Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain

Analgesic benefit of metamizole and ibuprofen vs. either medication alone: a randomized clinical trial

BACKGROUND

Postoperative pain relief remains a key problem after surgery. Multimodal pain therapy has proven beneficial in alleviating pain to a certain extent. However, when combining non-opioids, the focus has been on NSAIDs and paracetamol, but effects of combined use are only moderate. Metamizole could be a potent adjunct, due to its preclusion in several countries, data on its combined use are sparse, despite its common use in many countries. The aim of this study was to examine whether the combination of metamizole and ibuprofen is superior in relieving postoperative pain to either drug alone.

METHODS

For this randomized, placebo-controlled, cross-over study, 35 patients undergoing bilateral lower third molar extraction were randomized. Each patient received three applications of 1000mg metamizole + 400mg ibuprofen for surgery on one side and either 1000mg metamizole + placebo or 400mg ibuprofen + placebo on the other side. Pain ratings, rescue-medication (tramadol), and sleep were assessed for 18 hours.

RESULTS

The combined treatment of metamizole and ibuprofen showed lower mean pain scores over 12 hours than ibuprofen (2.4±1.3 vs 3.8±1.6; P=0.005)). Further, combined treatment showed lower mean pain scores over 6 hours than ibuprofen (2.0±1.2 vs. 3.1±1.6; P=0.022) or metamizole alone (2.0±1.2 vs. 3.3±1.7; P=0.015). Consumption of rescue medication was lowest in the combination-group (25% vs. 46%-metamizole; 50%-ibuprofen). The trial was stopped prematurely as the COVID-pandemic halted elective surgeries.

CONCLUSIONS

Combined use enables superior pain control compared to ibuprofen after molar extraction and tends to be superior to metamizole alone. The premature study-termination may overestimate this effect.

Pain Management of Acute and Chronic Postoperative Pain

Inadequate management of acute postoperative pain is associated with effects related to both physiological and psychological function. Postoperative pain increases the risk of perioperative complications, so postoperative pain should be prevented. Postoperative pain management by sufficient analgesia is important while considering the use of various kinds of analgesics. Insufficient management of postoperative pain may lead to chronic postsurgical pain (CPSP). It is suggested that CPSP is dependent not only upon biological factors but also upon psychological factors, including the type of surgery, age, physical health, mental health, and preoperative pain. As CPSP is a severe complication that may prolong hospitalization and interferes with activities of daily living (ADL) and quality of life (QoL), its prevention of development is paramount. Therefore, in order to prevent the onset of CPSP, it is necessary to craft analgesic management to prevent CPSP during the perioperative period.

Population Pharmacokinetic Modelling of Acetaminophen and Ibuprofen: the Influence of Body Composition, Formulation and Feeding in Healthy Adult Volunteers

BACKGROUND AND OBJECTIVE

Combined acetaminophen and ibuprofen are common antipyretic and analgesic drugs. Formulation and feeding affect drug absorption. Drug clearance has a nonlinear relationship with total body weight. The covariate effect of fat mass on acetaminophen and ibuprofen pharmacokinetics remains unexplored. This study sought to quantify acetaminophen and ibuprofen pharmacokinetics with intravenous, tablet, sachet and oral suspension formulations in fed and fasted states.

METHODS

Pooled time-concentration data for acetaminophen and ibuprofen were available from fasting and fed healthy adults. Data from intravenous, tablet, sachet and suspension formulations were analysed using nonlinear mixed-effects models. Body composition was considered as a covariate on clearances and volumes of distribution (V_d). Size metrics investigated were total body weight, fat and fat-free mass. Theory-based allometry was used to scale pharmacokinetic parameters to a 70 kg individual. A factor on absorption half-life and lag time quantified delays due to feeding for oral formulations. Pharmacokinetic-pharmacodynamic simulations were used to explore the time courses of pain response for acetaminophen and ibuprofen for each formulation.

RESULTS

Pooled data included 116 individuals (18-49 years, 49-116 kg) with 6095 acetaminophen and 6046 ibuprofen concentrations available for analysis. A two-compartment pharmacokinetic model with first-order elimination described disposition for both drugs. Normal fat mass was the best covariate to describe acetaminophen clearance (CL), with a factor for fat contribution (FFATCL) of 0.816. Acetaminophen volume of distribution was described using total body weight. Normal fat mass was the best covariate to describe ibuprofen clearance (FFATCL = 0.863) and volume of distribution: (FFATV = 0.718). Clearance and central volume of distribution were 24.0 L/h/70 kg and 43.5 L/h/70 kg for acetaminophen. Ibuprofen clearance and central volume of distribution were 3.79 L/h/70 kg and 10.5 L/h/70 kg. Bioavailability and absorption half-life were 86% and 12 min for acetaminophen and 94% and 27 min for ibuprofen. Absorption lag times were 5.3 min and 6.7 min for acetaminophen and ibuprofen, respectively. Feeding increased both absorption half-life and absorption lag time when compared to the tablet formulation under fasting conditions. Feeding had the most pronounced effect on the lag time associated with tablet formulation for both drugs. Time to a pain score reduction of 2 points (visual analogue score, 0-10) differed by only 5-10 min across all formulations for acetaminophen and ibuprofen.

CONCLUSION

Fat mass was an important covariate to describe acetaminophen and ibuprofen pharmacokinetics. The absorption half-lives of acetaminophen and ibuprofen were increased in fed states. The delay in absorption, quantified by a lag time, was protracted for both drugs.

Children undergoing outpatient complex penile surgery and hypospadias repair may not require opioid analgesics

BACKGROUND/PURPOSE

Pain control is important after penile surgery, and opioid use should be minimized as able. We sought to describe our experience performing complex penile surgeries with vs without post-operative opioids.

METHODS

A retrospective review of penile surgeries, including 3998 between 2009 and 2019. We identified patients <8 years who underwent outpatient penile surgery requiring either penile degloving or hypospadias repair. Patients who were or were not prescribed opioids were matched 1:1 by age and type of penile surgery. Primary outcomes of interest were pain-related encounters, delayed opioid prescription, and predictors of pain.

RESULTS

200 children were identified, 100 per group, with mean age 1.3 ± 0.8 years. 48% were penile degloving procedures, 31% hypospadias repairs with catheters, and the remaining 21% hypospadias repairs without catheters. Perioperative features were comparable between groups(p > 0.05). 59% of patients without opioids had an impromptu post-operative encounter vs 41%, and 20% had an associated pain complaint vs 9%(p = 0.026). Two patients in both groups received delayed opioid prescription(p = 1.00). The presence of a catheter (OR 2.9) and no opioid prescription (OR 2.6) were independent predictors for pain complaint.

CONCLUSIONS

Patients discharged without an opioid were more likely to contact a provider postoperatively and were more likely to endorse pain complaint (number needed to treat: 9).

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyzes, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Efficacy of Preemptive Analgesia on Tourniquet and Postoperative Pain Relief in Open Carpal Tunnel Release: A Prospective Randomized Control Trial

BACKGROUND

Preemptive analgesia has been used to reduce postsurgery pain and improve patient satisfaction. The effectiveness of multimodal preemptive analgesia in open carpal tunnel release under local anesthetic with a tourniquet is still debated. This study aimed to determine the effectiveness of preemptive analgesia on the postoperative tourniquet site and the surgical site.

METHODS

A total of 44 patients were randomly assigned to one of 2 groups. An experimental group was given 300 mg of gabapentin, 200 mg of celecoxib, and 500 mg of acetaminophen 2 hours before surgery. Placebos were given to the control group. All surgeries were done under local anesthetic by a specialist hand surgeon. A tourniquet was inflated to the recommended pressure. The outcomes included the immediate postoperative tourniquet site pain scores, surgical site pain scores (at 1, 6, 12, 18, and 24 hours after surgery), and acetaminophen consumption in the first 48 hours.

RESULT

The immediate postoperative tourniquet site pain score in the experimental group was significantly lower than in the placebo group. Although the surgical site pain score in the experimental group was significantly lower than the placebo group at 1, 6, 12, and 18 hours after surgery, these differences were not clinically significant. In addition, there was no statistically significant difference in surgical site pain score at 24 hours after surgery. The amount of acetaminophen consumed during the first 48 hours after surgery was significantly lower in the experimental group than in the placebo group.

CONCLUSION

Multimodal preemptive analgesia effectively reduced immediate postoperative pain at the tourniquet site in open carpal tunnel release. It also reduced postoperative acetaminophen consumption.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Visualizing Opioid-Use Variation in a Pediatric Perioperative Dashboard

BACKGROUND

Anesthesiologists integrate numerous variables to determine an opioid dose that manages patient nociception and pain while minimizing adverse effects. Clinical dashboards that enable physicians to compare themselves to their peers can reduce unnecessary variation in patient care and improve outcomes. However, due to the complexity of anesthetic dosing decisions, comparative visualizations of opioid-use patterns are complicated by case-mix differences between providers.

OBJECTIVES

This single-institution case study describes the development of a pediatric anesthesia dashboard and demonstrates how advanced computational techniques can facilitate nuanced normalization techniques, enabling meaningful comparisons of complex clinical data.

METHODS

We engaged perioperative-care stakeholders at a tertiary care pediatric hospital to determine patient and surgical variables relevant to anesthesia decision-making and to identify end-user requirements for an opioid-use visualization tool. Case data were extracted, aggregated, and standardized. We performed multivariable machine learning to identify and understand key variables. We integrated interview findings and computational algorithms into an interactive dashboard with normalized comparisons, followed by an iterative process of improvement and implementation.

RESULTS

The dashboard design process identified two mechanisms-interactive data filtration and machine-learning-based normalization-that enable rigorous monitoring of opioid utilization with meaningful case-mix adjustment. When deployed with real data encompassing 24,332 surgical cases, our dashboard identified both high and low opioid-use outliers with associated clinical outcomes data.

