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Jao SW, Hsiao KH, Lin HC, Lee CC, Lin TC, Chen WS, Lin CC, Lee TY, Jiang JK, Wu CC, Hu OYP. Safety and Efficacy of Oral Nalbuphine on Postoperative Pain in Hemorrhoidectomy Patients: A Randomized, Double-blind, Placebo-controlled, Pivotal Trial. Clin J Pain 2023; 39:686-694. [PMID: 37732966 DOI: 10.1097/ajp.0000000000001160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/30/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVES Severe postoperative pain requiring opioid treatment has been reported in 20% to 40% of hemorrhoidectomy patients. Compared with morphine, nalbuphine offers better hemodynamic stability, a lower risk of respiratory depression, and a lower potential for addiction. Nalbuphine was developed from the intravenous form into an oral form (PHN131) to alleviate moderate-to-severe pain. MATERIALS AND METHODS A randomized, double-blind, placebo-controlled, multiple-dose, parallel-design trial was conducted to evaluate the safety and efficacy of PHN131 in patients undergoing hemorrhoidectomy. Eligible patients were randomly assigned to receive either PHN131 soft capsules containing nalbuphine hydrochloride 60 mg or placebo capsules. Intramuscular diclofenac was the rescue analgesic. Pain was measured by the area under the curve of mean Visual Analog Scale pain intensity scores. RESULTS Visual Analog Scale results in patients receiving PHN131 were significantly lower than placebo group scores through 48 hours postoperatively (149.2±75.52 vs. 179.6±65.97; P =0.0301). According to Brief Pain Inventory Short-Form scores, the impact of pain on quality of life was significantly smaller for the PHN131 group than for the placebo group. Time to the first use of diclofenac postoperatively was significantly longer in the PHN131 group than in the placebo group. The cumulative dosage of diclofenac in the PHN131 group was only around half of that in the placebo group ( P <0.0001). Drug-related adverse events were mild-to-moderate and resolved by the treatment end. No drug-related severe adverse events were observed. DISCUSSION Our findings demonstrate that PHN131 is effective and well-tolerated in the treatment of moderate-to-severe post hemorrhoidectomy pain and may provide another option for patients to control their pain.
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Affiliation(s)
- Shu-Wen Jao
- Division of Colon and Rectal Surgery, Tri-Service General Hospital
- National Defense Medical Center
| | - Koung-Hung Hsiao
- Department of Colorectal Surgery, Taipei Tzu Chi Hospital, Taipei Branch
| | | | - Chia-Cheng Lee
- Division of Colon and Rectal Surgery, Tri-Service General Hospital
| | - Tzu-Chen Lin
- Division of Colon and Rectal Surgery, Taipei Veterans General Hospital
| | - Wei-Shone Chen
- Division of Colon and Rectal Surgery, En Chu Kong Hospital
| | - Chun-Chi Lin
- Division of Colon and Rectal Surgery, Taipei Veterans General Hospital
| | - Tsai-Yu Lee
- Division of Colon and Rectal Surgery, Sijhih Cathay General Hospital, New Taipei City
| | - Jeng-Kai Jiang
- Division of Colon and Rectal Surgery, Taipei Veterans General Hospital
| | - Chang-Chieh Wu
- National Defense Medical Center
- Division of Colon and Rectal Surgery, Tri-Service General Hospital Keelung Branch, Keelung City, Taiwan
| | - Oliver Yoa-Pu Hu
- School of Pharmacy, National Defense Medical Center
- School of Pharmacy, Taipei Medical University, Taipei City
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Lara-Cátedra C, López-Cabezas C, García-López I, Elviro-Lloréns M, Letéllez-Fernández J, de Rosales-Cabrera AMM, Alonso-Herreros JM, SalaVilajosana N. Map of use of parenteral analgesic admixtures in Spain. MEDPAIN project. FARMACIA HOSPITALARIA 2023; 47:161-167. [PMID: 37244846 DOI: 10.1016/j.farma.2023.03.010] [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: 01/20/2023] [Revised: 03/29/2023] [Accepted: 03/31/2023] [Indexed: 05/29/2023] Open
Abstract
OBJETIVE This study is the first part of the MEDPAIN project "Update of analgesic parenteral admixtures: studies of use, compatibility and stability", and its goal is to develop a national map about the use of analgesic parenteral admixtures in healthcare settings. METHODS Observational study, based on a survey aimed at Spanish hospital pharmacists, during the period December 2020-April 2021. The questionnaire was designed in the RedCap® platform and disseminated through the Spanish Society of Hospital Pharmacy distribution list. An analgesic parenteral admixture (AM) was defined as the combination of two or more drugs, with at least one of them being an analgesic. The same combination of active ingredients, at different concentration and/or administered by different routes, was considered as a unique AM in this study. Some registered endpoints were related to the characteristics of the healthcare settings participating in the study, and others were related to the AM, such as drugs, doses and concentration range, route of administration, frequency of use, indication and type of patient (adult/pediatric) and where they are prepared. RESULTS A total of 67 valid surveys from healthcare settings of 13 Spanish Autonomous Communities were received. They reported 462 AM. Every healthcare center informed an average of 6 AM (ICR p25-p75 =4.0-9.0). Most of the reported mixtures were used in adults (93.9%) at hospital settings (91.8%), and they were mostly protocolized and frequently used. The 21.4% of them were compounded at the Pharmacy service. The AM included 26 different drugs, with opioid analgesics being present at the 87.4% of them. Midazolam was the most usual adjuvant drug. According to the definition of AM in this study, there were finally 137 different combinations mainly with two drugs (40.6%), but also with three (37.7%), four (15.2%) and five ingredients (6.5%). CONCLUSION This study reveals the wide variability in current clinical practice and shows which are the most used analgesic parenteral admixtures in our country.
