1
|
Lirk P, Schreiber KL. Lessons learnt in evidence-based perioperative pain medicine: changing the focus from the medication and procedure to the patient. Reg Anesth Pain Med 2024:rapm-2023-105235. [PMID: 38355216 DOI: 10.1136/rapm-2023-105235] [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: 12/15/2023] [Accepted: 02/01/2024] [Indexed: 02/16/2024]
Abstract
Over time, the focus of evidence-based acute pain medicine has shifted, from a focus on drugs and interventions (characterized by numbers needed to treat), to an appreciation of procedure-specific factors (characterized by guidelines and meta-analyses), and now anesthesiologists face the challenge to integrate our current approach with the concept of precision medicine. Psychometric and biopsychosocial markers can potentially guide clinicians on who may need more aggressive perioperative pain management, or who would respond particularly well to a given analgesic intervention. The challenge will be to identify an easily assessable set of parameters that will guide perioperative physicians in tailoring the analgesic strategy to procedure and patient.
Collapse
Affiliation(s)
- Philipp Lirk
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kristin L Schreiber
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Joshi GP, Albrecht E, Van de Velde M, Kehlet H, Lobo DN. PROSPECT methodology for developing procedure-specific pain management recommendations: an update. Anaesthesia 2023; 78:1386-1392. [PMID: 37751453 DOI: 10.1111/anae.16135] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 09/28/2023]
Abstract
The procedure-specific postoperative pain management (PROSPECT) working group develops evidence-based pain management recommendations. PROSPECT methodology is unique and rigorous. However, several limitations were recognised that needed to be addressed, and several new factors were identified that improved PROSPECT methodology. The aim of this article is to present updated PROSPECT methodology for development of recommendations for procedure-specific pain management, focusing on the methodological revisions we will implement. In future, included randomised clinical trials will need to be prospectively registered on a publicly accessible clinical trials database and the study design, including the primary outcome in the registration, should coincide with that in the published manuscript. Placebo-controlled studies in which the analgesic intervention of interest is solely paracetamol, non-steroidal anti-inflammatory drugs, cyclo-oxygenase-2-specific inhibitors or opioids will not be included. Studies comparing one drug in a particular class with another in the same class will also not be included. Future projects will use the Cochrane Collaboration risk of bias tool for quality of reporting of methodology and results. A modified Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach will be used for grading of level of evidence and strength of recommendations. Finally, the updated PROSPECT methodology addresses several other limitations and implements new factors that all add rigour and transparency to developing procedure-specific pain management recommendations.
Collapse
Affiliation(s)
- G P Joshi
- Department of Anaesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - E Albrecht
- Program Director of Regional Anaesthesia, Department of Anaesthesia, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - M Van de Velde
- Department of Cardiovascular Sciences, Section Anaesthesiology, KU Leuven and University Hospital Leuven, Belgium
| | - H Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - D N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, Division of Translation Medical Sciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
3
|
Nielsen NI, Kehlet H, Gromov K, Troelsen A, Husted H, Varnum C, Kjærsgaard-Andersen P, Rasmussen LE, Pleckaitiene L, Foss NB. High dose dexamethasone in high pain responders undergoing total hip arthroplasty: A randomized controlled trial. Eur J Anaesthesiol 2023; 40:737-746. [PMID: 37166257 DOI: 10.1097/eja.0000000000001853] [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: 05/12/2023]
Abstract
BACKGROUND Postoperative pain after total hip arthroplasty (THA) may delay postoperative mobilization and discharge. Postoperative pain has been shown to be higher in pain catastrophisers and patients receiving opioids. A single dose of glucocorticoid reduces pain after THA, and an increased dose of glucocorticoids has been found to be effective in patients at high risk of postoperative pain after total knee arthroplasty (TKA), however, the ideal dose in THA remains unknown. OBJECTIVE To evaluate the effect of a high dose (1 mg kg -1 ) vs. intermediate dose (0.3 mg kg -1 ) of dexamethasone on pain after THA. DESIGN A randomized double-blind controlled study. SETTING A two-centre study including two large arthroplasty sites in Denmark was conducted from February 2019 to August 2020. PATIENTS A total of 160 patients undergoing THA by neuraxial block with multimodal analgesia, having a Pain Catastrophising Scale score >20 and/or preoperative opioid use were included. INTERVENTION Patients were randomly assigned to receive dexamethasone 1 mg kg -1 or 0.3 mg kg -1 before THA. MAIN OUTCOME MEASURES Primary outcome was percentage of patients experiencing moderate to severe pain (visual analogue scale, VAS > 30 mm on a 0 to 100 mm scale) on ambulating 24 h after surgery. Secondary outcomes included cumulated pain scores, C-reactive protein (CRP), opioid use, postoperative recovery scores, length of stay, complications, and re-admission within 30 and 90 days. RESULTS No difference was found in percentage of VAS >30 mm 24 h after surgery in the 5-m walk test (VAS > 30/VAS ≤ 30%); 33/42 (44%) vs. 32/43 (43%), relative risk = 1.04 (95% confidence interval 0.72-1.51; P = 0.814) in 1 mg kg -1vs. 0.3 mg kg -1 respectively. No differences were found in CRP and opioid use between groups. Also, no intergroup differences were found in recovery scores, re-admissions, or complications. CONCLUSION 1 mg kg -1vs. 0.3 mg kg -1 dexamethasone improved neither postoperative pain nor recovery in THA in a cohort of predicted high pain responders. TRIAL REGISTRATION ClinicalTrials.gov ID-number NCT03763760 and EudraCT-number 2018-2636-25.
