1
|
Grape S, El-Boghdadly K, Jaques C, Albrecht E. Efficacy and safety of intrathecal diamorphine: a systematic review and meta-analysis with meta-regression and trial sequential analysis. Anaesthesia 2024; 79:1081-1090. [PMID: 38922818 DOI: 10.1111/anae.16359] [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] [Accepted: 05/14/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Intrathecal diamorphine is believed to provide postoperative analgesia but is associated with adverse effects such as nausea and vomiting. There is little evidence of synthesis regarding intrathecal diamorphine in the contemporary literature. We performed a systematic review, meta-analysis with meta-regression and trial sequential analysis to determine the magnitude of intrathecal diamorphine efficacy and safety. METHODS We systematically searched the literature for trials comparing intrathecal diamorphine with a control group in patients undergoing all types of surgery. The primary efficacy and safety outcomes were intravenous morphine consumption and incidence of postoperative nausea and vomiting at 24 h following surgery, respectively. RESULTS Twelve trials were identified, which included data for 712 patients. Intrathecal doses of diamorphine ranged from 100 μg to 2500 μg. Intravenous morphine consumption at 24 h postoperatively was significantly reduced in the intrathecal diamorphine group, with a mean difference (95%CI) of -8 mg (-11 to -6), I2 = 93%, p < 0.001. There was a significant difference between three intrathecal diamorphine dosing subgroups but without correlation: mean differences (95%CI) -1 mg (-3-0), -26 mg (-40 to -11) and -6 mg (-15-4) in patients receiving doses of 0-200 μg, 201-400 μg and > 400 μg, respectively (p = 0.003). Intrathecal diamorphine increased postoperative nausea and vomiting with a risk ratio (95%CI) of 1.37 (1.19-1.58), I2 = 7%, p < 0.001. There were no differences in postoperative nausea and vomiting between the three intrathecal diamorphine dosing subgroups. There was no correlation observed with meta-regression of the primary efficacy and safety outcomes. The quality of evidence for all outcomes was very low. CONCLUSION There is very low level of evidence that intrathecal diamorphine provides effective analgesia after surgery, while increasing postoperative nausea and vomiting with doses > 200 μg.
Collapse
Affiliation(s)
- Sina Grape
- Department of Anaesthesia, Valais Hospital, Sion, Switzerland
- University of Lausanne, Lausanne, Switzerland
| | - Kariem El-Boghdadly
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Cecile Jaques
- Medical Library, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Eric Albrecht
- University of Lausanne, Lausanne, Switzerland
- Department of Anaesthesia, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| |
Collapse
|
2
|
Hewson DW, Tedore TR, Hardman JG. Impact of spinal or epidural anaesthesia on perioperative outcomes in adult noncardiac surgery: a narrative review of recent evidence. Br J Anaesth 2024; 133:380-399. [PMID: 38811298 PMCID: PMC11282476 DOI: 10.1016/j.bja.2024.04.044] [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: 02/20/2024] [Revised: 04/23/2024] [Accepted: 04/30/2024] [Indexed: 05/31/2024] Open
Abstract
Spinal and epidural anaesthesia and analgesia are important anaesthetic techniques, familiar to all anaesthetists and applied to patients undergoing a range of surgical procedures. Although the immediate effects of a well-conducted neuraxial technique on nociceptive and sympathetic pathways are readily observable in clinical practice, the impact of such techniques on patient-centred perioperative outcomes remains an area of uncertainty and active research. The aim of this review is to present a narrative synthesis of contemporary clinical science on this topic from the most recent 5-year period and summarise the foundational scholarship upon which this research was based. We searched electronic databases for primary research, secondary research, opinion pieces, and guidelines reporting the relationship between neuraxial procedures and standardised perioperative outcomes over the period 2018-2023. Returned citation lists were examined seeking additional studies to contextualise our narrative synthesis of results. Articles were retrieved encompassing the following outcome domains: patient comfort, renal, sepsis and infection, postoperative cancer, cardiovascular, and pulmonary and mortality outcomes. Convincing evidence of the beneficial effect of epidural analgesia on patient comfort after major open thoracoabdominal surgery outcomes was identified. Recent evidence of benefit in the prevention of pulmonary complications and mortality was identified. Despite mechanistic plausibility and supportive observational evidence, there is less certain experimental evidence to support a role for neuraxial techniques impacting on other outcome domains. Evidence of positive impact of neuraxial techniques is best established for the domains of patient comfort, pulmonary complications, and mortality, particularly in the setting of major open thoracoabdominal surgery. Recent evidence does not strongly support a significant impact of neuraxial techniques on cancer, renal, infection, or cardiovascular outcomes after noncardiac surgery in most patient groups.
Collapse
Affiliation(s)
- David W Hewson
- Department of Anaesthesia and Critical Care, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK; Academic Unit of Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Nottingham, UK.
| | - Tiffany R Tedore
- Department of Anesthesiology, Weill Cornell Medicine, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Jonathan G Hardman
- Department of Anaesthesia and Critical Care, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK; Academic Unit of Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| |
Collapse
|
3
|
Albrecht E, Renard Y, Desai N. Intravenous versus perineural dexamethasone to prolong analgesia after interscalene brachial plexus block: a systematic review with meta-analysis and trial sequential analysis. Br J Anaesth 2024; 133:135-145. [PMID: 38782616 PMCID: PMC11213995 DOI: 10.1016/j.bja.2024.03.042] [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: 01/30/2024] [Revised: 03/15/2024] [Accepted: 03/22/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND The efficacy of perineural vs intravenous dexamethasone as a local anaesthetic adjunct to increase duration of analgesia could be particular to specific peripheral nerve blocks because of differences in systemic absorption depending on the injection site. Given this uncertainty, we performed a systematic review with meta-analysis and trial sequential analysis comparing dexamethasone administered perineurally or intravenously combined with local anaesthetic for interscalene brachial plexus block. METHODS Following a search of various electronic databases, we included 11 trials (1145 patients). The primary outcome was the duration of analgesia defined as the time between peripheral nerve block or onset of sensory blockade and the time to first analgesic request or initial report of pain. RESULTS The primary outcome, duration of analgesia, was greater in the perineural dexamethasone group, with a mean difference (95% confidence interval) of 122 (62-183) min, I2=73%, P<0.0001. Trial sequential analysis indicated that firm evidence had been reached. The quality of evidence was downgraded to low, mainly because of moderate inconsistency and serious publication bias. No significant differences were present for any of the secondary outcomes, except for onset time of sensory and motor blockade and resting pain score at 12 h, but the magnitude of differences was not clinically relevant. CONCLUSIONS There is low-quality evidence that perineural administration of dexamethasone as a local anaesthetic adjunct increases duration of analgesia by an average of 2 h compared with intravenous injection for interscalene brachial plexus block. Given the limited clinical relevance of this difference, the off-label use of perineural administration, and the risk of drug crystallisation, we recommend intravenous dexamethasone administration. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42023466147).
Collapse
Affiliation(s)
- Eric Albrecht
- Department of Anaesthesia, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Yves Renard
- Department of Anaesthesia, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Neel Desai
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK; King's College London, London, UK
| |
Collapse
|
4
|
Salazar-Flórez JE, Arenas-Cardona LT, Marhx N, López-Guerrero E, Echeverri-Rendón ÁP, Giraldo-Cardona LS. Transversus Abdominis Plane Block versus Epidural Anesthesia for Pain Management Post-Caesarean Delivery: A Pilot Study. Local Reg Anesth 2024; 17:39-47. [PMID: 38650746 PMCID: PMC11033210 DOI: 10.2147/lra.s444947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/16/2024] [Indexed: 04/25/2024] Open
Abstract
Background Effective post-operative analgesia profoundly influences patient recovery and outcomes after caesarean delivery. The Transversus Abdominis Plane (TAP) block represents a potential alternative, potentially offering greater effectiveness than epidural analgesia while causing fewer adverse effects. Objective To assess if the abdominal transverse block provides superior postoperative pain relief in patients undergoing caesarean delivery compared to epidural analgesia. Methods Participants were divided into parallel groups: an experimental group receiving TAP block (n=25) and a control group receiving epidural analgesia (n=24). All patients received a 10 mg dose of hyoscine at the end of the surgery. Experimental Group received a total of 20 mL of 0.2% ropivacaine. In Epidural group received 0.2% ropivacaine at 4 mL/h for 24 hours. All participants were administered combined with neuroaxial block anesthesia. The patients selected for epidural analgesia received the mentioned dose, while the other group block had the epidural catheter removed after the cesarean section. The primary outcome was post-caesarean pain, evaluated using the Visual Analog Scale (VAS) at four intervals (0, 6, 12, and 24 hours). Also, surgical bleeding and residual motor were evaluated. VAS pain scores between the groups were compared using the Friedman test and Generalized Linear Model (GLM) for non-normally distributed data. The effect size was estimated with Eta Square ([Formula: see text]), considering values ≥0.38 as indicative of large effects. A two-tailed p-value < 0.05 was deemed statistically significant. Results Statistically significant differences in pain scores were noted at 0 and 6 hours post-surgery (p<0.01). The TAP block group reported lower pain scores at 0 hours (mean=0.04) and 6 hours (mean=1.16) compared to the epidural group, reflecting a substantial effect size. Conclusion The TAP block proves advantageous in mitigating postoperative pain for women post-caesarean delivery, particularly in the initial 6 postpartum hours. This relief promotes early mother-infant bonding and facilitates breastfeeding.
