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Palermo J, Tingey S, Khanna AK, Segal S. Evaluation and Prevention of Perioperative Respiratory Failure. J Clin Med 2024; 13:5083. [PMID: 39274295 PMCID: PMC11396761 DOI: 10.3390/jcm13175083] [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: 07/11/2024] [Revised: 08/12/2024] [Accepted: 08/18/2024] [Indexed: 09/16/2024] Open
Abstract
Respiratory failure is a common perioperative complication. The risk of respiratory failure can be reduced with effective preoperative evaluation, preventative measures, and knowledge of evidence-based management techniques. Effective preoperative screening methods include ARISCAT scoring, OSA screening, and the LAS VEGAS score (including the ASA physical status score). Evaluation by the six-minute walk test and a routine pulmonary physical exam has been shown to be effective at predicting postoperative pulmonary complications, whereas evidence on the predictive power of pulmonary function tests and chest radiography has been inconclusive. Preoperative smoking cessation and lung expansion maneuvers have been shown to decrease the risk of pulmonary complications postoperatively. Intraoperative management techniques that decrease the pulmonary complication risk include neuromuscular blockade reversal with sugammadex, limiting surgical times to less than 3 h when possible, lung-protective ventilation techniques, and multimodal analgesia to decrease opioid usage. In the immediate postoperative period, providers should be prepared to quickly treat bronchospasm, hypoventilation, and upper airway obstruction. For post-surgical patients who remain in the hospital, the risk of pulmonary complications can be decreased with lung expansion techniques, adequate analgesia, automated continuous postoperative ward monitoring, non-invasive ventilatory support, and early mobilization. This article was written to analyze the available literature on this topic in order to learn and practice the prevention of perioperative respiratory failure when caring for patients on a daily basis.
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Affiliation(s)
| | - Spencer Tingey
- Wake Forest University School of Medicine, Winston-Salem, NC 27101, USA
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Atrium Health Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
| | - Scott Segal
- Department of Anesthesiology, Atrium Health Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
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2
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Riester MR, Bosco E, Beaudoin FL, Gravenstein S, Schoenfeld AJ, Mor V, Zullo AR. Initial and Long-Term Prescribing of Opioids and Non-steroidal Anti-inflammatory Drugs Following Total Hip and Knee Arthroplasty. Geriatr Orthop Surg Rehabil 2024; 15:21514593241266715. [PMID: 39149698 PMCID: PMC11325315 DOI: 10.1177/21514593241266715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 06/07/2024] [Accepted: 06/14/2024] [Indexed: 08/17/2024] Open
Abstract
Introduction Limited evidence exists on health system characteristics associated with initial and long-term prescribing of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) following total hip and knee arthroplasty (THA/TKA), and if these characteristics differ among individuals based on preoperative NSAID exposure. We identified orthopedic surgeon opioid prescribing practices, hospital characteristics, and regional factors associated with initial and long-term prescribing of opioids and NSAIDs among older adults receiving THA/TKA. Materials and Methods This observational study included opioid-naïve Medicare beneficiaries aged ≥65 years receiving elective THA/TKA between January 1, 2014 and July 4, 2017. We examined initial (days 1-30 following THA/TKA) and long-term (days 90-180) opioid or NSAID prescribing, stratified by preoperative NSAID exposure. Risk ratios (RRs) for the associations between 10 health system characteristics and case-mix adjusted outcomes were estimated using multivariable Poisson regression models. Results The study population included 23,351 NSAID-naïve and 10,127 NSAID-prevalent individuals. Increases in standardized measures of orthopedic surgeon opioid prescribing generally decreased the risk of initial NSAID prescribing but increased the risk of long-term opioid prescribing. For example, among NSAID-naïve individuals, the RRs (95% confidence intervals [CIs]) for initial NSAID