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Bukhari S, Leth MF, Laursen CCW, Larsen ME, Tornøe AS, Eriksen VR, Hovmand AEK, Jakobsen JC, Maagaard M, Mathiesen O. Risks of serious adverse events with non-steroidal anti-inflammatory drugs in gastrointestinal surgery: A systematic review with meta-analysis and trial sequential analysis. Acta Anaesthesiol Scand 2024; 68:871-887. [PMID: 38629348 DOI: 10.1111/aas.14425] [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: 12/03/2023] [Revised: 03/19/2024] [Accepted: 03/21/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly recommended for perioperative opioid-sparing multimodal analgesic treatments. Concerns regarding the potential for serious adverse events (SAEs) associated with perioperative NSAID treatment are especially relevant following gastrointestinal surgery. We assessed the risks of SAEs with perioperative NSAID treatment in patients undergoing gastrointestinal surgery. METHODS We conducted a systematic review of randomised clinical trials assessing the harmful effects of NSAIDs versus placebo, usual care or no intervention in patients undergoing gastrointestinal surgery. The primary outcome was an incidence of SAEs. We systematically searched for eligible trials in five major databases up to January 2024. We performed risk of bias assessments to account for systematic errors, trial sequential analysis (TSA) to account for the risks of random errors, performed meta-analyses using R and used the Grading of Recommendations Assessment, Development and Evaluation framework to describe the certainty of evidence. RESULTS We included 22 trials enrolling 1622 patients for our primary analyses. Most trials were at high risk of bias. Meta-analyses (risk ratio 0.78; 95% confidence interval [CI] 0.51-1.19; I2 = 4%; p = .24; very low certainty of evidence) and TSA indicated a lack of information on the effects of NSAIDs compared to placebo on the risks of SAEs. Post-hoc beta-binomial regression sensitivity analyses including trials with zero events showed a reduction in SAEs with NSAIDs versus placebo (odds ratio 0.73; CI 0.54-0.99; p = .042). CONCLUSION In adult patients undergoing gastrointestinal surgery, there was insufficient information to draw firm conclusions on the effects of NSAIDs on SAEs. The certainty of the evidence was very low.
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Affiliation(s)
- Shaheer Bukhari
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Morten F Leth
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Christina C W Laursen
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Mia E Larsen
- Department of Anesthesiology, Nykøbing Falster Hospital, Nykøbing Falster, Denmark
| | - Anders S Tornøe
- Department of Anesthesiology, Nordland Hospital Trust, Bodø, Norway
| | - Vibeke R Eriksen
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Alfred E K Hovmand
- Department of Anesthesiology, University Hospital Northern Norway, Tromsø, Norway
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Mathias Maagaard
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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Huang X, Cai J, Lv Z, Zhou Z, Zhou X, Zhao Q, Sun J, Chen L. Postoperative pain after different doses of remifentanil infusion during anaesthesia: a meta-analysis. BMC Anesthesiol 2024; 24:25. [PMID: 38218762 PMCID: PMC10790271 DOI: 10.1186/s12871-023-02388-3] [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: 02/03/2023] [Accepted: 12/17/2023] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND This meta-analysis aimed to explore the correlation between the different doses of remifentanil-based anaesthesia and postoperative pain in randomised trials. METHODS The electronic databases including PubMed, Cochrane, clinical trial registries, and Google Scholar were searched up to November 2022 for randomised controlled trials (RCTs) that assessed the dose dependent efficacy of remifentanil for postoperative pain intensity and hyperalgesia. RESULTS 31 studies involving 2019 patients were included for analysis. Compared with the high remifentanil dose administration, patients in low doses showed less postoperative pain intensity at 1-2 h (weighted mean differences (WMD): 0.60, 95% CI, 0.05 to 1.15), 3-8 h (WMD: 0.38, 95% CI, 0.00 to 0.75), 24 h (WMD: 0.26, 95% CI, 0.04 to 0.48) and 48 h (WMD: 0.32, 95% CI, 0.09 to 0.55). Remifentanil-free regimen failed to decrease the pain score at 24 h (WMD: 0.10, 95% CI, -0.10 to 0.30) and 48 h (WMD: 0.15, 95% CI, -0.22 to 0.52) in comparison with remifentanil-based anaesthesia. After excluding trials with high heterogeneity, the dose of the remifentanil regimen was closely correlated with the postoperative pain score (P=0.03). In addition, the dose of the remifentanil regimen was not associated with the incidence of postoperative nausea and vomiting (PONV) (P=0.37). CONCLUSIONS Our meta-analysis reveals that the low dose of remifentanil infusion is recommendable for general anaesthesia maintenance. No evidence suggests that remifentanil-free regimen has superiority in reducing postoperative pain. Moreover, remifentanil doesn't have a dose dependent effect in initiating PONV. TRIAL REGISTRATION The protocol of present study was registered with PROSPERO (CRD42022378360).
