1
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McArthur R, Cash RE, Rafique Z, Dickson R, Crocker K, Crowe RP, Wells M, Chu K, Nguyen J, Patrick C. Intravenous Acetaminophen Versus Ketorolac for Prehospital Analgesia: A Retrospective Data Review. J Emerg Med 2024; 67:e259-e267. [PMID: 39030089 DOI: 10.1016/j.jemermed.2024.04.007] [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: 01/17/2024] [Revised: 04/18/2024] [Accepted: 04/22/2024] [Indexed: 07/21/2024]
Abstract
BACKGROUND Parenteral ketorolac and intravenous (IV) acetaminophen have been used for prehospital analgesia, yet limited data exist on their comparative effectiveness. STUDY OBJECTIVES To evaluate the comparative effectiveness of IV acetaminophen and parenteral ketorolac for analgesia in the prehospital setting. METHODS We conducted a retrospective cross-sectional evaluation of patients receiving IV acetaminophen or parenteral ketorolac for pain management in a large suburban EMS system between 1/1/2019 and 11/30/2021. The primary outcome was change in first to last pain score. Subgroup analysis was performed on patients with traumatic pain. We used inverse probability of treatment weighting (IPTW) and propensity score matching (PSM) to estimate the treatment effect of acetaminophen versus ketorolac among all patients and the subgroup of those with traumatic pain. RESULTS Of 2178 patients included, 856 (39.3%) received IV acetaminophen and 1322 (60.7%) received parenteral ketorolac. The unadjusted mean change in pain score was -1.9 (SD 2.4) for acetaminophen group and -2.4 (SD 2.4) for ketorolac. In the propensity score analyses, there was no statistically significant difference in pain score change for the acetaminophen group versus ketorolac among all patients (mean difference, IPTW: 0.11, 95% confidence interval [CI] -0.16, 0.37; PSM: 0.15, 95% CI -0.13, 0.43) and among those with traumatic pain (unadjusted: 0.18, 95% CI -0.35, 0.72; IPTW: 0.23, 95% CI -0.25, 0.71; PSM: -0.03, 95% CI -0.61, 0.54). CONCLUSIONS We found no statistically significant difference in mean pain reduction of IV acetaminophen and parenteral ketorolac for management of acute pain.
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Affiliation(s)
- Robert McArthur
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas.
| | | | - Zubaid Rafique
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | - Robert Dickson
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas; Montgomery County Hospital District EMS, Conroe, Texas
| | - Kevin Crocker
- Montgomery County Hospital District EMS, Conroe, Texas
| | | | - Michael Wells
- Montgomery County Hospital District EMS, Conroe, Texas
| | - Katherine Chu
- Sam Houston State University College of Osteopathic Medicine, Conroe, Texas
| | - James Nguyen
- Sam Houston State University College of Osteopathic Medicine, Conroe, Texas
| | - Casey Patrick
- Montgomery County Hospital District EMS, Conroe, Texas
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Xu H, Wang Z, Wang Z, Lei Y, Chen J, Zhou H, Li M, Diao J, Bian Y, Zhou B, Zhou Y. Recent trends in Tuina for chronic pain management: A bibliometric analysis and literature review. Complement Ther Med 2024; 84:103068. [PMID: 39004289 DOI: 10.1016/j.ctim.2024.103068] [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: 04/01/2024] [Revised: 07/09/2024] [Accepted: 07/11/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND The utilization of Tuina as a therapeutic intervention for the management of chronic pain has experienced a gradually increase in its popularity, and the purpose of this bibliometric analysis is to offer a comprehensive understanding of the current state and frontier trends, as well as to provide recommendations for future research directions. METHODS Publications on Tuina for chronic pain published between 2004 and 2023 were retrieved from the Web of Science Core Collection (WoSCC). Microsoft Excel, CiteSpace, VOSViewer, and the R package "bibliometrix" were used to quantitatively analyse the annual publication volume, countries/regions, journals, institutions, cited references, authors, and keywords. RESULTS A total of 287 publications were retrieved. The number of annual publications on the use of Tuina for treating chronic pain has gradually increased. Most publications were published in China and the United States. Notably, the most productive institution and author were identified as Shanghai University of Traditional Chinese Medicine and Min Fang, respectively. Medicine ranked first as the most influential affiliate and most productive journal. These publications came from 1650 authors, among whom Edzard Ernst had the most co-citations. Keyword analysis revealed that the new research frontier was low back pain. CONCLUSION The utilization of Tuina for the treatment of chronic pain has been gaining increasing recognition. Acupuncture, randomised controlled trials, systematic reviews, etc. were the main research subjects. Furthermore, low back pain is the new research frontier. This study provides an in-depth perspective on Tuina for chronic pain, which provides valuable reference material for clinicians with insights of therapeutic strategy, educators with valuable topics, and researchers with new research directions.
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Affiliation(s)
- Hui Xu
- Henan University of Chinese Medicine, Zhengzhou, Henan 450046, China
| | - Zheng Wang
- Henan University of Chinese Medicine, Zhengzhou, Henan 450046, China
| | - Zhen Wang
- Henan University of Chinese Medicine, Zhengzhou, Henan 450046, China
| | - Yang Lei
- Henan University of Chinese Medicine, Zhengzhou, Henan 450046, China
| | - Juntao Chen
- Henan University of Chinese Medicine, Zhengzhou, Henan 450046, China
| | - Hang Zhou
- Henan University of Chinese Medicine, Zhengzhou, Henan 450046, China
| | - Mengmeng Li
- Henan University of Chinese Medicine, Zhengzhou, Henan 450046, China
| | - Jieyao Diao
- Henan University of Chinese Medicine, Zhengzhou, Henan 450046, China
| | - Yanqin Bian
- Orthopedic Research Laboratory, University of California, Davis 95616, USA
| | - Bin Zhou
- Henan University of Chinese Medicine, Zhengzhou, Henan 450046, China; Tuina Department, Third Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, Henan 450046, China.
| | - Yunfeng Zhou
- Henan University of Chinese Medicine, Zhengzhou, Henan 450046, China.
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3
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Yeo JA, Tan MBH, Ong ET, Wong A, Koh XH, Gobindram A. Reducing costs and carbon footprint for preoperative oral paracetamol: implementation of a standardised pathway. Br J Anaesth 2024:S0007-0912(24)00409-4. [PMID: 39107165 DOI: 10.1016/j.bja.2024.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/24/2024] [Accepted: 06/10/2024] [Indexed: 08/09/2024] Open
Affiliation(s)
- Jo-Anne Yeo
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore.
| | - Michelle B H Tan
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore
| | - Ee Teng Ong
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore
| | - Adrian Wong
- Department of Pharmacy, Changi General Hospital, Singapore
| | - Xuan Han Koh
- Department of Health Services Research, Changi General Hospital, Singapore
| | - Avinash Gobindram
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore
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4
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Kim SH, Kang H, Jun IJ, Park HW, Yoo BH, Lim YH, Kim KM. Effect of perioperative intravenous ibuprofen versus acetaminophen on postoperative opioid consumption and pain after general anesthesia: a systematic review and meta-analysis with trial sequential analysis of randomized controlled trials. Korean J Anesthesiol 2024; 77:455-467. [PMID: 38711266 PMCID: PMC11294878 DOI: 10.4097/kja.24089] [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: 02/06/2024] [Revised: 04/02/2024] [Accepted: 04/09/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND Ibuprofen and acetaminophen are widely used as adjuvant analgesics for postoperative pain. This meta-analysis compared the effects of intravenous (IV) ibuprofen and acetaminophen on postoperative opioid consumption and pain intensity after general anesthesia. METHODS PubMed/MEDLINE, EMBASE, and Cochrane Library databases were searched to identify relevant studies published up to May 2023. Randomized controlled trials comparing the effects of perioperative IV ibuprofen and acetaminophen on postoperative opioid consumption and pain after general anesthesia were included in the meta-analysis and trial sequential analysis (TSA). RESULTS Eight studies with 494 participants were included. Compared to IV acetaminophen, IV ibuprofen significantly reduced 24 h opioid consumption, presented as morphine equivalents (mean difference [MD]: -6.01 mg, 95% CI [-8.60, -3.42], P < 0.00001, I2 = 55%), and pain scores (on a scale of 0-10) at 4-6 h (MD: -0.83, 95% CI [-1.29, -0.37], P = 0.0004, I2 = 65%) and 12 h (MD: -0.38, 95% CI [-0.68, -0.08], P = 0.01, I2 = 11%) postoperatively. These results were statistically significant in TSA. Pain scores at 24 h postoperatively and side effects were not significantly different between the two groups in the meta-analysis, and TSA revealed that the sample size was too small to adequately evaluate the effects, requiring further studies for conclusive results. CONCLUSIONS Perioperative IV ibuprofen reduced 24 h opioid consumption and pain severity up to 12 h postoperatively compared to acetaminophen. Additional research is required to assess pain intensity beyond 12 h and side effects.
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Affiliation(s)
- Sung Hye Kim
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - In-Jung Jun
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | | | - Byung Hoon Yoo
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Yun-Hee Lim
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Kye-Min Kim
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
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Govendir M, Vogelnest L, Shapiro AJ, Marschner C, Kimble B. Pharmacokinetic profile of oral and subcutaneous administration of paracetamol in the koala (Phascolarctos cinereus) and prediction of its analgesic efficacy. PLoS One 2024; 19:e0300703. [PMID: 38630750 PMCID: PMC11023281 DOI: 10.1371/journal.pone.0300703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 03/04/2024] [Indexed: 04/19/2024] Open
Abstract
The pharmacokinetic profile of paracetamol in koalas is described when administered orally at 15 mg/kg; followed by the same dose, administered every 12 hours (hrs), repeated five times. After the initial oral administration, the median (range) maximal plasma concentration (Cmax), the time Cmax was reached (Tmax) and elimination half-life (t1/2) were 16.93 μg/mL (13.66 to 20.25 μg/mL); 4 hrs (4 to 8 hrs) and 5.54 hrs (4.66 to 7.67 hrs), respectively. When paracetamol was administered orally at 15 mg/mL every 12 hrs, the trough total plasma concentration range remained comparable to the therapeutic range in humans i.e. 4 to 20 μg/mL that is known to provide some analgesia. However, there is a smaller proportion of free drug (i.e. not bound to plasma proteins; and the active form) available in koala plasma (approximately 40% unbound) compared to human plasma (approximately 80% unbound). Consequently, even when there are similar total drug plasma concentrations in both koala and human plasma, the therapeutic efficacy may be reduced in koalas compared to humans. The initial oral dose and subsequent twice daily doses resulted in no obvious adverse effects in any koala. Haematology, plasma electrolyte and biochemical analyte values remained within their reference ranges eight hrs after the last dose but there was a significant change in alanine transaminase (ALT) levels (an increase), and in total protein (a decrease) (both p = 0.03). A dose of 15 mg/kg was also administered as a subcutaneous injection, diluted 50:50 with saline, to two koalas. As the oral formulation and the subcutaneous administration resulted in comparable absorption, the study focused on the oral profile. Based on these results there is an argument to recommend a slight increase in the oral paracetamol dose for the koala, however further investigation is required to confirm whether repeated administration of a slightly higher dose may be associated with more severe or additional significant changes in haematology, electrolytes or biochemical analytes. However, a preferable recommendation would be to administer this dosage of paracetamol in combination with another analgesic such as tramadol, as a subcutaneous injection, to improve efficacy.