Collapse
Affiliation(s)
- Niklas I Nielsen
- From the Department of Anaesthesiology, Copenhagen University, Hvidovre Hospital, Hvidovre, Denmark (NIN, NBF), Section of Surgical Pathophysiology, University of Copenhagen, Blegdamsvej 9, Denmark (HK), Department of Orthopaedic Surgery, Copenhagen University, Hvidovre Hospital, Hvidovre, Denmark (KG, AT, HH), Department of Orthopaedic Surgery, Lillebaelt Hospital - Vejle, Vejle, Denmark (CV, PK-A, LER), Department of Anaesthesiology, Lillebaelt Hospital - Vejle, Vejle, Denmark (LP)
| | | | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Nielsen NI, Kehlet H, Gromov K, Troelsen A, Husted H, Varnum C, Kjærsgaard-Andersen P, Rasmussen LE, Pleckaitiene L, Foss NB. High-dose dexamethasone in low pain responders undergoing total knee arthroplasty: a randomised double-blind trial. Br J Anaesth 2023; 130:322-330. [PMID: 36526481 DOI: 10.1016/j.bja.2022.10.038] [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: 08/30/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Postoperative pain after total knee arthroplasty (TKA) is a continuing problem despite optimised multimodal analgesia. Previous studies have shown preoperative glucocorticoids to reduce postoperative pain, but knowledge about specific doses and effects in specific patient groups is lacking. METHODS A two-centre, double-blind, two-arm study comparing preoperative dexamethasone (1 mg kg-1vs 0.3 mg kg-1 i.v.) on postoperative pain in 160 planned TKA subjects with low preoperative pain catastrophising and no opioid use. Subjects received multimodal analgesia with paracetamol, cyclooxygenase-2 inhibitors, local anaesthetic infiltration analgesia, and rescue opioids. The primary outcome was percentage of subjects experiencing moderate to severe pain (visual analogue scale >30 mm) upon ambulation at 24 h. Secondary outcomes included pain scores, postoperative inflammation (C-reactive protein), opioid and antiemetics use, and 'Quality of Recovery-15' and 'Opioid-Related Symptom Distress Scale', length of stay, readmissions, and complications up to Day 90. RESULTS A total of 157 subjects (80 vs 77) were included. No difference was found between groups in the incidence of subjects experiencing visual analogue scale >30 on ambulation 24 h after surgery (56% vs 53%, relative risk =1.07, confidence interval: 0.8-1.4, P=0.65). No differences in other pain outcomes or use of rescue opioids and antiemetics, in Quality of Recovery-15 and Opioid-Related Symptom Distress Scale, length of stay, readmissions, or complications. C-reactive protein values were comparable at 24 h (13 [6-25] mg L-1vs 16 [9-38] mg L-1, P = 0.07), but lower at 48 h (26 [9-52] mg L-1vs 50 [30-72] mg L-1, P<0.01) in the high-dose group. CONCLUSION Use of 1 mg kg-1vs 0.3 mg kg-1 i.v. dexamethasone in low pain responders after TKA did not improve early postoperative pain or other outcomes in contrast to benefits in a high pain responder population. CLINICAL TRIAL REGISTRATION NCT03758170 (first registration 29-11-2018).
Collapse
Affiliation(s)
- Niklas I Nielsen
- Department of Anaesthesiology, Copenhagen University, Hvidovre Hospital, Hvidovre, Denmark.