CONCLUSION

A tool that gives anesthesiologists timely data on their practice patterns while adjusting for case-mix differences empowers physicians to track changes and variation in opioid administration over time. Such a tool can successfully trigger conversation amongst stakeholders in support of continuous improvement efforts. Clinical analytics dashboards can enable physicians to better understand their practice and provide motivation to change behavior, ultimately addressing unnecessary variation in high impact medication use and minimizing adverse effects.

Nonopioid Analgesics for the Perioperative Geriatric Patient: A Narrative Review

Management of acute perioperative pain in the geriatric patient can be challenging as the physiologic and pharmacokinetic changes associated with aging may predispose older patients to opioid-related side effects. Furthermore, elderly adults are more susceptible to postoperative delirium and postoperative cognitive dysfunction, which may be exacerbated by both poorly controlled postoperative pain and commonly used pain medications. This narrative review summarizes the literature published in the past 10 years for several nonopioid analgesics commonly prescribed to the geriatric patient in the perioperative period. Nonopioid analgesics are broken down as follows: medications prescribed throughout the perioperative period (acetaminophen and nonsteroidal anti-inflammatory drugs), medications limited to the acute perioperative setting (N-methyl-D-aspartate receptor antagonists, dexmedetomidine, dexamethasone, and local anesthetics), and medications to be used with caution in the geriatric patient population (gabapentinoids and muscle relaxants). Our search identified 1757 citations, but only 33 specifically focused on geriatric analgesia. Of these, only 21 were randomized clinical trials' and 1 was a systematic review. While guidance in tailoring pain regimens that focus on the use of nonopioid medications in the geriatric patient is lacking, we summarize the current literature and highlight that some nonopioid medications may extend benefits to the geriatric patient beyond analgesia.

The Opioid Analgesic Reduction Study (OARS)-a comparison of opioid vs. non-opioid combination analgesics for management of post-surgical pain: a double-blind randomized clinical trial

Background

Everyday people die unnecessarily from opioid overdose-related addiction. Dentists are among the leading prescribers of opioid analgesics. Opioid-seeking behaviors have been linked to receipt of initial opioid prescriptions following the common dental procedure of third molar extraction. With each opioid prescription, a patient’s risk for opioid misuse or abuse increases. With an estimated 56 million tablets of 5 mg hydrocodone annually prescribed after third molar extractions in the USA, 3.5 million young adults may be unnecessarily exposed to opioids by dentists who are inadvertently increasing their patient’s risk for addiction.

Methods

A double-blind, stratified randomized, multi-center clinical trial has been designed to evaluate whether a combination of over-the-counter non-opioid-containing analgesics is not inferior to the most prescribed opioid analgesic. The impacted 3rd molar extraction model is being used due to the predictable severity of the post-operative pain and generalizability of results. Within each site/clinic and gender type (male/female), patients are randomized to receive either OPIOID (hydrocodone/acetaminophen 5/300 mg) or NON-OPIOID (ibuprofen/acetaminophen 400/500 mg). Outcome data include pain levels, adverse events, overall patient satisfaction, ability to sleep, and ability to perform daily functions. To develop clinical guidelines and a clinical decision-making tool, pain management, extraction difficulty, and the number of tablets taken are being collected, enabling an experimental decision-making tool to be developed.

Discussion

The proposed methods address the shortcomings of other analgesic studies. Although prior studies have tested short-term effects of single doses of pain medications, patients and their dentists are interested in managing pain for the entire post-operative period, not just the first 12 h. After surgery, patients expect to be able to perform normal daily functions without feeling nauseous or dizzy and they desire a restful sleep at night. Parents of young people are concerned with the risks of opioid use and misuse, related either to treatments received or to subsequent use of leftover pills. Upon successful completion of this clinical trial, dentists, patients, and their families will be better able to make informed decisions regarding post-operative pain management.

Trial registration

ClinicalTrials.govNCT04452344. Registered on June 20, 2020

How to close the gaps between evidence and practice for perioperative opioids

Excellent resources are now available that distil the best evidence around opioid prescribing in the perioperative period, including the list of recommendations provided by the international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients. While some of the recommendations have been widely accepted as an essential part of postoperative practice, others have had slow and variable adoption. This article focuses on the items where theory and practice still diverge and suggests how best to close that gap. We must also remain mindful that while education is essential, it is on the lowest rung of implementation efficacy and, on its own, is a poor driver of behaviour change. Ongoing structural nudges and the use of local procedure-specific analgesic pathways will also be helpful in addressing the gap between evidence-based recommendations and practice.

Gaps in standardized postoperative pain management quality measures: A systematic review

BACKGROUND

The goal of this study was an assessment of availability postoperative pain management quality measures and National Quality Forum-endorsed measures. Postoperative pain is an important clinical timepoint because poor pain control can lead to patient suffering, chronic opiate use, and/or chronic pain. Quality measures can guide best practices, but it is unclear whether there are measures for managing pain after surgery.

METHODS

The National Quality Forum Quality Positioning System, Agency for Healthcare Research and Quality Indicators, and Centers for Medicare and Medicaid Services Measures Inventory Tool databases were searched in November 2019. We conducted a systematic literature review to further identify quality measures in research publications, clinical practice guidelines, and gray literature for the period between March 11, 2015 and March 11, 2020.

RESULTS

Our systematic review yielded 1,328 publications, of which 206 were pertinent. Nineteen pain management quality measures were identified from the quality measure databases, and 5 were endorsed by National Quality Forum. The National Quality Forum measures were not specific to postoperative pain management. Three of the non-endorsed measures were specific to postoperative pain.

CONCLUSION

The dearth of published postoperative pain management quality measures, especially National Quality Forum-endorsed measures, highlights the need for more rigorous evidence and widely endorsed postoperative pain quality measures to guide best practices.

A multimodal approach to reducing post-caesarean opioid use: a quality improvement initiative

OBJECTIVE

To evaluate the impact of a QI initiative to reduce post-caesarean opioid use.

DESIGN

Retrospective cohort study.

SETTING

Academic hospital in the USA.

POPULATION

Women over 18 years undergoing caesarean section.

METHODS

A quality improvement (QI) initiative titled Reduced Option for Opioid Therapy (ROOT) was implemented in women undergoing caesarean section. The intervention included implementation of a postpartum order set maximising the use of scheduled NSAIDs and acetaminophen. Additionally, nursing education promoted non-opioid therapy as first-line, with opioids reserved for breakthrough pain. Performance feedback was provided to nursing staff on a bimonthly basis. Post-caesarean opioid use was reviewed in the 6 months before and after implementation of ROOT.

MAIN OUTCOME MEASURES

The primary outcome was the total morphine milligram equivalents (MME) consumed during the postpartum admission. Secondary outcomes included opioid use per postoperative day, the proportion of opioid-free admissions, the percentage of patients discharged with a prescription for opioids, prescription size, and pain scores.

RESULTS

Following implementation of ROOT, median inpatient opioid use decreased by more than 60%, from 75 to 30 MME per admission (P < 0.001). The proportion of opioid-free admissions increased from 12.6% pre-intervention to 30.7% post-intervention (P < 0.001). Additionally, the median opioid dose prescribed at discharge decreased in the post-intervention cohort, and the proportion of patients discharged without an opioid prescription increased. The reduction in opioids was associated with a slight decrease in patient-reported pain scores.

CONCLUSIONS

Implementation of ROOT significantly reduced opioid use while achieving comparable pain control.

The effect of ketorolac on posterior minimally invasive transforaminal lumbar interbody fusion: an interim analysis from a randomized, double-blinded, placebo-controlled trial

BACKGROUND CONTEXT

Postoperative pain control following posterior lumbar fusion continues to be challenging and often requires high doses of opioids for pain relief. The use of ketorolac in spinal fusion is limited due to the risk of pseudarthrosis. However, recent literature suggests it may not affect fusion rates with short-term use and low doses.

PURPOSE

We sought to demonstrate noninferiority regarding fusion rates in patients who received ketorolac after undergoing minimally invasive (MIS) posterior lumbar interbody fusion. Additionally, we sought to demonstrate ketorolac's opioid-sparing effect on analgesia in the immediate postoperative period.

STUDY DESIGN/SETTING

This is a prospective, randomized, double-blinded, placebo-controlled trial. We are reporting our interim analysis.

PATIENT SAMPLE

Adults with degenerative spinal conditions eligible to undergo a one to three-level MIS transforaminal lumbar interbody fusion (TLIF).

OUTCOME MEASURES

Six-month and 1-year radiographic fusion as determined by Suk criteria, postoperative opioid consumption as measured by intravenous milligram morphine equivalent, length of stay, and drug-related complications. Self-reported and functional measures include validated visual analog scale, short-form 12, and Oswestry Disability Index.

METHODS

A double-blinded, randomized placebo-controlled, noninferiority trial of patients undergoing 1- to 3-level MIS TLIF was performed with bone morphogenetic protein (BMP). Patients were randomized to receive a 48-hour scheduled treatment of either intravenous ketorolac (15 mg every 6 hours) or saline in addition to a standardized pain regimen. The primary outcome was fusion. Secondary outcomes included 48-hour and total postoperative opioid use demonstrated as milligram morphine equivalence, pain scores, length of stay (LOS), and quality-of-life outcomes. Univariate analyses were performed. The present study provides results from a planned interim analysis.

RESULTS

Two hundred and forty-six patients were analyzed per protocol. Patient characteristics were comparable between the groups. There was no significant difference in 1-year fusion rates between the two treatments (p=.53). The difference in proportion of solid fusion between the ketorolac and placebo groups did not reach inferiority (p=.072, 95% confidence interval, -.07 to .21). There was a significant reduction in total/48-hour mean opioid consumption (p<.001) and LOS (p=.001) for the ketorolac group while demonstrating equivalent mean pain scores in 48 hours postoperative (p=.20). There was no significant difference in rates of perioperative complications.