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Affiliation(s)
- Xinyi Huang
- Department of Anaesthesiology, 1st affiliated hospital, Wenzhou Medical University, Ouhai District, Wenzhou, Zhejiang, China
| | - Jinxia Cai
- Department of Anaesthesiology, 1st affiliated hospital, Wenzhou Medical University, Ouhai District, Wenzhou, Zhejiang, China
| | - Zhu Lv
- Department of Anaesthesiology, 1st affiliated hospital, Wenzhou Medical University, Ouhai District, Wenzhou, Zhejiang, China
| | - Zijun Zhou
- Department of Anaesthesiology, 1st affiliated hospital, Wenzhou Medical University, Ouhai District, Wenzhou, Zhejiang, China
| | - Xiaotian Zhou
- Department of Anaesthesiology, 1st affiliated hospital, Wenzhou Medical University, Ouhai District, Wenzhou, Zhejiang, China
| | - Qimin Zhao
- Department of Anaesthesiology, 1st affiliated hospital, Wenzhou Medical University, Ouhai District, Wenzhou, Zhejiang, China
| | - Jiehao Sun
- Department of Anaesthesiology, 1st affiliated hospital, Wenzhou Medical University, Ouhai District, Wenzhou, Zhejiang, China.
| | - Long Chen
- Centre for Rehabilitation Medicine, Department of Anaesthesiology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China.
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Del Tedesco F, Sessa F, Xhemalaj R, Sollazzi L, Dello Russo C, Aceto P. Perioperative analgesia in the elderly. Saudi J Anaesth 2023; 17:491-499. [PMID: 37779570 PMCID: PMC10540995 DOI: 10.4103/sja.sja_643_23] [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: 07/22/2023] [Revised: 07/23/2023] [Accepted: 07/24/2023] [Indexed: 10/03/2023] Open
Abstract
The administration of analgesic drugs in elderly patients should take into account age-related physiological changes, loss of efficiency of homeostatic mechanisms, and pharmacological interactions with chronic therapies. Underestimation of pain in patients with impaired cognition is often linked to difficulties in pain assessment. In the preoperative phase, it is essential to assess the physical status, cognitive reserve, and previous chronic pain conditions to plan effective analgesia. Furthermore, an accurate pharmacological history of the patient must be collected to establish any possible interaction with the whole perioperative analgesic plan. The use of analgesic drugs with different mechanisms of action for pain relief in the intraoperative phase is a crucial step to achieve adequate postoperative pain control in older adults. The combined multimodal and opioid-sparing strategy is strongly recommended to reduce side effects. The use of various adjuvants is also preferable. Moreover, the implementation of non-pharmacological approaches may lead to faster recovery. High-quality postoperative analgesia in older patients can be achieved only with a collaborative interdisciplinary team. The aim of this review is to highlight the perioperative pain management strategies in the elderly with a special focus on intraoperative pharmacological interventions.