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Affiliation(s)
- Catalina Lara-Cátedra
- Servicio de Farmacia, Hospital Universitario La Paz, Madrid, España; Grupo de Trabajo Dolor, Sociedad Española de Farmacia Hospitalaria, España.
| | - Carmen López-Cabezas
- Servicio de Farmacia, Hospital Clínic Barcelona, Barcelona, España; Grupo de Trabajo Farmacotecnia, Sociedad Española de Farmacia Hospitalaria, España
| | - Isabel García-López
- Servicio de Farmacia, Hospital Infantil Universitario Niño Jesús, Madrid, España; Grupo de Trabajo Dolor, Sociedad Española de Farmacia Hospitalaria, España
| | - María Elviro-Lloréns
- Servicio de Farmacia, Clínica Nuestra Señora del Pilar, Zaragoza, España; Grupo de Trabajo Dolor, Sociedad Española de Farmacia Hospitalaria, España
| | - Javier Letéllez-Fernández
- Servicio de Farmacia, Hospital Universitario Fuenlabrada, Fuenlabrada, Madrid, España; Grupo de Trabajo Dolor, Sociedad Española de Farmacia Hospitalaria, España
| | - Ana María Martín de Rosales-Cabrera
- Servicio de Farmacia, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España; Grupo de Trabajo Farmacotecnia, Sociedad Española de Farmacia Hospitalaria, España
| | - José María Alonso-Herreros
- Servicio de Farmacia, Hospital Los Arcos Mar Menor, Pozo Aledo, Murcia, España; Grupo de Trabajo Farmacotecnia, Sociedad Española de Farmacia Hospitalaria, España
| | - Núria SalaVilajosana
- Servicio de Farmacia, Fundació Althaia, Manresa, Barcelona, España; Grupo de Trabajo Dolor, Sociedad Española de Farmacia Hospitalaria, España
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Lara-Cátedra C, López-Cabezas C, García-López I, Elviro-Lloréns M, Letéllez-Fernández J, Martín de Rosales-Cabrera AM, Alonso-Herreros JM, SalaVilajosana N. [Translated article] Map of use of parenteral analgesic admixtures in Spain. MEDPAIN project. FARMACIA HOSPITALARIA 2023; 47:T161-T167. [PMID: 37438171 DOI: 10.1016/j.farma.2023.06.002] [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: 01/20/2023] [Revised: 03/29/2023] [Accepted: 03/31/2023] [Indexed: 07/14/2023] Open
Abstract
OBJECTIVE This study is the first part of the MEDPAIN project "Update of analgesic parenteral admixtures: studies of use, compatibility and stability", and its goal is to develop a national map about the use of analgesic parenteral admixtures in healthcare settings. METHODS Observational study, based on a survey aimed at Spanish hospital pharmacists, during the period December 2020 - April 2021. The questionnaire was designed in the RedCap® platform and disseminated through the Spanish Society of Hospital Pharmacy distribution list. An analgesic parenteral admixture (AM) was defined as the combination of two or more drugs, with at least one of them being an analgesic. The same combination of active ingredients, at different concentration and/or administered by different routes, was considered as a unique AM in this study. Some registered endpoints were related to the characteristics of the healthcare settings participating in the study, and others were related to the AM, such as drugs, doses and concentration range, route of administration, frequency of use, indication and type of patient (adult/pediatric) and where they are prepared. RESULTS A total of 67 valid surveys from healthcare settings of 13 Spanish Autonomous Communities were received. They reported 462 AM. Every healthcare center informed an average of 6 AM (ICR p25-p75 = 4.0-9.0). Most of the reported mixtures were used in adults (93.9%) at hospital settings (91.8%), and they were mostly protocolized and frequently used. The 21.4% of them were compounded at the Pharmacy service. The AM included 26 different drugs, with opioid analgesics being present at the 87.4% of them. Midazolam was the most usual adjuvant drug. According to the definition of AM in this study, there were finally 137 different combinations mainly with two drugs (40.6%), but also with three (37.7%), four (15.2%) and five ingredients (6.5%). CONCLUSION In conclusion, this study reveals the wide variability in current clinical practice and shows which are the most used analgesic parenteral admixtures in our country.
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Affiliation(s)
| | | | - Isabel García-López
- Servicio de Farmacia, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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Song Y, He Q, Huang W, Yang L, Zhou S, Xiao X, Wang Z, Huang W. New insight into the analgesic recipe: A cohort study based on smart patient-controlled analgesia pumps records. Front Pharmacol 2022; 13:988070. [PMID: 36299897 PMCID: PMC9589502 DOI: 10.3389/fphar.2022.988070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/15/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose: Intravenous patient-controlled analgesia (IV-PCA) has been widely used; however, regimen criteria have not yet been established. In China, the most often used opioid is sufentanil, for which repeated doses are a concern, and empirical flurbiprofen axetil (FBP) as an adjuvant. We hypothesized that hydromorphone would be a better choice and also evaluated the effectiveness of FBP as an adjuvant. Methods: This historical cohort study was conducted in two tertiary hospitals in China and included 12,674 patients using hydromorphone or sufentanil for IV-PCA between April 1, 2017, and January 30, 2021. The primary outcome was analgesic insufficiency at static (AIS). The secondary outcomes included analgesic insufficiency with movement (AIM) and common opioid-related adverse effects such as postoperative nausea and vomiting (PONV) and dizziness. Results: Sufentanil, but not the sufentanil-FBP combination, was associated with higher risks of AIS and AIM compared to those for hydromorphone (OR 1.64 [1.23, 2.19], p < 0.001 and OR 1.42 [1.16, 1.73], p < 0.001). Hydromorphone combined with FBP also decreased the risk of both AIS and AIM compared to those for pure hydromorphone (OR 0.74 [0.61, 0.90], p = 0.003 and OR 0.80 [0.71, 0.91], p < 0.001). However, the risk of PONV was higher in patients aged ≤35 years using FBP (hydromorphone-FBP vs. hydromorphone and sufentanil-FBP vs. hydromorphone, OR 1.69 [1.22, 2.33], p = 0.001 and 1.79 [1.12, 2.86], p = 0.015). Conclusion: Hydromorphone was superior to sufentanil for IV-PCA in postoperative analgesia. Adding FBP may improve the analgesic effects of both hydromorphone and sufentanil but was associated with an increased risk of PONV in patients <35 years of age.
