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Buckley DN, Beattie WS. Dexamethasone and chronic postsurgical pain: the pendulum meets reductionistic thinking. Br J Anaesth 2024; 133:11-13. [PMID: 38744550 DOI: 10.1016/j.bja.2024.04.011] [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: 02/09/2024] [Revised: 04/04/2024] [Accepted: 04/15/2024] [Indexed: 05/16/2024] Open
Abstract
Reductionist thinking results in the bulk of anaesthesia trial designs being a single intervention to address what are in fact complex processes. The Perioperative Administration of Dexamethasone and Infection (PADDI) trial assessed the safety of a single preoperative dose of dexamethasone. Surprising to most, in the original report, a single dose of dexamethasone increased the incidence of the secondary outcome chronic postsurgical pain. Was this a chance finding or does dexamethasone increase chronic postsurgical pain? In an attempt to address this question, the PADDI investigators have now analysed this prespecified secondary outcome in two ways: as a substudy published earlier in this Journal, and as a retrospective analysis of the ENIGMA-II chronic pain database in this issue of the Journal. The PADDI investigators have now presented enough data to convince us that indeed a single dose of dexamethasone is safe and effective. However, the increase in chronic postsurgical pain seen in the original PADDI publication highlights the complexities, and the possible immunologic mechanisms, behind the genesis of chronic postsurgical pain. These publications from the PADDI group raise questions about other anti-inflammatory agents we use regularly for long-term postoperative pain management, and highlights the need for well-designed clinical trials to address this critically important patient-centred adverse functional outcome.
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Affiliation(s)
- D Norman Buckley
- Department of Anesthesia, Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - W Scott Beattie
- Department of Anesthesia and Pain Management, University Health Network, University of Toronto, Toronto, ON, Canada.
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Peyton PJ, Leslie K. The safety of nitrous oxide: glass half-full or half-empty? Br J Anaesth 2024:S0007-0912(24)00265-4. [PMID: 38816332 DOI: 10.1016/j.bja.2024.04.047] [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: 02/27/2024] [Revised: 04/18/2024] [Accepted: 04/19/2024] [Indexed: 06/01/2024] Open
Abstract
A systematic review of clinical trials confirms that including nitrous oxide in the gas mixture for general anaesthesia has minor short-term benefits and does not impact most patient safety outcomes. However, no risk-benefit analysis of nitrous oxide should ignore its known environmental effects. If continued nitrous oxide use is supported, strategies to minimise and monitor the contribution of medical nitrous oxide to global warming are vital.
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Affiliation(s)
- Philip J Peyton
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia; Department of Anaesthesia, Austin Health, Melbourne, VIC, Australia.
| | - Kate Leslie
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia; Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, VIC, Australia; Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
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Chen D, Yang H, Yang L, Tang Y, Zeng H, He J, Chen W, Qu Y, Hu Y, Xu Y, Liu D, Song H, Li Q. Preoperative psychological symptoms and chronic postsurgical pain: analysis of the prospective China Surgery and Anaesthesia Cohort study. Br J Anaesth 2024; 132:359-371. [PMID: 37953200 DOI: 10.1016/j.bja.2023.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND Both preoperative psychological symptoms and chronic postsurgical pain (CPSP) are prevalent conditions and major concerns among surgery patients, with inconclusive associations. METHODS Based on the China Surgery and Anaesthesia Cohort (CSAC), we recruited 8350 surgery patients (40-65 yr old) from two medical centres between July 2020 and March 2023. Patients with preoperative psychological symptoms (i.e. anxiety, depression, stress reaction, and poor sleep quality) were identified using corresponding well-established scales. We then examined the associations of individual preoperative psychological symptoms and major patterns of preoperative psychological symptoms (identified by k-means clustering analysis) with CPSP, and different pain trajectories within 3 months. Lastly, mediation analyses were conducted to elucidate the mediating role of surgery/anaesthesia-related factors and the presence of 1-month postoperative psychological symptoms on the studied associations. RESULTS We included 1302 (1302/8350, 15.6%) CPSP patients. When analysed separately, all studied preoperative psychological symptoms were associated with increased CPSP risk, with the most pronounced odds ratio noted for anxiety (1.52, 95% confidence interval [CI] 1.23-1.86). Compared with patients clustered in the minor symptom group, excess risk of CPSP and experiencing an increasing pain trajectory was increased among patients with preoperative psychological symptoms featured by sleep disturbances (odds ratio=1.46, 95% CI 1.25-1.70 for CPSP and 1.58, 95% CI 1.20-2.08 for increasing pain trajectory) and multiple psychological symptoms (1.84 [95% CI 1.48-2.28] and 4.34 [95% CI 3.20-5.88]). Mediation analyses revealed acute/subacute postsurgical pain and psychological symptoms existing 1 month after surgery as notable mediators of the observed associations. CONCLUSIONS The presence of preoperative psychological symptoms might individually or jointly increase the risk of chronic postsurgical pain or experiencing deterioration in pain trajectory. Interventions for managing acute/subacute postsurgical pain and psychological symptoms at 1 month after surgery might help reduce such risk. CLINICAL TRIAL REGISTRATION ChiCTR2000034039.
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Affiliation(s)
- Dongxu Chen
- Department of Anaesthesiology and West China Biomedical Big Data Centre, West China Hospital, Sichuan University, Chengdu, China; Laboratory of Anaesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, China; West China Biomedical Big Data Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Huazhen Yang
- West China Biomedical Big Data Centre, West China Hospital, Sichuan University, Chengdu, China; Med-X Center for Informatics, Sichuan University, Chengdu, China
| | - Lei Yang
- Department of Anaesthesiology and West China Biomedical Big Data Centre, West China Hospital, Sichuan University, Chengdu, China; Laboratory of Anaesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yuling Tang
- Department of Anaesthesiology and West China Biomedical Big Data Centre, West China Hospital, Sichuan University, Chengdu, China; Laboratory of Anaesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Huolin Zeng
- Department of Anaesthesiology and West China Biomedical Big Data Centre, West China Hospital, Sichuan University, Chengdu, China; Laboratory of Anaesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Junhui He
- Department of Anaesthesiology and West China Biomedical Big Data Centre, West China Hospital, Sichuan University, Chengdu, China; Laboratory of Anaesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Wenwen Chen
- West China Biomedical Big Data Centre, West China Hospital, Sichuan University, Chengdu, China; Med-X Center for Informatics, Sichuan University, Chengdu, China
| | - Yuanyuan Qu
- West China Biomedical Big Data Centre, West China Hospital, Sichuan University, Chengdu, China; Med-X Center for Informatics, Sichuan University, Chengdu, China
| | - Yao Hu
- West China Biomedical Big Data Centre, West China Hospital, Sichuan University, Chengdu, China; Med-X Center for Informatics, Sichuan University, Chengdu, China
| | - Yueyao Xu
- West China Biomedical Big Data Centre, West China Hospital, Sichuan University, Chengdu, China; Med-X Center for Informatics, Sichuan University, Chengdu, China
| | - Di Liu
- West China Biomedical Big Data Centre, West China Hospital, Sichuan University, Chengdu, China; Med-X Center for Informatics, Sichuan University, Chengdu, China; Sichuan University - Pittsburgh Institute, Sichuan University, Chengdu, China
| | - Huan Song
- West China Biomedical Big Data Centre, West China Hospital, Sichuan University, Chengdu, China; Med-X Center for Informatics, Sichuan University, Chengdu, China; Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavík, Iceland.
| | - Qian Li
- Department of Anaesthesiology and West China Biomedical Big Data Centre, West China Hospital, Sichuan University, Chengdu, China; Laboratory of Anaesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, China.
