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Watanabe Y, Nikaido T, Yabuki S, Abe J, Suzuki H, Shishido K, Kobayashi H, Yoshida R, Iinuma K, Nagamine S, Ono Y, Sato M, Oi N. Gender differences on preoperative psychologic factors affecting acute postoperative pain in patients with lumbar spinal disorders. J Orthop Sci 2024; 29:1174-1178. [PMID: 37838597 DOI: 10.1016/j.jos.2023.08.019] [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: 06/05/2023] [Revised: 08/16/2023] [Accepted: 08/29/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Psychosexual factors are one of the preoperative factors influencing acute postoperative pain. Because of gender differences in pain, the preoperative factors that influence acute postoperative pain may also differ between males and females. However, there have been no reports on such factors in patients with spinal disorders that focused on gender differences. Therefore, the purpose of this study was to examine the preoperative factors that influence acute postoperative pain, focusing on gender differences. METHODS The subjects were 75 males and 60 females admitted for surgery for lumbar spinal disorders. Preoperatively, the following were assessed: low back pain using the Numeric Rating Scale (NRS); anxiety and depression using the Japanese version of the Hospital Anxiety and Depression Scale (HADS); catastrophic thinking using the Pain Catastrophizing Scale (PCS); psychiatric problems using the Brief Scale for Psychiatric Problems in Orthopaedic Patients (BS-POP); and neurological assessments. Acute postoperative pain was also assessed using the NRS within 48 h, postoperatively. Based on these data, we analyzed gender differences in preoperative factors affecting acute postoperative pain in patients with lumbar spinal disorders. RESULTS Postoperative NRS and preoperative PCS scores were higher in females compared to males. In the males, the coefficient of determination of the multiple regression equation was 0.088, and PCS (β = 0.323, p = 0.015) was extracted as a significant factor. In the females, the coefficient of determination of the multiple regression equation was 0.075, and BS-POP (β = 0.300, p = 0.019) was extracted as a significant factor. CONCLUSION Preoperative factors influencing acute postoperative pain for patients with lumbar spinal disorders vary by gender. It was suggested that males should be screened using PCS. In females, on the other hand, PCS alone is not sufficient for evaluation. It was suggested that evaluation using BS-POP should be considered in addition to PCS.
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Affiliation(s)
- Yuki Watanabe
- Department of Rehabilitation Center, Fukushima Medical University Hospital, Fukushima City, Fukushima, Japan.
| | - Takuya Nikaido
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, Japan
| | - Shoji Yabuki
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, Japan
| | - Jumpei Abe
- Department of Rehabilitation Center, Fukushima Medical University Hospital, Fukushima City, Fukushima, Japan
| | - Hideki Suzuki
- Department of Rehabilitation Center, Fukushima Medical University Hospital, Fukushima City, Fukushima, Japan
| | - Keita Shishido
- Department of Rehabilitation Center, Fukushima Medical University Hospital, Fukushima City, Fukushima, Japan
| | - Hirotaka Kobayashi
- Department of Rehabilitation Center, Fukushima Medical University Hospital, Fukushima City, Fukushima, Japan
| | - Rii Yoshida
- Department of Rehabilitation Center, Fukushima Medical University Hospital, Fukushima City, Fukushima, Japan
| | - Kaori Iinuma
- Department of Rehabilitation Center, Fukushima Medical University Hospital, Fukushima City, Fukushima, Japan
| | - Sakiko Nagamine
- Department of Rehabilitation Center, Fukushima Medical University Hospital, Fukushima City, Fukushima, Japan
| | - Yoko Ono
- Department of Rehabilitation Center, Fukushima Medical University Hospital, Fukushima City, Fukushima, Japan
| | - Mari Sato
- Department of Rehabilitation Center, Fukushima Medical University Hospital, Fukushima City, Fukushima, Japan; Department of Rehabilitation Medicine, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, Japan
| | - Naoyuki Oi
- Department of Rehabilitation Center, Fukushima Medical University Hospital, Fukushima City, Fukushima, Japan; Department of Rehabilitation Medicine, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, Japan
