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Greig D, Sun CA, McBride D, Young B, Klomhaus A, Swaroop VT, Thompson RM. Efficacy of a Multimodal Surgical Site Injection for Postoperative Pain Control in Pediatric Patients With Cerebral Palsy Undergoing Hip Reconstruction: A Randomized Controlled Trial. J Pediatr Orthop 2024:01241398-990000000-00631. [PMID: 39140418 DOI: 10.1097/bpo.0000000000002779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Abstract
BACKGROUND One in 4 children with cerebral palsy (CP) will undergo orthopaedic surgery during their childhood. Despite its ubiquity, postoperative pain control has been poorly studied in this patient population. Moreover, poor pain management has been associated with adverse surgical outcomes. Multimodal analgesic injections have been well studied in the adult population, demonstrating safety and efficacy in reducing postoperative pain and narcotic consumption, but this modality has not been studied in pediatric patients undergoing similarly complex procedures. The objective of this study was to evaluate the efficacy of a multimodal surgical site injection for postoperative pain control following operative management of hip dysplasia in patients with CP. METHODS After obtaining IRB approval, a multicenter, randomized double-blind placebo control trial was completed. Patients below 18 years old with a diagnosis of CP who were scheduled for varus derotation osteotomy (VDRO) of the proximal femur were randomized to receive a surgical-site injection with either a combination of ropivacaine (3 mg/kg), epinephrine (0.5 mg), and ketorolac (0.5 mg/kg) (experimental group) or normal saline (control). All included patients had identical postoperative care, including immobilization, physical therapy, and standardized, multimodal postoperative pain control. Pain scores and narcotic consumption were recorded at regular intervals and compared between groups utilizing two-tailed t test or a nonparametric Mann-Whitney test for quantitative variables and a Fischer exact test for categorical variables. RESULTS Thirty-four patients were included, evenly divided between study arms. There were no significant differences in demographic variables, gross motor function classification system (GMFCS), comorbidities, preoperative radiographic parameters, or concomitant surgeries between groups. Patients in the experimental group required significantly lower narcotic medications at all postoperative time points from PACU until hospital discharge compared with controls (0.41 ± 0.42 vs. 1.87 ± 2.05 total morphine mEQ/kg, P=0.01). Similarly, patients in the experimental group were found to have significantly lower pain scores throughout their hospital stays compared with controls (1.0 ± 0.6 vs. 2.4 ± 1.1 mean pain score, P<0.001). There were no significant differences in operative time, OR time, blood transfusion requirements or hospital length of stay between groups. There were no adverse medication reactions or injection site complications in either group. CONCLUSIONS In patients with CP undergoing hip reconstruction, surgical-site injection with a multimodal analgesic combination improves pain control and reduces narcotic consumption in the early postoperative period with no observed adverse effects. SIGNIFICANCE Local multimodal analgesic injections should be adopted as part of standard multimodal pain control in this patient population for all osseous surgeries. LEVEL OF EVIDENCE Level I-therapeutic.
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Affiliation(s)
- Danielle Greig
- Department of Orthopaedic Surgery, Division of Pediatric Orthopaedic Surgery, David Geffen School of Medicine at the University of California, Los Angeles. Los Angeles, CA
| | - Christina A Sun
- Department of Orthopaedic Surgery, Division of Pediatric Orthopaedic Surgery, David Geffen School of Medicine at the University of California, Los Angeles. Los Angeles, CA
| | - Daniel McBride
- Department of Orthopedic Surgery, Division of Pediatric Orthopedic Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Bailey Young
- Department of Orthopaedic Surgery, Division of Pediatric Orthopaedic Surgery, David Geffen School of Medicine at the University of California, Los Angeles. Los Angeles, CA
| | - Alexandra Klomhaus
- Department of Orthopaedic Surgery, Division of Pediatric Orthopaedic Surgery, David Geffen School of Medicine at the University of California, Los Angeles. Los Angeles, CA
| | - Vineeta T Swaroop
- Department of Orthopedic Surgery, Division of Pediatric Orthopedic Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Rachel M Thompson
- Department of Orthopaedic Surgery, Division of Pediatric Orthopaedic Surgery, David Geffen School of Medicine at the University of California, Los Angeles. Los Angeles, CA
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Viscusi ER, de Leon-Casasola O, Cebrecos J, Jacobs A, Morte A, Ortiz E, Sust M, Vaqué A, Gottlieb I, Daniels S, Muse D, Kuss ME, Videla S, Gascón N, Plata-Salamán C. Celecoxib-tramadol co-crystal in patients with moderate-to-severe pain following bunionectomy with osteotomy: Secondary analyses by baseline pain intensity and use of rescue medication of a phase 3, randomized, double-blind, factorial, active- and placebo-controlled trial. Pain Pract 2024. [PMID: 38956758 DOI: 10.1111/papr.13399] [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: 07/04/2024]
Abstract
BACKGROUND In the randomized, phase 3, SUSA-301 trial, celecoxib-tramadol co-crystal (CTC) provided significantly greater analgesia compared with celecoxib, tramadol, or placebo in adults with acute, moderate-to-severe, postoperative pain. This post hoc, secondary analysis further evaluated the use of rescue medication and the incidence of treatment-emergent adverse events (TEAEs). METHODS Patients (N = 637) were randomized 2:2:2:1 to receive oral CTC 200 mg twice daily (BID; n = 184), tramadol 50 mg four times daily (QID; n = 183), celecoxib 100 mg BID (n = 181), or placebo QID (n = 89). Post hoc analyses were conducted on the use of rescue medications up to 4 and 48 h post-study drug dose, stratified by baseline pain intensity (moderate/severe), and on the incidence of TEAEs, stratified by rescue medication use. RESULTS A significantly lower proportion of patients received any rescue medication within 4 h post-study dose with CTC (49.5%) versus tramadol (61.7%, p = 0.0178), celecoxib (65.2%, p = 0.0024), and placebo (75.3%, p = 0.0001); this was also seen for oxycodone use. Fewer patients in the CTC group received ≥3 doses of rescue medication compared with the other groups, irrespective of baseline pain intensity. In patients who did not receive opioid rescue medication, CTC was associated with a lower incidence of nausea and vomiting TEAEs versus tramadol alone. In patients who received rescue oxycodone, the incidence of nausea was similar in the CTC and tramadol groups, and higher versus celecoxib and placebo. CONCLUSION Celecoxib-tramadol co-crystal was associated with reduced rescue medication use and an acceptable tolerability profile compared with tramadol or celecoxib alone in adults with acute, moderate-to-severe, postoperative pain.
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Affiliation(s)
- Eugene R Viscusi
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | | - Anna Vaqué
- Esteve Pharmaceuticals S.A., Barcelona, Spain
| | - Ira Gottlieb
- Chesapeake Research Group LLC, Pasadena, Maryland, USA
| | | | - Derek Muse
- JBR Clinical Research, Salt Lake City, Utah, USA
| | | | | | - Neus Gascón
- Esteve Pharmaceuticals S.A., Barcelona, Spain
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Aljohani DM, Almalki N, Dixon D, Adam R, Forget P. Experiences and perspectives of adults on using opioids for pain management in the postoperative period: A scoping review. Eur J Anaesthesiol 2024; 41:500-512. [PMID: 38757159 DOI: 10.1097/eja.0000000000002002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
BACKGROUND Opioids play an important role in peri-operative pain management. However, opioid use is challenging for healthcare practitioners and patients because of concerns related to opioid crises, addiction and side effects. OBJECTIVE This review aimed to identify and synthesise the existing evidence related to adults' experiences of opioid use in postoperative pain management. DESIGN Systematic scoping review of qualitative studies. Inductive content analysis and the Theoretical Domains Framework (TDF) were applied to analyse and report the findings and to identify unexplored gaps in the literature. DATA SOURCES Ovid MEDLINE, PsycInfo, Embase, CINAHL (EBSCO), Cochrane Library and Google Scholar. ELIGIBILITY CRITERIA All qualitative and mixed-method studies, in English, that not only used a qualitative approach that explored adults' opinions or concerns about opioids and/or opioid reduction, and adults' experience related to opioid use for postoperative pain control, including satisfaction, but also aspects of overall quality of a person's life (physical, mental and social well being). RESULTS Ten studies were included; nine were qualitative ( n = 9) and one used mixed methods. The studies were primarily conducted in Europe and North America. Concerns about opioid dependence, adverse effects, stigmatisation, gender roles, trust and shared decision-making between clinicians and patients appeared repeatedly throughout the studies. The TDF analysis showed that many peri-operative factors formed people's perceptions and experiences of opioids, driven by the following eight domains: Knowledge, Emotion, Beliefs about consequences, Beliefs about capabilities, Self-confidence, Environmental Context and Resources, Social influences and Decision Processes/Goals. Adults have diverse pain management goals, which can be categorised as proactive and positive goals, such as individualised pain management care, as well as avoidance goals, aimed at sidestepping issues such as addiction and opioid-related side effects. CONCLUSION It is desirable to understand the complexity of adults' experiences of pain management especially with opioid use and to support adults in achieving their pain management goals by implementing an individualised approach, effective communication and patient-clinician relationships. However, there is a dearth of studies that examine patients' experiences of postoperative opioid use and their involvement in opioid usage decision-making. A summary is provided regarding adults' experiences of peri-operative opioid use, which may inform future researchers, healthcare providers and guideline development by considering these factors when improving patient care and experiences.
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Affiliation(s)
- Dalia M Aljohani
- From the Pain and opioids after Surgery (PANDOS) European Society of Anaesthesiology and Intensive Care (ESAIC) Research Group (DMA, PF), Epidemiology Group, Institute of Applied Health Sciences, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK (PF), Department of Anesthesia Technology (DMA), Department of Nursing, Prince Sultan Military College of Health Sciences, Dhahran, Saudi Arabia (NA), Department of Nursing, University of the Highlands and Islands, Inverness, UK (DD), School of Applied Sciences, Edinburgh Napier University, Edinburgh, Scotland (DD), Health Psychology Group (DD), Academic Primary Care, Institute of Applied Health Sciences, University of Aberdeen (DMA, RA) and Department of Anaesthesia, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, Aberdeenshire, UK (PF)
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Barakat H, Al Nawwar R, Abou Nader J, Aouad M, Yazbeck Karam V, Gholmieh L. Opioid-free versus opioid-based anesthesia in major spine surgery: a prospective, randomized, controlled clinical trial. Minerva Anestesiol 2024; 90:482-490. [PMID: 38869262 DOI: 10.23736/s0375-9393.24.17962-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
BACKGROUND Major spine surgery is associated with severe postoperative pain and increased opioid consumption. Opioid-free anesthesia (OFA) is thought to provide adequate intraoperative analgesia with reduced postoperative opioid consumption. The aim of this study is to compare the impact of intraoperative OFA approach to the conventional opioid-based anesthesia (OBA) on postoperative pain, opioid consumption, and related side effects in patients undergoing multilevel spinal fusion surgery. METHODS Forty-eight patients undergoing elective major spine surgery were randomly allocated to either receive intraoperative dexmedetomidine and lidocaine (OFA group) or fentanyl during induction and intraoperative remifentanil (OBA group). All patients received intraoperative sevoflurane, propofol, rocuronium, ketamine, dexamethasone, ondansetron and postoperative paracetamol and patient-controlled analgesia device set to deliver intravenous morphine for 48 hours after surgery. Postoperative pain was measured using numerical rating scale. Opioid side effects were documented, when present. RESULTS OFA group required less morphine in the first 24 hours post-surgery (17.28±12.25 mg versus 27.96±19.75 mg, P<0.05). The incidence of postoperative nausea and vomiting (PONV) was significantly lower in the OFA group. More patients in the OFA group required antihypertensive medications compared to patients in the OBA group (P<0.05). In the post anesthesia care unit, OFA patients had a significantly longer stay than OBA patients (114.1±49.33 min versus 89.96±30.71 min, P<0.05). CONCLUSIONS OFA can be an alternative to OBA in patients undergoing multilevel spine fusion surgery. OFA reduces opioids consumption in the first 24 hours and PONV.
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Affiliation(s)
- Hanane Barakat
- Department of Anesthesiology, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon -
| | - Rony Al Nawwar
- Department of Anesthesiology, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Jessy Abou Nader
- Department of Anesthesiology, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Marie Aouad
- Department of Anesthesiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Vanda Yazbeck Karam
- Department of Anesthesiology, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Linda Gholmieh
- Department of Anesthesiology, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
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Melis EJ, Vriezekolk JE, van der Laan JCC, Smolders JMH, van den Bemt BJF, Fenten MGE. Long-term postoperative opioid use in orthopaedic patients. Eur J Pain 2024; 28:797-805. [PMID: 38108651 DOI: 10.1002/ejp.2219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 10/26/2023] [Accepted: 11/25/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND The prevalence of long-term opioid use after orthopaedic surgery varies from 1.4% to 24% and has mostly been studied with prescription data, making it difficult to estimate the size and impact of the problem. This study aims to assess the prevalence and predictors of long-term postoperative opioid use in a high volume and tertiary orthopaedic centre by using online patient reported measures. METHODS This Dutch prospective cohort study was conducted among adult patients who underwent any type of orthopaedic surgery from June to August 2021. Six months after surgery patients were invited to complete an online survey on current opioid use and patients' willingness to taper opioids. The demographics, clinical factors and preoperative opioid use were extracted from the patient file. RESULTS In total, 607 patients (mean age 61.2 years, 63.4% female) completed the survey. Seventy-six patients (12.5%) used opioids 6 months after surgery of which 20 (3.3%) did not use opioids before surgery. The median (Q1-Q3) postoperative daily dose after 6 months was 29.9 mg (10.0-76.1) morphine equivalents. Most of them (88.2%) wanted to taper opioids. Affected body region (OR's: 6.84-12.75) and pre-operative opioid use (OR = 35.33) were significant predictors of long-term opioid use. CONCLUSION The prevalence of long-term postoperative opioid use was 12.5%; one in thirty patients became a new long-term opioid user. Pre-operative opioid use and affected body region were predictive for long-term opioid use. These findings, together with the observation that long-term opioid users want to taper opioids, emphasize the relevance of prevention, recognition and tapering support in the perioperative setting. LEVEL OF EVIDENCE Level II. SIGNIFICANCE Short-term opioid use can unintentionally progress to long-term opioid use. The prevalence of long-term opioid use after orthopaedic surgery varies widely and is mostly prescription-based, making it difficult to estimate the magnitude of the problem. This study assessed long-term postoperative opioid use in a full breadth orthopaedic population using patient reported measures, making conclusions much more robust. The prevalence of long-term postoperative opioid use in this study was 12.5%.
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Affiliation(s)
- Eward J Melis
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Johanna E Vriezekolk
- Department of Research and Innovation, Sint Maartenskliniek, Nijmegen, The Netherlands
| | | | - José M H Smolders
- Department of Orthopaedics, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Bart J F van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Research and Innovation, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Maaike G E Fenten
- Department of Anaesthesiology, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Anaesthesiology, Pain and Palliative Care, Radboud University Medical Centre, Nijmegen, The Netherlands
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Segebarth PB, Schallmo M, Odum S, Hietpas K, Michalek C, Chapman TM, Leas D, Milam RA, Hamid N. Opioid-Free Analgesia is Safe and Effective in Anterior Cervical Spine Surgery: A Randomized Controlled Trial. Clin Spine Surg 2024; 37:138-148. [PMID: 38553433 DOI: 10.1097/bsd.0000000000001608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/28/2024] [Indexed: 05/07/2024]
Abstract
STUDY DESIGN Randomized controlled trial (RCT). OBJECTIVE Compare the efficacy of a multimodal, opioid-free (OF) pain management pathway with a traditional opioid-containing (OC) pathway in patients undergoing anterior cervical procedures. SUMMARY OF BACKGROUND DATA Previous studies have compared opioid-based pain regimens to opioid-sparing regimens following cervical spine surgery, but have been limited by high rates of crossover, retrospective designs, reliance on indwelling pain catheters, opioid utilization for early postoperative analgesia, and/or a lack of patient-reported outcome measures. METHODS This is a RCT in which patients were allocated to either an OF or OC perioperative pain management protocol. Eligible study participants included adult (age up to 18 y) patients who underwent primary, 1-level or 2-level anterior cervical surgery [anterior cervical discectomy and fusion (ACDF), anterior cervical disc arthroplasty (ACDA), or hybrid (ACDF and ACDA at different levels)] for degenerative pathology. The primary outcome variable was subjective pain level at 24 hours postoperative. The final study cohort consisted of 50 patients (22 OF, 28 OC). RESULTS Patients in the OF group reported lower median postoperative pain levels at 6 hours (4 for OF vs. 7 for OC; P =0.041) and 24 hours (3 for OF vs. 5 for OC; P =0.032). At 2-week and 6-week follow-up, pain levels were similar between groups. Patients in the OF group reported greater comfort at 12 hours (9 for OF vs. 5 for OC; P =0.003) and 24 hours (9 for OF vs. 5 for OC; P =0.011) postoperatively. Notably, there were no significant differences in patients' reported pain satisfaction, overall surgical satisfaction, or overall sense of physical and mental well-being. In addition, there were no significant differences in falls, delirium, or constipation postoperatively. CONCLUSIONS A multimodal OF pain management pathway following anterior cervical surgery for degenerative disease results in statistically noninferior pain control and equivalent patient-reported outcome measures compared with a traditional OC pathway.
