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Li D, Wang C, Yang Z, Kang P. Effect of Intravenous Corticosteroids on Pain Management and Early Rehabilitation in Patients Undergoing Total Knee or Hip Arthroplasty: A Meta-Analysis of Randomized Controlled Trials. Pain Pract 2017; 18:487-499. [PMID: 28851016 DOI: 10.1111/papr.12637] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 07/20/2017] [Accepted: 08/09/2017] [Indexed: 02/05/2023]
Affiliation(s)
- Donghai Li
- Department of Orthopaedics; West China Hospital; Sichuan University; Chengdu China
| | - Changde Wang
- Department of Orthopaedics; West China Hospital; Sichuan University; Chengdu China
| | - Zhouyuan Yang
- Department of Orthopaedics; West China Hospital; Sichuan University; Chengdu China
| | - Pengde Kang
- Department of Orthopaedics; West China Hospital; Sichuan University; Chengdu China
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McDonald C, Hennedige A, Henry A, Dawoud B, Kulkarni R, Gilbert K, Kyzas P, Morrison R, McCaul J. Management of cervicofacial infections: a survey of current practice in maxillofacial units in the UK. Br J Oral Maxillofac Surg 2017; 55:940-945. [DOI: 10.1016/j.bjoms.2017.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 09/07/2017] [Indexed: 11/28/2022]
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Gupta S, Mehta N, Mahajan A, Dar MR, Gupta N. Role of Oral Prednisolone in the Management of Postdural Puncture Headache after Spinal Anesthesia in Urological Patients. Anesth Essays Res 2017; 11:1075-1078. [PMID: 29284878 PMCID: PMC5735453 DOI: 10.4103/0259-1162.183565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND AIMS Postdural puncture headache (PDPH) is a frequently encountered complication of spinal anesthesia and may be associated with significant morbidity in some patients. Parenteral corticosteroids have been used in the management of PDPH both prophylactically and after the occurrence of headache. The aim of this study was to evaluate the effect of oral prednisolone in the management of PDPH after spinal anesthesia in urological patients. MATERIALS AND METHODS Sixty adult patients who developed PDPH after spinal anesthesia for urological surgeries were randomly allocated to two groups. Group C patients (n = 30) were managed conservatively, and Group P patients (n = 30) were given 20 mg of oral prednisolone for 4 days in addition to the conventional treatment. The intensity of headache was measured using visual analog scale (VAS). VAS score was taken just before the start of treatment (0 h) and at 12, 24, 48, 72, and 96 h after the start of treatment. STATISTICAL ANALYSIS Statistical analysis was performed using Statistical Packages for Social Science version 19 (SPSS, Inc., Chicago, IL, USA). RESULTS There was no statistically significant difference in the VAS score in patients before the start of treatment (0 h) and at 12 h after the start of treatment. The VAS scores were less and statistically significant in Group P at 24, 48, 72 and 96 h after the start of treatment (P < 0.05). CONCLUSION The use of oral prednisolone is effective in reducing the severity and duration of PDPH.
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Affiliation(s)
- Sunana Gupta
- Department of Anaesthesiology and Intensive Care, Acharya Shri Chander College of Medical Sciences and Hospital, Sidhra, Jammu, Jammu and Kashmir, India
| | - Nandita Mehta
- Department of Anaesthesiology and Intensive Care, Acharya Shri Chander College of Medical Sciences and Hospital, Sidhra, Jammu, Jammu and Kashmir, India
| | - Arti Mahajan
- Government Medical College and Hospital, Jammu, Jammu and Kashmir, India
| | - Mohd Reidwan Dar
- Department of Anaesthesiology and Intensive Care, Shri Mata Vaishno Devi Narayana Superspeciality Hospital, Katra, Jammu, Jammu and Kashmir, India
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Jørgensen C, Pitter F, Kehlet H. Safety aspects of preoperative high-dose glucocorticoid in primary total knee replacement. Br J Anaesth 2017; 119:267-275. [DOI: 10.1093/bja/aex190] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2017] [Indexed: 12/16/2022] Open
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Donohue NK, Prisco AR, Grindel SI. Pre-operative corticosteroid injections improve functional outcomes in patients undergoing arthroscopic repair of high-grade partial-thickness rotator cuff tears. Muscles Ligaments Tendons J 2017; 7:34-39. [PMID: 28717609 DOI: 10.11138/mltj/2017.7.1.034] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Subacromial corticosteroid injections (CSI's) are a common non-surgical treatment for rotator cuff tears. Few studies have assessed the effects of pre-operative CSI's on postoperative functional outcomes. METHODS A retrospective analysis was conducted of 132 patients with high-grade, partial-thickness rotator cuff tears (PTRCT's). The subjects were divided into two groups based on whether they received a CSI or not. The CSI group was further divided into three subgroups based on when they received a pre-operative injection: 0-3 months, 3-6 months, >6 months before surgery. The Visual Analog Scores (VAS), American Shoulder and Elbow Surgeon scores (ASES), and Constant scores were recorded prior to surgery and at a one-year post-operative follow-up appointment for each subject. RESULTS Patients who received a pre-operative CSI (n=92) improved significantly more than the non-injection group (n=40) in all outcome measures. The 0-3 months injection subgroup experienced a significant increase in ASES and Constant score (p=0.019 and 0.014, respectively) compared to the other two subgroups, but the VAS score decrease only trended toward significance (p=0.091). The sample as a whole experienced significant improvement in all three outcome measures. CONCLUSION Patients undergoing arthroscopic repair of a high-grade PTRCT may benefit from a pre-operative CSI 0-3 months before surgery. LEVEL OF EVIDENCE IIb.
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Affiliation(s)
- Nicholas K Donohue
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, USA
| | - Anthony R Prisco
- Department of Medicine, University of Minnesota, Minneapolis, USA
| | - Steven I Grindel
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, USA
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Li X, Sun Z, Han C, He L, Wang B. A systematic review and meta-analysis of intravenous glucocorticoids for acute pain following total hip arthroplasty. Medicine (Baltimore) 2017; 96:e6872. [PMID: 28489787 PMCID: PMC5428621 DOI: 10.1097/md.0000000000006872] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 03/31/2017] [Accepted: 04/07/2017] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Glucocorticoids are increasingly used perioperatively, principally to prevent postoperative nausea and vomiting (PONV), and acute postoperative pain following total hip arthroplasty (THA). The authors hypothesized that preoperative intravenous glucocorticoids is associated with less pain scores and PONV without increasing the complications after THA. METHODS Four databases (PubMed, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science) were searched with the limitations of randomized controlled trials (RCTs). The search cutoff date was set at November 6, 2016. Participants were patients who were prepared for primary THA. Intervention was preoperative intravenous glucocorticoids for postoperative pain control. Outcomes including the visual analog scale (VAS) scores at the postanesthesia care unit (PACU) and at 24 and 48 hours post operation, the occurrence of PONV and total morphine consumption were recorded. We calculated risk ratio (RR) with a 95% confidence interval (CI) for dichotomous outcomes, and the weighted mean difference (WMD) with a 95% CI for continuous outcomes. RESULTS A total of 6 studies were evaluated, which included 297 patients who underwent hip surgery with intravenous glucocorticoid treatment and control patients who underwent hip surgery without glucocorticoid treatment. Pooled results indicated that intravenous glucocorticoid treatment was associated with a reduction of VAS scores at the PACU (WMD = -9.06, 95% CI -12.67 to -5.45, P = .000) and total morphine consumption by 15.68 mg (WMD = -15.68, 95% CI -24.60 to -6.75, P = .001). No significant difference was observed in the VAS scores at 24 and 48 hours between the intravenous glucocorticoid and placebo treatments. Intravenous steroids can decrease the occurrence of PONV (RR = 0.46, 95% CI 0.26-0.82, P = .029). CONCLUSION Intravenous glucocorticoid treatment can decrease early pain intensity and PONV after THA. However, the evidence for the use of glucocorticoids is limited by the low number of studies and variation in dosing regimens. Thus, additional high-quality RCTs are needed to identify the optimal drug protocol and determine the safety of intravenous glucocorticoids.
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Affiliation(s)
- Xiuhua Li
- Department of Anesthesiology, Weifang Medical University
| | - Zheng Sun
- Department of Pathology, Affiliated Hospital of Weifang Medical University
| | - Chengbing Han
- Department of Oral and Maxillofacial Surgery, Weifang People's Hospital, Weifang
| | | | - Baoguo Wang
- Department of Anesthesiology, Beijing Sanbo Brain Hospital, Capital Medical University, Beijing, China
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Hartman J, Khanna V, Habib A, Farrokhyar F, Memon M, Adili A. Perioperative systemic glucocorticoids in total hip and knee arthroplasty: A systematic review of outcomes. J Orthop 2017; 14:294-301. [PMID: 28442852 DOI: 10.1016/j.jor.2017.03.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 03/26/2017] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Perioperative systemic glucocorticoids are frequently included in multimodal analgesia and antiemetic regimens administered to patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). The objective of this systematic review was to evaluate the available randomized controlled trials (RCTs) to determine the effect of perioperative systemic glucocorticoids on postoperative nausea and vomiting (PONV), pain, narcotic consumption, antiemetic consumption, length of stay in hospital, and major complications in patients undergoing elective THA or TKA. METHODS A predefined protocol of eligibility and methodology was used for conduct of systematic reviews. Two reviewers screened citations for inclusion, assessed methodological quality, and verified the extracted data. RESULTS Six RCTs were included for analysis. Across all outcomes analyzed, patients who received glucocorticoids experienced either a benefit or no difference compared to those patients who did not receive glucocorticoids. There were no instances in which perioperative glucocorticoids had a negative impact on any of the outcomes that were analyzed. Furthermore, perioperative glucocorticoids had no effect on the rates of superficial infection, deep infection, wound complications or deep vein thrombosis (DVT). CONCLUSION The results of this systematic review support the use of perioperative systemic glucocorticoids in patients undergoing elective total hip and knee arthroplasty. Perioperative glucocorticoids have overall positive outcomes with the benefits being more robust in those patients undergoing TKA compared to THA. Glucocorticoids did not increase the occurrence of major complications. There is limited data to support the conclusion that they can reduce length of stay in hospital.