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de Liyis BG, Hartawan IGAGU, Widyadharma IPE, Senapathi TGA, Mahadewa TGB. Cervical-Level Regional Paraspinal Nerve Block in Cervical Spine Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. World Neurosurg 2024:S1878-8750(24)01380-9. [PMID: 39127381 DOI: 10.1016/j.wneu.2024.08.021] [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: 07/16/2024] [Accepted: 08/04/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND Regional paraspinal nerve block techniques have shown promise in cervical spine surgery pain relief and opioid reduction. The study aims to evaluate cervical-level regional paraspinal nerve block techniques in cervical spine surgery. METHODS Systematic randomized controlled trial (RCT) searches in ScienceDirect, PubMed, Embase, and Cochrane was conducted until March 2024. Key outcome measures included postoperative pain scores and postoperative opioid utilization. Techniques assessed were erector spinae plane block (ESPB), inter-semispinal plane block (ISPB), and superficial cervical plexus block (CPB). RESULTS The study included 6 RCTs and 648 participants. Regional paraspinal nerve block significantly reduced postoperative pain scores at 4, 6, 8, 12, and 24 hours. Postoperative opioid usage was lower in the block group (mean difference [MD]: -1.68; 95% CI: -3.14 to -0.21; P = 0.02), with fewer complications (odds ratio: 0.51; 95% CI: 0.40-0.66; P = 0.001). Patients using fentanyl as postoperative opioid had significantly lower opioid usage with the block (MD: -1.39; 95% CI: -1.76 to -1.01; P < 0.001). Dosage >10 mL correlated with decreased opioid usage (MD: -2.78; 95% CI: -5.25 to -0.31; P < 0.001). ESPB (MD: -1.37; 95% CI: -1.83 to -0.90; P < 0.001) and ISPB (MD: -3.52; 95% CI: -7.09-0.00; P = 0.05) effectively reduced opioid consumption. Posterior approach (MD: -2.78; 95% CI: -5.25 to -0.31; P < 0.001), bilateral administration (MD: -2.14; 95% CI: -4.26 to -0.03; P < 0.001), and ultrasound-guided intervention (MD: -2.68; 95% CI: -5.24 to -0.12; P < 0.001) resulted in a significant reduction of opioid usage. CONCLUSIONS Cervical-level regional paraspinal nerve block effectively reduces postoperative pain and opioid usage, particularly with a dosage exceeding 10 mL, utilizing ESPB and ISPB techniques, administered posteriorly, bilaterally, and under ultrasound guidance.
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Affiliation(s)
- Bryan Gervais de Liyis
- Faculty of Medicine, Universitas Udayana, Prof. I.G.N.G Ngoerah General Hospital, Denpasar, Bali, Indonesia.
| | - I Gusti Agung Gede Utara Hartawan
- Faculty of Medicine, Department of Anesthesiology and Intensive Care, Universitas Udayana, Prof. I.G.N.G Ngoerah General Hospital, Denpasar, Bali, Indonesia
| | - I Putu Eka Widyadharma
- Faculty of Medicine, Department of Neurology, Universitas Udayana, Prof. I.G.N.G Ngoerah General Hospital, Denpasar, Bali, Indonesia
| | - Tjokorda Gde Agung Senapathi
- Faculty of Medicine, Department of Anesthesiology and Intensive Care, Universitas Udayana, Prof. I.G.N.G Ngoerah General Hospital, Denpasar, Bali, Indonesia
| | - Tjokorda Gde Bagus Mahadewa
- Department of Neurosurgery, Universitas Udayana, Prof. I.G.N.G Ngoerah General Hospital, Denpasar, Bali, Indonesia
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Flores EM, Gouveia FV, Matsumoto M, Bonacif THFS, Kuroki MA, Antunes GF, Campos ACP, Kimachi PP, Campos DO, Simões CM, Sampaio MMC, Andrade FEM, Valverde J, Barros ACSD, Pagano RL, Martinez RCR. One year follow-up on a randomized study investigating serratus anterior muscle and pectoral nerves type I block to reduced neuropathic pain descriptors after mastectomy. Sci Rep 2023; 13:4591. [PMID: 36944694 PMCID: PMC10030852 DOI: 10.1038/s41598-023-31589-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 03/14/2023] [Indexed: 03/23/2023] Open
Abstract
Breast cancer is the second most common diagnosed type of cancer in women. Chronic neuropathic pain after mastectomy occurs frequently and is a serious health problem. In our previous single-center, prospective, randomized controlled clinical study, we demonstrated that the combination of serratus anterior plane block (SAM) and pectoral nerve block type I (PECS I) with general anesthesia reduced acute postoperative pain. The present report describes a prospective follow-up study of this published study to investigate the development of chronic neuropathic pain 12 months after mastectomy by comparing the use of general anesthesia alone and general anesthesia with SAM + PECS I. Additionally, the use of analgesic medication, quality of life, depressive symptoms, and possible correlations between plasma levels of interleukin (IL)-1 beta, IL-6, and IL-10 collected before and 24 h after surgery as predictors of pain and depression were evaluated. The results showed that the use of SAM + PECS I with general anesthesia reduced numbness, hypoesthesia to touch, the incidence of patients with chronic pain in other body regions and depressive symptoms, however, did not significantly reduce the incidence of chronic neuropathic pain after mastectomy. Additionally, there was no difference in the consumption of analgesic medication and quality of life. Furthermore, no correlation was observed between IL-1 beta, IL-6, and IL-10 levels and pain and depression. The combination of general anesthesia with SAM + PECS I reduced the occurrence of specific neuropathic pain descriptors and depressive symptoms. These results could promote the use of SAM + PECS I blocks for the prevention of specific neuropathic pain symptoms after mastectomy.Registration of clinical trial: The Research Ethics Board of the Hospital Sirio-Libanes/Brazil approved the study (CAAE 48721715.0.0000.5461). This study is registered at Registro Brasileiro de Ensaios Clinicos (ReBEC), and ClinicalTrials.gov, Identifier: NCT02647385.
