Consensus Perioperative Management Best Practices for Patients on Transdermal Fentanyl Patches Undergoing Surgery

Pain management after laminectomy: a systematic review and procedure-specific post-operative pain management (prospect) recommendations

PURPOSE

With lumbar laminectomy increasingly being performed on an outpatient basis, optimal pain management is critical to avoid post-operative delay in discharge and readmission. The aim of this review was to evaluate the available literature and develop recommendations for optimal pain management after one- or two-level lumbar laminectomy.

METHODS

A systematic review utilizing the PROcedure-SPECific Post-operative Pain ManagemenT (PROSPECT) methodology was undertaken. Randomised controlled trials (RCTs) published in the English language from 1 January 2008 until 31 March 2020-assessing post-operative pain using analgesic, anaesthetic and surgical interventions-were identified from MEDLINE, EMBASE and Cochrane Databases.

RESULTS

Out of 65 eligible studies identified, 39 RCTs met the inclusion criteria. The analgesic regimen for lumbar laminectomy should include paracetamol and a non-steroidal anti-inflammatory drug (NSAID) or cyclooxygenase (COX)-2 selective inhibitor administered preoperatively or intraoperatively and continued post-operatively, with post-operative opioids for rescue analgesia. In addition, surgical wound instillation or infiltration with local anaesthetics prior to wound closure is recommended. Some interventions-gabapentinoids and intrathecal opioid administration-although effective, carry significant risks and consequently were omitted from the recommendations. Other interventions were also not recommended because there was insufficient, inconsistent or lack of evidence.

CONCLUSION

Perioperative pain management for lumbar laminectomy should include paracetamol and NSAID- or COX-2-specific inhibitor, continued into the post-operative period, as well as intraoperative surgical wound instillation or infiltration. Opioids should be used as rescue medication post-operatively. Future studies are necessary to evaluate the efficacy of our recommendations.

The efficacy of intra-articular fentanyl supplementation for knee arthroscopy: A meta-analysis of randomized controlled studies

INTRODUCTION

The efficacy of intra-articular fentanyl supplementation for pain control after knee arthroscopy remains controversial. We conduct a systematic review and meta-analysis to explore the influence of intra-articular fentanyl supplementation for pain intensity after arthroscopic knee surgery.

METHODS

We searched PubMed, EMbase, Web of Science, EBSCO, and Cochrane Library databases through May 2019 for randomized controlled trials (RCTs) assessing the efficacy and safety of intra-articular fentanyl supplementation for arthroscopic knee surgery. This meta-analysis is performed using the random-effects model.

RESULTS

Four RCTs are included in the meta-analysis. Overall, compared with control group after knee arthroscopy, intra-articular fentanyl supplementation is associated with reduced pain scores at 1 h (standard mean difference (Std MD) = -3.50; 95% confidence interval (CI) = -5.68 to -1.32; p = 0.002), 2 h (Std MD = -4.73; 95% CI = -8.75 to -0.71; p = 0.02), and 8 h (Std MD = -5.02; 95% CI = -9.73 to -0.30; p = 0.04) but shows no substantial impact on pain scores at 4 h (Std MD = -3.94; 95% CI = -7.93 to 0.05; p = 0.05) or the supplementary analgesia (risk ratio = 0.56; 95% CI = 0.09-3.59; p = 0.54).

CONCLUSIONS

Intra-articular fentanyl supplementation does benefit in pain control after knee arthroscopy.

Chronic pain and substance abuse disorders: Preoperative assessment and optimization strategies

There is an ever-increasing number of opioid users among chronic pain patients and safely managing them can be challenging for surgeons, anesthesiologists, pain experts, and addiction specialists. Healthcare providers must be familiar with phenomena typical of opioid users and abusers, including tolerance, physical dependence, hyperalgesia, and addiction. Insufficient pain management is very common in these patients. Patient-centered preoperative communication is integral to setting realistic expectations for postoperative pain, developing successful nonopioid analgesic regimens, minimizing opioid consumption during the postoperative period, and decreasing the number of opioid pills at the risk of diversion. Preoperative evaluation should identify comorbidities and identify risk factors for substance abuse and withdrawal. Intraoperative and postoperative strategies can ensure safe and effective pain management and minimize the potential for morbidity and mortality in this high-risk patient population.