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Gathege D, Abdulkarim A, Odaba D, Mugambi S. Effectiveness of Pain Control of Local Anaesthetic Wound Infusion Following Elective Midline Laparotomy: A Randomized Trial. World J Surg 2021; 45:2100-2107. [PMID: 33763741 DOI: 10.1007/s00268-021-06072-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Post-operative pain control is an important pillar in enhanced recovery after surgery. There is a paucity of data that compares efficacy of pain control between continuous local anaesthetic wound infusion and thoracic epidural analgesia in elective midline laparotomy patients OBJECTIVE: To evaluate pain control between continuous local anaesthetic wound infusion and thoracic epidural analgesia in elective laparotomy patients. DESIGN A randomized, single-blind, controlled clinical trial. SETTING Aga Khan University Hospital, Nairobi, Kenya. POPULATION Patients underwent elective laparotomy. METHODS Thirty-eight patients scheduled for elective laparotomy were randomized into two equal groups to receive either continuous local anaesthetic wound infusion or thoracic epidural analgesia. Data on the baseline patient characteristics, total morphine consumption at 72 h, visual analogue scores and rates of adverse effects were collected. RESULTS Baseline characteristics of the participants were similar. Continuous local anaesthetic wound infusion was equivalent to thoracic epidural analgesia in terms of pain scores and total morphine consumption at 72 h. Duration of hospital stay was shorter in the intervention arm. There were more surgical site infections in the intervention arm, while catheter dislodgement rate was higher in the thoracic epidural arm. CONCLUSION Continuous local anaesthetic wound infusion is equivalent to thoracic epidural analgesia in management of post-operative pain following elective midline laparotomy. CLINICAL TRIAL REGISTRATION Pan African Clinical Trial registry, number PACTR201808607220790.
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Affiliation(s)
| | | | - David Odaba
- Aga Khan University Hospital, Nairobi, Kenya
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152
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Benevides ML, Fialho DC, Linck D, Oliveira AL, Ramalho DHV, Benevides MM. Intravenous magnesium sulfate for postoperative analgesia after abdominal hysterectomy under spinal anesthesia: a randomized, double-blind trial. Braz J Anesthesiol 2021; 71:498-504. [PMID: 33762190 PMCID: PMC9373682 DOI: 10.1016/j.bjane.2021.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 09/29/2020] [Accepted: 01/02/2021] [Indexed: 12/23/2022] Open
Abstract
Background and objectives Abdominal Hysterectomy (AH) is associated with significant inflammatory response and can result in moderate to severe postoperative pain. This study aimed to evaluate the efficacy of magnesium infusion in reducing postoperative pain and analgesic consumption after AH under spinal anesthesia with Intrathecal Morphine (ITM). Method Eighty-six patients were included in this clinical, controlled, randomized, double-blind study. Patients received in Group Mg, MgSO4 50 mg kg−1 for 15 minutes followed by 15 mg kg−1 h−1 until the end of the surgery; and in Group C, (control) the same volume of isotonic saline. Both groups received 100 μg of ITM. All patients received dipyrone + ketoprofen intraoperatively and postoperatively, and dexamethasone intraoperatively only. We evaluated the intensity of pain, tramadol consumption, and adverse events 24 hours postoperatively. Results Serum magnesium concentrations were higher in Group Mg at the end, and one hour after the operation (p = 0.000). Postoperative pain scores were reduced in Group Mg at 6 hours at rest and on movement (p < 0.05). Tramadol consumption did not show a statistically significant difference between Group Mg and Group C (15.5 ± 36.6 mg and 29.2 ± 67.8 mg respectively, p = 0.53). Hemodynamic variables, the incidence of pruritus, nausea, and vomiting were similar in the two groups. Conclusion Infusion of MgSO4 during AH undergoing spinal anesthesia with ITM reduced at 6 hours at rest and on movement. More studies should be performed to evaluate the potential antinociceptive effect of MgSO4 in scenarios where a multimodal analgesia approach was employed.
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Affiliation(s)
| | | | - Daiane Linck
- Hospital Geral Universitário, Cuiabá, MT, Brazil
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153
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Zayed S, Lang P, Mendez LC, Read N, Sathya J, Venkatesan V, Moulin DE, Warner A, Palma DA. Opioid therapy vs. multimodal analgesia in head and neck Cancer (OPTIMAL-HN): study protocol for a randomized clinical trial. BMC Palliat Care 2021; 20:45. [PMID: 33740977 PMCID: PMC7980584 DOI: 10.1186/s12904-021-00735-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 02/26/2021] [Indexed: 03/17/2023] Open
Abstract
Background Radiation-induced mucositis (RIM) pain confers substantial morbidity for head and neck cancer (HNC) patients undergoing radiotherapy alone (RT) or chemoradiotherapy (CRT), often reducing treatment compliance. However, no standard currently exists for the treatment of RIM, and high dose opioid therapy, with its associated side effects and increased risk for chronic opioid use, remains the cornerstone of HNC pain management. The goal of this randomized clinical trial is to compare multimodal analgesia using analgesic medications with different mechanisms of action, to the institutional standard of opioid analgesia alone, in order to ascertain the optimal analgesic regimen for the management of RIM pain in HNC patients. Methods In this open-label, single-institution, non-inferiority, randomized clinical trial, sixty-two patients with mucosal head and neck malignancies treated with curative-intent radiation will be randomized in a 1:1 ratio, stratified by RT or CRT, between Arm 1: opioid analgesia alone as per the institutional standard, or Arm 2: multimodal analgesia using Pregabalin, Acetaminophen, and Naproxen, in addition to opioids, if required. The primary endpoint is the average 11-Numeric Rating Scale (11-NRS) score for pain during the last week of radiation treatment. Secondary endpoints include: average weekly opioid use, duration of opioid requirement, average daily 11-NRS score for pain, average weekly opioids dispensed, quality of life, hospitalizations for analgesic medication-induced complications, time to feeding tube insertion, weight loss, toxicity, treatment interruptions, and death within 3 months of completing RT treatment. Patients are eligible once analgesia is required for moderate 4/10 pain. Discussion This study will assess the efficacy and safety of multimodal analgesia and its impact on opioid requirements, clinical outcomes, and quality of life, as a potential new standard treatment for RIM pain in HNC patients undergoing definitive RT or CRT. Trial registration ClinicalTrials.gov Identifier: NCT04221165. Date of registration: January 9, 2020. Appendix 2 reports the World Health Organization trial registration dataset. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00735-0.
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Affiliation(s)
- Sondos Zayed
- Department of Radiation Oncology, London Health Sciences Centre, 800 Commissioners Road East, London, ON, N6A 5W9, Canada
| | - Pencilla Lang
- Department of Radiation Oncology, London Health Sciences Centre, 800 Commissioners Road East, London, ON, N6A 5W9, Canada
| | - Lucas C Mendez
- Department of Radiation Oncology, London Health Sciences Centre, 800 Commissioners Road East, London, ON, N6A 5W9, Canada
| | - Nancy Read
- Department of Radiation Oncology, London Health Sciences Centre, 800 Commissioners Road East, London, ON, N6A 5W9, Canada
| | - Jinka Sathya
- Department of Radiation Oncology, London Health Sciences Centre, 800 Commissioners Road East, London, ON, N6A 5W9, Canada
| | - Varagur Venkatesan
- Department of Radiation Oncology, London Health Sciences Centre, 800 Commissioners Road East, London, ON, N6A 5W9, Canada
| | - Dwight E Moulin
- Departments of Clinical Neurological Sciences and Oncology, London Health Sciences Centre, 800 Commissioners Road East, London, ON, N6A 5W9, Canada
| | - Andrew Warner
- Department of Radiation Oncology, London Health Sciences Centre, 800 Commissioners Road East, London, ON, N6A 5W9, Canada
| | - David A Palma
- Department of Radiation Oncology, London Health Sciences Centre, 800 Commissioners Road East, London, ON, N6A 5W9, Canada.
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154
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Hyland SJ, Brockhaus KK, Vincent WR, Spence NZ, Lucki MM, Howkins MJ, Cleary RK. Perioperative Pain Management and Opioid Stewardship: A Practical Guide. Healthcare (Basel) 2021; 9:333. [PMID: 33809571 PMCID: PMC8001960 DOI: 10.3390/healthcare9030333] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 12/20/2022] Open
Abstract
Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.
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Affiliation(s)
- Sara J. Hyland
- Department of Pharmacy, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA
| | - Kara K. Brockhaus
- Department of Pharmacy, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
| | | | - Nicole Z. Spence
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, MA 02118, USA;
| | - Michelle M. Lucki
- Department of Orthopedics, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Michael J. Howkins
- Department of Addiction Medicine, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Robert K. Cleary
- Department of Surgery, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
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155
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Jiang Y, Qi L, Liu J, Wu H, Li Y, Zou L, Guo Z, Wang J, Li H. Analgesic efficacy of imrecoxib for postoperative pain following oral surgery: a prospective randomized, active-controlled, non-inferiority trial. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:469. [PMID: 33850866 PMCID: PMC8039693 DOI: 10.21037/atm-21-264] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Imrecoxib, a novel cyclooxygenase (COX-2) selective non-steroidal anti-inflammatory drug (NSAID), has been approved in China for more than 9 years. This study aimed to assess the efficacy and safety of imrecoxib compared with celecoxib for patients with moderate or severe acute pain following oral surgery. Methods Patients with moderate or severe pain within 6 hours following surgery were enrolled in this randomized, active-control trial. Patients were randomly assigned (1:1) to receive either imrecoxib or celecoxib. Pain assessments on the visual analog scale, verbal rating scale, and pain relief were conducted at 0.5, 1, 2, 4, 6, 9, 12, and 24 hours after the first dose. Adverse events were also recorded. Results Eighty-seven patients were approached from November 2018 to August 2019. Of these, 60 were eligible for randomization. Ultimately, 56 patients (imrecoxib group, n=27; celecoxib group, n=29) were included in the analysis. The difference in total pain relief (TOTPAR) between the imrecoxib and celecoxib groups was 1.03 [95% confidence interval (CI): −1.31–3.77], with the lower bound of the CI above the specified non-inferiority boundary. No perioperative complications were observed in the imrecoxib group during the 24-hour period after the first dose. Conclusions Imrecoxib could significantly relieve pain and has a non-inferior analgesic efficacy compared to celecoxib with good tolerance following oral surgery.
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Affiliation(s)
- Yu Jiang
- Jiangsu Key Laboratory of Oral Diseases, Nanjing Medical University, Nanjing, China.,Department of Oral and Maxillofacial Surgery, Affiliated Hospital of Stomatology, Nanjing Medical University, Nanjing, China
| | - Lili Qi
- Jiangsu Key Laboratory of Oral Diseases, Nanjing Medical University, Nanjing, China.,Department of Oral and Maxillofacial Surgery, Affiliated Hospital of Stomatology, Nanjing Medical University, Nanjing, China
| | - Jie Liu
- Jiangsu Key Laboratory of Oral Diseases, Nanjing Medical University, Nanjing, China.,Department of Oral and Maxillofacial Surgery, Affiliated Hospital of Stomatology, Nanjing Medical University, Nanjing, China
| | - Heming Wu
- Jiangsu Key Laboratory of Oral Diseases, Nanjing Medical University, Nanjing, China.,Department of Oral and Maxillofacial Surgery, Affiliated Hospital of Stomatology, Nanjing Medical University, Nanjing, China
| | - Yi Li
- Jiangsu Hengrui Pharmaceutical Co., Ltd., Lianyungang, China
| | - Linhu Zou
- Jiangsu Hengrui Pharmaceutical Co., Ltd., Lianyungang, China
| | - Zhiwei Guo
- Jiangsu Hengrui Pharmaceutical Co., Ltd., Lianyungang, China
| | - Jinqiang Wang
- Jiangsu Hengrui Pharmaceutical Co., Ltd., Lianyungang, China
| | - Huaiqi Li
- Jiangsu Key Laboratory of Oral Diseases, Nanjing Medical University, Nanjing, China.,Department of Oral and Maxillofacial Surgery, Affiliated Hospital of Stomatology, Nanjing Medical University, Nanjing, China
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156
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Ogura Y, Gum JL, Steele P, Crawford CH, Djurasovic M, Owens RK, Laratta J, Brown M, Daniels C, Dimar JR, Glassman SD, Carreon LY. Drivers of in-hospital opioid consumption in patients undergoing lumbar fusion surgery. JOURNAL OF SPINE SURGERY 2021; 7:19-25. [PMID: 33834124 DOI: 10.21037/jss-20-626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background With the current opioid crisis, as many as 38% of patients are still on opioids one year after elective spine surgery. Identifying drivers of in-hospital opioid consumption may decrease subsequent opioid dependence. We aimed to identify the drivers of in-hospital opioid consumption in patients undergoing 1-2-level instrumented lumbar fusions. Methods This is a retrospective cohort study. Electronic medical record analysts identified consecutive patients undergoing 1-2 level instrumented lumbar fusions for degenerative lumbar conditions from 2016 to 2018 from a single-center hospital administrative database. Oral, intravenous, and transdermal opioid dose administrations were converted to morphine milligram equivalents (MME). Linear regression analysis was used to determine associations between postoperative day (POD) 4 cumulative in-hospital MMEs and the patients' baseline characteristics including body mass index (BMI), race, American Society of Anesthesiologists (ASA) grade, smoking status, marital status, insurance type, zip code, number of fused levels, approach and preoperative opioid use. Results A total of 1,502 patients were included. The mean cumulative MMEs at POD 4 was 251.5. Linear regression analysis yielded four drivers including younger age, preoperative opioid use, current smokers and more levels fused. There were no associations with surgical approach, zip code, ASA grade, marital status, BMI, race or insurance type. Conclusions Use of preoperative opioids and smoking are modifiable risk factors for higher in-hospital opioid consumption and can be targets for intervention prior to surgery in order to decrease in-hospital opioid use.
