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Schnabel A, Carstensen VA, Lohmöller K, Vilz TO, Willis MA, Weibel S, Freys SM, Pogatzki-Zahn EM. Perioperative pain management with regional analgesia techniques for visceral cancer surgery: A systematic review and meta-analysis. J Clin Anesth 2024; 95:111438. [PMID: 38484505 DOI: 10.1016/j.jclinane.2024.111438] [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: 08/14/2023] [Revised: 01/25/2024] [Accepted: 03/01/2024] [Indexed: 04/29/2024]
Abstract
STUDY OBJECTIVE Regional analgesia following visceral cancer surgery might provide an advantage but evidence for best treatment options related to risk-benefit is unclear. DESIGN Systematic review of randomized controlled trials (RCT) with meta-analysis and GRADE assessment. SETTING Postoperative pain treatment. PATIENTS Adult patients undergoing visceral cancer surgery. INTERVENTIONS Any kind of peripheral (PRA) or epidural analgesia (EA) with/without systemic analgesia (SA) was compared to SA with or without placebo treatment or any other regional anaesthetic techniques. MEASUREMENTS Primary outcome measures were postoperative acute pain intensity at rest and during activity 24 h after surgery, the number of patients with block-related adverse events and postoperative paralytic ileus. MAIN RESULTS 59 RCTs (4345 participants) were included. EA may reduce pain intensity at rest (mean difference (MD) -1.05; 95% confidence interval (CI): -1.35 to -0.75, low certainty evidence) and during activity 24 h after surgery (MD -1.83; 95% CI: -2.34 to -1.33, very low certainty evidence). PRA likely results in little difference in pain intensity at rest (MD -0.75; 95% CI: -1.20 to -0.31, moderate certainty evidence) and pain during activity (MD -0.93; 95% CI: -1.34 to -0.53, moderate certainty evidence) 24 h after surgery compared to SA. There may be no difference in block-related adverse events (very low certainty evidence) and development of paralytic ileus (very low certainty of evidence) between EA, respectively PRA and SA. CONCLUSIONS Following visceral cancer surgery EA may reduce pain intensity. In contrast, PRA had only limited effects on pain intensity at rest and during activity. However, we are uncertain regarding the effect of both techniques on block-related adverse events and paralytic ileus. Further research is required focusing on regional analgesia techniques especially following laparoscopic visceral cancer surgery.
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Affiliation(s)
- Alexander Schnabel
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Vivian A Carstensen
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Katharina Lohmöller
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Tim O Vilz
- Department of General, Visceral, Thorax and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Maria A Willis
- Department of General, Visceral, Thorax and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Stephanie Weibel
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Stephan M Freys
- Department of Surgery, DIAKO Ev. Diakonie-Krankenhaus Bremen, Bremen, Germany
| | - Esther M Pogatzki-Zahn
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany.
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Continuous transversus abdominis plane infusion via surgically inserted catheter for postoperative analgesia after abdominal aortic surgery by retroperitoneal approach: TAPCACAO study. Ann Vasc Surg 2022; 86:104-110. [PMID: 35809742 DOI: 10.1016/j.avsg.2022.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/13/2022] [Accepted: 05/18/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The purpose of our study was to evaluate the analgesic properties of continuous transversus abdominis plane (TAP) infusion with ropivacaine compared to placebo for postoperative analgesia in elective surgery of the abdominal aorta by retroperitoneal exposure. METHOD We conducted a prospective, single-center, randomized, double-blind study comparing a group of patients with a TAP catheter undoing ropivacaine infusion with a placebo group. Patients received a left retroperitoneal pararectal exposure for abdominal aortic surgery. A continuous infusion catheter was placed under visual control by the surgeon before closure and removed after 48 hours. All patients had postoperative patient-controlled analgesia with morphine. The primary endpoint was morphine consumption during the first 24 hours. RESULTS The analysis included 25 patients in the placebo group and 24 in the ropivacaine group. The average morphine consumption during the first 24 hours was significantly different, with 31 ± 16 mg in the ropivacaine group and 41 ± 17 mg in the placebo group (p = 0.019). At 48 hours, morphine consumption was still lower in the ropivacaine group (42 ± 26 mg) than in the placebo group (64 ± 25 mg) (p = 0.003). The opioid narcotic-related side effects of opioid infusion (postoperative nausea and vomiting, constipation) and length of hospital stay were similar in both populations. CONCLUSION Our study showed that continuous TAP block with ropivacaine via surgically inserted catheter significantly decreased morphine consumption at 24 and 48 hours after elective abdominal aortic surgery by retroperitoneal exposure.
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Handayani E, Widiyanto P, Pratidina ESG. Waterproof dressing combined with sodium chloride to promote healing in acute wounds: a case report from an Indonesian hospital. Br J Community Nurs 2022; 27:S34-S40. [PMID: 35274989 DOI: 10.12968/bjcn.2022.27.sup3.s34] [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: 11/11/2022]
Abstract
In this case study, the wound healing process of a patient who had undergone an appendectomy and whose wound was treated with waterproof dressing was analysed, and the coverage of granulation tissue was tracked. This study aimed to re-evaluate the use of waterproof dressing, combined with sodium chloride, on acute wounds in an Indonesian hospital. Data were collected and evaluated through the use of the Nursing Outcomes Classification (NOC) observation method. A waterproof dressing and sodium chloride (NaCl) were administered once every 2 days to promote wound healing. After three rounds (14 days) of using waterproof dressing, granulation tissue formed over the surface of the wound base. The end result of healing by primary intention was complete return to function, with minimal scarring and loss of skin appendages. Waterproof dressing was considered to be effective and characterised by the formation of 93.2% granulation tissue; epithelialisation was observed covering between 75-100% of the wound area. No complications occurred during the intervention.
