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Irechukwu JC, Eleje GU, Iwe BC, Ikpeze OC, Ikeotuonye AC, Ede EE, Okafor CC, Malachy DE, Okafor CG. A randomized controlled trial of rectal versus intramuscular diclofenac for post-operative analgesia after open myomectomy. Eur J Obstet Gynecol Reprod Biol 2024; 292:244-250. [PMID: 38043222 DOI: 10.1016/j.ejogrb.2023.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 10/25/2023] [Accepted: 11/21/2023] [Indexed: 12/05/2023]
Abstract
AIM To determine the efficacy and safety of rectal versus intramuscularly administered Diclofenac in reducing post-operative pain in the first 24 h after open-myomectomy. METHODS A single blind, placebo controlled randomized trial consisting of 90 consenting women that had open-abdominal-myomectomy. They were randomized into two-groups (rectal-group and intramuscular-group) of 45 women (1:1 ratio). Rectal-group received 75 mg of Diclofenac suppository 12 hourly for 24 h and placebo (3 ml of intramuscular injection-water) 12hourly for 24 h while intramuscular-group received intramuscular Diclofenac 75 mg 12 hourly for 24 h and placebo (Anusol suppository) 12 hourly for 24 h. Both groups received intramuscular Pentazocine 30 mg 6 hourly for 24 h as primary analgesic after myomectomy. Pain was assessed using a Ten-Point Visual-Analogue-Scale. Participants' satisfaction of the mode of the pain relief was assessed using the Likert-scale after 24 h. The primary outcome was the pain score using the visual-analogue-scale. The secondary outcome-measures were participants' satisfaction after 24 h of administration of the drugs, the need and frequency of rescue-analgesia and maternal-side-effects. RESULT The baseline socio-demographic characteristics were similar in both groups. There was no statistically significant difference between both groups in pain assessment at 1 h post-myomectomy (p-value > 0.05). However, the pain assessments at 6, 12, 18 and 24 h post-myomectomy were statistically significant with more pain in intramuscular-group when compared to rectal-group. Majority of participants in rectal-group were both very satisfied (35.6 %) and satisfied (55.6 %) when compared to intramuscular-group (11.1 %) and (31,1%) respectively (p-value < 0.05). Also majority of the participants in intramuscular-group were dissatisfied (17.8 %) with none of the participant showing any form of dissatisfaction (p-value < 0.05). Majority of the participant in rectal-group had no drug side effects when compared with intramuscular-group. Epigastric discomfort was commoner in rectal-group while drowsiness was commoner in intramuscular-group. CONCLUSION Rectal Diclofenac with intramuscular Pentazocine is significantly associated with better effectiveness in pain reduction and maternal satisfaction when compared with intramuscular Diclofenac and intramuscular Pentazocine following open-myomectomy. While epigastric discomfort was the commonest side-effect in rectal-group, drowsiness was commoner in intramuscular-group. TRIAL REGISTRATION Pan-African-clinical-trial-registry (PACTR); PACTR202206556144219.
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Affiliation(s)
- John C Irechukwu
- Department of Obstetrics and Gynaecology, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
| | - George U Eleje
- Effective Care Research Units, Department of Obstetrics and Gynaecology, Nnamdi, Azikiwe University, Nnewi Campus, Nigeria; Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | - Bobbie C Iwe
- Department of Obstetrics and Gynaecology, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
| | - Okechukwu C Ikpeze
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | - Arinze C Ikeotuonye
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | - Eziaha E Ede
- Department of Obstetrics and Gynaecology, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
| | - Chidinma C Okafor
- Department of Psychiatry, Leicestershire Partnership NHS Trust, Leicester, United Kingdom
| | - Divinefavour E Malachy
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | - Chigozie G Okafor
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria.
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Analgesia for Gynecologic Oncologic Surgeries: A Narrative Review. Curr Pain Headache Rep 2022; 26:1-13. [PMID: 35118596 DOI: 10.1007/s11916-022-00998-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Gynecologic oncologic malignancies are amongst the most common cancers affecting women across the world. This narrative review focuses on the current state of evidence around optimal perioperative pain management of patients undergoing surgeries for gynecologic malignancies with a specific focus on cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). RECENT FINDINGS Recent improvements in postoperative pain management following all types of gynecologic procedures, including minimally invasive, open-abdominal, or CRS + HIPEC, have been implemented through enhanced recovery after surgery (ERAS) protocols. These protocols encompass the use of preemptive analgesia, neuraxial and regional techniques, local anesthetic infiltration, and multimodal analgesia. The severity of postoperative pain varies for minimally invasive cancer surgery to open debulking procedures. Therefore, an individualized perioperative analgesic plan is critical depending on the surgical approach. For CRS + HIPEC, neuraxial techniques such as thoracic epidurals and opioid sparing multimodal analgesics have shown efficacy in the perioperative period. However, future research is needed as many of these patients develop chronic pain with very limited research done in this realm.
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Cheung CK, Adeola JO, Beutler SS, Urman RD. Postoperative Pain Management in Enhanced Recovery Pathways. J Pain Res 2022; 15:123-135. [PMID: 35058714 PMCID: PMC8765537 DOI: 10.2147/jpr.s231774] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/30/2021] [Indexed: 12/05/2022] Open
Abstract
Postoperative pain is a common but often inadequately treated condition. Enhanced recovery pathways (ERPs) are increasingly being utilized to standardize perioperative care and improve outcomes. ERPs employ multimodal postoperative pain management strategies that minimize opioid use and promote recovery. While traditional opioid medications continue to play an important role in the treatment of postoperative pain, ERPs also rely on a wide range of non-opioid pharmacologic therapies as well as regional anesthesia techniques to manage pain in the postoperative setting. The evidence for the use of these interventions continues to evolve rapidly given the increasing focus on enhanced postoperative recovery. This article reviews the current evidence and knowledge gaps pertaining to commonly utilized modalities for postoperative pain management in ERPs.
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Affiliation(s)
- Christopher K Cheung
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Janet O Adeola
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Sascha S Beutler
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Mulita F, Verras GI, Iliopoulos F, Kaplanis C, Liolis E, Tchabashvili L, Tsilivigkos C, Perdikaris I, Sgourou A, Papachatzopoulou A, Maroulis I. Analgesic effect of paracetamol monotherapy vs. the combination of paracetamol/parecoxib vs. the combination of pethidine/paracetamol in patients undergoing thyroidectomy. PRZEGLAD MENOPAUZALNY = MENOPAUSE REVIEW 2021; 20:226-230. [PMID: 35069077 PMCID: PMC8764955 DOI: 10.5114/pm.2021.110955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 06/19/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The purpose of this study was to investigate the analgesic effect of 3 different regimens of combination analgesics administered to patients undergoing thyroidectomy. MATERIAL AND METHODS A total of 152 patients undergoing total or subtotal thyroidectomy were enrolled. Patients allocated to group A received a combination of intravenous (IV) paracetamol and intramuscular (IM) pethidine, patients in group B received a combination of IV paracetamol and IV parecoxib, while patients in group C received IV paracetamol monotherapy. RESULTS The analgesic regimens of groups A and B were found to be of equivalent efficacy (p-value = 1.000). In contrast, patients in group C (paracetamol monotherapy) had higher numerical rating scale scores, compared to both patients in groups A (p-value < 0.001) and B (p-value < 0.001). CONCLUSIONS The combinations of IV paracetamol with either IM pethidine or IV parecoxib are superior to IV paracetamol monotherapy in achieving pain control in patients undergoing thyroid surgery.