Collapse
Affiliation(s)
| | - Leidy Tatiana Arenas-Cardona
- Department of Medicine, Hospital General de Occidente, University Health Sciences Center of University of Guadalajara, Jalisco, Mexico
| | - Ninemy Marhx
- Department of Medicine, Hospital General de Occidente, University Health Sciences Center of University of Guadalajara, Jalisco, Mexico
| | - Eduardo López-Guerrero
- Department of Medicine, Hospital General de Occidente, University Health Sciences Center of University of Guadalajara, Jalisco, Mexico
| | | | | |
Collapse
|
5
|
Li S, Wang Y, Zhang Y, Zhang H, Wang S, Ma K, Jiang L, Mao Y. Effect of ultrasound-guided transversus abdominis plane block in reducing atelectasis after laparoscopic surgery in children: A randomized clinical trial. Heliyon 2024; 10:e26594. [PMID: 38420373 PMCID: PMC10901023 DOI: 10.1016/j.heliyon.2024.e26594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 02/10/2024] [Accepted: 02/15/2024] [Indexed: 03/02/2024] Open
Abstract
Background Atelectasis is a commonly observed postoperative complication of general anesthesia in children. Pulmonary protective ventilation strategies have been reported to have a beneficial effect on postoperative atelectasis in children. Therefore, the present study aimed to evaluate the efficacy of the ultrasound-guided transversus abdominis plane (TAP) block technique in preventing the incidence of postoperative atelectasis in children. Materials and methods This study enrolled 100 consecutive children undergoing elective laparoscopic bilateral hernia repair and randomly divided them into the control and TAP groups. Conventional lung-protective ventilation was initiated in both groups after the induction of general anesthesia. The children in the TAP group received an ultrasound-guided TAP block with 0.3 mL/kg of 0.5% ropivacaine after the induction of anesthesia. Results Anesthesia-induced atelectasis was observed in 24% and 84% of patients in the TAP (n = 50) and control (n = 50) groups, respectively, before discharge from the post-anesthetic care unit (T3; PACU) (odds ratio [OR], 0.062; 95% confidence interval [CI], 0.019-0.179; P < 0.001). No significant difference was observed between the control and TAP groups in terms of the lung ultrasonography (LUS) scores 5 min after endotracheal intubation (T1). However, the LUS scores were lower in the TAP group than those in the control group at the end of surgery (T2, P < 0.01) and before discharge from the PACU (T3, P < 0.001). Moreover, the ace, legs, activity, cry and consolability (FLACC) pain scores in the TAP group were lower than those in the control group at each postoperative time point. Conclusion Ultrasound-guided TAP block effectively reduced the incidence of postoperative atelectasis and alleviated pain in children undergoing laparoscopic surgery.
Collapse
Affiliation(s)
- Siyuan Li
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200092, Shanghai, China
| | - Yan Wang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200092, Shanghai, China
| | - Yunqian Zhang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200092, Shanghai, China
| | - Hui Zhang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200092, Shanghai, China
| | - Shenghua Wang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200092, Shanghai, China
| | - Ke Ma
- Department of Pain Medicine, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200092, Shanghai, China
| | - Lai Jiang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200092, Shanghai, China
| | - Yanfei Mao
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200092, Shanghai, China
| |
Collapse
|
6
|
Xie J, De Souza E, Perez F, Suárez-Nieto MV, Wang E, Anderson TA. Perioperative Regional Anesthesia Pain Outcomes in Children: A Retrospective Study of 3160 Regional Anesthetics in Routine Practice. Clin J Pain 2024; 40:72-81. [PMID: 37942728 DOI: 10.1097/ajp.0000000000001172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 10/28/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVE Randomized controlled trials indicate regional anesthesia (RA) improves postoperative outcomes with reduced pain and opioid consumption. Therefore, we hypothesized children who received RA, regardless of technique, would have reduced pain/opioid use in routine practice. METHODS Using a retrospective cohort, we assessed the association of RA with perioperative outcomes in everyday practice at our academic pediatric hospital. Patients 18 years or below undergoing orthopedic, urologic, or general surgeries with and without RA from May 2014 to September 2021 were categorized as single shot, catheter based, or no block. Outcomes included intraoperative opioid exposure and dose, preincision anesthesia time, postanesthesia care unit (PACU) opioid exposure and dose, PACU antiemetic/antipruritic administration, PACU/inpatient pain scores, PACU/inpatient lengths of stay, and cumulative opioid exposure. Regression models estimated the adjusted association of RA with outcomes, controlling for multiple variables. RESULTS A total of 11,292 procedures with 3160 RAs were included. Compared with no-block group, single-shot and catheter-based blocks were associated with opioid-free intraoperative anesthesia and opioid-free PACU stays. Post-PACU (ie, while inpatient), single-shot blocks were not associated with improved pain scores or reduced opioid use. Catheter-based blocks were associated with reduced PACU and inpatient opioid use until 24 hours postop, no difference in opioid use from 24 to 36 hours, and a higher probability of use from 36 to 72 hours. RA was not associated with reduced cumulative opioid consumption. DISCUSSION Despite adjustment for confounders, the association of RA with pediatric pain/opioid use outcomes was mixed. Further investigation is necessary to maximize the benefits of RA.
Collapse
Affiliation(s)
- James Xie
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | | | | | | | | | | |
Collapse
|
7
|
Xu X, Tao Y, Yang Y, Zhang J, Sun M. Application of Butorphanol versus Sufentanil in Multimode Analgesia via Patient Controlled Intravenous Analgesia After Hepatobiliary Surgery: A Retrospective Cohort Study. Drug Des Devel Ther 2023; 17:3757-3766. [PMID: 38144418 PMCID: PMC10749102 DOI: 10.2147/dddt.s433136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 12/13/2023] [Indexed: 12/26/2023] Open
Abstract
Purpose We investigate the efficacy and safety of butorphanol in multimodal analgesia combined with dexmedetomidine and ketorolac via patient-controlled intravenous analgesia (PCIA) after hepatobiliary surgery, as compared with sufentanil. Patients and Methods Postoperative follow-up data of hepatobiliary surgery patients in Henan Provincial People's Hospital from March 2018 to June 2021 were collected retrospectively and divided into butorphanol group (group B) or sufentanil group (group S) according to the postoperative intravenous controlled analgesia scheme. The baseline characteristics and surgical information of the two groups were matched through propensity score matching (PSM). Results A total of 3437 patients were screened, and PSM yielded 1816 patients after matching, including 908 in the butorphanol group and 908 in the sufentanil group. Compared with group S, the incidence of moderate-to-severe pain on the first postoperative day and the second postoperative day was lower in group B during rest (3.2% vs 10.9%, P<0.001; 1.2% vs 4.6%, P<0.001), and during movement (7.0% vs 18.9%, P<0.001; 2.6% vs 8.7%, P<0.001). Patients receiving butorphanol had a lower morphine consumption (50mg vs 120mg, P<0.001). The bolus attempts of an analgesic pump in group B were significantly lower than in group S (1 vs 2, P<0.001). Postoperative hospital length of stay was shortened in group B (11d vs 12d, P=0.017). The occurrence of postoperative vomiting was lower in group B (1.4% vs 3.0%, P=0.025) than in group S. However, more patients in group B experienced dizziness (0.9% vs 0.1%, P=0.019). Conclusion Compared with sufentanil, the application of butorphanol in multimodal analgesia combined with dexmedetomidine and ketorolac via PCIA ameliorated postoperative pain after hepatobiliary surgery, with reduced opioid consumption and shorter postoperative hospital length of stay.
Collapse
Affiliation(s)
- Xiaodong Xu
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, 450003, People’s Republic of China
| | - Yuan Tao
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, 450003, People’s Republic of China
| | - Yitian Yang
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, 450003, People’s Republic of China
| | - Jiaqiang Zhang
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, 450003, People’s Republic of China
| | - Mingyang Sun
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, 450003, People’s Republic of China
| |
Collapse
|
8
|
Sangkum L, Tangjitbampenbun A, Chalacheewa T, Brennan K, Liu H. Peripheral Nerve Blocks for Cesarean Delivery Analgesia: A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1951. [PMID: 38004000 PMCID: PMC10673165 DOI: 10.3390/medicina59111951] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/23/2023] [Accepted: 10/31/2023] [Indexed: 11/26/2023]
Abstract
Effective postoperative analgesia using multimodal approach improves maternal and neonatal outcomes after cesarean delivery. The use of neuraxial approach (local anesthetic and opioids) and intravenous adjunctive drugs, such as nonsteroidal anti-inflammatory drugs and acetaminophen, currently represents the standard regimen for post-cesarean delivery analgesia. Peripheral nerve blocks may be considered in patients who are unable to receive neuraxial techniques; these blocks may also be used as a rescue technique in selected patients. This review discusses the relevant anatomy, current evidence, and advantages and disadvantages of the various peripheral nerve block techniques. Further research is warranted to compare the analgesic efficacy of these techniques, especially newer blocks (e.g., quadratus lumborum blocks and erector spinae plane blocks). Moreover, future studies should determine the safety profile of these blocks (e.g., fascial plane blocks) in the obstetric population because of its increased susceptibility to local anesthetic toxicity.
Collapse
Affiliation(s)
- Lisa Sangkum
- Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (L.S.); (A.T.); (T.C.)
| | - Amornrat Tangjitbampenbun
- Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (L.S.); (A.T.); (T.C.)
| | - Theerawat Chalacheewa
- Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (L.S.); (A.T.); (T.C.)
