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Yun M, Regen ND, Anchondo Y, Eddinger K, Malkmus S, Roberts SW, Donati E, Leonardi A, Yaksh TL. Acetaminophen effects upon formalin-evoked flinching, postformalin, and postincisional allodynia and conditioned place preference. Pain Rep 2024; 9:e1168. [PMID: 39139364 PMCID: PMC11321755 DOI: 10.1097/pr9.0000000000001168] [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: 10/13/2023] [Revised: 04/11/2024] [Accepted: 05/09/2024] [Indexed: 08/15/2024] Open
Abstract
Introduction We explored in mice, the analgesic, tolerance, dependency, and rewarding effects of systemic acetaminophen (APAP). Methods Studies employed adult mice (C57Bl6). (1) Intraplantar formalin flinching + post formalin allodynia. Mice were given intraperitoneal APAP in a DMSO (5%)/Tween 80 (5%) or a water-based formulation before formalin flinching on day 1 and tactile thresholds assessed before and after APAP at day 12. (2) Paw incision. At 24 hours and 8 days after hind paw incision in male mice, effects of intraperitoneal APAP on tactile allodynia were assessed. (3) Repeated delivery. Mice received daily (4 days) analgesic doses of APAP or vehicle and tested upon formalin flinching on day 5. (4) Conditioned place preference. For 3 consecutive days, vehicle was given in the morning in either of 2 chambers and in each afternoon, an analgesic dose of morphine or APAP in the other chamber. On days 5 and 10, animals were allowed to select a "preferred" chamber. Results Formalin in male mice resulted in biphasic flinching and an enduring postformalin tactile allodynia. Acetaminophen dose dependently decreased phase 2 flinching, and reversed allodynia was observed postflinching. At a comparable APAP dose, female mice showed similarly reduced phase 2 flinching. Incision allodynia was transiently reversed by APAP. Repeated APAP delivery showed no loss of effect after sequential injections or signs of withdrawal. Morphine, but not APAP or vehicle, resulted in robust place preference. Conclusions APAP decreased flinching and allodynia observed following formalin and paw incision and an absence of tolerance, dependence, or rewarding properties.
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Affiliation(s)
- Mijung Yun
- Department of Anesthesiology, University of California, San Diego, CA, USA
- Pain Clinic, Department of Anesthesiology and Pain Medicine, National Medical Center, Jung-gu, Seoul, Korea
| | | | - Yuvicza Anchondo
- Department of Anesthesiology, University of California, San Diego, CA, USA
| | - Kelly Eddinger
- Department of Anesthesiology, University of California, San Diego, CA, USA
| | - Shelle Malkmus
- Department of Anesthesiology, University of California, San Diego, CA, USA
| | - Steven W. Roberts
- Mechanical and Aerospace Engineering, University of California San Diego, San Diego, CA, USA
| | | | | | - Tony L. Yaksh
- Department of Anesthesiology, University of California, San Diego, CA, USA
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Phillipi MA, Song AY, Yieh L, Gong CL. Costs and outcomes associated with the administration of Intravenous Acetaminophen in neonates after esophageal atresia and tracheoesophageal fistula repair. Pediatr Neonatol 2024:S1875-9572(24)00117-7. [PMID: 38987066 DOI: 10.1016/j.pedneo.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 01/15/2024] [Accepted: 02/16/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND Over the last decade, the intravenous (IV) formulation of acetaminophen (APAP) has gained popularity as a safe and effective first-line analgesic in the neonatal intensive care unit and it is especially useful in peri-operative settings where oral agents are contraindicated. The primary objective was to examine the outcomes and costs associated with the use of IV APAP in combination with opioids versus opioids alone as a pain management strategy after neonatal esophageal atresia (EA) and tracheoesophageal fistula (TEF) repair. METHODS Data from the Pediatric Health Information System was used to examine 1137 hospitalizations for EA/TEF repair from October 2015 to September 2018. Neonates administered opioids only, or IV APAP in combination with opioids as pain management, were included. RESULTS Neonates receiving IV APAP experienced a longer median LOS, but a significantly lower mortality rate, a decreased mean daily cost, and reduced opioid use compared to neonates given only opioids. The two groups had no significant differences in pharmacy and total costs. CONCLUSION Our findings suggest that the use of IV APAP alongside opioids in EA/TEF repair is associated with reduced mortality and opioid use, as well as longer LOS.
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Affiliation(s)
- Michael A Phillipi
- School of Medicine, California University of Science and Medicine, 1501 Violet St, Colton, CA, 92324, USA.
