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Trauzeddel RF, Rothe LM, Nordine M, Dehé L, Scholtz K, Spies C, Hadzidiakos D, Winterer G, Borchers F, Kruppa J, Treskatsch S. Influence of a chronic beta-blocker therapy on perioperative opioid consumption - a post hoc secondary analysis. BMC Anesthesiol 2024; 24:80. [PMID: 38413849 PMCID: PMC10898005 DOI: 10.1186/s12871-024-02456-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 02/12/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Beta-blocker (BB) therapy plays a central role in the treatment of cardiovascular diseases. An increasing number of patients with cardiovascular diseases undergoe noncardiac surgery, where opioids are an integral part of the anesthesiological management. There is evidence to suggest that short-term intravenous BB therapy may influence perioperative opioid requirements due to an assumed cross-talk between G-protein coupled beta-adrenergic and opioid receptors. Whether chronic BB therapy could also have an influence on perioperative opioid requirements is unclear. METHODS A post hoc analysis of prospectively collected data from a multicenter observational (BioCog) study was performed. Inclusion criteria consisted of elderly patients (≥ 65 years) undergoing elective noncardiac surgery as well as total intravenous general anesthesia without the use of regional anesthesia and duration of anesthesia ≥ 60 min. Two groups were defined: patients with and without BB in their regular preopreative medication. The administered opioids were converted to their respective morphine equivalent doses. Multiple regression analysis was performed using the morphine-index to identify independent predictors. RESULTS A total of 747 patients were included in the BioCog study in the study center Berlin. 106 patients fulfilled the inclusion criteria. Of these, 37 were on chronic BB. The latter were preoperatively significantly more likely to have arterial hypertension (94.6%), chronic renal failure (27%) and hyperlipoproteinemia (51.4%) compared to patients without BB. Both groups did not differ in terms of cumulative perioperative morphine equivalent dose (230.9 (BB group) vs. 214.8 mg (Non-BB group)). Predictive factors for increased morphine-index were older age, male sex, longer duration of anesthesia and surgery of the trunk. In a model with logarithmised morphine index, only gender (female) and duration of anesthesia remained predictive factors. CONCLUSIONS Chronic BB therapy was not associated with a reduced perioperative opioid consumption. TRIAL REGISTRATION This study was registered at ClinicalTrials.gov ( NCT02265263 ) on the 15.10.2014 with the principal investigator being Univ.-Prof. Dr. med. Claudia Spies.
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Affiliation(s)
- Ralf F Trauzeddel
- Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Hindenburgdamm 30, Berlin, 12203, Germany
| | - Luisa M Rothe
- IS Global Campus Cliníc Rosselló, Barcelona Institute for Global Health, 132, 7è, Barcelona, 08036, Spain
| | - Michael Nordine
- Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | - Lukas Dehé
- Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Hindenburgdamm 30, Berlin, 12203, Germany
| | - Kathrin Scholtz
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Claudia Spies
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Daniel Hadzidiakos
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Georg Winterer
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Friedrich Borchers
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Jochen Kruppa
- Hochschule Osnabrück, University of Applied Sciences, Osnabrück, Germany
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Hindenburgdamm 30, Berlin, 12203, Germany.
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Wan FT, Chin SE, Gwee R, Chong Y, Au-Yong A, Matthews A, Zaw MWW, Lie SA, Loh L, Koh D, Ladlad J, Khoo N, Aw D, Chong CXZ, Ho LML, Ng JL, Sivarajah SS, Tan WJ, Foo FJ, Koh FH. Pre-operative erector spinae plane block should be considered a viable option for laparoscopic colectomies. Surg Endosc 2023; 37:7128-7135. [PMID: 37322360 DOI: 10.1007/s00464-023-10171-1] [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: 01/18/2023] [Accepted: 05/08/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND The Erector Spinae Plane (ESP) block is a recent development in the field of regional anaesthesia and has been increasingly explored for abdominal surgeries to reduce opioid use and improve pain control. Colorectal cancer is the commonest cancer in multi-ethnic Singapore and requires surgery for curative treatment. ESP is a promising alternative in colorectal surgeries, but few studies have evaluated its efficacy in such surgeries. Therefore, this study aims to evaluate the use of ESP blocks in laparoscopic colorectal surgeries to establish its safety and efficacy in this field. METHODS A prospective two-armed interventional cohort study comparing T8-T10 ESP blocks with conventional multimodal intravenous analgesia for laparoscopic colectomies was conducted in a single institution in Singapore. The decision for doing an ESP block versus conventional multimodal intravenous analgesia was made by a consensus between the attending surgeon and anesthesiologist. Outcomes measured were total intra-operative opioid consumption, post-operative pain control and patient outcome. Post-operative pain control was measured by pain score, analgesia use, and amount of opioids consumed. Patient outcome was determined by presence of ileus. RESULTS A total of 146 patients were included, of which 30 patients received an ESP block. Overall, the ESP group had a significantly lower median opioid usage both intra-operatively and post-operatively (p = 0.031). Fewer patients required patient-controlled analgesia and rescue analgesia post-operatively for pain control (p < 0.001) amongst the ESP group. Pain scores were similar and post-operative ileus was absent in both groups. Multivariate analysis found that the ESP block had an independent effect on reducing intra-opioid consumption (p = 0.014). Multivariate analysis of post-operative opioid use and pain scores did not yield statistically significant results. CONCLUSIONS The ESP block was an effective alternative regional anaesthesia for colorectal surgery that reduced intra-operative and post-operative opioid use while attaining satisfactory pain control.