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Affiliation(s)
- Jeffrey Hartman
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario L8L2X2, Canada
| | - Vickas Khanna
- Department of Orthopedic Surgery, St. Joseph's Healthcare, Hamilton, Ontario L8N4A6, Canada
| | - Anthony Habib
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario L8L2X2, Canada
| | - Forough Farrokhyar
- Department of Surgery, McMaster University, Hamilton, Ontario L8S4L8, Canada.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario L8S4L8, Canada
| | - Muzammil Memon
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario L8S4L8, Canada
| | - Anthony Adili
- Department of Orthopedic Surgery, St. Joseph's Healthcare, Hamilton, Ontario L8N4A6, Canada
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Samona J, Cook C, Krupa K, Swatsell K, Jackson A, Dukes C, Martin S. Effect of Intraoperative Dexamethasone on Pain Scores and Narcotic Consumption in Patients Undergoing Total Knee Arthroplasty. Orthop Surg 2017; 9:110-114. [PMID: 28294528 DOI: 10.1111/os.12313] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 04/04/2016] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To examine whether the addition of intravenous dexamethasone during total knee arthroplasty (TKA) would be effective at reducing postoperative pain scores and postoperative opioid consumption. METHODS A total of 102 patients undergoing TKA were placed into two groups: 55 subjects received intraoperative dexamethasone 8 mg intravenously (treatment group) and 47 did not receive dexamethasone at any time during the perioperative period. Comparison was made using the 0-10 numeric pain rating scale and the amount of opioids used in each group. RESULTS Patients who received dexamethasone required significantly less oral opioids compared to the control group. Pain scores at 24 h post-surgery were significantly less for the dexamethasone group compared to the control group. There was no difference between groups in regards to patient-controlled analgesic dose or pain scores in the post-anesthesia care unit, at 12 or 48 h post-surgery. CONCLUSION A single dose of dexamethasone given intraoperatively significantly decreased oral narcotic consumption and decreased pain scores 24 h postoperatively. Dexamethasone appears to be a safe modality to use to control pain in patients undergoing TKA.
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Affiliation(s)
- Jason Samona
- Hurley Medical Center Master of Anesthesia Program, University of Michigan-Flint, Flint, Michigan, USA.,Department of Orthopaedic Surgery, Hurley Medical Center, Flint, Michigan, USA
| | - Carrie Cook
- Hurley Medical Center Master of Anesthesia Program, University of Michigan-Flint, Flint, Michigan, USA.,Department of Orthopaedic Surgery, Hurley Medical Center, Flint, Michigan, USA
| | - Kyle Krupa
- Hurley Medical Center Master of Anesthesia Program, University of Michigan-Flint, Flint, Michigan, USA.,Department of Orthopaedic Surgery, Hurley Medical Center, Flint, Michigan, USA
| | - Krystle Swatsell
- Hurley Medical Center Master of Anesthesia Program, University of Michigan-Flint, Flint, Michigan, USA.,Department of Orthopaedic Surgery, Hurley Medical Center, Flint, Michigan, USA
| | - Andrew Jackson
- Hurley Medical Center Master of Anesthesia Program, University of Michigan-Flint, Flint, Michigan, USA.,Department of Orthopaedic Surgery, Hurley Medical Center, Flint, Michigan, USA
| | - Chase Dukes
- Hurley Medical Center Master of Anesthesia Program, University of Michigan-Flint, Flint, Michigan, USA.,Department of Orthopaedic Surgery, Hurley Medical Center, Flint, Michigan, USA
| | - Sidney Martin
- Hurley Medical Center Master of Anesthesia Program, University of Michigan-Flint, Flint, Michigan, USA.,Department of Orthopaedic Surgery, Hurley Medical Center, Flint, Michigan, USA
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Chen P, Li X, Sang L, Huang J. Perioperative intravenous glucocorticoids can decrease postoperative nausea and vomiting and pain in total joint arthroplasty: A meta-analysis and trial sequence analysis. Medicine (Baltimore) 2017; 96:e6382. [PMID: 28353565 PMCID: PMC5380249 DOI: 10.1097/md.0000000000006382] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND This meta-analysis aimed to demonstrate the efficacy and safety of intravenous glucocorticoids for reducing pain intensity and postoperative nausea and vomiting (PONV) in patients undergoing total joint arthroplasty (TJA). METHODS PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and Google databases were searched for randomized controlled trials (RCTs) comparing intravenous glucocorticoids versus no intravenous glucocorticoids or sham for patients undergoing TJA. Outcomes included visual analogue scale (VAS) pain at 12, 24, and 48 hours; the occurrence of PONV; length of hospital stay; the occurrence of infection; and blood glucose levels after surgery. We calculated risk ratios (RR) with a 95% confidence interval (CI) for dichotomous outcomes and the weighted mean difference (WMD) with a 95% CI for continuous outcomes. Trial sequential analysis was also used to verify the pooled results. RESULTS Thirteen clinical trials involving 821 patients were ultimately included in this meta-analysis. The pooled results indicated that intravenous steroids can decrease VAS at 12 hours (WMD = -8.54, 95% CI -11.55 to -5.53, P = 0.000; I = 35.1%), 24 hours (WMD = -7.48, 95% CI -13.38 to -1.59, P = 0.013; I = 91.8%), and 48 hours (WMD = -1.90, 95% CI -3.75 to -0.05, P = 0.044; I = 84.5%). Intravenous steroids can decrease the occurrence of PONV (RR = 0.56, 95% CI 0.44-0.73, P = 0.000; I = 33.1%). There was no significant difference in the length of hospital stay, occurrence of infection, and blood glucose levels after surgery. CONCLUSION Intravenous glucocorticoids not only alleviate early pain intensity but also decrease PONV after TJA. More high-quality RCTs are required to determine the safety of glucocorticoids before making final recommendations.
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Affiliation(s)
- Ping Chen
- Department of Orthopedics, The 2nd Affiliated Hospital of Guangzhou University of Chinese Medicine
| | - Xiwen Li
- Guangzhou University of Chinese Medicine, Guangzhou
| | - Lili Sang
- Department of Orthopedic, Traditional Chinese Medicine Hospital of Zhongshan, Zhongshan, Guangdong, China
| | - Jiangfa Huang
- Department of Orthopedics, The 2nd Affiliated Hospital of Guangzhou University of Chinese Medicine
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Frequency of Shoulder Corticosteroid Injections for Pain and Stiffness After Shoulder Surgery and Their Potential to Enhance Outcomes with Physiotherapy: A Retrospective Study. Pain Ther 2017; 6:45-60. [PMID: 28185130 PMCID: PMC5447542 DOI: 10.1007/s40122-017-0065-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Indexed: 11/03/2022] Open
Abstract
Introduction What is the rate of injecting patients with shoulder corticosteroid injections to alleviate excessive stiffness and pain within 6 months after shoulder surgery? Methods Retrospective 10-year review of a shoulder surgeon’s practice. Participants included 754 patients who had 945 non-arthroplasty shoulder surgeries. Outcome measures included the rate of injections, diagnoses, patient characteristics, and efficacy via questionnaire. Results Approximately one in five patients received a subacromial and/or glenohumeral corticosteroid injection. Over 95% of patients stated that the injections helped reduce shoulder pain and increased function 6 weeks post-injection. Twenty-two percent of cases (208/945) received glenohumeral and/or subacromial injections. The 208 injected cases had these diagnoses: rotator cuff tear (28% of injected patients), subacromial impingement (20%), glenohumeral instability (16%), subacromial impingement with acromioclavicular osteoarthritis (10%), adhesive capsulitis (7%), SLAP lesion (5%), biceps tendinopathy (3%), glenohumeral instability with subacromial impingement (3%), proximal humerus fracture (2%), calcific tendinitis (2%), and less common conditions (4%). Diagnoses among those with the highest rates of injected patients per diagnosis included: SLAP lesions (40%), calcific tendinitis (40%), adhesive capsulitis (29%), subacromial impingement (28%), proximal humerus fracture (24%), rotator cuff tear (19%), and glenohumeral instability (16%). Significant differences (p < 0.03) were found between patients who did and did not receive injections with respect to age (more likely younger patients with cuff tear) and sex (more likely female with subacromial impingement and instability) but not for diabetes or arthroscopic vs. open procedures. Conclusion This is the first study to establish the rates of postoperative shoulder corticosteroid injections within the first 6 months after various non-arthroplasty shoulder surgeries for patients with high pain/stiffness. These data will be useful for establishing guidelines for using corticosteroid injections along with physiotherapy.
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Shalu PS, Ghodki PS. To Study the Efficacy of Intravenous Dexamethasone in Prolonging the Duration of Spinal Anesthesia in Elective Cesarean Section. Anesth Essays Res 2017; 11:321-325. [PMID: 28663614 PMCID: PMC5490098 DOI: 10.4103/0259-1162.194537] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background and Aims: Various additives have been evaluated for the purpose of enhancing quality of analgesia and prolonging duration of spinal anesthesia. This randomized, double-blind study was conducted to evaluate the efficacy of intravenous dexamethasone in spinal anesthesia. Methods: A total of sixty patients scheduled for lower segment cesarean section under spinal anesthesia were randomly allocated into two groups, group SD and group SN, including thirty patients each. All the patients received injection bupivacaine 0.5% heavy 10 mg through spinal anesthesia. Group SD received injection dexamethasone 8 mg intravenously, and group SN received injection normal saline (NS) 2 cc immediately after spinal anesthesia. Duration of sensory block, motor block, postoperative analgesia, visual analog pain scale (VAS) score, time of rescue analgesia, total analgesic requirement in the first 24 h, intra- and post-operative hemodynamics, and side effects if any were recorded. Whenever demanded rescue analgesia was given in the form of injection tramadol 100 mg. Results: The mean duration of sensory block (min) in group SD and group SN was 162.50 and 106.17, respectively which was highly significant. Similarly, time to the requirement of first rescue analgesia was prolonged in group SD (8.67 h) as compared to group SN (4.40 h). Significant changes were also seen in VAS score in postoperative period after 1 h of surgery in group SD and group SN. Duration of motor block, intra- and post-operative hemodynamic parameters were comparable in both the groups. No side effects were recorded in both the groups. Conclusion: We concluded that administration of dexamethasone 8 mg intravenously prolongs the duration of postoperative analgesia and sensory block in patients undergoing lower segment cesarean section under spinal anesthesia.