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Affiliation(s)
- Filippo Del Tedesco
- Dipartimento di Scienze dell’emergenza, anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Flaminio Sessa
- Dipartimento di Scienze dell’emergenza, anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Rikardo Xhemalaj
- Dipartimento di Scienze dell’emergenza, anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Liliana Sollazzi
- Dipartimento di Scienze dell’emergenza, anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Cinzia Dello Russo
- Dipartimento di Sicurezza e Bioetica, Sezione di Farmacologia, Università Cattolica Del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Pharmacology and Therapeutics, Institute of Systems Molecular and Integrative Biology (ISMIB), University of Liverpool, Liverpool, United Kingdom
| | - Paola Aceto
- Dipartimento di Scienze dell’emergenza, anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
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Xie WJ, Hong JS, Feng CF, Chen HF, Li W, Li YC. Pharmacological interventions for preventing opioid-induced hyperalgesia in adults after opioid-based anesthesia: a systematic review and network meta-analysis. Front Pharmacol 2023; 14:1199794. [PMID: 37426819 PMCID: PMC10324676 DOI: 10.3389/fphar.2023.1199794] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/12/2023] [Indexed: 07/11/2023] Open
Abstract
Background: Opioid-induced hyperalgesia (OIH) is an adverse event of prolonged opioid use that increases pain intensity. The optimal drug to prevent these adverse effects is still unknown. We aimed to conduct a network meta-analysis to compare different pharmacological interventions for preventing the increase in postoperative pain intensity caused by OIH. Methods: Several databases were searched independently for randomized controlled trials (RCTs) comparing various pharmacological interventions to prevent OIH. The primary outcomes were postoperative pain intensity at rest after 24 h and the incidence of postoperative nausea and vomiting (PONV). Secondary outcomes included pain threshold at 24 h after surgery, total morphine consumption over 24 h, time to first postoperative analgesic requirement, and shivering incidence. Results: In total, 33 RCTs with 1711 patients were identified. In terms of postoperative pain intensity, amantadine, magnesium sulphate, pregabalin, dexmedetomidine, ibuprofen, flurbiprofen plus dexmedetomidine, parecoxib, parecoxib plus dexmedetomidine, and S (+)-ketamine plus methadone were all associated with milder pain intensity than placebo, with amantadine being the most effective (SUCRA values = 96.2). Regarding PONV incidence, intervention with dexmedetomidine or flurbiprofen plus dexmedetomidine resulted in a lower incidence than placebo, with dexmedetomidine showing the best result (SUCRA values = 90.3). Conclusion: Amantadine was identified as the best in controlling postoperative pain intensity and non-inferior to placebo in the incidence of PONV. Dexmedetomidine was the only intervention that outperformed placebo in all indicators. Clinical Trial Registration: https://www.crd.york.ac. uk/prospero/display_record.php?, CRD42021225361.