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Affiliation(s)
- Eva M Flores
- Division of Neuroscience, Hospital Sirio-Libanes, São Paulo, Brazil
- Anesthesiology Medical Center, Hospital Sirio-Libanes, São Paulo, Brazil
| | - Flavia V Gouveia
- Division of Neuroscience, Hospital Sirio-Libanes, São Paulo, Brazil
- Neuroscience and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada
| | - Marcio Matsumoto
- Division of Neuroscience, Hospital Sirio-Libanes, São Paulo, Brazil
- Anesthesiology Medical Center, Hospital Sirio-Libanes, São Paulo, Brazil
| | | | - Mayra A Kuroki
- Division of Neuroscience, Hospital Sirio-Libanes, São Paulo, Brazil
| | | | | | - Pedro P Kimachi
- Division of Neuroscience, Hospital Sirio-Libanes, São Paulo, Brazil
- Anesthesiology Medical Center, Hospital Sirio-Libanes, São Paulo, Brazil
| | - Diego O Campos
- Division of Neuroscience, Hospital Sirio-Libanes, São Paulo, Brazil
| | - Claudia M Simões
- Division of Neuroscience, Hospital Sirio-Libanes, São Paulo, Brazil
- Anesthesiology Medical Center, Hospital Sirio-Libanes, São Paulo, Brazil
| | | | | | - João Valverde
- Division of Neuroscience, Hospital Sirio-Libanes, São Paulo, Brazil
- Anesthesiology Medical Center, Hospital Sirio-Libanes, São Paulo, Brazil
| | | | - Rosana L Pagano
- Division of Neuroscience, Hospital Sirio-Libanes, São Paulo, Brazil
| | - Raquel C R Martinez
- Division of Neuroscience, Hospital Sirio-Libanes, São Paulo, Brazil.
- LIM/23, Institute of Psychiatry, University of Sao Paulo School of Medicine, Sao Paulo, Brazil.
- Instituto de Ensino e Pesquisa, Hospital Sirio-Libanes, Rua Professor Daher Cutait, 69, São Paulo, SP, 01308-060, Brazil.
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The Role of Regional Anesthesia in the Development of Chronic Pain: a Review of Literature. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00536-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Abstract
Purpose of Review
The acute management of pain using regional anesthesia techniques may prevent the development of persistent postsurgical pain (PPP), ultimately improving patient outcomes and enhancing overall quality of life in postsurgical patients. The purpose of this review is to describe the current literature regarding the role of regional anesthesia techniques in the perioperative setting to address and prevent PPP.
Recent Findings
Data was collected and analyzed using results from randomized controlled studies stratified into categories based on different surgical subspecialties. Conclusions were drawn from each surgical category regarding the role of regional anesthesia and/or local analgesia in acute and chronic pain management on the long-term results seen in the studies analyzed.
Summary
Preoperative consultations and optimized perioperative analgesia using regional anesthesia and local analgesia play a fundamental role preventing and treating postoperative pain after many types of surgery by managing pain in the acute setting to mitigate the future development of PPP. Additional studies in different surgical subspecialties are needed to confirm the role regional anesthesia plays in chronic postsurgical pain (CPSP) prevention.
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The Current Consideration, Approach, and Management in Postcesarean Delivery Pain Control: A Narrative Review. Anesthesiol Res Pract 2021; 2021:2156918. [PMID: 34589125 PMCID: PMC8476264 DOI: 10.1155/2021/2156918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 09/04/2021] [Indexed: 12/25/2022] Open
Abstract
Optimal postoperative analgesia has a significant impact on patient recovery and outcomes after cesarean delivery. Multimodal analgesia is the core principle for cesarean delivery and pain management. For a standard analgesic regimen, the use of long-acting neuraxial opioids (e.g., morphine) and adjunct drugs, such as scheduled acetaminophen and nonsteroidal anti-inflammatory drugs, is recommended unless contraindicated. Oral or intravenous opioids should be reserved for breakthrough pain. In addition to the aforementioned use of multimodal analgesia, preoperative evaluation is critical to individualize the analgesic regimen according to the patient requirements. Risk factors for severe postoperative pain or analgesia-related adverse effects will require modifications to the standard analgesic regimen (e.g., the use of ketamine, gabapentinoids, or regional anesthetic techniques). Further investigation is required to determine analgesic drugs or dose alterations based on preoperative predictions for patients at risk of severe pain. Outcomes beyond pain and analgesic use, such as functional recovery, should be determined to evaluate analgesic treatment protocols.
