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Gitman M, Bezinover D, Pai SL. Current Practices and Recent Advances in Perioperative Pain Management for Liver Transplantation Living Donors and Recipients. Transplantation 2024:00007890-990000000-00893. [PMID: 39375901 DOI: 10.1097/tp.0000000000005239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/09/2024]
Abstract
Analgesia in liver transplantation patients has been traditionally considered a secondary priority where perioperative management principally focused on survival rates in these critically ill patients. With recent advancements in both surgical and medical management, posttransplant survival rates have steadily improved. Outcome measurements are no longer limited to short-term mortality rates and hospital length of stay but are also measured by patient-centered outcomes, such as pain control and quality of life. As living donor liver transplantation has increased access to transplantation, it has also added a different patient population to manage in the perioperative period. For healthy patients undergoing living donor hepatectomies, it is important to reduce the impact of the surgery with proper perioperative pain management. We performed a literature search for articles related to perioperative pain management for liver transplantation living donors and recipients to identify current practices and recent advances. Neuraxial techniques, peripheral nerve blocks, and enteral and parenteral medications were all found to be feasible analgesia modalities for patients undergoing either liver transplant or donor hepatectomy. Patients may also benefit from nonpharmacological interventions and preoperative counseling. No particular perioperative analgesic modality was deemed superior to any other. For liver transplant living donors and recipients, perioperative pain management should emphasize the application of sustainable patient-centered pain control protocols.
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Affiliation(s)
- Marina Gitman
- Department of Anesthesiology, University of Miami, Jackson Memorial Hospital, Miami, FL
| | - Dmitri Bezinover
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sher-Lu Pai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
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Banatwala UESS, Syed ARS, Ain NU, Zulfikar A, Akhund II, Lodhi R, Baig R, Ghufran L, Rizwan A, Bai M, Khatri M, Kumar S. Assessing the efficacy of celecoxib after tonsillectomy and/or adenoidectomy: A systematic review and meta-analysis of randomised control trials. Clin Otolaryngol 2024; 49:578-587. [PMID: 38877737 DOI: 10.1111/coa.14177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/17/2024] [Accepted: 05/04/2024] [Indexed: 06/16/2024]
Abstract
OBJECTIVES Tonsillectomy and adenoidectomy are common surgical procedures that cause persistent pain, bleeding, and functional limitations. We aimed to investigate the efficacy of celecoxib compared with a placebo for managing post-tonsillectomy or adenoidectomy pain and other adverse events. DESIGN Systematic review and meta-analysis. METHODS We conducted a systematic literature search in the PubMed, Cochrane, and Google Scholar databases from inception until July 2023. Dichotomous outcomes have been reported as risk ratios (RR) while continuous outcomes were reported using mean differences (MD). A funnel plot was drawn to investigate publication bias. RESULTS From 1394 records identified, 6 randomised double-blind trials comprising 591 participants undergoing tonsillectomy and/or adenoidectomy were eligible for inclusion. A high dose (400 mg) of celecoxib was effective in decreasing the pain score for 'worst pain' after the procedure (MD: -10.98, [95% CI: -11.53, -10.42], p < .01, I2 = 0%) while a low dose (200 mg) was not significantly effective (p = 0.31). For managing other outcomes such as vomiting (RR: 1.37 [95% CI: 0.69, 2.68], p = 0.37, I2 = 67%), diarrhoea (RR: 1.41, [95% CI: 0.75, 2.64], p = .29, I2 = 42%), dizziness/drowsiness (RR: 0.90, [95% CI: 0.71, 1.15], p = .48, I2 = 0%), functional recovery time (p = .74), and headache (p = .91), there was no significant difference between the group on celecoxib and the placebo group regardless of dosage. Finally, there was no significant difference (RR: 1.02, [95% CI: 0.91, 1.15], p = .69, I2 = 0%) in the effect of the intervention on minimum bleeding, moderate bleeding, and profuse bleeding. CONCLUSION This meta-analysis provides robust evidence pooled from high-quality trials and raises questions about the efficacy of celecoxib for tonsillectomy and/or adenoidectomy, challenging existing perceptions.
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Affiliation(s)
| | | | - Noor Ul Ain
- Jinnah Sindh Medical University, Karachi, Pakistan
| | - Aimen Zulfikar
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | | | - Rija Lodhi
- Jinnah Sindh Medical University, Karachi, Pakistan
| | | | | | | | - Meena Bai
- Peoples University of Medical and Health Sciences for Women, Nawabshah, Pakistan
| | - Mahima Khatri
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Satesh Kumar
- Shaheed Mohtarma Benazir Bhutto Medical College Lyari, Karachi, Pakistan
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Chen Y, Wang E, Sites BD, Cohen SP. Integrating mechanistic-based and classification-based concepts into perioperative pain management: an educational guide for acute pain physicians. Reg Anesth Pain Med 2024; 49:581-601. [PMID: 36707224 DOI: 10.1136/rapm-2022-104203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/13/2023] [Indexed: 01/28/2023]
Abstract
Chronic pain begins with acute pain. Physicians tend to classify pain by duration (acute vs chronic) and mechanism (nociceptive, neuropathic and nociplastic). Although this taxonomy may facilitate diagnosis and documentation, such categories are to some degree arbitrary constructs, with significant overlap in terms of mechanisms and treatments. In clinical practice, there are myriad different definitions for chronic pain and a substantial portion of chronic pain involves mixed phenotypes. Classification of pain based on acuity and mechanisms informs management at all levels and constitutes a critical part of guidelines and treatment for chronic pain care. Yet specialty care is often siloed, with advances in understanding lagging years behind in some areas in which these developments should be at the forefront of clinical practice. For example, in perioperative pain management, enhanced recovery protocols are not standardized and tend to drive treatment without consideration of mechanisms, which in many cases may be incongruent with personalized medicine and mechanism-based treatment. In this educational document, we discuss mechanisms and classification of pain as it pertains to commonly performed surgical procedures. Our goal is to provide a clinical reference for the acute pain physician to facilitate pain management decision-making (both diagnosis and therapy) in the perioperative period.
