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Rook JM, Lee LK, Wagner JP, Sullins VF, Lee SL, Shekherdimian S, DeUgarte DA, Dichter CE, Jen HC. Six Years of Quality Improvement in Pectus Excavatum Repair: Implementation of Intercostal Nerve Cryoablation and ERAS Protocols for Patients Undergoing Nuss Procedure. J Pediatr Surg 2024:S0022-3468(24)00430-5. [PMID: 39117536 DOI: 10.1016/j.jpedsurg.2024.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 06/20/2024] [Accepted: 07/14/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND The Nuss procedure for pectus excavatum is associated with prolonged hospitalizations due to pain. We evaluated implementation of intercostal nerve cryoablation and enhanced recovery after surgery (ERAS) protocols on outcomes of Nuss procedures performed over six years at a single institution. METHODS This retrospective cohort study included patients who underwent Nuss procedure from 10/2017 to 09/2023. Patients received epidurals prior to 06/2019, cryoablation from 06/2019 to 07/2021, and ERAS with cryoablation and intraoperative methadone administration after 07/2021. We used multivariable linear regression to evaluate length of stay (LOS), inpatient morphine milligram equivalents (MMEs), and discharge opioids. We assessed the balancing measures of operative time, postoperative pain scores, and complications. RESULTS We identified 62 patients; 15 who received epidurals, 18 cryoablation, and 29 cryoablation with ERAS. Cryoablation was associated with a 62.3% (p < 0.001) decrease in length of stay, an 86.6% (p < 0.001) decrease in inpatient MMEs, and a 72.9% (p < 0.001) decrease in discharge opioids. Cryoablation was additionally associated with 24.5% (p = 0.02) longer operative times and 46.4% (p = 0.04) higher postoperative day one pain scores. Subsequent implementation of an ERAS protocol was associated with a further 82.8% (p = 0.04) decrease in discharge opioids and a 25.0% (p = 0.04) decrease in postoperative day one pain scores. CONCLUSIONS Over six years of quality improvement efforts, we found the implementation of cryoablation and ERAS protocols to be associated with a significant decrease in length of stay and opioid exposures. Protocolized pain management and cryoablation may work synergistically to improve outcomes without compromising patient experience. LEVEL OF EVIDENCE Level III - Retrospective comparative study.
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Affiliation(s)
- Jordan M Rook
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Greater Los Angeles Veterans Administration Healthcare System, Los Angeles, CA, USA; UCLA National Clinician Scholars Program, Los Angeles, CA, USA; Department of Health Policy & Management, UCLA Fielding School of Public Health, USA.
| | - Lisa K Lee
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Justin P Wagner
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Veronica F Sullins
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Steven L Lee
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA, USA
| | - Shant Shekherdimian
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Daniel A DeUgarte
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Christine E Dichter
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Howard C Jen
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Hu Y, Zhang QY, Qin GC, Zhu GH, Long X, Xu JF, Gong Y. Balanced opioid-free anesthesia with lidocaine and esketamine versus balanced anesthesia with sufentanil for gynecological endoscopic surgery: a randomized controlled trial. Sci Rep 2024; 14:11759. [PMID: 38782997 PMCID: PMC11116438 DOI: 10.1038/s41598-024-62824-3] [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: 10/05/2023] [Accepted: 05/21/2024] [Indexed: 05/25/2024] Open
Abstract
In this randomized controlled trial, 74 patients scheduled for gynecological laparoscopic surgery (American Society of Anesthesiologists grade I/II) were enrolled and randomly divided into two study groups: (i) Group C (control), received sufentanil (0.3 μg/kg) and saline, followed by sufentanil (0.1 μg/kg∙h) and saline; and (ii) Group F (OFA), received esketamine (0.15 mg/kg) and lidocaine (2 mg/kg), followed by esketamine (0.1 mg/kg∙h) and lidocaine (1.5 mg/kg∙h). The primary outcome was the 48-h time-weighted average (TWA) of postoperative pain scores. Secondary outcomes included time to extubation, adverse effects, and postoperative sedation score, pain scores at different time points, analgesic consumption at 48 h, and gastrointestinal functional recovery. The 48-h TWAs of pain scores were 1.32 (0.78) (95% CI 1.06-1.58) and 1.09 (0.70) (95% CI 0.87-1.33) for Groups F and C, respectively. The estimated difference between Groups F and C was - 0.23 (95% CI - 0.58 - 0.12; P = 0.195). No differences were found in any of the secondary outcomes and no severe adverse effects were observed in either group. Balanced OFA with lidocaine and esketamine achieved similar effects to balanced anesthesia with sufentanil in patients undergoing elective gynecological laparoscopic surgery, without severe adverse effects.Clinical Trial Registration: ChiCTR2300067951, www.chictr.org.cn 01 February, 2023.
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Affiliation(s)
- Yang Hu
- Institute of Anesthesiology and Critical Care Medicine, China Three Gorges University and Yichang Central People's Hospital, Yichang, 443000, Hubei, China
| | - Qing-Yun Zhang
- Institute of Anesthesiology and Critical Care Medicine, China Three Gorges University and Yichang Central People's Hospital, Yichang, 443000, Hubei, China
| | - Guan-Chao Qin
- Institute of Anesthesiology and Critical Care Medicine, China Three Gorges University and Yichang Central People's Hospital, Yichang, 443000, Hubei, China
| | - Guo-Hong Zhu
- Institute of Anesthesiology and Critical Care Medicine, China Three Gorges University and Yichang Central People's Hospital, Yichang, 443000, Hubei, China
| | - Xiang Long
- Institute of Anesthesiology and Critical Care Medicine, China Three Gorges University and Yichang Central People's Hospital, Yichang, 443000, Hubei, China
| | - Jin-Fei Xu
- Institute of Anesthesiology and Critical Care Medicine, China Three Gorges University and Yichang Central People's Hospital, Yichang, 443000, Hubei, China
| | - Yuan Gong
- Institute of Anesthesiology and Critical Care Medicine, China Three Gorges University and Yichang Central People's Hospital, Yichang, 443000, Hubei, China.
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Boyev A, Popat K, Gottumukkala VNR, Kwater AP, Chiang YJ, Prakash LR, Newhook TE, Arvide EM, Dewhurst WL, Bruno ML, Van Meter A, Hancher-Hodges S, Ghebremichael S, Williams U, Donahue H, Soliz J, Tzeng CWD. Postoperative pain scores and opioid use after standard bupivacaine vs. liposomal bupivacaine regional blocks for abdominal cancer surgery: A propensity score matched study. Am J Surg 2024:S0002-9610(24)00278-2. [PMID: 38789322 DOI: 10.1016/j.amjsurg.2024.05.011] [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: 02/04/2024] [Revised: 05/11/2024] [Accepted: 05/17/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Fascial plane blocks (FPBs) are widely used for abdominal surgery with the assumption that liposomal bupivacaine (LB) is more effective than standard bupivacaine (SB). METHODS This was a single-institution retrospective cohort study of patients administered FPBs with LB or SB + admixtures (dexamethasone/dexmedetomidine) for open abdominal cancer surgery. Propensity score matching generated a 2:1 (LB:SB) matched cohort. Opioid use (mg oral morphine equivalents, OME) and severe pain (≥3 pain scores ≥7 in a 24-h period) were compared. RESULTS Opioid use was >150 mg OME in 19.9 % (29/146) LB and 16.4 % (12/73) SB patients (p = 0.586). Severe pain was experienced by 44 % (64/146) LB and 53 % (39/73) SB patients (p = 0.198). On multivariable analysis, SB vs LB choice was not associated with high opioid volume >150 mg or severe pain. CONCLUSIONS FPBs with standard bupivacaine were not associated with higher 72-h opioid use or more severe pain compared to liposomal bupivacaine.
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Affiliation(s)
- Artem Boyev
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keyuri Popat
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vijaya N R Gottumukkala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrzej P Kwater
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laura R Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Timothy E Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elsa M Arvide
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Whitney L Dewhurst
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Morgan L Bruno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Antoinette Van Meter
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shannon Hancher-Hodges
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Semhar Ghebremichael
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Uduak Williams
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hart Donahue
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jose Soliz
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Shah N, Qazi R, Chu XP. Unraveling the Tapestry of Pain: A Comprehensive Review of Ethnic Variations, Cultural Influences, and Physiological Mechanisms in Pain Management and Perception. Cureus 2024; 16:e60692. [PMID: 38899250 PMCID: PMC11186588 DOI: 10.7759/cureus.60692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2024] [Indexed: 06/21/2024] Open
Abstract
The medical management of pain is a nuanced challenge influenced by sociocultural, demographic, and ethical factors. This review explores the intricate interplay of these dimensions in shaping pain perception and treatment outcomes. Sociocultural elements, encompassing cultural beliefs, language, societal norms, and healing practices, significantly impact individuals' pain experiences across societies. Gender expectations further shape these experiences, influencing reporting and responses. Patient implications highlight age-related and socioeconomic disparities in pain experiences, particularly among the elderly, with challenges in managing chronic pain and socioeconomic factors affecting access to care. Healthcare provider attitudes and biases contribute to disparities in pain management across racial and ethnic groups. Ethical considerations, especially in opioid use, raise concerns about subjective judgments and potential misuse. The evolving landscape of placebo trials adds complexity, emphasizing the importance of understanding psychological and cultural factors. In conclusion, evidence-based guidelines, multidisciplinary approaches, and tailored interventions are crucial for effective pain management. By acknowledging diverse influences on pain experiences, clinicians can provide personalized care, dismantle systemic barriers, and contribute to closing knowledge gaps, impacting individual and public health, well-being, and overall quality of life.
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Affiliation(s)
- Neelay Shah
- Neurology, University of Missouri Kansas City School of Medicine, Kansas City, USA
| | - Rida Qazi
- Neurology, University of Missouri Kansas City School of Medicine, Kansas City, USA
| | - Xiang-Ping Chu
- Biomedical Sciences, University of Missouri Kansas City School of Medicine, Kansas City, USA
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Aranda-Valderrama P, Greenberg RS, Vecchione TM, Finney AG, Prichett LM, Vanderhoek SM. Combined erector spinae plane block with surgical intercostal nerve cryoablation for Nuss procedure is associated with decreased opioid use and length of stay. Reg Anesth Pain Med 2024; 49:248-253. [PMID: 37407278 DOI: 10.1136/rapm-2023-104407] [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: 02/02/2023] [Accepted: 06/24/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Pain management for patients undergoing the Nuss procedure for treatment of pectus excavatum can be challenging. In an effort to improve pain management, our institution added bilateral single injection erector spinae plane (ESP) blocks to surgeon placed intercostal nerve cryoablation. We aimed to assess the efficacy of this practice change. METHODS Retrospective clinical data from a single academic medical center were evaluated. Due to an institutional change in clinical management, we were able to perform a before and after study. Twenty patients undergoing Nuss procedure who received bilateral ultrasound-guided single-shot T6 level ESP blocks and intercostal nerve cryoablation were compared with a historical control cohort of 20 patients who underwent Nuss procedure with intercostal nerve cryoablation alone. The primary outcome variables included postoperative pain scores, total hospital opioid use, and hospital length of stay. RESULTS Median total hospital intravenous morphine milligram equivalents was lower for the ESP group than for the control group (0.60 (IQR 0.35-0.88) vs 1.15 mg/kg (IQR 0.74-1.68), p<0.01). There was no difference in postoperative pain scores between the two groups. Mean hospital length of stay was 2.45 (SD 0.69) days for the control group and 1.95 (SD 0.69) days for the ESP group (p=0.03). No adverse events related to block placement were identified. CONCLUSIONS In a single-center academic practice, the addition of bilateral single injection ESP blocks at T6 to surgeon performed cryoablation reduced opioid consumption without a change in subjectively reported pain scores. The results from this pilot study can provide effect size estimates to guide the design of future randomized trials.
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Affiliation(s)
- Paola Aranda-Valderrama
- Division of Pediatric Anesthesia, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Robert S Greenberg
- Division of Pediatric Anesthesia, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tricia M Vecchione
- Division of Pediatric Anesthesia, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amanda G Finney
- Biostatistics, Epidemiology and Data Management (BEAD) Core, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Laura M Prichett
- Biostatistics, Epidemiology and Data Management (BEAD) Core, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Samuel M Vanderhoek
- Division of Pediatric Anesthesia, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Fu VX, Lagarde SM, Favoccia CT, Heisterkamp J, van Oers AE, Coene PPLO, Koopman JSHA, van den Berg SAA, Dik WA, Jeekel J, Wijnhoven BPL. Intraoperative Music to Promote Patient Outcome (IMPROMPTU): A Double-Blind Randomized Controlled Trial. J Surg Res 2024; 296:291-301. [PMID: 38306934 DOI: 10.1016/j.jss.2024.01.006] [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: 02/06/2023] [Revised: 12/03/2023] [Accepted: 01/02/2024] [Indexed: 02/04/2024]
Abstract
INTRODUCTION Perioperative music can have beneficial effects on postoperative pain, anxiety, opioid requirement, and the physiological stress response to surgery. The aim was to assess the effects of intraoperative music during general anesthesia in patients undergoing surgery for esophagogastric cancer. MATERIALS AND METHODS The IMPROMPTU study was a double-blind, placebo-controlled, randomized multicenter trial. Adult patients undergoing surgery for stage II-III esophagogastric cancer were eligible. Exclusion criteria were a hearing impairment, insufficient Dutch language knowledge, corticosteroids use, or objection to hearing unknown music. Patients wore active noise-cancelling headphones intraoperatively with preselected instrumental classical music (intervention) or no music (control). Computerized randomization with centralized allocation, stratified according to surgical procedure using variable block sizes, was employed. Primary endpoint was postoperative pain on the first postoperative day. Secondary endpoints were postoperative pain during the first postoperative week, postoperative opioid requirement, intraoperative medication requirement, the stress response to surgery, postoperative complication rate, length of stay, and mortality, with follow-up lasting 30 d. RESULTS From November 2018 to September 2020, 145 patients were assessed and 83 randomized. Seventy patients (music n = 31, control n = 39) were analyzed. Median age was 70 [IQR 63-70], and 48 patients (69%) were male. Music did not reduce postoperative pain (numeric rating scale 1.8 (SD0.94) versus 2.0 (1.0), mean difference -0.28 [95% CI -0.76-0.19], P = 0.236). No statistically significant differences were seen in medication requirement, stress response, complication rate, or length of stay. CONCLUSIONS Intraoperative, preselected, classical music during esophagogastric cancer surgery did not significantly improve postoperative outcome and recovery when compared to no music using noise-cancelling headphones.