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Methylprednisolone reduces pain and decreases knee swelling in the first 24 h after fast-track unicompartmental knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2017; 25:284-290. [PMID: 25564196 DOI: 10.1007/s00167-014-3501-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Accepted: 12/23/2014] [Indexed: 02/06/2023]
Abstract
PURPOSE Unicompartmental knee arthroplasty (UKA) results in less operative trauma and faster patient recovery than after a conventional total knee arthroplasty. Despite an increased focus on multimodal analgesic strategies, there is still a substantial level of patient-reported pain in the early postsurgical period after UKA. The purpose of the study was to evaluate the effect of a single preoperative dose of systemic methylprednisolone on postsurgical pain after fast-track UKA. METHODS Seventy-two patients in two consecutive series undergoing unilateral UKA were included in a prospective cohort study. The patients (n = 35) in the treatment group received a single preoperative dose of systemic methylprednisolone 125 mg, whereas the control group (n = 37) did not. Outcome measures were postsurgical pain at rest and during walking, consumption of opioids for pain rescue, knee swelling and knee range of motion, and complications. RESULTS In the first 24 h after surgery, the treatment group had less pain at rest (p < 0.001) and during walking (p < 0.001) and less consumption of opioids (p = 0.01) in comparison with the control group. Furthermore, the treatment group had 2.2 cm less knee swelling (p = 0.02) in the first post-operative day, and better knee extension (p = 0.004), whereas knee flexion was similar (n.s.) between groups. No serious complications were associated with the treatment. CONCLUSION Addition of a single preoperative dose of 125 mg systemic methylprednisolone to a multimodal analgesic regime significantly reduced postsurgical pain and opioid consumption and decreased knee swelling in the first 24 h after fast-track UKA. LEVEL OF EVIDENCE Therapeutic study, Level II.
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Analgesic Effect of Dexamethasone after Arthroscopic Knee Surgery: A Randomized Controlled Trial. Pain Res Manag 2016; 2016:4216469. [PMID: 27795670 PMCID: PMC5067317 DOI: 10.1155/2016/4216469] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 05/08/2016] [Indexed: 02/08/2023]
Abstract
Background. Dexamethasone is sometimes used as a coanalgesic because of its anti-inflammatory properties. Objective. To evaluate opioid use, postoperative pain intensity, and side effects after a single dose of dexamethasone in patients undergoing arthroscopic knee surgery. Methods. In this randomized controlled study patients were randomized to receive either 10 mg of intravenous dexamethasone (DM group) or 0.9% normal saline (NS group) during the intraoperative period. Primary outcomes were pain intensity and total morphine and codeine use after surgery. Results. Seventy-eight patients were included in the study. The DM group showed statistically significant higher pain intensity at the fourth postoperative hour (DM: 3.96/10, standard deviation [SD] 0.54; NS: 2.46/10, SD 0.45; p = 0.036). No statistically significant difference in total opioid use (morphine plus codeine) was identified with 15.9 (SD 1.97) codeine tablets used in DM group and 20 (SD 2.14) in NS group (p = 0.25). Discussion. Pain intensity tended to decrease in both groups suggesting morphine as the main source of analgesia. Conclusions. Intravenous dexamethasone during the intraoperative period has no clinical impact on postoperative pain intensity during the first 48 h after arthroscopic knee surgery. This trial is registered with R000020892.
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Aksakal M, Ermutlu C, Özkaya G, Özkan Y. Lornoxicam injection is inferior to betamethasone in the treatment of subacromial impingement syndrome. DER ORTHOPADE 2016; 46:179-185. [DOI: 10.1007/s00132-016-3302-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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65
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Analgesic effect of a single dose of betamethasone after ambulatory knee arthroscopy: a randomized controlled trial. J Anesth 2016; 30:803-10. [DOI: 10.1007/s00540-016-2209-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 06/21/2016] [Indexed: 10/21/2022]
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Chow E, Meyer RM, Ding K, Nabid A, Chabot P, Wong P, Ahmed S, Kuk J, Dar AR, Mahmud A, Fairchild A, Wilson CF, Wu JSY, Dennis K, Brundage M, DeAngelis C, Wong RKS. Dexamethasone in the prophylaxis of radiation-induced pain flare after palliative radiotherapy for bone metastases: a double-blind, randomised placebo-controlled, phase 3 trial. Lancet Oncol 2015; 16:1463-1472. [PMID: 26489389 DOI: 10.1016/s1470-2045(15)00199-0] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 07/23/2015] [Accepted: 07/24/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND Pain flare occurs after palliative radiotherapy, and dexamethasone has shown potential for prevention of such flare. We aimed to compare the efficacy of dexamethasone with that of placebo in terms of reduction of incidence of pain flare. METHODS In this double-blind, randomised, placebo-controlled phase 3 trial, patients from 23 Canadian centres were randomly allocated (1:1) with a web-based system and minimisation algorithm to receive either two 4 mg dexamethasone tablets or two placebo tablets taken orally at least 1 h before the start of radiation treatment (a single 8 Gy dose to bone metastases; day 0) and then every day for 4 days after radiotherapy (days 1-4). Patients were eligible if they had a non-haematological malignancy and bone metastasis (or metastases) corresponding to the clinically painful area or areas. Patients reported their worst pain scores and opioid analgesic intake before treatment and daily for 10 days after radiation treatment. They completed the European Organisation for Research and Treatment of Cancer (EORTC) quality of life QLQ-C15-PAL, the bone metastases module (EORTC QLQ-BM22), and the Dexamethasone Symptom Questionnaire at baseline, and at days 10 and 42 after radiation treatment. Pain flare was defined as at least a two-point increase on a scale of 0-10 in the worst pain score with no decrease in analgesic intake, or a 25% or greater increase in analgesic intake with no decrease in the worst pain score from days 0-10, followed by a return to baseline levels or below. Primary analysis of incidence of pain flare was by intention-to-treat (patients with missing primary data were classified as having pain flare). This study is registered with ClinicalTrials.gov, number NCT01248585, and is completed. FINDINGS Between May 30, 2011, and Dec 11, 2014, 298 patients were enrolled. 39 (26%) of 148 patients randomly allocated to the dexamethasone group and 53 (35%) of 150 patients in the placebo group had a pain flare (difference 8·9%, lower 95% confidence bound 0·0, one-sided p=0·05). Two grade 3 and one grade 4 biochemical hyperglycaemic events occurred in the dexamethasone group (without known clinical effects) compared with none in the placebo group. The most common adverse events were bone pain (61 [41%] of 147 vs 68 [48%] of 143), fatigue (58 [39%] of 147 vs 49 [34%] of 143), constipation (47 [32%] of 147 vs 37 [26%] of 143), and nausea (34 [23%] of 147 vs 34 [24%] of 143), most of which were mild grade 1 or 2. INTERPRETATION Dexamethasone reduces radiation-induced pain flare in the treatment of painful bone metastases. FUNDING The NCIC CTG's programmatic grant from the Canadian Cancer Society Research Institute.
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Affiliation(s)
- Edward Chow
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada.
| | - Ralph M Meyer
- Juravinski Hospital and Cancer Centre and McMaster University, Hamilton, ON, Canada
| | - Keyue Ding
- NCIC Clinical Trials Group, Cancer Research Institute, Queen's University, Kingston, ON, Canada
| | - Abdenour Nabid
- Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | | | - Philip Wong
- Centre Hospitalier de L'Université de Montréal, Montreal, QC, Canada
| | | | - Joda Kuk
- Grand River Regional Cancer Centre, Grand River Hospital, Kitchener, ON, Canada
| | - A Rashid Dar
- London Regional Cancer Program, London, ON, Canada
| | - Aamer Mahmud
- Cancer Centre of Southeastern Ontario, Kingston General Hospital, Kingston, ON, Canada
| | | | - Carolyn F Wilson
- NCIC Clinical Trials Group, Cancer Research Institute, Queen's University, Kingston, ON, Canada
| | - Jackson S Y Wu
- Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | - Kristopher Dennis
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | | | - Carlo DeAngelis
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Rebecca K S Wong
- Princess Margaret Hospital, Radiation Medicine Program, Ontario Cancer Institute, University of Toronto, Toronto, ON, Canada
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Asad MV, Khan FA. Effect of a single bolus of dexamethasone on intraoperative and postoperative pain in unilateral inguinal hernia surgery. J Anaesthesiol Clin Pharmacol 2015; 31:339-43. [PMID: 26330712 PMCID: PMC4541180 DOI: 10.4103/0970-9185.161669] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background and Aims: Opioids are commonly used to provide perioperative analgesia, but have many side-effects. Addition of co-analgesics results in reducing the dosage and hence the side-effects of opioids. The objective of this study was to compare the analgesic efficacy of fentanyl (1 micro/kg−1) administered alone, with fentanyl (0.75 micro/kg−1) and dexamethasone (8 mg) combination, in patients undergoing day care unilateral inguinal hernia repair. Material and Methods: Patients scheduled for the day care unilateral inguinal hernia repair were randomized to receive either saline and fentanyl 1 micro/kg−1 (control group) or 8 mg dexamethasone with fentanyl 0.75 micro/kg−1 (study group) immediately before induction of anesthesia in a double-blind clinical trial. Anesthesia technique and rescue analgesia regimen were standardized. Intraoperatively, pain was assessed based on hemodynamic variability and postoperatively by visual analog scale. Results: The mean heart rate, systolic and the diastolic blood pressure at 1, 5, 20 and at 30 min after incision, were significantly higher in the control group (P ≤ 0.001) when compared to the study group. Intra-operative rescue analgesia was required in 32 (100%) and 19 (59.4%) patients in control group and study group respectively (P = 0.0002). Mean pain scores measured at fixed time periods postoperatively were significantly higher in the control group when compared to study group (P ≤ 0.001). Postoperative rescue analgesia was needed in 32 (100%) versus 24 (75%) patients in the control group and study group respectively, but this difference was not statistically significant (P = 0.285). Conclusion: We conclude that the addition of 8 mg of preoperative intravenous dexamethasone to 0.75 micro/kg−1 fentanyl was effective in reducing intraoperative and postoperative pain in the 1st h after unilateral inguinal hernia surgery.
