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Farishta A, Iancau A, Janis JE, Joshi GP. Use of Muscle Relaxants for Acute Postoperative Pain: A Practical Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5938. [PMID: 38957722 PMCID: PMC11216677 DOI: 10.1097/gox.0000000000005938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 05/14/2024] [Indexed: 07/04/2024]
Abstract
Background Skeletal muscle relaxants have emerged as a broad category of analgesic adjuncts, aiming to improve pain relief and reduce opioid reliance. These drugs induce muscle relaxation and reduce muscle spasms, and therefore, they are commonly used in surgical procedures involving muscle manipulation, such as abdominal surgery, breast surgery, and spine surgery. However, their analgesic efficacy and opioid-sparing effects are poorly explored. Methods A scoping review of literature was performed with several electronic databases. We used a search string with a sequence of text words and word variants related to central muscle relaxants, pain management, postoperative pain, and specific muscle relaxants. Results Review of literature shows significant heterogeneity among the studies in terms of surgical procedures, patient populations, choice of muscle relaxant, and timing and duration of administration, potentially limiting the generalizability of the findings and the ability for pooled analysis. Conclusions Given the lack of evidence, we recommend that the use of skeletal muscle relaxants be reserved for patients in whom an optimal multimodal analgesic technique is not adequate. Also, there may be a limited role for these drugs in patients at high risk of postoperative pain undergoing surgical procedures with expected high opioid requirements. Due to the concerns of potential adverse effects, the decision to use muscle relaxants in vulnerable populations should be made carefully, weighing the benefits against the risks.
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Affiliation(s)
- Akil Farishta
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Tex
| | - Alex Iancau
- University of Texas Southwestern, Dallas, Tex
| | - Jeffrey E. Janis
- Department of Plastic and Reconstructive Surgery, The Ohio State University, Columbus, Ohio
| | - Girish P. Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Tex
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Bitay E, Gergely AL, Szabó ZI. One-Step Preparation of Fiber-Based Chlorzoxazone Solid Dispersion by Centrifugal Spinning. Polymers (Basel) 2023; 16:123. [PMID: 38201788 PMCID: PMC10781139 DOI: 10.3390/polym16010123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/22/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
An amorphous fiber-based solid dispersion of chlorzoxazone was prepared for the first time by employing centrifugal spinning, using polyvinylpyrrolidone as the fiber-forming polymer. After optimization of the spinning parameters, the obtained fibers were characterized using a set of analytical techniques, both in a solid- and solution-state. Morphological characterization revealed a slightly aligned, defect-free fibrous structure with an average fiber diameter of d = 3.07 ± 1.32 μm. The differential scanning calorimetric results indicated a crystalline-to-amorphous transition of the active substance during the centrifugal spinning process, while gas chromatographic determinations revealed a residual ethanol content of 0.42 ± 0.04%. UV spectroscopy indicated the incorporation of chlorzoxazone in the fibrous structures, with an average active substance content of 15.91 ± 0.36 w/w%. During small-volume dissolution studies, the prepared fiber mats presented immediate disintegration upon contact with the dissolution media, followed by rapid dissolution of the active substance, with 84.8% dissolved at 1 min and 93.7% at 3 min, outperforming the micronized, pure chlorzoxazone. The obtained results indicate that centrifugal spinning is a low-cost, high-yield, viable alternative to the currently used methods to prepare fiber-based amorphous solid dispersions of poorly soluble drugs. The prepared chlorzoxazone-loaded microfibers could be used as a buccal dosage form for the systematic delivery of chlorzoxazone and could potentially lead to a rapid onset of action and longer efficacy of the muscle relaxant drug.
