The effect of tramadol plus paracetamol on consumption of morphine after coronary artery bypass grafting

A Systematic Review of Multimodal Analgesic Effectiveness on Acute Postoperative Pain After Adult Cardiac Surgery

AIM

To synthesise the best available empirical evidence about the effectiveness of multimodal analgesics on pain after adult cardiac surgery.

DESIGN

A systematic review with meta-analysis.

METHODS

Indexed full-text papers or abstracts, in any language, of randomised controlled trials of adult patients undergoing cardiac surgery investigating multimodal postoperative analgesic regimen effect on mean level of patient-reported pain intensity at rest.

DATA SOURCES

Eight databases, via two platforms and three trial registries were searched from 1 January 1995 to 1 June 2024 returning 3823 citations.

RESULTS

Of the 123 full-text papers assessed, 29 were eligible for inclusion. Data were independently extracted by a minimum of two reviewers in Covidence. There were 2195 participants, aged 60.4 ± 6.6 (range 40-79) years, who were primarily male (n = 1522, 76.1%), randomised in the included studies. Risk of bias was high and reporting quality was poor. Patient-reported pain was measured at rest in 28 (96.6%) trials. Data were suitable for pooled analysis from 10 (34.5%) of these trials with an average rest pain intensity of 3.3 (SD 1.5) in the control and 2.7 (SD 1.9) in the intervention groups, respectively. No trials compared combinations of nonopioid, opioid-agonist-antagonist, partial opioid agonists or full opioid agonists. Most trials (n = 11, 37.9%) compared two different full opioid options for less than 72 h (n = 24, 82.7%).

CONCLUSIONS

Robust trials are needed to determine which multimodal analgesic combination will optimise patient recovery after adult cardiac surgery. There is an urgent need to test and refine high-quality end-point measures.

IMPLICATIONS FOR PATIENT CARE

Adequate assessment precedes ideal pain treatment. The findings from this review reveal neither are sufficient, and the impact of suboptimal pain management on postoperative recovery is grossly underinvestigated.

IMPACT

The optimal combination of multimodal analgesics is unknown despite being recommended in best practice guidelines for enhanced recovery after cardiac surgery. Almost 30% of adults continue to experience ongoing pain up to a year after cardiac surgery, and findings from this review reveal a dearth of robust empirical evidence for optimal pain management, and heterogeneity in the way pain is assessed, measured and managed. This review provides a premise for robust trials focused on acute postoperative recovery in cardiac surgery and beyond.

REPORTING METHOD

This review was conducted in accordance with the PRISMA-P statement.

PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public contribution.

PROTOCOL REGISTRATION

PROSPERO: CRD42022355834.

Recommendations for fast-track extubation in adult cardiac surgery patients: a consensus statement

INTRODUCTION

Enhanced recovery after cardiac surgery in selected low-risk patients, has the potential to improve outcomes and reduce the burden of healthcare costs. Anesthesia-related challenges play a major role in the successful implementation of Enhanced Recovery After Surgery (ERAS) protocols, with particular emphasis placed on fast-track extubation. Acknowledging the importance of this practice, the Italian Association of Cardiac Anesthesiologists and Intensive Care (ITACTAIC) has advocated for an initiative to establish a consensus offering practical recommendations for fast-track extubation after adult cardiac surgery.

EVIDENCE ACQUISITION

After conducting a systematic review, all randomised control trials (RCTs) published between 2013 and 2023 were meticulously selected and analysed during a consensus meeting that involved statement voting.

EVIDENCE SYNTHESIS

Out of the 2268 publications identified using the search string, 60 RCTs were selected and classified into six groups, each evaluating specific interventions associated with extubation within 6 hours post-surgery. The authors examined 20 RCTs pertaining to loco-regional anesthesia, 19 analysing elements of general anesthesia, 12 focused on surgery-related aspects and techniques, three examining ventilation, two exploring anesthesia depth monitoring, and four addressing miscellaneous aspects. The expert panel approved 16 statements with 15 achieving high agreement and one obtaining moderate agreement. Finally a total of eight interventions were considered associated with fast-track extubation: parasternal block, erector spinae plane block, alpha agonist in the operating room (OR), opioids in the OR, dexmedetomidine in the intensive care unit (ICU), minimal invasive surgical access, anesthesia depth monitoring, adaptative support ventilation.

