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Nezafati S, Eidy M, Khiavi RK, Darehchi SR, Pourlak T, Baybourdi V, Vahedpour H, Mousavi Z. The effect of local injection of bupivacaine with and without fentanyl at the operative site in mandibular open reduction on acute pain intensity and opioid requirement: a randomized clinical trial. Oral Maxillofac Surg 2024; 28:685-691. [PMID: 37953394 DOI: 10.1007/s10006-023-01188-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 10/29/2023] [Indexed: 11/14/2023]
Abstract
PURPOSE The aim of this study is to investigate the effects of bupivacaine local injection with and without fentanyl at the operative site in mandibular open reduction surgeries on the severity of acute pain and the need for opioids. METHODS This randomized clinical trial, age-sex-matched double-blind study included 44 patients with isolated mandibular fractures who would be candidates for open reduction. They were divided into two groups (intervention using fentanyl and control not using fentanyl). In both groups, the amount of opioid used, hemodynamic indices, oxygen saturation, and pain intensity were collected based on the Visual Analogue Scale (VAS) every 4 h for 24 h. RESULTS As for basic and demographic variables such as gender, age, ASA class, and duration of surgery (P > 0.05), there was neither a significant difference between the two groups nor was there any difference in nausea and vomiting and subsequent anti-nausea medication (P > 0.05). The need for a post-operative opioid in the bupivacaine + fentanyl group (13.6%) was significantly less than in those who received only bupivacaine (45.5%) (P < 0.05). Changes in pain scores over time were significantly different in the two groups, and bupivacaine + fentanyl reduced pain more than bupivacaine (P < 0.05). However, over time, there was no significant difference between the two groups in terms of changes in oxygen saturation, heart rate, systolic blood pressure, and diastolic blood pressure (P > 0.05). CONCLUSION The addition of fentanyl to bupivacaine for supraperiosteal injection in the open reduction surgery site reduces post-operative pain in the first 24 h and reduces the need for opioids without causing complications such as nausea and vomiting.
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Affiliation(s)
- Saeed Nezafati
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mahmoud Eidy
- Department of Anestheliology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reza Khorshidi Khiavi
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Saeed Rahimi Darehchi
- Department of Endodontics, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Tannaz Pourlak
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Vahid Baybourdi
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Hafez Vahedpour
- Department of Operative Dentistry, Faculty of Dentistry, Urmia University of Medical Sciences, Urmia, Iran
| | - Zohreh Mousavi
- Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Urmia University of Medical Sciences, Urmia, Iran
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Pinto VM, Gianesin B, Sardo S, Mazzi F, Baiardi G, Menotti S, Piras F, Quintino S, Robello G, Mattioli F, Finco G, Forni GL, De Franceschi L. Safety and efficacy of ketorolac continuous infusion for multimodal analgesia of vaso-occlusive crisis in patients with sickle cell disease. Orphanet J Rare Dis 2024; 19:22. [PMID: 38254184 PMCID: PMC10801952 DOI: 10.1186/s13023-023-02998-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 12/15/2023] [Indexed: 01/24/2024] Open
Abstract
Pain is an hallmark of sickle-cell-related acute clinical manifestations as part of acute vaso-occlusive crisis (VOC). In SCD pain has different origins such as vascular or neuropathic pain, which requires multimodal analgesia. This is based on the administration of drugs with different pharmacological mechanisms of action, maximizing analgesia and minimizing their adverse events and the risk of drug-addition in patients experiencing acute-recurrent pain events as in SCD. Ketorolac is a potent non-narcotic analgesic, being relatively safe and effective during pain-management in children and adults. Up to now, there is a lack of safety information on continuous infusion ketorolac as used to control acute pain in patients with SCD, and the benefits/risks ratio needs to be investigated. Here, we report for the first time the safety profile of ketorolac in the special population of patients with SCD. We confirmed that ketorolac in combination with tramadol, an opioid like molecule, is effective in pain control of adult patients with SCD experiencing acute severe VOCs defined by pain visual analog scale. Our study shows that short term (72 h) continuous infusion of ketorolac plus tramadol is not associated with adverse events such as liver or kidney acute disfunction or abnormalities in coagulation parameters during patients' hospitalization and within 30 days after patients discharge. This is extremely important for patients with SCD, who should have access to multimodal therapy to control recurrent acute pain crisis in order to limit central sensitization a fearsome issue of undertreated recurrent acute pain and of chronic pain.
