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Pfeiler PP, Rieder P, Kimelman M, Moog P, Dornseifer U. Limitations of Patient-Controlled Epidural Analgesia Following Abdominoplasty. Ann Plast Surg 2024; 93:283-289. [PMID: 38984655 DOI: 10.1097/sap.0000000000004020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2024]
Abstract
BACKGROUND Effective postoperative pain management is essential for patient satisfaction and an uneventful postoperative course, particularly in body contouring procedures. Systemic analgesic regimens can be supported by regional procedures, such as the transverse abdominis plane (TAP) block, but these have a limited duration of action. In contrast, thoracic epidural analgesia offers the possibility of a longer-lasting, individualized regional anesthesia administered by a patient-controlled analgesia pump. OBJECTIVES The aim of this study was to investigate the effects of a patient-controlled epidural analgesia to better classify the clinical value of this procedure in abdominoplasties. MATERIALS AND METHODS This work reviewed the digital medical charts of patients who underwent selective abdominoplasty without combined surgical procedures between September 2018 and August 2022. Evaluated data comprise the postoperative analgesia regimen, including on-demand medication, mobilization time, inpatient length of stay, and clinical outcome. The patients were grouped by the presence of a thoracic epidural catheter. This catheter was placed before anesthetic induction and a saturation dose was preoperatively applied. Postoperative PCEA patients received a basal rate and could independently administer boluses. Basal rate was individually adjusted during daily additional pain visits. RESULTS The study cohort included 112 patients. Significant differences in the demand for supportive nonepidural opiate medication were shown between the patient-controlled epidural analgesia (PCEA) group (n = 57) and the non-PCEA group (n = 55), depending on the time after surgery. PCEA patients demanded less medication during the early postoperative days (POD 0: PCEA 0.13 (±0.99) mg vs non-PCEA 2.59 (±4.55) mg, P = 0.001; POD 1: PCEA 0.79 mg (±3.06) vs non-PCEA 2.73 (±3.98) mg, P = 0.005), but they required more during the later postoperative phase (POD 3: PCEA 2.76 (±5.60) mg vs non-PCEA 0.61 (±2.01) mg, P = 0.008; POD 4: PCEA 1.64 (±3.82) mg vs non-PCEA 0.07 (±2.01) mg, P = 0.003). In addition, PCEA patients achieved full mobilization later (PCEA 2.67 (±0.82) days vs non-PCEA 1.78 (±1.09) days, P = 0.001) and were discharged later (PCEA 4.84 (±1.23) days vs non-PCEA 4.31 (±1.37) days, P = 0.005). CONCLUSION Because the postoperative benefits of PCEA are limited to potent analgesia immediately after abdominoplasty, less cumbersome, time-limited regional anesthesia procedures (such as TAP block) appear not only adequate but also more effective.
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Affiliation(s)
- Peter Paul Pfeiler
- From the Department of Plastic, Reconstructive and Aesthetic Surgery, ISAR Klinikum
| | - Paulina Rieder
- From the Department of Plastic, Reconstructive and Aesthetic Surgery, ISAR Klinikum
| | - Michael Kimelman
- From the Department of Plastic, Reconstructive and Aesthetic Surgery, ISAR Klinikum
| | - Philipp Moog
- Clinic for Plastic, Reconstructive and Hand Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Ulf Dornseifer
- From the Department of Plastic, Reconstructive and Aesthetic Surgery, ISAR Klinikum
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Romanò G, Klarskov N, Lassen PD, Bennich G, Hoffmann E. 3-Dimensional versus standard 2-D laparoscopy for benign hysterectomy: A randomized clinical trial. Eur J Obstet Gynecol Reprod Biol 2024; 298:187-191. [PMID: 38781785 DOI: 10.1016/j.ejogrb.2024.05.017] [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: 08/30/2023] [Revised: 04/22/2024] [Accepted: 05/15/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE Our aim was to evaluate possible short and long-term benefits of 3-dimensional (3-D) compared to 2-dimensional (2-D) laparoscopy for benign hysterectomy. Primary outcomes were long-term quality of life and postoperative pain. Secondary outcomes were operative time, surgical complications, time to return to work and length of hospitalization. STUDY DESIGN A randomized controlled trial conducted at two Danish university hospitals. In each arm, 190 patients were needed for an alpha of 3.3 % and a power of 90 %. For various reasons, however, the study was prematurely terminated after including 97 patients. Patients were randomized to either 2-D (n = 48) or 3-D (n = 49) laparoscopy. A laparoscopic hysterectomy was performed. Quality of life was assessed by the Short Form Health Survey 36 (SF-36) questionnaire at the time of inclusion and 6 weeks postoperatively. Postoperative pain was assessed using a Numeric Rating Scale (NRS) and by monitoring the amount of analgesic consumption. RESULTS Out of the 97 randomized patients, 77 patients completed both SF-36 questionnaires. No significant differences in mental (p = 0.5) and physical status (p = 0.9) were found. The 2-D group had significantly higher pain-score registered in the post anesthesia care unit (PACU) (p = 0.004) and higher consumption of oral morphine equivalent dose (MEqD) (p = 0.003) than the 3-D group. This regardless a higher rate of minilaparotomies in the 2D (n = 7) than in the 3D (n = 1) group (p < 0.03). The 2-D group had also higher rate of Clavien-Dindo 2 (CD2) (n = 2) and Clavien-Dindo 3 (CD3) complications (n = 3) (p = 0.03) than 3-D (n = 0). The other secondary outcome parameters did not vary between groups. CONCLUSIONS The results are severely hampered by the premature termination of the study, as less than 25 percent of the patients were recruited. Thus, no firm conclusions can be drawn regarding the quality of life and many of the secondary outcomes, as the lack of difference may be attributed to a type 2 error. However, the significant differences in postoperative pain and in complication rates suggest a greater advantage of 3-D laparoscopy than originally expected. Despite the methodological problems, the current data deserve attention in a sparsely investigated field, emphasizing the urgent need for further studies.
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Affiliation(s)
- Giorgia Romanò
- Department of Obstetrics and Gynecology, Herlev University Hospital, Herlev Ringvej 75, 2730 Herlev, Denmark.
| | - Niels Klarskov
- Department of Obstetrics and Gynecology, Herlev University Hospital, Herlev Ringvej 75, 2730 Herlev, Denmark; University of Copenhagen, Faculty of Health and Medical Science, Copenhagen, Denmark
| | - Pernille Danneskiold Lassen
- Department of Obstetrics and Gynecology, Roskilde University Hospital, Koegevej 7-13, 4000 Roskilde, Denmark
| | - Gitte Bennich
- Department of Obstetrics and Gynecology, Roskilde University Hospital, Koegevej 7-13, 4000 Roskilde, Denmark
| | - Elise Hoffmann
- Department of Obstetrics and Gynecology, Zealand University Hospital, Koegevej 7-13, 4000 Roskilde, Denmark
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Lin RJ, Munin MC, Belsky M, Smith B, Grose E, Nisenbaum R, Rosen CA, Smith LJ. Technical Challenges for Laryngeal Electromyography. Laryngoscope 2024; 134:831-834. [PMID: 37676073 DOI: 10.1002/lary.31035] [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: 03/27/2023] [Revised: 08/14/2023] [Accepted: 08/22/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND/OBJECTIVE Laryngeal electromyography (LEMG) is a useful diagnostic test in the evaluation of vocal fold paralysis (VFP). This study investigates factors that can make LEMG challenging to perform. METHODS Patients with subacute unilateral VFP presented for LEMG were prospectively enrolled. Demographic data including BMI, previous neck surgery, and anatomic factors were collected. Patient-reported pain related to the procedure was recorded on a visual analogue scale (VAS). Electromyographer and otolaryngologist recorded a consensus rating of the perceived difficulty in performing the test and confidence in using the results for clinical decision-making. RESULTS A total of 111 patients (56.8% female) were enrolled between August 2015 and August 2018. The mean age was 55 ± 14 years, and the average body mass index (BMI) was 28.5 ± 6.4. The mean patient-reported VAS score for pain was 35 ± 24. Notably, 31.2% of the tests were considered "very easy," 32.1% were considered "mildly challenging" and 23.9% and 12.8% were considered "moderately challenging" and "extremely challenging," respectively, by the clinicians. Common factors affecting LEMG difficulty included poorly palpable surface anatomy (50.5%) and patient intolerance (15.6%). Clinicians felt confident in 76.1% of the test findings. Bivariate analyses showed that prior neck surgery is associated with elevated VAS (p = 0.02), but clinician-perceived difficulty of performing the test is not associated with elevated VAS scores (p = 0.55). CONCLUSIONS Majority of LEMG tests are well tolerated by patients. Physicians reported more confidence using LEMG for clinical decision-making when the test was easier to perform. Difficult surface anatomy and patient intolerance affects clinician confidence in integrating the test results with clinical care. LEVEL OF EVIDENCE 3 Laryngoscope, 134:831-834, 2024.
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Affiliation(s)
- R Jun Lin
- Department of Otolaryngology - Head & Neck Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michael C Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Michael Belsky
- Department of Otolaryngology - Head & Neck Surgery, Stanford University, Stanford, California, U.S.A
| | - Brandon Smith
- Department of Otolaryngology - Head & Neck Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Elysia Grose
- Department of Otolaryngology - Head & Neck Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rosane Nisenbaum
- MAP Centre for Urban Health Solutions, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Clark A Rosen
- Department of Otolaryngology - Head & Neck Surgery, UCSF Voice & Swallowing Center, University of California San Francisco, San Francisco, California, U.S.A
| | - Libby J Smith
- Department of Otolaryngology - Head & Neck Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
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Pennington J, Contini S, Brown M, Goel N, Chen T. Efficacy of intrathecal morphine administration in pediatric patients undergoing selective dorsal rhizotomy. J Pediatr Rehabil Med 2023; 16:109-114. [PMID: 36806525 DOI: 10.3233/prm-220048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
PURPOSE The purpose of this study was to evaluate the effectiveness of intrathecal morphine following selective dorsal rhizotomy in pediatric patients previously diagnosed with cerebral palsy. METHODS This was a retrospective, cohort analysis over the course of four years. The analysis consisted of a treatment group which received intrathecal morphine (5 mcg/kg) injection and a control group that did not receive the injection prior to dural closure. All patients underwent multilevel laminectomies for selective dorsal rhizotomy at Akron Children's Hospital. The effectiveness of the treatment was measured by total dose of hydromorphone administered on patient-controlled analgesia (PCA), number of days on oral narcotics, and cumulative dose of oral narcotic. RESULTS Of the analyzed 15 pediatric patients, seven patients received intrathecal morphine injection while the other eight did not receive the treatment prior to dural closure. There was a difference of 1135 mcg in total PCA dose between the study group (3243 mcg) and the control group (4378 mcg). The total PCA dose based on weight was lower in the study group (163 mcg/kg) than in the control group (171 mcg/kg). CONCLUSION Based on these findings, the administration of intrathecal morphine clinically reduces the opiate need in the first 96 hours post-operatively.