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Affiliation(s)
- Yiyan Song
- Department of Anesthesia, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qiulan He
- Department of Anesthesia, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wenzhong Huang
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Lu Yang
- Department of Anesthesia, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shaopeng Zhou
- Department of Anesthesia, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Xiaoyu Xiao
- Department of Anesthesia, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Zhongxing Wang
- Department of Anesthesia, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- *Correspondence: Zhongxing Wang, ; Wenqi Huang,
| | - Wenqi Huang
- Department of Anesthesia, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- *Correspondence: Zhongxing Wang, ; Wenqi Huang,
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Cloesmeijer ME, van den Oever HLA, Mathôt RAA, Zeeman M, Kruisdijk-Gerritsen A, Bles CMA, Nassikovker P, de Meijer AR, van Steveninck FL, Arbouw MEL. Optimising the dose of clonidine to achieve sedation in intensive care unit patients with population pharmacokinetics. Br J Clin Pharmacol 2020; 86:1620-1631. [PMID: 32150285 PMCID: PMC7373711 DOI: 10.1111/bcp.14273] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 02/13/2020] [Accepted: 02/26/2020] [Indexed: 01/15/2023] Open
Abstract
Aims The aim of this study was to investigate the population pharmacokinetics (PK) of clonidine in intensive care unit (ICU) patients in order to develop a dosing regimen for sedation. Methods We included 24 adult mechanically ventilated, sedated patients from a mixed medical and surgical ICU. Intravenous clonidine was added to standard sedation in doses of 600, 1200 or 1800 μg/d. Within each treatment group, 4 patients received a loading dose of half the daily dose administered in 4 hours. Patients gave an average of 12 samples per individual. In total, 286 samples were available for analysis. Model development was conducted with NONMEM and various covariates were tested. After modelling, doses to achieve a target steady‐state plasma concentration of >1.5 μg/L were explored using stochastic Monte Carlo simulations for 1000 virtual patients. Results A 2‐compartment model was the best fit for the concentration‐time data. Clearance (CL) increased linearly with 0.213%/h; using allometric scaling, body weight was a significant covariate on the central volume of distribution (V1). Population PK parameters were: CL 17.1 (L/h), V1 124 (L/70 kg), intercompartmental CL 83.7 (L/h), and peripheral volume of distribution 178 (L), with 33.3% CV interindividual variability on CL and 66.8% CV interindividual variability on V1. Simulations revealed that a maintenance dose of 1200 μg/d provides target sedation concentrations of >1.5 μg/L in 95% of the patients. Conclusion A population PK model for clonidine was developed in an adult ICU. A dosing regimen of 1200 μg/d provided a target sedation concentration of >1.5 μg/L.
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Affiliation(s)
- Michael E Cloesmeijer
- Department of Hospital Pharmacy - Clinical Pharmacology, Amsterdam University Medical Centres, The Netherlands
| | | | - Ron A A Mathôt
- Department of Hospital Pharmacy - Clinical Pharmacology, Amsterdam University Medical Centres, The Netherlands
| | - Marieke Zeeman
- Department of Clinical Geriatrics, Deventer Hospital, The Netherlands
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Duncan D, Sankar A, Beattie WS, Wijeysundera DN. Alpha-2 adrenergic agonists for the prevention of cardiac complications among adults undergoing surgery. Cochrane Database Syst Rev 2018; 3:CD004126. [PMID: 29509957 PMCID: PMC6494272 DOI: 10.1002/14651858.cd004126.pub3] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The surgical stress response plays an important role on the pathogenesis of perioperative cardiac complications. Alpha-2 adrenergic agonists attenuate this response and may help prevent postoperative cardiac complications. OBJECTIVES To determine the efficacy and safety of α-2 adrenergic agonists for reducing mortality and cardiac complications in adults undergoing cardiac surgery and non-cardiac surgery. SEARCH METHODS We searched CENTRAL (2017, Issue 4), MEDLINE (1950 to April Week 4, 2017), Embase (1980 to May 2017), the Science Citation Index, clinical trial registries, and reference lists of included articles. SELECTION CRITERIA We included randomized controlled trials that compared α-2 adrenergic agonists (i.e. clonidine, dexmedetomidine or mivazerol) against placebo or non-α-2 adrenergic agonists. Included trials had to evaluate the efficacy and safety of α-2 adrenergic agonists for preventing perioperative mortality or cardiac complications (or both), or measure one or more relevant outcomes (i.e. death, myocardial infarction, heart failure, acute stroke, supraventricular tachyarrhythmia and myocardial ischaemia). DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality, extracted data and independently performed computer entry of abstracted data. We contacted study authors for additional information. Adverse event data were gathered from the trials. We evaluated included studies using the Cochrane 'Risk of bias' tool, and the quality of the evidence underlying pooled treatment effects using GRADE methodology. Given the clinical heterogeneity between cardiac and non-cardiac surgery, we analysed these subgroups separately. We expressed treatment effects as pooled risk ratios (RR) with 95% confidence intervals (CI). MAIN RESULTS We included 47 trials with 17,039 participants. Of these studies, 24 trials only included participants undergoing cardiac surgery, 23 only included participants undergoing non-cardiac surgery and eight only included participants undergoing vascular surgery. The α-2 adrenergic agonist studied was clonidine in 21 trials, dexmedetomidine in 24 trials and mivazerol in two trials.In non-cardiac surgery, there was high quality evidence that α-2 adrenergic agonists led to a similar risk of