016/j.bpa.2014.03.001] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 02/26/2014] [Accepted: 03/04/2014] [Indexed: 12/22/2022]
Abstract
This article reviews the current evidence for multimodal analgesic options for common surgical procedures. As perioperative physicians, we have come a long way from using only opioids for postoperative pain to combinations of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), selective Cyclo-oxygenase (COX-2) inhibitors, local anesthetics, N-methyl-d-aspartate (NMDA) receptor antagonists, and regional anesthetics. As discussed in this article, many of these agents have decreased narcotic requirements, improved patient satisfaction, and decreased postanesthesia care unit (PACU) times, as well as morbidity in the perioperative period.
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Affiliation(s)
- Karina Gritsenko
- Department of Anesthesiology, Montefiore Medical Center, Bronx, New York, NY, USA; Department of Family and Social Medicine, Montefiore Medical Center, Bronx, New York, NY, USA; Acute Pain, Regional, Chronic Pain, Montefiore Medical Center, Bronx, New York, NY, USA; Albert Einstein College of Medicine, Yeshiva University, Montefiore Medical Center, Bronx, New York, NY, USA.
| | - Yury Khelemsky
- Anesthesiology, Icahn School of Medicine of Mount Sinai, New York, NY, USA; Pain Medicine Fellowship Program, Icahn School of Medicine of Mount Sinai, New York, NY, USA
| | - Alan David Kaye
- Department of Anesthesiology, LSU School of Medicine, New Orleans, LA, USA; Interventional Pain Services, LSU School of Medicine, New Orleans, LA, USA; Department of Pharmacology, LSU School of Medicine, New Orleans, LA, USA; Department of Anesthesiology, Tulane School of Medicine, New Orleans, LA, USA; Department of Pharmacology, Tulane School of Medicine, New Orleans, LA, USA
| | - Nalini Vadivelu
- Anesthesiology Department, Yale University School of Medicine, New Haven, CT, USA
| | - Richard D Urman
- Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Brigham and Women's Hospital, USA
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Thing M, Lu Y, Ågårdh L, Larsen C, Østergaard J, He W, Wu W, Larsen F, Larsen SW. Prolonged naproxen joint residence time after intra-articular injection of lipophilic solutions comprising a naproxen glycolamide ester prodrug in the rat. Int J Pharm 2013; 451:34-40. [DOI: 10.1016/j.ijpharm.2013.04.056] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Revised: 04/16/2013] [Accepted: 04/17/2013] [Indexed: 10/26/2022]
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65
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Wallström Å, Frisman GH. Facilitating early recovery of bowel motility after colorectal surgery: a systematic review. J Clin Nurs 2013; 23:24-44. [DOI: 10.1111/jocn.12258] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2013] [Indexed: 12/15/2022]
Affiliation(s)
- Åsa Wallström
- Department of Surgery; County Council of Östergötland; Linköping Sweden
| | - Gunilla Hollman Frisman
- Division of Nursing Science; Department of Medicine and Health; Faculty of Health Science; Linköping Sweden
- Anaesthetics, Operations and Speciality Surgery Centre; County Council of Östergötland; Linköping Sweden
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A case-control study of risk factors for ileus and bowel obstruction following benign gynecologic surgery. Int J Gynaecol Obstet 2013; 122:108-11. [DOI: 10.1016/j.ijgo.2013.03.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 02/28/2013] [Accepted: 04/19/2013] [Indexed: 11/23/2022]
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Vather R, Trivedi S, Bissett I. Defining postoperative ileus: results of a systematic review and global survey. J Gastrointest Surg 2013; 17:962-72. [PMID: 23377782 DOI: 10.1007/s11605-013-2148-y] [Citation(s) in RCA: 322] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 01/16/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is a lack of an internationally accepted standardised clinical definition for postoperative ileus (POI). This has made it difficult to estimate incidence and identify risk factors and has compromised external validity of clinical trials. AIM To clarify terminology of POI and propose concise, clinically quantifiable definitions. METHODS A systematic review extracted definitions from randomised trials published between 1996 and 2011 investigating POI after abdominal surgery. This was followed by a global survey seeking opinions of those who have published in the field. RESULTS Definitions were extracted from 52 identified trials. Responses were received in the survey from 45 of 118 corresponding authors. Data were amalgamated to synthesise the following definitions: postoperative ileus (POI) "interval from surgery until passage of flatus/stool AND tolerance of an oral diet"; prolonged POI "two or more of nausea/vomiting, inability to tolerate oral diet over 24 h, absence of flatus over 24 h, distension, radiologic confirmation occurring on or after day 4 postoperatively without prior resolution of POI"; recurrent POI "two or more of nausea/vomiting, inability to tolerate oral diet over 24 h, absence of flatus over 24 h, distension, radiologic confirmation, occurring after apparent resolution of POI". Concordance of the latter two definitions with survey responses were ≥75 %. CONCLUSION We have proposed standardised endpoints for use in future studies to facilitate objective comparison of competing interventions.