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Affiliation(s)
- Yian Chen
- Anesthesiology, Stanford University School of Medicine, Stanford, California, USA
| | - Eric Wang
- Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Brian D Sites
- Anesthesiology and Orthopaedics, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Steven P Cohen
- Anesthesiology, Neurology, Physical Medicine & Rehabilitation and Psychiatry & Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Hysong AA, Odum SM, Lake NH, Hietpas KT, Michalek CJ, Hamid N, Gaston RG, Loeffler BJ. Opioid-Free Analgesia Provides Pain Control Following Thumb Carpometacarpal Joint Arthroplasty. J Bone Joint Surg Am 2023; 105:1750-1758. [PMID: 37651550 DOI: 10.2106/jbjs.22.01278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
BACKGROUND We hypothesized that an opioid-free (OF), multimodal pain management pathway for thumb carpometacarpal (CMC) joint arthroplasty would not have inferior pain control compared with that of a standard opioid-containing (OC) pathway. METHODS This was a single-center, randomized controlled clinical trial of patients undergoing primary thumb CMC joint arthroplasty. Patients were randomly allocated to either a completely OF analgesic pathway or a standard OC analgesic pathway. Patients in both cohorts received a preoperative brachial plexus block utilizing 30 mL of 0.5% ropivacaine that was administered via ultrasound guidance. The OF group was given a combination of cryotherapy, anti-inflammatory medications, acetaminophen, and gabapentin. The OC group was only given cryotherapy and opioid-containing medication for analgesia. Patient-reported pain was assessed with use of a 0 to 10 numeric rating scale at 24 hours, 2 weeks, and 6 weeks postoperatively. We compared the demographics, opioid-related side effects, patient satisfaction, and Veterans RAND 12-Item Health Survey (VR-12) results between these 2 groups. RESULTS At 24 hours postoperatively, pain scores in the OF group were statistically noninferior to, and lower than, those in the OC group (median, 2 versus 4; p = 0.008). Pain scores continued to differ significantly at 2 weeks postoperatively (median, 2 versus 4; p = 0.001) before becoming more similar at 6 weeks (p > 0.05). No difference was found between groups with respect to opioid-related side effects, patient satisfaction, or VR-12 results. CONCLUSIONS A completely opioid-free perioperative protocol is effective for the treatment of pain following thumb CMC joint arthroplasty in properly selected patients. LEVEL OF EVIDENCE Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexander A Hysong
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Susan M Odum
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | | | | | | | - Nady Hamid
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
- OrthoCarolina Hand Center, Charlotte, North Carolina
| | - Raymond G Gaston
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
- OrthoCarolina Hand Center, Charlotte, North Carolina
| | - Bryan J Loeffler
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
- OrthoCarolina Hand Center, Charlotte, North Carolina
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Girotra C, Padhye M, Mahajan P, Savla S, Nair A, Pardeshi P, Tomar G, Kini Y. Is Paracetamol Better than Diclofenac Sodium in Management of Postoperative Pain and Edema Following Major Maxillofacial Surgeries? J Maxillofac Oral Surg 2023; 22:187-195. [PMID: 36703676 PMCID: PMC9871110 DOI: 10.1007/s12663-022-01806-2] [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: 05/15/2022] [Accepted: 09/29/2022] [Indexed: 01/29/2023] Open
Abstract
Introduction Paracetamol is an optimal non-opioid analgesic and holds considerable advantages over NSAIDs in managing post-operative pain. Literature to date doesn't provide substantial documentation of it's efficacy and safety in major oral and maxillofacial surgeries. The study is designed to compare the effectiveness of intravenous paracetamol with diclofenac sodium for controlling post-operative pain and edema in major oral and maxillofacial surgeries. Method The double-blind randomised prospective study includes 140 healthy patients with ASA grades I and II. Patients were divided into Group A (1gm paracetamol) and B (75 mg diclofenac sodium), 70 patients each, undergoing similar surgical procedures. VAS and VRS were assessed for pain and thread method for measuring swelling. Mouth opening in space infections was measured with calliper and scale. Results Independent samples t-test and chi-square test showed longer pain-free interval, more interval between first and second dose, lesser number of doses required in Group A than Group B (p-value < 0.05). Independent samples t-test and Mann-Whitney test showed faster resolution of swelling in Group A (p-value < 0.05). Independent samples t-test showed lesser time taken for resolution of trismus in space infections in Group A (p-value < 0.05). Discussion Paracetamol 1 g was found to be an effective analgesic with less adverse effects. It is superior non-opioid analgesic in reducing the intensity of post-operative pain and swelling, also requires less number of doses than diclofenac sodium in major surgeries. Patients treated with paracetamol had better quality of life during post-operative period.
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Affiliation(s)
- Charu Girotra
- Department of Oral and Maxillofacial Surgery, School of Dentistry, D. Y. Patil University, Nerul, Navi Mumbai, India
| | - Mukul Padhye
- Department of Oral and Maxillofacial Surgery, School of Dentistry, D. Y. Patil University, Nerul, Navi Mumbai, India
| | - Pratibha Mahajan
- Sir H. N. Reliance Foundation Hospital and Research Centre, Mumbai, India
| | - Siddhi Savla
- D. Y. Patil University School of Dentistry, Sector 7 Nerul, Navi Mumbai, 400706 India
| | - Aishwarya Nair
- Department of Oral and Maxillofacial Surgery, School of Dentistry, D. Y. Patil University, Nerul, Navi Mumbai, India
| | | | - Gaurav Tomar
- Department of Oral and Maxillofacial Surgery, School of Dentistry, D. Y. Patil University, Nerul, Navi Mumbai, India
| | - Yogesh Kini
- Department of Oral and Maxillofacial Surgery, School of Dentistry, D. Y. Patil University, Nerul, Navi Mumbai, India
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Adie S, Griffin XL, Harris IA, Gorelik A, Chang WJ. Surgical (percutaneous pinning or plate fixation) versus non-surgical interventions for distal radius fractures in adults: an individual participant data review. Hippokratia 2022. [DOI: 10.1002/14651858.cd014933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Sam Adie
- School of Clinical Medicine; UNSW Medicine & Health; UNSW Sydney Australia
| | | | - Ian A Harris
- School of Clinical Medicine; UNSW Medicine & Health; UNSW Sydney Australia
| | - Alexandra Gorelik
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Malvern Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine; Monash University; Melbourne Australia
| | - Wei-Ju Chang
- Centre for Pain IMPACT; Neuroscience Research Australia; Randwick Australia
- School of Health Sciences, College of Health, Medicine and Wellbeing; The University of Newcastle; Callaghan Australia
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Polanco-García M, Granero R, Gallart L, García-Lopez J, Montes A. Finding the vulnerable postoperative population: A two-step cluster analysis of the PAIN-OUT registry. Eur J Pain 2022; 26:1732-1745. [PMID: 35762292 DOI: 10.1002/ejp.1997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/08/2022] [Accepted: 06/26/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Identifying predictors of poor postoperative outcomes is crucial for planning personalized pain treatments. The aim of this study was to examine pain outcomes using cluster analysis in N=2,678 patients from the PAIN-OUT registry at first postoperative day. METHODS Indicator variables of the clustering analysis assessed multiple domains, such as clinical and surgical conditions, analgesic-anesthetic variables, desire for more pain treatment and outcome variables of the International Pain Outcome Questionnaire (IPO) summarized as factor scores. RESULTS Two-step cluster identified the three-cluster solution as the optimal. Two empirical groups (C1 and C2) included patients with good postoperative outcomes discriminated by peripheral nerve block use, while the other cluster (C3) grouped patients with the worst outcomes, where all patients desired more pain treatment. C3 comprised about 20% of the participants, mostly lower limb, abdominal and spine procedures. The best predictors of belonging to C3 included younger age, being male, preoperative opioid use, bone and fracture reduction procedures, institution, number of comorbidities and morphine equivalents in the recovery room. CONCLUSIONS IPO factor scores can be used to select pain outcomes phenotypes in large clinical databases. Most of the predictors were present before the recovery period so perioperative planning should focus in the preoperative and intraoperative periods.
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Affiliation(s)
- Mauricio Polanco-García
- Department of Anesthesiology, Consorci Sanitari Integral, Hospital Sant Joan Despí Moisès Broggi and Hospital General de l'Hospitalet, Barcelona, Spain
| | - Roser Granero
- Ciber Fisiopatología Obesidad y Nutrición (CIBERobn), Instituto Salud Carlos III, Spain.,Department of Psychobiology and Methodology of Health Science, Universitat Autònoma de Barcelona, Spain
| | - Lluís Gallart
- Department of Anesthesiology, Hospital del Mar. IMIM (Hospital del Mar Medical Research Institute). Universitat Autònoma de Barcelona, Spain
| | - Jaume García-Lopez
- Department of Anesthesiology, Hospital del Mar. IMIM (Hospital del Mar Medical Research Institute). Universitat Autònoma de Barcelona, Spain
| | - Antonio Montes
- Department of Anesthesiology, Hospital del Mar. IMIM (Hospital del Mar Medical Research Institute). Universitat Autònoma de Barcelona, Spain
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Hamilton C, Alfille P, Mountjoy J, Bao X. Regional anesthesia and acute perioperative pain management in thoracic surgery: a narrative review. J Thorac Dis 2022; 14:2276-2296. [PMID: 35813725 PMCID: PMC9264080 DOI: 10.21037/jtd-21-1740] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/24/2022] [Indexed: 12/11/2022]
Abstract
Background and Objective Thoracic surgery causes significant pain which can negatively affect pulmonary function and increase risk of postoperative complications. Effective analgesia is important to reduce splinting and atelectasis. Systemic opioids and thoracic epidural analgesia (TEA) have been used for decades and are effective at treating acute post-thoracotomy pain, although both have risks and adverse effects. The advancement of thoracoscopic surgery, a focus on multimodal and opioid-sparing analgesics, and the development of ultrasound-guided regional anesthesia techniques have greatly expanded the options for acute pain management after thoracic surgery. Despite the expansion of surgical techniques and analgesic approaches, there is no clear optimal approach to pain management. This review aims to summarize the body of literature regarding systemic and regional anesthetic techniques for thoracic surgery in both thoracotomy and minimally invasive approaches, with a goal of providing a foundation for providers to make individualized decisions for patients depending on surgical approach and patient factors, and to discuss avenues for future research. Methods We searched PubMed and Google Scholar databases from inception to May 2021 using the terms “thoracic surgery”, “thoracic surgery AND pain management”, “thoracic surgery AND analgesia”, “thoracic surgery AND regional anesthesia”, “thoracic surgery AND epidural”. We considered articles written in English and available to the reader. Key Content and Findings There is a wide variety of strategies for treating acute pain after thoracic surgery, including multimodal opioid and non-opioid systemic analgesics, regional anesthesia including TEA and paravertebral blocks (PVB), and a recent expansion in the use of novel fascial plane blocks especially for thoracoscopy. The body of literature on the effectiveness of different approaches for thoracotomy and thoracoscopy is a rapidly expanding field and area of active debate. Conclusions The optimal analgesic approach for thoracic surgery may depend on patient factors, surgical factors, and institutional factors. Although TEA may provide optimal analgesia after thoracotomy, PVB and emerging fascial plane blocks may offer effective alternatives. A tailored approach using multimodal systemic therapies and regional anesthesia is important, and future studies comparing techniques are necessary to further investigate the optimal approach to improve patient outcomes.
