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Guo H, Zhang X, Wang JG, Kalika P, Ran R, Xie YB. S-ketamine Infusion on Chronic Postoperative Pain Following Breast Cancer Surgery: A Randomized Double-Blind Placebo-Controlled Trial. Clin Breast Cancer 2024; 24:e605-e612. [PMID: 38918160 DOI: 10.1016/j.clbc.2024.06.003] [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: 03/29/2024] [Accepted: 06/04/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND Chronic postoperative surgical pain (CPSP) is a frequent complication following breast surgery and poses a challenge in terms of treatment. We hypothesized that the incidence of CPSP would be reduced at 3 months post-breast surgery with the administration of S-ketamine compared to a placebo. PATIENTS AND METHODS Participants were recruited and randomly assigned to either the S-ketamine group (S) or the control group (C). In group S, S-ketamine was administered as a 1.5 mg kg-1 bolus followed by 2 mg kg-1h-1 infusion, while in group C, a placebo of 0.9% saline was administered in the same volume and rate as S-ketamine. The primary outcome was the incidence of CPSP, measured using a 0-10 numeric rating scale (NRS), at 3 months postsurgery. RESULTS A total of 72 patients scheduled for mastectomy were enrolled (group S, n = 33; group C, n = 32). The incidence of CPSP at 3 months postsurgery was significantly lower in group S compared to group C (18.2% vs. 48.3%, P < .05). There was no statistical difference between the 2 groups in terms of the incidence of moderate to severe pain. NRS scores for postoperative pain at rest and during movement were significantly lower at 4 h and 24 h post-surgery (P < .05, respectively). Patients in Group S had lower Patient Health Questionnaire-9 (PHQ-9) scores at one week and 3 months post-surgery compared to Group C (P < .05, respectively). CONCLUSION S-ketamine infusion reduces the incidence of CPSP 3 months after breast surgery.
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Affiliation(s)
- Hao Guo
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China; Department of Anesthesiology, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Xi Zhang
- Department of Anesthesiology, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Jia-Gao Wang
- Department of Anesthesiology, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Prakash Kalika
- Department of Critical Care Medicine, Om Hospital and Research Center, Kathmandu, Nepal
| | - Ran Ran
- Department of Anesthesiology, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, China.
| | - Yu-Bo Xie
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China; Guangxi Key Laboratory of Enhanced Recovery after Surgery for Gastrointestinal Cancer, The First Affiliated Hospital of Guangxi Medical University, Nanning, China.
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Zhou Y, Sun W, Fu Y, Wang J, Fan J, Liang Y, Jia W, Han R. Effect of esketamine combined with pregabalin on acute postsurgical pain in patients who underwent resection of spinal neoplasms: a randomized controlled trial. Pain 2024; 165:e96-e105. [PMID: 38501980 DOI: 10.1097/j.pain.0000000000003211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 01/31/2024] [Indexed: 03/20/2024]
Abstract
ABSTRACT Moderate-to-severe acute postsurgical pain (APSP) can prolong the recovery and worsen the prognosis of patients who undergo spinal surgery. Esketamine and pregabalin may resolve APSP without causing hyperpathia or respiratory depression after surgery. However, there are other risks, such as dissociative symptoms. We designed a randomized controlled trial to investigate the effect of the combination of these 2 drugs on the incidence of APSP in patients who underwent resection of spinal neoplasms. Patients aged 18 to 65 years were randomized to receive esketamine (a bolus dose of 0.5 mg·kg -1 and an infusion dose of 0.12 mg·kg -1 ·h -1 for 48 hours after surgery) combined with oral pregabalin (75-150 mg/day, starting 2 hours before surgery and ending at 2 weeks after surgery) or an identical volume of normal saline and placebo capsules. The primary outcome was the proportion of patients with moderate-to-severe APSP (visual analog scale score ≥ 40) during the first 48 hours after surgery. Secondary outcomes included the incidence of drug-related adverse events. A total of 90 patients were randomized. The incidence of moderate-to-severe APSP in the combined group (27.3%) was lower than that in the control group (60.5%) during the first 48 hours after surgery (odds ratio = 0.25, 95% CI = 0.10-0.61; P = 0.002). The occurrence of mild dissociative symptoms was higher in the combined group than in the control group (18.2% vs 0%). In conclusion, esketamine combined with pregabalin could effectively alleviate APSP after spinal surgery, but an analgesic strategy might increase the risk of mild dissociative symptoms.
