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King GA, Le A, Nickol M, Sarkis B, van der Merwe JM. Periarticular infiltration used in total joint replacements: an update and review article. J Orthop Surg Res 2023; 18:859. [PMID: 37957753 PMCID: PMC10641975 DOI: 10.1186/s13018-023-04333-z] [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] [Received: 09/27/2023] [Accepted: 10/31/2023] [Indexed: 11/15/2023] Open
Abstract
Periarticular infiltration following total knee and hip arthroplasty has been demonstrated to be equivalent to peripheral nerve blocks for postoperative pain management. The ideal cocktail has not been established yet. We have conducted a literature search on PubMed and Embase. Our search criteria included randomized controlled trials (RCTs) and systematic reviews (SRs). We tried to only include the most recent studies to keep the information current. The included research focused at Dexmedetomidine, Liposomal Bupivacaine, Ropivacaine, Epinephrine, Ketorolac, Morphine, Ketamine and Glucocorticosteroids. Each medication's mode of action, duration, ideal dosage, contraindications, side effects and effectiveness have been summarized in the review article. This article will help the clinician to make an informed evidence-based decision about which medications to include in their ideal cocktail.
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Affiliation(s)
- Gavin Anthony King
- College of Medicine - Department of Orthopaedic Surgery, University of Saskatchewan, Saskatoon, Canada
| | - Alexander Le
- College of Medicine - Department of Orthopaedic Surgery, University of Saskatchewan, Saskatoon, Canada
| | - Michaela Nickol
- College of Medicine - Department of Orthopaedic Surgery, University of Saskatchewan, Saskatoon, Canada
| | - Bianca Sarkis
- College of Medicine - Department of Orthopaedic Surgery, University of Saskatchewan, Saskatoon, Canada
- Faculty of Medicine - Division of Orthopaedic Surgery, University of Montreal, Montreal, Canada
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Thangaraju P, Varthya SB, Venkatesan S, Tamilselvan T, Singh S. Efficacy and safety of sufentanil sublingual tablet system in postoperative pain management: a systematic review and meta-analysis. BMJ Support Palliat Care 2023; 13:e20-e29. [PMID: 33653734 DOI: 10.1136/bmjspcare-2020-002693] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 01/16/2021] [Accepted: 02/03/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Sufentanil sublingual tablet system (SSTS) is a recently approved formulation for postoperative pain management that has become popular due to its pharmacokinetic properties such as good bioavailability, rapid attainment of equilibrium and elimination without any metabolites, along with its pharmacodynamic properties such as rapid onset and effective pain reduction. It is also relatively well tolerated by patients. OBJECTIVE This is a quantitative analysis of the efficacy and safety of SSTS in patients with moderate to severe postoperative pain. DESIGN This is a systematic review and meta-analysis. Databases such as Cochrane Library, MEDLINE and EMBASE were searched for eligible articles. SETTINGS Randomised controlled trials published after 2000 in English language and which assessed at least one of the outcome measures of interest with pain intensity difference between 12 hours and a maximum of 96 hours. PARTICIPANTS Adults with moderate to severe postoperative pain and taking SSTS for pain management. METHODS Data were analysed using Review Manager (RevMan) V.5.3. Risk of bias (RoB) assessment was done using RoB-2 scale, and overall grading of evidence of each outcome was done using GRADEpro Guideline Development Tool. RESULTS Analysis of SSTS versus control indicates a statistically significant reduction in summed pain intensity difference at 12 hours (mean difference (MD)=-12.33 (95% CI -15.5 to -9.17), p<0.00001), summed pain intensity difference at 48 hours (MD=-43.57 (95% CI -58.65 to -28.48), p<0.00001), time-weighted total pain relief over 12 hours (MD=-4.77 (95% CI -6.28 to -3.27), p<0.00001) and pain intensity difference (MD=-0.73 (95% CI -1.00 to -0.46), p<0.00001) with SSTS, alongside high quality of evidence. Success of treatment as assessed by Patient Global Assessment (OR=4.01 (95% CI 2.74 to 5.89), p<0.00001) and Healthcare Professional Global Assessment (OR=4.46 (95% CI 3.03 to 6.56), p<0.00001) scoring at 72 hours was observed in a significantly high number of individuals using SSTS, with high quality of evidence. There was no difference in adverse events except for dizziness (RR=1.90, 95% CI 1.02 to 3.52). There was a significantly higher number of total adverse events in orthopaedic surgery in the SSTS group than in the comparator. CONCLUSION SSTS is effective in postoperative pain management in patients with moderate to severe pain. It also has good tolerability and high patient satisfaction. PROSPERO REGISTRATION NUMBER CRD42018115458.