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Andreae MH, Maman SR, Behnam AJ. An Electronic Medical Record-Derived Individualized Performance Metric to Measure Risk-Adjusted Adherence with Perioperative Prophylactic Bundles for Health Care Disparity Research and Implementation Science. Appl Clin Inform 2020; 11:497-514. [PMID: 32726836 PMCID: PMC7390620 DOI: 10.1055/s-0040-1714692] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/01/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Health care disparity persists despite vigorous countermeasures. Clinician performance is paramount for equitable care processes and outcomes. However, precise and valid individual performance measures remain elusive. OBJECTIVES We sought to develop a generalizable, rigorous, risk-adjusted metric for individual clinician performance (MIP) derived directly from the electronic medical record (EMR) to provide visual, personalized feedback. METHODS We conceptualized MIP as risk responsiveness, i.e., administering an increasing number of interventions contingent on patient risk. We embedded MIP in a hierarchical statistical model, reflecting contemporary nested health care delivery. We tested MIP by investigating the adherence with prophylactic bundles to reduce the risk of postoperative nausea and vomiting (PONV), retrieving PONV risk factors and prophylactic antiemetic interventions from the EMR. We explored the impact of social determinants of health on MIP. RESULTS We extracted data from the EMR on 25,980 elective anesthesia cases performed at Penn State Milton S. Hershey Medical Center between June 3, 2018 and March 31, 2019. Limiting the data by anesthesia Current Procedural Terminology code and to complete cases with PONV risk and antiemetic interventions, we evaluated the performance of 83 anesthesia clinicians on 2,211 anesthesia cases. Our metric demonstrated considerable variance between clinicians in the adherence to risk-adjusted utilization of antiemetic interventions. Risk seemed to drive utilization only in few clinicians. We demonstrated the impact of social determinants of health on MIP, illustrating its utility for health science and disparity research. CONCLUSION The strength of our novel measure of individual clinician performance is its generalizability, as well as its intuitive graphical representation of risk-adjusted individual performance. However, accuracy, precision and validity, stability over time, sensitivity to system perturbations, and acceptance among clinicians remain to be evaluated.
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Affiliation(s)
- Michael H. Andreae
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
| | - Stephan R. Maman
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
- Penn State College of Medicine, Hershey, Pennsylvania, United States
| | - Abrahm J. Behnam
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
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Small C, Laycock H. Acute postoperative pain management. Br J Surg 2020; 107:e70-e80. [DOI: 10.1002/bjs.11477] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 11/22/2019] [Indexed: 12/16/2022]
Abstract
AbstractBackgroundAcute postoperative pain is common. Nearly 20 per cent of patients experience severe pain in the first 24 h after surgery, a figure that has remained largely unchanged in the past 30 years. This review aims to present key considerations for postoperative pain management.MethodsA narrative review of postoperative pain strategies was undertaken. Searches of the Cochrane Library, PubMed and Google Scholar databases were performed using the terms postoperative care, psychological factor, pain management, acute pain service, analgesia, acute pain and pain assessment.ResultsInformation on service provision, preoperative planning, pain assessment, and pharmacological and non-pharmacological strategies relevant to acute postoperative pain management in adults is presented, with a focus on enhanced recovery after surgery pathways.ConclusionAdequate perioperative pain management is integral to patient care and outcomes. Each of the biological, psychological and social dimensions of the pain experience should be considered and understood in order to provide optimum pain management in the postoperative setting.
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Affiliation(s)
- C Small
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - H Laycock
- Department of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
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Levene JL, Weinstein EJ, Cohen MS, Andreae DA, Chao JY, Johnson M, Hall CB, Andreae MH. Local anesthetics and regional anesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children: A Cochrane systematic review and meta-analysis update. J Clin Anesth 2019; 55:116-127. [PMID: 30640059 PMCID: PMC6461051 DOI: 10.1016/j.jclinane.2018.12.043] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 11/23/2018] [Accepted: 12/18/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Regional anesthesia may mitigate the risk of persistent postoperative pain (PPP). This Cochrane review, published originally in 2012, was updated in 2017. METHODS We updated our search of Cochrane CENTRAL, PubMed, EMBASE and CINAHL to December 2017. Only RCTs investigating local anesthetics (by any route) or regional anesthesia versus any combination of systemic (opioid or non-opioid) analgesia in adults or children, reporting any pain outcomes beyond three months were included. Data were extracted independently by at least two authors, who also appraised methodological quality with Cochrane 'Risk of bias' assessment and pooled data in surgical subgroups. We pooled studies across different follow-up intervals. As summary statistic, we reported the odds ratio (OR) with 95% confidence intervals and calculated the number needed to benefit (NNTB). We considered classical, Bayesian alternatives to our evidence synthesis. We explored heterogeneity and methodological bias. RESULTS 40 new and seven ongoing studies, identified in this update, brought the total included RCTs to 63. We were only able to synthesize data from 39 studies enrolling 3027 participants in a balanced design. Evidence synthesis favored regional anesthesia for thoracotomy (OR 0.52 [0.32 to 0.84], moderate-quality evidence), breast cancer surgery (OR 0.43 [0.28 to 0.68], low-quality evidence), and cesarean section (OR 0.46, [0.28 to 0.78], moderate-quality evidence). Evidence synthesis favored continuous infusion of local anesthetic after breast cancer surgery (OR 0.24 [0.08 to 0.69], moderate-quality evidence), but was inconclusive after iliac crest bone graft harvesting (OR 0.20, [0.04 to 1.09], low-quality evidence). CONCLUSIONS Regional anesthesia reduces the risk of PPP. Small study size, performance, null, and attrition bias considerably weakened our conclusions. We cannot extrapolate to other interventions or to children.