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kirill Gromov
- Department of Orthopaedic Surgery, Copenhagen University, Hvidovre Hospital, Hvidovre, Denmark
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Copenhagen University, Hvidovre Hospital, Hvidovre, Denmark
| | - Henrik Husted
- Department of Orthopaedic Surgery, Copenhagen University, Hvidovre Hospital, Hvidovre, Denmark
| | - Claus Varnum
- Department of Orthopaedic Surgery, Lillebaelt Hospital, Vejle, Denmark
| | | | - Lasse E Rasmussen
- Department of Orthopaedic Surgery, Lillebaelt Hospital, Vejle, Denmark
| | | | - Nicolai B Foss
- Department of Anaesthesiology, Copenhagen University, Hvidovre Hospital, Hvidovre, Denmark
| |
Collapse
|
5
|
Perioperative Intravenous Glucocorticoids in Total Joint Arthroplasty: A Systematic Review. J Am Acad Orthop Surg 2023; 31:e94-e106. [PMID: 36580055 DOI: 10.5435/jaaos-d-22-00232] [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] [Received: 03/14/2022] [Accepted: 08/10/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Total joint arthroplasties (TJAs) of the hip and knee are common orthopaedic procedures. Postoperative pain in TJA is managed with opioids, which carry notable adverse effects and are associated with high dependency rates. With newer multimodal pain control regimens, perioperative glucocorticoid administration has shown promise as a means of mitigating postoperative pain. The objective of this review was to identify the effects of perioperative intravenous glucocorticoid administration on postoperative outcomes in TJA. MATERIALS AND METHODS A systematic review was done. The EMBASE database was searched from inception through September 1, 2020, to identify studies of perioperative glucocorticoids in TJA. Primary outcomes were postoperative pain, nausea, and vomiting. Secondary outcomes included hospital length of stay, postoperative opioid utilization, antiemetic rescue medication use, and postoperative surgical complications. RESULTS Our search yielded 429 publications; 14 studies were ultimately included, incorporating 1704 patients. In 13 of 14 studies, pain scores improved with perioperative steroid administration. Regarding postoperative nausea and vomiting, most of the studies found a notable association between steroids and improved VAS-N (visual analogue scale for nausea) and decreased postoperative nausea and vomiting incidence. There were inconclusive data on the effects of perioperative steroids regarding postoperative length of stay, fatigue, and range of motion of the affected joint. In all 14 studies, no notable difference was found between study groups regarding postoperative surgical complications. CONCLUSION This systematic review supports the use of perioperative steroids in TJA for mitigating postoperative pain, nausea, and systemic inflammation. Additional randomized trials are needed to form a consensus on optimal dosing, delivery method, and timing of perioperative glucocorticoids in TJA.
Collapse
|
6
|
Lavand'homme PM, Kehlet H, Rawal N, Joshi GP. Pain management after total knee arthroplasty: PROcedure SPEcific Postoperative Pain ManagemenT recommendations. Eur J Anaesthesiol 2022; 39:743-757. [PMID: 35852550 PMCID: PMC9891300 DOI: 10.1097/eja.0000000000001691] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The PROSPECT (PROcedure SPEcific Postoperative Pain ManagemenT) Working Group is a global collaboration of surgeons and anaesthesiologists formulating procedure-specific recommendations for pain management after common operations. Total knee arthroplasty (TKA) is associated with significant postoperative pain that is difficult to treat. Nevertheless, pain control is essential for rehabilitation and to enhance recovery. OBJECTIVE To evaluate the available literature and develop recommendations for optimal pain management after unilateral primary TKA. DESIGN A narrative review based on published systematic reviews, using modified PROSPECT methodology. DATA SOURCES A literature search was performed in EMBASE, MEDLINE, PubMed and Cochrane Databases, between January 2014 and December 2020, for systematic reviews and meta-analyses evaluating analgesic interventions for pain management in patients undergoing TKA. ELIGIBILITY CRITERIA Each randomised controlled trial (RCT) included in the selected systematic reviews was critically evaluated and included only if met the PROSPECT requirements. Included studies were evaluated for clinically relevant differences in pain scores, use of nonopioid analgesics, such as paracetamol and nonsteroidal anti-inflammatory drugs and current clinical relevance. RESULTS A total of 151 systematic reviews were analysed, 106 RCTs met PROSPECT criteria. Paracetamol and nonsteroidal anti-inflammatory or cyclo-oxygenase-2-specific inhibitors are recommended. This should be combined with a single shot adductor canal block and peri-articular local infiltration analgesia together with a single intra-operative dose of intravenous dexamethasone. Intrathecal morphine (100 μg) may be considered in hospitalised patients only in rare situations when both adductor canal block and local infiltration analgesia are not possible. Opioids should be reserved as rescue analgesics in the postoperative period. Analgesic interventions that could not be recommended were also identified. CONCLUSION The present review identified an optimal analgesic regimen for unilateral primary TKA. Future studies to evaluate enhanced recovery programs and specific challenging patient groups are needed.
