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Saxena H, Weintraub NL, Tang Y. Potential Therapeutic Targets for Hypotension in Duchenne Muscular Dystrophy. Med Hypotheses 2024; 185:111318. [PMID: 38585412 PMCID: PMC10993928 DOI: 10.1016/j.mehy.2024.111318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Duchenne Muscular Dystrophy (DMD) is marked by genetic mutations occurring in the DMD gene, which is widely expressed in the cardiovascular system. In addition to developing cardiomyopathy, patients with DMD have been reported to be susceptible to the development of symptomatic hypotension, although the mechanisms are unclear. Analysis of single-cell RNA sequencing data has identified potassium voltage-gated channel subfamily Q member 5 (KCNQ5) and possibly ryanodine receptor 2 (RyR2) as potential candidate hypotension genes whose expression is significantly upregulated in the vascular smooth muscle cells of DMD mutant mice. We hypothesize that heightened KCNQ5 and RyR2 expression contributes to decreased arterial blood pressure in patients with DMD. Exploring pharmacological approaches to inhibit the KCNQ5 and RyR2 channels holds promise in managing the systemic hypotension observed in individuals with DMD. This avenue of investigation presents new prospects for improving clinical outcomes for these patients.
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Affiliation(s)
- Harshi Saxena
- Vascular Biology Center, Department of Medicine, Medical College of Georgia at Augusta University, 1460 Laney Walker Blvd, Augusta, GA 30912, USA
| | - Neal L Weintraub
- Vascular Biology Center, Department of Medicine, Medical College of Georgia at Augusta University, 1460 Laney Walker Blvd, Augusta, GA 30912, USA
| | - Yaoliang Tang
- Vascular Biology Center, Department of Medicine, Medical College of Georgia at Augusta University, 1460 Laney Walker Blvd, Augusta, GA 30912, USA
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Ma CH, Tworek KB, Kung JY, Kilcommons S, Wheeler K, Parker A, Senaratne J, Macintyre E, Sligl W, Karvellas CJ, Zampieri FG, Kutsogiannis DJ, Basmaji J, Lewis K, Chaudhuri D, Sharif S, Rewa OG, Rochwerg B, Bagshaw SM, Lau VI. Systemic Nonsteroidal Anti-Inflammatories for Analgesia in Postoperative Critical Care Patients: A Systematic Review and Meta-Analysis of Randomized Control Trials. Crit Care Explor 2023; 5:e0938. [PMID: 37396930 PMCID: PMC10309528 DOI: 10.1097/cce.0000000000000938] [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] [Indexed: 07/04/2023] Open
Abstract
While opioids are part of usual care for analgesia in the ICU, there are concerns regarding excess use. This is a systematic review of nonsteroidal anti-inflammatory drugs (NSAIDs) use in postoperative critical care adult patients. DATA SOURCES We searched Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, trial registries, Google Scholar, and relevant systematic reviews through March 2023. STUDY SELECTION Titles, abstracts, and full texts were reviewed independently and induplicate by two investigators to identify eligible studies. We included randomized control trials (RCTs) that compared NSAIDs alone or as an adjunct to opioids for systemic analgesia. The primary outcome was opioid utilization. DATA EXTRACTION In duplicate, investigators independently extracted study characteristics, patient demographics, intervention details, and outcomes of interest using predefined abstraction forms. Statistical analyses were conducted using Review Manager software Version 5.4. (The Cochrane Collaboration, Copenhagen, Denmark). DATA SYNTHESIS We included 15 RCTs (n = 1,621 patients) for admission to the ICU for postoperative management after elective procedures. Adjunctive NSAID therapy to opioids reduced 24-hour oral morphine equivalent consumption by 21.4 mg (95% CI, 11.8-31.0 mg reduction; high certainty) and probably reduced pain scores (measured by Visual Analog Scale) by 6.1 mm (95% CI, 12.2 decrease to 0.1 increase; moderate certainty). Adjunctive NSAID therapy probably had no impact on the duration of mechanical ventilation (1.6 hr reduction; 95% CI, 0.4 hr to 2.7 reduction; moderate certainty) and may have no impact on ICU length of stay (2.1 hr reduction; 95% CI, 6.1 hr reduction to 2.0 hr increase; low certainty). Variability in reporting adverse outcomes (e.g., gastrointestinal bleeding, acute kidney injury) precluded their meta-analysis. CONCLUSIONS In postoperative critical care adult patients, systemic NSAIDs reduced opioid use and probably reduced pain scores. However, the evidence is uncertain for the duration of mechanical ventilation or ICU length of stay. Further research is required to characterize the prevalence of NSAID-related adverse outcomes.
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Affiliation(s)
- Chen Hsiang Ma
- Department of Medicine, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Kimberly B Tworek
- Department of Medicine, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Janice Y Kung
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, AB, Canada
| | - Sebastian Kilcommons
- Department of Medicine, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Kathleen Wheeler
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Arabesque Parker
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Janek Senaratne
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Erika Macintyre
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Wendy Sligl
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Constantine J Karvellas
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Fernando G Zampieri
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Demetrios Jim Kutsogiannis
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - John Basmaji
- Department of Medicine, Division of Critical Care, Western University, London, ON, Canada
| | - Kimberley Lewis
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Dipayan Chaudhuri
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Sameer Sharif
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Oleksa G Rewa
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
- School of Public Health, University of Alberta, Edmonton, AB, Canada
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
| | - Vincent I Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
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Sinderovsky A, Grosman-Rimon L, Atrash M, Nakhoul A, Saadi H, Rimon J, Birati EY, Carasso S, Kachel E. The Effects of Preoperative Pain Education on Pain Severity in Cardiac Surgery Patients: A Pilot Randomized Control Trial. Pain Manag Nurs 2023:S1524-9042(23)00030-9. [PMID: 36941189 DOI: 10.1016/j.pmn.2023.02.003] [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: 05/08/2022] [Revised: 01/08/2023] [Accepted: 02/06/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND There is minimal research on the effect of individualized preoperative education on postoperative pain and postoperative pain medication intake. AIM The study objective was to assess the effect of individually tailored preoperative education on postoperative pain severity, number of pain breakthroughs, and use of pain medication in participants receiving the intervention compared to controls. METHODS A pilot study with 200 participants was conducted. The experimental group received an informational booklet and discussed their ideas surrounding pain and pain medication with the researcher. Controls received no intervention. Postoperative pain severity was measured by a Numerical Rating System (NRS), which was divided into mild (NRS 1-3), moderate (NRS 4-6), and severe (NRS 7-10). RESULTS In the participant cohort, 68.8% of participants were male, and the average age was 60.48±10.7. Average postoperative 48-hour cumulative pain scores were lower in those who received the intervention compared to controls; 50.0 (IQR 35.8-60.0) vs. 65 (IQR 51.0-73.0; p < .01) participants who received the intervention had less frequent pain breakthroughs when compared to controls (3.0 [IQR 2.0-5.0] vs. 6.0 [IQR 4.0-8.0; p < .01]). There was no significant difference in the amount of pain medication taken by either group. CONCLUSIONS Participants who receive individualized preoperative pain education are more likely to have decreased postoperative pain.
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Affiliation(s)
- Amanda Sinderovsky
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Liza Grosman-Rimon
- Division of Cardiovascular Medicine and Surgery, Tzafon Medical Center, Tiberias, Israel; School of Graduate Studies, The Academic Center Levinsky-Wingate, Wingate Institute, Netanya, Israel
| | - Muhamd Atrash
- Division of Cardiovascular Medicine and Surgery, Tzafon Medical Center, Tiberias, Israel
| | - Aida Nakhoul
- Division of Cardiovascular Medicine and Surgery, Tzafon Medical Center, Tiberias, Israel
| | - Hanadi Saadi
- Division of Cardiovascular Medicine and Surgery, Tzafon Medical Center, Tiberias, Israel
| | - Jordan Rimon
- Faculty of Health, York University, Toronto, Canada
| | - Edo Y Birati
- Division of Cardiovascular Medicine and Surgery, Tzafon Medical Center, Tiberias, Israel; The Azrieli Faculty of Medicine, Bar-Ilan University, Zefat, Israel
| | - Shemy Carasso
- The Azrieli Faculty of Medicine, Bar-Ilan University, Zefat, Israel; The Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem
| | - Erez Kachel
- Division of Cardiovascular Medicine and Surgery, Tzafon Medical Center, Tiberias, Israel; The Azrieli Faculty of Medicine, Bar-Ilan University, Zefat, Israel; Department of Cardiac Surgery, Sheba Medical Centre, Tel Hashomer, Israel.
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Réhabilitation améliorée après chirurgie cardiaque adulte sous CEC ou à cœur battant 2021. ANESTHÉSIE & RÉANIMATION 2022. [DOI: 10.1016/j.anrea.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Mertes PM, Kindo M, Amour J, Baufreton C, Camilleri L, Caus T, Chatel D, Cholley B, Curtil A, Grimaud JP, Houel R, Kattou F, Fellahi JL, Guidon C, Guinot PG, Lebreton G, Marguerite S, Ouattara A, Provenchère Fruithiot S, Rozec B, Verhoye JP, Vincentelli A, Charbonneau H. Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump. Anaesth Crit Care Pain Med 2022; 41:101059. [PMID: 35504126 DOI: 10.1016/j.accpm.2022.101059] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To provide recommendations for enhanced recovery after cardiac surgery (ERACS) based on a multimodal perioperative medicine approach in adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity, and reducing the length of hospital stay. DESIGN A consensus committee of 20 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Société française de chirurgie thoracique et cardio-vasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence. METHODS Six fields were defined: (1) selection of the patient pathway and its information; (2) preoperative management and rehabilitation; (3) anaesthesia and analgesia for cardiac surgery; (4) surgical strategy for cardiac surgery and bypass management; (5) patient blood management; and (6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analyses were performed using the GRADE approach. The recommendations were formulated according to the GRADE methodology and then voted on by all the experts according to the GRADE grid method. RESULTS The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing cardiac surgery under cardiopulmonary bypass or off-pump. After three rounds of voting and several amendments, a strong agreement was reached for the 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1-); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2-); and 4 are expert opinions. Finally, no recommendations were provided for 3 questions. CONCLUSIONS Strong agreement existed among the experts to provide recommendations to optimise the complete perioperative management of patients undergoing cardiac surgery.