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Affiliation(s)
| | | | | | | | | | - Yuchao Liang
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Wenqing Jia
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
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Chen Y, Wang E, Sites BD, Cohen SP. Integrating mechanistic-based and classification-based concepts into perioperative pain management: an educational guide for acute pain physicians. Reg Anesth Pain Med 2024; 49:581-601. [PMID: 36707224 DOI: 10.1136/rapm-2022-104203] [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: 11/16/2022] [Accepted: 01/13/2023] [Indexed: 01/28/2023]
Abstract
Chronic pain begins with acute pain. Physicians tend to classify pain by duration (acute vs chronic) and mechanism (nociceptive, neuropathic and nociplastic). Although this taxonomy may facilitate diagnosis and documentation, such categories are to some degree arbitrary constructs, with significant overlap in terms of mechanisms and treatments. In clinical practice, there are myriad different definitions for chronic pain and a substantial portion of chronic pain involves mixed phenotypes. Classification of pain based on acuity and mechanisms informs management at all levels and constitutes a critical part of guidelines and treatment for chronic pain care. Yet specialty care is often siloed, with advances in understanding lagging years behind in some areas in which these developments should be at the forefront of clinical practice. For example, in perioperative pain management, enhanced recovery protocols are not standardized and tend to drive treatment without consideration of mechanisms, which in many cases may be incongruent with personalized medicine and mechanism-based treatment. In this educational document, we discuss mechanisms and classification of pain as it pertains to commonly performed surgical procedures. Our goal is to provide a clinical reference for the acute pain physician to facilitate pain management decision-making (both diagnosis and therapy) in the perioperative period.
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Affiliation(s)
- Yian Chen
- Anesthesiology, Stanford University School of Medicine, Stanford, California, USA
| | - Eric Wang
- Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Brian D Sites
- Anesthesiology and Orthopaedics, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Steven P Cohen
- Anesthesiology, Neurology, Physical Medicine & Rehabilitation and Psychiatry & Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Al-Asadi M, Torabiardakani K, Darzi AJ, Gilron I, Marcucci M, Khan JS, Chaparro LE, Rosenbloom BN, Couban RJ, Thomas A, Busse JW, Sadeghirad B. Comparative benefits and harms of perioperative interventions to prevent chronic pain after orthopedic surgery: a systematic review and network meta-analysis of randomized trials. Syst Rev 2024; 13:114. [PMID: 38671531 PMCID: PMC11046964 DOI: 10.1186/s13643-024-02528-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Chronic postsurgical pain (CPSP) is common following musculoskeletal and orthopedic surgeries and is associated with impairment and reduced quality of life. Several interventions have been proposed to reduce CPSP; however, there remains uncertainty regarding which, if any, are most effective. We will perform a systematic review and network meta-analysis of randomised trials to assess the comparative benefits and harms of perioperative pharmacological and psychological interventions directed at preventing chronic pain after musculoskeletal and orthopedic surgeries. METHODS We will search MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from inception to present, without language restrictions. We will include randomised controlled trials that as follows: (1) enrolled adult patients undergoing musculoskeletal or orthopedic surgeries; (2) randomized them to any pharmacological or psychological interventions, or their combination directed at reducing CPSP, placebo, or usual care; and (3) assessed pain at 3 months or more after surgery. Screening for eligible trials, data extraction, and risk-of-bias assessment using revised Cochrane risk-of-bias tool (RoB 2.0) will be performed in duplicate and independently. Our main outcome of interest will be the proportion of surgical patients reporting any pain at ≥ 3 months after surgery. We will also collect data on other patient important outcomes, including pain severity, physical functioning, emotional functioning, dropout rate due to treatment-related adverse event, and overall dropout rate. We will perform a frequentist random-effects network meta-analysis to determine the relative treatment effects. When possible, the modifying effect of sex, surgery type and duration, anesthesia type, and veteran status on the effectiveness of interventions will be investigated using network meta-regression. We will use the GRADE approach to assess the certainty evidence and categorize interventions from most to least beneficial using GRADE minimally contextualised approach. DISCUSSION This network meta-analysis will assess the comparative effectiveness of pharmacological and psychological interventions directed at preventing CPSP after orthopedic surgery. Our findings will inform clinical decision-making and identify promising interventions for future research. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42023432503.