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Affiliation(s)
- Casey Hamilton
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Paul Alfille
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jeremi Mountjoy
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Xiaodong Bao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
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Kardash K, Harvey E, Payne S, Yang SS. Single-dose premedication enhances multimodal analgesia after knee arthroplasty. J Perioper Pract 2022:17504589211049292. [PMID: 35322698 DOI: 10.1177/17504589211049292] [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: 11/17/2022]
Abstract
BACKGROUND With the current trend to reduce postoperative opioid use to enhance recovery and address perioperative opioid addiction concerns, the challenge of managing pain after total knee arthroplasty has increased. This study examined the effect of adding a preoperative medication regime to a multimodal postoperative analgesia protocol that included regional anaesthesia. MATERIALS AND METHODS Sixty patients undergoing elective first-time unilateral knee arthroplasty received celecoxib 100mg, gabapentin 600mg and dexamethasone 10mg po one hour before skin incision. They were compared to a sequential retrospective cohort of 49 patients. All patients routinely received acetaminophen 650mg po q6h, ibuprofen 400mg po q8h, patient-controlled opioid analgesia and continuous adductor canal blocks postoperatively. Pain scores and opioid consumption were recorded at 4, 8, 12, 24 and 48h. RESULTS Pain scores and cumulative opioid use were statistically and clinically significantly reduced at all time points up to 48h. CONCLUSIONS Combining preoperative oral celecoxib, gabapentin and dexamethasone had a clinically significantly effect in reducing pain scores and opioid use for at least 48h. Most of this effect is probably due to dexamethasone.
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Affiliation(s)
- Kenneth Kardash
- Department of Anesthesia, Jewish General Hospital and McGill University, Montreal, Canada
| | - Eric Harvey
- Department of Anesthesia, Jewish General Hospital and McGill University, Montreal, Canada
| | - Stacey Payne
- Department of Nursing, Jewish General Hospital and McGill University, Montreal, Canada
| | - Stephen Su Yang
- Department of Anesthesia, Jewish General Hospital and McGill University, Montreal, Canada
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Faramarzi M, Roosta S, Eghbal MH, Nouri Rahmatabadi B, Faramarzi A, Mohammadi‐Samani S, Shishegar M, Sahmeddini MA. Comparison of celecoxib and acetaminophen for pain relief in pediatric day case tonsillectomy: A randomized double-blind study. Laryngoscope Investig Otolaryngol 2021; 6:1307-1315. [PMID: 34938867 PMCID: PMC8665471 DOI: 10.1002/lio2.685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/26/2021] [Accepted: 10/14/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Post-tonsillectomy pain is a common morbidity in children. The aim of this study was to compare the efficacy of celecoxib with acetaminophen on pain relief in pediatric day-case tonsillectomy. METHODS We compared the analgesic effect of celecoxib (99 patients) with acetaminophen (100 patients) for the management of post-tonsillectomy pain. Post-tonsillectomy pain score was evaluated three times a day for 7 days. In addition, the incidence of post-tonsillectomy bleeding and the rate of patients who returned to regular diet were evaluated. RESULTS In the first day, we observed lower mean pain score in the celecoxib group, than the acetaminophen group (P = 0.013). The overall pain score in other days was not significantly different between the two groups. In the celecoxib group, more patients resumed regular amount of oral intake within the first 3 days. Also, the rate of post-tonsillectomy bleeding in the two groups was not statistically different. CONCLUSION We recommend celecoxib as a more suitable choice than acetaminophen for post-tonsillectomy pain management in the first day and resuming regular diet within 3 days.Level of Evidence: 1b.
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Affiliation(s)
- Mohammad Faramarzi
- Department of Otorhinolaryngology – Head & Neck surgeryShiraz University of Medical SciencesShirazIran
- Otolaryngology Research CenterShiraz University of Medical SciencesShirazIran
| | - Sareh Roosta
- Otolaryngology Research CenterShiraz University of Medical SciencesShirazIran
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
| | - Mohammad Hossein Eghbal
- Shiraz Anesthesiology and Critical Care Research CenterShiraz University of Medical SciencesShirazIran
| | - Bahar Nouri Rahmatabadi
- Shiraz Anesthesiology and Critical Care Research CenterShiraz University of Medical SciencesShirazIran
| | - Ali Faramarzi
- Otolaryngology Research CenterShiraz University of Medical SciencesShirazIran
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
| | | | - Mahmood Shishegar
- Department of Otorhinolaryngology – Head & Neck surgeryShiraz University of Medical SciencesShirazIran
- Otolaryngology Research CenterShiraz University of Medical SciencesShirazIran
| | - Mohammad Ali Sahmeddini
- Shiraz Anesthesiology and Critical Care Research CenterShiraz University of Medical SciencesShirazIran
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[Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery]. Schmerz 2021; 35:265-281. [PMID: 34076782 DOI: 10.1007/s00482-021-00566-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Nonopioid analgesics are frequently used for perioperative analgesia; however, insufficient research is available on several practical issues. Often hospitals have no strategy for how to proceed, e.g., for informing patients or for the timing of perioperative administration of nonopioid analgesics. METHODS An expert panel representing the German national societies of pain, anaesthesiology and intensive care medicine and surgery developed recommendations for the perioperative use of nonopioid analgesics within a formal, structured consensus process. RESULTS The panel agreed that nonopioid analgesics shall be part of a multimodal analgesia concept and that patients have to be informed preoperatively about possible complications and alternative treatment options. Patients' history of pain and analgesic intake shall be evaluated. Patients at risk of severe postoperative pain and possible chronification of postsurgical pain shall be identified. Depending on the duration of surgery, nonopioid analgesics can already be administered preoperatively or intraoperatively so that plasma concentrations are sufficient after emergence from anesthesia. Nonopioid analgesics or combinations of analgesics shall be administered for a limited time only. An interdisciplinary written standard of care, comprising the nonopioid analgesic of choice, possible alternatives, adequate dosing and timing of administration as well as surgery-specific policies, have to be agreed upon by all departments involved. At discharge, the patient's physician shall be informed of analgesics given and those necessary after discharge. Patients shall be informed of possible side effects and symptoms and timely discontinuation of analgesic drugs. CONCLUSION The use of nonopioid analgesics as part of a perioperative multimodal concept should be approved and established as an interdisciplinary and interprofessional concept for the adequate treatment of postoperative pain.