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Affiliation(s)
- Paul-Michel Mertes
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Michel Kindo
- Department of Cardiac Surgery, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Julien Amour
- Institut de Perfusion, de Réanimation, d'Anesthésie de Chirurgie Cardiaque Paris Sud, IPRA, Hôpital Privé Jacques Cartier, Massy, France
| | - Christophe Baufreton
- Department of Cardiovascular and Thoracic Surgery, University Hospital, Angers, France; MITOVASC Institute CNRS UMR 6214, INSERM U1083, University, Angers, France
| | - Lionel Camilleri
- Department of Cardiovascular Surgery, CHU Clermont-Ferrand, T.G.I, I.P., CNRS, SIGMA, UCA, UMR 6602, Clermont-Ferrand, France
| | - Thierry Caus
- Department of Cardiac Surgery, UPJV, Amiens University Hospital, Amiens Picardy University Hospital, Amiens, France
| | - Didier Chatel
- Department of Cardiac Surgery (D.C.), Institut du Coeur Saint-Gatien, Nouvelle Clinique Tours Plus, Tours, France
| | - Bernard Cholley
- Anaesthesiology and Intensive Care Medicine, Hôpital Européen Georges-Pompidou, AP-HP, Université de Paris, INSERM, IThEM, Paris, France
| | - Alain Curtil
- Department of Cardiac Surgery, Clinique de la Sauvegarde, Lyon, France
| | | | - Rémi Houel
- Department of Cardiac Surgery, Saint Joseph Hospital, Marseille, France
| | - Fehmi Kattou
- Department of Anaesthesia and Intensive Care, Institut Mutualiste Montsouris, Paris, France
| | - Jean-Luc Fellahi
- Service d'Anesthésie-Réanimation, Hôpital Universitaire Louis Pradel, Hospices Civils de Lyon, Lyon, France; Faculté de Médecine Lyon Est, Université Claude-Bernard Lyon 1, Lyon, France
| | - Catherine Guidon
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, Marseille, France
| | - Pierre-Grégoire Guinot
- Department of Anaesthesiology and Intensive Care, Dijon University Hospital, Dijon, France; University of Bourgogne and Franche-Comté, LNC UMR1231, Dijon, France; INSERM, LNC UMR1231, Dijon, France; FCS Bourgogne-Franche Comté, LipSTIC LabEx, Dijon, France
| | - Guillaume Lebreton
- Sorbonne Université, INSERM, Unité mixte de recherche CardioMetabolisme et Nutrition, ICAN, AP-HP, Hôpital Pitié-Salpétrière, Paris, France
| | - Sandrine Marguerite
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Alexandre Ouattara
- CHU Bordeaux, Department of Anaesthesia and Critical Care, Magellan Medico-Surgical Centre, F-33000 Bordeaux, France; Univ. Bordeaux, INSERM, UMR 1034, Biology of Cardiovascular Diseases, F-33600 Pessac, France
| | - Sophie Provenchère Fruithiot
- Department of Anaesthesia, Université de Paris, Bichat-Claude Bernard Hospital, Paris, France; Centre d'Investigation Clinique 1425, INSERM, Université de Paris, Paris, France
| | - Bertrand Rozec
- Service d'Anesthésie-Réanimation, Hôpital Laennec, CHU Nantes, Nantes, France; Université de Nantes, CHU Nantes, CNRS, INSERM, Institut duDu Thorax, Nantes, France
| | - Jean-Philippe Verhoye
- Department of Thoracic and Cardiovascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - André Vincentelli
- Department of Cardiac Surgery, University of Lille, CHU Lille, Lille, France
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Ishida Y, Okada T, Kobayashi T, Funatsu K, Uchino H. Pain Management of Acute and Chronic Postoperative Pain. Cureus 2022; 14:e23999. [PMID: 35547410 PMCID: PMC9086530 DOI: 10.7759/cureus.23999] [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] [Accepted: 04/09/2022] [Indexed: 12/04/2022] Open
Abstract
Inadequate management of acute postoperative pain is associated with effects related to both physiological and psychological function. Postoperative pain increases the risk of perioperative complications, so postoperative pain should be prevented. Postoperative pain management by sufficient analgesia is important while considering the use of various kinds of analgesics. Insufficient management of postoperative pain may lead to chronic postsurgical pain (CPSP). It is suggested that CPSP is dependent not only upon biological factors but also upon psychological factors, including the type of surgery, age, physical health, mental health, and preoperative pain. As CPSP is a severe complication that may prolong hospitalization and interferes with activities of daily living (ADL) and quality of life (QoL), its prevention of development is paramount. Therefore, in order to prevent the onset of CPSP, it is necessary to craft analgesic management to prevent CPSP during the perioperative period.
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Assessment of Discharge Analgesic Prescription Patterns for Hospitalized Patients With Rib Fractures. J Surg Res 2022; 276:48-53. [PMID: 35334383 DOI: 10.1016/j.jss.2022.02.022] [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: 09/13/2021] [Revised: 01/26/2022] [Accepted: 02/14/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION There is a paucity of data describing opioid prescribing patterns for trauma patients. We investigated pain medication regimens prescribed at discharge for patients with traumatic rib fractures, as well as potential variables predictive of opioid prescribing. METHODS A single-center, retrospective analysis was performed of 337 adult patients presenting with ≥1 traumatic rib fractures between January and December 2019. The primary outcome was oral morphine milligram equivalents (MME) prescribed on discharge. A multivariable logistic regression analysis was performed to determine factors independently associated with above median (150) MME prescription at discharge. RESULTS The majority of patients were male (68.8%) with a median age of 53 y. Blunt trauma accounted for 97.3% of cases with a median Injury Severity Score(ISS) of 10. Locoregional pain procedures were utilized in 16.9% of patients. Opioids were the most common analgesic prescribed at discharge, and 74.1% of patients prescribed opioids on discharge were also prescribed a non-opioid adjunct. On multivariable analysis, daily MME prescribed during hospitalization (OR 1.01, 95% CI 1.01-1.02, P < 0.01) and number of rib fractures (OR 2.26, 95% CI 1.36-3.74, P < 0.01) were predictive of high MME prescribed on discharge. CONCLUSIONS For patients with traumatic rib fractures, daily MME during hospitalization and number of rib fractures were predictive of high MME prescribing on discharge. Further prospective studies evaluating strategies for pain management and protocolized approaches to opioid prescribing are needed to reduce unnecessary and inappropriate opioid use in this patient population.
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Hamed MA, Abdelhady MA, Hassan AASM, Boules ML. The Analgesic Effect of Ultrasound-guided Bilateral Pectointercostal Fascial Plane Block on Sternal Wound Pain After Open Heart Surgeries: A Randomized Controlled Study. Clin J Pain 2022; 38:279-284. [PMID: 35132025 DOI: 10.1097/ajp.0000000000001022] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 01/11/2022] [Indexed: 01/26/2023]
Abstract
OBJECTIVES We aimed to evaluate the analgesic efficacy of ultrasound-guided bilateral pectointercostal fascial plane block after open heart surgeries. METHODS Seventy patients aged above 18 years and scheduled for on-pump coronary artery bypass grafting or valve replacement or both through median sternotomy were enrolled in this study. Patients were randomly allocated into 2 groups of 35 (block group or control group). The block group had the block performed through 20 ml of a solution of 0.25% bupivacaine plus epinephrine (5 mcg/mL), and the control group received dry needling. The primary outcome was the 24-hour cumulative morphine consumption. The secondary outcomes were time to the first analgesic request, pain score, quality of oxygenation, intensive care unit stays, and hospital stay. RESULTS The cumulative morphine consumption in the first 24 hours was significantly lower in the block group, with a mean difference of -3.54 (95% confidence interval=-6.55 to -0.53; P=0.015). In addition, the median estimate time to the first analgesic request was significantly longer in the block group than in the control group. Finally, during the postoperative period (4 to 24 h), mean sternal wound objective pain scores were, on average, 0.58 units higher in the block group. CONCLUSION pectointercostal fascial block is an effective technique in reducing morphine consumption and controlling poststernotomy pain after cardiac surgeries. Also, it may have a role in better postoperative respiratory outcomes.
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Affiliation(s)
- Mohamed A Hamed
- Department of Anesthesiology, Faculty of Medicine, Fayoum University, Fayoum, Egypt
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Cheung CK, Adeola JO, Beutler SS, Urman RD. Postoperative Pain Management in Enhanced Recovery Pathways. J Pain Res 2022; 15:123-135. [PMID: 35058714 PMCID: PMC8765537 DOI: 10.2147/jpr.s231774] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/30/2021] [Indexed: 12/05/2022] Open
Abstract
Postoperative pain is a common but often inadequately treated condition. Enhanced recovery pathways (ERPs) are increasingly being utilized to standardize perioperative care and improve outcomes. ERPs employ multimodal postoperative pain management strategies that minimize opioid use and promote recovery. While traditional opioid medications continue to play an important role in the treatment of postoperative pain, ERPs also rely on a wide range of non-opioid pharmacologic therapies as well as regional anesthesia techniques to manage pain in the postoperative setting. The evidence for the use of these interventions continues to evolve rapidly given the increasing focus on enhanced postoperative recovery. This article reviews the current evidence and knowledge gaps pertaining to commonly utilized modalities for postoperative pain management in ERPs.
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Affiliation(s)
- Christopher K Cheung
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Janet O Adeola
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Sascha S Beutler
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Hadipourzadeh F, Mousavi S, Heydarpur A, Sadeghi A, Ferasat-Kish R. Evaluation of the Adding Paracetamol to Dexmedetomidine in Pain Management After Adult Cardiac Surgery. Anesth Pain Med 2021; 11:e110274. [PMID: 34540629 PMCID: PMC8438704 DOI: 10.5812/aapm.110274] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 05/29/2021] [Accepted: 05/30/2021] [Indexed: 12/30/2022] Open
Abstract
Background Postoperative pain control after cardiac surgery is usually based on Opioids. These drugs are associated with side effects, and the use of drugs with fewer side effects is important for analgesia. Dexmedetomidine and paracetamol have fewer side effects than opioids. Objectives The aim of the study was to evaluate the adding paracetamol to dexmedetomidine continuous infusion pump for pain management after adult cardiac surgery. Methods In this study, 100 patients were divided into two groups. One group received a continuous infusion of dexmedetomidine and paracetamol (DP), and the other received dexmedetomidine (D). These two groups were evaluated for MAP, HR, and the need for prescribing opioids before and after extubation. Also, duration of intubation and pain before extubation and 36 hours after every 4 hours. Results Patients in the DP group had lower mean MAP and HR during intubation period than the D group and needed fewer opioids and doses of opioids in addition to drug study infusion pre- (P = 0.001) and post-extubation (P = 0.001 and P = 0.022, respectively). The DP group patients were extubated earlier (P = 0.001). After extubation, the DP group had less pain than the D group. Conclusions This study showed that adding paracetamol to the dexmedetomidine infusion pump can provide better analgesia.