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Affiliation(s)
- Mohammed Al-Asadi
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | | | - Andrea J Darzi
- Department of Anesthesia, McMaster University, Hamilton, ON, L8S 4K1, Canada
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Ian Gilron
- Departments of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Canada
- Departments of Biomedical and Molecular Sciences, Queen's University, Kingston, Canada
- Centre for Neuroscience Studies, Queen's University, Kingston, Canada
- School of Policy Studies, Queen's University, Kingston, ON, Canada
| | - Maura Marcucci
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Clinical Epidemiology and Research Centre (CERC), Department of Biomedical Sciences, Humanitas University & IRCCS Humanitas Research Hospital, Milan, Italy
| | - James S Khan
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Luis E Chaparro
- Department of Anesthesia, Grand River Hospital, Kitchener, ON, Canada
| | - Brittany N Rosenbloom
- Toronto Academic Pain Medicine Institute, Women's College Hospital, Toronto, ON, Canada
| | - Rachel J Couban
- Department of Anesthesia, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - Andrew Thomas
- Canadian Armed Forces Health Services Centre, Edmonton, AB, Canada
| | - Jason W Busse
- Department of Anesthesia, McMaster University, Hamilton, ON, L8S 4K1, Canada
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Michael G. DeGroote National Pain Centre, McMaster University, Hamilton, ON, Canada
| | - Behnam Sadeghirad
- Department of Anesthesia, McMaster University, Hamilton, ON, L8S 4K1, Canada.
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada.
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Abouarab AH, Brülle R, Aboukilila MY, Weibel S, Schnabel A. Efficacy and safety of perioperative ketamine for the prevention of chronic postsurgical pain: A meta-analysis. Pain Pract 2024; 24:553-566. [PMID: 37971167 DOI: 10.1111/papr.13314] [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: 04/08/2023] [Revised: 09/23/2023] [Accepted: 10/19/2023] [Indexed: 11/19/2023]
Abstract
STUDY OBJECTIVE Assessment of the efficacy and safety of perioperative intravenous ketamine in reducing incidence and severity of chronic postsurgical pain. STUDY DESIGN A systematic review and meta-analysis of randomized controlled trials (RCTs). DATA SOURCES The following data sources were systematically searched: MEDLINE, CENTRAL, and EMBASE (till 02/2021). PATIENTS Adult patients undergoing any surgery. INTERVENTIONS Perioperative use of intravenous ketamine as an additive analgesic drug compared to placebo, no active control treatment, and other additive drugs. MEASUREMENTS Primary outcomes were number of patients with chronic postsurgical pain after 6 months and ketamine related adverse effects. Secondary outcomes were chronic postsurgical pain incidence after 3 and 12 months, chronic postsurgical neuropathic pain incidence, chronic postsurgical moderate to severe pain incidence, intensity of chronic postsurgical pain at rest, and during movement, oral morphine consumption after 3, 6, and 12 months and incidence of opioid-related adverse effects. MAIN RESULTS Thirty-six RCTs were included with a total of 3572 patients. Ketamine compared to placebo may result in no difference in the number of patients with chronic postsurgical pain after 6 months (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.71-1.05; I2 = 34%; 16 studies; low-certainty evidence). Ketamine may reduce the incidence of chronic postsurgical neuropathic pain after 3 months in comparison to placebo (RR 0.78, 95% CI 0.62-0.99, I2 = 31%, seven trials, low-certainty evidence). Ketamine compared to placebo may increase the risk for postoperative nystagmus (RR 9.04, 95% CI 1.15-70.90, I2 30%, two trials, low-certainty evidence) and postoperative visual disturbances (RR 2.29, 95% CI 1.05-4.99, I2 10%, seven trials, low-certainty evidence). CONCLUSIONS There is low-certainty evidence that perioperative ketamine has no effect on chronic postsurgical pain in adult patients. Low-certainty evidence suggests that ketamine compared to placebo may reduce incidence of chronic postsurgical neuropathic pain after 3 months. Questions like ideal dosing, treatment duration and more patient-related outcome measures remain unanswered, which warrants further studies. PROTOCOL REGISTRATION Prospero CRD42021223625, 07.01.2021.