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Affiliation(s)
- Victor X Fu
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
| | - Sjoerd M Lagarde
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Christian T Favoccia
- Department of Anesthesiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Joos Heisterkamp
- Department of Surgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Annemarie E van Oers
- Department of Anesthesiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | | | | | - Sjoerd A A van den Berg
- Department of Clinical Chemistry, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Willem A Dik
- Department of Immunology, Laboratory Medical Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Johannes Jeekel
- Department of Neuroscience, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Qin GC, Hu Y, Cha NH, Zhang QY, Gong Y. Intravenous lidocaine on postoperative pain and opioid consumption during gynecological surgery: a meta-analysis of randomized controlled trials. Minerva Obstet Gynecol 2024; 76:181-187. [PMID: 36255169 DOI: 10.23736/s2724-606x.22.05209-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
INTRODUCTION This study aimed to evaluate the role of intravenous lidocaine as a adjuvant anesthetics in patients undergoing gynecological surgery. EVIDENCE ACQUISITION We conducted a meta-analysis of randomized controlled trials (RCTs) from PubMed/Medline, Embase and clinic trails.gov involving the use of intravenous lidocaine in gynecological surgery. We used a more comprehensive search strategy to adequately screen for randomized controlled trials involving intravenous lidocaine infusion in gynecological surgery. First outcomes were postoperative pain scores. And secondary outcomes included 24 h postoperative opioids consumption, time to first flatus, and incidence of postoperative nausea and vomiting. EVIDENCE SYNTHESIS A total of 6 RCTs comprising 375 patients were included in the meta-analysis. There were statistically significant between postoperative pain scores. The consumption of opioids and anesthetics during surgery and 24 hours after surgery was statistically significant when compared with the control group. Postoperative pain scores were similar at 2, 4, 6, 8, 10, 12, 24, 48 hours between groups. No statistical differences were found in postoperative complications including nausea, vomiting and restoration of the intestinal function. CONCLUSIONS Our results indicated that the current literature supports the perioperative use of intravenous lidocaine as part of multimodal analgesia and beneficial to patients in early postoperative analgesia, reduced opioid consumption.
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Affiliation(s)
- Guan-Chao Qin
- Institute of Anesthesiology and Critical Care Medicine, Three Gorges University & Yichang Central People's Hospital, Yichang, China
| | - Yang Hu
- Institute of Anesthesiology and Critical Care Medicine, Three Gorges University & Yichang Central People's Hospital, Yichang, China
| | - Ning-Hui Cha
- Institute of Anesthesiology and Critical Care Medicine, Three Gorges University & Yichang Central People's Hospital, Yichang, China
| | - Qing-Yun Zhang
- Institute of Anesthesiology and Critical Care Medicine, Three Gorges University & Yichang Central People's Hospital, Yichang, China
| | - Yuan Gong
- Institute of Anesthesiology and Critical Care Medicine, Three Gorges University & Yichang Central People's Hospital, Yichang, China -
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Davis MP, McPherson ML, Reddy A, Case AA. Conversion ratios: Why is it so challenging to construct opioid conversion tables? J Opioid Manag 2024; 20:169-179. [PMID: 38700396 DOI: 10.5055/jom.0853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Standardizing opioid management is challenging due to the absence of a ceiling dose, the unknown ideal therapeutic plasma level, and the lack of an clear relationship between dose and therapeutic response. Opioid rotation or conversion, which is switching from one opioid, route of administration, or both, to another, to improve therapeutic response and reduce toxicities, occurs in 20-40 percent of patients treated with opioids. Opioid conversion is often needed when there are adverse effects, toxicities, or inability to tolerate a certain opioid formulation. A majority of patients benefit from opioid conversion, leading to improved analgesia and less adverse effects. There are different published ways of converting opioids in the literature. This review of 20 years of literature is centered on opioid conversions and aims to discuss the complexity of converting opioids. We discuss study designs, outcomes and measures, pain phenotypes, patient characteristics, comparisons of equivalent doses between opioids, reconciling conversion ratios between opioids, routes, directional differences, half-lives and metabolites, interindividual variability, and comparison to package insert information. Palliative care specialists have not yet come to a consensus on the ideal opioid equianalgesic table; however, we discuss a recently updated table, based on retrospective evidence, that may serve as a gold standard for practical use in the palliative care population. More robust, well-designed studies are needed to validate and guide future opioid conversion data.
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Affiliation(s)
- Mellar P Davis
- Geisinger Medical Center, Danville, Pennsylvania. ORCID: https://orcid.org/0000-0002-7903-3993
| | - Mary Lynn McPherson
- University of Maryland School of Pharmacy, Baltimore, Maryland. ORCID: https://orcid.org/0000-0001-6098-2112
| | - Akhila Reddy
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas. ORCID: https://orcid.org/0000-0002-7628-8675
| | - Amy A Case
- Department of Palliative and Supportive Care, Roswell Park Comprehensive Cancer Center, Buffalo, New York
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Mercadante S. An overview of the current drug treatment strategies for moderate to severe, chronic malignant tumor-related pain. Expert Opin Pharmacother 2024; 25:171-179. [PMID: 37016731 DOI: 10.1080/14656566.2023.2200137] [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: 03/10/2022] [Accepted: 04/04/2023] [Indexed: 04/06/2023]
Abstract
INTRODUCTION The pharmacological management of cancer pain is a complex issue that requires knowledge and experience in the use of analgesics. The aim of this expert review is to provide a panorama of the pharmacological strategies in cancer pain management. AREAS COVERED Opioid dose titration is a delicate process regarding the start of opioid treatment in different clinical conditions. How to improve the opioid response is a fundamental step, which includes different strategies when an initial treatment with opioids fails. The use of adjuvants is another relevant issue that should be considered in some specific circumstances to optimize the management of cancer pain management. Some clinical conditions, such as neuropathic pain and breakthrough pain, deserve a special attention. Relevant literature was selected to provide an overview of cancer pain management strategies. EXPERT OPINION Opioid therapy still remains the cornerstone of pharmacological management of cancer pain. Opioids should be used according to the level of tolerance, also personalizing the treatment (route, drug, and dosing). Adjuvant drugs may help in specific conditions, although their use should be balanced with the adverse effects. Breakthrough pain requires expertise in tailoring a treatment according to patient's profile and characteristics of episodes.
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Affiliation(s)
- Sebastiano Mercadante
- Main regional center of pain relief and supportive/palliative care, La Maddalena Cancer Center, Palermo, Italy
- Home palliative care program, Regional Home care program, SAMOT, Palermo, Italy
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Jeffries SD, Harutyunyan R, Morse J, Hemmerling TM. Investigation into the clinical performance of rectus sheath block in reducing postoperative pain following surgical intervention: A systematic review and meta-analysis of randomised controlled trials. Indian J Anaesth 2024; 68:142-152. [PMID: 38435659 PMCID: PMC10903772 DOI: 10.4103/ija.ija_1099_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 01/10/2024] [Accepted: 01/11/2024] [Indexed: 03/05/2024] Open
Abstract
Background and Aims Rectus sheath block (RSB) is an effective postoperative pain control technique in abdominal surgical procedures. This systematic review evaluated the efficacy and outcome data of patients undergoing RSB compared to the standard of care in both laparoscopic and open surgical procedures. Methods This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO ID: CRD42022372596). The search was restricted to randomised controlled trials (RCTs) comparing RSB effectiveness on postoperative pain to any standard general anaesthesia technique (control). We systematically explored PubMed, Medline, Central, Scopus and Web of Science for RCTs from inception to September 2023. The primary outcome was the evaluation of pain scores at rest 0-2, 10-12 and 12-24 h postoperatively. The secondary outcome was the analysis of postoperative intravenous (IV) morphine equivalent consumption at 24-h. A risk-of-bias tool for randomised trials (ROB 2.0, Cochrane, Copenhagen, Denmark) assessment and Grades of Recommendation, Assessment, Development and Evaluation (GRADE, Cochrane, Copenhagen, Denmark) analysis was conducted to evaluate the quality of the RCTs. Results Twenty RCTs involving 708 participants who received RSB intervention and 713 who received alternative analgesic care were included. RSB pain scores were significantly lower than control at 0-2 h (P < 0.001) and 10-12 h (P < 0.001) postoperatively. No significant effect was observed at 24 h (P = 0.11). RSB performance compared to control in 24-h IV morphine equivalency in milligrams was significantly lower (P < 0.001). Conclusion RSB implementation was associated with reduced postoperative pain scores and decreased opioid consumption in IV morphine equivalency up to 24 h following surgical intervention.
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Affiliation(s)
- Sean D. Jeffries
- Department of Experimental Surgery, McGill University Health Center, Montréal, Canada
- Department of Anaesthesia, McGill University, Montréal, Canada
| | - Robert Harutyunyan
- Department of Experimental Surgery, McGill University Health Center, Montréal, Canada
| | - Joshua Morse
- Department of Experimental Surgery, McGill University Health Center, Montréal, Canada
| | - Thomas M. Hemmerling
- Department of Experimental Surgery, McGill University Health Center, Montréal, Canada
- Department of Anaesthesia, McGill University, Montréal, Canada
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Burns ML, Hilliard P, Vandervest J, Mentz G, Josifoski A, Varghese J, Fisher C, Kheterpal S, Shah N, Bicket MC. Variation in Intraoperative Opioid Administration by Patient, Clinician, and Hospital Contribution. JAMA Netw Open 2024; 7:e2351689. [PMID: 38227311 DOI: 10.1001/jamanetworkopen.2023.51689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2024] Open
Abstract
Importance The opioid crisis has led to scrutiny of opioid exposures before and after surgical procedures. However, the extent of intraoperative opioid variation and the sources and contributing factors associated with it are unclear. Objective To analyze attributable variance of intraoperative opioid administration for patient-, clinician-, and hospital-level factors across surgical and analgesic categories. Design, Setting, and Participants This cohort study was conducted using electronic health record data collected from a national quality collaborative database. The cohort consisted of 1 011 268 surgical procedures at 46 hospitals across the US involving 2911 anesthesiologists, 2291 surgeons, and 8 surgical and 4 analgesic categories. Patients without ambulatory opioid prescriptions or use history undergoing an elective surgical procedure between January 1, 2014, and September 11, 2020, were included. Data were analyzed from January 2022 to July 2023. Main Outcomes and Measures The rate of intraoperative opioid administration as a continuous measure of oral morphine equivalents (OMEs) normalized to patient weight and case duration was assessed. Attributable variance was estimated in a hierarchical structure using patient, clinician, and hospital levels and adjusted intraclass correlations (ICCs). Results Among 1 011 268 surgical procedures (mean [SD] age of patients, 55.9 [16.2] years; 604 057 surgical procedures among females [59.7%]), the mean (SD) rate of intraoperative opioid administration was 0.3 [0.2] OME/kg/h. Together, clinician and hospital levels contributed to 20% or more of variability in intraoperative opioid administration across all analgesic and surgical categories (adjusting for surgical or analgesic category, ICCs ranged from 0.57-0.79 for the patient, 0.04-0.22 for the anesthesiologist, and 0.09-0.26 for the hospital, with the lowest ICC combination 0.21 for anesthesiologist and hosptial [0.12 for the anesthesiologist and 0.09 for the hospital for opioid only]). Comparing the 95th and fifth percentiles of opioid administration, variation was 3.3-fold among anesthesiologists (surgical category range, 2.7-fold to 7.7-fold), 4.3-fold among surgeons (surgical category range, 3.4-fold to 8.0-fold), and 2.2-fold among hospitals (surgical category range, 2.2-fold to 4.3-fold). When adjusted for patient and surgical characteristics, mean (square error mean) administration was highest for cardiac surgical procedures (0.54 [0.56-0.52 OME/kg/h]) and lowest for orthopedic knee surgical procedures (0.19 [0.17-0.21 OME/kg/h]). Peripheral and neuraxial analgesic techniques were associated with reduced administration in orthopedic hip (51.6% [95% CI, 51.4%-51.8%] and 60.7% [95% CI, 60.5%-60.9%] reductions, respectively) and knee (48.3% [95% CI, 48.0%-48.5%] and 60.9% [95% CI, 60.7%-61.1%] reductions, respectively) surgical procedures, but reduction was less substantial in other surgical categories (mean [SD] reduction, 13.3% [8.8%] for peripheral and 17.6% [9.9%] for neuraxial techniques). Conclusions and Relevance In this cohort study, clinician-, hospital-, and patient-level factors had important contributions to substantial variation of opioid administrations during surgical procedures. These findings suggest the need for a broadened focus across multiple factors when developing and implementing opioid-reducing strategies in collaborative quality-improvement programs.
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Affiliation(s)
- Michael L Burns
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Paul Hilliard
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - John Vandervest
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Graciela Mentz
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Ace Josifoski
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Jomy Varghese
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Clark Fisher
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Nirav Shah
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Mark C Bicket
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
- Opioid Prescribing Engagement Network, Institute for Healthcare Innovation and Policy, University of Michigan, Ann Arbor
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12
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Ou Y, Wu M, Liu D, Luo L, Xu X, Panayi AC, He J, Long Y, Feng J, Nian M, Cui Y. Efficacy and Safety of Nerve Block for Postoperative Analgesia in Patients Undergoing Breast Cosmetic Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Aesthetic Plast Surg 2024; 48:71-83. [PMID: 36939869 DOI: 10.1007/s00266-023-03320-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 03/04/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND To evaluate the postoperative analgesic efficacy and safety of nerve block (NB) in patients undergoing breast surgery for cosmetic purposes. METHODS PubMed, Web of Science, Embase and Cochrane Libraries were searched from inception to September 2022, to identify all eligible randomized controlled trials (RCTs). Continuous data are presented as mean difference (MD) with 95% confidence intervals (CI), whereas dichotomous data are provided as odds ratios (OR) with 95% CI. This meta-analysis was performed in RevMan 5.4. RESULTS A total of 10 RCTs with 565 patients were meta-analyzed. Compared to the control group, the pain score of the NB group was significantly lower at postoperative 2, 3-4, 6-8, 12-16 and 24 h. Opioid consumption in the first postoperative 24 h was significantly lower in the NB group (MD = - 9.02, 95% CI - 14.29 to - 3.75, P < 0.05), I2 = 95%). In addition, the NB group showed a prolonged time to first postoperative analgesic requirement (MD = 43.15, 95% CI 4.74-81.56, P < 0.05, I2 = 96%), decreased incidence of additional postoperative analgesia (OR 0.14, 95% CI 0.07-0.28, P < 0.05, I2 = 0%) and reduced incidence of postoperative nausea or vomiting (OR 0.33; 95% CI 0.22-0.48; P < 0.05; I2 = 0%). There was no significant difference in operation duration between the two groups. CONCLUSIONS Nerve block is an effective and safe option for postoperative analgesia after breast cosmetic surgery. LEVEL OF EVIDENCE II This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Yanting Ou
- Department of Plastic Surgery, Peking University Shenzhen Hospital, Shenzhen, 518036, Guangdong, China
- Shantou University Medical College, Shantou, China
| | - Mengfan Wu
- Department of Plastic Surgery, Peking University Shenzhen Hospital, Shenzhen, 518036, Guangdong, China
| | - Dandan Liu
- Department of Plastic Surgery, Peking University Shenzhen Hospital, Shenzhen, 518036, Guangdong, China
| | - Lin Luo
- Department of Plastic Surgery, Peking University Shenzhen Hospital, Shenzhen, 518036, Guangdong, China
| | - Xiangwen Xu
- Department of Plastic Surgery, Peking University Shenzhen Hospital, Shenzhen, 518036, Guangdong, China
| | - Adriana C Panayi
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Junjun He
- Department of Plastic Surgery, Peking University Shenzhen Hospital, Shenzhen, 518036, Guangdong, China
| | - Yun Long
- Department of Plastic Surgery, Peking University Shenzhen Hospital, Shenzhen, 518036, Guangdong, China
| | - Jun Feng
- Department of Plastic Surgery, Peking University Shenzhen Hospital, Shenzhen, 518036, Guangdong, China
| | - Mingxuan Nian
- Department of Plastic Surgery, Peking University Shenzhen Hospital, Shenzhen, 518036, Guangdong, China
| | - Yongyan Cui
- Department of Plastic Surgery, Peking University Shenzhen Hospital, Shenzhen, 518036, Guangdong, China.