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Affiliation(s)
- Merran Govendir
- Sydney School of Veterinary Science, The University of Sydney, Sydney, Australia
| | - Larry Vogelnest
- Taronga Conservation Society Australia, Mosman, NSW, Sydney, Australia
| | - Amanda J. Shapiro
- Sydney School of Veterinary Science, The University of Sydney, Sydney, Australia
| | - Caroline Marschner
- Sydney School of Veterinary Science, The University of Sydney, Sydney, Australia
| | - Benjamin Kimble
- Sydney School of Veterinary Science, The University of Sydney, Sydney, Australia
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6
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Tse G, Algaze C, Pageler N, Wood M, Chadwick W. Using Clinical Decision Support Systems to Decrease Intravenous Acetaminophen Use: Implementation and Lessons Learned. Appl Clin Inform 2024; 15:64-74. [PMID: 37995743 PMCID: PMC10807987 DOI: 10.1055/a-2216-5775] [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: 07/20/2023] [Accepted: 11/22/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Clinical decision support systems (CDSS) can enhance medical decision-making by providing targeted information to providers. While they have the potential to improve quality of care and reduce costs, they are not universally effective and can lead to unintended harm. OBJECTIVES To describe the implementation of an unsuccessful interruptive CDSS that aimed to promote appropriate use of intravenous (IV) acetaminophen at an academic pediatric hospital, with an emphasis on lessons learned. METHODS Quality improvement methodology was used to study the effect of an interruptive CDSS, which set a mandatory expiry time of 24 hours for all IV acetaminophen orders. This CDSS was implemented on April 5, 2021. The primary outcome measure was number of IV acetaminophen administrations per 1,000 patient days, measured pre- and postimplementation. Process measures were the number of IV acetaminophen orders placed per 1,000 patient days. Balancing measures were collected via survey data and included provider and nursing acceptability and unintended consequences of the CDSS. RESULTS There was no special cause variation in hospital-wide IV acetaminophen administrations and orders after CDSS implementation, nor when the CDSS was removed. A total of 88 participants completed the survey. Nearly half (40/88) of respondents reported negative issues with the CDSS, with the majority stating that this affected patient care (39/40). Respondents cited delays in patient care and reduced efficiency as the most common negative effects. CONCLUSION This study underscores the significance of monitoring CDSS implementations and including end user acceptability as an outcome measure. Teams should be prepared to modify or remove CDSS that do not achieve their intended goal or are associated with low end user acceptability. CDSS holds promise for improving clinical practice, but careful implementation and ongoing evaluation are crucial for maximizing their benefits and minimizing potential harm.
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Affiliation(s)
- Gabriel Tse
- Department of Pediatrics, Division of Pediatric Hospital Medicine, Stanford University School of Medicine, Stanford, California, United States
| | - Claudia Algaze
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, California, United States
| | - Natalie Pageler
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Stanford, California, United States
| | - Matthew Wood
- Center for Pediatric and Maternal Value, Lucile Packard Children's Hospital, Palo Alto, California, United States
| | - Whitney Chadwick
- Department of Pediatrics, Division of Pediatric Hospital Medicine, Stanford University School of Medicine, Stanford, California, United States
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7
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Smith WR, Valrie CR, Jaja C, Kenney MO. Precision, integrative medicine for pain management in sickle cell disease. FRONTIERS IN PAIN RESEARCH 2023; 4:1279361. [PMID: 38028431 PMCID: PMC10666191 DOI: 10.3389/fpain.2023.1279361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
Sickle cell disease (SCD) is a prevalent and complex inherited pain disorder that can manifest as acute vaso-occlusive crises (VOC) and/or chronic pain. Despite their known risks, opioids are often prescribed routinely and indiscriminately in managing SCD pain, because it is so often severe and debilitating. Integrative medicine strategies, particularly non-opioid therapies, hold promise in safe and effective management of SCD pain. However, the lack of evidence-based methods for managing SCD pain hinders the widespread implementation of non-opioid therapies. In this review, we acknowledge that implementing personalized pain treatment strategies in SCD, which is a guideline-recommended strategy, is currently fraught with limitations. The full implementation of pharmacological and biobehavioral pain approaches targeting mechanistic pain pathways faces challenges due to limited knowledge and limited financial and personnel support. We recommend personalized medicine, pharmacogenomics, and integrative medicine as aspirational strategies for improving pain care in SCD. As an organizing model that is a comprehensive framework for classifying pain subphenotypes and mechanisms in SCD, and for guiding selection of specific strategies, we present evidence updating pain research pioneer Richard Melzack's neuromatrix theory of pain. We advocate for using the updated neuromatrix model to subphenotype individuals with SCD, to better select personalized multimodal treatment strategies, and to identify research gaps fruitful for exploration. We present a fairly complete list of currently used pharmacologic and non-pharmacologic SCD pain therapies, classified by their mechanism of action and by their hypothesized targets in the updated neuromatrix model.
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Affiliation(s)
- Wally R. Smith
- Division of General Internal Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Cecelia R. Valrie
- Department of Psychology, Virginia Commonwealth University, Richmond, VA, United States
| | - Cheedy Jaja
- College of Nursing, University of South Florida School of Nursing, Tampa, FL, United States
| | - Martha O. Kenney
- Department of Anesthesiology, Duke University, Durham, NC, United States
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8
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Park YD, Chae YJ, Maeng HJ. Investigation of N-Acetyltransferase 2-Mediated Drug Interactions of Amifampridine: In Vitro and In Vivo Evidence of Drug Interactions with Acetaminophen. Pharmaceutics 2023; 15:pharmaceutics15051471. [PMID: 37242713 DOI: 10.3390/pharmaceutics15051471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 05/04/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023] Open
Abstract
Amifampridine is a drug used for the treatment of Lambert-Eaton myasthenic syndrome (LEMS) and was approved by the Food and Drug Administration (FDA) of the United States (US) in 2018. It is mainly metabolized by N-acetyltransferase 2 (NAT2); however, investigations of NAT2-mediated drug interactions with amifampridine have rarely been reported. In this study, we investigated the effects of acetaminophen, a NAT2 inhibitor, on the pharmacokinetics of amifampridine using in vitro and in vivo systems. Acetaminophen strongly inhibits the formation of 3-N-acetylamifmapridine from amifampridine in the rat liver S9 fraction in a mixed inhibitory manner. When rats were pretreated with acetaminophen (100 mg/kg), the systemic exposure to amifampridine significantly increased and the ratio of the area under the plasma concentration-time curve for 3-N-acetylamifampridine to amifampridine (AUCm/AUCp) decreased, likely due to the inhibition of NAT2 by acetaminophen. The urinary excretion and the amount of amifampridine distributed to the tissues also increased after acetaminophen administration, whereas the renal clearance and tissue partition coefficient (Kp) values in most tissues remained unchanged. Collectively, co-administration of acetaminophen with amifampridine may lead to relevant drug interactions; thus, care should be taken during co-administration.
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Affiliation(s)
- Yeo-Dim Park
- College of Pharmacy, Gachon University, Incheon 21936, Republic of Korea
| | - Yoon-Jee Chae
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Woosuk University, Wanju 55338, Republic of Korea
| | - Han-Joo Maeng
- College of Pharmacy, Gachon University, Incheon 21936, Republic of Korea
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9
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Thibault C, Pelletier É, Nguyen C, Trottier ED, Doré-Bergeron MJ, DeKoven K, Roy AM, Piché N, Delisle JF, Morin C, Paquette J, Kleiber N. The Three W's of Acetaminophen In Children: Who, Why, and Which Administration Mode. J Pediatr Pharmacol Ther 2023; 28:20-28. [PMID: 36777982 PMCID: PMC9901322 DOI: 10.5863/1551-6776-28.1.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 04/25/2022] [Indexed: 02/05/2023]
Abstract
Acetaminophen is one of the oldest medications commonly administered in children. Its efficacy in treating fever and pain is well accepted among clinicians. However, the available evidence supporting the use of acetaminophen's different modes of administration remains relatively scarce and poorly known. This short report summarizes the available evidence and provides a framework to guide clinicians regarding a rational use of acetaminophen in children.
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Affiliation(s)
- Céline Thibault
- Department of Pharmacology and Physiology (CT, NK), Université de Montreal, Montreal, QC, Canada,Research Center (CT, NK), CHU Sainte-Justine, Université de Montreal, Montreal, QC, Canada,Department of Pediatrics (CT, MJDB, NK), CHU Sainte-Justine, Montreal, QC, Canada,Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada
| | - Élaine Pelletier
- Department of Pharmacology and Physiology (CT, NK), Université de Montreal, Montreal, QC, Canada,Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Pharmacy (EP, CN, JFD, CM), CHU Sainte-Justine, Montreal, QC, Canada
| | - Christina Nguyen
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Pharmacy (EP, CN, JFD, CM), CHU Sainte-Justine, Montreal, QC, Canada
| | - Evelyne D. Trottier
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Pediatric Emergency Medicine (EDT), CHU Sainte Justine, Montreal, QC, Canada
| | - Marie-Joëlle Doré-Bergeron
- Department of Pediatrics (CT, MJDB, NK), CHU Sainte-Justine, Montreal, QC, Canada,Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada
| | - Kathryn DeKoven
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Anesthesiology (KD), CHU Sainte-Justine, Montreal, QC, Canada
| | - Anne-Marie Roy
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Nursing (AMR, JP), CHU Sainte-Justine, Montreal, QC, Canada
| | - Nelson Piché
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada
| | - Jean-Francois Delisle
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Pharmacy (EP, CN, JFD, CM), CHU Sainte-Justine, Montreal, QC, Canada
| | - Caroline Morin
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Pharmacy (EP, CN, JFD, CM), CHU Sainte-Justine, Montreal, QC, Canada
| | - Julie Paquette
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Nursing (AMR, JP), CHU Sainte-Justine, Montreal, QC, Canada
| | - Niina Kleiber
- Department of Pharmacology and Physiology (CT, NK), Université de Montreal, Montreal, QC, Canada,Research Center (CT, NK), CHU Sainte-Justine, Université de Montreal, Montreal, QC, Canada,Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Surgery (NP), CHU Sainte-Justine, Montreal, QC, Canada
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10
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Perioperative Multimodal Pain Management Approach in Older Adults With Polytrauma. J Surg Res 2022; 275:96-102. [DOI: 10.1016/j.jss.2021.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/29/2021] [Accepted: 12/27/2021] [Indexed: 11/21/2022]
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11
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Passias BJ, Johnson DB, Schuette HB, Secic M, Heilbronner B, Hyland SJ, Sager A. Preemptive multimodal analgesia and post-operative pain outcomes in total hip and total knee arthroplasty. Arch Orthop Trauma Surg 2022; 143:2401-2407. [PMID: 35499774 DOI: 10.1007/s00402-022-04450-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 04/15/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Use of multimodal analgesia (MMA) prior to orthopedic surgery has been adopted by many practitioners as a strategy to minimize use of opioid medications. The purpose of this investigation was to quantify the effect of a preemptive three-drug regimen (acetaminophen, celecoxib, and gabapentin) in terms of post-operative opioid consumption and pain control in the field of total joint arthroplasty. METHODS A retrospective chart review was conducted on 1691 patients who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA) and stratified by whether they received a preemptive three medication analgesic therapy (acetaminophen, celecoxib, and gabapentin) within 30 to 60 min prior to entering the operating room. Post-operative opioid consumption as well as subjectively reported patient pain scores were assessed throughout their hospital stay. RESULTS A total of 1416 eligible patients were identified with 485 undergoing THA and 931 undergoing TKA. Statistically significant reductions in oral morphine equivalents were shown on post-operative day zero and two within the TKA cohort, and non-significant reductions were demonstrated in other intervals for both procedure types. Statistically significant reductions in patient reported pain scores were shown in nearly every time interval in both procedure types. CONCLUSION The receipt of preemptive acetaminophen, celecoxib, and gabapentin 30-60 min prior to total joint arthroplasty demonstrated modest reductions in opioid requirements post-operatively. Patients receiving preemptive MMA reported lower pain scores throughout nearly every time interval during their admission after surgery. Further investigations are warranted regarding optimal preoperative medication therapies to promote adequate post-operative pain control-and ultimately diminished opioid consumption-in the setting of total joint arthroplasty.