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Affiliation(s)
- Yoji Ogura
- Norton Leatherman Spine Center, Louisville, KY, USA
| | | | | | | | | | - R Kirk Owens
- Norton Leatherman Spine Center, Louisville, KY, USA
| | | | - Morgan Brown
- Norton Leatherman Spine Center, Louisville, KY, USA
| | | | - John R Dimar
- Norton Leatherman Spine Center, Louisville, KY, USA
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157
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Ntalouka MP, Brotis AG, Bareka MV, Stertsou ES, Fountas KN, Arnaoutoglou EM. Multimodal Analgesia in Spine Surgery: An Umbrella Review. World Neurosurg 2021; 149:129-139. [PMID: 33610874 DOI: 10.1016/j.wneu.2021.02.040] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVE In recent years, there has been a growing interest regarding the implementation of multimodal analgesia as an important component of the ideal perioperative patient management. The aim of the current umbrella review was to establish the role of multimodal analgesia in patients undergoing spine surgery during the immediate postoperative period. METHODS A systematic review of the pertinent literature was performed. The evaluation was based on a multitude of primary endpoints including the postoperative requirements for patient-controlled analgesia, pain intensity, back-related disability, overall functionality, patient satisfaction, complications, length of hospitalization, and costs. RESULTS The results were summarized using a meta-analysis in the presence of quantitative data or in a narrative review, otherwise. There was a large body of high-quality evidence supporting that the implementation of multimodal analgesia improves patient outcome in terms of the intensity of postoperative pain, the requirements for postoperative opioid analgesia, and the opioid-associated side effects. Similarly, limited high-quality evidence supported that multimodal analgesia improved patients' functionality and satisfaction while decreasing the length of hospitalization and overall costs of surgery. However, the results were inconclusive as far as the disability was concerned. CONCLUSIONS Multimodal analgesia seems to have an essential role for the optimal management of patients undergoing spine surgery. Future research is required to optimize the multimodal analgesia protocols in this group of patients.
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Affiliation(s)
- Maria P Ntalouka
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, Larissa, Greece.
| | - Alexandros G Brotis
- Department of Neurosurgery, General University Hospital of Larissa, Larissa, Greece
| | - Metaxia V Bareka
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, Larissa, Greece
| | - Eleonora S Stertsou
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, Larissa, Greece
| | - Kostantinos N Fountas
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Eleni M Arnaoutoglou
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, Larissa, Greece
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158
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Lai J, Situ D, Xie M, Yu P, Wang J, Long H, Lai R. Continuous Paravertebral Analgesia versus Continuous Epidural Analgesia after Video-Assisted Thoracoscopic Lobectomy for Lung Cancer: A Randomized Controlled Trial. Ann Thorac Cardiovasc Surg 2021; 27:297-303. [PMID: 33597333 PMCID: PMC8560537 DOI: 10.5761/atcs.oa.20-00283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Whether continuous thoracic epidural analgesia (TEA) and continuous paravertebral block (PVB) have similar analgesic effects in patients undergoing video- assisted thoracic surgery (VATS) lobectomy was compared in this study. Methods: In all, 86 patients undergoing VATS lobectomy were enrolled in the prospective, randomized clinical trial. Group E received TEA. Group P received PVB. The primary endpoint was postoperative 24-hour visual rating scale (VAS) on coughing. Side effects and postoperative complications were also analyzed. Results: Pain scores at rest or on coughing at 24 and 48 h postoperatively were significantly lower in group E than in group P (P <0.05). At 24 h postoperatively, more patients in group E suffered from vomiting (32.6% vs 11.6%, P = 0.019), dizziness (55.8% vs 12.9%, P = 0.009), pruritus (27.9% vs 2.3%, P = 0.002), and hypotension (32.6% vs 4.7%, P = 0.002) than those in group P. Patients in group E were more satisfied (P = 0.047). Four patients in group P and two patients in group E suffered from pulmonary complications (P >0.05). The length of hospital and intensive care unit (ICU) stays were not significantly different. Conclusions: Though TEA has more adverse events than PVB, it may be superior to PVB in patients undergoing VATS lobectomy.
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Affiliation(s)
- Jielan Lai
- Collaborative Innovation Center for Cancer Medicine, State Key Laboratory of Oncology in South China, Sun Yat-Sen University Cancer Center, Guangzhou, China.,Department of Anesthesiology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Dongrong Situ
- Collaborative Innovation Center for Cancer Medicine, State Key Laboratory of Oncology in South China, Sun Yat-Sen University Cancer Center, Guangzhou, China.,Lung Cancer Research Institute, Sun Yat-sen University, Guangzhou, China.,Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Manxiu Xie
- Collaborative Innovation Center for Cancer Medicine, State Key Laboratory of Oncology in South China, Sun Yat-Sen University Cancer Center, Guangzhou, China.,Department of Anesthesiology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Ping Yu
- Collaborative Innovation Center for Cancer Medicine, State Key Laboratory of Oncology in South China, Sun Yat-Sen University Cancer Center, Guangzhou, China.,Department of Anesthesiology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Junchao Wang
- Collaborative Innovation Center for Cancer Medicine, State Key Laboratory of Oncology in South China, Sun Yat-Sen University Cancer Center, Guangzhou, China.,Department of Anesthesiology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Hao Long
- Collaborative Innovation Center for Cancer Medicine, State Key Laboratory of Oncology in South China, Sun Yat-Sen University Cancer Center, Guangzhou, China.,Lung Cancer Research Institute, Sun Yat-sen University, Guangzhou, China.,Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Renchun Lai
- Collaborative Innovation Center for Cancer Medicine, State Key Laboratory of Oncology in South China, Sun Yat-Sen University Cancer Center, Guangzhou, China.,Department of Anesthesiology, Sun Yat-Sen University Cancer Center, Guangzhou, China
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159
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Corsini EM, Hofstetter WL, Mitchell KG, Zhou N, Antonoff MB, Mehran RJ, Mena GE, Rice DC, Roth JA, Sepesi B, Swisher SG, Vaporciyan AA, Walsh GL. Ketorolac use and anastomotic leak in patients with esophageal cancer. J Thorac Cardiovasc Surg 2021; 161:448-454. [DOI: 10.1016/j.jtcvs.2020.02.133] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 01/30/2020] [Accepted: 02/04/2020] [Indexed: 02/07/2023]
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160
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Cain KE, Iniesta MD, Fellman BM, Suki TS, Siverand A, Corzo C, Lasala JD, Cata JP, Mena GE, Meyer LA, Ramirez PT. Effect of preoperative intravenous vs oral acetaminophen on postoperative opioid consumption in an enhanced recovery after surgery (ERAS) program in patients undergoing open gynecologic oncology surgery. Gynecol Oncol 2020; 160:464-468. [PMID: 33298309 DOI: 10.1016/j.ygyno.2020.11.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 11/21/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Both intravenous (IV) and oral acetaminophen provide effective opioid-sparing analgesia after surgery when used as part of a multimodal preemptive pain management strategy. The purpose of this study was to compare postoperative opioid consumption in patients undergoing open gynecologic oncology surgery who received preoperative IV vs oral acetaminophen within an enhanced recovery after surgery (ERAS) program. METHODS Retrospective data were collected on consecutive patients undergoing open gynecologic oncology surgery from May 1, 2016 to February 28, 2018 in patients receiving either 1 g IV or oral acetaminophen preoperatively. Patients were given a preoperative multimodal analgesia regimen including acetaminophen, celecoxib, pregabalin and tramadol. The primary outcomes were morphine equivalent daily doses (MEDD) on postoperative days (POD) 0 and 1. Secondary outcomes included highest patient-reported pain score in the post-anesthesia care unit (PACU) and intraoperative MEDD. Regression models adjusted by matched pairs were fit to estimate the average treatment effect of IV vs oral acetaminophen on MEDD. RESULTS Of 353 patients, 178 (50.4%) received IV acetaminophen and 175 (49.6%) received oral acetaminophen. When balancing across the matched samples, there was no difference in postoperative MEDD for POD 0 between the IV and oral acetaminophen groups (Beta = -1.11; 95% CI: -4.83 to 2.60; p = 0.56). On POD 1, there was no difference between the IV and oral groups (Beta = 2.24; 95% CI: -2.76 to 7.25; p = 0.38). CONCLUSIONS There was no difference in postoperative opioid consumption between patients receiving preoperative IV or oral acetaminophen within an ERAS program for patients undergoing open gynecologic oncology surgery.
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Affiliation(s)
- Katherine E Cain
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bryan M Fellman
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tina S Suki
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ashley Siverand
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Camila Corzo
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Javier D Lasala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Gabriel E Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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161
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Kassem H, Urits I, Viswanath O, Kaye AD, Eskander JP. Use of Dexmedetomidine With Dexamethasone for Extended Pain Relief in Adductor Canal/Popliteal Nerve Block During Achilles Tendon Repair. Cureus 2020; 12:e11917. [PMID: 33425503 PMCID: PMC7785491 DOI: 10.7759/cureus.11917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The use of regional anesthetic techniques in the peri-operative period has increased as a means to improve analgesia and patient outcomes. Traditionally, various local anesthetics are used and addition of adjuncts such as epinephrine, clonidine, and dexamethasone has shown to prolong the block effect. There has been ongoing research to support the prolongation of a regional block with the addition of dexamethasone and dexmedetomidine (Dex-Dex), providing analgesia for multiple days. We present a case of a 35-year-old female who underwent an Achilles tendon repair with an adductor/popliteal nerve block. Both dexmedetomidine and dexamethasone were added to the local anesthetic mixture with substantial postoperative analgesic control. The patient also did not require any supplemental opioid medication. This case emphasizes the proposed synergistic effect of dexmedetomidine and dexamethasone when added to the local anesthesia injectate for lower extremity peripheral nerve blocks.
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Affiliation(s)
- Hisham Kassem
- Anesthesiology and Perioperative Medicine, Mount Sinai Medical Center, Miami Beach, USA
| | - Ivan Urits
- Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Omar Viswanath
- Pain Management, Valley Anesthesiology and Pain Consultants, Phoenix, USA
| | - Alan D Kaye
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Jonathan P Eskander
- Anesthesiology and Pain Medicine, Portsmouth Anesthesia Associates, Portsmouth, USA
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Jiang C, Li Y, Li X, Guo J, Guo M, Yu S, Lin Z. Postoperative analgesic effect of acupotomy combined with patient-controlled analgesia in patients undergoing video-assisted thoracoscopic surgery: a study protocol for a randomized controlled trial. Trials 2020; 21:998. [PMID: 33276817 PMCID: PMC7716496 DOI: 10.1186/s13063-020-04926-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 11/21/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Postoperative acute pain is a common issue following thoracic surgery. Acupotomy is a common and safe intervention method for pain treatment in clinical practice. In previous preliminary experiments, we found that acupotomy has a good clinical effect and good safety in the treatment of pain after thoracoscopic surgery. However, due to a lack of a rigorous design and an adequate sample size, its efficacy still requires further confirmation. The purpose of this study will be to explore the efficacy and safety of acupotomy combined with patient-controlled analgesia (PCA) for the treatment of pain after video-assisted thoracic surgery (VATS). METHODS The study will be a single-centre, parallel group, randomized controlled trial. Seventy patients with significant pain after thoracoscopic surgery with a visual analogue scale (VAS) score ≥ 7 will be included and randomly distributed into two groups: G1, the acupotomy combined with PCA group; and G2, the conventional PCA group. The primary outcome measure is pain scores at rest and coughing evaluated with the VAS by a blinded observer in the postanaesthesia care unit (PACU) and postoperatively at 1, 2, 4, 8, 12, 24, 48, and 72 h. The secondary outcome measures are postoperative requirements for rescue analgesia, the cumulative amount of self-administered analgesics, the level of sedation (LOS), the Bruggemann comfort scale (BCS), and the functional activity score (FAS) concerning adverse effects and patient satisfaction. DISCUSSION This trial has the potential to identify an innovative and effective analgesic method for postoperative pain management for VATS. The findings may advocate for the inclusion of the treatment of comorbid pain after thoracoscopy in current pain management practice guidelines. TRIAL REGISTRATION Chinese Clinical Trial Registry ChiCTR1900027191 . Registered on 4 November 2019.