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Hussain N, Brull R, Vannabouathong C, Robinson C, Zhou S, D'Souza RS, Sawyer T, Terkawi AS, Abdallah FW. Analgesic Effectiveness of Motor-sparing Nerve Blocks for Total Knee Arthroplasty: A Network Meta-analysis. Anesthesiology 2023; 139:444-461. [PMID: 37364292 DOI: 10.1097/aln.0000000000004667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
BACKGROUND The analgesic effectiveness of contemporary motor-sparing nerve blocks used in combination for analgesia in total knee arthroplasty is unclear. This network meta-analysis was conducted to evaluate the analgesic effectiveness of adding single-injection or continuous adductor canal block (ACB) with or without infiltration of the interspace between the popliteal artery and the capsule of the posterior knee (iPACK) to intraoperative local infiltration analgesia (LIA), compared to LIA alone, after total knee arthroplasty. METHODS Randomized trials examining the addition of single-injection or continuous ACB with or without single-injection block at the iPACK to LIA for total knee arthroplasty were considered. The two primary outcomes were area-under-the-curve pain scores over 24 to 48 h and postoperative function at greater than 24 h. Secondary outcomes included rest pain scores at 0, 6, 12, and 24 h; opioid consumption (from 0 to 24 h and from 25 to 48 h); and incidence of nausea/vomiting. Network meta-analysis was conducted using a frequentist approach. RESULTS A total of 27 studies (2,317 patients) investigating the addition of (1) single-injection ACB, (2) continuous ACB, (3) single-injection ACB and single-injection block at the iPACK, and (4) continuous ACB and single-injection block at the iPACK to LIA, as compared to LIA alone, were included. For area-under-the-curve 24- to 48-h pain, the addition of continuous ACB with single-injection block at the iPACK displayed the highest P-score probability (89%) of being most effective for pain control. The addition of continuous ACB without single-injection block at the iPACK displayed the highest P-score probability (87%) of being most effective for postoperative function. CONCLUSIONS The results suggest that continuous ACB, but not single-injection ACB and/or single-injection block at the iPACK, provides statistically superior analgesia when added to LIA for total knee arthroplasty compared to LIA alone. However, the magnitude of these additional analgesic benefits is clinically questionable. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Nasir Hussain
- Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Richard Brull
- Department of Anesthesiology and Pain Management, Women's College Hospital and Toronto Western Hospital, Toronto, Ontario, Canada
| | - Chris Vannabouathong
- Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Christopher Robinson
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Harvard, Boston, Massachusetts
| | - Steven Zhou
- Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Tamara Sawyer
- College of Medicine, Central Michigan University, Saginaw, Michigan
| | - Abdullah Sulieman Terkawi
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California
| | - Faraj W Abdallah
- Department of Anesthesiology and Pain Medicine, and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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Padgett AM, Kapoor S, Rhodes LN, Keen K, Cao X, Locke LL, Warner WC, Sawyer JR, Sheffer BW, Spence DD, Kelly DM. Perioperative multimodal analgesic injection for patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion surgery. Spine Deform 2023; 11:977-984. [PMID: 37022606 DOI: 10.1007/s43390-023-00670-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 02/18/2023] [Indexed: 04/07/2023]
Abstract
PURPOSE This retrospective cohort study compared postoperative as-needed (PRN) opioid consumption pre and postimplementation of a perioperative multimodal analgesic injection composed of ropivacaine, epinephrine, ketorolac, and morphine in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Secondary outcomes include pain score measurements, time to ambulation, length of stay, blood loss, 90-day complication rate, operating room time, nonopioid medication usage, and total inpatient medication cost before and after the initiation of this practice. METHODS Consecutive patients weighing ≥ 20 kg who underwent PSF for a primary diagnosis of AIS between January 2017 and December 2020 were included. Data from 2018 were excluded to account for standardization of the practice. Patients treated in 2017 only received PCA. Patients treated in 2019 and 2020 only received the injection. Excluded were patients who had any diagnoses other than AIS, allergies to any of the experimental medications, or who were nonambulatory. Data were analyzed utilizing the two-sample t-test or Chi-squared test as appropriate. RESULTS Results of this study show that compared with 47 patients treated postoperatively with patient-controlled analgesia (PCA), 55 patients treated with a multimodal perioperative injection have significantly less consumption of PRN morphine equivalents (0.3 mEq/kg vs. 0.5 mEq/kg; p = 0.02). Furthermore, patients treated with a perioperative injection have significantly higher rates of ambulation on postoperative day 1 compared with those treated with PCA (70.9 vs. 40.4%; p = 0.0023). CONCLUSION Administration of a perioperative injection is effective and should be considered in the perioperative protocol in patients undergoing PSF for AIS. LEVEL OF EVIDENCE Therapeutic Level III.
