1
|
Pimenta RP, Takahashi CM, Barberato-Filho S, McClung DCF, Moraes FDS, de Souza IM, Bergamaschi CDC. Preemptive use of anti-inflammatories and analgesics in oral surgery: a review of systematic reviews. Front Pharmacol 2024; 14:1303382. [PMID: 38328575 PMCID: PMC10847331 DOI: 10.3389/fphar.2023.1303382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/22/2023] [Indexed: 02/09/2024] Open
Abstract
Objectives: This review of systematic reviews evaluated the effectiveness and safety of the preemptive use of anti-inflammatory and analgesic drugs in the management of postoperative pain, edema, and trismus in oral surgery. Materials and methods: The databases searched included the Cochrane Library, MEDLINE, EMBASE, Epistemonikos, Scopus, Web of Science, and Virtual Health Library, up to March 2023. Pairs of reviewers independently selected the studies, extracted the data, and rated their methodological quality using the AMSTAR-2 tool. Results: All of the 19 studies reviewed had at least two critical methodological flaws. Third molar surgery was the most common procedure (n = 15) and the oral route the most frequent approach (n = 14). The use of betamethasone (10, 20, and 60 mg), dexamethasone (4 and 8 mg), methylprednisolone (16, 20, 40, 60, 80, and 125 mg), and prednisolone (10 and 20 mg) by different routes and likewise of celecoxib (200 mg), diclofenac (25, 30, 50, 75, and 100 mg), etoricoxib (120 mg), ibuprofen (400 and 600 mg), ketorolac (30 mg), meloxicam (7.5, 10, and 15 mg), nimesulide (100 mg), and rofecoxib (50 mg) administered by oral, intramuscular, and intravenous routes were found to reduce pain, edema, and trismus in patients undergoing third molar surgery. Data on adverse effects were poorly reported. Conclusion: Further randomized clinical trials should be conducted to confirm these findings, given the wide variety of drugs, doses, and routes of administration used.
Collapse
Affiliation(s)
- Régis Penha Pimenta
- Pharmaceutical Sciences Graduate Course, University of Sorocaba, Sorocaba, São Paulo, Brazil
| | | | - Silvio Barberato-Filho
- Pharmaceutical Sciences Graduate Course, University of Sorocaba, Sorocaba, São Paulo, Brazil
| | | | - Fabio da Silva Moraes
- Pharmaceutical Sciences Graduate Course, University of Sorocaba, Sorocaba, São Paulo, Brazil
| | | | | |
Collapse
|
2
|
Hysong AA, Odum SM, Lake NH, Hietpas KT, Michalek CJ, Hamid N, Gaston RG, Loeffler BJ. Opioid-Free Analgesia Provides Pain Control Following Thumb Carpometacarpal Joint Arthroplasty. J Bone Joint Surg Am 2023; 105:1750-1758. [PMID: 37651550 DOI: 10.2106/jbjs.22.01278] [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: 09/02/2023]
Abstract
BACKGROUND We hypothesized that an opioid-free (OF), multimodal pain management pathway for thumb carpometacarpal (CMC) joint arthroplasty would not have inferior pain control compared with that of a standard opioid-containing (OC) pathway. METHODS This was a single-center, randomized controlled clinical trial of patients undergoing primary thumb CMC joint arthroplasty. Patients were randomly allocated to either a completely OF analgesic pathway or a standard OC analgesic pathway. Patients in both cohorts received a preoperative brachial plexus block utilizing 30 mL of 0.5% ropivacaine that was administered via ultrasound guidance. The OF group was given a combination of cryotherapy, anti-inflammatory medications, acetaminophen, and gabapentin. The OC group was only given cryotherapy and opioid-containing medication for analgesia. Patient-reported pain was assessed with use of a 0 to 10 numeric rating scale at 24 hours, 2 weeks, and 6 weeks postoperatively. We compared the demographics, opioid-related side effects, patient satisfaction, and Veterans RAND 12-Item Health Survey (VR-12) results between these 2 groups. RESULTS At 24 hours postoperatively, pain scores in the OF group were statistically noninferior to, and lower than, those in the OC group (median, 2 versus 4; p = 0.008). Pain scores continued to differ significantly at 2 weeks postoperatively (median, 2 versus 4; p = 0.001) before becoming more similar at 6 weeks (p > 0.05). No difference was found between groups with respect to opioid-related side effects, patient satisfaction, or VR-12 results. CONCLUSIONS A completely opioid-free perioperative protocol is effective for the treatment of pain following thumb CMC joint arthroplasty in properly selected patients. LEVEL OF EVIDENCE Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Alexander A Hysong
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Susan M Odum
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | | | | | | | - Nady Hamid
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
- OrthoCarolina Hand Center, Charlotte, North Carolina
| | - Raymond G Gaston
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
- OrthoCarolina Hand Center, Charlotte, North Carolina
| | - Bryan J Loeffler
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
- OrthoCarolina Hand Center, Charlotte, North Carolina
| |
Collapse
|
3
|
Zhou Y, Wang B, Duan K, Bai Z, Hu X, Xu M, Li X, Gao Y, Li J, Yang M, Zhang Y, Zhang W, Dai R, Shen Y, Wu Z, Jiang Y, Yu S, Ouyang W, Wang S. Preemptive QP001, a fast-acting meloxicam formulation, provides analgesia and reduces opioid consumption following abdominal surgery: a randomized controlled trial. Inflammopharmacology 2023; 31:2401-2410. [PMID: 37646897 DOI: 10.1007/s10787-023-01322-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/07/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND QP001, a novel meloxicam formulation, has been developed to manage moderate to severe postoperative pain. This study aimed to evaluate the efficacy and safety of QP001 injections for moderate to severe pain following abdominal surgery. METHOD This prospective, multicenter, randomized, double-blind, placebo-controlled clinical trial enlisted patients experiencing moderate to severe pain following abdominal surgery. These patients were randomized to receive either QP001 injections (30 mg or 60 mg) or a placebo pre-surgery. The primary efficacy endpoint was the total morphine consumption within 24 h after the first administration. RESULTS A total of 108 patients were enrolled, and 106 patients completed the study. The total morphine consumption in the QP001 30 mg group and 60 mg group, versus placebo group, were significantly lower over the following 24 h (5.11[5.46] vs 8.86[7.67], P = 0.011; 3.11[3.08] vs 8.86[7.67], P < 0.001), respectively. The total morphine consumption in the QP001 30 mg and 60 mg groups, versus placebo group, was also significantly decreased over the following 48 h, including the 24-48 h period (P ≤ 0.001). The QP001 30 mg and 60 mg groups, versus placebo, showed a significant decrease in the area under the curve for pain intensity-time as well as a significant decrease in the effective pressing times of the analgesic pump over the 24 h and 48 h periods (P < 0.05). The QP001 groups, versus placebo, show no significant different in Adverse Events or Adverse Drug Reactions (P > 0.05). CONCLUSION Preoperative/preemptive QP001 provides analgesia and reduces opioid consumption in patients with moderate to severe pain following abdominal surgery, while maintaining a favorable safety profile.