| | - Kristin Brennan
- Department of Anesthesiology, Penn Medicine Lancaster General Hospital, 555 N Duke St., Lancaster, PA 17602, USA;
| | - Henry Liu
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, The University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| |
Collapse
|
9
|
Xiao D, Sun Y, Gong F, Yin Y, Wang Y. A Systematic Review and Meta-Analysis Comparing the Effectiveness of Transversus Abdominis Plane Block and Caudal Block for Relief of Postoperative Pain in Children Who Underwent Lower Abdominal Surgeries. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1527. [PMID: 37763646 PMCID: PMC10533035 DOI: 10.3390/medicina59091527] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: Postoperative pain after lower abdominal surgery is typically severe. Traditionally, in pediatric anesthesia, a caudal block (CB) has been used for pain management in these cases. Nowadays, a transversus abdominis plane block (TAPB) seems to be an effective alternative. However, which technique for perioperative analgesia is better and more effective remains unclear in children who undergo abdominal surgeries. The aim of this study was to compare the efficacy and safety of a TAPB and CB for pain management in children after abdominal surgery by conducting a meta-analysis of published papers in this area. Methods: We conducted a thorough search of PubMed, EMBASE, the Cochrane Library, and the Web of Science for randomized controlled trials (RCTs) that compared a TAPB and CB for pain management in children who had abdominal surgery. Two researchers screened and assessed all the information with RevMan5.3 used for this meta-analysis. Pain scores, the total dose of rescue analgesic given, the mean duration of analgesia, the intraoperative and postoperative hemodynamic conditions 24 h after surgery, and adverse events were compared. Results: 15 RCTs that involved a total of 970 pediatric patients were included in this study. The results of this meta-analysis showed that there were no significant differences between the 2 groups in terms of postoperative pain scores at 1 h (SMD = 0.35; 95% CI = -0.54 to 1.24; p = 0.44, I2 = 94%), 6 h (SMD = -0.10; 95% CI = -0.44 to -0.23; p = 0.55, I2 = 69%), 12 h (SMD = -0.02; 95% CI = -0.45 to -0.40; p = 0.93, I2 = 80%), and 24 h (SMD = -0.66; 95% CI = -1.57 to -0.25; p = 0.15, I2 = 94%); additional analgesic requirement (OR 0.25; 95% CI 0.09 to 0.63; p = 0.004, I2 = 72%); total dose of rescue analgesic given in 24 h (SMD = -0.37; 95% CI = -1.33 to -0.58; p = 0.44; I2 = 97%); mean duration of analgesia (SMD = 1.29; 95% CI = 0.01 to 2.57; p = 0.05, I2 = 98%); parents' satisfaction (SMD = 0.44; 95% CI = -0.12 to 1.0; p = 0.12; I2 = 80%); and intraoperative and postoperative hemodynamic conditions 24 h after the surgery and adverse events (SMD = 0.78; 95% CI = 0.22 to 2.82; p = 0.70; I2 = 62%). Compared to a CB, a TAPB resulted in a small but significant reduction in additional analgesic requirement after surgery (OR 0.25; 95% CI 0.09 to 0.63; p = 0.004). Conclusions: TAPBs and CBs result in similar efficient early analgesia and safety profiles in children undergoing abdominal surgeries. Moreover, no disparities were observed for adverse effects between TAPBs and CBs.
Collapse
Affiliation(s)
- Dan Xiao
- Department of Pediatrics, Yongchuan Hospital Affiliated to Chongqing Medical University, Chongqing 402160, China; (D.X.); (Y.W.)
| | - Yiyuan Sun
- Day Surgery Center, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu 610017, China; (Y.S.); (Y.Y.)
| | - Fang Gong
- Department of Pediatrics, Yongchuan Hospital Affiliated to Chongqing Medical University, Chongqing 402160, China; (D.X.); (Y.W.)
| | - Yu Yin
- Day Surgery Center, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu 610017, China; (Y.S.); (Y.Y.)
| | - Yue Wang
- Department of Pediatrics, Yongchuan Hospital Affiliated to Chongqing Medical University, Chongqing 402160, China; (D.X.); (Y.W.)
| |
Collapse
|
10
|
Paladini A, Rawal N, Coca Martinez M, Trifa M, Montero A, Pergolizzi J, Pasqualucci A, Narvaez Tamayo MA, Varrassi G, De Leon Casasola O. Advances in the Management of Acute Postsurgical Pain: A Review. Cureus 2023; 15:e42974. [PMID: 37671225 PMCID: PMC10475855 DOI: 10.7759/cureus.42974] [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: 07/19/2023] [Accepted: 08/04/2023] [Indexed: 09/07/2023] Open
Abstract
Despite the millions of surgeries performed every year around the world, postoperative pain remains prevalent and is often addressed with inadequate or suboptimal treatments. Chronic postsurgical pain is surprisingly prevalent, and its rate varies with the type of surgery, as well as with certain patient characteristics. Thus, better clinical training is needed as well as patient education. As pain can be caused by more than one mechanism, multimodal or balanced postsurgical analgesia is appropriate. Pharmacological agents such as opioid and nonopioid pain relievers, as well as adjuvants and nonpharmacologic approaches, can be combined to provide better and opioid-sparing pain relief. Many specialty societies have guidelines for postoperative pain management that emphasize multimodal postoperative analgesia. These guidelines are particularly helpful when dealing with special populations such as pregnant patients or infants and children. Pediatric pain control, in particular, can be challenging as patients may be unable to communicate their pain levels. A variety of validated assessment tools are available for diagnosis. Related to therapy, most guidelines agree on the fact that codeine should be used with extreme caution in pediatric patients as some may be "rapid metabolizers" and its use may be life-threatening. Prehabilitation is a preoperative approach that prepares patients in advance of elective surgery with conditioning exercises and other interventions to optimize their health. Prehabilitation may have aerobic, strength-training, nutritional, and counseling components. Logistical considerations and degree of patient adherence represent barriers to effective prehabilitation programs. Notwithstanding all this, acute postoperative pain represents a clinical challenge that has not yet been well addressed.
Collapse
Affiliation(s)
- Antonella Paladini
- Department of Life, Health and Environmental Sciences (MESVA), University of L'Aquila, L'Aquila, ITA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Zhu C, Fang J, Yang J, Geng Q, Li Q, Zhang H, Xie Y, Zhang M. The Role of Ultrasound-Guided Multipoint Fascial Plane Block in ElderlyPatients Undergoing Combined Thoracoscopic-Laparoscopic Esophagectomy: A Prospective Randomized Study. Pain Ther 2023; 12:841-852. [PMID: 37099123 PMCID: PMC10199967 DOI: 10.1007/s40122-023-00514-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/04/2023] [Indexed: 04/27/2023] Open
Abstract
INTRODUCTION We estimated the safety and efficacy of ultrasound-guided multipoint fascial plane block, including serratus anterior plane block (SAPB) and bilateral transversus abdominis plane block (TAPB) in elderly patients who underwent combined thoracoscopic-laparoscopic esophagectomy (TLE). METHODS The authors enrolled 80 patients in this prospective study after patient selection using the inclusion and exclusion criteria who were scheduled for elective TLE from May 2020 to May 2021. Patients were randomly assigned to the treated group (group N) or the control group (group C) (n = 40 per group) using the sealed-envelope method. Multipoint fascial plane blocks, including serratus anterior plane block (SAPB) and bilateral TAPB, were performed on patients undergoing TLE using a solution of 60 mL 0.375% ropivacaine plus 2.5 mg dexamethasone by 3 injections of 20 mL each (group N) or no interventions (group C). RESULTS Systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) at T incision and 30 min after T incision were significantly higher in group C than in group N, and also significantly higher than at baseline (P < 0.01). Blood glucose at 60 min, 2 h after T incision, was significantly higher in group C than in group N and significantly higher than at baseline (P < 0.01). Compared to group N, the dosages of propofol and remifentanil used during surgery in group C were more than those in group N (P < 0.01). The time to first rescue analgesic in group C was earlier than in group N. The total postoperative use of sufentanil, and the number of patients requiring rescue analgesics in group C, were more than in group N (P < 0.01). CONCLUSIONS This study showed that applying the multipoint fascia pane block technique in TLE for elderly patients could significantly reduce postoperative pain, decrease the dosages of drugs used in general anesthesia, improve the quality of the awakening, and have no obvious adverse reactions. TRIAL REGISTRATION Chinese Clinical Trial Registry (ChiCTR-2000033617).
Collapse
Affiliation(s)
- Chenchen Zhu
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, No 9 Lujiang Road, Hefei, 230001, People's Republic of China
| | - Jun Fang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, No 9 Lujiang Road, Hefei, 230001, People's Republic of China
| | - Jia Yang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, No 9 Lujiang Road, Hefei, 230001, People's Republic of China
| | - Qingtian Geng
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, No 9 Lujiang Road, Hefei, 230001, People's Republic of China
| | - Qijian Li
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, No 9 Lujiang Road, Hefei, 230001, People's Republic of China
| | - Huaming Zhang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, No 9 Lujiang Road, Hefei, 230001, People's Republic of China
| | - Yanhu Xie
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, No 9 Lujiang Road, Hefei, 230001, People's Republic of China
| | - Min Zhang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, No 9 Lujiang Road, Hefei, 230001, People's Republic of China.
| |
Collapse
|
12
|
Maury T, Elnar A, Marchionni S, Frisoni R, Goetz C, Bécret A. Effect of rectus sheath anaesthesia versus thoracic epidural analgesia on postoperative recovery quality after elective open abdominal surgery in a French regional hospital: the study protocol of a randomised controlled QoR-RECT-CATH trial. BMJ Open 2023; 13:e069736. [PMID: 37221022 PMCID: PMC10410969 DOI: 10.1136/bmjopen-2022-069736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 04/20/2023] [Indexed: 05/25/2023] Open
Abstract
INTRODUCTION Enhanced recovery after surgery (ERAS) protocols increase patient well-being while significantly reducing mortality, costs and length-of-stay after surgery. A key component is multimodal analgesia that prevents postoperative pain and facilitates early refeeding and mobilisation. Thoracic epidural analgesia (TEA) was long the gold standard for locoregional anaesthesia in anterior abdominal wall surgery. However, newer wall-block techniques such as rectus-sheath block (RSB) may be preferable because they are less invasive and may provide equivalent analgesia with fewer side effects. Since the evidence base remains limited, the Quality Of Recovery enhanced by REctus sheat CATHeter (QoR-RECT-CATH) randomised controlled trial (RCT) was designed to assess whether RSB elicits better postoperative rehabilitation than TEA after laparotomy. METHODS AND ANALYSIS This open-label parallel-arm 1:1-allocated RCT will determine whether RSB is superior to TEA in 110 patients undergoing scheduled midline laparotomy in terms of postoperative rehabilitation quality. The setting is a regional French hospital that provides opioid-free anaesthesia for all laparotomies within an ERAS programme. Recruited patients will be ≥18 years, scheduled to undergo laparotomy, have American Society of Anesthesiologists (ASA) score 1-4 and lack contraindications to ropivacaine/TEA. TEA-allocated patients will receive an epidural catheter before surgery while RSB-allocated patients will receive rectus sheath catheters after surgery. All other pre/peri/postoperative procedures will be identical, including multimodal postoperative analgesia provided according to our standard of care. Primary objective is a change in total Quality-of-Recovery-15 French-language (QoR-15F) score on postoperative day (POD) 2 relative to baseline. QoR-15F is a patient-reported outcome measure that is commonly used to measure ERAS outcomes. The 15 secondary objectives include postoperative pain scores, opioid consumption, functional recovery measures and adverse events. ETHICS AND DISSEMINATION The French Ethics Committee (Sud-Ouest et Outre-Mer I Ethical Committee) gave approval. Subjects are recruited after providing written consent after receiving the information provided by the investigator. The results of this study will be made public through peer-reviewed publication and, if possible, conference publications. TRIAL REGISTRATION NUMBER NCT04985695.
