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Ni Y, Huang R, Yang S, Yang XY, Zeng S, Yao A, Huang J, Yang G. Pharmacokinetics and Safety of Oliceridine Fumarate Injection in Chinese Patients with Chronic Non-Cancer Pain: A Phase I, Single-Ascending-Dose, Open-Label Clinical Trial. Drug Des Devel Ther 2024; 18:2729-2743. [PMID: 38974123 PMCID: PMC11227858 DOI: 10.2147/dddt.s461416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 06/25/2024] [Indexed: 07/09/2024] Open
Abstract
Background Oliceridine is a novel G protein-biased ligand μ-opioid receptor agonist. This study aimed to assess the pharmacokinetics and safety profile of single-ascending doses of oliceridine fumarate injection in Chinese patients with chronic non-cancer pain. Methods Conducted as a single-center, open-label trial, this study administered single doses of 0.75, 1.5, and 3.0 mg to 32 adult participants. The trial was conducted in two parts. First, we conducted a preliminary test comprising the administration of a single dose of 0.75mg to 2 participants. Then, we conducted the main trial involving intravenous administration of escalating doses of oliceridine fumarate (0.75 to 3 mg) to 30 participants. Pharmacokinetic (PK) parameters were derived using non-compartmental analysis. Additionally, the safety evaluation encompassed the monitoring of adverse events (AEs). Results 32 participants were included in the PK and safety analyses. Following a 2-min intravenous infusion of oliceridine fumarate injection (0.75, 1.5, or 3 mg), Cmax and Tmax ranged from 51.293 to 81.914 ng/mL and 0.034 to 0.083 h, respectively. AUC0-t and half-life (t1/2) increased more than proportionally with dosage (1.85-2.084 h). Treatment emergent adverse events (TEAEs) were found to be consistent with the commonly reported adverse effects of opioids, both post-administration and as documented in the original trials conducted in the United States. Critically, no serious adverse events were observed. Conclusion Oliceridine demonstrated comparable PK parameters and a consistent PK profile in the Chinese population, in line with the PK results observed in the original trials conducted in the United States. Oliceridine was safe and well tolerated in Chinese patients with chronic non-cancer pain at doses ranging from 0.75 mg to 3.0 mg. Trial Registration The trial is registered at chictr.org.cn (ChiCTR2100047180).
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Affiliation(s)
- Yuncheng Ni
- Department of Pain, The Third Xiangya Hospital and Institute of Pain Medicine, Central South University, Changsha, Hunan, 410013, People’s Republic of China
| | - Ranglang Huang
- Department of General Surgery, The Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, People’s Republic of China
| | - Shuang Yang
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, People’s Republic of China
| | - Xiao Yan Yang
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, People’s Republic of China
| | - Shan Zeng
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, People’s Republic of China
| | - An Yao
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, People’s Republic of China
| | - Jie Huang
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, People’s Republic of China
| | - Guoping Yang
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, People’s Republic of China
- Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, Hunan, 410013, People’s Republic of China
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Selvamani BJ, Kalagara H, Volk T, Narouze S, Childs C, Patel A, Seering MS, Benzon HT, Sondekoppam RV. Infectious complications following regional anesthesia: a narrative review and contemporary estimates of risk. Reg Anesth Pain Med 2024:rapm-2024-105496. [PMID: 38839428 DOI: 10.1136/rapm-2024-105496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 05/22/2024] [Indexed: 06/07/2024]
Abstract
INTRODUCTION Infectious complications following regional anesthesia (RA) while rare, can be devastating. The objective of this review was to estimate the risk of infectious complications following central neuraxial blocks (CNB) such as epidural anesthesia (EA), spinal anesthesia (SA) and combined spinal epidural (CSE), and peripheral nerve blocks (PNB). MATERIALS AND METHODS A literature search was conducted in PubMed, Embase and Cochrane databases to identify reference studies reporting infectious complications in the context of RA subtypes. Both prospective and retrospective studies providing incidence of infectious complications were included for review to provide pooled estimates (with 95% CI). Additionally, we explored incidences specifically associated with spinal anesthesia, incidences of central nervous system (CNS) infections and, the incidences of overall and CNS infections following CNB in obstetric population. RESULTS The pooled estimate of overall infectious complications following all CNB was 9/100 000 (95% CI: 5, 13/100 000). CNS infections following all CNB was estimated to be 2/100 000 (95% CI: 1, 3/100 000) and even rarer following SA (1/100 000 (95% CI: 1, 2/100 000)). Obstetric population had a lower rate of overall (1/100 000 (95% CI: 1, 3/100 000)) and CNS infections (4 per million (95% CI: 0.3, 1/100 000)) following all CNB. For PNB catheters, the reported rate of infectious complications was 1.8% (95% CI: 1.2, 2.5/100). DISCUSSION Our review suggests that the risk of overall infectious complications following neuraxial anesthesia is very rare and the rate of CNS infections is even rarer. The infectious complications following PNB catheters seems significantly higher compared with CNB. Standardizing nomenclature and better reporting methodologies are needed for the better estimation of the infectious complications.
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Affiliation(s)
| | - Hari Kalagara
- Department of Anesthesiology and Perioperative Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Samer Narouze
- Western Reserve Hospital Partners, Cuyahoga Falls, Ohio, USA
| | | | - Aamil Patel
- University of Iowa Health Care, Iowa City, Iowa, USA
| | | | - Honorio T Benzon
- Departments of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rakesh V Sondekoppam
- Department of Anesthesia, University of Iowa Healthcare, Iowa City, Iowa, USA
- Department of Anesthesia and Pain Medicine, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
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Zugaj MR, Gutzeit O, Mayer VL, Ishak B, Gumbinger C, Weigand MA, Keßler J. Incomplete sensorimotor paresis after upper abdominal surgery with TEA and spinal epidural lipomatosis: a case report. Reg Anesth Pain Med 2024; 49:465-468. [PMID: 38580340 DOI: 10.1136/rapm-2024-105342] [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: 01/25/2024] [Accepted: 03/24/2024] [Indexed: 04/07/2024]
Abstract
INTRODUCTION This case report documents a postoperative, incomplete sensorimotor paraparesis from thoracic vertebral body 6 (Th6) after combined anesthesia for upper abdominal surgery in a patient who had a thoracic localization of spinal epidural lipomatosis (SEL). CASE PRESENTATION The patient was treated in our clinic with a thoracic epidural catheter (TEA) for perioperative analgesia during a partial duodenopancreatectomy. Paraparetic symptoms occurred 20 hours after surgery. Initial MRI did not show bleeding, infection or spinal cord damage and the neurosurgeon consultants recommended observation. The neurological examination and the third follow-up MRI on 15th postoperative day showed ventrolateral damage of the spinal cord at level Th6. It is possible that local anesthetic compressed the spinal cord in addition to the existing lipomatosis and the thoracic kyphosis. The paraparesis improved during follow-up paraplegiologic treatment. CONCLUSION So far, only two uncomplicated lumbar epidural catheter anesthesias have been described in patients who had a lumbar SEL. Epidural catheter anesthesia is a safe and effective method of pain control. But it is important to carefully identify and stratify patients with risk factors during the premedication visit. In patients who had kyphosis and thoracic localization of SEL, TEA may only be used after a risk-benefit assessment.
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Affiliation(s)
- Marco Richard Zugaj
- Heidelberg University, Medical Faculty, Department of Anesthesiology, Heidelberg, Baden-Württemberg, Germany
| | - Oliver Gutzeit
- Heidelberg University, Medical Faculty, Department of Anesthesiology, Heidelberg, Baden-Württemberg, Germany
| | - Victoria Louise Mayer
- Heidelberg University, Medical Faculty, Department of Nuclear Medicine, Heidelberg, Baden-Württemberg, Germany
| | - Basem Ishak
- Heidelberg University, Medical Faculty, Department of Neurosurgery, Heidelberg, Baden-Württemberg, Germany
| | - Christoph Gumbinger
- Heidelberg University, Medical Faculty, Department of Neurology, Heidelberg, Baden-Württemberg, Germany
| | - Markus Alexander Weigand
- Heidelberg University, Medical Faculty, Department of Anesthesiology, Heidelberg, Baden-Württemberg, Germany
| | - Jens Keßler
- Heidelberg University, Medical Faculty, Department of Anesthesiology, Heidelberg, Baden-Württemberg, Germany
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Küçük O, Sarı E, Zengin M, Ülger G, Öztürk Yalçın F, Baldemir R, Tunç M, Alagöz A. The Effect of Preprocedural Low-Dose Ketamine for Pain and Anxiety in Patients during Thoracic Epidural Catheterization. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:679. [PMID: 38674325 PMCID: PMC11052147 DOI: 10.3390/medicina60040679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 04/15/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024]
Abstract
Background and Objectives: Thoracic epidural catheterization (TEC) can be both uncomfortable and fearful for patients when performed awake with the thought that the procedure may be painful. The aim of this study was to assess the effect of low-dose intravenous ketamine administration on pain and anxiety during the TEC procedure. Materials and Methods: Sixty patients were randomly divided into two groups to receive intravenous (IV) placebo (Group P) and IV low-dose (0.15 mg/kg) ketamine (LDK) (Group K) 3 min before the procedure in a double-blind manner. A visual analog scale (VAS) was used to measure anxiety (VAS-A) and pain (VAS-P) scores. Vital parameters were monitored before premedication (T1), 20 min after premedication (T2), during skin anesthesia (T3), during TEC (T4), and 5 min after TEC (T5). VAS-A values were recorded at T1, T3, T4, and T5 periods, and VAS-P levels were noted at T3, T4, and T5 periods. Results: During TEC (T4), both VAS-P and VAS-A were significantly lower in Group K (p < 0.001). The mean VAS-A value was 10.6 mm lower, and the mean VAS-P value was 9 mm lower in Group K than in Group P at the T4 time point. Additionally, the mean VAS-P value was 7.7 mm lower in Group K compared to Group P at the T3 time point (p < 0.001). Both groups showed a statistically significant difference in VAS-A measurements when compared at their respective time points (p < 0.001). However, only Group P demonstrated a statistically significant difference in VAS-P measurements (p < 0.001). VAS-P values remained stable in Group K. The number of patients who did not recall the procedure was significantly higher in Group K (p < 0.001). Furthermore, the number of patients who would consent to the same procedure in the future was significantly higher in Group K (p = 0.007). Conclusions: A preprocedural LDK (0.15 mg/kg) can effectively prevent anxiety and pain experienced by patients during the TEC procedure. Administration of LDK may provide a more comfortable procedure process without causing ketamine-induced side effects (hemodynamic, respiratory, and psychological).
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Affiliation(s)
- Onur Küçük
- Department of Anesthesiology and Reanimation, Ankara Atatürk Sanatoryum Training and Research Hospital, University of Health Sciences, 06290 Ankara, Turkey; (O.K.); (R.B.)
| | - Esra Sarı
- Department of Anesthesiology and Reanimation, Ankara Atatürk Sanatoryum Training and Research Hospital, University of Health Sciences, 06290 Ankara, Turkey; (O.K.); (R.B.)
| | - Musa Zengin
- Department of Anesthesiology and Reanimation, Ankara Etlik City Hospital, Ministry of Health, 06170 Ankara, Turkey
| | - Gülay Ülger
- Department of Anesthesiology and Reanimation, Ankara Atatürk Sanatoryum Training and Research Hospital, University of Health Sciences, 06290 Ankara, Turkey; (O.K.); (R.B.)
| | - Fatma Öztürk Yalçın
- Department of Anesthesiology and Reanimation, Ankara Atatürk Sanatoryum Training and Research Hospital, University of Health Sciences, 06290 Ankara, Turkey; (O.K.); (R.B.)
| | - Ramazan Baldemir
- Department of Anesthesiology and Reanimation, Ankara Atatürk Sanatoryum Training and Research Hospital, University of Health Sciences, 06290 Ankara, Turkey; (O.K.); (R.B.)
| | - Mehtap Tunç
- Department of Anesthesiology and Reanimation, Ankara Atatürk Sanatoryum Training and Research Hospital, University of Health Sciences, 06290 Ankara, Turkey; (O.K.); (R.B.)
| | - Ali Alagöz
- Department of Anesthesiology and Reanimation, Ankara Atatürk Sanatoryum Training and Research Hospital, University of Health Sciences, 06290 Ankara, Turkey; (O.K.); (R.B.)
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van den Heuvel SA, van Boekel RL, Cox FJ, Ferré F, Minville V, Stamer UM, Vissers KC, Pogatzki-Zahn EM. Perioperative pain management models in four European countries: A narrative review of differences, similarities and future directions. Eur J Anaesthesiol 2024; 41:188-198. [PMID: 37889549 DOI: 10.1097/eja.0000000000001919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
There is general agreement that acute pain management is an important component of perioperative medicine. However, there is no consensus on the best model of care for perioperative pain management, mainly because evidence is missing in many aspects. Comparing the similarities and differences between countries might reveal some insights into different organisational models and how they work. Here, we performed a narrative review to describe and compare the structures, processes and outcomes of perioperative pain management in the healthcare systems of four European countries using Donabedian's framework as a guide. Our comparison revealed many similarities, differences and gaps. Different structures of acute pain services in the four countries with no common definition and standards of care were found. Protocols have been implemented in all countries and guidelines in some. If outcome is assessed, it is mainly pain intensity, and many patients experiencing more intense pain than others have common risk factors (e.g. preoperative pain, preoperative opioid intake, female sex and young age). Outcome assessment beyond pain intensity (such as pain-related physical function, which is important for early rehabilitation and recovery) is currently not well implemented. Developing common quality indicators, a European guideline for perioperative pain management (e.g. for patients at high risk for experiencing severe pain and other outcome parameters) and common criteria for acute pain services might pave the way forward for improving acute pain management in Europe. Finally, the education of general and specialist staff should be aligned in Europe, for example, by using the curricula of the European Pain Federation (EFIC).
