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Ibrahim T, Gebril A, Nasr MK, Samad A, Zaki HA. Unlocking the Optimal Analgesic Potential: A Systematic Review and Meta-Analysis Comparing Intravenous, Oral, and Rectal Paracetamol in Equivalent Doses. Cureus 2023; 15:e41876. [PMID: 37581156 PMCID: PMC10423591 DOI: 10.7759/cureus.41876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2023] [Indexed: 08/16/2023] Open
Abstract
Paracetamol (acetaminophen) is an extensively used analgesic for acute and chronic pain management. Currently, paracetamol is manufactured for oral, rectal, and intravenous (IV) use. Research has shown varied results on the analgesic properties of IV paracetamol compared to oral and rectal paracetamol; however, research on the same doses of paracetamol is limited. Therefore, this review was constructed to explore the analgesic properties of IV paracetamol compared with oral and rectal paracetamol administered in equivalent doses. A broad and thorough literature search was performed on five electronic databases, including PubMed, ScienceDirect, Medline, Scopus, and Google Scholar. Statistical analysis of all outcomes in our review was then performed using the Review Manager software. Outcomes were categorized as primary (pain relief and time to request rescue analgesia) and secondary (adverse events after analgesia). An extensive quality appraisal was also done using the Review Manager software's Cochrane risk of bias tool. The literature survey yielded 2,945 articles, of which 12 were used for review and analysis. The pooled analysis for patients undergoing surgical procedures showed that IV paracetamol had statistically similar postoperative pain scores at two (mean difference (MD) = -0.14; 95% confidence interval (CI) -0.58-0.29; p = 0.51), 24 (MD = 0.09; 95% CI = -0.02-0.21; p = 0.12), and 48 (MD = 0.04; 95% CI = -0.08-0.16; p = 0.52) hours as oral paracetamol. Similarly, the data on time to rescue analgesia showed no considerable difference between the IV and oral paracetamol groups (MD = -1.58; 95% CI = -5.51-2.35; p = 0.43). On the other hand, the pooled analysis for patients presenting non-surgical acute pain showed no significant difference in the mean pain scores between patients treated with IV and oral paracetamol (MD = -0.35; 95% CI = -2.19-1.48; p = 0.71). Furthermore, a subgroup analysis of analgesia-related adverse events showed that the incidences of vomiting/nausea and pruritus did not differ between patients receiving IV and oral paracetamol (odds ratio (OR) = 0.71; 95% CI = 0.45-1.11; p = 0.13 and OR = 0.48; 95% CI = 0.18-1.29; p = 0.05, respectively). A review of information from two trials comparing equal doses of IV and rectal paracetamol suggested that the postoperative pain scores were statistically similar between the groups. IV paracetamol is not superior to oral or rectal paracetamol administered in equal doses. Therefore, we cannot recommend or refute IV paracetamol as the first-line analgesia for acute and postoperative pain.
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Affiliation(s)
| | - Amr Gebril
- Emergency Medicine, NMC Royal Hospital, Khalifa City, ARE
| | - Mohammed K Nasr
- Emergency Medicine, Dr. Sulaiman Al Habib Hospital, Dubai, ARE
| | - Abdul Samad
- Acute Medicine/Emergency, NMC Royal Hospital, Khalifa City, ARE
| | - Hany A Zaki
- Emergency Medicine, Hamad Medical Corporation, Doha, QAT
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Madsen AM, Martin JM, Linder BJ, Gebhart JB. Perioperative opioid management for minimally invasive hysterectomy. Best Pract Res Clin Obstet Gynaecol 2022; 85:68-80. [PMID: 35752553 DOI: 10.1016/j.bpobgyn.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 05/18/2022] [Accepted: 05/20/2022] [Indexed: 12/14/2022]
Abstract
Given the high volume of hysterectomies performed, the contribution of gynecologists to the opioid crisis is potentially significant. Following a hysterectomy, most patients are over-prescribed opioids, are vulnerable to developing new persistent opioid use, and can be the source of misuse, diversion, or accidental exposure. People who misuse opioids are at risk of an overdose related death, which is now one of the leading causes of death in the United States and is rising in other countries. It is the physician's responsibility to reduce opioid use by making impactful practice changes, such as 1) using pre-emptive opioid sparing strategies, 2) optimizing multimodal nonopioid pain management, 3) restricting postoperative opioid prescribing, and 4) educating patients on proper disposal of unused opioids. These changes can be implemented with an enhanced recovery after surgery protocol, shared decision-making, and patient education strategies related to opioids.
