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De Leon-Casasola O. American Society of Regional Anesthesia and Pain Medicine 2021 John J. Bonica Award Lecture. Reg Anesth Pain Med 2023; 48:67-73. [PMID: 36328376 DOI: 10.1136/rapm-2022-104050] [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: 09/07/2022] [Accepted: 10/18/2022] [Indexed: 11/05/2022]
Abstract
I am as deeply inspired and humbled to receive this prestigious award, as I am profoundly indebted to the Bonica Award selection committee and the American Society of Regional Anesthesia and Pain Medicine Board of Directors for recognizing my contributions to the development, teaching, and practice of pain medicine in the tradition of Dr John J Bonica. I would also like to recognize my parents, Aura and Tito for providing me with the support and the environment to fulfill my professional goals. Moreover, the support that I have gotten from my team at the hospital, and the Chair of my Department, Dr Mark Lema needs to be underscored.
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Affiliation(s)
- Oscar De Leon-Casasola
- Department of Anesthesiology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA .,Roswell Park Comprehensive Cancer Institute and Department of Anesthesiology, University at Bufalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
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Hussain N, Brull R, Speer J, Hu LQ, Sawyer T, McCartney CJL, Abdallah FW. Analgesic benefits of the quadratus lumborum block in total hip arthroplasty: a systematic review and meta-analysis. Anaesthesia 2022; 77:1152-1162. [PMID: 35947882 DOI: 10.1111/anae.15823] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 02/06/2023]
Abstract
The quadratus lumborum block (QLB) is reported to reduce pain and improve function following total hip arthroplasty; however, randomised controlled trials evaluating the benefits of adding this block to general or spinal anaesthesia in this population are conflicting. We performed a systematic review seeking randomised controlled trials investigating QLB benefits for total hip arthroplasty, stratifying comparisons regarding the addition of QLB to either general or spinal anaesthesia. The primary outcome was 24-h area under the curve (AUC) pain score. Pain scores were interpreted in the context of a population-specific minimal clinically important difference of 1.86 cm on a 10-cm visual analogue scale, or an AUC pain score of 5.58 cm.h. Secondary outcomes included analgesic consumption, functional recovery and opioid-related side-effects. In all, 18 trials (1318 patients) were included. Adding QLB to general or spinal anaesthesia improved 24-h AUC rest pain scores by a mean difference (95%CI) of -3.56 cm.h (-6.70 to -0.42; p = 0.034) and - 4.19 cm.h (-7.20 to -1.18; p = 0.014), respectively. These improvements failed to reach the pre-determined minimal clinically important difference, as did the reduction in analgesic consumption. Quadratus lumborum block improved functional recovery for general, but not spinal, anaesthesia. Opioid-related side-effects were reduced with QLB regardless of anaesthetic modality. Low-to-moderate quality evidence suggests that the extent to which adding QLB to either general or spinal anaesthesia reduces postoperative pain and opioid consumption after total hip arthroplasty is statistically significant but may be clinically unimportant for most patients. However, adding QLB to general anaesthesia might enhance functional recovery. Taken together, our findings do not support the routine use of QLB as part of multimodal analgesic regimens for total hip arthroplasty.
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Affiliation(s)
- N Hussain
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Harvard, Boston, MA, USA
| | - R Brull
- Department of Anesthesiology and Pain Medicine, Women's College Hospital, University of Toronto, ON, Canada
| | - J Speer
- Department of Anesthesiology, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - L-Q Hu
- Department of Anesthesiology, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - T Sawyer
- Central Michigan University, College of Medicine, Saginaw, MI, USA
| | - C J L McCartney
- Department of Anesthesiology and Pain Medicine, and the Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - F W Abdallah
- Department of Anesthesiology and Pain Medicine, and the Ottawa Hospital Research Institute, University of Ottawa, ON, Canada.,Department of Anesthesia, and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, ON, Canada
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Adalbert JR, Ilyas AM. Implementing Prescribing Guidelines for Upper Extremity Orthopedic Procedures: A Prospective Analysis of Postoperative Opioid Consumption and Satisfaction. Hand (N Y) 2021; 16:491-497. [PMID: 31441326 PMCID: PMC8283100 DOI: 10.1177/1558944719867122] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background: A lack of established opioid-prescribing guidelines has prompted recent studies to propose preliminary guidelines to mitigate inadvertent overprescribing, diversion, and abuse. The purpose of our study was to assess the efficacy of a specific set of opioid-prescribing guidelines by prospective evaluation of patient consumption and satisfaction. Methods: During a consecutive period, all patients undergoing outpatient upper extremity surgical procedures were postoperatively prescribed opioids based on published guidelines that were specific to the anatomical location and procedure being performed. At the first postoperative visit, surgical details, opioid consumption patterns, and prescription efficacy and satisfaction were recorded. Results: A total of 201 patients reported any amount of prescription use, resulting in a mean consumption of 5.5 pills. Patients who underwent soft tissue procedures reported the lowest requirement (4.2 pills) compared with those who underwent fracture repairs (6.7 pills) or arthroscopy and arthroplasty/fusion procedures (8.7 pills). Patients undergoing hand procedures consumed fewer opioids (3.9 pills) compared with those undergoing wrist (6.3 pills) or elbow (8.1 pills) procedures. Of the patients requiring opioids, 82% reported being satisfied or at least neutral to the prescribed quantity (P < .001), and 92% reported being satisfied or at least neutral to the prescribed opioid analgesic efficacy (P < .001). Overall, the study refill request rate was 13%. Conclusions: Although the proposed guidelines tended to exceed patient need, the study confirmed strong patient satisfaction and an overall refill request rate of only 13%. We conclude that following anatomical and procedure-specific opioid-prescribing guidelines is an effective method of prescribing opioids postoperatively after upper extremity.