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Affiliation(s)
- Anthony M Padgett
- University of Tennessee Health Science Center, College of Medicine, Memphis, TN, USA
| | - Seerat Kapoor
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, TN, USA
- Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Leslie N Rhodes
- Le Bonheur Children's Hospital, Memphis, TN, USA
- University of Tennessee Health Science Center, College of Nursing, Memphis, TN, USA
| | - Katie Keen
- Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Xueyuan Cao
- University of Tennessee Health Science Center, College of Nursing, Memphis, TN, USA
| | | | - William C Warner
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Jeffrey R Sawyer
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Benjamin W Sheffer
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - David D Spence
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Derek M Kelly
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA.
- Department of Biomedical Engineering and Orthopaedic Surgery, University of Tennessee Health Science Center-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN, 38104, USA.
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Kumar M, Bhushan B, Vaishy A, Kishan R, Fageria RS, Repaswal A. Multimodal cocktail analgesic injection in PIVD with lower limb radiculopathy - A mixed design cohart study. J Clin Orthop Trauma 2022; 35:102049. [PMID: 36387936 PMCID: PMC9663881 DOI: 10.1016/j.jcot.2022.102049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 08/10/2022] [Accepted: 10/18/2022] [Indexed: 11/13/2022] Open
Abstract
Background The role of Sodium Channel Blocker and steroid is well established for pain relief in neuropathic pain by reducing inflamation and desensitization of nerve roots. Our study aims at analyzing the effectiveness of multimodal cocktail injections for redicular pain relief & functional outcome in patients with intervertebral disc herniation. Material and method This was a Mixed design (prospective & retrospective) cohort study; we included 113 patients between the age group of 18-70 years, diagnosed with Prolapse of intervertebral disc (PIVD) with lower limb radiculopathy with MRI finding L4-L5/L5-S1 vertebral disc involvement. Patients were injected with total 15 ml of cocktail injection in 3 divided doses at 3 identified sites in affected lower limb. . Patient was examined & evaluated clinically for VAS pain score, SLRT, Sensory, Motor Examination on day 2, day 7, day 15 & after 1 month. Result We found that the mean pre-VAS score was 7.83 followed by the mean VAS score on post 2 days was 1.05, post 7 days was 3.47, post 15 days was 3.9 and post 30 days was 3.81. There was a statistically significant difference in the mean VAS score (p-value<0.0001). After one month majority of patients (54.62%) had comfortable painless walk and comfortable walking distance increased up to 1 km in 45.37% of them. Conclusion Use of cocktail multimodal injections for radiculopathy pain suggests that this non-operative,OPD based technique could be reasonable, efficient, and safe.
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Affiliation(s)
- Manoj Kumar
- Department of Orthopaedics,Dr.S.N Medical College, Jodhpur, India
| | | | - Arun Vaishy
- Department of Orthopaedics,Dr.S.N Medical College, Jodhpur, India
| | - Rama Kishan
- Department of Orthopaedics,Dr.S.N Medical College, Jodhpur, India
| | | | - Anju Repaswal
- Department of Pathology, Sardar Patel Medical College, Bikaner, India
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Salwan A, Pisulkar GL, Taywade S, Awasthi AA, Saoji A, Jadawala VH, Shah P, Deshpande SV. A Review on the Efficacy of Extraosseous Local Infiltration of Multimodal Drug Cocktail for Pain Management After Total Knee or Hip Arthroplasty. Cureus 2022; 14:e30451. [DOI: 10.7759/cureus.30451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/18/2022] [Indexed: 11/07/2022] Open