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Affiliation(s)
- Annetta M Madsen
- Department of Obstetrics & Gynecology, Division of Urogynecology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jessica M Martin
- Department of Obstetrics & Gynecology, Division of Urogynecology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Brian J Linder
- Department of Obstetrics & Gynecology, Division of Urogynecology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - John B Gebhart
- Department of Obstetrics & Gynecology, Division of Urogynecology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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AUGS-IUGA Joint Clinical Consensus Statement on Enhanced Recovery After Urogynecologic Surgery: Developed by the Joint Writing Group of the International Urogynecological Association and the American Urogynecologic Society. Individual writing group members are noted in the Acknowledgements section. UROGYNECOLOGY (HAGERSTOWN, MD.) 2022; 28:716-734. [PMID: 36288110 DOI: 10.1097/spv.0000000000001252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Enhanced recovery after surgery (ERAS) evidence-based protocols for perioperative care can lead to improvements in clinical outcomes and cost savings. This article aims to present consensus recommendations for the optimal perioperative management of patients undergoing urogynecological surgery. METHODS A review of meta-analyses, randomized clinical trials, large nonrandomized studies, and review articles was conducted via PubMed and other databases for ERAS and urogynecological surgery. ERAS protocol components were established, and then quality of the evidence was both graded and used to form consensus recommendations for each topic. These recommendations were developed and endorsed by the writing group, which is comprised of the American Urogynecologic Society and the International Urogynecological Association members. RESULTS All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. The components of ERAS with a high level of evidence to support their use include fasting for 6 h and taking clear fluids up to 2 h preoperatively, euvolemia, normothermia, surgical site preparation, antibiotic and antithrombotic prophylaxis, strong antiemetics and dexamethasone to reduce postoperative nausea and vomiting, multimodal analgesia and restrictive use of opiates, use of chewing gum to reduce ileus, removal of catheter as soon as feasible after surgery and avoiding systematic use of drains/vaginal packs. CONCLUSIONS The evidence base and recommendations for a urogynecology-relevant ERAS perioperative care pathway are presented in this consensus review. There are several elements of ERAS with strong evidence of benefit in urogynecological surgery.
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AUGS-IUGA Joint clinical consensus statement on enhanced recovery after urogynecologic surgery. Int Urogynecol J 2022; 33:2921-2940. [DOI: 10.1007/s00192-022-05223-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 02/19/2022] [Indexed: 10/14/2022]
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Abstract
Pain and related disability remain a major social and therapeutic problem. Comorbidities and therapies increase drug interactions and side effects making pain management more compounded especially in the elderly who are the fastest-growing pain population. Multimodal analgesia consists of using two or more drugs and/or techniques that target different sites of pain, increasing the level of analgesia and decreasing adverse events from treatment. Paracetamol enhances multimodal analgesia in experimental and clinical pain states. Strong preclinical evidence supports that paracetamol has additive and synergistic interactions with anti-inflammatory, opioid and anti-neuropathic drugs in rodent models of nociceptive and neuropathic pain. Clinical studies in young and adult elderly patients confirm the utility of paracetamol in multimodal, non-opioid or opioid-sparing, therapies for the treatment of acute and chronic pain.
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Affiliation(s)
- Ulderico Freo
- Anesthesiology & Intensive Medicine, Department of Medicine - DIMED, University of Padua, Via Giustiniani, 2, 35128, Padua, Italy
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Pelzer D, Burgess E, Baker R, Cox J. Response from Authors to Letter to the Editor "Comparison of Preoperative Intravenous and Oral Acetaminophen: Methodological Issues". J Perianesth Nurs 2022; 37:9-10. [PMID: 35115153 DOI: 10.1016/j.jopan.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 09/05/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Diana Pelzer
- TriHealth Bethesda Butler Hospital, Hamilton, OH.
| | | | | | - Jennifer Cox
- TriHealth Bethesda Butler Hospital, Hamilton, OH
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Analgesia for Gynecologic Oncologic Surgeries: A Narrative Review. Curr Pain Headache Rep 2022; 26:1-13. [PMID: 35118596 DOI: 10.1007/s11916-022-00998-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Gynecologic oncologic malignancies are amongst the most common cancers affecting women across the world. This narrative review focuses on the current state of evidence around optimal perioperative pain management of patients undergoing surgeries for gynecologic malignancies with a specific focus on cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). RECENT FINDINGS Recent improvements in postoperative pain management following all types of gynecologic procedures, including minimally invasive, open-abdominal, or CRS + HIPEC, have been implemented through enhanced recovery after surgery (ERAS) protocols. These protocols encompass the use of preemptive analgesia, neuraxial and regional techniques, local anesthetic infiltration, and multimodal analgesia. The severity of postoperative pain varies for minimally invasive cancer surgery to open debulking procedures. Therefore, an individualized perioperative analgesic plan is critical depending on the surgical approach. For CRS + HIPEC, neuraxial techniques such as thoracic epidurals and opioid sparing multimodal analgesics have shown efficacy in the perioperative period. However, future research is needed as many of these patients develop chronic pain with very limited research done in this realm.