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Affiliation(s)
- Francesk Mulita
- Department of Surgery, General University Hospital of Patras, Greece
- Corresponding author: Francesk Mulita, MD, Department of Surgery, General University Hospital of Patras, Greece, e-mail:
| | | | - Fotios Iliopoulos
- Department of Surgery, General University Hospital of Patras, Greece
| | | | - Elias Liolis
- Department of Internal Medicine, Division of Oncology, General University Hospital of Patras, Greece
| | | | | | | | - Argyro Sgourou
- Biology Laboratory, School of Science and Technology, Hellenic Open University, Patras, Greece
| | | | - Ioannis Maroulis
- Department of Surgery, General University Hospital of Patras, Greece
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Mulita F, Parchas N, Solou K, Tchabashvili L, Gatomati F, Iliopoulos F, Maroulis I. Postoperative Pain Scores After Open Inguinal Hernia Repair: Comparison of Three Postoperative Analgesic Regimens. Med Arch 2020; 74:355-358. [PMID: 33424089 PMCID: PMC7780791 DOI: 10.5455/medarh.2020.74.355-358] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Pain management after open inguinal hernia repair has become an issue that physicians deal with on a daily basis. AIM The purpose of this study was to investigate the analgesic effect of three different regimens of analgesics administered to patients undergoing open inguinal hernia repair. METHODS A total of 259 patients undergoing open inguinal hernia repair were enrolled. Patients were randomly allocated to one of three groups on admission, which would determine the prescribed post-operative analgesic regimen. Patients allocated to group A receiving a combination of 1gr/8hours intravenous (IV) acetaminophen and 50mg/6hours intramuscular (IM) pethidine, patients in group B receiving a combination of 1gr/8hours IV acetaminophen and 40mg/12hours IV parecoxib, while patients of group C received 1gr/8hours IV acetaminophen monotherapy. All patients remained overnight at the hospital and discharged the day after. Analgesic therapy was administered at regular intervals. Pain was evaluated utilizing the numeric rating scale (NRS) at 5 time points: the first assessment was done at 45 minutes, the second at 2 hours, the third at 6 hours, the fourth at 12 hours and the fifth at 24 hours post-administration. The postoperative pain intensities measured by NRS within groups and between groups at each time were analyzed using one-way repeat measured ANOVA and Post Hoc Test-Bonferroni Correlation. RESULTS The analgesic regimens of groups A and B (combination regimens consisting of IV acetaminophen and intramuscular pethidine and IV acetaminophen and IV parecoxib, respectively) were found to be of equivalent efficacy (P-value=1.000). In contrast, patients in group C (acetaminophen monotherapy) had higher NRS scores, compared to both patients in groups A (P-value<0.0001) and B (P-value<0.0001). CONCLUSION The combinations of IV acetaminophen with either intramuscular pethidine or IV parecoxib are superior to IV acetaminophen monotherapy in achieving pain control in patients undergoing open inguinal hernia repair.
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Affiliation(s)
- Francesk Mulita
- Department of Surgery, General University Hospital of Patras, Greece
| | - Nikolaos Parchas
- Department of Orthopedics, General University Hospital of Patras, Greece
| | - Konstantina Solou
- Department of Orthopedics, General University Hospital of Patras, Greece
| | | | | | - Fotios Iliopoulos
- Department of Surgery, General University Hospital of Patras, Greece
| | - Ioannis Maroulis
- Department of Surgery, General University Hospital of Patras, Greece
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Perioperative Opioid-sparing Strategies: Utility of Conventional NSAIDs in Adults. Clin Ther 2019; 41:2612-2628. [DOI: 10.1016/j.clinthera.2019.10.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 10/03/2019] [Accepted: 10/09/2019] [Indexed: 12/17/2022]
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Rashwan D, Fathy El-Rahmawy G. Multimodal analgesia after upper limb orthopedic surgeries: Patient controlled intravenous low dose tramadol analgesia with or without intravenous acetaminophen – A comparative study. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2013.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Doaa Rashwan
- Anesthesia Department, Faculty of Medicine , Beni Sueif University , Egypt
| | - Ghada Fathy El-Rahmawy
- Anesthesia and Surgical Intensive Care Department, Faculty of Medicine , EL Mansoura University Hospital , Egypt
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Patel MK, Ekka M, Ekka S, Dalai H, Pujahari PS. A COMPARATIVE STUDY OF PREEMPTIVE ANALGESIC PROPERTY OF INTRAVENOUS PARACETAMOL AND DICLOFENAC SODIUM. ACTA ACUST UNITED AC 2018. [DOI: 10.18410/jebmh/2018/97] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Preemptive analgesia for postoperative hysterectomy pain control: systematic review and clinical practice guidelines. Am J Obstet Gynecol 2017; 217:303-313.e6. [PMID: 28351670 DOI: 10.1016/j.ajog.2017.03.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 03/07/2017] [Accepted: 03/13/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The objective of the study was to investigate the effectiveness of preemptive analgesia at pain control in women undergoing total abdominal hysterectomy. DATA SOURCES Eligible studies, published through May 31, 2016, were retrieved through Medline, Cochrane Central Register for Controlled Trials, and Cochrane Database of Systematic Reviews. STUDY ELIGIBILITY We included randomized controlled trials with the primary outcome of pain control in women receiving a preemptive medication prior to total abdominal hysterectomy. Comparators were placebo, different doses of the same medication as intervention, or other nonnarcotic or narcotic medication. STUDY APPRAISAL AND SYNTHESIS METHODS Study data were extracted by one reviewer and confirmed by a second reviewer. For each outcome we graded the quality of the evidence. Studies were classified by the type of medication used and by outcome type. RESULTS Eighty-four trials met eligibility, with 69 included. Among nonnarcotic medications, paracetamol, gabapentin, and rofecoxib combined with gabapentin resulted in improvements in pain assessment compared with placebo and other nonnarcotic medications. Patient satisfaction was higher in patients who were given gabapentin combined with paracetamol compared with gabapentin alone. Use of preemptive paracetamol, gabapentin, bupivacaine, and phenothiazine resulted in less narcotic usage than placebo. All narcotics (ketamine, morphine, fentanyl) resulted in improved pain control compared with placebo. Narcotics had a greater reduction in pain assessment scores compared with nonnarcotics, and their use resulted in lower total narcotic usage. CONCLUSION Preemptive nonnarcotic and narcotic medications prior to abdominal hysterectomy decrease total narcotic requirements and improve patient postoperative pain assessment and satisfaction scores.
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Butler K, Yi J, Wasson M, Klauschie J, Ryan D, Hentz J, Cornella J, Magtibay P, Kho R. Randomized controlled trial of postoperative belladonna and opium rectal suppositories in vaginal surgery. Am J Obstet Gynecol 2017; 216:491.e1-491.e6. [PMID: 28040448 DOI: 10.1016/j.ajog.2016.12.032] [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] [Received: 08/31/2016] [Revised: 11/03/2016] [Accepted: 12/22/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND After vaginal surgery, oral and parenteral narcotics are used commonly for pain relief, and their use may exacerbate the incidence of sedation, nausea, and vomiting, which ultimately delays convalescence. Previous studies have demonstrated that rectal analgesia after surgery results in lower pain scores and less intravenous morphine consumption. Belladonna and opium rectal suppositories may be used to relieve pain and minimize side effects; however, their efficacy has not been confirmed. OBJECTIVE We aimed to evaluate the use of belladonna and opium suppositories for pain reduction in vaginal surgery. MATERIALS AND METHODS A prospective, randomized, double-blind, placebo-controlled trial that used belladonna and opium suppositories after inpatient or outpatient vaginal surgery was conducted. Vaginal surgery was defined as (1) vaginal hysterectomy with uterosacral ligament suspension or (2) posthysterectomy prolapse repair that included uterosacral ligament suspension and/or colporrhaphy. Belladonna and opium 16A (16.2/60 mg) or placebo suppositories were administered rectally immediately after surgery and every 8 hours for a total of 3 doses. Patient-reported pain data were collected with the use of a visual analog scale (at 2, 4, 12, and 20 hours postoperatively. Opiate use was measured and converted into parenteral morphine equivalents. The primary outcome was pain, and secondary outcomes included pain medication, antiemetic medication, and a quality of recovery questionnaire. Adverse effects were surveyed at 24 hours and 7 days. Concomitant procedures for urinary incontinence or pelvic organ prolapse did not preclude enrollment. RESULTS Ninety women were randomly assigned consecutively at a single institution under the care of a fellowship-trained surgeon group. Demographics did not differ among the groups with mean age of 55 years, procedure time of 97 minutes, and prolapse at 51%. Postoperative pain scores were equivalent among both groups at each time interval. The belladonna and opium group used a mean of 57 mg morphine compared with 66 mg for placebo (P=.43) in 24 hours. Patient satisfaction with recovery was similar (P=.59). Antiemetic and ketorolac use were comparable among groups. Subgroup analyses of patients with prolapse and patients <50 years old did not reveal differences in pain scores. The use of belladonna and opium suppositories was uncomplicated, and adverse effects, which included constipation and urinary retention, were similar among groups. CONCLUSION Belladonna and opium suppositories are safe for use after vaginal surgery. Belladonna and opium suppositories did not reveal lower pain or substantially lower narcotic use. Further investigation may be warranted to identify a population that may benefit optimally from belladonna and opium use.