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Verret M, Lam NH, Lalu M, Nicholls SG, Turgeon AF, McIsaac DI, Hamtiaux M, Bao Phuc Le J, Gilron I, Yang L, Kaimkhani M, Assi A, El-Adem D, Timm M, Tai P, Amir J, Srichandramohan S, Al-Mazidi A, Fergusson NA, Hutton B, Zivkovic F, Graham M, Lê M, Geist A, Bérubé M, Poulin P, Shorr R, Daudt H, Martel G, McVicar J, Moloo H, Fergusson DA. Intraoperative pharmacologic opioid minimisation strategies and patient-centred outcomes after surgery: a scoping review. Br J Anaesth 2024; 132:758-770. [PMID: 38331658 PMCID: PMC10925893 DOI: 10.1016/j.bja.2024.01.006] [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: 10/13/2023] [Revised: 12/08/2023] [Accepted: 01/02/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Postoperative patient-centred outcome measures are essential to capture the patient's experience after surgery. Although a large number of pharmacologic opioid minimisation strategies (i.e. opioid alternatives) are used for patients undergoing surgery, it remains unclear which strategies are most promising in terms of patient-centred outcome improvements. This scoping review had two main objectives: (1) to map and describe evidence from clinical trials assessing the patient-centred effectiveness of pharmacologic intraoperative opioid minimisation strategies in adult surgical patients, and (2) to identify promising pharmacologic opioid minimisation strategies. METHODS We searched MEDLINE, Embase, CENTRAL, Web of Science, and CINAHL databases from inception to February 2023. We included trials investigating the use of opioid minimisation strategies in adult surgical patients and reporting at least one patient-centred outcome. Study screening and data extraction were conducted independently by at least two reviewers. RESULTS Of 24,842 citations screened for eligibility, 2803 trials assessed the effectiveness of intraoperative opioid minimisation strategies. Of these, 457 trials (67,060 participants) met eligibility criteria, reporting at least one patient-centred outcome. In the 107 trials that included a patient-centred primary outcome, patient wellbeing was the most frequently used domain (55 trials). Based on aggregate findings, dexmedetomidine, systemic lidocaine, and COX-2 inhibitors were promising strategies, while paracetamol, ketamine, and gabapentinoids were less promising. Almost half of the trials (253 trials) did not report a protocol or registration number. CONCLUSIONS Researchers should prioritise and include patient-centred outcomes in the assessment of opioid minimisation strategy effectiveness. We identified three potentially promising pharmacologic intraoperative opioid minimisation strategies that should be further assessed through systematic reviews and multicentre trials. Findings from our scoping review may be influenced by selective outcome reporting bias. STUDY REGISTRATION OSF - https://osf.io/7kea3.
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Affiliation(s)
- Michael Verret
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, Civic Campus, The Ottawa Hospital, Ottawa, ON, Canada; Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec City, QC, Canada.
| | - Nhat H Lam
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Manoj Lalu
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, Civic Campus, The Ottawa Hospital, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Stuart G Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Ottawa Methods Centre, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec City, QC, Canada; Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du CHU de Québec-Université Laval, Université Laval, Québec City, QC, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, Civic Campus, The Ottawa Hospital, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Myriam Hamtiaux
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - John Bao Phuc Le
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Ian Gilron
- Department of Anesthesiology & Perioperative Medicine, Biomedical & Molecular Sciences, Centre for Neuroscience Studies and School of Policy Studies, Queen's University, Kingston, ON, Canada
| | - Lucy Yang
- Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Alexandre Assi
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - David El-Adem
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Makenna Timm
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Peter Tai
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Joelle Amir
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Sriyathavan Srichandramohan
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Abdulaziz Al-Mazidi
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Nicholas A Fergusson
- Department of Anesthesiology, Perioperative & Pain Medicine, University of Calgary, Calgary, AB, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Fiona Zivkovic
- Patient partner, The Ottawa Hospital, Ottawa, ON, Canada
| | - Megan Graham
- Patient partner, The Ottawa Hospital, Ottawa, ON, Canada
| | - Maxime Lê
- Patient partner, The Ottawa Hospital, Ottawa, ON, Canada
| | - Allison Geist
- Patient partner, The Ottawa Hospital, Ottawa, ON, Canada
| | - Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du CHU de Québec-Université Laval, Université Laval, Québec City, QC, Canada; Faculty of Nursing, Université Laval, Québec City, QC, Canada; Quebec Pain Research Network, Sherbrooke, QC, Canada
| | - Patricia Poulin
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Risa Shorr
- Library Services, The Ottawa Hospital, Ottawa, ON, Canada
| | | | - Guillaume Martel
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Jason McVicar
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, Civic Campus, The Ottawa Hospital, Ottawa, ON, Canada
| | - Husein Moloo
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
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Madden K, Pallapothu S, Young Shing D, Adili A, Bhandari M, Carlesso L, Khan M, Kleinlugtenbelt YV, Krsmanovic A, Nowakowski M, Packham T, Romeril E, Tarride JE, Thabane L, Tushinski DM, Wallace C, Winemaker M, Shanthanna H. Opioid reduction and enhanced recovery in orthopaedic surgery (OREOS): a protocol for a feasibility randomised controlled trial in patients undergoing total knee arthroplasty. Pilot Feasibility Stud 2024; 10:30. [PMID: 38360686 PMCID: PMC10868001 DOI: 10.1186/s40814-024-01457-9] [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: 01/26/2023] [Accepted: 01/25/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Knee arthritis is a leading cause of limited function and long-term disability in older adults. Despite a technically successful total knee arthroplasty (TKA), around 20% of patients continue to have persisting pain with reduced function, and low quality of life. Many of them continue using opioids for pain control, which puts them at risk for potential long-term adverse effects such as dependence, overdose and risk of falls. Although persisting pain and opioid use after TKA have been recognised to be important issues, individual strategies to decrease their burden have limitations and multi-component interventions, despite their potential, have not been well studied. In this study, we propose a multi-component pathway including personalized pain management, facilitated by a pain management coordinator. The objectives of this pilot trial are to evaluate feasibility (recruitment, retention, and adherence), along with opioid-free pain control at 8 weeks after TKA. METHODS This is a protocol for a multicentre pilot randomised controlled trial using a 2-arm parallel group design. Adult participants undergoing unilateral total knee arthroplasty will be considered for inclusion and randomised to control and intervention groups. Participants in the intervention group will receive support from a pain management coordinator who will facilitate a multicomponent pain management pathway including (1) preoperative education on pain and opioid use, (2) preoperative risk identification and mitigation, (3) personalized post-discharge analgesic prescriptions and (4) continued support for pain control and recovery up to 8 weeks post-op. Participants in the control group will undergo usual care. The primary outcomes of this pilot trial are to assess the feasibility of participant recruitment, retention, and adherence to the interventions, and key secondary outcomes are persisting pain and opioid use. DISCUSSION The results of this trial will determine the feasibility of conducting a definitive trial for the implementation of a multicomponent pain pathway to improve pain control and reduce harms using a coordinated approach, while keeping an emphasis on patient centred care and shared decision making. TRIAL REGISTRATION Prospectively registered in Clinicaltrials.gov (NCT04968132).
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Affiliation(s)
- Kim Madden
- Department of Surgery, McMaster University, Hamilton, Canada.
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada.
- Department of Health Research Methods, McMaster University, Hamilton, Canada.
| | | | | | - Anthony Adili
- Department of Surgery, McMaster University, Hamilton, Canada
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Mohit Bhandari
- Department of Surgery, McMaster University, Hamilton, Canada
- Department of Health Research Methods, McMaster University, Hamilton, Canada
| | - Lisa Carlesso
- School of Rehabilitation Science, McMaster University, Hamilton, Canada
| | - Moin Khan
- Department of Surgery, McMaster University, Hamilton, Canada
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | | | - Adrijana Krsmanovic
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada
| | - Matilda Nowakowski
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada
| | - Tara Packham
- School of Rehabilitation Science, McMaster University, Hamilton, Canada
| | - Eric Romeril
- Hamilton Health Sciences-Juravinski Hospital, Hamilton, Canada
| | - Jean-Eric Tarride
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Health Research Methods, McMaster University, Hamilton, Canada
- Center for Health Economics and Policy Analyses, McMaster University, Hamilton, Canada
| | - Lehana Thabane
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Health Research Methods, McMaster University, Hamilton, Canada
| | - Daniel M Tushinski
- Department of Surgery, McMaster University, Hamilton, Canada
- Hamilton Health Sciences-Juravinski Hospital, Hamilton, Canada
| | - Christine Wallace
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | | | - Harsha Shanthanna
- Department of Surgery, McMaster University, Hamilton, Canada
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Anesthesia, McMaster University, Hamilton, Canada
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Oostvogels L, Weibel S, Meißner M, Kranke P, Meyer-Frießem CH, Pogatzki-Zahn E, Schnabel A. Erector spinae plane block for postoperative pain. Cochrane Database Syst Rev 2024; 2:CD013763. [PMID: 38345071 PMCID: PMC10860379 DOI: 10.1002/14651858.cd013763.pub3] [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] [Indexed: 02/15/2024]
Abstract
BACKGROUND Acute and chronic postoperative pain are important healthcare problems, which can be treated with a combination of opioids and regional anaesthesia. The erector spinae plane block (ESPB) is a new regional anaesthesia technique, which might be able to reduce opioid consumption and related side effects. OBJECTIVES To compare the analgesic effects and side effect profile of ESPB against no block, placebo block or other regional anaesthetic techniques. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Web of Science on 4 January 2021 and updated the search on 3 January 2022. SELECTION CRITERIA Randomised controlled trials (RCTs) investigating adults undergoing surgery with general anaesthesia were included. We included ESPB in comparison with no block, placebo blocks or other regional anaesthesia techniques irrespective of language, publication year, publication status or technique of regional anaesthesia used (ultrasound, landmarks or peripheral nerve stimulator). Quasi-RCTs, cluster-RCTs, cross-over trials and studies investigating co-interventions in either arm were excluded. DATA COLLECTION AND ANALYSIS Two review authors independently assessed all trials for inclusion and exclusion criteria, and risk of bias (RoB), and extracted data. We assessed risk of bias using the Cochrane RoB 2 tool, and we used GRADE to rate the certainty of evidence for the primary outcomes. The primary outcomes were postoperative pain at rest at 24 hours and block-related adverse events. Secondary outcomes were postoperative pain at rest (2, 48 hours) and during activity (2, 24 and 48 hours after surgery), chronic pain after three and six months, as well as cumulative oral morphine requirements at 2, 24 and 48 hours after surgery and rates of opioid-related side effects. MAIN RESULTS We identified 69 RCTs in the first search and included these in the systematic review. We included 64 RCTs (3973 participants) in the meta-analysis. The outcome postoperative pain was reported in 38 out of 64 studies; block-related adverse events were reported in 40 out of 64 studies. We assessed RoB as low in 44 (56%), some concerns in 24 (31%) and high in 10 (13%) of the study results. Overall, 57 studies reported one or both primary outcomes. Only one study reported results on chronic pain after surgery. In the updated literature search on 3 January 2022 we found 37 new studies and categorised these as awaiting classification. ESPB compared to no block There is probably a slight but not clinically relevant reduction in pain intensity at rest 24 hours after surgery in patients treated with ESPB compared to no block (visual analogue scale (VAS), 0 to 10 points) (mean difference (MD) -0.77 points, 95% confidence interval (CI) -1.08 to -0.46; 17 trials, 958 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between the groups treated with ESPB and those receiving no block (no events in 18 trials reported, 1045 participants, low-certainty evidence). ESPB compared to placebo block ESPB probably has no effect on postoperative pain intensity at rest 24 hours after surgery compared to placebo block (MD -0.14 points, 95% CI -0.29 to 0.00; 8 trials, 499 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between ESPB and placebo blocks (no events in 10 trials reported; 592 participants; low-certainty evidence). ESPB compared to other regional anaesthetic techniques Paravertebral block (PVB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PVB (MD 0.23 points, 95% CI -0.06 to 0.52; 7 trials, 478 participants; low-certainty evidence). There is probably no difference in block-related adverse events (risk ratio (RR) 0.27, 95% CI 0.08 to 0.95; 7 trials, 522 participants; moderate-certainty evidence). Transversus abdominis plane block (TAPB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to TAPB (MD -0.16 points, 95% CI -0.46 to 0.14; 3 trials, 160 participants; low-certainty evidence). There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.21 to 4.83; 4 trials, 202 participants; low-certainty evidence). Serratus anterior plane block (SAPB) The effect on postoperative pain could not be assessed because no studies reported this outcome. There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.06 to 15.59; 2 trials, 110 participants; low-certainty evidence). Pectoralis plane block (PECSB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PECSB (MD 0.24 points, 95% CI -0.11 to 0.58; 2 trials, 98 participants; low-certainty evidence). The effect on block-related adverse events could not be assessed. Quadratus lumborum block (QLB) Only one study reported on each of the primary outcomes. Intercostal nerve block (ICNB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to ICNB, but this is uncertain (MD -0.33 points, 95% CI -3.02 to 2.35; 2 trials, 131 participants; very low-certainty evidence). There may be no difference in block-related adverse events, but this is uncertain (RR 0.09, 95% CI 0.04 to 2.28; 3 trials, 181 participants; very low-certainty evidence). Epidural analgesia (EA) We are uncertain whether ESPB has an effect on postoperative pain intensity at rest 24 hours after surgery compared to EA (MD 1.20 points, 95% CI -2.52 to 4.93; 2 trials, 81 participants; very low-certainty evidence). A risk ratio for block-related adverse events was not estimable because only one study reported this outcome. AUTHORS' CONCLUSIONS ESPB in addition to standard care probably does not improve postoperative pain intensity 24 hours after surgery compared to no block. The number of block-related adverse events following ESPB was low. Further research is required to study the possibility of extending the duration of analgesia. We identified 37 new studies in the updated search and there are three ongoing studies, suggesting possible changes to the effect estimates and the certainty of the evidence in the future.
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Affiliation(s)
- Lisa Oostvogels
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Stephanie Weibel
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Michael Meißner
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Peter Kranke
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Christine H Meyer-Frießem
- Department of Anaesthesiology, Intensive Care Medicine and Pain Management, BG-Universitätsklinikum Bergmannsheil gGmbH, Bochum, Germany
| | - Esther Pogatzki-Zahn
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Alexander Schnabel
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
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10
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Hysong AA, Odum SM, Lake NH, Hietpas KT, Michalek CJ, Hamid N, Gaston RG, Loeffler BJ. Opioid-Free Analgesia Provides Pain Control Following Thumb Carpometacarpal Joint Arthroplasty. J Bone Joint Surg Am 2023; 105:1750-1758. [PMID: 37651550 DOI: 10.2106/jbjs.22.01278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
BACKGROUND We hypothesized that an opioid-free (OF), multimodal pain management pathway for thumb carpometacarpal (CMC) joint arthroplasty would not have inferior pain control compared with that of a standard opioid-containing (OC) pathway. METHODS This was a single-center, randomized controlled clinical trial of patients undergoing primary thumb CMC joint arthroplasty. Patients were randomly allocated to either a completely OF analgesic pathway or a standard OC analgesic pathway. Patients in both cohorts received a preoperative brachial plexus block utilizing 30 mL of 0.5% ropivacaine that was administered via ultrasound guidance. The OF group was given a combination of cryotherapy, anti-inflammatory medications, acetaminophen, and gabapentin. The OC group was only given cryotherapy and opioid-containing medication for analgesia. Patient-reported pain was assessed with use of a 0 to 10 numeric rating scale at 24 hours, 2 weeks, and 6 weeks postoperatively. We compared the demographics, opioid-related side effects, patient satisfaction, and Veterans RAND 12-Item Health Survey (VR-12) results between these 2 groups. RESULTS At 24 hours postoperatively, pain scores in the OF group were statistically noninferior to, and lower than, those in the OC group (median, 2 versus 4; p = 0.008). Pain scores continued to differ significantly at 2 weeks postoperatively (median, 2 versus 4; p = 0.001) before becoming more similar at 6 weeks (p > 0.05). No difference was found between groups with respect to opioid-related side effects, patient satisfaction, or VR-12 results. CONCLUSIONS A completely opioid-free perioperative protocol is effective for the treatment of pain following thumb CMC joint arthroplasty in properly selected patients. LEVEL OF EVIDENCE Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexander A Hysong
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Susan M Odum
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | | | | | | | - Nady Hamid
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
- OrthoCarolina Hand Center, Charlotte, North Carolina
| | - Raymond G Gaston
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
- OrthoCarolina Hand Center, Charlotte, North Carolina
| | - Bryan J Loeffler
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
- OrthoCarolina Hand Center, Charlotte, North Carolina
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11
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Phatak UR, Raji M, Chen L, Baillargeon JG, Yong-Fang K. Opioid Prescribing Patterns After Colorectal Resections in the United States of America. Cureus 2023; 15:e48890. [PMID: 38106740 PMCID: PMC10725122 DOI: 10.7759/cureus.48890] [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] [Accepted: 11/16/2023] [Indexed: 12/19/2023] Open
Abstract
Background The opioid epidemic is a significant source of morbidity and mortality in the United States of America. Minimizing opioid prescribing after operations has become an important component of post-operative care pathways. We hypothesized that opioid prescribing has decreased over time after colorectal resections. Methods This is a retrospective study from 2012 to 2019 using the Optum Clinformatics database (Eden Prairie, MN). We included patients aged 18 years or older who had an elective colorectal resection. Our primary outcome was the rate of opioid prescription at post-operative discharge. Secondary outcomes included the rates of gabapentinoid (GABA) prescribing post-operatively. Results Of 17,900 patients, the most common procedure was sigmoid colectomy (35%). Most procedures were open (N=10,626, 59.4%). The most common indication was benign disease (N=12,439, 69.5%). Post-operative opioid prescribing decreased from 64.4% in 2012 to 46.7% in 2019. In the adjusted model, the odds of post-operative opioid prescription were 37% lower in 2019 than in 2012 (OR, 0.63; 95% CI, 0.56-0.72; p<0.0001). At 60 days and one year post surgery, opioid prescribing decreased from 11.6% and 5.9% in 2012 to 7.2% and 5.2% in 2019 (p<0.0001). At 60 days, gabapentinoid prescribing increased from 2.3% in 2012 to 4.0% in 2019 (p=0.0016). Conclusions Our data show that opioid prescribing is common after colorectal surgery with an overall post-operative prescription rate of 55.8%. The modification of post-operative pathways to include guidance on opioid prescribing and non-opioid alternatives may curb opioid prescribing, decrease the number of new persistent opioid users, and decrease the number of opioids available for diversion.