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Affiliation(s)
- Braden J Passias
- Department of Orthopedic Surgery, OhioHealth Doctors Hospital, 5100 West Broad Street, Columbus, OH, 43228, USA.
| | - David B Johnson
- Department of Orthopedic Surgery, OhioHealth Doctors Hospital, 5100 West Broad Street, Columbus, OH, 43228, USA
| | - Hayden B Schuette
- Department of Orthopedic Surgery, OhioHealth Doctors Hospital, 5100 West Broad Street, Columbus, OH, 43228, USA
| | - Michelle Secic
- Secic Statistical Consltng Incorporated, 9685 Campton Ridge Dr, Chardon, OH, 44024, USA
| | - Brian Heilbronner
- Department of Pharmacy, OhioHealth Doctors Hospital, 5100 West Broad Street, Columbus, OH, 43228, USA
| | - Sarah J Hyland
- Department of Pharmacy, OhioHealth Grant Medical Center, 285 East State Street, Columbus, OH, 43215, USA
| | - Andrew Sager
- Department of Pharmacy, OhioHealth Doctors Hospital, 5100 West Broad Street, Columbus, OH, 43228, USA
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12
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Kenney MO, Smith WR. Moving Toward a Multimodal Analgesic Regimen for Acute Sickle Cell Pain with Non-Opioid Analgesic Adjuncts: A Narrative Review. J Pain Res 2022; 15:879-894. [PMID: 35386424 PMCID: PMC8979590 DOI: 10.2147/jpr.s343069] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 02/04/2022] [Indexed: 12/13/2022] Open
Abstract
Purpose of Review Sickle cell disease (SCD) is an inherited hemoglobinopathy with potential life-threatening complications that affect millions of people worldwide. Severe and disabling acute pain, referred to as a vaso-occlusive crisis (VOC), is a fundamental symptom of the disease and the primary driver for acute care visits and hospitalizations. Despite the publication of guidelines for VOC management over the past decade, management of VOCs remains unsatisfactory for patients and providers. Recent Findings Acute SCD pain includes pain secondary to VOCs and other forms of acute pain. Distinguishing VOC from non-VOC pain may be challenging for both patients and clinicians. Further, although opioids have been the gold-standard for VOC pain management for decades, the current highest standard of care for all acute pain is a multimodal approach that is less dependent on opioids, and, instead incorporates analgesics and adjuvants from different mechanistic pathways. In this narrative review, we focus on a multimodal pharmacologic approach for acute SCD pain management and explore the evidence for existing non-opioid pharmacological adjuncts. Moreover, we present an explanatory model of pain, which is not only novel in its application to SCD pain but also captures the multidimensional nature of the SCD pain experience and supports the need for such a multimodal approach. This model also highlights opportunities for new investigative and therapeutic targets - both pharmacological and non-pharmacological. Summary Multimodal pain regimens that are less dependent on opioids are urgently needed to improve acute pain outcomes for individuals with SCD. The proposed explanatory model for SCD pain offers novel opportunities to improve acute pain management for SCD patients.
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Affiliation(s)
- Martha O Kenney
- Division of Pediatric Anesthesiology, Department of Anesthesiology, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Wally R Smith
- Division of General Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
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Orović S, Petković N, Bulatović J, Stamenković D. Nonopioid analgesics for analgesia in critically ill patients: Friends, enemies, or collaborators. SERBIAN JOURNAL OF ANESTHESIA AND INTENSIVE THERAPY 2022. [DOI: 10.5937/sjait2206115o] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Patients in intensive care units (ICUs) experience pain, which they describe as a significant cause of stress during treatment. It can progress to chronic pain and significantly affect the quality of life. Opioids have long been the backbone of ICU pain therapy. The consequences of their long-term use are known today, such as prolonged ICU stay and mechanical ventilation, resulting in increased treatment costs. Additionally, abstinence syndrome is a consequence of abrupt opioid withdrawal. Also, there is a risk of tolerance and hyperalgesia after prolonged opioid use. Globally, opioid dependence after hospital opioid treatment is alarming, although there is still a lack of data on its incidence after ICU. Multimodal analgesia enables comfort to the patient, opioid-sparing, and avoidance of side effects of non-opioid analgesics. Nonsteroidal anti-inflammatory drugs (NSAIDs) are a broad group of drugs recommended with paracetamol to treat mild to moderate acute postoperative pain. Although often prescribed by intensivists, their use in treating painful conditions in ICU is controversial due to the possible consequences on the organs of critically ill patients. Due to the inhibition of cyclooxygenases, NSAIDs indirectly cause vasoconstriction of the renal arteries and arterioles, leading to kidney damage. NSAIDs inhibit platelet aggregation and may predispose to bleeding. Analgesia of a critically ill patient is a important part of their treatment, however it can be challenging in certain patients. Numerous combinations of pharmacological and non-pharmacological approaches can be adapted to the patient's current characteristics.
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Cao Q, Fan C, Yuan R, Dong H, Zhang S, Meng H. Comparison of intravenous and oral administration of acetaminophen in adults undergoing general anesthesia. Pain Pract 2021; 22:405-413. [PMID: 34775679 DOI: 10.1111/papr.13092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Acetaminophen is a widely clinically used analgesic. However, the clinical effect of the route of administration on postoperative analgesia as well as on postoperative nausea and vomiting in patients undergoing general anesthesia remains unclear. This study aimed to explore whether the route of administration of acetaminophen affects postoperative analgesia, nausea, and vomiting in patients undergoing general anesthesia. METHODS We included all randomized controlled trials investigating the effects of the route of administration of acetaminophen on postoperative pain, nausea, and vomiting in patients undergoing general anesthesia. Independent examiners reviewed the literature and extracted data, with disagreements resolved through negotiation or the involvement of a third party. The Cochrane risk assessment tool was used to evaluate the quality of the included randomized controlled trials. A narrative synthesis was conducted to summarize the qualitative information from the included studies. A meta-integration of quantitative data was performed using RevMan 5.4. RESULTS Ten studies met the inclusion criteria. Eight studies assessed postoperative pain, whereas two assessed postoperative nausea and vomiting. Data from the eight studies assessing postoperative pain confirmed that there was no difference between intravenously and orally administered acetaminophen in adults (OR = -0.13; 95% CI, -0.36 to 0.11; p = 0.3). Data from the two studies assessing postoperative nausea and vomiting revealed no difference between intravenously and orally administered acetaminophen in adults (OR = 0.89; 95% CI, 0.64-1.25; p = 0.51). The included studies were of poor quality, with a heterogeneity of 68%. CONCLUSIONS No differences in postoperative analgesia or postoperative nausea and vomiting were observed between the routes of administration (intravenous vs. oral) of acetaminophen in adult patients undergoing general anesthesia. There is a need for future large sample studies to increase the reliability of the results.
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Affiliation(s)
- Qinqin Cao
- Department of Anesthesiology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Chengjuan Fan
- Department of Urology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Ran Yuan
- Department of Anesthesiology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Hemin Dong
- Department of Anesthesiology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Shouxin Zhang
- Department of Anesthesiology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Haihong Meng
- Department of Anesthesiology, Affiliated Hospital of Jining Medical University, Jining, China
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Phillips SJ, Peck CJ, Pourtaheri N, Reategui A, Carney M, Dinis J, Park KE, Maniskas S, Lopez J, Steinbacher DM. Decreasing Inpatient Opioid Use Following Orthognathic Surgery. J Craniofac Surg 2021; 32:2808-2811. [PMID: 34727482 DOI: 10.1097/scs.0000000000008001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Strategies to decrease postoperative opioid use are important for mitigating the immediate and long-term risks associated with their use. We aimed to investigate the impact of perioperative various factors on inpatient opioid needs for patients undergoing orthognathic surgery. METHODS This was a retrospective cohort study of all patients who underwent orthognathic surgery performed by the senior author from 2012 to 2018. Patients were grouped into intravenous (IV) acetaminophen and no-IV acetaminophen cohorts. Opioid medications received by patients during hospital stay were converted to mean morphine equivalents (MME) for comparison. Additional factors that influenced opioid consumption, such as transexamic acid (TXA) and postoperative nausea and vomiting (PONV), were identified using univariate analysis. Factors found to have statistical significance were added to a multivariate linear regression model. RESULTS 319 patients were included. Those who received IV acetaminophen had lower rates of total opioid use (57.3 versus 74.8 MME; P = 0.002) and postoperative opioid use (24.0 versus 37.7 MME; P < 0.001). Perioperative prothrombotic agents, such as TXA, were associated with lower total and postoperative MME (P = 0.005, P = 0.002). Multivariate regression analysis showed that increased PONV resulted in increased postoperative opioid use, whereas perioperative acetaminophen lowered total and postoperative quantities. CONCLUSIONS Perioperative IV acetaminophen is an effective method for decreasing inpatient opioid analgesia after orthognathic surgery. Intravenous TXA and PONV control may provide additional benefit to decreasing inpatient opioid consumption. More research as to the mechanisms and ideal clinical applications for both IV acetaminophen and TXA are warranted.
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Affiliation(s)
- Sarah J Phillips
- Plastic and Oral and Maxillofacial SUrgery, Yale New Haven Health, New Haven CT
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16
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Panghal R, Mitra S, Singh J, Sarna R, Goel B. Oral acetaminophen as an adjunct to continuous epidural infusion and patient-controlled epidural analgesia in laboring parturients: a randomized controlled trial. J Anesth 2021; 35:794-800. [PMID: 34313843 DOI: 10.1007/s00540-021-02975-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 07/16/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Intravenous acetaminophen is safe and effective as an adjunct to labor analgesia with combined spinal-epidural (CSE) analgesia and patient-controlled epidural analgesia (PCEA). Oral acetaminophen is a much cheaper and safe option but has not been studied as an adjunct to labor analgesia till date. The aim of the present study is to evaluate the effect of oral acetaminophen as an adjunct in patients receiving local anesthetic-opioid combination using CSE analgesia. METHOD In this ethically approved randomized double-blind placebo-controlled trial, 60 consenting parturients were randomly allocated to two groups of 30 each: acetaminophen (who received oral acetaminophen 1 g) or placebo, 45 min before the procedure. CSE was administered as per hospital protocol. All the patients received continuous epidural infusion (CEI) of levobupivacaine 0.1% and fentanyl 2 mcg/mL at 5 ml/h and PCEA boluses of 5 mL of the same drug with a lockout interval of 15 min if needed. The primary outcome was hourly mean consumption of levobupivacaine and fentanyl mixture (mL/h). Secondary outcomes included pain score, sensory and motor block, hemodynamic parameters of mother, duration of the second stage of labor, mode of delivery, maternal satisfaction, Apgar scores, fetal heart rate, and adverse effects. RESULTS The mean drug consumption per hour was significantly less in the acetaminophen group than in the placebo group (7.66 mL/h, SD 2.01 vs. 9.01 mL/h, SD 2.83; p = 0.04). The requirement for bolus was also significantly less in the acetaminophen group than in the placebo group (median 2.5, IQR 3 vs. median 3.5, IQR 2; p = 0.04). CONCLUSION The use of 1 g of oral acetaminophen could be a cheap, safe, and effective adjunct to CEI plus PCEA in labor analgesia.