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Affiliation(s)
| | | | | | - Nupur Goel
- Northeast Ohio Medical University, Rootstown, OH, USA
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Réhabilitation améliorée après chirurgie cardiaque adulte sous CEC ou à cœur battant 2021. ANESTHÉSIE & RÉANIMATION 2022. [DOI: 10.1016/j.anrea.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Leth MF, Bukhari S, Laursen CCW, Larsen ME, Tornøe AS, Jakobsen JC, Maagaard M, Mathiesen O. Risk of serious adverse events associated with non-steroidal anti-inflammatory drugs in orthopaedic surgery. A protocol for a systematic review. Acta Anaesthesiol Scand 2022; 66:1257-1265. [PMID: 35986625 PMCID: PMC9826397 DOI: 10.1111/aas.14140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 08/17/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Postoperative pain is a common condition following orthopaedic surgeries and causes prolonged hospitalisation, delayed rehabilitation and hamper the quality of life. Non-steroidal anti-inflammatory drugs (NSAIDs) are effective analgesics and anti-inflammatory mediators in the treatment of postoperative pain. The association of NSAIDs with serious adverse events may however keep some clinicians and clinical decision makers from using NSAIDs perioperatively. The evidence regarding the risks of serious adverse events following perioperative use of NSAIDs in orthopaedic surgery is sparse and needs to be assessed in a systematic review. This is a protocol for a systematic review that aims to identify the risks of serious adverse events from perioperative use of NSAIDs in orthopaedic patients. METHODS Our methodology is based on the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols and the eight-step assessment procedure suggested by Jakobsen and colleagues. We wish to assess if NSAIDs versus placebo, usual care or no intervention, will influence the risks of serious adverse events in patients undergoing orthopaedic surgery. We will include all randomised trials assessing the use of NSAIDs perioperatively. To identify trials we will search the Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Cochrane Central Register, Science Citation Index Expanded on Web of Science and BIOSIS. Two authors will screen the literature and extract data. We will use the 'Risk of Bias 2 tool' to assess trials. Extracted data will be analysed using RStudio and Trial Sequential Analysis. We will create a 'Summary of Findings' table in which we will present our primary and secondary outcomes. We will assess the quality of evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE). DISCUSSION This systematic review can potentially aid clinicians and clinical decision makers in the use of NSAIDs for treatment of postoperative pain following orthopaedic surgeries.
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Affiliation(s)
- Morten Fiil Leth
- Centre for Anaesthesiological Research, Department of AnaesthesiologyZealand University HospitalKøgeDenmark
| | - Shaheer Bukhari
- Centre for Anaesthesiological Research, Department of AnaesthesiologyZealand University HospitalKøgeDenmark
| | | | - Mia Esta Larsen
- Department of AnaesthesiologyJuliane Marie Centre ‐ RigshospitaletCopenhagenDenmark
| | | | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812Copenhagen University Hospital – RigshospitaletCopenhagenDenmark,Department of Regional Health Research, Faculty of Health SciencesUniversity of Southern DenmarkOdenseDenmark
| | - Mathias Maagaard
- Centre for Anaesthesiological Research, Department of AnaesthesiologyZealand University HospitalKøgeDenmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of AnaesthesiologyZealand University HospitalKøgeDenmark,Department of Clinical MedicineCopenhagen UniversityCopenhagenDenmark
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Szatmary P, Grammatikopoulos T, Cai W, Huang W, Mukherjee R, Halloran C, Beyer G, Sutton R. Acute Pancreatitis: Diagnosis and Treatment. Drugs 2022; 82:1251-1276. [PMID: 36074322 PMCID: PMC9454414 DOI: 10.1007/s40265-022-01766-4] [Citation(s) in RCA: 149] [Impact Index Per Article: 74.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2022] [Indexed: 11/11/2022]
Abstract
Acute pancreatitis is a common indication for hospital admission, increasing in incidence, including in children, pregnancy and the elderly. Moderately severe acute pancreatitis with fluid and/or necrotic collections causes substantial morbidity, and severe disease with persistent organ failure causes significant mortality. The diagnosis requires two of upper abdominal pain, amylase/lipase ≥ 3 ×upper limit of normal, and/or cross-sectional imaging findings. Gallstones and ethanol predominate while hypertriglyceridaemia and drugs are notable among many causes. Serum triglycerides, full blood count, renal and liver function tests, glucose, calcium, transabdominal ultrasound, and chest imaging are indicated, with abdominal cross-sectional imaging if there is diagnostic uncertainty. Subsequent imaging is undertaken to detect complications, for example, if C-reactive protein exceeds 150 mg/L, or rarer aetiologies. Pancreatic intracellular calcium overload, mitochondrial impairment, and inflammatory responses are critical in pathogenesis, targeted in current treatment trials, which are crucially important as there is no internationally licenced drug to treat acute pancreatitis and prevent complications. Initial priorities are intravenous fluid resuscitation, analgesia, and enteral nutrition, and when necessary, critical care and organ support, parenteral nutrition, antibiotics, pancreatic exocrine and endocrine replacement therapy; all may have adverse effects. Patients with local complications should be referred to specialist tertiary centres to guide further management, which may include drainage and/or necrosectomy. The impact of acute pancreatitis can be devastating, so prevention or reduction of the risk of recurrence and progression to chronic pancreatitis with an increased risk of pancreas cancer requires proactive management that should be long term for some patients.
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Affiliation(s)
- Peter Szatmary
- Liverpool Pancreatitis Research Group, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Tassos Grammatikopoulos
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Wenhao Cai
- Liverpool Pancreatitis Research Group, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,West China Centre of Excellence for Pancreatitis and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Huang
- West China Centre of Excellence for Pancreatitis and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Rajarshi Mukherjee
- Liverpool Pancreatitis Research Group, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.,Department of Molecular Physiology and Cell Signalling, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool , UK
| | - Chris Halloran
- Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Georg Beyer
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Robert Sutton
- Liverpool Pancreatitis Research Group, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK. .,Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK. .,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
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Mertes PM, Kindo M, Amour J, Baufreton C, Camilleri L, Caus T, Chatel D, Cholley B, Curtil A, Grimaud JP, Houel R, Kattou F, Fellahi JL, Guidon C, Guinot PG, Lebreton G, Marguerite S, Ouattara A, Provenchère Fruithiot S, Rozec B, Verhoye JP, Vincentelli A, Charbonneau H. Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump. Anaesth Crit Care Pain Med 2022; 41:101059. [PMID: 35504126 DOI: 10.1016/j.accpm.2022.101059] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To provide recommendations for enhanced recovery after cardiac surgery (ERACS) based on a multimodal perioperative medicine approach in adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity, and reducing the length of hospital stay. DESIGN A consensus committee of 20 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Société française de chirurgie thoracique et cardio-vasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence. METHODS Six fields were defined: (1) selection of the patient pathway and its information; (2) preoperative management and rehabilitation; (3) anaesthesia and analgesia for cardiac surgery; (4) surgical strategy for cardiac surgery and bypass management; (5) patient blood management; and (6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analyses were performed using the GRADE approach. The recommendations were formulated according to the GRADE methodology and then voted on by all the experts according to the GRADE grid method. RESULTS The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing cardiac surgery under cardiopulmonary bypass or off-pump. After three rounds of voting and several amendments, a strong agreement was reached for the 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1-); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2-); and 4 are expert opinions. Finally, no recommendations were provided for 3 questions. CONCLUSIONS Strong agreement existed among the experts to provide recommendations to optimise the complete perioperative management of patients undergoing cardiac surgery.
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Affiliation(s)
- Paul-Michel Mertes
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Michel Kindo
- Department of Cardiac Surgery, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Julien Amour
- Institut de Perfusion, de Réanimation, d'Anesthésie de Chirurgie Cardiaque Paris Sud, IPRA, Hôpital Privé Jacques Cartier, Massy, France
| | - Christophe Baufreton
- Department of Cardiovascular and Thoracic Surgery, University Hospital, Angers, France; MITOVASC Institute CNRS UMR 6214, INSERM U1083, University, Angers, France
| | - Lionel Camilleri
- Department of Cardiovascular Surgery, CHU Clermont-Ferrand, T.G.I, I.P., CNRS, SIGMA, UCA, UMR 6602, Clermont-Ferrand, France
| | - Thierry Caus
- Department of Cardiac Surgery, UPJV, Amiens University Hospital, Amiens Picardy University Hospital, Amiens, France
| | - Didier Chatel
- Department of Cardiac Surgery (D.C.), Institut du Coeur Saint-Gatien, Nouvelle Clinique Tours Plus, Tours, France
| | - Bernard Cholley
- Anaesthesiology and Intensive Care Medicine, Hôpital Européen Georges-Pompidou, AP-HP, Université de Paris, INSERM, IThEM, Paris, France
| | - Alain Curtil
- Department of Cardiac Surgery, Clinique de la Sauvegarde, Lyon, France
| | | | - Rémi Houel
- Department of Cardiac Surgery, Saint Joseph Hospital, Marseille, France
| | - Fehmi Kattou
- Department of Anaesthesia and Intensive Care, Institut Mutualiste Montsouris, Paris, France
| | - Jean-Luc Fellahi
- Service d'Anesthésie-Réanimation, Hôpital Universitaire Louis Pradel, Hospices Civils de Lyon, Lyon, France; Faculté de Médecine Lyon Est, Université Claude-Bernard Lyon 1, Lyon, France
| | - Catherine Guidon
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, Marseille, France
| | - Pierre-Grégoire Guinot
- Department of Anaesthesiology and Intensive Care, Dijon University Hospital, Dijon, France; University of Bourgogne and Franche-Comté, LNC UMR1231, Dijon, France; INSERM, LNC UMR1231, Dijon, France; FCS Bourgogne-Franche Comté, LipSTIC LabEx, Dijon, France
| | - Guillaume Lebreton
- Sorbonne Université, INSERM, Unité mixte de recherche CardioMetabolisme et Nutrition, ICAN, AP-HP, Hôpital Pitié-Salpétrière, Paris, France
| | - Sandrine Marguerite
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Alexandre Ouattara
- CHU Bordeaux, Department of Anaesthesia and Critical Care, Magellan Medico-Surgical Centre, F-33000 Bordeaux, France; Univ. Bordeaux, INSERM, UMR 1034, Biology of Cardiovascular Diseases, F-33600 Pessac, France
| | - Sophie Provenchère Fruithiot
- Department of Anaesthesia, Université de Paris, Bichat-Claude Bernard Hospital, Paris, France; Centre d'Investigation Clinique 1425, INSERM, Université de Paris, Paris, France
| | - Bertrand Rozec
- Service d'Anesthésie-Réanimation, Hôpital Laennec, CHU Nantes, Nantes, France; Université de Nantes, CHU Nantes, CNRS, INSERM, Institut duDu Thorax, Nantes, France
| | - Jean-Philippe Verhoye
- Department of Thoracic and Cardiovascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - André Vincentelli
- Department of Cardiac Surgery, University of Lille, CHU Lille, Lille, France
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Brown S, McLoughlin J, Russ A, Casillas M, Buehler J, Heidel RE, Yates JR. Alvimopan retains efficacy in patients undergoing colorectal surgery within an established ERAS program. Surg Endosc 2022; 36:6129-6137. [PMID: 35043232 DOI: 10.1007/s00464-021-08928-7] [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: 07/20/2021] [Accepted: 11/22/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Post-operative ileus and delayed return of gastrointestinal function are complications seen frequently in patients undergoing colorectal surgery. Many enhanced recovery after surgery protocols include alvimopan to inhibit the effects of opiates in the gastrointestinal tract and lidocaine to augment analgesics. Limited data exist regarding alvimopan's efficacy in opiate-sparing regimens. METHODS This single-center, retrospective cohort analysis was conducted in a randomly selected population of adult patients undergoing colorectal resection between February 2018 and October 2019. Patients meeting inclusion criteria were divided into four groups dependent upon whether or not they received alvimopan (A or a) and/or lidocaine (L or l). The primary endpoint in this study was median time to first bowel movement or discharge, whichever came first. Our secondary endpoint was length of stay. RESULTS Of the 430 patients evaluated, a total of 192 patients were included in the final evaluation in the following groups: AL (n = 93), Al (n = 34), aL (n = 44), and al (n = 21). A significant difference was found among the groups for the primary outcome of median time to bowel movement or discharge (p = 0.001). Three subsequent pair-wise comparisons resulted in a significant difference in the primary outcome: group AL 39.4 h vs. group aL 54.0 h (p = 0.003), group AL 39.4 h vs. group al 55.4 h (p = 0.001), and group Al 44.9 h vs. group al 55.4 h (p = 0.01). Length of stay was significantly reduced by 1.8 days in groups AL and Al compared to group aL (p < 0.001). CONCLUSION Treatment with alvimopan resulted in a significant improvement in time to GI recovery and decreased length of stay in an established ERAS program. While lidocaine's reduction in opiates was minimal, the group receiving both alvimopan and lidocaine had the greatest reduction in time to GI recovery and length of stay.