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Affiliation(s)
- Fang-Ting Wan
- Lee Kong Chian School of Medicine, 11 Mandalay Road, Singapore, 308232, Singapore
| | - Shuen-Ern Chin
- Lee Kong Chian School of Medicine, 11 Mandalay Road, Singapore, 308232, Singapore
| | - Ryan Gwee
- Lee Kong Chian School of Medicine, 11 Mandalay Road, Singapore, 308232, Singapore
| | - Yvette Chong
- Colorectal Service, Department of General Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Angie Au-Yong
- Department of Anaesthesiology, SingHealth, Singapore, Singapore
| | - Abey Matthews
- Department of Anaesthesiology, SingHealth, Singapore, Singapore
| | - Ma-Wai-Wai Zaw
- Department of Anaesthesiology, SingHealth, Singapore, Singapore
| | - Sui-An Lie
- Department of Anaesthesiology, SingHealth, Singapore, Singapore
| | - Leonard Loh
- Department of Anaesthesiology, SingHealth, Singapore, Singapore
| | - Daphne Koh
- Department of Anaesthesiology, SingHealth, Singapore, Singapore
| | - Jasmine Ladlad
- Colorectal Service, Department of General Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Nathanelle Khoo
- Colorectal Service, Department of General Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Darius Aw
- Colorectal Service, Department of General Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Cheryl X Z Chong
- Colorectal Service, Department of General Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Leonard M L Ho
- Colorectal Service, Department of General Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Jia-Lin Ng
- Colorectal Service, Department of General Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Sharmini S Sivarajah
- Colorectal Service, Department of General Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Winson J Tan
- Colorectal Service, Department of General Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Fung-Joon Foo
- Colorectal Service, Department of General Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Frederick H Koh
- Colorectal Service, Department of General Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore.
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Multimodal Analgesia in the Aesthetic Plastic Surgery: Concepts and Strategies. Plast Reconstr Surg Glob Open 2022; 10:e4310. [PMID: 35572190 PMCID: PMC9094416 DOI: 10.1097/gox.0000000000004310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 03/17/2022] [Indexed: 12/13/2022]
Abstract
Postoperative pain management is crucial for aesthetic plastic surgery procedures. Poorly controlled postoperative pain results in negative physiologic effects and can affect length of stay and patient satisfaction. In light of the growing opioid epidemic, plastic surgeons must be keenly familiar with opioid-sparing multimodal analgesia regimens to optimize postoperative pain control. Methods A review study based on multimodal analgesia was conducted. Results We present an overview of pain management strategies pertaining to aesthetic plastic surgery and offer a multimodal analgesia model for outpatient aesthetic surgery practices. Conclusion This review article presents an evidence-based approach to multimodal pain management for aesthetic plastic surgery.
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Vazquez PM, Jensen EW. Different perspectives for monitoring nociception during general anesthesia. Korean J Anesthesiol 2022; 75:112-123. [PMID: 35172074 PMCID: PMC8980281 DOI: 10.4097/kja.22002] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 02/15/2022] [Indexed: 11/30/2022] Open
Abstract
Safe anesthesia is achieved using objective methods that estimate the patient’s state during different phases of surgery. A patient’s state under anesthesia is characterized by three major aspects, which are linked to the main effects produced by each of the families of anesthetic agents administered: hypnosis, analgesia, and muscular relaxation. While quantification techniques designed to assess muscular relaxation under neuromuscular blocking agents have a relatively long history with a high degree of standardization and understanding (e.g., the train-of-four), the knowledge and techniques used to the depth of hypnosis assessment suffer from a lesser degree in both standardization and interpretation due to brain complexity. The problem of standardization and interpretation in the analgesia and nociception assessment increases since it involves more systems, the central nervous system, and the autonomic nervous system. This helps to explain why there are multiple a priori valid approaches to develop nociception monitoring from different interpretations and physiological bases of noxious stimuli processing. Thus, in this review, the current monitoring technologies clinically available for estimating a patient’s nociception under general anesthesia are described.