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Affiliation(s)
- Sandra A van den Heuvel
- From the Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands (SAvdH, RLvB, KCV), Department of Anaesthesiology and Critical Care, Royal Brompton & Harefield Hospitals part of GSST, London, United Kingdom (FJC), Département d'Anaesthésie-Réanimation, Hôpital Pierre-Paul Riquet, Centre Hospitalo-universitaire Purpan, Toulouse, France (FF, VM), Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (UMS) and Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Muenster, Muenster, Germany (EMPZ)
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Oostvogels L, Weibel S, Meißner M, Kranke P, Meyer-Frießem CH, Pogatzki-Zahn E, Schnabel A. Erector spinae plane block for postoperative pain. Cochrane Database Syst Rev 2024; 2:CD013763. [PMID: 38345071 PMCID: PMC10860379 DOI: 10.1002/14651858.cd013763.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
BACKGROUND Acute and chronic postoperative pain are important healthcare problems, which can be treated with a combination of opioids and regional anaesthesia. The erector spinae plane block (ESPB) is a new regional anaesthesia technique, which might be able to reduce opioid consumption and related side effects. OBJECTIVES To compare the analgesic effects and side effect profile of ESPB against no block, placebo block or other regional anaesthetic techniques. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Web of Science on 4 January 2021 and updated the search on 3 January 2022. SELECTION CRITERIA Randomised controlled trials (RCTs) investigating adults undergoing surgery with general anaesthesia were included. We included ESPB in comparison with no block, placebo blocks or other regional anaesthesia techniques irrespective of language, publication year, publication status or technique of regional anaesthesia used (ultrasound, landmarks or peripheral nerve stimulator). Quasi-RCTs, cluster-RCTs, cross-over trials and studies investigating co-interventions in either arm were excluded. DATA COLLECTION AND ANALYSIS Two review authors independently assessed all trials for inclusion and exclusion criteria, and risk of bias (RoB), and extracted data. We assessed risk of bias using the Cochrane RoB 2 tool, and we used GRADE to rate the certainty of evidence for the primary outcomes. The primary outcomes were postoperative pain at rest at 24 hours and block-related adverse events. Secondary outcomes were postoperative pain at rest (2, 48 hours) and during activity (2, 24 and 48 hours after surgery), chronic pain after three and six months, as well as cumulative oral morphine requirements at 2, 24 and 48 hours after surgery and rates of opioid-related side effects. MAIN RESULTS We identified 69 RCTs in the first search and included these in the systematic review. We included 64 RCTs (3973 participants) in the meta-analysis. The outcome postoperative pain was reported in 38 out of 64 studies; block-related adverse events were reported in 40 out of 64 studies. We assessed RoB as low in 44 (56%), some concerns in 24 (31%) and high in 10 (13%) of the study results. Overall, 57 studies reported one or both primary outcomes. Only one study reported results on chronic pain after surgery. In the updated literature search on 3 January 2022 we found 37 new studies and categorised these as awaiting classification. ESPB compared to no block There is probably a slight but not clinically relevant reduction in pain intensity at rest 24 hours after surgery in patients treated with ESPB compared to no block (visual analogue scale (VAS), 0 to 10 points) (mean difference (MD) -0.77 points, 95% confidence interval (CI) -1.08 to -0.46; 17 trials, 958 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between the groups treated with ESPB and those receiving no block (no events in 18 trials reported, 1045 participants, low-certainty evidence). ESPB compared to placebo block ESPB probably has no effect on postoperative pain intensity at rest 24 hours after surgery compared to placebo block (MD -0.14 points, 95% CI -0.29 to 0.00; 8 trials, 499 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between ESPB and placebo blocks (no events in 10 trials reported; 592 participants; low-certainty evidence). ESPB compared to other regional anaesthetic techniques Paravertebral block (PVB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PVB (MD 0.23 points, 95% CI -0.06 to 0.52; 7 trials, 478 participants; low-certainty evidence). There is probably no difference in block-related adverse events (risk ratio (RR) 0.27, 95% CI 0.08 to 0.95; 7 trials, 522 participants; moderate-certainty evidence). Transversus abdominis plane block (TAPB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to TAPB (MD -0.16 points, 95% CI -0.46 to 0.14; 3 trials, 160 participants; low-certainty evidence). There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.21 to 4.83; 4 trials, 202 participants; low-certainty evidence). Serratus anterior plane block (SAPB) The effect on postoperative pain could not be assessed because no studies reported this outcome. There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.06 to 15.59; 2 trials, 110 participants; low-certainty evidence). Pectoralis plane block (PECSB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PECSB (MD 0.24 points, 95% CI -0.11 to 0.58; 2 trials, 98 participants; low-certainty evidence). The effect on block-related adverse events could not be assessed. Quadratus lumborum block (QLB) Only one study reported on each of the primary outcomes. Intercostal nerve block (ICNB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to ICNB, but this is uncertain (MD -0.33 points, 95% CI -3.02 to 2.35; 2 trials, 131 participants; very low-certainty evidence). There may be no difference in block-related adverse events, but this is uncertain (RR 0.09, 95% CI 0.04 to 2.28; 3 trials, 181 participants; very low-certainty evidence). Epidural analgesia (EA) We are uncertain whether ESPB has an effect on postoperative pain intensity at rest 24 hours after surgery compared to EA (MD 1.20 points, 95% CI -2.52 to 4.93; 2 trials, 81 participants; very low-certainty evidence). A risk ratio for block-related adverse events was not estimable because only one study reported this outcome. AUTHORS' CONCLUSIONS ESPB in addition to standard care probably does not improve postoperative pain intensity 24 hours after surgery compared to no block. The number of block-related adverse events following ESPB was low. Further research is required to study the possibility of extending the duration of analgesia. We identified 37 new studies in the updated search and there are three ongoing studies, suggesting possible changes to the effect estimates and the certainty of the evidence in the future.
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Affiliation(s)
- Lisa Oostvogels
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Stephanie Weibel
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Michael Meißner
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Peter Kranke
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Christine H Meyer-Frießem
- Department of Anaesthesiology, Intensive Care Medicine and Pain Management, BG-Universitätsklinikum Bergmannsheil gGmbH, Bochum, Germany
| | - Esther Pogatzki-Zahn
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Alexander Schnabel
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
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Shawqi M, Mohamed SAB, Hetta D. Could epidural analgesia be safely used for acute postoperative pain in older adults to enhance recovery? J Perioper Pract 2024; 34:39-46. [PMID: 36515403 DOI: 10.1177/17504589221135368] [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] [Indexed: 12/15/2022]
Abstract
Epidural analgesia is often considered cornerstone in multimodal analgesia when used in major surgeries. However, its role in managing acute postoperative pain in elderly patients is debatable because of its known potential complications. Furthermore, postoperative pain in elderly patients is under-treated because of complex comorbidities, and they are more prone to adverse events related to pain therapies. All systemic analgesic drugs have pharmacological limitations and precautions in elderly people. Recent meta-analyses showed that epidural analgesia provided better postoperative pain control compared to intravenous opioids. Interestingly, peripheral nerve blocks had no superior control of pain over epidural analgesia. In addition, epidural analgesia has shown to positively affect perioperative morbidities and mortalities, and reduce opioid-related side effects because of its non-analgesic effects on each organ system. When tailored in a specific multimodal approach, it shortens the intensive care and hospital stays. In conclusion, if complications are identified and treated early, and contraindications are ruled out, epidural analgesia can achieve sufficient postoperative pain management with insignificant adverse events in this population.
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Affiliation(s)
- Muhammad Shawqi
- South Egypt Cancer Institute, Assuit University, Assiut, Egypt
| | | | - Diab Hetta
- South Egypt Cancer Institute, Assuit University, Assiut, Egypt
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Barry G, Sehmbi H, Retter S, Bailey JG, Tablante R, Uppal V. Comparative efficacy and safety of non-neuraxial analgesic techniques for midline laparotomy: a systematic review and frequentist network meta-analysis of randomised controlled trials. Br J Anaesth 2023; 131:1053-1071. [PMID: 37770254 DOI: 10.1016/j.bja.2023.08.024] [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: 05/12/2023] [Revised: 07/24/2023] [Accepted: 08/12/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Fascial plane blocks provide effective analgesia after midline laparotomy; however, the most efficacious technique has not been determined. We conducted a systematic review and network meta-analysis of randomised controlled trials to synthesise the evidence with respect to pain, opioid consumption, and adverse events. METHODS We searched Ovid MEDLINE, Embase, Cochrane Central, and Scopus databases for studies comparing commonly used non-neuraxial analgesic techniques for midline laparotomy in adult patients. The co-primary outcomes of the study were 24-h cumulative opioid consumption and 24-h resting pain score, reported as i.v. morphine equivalents and 11-point numerical rating scale, respectively. We performed a frequentist meta-analysis using a random-effects model and a cluster-rank analysis of the co-primary outcomes. RESULTS Of 6115 studies screened, 67 eligible studies were included (n=4410). Interventions with the greatest reduction in 24-h cumulative opioid consumption compared with placebo/no intervention were single-injection quadratus lumborum block (sQLB; mean difference [MD] -16.1 mg, 95% confidence interval [CI] -29.9 to -2.3, very low certainty), continuous transversus abdominis plane block (cTAP; MD -14.0 mg, 95% CI -21.6 to -6.4, low certainty), single-injection transversus abdominis plane block (sTAP; MD -13.7 mg, 95% CI -17.4 to -10.0, low certainty), and continuous rectus sheath block (cRSB; MD -13.2 mg, 95% CI -20.3 to -6.1, low certainty). Interventions with the greatest reduction in 24-h resting pain score were cRSB (MD -1.2, 95% CI -1.8 to -0.6, low certainty), cTAP (MD -1.0, 95% CI -1.7 to -0.2, low certainty), and continuous wound infusion (cWI; MD -0.7, 95% CI -1.1 to -0.4, low certainty). Clustered-rank analysis including the co-primary outcomes showed cRSB and cTAP blocks to be the most efficacious interventions. CONCLUSIONS Based on current evidence, continuous rectus sheath block and continuous transversus abdominis plane block were the most efficacious non-neuraxial techniques at reducing 24-h cumulative opioid consumption and 24-h resting pain scores after midline laparotomy (low certainty). Future studies should compare techniques for upper vs lower midline laparotomy and other non-midline abdominal incisions. CLINICAL TRIAL REGISTRATION PROSPERO Registration Number: CRD42021269044.
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Affiliation(s)
- Garrett Barry
- Department of Anesthesia, Pain Management and Perioperative Medicine, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS, Canada
| | - Herman Sehmbi
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, ON, Canada
| | - Susanne Retter
- Department of Anesthesia, Pain Management and Perioperative Medicine, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS, Canada
| | - Jonathan G Bailey
- Department of Anesthesia, Pain Management and Perioperative Medicine, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS, Canada
| | - Rose Tablante
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, ON, Canada
| | - Vishal Uppal
- Department of Anesthesia, Pain Management and Perioperative Medicine, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS, Canada.
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Akcelik OB, Ayhan H, Tastan S. Comparison of the Effects of Body Mechanics Education Methods on Pain, Disability, and Quality of Life: A Randomized Controlled Study. Pain Manag Nurs 2023; 24:e152-e159. [PMID: 37775441 DOI: 10.1016/j.pmn.2023.08.009] [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: 06/20/2022] [Revised: 08/17/2023] [Accepted: 08/20/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Educating patients undergoing surgery for LDH is important to maintain the proper performance of body mechanics. PURPOSE The study compared the effects of standard, brochure-based, and video-based education on postoperative pain, disability, and the quality of life in patients undergoing surgery for lumbar disc herniation. DESIGN This was a randomized controlled study. SETTINGS The study was conducted in the Department of Neurosurgery of a training and research hospital in Turkey. PARTICIPANTS/SUBJECTS Sixty patients (n = 20 control, n = 20 video, n = 20 brochure) undergoing surgery for LDH who volunteered to participate. METHODS The study was carried out between 15 January and 30 July 2017. The data were collected preoperatively and postoperatively using the Patients' Characteristics Form, Oswestry Disability Index (ODI), Short-Form McGill Pain Questionnaire (SF-MPQ), Physical Functioning and Bodily Pain subscales of the Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36) and the Survey of Patient Satisfaction with Clinical Education and Materials. RESULTS All three groups were similar in terms of socio-demographic and clinical characteristics. Preoperative scores obtained from the ODI, SF-MPQ, and the two subscales of the SF-36 were not significantly different. However, there was a statistically significant difference between the video group (81.5 ± 24.3) and the control group (67.7 ± 18.6) in terms of the Physical Functioning subscale of the SF-36 in the postoperative period (p< .05). CONCLUSIONS Preoperative education on body mechanics increases the physical functioning of patients with LDH and facilitates the integration of information into their daily activities.