all-cause mortality compared with control groups (1.3% with α-2 adrenergic agonists versus 1.7% with control; RR 0.80, 95% CI 0.61 to 1.04; participants = 14,081; studies = 16). Additionally, the risk of cardiac mortality was similar between treatment groups (0.8% with α-2 adrenergic agonists versus 1.0% with control; RR 0.86, 95% CI 0.60 to 1.23; participants = 12,525; studies = 5, high quality evidence). The risk of myocardial infarction was probably similar between treatment groups (RR 0.94, 95% CI 0.69 to 1.27; participants = 13,907; studies = 12, moderate quality evidence). There was no associated effect on the risk of stroke (RR 0.93, 95% CI 0.55 to 1.56; participants = 11,542; studies = 7; high quality evidence). Conversely, α-2 adrenergic agonists probably increase the risks of clinically significant bradycardia (RR 1.59, 95% CI 1.18 to 2.13; participants = 14,035; studies = 16) and hypotension (RR 1.24, 95% CI 1.03 to 1.48; participants = 13,738; studies = 15), based on moderate quality evidence.There was insufficient evidence to determine the effect of α-2 adrenergic agonists on all-cause mortality in cardiac surgery (RR 0.52, 95% CI 0.26 to 1.04; participants = 1947; studies = 16) and myocardial infarction (RR 1.01, 95% CI 0.43 to 2.40; participants = 782; studies = 8), based on moderate quality evidence. There was one cardiac death in the clonidine arm of a study of 22 participants. Based on very limited data, α-2 adrenergic agonists may have reduced the risk of stroke (RR 0.37, 95% CI 0.15 to 0.93; participants = 1175; studies = 7; outcome events = 18; low quality evidence). Conversely, α-2 adrenergic agonists increased the risk of bradycardia from 6.4% to 12.0% (RR 1.88, 95% CI 1.35 to 2.62; participants = 1477; studies = 10; moderate quality evidence), but their effect on hypotension was uncertain (RR 1.19, 95% CI 0.87 to 1.64; participants = 1413; studies = 9; low quality evidence).These results were qualitatively unchanged in subgroup analyses and sensitivity analyses. AUTHORS' CONCLUSIONS Our review concludes that prophylactic α-2 adrenergic agonists generally do not prevent perioperative death or major cardiac complications. For non-cardiac surgery, there is moderate-to-high quality evidence that these agents do not prevent death, myocardial infarction or stroke. Conversely, there is moderate quality evidence that these agents have important adverse effects, namely increased risks of hypotension and bradycardia. For cardiac surgery, there is moderate quality evidence that α-2 adrenergic agonists have no effect on the risk of mortality or myocardial infarction, and that they increase the risk of bradycardia. The quality of evidence was inadequate to draw conclusions regarding the effects of alpha-2 agonists on stroke or hypotension during cardiac surgery.
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Affiliation(s)
- Dallas Duncan
- University of TorontoDepartment of Anesthesia123 Edward Street12th FloorTorontoONCanadaM5G 1E2
| | - Ashwin Sankar
- University of TorontoDepartment of Anesthesia123 Edward Street12th FloorTorontoONCanadaM5G 1E2
| | - W Scott Beattie
- Toronto General Hospital, University Health NetworkDepartment of AnaesthesiaEN 3‐453 Toronto General Hospital, University Health Network200 Elizabeth StreetTorontoONCanadaM5G 2C4
| | - Duminda N Wijeysundera
- St. Michael's HospitalLi Ka Shing Knowledge Institute30 Bond StreetTorontoOntarioCanadaM5B 1W8
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Tonner PH. Additives used to reduce perioperative opioid consumption 1: Alpha2-agonists. Best Pract Res Clin Anaesthesiol 2017; 31:505-512. [DOI: 10.1016/j.bpa.2017.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 09/25/2017] [Accepted: 10/26/2017] [Indexed: 01/22/2023]
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Abstract
BACKGROUND Drugs can prevent postoperative nausea and vomiting, but their relative efficacies and side effects have not been compared within one systematic review. OBJECTIVES The objective of this review was to assess the prevention of postoperative nausea and vomiting by drugs and the development of any side effects. SEARCH METHODS We searched The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2004), MEDLINE (January 1966 to May 2004), EMBASE (January 1985 to May 2004), CINAHL (1982 to May 2004), AMED (1985 to May 2004), SIGLE (to May 2004), ISI WOS (to May 2004), LILAC (to May 2004) and INGENTA bibliographies. SELECTION CRITERIA We included randomized controlled trials that compared a drug with placebo or another drug, or compared doses or timing of administration, that reported postoperative nausea or vomiting as an outcome. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted outcome data. MAIN RESULTS We included 737 studies involving 103,237 people. Compared to placebo, eight drugs prevented postoperative nausea and vomiting: droperidol, metoclopramide, ondansetron, tropisetron, dolasetron, dexamethasone, cyclizine and granisetron. Publication bias makes evidence for differences among these drugs unreliable. The relative risks (RR) versus placebo varied between 0.60 and 0.80, depending upon the drug and outcome. Evidence for side effects was sparse: droperidol was sedative (RR 1.32) and headache was more common after ondansetron (RR 1.16). AUTHORS' CONCLUSIONS Either nausea or vomiting is reported to affect, at most, 80 out of 100 people after surgery. If all 100 of these people are given one of the listed drugs, about 28 would benefit and 72 would not. Nausea and vomiting are usually less common and, therefore, drugs are less useful. For 100 people, of whom 30 would vomit or feel sick after surgery if given placebo, 10 people would benefit from a drug and 90 would not. Between one to five patients out of every 100 people may experience a mild side effect, such as sedation or headache, when given an antiemetic drug. Collaborative research should focus on determining whether antiemetic drugs cause more severe, probably rare, side effects. Further comparison of the antiemetic effect of one drug versus another is not a research priority.