Collapse
Affiliation(s)
- Patricia M Lavand'homme
- From the Department of Anaesthesiology and Perioperative Pain Service, Cliniques Universitaires St Luc, University Catholic of Louvain (UCL), Brussels, Belgium (PML), Section of Surgical Pathophysiology 7621, Rigshospitalet, Copenhagen, Denmark (HK), Department of Anaesthesiology, Orebro University, Orebro, Sweden (NR) and Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, United States (GPJ)
| | | | | | | |
Collapse
|
7
|
Bramley P, Wiles MD. How to perform and write a meta‐analysis. Anaesthesia 2022; 77:1299-1303. [DOI: 10.1111/anae.15755] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2022] [Indexed: 12/18/2022]
Affiliation(s)
- P. Bramley
- Department of Anaesthesia and Operating Services Sheffield Teaching Hospitals NHS Foundation Trust Sheffield UK
| | - M. D. Wiles
- Department of Anaesthesia and Operating Services Sheffield Teaching Hospitals NHS Foundation Trust Sheffield UK
- University of Sheffield Sheffield UK
| |
Collapse
|
8
|
Awada HN, Steinthorsdottir KJ, Schultz NA, Hillingsø JG, Larsen PN, Jans Ø, Kehlet H, Aasvang EK. High-dose preoperative glucocorticoid for prevention of emergence and postoperative delirium in liver resection: A double-blinded randomized clinical trial substudy. Acta Anaesthesiol Scand 2022; 66:696-703. [PMID: 35325467 PMCID: PMC9320957 DOI: 10.1111/aas.14057] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Emergence delirium (ED) and postoperative delirium (POD) are associated with increased morbidity and mortality and occur in up to one-third of patients undergoing major non-cardiac surgery, where the underlying pathogenesis is multifactorial, including increased inflammation. We aimed to assess the effect of pre-operative high- versus low-dose glucocorticoid on the occurrence of ED and POD. METHODS This was a substudy from a randomized, double-blinded clinical trial. Patients ≥18 years, undergoing open liver resection were randomized 1:1 to high-dose (HD, 10 mg/kg methylprednisolone) or low-dose (LD, 8 mg dexamethasone) glucocorticoid and assessed for ED and POD for a maximum of 4 days during hospitalization. The 3-min Diagnostic Interview for CAM-defined delirium (3D-CAM) was used for assessment, 15 and 90 min after arrival in the post-anesthesia care unit (PACU), and subsequently once daily in the ward. RESULTS Fifty-three patients were included in this secondary substudy (26 HD-group and 27 LD-group). ED occurred in n = 5 HD versus n = 6 LD patients 15 min after PACU arrival. At 90 min after PACU arrival, 4 patients had ED, all from LD-group, and resulted in significantly longer PACU admission, 273 versus 178 min in ED versus Non-ED patients. During the first 4 days in the ward, n = 5 patients had at least one occurrence of POD, all from LD-group. CONCLUSIONS The primary finding of the current substudy was a lower occurrence of ED/POD in the PACU 90 min after arrival and during the first four postoperative days in patients receiving high-dose glucocorticoid compared with patients receiving low-dose glucocorticoid. The two study groups were not evenly balanced concerning known explanatory factors, i.e., age and size of surgery, which calls for larger studies to elucidate the matter.
Collapse
Affiliation(s)
- Hussein Nasser Awada
- Department of Anesthesiology Centre for Cancer and Organ Diseases Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
- Surgical Pathophysiology Unit Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Kristin Julia Steinthorsdottir
- Department of Anesthesiology Centre for Cancer and Organ Diseases Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
- Surgical Pathophysiology Unit Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Nicolai A. Schultz
- Department of Gastrointestinal Surgery and Transplantation Centre for Cancer and Organ Diseases Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Jens G. Hillingsø
- Department of Gastrointestinal Surgery and Transplantation Centre for Cancer and Organ Diseases Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Peter Nørgaard Larsen
- Department of Gastrointestinal Surgery and Transplantation Centre for Cancer and Organ Diseases Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Øivind Jans
- Department of Anesthesiology Centre for Cancer and Organ Diseases Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Henrik Kehlet
- Surgical Pathophysiology Unit Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Eske Kvanner Aasvang
- Department of Anesthesiology Centre for Cancer and Organ Diseases Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
- Department of Clinical Medicine Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
| |
Collapse
|
9
|
Xu H, Xie J, Yang J, Huang Z, Wang D, Pei F. Synergistic Effect of a Prolonged Combination Course of Tranexamic Acid and Dexamethasone Involving High Initial Doses in Total Knee Arthroplasty: A Randomized Controlled Trial. J Knee Surg 2021; 36:515-523. [PMID: 34794198 DOI: 10.1055/s-0041-1739197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The optimal regimes of tranexamic acid (TXA) and dexamethasone (DXM) in total knee arthroplasty (TKA) are still uncertain. The aim of this study was to assess the efficacy and safety of a prolonged course of intravenous TXA and DXM involving a high initial dose in TKA. Patients who underwent primary TKA at our center were randomized to receive one of four regimes: control (group A), prolonged course of TXA (B), prolonged course of DXM (C), or the combination of a prolonged course of TXA and DXM (D). The four groups were compared in primary outcomes (fibrinolytic and inflammatory markers, knee function, postoperative pain levels, and consumption of opioids) and secondary outcomes (blood loss, maximal drop in hemoglobin, coagulation, fasting blood glucose, and complications). A total of 162 patients were enrolled. On postoperative days 2 and 3, fibrinolytic markers were lower in groups B and D than in groups A and C; inflammatory markers were lower in groups C and D than in groups A and B. Inflammatory markers were lower in group B than in group A on postoperative day 3. Postoperative pain levels and oxycodone consumption were lower, and knee function was better in groups C and D. The four groups did not differ in any of the secondary outcomes. A prolonged course of intravenous TXA and DXM involving high initial doses can effectively inhibit postoperative fibrinolytic and inflammatory responses, reduce pain, and improve knee function after TKA.