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Affiliation(s)
- Fatemehshima Hadipourzadeh
- Cardiac Anesthesia Department, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Corresponding Author: Cardiac Anesthesia Department, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Vali-Asr Street, Tehran, Iran. Tel: +98-2123923740, Fax:+98-21 22663293,
| | - SeyedMehdi Mousavi
- Cardiac Anesthesia Department, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Avaz Heydarpur
- Cardiac Anesthesia Department, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Sadeghi
- Cardiac Anesthesia Department, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Rasool Ferasat-Kish
- Cardiac Anesthesia Department, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
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Krakowski JC, Hallman MJ, Smeltz AM. Persistent Pain After Cardiac Surgery: Prevention and Management. Semin Cardiothorac Vasc Anesth 2021; 25:289-300. [PMID: 34416847 PMCID: PMC8669213 DOI: 10.1177/10892532211041320] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Persistent postoperative pain (PPP) after cardiac surgery is a significant complication that negatively affects patient quality of life and increases health care system burden. However, there are no standards or guidelines to inform how to mitigate these effects. Therefore, in this review, we will discuss strategies to prevent and manage PPP after cardiac surgery. Adequate perioperative analgesia may prove instrumental in the prevention of PPP. Although opioids have historically been the primary analgesic approach to cardiac surgery, an opioid-sparing strategy may prove advantageous in reducing side effects, avoiding secondary hyperalgesia, and decreasing risk of PPP. Implementing a multimodal analgesic plan using alternative medications and regional anesthetic techniques may offer superior efficacy while reducing adverse effects.
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Affiliation(s)
| | | | - Alan M Smeltz
- University of North Carolina at Chapel Hill, NC, USA
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Wilson SH, Hellman KM, James D, Adler AC, Chandrakantan A. Mechanisms, diagnosis, prevention and management of perioperative opioid-induced hyperalgesia. Pain Manag 2021; 11:405-417. [PMID: 33779215 DOI: 10.2217/pmt-2020-0105] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Opioid-induced hyperalgesia (OIH) occurs when opioids paradoxically enhance the pain they are prescribed to ameliorate. To address a lack of perioperative awareness, we present an educational review of clinically relevant aspects of the disorder. Although the mechanisms of OIH are thought to primarily involve medullary descending pathways, it is likely multifactorial with several relevant therapeutic targets. We provide a suggested clinical definition and directions for clinical differentiation of OIH from other diagnoses, as this may be confusing but is germane to appropriate management. Finally, we discuss prevention including patient education and analgesic management choices. As prevention may serve as the best treatment, patient risk factors, opioid mitigation, and both pharmacologic and non-pharmacologic strategies are discussed.
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Affiliation(s)
- Sylvia H Wilson
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Kevin M Hellman
- Department of Obstetrics & Gynecology, NorthShore University Health System & Pritzker School of Medicine at the University of Chicago, Evanston, IL 60201, USA
| | - Dominika James
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Adam C Adler
- Department of Anesthesiology & Perioperative Pain Medicine, Texas Children's Hospital, Houston, TX 77030, USA.,Department of Anesthesiology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Arvind Chandrakantan
- Department of Anesthesiology & Perioperative Pain Medicine, Texas Children's Hospital, Houston, TX 77030, USA.,Department of Anesthesiology, Baylor College of Medicine, Houston, TX 77030, USA
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13
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Pergolizzi JV, Magnusson P, Raffa RB, LeQuang JA, Coluzzi F. Developments in combined analgesic regimens for improved safety in postoperative pain management. Expert Rev Neurother 2020; 20:981-990. [PMID: 32749896 DOI: 10.1080/14737175.2020.1806058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Introduction: Fixed-dose combination analgesic regimens may be similarly effective to opioid monotherapy but with potentially less risk. A number of individualized combination regimens can be created, including nonopioid agents such as acetaminophen and nonsteroidal anti-inflammatory drugs, opioids, and adjunctive agents such as gabapentin, pregabalin, and muscle relaxants. Areas covered: When such combinations have a synergistic effect, analgesic benefits may be enhanced. Many combination analgesic regimens are opioid sparing, which sometimes but not always results in reduced opioid-associated side effects. Safety concerns for all analgesics must be considered but postoperative analgesia is typically administered for a brief period (days), reducing risks that may occur with prolonged exposure. Expert opinion: Judiciously considered combination analgesic regimens can be effective postoperative analgesics that reduce opioid consumption without compromising pain control, which are important factors for patient recovery and satisfaction. The specific combinations used must be based on the patient, the type and duration of the surgical procedure, and complementary mechanisms of action of the agents used. In opioid-sparing combination analgesic regimens, the short-term use of small doses of opioids in this setting may be helpful for appropriate patients.
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Affiliation(s)
| | - Peter Magnusson
- Centre for Research and Development, Uppsala/Region Gävleborg , Gävle, Sweden.,Department of Medicine, Cardiology Research Unit, Karolinska Institutet , Stockholm, Sweden
| | - Robert B Raffa
- Professor Emeritus and past Chair, Temple University School of Pharmacy , Philadelphia, Pennsylvania, USA.,Department of Pharmacology, University of Arizona College of Pharmacy , Tucson, Arizona, USA.,CSO, Neumentum , Palo Alto, California, USA
| | - Jo Ann LeQuang
- Pain Medicine, NEMA Research, Inc , Naples, Florida, USA
| | - Flaminia Coluzzi
- Department Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome , Rome, Italy
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Mijovski G, Podbregar M, Kšela J, Jenko M, Šoštarič M. Effectiveness of wound infusion of 0.2% ropivacaine by patient control analgesia pump after minithoracotomy aortic valve replacement: a randomized, double-blind, placebo-controlled trial. BMC Anesthesiol 2020; 20:172. [PMID: 32682395 PMCID: PMC7368743 DOI: 10.1186/s12871-020-01093-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 07/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Local anesthetic wound infusion has become an invaluable technique in multimodal analgesia. The effectiveness of wound infusion of 0.2% ropivacaine delivered by patient controlled analgesia (PCA) pump has not been evaluated in minimally invasive cardiac surgery. We tested the hypothesis that 0.2% ropivacaine wound infusion by PCA pump reduces the cumulative dose of opioid needed in the first 48 h after minithoracothomy aortic valve replacement (AVR). METHODS In this prospective, randomized, double-blind, placebo-controlled study, 70 adult patients (31 female and 39 male) were analyzed. Patients were randomized to receive 0.2% ropivacaine or 0.9% saline wound infusion by PCA pump for 48 h postoperatively. PCA pump was programmed at 5 ml h- 1 continuously and 5 ml of bolus with 60 min lockout. Pain levels were assessed and recorded hourly by Numeric Rating Scale (NRS). If NRS score was higher than three the patient was administered 3 mg of opioid piritramide repeated and titrated as needed until pain relief was achieved. The primary outcome was the cumulative dose of the opioid piritramide in the first 48 h after surgery. Secondary outcomes were frequency of NRS scores higher than three, patient's satisfaction with pain relief, hospital length of stay, side effects related to the local anesthetic and complications related to the wound catheter. RESULTS The cumulative dose of the opioid piritramide in the first 48 h after minithoracotomy AVR was significantly lower (p < 0.001) in the ropivacaine (R) group median 3 mg (IQR 6 mg) vs. 9 mg (IQR 9 mg). The number of episodes of pain where NRS score was greater than three median 2 (IQR 2), vs 3 (IQR 3), (p = 0.002) in the first 48 h after surgery were significantly lower in the ropivacaine group, compared to control. Patient satisfaction with pain relief in our study was high. There were no wound infections and no side-effects from the local anesthetic. CONCLUSIONS Wound infusion of local anesthetic by PCA pump significantly reduced opioid dose needed and improves pain control postoperatively. We have also shown that it is a feasible method of analgesia and it should be considered in the multimodal pain control strategy following minimally invasive cardiac surgery. TRIAL REGISTRATION ClinicalTrials.gov NCT03079830 , date of registration: March 15, 2017. Retrospecitvely registered.
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Affiliation(s)
- Gordan Mijovski
- Department of Anaesthesiology and Surgical Intensive Therapy, University Medical Centre Ljubljana, Faculty of Medicine, University of Ljubljana, Zaloška cesta 2, 1000, Ljubljana, Slovenia.
| | - Matej Podbregar
- Department of Anaesthesiology and Surgical Intensive Therapy, University Medical Centre Ljubljana, Faculty of Medicine, University of Ljubljana, Zaloška cesta 2, 1000, Ljubljana, Slovenia
| | - Juš Kšela
- Department of Cardiovascular Surgery, University Medical Centre Ljubljana, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Matej Jenko
- Department of Anaesthesiology and Surgical Intensive Therapy, University Medical Centre Ljubljana, Faculty of Medicine, University of Ljubljana, Zaloška cesta 2, 1000, Ljubljana, Slovenia
| | - Maja Šoštarič
- Department of Anaesthesiology and Surgical Intensive Therapy, University Medical Centre Ljubljana, Faculty of Medicine, University of Ljubljana, Zaloška cesta 2, 1000, Ljubljana, Slovenia
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15
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Manzoor S, Khan T, Zahoor SA, Wani SQ, Rather JM, Yaqoob S, Ali Z, Hakeem ZA, Dar BA. Post-thoracotomy ipsilateral shoulder pain: What should be preferred to optimize it - phrenic nerve infiltration or paracetamol infusion? Ann Card Anaesth 2020; 22:291-296. [PMID: 31274492 PMCID: PMC6639895 DOI: 10.4103/aca.aca_76_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Post thoracotomy ipsilateral shoulder pain (PTISP) is a distressing and highly prevalent problem after thoracic surgery and has not received much attention despite the incidence as high as 85%. Objectives To study the effect of phrenic nerve infiltration with Ropivacaine compared to paracetamol infusion on PTISP in thoracotomy patients with epidural analgesia as standard mode of incisional analgesia in both the groups. Study Design Prospective Randomised and Double Blind Study. Methods 126 adult patients were divided randomly into 2 groups, "Group A (Phrenic Nerve Infiltration Group) received 10 mL of 0.2% Ropivacaine close to the diaphragm into the periphrenic fat pad" and "Group B (Paracetamol Infusion Group) received 20mg/kg paracetamol infusion" 30 minutes prior to chest closure respectively. A blinded observer assessed the patients PTISP using the VAS score at 1, 4, 8, 12 and 24 hours (h) postoperatively. The time and number of any rescue analgesic medication were recorded. Results PTISP was relieved significantly in Group A (25.4℅) as compared to Group B (61.9℅), with significantly higher mean duration of analgesia in Group A. The mean time for first rescue analgesia was significantly higher in Group A (11.1 ± 7.47 hours) than in Group B (7.40 ± 5.30 hours). The number of rescue analgesic required was less in Group A 1.6 ± 1.16 as compared to Group B 2.9 ± 1.37 (P value <0.5). Conclusions Phrenic Nerve Infiltration significantly reduced the incidence and delayed the onset of PTISP as compared to paracetamol infusion and was not associated with any adverse effects.