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Affiliation(s)
- Pablo Martinez Vazquez
- Deutsches Primaten Zentrum (DPZ), 37077 Goettingen, Germany.,R&D of Quantium Medical/Fresenius Kabi. Barcelona, Spain
| | - Erik Weber Jensen
- R&D of Quantium Medical/Fresenius Kabi. Barcelona, Spain.,Automatic Control and Information (ESAII) Department, CREB. UPC-Barcelonatech, Barcelona, Spain
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Aguilar‐Catalan A, Fresno Bermejo L, Murison PJ. Continuous mandibular nerve block as sole analgesia for postoperative pain management after a hemi‐mandibulectomy in a French bulldog. VETERINARY RECORD CASE REPORTS 2022. [DOI: 10.1002/vrc2.308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Adrià Aguilar‐Catalan
- Hospital Clínic Veterinari, Universitat Autònoma de Barcelona Bellaterra Barcelona Spain
| | - Laura Fresno Bermejo
- Hospital Clínic Veterinari, Universitat Autònoma de Barcelona Bellaterra Barcelona Spain
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The use of multimodal low-opioid anesthesia for coronary artery bypass grafting surgery in conditions of artificial blood circulation. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 17:111-116. [PMID: 33014084 PMCID: PMC7526485 DOI: 10.5114/kitp.2020.99072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/01/2020] [Indexed: 11/17/2022]
Abstract
Introduction Cardiovascular diseases (CVD) are the main cause of death worldwide, and according to experts, they will continue to dominate the structure of global mortality. Aim The effectiveness of the multimodal low-opioid anesthesia technique in performing coronary artery bypass graft operations with artificial blood circulation. Material and methods Ninety-six patients aged 61.8 ±10.4 years underwent coronary artery bypass grafting under artificial blood circulation. Group I: propofol, sevoflurane, fentanyl, pipecuronium bromide (standard doses). Group II: dexketoprofen trometamol (50 mg), intravenous lidocaine (1% – 1 mg/kg bolus) and continuous lidocaine infusion (1.5–2 mg/kg/h), propofol, ketamine (0.5 mg/kg), magnesia sulfate, minimal doses of fentanyl. Results Average duration of anesthesia – 257.4 ±19.1 min; assisted blood circulation – 55 ±10 min. Mean dose of fentanyl in group I – 4.66 ±1.58 µg/kg/h, in group II – 1.29 ±0.32 µg/kg/h.Standard lab values and stress hormonal changes were within the normal range (mean cortisol: 479.3 ±26.4 nmol/l, lactate 1.61 ±0.2 mmol/l, glucose 6.42 ±0.9 mmol/l). Changes in heart rate within group I had a significant amplitude of dynamics, while in group II, these values were relatively at the same level throughout the entire anesthetic provision. Mean arterial pressure changes in group I were characterized by a significant reduction at the stage of induction, support and sternum reduction, whereas in group II it was relatively at the same level during the entire anesthetic management and significantly differed from baseline only at the stage of induction. Conclusions Multimodal low-opioid anesthesia during coronary artery bypass surgery with artificial blood circulation allows one to ensure adequate analgesia and avoid the intraoperative usage of routine doses of fentanyl, as indicated by the absence of hemodynamic and endocrine-metabolic changes.
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8
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The 4 Principles of Complex Abdominal Wall Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2549. [PMID: 32042542 PMCID: PMC6964925 DOI: 10.1097/gox.0000000000002549] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/04/2019] [Indexed: 12/20/2022]
Abstract
Abdominal wall defects are some of the most common and challenging problems encountered by plastic surgeons. A high proportion of patients with abdominal wall defects have significant comorbidities and/or contamination, putting them at high risk for complications. In addition to advanced surgical skills and precise anatomical knowledge, the plastic surgeon needs strict discipline and medical acumen, to optimize patients before and after surgery. In this paper, we discuss the goals of abdominal wall reconstruction, and the 4 steps to successful surgery: preoperative patient selection/optimization, durable and dynamic reconstruction of the musculofascial layer, careful attention to the skin and subcutaneous tissue, and meticulous postoperative management.