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Affiliation(s)
- Cai Jiang
- Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Yinyan Li
- Outpatient Department of Guoyitang affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
| | - Xiaomei Li
- Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Jinhua Guo
- Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Miaomiao Guo
- Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Shengxian Yu
- Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Zhonghua Lin
- Fujian Provincial Hospital, Fuzhou, Fujian, China.
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163
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Jenny JY, Bulaid Y, Boisrenoult P, Bonin N, Henky P, Tracol P, Chouteau J, Courtin C, Henry MP, Schwartz C, Mertl P, De Ladoucette A. Bleeding and thromboembolism risk of standard antithrombotic prophylaxis after hip or knee replacement within an enhanced recovery program. Orthop Traumatol Surg Res 2020; 106:1533-1538. [PMID: 33127330 DOI: 10.1016/j.otsr.2020.02.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 02/19/2020] [Accepted: 02/25/2020] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Prevention of venous thromboembolism (VTE) generally consists of low molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs) after total hip arthroplasty (THA) or total knee arthroplasty (TKA). Enhanced recovery after surgery (ERAS) protocols may reduce the VTE risk after these procedures. The aim of this study was to compare the risk of VTE and the risk of bleeding complications in a non-selected population of primary THA and TKA cases done within an ERAS protocol. HYPOTHESIS The risk of postoperative VTE after primary THA and TKA is lower than the risk of bleeding complications within an ERAS protocol. METHODS This was a prospective observational study conducted on a national scale in France. All patients who underwent primary unilateral THA or TKA at one of 11 participating hospitals between October 2016 and October 2017 were enrolled and followed for 3 months. The occurrence of a VTE or major bleeding event was recorded. No patients were lost to follow-up at 3 months. RESULTS Of the 1110 THA cases, there were 5 VTE (0.4%) and 19 bleeding events (1.7%). Of the 893 TKA cases, there were 9 VTE (1.0%) and 14 bleeding events (1.7%). There was no significant difference in the VTE incidence and bleeding event incidence after THA and TKA. The overall incidence of bleeding complications (1.7%) was significantly greater than the overall incidence of VTE complications (0.7%) (p=0.005). This was the case after THA (p=0.004) but not after TKA. DISCUSSION The primary finding of this study is that bleeding complications are significantly more common than VTE complications after THA or TKA within an ERAS protocol. Based on these findings, the cost-benefit ratio of antithrombotic prophylaxis by LMWH or DOACs in this context should be reassessed. LEVEL OF EVIDENCE IV; Prospective cohort study without control group.
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Affiliation(s)
- Jean-Yves Jenny
- Hôpitaux Universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France.
| | - Yassine Bulaid
- Centre Hospitalier Universitaire Amiens-Picardie, 80054 Amiens cedex 1, France
| | - Philippe Boisrenoult
- Center Hospitalier de Versailles, 177, rue de Versailles, 78150 Le Chesnay, France
| | - Nicolas Bonin
- Lyon Ortho Clinic, 29B, avenue des Sources, 69009 Lyon, France
| | - Pierre Henky
- Clinique Rhéna, 10, rue François Epailly, 67000 Strasbourg, France
| | - Philippe Tracol
- Cité Santé Plus, 1021, avenue Pierre Mendès France, 84300 Cavaillon, France
| | - Julien Chouteau
- Clinique d'Argonay, 685, route des Menthonnex, 74370 Argonay, France
| | - Cyril Courtin
- Hospices Civils de Lyon-Hôpital Lyon Sud, 165, chemin du Grand Revoyet, 69495 Pierre-Bénite, France
| | - Marc-Pierre Henry
- Centre Hospitalier Régional Universitaire de Brest, 2, avenue Foch, 29609 Brest cedex, France
| | - Claude Schwartz
- Polyclinique des Trois Frontières, 8, rue Saint-Damien, 68300 Saint-Louis, France
| | - Patrice Mertl
- Centre Hospitalier Universitaire Amiens-Picardie, 80054 Amiens cedex 1, France
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164
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Festa R, Tosi F, Pusateri A, Mensi S, Garra R, Mancino A, Frassanito P, Rossi M. The scalp block for postoperative pain control in craniosynostosis surgery: a case control study. Childs Nerv Syst 2020; 36:3063-3070. [PMID: 32418049 DOI: 10.1007/s00381-020-04661-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/04/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE Postoperative analgesia after corrective surgery of pediatric craniosynostosis is crucial in terms of short- and long-term outcomes. The objective of this observational study was to evaluate the effectiveness of an analgesic technique based on the scalp block versus traditional pharmacological approach. METHODS Thirteen patients, aged between 3 months and 2 years, undergoing surgical correction of craniosynostosis, received scalp nerve block before awakening (scalp block group). This group of patients was compared to a second group of 13 patients, retrieved from our database, treated with the traditional pharmacological approach (control group). Pain scores, need of rescue therapy, resumption of oral nutrition, degree of parent satisfaction at discharge, and length of stay in the Pediatric Intensive Care Unit (PICU) and in the hospital were compared between the two groups. RESULTS Objective Pain Score values were significantly lower in patients treated with scalp block at 30 min and at 8 h after extubation. The number of pharmacological interventions for the treatment of pain in PICU was significantly higher in Control group. Children in Scalp block group started earlier oral feeding than in Control group, both for clear fluids and milk. Length of stay in PICU was longer in Scalp block group than in Control group, though the difference between the mean data in the two groups is about 3 . This difference does not seem significant from a clinical standpoint, since it seems more related to logistic issues (e.g., availability of bed in the Pediatric Neurosurgery Unit, presence of a parent), rather than clinical problems contraindicating the discharge from PICU. Indeed, the overall hospital length of stay was similar between the two groups. CONCLUSION Scalp nerve block was effective for immediate postoperative pain control in patients younger than 2 years who underwent cranioplasty for craniosynostosis. The best pain control compared to conventional therapy allowed to limit the need for rescue analgesics in PICU and an earlier recovery time. ClinicalTrials.gov Identification: NCT04133467.
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Affiliation(s)
- Rossano Festa
- Anesthesia and Intensive care, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
| | - Federica Tosi
- Anesthesia and Intensive care, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
| | - Angela Pusateri
- Anesthesia and Intensive care, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
| | - Sonia Mensi
- Anesthesia and Intensive care, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
| | - Rossella Garra
- Anesthesia and Intensive care, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
| | - Aldo Mancino
- Anesthesia and Intensive care, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
| | - Paolo Frassanito
- Pediatric Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Largo Agostino Gemelli, 8, 00168, Roma, Italy.
| | - Marco Rossi
- Anesthesia and Intensive care, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy.,Dipartimento di Scienze dell'emergenza, anestesiologiche e della rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
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165
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Ogura Y, Gum JL, Steele P, Crawford CH, Djurasovic M, Owens RK, Laratta JL, Davis E, Brown M, Daniels C, Dimar JR, Glassman SD, Carreon LY. Multi-modal pain control regimen for anterior lumbar fusion drastically reduces in-hospital opioid consumption. JOURNAL OF SPINE SURGERY 2020; 6:681-687. [PMID: 33447670 DOI: 10.21037/jss-20-629] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background The opioid epidemic is at epic proportions currently in the United States. Exposure to opioids for surgery and subsequent postoperative pain management is a known risk factor for opioid dependence. In addition, opioids can have a negative impact on multiple aspects including clinical outcomes, length of hospital stay, and overall cost of care. Thus, the greatest effort to reduce perioperative opioid use is necessary and a multimodal pain control (MMPC) has been gaining popularity. However, its efficacy in spine surgery is not well known. We aimed to evaluate the efficacy of a MMPC protocol in patients undergoing lumbar single-level anterior lumbar interbody fusion (ALIF). Methods This is a retrospective comparative study. From a prospective, single-surgeon, surgical database, consecutive patients undergoing single-level ALIF with or without subsequent posterior fusion for degenerative lumbar conditions were identified before and after initiation of the MMPC protocol. The MMPC protocol consisted of a preoperative oral regimen of cyclobenzaprine (10 mg), gabapentin (600 mg), acetaminophen (1 g), and methadone (10 mg). Postoperatively they received a bilateral transverse abdominis plane block with 0.5% Ropivacaine prior to extubation. We compared in-hospital opioid consumption between the MMPC and non-MMPC cohorts as well as baseline demographic, the length of hospital stay, cost, and rate of postoperative ileus. Opioid consumption was calculated and normalized to the morphine milligram equivalents (MMEs). Results In total, 68 patients in the MMPC cohort and 39 in the non-MMPC cohort were identified. There was no difference in baseline demographics including sex, body mass index, smoking status, or preoperative opioid use between the two groups. Although there was no difference in the MMEs on the day of surgery (58.5 vs. 66.9, P=0.387), cumulative MMEs each day after surgery was significantly lower in the MMPC cohort, with final cumulative MMEs being reduced by 62% (120.2 vs. 314.8, P<0.001). There was no difference in postoperative ileus, length of stay, and hospital costs. Conclusions The use of a MMPC protocol in patients undergoing single-level ALIF for degenerative conditions reduced opioid consumption starting on the first day after surgery, resulting in a cumulative reduction of 62%.
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Affiliation(s)
- Yoji Ogura
- Norton Leatherman Spine Center, Louisville, KY, USA
| | | | | | | | | | - R Kirk Owens
- Norton Leatherman Spine Center, Louisville, KY, USA
| | | | - Eric Davis
- Norton Leatherman Spine Center, Louisville, KY, USA
| | - Morgan Brown
- Norton Leatherman Spine Center, Louisville, KY, USA
| | | | - John R Dimar
- Norton Leatherman Spine Center, Louisville, KY, USA
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166
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De Ladoucette A, Mertl P, Henry MP, Bonin N, Tracol P, Courtin C, Jenny JY. Fast track protocol for primary total hip arthroplasty in non-trauma cases reduces the length of hospital stay: Prospective French multicenter study. Orthop Traumatol Surg Res 2020; 106:1527-1531. [PMID: 33109491 DOI: 10.1016/j.otsr.2020.05.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 05/02/2020] [Accepted: 05/15/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Fast-track (FT) procedures continue to evolve; however, their benefits are still controversial. This led us to conduct a prospective study of FT procedures for total hip arthroplasty (THA) on a national scale in France with historical control data. The aims were to (1) evaluate the effectiveness of FT procedures after THA on the length of hospital stay (LOS) in a multicenter analysis, (2) measure the immediate return to home, rehospitalization and reoperation rates. HYPOTHESIS FT procedures reduce the LOS after primary THA for non-traumatic indications relative to national historical data. METHODS A prospective observational study was done at 11 hospital facilities throughout France. Patients who underwent primary THA for a non-traumatic condition and FT procedures were followed for 3 months. The average LOS, discharge to home, unexpected readmissions, and reoperation rate were compared to 2016 figures from the French national database of 104,745 procedures on the same population. RESULTS The study included 1,110 patients, 499 men (45%) and 611 women (55%), with a mean age of 67.5±11.9 years. The average LOS was 3.3±2.9 days versus 7.5±5.3 days in the national database (p<0.001). Eight hundred eighty patients (79%) were discharged directly to home versus 72,577 (69%) in the national database (p<0.001). Forty-two patients (4%) were readmitted to the hospital within 90 days of the THA versus 11,092 (11%) in the national database (p<0.001). Eighteen patients (1.6%) were reoperated within 90 days of the THA procedure versus 2100 (2.0%) in the national database (p=0.72). DISCUSSION FT procedures help to significantly reduce the average LOS and rehospitalization rate after primary THA for non-traumatic conditions and significantly increased the percentage of patients being discharged directly to home relative to national historical data, without altering the risk of reoperation. FT procedures should become the standard of care after THA. LEVEL OF EVIDENCE III; prospective case-control study.
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Affiliation(s)
| | - Patrice Mertl
- Centre hospitalier universitaire Amiens-Picardie, 80054 Amiens cedex 1, France
| | - Marc-Pierre Henry
- Centre hospitalier régional universitaire de Brest, 2, avenue Foch, 29609 Brest cedex, France
| | - Nicolas Bonin
- Lyon Ortho Clinic, 29B, avenue des Sources, 69009 Lyon, France
| | - Philippe Tracol
- Cité Santé Plus, 1021, avenue Pierre-Mendès-France, 84300 Cavaillon, France
| | - Cyril Courtin
- Hospices civils de Lyon - hôpital Lyon Sud, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France
| | - Jean-Yves Jenny
- Hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France.
