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Majumdar JR, Grbic J, Carlsson S, Barreiro D, Marte M, Laudone V, Assel MJ, Masson G. Impact of Replacing Fentanyl With Hydromorphone as the First-Line Postoperative Opioid Among Patients Undergoing Outpatient Cancer Surgery. J Perianesth Nurs 2024; 39:638-644.e1. [PMID: 38493405 PMCID: PMC11297671 DOI: 10.1016/j.jopan.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 11/10/2023] [Accepted: 11/11/2023] [Indexed: 03/18/2024]
Abstract
PURPOSE In response to a nationwide fentanyl shortage, our institution assessed whether changing our first-line postoperative intravenous opioid from fentanyl to hydromorphone impacted patient outcomes. The primary research aim was to evaluate the association between first-line opioid and rapidity of recovery. DESIGN The study team retrospectively obtained data on all consecutive patients extracted from the electronic medical record. The rapidity of recovery was defined as the time from entry into the postanesthesia care unit to the transition to Phase 2 for ambulatory extended recovery patients and as the length of total postanesthesia care unit stay for outpatients. METHODS Following intent-to-treat-principles, we tested the association between study period and rapidity of recovery (a priori clinically meaningful difference: 20 minutes) using multivariable linear regression, adjusting for anesthesia type (general vs monitored anesthesia care), American Society of Anesthesiologst physical status (ASA) score (1-2 vs 3-4), age, service, robotic procedure, and surgery start time. FINDINGS Ambulatory extended recovery patients treated in the hydromorphone period had, on average, a 0.25 minute (95% confidence interval [CI] -6.5, 7.0), nonstatistically significant (P > .9) longer time to transition. For outpatient procedures, those who received hydromorphone had, on average, 8.5-minute longer stays (95% CI 3.7-13, P < .001). Although we saw statistical evidence of an increased risk of resurgery associated with receiving hydromorphone (0.5%; 95% CI -0.1%, 1.0%; P = .039 on univariate analysis), the size of the estimate is clinically and biologically implausible and is most likely a chance finding related either to multiple testing or confounding. CONCLUSIONS The multidisciplinary team concluded that the increase in postoperative length of stay associated with hydromorphone was not clinically significant and the decrease waste of prefilled syringes outweighed the small potential increased risk of resurgery compared to the shorter-acting fentanyl. We will therefore use hydromorphone moving forward.
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Affiliation(s)
- Jennifer R Majumdar
- Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY; Hunter-Bellevue School of Nursing, Hunter College, City University of New York, New York, NY.
| | - John Grbic
- Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sigrid Carlsson
- Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY; Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY; Urology, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Donna Barreiro
- Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Marie Marte
- Advanced Practice Providers, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Vincent Laudone
- Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Melissa J Assel
- Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Geema Masson
- Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY
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Jin X, Deng R, Weng Q, Yang Q, Zhong W. Clinical Application of Different Doses of Hydromorphone Slow-Release Analgesia in Lumbar Fusion in Elderly Patients. Pain Ther 2024:10.1007/s40122-024-00632-3. [PMID: 38995609 DOI: 10.1007/s40122-024-00632-3] [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: 04/27/2024] [Accepted: 06/25/2024] [Indexed: 07/13/2024] Open
Abstract
INTRODUCTION The aim of this study is to examine the analgesic efficacy of varying doses of hydromorphone hydrochloride in conjunction with absorbable gelatin sponge for postoperative pain management in elderly individuals undergoing lumbar fusion surgery. Additionally, the study aims to assess the sustained release analgesic properties of this combination and to determine the optimal dosage of hydromorphone hydrochloride for effective pain relief. METHODS A total of 113 elderly patients (aged ≥ 65 years old) meeting the criteria for 1-2-level posterior lumbar fusion surgery at Ganzhou City People's Hospital between July 2022 and August 2023 were randomly assigned to four groups: group A (0.2 mg hydromorphone hydrochloride 1 ml), group B (0.3 mg hydromorphone hydrochloride 1.5 ml), group C (0.4 mg hydromorphone hydrochloride 2 ml), and group D (0.9% normal saline 2 ml) for standard anesthesia induction and maintenance. Prior to suturing the incision, gelfoam was utilized to administer epidural analgesia to each group. Following the surgical procedure, an intravenous analgesia pump was utilized for pain management. The baseline infusion rate was set at 0.5 ml/h. Patient-controlled analgesia (PCA) was administered at a dose of 2 ml, with a lockout interval of 20 min, allowing the patient to self-administer as needed. Pain relief was assessed using the visual analogue scale (VAS) prior to surgery, as well as at 1 day and 3 days post-operation. The frequency of PCA requests within the initial 48-h postoperative period, the remedial analgesia with dezocine, postoperative adverse reactions, and duration of hospitalization were documented for analysis. RESULTS The VAS scores of groups B and C were found to be significantly lower than those of group D 1 day after the operation. Additionally, VAS scores at 3 days post-operation, remedial rate of dezocine and PCA follow-up times at 48 h in groups A, B, and C were significantly lower compared to group D (P < 0.001). There was no statistically significant difference between group B and group C in VAS scores at 1 day and 3 days post-operation, as well as PCA follow-up times at 48 h post-operation (P < 0.001). Furthermore, the VAS scores of groups B and C were lower than those of group A at 1 day and 3 days post-operation (P < 0.05). The PCA frequency of group C was also lower than that of group A at 48 h post-operation (P < 0.05). CONCLUSION The combination of hydromorphone hydrochloride and absorbable gelatin sponge epidural analgesia has been shown to enhance postoperative pain management. A dosage of 0.4 mg of hydromorphone hydrochloride may be considered an appropriate analgesic dose, as it can provide effective pain relief without eliciting adverse reactions. TRIAL REGISTRATION ChiCTR.org.cn(ChiCTR2200064863). Registered on October 20, 2022.