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Abstract
Lack of physician familiarity with alternative pain control strategies is a major reason why opioids remain the most commonly used first-line treatment for pain after surgery. This is perhaps most problematic in abdominal wall reconstruction, where opioids may delay ambulation and return of bowel function, while negatively affecting mental status. In this article, we discuss multimodal strategies for optimal pain control in abdominal wall reconstruction. These strategies are straightforward and are proven to improve pain control while minimizing opioid-associated side effects.
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Geddes AT, Stathopoulou T, Viscasillas J, Lafuente P. Opioid‐free anaesthesia (OFA) in a springer spaniel sustaining a lateral humeral condylar fracture undergoing surgical repair. VETERINARY RECORD CASE REPORTS 2019. [DOI: 10.1136/vetreccr-2018-000681] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Alexander Thomas Geddes
- Department of Surgical SciencesUniversity of Wisconsin Madison School of Veterinary MedicineMadisonWisconsinUSA
| | | | - Jaime Viscasillas
- Clinical Sciences and ServicesThe Royal Veterinary CollegeHatfieldUK
| | - Pilar Lafuente
- Clinical Sciences and ServicesThe Royal Veterinary CollegeHatfieldUK
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Transversus Abdominis Plane Blocks in Microsurgical Breast Reconstruction: Analysis of Pain, Narcotic Consumption, Length of Stay, and Cost. Plast Reconstr Surg 2019; 142:252e-263e. [PMID: 29879000 DOI: 10.1097/prs.0000000000004632] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Transversus abdominis plane blocks are increasingly being used in microvascular breast reconstruction. The implications of these blocks on specific reconstructive, patient, and institutional outcomes remain to be fully elucidated. METHODS Patients undergoing abdominally based microvascular breast reconstruction from 2015 to 2017 were reviewed. Length of stay, complications, narcotic consumption, donor-site pain, and hospital expenses were compared between patients who did and did not receive transversus abdominis plane blocks with liposomal bupivacaine. Outcomes were subsequently compared in patients with elevated body mass index. RESULTS Fifty patients (43.9 percent) received blocks [27 (54.0 percent) under ultrasound guidance] and 64 patients (56.1 percent) did not. Patients with the blocks had significantly decreased oral and total narcotic consumption (p = 0.0001 and p < 0.0001, respectively) and significantly less donor-site pain (3.3 versus 4.3; p < 0.0001). There was no significant difference in hospital expenses between the two cohorts ($21,531.53 versus $22,050.15 per patient; p = 0.5659). Patients with a body mass index of 25 kg/m(2) or greater who received a block had a significantly decreased length of stay (3.8 days versus 4.4 days; p = 0.0345) and decreased narcotic consumption and postoperative pain compared with patients without blocks. Patients with a body mass index less than 25 kg/m(2) did not have a significant difference in postoperative pain, narcotic consumption, or length of stay between groups. CONCLUSIONS Transversus abdominis plane blocks with liposomal bupivacaine significantly reduce oral and total postoperative narcotic consumption and donor-site pain in all patients after abdominally based microvascular breast reconstruction without increasing hospital expenses. The blocks also significantly decrease length of stay in patients with a body mass index greater than or equal to 25 kg/m(2). CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Barker JC, DiBartola K, Wee C, Andonian N, Abdel-Rasoul M, Lowery D, Janis JE. Preoperative Multimodal Analgesia Decreases Postanesthesia Care Unit Narcotic Use and Pain Scores in Outpatient Breast Surgery. Plast Reconstr Surg 2018; 142:443e-450e. [PMID: 29979365 DOI: 10.1097/prs.0000000000004804] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The opioid epidemic demands changes in perioperative pain management. Of the 33,000 deaths attributable to opioid overdose in 2015, half received prescription opioids. Multimodal analgesia is a practice-altering evolution that reduces reliance on opioid medications. Ambulatory breast surgery is an ideal opportunity to implement these strategies. METHODS A retrospective review of 560 patients undergoing outpatient breast procedures was conducted. Patients received (1) no preoperative analgesia (n = 333); (2) intraoperative intravenous acetaminophen (n = 78); (3) preoperative oral acetaminophen and gabapentin (n = 95); or (4) preoperative oral acetaminophen, gabapentin