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Affiliation(s)
- Ryash Vather
- Department of Surgery, University of Auckland, Auckland, New Zealand
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68
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Nonsteroidal anti-inflammatory drugs and anastomotic dehiscence in bowel surgery: systematic review and meta-analysis of randomized, controlled trials. Dis Colon Rectum 2013; 56:126-34. [PMID: 23222290 DOI: 10.1097/dcr.0b013e31825fe927] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs are a key component of contemporary perioperative analgesia. Recent experimental and observational clinical data suggest an associated increased incidence of anastomotic dehiscence in bowel surgery. OBJECTIVE The aim of this study was to conduct a systematic review and meta-analysis of anastomotic dehiscence in randomized, controlled trials of perioperative nonsteroidal anti-inflammatory drugs. DATA SOURCES Published and unpublished trials in any language reported 1990 or later were identified by searching electronic databases, bibliographies, and relevant conference proceedings. STUDY SELECTION Trials of adults undergoing bowel surgery randomly assigned to perioperative nonsteroidal anti-inflammatory drugs or control were included. The number of patients with a bowel anastomosis and the incidence of anastomotic dehiscence had to be reported or be available from authors for the study to be included. INTERVENTION At least 1 dose of a nonsteroidal anti-inflammatory drug was given perioperatively within 48 hours of surgery. MAIN OUTCOME MEASURES The primary outcome measured was 30-day incidence of anastomotic dehiscence as defined by authors. RESULTS Six trials comprising 480 patients having a bowel anastomosis met inclusion criteria. In 4 studies, anastomotic dehiscence rates were higher in the intervention groups. Overall rates were 14/272 participants (5.1%) in intervention arms vs 5/208 (2.4%) in control arms. Peto OR was 2.16 (95% CI 0.85, 5.53; p = 0.11), and there was no heterogeneity between studies (I statistic 0%). LIMITATIONS Sizes of available trials were small, preventing firm conclusions and subset analysis of drugs of different cyclooxygenase specificity. A precise and consistent definition of anastomotic dehiscence was not used across trials. CONCLUSIONS A statistically significant difference in incidence of anastomotic dehiscence was not demonstrated. However, the Peto OR of 2.16 (0.85, 5.53) and lack of heterogeneity between trials suggest that this finding may be due to a lack of power of the available data rather than a lack of effect.
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69
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He A, Hersh EV. A review of intranasal ketorolac tromethamine for the short-term management of moderate to moderately severe pain that requires analgesia at the opioid level. Curr Med Res Opin 2012; 28:1873-80. [PMID: 23098098 DOI: 10.1185/03007995.2012.744302] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND An intranasal (IN) formulation of ketorolac was recently FDA approved in adult patients for the short-term management of moderate to moderately severe pain that requires analgesia at the opioid level. SCOPE The aim of this paper is to provide an overview of the clinical pharmacology, pharmacokinetics, efficacy, and tolerability of IN ketorolac. Databases used for this literature search include PubMed, International Pharmaceutical Abstracts, Cochrane Library and ClinicalTrials.gov from January 1980 to January 2012. All primary papers on IN ketorolac were eligible, including pharmacologic, pharmacokinetic, clinical, outcomes, and meta-analyses. The approved product labeling was a source of information, as well as the bibliographies of published articles which were reviewed for additional pertinent literature. FINDINGS The search yielded six relevant studies all of which were selected for this review and included efficacy and safety trials, one pharmacokinetics study, and one preclinical study. IN ketorolac is a non-steroidal inflammatory drug that exhibits its effect mainly by inhibiting cyclo-oxygenase (COX) 1 and 2 with high affinity for COX-1. Absorption of IN ketorolac displays a median t(max) of 0.50-0.75 hours and has a t(½) of approximately 5-6 hours. Primary analyses included evaluation of morphine use and summed pain intensity difference (SPID) which was assessed using a visual analog scale. In one of the two phase III studies, the mean SPID6 score was 83.3 in the IN ketorolac group versus 37.2 in the placebo group, p = 0.007. In another phase III study, the mean SPID6 score was 117.4 in the IN ketorolac group versus 89.9 in the placebo group, p = 0.032. IN ketorolac was well-tolerated with most adverse events associated with the route of administration. CONCLUSION Based on the clinical trials reviewed, IN ketorolac was associated with significant pain reduction in patients with various post-operative procedures, with good tolerability.