prescribing were 0.95 (0.93-0.97) for 1-2 orthopedic surgeon opioid prescriptions per THA/TKA procedure, 0.94 (0.92-0.97) for 3-4 prescriptions per procedure, and 0.91 (0.89-0.93) for 5+ opioid prescriptions per procedure (reference: <1 opioid prescription per procedure), while the RRs (95% CIs) for long-term opioid prescribing were 1.06 (1.04-1.08), 1.08 (1.06-1.11), and 1.13 (1.11-1.16), respectively. Variation in postoperative analgesic prescribing was observed across U.S. regions. For example, among NSAID-naïve individuals, the RR (95% CIs) for initial opioid prescribing were 0.98 (0.96-1.00) for Region 2 (New York), 1.09 (1.07-1.11) for Region 3 (Philadelphia), 1.07 (1.05-1.10) for Region 4 (Atlanta), 1.03 (1.01-1.05) for Region 5 (Chicago), 1.16 (1.13-1.18) for Region 6 (Dallas), 1.10 (1.08-1.12) for Region 7 (Kansas City), 1.09 (1.06-1.12) for Region 8 (Denver), 1.09 (1.07-1.12) for Region 9 (San Francisco), and 1.11 (1.08-1.13) for Region 10 (Seattle) (reference: Region 1 [Boston]). Hospital characteristics were not meaningfully associated with postoperative analgesic prescribing. The relationships between health system characteristics and postoperative analgesic prescribing were similar for NSAID-naïve and NSAID-prevalent participants. Discussion Future efforts aiming to improve the use of multimodal analgesia through increased NSAID prescribing and reduced long-term opioid prescribing following THA/TKA could consider targeting orthopedic surgeons with higher standardized opioid prescribing measures. Conclusions Orthopedic surgeon opioid prescribing measures and U.S. region were the greatest health system level predictors of initial, and long-term, prescribing of opioids and prescription NSAIDs among older Medicare beneficiaries following THA/TKA. These results can inform future studies that examine why variation in analgesic prescribing exists across geographic regions and levels of orthopedic surgeon opioid prescribing.
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Affiliation(s)
- Melissa R. Riester
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University School of Public Health, Providence, RI, USA
| | - Elliott Bosco
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University School of Public Health, Providence, RI, USA
| | - Francesca L. Beaudoin
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Stefan Gravenstein
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Andrew J. Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Andrew R. Zullo
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
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3
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Newgaard OR, Weingarten TN, Sprung J, Suginaka AT, Gurrieri C. Postoperative opioid-induced respiratory depression or oversedation requiring naloxone treatment in a community hospital: a case series. Proc AMIA Symp 2023; 37:55-60. [PMID: 38174010 PMCID: PMC10761176 DOI: 10.1080/08998280.2023.2269030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/27/2023] [Indexed: 01/05/2024] Open
Abstract
Background Postoperative opioid-induced respiratory depression and oversedation can lead to fatal events and increase perioperative mortality. In reports from major academic centers, naloxone administration has been used as a proxy for severe opioid overdose. Herein, we studied the incidence, clinical characteristics, and outcomes of postoperative naloxone use in a mid-size community hospital. Methods This was a retrospective review of adult patients who received naloxone within 48 postoperative hours between July 9, 2017, and May 31, 2022. Results During the study timeframe, a total of 23,362 surgical procedures were performed and a total of 19 patients received naloxone (8 in the recovery room, 11 on hospital wards), with an incidence of 8.1 [95% confidence interval 4.9-12.7] per 10,000 anesthetics. In 12 cases (63%), naloxone was indicated for oversedation, and in 7 cases (37%), for opioid-induced respiratory depression. All patients received naloxone within the first 24 postoperative hours. While all patients survived the opioid-related adverse event, 2 patients were intubated, 1 developed stress-induced cardiomyopathy, and 5 required intensive care unit admission. Conclusion The rate of early postoperative opioid-induced respiratory depression or oversedation in our community hospital was low; however, these patients often require a substantial escalation of medical management.