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Affiliation(s)
- Reecha Panghal
- Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Sector 32, Chandigarh, 160030, India
| | - Sukanya Mitra
- Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Sector 32, Chandigarh, 160030, India.
| | - Jasveer Singh
- Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Sector 32, Chandigarh, 160030, India
| | - Rashi Sarna
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bharti Goel
- Department of Obstetrics and Gynaecology, Government Medical College and Hospital, Chandigarh, India
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17
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Egbuta C, Mason KP. Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit. J Clin Med 2021; 10:1847. [PMID: 33922824 PMCID: PMC8122992 DOI: 10.3390/jcm10091847] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 12/15/2022] Open
Abstract
Critically ill pediatric patients often require complex medical procedures as well as invasive testing and monitoring which tend to be painful and anxiety-provoking, necessitating the provision of analgesia and sedation to reduce stress response. Achieving the optimal combination of adequate analgesia and appropriate sedation can be quite challenging in a patient population with a wide spectrum of ages, sizes, and developmental stages. The added complexities of critical illness in the pediatric population such as evolving pathophysiology, impaired organ function, as well as altered pharmacodynamics and pharmacokinetics must be considered. Undersedation leaves patients at risk of physical and psychological stress which may have significant long term consequences. Oversedation, on the other hand, leaves the patient at risk of needing prolonged respiratory, specifically mechanical ventilator, support, prolonged ICU stay and hospital admission, and higher risk of untoward effects of analgosedative agents. Both undersedation and oversedation put critically ill pediatric patients at high risk of developing PICU-acquired complications (PACs) like delirium, withdrawal syndrome, neuromuscular atrophy and weakness, post-traumatic stress disorder, and poor rehabilitation. Optimal analgesia and sedation is dependent on continuous patient assessment with appropriately validated tools that help guide the titration of analgosedative agents to effect. Bundled interventions that emphasize minimizing benzodiazepines, screening for delirium frequently, avoiding physical and chemical restraints thereby allowing for greater mobility, and promoting adequate and proper sleep will disrupt the PICU culture of immobility and reduce the incidence of PACs.
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Affiliation(s)
| | - Keira P. Mason
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, USA;
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Intravenous Acetaminophen vs Intravenous Diclofenac Sodium in Management of Skeletal Vaso-occlusive Crisis Among Children with Homozygous Sickle Cell Disease: A Randomized Controlled Trial. Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2160-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Ghafouri HB, Abazarian N, Yasinzadeh M, Modirian E. Intravenous Paracetamol vs Intranasal Desmopressin for Renal Colic in the Emergency Department: A Randomized Clinical Trial. PAIN MEDICINE 2020; 21:3437-3442. [PMID: 32797236 DOI: 10.1093/pm/pnaa240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate the analgesic efficacy of intranasal desmopressin alone vs intravenous paracetamol in patients referred to the emergency department with renal colic. DESIGN Randomized clinical trial. SETTING This study was conducted in the emergency unit of a university hospital. SUBJECTS Patients referred to the emergency room with renal colic. PRIMARY OUTCOME Effect of intranasal desmopressin in pain relief in comparison with intravenous paracetamol. METHODS In this trial, 240 patients diagnosed with renal colic were randomly divided into two groups to compare the analgesic effect of intravenous paracetamol (15 mg/kg) and intranasal desmopressin spray (40 μg). Pain scores were measured by a numeric rating scale at baseline and after 15, 30, and 60 minutes. Adverse effects and need for rescue analgesic (0.05 mg/kg max 3 mg morphine sulphate) were also recorded at the end of the study. RESULTS Three hundred patients were eligible for the study; however, 240 were included in the final analysis. The patients in the two groups were similar in their baseline characteristics and baseline pain scores. The mean pain score after 15 minutes was more reduced and was clinically significant (>3) in the desmopressin group (P < 0.0001). There was no significant difference between mean pain scores in the two groups after 30 minutes (P = 0.350) or 60 minutes (P = 0.269), but the efficacy of the two drugs was significant in terms of pain reduction (>6). CONCLUSIONS Our study showed that intranasal desmopressin is as effective as intravenous paracetamol for renal colic pain management; however, significant clinical reduction in pain score occurred faster with intranasal desmopressin.
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Affiliation(s)
- Hamed Basir Ghafouri
- Emergency Medicine, Trauma and Injury Research Center, Iran University of Medical Sciences, Tehran, Iran
| | | | - Mohammadreza Yasinzadeh
- Emergency Medicine, Trauma and Injury Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ehsan Modirian
- Emergency Medicine, Qazvin University of Medical Sciences, Qazvin, Iran
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20
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George S, Johns M. Review of nonopioid multimodal analgesia for surgical and trauma patients. Am J Health Syst Pharm 2020; 77:2052-2063. [DOI: 10.1093/ajhp/zxaa301] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AbstractPurposePain is a frequent finding in surgical and trauma patients, and effective pain control remains a common challenge in the hospital setting. Opioids have traditionally been the foundation of pain management; however, these agents are associated with various adverse effects and risks of dependence and diversion.SummaryIn response to the rising national opioid epidemic and the various risks associated with opioid use, multimodal pain management through use of nonopioid analgesics such as acetaminophen, nonsteroidal anti-inflammatory drugs, α 2 agonists, N-methyl-d-aspartate (NMDA) receptor antagonists, skeletal muscle relaxants, sodium channel blockers, and local anesthetics has gained popularity recently. Multimodal analgesia has synergistic therapeutic effects and can decrease adverse effects by enabling use of lower doses of each agent in the multimodal regimen. This review discusses properties of the various nonopioid analgesics and encourages pharmacists to play an active role in the selection, initiation, and dose-titration of multimodal analgesia. The choice of nonopioid agents should be based on patient comorbidities, hemodynamic stability, and the agents’ respective adverse effect profiles. A multidisciplinary plan for management of pain should be formulated during transitions of care and is an area of opportunity for pharmacists to improve patient care.ConclusionMultimodal analgesia effectively treats pain while decreasing adverse effects. There is mounting evidence to support use of this strategy to decrease opioid use. As medication experts, pharmacists can play a key role in the selection, initiation, and dose-titration of analgesic agents based on patient-specific factors.
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Affiliation(s)
- Stephy George
- Department of Pharmacy, Texas Health Harris Methodist Hospital, Fort Worth, TX
| | - Meagan Johns
- Department of Pharmacy, University of Texas Southwestern Medical Center, Dallas, TX
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21
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Shikatani Y, Soh J, Shien K, Kurosaki T, Ohtani S, Yamamoto H, Taniguchi A, Okazaki M, Sugimoto S, Yamane M, Oto T, Morimatsu H, Toyooka S. Effectiveness of scheduled intravenous acetaminophen in the postoperative pain management of video-assisted thoracic surgery. Surg Today 2020; 51:589-594. [PMID: 32880060 DOI: 10.1007/s00595-020-02127-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 08/13/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The scheduled administration of intravenous acetaminophen (scheduled-IV-AcA) is one of the more effective multimodal analgesic approaches for postoperative pain in abdominal/orthopedic surgeries. However, there is little evidence concerning scheduled-IV-AcA after general thoracic surgery, especially when limited to video-assisted thoracoscopic surgery (VATS). We investigated the efficacy of scheduled-IV-AcA administration in patients after undergoing VATS. METHODS Ninety-nine patients who underwent VATS lobectomy or segmentectomy via an 8-cm access window and 1 camera port were retrospectively reviewed by categorizing them into groups either with scheduled-IV-AcA (Group AcA: n = 29) or without it (Group non-AcA: n = 70). Group AcA received 1 g of IV-AcA every 6 h from the end of the operation until the end of POD2. Postoperative pain was measured using a numeric rating scale (NRS) three times per day until discharge. RESULTS NRS scores were significantly lower in Group AcA with motion (on POD1 to the first point of POD2) than in Group non-AcA. Group non-AcA was also more likely to use additional analgesics than Group AcA (39% vs. 17%, p = 0.058). CONCLUSIONS Scheduled-IV-AcA administration is a safe and effective multimodal analgesic approach in patients undergoing VATS pulmonary resection via an 8-cm access window.
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Affiliation(s)
- Yoshinobu Shikatani
- Department of General Thoracic, Breast and Endocrine Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, 700-8558, Japan
| | - Junichi Soh
- Department of General Thoracic, Breast and Endocrine Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, 700-8558, Japan.
| | - Kazuhiko Shien
- Department of General Thoracic, Breast and Endocrine Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, 700-8558, Japan
| | - Takeshi Kurosaki
- Department of General Thoracic, Breast and Endocrine Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, 700-8558, Japan
| | - Shinji Ohtani
- Department of General Thoracic, Breast and Endocrine Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, 700-8558, Japan
| | - Hiromasa Yamamoto
- Department of General Thoracic, Breast and Endocrine Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, 700-8558, Japan
| | - Arata Taniguchi
- Anesthesiology and Resuscitology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, Japan
| | - Mikio Okazaki
- Department of General Thoracic, Breast and Endocrine Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, 700-8558, Japan
| | - Seiichiro Sugimoto
- Department of General Thoracic, Breast and Endocrine Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, 700-8558, Japan
| | - Masaomi Yamane
- Department of General Thoracic, Breast and Endocrine Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, 700-8558, Japan
| | - Takahiro Oto
- Department of General Thoracic, Breast and Endocrine Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, 700-8558, Japan
| | - Hiroshi Morimatsu
- Anesthesiology and Resuscitology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, Japan
| | - Shinichi Toyooka
- Department of General Thoracic, Breast and Endocrine Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, 700-8558, Japan
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In Reply to the Letter to the Editor Regarding "Intravenous Acetaminophen (Paracetamol) for Postcraniotomy Pain; Systematic Review and Meta-analysis of Randomized Clinical Trials". World Neurosurg 2020; 140:458-459. [PMID: 32797975 DOI: 10.1016/j.wneu.2020.05.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 05/19/2020] [Indexed: 11/22/2022]
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Mallama M, Valencia A, Rijs K, Rietdijk WJR, Klimek M, Calvache JA. A systematic review and trial sequential analysis of intravenous vs. oral peri-operative paracetamol. Anaesthesia 2020; 76:270-276. [PMID: 32557588 PMCID: PMC7818191 DOI: 10.1111/anae.15163] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2020] [Indexed: 12/13/2022]
Abstract
Postoperative pain might be different after intravenous vs. oral paracetamol. We systematically reviewed randomised controlled trials in patients >15 years that compared intravenous with oral paracetamol for postoperative pain. We identified 14 trials with 1695 participants. There was inconclusive evidence for an effect of route of paracetamol administration on postoperative pain at 0–2 h (734 participants), 2–6 h (766 participants), 6–24 h (1115 participants) and >24 h (248 participants), with differences in standardised mean (95%CI) pain scores for intravenous vs. oral of −0.17 (−0.45 to 0.10), −0.09 (−0.24 to 0.06), 0.06 (−0.12 to 0.23) and 0.03 (−0.22 to 0.28), respectively. Trial sequential analyses suggested that a total of 3948 participants would be needed to demonstrate a meaningful difference in pain or its absence at 0–2 h. There were no differences in secondary outcomes. Intravenous paracetamol is more expensive than oral paracetamol. Substitution of oral paracetamol in half the patients given intravenous paracetamol in our hospital would save around £ 38,711 (€ 43,960 or US$ 47,498) per annum.