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Affiliation(s)
- Estrin Handayani
- Nursing Lecturer at the Department of Medical Surgical Nursing, Faculty of Health Sciences, Universitas Muhammadiyah Magelang, Indonesia
| | - Puguh Widiyanto
- Nursing Lecturer at the Department of Nursing, Faculty of Health Sciences, Universitas Muhammadiyah Magelang, Indonesia
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Updates on Wound Infiltration Use for Postoperative Pain Management: A Narrative Review. J Clin Med 2021; 10:jcm10204659. [PMID: 34682777 PMCID: PMC8537195 DOI: 10.3390/jcm10204659] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/03/2021] [Accepted: 10/08/2021] [Indexed: 12/29/2022] Open
Abstract
Local anesthetic wound infiltration (WI) provides anesthesia for minor surgical procedures and improves postoperative analgesia as part of multimodal analgesia after general or regional anesthesia. Although pre-incisional block is preferable, in practice WI is usually done at the end of surgery. WI performed as a continuous modality reduces analgesics, prolongs the duration of analgesia, and enhances the patient’s mobilization in some cases. WI benefits are documented in open abdominal surgeries (Caesarean section, colorectal surgery, abdominal hysterectomy, herniorrhaphy), laparoscopic cholecystectomy, oncological breast surgeries, laminectomy, hallux valgus surgery, and radical prostatectomy. Surgical site infiltration requires knowledge of anatomy and the pain origin for a procedure, systematic extensive infiltration of local anesthetic in various tissue planes under direct visualization before wound closure or subcutaneously along the incision. Because the incidence of local anesthetic systemic toxicity is 11% after subcutaneous WI, appropriate local anesthetic dosing is crucial. The risk of wound infection is related to the infection incidence after each particular surgery. For WI to fully meet patient and physician expectations, mastery of the technique, patient education, appropriate local anesthetic dosing and management of the surgical wound with “aseptic, non-touch” technique are needed.
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Mariano KCF, Papini JZB, de Faria NC, Heluany DNC, Botega ALL, Cereda CMS, de Paula E, Tófoli GR, de Araujo DR. Ropivacaine-Loaded Poloxamer Binary Hydrogels for Prolonged Regional Anesthesia: Structural Aspects, Biocompatibility, and Pharmacological Evaluation. BIOMED RESEARCH INTERNATIONAL 2021; 2021:7300098. [PMID: 34568494 PMCID: PMC8460376 DOI: 10.1155/2021/7300098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/11/2021] [Accepted: 08/21/2021] [Indexed: 11/17/2022]
Abstract
This study reports the development of thermosensitive hydrogels for delivering ropivacaine (RVC), a wide clinically used local anesthetic. For this purpose, poloxamer- (PL-) based hydrogels were synthesized for evaluating the influence of polymer concentration, hydrophilic-lipophilic balances, and binary system formation on biopharmaceutical properties and pharmacological performance. Transition temperatures were shifted, and rheological analysis revealed a viscoelastic behavior with enhanced elastic/viscous modulus relationship (G'/G " = 1.8 to 22 times), according to hydrogel composition and RVC incorporation. The RVC release from PL407 and PL407/338 systems followed the Higuchi model (R 2 = 0.923-0.989), indicating the drug diffusion from hydrogels to the medium. RVC-PL hydrogels were potentially biocompatible evoking low cytotoxic effects (in fibroblasts and Schwann cells) and mild/moderate inflammation signs on sciatic nerve nearby histological evaluation. In vivo pharmacological assays demonstrated that PL407 and PL407/338 evoked differential analgesic effects, by prolonging the sensory blockade duration up to ~340 and 250 min., respectively. All those results highlighted PL407 and PL407/338 as promising new strategies for sustaining analgesic effects during the postoperative period.