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Affiliation(s)
- Sobia Manzoor
- Department of Anaesthesiology, Pain and Critical Care, Sher I Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Talib Khan
- Department of Anaesthesiology, Pain and Critical Care; Division of Cardiovascular and Thoracic Anaesthesia and Cardiac SICU, Sher I Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Syed Amer Zahoor
- Department of Anaesthesiology, Pain and Critical Care; Division of Cardiovascular and Thoracic Anaesthesia and Cardiac SICU, Sher I Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Shaqul Qamar Wani
- Department of Radiation Oncology, Sher I Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Jan Mohamad Rather
- Department of General Surgery, Sher I Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Shaista Yaqoob
- Department of Anaesthesiology, Pain and Critical Care, Sher I Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Zulfiqar Ali
- Department of Anaesthesiology, Pain and Critical Care, Sher I Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Zubair Ashraf Hakeem
- Department of Cardiovascular and Thoracic Surgery, Sher I Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Bashir Ahmad Dar
- Department of Anaesthesiology, Pain and Critical Care, Sher I Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
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16
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Abstract
Supplemental Digital Content is available in the text. This systematic review and meta-analysis addresses the efficacy and safety of nonopioid adjunctive analgesics for patients in the ICU.
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17
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Padala SRAN, Badhe AS, Parida S, Jha AK. Comparison of preincisional and postincisional parasternal intercostal block on postoperative pain in cardiac surgery. J Card Surg 2020; 35:1525-1530. [PMID: 32579779 DOI: 10.1111/jocs.14651] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The optimum cardiac surgical pain management has known to maintain hemodynamic stability and, reduces respiratory and cardiovascular complications. Postoperative parasternal intercostal block has shown to reduce postoperative analgesic consumption after cardiac surgery. Therefore, this study sought to investigate the effectiveness of the preoperative ultrasound guided parasternal block in reducing postoperative pain after cardiac surgery. METHODS This was a randomized, prospective, interventional, single blind study comprised of 90 adult patients scheduled for cardiac surgery involving sternotomy. Preoperatively and postoperatively, 0.25% bupivacaine administered in 4 mL aliquots into the anterior (2nd-6th) intercostal spaces on each side about 2 cm lateral to the sternal edge with a total volume of 40 mL under ultrasound guidance and direct vision, respectively. Postoperative pain was rated according to visual analogue scale. Secondary outcomes included intraoperative and postoperative fentanyl consumptions, dosages of rescue medications, and time to extubation. MAIN RESULTS There was no significant differences in visual analogue score visual analogue score at all time points till 24 hours postoperatively. Intraoperative fentanyl requirements (microgram/kg) before cardiopulmonary bypass was significantly lower in pre-incisional group than the post-incisional group (0.16 ± 0.43 vs 0.68 ± 0.72; P = .0001). Furthermore, there were no significant difference in total fentanyl requirement (7.20 ± 2.66 vs 8.37 ± 3.13; P = .06) and tramadol requirement (0.02 ± 0.15 vs 0.07 ± 0.26; P = .28) within first 24 hours. However, time to extubation was significantly higher in the preoperative group (P = .02). CONCLUSIONS Preoperative and postoperative parasternal intercostal block provide comparable pain relief during the postoperative period.
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Affiliation(s)
| | - Ashok Shankar Badhe
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Satyen Parida
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Ajay Kumar Jha
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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18
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Osojnik I, Kamenik M. The Effect of Diclofenac on Bleeding, Platelet Function, and Consumption of Opioids Following Cardiac Surgery. Braz J Cardiovasc Surg 2020; 35:160-168. [PMID: 32369295 PMCID: PMC7199992 DOI: 10.21470/1678-9741-2019-0283] [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] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To establish whether the use of diclofenac reduces the administration of opioids and how it affects bleeding and platelet function after the coronary artery bypass grafting (CABG) surgery with use of cardiopulmonary bypass (CPB). METHODS A total of 72 patients undergoing CABG surgery were included in this retrospective randomized study and divided into two groups (34 patients received diclofenac and the control group of 38 patients did not). For postoperative analgesia, both groups were prescribed opioids (piritramide). The primary endpoint was to establish the consumption of opioids. The secondary endpoint was to determine bleeding and the function of platelets 20 hours after the surgery. RESULTS The consumption of piritramide (diclofenac group 26±8 mg vs. control group 28±8 mg), the blood loss, and the function of platelets did not significantly differ between the groups within 20 hours after surgery. C-reactive protein (CRP) was statistically significantly lower in the diclofenac group than in the control group (33±15 mg/L vs. 46±22 mg/L, respectively, P<0.05). CONCLUSION The study concluded that patients administered with diclofenac after the heart surgery did not consume less opioid analgesics and did not exhibit less symptoms linked to the consumption of opioids. Diclofenac in clinically administered doses does not interfere with the function of platelets and does not cause increased bleeding. Lower CRP in the diclofenac group may indicate a reduced inflammatory response after CPB. Therefore, diclofenac could be safe for use in patients undergoing CABG surgery but its value in reducing opioid consumption should be questioned.
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Affiliation(s)
- Irena Osojnik
- University Medical Centre Maribor Intensive Care and Pain Management Department of Anaesthesiology Maribor Slovenia Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Maribor, Slovenia
| | - Mirt Kamenik
- University Medical Centre Maribor Intensive Care and Pain Management Department of Anaesthesiology Maribor Slovenia Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Maribor, Slovenia.,University of Maribor Faculty of Medicine Department of Anesthesia and Reanimation Maribor Slovenia Department of Anesthesia and Reanimation, Faculty of Medicine, University of Maribor, Maribor, Slovenia
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19
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Turan A, Cohen B, Whitlock RP, Essber H, Niazi A, Makarova N, Saasouh W, Alfirevic A, Marciniak D, Sessler DI. Methylprednisolone Does Not Reduce Acute Postoperative Pain After Cardiac Surgery: Subanalysis of a Randomized Clinical Trial. Anesth Analg 2019; 129:1468-1473. [PMID: 31743165 DOI: 10.1213/ane.0000000000004061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pain after cardiac surgery is largely treated with opioids, but their poor safety profile makes nonopioid medications attractive as part of multimodal pathways. Anti-inflammatory drugs reduce acute postoperative pain, but the role of steroids in reducing acute poststernotomy pain is unclear. We evaluated the association between the intraoperative administration of methylprednisolone and postoperative analgesia, defined as a composite of pain scores and opioid consumption, during the initial 24 hours after cardiac surgery. METHODS We conducted a post hoc retrospective analysis of a large clinical trial in which adults having cardiac surgery were randomized 1:1 to receive 2 intraoperative doses of 250 mg IV methylprednisolone or placebo. Pain scores and opioid consumption were collected during the initial 24 hours after surgery. Methylprednisolone was considered to be associated with better pain control than placebo if proven noninferior (not worse) on both pain scores (defined a priori with delta of 1 point) and opioid consumption (delta of 20%) and superior to placebo in at least 1 of the 2 outcomes. This test was repeated in the opposite direction (testing whether placebo is better than methylprednisolone on postoperative pain management). RESULTS Of 251 eligible patients, 127 received methylprednisolone and 124 received placebo. Methylprednisolone was noninferior to placebo on pain with difference in mean (CI) pain scores of -0.25 (-0.71 to 0.21); P < .001. However, methylprednisolone was not noninferior to placebo on opioid consumption (ratio of geometric means [CI]: 1.11 [0.64-1.91]; P = .37). Because methylprednisolone was not noninferior to placebo on both outcomes, we did not proceed to superiority testing based on the a priori stopping rules. Similar results were found when testing the opposite direction. CONCLUSIONS In this post hoc analysis, we could not identify a beneficial analgesic effect after cardiac surgery associated with methylprednisolone administration. There are currently no data to suggest that methylprednisolone has significant analgesic benefit in adults having cardiac surgery.
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Affiliation(s)
- Alparslan Turan
- From the Departments of Outcomes Research
- General Anesthesia, Cleveland Clinic, Cleveland, Ohio
| | - Barak Cohen
- From the Departments of Outcomes Research
- Division of Anesthesia, Critical Care and Pain Management, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Richard P Whitlock
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | - Andrej Alfirevic
- Department of Cardiothoracic Anesthesia Cleveland Clinic, Cleveland, Ohio
| | - Donn Marciniak
- Department of Cardiothoracic Anesthesia Cleveland Clinic, Cleveland, Ohio
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Perioperative Opioid-sparing Strategies: Utility of Conventional NSAIDs in Adults. Clin Ther 2019; 41:2612-2628. [DOI: 10.1016/j.clinthera.2019.10.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 10/03/2019] [Accepted: 10/09/2019] [Indexed: 12/17/2022]
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Jannati M, Attar A. Analgesia and sedation post-coronary artery bypass graft surgery: a review of the literature. Ther Clin Risk Manag 2019; 15:773-781. [PMID: 31417264 PMCID: PMC6592068 DOI: 10.2147/tcrm.s195267] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 04/28/2019] [Indexed: 12/25/2022] Open
Abstract
This review aimed to study the role of analgesia and sedation after coronary artery bypass graft (CABG) surgery, regarding pain management, assisted respiration, overall postoperative health care, and hospitalization. Data were collected from Pubmed, Scopus, and Cochrane databases. The following terms were used for the search: “analgesia”, “sedation”, “coronary artery bypass grafting”, CABG”, and “opioids”. Articles between the years 1988 and 2018 were evaluated. Several opioid and non-opioid analgesics used to relieve surgical pain are regarded as critical risk factors for developing pulmonary and cardiovascular complications in all kinds of thoracic surgery, especially CABG procedures. Effective pain management in post-CABG patients is largely dependent on effective pain assessment, type of sedatives and analgesics administered, and evaluation of their effects on pain relief. A significant challenge is to determine adequate amounts of administered analgesics and sedatives for postoperative CABG patients, because patients often order more sedatives and analgesics than needed. The pain management process is deemed successful when patients feel comfortable after surgery, with no negative side effects. However, postoperative pain management patterns have not included many modern methods such as patient-controlled analgesia, and postoperative pain management drugs are still limited to a restricted range of opioid and non-opioid analgesics.