CONCLUSIONS

Short-term use of low-dose ketorolac in patients who have undergone MIS TLIF with BMP demonstrated noninferior fusion rates. Ketorolac safely demonstrated a significant reduction in postoperative opioid use and LOS while maintaining equivalent postoperative pain control.

Postoperative Pain Management in Enhanced Recovery Pathways

Postoperative pain is a common but often inadequately treated condition. Enhanced recovery pathways (ERPs) are increasingly being utilized to standardize perioperative care and improve outcomes. ERPs employ multimodal postoperative pain management strategies that minimize opioid use and promote recovery. While traditional opioid medications continue to play an important role in the treatment of postoperative pain, ERPs also rely on a wide range of non-opioid pharmacologic therapies as well as regional anesthesia techniques to manage pain in the postoperative setting. The evidence for the use of these interventions continues to evolve rapidly given the increasing focus on enhanced postoperative recovery. This article reviews the current evidence and knowledge gaps pertaining to commonly utilized modalities for postoperative pain management in ERPs.

Opioid Sparing Anesthesia and Enhanced Recovery After Surgery Protocol for Pancreaticoduodenectomy

Background

Opioid sparing anesthesia and enhanced recovery after surgery protocols are not innovative ideas. However, the utilization of pancreaticoduodenectomy is limited. With the rise in awareness of the opioid epidemic in the United States, we have created a multimodal approach to anesthesia and postoperative care to limit adverse effects of opioids and curb the use of opioids postoperatively.

Methods

We conducted a retrospective cohort study performed by chart review of an opioid-sparing anesthetic and enhanced recovery after surgery (ERAS) protocol initiated jointly by the anesthesiology departments and transplant surgery for pancreaticoduodenectomy from January 2017 to October 2019.

Results

Demographic data was found to be comparable between the control and protocol groups. Hospital length of stay, ICU length of stay, and opioid requirements significantly decreased in the protocol group. Hospital length of stay decreased from 8.92 to 5.72 days, ICU days decreased from 1.52 to 0.42 days, and narcotics for the first five hospital days were significantly decreased from 130.13 to 71.2 morphine milligram equivalents.

Conclusion

Proper postoperative pain management can improve patient satisfaction and decrease complication rates. Pancreaticoduodenectomy is a complicated procedure with relatively limited data regarding enhanced recovery after surgery protocols. Likewise, there is limited data regarding opioid-sparing anesthesia techniques. Our protocol produced promising hospital length of stay and reduced opioid administration during the first five hospital days without increasing 30-day readmission rates.

Is ABO Blood Group a Predictive Factor for the Amount of Opioid Consumption in the First 24 Hours After Cesarean Section?

Background

Cesarean section is the most common major surgery performed globally. Blood group O has been found as a factor affecting pain severity after cesarean section. We aimed to evaluate the predictive factors, including ABO blood group, for the amount of opioid consumption (measured as milligrams of morphine equivalent [MME]) within the first 24 hrs after cesarean section.

Methods

This retrospective study was done in 1530 pregnant women who had a cesarean section under the same regimen of spinal anesthesia (2.2 mL of 0.5% hyperbaric bupivacaine and morphine 0.2 mg). All were prescribed regular paracetamol and ibuprofen for postoperative pain control. Univariate and multinomial regression analyses were performed to identify the predictive factors for opioid consumption in the first 24 hrs postoperatively.

Results

About 2/5 of them (43.3%) received 0 mg MME, while 25.6%, 23.7% and 7.4% received 1–5, 6–10 and >10 mg MME, respectively. The majority have blood group O (40.6%), while 23.4%, 28% and 8% have blood group A, B and AB, respectively. After univariate and multinomial regression analyses, operation time, opioid consumption in PACU, maximum VNRS within the first 24 hrs and consumption of both paracetamol and ibuprofen were identified as predictive factors for postoperative opioid consumption. ABO blood group exhibited no correlation for opioid requirement postoperatively.

Conclusion

ABO blood group is not a predictive factor for opioid requirement within the first 24 hrs following cesarean section. Duration of operation, opioid given in PACU, maximum VNRS on ward and consumption of both paracetamol and ibuprofen have been found to be predictive factors for postcesarean opioid requirement.

Opioid-Free Recovery After Hernia Repair with HTX-011 as the Foundation of a Non-Opioid, Multimodal Analgesia Regimen in a Real-World Setting: A Randomized, Open-Label Study

INTRODUCTION

Helping Opioid Prescription Elimination (HOPE) is a project designed to provide surgeons with practical, real-world solutions to effectively manage postoperative pain and eliminate the need for opioids using HTX-011 (extended-release bupivacaine/low-dose meloxicam). In phase 3 herniorrhaphy and bunionectomy studies, HTX-011 without multimodal analgesia (MMA) was superior to bupivacaine hydrochloride in reducing pain and opioid consumption. Here, we examine the HOPE Hernia-1 study, which was designed to compare alternating ibuprofen/acetaminophen with concurrent use as part of an HTX-011-based non-opioid MMA regimen in patients undergoing herniorrhaphy and to evaluate the effectiveness of a personalized opioid prescription algorithm.

METHODS

Patients undergoing outpatient open inguinal herniorrhaphy with intraoperative administration of HTX-011 (300 mg bupivacaine/9 mg meloxicam) were randomly assigned to receive a scheduled oral regimen of ibuprofen plus acetaminophen, either taken together every 6 hours or alternating every 3 hours, for 5 days following surgery, while awake. Based on the opioid prescription algorithm evaluated here, patients could receive an oxycodone prescription upon discharge only if they had a numeric rating scale pain score of ≥ 6 at discharge and/or had received a postoperative rescue opioid.

RESULTS

The majority of patients did not require an opioid prescription through 2 weeks following surgery, and this was similar between cohorts (alternating MMA, 89.1%; concurrent MMA, 93.6%). Patient satisfaction was high for both regimens, and 95% of patients had an opioid-free recovery. No patient discharged without a prescription called back to request one. Treatment was well tolerated, without evidence of nonsteroidal anti-inflammatory drug-related toxicity.

CONCLUSIONS

HTX-011, used with over-the-counter products ibuprofen/acetaminophen and personalized opioid prescription algorithm in a real-world environment, has the potential to reduce opioid use and opioid prescriptions after herniorrhaphy without compromising patient satisfaction.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03237481.

Persistent Opioid Use After Cardiac Implantable Electronic Device Procedures

BACKGROUND

Prescription opioids are a major contributor to the ongoing epidemic of persistent opioid use (POU). The incidence of POU among opioid-naïve patients after cardiac implantable electronic device (CIED) procedures is unknown.

METHODS

This retrospective cohort study used data from a national administrative claims database from 2004 to 2018 of patients undergoing CIED procedures. Adult patients were included if they were opioid-naïve during the 180-day period before the procedure and did not undergo another procedure with anesthesia in the next 180 days. POU was defined by filling an additional opioid prescription >30 days after the CIED procedure.

RESULTS

Of the 143 400 patients who met the inclusion criteria, 15 316 (11%) filled an opioid prescription within 14 days of surgery. Among these patients, POU occurred in 1901 (12.4%) patients 30 to 180 days after surgery. The likelihood of developing POU was increased for patients who had a history of drug abuse (odds ratio, 1.52; P=0.005), preoperative muscle relaxant (odds ratio, 1.52; P<0.001) or benzodiazepine (odds ratio, 1.23; P=0.001) use, or opioid use in the previous 5 years (OR, 1.76; P<0.0001). POU did not differ after subcutaneous implantable cardioverter defibrillator or other CIED procedures (11.1 versus 12.4%; P=0.5). In a sensitivity analysis excluding high-risk patients who were discharged to a facility or who had a history of drug abuse or previous opioid, benzodiazepine, or muscle relaxant use, 8.9% of the remaining cohort had POU. Patients prescribed >135 mg of oral morphine equivalents had a significantly increased risk of POU.

CONCLUSIONS

POU is common after CIED procedures, and 12% of patients continued to use opioids >30 days after surgery. Higher initially prescribed oral morphine equivalent doses were associated with developing POU.

The Anti-Inflammation and Anti-Nociception Effect of Ketoprofen in Rats Could Be Strengthened Through Co-Delivery of a H2S Donor, S-Propargyl-Cysteine

PURPOSE

Ketoprofen (KETO) is a traditional non-steroidal anti-inflammatory drug (NSAIDs) with good analgesic and antipyretic effects. However, as NASIDs, the toxicity of KETO towards gastrointestinal (GI) system might limit its clinical use. S-propargyl-cysteine (SPRC) is an excellent endogenous H2S donor showed wide application in the field of anti-inflammation, anti-oxidative stress, or even the protection of cardiovascular system through the elevation of endogenous H2S concentration. As recently studies reported, co-administration of H2S donor might potentially mitigate the GI toxicity and relevant side effects induced by series of NSAIDs.

METHODS

In this study, we established a SPRC and KETO co-encapsulated poly (lactic-co-glycolic acid) microsphere (SK@MS), and its particle size, morphology, storage stability and in vitro release profile were firstly investigated. The elevation of endogenous H2S level of SK@MS was then calculated, and the pharmacodynamic study (anti-inflammation and analgesic effects) of SK@MS, SPRC, and KETO towards adjuvant induced arthritis (AIA) in rats were also studied. Finally, to test the potential side effect, the heart, liver, spleen, lung, kidney, stomach, small intestine, and large intestine were resected from rats and examined by H&E staining.

RESULTS

A monodispersed SK@MS could be observed under the SEM, and particle size was calculated around 25.12 μm. The loading efficiency (LE) for SPRC and KETO were 6.67% and 2.64%, respectively, while the encapsulation efficiency (EE) for SPRC and KETO were 37.20% and 68.28%, respectively. SK@MS showed a sustained release of SPRC and KETO in vitro, which was up-to 15 days. SK@MS could achieve a long-term elevation of the H2S concentration in vivo, while SPRC showed an instant H2S elevation and metabolize within 6 h. Interestingly, the KETO did not show any influence on the H2S concentration in vivo. After establishment of AIA model, neither SPRC nor KETO showed scarcely anti-inflammation and anti-nociception effect, while conversely, SK@MS showed an obvious mitigation towards paw edema and pain in AIA rats, which indicated an improved anti-inflammation and anti-nociception effect when co-delivery of SRC and KETO. Besides, low stimulation towards major organs in rats observed in any experimental group.