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- SOFCOT, 56, rue Boissonade, 75014 Paris, France
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167
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Abstract
OBJECTIVE To examine the results of a quality-improvement study that implemented an enhanced recovery after surgery (ERAS) program for cesarean delivery. METHODS A pre-post design was used to assess changes in opioid use, length of stay, and costs among all patients undergoing cesarean delivery before and after implementation of an evidence-based ERAS pathway for the preoperative, intraoperative, and postoperative management of patients beginning December 2018. RESULTS A total of 3,679 cesarean deliveries (scheduled and emergent) were included from January 1, 2018, through August 31, 2019, of which 2,171 occurred before implementation on December 17, 2018, and 1,508 occurred postimplementation. Eighty-four percent of patients received opioids as inpatients after cesarean delivery during the preimplementation period, as compared with 24% in the postimplementation period (odds ratio [OR] 16.8, 95% CI 14.3-19.9). Among patients who required any opioids, the total morphine milligram equivalents also significantly decreased (median 56.5 vs 15.0, mean relative change 0.32, 95% CI 0.28-0.35). Compared with the preimplementation period, those in the postimplementation period had a shorter postcesarean length of stay (3.2 vs 2.7 days, mean relative change 0.82, 95% CI 0.80-0.83, median 3 days in both periods), lower median direct costs by $349 (mean relative change 0.93, 95% CI 0.91-0.95), and no change in the 30-day readmission rate (1.4% vs 1.7%, OR 0.83, 95% CI 0.49-1.41). CONCLUSION An ERAS approach for the cesarean delivery population is associated with improved outcomes including decreases in opioid use, length of stay, and costs.
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168
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Alghamdi F, Roth C, Jatana KR, Elmaraghy CA, Rice J, Tobias JD, Thung AK. Opioid-Sparing Anesthetic Technique for Pediatric Patients Undergoing Adenoidectomy: A Pilot Study. J Pain Res 2020; 13:2997-3004. [PMID: 33239908 PMCID: PMC7682613 DOI: 10.2147/jpr.s281275] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 11/11/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION An opioid-sparing anesthetic involves a multi-modal technique with non-opioid medications targeting different analgesic pathways. Such techniques may decrease adverse effects related to opioids. These techniques may be considered in patients at higher risk for opioid-related adverse effects including obstructive sleep apnea or sleep disordered breathing. METHODS A prospective, pilot study was performed in 10 patients (3-8 years of age), presenting for adenoidectomy. The perioperative regimen included oral dextromethorphan (1 mg/kg) and acetaminophen (15 mg/kg) plus single boluses of intraoperative dexmedetomidine (0.5 μg/kg) and ketamine (0.5 mg/kg). Pain scores were assessed in the post anesthesia care unit (PACU) using the FLACC (Face, Legs, Activity, Cry, Consolability) scale. Patients with a pain score >4 received fentanyl as needed. PACU time, pain scores, and parent satisfaction were recorded. Postoperatively, patients were instructed to use oral acetaminophen or ibuprofen every 6 hours as needed for pain. RESULTS The study cohort included 10 patients, 3-8 years of age. All patients had opioid-free anesthetic care. PACU time ranged from 24 to 102 minutes (median: 56 minutes). FLACC pain scores were 0 for all PACU assessments. Nine patients were discharged home and 1 patient had a planned overnight admission. Following hospital discharge, the pain scores were satisfactory during the 72-hour study period and 90% of the patients' guardians were satisfied or highly satisfied with their child's pain control. CONCLUSION This opioid-sparing approach provided safe and effective pain control as well as parental satisfaction following adenoidectomy in children. Additional prospective studies are needed to determine whether this regimen is effective in a larger cohort of patients with and for other otolaryngology procedures.
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Affiliation(s)
- Faris Alghamdi
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and the Ohio State University College of Medicine, Columbus, OH, USA
| | - Catherine Roth
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and the Ohio State University College of Medicine, Columbus, OH, USA
| | - Kris R Jatana
- Department of Otolaryngology and Head & Neck Surgery, Nationwide Children’s Hospital and the Ohio State University, Columbus, OH, USA
| | - Charles A Elmaraghy
- Department of Otolaryngology and Head & Neck Surgery, Nationwide Children’s Hospital and the Ohio State University, Columbus, OH, USA
| | - Julie Rice
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and the Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and the Ohio State University College of Medicine, Columbus, OH, USA
| | - Arlyne K Thung
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and the Ohio State University College of Medicine, Columbus, OH, USA
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Liang M, Chen Y, Zhu W, Zhou D. Efficacy and safety of different doses of ropivacaine for laparoscopy-assisted infiltration analgesia in patients undergoing laparoscopic cholecystectomy: A prospective randomized control trial. Medicine (Baltimore) 2020; 99:e22540. [PMID: 33181643 PMCID: PMC7668433 DOI: 10.1097/md.0000000000022540] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Wound infiltration analgesia provides effective postoperative pain control in patients undergoing laparoscopic cholecystectomy (LC). However, the efficacy and safety of wound infiltration with different doses of ropivacaine is not well defined. This study investigated the analgesic effects and pharmacokinetic profile of varying concentrations of ropivacaine at port sites under laparoscopy assistance. METHODS In this randomized, double-blinded study, 132 patients were assigned to 4 groups: Group H: in which patients were infiltrated with 0.75% ropivacaine; Group M: 0.5% ropivacaine; Group L: 0.2% ropivacaine; and Group C: 0.9% normal saline only. The primary outcome was pain intensity estimated using numeric rating scale (NRS) at discharging from PACU and at 4 hours, 6 hours, 8 hours, and 24 hours after infiltration. Secondary outcomes included plasma concentrations of ropivacaine at 30 minutes after wound infiltration, rescue analgesia requirements after surgery, perioperative vital signs changes, and side effects. RESULTS The NRS in Group C was significantly higher at rest, and when coughing upon leaving PACU and at 4 hours, 6 hours, 8 hours, and 24 hours after infiltration (P < .05) and rescue analgesic consumption was significantly higher. Notably, these parameters were not significantly different between Groups H, Group M and Group L (P > .05). Intra-operative consumption of sevoflurane and remifentanil, HR at skin incision and MAP at skin incision, as well as 5 minutes after skin incision were significantly higher in Group C than in the other 3 groups (P < .01). In contrast, these parameters were not significantly different between Groups H, Group M and Group L (P > .05). The concentration of ropivacaine at 30 minutes after infiltration in Group H was significantly higher than that of Group L and Group M (P < .05). No significant differences were observed in the occurrence of side effects among the 4 groups (P > .05). CONCLUSIONS Laparoscopy-assisted wound infiltration with ropivacaine successfully decreases pain intensity in patients undergoing LC regardless of the doses used. Infiltration with higher doses results in higher plasma concentrations, but below the systematic toxicity threshold.
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Affiliation(s)
- Min Liang
- Department of Anesthesia, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou
- Department of Anesthesia, Liaocheng People's Hospital, Liaocheng, PR China
| | - Yijiao Chen
- Department of Anesthesia, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou
| | - Wenchao Zhu
- Department of Anesthesia, Liaocheng People's Hospital, Liaocheng, PR China
| | - Dachun Zhou
- Department of Anesthesia, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou
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170
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Tucker EM, Thompson JA, Muckler VC. Implementation of a Multimodal Analgesia Protocol Among Outpatient Neurosurgical Patients Undergoing Spine Surgery to Improve Patient Outcomes. J Perianesth Nurs 2020; 36:8-13. [PMID: 33153878 DOI: 10.1016/j.jopan.2020.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 05/25/2020] [Accepted: 05/31/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE This quality improvement project implemented an evidence-based multimodal analgesia protocol among patients undergoing outpatient spine surgery in an attempt to decrease postoperative opioid requirements, postoperative pain scores, and facility and postanesthesia care unit length of stay (LOS). DESIGN Two independent samples were compared with a preimplementation and postimplementation design. There were 37 patients in the preimplementation group and 36 patients in the postimplementation group. METHODS Data were collected by a retrospective chart review of neurosurgical patients undergoing spine surgery and included postoperative opioid requirements, postoperative pain scores, facility and postanesthesia care unit LOS, and the number of protocol components implemented on each patient. FINDINGS Intraoperative and postoperative by mouth opioid requirements were significantly decreased postimplementation. Postoperative opioid requirements decreased, and postimplementation pain scores were reduced across all time points. LOS did not significantly change. CONCLUSIONS This multimodal analgesia protocol significantly decreased opioid consumption among neurosurgical patients at this surgery center.
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171
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Nascimbeni R, Amato A, Cirocchi R, Serventi A, Laghi A, Bellini M, Tellan G, Zago M, Scarpignato C, Binda GA. Management of perforated diverticulitis with generalized peritonitis. A multidisciplinary review and position paper. Tech Coloproctol 2020; 25:153-165. [PMID: 33155148 PMCID: PMC7884367 DOI: 10.1007/s10151-020-02346-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/08/2020] [Indexed: 12/21/2022]
Abstract
Perforated diverticulitis is an emergent clinical condition and its management is challenging and still debated. The aim of this position paper was to critically review the available evidence on the management of perforated diverticulitis and generalized peritonitis in order to provide evidence-based suggestions for a management strategy. Four Italian scientific societies (SICCR, SICUT, SIRM, AIGO), selected experts who identified 5 clinically relevant topics in the management of perforated diverticulitis with generalized peritonitis that would benefit from a multidisciplinary review. The following 5 issues were tackled: 1) Criteria to decide between conservative and surgical treatment in case of perforated diverticulitis with peritonitis; 2) Criteria or scoring system to choose the most appropriate surgical option when diffuse peritonitis is confirmed 3); The appropriate surgical procedure in hemodynamically stable or stabilized patients with diffuse peritonitis; 4) The appropriate surgical procedure for patients with generalized peritonitis and septic shock and 5) Optimal medical therapy in patients with generalized peritonitis from diverticular perforation before and after surgery. In perforated diverticulitis surgery is indicated in case of diffuse peritonitis or failure of conservative management and the decision to operate is not based on the presence of extraluminal air. If diffuse peritonitis is confirmed the choice of surgical technique is based on intraoperative findings and the presence or risk of severe septic shock. Further prognostic factors to consider are physiological derangement, age, comorbidities, and immune status. In hemodynamically stable patients, emergency laparoscopy has benefits over open surgery. Options include resection and anastomosis, Hartmann’s procedure or laparoscopic lavage. In generalized peritonitis with septic shock, an open surgical approach is preferred. Non-restorative resection and/or damage control surgery appear to be the only viable options, depending on the severity of hemodynamic instability. Multidisciplinary medical management should be applied with the main aims of controlling infection, relieving postoperative pain and preventing and/or treating postoperative ileus. In conclusion, the complexity and diversity of patients with diverticular perforation and diffuse peritonitis requires a personalized strategy, involving a thorough classification of physiological derangement, staging of intra-abdominal infection and choice of the most appropriate surgical procedure.
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Affiliation(s)
- R Nascimbeni
- Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, 25124, Brescia, Italy.
| | - A Amato
- Unit of Coloproctology, Department of Surgery, Borea Hospital, Sanremo, Italy
| | - R Cirocchi
- Department of Surgical and Medical Sciences, University of Perugia, Terni, Italy
| | - A Serventi
- Department of Surgery, Galliano Hospital, Acqui Terme, Italy
| | - A Laghi
- Department of Surgical-Medical Sciences and Translational Medicine, "Sapienza" University of Rome, Rome, Italy
| | - M Bellini
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - G Tellan
- Department of Internal, Anesthesiological and Cardiovascular Clinical Sciences, "Sapienza" University of Rome, Rome, Italy
| | - M Zago
- Department of Robotic and Emergency Surgery, Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - C Scarpignato
- Department of Health Sciences, United Campus of Malta, Msida, Malta
- Faculty of Medicine, Chinese University of Hong Kong, ShaTin, Hong Kong
| | - G A Binda
- General Surgery, Biomedical Institute, Genoa, Italy
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172
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Corsini EM, Mitchell KG, Zhou N, Antonoff MB, Mehran RJ, Mena GE, Rajaram R, Roth JA, Sepesi B, Swisher SG, Vaporciyan AA, Walsh GL, Rice DC, Hofstetter WL. Liposomal Bupivacaine Intercostal Block Is Important for Reduction of Pulmonary Complications. Ann Thorac Surg 2020; 112:423-429. [PMID: 33129774 DOI: 10.1016/j.athoracsur.2020.09.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 08/03/2020] [Accepted: 09/16/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND We have previously demonstrated that Enhanced Recovery After Surgery protocols are associated with a reduction in pulmonary complications. As a component of enhanced recovery pathways, intercostal nerve blocks with liposomal bupivacaine are increasingly utilized, but the extent to which this element may contribute to such outcomes has not been evaluated. METHODS Patients undergoing lung resection for stage I to III non-small cell lung cancer at a single institution from 2006 to 2017 were examined for major postoperative pulmonary morbidity, defined as pneumonia, acute respiratory distress syndrome, respiratory arrest, reintubation, bronchoscopy, or need for discharge with oxygen. Pharmacy records were queried for administration of liposomal bupivacaine via posterior intercostal nerve block. Patients treated with and without liposomal bupivacaine were compared in a logistic regression to determine the impact on pulmonary morbidity. RESULTS A total of 2865 patients were identified, including 860 (30%) who were treated with liposomal bupivacaine via posterior intercostal block. Pulmonary morbidity occurred in 455 (16%). Adoption of liposomal bupivacaine analgesia occurred over several years, beginning in 2012 to full adoption by 2017. Liposomal bupivacaine management was associated with a reduction in pulmonary complications, as compared with nonuse (odds ratio, 0.63; P = .006). Additional factors associated with the occurrence of pulmonary morbidity were age, body mass index, smoking, spirometry values, and operative blood loss. CONCLUSIONS As a component of an active enhanced recovery program, liposomal bupivacaine is associated with a reduction in major pulmonary complications, and utilization should be evaluated on a hospital-by-hospital basis.