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Affiliation(s)
- Mansour Jannati
- Department of Cardiovascular Surgery, Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Armin Attar
- Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Kwanten LE, O'Brien B, Anwar S. Opioid-Based Anesthesia and Analgesia for Adult Cardiac Surgery: History and Narrative Review of the Literature. J Cardiothorac Vasc Anesth 2019; 33:808-816. [DOI: 10.1053/j.jvca.2018.05.053] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Indexed: 01/04/2023]
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Bell S, Rennie T, Marwick CA, Davey P. Effects of peri-operative nonsteroidal anti-inflammatory drugs on post-operative kidney function for adults with normal kidney function. Cochrane Database Syst Rev 2018; 11:CD011274. [PMID: 30488949 PMCID: PMC6517026 DOI: 10.1002/14651858.cd011274.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) provide effective analgesia during the post-operative period but can cause acute kidney injury (AKI) when used peri-operatively (at or around the time of surgery). This is an update of a Cochrane review published in 2007. OBJECTIVES This review looked at the effect of NSAIDs used in the peri-operative period on post-operative kidney function in patients with normal kidney function. SEARCH METHODS We searched Cochrane Kidney and Transplant's Specialised Register to 4 January 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Specialised Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs (RCTs in which allocation to treatment was obtained by alternation, use of alternate medical records, date of birth or other predictable methods) looking at the use of NSAIDs versus placebo for the treatment of post-operative pain in patients with normal kidney function were included. DATA COLLECTION AND ANALYSIS Data extraction was carried out independently by two authors as was assessment of risk of bias. Disagreements were resolved by a third author. Dichotomous outcomes are reported as relative risk (RR) and continuous outcomes as mean difference (MD) together with their 95% confidence intervals (CI). Meta-analyses were used to assess the outcomes of AKI, change in serum creatinine (SCr), urine output, renal replacement therapy (RRT), death (all causes) and length of hospital stay. MAIN RESULTS We identified 26 studies (8835 participants). Risk of bias was high in 17, unclear in 6and low in three studies. There was high risk of attrition bias in six studies.Only two studies measured AKI. The use of NSAIDs had uncertain effects on the incidence of AKI compared to placebo (7066 participants: RR 1.79, 95% CI 0.40 to 7.96; I2 = 59%; very low certainty evidence). One study was stopped early by the data monitoring committee due to increased rates of AKI in the NSAID group. Moreover, both of these studies were examining NSAIDs for indications other than analgesia and therefore utilised relatively low doses.Compared to placebo, NSAIDs may slightly increase serum SCr (15 studies, 794 participants: MD 3.23 μmol/L, 95% CI -0.80 to 7.26; I2 = 63%; low certainty evidence). Studies displayed moderate to high heterogeneity and had multiple exclusion criteria including age and so were not representative of patients undergoing surgery. Three of these studies excluded patients if their creatinine rose post-operatively.NSAIDs may make little or no difference to post-operative urine output compared to placebo (6 studies, 149 participants: SMD -0.02, 95% CI -0.31 to 0.27). No reliable conclusions could be drawn from these studies due to the differing units of measurements and measurement time points.It is uncertain whether NSAIDs leads to the need for RRT because the certainty of this evidence is very low (2 studies, 7056 participants: RR 1.57, 95% CI 0.49 to 5.07; I2 = 26%); there were few events and the results were inconsistent.It is uncertain whether NSAIDs lead to more deaths (2 studies, 312 participants: RR 1.44, 95% CI 0.19 to 11.12; I2 = 38%) or increased the length of hospital stay (3 studies, 410 participants: MD 0.12 days, 95% CI -0.48 to 0.72; I2 = 24%). AUTHORS' CONCLUSIONS Overall NSAIDs had uncertain effects on the risk of post-operative AKI, may slightly increase post-operative SCr, and it is uncertain whether NSAIDs lead to the need for RRT, death or increases the length of hospital stay. The available data therefore does not confirm the safety of NSAIDs in patients undergoing surgery. Further larger studies using the Kidney Disease Improving Global Outcomes definition for AKI including patients with co-morbidities are required to confirm these findings. .
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Affiliation(s)
- Samira Bell
- NHS Tayside, Ninewells HospitalRenal UnitDundeeUKDD1 9SY
- University of DundeeDivision of Population Health and GenomicsDundeeUK
| | | | - Charis A Marwick
- University of DundeeDivision of Population Health and GenomicsDundeeUK
| | - Peter Davey
- University of DundeeDivision of Population Health and GenomicsDundeeUK
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A Review of Perioperative Analgesic Strategies in Cardiac Surgery. Int Anesthesiol Clin 2018; 56:e56-e83. [PMID: 30204605 DOI: 10.1097/aia.0000000000000200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Decreased opioid consumption and enhance recovery with the addition of IV Acetaminophen in colorectal patients: a prospective, multi-institutional, randomized, double-blinded, placebo-controlled study (DOCIVA study). Surg Endosc 2018; 32:3432-3438. [DOI: 10.1007/s00464-018-6062-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 01/11/2018] [Indexed: 10/18/2022]
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Sousa-Uva M, Head SJ, Milojevic M, Collet JP, Landoni G, Castella M, Dunning J, Gudbjartsson T, Linker NJ, Sandoval E, Thielmann M, Jeppsson A, Landmesser U. 2017 EACTS Guidelines on perioperative medication in adult cardiac surgery. Eur J Cardiothorac Surg 2017; 53:5-33. [PMID: 29029110 DOI: 10.1093/ejcts/ezx314] [Citation(s) in RCA: 247] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Pregabalin Effect on Acute and Chronic Pain after Cardiac Surgery. Anesthesiol Res Pract 2017; 2017:2753962. [PMID: 28539936 PMCID: PMC5429923 DOI: 10.1155/2017/2753962] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 03/20/2017] [Accepted: 04/05/2017] [Indexed: 02/06/2023] Open
Abstract
Introduction. Pain after cardiac surgery affects long-term patient wellness. This study investigated the effect of preoperative pregabalin on acute and chronic pain after elective cardiac surgery with median sternotomy. Methods. Prospective double blind study. 93 cardiac surgery patients were randomly assigned into three groups: Group 1 received placebo, Group 2 received oral pregabalin 75 mg, and Group 3 received oral pregabalin 150 mg. Data were collected 8 hours, 24 hours, and 3 months postoperatively. Results. Patients receiving pregabalin required fewer morphine boluses (10 in controls versus 6 in Group 1 versus 4 in Group 2, p = 0.000) and had lower pain scores at 8 hours (4 versus 3 versus 3, p = 0.001) and 3 months (3 versus 2 versus 2, p = 0.000) and lower morphine consumption at 8 hours (14 versus 13 versus 12 mg, p = 0.000) and 24 hours (19.5 versus 16 versus 15 mg, p = 0.000). Percentage of patients with sleep disturbances or requiring analgesics was lower in the pregabalin group and even lower with higher pregabalin dose (16/31 versus 5/31 versus 3/31, p = 0.000, and 26/31 versus 16/31 versus 10/31, p = 0.000, resp.) 3 months after surgery. Conclusion. Preoperative oral pregabalin 75 or 150 mg reduces postoperative morphine requirements and acute and chronic pain after cardiac surgery.
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Nonsteroidal Anti-Inflammatory Drugs and Clinical Outcomes in Patients Undergoing Coronary Artery Bypass Surgery. Am J Med 2017; 130:462-468. [PMID: 27888052 DOI: 10.1016/j.amjmed.2016.10.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 10/18/2016] [Accepted: 10/18/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in perioperative pain management of patients undergoing coronary artery bypass graft surgery. However, the association of periprocedural use of NSAIDs and clinical outcomes after coronary artery bypass graft is understudied. METHODS We conducted a retrospective analysis using pooled data from 2 multicenter randomized controlled trials (PREVENT IV [n = 3014] and MEND-CABG II [n = 3023]). Rates of death, death or myocardial infarction, and death, myocardial infarction, or stroke in the 30 days following coronary artery bypass graft surgery were compared in patients using or not using perioperative NSAIDs. Inverse probability of treatment weighting and Cox proportional hazards regression models were used to adjust for confounding. RESULTS A total of 5887 patients were studied. Median age was 65 years, 78% were male, and 91% were White. NSAIDs were used in 2368 (40.2%) patients. The majority of patients (1822 [30.9%]) received NSAIDs after coronary artery bypass graft surgery; 289 (4.9%) used them prior to and after the surgery; and 257 (4.4) received NSAIDs prior to the surgery only. Adjusted 30-day outcomes were similar in patients receiving and not receiving NSAIDs (death: hazard ratio [HR] 1.18; 95% confidence interval [CI], 0.48-2.92; death or myocardial infarction: HR 0.87; 95% CI, 0.42-1.79; death, myocardial infarction, or stroke: HR 0.87; 95% CI, 0.46-1.65). CONCLUSION In this pooled data analysis, perioperative NSAID use was common among patients undergoing coronary artery bypass graft surgery and was not associated with an increased short-term risk for major adverse clinical outcomes.
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Guzmán-Hernández DS, Cid-Cerón MM, Romero-Romo M, Ramírez-Silva MT, Páez-Hernández ME, Corona-Avendaño S, Palomar-Pardavé M. Taking advantage of CTAB micelles for the simultaneous electrochemical quantification of diclofenac and acetaminophen in aqueous media. RSC Adv 2017. [DOI: 10.1039/c7ra07269d] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Cetyltrimethylammonium bromide hemimicelles, formed on the surfaces of a carbon paste electrode, selectively adsorbed diclofenac molecules from a neutral aqueous solution containing acetaminophen, allowing simultaneous quantification of both drugs.
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Affiliation(s)
| | - M. M. Cid-Cerón
- Universidad Autónoma Metropolitana-Iztapalapa
- Departamento de Química
- CDMX
- Mexico
| | - M. Romero-Romo
- Universidad Autónoma Metropolitana-Azcapotzalco
- Departamento de Materiales
- CDMX
- Mexico
| | - M. T. Ramírez-Silva
- Universidad Autónoma Metropolitana-Iztapalapa
- Departamento de Química
- CDMX
- Mexico
| | | | - S. Corona-Avendaño
- Universidad Autónoma Metropolitana-Azcapotzalco
- Departamento de Materiales
- CDMX
- Mexico
| | - M. Palomar-Pardavé
- Universidad Autónoma Metropolitana-Azcapotzalco
- Departamento de Materiales
- CDMX
- Mexico
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Brand J. Sedation and Analgesia. PHARMACEUTICAL SCIENCES 2017. [DOI: 10.4018/978-1-5225-1762-7.ch019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Patients in the cardiothoracic intensive care unit (CTICU) are subject to numerous physical and mental stresses. While most of these cannot be completely eliminated, intensivists have many tools in their armamentarium to alleviate patients' pain and suffering. This chapter will consider the importance of analgesia and sedation in the CTICU and the relevant consequences of over- or under-treatment. We will examine the tools available for monitoring and titrating analgesia and sedation in critically ill patients. The major classes of medications available will be reviewed, with particular attention to their clinical effects, metabolism and excretion, and hemodynamic characteristics. Lastly, experimental evidence will be assessed regarding the best strategies for treatment of pain and agitation in the CTICU, including use of non-pharmacologic adjuvants.