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Affiliation(s)
- Xianwei Jin
- Department of Medicine, Graduate School, Nanchang University, Nanchang, Jiangxi Province, China
| | - Ruiming Deng
- Department of Anesthesiology, The People's Hospital of Ganzhou, No. 16, Meiguan Avenue, Zhanggong District, Ganzhou, 341000, Jiangxi Province, China
| | - Qiaoling Weng
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Qiao Yang
- Department of Anesthesiology, The Maternal and Child Health Hospital of Ganzhou City, Ganzhou, Jiangxi Province, China
| | - Weibo Zhong
- Department of Anesthesiology, The People's Hospital of Ganzhou, No. 16, Meiguan Avenue, Zhanggong District, Ganzhou, 341000, Jiangxi Province, China.
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Shanthanna H, Wang L, Paul J, Lovrics P, Devereaux PJ, Bhandari M, Thabane L. A prospective cohort study of chronic postsurgical pain after ambulatory surgeries. Curr Med Res Opin 2024; 40:1187-1193. [PMID: 38809229 DOI: 10.1080/03007995.2024.2360128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 05/22/2024] [Indexed: 05/30/2024]
Abstract
OBJECTIVE The incidence and factors associated with chronic postsurgical pain (CPSP) after ambulatory surgeries have not been well studied. Our primary objective was to determine the incidence of CPSP and secondary objectives included assessment of intensity of CPSP, incidence of moderate-to-severe CPSP, and exploration of factors associated with CPSP. METHODS This is a prospective cohort study of ambulatory surgery patients having procedures with a potential to cause moderate-to-severe postoperative pain. All patients had participated in a randomized controlled trial (RCT) showing no difference in achieving satisfactory analgesia in a recovery unit with either morphine or hydromorphone. CPSP was defined as chronic pain that developed or increased in intensity after the surgical procedure and is localized to the surgical field or within the innervation territory of a nerve in the surgical field, and has persisted for 3 months post-surgery, with the exclusion of other causes of pain. Incidences of CPSP were reported as rate (%) with 95% CI, and intensity using a 0-10 numerical rating scale (95% CI). We used logistic regression to explore factors associated with CPSP adjusting for baseline catastrophizing and depression. RESULTS Among 402 RCT patients, 208 provided data for the 3-month outcome. Incidence of CPSP was 18.8% (39/208), 95% CI = 13.7%-24.7% and 78% (28/39) of them had moderate-to-severe CPSP. Average CPSP intensity was 5.5, 95% CI = 4.7-6.4. Every unit increase in pain over the first 24 h was significantly associated with increased odds of moderate-to-severe CPSP at 3 months; odds ratio = 1.28, 95% CI = 1.04-1.58. CONCLUSIONS Nearly one in five patients develop CPSP after ambulatory surgeries with the majority of them having moderate-to-severe pain. Considering that acute pain after discharge is associated with CPSP and that there are no formal care pathways to address this need, studies need to focus on evaluating feasible strategies to provide continuing care.