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Affiliation(s)
- Jacob L Levene
- Albert Einstein College of Medicine of Yeshiva University, Bronx, NY, United States of America
| | - Erica J Weinstein
- Albert Einstein College of Medicine of Yeshiva University, Bronx, NY, United States of America
| | - Marc S Cohen
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Doerthe A Andreae
- Department of Allergy/Immunology, Milton S Hershey Medical Center, Hershey, PA, United States of America
| | - Jerry Y Chao
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Matthew Johnson
- Human Development, Teachers College, Columbia University, New York, NY, United States of America
| | - Charles B Hall
- Division of Biostatistics, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Michael H Andreae
- Department of Anesthesiology & Perioperative Medicine, Milton S Hershey Medical Center, Hershey, PA, United States of America.
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de Araújo DR, Ribeiro LNDM, de Paula E. Lipid-based carriers for the delivery of local anesthetics. Expert Opin Drug Deliv 2019; 16:701-714. [PMID: 31172838 DOI: 10.1080/17425247.2019.1629415] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION There is a clinical need for pharmaceutical dosage forms devised to prolong the acting time of local anesthetic (LA) agents or to reduce their toxicity. Encapsulation of LA in drug delivery systems (DDSs) can provide long-term anesthesia for inpatients (e.g. in immediate postsurgical pain control, avoiding the side effects from systemic analgesia) and diminished systemic toxicity for outpatients (in ambulatory/dentistry procedures). The lipid-based formulations described here, such as liposomes, microemulsions, and lipid nanoparticles, have provided several nanotechnological advances and therapeutic alternatives despite some inherent limitations associated with the fabrication processes, costs, and preclinical evaluation models. AREAS COVERED A description of the currently promising lipid-based carriers, including liposomes, microemulsions, and nanostructured lipid carriers, followed by a systematic review of the existing lipid-based formulations proposed for LA. Trends in the research of these LA-in-DDS are then exposed, from the point of view of administration route and alternatives for non-traditionally administered LA molecules. EXPERT OPINION Considering the current state and potential future developments in the field, we discuss the reasons for why dozens of formulations published every year fail to reach clinical trials; only one lipid-based formulation for the delivery of local anesthetic (Exparel®) has been approved so far.
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Affiliation(s)
| | - Lígia Nunes de Morais Ribeiro
- b Department of Biochemistry and Tissue Biology , Institute of Biology, University of Campinas - UNICAMP , Campinas, São Paulo , Brazil
| | - Eneida de Paula
- b Department of Biochemistry and Tissue Biology , Institute of Biology, University of Campinas - UNICAMP , Campinas, São Paulo , Brazil
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Mao Y, Zuo Y, Mei B, Chen L, Liu X, Zhang Z, Gu E. Efficacy of perineural dexamethasone with ropivacaine in thoracic paravertebral block for postoperative analgesia in elective thoracotomy: a randomized, double-blind, placebo-controlled trial. J Pain Res 2018; 11:1811-1819. [PMID: 30254483 PMCID: PMC6140743 DOI: 10.2147/jpr.s164225] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Purpose The purpose of this study was to assess the efficacy of perineural dexamethasone with ropivacaine in multimodal analgesia for thoracic paravertebral block (TPVB) in patients undergoing elective thoracotomy. Patients and methods Ninety-six patients undergoing thoracotomy were enrolled in this trial and randomized to adjuvant therapy for TPVB: group S (saline), group R (0.5% ropivacaine), or group RD (5 mg dexamethasone and 0.5% ropivacaine). Postoperative analgesia, recovery duration, and chronic pain were recorded. Results Groups R and RD spent less time in the postanaesthesia care unit, had earlier out-of-bed activity, and had shorter postoperative hospital stays compared with group S. The RD group regained consciousness faster and had lower acute pain scores and used less patient-controlled analgesia during the first 72 h after surgery compared with group S. Postthoracotomy pain was decreased in group RD (19.0%) compared with group S (47.6%) 3 months postoperatively, p = 0.050. Conclusion Perineural dexamethasone with ropivacaine for TPVB improves postoperative analgesia quality, reduces recovery time, and may decrease the incidence of chronic pain after thoracotomy with an opioid-based anesthetic regimen.