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Affiliation(s)
| | - Toby N. Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Alex T. Suginaka
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Health System, Eau Claire, Wisconsin, USA
| | - Carmelina Gurrieri
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Health System, Eau Claire, Wisconsin, USA
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4
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Henricks EM, Pfeifer KJ. Pulmonary assessment and optimization for older surgical patients. Int Anesthesiol Clin 2023; 61:8-15. [PMID: 36794803 DOI: 10.1097/aia.0000000000000398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Affiliation(s)
- Evan M Henricks
- Division of Geriatric and Palliative Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kurt J Pfeifer
- Department of Medicine, Section of Perioperative & Consultative Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Hyland SJ, Wetshtein AM, Grable SJ, Jackson MP. Acute Pain Management Pearls: A Focused Review for the Hospital Clinician. Healthcare (Basel) 2022; 11:healthcare11010034. [PMID: 36611494 PMCID: PMC9818465 DOI: 10.3390/healthcare11010034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Acute pain management is a challenging area encountered by inpatient clinicians every day. While patient care is increasingly complex and costly in this realm, the availability of applicable specialists is waning. This narrative review seeks to support diverse hospital-based healthcare providers in refining and updating their acute pain management knowledge base through clinical pearls and point-of-care resources. Practical guidance is provided for the design and adjustment of inpatient multimodal analgesic regimens, including conventional and burgeoning non-opioid and opioid therapies. The importance of customized care plans for patients with preexisting opioid tolerance, chronic pain, or opioid use disorder is emphasized, and current recommendations for inpatient management of associated chronic therapies are discussed. References to best available guidelines and literature are offered for further exploration. Improved clinician attention and more developed skill sets related to acute pain management could significantly benefit hospitalized patient outcomes and healthcare resource utilization.
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Affiliation(s)
- Sara J. Hyland
- Department of Pharmacy, OhioHealth Grant Medical Center, Columbus, OH 43215, USA
- Correspondence:
| | - Andrea M. Wetshtein
- Department of Pharmacy, Cleveland Clinic Fairview Hospital, Cleveland, OH 44111, USA
| | - Samantha J. Grable
- Hospice and Palliative Medicine, OhioHealth Grant Medical Center, Columbus, OH 43215, USA
| | - Michelle P. Jackson
- Hospice and Palliative Medicine, OhioHealth Grant Medical Center, Columbus, OH 43215, USA
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Ohnuma T, Horres CR, Raghunathan K, Bartz RR, Krishnamoorthy V, Brookhart MA, Kent ML. Trends in multimodal analgesics among end-stage renal disease patients undergoing lower extremity amputation in the US from 2009 to 2018. Br J Anaesth 2021; 128:e43-e45. [PMID: 34852927 DOI: 10.1016/j.bja.2021.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/13/2021] [Accepted: 10/19/2021] [Indexed: 11/20/2022] Open
Affiliation(s)
- Tetsu Ohnuma
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.