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Affiliation(s)
- Wei-Ji Xie
- Department of Anesthesiology, State Key Laboratory of Oncology in Southern China, Sun Yat-sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Ji-Shuang Hong
- Department of Anesthesiology, State Key Laboratory of Oncology in Southern China, Sun Yat-sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Cheng-Fei Feng
- Department of Anesthesiology, State Key Laboratory of Oncology in Southern China, Sun Yat-sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Hao-Feng Chen
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wei Li
- Department of Anesthesiology, State Key Laboratory of Oncology in Southern China, Sun Yat-sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Yong-Chun Li
- Department of Anesthesiology, State Key Laboratory of Oncology in Southern China, Sun Yat-sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
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Fujii T, Nishiwaki K. Ketamine reduces the dose of remifentanil required during prolonged head and neck surgery: a propensity-matched analysis. NAGOYA JOURNAL OF MEDICAL SCIENCE 2022; 84:1-6. [PMID: 35392017 PMCID: PMC8971040 DOI: 10.18999/nagjms.84.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 05/11/2021] [Indexed: 11/29/2022]
Abstract
High-dose opioids induce hyperalgesia and tolerance, which negatively affects postoperative recovery. Prolonged surgery inevitably requires higher opioid doses. Ketamine reduces perioperative opioid consumption and prevents opioid-induced tolerance. However, its effects in cases of prolonged surgery remain unknown. This study aimed to evaluate the dose of intraoperative remifentanil, an ultrashort-acting µ-opioid agonist, administered after an intravenous ketamine bolus during prolonged head and neck surgery. This single-center, retrospective, observational study included 251 patients who underwent head and neck surgery (operation time ≥8 h) between January 2015 and December 2019. The participants were stratified into two groups: those who received an intravenous bolus of ketamine and those who did not (ketamine group and non-ketamine group, respectively). Propensity score-matching was used to match patients in a 1:1 ratio between the two groups, based on their covariates. The difference in intraoperative remifentanil dose administered between the two groups was assessed. After 1:1 propensity score-matching, 89 matched patients were selected from each group. The mean ± standard deviation dose of remifentanil administered was significantly lower in the ketamine group than in the non-ketamine group before (0.15±0.05 vs 0.17±0.05 µg/kg/min; P=0.01) and after matching (0.15±0.06 vs 0.17±0.05 µg/kg/min; P=0.03). In conclusion, intravenous ketamine administration may reduce the intraoperative dose of remifentanil required during prolonged head and neck surgery. However, further studies are required to evaluate the effect of this finding on enhanced recovery after surgery.
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Affiliation(s)
- Tasuku Fujii
- Department of Anesthesiology, Nagoya University Hospital, Nagoya, Japan
| | - Kimitoshi Nishiwaki
- Department of Anesthesiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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6
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Akter N, Ratnayake B, Joh DB, Chan SJ, Bonner E, Pandanaboyana S. Postoperative Pain Relief after Pancreatic Resection: Systematic Review and Meta-Analysis of Analgesic Modalities. World J Surg 2021; 45:3165-3173. [PMID: 34185150 PMCID: PMC8408074 DOI: 10.1007/s00268-021-06217-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 01/11/2023]
Abstract
Background This systematic review explored the efficacy of different pain relief modalities used in the management of postoperative pain following pancreatoduodenectomy (PD) and distal pancreatectomy (DP) and impact on perioperative outcomes. Methods MEDLINE (OVID), Embase, Pubmed, Web of Science and CENTRAL databases were searched using PRISMA framework. Primary outcomes included pain on postoperative day 2 and 4 and respiratory morbidity. Secondary outcomes included operation time, bile leak, delayed gastric emptying, postoperative pancreatic fistula, length of stay, and opioid use. Results Five randomized controlled trials and seven retrospective cohort studies (1313 patients) were included in the systematic review. Studies compared epidural analgesia (EDA) (n = 845), patient controlled analgesia (PCA) (n = 425) and transabdominal wound catheters (TAWC) (n = 43). EDA versus PCA following PD was compared in eight studies (1004 patients) in the quantitative meta-analysis. Pain scores on day 2 (p = 0.19) and 4 (p = 0.18) and respiratory morbidity (p = 0.42) were comparable between EDA and PCA. Operative times, bile leak, delayed gastric emptying, pancreatic fistula, opioid use, and length of stay also were comparable between EDA and PCA. Pain scores and perioperative outcomes were comparable between EDA and PCA following DP and EDA and TAWC following PD. Conclusions EDA, PCA and TAWC are the most frequently used analgesic modalities in pancreatic surgery. Pain relief and other perioperative outcomes are comparable between them. Further larger randomized controlled trials are warranted to explore the relative merits of each analgesic modality on postoperative outcomes with emphasis on postoperative complications. Supplementary Information The online version contains supplementary material available at 10.1007/s00268-021-06217-x.