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Stamer UM, Erlenwein J, Freys SM, Stammschulte T, Stichtenoth D, Wirz S. [Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery]. Anaesthesist 2021; 70:689-705. [PMID: 34282481 DOI: 10.1007/s00101-021-01010-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Nonopioid analgesics are frequently used for perioperative analgesia; however, insufficient research is available on several practical issues. Often hospitals have no strategy for how to proceed, e.g., for informing patients or for the timing of perioperative administration of nonopioid analgesics. METHODS An expert panel representing the German national societies of pain, anaesthesiology and intensive care medicine and surgery developed recommendations for the perioperative use of nonopioid analgesics within a formal, structured consensus process. RESULTS The panel agreed that nonopioid analgesics shall be part of a multimodal analgesia concept and that patients have to be informed preoperatively about possible complications and alternative treatment options. Patients' history of pain and analgesic intake shall be evaluated. Patients at risk of severe postoperative pain and possible chronification of postsurgical pain shall be identified. Depending on the duration of surgery, nonopioid analgesics can already be administered preoperatively or intraoperatively so that plasma concentrations are sufficient after emergence from anesthesia. Nonopioid analgesics or combinations of analgesics shall be administered for a limited time only. An interdisciplinary written standard of care, comprising the nonopioid analgesic of choice, possible alternatives, adequate dosing and timing of administration as well as surgery-specific policies, have to be agreed upon by all departments involved. At discharge, the patient's physician shall be informed of analgesics given and those necessary after discharge. Patients shall be informed of possible side effects and symptoms and timely discontinuation of analgesic drugs. CONCLUSION The use of nonopioid analgesics as part of a perioperative multimodal concept should be approved and established as an interdisciplinary and interprofessional concept for the adequate treatment of postoperative pain.
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Affiliation(s)
- Ulrike M Stamer
- Universitätsklinik für Anästhesiologie und Schmerztherapie, Inselspital, Universität Bern, Freiburgstrasse, 3010, Bern, Schweiz.
- Arbeitskreis Akutschmerz, Deutsche Schmerzgesellschaft e.V., Berlin, Deutschland.
| | - Joachim Erlenwein
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Göttingen, Deutschland
- Wissenschaftlicher Arbeitskreis Schmerzmedizin, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V., Nürnberg, Deutschland
| | - Stephan M Freys
- Chirurgische Klinik, DIAKO Ev. Diakonie-Krankenhaus Bremen, Bremen, Deutschland
- Chirurgische Arbeitsgemeinschaft Akutschmerz, Deutsche Gesellschaft für Chirurgie e.V., Berlin, Deutschland
| | - Thomas Stammschulte
- , Bern, Schweiz
- ehemalige Institution Arzneimittelkommission der deutschen Ärzteschaft, Berlin, Deutschland
| | - Dirk Stichtenoth
- Institut für Klinische Pharmakologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Stefan Wirz
- Abteilung für Anästhesie, Interdisziplinäre Intensivmedizin, Schmerzmedizin/Palliativmedizin, Zentrum für Schmerzmedizin, Weaningzentrum, CURA - GFO-Kliniken Bonn, Bad Honnef, Deutschland
- Arbeitskreis Tumorschmerz, Deutsche Schmerzgesellschaft e.V., Berlin, Deutschland
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Stamer UM, Erlenwein J, Freys SM, Stammschulte T, Stichtenoth D, Wirz S. [Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery]. Chirurg 2021; 92:647-663. [PMID: 34037807 PMCID: PMC8241738 DOI: 10.1007/s00104-021-01421-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2021] [Indexed: 11/17/2022]
Abstract
Hintergrund Nichtopioidanalgetika werden bei vielen Patienten zur perioperativen Analgesie eingesetzt. Zu einigen praktischen Fragen beim Einsatz von Nichtopioidanalgetika liegen z. T. nur wenig Informationen aus Studien vor, und in Krankenhäusern existieren häufig keine Konzepte zum Vorgehen, z. B. zur Patientenaufklärung und zum Zeitpunkt der perioperativen Gabe. Methodik Eine Expertengruppe der beteiligten Fachgesellschaften hat konsensbasierte Empfehlungen zum perioperativen Einsatz von Nichtopioidanalgetika erarbeitet und in einem strukturierten formalen Konsensusprozess verabschiedet. Ergebnisse Die Arbeitsgruppe stimmt überein, dass Nichtopioidanalgetika Bestandteil eines perioperativen multimodalen Analgesiekonzepts sein sollen und Patienten präoperativ über Nutzen, Risiken und alternative Behandlungsmöglichkeiten aufgeklärt werden sollen. Die präoperative Patienteninformation und -edukation soll auch eine Schmerz- und Analgetikaanamnese umfassen und Patienten mit Risikofaktoren für starke Schmerzen und eine Schmerzchronifizierung sollen identifiziert werden. Unter Berücksichtigung von Kontraindikationen können Nichtopioidanalgetika abhängig von der Operationsdauer auch schon prä- oder intraoperativ gegeben werden, um nach Beendigung der Anästhesie ausreichende Plasmakonzentrationen zu erzielen. Nichtopioidanalgetika oder Kombinationen von (Nichtopioid‑)Analgetika sollen nur für einen begrenzten Zeitraum gegeben werden. Ein gemeinsam erarbeiteter abteilungsübergreifender Behandlungsstandard mit dem Nichtopioidanalgetikum erster Wahl, weiteren Therapieoptionen sowie adäquaten Dosierungen, ergänzt durch eingriffsspezifische Konzepte, soll schriftlich hinterlegt werden. Bei Entlassung aus dem Krankenhaus soll der nachbehandelnde Arzt zu perioperativ gegebenen und aktuell noch eingenommenen Analgetika schriftliche Informationen erhalten. Patienten sollen zu möglichen Nebenwirkungen der Analgetika und ihrer Symptome, die auch nach Krankenhausentlassung auftreten können, und die befristete Einnahmedauer informiert werden. Schlussfolgerung Die Anwendung von Nichtopioidanalgetika soll als Bestandteil eines perioperativen multimodalen Analgesiekonzepts mit klaren Vorgaben zu Indikationen, Kontraindikationen, Dosierungen und Behandlungsdauer in einem abteilungsübergreifenden Behandlungsstandard schriftlich hinterlegt werden. Zusatzmaterial online Die Offenlegung von Interessen ist in der Online-Version dieses Artikels (10.1007/s00104-021-01421-w) enthalten.
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Affiliation(s)
- Ulrike M Stamer
- Universitätsklinik für Anästhesiologie und Schmerztherapie, Inselspital, Universität Bern, Freiburgstrasse, 3010, Bern, Schweiz. .,Arbeitskreis Akutschmerz, Deutsche Schmerzgesellschaft e.V., Berlin, Deutschland.