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Bakhsha F, Niaki AS, Jafari SY, Yousefi Z, Aryaie M. The Effects of Diclofenac Suppository and Intravenous Acetaminophen and their Combination on the Severity of Postoperative Pain in Patients Undergoing Spinal Anaesthesia During Cesarean Section. J Clin Diagn Res 2016; 10:UC09-12. [PMID: 27630929 DOI: 10.7860/jcdr/2016/15093.8120] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 12/03/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The main tasks of postoperative care are postoperative pain and complications control which play an important role in accelerating the recovery of patient's general condition. AIM This study was performed in order to compare the effects of diclofenac suppository, intravenous acetaminophen and their combination on the severity of postoperative pain in patients undergoing spinal anaesthesia for cesarean section in Sayyad Shirazi teaching Hospital, Gorgon, Iran. MATERIALS AND METHODS This was a double-blind clinical trial on 90 patients undergoing cesarean section. The patients were randomly divided into three groups, group A: 100 mg diclofenac suppository, group B: 1000 mg intravenous acetaminophen, group C: 100 mg diclofenac suppository and 500 mg intravenous acetaminophen. The same spinal anaesthesia circumstances were applied for all the participants. At the end of surgery, pain severity was assessed according to VAS scale at different times. Data were then analysed by SPSS 18 statistical software. RESULTS The mean age of participants was (28.27±6.07). There was significant difference between the mean pain scores of the three groups before the intervention (p=0.018), which was considered as co-variate. This difference was more notable between the combination of acetaminophen - diclofenac group and diclofenac alone. After the intervention, significant difference was observed in mean pain severity between acetaminophen group and the combination group and also between diclofenac and the combination group. During the study, the least mean pain severity was found in the combination group and the highest was observed in the diclofenac group. CONCLUSION Results of this study indicates a significant effect of concomitant use of intravenous acetaminophen and diclofenac suppository on pain severity reduction and reducing the need for repeated doses of narcotics and prolonging the postoperative analgesia.
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Affiliation(s)
- Fozieh Bakhsha
- Lecturer, Department of Anesthesia, Laboratory Sciences Research Center, Golestan University of Medical Sciences , Gorgan, Iran
| | - Alireza Seyedi Niaki
- Anesthesiologist, Department of Anesthesia, Sayad Shirazi Medical & Education Center, Golestan Unaiversity of Medical Sciences , Gorgan, IR Iran
| | - Seyed Yaghoub Jafari
- Lecturer, Department of Anesthesia, Laboratory Sciences Research Center, Golestan University of Medical Sciences , Gorgan, Iran
| | - Zahra Yousefi
- Lecturer, Department of Nursing, Laboratory Sciences Research Center, Golestan University of Medical Sciences , Gorgan, Iran
| | - Mohammad Aryaie
- Lecturer, Department of Epidemiology, Health Management and Social Development Research Center, Golestan University of Medical Sciences , Gorgan, Iran
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Abstract
Acute pain management is improving steadily over the past few years, but training and professional education are still lacking in many professions. Untreated or undertreated acute pain could have detrimental effects on the patient in terms of comfort and recovery from trauma or surgery. Acute undertreated pain can decrease a patient's vascular perfusion, increase oxygen demand, suppress the immune system, and possibly risk increased incidence of venous thrombosis. Although acute postoperative pain needs to be managed aggressively, patients are most vulnerable during this period for developing adverse effects, and therefore, patient assessment and careful drug therapy evaluation are necessary processes in therapeutic planning. Acute pain management requires careful and thorough initial assessment and follow-up reassessment in addition to frequent dosage adjustments, and managing analgesic induced side effects. Analgesic selection and dosing must be based on the patient's past and recent analgesic exposure. There is no single acute pain management regimen that is suitable for all patients. Analgesics must be tailored to the individual patient.
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Affiliation(s)
- Peter J. S. Koo
- Departments of Clinical Pharmacy and Pharmaceutical Services, University of California, San Francisco, San Francisco, California
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Pal A, Biswas J, Mukhopadhyay P, Sanyal P, Dasgupta S, Das S. Diclofenac is more effective for post-operative analgesia in patients undergoing lower abdominal gynecological surgeries: A comparative study. Anesth Essays Res 2015; 8:192-6. [PMID: 25886225 PMCID: PMC4173621 DOI: 10.4103/0259-1162.134502] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Aim: The present study aimed to compare the efficacy of injectable diclofenac intramuscularly (IM), injection paracetamol intravenously (IV), or a combination of both to provide post-operative analgesia in patients undergoing lower abdominal gynecological surgeries. Materials and Methods: A total of 90 female patients (American Society of Anesthesiologists I and II), aged 20-50 years, scheduled for elective total abdominal hysterectomy with or without bilateral salpingo-oophorectomy were randomized to receive 75 mg diclofenac IM 8 hourly (Group D) or 1 g paracetamol IV 8 hourly (Group P) or a combination of both 8 hourly (Group PD) for 24 h post-operative period from the start of surgery. The primary outcome measured was the requirement of rescue analgesic (tramadol), the secondary outcomes measured included visual analog score (VAS) for pain, time until first rescue analgesic administration, patient satisfaction score and any side effects. Results: The requirement of rescue analgesic was significantly lower in Groups D and PD compared to Group P. Mean (standard deviation) tramadol requirement during 24 h was 56.67 (62.60) mg, 20.00 (40.68) mg and 20.00 (40.68) mg in the Groups P, D and PD respectively. Less number of patients in Groups D and PD (20% in both the groups) required rescue analgesic compared to Group P (50%). The VAS showed a significant decrease in Groups D and PD compared to Group P between 4 and 12 h post-operatively. However, Group PD showed no significant difference when compared to Group D alone. Conclusion: Injection diclofenac IM is more effective than paracetamol IV in terms of rescue analgesic requirement, but the combination of diclofenac IM and paracetamol IV provides no added advantage over diclofenac IM alone.
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Affiliation(s)
- Anirban Pal
- Department of Anaesthesiology, Calcutta National Medical College and Hospital, Kolkatta, West Bengal, India
| | - Jhuma Biswas
- Department of Obstetrics and Gynecology, Bankura Sammilani Medical College and Hospital, Bankura, West Bengal, India
| | - Purnava Mukhopadhyay
- Department of Anaesthesiology, Calcutta National Medical College and Hospital, Kolkatta, West Bengal, India
| | - Poushali Sanyal
- Department of Obstetrics and Gynecology, Institute of Postgraduate Medical Education and Research, Kolkatta, West Bengal, India
| | - Shyamal Dasgupta
- Department of Obstetrics and Gynecology, North Bengal Medical College and Hospital, Darjeeling, West Bengal, India
| | - Shyamashis Das
- Department of Rheumatology, North Bengal Medical College and Hospital, Darjeeling, West Bengal, India
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Abstract
Studies on enhanced recovery after gynecological surgery are limited but seem to report outcome benefits similar to those reported after colorectal surgery. Regional anesthesia is recommended in enhanced recovery protocols. Effective regional anesthetic techniques in gynecologic surgery include spinal anesthesia, epidural analgesia, transversus abdominis plane blocks, local anesthetic wound infusions and intraperitoneal instillation catheters. Non-opioid analgesics including pregabalin, gabapentin, NSAIDs, COX-2 inhibitors, and paracetamol reduce opioid consumption after surgery. This population is at high risk for PONV, thus, a multimodal anti-emetic strategy must be employed, including strategies to reduce the baseline risk of PONV in conjunction with combination antiemetic therapy.
