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Steiness J, Lunn TH, Hägi-Pedersen D, Jakobsen JC, Mathiesen O. Optimal non-opioid analgesic combinations after total hip arthroplasty - Authors' reply. THE LANCET. RHEUMATOLOGY 2024:S2665-9913(24)00154-1. [PMID: 38901448 DOI: 10.1016/s2665-9913(24)00154-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 05/31/2024] [Indexed: 06/22/2024]
Affiliation(s)
- Joakim Steiness
- Department of Anaesthesiology, Zealand University Hospital, Køge, DK-4600, Denmark.
| | - Troels Haxholdt Lunn
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital, Bispebjerg Hospital, Copenhagen, Denmark
| | - Daniel Hägi-Pedersen
- Department of Anaesthesiology, Næstved-Slagelse_Ringsted Hospitals, Næstved, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen, Denmark; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Ole Mathiesen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Anaesthesiology, Zealand University Hospital, Køge, DK-4600, Denmark
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Karlsen APH, Laigaard J, Pedersen C, Thybo KH, Gasbjerg KS, Geisler A, Lunn TH, Hägi-Pedersen D, Jakobsen JC, Mathiesen O. Minimal important difference in postoperative morphine consumption after hip and knee arthroplasty using nausea, vomiting, sedation and dizziness as anchors. Acta Anaesthesiol Scand 2024; 68:610-618. [PMID: 38380438 DOI: 10.1111/aas.14388] [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: 09/07/2023] [Revised: 01/05/2024] [Accepted: 01/30/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Morphine-sparing effects are often used to evaluate non-opioid analgesic interventions. The exact effect that would warrant the implementation of these interventions in clinical practice (a minimally important difference) remains unclear. We aimed to determine this with anchor-based methods. METHODS This was a post hoc analysis of three studies investigating pain management after hip or knee arthroplasty (PANSAID [NCT02571361], DEX-2-TKA [NCT03506789] and Pain Map [NCT02340052]). The overall population was median aged 70, median ASA 2, 54% female. We examined the correlation between 0 and 24 h postoperative iv morphine equivalent consumption and the severity of nausea, vomiting, sedation and dizziness. The anchor was different severity degrees of these opioid-related adverse events. The primary outcome was the difference in morphine consumption between patients experiencing no versus only mild events. Secondary outcomes included the difference in morphine consumption between patients with mild versus moderate and moderate versus severe events. We used Hodges-Lehmann median differences, exact Wilcoxon-Mann-Whitney tests and quantile regression. RESULTS The difference in iv morphine consumption was 6 mg (95% confidence interval: 4-8) between patients with no versus only mild events, 5 mg (2-8) between patients with mild versus moderate events and 0 mg (-4 to 4) between patients with moderate versus severe events. CONCLUSIONS In populations comparable to this post-hoc analysis (orthopaedic surgery, median age 70 and ASA 2), we suggest a minimally important difference of 5 mg for 0-24 h postoperative iv morphine consumption.
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Affiliation(s)
- Anders Peder Højer Karlsen
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospitals, Copenhagen, Denmark
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
| | - Jens Laigaard
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Casper Pedersen
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
| | - Kasper Højgaard Thybo
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
| | - Kasper Smidt Gasbjerg
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
- Research Centre of Anaesthesiology and Intensive Care Medicine, Department of Anaesthesiology, Næstved-Slagelse-Ringsted Hospitals, Denmark
| | - Anja Geisler
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Troels Haxholdt Lunn
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospitals, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Hägi-Pedersen
- Research Centre of Anaesthesiology and Intensive Care Medicine, Department of Anaesthesiology, Næstved-Slagelse-Ringsted Hospitals, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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3
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Gasbjerg KS, Lunn TH, Hägi-Pedersen D, Overgaard S, Pedersen NA, Lindholm P, Lindberg-Larsen M, Brorson S, Schrøder HM, Thybo KH, Olsen MH, Mathiesen O, Jakobsen JC. Associations of dexamethasone's effect on morphine consumption after total knee arthroplasty-Subgroup analyses. Acta Anaesthesiol Scand 2024; 68:546-555. [PMID: 38267221 DOI: 10.1111/aas.14377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 11/15/2023] [Accepted: 01/09/2024] [Indexed: 01/26/2024]
Abstract
The DEXamethasone twice for pain treatment after Total Knee Arthroplasty (DEX-2-TKA) trial showed that adding one and two doses of 24 mg intravenous dexamethasone to paracetamol, ibuprofen and local infiltration analgesia, reduced morphine consumption (primary outcome) within 48 h after TKA. We aimed to explore the differences in the effect of dexamethasone on morphine consumption in different subgroups. Quantile regression adjusted for site was used to test for significant interaction between the predefined dichotomised subgroups and treatment group. The subgroups were defined based on baseline data: sex (male/female), age (≤65 years/>65 years), American Society of Anaesthesiologists (ASA)-score (ASA I + II/III), visual analogue score of preoperative pain at rest (≤30 mm/>30 mm), pain during mobilisation (≤30 mm/>30 mm), type of anaesthesia (spinal anaesthesia/general anaesthesia and spinal converted to general anaesthesia), and prior daily use of analgesics (either paracetamol and/or NSAID/neither). These analyses were supplemented with post hoc multivariate linear regression analyses. Test of interaction comparing sex in the pairwise comparison between DX2 (dexamethasone [24 mg] + dexamethasone [24 mg]) versus placebo (p = .02), showed a larger effect of dexamethasone on morphine consumption in male patients compared to females. Test of interaction comparing age in the pairwise comparison between DX1 (dexamethasone [24 mg] + placebo) versus placebo (p = .04), showed a larger effect of dexamethasone on morphine consumption in younger patients (≤65 years) compared to older. All remaining subgroup analyses showed no evidence of a difference. The supplemental multivariate analyses did not support any significant interaction for sex (p = .256) or age (p = .730) but supported a significant interaction with the type of anaesthesia (p < .001). Our results from the quantile regression analyses indicate that the male sex and younger age (≤65 years) may be associated with a larger analgesic effect of dexamethasone than the effects in other types of patients. However, this is not supported by post-hoc multivariate linear regression analyses. The two types of analyses both supported a possible interaction with the type of anaesthesia.