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Affiliation(s)
| | - Asif M. Ilyas
- Thomas Jefferson University, Philadelphia, PA, USA,Asif M. Ilyas, Rothman Institute, Thomas Jefferson University, 925 Chestnut Street, Philadelphia, PA 19107, USA.
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Wong KA, Goyal KS. Postoperative Pain Management of Non-"Opioid-Naive" Patients Undergoing Hand and Upper-Extremity Surgery. Hand (N Y) 2020; 15:651-658. [PMID: 30781996 PMCID: PMC7543219 DOI: 10.1177/1558944719828000] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Patients with prior opioid use are often difficult to manage postoperatively. We examined potential strategies for managing these patients: (1) prescribing a different opioid; and (2) encouraging the use of nonopioid analgesics over opioids. Methods: A pain control program was implemented at an outpatient hand and upper-extremity center. Patients were recruited before (n = 305) and after (n = 225) implementation. Seventy of them were taking opioids prior to surgery. Information about pain control satisfaction and opioid use was collected. The Fisher exact test was used to compare categorical variables with small expected frequencies. Wilcoxon rank sum test was used to compare nonnormally distributed continuous variables. Results: Opioid users used 28.8 ± 25.6 opioid pills; nonopioid users used 14.5 ± 21.5 pills. Furthermore, 41.4% of opioid users sought more pills after surgery compared with 14.0% among nonopioid users. The pain control program was more effective in reducing opioid consumption and waste and increasing nonopioid consumption for nonopioid users than for opioid users. Prior opioid users who were prescribed a different opioid after surgery used 24.6 ± 22.0 opioid pills. Patients prescribed the same opioid used 37.9 ± 30.8 pills. Conclusions: Patients taking opioids prior to hand and upper-extremity surgery use more opioid pills, seek more pills after surgery, and are less satisfied with their pain control than their nonopioid user counterparts. Furthermore, the comprehensive pain plan was less effective in this patient population. Prescribing a different opioid reduced medication requirements for these patients, but additional strategies are needed to address postoperative pain management.
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Affiliation(s)
- Kelvin A. Wong
- College of Medicine, The Ohio State University, Columbus, USA
| | - Kanu S. Goyal
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, USA
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Abstract
BACKGROUND The purpose of this study was to compare narcotic use in the 90-day postoperative period across orthopaedic trauma, spine, and adult reconstruction patients and examine whether patient-reported pain scores at discharge correlate with narcotic use during the 90-day postoperative period. METHODS Electronic medical record query was done between 2012 and 2015 using diagnosis-related groups for spine, adult reconstruction, and trauma procedures. Demographics, length of stay (LOS), visual analog scale pain scores during hospitalization, and narcotics prescribed in the 90-day postoperative period were collected. Multivariate analysis and linear regression were done. RESULTS Five thousand thirty patients were analyzed. Spine patients had the longest LOS, highest mean pain during LOS, and were prescribed the most morphine in the 90-day postoperative period. Linear regression revealed that pain scores at discharge markedly influence the quantity of narcotics prescribed in the 90-day postoperative period. DISCUSSION Patient-reported pain at hospital discharge was associated with increased narcotic use in the 90-day postoperative period.