and celecoxib (n = 54). Outcomes included postanesthesia care unit narcotic use, pain scores, postanesthesia care unit length of stay, rescue antiemetic use, and 30-day complications. RESULTS Both oral multimodal analgesia regimens significantly reduced postanesthesia care unit narcotic use (oral acetaminophen and gabapentin, 14.3 ± 1.7; oral gabapentin, acetaminophen, and celecoxib, 11.9 ± 2.2; versus no drug, 19.2 ± 1.1 mg oral morphine equivalents; p = 0.0006), initial pain scores (oral acetaminophen and gabapentin, 3.9 ± 0.4; oral gabapentin, acetaminophen, and celecoxib, 3.4 ± 0.7; versus no drug, 5.3 ± 0.3 on a 1 to 10 scale, p = 0.0002) and maximum pain scores (oral acetaminophen and gabapentin, 4.3 ± 0.4; oral gabapentin, acetaminophen, and celecoxib, 3.6 ± 0.7; versus no drug, 5.9 ± 0.3 on a 1 to 10 scale; p < 0.0001). Both oral regimens were better than no medications or intravenous acetaminophen alone in multivariate models after controlling for age, body mass index, American Society of Anesthesiologists class, length of surgery, prior narcotic prescription availability, and intraoperative local anesthetic. Postanesthesia care unit length of stay, antiemetic use, and 30-day complications were not different. CONCLUSIONS Preoperative oral multimodal analgesia reduces narcotic use and pain scores in outpatient breast plastic surgery. These regimens are inexpensive, improve pain control, and contribute to narcotic-sparing clinical practice in the setting of a national opioid epidemic. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Jenny C Barker
- From the Departments of Plastic Surgery, Anesthesia, and Biomedical Informatics, Center for Biostatistics, The Ohio State University Medical Center
| | - Kaitlin DiBartola
- From the Departments of Plastic Surgery, Anesthesia, and Biomedical Informatics, Center for Biostatistics, The Ohio State University Medical Center
| | - Corinne Wee
- From the Departments of Plastic Surgery, Anesthesia, and Biomedical Informatics, Center for Biostatistics, The Ohio State University Medical Center
| | - Nicole Andonian
- From the Departments of Plastic Surgery, Anesthesia, and Biomedical Informatics, Center for Biostatistics, The Ohio State University Medical Center
| | - Mahmoud Abdel-Rasoul
- From the Departments of Plastic Surgery, Anesthesia, and Biomedical Informatics, Center for Biostatistics, The Ohio State University Medical Center
| | - Deborah Lowery
- From the Departments of Plastic Surgery, Anesthesia, and Biomedical Informatics, Center for Biostatistics, The Ohio State University Medical Center
| | - Jeffrey E Janis
- From the Departments of Plastic Surgery, Anesthesia, and Biomedical Informatics, Center for Biostatistics, The Ohio State University Medical Center
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Zhou G, Ma L, Jing J, Jiang H. A meta-analysis of dexamethasone for pain management in patients with total knee arthroplasty. Medicine (Baltimore) 2018; 97:e11753. [PMID: 30170371 PMCID: PMC6393122 DOI: 10.1097/md.0000000000011753] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 07/08/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Pain management after a total-knee arthroplasty (TKA) has become an important issue in the field of medicine. This study conducted a meta-analysis from randomized controlled trials (RCTs) to assess the efficacy and safety of dexamethasone for pain management after TKA. METHODS PubMed, Medline, Embase, ScienceDirect, and the Cochrane Library were searched up to December 2017 for comparative RCTs involving dexamethasone and placebo for pain control after TKA. Primary outcomes were postoperative pain scores and opioid consumption. Secondary outcomes were length of hospital stay, adverse effects, and postoperative complications. We assessed statistical heterogeneity for each RCT with the use of a standard Chi-squared test and the I statistic. All data were carried out with Stata 14.0 software. RESULTS A total of 6 RCTs were included. The present meta-analysis indicated that there were significant differences between dexamethasone-treated groups and placebo groups regarding postoperative pain scores at 12, 24, and 48 hours after TKA. Administering dexamethasone could significantly reduce opioid consumption at 12 hours after TKA. However, no significant difference was found in opioid consumption at 24 and 48 hours after TKA. There was a decreased risk of adverse effects in dexamethasone groups. CONCLUSION Use of dexamethasone could result in a significant reduction in postoperative pain while minimizing adverse effects after TKA. Based on the current evidence available, more RCTs are needed for further investigation.