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4
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Hale J, Xu J, Wang D, Rodriguez-Patarroyo F, Bakal O, Kopac O, Yamak Altinpulluk E, Onal O, Brooker JE, Cruz M, Maurtua M, Agudelo-Jimenez R, Sessler DI, Turan A. Nitrous oxide for the treatment of complex regional pain syndrome: a randomized blinded trial. Reg Anesth Pain Med 2023:rapm-2023-104537. [PMID: 37898481 PMCID: PMC11055939 DOI: 10.1136/rapm-2023-104537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 10/02/2023] [Indexed: 10/30/2023]
Abstract
INTRODUCTION Complex Regional Pain Syndrome (CRPS) is a debilitating neuropathic condition often refractory to conventional treatments. N-methyl-D-aspartate (NMDA) receptor antagonists have a well-established role in the development and modulation of chronic neuropathic pain. Nitrous oxide is widely used and generally safe anesthetic gas with NMDA receptor antagonist activity. We therefore tested the hypothesis that brief periods of nitrous oxide exposure reduce pain in patients with CRPS. METHODS Patients with a diagnosis of CRPS were randomized to either 2 hours of nitrous oxide exposure on three alternating days (Nitrous Oxide) versus a placebo air/oxygen mixture (Air-Oxygen). Our primary outcome was patient-reported pain scores at 1 week and 1 month. Secondary and exploratory outcomes were physical and mental health (PRMOIS-29 v2 survey), specific neuropathic pain symptoms (McGill short-form questionnaire), and opioid consumption. RESULTS 44 patients participated in the study; 20 were randomized to Nitrous Oxide and 24 were assigned to Air-Oxygen. Pain scores did not differ significantly, with the estimated difference in means (Nitrous Oxide-Air-Oxygen) of -0.57 (95% CI: -1.42 to 0.28) points, p=0.19. There were also no differences detected in secondary outcomes, with the estimated difference in mean Z-scores for physical health (Nitrous Oxide-Air-Oxygen) of 0.13 (95% CI: -0.16 to 0.43), mental health 0.087 (95% CI: -0.31 to 0.48), and Patient Global Impression of Change score -0.7 (95% CI: -1.85 to 0.46). CONCLUSIONS Compared with air/oxygen, 2 hours of nitrous oxide/oxygen exposure for three sessions did not provide meaningful therapeutic potential for patients with chronic CRPS. Our results do not support using nitrous oxide for the treatment of CRPS.
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Affiliation(s)
- Jason Hale
- Department of Pain Management, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jijun Xu
- Department of Pain Management, Cleveland Clinic, Cleveland, Ohio, USA
| | - Dong Wang
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Omer Bakal
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Orkun Kopac
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Ozkan Onal
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Anesthesiology and Reanimation, Selcuk Universitesi, Konya, Turkey
| | - Jack E Brooker
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Miguel Cruz
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marco Maurtua
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ruben Agudelo-Jimenez
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
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Dimic N, Djuric M, Nenadic I, Bojic S, Bobos M, Janicijevic A, Bojanic M, Mijovic M, Stevanovic P. Nitrous Oxide — Application in Modern Anesthesia. CURRENT ANESTHESIOLOGY REPORTS 2023. [DOI: 10.1007/s40140-023-00554-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023]
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Gupta N, Gupta A, Narayanan M R V. Current status of nitrous oxide use in pediatric patients. World J Clin Pediatr 2022; 11:93-104. [PMID: 35433304 PMCID: PMC8985494 DOI: 10.5409/wjcp.v11.i2.93] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 07/05/2021] [Accepted: 02/27/2022] [Indexed: 02/06/2023] Open
Abstract
Nitrous oxide is one of the most commonly used inhalational anesthetic agents used in practice. It is a cost-effective, pleasant, safe, and versatile anesthetic agent with many desirable properties like good quality analgesia, decreased awareness, accelerated induction and recovery from anesthesia, and reduced utilization of other expensive inhalational agents with potential cost savings. The use of nitrous oxide has been questioned by a lot of studies and case reports perceiving its adverse systemic, hematological, immune, and neurologic adverse effects. However, the literature in the recent past has tried to resolve the controversies related to its use. The concerns over an increase in cardiovascular complications and mortality following nitrous oxide use have been negated by recent data. However, its use in certain vulnerable populations like children with cobalamin and folate deficiency or defects in their metabolic pathways remains a cause of concern for its toxic effects. In this narrative review, we aim to discuss the pharmacological properties of nitrous oxide, the potential advantages and drawbacks of the use of nitrous oxide in children, address the neurodevelopmental and other systemic effects, and throw light on the evidence regarding the safety of nitrous oxide use and its current role in pediatric procedural sedation and anesthesia practice. The literature related to its use in the pediatric population for painful procedures and surgeries has been summarized.
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Affiliation(s)
- Nishkarsh Gupta
- Department of Onco-Anesthesiology and Palliative Medicine, AIIMS, New Delhi 110029, Delhi, India
| | - Anju Gupta
- Department of Anesthesiology, Pain Medicine and Critical Care, AIIMS, New Delhi 110029, Delhi, India
| | - Vishnu Narayanan M R
- Department of Anesthesiology, Pain Medicine and Critical Care, AIIMS, New Delhi 110029, Delhi, India
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7
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Chan CS, Chan MTV. Use of nitrous oxide in contemporary anesthesia-an ongoing tug of war. Can J Anaesth 2021; 68:1597-1600. [PMID: 34448128 DOI: 10.1007/s12630-021-02094-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/02/2021] [Accepted: 08/02/2021] [Indexed: 11/25/2022] Open
Affiliation(s)
- Chee Sam Chan
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Matthew T V Chan
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China.
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Cata JP, Owusu-Agyemang P, Koyyalagunta D, Corrales G, Feng L, Fournier K. Impact of Ketamine on Opioid Use and Persistent Pain After Cytoreductive Surgery with Hyperthermic Chemotherapy. J Pain Res 2021; 14:2433-2439. [PMID: 34413677 PMCID: PMC8370593 DOI: 10.2147/jpr.s311995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 08/02/2021] [Indexed: 11/28/2022] Open
Abstract
Background Persistent pain and opioid use can be devastating after cytoreductive surgery (CRS) and hyperthermic intraoperative chemotherapy (HIPEC). Methods We conducted a retrospective study to investigate the impact of ketamine use on postoperative complications and persistent and chronic pain after CRS-HIPEC. Results Ketamine reduced perioperative opioid use before and after implementation of recovery after surgery programs. Ketamine did not impact the formation of persistent and chronic pain formation and long-term opioid use. Postoperative complications and postoperative re-operations were independent predictors of persistent pain. Interestingly, the risk of having a complication was increased by 1% for every doubling in opioids used intraoperatively. Conclusion Ketamine use reduces perioperative opioid consumption in patients undergoing CRS-HIPEC, but it is not associated with improvements in long-term opioid use and chronic pain.
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Affiliation(s)
- Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Pascal Owusu-Agyemang
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Dhanalakshmi Koyyalagunta
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - German Corrales
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Lei Feng
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keith Fournier
- Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA.,Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Pharmacotherapy for the Prevention of Chronic Pain after Surgery in Adults: An Updated Systematic Review and Meta-analysis. Anesthesiology 2021; 135:304-325. [PMID: 34237128 DOI: 10.1097/aln.0000000000003837] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Chronic postsurgical pain can severely impair patient health and quality of life. This systematic review update evaluated the effectiveness of systemic drugs to prevent chronic postsurgical pain. METHODS The authors included double-blind, placebo-controlled, randomized controlled trials including adults that evaluated perioperative systemic drugs. Studies that evaluated same drug(s) administered similarly were pooled. The primary outcome was the proportion reporting any pain at 3 or more months postsurgery. RESULTS The authors identified 70 new studies and 40 from 2013. Most evaluated ketamine, pregabalin, gabapentin, IV lidocaine, nonsteroidal anti-inflammatory drugs, and corticosteroids. Some meta-analyses showed statistically significant-but of unclear clinical relevance-reductions in chronic postsurgical pain prevalence after treatment with pregabalin, IV lidocaine, and nonsteroidal anti-inflammatory drugs. Meta-analyses with more than three studies and more than 500 participants showed no effect of ketamine on prevalence of any pain at 6 months when administered for 24 h or less (risk ratio, 0.62 [95% CI, 0.36 to 1.07]; prevalence, 0 to 88% ketamine; 0 to 94% placebo) or more than 24 h (risk ratio, 0.91 [95% CI, 0.74 to 1.12]; 6 to 71% ketamine; 5 to 78% placebo), no effect of pregabalin on prevalence of any pain at 3 months (risk ratio, 0.88 [95% CI, 0.70 to 1.10]; 4 to 88% pregabalin; 3 to 80% placebo) or 6 months (risk ratio, 0.78 [95% CI, 0.47 to 1.28]; 6 to 68% pregabalin; 4 to 69% placebo) when administered more than 24 h, and an effect of pregabalin on prevalence of moderate/severe pain at 3 months when administered more than 24 h (risk ratio, 0.47 [95% CI, 0.33 to 0.68]; 0 to 20% pregabalin; 4 to 34% placebo). However, the results should be interpreted with caution given small study sizes, variable surgical types, dosages, timing and method of outcome measurements in relation to the acute pain trajectory in question, and preoperative pain status. CONCLUSIONS Despite agreement that chronic postsurgical pain is an important topic, extremely little progress has been made since 2013, likely due to study designs being insufficient to address the complexities of this multifactorial problem. EDITOR’S PERSPECTIVE
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Coulombe MA, Décary E, Maximos S, Brulotte V, Drolet P, Tanoubi I, Issa R, Zaphiratos V, Verdonck O, Fortier LP, Godin N, Idrissi M, Raft J, Richebé P. Assessing the antinociceptive effect of nitrous oxide to tetanic stimulation in anaesthetised patients with new intra-operative nociception monitors: An observational study. Eur J Anaesthesiol 2021; 38:512-523. [PMID: 33399383 DOI: 10.1097/eja.0000000000001431] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Nitrous oxide (N2O) has been used since the 19th century for its analgesic, antinociceptive and anxiolytic effects during surgical procedures in awake and anaesthetised patients. However, quantification of noxious stimuli that occur under general anaesthesia is a constant challenge for anaesthesiologists, and recently two new indices have been developed to assess intra-operative nociception. OBJECTIVE The aim of this study was to quantify with new indices as well as with more classical clinical parameters the antinociceptive effect of N2O during general anaesthesia. DESIGN Prospective, open label, patient-blinded, observational and descriptive trial. SETTING Single-centre academic hospital. PARTICIPANTS Forty American Society of Anesthesiologists' physical status 1 to 3 patients undergoing general anaesthesia for elective abdominal surgery via laparotomy were recruited. MAIN OUTCOMES MEASURES Intra-operative pain was assessed using a standardised electrical stimulation of the forearm (tetanic stimulation at 70 mA, 100 Hz for 30 s), at 0, 25 and 50% inhaled N2O/O2. Heart rate (HR), mean arterial blood pressure, bispectral index, the analgesia nociception index and the nociception level (NOL) index were used to evaluate intra-operative nociception before and after each standardised tetanic stimulation. RESULTS There was a 16% reduction of the analgesia nociception index reaction, a 31% reduction of the NOL reaction and a 51% reduction of the HR reaction to a standardised electrical tetanic nociceptive stimulation during administration of 50% N2O. Administration of 50 or 25% inhaled N2O produced the same quality of antinociception based on HR and NOL index analyses. HR and the NOL index were the best parameters to identify the antinociceptive effect of intra-operatively administered N2O. CONCLUSION In anaesthetised patients, our study demonstrated clinically significant antinociceptive properties of N2O. Our results showed that low concentrations of N2O (25%) are as effective as higher concentrations (50%) to achieve a significant antinociceptive effect. These findings may help decrease negative effects of using higher concentrations of N2O, including its side effects and its environmental pollution. TRIAL REGISTRATION ClinicalTrials.gov registration identifier: NCT02701478.