| | - Ashley Y Song
- Bloomberg School of Public Health, Johns Hopkins University, 615 N Wolfe St, Baltimore, MD, 21205, USA
| | - Leah Yieh
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, 91101, USA
| | - Cynthia L Gong
- Keck School of Medicine, University of Southern California, 1975 Zonal Ave, Los Angeles, CA, 90033, USA
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Burgos J, Hevia E, Sanpera I, García V, de Santos Moreno MT, Mariscal G, Barrios C. Elevated blood metal ion levels in patients undergoing instrumented spinal surgery: a systematic review and meta-analysis. Spine J 2024; 24:947-960. [PMID: 38437920 DOI: 10.1016/j.spinee.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/24/2024] [Accepted: 02/25/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND CONTEXT Elevated blood metal levels have been reported in patients after spinal surgery using metallic implants. Although some studies have suggested an association between heightened blood metal concentrations and potential adverse effects, estimates of the incidence of abnormal metal levels after spinal surgery have been inconsistent. PURPOSE The aims of this systematic review and meta-analysis were to assess: (1) mean differences in blood metal ion levels between patients undergoing spinal fusion surgery and healthy controls, (2) odds of elevated blood metal ion levels after surgery compared to presurgery levels, and (3) pooled incidence of elevated blood metal ions overall and by metal type. STUDY DESIGN Systematic review and meta-analysis. PATIENTS SAMPLE The patient sample included 613 patients from 11 studies who underwent spinal surgery instrumentation. OUTCOME MEASURES Blood metal ion concentrations and the incidence of patients with elevated metal levels compared with in those the control group. METHODS A comprehensive search was conducted in PubMed, EMBASE, Scopus, and Cochrane Library to identify studies reporting blood metal ion levels after spinal fusion surgery. Mean differences (MD), odds ratios (OR), and incidence rates were pooled using random effects models. Heterogeneity was assessed using I2 statistics, and fixed-effects models were used if no heterogeneity was detected. Detailed statistical analysis was performed using the Review Manager version 5.4 software. RESULTS The analysis included 11 studies, with a total of 613 patients. Mean blood metal ion levels were significantly higher after spinal fusion surgery (MD 0.56, 95% CI 0.17-0.96; I2=86%). Specifically, titanium levels were significantly elevated (MD 0.81, 95% CI 0.32-1.30; I2=47%). The odds of elevated blood metal ions were higher after surgery (OR 8.17, 95% CI 3.38-19.72; I2=41%), primarily driven by chromium (OR 23.50, 95% CI 5.56-99.31; I2=30%). The incidence of elevated chromium levels was found to be 66.98% (95% CI 42.31-91.65). CONCLUSION In conclusion, blood metal ion levels, particularly titanium and chromium, were significantly increased after spinal fusion surgery compared to presurgery levels and healthy controls. Approximately 70% of the patients exhibited elevated blood levels of chromium and titanium.
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Affiliation(s)
- Jesús Burgos
- Vithas Internacional, C/ de Arturo Soria, 107, Cdad. Lineal, 28043 Madrid, Spain
| | - Eduardo Hevia
- Spine Unit, University of Navarra Clinic, C. del Marquesado de Sta. Marta, 1, San Blas-Canillejas, 28027, Madrid, Spain
| | - Ignacio Sanpera
- Pediatric Orthopedics, Son Espases Hospital, Spain de Valldemossa, 79, Nord, 07120 Palma, Illes Balears, Spain
| | - Vicente García
- Spine Surgery Section, Araba University Hospital, Jose Atxotegi Kalea, s/n, Txagorritxu, 01009 Gasteiz, Araba, Spain
| | - María Teresa de Santos Moreno
- Neuropediatrics Unit, San Carlos Clinic Hospital, Calle del Prof Martín Lagos, S/N, Moncloa - Aravaca, 28040 Madrid, Spain
| | - Gonzalo Mariscal
- Mediterranean Observatory for Clinical and Health Research (OMEDICS), Carrer Quevedo 1, 46001, Valencia, Spain; Institute for Research on Musculoskeletal Disorders, Valencia Catholic University, C/ de Quevedo, 2, Ciutat Vella, 46001 Valencia, Spain.
| | - Carlos Barrios
- Institute for Research on Musculoskeletal Disorders, Valencia Catholic University, C/ de Quevedo, 2, Ciutat Vella, 46001 Valencia, Spain
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Lorente R, Mariscal G, Lorente A. Incidence of genitourinary anomalies in congenital scoliosis: systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:3961-3969. [PMID: 37572143 DOI: 10.1007/s00586-023-07889-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 08/04/2023] [Accepted: 08/05/2023] [Indexed: 08/14/2023]
Abstract
PURPOSE The main objective of this study was to assess the overall incidence of genitourinary anomalies in patients with congenital scoliosis by providing the highest level of evidence. The secondary objective was to look for associations and trends influencing the incidence. METHODS A meta-analysis using PubMed, Embase, Scopus, and the Cochrane Collaboration Library database was carried out. We included studies focusing on patients with congenital scoliosis and genitourinary anomalies. The main outcome was the incidence of genitourinary anomalies in congenital scoliosis. We also collected the following data: patient gender, type of deformity (formation, segmentation, or mixed), deformity location, and associated anomalies. We included cohort studies. Data was extracted from published reports and combined using Review Manager 5.4. The quality of the included studies was assessed independently by two authors using the Methodological Index for Non-Randomized Studies (MINORS) criteria. RESULTS A total of eight cohort studies were included from a pool of 2781 patients. The incidence of genitourinary anomalies associated with congenital scoliosis was 22.91% (95% CI 13.39-32.43%). The incidence of surgically treated genitourinary anomalies was 13.92% (95% CI 4.54-23.31%). There were no differences related to gender (male 49.3% versus female 50.7%; p > 0.05). There were no differences regarding the type of deformity. The incidences of associated intraspinal, cardiac, musculoskeletal and craniofacial anomalies were 33.30%, 17.60%, 27.77% and 19.83% respectively. The most frequent genitourinary anomalies were: unilateral kidney (111/388); renal ectopia (50/367); obstructive uropathy (30/201), horseshoe kidney (30/313) and undescended testicle (16/180). CONCLUSIONS The incidence of genitourinary anomalies associated with congenital scoliosis was 22.91%, and 13.92% were surgically treated. Unilateral kidney was the most common genitourinary abnormality. There were no differences between genders and deformity types. It is important to consider the association between genitourinary anomalies and intraspinal or musculoskeletal anomalies.