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Affiliation(s)
- M Mallama
- Department of Anaesthesiology, Universidad del Cauca, Popayán, Colombia
| | - A Valencia
- Department of Anaesthesiology, Universidad del Cauca, Popayán, Colombia
| | - K Rijs
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - W J R Rietdijk
- Department of Intensive Care, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - M Klimek
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - J A Calvache
- Department of Anaesthesiology, Universidad del Cauca, Popayán, Colombia.,Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Ferrero C, Borland K. Anaesthetic complications and management of a great dane presenting with acute respiratory distress. VETERINARY RECORD CASE REPORTS 2020. [DOI: 10.1136/vetreccr-2019-001048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Camilla Ferrero
- Anaesthesia DepartmentAnderson Moores Veterinary SpecialistsWinchesterUK
| | - Karla Borland
- Anaesthesia DepartmentAnderson Moores Veterinary SpecialistsWinchesterUK
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Azimi Far A, Abdoli A, Poorolajal J, Salimi R. Paracetamol, ketorolac, and morphine in post-trauma headache in emergency department: A double blind randomized clinical trial. HONG KONG J EMERG ME 2020. [DOI: 10.1177/1024907920920747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction: Headache is one of the most common complaints of patients after head trauma. The aim of this study was the comparison of the analgesic effects of intravenous ketorolac, morphine, and paracetamol in patients with headache following head trauma. Methods: This clinical trial was performed on 105 referred patients to emergency unit with headache after head trauma. Patients were randomly divided into three groups of intravenous paracetamol (15 mg/kg in 100 mL normal saline), intravenous ketorolac (30 mg/kg in 100 mL normal saline), and intravenous morphine (0.1 mg/kg in 100 mL normal saline). Headache severity and side effects of drugs were assessed at baseline and 15, 30, and 60 min after intervention. Results: Headache severity score at baseline was similar among groups. After 15 min, headache severity score in paracetamol group was significantly lower than that in morphine and ketorolac groups (3.7 vs. 4.6 and 4.5, respectively). After 30 min, the score in paracetamol and ketorolac groups was significantly lower than that in morphine group (1.9 and 2.4 vs. 3.2, respectively). After 60 min, headache severity score in three groups was similar (1.6 in morphine and ketorolac groups and 1.5 in paracetamol group). The incidence of side effects in morphine group was significantly more than that in paracetamol and ketorolac groups. Conclusion: In emergency department, intravenous paracetamol and ketorolac obtain a faster and more effective onset compared with morphine for headache after head trauma.
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Affiliation(s)
- Alireza Azimi Far
- Department of Emergency, Besat Hospital, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Ali Abdoli
- Department of Neurosurgery, Besat Hospital, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Jalal Poorolajal
- Modeling of Noncommunicable Diseases Research Center & Department of Biostatistics and Epidemiology, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Rasoul Salimi
- Department of Emergency, Besat Hospital, Hamadan University of Medical Sciences, Hamadan, Iran
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Clinical evaluation of postoperative analgesia, cardiorespiratory parameters and changes in liver and renal function tests of paracetamol compared to meloxicam and carprofen in dogs undergoing ovariohysterectomy. PLoS One 2020; 15:e0223697. [PMID: 32059002 PMCID: PMC7021320 DOI: 10.1371/journal.pone.0223697] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 01/21/2020] [Indexed: 12/23/2022] Open
Abstract
Background In veterinary medicine, the administration of nonsteroidal anti-inflammatory analgesics (NSAIDs) for the control of postsurgical pain in dogs and cats is common given the anti-inflammatory, analgesic, and antipyretic effects of these drugs. This study compared the serum biochemical changes and postoperative analgesic effects of paracetamol, meloxicam, and carprofen in bitches submitted to an ovariohysterectomy using the Dynamic Interactive Visual Analog Scale (DIVAS) and Pain Scale of the University of Melbourne (UMPS) scoring systems. Methods Thirty bitches of different breeds underwent elective ovariohysterectomies and were randomly assigned to one of three treatment groups: a paracetamol group [15 mg kg-1 intravenous (IV)], a carprofen group (4 mg kg-1 IV), and a meloxicam group (0.2 mg kg-1 IV). All treatments were administered 30 minutes prior to surgery. Paracetamol was administered every 8 hours postoperatively for 48 hours total, while carprofen and meloxicam were intravenously administered every 24 hours. An evaluation of post-surgical pain was done with the DIVAS and the UMPS. The first post-surgical pain measurement was performed 1 hour after surgery and then 2, 4, 6, 8, 12, 16, 20, 24, 36, and 48 hours after surgery. Results All groups exhibited a gradual reduction in pain throughout the postoperative period in both scales; however, neither scale significantly differed between the three treatment groups (P > 0.05) during the 48 postoperative hours. Conclusions Paracetamol was as effective as meloxicam and carprofen for post-surgical analgesia in bitches subjected to elective ovariohysterectomy. The present study demonstrates that paracetamol may be considered a tool for the effective treatment of acute perioperative pain in dogs. Furthermore, this drug led to no adverse reactions or changes in the parameters assessed in the present study, indicating its safety.
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Donato J, Rao K, Lewis T. Pharmacology of Common Analgesic and Sedative Drugs Used in the Neonatal Intensive Care Unit. Clin Perinatol 2019; 46:673-692. [PMID: 31653302 DOI: 10.1016/j.clp.2019.08.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In this review of analgesic and sedation medication in neonates, important classes of old and newer medications commonly used in the neonatal intensive care unit setting are discussed. In addition to drug metabolism, efficacy, and safety for individual drugs, new insights into multimodal analgesic approaches suggest ways in which multiple analgesic drug classes can be combined to maximize efficacy and minimize toxicity. Opiate pharmacogenetics and the potential for a precision therapeutics approach is explored, with a final description of gaps in knowledge and a call for future research of pain and sedation control in the neonatal population.
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Affiliation(s)
- Jamesia Donato
- Department of Pediatrics, Division of Neonatology, UMKC School of Medicine, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Karishma Rao
- Department of Pediatrics, Division of Neonatology, UMKC School of Medicine, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Tamorah Lewis
- Department of Pediatrics, Division of Neonatology, UMKC School of Medicine, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA; Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Department of Pediatrics, Division of Pediatric Clinical Pharmacology, UMKC School of Medicine, Children's Mercy Hospital, Kansas City, MO, USA.
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Intravenous Acetaminophen Reduces Length of Stay Via Mediation of Postoperative Opioid Consumption After Posterior Spinal Fusion in a Pediatric Cohort. Clin J Pain 2019; 34:593-599. [PMID: 29200016 DOI: 10.1097/ajp.0000000000000576] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Since approval of intravenous acetaminophen (IV APAP), its use has become quite common without strong positive evidence. Our goal was to determine the effect of IV APAP on length of hospital stay (LOS) via mediation of opioid-related side effects in pediatric patients. MATERIALS AND METHODS After Institutional Review Board approval, 114 adolescents undergoing posterior spinal fusion were prospectively recruited and managed postoperatively with patient-controlled analgesia and adjuvant therapy. Patients were divided into 2 groups based on the use of IV APAP: control (n=70) and treatment (n=44). Association of IV APAP use with opioid outcomes was analyzed using inverse probability of treatment weighting (IPTW)-adjusted propensity scores to balance the 2 groups for all significant covariates except postoperative opioid consumption. Mediation analysis was carried out for LOS with IV APAP as the independent variable and morphine consumption as the mediator. RESULTS Oral intake was delayed by ∼1 day (P<0.001) and LOS was 0.6 days longer in the control group (P=0.044). After IPTW, time to oral intake remained significantly longer in the control group (P=0.014). The mediation model with IPTW revealed a significant negative association between IV APAP and morphine consumption (P<0.001), which significantly increased LOS (P<0.003). IV APAP had a significant opioid-sparing effect associated with shorter LOS. DISCUSSION IV APAP hastens oral intake and is associated with decreased LOS in an adolescent surgery population likely through decreased opioid consumption. Through addition of IV APAP in this population, LOS may be decreased, an important implication in the setting of escalating health care costs.
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Rakowski JA, Holloway RW, Ahmad S, Jeppson CN, James JA, Ghurani GB, Bigsby GE, Kendrick JE. A prospective randomized trial of intravenous ketorolac vs. acetaminophen administered with opioid patient-controlled analgesia in gynecologic surgery. Gynecol Oncol 2019; 155:468-472. [PMID: 31601494 DOI: 10.1016/j.ygyno.2019.09.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 09/19/2019] [Accepted: 09/23/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine which non-narcotic analgesic, acetaminophen (Ofirmev®) or ketorolac (Toradol®), provides better post-operative pain control when combined with an opioid patient-controlled analgesia (PCA) pump. Secondary objectives include comparisons of the rates of ileus, post-operative bleeding, transfusions, and length-of-hospitalization (LOH). METHODS A prospective, randomized trial of acetaminophen (A) 1-g intravenous (IV) every 6-h or ketorolac (K) 15-mg IV every 6-h from post-operative day 1-3 in addition to an opioid PCA for patients undergoing benign or malignant gynecologic laparotomy procedures was performed. Abstracted data included pain levels via visual analogue pain scales (VAS), amount of narcotic used, hepatic enzyme levels, hemoglobin, urine output, blood transfusions, time to return of flatus and LOH. RESULTS One-hundred patients were accrued and underwent 55 benign gynecologic laparotomies and 45 cancer-related laparotomies. VAS pain levels (3.3 K, 3.5 A) and morphine PCA use (79.1 oral morphine equivalents [OME] K vs. 84.5 A) were not different, however dilaudid PCA usage was less by K patients (84.4 OME K and 136.8 OME A, p < 0.001). There was a significant hemoglobin change between the two groups (2.6 g K vs. 2 g A, p = 0.015), however blood transfusions were equal (28% K, 22% A, p > 0.05). Return of flatus was 2.7-days for K vs. 3.4-days for A (p = 0.011) and LOH was not different (4.4-days K vs. 5.1-days A, p = 0.094). CONCLUSIONS Both intravenous ketorolac and acetaminophen provide similar post-operative analgesia through VAS pain scales and total usage of morphine via PCA pumps. Use of ketorolac with dilaudid PCA was associated with less dependence on dilaudid and a quicker return of bowel function than acetaminophen, however length of stay and transfusion rates were not different.
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Affiliation(s)
- Joseph A Rakowski
- AdventHealth Gynecologic Oncology, AdventHealth Cancer Institute, Orlando, FL, 32804, USA; Beaumont Gynecologic Oncology Associates, Beaumont Hospital-Dearborn, Dearborn, MI, 48124, USA.
| | - Robert W Holloway
- AdventHealth Gynecologic Oncology, AdventHealth Cancer Institute, Orlando, FL, 32804, USA
| | - Sarfraz Ahmad
- AdventHealth Gynecologic Oncology, AdventHealth Cancer Institute, Orlando, FL, 32804, USA.
| | - Corinne N Jeppson
- AdventHealth Gynecologic Oncology, AdventHealth Cancer Institute, Orlando, FL, 32804, USA
| | - Jeffrey A James
- AdventHealth Gynecologic Oncology, AdventHealth Cancer Institute, Orlando, FL, 32804, USA
| | - Giselle B Ghurani
- AdventHealth Gynecologic Oncology, AdventHealth Cancer Institute, Orlando, FL, 32804, USA
| | - Glenn E Bigsby
- AdventHealth Gynecologic Oncology, AdventHealth Cancer Institute, Orlando, FL, 32804, USA
| | - James E Kendrick
- AdventHealth Gynecologic Oncology, AdventHealth Cancer Institute, Orlando, FL, 32804, USA
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Arenillas M, Caro-Vadillo A, Gómez de Segura IA. Anesthetic management of a dog with severe subaortic stenosis and mitral valve disease complicated with atrial fibrillation undergoing ovariohysterectomy. Open Vet J 2019; 9:157-163. [PMID: 31360656 PMCID: PMC6626154 DOI: 10.4314/ovj.v9i2.11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 05/09/2019] [Indexed: 11/17/2022] Open
Abstract
The anesthetic management in patients with subaortic stenosis and mitral valve disease should involve intensive monitoring and the anesthesiologist's main concern is to ensure oxygen delivery and tissue perfusion. Since anesthetic procedures in such patients are rare, there is no previous report about the anesthetic management. A 5.5-year old, 32-kg Boxer, suffering a severe heart disease due to a final stage subaortic stenosis and mitral insufficiency, was anesthetized for an ovariohysterectomy to remove an ovarian tumor that was producing high-volume ascites. Methadone (0.3 mg kg-1) was administered intramuscularly (IM) for pre-anesthetic medication, etomidate (1.3 mg kg-1) and midazolam (0.2 mg kg-1) were used for the induction of anesthesia and after endotracheal intubation, anesthesia was maintained with sevoflurane vaporized in oxygen and air. Fentanyl (5-10 μg kg-1 h-1) and paracetamol (15 mg kg-1) were administered to improve analgesia. Previous persistent atrial fibrillation was refractory to medication (digoxin, diltiazem, and pimobendan) and continued during the anesthetic procedure. Dobutamine (1.5-5 μg kg-1 minute-1) helped to maintain mean arterial blood pressure above 60 mmHg. Epidural morphine (0.1 mg kg-1) and incisional bupivacaine (2 mg kg-1) were administered at the end of surgery to provide postoperative analgesia. Anesthesia was otherwise uneventful, and recovery was considered excellent.