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Affiliation(s)
| | | | | | | | | | - Cíntia Maria Saia Cereda
- São Leopoldo Mandic Faculty, São Leopoldo Mandic Research Institute, Campinas, São Paulo, Brazil
| | - Eneida de Paula
- Department of Biochemistry, State University of Campinas, Campinas, São Paulo, Brazil
| | - Giovana Radomille Tófoli
- São Leopoldo Mandic Faculty, São Leopoldo Mandic Research Institute, Campinas, São Paulo, Brazil
| | - Daniele Ribeiro de Araujo
- Human and Natural Sciences Center, Federal University of ABC, Santo André, SP, Brazil
- Drugs and Bioactives Delivery Systems Research Group–SISLIBIO, Federal University of ABC, Av. dos Estados, 5001 Bl. A, T3, Lab. 503-3. Bangú, Santo André, SP, Brazil
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Krunkaityte U, Razlevice I, Lukosiene L, Macas A, Malcius D. Efficacy of postoperative pain management using patient-controlled wound infusion method after laparotomy in children: Three cases. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2021. [DOI: 10.1016/j.epsc.2021.101973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Lee JE, Park YJ, Lee JW. Ropivacaine continuous wound infusion after mastectomy with immediate autologous breast reconstruction: A retrospective observational study. Medicine (Baltimore) 2021; 100:e26337. [PMID: 34128878 PMCID: PMC8213328 DOI: 10.1097/md.0000000000026337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 05/25/2021] [Indexed: 11/26/2022] Open
Abstract
Continuous wound infusion usually provides postoperative analgesia as a multimodal analgesia with systemic opioid use. When continuous wound infusion of local anesthetics (LA) supports successful postoperative analgesia without systemic opioid use, the side effects of opioid can be reduced. Nevertheless, continuous wound infusion after mastectomy with immediate autologous breast reconstruction leads to concerns about wound healing. This study evaluated analgesic effects and wound healing conditions of continuous wound infusion of LA compared with opioid-based, intravenous patient-controlled analgesia (IV PCA) in mastectomy with immediate autologous breast reconstruction.This retrospective observational study included females, aged between 33 and 67 years, who underwent mastectomy with immediate autologous breast reconstruction. Sixty-five patients were enrolled. The eligible patients were placed into 2 groups for managing postoperative pain, one used continuous wound infusion with 0.5% ropivacaine (ON-Q, n = 32) and the other used a fentanyl-based IV PCA (IV PCA, n = 33). Using the electronic medical record system, the postoperative recovery profiles were examined over 5 days using a visual analogue scale (VAS), incidence of postoperative nausea and vomiting (PONV), incidence of sleep disturbance, frequency of rescue analgesic use, analgesia-related adverse events, length of hospital stay, and degree of patient satisfaction. The condition of the surgical wound was observed for 1 year after surgery.The primary endpoint was the intensity of pain at 6 hours after surgery. The VAS was comparable between the groups (P > .05). Although recovery profiles and the degree of patient satisfaction were similar between the groups, the incidence of PONV was significantly lower in the ON-Q group than in the IV PCA group on the day of surgery and postoperative day 1. No patients had severe wound complications. The satisfaction score of analgesia in the ON-Q group was comparable with that of the patients in the IV PCA group.This study demonstrates that single use of continuous wound infusion showed comparable analgesia with fentanyl-based IV PCA in patients who underwent mastectomy with immediate autologous breast reconstruction. Furthermore, the continuous infusion of LA directly on the surgical site did not significantly affect wound healing.
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Affiliation(s)
| | | | - Jeong Woo Lee
- Department of Plastic and Reconstructive Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea
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Afshan G, Khan RI, Ahmed A, Siddiqui AS, Rehman A, Raza SA, Kerai R, Mustafa K. Post-operative pain management modalities employed in clinical trials for adult patients in LMIC; a systematic review. BMC Anesthesiol 2021; 21:160. [PMID: 34034672 PMCID: PMC8152022 DOI: 10.1186/s12871-021-01375-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 05/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Unrelieved postoperative pain afflicts millions each year in low and middle income countries (LMIC). Despite substantial advances in the study of pain, this area remains neglected. Current systematic review was designed to ascertain the types of clinical trials conducted in LMIC on postoperative pain management modalities over the last decade. METHODS A comprehensive search was performed in June 2019 on PubMed, Cochrane Library, CINAHL Plus, and Web of Science databases to identify relevant trials on the management of postoperative pain in LMIC. Out of 1450 RCTs, 108 studies were reviewed for quality evidence using structured form of critical appraisal skill program. Total of 51 clinical trials were included after applying inclusion/exclusion criteria. RESULTS Results are charted according to the type of surgery. Eleven trials on laparoscopic cholecystectomy used multimodal analgesia including some form of regional analgesia. Different analgesic modalities were studied in 4 trials on thoracotomy, but none used multimodal approach. In 11 trials on laparotomy, multimodal analgesia was employed along with the studied modalities. In 2 trials on hysterectomy, preemptive pregabalin or gabapentin were used for reduction in rescue analgesia. In 13 trials on breast surgical procedures and 10 on orthopaedic surgery, multimodal analgesia was used with some form of regional analgesia. CONCLUSION We found that over the past 10 years, clinical trials for postoperative pain modalities have evolved in LMIC according to the current postoperative pain management guidelines i.e. multi-modal approach with some form of regional analgesia. The current review shows that clinical trials were conducted using multimodal analgesia including but not limited to some form of regional analgesia for postoperative pain in LMIC however this research snapshot (of only three countries) may not exactly reflect the clinical practices in all 47 countries. Post Operative Pain Management Modalities Employed in Clinical Trials for Adult Patients in LMIC; A Systematic Review.