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Affiliation(s)
- Ahmed H Abouarab
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
| | - Rebecca Brülle
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
| | | | - Stephanie Weibel
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital of Würzburg, Würzburg, Germany
| | - Alexander Schnabel
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
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6
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Willis DE, Goldstein PA. Targeting Affective Mood Disorders With Ketamine to Prevent Chronic Postsurgical Pain. FRONTIERS IN PAIN RESEARCH 2022; 3:872696. [PMID: 35832728 PMCID: PMC9271565 DOI: 10.3389/fpain.2022.872696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 06/06/2022] [Indexed: 12/02/2022] Open
Abstract
The phencyclidine-derivative ketamine [2-(2-chlorophenyl)-2-(methylamino)cyclohexan-1-one] was added to the World Health Organization's Model List of Essential Medicines in 1985 and is also on the Model List of Essential Medicines for Children due to its efficacy and safety as an intravenous anesthetic. In sub-anesthetic doses, ketamine is an effective analgesic for the treatment of acute pain (such as may occur in the perioperative setting). Additionally, ketamine may have efficacy in relieving some forms of chronic pain. In 2019, Janssen Pharmaceuticals received regulatory-approval in both the United States and Europe for use of the S-enantiomer of ketamine in adults living with treatment-resistant major depressive disorder. Pre-existing anxiety/depression and the severity of postoperative pain are risk factors for development of chronic postsurgical pain. An important question is whether short-term administration of ketamine can prevent the conversion of acute postsurgical pain to chronic postsurgical pain. Here, we have reviewed ketamine's effects on the biopsychological processes underlying pain perception and affective mood disorders, focusing on non-NMDA receptor-mediated effects, with an emphasis on results from human trials where available.
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Affiliation(s)
- Dianna E. Willis
- Burke Neurological Institute, White Plains, NY, United States
- Feil Family Brain and Mind Institute, Weill Cornell Medicine, New York, NY, United States
| | - Peter A. Goldstein
- Feil Family Brain and Mind Institute, Weill Cornell Medicine, New York, NY, United States
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, United States
- Department of Medicine, Weill Cornell Medicine, New York, NY, United States
- *Correspondence: Peter A. Goldstein
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7
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McGregor RH, Warner FM, Linde LD, Cragg JJ, Osborn JA, Varshney VP, Schwarz SKW, Kramer JLK. Quality of meta-analyses of non-opioid, pharmacological, perioperative interventions for chronic postsurgical pain: a systematic review. Reg Anesth Pain Med 2022; 47:263-269. [DOI: 10.1136/rapm-2021-102981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/20/2021] [Indexed: 12/14/2022]
Abstract
BackgroundIn an attempt to aggregate observations from clinical trials, several meta-analyses have been published examining the effectiveness of systemic, non-opioid, pharmacological interventions to reduce the incidence of chronic postsurgical pain.ObjectiveTo inform the design and reporting of future studies, the purpose of our study was to examine the quality of these meta-analyses.Evidence reviewWe conducted an electronic literature search in Embase, MEDLINE, and the Cochrane Database of Systematic Reviews. Published meta-analyses, from the years 2010 to 2020, examining the effect of perioperative, systemic, non-opioid pharmacological treatments on the incidence of chronic postsurgical pain in adult patients were identified. Data extraction focused on methodological details. Meta-analysis quality was assessed using the A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2) critical appraisal tool.FindingsOur search yielded 17 published studies conducting 58 meta-analyses for gabapentinoids (gabapentin and pregabalin), ketamine, lidocaine, non-steroidal anti-inflammatory drugs, and mexiletine. According to AMSTAR 2, 88.2% of studies (or 15/17) were low or critically low in quality. The most common critical element missing was an analysis of publication bias. Trends indicated an improvement in quality over time and association with journal impact factor.ConclusionsWith few individual trials adequately powered to detect treatment effects, meta-analyses play a crucial role in informing the perioperative management of chronic postsurgical pain. In light of this inherent value and despite a number of attempts, high-quality meta-analyses are still needed.PROSPERO registration numberCRD42021230941.