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Affiliation(s)
- John Carlisle
- Torbay Hospital, South Devon Healthcare NHS Foundation TrustDepartment of AnaestheticsLawes BridgeTorquayDevonUKTQ2 7AA
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Sanchez Munoz MC, De Kock M, Forget P. What is the place of clonidine in anesthesia? Systematic review and meta-analyses of randomized controlled trials. J Clin Anesth 2017; 38:140-153. [DOI: 10.1016/j.jclinane.2017.02.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 01/31/2017] [Accepted: 02/04/2017] [Indexed: 11/15/2022]
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Indermun S, Choonara YE, Kumar P, Du Toit LC, Modi G, Luttge R, Pillay V. Patient-Controlled Analgesia: Therapeutic Interventions Using Transdermal Electro-Activated and Electro-Modulated Drug Delivery. J Pharm Sci 2014; 103:353-66. [DOI: 10.1002/jps.23829] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 11/28/2013] [Accepted: 12/03/2013] [Indexed: 01/14/2023]
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Nitta R, Goyagi T, Nishikawa T. Combination of oral clonidine and intravenous low-dose ketamine reduces the consumption of postoperative patient-controlled analgesia morphine after spine surgery. ACTA ACUST UNITED AC 2013; 51:14-7. [PMID: 23711600 DOI: 10.1016/j.aat.2013.03.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 12/04/2012] [Accepted: 12/07/2012] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Because ketamine, clonidine, and morphine modulate nociceptive pain, coadministration of these drugs would augment the activity of postoperative analgesic drugs. The purpose of this study was to evaluate the effects of coadministration of ketamine and clonidine on postoperative morphine consumption in patients after spine surgery. METHODS The patients undergoing spine surgery were allocated randomly to one of the four study groups, which are as follows: group M (n = 12), intravenously (IV) administered patient-controlled analgesia (PCA) morphine alone; group MK (n = 12), IV-PCA morphine plus intra- and postoperative ketamine; group MC (n = 13), IV-PCA morphine plus oral clonidine premedication; group MCK (n = 12), IV-PCA morphine plus intra- and postoperative ketamine and clonidine premedication. The patients in the MC and MCK groups received 4 μg/kg clonidine orally, whereas those in the MK and MCK groups received IV bolus of ketamine (10 mg) at a rate of 2 mg/kg/hour during anesthesia. Patients were arranged to use IV-PCA mode for administration of drugs, which was programmed to deliver a bolus dose of 2-mg morphine (groups M and MC), or boluses of 2-mg morphine and 2-mg ketamine (groups MK and MCK). Scores of visual analog scale (VAS) for pain, morphine requirement, vital signs, nausea, sedation, and other side effects were followed up to 60 hours after surgery. RESULTS Although there were significant differences in VAS pain scores at rest 24-48 hours after the surgery, the VAS pain score at movement was similar among the groups. The number of PCA request and cumulative morphine requirement were significantly lower in the MCK group than in the M group. CONCLUSION This study results show that the administration of perioperative low-dose ketamine combined with clonidine premedication could reduce the consumption of postoperative PCA morphine following spine surgery.
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Affiliation(s)
- Rie Nitta
- Department of Anesthesia and Intensive Care Medicine, Akita University, Graduate School of Medicine, Akita, Japan
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Chandrakantan A, Glass PSA. Multimodal therapies for postoperative nausea and vomiting, and pain. Br J Anaesth 2012; 107 Suppl 1:i27-40. [PMID: 22156268 DOI: 10.1093/bja/aer358] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Postoperative nausea and vomiting (PONV) and pain are two of the major concerns for patients presenting for surgery. The causes of PONV are multifactorial and can largely be categorized as patient risk factors, anaesthetic technique, and surgical procedure. Antiemetics work on several different receptor sites to prevent or treat PONV. This is probably why numerous studies have now demonstrated that using more than one antiemetic is usually more effective and results in fewer side-effects than simply increasing the dose of a single antiemetic. A multimodal approach to PONV should not be limited to drug therapy alone but should involve a holistic approach starting before operation and continuing intraoperatively with risk reduction strategies to which are added prophylactic antiemetics according to the assessed patient risk for PONV. With the increasing understanding of the pathophysiology of acute pain, especially the occurrence of peripheral and central hypersensitization, it is unlikely that a single drug or intervention is sufficiently broad in its action to be adequately effective, especially with moderate or greater pain. Although morphine and its congeners are usually the foundation of pain management regimens, as their dose increases so does the incidence of side-effects. Thus, the approach for the management of acute postoperative pain is to use multiple drugs or modalities (e.g. regional anaesthesia) to maximize pain relief and reduce side-effects.
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Affiliation(s)
- A Chandrakantan
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, USA.