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Affiliation(s)
- Ozgu Bakcek Akcelik
- From the Yuksek Ihtisas University, Vocational School of Health Services, Department of Medical Services and Techniques, Operating Room Services Program, Ankara, Turkey.
| | - Hatice Ayhan
- University of Health Sciences, Gulhane Faculty of Nursing, Ankara, Turkey
| | - Sevinc Tastan
- Eastern Mediterranean University, Health Sciences Faculty, Nursing Department, Famagusta, North Cyprus, Turkey
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Koushik SS, Bui A, Slinchenkova K, Badwal A, Lee C, Noss BO, Raghavan J, Viswanath O, Shaparin N. Analgesic Techniques for Rib Fractures-A Comprehensive Review Article. Curr Pain Headache Rep 2023; 27:747-755. [PMID: 37747621 DOI: 10.1007/s11916-023-01172-9] [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] [Accepted: 08/24/2023] [Indexed: 09/26/2023]
Abstract
PURPOSE OF REVIEW Rib fractures are a common traumatic injury that has been traditionally treated with systemic opioids and non-opioid analgesics. Due to the adverse effects of opioid analgesics, regional anesthesia techniques have become an increasingly promising alternative. This review article aims to explore the efficacy, safety, and constraints of medical management and regional anesthesia techniques in alleviating pain related to rib fractures. RECENT FINDINGS Recently, opioid analgesia, thoracic epidural analgesia (TEA), and paravertebral block (PVB) have been favored options in the pain management of rib fractures. TEA has positive analgesic effects, and many studies vouch for its efficacy; however, it is contraindicated for many patients. PVB is a viable alternative to those with contraindications to TEA and exhibits promising outcomes compared to other regional anesthesia techniques; however, a failure rate of up to 10% and adverse complications challenge its administration in trauma settings. Serratus anterior plane blocks (SAPB) and erector spinae blocks (ESPB) serve as practical alternatives to TEA or PVB with lower incidences of adverse effects while exhibiting similar levels of analgesia. ESPB can be performed by trained emergency physicians, making it a feasible procedure to perform that is low-risk and efficient in pain management. Compared to the other techniques, intercostal nerve block (ICNB) had less analgesic impact and required concurrent intravenous medication to achieve comparable outcomes to the other blocks. The regional anesthesia techniques showed great success in improving pain scores and expediting recovery in many patients. However, choosing the optimal technique may not be so clear and will depend on the patient's case and the team's preferences. The peripheral nerve blocks have impressive potential in the future and may very well surpass neuraxial techniques; however, further research is needed to prove their efficacy and weaknesses.
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Affiliation(s)
- Sarang S Koushik
- Department of Anesthesiology, Valleywise Health Medical Center, Creighton University School of Medicine, Phoenix, AZ, USA.
| | - Alex Bui
- Department of Anesthesiology, Valleywise Health Medical Center, Creighton University School of Medicine, Phoenix, AZ, USA
| | - Kateryna Slinchenkova
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, NY, USA
| | - Areen Badwal
- Creighton University School of Medicine, Phoenix, AZ, USA
| | - Chang Lee
- Creighton University School of Medicine, Phoenix, AZ, USA
| | - Bryant O Noss
- Creighton University School of Medicine, Phoenix, AZ, USA
| | | | - Omar Viswanath
- Innovative Pain and Wellness, LSU Health Sciences Center School of Medicine, Creighton University School of Medicine, Phoenix, AZ, USA
| | - Naum Shaparin
- Department of Anesthesiology, Albert Einstein College of Medicine, The Bronx, NY, USA
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11
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Grisales PA, Rauh JL, Benfield AL, Palmer MJ, Dobson S, Downard MG, Neff LP, Pranikoff T, Sieren LM, Petty JK, Tennant P, Zeller KA. Raising the Bar: Multimodal Analgesia with Transdermal Lidocaine for Nuss Repair of Pectus Excavatum Decreases Length of Stay and Opioid Use. J Pediatr Surg 2023; 58:2244-2248. [PMID: 37400309 DOI: 10.1016/j.jpedsurg.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 07/05/2023]
Abstract
INTRO Pain management for minimally invasive (Nuss) repair of pectus excavatum (PE) is challenging, particularly as the judicious use of opioids has become a patient safety priority. Multi-modal pain management protocols are increasingly used, but there is limited experience using transdermal lidocaine patches (TLP) in this patient population. METHODS Pediatric anesthesiologists and surgeons in a children's hospital within a hospital designed a multi-modal perioperative pain management protocol for patients undergoing Nuss repair of PE (IRB00068901). The protocol included use of TLP in addition to other adjuncts such as methadone, gabapentin, and NSAIDS. Following initiation of the protocol charts were reviewed retrospectively, comparing outcomes before and after implementation of the protocol. RESULTS Forty-nine patients underwent a Nuss procedure between 2013 and 2022, 15 prior to initiation of the protocol and 34 after. Patient demographics and operative length were similar between the two groups. Average length of stay decreased from 4.7 to 3.3 days and reported opioid use at the time of the first outpatient post-op visit dropped from 60% to 24% (p < 0.05). Morphine milligram equivalents (MME) usage was decreased following implementation during hospital admission, at discharge, and at first post-operative visit (464 vs. 169, 1288 vs. 218, and 214 vs. 56, respectfully, p < 0.05). There were no ED visits or readmissions <30 days related to post-operative pain. CONCLUSION Post-operative opioid usage and hospital length of stay were decreased after initiation of the protocol. Transdermal lidocaine patches may be a helpful adjunct to minimize narcotic requirements after repair of pectus excavatum. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Paula A Grisales
- Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, North Carolina, USA
| | - Jessica L Rauh
- Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, North Carolina, USA.
| | | | - Maria J Palmer
- Wake Forest School of Medicine, Pharmacy Department, USA
| | - Sean Dobson
- Department of Anesthesiology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, North Carolina, USA
| | - Martina G Downard
- Department of Anesthesiology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, North Carolina, USA
| | - Lucas P Neff
- Department of Surgery - Pediatrics, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, North Carolina, USA
| | - Thomas Pranikoff
- Department of Surgery - Pediatrics, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, North Carolina, USA
| | - Leah M Sieren
- Department of Surgery - Pediatrics, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, North Carolina, USA
| | - John K Petty
- Department of Surgery - Pediatrics, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, North Carolina, USA
| | - Phillip Tennant
- Department of Anesthesiology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, North Carolina, USA
| | - Kristen A Zeller
- Department of Surgery - Pediatrics, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, North Carolina, USA
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12
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Lusianawati, Suhardi CJ, Sumartono C, Wungu CDK. Efficacy and safety of the serratus anterior block compared to thoracic epidural analgesia in surgery: Systematic review and meta-analysis. Tzu Chi Med J 2023; 35:329-337. [PMID: 38035055 PMCID: PMC10683523 DOI: 10.4103/tcmj.tcmj_36_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/15/2023] [Accepted: 04/03/2023] [Indexed: 12/02/2023] Open
Abstract
Objectives The objective of this study was to compare the efficacy and safety of serratus anterior plane block (SAPB) and thoracic epidural analgesia (TEA) in thoracic region surgery. Materials and Methods We implemented a systematic search of PubMed, ScienceDirect, SCOPUS, and Web of Science and through gray literature for all randomized controlled trials that compared SAPB, a novel thoracic wall nerve block, and TEA in surgery. The evaluated outcomes included the Visual Analog Scale (VAS), hypotension, and postoperative nausea and vomiting (PONV). Review Manager, version 5.4.1, was implemented for the analysis of statistics. Results The pooled analysis included six trials that fulfilled the inclusion criteria. In total 384, surgery had received regional blocks (162 - SAPB and 163 - TEA). VAS did not differ significantly between SAPB and TEA, with a mean difference of 0.71, P = 0.08. PONV incidence did not differ significantly between SAPB and TEA (odds ratio = 0.25, P = 0.07). Hypotension incidence was lower in SAPB compared to TEA (odds ratio = 0.10, P = 0.0001). Conclusion SAPB yielded comparable VAS with TEA in pain management of thoracic region surgery. The incidence of hypotension was lower in SAPB than in TEA. No difference in PONV incidence was observed. SAPB can be a viable alternative to TEA in thoracic region surgery.
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Affiliation(s)
- Lusianawati
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Airlangga University/Dr. Soetomo Hospital, Surabaya, Indonesia
| | - Christian Julio Suhardi
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Airlangga University/Dr. Soetomo Hospital, Surabaya, Indonesia
| | - Christrijogo Sumartono
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Airlangga University/Dr. Soetomo Hospital, Surabaya, Indonesia
| | - Citrawati Dyah Kencono Wungu
- Department of Physiology and Medical Biochemistry, Faculty of Medicine, Airlangga University, Surabaya, Indonesia
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13
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Wang J, Cui X, Zhang Y, Sang X, Shen L. The effects of intermittent bolus paravertebral block on analgesia and recovery in open hepatectomy: a randomized, double-blinded, controlled study. BMC Surg 2023; 23:218. [PMID: 37543575 PMCID: PMC10404371 DOI: 10.1186/s12893-023-02125-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 07/25/2023] [Indexed: 08/07/2023] Open
Abstract
BACKGROUND We aimed to investigate the effects of intermittent bolus paravertebral block on analgesia and recovery in open hepatectomy. METHODS Eighty 18-70 years old, American Society of Anesthesiologists level I-III patients scheduled for hepatectomy with a J-shaped subcostal incision were enrolled and randomized to receive either intermittent bolus paravertebral ropivacaine (0.5% loading, 0.2% infusion) or 0.9% saline infusion at 1:1 ratio (25 ml loading before surgery, 0.125 ml/kg/h bolus for postoperative 48 h). The primary outcome was set as postoperative 48 h cumulative intravenous morphine consumption recorded by a patient-controlled analgesic pump. RESULTS Thirty-eight patients in each group completed the study. The cumulative morphine consumptions were lower in the paravertebral block than control group at postoperative 24 (difference -10.5 mg, 95%CI -16 mg to -6 mg, P < 0.001) and 48 (difference -12 mg, 95%CI -19.5 mg to -5 mg, P = 0.001) hours. The pain numerical rating scales at rest were lower in the paravertebral block than control group at postoperative 4 h (difference -2, 95%CI -3 to -1, P < 0.001). The active pain numerical rating scales were lower in the paravertebral block than control group at postoperative 12 h (difference -1, 95%CI -2 to 0, P = 0.005). Three months postoperatively, the paravertebral block group had lower rates of hypoesthesia (OR 0.28, 95%CI 0.11 to 0.75, P = 0.009) and numbness (OR 0.26, 95%CI 0.07 to 0.88, P = 0.024) than the control group. CONCLUSIONS Intermittent bolus paravertebral block provided an opioid-sparing effect and enhanced recovery both in hospital and after discharge in patients undergoing hepatectomy. TRIAL REGISTRATION clinicaltrials.gov (NCT04304274), date: 11/03/2020.
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Affiliation(s)
- Jin Wang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xulei Cui
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
| | - Yuelun Zhang
- Center Research Lab, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xinting Sang
- Department of Hepatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Le Shen
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
- State Key Laboratory of Complex Severe and Rare Disease, Beijing, China.
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Ito A, Iijima S. Changes in spinal alignment one month post abdominal surgery: A prospective cohort study. Medicine (Baltimore) 2023; 102:e33674. [PMID: 37115047 PMCID: PMC10146048 DOI: 10.1097/md.0000000000033674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
Following abdominal surgery, many patients assume a bending or stooping posture to protect the surgical wound. Such postural changes are known to induce side effects, but the improvement and persistence of these effects are unknown. Therefore, the purpose of this study was to clarify the nature of postural changes in patients undergoing abdominal surgery. In this prospective cohort study, we enrolled 25 patients who underwent abdominal surgery from February 2019 to January 2020. Measurements were obtained during the preoperative, pre-discharge, and first outpatient stages. The sacral tilt, lumbar lordotic, thoracic kyphosis, and overall tilt angles were measured in the static standing position in a private room. Wound pain was measured using a Visual Analogue Scale. Repeated measures analysis of variance was applied to compare spine measurements for each measurement period, followed by the Bonferroni method for each level. Pearson's product-moment correlation coefficient was performed to examine the relationship between wound pain and spinal column angle. The lumbar kyphosis angle was lower before discharge (-7.2 ± 7.4°) compared to preoperatively (-11.1 ± 7.5°) (95% CI 0.76, 7.08; P < .01, η2 = 0.21). Regarding the overall tilt angle, the anterior tilt angle increased before discharge (3.4 ± 3.9°) compared to preoperatively (1.1 ± 4.1°) (95% CI 0.86, 3.78; P < .01, η2 = 0.33). No statistically significant correlation with pain was observed. Compared to the preoperative period, the patients had an anterior tilt, mainly due to lumbar spine changes, prior to discharge from the hospital. Changes in spinal alignment were not associated with wound pain.
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Affiliation(s)
- Akihiro Ito
- Department of Physical Therapy, School of Health Science, International University of Health and Welfare, Otawara, Japan
- Department of Physical Therapy and Rehabilitation, International University of Health and Welfare Hospital, Nasushiobara, Japan
| | - Shinno Iijima
- Department of Physical Therapy and Rehabilitation, International University of Health and Welfare Hospital, Nasushiobara, Japan
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15
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Crettenand F, Assayed-Leonardi N, Rohrer F, Martinez Carrique S, Roth B. Is Continuous Wound Infiltration a Better Option for Postoperative Pain Management after Open Nephrectomy Compared to Thoracic Epidural Analgesia? J Clin Med 2023; 12:jcm12082974. [PMID: 37109313 PMCID: PMC10143069 DOI: 10.3390/jcm12082974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/10/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Despite increasingly advanced minimally invasive percutaneous ablation techniques, surgery remains the only evidence-based therapy in curative intent for larger (>3-4 cm) renal tumors. Although minimally invasive surgery using (robotic-assisted) laparoscopic or retroperitoneoscopic approaches has gained popularity, open nephrectomy (ON) is still performed in 25% of cases, especially in tumors with central localization (partial ON) or large tumors with/without cava thrombus (total ON). As postoperative pain is one of the drawbacks of ON, our study aims to assess recovery and post-operative pain management using continuous wound infiltration (CWI) compared to thoracic epidural analgesia (TEA). METHODS Since 2012, all patients undergoing ON at our tertiary cancer center at CHUV have been included in our prospective ERAS® (enhanced recovery after surgery) registry that is centrally stored in ERAS® Interactive Audit System (EIAS) secured server. This study represents an analysis of all patients operated on with partial or total ON at our center between 2012 and 2022. An additional analysis was performed for the estimations of the total cost of CWI and TEA, based on the diagnosis-related group method. RESULTS 92 patients were included and analyzed in this analysis (n = 64 (70%) with CWI; n = 28 (30%) with TEA). Adequate oral pain control was earlier achieved in the CWI group compared to the TEA group (median 3 vs. 4 days; p = 0.001), whereas immediate postoperative pain relief was better in the TEA group (p = 0.002). Consequently, opioid use was higher in the CWI group (p = 0.004). Still, reported nausea was lower in the CWI group (p = 0.002). Median time to bowel recovery was similar in both groups (p = 0.03). A shorter LOS (0.5 days) was observed in patients managed with CWI, although this was not statistically significant (p = 0.06). The use of CWI has reduced total hospital costs by nearly 40%. CONCLUSIONS TEA has better results in terms of postoperative pain management compared to CWI following ON. However, CWI is better tolerated, and causes less nausea and earlier recovery, which leads to a shorter length of stay. Given its simplicity and cost-effectiveness, CWI should be encouraged for ON.