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Affiliation(s)
- Harsha Shanthanna
- Department of Anesthesia, St Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
| | - Li Wang
- Department of Anesthesia, St Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
| | - James Paul
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Peter Lovrics
- Department of Surgery, St Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
| | - P J Devereaux
- Departments of Health Research Methods, Evidence, and Impact and Medicine, McMaster University, Hamilton, ON, Canada
| | - Mohit Bhandari
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Departments of Health Research Methods, Evidence, and Impact and Medicine, McMaster University, Hamilton, ON, Canada
- Biostatistics Unit, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
- Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
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Biskupiak J, Oderda G, Brixner D, Wandstrat TL. Gastrointestinal adverse effects associated with the use of intravenous oliceridine compared with intravenous hydromorphone or fentanyl in acute pain management utilizing adjusted indirect treatment comparison methods. J Comp Eff Res 2024; 13:e230041. [PMID: 38497192 PMCID: PMC11036942 DOI: 10.57264/cer-2023-0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 02/21/2024] [Indexed: 03/19/2024] Open
Abstract
Background: In the absence of head-to-head comparative data from randomized controlled trials, indirect treatment comparisons (ITCs) may be used to compare the relative effects of treatments versus a common comparator (either placebo or active treatment). For acute pain management, the effects of oliceridine have been compared in clinical trials to morphine but not to fentanyl or hydromorphone. Aim: To assess the comparative safety (specifically differences in the incidence of nausea, vomiting and opioid-induced respiratory depression [OIRD]) between oliceridine and relevant comparators (fentanyl and hydromorphone) through ITC analysis. Methods: A systematic literature review identified randomized clinical trials with oliceridine versus morphine and morphine versus fentanyl or hydromorphone. The ITC utilized the common active comparator, morphine, for the analysis. Results: A total of six randomized controlled trials (oliceridine - 2; hydromorphone - 3; fentanyl - 1) were identified for data to be used in the ITC analyses. The oliceridine data were reported in two studies (plastic surgery and orthopedic surgery) and were also reported in a pooled analysis. The ITC focused on nausea and vomiting due to limited data for OIRD. When oliceridine was compared with hydromorphone in the ITC analysis, oliceridine significantly reduced the incidence of nausea and/or vomiting requiring antiemetics compared with hydromorphone (both orthopedic surgery and pooled data), while results in plastic surgery were not statistically significant. When oliceridine was compared with hydromorphone utilizing data from Hong, the ITC only showed a trend toward reduced risk of nausea and vomiting with oliceridine that was not statistically significant across all three comparisons (orthopedic surgery, plastic surgery and combined). An ITC comparing oliceridine with a study of fentanyl utilizing the oliceridine orthopedic surgery data and combined orthopedic and plastic surgery data showed a trend toward reduced risk that was not statistically significant. Conclusion: In ITC analyses, oliceridine significantly reduced the incidence of nausea and/or vomiting or the need for antiemetics in orthopedic surgery compared with hydromorphone and a non-significant trend toward reduced risk versus fentanyl.
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Affiliation(s)
| | - Gary Oderda
- College of Pharmacy, University of Utah, UT USA
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Zhu S, Li J, Guan W, Li H, Fan W, Wu D, Zheng L. Clinical application of radiofrequency ablation-assisted coaxial trocar biopsies for pulmonary nodules at a high risk of bleeding. J Cancer Res Ther 2023; 19:972-977. [PMID: 37675725 DOI: 10.4103/jcrt.jcrt_2193_22] [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] [Indexed: 09/08/2023]
Abstract
Context The purpose of this study was to assess computed tomography (CT)-guided puncture biopsy of pulmonary nodules at a high risk of bleeding. First, a coaxial trocar technique was used to radiofrequency ablate small blood vessels in the puncture area, followed by a biopsy of the pulmonary nodule. Aim This study aimed to evaluate the effectiveness and safety of this procedure. Methods In this retrospective research, we assessed the relevant data of 45 patients who had undergone needle biopsy of pulmonary nodules at a high risk of bleeding. Twenty-five of these patients had CT-guided coaxial radiofrequency ablation (RFA)-assisted biopsy (group A). The remaining 20 had undergone conventional CT-guided needle biopsy (group B). We equated the technical success rate and the incidence of complications such as bleeding, pneumothorax, and pain in the two groups of needle biopsies. Results Both groups had a 100% success rate with puncture biopsy. The incidences of pneumothorax in groups A and B were 10% (2/20) and 24% (6/25), respectively; this difference is not significant (P > 0.050). The rates of bleeding in groups A and B were 10% (2/20) and 44% (11/25), respectively, and the rates of pain were 30% (6/20) and 60% (15/25), both of which were statistically significant (P = 0.030; P = 0.045, respectively). Conclusions CT-guided coaxial trocar technique for RFA-assisted biopsy of pulmonary nodules at a high risk of bleeding is effective and safe and can significantly reduce the risk of biopsy-induced pulmonary hemorrhage.
