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Tolj V, Adegbenro T, Brovman EY. Optimizing Pain Management in Cardiac Surgery: A Review of Analgesic Adjuvants. Curr Pain Headache Rep 2024:10.1007/s11916-024-01304-9. [PMID: 39141254 DOI: 10.1007/s11916-024-01304-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2024] [Indexed: 08/15/2024]
Abstract
PURPOSE OF REVIEW Pain management following cardiac surgery is a critical component in optimizing both short- and long-term patient outcomes, with poor pain management associated with significant acute and chronic opioid use, opioid dependence and a significant rate of opioid related adverse drug events. The significant burden of both acute and chronic pain following cardiac surgery has given rise to the need for multimodel analgesic strategies, to optimize outcomes and minimize side effects. RECENT FINDINGS While significant research has focused recently on the additive value of peripheral nerve blocks, less emphasis has been given to the value of non-opioid based analgesics in preference to traditional opioid based anesthetic and analgesic strategies. In this review, we examine the evidence for several common analgesics, highlighting the evidence supporting efficacy following cardiac surgery, as well as the safety concerns with each agent. We demonstrate the value of a multimodal analgesic strategy to reduce pain scores and improve patient-centered outcomes, and highlight the need for further studies of combination analgesic strategies.
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Affiliation(s)
- Vanja Tolj
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, 800 Washington St, Boston, MA, 02111, US
| | - Temitayo Adegbenro
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, 800 Washington St, Boston, MA, 02111, US
| | - Ethan Y Brovman
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, 800 Washington St, Boston, MA, 02111, US.
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Ibrahim T, Gebril A, Nasr MK, Samad A, Zaki HA. Unlocking the Optimal Analgesic Potential: A Systematic Review and Meta-Analysis Comparing Intravenous, Oral, and Rectal Paracetamol in Equivalent Doses. Cureus 2023; 15:e41876. [PMID: 37581156 PMCID: PMC10423591 DOI: 10.7759/cureus.41876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2023] [Indexed: 08/16/2023] Open
Abstract
Paracetamol (acetaminophen) is an extensively used analgesic for acute and chronic pain management. Currently, paracetamol is manufactured for oral, rectal, and intravenous (IV) use. Research has shown varied results on the analgesic properties of IV paracetamol compared to oral and rectal paracetamol; however, research on the same doses of paracetamol is limited. Therefore, this review was constructed to explore the analgesic properties of IV paracetamol compared with oral and rectal paracetamol administered in equivalent doses. A broad and thorough literature search was performed on five electronic databases, including PubMed, ScienceDirect, Medline, Scopus, and Google Scholar. Statistical analysis of all outcomes in our review was then performed using the Review Manager software. Outcomes were categorized as primary (pain relief and time to request rescue analgesia) and secondary (adverse events after analgesia). An extensive quality appraisal was also done using the Review Manager software's Cochrane risk of bias tool. The literature survey yielded 2,945 articles, of which 12 were used for review and analysis. The pooled analysis for patients undergoing surgical procedures showed that IV paracetamol had statistically similar postoperative pain scores at two (mean difference (MD) = -0.14; 95% confidence interval (CI) -0.58-0.29; p = 0.51), 24 (MD = 0.09; 95% CI = -0.02-0.21; p = 0.12), and 48 (MD = 0.04; 95% CI = -0.08-0.16; p = 0.52) hours as oral paracetamol. Similarly, the data on time to rescue analgesia showed no considerable difference between the IV and oral paracetamol groups (MD = -1.58; 95% CI = -5.51-2.35; p = 0.43). On the other hand, the pooled analysis for patients presenting non-surgical acute pain showed no significant difference in the mean pain scores between patients treated with IV and oral paracetamol (MD = -0.35; 95% CI = -2.19-1.48; p = 0.71). Furthermore, a subgroup analysis of analgesia-related adverse events showed that the incidences of vomiting/nausea and pruritus did not differ between patients receiving IV and oral paracetamol (odds ratio (OR) = 0.71; 95% CI = 0.45-1.11; p = 0.13 and OR = 0.48; 95% CI = 0.18-1.29; p = 0.05, respectively). A review of information from two trials comparing equal doses of IV and rectal paracetamol suggested that the postoperative pain scores were statistically similar between the groups. IV paracetamol is not superior to oral or rectal paracetamol administered in equal doses. Therefore, we cannot recommend or refute IV paracetamol as the first-line analgesia for acute and postoperative pain.
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Affiliation(s)
| | - Amr Gebril
- Emergency Medicine, NMC Royal Hospital, Khalifa City, ARE
| | - Mohammed K Nasr
- Emergency Medicine, Dr. Sulaiman Al Habib Hospital, Dubai, ARE
| | - Abdul Samad
- Acute Medicine/Emergency, NMC Royal Hospital, Khalifa City, ARE
| | - Hany A Zaki
- Emergency Medicine, Hamad Medical Corporation, Doha, QAT
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Makkad B, Heinke TL, Sheriffdeen R, Khatib D, Brodt JL, Meng ML, Grant MC, Kachulis B, Popescu WM, Wu CL, Bollen BA. Practice Advisory for Preoperative and Intraoperative Pain Management of Cardiac Surgical Patients: Part 2. Anesth Analg 2023; 137:26-47. [PMID: 37326862 DOI: 10.1213/ane.0000000000006506] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Pain after cardiac surgery is of moderate to severe intensity, which increases postoperative distress and health care costs, and affects functional recovery. Opioids have been central agents in treating pain after cardiac surgery for decades. The use of multimodal analgesic strategies can promote effective postoperative pain control and help mitigate opioid exposure. This Practice Advisory is part of a series developed by the Society of Cardiovascular Anesthesiologists (SCA) Quality, Safety, and Leadership (QSL) Committee's Opioid Working Group. It is a systematic review of existing literature for various interventions related to the preoperative and intraoperative pain management of cardiac surgical patients. This Practice Advisory provides recommendations for providers caring for patients undergoing cardiac surgery. This entails developing customized pain management strategies for patients, including preoperative patient evaluation, pain management, and opioid use-focused education as well as perioperative use of multimodal analgesics and regional techniques for various cardiac surgical procedures. The literature related to this field is emerging, and future studies will provide additional guidance on ways to improve clinically meaningful patient outcomes.
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Affiliation(s)
- Benu Makkad
- From the Department of Anesthesiology, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Timothy Lee Heinke
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Raiyah Sheriffdeen
- Department of Anesthesiology, Medstar Washington Hospital Center, Washington, DC
| | - Diana Khatib
- Department of Anesthesiology, Weil Cornell Medical College, New York, New York
| | - Jessica Louise Brodt
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
| | - Marie-Louise Meng
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Michael Conrad Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bessie Kachulis
- Department of Anesthesiology, Columbia University, New York, New York
| | - Wanda Maria Popescu
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Christopher L Wu
- Department of Anesthesiology, Hospital of Special Surgery, Weill Cornell Medical College, New York, New York
| | - Bruce Allen Bollen
- Missoula Anesthesiology, Missoula, Montana
- The International Heart Institute of Montana, Missoula, Montana
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4
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Pruskowski KA, Feth M, Hong L, Wiggins AR. Pharmacologic Management of Pain, Agitation, and Delirium in Burn Patients. Surg Clin North Am 2023; 103:495-504. [PMID: 37149385 DOI: 10.1016/j.suc.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] [Indexed: 05/08/2023]
Abstract
The majority of hospitalized burn patients experience pain, agitation, and delirium. The development of each one of these conditions can also lead to, or worsen, the others. Providers, therefore, need to thoroughly assess the underlying issue to determine the most effective treatment. Multimodal pharmacologic regimens are often used in conjunction with non-pharmacologic strategies to manage pain, agitation, and delirium. This review focuses on the pharmacologic management of these complicated patients in a critical-care setting.
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Affiliation(s)
- Kaitlin A Pruskowski
- US Army Institute of Surgical Research, 3698 Chambers Pass, ATTN: FCMR-SRT, JBSA Fort Sam, Houston, TX 78234, USA; Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
| | - Maximilian Feth
- US Army Institute of Surgical Research, 3698 Chambers Pass, ATTN: FCMR-SRT, JBSA Fort Sam, Houston, TX 78234, USA; Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Federal Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
| | - Linda Hong
- US Army Institute of Surgical Research, 3698 Chambers Pass, ATTN: FCMR-SRT, JBSA Fort Sam, Houston, TX 78234, USA
| | - Amanda R Wiggins
- US Army Institute of Surgical Research, 3698 Chambers Pass, ATTN: FCMR-SRT, JBSA Fort Sam, Houston, TX 78234, USA
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Meier KM, Zheng A, Rollins ZH, Asantey KA, Shah MD, Banooni AB, Liss ZJ. Elimination of postoperative narcotics in infant robotic pyeloplasty using caudal anesthesia and a non-narcotic pain pathway. J Endourol 2022; 36:1431-1435. [PMID: 35850585 DOI: 10.1089/end.2022.0263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Research suggests that narcotic pain medications are dramatically overprescribed. We hypothesize that narcotics are unnecessary for post-operative pain control in most infants undergoing robotic pyeloplasty. In this series, we report our experience combining caudal blocks with a non-narcotic postoperative pathway as a means of eliminating postoperative narcotics following infant robotic pyeloplasty. METHODS We reviewed 24 consecutive patients who underwent robotic pyeloplasty by a single surgeon treated with an end-procedure caudal block followed by a non-narcotic postoperative pain pathway treated between May 2017 and May 2021. The standardized postoperative pathway consisted of an end-procedure caudal block followed by alternating intravenous acetaminophen and ketorolac. We reviewed demographics, outcomes and unscheduled healthcare encounters within 30 postoperative days. RESULTS 63% (15/24) patients were male and average age was 12.1 months (range 4-34 months). 58% (9/15) underwent surgery on the left. 16.7% (4/24) of patients received a single postoperative dose of narcotics in the PACU. No patient required narcotic prescriptions at discharge or anytime thereafter. The average length of stay was 1.13 days. There was no pain-related, unscheduled visits or phone calls after discharge. CONCLUSIONS This series shows that a non-narcotic standardized pain management strategy is a viable option for infants undergoing robotic pyeloplasty. Post procedure caudal block is a good addition to a non-narcotic pathway. In the future, we intend to expand these findings to other pediatric urologic procedures in the hope of eliminating unnecessary narcotic use.