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Affiliation(s)
- François Crettenand
- Department of Urology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Nady Assayed-Leonardi
- Department of Urology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Felix Rohrer
- Department of Anesthesiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Silvia Martinez Carrique
- Department of Urology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Beat Roth
- Department of Urology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
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Ma Y, Deng Z, Feng X, Luo J, Meng Y, Lin J, Mu X, Yang X, Nie H. Effects of hydromorphone-based intravenous patient-controlled analgesia with and without a low basal infusion on postoperative hypoxaemia: study protocol for a randomised controlled clinical trial. BMJ Open 2022; 12:e064581. [PMID: 36385038 PMCID: PMC9670915 DOI: 10.1136/bmjopen-2022-064581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION When patients receive patient-controlled intravenous analgesia (PCIA), no basal infusion is always recommended, as the addition of a basal infusion increases the occurrence of postoperative opioid-induced respiratory depression. However, few studies have investigated whether low basal infusions increase the incidence of postoperative hypoxaemia relative to no basal infusion. We intend to conduct a clinical trial to test the hypothesis that PCIA with a low basal infusion does not increase the occurrence of postoperative hypoxaemia relative to PCIA with no basal infusion. METHODS AND ANALYSIS This single-centre parallel randomised controlled clinical trial will be conducted with 160 patients undergoing gastrointestinal tumour surgery. The assigned nurse will set analgesic pumps (low or no basal infusion PCIA) according to block-based randomisation sequence. Other investigators and all participants will be blinded to intervention allocation. All patients will be monitored continuously with the ep pod, a wireless wearable device, recording of oxygen saturation (SpO2) and daily ambulation duration for 48 hours postoperatively. Three follow-up evaluations will be conducted to assess the analgesic effect (Numeric Rating Scale (NRS) pain score) and opioid-related side effects (Overall Benefit of Analgesic Score (OBAS)). The primary outcome will be the area under the curve for hypoxaemia (defined as SpO2<95%) per hour. The secondary outcomes will be the areas under the curve for hypoxaemia defined as SpO2<90% and <85% per hour, hydromorphone consumption, OBASs at 24 and 48 hours postoperatively, NRS scores at 4, 24 and 48 hours postoperatively, and the ambulation time per hour over 48 hours. ETHICS AND DISSEMINATION The study has been approved by the Xijing Hospital Ethics Committee (KY20212163-F-1). Written informed consent will be obtained from all patients or their authorised surrogates. All data will be managed with confidentiality. Findings will be disseminated at international conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER ChiCTR2100054317.
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Affiliation(s)
- Yumei Ma
- Department of Anesthesiology and Perioperative Medicine, Fourth Military Medical University Xijing Hospital, Xian, Shaanxi, China
| | - Zhuomin Deng
- PMLS Upstream Marketing Department, Mindray Medical International Ltd, Shenzhen, Guangdong, China
| | - Xiangying Feng
- Department of General Surgery, Fourth Military Medical University Xijing Hospital, Xian, Shaanxi, China
| | - Jialin Luo
- Department of General Surgery, Fourth Military Medical University Xijing Hospital, Xian, Shaanxi, China
| | - Yang Meng
- Department of Anesthesiology and Perioperative Medicine, Fourth Military Medical University Xijing Hospital, Xian, Shaanxi, China
| | - Jingjing Lin
- Department of Anesthesiology and Perioperative Medicine, Fourth Military Medical University Xijing Hospital, Xian, Shaanxi, China
| | - Xiaoxiao Mu
- Department of Anesthesiology and Perioperative Medicine, Fourth Military Medical University Xijing Hospital, Xian, Shaanxi, China
| | - Xuan Yang
- Department of Anesthesiology and Perioperative Medicine, Fourth Military Medical University Xijing Hospital, Xian, Shaanxi, China
| | - Huang Nie
- Department of Anesthesiology and Perioperative Medicine, Fourth Military Medical University Xijing Hospital, Xian, Shaanxi, China
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Pöpping DM, Wenk M. [Epidural anesthesia : Clinical application and current developments]. DIE ANAESTHESIOLOGIE 2022; 71:893-906. [PMID: 36264325 DOI: 10.1007/s00101-022-01209-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/19/2022] [Indexed: 06/16/2023]
Abstract
Epidural anesthesia has been an established procedure in anesthesia for many years. Possibly due to its invasiveness, the associated fear of serious complications and the proliferation of alternative methods, an overall decline in its use can be observed. Several alternative procedures have been developed, especially the introduction of ultrasound into anesthesia, which are increasingly being used in clinical practice. The aim of this continuing medical education (CME) article is to shed light on the remaining range of indications for epidural anesthesia, to present the approaches and possible clinical benefits as well as to evaluate the effects that go beyond pure analgesia, according to the current evidence. In addition, potential complications and preventive approaches are discussed. This article is based on a literature search in PubMed and Google Scholar.
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Affiliation(s)
- Daniel M Pöpping
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Deutschland.
| | - Manuel Wenk
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Florence-Nightingale-Krankenhaus, Kaiserswerther Diakonie, Alte Landstraße 179, 40489, Düsseldorf, Deutschland
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18
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Ketelaers SHJ, Dhondt L, van Ham N, Harms AS, Scholten HJ, Nieuwenhuijzen GAP, Rutten HJT, Burger JWA, Bloemen JG, Vogelaar FJ. A prospective cohort study to evaluate continuous wound infusion with local analgesics within an enhanced recovery protocol after colorectal cancer surgery. Colorectal Dis 2022; 24:1172-1183. [PMID: 35637573 DOI: 10.1111/codi.16201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/29/2022] [Accepted: 05/22/2022] [Indexed: 02/08/2023]
Abstract
AIM To reduce detrimental opioid-related side effects, minimising the postoperative opioid consumption is needed, especially in older patients. Continuous wound infusion (CWI) with local analgesics appears to be an effective opioid-sparing alternative. However, the added value of CWI to an enhanced recovery protocol after colorectal cancer (CRC) surgery is unclear. The aim of this study was to evaluate the outcomes of CWI after CRC surgery within a strictly adhered to enhanced recovery protocol. METHODS In this multicentre prospective observational cohort study, patients who underwent CRC surgery between May 2019 and January 2021 were included. Patients were treated with CWI as adjunct to multimodal pain management within an enhanced recovery protocol. Postoperative opioid consumption, pain scores and outcomes regarding functional recovery were evaluated. RESULTS A cohort of 130 consecutive patients were included, of whom 36.2% were ≥75 years. Postoperative opioids were consumed by 80 (61.5%) patients on postoperative day 0, and by 28 (21.5%), 27 (20.8%), and 18 (13.8%) patients on postoperative days 1, 2, and 3, respectively. Median pain scores were <4 on all days. The median time until first passage of stool was 1.0 (IQR: 1.0-2.0) day. Postoperative delirium occurred in 0.8%. Median length of hospital stay was 3.0 days (IQR: 2.0-5.0). CONCLUSION In patients treated with CWI, low amounts of postoperative opioid consumption, adequate postoperative pain control, and enhanced recovery were observed. CWI seems a beneficial opioid-sparing alternative and may further improve the outcomes of an enhanced recovery protocol after CRC surgery, which seems especially valuable for older patients.
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Affiliation(s)
| | - Lieke Dhondt
- Department of Surgery, VieCuri Medical Centre, Venlo, The Netherlands
| | - Nikki van Ham
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Ansgar S Harms
- Department of Anaesthesiology, VieCuri Medical Centre, Venlo, The Netherlands
| | - Harm J Scholten
- Department of Anaesthesiology, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Harm J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands.,GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | | | - Johanne G Bloemen
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - F Jeroen Vogelaar
- Department of Surgery, VieCuri Medical Centre, Venlo, The Netherlands.,GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
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Kubulus C, Gürtesch CA, Wagenpfeil G, Sessler DI, Volk T. Antithrombotic drugs and the risk of bloody punctures in regional anesthesia - a retrospective registry analysis. Reg Anesth Pain Med 2022; 47:rapm-2022-103806. [PMID: 35922078 DOI: 10.1136/rapm-2022-103806] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/22/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION The risk of bleeding during regional anesthesia implementation in patients on antithrombotic therapy remains poorly characterized. We; therefore, analyzed bloody tap rates and adjusted ORs comparing patients who take antithrombotic medications with those who do not. METHODS 65,814 qualifying regional anesthetics (2007-2019) from the Network for Safety in Regional Anesthesia and Acute Pain Therapy registry were included in a retrospective cohort analysis. Procedures in patients who took antithrombotic drugs were compared with procedures in patients who did not. The primary outcome was bloody puncture, defined as any kind of blood aspiration during placement. Secondarily, we considered timely discontinuation of thromboprophylaxis and the impact of various drug classes. As a sensitivity analysis, we used propensity matched groups. RESULTS Patients on antithrombotic therapy were more likely to have a bloody puncture during peripheral nerve block implementation (adjusted OR 1.60; 95% CI 1.33 to 1.93; p<0.001) irrespective of whether therapy was discontinued. In contrast, bloody neuraxial blocks were no more common in patients who took antithrombotic medications (adjusted OR 0.95; 95% CI 0.82 to 1.10; p=0.523) so long as they were paused per guideline. Across both peripheral and neuraxial blocks, concurrent use of more than one platelet and/or coagulation cascade inhibitor nearly doubled the odds (adjusted OR, 1.89; 95% CI 1.48 to 2.40; p<0.001). DISCUSSION Patients on antithrombotic therapy receiving peripheral blocks are at increased risk for bloody punctures irrespective of discontinuation practice. Patients having neuraxial blocks are not at increased risk so long as antithrombotics are stopped per guidelines. Patients who take combined medications are at especially high risk. Guidelines for discontinuing antithrombotic treatments for neuraxial anesthesia appear to be effective and should possibly be extended to high-risk peripheral blocks.
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Affiliation(s)
- Christine Kubulus
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - Christine A Gürtesch
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - Gudrun Wagenpfeil
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Homburg/Saar, Germany
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA; Senior Fellow, Population Health Research Institute, McMaster University, Ontario, Canada
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg/Saar, Germany
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Hoelzen JP, Sander KJ, Sesia M, Roy D, Rijcken E, Schnabel A, Struecker B, Juratli MA, Pascher A. Robotic-Assisted Esophagectomy Leads to Significant Reduction in Postoperative Acute Pain: A Retrospective Clinical Trial. Ann Surg Oncol 2022; 29:7498-7509. [PMID: 35854033 PMCID: PMC9550779 DOI: 10.1245/s10434-022-12200-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 06/25/2022] [Indexed: 12/24/2022]
Abstract
Background Robot-assisted minimally invasive esophagectomy (RAMIE) shows promising results regarding postoperative complications in patients with esophageal cancer. To date, no data are available regarding postoperative analgesic consumption. The aim of this work is to evaluate analgesic consumption after esophagectomy. Methods A total of 274 Ivor Lewis esophageal resections performed sequentially from January 2012 to December 2020 were evaluated. RAMIE cases (n = 51) were compared with the hybrid technique (laparoscopic abdominal phase followed by open thoracotomy, n = 59) and open abdominothoracic esophagectomy (OTE) (n = 164). Data were collected retrospectively. The primary endpoint was the overall postoperative morphine consumption, which represents a reliable indirect measurement of pain. Pain levels recorded on the first, third, and fifth postoperative days were assessed as secondary endpoints. Results A total of 274 patients were included. The postoperative opioid consumption rate for patients who underwent RAMIE (quartiles: 0.14, 0.23, 0.36 mg morphine milligram equivalents (MME)/kg body weight (bw)/day) was significantly lower than in the open group (0.19, 0.33, 0.58 mg MME/kg bw/day, p = 0.016). The overall postoperative opioid consumption for patients who underwent RAMIE was significantly lower (2.45, 3.63, 7.20 mg MME/kg bw/day; morphine milligram equivalents per kilogram body weight) compared with the open (4.85, 8.59, 14.63 MME/kg bw/day, p < 0.0001) and hybrid (4.13, 6.84, 11.36 MME/kg bw/day, p = 0.008) groups. Patients who underwent RAMIE reported lower pain scores compared with the open group on the fifth postoperative day, both at rest (p = 0.004) and while performing activities (p < 0.001). Conclusions This study shows that patients who underwent RAMIE experienced similar postoperative pain while requiring significantly lower amounts of opioids compared with patients who underwent open and hybrid surgery. Further studies are required to verify the results.