CONCLUSION

A monodispersed was successfully prepared in this study, and SK@MS showed a sustained SPRC and KETO release in vitro and H2S release in vivo. In the pharmacodynamics study, SK@MS not only exhibited an excellent anti-inflammation and analgesic effects in AIA rats but also showed low stimulation towards rats.

PROSPECT guidelines for video-assisted thoracoscopic surgery: a systematic review and procedure-specific postoperative pain management recommendations

Video‐assisted thoracoscopic surgery has become increasingly popular due to faster recovery times and reduced postoperative pain compared with thoracotomy. However, analgesic regimens for video‐assisted thoracoscopic surgery vary significantly. The goal of this systematic review was to evaluate the available literature and develop recommendations for optimal pain management after video‐assisted thoracoscopic surgery. A systematic review was undertaken using procedure‐specific postoperative pain management (PROSPECT) methodology. Randomised controlled trials published in the English language, between January 2010 and January 2021 assessing the effect of analgesic, anaesthetic or surgical interventions were identified. We retrieved 1070 studies of which 69 randomised controlled trials and two reviews met inclusion criteria. We recommend the administration of basic analgesia including paracetamol and non‐steroidal anti‐inflammatory drugs or cyclo‐oxygenase‐2‐specific inhibitors pre‐operatively or intra‐operatively and continued postoperatively. Intra‐operative intravenous dexmedetomidine infusion may be used, specifically when basic analgesia and regional analgesic techniques could not be given. In addition, a paravertebral block or erector spinae plane block is recommended as a first‐choice option. A serratus anterior plane block could also be administered as a second‐choice option. Opioids should be reserved as rescue analgesics in the postoperative period.

The Nuts and Bolts of a Successful Non-Narcotic Perioperative Enhanced Recovery After Surgery Protocol

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols are widely utilized approaches to perioperative care that advocate preoperative counseling, multimodal perioperative medication management, and early postoperative mobilization to improve post-surgical patient outcomes and satisfaction.

OBJECTIVES

The authors aimed to elucidate the mechanism by which each medication utilized in the senior author's ERAS protocol acts, determine the efficacy of this protocol in postoperative pain management, and reveal other factors that may play a role in patients' degree of postoperative pain.

METHODS

A literature review was performed on the medications utilized in the senior author's ERAS protocol. Evidence from the author's previous study on the efficacy of this regimen and anecdotal evidence regarding the psychological component of pain was also compiled.

RESULTS

There is evidence that an ERAS protocol is as effective if not more effective than regimens involving opioid medications in management of postoperative pain. These medications act synergistically to block perception of pain by multiple pathways, while minimizing adverse effects that may be associated with high doses of a single medication and are affordable for both the patient and the surgeon.

CONCLUSIONS

ERAS protocols effectively manage postoperative pain while avoiding the adverse effects associated with opioid medications. Although an emphasis has often been placed on the medications involved in various protocols and avoidance of opioid medications, appropriate counseling on patients' expectations concerning postoperative "pain" or discomfort and a systemic shift in the approach to perioperative pain are perhaps the most important components to holistic non-narcotic postoperative care.

Enhanced Recovery Pathway as a Tool in Reducing Post-operative Hospital Stay After Caesarean Section, Compared to Conventional Care in COVID Era-A Pilot Study

Objectives

To study the implementation of ERAS (Enhanced recovery after surgery) pathway and its effect on duration of post-operative hospital stay and various phases of post-operative care in comparison with conventional care group.

Materials and Method

Prospective study conducted in Amrita institute of medical sciences, Kochi, Kerala. Women planned for elective and scheduled caesarean section were included in the study from September 2020 to October 2020 and compared with women who underwent caesarean section in the same period receiving standard perioperative care. Women who underwent emergency and urgent caesarean section and patients with medical or surgical comorbidities were excluded. Surgical procedure was the same in both arms. Intravenous hydration was goal directed. Oral feeding was started with liquids after 2 hours, solids were given after 4 hours. Intravenous paracetamol and diclofenac were given routinely. Intravenous tramadol and fentanyl were given if needed apart from these analgesics. Foleys catheter was removed after 12 hours. Conventional care group observed 6 h of fasting pre- and post-operatively. Catheter was retained for 24 h, 2500 ml IV fluids were infused on the first day followed by 1000 ml on the second day. The duration of hospital stay was based on clinical criteria and care providers decision.

Results

In ERAS arm, post-operative hospital stay was significantly reduced in comparison with conventional care group. (53.91 vs 77.71 h-p = 0.00) Early feeding, early ambulation, early catheter removal, multimodal and preemptive analgesia all contributed to early recovery of the patient.

Conclusion

In ERAS pathway length of post-operative stay was significantly reduced as compared to conventional care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13224-021-01461-6.

Opioids Are Infrequently Required following Ambulatory Otologic Surgery

OBJECTIVE

To determine the frequency with which postoperative opioid prescriptions are required after ambulatory otologic surgery.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary otology-neurotology practice.

PATIENTS

Patients (n = 447) given over-the-counter acetaminophen and ibuprofen following ambulatory otologic surgery between July 1, 2018 and June 30, 2020.

INTERVENTION

Opioid prescription upon request.

MAIN OUTCOME MEASURES

Patient, disease, and surgical variables such as age, sex, past medical history, chronic pain condition, surgical procedure, primary versus (vs.) revision surgery, and endoscopic vs. microscopic approach were examined for relationship to ad hoc opioid prescription rate.

RESULTS

Of 370 adult patients (mean age 49.0 yrs, range 18.0-88.5 yrs), 75 (20.3%) were prescribed opioids for postoperative pain, most commonly oxycodone-acetaminophen 5/325 mg. Of 77 pediatric patients (mean age 8.8 yrs, range 0.7-17.9 yrs), 5 (6.5%) were prescribed postoperative opioid analgesia. In the adult population, chronic pain condition, pain medication use at baseline, canal wall up mastoidectomy, tympanoplasty, tympanomeatal flap, bone removal of the mastoid, postauricular incision, and intraoperative microscopy were independent predictors of opioid pain prescription. When controlling for all significant variables, only chronic pain condition remained significant (odds ratio = 3.94; p = 0.0007). In the pediatric population, atresiaplasty, meatoplasty, and conchal cartilage removal were independently associated with opioid prescription, but none remained significant when analyzed in a multivariate linear model.

CONCLUSIONS

Pain following ambulatory otologic surgery may be adequately managed with over-the-counter pain medications in the majority of cases. Opioids may be necessary in adults with preexisting pain conditions.

Intraoperative Dexmedetomidine and Ketamine Infusions in an Enhanced Recovery After Thoracic Surgery Program: A Propensity Score Matched Analysis

OBJECTIVES

To assess the impact of intraoperative dexmedetomidine and ketamine on postoperative pain and opioid consumption within an ERAS program in thoracic pulmonary oncologic surgery.

DESIGN

Retrospective, propensity-score matched analysis SETTING: Enhanced Recovery After Surgery (ERAS) program.

PARTICIPANTS

Patients undergoing thoracic pulmonary oncologic surgery between March 2016 and April 2020.

INTERVENTIONS

Continuous infusion of dexmedetomidine and ketamine.

MEASUREMENTS & MAIN RESULTS

The authors initially analyzed data of 1,630 patients undergoing thoracic pulmonary oncologic surgery within their ERAS program. In total, 117 matched pairs were included in this analysis. Patients in the intraoperative dexmedetomidine + ketamine group were more likely to be opioid-free (76.6% vs 60.9%, P<0.01). Raw analysis showed lower pain scores at PACU admission (2.8±2.0 vs 3.4±2.0, P=0.03) and less opioid consumption at PACU admission (5 MED [0-10] vs 7.5 MED [0-15], P=0.03) in the dexmedetomidine + ketamine group; however, these differences were not present after adjusting for multiplicity. There were no significant differences in the length of PACU stay (1.9 hours [1.5-2.8] vs 2.0 hours [1.4-2.9], P=0.48) or hospital stay (three days [two-five] vs three days [two-five], P=0.08). Both groups had similar rates of pulmonary complications (5.9% vs 9.4%, P=0.326), ileus (0.9% vs 0.9%, P=1.00), and 30-day readmission (2.6% vs 4.3%, P=0.722).

CONCLUSIONS

There were no differences in postoperative pain scores and opioid consumption throughout their hospital stay between patients receiving concomitant dexmedetomidine and ketamine infusions versus patients who did not receive these infusions during thoracic surgery.

Pediatric Urologic Surgery: Reducing Opioid Use

Adequate pain management is important for successful postoperative recovery after any surgical procedure. Unfortunately, the USA and many other parts of the world are in the midst of an opioid epidemic, and healthcare providers are thus tasked with balancing the comfort and recovery of their patients after an operation against the individual and societal harms of the over-prescription of opioids. The goal of this article is to discuss the range of opioid formulations currently in use, examine why this may be problematic, and explore alternatives that provide similar efficacy and may improve overall safety in the pediatric population after urologic surgery. Improving the way opioids are prescribed through clinical practice guidelines as well as considering alternatives to opioids can ensure patients have access to safer and more effective pain treatments and potentially reduce opioid misuse.

Pain management after complex spine surgery: A systematic review and procedure-specific postoperative pain management recommendations

BACKGROUND

Complex spinal procedures are associated with intense pain in the postoperative period. Adequate peri-operative pain management has been shown to correlate with improved outcomes including early ambulation and early discharge.