Collapse
Affiliation(s)
- Hong Xu
- Department of Orthopaedic Surgery and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Sichuan, China
| | - Jinwei Xie
- Department of Orthopaedic Surgery and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Sichuan, China
| | - Jingli Yang
- College of Earth and Environmental Sciences and School of Public Health, Lanzhou University, Lanzhou, Gansu, China
| | - Zeyu Huang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Sichuan, China
| | - Duan Wang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Sichuan, China
| | - Fuxing Pei
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Sichuan, China
| |
Collapse
|
10
|
Nielsen NI, Kehlet H, Gromov K, Troelsen A, Husted H, Varnum C, Kjærsgaard-Andersen P, Rasmussen LE, Pleckaitiene L, Foss NB. High-dose steroids in high pain responders undergoing total knee arthroplasty: a randomised double-blind trial. Br J Anaesth 2021; 128:150-158. [PMID: 34749994 PMCID: PMC8787770 DOI: 10.1016/j.bja.2021.10.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/01/2021] [Accepted: 10/03/2021] [Indexed: 01/31/2023] Open
Abstract
Background Total knee arthroplasty (TKA) is associated with moderate-to-severe postoperative pain despite multimodal opioid-sparing analgesia. Pain catastrophising or preoperative opioid therapy is associated with increased postoperative pain. Preoperative glucocorticoid improves pain after TKA, but dose-finding studies and benefit in high pain responders are lacking. Methods A randomised double-blind controlled trial with preoperative high-dose intravenous dexamethasone 1 mg kg−1 or intermediate-dose dexamethasone 0.3 mg kg−1 in 88 patients undergoing TKA with preoperative pain catastrophising score >20 or regular opioid use was designed. The primary outcome was the proportion of patients experiencing moderate-to-severe pain (VAS >30) during a 5 m walk 24 h postoperatively. Secondary outcomes included pain at rest during nights and at passive leg raise, C-reactive protein, opioid use, quality of sleep, Quality of Recovery-15 and Opioid-Related Symptom Distress Scale, readmission, and complications. Results Moderate-to-severe pain when walking 24 h postoperatively was reduced (high dose vs intermediate dose, 49% vs 79%; P<0.01), along with pain at leg raise at 24 and 48 h (14% vs 29%, P=0.02 and 12% vs 31%, P=0.03, respectively). C-reactive protein was reduced in the high-dose group at both 24 and 48 h (both P<0.01). Quality of Recovery-15 was also improved (P<0.01). Conclusions When compared with preoperative dexamethasone 0.3 mg kg−1 i.v., dexamethasone 1 mg kg−1 reduced moderate-to-severe pain 24 h after TKA and improved recovery in high pain responders without apparent side-effects. Clinical trial registration NCT03763734.
Collapse
Affiliation(s)
- Niklas I Nielsen
- Department of Anaesthesiology, Copenhagen University, Hvidovre Hospital, Copenhagen, Denmark.