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Affiliation(s)
- Gauhar Afshan
- Department of Anaesthesiology, 2nd floor Private Wing, Aga Khan University, P.O. Box 3500, Stadium Road, Karachi, 74800, Pakistan.
| | - Robyna Irshad Khan
- Department of Anaesthesiology, 2nd floor Private Wing, Aga Khan University, P.O. Box 3500, Stadium Road, Karachi, 74800, Pakistan
| | - Aliya Ahmed
- Department of Anaesthesiology, 2nd floor Private Wing, Aga Khan University, P.O. Box 3500, Stadium Road, Karachi, 74800, Pakistan
| | - Ali Sarfraz Siddiqui
- Faculty of Health Sciences, Aga Khan University, P.O. Box 3500, Stadium Road, Karachi, Pakistan
| | - Azhar Rehman
- Faculty of Health Sciences, Aga Khan University, P.O. Box 3500, Stadium Road, Karachi, Pakistan
| | - Syed Amir Raza
- Faculty of Health Sciences, Aga Khan University, P.O. Box 3500, Stadium Road, Karachi, Pakistan
| | - Rozina Kerai
- Department of Anaesthesiology, 2nd floor Private Wing, Aga Khan University, P.O. Box 3500, Stadium Road, Karachi, 74800, Pakistan
| | - Khawaja Mustafa
- Department of Anaesthesiology, 2nd floor Private Wing, Aga Khan University, P.O. Box 3500, Stadium Road, Karachi, 74800, Pakistan
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ElSharkawy RA, Farahat TE, Abdelwahab K. Continuous preperitoneal infusion of ropivacaine for postoperative analgesia in patients undergoing major abdominal or pelvic surgeries. A prospective controlled randomized study. J Anaesthesiol Clin Pharmacol 2020; 36:195-200. [PMID: 33013034 PMCID: PMC7480288 DOI: 10.4103/joacp.joacp_333_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 05/21/2019] [Accepted: 05/25/2019] [Indexed: 11/04/2022] Open
Abstract
Background and Aims This study was conducted to compare continuous preperitoneal infusion (CPI) with continuous epidural infusion (CEI) of ropivacaine for pain relief and effect on pulmonary functions after major abdominal and pelvic surgeries. Material and Methods One hundred patients were randomized into two equal groups. Patients in CPI group (n = 50) received analgesia by continuous infusion of 0.2% ropivacaine, whereas those in the CEI group (n = 50) received continuous epidural infusion of 0.2% ropivacaine. The primary outcome was the first request of analgesia. The secondary outcome was the influence on the pulmonary functions. Results The time for the first request of analgesia was longer in the CPI group compared with that in the CEI group (7.3 ± 1.6 vs. 4.1 ± 1.1 h with P value = 0.001). The daily dose of morphine was lesser in CPI versus CEI group (11.3 ± 1 against 17.4 ± 0.9 mg). The pulmonary function tests were comparable except peak expiratory flow rate, which was better in CPI (170 ± 5.4) than CEI group (148.1 ± 5.8; with P value = 0.001). Conclusion Continuous preperitoneal infusion provides a superior analgesic effect than the continuous epidural infusion as regards delayed first request of analgesia, better pain scores, lesser usage of additional analgesics with better respiratory function.
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Affiliation(s)
| | - Tamer Elmetwally Farahat
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Egypt
| | - Khaled Abdelwahab
- Department of General Surgery, Faculty of Medicine, Mansoura University, Egypt
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Bailey JG, Morgan CW, Christie R, Ke JXC, Kwofie MK, Uppal V. Continuous peripheral nerve blocks compared to thoracic epidurals or multimodal analgesia for midline laparotomy: a systematic review and meta-analysis. Korean J Anesthesiol 2020; 74:394-408. [PMID: 32962328 PMCID: PMC8497905 DOI: 10.4097/kja.20304] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/22/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Continuous peripheral nerve blocks (CPNBs) have been investigated to control pain for abdominal surgery via midline laparotomy while avoiding the adverse events of opioid or epidural analgesia. The review compiles the evidence comparing CPNBs to multimodal and epidural analgesia. METHODS We conducted a systematic review using broad search terms in MEDLINE, EMBASE, Cochrane. Primary outcomes were pain scores and cumulative opioid consumption at 48 hours. Secondary outcomes were length of stay and postoperative nausea and vomiting (PONV). We rated the quality of the evidence using Cochrane and GRADE recommendations. The results were synthesized by meta-analysis using Revman. RESULTS Our final selection included 26 studies (1,646 patients). There was no statistically significant difference in pain control comparing CPNBs to either multimodal or epidural analgesia (low quality evidence). Less opioids were consumed when receiving epidural analgesia than CPNBs (mean difference [MD]: -16.13, 95% CI [-32.36, 0.10]), low quality evidence) and less when receiving CPNBs than multimodal analgesia (MD: -31.52, 95% CI [-42.81, -20.22], low quality evidence). The length of hospital stay was shorter when receiving epidural analgesia than CPNBs (MD: -0.78 days, 95% CI [-1.29, -0.27], low quality evidence) and shorter when receiving CPNBs than multimodal analgesia (MD: -1.41 days, 95% CI [-2.45, -0.36], low quality evidence). There was no statistically significant difference in PONV comparing CPNBs to multimodal (high quality evidence) or epidural analgesia (moderate quality evidence). CONCLUSIONS CPNBs should be considered a viable alternative to epidural analgesia when contraindications to epidural placement exist for patients undergoing midline laparotomies.