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Affiliation(s)
- Uma R Phatak
- Department of Surgery, University of Texas Medical Branch, Galveston, USA
| | - Mukaila Raji
- Department of Internal Medicine, Division of Geriatrics and Palliative Medicine, University of Texas Medical Branch, Galveston, USA
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, USA
| | - Lu Chen
- Department of Internal Medicine, Division of Geriatrics and Palliative Medicine, University of Texas Medical Branch, Galveston, USA
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, USA
| | - Jacques G Baillargeon
- Department of Internal Medicine, Division of Geriatrics and Palliative Medicine, University of Texas Medical Branch, Galveston, USA
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, USA
| | - Kuo Yong-Fang
- Department of Internal Medicine, Division of Geriatrics and Palliative Medicine, University of Texas Medical Branch, Galveston, USA
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, USA
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12
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Jain S, Lapointe-Gagner M, Alali N, Elhaj H, Poirier AS, Kaneva P, Alhashemi M, Lee L, Agnihotram RV, Feldman LS, Gagner M, Andalib A, Fiore JF. Prescription and consumption of opioids after bariatric surgery: a multicenter prospective cohort study. Surg Endosc 2023; 37:8006-8018. [PMID: 37460817 DOI: 10.1007/s00464-023-10265-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/27/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION In the current opioid crisis, bariatric surgical patients are at increased risk of harms related to postoperative opioid overprescribing. This study aimed to assess the extent to which opioids prescribed at discharge after bariatric surgery are consumed by patients. METHODS This multicenter prospective cohort study included adult patients (≥ 18yo) undergoing laparoscopic bariatric surgery. Preoperative assessments included demographics and patient-reported measures. Information regarding surgical and perioperative care interventions (including discharge prescriptions) was obtained from medical records. Self-reported opioid consumption was assessed weekly up to 30 days post-discharge. Number of opioid pills prescribed and consumed was compared using Wilcoxon signed-rank test. Zero-inflated negative binomial regression was used to identify predictors of post-discharge opioid consumption. RESULTS We analyzed 351 patients (mean age 44 ± 11 years, BMI 45 ± 8.0 kg/m2, 77% female, 71% sleeve gastrectomy, length of stay 1.6 ± 0.6 days). The quantity of opioids prescribed at discharge (median 15 pills [IQR 15-16], 112.5 morphine milligram equivalents (MMEs) [IQR 80-112.5]) was significantly higher than patient-reported consumption (median 1 pill [IQR 0-5], 7.5 MMEs [IQR 0-37.5]) (p < 0.001). Overall, 37% of patients did not take any opioids post-discharge and 78.5% of the opioid pills prescribed were unused. Increased post-discharge opioid consumption was associated with male sex (IRR 1.54 [95%CI 1.14 to 2.07]), higher BMI (1.03 [95%CI 1.01 to 1.05]), preoperative opioid use (1.48 [95%CI 1.04 to 2.10]), current smoking (2.32 [95%CI 1.44 to 3.72]), higher PROMIS-29 depression score (1.03 [95% CI 1.01 to 1.04]), anastomotic procedures (1.33 [95%CI 1.01 to 1.75]), and number of pills prescribed (1.04 [95%CI 1.01 to 1.06]). CONCLUSION This study supports that most opioid pills prescribed to bariatric surgery patients at discharge are not consumed. Patient and procedure-related factors may predict opioid consumption. Individualized post-discharge analgesia strategies with minimal or no opioids may be feasible and should be further investigated in future research.
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Affiliation(s)
- Shrieda Jain
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Maxime Lapointe-Gagner
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Naser Alali
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Hiba Elhaj
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Anne-Sophie Poirier
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Pepa Kaneva
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Mohsen Alhashemi
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Lawrence Lee
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Ramanakumar V Agnihotram
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Liane S Feldman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Michel Gagner
- Clinique Michel Gagner (Westmount Square Surgical Center), Westmount, QC, Canada
| | - Amin Andalib
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
- Center for Bariatric Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Julio F Fiore
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada.
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada.
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada.
- Montreal General Hospital, 1650 Cedar Ave, R2-104, Montreal, QC, H3G 1A4, Canada.
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13
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Ruckle DE, Chang AC, Wongworawat MD. The Effect of Upper Extremity Tourniquet Time on Postoperative Pain and Opiate Consumption. Hand (N Y) 2023; 18:1152-1155. [PMID: 35321573 PMCID: PMC10798213 DOI: 10.1177/15589447221084009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There is widespread use of pneumatic tourniquet for both upper and lower extremity orthopedic surgeries. Tourniquet use improves visualization, decreases blood loss, and as a result, decreases operative time. Exceeding a certain amount of tourniquet time can cause lasting neuromuscular damage. Orthopedic procedures cause significant pain, and the perioperative narcotic prescriptions after orthopedic surgery have been identified as one of the major contributors to the opioid epidemic. Our aim was to determine whether increasing tourniquet time had a negative impact on immediate postoperative opiate usage in the upper extremity, and to determine other factors associated with increased immediate postoperative opiate usage. METHODS A retrospective medical record review was performed on patients who underwent volar pleading for fracture fixation between January 2014 and December 2019 at a single institution. Postoperative pain, morphine equivalent dose (MED) usage, and demographic variables were collected. Multivariable analysis was performed, with P < .05 considered significant. RESULTS Immediate postoperative MED consumed was not correlated with operative time, tourniquet time, preoperative substance usage, or sex. However, postoperative MED consumed was correlated with preoperative narcotic use, high body mass index (BMI), and fracture surgery complexity. CONCLUSIONS Tourniquet usage under current guidelines does not appear to have an effect on postoperative pain and narcotic usage. Preoperative narcotic usage, BMI, and surgery complexity are significant factors for postoperative opiate consumption.
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14
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Zhou Y, Wang B, Duan K, Bai Z, Hu X, Xu M, Li X, Gao Y, Li J, Yang M, Zhang Y, Zhang W, Dai R, Shen Y, Wu Z, Jiang Y, Yu S, Ouyang W, Wang S. Preemptive QP001, a fast-acting meloxicam formulation, provides analgesia and reduces opioid consumption following abdominal surgery: a randomized controlled trial. Inflammopharmacology 2023; 31:2401-2410. [PMID: 37646897 DOI: 10.1007/s10787-023-01322-w] [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: 06/20/2023] [Accepted: 08/07/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND QP001, a novel meloxicam formulation, has been developed to manage moderate to severe postoperative pain. This study aimed to evaluate the efficacy and safety of QP001 injections for moderate to severe pain following abdominal surgery. METHOD This prospective, multicenter, randomized, double-blind, placebo-controlled clinical trial enlisted patients experiencing moderate to severe pain following abdominal surgery. These patients were randomized to receive either QP001 injections (30 mg or 60 mg) or a placebo pre-surgery. The primary efficacy endpoint was the total morphine consumption within 24 h after the first administration. RESULTS A total of 108 patients were enrolled, and 106 patients completed the study. The total morphine consumption in the QP001 30 mg group and 60 mg group, versus placebo group, were significantly lower over the following 24 h (5.11[5.46] vs 8.86[7.67], P = 0.011; 3.11[3.08] vs 8.86[7.67], P < 0.001), respectively. The total morphine consumption in the QP001 30 mg and 60 mg groups, versus placebo group, was also significantly decreased over the following 48 h, including the 24-48 h period (P ≤ 0.001). The QP001 30 mg and 60 mg groups, versus placebo, showed a significant decrease in the area under the curve for pain intensity-time as well as a significant decrease in the effective pressing times of the analgesic pump over the 24 h and 48 h periods (P < 0.05). The QP001 groups, versus placebo, show no significant different in Adverse Events or Adverse Drug Reactions (P > 0.05). CONCLUSION Preoperative/preemptive QP001 provides analgesia and reduces opioid consumption in patients with moderate to severe pain following abdominal surgery, while maintaining a favorable safety profile.
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Affiliation(s)
- Yingyong Zhou
- Department of Anesthesiology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Bin Wang
- General Surgery, Guiyang Baijun Taikang Hospital, Chenzhou, China
| | - Kaiming Duan
- Department of Anesthesiology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Zhihong Bai
- Department of Anesthesiology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Xianwen Hu
- Department of Anesthesiology, The Second Hospital of Anhui Medical University, Hefei, China
| | - Mingjun Xu
- Department of Anesthesiology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Xiaohong Li
- Department of Anesthesiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Yuanli Gao
- Department of Anesthesiology, Maanshan People's Hospital, Ma'anshan, China
| | - Jiangang Li
- Department of Anesthesiology, Qujing No.1 Hospital, Qujing, China
| | - Mengchang Yang
- Department of Anesthesiology, Sichuan Provincial People's Hospital, Chengdu, China
| | - Ying Zhang
- Department of Anesthesiology, The Affiliated Traditional Chinese Medical Hospital of Southwest Medical University, Luzhou, China
| | - Wei Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ruping Dai
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Yufei Shen
- Gynecology Department, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Ziteng Wu
- Nanjing Delova Biotech Co., Ltd, Nanjing, China
| | - Yan Jiang
- Nanjing Delova Biotech Co., Ltd, Nanjing, China
| | - Sen Yu
- Nanjing Delova Biotech Co., Ltd, Nanjing, China
| | - Wen Ouyang
- Department of Anesthesiology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Saiying Wang
- Department of Anesthesiology, The Third Xiangya Hospital of Central South University, Changsha, China.
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15
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Qian XL, Li P, Chen YJ, Xu SQ, Wang X, Feng SW. Opioid Free Total Intravenous Anesthesia With Dexmedetomidine-Esketamine-Lidocaine for Patients Undergoing Lumpectomy. J Clin Med Res 2023; 15:415-422. [PMID: 37822850 PMCID: PMC10563822 DOI: 10.14740/jocmr5000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 08/18/2023] [Indexed: 10/13/2023] Open
Abstract
Background The aim of the study was to evaluate the feasibility of the opioid-free anesthesia (OFA) technique with dexmedetomidine, esketamine, and lidocaine among patients diagnosed with benign breast mass and scheduled for lumpectomy. Methods We enrolled 80 female patients who were aged from 18 to 60 years, graded with American Society of Anesthesiologists physical status I or II, diagnosed with benign breast mass, and scheduled for lumpectomy. These patients were randomly treated with OFA or opioid-based anesthesia (OBA). Dexmedetomidine-esketamine-lidocaine and sufentanil-remifentanil were administered in OFA and OBA group, respectively. We mainly compared the analgesic efficacy of OFA and OBA technique, as well as intraoperative hemodynamics, the quality of recovery, and satisfaction score of patients. Results There was no significant difference between the two groups with regard to visual analogue scale (VAS) score at 2, 12, and 24 h after extubation. However, the time to first rescue analgesic was prolonged in OFA group than that in OFB group (6.18 ± 1.00 min vs. 7.40 ± 0.92 min, P = 0.000). Further, mean arterial pressure and heart rate at T0 (entering operating room), T1 (before anesthesia induction), T2 (immediately after intubation), T3, T4, and T5 (1, 5, and 10 min after surgical incision, respectively) were significantly higher in OFA group than that in OBA group. Incidence of hypotension and bradycardia was lower in OFA group. Consistently, fewer patients in OFA group consumed atropine (8% vs. 32%, P = 0.019) and ephedrine (5% vs. 38%, P = 0.001) compared to OBA group. Furthermore, patients in OFA group had a longer awakening time (7.14 ± 2.63 min vs. 4.54 ± 1.14 min, P = 0.000) and recovery time of orientation (11.76 ± 3.15 min vs. 6.92 ± 1.19 min, P = 0.000). Fewer patients in the OFA group experienced postoperative nausea and vomiting (PONV) (11% vs. 51%, P = 0.000) and consumed ondansetron (5% vs. 35%, P = 0.003) compared to OBA group. And patients in OFA group had a higher satisfaction score than those in OBA group (9 (8 - 9) vs. 7 (7 - 8), P = 0.000). Conclusion For patients undergoing lumpectomy, OFA technique with dexmedetomidine-esketamine-lidocaine showed a better postoperative analgesic efficacy, a more stable hemodynamics, and a lower incidence of PONV. However, such advantage of OFA technique should be weighed against a longer awakening time and recovery time of orientation in clinical practice.
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Affiliation(s)
- Xia Li Qian
- Department of Anesthesiology, Women’s Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, Jiangsu Province, China
- These two authors contributed equally to this work
| | - Ping Li
- Department of Anesthesiology, Women’s Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, Jiangsu Province, China
- These two authors contributed equally to this work
| | - Ya Jie Chen
- Department of Anesthesiology, Women’s Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, Jiangsu Province, China
| | - Shi Qin Xu
- Department of Anesthesiology, Women’s Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, Jiangsu Province, China
| | - Xian Wang
- Department of Anesthesiology, Women’s Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, Jiangsu Province, China
| | - Shan Wu Feng
- Department of Anesthesiology, Women’s Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, Jiangsu Province, China
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16
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Villa NAE, Shum K, Atkinson A, Ong A, Muller A, Espiridion E. Prevalence and Predictors of Long-term Opioid Use After Pelvic Fractures. Am Surg 2023; 89:3710-3715. [PMID: 37144563 DOI: 10.1177/00031348231173975] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND Opioids are effective in short-term pain treatment; however, their long-term effectiveness is unconfirmed. Many patients are exposed to opioids after pelvic injuries with little known about persistent use afterward. We assessed the prevalence and predictors of long-term opioid use following pelvic fractures. MATERIALS AND METHODS This retrospective study enrolled 277 patients with acute pelvic fractures over five years. Daily and total morphine milligram equivalents (MME) were calculated. The primary outcome was long-term opioid use (LOU) defined as ongoing opioid use 60-90 days post-discharge. The secondary outcome was intermediate-term opioid use (IOU) defined as ongoing opioid use 30-60 days post-discharge. Univariable and logistic regression analyses were performed. RESULTS Median (interquartile range) total inpatient opioid MME was 422 (157-1667) with a median daily MME of 69 (26-145). Long-term opioid use occurred in 16%, and IOU occurred in 29%. Univariable analysis found that total and daily inpatient opioid use were each significantly associated with LOU (median MME, 1241 vs 371; median MMEs, 127.7 vs 59.2, respectively) and IOU (median MME, 1140 vs 326; median MMEs, 111.8 vs 57.9, respectively). Logistic regression analysis found daily inpatient MME ≥50 (odds ratio [OR] 3.027, 95% confidence interval [CI] 1.059-8.652]) and pelvic fracture type (Tile B/C) (OR 2.992 [CI 1.324-6.763])were independent predictors of LOU. CONCLUSION Total and daily inpatient opioid use were significantly associated with LOU and IOU. Patients who received ≥50 MME/inpatient day had a higher likelihood of LOU. This study seeks to inform clinical decisions for pain management to prevent adverse outcomes.
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Affiliation(s)
| | - Kristina Shum
- Drexel University College of Medicine at Tower Health, Wyomissing, PA, USA
| | - Allison Atkinson
- Drexel University College of Medicine at Tower Health, Wyomissing, PA, USA
| | - Adrian Ong
- Department of Surgery, Reading Hospital, Reading, PA, USA
| | - Allison Muller
- Department of Surgery, Reading Hospital, Reading, PA, USA
| | - Eduardo Espiridion
- Drexel University College of Medicine at Tower Health, Wyomissing, PA, USA
- Department of Psychiatry, Reading Hospital, Reading, PA, USA
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17
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Ma L, Deng D, Zhang T, Zhao W, Liu C, Huang S, Xu F, Wang Y, Zhao S, Ding Y, Huang Y, Wang K, Zhang Y, Yang X, Cao S, Chen X. STING-IFN-I pathway relieves incision induced acute postoperative pain via inhibiting the neuroinflammation in dorsal root ganglion of rats. Inflamm Res 2023; 72:1551-1565. [PMID: 37433890 DOI: 10.1007/s00011-023-01764-6] [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: 12/10/2022] [Revised: 06/13/2023] [Accepted: 06/30/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND The purpose of this study was to study the effect of STING-IFN-I pathway on incision induced postoperative pain in rats and its possible mechanisms. METHODS The pain thresholds were evaluated by measuring the mechanical withdrawal threshold and the thermal withdrawal latency. The satellite glial cell and macrophage of DRG were analyzed. The expression of STING, IFN-a, P-P65, iNOS, TNF-α, IL-1β and IL-6 in DRG was evaluated. RESULTS The activation of STING-IFN-I pathway can reduce the mechanical hyperalgesia, thermal hyperalgesia, down-regulate the expression of P-P65, iNOS, TNF-α, IL-1β and IL-6, and inhibit the activation of satellite glial cell and macrophage in DRG. CONCLUSIONS The activation of STING-IFN-I pathway can alleviate incision induced acute postoperative pain by inhibiting the activation of satellite glial cell and macrophage, which reducing the corresponding neuroinflammation in DRG.