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Affiliation(s)
- Rafael Lorente
- Department of Orthopedic Surgery and Traumatology, University Hospital of Badajoz, Badajoz, Spain
| | - Gonzalo Mariscal
- Institute for Research On Musculoskeletal Disorders, School of Medicine, Valencia Catholic University, Carrer de Quevedo, 2, 46001, Valencia, Spain.
| | - Alejandro Lorente
- Department of Traumatology and Orthopaedic Surgery, University Hospital Ramón Y Cajal, Madrid, Spain
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Tsuzawa K, Onimaru H, Inagaki K, Izumizaki M. Involvement of cannabinoid receptors in depression of the putative nociceptive response in spinal cord preparations isolated from neonatal rats. J Physiol Sci 2023; 73:23. [PMID: 37803279 DOI: 10.1186/s12576-023-00881-5] [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: 08/17/2023] [Accepted: 09/30/2023] [Indexed: 10/08/2023]
Abstract
A metabolite of acetaminophen, AM404, which is an anandamide transporter inhibitor, induces analgesia mainly via activation of transient receptor potential channel 1 in the spinal cord, although the role of cannabinoid receptors remains to be studied. The ventral root reflex response induced by stimulation of the dorsal root in in vitro preparations of rat spinal cord is useful to assess the effect of analgesics. We analyzed the effects of AM404 and cannabinoid receptor antagonist AM251 on reflex responses in lumbar spinal cord preparations from newborn rats and found that the amplitude of the slow ventral root potential after administration of 10 µM AM404 was not significantly changed, whereas 10 µM AM251 significantly increased the amplitude. Administration of the cannabinoid receptor 1 agonist WIN55,212-2 (10 µM) did not significantly affect the reflex response. We suggest that endogenous cannabinoids in the spinal cord are involved in the antinociceptive mechanism through suppressive effects.
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Affiliation(s)
- Kayo Tsuzawa
- Department of Orthopedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8555, Japan
| | - Hiroshi Onimaru
- Department of Physiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8555, Japan.
| | - Katsunori Inagaki
- Department of Orthopedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8555, Japan
| | - Masahiko Izumizaki
- Department of Physiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8555, Japan
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Bojic S, Ladjevic N, Palibrk I, Soldatovic I, Likic-Ladjevic I, Meissner W, Zaslansky R, Stamer UM, Baumbach P, Stamenkovic D. Cost-effectiveness of the Perioperative Pain Management Bundle a registry-based study. Front Public Health 2023; 11:1157484. [PMID: 37744520 PMCID: PMC10513912 DOI: 10.3389/fpubh.2023.1157484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 08/18/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction The Perioperative Pain Management Bundle was introduced in 10 Serbian PAIN OUT network hospitals to improve the quality of postoperative pain management. The Bundle consists of 4 elements: informing patients about postoperative pain treatment options; administering a full daily dose of 1-2 non-opioid analgesics; administering regional blocks and/or surgical wound infiltration; and assessing pain after surgery. In this study, we aimed to assess the cost-effectiveness of the Bundle during the initial 24 h after surgery. Materials and methods The assessment of cost-effectiveness was carried out by comparing patients before and after Bundle implementation and by comparing patients who received all Bundle elements to those with no Bundle element. Costs of postoperative pain management included costs of the analgesic medications, costs of labor for administering these medications, and related disposable materials. A multidimensional Pain Composite Score (PCS), the effectiveness measurement, was obtained by averaging variables from the International Pain Outcomes questionnaire evaluating pain intensity, interference of pain with activities and emotions, and side effects of analgesic medications. The incremental cost-effectiveness ratio (ICER) was calculated as the incremental change in costs divided by the incremental change in PCS and plotted on the cost-effectiveness plane along with the economic preference analysis. Results The ICER value calculated when comparing patients before and after Bundle implementation was 181.89 RSD (1.55 EUR) with plotted ICERs located in the northeast and southeast quadrants of the cost-effectiveness plane. However, when comparing patients with no Bundle elements and those with all four Bundle elements, the calculated ICER was -800.63 RSD (-6.82 EUR) with plotted ICERs located in the southeast quadrant of the cost-effectiveness plane. ICER values differ across surgical disciplines. Conclusion The proposed perioperative pain management Bundle is cost-effective. The cost-effectiveness varies depending on the number of implemented Bundle elements and fluctuates across surgical disciplines.
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Affiliation(s)
- Suzana Bojic
- Department of Anesthesiology and Intensive Care, University Hospital Medical Centre “Dr. Dragisa Misovic – Dedinje”, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Nebojsa Ladjevic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Centre of Anaesthesia and Resuscitation University Clinical Centre of Serbia, Belgrade, Serbia
| | - Ivan Palibrk
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Centre of Anaesthesia and Resuscitation University Clinical Centre of Serbia, Belgrade, Serbia
| | - Ivan Soldatovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivana Likic-Ladjevic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Gynecology and Obstetrics, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Winfried Meissner
- Department of Anesthesiology and Intensive Care, University Hospital Jena, Jena, Germany
| | - Ruth Zaslansky
- Department of Anesthesiology and Intensive Care, University Hospital Jena, Jena, Germany
| | - Ulrike M Stamer
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Philipp Baumbach
- Department of Anesthesiology and Intensive Care, University Hospital Jena, Jena, Germany
| | - Dusica Stamenkovic
- Medical Faculty of Military Medical Academy, University of Defense, Belgrade, Serbia
- Department of Anesthesiology and Intensive Care, Military Medical Academy, Belgrade, Serbia
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Weraarchakul S, Sae-Jung S. Etoricoxib Can Reduce Post-Operative Morphine Consumption and Pain Score in Patients Undergoing Lumbar Laminectomy Compare to Acetaminophen: A Randomized Trial. Global Spine J 2023; 13:1433-1440. [PMID: 34325539 PMCID: PMC10448096 DOI: 10.1177/21925682211035719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Randomized controlled trial. OBJECTIVES This prospective trial aimed to compare the effectiveness of etoricoxib and acetaminophen in terms of post-operative morphine consumption and pain score in patients undergoing lumbar laminectomy. METHODS Forty lumbar-laminectomy patients aged between 18 and 50 years were enrolled, randomized, and allocated into either the etoricoxib group or the acetaminophen group. The measures assessed were the amount of morphine consumed and pain visual analog score (VAS) at 12, 24, and 48 hours after surgery. Adverse events were recorded. RESULTS Patients in the etoricoxib group had statistically significantly lower morphine consumption than those in the acetaminophen group at 12 hours (P-value = .006), 24 hours (P-value = .006) and 48 hours (P-value = .011). Patients in the etoricoxib group had lower VAS scores than those in the acetaminophen group at 0, 12, 24, 48 hours, the difference being statistically significant at 48 hours (P < .001). CONCLUSIONS Compared to acetaminophen, etoricoxib can significantly reduce post-operative morphine consumption and improve the pain score at 12, 24, and 48 hours.
