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Desai N, Pararajasingham S, Onwochei D, Albrecht E. Comparison of intravenous versus perineural dexamethasone as a local anaesthetic adjunct for peripheral nerve blocks in the lower limb: A meta-analysis and systematic review. Eur J Anaesthesiol 2024; 41:749-759. [PMID: 38988252 PMCID: PMC11377050 DOI: 10.1097/eja.0000000000002038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
BACKGROUND As a local anaesthetic adjunct, the systemic absorption of perineural dexamethasone in the lower limb could be restricted because of decreased vascularity when compared with the upper limb. OBJECTIVES To compare the pharmacodynamic characteristics of intravenous and perineural dexamethasone in the lower limb. DESIGN Systematic review of randomised controlled trials with meta-analysis. DATA SOURCES Systematic search of Central, Google Scholar, Ovid Embase and Ovid Medline to 18 July 2023. ELIGIBILITY CRITERIA Randomised controlled trials, which compared the intravenous with perineural administration of dexamethasone as a local anaesthetic adjunct in peripheral nerve blocks for surgery of the lower limb. RESULTS The most common peripheral nerve blocks were femoral, sciatic and ankle block. The local anaesthetic was long acting in all trials and the dose of dexamethasone was 8 mg in most trials. The primary outcome, the duration of analgesia, was investigated by all nine trials ( n = 546 patients). Overall, compared with intravenous dexamethasone, perineural dexamethasone increased the duration of analgesia from 19.54 to 22.27 h, a mean difference [95% confidence interval (CI) of 2.73 (1.07 to 4.38) h; P = 0.001, I2 = 87]. The quality of evidence was moderate owing to serious inconsistency. However, analysis based on the location of the peripheral nerve block, the type of local anaesthetic or the use of perineural adrenaline showed no difference in duration between intravenous and perineural dexamethasone. No differences were shown for any of the secondary outcomes related to efficacy and side effects. CONCLUSION In summary, moderate evidence supports the superiority of perineural dexamethasone over intravenous dexamethasone in prolonging the duration of analgesia. However, this difference is unlikely to be clinically relevant. Consideration of the perineural use of dexamethasone should recognise that this route of administration remains off label.
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Affiliation(s)
- Neel Desai
- From the Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK (ND, SP, DO) and Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland (EA)
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El-Boghdadly K, Levy NA, Fawcett WJ, Knaggs RD, Laycock H, Baird E, Cox FJ, Eardley W, Kemp H, Malpus Z, Partridge A, Partridge J, Patel A, Price C, Robinson J, Russon K, Walumbe J, Lobo DN. Peri-operative pain management in adults: a multidisciplinary consensus statement from the Association of Anaesthetists and the British Pain Society. Anaesthesia 2024. [PMID: 39319373 DOI: 10.1111/anae.16391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2024] [Indexed: 09/26/2024]
Abstract
BACKGROUND Nearly half of adult patients undergoing surgery experience moderate or severe postoperative pain. Inadequate pain management hampers postoperative recovery and function and may be associated with adverse outcomes. This multidisciplinary consensus statement provides principles that might aid postoperative recovery, and which should be applied throughout the entire peri-operative pathway by healthcare professionals, institutions and patients. METHODS We conducted a directed literature review followed by a four-round modified Delphi process to formulate recommendations for organisations and individuals. RESULTS We make recommendations for the entire peri-operative period, covering pre-admission; admission; intra-operative; post-anaesthetic care unit; ward; intensive care unit; preparation for discharge; and post-discharge phases of care. We also provide generic principles of peri-operative pain management that clinicians should consider throughout the peri-operative pathway, including: assessing pain to facilitate function; use of multimodal analgesia, including regional anaesthesia; non-pharmacological strategies; safe use of opioids; and use of protocols and training for staff in caring for patients with postoperative pain. CONCLUSIONS We hope that with attention to these principles and their implementation, outcomes for adult patients having surgery might be improved.
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Affiliation(s)
- 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
| | - Nicholas A Levy
- Department of Anaesthesia and Perioperative Medicine, West Suffolk NHS Foundation Trust, Suffolk, UK
| | - William J Fawcett
- Department of Anaesthesia and Pain Medicine, Royal Surrey NHS Foundation Trust, Surrey, UK
- School of Medicine, University of Surrey, Guildford, UK
| | - Roger D Knaggs
- School of Pharmacy, Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - Helen Laycock
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital, London, UK
| | - Emma Baird
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Felicia J Cox
- Pain Management Service, Critical Care and Anaesthesia, Royal Brompton and Harefield Hospitals (part of Guy's and St Thomas' NHS Foundation Trust), London, UK
| | - Will Eardley
- Department of Orthopaedics and Trauma, James Cook University Hospital, Middlesbrough, UK
| | - Harriet Kemp
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Zoey Malpus
- Manchester NHS Pain Service, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | | | - Judith Partridge
- Department of Peri-operative Care for Older People Undergoing Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Anjna Patel
- Department of Pre-operative Assessment, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
| | - Cathy Price
- Pain Management, Department of Chronic Pain, Solent NHS Trust, UK
| | | | - Kim Russon
- Department of Anaesthesia, Rotherham NHS Foundation Trust, Rotherham, UK
| | - Jackie Walumbe
- Department of Physiotherapy, University College London Hospitals NHS Foundation Trust, London, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Dileep N Lobo
- Nottingham Digestive Diseases Centre, Division of Translational Medical Sciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
- Division of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Macintyre PE, Jamcotchian MA, Stevens JA. Calling time on the use of modified-release opioids for acute pain. Med J Aust 2024. [PMID: 39148471 DOI: 10.5694/mja2.52417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 05/13/2024] [Indexed: 08/17/2024]
Affiliation(s)
- Pamela E Macintyre
- University of Adelaide, Adelaide, SA