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Affiliation(s)
- Shidi Zhu
- Department of Minimal-Invasive Intervention, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Jing Li
- Department of Minimal-Invasive Intervention, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Weiwei Guan
- Department of Minimal-Invasive Intervention, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Hailiang Li
- Department of Minimal-Invasive Intervention, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Weijun Fan
- Department of Minimally Invasive Interventional Radiology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Cancer for Cancer Medicine, Guangzhou, China
| | - Di Wu
- Department of Minimal-Invasive Intervention, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Lin Zheng
- Department of Minimal-Invasive Intervention, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
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Meissner K, Dahan A, Olofsen E, Göpfert C, Blood J, Wieditz J, Kharasch ED. Morphine and Hydromorphone Effects, Side Effects, and Variability: A Crossover Study in Human Volunteers. Anesthesiology 2023; 139:16-34. [PMID: 37014986 PMCID: PMC10517626 DOI: 10.1097/aln.0000000000004567] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
BACKGROUND Balancing between opioid analgesia and respiratory depression continues to challenge clinicians in perioperative, emergency department, and other acute care settings. Morphine and hydromorphone are postoperative analgesic standards. Nevertheless, their comparative effects and side effects, timing, and respective variabilities remain poorly understood. This study tested the hypothesis that IV morphine and hydromorphone differ in onset, magnitude, duration, and variability of analgesic and ventilatory effects. METHODS The authors conducted a randomized crossover study in healthy volunteers. Forty-two subjects received a 2-h IV infusion of hydromorphone (0.05 mg/kg) or morphine (0.2 mg/kg) 1 to 2 weeks apart. The authors measured arterial opioid concentrations, analgesia in response to heat pain (maximally tolerated temperature, and verbal analog pain scores at discrete preset temperatures to determine half-maximum temperature effect), dark-adapted pupil diameter and miosis, end-expired carbon dioxide, and respiratory rate for 12 h after dosing. RESULTS For morphine and hydromorphone, respectively, maximum miosis was less (3.9 [3.4 to 4.2] vs. 4.6 mm [4.0 to 5.0], P < 0.001; median and 25 to 75% quantiles) and occurred later (3.1 ± 0.9 vs. 2.3 ± 0.7 h after infusion start, P < 0.001; mean ± SD); maximum tolerated temperature was less (49 ± 2 vs. 50 ± 2°C, P < 0.001); verbal pain scores at end-infusion at the most informative stimulus (48.2°C) were 82 ± 4 and 59 ± 3 (P < 0.001); maximum end-expired CO2 was 47 (45 to 50) and 48 mmHg (46 to 51; P = 0.007) and occurred later (5.5 ± 2.8 vs. 3.0 ± 1.5 h after infusion start, P < 0.001); and respiratory nadir was 9 ± 1 and 11 ± 2 breaths/min (P < 0.001), and occurred at similar times. The area under the temperature tolerance-time curve was less for morphine (1.8 [0.0 to 4.4]) than hydromorphone (5.4°C-h [1.6 to 12.1] P < 0.001). Interindividual variability in clinical effects did not differ between opioids. CONCLUSIONS For morphine compared to hydromorphone, analgesia and analgesia relative to respiratory depression were less, onset of miosis and respiratory depression was later, and duration of respiratory depression was longer. For each opioid, timing of the various clinical effects was not coincident. Results may enable more rational opioid selection, and suggest hydromorphone may have a better clinical profile. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Konrad Meissner
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Germany
- Department of Anaesthesiology, Leiden University Medical Center, The Netherlands
- Department of Anesthesiology, Washington University in St. Louis, St. Louis MO, USA
| | - Albert Dahan
- Department of Anaesthesiology, Leiden University Medical Center, The Netherlands
| | - Erik Olofsen
- Department of Anaesthesiology, Leiden University Medical Center, The Netherlands
| | - Christine Göpfert
- Department of Anesthesiology, Washington University in St. Louis, St. Louis MO, USA
| | - Jane Blood
- Department of Anesthesiology, Washington University in St. Louis, St. Louis MO, USA
| | - Johannes Wieditz
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Germany
- Department of Medical Statistics, Universitätsmedizin Göttingen, Germany
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Yu H, Tian W, Xu Z, Jiang R, Jin L, Mao W, Chen Y, Yu H. Patient-controlled intravenous analgesia with opioids after thoracoscopic lung surgery: a randomized clinical trial. BMC Anesthesiol 2022; 22:253. [PMID: 35941536 PMCID: PMC9358799 DOI: 10.1186/s12871-022-01785-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 07/25/2022] [Indexed: 11/21/2022] Open
Abstract
Background Opioids remain the mainstream therapy for post-surgical pain. The choice of opioids administered by patient-controlled intravenous analgesia (PCIA) for thoracoscopic lung surgery is unclear. This study compared 3 opioid analgesics for achieving satisfactory analgesia with minimal emesis (SAME). Methods This randomized clinical trial enrolled patients scheduled for thoracoscopic lung surgery randomized to receive 1 of 3 opioids for PCIA: oxycodone (group O), hydromorphone (group H), and sufentanil (group S). The primary outcome was the proportion of subjects achieving SAME, i.e., no-to-mild pain (pain score < 4/10) with minimal nausea/vomiting (PONV score < 2/4) when coughing during the pulmonary rehabilitation exercise in the first 3 postoperative days. Results Of 555 enrolled patients, 184 patients in group O, 186 in group H and 184 in group S were included in the final analysis. The primary outcome of SAME was significantly different among group O, H and S (41.3% vs 40.3% vs 29.9%, P = 0.043), but no difference was observed between pairwise group comparisons. Patients in groups O and H had lower pain scores when coughing on the second day after surgery than those in group S, both with mean differences of 1 (3(3,4) and 3(3,4) vs 4(3,4), P = 0.009 and 0.039, respectively). The PONV scores were comparable between three groups (P > 0.05). There were no differences in other opioid-related side effects, patient satisfaction score, and QoR-15 score among three groups. Conclusions Given clinically relevant benefits detected, PCIA with oxycodone or hydromorphone is superior to sufentanil for achieving SAME as a supplement to multimodal analgesia in patients undergoing thoracoscopic lung surgery. Trial registration This study was registered at (ChiCTR2100045614, 19/04/2021). Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01785-4.