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Affiliation(s)
- Valeria Maria Pinto
- EO Ospedali Galliera, Centro della Microcitemia, delle Anemie Congenite e dei Disordini del Metabolismo del Ferro, Genoa, Italy
| | - Barbara Gianesin
- EO Ospedali Galliera, Centro della Microcitemia, delle Anemie Congenite e dei Disordini del Metabolismo del Ferro, Genoa, Italy
- For Anemia Foundation, Genoa, Italy
| | - Salvatore Sardo
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Filippo Mazzi
- Department of Medicine, University of Verona and AOUI Verona, Verona, Italy
| | - Giammarco Baiardi
- Department of Internal Medicine, Pharmacology & Toxicology Unit, University of Genoa, Genoa, Italy
- Clinical Pharmacology Unit, EO Ospedali Galliera, Genoa, Italy
| | - Sofia Menotti
- Department of Medicine, University of Verona and AOUI Verona, Verona, Italy
| | - Fabio Piras
- Department of Internal Medicine, Pharmacology & Toxicology Unit, University of Genoa, Genoa, Italy
| | - Sabrina Quintino
- EO Ospedali Galliera, Centro della Microcitemia, delle Anemie Congenite e dei Disordini del Metabolismo del Ferro, Genoa, Italy
| | - Giacomo Robello
- EO Ospedali Galliera, Centro della Microcitemia, delle Anemie Congenite e dei Disordini del Metabolismo del Ferro, Genoa, Italy
| | - Francesca Mattioli
- Department of Internal Medicine, Pharmacology & Toxicology Unit, University of Genoa, Genoa, Italy
- Clinical Pharmacology Unit, EO Ospedali Galliera, Genoa, Italy
| | - Gabriele Finco
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Gian Luca Forni
- EO Ospedali Galliera, Centro della Microcitemia, delle Anemie Congenite e dei Disordini del Metabolismo del Ferro, Genoa, Italy.
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Dou D, Jia Y, Yuan S, Wang Y, Li Y, Wang H, Ding J, Wu X, Bie D, Liu Q, An R, Yan H, Yan F. The protocol of Enhanced Recovery After Cardiac Surgery (ERACS) in congenital heart disease: a stepped wedge cluster randomized trial. BMC Pediatr 2024; 24:22. [PMID: 38183047 PMCID: PMC10768436 DOI: 10.1186/s12887-023-04422-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/14/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND The Enhanced Recovery After Cardiac Surgery (ERACS) programs are comprehensive multidisciplinary interventions to improve patients' recovery. The application of the ERAS principle in pediatric patients has not been identified completely. METHODS This study is a multicenter, stepwise design, cluster randomized controlled trial. 3030 patients presenting during control and intervention periods are eligible if they are aged from 28 days to 6 years old and awaiting elective correction surgery of congenital heart disease with cardiopulmonary bypass. 5 centers are randomly assigned to staggered start dates for one-way crossover from the control phase to the intervention phase. In the intervention periods, patients will receive a bundle strategy including preoperative, intraoperative, and postoperative approaches. During the control phase, patients receive the usual care. The primary outcome consists of major adverse cardiac and cerebrovascular events (MACCEs), postoperative pulmonary complications (PPCs), and acute kidney injury (AKI). DISCUSSION This study aims to explore whether the bundle of ERAS measurements could improve patients' recovery in congenital heart surgery. TRIAL REGISTRATION http://www. CLINICALTRIALS gov . (NCT05914103).
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Affiliation(s)
- Dou Dou
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Yuan Jia
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Su Yuan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Yang Wang
- Department of Medical Research & Biometrics Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Yinan Li
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Hongbai Wang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Jie Ding
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Xie Wu
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Dongyun Bie
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Qiao Liu
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Ran An
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Haoqi Yan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Fuxia Yan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China.
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King JL, Richey B, Yang D, Olsen E, Muscatelli S, Hake ME. Ketorolac and bone healing: a review of the basic science and clinical literature. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:673-681. [PMID: 37688640 DOI: 10.1007/s00590-023-03715-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/27/2023] [Indexed: 09/11/2023]
Abstract
Although the efficacy of ketorolac in pain management and the short duration of use align well with current clinical practice guidelines, few studies have specifically evaluated the impact of ketorolac on bony union after fracture or surgery. The purpose of this study was to review the current basic science and clinical literature on the use of ketorolac for pain management after fracture and surgery and the subsequent risk of delayed union or nonunion. Animal studies demonstrate a dose-dependent risk of delayed union in rodents treated with high doses of ketorolac for 4 weeks or greater; however, with treatment for 7 days or low doses, there is no evidence of risk of delayed union or nonunion. Current clinical evidence has also shown a dose-dependent increased risk of pseudoarthrosis and nonunion after post-operative ketorolac administration in orthopedic spine surgery. However, other orthopedic subspecialities have not demonstrated increased risk of delayed union or nonunion with the use of peri-operative ketorolac administration. While evidence exists that long-term ketorolac use may represent risks with regard to fracture healing, insufficient evidence currently exists to recommend against short-term ketorolac use that is limited to the peri-operative period. LEVEL OF EVIDENCE V: Narrative Review.