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Subramanian S, Haroutounian S, Palanca BJA, Lenze EJ. Ketamine as a therapeutic agent for depression and pain: mechanisms and evidence. J Neurol Sci 2022; 434:120152. [PMID: 35092901 DOI: 10.1016/j.jns.2022.120152] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 01/07/2022] [Accepted: 01/08/2022] [Indexed: 12/14/2022]
Abstract
Ketamine is an anesthetic drug which is now used to treat chronic pain conditions and psychiatric disorders, especially depression. It is an N-methyl-D-aspartate (NMDA) receptor antagonist with additional effects on α-Amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors, hyperpolarization-activated cyclic nucleotide-gated (HCN) channels, opioid receptors, and monoaminergic receptors. This article focuses on ketamine's role in treating depression and pain, two commonly comorbid challenging conditions with potentially shared neurobiologic circuitry. Many clinical trials have utilized intravenous or intranasal ketamine for treating depression and pain. Intravenous ketamine is more bioavailable than intranasal ketamine and both are effective for acute depressive episodes. Intravenous ketamine is advantageous for post-operative analgesia and is associated with a reduction in total opioid requirements. Few studies have treated chronic pain or concurrent depression and pain with ketamine. Larger, randomized control trials are needed to examine the safety and efficacy of intravenous vs. intranasal ketamine, ideal target populations, and optimal dosing to treat both depression and pain.
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Affiliation(s)
- Subha Subramanian
- Department of Psychiatry, Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
| | - Simon Haroutounian
- Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Ben Julian A Palanca
- Department of Psychiatry, Washington University in St. Louis School of Medicine, St. Louis, MO, USA; Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA; Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA
| | - Eric J Lenze
- Department of Psychiatry, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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9
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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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10
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Chen YYK, Boden KA, Schreiber KL. The role of regional anaesthesia and multimodal analgesia in the prevention of chronic postoperative pain: a narrative review. Anaesthesia 2021; 76 Suppl 1:8-17. [PMID: 33426669 DOI: 10.1111/anae.15256] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2020] [Indexed: 12/14/2022]
Abstract
Effective prevention of chronic postoperative pain is an important clinical goal, informed by a growing body of studies. Peri-operative regional anaesthesia remains one of the most important tools in the multimodal analgesic toolbox, blocking injury-induced activation and sensitisation of both the peripheral and central nervous system. We review the definition and taxonomy of chronic postoperative pain, its mechanistic basis and the most recent evidence for the preventative potential of multimodal analgesia, with a special focus on regional anaesthesia. While regional anaesthesia targets several important aspects of the mechanistic pathway leading to chronic postoperative pain, evidence for its efficacy is still mixed, possibly owing to the heterogeneity of risk profiles within the surgical patient, but also to variation in techniques and medications reported in the literature.
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Affiliation(s)
- Y-Y K Chen
- Department of Anesthesiology, Peri-operative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - K A Boden
- Department of Anesthesiology, Peri-operative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - K L Schreiber
- Department of Anesthesiology, Peri-operative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
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11
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Yang Y, Maher DP, Cohen SP. Emerging concepts on the use of ketamine for chronic pain. Expert Rev Clin Pharmacol 2020; 13:135-146. [DOI: 10.1080/17512433.2020.1717947] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Yunpeng Yang
- Department of Anesthesiology and Critical Care, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Dermot P. Maher
- Department of Anesthesiology and Critical Care, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Steven P. Cohen
- Department of Anesthesiology and Critical Care, Johns Hopkins School of Medicine, Baltimore, MD, USA
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12
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Abstract
OBJECTIVE In the context of the current opioid epidemic, there has been a renewed interest in the use of ketamine as an analgesic agent. METHODS We reviewed ketamine analgesia. RESULTS Ketamine is well-known as an antagonist for N-methyl-D-aspartate receptors. In addition, it can regulate the function of opioid receptors and sodium channels. Ketamine also increases signaling through α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors. These myriad of molecular and cellular mechanisms are responsible for a number of pharmacological functions including pain relief and mood regulation. Clinically, a number of studies have investigated the role of ketamine in the setting of acute and chronic pain, and there is evidence that ketamine can provide analgesia in a variety of pain syndromes. DISCUSSION In this review, we examined basic mechanisms of ketamine and its current clinical use and potential novel use in pain management.
