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Jones IA, LoBasso MA, Wier J, Gettleman BS, Richardson MK, Ratto CE, Lieberman JR, Heckmann ND. Perioperative Dexamethasone in Diabetic Patients: A Systematic Review and Meta-Analysis of Randomized, Placebo-Controlled Trials. Anesth Analg 2024; 139:479-489. [PMID: 39151134 DOI: 10.1213/ane.0000000000007007] [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: 08/18/2024]
Abstract
BACKGROUND The perioperative use of dexamethasone in diabetic patients remains controversial due to concerns related to infection and adverse events. This study aimed to determine whether clinical evidence supports withholding dexamethasone in diabetic patients due to concern for infection risk. We hypothesized that there is no difference in infectious outcomes between dexamethasone-treated patients and controls. METHODS A literature search was performed on November 22, 2022 to identify randomized, placebo-controlled trials investigating short-course (<72 hours), perioperative dexamethasone that explicitly included diabetic patients and measured at least 1 clinical outcome. Pertinent studies were independently searched in PubMed, Embase, and Cochrane. Authors for all identified studies were contacted with the aim of performing quantitative subgroup analyses of diabetic patients. The primary end point was surgical site infection and the secondary end point was a composite of adverse events. Qualitative remarks were reported based on the total available data and a quality assessment tool. Meta-analyses were performed using inverse variance with random effects. Heterogeneity was assessed via standard χ2 and I2 tests. RESULTS Sixteen unique studies were included, 5 of which were analyzed quantitatively. Of the 2592 diabetic patients, 2344 (1184 randomized to dexamethasone and 1160 to placebo) were analyzed in at least 1 quantitative outcome. Quantitative analysis showed that the use of perioperative dexamethasone had no effect on the risk of surgical site infections (log odds ratio [LOR], -0.10, 95%; 95% confidence interval [CI], -0.64 to 0.44) while significantly reducing the risk of composite adverse events (LOR, -0.33; 95% CI, -0.62 to -0.05). Qualitative analysis reinforced these findings, demonstrating noninferior to superior results across all clinical outcomes. There was high heterogeneity between the included studies. CONCLUSIONS Current evidence suggests perioperative dexamethasone may be given to diabetic patients without increasing the risk of infectious complications. Prospective investigations aimed at optimizing dose, frequency, and timing are needed, as well as studies aimed explicitly at exploring the use of dexamethasone in patients with poorly controlled diabetes.
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Affiliation(s)
- Ian A Jones
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Michael A LoBasso
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles, California
| | - Julian Wier
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Brandon S Gettleman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Mary K Richardson
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Christina E Ratto
- Department of Anesthesiology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Nathanael D Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
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Liu XY, Mou P, Cao J, Chen XM, Wang HY, Zeng WN, Zhou ZK. The effect of a split-dose intravenous dexamethasone and a single high-dose on postoperative blood glucose after total joint arthroplasty: a randomized double-blind placebo-controlled trial. J Orthop Surg Res 2024; 19:388. [PMID: 38956678 PMCID: PMC11221166 DOI: 10.1186/s13018-024-04887-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 06/27/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND In patients undergoing total joint arthroplasty (TJA), the administration of dexamethasone may contribute to perioperative blood glucose (BG) disturbances, potentially resulting in complications, even in patients without diabetes. This study aimed to demonstrate the impact of different administration regimens of dexamethasone in postoperative BG levels. METHODS In this randomized, controlled, double-blind trial, 136 patients without diabetes scheduled for TJA were randomly assigned to three groups: two perioperative saline injections (Group A, placebo); a single preoperative injection of 20 mg dexamethasone and a postoperative saline injection (Group B), and two perioperative injections of 10 mg dexamethasone (Group C). Primary outcomes were the postoperative fasting blood glucose (FBG) levels. Secondary outcome parameters were the postoperative postprandial blood glucose (PBG) levels. Postoperative complications within 90 days were also recorded. Risk factors for FBG ≥ 140 mg/dl and PBG ≥ 180 mg/dl were investigated. RESULTS Compared to Group A, there were transient increases in FBG and PBG on postoperative days (PODs) 0 and 1 in Groups B and C. Statistical differences in FBG and PBG among the three groups were nearly absent from POD 1 onward. Both dexamethasone regimens did not increase the risk for postoperative FBG ≥ 140 mg/dl or PBG ≥ 180 mg/dl. Elevated preoperative HbA1c levels may increase the risk of postoperative FBG ≥ 140 mg/dl or PBG ≥ 180 mg/dl, respectively. CONCLUSION Perioperative intravenous high-dose dexamethasone to patients without diabetes has transient effects on increasing BG levels after TJA. However, no differences were found between the split-dose and single high-dose regimens. The elevated preoperative HbA1c, but not the dexamethasone regimens were the risk factor for FBG ≥ 140 mg/dl and PBG ≥ 180 mg/dl. TRIAL REGISTRATION Chinese Clinical Trail Registry, ChiCTR2300069473. Registered 17 March 2023, https://www.chictr.org.cn/showproj.html?proj=186760 .