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Affiliation(s)
- Jonathan G Bailey
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Catherine W Morgan
- Dalhousie University Faculty of Medicine, Halifax, Nova Scotia, Canada.,Department of Family Medicine, McGill University Health Centre, Unité de médecine familiale, Montreal, Quebec, Canada
| | - Russell Christie
- Department of Anesthesiology and Pain Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | - Janny Xue Chen Ke
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - M Kwesi Kwofie
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Vishal Uppal
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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We Asked the Experts: Reducing Opioid Prescription After Abdominal Surgery; A Place for Nerve Block and Wound Infiltration. World J Surg 2020; 45:678-680. [PMID: 32915280 DOI: 10.1007/s00268-020-05777-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2020] [Indexed: 01/07/2023]
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Kone LB, Kunda NM, Tran TB, Maker AV. Surgeon-Placed Continuous Wound Infusion Pain Catheters Markedly Decrease Narcotic Use and Improve Outcomes After Pancreatic Tumor Resection. Ann Surg Oncol 2020; 28:2287-2295. [PMID: 32880771 DOI: 10.1245/s10434-020-09067-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 08/09/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Pancreatectomy results in significant postoperative pain and typically requires opioid analgesia for adequate pain control. Local anesthetics may decrease postoperative pain and opioid requirements but can be limited by onset of action, duration of effect, and inability to titrate dosing after administration. This can be overcome by surgeon placement of tunneled peri-incisional catheters with continuous wound infusion (CWI). METHODS This retrospective cohort study analyzed patients undergoing open pancreatic tumor resection. All the patients received patient-controlled analgesia (PCA), enabling an objective comparison of opioid requirements, and underwent the same recovery pathway. The patients received CWI (n = 45), PCA alone (n = 11), or epidural analgesia (EA) (n = 9). The primary outcome was total opioid use in terms of intravenous morphine milligram equivalents (MMEs) and patient-reported pain scores on a numeric rating scale (NRS) of 0 to 10. RESULTS No differences in baseline patient or tumor characteristics were observed. In both the uni- and multivariate analyses, CWI was associated with lower opioid use than PCA (MME, 83 vs 207 mg; p = 0.004) or EA (MME, 83 vs 156 mg; p < 0.001) without having a negative impact on pain scores. Furthermore, CWI was associated with a greater percentage of time that patients experienced optimal pain control (NRS, ≤ 4: 63% vs 50%; p = 0.033) and a shorter time to PCA independence (4.0 vs 4.9 days; p = 0.004) than PCA alone. In addition, CWI was associated with earlier ambulation [EA vs CWI: odds ratio (OR), 0.05; p = 0.021], improved spirometry performance (CWI vs PCA: regression coefficient (coef), 267; p = 0.013), and earlier urinary catheter removal (EA vs CWI: coef, 1.30; p = 0.013). The findings showed no differences in time to return of bowel function, antiemetic use, or hospital length of stay. CONCLUSIONS After open pancreatic tumor resection, CWI is safe and associated with decreased opioid requirements and improved functional outcomes without a negative impact on pain scores, supporting its potential for preferred use over PCA or EA alone.
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Affiliation(s)
- Lyonell B Kone
- Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, Chicago, IL, USA.,Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Nicholas M Kunda
- Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, Chicago, IL, USA.,Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Thuy B Tran
- Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, Chicago, IL, USA.,Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Ajay V Maker
- Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, Chicago, IL, USA. .,Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA.
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Zuckerman LM, Frames WL, Mirshahidi HR, Williams NL, Shields TG, Otoukesh S, Mirshahidi S. Antiproliferative effect of bupivacaine on patient-derived sarcoma cells. Mol Clin Oncol 2020; 13:7. [PMID: 32754321 PMCID: PMC7393627 DOI: 10.3892/mco.2020.2077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 05/26/2020] [Indexed: 12/15/2022] Open
Abstract
Sarcomas are rare tumors with limited treatment options. Although chemotherapy is standard for certain subtypes, overall survival has not improved in several decades. Bupivacaine has been shown to induce apoptosis and prevent cell growth in multiple different types of malignancies but has not been studied in sarcoma. The current study evaluated the effects of bupivacaine on multiple patient-derived sarcoma cells and a commercial sarcoma cell line. Multiple patient-derived sarcoma cell subtypes and a commercial synovial cell sarcoma cell line were exposed to bupivacaine for different durations and at different concentrations. The patient-derived cells included a high-grade conventional osteosarcoma, a high-grade undifferentiated pleomorphic sarcoma of bone, and a high-grade synovial sarcoma. Flow cytometry and an MTT assay were used to evaluate whether a treatment effect was observed. Treatment of all the subtypes of sarcomas in this study with bupivacaine demonstrated a time- and dose-dependent increase in apoptosis and decrease in cell viability. A cell viability assay demonstrated that the IC50 was between 0.04 and 0.05% and that the treatment effect occurred at clinically relevant doses in vitro. Bupivacaine was toxic to both the patient-derived cells and the commercial cell line at doses commonly used in the clinical setting. These findings provide a foundation for further in vivo studies to evaluate whether these effects will translate to the clinical setting. Although further research is necessary, bupivacaine shows promise as not only an adjunct for pain management but as a treatment modality for sarcoma.