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Affiliation(s)
| | - Fauzia Anis Khan
- Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan
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Preemptive multimodal analgesia for postoperative pain management after lumbar fusion surgery: a randomized controlled trial. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:1614-1619. [PMID: 26324284 DOI: 10.1007/s00586-015-4216-3] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 08/26/2015] [Accepted: 08/26/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE To assess the efficacy of a novel preemptive multimodal analgesic regimen for reducing postoperative pain and complications after primary lumbar fusion surgery. Preemptive multimodal analgesia is revealed to be an effective alternative to conventional morphine administration providing improved postoperative pain control with diminished side effects. However, an optimal regimen for spinal fusion surgery remains unknown. METHODS After Institutional Review Board approval, 80 patients who underwent primary lumbar 4-5 fusion surgery were randomly assigned to receive either only intravenous morphine or a preemptive multimodal (celecoxib, pregabalin, extended-release oxycodone, and acetaminophen) analgesic regimen. Postoperative pain and functional levels were measured by the visual analog scale (VAS) and Oswestry Disability Index (ODI), respectively, and intraoperative blood loss, postoperative Hemovac drain output, and nonunion rates were evaluated for complications. RESULTS No differences were observed in the patient demographics, intraoperative blood loss, postoperative Hemovac drain output, or nonunion rate between two groups. The VAS and ODI were lower at all postoperative time points, except the ODI on postoperative day 1 in patients randomized to receive the preemptive multimodal analgesic regimen. No major identifiable postoperative complications were observed in either treatment group. CONCLUSIONS The preemptive multimodal analgesic combination in this study appears to be safe and effective after lumbar fusion surgery.
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Halawi MJ, Grant SA, Bolognesi MP. Multimodal Analgesia for Total Joint Arthroplasty. Orthopedics 2015; 38:e616-25. [PMID: 26186325 DOI: 10.3928/01477447-20150701-61] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 07/17/2014] [Indexed: 02/03/2023]
Abstract
Optimal perioperative pain control for total joint arthroplasty remains a challenge. Whereas traditional regimens have relied heavily on opioids, newer multimodal pathways are increasingly gaining popularity as safer and more effective alternatives. The main premise of multimodal analgesia is decreased consumption of opioids, and hence lesser opioid-related adverse events. Other reported advantages include lower pain scores, faster functional recovery, higher patient satisfaction, and shorter length of hospital stay. Unfortunately, despite the advent of numerous analgesic techniques, the multimodal approach has remained widely variable, making direct comparison between studies difficult to interpret. This article provides an extensive review of traditional and modern perioperative interventions in pain management for total joint arthroplasty, including intravenous patient-controlled analgesia, epidural infusion, oral opioids, nonsteroidal anti-inflammatory drugs, acetaminophen, peripheral nerve blocks, periarticular infiltration, steroids, anticonvulsants, and long-acting local anesthetics. Emphasis is placed on pathophysiology, clinical evidence, and timing. A standardized multimodal analgesia protocol is also proposed based on best available evidence. In addition to pharmacologic interventions, patient education and interdisciplinary collaboration among the care teams play an important role in the success of any treatment pathway. With a growing demand for total joint arthroplasty in an era of bundled payments and accountable care, there has never been a greater need for a standardized multimodal analgesia pathway.
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Zhao X, Qin J, Tan Y, Mohanan R, Hu D, Chen L. Efficacy of steroid addition to multimodal cocktail periarticular injection in total knee arthroplasty: a meta-analysis. J Orthop Surg Res 2015; 10:75. [PMID: 25994175 PMCID: PMC4443605 DOI: 10.1186/s13018-015-0214-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 05/04/2015] [Indexed: 02/08/2023] Open
Abstract
Background Total knee arthroplasty (TKA) has been reported to be the most successful treatment for patients with advanced osteoarthritis, however, early postoperative pain has become an unresolved issue. The aim of this Meta-analysis is to evaluate the efficacy and safety of steroid addition to multimodal cocktail periarticular injection (MCPI) in patients undergoing TKA. Method Clinical randomized controlled trials concerning the efficacy and safety of MCPI containing steroids in TKA published up to December 2014 were retrieved from PubMed, Cochrane library, EMbase databases. The methodological quality of the included studies was assessed by the 12-item scale. Data analysis was performed using StataSE12.0. Results Six randomized controlled trials involving a total of 567 patients were assessed; the steroid group included 305 patients, and the control group included 262 patients. The meta-analysis showed that MCPI with steroids in TKA significantly reduced postoperative pain; duration of time required to perform straight-leg raising and length of hospital stay was (P < 0.05). Neither the early postoperative nor the long-term range of motion of knee showed any statistical difference between the non-steroid and steroid group (P >0.05). For safety, steroids did not increase the incidence of postoperative infection and wound oozing (P >0.05); no tendon rupture was reported up to now. In addition, steroids did not decrease the postoperative drainage through the reduction of prostaglandins (P >0.05). Conclusion For patients undergoing TKA, the addition of steroids to MCPI improved the analgesic effect and was proved to be highly safe. The duration of time required to perform straight-leg raising and length of hospital stay was significantly reduced. However, MCPI with steroids neither increased the early postoperative range of motion (ROM) or the long-term ROM of knee, nor did it reduce the postoperative drainage. However, the best results are acquired in patients without any altered immunological status.
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Affiliation(s)
- Xinyu Zhao
- Department of Orthopaedics, Zhongnan Hospital of Wuhan University, School of Medicine, Wuhan University, 169 Donghu Road, Wuhan, Hubei Province , 430071, China.
| | - Jun Qin
- Department of Orthopaedics, Zhongnan Hospital of Wuhan University, School of Medicine, Wuhan University, 169 Donghu Road, Wuhan, Hubei Province , 430071, China.
| | - Yang Tan
- Department of Orthopaedics, Zhongnan Hospital of Wuhan University, School of Medicine, Wuhan University, 169 Donghu Road, Wuhan, Hubei Province , 430071, China.
| | - Rahul Mohanan
- Department of Orthopaedics, Zhongnan Hospital of Wuhan University, School of Medicine, Wuhan University, 169 Donghu Road, Wuhan, Hubei Province , 430071, China.
| | - Dongcai Hu
- Department of Orthopaedics, Zhongnan Hospital of Wuhan University, School of Medicine, Wuhan University, 169 Donghu Road, Wuhan, Hubei Province , 430071, China.
| | - Liaobin Chen
- Department of Orthopaedics, Zhongnan Hospital of Wuhan University, School of Medicine, Wuhan University, 169 Donghu Road, Wuhan, Hubei Province , 430071, China.
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Jain R, Dua CK. Comparative analgesic efficacy of different doses of dexamethasone during infraumbilical surgery: A Randomized controlled trial. Anesth Essays Res 2015; 9:34-8. [PMID: 25886418 PMCID: PMC4383110 DOI: 10.4103/0259-1162.150153] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Postoperative pain is a common complaint and despite the availability of various drugs, is still not managed well. Analgesic effects of glucocorticoids are still to be substantially established. Hence, we designed randomized, double-blind, placebo-controlled trial to compare the effect of two different doses of dexamethasone on postoperative pain in patients undergoing infra-umbilical surgeries under spinal anesthesia. Methods: Ninety American Society of Anesthesiologists Grade I and II patients were randomized to receive injection dexamethasone 8 mg (Group DI), dexamethasone 16 mg (Group DII) or placebo (Group C) prior to performance of intrathecal block. Outcome studied was postoperative pain on the rest and motion and nausea and vomiting. Result: There was no difference in Visual Analog Scale (VAS) scores during rest in all the three groups. However, VAS scores on motion showed a significant decrease in Group DII at 24 and 36 h when compared to Group C (95% confidence interval [CI] of mean at 24 h for Group C = 5.6093–7.1049 and Group DII = 4.8709–5.9567, P = 0.04; 95% CI of mean at 36 h for Group C = 4.5868–5.8418 and Group DII = 3.5388–4.7378, P = 0.01). There was no significant difference in the incidence of postoperative nausea and vomiting or additional analgesic requirements. Conclusion: Dexamethasone 16 mg reduces postoperative pain on motion at 24 and 36 h. It has no effect on postoperative pain at rest or on nausea and vomiting.
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Affiliation(s)
- Ragi Jain
- Department of Anaesthesia, Santosh Medical and Dental College and Hospital, Ghaziabad, Uttar Pradesh, India
| | - C K Dua
- Department of Anaesthesia, Santosh Medical and Dental College and Hospital, Ghaziabad, Uttar Pradesh, India
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Widar F, Kashani H, Alsén B, Dahlin C, Rasmusson L. The effects of steroids in preventing facial oedema, pain, and neurosensory disturbances after bilateral sagittal split osteotomy: a randomized controlled trial. Int J Oral Maxillofac Surg 2015; 44:252-8. [DOI: 10.1016/j.ijom.2014.08.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 04/22/2014] [Accepted: 08/12/2014] [Indexed: 12/31/2022]
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Paulsen Ø, Klepstad P, Rosland JH, Aass N, Albert E, Fayers P, Kaasa S. Efficacy of Methylprednisolone on Pain, Fatigue, and Appetite Loss in Patients With Advanced Cancer Using Opioids: A Randomized, Placebo-Controlled, Double-Blind Trial. J Clin Oncol 2014; 32:3221-8. [DOI: 10.1200/jco.2013.54.3926] [Citation(s) in RCA: 131] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Corticosteroids are frequently used in cancer pain management despite limited evidence. This study compares the analgesic efficacy of corticosteroid therapy with placebo. Patients and Methods Adult patients with cancer receiving opioids with average pain intensity ≥ 4 (numeric rating scale [NRS], 0 to 10) in the last 24 hours were eligible. Patients were randomly assigned to methylprednisolone (MP) 16 mg twice daily or placebo (PL) for 7 days. Primary outcome was average pain intensity measured at day 7 (NRS, 0 to 10); secondary outcomes were analgesic consumption (oral morphine equivalents), fatigue and appetite loss (European Organisation for Research and Treatment of Cancer–Quality of Life Questionnaire C30, 0 to 100), and patient satisfaction (NRS, 0 to 10). Results A total of 592 patients were screened; 50 were randomly assigned, and 47 were analyzed. Baseline opioid level was 269.9 mg in the MP arm and 160.4 mg in the PL arm. At day-7 evaluation, there was no difference between the groups in pain intensity (MP, 3.60 v PL, 3.68; P = .88) or relative analgesic consumption (MP, 1.19 v PL, 1.20; P = .95). Clinically and statistically significant improvements were found in fatigue (−17 v 3 points; P .003), appetite loss (−24 v 2 points; P = .003), and patient satisfaction (5.4 v 2.0 points; P = .001) in favor of the MP compared with the PL group, respectively. There were no differences in adverse effects between the groups. Conclusion MP 32 mg daily did not provide additional analgesia in patients with cancer receiving opioids, but it improved fatigue, appetite loss, and patient satisfaction. Clinical benefit beyond a short-term effect must be examined in a future study.