OBJECTIVES

We aimed to evaluate the available literature and develop recommendations for optimal pain management after complex spine surgery.

DESIGN AND DATA SOURCES

A systematic review using the PROcedure SPECific postoperative pain managemenT methodology was undertaken. Randomised controlled trials and systematic reviews published in the English language from January 2008 to April 2020 assessing postoperative pain after complex spine surgery using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, EMBASE and Cochrane Databases.

RESULTS

Out of 111 eligible studies identified, 31 randomised controlled trials and four systematic reviews met the inclusion criteria. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, cyclo-oxygenase (COX)-2 specific-inhibitors or non-steroidal anti-inflammatory drugs (NSAIDs), intravenous ketamine infusion and regional analgesia techniques including epidural analgesia using local anaesthetics with or without opioids. Limited evidence was found for local wound infiltration, intrathecal and epidural opioids, erector spinae plane block, thoracolumbar interfascial plane block, intravenous lidocaine, dexmedetomidine and gabapentin.

CONCLUSIONS

The analgesic regimen for complex spine surgery should include pre-operative or intra-operative paracetamol and COX-2 specific inhibitors or NSAIDs, continued postoperatively with opioids used as rescue analgesics. Other recommendations are intra-operative ketamine and epidural analgesia using local anaesthetics with or without opioids. Although there is procedure-specific evidence in favour of intra-operative methadone, it is not recommended as it was compared with shorter-acting opioids and due to its limited safety profile. Furthermore, the methadone studies did not use non-opioid analgesics, which should be the primary analgesics to ultimately reduce overall opioid requirements, including methadone. Further qualitative randomised controlled trials are required to confirm the efficacy and safety of these recommended analgesics on postoperative pain relief.

Efficacy of Routinely used Analgesics in Management of Pulpal Pain Postoperatively a Clinical Study

Aim:

The aim of this study was to evaluate the efficacy of various routinely used analgesics in the management of pulpal pain preoperatively.

Materials and Methods:

A total of 150 patients were randomly selected and divided into five groups each. At initial visit, a self-administered questionnaire was given, and patients were asked to mark on the Visual Analog Scale (VAS) indicating severity of pain at that moment which is taken as a pretreatment VAS score. Group I patients received aceclofenac + paracetamol, Group II: ketorolac tromethamine, Group III: lornoxicam + paracetamol, Group IV: tramadol + paracetamol, and Group V: paracetamol. All the patients are requested to record their pain levels at 4 h, 6 h, 8 h, 24 h, and 48 h by means of VAS scores before and after treatment.

Results:

There was no significant decrease in frequency of pain when compared in the first three groups, whereas in Group III and Group IV, the patients experienced an effective reduction in pain because of sustained releasing ability of these drugs. Overall, there was no statistically significant differences among all the groups.

Conclusion:

This study suggests that there was no significant difference in reduction of pain preoperatively. However, lornoxicam + paracetamol and tramadol + paracetamol were effective because of their sustained releasing ability. Ketorolac was effective to reduce the pain for shorter duration. Paracetamol can be advised in compromised patients where safety is concerned.

A standardized post-cesarean analgesia regimen reduces postpartum opioid use

BACKGROUND

Optimal post-cesarean pain control is important. With the rising opioid epidemic it is imperative to maximize non-opioid based primary approaches to post-cesarean pain control. In 2018, we implemented a standardized post-cesarean analgesia regimen.

OBJECTIVE

To determine if implementation of a standardized postoperative analgesic regimen decreases opioid use following cesarean birth.

STUDY DESIGN

A standardized postoperative analgesia protocol was implemented in June 2018, which included scheduled oral acetaminophen (975 mg every 6 h) and nonsteroidal anti-inflammatory drugs (NSAIDs) (ketorolac 15 mg IV every 6 h for 5 doses followed by ibuprofen 600 mg oral every 6 h) with opioids available for breakthrough pain. There was no prior standardized protocol. A before-and-after study design was used to compare oral morphine milligram equivalents (MME) for nine months prior to and nine months after this protocol was implemented, excluding the two month period of protocol rollout. Women with opioid use disorder or postoperative intubation were excluded. The primary outcome was the cumulative MME used in the first 72 h postoperatively. Total dose at 12, 24, and 48 h were also compared.

RESULTS

Of 2340 women who underwent cesarean birth during the study period (1 July 2017 - 30 April 2019), 2001 women met inclusion criteria (914 before 10 April 2018 (pre-protocol) and 1087 after 17 June 2018 (post-protocol)). Baseline characteristics of the two groups were similar, including gestational age at delivery, maternal body mass index (BMI), planned versus unplanned cesarean birth, and type of intraoperative anesthesia used. The cumulative opioid dose in the first 72 h postoperatively was 216.3 ± 84.3 MME prior to implementation compared to 171.5 ± 91.5 MME following implementation (p < .001). The average cumulative MME use was higher in the pre-protocol period compared to post-protocol at all time periods: 12 h (57.3 ± 23.8 vs 48.6 ± 26.2 MME, p < .001), 24 h (98.1 ± 34.1 vs 82.1 ± 38.8 MME, p < .001), and 48 h (165.8 ± 58.3 vs 134.9 ± 66.2 MME, p < .001). The average pain scores were lower in the pre-protocol group (3 vs 3.3, p < .001).

CONCLUSION

Scheduled administration of acetaminophen and NSAIDs following cesarean birth significantly decreased the cumulative dose of opioids used in the first 72 h postoperatively.

Incorporation of an intercostal catheter into a multimodal analgesic strategy for uniportal video-assisted thoracoscopic surgery: a feasibility study

Background

Well-controlled postoperative pain is essential for early recovery after uniportal video-assisted thoracoscopic surgery (UVATS). Conventional analgesia like opioids and thoracic epidural anaesthesia have been associated with hypotension and urinary retention. Intercostal catheters are a regional analgesic alternative that can be inserted during UVATS to avoid these adverse effects. This feasibility study aims to evaluate the postoperative pain scores and analgesic requirements with incorporation of an intercostal catheter into a multimodal analgesic strategy for UVATS.

Methods

In this observational study, 26 consecutive patients who underwent UVATS were administered a multilevel intercostal block and oral paracetamol. All of these patients received 0.2% ropivacaine continuously at 4 ml/h via an intercostal catheter at the level of the incision. Rescue analgesia including etoricoxib, gabapentin and opioids were prescribed using a pain ladder approach. Postoperative pain scores and analgesic usage were assessed. The secondary outcomes were postoperative complications, days to ambulation and length of stay.

Results

No technical difficulties were encountered during placement of the intercostal catheter. There was only one case of peri-catheter leakage. Mean pain score was 0.31 (range 0–2) on post-operative day 1 and was 0.00 by post-operative day 5. 16 patients (61.6%) required only oral rescue analgesia. The number of patients who required rescue non-opioids only increased from 1 in the first 7 months to 8 in the next 7 months. There were no cases of hypotension or urinary retention. Median time to ambulation was 1 day (range 1–2). Mean post-operative length of stay was 4.17 ± 2.50 days.

Conclusions

Incorporation of an intercostal catheter into a multimodal analgesia strategy for UVATS is feasible and may provide adequate pain control with decreased opioid usage.

[Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery]

BACKGROUND

Nonopioid analgesics are frequently used for perioperative analgesia; however, insufficient research is available on several practical issues. Often hospitals have no strategy for how to proceed, e.g., for informing patients or for the timing of perioperative administration of nonopioid analgesics.

METHODS

An expert panel representing the German national societies of pain, anaesthesiology and intensive care medicine and surgery developed recommendations for the perioperative use of nonopioid analgesics within a formal, structured consensus process.

RESULTS

The panel agreed that nonopioid analgesics shall be part of a multimodal analgesia concept and that patients have to be informed preoperatively about possible complications and alternative treatment options. Patients' history of pain and analgesic intake shall be evaluated. Patients at risk of severe postoperative pain and possible chronification of postsurgical pain shall be identified. Depending on the duration of surgery, nonopioid analgesics can already be administered preoperatively or intraoperatively so that plasma concentrations are sufficient after emergence from anesthesia. Nonopioid analgesics or combinations of analgesics shall be administered for a limited time only. An interdisciplinary written standard of care, comprising the nonopioid analgesic of choice, possible alternatives, adequate dosing and timing of administration as well as surgery-specific policies, have to be agreed upon by all departments involved. At discharge, the patient's physician shall be informed of analgesics given and those necessary after discharge. Patients shall be informed of possible side effects and symptoms and timely discontinuation of analgesic drugs.

CONCLUSION

The use of nonopioid analgesics as part of a perioperative multimodal concept should be approved and established as an interdisciplinary and interprofessional concept for the adequate treatment of postoperative pain.

[Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery]

BACKGROUND

Nonopioid analgesics are frequently used for perioperative analgesia; however, insufficient research is available on several practical issues. Often hospitals have no strategy for how to proceed, e.g., for informing patients or for the timing of perioperative administration of nonopioid analgesics.

METHODS

An expert panel representing the German national societies of pain, anaesthesiology and intensive care medicine and surgery developed recommendations for the perioperative use of nonopioid analgesics within a formal, structured consensus process.

RESULTS

The panel agreed that nonopioid analgesics shall be part of a multimodal analgesia concept and that patients have to be informed preoperatively about possible complications and alternative treatment options. Patients' history of pain and analgesic intake shall be evaluated. Patients at risk of severe postoperative pain and possible chronification of postsurgical pain shall be identified. Depending on the duration of surgery, nonopioid analgesics can already be administered preoperatively or intraoperatively so that plasma concentrations are sufficient after emergence from anesthesia. Nonopioid analgesics or combinations of analgesics shall be administered for a limited time only. An interdisciplinary written standard of care, comprising the nonopioid analgesic of choice, possible alternatives, adequate dosing and timing of administration as well as surgery-specific policies, have to be agreed upon by all departments involved. At discharge, the patient's physician shall be informed of analgesics given and those necessary after discharge. Patients shall be informed of possible side effects and symptoms and timely discontinuation of analgesic drugs.