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13
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Oh J, Yeo J. Trends in the prescription of opioids and gabapentinoids in patients with failed back surgery syndrome in Korea: a population-based study. Korean J Pain 2024; 37:73-83. [PMID: 38130090 PMCID: PMC10764216 DOI: 10.3344/kjp.23246] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 12/06/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023] Open
Abstract
Background Failed back surgery syndrome (FBSS) is a chronic condition that is characterized by persistent back pain following one or more spinal surgeries. Pharmacological interventions, such as the use of opioids and gabapentinoids, are frequently used in the treatment of FBSS. However, prolonged and excessive use of these medications can lead to dependence and adverse effects. This study investigates trends in opioid and gabapentinoid prescriptions among patients with FBSS in Korea from 2016 to 2020. Methods Data from the Health Insurance and Review Agency were analyzed, and claims listing FBSS were selected for the study. Prescription patterns of opioids and gabapentinoids were classified based on the number of days prescribed per year. Results Of the 390,095 patients diagnosed with FBSS, 41.6% of the patients were prescribed gabapentinoids, and 42.0% of them were prescribed opioids, while 10.6% of the patients were classified as long-term gabapentinoid users, 11.4% as long-term opioid users, and 7.4% of the patients were found to have long-term prescriptions for both drugs. The proportion of patients who received both gabapentinoid and opioid prescriptions increased annually. The doses of opioids prescribed have also increased along with the increase in the number of patients receiving opioid prescriptions. Conclusions The prescription rates of opioids and gabapentinoids among patients with FBSS in Korea continue to increase steadily, posing potential risks of addiction and adverse effects. Further research is needed to better understand the actual status of addiction in patients with FBSS.
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Affiliation(s)
- Jinyoung Oh
- Department of Anesthesiology and Pain Medicine, Kyungpook National University School of Medicine, Kyunpook National University Chilgok Hospital, Daegu, Korea
| | - Jinseok Yeo
- Department of Anesthesiology and Pain Medicine, Kyungpook National University School of Medicine, Kyunpook National University Chilgok Hospital, Daegu, Korea
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14
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Canoura J, Liu Y, Alkhamis O, Xiao Y. Aptamer-Based Fentanyl Detection in Biological Fluids. Anal Chem 2023; 95:18258-18267. [PMID: 38033203 DOI: 10.1021/acs.analchem.3c04104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Fentanyl is a widely abused analgesic and anesthetic drug with a narrow therapeutic window that creates easy opportunities for overdose and death. Rapid, accurate, and sensitive fentanyl detection in biosamples is crucial for therapeutic drug monitoring and overdose diagnosis. Unfortunately, current methods are limited to either sophisticated laboratory-based tests or antibody-based immunoassays, which are prone to false results and are mainly used with urine samples. Here, we have utilized library-immobilized SELEX to isolate new aptamers─nucleic acid-based bioreceptors that are well-suited for biosensing─that can specifically bind fentanyl under physiological conditions. We isolated multiple aptamers with nanomolar affinity and excellent specificity against dozens of interferents and incorporated one of these into an electrochemical aptamer-based sensor that can rapidly detect fentanyl at clinically relevant concentrations in 50% diluted serum, urine, and saliva. Given the excellent performance of these sensors, we believe that they could serve as the basis for point-of-care devices for monitoring fentanyl during medical procedures and determining fentanyl overdose.
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Affiliation(s)
- Juan Canoura
- Department of Chemistry, North Carolina State University, 2620 Yarbrough Drive, Raleigh, North Carolina , 27607, United States
| | - Yingzhu Liu
- Department of Chemistry, North Carolina State University, 2620 Yarbrough Drive, Raleigh, North Carolina , 27607, United States
| | - Obtin Alkhamis
- Department of Chemistry, North Carolina State University, 2620 Yarbrough Drive, Raleigh, North Carolina , 27607, United States
| | - Yi Xiao
- Department of Chemistry, North Carolina State University, 2620 Yarbrough Drive, Raleigh, North Carolina , 27607, United States
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15
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Abdel Shaheed C, Ivers R, Vizza L, McLachlan A, Kelly PJ, Blyth F, Stanaway F, Clare PJ, Thompson R, Lung T, Degenhardt L, Reid S, Martin B, Wright M, Osman R, French S, McCaffery K, Campbell G, Jenkins H, Mathieson S, Boogs M, McMaugh J, Bennett C, Maher C. Clinical Observation, Management and Function Of low back pain Relief Therapies (COMFORT): A cluster randomised controlled trial protocol. BMJ Open 2023; 13:e075286. [PMID: 37989377 PMCID: PMC10668201 DOI: 10.1136/bmjopen-2023-075286] [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: 05/03/2023] [Accepted: 10/04/2023] [Indexed: 11/23/2023] Open
Abstract
INTRODUCTION Low back pain (LBP) is commonly treated with opioid analgesics despite evidence that these medicines provide minimal or no benefit for LBP and have an established profile of harms. International guidelines discourage or urge caution with the use of opioids for back pain; however, doctors and patients lack practical strategies to help them implement the guidelines. This trial will evaluate a multifaceted intervention to support general practitioners (GPs) and their patients with LBP implement the recommendations in the latest opioid prescribing guidelines. METHODS AND ANALYSIS This is a cluster randomised controlled trial that will evaluate the effect of educational outreach visits to GPs promoting opioid stewardship alongside non-pharmacological interventions including heat wrap and patient education about the possible harms and benefits of opioids, on GP prescribing of opioids medicines dispensed. At least 40 general practices will be randomised in a 1:1 ratio to either the intervention or control (no outreach visits; GP provides usual care). A total of 410 patient-participants (205 in each arm) who have been prescribed an opioid for LBP will be enrolled via participating general practices. Follow-up of patient-participants will occur over a 1-year period. The primary outcome will be the cumulative dose of opioid dispensed that was prescribed by study GPs over 1 year from the enrolment visit (in morphine milligram equivalent dose). Secondary outcomes include prescription of opioid medicines, benzodiazepines, gabapentinoids, non-steroidal anti-inflammatory drugs by study GPs or any GP, health services utilisation and patient-reported outcomes such as pain, quality of life and adverse events. Analysis will be by intention to treat, with a health economics analysis also planned. ETHICS AND DISSEMINATION The trial received ethics approval from The University of Sydney Human Research Ethics Committee (2022/511). The results will be disseminated via publications in journals, media and conference presentations. TRIAL REGISTRATION NUMBER ACTRN12622001505796.
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Affiliation(s)
- Christina Abdel Shaheed
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney, Sydney, New South Wales, Australia
| | - Rowena Ivers
- Graduate School of Medicine, University of Wollongong, Sydney, New South Wales, Australia
| | - Lisa Vizza
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney, Sydney, New South Wales, Australia
| | - Andrew McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Patrick J Kelly
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Fiona Blyth
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Fiona Stanaway
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Philip James Clare
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Prevention Research Collaboration, University of Sydney, Sydney, New South Wales, Australia
- National Drug and Alcohol Research Centre (NDARC), Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Rachel Thompson
- Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Thomas Lung
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre (NDARC), Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Sharon Reid
- Specialty of Addiction Medicine, Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Bradley Martin
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences College of Pharmacy, Arkansas, Arkansas, USA
| | - Michael Wright
- Centre for Health Economics Research Evaluation, University of Technology Sydney, Sydney, New South Wales, Australia
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Rawa Osman
- Quality Use of Medicines (QUM) Connect, Sydney, New South Wales, Australia
| | - Simon French
- Department of Chiropractic, Macquarie University, Sydney, New South Wales, Australia
| | - Kirsten McCaffery
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Health Literacy Lab, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Gabrielle Campbell
- School of Psychology, University of Queensland, Queensland, Queensland, Australia
| | - Hazel Jenkins
- Department of Chiropractic, Macquarie University, Sydney, New South Wales, Australia
| | - Stephanie Mathieson
- Sydney Musculoskeletal Health, University of Sydney, Sydney, New South Wales, Australia
- Kolling Institute, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Monika Boogs
- Painaustralia Consumer Advisory Group, Canberra, ACT, Australia
| | - Jarrod McMaugh
- Pharmaceutical Society of Australia, Canberra, ACT, Australia
| | - Carol Bennett
- Alliance for Gambling Reform, National, Victoria, Australia
- College of Arts and Social Sciences, The Australian National University, Canberra, ACT, Australia
- Department of Health, Therapeutic Goods Administration National Medicines Scheduling Advisory Committee, Canberra, ACT, Australia
- Faculty of Health Science, University of Canberra, Canberra, ACT, Australia
| | - Christopher Maher
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney, Sydney, New South Wales, Australia
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16
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Spaans LN, van Steenwijk QCA, Seiranjan A, Janssen N, de Loos ER, Susa D, Eerenberg JP, Bouwman RA(A, Dijkgraaf MG, van den Broek FJC. Pain management after pneumothorax surgery: intercostal nerve block or thoracic epidural analgesia. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 37:ivad180. [PMID: 37941433 PMCID: PMC10645434 DOI: 10.1093/icvts/ivad180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 10/11/2023] [Accepted: 11/03/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVES In patients undergoing video-assisted thoracoscopic surgery for pneumothorax, the benefits and risks of single-shot intercostal nerve block as loco-regional analgesia are not well known. We retrospectively compared the effectiveness of intercostal nerve blocks as a viable alternative to thoracic epidural analgesia (TEA) regarding pain control and enhanced recovery. METHODS A retrospective multicentre analysis with single-centre propensity score matching was performed in patients undergoing video-assisted thoracoscopic surgery for pneumothorax receiving either TEA or intercostal nerve block. The primary outcome was a proportion of pain scores ≥4 (scale 0-10) until postoperative day (POD) 3. Secondary outcomes included variation in pain over time, additional opioid use, length of stay, mobility, complications and recurrence rate. RESULTS In 218 patients, TEA was compared to intercostal nerve block and showed no difference in the proportion of pain scores ≥4 {14.3% [interquartile range (IQR) 0.0-33.3] vs 11.1% (IQR 0.0-27.3) respectively, P = 0.24}, more frequently needed additional opioids on the day of surgery (18% vs 48%) and first POD (20% vs 42%), had a shorter length of stay (4.0 days [IQR 3.0-7.0] vs 3.0 days [IQR 2.8-4.0]) and were significantly more mobile until POD 3, while having similar recurrences. Intercostal nerve block had higher pain scores early in the course whereas TEA had higher late (rebound) pain scores. CONCLUSIONS In a multimodal analgesic setting with additional opioids, intercostal nerve block shows comparable moments of unacceptable pain from POD 0-3 compared to TEA and is linked to improved mobility. Results require randomized confirmation.