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Lee GC, Berkowitz R, Hacker S, Hu J, Rechter A. HTX-011 in Combination with Multimodal Analgesic Regimen Minimized Severe Pain and Opioid Use after Total Knee Arthroplasty in an Open-Label Study. J Knee Surg 2022. [PMID: 35688442 DOI: 10.1055/s-0042-1747945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Total knee arthroplasty (TKA) can be associated with significant postoperative pain despite multimodal analgesic (MMA) protocols, and most patients require the use of opioids postoperatively. HTX-011 is a dual-acting local anesthetic containing bupivacaine and low-dose meloxicam in an extended-release polymer. In a prior randomized controlled trial (RCT), HTX-011 reduced pain and opioid use through 72 hours after TKA compared with bupivacaine hydrochloride. This open-label study (NCT03974932) evaluated the efficacy and safety of HTX-011 combined with an MMA regimen in patients undergoing TKA under spinal anesthesia. All patients received intraoperative HTX-011 (400 mg bupivacaine/12 mg meloxicam) in combination with an MMA regimen consisting of preoperative acetaminophen, celecoxib, and pregabalin and postoperative acetaminophen and celecoxib until discharge. Opioid rescue was allowed upon patient request for additional pain control. Pain scores, opioid consumption, discharge readiness, and adverse events were recorded. Fifty-one patients were treated. Compared with the prior RCT, HTX-011 with this MMA regimen further lowered pain scores and reduced opioid use. Mean patient-reported pain scores remained in the mild range, and 82% of patients or more did not experience severe pain at any individual time point through 72 hours after surgery. Mean total opioid consumption was low over 72 hours: 24.8 morphine milligram equivalents (1-2 tablets of oxycodone 10 mg/day). Approximately 60% of patients were ready for discharge by 12 hours, and 39% were discharged without an opioid prescription and did not call back for pain management. The treatment regimen was well tolerated, and no added risk was observed with the addition of MMA. HTX-011 with an MMA regimen reduced postoperative pain and opioid use following TKA.
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Affiliation(s)
- Gwo-Chin Lee
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Richard Berkowitz
- University Orthopedic and Joint Replacement Center, Tamarac, Florida
| | - Scott Hacker
- Grossmont Orthopedic Medical Group, La Mesa, California
| | - Jia Hu
- Heron Therapeutics, Inc., San Diego, California
| | - Alan Rechter
- Department of Orthopaedic Surgery, Orthopaedic Associates, LLP, Houston, Texas
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Et T, Korkusuz M, Basaran B, Yarımoğlu R, Toprak H, Bilge A, Kumru N, Dedeli İ. Comparison of iPACK and periarticular block with adductor block alone after total knee arthroplasty: a randomized clinical trial. J Anesth 2022; 36:276-286. [PMID: 35157136 PMCID: PMC8853355 DOI: 10.1007/s00540-022-03047-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/01/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE The infiltration between the popliteal artery and the capsule of the posterior knee (iPACK) has been described to provide analgesia without loss of muscle strength and is effective in functional recovery. This study compared iPACK + ACB (adductor canal block) with PAI (periarticular infiltration) + ACB and ACB alone in terms of postoperative analgesia and functional improvement. METHODS This double-blinded randomized controlled trial included 105 patients undergoing unilateral total knee arthroplasty. Patients received ACB, iPACK + ACB, and PAI + ACB along with spinal anesthesia. The primary outcome was the area under the curve (AUC) numeric rating scale (NRS) at 48 h. Secondary outcomes were cumulative postoperative analgesic consumption within 48 h, timed up-and-go test, range of motion, length of hospital stay, patient satisfaction, and adverse events. RESULTS The 48-h AUC movement NRS score in the iPACK + ACB group was significantly lower than in the PAI + ACB and ACB groups (p < 0.05). At the postoperative 48th h, the opioid consumption of the iPACK + ACB group was lower than those of the ACB and PAI + ACB groups (p < 0.001). The patients in the iPACK + ACB group had significantly shorter discharge and mobilization days than the ACB and PAI + ACB groups (p < 0.001). CONCLUSIONS The adding of an iPACK block to the ACB improves postoperative analgesia and reduces opioid consumption. In addition, this approach improves functional performance and reduces hospital stay.
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Affiliation(s)
- Tayfun Et
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Karamanoglu Mehmetbey University, Karaman, Turkey.