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14
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Psychological factors predict an unfavorable pain trajectory after hysterectomy: a prospective cohort study on chronic postsurgical pain. Pain 2019; 159:956-967. [PMID: 29419656 DOI: 10.1097/j.pain.0000000000001170] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Chronic postsurgical pain (CPSP) is a well-recognized potential complication with negative personal, social, and health care consequences. However, limited data exist on CPSP and on the course of pain over time after hysterectomy. Using data from a prospective cohort study on a consecutive sample assessed at 4 time points, presurgery (T1), 48 hours (T2), 4 months (T3), and 5 years postsurgery (T4), we sought to examine women's PSP trajectories using assessments of pain at T3 and T4. In addition, this study aimed to investigate presurgical and postsurgical risk factors associated with an unfavourable pain trajectory (PT). Based on pain data collected at T3 and T4, 3 distinct trajectories of PSP emerged: no CPSP (PT1; n = 88), prolonged PSP (PT2; n = 53), and CPSP (PT3; n = 29). Moreover, reported CPSP prevalence at 5 years was 17.1%. Multinomial logistic regression models controlling for age, presurgical pain, and type of hysterectomy tested for baseline and acute postsurgical predictive variables. Membership in PT2 and PT3 was predicted by presurgical anxiety (odds ratio [OR] = 1.131, P = 0.015; OR = 1.175, P = 0.009, respectively), emotional representation of the surgical disease (OR = 1.155, P = 0.034; OR = 1.213, P = 0.020, respectively), and pain catastrophizing (OR = 1.079, P = 0.043; OR = 1.143, P = 0.001, respectively). Furthermore, acute PSP intensity and frequency determined membership of women in PT3 (OR = 1.211, P = 0.033; OR = 3.000, P = 0.029, respectively), and postsurgical anxiety (OR = 1.182, P = 0.026) also played a key predictive role. This study identified factors that can be easily screened before and after surgery and are amenable to change through carefully designed timely and tailored interventions for women at risk of an unfavorable PSP trajectory posthysterectomy.
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Abstract
Pain management is complex regardless of whether the pain is acute or chronic in nature or non-cancer or cancer related. In addition, relatively few pain pharmacotherapy options with adequate efficacy and safety data currently exist. Consequently, interest in the role of NMDA receptor antagonists as a pharmacological pain management strategy has surfaced. This narrative review provides an overview of the NMDA receptor and elaborates on the pharmacotherapeutic profile and pain management literature findings for the following NMDA receptor antagonists: ketamine, memantine, dextromethorphan, and magnesium. The literature on this topic is characterized by small studies, many of which exhibit methodological flaws. To date, ketamine is the most studied NMDA receptor antagonist for both acute and chronic pain management. Although further research about NMDA receptor antagonists for analgesia is needed and the optimal dosage/administration regimens for these drugs have yet to be determined, ketamine appears to hold the most promise and may be of particular value in the perioperative pain management realm.
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17
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Seki H, Ideno S, Ishihara T, Watanabe K, Matsumoto M, Morisaki H. Postoperative pain management in patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis: a narrative review. SCOLIOSIS AND SPINAL DISORDERS 2018; 13:17. [PMID: 30214945 PMCID: PMC6134554 DOI: 10.1186/s13013-018-0165-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 07/31/2018] [Indexed: 12/12/2022]
Abstract
Posterior spinal fusion for adolescent idiopathic scoliosis is one of the most invasive surgical procedures performed in children and adolescents. Because of the extensive surgical incision and massive tissue trauma, posterior spinal fusion causes severe postoperative pain. Intravenous patient-controlled analgesia with opioids has been the mainstay of postoperative pain management in these patients. However, the use of systemic opioids is sometimes limited by opioid-related side effects, resulting in poor analgesia. To improve pain management while reducing opioid consumption and opioid-related complications, concurrent use of analgesics and analgesic modalities with different mechanisms of action seems to be rational. The efficacy of intrathecal opioids and nonsteroidal anti-inflammatory drugs as components of multimodal analgesia in scoliosis surgery has been well established. However, there is either controversy or insufficient evidence regarding the use of other analgesic methods, such as continuous ketamine infusion, perioperative oral gabapentin, acetaminophen, continuous wound infiltration of local anesthetics, a single dose of systemic dexamethasone, and lidocaine infusion in this patient population. Moreover, appropriate combinations of analgesics have not been established. The aim of this literature review is to provide detailed information of each analgesic technique so that clinicians can make appropriate choices regarding pain management in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion.