CONCLUSIONS

In the first consensus document ever published by a scientific society addressing practical recommendations for fast-track extubation post-cardiac surgery, the authors identified sixteen interventions commonly associated with fast-track extubation in selected adult cardiac surgery patients.

Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump

OBJECTIVE

To provide recommendations for enhanced recovery after cardiac surgery (ERACS) based on a multimodal perioperative medicine approach in adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity, and reducing the length of hospital stay.

DESIGN

A consensus committee of 20 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Société française de chirurgie thoracique et cardio-vasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence.

METHODS

Six fields were defined: (1) selection of the patient pathway and its information; (2) preoperative management and rehabilitation; (3) anaesthesia and analgesia for cardiac surgery; (4) surgical strategy for cardiac surgery and bypass management; (5) patient blood management; and (6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analyses were performed using the GRADE approach. The recommendations were formulated according to the GRADE methodology and then voted on by all the experts according to the GRADE grid method.

RESULTS

The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing cardiac surgery under cardiopulmonary bypass or off-pump. After three rounds of voting and several amendments, a strong agreement was reached for the 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1-); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2-); and 4 are expert opinions. Finally, no recommendations were provided for 3 questions.

CONCLUSIONS

Strong agreement existed among the experts to provide recommendations to optimise the complete perioperative management of patients undergoing cardiac surgery.

Original Research: Combating the Opioid Epidemic Through Nurse Use of Multimodal Analgesia: An Integrative Literature Review

BACKGROUND

Opioid misuse and addiction have become a national crisis. New pain management guidelines call for the use of multimodal analgesia to manage acute pain. In hospital settings, a clinical decision aid that emphasizes multimodal analgesia may improve nurses' use of this opioid-sparing strategy.

PURPOSE

This integrative review was conducted to provide nurses with evidence-based information on the opioid-sparing benefits of multimodal analgesia.

METHODS

A literature search was conducted using several electronic databases and Google Scholar. These initial searches yielded 136 articles of interest. Twenty-eight were selected for retrieval and in-depth appraisal; of these, 13 met all inclusion criteria.

RESULTS

Of the 13 reviewed studies, six were randomized controlled trials, six were retrospective cohort or population-based studies, and one was a qualitative study. Overall, the findings provided strong evidence that multimodal analgesia is effective in managing acute pain in surgical patients while reducing opioid requirements. Several studies also found that multimodal analgesia was associated with shorter hospital lengths of stay.

CONCLUSIONS

With the appropriate tools and education, nurses can make the transition from traditional opioids to multimodal analgesia strategies. In so doing, they can have a significant positive impact on the opioid epidemic. Hospital leaders must address nursing practice regarding the use of opioids alone versus multimodal analgesia for the management of acute pain. Clinical decision tools such as the Michigan Opioid Safety Score may help nurses adopt new acute pain management guidelines. Further research regarding nursing practice and the opioid epidemic is needed.

Nonopioid Analgesics in Postoperative Pain Management After Cardiac Surgery

Opioid analgesia is still considered the standard of practice for cardiac surgery. In recent years, combinations of several nonnarcotic analgesics and regional analgesia have shown promise in restricting opioid use during and after cardiac surgery. Ketamine infusion, dexmedetomidine infusion, acetaminophen, ketorolac, and gabapentin are useful adjuvants in cardiac anesthesia practice and have opioid-sparing properties. The beneficial effects of nonnarcotic multimodal analgesia on intraoperative stress response, recovery profile, postoperative pain, and persistent opioid use after cardiac surgery are yet to be established, and further randomized clinical trials are required.

Endogenous opiates and behavior: 2017

This paper is the fortieth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2017 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Non-opioid analgesics as adjuvants to opioid for pain management in adult patients in the ICU: A systematic review and meta-analysis

PURPOSE

To identify the impact of non-opioid analgesics as adjuvants to opioid on opioid consumption and its side effects, as well as the analgesic effectiveness in adult patients in the ICU.

METHODS

Only randomized clinical trials using non-opioid analgesics for analgesia in the ICU were included. Pooled analyses with 95% CI were determined.