- Department of Anesthesiology and Intensive Care Medicine, Karaman Training and Research Hospital, Karaman, Turkey.
| | - Muhammet Korkusuz
- Department of Anesthesiology and Intensive Care Medicine, Karaman Training and Research Hospital, Karaman, Turkey
| | - Betül Basaran
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Karamanoglu Mehmetbey University, Karaman, Turkey
| | - Rafet Yarımoğlu
- Department of Anesthesiology and Intensive Care Medicine, Karaman Training and Research Hospital, Karaman, Turkey
| | - Hatice Toprak
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Karamanoglu Mehmetbey University, Karaman, Turkey
| | - Ayşegül Bilge
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Karamanoglu Mehmetbey University, Karaman, Turkey
| | - Nuh Kumru
- Department of Anesthesiology and Intensive Care Medicine, Karaman Training and Research Hospital, Karaman, Turkey
| | - İlker Dedeli
- Department of Orthopedics and Traumatology, Karaman Training and Research Hospital, Karaman, Turkey
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Does Surgical-site Multimodal Drug Injection After Palmar Plating of Distal Radius Fractures Improve Pain Scores? Clin Orthop Relat Res 2020; 478:2663-2669. [PMID: 32187097 PMCID: PMC7572034 DOI: 10.1097/corr.0000000000001212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although palmar locked plating is a stable fixation method frequently used to treat unstable distal radius fractures (DRFs), surgical treatment may be painful, and so interventions to decrease that pain might improve our patients' experiences with surgery. Some surgeons use local multimodal drug injections to decrease postoperative pain after lower-extremity arthroplasty, but little is known about the effectiveness of a local multimodal drug injection in patients who undergo palmar plating for DRFs. QUESTIONS/PURPOSES (1) Do patients who receive a local multimodal drug injection after palmar plating for unstable DRFs have better pain scores at 4, 8, 24, and 48 hours after surgery than patients who have not received such an injection? (2) Do patients who receive a local multimodal drug injection have lower fentanyl consumption and administration of anti-emetic drugs within the first 48 hours after surgery than patients who have not received such an injection? METHODS A randomized controlled study was performed between August 2018 and August 2019 at a single tertiary care referral center. Patients who underwent palmar plating for DRFs under general anesthesia were eligible for inclusion. Patients were allocated into two groups: Those who received a local multimodal drug injection, and those who did not receive an injection. During the study period, 101 patients treated with palmar plating for DRFs met the inclusion criteria and were enrolled and randomized. Fifty-two patients were allocated to the multimodal injection group and 49 were allocated to the control group. Three patients (two in the multimodal injection group and one in the control group) were excluded after randomization because their pain level was not registered at any timepoint and so they could not be analyzed; our analysis was by intention to treat, and there was no crossover. After palmar plating, patients in the multimodal injection group received an injection of ropivacaine (10 mL), morphine (5 mL), ceftezole (5 mL) as well as normal saline (5 mL) to the periosteal area, pronator quadratus muscle, subcutaneous area, and skin. There were no differences between the groups in terms of age (62 years ± 13 years in the multimodal injection group versus 62 years ± 11 years in the control group; p = 0.93), gender (84% [42 of 50] women in the multimodal injection group versus 77% [37 of 48] women in the control group; p = 0.39), hand dominance (70% [35 of 50] dominant wrist in the multimodal injection group versus 60% [29 of 48] dominant wrist in the control group; p = 0.32) and AO/Orthopaedic Trauma Association (AO/OTA) classification (p = 0.57). All patients underwent treatment with the same perioperative protocol, and 25 μg of fentanyl was injected intravenously when a patient complained of pain and asked for additional pain control after surgery. In addition, when a patient complained of nausea or vomiting associated with fentanyl use, an anti-emetic drug was also injected. All nursing staff who administered the analgesics and anti-emetic drugs were blinded to treatment allocation. These two groups were compared regarding their pain level using a 100-mm VAS at 4, 8, 24, and 48 hours postoperatively. The minimum clinically important difference (MCID) for the VAS score was set to 20 mm. VAS scores were also collected by nursing staff who remained blinded to the treatment allocation. The total amount of fentanyl use and the number of patients who received anti-emetic drugs associated with administration of fentanyl within the first 48 hours were also recorded. RESULTS With an MCID of 20 points, we found no clinically important reduction in VAS scores among patients who received a local multimodal injection compared with those who did not receive an injection at 4 hours (34 ± 15 versus 41 ± 20, mean difference -7.079 [95% CI -13.986 to -0.173]; p = 0.045), 8 hours (27 ± 16 versus 40 ± 19, mean difference -12.263 [95% CI -19.174 to -5.353]; p = 0.001), 24 hours (18 ± 12 versus 29 ± 20, mean difference -11.042 [95% CI -17.664 to -4.419]; p = 0.001), and 48 hours (9 ± 8 versus 10 ± 6, mean difference -1.318 [95% CI -4.000 to 1.365]; p = 0.33). Within the first 48 hours after surgery, fentanyl consumption was lower in patients receiving a local multimodal injection than in control patients (25 μg [range 0-100 μg] versus 37.5 μg [range 0-125 μg], difference of medians -12.5; p = 0.01). There was also a difference between the study groups in terms of the proportion of patients who received anti-emetic medications (16% [8 of 50] in the multimodal injection group versus 35% [17 of 48] in the control group, odds ratio = 2.879 [95% CI 1.102 to 7.519]; p = 0.03). CONCLUSIONS Our data suggest that patients who received a surgical-site multimodal analgesic injection after palmar plating for a distal radius fracture had no clinically important reduction in pain scores, but they did consume lower doses of opioid analgesics and fewer of these patients received anti-emetic drugs within 2 days of surgery. The high-potency opioids or other analgesia usually used for postoperative pain management have many side effects. Thus, reducing additional analgesia is as important as postoperative pain management and a surgical-site multimodal analgesic injection is one of the methods to achieve this a goal. LEVEL OF EVIDENCE Level I, therapeutic study.