Collapse
Affiliation(s)
- Yingyong Zhou
- Department of Anesthesiology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Bin Wang
- General Surgery, Guiyang Baijun Taikang Hospital, Chenzhou, China
| | - Kaiming Duan
- Department of Anesthesiology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Zhihong Bai
- Department of Anesthesiology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Xianwen Hu
- Department of Anesthesiology, The Second Hospital of Anhui Medical University, Hefei, China
| | - Mingjun Xu
- Department of Anesthesiology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Xiaohong Li
- Department of Anesthesiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Yuanli Gao
- Department of Anesthesiology, Maanshan People's Hospital, Ma'anshan, China
| | - Jiangang Li
- Department of Anesthesiology, Qujing No.1 Hospital, Qujing, China
| | - Mengchang Yang
- Department of Anesthesiology, Sichuan Provincial People's Hospital, Chengdu, China
| | - Ying Zhang
- Department of Anesthesiology, The Affiliated Traditional Chinese Medical Hospital of Southwest Medical University, Luzhou, China
| | - Wei Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ruping Dai
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Yufei Shen
- Gynecology Department, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Ziteng Wu
- Nanjing Delova Biotech Co., Ltd, Nanjing, China
| | - Yan Jiang
- Nanjing Delova Biotech Co., Ltd, Nanjing, China
| | - Sen Yu
- Nanjing Delova Biotech Co., Ltd, Nanjing, China
| | - Wen Ouyang
- Department of Anesthesiology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Saiying Wang
- Department of Anesthesiology, The Third Xiangya Hospital of Central South University, Changsha, China.
| |
Collapse
|
4
|
Immune Modulatory Effects of Nonsteroidal Anti-inflammatory Drugs in the Perioperative Period and Their Consequence on Postoperative Outcome. Anesthesiology 2022; 136:843-860. [PMID: 35180291 DOI: 10.1097/aln.0000000000004141] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Nonsteroidal anti-inflammatory drugs are among the most commonly administered drugs in the perioperative period due to their prominent role in pain management. However, they potentially have perioperative consequences due to immune-modulating effects through the inhibition of prostanoid synthesis, thereby affecting the levels of various cytokines. These effects may have a direct impact on the postoperative outcome of patients since the immune system aims to restore homeostasis and plays an indispensable role in regeneration and repair. By affecting the immune response, consequences can be expected on various organ systems. This narrative review aims to highlight these potential immune system-related consequences, which include systemic inflammatory response syndrome, acute respiratory distress syndrome, immediate and persistent postoperative pain, effects on oncological and neurologic outcome, and wound, anastomotic, and bone healing.
Collapse
|
5
|
Watanabe J, Rifu K, Kagaya T, Kotani K, Sata N. The efficacy and safety of preoperative glucocorticoids in herniorrhaphy: a systematic review and meta-analysis. Surg Today 2022; 52:1237-1245. [PMID: 34997333 DOI: 10.1007/s00595-021-02431-1] [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: 05/20/2021] [Accepted: 07/14/2021] [Indexed: 11/26/2022]
Abstract
Postoperative pain is the main reason for delayed recovery after herniorrhaphy. Preoperative glucocorticoid administration may improve postoperative recovery. The present study assessed the efficacy of preoperative glucocorticoids in facilitating recovery after herniorrhaphy. Randomized controlled trials (RCTs) conducted up to January 2021 were searched in electronic databases and trial registries. Meta-analyses were performed using random effects models. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to assess the certainty of evidence. Seven RCTs (744 patients) were included in the meta-analysis. Preoperative glucocorticoid administration reduced patients' pain on postoperative day 0 (standard mean difference [SMD] = - 0.73, 95% confidence interval [CI] - 1.45 to - 0.01; I2 = 94%). However, there was no marked difference in rescue analgesic use (risk ratio [RR] = - 0.06, 95% CI - 0.28 to - 0.16; I2 = 0%) or vomiting (RR = 0.78, 95% CI 0.50-1.20; I2 = 30%) between preoperative glucocorticoid administration and control. The certainty of evidence was moderate because of inconsistencies or imprecision. No serious adverse effects were observed. Preoperative glucocorticoid administration reduced pain in patients following herniorrhaphy without increasing the occurrence of adverse events. Further studies will be required to confirm the efficacy of preoperative glucocorticoids.
Collapse
Affiliation(s)
- Jun Watanabe
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke City, Tochigi, 329-0498, Japan.
- Division of Community and Family Medicine, Jichi Medical University, Shimotsuke City, Tochigi, Japan.
| | - Kazuma Rifu
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke City, Tochigi, 329-0498, Japan
| | - Takehiro Kagaya
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke City, Tochigi, 329-0498, Japan
| | - Kazuhiko Kotani
- Division of Community and Family Medicine, Jichi Medical University, Shimotsuke City, Tochigi, Japan
| | - Naohiro Sata
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke City, Tochigi, 329-0498, Japan
| |
Collapse
|
6
|
Aurilio C, Pace MC, Sansone P, Giaccari LG, Coppolino F, Pota V, Barbarisi M. Multimodal analgesia in neurosurgery: a narrative review. Postgrad Med 2021; 134:267-276. [PMID: 34872428 DOI: 10.1080/00325481.2021.2015221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Pain following brain surgery can compromise the result of surgery. Several pharmacological interventions have been used to prevent postoperative pain in adults undergoing brain surgery. Pain following craniotomy is considered to be moderate to severe during the first two post-operative days. Opioids have been historically the mainstay and are the current prominent strategy for pain treatment. They produce analgesia but may alter respiratory, cardiovascular, gastrointestinal, and neuroendocrine functions. All these side effects may affect the normal postoperative course of craniotomy by affecting neurological function and increasing intracranial pressure. Therefore, their use in neurosurgery is limited, and opioids are used in case of strict necessity or as rescue medication. In addition to opioids, drugs with differing mechanisms of actions target pain pathways, resulting in additive and/or synergistic effects. Some of these agents include acetaminophen/non-steroidal anti-inflammatory drugs (NSAIDs), alpha-2 agonists, NMDA receptor antagonists, gabapentinoids, and local anesthesia techniques. Multimodal analgesia should be a balance between adequate analgesia and less drug-induced sedation, respiratory depression, hypercapnia, nausea, and vomiting, which may increase intracranial pressure. Non-opioid analgesics can be an useful pharmacological alternative in multimodal regimes to manage post-craniotomy pain. This narrative review aims to outline the current clinical evidence of multimodal analgesia for post craniotomy pain control.
Collapse
Affiliation(s)
- Caterina Aurilio
- Department of Women, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Maria Caterina Pace
- Department of Women, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Pasquale Sansone
- Department of Women, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Luca Gregorio Giaccari
- Department of Women, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Francesco Coppolino
- Department of Women, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Vincenzo Pota
- Department of Women, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Manlio Barbarisi
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| |
Collapse
|
7
|
Lipp K, Casamassimo P, Griffen A, Smiley M, Bryant J, Draper J, Kumar A. Effect of Intrapapillary Local Anesthetic on Postoperative Pain Following Dental Treatment Under General Anesthesia in Pediatric Patients. Anesth Prog 2021; 68:206-213. [PMID: 34911068 DOI: 10.2344/anpr-68-02-06] [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: 01/07/2021] [Accepted: 03/23/2021] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE This randomized, prospective, blinded study compared pain in children following dental treatment under general anesthesia (GA) using 1 of 2 established analgesia methods. METHODS Patients age 4 to 7 years were randomly assigned to a control group (intravenous [IV] analgesics) or experimental group (IV analgesics and intrapapillary local anesthetic infiltrations) between July 2017 and February 2018. During recovery from surgery, Faces, Legs, Activity, Cry, and Consolability (FLACC) scores were recorded upon regaining consciousness and reassessed every 15 minutes until discharge. Overall pain occurrence (FLACC ≥1) and moderate/severe pain occurrence (FLACC ≥4) were analyzed using mixed effects logistic regression (N = 88). RESULTS The experimental group had a 17% lower overall pain occurrence than the control group (16 vs 33%; p = .02). Moderate/severe pain occurrence between the groups was not significant (9 vs 22%; p = .23). The dental treatment subjects received (number of completed stainless steel crowns, extractions, and/or pulpotomies) did not significantly affect pain occurrence. CONCLUSION Local anesthesia intrapapillary infiltrations around stainless steel crowns decrease overall pain occurrence but not moderate/severe pain occurrence following dental treatment under GA in pediatric patients.