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Affiliation(s)
- Nasreen Akter
- HPB and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Bathiya Ratnayake
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Daniel B Joh
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Sara-Jane Chan
- HPB and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Emily Bonner
- Perioperative and Critical Care Department, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Sanjay Pandanaboyana
- HPB and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK. .,Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK.
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Kim SY, Lee S, Lee Y, Kim H, Kim KM. Effect of single dose preoperative intravenous ibuprofen on postoperative pain and opioid consumption: a systematic review and meta-analysis. Korean J Anesthesiol 2021; 74:409-421. [PMID: 33611881 PMCID: PMC8497907 DOI: 10.4097/kja.21050] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/19/2021] [Indexed: 11/21/2022] Open
Abstract
Background Ibuprofen, a well-known analgesic, is commonly used as a component of a multimodal analgesic approach for postoperative pain. This systematic review and meta-analysis aimed to investigate whether a single-dose preoperative intravenous ibuprofen can reduce postoperative pain and opioid consumption. Methods PubMed/MEDLINE, Embase, Cochrane Library (CENTRAL), and Web of Science databases were searched to identify relevant studies published up to May 2020. Randomized controlled trials comparing preoperative single-dose intravenous ibuprofen effect with the control group on postoperative pain and opioid consumption after surgery under general anesthesia were included. Results Six studies involving 366 participants were included. Single-dose administration of intravenous ibuprofen preoperatively significantly reduced postoperative pain score on a scale of 0-10 at 1 h (MD: -1.64, 95% CI [-2.56, -0.72], P < 0.001, I2 = 95%), at 4-6 h (MD: -1.17, 95% CI [-2.09, -0.26], P < 0.001, I2 = 94%), and 24 h (MD: -0.58, 95% CI [-0.99, -0.18], P < 0.001, I2 = 90%). Cumulative opioid consumption, presented as fentanyl equivalents, was also reduced significantly in the ibuprofen group compared to placebo group until postoperative 4-6 h (MD: -56.35 μg, 95% CI [-101.10, -11.60], P < 0.001, I2 = 91%) and 24 h (MD: -131.39 μg, 95% CI [-224.56, -38.21], P < 0.001, I2 = 95%). Conclusions Preoperative single-dose intravenous ibuprofen can reduce postoperative pain and opioid consumption until 24 h postoperatively. Considering the high heterogeneity and small number of studies included, care should be taken when generalizing these findings.
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Affiliation(s)
- Su Yeon Kim
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Sangseok Lee
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Yeji Lee
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Hyunho Kim
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Kye-Min Kim
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
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Albrecht E, Grape S, Frauenknecht J, Kilchoer L, Kirkham KR. Low- versus high-dose intraoperative opioids: A systematic review with meta-analyses and trial sequential analyses. Acta Anaesthesiol Scand 2020; 64:6-22. [PMID: 31506922 DOI: 10.1111/aas.13470] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 09/03/2019] [Accepted: 09/04/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Opioid-induced hyperalgesia is a state of nociceptive sensitisation secondary to opioid administration. The objective of this meta-analysis was to test the hypothesis that high-dose intraoperative opioids contribute to increased post-operative pain and hyperalgesia when compared with a low-dose regimen in patients under general anaesthesia. METHODS We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines and rated the certainty of evidence with the Grading of Recommendations, Assessment, Development and Evaluation system. Only trials investigating pain outcomes and comparing two different dosages of the same intraoperative opioid in patients under general anaesthesia were included. The primary outcome was pain score (analogue scale, 0-10) at 24 post-operative hours. Secondary outcomes included pain score and cumulative intravenous morphine equivalents (mg) consumed at 2 post-operative hours, together with mechanical pain threshold (g·mm-2 ). RESULTS Twenty-seven randomised controlled trials, including 1630 patients, were identified. Pain score at rest at 24 post-operative hours was increased in the high-dose group (mean difference [95% CI]: -0.2 [-0.4, -0.1]; trial sequential analysis-adjusted CI: -0.4, -0.02; low certainty of evidence). Similarly, at 2 post-operative hours, both pain score (mean difference [95% CI]: -0.4 [-0.6, -0.2]; low certainty of evidence) and cumulative intravenous morphine equivalents consumed (mean difference [95% CI]: -1.6 mg [-2.6, -0.7]; low certainty of evidence) were significantly higher in the high-dose group. Finally, the threshold for mechanical pain was significantly lower in the high-dose group (mean difference to pressure [95% CI]: 3.8 g·mm-2 [1.8, 5.8]; low certainty of evidence). CONCLUSIONS There is low certainty of evidence that high-dose intraoperative opioid administration increases pain scores in the post-operative period, when compared with a low-dose regimen.