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Affiliation(s)
- Supanut Weraarchakul
- Department of Orthopaedics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Surachai Sae-Jung
- Department of Orthopaedics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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Oral Ketorolac as an Adjuvant Agent for Postoperative Pain Control After Arthroscopic Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Controlled Study. J Am Acad Orthop Surg 2022; 30:e1580-e1590. [PMID: 36476466 DOI: 10.5435/jaaos-d-21-00721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 07/05/2022] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Successful outpatient anterior cruciate ligament (ACL) reconstruction hinges on effective analgesia. Routinely, oral narcotic agents have been the preferred analgesic postoperatively in orthopaedic surgery. However, these agents have several known adverse effects and are associated with a potential for abuse. This study evaluates the efficacy of ketorolac, a nonsteroidal anti-inflammatory drug with analgesic properties, as an adjuvant agent for postoperative pain control after ACL reconstruction. METHODS Adult patients undergoing primary ACL reconstruction were prospectively enrolled. Exclusion criteria involved patients with a history of bleeding diathesis, renal dysfunction, chronic analgesia use, or alcohol abuse. Eligible patients were randomized into one of two groups. The control group received a standard-of-care pain protocol involving oxycodone-acetaminophen 5 to 325 on discharge. The ketorolac group additionally received intravenous ketorolac postoperatively and 3 days of oral ketorolac on discharge. Pain levels and total narcotic utilization were recorded three times per day for the first 5 days after surgery. Pain and functional outcomes were obtained at 2 and 6 weeks postoperatively. RESULTS The final analysis included 48 patients; the mean age of the cohort was 32 ± 11.6 years, and 60.4% of patients were female. No differences were observed in preoperative demographics, comorbidities, and preoperative functional scores between the two groups. Over the first 5 days after surgery, patients in the ketorolac group consumed a mean of 45.4% fewer narcotic pills than the control group (P < 0.001). In addition, mean postoperative pain scores were 22.36 points lower for patients in the ketorolac group (P < 0.001). There was no difference in functional outcome scores at up to 6 weeks postoperatively or adverse events between the two groups with no reported cases of gastrointestinal bleeding. DISCUSSION The use of adjunctive intravenous and short-term oral ketorolac substantially reduces narcotic utilization and pain levels after ACL reconstruction. CLINICALTRIALGOV REGISTRATION NUMBER NCT04246554.
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Xie H, Chen SH, Li L, Ge WH. The cost-effectiveness analysis of analgesic treatment options for postoperative pain following laparotomy surgeries. Int J Clin Pharm 2022; 45:355-363. [PMID: 36446996 DOI: 10.1007/s11096-022-01473-w] [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: 05/22/2022] [Accepted: 08/14/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Postoperative pain control remains unsatisfactory. Patients who underwent laparotomy may have moderate to severe acute postoperative pain. Comparative cost-effectiveness of the following postoperative pain treatment options remains to be investigated: patient-controlled intravenous analgesia (PCIA) with flurbiprofen therapy, flurbiprofen monotherapy, parecoxib monotherapy, or dezocine monotherapy. AIM To provide a cost-effectiveness analysis (CEA) of four analgesic regimens for patients with postoperative pain following laparotomy surgeries. METHOD Patients with postoperative pain following laparotomy were retrospectively reviewed from a postoperative pain management database created by pharmacists, and divided into four groups according to analgesic regimens. The clinical outcomes were visual analogue scale (VAS) scores and the incidence of adverse drug events. The CEA was conducted by developing a decision tree model based on retrospective data. The maximum incremental cost-effectiveness ratio (ICER) of the four regimens was used as the willingness-to-pay (WTP) value. Meanwhile, the uncertainty of the base-case results was examined by one-way and probabilistic sensitivity analyses. RESULTS A total of 677 patients were included in the retrospective study. PCIA with flurbiprofen therapy had the lowest VAS scores at 6, 24, 48 h postoperatively. Based on the base-case results, PCIA plus flurbiprofen was the optimal regimen with the highest effectiveness, while flurbiprofen monotherapy had the lowest cost. PCIA plus flurbiprofen was the optimal regimen even with a WTP value of 0 dollars. CONCLUSION PCIA plus flurbiprofen therapy was the optimal regimen. Parecoxib monotherapy was more cost-effective than flurbiprofen monotherapy. The findings may guide the selection of postoperative pain management.
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Affiliation(s)
- Han Xie
- State Key Laboratory of Quality Research in Chinese Medicines, Macau University of Science and Technology, Taipa, Macau (SAR), China
- Department of Pharmacy, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Si-Huang Chen
- Department of Pharmacy, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Li Li
- Department of Pharmacy, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Wei-Hong Ge
- Department of Pharmacy, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China.