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Affiliation(s)
- Guanghong Zhou
- Operating Room, China-Japan Union Hospital of Jilin University
| | - Liping Ma
- Nursing Department, Nanhu District of China-Japan Union Hospital of Jilin University
| | - Junhai Jing
- Department of Oncology, Changling People's Hospital, Jilin, China
| | - Hao Jiang
- Operating Room, China-Japan Union Hospital of Jilin University
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Direct visualization transversus abdominis plane blocks offer superior pain control compared to ultrasound guided blocks following open posterior component separation hernia repairs. Hernia 2018; 22:627-635. [PMID: 29721629 DOI: 10.1007/s10029-018-1775-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 04/21/2018] [Indexed: 01/11/2023]
Abstract
PURPOSE Transversus abdominis plane (TAP) blockade with long-acting anesthetic can be used during open ventral hernia repair (VHR) with posterior component separation (PCS). TAP block can be performed under ultrasound guidance (US-TAP) or under direct visualization (DV-TAP). We hypothesized that US-TAP and DV-TAP provide equivalent postoperative analgesia following open VHR. METHODS A retrospective review of patients undergoing open VHR with PCS who received TAP blocks with 266 mg of liposomal bupivacaine was performed. Data included demographics, comorbidities, length of stay (LOS), average postoperative day (POD) pain scores, and narcotic requirements (normalized to mg oral morphine). Statistical analysis utilized Student's t test and Fisher's exact test. RESULTS Thirty-nine patients were identified (22 DV-TAP). There were no differences between the groups with respect to demographics, comorbidities, pre-operative pain medication usage (narcotic and non-narcotic) or herniorrhaphy-related data. The average POD0 pain score was lower for the DV-TAP group (2.35 vs 4.18; p = 0.019). Narcotic requirements on POD0 (48.0 vs 103.76 mg; p = 0.02), POD1 (128.45 vs 273.82 mg; p = 0.03), POD4 (54.29 vs 160.75 mg; p = 0.042), and during the complete hospitalization (408.52 vs 860.92 mg; p = 0.013) were lower in the DV-TAP group. There were no differences between initiation of diet or LOS. During the study, no changes were made to the VHR enhanced recovery pathway. CONCLUSIONS DV-TAP blocks appear to provide superior analgesia in the immediate postoperative period. To achieve similar post-operative pain scores, patients in the US-TAP group required significantly more narcotic administration during their hospitalization. The study highlights DV-TAP as a valuable addition to VHR recovery pathways.
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Zhao T, Shen Z, Sheng S. The efficacy and safety of nefopam for pain relief during laparoscopic cholecystectomy: A meta-analysis. Medicine (Baltimore) 2018; 97:e0089. [PMID: 29517677 PMCID: PMC5882431 DOI: 10.1097/md.0000000000010089] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Pain control after laparoscopic cholecystectomy (LC) has become an important topic. We performed a meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of nefopam for pain management after LC. METHODS PubMed, Medline, Embase, ScienceDirect, and the Cochrane Library were searched up to November 2017 for comparative articles involving nefopam and placebo for reducing postoperative pain after LC. Primary outcomes were postoperative pain scores and opioid consumption. Secondary outcomes were length of hospital stay, opioid-related adverse effects, and postoperative complications. We assessed statistical heterogeneity for each RCT by using a standard Chi test and the I statistic. The meta-analysis was undertaken using Stata 12.0. RESULTS A total of 215 patients were analyzed across 4 RCTs. We found that there were significant differences between nefopam and placebo groups regarding the postoperative pain scores and opioid requirements at 6, 12, and 24 hours. Moreover, there was a decreased risk of opioid-related adverse effects in the nefopam groups. No significant differences were identified in terms of the incidence of postoperative complications. CONCLUSION Intravenous nefopam infusion resulted in significant reduction in postoperative pain scores and opioid requirements while decreasing opioid-related adverse effects. Additionally, no increased risk of venous thromboembolism was found. The current evidence suggests that more RCTs will be needed in further investigations.
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Affiliation(s)
| | - Zhen Shen
- Department of Gastrointestinal Surgery, China–Japan Union Hospital of Jilin University, Jilin, China
| | - Shihou Sheng
- Department of Gastrointestinal Surgery, China–Japan Union Hospital of Jilin University, Jilin, China
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Soliz JM, Lipski I, Hancher-Hodges S, Speer BB, Popat K. Subcostal Transverse Abdominis Plane Block for Acute Pain Management: A Review. Anesth Pain Med 2017; 7:e12923. [PMID: 29696110 PMCID: PMC5903215 DOI: 10.5812/aapm.12923] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 05/09/2017] [Accepted: 10/10/2017] [Indexed: 11/16/2022] Open
Abstract
The subcostal transverse abdominis plane (SCTAP) block is the deposition of local anesthetic in the transverse abdominis plane inferior and parallel to the costal margin. There is a growing consensus that the SCTAP block provides better analgesia for upper abdominal incisions than the traditional transverse abdominis plane block. In addition, when used as part of a four-quadrant transverse abdominis plane block, the SCTAP block may provide adequate analgesia for major abdominal surgery. The purpose of this review is to discuss the SCTAP block, including its indications, technique, local anesthetic solutions, and outcomes.