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Affiliation(s)
- Lee M Zuckerman
- Department of Surgery, Division of Orthopaedic Surgery, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - William L Frames
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA 92354, USA
| | - Hamid R Mirshahidi
- Division of Hematology and Oncology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA
| | - Nadine L Williams
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA 92354, USA
| | - Troy G Shields
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA 92354, USA
| | - Salman Otoukesh
- Division of Hematology and Oncology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA
| | - Saied Mirshahidi
- Loma Linda Cancer Center Biospecimen Laboratory, Loma Linda University Medical Center, Loma Linda, CA 92354, USA
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14
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Paladini G, Di Carlo S, Musella G, Petrucci E, Scimia P, Ambrosoli A, Cofini V, Fusco P. Continuous Wound Infiltration of Local Anesthetics in Postoperative Pain Management: Safety, Efficacy and Current Perspectives. J Pain Res 2020; 13:285-294. [PMID: 32099452 PMCID: PMC6999584 DOI: 10.2147/jpr.s211234] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/14/2020] [Indexed: 12/18/2022] Open
Abstract
Local infiltration and continuous infusion of surgical wound with anesthetics are parts of multimodal analgesia for postoperative pain control. The techniques, given the simplicity of execution that does not increase the timing of the intervention and does not require additional technical skills, are applied in several kinds of surgeries. The continuous wound infiltration can be used for days and a variety of continuous delivery methods can be chosen, including patient-controlled analgesia, continuous infusion or intermittent bolus. The purpose of this narrative review is to analyze the literature, in particular by researching the safety, efficacy and current perspectives of continuous wound infiltration for postoperative pain management in different surgical settings. We have identified 203 articles and 95 of these have been taken into consideration: 17 for the lower limb surgery; 7 for the upper limb surgery, 51 for the laparotomy/laparoscopic surgery of the abdominopelvic area, 13 studies regarding breast surgery and 7 for cardiothoracic surgery. The analysis of these studies reveals that the technique has a variable effectiveness based on the type of structure involved: it is better in structures rich in subcutaneous and connective tissue, while the effectiveness is limited in anatomic districts with a greater variability of innervation. However, regardless the heterogeneity of results, a general reduction in pain intensity and in opioid consumption has been observed with continuous wound infiltration: it is an excellent analgesic technique that can be included in the multimodal treatment of postoperative pain or represents a valid alternative when other options are contraindicated.
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Affiliation(s)
- Giuseppe Paladini
- Department of Anesthesia, Perioperative Medicine and Intensive Care Therapy, Filippo Del Ponte Women and Children's Hospital, ASST Sette Laghi, Varese, Italy
| | - Stefano Di Carlo
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti, Chieti, Italy
| | - Giuseppe Musella
- Department of Anesthesia, Perioperative Medicine and Intensive Care Therapy, Filippo Del Ponte Women and Children's Hospital, ASST Sette Laghi, Varese, Italy
| | - Emiliano Petrucci
- Department of Anesthesia and Intensive Care, San Salvatore Academic Hospital of L'Aquila, L'Aquila, Italy
| | - Paolo Scimia
- Department of Anesthesia and Intensive Care, ASUR Marche AV5, San Benedetto Del Tronto, Italy
| | - Andrea Ambrosoli
- Department of Anesthesia, Perioperative Medicine and Intensive Care Therapy, Filippo Del Ponte Women and Children's Hospital, ASST Sette Laghi, Varese, Italy
| | - Vincenza Cofini
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Pierfrancesco Fusco
- Department of Anesthesia and Intensive Care, San Salvatore Academic Hospital of L'Aquila, L'Aquila, Italy
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15
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Liang SS, Ying AJ, Affan ET, Kakala BF, Strippoli GFM, Bullingham A, Currow H, Dunn DW, Yeh ZY. Continuous local anaesthetic wound infusion for postoperative pain after midline laparotomy for colorectal resection in adults. Cochrane Database Syst Rev 2019; 10:CD012310. [PMID: 31627242 PMCID: PMC6953380 DOI: 10.1002/14651858.cd012310.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Colorectal resection through a midline laparotomy is a commonly performed surgical procedure to treat various bowel conditions. The typical postoperative hospital stay after this operation is 6 to 10 days. The main factors hindering early recovery and discharge are thought to include postoperative pain and delayed return of bowel function.Continuous infusion of a local anaesthetic into tissues surrounding the surgical incision via a multi-lumen indwelling wound catheter placed by the surgeon prior to wound closure may reduce postoperative pain, opioid consumption, the time to return of bowel function, and the length of hospital stay. OBJECTIVES To evaluate the efficacy and adverse events of continuous local anaesthetic wound infusion for postoperative pain after midline laparotomy for colorectal resection in adults. SEARCH METHODS We searched the CENTRAL, MEDLINE and Embase databases to January 2019 to identify trials relevant to this review. We also searched reference lists of relevant trials and reviews for eligible trials. Additionally, we searched two clinical trials registers for ongoing trials. SELECTION CRITERIA We considered randomised controlled trials (including non-standard designs) or quasi-randomised controlled trials comparing continuous wound infusion of a local