Collapse
Affiliation(s)
- Thomas Maury
- Department of Anaesthesiology, Regional Hospital Centre Metz-Thionville, Metz Cedex 03, France
- Faculty of Medicine, Université de Lorraine-Site de Nancy, Vandoeuvre lès Nancy, France
| | - Arpiné Elnar
- Clinical Research Support Unit, Regional Hospital Centre Metz-Thionville, Metz, France
| | - Sandra Marchionni
- Clinical Research Support Unit, Regional Hospital Centre Metz-Thionville, Metz, France
| | - Romain Frisoni
- Department of Digestive Surgery, Regional Hospital Centre Metz-Thionville, Metz, France
- Department of Digestive Surgery, Private Hospital Jeanne d'Arc, Lunéville, France
| | - Christophe Goetz
- Clinical Research Support Unit, Regional Hospital Centre Metz-Thionville, Metz, France
| | - Antoine Bécret
- Department of Anaesthesiology, Regional Hospital Centre Metz-Thionville, Metz Cedex 03, France
| |
Collapse
|
13
|
Muacevic A, Adler JR, Gupta V, Verma S. Ultrasound-Guided Transversus Abdominis Plane Block Versus Single-Shot Epidural Block for Postoperative Analgesia in Patients Undergoing Inguinal Hernia Surgery. Cureus 2023; 15:e33876. [PMID: 36819433 PMCID: PMC9933787 DOI: 10.7759/cureus.33876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2023] [Indexed: 01/19/2023] Open
Abstract
Background Transversus abdominis plane (TAP) block and epidural analgesia are two frequently used regional anaesthesia techniques that attenuate postoperative pain after inguinal hernia repair. Aim To compare the analgesic efficacy between the single-shot epidural block and TAP block for postoperative analgesia in patients undergoing inguinal hernia repair surgery. Methods Forty patients of either gender undergoing elective inguinal hernia surgery of American Society of Anesthesiologists (ASA) class Ⅰ and Ⅱ were randomly allocated into two groups. Group E received a single-shot epidural with 20 ml of 0.25% bupivacaine. Group T received a TAP block with 20 ml of 0.25% bupivacaine under ultrasound guidance. Postoperative pain was evaluated by the visual analog scale (VAS). Rescue analgesia was given on VAS score ≥ 4 or on-demand in the postoperative period. The primary outcome included VAS score at 15 min, 1st h, 2nd h, 6th h, 12th h, and 24th h after the block. The secondary outcome was the analgesia duration, the total rescue analgesia dose required, and the patient satisfaction level. Results The VAS pain scores were significantly lower in the epidural group compared to the TAP group at the 2nd, 6th, 12th, and 24th h postoperatively (p<0.0001). The mean duration of analgesia was significantly more in Group E (576.75±96.64 min) compared to Group T (276.75±105.56 min). The total analgesic consumption was seen significantly more in 24 h in Group T than in Group E. Patient satisfaction score was significantly higher with a mean value of 5.55±0.6 in group E compared to 4.75±0.72 in group T. Conclusion A single-shot epidural provides better postoperative pain control than a TAP block. The duration of the first analgesic demand was prolonged, with less analgesic consumption in the epidural group.
Collapse
|
14
|
Transverse abdominis plane block compared with patient-controlled epidural analgesia following abdominal surgery: a meta-analysis and trial sequential analysis. Sci Rep 2022; 12:20606. [PMID: 36446941 PMCID: PMC9709047 DOI: 10.1038/s41598-022-25073-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 11/24/2022] [Indexed: 11/30/2022] Open
Abstract
Thoracic epidural analgesia (TEA) and transversus abdominis plane (TAP) block are used for pain control after abdominal surgery. Although there have been several meta-analyses comparing these two techniques, the conclusion was limited by a small number of studies and heterogeneity among studies. Our meta-analysis used the Medline, EMBASE, and Cochrane central library databases from their inception through September 2022. Randomized controlled trials (RCTs) comparing TEA and TAP block were included. The pre-specified primary outcome was the pain score at rest at 12 h postoperatively. Twenty-two RCTs involving 1975 patients were included. Pooled analyses showed the pain score at rest at 12 h postoperatively was significantly different between groups favoring TEA group (Mean difference [MD] 0.58, 95% confidence interval CI - 0.01, 1.15, P = 0.04, I2 = 94%). TEA group significantly reduced the pain score at 48 h at rest (MD 0.59, 95% CI 0.15, 1.03, P = 0.009, I2 = 86%) and at 48 h at movement (MD 0.53, 95% CI 0.07, 0.99, P = 0.03, I2 = 76%). However, there was no significant difference at other time points. Time to ambulation was shorter in TAP block but the incidence of hypotension at 24 h and 72 h was significantly lower in TAP block compared to TEA. Trial sequential analysis showed that the required information size has not yet been reached. Our meta-analysis demonstrated there was no significant or clinically meaningful difference in the postoperative pain scores between TEA and TAP block group. Given the insufficient information size revealed by TSA, the high risk of bias of our included studies, and the significant heterogeneity of our meta-analysis results, our results should be interpreted carefully but it is not likely that the addition of further studies could prove any clinically meaningful difference in pain score between these two techniques.
Collapse
|
15
|
Yang M, Kang C, Zhu S. Effects of epidural anesthesia in pheochromocytoma and paraganglioma surgeries: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e31768. [PMID: 36451496 PMCID: PMC9704962 DOI: 10.1097/md.0000000000031768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Anesthetic management is a great challenge during the surgical resection of pheochromocytomas and paragangliomas (PPGLs) due to potential hemodynamic fluctuations and/or postoperative complications. Although combined epidural-general anesthesia is commonly used in PPGLs surgeries, there is still no consensus whether combined epidural-general anesthesia was superior than general anesthesia alone for these populations. For the first time, we conducted this systematic review and meta-analysis to summarize the effects of combined epidural-general anesthesia versus general anesthesia alone on hemodynamic fluctuations as well as postoperative complications in patients undergone PPGLs surgeries. METHODS This systematic review and meta-analysis was performed according to the preferred reporting items for systematic reviews and meta-analyses statement. The primary outcome were hemodynamic fluctuations, including intraoperative hypotension, postoperative hypotension, and hypertensive crisis. Secondary outcome was the incidence of postoperative complications during hospital stay. RESULTS Finally, three retrospective cohort studies involving 347 patients met the inclusion criteria. A meta-analysis was not performed since outcomes from included studies were not available to be pooled. On the basis of the findings of non-randomized controlled trials (RCTs) literature, 2 studies suggested that combined epidural-general anesthesia was associated with intraoperative and postoperative hypotension, although one study reported that epidural anesthesia use reduced the incidence of postoperative complications in patients undergone surgical resection of PPGLs. CONCLUSIONS Currently, no published RCTs have yet assessed clinically relevant outcomes with respect to the application of epidural anesthesia during PPGLs surgeries. Well-designed RCTs should nonetheless be encouraged to properly assess the efficacy and safety of epidural anesthesia for PPGLs surgeries.
Collapse
Affiliation(s)
- Min Yang
- Department of Anesthesiology, Northwest Women’s and Children’s Hospital, Xi’an, China
| | - Chao Kang
- Department of Anesthesiology, Northwest Women’s and Children’s Hospital, Xi’an, China
| | - Shuai Zhu
- Department of Anesthesiology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- * Correspondence: Shuai Zhu, Department of Anesthesiology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, China (e-mail: )
| |
Collapse
|
16
|
Alsharari AF, Abuadas FH, Alnassrallah YS, Salihu D. Transversus Abdominis Plane Block as a Strategy for Effective Pain Management in Patients with Pain during Laparoscopic Cholecystectomy: A Systematic Review. J Clin Med 2022; 11:6896. [PMID: 36498471 PMCID: PMC9735918 DOI: 10.3390/jcm11236896] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 11/24/2022] Open
Abstract
Laparoscopic cholecystectomy (LC), unlike laparotomy, is an invasive surgical procedure, and some patients report mild to moderate pain after surgery. Transversus abdominis plane (TAP) block has been shown to be an appropriate method for postoperative analgesia in patients undergoing abdominal surgery. However, there have been few studies on the efficacy of TAP block after LC surgery, with unclear information on the optimal dose, long-term effects, and clinical significance, and the analgesic efficacy of various procedures, hence the need for this review. Five electronic databases (PubMed, Academic Search Premier, Web of Science, CINAHL, and Cochrane Library) were searched for eligible studies published from inception to the present. Post-mean and standard deviation values for pain assessed were extracted, and mean changes per group were calculated. Clinical significance was determined using the distribution-based approach. Four different local anesthetics (Bupivacaine, Ropivacaine, Lidocaine, and Levobupivacaine) were used at varying concentrations from 0.2% to 0.375%. Ten different drug solutions (i.e., esmolol, Dexamethasone, Magnesium Sulfate, Ketorolac, Oxycodone, Epinephrine, Sufentanil, Tropisetron, normal saline, and Dexmedetomidine) were used as adjuvants. The optimal dose of local anesthetics for LC could be 20 mL with 0.4 mL/kg for port infiltration. Various TAP procedures such as ultrasound-guided transversus abdominis plane (US-TAP) block and other strategies have been shown to be used for pain management in LC; however, TAP blockade procedures were reported to be the most effective method for analgesia compared with general anesthesia and port infiltration. Instead of 0.25% Bupivacaine, 1% Pethidine could be used for the TAP block procedures. Multimodal analgesia could be another strategy for pain management. Analgesia with TAP blockade decreases opioid consumption significantly and provides effective analgesia. Further studies should identify the long-term effects of different TAP block procedures.