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Affiliation(s)
- Lulin Ma
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Daling Deng
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Tianhao Zhang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Wenjing Zhao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Chengxi Liu
- Department of Anesthesiology, The Second Affiliated Hospital of University of South China, Hengyang, China
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Shiqian Huang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Feng Xu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Yafeng Wang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Shuai Zhao
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
- Department of Pain Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yuanyuan Ding
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Yan Huang
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
- Department of Anesthesiology, The First People's Hospital of Jiangxia District, Wuhan, China
| | - Kaixin Wang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Yanyan Zhang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Xinxin Yang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Song Cao
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
- Department of Pain Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Xiangdong Chen
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China.
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18
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Lambert DG. Opioids and opioid receptors; understanding pharmacological mechanisms as a key to therapeutic advances and mitigation of the misuse crisis. BJA OPEN 2023; 6:100141. [PMID: 37588171 PMCID: PMC10430815 DOI: 10.1016/j.bjao.2023.100141] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/05/2023] [Accepted: 04/12/2023] [Indexed: 08/18/2023]
Abstract
Opioids are a mainstay in acute pain management and produce their effects and side effects (e.g., tolerance, opioid-use disorder and immune suppression) by interaction with opioid receptors. I will discuss opioid pharmacology in some controversial areas of enquiry of anaesthetic relevance. The main opioid target is the µ (mu,MOP) receptor but other members of the opioid receptor family, δ (delta; DOP) and κ (kappa; KOP) opioid receptors also produce analgesic actions. These are naloxone-sensitive. There is important clinical development relating to the Nociceptin/Orphanin FQ (NOP) receptor, an opioid receptor that is not naloxone-sensitive. Better understanding of the drivers for opioid effects and side effects may facilitate separation of side effects and production of safer drugs. Opioids bind to the receptor orthosteric site to produce their effects and can engage monomer or homo-, heterodimer receptors. Some ligands can drive one intracellular pathway over another. This is the basis of biased agonism (or functional selectivity). Opioid actions at the orthosteric site can be modulated allosterically and positive allosteric modulators that enhance opioid action are in development. As well as targeting ligand-receptor interaction and transduction, modulating receptor expression and hence function is also tractable. There is evidence for epigenetic associations with different types of pain and also substance misuse. As long as the opioid narrative is defined by the 'opioid crisis' the drive to remove them could gather pace. This will deny use where they are effective, and access to morphine for pain relief in low income countries.
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Truong A, Yao L, Fleshner PR, Zaghiyan KN. Feasibility of opioid-free surgery for inflammatory bowel disease. Colorectal Dis 2023; 25:976-983. [PMID: 36718946 DOI: 10.1111/codi.16493] [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: 07/05/2022] [Revised: 11/16/2022] [Accepted: 01/01/2023] [Indexed: 02/01/2023]
Abstract
AIM Patients undergoing colorectal surgery or those with inflammatory bowel disease (IBD) are particularly at risk for opioid-related complications and progression to long-term opioid dependence. The aim of this work is to explore the real-world possibility of perioperative opioid avoidance in colorectal surgery and IBD. METHOD We conducted a retrospective analysis of patients aggregated from two prospective studies on multimodal postoperative pain control conducted at a single tertiary referral centre. All patients underwent major colorectal surgery with bowel resection. Patients with chronic preoperative opioid use were excluded. Opioid use was measured in oral morphine equivalents (OME) each postoperative day (POD) and cumulatively for the first 72 h. RESULTS Our cohort of 209 patients included 148 (71%) with IBD and 61 (29%) non-IBD patients. IBD patients required significantly more opioids cumulatively over the first 72 postoperative hours compared with non-IBD patients [median OME 77 mg (interquartile range 33-148 mg) vs. 4 mg (interquartile range 17-82 mg), respectively; p = 0.001]. Five percent of IBD patients achieved opioid-free postoperative pain control during the entire 72 h postoperative period compared with 12% of non-IBD patients. Only 7% of IBD patients avoided opioid use on POD 1 compared with 20% of non-IBD patients (p = 0.02); however the number of IBD patients increased to 16% on POD 2 then 40% on POD 3, closely resembling the non-IBD cohort at 49% (p = 0.22). CONCLUSION In the era of modern enhanced recovery protocols and minimally invasive techniques, we show that early postoperative opioid avoidance is feasible in a limited number of IBD patients after colorectal surgery.
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Affiliation(s)
- Adam Truong
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Lucille Yao
- Cedars-Sinai Medical Center, Los Angeles, California, USA
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20
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Gao B, Chen J, Liu Y, Hu S, Wang R, Peng F, Fang C, Gan Y, Su S, Han Y, Yang X, Li B. Efficacy and safety of enhanced recovery after surgery protocol on minimally invasive bariatric surgery: a meta-analysis. Int J Surg 2023; 109:1015-1028. [PMID: 36999781 PMCID: PMC10389529 DOI: 10.1097/js9.0000000000000372] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 03/16/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS), a multidisciplinary and multimodal perioperative care protocol, has been widely used in several surgical fields. However, the effect of this care protocol on patients receiving minimally invasive bariatric surgery remains unclear. This meta-analysis compared the clinical outcomes of the ERAS protocol and standard care (SC) in patients who underwent minimally invasive bariatric surgery. MATERIAL AND METHODS PubMed, Web of Science, Cochrane Library, and Embase databases were systematically searched to identify literature reporting the effects of the ERAS protocol on clinical outcomes in patients undergoing minimally invasive bariatric surgery. All the articles published until 01 October 2022, were searched, followed by data extraction of the included literature and independent quality assessment. Then, pooled mean difference (MD) and odds ratio with a 95% CI were calculated by either a random-effects or fixed-effects model. RESULTS Overall, 21 studies involving 10 764 patients were included in the final analysis. With the ERAS protocol, the length of hospitalization (MD: -1.02, 95% CI: -1.41 to -0.64, P <0.00001), hospitalization costs (MD: -678.50, 95% CI: -1196.39 to -160.60, P =0.01), and the incidence of 30-day readmission (odds ratio =0.78, 95% CI: 0.63-0.97, P =0.02) were significantly reduced. The incidences of overall complications, major complications (Clavien-Dindo grade ≥3), postoperative nausea and vomiting, intra-abdominal bleeding, anastomotic leak, incisional infection, reoperation, and mortality did not differ significantly between the ERAS and SC groups. CONCLUSIONS The current meta-analysis indicated that the ERAS protocol could be safely and feasibly implemented in the perioperative management of patients receiving minimally invasive bariatric surgery. Compared with SC, this protocol leads to significantly shorter hospitalization lengths, lower 30-day readmission rate, and hospitalization costs. However, no differences were observed in postoperative complications and mortality.
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Affiliation(s)
- Benjian Gao
- Department of General Surgery (Hepatopancreatobiliary Surgery
- Academician (Expert) Workstation of Sichuan Province, Metabolic Hepatobiliary and Pancreatic Diseases Key Laboratory of Luzhou City, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Jianfei Chen
- Department of General Surgery (Hepatopancreatobiliary Surgery
- Academician (Expert) Workstation of Sichuan Province, Metabolic Hepatobiliary and Pancreatic Diseases Key Laboratory of Luzhou City, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Yongfa Liu
- Department of General Surgery (Hepatopancreatobiliary Surgery
- Academician (Expert) Workstation of Sichuan Province, Metabolic Hepatobiliary and Pancreatic Diseases Key Laboratory of Luzhou City, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Shuai Hu
- Department of General Surgery (Hepatopancreatobiliary Surgery
- Academician (Expert) Workstation of Sichuan Province, Metabolic Hepatobiliary and Pancreatic Diseases Key Laboratory of Luzhou City, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Rui Wang
- Department of General Surgery (Hepatopancreatobiliary Surgery
- Academician (Expert) Workstation of Sichuan Province, Metabolic Hepatobiliary and Pancreatic Diseases Key Laboratory of Luzhou City, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Fangyi Peng
- Department of General Surgery (Hepatopancreatobiliary Surgery
- Academician (Expert) Workstation of Sichuan Province, Metabolic Hepatobiliary and Pancreatic Diseases Key Laboratory of Luzhou City, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Chen Fang
- Department of General Surgery (Hepatopancreatobiliary Surgery
- Academician (Expert) Workstation of Sichuan Province, Metabolic Hepatobiliary and Pancreatic Diseases Key Laboratory of Luzhou City, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Yu Gan
- Department of General Surgery (Hepatopancreatobiliary Surgery
- Academician (Expert) Workstation of Sichuan Province, Metabolic Hepatobiliary and Pancreatic Diseases Key Laboratory of Luzhou City, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Song Su
- Department of General Surgery (Hepatopancreatobiliary Surgery
- Academician (Expert) Workstation of Sichuan Province, Metabolic Hepatobiliary and Pancreatic Diseases Key Laboratory of Luzhou City, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Yunwei Han
- Department of Oncology, The Affiliated Hospital of Southwest Medical University
| | - Xiaoli Yang
- Department of General Surgery (Hepatopancreatobiliary Surgery
- Academician (Expert) Workstation of Sichuan Province, Metabolic Hepatobiliary and Pancreatic Diseases Key Laboratory of Luzhou City, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Bo Li
- Department of General Surgery (Hepatopancreatobiliary Surgery
- Academician (Expert) Workstation of Sichuan Province, Metabolic Hepatobiliary and Pancreatic Diseases Key Laboratory of Luzhou City, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
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21
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Johnson E, Yoshida M, Hallway A, Byrnes M, Waljee J, Englesbe M, Howard R. "I Prefer to Stay Away": A Qualitative Study of Patients in an Opioid-Sparing Pain Management Protocol. Ann Surg 2023; 277:596-602. [PMID: 34787984 DOI: 10.1097/sla.0000000000005087] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to explore beliefs and behaviors of opioid pain medications among patients undergoing elective surgery. BACKGROUND Opioid dependence after surgery is a major contributor to the ongoing opioid epidemic. Recent efforts by surgeons and health systems have sought to improve the education patients receive regarding safe opioid use after surgery; however, little is known about patients' pre-existing beliefs surrounding opioids. METHODS Semistructured interviews were conducted with patients who underwent 1 of 4 common elective surgical procedures at 1 institution. Patients were specifically asked about their knowledge and beliefs about opioids before surgery and their opinions of opioid-sparing recovery after surgery. Coding was conducted through iterative steps, beginning with an initial cycle of rapid analysis, followed by focused coding, and thematic analysis. RESULTS Twenty-one patients were interviewed. Three major themes emerged regarding patient opinions about using opioids after surgery. First, there was widespread awareness among patients about opioid medications, and preoperatively, patients had specific intentions about using opioids, often informed by this awareness. Second, patients described a spectrum of opioid related behavior which both aligned and conflicted with preoperative intentions. Third, there was tension among patients about opioid-free postoperative recovery, with patients expressing support, opposition, and emphasis on tailoring recovery to patient needs. CONCLUSIONS Patients undergoing common surgical procedures often arrive at their surgical encounter with strong, pre-formed opinions about opioids. Eliciting these preexisting opinions may help surgeons better counsel patients about safe opioid use after surgery.
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Affiliation(s)
- Emily Johnson
- University of Michigan Medical School, Ann Arbor, MI
| | - Maxwell Yoshida
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI
| | | | - Mary Byrnes
- Center for Health Outcomes and Policy, Michigan Medicine, Ann Arbor, MI
- Department of Surgery, Michigan Medicine, Ann Arbor, Mi
| | - Jennifer Waljee
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI
- Center for Health Outcomes and Policy, Michigan Medicine, Ann Arbor, MI
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Michael Englesbe
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI
- Section of Transplant Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Ryan Howard
- Center for Health Outcomes and Policy, Michigan Medicine, Ann Arbor, MI
- Department of Surgery, Michigan Medicine, Ann Arbor, Mi
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22
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The Impact of Peripheral Nerve Block on the Quality of Care After Ankle Fracture Surgery: A Quality Improvement Study. J Orthop Trauma 2023; 37:e111-e117. [PMID: 36253899 DOI: 10.1097/bot.0000000000002510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To increase peripheral nerve block (PNB) administration for ankle fracture surgeries (AFSs) at our institution to above 50% by January 1st, 2021. DESIGN Longitudinal, single-center quality improvement study conducted at a high-volume tertiary care center. PATIENTS All patients undergoing isolated AFS for unimalleolar, bimalleolar, or trimalleolar ankle fracture from July 2017 to April 2021 were included in this study. INTERVENTION Interventions implemented to minimize barriers for PNB administration included recruitment and training of expert anesthesiologists in regional anesthesia, procurement of ultrasound machines, implementation of a dedicated block room, and creation of a pamphlet for patients describing multimodal analgesia. MAIN OUTCOME MEASUREMENT The primary outcome was the percentage of patients receiving PNB for AFS. Secondary outcomes included hospital length-of-stay, postanesthesia care unit (PACU) and 24-hour postoperative opioid consumption (mean oral morphine equivalent [OME]), proportion of patients not requiring opioid analgesic in PACU, and PACU and 24-hour postoperative nausea/vomiting requiring antiemetic. RESULTS The PNB and non-PNB groups included 78 and 157 patients, respectively. PNB administration increased from <5% to 53% after implementation of the improvement bundle. Mean PACU and 24-hour opioid analgesic consumption was lower in the PNB group (PACU OME 38.96 mg vs. 55.42 mg, P = 0.001; 24-hour OME 50.83 mg vs. 65.69 mg, P = 0.008). A greater proportion of patients in the PNB group did not require PACU opioids (62.8% vs. 27.4%, P < 0.001). CONCLUSIONS By performing a root cause analysis and implementing a multidisciplinary, patient-centered improvement bundle, we increased PNB administration for AFSs, resulting in reduced postoperative opioid analgesia consumption. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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23
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Potter T, Soni P, Krywyj M, Petitt J, Jarmula J, Obiri-Yeboah D, Oyem P, Momin A, Easley K, Sindwani R, Woodard T, Recinos PF, Kshettry VR. Predictive Factors for Postoperative Opioid Use in Elective Endoscopic Endonasal Skull Base Surgery. Laryngoscope 2023; 133:494-499. [PMID: 35353373 DOI: 10.1002/lary.30116] [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: 01/31/2022] [Revised: 03/14/2022] [Accepted: 03/21/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE In 2017, the United States opioid epidemic was declared a public health emergency. Increased efforts have been made to understand and reduce patient opioid use in neurosurgery. However, the factors associated with postoperative opioid use remain understudied in endoscopic endonasal skull base surgery (EESBS). We identified the demographic and surgical factors associated with postoperative opioid use in EESBS. METHODS A retrospective review was conducted of patients who underwent elective EESBS between January 2015 and December 2020. Patient demographics, relevant clinical history, and operative data were collected and analyzed. Total opioid use was calculated 24, 48, and 72 hours postoperatively. Multivariable linear regression analyses were performed to identify factors associated with opioid use. RESULTS There were 454 patients included. A history of anxiety/depression and younger patient age were associated with a significant increase in opioid use at 24 (28.2 MME, p < 0.001), 48 (53.4 MME, p < 0.001), and 72 (89.4 MME, p < 0.001) hours after surgery. Nasoseptal flap use was significantly associated with increased opioid use at 24 (12.8 MME, p < 0.49) and 48 (19.6 MME, p < 0.048) h postoperatively while controlling for intraoperative variables and surgical approach (trans-sellar vs. expanded). No significant association was observed for patient sex, history of migraines, preoperative opioid use, length of surgery, or surgical approach. CONCLUSION In patients undergoing EESBS, patient history of anxiety/depression, younger patient age, and nasoseptal flap use are associated with increased postoperative opioid use. Knowledge of these risk factors may guide perioperative prescribing patterns to both adequately control postoperative pain and reduce opioid use. LEVEL OF EVIDENCE 4 Laryngoscope, 133:494-499, 2023.
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Affiliation(s)
- Tamia Potter
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Pranay Soni
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Maria Krywyj
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jordan Petitt
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Jakub Jarmula
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Derrick Obiri-Yeboah
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Precious Oyem
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Arbaz Momin
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Kathryn Easley
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Raj Sindwani
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA.,Department of Otolaryngology-Head & Neck Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Troy Woodard
- Department of Otolaryngology-Head & Neck Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Pablo F Recinos
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA.,Department of Otolaryngology-Head & Neck Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Varun R Kshettry
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
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24
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Do U, Pook M, Najafi T, Rajabiyazdi F, El-Kefraoui C, Balvardi S, Barone N, Elhaj H, Nguyen-Powanda P, Lee L, Baldini G, Feldman LS, Fiore JF. S110-Opioid-free analgesia after outpatient general surgery: A qualitative study focused on the perspectives of patients and clinicians involved in a pilot trial. Surg Endosc 2023; 37:2269-2280. [PMID: 35918552 DOI: 10.1007/s00464-022-09472-8] [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: 03/26/2022] [Accepted: 07/12/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Opioid-free analgesia (OFA) may mitigate opioid-related harms after outpatient general surgery; however, the comparative effectiveness of this approach should be assessed in robust randomized controlled trials (RCTs). Undertaking an RCT on OFA raises important practical concerns, including surgeon and patient hesitation regarding pain management without opioids. We conducted a qualitative study to explore patients' and clinicians' perspectives and experiences with a pilot trial focused on OFA after outpatient general surgery. METHODS Patients undergoing outpatient abdominal and breast procedures were randomized to receive post-discharge opioid analgesia (OA) or OFA. Semi-structured interviews with patients and clinicians involved in the trial were conducted to elicit personal perspectives and experiences. Purposive sampling for maximum variation was used to recruit participants with diverse characteristics. Transcribed interviews were assessed using inductive thematic analysis. RESULTS Ten patients (5 abdominal, 5 breast) and 10 clinicians (6 surgeons, 2 anesthesiologists, 2 nurses) were interviewed. Five major themes emerged: readiness for trial engagement, pre-trial thoughts about the interventions, postoperative pain experiences, intervention acceptability, and trial refinement. Most patients were open to OFA. Clinicians expressed willingness to prescribe OFA, particularly after less invasive procedures and when using peripheral nerve blocks (PNBs). Concerns were raised regarding the adequacy of pain control and side effects of non-opioid drugs (e.g., NSAID-induced bleeding, kidney injury). Overall, participants were enthusiastic about the trial and recognized its relevance; clinicians praised the study design and organization; and patients valued the use of electronic questionnaires. Suggestions for improvements included preventing potential bias arising from the use of PNBs (i.e., via standardization or stratification) and reducing patient burden (i.e., decreasing postoperative questionnaires). CONCLUSION Patients and clinicians who participated in a pilot RCT generally accept the clinical equipoise between OA versus OFA after outpatient general surgery and recognize the need for methodologically robust trials to inform evidence-based analgesia prescribing.