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Affiliation(s)
- Ørnulf Paulsen
- Ørnulf Paulsen, Telemark Hospital Trust, Skien; Ørnulf Paulsen, Pål Klepstad, Peter Fayers, and Stein Kaasa, Norwegian University of Science and Technology; Pål Klepstad and Stein Kaasa, St Olavs Hospital, Trondheim University Hospital, Trondheim; Jan Henrik Rosland, Haraldsplass Deaconess Hospital and University of Bergen, Bergen; Nina Aass, Oslo University Hospital and University of Oslo, Oslo; Eva Albert, Sørlandet Hospital Kristiansand, Kristiansand, Norway; and Peter Fayers, University of Aberdeen,
| | - Pål Klepstad
- Ørnulf Paulsen, Telemark Hospital Trust, Skien; Ørnulf Paulsen, Pål Klepstad, Peter Fayers, and Stein Kaasa, Norwegian University of Science and Technology; Pål Klepstad and Stein Kaasa, St Olavs Hospital, Trondheim University Hospital, Trondheim; Jan Henrik Rosland, Haraldsplass Deaconess Hospital and University of Bergen, Bergen; Nina Aass, Oslo University Hospital and University of Oslo, Oslo; Eva Albert, Sørlandet Hospital Kristiansand, Kristiansand, Norway; and Peter Fayers, University of Aberdeen,
| | - Jan Henrik Rosland
- Ørnulf Paulsen, Telemark Hospital Trust, Skien; Ørnulf Paulsen, Pål Klepstad, Peter Fayers, and Stein Kaasa, Norwegian University of Science and Technology; Pål Klepstad and Stein Kaasa, St Olavs Hospital, Trondheim University Hospital, Trondheim; Jan Henrik Rosland, Haraldsplass Deaconess Hospital and University of Bergen, Bergen; Nina Aass, Oslo University Hospital and University of Oslo, Oslo; Eva Albert, Sørlandet Hospital Kristiansand, Kristiansand, Norway; and Peter Fayers, University of Aberdeen,
| | - Nina Aass
- Ørnulf Paulsen, Telemark Hospital Trust, Skien; Ørnulf Paulsen, Pål Klepstad, Peter Fayers, and Stein Kaasa, Norwegian University of Science and Technology; Pål Klepstad and Stein Kaasa, St Olavs Hospital, Trondheim University Hospital, Trondheim; Jan Henrik Rosland, Haraldsplass Deaconess Hospital and University of Bergen, Bergen; Nina Aass, Oslo University Hospital and University of Oslo, Oslo; Eva Albert, Sørlandet Hospital Kristiansand, Kristiansand, Norway; and Peter Fayers, University of Aberdeen,
| | - Eva Albert
- Ørnulf Paulsen, Telemark Hospital Trust, Skien; Ørnulf Paulsen, Pål Klepstad, Peter Fayers, and Stein Kaasa, Norwegian University of Science and Technology; Pål Klepstad and Stein Kaasa, St Olavs Hospital, Trondheim University Hospital, Trondheim; Jan Henrik Rosland, Haraldsplass Deaconess Hospital and University of Bergen, Bergen; Nina Aass, Oslo University Hospital and University of Oslo, Oslo; Eva Albert, Sørlandet Hospital Kristiansand, Kristiansand, Norway; and Peter Fayers, University of Aberdeen,
| | - Peter Fayers
- Ørnulf Paulsen, Telemark Hospital Trust, Skien; Ørnulf Paulsen, Pål Klepstad, Peter Fayers, and Stein Kaasa, Norwegian University of Science and Technology; Pål Klepstad and Stein Kaasa, St Olavs Hospital, Trondheim University Hospital, Trondheim; Jan Henrik Rosland, Haraldsplass Deaconess Hospital and University of Bergen, Bergen; Nina Aass, Oslo University Hospital and University of Oslo, Oslo; Eva Albert, Sørlandet Hospital Kristiansand, Kristiansand, Norway; and Peter Fayers, University of Aberdeen,
| | - Stein Kaasa
- Ørnulf Paulsen, Telemark Hospital Trust, Skien; Ørnulf Paulsen, Pål Klepstad, Peter Fayers, and Stein Kaasa, Norwegian University of Science and Technology; Pål Klepstad and Stein Kaasa, St Olavs Hospital, Trondheim University Hospital, Trondheim; Jan Henrik Rosland, Haraldsplass Deaconess Hospital and University of Bergen, Bergen; Nina Aass, Oslo University Hospital and University of Oslo, Oslo; Eva Albert, Sørlandet Hospital Kristiansand, Kristiansand, Norway; and Peter Fayers, University of Aberdeen,
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Betamethasone in prevention of postoperative nausea and vomiting following breast surgery. J Clin Anesth 2014; 26:461-5. [DOI: 10.1016/j.jclinane.2014.02.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 02/10/2014] [Accepted: 02/12/2014] [Indexed: 11/20/2022]
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Uesugi K, Kitano N, Kikuchi T, Sekiguchi M, Konno SI. Comparison of peripheral nerve block with periarticular injection analgesia after total knee arthroplasty: a randomized, controlled study. Knee 2014; 21:848-52. [PMID: 24827696 DOI: 10.1016/j.knee.2014.04.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Revised: 04/03/2014] [Accepted: 04/09/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Pain after total knee arthroplasty (TKA) is usually severe. Recently, the usefulness of local periarticular injection analgesia (PAI) and peripheral nerve block (PNB) has been reported. We report a prospective blinded randomized trial of PAI versus PNB in patients undergoing primary TKA, in accordance with the CONSORT statement 2010. METHODS A total of 210 patients undergoing TKA under spinal anesthesia were randomized to receive PNB group or PAI group. In the PNB group, femoral nerve block and sciatic nerve block were performed. In the PAI group, a special mixture containing ropivacaine, saline, epinephrine, morphine hydrochloride, and dexamethasone was injected into the periarticular soft tissue. Pain intensity at rest was assessed using a numerical rating scale (NRS: 0-10) after surgery. Use of a diclofenac sodium suppository (25mg) was allowed for all patients at any time after surgery, and the diclofenac sodium suppository usage was assessed. The NRS for patient satisfaction at 48 hours after surgery was examined. RESULTS The average NRS for pain at rest up to 48 hours after surgery was low in both groups. Within 48 hours after surgery, the diclofenac sodium suppository usage was similar in both groups. There were no significant differences in the NRS for patient satisfaction in both groups. CONCLUSIONS The analgesic effects of PAI and PNB are similar. PAI may be considered superior to PNB because it is easier to perform. LEVEL OF EVIDENCE Therapeutic Level 1.
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Affiliation(s)
- Kazuhide Uesugi
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan.
| | - Naoko Kitano
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Tadashi Kikuchi
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Miho Sekiguchi
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Shin-Ichi Konno
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
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BJØRNHOLDT KT, MØNSTED PN, SØBALLE K, NIKOLAJSEN L. Dexamethasone for pain after outpatient shoulder surgery: a randomised, double-blind, placebo-controlled trial. Acta Anaesthesiol Scand 2014; 58:751-8. [PMID: 24825530 DOI: 10.1111/aas.12333] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND Dexamethasone has analgesic properties when given intravenously before surgery, but the optimal dose has not been determined. We hypothesised that a dose of 40 mg dexamethasone would improve analgesia after outpatient shoulder surgery compared with 8 mg. METHODS A randomised, double-blind, placebo-controlled clinical trial was conducted at Horsens Regional Hospital, Denmark. Patients scheduled for arthroscopic subacromial decompression and/or acromioclavicular joint resection as an outpatient procedure (n = 101) were randomised to receive intravenous dexamethasone 40 mg (D40), 8 mg (D8) or placebo (D0) before surgery. The primary outcome was pain intensity 8 h after surgery rated on a numeric rating scale of 0 to 10. Secondary outcomes were pain intensity, analgesic consumption and side effects during the first 3 days after surgery. RESULTS Data from 73 patients were available for analysis: (D40: 25, D8: 26, D0: 22 patients). Eight hours after surgery, pain intensity were: [median (interquartile range)] group D40: 2 (1-4), group D8: 2.5 (1-5), group D0: 4 (2-7). There was no significant difference in pain intensity between group D40 and D8 after 8 h (P = 0.46) or at any other time. When comparing all three groups, a statistically significant dose-response relationship was seen for present, average and worst pain intensity after 8 h and on the following morning. No differences were found in analgesic consumption. No serious side effects were observed. CONCLUSION Although our data supported a dose-response relationship, increasing the dexamethasone dose from 8 to 40 mg did not improve analgesia significantly after outpatient shoulder surgery.
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Affiliation(s)
- K. T. BJØRNHOLDT
- Department of Orthopaedics; Horsens Regional Hospital; Horsens Denmark
| | - P. N. MØNSTED
- Department of Orthopaedics; Horsens Regional Hospital; Horsens Denmark
| | - K. SØBALLE
- Department of Orthopaedics; Aarhus University Hospital; Aarhus Denmark
| | - L. NIKOLAJSEN
- Department of Anaesthesiology; Aarhus University Hospital; Aarhus Denmark
- Danish Pain Research Center; Aarhus University Hospital; Aarhus Denmark
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Williams BA, Schott NJ, Mangione MP, Ibinson JW. Perineural Dexamethasone and Multimodal Perineural Analgesia. Anesth Analg 2014; 118:912-4. [DOI: 10.1213/ane.0000000000000203] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Rahimzadeh P, Imani F, Faiz SHR, Nikoubakht N, Sayarifard A. Effect of intravenous methylprednisolone on pain after intertrochanteric femoral fracture surgery. J Clin Diagn Res 2014; 8:GC01-4. [PMID: 24959459 DOI: 10.7860/jcdr/2014/8232.4305] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2013] [Accepted: 02/02/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pain after surgery is one of the major problems in patients with intertrochanteric fracture. This study investigates administration of single-dose Methylprednisolone prior to surgery with the goal of reducing Post-operative pain. MATERIALS AND METHODS The study was a Double Blind Randomized Clinical Trial. Eighty two patients with stable intertrochanteric unilateral fracture were selected and divided into two groups: one received Methylprednisolone (MP) 125 mg and the other received placebo. Pain was evaluated at rest and 45° flexion of the hip in times 4, 6, 8, 12, 24, 36, and 48 hours and during walking in times 24, 36, and 48 hours after the surgery. Post-operative nausea, vomiting and fatigue and changes in C - reactive protein (CRP) levels before and after the surgery were also recorded. RESULTS Pain at rest, 45° flexion of the hip and during walking after the surgery was significantly lower in the MP group compared to the control group (p < 0.001). Fatigue (p = 0.002) and changes in CRP (p=0.001) were significantly lower in MP group. Incidence of nausea, vomiting (p = 0.37) and opioid consumption (p = 0.49) were not significantly different between the two groups. CONCLUSION Single-dose methylprednisolone 125 mg (IV) can reduce Post-operative pain in patients with intertrochanteric fracture undergoing elective surgery.