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Affiliation(s)
- Marie-Andrée Coulombe
- From the Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montreal, University of Montreal, Montreal, Quebec, Canada (M-AC, ED, SM, VB, PD, IT, RI, VZ, OV, L-PF, NG, MI, JR, PR)
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11
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Bessière B, Iris F, Milet A, Beopoulos A, Billoet C, Farjot G. A new mechanistic approach for the treatment of chronic neuropathic pain with nitrous oxide integrated from a systems biology narrative review. Med Gas Res 2021; 11:34-41. [PMID: 33642336 PMCID: PMC8103977 DOI: 10.4103/2045-9912.310058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 07/24/2020] [Accepted: 07/24/2020] [Indexed: 12/25/2022] Open
Abstract
The limitations of the currently available treatments for chronic neuropathic pain highlight the need for safer and more effective alternatives. The authors carried out a focused review using a systems biology approach to integrate the complex mechanisms of nociception and neuropathic pain, and to decipher the effects of nitrous oxide (N2O) on those pathways, beyond the known effect of N2O on N-methyl-D-aspartate receptors. This review identified a number of potential mechanisms by which N2O could impact the processes involved in peripheral and central sensitization. In the ascending pathway, the effects of N2O include activating TWIK-related K+ channel 1 potassium channels on first-order neurons, blocking voltage-dependent calcium channels to attenuate neuronal excitability, attenuating postsynaptic glutamatergic receptor activation, and possibly blocking voltage-dependent sodium channels. In the descending pathway, N2O induces the release of endogenous opioid ligands and stimulates norepinephrine release. In addition, N2O may mediate epigenetic changes by inhibiting methionine synthase, a key enzyme involved in DNA and RNA methylation. This could explain why this short-acting analgesic has shown long-lasting anti-pain sensitization effects in animal models of chronic pain. These new hypotheses support the rationale for investigating N2O, either alone or in combination with other analgesics, for the management of chronic neuropathic pain.
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Affiliation(s)
- Baptiste Bessière
- Air Liquide Santé International, Paris Innovation Campus, Jouy-en-Josas, France
| | | | - Aude Milet
- Air Liquide Santé International, Paris Innovation Campus, Jouy-en-Josas, France
| | | | - Catherine Billoet
- Air Liquide Santé International, Paris Innovation Campus, Jouy-en-Josas, France
| | - Géraldine Farjot
- Air Liquide Santé International, Paris Innovation Campus, Jouy-en-Josas, France
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Glare P, Aubrey KR, Myles PS. Transition from acute to chronic pain after surgery. Lancet 2019; 393:1537-1546. [PMID: 30983589 DOI: 10.1016/s0140-6736(19)30352-6] [Citation(s) in RCA: 409] [Impact Index Per Article: 81.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 10/20/2018] [Accepted: 02/07/2019] [Indexed: 12/14/2022]
Abstract
Over the past decade there has been an increasing reliance on strong opioids to treat acute and chronic pain, which has been associated with a rising epidemic of prescription opioid misuse, abuse, and overdose-related deaths. Deaths from prescription opioids have more than quadrupled in the USA since 1999, and this pattern is now occurring globally. Inappropriate opioid prescribing after surgery, particularly after discharge, is a major cause of this problem. Chronic postsurgical pain, occurring in approximately 10% of patients who have surgery, typically begins as acute postoperative pain that is difficult to control, but soon transitions into a persistent pain condition with neuropathic features that are unresponsive to opioids. Research into how and why this transition occurs has led to a stronger appreciation of opioid-induced hyperalgesia, use of more effective and safer opioid-sparing analgesic regimens, and non-pharmacological interventions for pain management. This Series provides an overview of the epidemiology and societal effect, basic science, and current recommendations for managing persistent postsurgical pain. We discuss the advances in the prevention of this transitional pain state, with the aim to promote safer analgesic regimens to better manage patients with acute and chronic pain.
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Affiliation(s)
- Paul Glare
- Pain Management Research Institute, University of Sydney, Sydney, NSW, Australia
| | - Karin R Aubrey
- Pain Management Research Institute, University of Sydney, Sydney, NSW, Australia; Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, VIC.
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Abstract
Chronic postsurgical pain affects between 5 and 75% of patients, often with an adverse impact on quality of life. While the transition of acute to chronic pain is a complex process-involving multiple mechanisms at different levels-the current strategies for prevention have primarily been restricted to perioperative pharmacological interventions. In the present paper, we first present an up-to-date narrative literature review of these interventions. In the second section, we develop several ways by which we could overcome the limitations of the current approaches and enhance the outcome of our surgical patients, including the better identification of individual risk factors, tailoring treatment to individual patients, and improved acute and subacute pain evaluation and management. The third and final section covers the treatment of established CPSP. Given that evidence for the current therapeutic options is limited, we need high-quality trials studying multimodal interventions matched to pain characteristics.
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Affiliation(s)
- Arnaud Steyaert
- Department of Anesthesiology, Acute and Transitional Pain Service, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.
| | - Patricia Lavand'homme
- Department of Anesthesiology, Acute and Transitional Pain Service, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
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Abstract
Abstract
The development of chronic pain is considered a major complication after surgery. Basic science research in animal models helps us understand the transition from acute to chronic pain by identifying the numerous molecular and cellular changes that occur in the peripheral and central nervous systems. It is now well recognized that inflammation and nerve injury lead to long-term synaptic plasticity that amplifies and also maintains pain signaling, a phenomenon referred to as pain sensitization. In the context of surgery in humans, pain sensitization is both responsible for an increase in postoperative pain via the expression of wound hyperalgesia and considered a critical factor for the development of persistent postsurgical pain. Using specific drugs that block the processes of pain sensitization reduces postoperative pain and prevents the development of persistent postoperative pain. This narrative review of the literature describes clinical investigations evaluating different preventative pharmacologic strategies that are routinely used by anesthesiologists in their daily clinical practices for preventing persistent postoperative pain. Nevertheless, further efforts are needed in both basic and clinical science research to identify preclinical models and novel therapeutics targets. There remains a need for more patient numbers in clinical research, for more reliable data, and for the development of the safest and the most effective strategies to limit the incidence of persistent postoperative pain.