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kirill Gromov
- Department of Orthopaedic Surgery, Copenhagen University, Hvidovre Hospital, Copenhagen, Denmark
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Copenhagen University, Hvidovre Hospital, Copenhagen, Denmark
| | - Henrik Husted
- Department of Orthopaedic Surgery, Copenhagen University, Hvidovre Hospital, Copenhagen, Denmark
| | - Claus Varnum
- Department of Orthopaedic Surgery, Lillebaelt Hospital, Vejle, Denmark
| | | | - Lasse E Rasmussen
- Department of Orthopaedic Surgery, Lillebaelt Hospital, Vejle, Denmark
| | | | - Nicolai B Foss
- Department of Anaesthesiology, Copenhagen University, Hvidovre Hospital, Copenhagen, Denmark
| |
Collapse
|
11
|
Mena GE, Zorrilla-Vaca A, Vaporciyan A, Mehran R, Lasala JD, Williams W, Patel C, Woodward T, Kruse B, Joshi G, Rice D. Intraoperative Dexmedetomidine and Ketamine Infusions in an Enhanced Recovery After Thoracic Surgery Program: A Propensity Score Matched Analysis. J Cardiothorac Vasc Anesth 2021; 36:1064-1072. [PMID: 34690059 DOI: 10.1053/j.jvca.2021.09.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/15/2021] [Accepted: 09/22/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To assess the impact of intraoperative dexmedetomidine and ketamine on postoperative pain and opioid consumption within an ERAS program in thoracic pulmonary oncologic surgery. DESIGN Retrospective, propensity-score matched analysis SETTING: Enhanced Recovery After Surgery (ERAS) program. PARTICIPANTS Patients undergoing thoracic pulmonary oncologic surgery between March 2016 and April 2020. INTERVENTIONS Continuous infusion of dexmedetomidine and ketamine. MEASUREMENTS & MAIN RESULTS The authors initially analyzed data of 1,630 patients undergoing thoracic pulmonary oncologic surgery within their ERAS program. In total, 117 matched pairs were included in this analysis. Patients in the intraoperative dexmedetomidine + ketamine group were more likely to be opioid-free (76.6% vs 60.9%, P<0.01). Raw analysis showed lower pain scores at PACU admission (2.8±2.0 vs 3.4±2.0, P=0.03) and less opioid consumption at PACU admission (5 MED [0-10] vs 7.5 MED [0-15], P=0.03) in the dexmedetomidine + ketamine group; however, these differences were not present after adjusting for multiplicity. There were no significant differences in the length of PACU stay (1.9 hours [1.5-2.8] vs 2.0 hours [1.4-2.9], P=0.48) or hospital stay (three days [two-five] vs three days [two-five], P=0.08). Both groups had similar rates of pulmonary complications (5.9% vs 9.4%, P=0.326), ileus (0.9% vs 0.9%, P=1.00), and 30-day readmission (2.6% vs 4.3%, P=0.722). CONCLUSIONS There were no differences in postoperative pain scores and opioid consumption throughout their hospital stay between patients receiving concomitant dexmedetomidine and ketamine infusions versus patients who did not receive these infusions during thoracic surgery.
Collapse
Affiliation(s)
- Gabriel E Mena
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Andres Zorrilla-Vaca
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX; Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX; Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, MA.
| | - Ara Vaporciyan
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Reza Mehran
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Javier D Lasala
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Wendell Williams
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carla Patel
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - TaCharra Woodward
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brittany Kruse
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Girish Joshi
- Department of Anesthesiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - David Rice
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
| |
Collapse
|
12
|
Opioid-free Anesthesia: Reply. Anesthesiology 2021; 135:758-759. [PMID: 34388826 DOI: 10.1097/aln.0000000000003907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
13
|
Kehlet H. Preoperative oral carbohydrate to enhance recovery-need for better study analysis. Langenbecks Arch Surg 2021; 406:2563. [PMID: 34374849 DOI: 10.1007/s00423-021-02277-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 07/13/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Henrik Kehlet
- Section for Surgical Pathophysiology, 7621, Rigshospitalet, Copenhagen University, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| |
Collapse
|
14
|
Joshi GP, Kehlet H. Meta-analyses of gabapentinoids for pain management after knee arthroplasty: A caveat emptor? A narrative review. Acta Anaesthesiol Scand 2021; 65:865-869. [PMID: 33728646 DOI: 10.1111/aas.13820] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/15/2021] [Accepted: 03/01/2021] [Indexed: 12/21/2022]
Abstract
The use of gabapentinoids for perioperative pain management after total knee arthroplasty has been the subject of nine systematic reviews and meta-analyses. A critical analysis of the clinical aspects of the methodology of these publications shows major flaws which limit the interpretation for the recommended use of perioperative gabapentinoids in pain management for unilateral primary total knee arthroplasty. Consequently, readers and authors of systematic reviews and meta-analyses should critically assess the clinical aspects of the included studies.