| | - Joachim Erlenwein
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Göttingen, Deutschland.,Wissenschaftlicher Arbeitskreis Schmerzmedizin, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V., Nürnberg, Deutschland
| | - Stephan M Freys
- Chirurgische Klinik, DIAKO Ev. Diakonie-Krankenhaus Bremen, Bremen, Deutschland.,Chirurgische Arbeitsgemeinschaft Akutschmerz, Deutsche Gesellschaft für Chirurgie e.V., Berlin, Deutschland
| | - Thomas Stammschulte
- , Bern, Schweiz.,ehemalige Institution Arzneimittelkommission der deutschen Ärzteschaft, Berlin, Deutschland
| | - Dirk Stichtenoth
- Institut für Klinische Pharmakologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Stefan Wirz
- Abteilung für Anästhesie, Interdisziplinäre Intensivmedizin, Schmerzmedizin/Palliativmedizin, Zentrum für Schmerzmedizin, Weaningzentrum, CURA - GFO-Kliniken Bonn, Bad Honnef, Deutschland.,Arbeitskreis Tumorschmerz, Deutsche Schmerzgesellschaft e.V., Berlin, Deutschland
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14
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Reduction in Opiate Use, Pain, Nausea, and Length of Stay After Implementation of a Bariatric Enhanced Recovery After Surgery Protocol. Obes Surg 2021; 31:2896-2905. [PMID: 33712934 DOI: 10.1007/s11695-021-05338-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/26/2021] [Accepted: 03/04/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Evaluate adherence to bariatric surgery enhanced recovery after surgery (ERAS) protocols in pre-operative, operative, and post-operative phases, and to compare opiate use, nausea control, and length of stay (LOS) versus historical controls. MATERIALS AND METHODS A retrospective, observational cohort study was conducted to evaluate adherence to ERAS protocols and compare opiate and antiemetic use, pain intensity, and LOS versus those of traditional care (TC) patients preceding protocol implementation at Erie County Medical Center, a community-based hospital in Buffalo, NY, USA. RESULTS One hundred ERAS and TC patients were compared. Patients were similar in age (42.5 years), gender (female, ~ 80%), race (~ 80 white), and BMI (47 kg/m2). The primary procedure performed was sleeve gastrectomy (89% ERAS, 86% TC). Protocol adherence was high for ERAS phases: prior to admission (85-98%), pre-operative (96-100%), operative (93-99%), post-anesthesia care unit (PACU) (55-61%), and floor (86-98%). Opiate morphine milligram equivalent (MME) was reduced in ERAS vs. TC in hospital by 73% (43.5 ± 42.4 vs. 160 ± 116; p < 0.001), discharge prescribing by 53% (34.8 ± 38.2 vs. 74 ± 125 MME; p = 0.003), and in total by 69% (78.3 ± 67.5 vs. 252 ± 160; p < 0.001). Despite lower opiate use, ERAS had lower pain intensity entering PACU (1.1 ± 1.8 vs. 1.9 ± 2.6; p < 0.011), leaving PACU (1.7 ± 1.5 vs. 2.9 ± 1.5; p < 0.001), and floor day 0 (5.0 ± 2.1 vs. 5.9 ± 1.8; p < 0.001). Fewer ERAS required antiemetic day 0 (63% vs. 94%; p < 0.001). ERAS were discharged in fewer hours than TC (41.1 ± 15.5 vs. 52.1 ± 18.9 h; p < 0.001). CONCLUSIONS Bariatric surgery ERAS protocols were implemented with a high rate of adherence and yielded profound reduction in operative and post-operative opiate use while improving pain control and nausea management in hospital and decreasing LOS.
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Ren Y, Sun D, Pei L, Liu X, Liu Y, Liu H. A Full Enhanced Recovery after Surgery Program in Gynecologic Laparoscopic Procedures: A Randomized Controlled Trial. J Minim Invasive Gynecol 2021; 28:1610-1617.e6. [PMID: 33676007 DOI: 10.1016/j.jmig.2021.01.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/28/2021] [Accepted: 01/29/2021] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE To assess whether a full enhanced recovery after surgery (ERAS) program can further improve perioperative outcomes among patients undergoing gynecologic laparoscopic procedures relative to those receiving limited ERAS management. DESIGN Randomized controlled trial. SETTING Tertiary hospital, China: December 2018 to October 2019. PATIENTS Total of 144 women scheduled for simple elective gynecologic laparoscopic surgery. INTERVENTIONS The participants were randomized into 2 groups: full ERAS intervention or limited ERAS management (without preoperative carbohydrate loading or total intravenous anesthesia or opiate-sparing multimodal analgesia). MEASUREMENTS AND MAIN RESULTS The primary outcome was postoperative length of stay (LOS), and the secondary outcomes included postoperative pain, time to postoperative milestones, morbidity, and in-hospital cost. Postoperative LOS for the full ERAS program showed a 1-day reduction in comparison with the limited ERAS group (median of 1.0 day vs 2.0 days, respectively; p = .001). Multivariate regression analysis identified preoperative carbohydrate loading and opioid-sparing analgesia as the independent factors for discharging on postoperative day 1. Patients in the full ERAS program reported less pain within 72 hours after surgery and had a lower narcotic consumption rate compared with those in the limited ERAS management. They also enjoyed better and faster recovery as demonstrated by the Quality of Recovery-15 scale on postoperative day 3: 137.0 (interquartile range, 126.3-141.0) for full ERAS program vs 130.0 (23.5-139.0) for limited ERAS management, respectively (p = .030). There were no significant differences between the groups regarding postoperative 30-day morbidity, readmission rate, or in-hospital cost. CONCLUSION The addition of full ERAS management can further reduce postoperative LOS and improve patients' quality of life after laparoscopic surgery for gynecologic diseases.
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Affiliation(s)
- Yuan Ren
- Departments of Obstetrics and Gynecology (Drs. Ren, Sun, H. Liu, Mrs. X. Liu, and Mrs. Y. Liu); Anesthesiology (Dr. Pei), Peking Union Medical College Hospital, Beijing, China; Outcomes Research Consortium (Dr. Pei), Cleveland, Ohio
| | - Dawei Sun
- Departments of Obstetrics and Gynecology (Drs. Ren, Sun, H. Liu, Mrs. X. Liu, and Mrs. Y. Liu); Anesthesiology (Dr. Pei), Peking Union Medical College Hospital, Beijing, China; Outcomes Research Consortium (Dr. Pei), Cleveland, Ohio
| | - Lijian Pei
- Departments of Obstetrics and Gynecology (Drs. Ren, Sun, H. Liu, Mrs. X. Liu, and Mrs. Y. Liu); Anesthesiology (Dr. Pei), Peking Union Medical College Hospital, Beijing, China; Outcomes Research Consortium (Dr. Pei), Cleveland, Ohio
| | - Xia Liu
- Departments of Obstetrics and Gynecology (Drs. Ren, Sun, H. Liu, Mrs. X. Liu, and Mrs. Y. Liu); Anesthesiology (Dr. Pei), Peking Union Medical College Hospital, Beijing, China; Outcomes Research Consortium (Dr. Pei), Cleveland, Ohio
| | - Ying Liu
- Departments of Obstetrics and Gynecology (Drs. Ren, Sun, H. Liu, Mrs. X. Liu, and Mrs. Y. Liu); Anesthesiology (Dr. Pei), Peking Union Medical College Hospital, Beijing, China; Outcomes Research Consortium (Dr. Pei), Cleveland, Ohio
| | - Haiyuan Liu
- Departments of Obstetrics and Gynecology (Drs. Ren, Sun, H. Liu, Mrs. X. Liu, and Mrs. Y. Liu); Anesthesiology (Dr. Pei), Peking Union Medical College Hospital, Beijing, China; Outcomes Research Consortium (Dr. Pei), Cleveland, Ohio.
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Shing EZ, Leas D, Michalek C, Wally MK, Hamid N. Study protocol: randomized controlled trial of opioid-free vs. traditional perioperative analgesia in elective orthopedic surgery. BMC Musculoskelet Disord 2021; 22:104. [PMID: 33485328 PMCID: PMC7824925 DOI: 10.1186/s12891-021-03972-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 01/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The medical community is beginning to recognize the contribution of prescription opioids in the growing national opioid crisis. Many studies have compared the safety and efficacy of alternative analgesics to opioids, but none utilizing a completely opioid-free perioperative protocol in orthopedics. METHODS We developed and tested an opioid-free perioperative analgesic pathway (from preoperative to postoperative period) among patients undergoing common elective orthopedic procedures. Patients will be randomized to receive either traditional opioid-including or completely opioid-free perioperative medications. This study is being conducted across multiple orthopedic subspecialties in patients undergoing the following common elective orthopedic procedures: single-level or two-level ACDF/ACDA, 1st CMC arthroplasty, Hallux Valgus/Rigidus corrections, diagnostic knee arthroscopies, total hip arthroplasty (THA), and total shoulder arthroplasty/reverse total shoulder arthroplasty (TSA/RTSA). The primary outcome measure is pain score at 24 h postoperatively. Secondary outcome measures include pain scores at additional time points, medication side effects, and several patient-reported variables such as patient satisfaction, quality of life, and functional status. DISCUSSION We describe the methods for a feasibility randomized controlled trial comparing opioid-free perioperative analgesics to traditional opioid-including protocols. We present this study so that it may be replicated and incorporated into future studies at other institutions, as well as disseminated to additional orthopedic and/or non-orthopedic surgical procedures. The ultimate goal of presenting this protocol is to aid recent efforts in reducing the impact of prescription opioids on the national opioid crisis. TRIAL REGISTRATION The protocol was approved by the local institutional review board and registered with clinicaltrials.gov (Identifier: NCT04176783 ) on November 25, 2019, retrospectively registered.