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The Role Multimodal Pain Management Plays With Successful Total Knee and Hip Arthroplasty. TOPICS IN GERIATRIC REHABILITATION 2019. [DOI: 10.1097/tgr.0000000000000215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lawson McLean A, Kalff R, Reichart R. Spinal Cord Stimulation for Acute Pain Following Surgery for Cervical Myelopathy: A Novel Treatment Strategy. Pain Pract 2018; 19:310-315. [PMID: 30369016 DOI: 10.1111/papr.12742] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 09/28/2018] [Accepted: 10/19/2018] [Indexed: 01/15/2023]
Abstract
BACKGROUND Chronic pain syndromes caused by degenerative and postinfectious changes in the cervical spine continue to pose significant management challenges to neurosurgeons and pain practitioners. The identification of an individualized treatment plan, astute surgical technique, comprehensive and multimodal analgesia, and adequate rehabilitation processes do not necessarily result in diminished pain. CASE SUMMARY We present the case of a patient with chronic pain treated surgically for degenerative cervical myelopathy secondary to cervical spinal stenosis. Following this surgery, the patient experienced an intractable postoperative pain syndrome that had anatomical borders, and an intensity and character that were different from the background chronic pain from which he suffered. We successfully implanted a cervical spinal cord stimulation (SCS) lead in the period following his stenosis surgery, which had good therapeutic effect on the postoperative-onset pain. To the best of our knowledge, this is the first description of SCS having a strong positive effect on an acute exacerbation of neuropathic pain. At follow-up 12 months later, assessment of the patient's pain diary revealed a modal pain intensity of 3/10 on the numeric rating scale over the preceding 3 months. The Brief Pain Inventory (Short Form) scores at this time were 10/40 in the pain severity domain and 18/70 in the interference with function domain, demonstrating the long-term effectiveness of this SCS strategy. CONCLUSION While SCS has hitherto been untested as a therapy for acute-onset pain, this report demonstrates its utility as a salvage treatment in select cases of uncontrollable postoperative pain.
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Affiliation(s)
- Aaron Lawson McLean
- Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, Jena University Hospital, Jena, Germany
| | - Rolf Kalff
- Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, Jena University Hospital, Jena, Germany
| | - Rupert Reichart
- Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, Jena University Hospital, Jena, Germany
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Stewart TM, Pulos N, Curry TB, Gazelka HM, Brown MJ, Shin AY. Team Approach: Multimodal Perioperative Pain Management in Upper-Extremity Surgery. JBJS Rev 2018; 6:e5. [DOI: 10.2106/jbjs.rvw.17.00190] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Cohen SP, Bhatia A, Buvanendran A, Schwenk ES, Wasan AD, Hurley RW, Viscusi ER, Narouze S, Davis FN, Ritchie EC, Lubenow TR, Hooten WM. Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Chronic Pain From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Reg Anesth Pain Med 2018; 43:521-546. [PMID: 29870458 PMCID: PMC6023575 DOI: 10.1097/aap.0000000000000808] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND Over the past 2 decades, the use of intravenous ketamine infusions as a treatment for chronic pain has increased dramatically, with wide variation in patient selection, dosing, and monitoring. This has led to a chorus of calls from various sources for the development of consensus guidelines. METHODS In November 2016, the charge for developing consensus guidelines was approved by the boards of directors of the American Society of Regional Anesthesia and Pain Medicine and, shortly thereafter, the American Academy of Pain Medicine. In late 2017, the completed document was sent to the American Society of Anesthesiologists' Committees on Pain Medicine and Standards and Practice Parameters, after which additional modifications were made. Panel members were selected by the committee chair and both boards of directors based on their expertise in evaluating clinical trials, past research experience, and clinical experience in developing protocols and treating patients with ketamine. Questions were developed and refined by the committee, and the groups responsible for addressing each question consisted of modules composed of 3 to 5 panel members in addition to the committee chair. Once a preliminary consensus was achieved, sections were sent to the entire panel, and further revisions were made. In addition to consensus guidelines, a comprehensive narrative review was performed, which formed part of the basis for guidelines. RESULTS Guidelines were prepared for the following areas: indications; contraindications; whether there was evidence for a dose-response relationship, or a minimum or therapeutic dose range; whether oral ketamine or another N-methyl-D-aspartate receptor antagonist was a reasonable treatment option as a follow-up to infusions; preinfusion testing requirements; settings and personnel necessary to administer and monitor treatment; the use of preemptive and rescue medications to address adverse effects; and what constitutes a positive treatment response. The group was able to reach consensus on all questions. CONCLUSIONS Evidence supports the use of ketamine for chronic pain, but the level of evidence varies by condition and dose range. Most studies evaluating the efficacy of ketamine were small and uncontrolled and were either unblinded or ineffectively blinded. Adverse effects were few and the rate of serious adverse effects was similar to placebo in most studies, with higher dosages and more frequent infusions associated with greater risks. Larger studies, evaluating a wider variety of conditions, are needed to better quantify efficacy, improve patient selection, refine the therapeutic dose range, determine the effectiveness of nonintravenous ketamine alternatives, and develop a greater understanding of the long-term risks of repeated treatments.