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Affiliation(s)
- Andy He
- College of Pharmacy and Health Sciences, St. John's University, Queens, NY 11439, USA.
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Patel S, Lutz JM, Panchagnula U, Bansal S. Anesthesia and perioperative management of colorectal surgical patients - A clinical review (Part 1). J Anaesthesiol Clin Pharmacol 2012; 28:162-71. [PMID: 22557737 PMCID: PMC3339719 DOI: 10.4103/0970-9185.94831] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Colorectal surgery is commonly performed for colorectal cancer and other pathology such as diverticular and inflammatory bowel disease. Despite significant advances, such as laparoscopic techniques and multidisciplinary recovery programs, morbidity and mortality remain high and vary among surgical centers. The use of scoring systems and assessment of functional capacity may help in identifying high-risk patients and predicting complications. An understanding of perioperative factors affecting colon blood flow and oxygenation, suppression of stress response, optimal fluid therapy, and multimodal pain management are essential. These fundamental principles are more important than any specific choice of anesthetic agents. Anesthesiologists can significantly contribute to enhance recovery and improve the quality of perioperative care.
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Affiliation(s)
- Santosh Patel
- Department of Anaesthesia, Consultant Anaesthetist, The Pennine Acute Hospitals NHS Trust, Rochdale, UK
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Amlong CA, Schroeder KM, Andrei AC, Han S, Donnelly MJ. The analgesic efficacy of transversus abdominis plane blocks in ileostomy takedowns: a retrospective analysis. J Clin Anesth 2012; 24:373-7. [DOI: 10.1016/j.jclinane.2011.10.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Revised: 09/28/2011] [Accepted: 10/09/2011] [Indexed: 10/28/2022]
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Retrospective evaluation of inpatient celecoxib use after total hip and knee arthroplasty at a Veterans Affairs Medical Center. J Arthroplasty 2012; 27:1033-40. [PMID: 22386610 DOI: 10.1016/j.arth.2012.01.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 01/20/2012] [Indexed: 02/01/2023] Open
Abstract
A retrospective cohort study (1.5 years) was performed to investigate the efficacy of celecoxib vs non-celecoxib use in patient who underwent total knee arthroplasty (TKA) and total hip arthroplasty (THA). Study time frame encompassed a pre and post period of a local policy decision opening access to short-term celecoxib use after TKA/THA. Primary end point was the amount of opioid use during their inpatient stay postprocedure. The TKA (n = 81) and THA (n = 60) groups were analyzed independently. Both celecoxib groups used significantly less opioids during their inpatient stay vs noncelecoxib groups, given in oral morphine milligram equivalents (TKA: 203 vs 337 mg, P = .002; THA: 214 vs 336 mg, P = .005). Other secondary outcome measures showed that the celecoxib groups also reported reduction in pain scores, total as needed (PRN) opioid doses, PRN opioid doses per day, average dose of PRN opioids, total PRN opioids, use of intravenous opioids, and rehabilitation facility admissions (in the TKA group only). Linear regression analysis showed a statistically significant inverse relationship between opioid consumption and age. Short-term celecoxib use after TKA/THA may lead to a reduction in overall opioid use and improved pain scores; however, further studies will be required to validate the results of this study.
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73
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Perioperative bowel management for gynecologic surgery. Am J Obstet Gynecol 2011; 205:309-14. [PMID: 21704963 DOI: 10.1016/j.ajog.2011.05.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Revised: 04/19/2011] [Accepted: 05/05/2011] [Indexed: 11/23/2022]
Abstract
Postoperative intestinal care after major gynecologic surgery has changed considerably. The purpose of this review was to describe these changes. Our findings are that (1) preoperative mechanical bowel preparation does not lower the risk of anastomotic leakage and infection, (2) elective postoperative nasogastric tube decompression increases postoperative pneumonia and does not decrease the incidence of other postoperative complications, (3) early feeding after major gynecologic surgery reduces hospital stay and does not increase (and may decrease) pneumonia and other postoperative complications, and (4) early feeding, gum chewing, bowel stimulation, alvimopan, and ketorolac may decrease the incidence of postoperative ileus.