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Affiliation(s)
- Kasper S Gasbjerg
- Research Centre of Anaesthesiology and Intensive Care Medicine, Department of Anaesthesiology, Naestved-Slagelse-Ringsted Hospitals, Naestved, Denmark
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Troels H Lunn
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Daniel Hägi-Pedersen
- Research Centre of Anaesthesiology and Intensive Care Medicine, Department of Anaesthesiology, Naestved-Slagelse-Ringsted Hospitals, Naestved, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Søren Overgaard
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
- Department of Orthopaedics, Bispebjerg and Frederiksberg University Hospital, Copenhagen, Denmark
| | - Niels A Pedersen
- Department of Anaesthesia, Gildhøj Private Hospital, Brøndby, Denmark
| | - Peter Lindholm
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Martin Lindberg-Larsen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
| | - Stig Brorson
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
- Department of Orthopaedic Surgery, Zealand University Hospital, Køge, Denmark
| | - Henrik M Schrøder
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Orthopaedic Surgery, Naestved-Slagelse-Ringsted Hospitals, Naestved, Denmark
| | - Kasper H Thybo
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Markus H Olsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Janus C Jakobsen
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
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Stormholt ER, Steiness J, Derby CB, Larsen ME, Maagaard M, Mathiesen O. Glucocorticoids added to paracetamol and NSAIDs for post-operative pain: A systematic review with meta-analysis and trial sequential analysis. Acta Anaesthesiol Scand 2023; 67:688-702. [PMID: 36919281 DOI: 10.1111/aas.14237] [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: 12/07/2022] [Revised: 02/27/2023] [Accepted: 03/05/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as the basic pain treatment regimen for most surgeries. Glucocorticoids have well-known anti-inflammatory and anti-emetic properties and may also demonstrate analgesic effects. We assessed benefit and harm of adding glucocorticoids to a combination of paracetamol and NSAIDs for post-operative pain management. METHODS We searched Embase, Medline and CENTRAL for randomised clinical trials investigating the addition of glucocorticoids versus placebo/no intervention to paracetamol and an NSAID in adults undergoing any type of surgery. We assessed three primary outcomes: cumulative opioid consumption at 24 h postoperatively, serious adverse events and pain at rest at 24 h postoperatively. We performed meta-analysis and trial sequential analysis (TSA), assessed risk of bias using the Risk of Bias 2 tool and used the Grading of Recommendations Assessment, Development and Evaluation approach to evaluate the certainty of the evidence. RESULTS We identified 12 relevant trials of which nine trials randomising 804 participants were included in quantitative analysis. When added to paracetamol and NSAIDs, we found no evidence of a difference of glucocorticoids versus placebo/no intervention in cumulative opioid consumption at 24 h postoperatively (mean difference [MD] -0.28, TSA-adjusted 95% confidence interval [CI] -1.90 to 1.33, p = .68, moderate certainty of evidence), serious adverse events (risk ratio (RR) 0.99, TSA-adjusted 95% CI 0.27-3.63, p = .93, very low certainty of evidence) or pain on the Numeric Rating Scale at 24 h postoperatively (MD -0.39, TSA-adjusted 95% CI -0.84 to 0.17, p = .10, moderate certainty of evidence). All outcomes were assessed to be at high risk of bias and TSA showed that we had insufficient information for most outcomes. CONCLUSION Glucocorticoids added to a baseline therapy of paracetamol and an NSAID likely result in little to no difference in cumulative opioid consumption and pain at rest at 24 h postoperatively. In addition, the evidence is very uncertain about the effect on serious adverse events. For most outcomes we did not have sufficient information to draw firm conclusions and the certainty of the evidence varied from moderate to very low. EDITORIAL COMMENT Multimodal approaches for post-operative analgesia are favoured, including paracetamol and nonsteroidal anti-inflammatory drugs. In this meta-analysis, pooled results from clinical trials are assessed to describe possible benefit of addition of glucocorticoid treatment for analgesia. The findings did not identify additional benefit, though the certainty of the evidence was not high.