Collapse
Affiliation(s)
- Kelly Lipp
- Department of Pediatric Dentistry, Ohio State University Columbus, Ohio
| | - Paul Casamassimo
- Department of Pediatric Dentistry, Ohio State University Columbus, Ohio
| | - Ann Griffen
- Department of Pediatric Dentistry, Ohio State University Columbus, Ohio
| | - Megann Smiley
- Department of Pediatric Dentistry, Ohio State University Columbus, Ohio
| | - Jason Bryant
- Department of Pediatric Dentistry, Ohio State University Columbus, Ohio
| | - John Draper
- Department of Pediatric Dentistry, Ohio State University Columbus, Ohio
| | - Ashok Kumar
- Department of Pediatric Dentistry, Ohio State University Columbus, Ohio
| |
Collapse
|
8
|
Klifto KM, Elhelali A, Payne RM, Cooney CM, Manahan MA, Rosson GD. Perioperative systemic nonsteroidal anti-inflammatory drugs (NSAIDs) in women undergoing breast surgery. Cochrane Database Syst Rev 2021; 11:CD013290. [PMID: 34753201 PMCID: PMC8577884 DOI: 10.1002/14651858.cd013290.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Breast surgery encompasses oncologic, reconstructive, and cosmetic procedures. With the recent focus on the over-prescribing of opioids in the literature, it is important to assess the effectiveness and safety of non-opioid pain medication regimens including nonsteroidal anti-inflammatory drugs (NSAIDs) or NSAID pain medications. Clinicians have differing opinions on the safety of perioperative (relating to, occurring in, or being the period around the time of a surgical operation) NSAIDs for breast surgery given the unclear risk/benefit ratio. NSAIDs have been shown to decrease inflammation, pain, and fever, while potentially increasing the risks of bleeding complications. OBJECTIVES To assess the effects of perioperative NSAID use versus non-NSAID analgesics (other pain medications) in women undergoing any form of breast surgery. SEARCH METHODS The Cochrane Breast Information Specialist searched the Cochrane Breast Cancer Group (CBCG) Specialized Register, CENTRAL (the Cochrane Library), MEDLINE, Embase, The WHO International Clinical Trials Registry Platform (ICTRP) and Clinicaltrials.gov registries to 21 September 2020. Full articles were retrieved for potentially eligible trials. SELECTION CRITERIA We considered all randomized controlled trials (RCTs) looking at perioperative NSAID use in women undergoing breast surgery. DATA COLLECTION AND ANALYSIS Two review authors independently screened studies, extracted data and assessed risk of bias, and certainty of the evidence using the GRADE approach. The main outcomes were incidence of breast hematoma within 90 days (requiring reoperation, interventional drainage, or no treatment) of breast surgery and pain intensity 24 hours following surgery, incidence rate or severity of postoperative nausea, vomiting or both, bleeding from any location within 90 days, need for blood transfusion, other side effects of NSAID use, opioid use within 24 hours of surgery, length of hospital stay, breast cancer recurrence, and non-prescribed NSAID use. Data were presented as risk ratios (RRs) for dichotomous outcomes and standardized mean differences (SMDs) for continuous outcomes. MAIN RESULTS We included 12 RCTs with a total of 1596 participants. Seven studies compared NSAIDs (ketorolac, diclofenac, flurbiprofen, parecoxib and celecoxib) to placebo. Four studies compared NSAIDs (ketorolac, flurbiprofen, ibuprofen, and celecoxib) to other analgesics (morphine, hydrocodone, hydromorphone, fentanyl). One study compared NSAIDs (diclofenac) to no intervention. NSAIDs compared to placebo Most outcomes are judged to have low-certainty evidence unless stated otherwise. There may be little to no difference in the incidence of breast hematomas within 90 days of breast surgery (RR 0.33, 95% confidence interval (CI) 0.05 to 2.02; 2 studies, 230 participants; I2 = 0%). NSAIDs may reduce pain intensity 24 (± 12) hours following surgery compared to placebo (SMD -0.26, 95% CI -0.49 to -0.03; 3 studies, 310 participants; I2 = 73%). There may be little to no difference in the incidence rates or severities of postoperative nausea, vomiting, or both (RR 1.15, 95% CI 0.58 to 2.27; 4 studies, 939 participants; I2 = 81%), bleeding from any location within 90 days (RR 1.05, 95% CI 0.89 to 1.24; 2 studies, 251 participants; I2 = 8%), or need for blood transfusion compared to placebo groups, but we are very uncertain (RR 4.62, 95% CI 0.23 to 91.34; 1 study, 48 participants; very low-certainty evidence). There may be no difference in other side effects (RR 1.12, 95% CI 0.44 to 2.86; 2 studies, 251 participants; I2 = 0%). NSAIDs may reduce opioid use within 24 hours of surgery compared to placebo (SMD -0.45, 95% CI -0.85 to -0.05; 4 studies, 304 participants; I2 = 63%). NSAIDs compared to other analgesics There is little to no difference in the incidence of breast hematomas within 90 days of breast surgery, but we are very uncertain (RR 0.33, 95% CI 0.01 to 7.99; 1 study, 100 participants; very low-certainty evidence). NSAIDs may reduce pain intensity 24 (± 12) hours following surgery (SMD -0.68, 95% CI -0.97 to -0.39; 3 studies, 200 participants; I2 = 89%; low-certainty evidence) and probably reduce the incidence rates or severities of postoperative nausea, vomiting, or both compared to other analgesics (RR 0.18, 95% CI 0.06 to 0.57; 3 studies, 128 participants; I2 = 0%; moderate-certainty evidence). There is little to no difference in the development of bleeding from any location within 90 days of breast surgery or in other side effects, but we are very uncertain (bleeding: RR 0.33, 95% CI 0.01 to 7.99; 1 study, 100 participants; other side effects: RR 0.11, 95% CI 0.01 to 1.80; 1 study, 48 participants; very low-certainty evidence). NSAIDs may reduce opioid use within 24 hours of surgery compared to other analgesics (SMD -6.87, 95% CI -10.93 to -2.81; 3 studies, 178 participants; I2 = 96%; low-certainty evidence). NSAIDs compared to no intervention There is little to no difference in pain intensity 24 (± 12) hours following surgery compared to no intervention, but we are very uncertain (SMD -0.54, 95% CI -1.09 to 0.00; 1 study, 60 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS Low-certainty evidence suggests that NSAIDs may reduce postoperative pain, nausea and vomiting, and postoperative opioid use. However, there was very little evidence to indicate whether NSAIDs affect the rate of breast hematoma or bleeding from any location within 90 days of breast surgery, the need for blood transfusion and incidence of other side effects compared to placebo or other analgesics. High-quality large-scale RCTs are required before definitive conclusions can be made.
Collapse
Affiliation(s)
- Kevin M Klifto
- Division of Plastic and Reconstructive Surgery, University of Missouri School of Medicine, Columbia, USA
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Ala Elhelali
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Rachael M Payne
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St Louis, USA
| | - Carisa M Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Michele A Manahan
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Gedge D Rosson
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| |
Collapse
|
9
|
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.