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Zafirova Z, Sheehan C, Hosseinian L. Update on nitrous oxide and its use in anesthesia practice. Best Pract Res Clin Anaesthesiol 2018; 32:113-123. [DOI: 10.1016/j.bpa.2018.06.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 06/22/2018] [Indexed: 01/22/2023]
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Opioid-induced hyperalgesia in clinical anesthesia practice: what has remained from theoretical concepts and experimental studies? Curr Opin Anaesthesiol 2018; 30:458-465. [PMID: 28590258 DOI: 10.1097/aco.0000000000000485] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This article reviews the phenomenon of opioid-induced hyperalgesia (OIH) and its implications for clinical anesthesia. The goal of this review is to give an update on perioperative prevention and treatment strategies, based on findings in preclinical and clinical research. RECENT FINDINGS Several systems have been suggested to be involved in the pathophysiology of OIH with a focus on the glutaminergic system. Very recently preclinical data revealed that peripheral μ-opioid receptors (MORs) are key players in the development of OIH and acute opioid tolerance (AOT). Peripheral MOR antagonists could, thus, become a new prevention/treatment option of OIH in the perioperative setting. Although the impact of OIH on postoperative pain seems to be moderate, recent evidence suggests that increased hyperalgesia following opioid treatment correlates with the risk of developing persistent pain after surgery. In clinical practice, distinction among OIH, AOT and acute opioid withdrawal remains difficult, especially because a specific quantitative sensory test to diagnose OIH has not been validated yet. SUMMARY Since the immediate postoperative period is not ideal to initiate long-term treatment for OIH, the best strategy is to prevent its occurrence. A multimodal approach, including choice of opioid, dose limitations and addition of nonopioid analgesics, is recommended.
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Abstract
INTRODUCTION For a drug that has been omnipresent for nearly 200 years, nitrous oxide's (N2O) future seems less certain than its illustrious past. Environmental concerns are coming to the fore and may yet outweigh important clinical benefits. SOURCES OF DATA After determining the scope of the review, the authors used PubMed with select phrases encompassing the words in the scope. Both preclinical and clinical reports were considered. AREAS OF AGREEMENT The analgesic and anaesthetic advantages of N2O remain despite a plethora of newer agents. AREAS OF CONTROVERSY N2O greenhouse gas effect and its inhibition of key enzymes involved in protein and DNA synthesis have provided further fuel for those intent on eliminating its further clinical use. GROWING POINTS The use of N2O for treatment-resistant depression has gained traction. AREAS TIMELY FOR DEVELOPING RESEARCH Comparative studies for N2O role in combatting the prescription opioid analgesic epidemic may well provide further clinical impetus.
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Affiliation(s)
- V Lew
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA,USA
| | - E McKay
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA,USA
| | - M Maze
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA,USA
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Sneyd J. Thiopental to desflurane - an anaesthetic journey. Where are we going next? Br J Anaesth 2017; 119:i44-i52. [DOI: 10.1093/bja/aex328] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2017] [Indexed: 01/06/2023] Open
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Peyton PJ, Wu C, Jacobson T, Hogg M, Zia F, Leslie K. The effect of a perioperative ketamine infusion on the incidence of chronic postsurgical pain-a pilot study. Anaesth Intensive Care 2017; 45:459-465. [PMID: 28673215 DOI: 10.1177/0310057x1704500408] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Chronic postsurgical pain (CPSP) is a common and debilitating complication of major surgery. We undertook a pilot study at three hospitals to assess the feasibility of a proposed large multicentre placebo-controlled randomised trial of intravenous perioperative ketamine to reduce the incidence of CPSP. Ketamine, 0.5 mg/kg pre-incision, 0.25 mg/kg/hour intraoperatively and 0.1 mg/kg/hour for 24 hours, or placebo, was administered to 80 patients, recruited over a 15-month period, undergoing abdominal or thoracic surgery under general anaesthesia. The primary endpoint was CPSP in the area of the surgery reported at six-month telephone follow-up using a structured questionnaire. Fourteen patients (17.5%) reported CPSP (relative risk [95% confidence interval] if received ketamine 1.18 [0.70 to 1.98], P=0.56). Four patients in the treatment group and three in the control group reported ongoing analgesic use to treat CPSP and two patients in each group reported their worst pain in the previous 24 hours at ≥3/10 at six months. There were no significant differences in adverse event rates, quality of recovery scores, or cumulative morphine equivalents consumption in the first 72 hours. Numeric Rating Scale pain scores (median [interquartile range, IQR]) for average pain in the previous 24 hours among those patients reporting CPSP were 17.5 [0 to 40] /100 with no difference between treatment groups. A large (n=4,000 to 5,000) adequately powered multicentre trial is feasible using this population and methodology.
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Affiliation(s)
- P J Peyton
- Associate Professor, Anaesthesia, Perioperative and Pain Medicine Unit, Melbourne Medical School, University of Melbourne, Associate Professor, Department of Surgery, Austin Health, University of Melbourne, Head of Research, Dept of Anaesthesia, Austin Health, Melbourne, Victoria
| | - C Wu
- Anaesthetic Registrar, Department of Anaesthesia, Austin Health, Melbourne, Victoria
| | - T Jacobson
- Medical student, University of Melbourne, Austin Health Medical Education, Melbourne, Victoria
| | - M Hogg
- Head of Pain Services, Melbourne Health, Melbourne, Victoria
| | - F Zia
- Staff Anaesthetist, Ballarat Health Services, Department of Anaesthesia, Ballarat, Victoria
| | - K Leslie
- Honorary Professorial Fellow, Anaesthesia, Perioperative and Pain Medicine Unit, Melbourne Medical School, and Department of Pharmacology and Therapeutics, University of Melbourne; Honorary Adjunct Professor, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria
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Anwar S, O'Brien B. The role of intraoperative interventions to minimise chronic postsurgical pain. Br J Pain 2017; 11:186-191. [PMID: 29123663 DOI: 10.1177/2049463717720640] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Chronic postsurgical pain (CPSP) is the most common complication following surgery, with increasing evidence of both its prevalence and severity. While awareness of the various risk factors for this long-term condition is also increasing, effective prevention remains elusive. In this review, we describe the increasing evidence for preventive or 'protective' strategies. Controversies and conflicting human data are presented along with suggestions for improved future study.
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Affiliation(s)
- Sibtain Anwar
- Department of Perioperative Medicine, Barts Heart Centre, London, UK.,NIHR Biomedical Research Centre at Barts, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, London, UK
| | - Ben O'Brien
- Department of Perioperative Medicine, Barts Heart Centre, London, UK.,NIHR Biomedical Research Centre at Barts, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, London, UK
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Joshi GP, Pennant JH, Kehlet H. Evaluation of Nitrous Oxide in the Gas Mixture for Anesthesia (ENIGMA) Studies. Anesth Analg 2017; 124:2077-2079. [DOI: 10.1213/ane.0000000000001749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Prevention of chronic post-surgical pain: the importance of early identification of risk factors. J Anesth 2017; 31:424-431. [PMID: 28349202 DOI: 10.1007/s00540-017-2339-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 03/17/2017] [Indexed: 01/30/2023]
Abstract
Chronic post-surgical pain (CPSP) is currently an inevitable surgical complication. Despite the advances in surgical techniques and the development of new modalities for pain management, CPSP can affect 15-60% of all surgical patients. The development of chronic pain represents a burden to both the patient and to the community. In order to have a meaningful impact on this debilitating condition it is essential to identify those at risk. Early identification of patients at risk will help to reduce the percentage of patients who go on to develop CPSP. Unfortunately, evidence about any effective actions to reduce this condition is limited. This review will focus on providing context to the challenging problem of CPSP. The possible role of both the surgeon and anesthesiologist in reducing the incidence of this problem will be explored.
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Affiliation(s)
- Daniel I. Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, USA
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Chan M, Peyton P, Myles P, Leslie K, Buckley N, Kasza J, Paech M, Beattie W, Sessler D, Forbes A, Wallace S, Chen Y, Tian Y, Wu W. Chronic postsurgical pain in the Evaluation of Nitrous Oxide in the Gas Mixture for Anaesthesia (ENIGMA)-II trial. Br J Anaesth 2016; 117:801-811. [DOI: 10.1093/bja/aew338] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2016] [Indexed: 12/18/2022] Open
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Abstract
PURPOSE OF REVIEW The purpose of this review is to describe an evidence-based drug strategy applicable to any obese patient, rather than to present one standard 'ideal' anaesthetic drug combination. The ultimate choice of specific drugs in any given situation will depend upon clinician experience, patient specifics, and drug availability. The fundamental principle in anaesthesia for the obese patient is to use the shortest acting, least fat soluble agents to ensure rapid recovery to safe levels of alertness and mobility. RECENT FINDINGS No new drugs have been introduced over the past few years, but we have seen an introduction of enhanced recovery after surgery-based protocols into bariatric surgery. Our understanding of how obesity affects pharmacokinetics/dynamics of our drugs is improving, with new and better use of established drugs. Allometric scaling is being tested in the different pharmacokinetic/dynamic models used in target controlled infusion devices, with improved performance as a result. Obstructive sleep apnoea has a significant impact upon outcome and utilization of clinical resources, including critical care beds. If an improved drug dosing strategy will reduce this impact, then this would be a step forward. SUMMARY This review introduces newer findings to help us use anaesthetic and analgesic drugs more safely in the morbidly obese. However, there remain many areas of uncertainty with a lack of consensus on many issues.