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Affiliation(s)
- Hong Yu
- Department of Anesthesiology, West China Hospital, Sichuan University. No, 37 Guoxue Alley, Chengdu, 610041, China
| | - Wei Tian
- Department of Anesthesiology, The First People's Hospital of Neijiang, Neijiang, 641000, China
| | - Zhao Xu
- Department of Anesthesiology, West China Hospital, Sichuan University. No, 37 Guoxue Alley, Chengdu, 610041, China
| | - Rongjuan Jiang
- Department of Anesthesiology, Chengdu Second People's Hospital, Chengdu, 610017, China
| | - Liang Jin
- Department of Anesthesiology, The People's Hospital of Leshan, Leshan, 614099, China
| | - Wenjie Mao
- Department of Anesthesiology, The People's Hospital of Jianyang, Chengdu, 641499, China
| | - Ying Chen
- Department of Anesthesiology, Liangshan Hospital of Integrated Traditional and Western Medicine, Xichang, 615099, China
| | - Hai Yu
- Department of Anesthesiology, West China Hospital, Sichuan University. No, 37 Guoxue Alley, Chengdu, 610041, China.
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Du Y, Shi H, Yang X, Wu W. Machine learning for infection risk prediction in postoperative patients with non-mechanical ventilation and intravenous neurotargeted drugs. Front Neurol 2022; 13:942023. [PMID: 35979059 PMCID: PMC9376287 DOI: 10.3389/fneur.2022.942023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/08/2022] [Indexed: 01/30/2023] Open
Abstract
Drug efficacy can be improved by understanding the effects of anesthesia on the neurovascular system. In this study, we used machine learning algorithms to predict the risk of infection in postoperative intensive care unit (ICU) patients who are on non-mechanical ventilation and are receiving hydromorphone analgesia. In this retrospective study, 130 patients were divided into high and low dose groups of hydromorphone analgesic pump patients admitted after surgery. The white blood cells (WBC) count and incidence rate of infection was significantly higher in the high hydromorphone dosage group compared to the low hydromorphone dosage groups (p < 0.05). Furthermore, significant differences in age (P = 0.006), body mass index (BMI) (P = 0.001), WBC count (P = 0.019), C-reactive protein (CRP) (P = 0.038), hydromorphone dosage (P = 0.014), and biological sex (P = 0.024) were seen between the infected and non-infected groups. The infected group also had a longer hospital stay and an extended stay in the intensive care unit compared to the non-infected group. We identified important risk factors for the development of postoperative infections by using machine learning algorithms, including hydromorphone dosage, age, biological sex, BMI, and WBC count. Logistic regression analysis was applied to incorporate these variables to construct infection prediction models and nomograms. The area under curves (AUC) of the model were 0.835, 0.747, and 0.818 in the training group, validation group, and overall pairwise column group, respectively. Therefore, we determined that hydromorphone dosage, age, biological sex, BMI, WBC count, and CRP are significant risk factors in developing postoperative infections.