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Affiliation(s)
- Kristen M Meier
- Beaumont Health System, 7005, Department of Urology, Royal Oak, Michigan, United States;
| | - Anna Zheng
- Michigan Institute of Urology, 20952 Twelve Mile Road, Suite #200, St. Clair Shores , Michigan, United States, 48081;
| | - Zach H Rollins
- Oakland University William Beaumont School of Medicine, 159878, Rochester, Michigan, United States;
| | - Kwesi A Asantey
- Oakland University William Beaumont School of Medicine, 159878, Rochester, Michigan, United States;
| | - Mit D Shah
- Beaumont Health System, 7005, Department of Urology, Royal Oak, Michigan, United States;
| | - Andrew B Banooni
- Beaumont Health System, 7005, Department of Anesthesia, Royal Oak, Michigan, United States;
| | - Zachary J Liss
- Beaumont Health System, 7005, Department of Urology, Royal Oak, Michigan, United States.,Oakland University William Beaumont School of Medicine, 159878, Rochester, Michigan, United States.,Michigan Institute of Urology, St. Clair Shores , United States;
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6
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Pota V, Coppolino F, Barbarisi A, Passavanti MB, Aurilio C, Sansone P, Pace MC. Pain in Intensive Care: A Narrative Review. Pain Ther 2022; 11:359-367. [PMID: 35220551 PMCID: PMC9098741 DOI: 10.1007/s40122-022-00366-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 02/09/2022] [Indexed: 11/26/2022] Open
Affiliation(s)
- Vincenzo Pota
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy.
| | - Francesco Coppolino
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy
| | - Alfonso Barbarisi
- Department of Translational Medical Science, Telematic University Pegaso, Naples, Italy
| | - Maria Beatrice Passavanti
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy
| | - Caterina Aurilio
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy
| | - Pasquale Sansone
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy
| | - Maria Caterina Pace
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy
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Cao Q, Fan C, Yuan R, Dong H, Zhang S, Meng H. Comparison of intravenous and oral administration of acetaminophen in adults undergoing general anesthesia. Pain Pract 2021; 22:405-413. [PMID: 34775679 DOI: 10.1111/papr.13092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Acetaminophen is a widely clinically used analgesic. However, the clinical effect of the route of administration on postoperative analgesia as well as on postoperative nausea and vomiting in patients undergoing general anesthesia remains unclear. This study aimed to explore whether the route of administration of acetaminophen affects postoperative analgesia, nausea, and vomiting in patients undergoing general anesthesia. METHODS We included all randomized controlled trials investigating the effects of the route of administration of acetaminophen on postoperative pain, nausea, and vomiting in patients undergoing general anesthesia. Independent examiners reviewed the literature and extracted data, with disagreements resolved through negotiation or the involvement of a third party. The Cochrane risk assessment tool was used to evaluate the quality of the included randomized controlled trials. A narrative synthesis was conducted to summarize the qualitative information from the included studies. A meta-integration of quantitative data was performed using RevMan 5.4. RESULTS Ten studies met the inclusion criteria. Eight studies assessed postoperative pain, whereas two assessed postoperative nausea and vomiting. Data from the eight studies assessing postoperative pain confirmed that there was no difference between intravenously and orally administered acetaminophen in adults (OR = -0.13; 95% CI, -0.36 to 0.11; p = 0.3). Data from the two studies assessing postoperative nausea and vomiting revealed no difference between intravenously and orally administered acetaminophen in adults (OR = 0.89; 95% CI, 0.64-1.25; p = 0.51). The included studies were of poor quality, with a heterogeneity of 68%. CONCLUSIONS No differences in postoperative analgesia or postoperative nausea and vomiting were observed between the routes of administration (intravenous vs. oral) of acetaminophen in adult patients undergoing general anesthesia. There is a need for future large sample studies to increase the reliability of the results.
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Affiliation(s)
- Qinqin Cao
- Department of Anesthesiology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Chengjuan Fan
- Department of Urology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Ran Yuan
- Department of Anesthesiology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Hemin Dong
- Department of Anesthesiology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Shouxin Zhang
- Department of Anesthesiology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Haihong Meng
- Department of Anesthesiology, Affiliated Hospital of Jining Medical University, Jining, China
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8
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A Narrative Review on Perioperative Pain Management Strategies in Enhanced Recovery Pathways-The Past, Present and Future. J Clin Med 2021; 10:jcm10122568. [PMID: 34200695 PMCID: PMC8229260 DOI: 10.3390/jcm10122568] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/05/2021] [Accepted: 06/08/2021] [Indexed: 12/14/2022] Open
Abstract
Effective pain management is a key component in the continuum of perioperative care to ensure optimal outcomes for surgical patients. The overutilization of opioids in the past few decades for postoperative pain control has been a major contributor to the current opioid epidemic. Multimodal analgesia (MMA) and enhanced recovery after surgery (ERAS) pathways have been repeatedly shown to significantly improve postoperative outcomes such as pain, function and satisfaction. The current review aims to examine the history of perioperative MMA strategies in ERAS and provide an update with recent evidence. Furthermore, this review details recent advancements in personalized pain medicine. We speculate that the next important step for improving perioperative pain management could be through incorporating these personalized metrics, such as clinical pharmacogenomic testing and patient-reported outcome measurements, into ERAS program.
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9
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Nazarnia S, Subramaniam K. Nonopioid Analgesics in Postoperative Pain Management After Cardiac Surgery. Semin Cardiothorac Vasc Anesth 2021; 25:280-288. [PMID: 33899581 DOI: 10.1177/1089253221998552] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Opioid analgesia is still considered the standard of practice for cardiac surgery. In recent years, combinations of several nonnarcotic analgesics and regional analgesia have shown promise in restricting opioid use during and after cardiac surgery. Ketamine infusion, dexmedetomidine infusion, acetaminophen, ketorolac, and gabapentin are useful adjuvants in cardiac anesthesia practice and have opioid-sparing properties. The beneficial effects of nonnarcotic multimodal analgesia on intraoperative stress response, recovery profile, postoperative pain, and persistent opioid use after cardiac surgery are yet to be established, and further randomized clinical trials are required.
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Affiliation(s)
- Soheyla Nazarnia
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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10
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Tompkins DM, DiPasquale A, Segovia M, Cohn SM. Review of Intravenous Acetaminophen for Analgesia in the Postoperative Setting. Am Surg 2021; 87:1809-1822. [PMID: 33522265 DOI: 10.1177/0003134821989056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Acetaminophen is a non-opioid analgesic commonly utilized for pain control after several types of surgical procedures. METHODS This scoping primary literature review provides recommendations for intravenous (IV) acetaminophen use based on type of surgery. RESULTS Intravenous acetaminophen has been widely studied for postoperative pain control and has been compared to other agents such as NSAIDs, opioids, oral/rectal acetaminophen, and placebo. Some of the procedures studied include abdominal, gynecologic, orthopedic, neurosurgical, cardiac, renal, and genitourinary surgeries. Results of these studies have been conflicting and largely have not shown consistent clinical benefit. CONCLUSION Overall, findings from this review did not support the notion that IV acetaminophen has significant efficacy for postoperative analgesia. Given the limited clinical benefit of IV acetaminophen, especially when compared to the oral or rectal formulations, use is generally not justifiable.
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Affiliation(s)
- Danielle M Tompkins
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA.,Department of Pharmacy, 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Arielle DiPasquale
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA
| | - Michelle Segovia
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA
| | - Stephen M Cohn
- Department of Surgery, 3673Hackensack University Medical Center, Hackensack, NJ, USA
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Radical Cystectomy. Bladder Cancer 2021. [DOI: 10.1007/978-3-030-70646-3_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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12
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Kor TM, Naranjo J, Deljou A, Evans KD, Schroeder D, Sprung J, Weingarten TN. Intravenous Versus Oral Acetaminophen in Outpatient Cystoscopy Procedures: Retrospective Comparison of Postoperative Opioid Requirements and Analgesia Scores. Am Surg 2020; 86:1691-1696. [PMID: 32853023 DOI: 10.1177/0003134820945204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To assess if the choice of acetaminophen formulation (intravenous vs oral) when administered preoperatively for ambulatory cystoscopy procedures is associated with differences in anesthetic outcomes. METHODS Medical records of adult patients undergoing ambulatory cystoscopy procedures at an outpatient procedural center from July 1, 2014, through November 30, 2017, were abstracted. The association between anesthetic outcomes (severe pain, rescue opioids, postoperative nausea, and vomiting) and acetaminophen formulation was assessed. Propensity-adjusted analyses were performed using inverse probability of treatment weighting to account for potential confounders. RESULTS During the study time frame, there were 611 intravenous and 2955 oral acetaminophen administrations for cystoscopy procedures. Postoperative bladder spasms were a major contributor to severe pain and complicated 1036 cases, with similar rates between intravenous (N = 183, 29.9%) and oral (N = 853, 28.9%) formulations, P = .625. After adjusting for bladder spasms, intravenous acetaminophen was associated with longer anesthesia recovery (estimate 5.2 [95% CI 0.5-9.9] minutes, P = .030), use of rescue opioids (odds ratio 1.33 [1.07-1.66], P = .012), and postoperative nausea and vomiting (1.40 [1.02-1.93], P = .037), but not severe pain (1.07 [0.81-1.40], P = .640). CONCLUSION Preoperative intravenous acetaminophen compared to oral acetaminophen for ambulatory cystoscopy procedures was not associated with better anesthetic outcomes. Bladder spasms were a major contributor to postoperative pain.