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Affiliation(s)
- Mario Arenillas
- Department of Animal Medicine and Surgery, Facultad de Veterinaria, Hospital Clínico Veterinario, Universidad Complutense de Madrid, Madrid, Spain
| | - Alicia Caro-Vadillo
- Department of Animal Medicine and Surgery, Facultad de Veterinaria, Hospital Clínico Veterinario, Universidad Complutense de Madrid, Madrid, Spain
| | - Ignacio A Gómez de Segura
- Department of Animal Medicine and Surgery, Facultad de Veterinaria, Hospital Clínico Veterinario, Universidad Complutense de Madrid, Madrid, Spain
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Baichoo P, Asuncion A, El-Chaar G. Intravenous Acetaminophen For the Management of Pain During Vaso-occlusive Crises in Pediatric Patients. P & T : A PEER-REVIEWED JOURNAL FOR FORMULARY MANAGEMENT 2019; 44:5-8. [PMID: 30675085 PMCID: PMC6336200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Children with sickle cell disease experience vaso-occlusive crises (VOC) that requires opioid pharmacotherapy. Multimodal analgesic therapy may reduce pain and opioid-induced adverse effects. OBJECTIVE The primary objective was to examine the effectiveness of intravenous (IV) acetaminophen in children presenting with pain from VOC. Secondary objectives were to document the safety and opioid-sparing effects of IV acetaminophen during VOC in pediatric patients. SETTING Children's Medical Center, NYU-Winthrop Hospital. METHOD This retrospective study had two groups of patients, those who received opioids alone (group O) and those who received acetaminophen with opioids (group OA). Children two to 19 years of age who were admitted to the children's medical center for VOC were eligible for inclusion. MAIN OUTCOME MEASURE A reduction in pain by at least 1 out of 10. With every analgesic dose, we documented pain scales and pain scores before and after each dose, the number of doses administered per day, and mg/kg/day. Data were analyzed using the mixed effect model. All opioids administered to patients were converted to morphine equivalents. We documented length of stay and adverse events. RESULTS We had a total of 46 children: 28 in group O and 18 in group OA. Acetaminophen reduced the pain from VOC by 2.3/10. There were trends in different assessments of opioid-sparing effects, in reducing opioid dosage (-0.5 mg/kg morphine equivalent; P = 0.45), reducing overall morphine equivalent doses (-18.5 mg; P = 0.066), and opioid-related adverse effects. CONCLUSION This is the first study to demonstrate the effectiveness of IV acetaminophen in treating VOC pain in children, supporting multimodal analgesic therapy in this setting. Opioid-sparing effects were also encouraging.
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Shah UD, Dudhwala KN, Vakil MS. Prospective, double-blind randomized study of comparison of analgesic efficacy of parenteral paracetamol and diclofenac for postoperative pain relief. J Anaesthesiol Clin Pharmacol 2019; 35:188-191. [PMID: 31303707 PMCID: PMC6598591 DOI: 10.4103/joacp.joacp_384_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background and Aims: Injectable paracetamol has analgesic and antipyretic activities, especially used in postoperative period. The aim of this study was to assess the analgesic efficacy and safety of IV paracetamol in comparison with IV diclofenac for postoperative pain relief. Material and Methods: Randomly selected 120 patients who underwent elective surgery under general anesthesia were divided into two groups: group A (paracetamol group): patients received IV paracetamol (15 mg/kg)/100 mL, 30 min before completion of surgery over the period of 15 min (rounded of to 1 g), the selected cases were in range of 60-70 kg body weight. Group B (diclofenac group): patients received IV diclofenac (1 mg/kg) diluted in 100 mL NS, 30 min before completion of surgery over the period of 15 min (rounded of to 75 mg). Pain relief and side effects were observed in postoperative period. Statistical analysis of continuous data was done by unpaired t-test and Chi-square test was applied for discrete data. Results: Both IV paracetamol and IV diclofenac were effective for postoperative pain relief. No significant differences were found between them for any measures of analgesic activity. Only minor and common adverse events were reported, with no overall differences between groups. Conclusion: Both paracetamol and diclofenac drugs are safe to provide analgesia through IV route in postoperative period without any major significant side effects.
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Affiliation(s)
- Ushma D Shah
- Department of Anaesthesiology, SAL Hospital and Medical Institute, Ahmedabad, Gujarat, India
| | - Krunal N Dudhwala
- Department of Anaesthesiology, SAL Hospital and Medical Institute, Ahmedabad, Gujarat, India
| | - Mukesh S Vakil
- Department of Anaesthesiology, SAL Hospital and Medical Institute, Ahmedabad, Gujarat, India
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Hansen RN, Pham AT, Böing EA, Lovelace B, Wan GJ, Thomas DA, Fontes ML. Hospitalization costs and resource allocation in cholecystectomy with use of intravenous versus oral acetaminophen. Curr Med Res Opin 2018; 34:1549-1555. [PMID: 29192528 DOI: 10.1080/03007995.2017.1412301] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To evaluate intravenous (IV) acetaminophen (APAP) vs oral APAP use as adjunctive analgesics in cholecystectomy patients by comparing associated hospital length of stay (LOS), hospital costs, opioid use, and rates of nausea/vomiting, respiratory depression, and bowel obstruction. METHODS We conducted a retrospective analysis of the Premier Database (January 2012 to September 2015) including cholecystectomy patients who received either IV APAP or oral APAP. Differences in LOS, hospitalization costs, mean daily morphine equivalent dose (MED), and potential opioid-related adverse events were estimated. Multivariable logistic regression was performed for the binary outcomes and instrumental variable regressions, using the quarterly rate of IV APAP use for all hospitalizations by hospital as the instrument in two-stage least squares regressions for continuous outcomes. Models were adjusted for patient demographics, clinical risk factors, and hospital characteristics. RESULTS Among 61,017 cholecystectomy patients, 31,133 (51%) received IV APAP. Subjects averaged 51 and 57 years of age, respectively, in the IV and oral APAP cohorts. In the adjusted models, IV APAP was associated with 0.42 days shorter LOS (95% CI = -0.58 to -0.27; p < .0001), $1,045 lower hospitalization costs (95% CI = -$1,521 to -$569; p < .0001), 2 mg lower average daily MED (95% CI = -3 mg to -0.9 mg; p = .0005), and lower rates of respiratory depression (odds ratio [OR] = 0.89, 95% CI = 0.82-0.97; p = .006), and nausea and vomiting (OR = 0.86, 95% CI = 0.86-0.86; p < .0001). CONCLUSIONS In patients having cholecystectomy, the addition of IV APAP to perioperative pain management is associated with shorter LOS, lower costs, reduced opioid use, and less frequent nausea/vomiting and respiratory depression compared to oral APAP. These findings should be confirmed in a prospective study comparing IV and oral APAP.
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Affiliation(s)
- Ryan N Hansen
- a University of Washington , School of Pharmacy , Seattle , WA , USA
| | - An T Pham
- b University of California San Francisco , School of Pharmacy , San Francisco , CA , USA
| | - Elaine A Böing
- c Mallinckrodt Pharmaceuticals, Health Economics and Outcomes Research Department , Bedminster , NJ , USA
| | - Belinda Lovelace
- c Mallinckrodt Pharmaceuticals, Health Economics and Outcomes Research Department , Bedminster , NJ , USA
| | - George J Wan
- c Mallinckrodt Pharmaceuticals, Health Economics and Outcomes Research Department , Bedminster , NJ , USA
| | - Donna A Thomas
- d Yale University School of Medicine , New Haven , CT , USA
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Impact of Intravenous Acetaminophen on Perioperative Opioid Utilization and Outcomes in Open Colectomies. Anesthesiology 2018; 129:77-88. [DOI: 10.1097/aln.0000000000002227] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Abstract
Background
The value of intravenous acetaminophen in postoperative pain management remains debated. The authors tested the hypothesis that intravenous acetaminophen use, in isolation and in comparison to oral, would be associated with decreased opioid utilization (clinically significant reduction defined as 25%) and opioid-related adverse effects in open colectomy patients.
Methods
Using national claims data from open colectomy patients (Premier Healthcare Database, Premier Healthcare Solutions, Inc., USA; 2011 to 2016; n = 181,640; 602 hospitals), we separately categorized oral and intravenous acetaminophen use: 1 (1,000 mg) or more than 1 dose on the day of surgery, postoperative day 1, or later. Multilevel models measured associations between intravenous or oral acetaminophen and (1) opioid utilization and (2) opioid-related adverse effects. Percent change and multiplicity-adjusted 99.5% CI are reported.
Results
Overall, 25.1% of patients received intravenous acetaminophen, of whom 48.0% (n = 21,878) received 1 dose on the day of surgery. In adjusted analyses, particularly more than 1 dose of intravenous acetaminophen (versus nonuse) on postoperative day 1 was associated with a −12.4% (99.5% CI, −15.2 to −9.4%) change in opioid utilization. In comparison, a stronger reduction was seen in those receiving more than 1 oral acetaminophen dose: −22.6% (99.5% CI, −26.2 to −18.9%). Unadjusted group medians were 550 and 490 oral morphine equivalents, respectively. Intravenous versus oral differences were less pronounced among those receiving more than 1 acetaminophen dose on the day of surgery: −8.0% (99.5% CI, −11.0 to −4.9%) median 499 oral morphine equivalents versus −8.7% (99.5% CI, −14.4 to −2.7%) median 445 oral morphine equivalents, respectively; all statistically significant, but none clinically significant. Comparable outcome patterns existed for opioid-related adverse effects.
Conclusions
The demonstrated marginal effects do not support routine use of intravenous acetaminophen given alternative nonopioid analgesic options.
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Vittinghoff M, Lönnqvist PA, Mossetti V, Heschl S, Simic D, Colovic V, Dmytriiev D, Hölzle M, Zielinska M, Kubica-Cielinska A, Lorraine-Lichtenstein E, Budić I, Karisik M, Maria BDJ, Smedile F, Morton NS. Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative). Paediatr Anaesth 2018; 28:493-506. [PMID: 29635764 DOI: 10.1111/pan.13373] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2018] [Indexed: 12/21/2022]
Abstract
The main remit of the European Society for Paediatric Anaesthesiology (ESPA) Pain Committee is to improve the quality of pain management in children. The ESPA Pain Management Ladder is a clinical practice advisory based upon expert consensus to help to ensure a basic standard of perioperative pain management for all children. Further steps are suggested to improve pain management once a basic standard has been achieved. The guidance is grouped by the type of surgical procedure and layered to suggest basic, intermediate, and advanced pain management methods. The committee members are aware that there are marked differences in financial and personal resources in different institutions and countries and also considerable variations in the availability of analgesic drugs across Europe. We recommend that the guidance should be used as a framework to guide best practice.