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Wehrfritz A, Senger AS, Just P, Albart M, Münchsmeier M, Ihmsen H, Schüttler J, Jeleazcov C. Patient-controlled analgesia after cardiac surgery with median sternotomy: no advantages of hydromorphone when compared to morphine. J Cardiothorac Vasc Anesth 2022; 36:3587-3595. [DOI: 10.1053/j.jvca.2022.04.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/24/2022] [Accepted: 04/30/2022] [Indexed: 11/11/2022]
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Shi W, Chen Y, Zhang MQ, Che GW, Yu H. Effects of methylprednisolone on early postoperative pain and recovery in patients undergoing thoracoscopic lung surgery: A randomized controlled trial. J Clin Anesth 2021; 75:110526. [PMID: 34610541 DOI: 10.1016/j.jclinane.2021.110526] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/17/2021] [Accepted: 09/23/2021] [Indexed: 02/05/2023]
Abstract
STUDY OBJECTIVE Evidence from previous studies indicates that glucocorticoids offer effective postoperative analgesia and improve the quality of recovery (QoR). The aim of this study was to evaluate the efficacy of preoperative methylprednisolone on early postoperative pain and QoR following thoracoscopic lung surgery. DESIGN A prospective, single-center, three-arm, double-blinded, randomized trial. SETTING Tertiary university hospital. PATIENTS Adult patients aged ≥18 years undergoing thoracoscopic lung surgery were eligible for participation. INTERVENTIONS Patients enrolled in this study were randomized to receive preoperative methylprednisolone (40 mg or 120 mg) or identical volumes of 0.9% saline. MEASUREMENTS The primary outcome was the proportion of moderate-to-severe pain (numerical rating scale [NRS] ≥ 4 when coughing during pulmonary rehabilitation exercises) on the first day postoperatively. The postoperative pain scores, QoR-15 scores and other secondary outcomes were also recorded. MAIN RESULTS Of the 180 enrolled patients, 173 patients were included in the primary analysis. The results showed that the proportion of moderate-to-severe pain was not significantly different between the combined methylprednisolone group and the placebo group (51.7% vs. 64.9%; absolute difference, 13.2%; 95% CI, -2.1% to 29.3%; P = 0.10). Patients who received methylprednisolone treatment had lower pain scores at rest and coughing on the first day after surgery than those who received placebo treatment, with mean differences of 0.5 and 0.7, respectively (P < 0.01). QoR-15 scores were higher in patients treated with methylprednisolone at day 1 (mean difference, 6.9; P < 0.001) and day 2 (mean difference, 7.2; P < 0.001) than in patients who received placebo treatment. No side-effects associated with methylprednisolone treatment were observed. CONCLUSIONS Our findings suggested that preoperative methylprednisolone (either high or low dose) has limited impact on early postoperative pain and recovery in patients undergoing thoracoscopic lung surgery, with no clinically relevant benefits detected when compared with placebo. TRIAL REGISTRATION Chinese Clinical Trail Register (identifier: ChiCTR1900021020).
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Affiliation(s)
- Wei Shi
- Department of Anesthesiology, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Ying Chen
- Department of Anesthesiology, Hospital of Integrated Traditional Chinese and Western Medicine of Liangshan Prefecture, Liangshan 615000, Sichuan, China
| | - Meng-Qiu Zhang
- Department of Anesthesiology, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Guo-Wei Che
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Hai Yu
- Department of Anesthesiology, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China.
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Hydromorphone Protects against CO 2 Pneumoperitoneum-Induced Lung Injury via Heme Oxygenase-1-Regulated Mitochondrial Dynamics. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2021; 2021:9034376. [PMID: 33927798 PMCID: PMC8053056 DOI: 10.1155/2021/9034376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 03/04/2021] [Accepted: 03/19/2021] [Indexed: 01/01/2023]
Abstract
Various pharmacological agents and protective methods have been shown to reverse pneumoperitoneum-related lung injury, but identifying the best strategy is challenging. Herein, we employed lung tissues and blood samples from C57BL/6 mice with pneumoperitoneum-induced lung injury and blood samples from patients who received laparoscopic gynecological surgery to investigate the therapeutic role of hydromorphone in pneumoperitoneum-induced lung injury along with the underlying mechanism. We found that pretreatment with hydromorphone alleviated lung injury in mice that underwent CO2 insufflation, decreased the levels of myeloperoxidase (MPO), total oxidant status (TOS), and oxidative stress index (OSI), and increased total antioxidant status (TAS). In addition, after pretreatment with hydromorphone, upregulated HO-1 protein expression, reduced mitochondrial DNA content, and improved mitochondrial morphology and dynamics were observed in mice subjected to pneumoperitoneum. Immunohistochemical staining also verified that hydromorphone could increase the expression of HO-1 in lung tissues in mice subjected to CO2 pneumoperitoneum. Notably, in mice treated with HO-1-siRNA, the protective effects of hydromorphone against pneumoperitoneum-induced lung injury were abolished, and hydromorphone did not have additional protective effects on mitochondria. Additionally, in clinical patients who received laparoscopic gynecological surgery, pretreatment with hydromorphone resulted in lower serum levels of club cell secretory protein-16 (CC-16) and intercellular adhesion molecule-1 (ICAM-1), a lower prooxidant-antioxidant balance (PAB), and higher heme oxygenase-1 (HO-1) activity than morphine pretreatment. Collectively, our results suggest that hydromorphone protects against CO2 pneumoperitoneum-induced lung injury via HO-1-regulated mitochondrial dynamics and may be a promising strategy to treat CO2 pneumoperitoneum-induced lung injury.