| | - C Russell Horres
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA; Patient Safety Center of Inquiry, Durham VA Medical Center, Durham, NC, USA
| | - Raquel R Bartz
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | | | - M Alan Brookhart
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Michael L Kent
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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McGauvran MM, Ohnuma T, Raghunathan K, Krishnamoorthy V, Johnson S, Lo T, Pyati S, Van De Ven T, Bartz RR, Gaca J, Thompson A. Association Between Gabapentinoids and Postoperative Pulmonary Complications in Patients Undergoing Thoracic Surgery. J Cardiothorac Vasc Anesth 2021; 36:2295-2302. [PMID: 34756676 DOI: 10.1053/j.jvca.2021.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/26/2021] [Accepted: 10/02/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Perioperative gabapentinoids in general surgery have been associated with an increased risk of postoperative pulmonary complications (PPCs), while resulting in equivocal pain relief. This study's aim was to examine the utilization of gabapentinoids in thoracic surgery to determine the association of gabapentinoids with PPCs and perioperative opioid utilization. DESIGN A multicenter retrospective cohort study. SETTING Hospitals in the Premier Healthcare Database from 2012 to 2018. PARTICIPANTS A total of 70,336 patients undergoing elective open thoracotomy, video-assisted thoracic surgery, and robotic-assisted thoracic surgery. INTERVENTIONS Propensity score analyses were used to assess the association between gabapentinoids on day of surgery and the primary composite outcome of PPCs, defined as respiratory failure, pneumonia, reintubation, pulmonary edema, and noninvasive and invasive ventilation. Secondary outcomes included invasive and noninvasive ventilation, hospital mortality, length of stay, opioid consumption on day of surgery, and average daily opioid consumption after day of surgery. RESULTS Overall, 8,142 (12%) patients received gabapentinoids. The prevalence of gabapentin on day of surgery increased from 3.8% in 2012 to 15.9% in 2018. Use of gabapentinoids on day of surgery was associated with greater odds of PPCs (odds ratio [OR] 1.19, 95% CI 1.11-1.28), noninvasive mechanical ventilation (OR 1.30, 95% CI 1.16-1.45), and invasive mechanical ventilation (OR 1.14, 95% CI 1.02-1.28). Secondary outcomes indicated no clinically meaningful associations of gabapentinoid use with opioid consumption, hospital mortality, or length of stay. CONCLUSIONS Perioperative gabapentinoid administration in elective thoracic surgery may be associated with a higher risk of PPCs and no opioid-sparing effect.
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Affiliation(s)
| | - Tetsu Ohnuma
- CAPER Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC.
| | - Karthik Raghunathan
- CAPER Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC; Patient Safety Center of Inquiry, Durham VA Medical Center, Durham, NC
| | - Vijay Krishnamoorthy
- CAPER Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Selby Johnson
- CAPER Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Theresa Lo
- CAPER Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Srinivas Pyati
- CAPER Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC; Patient Safety Center of Inquiry, Durham VA Medical Center, Durham, NC
| | - Thomas Van De Ven
- CAPER Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Raquel R Bartz
- CAPER Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Jeffrey Gaca
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Annemarie Thompson
- CAPER Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
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Knezevic NN, Aijaz T, Camacho-Ortega A, Candido KD. A Retrospective Analysis of Gabapentinoid and Opioids to Opioid Monotherapy for Pain Relief in Patients with Chronic Neck and Low Back Pain. PAIN MEDICINE 2021; 22:1760-1766. [PMID: 33502505 DOI: 10.1093/pm/pnab006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE We compared the reduction in pain and opioid consumption in patients with chronic spinal pain on concomitant gabapentinoids and opioids with patients using opioids only. DESIGN This was a retrospective chart review of patients with chronic neck or low back pain who were on opioids with at least a 24-month follow-up. SETTING Single-center pain clinic in an urban setting. SUBJECTS 167 patients with chronic spinal pain lasting at least six months. METHODS Patients on gabapentin or pregabalin were included in the gabapentinoid group, while the other patients were included in the non-gabapentinoid group. Primary outcome was assessment of pain scores measured via a numeric rating scale (NRS), and secondary outcomes were response to the treatment (>2 point reduction on NRS) and daily opioid use measured in morphine milliequivalents. RESULTS Pain scores were reduced in the first six months and plateaued after that in both groups. At the end of 24 months, the average pain score was 6.71 in the gabapentinoid group, while the average pain score was 7.18 in the non-gabapentinoid group. There was no statistical significance between the groups (p = 0.28). There was no difference in response to treatment in gabapentinoid group (33.3%) when compared with non-gabapentinoid group (32.7%). We also failed to find any significant difference in daily opioid usage between the two groups. CONCLUSION Gabapentinoids may not lead to reduction in pain or opioid consumption in patients with chronic spinal pain. A careful approach must be adopted while prescribing gabapentinoids in the chronic spinal pain patient population.