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Affiliation(s)
- Louisa N Spaans
- Department of Surgery, Maxima Medical Center, Eindhoven, Netherlands
- Department of Epidemiology and Data Science, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
- Methodology, Amsterdam Public Health, Amsterdam, Netherlands
| | | | - Adelina Seiranjan
- Department of Surgery, Maxima Medical Center, Eindhoven, Netherlands
| | - Nicky Janssen
- Department of Surgery, Zuyderland Medical Centre, Heerlen, Netherlands
| | - Erik R de Loos
- Department of Surgery, Zuyderland Medical Centre, Heerlen, Netherlands
| | - Denis Susa
- Department of Surgery, Bravis Hospital, Bergen op Zoom, Netherlands
| | - Jan P Eerenberg
- Department of Surgery, Tergooi Medical Centre, Hilversum, Netherlands
| | - R A (Arthur) Bouwman
- Department of Anesthesiology and Pain Medicine, Catharina Hospital, Eindhoven, Netherlands
- Department of Electrical Engineering, Signal Processing Systems, Eindhoven Technical University, Eindhoven, Netherlands
| | - Marcel G Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
- Methodology, Amsterdam Public Health, Amsterdam, Netherlands
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17
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Boyev A, Jain AJ, Newhook TE, Prakash LR, Chiang YJ, Bruno ML, Arvide EM, Dewhurst WL, Kim MP, Maxwell JE, Ikoma N, Snyder RA, Lee JE, Katz MHG, Tzeng CWD. Opioid-Free Discharge After Pancreatic Resection Through a Learning Health System Paradigm. JAMA Surg 2023; 158:e234154. [PMID: 37672236 PMCID: PMC10483385 DOI: 10.1001/jamasurg.2023.4154] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/16/2023] [Indexed: 09/07/2023]
Abstract
Importance Postoperative opioid overprescribing leads to persistent opioid use and excess pills at risk for misuse and diversion. A learning health system paradigm using risk-stratified pancreatectomy clinical pathways (RSPCPs) may lead to reduction in inpatient and discharge opioid volume. Objective To analyze the outcomes of 2 iterative RSPCP updates on inpatient and discharge opioid volumes. Design, Setting, and Participants This cohort study included 832 consecutive adult patients at an urban comprehensive cancer center who underwent pancreatic resection between October 2016 and April 2022, comprising 3 sequential pathway cohorts (version [V] 1, October 1, 2016, to January 31, 2019 [n = 363]; V2, February 1, 2019, to October 31, 2020 [n = 229]; V3, November 1, 2020, to April 30, 2022 [n = 240]). Exposures After V1 of the pathway established a baseline and reduced length of stay (n = 363), V2 (n = 229) updated patient and surgeon education handouts, limited intravenous opioids, suggested a 3-drug (acetaminophen, celecoxib, methocarbamol) nonopioid bundle, and implemented the 5×-multiplier (last 24-hour oral morphine equivalents [OME] multiplied by 5) to calculate discharge volume. Pathway version 3 (n = 240) required the nonopioid bundle as default in the recovery room and scheduled conversion to oral medications on postoperative day 1. Main Outcomes and Measures Inpatient and discharge opioid volume in OME across the 3 RSPCPs were compared using nonparametric testing and trend analyses. Results A total of 832 consecutive patients (median [IQR] age, 65 [56-72] years; 410 female [49.3%] and 422 male [50.7%]) underwent 541 pancreatoduodenectomies, 285 distal pancreatectomies, and 6 other pancreatectomies. Early nonopioid bundle administration increased from V1 (acetaminophen, 320 patients [88.2%]; celecoxib or anti-inflammatory, 98 patients [27.0%]; methocarbamol, 267 patients [73.6%]) to V3 (236 patients [98.3%], 163 patients [67.9%], and 238 patients [99.2%], respectively; P < .001). Total inpatient OME decreased from a median 290 mg (IQR, 157-468 mg) in V1 to 184 mg (IQR, 103-311 mg) in V2 to 129 mg (IQR, 75-206 mg) in V3 (P < .001). Discharge OME decreased from a median 150 mg (IQR, 100-225 mg) in V1 to 25 mg (IQR, 0-100 mg) in V2 to 0 mg (IQR, 0-50 mg) in V3 (P < .001). The percentage of patients discharged opioid free increased from 7.2% (26 of 363) in V1 to 52.5% (126 of 240) in V3 (P < .001), with 187 of 240 (77.9%) in V3 discharged with 50 mg OME or less. Median pain scores remained 3 or lower in all cohorts, with no differences in postdischarge refill requests. A subgroup analysis separating open and minimally invasive surgical cases showed similar results in both groups. Conclusions and Relevance In this cohort study, the median total inpatient OME was halved and median discharge OME reduced to zero in association with a learning health system model of iterative opioid reduction that is freely adaptable by other hospitals. These findings suggest that opioid-free discharge after pancreatectomy and other major cancer operations is realistic and feasible with this no-cost blueprint.
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Affiliation(s)
- Artem Boyev
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anish J Jain
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Timothy E Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Laura R Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Morgan L Bruno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elsa M Arvide
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Whitney L Dewhurst
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jessica E Maxwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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18
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Boyev A, Prakash LR, Chiang YJ, Childers CP, Jain AJ, Newhook TE, Bruno ML, Arvide EM, Dewhurst WL, Kim MP, Ikoma N, Lee JE, Snyder RA, Katz MHG, Tzeng CWD, Maxwell JE. Postoperative Opioid Use Is Associated with Increased Rates of Grade B/C Pancreatic Fistula After Distal Pancreatectomy. J Gastrointest Surg 2023; 27:2135-2144. [PMID: 37468733 DOI: 10.1007/s11605-023-05751-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/03/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) is a major source of morbidity after distal pancreatectomy. This study examined the association between postoperative opioid use and CR-POPF in the context of opioid-sparing postoperative care. METHODS A case-control study was performed on consecutive patients who underwent distal pancreatectomy between October 2016 and April 2022 at a single institution. Patients who developed CR-POPF were compared to controls. Multivariable regression modeling was used to identify factors associated with CR-POPF. RESULTS A total of 281 patients underwent 187 open, 20 laparoscopic, and 74 robotic-assisted operations. The rate of CR-POPF was 21% (n = 58). CR-POPF rate declined from 32 to 8% over the study period (p < 0.001). Median oral morphine equivalents (OME) administered on POD 0-1 and 0-3 were 94 and 129 mg, respectively, in patients who did not develop a fistula versus 130 and 180 mg in those who did (both p ≤ 0.001). POD 0-3 OME (OR 1.11, p = 0.044) was independently associated with increased odds of CR-POPF, with each additional 50 mg (equivalent to 10 tramadol pills) increasing the relative risk by 11% and absolute risk by 2%. CONCLUSION Early postoperative opioid use after distal pancreatectomy was associated with increased odds of CR-POPF. Decreasing perioperative opioid use through enhanced postoperative management is a low-cost and generalizable approach that may reduce rates of CR-POPF after distal pancreatectomy.
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Affiliation(s)
- Artem Boyev
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Laura R Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Christopher P Childers
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Anish J Jain
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Timothy E Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Morgan L Bruno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Elsa M Arvide
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Whitney L Dewhurst
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Jessica E Maxwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
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Lawlor P, Cohen L, Adeli SR, Besserer E, Gratton V, Murphy R, Warmels G, Bruni A, Kabir M, Noel C, Heidinger B, Anderson K, Arsenault-Mehta K, Wooller K, Lapenskie J, Webber C, Bedard D, Enright P, Desjardins I, Bhimji K, Dyason C, Iyengar A, Bush SH, Isenberg S, Tanuseputro P, Vanderspank-Wright B, Downar J, Parsons H. Comorbidities, symptoms and end-of-life medication use in hospitalised decedents before and during the COVID-19 pandemic: a retrospective regional cohort study in Ottawa, Canada. BMJ Open 2023; 13:e075518. [PMID: 37669840 PMCID: PMC10481717 DOI: 10.1136/bmjopen-2023-075518] [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: 05/11/2023] [Accepted: 08/23/2023] [Indexed: 09/07/2023] Open
Abstract
OBJECTIVE To compare comorbidities, symptoms and end-of-life (EoL) palliative medication (antisecretories, opioids, antipsychotics and sedatives) use among decedents before and during the COVID-19 pandemic. DESIGN In a retrospective cohort study, decedent records in three acute care hospitals were abstracted, generating a prepandemic (November 2019-February 2020) group (pre-COVID) and two intrapandemic (March-August 2020, wave 1) groups, one without (COVID-ve) and one with COVID-19 infection (COVID+ve). Control group decedents were matched 2:1 on age, sex and care service (medicine/intensive care unit (ICU)) with COVID+ve decedents. SETTING Three regional acute care teaching hospitals in Ottawa, Canada PARTICIPANTS: Decedents (N=425): COVID+ve (n=85), COVID-ve (n=170) and pre-COVID (n=170). MAIN OUTCOME MEASURES Data were abstracted regarding demographics, admission comorbidities and symptoms, and EoL medication use; opioid doses were standardised to parenteral morphine equivalent daily dose (MEDD), and the predictors of upper quartile MEDD in the last 24 hours of life were examined in multivariable logistic regression with adjusted ORs (aORs) and 95% CIs. RESULTS The prevalence of dementia (41% vs 28% and 26%, p=0.03), breathlessness (63.5% vs 42% and 47%, p<0.01), cough (40% vs 27% and 19%, p<0.01) and fever (54% vs 9% and 13.5%) was higher in COVID+ve versus pre-COVID and COVID-ve groups, respectively. The median (IQR) of MEDD over the last 72 hours of life was 16.7 (9-36.5) vs 13.5 (5.7-21.8) and 10.5 (5.3-23.8) for COVID+ve versus pre-COVID and COVID-ve groups, respectively, (p=0.007). Male sex, COVID+ve grouping, ICU death and high-flow nasal cannula use predicted upper quartile MEDD dose, aORs (95% CIs): 1.84 (1.05 to 3.22), 2.62 (1.29 to 5.3), 5.14 (2.47 to 10.7) and 1.93 (1.05 to 3.52), respectively. COVID+ve group decedents used highest lorazepam and propofol doses. CONCLUSIONS COVID-19 decedents, particularly those in ICU, required higher EoL opioid and sedating medication doses than matched prepandemic or intrapandemic controls. These findings should inform and guide clinical practice.
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Affiliation(s)
- Peter Lawlor
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Leila Cohen
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | | | - Ella Besserer
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Valérie Gratton
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
- Department of Medicine, Hopital Monfort, Ottawa, Ontario, Canada
| | - Rebekah Murphy
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Grace Warmels
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Adrianna Bruni
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Monisha Kabir
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Chelsea Noel
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Brandon Heidinger
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Koby Anderson
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | | | - Krista Wooller
- Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
- Department of Medicine, Division of Internal Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Julie Lapenskie
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Daniel Bedard
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
| | - Paula Enright
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Isabelle Desjardins
- Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
- Department of Medicine, Division of Internal Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Khadija Bhimji
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Claire Dyason
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Akshai Iyengar
- Department of Medicine, Division of Critical Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Critical Care, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Sarina Isenberg
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Peter Tanuseputro
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Brandi Vanderspank-Wright
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Nursing, University of Ottawa Faculty of Health Sciences, Ottawa, Ontario, Canada
| | - James Downar
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Division of Critical Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Critical Care, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Henrique Parsons
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
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Wen RY, Edmonds KP, Atayee RS. Comparing National Methadone Equianalgesic Tools. J Pain Palliat Care Pharmacother 2023; 37:246-250. [PMID: 37010231 DOI: 10.1080/15360288.2023.2194873] [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: 10/31/2022] [Revised: 02/17/2023] [Accepted: 03/20/2023] [Indexed: 04/04/2023]
Abstract
Methadone is an effective analgesic with unique pharmacokinetic and pharmacodynamic variables. There is no national consensus on methadone equianalgesia tools. Our study aimed to compare methadone equianalgesic tools from various national institutions with the primary objective to summarize current practice and secondary objective to determine if a national consensus can be established. Out of 25 institutional methadone equianalgesic tools reviewed, 18 contained sufficient data and were included in this study. Fifteen (15) of the institution evaluated tools utilized a wide variety of dose-dependent modalities for methadone conversion with the hospice and palliative care (HAPC) Consensus method being the most common. Based on the variability of the equianalgesia tools evaluated in this study, we were unable to recommend a consensus methadone conversion method. Further trials exploring methadone equianalgesia beyond our study are needed.
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21
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Arraut J, Thomas J, Oakley C, Umeh UO, Furgiuele DL, Schwarzkopf R. Peripheral Nerve Catheter Reduces Postoperative Opioid Consumption and Pain in Revision Total Knee Arthroplasty. Arthroplast Today 2023; 22:101155. [PMID: 37663072 PMCID: PMC10472143 DOI: 10.1016/j.artd.2023.101155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/22/2023] [Accepted: 05/08/2023] [Indexed: 09/05/2023] Open
Abstract
Background Patients undergoing revision total knee arthroplasty (rTKA) have historically received high doses of opioids during the perioperative period. As awareness of opioid use has heightened, opioid administration has continuously decreased. This study aimed to evaluate if peripheral nerve catheter (PNC) use in rTKA reduces opiate consumption while maintaining similar pain control and postoperative function levels. Methods A retrospective review of 354 patients who underwent rTKA between July 2019 and January 2022 was conducted. Fifty total patients who received an adductor canal PNC were propensity-matched 1:1 to a control group of 50 patients that did not receive a PNC. To assess the primary outcome of opiate consumption, nursing documented opiate administration events were converted into morphine milligram equivalents per 24-hour interval. Postoperative pain and functional status were assessed using the verbal rating scale for pain and the Activity Measure for Post-Acute Care scores, respectively. Results Compared to the control group, the PNC group demonstrated significantly lower overall inpatient opiate consumption (98.68 ± 117.03 vs 176.69 ± 203.47 morphine milligram equivalents; 44.15% decrease, P = .021) and lower verbal rating scale pain scores at 60 to 72 hours postoperatively (4.85 ± 1.24 vs 5.83 ± 1.35; 16.81% decrease, P = .038). There was no significant difference in Activity Measure for Post-Acute Care scores postoperatively (raw score: 19.41 ± 3.61 vs 19.46 ± 3.18; 0.26% decrease, P = .952). Finally, the PNC cohort was significantly less likely to be readmitted within 90 days after surgery (0.0% vs 12.0%; P = .012). Conclusions In rTKA patients, PNC can significantly reduce inpatient opioid consumption while maintaining a comparable functional recovery and superior pain control. Level III Evidence Retrospective Cohort Study.
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Affiliation(s)
- Jerry Arraut
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Jeremiah Thomas
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Christian Oakley
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Uchenna O. Umeh
- Department of Anesthesiology, Critical Care and Pain Medicine, Hospital for Special Surgery, New York, NY, USA
| | - David L. Furgiuele
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Langone Health, New York, NY, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
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22
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Arraut J, Thomas J, Oakley C, Schmicker T, Aggarwal VK, Schwarzkopf R, Rozell JC. Effects of Dexamethasone on Postoperative Glycemic Control in Diabetic Patients Following Primary Total Joint Arthroplasty: A Retrospective Cohort Study. J Arthroplasty 2023:S0883-5403(23)00348-0. [PMID: 37040822 DOI: 10.1016/j.arth.2023.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 03/24/2023] [Accepted: 04/03/2023] [Indexed: 04/13/2023] Open
Abstract
INTRODUCTION Concerns regarding the effects of dexamethasone on diabetics' glucose control have stymied its use following total joint arthroplasty (TJA). This study aimed to evaluate the effects of two intravenous (IV) perioperative doses of dexamethasone on glucose levels, pain scores, and inpatient opioid consumption following TJA in diabetic patients. METHODS A retrospective review of 523 diabetic patients who underwent primary elective THA and 953 diabetic patients who underwent primary elective TKA between May 6, 2020 and December 17, 2021. Patients who received one dose (1D) of perioperative dexamethasone 10 mg IV were compared to patients who received two doses (2D). Primary outcomes included postoperative glucose levels, opioid consumption as morphine milligram equivalences (MMEs), postoperative pain as Verbal Rating Scale (VRS) pain scores, and postoperative complications. RESULTS The 2D TKA cohort had significantly greater average and maximum blood glucose levels from 24 to 60 hours compared to the 1D TKA cohort. The 2D THA cohort had significantly greater average blood glucose levels at 24 to 36 hours compared to the 1D THA cohort. However, the 2D TKA group had significantly reduced opioid consumption from 24 to 72 hours and reduced total consumption compared to the 1D TKA group. VRS pain scores did not differ between cohorts for both TKA and THA at any interval. CONCLUSION Administration of a second perioperative dose of dexamethasone was associated with increased postoperative blood glucose levels. However, the observed effect on glucose control may not outweigh the clinical benefits of a second perioperative dose of glucocorticoids.