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Affiliation(s)
- Jeanette R Bauchat
- Northwestern University, Feinberg School of Medicine, 250 East Huron Street, F5-704, Chicago, IL 60611, USA
| | - Ashraf S Habib
- Duke University Medical Center, Box 3094, Durham, NC 27710, USA.
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Coetzee JF. Safety of pain control with morphine: new (and old) aspects of morphine pharmacokinetics and pharmacodynamics. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2010.10872660] [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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Palmer P, Ji X, Stephens J. Cost of opioid intravenous patient-controlled analgesia: results from a hospital database analysis and literature assessment. CLINICOECONOMICS AND OUTCOMES RESEARCH 2014; 6:311-8. [PMID: 25018642 PMCID: PMC4073913 DOI: 10.2147/ceor.s64077] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Intravenous patient-controlled analgesia (PCA) equipment and opioid cost analyses on specific procedures are lacking. This study estimates the intravenous PCA hospital cost for the first 48 postoperative hours for three inpatient surgeries. Methods Descriptive analyses using the Premier database (2010–2012) of more than 500 US hospitals were conducted on cost (direct acquisition and indirect cost for the hospital, such as overhead, labor, pharmacy services) of intravenous PCA after total knee/hip arthroplasty (TKA/THA) or open abdominal surgery. Weighted average cost of equipment and opioid drug and the literature-based cost of adverse events and complications were aggregated for total costs. Results Of 11,805,513 patients, 272,443 (2.3%), 139,275 (1.2%), and 195,062 (1.7%) had TKA, THA, and abdominal surgery, respectively, with approximately 20% of orthopedic and 29% of abdominal patients having specific intravenous PCA database cost entries. Morphine (57%) and hydromorphone (44%) were the most frequently used PCA drugs, with a mean cost per 30 cc syringe of $16 (30 mg) and $21 (6 mg), respectively. The mean number of syringes used for morphine and hydromorphone in the first 48 hours were 1.9 and 3.2 (TKA), 2.0 and 4.2 (THA), and 2.5 and 3.9 (abdominal surgery), respectively. Average costs of PCA pump, intravenous tubing set, and drug ranged from $46 to $48, from $20 to $22, and from $33 to $46, respectively. Pump, tubing, and saline required to maintain patency of the intravenous PCA catheter over 48 hours ranged from $9 to $13, from $8 to $9, and from $20 to $22, respectively. Supplemental non-PCA opioid use ranged from $56 for THA to $87 for abdominal surgery. Aggregated mean intravenous PCA equipment and opioid cost per patient were $196 (THA), $204 (TKA), and $243 (abdominal surgery). Total costs, including for adverse events, complications, and intravenous PCA errors, ranged from $647 to $694. Conclusion Although there is variation between different types of surgery, the hospital cost of intravenous PCA after major surgery is substantial. Novel technology should demonstrate cost-effectiveness in addition to clinical superiority.
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Affiliation(s)
| | - Xiang Ji
- Pharmerit International, Bethesda, MD, USA
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Wen Y, Wang M, Yang J, Wang Y, Sun H, Zhao J, Liu W, Zhou Z, Deng H, Castillo-Pedraza C, Zhang Y, Candiotti KA. A Comparison of Fentanyl and Flurbiprofen Axetil on Serum VEGF-C, TNF-α, and IL-1ß Concentrations in Women Undergoing Surgery for Breast Cancer. Pain Pract 2014; 15:530-7. [PMID: 24807396 DOI: 10.1111/papr.12206] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 02/26/2014] [Indexed: 12/23/2022]
Affiliation(s)
- Yiyun Wen
- Department of Anesthesiology; Hunan Provincial Tumor Hospital; The Affiliated Tumor Hospital of Xiangya Medical School of Central South University; Changsha China
| | - Mingde Wang
- Department of Anesthesiology; Hunan Provincial Tumor Hospital; The Affiliated Tumor Hospital of Xiangya Medical School of Central South University; Changsha China
| | - Jinfeng Yang
- Department of Anesthesiology; Hunan Provincial Tumor Hospital; The Affiliated Tumor Hospital of Xiangya Medical School of Central South University; Changsha China
| | - Yichun Wang
- Department of ICU; Hunan Provincial Tumor Hospital; The Affiliated Tumor Hospital of Xiangya Medical School of Central South University; Changsha China
| | - Huiping Sun
- Department of Anesthesiology; Hunan Provincial Tumor Hospital; The Affiliated Tumor Hospital of Xiangya Medical School of Central South University; Changsha China
| | - Jianghong Zhao
- Department of Anesthesiology; Hunan Provincial Tumor Hospital; The Affiliated Tumor Hospital of Xiangya Medical School of Central South University; Changsha China
| | - Weizhen Liu
- Department of Anesthesiology; Hunan Provincial Tumor Hospital; The Affiliated Tumor Hospital of Xiangya Medical School of Central South University; Changsha China
| | - Zhengyu Zhou
- The Care Central of Breast Cancer; Hunan Provincial Tumor Hospital; The Affiliated Tumor Hospital of Xiangya Medical School of Central South University; Changsha China
| | - Hongwu Deng
- The Care Central of Breast Cancer; Hunan Provincial Tumor Hospital; The Affiliated Tumor Hospital of Xiangya Medical School of Central South University; Changsha China
| | - Catalina Castillo-Pedraza
- Department of Anesthesiology; Perioperative Medicine and Pain Management; University of Miami - Miller School of Medicine; Miami Florida U.S.A
| | - Yi Zhang
- The Care Central of Breast Cancer; Hunan Provincial Tumor Hospital; The Affiliated Tumor Hospital of Xiangya Medical School of Central South University; Changsha China
| | - Keith A. Candiotti
- Department of Anesthesiology; Perioperative Medicine and Pain Management; University of Miami - Miller School of Medicine; Miami Florida U.S.A
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Ebrahim AJ, Mozaffar R, Nadia BH, Ali J. Early post-operative relief of pain and shivering using diclofenac suppository versus intravenous pethidine in spinal anesthesia. J Anaesthesiol Clin Pharmacol 2014; 30:243-7. [PMID: 24803766 PMCID: PMC4009648 DOI: 10.4103/0970-9185.130038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Pain and shivering are two challenging components in the post operative period. Many drugs were used for prevention and treatment of them. The aim of this study was to compare the effects of prophylactic prescription of diclofenac suppository versus intravenous (IV) pethidine in spinal anesthesia. Materials and Methods: We conducted a multi central, prospective, double-blind, randomized clinical trial on a total of 180 patients who were scheduled for surgery under spinal anesthesia including 60 patients in three groups. Patients were randomly allocated to receive 100 mg sodium diclofenac suppository or 30 mg IV pethidine or placebo. Categorical and continuous variables were analyzed by Chi-square test, t-test, Mann-Whitney and ANOVA or Kruskal-Wallis tests. Results: There was no statistical difference with regard to patient characteristics and hemodynamic indices among the three groups. Nine (15%), 10 (16.65%) and 24 (40%) of patients in diclofenac, pethidine and control groups reported pain and 2, 2, 7 patients received treatment due to it, respectively (P = 0.01). Prevalence of shivering in pethidine group and diclofenac group was the same and both of them were different from the control group (P < 0.001). Pruritus was repetitive in the pethidine group and was statistically significant (P = 0.036) but, post-operative nausea and vomiting was not significantly different among groups. Conclusion: A single dose of sodium diclofenac suppository can provide satisfactory analgesia immediately after surgery and decrease shivering without remarkable complications. This investigation highlights the role of pre-operative administration of a single dose of rectal diclofenac as a sole analgesic for early post-operative period.