anaesthetic versus a placebo or a sham after midline laparotomy for colorectal resection in adults. We did not compare continuous local anaesthetic wound infusion to other techniques, such as transverse abdominis plane block or thoracic epidural analgesia. We allowed non-randomised analgesic co-interventions carried out equally in the intervention and control groups. DATA COLLECTION AND ANALYSIS Two review authors independently identified trials for inclusion and assessed their quality using the Cochrane 'Risk of bias' tool. We extracted data using standardised forms, including pain at rest and on movement (10-point scale), opioid consumption via a patient-controlled analgesia (PCA) system (mg morphine equivalent), postoperative opioid-related adverse events, the time to rescue analgesia, the time to first flatus and to first bowel movement, the time to ambulation, the length of hospital stay, serious postoperative adverse events, and patient satisfaction. We quantitatively synthesised the data by meta-analysis. We summarised and graded the certainty of the evidence for critical outcomes using the GRADEpro tool and created a 'Summary of findings' table. MAIN RESULTS This review included six randomised controlled trials that enrolled a total of 564 adults undergoing elective midline laparotomy for colorectal resection comparing continuous wound infusion of a local anaesthetic to a normal saline placebo. Due to 23 post-randomisation exclusions, a total of 541 participants contributed data to the analysis of at least one outcome (local anaesthetic 268; control 273). Most participants were aged 55 to 65 years, with normal body mass index and low to moderate anaesthetic risk (American Society of Anesthesiologists class I-III). Random sequence generation, allocation concealment, and blinding were appropriately carried out in most trials. However, we had to downgrade the certainty of the evidence for most outcomes due to serious study limitations (risk of bias), inconsistency, indirectness, imprecision and reporting bias.Primary outcomesOn postoperative day 1, pain at rest (mean difference (MD) -0.59 (from 3.1), 95% confidence interval (CI) -1.12 to -0.07; 5 studies, 511 participants; high-certainty evidence), pain on movement (MD -1.1 (from 6.1), 95% CI -2.3 to -0.01; 3 studies, 407 participants; low-certainty evidence) and opioid consumption via PCA (MD -12 mg (from 41 mg), 95% CI -20 to -4; 6 studies, 528 participants; moderate-certainty evidence) were reduced in the local anaesthetic group compared to the control group.Secondary outcomesThere was a reduction in the time to first bowel movement (MD -0.67 from 4.4 days, 95% CI -1.17 to -0.17; 4 studies, 197 participants; moderate-certainty evidence) and the length of hospital stay (MD -1.2 from 7.4 days, 95% CI -2.0 to -0.3; 4 studies, 456 participants; high-certainty evidence) in the local anaesthetic group compared to the control group.There was no evidence of a difference in any serious postoperative adverse events until hospital discharge (RR 1.04, 95% CI 0.68 to 1.58; 6 studies, 541 participants; low-certainty evidence) between the two study groups. AUTHORS' CONCLUSIONS After elective midline laparotomy for colorectal resection, continuous wound infusion of a local anaesthetic compared to a normal saline placebo reduces postoperative pain at rest and the length of hospital stay, on the basis of high-certainty evidence. This means we are very confident that the effect estimates for these outcomes lie close to the true effects. There is moderate-certainty evidence to indicate that the intervention probably reduces opioid consumption via PCA and the time to first bowel movement. This means we are moderately confident that effect estimates for these outcomes are likely to be close to the true effects, but there is a possibility that they are substantially different. The intervention may reduce postoperative pain on movement, however, this conclusion is based on low-certainty evidence. This means our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect. There is low-certainty evidence to indicate that the intervention may have little or no effect on the rates of any serious postoperative adverse events until hospital discharge. High-quality randomised controlled trials to evaluate the intervention with a focus on important clinical and patient-centred outcomes are needed.
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Affiliation(s)
- Sophie S Liang
- Westmead HospitalDepartment of AnaesthesiaCnr Hawkesbury & Darcy RdsWestmeadNew South WalesAustralia2145
- The University of SydneySydney Medical SchoolSydneyNew South WalesAustralia2006
| | - Andrew J Ying
- Blacktown HospitalDepartment of Surgery18 Blacktown RdBlacktownNew South WalesAustralia2148
| | - Eshan T Affan
- The University of SydneySydney Medical SchoolSydneyNew South WalesAustralia2006
- Blacktown HospitalDepartment of Surgery18 Blacktown RdBlacktownNew South WalesAustralia2148
| | - Benedict F Kakala
- The University of SydneySydney Medical SchoolSydneyNew South WalesAustralia2006
- Westmead HospitalGeneral SurgeryCnr Darcy Rd & Bridge StWestmeadNew South WalesAustralia2145
| | - Giovanni FM Strippoli
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Alan Bullingham
- Westmead HospitalDepartment of AnaesthesiaCnr Hawkesbury & Darcy RdsWestmeadNew South WalesAustralia2145
- Blacktown HospitalDepartment of Anaesthesia18 Blacktown RdBlacktownNew South WalesAustralia2148
| | - Helen Currow
- Blacktown HospitalDepartment of Anaesthesia18 Blacktown RdBlacktownNew South WalesAustralia2148
- University of Western SydneySchool of MedicineLocked Bag 1797PenrithNew South WalesAustralia2751
| | - David W Dunn
- Blacktown HospitalDepartment of Surgery18 Blacktown RdBlacktownNew South WalesAustralia2148
| | - Zeigfeld Yu‐Ting Yeh
- Blacktown HospitalDepartment of Surgery18 Blacktown RdBlacktownNew South WalesAustralia2148
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16