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Affiliation(s)
- Jordan Brand
- San Francisco VA Medical Center, USA & University of California – San Francisco, USA
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Bhoyar K, Patil V, Shetmahajan M. Opioid sparing effect of diclofenac sodium when used as an intra-operative analgesic during maxillofacial cancer surgeries. Indian J Anaesth 2016; 59:748-52. [PMID: 26755843 PMCID: PMC4697250 DOI: 10.4103/0019-5049.170038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Kalpesh Bhoyar
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Vijaya Patil
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Madhavi Shetmahajan
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India
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Qazi SM, Sindby EJ, Nørgaard MA. Ibuprofen - a Safe Analgesic During Cardiac Surgery Recovery? A Randomized Controlled Trial. J Cardiovasc Thorac Res 2015; 7:141-8. [PMID: 26702342 PMCID: PMC4685279 DOI: 10.15171/jcvtr.2015.31] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 11/05/2015] [Indexed: 12/22/2022] Open
Abstract
Introduction: Postoperative pain-management with non-steroid anti-inflammatory drugs has been controversial, due to related side-effects. We investigated whether there was a significant difference between an oxycodone-based pain-management regimen versus a slow-release ibuprofen based regimen, in a short term post-cardiac surgery setting. Particular attention was given to the rate of myocardial infarction, sternal healing, gastro-intestinal complications, renal failure and all-cause mortality.
Methods: This was a single-centre, open label parallel design randomised controlled study. Patients, who were undergoing cardiac surgery for the first time, were randomly allocated either to a regimen of slow-release oxycodone (10 mg twice daily) or slow-release ibuprofen (800 mg twice daily) combined with lansoprazole. Data relating to blood-tests, angiographies, surgical details and administered medicine were obtained from patient records. The follow-up period was 1 to 37 months (median 25 months).
Results: One hundred eighty-two patients were included in the trial and available for intention to treat analysis. There were no significant difference between the groups (P>0.05) in the rates of sternal healing, postoperative myocardial infarction or gastrointestinal bleeding. The preoperative levels of creatinine were found to increase by 100% in nine patients (9.6%) in the ibuprofen group, resulting in an acute renal injury (in accordance with the RIFLE-criteria). Eight of these patients returned to normal renal function within 14 days. The levels of creatinine in patients in the oxycodone group were not found to increase to the same magnitude.
Conclusion: The results of this study suggest that patients treated postoperatively, following cardiac surgery, are at no greater risk of harm if short term slow release ibuprofen combined with lansoprazole treatment is used when compared to an oxycodone based regimen. Renal function should, however, be closely monitored and in the event of any decrease in renal function ibuprofen must be discontinued.
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Affiliation(s)
- Saddiq Mohammad Qazi
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Hobrovej 18-22 9000 Aalborg, Denmark
| | - Eske Jesper Sindby
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Hobrovej 18-22 9000 Aalborg, Denmark
| | - Martin Agge Nørgaard
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Hobrovej 18-22 9000 Aalborg, Denmark
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Bameshki A, Peivandi Yazdi A, Sheybani S, Rezaei Boroujerdi H, Taghavi Gilani M. The Assessment of Addition of Either Intravenous Paracetamol or Diclofenac Suppositories to Patient-Controlled Morphine Analgesia for Postgastrectomy Pain Control. Anesth Pain Med 2015; 5:e29688. [PMID: 26587407 PMCID: PMC4644315 DOI: 10.5812/aapm.29688] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Revised: 06/19/2015] [Accepted: 07/07/2015] [Indexed: 12/27/2022] Open
Abstract
Background: Major surgical procedures, such as gastrectomy, result in extensive postoperative pain, which can lead to increased morbidity, discomfort and dissatisfaction among the patients. Objectives: The aim of this study was to evaluate the effect of adding diclofenac suppositories or intravenous paracetamol, on morphine consumption and on the quality of postgastrectomy pain control. Patients and Methods: This randomized double blinded clinical trial was carried out in 90 patients with gastric cancer, who were candidates for gastrectomy, which were divided into three similar groups. The patients were transferred to an intensive care unit after the operation and received patient-controlled analgesia (PCA) with morphine, morphine PCA plus intravenous paracetamol 1 g, every 6 hours, and morphine PCA plus diclofenac suppositories, 100 mg every 8 hours. The patients were evaluated for up to 24 hours after the operation for the severity of pain, alertness, and opioid complications. Results: There was no significant difference in pain scores among the three groups (P values, after extubation, at 2, 4, 6, 12, 18 and 24 hours were 0.72, 0.19, 0.21, 0.66, 0.54, 0.56, and 0.25, respectively), although morphine consumption was greater in the morphine group, compared with the other two groups (21.4 ± 7.7 mg in morphine group vs. 14.3 ± 5.8 mg in morphine-paracetamol group and 14.3 ± 3.9 in morphine-diclofenac group; P = 0.001). In morphine group, during the first 24 hours, the patients had lower levels of consciousness (P values, after extubation, at 2, 4, 6, 12, 18 and 24 hour were 0.6, 0.95, 0.28, 0.005, 0.027, 0.022 and 0.004 respectively), even though the incidence of complications was similar among the three groups. Conclusions: In this study, intravenous paracetamol or diclofenac suppositories, administered for postgastrectomy pain control, decreased morphine consumption by almost 32% and also improved alertness. Nevertheless, the amount of opioids did not affect the incidence of complications.
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Affiliation(s)
- Alireza Bameshki
- Cardiac Anesthesia Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Arash Peivandi Yazdi
- Cardiac Anesthesia Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Shima Sheybani
- Cardiac Anesthesia Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hengameh Rezaei Boroujerdi
- Cardiac Anesthesia Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mehryar Taghavi Gilani
- Cardiac Anesthesia Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- Corresponding author: Mehryar Taghavi Gilani, Cardiac Anesthesia Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. Tel/Fax: +98-5118525209, E-mail:
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Choudhuri AH, Uppal R. A comparison between intravenous paracetamol plus fentanyl and intravenous fentanyl alone for postoperative analgesia during laparoscopic cholecystectomy. Anesth Essays Res 2015; 5:196-200. [PMID: 25885388 PMCID: PMC4173397 DOI: 10.4103/0259-1162.94777] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
PURPOSE our study compared the effect of fentanyl alone with fentanyl plus intravenous Paracetamol for analgesic efficacy, opioid sparing effects, and opioid-related side effects after laparoscopic cholecystectomy. MATERIALS AND METHODS eighty patients undergoing laparoscopic cholecystectomy were randomized into two groups, who were given either an IV placebo or an IV injection of 1g paracetamol just before induction. Both groups received fentanyl during induction and IM diclofenac for pain relief every 8 hourly for 24 h after surgery. The postoperative pain relief was evaluated by a visual analog scale (VAS) and consumption of fentanyl as rescue analgesic in the postoperative period for 24 h after surgery was measured. The incidence of PONV and sedation scores was also measured in the postoperative period. RESULTS the mean VAS score in first and second hour after surgery was less in the group receiving IV Paracetamol (3.3±0.4* vs. 5.2±0.9; 3.1±0.4* vs. 4.3±0.3); the fentanyl consumption over first 24 h was also less in the group receiving IV paracetamol (50±14.9 vs. 150±25.8). The time requirement of first dose of rescue analgesic in the postoperative period was also significantly prolonged in the group receiving IV paracetamol (76±24.7 vs. 48±15.8). There was no difference in the sedation scores and in the incidence of PONV in the two groups. CONCLUSION The study demonstrates the usefulness of intravenous paracetamol as pre-emptive analgesic in the treatment of postoperative pain after laparoscopic cholecystectomy.
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Affiliation(s)
| | - Rajeev Uppal
- Department of Anesthesiology and Intensive Care, GB Pant Hospital, New Delhi, India
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Hassan HIEA. Perioperative analgesic effects of intravenous paracetamol: Preemptive versus preventive analgesia in elective cesarean section. Anesth Essays Res 2015; 8:339-44. [PMID: 25886332 PMCID: PMC4258976 DOI: 10.4103/0259-1162.143135] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Cesarean section (CS) is the one of the most common surgical procedure in women. There is preoperative stress effect before the delivery of the baby as (intubation and skin incision). There is acute postoperative pain, which may be progressed to chronic pain. All these perioperative stress effects need for various approach of treatment, which including systemic and neuraxial analgesia. The different analgesia modalities may affect and impair early interaction between mother and infant. Preemptive intravenous (I.V.) paracetamol (before induction) may reduce stress response before the delivery of the baby, intraoperative opioids and postoperative pain. Objectives: The aim of this study to compare between the administration of I.V. paracetamol as: Preemptive analgesia (preoperative) and preventive analgesia (at the end of surgery) as regards of hemodynamic, pain control, duration of analgesia, cumulative doses of intraoperative opioids and their related side-effects and to compare between two different protocols of postoperative analgesia and their cumulative doses. Patients and Methods: Sixty patients undergoing elective CS were randomly enrolled in this study and divided into two groups of 30 patients each. Group I: i.V. paracetamol 1 g (100 ml) was given 30 min before induction of anesthesia. Group II: i.V. paracetamol 1 g (100 ml) was given 30 min before the end of surgery. Heart rate, systolic blood pressure, diastolic blood pressure, and peripheral oxygen saturation were recorded. Postoperative pain was assessed by visual analog score. Postoperative pethidine was given by two different protocols: group I: 0.5 mg/kg was divided into 0.25 mg/kg intramuscular and 0.25 mg/kg I.V. Group II was given pethidine 0.5 mg/kg I.V. Doses of intraoperative fentanyl, postoperative pethidine, duration of paracetamol analgesic time, time to next analgesia, and side-effects of opioid were noted and compared. Result: Preemptive group had hemodynamic stability, especially before delivery of the baby P < 0.001. Preventive group had longer duration of paracetamol analgesia and higher intraoperative opioid P < 0.001 and P < 0.01, respectively. Preemptive group had longer time for next analgesia and lower incidences of postoperative side-effects P < 0.001 and P < 0.05. Preemptive group had higher pain scores in immediate postoperative and after 6 h but preventive group had higher pain scores in 4 and 8 h postoperatively P < 0.001 and P < 0.01, respectively. Conclusion: Preemptive paracetamol and immediate postoperative opioid analgesia were more effective than preventive paracetamol.
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Majumdar S, Das A, Kundu R, Mukherjee D, Hazra B, Mitra T. Intravenous paracetamol infusion: Superior pain management and earlier discharge from hospital in patients undergoing palliative head-neck cancer surgery. Perspect Clin Res 2014; 5:172-7. [PMID: 25276627 PMCID: PMC4170535 DOI: 10.4103/2229-3485.140557] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: Paracetamol; a cyclooxygenase inhibitor; acts through the central nervous system as well as serotoninergic system as a nonopioid analgesic. A prospective, double-blinded, and randomized-controlled study was carried out to compare the efficacy of preoperative 1g intravenous (iv) paracetamol with placebo in providing postoperative analgesia in head-neck cancer surgery. Materials and Methods: From 2008 February to 2009 December, 80 patients for palliative head-neck cancer surgery were randomly divided into (F) and (P) Group receiving ivplacebo and iv paracetamol, respectively, 5 min before induction. Everybody received fentanyl before induction and IM diclofenac for pain relief at8 hourly for 24 h after surgery. Visual analogue scale (VAS) and amount of fentanyl were measured for postoperative pain assessment (24 h). Results and Statistical analysis: The mean VAS score in 1st, 2nd postoperative hour, and fentanyl requirement was less and the need for rescue analgesic was delayed in ivparacetamol group which were all statistically significant. Paracetamol group had a shorter surgical intensive care unit (SICU) and hospital stay which was also statistically significant. Conclusion: The study demonstrates the effectiveness of ivparacetamol as preemptive analgesic in the postoperative pain control after head-neck cancer surgery and earlier discharge from hospital.