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Steyaert A, Forget P, Dubois V, Lavand'homme P, De Kock M. Does the perioperative analgesic/anesthetic regimen influence the prevalence of long-term chronic pain after mastectomy? J Clin Anesth 2016; 33:20-5. [PMID: 27555127 DOI: 10.1016/j.jclinane.2015.07.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 11/11/2014] [Accepted: 07/14/2015] [Indexed: 12/01/2022]
Abstract
STUDY OBJECTIVE To investigate if the anesthetic/analgesic regimen is associated with the risk of reporting long-term chronic postmastectomy pain (CPMP). DESIGN Cross-sectional survey SETTING Academic hospital PATIENTS A total of 267 women having undergone mastectomy with axillary lymph node dissection between 2003 and 2008 INTERVENTIONS: All patients were contacted between October and December 2012, with a questionnaire asking for persistent pain after surgery and its characteristics. MEASUREMENTS Besides demographical data, tumor characteristics, and adjuvant treatment, we recorded type and doses of intraoperative anesthetics/analgesics (sufentanil, ketamine, clonidine, nonsteroidal anti-inflammatory drugs, MgSO4, propofol, or halogenated agents). RESULTS Of the 128 patients returning analyzable questionnaires, 43.8% reported chronic pain (48.2% with neuropathic characteristics). Multivariate logistic/linear regression model showed 4 factors independently associated with persistent pain: recall of preoperative pain (odds ratio [OR], 1.27; 95% confidence interval [CI], 1.09-1.48), chemotherapy (OR, 1.32; 95% CI, 1.13-1.55), need for strong opioids in postanesthesia care unit (OR, 1.30; 95% CI, 1.11-1.53), and halogenated agent anesthesia (OR, 0.81; 95% CI, 0.70-0.95). CONCLUSION In conclusion, our study confirms the high prevalence of CPMP, 4 to 9 years after surgery. Recall of preoperative pain, chemotherapy, and need for strong opioids in the postanesthesia care unit were all associated with the presence of chronic pain. Of the intraoperative analgesics/anesthetics studied, only use of halogenated agents was associated with a lower prevalence of CPMP.
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Affiliation(s)
- Arnaud Steyaert
- Department of Anesthesiology, Cliniques universitaires Saint-Luc, Institute of Neuroscience, Université catholique de Louvain, Avenue Hippocrate 10, 1200 Brussels, Belgium.
| | - Patrice Forget
- Department of Anesthesiology, Cliniques universitaires Saint-Luc, Institute of Neuroscience, Université catholique de Louvain, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Virginie Dubois
- Department of Anesthesiology, Cliniques universitaires Saint-Luc, Institute of Neuroscience, Université catholique de Louvain, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Patricia Lavand'homme
- Department of Anesthesiology, Cliniques universitaires Saint-Luc, Institute of Neuroscience, Université catholique de Louvain, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Marc De Kock
- Department of Anesthesiology, Cliniques universitaires Saint-Luc, Institute of Neuroscience, Université catholique de Louvain, Avenue Hippocrate 10, 1200 Brussels, Belgium
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A randomized phase I trial evaluating the effects of inhaled 50-50% N2O-O2on remifentanil-induced hyperalgesia and allodynia in human volunteers. Eur J Pain 2016; 20:1467-77. [DOI: 10.1002/ejp.870] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2016] [Indexed: 11/07/2022]
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Impact of nitrous oxide on the haemodynamic consequences of venous carbon dioxide embolism: An experimental study. Eur J Anaesthesiol 2015; 33:356-60. [PMID: 26627915 DOI: 10.1097/eja.0000000000000384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Nitrous oxide (N2O) is still considered an important component of general anaesthesia. However, should gas embolisation occur as result of carbon dioxide (CO2) pneumoperitoneum, N2O may compromise safety, as the consequences of a gas embolus consisting of a combination of CO2 and N2O may be more severe than CO2 alone. OBJECTIVE This experimental study was designed to compare the cardiopulmonary consequences of gas embolisation with a N2O/CO2 mixture, or CO2 alone. DESIGN Experimental study. SETTING Research Institute Against Digestive Cancer laboratory, Strasbourg, France. ANIMALS Seven Large-White pigs receiving standardised inhalation anaesthesia. INTERVENTIONS Each animal, acting as its own control, was studied in two successive experimental conditions - intravenous gas injections of 2 ml kg of 100% CO2 and 2 ml kg of a gas mixture consisting of 10% N2O and 90% CO2. MAIN OUTCOMES MEASURES Haemodynamic and ventilatory consequences of embolisation with the gases. RESULTS We found that the haemodynamic (heart rate, mean arterial blood pressure, central venous pressure, mean pulmonary artery pressure, pulmonary artery occlusion pressure and transoesophageal echocardiography parameters) and ventilatory (arterial oxygen saturation, end-tidal CO2 concentration and mixed venous oxygen saturation) consequences of embolisation with either 100% CO2 or 10% N2O with 90% CO2 were similar. CONCLUSION The findings of this study may alleviate concerns that the use of N2O, as a part of a balanced general anaesthesia technique, may have greater adverse consequences should embolisation of pneumoperitoneal gas containing N2O occur.
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Sun R, Jia WQ, Zhang P, Yang K, Tian JH, Ma B, Liu Y, Jia RH, Luo XF, Kuriyama A. Nitrous oxide-based techniques versus nitrous oxide-free techniques for general anaesthesia. Cochrane Database Syst Rev 2015; 2015:CD008984. [PMID: 26545294 PMCID: PMC9326975 DOI: 10.1002/14651858.cd008984.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Nitrous oxide has been used for over 160 years for the induction and maintenance of general anaesthesia. It has been used as a sole agent but is most often employed as part of a technique using other anaesthetic gases, intravenous agents, or both. Its low tissue solubility (and therefore rapid kinetics), low cost, and low rate of cardiorespiratory complications have made nitrous oxide by far the most commonly used general anaesthetic. The accumulating evidence regarding adverse effects of nitrous oxide administration has led many anaesthetists to question its continued routine use in a variety of operating room settings. Adverse events may result from both the biological actions of nitrous oxide and the fact that to deliver an effective dose, nitrous oxide, which is a relatively weak anaesthetic agent, needs to be given in high concentrations that restrict oxygen delivery (for example, a common mixture is 30% oxygen with 70% nitrous oxide). As well as the risk of low blood oxygen levels, concerns have also been raised regarding the risk of compromising the immune system, impaired cognition, postoperative cardiovascular complications, bowel obstruction from distention, and possible respiratory compromise. OBJECTIVES To determine if nitrous oxide-based anaesthesia results in similar outcomes to nitrous oxide-free anaesthesia in adults undergoing surgery. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014 Issue 10); MEDLINE (1966 to 17 October 2014); EMBASE (1974 to 17 October 2014); and ISI Web of Science (1974 to 17 October 2014). We also searched the reference lists of relevant articles, conference proceedings, and ongoing trials up to 17 October 2014 on specific websites (http://clinicaltrials.gov/, http://controlled-trials.com/, and http://www.centerwatch.com). SELECTION CRITERIA We included randomized controlled trials (RCTs) comparing general anaesthesia where nitrous oxide was part of the anaesthetic technique used for the induction or maintenance of general anaesthesia (or both) with any general anaesthesia using a volatile anaesthetic or propofol-based maintenance of anaesthesia but no nitrous oxide for adults undergoing surgery. Our primary outcome was inhospital case fatality rate. Secondary outcomes were complications and length of stay. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted the outcome data. We used meta-analysis for data synthesis. Heterogeneity was examined with the Chi² test and by calculating the I² statistic. We used a fixed-effect model if the measure of inconsistency was low for all comparisons (I² statistic < 50%); otherwise we used a random-effects model for measures with high inconsistency. We undertook subgroup analyses to explore inconsistency and sensitivity analyses to evaluate whether the results were robust. We assessed the quality of evidence of the main outcomes using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. MAIN RESULTS We included 35 trials (13,872 adult participants). Seven included studies were at low risk of bias. We identified eight studies as awaiting classification since we could not obtain the full texts, and had insufficient information to include or exclude them. We included data from 24 trials for quantitative synthesis. The results of meta-analyses showed that nitrous oxide-based techniques increased the incidence of pulmonary atelectasis (odds ratio (OR) 1.57, 95% confidence interval (CI) 1.18 to 2.10, P = 0.002), but had no effects on the inhospital case fatality rate, the incidence of pneumonia, myocardial infarction, stroke, severe nausea and vomiting, venous thromboembolism, wound infection, or the length of hospital stay. The sensitivity analyses suggested that the results of the meta-analyses were all robust except for the outcomes of pneumonia, and severe nausea and vomiting. Two trials reported length of intensive care unit (ICU) stay but the data were skewed so were not pooled. Both trials reported that nitrous oxide-based techniques had no effects on the length of ICU stay. We rated the quality of evidence for two outcomes (pulmonary atelectasis, myocardial infarction) as high, four outcomes (inhospital case fatality rate, stroke, venous thromboembolism, length of hospital stay) as moderate, and three (pneumonia, severe nausea and vomiting, wound infection rate) as low. AUTHORS' CONCLUSIONS Given the evidence from this Cochrane review, the avoidance of nitrous oxide may be reasonable in participants with pre-existing poor pulmonary function or at high risk of postoperative nausea and vomiting. Since there are eight studies awaiting classification, selection bias may exist in our systematic review.