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Affiliation(s)
- Elaine Z Shing
- Carolinas Medical Center, Atrium Health Musculoskeletal Institute, P.O. Box 32861, Charlotte, NC, 28232, USA.
| | - Daniel Leas
- Carolina Neurosurgery and Spine Associates, Charlotte, NC, USA
| | | | - Meghan K Wally
- Carolinas Medical Center, Atrium Health Musculoskeletal Institute, P.O. Box 32861, Charlotte, NC, 28232, USA
| | - Nady Hamid
- OrthoCarolina Shoulder and Elbow Center, Charlotte, NC, USA
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17
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Nonopioid Modalities for Acute Postoperative Pain in Abdominal Transplant Recipients. Transplantation 2020; 104:694-699. [PMID: 31815897 DOI: 10.1097/tp.0000000000003053] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The field of abdominal organ transplantation is multifaceted, with the clinician balancing recipient comorbidities, risks of the surgical procedure, and the pathophysiology of immunosuppression to ensure optimal outcomes. An underappreciated element throughout this process is acute pain management related to the surgical procedure. As the opioid epidemic continues to grow with increasing numbers of transplant candidates on opioids as well the increase in the development of enhanced recovery after surgery protocols, there is a need for greater focus on optimal postoperative pain control to minimize opioid use and improve outcomes. This review will summarize the physiology of acute pain in transplant recipients, assess the impact of opioid use on post-transplant outcomes, present evidence supporting nonopioid analgesia in transplant surgery, and briefly address the perioperative approach to the pretransplant recipient on opioids.
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Perioperative Pregabalin for Preventive Analgesia in Breast Cancer Surgery: A Meta-analysis of Randomized Controlled Trials. Clin J Pain 2020; 36:968-977. [PMID: 32960823 DOI: 10.1097/ajp.0000000000000883] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Pregabalin is a drug for neuropathic pain. Antipronociceptive properties of pregabalin have led to its recent use as an adjuvant to the multimodal postoperative pain regimen. This meta-analysis was conducted to evaluate the efficacy of perioperative pregabalin on acute and chronic postsurgical pain (CPSP) after breast cancer surgery. METHODS A meta-analysis including 8 randomized controlled trials searched from MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials was conducted. Subgroup analysis was performed according to doses and timecourse of pregabalin administration. Review Manager 5.3 was selected to conduct the meta-analysis. RESULTS Preoperative pregabalin in breast cancer surgery alleviated acute postoperative pain at rest 24 hours after surgery by 0.31 points on an 0 to 10 Numerical Rating Scale (95% confidence interval [CI] -0.57 to -0.05). Morphine consumption showed a decrease in postoperative use by 1.09 mg (95% CI: -1.61 to -0.57). The incidence of CPSP 3 months after surgery was reduced to 46% (95% CI: 0.25-0.85). Postoperative nausea and vomiting, dizziness, and sedation showed no overall significant reductions. However, a decrease in the incidence of postoperative nausea and vomiting and an increase in the incidence of dizziness were noted when patients received 300 mg of pregabalin before surgery. DISCUSSION This study demonstrated that pregabalin showed more efficacy on chronic pain than acute pain after a breast cancer surgery. Further study based on doses and treatment course of pregabalin should be conducted to establish stronger evidence of treatment effects.
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19
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Leas DP, Connor PM, Schiffern SC, D'Alessandro DF, Roberts KM, Hamid N. Opioid-free shoulder arthroplasty: a prospective study of a novel clinical care pathway. J Shoulder Elbow Surg 2019; 28:1716-1722. [PMID: 31072655 DOI: 10.1016/j.jse.2019.01.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 01/17/2019] [Accepted: 01/21/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Opioid therapy has been a cornerstone of perioperative pain control for decades in the United States, despite our increased understanding of the morbidity and mortality linked to opioids. The purpose of this study is to explore the safety, efficacy, and feasibility of an entirely opioid-free perioperative pathway in patients undergoing elective shoulder arthroplasty. METHODS Thirty-five patients undergoing elective total shoulder arthroplasty with a mean age of 71 (range, 50-87) years elected into a comprehensive opioid-free, multimodal pain management protocol. Opioid use was completely eliminated for all points in the perioperative period including during regional and general anesthesia. Data were collected regarding patient-reported pain, opioid consumption in the perioperative period, postoperative delirium, nausea, constipation, and falls. RESULTS Pain level at the primary outcome point of 24 hours or discharge was rated at 2.5 on the numeric rating scale. Stable, low pain scores were demonstrated at all time points postoperatively. Low rates of nausea, falls, and constipation were reported. Only 1 patient required "rescue" opioid medications during the in-patient stay, and an additional patient was given a low-dose opioid prescription at the 2-week postoperative appointment. CONCLUSIONS An opioid-free, multimodal pain management pathway is a safe and effective option in properly selected patients undergoing shoulder arthroplasty with a very low risk of requiring rescue opioids. This study is the first such study to present a surgical protocol entirely free of opioids at all portions of the patient care pathway.
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Affiliation(s)
- Daniel P Leas
- Department of Orthopaedic Surgery, Atrium Health, Charlotte, NC, USA
| | - Patrick M Connor
- OrthoCarolina Shoulder and Elbow Center, Charlotte, NC, USA; OrthoCarolina Sports Medicine Center, Charlotte, NC, USA
| | | | - Donald F D'Alessandro
- OrthoCarolina Shoulder and Elbow Center, Charlotte, NC, USA; OrthoCarolina Sports Medicine Center, Charlotte, NC, USA
| | | | - Nady Hamid
- OrthoCarolina Shoulder and Elbow Center, Charlotte, NC, USA.
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Moulder JK, Boone JD, Buehler JM, Louie M. Opioid Use in the Postoperative Arena: Global Reduction in Opioids After Surgery Through Enhanced Recovery and Gynecologic Surgery. Clin Obstet Gynecol 2019; 62:67-86. [PMID: 30407228 DOI: 10.1097/grf.0000000000000410] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Enhanced recovery programs aim to reduce surgical stress to improve the patient perioperative experience. Through a combination of multimodal analgesia and maintaining a physiological state, postoperative recovery is improved. Many analgesic adjuncts are available that improve postoperative pain control and limit opioid analgesia requirements. Adjuncts are often used in combination, but different interventions may be incorporated for patient-specific and procedure-specific needs. Postoperative pain control can be optimized by continuing nonopioid adjuncts, and prescribing opioid analgesia to address breakthrough pain. Prescribing practices should balance optimizing pain relief, minimizing the risk of chronic pain, while limiting the potential for opioid misuse.
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Affiliation(s)
| | | | - Jason M Buehler
- Anesthesiology, University of Tennessee Medical Center Knoxville, Graduate School of Medicine, Knoxville, Tennessee
| | - Michelle Louie
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
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21
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Soffin EM, Gibbons MM, Wick EC, Kates SL, Cannesson M, Scott MJ, Grant MC, Ko SS, Wu CL. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Hip Fracture Surgery. Anesth Analg 2019; 128:1107-1117. [PMID: 31094775 DOI: 10.1213/ane.0000000000003925] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Enhanced recovery after surgery (ERAS) protocols represent patient-centered, evidence-based, multidisciplinary care of the surgical patient. Although these patterns have been validated in numerous surgical specialities, ERAS has not been widely described for patients undergoing hip fracture (HFx) repair. As part of the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery, we have conducted a full evidence review of interventions that form the basis of the anesthesia components of the ERAS HFx pathway. A literature search was performed for each protocol component, and the highest levels of evidence available were selected for review. Anesthesiology components of care were identified and evaluated across the perioperative continuum. For the preoperative phase, the use of regional analgesia and nonopioid multimodal analgesic agents is suggested. For the intraoperative phase, a standardized anesthetic with postoperative nausea and vomiting prophylaxis is suggested. For the postoperative phase, a multimodal (primarily nonopioid) analgesic regimen is suggested. A summary of the best available evidence and recommendations for inclusion in ERAS protocols for HFx repair are provided.