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Affiliation(s)
- Maria Vittinghoff
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Per-Arne Lönnqvist
- Paediatric Anaesthesia & Intensive Care, Section of Anaesthesiology & Intensive Care, Department of Physiology & Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Valeria Mossetti
- Department of Anesthesia and Intensive Care, Regina Margherita Children's Hospital, Torino, Italy
| | - Stefan Heschl
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Dusica Simic
- University Children's Hospital, Medical Faculty University of Belgrade, Serbia
| | - Vesna Colovic
- Royal Manchester Children's Hospital, Central Manchester University Hospitals, Manchester, UK
| | - Dmytro Dmytriiev
- Department of Anesthesiology and Intensive Care, Vinnitsa National Medical University, Vinnitsa, Ukraine
| | - Martin Hölzle
- Section of Paediatric Anaesthesia, Department of Anaesthesia, Luzerner Kantonsspital, Luzern, Switzerland
| | - Marzena Zielinska
- Department of Paediatric Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | - Anna Kubica-Cielinska
- Department of Paediatric Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | | | - Ivana Budić
- Centre for Anesthesiology and Resuscitation, Clinical Centre Nis Department of Anesthesiology, Medical Faculty, University of Nis, Nis, Serbia
| | - Marijana Karisik
- Institute for Children Diseases, Department of Anaesthesiology, Clinical Centre of Montenegro, Podgorica, Montenegro
| | - Belen De Josè Maria
- Department of Pediatric Anesthesia, Hospital Sant Joan de Deu, University of Barcelona, Barcelona, Spain
| | - Francesco Smedile
- Department of Pediatric Anesthesiology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Neil S Morton
- Paediatric Anaesthesia and Pain Management, University of Glasgow, Glasgow, UK
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A Multimodal Analgesic Protocol Reduces Opioid-Related Adverse Events and Improves Patient Outcomes in Laparoscopic Sleeve Gastrectomy. Obes Surg 2018; 27:3075-3081. [PMID: 28674840 DOI: 10.1007/s11695-017-2790-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed procedures for the treatment of obesity. Patients with obesity are more prone to experience opioid-related adverse events (ORAE). OBJECTIVES The objective of this study is to determine if a multimodal analgesia protocol (MAP) reduces ORAE and provides effective pain relief for patients after LSG. SETTING This study was conducted at University Hospital, Singapore. METHODS The MAP consists of mandatory pre-operative etoricoxib, intra-operative acetaminophen, and post-operative acetaminophen with optional post-operative tramadol. We identified and collected data for patients who underwent LSG between May 2010 and November 2015 and compared patients before and after the implementation of the MAP. RESULTS One hundred fifty-eight patients were included and 68 patients were treated with the MAP. There were no differences in age, gender, body mass index, ethnicity, or comorbidities between the two groups except for the incidence of hypertension (p = 0.015). There was a significant reduction in the incidence of ORAE from 33.3 to 8.8% (p < 0.001) after the implementation of the MAP. There was also a significant reduction in the use of opioids intra-operatively from 58.2 to 43.6 mg (p < 0.001) and post-operatively from 23.7 to 0.7 mg (p < 0.001). Pain scores were similar at 1, 6, and 48 post-operatively, while pain scores were significantly reduced at 12 (p = 0.033) and 24 h (p = 0.02) post-operatively. Multivariate analysis showed that these results remained significant. CONCLUSION Our study suggests that a MAP reduces ORAE and provides effective pain relief for patients undergoing LSG.
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Chidambaran V, Subramanyam R, Ding L, Sadhasivam S, Geisler K, Stubbeman B, Sturm P, Jain V, Eckman MH. Cost-effectiveness of intravenous acetaminophen and ketorolac in adolescents undergoing idiopathic scoliosis surgery. Paediatr Anaesth 2018; 28:237-248. [PMID: 29377376 PMCID: PMC6004284 DOI: 10.1111/pan.13329] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Enhanced recovery after surgery protocols increasingly use multimodal analgesia after major surgeries with intravenous acetaminophen and ketorolac, despite no documented cost-effectiveness of these strategies. AIMS The goal of this prospective cohort study was to model cost-effectiveness of adding acetaminophen or acetaminophen + ketorolac to opioids for postoperative outcomes in children having scoliosis surgery. METHODS Of 106 postsurgical children, 36 received only opioids, 26 received intravenous acetaminophen, and 44 received acetaminophen + ketorolac as analgesia adjuncts. Costs were calculated in 2015 US $. Decision analytic model was constructed with Decision Maker® software. Base-case and sensitivity analyses were performed with effectiveness defined as avoidance of opioid adverse effects. RESULTS The groups were comparable demographically. Compared with opioids-only strategy, subjects in the intravenous acetaminophen + ketorolac strategy consumed less opioids (P = .002; difference in mean morphine consumption on postoperative days 1 and 2 was -0.44 mg/kg (95% CI -0.72 to -0.16); tolerated meals earlier (P < .001; RR 0.250 (0.112-0.556)) and had less constipation (P < .001; RR 0.226 (0.094-0.546)). Base-case analysis showed that of the 3 strategies, use of opioids alone is both most costly and least effective, opioids + intravenous acetaminophen is intermediate in both cost and effectiveness; and opioids + intravenous acetaminophen and ketorolac is the least expensive and most effective strategy. The addition of intravenous acetaminophen with or without ketorolac to an opioid-only strategy saves $510-$947 per patient undergoing spine surgery and decreases opioid side effects. CONCLUSION Intravenous acetaminophen with or without ketorolac reduced opioid consumption, opioid-related adverse effects, length of stay, and thereby cost of care following idiopathic scoliosis in adolescents compared with opioids-alone postoperative analgesia strategy.
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Affiliation(s)
- Vidya Chidambaran
- Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA,Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Rajeev Subramanyam
- Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA,Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Lili Ding
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA,Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Senthilkumar Sadhasivam
- Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA,Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Kristie Geisler
- Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Bobbie Stubbeman
- Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Peter Sturm
- Division of Orthopedic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Viral Jain
- Division of Orthopedic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Mark H. Eckman
- Department of Internal Medicine, Division of General Internal Medicine, and Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, OH, USA
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Decreased opioid consumption and enhance recovery with the addition of IV Acetaminophen in colorectal patients: a prospective, multi-institutional, randomized, double-blinded, placebo-controlled study (DOCIVA study). Surg Endosc 2018; 32:3432-3438. [DOI: 10.1007/s00464-018-6062-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 01/11/2018] [Indexed: 10/18/2022]
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Roberts CA, Shah-Becker S, O’Connell Ferster A, Baker A, Stahl LE, Sedeek K, Carr MM. Randomized Prospective Evaluation of Intraoperative Intravenous Acetaminophen in Pediatric Adenotonsillectomy. Otolaryngol Head Neck Surg 2017; 158:368-374. [PMID: 28873028 DOI: 10.1177/0194599817728911] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Objective To establish the safety and efficacy of single-dose intraoperative intravenous (IV) acetaminophen in postoperative pain management following adenotonsillectomy in addition to a standardized regimen of oral pain medication. Study Design Randomized, controlled prospective clinical trial. Setting Single academic medical center. Subjects and Methods Patients between the ages of 3 and 17 years scheduled for tonsillectomy or adenotonsillectomy by a single surgeon between December 2014 and November 2016 were recruited. Patients were randomly assigned to 1 of 2 groups; group 1 received a single intraoperative dose of IV acetaminophen, and group 2 did not. Induction and maintenance of anesthesia, as well as operative technique, were standardized. Nursing pain scores, pain medications administered, and recovery times were reviewed during the 24-hour postoperative period. Postoperative pain regimen included standing alternating oral acetaminophen and ibuprofen. Results In total, 260 patients were included in the study, and 131 (50.4%) received a single intraoperative dose of IV acetaminophen. Patients receiving IV acetaminophen were more likely to experience postoperative nausea and vomiting than patients who did not receive IV acetaminophen (1.53% vs 0.00%, P = .016). There were no significant differences noted for postoperative pain scores, requirements for breakthrough pain medications, time to discharge from the recovery room or hospital, or postoperative complications. Conclusion The use of a single intraoperative dose of IV acetaminophen was associated with minimal additional adverse effects. However, a single intraoperative IV dose of acetaminophen added to standard narcotic and nonnarcotic pain medication does not provide a statistically significant improvement in pain control.
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Affiliation(s)
- Christopher A. Roberts
- Department of Otolaryngology–Head and Neck Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Shivani Shah-Becker
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
| | - Ashley O’Connell Ferster
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
| | - Aaron Baker
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
| | - Lauren E. Stahl
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
| | - Khaled Sedeek
- Department of Anesthesiology, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
| | - Michele M. Carr
- Department of Otolaryngology–Head and Neck Surgery, West Virginia University, Morgantown, West Virginia, USA
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Mian P, Tibboel D, Morlion B, Allegaert K. Continuous Intravenous Acetaminophen for Analgesia: First, Back to the Drawing Table? J Clin Pharmacol 2017; 57:1353-1354. [PMID: 28884853 DOI: 10.1002/jcph.965] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 05/19/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Paola Mian
- Erasmus MC-Sophia Children's Hospital, Intensive Care and Department of Paediatric Surgery, Rotterdam, The Netherlands
| | - Dick Tibboel
- Erasmus MC-Sophia Children's Hospital, Intensive Care and Department of Paediatric Surgery, Rotterdam, The Netherlands
| | - Bart Morlion
- The Leuven Centre for Algology, University Hospitals Leuven, University of Leuven, Leuven, Belgium
| | - Karel Allegaert
- Erasmus MC-Sophia Children's Hospital, Intensive Care and Department of Paediatric Surgery, Rotterdam, The Netherlands.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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Abstract
Pain is a significant morbidity resulting from head and neck cancer. Pain may also be the result of the treatments directed against head and neck cancer. An experienced practitioner may manage this pain by understanding the multifactorial mechanisms of pain and the various pharmacotherapies available. Pain should be managed with multiple medications in a multimodal approach, and nonpharmacologic therapies should be considered as well.
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Affiliation(s)
- Jakun W Ing
- University of California Los Angeles, Comprehensive Pain Center, 1245 16th Street, Suite 225, Santa Monica, CA 90404, USA.
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Meyering SH, Stringer RW, Hysell MK. Randomized Trial of Adding Parenteral Acetaminophen to Prochlorperazine and Diphenhydramine to Treat Headache in the Emergency Department. West J Emerg Med 2017; 18:373-381. [PMID: 28435487 PMCID: PMC5391886 DOI: 10.5811/westjem.2016.12.29218] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 12/12/2016] [Accepted: 12/13/2016] [Indexed: 11/16/2022] Open
Abstract
Introduction Headaches represent over three million emergency department (ED) visits per year, comprising 2.4% of all ED visits. There are many proposed methods and clinical guidelines of treating acute headache presentations. However, data on intravenous acetaminophen usage in these settings are lacking. In this study, we sought to determine the efficacy of intravenous (IV) acetaminophen as an adjunct to a standard therapy for the treatment of patients who present to the ED with a chief complaint of “headache.” Methods We conducted a single site, randomized, double-blind, placebo-controlled trial investigating the clinical efficacy of IV acetaminophen as an adjunct to a standard therapy with prochlorperazine and diphenhydramine for the treatment of patients who present to the ED with a chief complaint of “headache” or variants thereof. (See below for variants). The primary outcome measure of the efficacy of parenteral acetaminophen as an adjunct treatment for headache in addition to a standard therapy was a threshold two-point reduction in visual analog scale (VAS) pain scores on a 1–10 level at 90 minutes. Secondary outcomes measures included assessment of decreased requirement of “rescue” pain medicines, defined as any analgesic medications outside of diphenhydramine, prochlorperazine and acetaminophen, with particular interest to potential opioid-sparing effects with parenteral acetaminophen. Additional secondary outcome measure included time to disposition from arrival in the ED. Results For the acetaminophen group the initial mean pain score was 8.67, for the placebo group 8.61. At 90 minutes pain score was 2.23 for the acetaminophen group and 3.99 for placebo (p<0.01, 95% confidence interval (CI) [0.8%–16%]. Of 45 patients in each group, we observed at least a threshold two-point decrease in pain score 36/45 (80%) with acetaminophen vs. 25/45 (55%) with placebo (p <0.01) 95% CI [5%–41%], number needed to treat (NNT) = 4). Secondary outcome measure did not demonstrate a difference in length of stay (161 minutes for acetaminophen arm and 159 minutes for placebo). However, 17/45 (38%) of patients who received IV acetaminophen required rescue analgesia, opposed to 24/45 (53%) of patients in the placebo group (p=0.13) 95% CI [−5%–34%]. Conclusion IV acetaminophen when used with prochlorperazine and diphenhydramine to treat acute headaches in the ED resulted in statistically significant pain reduction compared with prochlorperazine and diphenhydramine alone as measured by both threshold of lowering VAS pain score by at least two points (NNT = 4) and overall decline in VAS pain score. Further study is required to validate these results.