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Affiliation(s)
- Todd M Kor
- 6915 Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Julian Naranjo
- 6915 Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Atousa Deljou
- 6915 Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kimberly D Evans
- 6915 Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Darrell Schroeder
- 6915 Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Juraj Sprung
- 6915 Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Toby N Weingarten
- 6915 Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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13
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Antill AC, Frye SW, McMillen JC, Haynes JC, Ford BR, Bollig RW, Daley BJ. Treatment With Oral Versus Intravenous Acetaminophen in Elderly Trauma Patients With Rib Fractures: A Prospective Randomized Trial. Am Surg 2020; 86:926-932. [PMID: 32749863 DOI: 10.1177/0003134820940268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Rib fractures are common injuries among traumatically injured patients, and elderly patients with rib fractures are at increased risk for adverse events and death. The purpose of this study was to determine if oral Per os (PO) acetaminophen is as effective as intravenous (IV) acetaminophen in treating the pain associated with rib fractures. METHODS We performed a single-center, randomized, placebo-controlled, double-blinded study. Trauma patients who were ≥65 years old and had ≥1 rib fracture were included in this study. Patients were randomized into IV acetaminophen and oral placebo (n = 63) or IV placebo and oral solution acetaminophen (n = 75) groups. The primary outcome was a mean reduction in pain score at 24 hours, and secondary outcomes included opioid use, intensive care unit (ICU) length of stay (LOS), hospital LOS, hospital mortality, the difference in incentive spirometry, and development of pneumonia. RESULTS Among the 138 patients included, there was no statistically significant difference between the 2 study groups in a mean reduction in pain score at 24 hours after injury (PO: 3.24, IV: 2.49; P = .230). Opioid pain medication use was equivalent between groups (P = .212), and there was no significant difference in hospital mortality rate between groups (P = .827). There was no statistically significant difference in ICU LOS, hospital LOS, or development of pneumonia. DISCUSSION In elderly trauma patients (age ≥65 years) with 1 or more rib fractures, PO acetaminophen is equivalent to IV acetaminophen for pain control, with no difference in morbidity or mortality. Oral acetaminophen should be preferentially used over IV acetaminophen when treating the elderly trauma patient with rib fractures.
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Affiliation(s)
- Andrew C Antill
- 21823 Department of Surgery, University of Tennessee Medical Center, Knoxville, TN, USA
| | - Sarah W Frye
- Department of Pharmacy, Spartanburg Medical Center, SC, USA
| | - James C McMillen
- Department of Pharmacy, University of Tennessee Medical Center, Knoxville, TN, USA
| | - James C Haynes
- Department of Surgery, WellStar North Fulton Hospital, Roswell, GA, USA
| | - Benjamin R Ford
- Department of Surgery, Roper Saint Francis Healthcare, Charleston, SC, USA
| | - Reagan W Bollig
- 21823 Department of Surgery, University of Tennessee Medical Center, Knoxville, TN, USA
| | - Brian J Daley
- 21823 Department of Surgery, University of Tennessee Medical Center, Knoxville, TN, USA
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14
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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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15
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Mallama M, Valencia A, Rijs K, Rietdijk WJR, Klimek M, Calvache JA. A systematic review and trial sequential analysis of intravenous vs. oral peri-operative paracetamol. Anaesthesia 2020; 76:270-276. [PMID: 32557588 PMCID: PMC7818191 DOI: 10.1111/anae.15163] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2020] [Indexed: 12/13/2022]
Abstract
Postoperative pain might be different after intravenous vs. oral paracetamol. We systematically reviewed randomised controlled trials in patients >15 years that compared intravenous with oral paracetamol for postoperative pain. We identified 14 trials with 1695 participants. There was inconclusive evidence for an effect of route of paracetamol administration on postoperative pain at 0–2 h (734 participants), 2–6 h (766 participants), 6–24 h (1115 participants) and >24 h (248 participants), with differences in standardised mean (95%CI) pain scores for intravenous vs. oral of −0.17 (−0.45 to 0.10), −0.09 (−0.24 to 0.06), 0.06 (−0.12 to 0.23) and 0.03 (−0.22 to 0.28), respectively. Trial sequential analyses suggested that a total of 3948 participants would be needed to demonstrate a meaningful difference in pain or its absence at 0–2 h. There were no differences in secondary outcomes. Intravenous paracetamol is more expensive than oral paracetamol. Substitution of oral paracetamol in half the patients given intravenous paracetamol in our hospital would save around £ 38,711 (€ 43,960 or US$ 47,498) per annum.
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Affiliation(s)
- M Mallama
- Department of Anaesthesiology, Universidad del Cauca, Popayán, Colombia
| | - A Valencia
- Department of Anaesthesiology, Universidad del Cauca, Popayán, Colombia
| | - K Rijs
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - W J R Rietdijk
- Department of Intensive Care, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - M Klimek
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - J A Calvache
- Department of Anaesthesiology, Universidad del Cauca, Popayán, Colombia.,Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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16
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White PF. Cost-effective multimodal analgesia in the perioperative period: Use of intravenous vs. oral acetaminophen. J Clin Anesth 2019; 61:109625. [PMID: 31676119 DOI: 10.1016/j.jclinane.2019.109625] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 09/20/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Paul F White
- Cedars-Sinai Medical Center, Los Angeles, CA, United States; White Mountain Institute, The Sea Ranch, CA, United States.
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17
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Comparison of clinical outcomes of acetaminophen IV vs PO in the peri-operative setting for laparoscopic inguinal hernia repair surgeries: A triple-blinded, randomized controlled trial. J Clin Anesth 2019; 61:109628. [PMID: 31669049 DOI: 10.1016/j.jclinane.2019.109628] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 09/18/2019] [Accepted: 09/20/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Acetaminophen is available in a variety of modalities but there is conflicting evidence as to whether intravenous provides superior analgesia than oral formulations METHODS: A prospective, randomized, triple-blinded clinical trial was conducted in which 100 participants, scheduled for any laparoscopic unilateral hernia repair surgery in the ambulatory setting, were computer randomized to receive either 975 mg oral acetaminophen or 1000 mg of intravenous acetaminophen. The primary outcomes evaluated were post-anesthesia care unit (PACU) pain scores at arrival, 1 hour discharge, 6 hour post-op as well as total opioid use intraoperatively and in PACU. Secondary outcomes were PACU length of stay, patient reported total opioid use in the first 24 h, pain scores 24 hour post-op and patient satisfaction. RESULTS We found that no significant difference was appreciated between the oral and intravenous acetaminophen groups in any of the primary or secondary outcomes with the p-value of the pain score on arrival of 0.173, pain score at 1 h 0.544, pain score on discharge from PACU 0.586, pain score at 6 h 0.234, pain score at 24 h 0.133, total morphine milligram equivalents (MME) intraoperatively 0.096, total MME in PACU 0.960, time in PACU 0.15, home opioid MME 0.336, and overall patient satisfaction 0.067. CONCLUSIONS We concluded that in the ambulatory surgery population the efficacy of oral and intravenous acetaminophen is equivalent.
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18
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Zhao H, Yang S, Wang H, Zhang H, An Y. Non-opioid analgesics as adjuvants to opioid for pain management in adult patients in the ICU: A systematic review and meta-analysis. J Crit Care 2019; 54:136-144. [PMID: 31446231 DOI: 10.1016/j.jcrc.2019.08.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 08/12/2019] [Accepted: 08/12/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE To identify the impact of non-opioid analgesics as adjuvants to opioid on opioid consumption and its side effects, as well as the analgesic effectiveness in adult patients in the ICU. METHODS Only randomized clinical trials using non-opioid analgesics for analgesia in the ICU were included. Pooled analyses with 95% CI were determined. RESULTS Twelve studies (mainly surgical and Guillain-Barre syndrome patients) were included. Non-opioid analgesics as adjuvants to opioid were associated with a significant reduction in the consumption of opioids when compared with opioid use alone at Day 1 (MD -15.40; 95% CI -22.41 to -8.39; P < .001) and Day 2 (MD -22.93; 95% CI -27.70 to -18.16; P < .001). Non-opioid analgesics as adjuvants to opioid were associated with a significantly lower incidence of nausea and vomiting when compared with opioid use alone (RR 0.46; 95% CI 0.30 to 0.68; P < .001). Non-opioid analgesics as adjuvants to opioid significantly decreased the pain score at Day 1 (MD -0.68; 95% CI -1.28 to -0.08; P = .03) and Day 2 (MD -1.36; 95% CI -2.47 to -0.24; P = .02). CONCLUSIONS Non-opioid analgesics as adjuvants to opioid reduced the consumption and the side effects of opioids in adult surgical and Guillain-Barre syndrome patients in the ICU. TRIAL REVIEW REGISTRATION PROSPERO international prospective register of systematic reviews on January 23, 2017, registration number CRD42017055768.