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Affiliation(s)
- Skyler Brown
- University of Tennessee Medical Center, Knoxville, TN, USA
- Department of Pharmacy, University of Tennessee Medical Center, 1924 Alcoa Hwy, Box 41, Knoxville, TN, 37920, USA
| | - James McLoughlin
- University of Tennessee Medical Center, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Andrew Russ
- University of Tennessee Medical Center, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Mark Casillas
- University of Tennessee Medical Center, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Jason Buehler
- University of Tennessee Medical Center, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Robert E Heidel
- University of Tennessee Medical Center, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - John R Yates
- University of Tennessee Medical Center, Knoxville, TN, USA.
- Department of Pharmacy, University of Tennessee Medical Center, 1924 Alcoa Hwy, Box 41, Knoxville, TN, 37920, USA.
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Yong LS, Lin MW, Chen KC, Huang PM, Lee JM. Drainless Thoracoscopic Lobectomy for Lung Cancer. J Clin Med 2021; 10:jcm10163679. [PMID: 34441975 PMCID: PMC8396950 DOI: 10.3390/jcm10163679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES: Drainless video-assisted thoracoscopic (VATS) wedge resection has been demonstrated as feasible in treating various lung diseases. However, it remains unknown whether this surgical technique can be effectively applied to lobectomy. In the current study, we evaluated the perioperative outcome of drainless, minimally invasive lobectomy in patients with lung cancer. METHODS: A total of 26 lung cancer patients who received surgery-performed pulmonary lobectomy were enrolled. The perioperative outcomes were analyzed based on a propensity score matching a comparison with those who had chest drainage. RESULTS: No major surgical morbidity and mortality was noted during the perioperative period. The mean of postoperative hospital stay was 5.08 ± 2.48 days. There was no significant difference in postoperative hospital stay between the two groups of patients. However, the presence of significant postoperative pain (VAS score > 30) on the first day after surgery was less in the drainless group (34.6% vs. 3.8%; p = 0.005). CONCLUSIONS: Our results demonstrated that drainless, minimally invasive lobectomy for selected lung cancer patients is feasible. Further evaluation of its impact on short- and long-term surgical outcomes is required in the future.
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Verdecchia NM, Rodosky MW, Kentor M, Orebaugh SL. Liposomal bupivacaine infiltration in the surgical site for analgesia after rotator cuff repair: a randomized, double-blinded, placebo-controlled trial. J Shoulder Elbow Surg 2021; 30:986-993. [PMID: 33290853 DOI: 10.1016/j.jse.2020.10.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 10/22/2020] [Accepted: 10/30/2020] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Arthroscopic rotator cuff repair is among the most painful of orthopedic surgeries. Liposomal bupivacaine is Food and Drug Administration approved for administration into surgical sites to provide postsurgical analgesia and has been used to address postoperative pain after many types of surgery, including total shoulder arthroplasty. However, its efficacy for pain control after rotator cuff repair is unclear. METHODS In this randomized, double-blind, placebo-controlled trial, we compared liposomal bupivacaine with an equivalent volume of saline injected into the subacromial space and arthroscopy portal sites in patients undergoing rotator cuff repair under the interscalene block with sedation. The primary outcome measure was numeric rating pain score at the time of block resolution, as reported during the follow-up phone call on postoperative day 1. Secondary outcomes included mean pain scores at rest as well as oral morphine equivalent requirements on postoperative days 1, 2, and 3. This study provides Level 1 evidence. RESULTS There were no statistically significant differences in the primary outcome of numeric rating pain scores on resolution of the interscalene nerve block, nor in those reported on postoperative day 1 or 2. There was a minor but statistically significant difference in mean resting pain scores on day 3, though opioid consumption and patient satisfaction score did not differ between groups. In those instructed to perform passive range-of-motion exercises, there was no difference in reported mean pain scores among the groups. DISCUSSION In this study of patients undergoing arthroscopic rotator cuff repair, we found no statistically significant difference in mean pain scores on interscalene block resolution, a result consistent with a number of studies investigating liposomal bupivacaine for total shoulder arthroplasty. A modest reduction in pain was evident only on day 3, and there was no impact on perioperative opioid requirements, opioid-related side effects, or pain with motion. Liposomal bupivacaine, when injected into the subacromial space and the tissues around the arthroscopy port sites, provided minimal improvement in pain control in this patient population.
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Affiliation(s)
- Nicole M Verdecchia
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Mark W Rodosky
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael Kentor
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Steven L Orebaugh
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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12
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Predicting Unacceptable Pain in Cardiac Surgery Patients Receiving Morphine Maintenance and Rescue Doses: A Model-Based Pharmacokinetic-Pharmacodynamic Analysis. Anesth Analg 2021; 132:726-734. [PMID: 33122543 DOI: 10.1213/ane.0000000000005228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Optimal analgesic treatment following cardiac surgery is crucial for both patient comfort and successful postoperative recovery. While knowledge of both the pharmacokinetics and pharmacodynamics of analgesics is required to predict optimal drug dosing, models quantifying the pharmacodynamics are scarce. Here, we quantify the pharmacodynamics of morphine by modeling the need for rescue morphine to treat unacceptable pain in 118 patients after cardiac surgery. METHODS The rescue morphine event data were analyzed with repeated time-to-event (RTTE) modeling using NONMEM. Postoperative pain titration protocol consisted of continuous morphine infusions (median duration 20.5 hours) with paracetamol 4 times daily and rescue morphine in case of unacceptable pain (numerical rating scale ≥4). RESULTS Patients had a median age of 73 years (interquartile range [IQR]: 63-77) and median bodyweight of 80 kg (IQR: 72-90 kg). Most patients (55%) required at least 1 rescue morphine dose. The hazard for rescue morphine following cardiac surgery was found to be significantly influenced by time after surgery, a day/night cycle with a peak at 23:00 (95% confidence interval [CI], 19:35-02:03) each day, and an effect of morphine concentration with 50% hazard reduction at 9.3 ng·mL-1 (95% CI, 6.7-16). CONCLUSIONS The pharmacodynamics of morphine after cardiac surgery was successfully quantified using RTTE modeling. Future studies can be used to expand the model to better predict morphine's pharmacodynamics on the individual level and to include the pharmacodynamics of other analgesics so that improved postoperative pain treatment protocols can be developed.
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13
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Jenkins NW, Parrish JM, Singh K. Commentary: Patient-Controlled Analgesia Following Lumbar Spinal Fusion Surgery Is Associated With Increased Opioid Consumption and Opioid-Related Adverse Events. Neurosurgery 2020; 87:E311-E312. [PMID: 32357227 DOI: 10.1093/neuros/nyaa120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 02/20/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Nathaniel W Jenkins
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - James M Parrish
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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14
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Van Tittelboom V, Poelaert R, Malbrain MLNG, La Meir M, Staessens K, Poelaert J. Sublingual Sufentanil Tablet System Versus Continuous Morphine Infusion for Postoperative Analgesia in Cardiac Surgery Patients. J Cardiothorac Vasc Anesth 2020; 35:1125-1133. [PMID: 32951999 DOI: 10.1053/j.jvca.2020.08.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/11/2020] [Accepted: 08/12/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE(S) To assess the effectiveness and side effects of a patient-controlled sublingual sufentanil tablet system for postoperative analgesia after cardiac surgery and to compare it to a nurse-controlled continuous morphine infusion. DESIGN Prospective, open-label, randomized controlled trial. SETTING Single university academic center. PARTICIPANTS Adult patients undergoing cardiac surgery, which included a sternotomy. INTERVENTIONS Sublingual sufentanil tablet system versus nurse-controlled continuous morphine infusion. MEASUREMENTS AND MAIN RESULTS A total of 483 cardiac surgery patients were screened for eligibility, of whom 64 patients completed the study. No statistically significant differences were found for baseline characteristics between both groups. All mean numeric rating scale (NRS) pain scores from after extubation until intensive care unit discharge were ≤3 in both groups. The cumulative mean NRS pain score from 24 hours after extubation (primary outcome) (t = hours after extubation) was significantly different in favor of the morphine group: (t = 0-24) (0.8 [0.7] v 1.3 [0.8]; p = 0.006). Later cumulative mean pain scores were also in favor of the morphine group: (t = 24-48) (0.2 [0.3] v 0.6 [0.5]; p = 0.001) and (t = 48-63) (0.0 [0.0] v 0.1 [0.2]; p = 0.013). The cumulative opioid dose (in milligrams intravenous morphine equivalents) was significantly higher in the morphine group compared with the sublingual sufentanil group (241.94 [218.73] v 39.84 [21.96]; p = 0.0001). No differences were found for the incidences of postoperative nausea and vomiting, sedation, hypoventilation, bradycardia, or hypotension between both groups (secondary outcomes). CONCLUSIONS Despite resulting in statistically significantly higher pain scores, a patient-controlled sublingual sufentanil tablet system offers adequate analgesia after cardiac surgery and reduces opioid consumption when compared with continuous morphine infusion.