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Affiliation(s)
- Xiao-Yang Liu
- Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Ping Mou
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Jian Cao
- Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Xu-Ming Chen
- Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Hao-Yang Wang
- Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Wei-Nan Zeng
- Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Zong-Ke Zhou
- Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China.
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Özbaş N, Şahan N, Aydın E. The Effect of Foot Reflexology on Pain and Kinesiophobia in Patients Following Total Knee Arthroplasty: A Double-Blind Randomized Controlled Study. Orthop Nurs 2024; 43:223-233. [PMID: 39047275 DOI: 10.1097/nor.0000000000001043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2024] Open
Abstract
Nonpharmacological methods are used in the management of pain and kinesiophobia following total knee arthroplasty. The aim of this double-blind randomized controlled trial was to examine the effect of foot reflexology on pain and kinesiophobia in patients following total knee arthroplasty. A total of 40 patients (20 in the control group and 20 in the intervention group) were randomly assigned to either of two groups for the study. The intervention group was exposed to foot reflexology. Postoperative Visual Analog Scale scores decreased faster in the intervention group compared to the control group (F = 80.417; p < .001; η2 = 0.685). The Western Ontario and McMaster Universities Osteoarthritis Index scores decreased in the intervention group over time, while they increased in the control group (p < .05). While a gradual increase was observed in the Tampa Scale for Kinesiophobia scores in the control group, there was a decrease in the intervention group (F = 84.860; p < .001; η2 = 0.696). The amount of analgesics used was lower in the intervention group (p < .05). Foot reflexology can be applied as an effective and safe method to manage pain and kinesiophobia in total knee arthroplasty patients.
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Affiliation(s)
- Nilgün Özbaş
- Nilgün Özbaş, PhD, Surgical Diseases Nursing, Nursing Department, Akdağmadeni Health College, Yozgat Bozok University, Akdağmadeni, Yozgat, Turkey
- Nilay Şahan, PhD, Department of Occupational Therapy, Faculty of Health Sciences, Çankırı Karatekin University, Çankiri, Turkey
- Erbil Aydın, PhD, Department of Orthopedics and Traumatology, Dışkapı Yıldırım Beyazıt Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Nilay Şahan
- Nilgün Özbaş, PhD, Surgical Diseases Nursing, Nursing Department, Akdağmadeni Health College, Yozgat Bozok University, Akdağmadeni, Yozgat, Turkey
- Nilay Şahan, PhD, Department of Occupational Therapy, Faculty of Health Sciences, Çankırı Karatekin University, Çankiri, Turkey
- Erbil Aydın, PhD, Department of Orthopedics and Traumatology, Dışkapı Yıldırım Beyazıt Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Erbil Aydın
- Nilgün Özbaş, PhD, Surgical Diseases Nursing, Nursing Department, Akdağmadeni Health College, Yozgat Bozok University, Akdağmadeni, Yozgat, Turkey
- Nilay Şahan, PhD, Department of Occupational Therapy, Faculty of Health Sciences, Çankırı Karatekin University, Çankiri, Turkey
- Erbil Aydın, PhD, Department of Orthopedics and Traumatology, Dışkapı Yıldırım Beyazıt Training and Research Hospital, University of Health Sciences, Ankara, Turkey
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Ferreira GE, Patanwala AE, Turton H, Langford AV, Harris IA, Maher CG, McLachlan AJ, Glare P, Lin CWC. How is postoperative pain after hip and knee replacement managed? An analysis of two large hospitals in Australia. Perioper Med (Lond) 2024; 13:49. [PMID: 38822448 PMCID: PMC11143609 DOI: 10.1186/s13741-024-00403-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 05/20/2024] [Indexed: 06/03/2024] Open
Abstract