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Affiliation(s)
- Poupak Rahimzadeh
- Assistant Professor, Anesthesiologist, Department of Anesthesiology and Pain Medicine, Rasoul-Akram Medical Center , Iran. University of Medical Sciences Tehran, Iran
| | - Farnad Imani
- Anesthesiologist, Department of Anesthesiology and Pain Medicine, Rasoul-Akram Medical Center , Iran. University of Medical Sciences, Tehran, Iran
| | - Seyed Hamid Reza Faiz
- Anesthesiologist, Department of Anesthesiology and Pain Medicine, Rasoul-Akram Medical Center , Iran. University of Medical Sciences, Tehran, Iran
| | - Nasim Nikoubakht
- Resident of Anesthesiology, Department of Anesthesiology and Pain Medicine, Rasoul-Akram Medical Center , Iran. University of Medical Sciences, Tehran, Iran
| | - Azadeh Sayarifard
- Assistant Professor, Preventive and Community Medicine Specialist, Community Based Participatory Research Center, Iranian Institute for Reduction of High-Risk Behaviors , Tehran University of Medical Sciences, Tehran, Iran
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79
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Kwon SK, Yang IH, Bai SJ, Han CD. Periarticular injection with corticosteroid has an additional pain management effect in total knee arthroplasty. Yonsei Med J 2014; 55:493-8. [PMID: 24532523 PMCID: PMC3936618 DOI: 10.3349/ymj.2014.55.2.493] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 07/29/2013] [Accepted: 08/20/2013] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Although the analgesic effects of corticosteroids have been well documented, little information is available on periarticular injection (PI) containing corticosteroids for early postoperative pain management after total knee arthroplasty (TKA). We performed a prospective double-blind randomized trial to evaluate the efficacy and safety of an intraoperative corticosteroid PI in patients undergoing TKA. MATERIALS AND METHODS Seventy-six consecutive female patients undergoing bilateral staged TKA were randomized to receive steroid or non-steroid PI, with 3 months separating the procedures. The steroid group received PI with a mixture containing triamcinolone acetonide (40 mg). The non-steroid group received the same injection mixture without corticosteroid. During the postoperative period, nighttime pain, functional recovery [straight leg raising (SLR) ability and maximal flexion], patient satisfaction, and complications were recorded. Short-term postoperative clinical scores and patient satisfaction were evaluated at 6 months. RESULTS The pain level was significantly lower in the PI steroid than the non-steroid group on the night of the operation (VAS, 1.2 vs. 2.3; p=0.021). Rebound pain was observed in both groups at POD1 (VAS, 3.2 vs. 3.8; p=0.248), but pain remained at a low level thereafter. No significant differences were seen in maximal flexion, frequency of acute rescuer, clinical scores, and patient satisfaction. The steroid group was able to perform SLR earlier than the non-steroid group (p=0.013). The incidence of complications was similar between the groups. CONCLUSION PI containing a corticosteroid provided an additional pain-relieving effect on the night of the operation. In addition, corticosteroid PI did not increase the perioperative complications of TKA.
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Affiliation(s)
- Sae Kwang Kwon
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea.
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80
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Naghibi T, Dobakhti F, Mazloomzadeh S, Dabiri A, Molai B. Comparison between intrathecal and intravenous betamethasone for post-operative pain following cesarean section: a randomized clinical trial. Pak J Med Sci 2013; 29:514-8. [PMID: 24353567 PMCID: PMC3809247 DOI: 10.12669/pjms.292.2863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2012] [Revised: 01/05/2013] [Accepted: 01/10/2013] [Indexed: 11/24/2022] Open
Abstract
Objective: Inadequate postoperative pain relief after cesarean section can increase complications. In this study, we evaluated the effect of intrathecal betamethasone as an adjunct to bupivacaine on postoperative pain in patients undergoing cesarean section. Methodology: Ninety-nine patients undergoing cesarean section were assigned to one of three groups. Group 1 (Control) patients received intrathecal bupivacaine, Group 2 patients received intrathecal bupivacaine plus preservative free betamethasone and Group 3 patients received betamethasone intravenously with intrathecal bupivacaine. After surgery, diclofenac in suppository form was administered as needed for analgesia. Postoperative diclofenac requirements, time to first analgesic administration and visual analogue scale pain scores were recorded by a blinded observer. Results: Supplemental analgesic dose requirement with diclofenac for the first 24 hours were significantly less in both groups that received betamethasone compared to the control group (P <0.0001). The mean duration of postoperative analgesia was 336.8±86 min in Intrathecal group and 312.4±106 min in Intravenous group compared with 245.4±93 min in control group (P =0.001). Visual analogue scale scores were significantly less at 4 hours (P<0.0001) and 6 hours (P<0.0001) after surgery in groups that received betamethasone in comparison to control group. The pain scores at 6 hours after surgery were higher in the Intravenous group compared with the Intrathecal group (P = 0.001); However visual analogue scale was not different at 12 and 24 hours after surgery between groups (p > 0.05). Conclusion: Intrathecal betamethasone reduced pain and decreased the required dose of diclofenac in 24 hours after cesarean section.
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Affiliation(s)
- Taraneh Naghibi
- Taraneh Naghibi, Department of Anesthesiology and Critical Care Medicine, School of Medicine, Zanjan University of Medical Science, Zanjan, Iran
| | - Faramarz Dobakhti
- Faramarz Dobakhti, School of Pharmacy, Zanjan University of Medical Science, Zanjan, Iran
| | - Saideh Mazloomzadeh
- Saideh Mazloomzadeh, School of Medicine, Zanjan University of Medical Science, Zanjan, Iran
| | - Atosa Dabiri
- Atosa Dabiri, Department of Gynecology and Obstetrics, Zanjan University of Medical Science, Zanjan, Iran
| | - Behnaz Molai
- Behnaz Molai, Department of Gynecology and Obstetrics, School of Medicine, Zanjan University of Medical Science, Zanjan, Iran
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81
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Ikeuchi M, Kamimoto Y, Izumi M, Sugimura N, Takemura M, Fukunaga K, Yokoyama M, Tani T. Local infusion analgesia using intra-articular double lumen catheter after total knee arthroplasty: a double blinded randomized control study. Knee Surg Sports Traumatol Arthrosc 2013; 21:2680-4. [PMID: 22491708 DOI: 10.1007/s00167-012-2004-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 04/02/2012] [Indexed: 11/28/2022]
Abstract
PURPOSE Although intra-operative local infiltration analgesia has gained increasing popularity in joint replacement surgery, it is not clear whether postoperative local infusion analgesia using an indwelling catheter provides clinically important additional effects. We, therefore, conducted a randomized controlled trial to clarify the efficacy of the originally developed local infusion analgesia technique in total knee arthroplasty. METHODS Forty patients were randomly allocated to the local infusion analgesia or control group. Patients in the local infusion analgesia group received intermittent bolus intra-articular injection of analgesics consisting of ropivacaine, dexamethasone, and isepamicin until postoperative 48 h. Primary outcome was pain severity at rest using 100-mm visual analogue scale. RESULTS Pain severity in patients of the local infusion analgesia group was lower than control group, and there were significant differences between groups at POD1 (p = 0.025) and POD3 (p = 0.007). Reduction of postoperative pain was associated with a decrease in C-reactive protein level and earlier achievement of straight leg raise. In addition, postoperative drain volume was reduced in the local infusion analgesia group. CONCLUSION Although larger studies are needed to examine its safety, the local infusion analgesia alone provided clinically significant analgesic effects and rapid recovery in total knee arthroplasty.
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Affiliation(s)
- Masahiko Ikeuchi
- Department of Orthopedic Surgery, Kochi University, 185-1 Oko-cho, Nankoku, Kochi, 783-8505, Japan,
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82
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Jiang J, Teng Y, Fan Z, Khan MS, Cui Z, Xia Y. The efficacy of periarticular multimodal drug injection for postoperative pain management in total knee or hip arthroplasty. J Arthroplasty 2013; 28:1882-7. [PMID: 23910819 DOI: 10.1016/j.arth.2013.06.031] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 06/21/2013] [Accepted: 06/23/2013] [Indexed: 02/01/2023] Open
Abstract
The efficacy of periarticular multimodal drug injection (PMDI) to reduce pain after total knee or hip arthroplasty (TKA or THA) still remains controversial. Our study aimed at evaluating the efficacy of PMDI after TKA or THA. A fully recursive literature search was conducted to identify relevant randomized controlled trials. Ultimately, 21 studies were included in the analysis. Pooled results showed that the PMDI group had better pain relief, less opioid consumption, larger range of motion, and lower rates of nausea and vomiting than the placebo group. No significant difference was seen in regard to the length of hospital stay between the two groups. In conclusion, PMDI should be recommended for the pain management after TKA or THA.