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The Effect of Subcutaneous and Intraperitoneal Instillation of Local Anesthetics on Postoperative Pain after Laparoscopic Varicocelectomy: A Randomized Controlled Trial. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8111051. [PMID: 34828764 PMCID: PMC8622504 DOI: 10.3390/children8111051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/09/2021] [Accepted: 11/12/2021] [Indexed: 11/16/2022]
Abstract
Background: The main goal of the present randomized clinical trial was to investigate the effects of subcutaneous administration of two different local anesthetics at trocar incision sites at the abdominal wall in combination with intraoperative intraperitoneal instillation of local anesthetics, on the character of postoperative pain, in adolescents who underwent laparoscopic varicocelectomy. Methods: A total of 60 patients with a median age of 16 years, who received laparoscopic varicocele repair, were included in this randomized clinical trial. The patients were randomly assigned to three study groups receiving 2% lidocaine, 0.5% levobupivacaine, or the control group. The Visual Analogue Scale (VAS) was used by a blinded nurse at four different time points (2, 6, 12 and 24 h after the surgery) to measure pain intensity. Results: The significant effect of time on the pain intensity (p = 0.001) was found. Additionally, the interaction between time and different local analgesics (p < 0.001) was observed. In patients in whom 0.5% levobupivacaine has been used, significantly lower VAS pain scores were recorded at each time point assessed, in comparison with the patients who received 2% lidocaine or the patients from the control group in whom no local anesthetic was applied (p < 0.001). Furthermore, in patients in whom 2% lidocaine was administrated, significantly lower pain levels according to VAS were reported than in those from the control group, except for the time point at 24 h after surgery when pain levels were comparable. Concerning the postoperative pain control, the number of patients who requested oral analgesics postoperatively was significantly lower in the group of patients in whom local anesthetic was administrated intraoperatively (2% lidocaine—n = 4, 20%; 0.5% levobupivacaine—n = 1, 5%) compared to the patients who did not receive any local anesthetic during the surgery (n = 13; 65%) (p < 0.001). Conclusion: A significant reduction in postoperative pain intensity and analgesics consumption in patients undergoing laparoscopic varicocelectomy who received intraoperative local anesthetic was observed. The best effect on postoperative pain intensity, according to the VAS score, was achieved by 0.5% levobupivacaine.
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Stagg K. Intravenous versus oral paracetamol for postoperative analgesia: A systematic review. J Perioper Pract 2020; 31:373-378. [PMID: 33345698 DOI: 10.1177/1750458920950652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Paracetamol is a widely used analgesic agent that can be given by several different routes of administration. In the surgical setting, intravenous infusions of paracetamol are used, but an alternative is using oral paracetamol as a premedication. This systematic review is the first to compare the relative efficacy of intravenous and oral paracetamol at providing postoperative analgesia. Nine relevant studies were identified. Intravenous paracetamol resulted in a postoperative pain score of 0.5 points lower than in those receiving oral paracetamol premedication. Patients receiving intravenous paracetamol also had a small reduction in postoperative opioid requirements, but the time at which rescue analgesia was required did not differ. These results suggest that intravenous paracetamol may offer a small advantage over oral paracetamol premedication at providing postoperative analgesia.