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Affiliation(s)
- Erin M Corsini
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kyle G Mitchell
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nicolas Zhou
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mara B Antonoff
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Reza J Mehran
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gabriel E Mena
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ravi Rajaram
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jack A Roth
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Boris Sepesi
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephen G Swisher
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ara A Vaporciyan
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Garrett L Walsh
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David C Rice
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Wayne L Hofstetter
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas.
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173
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Yu W, Wu X, Liu L, Long B, Tian Y, Ma C, Dong Y. The Median Effective Dose of One Intravenous Bolus of Oxycodone for Postoperative Analgesia After Myomectomy and Hysterectomy With Local Ropivacaine Wound Infiltration: An Up-Down Dose-Finding Study. Anesth Analg 2020; 131:1599-1606. [PMID: 33079884 DOI: 10.1213/ane.0000000000005011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Oxycodone has been shown to be an effective analgesic for early postoperative analgesia, especially for abdominal operations associated with severe visceral pain. However, the dose needed varies depending on the operation and application of multimodal analgesia, such as local ropivacaine wound infiltration. Therefore, we conducted this study to estimate the median effective dose (ED50) of oxycodone that provides analgesia for hysterectomy and myomectomy with local ropivacaine wound infiltration. METHODS In this dose-finding study, the ED50 of oxycodone for postoperative analgesia was estimated separately for laparoscopic hysterectomy, transabdominal hysterectomy, laparoscopic myomectomy, and transabdominal myomectomy. We used the sequential allocation designed by Dixon. Trials were conducted simultaneously in the 4 surgical type groups. A predefined dose of oxycodone was injected 30 minutes before the end of the operation with an initial dose of 0.1 mg/kg. A series of trials were performed following the rule of a relative 10% increase in dose after inadequate analgesia and a relative 10% decrease in dose after adequate analgesia. The study was conducted until the collection of 7 crossover points was achieved. Local ropivacaine wound infiltration was administered during abdominal stitching. The mean blood pressure (MBP) and heart rate (HR) were analyzed to assess the hemodynamic changes associated with oxycodone administration. RESULTS A total of 113 patients were included in the estimation of ED50: 28 each in the laparoscopic hysterectomy group and transabdominal myomectomy group, 27 in the transabdominal hysterectomy group, and 30 in the laparoscopic myomectomy group. The estimated oxycodone ED50 (95% confidence interval [CI]) after laparoscopic hysterectomy, transabdominal hysterectomy, laparoscopic myomectomy, and transabdominal myomectomy was 0.060 mg/kg (0.053-0.068), 0.079 mg/kg (0.072-0.086), 0.060 mg/kg (0.051-0.071), and 0.092 mg/kg (0.086-0.098), respectively, for postoperative analgesia with local ropivacaine wound infiltration. The ED50 of oxycodone was different between laparoscopic surgeries and transabdominal surgeries (P < .001). The MBP and HR before and after oxycodone injection were different, regardless of surgical type. CONCLUSIONS The oxycodone ED50 for postoperative analgesia was lower for laparoscopic hysterectomy (0.060 mg/kg) and laparoscopic myomectomy (0.060 mg/kg) than for transabdominal hysterectomy (0.079 mg/kg) and transabdominal myomectomy (0.092 mg/kg) when combined with local ropivacaine wound infiltration. A single intravenous injection of oxycodone is associated with an acceptable decrease in MBP and HR within a short time.
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Affiliation(s)
- Wantong Yu
- From the Department of Anesthesiology of Shengjing Hospital, China Medical University, Shenyang, China
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174
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Ernstsen C, Christensen SL, Olesen J, Kristensen DM. No additive effect of combining sumatriptan and olcegepant in the GTN mouse model of migraine. Cephalalgia 2020; 41:329-339. [PMID: 33059476 DOI: 10.1177/0333102420963857] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Despite recent advances in migraine treatment there is a need for therapies with higher clinical efficacy and/or fewer side effects. Triptans (5-HT1B/1D/1F agonists) are essential in the present treatment regime and gepants (CGRP-receptor antagonists) are recognized as effective in acute migraine treatment. Triptans and gepants have different mechanisms of action and here we tested the hypothesis that a combination of these drugs (sumatriptan and olcegepant) would result in an additive effect. METHODS Using the validated glyceryl trinitrate mouse model of migraine, we initially tested dose-response relationships of sumatriptan (0.1, 0.3, and 0.6 mg/kg IP) and olcegepant (0.25, 0.50, and 1.0 mg/kg IP) to find suitable high and low doses. Subsequently, we performed a combination study of the two drugs with a low and a high dose. All experiments were vehicle (placebo) controlled and blinded. RESULTS Sumatriptan significantly reduced glyceryl trinitrate-induced allodynia (F(4,54) = 13.51, p < 0.0001) at all doses. Olcegepant also reduced glyceryl trinitrate-induced allodynia (F(4,53) = 16.11, p < 0.0001) with the two higher doses being significantly effective. Combining 0.50 mg/kg olcegepant with 0.1 or 0.6 mg/kg sumatriptan did not have any improved effect compared to either drug alone (p > 0.50 on all days) in our mouse model. CONCLUSION Combining olcegepant and sumatriptan did not have an additive effect compared to single-drug treatment in this study. Triptan-gepant combinations will therefore most likely not improve migraine treatment. Nevertheless, further studies are necessary, and combinations should also be examined in patients with migraine.
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Affiliation(s)
- Charlotte Ernstsen
- Department of Neurology, Danish Headache Center, Rigshospitalet Glostrup, University of Copenhagen, Glostrup, Denmark
| | - Sarah L Christensen
- Department of Neurology, Danish Headache Center, Rigshospitalet Glostrup, University of Copenhagen, Glostrup, Denmark
| | - Jes Olesen
- Department of Neurology, Danish Headache Center, Rigshospitalet Glostrup, University of Copenhagen, Glostrup, Denmark
| | - David M Kristensen
- Department of Neurology, Danish Headache Center, Rigshospitalet Glostrup, University of Copenhagen, Glostrup, Denmark.,University of Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail) - UMR_S 1085, Rennes, France
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175
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Yang YJ, Huang X, Gao XN, Xia B, Gao JB, Wang C, Zhu XL, Shi XJ, Tao HR, Luo ZJ, Huang JH. An Optimized Enhanced Recovery After Surgery (ERAS) Pathway Improved Patient Care in Adolescent Idiopathic Scoliosis Surgery: A Retrospective Cohort Study. World Neurosurg 2020; 145:e224-e232. [PMID: 33059078 DOI: 10.1016/j.wneu.2020.10.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 10/01/2020] [Accepted: 10/03/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE An optimized Enhanced Recovery After Surgery (ERAS) program is lacking for adolescent idiopathic scoliosis (AIS). The aim of the present study was to evaluate the impact and feasibility of an optimized ERAS pathway in patients with surgically treated AIS. METHODS In total, 79 patients with AIS who underwent corrective surgery without 3-column osteotomy were recruited from Xijing Hospital of the Fourth Military Medical University between 2012 and 2018. Forty-four patients were treated according to a traditional protocol and 35 were managed using an optimized ERAS pathway, which was designed and implemented by a multidisciplinary team. The following data were collected and retrospectively analyzed, demographic characteristics, Cobb angle, curve type (Lenke), surgical duration, fusion level, correction rate, estimated blood loss, postoperative hemoglobin level, postoperative pain score, pain relief time, hemovac drainage, drainage removal time, first ambulation time, length of hospital stay, and postoperative complications. RESULTS There was no significant difference between the traditional and ERAS groups with respect to demographic characteristics, Cobb angle, curve type (Lenke), fusion level, and correction rate. However, the ERAS group had a shorter surgical duration, less blood loss and hemovac drainage, a higher postoperative hemoglobin level, and earlier pain relief, ambulation, and discharge. The rates of postoperative nausea and vomiting were lower in the ERAS group than in the traditional group. CONCLUSIONS The ERAS pathway is capable of improving the perioperative status of patients with AIS by offering stronger analgesia, faster ambulation, and earlier discharge.
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Affiliation(s)
- Yu-Jie Yang
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xin Huang
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China; Department of Orthopaedics, Chinese PLA General Hospital-Fourth Medical Center, Beijing, China
| | - Xiao-Ning Gao
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Bing Xia
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Jian-Bo Gao
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Chen Wang
- Department of Anesthesiology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiao-Ling Zhu
- Department of Anesthesiology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiao-Juan Shi
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Hui-Ren Tao
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Zhuo-Jing Luo
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Jing-Hui Huang
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China.
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176
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Galli M, Vergari A, Vitiello R, Nestorini R, Peruzzi M, Chierichini A, Spinazzola G, Rossi M. Comparative Evaluation of Two Different Post-Operative Analgesia after Hallux Valgus Correction in Day Surgery Patients. Malays Orthop J 2020; 14:57-63. [PMID: 32983378 PMCID: PMC7513642 DOI: 10.5704/moj.2007.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction The aim of this study was the evaluation of two different techniques on post-operative analgesia and motor recovery after hallux valgus correction in one-day surgery patients. Material and Methods We enrolled 26 patients scheduled for hallux valgus surgery and treated with the same surgical technique (SCARF osteotomy). After subgluteal sciatic nerve block with a short acting local anaesthetic (Mepivacaine 1.5%, 15ml), each patient received an ultrasound-guided Posterior Tibialis Nerve Block (PTNB) with Levobupivacaine 0.5% (7-8ml). We measured the postoperative intensity of pain using a Visual Analogue Scale (VAS), the consumption of oxycodone after operative treatment and the motor recovery. VAS was detected at baseline (time 0, before the surgery) and at 3, 6, 12 and 24 hours after the operative procedure (T1, T2, T3, T4 respectively). Control group of 26 patients were treated with another post-operative analgesia technique: local infiltration (Local Infiltration Anaesthesia, LIA) with Levobupivacaine 0.5% (15ml) performed by the surgeon. Results PTNB group showed a significant reduction of VAS score from the sixth hour after surgery compared to LIA group (p<0.028 at T2, p<0.05 at T3 and p<0.002 at T4, respectively). Instead, no significant differences were found in terms of post-operative oxycodone consumption and motor recovery after surgery.Conclusions: PTNB resulted in a valid alternative to LIA approach for post-operative pain control due to its better control of post-operative pain along the first 24 hours. In a multimodal pain management according to ERAS protocol, both PTNB and LIA should be considered as clinically effective analgesic techniques.
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Affiliation(s)
- M Galli
- Department of Orthopaedics and Traumatology, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - A Vergari
- Department of Anaesthesiology, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - R Vitiello
- Department of Orthopaedics and Traumatology, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - R Nestorini
- Department of Anaesthesiology, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - M Peruzzi
- Department of Orthopaedics and Traumatology, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - A Chierichini
- Department of Anaesthesiology, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - G Spinazzola
- Department of Anaesthesiology, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - M Rossi
- Department of Anaesthesiology, Universita Cattolica del Sacro Cuore, Rome, Italy
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177
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Khaw D, Bucknall T, Considine J, Duke M, Hutchinson A, Redley B, de Steiger R, Botti M. Six-year trends in postoperative prescribing and use of multimodal analgesics following total hip and knee arthroplasty: A single-site observational study of pain management. Eur J Pain 2020; 25:107-121. [PMID: 32969139 DOI: 10.1002/ejp.1652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 08/12/2020] [Accepted: 08/18/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Guidelines for acute postoperative pain management recommend administering analgesics in multimodal combination to facilitate synergistic benefit, reduce opioid requirements and decrease side-effects. However, limited observational research has examined the extent to which multimodal analgesics are prescribed and administered postoperatively following joint replacement. METHODS In this longitudinal study, we used three-point prevalence surveys to observe the 6-year trends in prescribing and use of multimodal analgesics on the orthopaedic wards of a single Australian private hospital. We collected baseline postoperative data from total hip and knee arthroplasty patients in May/June 2010 (Time 1, n = 86), and follow-up data at 1 year (Time 2, n = 199) and 5 years (Time 3, n = 188). During the follow-up, data on prescribing practices were presented to anaesthetists. RESULTS We found a statistically significant increase in the prescribing (p < 0.001) and use (p < 0.001) of multimodal analgesics over time. The use of multimodal analgesics was associated with lower rest pain (p = 0.027) and clinically significant reduction in interference with activities (p < 0.001) and sleep (p < 0.001). However, dynamic pain was high and rescue opioids were likely under-administered at all time points. Furthermore, while patients reported high levels of side-effects, use of adjuvant medications was low. CONCLUSIONS We observed significant practice change in inpatient analgesic prescribing in favour of multimodal analgesia, in keeping with contemporary recommendations. Surveys, however, appeared to identify a clinical gap in the bedside assessment and management of breakthrough pain and medication side-effects, requiring additional targeted interventions. SIGNIFICANCE Evaluation of 6-year trends in a large Australian metropolitan private hospital indicated substantial growth in postoperative multimodal analgesic prescribing. In the context of growing global awareness concerning multimodal analgesia, findings suggested diffusion of best-evidence prescribing into clinical practice. Findings indicated the effects of postoperative multimodal analgesia in real-world conditions outside of experimental trials. Postoperative multimodal analgesia in the clinical setting was only associated with a modest reduction in rest pain, but substantially reduced interference from pain on activities and sleep.