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Affiliation(s)
- Rao Sun
- Lanzhou UniversityEvidence‐Based Medicine Center, School of Basic Medical SciencesLanzhou CityChina
| | - Wen Qin Jia
- Gansu Provincial HospitalDepartment of AnesthesiaNo. 204, Donggang West RoadLanzhou CityGansuChina730000
| | - Peng Zhang
- Nanyang Central HospitalDepartment of Pediatric SurgeryNanyangHenanChina473000
| | - KeHu Yang
- Lanzhou UniversityKey Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu ProvinceNo. 199, Donggang West RoadLanzhou CityGansuChina730000
| | - Jin Hui Tian
- Lanzhou UniversityEvidence‐Based Medicine Center, School of Basic Medical SciencesLanzhou CityChina
| | - Bin Ma
- Lanzhou UniversityEvidence‐Based Medicine Center, School of Basic Medical SciencesLanzhou CityChina
| | - Yali Liu
- Lanzhou UniversityEvidence‐Based Medicine Center, School of Basic Medical SciencesLanzhou CityChina
| | - Run H Jia
- Chinese Medicine Hospital in Gansu ProvinceDepartment of RadiologyLanzhou CityGansuChina730000
| | - Xiao F Luo
- Lanzhou UniversityEpidemiology and Health Statistics Institution of School of Public HealthNo. 199, Donggang West RoadLanzhou CityGansuChina730000
| | - Akira Kuriyama
- Kurashiki Central HospitalDepartment of General Medicine1‐1‐1 MiwaKurashikiOkayamaJapan710‐8602
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Ben Boujema M, Laboureyras E, Pype J, Bessière B, Simonnet G. Nitrous oxide persistently alleviates pain hypersensitivity in neuropathic rats: A dose-dependent effect. Pain Res Manag 2015; 20:309-15. [PMID: 26371891 PMCID: PMC4676501 DOI: 10.1155/2015/809059] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite numerous pharmacological approaches, there are no common analgesic drugs that produce meaningful relief for the majority of patients with neuropathic pain. Although nitrous oxide (N2O) is a weak analgesic that acts via opioid-dependent mechanisms, it is also an antagonist of the N-methyl-D-aspartate receptor (NMDAR). The NMDAR plays a critical role in the development of pain sensitization induced by nerve injury. OBJECTIVE Using the chronic constriction injury of the sciatic nerve in male rats as a preclinical model of neuropathic pain, the first aim of the present study was to evaluate the lowest N2O concentration and the shortest time of N2O postinjury exposure that would produce persistent relief of neuropathic pain. The second aim was to compare the effects of N2O with gabapentin, a reference drug used in human neuropathic pain relief. METHODS Changes in the nociceptive threshold were evaluated using the paw pressure vocalization test in rats. RESULTS Among the various N2O concentrations tested, which ranged from 25% to 50%, only 50% N2O single exposure for 1 h 15 min induced a persistent (minimum of three weeks) and significant (60%) reduction in pain hypersensitivity. A single gabapentin dose (75 mg⁄kg to 300 mg⁄kg, intraperitoneally) induced an acute (1 h to 1 h 30 min) dose-dependent effect, but not a persistent effect such as that observed with N2O. CONCLUSIONS These preclinical results suggest that N2O is advantageous for long-lasting neuropathic pain relief after sciatic nerve injury compared with other drugs used in humans such as gabapentinoids or NMDAR antagonists. The present preclinical study provides a rationale for developing comparative clinical studies.
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Affiliation(s)
- Meric Ben Boujema
- Team “Homéostasie-Allostasie-Pathologie-Réhabilitation”, UMR CNRS 5287, INCIA, Université de Bordeaux, Bordeaux
| | - Emilie Laboureyras
- Team “Homéostasie-Allostasie-Pathologie-Réhabilitation”, UMR CNRS 5287, INCIA, Université de Bordeaux, Bordeaux
| | - Jan Pype
- Air Liquide Santé International, Centre de Recherche Paris-Saclay, Jouy-en-Josas, France
| | - Baptiste Bessière
- Air Liquide Santé International, Centre de Recherche Paris-Saclay, Jouy-en-Josas, France
| | - Guy Simonnet
- Team “Homéostasie-Allostasie-Pathologie-Réhabilitation”, UMR CNRS 5287, INCIA, Université de Bordeaux, Bordeaux
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Turan A, Sarwar S, Atim A, Deogaonkar A, Yousef HF, Katyal S, Liu J, You J, Leizman D, Mekhail N, Sessler DI. Nitrous Oxide for the Treatment of Chronic Low Back Pain. Anesth Analg 2015; 121:1350-9. [DOI: 10.1213/ane.0000000000000951] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Potential strategies for preventing chronic postoperative pain: a practical approach: Continuing Professional Development. Can J Anaesth 2015; 62:1329-41. [DOI: 10.1007/s12630-015-0499-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 08/21/2015] [Accepted: 09/16/2015] [Indexed: 12/12/2022] Open
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General anaesthetic agents do not influence persistent pain after breast cancer surgery. Eur J Anaesthesiol 2015; 32:697-704. [DOI: 10.1097/eja.0000000000000215] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Abstract
Background:
Proteases have been shown to modulate pain signaling in the spinal cord and may contribute to the development of chronic postsurgical pain. By using peripheral inflammation in rats as a chronic pain model, the authors identified the deregulation of proteases and their inhibitors as a hallmark of chronic pain development using a genome-wide screening approach.
Methods:
A microarray analysis was performed and identified spinal cathepsin G (CTSG) as the most up-regulated gene in rats with persistent hyperalgesia after intraplantar injection of complete Freund’s adjuvant (n = 4). Further experiments were performed to elucidate the mechanisms of CTSG-induced hyperalgesia by intrathecally applying specific CTSG inhibitor (n = 10). The authors also evaluated the association between CTSG gene polymorphisms and the risk of chronic postsurgical pain in 1,152 surgical patients.
Results:
CTSG blockade reduced heat hyperalgesia, accompanied by a reduction in neutrophil infiltration and interleukin 1β levels in the dorsal horns. In the gene association study, 246 patients (21.4%) reported chronic postsurgical pain at 12-month follow-up. Patients with AA genotypes at polymorphisms rs2070697 (AA-15.3%, GA-24.1%, and GG-22.3%) or rs2236742 (AA-6.4%, GA-20.4%, and GG-22.6%) in the CTSG gene had lower risk for chronic postsurgical pain compared with wild-types. The adjusted odds ratios were 0.67 (95% CI, 0.26 to 0.99) and 0.34 (95% CI, 0.21 to 0.98), respectively.
Conclusions:
This study demonstrated that CTSG is a pronociceptive mediator in both animal model and human study. CTSG represents a new target for pain control and a potential marker to predict patients who are prone to develop chronic pain after surgery.
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Mattos Júnior FM, Mattos RV, Teixeira MJ, Siqueira SRDTD, Siqueira JTTD. Chronic pain relief after the exposure of nitrous oxide during dental treatment: longitudinal retrospective study. ARQUIVOS DE NEURO-PSIQUIATRIA 2015. [DOI: 10.1590/0004-282x20150061] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The objective was to investigate the effect of nitrous/oxygen in chronic pain. Seventy-seven chronic pain patients referred to dental treatment with conscious sedation with nitrous oxide/oxygen had their records included in this research. Data were collected regarding the location and intensity of pain by the visual analogue scale before and after the treatment. Statistical analysis was performed comparing pre- and post-treatment findings. It was observed a remarkable decrease in the prevalence of pain in this sample (only 18 patients still had chronic pain, p < 0.001) and in its intensity (p < 0.001). Patients that needed fewer sessions received higher proportions of nitrous oxide/oxygen. Nitrous oxide may be a tool to be used in the treatment of chronic pain, and future prospective studies are necessary to understand the underlying mechanisms and the effect of nitrous oxide/oxygen in patients according to the pain diagnosis and other characteristics.