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Cain KE, Iniesta MD, Fellman BM, Suki TS, Siverand A, Corzo C, Lasala JD, Cata JP, Mena GE, Meyer LA, Ramirez PT. Effect of preoperative intravenous vs oral acetaminophen on postoperative opioid consumption in an enhanced recovery after surgery (ERAS) program in patients undergoing open gynecologic oncology surgery. Gynecol Oncol 2020; 160:464-468. [PMID: 33298309 DOI: 10.1016/j.ygyno.2020.11.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 11/21/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Both intravenous (IV) and oral acetaminophen provide effective opioid-sparing analgesia after surgery when used as part of a multimodal preemptive pain management strategy. The purpose of this study was to compare postoperative opioid consumption in patients undergoing open gynecologic oncology surgery who received preoperative IV vs oral acetaminophen within an enhanced recovery after surgery (ERAS) program. METHODS Retrospective data were collected on consecutive patients undergoing open gynecologic oncology surgery from May 1, 2016 to February 28, 2018 in patients receiving either 1 g IV or oral acetaminophen preoperatively. Patients were given a preoperative multimodal analgesia regimen including acetaminophen, celecoxib, pregabalin and tramadol. The primary outcomes were morphine equivalent daily doses (MEDD) on postoperative days (POD) 0 and 1. Secondary outcomes included highest patient-reported pain score in the post-anesthesia care unit (PACU) and intraoperative MEDD. Regression models adjusted by matched pairs were fit to estimate the average treatment effect of IV vs oral acetaminophen on MEDD. RESULTS Of 353 patients, 178 (50.4%) received IV acetaminophen and 175 (49.6%) received oral acetaminophen. When balancing across the matched samples, there was no difference in postoperative MEDD for POD 0 between the IV and oral acetaminophen groups (Beta = -1.11; 95% CI: -4.83 to 2.60; p = 0.56). On POD 1, there was no difference between the IV and oral groups (Beta = 2.24; 95% CI: -2.76 to 7.25; p = 0.38). CONCLUSIONS There was no difference in postoperative opioid consumption between patients receiving preoperative IV or oral acetaminophen within an ERAS program for patients undergoing open gynecologic oncology surgery.
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Affiliation(s)
- Katherine E Cain
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bryan M Fellman
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tina S Suki
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ashley Siverand
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Camila Corzo
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Javier D Lasala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Gabriel E Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Ramirez MF, Kamdar BB, Cata JP. Optimizing Perioperative Use of Opioids: A Multimodal Approach. CURRENT ANESTHESIOLOGY REPORTS 2020; 10:404-415. [PMID: 33281504 DOI: 10.1007/s40140-020-00413-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose of Review The main purpose of this article is to review recent literature regarding multimodal analgesia medications, citing their recommended doses, efficacy, and side effects. The second part of this report will provide a description of drugs in different stages of development which have novel mechanisms with less side effects such as tolerance and addiction. Recent Findings Multimodal analgesia is a technique that facilitates perioperative pain management by employing two or more systemic analgesics along with regional anesthesia, when possible. Even though opioids and non-opioid analgesics remain the most common medication used for acute pain management after surgery, they have many undesirable side effects including the potential for misuse. Newer analgesics including peripheral acting opioids, nitric oxide inhibitors, calcitonin gene-related peptide receptor antagonists, interleukin-6 receptor antagonists and gene therapy are under intensive investigation. Summary A patient's first exposure to opioids is often in the perioperative setting, a vulnerable time when multimodal therapy can play a large role in decreasing opioid exposure. Additionally, the current shift towards faster recovery times, fewer post-operative complications and improved cost-effectiveness during the perioperative period has made multimodal analgesia a central pillar of Enhanced Recovery After Surgery (ERAS) protocols.
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Affiliation(s)
- Maria F Ramirez
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Brinda B Kamdar
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
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Kor TM, Naranjo J, Deljou A, Evans KD, Schroeder D, Sprung J, Weingarten TN. Intravenous Versus Oral Acetaminophen in Outpatient Cystoscopy Procedures: Retrospective Comparison of Postoperative Opioid Requirements and Analgesia Scores. Am Surg 2020; 86:1691-1696. [PMID: 32853023 DOI: 10.1177/0003134820945204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To assess if the choice of acetaminophen formulation (intravenous vs oral) when administered preoperatively for ambulatory cystoscopy procedures is associated with differences in anesthetic outcomes. METHODS Medical records of adult patients undergoing ambulatory cystoscopy procedures at an outpatient procedural center from July 1, 2014, through November 30, 2017, were abstracted. The association between anesthetic outcomes (severe pain, rescue opioids, postoperative nausea, and vomiting) and acetaminophen formulation was assessed. Propensity-adjusted analyses were performed using inverse probability of treatment weighting to account for potential confounders. RESULTS During the study time frame, there were 611 intravenous and 2955 oral acetaminophen administrations for cystoscopy procedures. Postoperative bladder spasms were a major contributor to severe pain and complicated 1036 cases, with similar rates between intravenous (N = 183, 29.9%) and oral (N = 853, 28.9%) formulations, P = .625. After adjusting for bladder spasms, intravenous acetaminophen was associated with longer anesthesia recovery (estimate 5.2 [95% CI 0.5-9.9] minutes, P = .030), use of rescue opioids (odds ratio 1.33 [1.07-1.66], P = .012), and postoperative nausea and vomiting (1.40 [1.02-1.93], P = .037), but not severe pain (1.07 [0.81-1.40], P = .640). CONCLUSION Preoperative intravenous acetaminophen compared to oral acetaminophen for ambulatory cystoscopy procedures was not associated with better anesthetic outcomes. Bladder spasms were a major contributor to postoperative pain.