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Affiliation(s)
- Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois.,Department of Anesthesiology, University of Illinois, Chicago, Illinois.,Department of Surgery, University of Illinois, Chicago, Illinois, USA
| | - Tabish Aijaz
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois
| | - Alvaro Camacho-Ortega
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois
| | - Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois.,Department of Anesthesiology, University of Illinois, Chicago, Illinois.,Department of Surgery, University of Illinois, Chicago, Illinois, USA
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Comparison of the Effect of Different Local Analgesia Administration Techniques in Total Hip Arthroplasty: A Retrospective Comparative Cohort Study. Pain Res Manag 2021; 2021:9914590. [PMID: 34349850 PMCID: PMC8328737 DOI: 10.1155/2021/9914590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 06/22/2021] [Accepted: 07/14/2021] [Indexed: 11/22/2022]
Abstract
Objective To improve postoperative pain management, several authors have described the use of periarticular injection (PAI) or intra-articular injection (IAI) following total hip arthroplasty (THA). However, no comparative studies examining the results between PAI and IAI following THA have been published. This study aimed to evaluate the analgesic and anti-inflammatory effects of PAI and IAI following THA. Methods This single-center, retrospective cohort study enrolled patients who underwent unilateral primary THA. A total of 278 patients (281 hips) were included in the final analyses, with 112 patients (113 hips) in the control group, 85 patients (87 hips) in the PAI group, and 81 patients (81 hips) in the IAI group. Numeric rating scale (NRS) scores and laboratory data were assessed preoperatively and on postoperative days (POD) 1 and 7. Results NRS scores, creatine phosphokinase, and C-reactive protein levels in the PAI and IAI groups were significantly lower than those in the control group on POD 1 and 7. D-dimer levels were significantly lower in the PAI and IAI groups than in the control group on POD 7. The white blood cell count was significantly higher in the PAI and IAI groups than in the control group on POD 1 and 7. Aspartate transaminase, alanine aminotransferase, blood urea nitrogen, and creatinine levels were within the reference ranges in all three groups at all time points. NRS scores and laboratory data showed no significant differences between the PAI and IAI groups at all time points. Conclusion PAI and IAI have equivalent analgesic and anti-inflammatory effects. Considering the technical challenges of PAI, IAI may be preferable because of its simplicity in the case of using a closed suction drain.
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10
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Nagavelli H, Mariano ER, Krishnamoorthy V, Ray ND, Hsia HL, Ellis AR, Memtsoudis SG, Bryan WE, Pepin MJ, Raghunathan K. Evaluation of trends in continuous peripheral nerve block utilization for total knee arthroplasty within and outside the Veterans Affairs Healthcare System. Reg Anesth Pain Med 2021; 47:62-63. [PMID: 34083357 DOI: 10.1136/rapm-2021-102731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/19/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Harika Nagavelli
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA.,Anesthesiology Service, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Edward R Mariano
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA .,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Neil D Ray
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Hung-Lun Hsia
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA.,Anesthesiology Service, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Alan R Ellis
- School of Social Work, North Carolina State University, Raleigh, North Carolina, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA.,Departments of Anesthesiology and Public Health, Weill Cornell Medical College, New York, New York, USA
| | - William E Bryan
- Pharmacy Service, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Marc J Pepin
- Pharmacy Service, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA.,Anesthesiology Service, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
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11
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Lo T, Schiller R, Raghunathan K, Krishnamoorthy V, Jawitz OK, Pyati S, Van De Ven T, Bartz RR, Thompson A, Ohnuma T. Changes in analgesic strategies for lobectomy from 2009 to 2018. JTCVS OPEN 2021; 6:224-236. [PMID: 36003558 PMCID: PMC9390760 DOI: 10.1016/j.xjon.2021.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 03/19/2021] [Indexed: 10/27/2022]
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12
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Hyland SJ, Brockhaus KK, Vincent WR, Spence NZ, Lucki MM, Howkins MJ, Cleary RK. Perioperative Pain Management and Opioid Stewardship: A Practical Guide. Healthcare (Basel) 2021; 9:333. [PMID: 33809571 PMCID: PMC8001960 DOI: 10.3390/healthcare9030333] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 12/20/2022] Open
Abstract
Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.