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Affiliation(s)
- Jerry Arraut
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Jeremiah Thomas
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Christian Oakley
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Thomas Schmicker
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Vinay K Aggarwal
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Joshua C Rozell
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York.
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Yang W, Yan S, Yu F, Jiang C. Appropriate Duration of Perioperative Intravenous Administration of Lidocaine to Provide Satisfactory Analgesia for Adult Patients Undergoing Colorectal Surgery: A Meta-Analysis of Randomized Controlled Trials. Anesth Analg 2023; 136:494-506. [PMID: 36727863 DOI: 10.1213/ane.0000000000006347] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Perioperative lidocaine infusion has been reported to alleviate pain intensity after colorectal surgery. However, there is no consensus on whether prolonged lidocaine infusion is more effective than short lidocaine infusion. This meta-analysis aimed to determine an appropriate duration of lidocaine infusion in patients undergoing colorectal surgery. METHODS We searched the PubMed, EMBASE, Web of Science, and Cochrane Library databases to identify articles published before December 17, 2021. Randomized controlled trials comparing intravenous lidocaine with placebo for pain relief in patients undergoing colorectal surgery were included. The primary outcome was pain scores (visual analog scale [VAS], 0-10 cm) at 24 hours postoperatively at rest and on movement. Secondary outcomes included pain scores at 12, 48, and 72 hours postoperatively, analgesic consumption (mg), gastrointestinal function return (hour), length of hospital stay (days), and incidence of complications. According to the duration of lidocaine infusion, studies were grouped into infusion for at least 24 hours (prolonged lidocaine infusion) and less than 24 hours (short lidocaine infusion) to assess the impact of lidocaine infusion duration on the outcomes of interests. Quantitative analyses were performed using a random effects model. RESULTS Eleven studies with 548 patients were included. Five studies used prolonged lidocaine infusion, while 6 studies used short lidocaine infusion. Prolonged lidocaine infusion reduced postoperative pain scores versus placebo at 24 hours at rest (mean difference [MD], -0.91 cm; 95% confidence interval [CI], -1.54 to -0.28; P = .02) and on movement (MD, -1.69 cm; 95% CI, -2.15 to -1.22; P < .001), while short lidocaine infusion showed no benefit. Compared with placebo, prolonged lidocaine infusion reduced pain scores at 12 hours at rest and at 12 and 48 hours on movement, but short lidocaine infusion did not. However, there was no significant difference in pain scores between the prolonged and short lidocaine infusion groups at these time points. Compared with placebo, prolonged lidocaine infusion shortened the length of hospital stay (MD, -1.30 days; 95% CI, -1.72 to -0.88; P < .001) and time to first postoperative defecation (MD, -12.51 hours; 95% CI, -22.67 to -2.34; P = .02). There were no differences between groups regarding the other outcomes. CONCLUSIONS The analgesic effect of intravenous lidocaine may depend on the duration of infusion, and our results suggest that lidocaine infusion should be administered for at least 24 hours after colorectal surgery. Since overall evidence quality was low, further high-quality, large-sample trials are needed to explore an optimal lidocaine infusion strategy in patients undergoing colorectal surgery.
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Affiliation(s)
- Wei Yang
- From the Department of Anesthesiology, West China Hospital, Sichuan University and The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
- Department of Anesthesiology and Translational Neuroscience Center, Laboratory of Anesthesia and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Siyu Yan
- From the Department of Anesthesiology, West China Hospital, Sichuan University and The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
- Department of Anesthesiology and Translational Neuroscience Center, Laboratory of Anesthesia and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Feng Yu
- From the Department of Anesthesiology, West China Hospital, Sichuan University and The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
- Department of Anesthesiology and Translational Neuroscience Center, Laboratory of Anesthesia and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Chunling Jiang
- From the Department of Anesthesiology, West China Hospital, Sichuan University and The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
- Department of Anesthesiology and Translational Neuroscience Center, Laboratory of Anesthesia and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
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Arraut J, Thomas J, Oakley CT, Barzideh OS, Rozell JC, Schwarzkopf R. The AAHKS Best Podium Presentation Research Award: A Second Dose of Dexamethasone Reduces Postoperative Opioid Consumption and Pain in Total Joint Arthroplasty. J Arthroplasty 2023:S0883-5403(23)00098-0. [PMID: 36775214 DOI: 10.1016/j.arth.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 01/30/2023] [Accepted: 02/03/2023] [Indexed: 02/14/2023] Open
Abstract
BACKGROUND The optimal administration of dexamethasone for postoperative pain management and recovery following primary elective total joint arthroplasty (TJA) remains unclear. This study aimed to evaluate the effect of a second intravenous (IV) dose of dexamethasone on postoperative pain scores, inpatient opioid consumption, and functional recovery after total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS A retrospective review was conducted of 2,256 primary elective THAs and 1,951 primary elective TKAs between May 2020 and April 2021. Patients who received 2 perioperative doses (2D) of dexamethasone 10 mg IV were propensity-matched 1:1 to a control group who received 1 perioperative dose (1D). Primary outcomes were opiate consumption as morphine milligram equivalences (MMEs), postoperative pain as Verbal Rating Scale (VRS) pain scores, and functional status assessed by the Activity Measure for Post-Acute Care (AM-PAC) scores. RESULTS The 2D THA and 2D TKA cohorts consumed significantly less opiates at the 24 to 48-hour and 48 to 72-hour intervals. The 2D TKA cohort had significantly lower total opiate consumption compared to the 1D TKA cohort. Compared to the 1D cohorts, the 2D THA cohort and 2D TKA cohorts had significantly lower pain scores at the 48 to 60-hour interval; additionally, the 2D TKA cohort had significantly lower pain scores in the 36 to 48-hour interval. AM-PAC scores did not differ between cohorts for both TKA and THA at any interval. CONCLUSION The administration of a second perioperative dexamethasone dose significantly decreased opioid consumption in the immediate postoperative period. Inpatient opioid administration can be significantly reduced while maintaining comparable functional recovery and superior pain control. LEVEL III EVIDENCE Retrospective Cohort Study.
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Affiliation(s)
- Jerry Arraut
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Jeremiah Thomas
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Christian T Oakley
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Omid S Barzideh
- Department of Orthopedic Surgery, NYU Langone Health, Mineola, New York
| | - Joshua C Rozell
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
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25
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Atyia SA, Smetana KS, Tong MC, Thompson MJ, Cape KM, May CC. Evaluation of Dexmedetomidine Dosing in Obese Critically Ill Patients. J Pharm Pract 2023; 36:67-73. [PMID: 34109869 DOI: 10.1177/08971900211021578] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Dexmedetomidine is a highly selective α2-adrenoreceptor agonist that produces dose-dependent sedation, anxiolysis, and analgesia without respiratory depression. Due to these ideal sedative properties, there has been increased interest in utilizing dexmedetomidine as a first-line sedative for critically ill patients requiring light sedation. OBJECTIVE To evaluate the ability to achieve goal intensive care unit (ICU) sedation before and after an institutional change of dosing from actual (ABW) to adjusted (AdjBW) body weight in obese patients on dexmedetomidine. METHODS This study included patients ≥ 18 years old, admitted to a surgical or medical ICU, required dexmedetomidine for at least 8 hours as a single continuous infusion sedative, and weighed ≥ 120% of ideal body weight. Percentage of RASS measurements within goal range (-1 to +1) during the first 48 hours after initiation of dexmedetomidine as the sole sedative agent or until discontinuation dosed on ABW compared to AdjBW was evaluated. RESULTS 100 patients were included in the ABW cohort and 100 in the AdjBW cohort. The median dosing weight was significantly higher in the ABW group (95.9 [78.9-119.5] vs 82.2 [72.1-89.8] kg; p = 0.001). There was no statistical difference in percent of RASS measurements in goal range (61.5% vs 69.6%, p = 0.267) in patients that received dexmedetomidine dosed based on ABW versus AdjBW. CONCLUSION Dosing dexmedetomidine using AdjBW in obese critically ill patients for ongoing ICU sedation resulted in no statistical difference in the percent of RASS measurements within goal when compared to ABW dosing. Further studies are warranted.
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Affiliation(s)
- Sara A Atyia
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Keaton S Smetana
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Minh C Tong
- The Ohio State University College of Pharmacy, Columbus, OH, USA
| | - Molly J Thompson
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kari M Cape
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Casey C May
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Donado C, Harris EM, Heeney MM, Solodiuk JC, Greco CD, Archer NM. Patient Controlled Analgesia for Vaso-Occlusive Episodes in Children: A Retrospective Study. J Pain Symptom Manage 2023; 65:e409-e415. [PMID: 36641004 DOI: 10.1016/j.jpainsymman.2022.12.147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 11/29/2022] [Accepted: 12/24/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To describe Patient-Controlled Analgesia (PCA) administration in pediatric patients admitted with sickle cell vaso-occlusive episode (VOE). METHODS This single-center retrospective study included all inpatient hematology admissions for VOE between 2014 and 2020. PCA-ratio was calculated as the ratio of bolus over continuous IV opioids dose, and time to PCA adjustment as time between first PCA order and a subsequent order that increased dosing or changed opioid medication. RESULTS A total of 866 encounters (172 unique patients) with PCA for VOE were included. The mean age was 15.4 years old (SD = 5.0). On average, after admission (hospital arrival), the first opioid dose was given at 1 hour, PCA started at 3.5 hours, and mean length of stay was 4.3 days (SD = 2.5). The mean initial PCA-ratio was 1.7 (SD = 0.6). There were no significant associations between age, gender, initial pain score, or admission hemoglobin and PCA-ratio (linear regression model P = 0.443). In 24.7% of encounters, the PCA was adjusted within 6 hours. After adjusting by age and gender, lower admission pain scores (OR = 1.15, P = 0.004), lower PCA-ratio (OR = 2.1, P = 0.003), longer time to PCA start (OR = 1.2, P = 0.001), and no adjuvant ketamine (OR = 2.4, P < 0.001) were associated with PCA unadjusted within 6 hours. CONCLUSION At our institution, patients with VOE received opioids and PCA within the first hours of admission. PCAs were started at a ratio of 1.5-1.8, considered normal continuous. While no specific PCA-ratio was clearly superior for pain control, lower ratios (high continuous infusion) were associated with not requiring PCA adjustments at 6 hours. Prospective studies are needed.
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Affiliation(s)
- Carolina Donado
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital (C.D., J.C.S., C.D.G.), Boston, Massachusetts, USA; Department of Anaesthesia, Harvard Medical School (C.D., J.C.S., C.D.G.), Boston, Massachusetts, USA
| | - Emily M Harris
- Department of Pediatrics, Boston Children's Hospital (E.M.H., M.M.H., N.M.A.), Boston, Massachusetts, USA
| | - Matthew M Heeney
- Department of Pediatrics, Boston Children's Hospital (E.M.H., M.M.H., N.M.A.), Boston, Massachusetts, USA; Division of Hematology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center (M.M.H., N.M.A.), Boston, Massachusetts, USA
| | - Jean C Solodiuk
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital (C.D., J.C.S., C.D.G.), Boston, Massachusetts, USA; Department of Anaesthesia, Harvard Medical School (C.D., J.C.S., C.D.G.), Boston, Massachusetts, USA
| | - Christine D Greco
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital (C.D., J.C.S., C.D.G.), Boston, Massachusetts, USA; Department of Anaesthesia, Harvard Medical School (C.D., J.C.S., C.D.G.), Boston, Massachusetts, USA
| | - Natasha M Archer
- Department of Pediatrics, Boston Children's Hospital (E.M.H., M.M.H., N.M.A.), Boston, Massachusetts, USA; Division of Hematology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center (M.M.H., N.M.A.), Boston, Massachusetts, USA.
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Mercadante S, Adile C, Ferrera P, Grassi Y, Cascio AL, Casuccio A. Conversion ratios for opioid switching: a pragmatic study. Support Care Cancer 2022; 31:91. [PMID: 36580152 DOI: 10.1007/s00520-022-07514-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 12/03/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND The final conversion ratios among opioids used for successful switching are unknown. The aim of this study was to determine the initial and final conversion ratios used for a successful opioid switching in cancer patients, and eventual associated factors. METHODS Ninety-five patients who were successfully switched were evaluated. The following data were collected: age, gender, Karnofsky performance score, primary cancer, cognitive function, the presence of neuropathic, and incident pain. Opioids, route of administration, and their doses expressed in oral morphine equivalents used before OS were recorded as well as opioids use for starting opioid switching, and at time of stabilization. Physical and psychological symptoms were routinely evaluated by Edmonton Symptom Assessment Scale. RESULTS No statistical changes were observed between the initial conversion ratios and those achieved at time of stabilization for all the sequences of opioid switching. When considering patients switched to methadone, there was no association between factors taken into considerations. CONCLUSION Opioid switching is a highly effective and safe technique, improving analgesia and reducing the opioid-related symptom burden. The final conversion ratios were not different from those used for starting opioid switching. Patients receiving higher doses of opioids should be carefully monitored for individual and unexpected responses in an experienced palliative care unit, particularly those switched to methadone. Future studies should provide data regarding the profile of patients with difficult pain to be hospitalized.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy.
| | - Claudio Adile
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy
| | - Patrizia Ferrera
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy
| | - Yasmine Grassi
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy
| | - Alessio Lo Cascio
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy
| | - Alessandra Casuccio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
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Wen RY, Atayee RS, Edmonds KP. A Comparison of Institutional Opioid Equianalgesia Tools: A National Study. J Palliat Med 2022; 25:1686-1691. [PMID: 35559657 PMCID: PMC9836696 DOI: 10.1089/jpm.2021.0678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2022] [Indexed: 01/22/2023] Open
Abstract
Context: Equianalgesic tools are commonly utilized to guide dose of analgesic therapy, but there is no national consensus on equianalgesic calculations in the United States. Objectives: To propose a summary of current opioid equianalgesic data that include variations and trends among national institutions. Methods: Opioid equianalgesic tools were obtained between May and September 2021. For meperidine, tramadol, codeine, hydrocodone, morphine, oxycodone, oxymorphone, hydromorphone, levorphanol, fentanyl, and tapentadol, details of adjustment for incomplete tolerance, opioid equianalgesic ratios, and formulation types were collected and analyzed. Baseline opioid pharmaco kinetic data were obtained through manufacturer labels on FDA databases, including half-life (T1/2), volume of distribution (Vd), clearance (Cl), area under the curve (AUC), max concentration (Cmax), and time to max concentration (Tmax). Results: Thirty-two institutions' equianalgesic tools were included with each study opioid appearing on an average of 23 institutions' tools. Few tools contained guidance on levorphanol or tapentadol; or included minimum and maximum recommended doses. All tools included guidance on fentanyl, hydromorphone, oxycodone, morphine, and hydrocodone. A minority of tools included guidance on cross-tolerance considerations (n = 12, 37.5%). Oral-tramadol-to-oral-morphine and oral-hydromorphone-to-intravenous (IV)-hydromorphone had the largest variances across equianalgesic tools (6.7 ± 2.8 and 4.06 ± 1.2 mg, respectively). Conclusion: Opioid equianalgesia tools from across the United States demonstrated significant variation in their inclusion of guidance on adjustment for incomplete cross-tolerance, oral-to-IV, and oral-to-oral opioid equianalgesic ratios, and which opioids and formulations were listed. Tramadol and hydromorphone had the most variation in their equianalgesic guidance among the opioids.