Collapse
Affiliation(s)
- Girish P. Joshi
- Anesthesiology and Pain Management University of Texas Southwestern Medical Center Dallas TX USA
| | - Henrik Kehlet
- Section of Surgical PathophysiologyRigshospitalet Copenhagen Denmark
| |
Collapse
|
15
|
Feeley AA, Feeley TB, Feeley IH, Sheehan E. Postoperative Infection Risk in Total Joint Arthroplasty After Perioperative IV Corticosteroid Administration: A Systematic Review and Meta-Analysis of Comparative Studies. J Arthroplasty 2021; 36:3042-3053. [PMID: 33902983 DOI: 10.1016/j.arth.2021.03.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/16/2021] [Accepted: 03/31/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Perioperative corticosteroid administration is associated with reduced postoperative nausea, pain, and enhanced recovery after surgery. However, potential complications including wound and periprosthetic joint infections remain a concern for surgeons after total joint arthroplasty (TJA). METHODS A systematic review of the search databases PubMed, Google Scholar, and EMBASE was made in January 2021 to identify comparative studies evaluating infection risk after perioperative corticosteroid administration in TJA. PRISMA guidelines were used for this review. Meta-analysis was used to assess infection risk in accordance with joint and corticosteroid dosing regimen used. RESULTS 201 studies were returned after initial search strategy, with 29 included for review after application of inclusion and exclusion criteria. Studies were categorized as using low- or high-dose corticosteroid with single or repeat dosing regimens. Single low-dose corticosteroid administration was not associated with an increased risk of infection (P = .4; CI = 0.00-0.00). Single high-dose corticosteroid was not associated with an increased infection risk (P = .3; CI = 0.00-0.01) nor did repeat low-dose regimens result in increased risk of infection (P = .8; CI = -0.02-0.02). Studies assessing repeat high-dosing regimens reported no increased infection, with small numbers of participants included. No significant risk difference in infection risk was noted in hip (P = .59; CI = -0.03-0.02) or knee (P = .2; CI = 0.00-0.01) arthroplasty. Heterogeneity in patient profiles included in studies to date was noted. CONCLUSION Use of perioperative corticosteroid in TJA does not appear to be associated with increased risk of postoperative infection in patients with limited comorbidities. Further research is warranted to evaluate postoperative complications after TJA in these at-risk patient populations.
Collapse
Affiliation(s)
- Aoife A Feeley
- Department of Orthopaedics, Midland Regional Hospital Tullamore, Puttaghan, Tullamore, Ireland
| | - Tara B Feeley
- Department of Anaesthetics, Starship Children's Hospital, Auckland, New Zealand
| | - Iain H Feeley
- Department of Orthopaedics, National Orthopaedic Hospital Cappagh, Cappoge, Dublin, Ireland
| | - Eoin Sheehan
- Department of Orthopaedics, Midland Regional Hospital Tullamore, Puttaghan, Tullamore, Ireland
| |
Collapse
|
16
|
Tam KW, Cheng PL, Loh EW, Chen JT. Reply to Letter to Editor concerning "Effects of preoperative oral carbohydrate on postoperative discomfort in patients undergoing elective surgery: a meta-analysis of randomized controlled trials". Langenbecks Arch Surg 2021; 406:2565-2566. [PMID: 34275014 DOI: 10.1007/s00423-021-02278-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Ka-Wai Tam
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.
- Center for Evidence-Based Health Care, Shuang Ho Hospital, Taipei Medical University, No. 291, Zhongzheng Road, Zhonghe District, New Taipei City, 23561, Taiwan.
- Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.
| | - Po-Lung Cheng
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - El-Wui Loh
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
- Center for Evidence-Based Health Care, Shuang Ho Hospital, Taipei Medical University, No. 291, Zhongzheng Road, Zhonghe District, New Taipei City, 23561, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Jui-Tai Chen
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| |
Collapse
|
17
|
El-Boghdadly K, Short AJ, Gandhi R, Chan V. Addition of dexamethasone to local infiltration analgesia in elective total knee arthroplasty: double-blind, randomized control trial. Reg Anesth Pain Med 2020; 46:130-136. [PMID: 33199379 DOI: 10.1136/rapm-2020-102079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/21/2020] [Accepted: 10/24/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Total knee arthroplasty is associated with significant pain, and effective analgesia is beneficial to patient satisfaction and functional outcomes. Studies have demonstrated that dexamethasone may have a facilitatory role on the action of local anesthesia, but this effect, when added to a local infiltration analgesia (LIA) mixture for patients having knee arthroplasty, is underexplored. Our hypothesis was that the addition of dexamethasone to local anesthetic infiltration would improve analgesic outcomes following total knee arthroplasty. METHODS We performed a double-blind, randomized controlled trial of 140 patients undergoing elective, unilateral, total knee arthroplasty. Patients were randomly allocated to receive either 2 mL of saline 0.9% or 2 mL of dexamethasone 4 mg/mL added to a LIA mixture. Our primary outcome was 24 hours of oral morphine equivalent consumption. Our secondary outcomes included short-term and long-term analgesic and functional outcomes and adverse events. RESULTS A total of 72 patients were included in the saline group and 68 were included in the dexamethasone group. We found comparable 24 hours of morphine consumption between saline and dexamethasone groups, with a median of 60 (IQR 40-105 (range 16-230)) mg and 56 (IQR 41-75 (range 0-300)) mg, respectively (p=0.096). Dexamethasone was associated with a statistically significant reduction in total inpatient opioid consumption, incidence of requiring rescue patient-controlled analgesia, length of hospital stay, and postoperative nausea, compared with saline. Patients in the dexamethasone group had a greater range of joint movement and distance walked on postoperative day 1 than the saline group. There were no differences in rest or active pain scores, timed up and go or 3-month outcomes. CONCLUSIONS Dexamethasone 8 mg was associated with no improvements in 24 hours of morphine consumption but was associated with modest improvements in short-term analgesia, short-term function, length of stay and postoperative nausea. There were no long-term benefits in the use of dexamethasone in LIA for patients undergoing total knee arthroplasty. TRIAL REGISTRATION NUMBER NCT02760043.