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Affiliation(s)
- Emma Ritsmer Stormholt
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Joakim Steiness
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Anaesthesiology, Naestved Hospital, Naestved, Denmark
| | - Cecilie Bauer Derby
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Mia Esta Larsen
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Intensive Care, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mathias Maagaard
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Nørskov AK, Jakobsen JC, Afshari A, Bisgaard J, Geisler A, Hägi-Pedersen D, Lange KHW, Lundstrøm LH, Lunn TH, Maagaard M, Møller AM, Nedergaard HK, Nikolajsen L, Olsen MH, Juhl-Olsen P, Rasmussen BS, Vested M, Vester-Andersen M, Wikkelsø A, Mathiesen O. Collaboration for Evidence-based Practice and Research in Anaesthesia (CEPRA): A consortium initiative for perioperative research. Acta Anaesthesiol Scand 2023; 67:804-810. [PMID: 36922719 DOI: 10.1111/aas.14235] [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: 02/07/2023] [Accepted: 02/21/2023] [Indexed: 03/18/2023]
Abstract
Evidence in perioperative care is insufficient. There is an urgent need for large perioperative research programmes, including pragmatic randomised trials, testing daily clinical treatments and unanswered question, thereby providing solid evidence for effects of interventions given to a large and growing number of patients undergoing surgery and anaesthesia. This may be achieved through large collaborations. Collaboration for Evidence-based Practice and Research in Anaesthesia (CEPRA) is a novel collaborative research network founded to pursue evidence-based answers to major clinical questions in perioperative medicine. The aims of CEPRA are to (1) improve clinical treatment and outcomes and optimise the use of resources for patients undergoing anaesthesia and perioperative care, and (2) disseminate results and inform caretakers, patients and relatives, and policymakers of evidence-based treatments in anaesthesia and perioperative medicine. CEPRA is inclusive in its concept. We aim to extend our collaboration with all relevant clinical collaborators and patient associations and representatives. Although initiated in Denmark, CEPRA seeks to develop an international network infrastructure, for example, with other Nordic countries. The work of CEPRA will follow the highest methodological standards. The organisation aims to structure and optimise any element of the research collaboration to reduce economic costs and harness benefits from well-functioning research infrastructure. This includes successive continuation of trials, harmonisation of outcomes, and alignment of data management systems. This paper presents the initiation and visions of the CEPRA network. CEPRA aims to be inclusive, patient-focused, methodologically sound, and to optimise all aspects of research logistics. This will translate into faster research conduct, reliable results, and accelerated clinical implementation of results, thereby benefiting millions of patients whilst being cost and labour-saving.
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Affiliation(s)
- Anders Kehlet Nørskov
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Arash Afshari
- Department of Paediatric and Obstetric Anaesthesia, Juliane Marie Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Jannie Bisgaard
- Department of Anaesthesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Anja Geisler
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Daniel Hägi-Pedersen
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Research Centre of Anaesthesiology and Intensive Care Medicine, Department of Anaesthesiology, Naestved-Slagelse-Ringsted Hospital, Slagelse, Denmark
| | - Kai Henrik Wiborg Lange
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Lars Hyldborg Lundstrøm
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Troels Haxholdt Lunn
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Mathias Maagaard
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Ann Merete Møller
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Herlev Anaesthesia Critical and Emergency Care Science Unit, Department of Anaesthesiology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
- Cochrane Anaesthesia Group and Cochrane Emergency and Critical Care Group, Copenhagen, Denmark
| | - Helene Korvenius Nedergaard
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Anaesthesiology, Intensive Care University Hospital of Southern Denmark, Kolding, Denmark
| | - Lone Nikolajsen
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Markus Harboe Olsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Peter Juhl-Olsen
- Department of Cardiothoracic- and Vascular Surgery, Anaesthesia Section, Aarhus University Hospital, Aarhus, Denmark
| | - Bodil Steen Rasmussen
- Department of Anaesthesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Matias Vested
- Department of Anaesthesia, Centre of Head and Orthopedics, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Morten Vester-Andersen
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Herlev Anaesthesia Critical and Emergency Care Science Unit, Department of Anaesthesiology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Anne Wikkelsø
- Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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Pedersen C, Vilhelmsen FJ, Laigaard J, Mathiesen O, Karlsen APH. Opioid consumption and non-opioid multimodal analgesic treatment in pain management trials after hip and knee arthroplasties: A meta-epidemiological study. Acta Anaesthesiol Scand 2023; 67:613-620. [PMID: 36759566 DOI: 10.1111/aas.14213] [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: 10/12/2022] [Revised: 01/30/2023] [Accepted: 02/01/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND The leading principle in peri-operative pain management is multimodal analgesia, which reduces opioid requirements and associated adverse effects. Pragmatic pain trials should optimally test interventions in addition to multimodal non-opioid analgesics and interventions to ensure clinical relevance and baseline levels of opioid consumption that reflect clinical settings. We aimed to investigate opioid consumption and use of non-opioid analgesics administered adjunct to interventions in post-operative pain trials after total hip and knee arthroplasty. METHODS A systematic literature search was conducted 7 January 2020 in The Cochrane Library's CENTRAL, PubMed, and EMBASE. Trials investigating analgesic interventions for post-operative pain in adults undergoing total hip or knee arthroplasty were included. The primary outcome was the aggregated median 0-24 h post-operative opioid consumption. Further, we assessed the use of paracetamol, non-steroidal anti-inflammatory drugs, gabapentinoids, high-dose glucocorticoids, local infiltration analgesia and nerve blocks administered as co-interventions equally to all participants. We assessed trends over time for all outcomes. RESULTS Of 14,200 records, 570 trials were included. Median 0-24 h opioid consumption was 21 and 22 mg iv morphine equivalents in hip and knee arthroplasty trials, respectively. Meta-regression showed no overall linear correlation between opioid consumption and publication year. The use of multimodal non-opioid analgesia increased over time, though only 48% of trials published from 2010 to 2020 administered two or more non-opioid analgesics. Applying more non-opioid analgesics was associated with lower opioid consumption in intervention groups. CONCLUSION Post-operative 0-24 h morphine consumption was median 21-22 mg. The demonstrated differences in non-opioid multimodal analgesic regimens between research and clinical settings, can potentially diminish the demonstrated opioid-sparing effects of trial interventions when such are implemented in a clinical context.
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Affiliation(s)
- Casper Pedersen
- Department of Anaesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark
| | - Frej Juul Vilhelmsen
- Department of Anaesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark
| | - Jens Laigaard
- Department of Anaesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark
| | - Ole Mathiesen
- Department of Anaesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark.,Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Anders Peder Højer Karlsen
- Department of Anaesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark.,Department of Anaesthesia, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
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7
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Karlsen APH, Pedersen C, Laigaard J, Thybo KH, Gasbjerg KS, Geisler A, Lunn TH, Hägi-Pedersen D, Jakobsen JC, Mathiesen O. Minimal important difference in opioid consumption based on adverse event reduction-A study protocol. Acta Anaesthesiol Scand 2023; 67:248-253. [PMID: 36428272 PMCID: PMC10107239 DOI: 10.1111/aas.14175] [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: 11/07/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The patient-relevant minimal important difference for opioid consumption remains undetermined, despite its frequent use as primary outcome in trials on postoperative pain management. A minimal important difference is necessary to evaluate whether significant trial results are clinically relevant. Further, it can be used as effect size to ensure that trials are powered to find clinically relevant effects. By exploring the dose-response relationship between postoperative opioid consumption and opioid-related adverse effects, we aim to approximate the minimal important difference in opioid consumption anchored to opioid-related adverse effects. METHODS This is a post-hoc analysis of aggregated data from two clinical trials (PANSAID NCT02571361 and DEX2TKA NCT03506789) and one observational cohort study (Pain Map NCT02340052) on pain management after total hip and knee arthroplasty. The primary outcome is the Hodges-Lehmann median difference in opioid consumption between patients with no opioid-related adverse effects and patients experiencing the mildest degree of one or more opioid-related adverse effects (i.e., mild nausea, sedation and/or dizziness or vomiting). Secondary outcomes include the Hodges-Lehmann median difference in opioid consumption that corresponds to one point on a cumulated opioid-related adverse event 0-10 scale. Further, we will explore the proportion of patients that experience opioid-related adverse effects for consecutive opioid dose intervals of 2 mg iv morphine equivalents. Quantile regression will be used to assess any significant interactions with patient baseline characteristics. CONCLUSIONS This study will hopefully bring us one step closer to determining relevant opioid reductions and thereby improve our understanding of intervention effects and planning of future trials.