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Markiewitz ND, Swarup I, Talwar D, Muhly WT, Wells L, Williams BA. Perioperative Pain Management Practices Vary Across Time and Setting for Pediatric ACL Reconstruction: Trends From a National Database in the United States. Orthop J Sports Med 2022; 10:23259671211068831. [PMID: 35071660 PMCID: PMC8777349 DOI: 10.1177/23259671211068831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/07/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Surgical and anesthetic techniques have enabled a shift to the ambulatory
setting for the majority of patients with anterior cruciate ligament (ACL)
tears. While this change likely reflects improvements in acute pain
management, little is known about national trends in pediatric perioperative
pain management after ACL reconstruction (ACLR). Purpose: To describe recent trends in the United States in perioperative pain
management for pediatric ACLR. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Pediatric patients (age, ≤18 years) who underwent ACLR with peripheral nerve
blocks between January 2008 and December 2017 were identified in the
Pediatric Health Information System database. We modeled the use of oral and
intravenous analgesic medications over time using Bayesian logistic mixed
models. Models were adjusted for patient age, sex, race, primary payer, and
treatment setting (ambulatory, observation, or inpatient). Results: The study criteria produced a sample of 18,605 patients. Older children were
more likely to receive intravenous acetaminophen, intravenous ketorolac, and
oral and intravenous opioids. Younger children were more likely to receive
ibuprofen. In our adjusted logistic model, treatment setting was found to be
an independent predictor of the utilization of all medications. We found an
increase in the overall utilization of oral acetaminophen (adjusted odds
ratio [adj OR], 1.14 [95% CI, 1.04-1.23]), intravenous acetaminophen (adj
OR, 1.42 [95% CI, 1.22-1.65]), and oral opioids (adj OR, 1.16 [95% CI,
1.06-1.28]) over the study period at a typical hospital. We found
significant heterogeneity in medication use across hospitals, with the most
heterogeneity in intravenous acetaminophen. Other studied descriptive
variables did not appear to predict practices. Conclusion: After adjusting for patient characteristics and treatment settings, pain
management strategies varied among hospitals and over time. Patient age and
treatment setting predicted practices. Regional anesthesia, opioid
medications, and intravenous ketorolac remained the mainstays of treatment,
while intravenous acetaminophen emerged in use over the course of the study
period. The variability in the pain management of pediatric patients
undergoing ACLR suggests that further study is necessary to establish the
most effective means of perioperative pain management in these patients.
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Affiliation(s)
- Nathan D. Markiewitz
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ishaan Swarup
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Divya Talwar
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Wallis T. Muhly
- Division of Anesthesia, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lawrence Wells
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Brendan A. Williams
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Li Y, Swallow J, Robbins C, Caird MS, Leis A, Hong RA. Gabapentin and intrathecal morphine combination therapy results in decreased oral narcotic use and more consistent pain scores after posterior spinal fusion for adolescent idiopathic scoliosis. J Orthop Surg Res 2021; 16:672. [PMID: 34781972 PMCID: PMC8594153 DOI: 10.1186/s13018-021-02525-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/03/2021] [Indexed: 12/04/2022] Open
Abstract
Background Gabapentin and intravenous patient-controlled analgesia (PCA) can reduce postoperative pain scores, postoperative opioid use, and time to completing physical therapy compared to PCA alone after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Gabapentin combined with intrathecal morphine has not been studied. The primary purpose of this retrospective study was to evaluate whether perioperative gabapentin and intrathecal morphine provide more effective pain control than intrathecal morphine alone after PSF for AIS. Methods Patients aged 11 to 18 years who underwent PSF for AIS were identified. Patients who received intrathecal morphine only (ITM group) were matched by age and sex to patients who received intrathecal morphine and perioperative gabapentin (ITM+GABA group). The ITM+GABA group received gabapentin preoperatively and for up to 2 days postoperatively. Both groups received oxycodone and the same non-narcotic adjuvant medications. Results Our final study group consisted of 50 patients (25 ITM, 25 ITM+GABA). The ITM+GABA group had significantly lower mean total oxycodone consumption during the hospitalization (0.798 vs 1.036 mg/kg, P<0.015). While the ITM group had a lower mean pain score between midnight and 8 am on POD 1 (2.4 vs 3.7, P=0.026), pain scores were significantly more consistent throughout the postoperative period in ITM+GABA group. The ITM+GABA group experienced less nausea/vomiting (52% vs 84%, P=0.032) and pruritus (44% vs 72%, P=0.045). Time to physical therapy discharge and length of hospital stay were similar. Conclusion Addition of gabapentin resulted in reduced oral opioid consumption and more consistent postoperative pain scores after PSF for AIS. The patients who received intrathecal morphine and gabapentin also experienced a lower rate of nausea/vomiting and pruritus. Trial registration All data was collected retrospectively from chart review, with institutional IRB approval. Trial registration is not applicable.
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Affiliation(s)
- Ying Li
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI, USA
| | - Jennylee Swallow
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI, USA
| | - Christopher Robbins
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michelle S Caird
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI, USA
| | - Aleda Leis
- Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA
| | - Rebecca A Hong
- Department of Anesthesiology, C.S. Mott Children's Hospital, Michigan Medicine, 1540 E. Hospital Drive, SPC 4245, Ann Arbor, MI, 48109-4245, USA.
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12
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Waelkens P, Alsabbagh E, Sauter A, Joshi GP, Beloeil H. Pain management after complex spine surgery: A systematic review and procedure-specific postoperative pain management recommendations. Eur J Anaesthesiol 2021; 38:985-994. [PMID: 34397527 PMCID: PMC8373453 DOI: 10.1097/eja.0000000000001448] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Complex spinal procedures are associated with intense pain in the postoperative period. Adequate peri-operative pain management has been shown to correlate with improved outcomes including early ambulation and early discharge. OBJECTIVES We aimed to evaluate the available literature and develop recommendations for optimal pain management after complex spine surgery. DESIGN AND DATA SOURCES A systematic review using the PROcedure SPECific postoperative pain managemenT methodology was undertaken. Randomised controlled trials and systematic reviews published in the English language from January 2008 to April 2020 assessing postoperative pain after complex spine surgery using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, EMBASE and Cochrane Databases. RESULTS Out of 111 eligible studies identified, 31 randomised controlled trials and four systematic reviews met the inclusion criteria. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, cyclo-oxygenase (COX)-2 specific-inhibitors or non-steroidal anti-inflammatory drugs (NSAIDs), intravenous ketamine infusion and regional analgesia techniques including epidural analgesia using local anaesthetics with or without opioids. Limited evidence was found for local wound infiltration, intrathecal and epidural opioids, erector spinae plane block, thoracolumbar interfascial plane block, intravenous lidocaine, dexmedetomidine and gabapentin. CONCLUSIONS The analgesic regimen for complex spine surgery should include pre-operative or intra-operative paracetamol and COX-2 specific inhibitors or NSAIDs, continued postoperatively with opioids used as rescue analgesics. Other recommendations are intra-operative ketamine and epidural analgesia using local anaesthetics with or without opioids. Although there is procedure-specific evidence in favour of intra-operative methadone, it is not recommended as it was compared with shorter-acting opioids and due to its limited safety profile. Furthermore, the methadone studies did not use non-opioid analgesics, which should be the primary analgesics to ultimately reduce overall opioid requirements, including methadone. Further qualitative randomised controlled trials are required to confirm the efficacy and safety of these recommended analgesics on postoperative pain relief.