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Affiliation(s)
- Yu Mao
- Key Laboratory of Brain Function and Disease of Chinese Academy of Science, Department of Biophysics and Neurobiology, University of Science and Technology of China, Hefei City, Anhui 230027, People's Republic of China.,Department of Anaesthesiology, First Affiliated Hospital of Anhui Medical University, Hefei City, Anhui 230031, People's Republic of China,
| | - Youmei Zuo
- Department of Anaesthesiology, First Affiliated Hospital of Anhui Medical University, Hefei City, Anhui 230031, People's Republic of China,
| | - Bin Mei
- Department of Anaesthesiology, First Affiliated Hospital of Anhui Medical University, Hefei City, Anhui 230031, People's Republic of China,
| | - Lijian Chen
- Department of Anaesthesiology, First Affiliated Hospital of Anhui Medical University, Hefei City, Anhui 230031, People's Republic of China,
| | - Xuesheng Liu
- Department of Anaesthesiology, First Affiliated Hospital of Anhui Medical University, Hefei City, Anhui 230031, People's Republic of China,
| | - Zhi Zhang
- Key Laboratory of Brain Function and Disease of Chinese Academy of Science, Department of Biophysics and Neurobiology, University of Science and Technology of China, Hefei City, Anhui 230027, People's Republic of China
| | - Erwei Gu
- Department of Anaesthesiology, First Affiliated Hospital of Anhui Medical University, Hefei City, Anhui 230031, People's Republic of China,
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Weinstein EJ, Levene JL, Cohen MS, Andreae DA, Chao JY, Johnson M, Hall CB, Andreae MH. Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children. Cochrane Database Syst Rev 2018; 6:CD007105. [PMID: 29926477 PMCID: PMC6377212 DOI: 10.1002/14651858.cd007105.pub4] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Regional anaesthesia may reduce the rate of persistent postoperative pain (PPP), a frequent and debilitating condition. This review was originally published in 2012 and updated in 2017. OBJECTIVES To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of PPP beyond three months in adults and children undergoing elective surgery. SEARCH METHODS We searched CENTRAL, MEDLINE, and Embase to December 2016 without any language restriction. We used a combination of free text search and controlled vocabulary search. We limited results to randomized controlled trials (RCTs). We updated this search in December 2017, but these results have not yet been incorporated in the review. We conducted a handsearch in reference lists of included studies, review articles and conference abstracts. We searched the PROSPERO systematic review registry for related systematic reviews. SELECTION CRITERIA We included RCTs comparing local or regional anaesthesia versus conventional analgesia with a pain outcome beyond three months after elective, non-orthopaedic surgery. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed trial quality and extracted data and adverse events. We contacted study authors for additional information. We presented outcomes as pooled odds ratios (OR) with 95% confidence intervals (95% CI), based on random-effects models (inverse variance method). We analysed studies separately by surgical intervention, but pooled outcomes reported at different follow-up intervals. We compared our results to Bayesian and classical (frequentist) models. We investigated heterogeneity. We assessed the quality of evidence with GRADE. MAIN RESULTS In this updated review, we identified 40 new RCTs and seven ongoing studies. In total, we included 63 RCTs in the review, but we were only able to synthesize data on regional anaesthesia for the prevention of PPP beyond three months after surgery from 39 studies, enrolling a total of 3027 participants in our inclusive analysis.Evidence synthesis of seven RCTs favoured epidural anaesthesia for thoracotomy, suggesting the odds of having PPP three to 18 months following an epidural for thoracotomy were 0.52 compared to not having an epidural (OR 0.52 (95% CI 0.32 to 0.84, 499 participants, moderate-quality evidence). Simlarly, evidence synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low-quality evidence). Pooling data at three to 8 months after surgery from four RCTs favoured regional anaesthesia after caesarean section with an OR of 0.46, (95% CI 0.28 to 0.78; 551 participants, moderate-quality evidence). Evidence synthesis of three RCTs investigating continuous infusion with local anaesthetic for the prevention of PPP three to 55 months after iliac crest bone graft harvesting (ICBG) was inconclusive (OR 0.20, 95% CI 0.04 to 1.09; 123 participants, low-quality evidence). However, evidence synthesis of two RCTs also favoured the infusion of intravenous local anaesthetics for the prevention of PPP three to six months after breast cancer surgery with an OR of 0.24 (95% CI 0.08 to 0.69, 97 participants, moderate-quality evidence).We did not synthesize evidence for the surgical subgroups of limb amputation, hernia repair, cardiac surgery and laparotomy. We could not pool evidence for adverse effects because the included studies did not examine them systematically, and reported them sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered evidence synthesis. High risk of bias from missing data and lack of blinding across a number of included studies reduced our confidence in the findings. Thus results must be interpreted with caution. AUTHORS' CONCLUSIONS We conclude that there is moderate-quality evidence that regional anaesthesia may reduce the risk of developing PPP after three to 18 months after thoracotomy and three to 12 months after caesarean section. There is low-quality evidence that regional anaesthesia may reduce the risk of developing PPP three to 12 months after breast cancer surgery. There is moderate evidence that intravenous infusion of local anaesthetics may reduce the risk of developing PPP three to six months after breast cancer surgery.Our conclusions are considerably weakened by the small size and number of studies, by performance bias, null bias, attrition and missing data. Larger, high-quality studies, including children, are needed. We caution that except for breast surgery, our evidence synthesis is based on only a few small studies. On a cautionary note, we cannot extend our conclusions to other surgical interventions or regional anaesthesia techniques, for example we cannot conclude that paravertebral block reduces the risk of PPP after thoracotomy. There are seven ongoing studies and 12 studies awaiting classification that may change the conclusions of the current review once they are published and incorporated.