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Affiliation(s)
- Steven P. Cohen
- From the Departments of Anesthesiology & Critical Care Medicine, Neurology, and Physical Medicine & Rehabilitation, Johns Hopkins School of Medicine; and
- Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Anuj Bhatia
- Department of Anesthesiology, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Eric S. Schwenk
- Department of Anesthesiology, Jefferson Medical College, Philadelphia; and
| | - Ajay D. Wasan
- Departments of Anesthesiology and Psychiatry, University of Pittsburgh, Pittsburgh, PA
| | - Robert W. Hurley
- Departments of Anesthesiology and Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Eugene R. Viscusi
- Department of Anesthesiology, Jefferson Medical College, Philadelphia; and
| | - Samer Narouze
- Departments of Anesthesiology and Neurosurgery, Western Reserve Hospital, Akron, OH
| | - Fred N. Davis
- Procare Pain Solutions and
- Department of Anesthesiology, Michigan State University College of Human Medicine, Grand Rapids, MI
| | - Elspeth C. Ritchie
- Department of Psychiatry, Uniformed Services University of the Health Sciences, Georgetown University School of Medicine, Bethesda, MD; and
- Howard University College of Medicine, Washington, DC; and
| | | | - William M. Hooten
- Departments of Anesthesiology and Psychiatry, Mayo College of Medicine, Rochester, MN
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Schaefer CP, Arkwright NB, Jacobs LM, Jarvis CK, Hunn KC, Largent-Milnes TM, Tome ME, Davis TP. Chronic morphine exposure potentiates p-glycoprotein trafficking from nuclear reservoirs in cortical rat brain microvessels. PLoS One 2018; 13:e0192340. [PMID: 29414996 PMCID: PMC5802945 DOI: 10.1371/journal.pone.0192340] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/22/2018] [Indexed: 11/19/2022] Open
Abstract
The rates of opioid prescription and use have continued to increase over the last few decades resulting in a greater number of opioid tolerant patients. Treatment of acute pain from surgery and injury is a clinical challenge for these patients. Several pain management strategies including prescribing increased opioids are used clinically with limited success; all currently available strategies have significant limitations. Many opioids are a substrate for p-glycoprotein (p-gp), an efflux transporter at the blood-brain barrier (BBB). Increased p-gp is associated with a decreased central nervous system uptake and analgesic efficacy of morphine. Our laboratory previously found that acute peripheral inflammatory pain (PIP) induces p-gp trafficking from the nucleus to the luminal surface of endothelial cells making up the BBB concomitant with increased p-gp activity and decreased morphine analgesic efficacy. In the current study, we tested whether PIP-induced p-gp trafficking could contribute to decreased opioid efficacy in morphine tolerant rats. A 6-day continuous dosing of morphine from osmotic minipumps was used to establish morphine tolerance in female rats. PIP induced p-gp trafficking away from nuclear stores showed a 2-fold increase in morphine tolerant rats. This observation suggests that p-gp trafficking contributes to the decreased morphine analgesic effects in morphine tolerant rats experiencing an acute pain stimulus. Attenuating p-gp trafficking during an acute pain stimulus could improve pain management by increasing the amount of opioid that could reach CNS analgesic targets and decrease the need for the dose escalation that is a serious challenge in pain management.