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Affiliation(s)
- Damien Khaw
- Faculty of Health, School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia.,Centre for Quality and Patient Safety Research-Epworth HealthCare Partnership, Melbourne, VIC, Australia
| | - Tracey Bucknall
- Faculty of Health, School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia.,Centre for Quality and Patient Safety Research Alfred Health Partnership, Melbourne, VIC, Australia
| | - Julie Considine
- Faculty of Health, School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia.,Centre for Quality and Patient Safety Research-Eastern Health Partnership, Melbourne, VIC, Australia
| | - Maxine Duke
- Faculty of Health, School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia
| | - Ana Hutchinson
- Faculty of Health, School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia.,Centre for Quality and Patient Safety Research-Epworth HealthCare Partnership, Melbourne, VIC, Australia
| | - Bernice Redley
- Faculty of Health, School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia.,Centre for Quality and Patient Safety Research-Monash Health Partnership, Melbourne, VIC, Australia
| | - Richard de Steiger
- Department of Surgery, Epworth Healthcare, University of Melbourne, Melbourne, VIC, Australia
| | - Mari Botti
- Faculty of Health, School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia.,Centre for Quality and Patient Safety Research-Epworth HealthCare Partnership, Melbourne, VIC, Australia
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178
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Ramirez MF, Kamdar BB, Cata JP. Optimizing Perioperative Use of Opioids: A Multimodal Approach. CURRENT ANESTHESIOLOGY REPORTS 2020; 10:404-415. [PMID: 33281504 DOI: 10.1007/s40140-020-00413-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose of Review The main purpose of this article is to review recent literature regarding multimodal analgesia medications, citing their recommended doses, efficacy, and side effects. The second part of this report will provide a description of drugs in different stages of development which have novel mechanisms with less side effects such as tolerance and addiction. Recent Findings Multimodal analgesia is a technique that facilitates perioperative pain management by employing two or more systemic analgesics along with regional anesthesia, when possible. Even though opioids and non-opioid analgesics remain the most common medication used for acute pain management after surgery, they have many undesirable side effects including the potential for misuse. Newer analgesics including peripheral acting opioids, nitric oxide inhibitors, calcitonin gene-related peptide receptor antagonists, interleukin-6 receptor antagonists and gene therapy are under intensive investigation. Summary A patient's first exposure to opioids is often in the perioperative setting, a vulnerable time when multimodal therapy can play a large role in decreasing opioid exposure. Additionally, the current shift towards faster recovery times, fewer post-operative complications and improved cost-effectiveness during the perioperative period has made multimodal analgesia a central pillar of Enhanced Recovery After Surgery (ERAS) protocols.
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Affiliation(s)
- Maria F Ramirez
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Brinda B Kamdar
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
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Abstract
Trends in pediatric pain management are moving toward thinking beyond opioids. Regional anesthetic techniques, such as quadratus lumborum and erector spinae plane blocks, demonstrate efficacy and safety in pediatric populations. Extremity blocks with motor-sparing characteristics also are used. Adjuvants may be added to pediatric peripheral nerve blocks to increase duration of action and improve block efficacy. For medical management, pediatric pain management frequently uses nonopioid medications. These opioid-sparing medications and regional techniques are used to facilitate enhanced recovery after surgery in pediatric surgical patients. Virtual reality is a field where technology can aid in managing acute pain in pediatric patients.
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Affiliation(s)
- Charlotte M Walter
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, OH 45229-3026, USA.
| | - Niekoo Abbasian
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, OH 45229-3026, USA
| | - Vanessa A Olbrecht
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, OH 45229-3026, USA
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180
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Maeda S, Higuchi H, Fujimoto M, Miyake S, Honda-Wakasugi Y, Miyawaki T. Assessing the Effectiveness of Combined Analgesics for Bilateral Ramus Osteotomies. Anesth Prog 2020; 67:140-145. [PMID: 32992331 DOI: 10.2344/anpr-67-01-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 11/08/2019] [Indexed: 11/11/2022] Open
Abstract
Pain management is important for alleviating patients' suffering and early recovery. Although analgesic combinations are known to be effective, a comparison of the effectiveness of different combinations has never been performed specifically for ramus osteotomy procedures. Therefore, the purpose of this observational retrospective cohort study was to identify an effective combination for pain management throughout the intraoperative and immediate postoperative period for patients undergoing bilateral ramus osteotomy procedures. Inclusion criteria consisted of patients who had undergone bilateral mandibular ramus osteotomies over a 2-year period. The analyzed predictor variables included patient gender, age, body weight, operation, anesthetic method, duration of operation, intraoperative use of fentanyl, nonsteroidal anti-inflammatory drugs (NSAIDs), and intravenous acetaminophen administered in the operating room at the end of the surgery. The outcome variable was the necessity for additional rescue analgesics (yes/no) in the recovery room. Bivariate statistics and multivariate analysis were computed with a p-value of <0.05. The study sample was comprised of 78 patients requiring bilateral mandibular ramus osteotomies. From the multivariate analysis, the combination of NSAIDs-acetaminophen-fentanyl was an independent factor for no additional rescue analgesics during the first 1 hour after bilateral ramus osteotomies, indicating that the combination is significantly effective for bilateral ramus osteotomies compared with the other combinations. Considering that this study consisted of a small sample size, the results of this study suggest that some of the combinations, particularly NSAIDs-acetaminophen-fentanyl, are more effective than NSAIDs alone for postoperative pain control immediately following bilateral ramus osteotomy procedures.
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Affiliation(s)
- Shigeru Maeda
- Department of Dental Anesthesiology, Okayama University Hospital, Okayama, Japan
| | - Hitoshi Higuchi
- Department of Dental Anesthesiology, Okayama University Hospital, Okayama, Japan
| | - Maki Fujimoto
- Department of Dental Anesthesiology and Special Care Dentistry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Saki Miyake
- Department of Dental Anesthesiology and Special Care Dentistry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yuka Honda-Wakasugi
- Department of Dental Anesthesiology and Special Care Dentistry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takuya Miyawaki
- Department of Dental Anesthesiology and Special Care Dentistry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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181
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Abstract
Enhanced recovery after surgery (ERAS) is a multimodal perioperative strategy originally developed to attenuate the postsurgical stress response in patients after colorectal surgery. Patients undergoing gynecologic surgery who had ERAS had significantly shorter hospital length of stay, reduced hospital-related costs, and acceptable pain management with reduced opioid use, without compromising patient satisfaction. Intrathecal hydromorphone is an effective alternative ERAS protocol analgesia for these patients and will not compromise patient outcomes or healthcare costs.
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182
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Nishijima M, Baba H, Murotani K, Tokai R, Watanabe T, Hirano K, Shibuya K, Hojo S, Matsui K, Yoshioka I, Okumura T, Fujii T. Early ambulation after general and digestive surgery: a retrospective single-center study. Langenbecks Arch Surg 2020; 405:613-622. [PMID: 32666405 DOI: 10.1007/s00423-020-01925-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/29/2020] [Indexed: 01/09/2023]
Abstract
PURPOSE Postoperative early ambulation contributes to the improvement of postoperative outcomes; however, the definition of "early" ambulation is unclear. In this study, we aimed to define desirable "early" ambulation after digestive surgery in terms of short-term outcomes and to identify the risk factors for delayed ambulation. METHODS We retrospectively analyzed 718 patients who underwent major digestive surgery between January 2016 and May 2019 in our hospital. The timing of first ambulation after surgery was reviewed and correlated with short-term postoperative outcomes and perioperative patient characteristics. RESULTS Of 718 patients, 55% underwent first ambulation at postoperative day (POD) 1, 31% at POD 2, and the remaining patients at POD 3 or later. Whereas short-term outcomes were equivalent among patients with first ambulation at POD 1 and those at POD 2, patients who delayed ambulation until POD 3 or after had an increased incidence of infectious complications (P = 0.004), longer hospitalization (P < 0.001), and a decreased home discharge rate (P < 0.001). Multivariate analysis showed that significant predictors of delayed ambulation (POD ≥ 3) were poor Eastern Cooperative Oncology Group performance status (ECOG-PS), low controlling nutritional status (CONUT), nonlaparoscopic surgery, and transvenous opioid use. Of these factors, the combination of ECOG-PS, CONUT, and nonlaparoscopic surgery clearly stratified patients into four-grade risk groups regarding delayed ambulation (P for trend < 0.001). CONCLUSION Our results suggest that first ambulation before POD 2 could be desirable for better short-term outcomes. Active preoperative intervention, such as nutritional care and prehabilitation, in patients with multiple risk factors for delayed ambulation could improve the postoperative course.
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Affiliation(s)
- Mizuki Nishijima
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Hayato Baba
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan.
| | - Kenta Murotani
- Biostatistics Center, Graduate School of Medicine, Kurume University, Kurume, Japan
| | - Ryutaro Tokai
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Toru Watanabe
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Katsuhisa Hirano
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Kazuto Shibuya
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Shozo Hojo
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Koshi Matsui
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Isaku Yoshioka
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Tomoyuki Okumura
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
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183
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A Practical Approach to Acute Postoperative Pain Management in Chronic Pain Patients. J Perianesth Nurs 2020; 35:564-573. [PMID: 32660812 DOI: 10.1016/j.jopan.2020.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 02/27/2020] [Accepted: 03/02/2020] [Indexed: 01/08/2023]
Abstract
In the United States, more than 100 million people suffer from chronic pain. Among patients presenting for surgery, about one in four have chronic pain. Acute perioperative pain management in this population is challenging because many patients with chronic pain require long-term opioids for the management of this pain, which may result in tolerance, physical dependence, addiction, and opioid-induced hyperalgesia. These challenges are compounded by the ongoing opioid epidemic that has resulted in calls for a reduction in opioid use, with a concurrent increase in the number of patients with chronic opioid exposure presenting for surgery. This article aims to summarize practical considerations for acute postoperative pain management in patients with chronic pain conditions. A patient-centered acute pain management plan, including nonopioid analgesics, regional anesthesia, and careful selection of opioid medications, can lead to adequate analgesia and satisfaction with care. Also, a meticulous rotation from one opioid to another may decrease opioid requirement, increase analgesic effectiveness, and improve satisfaction with care.