CONCLUSION

The use of nonopioid analgesics as part of a perioperative multimodal concept should be approved and established as an interdisciplinary and interprofessional concept for the adequate treatment of postoperative pain.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyses, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Fixed-Dose Combination of NSAIDs and Spasmolytic Agents in the Treatment of Different Types of Pain-A Practical Review

This review presents the most common disease entities in which combinations of NSAIDs and spasmolytic drugs are used to reduce pain. The benefits of fixed-dose combination products (FDCs) are that they improve the response in people with insufficient monotherapy. Using the synergy or additive effect of drugs, it is possible to obtain a significant therapeutic effect and faster action with the use of smaller doses of individual drugs. In addition, one active ingredient may counteract adverse reactions from the other. Another essential aspect of the use of FDCs is the improvement of medical adherence due to the reduction in the pill burden on patients. It is also possible to develop a fixed-dosed combination product de novo to address a new therapeutic claim and be protected by patents so that the manufacturer can obtain exclusive rights to sell a particular FDC or a formulation thereof. The proposed fixed-dose combinations should always be based on valid therapeutic principles and consider the combined safety profile of all active substances included in the medicinal product. This review aims to identify which combinations of NSAIDs and spasmolytics have been developed and tested and which combinations are still under development.

Pre-emptive and preventive NSAIDs for postoperative pain in adults undergoing all types of surgery

BACKGROUND

Postoperative pain is a common consequence of surgery and can have many negative perioperative effects. It has been suggested that the administration of analgesia before a painful stimulus may improve pain control. We defined pre-emptive nonsteroidal anti-inflammatories (NSAIDs) as those given before surgery but not continued afterwards and preventive NSAIDs as those given before surgery and continued afterwards. These were compared to a control group given the NSAIDs after surgery instead of before surgery.

OBJECTIVES

To assess the efficacy of preventive and pre-emptive NSAIDs for reducing postoperative pain in adults undergoing all types of surgery.

SEARCH METHODS

We searched the following electronic databases: CENTRAL, MEDLINE, Embase, AMED and CINAHL (up to June 2020). In addition, we searched for unpublished studies in three clinical trial databases, conference proceedings, grey literature databases, and reference lists of retrieved articles. We did not apply any restrictions on language or date of publication.

SELECTION CRITERIA

We included parallel-group randomized controlled trials (RCTs) only. We included adult participants undergoing any type of surgery. We defined pre-emptive NSAIDs as those given before surgery but not continued afterwards and preventive NSAIDs as those given before surgery and continued afterwards. These were compared to a control group given the NSAIDs after surgery instead of before surgery. We included studies that gave the medication by any route but not given on the skin.

DATA COLLECTION AND ANALYSIS

We used the standard methods expected by Cochrane, as well as a novel publication bias test developed by our research group. We used GRADE to assess the certainty of the evidence for each outcome. Outcomes included acute postoperative pain (minimal clinically important difference (MCID): 1.5 on a 0-10 scale), adverse events of NSAIDs, nausea and vomiting, 24-hour morphine consumption (MCID: 10 mg reduction), time to analgesic request (MCID: one hour), pruritus, sedation, patient satisfaction, chronic pain and time to first bowel movement (MCID: 12 hours).

MAIN RESULTS

We included 71 RCTs. Seven studies are awaiting classification. We included 45 studies that evaluated pre-emptive NSAIDs and 26 studies that evaluated preventive NSAIDs. We considered only four studies to be at low risk of bias for most domains. The operations and NSAIDs used varied, although most studies were conducted in abdominal, orthopaedic and dental surgery. Most studies were conducted in secondary care and in low-risk participants. Common exclusions were participants on analgesic medications prior to surgery and those with chronic pain. Pre-emptive NSAIDs compared to post-incision NSAIDs For pre-emptive NSAIDs, there is probably a decrease in early acute postoperative pain (MD -0.69, 95% CI -0.97 to -0.41; studies = 36; participants = 2032; I² = 96%; moderate-certainty evidence). None of the included studies that reported on acute postoperative pain reported adverse events as an outcome. There may be little or no difference between the groups in short-term (RR 1.00, 95% CI 0.34 to 2.94; studies = 2; participants = 100; I² = 0%; low-certainty evidence) or long-term nausea and vomiting (RR 0.85, 95% CI 0.52 to 1.38; studies = 5; participants = 228; I² = 29%; low-certainty evidence). There may be a reduction in late acute postoperative pain (MD -0.22, 95% CI -0.44 to 0.00; studies = 28; participants = 1645; I² = 97%; low-certainty evidence). There may be a reduction in 24-hour morphine consumption with pre-emptive NSAIDs (MD -5.62 mg, 95% CI -9.00 mg to -2.24 mg; studies = 16; participants = 854; I² = 99%; low-certainty evidence) and an increase in the time to analgesic request (MD 17.04 minutes, 95% CI 3.77 minutes to 30.31 minutes; studies = 18; participants = 975; I² = 95%; low-certainty evidence). There may be little or no difference in opioid adverse events such as pruritus (RR 0.40, 95% CI 0.09 to 1.76; studies = 4; participants = 254; I² = 0%; low-certainty evidence) or sedation (RR 0.51, 95% CI 0.16 to 1.68; studies = 4; participants = 281; I² = 0%; low-certainty evidence), although the number of included studies for these outcomes was small. No study reported patient satisfaction, chronic pain or time to first bowel movement for pre-emptive NSAIDs. Preventive NSAIDs compared to post-incision NSAIDs For preventive NSAIDs, there may be little or no difference in early acute postoperative pain (MD -0.14, 95% CI -0.39 to 0.12; studies = 18; participants = 1140; I² = 75%; low-certainty evidence). One study reported adverse events from NSAIDs (reoperation for bleeding) although the events were low which did not allow any meaningful conclusions to be drawn (RR 1.95; 95% CI 0.18 to 20.68). There may be little or no difference in rates of short-term (RR 1.26, 95% CI 0.49 to 3.30; studies = 1; participants = 76; low-certainty evidence) or long-term (RR 0.85, 95% CI 0.52 to 1.38; studies = 5; participants = 456; I² = 29%; low-certainty evidence) nausea and vomiting. There may be a reduction in late acute postoperative pain (MD -0.33, 95% CI -0.59 to -0.07; studies = 21; participants = 1441; I² = 81%; low-certainty evidence). There is probably a reduction in 24-hour morphine consumption (MD -1.93 mg, 95% CI -3.55 mg to -0.32 mg; studies = 16; participants = 1323; I² = 49%; moderate-certainty evidence). It is uncertain if there is any difference in time to analgesic request (MD 8.51 minutes, 95% CI -31.24 minutes to 48.27 minutes; studies = 8; participants = 410; I² = 98%; very low-certainty evidence). As with pre-emptive NSAIDs, there may be little or no difference in other opioid adverse events such as pruritus (RR 0.56, 95% CI 0.09 to 3.35; studies = 3; participants = 211; I² = 0%; low-certainty evidence) and sedation (RR 0.84, 95% CI 0.44 to 1.63; studies = 5; participants = 497; I² = 0%; low-certainty evidence). There is probably little or no difference in patient satisfaction (MD -0.42; 95% CI -1.09 to 0.25; studies = 1; participants = 72; moderate-certainty evidence). No study reported on chronic pain. There is probably little or no difference in time to first bowel movement (MD 0.00; 95% CI -15.99 to 15.99; studies = 1; participants = 76; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

There was some evidence that pre-emptive and preventive NSAIDs reduce both pain and morphine consumption, although this was not universal for all pain and morphine consumption outcomes. Any differences found were not clinically significant, although we cannot exclude this in more painful operations. Moreover, without any evidence of reductions in opioid adverse effects, the clinical significance of these results is questionable although few studies reported these outcomes. Only one study reported clinically significant adverse events from NSAIDs administered before surgery and, therefore, we have very few data to assess the safety of either pre-emptive or preventive NSAIDs. Therefore, future research should aim to adhere to the highest methodology and be adequately powered to assess serious adverse events of NSAIDs and reductions in opioid adverse events.

[Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery]

Hintergrund

Nichtopioidanalgetika werden bei vielen Patienten zur perioperativen Analgesie eingesetzt. Zu einigen praktischen Fragen beim Einsatz von Nichtopioidanalgetika liegen z. T. nur wenig Informationen aus Studien vor, und in Krankenhäusern existieren häufig keine Konzepte zum Vorgehen, z. B. zur Patientenaufklärung und zum Zeitpunkt der perioperativen Gabe.

Methodik

Eine Expertengruppe der beteiligten Fachgesellschaften hat konsensbasierte Empfehlungen zum perioperativen Einsatz von Nichtopioidanalgetika erarbeitet und in einem strukturierten formalen Konsensusprozess verabschiedet.

Ergebnisse

Die Arbeitsgruppe stimmt überein, dass Nichtopioidanalgetika Bestandteil eines perioperativen multimodalen Analgesiekonzepts sein sollen und Patienten präoperativ über Nutzen, Risiken und alternative Behandlungsmöglichkeiten aufgeklärt werden sollen. Die präoperative Patienteninformation und -edukation soll auch eine Schmerz- und Analgetikaanamnese umfassen und Patienten mit Risikofaktoren für starke Schmerzen und eine Schmerzchronifizierung sollen identifiziert werden. Unter Berücksichtigung von Kontraindikationen können Nichtopioidanalgetika abhängig von der Operationsdauer auch schon prä- oder intraoperativ gegeben werden, um nach Beendigung der Anästhesie ausreichende Plasmakonzentrationen zu erzielen. Nichtopioidanalgetika oder Kombinationen von (Nichtopioid‑)Analgetika sollen nur für einen begrenzten Zeitraum gegeben werden. Ein gemeinsam erarbeiteter abteilungsübergreifender Behandlungsstandard mit dem Nichtopioidanalgetikum erster Wahl, weiteren Therapieoptionen sowie adäquaten Dosierungen, ergänzt durch eingriffsspezifische Konzepte, soll schriftlich hinterlegt werden. Bei Entlassung aus dem Krankenhaus soll der nachbehandelnde Arzt zu perioperativ gegebenen und aktuell noch eingenommenen Analgetika schriftliche Informationen erhalten. Patienten sollen zu möglichen Nebenwirkungen der Analgetika und ihrer Symptome, die auch nach Krankenhausentlassung auftreten können, und die befristete Einnahmedauer informiert werden.