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Affiliation(s)
- Charles P. Schaefer
- Department of Pharmacology, University of Arizona, Tucson, Arizona, United States of America
| | - Nathan B. Arkwright
- Department of Pharmacology, University of Arizona, Tucson, Arizona, United States of America
| | - Leigh M. Jacobs
- Department of Pharmacology, University of Arizona, Tucson, Arizona, United States of America
| | - Chelsea K. Jarvis
- Department of Pharmacology, University of Arizona, Tucson, Arizona, United States of America
| | - Kristen C. Hunn
- Department of Pharmacology, University of Arizona, Tucson, Arizona, United States of America
| | - Tally M. Largent-Milnes
- Department of Pharmacology, University of Arizona, Tucson, Arizona, United States of America
| | - Margaret E. Tome
- Department of Pharmacology, University of Arizona, Tucson, Arizona, United States of America
- * E-mail:
| | - Thomas P. Davis
- Department of Pharmacology, University of Arizona, Tucson, Arizona, United States of America
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Soffin EM, Waldman SA, Stack RJ, Liguori GA. An Evidence-Based Approach to the Prescription Opioid Epidemic in Orthopedic Surgery. Anesth Analg 2017; 125:1704-1713. [DOI: 10.1213/ane.0000000000002433] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Labrum JT, Ilyas AM. The Opioid Epidemic: Postoperative Pain Management Strategies in Orthopaedics. JBJS Rev 2017; 5:e14. [DOI: 10.2106/jbjs.rvw.16.00124] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Pozek JPJ, Goldberg SF, Baratta JL, Schwenk ES. Practical Management of the Opioid-Tolerant Patient in the Perioperative Surgical Home. Adv Anesth 2017; 35:175-190. [PMID: 29103572 DOI: 10.1016/j.aan.2017.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- John-Paul J Pozek
- Sidney Kimmel Medical College, Thomas Jefferson University, Gibbon Building, Suite 8130, 111 South 11th Street, Philadelphia, PA 19107, USA.
| | - Stephen F Goldberg
- Sidney Kimmel Medical College, Thomas Jefferson University, Gibbon Building, Suite 8130, 111 South 11th Street, Philadelphia, PA 19107, USA
| | - Jaime L Baratta
- Sidney Kimmel Medical College, Thomas Jefferson University, Gibbon Building, Suite 8130, 111 South 11th Street, Philadelphia, PA 19107, USA
| | - Eric S Schwenk
- Sidney Kimmel Medical College, Thomas Jefferson University, Gibbon Building, Suite 8130, 111 South 11th Street, Philadelphia, PA 19107, USA
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Bennett M, Bonanno L, Kuhn W. Effectiveness of ketamine as an adjuvant to opioid-based therapy in decreasing pain associated with opioid tolerance in adults undergoing orthopedic surgery. ACTA ACUST UNITED AC 2016; 14:22-28. [DOI: 10.11124/jbisrir-2016-003160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Wenzel JT, Schwenk ES, Baratta JL, Viscusi ER. Managing Opioid-Tolerant Patients in the Perioperative Surgical Home. Anesthesiol Clin 2016; 34:287-301. [PMID: 27208711 DOI: 10.1016/j.anclin.2016.01.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Management of acute postoperative pain is important to decrease perioperative morbidity and improve patient satisfaction. Opioids are associated with potential adverse events that may lead to significant risk. Uncontrolled pain is a risk factor in the transformation of acute pain to chronic pain. Balancing these issues can be especially challenging in opioid-tolerant patients undergoing surgery, for whom rapidly escalating opioid doses in an effort to control pain can be associated with increased complications. In the perioperative surgical home model, anesthesiologists are positioned to coordinate a comprehensive perioperative analgesic plan that begins with the preoperative assessment and continues through discharge.
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Affiliation(s)
- John T Wenzel
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Suite 8130, Gibbon Building, 111 South 11th Street, Philadelphia, PA 19107, USA.
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Suite 8130, Gibbon Building, 111 South 11th Street, Philadelphia, PA 19107, USA
| | - Jaime L Baratta
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Suite 8130, Gibbon Building, 111 South 11th Street, Philadelphia, PA 19107, USA
| | - Eugene R Viscusi
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Suite 8130, Gibbon Building, 111 South 11th Street, Philadelphia, PA 19107, USA
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Abstract
PURPOSE OF REVIEW The management of acute pain in the opioid-tolerant patient is an area in perioperative medicine that is growing, as the use of opioids for chronic noncancer pain has been tolerated in the USA. Adding to this population is an increase in opioid abusers, addicts and those in recovery and maintenance programmes. These patients will continue to present for surgery and with acute pain that anaesthesiologists and other members of the healthcare team must become more adept at managing. RECENT FINDINGS This review covers some of the strategies that may be used by practitioners in the management of acute pain in the opioid-tolerant patient. It is important to collect a detailed history of opioid and drugs of abuse, including the timing of the last dose in order to avoid precipitation of withdrawal. The use of multimodal anaesthetic and analgesic strategies is important for both patient safety and satisfaction and can enhance recovery and discharge home. SUMMARY There is a need for more high-level evidence-based guidelines to help practitioners achieve the best care of this growing high-risk population of patients.
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