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Affiliation(s)
| | - Ruben Poelaert
- Department of Anesthesiology and Perioperative Medicine, UZ Brussels, Jette, Belgium
| | - Manu L N G Malbrain
- Department of Intensive Care, UZ Brussels, Faculty of Medicine and Pharmacy, Jette, Belgium
| | - Mark La Meir
- Department of Cardiac Surgery, UZ Brussels, Faculty of Medicine and Pharmacy, Jette, Belgium
| | | | - Jan Poelaert
- Department of Anesthesiology and Perioperative Medicine, UZ Brussels, Faculty of Medicine and Pharmacy, Jette, Belgium
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Javaherforooshzadeh F, Abdalbeygi H, Janatmakan F, Gholizadeh B. Comparing the effects of ketorolac and Paracetamol on postoperative pain relief after coronary artery bypass graft surgery. A randomized clinical trial. J Cardiothorac Surg 2020; 15:80. [PMID: 32393370 PMCID: PMC7216617 DOI: 10.1186/s13019-020-01125-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 04/28/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction Pain management after coronary artery bypass graft (CABG) surgery remains challenging. Objective This study aimed to compare the effects of Ketorolac and Paracetamol on postoperative CABG pain relief. Method This double-blind randomized clinical trial study was conducted in Ahvaz, Iran, from September 2018–December 2019. Two consecutive groups of 60 patients undergoing elective on-pump coronary artery bypass graft surgery. Intervention The patients were divided into 0.5 mg/kg of ketorolac mg/dl and 10 mg/kg of Paracetamol after surgery for pain management. Primary outcomes were: visual analog pain scale (VAS) at the time point immediately after extubation (baseline) and at 6, 12, 24 and 48 h and the total dose of morphine consumption. Secondary outcomes included the hemodynamic variables, weaning time, chest tube derange, in-hospital mortality and myocardial infarction. Statistical analysis: The data were analyzed using SPSS version 22(SPSS, Chicago, IL). The Mann-Whitney U-test was used to compare demographic data, VAS scores, vital signs, and side effects. Repeated measurements were tested within groups using Friedman’s ANOVA and the Wilcoxon rank-sum test. Values were expressed as means ± standard deviations. Statistical significance was defined as a p-value < 0.05. Results Compared with baseline scores, there were significant declines in VAS scores in both groups throughout the time sequence (P< 0.05). The statistical VAS score was slightly higher in the Paracetamol group at most time points, except for the time of 6 h. However, at 24 and 48 h, the VAS score in group Paracetamol was significantly higher than in group Ketorolac. There were no significant differences between groups about hemodynamic variables. Conclusion The efficacy of ketorolac is comparable to that of Paracetamol in postoperative CABG pain relief. Trial registry IRCT20150216021098N5. Registered at 2019-09-12.
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Affiliation(s)
- Fatemeh Javaherforooshzadeh
- Department of Cardiac Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Hasan Abdalbeygi
- Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Farahzad Janatmakan
- Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Behnam Gholizadeh
- Atherosclerosis Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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16
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Osojnik I, Kamenik M. The Effect of Diclofenac on Bleeding, Platelet Function, and Consumption of Opioids Following Cardiac Surgery. Braz J Cardiovasc Surg 2020; 35:160-168. [PMID: 32369295 PMCID: PMC7199992 DOI: 10.21470/1678-9741-2019-0283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To establish whether the use of diclofenac reduces the administration of opioids and how it affects bleeding and platelet function after the coronary artery bypass grafting (CABG) surgery with use of cardiopulmonary bypass (CPB). METHODS A total of 72 patients undergoing CABG surgery were included in this retrospective randomized study and divided into two groups (34 patients received diclofenac and the control group of 38 patients did not). For postoperative analgesia, both groups were prescribed opioids (piritramide). The primary endpoint was to establish the consumption of opioids. The secondary endpoint was to determine bleeding and the function of platelets 20 hours after the surgery. RESULTS The consumption of piritramide (diclofenac group 26±8 mg vs. control group 28±8 mg), the blood loss, and the function of platelets did not significantly differ between the groups within 20 hours after surgery. C-reactive protein (CRP) was statistically significantly lower in the diclofenac group than in the control group (33±15 mg/L vs. 46±22 mg/L, respectively, P<0.05). CONCLUSION The study concluded that patients administered with diclofenac after the heart surgery did not consume less opioid analgesics and did not exhibit less symptoms linked to the consumption of opioids. Diclofenac in clinically administered doses does not interfere with the function of platelets and does not cause increased bleeding. Lower CRP in the diclofenac group may indicate a reduced inflammatory response after CPB. Therefore, diclofenac could be safe for use in patients undergoing CABG surgery but its value in reducing opioid consumption should be questioned.
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Affiliation(s)
- Irena Osojnik
- University Medical Centre Maribor Intensive Care and Pain Management Department of Anaesthesiology Maribor Slovenia Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Maribor, Slovenia
| | - Mirt Kamenik
- University Medical Centre Maribor Intensive Care and Pain Management Department of Anaesthesiology Maribor Slovenia Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Maribor, Slovenia.,University of Maribor Faculty of Medicine Department of Anesthesia and Reanimation Maribor Slovenia Department of Anesthesia and Reanimation, Faculty of Medicine, University of Maribor, Maribor, Slovenia
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17
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Nachiyunde B, Lam L. The efficacy of different modes of analgesia in postoperative pain management and early mobilization in postoperative cardiac surgical patients: A systematic review. Ann Card Anaesth 2019; 21:363-370. [PMID: 30333328 PMCID: PMC6206788 DOI: 10.4103/aca.aca_186_17] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Cardiac surgery induces severe postoperative pain and impairment of pulmonary function, increases the length of stay (LOS) in hospital, and increases mortality and morbidity; therefore, evaluation of the evidence is needed to assess the comparative benefits of different techniques of pain management, to guide clinical practice, and to identify areas of further research. A systematic search of the Cochrane Central Register of Controlled Trials, DARE database, Joanna Briggs Institute, Google scholar, PUBMED, MEDLINE, EMBASE, Academic OneFile, SCOPUS, and Academic search premier was conducted retrieving 1875 articles. This was for pain management postcardiac surgery in intensive care. Four hundred and seventy-one article titles and 266 abstracts screened, 52 full text articles retrieved for critical appraisal, and ten studies were included including 511 patients. Postoperative pain (patient reported), complications, and LOS in intensive care and the hospital were evaluated. Anesthetic infiltrations and intercostal or parasternal blocks are recommended the immediate postoperative period (4-6 h), and patient-controlled analgesia (PCA) and local subcutaneous anesthetic infusions are recommended immediate postoperative and 24-72 h postcardiac surgery. However, the use of mixed techniques, that is, PCA with opioids and local anesthetic subcutaneous infusions might be the way to go in pain management postcardiac surgery to avoid oversedation and severe nausea and vomiting from the narcotics. Adequate studies in the use of ketamine for pain management postcardiac surgery need to be done and it should be used cautiously.
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Affiliation(s)
- Brenda Nachiyunde
- Department of Health Sciences, School of Nursing and Midwifery, University of South Australia, City East Campus, Adelaide SA 5001, Australia
| | - Louisa Lam
- School of Nursing and Healthcare Professions, Federation University Australia, Berwick, Victoria, 3806, Australia
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18
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Myles PS, Myles DB, Galagher W, Boyd D, Chew C, MacDonald N, Dennis A. Measuring acute postoperative pain using the visual analog scale: the minimal clinically important difference and patient acceptable symptom state. Br J Anaesth 2018; 118:424-429. [PMID: 28186223 DOI: 10.1093/bja/aew466] [Citation(s) in RCA: 512] [Impact Index Per Article: 85.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2016] [Indexed: 12/16/2022] Open
Abstract
Background The 100 mm visual analog scale (VAS) score is widely used to measure pain intensity after surgery. Despite this widespread use, it is unclear what constitutes the minimal clinically important difference (MCID); that is, what minimal change in score would indicate a meaningful change in a patient's pain status. Methods We enrolled a sequential, unselected cohort of patients recovering from surgery and used a VAS to quantify pain intensity. We compared changes in the VAS with a global rating-of-change questionnaire using an anchor-based method and three distribution-based methods (0.3 sd , standard error of the measurement, and 5% range). We then averaged the change estimates to determine the MCID for the pain VAS. The patient acceptable symptom state (PASS) was defined as the 25th centile of the VAS corresponding to a positive patient response to having made a good recovery from surgery. Results We enrolled 224 patients at the first postoperative visit, and 219 of these were available for a second interview. The VAS scores improved significantly between the first two interviews. Triangulation of distribution and anchor-based methods resulted in an MCID of 9.9 for the pain VAS, and a PASS of 33. Conclusions Analgesic interventions that provide a change of 10 for the 100 mm pain VAS signify a clinically important improvement or deterioration, and a VAS of 33 or less signifies acceptable pain control (i.e. a responder), after surgery.
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Affiliation(s)
- P S Myles
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - D B Myles
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - W Galagher
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - D Boyd
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - C Chew
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - N MacDonald
- Department of Anaesthesia, Royal Women's Hospital, Parkville, Victoria, Australia
| | - A Dennis
- Department of Anaesthesia, Royal Women's Hospital, Parkville, Victoria, Australia
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Zubrzycki M, Liebold A, Skrabal C, Reinelt H, Ziegler M, Perdas E, Zubrzycka M. Assessment and pathophysiology of pain in cardiac surgery. J Pain Res 2018; 11:1599-1611. [PMID: 30197534 PMCID: PMC6112778 DOI: 10.2147/jpr.s162067] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Analysis of the problem of surgical pain is important in view of the fact that the success of surgical treatment depends largely on proper pain management during the first few days after a cardiosurgical procedure. Postoperative pain is due to intraoperative damage to tissue. It is acute pain of high intensity proportional to the type of procedure. The pain is most intense during the first 24 hours following the surgery and decreases on subsequent days. Its intensity is higher in younger subjects than elderly and obese patients, and preoperative anxiety is also a factor that increases postoperative pain. Ineffective postoperative analgesic therapy may cause several complications that are dangerous to a patient. Inappropriate postoperative pain management may result in chronic pain, immunosuppression, infections, and less effective wound healing. Understanding and better knowledge of physiological disorders and adverse effects resulting from surgical trauma, anesthesia, and extracorporeal circulation, as well as the development of standards for intensive postoperative care units are critical to the improvement of early treatment outcomes and patient comfort.