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Affiliation(s)
- Ali Janpour Ebrahim
- Department of Anaesthesiology and Intensive Care, Babol University of Medical Sciences, Babol, Iran
| | - Rabiee Mozaffar
- Department of Anaesthesiology and Intensive Care, Babol University of Medical Sciences, Babol, Iran
| | - Bani-Hashem Nadia
- Department of Anaesthesiology and Intensive Care, Babol University of Medical Sciences, Babol, Iran
| | - Jabbari Ali
- Department of Anaesthesiology and Intensive Care, Babol University of Medical Sciences, Babol, Iran ; Department of Anaesthesiology and Intensive Care, Golestan University of Medical Sciences, Golestan, Iran
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Sanchez-Covarrubias L, Slosky LM, Thompson BJ, Zhang Y, Laracuente ML, DeMarco KM, Ronaldson PT, Davis TP. P-glycoprotein modulates morphine uptake into the CNS: a role for the non-steroidal anti-inflammatory drug diclofenac. PLoS One 2014; 9:e88516. [PMID: 24520393 PMCID: PMC3919782 DOI: 10.1371/journal.pone.0088516] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 01/07/2014] [Indexed: 02/06/2023] Open
Abstract
Our laboratory has previously demonstrated that peripheral inflammatory pain (PIP), induced by subcutaneous plantar injection of λ-carrageenan, results in increased expression and activity of the ATP-dependent efflux transporter P-glycoprotein (P-gp) that is endogenously expressed at the blood-brain barrier (BBB). The result of increased P-gp functional expression was a significant reduction in CNS uptake of morphine and, subsequently, reduced morphine analgesic efficacy. A major concern in the treatment of acute pain/inflammation is the potential for drug-drug interactions resulting from P-gp induction by therapeutic agents co-administered with opioids. Such effects on P-gp activity can profoundly modulate CNS distribution of opioid analgesics and alter analgesic efficacy. In this study, we examined the ability of diclofenac, a non-steroidal anti-inflammatory drug (NSAID) that is commonly administered in conjunction with the opioids during pain therapy, to alter BBB transport of morphine via P-gp and whether such changes in P-gp morphine transport could alter morphine analgesic efficacy. Administration of diclofenac reduced paw edema and thermal hyperalgesia in rats subjected to PIP, which is consistent with the known mechanism of action of this NSAID. Western blot analysis demonstrated an increase in P-gp expression in rat brain microvessels not only following PIP induction but also after diclofenac treatment alone. Additionally, in situ brain perfusion studies showed that both PIP and diclofenac treatment alone increased P-gp efflux activity resulting in decreased morphine brain uptake. Critically, morphine analgesia was significantly reduced in animals pretreated with diclofenac (3 h), as compared to animals administered diclofenac and morphine concurrently. These novel findings suggest that administration of diclofenac and P-gp substrate opioids during pain pharmacotherapy may result in a clinically significant drug-drug interaction.
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Affiliation(s)
- Lucy Sanchez-Covarrubias
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Lauren M. Slosky
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Brandon J. Thompson
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Yifeng Zhang
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Mei-Li Laracuente
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Kristin M. DeMarco
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Patrick T. Ronaldson
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Thomas P. Davis
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, Arizona, United States of America
- * E-mail:
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Jabalameli M, Hazegh P, Talakoub R. Preemptive subcutaneous tramadol for post-operative pain in lower abdomen surgeries: A randomized double blinded placebo-control study. Adv Biomed Res 2013; 2:68. [PMID: 24223383 PMCID: PMC3814855 DOI: 10.4103/2277-9175.115816] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 09/09/2012] [Indexed: 11/13/2022] Open
Abstract
Background: Recently, the preemptive analgesic effects of subcutaneous infiltration of tramadol (T) in the site of incision have not been extensively studied. In this study, we investigated the effect of subcutaneous T infiltration before the incision of surgery on post-operative pain, in lower abdomen surgeries. Materials and Methods: This double-blind study was carried out on 90 patients (18-65 years) of American Society Anesthesiologists physical status I and II who were candidates for a lower abdomen surgery during 2011. They were randomly assigned to receive preemptive subcutaneous T or normal saline (NS). The visual analogue scale for pain (VAS) in rest and cough position and opium total dose consumption were compared between two groups in times 0, 15, 30, 60 min and 2, 4, 6, 12, 24 h after the surgery. Results: The VAS in cough and rest position in the first 24 h following the surgery was lower in group T (P < 0.05). Opium consumption was lower in group T (P < 0.05). Conclusion: Subcutaneous preemptive infiltration of T before surgical incision reduces post-operative opioid consumption.
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Affiliation(s)
- Mitra Jabalameli
- Department of Anesthesiology, Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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21
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Intraperitoneal instillation of saline and local anesthesia for prevention of shoulder pain after laparoscopic cholecystectomy: a systematic review. Surg Endosc 2013; 27:2283-92. [DOI: 10.1007/s00464-012-2760-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 11/26/2012] [Indexed: 12/11/2022]
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Shoar S, Esmaeili S, Safari S. Pain management after surgery: a brief review. Anesth Pain Med 2012; 1:184-6. [PMID: 24904790 PMCID: PMC4018688 DOI: 10.5812/kowsar.22287523.3443] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2011] [Revised: 11/19/2011] [Accepted: 11/22/2011] [Indexed: 11/16/2022] Open
Abstract
Proper pain management, particularly postoperative pain management, is a major concern for clinicians as well as for patients undergoing surgery. Although many advances have been made in the field of pain management, particularly during the past decades, not all patients achieve complete relief from postoperative pain. In this paper, we have emphasized the importance of postoperative analgesia and discussed the new developments in this field.
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Affiliation(s)
- Saeed Shoar
- Student Scientific Research Center (SSRC), Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Sara Esmaeili
- Student Scientific Research Center (SSRC), Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Saeid Safari
- Department of Anesthesiology, Tehran University of Medical Sciences (TUMS), Tehran, Iran
- Corresponding author: Saeid Safari, Department of Anesthesiology, Tehran University of Medical Sciences (TUMS), Tehran, Iran. Tel: +98-9392117300, Fax: +98-2166515758, E-mail:
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Maund E, McDaid C, Rice S, Wright K, Jenkins B, Woolacott N. Paracetamol and selective and non-selective non-steroidal anti-inflammatory drugs for the reduction in morphine-related side-effects after major surgery: a systematic review. Br J Anaesth 2011; 106:292-7. [PMID: 21285082 DOI: 10.1093/bja/aeq406] [Citation(s) in RCA: 286] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Non-opioid analgesics, paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), or cyclo-oxygenase 2 (COX-2) inhibitors are often given along with morphine as part of multimodal analgesia after major surgery. We have undertaken a systematic review and a mixed treatment comparison (MTC) analysis in order to determine explicitly which class of non-opioid analgesic, paracetamol, NSAIDs, or COX-2 inhibitors is the most effective in reducing morphine consumption and morphine-related adverse effects. Sixty relevant studies were identified. The MTC found that when paracetamol, NSAIDs, or COX-2 inhibitors were added to patient-controlled analgesia (PCA) morphine, there was a statistically significant reduction in morphine consumption: paracetamol [mean difference (MD) -6.34 mg; 95% credibility interval (CrI) -9.02, -3.65], NSAIDs (MD -10.18; 95% CrI -11.65, -8.72), and COX-2 inhibitors (MD -10.92; 95% CrI -12.77, -9.08). There was a significant reduction in nausea and postoperative nausea and vomiting with NSAIDs compared with placebo (odds ratio 0.70; 95% CrI 0.53, 0.88) but not for paracetamol or COX-2 inhibitors, nor for NSAIDs compared with paracetamol or COX-2 inhibitors. There was no statistically significant difference in sedation between any intervention and comparator. On the basis of six trials (n=695), 2.4% of participants receiving an NSAID experienced surgical-related bleeding compared with 0.4% with placebo. The MTC found that there is a decrease in 24 h morphine consumption when paracetamol, NSAID, or COX-2 inhibitors are given in addition to PCA morphine after surgery, with no clear difference between them. Similarly, the benefits in terms of reduction in morphine-related adverse effects do not strongly favour one of the three non-opioid analgesics.