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Affiliation(s)
- Uyen Do
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Makena Pook
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Tahereh Najafi
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Fateme Rajabiyazdi
- Department of Systems and Computer Engineering, Carleton University, Ottawa, ON, Canada
| | - Charbel El-Kefraoui
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Saba Balvardi
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Department of Surgery, McGill University, Montreal, QC, Canada
| | - Natasha Barone
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Hiba Elhaj
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Philip Nguyen-Powanda
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Lawrence Lee
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Division of Experimental Surgery, McGill University, Montreal, QC, Canada.,Department of Surgery, McGill University, Montreal, QC, Canada.,Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Gabriele Baldini
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Department of Anesthesia, McGill University, Montreal, QC, Canada
| | - Liane S Feldman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Division of Experimental Surgery, McGill University, Montreal, QC, Canada.,Department of Surgery, McGill University, Montreal, QC, Canada.,Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Julio F Fiore
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada. .,Division of Experimental Surgery, McGill University, Montreal, QC, Canada. .,Department of Surgery, McGill University, Montreal, QC, Canada. .,Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada. .,Montreal General Hospital, 1650 Cedar Ave, R2-104, Montreal, QC, H3G 1A4, Canada.
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25
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Boudiab EM, Lapkus M, Reilly J, Studzinski D, Czako P, Asbahi M, Schostak M, Schmidt C, Nagar S. Cervical Endocrine Surgery With a Novel Opioid-Limited Perioperative Protocol. Am Surg 2023; 89:355-361. [PMID: 34114505 DOI: 10.1177/00031348211025736] [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: 11/15/2022]
Abstract
BACKGROUND Recent studies have demonstrated that patients undergoing cervical endocrine surgery could be comfortably discharged with minimal opioid analgesia. However, no study to date has examined the efficacy of limiting administration of opioids intraoperatively. We have developed a novel protocol for patients undergoing cervical endocrine surgery that eliminates perioperative opioids. We sought to determine the efficacy of this protocol and its impact on opioid use at discharge. METHODS We conducted a prospective opt-in opioid-limited surgery program study to opioid-naive patients scheduled for cervical endocrine surgery beginning in August 2019. Postoperatively, nonopioid analgesia was encouraged, but patients were also given a low dose prescription for opioids at discharge. Patients were then matched with 2 retrospective control groups, patients from 2014-2016 and 2017-2018, in order to account for increased public awareness of opioid-prescribing patterns. Primary end points included perioperative opioid use. Secondary end points included postoperative pain scores and complications. RESULTS 218 patients underwent cervical endocrine surgery with our opioid-limited protocol between August 2019 and February 2020. Nine patients received opioids intraoperatively (4%) and 109 (50%) filled their opioid prescriptions at discharge. Compared to retrospective control groups, the average oral morphine equivalents (OME) administered intraoperatively and prescribed postoperatively were significantly lower (P < .0001). Pain scores and complication rates were similar in all groups (P = .7247). DISCUSSION Our novel opioid-limited surgery protocol used in conjunction with preoperative counseling is an effective approach for pain control in patients undergoing cervical endocrine surgery and limits opioid exposure throughout the perioperative period.
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Affiliation(s)
- Elizabeth M Boudiab
- Department of General Surgery, 7005Beaumont Health System, Royal Oak, MI, USA
| | - Morta Lapkus
- Department of General Surgery, 7005Beaumont Health System, Royal Oak, MI, USA
| | - Jordan Reilly
- Department of General Surgery, 7005Beaumont Health System, Royal Oak, MI, USA
| | - Diane Studzinski
- Department of General Surgery, 7005Beaumont Health System, Royal Oak, MI, USA
| | - Peter Czako
- Department of General Surgery, 7005Beaumont Health System, Royal Oak, MI, USA
| | - Moumen Asbahi
- Department of Anesthesiology, 7005Beaumont Health System, Royal Oak, MI, USA
| | - Michael Schostak
- Department of Anesthesiology, 7005Beaumont Health System, Royal Oak, MI, USA
| | - Carol Schmidt
- Department of Anesthesiology, 7005Beaumont Health System, Royal Oak, MI, USA
| | - Sapna Nagar
- Department of General Surgery, 7005Beaumont Health System, Royal Oak, MI, USA
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26
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van Deventer L, Bronstone A, Leonardi C, Bennett M, Yager P, Dasa V. A modern multimodal pain protocol eliminates the need for opioids for most patients following total knee arthroplasty: results from a retrospective comparative cohort study. J Exp Orthop 2023; 10:20. [PMID: 36806032 PMCID: PMC9940069 DOI: 10.1186/s40634-023-00585-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 02/04/2023] [Indexed: 02/22/2023] Open
Abstract
PURPOSE Modern multimodal analgesia has been shown to significantly reduce opioid use following total knee arthroplasty (TKA). This study was conducted to determine if changing TKA discharge opioid prescriptions from automatic to upon request resulted in more opioid free recoveries without compromising pain control. METHODS Between December 2019 and August 2021, an orthopedic surgeon performed 144 primary unilateral TKAs; patients received the same multimodal analgesia protocol except for postoperative opioid prescribing. The first consecutively-treated cohort automatically received an opioid prescription following discharge (automatic group) and the second cohort received opioid prescriptions only upon request (upon request group). Opioid prescription data were derived from a prescription monitoring program and patient-reported outcomes (PROs) were collected preoperatively and at 2 and 12 weeks postoperatively. RESULTS A higher percentage of the upon request group was opioid free 3 months after TKA compared with the automatic group (55.6% vs 4.3%, p < 0.0001) without compromising pain or function. Among opioid-naïve patients, 72% in the upon request group were opioid free after TKA compared with 5.4% in the automatic group. Opioid prescribing was not significantly reduced among opioid-experienced patients regardless of the pain protocol. CONCLUSION Requiring patients to request opioid prescriptions following TKA resulted in a higher rate of opioid free TKA, especially among opioid-naïve patients, without increasing pain compared with offering all patients an initial opioid prescription. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Leland van Deventer
- grid.279863.10000 0000 8954 1233School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA USA
| | - Amy Bronstone
- grid.279863.10000 0000 8954 1233Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112 USA
| | - Claudia Leonardi
- grid.279863.10000 0000 8954 1233School of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA USA
| | - Matthew Bennett
- grid.279863.10000 0000 8954 1233School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA USA
| | - Peter Yager
- grid.279863.10000 0000 8954 1233School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA USA ,grid.279863.10000 0000 8954 1233Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112 USA
| | - Vinod Dasa
- School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA. .,Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, Box T6-7, New Orleans, LA, 70112, USA.
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27
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Wu EB, Hsiao CC, Hung KC, Hung CT, Chen CC, Wu SC, Chin JC, Chen IW, Luo SD. Opioid-Sparing Analgesic Effects from Interscalene Block Impact Anesthetic Management During Shoulder Arthroscopy: A Retrospective Observational Study. J Pain Res 2023; 16:119-128. [PMID: 36660557 PMCID: PMC9844143 DOI: 10.2147/jpr.s397282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 01/09/2023] [Indexed: 01/14/2023] Open
Abstract
Purpose Ultrasound-guided interscalene nerve block (UISB) is commonly used to alleviate postoperative pain during shoulder arthroscopy. This retrospective observational study aimed to evaluate the intraoperative advantages and analgesic effects of preoperative UISB. Patients and Methods In this retrospective observational study, a total of 170 patients underwent shoulder arthroscopy at a tertiary medical center in southern Taiwan throughout 2019. After applying the exclusion criteria, 142 of these cases were included, with 74 and 68 in the UISB group and control groups, respectively. The primary outcome was the evaluation of intraoperative morphine milligram equivalent (MME) consumption. Secondary outcomes were sevoflurane consumption, the use of intraoperative antihypertensive drugs, and postoperative visual analog scale (VAS) scores in the post-anesthesia care unit (PACU) and in the ward at 24 h after surgery. Results Preoperative UISB effectively reduced opioids and volatile gases during surgery, supported by a 48.1% and 14.8% reduction in the median intraoperative MME and sevoflurane concentrations, respectively, and showed less need for antihypertensive drugs. The preoperative UISB group also showed significantly better performance on the VAS in both the PACU and ward. Conclusion Taken together, the preoperative UISB reduced not only intraoperative MME and sevoflurane consumption but also had satisfactory VAS scores in both the PACU and ward without any symptomatic respiratory complications. In summary, preoperative UISB is a reliable adjuvant analgesic technique and a key factor in achieving opioid-sparing and sevoflurane-sparing anesthesia and multimodal analgesia during shoulder arthroscopy.
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Affiliation(s)
- En-Bo Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chia-Chi Hsiao
- Department of Family Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Chao-Ting Hung
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Chun Chen
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Jo-Chi Chin
- Department of Anesthesiology, Park One International Hospital, Kaohsiung, Taiwan
| | - I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan,I-Wen Chen, No. 901, Zhonghua Road, Yongkang District, Tainan City, 710, Taiwan, Tel +886-6-2812811, Email
| | - Sheng-Dean Luo
- Division of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital and Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Kaohsiung, Taiwan,Correspondence: Sheng-Dean Luo, No. 123, Ta-Pei Road, Niao-Song District, Kaohsiung City, 833, Taiwan, Tel +886-7-7317123 (ext. 2788), Email
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28
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Tan Z, Dong Y, Li Q. Dynamics of Acute Postsurgical Pain over the Last Decade: A Bibliometric Analysis. Pain Res Manag 2022; 2022:8090209. [PMID: 36385903 PMCID: PMC9663218 DOI: 10.1155/2022/8090209] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 10/16/2022] [Accepted: 10/19/2022] [Indexed: 09/26/2023]
Abstract
OBJECTIVE Minimizing acute postsurgical pain (APSP) remains a challenge, despite extensive research about it. This study comprehensively analyzed the literature on APSP to assess how the field has developed and where it may go in the future. METHODS Studies on APSP indexed in the Web of Science Core Collection and published from 2012 to 2021 were assessed for eligibility. Data from included studies were analyzed using CiteSpace, Python, and Microsoft. RESULTS Analysis of 5,236 publications on APSP showed that the number of articles per year has increased linearly. The United States leads other countries in terms of the number and centrality of publications. Cocitation analysis suggests that the field focused earlier on the incidence and risk factors of APSP, shifting later to a focus on the reduction and management of adverse outcomes due to APSP. The top-ranked keyword cluster during the study period was "short-term outcomes" (#0), followed by "risk factors" (#1). The strongest burst occurred for the keyword "combination," followed by "multimodal analgesia." The most recent burst occurred for the keywords "regional analgesia," "opioid use," "erector spinae plane block," and "infiltration." CONCLUSIONS Hotspots in APSP research since 2012 have been incidence, risk factors, and control of negative outcomes. Future research is likely to concentrate on the use of opioids and technological innovations in regional anesthesia. Our findings may help APSP researchers and clinicians understand their field, optimize clinical practice, and plan future research.
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Affiliation(s)
- Zhimin Tan
- Department of Anesthesiology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu 610041, Sichuan, China
| | - Yanjie Dong
- Department of Anesthesiology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu 610041, Sichuan, China
| | - Qian Li
- Department of Anesthesiology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu 610041, Sichuan, China
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29
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McLemore EC, Lee L, Hedrick TL, Rashidi L, Askenasy EP, Popowich D, Sylla P. Same day discharge following elective, minimally invasive, colorectal surgery : A review of enhanced recovery protocols and early outcomes by the SAGES Colorectal Surgical Committee with recommendations regarding patient selection, remote monitoring, and successful implementation. Surg Endosc 2022; 36:7898-7914. [PMID: 36131162 PMCID: PMC9491699 DOI: 10.1007/s00464-022-09606-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 08/28/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND As enhanced recovery programs (ERPs) have continued to evolve, the length of hospitalization (LOS) following elective minimally invasive colorectal surgery has continued to decline. Further refinements in multimodal perioperative pain management strategies have resulted in reduced opioid consumption. The interest in ambulatory colectomy has dramatically accelerated during the COVID-19 pandemic. Severe restrictions in hospital capacity and fear of COVID transmission forced surgical teams to rethink strategies to further reduce length of inpatient stay. METHODS Members of the SAGES Colorectal Surgery Committee began reviewing the emergence of SDD protocols and early publications for SDD in 2019. The authors met at regular intervals during 2020-2022 period reviewing SDD protocols, safe patient selection criteria, surrogates for postoperative monitoring, and early outcomes. RESULTS Early experience with SDD protocols for elective, minimally invasive colorectal surgery suggests that SDD is feasible and safe in well-selected patients and procedures. SDD protocols are associated with reduced opioid use and prescribing. Patient perception and experience with SDD is favourable. For early adopters, SDD has been the natural evolution of well-developed ERPs. Like all ERPs, SDD begins in the office setting, identifying the correct patient and procedure, aligning goals and objectives, and the perioperative education of the patient and their supporting significant others. A thorough discussion with the patient regarding expected activity levels, oral intake, and pain control post operatively lays the foundation for a successful application of SDD programs. These observations may not apply to all patient populations, institutions, practice types, or within the scope of an existing ERP. However, if the underlying principles of SDD can be incorporated into an existing institutional ERP, it may further reduce the incidence of post operative ileus, prolonged LOS, and improve the effectiveness of oral analgesia for postoperative pain management and reduced opioid use and prescribing. CONCLUSIONS The SAGES Colorectal Surgery Committee has performed a comprehensive review of the early experience with SDD. This manuscript summarizes SDD early results and considerations for safe and stepwise implementation of SDD with a specific focus on ERP evolution, patient selection, remote monitoring, and other relevant considerations based on hospital settings and surgical practices.
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Affiliation(s)
- Elisabeth C McLemore
- Bernard J. Tyson Kaiser Permanente School of Medicine, Los Angeles Medical Center, Los Angeles, CA, 90027, USA.
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Colon and Rectal Surgery, Los Angeles Medical Center, 4760 Sunset Blvd, 3rd Floor, Los Angeles, CA, 90027, USA.
| | - Lawrence Lee
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Traci L Hedrick
- Department of Surgery, University of Virginia Health, Charlottesville, VA, USA
| | | | - Erik P Askenasy
- Division of Colon and Rectal Surgery, University of Texas Health, Houston, TX, USA
| | - Daniel Popowich
- Division of Colon and Rectal Surgery, St. Francis Hospital, New York, NY, USA
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30
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Jiang YY, Li ZP, Yao M, Zhou QH. Standard opioid-containing versus opioid-sparing anesthesia on early postoperative recovery after video-assisted thoracic surgery: A propensity-weighted analysis. Front Surg 2022; 9:1015467. [PMID: 36338614 PMCID: PMC9634401 DOI: 10.3389/fsurg.2022.1015467] [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: 08/09/2022] [Accepted: 09/30/2022] [Indexed: 01/24/2023] Open
Abstract
PURPOSE Opioids have several adverse effects. At present, there are no large clinical studies on the effects of opioid-sparing anesthesia on early postoperative recovery after thoracoscopic surgery. This study was to investigate the effects of opioid-sparing anesthesia on early postoperative recovery after thoracoscopic surgery. METHODS Adult patients who underwent video-assisted thoracic surgery from 1 January 2019 to 28 February 2021 were enrolled by reviewing the electronic medical records. Participants were divided into opioid-sparing anesthesia (OSA group) and opioid-containing anesthesia (STD group) based on intraoperative opioid usage. The propensity-score analysis was to compare the early postoperative recovery of two groups. The outcome measurements included the incidence of postoperative nausea and vomiting (PONV) during an entire hospital stay, need for rescue antiemetic medication, postoperative-pain episodes within 48 h after surgery, need for rescue analgesia 48 h postoperatively, duration of postoperative hospital stay, length of PACU stay, postoperative fever, postoperative shivering, postoperative atrial fibrillation, postoperative pulmonary infection, postoperative hypoalbuminemia, postoperative hypoxemia, intraoperative blood loss, and intraoperative urine output. RESULTS A total of 1,975 patients were identified. No significant difference was observed in patient characteristics between the OSA and STD groups after adjusting for propensity score-based inverse probability treatment weighting. The incidence of postoperative nausea and vomiting was significantly lower in the OSA group than in the STD group (14.7% vs. 18.9%, p = 0.041). The rescue antiemetic use rate was lower in the OSA group than in the STD group (7.5% vs.12.2%; p = 0.002). PACU duration was longer in the OSA group than in the STD group (70.8 ± 29.0 min vs. 67.3 ± 22.7 min; p = 0.016). The incidence of postoperative fever was higher in the STD group than that in the OSA group (11.0% vs.7.7%; p = 0.032). There were no differences between the groups in terms of other outcomes. CONCLUSIONS Our results suggest that opioid-sparing anesthesia has a lower incidence of postoperative complications than opioid-based anesthetic techniques.