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12
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Prielipp RC, Fulesdi B, Brull SJ. In Response. Anesth Analg 2021; 132:e61-e63. [PMID: 33723200 DOI: 10.1213/ane.0000000000005414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Richard C Prielipp
- Department of Anesthesiology, University of Minnesota, Minneapolis, Minnesota,
| | - Bela Fulesdi
- Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
| | - Sorin J Brull
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
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13
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Beard TL, Michalsky C, Candiotti KA, Rider P, Wase L, Habib AS, Demitrack MA, Fossler MJ, Viscusi ER. Oliceridine is Associated with Reduced Risk of Vomiting and Need for Rescue Antiemetics Compared to Morphine: Exploratory Analysis from Two Phase 3 Randomized Placebo and Active Controlled Trials. Pain Ther 2020; 10:401-413. [PMID: 33210266 PMCID: PMC8119517 DOI: 10.1007/s40122-020-00216-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 10/28/2020] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Use of parenteral opioids is a major risk factor for postoperative nausea and vomiting. Conventional opioids bind to µ-opioid receptors (MOR), stimulate both the G-protein signaling (achieving analgesia); and the β-arrestin pathway (associated with opioid-related adverse effects). Oliceridine, a next-generation IV opioid, is a G-protein selective MOR agonist, with limited recruitment of β-arrestin. In two randomized, placebo- and morphine-controlled phase 3 studies of patients with moderate-to-severe acute pain following bunionectomy or abdominoplasty, oliceridine at demand doses of 0.1, 0.35, and 0.5 mg provided rapid and sustained analgesia vs. placebo with favorable gastrointestinal (GI) tolerability. In this exploratory analysis, we utilized a clinical endpoint assessing gastrointestinal tolerability, "complete GI response" defined as the proportion of patients with no vomiting and no use of rescue antiemetic to characterize the GI tolerability profile of oliceridine vs. morphine. METHODS A logistic regression model was utilized to compare oliceridine (pooled regimens) vs. morphine, after controlling for analgesia (using the sum of pain intensity difference [SPID]-48/24 [bunionectomy/abdominoplasty] with pre-rescue scores carried forward for 6 h). This analysis excluded patients receiving placebo and was performed for each study separately and for pooled data from both studies. RESULTS In the unadjusted analysis, a significantly greater proportion of patients in the placebo (76.4%), oliceridine 0.1 mg (68.0%), and 0.35 mg (46.2%) demand dose achieved complete GI response vs. morphine 1 mg (30.8%), p ≤ 0.005. In the adjusted analysis, after controlling for analgesia, the odds ratio of experiencing a complete GI response with oliceridine (pooled regimens) vs. morphine was 3.14 (95% CI: 1.78, 5.56; p < 0.0001) in bunionectomy study and 1.92 (95% CI: 1.09, 3.36; p = 0.024) in abdominoplasty study. CONCLUSIONS When controlled for the analgesic effects (constant SPID-48/24), the odds ratio for complete GI response was higher with oliceridine than morphine, suggesting better GI tolerability with oliceridine.
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Affiliation(s)
- Timothy L Beard
- Department of Surgery and Clinical Research, Summit Medical Group, Bend Memorial Clinic, Bend, OR, USA.
| | | | - Keith A Candiotti
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Paul Rider
- Department of Surgery, University of South Alabama Medical Center, Mobile, AL, USA
| | | | - Ashraf S Habib
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | | | | | - Eugene R Viscusi
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
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14
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Rodrigues S, Shin D, Conway M, Smulski S, Trenker E, Shanthanna H, Vanniyasingam T, Thabane L, Paul J. Hydromorphone versus morphine: a historical cohort study to evaluate the quality of postoperative analgesia. Can J Anaesth 2020; 68:226-234. [PMID: 33170454 DOI: 10.1007/s12630-020-01849-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/07/2020] [Accepted: 08/16/2020] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Opioids are the most widely used therapy for pain during the postoperative period. It has been suggested by some that hydromorphone is clinically superior. Our primary objective was to determine if there is a difference in postoperative pain score ratings between adult patients receiving intravenous hydromorphone vs intravenous morphine on discharge from the post-anesthesia care unit (PACU). METHODS For this historical cohort study, convenience sampling was used to identify the first 605 patients ≥ 18 yr undergoing elective, non-cardiac surgery. Patients were categorized based on treatment in the PACU with hydromorphone (n = 326) or morphine (n = 279). Pain scores (scale of 0-10), nausea/vomiting (scale of 0-3), pruritis (scale of 0-3), and sedation (scale of 0-4), as well as total opioid dose administered from arrival in the PACU until readiness to discharge were evaluated. RESULTS For the primary outcome of pain reported at discharge from the PACU, there was no significant difference between the mean (standard deviation) hydromorphone numeric rating scale (NRS) [2.8 (1.6)] and the morphine NRS [2.5 (1.5)] after adjusting for potential confounders (adjusted mean difference, 0.10; 95% confidence interval, -0.21 to 0.42; P = 0.53). Similarly, there were no significant between-group differences in length of stay in the PACU, satisfactory analgesia, nausea/vomiting, and sedation. CONCLUSION This study serves to help guide the decision-making process for selecting either morphine or hydromorphone for acute postoperative analgesia. Overall, we found no significant difference for analgesia or for common opioid-related adverse effects between these two opioids in the postoperative period at the time of discharge from the PACU. Furthermore, according to this data, the equipotency ratio of hydromorphone to morphine is closer to 1:6.5 rather than the commonly employed 1:5 ratio.