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Affiliation(s)
- Erica J Weinstein
- Albert Einstein College of Medicine of Yeshiva University1300 Morris Park AveBronxNYUSA10461
| | - Jacob L Levene
- Albert Einstein College of Medicine of Yeshiva University1300 Morris Park AveBronxNYUSA10461
| | - Marc S Cohen
- Montefiore Medical Center, Albert Einstein College of MedicineDepartment of Anesthesiology111 E 210 StreetBronxNYUSA#N4‐005
| | - Doerthe A Andreae
- Milton S Hershey Medical CenterDepartment of Allergy/ Immunology500 University DrHersheyPAUSA17033
| | - Jerry Y Chao
- Montefiore Medical Center, Albert Einstein College of MedicineDepartment of Anesthesiology111 E 210 StreetBronxNYUSA#N4‐005
| | - Matthew Johnson
- Teachers College, Columbia UniversityHuman DevelopmentNew YorkNYUSA10027
| | - Charles B Hall
- Albert Einstein College of MedicineDivision of Biostatistics, Department of Epidemiology and Population Health1300 Morris Park AvenueBronxNYUSA10461
| | - Michael H Andreae
- Milton S Hershey Medical CentreDepartment of Anesthesiology & Perioperative Medicine500 University DriveH187HersheyPAUSA17033
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Weinstein EJ, Levene JL, Cohen MS, Andreae DA, Chao JY, Johnson M, Hall CB, Andreae MH. Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children. Cochrane Database Syst Rev 2018; 4:CD007105. [PMID: 29694674 PMCID: PMC6080861 DOI: 10.1002/14651858.cd007105.pub3] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Regional anaesthesia may reduce the rate of persistent postoperative pain (PPP), a frequent and debilitating condition. This review was originally published in 2012 and updated in 2017. OBJECTIVES To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of PPP beyond three months in adults and children undergoing elective surgery. SEARCH METHODS We searched CENTRAL, MEDLINE, and Embase to December 2016 without any language restriction. We used a combination of free text search and controlled vocabulary search. We limited results to randomized controlled trials (RCTs). We updated this search in December 2017, but these results have not yet been incorporated in the review. We conducted a handsearch in reference lists of included studies, review articles and conference abstracts. We searched the PROSPERO systematic review registry for related systematic reviews. SELECTION CRITERIA We included RCTs comparing local or regional anaesthesia versus conventional analgesia with a pain outcome beyond three months after elective, non-orthopaedic surgery. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed trial quality and extracted data and adverse events. We contacted study authors for additional information. We presented outcomes as pooled odds ratios (OR) with 95% confidence intervals (95% CI), based on random-effects models (inverse variance method). We analysed studies separately by surgical intervention, but pooled outcomes reported at different follow-up intervals. We compared our results to Bayesian and classical (frequentist) models. We investigated heterogeneity. We assessed the quality of evidence with GRADE. MAIN RESULTS In this updated review, we identified 40 new RCTs and seven ongoing studies. In total, we included 63 RCTs in the review, but we were only able to synthesize data on regional anaesthesia for the prevention of PPP beyond three months after surgery from 41 studies, enrolling a total of 3143 participants in our inclusive analysis.Evidence synthesis of seven RCTs favoured epidural anaesthesia for thoracotomy, suggesting the odds of having PPP three to 18 months following an epidural for thoracotomy were 0.52 compared to not having an epidural (OR 0.52 (95% CI 0.32 to 0.84, 499 participants, moderate-quality evidence). Simlarly, evidence synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low-quality evidence). Pooling data at three to 8 months after surgery from four RCTs favoured regional anaesthesia after caesarean section with an OR of 0.46, (95% CI 0.28 to 0.78; 551 participants, moderate-quality evidence). Evidence synthesis of three RCTs investigating continuous infusion with local anaesthetic for the prevention of PPP three to 55 months after iliac crest bone graft harvesting (ICBG) was inconclusive (OR 0.20, 95% CI 0.04 to 1.09; 123 participants, low-quality evidence). However, evidence synthesis of two RCTs also favoured the infusion of intravenous local anaesthetics for the prevention of PPP three to six months after breast cancer surgery with an OR of 0.24 (95% CI 0.08 to 0.69, 97 participants, moderate-quality evidence).We did not synthesize evidence for the surgical subgroups of limb amputation, hernia repair, cardiac surgery and laparotomy. We could not pool evidence for adverse effects