Collapse
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;
| |
Collapse
|
10
|
Kim SY, Lee S, Lee Y, Kim H, Kim KM. Effect of single dose preoperative intravenous ibuprofen on postoperative pain and opioid consumption: a systematic review and meta-analysis. Korean J Anesthesiol 2021; 74:409-421. [PMID: 33611881 PMCID: PMC8497907 DOI: 10.4097/kja.21050] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/19/2021] [Indexed: 11/21/2022] Open
Abstract
Background Ibuprofen, a well-known analgesic, is commonly used as a component of a multimodal analgesic approach for postoperative pain. This systematic review and meta-analysis aimed to investigate whether a single-dose preoperative intravenous ibuprofen can reduce postoperative pain and opioid consumption. Methods PubMed/MEDLINE, Embase, Cochrane Library (CENTRAL), and Web of Science databases were searched to identify relevant studies published up to May 2020. Randomized controlled trials comparing preoperative single-dose intravenous ibuprofen effect with the control group on postoperative pain and opioid consumption after surgery under general anesthesia were included. Results Six studies involving 366 participants were included. Single-dose administration of intravenous ibuprofen preoperatively significantly reduced postoperative pain score on a scale of 0-10 at 1 h (MD: -1.64, 95% CI [-2.56, -0.72], P < 0.001, I2 = 95%), at 4-6 h (MD: -1.17, 95% CI [-2.09, -0.26], P < 0.001, I2 = 94%), and 24 h (MD: -0.58, 95% CI [-0.99, -0.18], P < 0.001, I2 = 90%). Cumulative opioid consumption, presented as fentanyl equivalents, was also reduced significantly in the ibuprofen group compared to placebo group until postoperative 4-6 h (MD: -56.35 μg, 95% CI [-101.10, -11.60], P < 0.001, I2 = 91%) and 24 h (MD: -131.39 μg, 95% CI [-224.56, -38.21], P < 0.001, I2 = 95%). Conclusions Preoperative single-dose intravenous ibuprofen can reduce postoperative pain and opioid consumption until 24 h postoperatively. Considering the high heterogeneity and small number of studies included, care should be taken when generalizing these findings.
Collapse
Affiliation(s)
- Su Yeon Kim
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Sangseok Lee
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Yeji Lee
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Hyunho Kim
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Kye-Min Kim
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| |
Collapse
|
11
|
Ling YH, Tai YH, Wu HL, Fu WL, Tsou MY, Chang KY. Evaluating the association of preoperative parecoxib with acute pain trajectories after video-assisted thoracoscopic surgery: a single-centre cohort study in Taiwan. BMJ Open 2021; 11:e038985. [PMID: 33579761 PMCID: PMC7883868 DOI: 10.1136/bmjopen-2020-038985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE The efficacy of parecoxib as pre-emptive analgesia still remains controversial. This study aimed to investigate how pre-emptive analgesia with parecoxib affected postoperative pain trajectories over time in patients undergoing thoracic surgery. DESIGN Retrospective cohort study. SETTING A single medical centre in Taiwan. PARTICIPANTS We collected 515 patients undergoing video-assisted thoracoscopic surgery at a tertiary medical centre between September 2016 and August 2017. INTERVENTIONS Pre-emptive parecoxib before surgery. PRIMARY AND SECONDARY OUTCOME MEASURES Daily numeric rating pain scores in the first postoperative week. RESULTS A total of 196 (38.1%) of the recruited patients received parecoxib preoperatively. The latent curve analysis revealed that woman, higher body weight and postoperative use of parecoxib were associated with increased baseline level of pain scores over time (p=0.035, 0.005 and 0.048, respectively) but epidural analgesia and preoperative use of parecoxib were inclined to decrease it (both p<0.001). Regarding the decreasing trends of changes in daily pain scores, older age and epidural analgesia tended to steepen the slope (p=0.014 and <0.001, respectively). Preoperative use of parecoxib were also related to decreased frequency of rescue morphine medication (HR=0.4; 95% CI 0.25 to 0.65). CONCLUSIONS Pre-emptive analgesia with parecoxib was associated with decreased baseline pain scores but had no connection with pain decreasing trends over time. Latent curve analysis provided insights into the dynamic relationships among the analgesic modalities, patient characteristics and postoperative pain trajectories.
Collapse
Affiliation(s)
- Yu-Hsiang Ling
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ying-Hsuan Tai
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsiang-Ling Wu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wei-Lun Fu
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Mei-Yung Tsou
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kuang-Yi Chang
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
| |
Collapse
|
12
|
Shing EZ, Leas D, Michalek C, Wally MK, Hamid N. Study protocol: randomized controlled trial of opioid-free vs. traditional perioperative analgesia in elective orthopedic surgery. BMC Musculoskelet Disord 2021; 22:104. [PMID: 33485328 PMCID: PMC7824925 DOI: 10.1186/s12891-021-03972-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 01/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The medical community is beginning to recognize the contribution of prescription opioids in the growing national opioid crisis. Many studies have compared the safety and efficacy of alternative analgesics to opioids, but none utilizing a completely opioid-free perioperative protocol in orthopedics. METHODS We developed and tested an opioid-free perioperative analgesic pathway (from preoperative to postoperative period) among patients undergoing common elective orthopedic procedures. Patients will be randomized to receive either traditional opioid-including or completely opioid-free perioperative medications. This study is being conducted across multiple orthopedic subspecialties in patients undergoing the following common elective orthopedic procedures: single-level or two-level ACDF/ACDA, 1st CMC arthroplasty, Hallux Valgus/Rigidus corrections, diagnostic knee arthroscopies, total hip arthroplasty (THA), and total shoulder arthroplasty/reverse total shoulder arthroplasty (TSA/RTSA). The primary outcome measure is pain score at 24 h postoperatively. Secondary outcome measures include pain scores at additional time points, medication side effects, and several patient-reported variables such as patient satisfaction, quality of life, and functional status. DISCUSSION We describe the methods for a feasibility randomized controlled trial comparing opioid-free perioperative analgesics to traditional opioid-including protocols. We present this study so that it may be replicated and incorporated into future studies at other institutions, as well as disseminated to additional orthopedic and/or non-orthopedic surgical procedures. The ultimate goal of presenting this protocol is to aid recent efforts in reducing the impact of prescription opioids on the national opioid crisis. TRIAL REGISTRATION The protocol was approved by the local institutional review board and registered with clinicaltrials.gov (Identifier: NCT04176783 ) on November 25, 2019, retrospectively registered.
Collapse
Affiliation(s)
- Elaine Z Shing
- Carolinas Medical Center, Atrium Health Musculoskeletal Institute, P.O. Box 32861, Charlotte, NC, 28232, USA.
| | - Daniel Leas
- Carolina Neurosurgery and Spine Associates, Charlotte, NC, USA
| | | | - Meghan K Wally
- Carolinas Medical Center, Atrium Health Musculoskeletal Institute, P.O. Box 32861, Charlotte, NC, 28232, USA
| | - Nady Hamid
- OrthoCarolina Shoulder and Elbow Center, Charlotte, NC, USA
| |
Collapse
|
13
|
Singh T, Kathuria S, Jain R, Sood D, Gupta S. Premedication with pregabalin 150mg versus 300mg for postoperative pain relief after laparoscopic cholecystectomy. J Anaesthesiol Clin Pharmacol 2021; 36:518-523. [PMID: 33840934 PMCID: PMC8022042 DOI: 10.4103/joacp.joacp_440_19] [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: 12/31/2019] [Revised: 02/01/2020] [Accepted: 03/06/2020] [Indexed: 11/04/2022] Open
Abstract
Background and Aims Pregabalin has been used in various studies for postoperative pain relief in varying doses. However, there is no conclusive evidence to support a safe and effective dose of pregabalin. The present study was designed to compare the efficacy of two different preoperative doses of pregabalin (150 mg and 300mg) in patients undergoing laparoscopic cholecystectomy for postoperative pain relief. Material and Methods Ninety adult patients of either sex with American Society of Anesthesiologist physical status I and II scheduled for elective laparoscopic cholecystectomy under general anesthesia were randomized to receive pregabalin 150mg (group A), pregabalin 300mg (group B), or placebo (group C) orally 1 h before surgery. The pain was assessed using a visual analog scale (VAS) and a verbal rating scale (VRS) for the initial 24 h postoperatively. The primary outcome of our study was the comparative assessment of the severity of pain in the postoperative period in three groups. Postoperative analgesic consumption and incidence of side effects were assessed as secondary outcome measures. Results VAS score was significantly more in group C than group A and B (P-value <0.05). The total amount of fentanyl required in 24 h was least in group B (228.33 ± 42.41μg) followed by group A (292.50 ± 46.49μg) and group C (322.50 ± 39.58μg) (P-value 0.0001). The incidence of sedation, dizziness, and visual disturbances was more in group B as compared to group A and was least in group C. Conclusions Pregabalin 150 mg is effective in decreasing postoperative pain after laparoscopic cholecystectomy with fewer incidences of adverse effects such as sedation and visual disturbances as compared to pregabalin 300 mg.