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Affiliation(s)
- Shannon Rodrigues
- Department of Anesthesiology, McMaster University, Health Sciences Centre, 2V9, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
| | - David Shin
- Department of Anesthesiology, McMaster University, Health Sciences Centre, 2V9, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - Matthew Conway
- Department of Anesthesiology, McMaster University, Health Sciences Centre, 2V9, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - Stefanie Smulski
- Department of Anesthesiology, McMaster University, Health Sciences Centre, 2V9, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - Emily Trenker
- Department of Anesthesiology, McMaster University, Health Sciences Centre, 2V9, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - Harsha Shanthanna
- Department of Anesthesiology, McMaster University, Health Sciences Centre, 2V9, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - Thuva Vanniyasingam
- Department of Health Research Methods, Evidence & Impact, Health Sciences Centre, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence & Impact, Health Sciences Centre, McMaster University, Hamilton, ON, Canada
| | - James Paul
- Department of Anesthesiology, McMaster University, Health Sciences Centre, 2V9, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
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15
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Analgesic Efficacy of Preemptive Transversus Abdominis Plane Block in Patients Undergoing Laparoscopic Colorectal Cancer Surgery. J Clin Med 2020; 9:jcm9051577. [PMID: 32455933 PMCID: PMC7291263 DOI: 10.3390/jcm9051577] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/18/2020] [Accepted: 05/21/2020] [Indexed: 12/18/2022] Open
Abstract
Despite rapid advancements in laparoscopic surgical devices and techniques, pain remains a significant issue. We examined the efficacy of preemptive transversus abdominis plane (TAP) block for acute postoperative pain in patients undergoing laparoscopic colorectal cancer surgery. We retrospectively analyzed 153 patients who underwent laparoscopic colorectal cancer surgery with or without TAP block; among them, 142 were allocated to the TAP or non-TAP group. We performed between-group comparisons of demographic, clinical, and anesthetic data and pain scores at a postoperative anesthesia care unit (PACU) and at postoperative days 1, 3, and 5. There were no significant between-group differences in demographic and clinical characteristics. The mean arterial pressure, heart rate, and minimum alveolar concentration (MAC) were significantly lower in the TAP group at the start and end of surgery. The post-extubation bispectral index was significantly higher in the TAP group. There were no significant between-group differences in the pain scores and opioid consumption at the PACU or at postoperative days 1, 3, and 5, or in the time to pass flatus, the hospital stay length, and postoperative complications. Preemptive TAP block showed an intraoperative, but not postoperative, analgesic effect, characterized by a low mean arterial pressure, heart rate, and MAC.
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Kendall MC, Alves L, Traill LL, De Oliveira GS. The effect of ultrasound-guided erector spinae plane block on postsurgical pain: a meta-analysis of randomized controlled trials. BMC Anesthesiol 2020; 20:99. [PMID: 32357842 PMCID: PMC7195766 DOI: 10.1186/s12871-020-01016-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 04/16/2020] [Indexed: 12/11/2022] Open
Abstract
Background The effect of erector spinae plane block has been evaluated by clinical trials leading to a diversity of results. The main objective of the current investigation is to compare the analgesic efficacy of erector spinae plane block to no block intervention in patients undergoing surgical procedures. Methods We performed a quantitative systematic review of randomized controlled trials in PubMed, Embase, Cochrane Library, and Google Scholar electronic databases from their inception through July 2019. Included trials reported either on opioid consumption or pain scores as postoperative pain outcomes. Methodological quality of included studies was evaluated using Cochrane Collaboration’s tool. Results Thirteen randomized controlled trials evaluating 679 patients across different surgical procedures were included. The aggregated effect of erector spinae plane block on postoperative opioid consumption revealed a significant effect, weighted mean difference of − 8.84 (95% CI: − 12.54 to − 5.14), (P < 0.001) IV mg morphine equivalents. The effect of erector spinae plane block on post surgical pain at 6 h compared to control revealed a significant effect weighted mean difference of − 1.31 (95% CI: − 2.40 to − 0.23), P < 0.02. At 12 h, the weighted mean difference was of − 0.46 (95% CI: − 1.01 to 0.09), P = 0.10. No block related complications were reported. Conclusions Our results provide moderate quality evidence that erector spinae plane block is an effective strategy to improve postsurgical analgesia.
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Affiliation(s)
- Mark C Kendall
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
| | - Lucas Alves
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Lauren L Traill
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Gildasio S De Oliveira
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Shim H, Gan TJ. Side effect profiles of different opioids in the perioperative setting: are they different and can we reduce them? Br J Anaesth 2019; 123:266-268. [DOI: 10.1016/j.bja.2019.06.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 06/11/2019] [Accepted: 06/12/2019] [Indexed: 11/29/2022] Open
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