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Affiliation(s)
- Jesse Landon King
- Department of Orthopaedic Surgery, University of Michigan, Michigan Medicine, 1500 E. Medical Center Drive, 2912 Taubman Center, Box 5328, Ann Arbor, MI, 48109-5328, USA.
| | - Bradley Richey
- Department of Orthopaedic Surgery, University of Michigan, Michigan Medicine, 1500 E. Medical Center Drive, 2912 Taubman Center, Box 5328, Ann Arbor, MI, 48109-5328, USA
| | - Daniel Yang
- Department of Orthopaedic Surgery, University of Michigan, Michigan Medicine, 1500 E. Medical Center Drive, 2912 Taubman Center, Box 5328, Ann Arbor, MI, 48109-5328, USA
| | - Eric Olsen
- Department of Orthopaedic Surgery, University of Michigan, Michigan Medicine, 1500 E. Medical Center Drive, 2912 Taubman Center, Box 5328, Ann Arbor, MI, 48109-5328, USA
| | - Stefano Muscatelli
- Department of Orthopaedic Surgery, University of Michigan, Michigan Medicine, 1500 E. Medical Center Drive, 2912 Taubman Center, Box 5328, Ann Arbor, MI, 48109-5328, USA
| | - Mark E Hake
- Department of Orthopaedic Surgery, University of Michigan, Michigan Medicine, 1500 E. Medical Center Drive, 2912 Taubman Center, Box 5328, Ann Arbor, MI, 48109-5328, USA
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Ringsten M, Kredo T, Ebrahim S, Hohlfeld A, Bruschettini M. Diclofenac for acute postoperative pain in children. Cochrane Database Syst Rev 2023; 12:CD015087. [PMID: 38078559 PMCID: PMC10712214 DOI: 10.1002/14651858.cd015087.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
BACKGROUND Many children undergo various surgeries, which often lead to acute postoperative pain. This pain influences recovery and quality of life. Non-steroidal anti-inflammatory drugs (NSAIDs), specifically cyclo-oxygenase (COX) inhibitors such as diclofenac, can be used to treat pain and reduce inflammation. There is uncertainty regarding diclofenac's benefits and harms compared to placebo or other drugs for postoperative pain. OBJECTIVES To assess the efficacy and safety of diclofenac (any dose) for acute postoperative pain management in children compared with placebo, other active comparators, or diclofenac administered by different routes (e.g. oral, rectal, etc.) or strategies (e.g. 'as needed' versus 'as scheduled'). SEARCH METHODS We used standard, extensive Cochrane search methods. We searched CENTRAL, MEDLINE, and trial registries on 11 April 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) in children under 18 years of age undergoing surgery that compared diclofenac (delivered in any dose and route) to placebo or any active pharmacological intervention. We included RCTs comparing different administration routes of diclofenac and different strategies. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Our primary outcomes were: pain relief (PR) reported by the child, defined as the proportion of children reporting 50% or better postoperative pain relief; pain intensity (PI) reported by the child; adverse events (AEs); and serious adverse events (SAEs). We presented results using risk ratios (RR), mean differences (MD), and standardised mean differences (SMD), with the associated confidence intervals (CI). MAIN RESULTS We included 32 RCTs with 2250 children. All surgeries were done using general anaesthesia. Most studies (27) included children above age three. Only two studies had an overall low risk of bias; 30 had an unclear or high risk of bias in one or several domains. Diclofenac versus placebo (three studies) None of the included studies reported on PR or PI. We are very uncertain about the benefits and harms of diclofenac versus placebo on nausea/vomiting (RR 0.83, 95% CI 0.38 to 1.80; 2 studies, 100 children) and any reported bleeding (RR 3.00, 95% CI 0.34 to 26.45; 2 studies, 100 children), both very low-certainty evidence. None of the included studies reported SAEs. Diclofenac versus opioids (seven studies) We are very uncertain if diclofenac reduces PI at 2 to 24 hours postoperatively compared to opioids (median pain intensity 0.3 (interquartile range (IQR) 0.0 to 2.5) for diclofenac versus median 0.7 (IQR 0.1 to 2.4) in the opioid group; 1 study, 50 children; very low-certainty evidence). None of the included studies reported on PR or PI for other time points. Diclofenac probably results in less nausea/vomiting compared to opioids (41.0% in opioids, 31.0% in diclofenac; RR 0.75, 95% CI 0.58 to 0.96; 7 studies, 463 participants), and probably increases any reported bleeding (5.4% in opioids, 16.5% in diclofenac; RR 3.06, 95% CI 1.31 to 7.13; 2 studies, 222 participants), both moderate-certainty evidence. None of the included studies reported SAEs. Diclofenac versus paracetamol (10 studies) None of the included studies assessed child-reported PR. Compared to paracetamol, we are very uncertain if diclofenac: reduces PI at 0 to 2 hours postoperatively (SMD -0.45, 95% CI -0.74 to -0.15; 2 studies, 180 children); reduces PI at 2 to 24 hours postoperatively (SMD -0.64, 95% CI -0.89 to -0.39; 3 studies, 300 children); reduces nausea/vomiting (RR 0.47, 95% CI 0.25 to 0.87; 5 studies, 348 children); reduces bleeding events (RR 0.57, 95% CI 0.12 to 2.62; 5 studies, 332 participants); or reduces SAEs (RR 0.50, 95% CI 0.05 to 5.22; 1 study, 60 children). The evidence certainty was very low for all outcomes. Diclofenac versus bupivacaine (five studies) None of the included studies reported on PR or PI. Compared to bupivacaine, we are very uncertain about the effect of diclofenac on nausea/vomiting (RR 1.28, 95% CI 0.58 to 2.78; 3 studies, 128 children) and SAEs (RR 4.52, 95% CI 0.23 to 88.38; 1 study, 38 children), both very low-certainty evidence. Diclofenac versus active pharmacological comparator (10 studies) We are very uncertain about the benefits and harms of diclofenac versus any other active pharmacological comparator (dexamethasone, pranoprofen, fluorometholone, oxybuprocaine, flurbiprofen, lignocaine), and for different routes and delivery of diclofenac, due to few and small studies, no reporting of key outcomes, and very low-certainty evidence for the reported outcomes. We are unable to draw any meaningful conclusions from the numerical results. AUTHORS' CONCLUSIONS We remain uncertain about the efficacy of diclofenac compared to placebo, active comparators, or by different routes of administration, for postoperative pain management in children. This is largely due to authors not reporting on clinically important outcomes; unclear reporting of the trials; or poor trial conduct reducing our confidence in the results. We remain uncertain about diclofenac's safety compared to placebo or active comparators, except for the comparison of diclofenac with opioids: diclofenac probably results in less nausea and vomiting compared with opioids, but more bleeding events. For healthcare providers managing postoperative pain, diclofenac is a COX inhibitor option, along with other pharmacological and non-pharmacological approaches. Healthcare providers should weigh the benefits and risks based on what is known of their respective pharmacological effects, rather than known efficacy. For surgical interventions in which bleeding or nausea and vomiting are a concern postoperatively, the risks of adverse events using opioids or diclofenac for managing pain should be considered.
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Affiliation(s)
- Martin Ringsten
- Department of Health Sciences, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Lund University, Skåne University Hospital, Lund, Sweden
| | - Tamara Kredo
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Sumayyah Ebrahim
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Surgery, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Ameer Hohlfeld
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Matteo Bruschettini
- Cochrane Sweden, Lund University, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
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Shahrokhzadeh N, Khorramnia S, Jafari A, Ahmadinia H. Effectiveness of Topical Ketorolac in Post-hemorrhoidectomy Pain Management: A Clinical Trial. Anesth Pain Med 2023; 13:e130904. [PMID: 37489166 PMCID: PMC10363361 DOI: 10.5812/aapm-130904] [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] [Received: 08/16/2022] [Revised: 01/23/2023] [Accepted: 01/27/2023] [Indexed: 07/26/2023] Open
Abstract
Background Postoperative pain management is one of the major challenges of surgeons and anesthesiologists. Objectives This study aimed to determine the efficacy of topical ketorolac in post-hemorrhoidectomy pain management. Methods This clinical trial was conducted on 84 candidates for hemorrhoidectomy (grade-II hemorrhoids) who visited Ali ibn Abi-Talib hospital of Rafsanjan, Kerman, Iran (2020 - 2021). The participants were selected through convenience sampling and randomly assigned to three groups of 28. The subjects were treated in topical (4 mL 0.5% Marcaine + 1 mL ketorolac at the surgical site), intramuscular (4 mL 0.5% Marcaine at the surgical site + 1 mL ketorolac intramuscularly), and control (4 mL 0.5% Marcaine at the surgical site) groups. Pain intensity was measured using the Numerical Pain Rating Scale 1, 6, 12, and 24 hours after surgery. The obtained data were analyzed using two-way repeated measures analysis of variance. Results Female and male patients constituted 46.4% and 53.6% of the participants, respectively. The mean pain intensity was significantly lower in the topical group than in intramuscular and control treatments in all four stages of pain assessment (P < 0.001). Some participants were treated with pethidine due to high pain intensity. However, the mean pain intensity gradually reduced over time in all three groups. Conclusions Study findings suggested that the topical administration of ketorolac and Marcaine was more effective than Marcaine used alone for relieving pain in patients undergoing hemorrhoidectomy.