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American Society for Pain Management Nursing Guidelines on Monitoring for Opioid-Induced Sedation and Respiratory Depression. Pain Manag Nurs 2011; 12:118-145.e10. [DOI: 10.1016/j.pmn.2011.06.008] [Citation(s) in RCA: 171] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 06/28/2011] [Accepted: 06/28/2011] [Indexed: 11/21/2022]
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Fanning J, Hojat R. Safety and Efficacy of Immediate Postoperative Feeding and Bowel Stimulation to Prevent Ileus After Major Gynecologic Surgical Procedures. J Osteopath Med 2011; 111:469-72. [DOI: 10.7556/jaoa.2011.111.8.469] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Abstract
Context: Postoperative ileus is a major complication of abdominal surgical procedures
Objective: To evaluate the incidence of ileus and gastrointestinal morbidity in patients who received immediate postoperative feeding and bowel stimulation after undergoing major gynecologic surgical procedures.
Methods: During a 5-year period, the authors tracked demographic, surgical outcome, and follow-up information for 707 patients who underwent major gynecologic operations. All patients received the same postoperative orders, including immediate feeding of a diet of choice and bowel stimulation with 30 mL of magnesium hydroxide (milk of magnesia) twice daily until bowel movements occurred.
Results: Of 707 patients, 6 (<1%) had postoperative ileus. No patients experienced postoperative bowel obstruction and 2 patients (0.3%) had postoperative intestinal leak. No serious adverse effects associated with bowel stimulation were reported.
Conclusion: Immediate postoperative feeding and bowel stimulation is a safe and effective approach to preventing ileus in patients who undergo major gynecologic surgical procedures.
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Maxson PM, Lovely JK, Wrobleski DM, Isaacson EC. Using evidence to enhance the recovery of patients undergoing colorectal surgery: part 2. J Contin Educ Nurs 2011; 42:197-8. [PMID: 21534509 DOI: 10.3928/00220124-20110421-03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This is the second part of a three-part series describing how an enhanced recovery clinical pathway uses a multidisciplinary team to reduce postoperative stress and complications, improve recovery, and decrease hospital length of stay without affecting patient safety for patients undergoing colorectal surgery. Last month, patient education and discharge planning were discussed. This part discusses multimodal analgesia and standardized postoperative nausea and vomiting prophylaxis. Next month, fluids, diet, tubes and drains, and early mobilization will be discussed.
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Davis MP. Opioid tolerance and hyperalgesia: basic mechanisms and management in review. PROGRESS IN PALLIATIVE CARE 2011. [DOI: 10.1179/174329111x13045147380537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Lee TG, Kang SB, Kim DW, Hong S, Heo SC, Park KJ. Comparison of early mobilization and diet rehabilitation program with conventional care after laparoscopic colon surgery: a prospective randomized controlled trial. Dis Colon Rectum 2011; 54:21-8. [PMID: 21160309 DOI: 10.1007/dcr.0b013e3181fcdb3e] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Although laparoscopic surgery may permit earlier recovery compared with open surgery, no published randomized controlled trial has investigated the benefit of a multimodal rehabilitation program after laparoscopic colonic resection. This study aimed to evaluate the efficacy of a rehabilitation program after laparoscopic colon surgery in the context of a randomized controlled trial. METHODS Between September 2007 and October 2009, 100 patients who had received laparoscopic colon surgery were selected for the study and randomly assigned on a 1:1 basis to a rehabilitation program group with early mobilization and diet (n = 46) or conventional care group (n = 54). The rehabilitation program group received early oral feeding, early ambulation, and regular laxative. The primary outcome was recovery time, measured with criteria of tolerable diet for 24 hours, safe ambulation, analgesic-free, and afebrile status without major complications. Secondary outcomes were postoperative hospital stay, complications, quality of life by Short Form 36, pain by visual analog scale, and readmission. This study was registered (ID number NCT00606944, http://register.clinicaltrials.gov). RESULTS Recovery time was shorter in the rehabilitation program group than in the conventional care group (median (interquartile range), 4 (3-5) d vs 6 (5-7) d, respectively; P < .0001). There was no difference in postoperative hospital stay between the 2 groups (rehabilitation program group, 7 (6-8) d vs conventional care group, 8 (7-9) d; P = .065). There was no difference in complication rates between the rehabilitation program group and conventional care group (10.9% vs 20.4%, respectively; P = .136). Quality of life and pain were similar in both groups. There were no readmissions or mortality. CONCLUSIONS A rehabilitation program with early mobilization and diet after laparoscopic colon surgery results in reduced recovery time without increased complications. These results suggest that a multimodal rehabilitation program may increase the short-term benefits after laparoscopic colon surgery.