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Affiliation(s)
- Anders Peder Højer Karlsen
- Department of Anaesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark.,Department of Anaesthesiology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Casper Pedersen
- Department of Anaesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark
| | - Jens Laigaard
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Kasper Højgaard Thybo
- Department of Anaesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark
| | - Kasper Smidt Gasbjerg
- Department of Anaesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark
| | - Anja Geisler
- Department of Anaesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Troels Haxholdt Lunn
- Department of Anaesthesiology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Hägi-Pedersen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Anaesthesiology, Research Centre of Anaesthesiology and Intensive Care Medicine, Naestved-Slagelse-Ringsted Hospitals, Ringsted, Denmark
| | - Janus Christian Jakobsen
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ole Mathiesen
- Department of Anaesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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8
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Jørgensen CC, Petersen PB, Daugberg LO, Jakobsen T, Gromov K, Varnum C, Andersen MR, Palm H, Kehlet H. Peripheral nerve-blocks and associations with length of stay and readmissions in fast-track total hip and knee arthroplasty. Acta Anaesthesiol Scand 2023; 67:169-176. [PMID: 36354132 PMCID: PMC10098538 DOI: 10.1111/aas.14169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/05/2022] [Accepted: 11/04/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Peripheral nerve blocks (PNB) have recently been recommended in total hip (THA) and knee (TKA) arthroplasty as they may reduce pain, morphine consumption, length of stay (LOS) and complications. However, whether PNBs are associated with early discharge within an enhanced recovery protocol including multimodal analgesia is uncertain. METHODS An observational multicenter study from January to August 2017 in six Danish Arthroplasty Centers with established fast-track protocols. Prospective recording of preoperative characteristics and information on PNB, LOS and readmissions through the Danish National Patient Registry and medical records. Multiple logistic regression was used to investigate associations between PNB and a LOS >1 day, LOS >4 days, and 30-days readmissions. We also reported on mobilization, pain, opioid and fall-related complications leading to LOS >4 days or readmissions. RESULTS A total of 2027 (58.6%) THA and 1432 (41.4%) TKAs with a median LOS of 1 day (IQR 1-2) and 5.3% (CI:4.6-6.1) 30-days readmission rate were identified. PNB was used in 40.7% (CI:38.2-43.3) of TKA and 2.7% (CI:2.0-3.5) of THA, but with considerable interdepartmental variation (0.0-89.0% for TKA). There was no association between PNB and LOS >1 day (OR:1.19 CI:0.82-1.72; p = .354), LOS >4 days (OR:1.4 CI:0.68-2.89; p = .359) or 30-days readmissions (OR:1.02 CI:0.63-1.65; p = .935) in TKA. Logistic regression in THA was not possible due to limited use of PNB. In TKA there were 12 (2.1% CI:1.2-3.6) with and 1 (0.1% CI:0.02-0.7) without a PNB, who had mobilization, pain or opioid-related complications, and 5 (0.9% CI:0.4-2.0) versus 4 (0.5% CI:0.2-1.2) who fell. Correspondingly, 2 (3.7% CI:1.0-12.6) and 11 (0.6% CI:0.3-1.0) of THA patients had these complications, while 0 (0.0% CI:0.0-6.6) and 17 (0.8% CI:0.5-1.3) fell. CONCLUSION Routine use of peripheral nerve blocks was not associated with early discharge or 30-days readmissions in fast-track THA and TKA. Future studies should focus on benefits of PNB in high-risk patients.
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Affiliation(s)
- Christoffer C Jørgensen
- Section for Surgical Pathophysiology and the Center for Fast-Track Hip and Knee Replacement, Rigshospitalet Copenhagen University, Copenhagen, Denmark
| | - Pelle B Petersen
- Section for Surgical Pathophysiology and the Center for Fast-Track Hip and Knee Replacement, Rigshospitalet Copenhagen University, Copenhagen, Denmark
| | - Louise O Daugberg
- Department of Orthopedics, Holstebro Hospital, Center for Fast-Track Hip and Knee Replacement, Copenhagen, Denmark
| | - Thomas Jakobsen
- Department of Orthopedics, Interdisciplinary Orthopedics and the Center for Fast-Track Hip and Knee Replacement, Aalborg University Hospital, Copenhagen, Denmark
| | - Kirill Gromov
- Department of Orthopedics and the Center for Fast-Track Hip and Knee Replacement, Hvidovre University Hospital, Copenhagen, Denmark
| | - Claus Varnum
- Department of Orthopedics and the Center for Fast-Track Hip and Knee Replacement, Lillebaelt Hospital - Vejle, Copenhagen, Denmark
| | - Mikkel R Andersen
- Department of Orthopedics and the Center for Fast-Track Hip and Knee Replacement, Gentofte Hospital, Copenhagen, Denmark
| | - Henrik Palm