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Affiliation(s)
- Marek Zubrzycki
- Department of Cardiac Surgery, University of Ulm Medical Center, Ulm, Germany,
| | - Andreas Liebold
- Department of Cardiac Surgery, University of Ulm Medical Center, Ulm, Germany,
| | - Christian Skrabal
- Department of Cardiac Surgery, University of Ulm Medical Center, Ulm, Germany,
| | - Helmut Reinelt
- Department of Cardiac Anesthesiology, University of Ulm Medical Center, Ulm, Germany
| | - Mechthild Ziegler
- Department of Cardiac Anesthesiology, University of Ulm Medical Center, Ulm, Germany
| | - Ewelina Perdas
- Department of Cardiovascular Physiology, Medical University of Lodz, Lodz, Poland
| | - Maria Zubrzycka
- Department of Cardiovascular Physiology, Medical University of Lodz, Lodz, Poland
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Sousa-Uva M, Head SJ, Milojevic M, Collet JP, Landoni G, Castella M, Dunning J, Gudbjartsson T, Linker NJ, Sandoval E, Thielmann M, Jeppsson A, Landmesser U. 2017 EACTS Guidelines on perioperative medication in adult cardiac surgery. Eur J Cardiothorac Surg 2017; 53:5-33. [PMID: 29029110 DOI: 10.1093/ejcts/ezx314] [Citation(s) in RCA: 250] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Use of Fentanyl Iontophoretic Transdermal System (ITS) (IONSYS ®) in the Management of Patients with Acute Postoperative Pain: A Case Series. Pain Ther 2016; 5:237-248. [PMID: 27817153 PMCID: PMC5130911 DOI: 10.1007/s40122-016-0061-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Indexed: 01/22/2023] Open
Abstract
Fentanyl iontophoretic transdermal system (ITS) [IONSYS®, The Medicines Company, Parsippany, NJ, USA] is a needle-free, patient-controlled, postoperative opioid pain management treatment. It is indicated for the short-term management of acute postoperative pain in adults requiring opioid analgesia in the hospital. The safety and effectiveness of fentanyl ITS for acute postoperative pain management has been demonstrated in a range of surgery and patient types studied in seven phase 3 trials (three placebo-controlled trials and four active-comparator trials). The majority of the patients in the phase 3 trials had undergone either abdominal/pelvic, orthopedic, or thoracic surgery. Consistent with the prescribing information, physicians in clinical practice may treat patients with this system following any type of surgery including those that may not have been included in the phase 3 trials. The purpose of this case series is to illustrate how fentanyl ITS is being utilized for postoperative pain management in real-world clinical practice following a variety of surgeries and in current pain management protocols that may have evolved since the completion of the phase 3 program. There are seven cases from three clinical centers described within this case series, each using fentanyl ITS according to the prescribing information. The surgery types included are bariatric (N = 3), prostate (N = 2), colorectal (N = 1), and perirectal abscess drainage (N = 1). A systematic review of each patient chart was conducted via a standardized retrospective assessment by the clinicians who managed each patient. Additionally, each healthcare professional was interviewed regarding their overall experience and key learnings using fentanyl ITS. Overall, fentanyl ITS was effective and well tolerated in these case reports in current-day clinical practice settings. These case studies are informative about fentanyl ITS use shortly after product approval and set the stage for additional clinical research.
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Pestano CR, Lindley P, Ding L, Danesi H, Jones JB. Meta-Analysis of the Ease of Care From the Nurses' Perspective Comparing Fentanyl Iontophoretic Transdermal System (ITS) Vs Morphine Intravenous Patient-Controlled Analgesia (IV PCA) in Postoperative Pain Management. J Perianesth Nurs 2016; 32:329-340. [PMID: 28739065 DOI: 10.1016/j.jopan.2015.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 11/17/2015] [Accepted: 11/23/2015] [Indexed: 10/20/2022]
Abstract
PURPOSE The aim of this meta-analysis was to compare the ease of care (EOC) of fentanyl iontophoretic transdermal system (ITS) vs the morphine intravenous patient-controlled analgesia (IV PCA) as assessed by the nurse. DESIGN Meta-analysis of three phase 3B randomized active-comparator trials. METHODS This meta-analysis according to Cochrane's approach assessed EOC using a validated nurse questionnaire (22 items grouped into three subscales, which include time efficiency, convenience, and satisfaction) in adult patients treated with fentanyl ITS or morphine IV PCA for postoperative pain management. The weighted mean difference (WMD) between treatments was calculated. FINDING EOC analyses were based on responses to questionnaires from 848 (fentanyl ITS) and 761 (morphine IV PCA) nurses. Fentanyl ITS was reported to provide significant advantages compared with morphine IV PCA in terms of nurses' overall EOC (WMD = -0.57, P < .0001) and each of the subscales: time efficiency (WMD = -0.58, P < .0001), convenience (WMD = -0.57, P < .0001), and satisfaction (WMD = -0.47, P < .0001). CONCLUSIONS In this meta-analysis, fentanyl ITS is associated with a superior EOC profile from the nurses' perspective than morphine IV PCA.
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Hartrick CT, Abraham J, Ding L. Ease-of-care from the physical therapists’ perspective comparing fentanyl iontophoretic transdermal system versus morphine intravenous patient-controlled analgesia in postoperative pain management. J Comp Eff Res 2016; 5:529-537. [DOI: 10.2217/cer-2016-0038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Aim: To compare the ease-of-care (EOC) examining time efficiency, convenience and satisfaction of fentanyl iontophoretic transdermal system ([ITS] IONSYS®) and morphine intravenous patient-controlled analgesia (iv. PCA) in postoperative pain management using a validated physical therapist (PT) EOC questionnaire. Materials & methods: This meta-analysis assessed EOC of fentanyl ITS versus morphine iv. PCA using data from two randomized, active-comparator studies (fentanyl ITS: n = 720 and morphine iv. PCA: n = 739) which used the PT EOC questionnaire (22 items grouped into three subscales; time efficiency, convenience and satisfaction). Each item was scored on a 6-point Likert scale. For time efficiency, PT whose average scores were ≤2 on all items of the time efficiency and convenience subscales or ≥4 on both satisfaction items were considered responders. Results: There were EOC questionnaires from 264 (fentanyl ITS) and 254 (morphine iv. PCA) PTs. There were significantly greater proportions of PTs classified as responders for fentanyl ITS than morphine iv. PCA for overall EOC (81.0 vs 55.7%, respectively), time efficiency (83.1 vs 59.5%, respectively), convenience (87.4 vs 72.0%, respectively) and satisfaction (51.9 vs 30.0%, respectively), all p < 0.0001. Conclusion: In this meta-analysis, fentanyl ITS is associated with a superior EOC profile (overall, time efficiency, convenience and satisfaction) from the PTs’ perspective when compared with morphine iv. PCA.
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Affiliation(s)
| | | | - Li Ding
- The Medicines Company, Parsippany, NJ, USA
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Sampietro-Colom L, Martin J, Moodie J, Zhu F, Cheng D. Hospital-Based HTA and Know4Go at MEDICI in London, Ontario, Canada. HOSPITAL-BASED HEALTH TECHNOLOGY ASSESSMENT 2016. [PMCID: PMC7123960 DOI: 10.1007/978-3-319-39205-9_12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
The majority of healthcare in Canada is universally provided and publicly funded through the provincial government.
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Affiliation(s)
- Laura Sampietro-Colom
- 0000 0000 9635 9413grid.410458.cAssessment of Innovations and New Technologies, Hospital Clinic Barcelona, Barcelona, Catalonia, Spain
| | - Janet Martin
- 0000 0004 1936 8884grid.39381.30Centre for Medical Evidence, Decision Integrity & Clinical Impact (MEDICI), Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario Canada
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Bainbridge D, Cheng DC. Early extubation and fast-track management of off-pump cardiac patients in the intensive care unit. Semin Cardiothorac Vasc Anesth 2016; 19:163-8. [PMID: 25975598 DOI: 10.1177/1089253215584919] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Off-pump surgery was the original approach to treating patients with cardiac disease in the era before cardiopulmonary bypass. With the advent and refinement of cardiopulmonary bypass, the use of this technique fell out of favor and was quickly surpassed by on-pump techniques. However, the limitations of bypass surgery, especially for coronary artery bypass procedures, was still significant, leading to renewed interest in this technique. Postoperative care for off-pump coronary artery bypass (OPCAB) surgery presents both a challenge and opportunity to the intensivist. OPCAB patients can be treated in a fast-track manner allowing rapid recovery and early extubation and discharge from the intensive care unit. This is supported through the use of protocols that help standardize care and set expectations for the post-cardiac care team. Importantly, complications that may delay recovery including hypothermia, hypotension, and bleeding must be recognized early and treated aggressively to prevent unwanted complications and intensive care delays. Finally, care of these patients has shifted to the post-anesthesia recovery room, making knowledge of the care of these patients in the early postoperative period essential for cardiac anesthesiologists. This article will discuss the care of OPCAB patients following surgery and include approaches to managing patients who return both intubated and extubated.
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Affiliation(s)
- Daniel Bainbridge
- Department of Anesthesia & Perioperative Medicine, Western University, London, Ontario, Canada
| | - Davy C Cheng
- Department of Anesthesia & Perioperative Medicine, Western University, London, Ontario, Canada
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Baron R, Binder A, Biniek R, Braune S, Buerkle H, Dall P, Demirakca S, Eckardt R, Eggers V, Eichler I, Fietze I, Freys S, Fründ A, Garten L, Gohrbandt B, Harth I, Hartl W, Heppner HJ, Horter J, Huth R, Janssens U, Jungk C, Kaeuper KM, Kessler P, Kleinschmidt S, Kochanek M, Kumpf M, Meiser A, Mueller A, Orth M, Putensen C, Roth B, Schaefer M, Schaefers R, Schellongowski P, Schindler M, Schmitt R, Scholz J, Schroeder S, Schwarzmann G, Spies C, Stingele R, Tonner P, Trieschmann U, Tryba M, Wappler F, Waydhas C, Weiss B, Weisshaar G. Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) - short version. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2015; 13:Doc19. [PMID: 26609286 PMCID: PMC4645746 DOI: 10.3205/000223] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Indexed: 02/08/2023]
Abstract
In 2010, under the guidance of the DGAI (German Society of Anaesthesiology and Intensive Care Medicine) and DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine), twelve German medical societies published the “Evidence- and Consensus-based Guidelines on the Management of Analgesia, Sedation and Delirium in Intensive Care”. Since then, several new studies and publications have considerably increased the body of evidence, including the new recommendations from the American College of Critical Care Medicine (ACCM) in conjunction with Society of Critical Care Medicine (SCCM) and American Society of Health-System Pharmacists (ASHP) from 2013. For this update, a major restructuring and extension of the guidelines were needed in order to cover new aspects of treatment, such as sleep and anxiety management. The literature was systematically searched and evaluated using the criteria of the Oxford Center of Evidence Based Medicine. The body of evidence used to formulate these recommendations was reviewed and approved by representatives of 17 national societies. Three grades of recommendation were used as follows: Grade “A” (strong recommendation), Grade “B” (recommendation) and Grade “0” (open recommendation). The result is a comprehensive, interdisciplinary, evidence and consensus-based set of level 3 guidelines. This publication was designed for all ICU professionals, and takes into account all critically ill patient populations. It represents a guide to symptom-oriented prevention, diagnosis, and treatment of delirium, anxiety, stress, and protocol-based analgesia, sedation, and sleep-management in intensive care medicine.