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Breivik H. Nitrous oxide in oxygen (50:50) is analgesic that requires optimal inhalation procedure. Scand J Pain 2015; 7:35-37. [PMID: 29911594 DOI: 10.1016/j.sjpain.2015.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Harald Breivik
- Faculty of Medicine, University of Oslo, Oslo Norway
- Department of Anaesthesiology, Oslo University Hospital, PB 4950 Nydalen, Nydalen, 0424 Oslo, Norway
- Department of Pain Management and Research, Oslo University Hospital, PB 4950 Nydalen, Nydalen, 0424 Oslo, Norway
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Analgesic therapy for major spine surgery. Neurosurg Rev 2015; 38:407-18; discussion 419. [DOI: 10.1007/s10143-015-0605-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 07/13/2014] [Accepted: 11/16/2014] [Indexed: 12/11/2022]
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Angst MS. Intraoperative Use of Remifentanil for TIVA: Postoperative Pain, Acute Tolerance, and Opioid-Induced Hyperalgesia. J Cardiothorac Vasc Anesth 2015; 29 Suppl 1:S16-22. [PMID: 26025041 DOI: 10.1053/j.jvca.2015.01.026] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Martin S Angst
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA.
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Collins M. A Case Report on the Anxiolytic Properties of Nitrous Oxide during Labor. J Obstet Gynecol Neonatal Nurs 2015; 44:87-92. [DOI: 10.1111/1552-6909.12522] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Abnormal quantitative sensory testing is associated with persistent pain one year after TKA. Clin Orthop Relat Res 2015; 473:246-54. [PMID: 25293497 PMCID: PMC4390964 DOI: 10.1007/s11999-014-3990-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 09/29/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Up to 15% of patients report at least moderate persistent pain after TKA. Such pain may be associated with the presence of widespread hyperalgesia and neuropathic-type pain. QUESTIONS/PURPOSES We asked if there was a difference among patients who report moderate to severe pain or no pain at least 12 months after TKA regarding (1) pressure pain threshold, (2) thermal (cold/heat) pain and detection thresholds, and (3) self-reported neuropathic pain. PATIENTS AND METHOD Fifty-three volunteers were recruited from patients reporting no pain or moderate to severe pain, according to the Knee Society Score©. Differences between the moderate-to-severe and no-pain groups regarding pressure pain, heat and cold thresholds, and self-reported neuropathic-type pain were analyzed using independent t-tests. RESULTS Patients in the moderate-to-severe pain group exhibited reduced pressure pain threshold in the knee with the TKA (p=0.025) and at the elbow (p=0.002). This group also showed greater pain sensitivity to cold at the knee (p=0.008) and elbow (p=0.010), and increased heat pain sensitivity at the elbow (p=0.032). Cold and heat detection thresholds were impaired in this group at the elbow (cold, p=0.034; heat, p=0.010), although only heat detection was impaired at the knee (p=0.009). The moderate-to-severe pain group also reported more neuropathic-type pain (p=0.001). CONCLUSION Persistent pain after TKA was associated with widespread pressure, cold hyperalgesia, and greater neuropathic-type pain. LEVEL OF EVIDENCE Level III, prognostic study.
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Myles PS, Leslie K, Chan MTV, Forbes A, Peyton PJ, Paech MJ, Beattie WS, Sessler DI, Devereaux PJ, Silbert B, Schricker T, Wallace S. The safety of addition of nitrous oxide to general anaesthesia in at-risk patients having major non-cardiac surgery (ENIGMA-II): a randomised, single-blind trial. Lancet 2014; 384:1446-54. [PMID: 25142708 DOI: 10.1016/s0140-6736(14)60893-x] [Citation(s) in RCA: 134] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Nitrous oxide is commonly used in general anaesthesia but concerns exist that it might increase perioperative cardiovascular risk. We aimed to gather evidence to establish whether nitrous oxide affects perioperative cardiovascular risk. METHODS We did an international, randomised, assessor-blinded trial in patients aged at least 45 years with known or suspected coronary artery disease having major non-cardiac surgery. Patients were randomly assigned via automated telephone service, stratified by site, to receive a general anaesthetic with or without nitrous oxide. Attending anaesthetists were aware of patients' group assignments, but patients and assessors were not. The primary outcome measure was a composite of death and cardiovascular complications (non-fatal myocardial infarction, stroke, pulmonary embolism, or cardiac arrest) within 30 days of surgery. Our modified intention-to-treat population included all patients randomly assigned to groups and undergoing induction of general anaesthesia for surgery. This trial is registered at ClinicalTrials.gov, number NCT00430989. FINDINGS Of 10,102 eligible patients, we enrolled 7112 patients between May 30, 2008, and Sept 28, 2013. 3543 were assigned to receive nitrous oxide and 3569 were assigned not to receive nitrous oxide. 3483 patients receiving nitrous oxide and 3509 not receiving nitrous oxide were assessed for the primary outcome. The primary outcome occurred in 283 (8%) patients receiving nitrous oxide and in 296 (8%) patients not receiving nitrous oxide (relative risk 0·96, 95% CI 0·83–1·12; p=0·64). Surgical site infection occurred in 321 (9%) patients assigned to nitrous oxide, and in 311 (9%) patients in the no-nitrous oxide group (p=0·61), and severe nausea and vomiting occurred in 506 patients (15%) assigned to nitrous oxide and 378 patients (11%) not assigned to nitrous oxide (p<0·0001). INTERPRETATION Our findings support the safety profile of nitrous oxide use in major non-cardiac surgery. Nitrous oxide did not increase the risk of death and cardiovascular complications or surgical-site infection, the emetogenic effect of nitrous oxide can be controlled with antiemetic prophylaxis, and a desired effect of reduced volatile agent use was shown. FUNDING Australian National Health and Medical Research Council; Australian and New Zealand College of Anaesthetists; Heart and Stroke Foundation of Quebec, Heart and Stroke Foundation of Ontario, Canada; General Research Fund of the Research Grant Council, Hong Kong Special Administrative Region, China.
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Avidan MS, Fritz BA, Maybrier HR, Muench MR, Escallier KE, Chen Y, Ben Abdallah A, Veselis RA, Hudetz JA, Pagel PS, Noh G, Pryor K, Kaiser H, Arya VK, Pong R, Jacobsohn E, Grocott HP, Choi S, Downey RJ, Inouye SK, Mashour GA. The Prevention of Delirium and Complications Associated with Surgical Treatments (PODCAST) study: protocol for an international multicentre randomised controlled trial. BMJ Open 2014; 4:e005651. [PMID: 25231491 PMCID: PMC4166247 DOI: 10.1136/bmjopen-2014-005651] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Postoperative delirium is one of the most common complications of major surgery, affecting 10-70% of surgical patients 60 years and older. Delirium is an acute change in cognition that manifests as poor attention and illogical thinking and is associated with longer intensive care unit (ICU) and hospital stay, long-lasting cognitive deterioration and increased mortality. Ketamine has been used as an anaesthetic drug for over 50 years and has an established safety record. Recent research suggests that, in addition to preventing acute postoperative pain, a subanaesthetic dose of intraoperative ketamine could decrease the incidence of postoperative delirium as well as other neurological and psychiatric outcomes. However, these proposed benefits of ketamine have not been tested in a large clinical trial. METHODS The Prevention of Delirium and Complications Associated with Surgical Treatments (PODCAST) study is an international, multicentre, randomised controlled trial. 600 cardiac and major non-cardiac surgery patients will be randomised to receive ketamine (0.5 or 1 mg/kg) or placebo following anaesthetic induction and prior to surgical incision. For the primary outcome, blinded observers will assess delirium on the day of surgery (postoperative day 0) and twice daily from postoperative days 1-3 using the Confusion Assessment Method or the Confusion Assessment Method for the ICU. For the secondary outcomes, blinded observers will estimate pain using the Behavioral Pain Scale or the Behavioral Pain Scale for Non-Intubated Patients and patient self-report. ETHICS AND DISSEMINATION The PODCAST trial has been approved by the ethics boards of five participating institutions; approval is ongoing at other sites. Recruitment began in February 2014 and will continue until the end of 2016. Dissemination plans include presentations at scientific conferences, scientific publications, stakeholder engagement and popular media. REGISTRATION DETAILS The study is registered at clinicaltrials.gov, NCT01690988 (last updated March 2014). The PODCAST trial is being conducted under the auspices of the Neurological Outcomes Network for Surgery (NEURONS). TRIAL REGISTRATION NUMBER NCT01690988 (last updated December 2013).