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Affiliation(s)
- Raymond Y. Wen
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, USA
| | - Rabia S. Atayee
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, USA
- Palliative Care Program, Department of Medicine, UC San Diego Health Sciences, and Division of Geriatrics, Gerontology, La Jolla, California, USA
| | - Kyle P. Edmonds
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, USA
- Palliative Care Program, Department of Medicine, UC San Diego Health Sciences, and Division of Geriatrics, Gerontology, La Jolla, California, USA
- Section of Palliative Care, Division of Geriatrics, Gerontology, La Jolla, California, USA
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Koo CH, Kim J, Na HS, Ryu JH, Shin HJ. The effect of lidocaine patch for postoperative pain: A meta-analysis of randomized controlled trials. J Clin Anesth 2022; 81:110918. [DOI: 10.1016/j.jclinane.2022.110918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 05/31/2022] [Accepted: 06/25/2022] [Indexed: 12/29/2022]
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Oh TK, Kim HG, Song IA. New, long-term opioid use after lung cancer surgery is associated with reduced 2-year survival: a retrospective population-based cohort study in South Korea. Reg Anesth Pain Med 2022; 47:rapm-2022-103769. [PMID: 36096683 DOI: 10.1136/rapm-2022-103769] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/29/2022] [Indexed: 01/02/2023]
Abstract
INTRODUCTION We aimed to investigate the proportion and associated factors for new long-term opioid use and its long-term effects after lung cancer surgery. METHODS The South Korean National Health Insurance Database was used as a nationwide registration data source. All patients undergoing lung cancer surgery between 2011 and 2018 were included, and patients who were preoperative opioid users were excluded from the analysis. New long-term opioid use was defined as an active opioid prescription at 6 months postoperatively. RESULTS In total, 54 509 patients were included in the final analysis. At 6 months postoperatively, 3325 (6.1%) patients who were newly prescribed opioids comprised the new long-term opioid user group. Older age, male sex, wider surgical extent, open thoracotomy, increased Charlson Comorbidity Index score, neoadjuvant or adjuvant chemotherapy, preoperative anxiety disorder and insomnia disorder were associated with a higher rate of new long-term opioid use. The new long-term opioid user group showed a 40% (HR, 1.40; 95% CI 1.29 to 1.53; p<0.001) higher risk of 2-year all-cause mortality. Moreover, the new long-term potent opioid user and less potent opioid user groups showed a 92% (HR, 1.92; 95% CI 1.67 to 2.21; p<0.001) and 22% (HR, 1.22; 95% CI 1.10 to 1.36; p<0.001) higher risk of 2-year all-cause mortality, respectively. CONCLUSIONS Among preoperative opioid-naive patients in South Korea, 6.1% became new long-term opioid users after lung cancer surgery. Certain factors are potential risk factors for new long-term opioid use, which could be associated with poorer long-term survival outcomes.
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Affiliation(s)
- Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyeong Geun Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - In-Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Löchel J, Wassilew GI, Krämer M, Kohler C, Zahn RK, Leopold VJ. Transversus Abdominis Plane Block Reduces Intraoperative Opioid Consumption in Patients Undergoing Periacetabular Osteotomy. J Clin Med 2022; 11:jcm11174961. [PMID: 36078890 PMCID: PMC9456368 DOI: 10.3390/jcm11174961] [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: 06/14/2022] [Revised: 08/08/2022] [Accepted: 08/15/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Administering intraoperative analgesia in patients undergoing periacetabular osteotomy (PAO) is challenging due to both the relevant surgical approach and osteotomies, which are associated with pain. The aim of this study was to assess the effect of the transversus abdominis plane block (TAPb) on intraoperative opioid consumption and circulation parameters in PAO patients. Patients and Methods: We conducted a two-group randomized-controlled trial involving 42 consecutive patients undergoing PAO for symptomatic developmental dysplasia of the hip (DDH) in our department. Patients assigned to the study group received an ultrasound-guided TAPb with 0.75% ropivacaine before the beginning of the surgery and after general anesthesia induction. Patients assigned to the control group did not receive a TAPb. General anesthesia was conducted according to a defined study protocol. The primary endpoint of the study was the intraoperative opioid consumption, measured in morphine equivalent dose (MED). Secondary endpoints were the assessment of intraoperative heart rate, mean arterial pressure (MAP), need for hypotension treatment, and length of hospital stay (LOHS). A total of 41 patients (n = 21 TAPb group, n = 20 control group) completed the study; of these, 33 were women (88.5%) and 8 were men (19.5%). The mean age at the time of surgery was 28 years (18–43, SD ± 7.4). All operations were performed by a single high-volume surgeon and all TAPb procedures were performed by a single experienced senior anesthesiologist. Results: We observed a significantly lower intraoperative opioid consumption in the TAPb group compared to the control group (930 vs. 1186 MED per kg bodyweight; p = 0.016). No significant differences were observed in the secondary outcome parameters. We observed no perioperative complications. Conclusion: Ultrasound-guided TAPb significantly reduces intraoperative opioid consumption in patients undergoing PAO.
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Affiliation(s)
- Jannis Löchel
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery Augustenburger Platz 1, D–13353 Berlin, Germany
- Correspondence:
| | - Georgi I. Wassilew
- Department for Orthopaedic Surgery, University of Greifswald, Ferdinand-Sauerbruch-Straße, D–17475 Greifswald, Germany
| | - Michael Krämer
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Clinic for Anesthesiology and Intensive Care, Charitéplatz 1, D–10117 Berlin, Germany
| | - Christopher Kohler
- Orthopädisches Versorgungszentrum Zehlendorf, Clayallee 225A, D–14195 Berlin, Germany
| | - Robert Karl Zahn
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery Augustenburger Platz 1, D–13353 Berlin, Germany
| | - Vincent Justus Leopold
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery Augustenburger Platz 1, D–13353 Berlin, Germany
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Polanco-García M, Granero R, Gallart L, García-Lopez J, Montes A. Finding the vulnerable postoperative population: A two-step cluster analysis of the PAIN-OUT registry. Eur J Pain 2022; 26:1732-1745. [PMID: 35762292 DOI: 10.1002/ejp.1997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/08/2022] [Accepted: 06/26/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Identifying predictors of poor postoperative outcomes is crucial for planning personalized pain treatments. The aim of this study was to examine pain outcomes using cluster analysis in N=2,678 patients from the PAIN-OUT registry at first postoperative day. METHODS Indicator variables of the clustering analysis assessed multiple domains, such as clinical and surgical conditions, analgesic-anesthetic variables, desire for more pain treatment and outcome variables of the International Pain Outcome Questionnaire (IPO) summarized as factor scores. RESULTS Two-step cluster identified the three-cluster solution as the optimal. Two empirical groups (C1 and C2) included patients with good postoperative outcomes discriminated by peripheral nerve block use, while the other cluster (C3) grouped patients with the worst outcomes, where all patients desired more pain treatment. C3 comprised about 20% of the participants, mostly lower limb, abdominal and spine procedures. The best predictors of belonging to C3 included younger age, being male, preoperative opioid use, bone and fracture reduction procedures, institution, number of comorbidities and morphine equivalents in the recovery room. CONCLUSIONS IPO factor scores can be used to select pain outcomes phenotypes in large clinical databases. Most of the predictors were present before the recovery period so perioperative planning should focus in the preoperative and intraoperative periods.
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Affiliation(s)
- Mauricio Polanco-García
- Department of Anesthesiology, Consorci Sanitari Integral, Hospital Sant Joan Despí Moisès Broggi and Hospital General de l'Hospitalet, Barcelona, Spain
| | - Roser Granero
- Ciber Fisiopatología Obesidad y Nutrición (CIBERobn), Instituto Salud Carlos III, Spain.,Department of Psychobiology and Methodology of Health Science, Universitat Autònoma de Barcelona, Spain
| | - Lluís Gallart
- Department of Anesthesiology, Hospital del Mar. IMIM (Hospital del Mar Medical Research Institute). Universitat Autònoma de Barcelona, Spain
| | - Jaume García-Lopez
- Department of Anesthesiology, Hospital del Mar. IMIM (Hospital del Mar Medical Research Institute). Universitat Autònoma de Barcelona, Spain
| | - Antonio Montes
- Department of Anesthesiology, Hospital del Mar. IMIM (Hospital del Mar Medical Research Institute). Universitat Autònoma de Barcelona, Spain
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Grap SM, Lehman EB, Heasley V, Dalal PG, Parekh UR. Addition of Local Anesthetic Epidural Infusion Catheter to Intravenous Opioid Analgesia for Postoperative Pain Control in Children Undergoing Video Assisted Thoracoscopic Surgery (VATS). J Perianesth Nurs 2022; 37:889-893. [PMID: 35623994 DOI: 10.1016/j.jopan.2022.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/27/2022] [Accepted: 02/05/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE Postoperative analgesia following minimally invasive video assisted thoracoscopic surgery (VATS) in pediatric patients may involve intravenous opioid analgesics and continuous local anesthetic infusions via an epidural infusion catheter. The use of epidural catheters may avoid systemic side effects of intravenous opioids in this vulnerable population. DESIGN Our primary aim was to compare total morphine equivalents (MEQ) required, and pain scores between local anesthetic epidural infusion catheters combined with intravenous opioids, versus intravenous opioids alone in pediatric patients following VATS procedure. METHODS Following Institutional Review Board approval, we performed a retrospective chart review of children (ages 1 month to 18 years) who underwent VATS procedure for noncardiac thoracic surgery. Based on the postoperative analgesic technique used, the study population was divided into two groups that is, epidural group and nonepidural group. Both groups received intravenous systemic opioids. The primary outcome variables were total MEQ required and pain scores in the perioperative period. FINDINGS Ninety-two patients were included in the study. Of these, 22 patients belonged to the epidural group versus 70 patients to the nonepidural group. There was no statistical difference in MEQ requirements or pain scores between the groups intraoperatively (P = .304), in the postanesthesia care unit (P = .166), or at postoperative time intervals of 24 hours (P = .805) and 48 hours (P = .844). The presence of infection or empyema was a significant factor for the avoidance of epidural placement by providers (P = .003). CONCLUSIONS There was no significant difference in the perioperative MEQ or postoperative pain scores between the epidural catheter group and the nonepidural group. More research is necessary to determine if this could be due to epidural catheter malposition and/or inadequate dermatomal coverage of surgical chest tubes.
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Affiliation(s)
- Shannon M Grap
- Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center & Children's Hospital, Hershey, PA.
| | - Erik B Lehman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Victoria Heasley
- Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center & Children's Hospital, Hershey, PA
| | - Priti G Dalal
- Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center & Children's Hospital, Hershey, PA
| | - Uma R Parekh
- Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center & Children's Hospital, Hershey, PA
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Choi BM, Hwang CS, Yoon YS, Park IJ, Yoo MW, Kim BS. Novel temperature-responsive hydrogel injected to the incision site for postoperative pain relief in laparoscopic abdominal surgery: a single-blind, randomized, pivotal clinical trial. Surg Endosc 2022; 36:5794-5802. [PMID: 35556170 DOI: 10.1007/s00464-022-09252-4] [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: 05/30/2021] [Accepted: 04/08/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND A temperature-responsive hydrogel (PF-72; TGel Bio, Inc., Ltd, Seoul, Korea), developed as a sustained drug delivery device, can be mixed with ropivacaine to reduce pain in the incision area. The hydrogel is soluble at low temperatures (2-8 °C) and is converted into a gel at high temperatures (> 30 °C). We aimed to evaluate whether the administration of ropivacaine using PF-72 at incision sites reduces pain until 72 h postoperatively in patients undergoing laparoscopic stomach or colorectal surgery. METHODS Patients were randomly assigned to the control group (0.75% ropivacaine) or PF-72 group (PF-72 mixed with 0.75% ropivacaine). Before surgical incision closure, 0.75% ropivacaine or PF-72 mixed with 0.75% ropivacaine was injected into the subcutaneous fat and muscle of all incisions. Postoperative pain was evaluated by the Numerical Rating Scale (NRS, 0 = no pain, 10 = most severe pain) for wound pain at 3, 6, 24, 48, and 72 h after the end of surgery. RESULTS Ninety-nine patients (control, n = 51; PF-72, n = 48) were included in the analysis. The areas under the curve of NRS for wound pain until 72 h in the control group and the PF-72 group were 188.7 ± 46.1 and 135.3 ± 49.9 h, respectively (P < 0.001). The frequency of the administration of rescue analgesics in the general ward was similar between the two groups. CONCLUSION PF-72 mixed with 0.75% ropivacaine reduced postoperative pain until 72 h in patients undergoing laparoscopic surgery. Although the study population was not large enough for safety evaluation, no adverse events associated with PF-72 were observed.
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Affiliation(s)
- Byung-Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | | | - Yong Sik Yoon
- Division of colon and rectal surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - In Ja Park
- Division of colon and rectal surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Moon-Won Yoo
- Division of gastrointestinal surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, South Korea
| | - Beom Su Kim
- Division of gastrointestinal surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, South Korea.