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Affiliation(s)
| | | | | | | | - Stephan Braune
- German Society of Internal Medicine Intensive Care (DGIIN)
| | - Hartmut Buerkle
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Peter Dall
- German Society of Gynecology & Obstetrics (DGGG)
| | - Sueha Demirakca
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | | | - Verena Eggers
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Ingolf Eichler
- German Society for Thoracic and Cardiovascular Surgery (DGTHG)
| | | | | | | | - Lars Garten
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | | | - Irene Harth
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | | | | | - Johannes Horter
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Ralf Huth
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | - Uwe Janssens
- German Society of Internal Medicine Intensive Care (DGIIN)
| | | | | | - Paul Kessler
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | | | | | - Matthias Kumpf
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | - Andreas Meiser
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Anika Mueller
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | | | | | - Bernd Roth
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | | | | | | | - Monika Schindler
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | - Reinhard Schmitt
- German Society for Specialised Nursing and Allied Health Professions (DGF)
| | - Jens Scholz
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Stefan Schroeder
- German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN)
| | | | - Claudia Spies
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | | | - Peter Tonner
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Uwe Trieschmann
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Michael Tryba
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Frank Wappler
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Christian Waydhas
- German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI)
| | - Bjoern Weiss
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Guido Weisshaar
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
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Cooke M, Rapchuk I, Doi SA, Spooner A, Wendt T, Best J, Edwards M, O'Connell L, McCabe D, McDonald J, Fraser J, Rickard C. Wrist acupressure for post-operative nausea and vomiting (WrAP): A pilot study. Complement Ther Med 2015; 23:372-80. [PMID: 26051572 DOI: 10.1016/j.ctim.2015.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 03/16/2015] [Accepted: 03/21/2015] [Indexed: 10/23/2022] Open
Abstract
Post-operative nausea and vomiting are undesirable complications following anaesthesia and surgery. It is thought that acupressure might prevent nausea and vomiting through an alteration in endorphins and serotonin levels. In this two-group, parallel, superiority, randomised control pilot trial we aimed to test pre-defined feasibility outcomes and provide preliminary evidence for the efficacy of PC 6 acupoint stimulation vs. placebo for reducing post-operative nausea and vomiting in cardiac surgery patients. Eighty patients were randomly assigned to either an intervention PC 6 acupoint stimulation via beaded intervention wristbands group (n=38) or placebo sham wristband group (n=42). The main outcome was assessment of pre-defined feasibility criteria with secondary outcomes for nausea, vomiting, rescue anti-emetic therapy, quality of recovery and adverse events. Findings suggest that a large placebo-controlled randomised controlled trial to test the efficacy of PC 6 stimulation on PONV in the post-cardiac surgery population is feasible and justified given the preliminary clinically significant reduction in vomiting in the intervention group in this pilot. The intervention was tolerated well by participants and if wrist acupressure of PC 6 acupoint is proven effective in a large trial it is a simple non-invasive intervention that could easily be incorporated into practice.
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Affiliation(s)
- Marie Cooke
- NHMRC Centre for Research Excellence in Nursing Interventions, Menzies Health Institute Queensland, Centre for Health Practice Innovation, Australia.
| | - Ivan Rapchuk
- Department of Anaesthesia and Perfusion, Critical Care Research Group, The Prince Charles Hospital, Australia
| | - Suhail A Doi
- Research School of Population Health, Australian National University, Australia
| | - Amy Spooner
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Australia
| | - Tameka Wendt
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Australia
| | - Jessica Best
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Australia
| | - Melannie Edwards
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Australia
| | - Leanda O'Connell
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Australia
| | - Donna McCabe
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Australia
| | - John McDonald
- Microbiology and Immunology Research Group, Griffith University, Australia
| | - John Fraser
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Australia
| | - Claire Rickard
- NHMRC Centre for Research Excellence in Nursing Interventions, Menzies Health Institute Queensland, Centre for Health Practice Innovation, Australia
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Cooke M, Rickard C, Rapchuk I, Shekar K, Marshall AP, Comans T, Doi S, McDonald J, Spooner A. PC6 acupoint stimulation for the prevention of postcardiac surgery nausea and vomiting: a protocol for a two-group, parallel, superiority randomised clinical trial. BMJ Open 2014; 4:e006179. [PMID: 25394818 PMCID: PMC4244418 DOI: 10.1136/bmjopen-2014-006179] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Postoperative nausea and vomiting (PONV) are frequent but unwanted complications for patients following anaesthesia and cardiac surgery, affecting at least a third of patients, despite pharmacological treatment. The primary aim of the proposed research is to test the efficacy of PC6 acupoint stimulation versus placebo for reducing PONV in cardiac surgery patients. In conjunction with this we aim to develop an understanding of intervention fidelity and factors that support, or impede, the use of PC6 acupoint stimulation, a knowledge translation approach. METHODS AND ANALYSIS 712 postcardiac surgery participants will be recruited to take part in a two-group, parallel, superiority, randomised controlled trial. Participants will be randomised to receive a wrist band on each wrist providing acupressure to PC six using acupoint stimulation or a placebo. Randomisation will be computer generated, use randomly varied block sizes, and be concealed prior to the enrolment of each patient. The wristbands will remain in place for 36 h. PONV will be evaluated by the assessment of both nausea and vomiting, use of rescue antiemetics, quality of recovery and cost. Patient satisfaction with PONV care will be measured and clinical staff interviewed about the clinical use, feasibility, acceptability and challenges of using acupressure wristbands for PONV. ETHICS AND DISSEMINATION Ethics approval will be sought from appropriate Human Research Ethics Committee/s before start of the study. A systematic review of the use of wrist acupressure for PC6 acupoint stimulation reported minor side effects only. Study progress will be reviewed by a Data Safety Monitoring Committee (DSMC) for nausea and vomiting outcomes at n=350. Dissemination of results will include conference presentations at national and international scientific meetings and publications in peer-reviewed journals. Study participants will receive a one-page lay-summary of results. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry--ACTRN12614000589684.
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Affiliation(s)
- Marie Cooke
- NHMRC Centre for Research Excellence in Nursing Interventions, Griffith Health Institute, Centre for Health Practice Innovation, Nathan, Queensland, Australia
| | - Claire Rickard
- NHMRC Centre for Research Excellence in Nursing Interventions, Griffith Health Institute, Centre for Health Practice Innovation, Nathan, Queensland, Australia
| | - Ivan Rapchuk
- Department of Anaesthesia and Perfusion, Critical Care Research Group, The Prince Charles Hospital,Chermside, Queensland, Australia
| | - Kiran Shekar
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Chermside, Queensland, Australia
| | - Andrea P Marshall
- Griffith Health Institute, Centre for Health Practice Innovation and Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Tracy Comans
- Griffith Health Institute, Population and Social Health Research Program, Brisbane, Queensland, Australia
| | - Suhail Doi
- Department of Clinical Epidemiology Unit, School of Population Health, University of Queensland, Herston, Queensland, Australia
| | - John McDonald
- Microbiology and Immunology Research Group, Griffith University, Gold Coast, Queensland, Australia
| | - Amy Spooner
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Queensland, Australia
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Ryan R, Santesso N, Lowe D, Hill S, Grimshaw J, Prictor M, Kaufman C, Cowie G, Taylor M. Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. Cochrane Database Syst Rev 2014; 2022:CD007768. [PMID: 24777444 PMCID: PMC6491214 DOI: 10.1002/14651858.cd007768.pub3] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Many systematic reviews exist on interventions to improve safe and effective medicines use by consumers, but research is distributed across diseases, populations and settings. The scope and focus of such reviews also vary widely, creating challenges for decision-makers seeking to inform decisions by using the evidence on consumers' medicines use.This is an update of a 2011 overview of systematic reviews, which synthesises the evidence, irrespective of disease, medicine type, population or setting, on the effectiveness of interventions to improve consumers' medicines use. OBJECTIVES To assess the effects of interventions which target healthcare consumers to promote safe and effective medicines use, by synthesising review-level evidence. METHODS SEARCH METHODS We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching databases from their start dates to March 2012. SELECTION CRITERIA We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview. DATA COLLECTION AND ANALYSIS We used standardised forms to extract data, and assessed reviews for methodological quality using the AMSTAR tool. We used standardised language to summarise results within and across reviews; and gave bottom-line statements about intervention effectiveness. Two review authors screened and selected reviews, and extracted and analysed data. We used a taxonomy of interventions to categorise reviews and guide syntheses. MAIN RESULTS We included 75 systematic reviews of varied methodological quality. Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation and skills acquisition. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most frequently-reported outcome, but others such as knowledge, clinical and service-use outcomes were also reported. Adverse events were less commonly identified, while those associated with the interventions themselves, or costs, were rarely reported.Looking across reviews, for most outcomes, medicines self-monitoring and self-management programmes appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes; and to reduce mortality in people self-managing antithrombotic therapy. However, some participants were unable to complete these interventions, suggesting they may not be suitable for everyone.Other promising interventions to improve adherence and other key medicines-use outcomes, which require further investigation to be more certain of their effects, include:· simplified dosing regimens: with positive effects on adherence;· interventions involving pharmacists in medicines management, such as medicines reviews (with positive effects on adherence and use, medicines problems and clinical outcomes) and pharmaceutical care services (consultation between pharmacist and patient to resolve medicines problems, develop a care plan and provide follow-up; with positive effects on adherence and knowledge).Several other strategies showed some positive effects, particularly relating to adherence, and other outcomes, but their effects were less consistent overall and so need further study. These included:· delayed antibiotic prescriptions: effective to decrease antibiotic use but with mixed effects on clinical outcomes, adverse effects and satisfaction;· practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives: with positive, although somewhat mixed effects on adherence;· education delivered with self-management skills training, counselling, support, training or enhanced follow-up; information and counselling delivered together; or education/information as part of pharmacist-delivered packages of care: with positive effects on adherence, medicines use, clinical outcomes and knowledge, but with mixed effects in some studies;· financial incentives: with positive, but mixed, effects on adherence.Several strategies also showed promise in promoting immunisation uptake, but require further study to be more certain of their effects. These included organisational interventions; reminders and recall; financial incentives; home visits; free vaccination; lay health worker interventions; and facilitators working with physicians to promote immunisation uptake. Education and/or information strategies also showed some positive but even less consistent effects on immunisation uptake, and need further assessment of effectiveness and investigation of heterogeneity.There are many different potential pathways through which consumers' use of medicines could be targeted to improve outcomes, and simple interventions may be as effective as complex strategies. However, no single intervention assessed was effective to improve all medicines-use outcomes across all diseases, medicines, populations or settings.Even where interventions showed promise, the assembled evidence often only provided part of the picture: for example, simplified dosing regimens seem effective for improving adherence, but there is not yet sufficient information to identify an optimal regimen.In some instances interventions appear ineffective: for example, the evidence suggests that directly observed therapy may be generally ineffective for improving treatment completion, adherence or clinical outcomes.In other cases, interventions may have variable effects across outcomes. As an example, strategies providing information or education as single interventions appear ineffective to improve medicines adherence or clinical outcomes, but may be effective to improve knowledge; an important outcome for promoting consumers' informed medicines choices.Despite a doubling in the number of reviews included in this updated overview, uncertainty still exists about the effectiveness of many interventions, and the evidence on what works remains sparse for several populations, including children and young people, carers, and people with multimorbidity. AUTHORS' CONCLUSIONS This overview presents evidence from 75 reviews that have synthesised trials and other studies evaluating the effects of interventions to improve consumers' medicines use.Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform decisions about which interventions may be most promising to improve particular outcomes. The intervention taxonomy may also assist people to consider the strategies available in relation to specific purposes, for example, gaining skills or being involved in decision making. Researchers and funders can use this overview to identify where more research is needed and assess its priority. The limitations of the available literature due to the lack of evidence for important outcomes and important populations, such as people with multimorbidity, should also be considered in practice and policy decisions.