- Royal Adelaide Hospital, Adelaide, SA
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Huang YT, Dixon WG, O’Neill TW, Jani M. Postoperative opioids administered to inpatients with major or orthopaedic surgery: A retrospective cohort study using data from hospital electronic prescribing systems. PLoS One 2024; 19:e0305531. [PMID: 38917135 PMCID: PMC11198745 DOI: 10.1371/journal.pone.0305531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 06/02/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Opioids administered in hospital during the immediate postoperative period are likely to influence post-surgical outcomes, but inpatient prescribing during the admission is challenging to access. Modified-release(MR) preparations have been especially associated with harm, whilst certain populations such as the elderly or those with renal impairment may be vulnerable to complications. This study aimed to assess postoperative opioid utilisation patterns during hospital stay for people admitted for major/orthopaedic surgery. METHODS Patients admitted to a teaching hospital in the North-West of England between 2010-2021 for major/orthopaedic surgery with an admission for ≥1 day were included. We examined opioid administrations in the first seven days post-surgery in hospital, and "first 48 hours" were defined as the initial period. Proportions of MR opioids, initial immediate-release(IR) oxycodone and initial morphine milligram equivalents (MME)/day were calculated and summarised by calendar year. We also assessed the proportion of patients prescribed an opioid at discharge. RESULTS Among patients admitted for major/orthopaedic surgery, 71.1% of patients administered opioids during their hospitalisation. In total 50,496 patients with 60,167 hospital admissions were evaluated. Between 2010-2017 MR opioids increased from 8.7% to 16.1% and dropped to 11.6% in 2021. Initial use of oxycodone IR among younger patients (≤70 years) rose from 8.3% to 25.5% (2010-2017) and dropped to 17.2% in 2021. The proportion of patients on ≥50MME/day ranged from 13% (2021) to 22.9% (2010). Of the patients administered an opioid in hospital, 26,920 (53.3%) patients were discharged on an opioid. CONCLUSIONS In patients hospitalised with major/orthopaedic surgery, 4 in 6 patients were administered an opioid. We observed a high frequency of administered MR opioids in adult patients and initial oxycodone IR in the ≤70 age group. Patients prescribed with ≥50MME/day ranged between 13-22.9%. This is the first published study evaluating UK inpatient opioid use, which highlights opportunities for improving safer prescribing in line with latest recommendations.
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Affiliation(s)
- Yun-Ting Huang
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester, United Kingdom
| | - William G. Dixon
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester, United Kingdom
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance, Salford, United Kingdom
| | - Terence W. O’Neill
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester, United Kingdom
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance, Salford, United Kingdom
| | - Meghna Jani
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester, United Kingdom
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance, Salford, United Kingdom
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Baamer RM, Humes DJ, Toh LS, Knaggs RD, Lobo DN. Temporal trends and patterns in initial opioid prescriptions after hospital discharge following colectomy in England over 10 years. BJS Open 2023; 7:zrad136. [PMID: 38146708 PMCID: PMC10750262 DOI: 10.1093/bjsopen/zrad136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 10/21/2023] [Indexed: 12/27/2023] Open
Abstract
BACKGROUND While opioid analgesics are often necessary for the management of acute postoperative pain, appropriate prescribing practices are crucial to avoid harm. The aim was to investigate the changes in the proportion of people receiving initial opioid prescriptions after hospital discharge following colectomy, and describe trends and patterns in prescription characteristics. METHODS This was a retrospective cohort study. Patients undergoing colectomy in England between 2010 and 2019 were included using electronic health record data from linked primary (Clinical Practice Research Datalink Aurum) and secondary (Hospital Episode Statistics) care. The proportion of patients having an initial opioid prescription issued in primary care within 90 days of hospital discharge was calculated. Prescription characteristics of opioid type and formulation were described. RESULTS Of 95 155 individuals undergoing colectomy, 15 503 (16.3%) received opioid prescriptions. There was a downward trend in the proportion of patients with no prior opioid exposure (opioid naive) who had a postdischarge opioid prescription (P <0.001), from 11.4% in 2010 to 6.7% in 2019 (-41.3%, P <0.001), whereas the proportions remained stable for those prescribed opioids prior to surgery, from 57.5% in 2010 to 58.3% in 2019 (P = 0.637). Codeine represented 44.5% of all prescriptions and prescribing increased by 14.5% between 2010 and 2019. Prescriptions for morphine and oxycodone rose significantly by 76.6% and 31.0% respectively, while tramadol prescribing dropped by 48.0%. The most commonly prescribed opioid formulations were immediate release (83.9%), followed by modified release (5.8%) and transdermal (3.2%). There was a modest decrease in the prescribing of immediate-release formulations from 86.0% in 2010 to 82.0% in 2019 (P <0.001). CONCLUSION Over the 10 years studied, there was a changing pattern of opioid prescribing following colectomy, with a decrease in the proportion of opioid-naive patients prescribed postdischarge opioids.
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Affiliation(s)
- Reham M Baamer
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - David J Humes
- Nottingham Digestive Diseases Centre, Division of Translational Medical Sciences, School of Medicine, University of Nottingham, Queen’s Medical Centre, Nottingham, UK
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, UK
| | - Li Shean Toh
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Roger D Knaggs
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
- Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - Dileep N Lobo
- Nottingham Digestive Diseases Centre, Division of Translational Medical Sciences, School of Medicine, University of Nottingham, Queen’s Medical Centre, Nottingham, UK
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, UK
- David Greenfield Metabolic Physiology Unit, MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham, UK
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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