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Affiliation(s)
- Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Bradley A Fritz
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Hannah R Maybrier
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Maxwell R Muench
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Krisztina E Escallier
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Yulong Chen
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Robert A Veselis
- Department of Anesthesiology, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Judith A Hudetz
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Paul S Pagel
- Clement J. Zablocki VA Medical Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Gyujeong Noh
- Department of Anesthesiology, Asan Medical Center, Seoul, South Korea
| | - Kane Pryor
- Department of Anesthesiology, Weill Cornell Medical College, New York, New York, USA
| | - Heiko Kaiser
- Department of Anesthesiology, University of Bern, Bern, Switzerland
| | - Virendra Kumar Arya
- Department of Anesthesiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ryan Pong
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Eric Jacobsohn
- Department of Anesthesiology, University of Manitoba-Faculty of Medicine, Winnipeg, Manitoba, Canada
| | - Hilary P Grocott
- Department of Anesthesiology, University of Manitoba-Faculty of Medicine, Winnipeg, Manitoba, Canada
| | - Stephen Choi
- Department of Anesthesiology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Robert J Downey
- Department of Surgery, Thoracic, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - George A Mashour
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan, USA
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The effect of nitrous oxide anesthesia on early postoperative opioid consumption and pain. Reg Anesth Pain Med 2014; 39:31-6. [PMID: 24310050 DOI: 10.1097/aap.0000000000000039] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Many patients experience moderate to severe postoperative pain. Nitrous oxide (N₂O) exerts analgesia by inhibition of N-methyl-D-aspartate receptors. Ketamine, another N-methyl-D-aspartate receptor antagonist, reduces postoperative opioid consumption and pain. A similar effect of N₂O is plausible, yet understudied. The goal of this study was to determine the effects of N₂O anesthesia on early postsurgical opioid consumption and pain. METHODS This was a retrospective, secondary analysis of the Vitamins In Nitrous Oxide trial, where 500 patients undergoing general anesthesia for noncardiac surgery received 60% N₂O and 125 received no N₂O (otherwise, inclusion/exclusion criteria were identical). Exclusion criteria for this study were regional anesthesia, not extubated after surgery, transfer to intensive care unit, no available postanesthesia care unit record, postsurgical sedation, or treated with naloxone. Primary outcomes were cumulative opioid consumption measured in morphine equivalents and pain scores during the immediate recovery phase. RESULTS Four hundred forty-two patients met inclusion criteria. No difference in intraoperative and postoperative opioid consumption was observed between patients who received N₂O (n = 353) and patients who did not (n = 89). The median [interquartile range] postoperative morphine equivalent dose was 6.7 mg [1.7-14.1 mg] for patients who received N₂O and 6.7 mg [2.1-15.4 mg] for patients who did not (P = 0.73). The maximum pain score was 6 [4-8] for patients who received N₂O versus 6 [3-8] for patients who received N₂O-free anesthesia (P = 0.52). The prevalence of moderate to severe pain was 69% for patients who received N₂O and 68% for patients who did not (P = 0.90). CONCLUSIONS Nitrous oxide anesthesia was not associated with decreased opioid administration, pain, or incidence of moderate to severe pain in the early postoperative phase.
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Role of Nitrous Oxide in Ambulatory Anaesthesia. CURRENT ANESTHESIOLOGY REPORTS 2014. [DOI: 10.1007/s40140-014-0072-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Joshi GP, Schug SA, Kehlet H. Procedure-specific pain management and outcome strategies. Best Pract Res Clin Anaesthesiol 2014; 28:191-201. [DOI: 10.1016/j.bpa.2014.03.005] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 03/28/2014] [Indexed: 11/16/2022]
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Imberger G, Orr A, Thorlund K, Wetterslev J, Myles P, Møller AM. Does anaesthesia with nitrous oxide affect mortality or cardiovascular morbidity? A systematic review with meta-analysis and trial sequential analysis. Br J Anaesth 2014; 112:410-26. [PMID: 24408738 DOI: 10.1093/bja/aet416] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The role of nitrous oxide in modern anaesthetic practice is contentious. One concern is that exposure to nitrous oxide may increase the risk of cardiovascular complications. ENIGMA II is a large randomized clinical trial currently underway which is investigating nitrous oxide and cardiovascular complications. Before the completion of this trial, we performed a systematic review and meta-analysis, using Cochrane methodology, on the outcomes that make up the composite primary outcome. METHODS We used conventional meta-analysis and trial sequential analysis (TSA). We reviewed 8282 abstracts and selected 138 that fulfilled our criteria for study type, population, and intervention. We attempted to contact the authors of all the selected publications to check for unpublished outcome data. RESULTS Thirteen trials had outcome data eligible for our outcomes. We assessed three of these trials as having a low risk of bias. Using conventional meta-analysis, the relative risk of short-term mortality in the nitrous oxide group was 1.38 [95% confidence interval (CI) 0.22-8.71] and the relative risk of long-term mortality in the nitrous oxide group was 0.94 (95% CI 0.80-1.10). In both cases, TSA demonstrated that the data were far too sparse to make any conclusions. There were insufficient data to perform meta-analysis for stroke, myocardial infarct, pulmonary embolus, or cardiac arrest. CONCLUSION This systematic review demonstrated that we currently do not have robust evidence for how nitrous oxide used as part of general anaesthesia affects mortality and cardiovascular complications.
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Affiliation(s)
- G Imberger
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Blegdamsvej 9, Copenhagen Ø DK-2100, Denmark
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The perioperative use of nitrous oxide: renaissance of an old gas or funeral of an ancient relict? Curr Opin Anaesthesiol 2013; 26:354-60. [PMID: 23426038 DOI: 10.1097/aco.0b013e32835f8151] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Conflicting reports about adverse events following nitrous oxide (N(2)O) application have spurred a discussion whether N(2)O should be abandoned from clinical practice. Concurrently, N(2)O is increasingly used as a single anesthetic agent in medical procedures. This article reviews and discusses reports about the present use of N(2)O. RECENT FINDINGS Multiple publications demonstrate an increasing use of N(2)O as a procedural analgesic and sedative. Results from the Evaluation of Nitrous Oxide in the Gas Mixture for Anesthesia trial have been contrasted by recent studies reporting no increased risk for perioperative complications, particularly related to the cardiovascular and cerebrovascular system. Recent studies show that electroencephalogram-based anesthesia depth monitoring is not compatible with the use of N(2)O because of its distinct influence on electroencephalogram wave patterns. The clinical relevance of the proposed neurotoxicity, immunosuppression and influence on methionine metabolism remains unclear. Recently, its acute and long-term analgesic potency has been proven. Occupational exposure might pose a relevant health hazard. SUMMARY Based on the present literature, abolishment of N(2)O is controversial. When avoided in patients at risk for adverse events, N(2)O is still a valuable supplement to general anesthesia and a potent procedural analgesic drug. In the latter, its use by nonanesthesiologists should be discouraged.
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Law CJ, Jacobson GM, Kluger M, Chaddock M, Scott M, Sleigh JW. Randomized controlled trial of the effect of depth of anaesthesia on postoperative pain. Br J Anaesth 2013; 112:675-80. [PMID: 24322572 DOI: 10.1093/bja/aet419] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Our hypothesis was that deep anaesthesia, as estimated by a low target bispectral index (BIS) of 30-40, would result in less postoperative pain than that achieved at a conventional depth of anaesthesia. METHODS We undertook a randomized double-blind controlled study at two tertiary teaching hospitals in New Zealand (2010-1) recruiting 135 adult patients ASA I-II presenting for non-emergent surgery under general anaesthesia requiring tracheal intubation. Anaesthesia was maintained with desflurane and a multimodal analgesia regimen comprising fentanyl infusion, i.v. paracetamol, and parecoxib. Patients were randomly assigned to either a low BIS (30-40) group or a high BIS (45-60) group. Desflurane concentrations were titrated to achieve these targets. Postoperative pain was assessed by: the pain on awakening (0-10, verbal rating scale, VRS(awake)) in the post-anaesthetic care unit; pain on activity at 20-24 h after operation (VRS(d1A)); and the rate of morphine patient-controlled analgesia (PCA) usage over the first 24 h. RESULTS There was no statistically significant difference between the two groups for any of the pain scores. The median [inter-quartile range (IQR)] VRS(awake) was 4.0 (0-8) for the low and 4.0 (0-8) for the high BIS groups (P=0.56). The median (IQR) VRS(d1A) was 3.0 (1-5) for the low and 3.0 (1.5-4.5) for the high BIS groups (P=0.83). The median PCA morphine consumption in the low BIS group was 0.61 mg h(-1) (0.04-1.5) vs 0.43 mg h(-1) (0-1.59) in the high BIS group (P=0.98). CONCLUSIONS We conclude that there is no clinically useful analgesic effect of a deep anaesthesia regimen.
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Affiliation(s)
- C J Law
- Department of Anaesthesia, Anglesea Hospital, Knox Street Clinic, PO Box 228, Hamilton Waikato 3204, New Zealand
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