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Affiliation(s)
- Huiying Zhao
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China.
| | - Shuguang Yang
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Huixia Wang
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Hua Zhang
- Epidemiology Center, Peking University Third Hospital, Beijing, China
| | - Youzhong An
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China.
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19
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Kim DE, Pruskowski KA, Ainsworth CR, Linsenbardt HR, Rizzo JA, Cancio LC. A Review of Adjunctive Therapies for Burn Injury Pain During the Opioid Crisis. J Burn Care Res 2019; 40:983-995. [DOI: 10.1093/jbcr/irz111] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Abstract
Opioids are the mainstay of pain management after burn injury. The United States currently faces an epidemic of opioid overuse and abuse, while simultaneously experiencing a nationwide shortage of intravenous narcotics. Adjunctive pain management therapies must be sought and utilized to reduce the use of opioids in burn care to prevent the long-term negative effects of these medications and to minimize the dependence on opioids for analgesia. The purpose of this review was to identify literature on adjunctive pain management therapies that have been demonstrated to reduce pain severity or opioid consumption in adult burn patients. Three databases were searched for prospective studies, randomized controlled trials, and systematic reviews that evaluated adjunctive pain management strategies published between 2008 and 2019 in adult burn patients. Forty-six studies were analyzed, including 24 randomized controlled trials, six crossover trials, and 10 systematic reviews. Various adjunctive pain management therapies showed statistically significant reduction in pain severity. Only one randomized controlled trial on music therapy for acute background pain showed a reduction in opioid use. One cohort study on hypnosis demonstrated reduced opioid use compared with historical controls. We recommend the development of individualized analgesic regimens with the incorporation of adjunctive therapies in order to improve burn pain management in the midst of an abuse crisis and concomitant national opioid shortage.
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Affiliation(s)
- Daniel E Kim
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Kaitlin A Pruskowski
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Craig R Ainsworth
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | | | - Julie A Rizzo
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Leopoldo C Cancio
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
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20
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Noroozi M, Doroudian MR, Sarkouhi A, nejad MA, Barkhori A, Moghadari M, Shaabani M. Synergistic effects of Paracetamol and Dexamethasone with Lidocaine in Intravenous regional anesthesia (IVRA) of upper limbs: A randomized clinical trial. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2015.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Mehrdad Noroozi
- Department of Anesthesiology, Kerman University of Medical Sciences, Iran
| | | | - Ali Sarkouhi
- Department of Anesthesiology, Kerman University of Medical Sciences, Iran
| | - Mehdi Ahmadi nejad
- Department of Anesthesiology, Kerman University of Medical Sciences, Iran
| | - Ali Barkhori
- Department of Anesthesiology, Kerman University of Medical Sciences, Iran
| | - Masoud Moghadari
- Center for Clinical Research, Shahid Bahonar Hospital, Kerman, Iran
| | - Mohammad Shaabani
- Department of Anesthesiology, Kerman University of Medical Sciences, Iran
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Maxwell EN, Johnson B, Cammilleri J, Ferreira JA. Intravenous Acetaminophen-Induced Hypotension: A Review of the Current Literature. Ann Pharmacother 2019; 53:1033-1041. [PMID: 31046402 DOI: 10.1177/1060028019849716] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: Recent literature suggests that intravenous (IV) administration may cause hypotension in hospitalized patients; data further suggest that this effect is most pronounced in the critically ill. The purpose of this review is to identify and evaluate current literature that addresses the incidence and implications of IV acetaminophen-induced hypotension. Data Sources: A literature search of MEDLINE, Cochrane, and EMBASE databases was performed (2002-2019) using the following terms: acetaminophen, paracetamol, intravenous, and hypotension. Abstracts and peer-reviewed publications were reviewed. Study Selection and Data Extraction: Relevant English-language studies conducted in humans evaluating the hemodynamic effects of IV acetaminophen were considered. Data Synthesis: A majority of the 19 studies included in this review identified a statistically significant drop in hemodynamic variables after the administration of 500 to 1000 mg IV acetaminophen as measured by changes in systolic blood pressure, diastolic blood pressure, or mean arterial pressure. Of the trials reporting vasopressor use, the authors found a significant increase in vasopressor requirements following IV acetaminophen administration. Relevance to Patient Care and Clinical Practice: This review represents the first comprehensive review of IV acetaminophen-induced hypotension. The findings raise the question of whether IV acetaminophen is an appropriate choice for inpatient pain or temperature management in the critically ill. Conclusions: Available evidence indicates that the administration of IV acetaminophen may be harmful in the critically ill. Additional monitoring is likely required when using IV acetaminophen in this specific population, particularly if a patient is hemodynamically unstable prior to administration.
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22
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Afonso AM, Tokita HK, McCormick PJ, Twersky RS. Enhanced Recovery Programs in Outpatient Surgery. Anesthesiol Clin 2019; 37:225-238. [PMID: 31047126 DOI: 10.1016/j.anclin.2019.01.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Although enhanced recovery pathways were initially implemented in inpatients, their principles are relevant in the ambulatory setting. Opioid minimization and addressing pain and nausea through multimodal analgesia, regional anesthesia, and robust preoperative education programs are integral to the success of ambulatory enhanced recovery programs. Rather than measurements of length of stay as in traditional inpatient programs, the focus of enhanced recovery programs in ambulatory surgery should be on improved quality of recovery, pain management, and early ambulation.
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Affiliation(s)
- Anoushka M Afonso
- Enhanced Recovery Programs (ERP), Department of Anesthesiology & Critical Care Medicine, Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, M-301, New York, NY 10065, USA.
| | - Hanae K Tokita
- Department of Anesthesiology & Critical Care, Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Patrick J McCormick
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Rebecca S Twersky
- Department of Anesthesiology & Critical Care Medicine, Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, 1133 York Avenue, Suite 312, New York, NY 10065, USA
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23
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Subramaniam B, Shankar P, Shaefi S, Mueller A, O’Gara B, Banner-Goodspeed V, Gallagher J, Gasangwa D, Patxot M, Packiasabapathy S, Mathur P, Eikermann M, Talmor D, Marcantonio ER. Effect of Intravenous Acetaminophen vs Placebo Combined With Propofol or Dexmedetomidine on Postoperative Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial. JAMA 2019; 321:686-696. [PMID: 30778597 PMCID: PMC6439609 DOI: 10.1001/jama.2019.0234] [Citation(s) in RCA: 169] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 01/16/2019] [Indexed: 01/04/2023]
Abstract
Importance Postoperative delirium is common following cardiac surgery and may be affected by choice of analgesic and sedative. Objective To evaluate the effect of postoperative intravenous (IV) acetaminophen (paracetamol) vs placebo combined with IV propofol vs dexmedetomidine on postoperative delirium among older patients undergoing cardiac surgery. Design, Setting, and Participants Randomized, placebo-controlled, factorial clinical trial among 120 patients aged 60 years or older undergoing on-pump coronary artery bypass graft (CABG) surgery or combined CABG/valve surgeries at a US center. Enrollment was September 2015 to April 2018, with follow-up ending in April 2019. Interventions Patients were randomized to 1 of 4 groups receiving postoperative analgesia with IV acetaminophen or placebo every 6 hours for 48 hours and postoperative sedation with dexmedetomidine or propofol starting at chest closure and continued for up to 6 hours (acetaminophen and dexmedetomidine: n = 29; placebo and dexmedetomidine: n = 30; acetaminophen and propofol: n = 31; placebo and propofol: n = 30). Main Outcomes and Measures The primary outcome was incidence of postoperative in-hospital delirium by the Confusion Assessment Method. Secondary outcomes included delirium duration, cognitive decline, breakthrough analgesia within the first 48 hours, and ICU and hospital length of stay. Results Among 121 patients randomized (median age, 69 years; 19 women [15.8%]), 120 completed the trial. Patients treated with IV acetaminophen had a significant reduction in delirium (10% vs 28% placebo; difference, -18% [95% CI, -32% to -5%]; P = .01; HR, 2.8 [95% CI, 1.1-7.8]). Patients receiving dexmedetomidine vs propofol had no significant difference in delirium (17% vs 21%; difference, -4% [95% CI, -18% to 10%]; P = .54; HR, 0.8 [95% CI, 0.4-1.9]). There were significant differences favoring acetaminophen vs placebo for 3 prespecified secondary outcomes: delirium duration (median, 1 vs 2 days; difference, -1 [95% CI, -2 to 0]), ICU length of stay (median, 29.5 vs 46.7 hours; difference, -16.7 [95% CI, -20.3 to -0.8]), and breakthrough analgesia (median, 322.5 vs 405.3 µg morphine equivalents; difference, -83 [95% CI, -154 to -14]). For dexmedetomidine vs propofol, only breakthrough analgesia was significantly different (median, 328.8 vs 397.5 µg; difference, -69 [95% CI, -155 to -4]; P = .04). Fourteen patients in both the placebo-dexmedetomidine and acetaminophen-propofol groups (46% and 45%) and 7 in the acetaminophen-dexmedetomidine and placebo-propofol groups (24% and 23%) had hypotension. Conclusions and Relevance Among older patients undergoing cardiac surgery, postoperative scheduled IV acetaminophen, combined with IV propofol or dexmedetomidine, reduced in-hospital delirium vs placebo. Additional research, including comparison of IV vs oral acetaminophen and other potentially opioid-sparing analgesics, on the incidence of postoperative delirium is warranted. Trial Registration ClinicalTrials.gov Identifier: NCT02546765.