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Affiliation(s)
- Yan-yu Jiang
- Graduate School, Bengbu Medical College, Bengbu, China,Graduate School, Bengbu Medical College, Bengbu, China
| | - Zhen-ping Li
- Graduate School, Bengbu Medical College, Bengbu, China
| | - Ming Yao
- Graduate School, Bengbu Medical College, Bengbu, China
| | - Qing-he Zhou
- Graduate School, Bengbu Medical College, Bengbu, China,Department of Anesthesiology and Pain Medicine, The Affiliated Hospital of Jiaxing University, Jiaxing, China,Correspondence: Qing-he Zhou
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31
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Chen C, Xiang G, Chen K, Liu Q, Deng X, Zhang H, Yang D, Yan F. Ultrasound-guided Bilateral Serratus Anterior Plane Block for Postoperative Analgesia in Ear Reconstruction after Costal Cartilage Harvest: A Randomized Controlled Trial. Aesthetic Plast Surg 2022; 46:2006-2014. [PMID: 35918438 DOI: 10.1007/s00266-022-03027-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/12/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Costal cartilages harvest for ear reconstruction is accompanied by severe pain in chest. However, there is no perfect solution for reducing this chest pain. OBJECTIVE Evaluate the efficacy and safety of analgesia using ultrasound-guided bilateral serratus anterior plane block (SAPB) in children receiving costal cartilage harvest for ear reconstruction. METHODS Sixty children undergoing ear reconstruction using costal cartilage were randomized to an SAPB group (SAPB with 3 mg/kg 0.25% ropivacaine) or an incision infiltration (II) group (II with 3 mg/kg 0.75% ropivacaine), and 29 in each group completed the study. All children received patient-controlled intravenous analgesia (PCIA). The primary outcomes were numerical rating scale (NRS) scores of pain while rest and coughing at 1, 6, 12, 24, and 48 h after surgery. The secondary outcomes were sufentanil use within 24 h, duration of analgesia, use of oral rescue analgesics, first time out of bed, and incidence of treatment-related adverse effects. RESULTS The SAPB group had lower rest and coughing NRS scores at 6 and 12 h after surgery (all P < 0.001), but the scores were similar at other times. The SAPB group used less sufentanil within 24 h, but had a longer duration of analgesia (both P < 0.001). The II group used more oral rescue analgesics within 48 h, had a longer time until first time out of bed, and had more opioid-related side effects (all P < 0.01). There were no SAPB-related complications. CONCLUSION Ultrasound-guided SAPB can provide safe and effective regional pain relief after costal cartilage harvest for ear reconstruction. LEVEL OF EVIDENCE II This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/00266 .
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Affiliation(s)
- Chunmei Chen
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shi Jing Shan, No.33, Ba Da Chu Road, Beijing, 100144, China
| | - Guihua Xiang
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shi Jing Shan, No.33, Ba Da Chu Road, Beijing, 100144, China
| | - Keyu Chen
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shi Jing Shan, No.33, Ba Da Chu Road, Beijing, 100144, China
| | - Quanle Liu
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shi Jing Shan, No.33, Ba Da Chu Road, Beijing, 100144, China
| | - Xiaoming Deng
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shi Jing Shan, No.33, Ba Da Chu Road, Beijing, 100144, China
| | - Hang Zhang
- Department of Nursing, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shi Jing Shan, No.33, Ba Da Chu Road, Beijing, 100144, China
| | - Dong Yang
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shi Jing Shan, No.33, Ba Da Chu Road, Beijing, 100144, China.
| | - Fuxia Yan
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 North Lishi Road, XiCheng District, Beijing, 100037, China.
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32
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Wu EB, Hung CT, Luo SD, Wu SC, Lee TY, Chin JC, Tsai PN, Yang JCS. Analgesic and Anesthetic Efficacy of Rocuronium/Sugammadex in Otorhinolaryngologic Surgery: A Propensity Score-Matched Analysis. Pharmaceuticals (Basel) 2022; 15:ph15070894. [PMID: 35890192 PMCID: PMC9318942 DOI: 10.3390/ph15070894] [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: 06/01/2022] [Revised: 07/01/2022] [Accepted: 07/16/2022] [Indexed: 12/10/2022] Open
Abstract
The use of rocuronium/sugammadex in otorhinolaryngologic surgery improves intubation conditions and surgical rating scales. This study primarily aimed to evaluate the effect of the combination of rocuronium and sugammadex on intraoperative anesthetic consumption. The secondary outcomes were the intraoperative and postoperative morphine milligram equivalent (MME) consumption, duration of intraoperative hypertension, extubation time, incidence of delayed extubation and postoperative nausea and vomiting, pain score, and length of stay. A total of 2848 patients underwent otorhinolaryngologic surgery at a tertiary medical center in southern Taiwan. After applying the exclusion criteria, 2648 of these cases were included, with 167 and 2481 in the rocuronium/sugammadex and cisatracurium/neostigmine groups, respectively. To reduce potential bias, 119 patients in each group were matched by propensity scores for sex, age, body weight, and type of surgery. We found that the rocuronium/sugammadex group was associated with significant preservation of the intraoperative sevoflurane and MME consumption, with reductions of 14.2% (p = 0.009) and 11.8% (p = 0.035), respectively. The use of the combination of rocuronium and sugammadex also significantly increased the dose of intraoperative labetalol (p = 0.002), although there was no significant difference in intraoperative hypertensive events between both groups. In conclusion, our results may encourage the use of the combination of rocuronium and sugammadex as part of volatile-sparing and opioid-sparing anesthesia in otorhinolaryngologic surgery.
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Affiliation(s)
- En-Bo Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Rd., Niao-Song Dist., Kaohsiung City 833, Taiwan; (E.-B.W.); (C.-T.H.); (S.-C.W.); (P.-N.T.)
| | - Chao-Ting Hung
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Rd., Niao-Song Dist., Kaohsiung City 833, Taiwan; (E.-B.W.); (C.-T.H.); (S.-C.W.); (P.-N.T.)
| | - Sheng-Dean Luo
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City 833, Taiwan;
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Rd., Niao-Song Dist., Kaohsiung City 833, Taiwan; (E.-B.W.); (C.-T.H.); (S.-C.W.); (P.-N.T.)
| | - Tsung-Yang Lee
- Department of Anesthesiology, Jen-Ai Hospital, Taichung 412, Taiwan;
| | - Jo-Chi Chin
- Department of Anesthesiology, Park One International Hospital, No. 100, Bo’ai 2nd Rd., Zuoying Dist., Kaohsiung City 813, Taiwan;
| | - Peng-Neng Tsai
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Rd., Niao-Song Dist., Kaohsiung City 833, Taiwan; (E.-B.W.); (C.-T.H.); (S.-C.W.); (P.-N.T.)
| | - Johnson Chia-Shen Yang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, No. 123, Ta-Pei Rd., Niao-Song Dist., Kaohsiung City 833, Taiwan
- Correspondence: ; Tel.: +886-7-7317123 (ext. 2788)
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Do U, El-Kefraoui C, Pook M, Balvardi S, Barone N, Nguyen-Powanda P, Lee L, Baldini G, Feldman LS, Fiore JF. Feasibility of Prospectively Comparing Opioid Analgesia With Opioid-Free Analgesia After Outpatient General Surgery: A Pilot Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2221430. [PMID: 35849399 PMCID: PMC9294998 DOI: 10.1001/jamanetworkopen.2022.21430] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE The overprescription of opioids to surgical patients is recognized as an important factor contributing to the opioid crisis. However, the value of prescribing opioid analgesia (OA) vs opioid-free analgesia (OFA) after postoperative discharge remains uncertain. OBJECTIVE To investigate the feasibility of conducting a full-scale randomized clinical trial (RCT) to assess the comparative effectiveness of OA vs OFA after outpatient general surgery. DESIGN, SETTING, AND PARTICIPANTS This parallel, 2-group, assessor-blind, pragmatic pilot RCT was conducted from January 29 to September 3, 2020 (last follow-up on October 2, 2020). at 2 university-affiliated hospitals in Montreal, Quebec, Canada. Participants were adult patients (aged ≥18 years) undergoing outpatient abdominal (ie, cholecystectomy, appendectomy, or hernia repair) or breast (ie, partial or total mastectomy) general surgical procedures. Exclusion criteria were contraindications to drugs used in the trial, preoperative opioid use, conditions that could affect assessment of outcomes, and intraoperative or early complications requiring hospitalization. INTERVENTIONS Patients were randomized 1:1 to receive OA (around-the-clock nonopioids and opioids for breakthrough pain) or OFA (around-the-clock nonopioids with increasing doses and/or addition of nonopioid medications for breakthrough pain) after postoperative discharge. MAIN OUTCOMES AND MEASURES Main outcomes were a priori RCT feasibility criteria (ie, rates of surgeon agreement, patient eligibility, patient consent, treatment adherence, loss to follow-up, and missing follow-up data). Secondary outcomes included pain intensity and interference, analgesic intake, 30-day unplanned health care use, and adverse events. Between-group comparison of outcomes followed the intention-to-treat principle. RESULTS A total of 15 surgeons were approached; all (100%; 95% CI, 78%-100%) agreed to have patients recruited and adhered to the study procedures. Rates of patient eligibility and consent were 73% (95% CI, 66%-78%) and 57% (95% CI, 49%-65%), respectively. Seventy-six patients were randomized (39 [51%] to OA and 37 [49%] to OFA) and included in the intention-to-treat analysis (mean [SD] age, 55.5 [14.5] years; 50 [66%] female); 40 (53%) underwent abdominal surgery, and 36 (47%) underwent breast surgery. Seventy-five patients (99%; 95% CI, 93%-100%) adhered to the allocated treatment; 1 patient randomly assigned to OFA received an opioid prescription. Seventeen patients (44%) randomly assigned to OA consumed opioids after discharge. Seventy-three patients (96%; 95% CI, 89%-99%) completed the 30-day follow-up. The rate of missing questionnaires was 37 of 3724 (1%; 95% CI, 0.7%-1.4%). All the a priori RCT feasibility criteria were fulfilled. CONCLUSIONS AND RELEVANCE The findings of this pilot RCT support the feasibility of conducting a robust, full-scale RCT to inform evidence-based prescribing of analgesia after outpatient general surgery. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04254679.
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Affiliation(s)
- Uyen Do
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Charbel El-Kefraoui
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Makena Pook
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Saba Balvardi
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Natasha Barone
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Philip Nguyen-Powanda
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Lawrence Lee
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Gabriele Baldini
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Anesthesia, McGill University, Montreal, Quebec, Canada
| | - Liane S. Feldman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Julio F. Fiore
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
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Zárate Rodriguez JG, Leigh N, Edgley C, Cos H, Wolfe R, Sanford D, Hammill CW. Preoperative transversus abdominis plane block decreases intraoperative opiate use during pancreatoduodenectomy. HPB (Oxford) 2022; 24:1162-1167. [PMID: 35012875 DOI: 10.1016/j.hpb.2021.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/07/2021] [Accepted: 12/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Multimodal analgesia and regional anesthetic blocks, such as transversus abdominis plane (TAP) block, decrease postoperative opiate consumption but their effect on intraoperative opiates is unknown. METHODS This was a retrospective review of patients undergoing pancreatoduodenectomy between June 2018 and February 2021, in which perioperative data, operative times, and medication administration data were collected. Intraoperative opiate use was calculated in total morphine equivalent doses (MED) for each patient and adjusted for operative time. Univariate analysis and multivariate linear regression were performed to determine factors affecting intraoperative opiate requirements. RESULTS Of the 169 patients in the study, 51 (30.2%) received pre-surgical TAP blocks and 118 (69.8%) did not. There were no statistically significant differences in intraoperative opiate use with preoperative acetaminophen (p = 0.527), celecoxib (p = 0.553), gabapentin (p = 0.308), intraoperative ketorolac (p = 0.698) or epidural placement (p = 0.086). Minimally invasive surgery had lower intraoperative opiate use compared to open (p = 0.011), as well as pre-surgical TAP block compared to no pre-surgical block (5.24 vs 7.27 MED/hour, p < 0.001). On multivariate linear regression, pre-surgical TAP block (p = 0.001) was independently associated with decreased intraoperative opiate use. CONCLUSION Preoperative TAP blocks were associated with decreased intraoperative opiate use during pancreatoduodenectomy and should be considered for routine use.
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Affiliation(s)
- Jorge G Zárate Rodriguez
- Department of Surgery, Washington University in St Louis, St Louis, MO, USA; Barnes-Jewish Hospital, St Louis, MO, USA
| | - Natasha Leigh
- Department of Surgery, Washington University in St Louis, St Louis, MO, USA; Barnes-Jewish Hospital, St Louis, MO, USA
| | - Carla Edgley
- University College Dublin School of Medicine, Ireland
| | - Heidy Cos
- Department of Surgery, Washington University in St Louis, St Louis, MO, USA; Barnes-Jewish Hospital, St Louis, MO, USA
| | | | - Dominic Sanford
- Department of Surgery, Washington University in St Louis, St Louis, MO, USA; Barnes-Jewish Hospital, St Louis, MO, USA
| | - Chet W Hammill
- Department of Surgery, Washington University in St Louis, St Louis, MO, USA; Barnes-Jewish Hospital, St Louis, MO, USA.
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Fiore JF, El-Kefraoui C, Chay MA, Nguyen-Powanda P, Do U, Olleik G, Rajabiyazdi F, Kouyoumdjian A, Derksen A, Landry T, Amar-Zifkin A, Bergeron A, Ramanakumar AV, Martel M, Lee L, Baldini G, Feldman LS. Opioid versus opioid-free analgesia after surgical discharge: a systematic review and meta-analysis of randomised trials. Lancet 2022; 399:2280-2293. [PMID: 35717988 DOI: 10.1016/s0140-6736(22)00582-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 03/12/2022] [Accepted: 03/18/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Excessive opioid prescribing after surgery has contributed to the current opioid crisis; however, the value of prescribing opioids at surgical discharge remains uncertain. We aimed to estimate the extent to which opioid prescribing after discharge affects self-reported pain intensity and adverse events in comparison with an opioid-free analgesic regimen. METHODS In this systematic review and meta-analysis, we searched MEDLINE, Embase, the Cochrane Library, Scopus, AMED, Biosis, and CINAHL from Jan 1, 1990, until July 8, 2021. We included multidose randomised controlled trials comparing opioid versus opioid-free analgesia in patients aged 15 years or older, discharged after undergoing a surgical procedure according to the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity definition (minor, moderate, major, and major complex). We screened articles, extracted data, and assessed risk of bias (Cochrane's risk-of-bias tool for randomised trials) in duplicate. The primary outcomes of interest were self-reported pain intensity on day 1 after discharge (standardised to 0-10 cm visual analogue scale) and vomiting up to 30 days. Pain intensity at further timepoints, pain interference, other adverse events, risk of dissatisfaction, and health-care reutilisation were also assessed. We did random-effects meta-analyses and appraised evidence certainty using the Grading of Recommendations, Assessment, Development, and Evaluations scoring system. The review was registered with PROSPERO (ID CRD42020153050). FINDINGS 47 trials (n=6607 patients) were included. 30 (64%) trials involved elective minor procedures (63% dental procedures) and 17 (36%) trials involved procedures of moderate extent (47% orthopaedic and 29% general surgery procedures). Compared with opioid-free analgesia, opioid prescribing did not reduce pain on the first day after discharge (weighted mean difference 0·01cm, 95% CI -0·26 to 0·27; moderate certainty) or at other postoperative timepoints (moderate-to-very-low certainty). Opioid prescribing was associated with increased risk of vomiting (relative risk 4·50, 95% CI 1·93 to 10·51; high certainty) and other adverse events, including nausea, constipation, dizziness, and drowsiness (high-to-moderate certainty). Opioids did not affect other outcomes. INTERPRETATION Findings from this meta-analysis support that opioid prescribing at surgical discharge does not reduce pain intensity but does increase adverse events. Evidence relied on trials focused on elective surgeries of minor and moderate extent, suggesting that clinicians can consider prescribing opioid-free analgesia in these surgical settings. Data were largely derived from low-quality trials, and none involved patients having major or major-complex procedures. Given these limitations, there is a great need to advance the quality and scope of research in this field. FUNDING The Canadian Institutes of Health Research.