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Affiliation(s)
- Todd M Kor
- 6915 Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Julian Naranjo
- 6915 Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Atousa Deljou
- 6915 Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kimberly D Evans
- 6915 Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Darrell Schroeder
- 6915 Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Juraj Sprung
- 6915 Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Toby N Weingarten
- 6915 Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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Brenin DR, Dietz JR, Baima J, Cheng G, Froman J, Laronga C, Ma A, Manahan MA, Mariano ER, Rojas K, Schroen AT, Tiouririne NAD, Wiechmann LS, Rao R. Pain Management in Breast Surgery: Recommendations of a Multidisciplinary Expert Panel-The American Society of Breast Surgeons. Ann Surg Oncol 2020; 27:4588-4602. [PMID: 32783121 DOI: 10.1245/s10434-020-08892-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/02/2020] [Indexed: 12/13/2022]
Abstract
Opioid overdose accounted for more than 47,000 deaths in the United States in 2018. The risk of new persistent opioid use following breast cancer surgery is significant, with up to 10% of patients continuing to fill opioid prescriptions one year after surgery. Over prescription of opioids is far too common. A recent study suggested that up to 80% of patients receiving a prescription for opioids post-operatively do not need them (either do not fill the prescription or do not use the medication). In order to address this important issue, The American Society of Breast Surgeons empaneled an inter-disciplinary committee to develop a consensus statement on pain control for patients undergoing breast surgery. Representatives were nominated by the American College of Surgeons, the Society of Surgical Oncology, The American Society of Plastic Surgeons, and The American Society of Anesthesiologists. A broad literature review followed by a more focused review was performed by the inter-disciplinary panel which was comprised of 14 experts in the fields of breast surgery, anesthesiology, plastic surgery, rehabilitation medicine, and addiction medicine. Through a process of multiple revisions, a consensus was developed, resulting in the outline for decreased opioid use in patients undergoing breast surgery presented in this manuscript. The final document was reviewed and approved by the Board of Directors of the American Society of Breast Surgeons.
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Affiliation(s)
- David R Brenin
- Department of Surgery, University of Virginia, Charlottesville, VA, USA.
| | - Jill R Dietz
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jennifer Baima
- Department of Physical Medicine and Rehabilitation, UMass Memorial Medical Center, Worcester, MA, USA
| | - Gloria Cheng
- Department of Anesthesia, University of Texas Southwestern, Dallas, TX, USA
| | - Joshua Froman
- Department of Surgery, Mayo Clinic, Owatonna, MN, USA
| | | | - Ayemoethu Ma
- Surgery and Integrative Medicine, Scripps Health, La Jolla, CA, USA
| | - Michele A Manahan
- Department of Plastic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Edward R Mariano
- Department of Anesthesia, Stanford University, Stanford, CA, USA
| | - Kristin Rojas
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Anneke T Schroen
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | | | - Lisa S Wiechmann
- New York Presbyterian Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Roshni Rao
- New York Presbyterian Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
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Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the most recent evidence-based interventions for perioperative pain management in minimally invasive gynecologic surgery. RECENT FINDINGS With particular emphasis on preemptive interventions in recent studies, we found preoperative counseling, nutrition, exercise, psychological interventions, and a combination of acetaminophen, celecoxib, and gabapentin are highly important and effective measures to reduce postoperative pain and opioid demand. Intraoperative local anesthetics may help at incision sites, as a paracervical block, and a transversus abdominus plane block. Postoperatively, an effort should be made to utilize non-narcotic interventions such as abdominal binders, ice packs, simethicone, bowel regimens, gabapentin, and scheduled NSAIDs and acetaminophen. When prescribing narcotics, providers should be aware of recommended amounts of opioids required per procedure so as to avoid overprescribing. SUMMARY Our findings emphasize the evolving importance of preemptive interventions, including prehabilitation and pharmacologic agents, to improve postoperative pain after minimally invasive gynecologic surgery. Additionally, a multimodal approach to nonnarcotic intraoperative and postoperative interventions decreases narcotic requirement and improves opioid stewardship.
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