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American Society for Pain Management Nursing Guidelines on Monitoring for Opioid-Induced Sedation and Respiratory Depression. Pain Manag Nurs 2011; 12:118-145.e10. [DOI: 10.1016/j.pmn.2011.06.008] [Citation(s) in RCA: 171] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 06/28/2011] [Accepted: 06/28/2011] [Indexed: 11/21/2022]
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Chan AKM, Cheung CW, Chong YK. Alpha-2 agonists in acute pain management. Expert Opin Pharmacother 2010; 11:2849-68. [DOI: 10.1517/14656566.2010.511613] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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King KS, Darmani N, Adams KT, Pacak K. Exercise-induced nausea and vomiting: another sign and symptom of pheochromocytoma and paraganglioma. Endocrine 2010; 37:403-7. [PMID: 20960160 PMCID: PMC4130359 DOI: 10.1007/s12020-010-9319-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Accepted: 03/08/2010] [Indexed: 10/19/2022]
Abstract
A cohort of nine patients, mostly young adults, presented with a new sign/symptom of pheochromocytoma/paraganglioma: exercise-induced nausea and vomiting. The aims of this article are to introduce this sign/symptom and offer a possible hypothesis for the observation. Following a 2000 report from a paraganglioma patient experiencing exercise-induced nausea and vomiting, we began asking patients about instances of nausea and vomiting with exercise. A total of nine patients, 4.4% of our pheochromocytoma/paraganglioma population, presented with reports of exercise-induced nausea and vomiting, initially with moderate-to-intense levels of exercise, at the first presentation of their disease. All of these patients reported a cessation of exercise-induced nausea and vomiting following the removal of their primary tumor. Two patients with metastatic disease to the lungs reported a recurrence of exercise-induced nausea and vomiting. The majority of patients studied were young adults with mean onset age of 19.4 years (range of 9-51 years) and the mean age of diagnosis being 24.1 years (range of 11-53 years). Exercise-induced nausea and vomiting should be considered a sign/symptom of pheochromocytoma/paraganglioma and should be addressed in the clinical evaluation of these patients, especially in young adults. Whether exercise-induced elevated catecholamine levels could account for the induced nausea and vomiting via activation of adrenergic receptors in the area postrema remains to be established.
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Affiliation(s)
- Kathryn S. King
- Reproductive and Adult Endocrinology Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892, USA
| | - Nissar Darmani
- Department of Basic Medical Sciences and Research, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, California 91766, USA
| | - Karen T. Adams
- Reproductive and Adult Endocrinology Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892, USA
| | - Karel Pacak
- Reproductive and Adult Endocrinology Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892, USA
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Wijeysundera DN, Bender JS, Beattie WS. Alpha-2 adrenergic agonists for the prevention of cardiac complications among patients undergoing surgery. Cochrane Database Syst Rev 2009:CD004126. [PMID: 19821319 DOI: 10.1002/14651858.cd004126.pub2] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The surgical stress response plays an important role on the pathogenesis of perioperative cardiac complications. Alpha-2 adrenergic agonists attenuate this response and may thereby prevent cardiac complications. OBJECTIVES This review assessed the efficacy and safety of preoperative (within 24 hours), intraoperative, and postoperative (first 48 hours) alpha-2 adrenergic agonists for preventing mortality and cardiac complications after surgery performed under either general or neuraxial anaesthesia, or both. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 3), MEDLINE (1950 to August week 4 2008), EMBASE (1980 to week 36 2008), the Science Citation Index, and reference lists of articles. SELECTION CRITERIA We included randomized controlled trials that compared alpha-2 adrenergic agonists (clonidine, dexmedetomidine, or mivazerol) against placebo or non-alpha-2 adrenergic agonists. Included studies had to report on mortality, myocardial infarction, myocardial ischaemia, or supraventricular tachyarrhythmia. DATA COLLECTION AND ANALYSIS Three authors independently assessed trial quality and extracted data. Two authors independently performed computer entry of abstracted data. We contacted study authors for additional information. Adverse event data were gathered from the trials. MAIN RESULTS We included 31 studies (4578 participants). Study quality was generally inadequate, with only six studies clearly reporting methods for blinding and allocation concealment. Overall, alpha-2 adrenergic agonists reduced mortality (relative risk (RR) 0.66; 95% CI 0.44 to 0.98; P = 0.04) and myocardial ischaemia (RR 0.68; 95% CI 0.57 to 0.81; P < 0.0001). However, their effects appeared to vary with the surgical procedure. The most encouraging data pertained to vascular surgery, where they reduced mortality (RR 0.47; 95% CI 0.25 to 0.90; P = 0.02), cardiac mortality (RR 0.36; 95% CI 0.16 to 0.79; P = 0.01), and myocardial infarction (RR 0.66; 95% CI 0.46 to 0.94; P = 0.02). With regard to adverse effects, alpha-2 adrenergic agonists significantly increased perioperative hypotension (RR 1.32; 95% CI 1.07 to 1.62; P = 0.009) and bradycardia (RR 1.66; 95% CI 1.14 to 2.41; P = 0.008). AUTHORS' CONCLUSIONS Our study provides encouraging evidence that alpha-2 adrenergic agonists may reduce cardiac risk, especially during vascular surgery. Nonetheless, these data remain insufficient to make firm conclusions about their efficacy and safety. A large randomized trial of alpha-2 adrenergic agonists is therefore warranted. Additionally, future research must determine which specific alpha-2 adrenergic agonist should be used, and whether it is safe to combine them with other perioperative interventions (for example beta-adrenergic blockade).
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Affiliation(s)
- Duminda N Wijeysundera
- Department of Anesthesia, Toronto General Hospital and University of Toronto, EN 3-450, Toronto General Hospital,, 200 Elizabeth Street, Toronto, Ontario, Canada, M5G 2C4
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Farmery AD, Wilson-MacDonald J. The analgesic effect of epidural clonidine after spinal surgery: a randomized placebo-controlled trial. Anesth Analg 2009; 108:631-4. [PMID: 19151300 DOI: 10.1213/ane.0b013e31818e61b8] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Clonidine is an alpha(2) adrenoreceptor and imidazoline receptor agonist, which has analgesic, sedative, and minimum alveolar anesthetic concentration-sparing effects. It has been used orally, IV, and epidurally. In spinal surgery, there is a reluctance to use local anesthetic-based epidural analgesia postoperatively because of fears of masking important signs of nerve root or spinal cord injury. METHODS We randomized 66 patients undergoing uncomplicated decompressive spinal surgery to receive an epidural infusion of either clonidine (Group C) or saline placebo (Group P) postoperatively. Morphine consumption by patient-controlled analgesia device was recorded for 36 h. RESULTS Morphine consumption was significantly lower in Group C. The mean consumption at 36 h was 35 mg (95% confidence interval 21-50 mg) in Group C, compared with 61 mg (95% confidence interval 48-74 mg) in the control group. Nausea was significantly reduced in Group C (6.5%), when compared with placebo (38.2%). CONCLUSION Low-dose epidural clonidine significantly reduced the demand for morphine and reduced postoperative nausea with few side effects.