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Affiliation(s)
- Stefan H Meyering
- Michigan State University, Lakeland Healthcare, Department of Emergency Medicine, St. Joseph, Michigan
| | - Ryan W Stringer
- Michigan State University, Lakeland Healthcare, Department of Emergency Medicine, St. Joseph, Michigan
| | - Matthew K Hysell
- Michigan State University, Lakeland Healthcare, Department of Emergency Medicine, St. Joseph, Michigan
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Douzjian DJ, Kulik A. Old Drug, New Route: A Systematic Review of Intravenous Acetaminophen After Adult Cardiac Surgery. J Cardiothorac Vasc Anesth 2017; 31:694-701. [DOI: 10.1053/j.jvca.2016.03.134] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Indexed: 11/11/2022]
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Candido KD, Perozo OJ, Knezevic NN. Pharmacology of Acetaminophen, Nonsteroidal Antiinflammatory Drugs, and Steroid Medications: Implications for Anesthesia or Unique Associated Risks. Anesthesiol Clin 2017; 35:e145-e162. [PMID: 28526157 DOI: 10.1016/j.anclin.2017.01.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Acetaminophen, nonsteroidal antiinflammatory drugs (NSAIDs), and corticosteroids, historically used in perioperative management, are potent analgesic medications. They primarily inhibit the cyclooxygenase (COX) enzyme, decreasing the synthesis of prostaglandins, and modulating pain and temperature. Acetaminophen does not inhibit this synthesis at the inflammatory site. The primary mechanism of action of corticosteroids involves regulation of nuclear expression of genes involved in inflammatory pathways and other systemic effects. Metaanalyses have added purposeful perioperative indications, clarified misconceptions, and established protocols for administering these drugs. Some indications, doses, clinical considerations, and adverse effects need to be further studied.
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Affiliation(s)
- Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, 836 West Wellington Avenue, Suite 4815, Chicago, IL 60657, USA; Department of Anesthesiology, University of Illinois, 1740 W. Taylor Street, Chicago, IL 60612, USA; Department of Surgery, University of Illinois, 840 S. Wood Street, Chicago, IL 60612, USA.
| | - Oscar J Perozo
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, 836 West Wellington Avenue, Suite 4815, Chicago, IL 60657, USA
| | - Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, 836 West Wellington Avenue, Suite 4815, Chicago, IL 60657, USA; Department of Anesthesiology, University of Illinois, 1740 W. Taylor Street, Chicago, IL 60612, USA; Department of Surgery, University of Illinois, 840 S. Wood Street, Chicago, IL 60612, USA
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Roberts CA, Shah-Becker S, Derr JB, Sedeek K, Carr MM. Effect of single dose intraoperative IV acetaminophen in pediatric tonsillectomy or adenotonsillectomy. EGYPTIAN JOURNAL OF ANAESTHESIA 2017. [DOI: 10.1016/j.egja.2016.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Christopher A. Roberts
- The Pennsylvania State University, College of Medicine, 500 University Drive, Hershey, PA, USA
| | - Shivani Shah-Becker
- The Pennsylvania State University, College of Medicine, Department of Surgery, 500 University Drive, Hershey, PA, USA
| | - Jonathan B. Derr
- The Pennsylvania State University, College of Medicine, Department of Surgery, 500 University Drive, Hershey, PA, USA
| | - Khaled Sedeek
- The Pennsylvania State University, College of Medicine, Department of Anesthiology, 500 University Drive, Hershey, PA, USA
| | - Michele M. Carr
- The Pennsylvania State University, College of Medicine, Department of Surgery, 500 University Drive, Hershey, PA, USA
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Ohkura Y, Haruta S, Shindoh J, Tanaka T, Ueno M, Udagawa H. Effectiveness of postoperative intravenous acetaminophen (Acelio) after gastrectomy: A propensity score-matched analysis. Medicine (Baltimore) 2016; 95:e5352. [PMID: 27858921 PMCID: PMC5591169 DOI: 10.1097/md.0000000000005352] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The aim of this study was to investigate the efficacy of postoperative scheduled intravenous acetaminophen to reduce the opioid use and enhance recovery after gastrectomy.Opioid use is reportedly associated with delayed recovery of gastrointestinal (GI) peristalsis and postoperative nausea/vomiting (PONV) despite of acceptable efficacy for pain control.Of 147 and 96 consecutive patients who underwent gastrectomy for gastric cancer before and after introduction of postoperative scheduled intravenous acetaminophen, propensity score matched population was created and short-term clinical outcomes were compared.Significant defervescence was demonstrated in Acetaminophen group (A-group) compared with control group (C-group) during the perioperative period (P < 0.001), whereas no significant difference was observed in postoperative inflammatory parameters. The incidence of postoperative complications was similar between the groups. The number of patient-controlled analgesia (PCA) pushes was significantly reduced in the A-group (P = 0.007) and the frequency of use of other nonopioid analgesics was also significantly reduced in the A-group (P < 0.001). Both daily and cumulative opioid use was significantly reduced in the A-group (P < 0.001). The time to first flatus and defecation was decreased in the A-group (P < 0.001 and P = 0.038, respectively). The incidence of PONV was significantly reduced from 26.0% to 12.5% after introduction of intravenous acetaminophen (P = 0.017), and hospital stay tended to be decreased in the A-group (13.2 vs 14.7 days, P = 0.069)Postoperative scheduled intravenous acetaminophen decreased opioid use and may be associated with enhanced recovery after gastrectomy.
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Affiliation(s)
- Yu Ohkura
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
- Correspondence: Yu Ohkura, Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo 105-8470, Japan (e-mail: )
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Holmes S, Singh M, Su C, Cunningham RL. Effects of Oxidative Stress and Testosterone on Pro-Inflammatory Signaling in a Female Rat Dopaminergic Neuronal Cell Line. Endocrinology 2016; 157:2824-35. [PMID: 27167771 PMCID: PMC4929547 DOI: 10.1210/en.2015-1738] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Parkinson's disease, a progressive neurodegenerative disorder, is associated with oxidative stress and neuroinflammation. These pathological markers can contribute to the loss of dopamine neurons in the midbrain. Interestingly, men have a 2-fold increased incidence for Parkinson's disease than women. Although the mechanisms underlying this sex difference remain elusive, we propose that the primary male sex hormone, testosterone, is involved. Our previous studies show that testosterone, through a putative membrane androgen receptor, can increase oxidative stress-induced neurotoxicity in dopamine neurons. Based on these results, this study examines the role of nuclear factor κ B (NF-κB), cyclooxygenase-2 (COX2), and apoptosis in the deleterious effects of androgens in an oxidative stress environment. We hypothesize, under oxidative stress environment, testosterone via a putative membrane androgen receptor will exacerbate oxidative stress-induced NF-κB/COX2 signaling in N27 dopaminergic neurons, leading to apoptosis. Our data show that testosterone increased the expression of COX2 and apoptosis in dopamine neurons. Inhibiting the NF-κB and COX2 pathway with CAPE and ibuprofen, respectively, blocked testosterone's negative effects on cell viability, indicating that NF-κB/COX2 cascade plays a role in the negative interaction between testosterone and oxidative stress on neuroinflammation. These data further support the role of testosterone mediating the loss of dopamine neurons under oxidative stress conditions, which may be a key mechanism contributing to the increased incidence of Parkinson's disease in men compared with women.
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Affiliation(s)
- Shaletha Holmes
- Department of Pharmacology and Neuroscience, Institute for Aging and Alzheimer's Disease Research, University of North Texas Health Science Center, Fort Worth, Texas 76107
| | - Meharvan Singh
- Department of Pharmacology and Neuroscience, Institute for Aging and Alzheimer's Disease Research, University of North Texas Health Science Center, Fort Worth, Texas 76107
| | - Chang Su
- Department of Pharmacology and Neuroscience, Institute for Aging and Alzheimer's Disease Research, University of North Texas Health Science Center, Fort Worth, Texas 76107
| | - Rebecca L Cunningham
- Department of Pharmacology and Neuroscience, Institute for Aging and Alzheimer's Disease Research, University of North Texas Health Science Center, Fort Worth, Texas 76107
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Mamoun NF, Lin P, Zimmerman NM, Mascha EJ, Mick SL, Insler SR, Sessler DI, Duncan AE. Intravenous acetaminophen analgesia after cardiac surgery: A randomized, blinded, controlled superiority trial. J Thorac Cardiovasc Surg 2016; 152:881-889.e1. [PMID: 27236864 DOI: 10.1016/j.jtcvs.2016.04.078] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 03/14/2016] [Accepted: 04/23/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pain after cardiac surgery traditionally has been controlled by intravenous opioids and nonsteroidal antiinflammatory drugs. An intravenous analgesic with fewer adverse effects is needed. Therefore, we tested the primary hypothesis that intravenous acetaminophen is more effective than placebo for pain management, which was defined a priori as superior on either pain intensity score and/or opioid consumption and not worse on either. METHODS In this single-center, double-blind trial, 147 patients having cardiac surgery via median sternotomy were randomized to receive either 1 g of intravenous acetaminophen (73 patients) every 6 hours for 24 hours or comparable placebo (74 patients) starting in the operating room after sternal closure. Cumulative opioid consumption (in morphine equivalents) and pain intensity scores (on a 0-10 Numeric Rating Scale) were measured at 4, 6, 8, 12, 16, 20, and 24 hours after surgery. We estimated ratio of mean opioid consumption by using multivariable linear regression (noninferiority delta = 1.15) and pain score difference by using repeated measures regression (noninferiority delta = 1). RESULTS Acetaminophen was superior to placebo on mean pain intensity scores and noninferior on opioid consumption, with estimated difference in mean pain (95% confidence interval) of -0.90 (-1.39, -0.42), P < .001 (superior), and estimated ratio of means in opioid consumption (90% confidence interval) of 0.89 (0.73-1.10), P = .28 (noninferior; not superior). CONCLUSIONS Intravenous acetaminophen reduced pain after cardiac surgery, but not opioid consumption. Intravenous acetaminophen can be an effective analgesic adjunct in patients recovering from median sternotomy.
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Affiliation(s)
- Negmeldeen F Mamoun
- Department of Cardiothoracic Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Peirong Lin
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nicole M Zimmerman
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Edward J Mascha
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Stephanie L Mick
- Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Steven R Insler
- Department of Cardiothoracic Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Andra E Duncan
- Department of Cardiothoracic Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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