- Department of Orthopedics and the Center for Fast-Track Hip and Knee Replacement, Bispebjerg Hospital, Copenhagen, Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology and the Center for Fast-Track Hip and Knee Replacement, Rigshospitalet Copenhagen University, Copenhagen, Denmark
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Patient-Important Outcomes Other Than Mortality in Contemporary ICU Trials: A Scoping Review. Crit Care Med 2022; 50:e759-e771. [PMID: 35894598 DOI: 10.1097/ccm.0000000000005637] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Randomized clinical trials (RCTs) conducted in adult ICU patients increasingly include patient-important outcomes other than mortality. This comes with challenges regarding outcome choices/definitions, handling of deceased patients and missing data in analyses, and choices of effect measures and statistical methods due to complex distributions. This scoping review aimed to characterize how these challenges are handled in relevant contemporary RCTs. DATA SOURCES We systematically searched 10 selected journals for RCTs conducted primarily in adult ICU patients published between 1 January 2018 and 5 May 2022 reporting at least one patient-important outcome other than mortality, including "days alive without"…-type outcomes, functional/cognitive/neurologic outcomes, health-related quality of life (HRQoL) outcomes, and ordinal/other outcomes. STUDY SELECTION Abstracts and full-texts were assessed independently and in duplicate by two reviewers. DATA EXTRACTION Data were extracted independently and in duplicate by two reviewers using predefined and pilot-tested extraction forms and subsequently categorized to facilitate analysis. DATA SYNTHESIS We included 687 outcomes from 167 RCTs, with 32% of RCTs using a patient-important outcome other than mortality as a (co-)primary outcome, most frequently "days alive without"…-type outcomes. Many different functional/cognitive/neurologic (103) and HRQoL (29) outcomes were reported. Handling of deceased patients varied, with analyses frequently restricted to survivors only for functional/cognitive/neurologic (62%) and HRQoL (89%) outcomes. Follow-up was generally longer and missing data proportions higher for functional/cognitive/neurologic and HRQoL outcomes. Most outcomes were analyzed using nonparametric tests (31%), linear regression/t tests (27%), chi-square-like tests (12%), and proportional odds logistic regression (9%), often without presentation of actual treatment effects estimates (38%). CONCLUSIONS In this sample of RCTs, substantial variation in practice and suboptimal methodological choices were observed. This calls for increased focus on standardizing outcome choices and definitions, adequate handling of missing data and deceased patients in analyses, and use of statistical methods quantifying effect sizes.
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11
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Laigaard J, Karlsen A, Maagaard M, Rosenberg LK, Creutzburg A, Lunn TH, Mathiesen O, Overgaard S. Perioperative prevention of persistent pain after total hip and knee arthroplasty-Protocol for two systematic reviews. Acta Anaesthesiol Scand 2022; 66:772-777. [PMID: 35325472 PMCID: PMC9315006 DOI: 10.1111/aas.14061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/12/2022] [Indexed: 11/30/2022]
Abstract
Background Between 9% and 20% of patients experience moderate to severe persistent postoperative pain after total hip or knee arthroplasty. Severe immediate postoperative pain limits rehabilitation and is associated with the development of persistent postoperative pain. Therefore, perioperative analgesic and physiotherapeutic interventions are of interest to reduce persistent pain. In two systematic reviews with identical methodology, we aim to investigate the effects of (a) perioperative analgesic interventions and (b) physiotherapeutic interventions in reducing persistent pain after total hip and knee arthroplasty. Methods We will include randomised and cluster‐randomised controlled trials on perioperative analgesic and physiotherapeutic interventions for patients undergoing elective total hip or knee arthroplasty for osteoarthritis. After contact with the authors, trials without pain data 3–24 months postoperatively will be excluded. Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and reference lists will be searched for eligible trials. Two authors will independently screen, extract data and assess the risk of bias. The primary outcome is pain scores 3–24 months postoperatively. Meta‐analyses will be performed for interventions with two or more trials. We will conduct trial sequential analyses and assign Grading of Recommendations, Assessment, Development and Evaluation (GRADE) ratings. Conclusion No previous review on reduction of persistent postoperative pain has included non‐pharmacological or invasive analgesic techniques. These two reviews with identical methodology will summarise the evidence of analgesic and physiotherapeutic perioperative interventions to prevent persistent pain. PROSPERO registration CRD42021284175.