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Affiliation(s)
- Rebecca Ryan
- Centre for Health Communication and Participation, School of Public Health and Human Biosciences, La Trobe University, Bundoora, VIC, Australia, 3086
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Sedighinejad A, Haghighi M, Naderi Nabi B, Rahimzadeh P, Mirbolook A, Mardani-Kivi M, Nekufard M, Biazar G. Magnesium sulfate and sufentanil for patient-controlled analgesia in orthopedic surgery. Anesth Pain Med 2014; 4:e11334. [PMID: 24660152 PMCID: PMC3961029 DOI: 10.5812/aapm.11334] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 06/22/2013] [Accepted: 09/22/2013] [Indexed: 01/09/2023] Open
Abstract
Background: Postoperative analgesia is one of the concerns of anesthesiologists and patients. Systemic opioid administration is the gold standard in reducing the severe pain after the surgery but some side effects prevent the use of adequate dosage of opioids. Objectives: The aim of this study was to evaluate the result of adding magnesium sulphate to sufentanil in patient-controlled intravenous analgesia (PCIA) system. Patients and Methods: In this randomized clinical trial, 60 patients candidate for lower limb orthopedic surgery were recruited in Poursina Medical Center for six months. They were randomly classified in two group of patient-controlled intravenous analgesia for postoperative pain control, one was group S [(sufentanil) (n = 30)] and the other was group S + M [(magnesium sulphate/sufentanil) (n = 30)]. The drug infusion rate was 5 mL/h. Each mL of solution in group S contained 1 mcg of sufentanil and in group M + S, 1 mcg of sufentanil and 200 mcg magnesium sulphate, respectively. Pain score, sedation score, satisfaction score, nausea and vomiting score were evaluated 6, 12, 24, 36 and 48 hours after surgery. Results: The demographic data between two groups were not significantly different. The pain scores after 6, 12 and 24 hours in S and S + M groups were significantly different. But the comparison of Visual Analogue Scale (VAS) scores after 36 and 48 hours didn’t show significant differences (P < 0.001). Comparison of the sedation, nausea and vomiting scores between two groups did not show any difference. But the number of patient’s satisfaction in S + M group was more than S group which suggests significant differences (P < 0.05). Conclusions: This study showed that magnesium sulphate added to sufentanil through PCIA is an effective method to alleviate pain in patients undergoing lower limb orthopedic surgery. Moreover, we found fewer side effects on magnesium-sufentanil regimen in terms of in nausea, vomiting, and sedation; and patients’ satisfaction in this regimen was more rather than that in the regiment of sufentanil alone.
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Affiliation(s)
- Abass Sedighinejad
- Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Mohammad Haghighi
- Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Bahram Naderi Nabi
- Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran
- Corresponding author: Bahram Naderi Nabi, Guilan Pain Clinic, Guilan Building, Ansari High Way, Golbagh Namaz Blv., Rasht, Iran. Tel/Fax +98-1317731634. E-mail:
| | - Poupak Rahimzadeh
- Anesthesiology Department, Rasoul-e-Akram Medical Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ahmadreza Mirbolook
- Orthopedic Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Mohsen Mardani-Kivi
- Orthopedic Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Majid Nekufard
- Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Gelareh Biazar
- Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran
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Objectifying acupuncture effects by lung function and numeric rating scale in patients undergoing heart surgery. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2013; 2013:219817. [PMID: 23573118 PMCID: PMC3612470 DOI: 10.1155/2013/219817] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Accepted: 12/10/2012] [Indexed: 11/17/2022]
Abstract
Rationale. Poststernotomy pain and impaired breathing are common clinical problems in early postoperative care following heart surgery. Insufficiently treated pain increases the risk of pulmonary complications. High-dose opioids are used for pain management, but they may cause side effects such as respiratory depression. Study Design. We performed a prospective, randomized, controlled, observer-blinded, three-armed clinical trial with 100 patients. Group 1 (n = 33) and Group 2 (n = 34) received one 20 min session of standardized acupuncture treatment with two different sets of acupoints. Group 3 (n = 33) served as standard analgesia control without additional intervention. Results. Primary endpoint analysis revealed a statistically significant analgesic effect for both acupuncture treatments. Group 1 showed a mean percentile pain reduction (PPR) of 18% (SD 19, P < 0.001). Group 2 yielded a mean PPR of 71% (SD 13, P < 0.001). In Group 1, acupuncture resulted in a mean forced vital capacity (FVC) increase of 30 cm(3) (SD 73) without statistical significance (P = 0.303). In Group 2, posttreatment FVC showed a significant increase of 306 cm(3) (SD 215, P < 0.001). Conclusion. Acupuncture revealed specific analgesic effects after sternotomy. Objective measurement of poststernotomy pain via lung function test was possible.
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Analgesic Efficacy and Tolerability of Intravenous Morphine Versus Combined Intravenous Morphine and Oxycodone in a 2-Center, Randomized, Double-Blind, Pilot Trial of Patients With Moderate to Severe Pain After Total Hip Replacement. Clin Ther 2012; 34:1751-60. [DOI: 10.1016/j.clinthera.2012.06.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Revised: 06/19/2012] [Accepted: 06/22/2012] [Indexed: 11/21/2022]
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Ebneshahidi A, Akbari M, Heshmati B. Patient-controlled versus nurse-controlled post-operative analgesia after caesarean section. Adv Biomed Res 2012; 1:6. [PMID: 23210065 PMCID: PMC3507036 DOI: 10.4103/2277-9175.94428] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Accepted: 01/10/2012] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The aim of this study was to compare the differences in the quality of analgesia by patient-controlled analgesia (PCA) and nurse-controlled analgesia (NCA) for post-caesarean section analgesia. MATERIALS AND METHODS 350 women who undertake elective cesarean section were assigned to the three groups. Group I (n=200), IV-PCA morphine; group II (n=100), IV-PCA methadone; group III (n=50) NCA morphine. Data collected during the 24 h observation period included visual analog scale (VAS) pain and patient satisfaction scores, the incidence of nausea and vomiting, severe sedation and pruritis. RESULTS VAS pain scores for each time at which it was evaluated were higher for NCA group than other groups. Also patient satisfaction was significantly increased in the IV-PCA Group as compared with group III. The prevalence of pruritis was higher for NCA group than other groups. CONCLUSION In post caesarean section, PCA morphine or methadone improves 24-h VAS compared with NCA.
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Affiliation(s)
- Amin Ebneshahidi
- Department of Anesthesiology, Sadi Hospital, Isfahan, Iran. ; Persia Research Center, Isfahan, Iran
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, DiSesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD, Jacobs AK, Anderson JL, Albert N, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Kushner FG, Ohman EM, Stevenson W, Yancy CW. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Thorac Cardiovasc Surg 2012; 143:4-34. [PMID: 22172748 DOI: 10.1016/j.jtcvs.2011.10.015] [Citation(s) in RCA: 183] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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van Valen R, van Vuuren H, van Domburg RT, van der Woerd D, Hofland J, Bogers AJJC. Pain management after cardiac surgery: experience with a nurse-driven pain protocol. Eur J Cardiovasc Nurs 2012; 11:62-9. [DOI: 10.1177/1474515111430879] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Richard van Valen
- Department of Cardio-Thoracic Surgery, Erasmus Medical Center, the Netherlands
| | | | | | | | - Jan Hofland
- Department of Anesthesiology, Erasmus Medical Center, the Netherlands
| | - Ad JJC Bogers
- Department of Cardio-Thoracic Surgery, Erasmus Medical Center, the Netherlands
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, DiSesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. Anesth Analg 2012; 114:11-45. [DOI: 10.1213/ane.0b013e3182407c25] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:2610-42. [PMID: 22064600 DOI: 10.1161/cir.0b013e31823b5fee] [Citation(s) in RCA: 337] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 58:e123-210. [PMID: 22070836 DOI: 10.1016/j.jacc.2011.08.009] [Citation(s) in RCA: 582] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:e652-735. [PMID: 22064599 DOI: 10.1161/cir.0b013e31823c074e] [Citation(s) in RCA: 390] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Dev R, Del Fabbro E, Bruera E. Patient-controlled analgesia in patients with advanced cancer. Should patients be in control? J Pain Symptom Manage 2011; 42:296-300. [PMID: 21444180 DOI: 10.1016/j.jpainsymman.2010.11.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Revised: 11/18/2010] [Accepted: 11/23/2010] [Indexed: 11/29/2022]
Abstract
Patient-controlled analgesia (PCA) has been incorporated into the management of chronic pain in cancer patients despite limited evidence of safety and efficacy. Potential benefits of PCA include decreased delay in the administration of opioids from the time requested, rapidity and ease of dose titration, and adaptability to the variable analgesic dosing needs, as well as diurnal changes in patients. PCA may be beneficial for the initial titration of opioids but has the potential to either induce or exacerbate delirium in cancer patients. Clinicians need to closely monitor for symptoms of delirium in advanced cancer patients. The following case presentation highlights the complication of delirium in a cancer patient who was prescribed PCA. Patients with advanced cancer are at increased risk for delirium, which is often difficult to predict.
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Affiliation(s)
- Rony Dev
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
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Lehmann DF. Teaching from catastrophe: using therapeutic misadventures from hydromorphone to teach key principles in clinical pharmacology. J Clin Pharmacol 2010; 51:1596-602. [PMID: 21098693 DOI: 10.1177/0091270010384482] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- David F Lehmann
- SUNY Upstate Medical University, 750 E. Adams Street, Syracuse, NY 13210, USA.
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Baron DM, Metnitz PGH, Gustorff B. [Sedation and analgesia in intensive care: physiology and application]. Wien Klin Wochenschr 2010; 122:455-64. [PMID: 20683673 DOI: 10.1007/s00508-010-1418-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Many therapeutic and diagnostic procedures in intensive care medicine are perceived as painful by most patients. As a consequence analgesia and sedation represent two of the main pillars in the treatment of the critically ill. Adaptation to the individual needs of the patients poses one of the biggest challenges that we are confronted with. Both morbidity and mortality can be positively influenced by adequate treatment. In the first part of this review we will discuss the physiology of sleep patterns and pain. Furthermore modes of action and side effects of the most common anesthetics and analgetics will be presented. Finally, the last part of the manuscript deals with the practical application of these therapeutics and their monitoring in intensive care medicine.