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Affiliation(s)
- Piet Waelkens
- From the Department of Anaesthesiology, KU Leuven and University Hospital Leuven, Leuven, Belgium (PW), CHU Rennes, Anesthesia and Intensive Care Department, Rennes, France (EA), the Department of Anaesthesiology and Pain Management, University of Oslo, Oslo, Norway (AS), the Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (AS), the Department of Anaesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA (GPJ), the University Rennes, CHU Rennes, Inserm, INRA, CIC 1414 NuMeCan, Anesthesia and Intensive Care Department, Rennes, France (HB)
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13
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Albertz M, Whitlock P, Yang F, Ding L, Uchtman M, Mecoli M, Olbrecht V, Moore D, McCarthy J, Chidambaran V. Pragmatic comparative effectiveness study of multimodal fascia iliaca nerve block and continuous lumbar epidural-based protocols for periacetabular osteotomy. J Hip Preserv Surg 2021; 7:728-739. [PMID: 34377516 PMCID: PMC8349585 DOI: 10.1093/jhps/hnab010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 12/25/2022] Open
Abstract
Perioperative pain management protocols have a significant impact on early surgical outcomes and recovery. We hypothesized that multimodal protocol including fascia iliaca compartment nerve block (MM-FICNB) would decrease the length of hospital stay (LOS) by facilitating earlier mobilization, without compromising analgesia, compared to a traditional lumbar epidural-based protocol (EP). Demographics/comorbidities, surgical/block characteristics and perioperative pain/mobilization data were collected from a prospectively recruited MM-FICNB group (N = 16) and a retrospective EP cohort (N = 16) who underwent PAO using similar surgical techniques, physical therapy/discharge criteria. Association of MM-FICNB group with LOS (primary outcome), postoperative pain, postoperative opioid requirements in morphine equivalent rates (MER) (mcg/kg/h) and time to complete physical therapy were tested using multivariable and survival regression. Patient and surgical characteristics were similar between groups. Median time for FICNB performance was significantly less than epidural (6 versus 15 min; P < 0.001). LOS was significantly decreased in the MM-FICNB group (2.88 ± 0.72 days) compared to the EP group (4.38 ± 1.02 days); P < 0.001. MM-FICNB group had significantly lower MER on POD1 (P = 0.006) and POD2 (P < 0.001), with similar pain scores on all POD. MM-FICNB group was associated with decreased LOS and earlier mobilization (P < 0.001) by covariate-adjusted multivariate regression. Cox proportional hazard regression model showed MM-FICNB subjects had 63 (95% CI 7–571, P < 0.001) times the chance of completing physical therapy goals, compared to EP. Compared to EP, MM-FICNB protocol allowed earlier mobilization and decreased post-surgical hospitalization by 1.5 days, without compromising analgesia, with important implications for value-based healthcare and cost-effectiveness.
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Affiliation(s)
- Megan Albertz
- Department of Anesthesiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Patrick Whitlock
- Department of Orthopedics, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Fang Yang
- Division of Biostatistics, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Lili Ding
- Division of Biostatistics, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Molly Uchtman
- Department of Orthopedics, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Marc Mecoli
- Department of Anesthesiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Vanessa Olbrecht
- Department of Anesthesiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - David Moore
- Department of Anesthesiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - James McCarthy
- Department of Orthopedics, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Vidya Chidambaran
- Department of Anesthesiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
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14
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Pennington Z, Cottrill E, Lubelski D, Ehresman J, Lehner K, Groves ML, Sponseller P, Sciubba DM. Clinical utility of enhanced recovery after surgery pathways in pediatric spinal deformity surgery: systematic review of the literature. J Neurosurg Pediatr 2021; 27:225-238. [PMID: 33254141 DOI: 10.3171/2020.7.peds20444] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVES More than 7500 children undergo surgery for scoliosis each year, at an estimated annual cost to the health system of $1.1 billion. There is significant interest among patients, parents, providers, and payors in identifying methods for delivering quality outcomes at lower costs. Enhanced recovery after surgery (ERAS) protocols have been suggested as one possible solution. Here the authors conducted a systematic review of the literature describing the clinical and economic benefits of ERAS protocols in pediatric spinal deformity surgery. METHODS The authors identified all English-language articles on ERAS protocol use in pediatric spinal deformity surgery by using the following databases: PubMed/MEDLINE, Web of Science, Cochrane Reviews, EMBASE, CINAHL, and OVID MEDLINE. Quantitative analyses of comparative articles using random effects were performed for the following clinical outcomes: 1) length of stay (LOS); 2) complication rate; 3) wound infection rate; 4) 30-day readmission rate; 5) reoperation rate; and 6) postoperative pain scores. RESULTS Of 950 articles reviewed, 7 were included in the qualitative analysis and 6 were included in the quantitative analysis. The most frequently cited benefits of ERAS protocols were shorter LOS, earlier urinary catheter removal, and earlier discontinuation of patient-controlled analgesia pumps. Quantitative analyses showed ERAS protocols to be associated with shorter LOS (mean difference -1.12 days; 95% CI -1.51, -0.74; p < 0.001), fewer postoperative complications (OR 0.37; 95% CI 0.20, 0.68; p = 0.001), and lower pain scores on postoperative day (POD) 0 (mean -0.92; 95% CI -1.29, -0.56; p < 0.001) and POD 2 (-0.61; 95% CI -0.75, -0.47; p < 0.001). There were no differences in reoperation rate or POD 1 pain scores. ERAS-treated patients had a trend toward higher 30-day readmission rates and earlier discontinuation of patient-controlled analgesia (both p = 0.06). Insufficient data existed to reach a conclusion about cost differences. CONCLUSIONS The results of this systematic review suggest that ERAS protocols may shorten hospitalizations, reduce postoperative complication rates, and reduce postoperative pain scores in children undergoing scoliosis surgery. Publication biases exist, and therefore larger, prospective, multicenter data are needed to validate these results.