Schlussfolgerung

Die Anwendung von Nichtopioidanalgetika soll als Bestandteil eines perioperativen multimodalen Analgesiekonzepts mit klaren Vorgaben zu Indikationen, Kontraindikationen, Dosierungen und Behandlungsdauer in einem abteilungsübergreifenden Behandlungsstandard schriftlich hinterlegt werden.

Zusatzmaterial online

Die Offenlegung von Interessen ist in der Online-Version dieses Artikels (10.1007/s00104-021-01421-w) enthalten.

Association of gabapentinoid utilization with postoperative pulmonary complications in gynecologic surgery: a retrospective cohort study

OBJECTIVE

To investigate gabapentinoid utilization and association with postoperative pulmonary complications after gynecologic surgery.

METHODS

After Institutional Review Board approval, we performed this retrospective cohort study using the Premier Healthcare Database. We used ICD-10 and charge codes to identify adults who underwent elective gynecologic surgery from 2015 to 2018 and received either gabapentin or pregabalin on the day of surgery. Our primary outcome was a composite of pulmonary complications: respiratory failure, pneumonia, reintubation, pulmonary edema, and non-invasive or invasive ventilation. Secondary outcomes included mortality, intensive care unit admission, mechanical or non-invasive ventilation, hospital length of stay, re-admission within 30 days, opioid consumption and antiemetic use. Multivariable generalized linear mixed models were utilized to examine the associations between gabapentinoids and our outcome measures, adjusted for all covariates.

RESULTS

Data from 253,013 patients were analyzed, with 19,121 (7.6%) receiving gabapentinoids. Gabapentinoid utilization increased from 3.9% in 2015 to 12.3% in 2018, and was associated with increased pulmonary complications (OR 1.19; 95% CI 1.03-1.38), non-invasive ventilation (odds ratio [OR] 1.53; 95% CI 1.29-1.81), duration of hospital stay (% change 1.75; 95% CI 0.92-2.59), daily antiemetic doses on day of surgery (mean difference [MD] 1.37; 95% CI 1.26-1.49) and subsequently (MD 1.61; 95% CI 1.30-1.99), and higher daily average (MD 4.59 mg; 95% CI 3.55-5.63) and total (MD 8.74 mg; 95% CI 6.83-10.62) parenteral morphine equivalents.

CONCLUSIONS

Gabapentinoid utilization in gynecologic surgery is increasing and is associated with postoperative pulmonary complications.

Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit

Critically ill pediatric patients often require complex medical procedures as well as invasive testing and monitoring which tend to be painful and anxiety-provoking, necessitating the provision of analgesia and sedation to reduce stress response. Achieving the optimal combination of adequate analgesia and appropriate sedation can be quite challenging in a patient population with a wide spectrum of ages, sizes, and developmental stages. The added complexities of critical illness in the pediatric population such as evolving pathophysiology, impaired organ function, as well as altered pharmacodynamics and pharmacokinetics must be considered. Undersedation leaves patients at risk of physical and psychological stress which may have significant long term consequences. Oversedation, on the other hand, leaves the patient at risk of needing prolonged respiratory, specifically mechanical ventilator, support, prolonged ICU stay and hospital admission, and higher risk of untoward effects of analgosedative agents. Both undersedation and oversedation put critically ill pediatric patients at high risk of developing PICU-acquired complications (PACs) like delirium, withdrawal syndrome, neuromuscular atrophy and weakness, post-traumatic stress disorder, and poor rehabilitation. Optimal analgesia and sedation is dependent on continuous patient assessment with appropriately validated tools that help guide the titration of analgosedative agents to effect. Bundled interventions that emphasize minimizing benzodiazepines, screening for delirium frequently, avoiding physical and chemical restraints thereby allowing for greater mobility, and promoting adequate and proper sleep will disrupt the PICU culture of immobility and reduce the incidence of PACs.

In the Arms of Morpheus without Morphia; Mitigating the United States Opioid Epidemic by Decreasing the Surgical Use of Opioids

The opioid epidemic is a major public health issue in the United States. Exposure of opioid naïve-patients to opioids in the perioperative period is a well-documented source of continued use with one in 20 opioid-naïve surgical patients continuing to use opioids beyond 90 days. There is no association with magnitude of surgery, major versus minor, and the strongest predictor of continued use is surgical exposure. Causal factors include over reliance on opioids for intraoperative and postoperative analgesia and excessive ambulatory opioid prescribing. Opioid-induced hyperalgesia can paradoxically result from intraoperative (anesthesia controlled) opioid administration. Increasing size of initial prescription is a strong predictor of continued use necessitating procedure specific supplies limited to under 3-days. Alternative multimodal pain management (non-opioid medications and regional anesthesia) that limit opioid use must be a high priority with opioids reserved for severe breakthrough pain. Barriers to implementation of opioid-sparing pathways include reluctance to adopt protocols and apprehension about opioid elimination. Considering the number of surgeries performed annually in the United States, perioperative physicians must aggressively address modifiable factors in surgical patients. Patient care pathways need to be constructed collaboratively by surgeons and anesthesiologists with continuing feedback to optimize patient outcomes including iatrogenic opioid dependence.

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.

Predicting Acute Pain After Surgery: A Multivariate Analysis

OBJECTIVES

To identify perioperative practice patterns that predictably impact postoperative pain.

BACKGROUND

Despite significant advances in perioperative medicine, a significant portion of patients still experience severe pain after major surgery. Postoperative pain is associated with serious adverse outcomes that are costly to patients and society.

METHODS

The presented analysis took advantage of a unique observational data set providing unprecedented detailed pharmacological information. The data were collected by PAIN OUT, a multinational registry project established by the European Commission to improve postoperative pain outcomes. A multivariate approach was used to derive and validate a model predictive of pain on postoperative day 1 (POD1) in 1008 patients undergoing back surgery.

RESULTS

The predictive and validated model was highly significant (P = 8.9E-15) and identified modifiable practice patterns. Importantly, the number of nonopioid analgesic drug classes administered during surgery predicted decreased pain on POD1. At least 2 different nonopioid analgesic drug classes (cyclooxygenase inhibitors, acetaminophen, nefopam, or metamizol) were required to provide meaningful pain relief (>30%). However, only a quarter of patients received at least 2 nonanalgesic drug classes during surgery. In addition, the use of very short-acting opioids predicted increased pain on POD1, suggesting room for improvement in the perioperative management of these patients. Although the model was highly significant, it only accounted for a relatively small fraction of the observed variance.

CONCLUSION

The presented analysis offers detailed insight into current practice patterns and reveals modifications that can be implemented in today's clinical practice. Our results also suggest that parameters other than those currently studied are relevant for postoperative pain including biological and psychological variables.

Synergistic interaction between matrine and paracetamol in the acetic acid writhing test in mice

The purpose of this study was to investigate the analgesic interaction between matrine and paracetamol in an acetic acid-induced writhing model in mice. Fifty percent effective dose (ED₅₀) values of the individual drugs were determined, and the different proportions of matrine and paracetamol were assayed using the isobolographic method. Our study demonstrated that both of matrine and paracetamol dose-dependently inhibited the writhing response evoked by acetic acid, and the ED₅₀ values and their 95% confidence intervals against these tonic pain were 21.10 (17.86-24.92) mg/kg and 61.30 (50.71-74.10) mg/kg for matrine and paracetamol, respectively. At the fixed ratios of 1:1, 1:3 and 3:1, the experimental ED₅₀ values of matrine and paracetamol combinations and their 95% confidence intervals were 10.52 (5.14-21.55) mg/kg, 9.13 (4.46-18.70) mg/kg and 4.98 (4.17-5.95) mg/kg, respectively, their theoretical ED₅₀ values and 95% confidence intervals were 41.20 (36.31-46.74) mg/kg, 51.25 (44.19-59.44) mg/kg and 31.15 (27.25-35.60) mg/kg, and the experimental ED₅₀ values of matrine and paracetamol combination were significantly lower than their calculated theoretical ED₅₀ values (all P < 0.01), as revealed by isobolographic analysis. Furthermore, the experimental regression line was also significantly different from the calculated additive equal-effect line over the range of the tested doses (all P < 0.01). Our results suggest that the combination of matrine with paracetamol exerts analgesic synergistic interactions in a mouse acetic acid-induced writhing model, thereby offering a possible therapeutic alternative for the clinical management of inflammatory pain.

Impact of a multimodal analgesic protocol modification on opioid consumption after cesarean delivery: a retrospective cohort study

INTRODUCTION

Adequate pain control is a mainstay in enhanced recovery after surgery (ERAS) protocols. ERAS protocols are widely accepted in colorectal and gynecologic surgeries and are increasingly implemented in the obstetric setting. Multimodal analgesia incorporating non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen is a mainstay of ERAS protocols for cesarean delivery, but little research has focused on the choice of NSAIDs or timing of initiation in women undergoing cesarean delivery. At our institution, patients undergoing cesarean delivery receive a standardized multimodal analgesic regimen consisting of neuraxial morphine with NSAIDs and acetaminophen. Our initial protocol involved starting the oral analgesics in the recovery room. There was variability in whether these medications were given in a timely manner or withheld in the setting of postoperative nausea and vomiting. We modified this protocol and performed a retrospective analysis to assess the impact of this change on postoperative opioid rescue requirements in women undergoing cesarean delivery under neuraxial anesthesia.