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Affiliation(s)
- Enikő Bitay
- Department of Mechanical Engineering, Faculty of Technical and Human Sciences, Sapientia Hungarian University of Transylvania, Calea Sighișoarei nr. 2, 540485 Târgu-Mureş, Romania;
- Bánki Donát Faculty of Mechanical and Safety Engineering, Óbuda University, Népszínház u. 8, 1081 Budapest, Hungary
- Research Institute of the Transylvanian Museum Society, 2–4 Napoca Street, 400009 Cluj-Napoca, Romania
| | - Attila Levente Gergely
- Department of Mechanical Engineering, Faculty of Technical and Human Sciences, Sapientia Hungarian University of Transylvania, Calea Sighișoarei nr. 2, 540485 Târgu-Mureş, Romania;
| | - Zoltán-István Szabó
- Department of Drugs Industry and Pharmaceutical Management, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Gh. Marinescu 38, 540485 Târgu-Mureş, Romania;
- Sz-imfidum Ltd., Lunga nr. 504, 525401 Covasna, Romania
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Verdiner R, Khurmi N, Choukalas C, Erickson C, Poterack K. Does adding muscle relaxant make post-operative pain better? a narrative review of the literature from US and European studies. Anesth Pain Med (Seoul) 2023; 18:340-348. [PMID: 37919918 PMCID: PMC10635846 DOI: 10.17085/apm.23055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 11/04/2023] Open
Abstract
Centrally acting skeletal muscle relaxants (CASMR) are widely prescribed as adjuncts for acute and chronic pain. Given the recent interest in multimodal analgesia and reducing opioid consumption, there has been an increase in its use for perioperative/postoperative pain control. The mechanism of action, pharmacodynamics, and pharmacokinetics of these drugs vary. Their use has been studied in a wide range of operative and non-operative settings. The best evidence for the efficacy of CASMRs is in acute, nonoperative musculoskeletal pain and, in the operative setting, in patients undergoing total knee arthroplasty and abdominal surgery, including inguinal herniorrhaphy and hemorrhoidectomy. The risk of complications and side effects, coupled with the limited evidence of efficacy, should prompt careful consideration of individual patient circumstances when prescribing CASMRs as part of perioperative pain management strategies.
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Affiliation(s)
| | - Narjeet Khurmi
- Department of Anesthesiology, Mayo Clinic, Phoenix, AZ, USA
| | - Christopher Choukalas
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, USA
| | - Colby Erickson
- Midwestern Osteopathic Medical School, Glendale, CA, USA
| | - Karl Poterack
- Department of Anesthesiology, Mayo Clinic, Phoenix, AZ, USA
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Postoperative Pain Management in Pediatric Spinal Fusion Surgery for Idiopathic Scoliosis. Paediatr Drugs 2020; 22:575-601. [PMID: 33094437 DOI: 10.1007/s40272-020-00423-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2020] [Indexed: 12/12/2022]
Abstract
This article reviews and summarizes current evidence and knowledge gaps regarding postoperative analgesia after pediatric posterior spine fusion for adolescent idiopathic scoliosis, a common procedure that results in severe acute postoperative pain. Inadequate analgesia may delay recovery, cause patient dissatisfaction, and increase chronic pain risk. Despite significant adverse effects, opioids are the analgesic mainstay after scoliosis surgery. However, growing emphasis on opioid minimization and enhanced recovery has increased adoption of multimodal analgesia (MMA) regimens. While opioid adverse effects remain a concern, MMA protocols must also consider risks and benefits of adjunct medications. We discuss use of opioids via different administration routes and elaborate on the effect of MMA components on opioid/pain and recovery outcomes including upcoming regional analgesia. We also discuss risk for prolonged opioid use after surgery and chronic post-surgical pain risk in this population. Evidence supports use of neuraxial opioids at safe doses, low-dose ketorolac, and methadone for postoperative analgesia. There may be a role for low-dose ketamine in those who are opioid-tolerant or have chronic pain, but the evidence for preoperative gabapentinoids and intravenous lidocaine is currently insufficient. There is a need for further studies to evaluate pediatric-specific optimal MMA dosing regimens after scoliosis surgery. Questions remain regarding how best to prevent acute opioid tolerance, opioid-induced hyperalgesia, and chronic postsurgical pain. We anticipate that this timely update will enable clinicians to develop efficient pain regimens and provide impetus for future research to optimize recovery outcomes after spine fusion.