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Affiliation(s)
- Jens Laigaard
- Department of Anesthesiology Centre for Anaesthesiological Research Zealand University Hospital Køge Denmark
- Department of Orthopaedic Surgery and Traumatology Copenhagen University Hospital Bispebjerg and Frederiksberg Copenhagen Denmark
| | - Anders Karlsen
- Department of Anesthesiology Centre for Anaesthesiological Research Zealand University Hospital Køge Denmark
| | - Mathias Maagaard
- Department of Anesthesiology Centre for Anaesthesiological Research Zealand University Hospital Køge Denmark
| | - Lukas Kristian Rosenberg
- Department of Orthopaedic Surgery and Traumatology Copenhagen University Hospital Bispebjerg and Frederiksberg Copenhagen Denmark
| | - Andreas Creutzburg
- Department of Anaesthesia Centre of Head and Orthopaedics, Rigshospitalet Copenhagen Denmark
| | - Troels Haxholdt Lunn
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
- Department of Anesthesia and Intensive Care Copenhagen University Hospital Bispebjerg and Frederiksberg Copenhagen Denmark
| | - Ole Mathiesen
- Department of Anesthesiology Centre for Anaesthesiological Research Zealand University Hospital Køge Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Søren Overgaard
- Department of Orthopaedic Surgery and Traumatology Copenhagen University Hospital Bispebjerg and Frederiksberg Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
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Gasbjerg KS, Hägi-Pedersen D, Lunn TH, Laursen CC, Holmqvist M, Vinstrup LØ, Ammitzboell M, Jakobsen K, Jensen MS, Pallesen MJ, Bagger J, Lindholm P, Pedersen NA, Schrøder HM, Lindberg-Larsen M, Nørskov AK, Thybo KH, Brorson S, Overgaard S, Jakobsen JC, Mathiesen O. Effect of dexamethasone as an analgesic adjuvant to multimodal pain treatment after total knee arthroplasty: randomised clinical trial. BMJ 2022; 376:e067325. [PMID: 34983775 PMCID: PMC8724786 DOI: 10.1136/bmj-2021-067325] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To investigate the effects of one and two doses of intravenous dexamethasone in patients after total knee arthroplasty. DESIGN Randomised, blinded, placebo controlled trial with follow-up at 90 days. SETTING Five Danish hospitals, September 2018 to March 2020. PARTICIPANTS 485 adult participants undergoing total knee arthroplasty. INTERVENTION A computer generated randomised sequence stratified for site was used to allocate participants to one of three groups: DX1 (dexamethasone (24 mg)+placebo); DX2 (dexamethasone (24 mg)+dexamethasone (24 mg)); or placebo (placebo+placebo). The intervention was given preoperatively and after 24 hours. Participants, investigators, and outcome assessors were blinded. All participants received paracetamol, ibuprofen, and local infiltration analgesia. MAIN OUTCOME MEASURES The primary outcome was total intravenous morphine consumption 0 to 48 hours postoperatively. Multiplicity adjusted threshold for statistical significance was P<0.017 and minimal important difference was 10 mg morphine. Secondary outcomes included postoperative pain. RESULTS 485 participants were randomised: 161 to DX1, 162 to DX2, and 162 to placebo. Data from 472 participants (97.3%) were included in the primary outcome analysis. The median (interquartile range) morphine consumptions at 0-48 hours were: DX1 37.9 mg (20.7 to 56.7); DX2 35.0 mg (20.6 to 52.0); and placebo 43.0 mg (28.7 to 64.0). Hodges-Lehmann median differences between groups were: -2.7 mg (98.3% confidence interval -9.3 to 3.7), P=0.30 between DX1 and DX2; 7.8 mg (0.7 to 14.7), P=0.008 between DX1 and placebo; and 10.7 mg (4.0 to 17.3), P<0.001 between DX2 and placebo. Postoperative pain was reduced at 24 hours with one dose, and at 48 hours with two doses, of dexamethasone. CONCLUSION Two doses of dexamethasone reduced morphine consumption during 48 hours after total knee arthroplasty and reduced postoperative pain. TRIAL REGISTRATION Clinicaltrials.gov NCT03506789.
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Affiliation(s)
- Kasper Smidt Gasbjerg
- Department of Anaesthesiology, Næstved, Slagelse and Ringsted Hospitals, Næstved, Denmark
| | - Daniel Hägi-Pedersen
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Anaesthesiology, Næstved, Slagelse and Ringsted Hospitals, Slagelse, Denmark
| | - Troels Haxholdt Lunn
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Christina Cleveland Laursen
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
- Copenhagen Centre for Translational Research, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Majken Holmqvist
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Louise Ørts Vinstrup
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
- Copenhagen Centre for Translational Research, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Mette Ammitzboell
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Karina Jakobsen
- Department of Anaesthesiology, Næstved, Slagelse and Ringsted Hospitals, Næstved, Denmark
| | - Mette Skov Jensen
- Department of Anaesthesiology, Næstved, Slagelse and Ringsted Hospitals, Næstved, Denmark
| | - Marie Jøhnk Pallesen
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jens Bagger
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Peter Lindholm
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | | | | | - Martin Lindberg-Larsen
- Orthopaedic Research Unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Anders Kehlet Nørskov
- Department of Anaesthesiology, Nordsjællands University Hospital, Hillerød, Denmark Anders
- Copenhagen Trial Unit Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Capital Region of Denmark, Copenhagen, Denmark
| | - Kasper Højgaard Thybo
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Stig Brorson
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Orthopaedic Surgery, Zealand University Hospital, Køge, Denmark