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Affiliation(s)
- Jens P Hoelzen
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Muenster, Germany.
| | - Karl J Sander
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Muenster, Germany
| | - Matteo Sesia
- Department of Data Sciences and Operations, Marshall School of Business, University of Southern California, Los Angeles, CA, USA
| | | | - Emile Rijcken
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Muenster, Germany
| | - Alexander Schnabel
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Benjamin Struecker
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Muenster, Germany
| | - Mazen A Juratli
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Muenster, Germany
| | - Andreas Pascher
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Muenster, Germany
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Jayaprabhu NB, Avula J, Chandy TT, Varghese G, Yadav B, Rebekah G. A Randomized Controlled Trial Comparing Intravenous Lidocaine Infusion With Thoracic Epidural for Perioperative Analgesia and Quality of Recovery After Surgery in Laparoscopic Left-Sided Colon and Sphincter-Sparing Rectal Resection Surgery. Cureus 2022; 14:e23758. [PMID: 35509732 PMCID: PMC9059900 DOI: 10.7759/cureus.23758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2022] [Indexed: 11/12/2022] Open
Abstract
Background Protocols for Enhanced Recovery after Surgery (ERAS) have been constantly evolving, and the best method of managing perioperative pain, especially in laparoscopic surgeries, is still debatable. The primary goal of these protocols is to steer toward opioid-sparing analgesia. Intravenous lidocaine, which has both analgesic and anti-inflammatory properties, may improve the overall recovery of patients. Objectives The aim of this randomized controlled trial was to compare the efficacy of intravenous lidocaine infusion (IVL) with thoracic epidural analgesia (TEA) in the management of perioperative pain and recovery in the laparoscopic left-sided colon and sphincter-sparing rectal surgery. Methods In this study, 37 patients were randomized to either the IVL group or the TEA group. IVL infusion was started before the surgical incision and stopped 30 minutes after transferring the patient to the postanesthesia care unit (PACU). Postoperative pain scores, opioid consumption, rescue analgesic doses, quality of recovery scores, time to discharge, and adverse events were recorded prospectively. Data were analyzed using two independent sample t-test and paired t-test, with p < 0.05 taken as statistically significant. Results The mean difference of overall NRS (numerical rating scale) pain scores in the ward was significantly higher in the IVL group as compared to the TEA group, which was 3.58 (2.29) vs 2.23 1.95) (p < 0.001). The IVL group required more mean rescue opioid boluses than the TEA group, which was 11.36 (8.684) vs 5.96 (6.215) (p < 0.001). However, both IVL and TEA groups had similar pain scores intraoperatively and in the PACU. Conclusions TEA provides better analgesia and decreased opioid requirements compared to intravenous lidocaine during the 24-hour period in the ward after laparoscopic left-sided colon and sphincter-sparing rectal surgery, although there was no difference in the quality of recovery between IVL and TEA groups.
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Affiliation(s)
| | - Jyothi Avula
- Anaesthetics, New Cross Hospital, Royal Wolverhampton NHS Trust, Wolverhampton, GBR
- Department of Anaesthesiology, Christian Medical College Vellore, Vellore, IND
| | - Tony T Chandy
- Department of Anaesthesiology, Christian Medical College Vellore, Vellore, IND
| | - Gigi Varghese
- Department of Colorectal Surgery, Royal Stoke University Hospital (RSUH) University Hospitals of North Midlands NHS Trust (UHNM), Stoke On Trent, GBR
- Department of Colorectal Surgery, Christian Medical College Vellore, Vellore, IND
| | - Bijesh Yadav
- Department of Biostatistics, Christian Medical College Vellore, Vellore, IND
| | - Grace Rebekah
- Department of Biostatistics, Christian Medical College Vellore, Vellore, IND
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Xue Q, Chu Z, Zhu J, Zhang X, Chen H, Liu W, Jia B, Zhang Y, Wang Y, Huang C, Hu X. Analgesic Efficacy of Transverse Abdominis Plane Block and Quadratus Lumborum Block in Laparoscopic Sleeve Gastrectomy: A Randomized Double-Blinded Clinical Trial. Pain Ther 2022; 11:613-626. [PMID: 35312948 PMCID: PMC9098772 DOI: 10.1007/s40122-022-00373-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/07/2022] [Indexed: 10/27/2022] Open
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Long B, Carlson J, Montrief T, Koyfman A. High risk and low prevalence diseases: Spinal epidural abscess. Am J Emerg Med 2022; 53:168-172. [DOI: 10.1016/j.ajem.2022.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 12/31/2021] [Accepted: 01/04/2022] [Indexed: 02/07/2023] Open
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Lei Y, Liu H, Xia F, Gan S, Wang Y, Huo W, Wang Q, Ji F. Effects of Esketamine on Acute and Chronic Pain After Thoracoscopy Pulmonary Surgery Under General Anesthesia: A Multicenter-Prospective, Randomized, Double-Blind, and Controlled Trial. Front Med (Lausanne) 2021; 8:693594. [PMID: 34568362 PMCID: PMC8455819 DOI: 10.3389/fmed.2021.693594] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 07/26/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Post-operative pain management for patients undergoing thoracoscopy surgery is challenging for clinicians which increase both health and economic burden. The non-selective NMDA receptor antagonist esketamine possesses an analgesic effect twice that of ketamine. The application of esketamine might be beneficial in alleviating acute and chronic pain after thoracic surgery. The current study describes the protocol aiming to evaluate the analgesic effect of esketamine after pulmonary surgery via visual analog scale (VAS) score for acute and chronic pain. Methods: A multi-center, prospective, randomized, controlled, double-blind study is designed to explore the analgesic effect of esketamine in randomized patients undergoing video-assisted thoracoscopic surgery (VATS) with general anesthesia. Patients will be randomly assigned to Esketamine Group (Group K) and Control Group (Group C) in a ratio of 1:1. Group K patients will receive esketamine with a bolus of 0.1 mg/kg after anesthesia induction, 0.1 mg/kg/h throughout the operation and 0.015 mg/kg/h in PCIA after surgery while Group C patients will receive the same volume of normal saline. The primary outcome is to measure the pain intensity through the VAS score at 3 months after the operation. The secondary outcome includes VAS score at 1, 4, 8, 24, and 48 h and on the 7th day and 1 month after the operation, complications, ketamine-related neurological side effects, recovery time of bowel function, and total amount of supplemental analgesics. Discussion: The results of the current study might illustrate the analgesic effect of esketamine for patients undergoing thoracoscopy pulmonary surgery and provide evidence and insight for perioperative pain management. Study Registration: The trial was registered with Chinese Clinical Trial Registry (CHICTR) on Nov 18th, 2020 (ChiCTR2000040012).
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Affiliation(s)
- Yishan Lei
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Huayue Liu
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Fan Xia
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Shulin Gan
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yulan Wang
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Wenwen Huo
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Qinyun Wang
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Fuhai Ji
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, China
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The Cognitive Neuraxis: Epidurals and Postoperative Delirium. Anesthesiology 2021; 135:197-199. [PMID: 34197575 DOI: 10.1097/aln.0000000000003824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Kone LB, Maker VK, Banulescu M, Maker AV. Epidural Analgesia Is Associated with Prolonged Length of Stay After Open HPB Surgery in Over 27,000 Patients. J Gastrointest Surg 2021; 25:1716-1726. [PMID: 32725519 DOI: 10.1007/s11605-020-04751-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 07/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The impact of epidural analgesia (EA) on postoperative morbidity and length of stay (LOS) after HPB surgery remains to be determined. These specific outcomes have been highlighted by the implementation of multiple enhanced recovery pathways (ERAS). The authors hypothesized that EA in the current environment may be associated with LOS and other outcomes. METHODS The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) databases from 2014 to 2017 for patients undergoing open hepatopancreaticobiliary (HPB) surgery were included in a retrospective cohort analysis with propensity score matching (PSM) comparing EA with control. RESULTS Twenty-seven thousand two hundred eighteen patients underwent open HPB surgery, of which 6048 (22%) received EA. There was an increase use of EA over time (from 19.3 to 25.5%, p = 0.001). On PSM, EA was associated with more than half of a day increase in LOS for both pancreatic (p < 0.001) and hepatic surgery (p < 0.001). Furthermore, for pancreatic surgery, there was an increase in urinary tract infection (2.5% vs. 3.3%, p = 0.018), time to drain removal (7.8 vs. 8.7 days, p < 0.001), and discharge to rehabilitation (2.9% vs. 4.3%, p = 0.029). For hepatic surgery, there was an increase in blood transfusion requirements (17% vs. 20%, p = 0.019). There were no differences in overall morbidity and mortality. CONCLUSION In this cohort of over 27,000 patients with granular surgical details, there was a significant increase in LOS associated with EA after HPB surgery, along with increased procedure-specific UTI and blood transfusion. With the ever-increasing need for standardized and efficient patient care pathways that reduce LOS, alternative analgesic adjuncts may be considered to optimize patient outcomes.
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Affiliation(s)
- Lyonell B Kone
- Department of Surgery, Division of Surgical Oncology, University of Illinois, 835 S. Wolcott St. MC790, Chicago, IL, 60612, USA
- Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Vijay K Maker
- Department of Surgery, Division of Surgical Oncology, University of Illinois, 835 S. Wolcott St. MC790, Chicago, IL, 60612, USA
- Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Mihaela Banulescu
- Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Ajay V Maker
- Department of Surgery, Division of Surgical Oncology, University of Illinois, 835 S. Wolcott St. MC790, Chicago, IL, 60612, USA.
- Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA.
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Gathege D, Abdulkarim A, Odaba D, Mugambi S. Effectiveness of Pain Control of Local Anaesthetic Wound Infusion Following Elective Midline Laparotomy: A Randomized Trial. World J Surg 2021; 45:2100-2107. [PMID: 33763741 DOI: 10.1007/s00268-021-06072-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Post-operative pain control is an important pillar in enhanced recovery after surgery. There is a paucity of data that compares efficacy of pain control between continuous local anaesthetic wound infusion and thoracic epidural analgesia in elective midline laparotomy patients OBJECTIVE: To evaluate pain control between continuous local anaesthetic wound infusion and thoracic epidural analgesia in elective laparotomy patients. DESIGN A randomized, single-blind, controlled clinical trial. SETTING Aga Khan University Hospital, Nairobi, Kenya. POPULATION Patients underwent elective laparotomy. METHODS Thirty-eight patients scheduled for elective laparotomy were randomized into two equal groups to receive either continuous local anaesthetic wound infusion or thoracic epidural analgesia. Data on the baseline patient characteristics, total morphine consumption at 72 h, visual analogue scores and rates of adverse effects were collected. RESULTS Baseline characteristics of the participants were similar. Continuous local anaesthetic wound infusion was equivalent to thoracic epidural analgesia in terms of pain scores and total morphine consumption at 72 h. Duration of hospital stay was shorter in the intervention arm. There were more surgical site infections in the intervention arm, while catheter dislodgement rate was higher in the thoracic epidural arm. CONCLUSION Continuous local anaesthetic wound infusion is equivalent to thoracic epidural analgesia in management of post-operative pain following elective midline laparotomy. CLINICAL TRIAL REGISTRATION Pan African Clinical Trial registry, number PACTR201808607220790.
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Affiliation(s)
| | | | - David Odaba
- Aga Khan University Hospital, Nairobi, Kenya
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Abd Ellatif SE, Abdelnaby SM. Ultrasound guided erector spinae plane block versus quadratus lumborum block for postoperative analgesia in patient undergoing open nephrectomy: A randomized controlled study. EGYPTIAN JOURNAL OF ANAESTHESIA 2021. [DOI: 10.1080/11101849.2021.1894661] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Shereen E. Abd Ellatif
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Sara M. Abdelnaby
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Cook FAB, Millar E, Mclennan F, Janssens M, Stretton C. Non-Obstetric Safety of Epidurals (NOSE). BMJ Open Qual 2021; 10:bmjoq-2020-000943. [PMID: 33452182 PMCID: PMC7813294 DOI: 10.1136/bmjoq-2020-000943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 12/08/2020] [Accepted: 12/23/2020] [Indexed: 11/23/2022] Open
Abstract
Epidurals are a useful perioperative procedure for effective analgesia that allow early mobilisation after major surgery and help to minimise postoperative pulmonary, cardiovascular and thromboembolic complications. However, there are potential rare but life-changing complications such as an epidural haematoma. These require a high standard of post-epidural care for prompt recognition and prevention of permanent paralysis. Following a local critical incident of delayed diagnosis of an epidural haematoma in a patient after epidural catheter removal, a multidisciplinary team undertook a Quality Improvement (QI) project to improve epidural safety. To achieve this aim, it is essential that healthcare staff are aware of the early signs of neurological complications during and after epidurals and of what action to take in the event of a developing complication. The application of robust QI methodology has contributed to a sustained improvement in the healthcare staff competence (as measured using a pulse survey) at managing patients who have received perioperative epidurals. This increased from a baseline mean survey score of 38% on three surgical step down wards (general surgery, vascular and gynaecology) to 68% (averaged over the most recent 3 months of the project time frame). Educational interventions alone rarely lead to meaningful and lasting impact for all healthcare staff, due to high turnover of staff and shift working patterns. However, with multiple plan, do, study, act cycles, and a robust QI approach, there was also sustained improvement in process measures, including the occurrence of written handover from high dependency to the step down wards (baseline 33%–71%), ensuring the application of yellow epidural alert wristbands to make these patients readily identifiable (56%–86%), and early signs in improvement in reliability of motor block checks for 24 hours’ post-catheter removal (47%–69%).