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Affiliation(s)
- Balachundhar Subramaniam
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Puja Shankar
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ariel Mueller
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Brian O’Gara
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Valerie Banner-Goodspeed
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jackie Gallagher
- Department of Medicine, Division of Gerontology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Doris Gasangwa
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Melissa Patxot
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Senthil Packiasabapathy
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Pooja Mathur
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Daniel Talmor
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Edward R. Marcantonio
- Department of Medicine, Division of Gerontology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Kinoshita J, Fushida S, Kaji M, Oyama K, Fujimoto D, Hirono Y, Tsukada T, Fujimura T, Ohyama S, Yabushita K, Kadoya N, Nishijima K, Ohta T. A randomized controlled trial of postoperative intravenous acetaminophen plus thoracic epidural analgesia vs. thoracic epidural analgesia alone after gastrectomy for gastric cancer. Gastric Cancer 2019; 22:392-402. [PMID: 30088162 PMCID: PMC6394709 DOI: 10.1007/s10120-018-0863-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 07/30/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acetaminophen is used in multimodal therapy for postoperative pain management. However, the additional effects of acetaminophen in combination with thoracic epidural analgesia (TEA) are not well understood. This prospective, multicenter randomized study was conducted to evaluate the efficacy of routine intravenous (i.v.) acetaminophen in combination with TEA for the management of postoperative pain in gastric cancer surgery. METHODS A total of 120 patients who underwent distal gastrectomy were randomly assigned in a 1:1 ratio to receive i.v. acetaminophen every 6 h and TEA during the first 3 postoperative days (acetaminophen group) or TEA alone (control group). The primary endpoint was the sum of TEA rescue doses during the first 2 postoperative days. RESULTS Final analysis included 58 patients in the acetaminophen group and 56 patients in the control group. The median number of TEA rescue doses was significantly lower in the acetaminophen group compared with the control group (3.0 vs. 8.0, p = 0.013). The median area under the curve (AUC) of the pain scores at coughing was significantly less in the acetaminophen group compared with the control group (285 vs. 342, p = 0.046) without an increase in postoperative complications. TEA rescue doses and pain score AUCs were significantly reduced by acetaminophen in patients who underwent open gastrectomy (p = 0.037 and 0.045), whereas there was no significant difference between patients who underwent laparoscopic gastrectomy in the two groups. CONCLUSIONS In gastric cancer surgery patients, routine i.v. acetaminophen in combination with TEA provides superior postoperative pain management compared with TEA alone.
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Affiliation(s)
- Jun Kinoshita
- Department of Gastroenterological Surgery, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Sachio Fushida
- Department of Gastroenterological Surgery, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, 920-8641, Japan.
| | - Masahide Kaji
- Department of Surgery, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Katsunobu Oyama
- Department of Gastroenterological Surgery, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Daisuke Fujimoto
- First Department of Surgery, Fukui University Hospital, Fukui, Japan
| | - Yasuo Hirono
- First Department of Surgery, Fukui University Hospital, Fukui, Japan
| | - Tomoya Tsukada
- Department of Surgery, Toyama Prefectural Central Hospital, Toyama, Japan
| | | | - Shigekazu Ohyama
- Department of Surgery, National Hospital Organization Kanazawa Medical Center, Kanazawa, Japan
| | | | - Naotaka Kadoya
- Department of Surgery, Toyama Rosai Hospital, Uozu, Japan
| | - Koji Nishijima
- Department of Surgery, Japanese Red Cross Kanazawa Hospital, Kanazawa, Japan
| | - Tetsuo Ohta
- Department of Gastroenterological Surgery, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
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Intravenous Acetaminophen Improves Outcomes After Transapical Transcatheter Aortic Valve Replacement. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018; 13:287-291. [PMID: 30138242 PMCID: PMC6203427 DOI: 10.1097/imi.0000000000000513] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Complications with opioid-based postoperative pain management have led to guideline recommendations for a multimodal analgesia strategy incorporating nonopioid agents. We evaluated the opioid-sparing effect of intravenous acetaminophen in patients undergoing transapical transcatheter aortic valve replacement. METHODS A multimodal pain management strategy that incorporated intravenous acetaminophen was retrospectively evaluated in 43 patients undergoing transapical transcatheter aortic valve replacement between November 2012 and March 2014. Before intravenous acetaminophen formulary availability, 23 patients received standard postoperative pain management interventions including intravenous narcotics and oral narcotics/acetaminophen. After intravenous acetaminophen availability, 20 patients received intravenous acetaminophen (4 g/d, ≥4 doses) and supplemental intravenous and nonacetaminophen oral narcotics. Daily narcotic dose (standardized to morphine equivalents), drug cost, and hospital length of stay were compared between groups. RESULTS Baseline characteristics were similar between intravenous acetaminophen (n = 20) and nonintravenous acetaminophen (n = 23) patients including the Society of Thoracic Surgery mortality risk (10.5% vs 9.0%, P = 0.3). The median number of intravenous acetaminophen doses was 6.5 (interquartile range = 4.0-18.5), with a median cost per patient of US $221 (interquartile range = $136-$629). Patients who received intravenous acetaminophen used significantly fewer morphine equivalents on postoperative day 0 compared with patients not receiving intravenous acetaminophen (22.5 vs 45.0 morphine equivalents, P = 0.03) and had a shorter median length of stay (5.0 vs 7.0 days, P = 0.007). After adjusting for the Society of Thoracic Surgery risk, intravenous acetaminophen continued to be associated with a reduction in median postoperative length of stay [-1.9 days (95% confidence interval = -0.9 to -8.2 days), P = 0.049]. CONCLUSIONS In patients undergoing transapical transcatheter aortic valve replacement, a multimodal pain management strategy incorporating intravenous acetaminophen was associated with reductions in narcotic use on the day of surgery and overall length of stay.
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Hansen RN, Pham AT, Boing EA, Lovelace B, Wan GJ, Urman RD. Reduced length of stay and hospitalization costs among inpatient hysterectomy patients with postoperative pain management including IV versus oral acetaminophen. PLoS One 2018; 13:e0203746. [PMID: 30212524 PMCID: PMC6136753 DOI: 10.1371/journal.pone.0203746] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 08/27/2018] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To compare the outcomes of hysterectomy patients who received standard pain management including IV acetaminophen (IV APAP) versus oral APAP. METHODS We performed a retrospective analysis of the Premier Database (January 2012 to September 2015) comparing hysterectomy patients who received postoperative pain management including IV APAP to those who received oral APAP starting on the day of surgery and continuing up to the third post-operative day, with no exclusions based on additional pain management. We compared the groups on length of stay (LOS), hospitalization costs, and average daily morphine equivalent dose (MED). The quarterly rate of IV APAP use for all hospitalizations by hospital was used as an instrumental variable in two-stage least squares regressions also adjusting for patient demographics, clinical risk factors, and hospital characteristics. RESULTS We identified 22,828 hysterectomy patients including 14,811 (65%) who had received IV APAP. Study subjects averaged 50 and 52 years of age, respectively in the IV APAP and oral APAP cohorts and were predominantly non-Hispanic Caucasians (≥60% in both cohorts). Instrumental variable models found IV APAP associated with 0.8 days shorter hospitalization (95% CI: -0.92 to -0.68, p<0.0001) and $2,449 lower hospitalization costs (95% CI: -$2,902 to -$1,996, p<0.0001). Average daily MED trended lower without statistical significance (-1.41 mg, 95% CI: -3.43 mg to 0.61 mg, p = 0.17). CONCLUSIONS Compared to oral APAP, managing post-hysterectomy pain with IV APAP is associated with shorter LOS and lower total hospitalization costs.
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Affiliation(s)
- Ryan N. Hansen
- University of Washington, School of Pharmacy, Seattle, Washington, United States of America
- * E-mail:
| | - An T. Pham
- Mallinckrodt Pharmaceuticals, Health Economics and Outcomes Research Department, Hampton, New Jersey, United States of America
- University of California San Francisco, School of Pharmacy, San Francisco, California, United States of America
| | - Elaine A. Boing
- Mallinckrodt Pharmaceuticals, Health Economics and Outcomes Research Department, Hampton, New Jersey, United States of America
| | - Belinda Lovelace
- Mallinckrodt Pharmaceuticals, Health Economics and Outcomes Research Department, Hampton, New Jersey, United States of America
| | - George J. Wan
- Mallinckrodt Pharmaceuticals, Health Economics and Outcomes Research Department, Hampton, New Jersey, United States of America
| | - Richard D. Urman
- Harvard Medical School and Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
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Plunkett A, Haley C, McCoart A, Beltran T, Highland KB, Berry-Caban C, Lamberth S, Bartoszek M. A Preliminary Examination of the Comparative Efficacy of Intravenous vs Oral Acetaminophen in the Treatment of Perioperative Pain. PAIN MEDICINE 2018; 18:2466-2473. [PMID: 28034981 DOI: 10.1093/pm/pnw273] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objective The management of postoperative pain is a major health care issue. While the cost of intravenous acetaminophen (IVA) is significantly greater than its oral acetaminophen (OA) counterpart, less is known regarding comparative effectiveness of these routes. The purpose of this study was to determine whether perioperative IVA is equivalent in reducing postoperative pain compared with perioperative OA for laparoscopic cholecystectomy (LapChole). Design Double-blinded, prospective, randomized placebo-controlled trial. Setting Womack Army Medical Center, Fort Bragg, North Carolina. Subjects Adults (age > 18 years) active duty military, veterans, and beneficiaries receiving a laparoscopic cholecystectomy. Methods This study was conducted at Womack Army Medical Center (WAMC), Fort Bragg, North Carolina, between January 2013 and June 2015. Sixty-seven subjects with symptomatic cholelithiasis were randomly assigned to receive two doses (1,000 mg each) of either IVA or OA. A numerical rating scale (NRS) score of pain was obtained preoperatively and every six hours for 24 hours postoperation. The primary objective was to assess whether treatment groups had significantly different 24-hour postoperative sum of pain intensity differences (SPID24) using an analysis of covariance test. Results Sixty subjects completed the study and were included in the analysis. Treatment groups did not differ in SPID24, even when controlling for age, gender, and preoperative pain levels (F(1,55) = 0.39, P = 0.54, partial η2 = 0.007), nor did 24-hour opioid consumption when controlling for age, gender, and operation time (F(1, 46) = 0.47, P = 0.50, partial η2 = 0.01). Furthermore, treatment groups were equally as likely to report average postoperative NRS scores of 4 or higher (β = 0.24, Exp(B) = 1.28, P = 0.68). Conclusions The results show no evidence of differences between IVA or OA in pain or opioid consumption among a sample of patients undergoing LapChole. Due to low sample size, these descriptive findings warrant larger studies, which may have a significant economic impact.