Collapse
Affiliation(s)
| | | | | | - Dauda Salihu
- College of Nursing, Jouf University, Sakaka 72388, Saudi Arabia
| |
Collapse
|
17
|
Holtz M, Liao N, Lin JH, Asche CV. Economic Outcomes and Incidence of Postsurgical Hypotension With Liposomal Bupivacaine vs Epidural Analgesia in Abdominal Surgeries. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2022; 9:86-94. [PMID: 36168593 PMCID: PMC9473799 DOI: 10.36469/001c.37739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 08/09/2022] [Indexed: 06/16/2023]
Abstract
Background: Epidural analgesia can be associated with high costs and postsurgical risks such as hypotension, despite its widespread use and value in providing opioid-sparing pain management. We tested the hypothesis that liposomal bupivacaine (LB) might be a reliable alternative to epidural analgesia in this real-world study. Objectives: To compare economic outcomes and hypotension incidence associated with use of LB and epidural analgesia for abdominal surgery. Methods: This retrospective analysis identified records of adults who underwent abdominal surgeries between January 2016 and September 2019 with either LB administration or traditional epidural analgesia using the Premier Healthcare Database. Economic outcomes included length of stay, hospital costs, rates of discharge to home, and 30-day hospital readmissions. Secondary outcomes included incidence of postsurgical hypotension and vasopressor use. Subgroup analyses were stratified by surgical procedure (colorectal, abdominal) and approach (endoscopic, open). A generalized linear model adjusted for patient and hospital characteristics was used for all comparisons. Results: A total of 5799 surgical records (LB, n=4820; epidural analgesia, n=979) were included. Compared with cases where LB was administered, cases of epidural analgesia use were associated with a 1.6-day increase in length of stay (adjusted rate ratio [95% confidence interval (CI), 1.2 [1.2-1.3]]; P<.0001) and $6304 greater hospital costs (adjusted rate ratio [95% CI], 1.2 [1.2-1.3]]; P<.0001). Cost differences were largely driven by room-and-board fees. Epidural analgesia was associated with reduced rates of discharge to home (P<.0001) and increased 30-day readmission rates (P=.0073) compared with LB. Epidural analgesia was also associated with increased rates of postsurgical hypotension (30% vs 11%; adjusted odds ratio [95% CI], 2.8 [2.3-3.4]; P<.0001) and vasopressor use (22% vs 7%; adjusted odds ratio [95% CI], 3.1 [2.5-4.0]; P<.0001) compared with LB. Subgroup analyses by surgical procedure and approach were generally consistent with overall comparisons. Discussion: Our results are consistent with previous studies that demonstrated epidural analgesia can be associated with higher utilization of healthcare resources and complications compared with LB. Conclusions: Compared with epidural analgesia, LB was associated with economic benefits and reduced incidence of postsurgical hypotension and vasopressor use.
Collapse
Affiliation(s)
| | - Nick Liao
- Pacira Biosciences, Inc, Parsippany, New Jersey
| | | | - Carl V Asche
- Department of Internal Medicine, University of Illinois College of Medicine, Peoria, Illinois
| |
Collapse
|
18
|
Xue FS, Tian T, Li XT. Comment on “Transversus abdominis plane block with liposomal bupivacaine versus continuous epidural analgesia for major abdominal surgery: The EXPLANE randomized trial”. J Clin Anesth 2022; 80:110869. [DOI: 10.1016/j.jclinane.2022.110869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 04/17/2022] [Accepted: 04/23/2022] [Indexed: 11/29/2022]
|
19
|
Liu KY, Lu YJ, Lin YC, Wei PL, Kang YN. Transversus abdominis plane block for laparoscopic colorectal surgery: A meta-analysis of randomised controlled trials. Int J Surg 2022; 104:106825. [PMID: 35953018 DOI: 10.1016/j.ijsu.2022.106825] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/19/2022] [Accepted: 07/27/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND The effectiveness of transversus abdominis plane block (TAP) on pain management after laparoscopic colorectal surgery (CRS) remains unclear since the only relevant meta-analysis on this topic did not separate laparoscopic CRS from open CRS. The aim of the study was to compare the analgesic efficacy and safety of TAP with non-TAP in patients undergoing laparoscopic CRS. METHODS Four databases were searched for randomized controlled trials (RCTs) on this topic using relevant keywords. Two authors independently completed evidence selection, data extraction, and critical appraisal. Available data were pooled in the random-effects model, and point estimates with 95% confidence interval (CI) were reported for postoperative pain at rest and on coughing, opioid consumption, length of hospital stay, and adverse events. RESULTS A total of 14 RCTs (n = 1216) contributed to the present synthesis. Pooled result showed that patients in the TAP group had lower pain at rest than those in the non-TAP group at postoperative 2-h (mean difference [MD] = -1.42; P < 0.05), 4-h (MD = -0.97; P < 0.05), 12-h (MD = -0.75; P < 0.05), and 24-h (MD = -0.61; P < 0.05). Patients in the TAP group also had lower postoperative pain on coughing than those in the non-TAP group on the first day (MD = -1.02; P < 0.05). Moreover, TAP had lesser postoperative opioid consumption than non-TAP (standardized mean difference, -0.26; P < 0.05; I-square = 20%), and there were non-significant differences in hospital stay and adverse event between the two groups. CONCLUSION Intraoperative TAP is a safe and feasible pain management for laparoscopic CRS, particularly it is recommended when patient-controlled analgesia is not delivered. Therefore, laparoscopic TAP block might be a favorable administered strategy.
Collapse
Affiliation(s)
- Kai-Yuan Liu
- Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yen-Jung Lu
- Division of Colorectal Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yu-Cih Lin
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei, Taiwan; School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Po-Li Wei
- Department of Surgery, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of Colorectal Surgery, Department of Surgery, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan; Cancer Research Center, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan; Translational Laboratory, Department of Medical Research, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan; Graduate Institute of Cancer Biology and Drug Discovery, Taipei Medical University, Taipei, Taiwan 3. Evidence-Based Medicine Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
| | - Yi-No Kang
- Evidence-based Medicine Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Research Center of Big Data and Meta-analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan; Institute of Health Policy & Management, College of Public Health, National Taiwan University, Taipei, Taiwan.
| |
Collapse
|
20
|
Pirie K, Traer E, Finniss D, Myles PS, Riedel B. Current approaches to acute postoperative pain management after major abdominal surgery: a narrative review and future directions. Br J Anaesth 2022; 129:378-393. [PMID: 35803751 DOI: 10.1016/j.bja.2022.05.029] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/27/2022] [Accepted: 05/28/2022] [Indexed: 11/02/2022] Open
Abstract
Poorly controlled postoperative pain is associated with increased morbidity, negatively affects quality of life and functional recovery, and is a risk factor for persistent pain and longer-term opioid use. Up to 10% of opioid-naïve patients have persistent opioid use after many types of surgeries. Opioid-related side-effects and the opioid abuse epidemic emphasise the need for alternative, opioid-minimising, multimodal analgesic strategies, including neuraxial (epidural/intrathecal) techniques, truncal nerve blocks, and lidocaine infusions. The preference for minimally invasive surgical techniques has changed anaesthetic and analgesic requirements in abdominal surgery compared with open laparotomy, leading to a decline in popularity of epidural anaesthesia and an increasing interest in intrathecal morphine and truncal nerve blocks. Limited research exists on patient quality of recovery using specific analgesic techniques after intra-abdominal surgery. Poorly controlled postoperative pain after major abdominal surgery should be a research priority as it affects patient-centred short-term and long-term outcomes (including quality of life scores, return to function measurements, disability-free survival) and has broad community health and economic implications.
Collapse
Affiliation(s)
- Katrina Pirie
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia; Central Clinical School, Monash University, Melbourne, Victoria, Australia.
| | - Emily Traer
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Damien Finniss
- Department of Anaesthesia & Pain Management, Royal North Shore Hospital, Sydney, Australia
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia; Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Bernhard Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| |
Collapse
|
21
|
Kong H, Xu LM, Wang DX. Perioperative neurocognitive disorders: A narrative review focusing on diagnosis, prevention, and treatment. CNS Neurosci Ther 2022; 28:1147-1167. [PMID: 35652170 PMCID: PMC9253756 DOI: 10.1111/cns.13873] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 05/03/2022] [Accepted: 05/06/2022] [Indexed: 12/13/2022] Open
Abstract
Perioperative neurocognitive disorders (NCDs) refer to neurocognitive abnormalities detected during the perioperative periods, including preexisting cognitive impairment, preoperative delirium, delirium occurring up to 7 days after surgery, delayed neurocognitive recovery, and postoperative NCD. The Diagnostic and Statistical Manual of Mental Disorders‐5th edition (DSM‐5) is the golden standard for diagnosing perioperative NCDs. Given the impracticality of using the DSM‐5 by non‐psychiatric practitioners, many diagnostic tools have been developed and validated for different clinical scenarios. The etiology of perioperative NCDs is multifactorial and includes predisposing and precipitating factors. Identifying these risk factors is conducive to preoperative risk stratification and perioperative risk reduction. Prevention for perioperative NCDs should include avoiding possible contributors and implementing nonpharmacologic and pharmacological interventions. The former generally includes avoiding benzodiazepines, anticholinergics, prolonged liquid fasting, deep anesthesia, cerebral oxygen desaturation, and intraoperative hypothermia. Nonpharmacologic measures include preoperative cognitive prehabilitation, comprehensive geriatric assessment, implementing fast‐track surgery, combined use of regional block, and sleep promotion. Pharmacological measures including dexmedetomidine, nonsteroidal anti‐inflammatory drugs, and acetaminophen are found to have beneficial effects. Nonpharmacological treatments are the first‐line measures for established perioperative NCDs. Pharmacological treatments are still limited to severely agitated or distressed patients.