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Affiliation(s)
| | - Emma Millar
- South East Scotland School of Anaesthesia, NHS Lothian, Edinburgh, UK
| | - Flora Mclennan
- South East Scotland School of Anaesthesia, NHS Lothian, Edinburgh, UK
| | - Marc Janssens
- Anaesthetics, Royal Infirmary of Edinburgh, Edinburgh, UK
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Bodilsen J, Mariager T, Vestergaard HH, Christiansen MH, Kunwald M, Lüttichau HR, Kristensen BT, Bjarkam CR, Nielsen H. Association of Lumbar Puncture With Spinal Hematoma in Patients With and Without Coagulopathy. JAMA 2020; 324:1419-1428. [PMID: 33048155 PMCID: PMC8094417 DOI: 10.1001/jama.2020.14895] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Coagulopathy may deter physicians from performing a lumbar puncture. OBJECTIVE To determine the risk of spinal hematoma after lumbar puncture in patients with and without coagulopathy. DESIGN, SETTING, AND PARTICIPANTS Danish nationwide, population-based cohort study using medical registries to identify persons who underwent lumbar puncture and had cerebrospinal fluid analysis (January 1, 2008-December 31, 2018; followed up through October 30, 2019). Coagulopathy was defined as platelets lower than 150 × 109/L, international normalized ratio (INR) greater than 1.4, or activated partial thromboplastin time (APTT) longer than 39 seconds. EXPOSURES Coagulopathy at the time of lumbar puncture. MAIN OUTCOMES AND MEASURES Thirty-day risk of spinal hematoma. Risks were provided as numbers and percentages with 95% CIs. Secondary analyses included risks of traumatic lumbar puncture (>300 × 106 erythrocytes/L after excluding patients diagnosed with subarachnoid hemorrhage). Adjusted hazard rate ratios (HRs) were computed using Cox regression models. RESULTS A total of 83 711 individual lumbar punctures were identified among 64 730 persons (51% female; median age, 43 years [interquartile range, 22-62 years]) at the time of the procedure. Thrombocytopenia was present in 7875 patients (9%), high INR levels in 1393 (2%), and prolonged APTT in 2604 (3%). Follow-up was complete for more than 99% of the study participants. Overall, spinal hematoma occurred within 30 days for 99 of 49 526 patients (0.20%; 95% CI, 0.16%-0.24%) without coagulopathy vs 24 of 10 371 patients (0.23%; 95% CI, 0.15%-0.34%) with coagulopathy. Independent risk factors for spinal hematoma were male sex (adjusted hazard ratio [HR], 1.72; 95% CI, 1.15-2.56), those aged 41 through 60 years (adjusted HR, 1.96; 95% CI, 1.01-3.81) and those aged 61 through 80 years (adjusted HR, 2.20; 95% CI, 1.12-4.33). Risks did not increase significantly according to overall severity of coagulopathy, in subgroup analyses of severity of coagulopathy by pediatric specialty or medical indication (infection, neurological condition, and hematological malignancy), nor by cumulative number of procedures. Traumatic lumbar punctures occurred more frequently among patients with INR levels of 1.5 to 2.0 (36.8%; 95% CI, 33.3%-40.4%), 2.1 to 2.5 (43.7%; 95% CI, 35.8%-51.8%), and 2.6 to 3.0 (41.9% 95% CI 30.5-53.9) vs those with normal INR (28.2%; 95% CI, 27.7%-28.75%). Traumatic spinal tap occurred more often in patients with an APTT of 40 to 60 seconds (26.3%; 95% CI, 24.2%-28.5%) vs those with normal APTT (21.3%; 95% CI, 20.6%-21.9%) yielding a risk difference of 5.1% (95% CI, 2.9%-7.2%). CONCLUSIONS AND RELEVANCE In this Danish cohort study, risk of spinal hematoma following lumbar puncture was 0.20% among patients without coagulopathy and 0.23% among those with coagulopathy. Although these findings may inform decision-making about lumbar puncture by describing rates in this sample, the observed rates may reflect bias due to physicians selecting relatively low-risk patients for lumbar puncture.
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Affiliation(s)
- Jacob Bodilsen
- Departments of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Theis Mariager
- Departments of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
| | | | | | - Mikkel Kunwald
- Department of Neurosurgery, Aalborg University Hospital, Aalborg, Denmark
| | - Hans Rudolf Lüttichau
- Department of Pulmonary and Infectious Diseases, Herlev Gentofte Hospital, Copenhagen, Denmark
| | | | - Carsten Reidies Bjarkam
- Department of Neurosurgery, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Henrik Nielsen
- Departments of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
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Makito K, Mouri H, Matsui H, Michihata N, Fushimi K, Yasunaga H. Spinal epidural hematoma and abscess after neuraxial anesthesia: a historical cohort study using the Japanese Diagnosis Procedure Combination database. Can J Anaesth 2020; 68:42-52. [PMID: 33037571 DOI: 10.1007/s12630-020-01827-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 07/12/2020] [Accepted: 07/13/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Spinal epidural hematoma and abscess are rare complications of neuraxial anesthesia but can cause severe neurologic deficits. The incidence of these complications vary widely in existing studies and the risk factors remain uncertain. We estimated the incidence of these complications and explored associations using a national inpatient database in Japan. METHODS Using Japanese Diagnosis Procedure Combination data on surgical inpatients who underwent neuraxial anesthesia from July 2010 to March 2017, we identified patients with spinal epidural hematoma and/or abscess. We investigated age, sex, Charlson comorbidity index, antithrombotic therapy, type of surgery, admission, and hospital for association with these complications. The incidences of spinal epidural hematoma and abscess were estimated separately, and a nested case-control study was performed to examine factors associated with these complications. RESULTS We identified 139 patients with spinal epidural hematoma and/or abscess among 3,833,620 surgical patients undergoing neuraxial anesthesia. The incidences of spinal epidural hematoma and abscess were 27 (95% confidence interval [CI], 22 to 32) and 10 (7 to 13) per one million patients, respectively. Spinal anesthesia was associated with significantly fewer complications compared with epidural or combined spinal epidural anesthesia (odds ratio, 0.15; 95% CI, 0.08 to 0.32). Antiplatelet agent (odds ratio, 0.49; 95% CI, 0.06 to 3.91) and anticoagulants (odds ratio, 1.65; 95% CI, 0.95 to 2.85) were not significantly associated with these complications. CONCLUSIONS This analysis identified the incidences of spinal epidural hematoma and/or abscess after neuraxial anesthesia. Additional large-scale studies are warranted to examine the incidences and factors associated with these complications.
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Affiliation(s)
- Kanako Makito
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan.
| | - Hideyuki Mouri
- Department of Anesthesiology and Intensive Care Medicine, Kanazawa University, Kanazawa, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Nobuaki Michihata
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Graduate School of Medicine, Tokyo, Medical and Dental University, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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Pownall W, Rytz U, Schuepbach G, Spadavecchia C, Rohrbach H. The influence of the choice of preemptive analgesia on long-term postsurgical pain after tibial plateau leveling osteotomy in dogs. Vet Surg 2020; 50:71-80. [PMID: 32956535 DOI: 10.1111/vsu.13515] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/02/2020] [Accepted: 08/24/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the prevalence of chronic postsurgical pain (CPSP) after tibial plateau leveling osteotomy (TPLO) in dogs and to determine the influence of preemptive locoregional analgesia on CPSP. STUDY DESIGN Retrospective study. ANIMALS One hundred twenty client-owned dogs. METHODS Medical records of dogs that underwent TPLO between 2012 and 2016 were reviewed for demographic information and type of preemptive analgesia. Owners were contacted to retrospectively assess the quality of life of their dogs by using the Helsinki Chronic Pain Index (HCPI) before and 6 months after surgery and at the time of questioning. An HCPI score > 12 was considered indicative of CPSP. Medical records were reviewed for demographic information and type of preemptive analgesia. A cumulative logit model was used to assess correlation of type of perioperative analgesia, HCPI, and demographic data. RESULTS The HCPI score was consistent with CPSP in 41 of 101 dogs with long-term follow-up (2.9 ± 1.5 years after surgery). Chronic postsurgical pain was documented in 11 of 32 and 13 of 28 dogs that received a spinal or epidural injection, respectively, or in 28 of 80 and 25 of 67 dogs with sciatic-femoral block at 6 months or with long-term follow-up after TPLO, respectively (P > .05). A negative correlation was found between HCPI and both weight and age 6 months after surgery. Only weight remained negatively correlated 2.9 years after surgery. CONCLUSION Forty-one percent of dogs that were evaluated exhibited HCPI values compatible with CPSP long-term after TPLO, regardless of the type of preemptive analgesia. Increased body weight was a negative prognostic factor for CPSP development. CLINICAL SIGNIFICANCE Additional studies are required to evaluate CPSP development after TPLO.
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Affiliation(s)
- William Pownall
- Department of Surgery, Small Animal Clinic, Vetsuisse Faculty, University of Berne, Berne, Switzerland
| | - Ulrich Rytz
- Department of Surgery, Small Animal Clinic, Vetsuisse Faculty, University of Berne, Berne, Switzerland
| | - Gertraud Schuepbach
- Department of Clinical Research and Veterinary Public Health, Vetsuisse Faculty, University of Berne, Berne, Switzerland
| | - Claudia Spadavecchia
- Division of Veterinary Anaesthesia and Pain Management, Vetsuisse Faculty, University of Berne, Berne, Switzerland
| | - Helene Rohrbach
- Division of Veterinary Anaesthesia and Pain Management, Vetsuisse Faculty, University of Berne, Berne, Switzerland
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Manassero A, Bossolasco M, Carrega M, Coletta G. Postoperative Thoracic Epidural Analgesia: Adverse Events from a Single-Center Series of 3126 Patients. Local Reg Anesth 2020; 13:111-119. [PMID: 32982397 PMCID: PMC7490049 DOI: 10.2147/lra.s272410] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 08/27/2020] [Indexed: 11/25/2022] Open
Abstract
Purpose Thoracic epidural analgesia (TEA) has been shown to reduce postsurgical morbidity and mortality; nevertheless, major and minor complications can occur. We report our 10-year experience with TEA and incidence of complications. Patients and Methods Patients received continuous infusion TEA (0.2% ropivacaine and 2 µg ml−1 fentanyl) to control postoperative pain. Every 8 hours, the acute pain service recorded the analgesia regimen and occurrence of side effects. The initial infusion rate was tapered daily in response to improvement in pain symptoms or occurrence of side effects. Results A total of 3126 patients received TEA. The median age was 65 years (range, 18–94) and the duration of catheter placement was 3.5 days (range, 2–8). Three major complications were identified (1:1042): two subarachnoid blocks and one epidural abscess which led to permanent sequela (1:3126). Minor complications were hypotension (4.8%), pruritus (4.4%), accidental catheter removal (3.7%), insertion site inflammation (2.5%), motor weakness (2.0%), postoperative nausea and vomiting (1.8%), catheter disconnection (1.9%), catheter occlusion (0.3%), post-dural puncture headache (0.5%), and catheter fragment retention (0.06%), which were the reasons for a 7.4% rate of early discontinuation of epidural analgesia. No occurrence of epidural hematoma, local anesthetic systemic toxicity, and cardiovascular/respiratory depression was recorded. Conclusion Postoperative TEA is an advanced technique that poses certain difficulties that can subvert its great potential. While serious complications were rare, minor complications occurred more often and affected the postoperative course negatively. A risk/benefit evaluation of each patient should be done before employing the technique.
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Affiliation(s)
- Alberto Manassero
- Department of Emergency and Critical Care, Division of Operating Room Management, S. Croce e Carle Hospital, Cuneo, Italy
| | - Matteo Bossolasco
- Department of Emergency and Critical Care, Division of Operating Room Management, S. Croce e Carle Hospital, Cuneo, Italy
| | - Mattia Carrega
- Department of Emergency and Critical Care, Division of Operating Room Management, S. Croce e Carle Hospital, Cuneo, Italy
| | - Giuseppe Coletta
- Department of Emergency and Critical Care, Division of Operating Room Management, S. Croce e Carle Hospital, Cuneo, Italy
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Patient satisfaction with continuous epidural analgesia after major surgical procedures at a Swedish University hospital. PLoS One 2020; 15:e0235636. [PMID: 32614891 PMCID: PMC7331990 DOI: 10.1371/journal.pone.0235636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 06/18/2020] [Indexed: 12/01/2022] Open
Abstract
Objective The use of epidural analgesia after major surgery is a well-established analgesia method. Epidural analgesia for postoperative pain relief needs to be monitored regularly in order to evaluate patient satisfaction and avoid side effects. However, due to the new available regional techniques, the role of epidural analgesia is being questioned and data about patient satisfaction is lacking. The current study was designed to evaluate patient satisfaction with epidural analgesia, its efficacy and reasons for premature termination of epidural analgesia. Materials and methods We conducted a retrospective survey of all patients who undergone surgery at Uppsala University hospital between October 2012 and January 2014 requiring continuous epidural analgesia for postoperative pain relief. Patients’ satisfaction with epidural analgesia and its effectiveness were evaluated by using paper questionnaire. Results During the study period 579 epidurals were inserted in patients scheduled for vascular, hepatobiliary, esophageal and other major abdominal surgery. The average treatment time was 3.8±1.8 days. Epidural analgesia consisted either of bupivacaine 0.1%+sufentanil 1 μg/ml solution or ropivacaine 0.2% solution. If patient needed opiates during treatment with epidural analgesia, only ropivacaine 0,2% solution was used. 494 (87.9%) patients were satisfied with their analgesia with no difference in satisfaction between sexes being observed. In 62 cases (11.2%) patient controlled analgesia was used on top of epidural analgesia with ropivacaine 0.2% solution, and 50.8% of patients were satisfied in this group. 514 (91.4%) patients were reported as having a good effect, 24 (4.3%) patients reported or were tested to show some effect, and 24 (4.3%) had no effect. No major neurological complications (epidural hematoma or abscess) were observed. Conclusions Our retrospective survey indicates that patients are satisfied with continuous epidural analgesia used in major surgery.
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Suksompong S, von Bormann S, von Bormann B. Regional Catheters for Postoperative Pain Control: Review and Observational Data. Anesth Pain Med 2020; 10:e99745. [PMID: 32337170 PMCID: PMC7158241 DOI: 10.5812/aapm.99745] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/22/2020] [Accepted: 01/29/2020] [Indexed: 12/11/2022] Open
Abstract
Context Perioperative analgesia is an essential but frequently underrated component of medical care. The purpose of this work is to describe the actual situation of surgical patients focusing on effective pain control by discarding prejudice against ‘aggressive’ measures. Evidence Acquisition This is a narrative review about continuous regional pain therapy with catheters in the postoperative period. Included are the most-relevant literature as well as own experiences. Results As evidenced by an abundance of studies, continuous regional/neuraxial blocks are the most effective approach for relief of severe postoperative pain. Catheters have to be placed in adequate anatomical positions and meticulously maintained as long as they remain in situ. Peripheral catheters in interscalene, femoral, and sciatic positions are effective in patients with surgery of upper and lower limbs. Epidural catheters are effective in abdominal and thoracic surgery, birth pain, and artery occlusive disease, whereas paravertebral analgesia may be beneficial in patients with unilateral approach of the truncus. However, failure rates are high, especially for epidural catheter analgesia. Unfortunately, many reports lack a comprehensive description of catheter application, management, failure rates and complications and thus cannot be compared with each other. Conclusions Effective control of postoperative pain is possible by the application of regional/neuraxial catheters, measures requiring dedication, skill, effort, and funds. Standard operating procedures contribute to minimizing complications and adverse side effects. Nevertheless, these methods are still not widely accepted by therapists, although more than 50% of postoperative patients suffer from ‘moderate, severe or worst’ pain.