Collapse
Affiliation(s)
- Tanveer Singh
- Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Suneet Kathuria
- Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Richa Jain
- Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Dinesh Sood
- Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Shikha Gupta
- Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| |
Collapse
|
14
|
Procedure-specific and patient-specific pain management for ambulatory surgery with emphasis on the opioid crisis. Curr Opin Anaesthesiol 2020; 33:753-759. [PMID: 33027075 DOI: 10.1097/aco.0000000000000922] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Postoperative pain is frequent while, on the other hand, there is a grooving general concern on using effective opioid pain killers in view of the opioid crisis and significant incidence of opioid abuse. The present review aims at describing nonopioid measures in order to optimize and tailor perioperative pain management in ambulatory surgery. RECENT FINDINGS Postoperative pain should be addressed both preoperatively, intraoperatively and postoperatively. The management should basically be multimodal, nonopioid and procedure-specific. Opioids should only be used when needed on top of multimodal nonopioid prophylaxis, and then limited to a few days at maximum, unless strict control is applied. The individual patient should be screened preoperatively for any risk factors for severe postoperative pain and/or any abuse potential. SUMMARY Basic multimodal analgesia should start preoperatively or peroperatively and include paracetamol, cyclo-oxygenase (COX)-2 specific inhibitor or conventional nonsteroidal anti-inflammatory drug (NSAID) and in most cases dexamethasone and local anaesthetic wound infiltration. If any of these basic analgesics are contraindicated or there is an extra risk of severe postoperative pain, further measures may be considered: nerve-blocks or interfascial plane blocks, gabapentinnoids, clonidine, intravenous lidocaine infusion or ketamine infusion. In the abuse-prone patient, a preferably nonopioid perioperative approach should be aimed at.
Collapse
|
15
|
Abstract
Multimodal pain management of cardiac surgical patients is a paradigm shift in postoperative care. This promising approach features complementary medications and techniques that spare opioids and improves symptomatic and functional recovery. Although the specific elements remain to be defined, the collaboration of the health care team and patient and continuous iterative programmatic improvements are important pillars of this approach.
Collapse
|
16
|
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the most recent evidence-based interventions for perioperative pain management in minimally invasive gynecologic surgery. RECENT FINDINGS With particular emphasis on preemptive interventions in recent studies, we found preoperative counseling, nutrition, exercise, psychological interventions, and a combination of acetaminophen, celecoxib, and gabapentin are highly important and effective measures to reduce postoperative pain and opioid demand. Intraoperative local anesthetics may help at incision sites, as a paracervical block, and a transversus abdominus plane block. Postoperatively, an effort should be made to utilize non-narcotic interventions such as abdominal binders, ice packs, simethicone, bowel regimens, gabapentin, and scheduled NSAIDs and acetaminophen. When prescribing narcotics, providers should be aware of recommended amounts of opioids required per procedure so as to avoid overprescribing. SUMMARY Our findings emphasize the evolving importance of preemptive interventions, including prehabilitation and pharmacologic agents, to improve postoperative pain after minimally invasive gynecologic surgery. Additionally, a multimodal approach to nonnarcotic intraoperative and postoperative interventions decreases narcotic requirement and improves opioid stewardship.
Collapse
|
17
|
Sierżantowicz R, Lewko J, Bitiucka D, Lewko K, Misiak B, Ładny JR. Evaluation of Pain Management after Surgery: An Observational Study. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E65. [PMID: 32046199 PMCID: PMC7073849 DOI: 10.3390/medicina56020065] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/23/2020] [Accepted: 02/03/2020] [Indexed: 01/23/2023]
Abstract
Background and Objectives: Choosing a pain management strategy is essential for improving recovery after surgery. Effective pain management reduces the stress response, facilitates mobilization, and improves the quality of the postoperative period. The aim of the study was to assess the effectiveness of pain management in patients after surgery. Materials and Methods: The study included 216 patients operated on in the following surgical wards: the Department of Cardiosurgery and the Department of General and Endocrine Surgery. Patients were hospitalized on average for 6 ± 4.5 days. Patients were randomly selected for the study using a questionnaire technique with a numerical rating scale. Results: Immediately after surgery, pre-emptive analgesia, multimodal analgesia, and analgosedation were used significantly more frequently than other methods (p < 0.001). In the subsequent postoperative days, the method of administering drugs on demand was used most often. Patients with confirmed complications during postoperative wound healing required significantly more frequent use of drugs from Steps 2 and 3 of the World Health Organization (WHO) analgesic ladder compared with patients without complications. Conclusion: The mode of patient admission for surgery significantly affected the level of pain perception. Different pain management methods were used and not every method was effective.
Collapse
Affiliation(s)
- Regina Sierżantowicz
- Department of Surgical Nursing, Medical University of Bialystok; Szpitalna 37, 15-295 Bialytsok, Poland; (R.S.); (D.B.)
| | - Jolanta Lewko
- Department of Integrated Medical Care, Medical University of Bialystok, M. Skłodowskiej-Curie str. 7a, 15-096, Bialystok, Poland
| | - Dorota Bitiucka
- Department of Surgical Nursing, Medical University of Bialystok; Szpitalna 37, 15-295 Bialytsok, Poland; (R.S.); (D.B.)
| | - Karolina Lewko
- International Medical Students Association-Poland (IFMSA-Poland), Medical University of Białystok, Kilińskiego 1, 15-089 Bialystok, Poland;
| | - Bianka Misiak
- University of Medical Science, Krakowska 9,15-875 Bialystok, Poland;
| | - Jerzy Robert Ładny
- Department of General and Endocrine Surgery, Medical University of Bialystok; M. Skłodowskiej-Curie 24a, 15-276 Bialystok, Poland;
| |
Collapse
|
18
|
Chakravarthy V, Yokoi H, Manlapaz MR, Krishnaney AA. Enhanced Recovery in Spine Surgery and Perioperative Pain Management. Neurosurg Clin N Am 2020; 31:81-91. [DOI: 10.1016/j.nec.2019.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|
19
|
|
20
|
Makkar JK, Jain K, Kuberan A, Balasubramanian M, Bhatia N, Singh PM. Pre-emptive multimodal analgesic regimen reduces post-operative epidural demand boluses in traumatic shaft of femur fracture - A randomised controlled trial. Indian J Anaesth 2019; 63:895-899. [PMID: 31772397 PMCID: PMC6868665 DOI: 10.4103/ija.ija_363_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/23/2019] [Accepted: 08/26/2019] [Indexed: 11/17/2022] Open
Abstract
Background and Aims: The efficacy of preemptive multimodal analgesia in post-traumatic patients has not been elucidated. Our aim was to evaluate the efficacy of preemptive MMA regimen in reducing the epidural demand boluses in the first 48 hours following the traumatic shaft of femur fractures. Methods: Patients scheduled for traumatic femur fracture surgery were randomised (n = 135) into two groups in this double blind, placebo controlled trial. Patients received either (Preemptive multimodal group) intravenous acetaminophen 1 gm, diclofenac 75 mg, morphine 3 mg, 75 mg Pregabalin (per oral) or a placebo 30 minutes pre-operatively. Intra-operatively, all patients were managed with spinal and epidural anaesthesia. Post-operatively, patients received patient-controlled epidural analgesia (PCEA) programmed to deliver a bolus of 5 ml of 0.2% Ropivacaine with 2 μg/ml of Fentanyl with lockout interval time of 15 min. Primary outcome was number of PCEA boluses received post-operatively over 48 h. Secondary outcomes measures were time to receive first epidural bolus, postoperative VAS scores and episodes of post-operative nausea, vomiting and sedation. Total number of PCEA bolus doses over 48 hours and VAS scores were analysed using Mann-Whitney test. Results: Significant reduction in median number of demand boluses were observed in preemptive multimodal group (3 [2-4]) compared to placebo group (5 [4-7]); P = 0.00. Time to first rescue epidural bolus was significantly greater in preemptive multimodal group than placebo group. Conclusion: The use of preemptive MMA regimen reduced the requirement of demand epidural bolus doses.