METHODS

This retrospective analysis included patients who underwent cesarean deliveries from 1 July 2014 to 22 August 2017. With the initial analgesic protocol, patients received neuraxial morphine, followed by naproxen 500 mg PO Q12 hours and acetaminophen 650-975 mg PO Q6 hours initiated in the recovery room. After protocol revision in January 2016, the same neuraxial morphine dose was used in addition to acetaminophen 975 mg PR at the start of the case and ketorolac 15-30 mg IV at the end of the case. Postoperatively, patients received acetaminophen PO 975 mg Q6 hours, ketorolac IV 15 mg Q6 hours for 3 doses, transitioning to ibuprofen 600 mg Q6 hours. Fentanyl, oxycodone, and intravenous hydromorphone were given for breakthrough pain with both protocols. The primary outcome of the study is the need for rescue opioid analgesia. Secondary outcomes are total opioid usage, time to first rescue opioid, maximum reported pain scores, and need for rescue antiemetics. Univariate and multivariate analyses were performed controlling for variables significantly different between the two cohorts.

RESULTS

3250 patients were included in our analysis (1574 in the old protocol and 1676 in the new protocol). There was no significant difference in patient demographics or intraoperative characteristics between the two cohorts except for more primiparous women (25% vs. 17%), more Pfannenstiel incision (98% vs. 96%), and less repeat cesarean deliveries (40% vs. 44%) in the new protocol cohort. Need for rescue opioids was reduced with the new protocol at 2, 24, and 48 h [(36.46% vs. 75.73%, p < .0001), (74.28% vs 91.99%, p < .0001), (87.53% vs 95.49% p < .0001), respectively]. Among those who received opioids, opioid consumption over 48 h was reduced (median [IQR]: 55 [30, 95] vs. 40 [20, 70] mg oxycodone equivalents) after protocol revision (GMR 0.75, 95% CI 0.7, 0.80, p < .0001). The time to first rescue opioid medication was significantly longer in the new protocol compared to the old protocol (175 [79, 1057] min vs 51 [28, 104] min, p < .001).

CONCLUSION

There was a significant decrease in the need for and the dose of rescue opioid medications with the new protocol. This highlights the importance of optimizing the choice of agents, as well as route and timing of administration of the components of the postoperative multimodal analgesic regimen.

Efficacy and Safety of Ibuprofen Plus Paracetamol in a Fixed-Dose Combination for Acute Postoperative Pain in Adults: Meta-Analysis and a Trial Sequential Analysis

BACKGROUND

Ibuprofen and paracetamol (acetaminophen) are very commonly used for analgesia and pain. In 2020, the US FDA gave its first approval of a fixed-dose combination (FDC) of the two drugs in the same tablet for postoperative pain. There has been no quantitative, summative analysis of the FDC effect size measures against postoperative pain in adults. Similar analyses exist, but only in pediatric patients.

OBJECTIVE

This was the first meta-analysis to compare the efficacy and safety outcomes of the ibuprofen/paracetamol FDC against placebo, administered postoperatively, for moderate to severe pain relief in adults.

METHODS

The MEDLINE, EMBASE, and Cochrane CENTRAL databases, in addition to the grey literature, were searched for clinical trials until April 2020, to identify comparative literature studies of the ibuprofen/paracetamol FDC in acute postoperative pain in adults. No restrictions on doses, formulations (oral, intravenous), and underlying type of surgery were applied. Independent reviewers performed the study selection, data extraction, and the risk-of-bias and quality-of-evidence assessments based on the Cochrane criteria. The outcome measures of interest in the meta-analysis were ≥ 50% pain relief , need for rescue medications, and occurrence of adverse drug events. Statistical analyses using a random-effects model were performed, at a statistical significance of p < 0.05. The RevMan software was used for analysis. A trial sequential analysis (TSA) was conducted to assess how precise and conclusive the meta-analysis outcomes are.

RESULTS

Seven double-blind, randomized controlled trials with 2947 participants were included. The FDC dose was at three different levels: 75-100 mg ibuprofen/250 mg paracetamol, 150-200 mg ibuprofen/500 mg paracetamol (FDA-approved dose level), and 292.5-400 mg ibuprofen/975-1000 mg paracetamol. The ≥ 50% pain relief outcome was more achieved with the FDC compared to placebo (risk ratio [RR] 2.60, 95% confidence interval [CI] 2.11-3.20, p < 0.00001), as was the reduced need for rescue medications (RR 0.51, 95% CI 0.37-0.71, p < 0.0001). While inconclusive based on TSA, the FDC was at the highest doses at least as well tolerated as placebo regarding the occurrence of adverse events, including severe, common, and treatment-related adverse events, as well as those that lead to discontinuation, but it was also significantly associated with lower rates of headache and nausea. Subgroup analyses confirmed that the efficacy and safety of the FDC were maintained regardless of doses and formulations. The sensitivity analysis confirmed outcomes against potential publication bias and identified sources of heterogeneity in analyses.

CONCLUSION

The ibuprofen plus paracetamol FDC is conclusively an effective analgesic against placebo in acute postoperative, moderate to severe pain in adults. It is also superiorly well tolerated, including at the higher dose of 292.5-400 mg ibuprofen/975-1000 mg paracetamol; however, safety outcomes were inconclusive. Future studies need to confirm the safety of FDC and its benefits against other marketed analgesics in postoperative pain.

Enhanced recovery after surgery and anesthetic outcomes in pediatric reconstructive urologic surgery

PURPOSE

Enhanced recovery after surgery (ERAS) is a perioperative management strategy to hasten postoperative recovery. We examined the effects of a pilot implementation of ERAS for pediatric patients on anesthetic outcomes.

METHODS

We performed a prospective case-control study utilizing an ERAS protocol in patients aged < 18 years undergoing urologic reconstruction that included a bowel anastomosis. Protocol elements included: multimodal analgesia, opioid minimization, and routine nausea/vomiting prophylaxis. ERAS patients were propensity-matched with historical controls. Outcomes of interest included maximum PACU pain score, time to first opioid, opioid-free days, and need for opioids on day of discharge.

RESULTS

A total of 13 ERAS patients and 26 historical controls were included, with median ages 9.9 years (IQR 9.1-11) and 10.4 years (IQR 8.0-12.4), respectively. ERAS increased the percentage of patients who did not receive any intraoperative or postoperative opioids (0% vs 15%, p = 0.046 for both) and reduced maximum PACU pain score (3 vs 0, p < 0.001). The use of postoperative supplemental oxygen was decreased in the ERAS group (85% vs 38%, p = 0.013).

CONCLUSIONS

The implementation of an ERAS protocol appears to decrease postoperative pain, opioid usage, and positively impact other anesthetic outcomes in children undergoing urologic reconstructive surgery utilizing a bowel anastomosis.

Effect of preoperative intravenous vs oral acetaminophen on postoperative opioid consumption in an enhanced recovery after surgery (ERAS) program in patients undergoing open gynecologic oncology surgery

OBJECTIVE

Both intravenous (IV) and oral acetaminophen provide effective opioid-sparing analgesia after surgery when used as part of a multimodal preemptive pain management strategy. The purpose of this study was to compare postoperative opioid consumption in patients undergoing open gynecologic oncology surgery who received preoperative IV vs oral acetaminophen within an enhanced recovery after surgery (ERAS) program.

METHODS

Retrospective data were collected on consecutive patients undergoing open gynecologic oncology surgery from May 1, 2016 to February 28, 2018 in patients receiving either 1 g IV or oral acetaminophen preoperatively. Patients were given a preoperative multimodal analgesia regimen including acetaminophen, celecoxib, pregabalin and tramadol. The primary outcomes were morphine equivalent daily doses (MEDD) on postoperative days (POD) 0 and 1. Secondary outcomes included highest patient-reported pain score in the post-anesthesia care unit (PACU) and intraoperative MEDD. Regression models adjusted by matched pairs were fit to estimate the average treatment effect of IV vs oral acetaminophen on MEDD.

RESULTS

Of 353 patients, 178 (50.4%) received IV acetaminophen and 175 (49.6%) received oral acetaminophen. When balancing across the matched samples, there was no difference in postoperative MEDD for POD 0 between the IV and oral acetaminophen groups (Beta = -1.11; 95% CI: -4.83 to 2.60; p = 0.56). On POD 1, there was no difference between the IV and oral groups (Beta = 2.24; 95% CI: -2.76 to 7.25; p = 0.38).

CONCLUSIONS

There was no difference in postoperative opioid consumption between patients receiving preoperative IV or oral acetaminophen within an ERAS program for patients undergoing open gynecologic oncology surgery.

Perioperative Nonsteroidal Anti-Inflammatory Agents in the COVID-19 Orthopedic Patient

BACKGROUND

SARS-CoV-2 infection can cause serious complications beyond lung injury and respiratory failure, including sepsis, cardiovascular injury, renal failure, coagulation abnormalities, and neurologic injury. Widely used medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) have been flagged as having the potential to cause harm in the context of COVID-19. It is unknown if the benefits of NSAID use in the orthopedic population will outweigh the potential risks of increased morbidity in COVID-19 orthopedic patients.

METHODS

We conducted a narrative review of the use of NSAIDs in the orthopedic patient with COVID-19, focusing on the effects of NSAIDs on the inflammatory process, the role of NSAIDs in orthopedics, and the associations between NSAID use and complications of pneumonia.

RESULTS

We found that it may be appropriate to consider NSAID use in otherwise healthy orthopedic patients with COVID-19 and significant pain.

CONCLUSIONS

In this context, we recommend that NSAIDs be used at the lowest effective dose for the shortest duration possible in orthopedic patients with COVID-19. However, pending further data and based on the concerns outlined in this review, we recommend avoiding NSAIDs in orthopedic patients with significant comorbidities and those who are undergoing major orthopedic surgery.