BACKGROUND Multimodal analgesia regimens are recommended for the postoperative period after hip and knee replacement surgeries. However, there are no data on practice patterns for analgesic use in the immediate postoperative period after hip and knee replacements in Australia. OBJECTIVES To describe analgesic prescribing patterns in the inpatient postoperative phase for patients undergoing hip and knee replacement. METHODS Retrospective study of electronic medical record data from two major hospitals in Sydney, Australia. We identified analgesic medication prescriptions for all patients aged 18 years and older who underwent hip or knee replacement surgery in 2019. We extracted data on pain medications prescribed while in the ward up until discharge. These were grouped into distinct categories based on the Anatomical Therapeutic Chemical classification. We described the frequency (%) of pain medications used by category and computed the average oral morphine equivalent daily dose (OMEDD) during hospitalisation. RESULTS We identified 1282 surgeries in 1225 patients. Patients had a mean (SD) age of 69 (11.8) years; most (57.1%) were female. Over 99% of patients were prescribed opioid analgesics and paracetamol during their hospital stay. Most patients (61.4%) were managed with paracetamol and opioids only. The most common prescribed opioid was oxycodone (87.3% of patients). Only 19% of patients were prescribed nonsteroidal anti-inflammatories (NSAIDs). The median (IQR) average daily OMEDD was 50.2 mg (30.3-77.9). CONCLUSION We identified high use of opioids analgesics as the main strategies for pain control after hip and knee replacement in hospital. Other analgesics were much less frequently used, such as NSAIDs, and always in combination with opioids and paracetamol.
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Affiliation(s)
- Giovanni E Ferreira
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia.
- Royal Prince Alfred Hospital, Level 10 North, King George V Building, Missenden Road, PO Box M179, Camperdown, NSW, 2050, Australia.
| | - Asad E Patanwala
- Pharmacy Department, Royal Prince Alfred Hospital, Sydney, Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Hannah Turton
- Pharmacy Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Aili V Langford
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Ian A Harris
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia
- Orthopaedic Department, South Western Sydney Local Health District, Liverpool Hospital, Sydney, Australia
| | - Chris G Maher
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Paul Glare
- Northern Clinical School, Faculty of Medicine & Health, University of Sydney, Sydney, Australia
| | - Chung-Wei Christine Lin
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia
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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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Laconi G, Coppens S, Roofthooft E, Van De Velde M. High dose glucocorticoids for treatment of postoperative pain: A systematic review of the literature and meta-analysis. J Clin Anesth 2024; 93:111352. [PMID: 38091865 DOI: 10.1016/j.jclinane.2023.111352] [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: 04/27/2023] [Revised: 10/30/2023] [Accepted: 11/22/2023] [Indexed: 01/14/2024]
Abstract
STUDY OBJECTIVE Glucocorticoids as a component of multimodal analgesia have been studied for many years and their post-operative analgesic effects appear to be dose-dependent. We conducted a systematic review of randomized controlled trials (RCTs) to evaluate the evidence of peri-operative high dose corticosteroid therapy in comparison to placebo (placebo drug) or control group (no treatment) for improving the quality of post-operative analgesia as indicated by a reduction of 10 mm in 100 mm Visual Analogue Scale (VAS) or reduction of 1 point in a 0-10 point VAS scale, or a reduction of 1 point in an 11-point Numerical Rating Scale (NRS) score, or reduction of rescue opioid analgesia, in patients undergoing all types of surgery. DESIGN Systematic review of RCTs with meta-analysis. SETTING Acute postoperative pain treatment in non-obese adult population. INTERVENTIONS Perioperative administration of high dose of Dexamethasone (≥ 0,2 mg/Kg or ≥ 15 mg), or a corresponding dose of a systemic glucocorticoid. MEASUREMENTS Primary outcomes were postoperative pain measured in 0-100 mm VAS score at 24 h after surgery upon rest and movement. Secondary outcomes were