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Hirata Y, Witt RG, Prakash LR, Arvide EM, Robinson KA, Gottumukkala V, Tzeng CWD, Mansfield P, Badgwell BD, Ikoma N. Analysis of Opioid Use in Patients Undergoing Open Versus Robotic Gastrectomy. Ann Surg Oncol 2022; 29:5861-5870. [PMID: 35507230 DOI: 10.1245/s10434-022-11836-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/11/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND Minimally invasive, robotic gastrectomy is associated with better short-term outcomes and quicker functional recovery. However, the degree to which the robotic approach influences postoperative pain and opioid use after gastrectomy is unknown. Our primary aim was to determine whether the robotic approach to gastrectomy reduces postoperative opioid use compared with the open approach. METHODS Patients who underwent gastrectomy (November 2018 to September 2021) were identified retrospectively. Clinical characteristics, short-term surgical outcomes, oral morphine equivalent (OME) use, and pain scores were collected. Both groups were managed through an enhanced recovery program in the perioperative period. RESULTS Of 81 patients, 50 underwent open and 31 underwent robotic gastrectomy. Compared with open gastrectomy patients, robotic gastrectomy patients had longer surgery time (360 vs. 288 min), less blood loss (50 vs. 138 mL), and shorter hospital stay (4 vs. 6 days) (all medians, P < 0.001). Robotic gastrectomy patients used lower OMEs on postoperative days 0-4 (all P < 0.05) and in total for days 0-4 (total mean dose 65.0 vs. 169.5 mg; P < 0.001) than did open gastrectomy patients. The robotic gastrectomy patients were prescribed a lower mean OME dose than the open gastrectomy patients (19.0 vs. 29.0 mg, respectively; P = 0.001). Multivariable analysis showed that robotic approach was associated with lower opioid use (odds ratio 3.70; 95% CI 1.01-14.3; P = 0.049). CONCLUSIONS Compared with open gastrectomy, robotic gastrectomy reduces opioid use in the early postoperative period and is associated with fewer OME discharge prescriptions and shorter hospital stay.
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Affiliation(s)
- Yuki Hirata
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Russell G Witt
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laura R Prakash
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elsa M Arvide
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kristen A Robinson
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vijaya Gottumukkala
- Departments of Anesthesiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul Mansfield
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Wehrfritz A, Senger AS, Just P, Albart M, Münchsmeier M, Ihmsen H, Schüttler J, Jeleazcov C. Patient-controlled analgesia after cardiac surgery with median sternotomy: no advantages of hydromorphone when compared to morphine. J Cardiothorac Vasc Anesth 2022; 36:3587-3595. [DOI: 10.1053/j.jvca.2022.04.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/24/2022] [Accepted: 04/30/2022] [Indexed: 11/11/2022]
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Non-Peptide Opioids Differ in Effects on Mu-Opioid (MOP) and Serotonin 1A (5-HT 1A) Receptors Heterodimerization and Cellular Effectors (Ca 2+, ERK1/2 and p38) Activation. Molecules 2022; 27:molecules27072350. [PMID: 35408749 PMCID: PMC9000251 DOI: 10.3390/molecules27072350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/24/2022] [Accepted: 04/02/2022] [Indexed: 11/17/2022] Open
Abstract
The importance of the dynamic interplay between the opioid and the serotonin neuromodulatory systems in chronic pain is well recognized. In this study, we investigated whether these two signalling pathways can be integrated at the single-cell level via direct interactions between the mu-opioid (MOP) and the serotonin 1A (5-HT1A) receptors. Using fluorescence cross-correlation spectroscopy (FCCS), a quantitative method with single-molecule sensitivity, we characterized in live cells MOP and 5-HT1A interactions and the effects of prolonged (18 h) exposure to selected non-peptide opioids: morphine, codeine, oxycodone and fentanyl, on the extent of these interactions. The results indicate that in the plasma membrane, MOP and 5-HT1A receptors form heterodimers that are characterized with an apparent dissociation constant Kdapp = (440 ± 70) nM). Prolonged exposure to all non-peptide opioids tested facilitated MOP and 5-HT1A heterodimerization and stabilized the heterodimer complexes, albeit to a different extent: Kd, Fentanylapp = (80 ± 70) nM), Kd,Morphineapp = (200 ± 70) nM, Kd, Codeineapp = (100 ± 70) nM and Kd, Oxycodoneapp = (200 ± 70) nM. The non-peptide opioids differed also in the extent to which they affected the mitogen-activated protein kinases (MAPKs) p38 and the extracellular signal-regulated kinase (Erk1/2), with morphine, codeine and fentanyl activating both pathways, whereas oxycodone activated p38 but not ERK1/2. Acute stimulation with different non-peptide opioids differently affected the intracellular Ca2+ levels and signalling dynamics. Hypothetically, targeting MOP−5-HT1A heterodimer formation could become a new strategy to counteract opioid induced hyperalgesia and help to preserve the analgesic effects of opioids in chronic pain.
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Pande CK, Noll L, Afonso N, Serrano F, Monteiro S, Guffey D, Puri K, Achuff BJ, Akcan-Arikan A, Shekerdemian L. Neurodevelopmental Outcomes in Infants with Cardiac Surgery Associated Acute Kidney Injury. Ann Thorac Surg 2022; 114:2347-2354. [PMID: 35346625 DOI: 10.1016/j.athoracsur.2022.03.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 02/28/2022] [Accepted: 03/12/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Infants who undergo surgery for congenital heart disease (CHD) are at risk of neurodevelopmental delay. Cardiac surgery associated acute kidney injury (CS-AKI) is common but its association with neurodevelopment has not been explored. METHODS Single center retrospective observational study of infants who underwent cardiac surgery in the first year of life who had neurodevelopmental testing using the Bayley Scale for Infant Development version 3. Single and recurrent episodes of Stage 2 and 3 CS-AKI were determined. RESULTS 203 children with median age at first surgery of 12 days. 31% had ≥ 1 episode of severe CS-AKI; of those, 16% had recurrent CS-AKI. Median age at neurodevelopmental assessment was 20 months. The incidence of delay was similar in patients with and without CS-AKI but all children with recurrent CS-AKI had a delay in ≥1 domain and had significantly lower scores in all 3 domains (cognitive, language, motor). CONCLUSIONS This is the first study to assess the association of CS-AKI with neurodevelopmental delay after surgery for CHD in infancy. Infants who develop recurrent CS-AKI in the first year of life were more likely to be delayed and have lower neurodevelopmental scores.
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Affiliation(s)
- Chetna K Pande
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine
| | - Lisa Noll
- Division of Psychology, Department of Pediatrics, Baylor College of Medicine
| | - Natasha Afonso
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine
| | - Faridis Serrano
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine
| | - Sonia Monteiro
- Division of Developmental Pediatrics, Department of Pediatrics, Baylor College of Medicine
| | - Danielle Guffey
- Institute for Clinical and Translational Research, Baylor College of Medicine
| | - Kriti Puri
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine
| | - Barbara-Jo Achuff
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine
| | - Ayse Akcan-Arikan
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine; Division of Nephrology, Department of Pediatrics, Baylor College of Medicine
| | - Lara Shekerdemian
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine.
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Pelzer D, Burgess E, Baker R, Cox J. Response from Authors to Letter to the Editor "Comparison of Preoperative Intravenous and Oral Acetaminophen: Methodological Issues". J Perianesth Nurs 2022; 37:9-10. [PMID: 35115153 DOI: 10.1016/j.jopan.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 09/05/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Diana Pelzer
- TriHealth Bethesda Butler Hospital, Hamilton, OH.
| | | | | | - Jennifer Cox
- TriHealth Bethesda Butler Hospital, Hamilton, OH
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Evaluating the Efficacy of Two Regional Pain Management Modalities in Autologous Breast Reconstruction. Plast Reconstr Surg Glob Open 2022; 10:e4010. [PMID: 35070591 PMCID: PMC8769083 DOI: 10.1097/gox.0000000000004010] [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: 08/11/2021] [Accepted: 11/03/2021] [Indexed: 11/26/2022]
Abstract
At our institution, multimodal opiate-sparing pain management is the cornerstone of our enhanced recovery program for autologous breast reconstruction. The purpose of this study was to compare postoperative outcomes and pain control metrics following implementation of an enhanced recovery program with two different regional analgesia approaches.
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Kulkarni VA, Kephart DT, Ball MA, Tumber S, Davidson LT, Davids JR. Neuraxial anesthesia for post-operative pain control after hip surgery in children with cerebral palsy and pre-existing intrathecal baclofen pumps. J Pediatr Rehabil Med 2022; 15:3-11. [PMID: 35275572 DOI: 10.3233/prm-210027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE The purpose of this study is to describe the efficacy and adverse events of neuraxial anesthesia for post-operative pain control in non-ambulatory children with cerebral palsy with pre-existing intrathecal baclofen (ITB) pumps undergoing hip reconstructive or palliative surgery. METHODS Twelve children (mean age 11.25 years) were included in the study with the following neuraxial anesthesia methods: indwelling epidural catheter (8 patients), neuraxial opioids administered through the side port of the ITB pump (3 patients), and single injection spinal anesthetic (1 patient). Observational pain scores and opioid requirements were quantified for all patients. RESULTS There were no ITB pump or surgical complications at a mean follow-up of 2.2 years. The average length of stay was 6 days. Patients had good post-operative pain control with a mean observational pain score of 0.7 and mean morphine equivalent use of 0.26mg/kg/day. Four patients required anti-emetics to control nausea and three patients had urinary retention requiring repeat catheterization, but all medical complications resolved prior to discharge. CONCLUSION Neuraxial anesthesia can effectively control post-operative pain in children with a pre-existing ITB pump. Utilizing the side port of the ITB pump for administration of neuraxial opioids is an option when epidural or spinal anesthesia is not possible.
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Affiliation(s)
- Vedant A Kulkarni
- Department of Orthopaedic Surgery, Shriners Hospitals for Children - Northern California, Sacramento, CA, USA
| | - Donald T Kephart
- Department of Orthopaedic Surgery, Shriners Hospitals for Children - Northern California, Sacramento, CA, USA
| | - Madeleine A Ball
- Department of Orthopaedic Surgery, Shriners Hospitals for Children - Northern California, Sacramento, CA, USA
| | - Sundeep Tumber
- Department of Anesthesia, Shriners Hospitals for Children - Northern California, Sacramento, CA, USA
| | - Loren T Davidson
- Department of Physical Medicine and Rehabilitation, Shriners Hospitals for Children - Northern California, Sacramento, CA, USA
| | - Jon R Davids
- Department of Orthopaedic Surgery, Shriners Hospitals for Children - Northern California, Sacramento, CA, USA
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Albrecht E, Pereira P, Bayon V, Berger M, Wegrzyn J, Antoniadis A, Heinzer R. The Relationship Between Postoperative Opioid Analgesia and Sleep Apnea Severity in Patients Undergoing Hip Arthroplasty: A Randomized, Controlled, Triple-Blinded Trial. Nat Sci Sleep 2022; 14:303-310. [PMID: 35241942 PMCID: PMC8887967 DOI: 10.2147/nss.s348834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 02/14/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Residual postoperative pain after hip arthroplasty is usually treated with oral opioids. While classic opioids are associated with respiratory depression and worsening of sleep apnea, tramadol has been reported to preserve respiratory function. However, this has not been investigated in a prospective trial using respiratory polygraphy. This randomized controlled triple-blinded trial tested the hypothesis that postoperative treatment with oral opioids such as oxycodone would increase sleep apnea severity, measured with a respiratory polygraphy, compared with oral tramadol. PATIENTS AND METHODS Sixty patients undergoing hip arthroplasty under spinal anesthesia with 15 mg isobaric bupivacaine 0.5% were randomized to receive postoperative pain treatment with either oral oxycodone (controlled-release 10 mg every 12 hours and immediate-release 5 mg every 4 hours as needed) or oral tramadol (controlled-release 100 mg every 8 hours and immediate-release 50 mg every 4 hours as needed). Respiratory polygraphy was performed on the first postoperative night. The primary outcome was the apnea-hypopnea index in the supine position. Secondary outcomes included the oxygen desaturation index, postoperative pain scores and intravenous morphine consumption. RESULTS Mean supine apnea-hypopnea index on postoperative night 1 was 11.3 events.h-1 (95% confidence interval, 4.8-17.7) in the oxycodone group and 10.7 (4.6-16.8) events.h-1 in the tramadol group (p=0.89). There were no significant differences between the oxycodone and tramadol groups with respect to any secondary sleep-related or pain-related outcomes. CONCLUSION Oral oxycodone did not increase sleep apnea severity measured using respiratory polygraphy compared with oral tramadol on the first postoperative night after hip arthroplasty. TRIAL REGISTRATION NUMBER Clinicaltrials.gov - NCT03454217 (date of registration: 05/03/2018).
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Affiliation(s)
- Eric Albrecht
- Department of Anesthesia, University Hospital of Lausanne and University of Lausanne, Lausanne, Vaud, Switzerland
| | - Pedro Pereira
- Department of Anesthesia, University Hospital of Lausanne and University of Lausanne, Lausanne, Vaud, Switzerland
| | - Virginie Bayon
- Center for Investigation and Research in Sleep, University Hospital of Lausanne and University of Lausanne, Lausanne, Vaud, Switzerland
| | - Mathieu Berger
- Center for Investigation and Research in Sleep, University Hospital of Lausanne and University of Lausanne, Lausanne, Vaud, Switzerland
| | - Julien Wegrzyn
- Department of Orthopedic Surgery, University Hospital of Lausanne and University of Lausanne, Lausanne, Vaud, Switzerland
| | - Alexander Antoniadis
- Department of Orthopedic Surgery, University Hospital of Lausanne and University of Lausanne, Lausanne, Vaud, Switzerland
| | - Raphaël Heinzer
- Center for Investigation and Research in Sleep, University Hospital of Lausanne and University of Lausanne, Lausanne, Vaud, Switzerland
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Morse JD, Hannam JA, Anderson BJ, Kokki H, Kokki M. Oxycodone target concentration dosing for acute pain in children. Paediatr Anaesth 2021; 31:1325-1331. [PMID: 34469616 DOI: 10.1111/pan.14282] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 08/18/2021] [Accepted: 08/28/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Oxycodone pharmacokinetics have been described in premature neonates through to obese adults. Covariate influences have been accounted for using allometry (size) and maturation of oxycodone clearance with age. The target concentration is dependent on pain intensity that may differ over pain duration or between individuals. METHODS We assumed a target concentration of 35 mcg.L-1 (acceptable range ±20%) to be associated with adequate analgesia without increased risk of adverse effects from respiratory depression. Pharmacokinetic simulation was used to estimate dose in neonates through to obese adults given intravenous or parenteral oxycodone. RESULTS There were 84% of simulated oxycodone concentrations within the acceptable range during maintenance dosing. Variability around the simulated target concentration decreased with age. The maturation of oxycodone clearance is reflected in changes to context-sensitive halftime where clearance is immature in neonates compared with older children and adults. The intravenous loading and maintenance doses for a typical 5-year-old child are 100 mcg.kg-1 and 33 mcg.kg-1 .h-1 . In a typical adult, the loading dose is 100 mcg.kg-1 and maintenance dose 23 mcg.kg-1 .h-1 . CONCLUSION Simulation was used to suggest loading and maintenance doses to attain an oxycodone concentration of 35 mcg.L-1 predicted in adults. Although the covariates age and weight contribute 92% variability for clearance, there remains variability accounting for 16% of concentrations outside the target range. Duration of analgesic effect after ceasing infusion is anticipated to be longer in neonates where context-sensitive halftime is greater than older children and adults.