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Affiliation(s)
- Hiroyuki Seki
- 1Department of Anesthesiology, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582 Japan
| | - Satoshi Ideno
- 1Department of Anesthesiology, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582 Japan
| | - Taiga Ishihara
- 1Department of Anesthesiology, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582 Japan
| | - Kota Watanabe
- 2Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582 Japan
| | - Morio Matsumoto
- 2Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582 Japan
| | - Hiroshi Morisaki
- 1Department of Anesthesiology, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582 Japan
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18
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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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Mauermann E, Ruppen W, Bandschapp O. Different protocols used today to achieve total opioid-free general anesthesia without locoregional blocks. Best Pract Res Clin Anaesthesiol 2017; 31:533-545. [DOI: 10.1016/j.bpa.2017.11.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 08/08/2017] [Accepted: 11/08/2017] [Indexed: 12/20/2022]
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Gan TJ. Poorly controlled postoperative pain: prevalence, consequences, and prevention. J Pain Res 2017; 10:2287-2298. [PMID: 29026331 PMCID: PMC5626380 DOI: 10.2147/jpr.s144066] [Citation(s) in RCA: 625] [Impact Index Per Article: 89.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
This review provides an overview of the clinical issue of poorly controlled postoperative pain and therapeutic approaches that may help to address this common unresolved health-care challenge. Postoperative pain is not adequately managed in greater than 80% of patients in the US, although rates vary depending on such factors as type of surgery performed, analgesic/anesthetic intervention used, and time elapsed after surgery. Poorly controlled acute postoperative pain is associated with increased morbidity, functional and quality-of-life impairment, delayed recovery time, prolonged duration of opioid use, and higher health-care costs. In addition, the presence and intensity of acute pain during or after surgery is predictive of the development of chronic pain. More effective analgesic/anesthetic measures in the perioperative period are needed to prevent the progression to persistent pain. Although clinical findings are inconsistent, some studies of local anesthetics and nonopioid analgesics have suggested potential benefits as preventive interventions. Conventional opioids remain the standard of care for the management of acute postoperative pain; however, the risk of opioid-related adverse events can limit optimal dosing for analgesia, leading to poorly controlled acute postoperative pain. Several new opioids have been developed that modulate μ-receptor activity by selectively engaging intracellular pathways associated with analgesia and not those associated with adverse events, creating a wider therapeutic window than unselective conventional opioids. In clinical studies, oliceridine (TRV130), a novel μ-receptor G-protein pathway-selective modulator, produced rapid postoperative analgesia with reduced prevalence of adverse events versus morphine.
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Affiliation(s)
- Tong J Gan
- Stony Brook University, Stony Brook, NY, USA
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21
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Abstract
The efficacy of the N-methyl-D-aspartate receptor antagonist ketamine as an analgesic agent is still under debate, especially for indications such as chronic pain. To understand the efficacy of ketamine for relief of pain, we performed a literature search for relevant narrative and systematic reviews and meta-analyses. We retrieved 189 unique articles, of which 29 were deemed appropriate for use in this review. Ketamine treatment is most effective for relief of postoperative pain, causing reduced opioid consumption. In contrast, for most other indications (that is, acute pain in the emergency department, prevention of persistent postoperative pain, cancer pain, and chronic non-cancer pain), the efficacy of ketamine is limited. Ketamine's lack of analgesic effect was associated with an increase in side effects, including schizotypical effects.