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Affiliation(s)
- Saikat Majumdar
- Department of Anaesthesiology, Nil Ratan Sircar Medical College, Kolkata, West Bengal, India
| | - Anjan Das
- Department of Anaesthesiology, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
| | - Ratul Kundu
- Department of Anaesthesiology, Institute of Post-Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Dipankar Mukherjee
- Department of Anaesthesiology, Nil Ratan Sircar Medical College, Kolkata, West Bengal, India
| | - Bimal Hazra
- Department of Anaesthesiology, Nil Ratan Sircar Medical College, Kolkata, West Bengal, India
| | - Tapobrata Mitra
- Department of Anaesthesiology, Bangur Institute of Neurology, Kolkata, West Bengal, India
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Gjeilo KH, Stenseth R, Klepstad P. Risk factors and early pharmacological interventions to prevent chronic postsurgical pain following cardiac surgery. Am J Cardiovasc Drugs 2014; 14:335-42. [PMID: 24934698 DOI: 10.1007/s40256-014-0083-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Chronic postsurgical pain (CPSP) after cardiac surgery represents a significant clinical problem. The prevalence of CPSP varies widely between studies, but severe CPSP is present in less than 10% of the patients. Important differential diagnoses for CPSP after cardiac surgery are myocardial ischemia, sternal instability and mediastinitis. CPSP after cardiac surgery may be thoracic pain present at the site of the sternotomy or leg pain due to vein-graft harvesting. The CPSP can be neuropathic pain, visceral pain, somatic pain or mixed pain. Potential risk factors for CPSP are young age, female gender, overweight, psychological factors, preoperative pain, surgery-related factors and severe postoperative pain. In addition to standard postoperative analgesics, the use of N-methyl-D-aspartate (NMDA) antagonists, alpha-2 agonists, local anesthetics, gabapentinoids, and corticosteroids are all proposed to reduce the risk for CPSP after cardiac surgery. Still, no specific pharmacological therapy, cognitive therapy or physical therapy is established to protect against CPSP. The only convincing prevention of CSPS is adequate treatment of acute postoperative pain irrespective of method. Hence, interventions against acute pain, preferably in a step-wise approach titrating the interventions for each patient's individual needs, are essential concerning prevention of CPSP after cardiac surgery. It is also important that surgeons consider the risk for CPSP as a part of the basis for decision-making around performing a surgical procedure and that patients are informed of this risk.
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Affiliation(s)
- Kari Hanne Gjeilo
- Department of Cardiothoracic Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway,
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Palmer P, Ji X, Stephens J. Cost of opioid intravenous patient-controlled analgesia: results from a hospital database analysis and literature assessment. CLINICOECONOMICS AND OUTCOMES RESEARCH 2014; 6:311-8. [PMID: 25018642 PMCID: PMC4073913 DOI: 10.2147/ceor.s64077] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Intravenous patient-controlled analgesia (PCA) equipment and opioid cost analyses on specific procedures are lacking. This study estimates the intravenous PCA hospital cost for the first 48 postoperative hours for three inpatient surgeries. Methods Descriptive analyses using the Premier database (2010–2012) of more than 500 US hospitals were conducted on cost (direct acquisition and indirect cost for the hospital, such as overhead, labor, pharmacy services) of intravenous PCA after total knee/hip arthroplasty (TKA/THA) or open abdominal surgery. Weighted average cost of equipment and opioid drug and the literature-based cost of adverse events and complications were aggregated for total costs. Results Of 11,805,513 patients, 272,443 (2.3%), 139,275 (1.2%), and 195,062 (1.7%) had TKA, THA, and abdominal surgery, respectively, with approximately 20% of orthopedic and 29% of abdominal patients having specific intravenous PCA database cost entries. Morphine (57%) and hydromorphone (44%) were the most frequently used PCA drugs, with a mean cost per 30 cc syringe of $16 (30 mg) and $21 (6 mg), respectively. The mean number of syringes used for morphine and hydromorphone in the first 48 hours were 1.9 and 3.2 (TKA), 2.0 and 4.2 (THA), and 2.5 and 3.9 (abdominal surgery), respectively. Average costs of PCA pump, intravenous tubing set, and drug ranged from $46 to $48, from $20 to $22, and from $33 to $46, respectively. Pump, tubing, and saline required to maintain patency of the intravenous PCA catheter over 48 hours ranged from $9 to $13, from $8 to $9, and from $20 to $22, respectively. Supplemental non-PCA opioid use ranged from $56 for THA to $87 for abdominal surgery. Aggregated mean intravenous PCA equipment and opioid cost per patient were $196 (THA), $204 (TKA), and $243 (abdominal surgery). Total costs, including for adverse events, complications, and intravenous PCA errors, ranged from $647 to $694. Conclusion Although there is variation between different types of surgery, the hospital cost of intravenous PCA after major surgery is substantial. Novel technology should demonstrate cost-effectiveness in addition to clinical superiority.
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Affiliation(s)
| | - Xiang Ji
- Pharmerit International, Bethesda, MD, USA
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Pergolizzi JV, Pappagallo M, LeQuang J, Labhsetwar S, Taylor R. New health care measures: emphasis on better management of postsurgical pain and postoperative nausea and vomiting. Hosp Pract (1995) 2014; 42:65-74. [PMID: 24566598 DOI: 10.3810/hp.2014.02.1093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Value-based purchasing and the Hospital Consumer Assessment of Healthcare Providers and Systems are tying patient-centric measures to reimbursements. Hospitals should be particularly concerned about management of postoperative pain and control of postoperative nausea and vomiting (PONV), known to adversely impact overall patient satisfaction. Anesthesiologists are likely to be on the frontlines of these transitions. Although postoperative pain is not always effectively managed, clinicians have the pharmacological tools and guidelines for better pain control. Considerable work has been done in PONV to better identify high-risk patients and effective prophylactic agents. Postoperative pain control and preventing PONV are two relatively straightforward ways to respond to new quality metrics. The aim of this review is to raise practitioner awareness of these new quality metrics and provide an overview of the current tools and methods used to improve postoperative pain control and PONV.
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Affiliation(s)
- Joseph V Pergolizzi
- Adjunct Professor of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Associate Professor of Pharmacology, TemplenUniversity School of Medicine, Philadelphia, PA
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Ebrahim AJ, Mozaffar R, Nadia BH, Ali J. Early post-operative relief of pain and shivering using diclofenac suppository versus intravenous pethidine in spinal anesthesia. J Anaesthesiol Clin Pharmacol 2014; 30:243-7. [PMID: 24803766 PMCID: PMC4009648 DOI: 10.4103/0970-9185.130038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Pain and shivering are two challenging components in the post operative period. Many drugs were used for prevention and treatment of them. The aim of this study was to compare the effects of prophylactic prescription of diclofenac suppository versus intravenous (IV) pethidine in spinal anesthesia. Materials and Methods: We conducted a multi central, prospective, double-blind, randomized clinical trial on a total of 180 patients who were scheduled for surgery under spinal anesthesia including 60 patients in three groups. Patients were randomly allocated to receive 100 mg sodium diclofenac suppository or 30 mg IV pethidine or placebo. Categorical and continuous variables were analyzed by Chi-square test, t-test, Mann-Whitney and ANOVA or Kruskal-Wallis tests. Results: There was no statistical difference with regard to patient characteristics and hemodynamic indices among the three groups. Nine (15%), 10 (16.65%) and 24 (40%) of patients in diclofenac, pethidine and control groups reported pain and 2, 2, 7 patients received treatment due to it, respectively (P = 0.01). Prevalence of shivering in pethidine group and diclofenac group was the same and both of them were different from the control group (P < 0.001). Pruritus was repetitive in the pethidine group and was statistically significant (P = 0.036) but, post-operative nausea and vomiting was not significantly different among groups. Conclusion: A single dose of sodium diclofenac suppository can provide satisfactory analgesia immediately after surgery and decrease shivering without remarkable complications. This investigation highlights the role of pre-operative administration of a single dose of rectal diclofenac as a sole analgesic for early post-operative period.
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Affiliation(s)
- Ali Janpour Ebrahim
- Department of Anaesthesiology and Intensive Care, Babol University of Medical Sciences, Babol, Iran
| | - Rabiee Mozaffar
- Department of Anaesthesiology and Intensive Care, Babol University of Medical Sciences, Babol, Iran
| | - Bani-Hashem Nadia
- Department of Anaesthesiology and Intensive Care, Babol University of Medical Sciences, Babol, Iran
| | - Jabbari Ali
- Department of Anaesthesiology and Intensive Care, Babol University of Medical Sciences, Babol, Iran ; Department of Anaesthesiology and Intensive Care, Golestan University of Medical Sciences, Golestan, Iran
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Rafiq S, Steinbrüchel DA, Wanscher MJ, Andersen LW, Navne A, Lilleoer NB, Olsen PS. Multimodal analgesia versus traditional opiate based analgesia after cardiac surgery, a randomized controlled trial. J Cardiothorac Surg 2014; 9:52. [PMID: 24650125 PMCID: PMC3975463 DOI: 10.1186/1749-8090-9-52] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 03/17/2014] [Indexed: 12/16/2022] Open
Abstract
Background To evaluate if an opiate sparing multimodal regimen of dexamethasone, gabapentin, ibuprofen and paracetamol had better analgesic effect, less side effects and was safe compared to a traditional morphine and paracetamol regimen after cardiac surgery. Methods Open-label, prospective randomized controlled trial. 180 patients undergoing cardiac procedures through median sternotomy, were included in the period march 2007- August 2009. 151 patients were available for analysis. Pain was assessed with the 11-numeric rating scale (11-NRS). Results Patients in the multimodal group demonstrated significantly lower average pain scores from the day of surgery throughout the third postoperative day. Extensive nausea and vomiting, was found in no patient in the multimodal group but in 13 patients in the morphine group, p < 0.001. Postoperative rise in individual creatinine levels demonstrated a non-significant rise in the multimodal group, 33.0±53.4 vs. 19.9±48.5, p = 0.133. Patients in the multimodal group suffered less major in-hospital events in crude numbers: myocardial infarction (MI) (1 vs. 2, p = 0.54), stroke (0 vs. 3, p = 0.075), dialysis (1 vs. 2, p = 0.54), and gastrointestinal (GI) bleeding (0 vs. 1, p = 0.31). 30-day mortality was 1 vs. 2, p = 0.54. Conclusions In patients undergoing cardiac surgery, a multimodal regimen offered significantly better analgesia than a traditional opiate regimen. Nausea and vomiting complaints were significantly reduced. No safety issues were observed with the multimodal regimen. Trial registration Clinicaltrials.gov identifier: NCT01966172
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Affiliation(s)
- Sulman Rafiq
- Department of Cardiothoracic Surgery, The Heart Centre, Rigshospitalet, Blegdamsvej 9, Copenhagen O 2100, Denmark.