Collapse
Affiliation(s)
- Hao Kong
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Long-Ming Xu
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Dong-Xin Wang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China.,Outcomes Research Consortium, Cleveland, Ohio, USA
| |
Collapse
|
22
|
El-Boghdadly K, Jack JM, Heaney A, Black ND, Englesakis MF, Kehlet H, Chan VWS. Role of regional anesthesia and analgesia in enhanced recovery after colorectal surgery: a systematic review of randomized controlled trials. Reg Anesth Pain Med 2022; 47:282-292. [PMID: 35264431 DOI: 10.1136/rapm-2021-103256] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/25/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Effective analgesia is an important element of enhanced recovery after surgery (ERAS), but the clinical impact of regional anesthesia and analgesia for colorectal surgery remains unclear. OBJECTIVE We aimed to determine the impact of regional anesthesia following colorectal surgery in the setting of ERAS. EVIDENCE REVIEW We performed a systematic review of nine databases up to June 2020, seeking randomized controlled trials comparing regional anesthesia versus control in an ERAS pathway for colorectal surgery. We analyzed the studies with successful ERAS implementation, defined as ERAS protocols with a hospital length of stay of ≤5 days. Data were qualitatively synthesized. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. FINDINGS Of the 29 studies reporting ERAS pathways, only 13 comprising 1170 patients were included, with modest methodological quality and poor reporting of adherence to ERAS pathways. Epidural analgesia had limited evidence of outcome benefits in open surgery, while spinal analgesia with intrathecal opioids may potentially be associated with improved outcomes with no impact on length of stay in laparoscopic surgery, though dosing must be further investigated. There was limited evidence for fascial plane blocks or other regional anesthetic techniques. CONCLUSIONS Although there was variable methodological quality and reporting of ERAS, we found little evidence demonstrating the clinical benefits of regional anesthetic techniques in the setting of successful ERAS implementation, and future studies must report adherence to ERAS in order for their interventions to be generalizable to modern clinical practice. PROSPERO REGISTRATION NUMBER CRD42020161200.
Collapse
Affiliation(s)
- Kariem El-Boghdadly
- Department of Anaesthesia and Perioperative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK .,Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - James M Jack
- Department of Anaesthesia and Perioperative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Aine Heaney
- Department of Anaesthesia and Perioperative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nick D Black
- Department of Anaesthesia, Belfast Health and Social Care Trust, Belfast, UK
| | - Marina F Englesakis
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Henrik Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen, Denmark
| | - Vincent W S Chan
- Department of Anesthesiology and Pain Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| |
Collapse
|
23
|
Han K, Zhang Y, Bai R, An R, Zhang S, Xue M, Shen X. Application of Ultrasound-Guided Transversus Abdominis Plane Block Combined with Nalbuphine Patient-Controlled Intravenous Analgesia in Postoperative Analgesia After Laparotomy: A Randomized Controlled Trial. Pain Ther 2022; 11:627-641. [PMID: 35420393 PMCID: PMC9098735 DOI: 10.1007/s40122-022-00379-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 03/17/2022] [Indexed: 12/01/2022] Open
Abstract
Introduction Pain is a common postoperative complication. The ideal postoperative analgesia is awake, safe, mobile, and without side effects. The objective of this study is to provide new ideas for postoperative analgesia by observing the safety and analgesic effect of different analgesic methods in patients undergoing laparotomy after surgery. Methods Patients, who underwent laparotomy between September 2019 and December 2020, were randomly divided into three groups: group S received sufentanil, group N received nalbuphine, group T + N received postoperative bilateral transversus abdominis plane block (TAPB) and nalbuphine. The primary outcomes included visual analog scale (VAS) score and the use of postoperative analgesic pump. Secondary outcomes included quality of life recovery (QoR-15) scale score and incidence of postoperative adverse reactions. Results Compared with group S and N, there were significant differences in the resting VAS score within 48 h after surgery, dynamic VAS score within 12 h after surgery, the first compression time, and cumulative use of patient-controlled intravenous analgesia (PCIA) drugs at 24 h in group T + N (P < 0.05). The QoR-15 score within 48 h after surgery in group T + N was significantly higher than group N (P < 0.05). The first exhaust time and the incidence of nausea and vomiting in group T + N were significantly lower than those in group N (P < 0.05). Conclusions Sufentanil PCIA and nalbuphine PCIA have equivalent analgesic effects, while TAPB combined with nalbuphine PCIA can ensure a good analgesic effect, thereby reducing the incidence of adverse reactions.
Collapse
Affiliation(s)
- Kunyu Han
- Department of Anesthesiology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Yuhe Zhang
- Department of Anesthesiology, Xianyang Hospital of Yan'an University, Xianyang, 712000, Shaanxi, China
| | - Ruiping Bai
- Department of Anesthesiology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Rui An
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Simei Zhang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Mengwen Xue
- Department of Anesthesiology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China.
| | - Xin Shen
- Department of Anesthesiology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China.
| |
Collapse
|
24
|
Xue Q, Chu Z, Zhu J, Zhang X, Chen H, Liu W, Jia B, Zhang Y, Wang Y, Huang C, Hu X. Analgesic Efficacy of Transverse Abdominis Plane Block and Quadratus Lumborum Block in Laparoscopic Sleeve Gastrectomy: A Randomized Double-Blinded Clinical Trial. Pain Ther 2022; 11:613-626. [PMID: 35312948 PMCID: PMC9098772 DOI: 10.1007/s40122-022-00373-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/07/2022] [Indexed: 10/27/2022] Open
|
25
|
Lee SY, Ryu CG, Koo YH, Cho H, Jung H, Park YH, Kang H, Lee SE, Shin HY. The effect of ultrasound-guided transversus abdominis plane block on pulmonary function in patients undergoing laparoscopic cholecystectomy: a prospective randomized study. Surg Endosc 2022; 36:7334-7342. [PMID: 35182213 DOI: 10.1007/s00464-022-09131-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/09/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Transversus abdominis plane block (TAPB) is commonly used for postoperative pain control after laparoscopic cholecystectomy. However, few studies have analyzed its effect on pulmonary function. The goal of this study was to elucidate the effect of ultrasound-guided bilateral TAPB on pulmonary function preservation and analgesia after laparoscopic cholecystectomy. METHODS We enrolled 58 patients who underwent laparoscopic cholecystectomy. Among them, 53 were randomized to group T (n = 27) and group C (n = 26). Group T and group C received ultrasound-guided bilateral TAPB with 40 ml of 0.375% ropivacaine and 40 ml of 0.9% normal saline, respectively. Visual analog scale (VAS) scores, patient-controlled analgesia (PCA) consumption, forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC, peak expiratory flow rate (PEF), and modified Borg scale scores were measured until 24 h post-surgery. RESULTS The VAS scores were significantly lower in group T than in group C at 1 and 8 h after the surgery. PCA consumption was significantly lower in group T than in group C at all postoperative time points. FEV1, PEF, and FEV1/FVC were more preserved in group T than in group C at 1 h. Group T had significantly lower modified Borg scale scores than did group C at 1 and 8 h. CONCLUSION Ultrasound-guided TAPB is effective in pulmonary function preservation and pain control after laparoscopic cholecystectomy. Therefore, it could be a great option for multimodal analgesia, preservation of pulmonary function, prevention of pulmonary complications including atelectasis, and promotion of postoperative recovery after laparoscopic cholecystectomy. CLINICAL REGISTRATION This study was enrolled in the Clinical Research Information Service (Clinical Research Information Service, KCT0004435, Hwa Yong Shin, 2019-08-19).
Collapse
Affiliation(s)
- Seung Young Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Choon Gun Ryu
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Young Hyun Koo
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Hana Cho
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Haesun Jung
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Yong Hee Park
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Seung Eun Lee
- Department of Surgery, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Hwa Yong Shin
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul, Republic of Korea.
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, 102 Heukseok-ro, Dongjak-gu, Seoul, 06973, Republic of Korea.
| |
Collapse
|
26
|
El Sherif FA, Abdel-Ghaffar H, Othman A, Mohamed S, Omran M, Shouman S, Hassan N, Allam A, Hassan S. Pharmacokinetics and Pharmacodynamics of Dexmedetomidine Administered as an Adjunct to Bupivacaine for Transversus Abdominis Plane Block in Patients Undergoing Lower Abdominal Cancer Surgery. J Pain Res 2022; 15:1-12. [PMID: 35035233 PMCID: PMC8753994 DOI: 10.2147/jpr.s335806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 12/16/2021] [Indexed: 11/23/2022] Open
Abstract
Background Despite the growing interest in dexmedetomidine as an adjunct to truncal blocks, little is known about the systemic absorption of dexmedetomidine after these blocks and its role in analgesia and in hemodynamics. Objective We investigated the pharmacokinetics and pharmacodynamics of dexmedetomidine as an adjunct to transversus abdominis plane (TAP) block in patients undergoing lower abdominal cancer surgery. Methods Twenty-four adult patients were randomized to receive a bilateral single-injection TAP block before surgery with 20 mL of bupivacaine 0.5% (TAP group, n = 12) or combined with 1 µg/kg dexmedetomidine (TAP-DEX group, n = 12) and diluted with saline to a volume of 40 mL (20 mL on each side). Plasma concentrations of dexmedetomidine and its pharmacokinetics were investigated using non-compartmental methods, postoperative analgesia, hemodynamics, and adverse events (nausea, vomiting, itching, hypotension, bradycardia, and respiratory depression). Results Dexmedetomidine was detected in the plasma of 11 patients in the TAP-DEX group. The mean dexmedetomidine peak plasma concentration (Cmax) was 0.158 ± 0.085 (range, 0.045-0.31) ng/mL. The median time to reach peak plasma concentration of dexmedetomidine (Tmax) was 15 (15-45) min. From 2 to 8 h postoperatively, visual analog pain scale (VAS) scores at rest and during movement were significantly lower in the TAP-DEX group. Analgesia time was (11.3 ± 3.12 vs 9.0 ± 4.69 h; P = 0.213) and postoperative morphine consumption was (7.4 ± 3.24 vs 11.5 ± 4.46 mg; P = 0.033) in TAP-DEX and TAP groups, respectively. Lower mean heart rate and mean blood pressure were recorded in the TAP-DEX group intraoperatively and 2 h postoperatively (P < 0.05). Except for mild nausea and vomiting, no adverse events were recorded in either group. Conclusion Systemic absorption of dexmedetomidine administered in a TAP block is common. Direct central effects on the locus coeruleus caused by this systemic absorption may play a role in the analgesia and hemodynamic effects produced by TAP-dexmedetomidine in addition to local mechanisms. Trial Registration ClinicalTrial.gov (identifier: NCT03328299).