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Investigating the Effect of Perioperative Chlorzoxazone on Acute Postoperative Pain After Total Hip and Knee Replacement Surgery. Clin J Pain 2020; 36:352-358. [DOI: 10.1097/ajp.0000000000000805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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He J, Li N, Xu J, Zhu J, Yu Y, Chen X, Lu Y. An LC-MS/MS Validated Method for Quantification of Chlorzoxazone in Human Plasma and Its Application to a Bioequivalence Study. J Chromatogr Sci 2019; 57:751-757. [PMID: 31363741 DOI: 10.1093/chromsci/bmz052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 02/27/2019] [Accepted: 06/07/2019] [Indexed: 11/13/2022]
Abstract
A simple, sensitive, specific, accurate liquid chromatography-tandem mass spectrometry (LC-MS/MS) assay for determination of chlorzoxazone in human plasma was developed and validated to evaluate the pharmacokinetic characteristics of chlorzoxazone test or reference formulation. Sample preparation was achieved by one step protein precipitation and dilution with acetontrile. The chromatographic separation was performed at 40°C with a gradient mobile phase (0.3 mL/min) and a Shimadzu VP-ODS C18 analytical column (column size: 150 × 2.0 mm). TSQ quantum access triple-quadrapole MS/MS detection was operated in a negative mode by multiple reaction monitoring. Ion transitions at m/z 168.0→132.1 for chlorzoxazone and m/z 451.3→379.3 for repaglinide (internal standard) were used for the LC-MS/MS analysis. The calibration was linear (r ≥ 0.995) over the tested concentration range of 0.2-20 μg/mL for chlorzoxazone in plasma. Precision, accuracy, recovery, matrix effect and stability for chlorzoxazone were evaluated and were excellent within the range of tested concentrations. This method was successfully applied to a bioequivalence study in 20 healthy Chinese volunteers. This method could also contribute to the personalized medication and therapeutic drug monitoring of chlorzoxazone.
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Affiliation(s)
- Jiake He
- Department of Pharmacy, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Clinical Pharmacokinetics Laboratory, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China.,Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Ning Li
- Clinical Pharmacokinetics Laboratory, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Jiaqiu Xu
- Clinical Pharmacokinetics Laboratory, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Jing Zhu
- Clinical Pharmacokinetics Laboratory, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Yang Yu
- Department of Pharmacy, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Xijing Chen
- Clinical Pharmacokinetics Laboratory, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Yang Lu
- Clinical Pharmacokinetics Laboratory, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
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Creighton DW, Kumar AH, Grant SA. Perioperative Multimodal Pain Management: an Evidence-Based Update. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00340-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Abstract
PURPOSE OF REVIEW Pain management in neurocritical care is a subject often avoided because of concerns over the side-effects of analgesics and the potential to cause additional neurological injury with treatment. The sedation and hypercapnia caused by opioids have been feared to mask the neurological examination and contribute to elevations in intracranial pressure. Nevertheless, increasing attention to patient satisfaction has sparked a resurgence in pain management. As opioids have remained at the core of analgesic therapy, the increasing attention to pain has contributed to a growing epidemic of opioid dependence. In this review, we summarize the most recent literature regarding opioids and their alternatives in the treatment of acute pain in patients receiving neurocritical care. RECENT FINDINGS Studies on pain management in neurocritical care continue to explore nonopioid analgesics as part of a multimodal strategy aimed at decreasing overall opioid consumption. Agents including local anesthetics, acetaminophen, ketamine, gabapentinoids, and dexmedetomidine continue to demonstrate efficacy. In addition, the prolonged longitudinal course of many recent trials has also revealed more about the transition from acute to chronic pain following hospitalization. SUMMARY In an era of increasing attention to patient satisfaction mitigated by growing concerns over the harms imposed by opioids, alternative analgesic therapies are being investigated with promising results.
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