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Affiliation(s)
| | - Saeed Khorramnia
- Department of Anesthesiology, School of Medicine, Ali Ibn Abitaleb Educational and Tretment Hospital, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Amin Jafari
- Department of Surgery, School of Medicine, Ali Ibn Abitaleb Educational and Tretment Hospital, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Hassan Ahmadinia
- School of Health, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
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7
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Piantoni L, Tello CA, Remondino RG, Galaretto E, Noel MA. Protocolo multimodal farmacológico perioperatorio para la cirugía de columna en pediatría. REVISTA DE LA ASOCIACIÓN ARGENTINA DE ORTOPEDIA Y TRAUMATOLOGÍA 2022. [DOI: 10.15417/issn.1852-7434.2022.87.6.1490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Introducción: La cirugía de columna es uno de los procedimientos con mayor morbimortalidad dentro de la población pediátrica; el manejo farmacológico del dolor en dicha población aún no se encuentra estandarizado. La analgesia multimodal trata de responder a esta problemática.
Objetivo: Sobre la base de una revisión sistemática de la bibliografía, desarrollar un detallado protocolomultimodal farmacológico para el manejo del dolor pre- y posoperatorio intra/extrahospitalario para la cirugía de columna en niños.
Materiales y Métodos: Se realizó una revisión sistemática de textos completos en inglés o español en PubMed, Embase, Cochrane Library y LILACS Database publicados entre 2000 y 2021; se aplicó el diagrama de flujo PRISMA.
Resultados: De 756 artículos preseleccionados, 38 fueron incluidos en la evaluación final. Dada la dificultad bioética de desarrollar trabajos en formato de ensayos clínicos con fármacos y combinaciones de ellos en la población pediátrica, desarrollamos un protocolo detallado de manejo del dolor pre- y posoperatorio por vía intravenosa/oral, intra- y extrahospitalario, para aplicar en niños sometidos a cirugía de columna.
Conclusión: Logramos desarrollar un detallado protocolo multimodal farmacológico para el perioperatorio intra- y extrahospitalario de cirugía de columna en niños, sencillo y reproducible, tendiente a acelerar la recuperación funcional del paciente y disminuir los costos socioeconómicos globales.Nivel de Evidencia: II
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8
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Isiordia-Espinoza MA, Alonso-Castro ÁJ, Serafín-Higuera N, Castañeda-Santana DI, de la Rosa Coronado M, Bologna-Molina RE. Postoperative administration of ketorolac compared to other drugs for pain control after third molar surgery: A meta-analysis of double-blind, randomized, clinical trials. Br J Clin Pharmacol 2022; 88:2591-2604. [PMID: 35083768 DOI: 10.1111/bcp.15241] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 01/10/2022] [Accepted: 01/22/2022] [Indexed: 02/05/2023] Open
Abstract
AIMS The aim of this study was to evaluate the analgesic effectiveness and adverse reactions of ketorolac in comparison with other drugs when administered postoperatively after third molar surgery. METHODS PubMed and Google Scholar were utilized to search for articles comparing the efficacy and safety of ketorolac and other analgesic agents after third molar surgery. Data from papers with a lower risk of bias were recorded. The overall evaluation of analgesia onset, general and subgroup evaluation of the number of patients requiring rescue analgesic medication, general and subgroup assessment of the study medication (satisfaction on the study drugs), and the overall estimation of adverse effects were performed using the Review Manager Software 5.3 to analyse the data and obtain the meta-analysis plot. RESULTS The subgroup evaluation of the study medication showed that patients who received ketorolac 30 mg were more satisfied than those who were given parecoxib 1 mg (odds ratio [OR] = 8.57, 95% confidence interval [CI] = 3.66-20.08, P = .00001), parecoxib 2 mg (OR = 7.17, 95% CI = 2.88-17.86, P = .0001), parecoxib 5 mg (OR = 3.03, 95% CI = 1.69-5.41, P = .0002), and parecoxib 10 mg (OR = 2.42, 95% CI = 1.36-4.32, P = .003). Moreover, patients who received ketorolac reported fewer adverse reactions compared with those who had received opioid analgesics (OR = 0.14, 95% CI = 0.32-1.76, P = .0001). CONCLUSIONS The data from this study demonstrates that the postoperative administration of ketorolac 30 mg presents better results on patient satisfaction when compared to parecoxib 1 mg to 10 mg, and presents a similar satisfaction to parecoxib 20 mg following third molar removal.