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Affiliation(s)
- Andrew D Farmery
- Nuffield Department of Anaesthetics, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK.
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[Patient-controlled analgesia. Pain and Locoregional Anesthesia Committee and the Standards Committee of the French Society of Anesthesia and Intensive Care]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2009; 28:e49-59. [PMID: 19186023 DOI: 10.1016/j.annfar.2008.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Yeh YC, Lin TF, Lin FS, Wang YP, Lin CJ, Sun WZ. Combination of opioid agonist and agonist-antagonist: patient-controlled analgesia requirement and adverse events among different-ratio morphine and nalbuphine admixtures for postoperative pain. Br J Anaesth 2008; 101:542-548. [PMID: 18640992 DOI: 10.1093/bja/aen213] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND Nalbuphine, a mixed agonist-antagonist opioid, has a potential to attenuate the mu-opioid effects and to enhance the kappa-opioid effects. However, when morphine and nalbuphine are mixed together, the clinical interactions in different combining ratios on analgesic effect and adverse events are unknown. METHODS This randomized, double-blind controlled study investigated five different combining ratios of morphine and nalbuphine in 311 patients undergoing gynaecologic operations. The concentrations [morphine (mg ml(-1))]/[nalbuphine (mg ml(-1))] were 1/0 in Group 1, 0.75/0.25 (ratio 1:3) in Group 2, 0.5/0.5 (ratio 1:1) in Group 3, 0.25/0.75 (ratio 3:1) in Group 4, and 0/1 in Group 5. Patient-controlled analgesia (PCA) requirement, postoperative pain, and adverse events were evaluated throughout the postoperative 24 h period. RESULTS Twenty-four hour PCA requirements were similar among the five groups. Verbal rating scores for pain were statistically higher in Groups 2 and 4 than in Group 3. The incidences of pruritus were higher in Group 1 (15.6%) than in Group 2 (6.2%), Group 3 (3.4%), Group 4 (1.6%), and Group 5 (0%). The incidences and severity of dizziness, nausea, and vomiting were not significantly different. CONCLUSIONS The interaction between morphine and nalbuphine in PCA admixture on analgesia is additive. Combinations of morphine and nalbuphine in PCA can decrease the incidence of pruritus, and the antipruritus effect is ratio-dependent. This may provide a novel combination strategy of opioid agonist and agonist-antagonist for postoperative pain management after gynaecologic surgery.
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Affiliation(s)
- Y-C Yeh
- Department of Anaesthesiology, National Taiwan University Hospital, No. 7, Chung San South Road, Taipei, Taiwan, Republic of China
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Abstract
The anesthetic management of the MO patient requires an important focus on a number of issues beginning with a careful preoperative evaluation and synthesizing pre-existing disease processes with the anesthetic management plan. The common misperception that all MO patients are "full stomach" has been challenged and may be a nonissue. New approaches to pre-oxygenation to lessen the likelihood of desaturation during apnea may be a valuable tool if difficulty is encountered in tracheal intubation. In addition, promising results have been demonstrated with the use of the ILMA for ventilation and for blindly establishing tracheal tube placement. Proper patient positioning is essential to aid in successful intubation when a laryngoscope is employed. Intraoperative anesthetic management can be guided with a processed electroencephalogram monitor to help improve emergence and to enhance wakefulness in the PACU. Careful consideration must be given to postoperative analgesic needs by minimizing the use of opioids and employing nonopioid analgesics including NSAIDs, alpha2-adrenergic agonists, and low doses of ketamine.
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Affiliation(s)
- Thomas J Ebert
- The Medical College of Wisconsin, VA Medical Center, Anesthesiology/112A, 5000 W. National Avenue, Milwaukee, WI 53295, USA.
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Abstract
BACKGROUND Drugs can prevent postoperative nausea and vomiting, but their relative efficacies and side effects have not been compared within one systematic review. OBJECTIVES The objective of this review was to assess the prevention of postoperative nausea and vomiting by drugs and the development of any side effects. SEARCH STRATEGY We searched The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2004), MEDLINE (January 1966 to May 2004), EMBASE (January 1985 to May 2004), CINAHL (1982 to May 2004), AMED (1985 to May 2004), SIGLE (to May 2004), ISI WOS (to May 2004), LILAC (to May 2004) and INGENTA bibliographies. SELECTION CRITERIA We included randomized controlled trials that compared a drug with placebo or another drug, or compared doses or timing of administration, that reported postoperative nausea or vomiting as an outcome. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted outcome data. MAIN RESULTS We included 737 studies involving 103,237 people. Compared to placebo, eight drugs prevented postoperative nausea and vomiting: droperidol, metoclopramide, ondansetron, tropisetron, dolasetron, dexamethasone, cyclizine and granisetron. Publication bias makes evidence for differences among these drugs unreliable. The relative risks (RR) versus placebo varied between 0.60 and 0.80, depending upon the drug and outcome. Evidence for side effects was sparse: droperidol was sedative (RR 1.32) and headache was more common after ondansetron (RR 1.16). AUTHORS' CONCLUSIONS Either nausea or vomiting is reported to affect, at most, 80 out of 100 people after surgery. If all 100 of these people are given one of the listed drugs, about 28 would benefit and 72 would not. Nausea and vomiting are usually less common and, therefore, drugs are less useful. For 100 people, of whom 30 would vomit or feel sick after surgery if given placebo, 10 people would benefit from a drug and 90 would not. Between one to five patients out of every 100 people may experience a mild side effect, such as sedation or headache, when given an antiemetic drug. Collaborative research should focus on determining whether antiemetic drugs cause more severe, probably rare, side effects. Further comparison of the antiemetic effect of one drug versus another is not a research priority.