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Affiliation(s)
| | | | - Benno von Bormann
- Institute of Medicine, Suranaree University of Technology, Korat, Thailand
- Corresponding Author: Institute of Medicine, Suranaree University of Technology, 111 Maha Witthayalai Rd, Nakhon Ratchasima 30000, Thailand. Tel: +66(0)918825723,
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Yang Y, Xiong C, Xia L, Kang SS, Jian JJ, Yang XQ, Chen L, Wang Y, Yu JJ, Xu XZ. Consistency of postoperative pain assessments between nurses and patients undergoing enhanced recovery after gynaecological surgery. J Clin Nurs 2020; 29:1323-1331. [PMID: 31972867 DOI: 10.1111/jocn.15200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 12/17/2019] [Accepted: 01/10/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Yu'E Yang
- Department of Obstetrics and Gynaecology The Affiliated Hospital of Jiangnan University Wuxi China
| | - Chang Xiong
- Wuxi School of Medicine Jiangnan University Wuxi China
| | - Ling Xia
- Department of Obstetrics and Gynaecology The Affiliated Hospital of Jiangnan University Wuxi China
| | - Si Si Kang
- Department of Obstetrics and Gynaecology The Affiliated Hospital of Jiangnan University Wuxi China
| | - Jin Jin Jian
- Department of Anesthesiology The Affiliated Hospital of Jiangnan University Wuxi China
| | - Xue Qing Yang
- Wuxi School of Medicine Jiangnan University Wuxi China
| | - Ling Chen
- Wuxi School of Medicine Jiangnan University Wuxi China
| | - Yuan Wang
- Department of Obstetrics and Gynaecology The Affiliated Hospital of Jiangnan University Wuxi China
| | - Jin Jin Yu
- Department of Obstetrics and Gynaecology The Affiliated Hospital of Jiangnan University Wuxi China
| | - Xi Zhong Xu
- Department of Obstetrics and Gynaecology The Affiliated Hospital of Jiangnan University Wuxi China
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Perioperative Epidural Use and Risk of Delirium in Surgical Patients: A Secondary Analysis of the PODCAST Trial. Anesth Analg 2020; 128:944-952. [PMID: 30768457 DOI: 10.1213/ane.0000000000004038] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Postoperative delirium is an important public health concern without effective prevention strategies. This study tested the hypothesis that perioperative epidural use would be associated with decreased risk of delirium through postoperative day 3. METHODS This was a secondary, observational, nonrandomized analysis of data from The Prevention of Delirium and Complications Associated With Surgical Treatments Trial (PODCAST; NCT01690988). The primary outcome of the current study was the incidence of delirium (ie, any positive delirium screen, postanesthesia care unit through postoperative day 3) in surgical patients (gastrointestinal, hepatobiliary-pancreatic, gynecologic, and urologic) receiving postoperative epidural analgesia compared to those without an epidural. As a secondary outcome, all delirium assessments were then longitudinally analyzed in relation to epidural use throughout the follow-up period. Given the potential relevance to delirium, postoperative pain, opioid consumption, sleep disturbances, and symptoms of depression were also analyzed as secondary outcomes. A semiparsimonious multivariable logistic regression model was used to test the association between postoperative epidural use and delirium incidence, and generalized estimating equations were used to test associations with secondary outcomes described. Models included relevant covariates to adjust for confounding. RESULTS In total, 263 patients were included for analysis. Epidural use was not independently associated with reduced delirium incidence (adjusted odds ratio, 0.65 [95% CI, 0.32-1.35]; P = .247). However, when analyzing all assessments over the follow-up period, epidural patients were 64% less likely to experience an episode of delirium (adjusted odds ratio, 0.36 [95% CI, 0.17-0.78]; P = .009). Adjusted pain scores (visual analog scale, 0-100 mm) were significantly lower in the epidural group on postoperative day 1 (morning, -16 [95% CI, -26 to -7], P < .001; afternoon, -15 [95% CI, -25 to -5], P < .01) and postoperative day 3 (morning, -13 [95% CI, -20 to -5], P < .01). Adjusted mean oral and IV morphine equivalents were also significantly lower on postoperative day 1 in the epidural group (74% lower [95% CI, 55%-85%]; P < .0001). Finally, postoperative epidural use was not significantly associated with new sleep disturbances or changes in depression symptoms. CONCLUSIONS Postoperative epidural use was not associated with a reduced overall incidence of delirium. However, longitudinal analysis revealed reduced adjusted odds of experiencing an episode of delirium in the epidural group. Epidural use was also associated with reduced postoperative pain and opioid consumption. An appropriately designed follow-up study is warranted to further analyze the relationship among epidural use, postoperative delirium, and related outcomes.
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Brück S, Annecke T, Bremerich D, Byhahn C, Chappell D, Kaufner L, Schlösser L, Kranke P. „Hot topics“ aus der geburtshilflichen Anästhesie. Anaesthesist 2020; 69:11-19. [DOI: 10.1007/s00101-019-00718-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Freys SM, Pogatzki-Zahn E. Pain therapy to reduce perioperative complications. Innov Surg Sci 2019; 4:158-166. [PMID: 33977126 PMCID: PMC8059349 DOI: 10.1515/iss-2019-0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 09/16/2019] [Indexed: 12/19/2022] Open
Abstract
The incidence rates of adverse events secondary to any operation are a well-known problem in any surgical field. One outstanding example of such adverse events is postoperative pain. Thus, the incidence of acute postoperative pain following any surgical procedure and its treatment are central issues for every surgeon. In the times of Enhanced Recovery After Surgery (ERAS) programs, acute pain therapy became an increasingly well investigated and accepted aspect in almost all surgical subspecialties. However, if it comes to the reduction of postoperative complications, in the actual context of postoperative pain, surgeons tend to focus on the operative process rather than on the perioperative procedures. Undoubtedly, postoperative pain became an important factor with regard to the quality of surgical care: both, the extent and the quality of the surgical procedure and the extent and the quality of the analgesic technique are decisive issues for a successful pain management. There is growing evidence that supports the role of acute pain therapy in reducing postoperative morbidity, and it has been demonstrated that high pain scores postoperatively may contribute to a complicated postoperative course. This overview comprises the current knowledge on the role of acute pain therapy with regard to the occurrence of postoperative complications. Most of the knowledge is derived from studies that primarily focus on the type and quality of postoperative pain therapy in relation to specific surgical procedures and only secondary on complications. As far as existent, data that report on the recovery period after surgery, on the rehabilitation status, on perioperative morbidity, on the development of chronic pain after surgery, and on possible solutions of the latter problem with the institution of transitional pain services will be presented.
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Affiliation(s)
- Stephan M. Freys
- Chirurgische Klinik, DIAKO Ev. Diakonie-Krankenhaus, Gröpelinger Heerstr. 406-408, 28239 Bremen, Germany
| | - Esther Pogatzki-Zahn
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Münster, Germany
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Coates MD, Kim JS, Carkaci-Salli N, Vrana KE, Koltun WA, Puhl HL, Adhikary SD, Janicki PK, Ruiz-Velasco V. Impact of the Na V1.8 variant, A1073V, on post-sigmoidectomy pain and electrophysiological function in rat sympathetic neurons. J Neurophysiol 2019; 122:2591-2600. [PMID: 31642403 DOI: 10.1152/jn.00542.2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
NaV1.8 channels play a crucial role in regulating the action potential in nociceptive neurons. A single nucleotide polymorphism in the human NaV1.8 gene SCN10A, A1073V (rs6795970, G>A), has been linked to the diminution of mechanical pain sensation as well as cardiac conduction abnormalities. Furthermore, studies have suggested that this polymorphism may result in a "loss-of-function" phenotype. In the present study, we performed genomic analysis of A1073V polymorphism presence in a cohort of patients undergoing sigmoid colectomy who provided information regarding perioperative pain and analgesic use. Homozygous carriers reported significantly reduced severity in postoperative abdominal pain compared with heterozygous and wild-type carriers. Homozygotes also trended toward using less analgesic/opiates during the postoperative period. We also heterologously expressed the wild-type and A1073V variant in rat superior cervical ganglion neurons. Electrophysiological testing demonstrated that the mutant NaV1.8 channels activated at more depolarized potentials compared with wild-type channels. Our study revealed that postoperative abdominal pain is diminished in homozygous carriers of A1073V and that this is likely due to reduced transmission of action potentials in nociceptive neurons. Our findings reinforce the importance of NaV1.8 and the A1073V polymorphism to pain perception. This information could be used to develop new predictive tools to optimize patient pain experience and analgesic use in the perioperative setting.NEW & NOTEWORTHY We present evidence that in a cohort of patients undergoing sigmoid colectomy, those homozygous for the NaV1.8 polymorphism (rs6795970) reported significantly lower abdominal pain scores than individuals with the homozygous wild-type or heterozygous genotype. In vitro electrophysiological recordings also suggest that the mutant NaV1.8 channel activates at more depolarizing potentials than the wild-type Na+ channel, characteristic of hypoactivity. This is the first report linking the rs6795970 mutation with postoperative abdominal pain in humans.
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Affiliation(s)
- Matthew D Coates
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Joyce S Kim
- Heart and Vascular Institute, Department of Internal Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Nurgul Carkaci-Salli
- Department of Pharmacology, Penn State College of Medicine, Hershey, Pennsylvania
| | - Kent E Vrana
- Department of Pharmacology, Penn State College of Medicine, Hershey, Pennsylvania
| | - Walter A Koltun
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Henry L Puhl
- Section on Transmitter Signaling, Laboratory of Molecular Physiology, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland
| | - Sanjib D Adhikary
- Department of Anesthesiology and Perioperative Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Piotr K Janicki
- Department of Anesthesiology and Perioperative Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Victor Ruiz-Velasco
- Department of Anesthesiology and Perioperative Medicine, Penn State College of Medicine, Hershey, Pennsylvania
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Jabehdar Maralani P, Schieda N, Hecht EM, Litt H, Hindman N, Heyn C, Davenport MS, Zaharchuk G, Hess CP, Weinreb J. MRI safety and devices: An update and expert consensus. J Magn Reson Imaging 2019; 51:657-674. [PMID: 31566852 DOI: 10.1002/jmri.26909] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 12/22/2022] Open
Abstract
The use of magnetic resonance imaging (MRI) is increasing globally, and MRI safety issues regarding medical devices, which are constantly being developed or upgraded, represent an ongoing challenge for MRI personnel. To assist the MRI community, a panel of 10 radiologists with expertise in MRI safety from nine high-volume academic centers formed, with the objective of providing clarity on some of the MRI safety issues for the 10 most frequently questioned devices. Ten device categories were identified. The panel reviewed the literature, including key MRI safety issues regarding screening and adverse event reports, in addition to the manufacturer's Instructions For Use. Using a Delphi-inspired method, 36 practical recommendations were generated with 100% consensus that can aid the clinical MRI community. Level of Evidence: 5 Technical Efficacy Stage: 5 J. Magn. Reson. Imaging 2020;51:657-674.
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Affiliation(s)
| | - Nicola Schieda
- Department of Radiology, University of Ottawa, Ottawa, Canada
| | - Elizabeth M Hecht
- Department of Radiology, Columbia University, New York, New York, USA
| | - Harold Litt
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nicole Hindman
- Department of Radiology, New York University, New York, New York, USA
| | - Chinthaka Heyn
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | | | - Greg Zaharchuk
- Department of Radiology, Stanford University, Stanford, California, USA
| | - Christopher P Hess
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California, USA
| | - Jeffrey Weinreb
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, Connecticut, USA
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Practice advisory on the bleeding risks for peripheral nerve and interfascial plane blockade: evidence review and expert consensus. Can J Anaesth 2019; 66:1356-1384. [DOI: 10.1007/s12630-019-01466-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 01/31/2019] [Accepted: 02/11/2019] [Indexed: 12/14/2022] Open
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Prolonged Catheter Use and Infection in Regional Anesthesia: A Retrospective Registry Analysis. Anesthesiology 2019; 128:764-773. [PMID: 29420315 DOI: 10.1097/aln.0000000000002105] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Prolonged catheter use is controversial because of the risk of catheter-related infection, but the extent to which the risk increases over time remains unknown. We thus assessed the time-dependence of catheter-related infection risk up to 15 days. METHODS Our analysis was based on the German Network for Regional Anesthesia, which includes 25 centers. We considered 44,555 patients who had surgery between 2007 and 2014 and had continuous regional anesthesia as well as complete covariable details. Cox regression analysis was performed and adjusted for confounding covariables to examine the relationship between catheter duration and probability of infection-free catheter use. RESULTS After adjustment for confounding factors, the probability of infection-free catheter use decreases with each day of peripheral and epidural catheter use. In peripheral catheters, it was 99% at day 4 of catheter duration, 96% at day 7, and 73% at day 15. In epidural catheters, it was 99% at day 4 of catheter duration, 95% at day 7, and 73% at day 15. Only 31 patients (0.07%) had severe infections that prompted surgical intervention. Among these were five catheters that initially had only mild or moderate signs of infection and were left in situ; all progressed to severe infections. CONCLUSIONS Infection risk in catheter use increases over time, especially after four days. Infected catheters should be removed as soon as practical. VISUAL ABSTRACT An online visual overview is available for this article at http://links.lww.com/ALN/B683.