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Affiliation(s)
- Sara J. Hyland
- Department of Pharmacy, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA
| | - Kara K. Brockhaus
- Department of Pharmacy, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
| | | | - Nicole Z. Spence
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, MA 02118, USA;
| | - Michelle M. Lucki
- Department of Orthopedics, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Michael J. Howkins
- Department of Addiction Medicine, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Robert K. Cleary
- Department of Surgery, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
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Alyamani OA, Bahatheq MS, Azzam HA, Hilal FM, Farsi S, Bahaziq W, Alshoaiby AN. Perioperative pain management in COVID-19 patients: Considerations and recommendations by the Saudi Anesthesia Society (SAS) and Saudi Society of Pain Medicine (SSPM). Saudi J Anaesth 2021; 15:59-69. [PMID: 33824647 PMCID: PMC8016059 DOI: 10.4103/sja.sja_765_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 07/15/2020] [Accepted: 07/16/2020] [Indexed: 01/08/2023] Open
Abstract
The COVID-19 pandemic has swept across the world over the past few months. Many articles have been published on the safety of anesthetic medications and procedures used in COVID-19 positive patients presenting for surgery. Several other articles covered the chronic pain management aspect during the pandemic. Our review aimed to focus on perioperative pain management for COVID-19 patients. We conducted a literature search for pertinent recent articles that cover considerations and recommendations concerning perioperative pain management in COVID-19 patients. We also searched the literature for the relevant adverse effects of the commonly used medications in the treatment of COVID-19, and their potential drug-drug interactions with the common medications used in perioperative pain management. Professional societies recommend prioritizing regional anesthesia techniques, which have many benefits over other perioperative pain management options. When neuraxial and continuous peripheral nerve block catheters are not an option, patient-controlled analgesia (PCA) should be considered if applicable. Many of the medications used for the treatment of COVID-19 and its symptoms can interfere with the metabolism of medications used in perioperative pain management. We formulated an up-to-date guide for anesthesia providers to help them manage perioperative pain in COVID-19 patients presenting for surgery.
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Affiliation(s)
- Omar A. Alyamani
- Department of Anesthesia and Critical Care, Faculty of Medicine, King Abdulaziz University, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Mohammed S. Bahatheq
- Department of Anesthesia and Perioperative Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Hatem A. Azzam
- Department of Anesthesia and Perioperative Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Faisal M. Hilal
- Department of Anesthesia, King Fahad Hospital, Ministry of Health, Jeddah, Saudi Arabia
| | - Sara Farsi
- Department of Anesthesia and Critical Care, Faculty of Medicine, King Abdulaziz University, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Wadeeah Bahaziq
- Department of Anesthesia and Critical Care, Faculty of Medicine, King Abdulaziz University, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Ali N. Alshoaiby
- Department of Anesthesia and Perioperative Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
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Abstract
Treating acute pain after thoracotomy surgery and preventing the development of chronic post-thoracotomy pain syndrome (PTPS) remain significant challenges in this surgical population. While appropriately treated acute thoracotomy pain often resolves, a significant number of patients develop PTPS, with up to 65% of patients experiencing some pain and 10% suffering life-altering, debilitating pain. Currently, there is very little known about specific molecular targets or novel therapeutic combinations that effectively prevent PTPS. Identifying modifiable clinical risk factors (procedure, physical and mental health, preoperative pain in the surgical area and another regions) seems to the most pragmatic approach for prevention for now. Effective acute pain management adopting a multimodal approach can result in a decreased incidence of PTPS. Interventional techniques such as paraverterbral blocks, intercostal blocks, and erector spinae blocks show some promise as well. Future research should be focused on minimally invasive surgeries and also the effect of ERAS protocols, including early mobilization, nutrition, and early removal of drains, on the development of PTPS.
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