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Affiliation(s)
- E Maund
- Centre for Reviews and Dissemination, University of York, York YO10 5DD, UK.
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Biglarnia AR, Tufveson G, Lorant T, Lennmyr F, Wadström J. Efficacy and safety of continuous local infusion of ropivacaine after retroperitoneoscopic live donor nephrectomy. Am J Transplant 2011; 11:93-100. [PMID: 21199350 DOI: 10.1111/j.1600-6143.2010.03358.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Morphine-based analgesia is effective but can compromise donor safety. We investigated whether continuous infusion of local anesthetics (CILA) can provide sufficient pain control and reduce morbidity related to opiate analgesics after hand-assisted retroperitoneoscopic (HARS) live donor nephrectomy. Forty consecutive live kidney donors underwent HARS and were treated with the ON-Q system providing CILA with 0.5% ropivacaine through two SilvaGard catheters placed in the retroperitoneal cavity and the rectus sheath, respectively. The case control group consisted of 40 donors matched with regard to sex, age, BMI and surgical technique. All donors were maintained on standardized multimodal analgesia combining nurse-controlled oxycodone treatment and acetaminophen. CILA donors had lower median cumulative consumption of morphine equivalents (CCME) (7 mg [0-56] vs. 42 mg [15-127]; p < 0.0000001), lower incidence of nausea (18 [45%] vs. 35 [87.5%] donors; p < 0.001), shorter time in postoperative care unit (160 vs. 242.5 min; p < 0.001) and shorter hospital stay (4 [4-7] vs. 6 [4-11] days; p < 0.001). In 32.5% of CILA donors the CCME was 0 mg (0% in matched control group, p < 0.001). CILA with 0.5% ropivacaine provides effective postoperative pain relief, reduces the need for opioid treatment and promotes postoperative recovery.
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Affiliation(s)
- A-R Biglarnia
- Department of Surgical Sciences, Section of Transplantation Surgery, Uppsala University Hospital, Uppsala, Sweden.
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[Postoperative multimodal pain management : Cost-minimisation analysis from a hospital's point of view]. Schmerz 2010; 24:373-9. [PMID: 20490570 DOI: 10.1007/s00482-010-0930-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Adequate pain management after major surgery is important to improve patients' quality of life and to support the healing process. Since the cost for pain management is included in the DRG system for hospital reimbursement, hospitals should aim to provide adequate postoperative pain management at the lowest possible cost. In this study we compare two multimodal pain management schemes for postoperative pain management in a cost-minimisation analysis. METHODS In a decision analytic model two treatment regimes for postoperative pain management are compared in a cost-minimisation analysis: diclofenac + morphine vs paracetamol vs morphine. The study is performed from the perspective of a public hospital. Due to the short time horizon costs are not discounted. RESULTS Assuming comparable effectiveness for adequate postoperative pain management, the expected value in the decision tree model for the combination diclofenac + morphine is 13.37 EUR and for the combination paracetamol + morphine 32.23 EUR, respectively. The results are robust under various one- and two-way sensitivity analyses. CONCLUSION With no contraindications given the combination diclofenac + morphine is more cost-effective for postoperative pain management after major surgery compared to paracetamol + morphine.
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Gehling M, Arndt C, Eberhart LHJ, Koch T, Krüger T, Wulf H. Postoperative analgesia with parecoxib, acetaminophen, and the combination of both: a randomized, double-blind, placebo-controlled trial in patients undergoing thyroid surgery. Br J Anaesth 2010; 104:761-7. [PMID: 20427369 DOI: 10.1093/bja/aeq096] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We assessed the analgesic efficacy of parecoxib, acetaminophen, and the combination of both compared with placebo in patients undergoing elective thyroid or parathyroid surgery. METHODS We randomized 140 patients to receive one of the following i.v. treatments using a double-blinded double-dummy technique: placebo, 80 mg 24 h(-1) parecoxib, 5 g 24 h(-1) acetaminophen, or 80 mg parecoxib plus 5 g acetaminophen. We provided rescue analgesia with piritramide delivered by a patient-controlled analgesia device. We measured opioid consumption and pain intensity over 24 h after operation. RESULTS Patient characteristic data, anaesthetic, and surgical characteristics of the patients in the four groups were similar. Parecoxib, acetaminophen, and the combination significantly reduced opioid requirements during 24 h after surgery [mean (sd) 12.5 (10.9) mg for parecoxib, 14.2 (12.3) mg for acetaminophen, and 11.9 (10.7) mg for combination] compared with placebo [23.5 (15.3) mg, P<0.05]. However, the combination of parecoxib and acetaminophen did not have any advantage over individual drugs in terms of opioid consumption in our trial (P>0.05). CONCLUSIONS Parecoxib and acetaminophen effectively reduce postoperative opioid requirements after thyroid or parathyroid surgery. The combination of these drugs is not associated with a further reduction in opioid consumption.
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Affiliation(s)
- M Gehling
- Department of Anaesthesiology and Intensive Care Medicine, Philipps-University Marburg, Marburg, Germany.
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Gómez Ríos MA, Vázquez Barreiro L, Nieto Serradilla L, Diz Gómez JC, López Alvarez S. [Efficacy of a continuous infusion of local anesthetic into the surgical wound for pain relief after abdominal hysterectomy]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2009; 56:417-424. [PMID: 19856688 DOI: 10.1016/s0034-9356(09)70422-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To assess the quality of postoperative analgesia provided by intravenous administration of paracetamol and ketorolac plus morphine in bolus doses with or without continuous infusion of local anesthetic into the surgical wound after abdominal hysterectomy. Patient satisfaction was included among the outcomes assessed. MATERIAL AND METHODS Prospective pilot study in ASA 1-2 patients randomized to 2 groups: women in the subcutaneous catheter group received intravenous analgesics plus a continuous infusion (2 mL/h) of 0.25% bupivacaine whereas women in the control group received only the intravenous analgesics. The outcome measures were pain intensity assessed on a verbal numerical scale at rest and with movement, morphine requirements in the first 48 hours after surgery, and complications related to the drugs used or the technique. RESULTS Twenty-six patients were enrolled; 10 were randomized to the catheter group and 16 to the control group. Statistically significant between-group differences in pain both at rest and with movement were found while the women were in the postoperative recovery unit. Postoperative pain with movement was also significantly different at 24 hours (P<.004) and 48 hours (P<.02). Similarly, mean (SD) morphine requirements in the recovery unit were significantly greater in the control group, at 8 (2.27) mg, compared with 3.20 (1.79) mg in the catheter group (P<.002). Walking began earlier in the catheter group. No differences were found in the incidences of complications. CONCLUSIONS Postoperative pain is effectively relieved by continuous infusion of local anesthetic into the surgical wound after abdominal hysterectomy. This technique provides good analgesia with less morphine consumption and scarce adverse effects. Patient satisfaction and the sense of receiving quality pain management are high.
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Affiliation(s)
- M A Gómez Ríos
- Servicio de Anestesiología y Reanimación, 1Complexo Hospitalario Universitario A Coruña, Coruña.