Collapse
Affiliation(s)
- Jeetinder K Makkar
- Department of Anaesthesia and Intensive Care, Post Graduate Institute Medical Education and Research, Chandigarh, India
| | - Kajal Jain
- Department of Anaesthesia and Intensive Care, Post Graduate Institute Medical Education and Research, Chandigarh, India
| | - Aswini Kuberan
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Post Graduate Medical Education and Research, Dhanvantari Nagar, Puducherry, India
| | - Mukilan Balasubramanian
- Department of Anaesthesia and Intensive Care, Post Graduate Institute Medical Education and Research, Chandigarh, India
| | - Nidhi Bhatia
- Department of Anaesthesia and Intensive Care, Post Graduate Institute Medical Education and Research, Chandigarh, India
| | - Preet M Singh
- Department of Anaesthesia and Intensive Care, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
21
|
Leas DP, Connor PM, Schiffern SC, D'Alessandro DF, Roberts KM, Hamid N. Opioid-free shoulder arthroplasty: a prospective study of a novel clinical care pathway. J Shoulder Elbow Surg 2019; 28:1716-1722. [PMID: 31072655 DOI: 10.1016/j.jse.2019.01.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 01/17/2019] [Accepted: 01/21/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Opioid therapy has been a cornerstone of perioperative pain control for decades in the United States, despite our increased understanding of the morbidity and mortality linked to opioids. The purpose of this study is to explore the safety, efficacy, and feasibility of an entirely opioid-free perioperative pathway in patients undergoing elective shoulder arthroplasty. METHODS Thirty-five patients undergoing elective total shoulder arthroplasty with a mean age of 71 (range, 50-87) years elected into a comprehensive opioid-free, multimodal pain management protocol. Opioid use was completely eliminated for all points in the perioperative period including during regional and general anesthesia. Data were collected regarding patient-reported pain, opioid consumption in the perioperative period, postoperative delirium, nausea, constipation, and falls. RESULTS Pain level at the primary outcome point of 24 hours or discharge was rated at 2.5 on the numeric rating scale. Stable, low pain scores were demonstrated at all time points postoperatively. Low rates of nausea, falls, and constipation were reported. Only 1 patient required "rescue" opioid medications during the in-patient stay, and an additional patient was given a low-dose opioid prescription at the 2-week postoperative appointment. CONCLUSIONS An opioid-free, multimodal pain management pathway is a safe and effective option in properly selected patients undergoing shoulder arthroplasty with a very low risk of requiring rescue opioids. This study is the first such study to present a surgical protocol entirely free of opioids at all portions of the patient care pathway.
Collapse
Affiliation(s)
- Daniel P Leas
- Department of Orthopaedic Surgery, Atrium Health, Charlotte, NC, USA
| | - Patrick M Connor
- OrthoCarolina Shoulder and Elbow Center, Charlotte, NC, USA; OrthoCarolina Sports Medicine Center, Charlotte, NC, USA
| | | | - Donald F D'Alessandro
- OrthoCarolina Shoulder and Elbow Center, Charlotte, NC, USA; OrthoCarolina Sports Medicine Center, Charlotte, NC, USA
| | | | - Nady Hamid
- OrthoCarolina Shoulder and Elbow Center, Charlotte, NC, USA.
| |
Collapse
|
22
|
Abdeen A, Abou-Zaid OA, Abdel-Maksoud HA, Aboubakr M, Abdelkader A, Abdelnaby A, Abo-Ahmed AI, El-Mleeh A, Mostafa O, Abdel-Daim M, Aleya L. Cadmium overload modulates piroxicam-regulated oxidative damage and apoptotic pathways. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2019; 26:25167-25177. [PMID: 31256392 DOI: 10.1007/s11356-019-05783-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 06/17/2019] [Indexed: 06/09/2023]
Abstract
Cadmium (Cd) is a common environmental pollutant that threatens humans' and animals' health. Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used drugs due to their wide therapeutic action; however, they have significant side effects. Since, under many circumstances, humans and animals may be co-exposed to Cd and NSAIDs, the current investigation was assigned to explore the intertwining relationship between Cd and NSAIDs. Four groups of male Wister rats were used: control group: rats received saline; Cd group: rats received cadmium (Cd, 2 mg/kg) orally; Px group: rats received a NSAID (piroxicam, Px, 7 mg/kg, i.p.); and Cd+Px group: rats received both Cd+Px. All treatments were given once a day for 28 consecutive days. Then, blood samples, stomach, liver, and kidney tissues were collected. The results indicated that Px provoked gastric ulcer indicated by high ulcer index, while Cd had no effect on the gastric mucosa. In addition, treatment with Cd or Px alone significantly induced liver and kidney injuries indicated by serum elevations of AST, ALT, ALP, ALB, total protein, creatinine, and urea along with histopathological alterations. Significant increases in malondialdehyde and reduction in GSH and CAT contents were reported along with up-regulated expression of Bax and Bcl-2 after Cd or Px exposure. However, when Cd and Px were given in a combination, Cd obviously potentiated the Px-inflicted cellular injury and death in the liver and kidney but not in the stomach when compared to their individual exposure. This study concluded that oxidative stress mechanisms were supposed to be the main modulator in promoting Cd and Px toxicities when given in combination.
Collapse
Affiliation(s)
- Ahmed Abdeen
- Department of Forensic Medicine and Toxicology, Faculty of Veterinary Medicine, Benha University, Toukh, 13736, Egypt.
- Department of Biochemistry and Clinical Biochemistry, Faculty of Veterinary Medicine, Benha University, Toukh, 13736, Egypt.