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Affiliation(s)
- Jose M Soliz
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Corresponding author: Jose M Soliz, M.D., Associate Professor, Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd.Houston, TX 77030, E-mail:
| | - Ian Lipski
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shannon Hancher-Hodges
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Barbra Bryce Speer
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keyuri Popat
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Labrum JT, Ilyas AM. The Opioid Epidemic: Postoperative Pain Management Strategies in Orthopaedics. JBJS Rev 2017; 5:e14. [DOI: 10.2106/jbjs.rvw.16.00124] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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de Raaff CA, Gorter-Stam MA, de Vries N, Sinha AC, Jaap Bonjer H, Chung F, Coblijn UK, Dahan A, van den Helder RS, Hilgevoord AA, Hillman DR, Margarson MP, Mattar SG, Mulier JP, Ravesloot MJ, Reiber BM, van Rijswijk AS, Singh PM, Steenhuis R, Tenhagen M, Vanderveken OM, Verbraecken J, White DP, van der Wielen N, van Wagensveld BA. Perioperative management of obstructive sleep apnea in bariatric surgery: a consensus guideline. Surg Obes Relat Dis 2017; 13:1095-1109. [DOI: 10.1016/j.soard.2017.03.022] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 03/21/2017] [Accepted: 03/22/2017] [Indexed: 12/31/2022]
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Pain Management in Abdominal Wall Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1400. [PMID: 28740797 PMCID: PMC5505858 DOI: 10.1097/gox.0000000000001400] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 05/09/2017] [Indexed: 01/31/2023]
Abstract
Background: In abdominal wall reconstruction, adequate pain control and minimization of narcotic consumption are essential to improving patient outcomes and satisfaction. Previous studies have examined the role of individual strategies, such as neuraxial analgesia and multimodal analgesia. However, there has not been a study that examined all potential determinants of postoperative narcotic requirements, including intraoperative strategies. Methods: Consecutive patients who underwent abdominal wall reconstruction were reviewed. Preoperative factors (chronic preoperative narcotic usage, indication for abdominal wall reconstruction, administration of neuraxial analgesia), intraoperative factors (intraoperative narcotics administered, method of mesh fixation), and postoperative factors (multimodal analgesia, complications) were collected. The main outcomes were daily amount of opioids used and length of hospital stay. Results: Ninety-three patients were included in the study. Patients who had an epidural required lower doses of opioids postoperatively, while those on chronic preoperative opioids, those whose mesh was fixated using transfascial sutures, and those who received large doses of opioids intraoperatively required higher doses of postoperative opioids. Hospital length of stay was longer in patients who received transfascially sutured mesh and those on chronic opioids preoperatively. Conclusions: This study provides potential strategies to improve pain control and minimize narcotic consumption postoperatively in patients undergoing abdominal wall reconstruction. Intraoperative administration of opioids should be minimized to avoid the development of tolerance. Epidural analgesia reduces postoperative narcotic requirement and may be especially beneficial in patients at highest risk for postoperative pain, including those on chronic opioids, and those in whom transfascial sutures are used for mesh fixation.
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21
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Mulier J. Opioid free general anesthesia: A paradigm shift? ACTA ACUST UNITED AC 2017; 64:427-430. [PMID: 28431750 DOI: 10.1016/j.redar.2017.03.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 03/09/2017] [Indexed: 10/19/2022]
Affiliation(s)
- J Mulier
- Chairman, Department of Anesthesiology, Intensive Care, and Reanimation, AZ Sint Jan Brugge-Oostende, Brujas, Bélgica.