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Affiliation(s)
- Jin Jiang
- Orthopaedics Key Laboratory of Gansu province, Department of Orthopaedics, the Second Hospital of Lanzhou University, Lanzhou, Gansu Province, China
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83
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Tumber PS. Optimizing perioperative analgesia for the complex pain patient: medical and interventional strategies. Can J Anaesth 2013; 61:131-40. [PMID: 24242954 DOI: 10.1007/s12630-013-0073-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 10/25/2013] [Indexed: 12/11/2022] Open
Affiliation(s)
- Paul S Tumber
- University Health Network and Wasser Pain Centre, Mt. Sinai Hospital, University of Toronto, Toronto, ON, Canada,
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84
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Koh IJ, Chang CB, Lee JH, Jeon YT, Kim TK. Preemptive low-dose dexamethasone reduces postoperative emesis and pain after TKA: a randomized controlled study. Clin Orthop Relat Res 2013; 471:3010-20. [PMID: 23645340 PMCID: PMC3734432 DOI: 10.1007/s11999-013-3032-5] [Citation(s) in RCA: 102] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2012] [Accepted: 04/25/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Dexamethasone is a potent analgesic and antiemetic. However, the benefit of dexamethasone after TKA is unclear, as is the efficacy in a current multimodal regime. QUESTIONS/PURPOSES We determined (1) whether the addition of dexamethasone to a protocol including ramosetron further reduces postoperative emesis compared with ramosetron alone; (2) whether it reduces postoperative pain; and (3) whether it increases the risk for wound complications in a current multimodal regime after TKA. METHODS We randomized 269 patients undergoing TKAs to receive dexamethasone (10 mg) 1 hour before surgery and ramosetron immediately after surgery (Dexa-Ra group, n = 135), or ramosetron alone (Ra group, n = 134). We recorded the incidence of postoperative nausea and vomiting (PONV), severity of nausea, incidence of antiemetic requirement, complete response, pain level, and opioid consumption. Patients were assessed 0 to 6, 6 to 24, 24 to 48, and 48 to 72 hours postoperatively. In addition, patients were evaluated for wound complications and periprosthetic joint infections at a minimum of 1 year after surgery. RESULTS The Dexa-Ra group had a lower incidence of PONV during the entire 72-hour evaluation period and experienced less severe nausea for the first 6 hours after TKA, although not between 6 to 72 hours. Overall use of a rescue antiemetic was less frequent, and complete response was more frequent in the Dexa-Ra group. Patients in the Dexa-Ra group experienced lower pain and consumed less opioids during the 6- to 24-hour period and during the overall study period. No differences were found in wound complications between the groups, and each group had one case of periprosthetic joint infection. CONCLUSIONS Patients who received prophylactic dexamethasone in addition to ramosetron had reduced postoperative emesis and pain without increased risks for wound complications, compared with patients who received ramosetron alone in patients managed using a multimodal regimen after TKA.
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Affiliation(s)
- In Jun Koh
- />Department of Orthopaedic Surgery, Uijeongbu St. Mary’s Hospital, 271, Cheonbo-ro, Uijeongbu-si, Gyeonggi-do Korea
- />Department of Orthopaedic Surgery, Catholic University of Korea College of Medicine, Seoul, Korea
| | - Chong Bum Chang
- />Joint Reconstruction Center, Seoul National University Bundang Hospital, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do (463-707) Korea
- />Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Ha Lee
- />Joint Reconstruction Center, Seoul National University Bundang Hospital, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do (463-707) Korea
| | - Young-Tae Jeon
- />Department of Anesthesiology and Pain Medicine, Seoul National University Bundang, Hospital, Seongnam, Korea
| | - Tae Kyun Kim
- />Joint Reconstruction Center, Seoul National University Bundang Hospital, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do (463-707) Korea
- />Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Korea
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85
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Backes JR, Bentley JC, Politi JR, Chambers BT. Dexamethasone reduces length of hospitalization and improves postoperative pain and nausea after total joint arthroplasty: a prospective, randomized controlled trial. J Arthroplasty 2013; 28:11-7. [PMID: 23937923 DOI: 10.1016/j.arth.2013.05.041] [Citation(s) in RCA: 145] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Revised: 05/25/2013] [Accepted: 05/30/2013] [Indexed: 02/01/2023] Open
Abstract
Controlling postoperative pain and nausea after total joint arthroplasty remains an important challenge. We conducted a prospective, randomized controlled trial with 120 patients to determine if the addition of perioperative dexamethasone to a multimodal regimen improves antiemetic and analgesic control, enhances mobility, and shortens hospital length of stay after total hip and knee arthroplasty. Patients administered 10mg of intravenous dexamethasone intraoperatively consumed less daily rescue anti-emetic and analgesic medication, reported superior VAS nausea and pain scores, ambulated further distances, and had a significantly shorter length of stay compared to the control group (P<0.05). A second, 24-hour postoperative dose of 10mg intravenous dexamethasone provided significant additional pain and nausea control and further reduced length of stay (P<0.05). No adverse events were detected with the administration of the intraoperative and/or postoperative dexamethasone.
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Affiliation(s)
- Jeffrey R Backes
- Department of Orthopedics, Mount Carmel Health System, Columbus, Ohio
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86
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Lunn TH, Kehlet H. Perioperative glucocorticoids in hip and knee surgery - benefit vs. harm? A review of randomized clinical trials. Acta Anaesthesiol Scand 2013; 57:823-34. [PMID: 23581549 DOI: 10.1111/aas.12115] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2013] [Indexed: 12/17/2022]
Abstract
Glucocorticoids are frequently used to prevent post-operative nausea and vomiting (PONV), and may be part of multimodal analgesic regimes. The objective of this review was to evaluate the overall benefit vs. harm of perioperative glucocorticoids in patients undergoing hip or knee surgery. A wide search was performed in PubMed, Embase, and Cochrane Central to identify relevant randomized clinical trials. A systematic approach was used, starting from the PRISMA recommendations. The Cochrane Collaboration's tool was used for risk of bias assessment. Studies were divided into three groups: systemic glucocorticoid administration analogous to > 10 mg or ≤ 10 mg dexamethasone, and local glucocorticoid administration. Seventeen studies with data from 1081 patients were included in the final qualitative synthesis. Benefit (of any kind) with glucocorticoid vs. placebo was reported in 15 studies. PONV was reduced with systemic glucocorticoid. Pain was reduced with high-dose systemic and local glucocorticoid, but not with low-dose systemic glucocorticoid. Systemic inflammatory markers were reduced with low-dose and high-dose systemic glucocorticoid, and with local glucocorticoid. Functional recovery was improved with local glucocorticoid. All studies were small-sized and none sufficiently powered to meaningfully evaluate uncommon adverse events. Most of the local administration studies had poor scientific quality (high risk of bias). Due to clinical heterogeneity and poor scientific quality, no meta-analysis was performed. In conclusion, in addition to PONV reduction with low-dose systemic glucocorticoid, this review supports high-dose systemic glucocorticoid to ameliorate post-operative pain after hip and knee surgery. However, large-scale safety and dose-finding studies are warranted before final recommendations.
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Affiliation(s)
- T H Lunn
- Department of Anaesthesiology, Hvidovre University Hospital, Copenhagen, Denmark.
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87
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Simsa J, Magnusson N, Hedberg M, Lorentz T, Gunnarsson U, Sandblom G. Betamethasone in hernia surgery: a randomized controlled trial. Eur J Pain 2013; 17:1511-6. [PMID: 23712446 DOI: 10.1002/j.1532-2149.2013.00333.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Post-operative pain and nausea may be a problem in day-case surgery. This study aims to investigate the effect of betamethasone on pain and nausea in inguinal hernia surgery. METHODS Patients aged 18-70 years scheduled for open inguinal hernia surgery at two Swedish hospitals, March 2005-December 2009, were eligible for inclusion. Patients were randomized, to either treatment with 12 mg betamethasone intravenously or placebo. Post-operative pain was assessed using a visual analogue scale on the recovery ward, each day the first post-operative week and at 1 month after surgery. One year after surgery, residual pain was estimated by the Inguinal Pain Questionnaire. RESULTS A total of 398 patients were included (21 women, 377 men). Pain at rest on the day of surgery was significantly lower in the treatment group (p = 0.012). The pain was also significantly lower in the treatment group the day after surgery (p < 0.001), but not during the remaining part of the first post-operative week. Bleeding complications were reported by 17 patients (8.5%) in the Betamethasone group and seven (3.5%) in the placebo group (p = 0.028). One month after surgery, 21 out of 173 (12%) in the betamethasone group still had pain, compared to 33 out of 159 (21%) in the placebo arm (p = 0.049). After 1 year, no significant difference in pain was seen. CONCLUSION A 12 mg betamethasone reduced pain during the first 24 h and at 1 month after inguinal hernia surgery. If combined with diclofenac, however, this dose may increase the risk for bleeding complications.
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Affiliation(s)
- J Simsa
- Department of Anesthesiology, Ludvika Hospital, Sweden
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88
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Peters SM, Yancy H, Deaver C, Jones YL, Kenyon E, Chiesa OA, Esparza J, Screven R, Lancaster V, Stubbs JT, Yang M, Wiesenfeld PL, Myers MJ. In vivo characterization of inflammatory biomarkers in swine and the impact of flunixin meglumine administration. Vet Immunol Immunopathol 2012; 148:236-42. [DOI: 10.1016/j.vetimm.2012.05.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 04/25/2012] [Accepted: 04/29/2012] [Indexed: 12/22/2022]
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89
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Chegini S, Dhariwal DK. Review of evidence for the use of steroids in orthognathic surgery. Br J Oral Maxillofac Surg 2012; 50:97-101. [DOI: 10.1016/j.bjoms.2010.11.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2010] [Accepted: 11/04/2010] [Indexed: 11/26/2022]
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90
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Pierse JE, Dym H, Clarkson E. Diagnosis and management of common postextraction complications. Dent Clin North Am 2012; 56:75-viii. [PMID: 22117943 DOI: 10.1016/j.cden.2011.09.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Extraction of impacted teeth is one of the most common surgical procedures performed by oral and maxillofacial surgeons. Every surgical procedure results in some degree of postoperative bleeding and inflammation, typically manifesting as pain and edema. Although the complex physiology of the human body is beyond the scope of this article, the educated clinician should have an understanding of the time line associated with these processes so as to determine whether a patient's complaint of postoperative bleeding, pain, or swelling represents a normal response to surgical trauma or an aberrant reaction.