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Preperitoneal or Subcutaneous Wound Catheters as Alternative for Epidural Analgesia in Abdominal Surgery. Ann Surg 2019; 269:252-260. [DOI: 10.1097/sla.0000000000002817] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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17
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De Gregori S, De Gregori M, Bloise N, Bugada D, Molinaro M, Filisetti C, Allegri M, Schatman ME, Cobianchi L. In vitro and in vivo quantification of chloroprocaine release from an implantable device in a piglet postoperative pain model. J Pain Res 2018; 11:2837-2846. [PMID: 30510443 PMCID: PMC6231440 DOI: 10.2147/jpr.s180163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background The pharmacokinetic properties and clinical advantages of the local anesthetic chloroprocaine are well known. Here, we studied the pharmacokinetic profile of a new hydrogel device loaded with chloroprocaine to investigate the potential advantages of this new strategy for postoperative pain (POP) relief. Materials and methods We performed both in vitro and in vivo analyses by considering plasma samples of four piglets receiving slow-release chloroprocaine. To quantify chloroprocaine and its inactive metabolite 4-amino-2-chlorobenzoic acid (ACBA), a HPLC–tandem mass spectrometry (HPLC-MS/MS) analytical method was used. Serial blood samples were collected over 108 hours, according to the exposure time to the device. Results Chloroprocaine was consistently found to be below the lower limit of quantification, even though a well-defined peak was observed in every chromatogram at an unexpected retention time. Concerning ACBA, we found detectable plasma concentrations between T0 and T12h, with a maximum plasma concentration (Cmax) observed 3 hours after the device application. In the in vitro analyses, the nanogel remained in contact with plasma at 37°C for 90 minutes, 3 hours, 1 day, and 7 days. Chloroprocaine Cmax was identified 1 day following exposure and Cmin after 7 days, respectively. Additionally, ACBA reached the Cmax following 7 days of exposure. Conclusion A thorough review of the literature indicates that this is the first study analyzing both in vivo and in vitro pharmacokinetic profiles of a chloroprocaine hydrogel device and is considered as a pilot study on the feasibility of including this approach to the management of POP.
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Affiliation(s)
- Simona De Gregori
- Clinical and Experimental Pharmacokinetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy,
| | - Manuela De Gregori
- Clinical and Experimental Pharmacokinetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy, .,Pain Therapy Service, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Study in Multidisciplinary Pain Research Group, Parma, Italy.,Young Against Pain Group, Parma, Italy
| | - Nora Bloise
- Department of Molecular Medicine, Centre for Health Technologies, INSTM UdR of Pavia, University of Pavia, Pavia, Italy.,Department of Occupational Medicine, Toxicology and Environmental Risks, Istituti Clinici Scientifici Maugeri, IRCCS, Lab of Nanotechnology, Pavia, Italy
| | - Dario Bugada
- Study in Multidisciplinary Pain Research Group, Parma, Italy.,Young Against Pain Group, Parma, Italy.,Emergency and Intensive Care Department - ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Mariadelfina Molinaro
- Clinical and Experimental Pharmacokinetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy,
| | | | - Massimo Allegri
- Study in Multidisciplinary Pain Research Group, Parma, Italy.,Anesthesia and Intensive Care Service, IRCCS MultiMedica Hospital, Sesto San Giovanni, Milano, Italy
| | - Michael E Schatman
- Study in Multidisciplinary Pain Research Group, Parma, Italy.,Research and Network Development, Boston Pain Care, Waltham, MA, USA.,Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Lorenzo Cobianchi
- General Surgery Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
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18
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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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19
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Mazy A, Gad M, Bedairy M. Preperitoneal postcesarean section bupivacaine analgesia: Comparison between dexamethasone and dexmedetomidine as adjuvants. Saudi J Anaesth 2018; 12:183-189. [PMID: 29628825 PMCID: PMC5875203 DOI: 10.4103/sja.sja_450_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: The peritoneal wound is frequently neglected during laparotomy. The preperitoneal local anesthetics and many adjuvants were effective for postcesarean analgesia. Analgesia may involve somatic and autonomic components. The preperitoneal bupivacaine and the promising adjuvants dexamethasone or dexmedetomidine were compared in this study. Patients and Methods: Sixty patients subjected to a cesarean section (CS) under general anesthesia divided into two groups using a bolus of preperitoneal bupivacaine 0.7 mg/kg with either 1ug/kg dexmedetomidine (Group P) or 8 mg dexamethasone (Group D). The time to the first analgesic request was the primary outcome. Results: There was a significantly prolonged time to the first analgesic request in the Group P than the Group D and less required preperitoneal injections in the Group P, also pain assessed by Numerical Rating Scale (NRS) was lower in the Group P than the Group D after 6 h postoperatively up to 24 h. Conclusions: Dexmedetomidine provided better analgesia than dexamethasone as an adjuvant to preperitoneal bupivacaine post-CS.
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Affiliation(s)
- Alaa Mazy
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mona Gad
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohamed Bedairy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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