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Affiliation(s)
| | | | | | | | | | | | - Paul Sponseller
- 2Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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15
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Lide RC, Creighton EW, Yeh J, Troughton M, Hollowoa B, Merrill T, Robbins A, Orman G, Breckling M, Vural E, Moreno M, Stack BC. Opioid reduction in ambulatory thyroid and parathyroid surgery after implementing enhanced recovery after surgery protocol. Head Neck 2021; 43:1545-1552. [PMID: 33502069 DOI: 10.1002/hed.26617] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 11/22/2020] [Accepted: 01/14/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Opioid abuse is widespread in the United States and the risk for chronic use is increased in surgical patients, including patients with thyroid and parathyroid. METHODS Records for 171 patients prior to and 67 patients following implementation of an enhanced recovery after surgery (ERAS) protocol for ambulatory thyroid/parathyroid surgeries were reviewed. The ERAS included superficial cervical plexus block, multimodal premedication, and postoperative reliance on acetaminophen and ibuprofen with judicious prescribing of opioids. RESULTS Post-ERAS patients were prescribed a mean 72 morphine milligram equivalents (MME); pre-ERAS patients were prescribed a mean 163 MME (p < 0.001). 97.1% of pre-ERAS patients were prescribed opioids with 91.1% filled; 68.7% of post-ERAS study patients were prescribed opioids with 84.8% filled. CONCLUSION Implementation of ERAS and focus on prescribing practices decreased the MME prescribed and used for ambulatory thyroid and parathyroid surgery. Future steps include increased patient education and tracking pain scores and medication utilization out of hospital.
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Affiliation(s)
- Riley C Lide
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Erin Weatherford Creighton
- Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jessica Yeh
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Mikayla Troughton
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Blake Hollowoa
- Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Tyler Merrill
- Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Alexa Robbins
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Gray Orman
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Meghan Breckling
- College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Emre Vural
- Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Mauricio Moreno
- Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Brendan C Stack
- Department of Otolaryngology - Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA
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16
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Postoperative Pain Management in Pediatric Spinal Fusion Surgery for Idiopathic Scoliosis. Paediatr Drugs 2020; 22:575-601. [PMID: 33094437 DOI: 10.1007/s40272-020-00423-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2020] [Indexed: 12/12/2022]
Abstract
This article reviews and summarizes current evidence and knowledge gaps regarding postoperative analgesia after pediatric posterior spine fusion for adolescent idiopathic scoliosis, a common procedure that results in severe acute postoperative pain. Inadequate analgesia may delay recovery, cause patient dissatisfaction, and increase chronic pain risk. Despite significant adverse effects, opioids are the analgesic mainstay after scoliosis surgery. However, growing emphasis on opioid minimization and enhanced recovery has increased adoption of multimodal analgesia (MMA) regimens. While opioid adverse effects remain a concern, MMA protocols must also consider risks and benefits of adjunct medications. We discuss use of opioids via different administration routes and elaborate on the effect of MMA components on opioid/pain and recovery outcomes including upcoming regional analgesia. We also discuss risk for prolonged opioid use after surgery and chronic post-surgical pain risk in this population. Evidence supports use of neuraxial opioids at safe doses, low-dose ketorolac, and methadone for postoperative analgesia. There may be a role for low-dose ketamine in those who are opioid-tolerant or have chronic pain, but the evidence for preoperative gabapentinoids and intravenous lidocaine is currently insufficient. There is a need for further studies to evaluate pediatric-specific optimal MMA dosing regimens after scoliosis surgery. Questions remain regarding how best to prevent acute opioid tolerance, opioid-induced hyperalgesia, and chronic postsurgical pain. We anticipate that this timely update will enable clinicians to develop efficient pain regimens and provide impetus for future research to optimize recovery outcomes after spine fusion.
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17
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Shao B, Tariq AA, Goldstein HE, Alexiades NG, Mar KM, Feldstein NA, Anderson RCE, Giordano M. Multimodal Analgesia After Posterior Fossa Decompression With and Without Duraplasty for Children With Chiari Type I. Hosp Pediatr 2020; 10:447-451. [PMID: 32321740 DOI: 10.1542/hpeds.2019-0298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Multimodal analgesia (MMA) may reduce opioid use after surgery for Chiari malformation type I. An MMA protocol was implemented after both posterior fossa decompression without dural opening (PFD) and posterior fossa decompression with duraplasty (PFDD). METHODS Scheduled nonsteroidal antiinflammatory drugs (ketorolac or ibuprofen) and diazepam were alternated with acetaminophen, and as-needed oxycodone or intravenous morphine. The primary outcome was total opioid requirement over postoperative days 0 to 2. RESULTS From 2012 to 2017, 49 PFD and 29 PFDD procedures were performed, and 46 of 78 patients used the protocol. Patients with PFD required less opioids than patients with PFDD. Among patients with PFDD, patients with MMA protocol usage had a lower mean opioid requirement than patients with no MMA protocol usage (0.53 ± 0.49 mgEq/kg versus 1.4 ± 1.0 mgEq/kg, P = .0142). In multivariable analysis, MMA protocol usage status independently predicted a mean decrease in opioid requirement of 0.146 mg equivalents/kg (P = .0497) after adjustment for procedure and surgeon. Statistically significant differences were not demonstrated in antiemetic requirements, discharge opioid prescriptions, total direct cost, and length of stay. CONCLUSIONS A protocol of scheduled nonsteroidal antiinflammatory drugs alternating with scheduled acetaminophen and diazepam was associated with opioid use reductions.