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Affiliation(s)
- Joseph E Pierse
- Department of Dentistry/Oral & Maxillofacial Surgery, The Brooklyn Hospital Center, 121 DeKalb Avenue, Box 187, Brooklyn, NY 11201, USA
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91
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Fredheim OMS, Borchgrevink PC, Kvarstein G. [Post-operative pain management in hospitals]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2011; 131:1772-6. [PMID: 21946595 DOI: 10.4045/tidsskr.10.1184] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Relief of post-operative pain has a bearing on the patient's well-being, mobilisation and time confined to bed. The article discusses indications, contraindications and the efficacy of the various treatment modalities. MATERIAL AND METHOD We have examined review articles, meta-analyses and randomised controlled trials, identified through literature searches in PubMed. RESULTS The use of several medicines and techniques (multimodal pain treatment) is necessary to achieve a good balance between pain relief, side effects and risk. Systemic administration of paracetamol, NSAIDs, opioids and glucocorticoids is effective for post-operative pain. The same applies to epidural analgesia, peripheral nerve blocks and local anaesthetic wound infiltration. Subanaesthetic doses of ketamine have an opioid-sparing effect, but the optimal dosing regimen is uncertain. Gabapentinoids have an effect on post-operative pain, but the effect appears to vary depending on the type of operation and analgesic regimen. The effect of one analgesic will depend on which other drugs are used in multimodal pain treatment. Epidural analgesia, peripheral nerve blocks or extensive local infiltration analgesia is often necessary to relieve movement-related pain. INTERPRETATION Many treatment modalities are effective for post-operative pain. It is crucial that the treatment is well organised and that it includes routines for systematic pain assessment, efficacy and side effects of the pain management.
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Affiliation(s)
- Olav Magnus S Fredheim
- Nasjonalt kompetansesenter for sammensatte lidelser og Avdeling for smerte og sammensatte lidelser, Klinikk for anestesi og akuttmedisin, St. Olavs hospital, Norway.
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92
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Afsharimani B, Cabot PJ, Parat MO. Morphine use in cancer surgery. Front Pharmacol 2011; 2:46. [PMID: 21852973 PMCID: PMC3151591 DOI: 10.3389/fphar.2011.00046] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Accepted: 07/25/2011] [Indexed: 12/19/2022] Open
Abstract
Morphine is the core of perioperative pain management. However, when it comes to cancer surgery the possibility that this drug might affect tumor recurrence and metastasis has raised concerns. The results of two recent retrospective clinical trials indicated that regional anesthesia/analgesia might be beneficial in prostate and breast cancer surgery. It was proposed that morphine could be responsible for the higher recurrence and mortality rate observed in the general anesthesia/opioid analgesia groups. Nevertheless, the results of several other retrospective studies and one randomized prospective trial failed to confirm any advantage for regional anesthesia/analgesia over general anesthesia and opioid analgesia. Moreover laboratory data on the effect of morphine on cancer are contradictory, ranging from tumor-promoting to anti-tumor effects. Considering that surgical stress and pain promote the recurrence and spread of cancer, choosing a proper analgesic strategy is of high significance. Although the question of whether morphine causes any harm to cancer patients remains unanswered, alternative analgesic regimens could be used concomitant to or instead of morphine to limit its potential adverse effects.
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93
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Adjuvant dexamethasone with bupivacaine prolongs the duration of interscalene block: a prospective randomized trial. J Anesth 2011; 25:704-9. [DOI: 10.1007/s00540-011-1180-x] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2010] [Accepted: 05/23/2011] [Indexed: 10/18/2022]
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94
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Liu W, Cong R, Li X, Wu Y, Wu H. Reduced opioid consumption and improved early rehabilitation with local and intraarticular cocktail analgesic injection in total hip arthroplasty: a randomized controlled clinical trial. PAIN MEDICINE 2011; 12:387-93. [PMID: 21266004 DOI: 10.1111/j.1526-4637.2010.01043.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Postoperative pain after total hip arthroplasty (THA) is not well tolerated. We assessed postoperative pain relief and the need for opioid use after using a cocktail of local and intraarticular analgesic injection (LIA) after THA. METHODS Eighty patients undergoing THA under spinal anesthesia were randomly assigned to receive either LIA or placebo. The LIA was composed of 5 mg morphine, 30 mg bupivacaine (15 mg/1.5 mL), 1 mL betamethasone, and 0.5 mL epinephrine (1:1,000) intraoperatively. We compared three outcomes total morphine consumption, visual analog scale (VAS) at rest and during activity, and hip flexion angle while standing. RESULTS When compared with placebo, opioid consumption was significantly reduced in the trial group, as well as VAS at rest and during mobilization. Earlier rehabilitation and better range of motion (ROM) were achieved in the trial group. There were no significant differences in side effects or postoperative wound healing between groups. CONCLUSION In patients undergoing THA, LIA may reduce postoperative systemic opioid use and offer better pain control and earlier rehabilitation, without observable risks.
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Affiliation(s)
- Wei Liu
- Department of Orthopaedics, Changzheng Hospital, Shanghai, China
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95
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Affiliation(s)
- Shital N Parikh
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 2017, Cincinnati, OH 45229, USA.
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96
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Abstract
The relationship between corticosteroids (endogenous and exogenous) and stress is well known, as is the use of steroids as concomitant treatment in pain management during acute inflammation. In the past, steroids have not been considered the first line of treatment in pain management. In this review, we examine new scientific and clinical evidence that demonstrates the direct role that steroids play in the generation and clinical management of chronic pain. We will discuss the new findings demonstrating the fact that steroids and related mediators produce paradoxical effects on pain such as analgesia, hyperalgesia, and even placebo analgesia. In addition, we will examine the physiologic effect of stress, high allostatic load, and idiopathic disease states such as chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, and burnout. The recently observed positive relationship between glutaminergic activity in the insula and clinical pain will be examined in the context of understanding the central role of steroids in chronic pain. The complex role of the hypothalamic-pituitary-adrenal axis in pain will be discussed as well as other heterogeneous forms of chronic pain that involve many components of the central nervous system. Components of the hypothalamic-pituitary-adrenal axis have paradoxical effects on certain types of pain that are dependent on dose and on site (whether peripheral or central) and mode of application. Recent studies on glia have shown that they prolong a state of neuronal hypersensitization in the dorsal root ganglia by releasing growth factors and other substances that act on the immune system. We will discuss the implication of these new findings directly linking pain to steroids, stress, and key higher brain regions in the context of future therapeutic targets.
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Affiliation(s)
- Bruce S McEwen
- Laboratory of Neuroendocrinology, The Rockefeller University, New York, NY 10065, USA.
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97
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Mullaji A, Kanna R, Shetty GM, Chavda V, Singh DP. Efficacy of periarticular injection of bupivacaine, fentanyl, and methylprednisolone in total knee arthroplasty:a prospective, randomized trial. J Arthroplasty 2010; 25:851-7. [PMID: 20022457 DOI: 10.1016/j.arth.2009.09.007] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2008] [Accepted: 09/30/2009] [Indexed: 02/01/2023] Open
Abstract
We evaluated the efficacy of periarticular infiltration of corticosteroid, opioid, and a local anesthetic by comparing pain scores, knee flexion, and quadriceps function on the day of surgery, first postoperative day, day of discharge, and 2 and 4 weeks after surgery between the infiltrated and the noninfiltrated knee in 40 patients undergoing simultaneous bilateral computer-assisted total knee arthroplasty who were randomized to receive the injection in the right or left knee. In comparison to the noninfiltrated side, the infiltrated knee showed significantly lower pain scores, significantly greater active flexion up to 4 weeks, and superior quadriceps recovery up to 2 weeks after surgery. This simple and inexpensive technique can significantly reduce pain and hasten functional recovery in the first month after total knee arthroplasty.
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Affiliation(s)
- Arun Mullaji
- Department of Orthopaedic Surgery, Breach Candy Hospital, Mumbai, India
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98
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Elvir-Lazo OL, White PF. Postoperative pain management after ambulatory surgery: role of multimodal analgesia. Anesthesiol Clin 2010; 28:217-24. [PMID: 20488391 DOI: 10.1016/j.anclin.2010.02.011] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Multimodal (or balanced) analgesia represents an increasingly popular approach to preventing postoperative pain. The approach involves administering a combination of opioid and nonopioid analgesics. Nonopioid analgesics are increasingly being used as adjuvants before, during, and after surgery to facilitate the recovery process after ambulatory surgery. Early studies evaluating approaches to facilitating the recovery process have demonstrated that the use of multimodal analgesic techniques can improve early recovery as well as other clinically meaningful outcomes after ambulatory surgery. The potential beneficial effects of local anesthetics, NSAIDs, and gabapentanioids in improving perioperative outcomes continue to be investigated.
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99
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Fu PL, Xiao J, Zhu YL, Wu HS, Li XH, Wu YL, Qian QR. Efficacy of a Multimodal Analgesia Protocol in Total Knee Arthroplasty: A Randomized, Controlled Trial. J Int Med Res 2010; 38:1404-12. [PMID: 20926013 DOI: 10.1177/147323001003800422] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A total of 100 osteoarthritis patients undergoing unilateral total knee arthroplasty were randomly assigned to receive either a multimodal analgesia protocol, comprising oral celecoxib and tramadol before and after surgery and intra-articular injection of large doses of morphine, ropivacaine, adrenaline and betamethasone during surgery (trial group), or oral and intra-articular placebo (control group). All patients received patient-controlled analgesia for 48 h after surgery. Morphine consumption up to 48 h after surgery was significantly lower in the trial than in the control group. Compared with the control group, the trial group had significantly lower visual analogue scale (VAS) scores for pain at rest from 6 h to 7 days after surgery and significantly lower VAS scores during activity from 24 h to 7 days after surgery. Active straight leg raise and active 90° knee flexion were achieved sooner and range of knee movement at postoperative days 1–15 were significantly greater in the trial group. Postoperative wound healing, infection, blood pressure, heart rate, rash, respiratory depression, urinary retention and deep vein thrombosis were similar in the two groups, but nausea and vomiting were significantly less frequent in the trial group.
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Affiliation(s)
- PL Fu
- Department of Orthopaedics, Changzheng Hospital, Shanghai, China
| | - J Xiao
- Department of Orthopaedics, Changzheng Hospital, Shanghai, China
| | - YL Zhu
- Department of Orthopaedics, Changzheng Hospital, Shanghai, China
| | - HS Wu
- Department of Orthopaedics, Changzheng Hospital, Shanghai, China
| | - XH Li
- Department of Orthopaedics, Changzheng Hospital, Shanghai, China
| | - YL Wu
- Department of Orthopaedics, Changzheng Hospital, Shanghai, China
| | - QR Qian
- Department of Orthopaedics, Changzheng Hospital, Shanghai, China
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100
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Abstract
There are many causes of heel pain. Not all are characterized as plantar fasciitis or osseous pathology. Sometimes patients present with heel pain caused by a dermatologic entity. This article describes some of the most common pathologies.
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Affiliation(s)
- George F Wallace
- Podiatry Service, University Hospital - University of Medicine and Dentistry of New Jersey, 150 Bergen Street, G-142, Newark, NJ 07103, USA.
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