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184
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Foo RMC, Hoff C, Sekhri NK, Weber G. Attitudes toward and Barriers to Acetaminophen Use in the Chronic Pain Population: A Cross-Sectional Study. J Pain Palliat Care Pharmacother 2020; 34:107-113. [DOI: 10.1080/15360288.2020.1734139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- R. Marcus C. Foo
- R. Marcus C. Foo, MS, is with the New York Medical College, Valhalla, New York, USA. Chantal Hoff, MPH, is Children's Health Fund, New York, New York, USA. Nitin K. Sekhri, MD, is with the Department of Anesthesiology, New York Medical College, Valhalla, New York, USA. Garret Weber, MD, is with the Department of Anesthesiology, New York Medical College, Valhalla, New York, USA
| | - Chantal Hoff
- R. Marcus C. Foo, MS, is with the New York Medical College, Valhalla, New York, USA. Chantal Hoff, MPH, is Children's Health Fund, New York, New York, USA. Nitin K. Sekhri, MD, is with the Department of Anesthesiology, New York Medical College, Valhalla, New York, USA. Garret Weber, MD, is with the Department of Anesthesiology, New York Medical College, Valhalla, New York, USA
| | - Nitin K. Sekhri
- R. Marcus C. Foo, MS, is with the New York Medical College, Valhalla, New York, USA. Chantal Hoff, MPH, is Children's Health Fund, New York, New York, USA. Nitin K. Sekhri, MD, is with the Department of Anesthesiology, New York Medical College, Valhalla, New York, USA. Garret Weber, MD, is with the Department of Anesthesiology, New York Medical College, Valhalla, New York, USA
| | - Garret Weber
- R. Marcus C. Foo, MS, is with the New York Medical College, Valhalla, New York, USA. Chantal Hoff, MPH, is Children's Health Fund, New York, New York, USA. Nitin K. Sekhri, MD, is with the Department of Anesthesiology, New York Medical College, Valhalla, New York, USA. Garret Weber, MD, is with the Department of Anesthesiology, New York Medical College, Valhalla, New York, USA
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185
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Guo J, Yuan F, Yang Y, Li Y, Bao F, Guo X, Feng Z. Genetic Polymorphisms of Cytokines Might Affect Postoperative Sufentanil Dosage for Analgesia in Patients. J Pain Res 2020; 13:1461-1470. [PMID: 32606912 PMCID: PMC7305826 DOI: 10.2147/jpr.s250174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 05/06/2020] [Indexed: 11/23/2022] Open
Abstract
Objective To explore the effect of genetic polymorphisms of cytokines on the dosage of sufentanil for patient-controlled intravenous analgesia (PCIA) after radical lung cancer surgery. Methods A total of 100 patients, aged 18 years and above, with ASA grade Ⅰ-Ⅱ and body mass index (BMI) 18.5 to 30, and who were scheduled for radical lung cancer surgery under total intravenous anaesthesia with PCIA of sufentanil from September 2015 to March 2016, were selected. DNA was collected from peripheral blood samples before surgery, and the iMLDRTM multiple single-nucleotide polymorphism typing kit was used to detect 16 related single-nucleotide polymorphism (SNP) sites of interleukin-1A (IL-1A), interleukin-1β (IL-1β), interleukin-1RN (IL-1RN), interleukin-6 (IL-6), C-X-C motif chemokine ligand 8 (CXCL8), interleukin-10 (IL-10), tumour necrosis factor (TNF), nuclear factor kappa-B1 (NFκB1), REL (REL proto-oncogene, NF-kB subunit), and nuclear factor kappa-B inhibitor alpha (NFκBIA). The general characteristics of patients, surgery and anaesthesia data, postoperative resting VAS pain scores, postoperative opioid dosages of sufentanil for PCIA and opioid-related adverse events were recorded. The effects of the examined genetic polymorphisms of the cytokines on the dosage of sufentanil were analysed. Results Eight of 100 patients withdrew for various reasons, and, eventually, 92 patients were included. The patients’ resting visual analogue scale (VAS) scores at 24 h, 48 h, and 72 h after surgery were 2.3 ± 1.2, 2.0 ± 0.9, and 1.9 ± 1.0, respectively. The total amounts of sufentanil used were 34.7 ± 10.5 μg, 65.2 ± 13.7 μg, and 94.7 ± 11.6 μg, respectively. We found that the TT genotype of NFκBIA rs696 had higher PCIA sufentanil dosages than the CC genotype and the CT genotype at 48–72 h postoperation (p=0.023, p=0.025, respectively). Conclusion The genetic polymorphisms of the cytokine NFκBIA rs696 might affect the dosage of sufentanil for PCIA after radical lung cancer surgery. The specific mechanism needs further study.
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Affiliation(s)
- Jian Guo
- Department of Pain Medicine, The First Affiliated Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang 310003, People's Republic of China.,Department of Anesthesiology, The Fourth Affiliated Hospital, Zhejiang University, School of Medicine, Yiwu, Zhejiang 322000, People's Republic of China
| | - Fei Yuan
- Department of Anesthesiology, Shaoxing Second Hospital, Shaoxing, Zhejiang 312000, People's Republic of China
| | - Yixin Yang
- Department of Pain Medicine, The First Affiliated Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang 310003, People's Republic of China
| | - Yunze Li
- Department of Pain Medicine, The First Affiliated Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang 310003, People's Republic of China
| | - Fangping Bao
- Department of Anesthesiology, The Fourth Affiliated Hospital, Zhejiang University, School of Medicine, Yiwu, Zhejiang 322000, People's Republic of China
| | - Xuejiao Guo
- Department of Pain Medicine, The First Affiliated Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang 310003, People's Republic of China
| | - Zhiying Feng
- Department of Pain Medicine, The First Affiliated Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang 310003, People's Republic of China
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186
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Jenny JY, Courtin C, Boisrenoult P, Chouteau J, Henky P, Schwartz C, de Ladoucette A. Fast-track procedures after primary total knee arthroplasty reduce hospital stay by unselected patients: a prospective national multi-centre study. INTERNATIONAL ORTHOPAEDICS 2020; 45:133-138. [PMID: 32601722 DOI: 10.1007/s00264-020-04680-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 06/22/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE The aim of this study was to evaluate the impact of fast-track procedures (FTPs) on length of hospital stay after primary total knee arthroplasty (TKA) in a prospective, national, multicentric analysis. The innovative point was that no patient selection was used. The hypothesis was that FTPs reduce hospital stay after primary TKA for non-traumatic conditions compared with the national database. METHODS An observational prospective study was conducted in ten centres throughout France. A total of 839 patients included in FTPs were followed up for three months. The average LOS, direct return home rate, unscheduled re-admission rate, and re-intervention rate were compared with those in the national database (93,329 TKAs). Knee society and Oxford score were collected. RESULTS The mean LOS was 4.4 ± 3.3 days, while the national base LOS was 6.4 ± 3.1 days (p < 0.001). A total of 560 patients (66.7%) were able to return home, compared with 47,617 (49.6%) in the national database (p < 0.001). Thirty-five patients (4.2%) were re-admitted within 90 days of the intervention, compared with 10,399 (10.8%) in the national database (p < 0.001). Seventeen patients (2.0%) were re-operated upon within 90 days after the TKA, compared with 529 (0.5%) in the national database (p < 0.05). CONCLUSION The FTPs used by unselected patients allowed a significant decrease in the mean LOS and in the rate of re-admission and a significant increase of the rate of direct home return after primary TKA compared with the national database. The significant increase in the re-operation rate warrants further investigation. However, FTP should become the standard of care after this intervention.
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Affiliation(s)
- Jean-Yves Jenny
- University Hospital Strasbourg, Pôle Locomax, 1 Avenue, Molière, 67200, Strasbourg, France.
| | - Cyril Courtin
- Hospices Civils de Lyon, 3 quai des Célestins, 69001, Lyon, France
| | - Philippe Boisrenoult
- Centre Hospitalier de Versailles, 177 rue de Versailles, 78150, Le Chesnay, France
| | - Julien Chouteau
- Clinique d'Argonay, 685 route des Menthonnex, 74370, Argonay, France
| | - Pierre Henky
- Clinique Rhéna, 10 rue François Epailly, 67000, Strasbourg, France
| | - Claude Schwartz
- Polyclinique des Trois Frontières, 8 rue Saint-Damien, 68300, Saint-Louis, France
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187
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Dhanjal ST, Jannace KC, Giordano NA, Highland KB. Application of the Joint Trauma System Clinical Practice Guideline for Pain, Anxiety, and Delirium in a Combat Support Hospital in Iraq. Mil Med 2020; 185:e573-e578. [PMID: 31889192 DOI: 10.1093/milmed/usz455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION The 2017 Joint Trauma System Clinical Practice Guideline for Pain, Anxiety, and Delirium (JTS CPG) provides an evidence-based framework for managing pain, anxiety, and delirium in combat settings. In this study, we evaluate the use of multimodal analgesia and assess pain outcomes, as indicated by the JTS CPG, at the combat support hospital (CSH). MATERIALS AND METHODS In this quality improvement project, data were collected for all patients, presenting to the CSH in Baghdad, Iraq, who received consultation from the acute pain service from October 10, 2017 to February 27, 2018. Univariate analyses described patient demographic and clinical characteristics. Defense and Veterans Pain Rating Scale (DVPRS) scores, physical therapy completion, and sleep duration were recorded for each patient daily. Correlations assessed relationships between variables, including clinical characteristics and DVPRS scores. RESULTS 34 patients were included in this study. About 65% of the patients included in this study were Iraqi military, while the other 35% were U.S. or Coalition Forces. Over half received more than one class of analgesic medication. The majority of patients received regional anesthesia, with 17 different techniques utilized. The DVPRS had acceptable internal consistency (Cronbach alpha = 0.87, 95% CI 0.80, 0.95). There was a significant difference in median DVPRS pain intensity scores between those who met physical therapy goals and those who did not. Sleep duration was negatively correlated with both the DVPRS pain intensity and sleep scores. CONCLUSIONS This report indicates that acute pain service teams integrated in a CSH can feasibly implement JTS CPGs using a team-based approach. Given the military's emphasis on managing complex pain and disability among survivors beginning in the combat environment, it is imperative that innovations and best practices, like the JTS CPG, be assessed in the combat setting.
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Affiliation(s)
- Sandeep T Dhanjal
- Department of Anesthesiology, Brooke Army Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston TX 78234
| | - Kalyn C Jannace
- Defense and Veterans Center for Integrative Pain Management, Department of Military and Emergency Medicine, Uniformed Services University, 11300 Rockville Pike, Suite 709, Rockville, MD 20852
| | - Nicholas A Giordano
- Defense and Veterans Center for Integrative Pain Management, Department of Military and Emergency Medicine, Uniformed Services University, 11300 Rockville Pike, Suite 709, Rockville, MD 20852
| | - Krista B Highland
- Defense and Veterans Center for Integrative Pain Management, Department of Military and Emergency Medicine, Uniformed Services University, 11300 Rockville Pike, Suite 709, Rockville, MD 20852.,Henry M Jackson Foundation, 6720A Rockledge Drive, Bethesda, MD 20817
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188
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Cata JP, Gorur A, Yuan X, Berg NK, Sood AK, Eltzschig HK. Role of Micro-RNA for Pain After Surgery. Anesth Analg 2020; 130:1638-1652. [DOI: 10.1213/ane.0000000000004767] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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189
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Repine KM, Hendrickse A, Tran TT, Bartels K, Fernandez-Bustamante A. Opioid-Free Epidural-Free Anesthesia for Open Hepatectomy: A Case Report. A A Pract 2020; 14:e01238. [PMID: 32643901 PMCID: PMC7323843 DOI: 10.1213/xaa.0000000000001238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2020] [Indexed: 12/26/2022]
Abstract
Opioid-free perioperative approaches hold promise to reduce opioid use after surgery and their associated side effects. Here, we report the perioperative analgesic plan of a patient who requested opioid-free care for an open partial hepatectomy. Opioid-free anesthesia care for abdominal surgery is usually dependent on epidural analgesia. However, as in this case, placing an epidural is not always an option due to contraindications such as infection, coagulopathy, or patient refusal. Our multimodal management plan provided an alternative opioid-free, epidural-free perioperative strategy that may prove useful for other patients undergoing similar surgeries.
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Affiliation(s)
- Kelsey M. Repine
- From the University of Colorado School of Medicine, Aurora, Colorado
| | | | | | - Karsten Bartels
- Departments of Anesthesiology
- Surgery
- Psychiatry, University of Colorado School of Medicine, Aurora, Colorado
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190
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Kaye AD, Granier AL, Garcia AJ, Carlson SF, Fuller MC, Haroldson AR, White SW, Krueger OL, Novitch MB, Cornett EM. Non-Opioid Perioperative Pain Strategies for the Clinician: A Narrative Review. Pain Ther 2020; 9:25-39. [PMID: 31933147 PMCID: PMC7203361 DOI: 10.1007/s40122-019-00146-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Indexed: 12/11/2022] Open
Abstract
Alternative and non-opioid options for pain management are necessary in perioperative patient care. Opioids are no longer touted as cure-all medications, and furthermore, there have been tremendous advances in alternative therapies such as in interventional pain, physical therapy, exercise, and nutritional counseling that have proven benefits to combat pain. The center for disease control now strongly recommends the use of multimodal analgesia and multidisciplinary approaches based on the individual needs of patients: personalized medicine. In this manuscript, the specifics of non-opioid pharmacological and non-pharmacological analgesic approaches will be discussed as well as their possible indications and uses to reduce the need for excessive use of opioids for adequate pain control.
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Affiliation(s)
- Alan David Kaye
- Anesthesiology and Pharmacology, Toxicology, and Neurosciences, LSU School of Medicine, Shreveport, LA, USA
- Anesthesiology and Pharmacology, LSU School of Medicine, New Orleans, LA, USA
- Anesthesiology and Pharmacology, Tulane School of Medicine, New Orleans, LA, USA
| | | | - Andrew J Garcia
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | | | | | | | | | | | - Matthew B Novitch
- Department of Anesthesiology, University of Washington, Seattle, WA, USA
| | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA.
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191
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Ceuppens C, Dudi-Venkata NN, Lee YD, Beh YZ, Bedrikovetski S, Thomas ML, Kroon HM, Sammour T. Feasibility study of an online modifiable Enhanced Recovery After Surgery protocol with specific focus on opioid avoidance. ANZ J Surg 2020; 90:1947-1952. [PMID: 32407004 DOI: 10.1111/ans.15976] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 04/25/2020] [Accepted: 04/29/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND The high and increasing rate of opioid use is a serious issue in the Western world affecting the population's physical and mental health. In most cases, opioid dependency starts with prescriptions by medical professionals, so efforts aimed at reducing in-hospital opioid use should result in less long-term dependency. The aim of the current study was to evaluate the feasibility of implementing an opioid-scarce protocol as part of a new online modifiable Enhanced Recovery After Surgery (mERAS) programme. METHODS A single-centre retrospective study was conducted comparing a cohort treated under the new opioid-scarce mERAS protocol (n = 96; May 2018-Nov 2018) to those treated under the original ERAS protocol (n = 84; November 2017-April 2018). The primary outcome was the quantity and duration of opioid use. RESULTS Fewer patients used fentanyl via intravenous patient-controlled analgesia in the mERAS group (54% versus 70%; P = 0.03). The mERAS group was also less likely to use oral oxycodone (80% versus 99%; P < 0.0001) and for a shorter duration (median 3 versus 5 days; P = 0.0002). More local anaesthetic transversus abdominis plane catheters were used in the mERAS group (34% versus 6% in the control group; P < 0.0001). CONCLUSION Opioid use can be significantly reduced after elective colorectal surgery by employing an opioid-scarce ERAS protocol. Further data is required to confirm the clinical benefits of this approach.