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Affiliation(s)
- Taek-Gu Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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Leslie JB, Viscusi ER, Pergolizzi JV, Panchal SJ. Anesthetic Routines: The Anesthesiologist's Role in GI Recovery and Postoperative Ileus. Adv Prev Med 2010; 2011:976904. [PMID: 21991449 PMCID: PMC3168940 DOI: 10.4061/2011/976904] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Accepted: 11/13/2010] [Indexed: 12/22/2022] Open
Abstract
All patients undergoing bowel resection experience postoperative ileus, a transient cessation of bowel motility that prevents effective transit of intestinal contents or tolerance of oral intake, to varying degrees. An anesthesiologist plays a critical role, not only in the initiation of surgical anesthesia, but also with the selection and transition to effective postoperative analgesia regimens. Attempts to reduce the duration of postoperative ileus have prompted the study of various preoperative, perioperative, and postoperative regimens to facilitate gastrointestinal recovery. These include modifiable variables such as epidural anesthesia and analgesia, opioid-sparing anesthesia and analgesia, fluid restriction, colloid versus crystalloid combinations, prokinetic drugs, and use of the new peripherally acting mu-opioid receptor (PAM-OR) antagonists. Review and appropriate adaptation of these multiple modifiable interventions by anesthesiologists and their surgical colleagues will facilitate implementation of a best-practice management routine for bowel resection procedures that will benefit the patient and the healthcare system.
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Affiliation(s)
- John B Leslie
- Department of Anesthesiology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259-5404, USA
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Current world literature. Neuroanaesthesia. Pain medicine. Regional anaesthesia. Curr Opin Anaesthesiol 2010; 23:671-8. [PMID: 20811177 DOI: 10.1097/aco.0b013e32833f3f68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Bapuji SB, Sawatzky JAV. Understanding weight loss in patients with colorectal cancer: a human response to illness. Oncol Nurs Forum 2010; 37:303-10. [PMID: 20439214 DOI: 10.1188/10.onf.303-310] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE/OBJECTIVES To provide a comprehensive overview of weight loss in patients with colorectal cancer (CRC) within the context of the Human Response to Illness (HRTI) model. DATA SOURCES Research from 1990-2008 and classic research from the 1980s were included. PubMed, CINAHL(R), and Google Scholar were searched for the terms cancer, CRC, weight loss, and cancer cachexia. DATA SYNTHESIS Progressive, unintentional weight loss is a common issue in patients with CRC that has a devastating effect on patients' self-image, quality of life, and survival. Physiologic abnormalities, responses to the tumor, and treatments contribute to weight loss in these patients. In addition, cancer cachexia is an end-stage wasting syndrome and a major cause of morbidity and mortality in this population. CONCLUSIONS The HRTI model provides an appropriate framework to gain a comprehensive understanding of the physiologic, pathophysiologic, behavioral, and experiential perspectives of weight loss and cancer cachexia in patients with CRC. IMPLICATIONS FOR NURSING By examining weight loss in patients with CRC within the context of the four perspectives of the HRTI model, oncology and gastroenterology nurses can gain insight into optimal, evidence-based assessment and management of this patient population. In addition, current gaps in knowledge can be identified and provide guidance for future nursing research.
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Higher pain scores, similar opioid doses and side effects associated with antipyretic analgesics in specialised tertiary pain care. Inflamm Res 2010; 59:989-95. [PMID: 20490889 DOI: 10.1007/s00011-010-0215-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Revised: 04/22/2010] [Accepted: 04/29/2010] [Indexed: 01/10/2023] Open
Abstract
PURPOSE To evaluate whether non-opioid antipyretic analgesics are associated with lower pain scores, opioid doses and side effects in pain patients in tertiary care. METHODS In a cross-sectional observational study, data from 519 Caucasians (197 men, 322 women; mean age 55.6 ± 15 years) who had undertaken pain therapy for various causes for 77.5 ± 90.8 months, obtained in three separate study centres, was analysed for actual 24-h pain scores, daily opioid doses and the occurrence of side effects. RESULTS Of the 519 patients, 352 received opioids and 260 antipyretic analgesics, from whom 154 received both classes and 304 only either class. The administration of non-opioid antipyretic analgesics was associated with higher average pain scores (4.6 ± 2.5 vs 3.9 ± 2.6; P = 0.01), tendentially higher average oral morphine equivalent doses (121.8 ± 162.2 vs 146.7 ± 242.4 mg/d; P = 0.25) and a similar incidence of side effects (P = 0.21). These results were correspondingly seen when analysing the three study centres separately as independent cohorts. CONCLUSIONS With the caution advised for cross-sectional data, the results dispute a clinical benefit of non-opioid antipyretic analgesics for most chronic pain patients in tertiary care and draw attention towards prospectively re-evaluating the utility of non-opioid antipyretic analgesics in tertiary pain care in a randomised placebo controlled trial.
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