| | - Omayma A Abou-Zaid
- Department of Biochemistry and Clinical Biochemistry, Faculty of Veterinary Medicine, Benha University, Toukh, 13736, Egypt
| | - Hussein A Abdel-Maksoud
- Department of Biochemistry and Clinical Biochemistry, Faculty of Veterinary Medicine, Benha University, Toukh, 13736, Egypt
| | - Mohamed Aboubakr
- Department of Pharmacology, Faculty of Veterinary Medicine, Benha University, Toukh, 13736, Egypt
| | - Afaf Abdelkader
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Benha University, Benha, 13518, Egypt
| | - Amany Abdelnaby
- Agricultural Research Center, Animal Health Research Institute, Dokki, Giza, 12618, Egypt
| | - Ahmed I Abo-Ahmed
- Department of Anatomy and Embryology, Faculty of Veterinary Medicine, Benha University, Toukh, 13736, Egypt
| | - Amany El-Mleeh
- Department of Pharmacology, Faculty of Veterinary Medicine, Menufyia University, Shebin El Kom, 32514, Egypt
| | - Ola Mostafa
- Histology and Cell Biology Department, Faculty of Medicine, Benha University, Benha, 13518, Egypt
| | - Mohamed Abdel-Daim
- Department of Zoology, Science College, King Saud University, Riyadh, 11451, Saudi Arabia
- Pharmacology Department, Faculty of Veterinary Medicine, Suez Canal University, Ismailia, 41522, Egypt
| | - Lotfi Aleya
- Chrono-Environment Laboratory, Bourgogne Franche-Comté University, UMR CNRS 6249, 25030, Besançon Cedex, France
| |
Collapse
|
23
|
Abstract
In the past, best practices for perioperative management have been based as much on dogma as science. The creation of optimized perioperative pathways, known as enhanced recovery after surgery, has been shown to simultaneously improve patient outcomes and reduce cost. In this article, we critically review interventions (and omission of interventions) that should be considered by every surgical team to optimize preanesthesia care. This includes patient education, properly managing existing medical comorbidities, optimizing nutrition, and the use of medications before incision that have been shown to reduce surgical stress, opioid requirements, and postoperative complications. Anesthetic techniques, the use of adjunct medications administered after incision, and postoperative management are beyond the scope of this review. When possible, we have relied on randomized trials, meta-analyses, and systematic reviews to support our recommendations. In some instances, we have drawn from the general and colorectal surgery literature if evidence in gynecologic surgery is limited or of poor quality. In particular, hospital systems should aim to adhere to antibiotic and thromboembolic prophylaxis for 100% of patients, the mantra, "nil by mouth after midnight" should be abandoned in favor of adopting a preoperative diet that maintains euvolemia and energy stores to optimize healing, and bowel preparation should be abandoned for patients undergoing gynecologic surgery for benign indications and minimally invasive gynecologic surgery.
Collapse
|
24
|
Klifto KM, Major MR, Leto Barone AA, Payne RM, Elhelali A, Seal SM, Cooney CM, Manahan MA, Rosson GD. Perioperative systemic nonsteroidal anti-inflammatory drugs (NSAIDs) in women undergoing breast surgery. Hippokratia 2019. [DOI: 10.1002/14651858.cd013290] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Kevin M Klifto
- Johns Hopkins University School of Medicine; Department of Plastic and Reconstructive Surgery; 601 N. Caroline Street Baltimore USA 21287
| | - Melanie R Major
- Johns Hopkins University School of Medicine; Department of Plastic and Reconstructive Surgery; 601 N. Caroline Street Baltimore USA 21287
| | - Angelo A Leto Barone
- Johns Hopkins University School of Medicine; Department of Plastic and Reconstructive Surgery; 601 N. Caroline Street Baltimore USA 21287
| | - Rachael M Payne
- Washington University School of Medicine; Division of Plastic and Reconstructive Surgery, Department of Surgery; St Louis USA
| | - Ala Elhelali
- National University of Ireland; Department of Nursing and Midwifery; Aras Moyola, National University of Ireland Galway Galway Ireland
| | - Stella M Seal
- Johns Hopkins University School of Medicine; Welch Medical Library; 2024 E. Monument St. Baltimore USA 21287
| | - Carisa M Cooney
- Johns Hopkins University School of Medicine; Department of Plastic and Reconstructive Surgery; 601 N. Caroline Street Baltimore USA 21287
| | - Michele A Manahan
- Johns Hopkins University School of Medicine; Department of Plastic and Reconstructive Surgery; 601 N. Caroline Street Baltimore USA 21287
| | - Gedge D Rosson
- Johns Hopkins University School of Medicine; Department of Plastic and Reconstructive Surgery; 601 N. Caroline Street Baltimore USA 21287
| |
Collapse
|
25
|
Hida M, Deguchi Y, Miyaguchi K, Nakazono M, Hirata N, Nakagawa R, Kitayama A. Association between Acute Postoperative Pain and Recovery of Independent Walking Ability after Surgical Treatment of Hip Fracture. Prog Rehabil Med 2018; 3:20180012. [PMID: 32789237 DOI: 10.2490/prm.20180012] [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: 02/09/2018] [Accepted: 06/11/2018] [Indexed: 11/09/2022] Open
Abstract
Objective The intensity of pain after surgical treatment of hip fracture has a negative effect on functional recovery. However, the effects of acute postoperative pain on the recovery of walking ability after the surgery remain unclear. This study aimed to investigate the association between acute postoperative pain and the recovery of functional gait among patients who had independent walking ability prior to hip fracture. Methods This was an observational study that included 41 patients with a mean age of 81.3±7.3 years who underwent surgical treatment for traumatic hip fracture at a general hospital. The primary outcome was the time to recovery of independent gait postsurgery. Based on the median time to recovery, patients were classified into an early independent walking group and an independent walking group. Stepwise logistic regression analysis was performed to identify predictive factors of the time to recovery of independent walking. Results The median time to recovery of independent gait was 24 days (range, 7-50 days). In total, 20 patients were classified in the early independent walking group and 21 in the independent walking group. On logistic regression analysis, the total pain intensity, reported during activities of daily living (ADL) on postoperative days 5 and 6, and the knee extensor strength were predictive of the time to recovery of independent walking. Conclusions The degree of recovery of gait function of patients surgically treated for hip fracture was found to be predicted by the pain intensity measured during ADL and the knee extensor strength assessed in the acute phase. Effective management of acute pain after surgical treatment of hip fracture may help improve functional recovery of gait.
Collapse
Affiliation(s)
- Mitsumasa Hida
- School of Rehabilitation, Osaka Kawasaki Rehabilitation University, Osaka, Japan.,Nara Yukokai Hospital, Nara, Japan
| | | | | | | | | | | | - Atsushi Kitayama
- Department of Rehabilitation, Faculty of Allied Health Sciences, Yamato University, Osaka, Japan
| |
Collapse
|
26
|
Benefits and harms associated with analgesic medications used in the management of acute dental pain. J Am Dent Assoc 2018; 149:256-265.e3. [DOI: 10.1016/j.adaj.2018.02.012] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 02/13/2018] [Accepted: 02/14/2018] [Indexed: 01/08/2023]
|
27
|
Association of inflammatory mediators with pain perception. Biomed Pharmacother 2017; 96:1445-1452. [DOI: 10.1016/j.biopha.2017.12.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 12/01/2017] [Accepted: 12/01/2017] [Indexed: 12/31/2022] Open
|
28
|
Mauermann E, Ruppen W, Bandschapp O. Different protocols used today to achieve total opioid-free general anesthesia without locoregional blocks. Best Pract Res Clin Anaesthesiol 2017; 31:533-545. [DOI: 10.1016/j.bpa.2017.11.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 08/08/2017] [Accepted: 11/08/2017] [Indexed: 12/20/2022]
|
29
|
Regan DW, Kashiwagi D, Dougan B, Sundsted K, Mauck K. Update in perioperative medicine: practice changing evidence published in 2016. Hosp Pract (1995) 2017; 45:158-164. [PMID: 28749248 DOI: 10.1080/21548331.2017.1359060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 07/20/2017] [Indexed: 06/07/2023]
Abstract
This summary reviews 18 key articles published in 2016 which have significant practice implications for the perioperative medical care of surgical patients. Due to the multi-disciplinary nature of the practice of perioperative medicine, important new evidence is published in journals representing a variety of medical and surgical specialties. Keeping current with the evidence that drives best practice in perioperative medicine is therefore challenging. We set out to identify, critically review, and summarize key evidence which has the most potential for practice change. We integrated the new evidence into the existing body of medical knowledge and identified practical implications for real world patient care. The articles address issues related to anticoagulation, transfusion threshold, immunosuppressive medications, postoperative delirium, myocardial injury after noncardiac surgery, postoperative pain management, perioperative management of antihypertensives, perioperative fasting, and perioperative diabetic control.