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Sanchez-Covarrubias L, Slosky LM, Thompson BJ, Zhang Y, Laracuente ML, DeMarco KM, Ronaldson PT, Davis TP. P-glycoprotein modulates morphine uptake into the CNS: a role for the non-steroidal anti-inflammatory drug diclofenac. PLoS One 2014; 9:e88516. [PMID: 24520393 PMCID: PMC3919782 DOI: 10.1371/journal.pone.0088516] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 01/07/2014] [Indexed: 02/06/2023] Open
Abstract
Our laboratory has previously demonstrated that peripheral inflammatory pain (PIP), induced by subcutaneous plantar injection of λ-carrageenan, results in increased expression and activity of the ATP-dependent efflux transporter P-glycoprotein (P-gp) that is endogenously expressed at the blood-brain barrier (BBB). The result of increased P-gp functional expression was a significant reduction in CNS uptake of morphine and, subsequently, reduced morphine analgesic efficacy. A major concern in the treatment of acute pain/inflammation is the potential for drug-drug interactions resulting from P-gp induction by therapeutic agents co-administered with opioids. Such effects on P-gp activity can profoundly modulate CNS distribution of opioid analgesics and alter analgesic efficacy. In this study, we examined the ability of diclofenac, a non-steroidal anti-inflammatory drug (NSAID) that is commonly administered in conjunction with the opioids during pain therapy, to alter BBB transport of morphine via P-gp and whether such changes in P-gp morphine transport could alter morphine analgesic efficacy. Administration of diclofenac reduced paw edema and thermal hyperalgesia in rats subjected to PIP, which is consistent with the known mechanism of action of this NSAID. Western blot analysis demonstrated an increase in P-gp expression in rat brain microvessels not only following PIP induction but also after diclofenac treatment alone. Additionally, in situ brain perfusion studies showed that both PIP and diclofenac treatment alone increased P-gp efflux activity resulting in decreased morphine brain uptake. Critically, morphine analgesia was significantly reduced in animals pretreated with diclofenac (3 h), as compared to animals administered diclofenac and morphine concurrently. These novel findings suggest that administration of diclofenac and P-gp substrate opioids during pain pharmacotherapy may result in a clinically significant drug-drug interaction.
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Affiliation(s)
- Lucy Sanchez-Covarrubias
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Lauren M. Slosky
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Brandon J. Thompson
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Yifeng Zhang
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Mei-Li Laracuente
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Kristin M. DeMarco
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Patrick T. Ronaldson
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Thomas P. Davis
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, Arizona, United States of America
- * E-mail:
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Darvish H, Memar Ardestani B, Mohammadkhani Shali S, Tajik A. Analgesic Efficacy of Diclofenac and Paracetamol vs. Meperidine in Cesarean Section. Anesth Pain Med 2013; 4:e9997. [PMID: 24660150 PMCID: PMC3961033 DOI: 10.5812/aapm.9997] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Revised: 03/28/2013] [Accepted: 07/08/2013] [Indexed: 01/07/2023] Open
Abstract
Background: One of the most important complications in cesarean surgery is postoperative pain, and different ways have been proposed to control it. Objectives: The purpose of this study was to determine the efficacy of Diclofenac and Paracetamol combination in comparison with Meperidine on postoperative pain after cesarean surgery. Patients and Methods: One hundred and twenty women candidates for elective cesarean section under spinal anesthesia categorized as ASA class I were selected and randomly assigned to receive either Diclofenac suppository at the end of the operation and thereafter 1 gram infused bolus of Paracetamol (group A), or 20 mg bolus of Meperidine after transition to recovery room (group B) to control postoperative pain. Results: Postoperative pain was present in recovery in 38.3% and 23.3% in groups B and A, respectively (P = 0.009). Postoperative pain was seen after six hours of operation in 38.7% and 16.7% in groups B and A, respectively (P = 0.010). Postoperative pain was present after 12 hours of operation in 38.3% and 15% in groups B and A, respectively (P = 0.002). The additive Meperidine use was the same between the two groups in recovery (P > 0.05). The additive Meperidine use was seen after six hours of operation in 26.7% and 6.7% in groups B and A, respectively (P = 0.013). The additive Meperidine use was seen after 12 hours of operation in 16.7% and none of the patients in groups B and A, respectively (P = 0.004). The frequency of drug adverse effects was the same between the two groups (P > 0.05). Conclusions: Totally, according to the obtained results it may be concluded that Paracetamol and Diclofenac combination would have a better efficacy in postoperative pain control and need reduction to additive analgesia compared to Meperidine.
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Affiliation(s)
- Heidar Darvish
- Anesthesiology Department, Amiralmomenin Hospital, Islamic Azad University, Tehran Medical Branch, Tehran, IR Iran
- Corresponding author: Heidar Darvish, Anesthesiology Department, Amiralmomenin Hospital, Islamic Azad University, Tehran Medical Branch, Tehran, Iran. Tel: +98-9121036599, Fax: +98-2122901217, E-mail:
| | - Behrouz Memar Ardestani
- Anesthesiology Department, Amiralmomenin Hospital, Islamic Azad University, Tehran Medical Branch, Tehran, IR Iran
| | | | - Ali Tajik
- Department of Community Medicine, Tehran University of Medical Sciences, Tehran, Iran
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Kandasamy A, Ramalingam SK, Simon HA, Arumugham S, Reddy BD, Krupananda H. Ultra fast-tracking versus a conventional strategy in valve replacement surgery. Indian J Anaesth 2013; 57:298-300. [PMID: 23983293 PMCID: PMC3748689 DOI: 10.4103/0019-5049.115567] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Ashok Kandasamy
- Department of Cardiothoracic Anaesthesia, SRM Medical College Hospital and Research Centre, Potheri, Kattankulathur, Tamil Nadu, India
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Abstract
In the postoperative pain setting, the use of opioid analgesics remains essential in achieving effective analgesia and in avoiding the deleterious sequelae of uncontrolled pain that can worsen patient outcomes. However, postoperative pain remains undertreated in many patients. Choosing the most appropriate use of opioids in the postoperative setting, especially for patients undergoing ongoing opioid treatment for chronic pain, can pose daunting challenges for many clinicians. In this article, we examine the pitfalls that may be encountered when implementing postoperative pain management strategies with opioid analgesics, especially in patients receiving chronic opioid therapy prior to admission, and the critical steps for appropriate and effective analgesia in this setting.
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Affiliation(s)
- Eugene R Viscusi
- Associate Professor, Director, Acute Pain Management, Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Ali Hammad Y, Atalla S, Alabdrubalnabi Z. Efficacy and side effects of small versus large bolus size morphine patient controlled analgesia combined with paracetamol. EGYPTIAN JOURNAL OF ANAESTHESIA 2012. [DOI: 10.1016/j.egja.2011.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Affiliation(s)
- Yasser Ali Hammad
- Faculty of Medicine, Suez Canal University , Anesthesia Department , King Fahd Specialist Hospital Dammam , Saudi Arabia
| | - Sahar Atalla
- King Faisal Specialist Hospital & Research Centre, Saudi Arabia
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Mazzeffi M, Khelemsky Y. Poststernotomy Pain: A Clinical Review. J Cardiothorac Vasc Anesth 2011; 25:1163-78. [DOI: 10.1053/j.jvca.2011.08.001] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Indexed: 11/11/2022]
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Mencía S, Botrán M, López-Herce J, del Castillo J. Manejo de la sedoanalgesia y de los relajantes musculares en las unidades de cuidados intensivos pediátricos españolas. An Pediatr (Barc) 2011; 74:396-404. [DOI: 10.1016/j.anpedi.2010.12.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Revised: 11/15/2010] [Accepted: 12/09/2010] [Indexed: 10/18/2022] Open
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Gombotz H, Lochner R, Sigl R, Blasl J, Herzer G, Trimmel H. Opiate sparing effect of fixed combination of diclophenac and orphenadrine after unilateral total hip arthroplasty: A double-blind, randomized, placebo-controlled, multi-centre clinical trial. Wien Med Wochenschr 2010; 160:526-34. [DOI: 10.1007/s10354-010-0829-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Accepted: 07/13/2010] [Indexed: 11/28/2022]
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Dhawan N, Das S, Kiran U, Chauhan S, Bisoi AK, Makhija N. Effect of rectal diclofenac in reducing postoperative pain and rescue analgesia requirement after cardiac surgery. Pain Pract 2009; 9:385-93. [PMID: 19622108 DOI: 10.1111/j.1533-2500.2009.00299.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Adequate analgesic medication is mandatory after coronary artery bypass grafting (CABG) surgery. The aim of this study was to assess the analgesic efficacy, side effects, and need for rescue analgesia after CABG surgery comparing diclofenac and placebo rectal suppository. METHODS Thirty-seven consenting adults undergoing elective CABG surgery were randomly assigned in a double-blind fashion to receive either rectal diclofenac 100 mg (Group 1, n = 19) or placebo suppository (Group 2, n = 18) postoperatively, just after extubation. Both groups were given intravenous tramadol as a rescue analgesic. Pain scores in the two groups were assessed on a 10-cm visual analog scale at 0, 0.5, 1, 1.5, 2, 6, 12, 18, and 24 hours after suppository administration. Rescue analgesic consumption, sedation, nausea, and vomiting in both the groups were also recorded. RESULTS Twenty-four-hour tramadol consumption in Group 1 was 92.5 +/- 33.5 mg compared to 157.5 +/- 63.4 mg in Group 2 (P = 0.002). Patients in the placebo group had significantly greater pain scores 1.5 to 12 hours after extubation. Group 1 patients were significantly more awake compared to Group 2 (P < 0.05). The incidence of postoperative nausea was less in Group 1 than in Group 2 (P = 0.001). Though not statistically significant, three patients in Group 2 each had a single episode of vomiting, whereas no patient had vomiting in Group 1. CONCLUSION Rectal diclofenac suppository with tramadol provides adequate pain relief after cardiac surgery, and also reduces tramadol consumption and side effects commonly associated with tramadol.
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Affiliation(s)
- Naresh Dhawan
- Department of Cardiac Anesthesia, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110029, India.
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