| | - Søren Overgaard
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
- Orthopaedic Research Unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Janus Christian Jakobsen
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Copenhagen Trial Unit Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Capital Region of Denmark, Copenhagen, Denmark
| | - Ole Mathiesen
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
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Laigaard J, Pedersen C, Rønsbo TN, Mathiesen O, Karlsen APH. Minimal clinically important differences in randomised clinical trials on pain management after total hip and knee arthroplasty: a systematic review. Br J Anaesth 2021; 126:1029-1037. [PMID: 33678402 DOI: 10.1016/j.bja.2021.01.021] [Citation(s) in RCA: 147] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 12/19/2020] [Accepted: 01/10/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Sample size determination is essential for reliable hypothesis testing in clinical trials and should rely on adequate sample size calculations with alpha, beta, variance, and an effect size being the minimal clinically important difference (MCID). This facilitates interpretation of the clinical relevance of statistically significant results. No gold standard for MCIDs exists in postoperative pain research. METHODS We searched Cochrane Central Register of Controlled Trials, MEDLINE, and Embase for English language articles on randomised trials investigating analgesic interventions after total hip or knee arthroplasty. Primary outcomes were the reported MCIDs for pain score and cumulated rescue opioid consumption. Secondary outcomes included reported sample size calculations and propensity to report statistical significance without reaching MCID. Trend analyses were conducted using statistical process control. RESULTS We included 570 trials. Median MCID for 0-24 h opioid consumption was 10 mg i.v. morphine equivalents for absolute reductions (interquartile range [IQR]: 6.8-14.5) and relative 40% (IQR: 30-50%). Median MCIDs for pain scores were absolute 15 mm at rest (IQR: 10-20) and 18 mm during movement (IQR: 10-20) on a 0-100 mm VAS and relative 30% (IQR: 20-30%). No trends were demonstrated for MCIDs. Adequate sample size calculations were reported in 34% of trials. In 46% of trials with statistically significant primary outcomes, the differences did not reach the predetermined MCID. CONCLUSIONS We provide clinician-perceived MCID estimates for rescue opioid consumption and pain scores that can be used for sample size calculations until reliable evidence-based patient-rated MCIDs emerge. Nearly half of the trials with significant findings did not reach the predetermined MCID.
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Affiliation(s)
- Jens Laigaard
- Centre for Anaesthesiological Research, Department of Anaesthesia, Zealand University Hospital, Køge, Denmark.
| | - Casper Pedersen
- Centre for Anaesthesiological Research, Department of Anaesthesia, Zealand University Hospital, Køge, Denmark
| | - Thea Nørgaard Rønsbo
- Centre for Anaesthesiological Research, Department of Anaesthesia, Zealand University Hospital, Køge, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anaesthesia, Zealand University Hospital, Køge, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anders Peder Højer Karlsen
- Centre for Anaesthesiological Research, Department of Anaesthesia, Zealand University Hospital, Køge, Denmark
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Zhang WC, Xiao D. Efficacy of proprioceptive training on the recovery of total joint arthroplasty patients: a meta-analysis. J Orthop Surg Res 2020; 15:505. [PMID: 33143719 PMCID: PMC7640714 DOI: 10.1186/s13018-020-01970-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 09/23/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Optimal balance control is of paramount importance for function recovery after total joint arthroplasty (TJA). The study objective of this meta-analysis was to assess the short- and mid-term effects of proprioceptive and balance training for patients undergoing TJA. METHODS Electronic searches were conducted from PubMed, Cochrane library, and Embase databases to identify eligible RCTs through May 2020. Standard mean difference (SMD) with 95% confidence interval (95%CI) was applied to calculate pooled effect estimates between proprioceptive and balance training and control group. Main outcomes were self-reported functionality, balance, pain, quality of life, and function (range of motion). RESULTS Seven randomized controlled trials were finally included in this meta-analysis. Pooled results found that balance and proprioceptive trainings have a positive role in improving self-reported functionality at short-term after TJA. Moreover, balance and proprioceptive trainings were associated with an increase of the balance at short- and mid-term after TJA. These results were further confirmed by subgroup analysis between preoperative and postoperative administration of balance and proprioceptive trainings. CONCLUSION Our meta-analysis suggests that balance and proprioceptive trainings after TJA improved self-reported functionality and balance. These improvements were maintained at mid-terms. More research is needed to confirm balance and proprioceptive trainings for pain and quality of life for TJA.
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Affiliation(s)
- Wen-Chao Zhang
- Department of Neurorehabilitation, The Affiliated Rehabilitation Hospital of Chongqing Medical University, No. 50, Wenhuaqicun, Chongqing, Jiulongpo district, China
| | - Deng Xiao
- Department of Neurorehabilitation, The Affiliated Rehabilitation Hospital of Chongqing Medical University, No. 50, Wenhuaqicun, Chongqing, Jiulongpo district, China.
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