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Affiliation(s)
- Eric Albrecht
- Department of Anaesthesia Lausanne University Hospital Lausanne Switzerland
| | - Sina Grape
- Department of Anaesthesia and Intensive Care Medicine Valais Hospital Sion Switzerland
| | | | - Laurent Kilchoer
- Department of Anaesthesia Lausanne University Hospital Lausanne Switzerland
| | - Kyle R. Kirkham
- Department of Anaesthesia Toronto Western Hospital University of Toronto Toronto Canada
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Kendall MC, Castro-Alves LJ. Transversus abdominis block (TAP) versus thoracic epidural analgesia: Do we have a winner? Am J Surg 2019; 217:813. [DOI: 10.1016/j.amjsurg.2018.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 01/11/2018] [Indexed: 11/15/2022]
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10
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Castro-Alves LJ, Kendall MC. Comment to: Pre-peritoneal local anaesthetic does not reduce post-operative pain in laparoscopic total extra-peritoneal inguinal hernia repair: double-blinded randomized controlled trial. Kulasegaran S, Rohan M, Pearless L, Hulme-Moir M. Hernia 2019; 23:177. [DOI: 10.1007/s10029-018-1737-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 01/12/2018] [Indexed: 11/28/2022]
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Lee HC, Ryu HG, Kim HJ, Park Y, Yoon SB, Yang SM, Oh HW, Jung CW. Excessive remifentanil during total intravenous anesthesia is associated with increased risk of pain after robotic thyroid surgery. PLoS One 2018; 13:e0209078. [PMID: 30550587 PMCID: PMC6294434 DOI: 10.1371/journal.pone.0209078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 11/29/2018] [Indexed: 01/16/2023] Open
Abstract
The widespread use of remifentanil during total intravenous anesthesia (TIVA) has raised concerns about the risk of postoperative remifentanil-associated pain. Although a recent meta-analysis suggests that remifentanil-associated pain is unlikely to occur in patients with TIVA because of the protective effect of co-administered propofol, the evidence is not conclusive. We retrospectively assessed 635 patients who received robotic thyroid surgery under TIVA to evaluate the risk of remifentanil-associated pain. Postoperative pain was evaluated using 11-point numeric rating scale (NRS). Time dependent Cox proportional hazards regression analysis was used to determine the risk factors of treatment-requiring pain (NRS > 4) during the first 48 postoperative hours. Postoperative pain rapidly decreased, and treatment-requiring pain remained in 12.8% (81 out of 635) of patients at 48 hours postoperatively. After adjusting for the time-dependent analgesic consumption, intraoperative use of remifentanil > 0.2 mcg/kg/min was a positive predictor of postoperative pain with a hazard ratio of 1.296 (95% C.I., 1.014–1.656, P = 0.039) during 48 hours after surgery. In conclusion, excessive use of remifentanil during TIVA was associated with increased risk of pain after robotic thyroid surgery. Prospective trials are required to confirm these results and determine whether decreasing remifentanil consumption below the threshold can reduce postoperative pain.