Collapse
Affiliation(s)
- Fatma A El Sherif
- Anesthesia, Intensive Care and Pain Management Department, South Egypt Cancer Institute, Assiut University, Assiut, Egypt
| | - Hala Abdel-Ghaffar
- Anesthesia and Intensive Care Department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed Othman
- Anesthesia, Intensive Care and Pain Management Department, South Egypt Cancer Institute, Assiut University, Assiut, Egypt
| | - Sahar Mohamed
- Anesthesia, Intensive Care and Pain Management Department, South Egypt Cancer Institute, Assiut University, Assiut, Egypt
| | - Mervat Omran
- Cancer Biology Department (Pharmacology and Experimental Oncology), National Cancer Institute, Cairo University, Cairo, Egypt
| | - Samia Shouman
- Cancer Biology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Nivin Hassan
- Cancer Biology Department (Pharmacology and Experimental Oncology), South Egypt Cancer Institute, Assiut University, Assiut, Egypt
| | - Ayat Allam
- Pharmaceutics Department, Faculty of Pharmacy, Assiut University, Assiut, 71515, Egypt.,Pharmaceutics Department, Faculty of Pharmacy, Sphinx University, New Assiut City, Egypt.,Assiut International Center of Nanomedicine, AL-Rajhy Liver Hospital, Assiut University, Assiut, 71515, Egypt
| | - Sahar Hassan
- Clinical Pharmacy Department, Faculty of Pharmacy, Assiut University, Assiut, Egypt
| |
Collapse
|
27
|
Cheung CK, Adeola JO, Beutler SS, Urman RD. Postoperative Pain Management in Enhanced Recovery Pathways. J Pain Res 2022; 15:123-135. [PMID: 35058714 PMCID: PMC8765537 DOI: 10.2147/jpr.s231774] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/30/2021] [Indexed: 12/05/2022] Open
Abstract
Postoperative pain is a common but often inadequately treated condition. Enhanced recovery pathways (ERPs) are increasingly being utilized to standardize perioperative care and improve outcomes. ERPs employ multimodal postoperative pain management strategies that minimize opioid use and promote recovery. While traditional opioid medications continue to play an important role in the treatment of postoperative pain, ERPs also rely on a wide range of non-opioid pharmacologic therapies as well as regional anesthesia techniques to manage pain in the postoperative setting. The evidence for the use of these interventions continues to evolve rapidly given the increasing focus on enhanced postoperative recovery. This article reviews the current evidence and knowledge gaps pertaining to commonly utilized modalities for postoperative pain management in ERPs.
Collapse
Affiliation(s)
- Christopher K Cheung
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Janet O Adeola
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Sascha S Beutler
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
28
|
Elsharkawy H, Kolli S, Soliman LM, Seif J, Drake RL, Mariano ER, El-Boghdadly K. The External Oblique Intercostal Block: Anatomic Evaluation and Case Series. PAIN MEDICINE 2021; 22:2436-2442. [PMID: 34626112 DOI: 10.1093/pm/pnab296] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/29/2021] [Accepted: 07/15/2021] [Indexed: 12/22/2022]
Abstract
STUDY OBJECTIVE We report a modified block technique aimed at obtaining upper midline and lateral abdominal wall analgesia: the external oblique intercostal (EOI) block. DESIGN A cadaveric study and retrospective cohort study assessing the potential analgesic effect of the EOI block. SETTING Cadaver lab and operating room. PATIENTS Two unembalmed cadavers and 22 patients. INTERVENTIONS Bilateral ultrasound-guided EOI blocks on cadavers with 29 mL of bupivacaine 0.25% with 1 mL of India ink; single-injection or continuous EOI blocks in patients. MEASUREMENTS Dye spread in cadavers and loss of cutaneous sensation in patients. MAIN RESULTS In the cadaveric specimens, we identified consistent staining of both lateral and anterior branches of intercostal nerves from T7 to T10. We also found consistent dermatomal sensory blockade of T6-T10 at the anterior axillary line and T6-T9 at the midline in patients receiving the EOI block. CONCLUSIONS We demonstrate the potential mechanism of this technique with a cadaveric study that shows consistent staining of both lateral and anterior branches of intercostal nerves T7-T10. Patients who received this block exhibited consistent dermatomal sensory blockade of T6-T10 at the anterior axillary line and T6-T9 at the midline. This block can be used in multiple clinical settings for upper abdominal wall analgesia.
Collapse
Affiliation(s)
- Hesham Elsharkawy
- Department of Anesthesiology, Pain and Healing Center, MetroHealth, Case Western Reserve University, Cleveland, Ohio, USA.,Outcomes Research Consortium, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sree Kolli
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - John Seif
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Richard L Drake
- Department of Anatomy and Department of Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, USA
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA.,Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Kariem El-Boghdadly
- Department of Anaesthesia and Perioperative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
| |
Collapse
|
29
|
Howle R, Ng SC, Wong HY, Onwochei D, Desai N. Comparison of analgesic modalities for patients undergoing midline laparotomy: a systematic review and network meta-analysis. Can J Anaesth 2021; 69:140-176. [PMID: 34739706 DOI: 10.1007/s12630-021-02128-6] [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: 07/01/2021] [Revised: 09/08/2021] [Accepted: 09/08/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Midline laparotomy is associated with severe pain. Epidural analgesia has been the established standard, but multiple alternative regional anesthesia modalities are now available. We aimed to compare continuous and single-shot regional anesthesia techniques in this systematic review and network meta-analysis. METHODS We included randomized controlled trials on adults who were scheduled for laparotomy with solely a midline incision under general anesthesia and received neuraxial or regional anesthesia for pain. Network meta-analysis was performed with a frequentist method, and continuous and dichotomous outcomes were presented as mean differences and odds ratios, respectively, with 95% confidence intervals. The quality of evidence was rated with the grading of recommendations, assessment, development, and evaluation system. RESULTS Overall, 36 trials with 2,056 patients were included. None of the trials assessed erector spinae plane or quadratus lumborum block, and rectus sheath blocks and transversus abdominis plane blocks were combined into abdominal wall blocks (AWB). For the co-primary outcome of pain score at rest at 24 hr, with a minimal clinically important difference (MCID) of 1, epidural was clinically superior to control and single-shot AWB; epidural was statistically but not clinically superior to continuous wound infiltration (WI); and no statistical or clinical difference was found between control and single-shot AWB. For the co-primary outcome of cumulative morphine consumption at 24 hr, with a MCID of 10 mg, epidural and continuous AWB were clinically superior to control; epidural was clinically superior to continuous WI, single-shot AWB, single-shot WI, and spinal; and continuous AWB was clinically superior to single-shot AWB. The quality of evidence was low in view of serious limitations and imprecision. Other results of importance included: single-shot AWB did not provide clinically relevant analgesic benefit beyond two hr; continuous WI was clinically superior to single-shot WI by 8-12 hr; and clinical equivalence was found between epidural, continuous AWB, and continuous WI for the pain score at rest, and epidural and continuous WI for the cumulative morphine consumption at 48 hr. CONCLUSIONS Single-shot AWB were only clinically effective for analgesia in the early postoperative period. Continuous regional anesthesia modalities increased the duration of analgesia relative to their single-shot counterparts. Epidural analgesia remained clinically superior to alternative continuous regional anesthesia techniques for the first 24 hr, but reached equivalence, at least with respect to static pain, with continuous AWB and WI by 48 hr. TRIAL REGISTRATION PROSPERO (CRD42021238916); registered 25 February 2021.
Collapse
Affiliation(s)
- Ryan Howle
- Department of Anaesthesia, Mater Misericordiae University Hospital, Dublin, Ireland.
| | - Su-Cheen Ng
- Department of Anaesthesia, Beacon Hospital, Dublin, Ireland
| | - Heung-Yan Wong
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Desire Onwochei
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
| | - Neel Desai
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
| |
Collapse
|
30
|
Shimada T, Cohen B, Shah K, Mosteller L, Bravo M, Ince I, Esa WAS, Cywinski J, Sessler DI, Ruetzler K, Turan A. Associations between intraoperative and post-anesthesia care unit hypotension and surgical ward hypotension. J Clin Anesth 2021; 75:110495. [PMID: 34560444 DOI: 10.1016/j.jclinane.2021.110495] [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: 05/14/2021] [Revised: 08/03/2021] [Accepted: 08/23/2021] [Indexed: 01/18/2023]
Abstract
STUDY OBJECTIVE To test whether patients who experience hypotension in the post-anesthesia care unit or during surgery are most likely to experience hypotension on surgical wards. DESIGN A prediction study using data from two randomized controlled trials. SETTING Operating room, post-anesthesia care unit, and surgical ward. PATIENTS 550 adult patients having abdominal surgery with ASA physical status I-IV. INTERVENTIONS Blood pressure measurement per routine intraoperatively, and with continuous non-invasive monitoring postoperatively. MEASUREMENTS The primary predictors were minimum mean arterial pressure (<60, <65, <70 and < 80 mmHg) and minimum systolic blood pressure (<70, <75, <80, <85 mmHg) in the post-anesthesia care unit. The secondary predictors were intraoperative minimum blood pressures with the same thresholds as the primary ones. Our outcome was ward hypotension defined as mean pressure < 70 mmHg or systolic pressure < 85 mmHg. A threshold was considered clinically useful if both sensitivity and specificity exceeded 0.75. MAIN RESULTS Minimum mean and systolic pressures in the post-anesthesia care unit similarly predicted ward mean or systolic hypotension, with the areas under the curves near 0.74. The best performing threshold was mean pressure < 80 mmHg in the post-anesthesia care unit which had a sensitivity of 0.41 (95% confidence interval [CI], 0.35, 0.47) and specificity of 0.91 (95% CI, 0.87, 0.94) for ward mean pressure < 70 mmHg and a sensitivity of 0.44 (95% CI, 0.37, 0.51) and specificity of 0.88 (95% CI, 0.84, 0.91) for ward systolic pressure < 85 mmHg. The areas under the curves using intraoperative hypotension to predict ward hypotension were roughly similar at about 0.60, with correspondingly low sensitivity and specificity. CONCLUSIONS Intraoperative hypotension poorly predicted ward hypotension. Pressures in the post-anesthesia care unit were more predictive, but the combination of sensitivity and specificity remained poor. Unless far better predictors are identified, all surgical inpatients should be considered at risk for postoperative hypotension.