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Affiliation(s)
- Belinda Shao
- Departments of Neurological Surgery and.,Department of Neurosurgery, Brown University, Providence, Rhode Island
| | - Abdul A Tariq
- Value Institute, New York-Presbyterian Hospital, New York, New York; and
| | | | | | - Krista M Mar
- Department of Information Services and Technology, Jefferson Health, Philadelphia, Pennsylvania
| | | | | | - Mirna Giordano
- Pediatrics, Columbia University Irving Medical Center, Columbia University, New York, New York;
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White PF. Cost-effective multimodal analgesia in the perioperative period: Use of intravenous vs. oral acetaminophen. J Clin Anesth 2019; 61:109625. [PMID: 31676119 DOI: 10.1016/j.jclinane.2019.109625] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 09/20/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Paul F White
- Cedars-Sinai Medical Center, Los Angeles, CA, United States; White Mountain Institute, The Sea Ranch, CA, United States.
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20
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Wang H, Xiu P, Wang L, Song Y. [Progress in perioperative pain management of pediatric and adolescent spinal deformity corrective surgery]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:644-649. [PMID: 31090362 PMCID: PMC8337207 DOI: 10.7507/1002-1892.201810122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 03/27/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To review the advances in perioperative pain management of pediatric and adolescent spinal deformity corrective surgery. METHODS Regular analgesics, drug administrations, and analgesic regimens were reviewed and summarized by consulting domestic and overseas related literatures about perioperative pain management of pediatric and adolescent spinal deformity corrective surgery in recent years. RESULTS As for perioperative analgesis regimens of pediatric and adolescent spinal deformity corrective surgery, regular analgesics include non-steroidal anti-inflammatory drugs, opioids, antiepileptic drugs, adrenergic agonists, and local anesthetic, etc. Besides drug administration by mouth, intravenous injection, and intramuscular injection, the administration also includes patient controlled analgesia, epidural injection, and intrathecal injection. Multimodal analgesia is the most important regimen currently. CONCLUSION Heretofore, a number of perioperative pain managements of pediatric and adolescent spinal deformity corrective surgery have been applied clinically, but the ideal regimen has not been developed. To design a safe and effective analgesic regimen needs further investigations.
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Affiliation(s)
- Haozhong Wang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Peng Xiu
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Lei Wang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Yueming Song
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041,
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Rugytė D, Gudaitytė J. Intravenous Paracetamol in Adjunct to Intravenous Ketoprofen for Postoperative Pain in Children Undergoing General Surgery: A Double-Blinded Randomized Study. ACTA ACUST UNITED AC 2019; 55:medicina55040086. [PMID: 30939851 PMCID: PMC6524359 DOI: 10.3390/medicina55040086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 02/28/2019] [Accepted: 03/26/2019] [Indexed: 02/07/2023]
Abstract
Background and objectives: The combination of non-steroidal anti-inflammatory drugs and paracetamol is widely used for pediatric postoperative pain management, although the evidence of superiority of a combination over either drug alone is insufficient. We aimed to find out if intravenous (i.v.) paracetamol in a dose of 60 mg kg-1 24 h-¹, given in addition to i.v. ketoprofen (4.5 mg kg-1 24 h-¹), improves analgesia, physical recovery, and satisfaction with postoperative well-being in children and adolescents following moderate and major general surgery. Materials and Methods: Fifty-four patients were randomized to receive either i.v. paracetamol or normal saline as a placebo in adjunct to i.v. ketoprofen. For rescue analgesia in patients after moderate surgery, i.v. tramadol (2 mg kg-¹ up two doses in 24 h), and for children after major surgery, i.v. morphine-patient-controlled analgesia (PCA) were available. The main outcome measure was the amount of opioid consumed during the first 24 h after surgery. Pain level at 1 and over 24 h, time until the resumption of normal oral fluid intake, spontaneous urination after surgery, and satisfaction with postoperative well-being were also assessed. Results: Fifty-one patients (26 in the placebo group and 25 in the paracetamol group) were studied. There was no difference in required rescue tramadol doses (n = 11 in each group) or 24-h morphine consumption (mean difference (95% CI): 0.06 (⁻0.17; 0.29) or pain scores between placebo and paracetamol groups. In patients given morphine-PCA, time to normal fluid intake was faster in the paracetamol than the placebo subgroup: median difference (95% CI): 7.5 (1.3; 13.7) h, p = 0.02. Parental satisfaction score was higher in the paracetamol than the placebo group (mean difference: ⁻1.3 (⁻2.5; ⁻0.06), p = 0.04). Conclusions: There were no obvious benefits to opioid requirement or analgesia of adding regular intravenous paracetamol to intravenous ketoprofen in used doses. However, intravenous paracetamol may contribute to faster recovery of normal functions and higher satisfaction with postoperative well-being.
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MESH Headings
- Acetaminophen/administration & dosage
- Acetaminophen/adverse effects
- Administration, Intravenous
- Adolescent
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/adverse effects
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/therapeutic use
- Anti-Inflammatory Agents, Non-Steroidal/administration & dosage
- Child
- Child, Preschool
- Double-Blind Method
- Drug Therapy, Combination
- Female
- Follow-Up Studies
- Humans
- Infant
- Ketoprofen/administration & dosage
- Male
- Morphine/administration & dosage
- Morphine/therapeutic use
- Pain, Postoperative/drug therapy
- Patient Satisfaction
- Statistics, Nonparametric
- Tramadol/administration & dosage
- Tramadol/therapeutic use
- Treatment Outcome
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Affiliation(s)
- Danguolė Rugytė
- Department of Anesthesiology, Lithuanian University of Health Sciences, 44307Kaunas, Lithuania.
| | - Jūratė Gudaitytė
- Department of Anesthesiology, Lithuanian University of Health Sciences, 44307Kaunas, Lithuania.
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