Collapse
Affiliation(s)
- Kariem El-Boghdadly
- Department of Theatres, Anaesthesia and Perioperative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK .,King's College London, London, London, UK
| | - Anthony James Short
- Department of Anaesthetics, Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan, UK
| | - Rajiv Gandhi
- Division of Orthopedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Vincent Chan
- Department of Anesthesia and Pain Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| |
Collapse
|
18
|
Ganio EA, Stanley N, Lindberg-Larsen V, Einhaus J, Tsai AS, Verdonk F, Culos A, Ghaemi S, Rumer KK, Stelzer IA, Gaudilliere D, Tsai E, Fallahzadeh R, Choisy B, Kehlet H, Aghaeepour N, Angst MS, Gaudilliere B. Preferential inhibition of adaptive immune system dynamics by glucocorticoids in patients after acute surgical trauma. Nat Commun 2020; 11:3737. [PMID: 32719355 PMCID: PMC7385146 DOI: 10.1038/s41467-020-17565-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 07/03/2020] [Indexed: 02/08/2023] Open
Abstract
Glucocorticoids (GC) are a controversial yet commonly used intervention in the clinical management of acute inflammatory conditions, including sepsis or traumatic injury. In the context of major trauma such as surgery, concerns have been raised regarding adverse effects from GC, thereby necessitating a better understanding of how GCs modulate the immune response. Here we report the results of a randomized controlled trial (NCT02542592) in which we employ a high-dimensional mass cytometry approach to characterize innate and adaptive cell signaling dynamics after a major surgery (primary outcome) in patients treated with placebo or methylprednisolone (MP). A robust, unsupervised bootstrap clustering of immune cell subsets coupled with random forest analysis shows profound (AUC = 0.92, p-value = 3.16E-8) MP-induced alterations of immune cell signaling trajectories, particularly in the adaptive compartments. By contrast, key innate signaling responses previously associated with pain and functional recovery after surgery, including STAT3 and CREB phosphorylation, are not affected by MP. These results imply cell-specific and pathway-specific effects of GCs, and also prompt future studies to examine GCs' effects on clinical outcomes likely dependent on functional adaptive immune responses.
Collapse
Affiliation(s)
- Edward A Ganio
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Natalie Stanley
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | | | - Jakob Einhaus
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Amy S Tsai
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Franck Verdonk
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Anthony Culos
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Sajjad Ghaemi
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
- Digital Technologies Research Centre, National Research Council Canada, Toronto, ON, Canada
| | - Kristen K Rumer
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Ina A Stelzer
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Dyani Gaudilliere
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - Eileen Tsai
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Ramin Fallahzadeh
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Benjamin Choisy
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Henrik Kehlet
- Section of Surgical Pathophysiology 7621, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Nima Aghaeepour
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Martin S Angst
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Brice Gaudilliere
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA.
| |
Collapse
|
19
|
Author's Reply: Evidence-Based Management of Postoperative Pain in Adults Undergoing Laparoscopic Sleeve Gastrectomy. World J Surg 2020; 44:3965-3966. [PMID: 32621036 DOI: 10.1007/s00268-020-05673-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
20
|
Wiles MD. Is blood pressure maintenance more important than type of anaesthesia for patients undergoing mechanical thrombectomy after ischaemic stoke? Anaesthesia 2020; 75:716-719. [DOI: 10.1111/anae.14974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2019] [Indexed: 12/25/2022]
Affiliation(s)
- M. D. Wiles
- Department of Anaesthesia and Operating Services Sheffield Teaching Hospitals NHS Foundation Trust Sheffield UK
| |
Collapse
|