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Affiliation(s)
- Julio F Fiore
- Department of Surgery, McGill University, Montreal, QC, Canada; Division of Experimental Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada.
| | - Charbel El-Kefraoui
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | | | - Philip Nguyen-Powanda
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Uyen Do
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Ghadeer Olleik
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Fateme Rajabiyazdi
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Department of Systems and Computer Engineering, Carleton University, ON, Canada
| | - Araz Kouyoumdjian
- Department of Surgery, McGill University, Montreal, QC, Canada; Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Alexa Derksen
- Patient Representative, Université de Montréal, Montreal, QC, Canada
| | - Tara Landry
- Medical Libraries, McGill University Health Centre, Montreal, QC, Canada; Bibliothèque de la Santé, Université de Montréal, Montreal, QC, Canada
| | | | - Amy Bergeron
- Medical Libraries, McGill University Health Centre, Montreal, QC, Canada
| | - Agnihotram V Ramanakumar
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Marc Martel
- Faculty of Dentistry, McGill University, Montreal, QC, Canada; Department of Anaesthesia, McGill University, Montreal, QC, Canada
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, QC, Canada; Division of Experimental Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Gabriele Baldini
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada; Department of Anaesthesia, McGill University, Montreal, QC, Canada
| | - Liane S Feldman
- Department of Surgery, McGill University, Montreal, QC, Canada; Division of Experimental Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
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Patel AB, Bibawy PP, Majeed Z, Gan WL, Ackland GL. Trans-auricular vagus nerve stimulation to reduce perioperative pain and morbidity: protocol for a single-blind analyser-masked randomised controlled trial. BJA OPEN 2022; 2:None. [PMID: 35832337 PMCID: PMC9258962 DOI: 10.1016/j.bjao.2022.100017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 05/02/2022] [Accepted: 05/18/2022] [Indexed: 11/22/2022]
Abstract
Background Established or acquired loss of parasympathetic vagal tone is associated with complications, including pain, after noncardiac surgery. We describe a study protocol designed to test the hypothesis that transcutaneous auricular nerve stimulation may preserve efferent parasympathetic activity to reduce pain and morbidity after noncardiac surgery. Methods Participants aged >18 yr scheduled for urgent/elective orthopaedic surgery (n=86) will be randomly allocated to bilateral transcutaneous auricular nerve stimulation or sham protocol for 50 min at the same time of day, before and 24 h after surgery. Holter monitoring, the analysis of which is masked to allocation, will quantify autonomic modulation of HR. The primary outcome will be pain, quantified by absolute changes in VAS 24 h after surgery following sham or stimulation. Secondary outcomes include presence or absence of >10 mm change in the 100 mm VAS (which defines a minimum clinically important change) and postoperative morbidity (Postoperative Morbidity Survey) before and 24 h after surgery. The relationship between the explanatory variable (HR variability), VAS, and morbidity will be examined using a multilevel (mixed-error component) regression model. Safety and complications of the intervention will also be recorded. The study was approved by the NHS Research Ethics Committee (21/LO/0272). As of 25 December 2021, 34/86 participants (mean [standard deviation] age: 48 [19] yr; 14 females [41.2%]) have been recruited, with complete collection of Holter data. Conclusions This phase 2b study will explore whether noninvasive autonomic neuromodulation may reduce pain or morbidity using trans-auricular vagus nerve stimulation, providing proof-of-concept data for a non-pharmacological, generalisable approach to improve perioperative outcomes. Clinical trial registration Researchregistry7566.
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Affiliation(s)
- Amour B.U. Patel
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Phillip P.W.M. Bibawy
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Zehra Majeed
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Weng Liang Gan
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Gareth L. Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Opioid-Sparing Analgesia Impacts the Perioperative Anesthetic Management in Major Abdominal Surgery. Medicina (B Aires) 2022; 58:medicina58040487. [PMID: 35454326 PMCID: PMC9029402 DOI: 10.3390/medicina58040487] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/23/2022] [Accepted: 03/26/2022] [Indexed: 12/13/2022] Open
Abstract
Background and Objectives: The management of acute postoperative pain (APP) following major abdominal surgery implies various analgetic strategies. Opioids lie at the core of every analgesia protocol, despite their side effect profile. To limit patients’ exposure to opioids, considerable effort has been made to define new opioid-sparing anesthesia techniques relying on multimodal analgesia. Our study aims to investigate the role of adjuvant multimodal analgesic agents, such as ketamine, lidocaine, and epidural analgesia in perioperative pain control, the incidence of postoperative cognitive dysfunction (POCD), and the incidence of postoperative nausea and vomiting (PONV) after major abdominal surgery. Materials and Methods: This is a clinical, observational, randomized, monocentric study, in which 80 patients were enrolled and divided into three groups: Standard group, C (n = 32), where patients received perioperative opioids combined with a fixed regimen of metamizole/acetaminophen for pain control; co-analgetic group, Co-A (n = 26), where, in addition to standard therapy, patients received perioperative systemic ketamine and lidocaine; and the epidural group, EA (n = 22), which included patients that received standard perioperative analgetic therapy combined with epidural analgesia. We considered the primary outcome, the postoperative pain intensity, assessed by the visual analogue scale (VAS) at 1 h, 6 h, and 12 h postoperatively. The secondary outcomes were the total intraoperative fentanyl dose, total postoperative morphine dose, maximal intraoperative sevoflurane concentration, confusion assessment method for intensive care units score (CAM-ICU) at 1 h, 6 h, and 12 h postoperatively, and the postoperative dose of ondansetron as a marker for postoperative nausea and vomiting (PONV) severity. Results: We observed a significant decrease in VAS score, as the primary outcome, for both multimodal analgesic regimens, as compared to the control. Moreover, the intraoperative fentanyl and postoperative morphine doses were, consequently, reduced. The maximal sevoflurane concentration and POCD were reduced by EA. No differences were observed between groups concerning PONV severity. Conclusions: Multimodal analgesia concepts should be individualized based on the patient’s needs and consent. Efforts should be made to develop strategies that can aid in the reduction of opioid use in a perioperative setting and improve the standard of care.
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Interscalene Brachial Plexus Block with Liposomal Bupivacaine versus Standard Bupivacaine with Perineural Dexamethasone: A Noninferiority Trial. Anesthesiology 2022; 136:434-447. [PMID: 35041742 DOI: 10.1097/aln.0000000000004111] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The interscalene nerve block provides analgesia for shoulder surgery. To extend block duration, provide adequate analgesia, and minimize opioid consumption, the use of adjuvants such as dexamethasone as well as the application of perineural liposomal bupivacaine have been proposed. This randomized, double-blinded, noninferiority trial hypothesized that perineural liposomal bupivacaine is noninferior to standard bupivacaine with perineural dexamethasone in respect to average pain scores in the first 72 h after surgery. METHODS A total of 112 patients undergoing ambulatory shoulder surgery were randomized into two groups. The liposomal bupivacaine group received a 15-ml premixed admixture of 10 ml of 133 mg liposomal bupivacaine and 5 ml of 0.5% bupivacaine (n = 55), while the bupivacaine with dexamethasone group received an admixture of 15 ml of 0.5% standard bupivacaine with 4 mg dexamethasone (n = 56), respectively. The primary outcome was the average numerical rating scale pain scores at rest over 72 h. The mean difference between the two groups was compared against a noninferiority margin of 1.3. Secondary outcomes were analgesic block duration, motor and sensory resolution, opioid consumption, numerical rating scale pain scores at rest and movement on postoperative days 1 to 4 and again on postoperative day 7, patient satisfaction, readiness for postanesthesia care unit discharge, and adverse events. RESULTS A liposomal bupivacaine group average numerical rating scale pain score over 72 h was not inferior to the bupivacaine with dexamethasone group (mean [SD], 2.4 [1.9] vs. 3.4 [1.9]; mean difference [95% CI], -1.1 [-1.8, -0.4]; P < 0.001 for noninferiority). There was no significant difference in duration of analgesia between the groups (26 [20, 42] h vs. 27 [20, 39] h; P = 0.851). Motor and sensory resolutions were similar in both groups: 27 (21, 48) h versus 27 (19, 40) h (P = 0.436) and 27 [21, 44] h versus 31 (20, 42) h (P = 0.862), respectively. There was no difference in opioid consumption, readiness for postanesthesia care unit discharge, or adverse events. CONCLUSIONS Interscalene nerve blocks with perineural liposomal bupivacaine provided effective analgesia similar to the perineural standard bupivacaine with dexamethasone. The results show that bupivacaine with dexamethasone can be used interchangeably with liposomal bupivacaine for analgesia after shoulder surgery. EDITOR’S PERSPECTIVE
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De Cassai A, Geraldini F, Tulgar S, Ahiskalioglu A, Mariano ER, Dost B, Fusco P, Petroni GM, Costa F, Navalesi P. Opioid-free anesthesia in oncologic surgery: the rules of the game. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:8. [PMID: 37386559 DOI: 10.1186/s44158-022-00037-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/20/2022] [Indexed: 07/01/2023]
Abstract
BACKGROUND Opioids are frequently used in the postoperative period due to their analgesic properties. While these drugs reduce nociceptive somatic, visceral, and neuropathic pain, they may also lead to undesirable effects such as respiratory depression, urinary retention, nausea and vomiting, constipation, itching, opioid-induced hyperalgesia, tolerance, addiction, and immune system disorders. Anesthesiologists are in the critical position of finding balance between using opioids when they are necessary and implementing opioid-sparing strategies to avoid the known harmful effects. This article aims to give an overview of opioid-free anesthesia. MAIN BODY This paper presents an overview of opioid-free anesthesia and opioid-sparing anesthetic techniques. Pharmacological and non-pharmacological strategies are discussed, highlighting the possible advantages and drawbacks of each approach. CONCLUSIONS Choosing the best anesthetic protocol for a patient undergoing cancer surgery is not an easy task and the available literature provides no definitive answers. In our opinion, opioid-sparing strategies should always be implemented in routine practice and opioid-free anesthesia should be considered whenever possible. Non-pharmacological strategies such as patient education, while generally underrepresented in scientific literature, may warrant consideration in clinical practice.
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Affiliation(s)
- Alessandro De Cassai
- UOC Anaesthesia and Intensive Care Unit, University Hospital of Padua, Via Giustiniani 1, 35127, Padua, Italy.
| | - Federico Geraldini
- UOC Anaesthesia and Intensive Care Unit, University Hospital of Padua, Via Giustiniani 1, 35127, Padua, Italy
| | - Serkan Tulgar
- Samsun University Faculty of Medicine, Training and Research Hospital, Samsun, Samsun, Turkey
| | - Ali Ahiskalioglu
- Department of Anesthesiology and Reanimation, Ataturk University Faculty of Medicine, Erzurum, Turkey
- Clinical Research, Development and Design Application and Research Center, Ataturk University School of Medicine, Erzurum, Turkey
| | - Edward R Mariano
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Burhan Dost
- Department of Anesthesiology and Reanimation, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
| | - Pierfrancesco Fusco
- Department of Anesthesia and Intensive Care Unit, San Salvatore Academic Hospital of L'Aquila, L'Aquila, Italy
| | - Gian Marco Petroni
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Fabio Costa
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Paolo Navalesi
- UOC Anaesthesia and Intensive Care Unit, University Hospital of Padua, Via Giustiniani 1, 35127, Padua, Italy
- University of Padova, Department of Medicine, Padua, Italy
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Lovecchio F, Premkumar A, Steinhaus M, Alexander K, Mejia D, Yoo JS, Lafage V, Iyer S, Huang R, Lebl D, Qureshi S, Kim HJ, Singh K, Albert T. Early Opioid Consumption Patterns After Anterior Cervical Spine Surgery. Clin Spine Surg 2022; 35:E121-E126. [PMID: 33783369 DOI: 10.1097/bsd.0000000000001176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 02/24/2021] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This is a prospective observational study. OBJECTIVE The aim was to record daily opioid use and pain levels after 1-level or 2-level anterior cervical discectomy and fusion (ACDF) or cervical disc arthroplasty (CDA). SUMMARY OF BACKGROUND DATA Data to inform opioid prescription guidelines following ACDF or CDA is lacking. Understanding postoperative opioid consumption behaviors is critical to provide appropriate postdischarge prescriptions. METHODS Patients undergoing 1-level or 2-level primary ACDF or CDA were consecutively enrolled at 2 participating institutions between March 2018 and March 2019. Patients with opioid dependence (defined as daily use ≥6 mo before surgery) were excluded. Starting postoperative day 1, daily opioid use and numeric pain rating scale pain levels were collected through a Health Insurance Portability and Accountability Act-compliant, automated text-messaging system. To facilitate clinical applications, opioid use was converted from oral morphine equivalents into "pills" (oxycodone 5 mg equivalents). After 6 weeks or upon patient-reported cessation of opioid use, final survey questions were asked. Refill data were verified from the state prescription registry. Risk factors for patients in top quartile of consumption were analyzed. RESULTS Of 57 patients, 48 completed the daily queries (84.2%). Mean age of the patient sample was 50.2±10.9 years. Thirty-two patients (66.7%) underwent ACDF and 16 CDA (33.3%); 64.6% one level; 35.4% two levels. Median postdischarge use was 6.7 pills (range: 0-160). Cumulative opioid use did not vary between the 1-level and 2-level groups (median pill consumption, 10 interquartile range: 1.3-31.3 vs. 4 interquartile range: 0-18, respectively, P=0.085). Thirteen patients (27.1%) did not use any opioids after discharge. Of those patients that took opioids after discharge, half ceased opioids by postoperative day 8. Preoperative intermittent opioid use was associated with the top quartile of opioid consumption (9.1% vs. 50%, P=0.006). CONCLUSION Given that most patients use few opioids, patients could be offered the option of a 12 oxycodone 5 mg (90 oral morphine equivalents) discharge prescription, accompanied by education on appropriate opioid use and disposal.
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Affiliation(s)
| | | | | | | | | | - Joon S Yoo
- Midwest Orthopaedics at Rush, Chicago, IL
| | | | | | | | | | | | - Han Jo Kim
- Hospital for Special Surgery, New York, NY
| | - Kern Singh
- Midwest Orthopaedics at Rush, Chicago, IL
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Cheung CK, Adeola JO, Beutler SS, Urman RD. Postoperative Pain Management in Enhanced Recovery Pathways. J Pain Res 2022; 15:123-135. [PMID: 35058714 PMCID: PMC8765537 DOI: 10.2147/jpr.s231774] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/30/2021] [Indexed: 12/05/2022] Open
Abstract
Postoperative pain is a common but often inadequately treated condition. Enhanced recovery pathways (ERPs) are increasingly being utilized to standardize perioperative care and improve outcomes. ERPs employ multimodal postoperative pain management strategies that minimize opioid use and promote recovery. While traditional opioid medications continue to play an important role in the treatment of postoperative pain, ERPs also rely on a wide range of non-opioid pharmacologic therapies as well as regional anesthesia techniques to manage pain in the postoperative setting. The evidence for the use of these interventions continues to evolve rapidly given the increasing focus on enhanced postoperative recovery. This article reviews the current evidence and knowledge gaps pertaining to commonly utilized modalities for postoperative pain management in ERPs.
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Affiliation(s)
- Christopher K Cheung
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Janet O Adeola
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Sascha S Beutler
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Drudis R, Colomina J, Torra M, Sabate S, Villalba P, Marco G, Triquell X, Del Pozo D, Palliso F, Montero A. Adductor canal block performed 20 hours after total knee arthroplasty to improve postoperative analgesia and functional recovery: a double-blind randomized controlled clinical trial. Minerva Anestesiol 2021; 88:238-247. [PMID: 34709013 DOI: 10.23736/s0375-9393.21.15838-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The goal of postoperative pain protocols in total knee arthroplasty (TKA) is to get pain free patients throughout severe pain period without impairing walking ability. The aim of the study was to investigate if an adductor canal block performed 20 hours after TKA, in patients treated with systemic analgesia and intraoperative local infiltration anaesthesia (LIA), improves postoperative pain and functional outcomes. METHODS A prospective randomized, double blinded controlled study was conducted. One hundred eighty-three patients undergoing primary TKA were randomized to receive either a sham block or an adductor canal block with 20 ml of ropivacaine 0.5%. The primary outcome was resting and dynamic pain scores using the numerical pain rating scale (NPRS). Secondary outcomes included opioid rescue requirements, quadriceps and adductor muscle strength, patient ability for ambulation and complications. RESULTS Two hours after the block, in adductor canal block group NPRS was significantly lower at rest (1[0-2] vs. 3[2-5], P<0.001) and with mobilization (5[3-6] vs. 6[5-8], P<0.001), and quadriceps strength was significantly higher (3.7[2.7-6] vs. 3(1.7-4.9), P=0.023). The differences were not maintained beyond 24 hours post-block. In the first 24 hours the percentage of patients with tramadol requirements was lower in the adductor canal block group (36[38.3] vs 52[58,4], P =0.006). Other secondary outcomes were similar between groups. There were no patient falls. CONCLUSIONS An adductor canal block done 20 hours after total knee arthroplasty reduces pain and opioid requirements without increasing the risk of falls. An optimal pain control, especially at movement was not achieved.