Collapse
Affiliation(s)
- Dennis W Regan
- a General Internal Medicine , Mayo Clinic , Rochester , MN , USA
| | | | - Brian Dougan
- a General Internal Medicine , Mayo Clinic , Rochester , MN , USA
| | - Karna Sundsted
- a General Internal Medicine , Mayo Clinic , Rochester , MN , USA
| | - Karen Mauck
- a General Internal Medicine , Mayo Clinic , Rochester , MN , USA
| |
Collapse
|
30
|
Wang K, Luo J, Zheng L, Luo T. Preoperative flurbiprofen axetil administration for acute postoperative pain: a meta-analysis of randomized controlled trials. J Anesth 2017; 31:852-860. [PMID: 28936554 DOI: 10.1007/s00540-017-2409-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 09/05/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Non-steroidal anti-inflammatory drugs have been shown to effectively decrease postoperative pain and reduce opioid requirements. Flurbiprofen axetil is an injectable non-selective cyclooxygenase inhibitor that has a high affinity for inflammatory tissues to achieve targeted drug therapy and prolonged duration of action. This meta-analysis examined the use of preoperative flurbiprofen axetil and its impact on postoperative analgesia. METHODS An electronic literature search of the Library of PubMed, Cochrane CENTRAL, and EMBASE databases was conducted in Feb 2016. Searches were limited to randomized controlled trials. The primary outcome was pain scores. The secondary outcomes included cumulative postoperative opioid consumption and opioid-related adverse effects. RESULTS A total of nine RCT studies involving 457 patients were included in this study. Compared to patients without perioperative flurbiprofen axetil, patients treated with preoperative flurbiprofen axetil had lower pain scores at 2 h (SMD -1.00; 95% CI -1.57 to -0.43, P = 0.0006), 6 h (SMD -1.22; 95% CI -2.01 to -0.43; P = 0.002), 12 h (SMD -1.19; 95% CI -2.10 to -0.28; P = 0.01), and 24 h (SMD -0.79; 95% CI -1.31 to -0.27; P = 0.003) following surgery. Preoperative flurbiprofen axetil had no significant effect on postoperative opioid consumption (SMD -13.11; 95% CI -34.56 to 8.33; P = 0.23). There was no significant difference between the groups with regard to adverse effects. Compared to patients with postoperative flurbiprofen axetil, however, preoperative flurbiprofen axetil resulted in decreased pain score only at 2 h after operation. CONCLUSIONS Preoperative use of flurbiprofen axetil will result in significantly lower postoperative pain scores, but no difference in nausea, vomiting, and opioid consumption compared to those who did not receive flurbiprofen axetil. However, more homogeneous and well-designed clinical studies are necessary to determine whether preoperative flurbiprofen axetil administration has more efficacy than that given at the end of surgery.
Collapse
Affiliation(s)
- Ke Wang
- Department of Anesthesiology, Peking University Shenzhen Hospital, 1120 Lianhua Road, Shenzhen, 518036, Guangdong, People's Republic of China
| | - Jun Luo
- Department of Pathology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, People's Republic of China
| | - Limin Zheng
- Department of Anesthesiology, Peking University Shenzhen Hospital, 1120 Lianhua Road, Shenzhen, 518036, Guangdong, People's Republic of China.
| | - Tao Luo
- Department of Anesthesiology, Peking University Shenzhen Hospital, 1120 Lianhua Road, Shenzhen, 518036, Guangdong, People's Republic of China.
| |
Collapse
|
31
|
Prabhu M, Bortoletto P, Bateman BT. Perioperative pain management strategies among women having reproductive surgeries. Fertil Steril 2017; 108:200-206. [PMID: 28697915 PMCID: PMC5545053 DOI: 10.1016/j.fertnstert.2017.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 06/06/2017] [Indexed: 12/14/2022]
Abstract
This review presents opioid-sparing strategies for perioperative pain management among women undergoing reproductive surgeries and procedures. Recommendations are provided regarding the use of nonsteroidal anti-inflammatory drugs, acetaminophen, other adjunctive medications, and regional anesthetic blocks. Additional considerations for chronic opioid users or patients using opioid replacement or antagonist therapy are discussed.
Collapse
Affiliation(s)
- Malavika Prabhu
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Massachusetts General Hospital, 55 Fruit Street, Boston MA 02114,
| | - Pietro Bortoletto
- Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women’s Hospital, 75 Francis Street, Boston MA 02115,
| | - Brian T. Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, and Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, ., 617-529-7058
| |
Collapse
|
32
|
Kaye AD, Cornett EM, Helander E, Menard B, Hsu E, Hart B, Brunk A. An Update on Nonopioids: Intravenous or Oral Analgesics for Perioperative Pain Management. Anesthesiol Clin 2017; 35:e55-e71. [PMID: 28526161 DOI: 10.1016/j.anclin.2017.01.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Despite an appreciation for many unwanted physiologic effects from inadequate postoperative pain relief, moderate to severe postoperative pain remains commonplace. Although treatment options have evolved in recent years, the use of nonopioid analgesics agents can reduce acute pain-associated morbidity and mortality. This review focuses on the importance of effective postoperative nonopioid analgesic agents, such as acetaminophen, nonsteroidal anti-inflammatory agents, gabapentinoid agents, NMDA antagonists, alpha 2 agonists, and steroids, in opioid sparing and enhancing recovery. A careful literature review focusing on these treatment options, potential benefits, and side effects associated with these strategies is emphasized in this review.
Collapse
Affiliation(s)
- Alan D Kaye
- Department of Anesthesiology, LSU School of Medicine, 1542 Tulane Avenue, New Orleans, LA 70112, USA; Department of Pharmacology, Louisiana State University School of Medicine, Louisiana State University Health Science Center, 1542 Tulane Avenue, New Orleans, LA 70112, USA.
| | - Elyse M Cornett
- Department of Anesthesiology, LSU School of Medicine, 1501 Kings Highway, Shreveport, LA 71130, USA
| | - Erik Helander
- Department of Anesthesiology, LSU School of Medicine, 1542 Tulane Avenue, New Orleans, LA 70112, USA
| | - Bethany Menard
- Department of Anesthesiology, LSU School of Medicine, 1542 Tulane Avenue, New Orleans, LA 70112, USA
| | - Eric Hsu
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, UCLA School of Medicine, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095-7403, USA
| | - Brendon Hart
- Department of Anesthesiology, LSU School of Medicine, 1501 Kings Highway, Shreveport, LA 71130, USA
| | - Andrew Brunk
- Department of Anesthesiology, LSU School of Medicine, 1542 Tulane Avenue, New Orleans, LA 70112, USA
| |
Collapse
|
33
|
|
34
|
Abstract
PURPOSE OF REVIEW Management of acute pain following surgery using a multimodal approach is recommended by the American Society of Anesthesiologists whenever possible. In addition to opioids, drugs with differing mechanisms of actions target pain pathways resulting in additive and/or synergistic effects. Some of these agents include alpha 2 agonists, NMDA receptor antagonists, gabapentinoids, dexamethasone, NSAIDs, acetaminophen, and duloxetine. RECENT FINDINGS Alpha 2 agonists have been shown to have opioid-sparing effects, but can cause hypotension and bradycardia and must be taken into consideration when administered. Acetaminophen is commonly used in a multimodal approach, with recent evidence lacking for the use of IV over oral formulations in patients able to take medications by mouth. Studies involving gabapentinoids have been mixed with some showing benefit; however, future large randomized controlled trials are needed. Ketamine is known to have powerful analgesic effects and, when combined with magnesium and other agents, may have a synergistic effect. Dexamethasone reduces postoperative nausea and vomiting and has been demonstrated to be an effective adjunct in multimodal analgesia. The serotonin-norepinephrine reuptake inhibitor, duloxetine, is a novel agent, but studies are limited and further evidence is needed. Overall, a multimodal analgesic approach should be used when treating postoperative pain, as it can potentially reduce side effects and provide the benefit of treating pain through different cellular pathways.
Collapse
|
35
|
|