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Is It Time to Reconsider Postoperative Epidural Analgesia in Patients Undergoing Elective Ventral Hernia Repair?: An AHSQC Analysis. Ann Surg 2019; 267:971-976. [PMID: 28288066 DOI: 10.1097/sla.0000000000002214] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE We aimed to evaluate the association of epidural analgesia (EA) with hospital length of stay (LOS), wound morbidity, postoperative complications, and patient-reported outcomes in patients undergoing ventral hernia repair (VHR). BACKGROUND EA has been shown to reduce LOS in certain surgical populations. The LOS benefit in VHR is unclear. METHODS Patients having VHR performed in the Americas Hernia Society Quality Collaborative (AHSQC) were separated into 2 comparable groups matched on several confounding factors using a propensity score algorithm: one group received postoperative EA, and the other did not. The groups were then evaluated for hospital LOS, 30-day wound morbidity, other complications, and 30-day patient-reported outcomes using pain and hernia-specific quality-of-life instruments. RESULTS A 1:1 match was achieved and the final analysis included 763 patients receiving EA and 763 not receiving EA. The EA group had an increased LOS (5.49 vs 4.90 days; P < 0.05). The rate of wound events was similar between the groups. There was an increased risk of having any postoperative complication associated with having EA (26% vs 21%; P < 0.05). Pain intensity-scaled scores were significantly higher (worse) in the EA group versus the non-EA group (47.6 vs 44.0; P = 0.04). CONCLUSIONS The LOS benefit of EA noted for other operations may not apply to patients undergoing VHR. Further study is necessary to determine the beneficial role of invasive pain management procedures in this group of patients with an extremely common disease state.
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Epidural morphine improves postoperative analgesia in patients after total knee arthroplasty: A randomized controlled trial. PLoS One 2019; 14:e0219116. [PMID: 31260468 PMCID: PMC6602200 DOI: 10.1371/journal.pone.0219116] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 06/15/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients after total knee arthroplasty (TKA) often develop moderate to severe pain. This study compared the analgesic effect of low-dose epidural morphine vs. a comparable saline injection in patients following TKA surgery. METHODS This randomized, double-blinded, and placebo-controlled trial was conducted in a tertiary hospital in Beijing between July 1, 2017 and May 30, 2018. One hundred and ten patients following TKA under combined spinal-epidural anesthesia were randomized to receive either epidural morphine (2 mg diluted to 5 ml normal saline, the epidural morphine group) or placebo (5 ml normal saline, the placebo group). For all patients, single-injection femoral nerve block was performed, and a supplementary patient-controlled intravenous analgesia pump was provided. The severity of pain was assessed with the numerical rating scale (NRS, an 11-point scale where 0 = no pain and 10 = the worst pain) at 6, 12, 24, 36, and 48 hours after surgery. The primary endpoint was moderate to severe pain (NRS pain score ≥4) within 48 hours after surgery. RESULTS The percentage with moderate to severe pain within 48 hours was lower in the epidural morphine group than in the placebo group (58.2% [32/55] with epidural morphine vs. 76.4% [42/55] with placebo; OR 0.43, 95% CI 0.19-0.98; p = 0.042). Furthermore, the cumulative morphine consumption within 48 hours was lower (18.4±6.1 mg vs. 22.4±7.3 mg; p = 0.002) whereas the mental component summary score of 30-day quality of life was higher (63.8±2.9 vs. 61.9±4.2; p = 0.008) in the epidural morphine group than in the placebo group. CONCLUSIONS For patients following TKA, the addition of epidural morphine to single-injection femoral nerve block improves the quality of analgesia within 48 hours, without increasing adverse events. TRIAL REGISTRATION ClinicalTrials.gov NCT03203967.
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Deni F, Greco M, Turi S, Meani R, Comotti L, Perotti V, Mello A, Colnaghi E, Pasculli N, Nardelli P, Landoni G, Beretta L. Acute Pain Service: A 10-Year Experience. Pain Pract 2019; 19:586-593. [PMID: 30791208 DOI: 10.1111/papr.12777] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 02/08/2019] [Accepted: 02/12/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Pain management after surgery is crucial to decrease perioperative morbidity and mortality. Acute pain services (APS) are multidisciplinary teams that represent a modern strategy to address pain inside hospitals. The APS defines and applies pain treatment protocols specific for each surgery. To evaluate the performance of the APS at our institute, we performed a large retrospective cohort study focusing on complications of epidural analgesia and IV opiates. METHODS Data from the 10 years of activity of the APS were collected. Pain was assessed using the VAS at rest (VASr) and during movement (VASm) at each daily visit; the presence of side effects and complications was also assessed. RESULTS A total of 17,913 adult patients were followed by APS during the study period. Epidural analgesia was used in 7,776 cases (43%), while 9,239 (52%) patients used IV patient-controlled analgesia (PCA). A combination of the 2 was used in 87 patients (0.5%). A total of 456 perineural catheters (2.6%) were placed, while 442 patients(2.5%) used other analgesic techniques. We recorded 163 dural punctures during catheter placement, with no epidural hematoma, epidural abscess, or meningitis, and no permanent modification in sensitive or motor functions. CONCLUSIONS In our large case series, APS was confirmed safe and effective in treating postoperative pain, using both epidural analgesia and IV PCA with morphine.
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Affiliation(s)
- Francesco Deni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimiliano Greco
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center - IRCCS, Rozzano, MI, Italy
| | - Stefano Turi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Renato Meani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Laura Comotti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Valeria Perotti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandra Mello
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Eleonora Colnaghi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicola Pasculli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Pasquale Nardelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Luigi Beretta
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
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Analysis of Multiple Routes of Analgesic Administration in the Immediate Postoperative Period: a 10-Year Experience. Curr Pain Headache Rep 2019; 23:22. [DOI: 10.1007/s11916-019-0754-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Paul JE, Chong MA, Buckley N, Harsha P, Shanthanna H, Tidy A, Buckley D, Clarke A, Young C, Wong T, Vanniyasingam T, Thabane L. Vital sign monitoring with continuous pulse oximetry and wireless clinical notification after surgery (the VIGILANCE pilot study)-a randomized controlled pilot trial. Pilot Feasibility Stud 2019; 5:36. [PMID: 30858986 PMCID: PMC6391749 DOI: 10.1186/s40814-019-0415-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 02/07/2019] [Indexed: 11/17/2022] Open
Abstract
Background Respiratory depression is a serious perioperative complication associated with morbidity and mortality. Recently, technology has become available to wirelessly monitor patients on regular surgical wards with continuous pulse oximetry and wireless clinician notification with alarms. When a patient’s SpO2 falls below a set threshold, the clinician is notified via a pager and may intervene earlier to prevent further clinical deterioration. To date, the technology has not been evaluated with a randomized controlled trial (RCT). Methods We designed a parallel-group unblinded pilot RCT of a wireless monitoring system on two surgical wards in an academic teaching hospital. Postsurgical patients with an anticipated length of stay of at least 1 day were included and randomized to standard care or standard care plus wireless respiratory monitoring for up to a 72-h period. The primary outcomes were feasibility outcomes: average patients recruited per week and tolerability of the system by patients. Secondary outcomes included (1) respiratory events (naloxone administration for respiratory depression, ICU transfers, and cardiac arrest team activation) and (2) system alarm types and details. The analysis of the outcomes was based on descriptive statistics and estimates reported using point (95% confidence intervals). Criteria for success of feasibility were recruitment of an average of 15 patients/week and 90% of the patients tolerating the system. Results The pilot trial enrolled 250 of the 335 patients screened for eligibility, with 126 and 124 patients entering the standard monitoring and wireless groups, respectively. Baseline demographics were similar between groups, except for slightly more women in the wireless group. Average patient recruitment per week was 14 95% CI [12, 16] patients. The wireless monitoring was quite tolerable with 86.6% (95% CI 78.2–92.7%) of patients completing the full course, and there were no other adverse events directly attributable to the monitoring. With regard to secondary outcomes, the respiratory event rate was low with only 1 event in the wireless group and none in the control group. The average number of alarms per week was 4.0 (95% CI, 1.6–6.4). Conclusions This pilot study demonstrated adequate patient recruitment and high tolerability of the wireless monitoring system. A full RCT that is powered to detect patient important outcomes such as respiratory depression is now underway. Trial registration ClinicalTrials.gov, Registration number NCT02907255, registered 7 September 2016—retrospectively registered.
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Affiliation(s)
- James E Paul
- 1Department of Anesthesia, McMaster University, Hamilton, Ontario Canada
| | | | - Norman Buckley
- 1Department of Anesthesia, McMaster University, Hamilton, Ontario Canada
| | - Prathiba Harsha
- 1Department of Anesthesia, McMaster University, Hamilton, Ontario Canada
| | - Harsha Shanthanna
- 1Department of Anesthesia, McMaster University, Hamilton, Ontario Canada
| | - Antonella Tidy
- 1Department of Anesthesia, McMaster University, Hamilton, Ontario Canada
| | - Diane Buckley
- 1Department of Anesthesia, McMaster University, Hamilton, Ontario Canada
| | - Anne Clarke
- 1Department of Anesthesia, McMaster University, Hamilton, Ontario Canada
| | - Christopher Young
- 3Department of Anesthesia, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada
| | - Timothy Wong
- 1Department of Anesthesia, McMaster University, Hamilton, Ontario Canada
| | | | - Lehana Thabane
- 1Department of Anesthesia, McMaster University, Hamilton, Ontario Canada.,5Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario Canada
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Rockett M, Vanstone R, Chand J, Waeland D. A survey of acute pain services in the UK. Anaesthesia 2019; 72:1237-1242. [PMID: 28891060 DOI: 10.1111/anae.14007] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2017] [Indexed: 01/23/2023]
Abstract
The organisational state of inpatient pain management in UK hospitals is difficult to determine. We sent an electronic questionnaire to 209 acute pain service leads throughout the UK. Questions were about staffing and service provision. We received 141 responses (67%); 47% of all UK hospitals. Each service was responsible for a median (IQR [range]) of 566 (400-839 [120-2800]) beds. Each acute pain specialist nurse was responsible for 299 (238-534 [70-1923]) beds. The mean (SD) number of consultant hours per week was 5.54 (4.62), delivered by a median of 1.0 (1.0-2.5 [0.2-7.0]) consultant. Overnight cover was provided by 20 (15%) acute pain services, and weekend cover by 39 (29%). Acute pain services commonly (in 50 (35%) hospitals) had roles in addition to acute pain management. Most teams (105, (77%)) reviewed medical patients and patients with chronic pain (in 131, (96%) teams). Half of the services (56, (49%)), reported that they were part of an integrated acute and chronic pain service, however, 83 (59%) did not have any members who work in chronic pain clinics. The majority (79, (70%)) were able to access a nominated chronic pain consultant for advice. Provision of acute pain services throughout the UK is highly variable. The majority do not meet core UK standards.
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Affiliation(s)
- M Rockett
- Department of Anaesthesia, Critical Care and Pain Medicine, Derriford Hospital, Plymouth, UK
| | - R Vanstone
- Department of Anaesthesia, Critical Care and Pain Medicine, Derriford Hospital, Plymouth, UK
| | - J Chand
- Faculty of Pain Medicine, Royal College of Anaesthetists, London, UK
| | - D Waeland
- Faculty of Pain Medicine, Royal College of Anaesthetists, London, UK
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Zhu Q, Li L, Yang Z, Shen J, Zhu R, Wen Y, Cai W, Liu L. Ultrasound guided continuous Quadratus Lumborum block hastened recovery in patients undergoing open liver resection: a randomized controlled, open-label trial. BMC Anesthesiol 2019; 19:23. [PMID: 30777027 PMCID: PMC6380018 DOI: 10.1186/s12871-019-0692-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 02/06/2019] [Indexed: 12/22/2022] Open
Abstract
Background Quadratus lumborum (QL) block is increasingly being used as a new abdominal nerve block technique. In some studies of mid and lower abdominal and hip analgesia, continuous QL block achieved favorable outcomes as an alternative to continuous intravenous analgesia with opioids. However, the use of continuous QL block for upper abdominal pain is less well characterized. This study aimed to investigate the effects of continuous anterior QL block (CQLB) on postoperative pain and recovery in patients undergoing open liver resection. Methods Sixty-three patients underwent elective open liver resection were randomly divided into continuous anterior QL block (CQLB, n = 32) group and patient-controlled intravenous analgesia (PCIA, n = 31) group. Patients in CQLB group underwent ultrasound-guided anterior QL block at the second lumbar vertebral transverse processes before general anesthesia, followed by postoperative CQLB analgesia. Patients in PCIA group underwent continuous intravenous analgesia postoperatively. Postoperative numerical rating scale (NRS) pain scores upon coughing and at rest, self-administered analgesic counts, rate of rescue analgesic use, time to first out-of-bed activity and anal flatus after surgery, and incidences of analgesic-related adverse effects were recorded. Results Postoperative NRS pain scores on coughing in CQLB group at different time points and NRS pain score at rest 48 h after surgery were significantly lower than those in PCIA group (P < 0.05). Time to first out-of-bed activity and anal flatus after surgery in CQLB group were significantly earlier than those in PCIA group (P < 0.05). No significant differences of postoperative self-administered analgesic counts, rate of postoperative rescue analgesic usage, or incidences of analgesic-related adverse effects were found between the two groups (P > 0.05). Conclusions Ultrasound-guided anterior QL block significantly alleviated the pain during coughing after surgery, shortened the time to first out-of-bed activity and anal flatus, promoting postoperative recovery of the patients undergoing open liver resection. Trial registration This study has been registered in April 1, 2018 on Chinese Clinical Trail Registry, the registration number is ChiCTR1800015454.
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Affiliation(s)
- Qiang Zhu
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Hunan, China
| | - Li Li
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Hunan, China
| | - Zhaoyun Yang
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Hunan, China
| | - Jinmei Shen
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Hunan, China
| | - Rong Zhu
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Hunan, China
| | - Yu Wen
- Department of Hepatobiliary Surgery, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Hunan, China
| | - Wenwu Cai
- Department of Hepatobiliary Surgery, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Hunan, China
| | - Lei Liu
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Hunan, China.
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