because the included studies did not examine them systematically, and reported them sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered evidence synthesis. High risk of bias from missing data and lack of blinding across a number of included studies reduced our confidence in the findings. Thus results must be interpreted with caution. AUTHORS' CONCLUSIONS We conclude that there is moderate-quality evidence that regional anaesthesia may reduce the risk of developing PPP after three to 18 months after thoracotomy and three to 12 months after caesarean section. There is low-quality evidence that regional anaesthesia may reduce the risk of developing PPP three to 12 months after breast cancer surgery. There is moderate evidence that intravenous infusion of local anaesthetics may reduce the risk of developing PPP three to six months after breast cancer surgery.Our conclusions are considerably weakened by the small size and number of studies, by performance bias, null bias, attrition and missing data. Larger, high-quality studies, including children, are needed. We caution that except for breast surgery, our evidence synthesis is based on only a few small studies. On a cautionary note, we cannot extend our conclusions to other surgical interventions or regional anaesthesia techniques, for example we cannot conclude that paravertebral block reduces the risk of PPP after thoracotomy. There are seven ongoing studies and 12 studies awaiting classification that may change the conclusions of the current review once they are published and incorporated.
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Affiliation(s)
- Erica J Weinstein
- Albert Einstein College of Medicine of Yeshiva University1300 Morris Park AveBronxUSA10461
| | - Jacob L Levene
- Albert Einstein College of Medicine of Yeshiva University1300 Morris Park AveBronxUSA10461
| | - Marc S Cohen
- Montefiore Medical Center, Albert Einstein College of MedicineDepartment of Anesthesiology111 E 210 StreetBronxUSA#N4‐005
| | - Doerthe A Andreae
- Milton S Hershey Medical CenterDepartment of Allergy/ Immunology500 University DrHersheyUSA17033
| | - Jerry Y Chao
- Montefiore Medical Center, Albert Einstein College of MedicineDepartment of Anesthesiology111 E 210 StreetBronxUSA#N4‐005
| | - Matthew Johnson
- Teachers College, Columbia UniversityHuman DevelopmentNew YorkUSA10027
| | - Charles B Hall
- Albert Einstein College of MedicineDivision of Biostatistics, Department of Epidemiology and Population Health1300 Morris Park AvenueBronxUSA10461
| | - Michael H Andreae
- Milton S Hershey Medical CentreDepartment of Anesthesiology & Perioperative Medicine500 University DriveH187HersheyUSA17033
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White RS, Sastow DL, Gaber-Baylis LK, Tangel V, Fisher AD, Turnbull ZA. Readmission Rates and Diagnoses Following Total Hip Replacement in Relation to Insurance Payer Status, Race and Ethnicity, and Income Status. J Racial Ethn Health Disparities 2018; 5:1202-1214. [DOI: 10.1007/s40615-018-0467-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 01/26/2018] [Accepted: 01/30/2018] [Indexed: 01/08/2023]
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Andreae MH. Contextualizing and individualizing truth-telling about pain in a tough and unjust world. AJOB Neurosci 2018; 9:190-192. [PMID: 30956889 DOI: 10.1080/21507740.2018.1496167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
We consider recent research findings regarding patients' individual pain perception and phenotype, embodied in the altered neural network vulnerability, the result of connatal setup and acquired exposure, to question Dr. Gligorov's inferences. We contextualize Dr. Gligorov's discourse with concrete clinical cases embedded in obstetric anesthesia scenarios, where physicians may knowingly administer placebo pain medication and where truth-telling about pain has important immediate and long-term clinical consequences, in particular during subsequent repeated clinical encounters. Furthermore, truth-telling about pain implies acknowledging the social and economic context in which pain is treated, or more often not treated. In particular minorities and indigent populations are routinely undertreated for pain due to structural or individual bias driving cruel healthcare disparities. Finally, we argue that the patients' viewpoint is lacking in this debate at present but all stakeholders' perspective are important in the discussion of truth-telling about pain.
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Affiliation(s)
- Michael H Andreae
- Department of Anesthesiology, Penn State Health Milton S. Hershey Medical Center, Mail Code H187, 500 University Drive, Hershey, PA,
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