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Khansa I, Janis JE. Abdominal Wall Reconstruction Using Retrorectus Self-adhering Mesh: A Novel Approach. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2016; 4:e1145. [PMID: 27975037 PMCID: PMC5142503 DOI: 10.1097/gox.0000000000001145] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 10/05/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND In abdominal wall reconstruction, the retrorectus plane offers an ideal location for mesh placement. Mesh fixation in this plane is often achieved using transfascial sutures, which risks entrapping intercostal nerves and causing significant pain, and takes time to place. A novel alternative is the use of sutureless self-adhering mesh. Although the use of this mesh in inguinal hernias has been well described, studies on its use in abdominal wall reconstruction are lacking. METHODS Consecutive patients who underwent ventral hernia repair with retrorectus mesh were reviewed. This included patients who received transfascially sutured mesh and those who received sutureless self-adhering mesh. All patients were followed up for at least 12 months. The amount of narcotics required by each patient postoperatively was calculated. Surgical-site occurrences (SSOs) and hernia recurrence and bulge were measured. RESULTS Twenty-six patients underwent abdominal wall reconstruction with retrorectus mesh. This included 12 patients with transfascially sutured mesh and 14 patients with self-adhering mesh. Mean follow-up was 600 days. Baseline characteristics were similar between the 2 groups. Patients receiving self-adhering mesh required significantly less narcotics than patients with transfascially sutured mesh. There were no significant differences in the rate of SSOs between the 2 groups. No hernia recurrences, bulges, or chronic pain occurred in either group. CONCLUSIONS This is the first study to compare the outcomes of retrorectus self-adhering mesh and transfascially sutured mesh in abdominal wall reconstruction. Our results show low rates of SSO, recurrence, and bulge with both options, with significantly less acute pain with self-adhering mesh.
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Affiliation(s)
- Ibrahim Khansa
- Department of Plastic Surgery, the Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jeffrey E Janis
- Department of Plastic Surgery, the Ohio State University Wexner Medical Center, Columbus, Ohio
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Butts SC, Floyd E, Lai E, Rosenfeld RM, Doerr T. Reporting of Postoperative Pain Management Protocols in Randomized Clinical Trials of Mandibular Fracture Repair: A Systematic Review. JAMA FACIAL PLAST SU 2015; 17:440-8. [PMID: 26335408 DOI: 10.1001/jamafacial.2015.1011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The control of pain associated with mandibular fractures is an important treatment outcome that affects function, adherence to treatment regimens, and patient comfort and satisfaction. OBJECTIVE To explore the pain management protocols reported in studies of mandibular fractures, including the reporting of quality-of-life measures. EVIDENCE REVIEW PubMed/MEDLINE, EMBASE, Cochrane CENTRAL, and clinicaltrials.gov were searched for randomized clinical trials published from 1970 to July 2014. We followed PRISMA reporting standards to assess study eligibility and extract data. Studies of patients older than 16 years who underwent operative mandibular fracture management were included. The primary data collected included the type of analgesic prescribed, associated adverse effects of the analgesic, method of pain assessment, and use of quality-of-life measures. A pain attentiveness score was assigned to studies based on the comprehensiveness of the information reported. Several variables were reviewed to determine the factors that predict reporting of pain-related data. Assessments of risk for bias were performed using the Cochrane Collaboration's domain-based evaluation method. FINDINGS The initial search identified 111 articles, of which 38 met inclusion criteria. Among the 38 reviewed articles, there were 38 trials and 1808 unique patients represented. Among the 38 articles, the procedures reported included maxillomandibular fixation only in 6 (16%), open reduction with internal fixation only in 20 (53%), and both in 12 (32%). Specific analgesics prescribed were reported in only 5 of the 38 studies (13%), and 3 of these used a combination of nonsteroidal anti-inflammatory drugs and acetaminophen (paracetamol). Thirteen studies (34%) reported pain assessments and 5 (13%) included quality-of-life measures. Geographic region was the only variable that predicted pain attentiveness, with studies from Europe (3 of 11 studies [27%]) and Asia (6 of 16 studies [38%]) most likely to have a high pain attentiveness score. A low rating was least common in the United States (2 of 5 studies [40%]) (P = .047, Fisher exact test). Most of the studies had unclear (n = 27) or high (n = 6) risks for bias in the key domains assessed. CONCLUSIONS AND RELEVANCE Pain management is a neglected outcome in randomized clinical trials of mandibular trauma; most studies did not describe the specific analgesics used. Many randomized clinical trials (13 [34%]) assessed pain levels among patients without providing information about the agents prescribed. The incorporation of validated pain measures and quality-of-life scores in future studies of mandibular trauma would focus attention on this key outcome measure.
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Affiliation(s)
- Sydney C Butts
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, State University of New York Downstate Medical Center, College of Medicine, Brooklyn
| | - Elizabeth Floyd
- Department of Otolaryngology, State University of New York Downstate Medical Center, Brooklyn
| | - Erica Lai
- School of Public Health, State University of New York Downstate Medical Center, Brooklyn
| | - Richard M Rosenfeld
- Department of Otolaryngology, State University of New York Downstate Medical Center, Brooklyn
| | - Timothy Doerr
- Department of Otolaryngology, University of Rochester Medical Center, Rochester, New York
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