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Affiliation(s)
- J B Carlisle
- NHS, Department of Anaesthetics, Torbay Hospital, Lawes Bridge, Torquay, Devon, UK EX6 7LU.
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Brill S, Ginosar Y, Davidson EM. Perioperative management of chronic pain patients with opioid dependency. Curr Opin Anaesthesiol 2006; 19:325-31. [PMID: 16735818 DOI: 10.1097/01.aco.0000192813.38236.99] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW In this article, we discuss the perioperative anesthesia and pain management of patients with chronic pain receiving chronic opioid administration. In our practice we may expect to be confronted with opioid-dependent patients in routine anesthesia practice and should acquire specific knowledge and skills to effectively manage the perioperative and acute pain management issues that arise. RECENT FINDINGS The number of patients treated chronically with opioids has increased steadily over the past decade; currently about 10% of all chronic-pain patients are treated with opioids. As these patients are no longer confined to terminally ill cancer patients, growing numbers of these patients are facing surgical interventions. SUMMARY In our clinical practice, we should employ multimodal pain management therapy by using an around-the-clock regimen of nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, acetaminophen, and regional blockade. Dosing regimens should be individualized to optimize efficacy while minimizing the risk of adverse events.
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Affiliation(s)
- Silviu Brill
- Sheba Medical Center, Department of Anesthesia and Intensive Care, Tel Hashomer, and Department of Anesthesiology and Critical Care Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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Abstract
One of the most common methods for providing postoperative analgesia is via patient-controlled analgesia (PCA). Although the typical approach is to administer opioids via a programmable infusion pump, other drugs and other modes of administration are available. This article reviews the history and practice of many aspects of PCA and provides extensive guidelines for the practice of PCA-administered opioids. In addition, potential adverse effects and recommendations for their monitoring and treatment are reviewed.
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Affiliation(s)
- Jeffrey A Grass
- Department of Anesthesiology, Western Pennsylvania Hospital and Allegheny General Hospital, Pittsburgh, Pennsylvania
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Abstract
Given the expanding role of ambulatory surgery and the need to facilitate an earlier hospital discharge, improving postoperative pain control has become an increasingly important issue for all anesthesiologists. As a result of the shift from inpatient to outpatient surgery, the use of IV patient-controlled analgesia and continuous epidural infusions has steadily declined. To manage the pain associated with increasingly complex surgical procedures on an ambulatory or short-stay basis, anesthesiologists and surgeons should prescribe multimodal analgesic regimens that use non-opioid analgesics (e.g., local anesthetics, nonsteroidal antiinflammatory drugs, cyclooxygenase inhibitors, acetaminophen, ketamine, alpha 2-agonists) to supplement opioid analgesics. The opioid-sparing effects of these compounds may lead to reduced nausea, vomiting, constipation, urinary retention, respiratory depression and sedation. Therefore, use of non-opioid analgesic techniques can lead to an improved quality of recovery for surgical patients.
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Affiliation(s)
- Paul F White
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
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Abstract
Patient-controlled analgesia was introduced as a technique that would allow greater flexibility in opioid delivery for the management of acute pain. However, so far, any benefit compared with conventional methods of pain relief appears to be small. This article reviews some of the factors that could limit the usefulness of intravenous patient-controlled analgesia in the clinical setting and what strategies might allow patient-controlled analgesia to become more effective.
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Affiliation(s)
- Pamela E Macintyre
- Department of Anaesthesia, Acute Pain Service, Hyperbaric and Pain Medicine, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, 5000 Australia.
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Abstract
Patient-controlled analgesia (PCA) has become the gold standard for acute pain management since it was first introduced 20 years ago, and its merits have been discussed in quite a large number of publications. This review summarizes the more recent developments, such as new application devices and strategies, including intranasal, spinal, and regional PCA; patient-controlled sedation; experience with children and elderly people; and some data from chronic pain situations. Analyzing PCA literature from 2001 onwards confirms the author's long belief that the PCA principle ("WYNIWYG": what you need is what you get) was the most important aspect of a patient-controlled strategy, more or less independent of the type of drug or machine. Discovering this principle has changed the understanding of pain and suffering.
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Affiliation(s)
- Klaus A Lehmann
- Department of Anesthesiology, University of Cologne, Cologne, Germany
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Abstract
Postoperative pain remains a major problem. A multi-modal analgesic approach is recommended to optimize pain management and reduce opiate-related adverse effects. Several analgesic adjuncts have been investigated, and many have proved to have a useful analgesic effect. This article reviews the literature regarding use of analgesic adjuncts in the perioperative period.
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Affiliation(s)
- Ashraf S Habib
- Department of Anesthesiology, Duke University Medical Center, Box 3094, Durham, NC 27710, USA
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Abstract
This review covers beta-phenylethylamines and isoquinoline alkaloids derived from them, including further products of oxidation. condensation with formaldehyde and rearrangement, some of which do not contain an isoquinoline system, together with naphthylisoquinoline alkaloids, which have a different biogenetic origin. The occurrence of the alkaloids, with the structures of new bases, together with their reactions, syntheses and biological activities are reported. The literature from July 2002 to June 2003 is reviewed, with 568 references cited.
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Abstract
This paper is the twenty-fifth consecutive installment of the annual review of research concerning the endogenous opioid system, now spanning over a quarter-century of research. It summarizes papers published during 2002 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurologic disorders (Section 11); electrical-related activity and neurophysiology (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration and thermoregulation (Section 16); and immunological responses (Section 17).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, CUNY, 65-30 Kissena Blvd., Flushing, NY 11367, USA.
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Carey C, Jagger S. Comparison of morphine alone with morphine plus clonidine for postoperative patient-controlled analgesia. Br J Anaesth 2003; 90:253; author reply 253. [PMID: 12538390 DOI: 10.1093/bja/aeg513] [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: 11/12/2022] Open
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