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Affiliation(s)
- Reis Drudis
- Department of Anaesthesiology, Hospital Universitari de Santa Maria, Lleida, Spain -
| | - Jordi Colomina
- Department of Orthopaedic Surgery, Hospital Universitari de Santa Maria, Lleida, Spain
| | - Montserrat Torra
- Department of Anaesthesiology, Hospital Universitari de Santa Maria, Lleida, Spain
| | - Sergi Sabate
- Department of Anaesthesiology, Hospital Universitari Santa Creu i Sant Pau, Fundació Puigvert, Barcelona, Spain
| | - Paz Villalba
- Department of Anaesthesiology, Hospital Universitari de Santa Maria, Lleida, Spain
| | - Gregorio Marco
- Department of Anaesthesiology, Hospital Universitari de Santa Maria, Lleida, Spain
| | - Xenia Triquell
- Department of Anaesthesiology, Hospital Universitari de Santa Maria, Lleida, Spain
| | - Dolors Del Pozo
- Department of Anaesthesiology, Hospital Universitari de Santa Maria, Lleida, Spain
| | - Francesc Palliso
- Department of Orthopaedic Surgery, Hospital Universitari de Santa Maria, Lleida, Spain
| | - Antonio Montero
- Department of Anaesthesiology, Hospital Universitari Arnau de Vilanova, Av. Lleida, Spain
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Reudink M, Fu VX, Mackenbach KTR, Jeekel J, Slooter GD, Dias EM. Implementation of perioperative music in day care surgery. Acta Chir Belg 2021; 123:281-289. [PMID: 34641770 DOI: 10.1080/00015458.2021.1988232] [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: 10/20/2022]
Abstract
BACKGROUND Perioperative music can have beneficial effects on postoperative pain and perioperative opioid requirement. This study aims to assess the implementation feasibility of music in day care surgery through adherence to implementation, as well as its effects. METHODS This implementation study employed a prospective single-center study design. Perioperative music was implemented as part of standard surgical care during day care surgery procedures. The music intervention consisted of preselected playlists. Primary outcome was adherence to implementation. Barriers and attitudes towards music of patients and perioperative care providers were evaluated. Furthermore, the effects of music were assessed through a matched cohort analysis. This study was registered with the Netherlands Trial Register (NL8213). RESULTS From January to April 2020, a total of 109 patients received the music intervention and 97 were analyzed after matching to retrospective controls. Adherence rate to the music intervention was 92% preoperatively, 81% intraoperatively, and 86% postoperatively, with 83% of patients satisfied with the preselected music, and 93% finding music to be beneficial to surgical care. All health care providers believed perioperative music to be beneficial (63%) or were neutral (37%) towards its use. Postoperative pain was not significantly different (mean numeric rating scale 0.74; the music intervention group versus 0.68; control group, p = .363). Although not statistically significant, postoperative opioid requirement in the music group was lower (30% versus 40%, p = .132). CONCLUSION Perioperative music implementation in day care surgery is feasible with high adherence rates, patient satisfaction levels, and positive attitudes of health care providers towards its use.
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Affiliation(s)
- Muriël Reudink
- Department of Surgery, Máxima Medical Center Veldhoven, Veldhoven, The Netherlands
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Victor X. Fu
- Department of Surgery, Erasmus MC, Rotterdam, The Netherlands
- Department of Neuroscience, Erasmus MC, Rotterdam, The Netherlands
| | | | - Johannes Jeekel
- Department of Neuroscience, Erasmus MC, Rotterdam, The Netherlands
| | - Gerrit D. Slooter
- Department of Surgery, Máxima Medical Center Veldhoven, Veldhoven, The Netherlands
| | - Esther M. Dias
- Department of Anesthesiology, Máxima Medical Center Veldhoven, Veldhoven, The Netherlands
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Morgaz J, Latorre DF, Serrano-Rodríguez JM, Granados MM, Domínguez JM, Fernández-Sarmiento JA, Quiros-Carmona S, Navarrete-Calvo R. Preperitoneal ropivacaine infusion versus epidural ropivacaine-morphine for postoperative analgesia in dogs undergoing ovariohysterectomy: a randomized clinical trial. Vet Anaesth Analg 2021; 48:935-942. [PMID: 34561181 DOI: 10.1016/j.vaa.2021.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 04/02/2021] [Accepted: 04/21/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess the effect of continuous wound infusion (CWI) with preperitoneal ropivacaine on postoperative analgesia and compare it with the epidural administration of ropivacaine and morphine in bitches undergoing ovariohysterectomy. STUDY DESIGN A parallel, randomized, clinical, prospective and nonblinded study. ANIMALS A group of 38 Greyhound bitches. METHODS In the catheter group (CathG), CWI with ropivacaine 1% (1 mg kg-1 + 0.8 mg kg-1 hour-1) was applied to the preperitoneal space over the surgical incision. In the epidural group (EpiG), ropivacaine 0.5% (1.3 mg kg-1) and morphine (0.1 mg kg-1) were epidurally administered. Occipital-coccygeal length was used to calculate the volume for the epidural. Pain was scored using a dynamic interactive visual analogue scale (DIVAS) and Glasgow composite measure pain scale-short form (CMPS-SF) before anaesthesia and at 2, 4, 6, 18, 21 and 24 hours after extubation. Incisional sensitivity using a dynamometer (MWTs-incision) was evaluated simultaneously. Plasma ropivacaine and cortisol concentrations, degree of sedation, motor blockade and response to interdigital clamping were measured or assessed. A two-way mixed analysis of variance and a Mann-Whitney U test were used to analyse data; p < 0.05. RESULTS No differences were detected in the DIVAS (p = 0.301), CMPS-SF (p = 0.600) scores, MWTs-incision measurements (p = 0.257) and cortisol values (p = 0.878) between the groups. Rescue analgesia was required in two dogs, one in each group, at 2 hours. Sedation, motor blockade and negative response to interdigital clamping were detected in EpiG at 2, 4 and 6 hours. Mean plasma ropivacaine values were higher in CathG (0.475 ± 0.164 ng mL-1) than in EpiG (0.184 ± 0.213 ng mL-1; p = 0.001). CONCLUSION AND CLINICAL RELEVANCE Compared with epidural ropivacaine and morphine, CWI with preperitoneal ropivacaine is an effective analgesic technique for postoperative pain management in bitches undergoing ovariohysterectomy without motor blockade.
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Affiliation(s)
- Juan Morgaz
- Department of Animal Medicine and Surgery, Veterinary Faculty, University of Córdoba, Córdoba, Spain.
| | - David F Latorre
- Health Sciences Faculty in the Technology University of Pereira, Pereira, Colombia
| | - Juan M Serrano-Rodríguez
- Department of Nursing, Pharmacology and Physiotherapy, Pharmacology Area, University of Córdoba, Córdoba, Spain
| | - María M Granados
- Department of Animal Medicine and Surgery, Veterinary Faculty, University of Córdoba, Córdoba, Spain
| | - Juan M Domínguez
- Department of Animal Medicine and Surgery, Veterinary Faculty, University of Córdoba, Córdoba, Spain
| | | | - Setefilla Quiros-Carmona
- Department of Animal Medicine and Surgery, Veterinary Faculty, University of Córdoba, Córdoba, Spain
| | - Rocío Navarrete-Calvo
- Department of Animal Medicine and Surgery, Veterinary Faculty, University of Córdoba, Córdoba, Spain
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Stopar-Pintaric T, Blajic I, Visic U, Znider M, Plesnicar A, Vlassakov K, Lucovnik M. Posteromedial quadratus lumborum block versus wound infiltration after caesarean section: A randomised, double-blind, controlled study. Eur J Anaesthesiol 2021; 38:S138-S144. [PMID: 33988528 DOI: 10.1097/eja.0000000000001531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Reducing pain and minimising the use of opioids after caesarean section are crucial to enhancing maternal recovery and promoting mother-newborn interaction. Various techniques have been implemented to improve analgesia. We compared the analgesic efficacy of posteromedial quadratus lumborum block with that of wound infiltration following elective caesarean section. OBJECTIVE We hypothesised that within a multimodal analgesia approach, posteromedial quadratus lumborum block would, due to its potential to relieve visceral pain, result in a 15% reduction in 24-h postoperative opioid consumption compared with wound infiltration. DESIGN A double-blind, randomised, placebo-controlled clinical study. SETTING A single-centre study between August 2019 and May 2020. PATIENTS One hundred and sixteen women were randomly allocated into two groups. In the quadratus lumborum group, 20 ml 0.9% saline was injected into the surgical wound followed by bilateral posteromedial quadratus lumborum block using 20 ml 0.25% levobupivacaine per side. In the wound infiltration group, 20 ml of 0.25% levobupivacaine was injected into the surgical wound followed by a bilateral posteromedial quadratus lumborum injection with 20 ml 0.9% saline per side. MAIN OUTCOME MEASURES The primary outcome was opioid (piritramide) consumption at 24 h. Secondary outcomes were piritramide consumption at 48 h, time-to-first analgesic request, pain scores at rest and with movement, surgery-to-first-ambulation time, surgery-to-breastfeeding time, sedation, pruritus and complications. RESULTS Piritramide consumption in 24 h was significantly lower with posteromedial quadratus lumborum block (1.5 ± 1.8 mg) than with wound infiltration (2.2 ± 1.7 mg) (P = 0.04), mean difference of -0.7 mg, (95% CI -1.3 to -0.03). In those who required piritramide, time-to-first analgesic request was significantly longer with posteromedial quadratus lumborum block 11 [7 to 14] h, than with wound infiltration 7 [5 to 11] h (P = 0.02). Pain scores were low, with no differences recorded at rest and with movement. There were no differences in time-to-ambulation and time-to-breastfeed between the groups. CONCLUSION As a component of multimodal post-caesarean section analgesia, posteromedial quadratus lumborum block was associated with lower 24-h opioid consumption compared with wound infiltration. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT04000308.
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Affiliation(s)
- Tatjana Stopar-Pintaric
- From the Department of Anaesthesiology and Intensive Therapy, University Medical Centre Ljubljana (TSP, IB), the Institute of Anatomy, Faculty of Medicine, University of Ljubljana (TSP), the Department of Perinatology, Division of Obstetrics and Gynaecology, University Medical Centre Ljubljana (UV, ML), the Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia (MZ, AP, ML), the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, USA (KV)
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46
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Singer KE, Philpott CD, Bercz AP, Phillips T, Salyer CE, Hanseman D, Droege ME, Goodman MD, Makley AT. Impact of a Multimodal Analgesia Protocol on Inpatient and Outpatient Opioid Use in Acute Trauma. J Surg Res 2021; 268:9-16. [PMID: 34280664 DOI: 10.1016/j.jss.2021.05.052] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/16/2021] [Accepted: 05/29/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Multimodal analgesia protocols have been implemented after elective surgery to reduce opioid use, however there is limited data on utility after polytrauma. Therefore, we investigated the impact of a multimodal analgesia protocol on inpatient and post-discharge outpatient opioid use after polytrauma. METHODS A retrospective review of patients admitted to a Level I trauma center between September 2017-February 2018 (prior to multimodal protocol; "pre-cohort") and October 2018-April 2019 (after multimodal protocol; "post-cohort") was performed. An outpatient controlled substance registry was utilized to capture morphine milligram equivalents (MME) and gabapentin dispensed in the 6 mo after injury. RESULTS 620 patients were included (295 pre-cohort, 325 post-cohort). Total inpatient MME decreased from 177.5 mg-130 mg (P= 0.01) between the cohorts. Daily inpatient MME decreased from 70.8 mg-44.7 mg (P< 0.01). Intravenous hydromorphone decreased from 2 mg in the pre-cohort to 1 mg in the post-cohort (P= 0.02). Inpatient oxycodone decreased from 45 mg-30 mg (P= 0.01). Concurrently, gabapentin increased from 0 mg-400 mg in the post-cohort (P< 0.01). Patients in the post-cohort were prescribed fewer MMEs than the pre-cohort at discharge (P< 0.05). However, the number of patients prescribed gabapentin increased from 6.1%-16% (P< 0.01). CONCLUSION Implementation of an updated multimodal analgesia protocol decreased total MME, daily MME, hydromorphone, and oxycodone consumed while increasing gabapentin use. This suggests that while reducing opioid usage in-hospital is critical to reducing outpatient usage, multimodal pain protocols may lead to an increase in gabapentin prescriptions and utilization after discharge.
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Affiliation(s)
- Kathleen E Singer
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio.
| | | | - Aron P Bercz
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Tabatha Phillips
- Department of Pharmacology, University of Cincinnati, Cincinnati, Ohio
| | - Christen E Salyer
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Dennis Hanseman
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Molly E Droege
- Department of Pharmacology, University of Cincinnati, Cincinnati, Ohio
| | - Michael D Goodman
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Amy T Makley
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio
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Garnier J, Mokart D, Ewald J, Lelong B, De Chaisemartin C, Marchese U, Meillat H, Guiramand J, Al Faraï A, Delpero J, Turrini O. Aspiration pneumonia following oncologic digestive surgery: Proposal for a classification. Health Sci Rep 2021; 4:e253. [PMID: 33778165 PMCID: PMC7990079 DOI: 10.1002/hsr2.253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 01/07/2021] [Accepted: 02/03/2021] [Indexed: 12/08/2022] Open
Affiliation(s)
- Jonathan Garnier
- Department of Surgical OncologyInstitut Paoli‐CalmettesMarseilleFrance
| | - Djamel Mokart
- Department of Intensive CareInstitut Paoli‐CalmettesMarseilleFrance
| | - Jacques Ewald
- Department of Surgical OncologyInstitut Paoli‐CalmettesMarseilleFrance
| | - Bernard Lelong
- Department of Surgical OncologyInstitut Paoli‐CalmettesMarseilleFrance
| | | | - Ugo Marchese
- Department of Surgical OncologyInstitut Paoli‐CalmettesMarseilleFrance
| | - Helene Meillat
- Department of Surgical OncologyInstitut Paoli‐CalmettesMarseilleFrance
| | - Jerome Guiramand
- Department of Surgical OncologyInstitut Paoli‐CalmettesMarseilleFrance
| | - Abdallah Al Faraï
- Department of Surgical OncologyInstitut Paoli‐CalmettesMarseilleFrance
| | | | - Olivier Turrini
- Department of Surgical OncologyAix‐Marseille University, Institut Paoli‐Calmettes, CRCMMarseilleFrance
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Cabañero D, Maldonado R. Synergism between oral paracetamol and nefopam in a murine model of postoperative pain. Eur J Pain 2021; 25:1770-1787. [PMID: 33909343 DOI: 10.1002/ejp.1787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/08/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND The use of paracetamol or nefopam for postoperative pain control is limited by the need of high doses associated with unwanted effects. Previous works suggest positive interactions between both compounds that may be exploited to obtain potentiation of antinociception. METHODS Mechanical and heat antinociception induced by oral doses of paracetamol, nefopam or their combination was studied by isobolographic analysis in a murine model of postsurgical pain. The effective doses that produced 50% antinociception (ED50 ) were calculated from the log dose-response curves for each compound. Subsequently, the effects of ED8.7 s, ED12.5 s, ED17.5 s and ED35 s of nefopam and paracetamol combined were assessed. RESULTS Oral paracetamol induced dose-dependent relief of postoperative sensitivity and showed higher efficacy reducing mechanical hypersensitivity (ED50 177.3 ± 15.4 mg/kg) than heat hyperalgesia (ED50 278.6 ± 43 mg/kg). Oral nefopam induced dose-dependent antinociception with similar efficacy for mechanical and heat hypersensitivity (ED50 s 5.42 ± 0.81 vs. 5.83 ± 0.72). Combinations of increasing isoeffective doses revealed that combined ED17.5 s (85.76 mg/kg paracetamol and 1.9 mg/kg nefopam) and ED35 s (132.67 mg/kg and 3.73 mg/kg) showed synergistic effects leading to 75% and 90% mechanical antinociception, respectively. These mixtures were defined by interaction indexes of 0.43 and 0.41 and ratios 45:1 and 35:1 paracetamol:nefopam, respectively. The same combinations showed additive effects for the inhibition of incisional thermal hyperalgesia. CONCLUSIONS AND LIMITATIONS This work describes a synergistic antinociceptive interaction between low doses of nefopam and paracetamol for the treatment of postoperative hypersensitivity to peripheral stimuli. The promising results obtained on reflexive nociceptive responses of young male mice subjected to plantar surgery highlight the interest of further research evaluating the effects of this mixture on the affective-motivational component of pain and in females and additional age groups. Confirmation of pain-relieving efficacy and safety of this oral combination clinically available in European and Asian countries could provide a useful tool for postsurgical pain management. SIGNIFICANCE Early postoperative pain is currently undertreated and has been recognized as a relevant source of chronic postsurgical pain. Oral efficient treatments could facilitate fast-track surgeries and patient recovery at home. Here, we identify in a mouse model of postoperative pain a potent synergistic oral combination consisting of low paracetamol and nefopam doses that provides relief of postsurgical hypersensitivity to mechanical and thermal stimuli. Oral multimodal paracetamol-nefopam mixtures represent a potential clinically available pharmacological strategy for the relief of incisional sensitivity and the promotion of patient recovery.
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Affiliation(s)
- David Cabañero
- Neuropharmacology Laboratory, Department of Experimental and Health Sciences, Pompeu Fabra University, Barcelona, Spain
| | - Rafael Maldonado
- Neuropharmacology Laboratory, Department of Experimental and Health Sciences, Pompeu Fabra University, Barcelona, Spain.,IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
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Abstract
Opioids form an important component of general anesthesia and perioperative analgesia. Discharge opioid prescriptions are identified as a contributor for persistent opioid use and diversion. In parallel, there is increased enthusiasm to advocate opioid-free strategies, which include a combination of known analgesics and adjuvants, many of which are in the form of continuous infusions. This article critically reviews perioperative opioid use, especially in view of opioid-sparing versus opioid-free strategies. The data indicate that opioid-free strategies, however noble in their cause, do not fully acknowledge the limitations and gaps within the existing evidence and clinical practice considerations. Moreover, they do not allow analgesic titration based on patient needs; are unclear about optimal components and their role in different surgical settings and perioperative phases; and do not serve to decrease the risk of persistent opioid use, thereby distracting us from optimizing pain and minimizing realistic long-term harms.
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50
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Srivastava D, Wilkinson P. Surgery and opioids: some cracks in an enduring romance. Br J Anaesth 2021; 126:1088-1092. [PMID: 33707092 DOI: 10.1016/j.bja.2021.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 10/22/2022] Open
Affiliation(s)
| | - Paul Wilkinson
- Department of Anaesthesia, Newcastle Pain Management Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, UK.
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