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Postoperative recovery profile after elective abdominal hysterectomy: a prospective, observational study of a multimodal anaesthetic regime. Eur J Anaesthesiol 2009; 26:382-8. [DOI: 10.1097/eja.0b013e32831f3429] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Placer Galán C, Mujika JA, Elósegui JL, Irureta I, Bollo E, Esteban E, Enríquez-Navascués JM. [A single rectal diclofenac dose reduces post-haemorrhoidectomy urine retention: results of a randomised, controlled clinical study]. Cir Esp 2008; 83:301-5. [PMID: 18570844 DOI: 10.1016/s0009-739x(08)70580-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Post-surgical urinary retention requiring a catheter has a mean incidence of 15% (1% to 52%) in the post-operative period after anal surgery. The primary objective of this study was to assess the efficacy of topical rectal Diclofenac in reducing post-surgical haemorrhoidectomy urinary retention. Its impact on the reduced need for post-surgery analgesia has also been assessed as a secondary objective. PATIENTS AND METHOD The 157 patients intervened for symptomatic haemorrhoids were randomised into two groups: Group with 100 mg diclofenac anal suppository after surgery; and Control group without diclofenac. Haemorrhoidectomy was performed with diathermy, without pedicle ligatures and with hyperbaric spinal anaesthesia. No anal dressings were used and the use of drips was restricted during the post-operative period. Metamizole and diclofenac were used as post-surgical intravenous analgesia in all patients. Meperidine was chosen as rescue analgesia. The descriptive variables evaluated in the patient series were: age, sex, grade and number of haemorrhoid groups, and post-surgical complications. The response variables were: need or not for a urethral catheter, post-surgical pain (Visual Analogue Scale) VAS and rescue analgesia requirements. RESULTS The 86 males (54.6%) and 71 females (45.4%), with a mean age of 54 years (26-82 years) were randomised into 2 groups: 73 (46.5%) in the diclofenac group and 84 (53.5% in the control group. Of the haemorrhoidectomies performed, 95 were open and 63 were closed. There were no differences as regards the distribution by, age, sex, haemorrhoid grade or in the number of haemorrhoid groups extirpated. Only 1 (1.3%) patient in the diclofenac group and 8 (9.5%) in the control group (p = 0.028) had urine retention. Rescue analgesia was required by 9 (12.3%) patients in the study group compared to 20 (33.3%) in the control group (p = 0.002). The assessment of the magnitude of therapeutic effect of diclofenac gave an RRR of 85.6% (95% CI, 12.3-98.2), RAR, 8.2% (95% CI, 1.3-15) and an NNT of 13 (95% CI, 7-77). CONCLUSIONS The placing of a 100 mg diclofenac suppository at the end of a haemorrhoidectomy reduces urinary retention and rescue analgesia requirements.
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Affiliation(s)
- Carlos Placer Galán
- Departamento de Cirugía. Hospital Donostia, San Sebastián, Guipúzcoa. España.
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Munishankar B, Fettes P, Moore C, McLeod G. A double-blind randomised controlled trial of paracetamol, diclofenac or the combination for pain relief after caesarean section. Int J Obstet Anesth 2008; 17:9-14. [DOI: 10.1016/j.ijoa.2007.06.006] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2006] [Revised: 06/01/2006] [Accepted: 06/19/2007] [Indexed: 11/25/2022]
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Yamashita K, Fukusaki M, Ando Y, Fujinaga A, Tanabe T, Terao Y, Sumikawa K. Preoperative administration of intravenous flurbiprofen axetil reduces postoperative pain for spinal fusion surgery. J Anesth 2006; 20:92-5. [PMID: 16633764 DOI: 10.1007/s00540-006-0389-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2005] [Accepted: 01/19/2006] [Indexed: 11/27/2022]
Abstract
PURPOSE The aim of the study was to investigate postoperative analgesia and the opioid-sparing effect of the preoperative administration of intravenous flurbiprofen axetil in patients undergoing spinal fusion surgery. METHODS Thirty-six patients were randomly allocated into one of three groups. Group A received preoperative flurbiprofen axetil, 1 mg x kg(-1). Group B received postoperative flurbiprofen axetil, 1 mg x kg(-1). Group C received a placebo. All groups were given a standardized anesthesia and intravenous morphine via a patient-controlled analgesia device for postoperative analgesia. The pain score was evaluated by a visual analog scale (VAS) at 0 (T(0)), 1 (T(1)), 2 (T(2)), 6 (T(3)), 12 (T(4)), and 24 (T(5)) h after surgery, and the morphine requirement was recorded during the study period. RESULTS VAS in group A was significantly lower than that in group B at T(0) and T(1). VAS in group A was significantly lower than that in group C throughout the time course after surgery. Postoperative morphine consumption in group A was significantly lower than that in groups B and C at T(0) to T(3). CONCLUSION As compared with postoperative administration, preoperative administration of intravenous flurbiprofen axetil provides better postoperative analgesia and an opioid-sparing effect in patients undergoing spinal fusion surgery under general anesthesia.
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Affiliation(s)
- Kazunori Yamashita
- Department of Anesthesia, Nagasaki Rosai Hospital, 2-12-5 Setogoshi, Sasebo 857-0134, Japan
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Abstract
There is experimental evidence that nimodipine, an L-type dihydropiridine calcium channel blocker with relatively high blood-brain barrier penetration, enhances the antinociceptive properties of morphine. We tested the hypothesis that oral nimodipine taken preoperatively and 6 hourly for 48 h postoperatively would reduce visual analog scale pain scores and morphine consumption in morphine-naive patients with acute postoperative pain. Forty patients undergoing total knee replacement surgery (age 70 +/- 7 yr, 28 male) were randomized by computer-generated numbers to receive capsules containing either nimodipine 30 mg or placebo in a double-blind study design. All patients received 3 capsules (nimodipine 90 mg or placebo) 1-2 h before induction of anesthesia followed by oral nimodipine 30 mg or placebo 6 hourly for 48 hours postoperatively. Spinal anesthesia was induced with hyperbaric bupivacaine 0.5% (2.4-3.0 mL) and fluids and ephedrine were given at the discretion of the anesthesiologist. Morphine patient-controlled analgesia (PCA, bolus 1 mg, lockout 5 min) was given for postoperative analgesia. Primary outcome measures were visual analog pain scores at rest and on moving (sitting forward) and PCA morphine consumption. Morphine consumption was significantly larger in nimodipine patients at 12 h (39 +/- 18 versus 29 +/- 15; P = 0.04), 24 h (62 +/- 23 versus 45 +/- 24; P = 0.02), and 48 h (88 +/- 34 versus 61 +/- 27; P = 0.01). There were no significant differences in pain scores at rest or moving or in time to first use of morphine analgesia. This study has demonstrated increased morphine consumption after 12 h in postoperative patients receiving nimodipine, suggesting that, in patients undergoing knee replacement surgery, it has no adjunctive analgesic effect and may actually inhibit the analgesic effect of morphine.
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Affiliation(s)
- Gerri Casey
- Department of Anaesthesia, University Hospitals of Leicester, Leicester General Hospital, Leicester LE5 4PW, UK
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Everett B, Salamonson Y. Differences in Postoperative Opioid Consumption in Patients Prescribed Patient-Controlled Analgesia Versus Intramuscular Injection. Pain Manag Nurs 2005; 6:137-44. [PMID: 16337562 DOI: 10.1016/j.pmn.2005.09.001] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2005] [Revised: 08/31/2005] [Accepted: 09/01/2005] [Indexed: 11/29/2022]
Abstract
The purpose of this study was to examine differences in opioid consumption in patients prescribed patient-controlled analgesia (PCA) versus intramuscular injection (IMI) in the early postoperative period after open abdominal surgery. A retrospective audit of 115 patients elicited demographic and clinical data. No significant differences were found between the demographic variables of the PCA and IMI groups. There was a significant difference in the mean opioid dose used during the first 3 postoperative days (p < .01). Mean opioid consumption was 136.89 mg for the PCA group and 50.79 mg for the IMI group. Although there was a reduction in the amount of opioid consumed over the first 3 postoperative days, the PCA group consistently consumed more opioid analgesia compared with the IMI group. Furthermore, there was a disproportionate reduction in opioid consumption between the two groups from Day 1 (r = .34; p < .01) to Day 3 (r = .14; p = .14). This study shows that the amount of analgesia consumed during the postoperative period by patients who had abdominal surgery varied markedly depending on the mode of analgesia (PCA or IMI). The difference in analgesic consumption was also found to increase throughout the 3-day postoperative period. This divergence in the amount of opioid consumption between patients who were prescribed PCA and patients who were prescribed IM analgesia heightens the need for vigilance in assessment and management of pain during the early postoperative period, particularly in patients prescribed IM analgesia on an "as-needed" basis.