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Affiliation(s)
- Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ho-Geol Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyung-Jun Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yoonsang Park
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Soo Bin Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seong Mi Yang
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hye-Won Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chul-Woo Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- * E-mail:
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Castro-Alves LJ, Kendall MC. Letter to Editor concerning "Comparative study of the efficacy of transdermal buprenorphine patches and prolonged-release tramadol tablets for postoperative pain control after spinal fusion surgery: a prospective, randomized controlled non-inferiority trial" by Kim HJ, Ahn HS, Nam Y, Chang BS, Lee CK, Yeom JS (2017) Eur Spine J 26:2961-2968. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:2882-2883. [PMID: 30293115 DOI: 10.1007/s00586-018-5781-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 10/01/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Lucas J Castro-Alves
- Department of Anesthesiology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
| | - Mark C Kendall
- Department of Anesthesiology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA.
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De Oliveira GS. Optimal analgesic regimen for bariatric surgery: No opioid is rarely the option…. J Clin Anesth 2018; 51:123-124. [PMID: 30142488 DOI: 10.1016/j.jclinane.2018.08.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 08/14/2018] [Indexed: 01/22/2023]
Affiliation(s)
- Gildasio S De Oliveira
- School of Medicine, Brown University, Providence, USA; Department of Anesthesiology, Rhode Island Hospital, Providence, RI, USA; Department of Surgery, Alpert School of Medicine, Brown University, Providence, RI, USA; Department of Health Services Research, School of Public Health, Providence, RI, USA.
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Castro-Alves LJ, Kendall MC. Confounding factors in the efficacy of rectus sheath block? J Pediatr Surg 2018; 53:1637. [PMID: 29776737 DOI: 10.1016/j.jpedsurg.2018.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 01/23/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Lucas J Castro-Alves
- Department of Anesthesiology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, United States
| | - Mark C Kendall
- Department of Anesthesiology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, United States.
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Kendall MC, Castro-Alves LJ. Pain outcomes and recovery after robotic laparoscopic transabdominal preperitoneal inguinal hernia repair. J Robot Surg 2018; 13:185. [PMID: 29546584 DOI: 10.1007/s11701-018-0795-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 03/08/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Mark C Kendall
- Clinical Research, Department of Anesthesiology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02818, USA.
| | - Lucas J Castro-Alves
- Clinical Research, Department of Anesthesiology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02818, USA
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The Evidence for Ropivacaine Wound Infiltration and Postsurgical Pain. J Surg Res 2018. [PMID: 29530317 DOI: 10.1016/j.jss.2018.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Castro-Alves LJ, Kendall MC. Confounding and Adjustment Factors in the Effect of Intravenous Parecoxib on Shoulder Pain after Thoracotomy? J Cardiothorac Vasc Anesth 2018; 32:e55. [PMID: 29501226 DOI: 10.1053/j.jvca.2018.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Lucas J Castro-Alves
- Department of Anesthesiology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI
| | - Mark C Kendall
- Department of Anesthesiology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI
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Kendall MC, Castro-Alves LJ. Comment on a paper by Von Dincklage et al. entitled 'Higher doses of intraoperative analgesia are associated with lower levels of persistent pain and less analgesic consumption six months after total hip arthroplasty'. Eur J Pain 2018; 22:822. [PMID: 29364573 DOI: 10.1002/ejp.1198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2018] [Indexed: 11/10/2022]
Affiliation(s)
- M C Kendall
- Department of Anesthesiology, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - L J Castro-Alves
- Department of Anesthesiology, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA
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Lavand'homme P, Steyaert A. Opioid-free anesthesia opioid side effects: Tolerance and hyperalgesia. Best Pract Res Clin Anaesthesiol 2017; 31:487-498. [DOI: 10.1016/j.bpa.2017.05.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 04/24/2017] [Accepted: 05/10/2017] [Indexed: 12/13/2022]
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