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Affiliation(s)
- Ellen M Soffin
- From the Department of Anesthesiology, The Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Melinda M Gibbons
- Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Elizabeth C Wick
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, Maryland
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Maxime Cannesson
- Department of Anesthesiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Michael J Scott
- Department of Anesthesiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Samantha S Ko
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Christopher L Wu
- From the Department of Anesthesiology, The Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
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22
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Soffin EM, Lee BH, Kumar KK, Wu CL. The prescription opioid crisis: role of the anaesthesiologist in reducing opioid use and misuse. Br J Anaesth 2019; 122:e198-e208. [PMID: 30915988 PMCID: PMC8176648 DOI: 10.1016/j.bja.2018.11.019] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/12/2018] [Accepted: 11/12/2018] [Indexed: 12/14/2022] Open
Abstract
Reports of strategies to prevent and treat the opioid epidemic are growing. Significant attention has been paid to the benefits of opioid addiction research, clinical prescribing, and public policy initiatives in curbing the epidemic. However, the role of the anaesthesiologist in minimising opioid use and misuse remains underexplored. For many patients with an opioid use disorder, the perioperative period represents the source of initial exposure. As perioperative physicians, anaesthesiologists are in the unique position to manage pain effectively while simultaneously decreasing opioid consumption. Multiple opportunities exist for anaesthesiologists to minimise opioid exposure and prevent subsequent persistent opioid use. We present a global strategy for decreasing perioperative opioid use and misuse among surgical patients. A historical perspective of the opioid epidemic is presented, together with an analysis of opioid supply and demand forces. We then present specific temporal strategies for opioid use reduction in the perioperative period. We emphasise the importance of preoperative identification of patients at risk for long-term opioid use and misuse, review the evidence supporting the opioid sparing capacity of individual multimodal analgesic agents, and discuss the benefits of regional anaesthesia for minimising opioid consumption. We describe postoperative and post-discharge tools, including effective multimodal analgesia and the role of a transitional pain service. Finally, we offer general institutional strategies that can be led by anaesthesiologists, identify gaps in knowledge, and offer directions for future research.
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Affiliation(s)
- Ellen M Soffin
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Bradley H Lee
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Kanupriya K Kumar
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Christopher L Wu
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD, USA.
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Ban KA, Gibbons MM, Ko CY, Wick EC, Cannesson M, Scott MJ, Grant MC, Wu CL. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. Anesth Analg 2019; 128:879-889. [DOI: 10.1213/ane.0000000000003366] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Colvin LA, Bull F, Hales TG. Perioperative opioid analgesia-when is enough too much? A review of opioid-induced tolerance and hyperalgesia. Lancet 2019; 393:1558-1568. [PMID: 30983591 DOI: 10.1016/s0140-6736(19)30430-1] [Citation(s) in RCA: 277] [Impact Index Per Article: 55.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 11/21/2018] [Accepted: 02/15/2019] [Indexed: 12/12/2022]
Abstract
Opioids are a mainstay of acute pain management but can have many adverse effects, contributing to problematic long-term use. Opioid tolerance (increased dose needed for analgesia) and opioid-induced hyperalgesia (paradoxical increase in pain with opioid administration) can contribute to both poorly controlled pain and dose escalation. Hyperalgesia is particularly problematic as further opioid prescribing is largely futile. The mechanisms of opioid tolerance and hyperalgesia are complex, involving μ opioid receptor signalling pathways that offer opportunities for novel analgesic alternatives. The intracellular scaffold protein β-arrestin-2 is implicated in tolerance, hyperalgesia, and other opioid side-effects. Development of agonists biased against recruitment of β-arrestin-2 could provide analgesic efficacy with fewer side-effects. Alternative approaches include inhibition of peripheral μ opioid receptors and blockade of downstream signalling mechanisms, such as the non-receptor tyrosine kinase Src or N-methyl-D-aspartate receptors. Furthermore, it is prudent to use multimodal analgesic regimens to reduce reliance on opioids during the perioperative period. In the third paper in this Series we focus on clinical and mechanism-based understanding of tolerance and opioid-induced hyperalgesia, and discuss current and future strategies for pain management.
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Affiliation(s)
- Lesley A Colvin
- Division of Population Health and Genomics, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK.
| | - Fiona Bull
- Institute for Academic Anaesthesia, Division of Systems Medicine, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
| | - Tim G Hales
- Institute for Academic Anaesthesia, Division of Systems Medicine, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
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Soffin EM, Gibbons MM, Ko CY, Kates SL, Wick EC, Cannesson M, Scott MJ, Wu CL. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. Anesth Analg 2019; 128:454-465. [DOI: 10.1213/ane.0000000000003663] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Soffin EM, Gibbons MM, Ko CY, Kates SL, Wick E, Cannesson M, Scott MJ, Wu CL. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. Anesth Analg 2019; 128:441-453. [DOI: 10.1213/ane.0000000000003564] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Gabriel RA, Swisher MW, Sztain JF, Furnish TJ, Ilfeld BM, Said ET. State of the art opioid-sparing strategies for post-operative pain in adult surgical patients. Expert Opin Pharmacother 2019; 20:949-961. [DOI: 10.1080/14656566.2019.1583743] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Rodney A. Gabriel
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA
- Division of Biomedical Informatics, University of California, San Diego, La Jolla, CA, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Matthew W. Swisher
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Jacklynn F. Sztain
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA
| | - Timothy J. Furnish
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA
| | - Brian M. Ilfeld
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Engy T. Said
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA
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Abstract
OBJECTIVE Dexketoprofen trometamol is a modified non-selective COX inhibitor with a rapid onset of action that is available as both oral and parenteral formulations. The aim of this narrative review was to assess the efficacy and tolerability/safety of dexketoprofen trometamol in acute pain states using the best available published scientific evidence (randomized controlled clinical trials and systematic reviews/meta-analyses). METHODS Literature retrieval was performed via Medline, Embase and the Cochrane Library (from inception up to March 2017) using combinations of the terms "randomized controlled trials", "dexketoprofen", "celecoxib", "etoricoxib", "parecoxib" and "acute pain". RESULTS Single-dose dexketoprofen trometamol provides effective analgesia in the treatment of acute pain, such as postoperative pain (dental and non-dental surgery), renal colic, acute musculoskeletal disorders and dysmenorrhea, and reduces opioid consumption in the postoperative setting. It has a rapid onset of action (within 30 minutes) and is well tolerated during short-term treatment. Direct comparisons with COX-2 inhibitors are lacking; however, the efficacy and tolerability of single-dose dexketoprofen trometamol appears to be consistent with that seen with celecoxib, etoricoxib and parecoxib in the acute pain setting. CONCLUSION In conclusion, dexketoprofen trometamol appears to provide similar analgesic efficacy to COX-2 inhibitors when used to treat acute pain, has a rapid onset of action, is well tolerated, and has an opioid-sparing effect when used as part of a multimodal regimen in the acute pain setting.