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Affiliation(s)
- Mario Alberto Isiordia-Espinoza
- Instituto de Investigación en Ciencias Médicas, Departamento de Clínicas, División de Ciencias Biomédicas, Centro Universitario de los Altos, Universidad de Guadalajara, Tepatitlán de Morelos, Jalisco, Mexico
| | - Ángel Josabad Alonso-Castro
- Departamento de Farmacia, División de Ciencias Naturales y Exactas, Universidad de Guanajuato, Guanajuato, Mexico
| | - Nicolás Serafín-Higuera
- Facultad de Odontología, Universidad Autónoma de Baja California, Mexicali, Baja California, Mexico
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9
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Lee GG, Park JS, Kim HS, Yoon DS, Lim JH. Clinical effect of preoperative intravenous non-steroidal anti-inflammatory drugs on relief of postoperative pain in patients after laparoscopic cholecystectomy: Intravenous ibuprofen vs. intravenous ketorolac. Ann Hepatobiliary Pancreat Surg 2022; 26:251-256. [PMID: 35264467 PMCID: PMC9428437 DOI: 10.14701/ahbps.21-151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 11/17/2022] Open
Abstract
Backgrounds/Aims Postoperative pain management is a key to enhanced recovery after surgery. The aim of this study was to evaluate clinical effect of preoperative intravenous (IV) non-steroidal anti-inflammatory drugs (NSAIDs) on relief of postoperative pain in patients after laparoscopic cholecystectomy. Methods This single center, retrospective study was conducted between September 2019 and May 2020. A total of 163 patients were divided into two groups: Ibuprofen group (preoperative IV ibuprofen, n = 77) and Ketorolac group (preoperative IV ketorolac, n = 86). The primary outcome was postoperative pain score measured immediately in the recovery room. Results There was no difference in demographic characteristics between the two groups of patients. Postoperative pain score measured immediately in the recovery room was significantly higher in the Ibuprofen group than in the Ketorolac group (mean value: 5.09 vs. 4.61; p = 0.027). The number of patients who needed analgesics immediately in the recovery room was also higher in the Ibuprofen group than in the Ketorolac group (28 [36.4%] vs. 18 [20.9%]; p = 0.036). Conclusions In this study, preoperative IV injection with ketorolac reduced postoperative pain and analgesic requirement in the recovery room more effectively than that with ibuprofen. However, both showed similar effects on peak pain and pain at discharge. Numbers of patients requiring additional analgesics were also similar between the two groups.
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Affiliation(s)
- Gyeong Geon Lee
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Seong Park
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyung Sun Kim
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Sup Yoon
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Hong Lim
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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10
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Pain Management in Pediatric Trauma. CURRENT TRAUMA REPORTS 2021. [DOI: 10.1007/s40719-021-00216-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are often used for pediatric pain management in the emergency setting and postoperatively. This narrative literature review evaluates pain relief, opioid requirements, and adverse effects associated with NSAID use. A PubMed search was conducted to identify randomized controlled trials evaluating the use of conventional systemic NSAIDs as pain management for children in the perioperative or emergency department (traumatic injury) setting. Trials of cyclooxygenase-2 inhibitors ("coxibs") were excluded. Search results included studies of ibuprofen (n = 12), ketoprofen (n = 5), ketorolac (n = 6), and diclofenac (n = 4). NSAIDs reduced the opioid requirement in 10 of 13 studies in which this outcome was measured. NSAID use did not compromise pain relief; NSAIDs provided improved or similar pain scores compared with opioids (or other control) in 24 of 27 studies. Adverse event frequencies were reported in 26 studies; adverse event frequencies with NSAIDs were lower than with opioids (or other control) in three of 26 studies, similar in 21 of 26 studies, and more frequent in two of 26 studies. Perioperative and emergency department use of NSAIDs may reduce opioid requirements while maintaining pain control, with similar or reduced frequencies of opioid-associated adverse events.