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MESH Headings
- Adult
- Analgesia, Patient-Controlled/nursing
- Analgesia, Patient-Controlled/statistics & numerical data
- Analgesics, Opioid/administration & dosage
- Cholecystectomy/adverse effects
- Clinical Nursing Research
- Colorectal Surgery/adverse effects
- Drug Monitoring/nursing
- Drug Utilization/statistics & numerical data
- Female
- Hospitals, Public
- Humans
- Hysterectomy/adverse effects
- Injections, Intramuscular/nursing
- Injections, Intramuscular/statistics & numerical data
- Male
- Middle Aged
- New South Wales
- Nurse's Role
- Nursing Assessment
- Nursing Audit
- Pain Measurement/nursing
- Pain, Postoperative/diagnosis
- Pain, Postoperative/drug therapy
- Pain, Postoperative/etiology
- Pain, Postoperative/nursing
- Perioperative Nursing
- Postoperative Care/nursing
- Retrospective Studies
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Affiliation(s)
- Bronwyn Everett
- School of Nursing, Family and Community Health, College of Social and Health Sciences, University of Western Sydney, New South Wales, Australia
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Hunter JM. The recovery period. Br J Anaesth 2005; 95:1-2. [PMID: 15941733 DOI: 10.1093/bja/aei139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Akca T, Colak T, Kanik A, Yaylak F, Caglikulekci M, Aydin S. The effect of preoperative intravenous use of tenoxicam: a prospective, double-blind, placebo-controlled study. J INVEST SURG 2005; 17:333-8. [PMID: 15764501 DOI: 10.1080/08941930490524390] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In this study, we aimed to investigate the postoperative pain relief effect of preoperative tenoxicam usage in patients who undergo elective laparoscopic cholecystectomy or groin hernia repair. Eighty patients undergoing laparoscopic cholecystectomy or groin hernia repair procedures were randomized to receive either physiologic serum at 100 mL (group I, n = 40) or 20 mg iv tenoxicam (group II, n = 40) immediately before induction. Postoperative analgesic requirement, peroperative side effects and complications of drugs, operating time, post-operative mobilization time and pain score, hospitalization time, and patient pleasure were recorded. Postoperative pain was assessed by the visual analogue scale (VAS) on the recovery unit (RU), at 4, 8, and 24 h and every day at the same times in the morning. The RU median VAS score was also not different when Group 1 was compared with Group 2 (p = .97). However, the postoperative 4-h and 8-h median VAS score was significantly less (p = .01 and p = .03, respectively); first postoperative mobilization time was earlier in group 2 (p = .32). The median pain score and intramuscular analgesic requirement of patients were also reduced in Group 2 in postoperative day 1 (p = .015). The median duration of intramuscular analgesic requirement and total amount of intramuscular analgesic used in patients were also significantly less in Group 2 (p = .0001 and p = .0001, respectively). Thus, this study showed that preoperative use of iv tenoxicam is safe, simple, and effective for postoperative pain relief after laparoscopic cholecystectomy or inguinal hernia repair.
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Affiliation(s)
- Tamer Akca
- Department of General Surgery, Mersin University Medical Faculty, Mersin, Turkey.
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Ng A, Swami A, Smith G, Robertson G, Lloyd DM. Is intraperitoneal levobupivacaine with epinephrine useful for analgesia following laparoscopic cholecystectomy? A randomized controlled trial. Eur J Anaesthesiol 2004. [DOI: 10.1097/00003643-200408000-00011] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ng A, Temple A, Smith G, Emembolu J. Early analgesic effects of parecoxib versus ketorolac following laparoscopic sterilization: a randomized controlled trial †. Br J Anaesth 2004; 92:846-9. [PMID: 15121727 DOI: 10.1093/bja/aeh161] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The aim of this prospective double blind randomized controlled trial was to compare the effects of ketorolac and parecoxib on early postoperative pain. METHOD We studied 36 ASA I/II patients who received a standardized general anaesthetic for laparoscopic sterilization. Patients were allocated randomly to receive either parecoxib 40 mg i.v. or ketorolac 30 mg i.v., at induction. After surgery, patients were assessed on awakening and then at 1, 2, and 3 h. Abdominal pain at rest and on inspiration, in addition to nausea and sedation were assessed on a 100 mm visual analogue scale. RESULTS Of 36 patients, one was excluded from analysis. In the remaining patients, pain scores at rest and on inspiration were significantly lower in patients given ketorolac compared with those given parecoxib. This difference was attributable to the higher pain scores on awakening and at 1 h postoperatively in the parecoxib group compared with the ketorolac group. Despite this initial difference, there was no significant difference between the two groups in the number of patients receiving rescue analgesia. The median (interquartile range) time to consumption of rescue cocodamol of 60 (46-74) min in the parecoxib group was not significantly shorter than that of 100 (70-130) min in the ketorolac group. The amount of cyclizine given, nausea and sedation did not differ significantly between the groups. CONCLUSION We found that parecoxib 40 mg i.v. given at induction of anaesthesia was less effective than or ketorolac 30 mg i.v., in the first hour after laparoscopic sterilization.
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Affiliation(s)
- A Ng
- University Division of Anaesthesia, Critical Care and Pain Management and Department of Obstetrics and Gynaecology, Leicester Royal Infirmary, Leicester LE1 5WW, UK.
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Sigston P, Yates D, Leonardi S. Use of PCA morphine as the sole analgesic for postoperative pain relief after TAH. Br J Anaesth 2003; 91:923; author reply 923. [PMID: 14677531 DOI: 10.1093/bja/aeg648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Ng A, Smith G, Davidson AC. Analgesic effects of parecoxib following total abdominal hysterectomy. Br J Anaesth 2003; 90:746-9. [PMID: 12765890 DOI: 10.1093/bja/aeg139] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Forty-eight ASA I-II patients undergoing total abdominal hysterectomy (TAH) were studied in a double blind, randomized placebo controlled trial of parecoxib for postoperative analgesia. METHODS All patients were given propofol 2-4 mg kg(-1) i.v., a non-depolarizing muscle relaxant, morphine 10 mg i.v. and prochlorperazine 12.5 mg i.m. intraoperatively. Their lungs were ventilated with nitrous oxide and isoflurane 1-1.5% in oxygen. Morphine was self-administered for postoperative analgesia via a patient controlled analgesia (PCA) device. Patients were allocated randomly to receive either parecoxib 40 mg i.v. or normal saline on induction of anaesthesia. RESULTS Twelve patients did not complete the study. Of the remaining 36 patients, there was no significant difference between the treatment groups in age, weight, ASA status, duration of surgery, or intraoperative dose of morphine. However, mean (95% CI) 24 h morphine consumption of 54 (42-65) mg in the parecoxib group was significantly (P=0.04) lower than that of 72 (58-86) mg in the placebo group. Pain intensity scores on sitting up were significantly lower (P=0.02) in the parecoxib group compared with placebo. There was no significant difference between the treatment groups in pain intensity scores at rest and on deep inspiration, or in nausea, total number of vomiting episodes, median number of rescue antiemetic doses, and sedation scores. CONCLUSIONS Parecoxib 40 mg i.v. may be recommended in patients having TAH as it provides morphine-sparing analgesia.
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Affiliation(s)
- A Ng
- University Department of Anaesthesia, Critical Care and Pain Management and Department of Obstetrics and Gynaecology, Leicester Royal Infirmary, Leicester LE1 5WW, UK.
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Ng A, Smith G. I: Intraperitoneal administration of analgesia: is this practice of any utility? Br J Anaesth 2002; 89:535-7. [PMID: 12393350 DOI: 10.1093/bja/aef219] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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