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Affiliation(s)
- Kelly Jonkman
- Department of Anesthesiology, Anesthesia & Pain Research Unit, Leiden University Medical Center, Leiden, Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Anesthesia & Pain Research Unit, Leiden University Medical Center, Leiden, Netherlands
| | - Tine van de Donk
- Department of Anesthesiology, Anesthesia & Pain Research Unit, Leiden University Medical Center, Leiden, Netherlands
| | - Leon Aarts
- Department of Anesthesiology, Anesthesia & Pain Research Unit, Leiden University Medical Center, Leiden, Netherlands
| | - Marieke Niesters
- Department of Anesthesiology, Anesthesia & Pain Research Unit, Leiden University Medical Center, Leiden, Netherlands
| | - Monique van Velzen
- Department of Anesthesiology, Anesthesia & Pain Research Unit, Leiden University Medical Center, Leiden, Netherlands
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22
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Rai A, Meng H, Weinrib A, Englesakis M, Kumbhare D, Grosman-Rimon L, Katz J, Clarke H. A Review of Adjunctive CNS Medications Used for the Treatment of Post-Surgical Pain. CNS Drugs 2017; 31:605-615. [PMID: 28577135 DOI: 10.1007/s40263-017-0440-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Inadequate post-operative pain management can have significant impacts on patients' quality of life. Effective management of acute pain after surgery is important for early mobilization and discharge from hospital, patient satisfaction, and overall well-being. Utilizing multimodal analgesic strategies has become the mainstay of acute post-operative pain management. A comprehensive search was performed, assessing the published or otherwise publically available literature on different central nervous system (CNS) drugs [excluding opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and acetaminophen] and their uses to treat acute post-surgical pain. Included among the drugs evaluated in this review are anticonvulsants, N-methyl-D-aspartic acid (NMDA) agonists, local anesthetics, α2-agonists, cannabinoids, serotonin-noradrenaline reuptake inhibitors (SNRIs), and serotonin-noradrenaline-dopamine reuptake inhibitors (SNDRIs). Timing, dosing, routes of administration, as well as mechanisms of action are discussed for these CNS drugs.
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Affiliation(s)
- Ajit Rai
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, 3 EB-317, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada
| | - Howard Meng
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, 3 EB-317, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada.,Department of Anesthesia, University of Toronto, RM 1200, 12th floor, 123 Edward St., Toronto, Ontario, M5G 1E2, Canada
| | - Aliza Weinrib
- Department of Anesthesia, University of Toronto, RM 1200, 12th floor, 123 Edward St., Toronto, Ontario, M5G 1E2, Canada.,Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada.,Department of Psychology, York University, 4700, Keele St., BSB 232, Toronto, ON, M3J 1P3, Canada
| | - Marina Englesakis
- Library and Information Services, Toronto General HospitalUniversity Health Network, 1 EN-418, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada
| | - Dinesh Kumbhare
- Division of Physical Medicine and Rehabilitation, Department of Medicine, Toronto Rehabilitation Institute, University Health Network, 550 University Ave, Toronto, ON, M5G 2A2, Canada
| | - Liza Grosman-Rimon
- Division of Physical Medicine and Rehabilitation, Department of Medicine, Toronto Rehabilitation Institute, University Health Network, 550 University Ave, Toronto, ON, M5G 2A2, Canada
| | - Joel Katz
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, 3 EB-317, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada.,Department of Anesthesia, University of Toronto, RM 1200, 12th floor, 123 Edward St., Toronto, Ontario, M5G 1E2, Canada.,Department of Psychology, York University, 4700, Keele St., BSB 232, Toronto, ON, M3J 1P3, Canada
| | - Hance Clarke
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, 3 EB-317, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada. .,Department of Anesthesia, University of Toronto, RM 1200, 12th floor, 123 Edward St., Toronto, Ontario, M5G 1E2, Canada. .,Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada.
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Abstract
All chronic pain begins at some discrete point in time. Significant strides in the understanding of mechanisms and risk factors associated with the transition from a new, or acute, pain experience to a chronic pain condition have been made over the past 20 years. These insights provide the hope of one day being able to modify or even halt this pathophysiologic progression. This article reviews some of the current knowledge of this transition as well as the evidence currently available to best prevent and treat it using persistent surgical pain as a model.
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Affiliation(s)
- Ignacio J Badiola
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Penn Pain Medicine Center, 1840 South Street, Philadelphia, PA 19146, USA.
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Intraoperative ketamine reduces immediate postoperative opioid consumption after spinal fusion surgery in chronic pain patients with opioid dependency: a randomized, blinded trial. Pain 2017; 158:463-470. [DOI: 10.1097/j.pain.0000000000000782] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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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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26
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Breivik H. Ketamine has anti-hyperalgesic effects and relieves acute pain, but does not prevent persistent postoperative pain (PPP). Scand J Pain 2015; 7:40-41. [DOI: 10.1016/j.sjpain.2015.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Harald Breivik
- Faculty of Medicine , University of Oslo , Oslo , Norway
- Department of Anaesthesiology , Oslo University Hospital , PB 4950 Nydalen, 0424 Oslo , Norway
- Department of Pain Management and Research , Oslo University Hospital , PB 4950 Nydalen, 0424 Oslo , Norway
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