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Affiliation(s)
- James D Morse
- Department of Pharmacology & Clinical Pharmacology, The University of Auckland, Auckland, New Zealand
| | - Jacqueline A Hannam
- Department of Pharmacology & Clinical Pharmacology, The University of Auckland, Auckland, New Zealand
| | - Brian J Anderson
- Department of Anaesthesiology, Faculty of Medicine and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Hannu Kokki
- School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Merja Kokki
- Department of Anesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland
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ALMouaalamy N, Alharbi ZM, Aldosari FM, Saif SA, Alsulimani EF, Aldawsari MK, AlRahimi J. The Practice of Pain Assessment and Management in a Tertiary Oncology Center. Cureus 2021; 13:e18837. [PMID: 34804692 PMCID: PMC8594563 DOI: 10.7759/cureus.18837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2021] [Indexed: 11/30/2022] Open
Abstract
Background Pain is one of the common and devastating symptoms that affects millions of cancer patients globally. Despite published guidelines and education on the assessment and management of cancer-related pain, underestimated or undertreated pain continues to be a considerable worldwide public health concern among cancer patients. In this study, we aimed to assess physicians’ adherence to the World Health Organization (WHO) guidelines in the management and assessment of pain in oncology patients based on the available score of pain in the Princess Noorah Oncology Center (PNOC) at the King Abdulaziz Medical City in Jeddah. Methodology This cross-sectional, retrospective chart review study studied 451 patients (selected through computerized random sampling) who were admitted to the PNOC during the study period. Results The pain was assessed using the Brief Pain Inventory in almost all patients (n = 450, 99.8%). The pain was categorized as mild in 386 (85.6%) patients, moderate in 46 (10.2%) patients, and severe in 19 (4.2%) patients. Opioid prescriptions were significantly higher among patients with moderate (76.1%) and severe pain (89.5%) compared to those with mild pain (39.1%; p < 0.0001). Conclusions The practice of pain documentation for cancer patients was adequate as indicated by reporting the pain scores of 99.8% of inpatients. Patients with moderate and severe pain were more likely to receive opioids and a combination of opioids plus non-opioid analgesics, whereas the prescription of analgesics was predicted by experiencing moderate cancer pain.
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Affiliation(s)
- Nabil ALMouaalamy
- Oncology Department/Palliative, Princess Noorah Oncology Center, King Abdulaziz Medical City, National Guard Health Affairs, Jeddah, SAU.,Research, King Abdullah International Medical Research Center, Jeddah, SAU.,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Ziyad M Alharbi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Faisal M Aldosari
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Saif A Saif
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Enad F Alsulimani
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Mohammed K Aldawsari
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Jamilah AlRahimi
- Cardiology, King Abdulaziz Medical City, King Faisal Cardiac Center, Jeddah, SAU.,Research, King Abdullah International Medical Research Center, Jeddah, SAU.,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
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Ego A, Peluso L, Gorham J, Diosdado A, Restuccia G, Creteur J, Taccone FS. Use of Sedatives and Neuromuscular-Blocking Agents in Mechanically Ventilated Patients with COVID-19 ARDS. Microorganisms 2021; 9:2393. [PMID: 34835518 PMCID: PMC8624865 DOI: 10.3390/microorganisms9112393] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/12/2021] [Accepted: 11/18/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To assess differences in the use of analgesics, sedatives and neuromuscular-blocking agents (NMBA) in patients with acute respiratory distress syndrome (ARDS) due to COVID-19 or other conditions. METHODS Retrospective observational cohort study, single-center tertiary Intensive Care Unit. COVID-19 patients with ARDS (March-May 2020) and non-COVID ARDS patients (2017-2020) on mechanical ventilation and receiving sedation for at least 48 h. RESULTS A total of 39 patients met the inclusion criteria in each group, with similar demographics at baseline. COVID-19 patients had a longer duration of MV (median 22 (IQRs 16-29) vs. 9 (6-18) days; p < 0.01), of sedatives administration (18 (11-22) vs. 5 (4-9) days; p < 0.01) and NMBA therapy (12 (9-16) vs. 3 (2-7) days; p < 0.01). During the first 7 days of sedation, compared to non-COVID patients, COVID patients received more frequently a combination of multiple sedative drugs (76.9% vs. 28.2%; p < 0.01) and a higher NMBA regimen (cisatracurium: 3.0 (2.1-3.7) vs. 1.3 (0.9-1.9) mg/kg/day; p < 0.01). CONCLUSIONS The duration and consumption of sedatives and NMBA was significantly increased in patients with COVID-19 related ARDS than in non-COVID ARDS. Different sedation strategies and protocols might be needed in COVID-19 patients with ARDS, with potential implications on long-term complications and drugs availability.
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Affiliation(s)
- Amédée Ego
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (L.P.); (J.G.); (A.D.); (G.R.); (J.C.); (F.S.T.)
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Intrathecal Morphine for Analgesia in Minimally Invasive Cardiac Surgery: A Randomized, Placebo-controlled, Double-blinded Clinical Trial. Anesthesiology 2021; 135:864-876. [PMID: 34520520 DOI: 10.1097/aln.0000000000003963] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intrathecal morphine decreases postoperative pain in standard cardiac surgery. Its safety and effectiveness have not been adequately evaluated in minimally invasive cardiac surgery. The authors hypothesized that intrathecal morphine would decrease postoperative morphine consumption after minimally invasive cardiac surgery. METHODS In this randomized, placebo-controlled, double-blinded clinical trial, patients undergoing robotic totally endoscopic coronary artery bypass received either intrathecal morphine (5 mcg/kg) or intrathecal saline before surgery. The primary outcome was postoperative morphine equivalent consumption in the first 24 h after surgery; secondary outcomes included pain scores, side effects, and patient satisfaction. Pain was assessed via visual analog scale at 1, 2, 6, 12, 24, and 48 h after intensive care unit arrival. Opioid-related side effects (nausea/vomiting, pruritus, urinary retention, respiratory depression) were assessed daily. Patient satisfaction was evaluated with the Revised American Pain Society Outcome Questionnaire. RESULTS Seventy-nine patients were randomized to receive intrathecal morphine (n = 37) or intrathecal placebo (n = 42), with 70 analyzed (morphine 33, placebo 37). Intrathecal morphine patients required significantly less median (25th to 75th percentile) morphine equivalents compared to placebo during first postoperative 24 h (28 [16 to 46] mg vs. 59 [41 to 79] mg; difference, -28 [95% CI, -40 to -18]; P < 0.001) and second postoperative 24 h (0 [0 to 2] mg vs. 5 [0 to 6] mg; difference, -3.3 [95% CI, -5 to 0]; P < 0.001), exhibited significantly lower visual analog scale pain scores at rest and cough at all postoperative timepoints (overall treatment effect, -4.1 [95% CI, -4.9 to -3.3] and -4.7 [95% CI, -5.5 to -3.9], respectively; P < 0.001), and percent time in severe pain (10 [0 to 40] vs. 40 [20 to 70]; P = 0.003) during the postoperative period. Mild nausea was more common in the intrathecal morphine group (36% vs. 8%; P = 0.004). CONCLUSIONS When given before induction of anesthesia for totally endoscopic coronary artery bypass, intrathecal morphine decreases use of postoperative opioids and produces significant postoperative analgesia for 48 h. EDITOR’S PERSPECTIVE
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Spénard S, Gélinas C, D Trottier E, Tremblay-Racine F, Kleiber N. Morphine or hydromorphone: which should be preferred? A systematic review. Arch Dis Child 2021; 106:1002-1009. [PMID: 33461958 DOI: 10.1136/archdischild-2020-319059] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 11/20/2020] [Accepted: 12/13/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To systematically review available paediatric literature on comparisons between morphine (Mo) and hydromorphone (Hm), to guide clinicians to rationally use these medications. DESIGN Systematic review within four databases for all studies published from 1963 to July 2019. SETTING All paediatric settings. ELIGIBILITY All studies comparing Mo to Hm in individuals younger than 21 years. MAIN OUTCOME MEASURES The primary outcome was to compare clinical efficacy and side effects of Mo and Hm. The secondary outcomes were the comparison of pharmacokinetic profiles and the description of predefined Mo to Hm conversion ratios used across the paediatric literature. RESULTS Among 754 abstracts reviewed, 59 full-text articles met inclusion criteria and 24 studies were included in the analysis: 4 studies compared pharmacodynamics of Mo and Hm and 20 studies reported the use of a predefined Mo to Hm conversion ratio. Most studies had a poor methodological quality. Available evidence suggests that, when given intravenously, the equianalgesic ratio of Mo to Hm is 5:1. Intravenous administration with this ratio results in a similar rate of adverse effects, including pruritus and nausea. The epidural administration with a ratio of 10:1 results in more pruritus and urinary retention with Mo than Hm. Pharmacokinetic data were reported in only one study. A wide range of pre-established ratios for different routes of administration were reported, but few were based on evidence. CONCLUSION Current literature does not permit a rational choice between Mo and Hm. A ratio of 5:1 seems adequate for intravenous administration and leads to a similar rate of adverse effects.
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Affiliation(s)
- Sarah Spénard
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.,Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Charles Gélinas
- Department of Anesthesia, McGill University, Montreal, Quebec, Canada
| | - Evelyne D Trottier
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
| | - Fannie Tremblay-Racine
- Library, CHU Sainte-Justine, Montreal, Quebec, Canada.,Institut Universitaire de Réadaptation en Déficience Physique de Montréal (IURDPM), CIUSSS Centre-Sud-de-l'Ile-de-Montreal, Montreal, Quebec, Canada
| | - Niina Kleiber
- Department of Pediatrics, Division of General Pediatrics And Clinical Pharmacology Unit, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada .,Research Center, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada.,Department of Pharmacology and Physiology, Université de Montréal, Montréal, Quebec, Canada
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Minimally Invasive Versus Standard Surgery in Idiopathic Scoliosis Patients: A Comparative Study. Spine (Phila Pa 1976) 2021; 46:1326-1335. [PMID: 34517401 DOI: 10.1097/brs.0000000000004011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of prospective case-control study. OBJECTIVE To compare minimally invasive scoliosis surgery (MIS) and posterior spinal fusion (PSF) in a large group of patients. SUMMARY OF BACKGROUND DATA MIS, has been shown to have benefits over standard PSF in adolescent idiopathic scoliosis (AIS). METHODS Radiographic, clinical, and operative review of a multi-institutional prospective database from 2013 to 2018. MIS patients with minimum 2-year XR follow up were compared with open PSF technique patients. RESULTS Four hundred eighty five patients were included; 192 MIS and 293 PSF. Preoperative Cobb (P = 0.231) and kyphosis were similar (P = 0.501). Cobb correction was comparable (P = 0.46), however percent improvement in thoracic kyphosis was significantly higher in MIS (P < 0.001). MIS had significantly lower blood loss (P < 0.001), transfusions (P < 0.001), fixation points (P < 0.001), opioid consumption (P = 0.001), and hospital stay (P < 0.001). Operative time was shorter (P = 0.001) and 30-day complications rate was similar (P = 0.81). CONCLUSION This is the largest study comparing the surgical outcomes of MIS and PSF. MIS patients benefit from increased kyphosis, fewer transfusion, lower opioid consumption, and shorter hospital stay with similar Cobb correction. Increased postoperative kyphosis is likely from muscle sparing dissection in MIS.Level of Evidence: 3.
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Does intraoperative and postoperative analgesia cause bile leakage after hepatectomy? Surg Today 2021; 52:690-696. [PMID: 34542715 DOI: 10.1007/s00595-021-02377-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/04/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To evaluate the effect of morphine or morphine equivalents on the risk of bile leakage (BL) after hepatectomy. METHODS The subjects of this retrospective study were 379 patients who underwent hepatectomy without biliary reconstruction and biliary decompression tube insertion at Gunma University between 2016 and 2020. Clinical BL was defined as International Study Group of Liver Surgery post-hepatectomy bile leakage Grade B or C. RESULTS Intra- and post-operative analgesia comprised intravenous patient-controlled analgesia (IV-PCA) with fentanyl (n = 58), epidural analgesia with fentanyl (n = 157), epidural analgesia with morphine (n = 151), and epidural analgesia with ropivacaine or levobupivacaine (n = 13). Clinical BL was diagnosed in 14 of the 379 (3.7%) patients. The significant risk factors for clinical BL were hepatocellular carcinoma (HCC), elevated serum total bilirubin, high indocyanine green retention at 15 min, elevated Mac-2-binding protein glycosylated isomer, prolonged duration of surgery, and a large volume of blood loss. There was no significant correlation of clinical BL with intra- and post-operative analgesia and total oral morphine equivalents. CONCLUSION Intra- and post-operative IV-PCA and epidural analgesia were not related to clinical BL after hepatectomy. Based on our data, fentanyl and morphine can be administered safely as epidural or intravenous analgesic agents.
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Quadratus lumborum block for postoperative analgesia after cesarean section: a meta-analysis of randomized controlled trials with trial sequential analysis. Sci Rep 2021; 11:18104. [PMID: 34518565 PMCID: PMC8438068 DOI: 10.1038/s41598-021-96546-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 07/23/2021] [Indexed: 11/09/2022] Open
Abstract
The aim of this study was to assess the analgesic efficacy of QLB versus controls in women undergoing cesarean section (CS). We systematically searched Cochrane Library, PUBMED, EMBASE, VIP, WANFANG, and China National Knowledge Infrastructure. Trials were eligible if parturients received QLB during CS. GRADE system was used to assess the certainty of evidence and Trial sequential analyses (TSA) were performed to determine whether the results are supported by sufficient data. Thirteen studies involving 1269 patients were included. Compared to controls, QLB significantly reduced the cumulative postoperative intravenous opioid consumption (in milligram morphine equivalents) at 24 h (MD, - 11.51 mg; 95% CI - 17.05 to - 5.96) and 48 h (MD, - 15.87 mg; 95% CI - 26.36 to - 5.38), supported by sufficient data confirmed by TSA. The postoperative pain scores were significantly reduced by QLB at 4 h, 6 h, 12 h, 24 h, and 48 h postoperatively by QLB compared with control. Moreover, the time to first request for rescue analgesic and the incidence of PONV were also significantly reduced by QLB. The quality of evidence of most results were low and moderate assessed by GRADE.
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