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Affiliation(s)
| | - Chelsey Haley
- Defense and Veterans Center for Integrative Pain Management, Henry M. Jackson Foundation, Womack Army Medical Center, Fort Bragg, North Carolina
| | - Amy McCoart
- Defense and Veterans Center for Integrative Pain Management, Henry M. Jackson Foundation, Womack Army Medical Center, Fort Bragg, North Carolina
| | | | - Krista Beth Highland
- Defense and Veterans Center for Integrative Pain Management, Henry M. Jackson Foundation, Uniformed Services University of the Health Sciences, Rockville, Maryland, USA
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Hickman SR, Mathieson KM, Bradford LM, Garman CD, Gregg RW, Lukens DW. Randomized trial of oral versus intravenous acetaminophen for postoperative pain control. Am J Health Syst Pharm 2018. [DOI: 10.2146/ajhp170064] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | | | | | | | | | - Douglas W. Lukens
- Kettering Medical Center System, Kettering, OH, and Fort Hamilton Hospital, Hamilton, OH
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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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Nichols DC, Nadpara PA, Taylor PD, Brophy GM. Intravenous Versus Oral Acetaminophen for Pain Control in Neurocritical Care Patients. Neurocrit Care 2017; 25:400-406. [PMID: 27351176 DOI: 10.1007/s12028-016-0289-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Acetaminophen (APAP) is used in neurocritical care (NCC) patients for analgesia without sedation or antiplatelet activity. Research suggests that intravenous (IV) APAP produces earlier and higher serum levels compared to oral (PO) APAP. This retrospective study evaluates the associated analgesic effects of IV and PO APAP and use of adjunctive opioids in NCC patients with moderate-severe pain. METHODS Patients admitted to the neuroscience intensive care unit (NSICU) between May 2012 and April 2013 who received ≥1 dose of IV APAP were included in the study. IV and PO APAP doses administered with a predose pain score ≥4 within 1 h of dosing were compared. Pain intensity difference (PID) was calculated as the change between the pain score prior to each dose and scores at 30 min, 1, 2, 3, and 6 h postdose. Pre- and postdose morphine milligram equivalents (MME) were also calculated. RESULTS 309 NSICU patients received 459 doses of IV and 440 doses of PO APAP meeting our inclusion criteria. The PID at 30 min postdosing was significantly higher among those receiving IV APAP compared to those receiving PO APAP (p = 0.003). No significant difference in PID was seen at 1, 2, 3, and 6 h; and there was no significant difference in pre- or postdose MME between the two groups. CONCLUSION IV APAP was more effective than PO APAP at relieving pain within 30 min of dosing, but this difference was not sustained over 6 h. Further studies are needed to assess the benefits of this rapid onset of action.
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Affiliation(s)
- Dan C Nichols
- Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA.,Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - Pramit A Nadpara
- Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
| | - Perry D Taylor
- Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA.,Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - Gretchen M Brophy
- Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA. .,Virginia Commonwealth University Medical Center, Richmond, VA, USA. .,Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, 410 N 12th Street, P.O. Box 980533, Richmond, VA, 23298-0533, USA.
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Turini GA, Clark MA, Machan J, Tucci C, Renzulli JF. The Role of a Standardized Clinical Care Pathway in Patient Satisfaction and Quality of Life Outcomes after Robotic Assisted Laparoscopic Radical Prostatectomy. UROLOGY PRACTICE 2017; 4:232-238. [PMID: 37592643 DOI: 10.1016/j.urpr.2016.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Clinical care pathways reduce length of stay, variability in practice and costs, yet avoid compromising quality of care or increasing complications. In this study we describe a standardized care pathway, focusing on preoperative and postoperative education as well as immediate postoperative patient care after robotic assisted laparoscopic radical prostatectomy. METHODS A standardized robotic assisted laparoscopic radical prostatectomy care pathway was introduced at our institution in July 2014. A total of 108 men who underwent robotic assisted laparoscopic radical prostatectomy during 2014 were enrolled in this retrospective chart review and were subsequently mailed a quality of life survey. Data regarding length of stay and number of unplanned calls to the urology office or visits to the emergency department were collected from the chart review. The mailed survey was composed of original questions as well as questions adapted from the FACT-P (Functional Assessment of Cancer Therapy-Prostate). Patients who underwent robotic assisted laparoscopic radical prostatectomy between January and June 2014 were compared to those who underwent the same surgery between July and December 2014. RESULTS Demographically the 2 cohorts of men who underwent robotic assisted laparoscopic radical prostatectomy were similar. There was a significant reduction in postoperative length of stay in the post-care pathway cohort. Hospital readmissions were reduced by 75%. Despite earlier discharge home, there was no difference in the number of postoperative calls to the urology office or visits to the emergency department, or in overall patient satisfaction. CONCLUSIONS The implementation of a standardized care pathway for patients undergoing robotic assisted laparoscopic radical prostatectomy at our institution resulted in a reduced postoperative length of stay and readmission rate. Despite a more rapid discharge from the hospital, patient satisfaction and postoperative quality of life were not negatively impacted.
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Affiliation(s)
- George A Turini
- Minimally Invasive Urology Institute, Miriam Hospital, Brown University, Providence, Rhode Island
| | - Melissa A Clark
- Warren Alpert School of Medicine and Brown University School of Public Health, Providence, Rhode Island
| | - Jason Machan
- Biostatistics Core Research Services, The Rhode Island Hospital, Providence, Rhode Island
| | - Christopher Tucci
- Minimally Invasive Urology Institute, Miriam Hospital, Brown University, Providence, Rhode Island
| | - Joseph F Renzulli
- Minimally Invasive Urology Institute, Miriam Hospital, Brown University, Providence, Rhode Island
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Douzjian DJ, Kulik A. Old Drug, New Route: A Systematic Review of Intravenous Acetaminophen After Adult Cardiac Surgery. J Cardiothorac Vasc Anesth 2017; 31:694-701. [DOI: 10.1053/j.jvca.2016.03.134] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Indexed: 11/11/2022]
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Altun D, Çınar Ö, Özker E, Türköz A. The effect of tramadol plus paracetamol on consumption of morphine after coronary artery bypass grafting. J Clin Anesth 2017; 36:189-193. [DOI: 10.1016/j.jclinane.2016.10.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 07/18/2016] [Accepted: 10/27/2016] [Indexed: 11/30/2022]
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Intravenous Acetaminophen for Renal Colic in the Emergency Department: Where Do We Stand? Am J Ther 2017; 24:e12-e19. [DOI: 10.1097/mjt.0000000000000526] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Gan TJ, Singla N, Daniels SE, Hamilton DA, Lacouture PG, Reyes CR, Carr DB. Postoperative opioid sparing with injectable hydroxypropyl-β-cyclodextrin-diclofenac: pooled analysis of data from two Phase III clinical trials. J Pain Res 2016; 10:15-29. [PMID: 28053554 PMCID: PMC5191619 DOI: 10.2147/jpr.s106578] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Purpose Use of nonopioid analgesics (including nonsteroidal anti-inflammatory drugs) for postoperative pain management can reduce opioid consumption and potentially prevent opioid-related adverse events. This study examined the postoperative opioid-sparing effect of repeated-dose injectable diclofenac formulated with hydroxypropyl-β-cyclodextrin (HPβCD)-diclofenac. Patients and methods Pooled data from two double-blind, randomized, placebo- and active comparator-controlled Phase III trials were analyzed. Patients received HPβCD-diclofenac, placebo, or ketorolac by intravenous injection every 6 hours for up to 5 days following abdominal/pelvic or orthopedic surgery. Rescue opioid use was evaluated from the time of first study drug administration to up to 120 hours following the first dose in the overall study population and in subgroups defined by baseline pain severity, age, and HPβCD-diclofenac dose. Results Overall, 608 patients received ≥1 dose of study medication and were included in the analysis. While 93.2% of patients receiving placebo required opioids, the proportion of patients requiring opioids was significantly lower for patients receiving HPβCD-diclofenac (18.75, 37.5, or 50 mg) or ketorolac (P<0.005 for all comparisons). Mean cumulative opioid dose and number of doses were significantly lower among patients receiving HPβCD-diclofenac versus placebo for the 0–24 through 0–120 hour time periods (P<0.0001), as well as versus ketorolac for the 0–72 through 0–120 hour time periods (P<0.05). HPβCD-diclofenac significantly reduced opioid consumption versus placebo in subgroups based on baseline pain severity (moderate, severe) and age (<65 years, ≥65 years) from the 0–24 hour period onward. When compared to ketorolac, HPβCD-diclofenac also significantly reduced cumulative opioid consumption among patients with moderate baseline pain (0–72 through 0–120 hours) and opioid dose number among patients ≥65 years old (0–24 through 0–120 hours). Conclusion HPβCD-diclofenac can reduce postoperative opioid requirements. As this analysis was not powered to compare opioid-related adverse event rates, follow-up studies examining the clinical impact of HPβCD-diclofenac’s opioid sparing are warranted.