Collapse
Affiliation(s)
- Tetsuya Shimada
- Department of OUTCOMES RESEARCH, Cleveland Clinic, Cleveland, OH, United States; Department of Anesthesiology, National Hospital Organization, Murayama Medical Center, Musashimurayama, Tokyo, Japan; Department of Anesthesiology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Barak Cohen
- Department of OUTCOMES RESEARCH, Cleveland Clinic, Cleveland, OH, United States; Division of Anesthesia, Intensive Care and Pain Management, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Karan Shah
- Department of OUTCOMES RESEARCH, Cleveland Clinic, Cleveland, OH, United States; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, United States
| | - Lauretta Mosteller
- Department of OUTCOMES RESEARCH, Cleveland Clinic, Cleveland, OH, United States
| | - Mauro Bravo
- Department of OUTCOMES RESEARCH, Cleveland Clinic, Cleveland, OH, United States
| | - Ilker Ince
- Department of OUTCOMES RESEARCH, Cleveland Clinic, Cleveland, OH, United States; Anesthesiology Clinical Research Office, Ataturk University, Erzurum, Turkey
| | - Wael Ali Sakr Esa
- Department of General Anesthesia, Cleveland Clinic, Cleveland, OH, United States
| | - Jacek Cywinski
- Department of General Anesthesia, Cleveland Clinic, Cleveland, OH, United States
| | - Daniel I Sessler
- Department of OUTCOMES RESEARCH, Cleveland Clinic, Cleveland, OH, United States
| | - Kurt Ruetzler
- Department of OUTCOMES RESEARCH, Cleveland Clinic, Cleveland, OH, United States; Department of General Anesthesia, Cleveland Clinic, Cleveland, OH, United States
| | - Alparslan Turan
- Department of OUTCOMES RESEARCH, Cleveland Clinic, Cleveland, OH, United States; Department of General Anesthesia, Cleveland Clinic, Cleveland, OH, United States.
| |
Collapse
|
31
|
Gonvers E, El-Boghdadly K, Grape S, Albrecht E. Efficacy and safety of intrathecal morphine for analgesia after lower joint arthroplasty: a systematic review and meta-analysis with meta-regression and trial sequential analysis. Anaesthesia 2021; 76:1648-1658. [PMID: 34448492 PMCID: PMC9292760 DOI: 10.1111/anae.15569] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2021] [Indexed: 12/17/2022]
Abstract
Widespread adoption of intrathecal morphine into clinical practice is hampered by concerns about its potential side‐effects. We undertook a systematic review, meta‐analysis and trial sequential analysis with the primary objective of determining the efficacy and safety of intrathecal morphine. Our secondary objective was to determine the dose associated with greatest efficacy and safety. We also assessed the impact of intrathecal morphine on respiratory depression. We systematically searched the literature for trials comparing intrathecal morphine with a control group in patients undergoing hip or knee arthroplasty under spinal anaesthesia. Our primary efficacy outcome was rest pain score (0–10) at 8–12 hours; our primary safety outcome was the rate of postoperative nausea and vomiting within 24 hours. Twenty‐nine trials including 1814 patients were identified. Rest pain score at 8–12 hours was significantly reduced in the intrathecal morphine group, with a mean difference (95%CI) of −1.7 (−2.0 to −1.3), p < 0.0001 (19 trials; 1420 patients; high‐quality evidence), without sub‐group differences between doses (p = 0.35). Intrathecal morphine increased postoperative nausea and vomiting, with a risk ratio (95%CI) of 1.4 (1.3–1.6), p < 0.0001 (24 trials; 1603 patients; high‐quality evidence). However, a sub‐group analysis by dose revealed that rates of postoperative nausea and vomiting within 24 hours were similar between groups at a dose of 100 µg, while the risk significantly increased with larger doses (p value for sub‐group difference = 0.02). Patients receiving intrathecal morphine were no more likely to have respiratory depression, the risk ratio (95%CI) being 0.9 (0.5–1.7), p = 0.78 (16 trials; 1173 patients; high‐quality evidence). In conclusion, there is good evidence that intrathecal morphine provides effective analgesia after lower limb arthroplasty, without an increased risk of respiratory depression, but at the expense of an increased rate of postoperative nausea and vomiting. A dose of 100 µg is a ‘ceiling’ dose for analgesia and a threshold dose for increased rate of postoperative nausea and vomiting.
Collapse
Affiliation(s)
- E Gonvers
- Department of Anaesthesia, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - K El-Boghdadly
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
| | - S Grape
- Department of Anaesthesia, Valais Hospital, Sion, Switzerland
| | - E Albrecht
- Department of Anaesthesia, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| |
Collapse
|
32
|
Söhle M, Coburn M. [Perioperative Medicine in Visceral Surgery in the Elderly Patient from an Anaesthesiological Perspective]. Zentralbl Chir 2021; 146:296-305. [PMID: 34154008 DOI: 10.1055/a-1447-1051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Demographic change is leading to an increasing number of old patients both in our society and in hospitals. With increasing age, not only the number of pre-existing conditions increases, but also the postoperative complication rate and mortality. Ultimately, however, it is not age that is decisive, but the condition of the patient and his or her capacity to face the physical and mental challenges of a surgical procedure. Frail patients are particularly at risk of complications, and an essential strategy - known as prehabilitation - is to put them in a better state pre-operatively through physical and mental training, as well as nutritional counselling. Delirium is one of the most frequent postoperative complications. Measures such as refraining from premedication with benzodiazepines, measuring the depth of anaesthesia, refraining from long-acting opioids, performing fast-track surgery, and providing glasses/hearing aids quickly postoperatively can reduce the risk of delirium. Close interdisciplinary consultation between surgeons, anaesthetists, geriatricians and physiotherapists is essential to coordinate the perioperative procedure and reduce the perioperative risk for elderly patients.
Collapse
Affiliation(s)
- Martin Söhle
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Deutschland
| | - Mark Coburn
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Deutschland
| |
Collapse
|
33
|
Response to comment on: The analgesic efficacy of iPACK after knee surgery: A systematic review and meta-analysis with trial sequential analysis. J Clin Anesth 2021; 74:110401. [PMID: 34166863 DOI: 10.1016/j.jclinane.2021.110401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 11/23/2022]
|
34
|
Yeung J, Small C. Impact of regional analgesia in surgery. Br J Surg 2021; 108:1009-1010. [PMID: 34131701 PMCID: PMC10364902 DOI: 10.1093/bjs/znab214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/16/2021] [Indexed: 11/14/2022]
Affiliation(s)
- J Yeung
- Warwick Medical School, Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - C Small
- Hereford County Hospital, Wye Valley NHS Trust, Hereford, UK
| |
Collapse
|
35
|
Hamid HKS, Marc-Hernández A, Saber AA. Transversus abdominis plane block versus thoracic epidural analgesia in colorectal surgery: a systematic review and meta-analysis. Langenbecks Arch Surg 2020; 406:273-282. [PMID: 32974803 DOI: 10.1007/s00423-020-01995-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/22/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND The efficacy of transversus abdominis plane (TAP) block compared with thoracic epidural analgesia (TEA) in abdominal surgery has been controversial. We conducted this systematic review and meta-analysis to assess outcomes of TAP block and TEA in a procedure-specific manner in colorectal surgery. METHODS A systematic literature search of the PubMed, Embase, Cochrane Library, and Scopus databases was conducted through July 10, 2020, to identify randomized controlled trials (RCTs) comparing TAP block with TEA in colorectal surgery. Primary outcomes were pain scores at rest and movement at 24 h postoperatively. Secondary outcomes included postoperative pain scores at 0-2 and 48 h, opioid consumption, postoperative nausea and vomiting (PONV), functional recovery, hospital stay, and adverse events. RESULTS Six RCTs with 568 patients were included. Methodological quality of these RCTs ranged from moderate to high. TAP block provided comparable pain control, lower 24 h and total opioid consumption, shorter time to ambulation and urinary catheter time, and lower incidence of sensory disturbance and postoperative hypotension compared with TEA. Meanwhile, the 48-h opioid consumption, PONV incidence, and hospital stay were similar between groups. When laparoscopic surgery was the only surgical approach employed, TAP block provided additional benefits of shorter time to first flatus and lower incidence of PONV compared with TEA. CONCLUSIONS Perhaps more germane to minimally invasive procedures, TAP block is equivalent to TEA in terms of postoperative pain control and provides better functional recovery with lower incidence of adverse events in patients undergoing colorectal surgery.
Collapse
Affiliation(s)
- Hytham K S Hamid
- Department of Surgery, Soba University Hospital, Khartoum, Sudan.
| | | | - Alan A Saber
- Department of Surgery, Newark Beth Israel Medical Center, Newark, NJ, USA
| |
Collapse
|
36
|
Kirkham KR, Taljaard M. Enough is enough: does trial sequential analysis tell us when we don't need to do any more studies? Anaesthesia 2020; 76:594-597. [PMID: 32789855 DOI: 10.1111/anae.15242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2020] [Indexed: 11/30/2022]
Affiliation(s)
- K R Kirkham
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - M Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
37
|
Chitnis SS, Tang R, Mariano ER. The role of regional analgesia in personalized postoperative pain management. Korean J Anesthesiol 2020; 73:363-371. [PMID: 32752602 PMCID: PMC7533178 DOI: 10.4097/kja.20323] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 07/15/2020] [Indexed: 12/29/2022] Open
Abstract
Pain management plays a fundamental role in enhanced recovery after surgery pathways. The concept of multimodal analgesia in providing a balanced and effective approach to perioperative pain management is widely accepted and practiced, with regional anesthesia playing a pivotal role. Nerve block techniques can be utilized to achieve the goals of enhanced recovery, whether it be the resolution of ileus or time to mobilization. However, the recent expansion in the number and types of nerve block approaches can be daunting for general anesthesiologists. Which is the most appropriate regional technique to choose, and what skills and infrastructure are required for its implementation? A multidisciplinary team-based approach for defining the goals is essential, based on each patient's needs, and incorporating patient, surgical, and social factors. This review provides a framework for a personalized approach to postoperative pain management with an emphasis on regional anesthesia techniques.
Collapse
Affiliation(s)
- Shruti S Chitnis
- Department of Anesthesiology and Perioperative Care, University of British Columbia, Vancouver General Hospital, BC, Canada
| | - Raymond Tang
- Department of Anesthesiology and Perioperative Care, University of British Columbia, Vancouver General Hospital, BC, Canada
| | - Edward R Mariano
- Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| |
Collapse
|