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Affiliation(s)
- Charlotte Ceuppens
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Faculty of Medical Sciences, Erasmus University, Rotterdam, The Netherlands
| | - Nagendra N Dudi-Venkata
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Faculty of Health and Medical Science, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Yanni D Lee
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Yong Z Beh
- Faculty of Health and Medical Science, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Sergei Bedrikovetski
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Faculty of Health and Medical Science, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Michelle L Thomas
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Hidde M Kroon
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tarik Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Faculty of Health and Medical Science, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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192
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Everson M, McLain N, Collins MJ, Rayborn M. Perioperative Pain Management Strategies in the Age of an Opioid Epidemic. J Perianesth Nurs 2020; 35:347-352. [PMID: 32305324 DOI: 10.1016/j.jopan.2020.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 01/03/2020] [Accepted: 01/05/2020] [Indexed: 12/13/2022]
Abstract
According to the US Department of Health and Human Services 2016 and 2017 data, an estimated 130 people per day died from opioid-related drug overdoses; 42,249 people died from overdosing on opioids; and 2.1 million people had opioid-use disorder. Health care organizations such as the American Association of Nurse Anesthetists, the Association of periOperative Registered Nurses, the American Society of PeriAnesthesia Nurses, the American Society of Anesthesiologists, the American College of Surgeons, and the American Medical Association have information related to pain management and/or the opioid epidemic on their Web sites. It is imperative for health care providers to be cognizant of, and use low-dose opioid/opioid-free pain management therapies. This article reviews the pain process and outlines low-dose opioid/opioid-free pain management modalities.
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Affiliation(s)
- Marjorie Everson
- Johns Hopkins University School of Nursing, Baltimore, MD; Per Diem CRNA Benefis Health System, Great Falls, MT.
| | - Nina McLain
- Nurse Anesthesia Program, University of Southern Mississippi, Hattiesburg, MS
| | - Mary Jane Collins
- Nurse Anesthesia Program, University of Southern Mississippi, Hattiesburg, MS
| | - Michong Rayborn
- Nurse Anesthesia Program, University of Southern Mississippi, Hattiesburg, MS
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193
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Baker J, Brovman EY, Rao N, Beutler SS, Urman RD. Potential Opioid-Related Adverse Drug Events Are Associated With Decreased Revenue in Hip Replacement Surgery in the Older Population. Geriatr Orthop Surg Rehabil 2020; 11:2151459320915328. [PMID: 32231864 PMCID: PMC7097868 DOI: 10.1177/2151459320915328] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 02/11/2020] [Accepted: 02/20/2020] [Indexed: 01/19/2023] Open
Abstract
Introduction Opioid-related adverse drug events (ORADEs) are an increasingly recognized complication associated with the common prescription of opioids after orthopedic surgery. In this study, we attempted to understand how potential ORADEs following hip replacement surgery in older patients affected hospital length of stay, hospital revenue, and their association with specific risk factors and clinically relevant diseases occurring during hospitalization. Methods We conducted a retrospective study using the Centers for Medicare and Medicaid Services Administrative Database to analyze Medicare discharges after hip replacement surgery to identify potential ORADEs. The impact of potential ORADEs on mean hospital length of stay (LOS) and hospital revenue was analyzed. Results The potential ORADE rate in patients who underwent hip replacement surgery was 8.6%. The mean LOS for discharges with a potential ORADE was 1.41 days longer than that for discharges without an ORADE. The mean hospital revenue per day with a potential ORADE was US$1708 less than without an ORADE. Potential ORADEs were also found to be strongly associated with poor patient outcomes such as pneumonia, septicemia, and shock. Discussion Potential ORADEs in hip replacement surgery in older patients are associated with longer hospitalizations, decreased hospital revenue per day, certain patient risk factors, and clinically relevant diseases occurring during hospitalizations. Our finding of an association between potential ORADEs and decreased hospital revenue per day may be attributed to the management of these adverse events, as a patient may need to undergo additional testing, may need additional treatment regimens, and may need a higher level of care. Conclusion By reducing the use of opioids and employing a multimodal analgesic approach, we may improve patient care, decrease hospital lengths of stay, and increase hospital revenue.
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Affiliation(s)
- Justin Baker
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ethan Y Brovman
- Department of Anesthesiology, Tufts Medical Center, Boston, MA, USA
| | | | - Sascha S Beutler
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Center for Perioperative Research, Brigham and Women's Hospital, Boston, MA, USA
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194
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The Impact of Preventative Multimodal Analgesia on Postoperative Opioid Requirement and Pain Control in Patients Undergoing Lumbar Fusions. Clin Spine Surg 2020; 33:E135-E140. [PMID: 31693519 DOI: 10.1097/bsd.0000000000000913] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN A prospective observational study with a historical reference group. OBJECTIVES The main objectives of this study were to determine the impact of preventative multimodal analgesia (PMA) on postoperative opioid requirements and analgesic effectiveness in patients undergoing lumbar fusion surgery. SUMMARY OF BACKGROUND DATA PMA addresses the multiple pathways of acute and chronic pain by interfering with peripheral and central sensitization and should provide a way to achieve safer and more effective pain management with reduced opioid medication use. MATERIALS AND METHODS This study compared postoperative opioid requirement and analgesic effect in a total of 101 patients undergoing elective, 1-level or 2-level transforaminal lumbar interbody fusion surgeries for symptomatic lumbar degenerative disk disease. The PMA patient group included 51 consecutive patients who received 1000 mg of acetaminophen, 300-900 mg of gabapentin, and 200-400 mg of celecoxib 1 hour before their index procedure. The reference group included 50 patients who received 15 mg of morphine-equivalent dose (MED) preoperatively.Multiple linear regression was used to evaluate the effect of PMA on postoperative pain and MED over 4 postoperative days, while controlling for all variables likely to influence these outcomes, including age, sex, baseline opioid use, duration of surgery, postoperative intrathecal morphine use and the administration of muscle relaxants and anticonvulsants. RESULTS The differences in opioid requirement and postoperative pain scores were statistically significant on all 4 postoperative days. The effect size varied from -0.54 to -0.99 (34.8%-54.2% MED reduction) for the postoperative opioid requirement and from -0.59 to -1.16 (28.9%-37.3% visual analog scale reduction) for postoperative pain indicating that these measures were reduced by about ½ to 1 SD in the PMA patient group. CONCLUSIONS PMA is a highly effective and safe method for postoperative pain management in patients undergoing elective lumbar fusion surgeries by improving pain control and reducing opioid requirement. LEVEL OF EVIDENCE Level III.
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195
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Lee BH, Wu CL. Educating Patients Regarding Pain Management and Safe Opioid Use After Surgery. Anesth Analg 2020; 130:574-581. [DOI: 10.1213/ane.0000000000004436] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Reducing Opioid Prescribing After Ambulatory Plastic Surgery With an Opioid-Restrictive Pain Protocol. Ann Plast Surg 2020; 84:S431-S436. [DOI: 10.1097/sap.0000000000002272] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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197
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Cyr AE. Underutilization of Enhanced Recovery After Surgery (ERAS) in Breast Surgery: An Opportunity to Reduce Opioid Usage. Ann Surg Oncol 2020; 27:966-968. [DOI: 10.1245/s10434-020-08198-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Indexed: 12/15/2022]
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198
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Zhuang Q, Tao L, Lin J, Jin J, Qian W, Bian Y, Li Y, Dong Y, Peng H, Li Y, Fan Y, Wang W, Feng B, Gao N, Sun T, Lin J, Zhang M, Yan S, Shen B, Pei F, Weng X. Postoperative intravenous parecoxib sodium followed by oral celecoxib post total knee arthroplasty in osteoarthritis patients (PIPFORCE): a multicentre, double-blind, randomised, placebo-controlled trial. BMJ Open 2020; 10:e030501. [PMID: 31924632 PMCID: PMC6955469 DOI: 10.1136/bmjopen-2019-030501] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES To evaluate the morphine-sparing effects of the sequential treatment versus placebo in subjects undergoing total knee arthroplasty (TKA), the effects on pain relief, inflammation control and functional rehabilitation after TKA and safety. DESIGN Double-blind, pragmatic, randomised, placebo-controlled trial. SETTING Four tertiary hospitals in China. PARTICIPANTS 246 consecutive patients who underwent elective unilateral TKA because of osteoarthritis (OA). INTERVENTIONS Patients were randomised 1:1 to the parecoxib/celecoxib group or the control group. The patients in the parecoxib/celecoxib group were supplied sequential treatment with intravenous parecoxib 40 mg (every 12 hours) for the first 3 days after surgery, followed by oral celecoxib 200 mg (every 12 hours) for up to 6 weeks. The patients in the control group were supplied with the corresponding placebo under the same instructions. PRIMARY AND SECONDARY OUTCOME MEASURES The primary endpoint was the cumulative opioid consumption at 2 weeks post operation (intention-to-treat analysis). Secondary endpoints included the Knee Society Score, patient-reported outcomes and the cumulative opioid consumption. RESULTS The cumulative opioid consumption at 2 weeks was significantly smaller in the parecoxib/celecoxib group than in the control group (median difference, 57.31 (95% CI 34.66 to 110.33)). The parecoxib/celecoxib group achieving superior Knee Society Scores and EQ-5D scores and greater Visual Analogue Scale score reduction during 6 weeks. Interleukin 6, erythrocyte sedation rate and C-reactive protein levels were reduced at 72 hours, 2 weeks and 4 weeks and prostaglandin E2 levels were reduced at 48 hours and 72 hours in the parecoxib/celecoxib group compared with the placebo group. The occurrence of adverse events (AEs) was significantly lower in the parecoxib/celecoxib group. CONCLUSIONS The sequential intravenous parecoxib followed by oral celecoxib regimen reduces morphine consumption, achieves better pain control and functional recovery and leads to less AEs than placebo after TKA for OA. TRIAL REGISTRATION NUMBER ClinicalTrials.gov (ID: NCT02198924).
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Affiliation(s)
- Qianyu Zhuang
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
| | - Liyuan Tao
- Research Center of Clinical Epidemiology, Peking University 3rd Hospital, Beijing, China
| | - Jin Lin
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
| | - Jin Jin
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
| | - Wenwei Qian
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
| | - Yanyan Bian
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
| | - Yulong Li
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
| | - Yulei Dong
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
| | - Huiming Peng
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
| | - Ye Li
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
| | - Yu Fan
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
| | - Wei Wang
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
| | - Bin Feng
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
| | - Na Gao
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
| | - Tiezheng Sun
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
| | - Jianhao Lin
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
| | - Miaofeng Zhang
- Department of Orthopedics, The Second Affiliated Hospital of Zhejiang University, Zhejiang, China
| | - Shigui Yan
- Department of Orthopedics, The Second Affiliated Hospital of Zhejiang University, Zhejiang, China
| | - Bin Shen
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, China
| | - Fuxing Pei
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, China
| | - Xisheng Weng
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
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199
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Wong T, Georgiadis PL, Urman RD, Tsai MH. Non-Operating Room Anesthesia: Patient Selection and Special Considerations. Local Reg Anesth 2020; 13:1-9. [PMID: 32021414 PMCID: PMC6956865 DOI: 10.2147/lra.s181458] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 11/25/2019] [Indexed: 12/18/2022] Open
Abstract
Non-operating room anesthesia (NORA) represents a growing field of medicine with an increasing trend in the number of cases performed over the previous decade. As a result, anesthesia providers will need to enhance their familiarity with the resources, personnel, and environment outside of the operating room. Anesthesia delivery in NORA settings should be held with the same high-quality standards as that within the operating room. This review looks at special considerations in patient selection and the preoperative, intraoperative, and postoperative periods. In addition, there is a discussion on the unique aspects of specific NORA areas and the considerations that come with them.
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Affiliation(s)
- Timothy Wong
- University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Paige L Georgiadis
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Mitchell H Tsai
- Department of Anesthesiology, Department of Orthopaedics and Rehabilitation (by Courtesy), Department of Surgery (by Courtesy), University of Vermont Larner College of Medicine, Burlington, VT, USA
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200
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Gabriel RA, Burton BN, Urman RD, Waterman RS. Genomics Testing and Personalized Medicine in the Preoperative Setting. Surg Oncol Clin N Am 2020; 29:73-86. [DOI: 10.1016/j.soc.2019.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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