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Chen J, Hu W, Li SM, Li XL, Yang ZM. The efficacy of ketamine in total knee arthroplasty: a randomized controlled trial protocol. Medicine (Baltimore) 2020; 99:e20645. [PMID: 32541504 PMCID: PMC7302669 DOI: 10.1097/md.0000000000020645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/11/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Appropriate pain management is essential to improve the postoperative recovery after total knee arthroplasty (TKA). There is a paucity of literature on ketamine for TKA procedures. The aim of this study was to evaluate the analgesic efficacy of ketamine in patients undergoing primary TKA. METHODS This study was designed as a prospective, double blind, single center, randomized controlled trial. The participants were randomly assigned to either the ketamine or placebo groups, using a set of random numbers for the allocation sequence. All patients underwent TKA without patella resurfacing under spinal anesthesia. Preoperative workup, surgical technique, and postoperative management were standardized for all the patients. The primary outcome of this noninferiority study is opioid consumption within the first 24 hours following surgery, pain scores, distance ambulated, patient satisfaction, length of hospital stay, and complications. RESULTS The results of this study were expected to provide useful information on the effectiveness and safety of ketamine for immediate postoperative analgesia after TKA surgery. TRIAL REGISTRATION This study protocol was registered in Research Registry (researchregistry5575).
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Affiliation(s)
- Jing Chen
- Department of Orthopedics, Aerospace Center Hospital, Beijing
| | - Wei Hu
- Department of Orthopedics, Ningxia Armed Police Corps Hospital, Ningxia Hui Autonomous Region
| | - Shu-Ming Li
- Department of Orthopedics, Aerospace Center Hospital, Beijing
| | - Xiao-Lin Li
- Department of Orthopedics, Ningxia Armed Police Corps Hospital, Ningxia Hui Autonomous Region
| | - Zhan-Min Yang
- Department of Anesthesiology, Aerospace Center Hospital, Beijing, China
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Zhao Y, Zhang L, Wang Y, Liao C, Chen Y, Zhen Q, Li Y. Acupuncture therapy for postoperative pain of anorectal diseases: A systematic review protocol. Medicine (Baltimore) 2020; 99:e19112. [PMID: 32049824 PMCID: PMC7035068 DOI: 10.1097/md.0000000000019112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The incidence of anorectal diseases has been increasing year by year, and the acupuncture treatment for postoperative pain of anorectal diseases has the excellent therapeutic effect. Currently, there are no relevant articles for systematic review. METHODS We will search the randomized controlled trials related to acupuncture therapy and postoperative anorectal diseases from inception to January 2020. The following database is our focus area: PubMed, EMBASE, Springer, EBSCO, Web of Science, Cochrane, Controlled Trials Register (CENTRAL), the Cochrane Central Register of Controlled Trials (CENTRAL), China National Knowledge Infrastructure (CNKI), Wan-Fang Database and Chinese Scientific Journal Database (VIP database). The primary outcome is the pain of visual analogue scale (VAS). The secondary outcomes are the Symptom Checklist, Wong-Baker Faces Pain Rating (WB) Scale, verbalrating scale (VRS), and 36-Item Short Form Health Survey (SF-36) scale. We will use Review Manager Software (RevMan) V.5.2 for data analysis and quantitative data synthesis. The Cochrane collaborative tool will be used to assess the risk of bias in the included studies. RESULTS Given the available evidence, this study will provide high level results for acupuncture therapy in treating postoperative pain of anorectal diseases. CONCLUSION The conclusions of this study will provide evidence for whether acupuncture is effective in treating postoperative pain of anorectal diseases. PROSPERO REGISTRATION NUMBER CRD42020150015.
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