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Affiliation(s)
- David M Baron
- Univ.Klinik für Anästhesie, Allgemeine Intensivmedizin und Schmerztherapie, Medizinische Universität Wien, Wien, Austria
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Wang HL, Tsai YF. Nurses’ knowledge and barriers regarding pain management in intensive care units. J Clin Nurs 2010; 19:3188-96. [DOI: 10.1111/j.1365-2702.2010.03226.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Izumi Y, Amaya F, Hosokawa K, Ueno H, Hosokawa T, Hashimoto S, Tanaka Y. Five-day pain management regimen using patient-controlled analgesia facilitates early ambulation after cardiac surgery. J Anesth 2010; 24:187-91. [DOI: 10.1007/s00540-010-0878-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2009] [Accepted: 11/26/2009] [Indexed: 11/25/2022]
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Harding G, Schein JR, Nelson WW, Vallow S, Olson WH, Hewitt DJ, Polomano RC. Development and validation of a new instrument to evaluate the ease of use of patient-controlled analgesic modalities for postoperative patients. J Med Econ 2010; 13:42-54. [PMID: 20001659 DOI: 10.3111/13696990903484637] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To describe the development and psychometric evaluation of a questionnaire assessing the ease of use that patients associate with patient-controlled analgesia (PCA) modalities. METHODS Qualitative interviews were conducted with patients who had experience with intravenous (IV) PCA for postoperative pain management to generate items relevant to the ease of using PCA modalities. The content validity of the resulting questionnaire was examined through follow-up patient interviews, and an expert panel reviewed the questionnaire. Cognitive debriefing interviews were conducted with patients to determine the clarity and content of the instructions, items, and response scales, and the ease of completing the instrument. Psychometric evaluation was performed with patients who had undergone surgery and received IV PCA for postoperative pain management. Item and scale quality and the internal consistency reliability of the questionnaire were assessed. Construct validity was evaluated by examining the relationship between subscales of the questionnaire with patient-reported outcome measures. Known-groups validity was determined by assessing the instrument's ability to differentiate between patients with versus without an IV PCA problem. A potential limitation of this study was the exclusive sampling of patients who had experience with IV PCA. RESULTS The Patient Ease-of-Care (EOC) Questionnaire included 23 items in the following subscales: Confidence with Device, Comfort with Device, Movement, Dosing Confidence, Pain Control, Knowledge/Understanding, and Satisfaction. Coefficient alpha reliability estimates were ≥ 0.66 for Overall EOC (includes all subscales except Satisfaction) and all EOC subscales. Construct validity was supported by the moderate relationship between the Pain Control subscale and measures of pain severity and pain interference; additional evidence of construct validity was provided by correlations of the Confidence with Device subscale, the Satisfaction subscale, and Overall EOC with measures of pain severity, pain interference, and satisfaction. Significant mean score differences were reported between participants with and without IV PCA problems for Overall EOC and for the Comfort with Device, Confidence with Device, Movement, Pain Control, and Satisfaction subscales indicating known-groups validity. CONCLUSIONS Results provide evidence for the reliability and validity of the Patient EOC Questionnaire as a measure of the ease of use that patients associate with PCA systems and may be useful for evaluating emerging PCA modalities.
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Affiliation(s)
- Gale Harding
- Center for Health Outcomes Research, United BioSource Corporation, 7101 Wisconsin Avenue, Bethesda, MD 20814, USA.
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Martin J, Heymann A, Bäsell K, Baron R, Biniek R, Bürkle H, Dall P, Dictus C, Eggers V, Eichler I, Engelmann L, Garten L, Hartl W, Haase U, Huth R, Kessler P, Kleinschmidt S, Koppert W, Kretz FJ, Laubenthal H, Marggraf G, Meiser A, Neugebauer E, Neuhaus U, Putensen C, Quintel M, Reske A, Roth B, Scholz J, Schröder S, Schreiter D, Schüttler J, Schwarzmann G, Stingele R, Tonner P, Tränkle P, Treede RD, Trupkovic T, Tryba M, Wappler F, Waydhas C, Spies C. Evidence and consensus-based German guidelines for the management of analgesia, sedation and delirium in intensive care--short version. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2010; 8:Doc02. [PMID: 20200655 PMCID: PMC2830566 DOI: 10.3205/000091] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Indexed: 12/28/2022]
Abstract
Targeted monitoring of analgesia, sedation and delirium, as well as their appropriate management in critically ill patients is a standard of care in intensive care medicine. With the undisputed advantages of goal-oriented therapy established, there was a need to develop our own guidelines on analgesia and sedation in intensive care in Germany and these were published as 2(nd) Generation Guidelines in 2005. Through the dissemination of these guidelines in 2006, use of monitoring was shown to have improved from 8 to 51% and the use of protocol-based approaches increased to 46% (from 21%). Between 2006-2009, the existing guidelines from the DGAI (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin) and DIVI (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) were developed into 3(rd) Generation Guidelines for the securing and optimization of quality of analgesia, sedation and delirium management in the intensive care unit (ICU). In collaboration with another 10 professional societies, the literature has been reviewed using the criteria of the Oxford Center of Evidence Based Medicine. Using data from 671 reference works, text, diagrams and recommendations were drawn up. In the recommendations, Grade "A" (very strong recommendation), Grade "B" (strong recommendation) and Grade "0" (open recommendation) were agreed. As a result of this process we now have an interdisciplinary and consensus-based set of 3(rd) Generation Guidelines that take into account all critically illness patient populations. The use of protocols for analgesia, sedation and treatment of delirium are repeatedly demonstrated. These guidelines offer treatment recommendations for the ICU team. The implementation of scores and protocols into routine ICU practice is necessary for their success.
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Affiliation(s)
- Jörg Martin
- Department of Anesthesiology and Operative Intensive Care, Klinik am Eichert, Göppingen, Germany
| | - Anja Heymann
- Department of Anesthesiology and Operative Intensive Care, Charité Campus Virchow, Berlin, Germany
| | | | - Ralf Baron
- Department of Neurology, Christian-Albrechts University, Kiel, Germany
| | - Rolf Biniek
- Department of Neurology, LVR-Klinik Bonn, Germany
| | - Hartmut Bürkle
- Clinic for Anaesthesiology and Operative Intensive Care and Pain Clinic of Memmingen, Germany
| | | | | | - Verena Eggers
- Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Ingolf Eichler
- Department of Cardiac and Vascular Surgery, Klinikum Dortmund GgmbH, Germany
| | - Lothar Engelmann
- Department of Internal Medicine and Intensive Care Medicine, University of Leipzig, Germany
| | - Lars Garten
- Department of Neonatology, Charité University Medicine Berlin, Germany
| | - Wolfgang Hartl
- Department of Surgery Grosshadern, University of Munich, Germany
| | - Ulrike Haase
- Department of Anesthesiology and Intensive Care Medicine, Charité Campus Mitte, Berlin, Germany
| | - Ralf Huth
- University Children's Hospital of Mainz, Germany
| | - Paul Kessler
- Department of Anesthesiology and Intensive Care Medicine, Orthopedic University Hospital, Frankfurt, Germany
| | - Stefan Kleinschmidt
- Department of Anesthesiology, Intensive Care Medicine and Pain Management, BG Trauma Clinic Ludwigshafen, Germany
| | - Wolfgang Koppert
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Germany
| | - Franz-Josef Kretz
- Olgahospital, Department of Anesthesiology and Operative Intensive Care, Stuttgart, Germany
| | | | - Guenter Marggraf
- West German Heart Center Essen, Department of Thoracic and Cardiovascular Surgery, University Hospital Essen, Germany
| | - Andreas Meiser
- Department of Anesthesiology, Intensive Care and Pain, Saarland University Hospital, Homburg, Germany
| | - Edmund Neugebauer
- IFOM - Institute for Research in Operative Medicine, Institute for Surgical Research, Private University of Witten/ Herdecke GmbH, Köln, Germany
| | - Ulrike Neuhaus
- Department of Anesthesiology and Operative Intensive Care, Charité Campus Virchow, Berlin, Germany
| | - Christian Putensen
- Anesthesiology and Operative Intensive Care, University of Bonn, Germany
| | | | - Alexander Reske
- Department of Anesthesiology and Intensive Care, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - Bernard Roth
- Department of General Pediatrics, Cologne, Germany
| | - Jens Scholz
- Department of Anesthesiology and Surgical Intensive Care, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Stefan Schröder
- Department of Psychiatry and Psychotherapy, CMM Hospital Guestrow, Germany
| | - Dierk Schreiter
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Dresden, Germany
| | | | | | - Robert Stingele
- Department of Neurology, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Peter Tonner
- Department of Anesthesiology and Intensive Care Medicine, Emergency Medicine Hospital Links der Weser GmbH, Bremen, Germany
| | - Philip Tränkle
- Department of Internal Medicine, Division III, ICU 3IS, Tübingen, Germany
| | - Rolf Detlef Treede
- Department of Neurophysiology, Center for Biomedicine and Medical Technology Mannheim (CBTM), Germany
| | - Tomislav Trupkovic
- Department of Anesthesiology, Intensive Care Medicine and Pain Management, BG Trauma Clinic Ludwigshafen, Germany
| | - Michael Tryba
- Anesthesiology and Operative Intensive Care, Klinikum Kassel, Germany
| | - Frank Wappler
- Department of Anesthesiology and Operative Intensive Care, Hospital Cologne-Merheim, University of Witten/ Herdecke, Cologne, Germany
| | | | - Claudia Spies
- Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
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Helfand M, Freeman M. Assessment and management of acute pain in adult medical inpatients: a systematic review. PAIN MEDICINE 2010; 10:1183-99. [PMID: 19818030 DOI: 10.1111/j.1526-4637.2009.00718.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To review the literature addressing effective care for acute pain in inpatients on medical wards. METHODS We searched Medline, PubMed Clinical Queries, and the Cochrane Database for systematic reviews published in 1996 through April 2007 on the assessment and management of acute pain in inpatients, including patients with impaired self-report or chemical dependencies. We conducted a focused search for studies on the timing and frequency of assessment, and on the use of patient-controlled analgesia (PCA) for nonsurgical pain. Two investigators performed a critical analysis of the literature and compiled narrative summaries to address the key questions. RESULTS We found no evidence that directly linked the timing, frequency, or method of pain assessment with outcomes or safety in medical inpatients. There is good evidence that treating abdominal pain does not compromise timely diagnosis and treatment of the surgical abdomen. Pain management teams and other systemwide interventions improve assessment and use of analgesics, but do not clearly affect pain outcomes. The safety and effectiveness of PCA in medical patients have not been studied. There is weak evidence that most cognitively impaired individuals can understand at least one self-assessment measure. Almost no evidence is available to guide management of pain in delirium. Evidence for managing pain in patients with substance abuse disorders or chronic opioid use is weak, being derived from case reports, retrospective studies, and expert opinion. CONCLUSIONS Pain is a prevalent problem for medical inpatients. Clinical research is needed to guide the assessment and management of pain in this setting.
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Affiliation(s)
- Mark Helfand
- Evidence-Based Synthesis Program, Portland Veterans Affairs Medical Center, Portland, OR 97239, USA.
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[Patient-controlled analgesia. Pain and Locoregional Anesthesia Committee and the Standards Committee of the French Society of Anesthesia and Intensive Care]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2009; 28:e49-59. [PMID: 19186023 DOI: 10.1016/j.annfar.2008.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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