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Affiliation(s)
- Maureen F Cooney
- Pain Management, Westchester Medical Center, Valhalla, NY, 10595, USA.
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12
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Egbuta C, Mason KP. Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit. J Clin Med 2021; 10:1847. [PMID: 33922824 PMCID: PMC8122992 DOI: 10.3390/jcm10091847] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 12/15/2022] Open
Abstract
Critically ill pediatric patients often require complex medical procedures as well as invasive testing and monitoring which tend to be painful and anxiety-provoking, necessitating the provision of analgesia and sedation to reduce stress response. Achieving the optimal combination of adequate analgesia and appropriate sedation can be quite challenging in a patient population with a wide spectrum of ages, sizes, and developmental stages. The added complexities of critical illness in the pediatric population such as evolving pathophysiology, impaired organ function, as well as altered pharmacodynamics and pharmacokinetics must be considered. Undersedation leaves patients at risk of physical and psychological stress which may have significant long term consequences. Oversedation, on the other hand, leaves the patient at risk of needing prolonged respiratory, specifically mechanical ventilator, support, prolonged ICU stay and hospital admission, and higher risk of untoward effects of analgosedative agents. Both undersedation and oversedation put critically ill pediatric patients at high risk of developing PICU-acquired complications (PACs) like delirium, withdrawal syndrome, neuromuscular atrophy and weakness, post-traumatic stress disorder, and poor rehabilitation. Optimal analgesia and sedation is dependent on continuous patient assessment with appropriately validated tools that help guide the titration of analgosedative agents to effect. Bundled interventions that emphasize minimizing benzodiazepines, screening for delirium frequently, avoiding physical and chemical restraints thereby allowing for greater mobility, and promoting adequate and proper sleep will disrupt the PICU culture of immobility and reduce the incidence of PACs.
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Affiliation(s)
| | - Keira P. Mason
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, USA;
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13
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Stone SB. Ketorolac in Postoperative Neonates and Infants: A Systematic Review. J Pediatr Pharmacol Ther 2021; 26:240-247. [PMID: 33833624 DOI: 10.5863/1551-6776-26.3.240] [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: 06/09/2020] [Accepted: 09/22/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the pharmacokinetics and pharmacodynamics, dosing, efficacy, and safety of ketorolac in postoperative patients younger than 6 months of age. METHODS PubMed (1988-July 2020), Medline (1946-July 2020), and EBSCO Discovery Service (1988-July 2020) were searched to identify relevant published articles using the following search terms: ketorolac, neonate, infant. English-language articles evaluating the use of ketorolac in infants younger than 6 months of age were included. RESULTS Eight reports that included 239 infants receiving ketorolac were included. Of the included patients, 237 were younger than 6 months of age. Ketorolac exhibits rapid elimination of the analgesia-producing S (-) isomer, elimination half-life of 0.83 hours. Most patients received 0.5 mg/kg/dose every 6 hours for 48 to 72 hours. Analgesia was demonstrated by reduced use of open-label morphine and significant lowering of Neonatal/Infant Pain Scale scores. Adverse effects were minimal when ketorolac was used in term neonates and infants without baseline renal dysfunction. CONCLUSIONS Randomized placebo-controlled trials of ketorolac use in this population are lacking; however, most published reports noted efficacy and safety with ketorolac in properly selected infants.