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Affiliation(s)
- Magdi Hanna
- a Analgesics and Pain Research (APR) , Beckenham, Kent , UK
| | - Jee Y Moon
- b Department of Anesthesiology and Pain Medicine , Seoul National University Hospital College of Medicine and the Integrated Cancer Management Center, Seoul National University Cancer Hospital , Seoul , Korea
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Jiang Y, Li J, Lin H, Huang Q, Wang T, Zhang S, Zhang Q, Rong Z, Xiong J. The efficacy of gabapentin in reducing pain intensity and morphine consumption after breast cancer surgery: A meta-analysis. Medicine (Baltimore) 2018; 97:e11581. [PMID: 30235654 PMCID: PMC6160249 DOI: 10.1097/md.0000000000011581] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The purpose of this meta-analysis from randomized controlled trials (RCTs) was to determine the efficacy and safety of the preoperative use of gabapentin for the treatment of acute and chronic postoperative pain following breast cancer surgery. METHODS In November 2017, a systematic computer-based search was conducted in PubMed, Embase, Web of Science, Cochrane Library, and Google databases. RCTs comparing gabapentin with placebo in patients undergoing breast cancer surgery were retrieved. The primary endpoint was the visual analog scale (VAS) after surgery and 24 hours after surgery and total morphine consumption. The secondary outcomes were incidence of chronic pain and complications (the incidence of nausea). Software Stata 12.0 was used for meta-analysis. RESULTS Finally, 9 RCTs were included in the meta-analysis. Results indicated that gabapentin was associated with reduced pain scores after surgery and 24 hours after surgery. Meanwhile, oral gabapentin was associated with a reduction of the total morphine consumption after breast cancer surgery. Similarly, gabapentin was associated with a reduction in the incidence of chronic pain and the incidence of nausea. CONCLUSIONS Preoperative use of gabapentin was able to reduce acute and chronic postoperative pain, total morphine consumption and the occurrence of nausea following breast cancer surgery. Further studies should determine the optimal dose of gabapentin for pain control after breast cancer surgery.
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Affiliation(s)
- Yunfeng Jiang
- Oncology Department, The First Affiliated Hospital of Guangxi University of Chinese Medicine
| | | | - Huasheng Lin
- Department of Spleen and Stomach Liver Disease, Nanning, Guangxi
| | - Qiaotong Huang
- Oncology Department, The First Affiliated Hospital of Guangxi University of Chinese Medicine
| | - Tongbiao Wang
- Oncology Department, The First Affiliated Hospital of Guangxi University of Chinese Medicine
| | - Shijie Zhang
- Oncology Department, The First Affiliated Hospital of Guangxi University of Chinese Medicine
| | - Qing Zhang
- College of Education Science, Guangxi Teachers Education University, Nanning
| | - Zheng Rong
- Oncology Department, The First Affiliated Hospital of Guangxi University of Chinese Medicine
| | - Jun Xiong
- Department of Acupuncture and Moxibustion, The Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, Nanchang, Jiangxi, China
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Opioid-induced hyperalgesia in clinical anesthesia practice: what has remained from theoretical concepts and experimental studies? Curr Opin Anaesthesiol 2018; 30:458-465. [PMID: 28590258 DOI: 10.1097/aco.0000000000000485] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This article reviews the phenomenon of opioid-induced hyperalgesia (OIH) and its implications for clinical anesthesia. The goal of this review is to give an update on perioperative prevention and treatment strategies, based on findings in preclinical and clinical research. RECENT FINDINGS Several systems have been suggested to be involved in the pathophysiology of OIH with a focus on the glutaminergic system. Very recently preclinical data revealed that peripheral μ-opioid receptors (MORs) are key players in the development of OIH and acute opioid tolerance (AOT). Peripheral MOR antagonists could, thus, become a new prevention/treatment option of OIH in the perioperative setting. Although the impact of OIH on postoperative pain seems to be moderate, recent evidence suggests that increased hyperalgesia following opioid treatment correlates with the risk of developing persistent pain after surgery. In clinical practice, distinction among OIH, AOT and acute opioid withdrawal remains difficult, especially because a specific quantitative sensory test to diagnose OIH has not been validated yet. SUMMARY Since the immediate postoperative period is not ideal to initiate long-term treatment for OIH, the best strategy is to prevent its occurrence. A multimodal approach, including choice of opioid, dose limitations and addition of nonopioid analgesics, is recommended.
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Postoperative opioid prescribing: Getting it RIGHTT. Am J Surg 2018; 215:707-711. [DOI: 10.1016/j.amjsurg.2018.02.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 01/03/2018] [Accepted: 02/01/2018] [Indexed: 11/23/2022]
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Kumar K, Kirksey MA, Duong S, Wu CL. A Review of Opioid-Sparing Modalities in Perioperative Pain Management. Anesth Analg 2017; 125:1749-1760. [DOI: 10.1213/ane.0000000000002497] [Citation(s) in RCA: 176] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Preoperative pregabalin or gabapentin for acute and chronic postoperative pain among patients undergoing breast cancer surgery: A systematic review and meta-analysis of randomized controlled trials. J Plast Reconstr Aesthet Surg 2017; 70:1317-1328. [DOI: 10.1016/j.bjps.2017.05.054] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 05/19/2017] [Accepted: 05/28/2017] [Indexed: 01/28/2023]
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Scott MJ, McEvoy MD, Gordon DB, Grant SA, Thacker JKM, Wu CL, Gan TJ, Mythen MG, Shaw AD, Miller TE. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) Joint Consensus Statement on Optimal Analgesia within an Enhanced Recovery Pathway for Colorectal Surgery: Part 2-From PACU to the Transition Home. Perioper Med (Lond) 2017; 6:7. [PMID: 28413628 PMCID: PMC5390469 DOI: 10.1186/s13741-017-0063-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 03/14/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Within an enhanced recovery pathway (ERP), the approach to treating pain should be multifaceted and the goal should be to deliver "optimal analgesia", which we define in this paper as a technique that optimizes patient comfort and facilitates functional recovery with the fewest medication side effects. METHODS With input from a multidisciplinary, international group of experts and through a structured review of the literature and use of a modified Delphi method, we achieved consensus surrounding the topic of optimal analgesia in the perioperative period for colorectal surgery patients. DISCUSSION As a part of the first Perioperative Quality Improvement (POQI) workgroup meeting, we sought to develop a consensus document describing a comprehensive, yet rational and practical, approach for developing an evidence-based plan for achieving optimal analgesia, specifically for a colorectal surgery within an ERP. The goal was twofold: (a) that application of this process would lead to improved patient outcomes and (b) that investigation of the questions raised would identify knowledge gaps to aid the direction for research into analgesia within ERPs in the years to come. This document details the evidence for a wide range of analgesic components, with particular focus on care in the post-anesthesia care unit, general care ward, and transition to home after discharge. The preoperative and operative consensus statement for analgesia was covered in Part 1 of this paper. The overall conclusion is that the combination of analgesic techniques employed in the perioperative period is not important as long as it is effective in delivering the goal of "optimal analgesia" as set forth in this document.
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Affiliation(s)
- Michael J. Scott
- Department of Anesthesiology, Virginia Commonwealth University Health System, 1200 East Broad Street, P.O. Box 980695, Richmond, Virginia 23298-0695 USA
- University College London, London, UK
| | - Matthew D. McEvoy
- CIPHER (Center for Innovation in Perioperative Health, Education, and Research), Vanderbilt University Medical Center, TN, USA
- Department of Anesthesiology, Vanderbilt University School of Medicine, 2301VUH,, Nashville, TN 37232 USA
| | - Debra B. Gordon
- Department of Anesthesiology & Pain Medicine, Harborview Integrated Pain Care Program, University of Washington, Seattle, WA USA
| | - Stuart A. Grant
- Department of Anesthesiology, Medical Student Education, Division of Regional Division, Duke University Medical Center, Durham, UK
| | - Julie K. M. Thacker
- Department of Surgery, Division of Advanced Oncologic and GI Surgery, Duke University Medical Center, Durham, UK
| | - Christopher L. Wu
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Tong J. Gan
- Department of Anesthesiology, Stony Brook University School of Medicine, Stony Brook, USA
| | - Monty G. Mythen
- University College London Hospitals National Institute of Health Research Biomedical Research Centre, London, UK
| | - Andrew D. Shaw
- Department of Anesthesiology, Vanderbilt University, TN, USA
| | - Timothy E. Miller
- Division of General, Vascular and Transplant Anesthesia, Duke University Medical Center, Durham, UK
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