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Affiliation(s)
- Tong J Gan
- Department of Anesthesiology, Stony Brook University, NY
| | | | | | - Douglas A Hamilton
- Javelin Pharmaceuticals, Inc., Cambridge, MA; New Biology Ventures, LLC, San Mateo, CA
| | - Peter G Lacouture
- Magidom Discovery, LLC, St Augustine, FL; Department of Emergency Medicine, Brown University School of Medicine, Providence, RI
| | | | - Daniel B Carr
- Javelin Pharmaceuticals, Inc., Cambridge, MA; Department of Anesthesiology, Tufts Medical Center, Boston, MA, USA
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Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. THE JOURNAL OF PAIN 2016; 17:131-57. [PMID: 26827847 DOI: 10.1016/j.jpain.2015.12.008] [Citation(s) in RCA: 1598] [Impact Index Per Article: 199.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 12/11/2015] [Accepted: 12/14/2015] [Indexed: 12/11/2022]
Abstract
UNLABELLED Most patients who undergo surgical procedures experience acute postoperative pain, but evidence suggests that less than half report adequate postoperative pain relief. Many preoperative, intraoperative, and postoperative interventions and management strategies are available for reducing and managing postoperative pain. The American Pain Society, with input from the American Society of Anesthesiologists, commissioned an interdisciplinary expert panel to develop a clinical practice guideline to promote evidence-based, effective, and safer postoperative pain management in children and adults. The guideline was subsequently approved by the American Society for Regional Anesthesia. As part of the guideline development process, a systematic review was commissioned on various aspects related to various interventions and management strategies for postoperative pain. After a review of the evidence, the expert panel formulated recommendations that addressed various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care. The recommendations are based on the underlying premise that optimal management begins in the preoperative period with an assessment of the patient and development of a plan of care tailored to the individual and the surgical procedure involved. The panel found that evidence supports the use of multimodal regimens in many situations, although the exact components of effective multimodal care will vary depending on the patient, setting, and surgical procedure. Although these guidelines are based on a systematic review of the evidence on management of postoperative pain, the panel identified numerous research gaps. Of 32 recommendations, 4 were assessed as being supported by high-quality evidence, and 11 (in the areas of patient education and perioperative planning, patient assessment, organizational structures and policies, and transitioning to outpatient care) were made on the basis of low-quality evidence. PERSPECTIVE This guideline, on the basis of a systematic review of the evidence on postoperative pain management, provides recommendations developed by a multidisciplinary expert panel. Safe and effective postoperative pain management should be on the basis of a plan of care tailored to the individual and the surgical procedure involved, and multimodal regimens are recommended in many situations.
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Apfel CC, Souza K, Portillo J, Dalal P, Bergese SD. Patient satisfaction with intravenous acetaminophen: a pooled analysis of five randomized, placebo-controlled studies in the acute postoperative setting. J Healthc Qual 2016; 37:155-62. [PMID: 24433365 DOI: 10.1111/jhq.12062] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Intravenous (IV) acetaminophen has been shown to reduce postoperative pain and opioid consumption, which may lead to increased patient satisfaction. To determine the effect IV acetaminophen has on patient satisfaction, a pooled analysis from methodologically homogenous studies was conducted. We obtained patient-level data from five randomized, placebo-controlled studies in adults undergoing elective surgery in which patient satisfaction was measured using a 4-point categorical rating scale. The primary endpoint was "excellent" satisfaction and the secondary endpoint was "good" or "excellent" satisfaction at 24 hr after first study drug administration. Bivariate analyses were conducted using the chi-square test and Student's t-test and multivariable analyses were conducted using logistic regression analysis. Patients receiving IV acetaminophen were more than twice as likely as those who received placebo to report "excellent" patient satisfaction ratings (32.3% vs. 15.9%, respectively). Of all variables that remained statistically significant in the multivariable analysis (i.e., type of surgery, duration of anesthesia, last pain rating, and opioid consumption), IV acetaminophen had the strongest positive effect on "excellent" patient satisfaction with an odds ratio of 2.76 (95% CI 1.81-4.23). Results for "excellent" or "good" satisfaction were similar. When given as part of a perioperative analgesic regimen, IV acetaminophen was associated with significantly improved patient satisfaction.
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Nwagbologu N, Sarangarm P, D'Angio R. Effect of Intravenous Acetaminophen on Postoperative Opioid Consumption in Adult Orthopedic Surgery Patients. Hosp Pharm 2016; 51:730-737. [PMID: 27803502 DOI: 10.1310/hpj5109-730] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background: Postoperative pain is managed with opioids, which are associated with adverse effects. The efficacy of intravenous (IV) acetaminophen in reducing opioid consumption has been studied with inconsistent results. The primary outcome of this study was to assess the effect of IV acetaminophen on opioid consumption 24 hours postoperatively. Secondary outcomes included the opiate consumption at 48 hours after the operation, opioid-related side effects 72 hours after the operation, discharge disposition, and length of stay. Methods: This was an IRB-approved, retrospective cohort study including adult patients who underwent an elective total knee arthroplasty (TKA). Patients were stratified into IV and no IV acetaminophen groups; patients who had received at least one dose of IV acetaminophen were included in the IV acetaminophen group. Total opioids were collected, converted to morphine equivalents, and compared between groups. Patients were excluded for alcohol abuse, substance abuse treatment, non-elective TKA, or medication mischarting. Results: Of the 161 patients evaluated, 148 patients were included: 86 in the IV acetaminophen and 62 in the no IV acetaminophen group. There were no differences in mean morphine equivalents between groups postoperatively at 24 hours (54.2 ± 35.9 mg vs 45.4 ± 30.2 mg; p = .12) and 48 hours (99.2 ± 68.7 mg vs 79.5 ± 49.1 mg; p = .06). There were no differences in secondary outcomes (administration of bowel regimen medications, antiemetics, naloxone, discharge disposition, or length of stay) between the groups. Conclusion: The use of IV acetaminophen was not associated with a decrease in opiate use, opiate-related side effects, or any secondary outcomes in patients who underwent TKA.
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Affiliation(s)
- Andrew Lowe
- Comprehensive Pharmacy Services Costa Mesa, CA
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Mamoun NF, Lin P, Zimmerman NM, Mascha EJ, Mick SL, Insler SR, Sessler DI, Duncan AE. Intravenous acetaminophen analgesia after cardiac surgery: A randomized, blinded, controlled superiority trial. J Thorac Cardiovasc Surg 2016; 152:881-889.e1. [PMID: 27236864 DOI: 10.1016/j.jtcvs.2016.04.078] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 03/14/2016] [Accepted: 04/23/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pain after cardiac surgery traditionally has been controlled by intravenous opioids and nonsteroidal antiinflammatory drugs. An intravenous analgesic with fewer adverse effects is needed. Therefore, we tested the primary hypothesis that intravenous acetaminophen is more effective than placebo for pain management, which was defined a priori as superior on either pain intensity score and/or opioid consumption and not worse on either. METHODS In this single-center, double-blind trial, 147 patients having cardiac surgery via median sternotomy were randomized to receive either 1 g of intravenous acetaminophen (73 patients) every 6 hours for 24 hours or comparable placebo (74 patients) starting in the operating room after sternal closure. Cumulative opioid consumption (in morphine equivalents) and pain intensity scores (on a 0-10 Numeric Rating Scale) were measured at 4, 6, 8, 12, 16, 20, and 24 hours after surgery. We estimated ratio of mean opioid consumption by using multivariable linear regression (noninferiority delta = 1.15) and pain score difference by using repeated measures regression (noninferiority delta = 1). RESULTS Acetaminophen was superior to placebo on mean pain intensity scores and noninferior on opioid consumption, with estimated difference in mean pain (95% confidence interval) of -0.90 (-1.39, -0.42), P < .001 (superior), and estimated ratio of means in opioid consumption (90% confidence interval) of 0.89 (0.73-1.10), P = .28 (noninferior; not superior). CONCLUSIONS Intravenous acetaminophen reduced pain after cardiac surgery, but not opioid consumption. Intravenous acetaminophen can be an effective analgesic adjunct in patients recovering from median sternotomy.