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14
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Benea C, Turner KA, Roseman M, Bero LA, Lexchin J, Turner EH, Thombs BD. Reporting of financial conflicts of interest in meta-analyses of drug trials published in high-impact medical journals: comparison of results from 2017 to 2018 and 2009. Syst Rev 2020; 9:77. [PMID: 32268911 PMCID: PMC7140556 DOI: 10.1186/s13643-020-01318-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 03/01/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND A previous study found that 2 of 29 (6.9%) meta-analyses published in high-impact journals in 2009 reported included drug trials' funding sources, and none reported trial authors' financial conflicts of interest (FCOIs) or industry employment. It is not known if reporting has improved since 2009. Our objectives were to (1) investigate the extent to which pharmaceutical industry funding and author-industry FCOIs and employment from included drug trials are reported in meta-analyses published in high-impact journals and (2) compare current reporting with results from 2009. METHODS We searched PubMed (January 2017-October 2018) for systematic reviews with meta-analyses including ≥ 2 randomized controlled trials (RCTs) of patented drugs. We included 3 meta-analyses published January 2017-October 2018 from each of 4 high-impact general medicine journals, high-impact journals from 5 specialty areas, and the Cochrane Database of Systematic Reviews, as in the previous study. RESULTS Among 29 meta-analyses reviewed, 13 of 29 (44.8%) reported the funding source of included trials compared to 2 of 29 (6.9%) in 2009, a difference of 37.9% (95% confidence interval, 15.7 to 56.3%); this included 7 of 11 (63.6%) from general medicine journals, 3 of 15 (20.0%) from specialty medicine journals, and 3 of 3 (100%) Cochrane reviews. Only 2 of 29 meta-analyses (6.9%) reported trial author FCOIs, and none reported trial author-industry employment. PROTOCOL PUBLICATION A protocol was uploaded to the Open Science Framework prior to initiating the study. https://osf.io/8xt5p/ LIMITATIONS: We examined only a relatively small number of meta-analyses from selected high-impact journals and compared results to a similarly small sample from an earlier time period. CONCLUSIONS Reporting of drug trial sponsorship and author FCOIs in meta-analyses published in high-impact journals has increased since 2009 but is still suboptimal. Standards on reporting of trial funding described in the forthcoming revised PRISMA statement should be adapted and enforced by journals to improve reporting.
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Affiliation(s)
- Carla Benea
- Lady Davis Institute of the Jewish General Hospital, 4333 Cote Ste Catherine Road, Montreal, Quebec H3T 1E4 Canada
| | - Kimberly A. Turner
- Lady Davis Institute of the Jewish General Hospital, 4333 Cote Ste Catherine Road, Montreal, Quebec H3T 1E4 Canada
- Department of Psychiatry, McGill University, Montreal, Quebec Canada
| | - Michelle Roseman
- Kingsway Medical Centre Family Health Organization, Toronto, Ontario Canada
| | - Lisa A. Bero
- Charles Perkins Centre and School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales Australia
| | - Joel Lexchin
- School of Health Policy and Management, York University, Toronto, Ontario Canada
- Emergency Department, University Health Network, Toronto, Ontario Canada
| | - Erick H. Turner
- Behavioral Health and Neurosciences Division, VA Portland Health Care System, Portland, Oregon USA
- Department of Psychiatry, Oregon Health & Science University, Portland, Oregon USA
| | - Brett D. Thombs
- Lady Davis Institute of the Jewish General Hospital, 4333 Cote Ste Catherine Road, Montreal, Quebec H3T 1E4 Canada
- Department of Psychiatry, McGill University, Montreal, Quebec Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec Canada
- Department of Medicine, McGill University, Montreal, Quebec Canada
- Biomedical Ethics Unit, McGill University, Montreal, Quebec Canada
- Department of Psychology, McGill University, Montreal, Quebec Canada
- Department of Educational and Counselling Psychology, McGill University, Montreal, Quebec Canada
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Kendall MC, Alves LJC, Suh EI, McCormick ZL, De Oliveira GS. Regional anesthesia to ameliorate postoperative analgesia outcomes in pediatric surgical patients: an updated systematic review of randomized controlled trials. Local Reg Anesth 2018; 11:91-109. [PMID: 30532585 PMCID: PMC6244583 DOI: 10.2147/lra.s185554] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Regional anesthesia is becoming increasingly popular among anesthesiologists in the management of postoperative analgesia following pediatric surgery. The main objective of this review was to systematically evaluate the last 5 years of randomized controlled trials on the role of regional anesthesia techniques in alleviating postoperative pain associated with various pediatric surgical procedures. Forty studies on 2,408 pediatric patients were evaluated. The majority of the articles published from 2013 to 2017 reported that the use of regional anesthesia minimized postoperative pain and reduced opioid consumption. Only a few surgical procedures (cholecystectomy, inguinal hernia repair, and non-laparoscopic major abdominal surgery) reported no significant difference in the postoperative pain relief compared with the standard anesthetic management. The growing number of randomized controlled trials in the pediatric literature is very promising; however, additional confirmation is needed to reinforce the use of specific regional anesthesia techniques to provide optimal postoperative pain relief for a few surgical procedures (reconstructive ear surgery, chest wall deformity, hypospadias, umbilical hernia, cleft palate repair) in pediatric patients. More randomized controlled trials are needed to establish regional anesthesia as an essential component of postoperative analgesia management in children.
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Affiliation(s)
- Mark C Kendall
- Department of Anesthesiology, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA,
| | | | - Edward I Suh
- Department of Anesthesiology, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA,
| | - Zachary L McCormick
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, USA
| | - Gildasio S De Oliveira
- Department of Anesthesiology, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA,
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