RESULTS

Twelve studies (mainly surgical and Guillain-Barre syndrome patients) were included. Non-opioid analgesics as adjuvants to opioid were associated with a significant reduction in the consumption of opioids when compared with opioid use alone at Day 1 (MD -15.40; 95% CI -22.41 to -8.39; P < .001) and Day 2 (MD -22.93; 95% CI -27.70 to -18.16; P < .001). Non-opioid analgesics as adjuvants to opioid were associated with a significantly lower incidence of nausea and vomiting when compared with opioid use alone (RR 0.46; 95% CI 0.30 to 0.68; P < .001). Non-opioid analgesics as adjuvants to opioid significantly decreased the pain score at Day 1 (MD -0.68; 95% CI -1.28 to -0.08; P = .03) and Day 2 (MD -1.36; 95% CI -2.47 to -0.24; P = .02).

CONCLUSIONS

Non-opioid analgesics as adjuvants to opioid reduced the consumption and the side effects of opioids in adult surgical and Guillain-Barre syndrome patients in the ICU.

TRIAL REVIEW REGISTRATION

PROSPERO international prospective register of systematic reviews on January 23, 2017, registration number CRD42017055768.

Effect on Morphine Requirement of Early Administration of Oral Acetaminophen vs. Acetaminophen/Tramadol Combination in Acute Pain

OBJECTIVES

To evaluate the effect on opioid requirement of pain treatment starting at triage, and to evaluate satisfaction in emergency department (ED) patients with acute pain.

METHODS

This is a single-blind, randomized, prospective study conducted in the ED. The included patients were randomly assigned to single oral doses of placebo, acetaminophen, or a tramadol/acetaminophen combination. Protocol treatment was given at triage. The primary outcome was the need for rescue morphine during ED stay. The secondary outcome included patient satisfaction, ED length of stay, and percentage of patients discharged from the ED with a VAS score of <30.

RESULTS

We included 1,485 patients: 496 patients in the placebo group, 497 in the acetaminophen group, and 492 in the tramadol/acetaminophen combination group. The groups were similar regarding demographic and clinical characteristics and baseline VAS pain scores. Rescue morphine was significantly decreased in the tramadol/acetaminophen combination group compared to that in the placebo and acetaminophen groups (11.5%, 23.2%, and 18.9%, respectively; P = 0.03). Patient satisfaction was higher in the tramadol/acetaminophen combination group (77% vs. 69% in the acetaminophen group and 68% in the placebo group). A VAS score of <30 was observed in 84% of patients in the placebo group, 83% in the acetaminophen group, and 87% in the tramadol/acetaminophen combination group (P = 0.01 between the acetaminophen group and tramadol/acetaminophen combination group). The ED length of stay was 60 minutes for the acetaminophen group and tramadol/acetaminophen combination group and 71 minutes for the placebo group (P = 0.04).

CONCLUSION

Oral tramadol/acetaminophen combination administered early in triage was associated with a decrease in intravenous morphine requirement and increase in satisfaction among ED patients with acute pain when compared with patients taking acetaminophen. No significant increase in side effects was found. This intervention may be considered in EDs with an aim of similar benefits.

[Consensus statement on the use of acetaminophen/tramadol in patients with moderate-severe pain]

OBJECTIVES

To present recommendations on the use of the paracetamol/tramadol (P/T) combination in patients with moderate-intense pain based on best evidence and experience.

METHODS

The method of nominal groups and Delphi was followed, and supported by a systematic literature review (SLR). A multidisciplinary panel of 12 experts in pain management was selected. In the first nominal group meeting, the aim, scope, users, and sections of the consensus document, were defined, along with the preliminary general recommendations. For the SLR, the inclusion and exclusion criteria, as well as the search strategies, were defined. Two reviewers selected and analysed the articles. This evidence was discussed in a second nominal group meeting, and definitive recommendations were developed. For each recommendation, the evidence levels and grade of recommendation grades were classified according to the Oxford model, and the grade according to the Delphi technique. It was defined as an agreement if at least 70% of the participants scored ≥7 for each recommendation (1=total disagreement to 10=total agreement).

RESULTS

A total of 20 recommendations were produced, which covered general aspects, such as the assessment of pain, and those specific to P/T management. These latter included the indications of the P/T combination (patient profile, dosing, prescription, formulations), risk management (contraindications, precautions, interactions, concomitant use with other medications, follow-up, special situations), and patient education.

CONCLUSIONS

These recommendations attempt to resolve any of the routine clinical questions, and help in the making of decisions on the use of the P/T combination in patients with moderate-intense pain.