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Affiliation(s)
- Negmeldeen F Mamoun
- Department of Cardiothoracic Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Peirong Lin
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nicole M Zimmerman
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Edward J Mascha
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Stephanie L Mick
- Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Steven R Insler
- Department of Cardiothoracic Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Andra E Duncan
- Department of Cardiothoracic Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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Jelacic S, Bollag L, Bowdle A, Rivat C, Cain KC, Richebe P. Intravenous Acetaminophen as an Adjunct Analgesic in Cardiac Surgery Reduces Opioid Consumption But Not Opioid-Related Adverse Effects: A Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2016; 30:997-1004. [PMID: 27521969 DOI: 10.1053/j.jvca.2016.02.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The authors hypothesized that intravenous acetaminophen as an adjunct analgesic would significantly decrease 24-hour postoperative opioid consumption. DESIGN Double-blind, randomized, placebo-controlled trial. SETTING A single academic medical center. PARTICIPANTS The study was comprised of 68 adult patients undergoing cardiac surgery. INTERVENTIONS Patients were assigned randomly to receive either 1,000 mg of intravenous acetaminophen or placebo immediately after anesthesia induction, at the end of surgery, and then every 6 hours for the first 24 hours in the intensive care unit, for a total of 6-1,000 mg doses. MEASUREMENTS AND MAIN RESULTS The primary outcome was 24-hour postoperative opioid consumption. The secondary outcomes included 48-hour postoperative opioid consumption, incisional pain scores, opioid-related adverse effects, length of mechanical ventilation, length of intensive care unit stay, and the extent of wound hyperalgesia assessed at 24 and 48 hours postoperatively. The mean±standard deviation postoperative 24-hour opioid consumption expressed in morphine equivalents was significantly less in the acetaminophen group (45.6±29.5 mg) than in the placebo group (62.3±29.5 mg), representing a 27% reduction in opioid consumption (95% CI, 2.3-31.1 mg; p = 0.024). There were no differences in pain scores and opioid-related adverse effects between the 2 groups. A significantly greater number of patients in the acetaminophen group responded "very much" and "extremely well" when asked how their overall pain experience met their expectation (p = 0.038). CONCLUSIONS The administration of intravenous acetaminophen during cardiac surgery and for the first 24 hours postoperatively reduced opioid consumption and improved patient satisfaction with their overall pain experience but did not reduce opioid side effects.
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Affiliation(s)
| | | | | | - Cyril Rivat
- Department of Anesthesiology and Pain Medicine
| | - Kevin C Cain
- Biostatistics, University of Washington School of Public Health, Seattle, WA
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IV acetaminophen: Efficacy of a single dose for postoperative pain after hip arthroplasty: subset data analysis of 2 unpublished randomized clinical trials. Am J Ther 2015; 22:2-10. [PMID: 24413368 DOI: 10.1097/mjt.0000000000000026] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Inadequate control of postoperative pain after orthopedic procedures may trigger complications that increase morbidity. Multimodal analgesia is used to manage pain effectively after surgical procedures and reduce the need for rescue analgesia. Intravenous (IV) acetaminophen (OFIRMEV; Cadence Pharmaceuticals, Inc.), an analgesic that has been studied and used in the multimodal management of acute pain after major orthopedic procedures, combines the safety seen with oral and rectal formulations with a preferred route of administration. Two double-blind, randomized, placebo-controlled clinical trials were conducted (total 130 patients) to determine the efficacy and safety of single-dose IV acetaminophen in patients following total hip arthroplasty. Although both studies were stopped prematurely, overlap in patient populations, study design, and methodologies in the single-dose phase of these studies allowed for analysis of their results to be presented concurrently. Both trials demonstrated IV acetaminophen having greater efficacy than placebo in terms of primary endpoints [pain intensity differences from T0.5 to T3 (P < 0.05 in both studies)]. The use of IV acetaminophen also reduced the need for rescue opioid consumption, with patients receiving IV acetaminophen consuming, on average, less than half the amount of rescue medication as those receiving placebo. IV acetaminophen was effective in treating moderate-to-severe pain after total hip arthroplasty and reduced the need for rescue opioid consumption.
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Postoperative Critical Care of the Adult Cardiac Surgical Patient. Part I: Routine Postoperative Care. Crit Care Med 2015; 43:1477-97. [PMID: 25962078 DOI: 10.1097/ccm.0000000000001059] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Cardiac surgery, including coronary artery bypass, cardiac valve, and aortic procedures, is among the most common surgical procedures performed in the United States. Successful outcomes after cardiac surgery depend on optimum postoperative critical care. The cardiac intensivist must have a comprehensive understanding of cardiopulmonary physiology and the sequelae of cardiopulmonary bypass. In this concise review, targeted at intensivists and surgeons, we discuss the routine management of the postoperative cardiac surgical patient. DATA SOURCE AND SYNTHESIS Narrative review of relevant English-language peer-reviewed medical literature. CONCLUSIONS Critical care of the cardiac surgical patient is a complex and dynamic endeavor. Adequate fluid resuscitation, appropriate inotropic support, attention to rewarming, and ventilator management are key components. Patient safety is enhanced by experienced personnel, a structured handover between the operating room and ICU teams, and appropriate transfusion strategies.
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Jibril F, Sharaby S, Mohamed A, Wilby KJ. Intravenous versus Oral Acetaminophen for Pain: Systematic Review of Current Evidence to Support Clinical Decision-Making. Can J Hosp Pharm 2015; 68:238-47. [PMID: 26157186 DOI: 10.4212/cjhp.v68i3.1458] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Intravenous (IV) acetaminophen is increasingly used around the world for pain control for a variety of indications. However, it is unclear whether IV administration offers advantages over oral administration. OBJECTIVE To identify, summarize, and critically evaluate the literature comparing analgesic efficacy, safety, and pharmacokinetics for IV and oral dosage forms of acetaminophen. DATA SOURCES A literature search of the PubMed, Embase, and International Pharmaceutical Abstracts databases was supplemented with keyword searches of Science Direct, Wiley Library Online, and Springer Link databases for the period 1948 to November 2014. The reference lists of identified studies were searched manually. STUDY SELECTION AND DATA EXTRACTION Randomized controlled trials comparing IV and oral dosage forms of acetaminophen were included if they assessed an efficacy, safety, or pharmacokinetic outcome. For each study, 2 investigators independently extracted data (study design, population, interventions, follow-up, efficacy outcomes, safety outcomes, pharmacokinetic outcomes, and any other pertinent information) and completed risk-of-bias assessments. DATA SYNTHESIS Six randomized clinical trials were included. Three of the studies reported outcomes pertaining to efficacy, 4 to safety, and 4 to pharmacokinetics. No clinically significant differences in efficacy were found between the 2 dosage forms. Safety outcomes were not reported consistently enough to allow adequate assessment. No evidence was found to suggest that increased bioavailability of the IV formulation enhances efficacy outcomes. For studies reporting clinical outcomes, the results of risk-of-bias assessments were largely unclear. CONCLUSIONS For patients who can take an oral dosage form, no clear indication exists for preferential prescribing of IV acetaminophen. Decision-making must take into account the known adverse effects of each dosage form and other considerations such as convenience and cost. Future studies should assess multiple-dose regimens over longer periods for patients with common pain indications such as cancer, trauma, and surgery.
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Affiliation(s)
- Farah Jibril
- BSc(Pharm), PharmD, is a Clinical Pharmacist at the National Center for Cancer Care and Research, Doha, Qatar
| | - Sherif Sharaby
- Sherif Sharaby, BSc(Pharm), is a Pharmacist with the San Joaquin Valley Rehabilitation Hospital, Fresno, California
| | - Ahmed Mohamed
- BSc(Pharm), PhD, is an Assistant Professor with the College of Pharmacy, Qatar University, Doha, Qatar
| | - Kyle J Wilby
- BSP, ACPR, PharmD, is an Assistant Professor - Clinical Pharmacy and Practice, College of Pharmacy, Qatar University, Doha, Qatar
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Minimize the risk of chronic pain after cardiac surgery by treating acute postoperative pain. DRUGS & THERAPY PERSPECTIVES 2015. [DOI: 10.1007/s40267-015-0191-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Messerer B, Grögl G, Stromer W, Jaksch W. [Pediatric perioperative systemic pain therapy: Austrian interdisciplinary recommendations on pediatric perioperative pain management]. Schmerz 2015; 28:43-64. [PMID: 24550026 DOI: 10.1007/s00482-013-1384-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Many analgesics used in adult medicine are not licensed for pediatric use. Licensing limitations do not, however, justify that children are deprived of a sufficient pain therapy particularly in perioperative pain therapy. The treatment is principally oriented to the strength of the pain. Due to the degree of pain caused, intramuscular and subcutaneous injections should be avoided generally. NON-OPIOIDS The basis of systemic pain therapy for children are non-opioids and primarily non-steroidal anti-inflammatory drugs (NSAIDs). They should be used prophylactically. The NSAIDs are clearly more effective than paracetamol for acute posttraumatic and postoperative pain and additionally allow economization of opioids. Severe side effects are rare in children but administration should be carefully considered especially in cases of hepatic and renal dysfunction or coagulation disorders. Paracetamol should only be taken in pregnancy and by children when there are appropriate indications because a possible causal connection with bronchial asthma exists. To ensure a safe dosing the age, body weight, duration of therapy, maximum daily dose and dosing intervals must be taken into account. Dipyrone is used in children for treatment of visceral pain and cholic. According to the current state of knowledge the rare but severe side effect of agranulocytosis does not justify a general rejection for short-term perioperative administration. OPIOIDS In cases of insufficient analgesia with non-opioid analgesics, the complementary use of opioids is also appropriate for children of all age groups. They are the medication of choice for episodes of medium to strong pain and are administered in a titrated form oriented to effectiveness. If severe pain is expected to last for more than 24 h, patient-controlled anesthesia should be implemented but requires a comprehensive surveillance by nursing personnel. KETAMINE Ketamine is used as an adjuvant in postoperative pain therapy and is recommended for use in pediatric sedation and analgosedation.
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Affiliation(s)
- B Messerer
- Universitätsklinik für Anästhesiologie und Intensivmedizin, Medizinische Universität Graz, LKH-Universitätsklinikum Graz, Auenbruggerplatz 29, 8036, Graz, Österreich,
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