postoperative pain 0-100 mm VAS score 48 h after surgery, postoperative rescue analgesic requirement, postoperative nausea and vomiting (PONV), relevant adverse events. MAIN RESULTS 47 RCT's were included (3943 patients). The Mean Difference (MD) of 100 mm VAS scores for pain at rest 24 h after surgery was -6.18 mm 95% CI [-8.53, -3.83], at motion -8.86 mm 95% CI [-11.82, -5.89]. Opioid analgesic requirements evaluated in Oral Morphine Equivalents (OME) was -10.00 mg 95% CI [-13.65, -6.34]. PONV events Odds Ratio of 0.29 95%CI [0.24, 0.36]. Major adverse events OR was 0.88 95% CI [0.65, 1.19]. Minor adverse events OR 1.29 95% CI [0.86, 1.92]. CONCLUSION High doses of glucocorticoids are one of the many possible tools available in multimodal postoperative analgesia, possibly reducing opioids consumption and recurrence of PONV but with no relevant effects in terms of reduction of postoperative VAS score. Available data show a safe therapeutic profile, without increase adverse events. PROTOCOL REGISTRATION CRD42020137119.
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Affiliation(s)
- Giulia Laconi
- Anesthesia and Intensive Care Unit, AOU Sant'Anna, Ferrara, Italy.
| | - Steve Coppens
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Biomedical Sciences Group, University of Leuven, Leuven, Belgium
| | - Eva Roofthooft
- Department of Anesthesia, GZA Hospitals, Antwerp, Belgium and Department of Cardiovascular sciences, KULeuven, Leuven, Belgium
| | - Marc Van De Velde
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Biomedical Sciences Group, University of Leuven, Leuven, Belgium
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Liu F, Duan M, Fu H, Wang T. The efficacy and safety of perioperative glucocorticoid for total knee arthroplasty: a systematic review and meta-analysis. BMC Anesthesiol 2024; 24:144. [PMID: 38622510 PMCID: PMC11017604 DOI: 10.1186/s12871-024-02530-9] [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: 07/30/2023] [Accepted: 04/08/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND An increasing number of individuals undergo total knee arthroplasty (TKA), which can result in pain, limited motor function and adverse complications such as infection, nausea and vomiting. Glucocorticoids have been shown anti-inflammatory and antiemetic effects, but can also elevate blood glucose levels and increase the risk of wound infection. Thus, it is essential to investigate the efficacy and safety of glucocorticoid usage in TKA. METHOD A comprehensive systematic search of PubMed, Medline, EMBASE, Cochrane databases, to identify relevant randomized controlled trials (RCTs) of glucocorticoid application in TKA. The primary outcomes assessed were the postoperative pain assessment. Secondary outcomes included the range of motion in knee joint, levels of inflammatory cytokines, adverse complications, and the length of hospital stay. RESULTS Thirty-six randomized controlled trials were included in the final analysis. The glucocorticoid group exhibited significant reduction in the resting VAS scores on postoperative days 1, 2 (POD1, 2)and postoperative 3 months (POM3), as well as decreased morphine consumption on POD1 and increased range of motion (ROM) in knee joint on POD1, 3. Additionally, the glucocorticoid group exhibited decreased levels of postoperative inflammatory cytokines and the incidence of PONV along with a shorter length of hospital stay. The blood glucose concentration was significantly increased in the glucocorticoid group on POD1 compared with the control group. While the blood glucose on POD2 and occurrence of postoperative adverse complications were similar between two groups including wound infection and venous thrombosis. The periarticular injection analgesia (PIA) group demonstrated lower VAS scores on POD2 comparing to the systemic administration (SA) group according to two studies. However, there was no significant difference of the resting VAS on POD1 and POD2 between PIA and SA group across all studies. CONCLUSION Perioperative glucocorticoids treatment in TKA significantly reduced short-term pain score and opioid-use which was probably not patient relevant. The application of glucocorticoids in TKA implied a beneficial trend in analgesic, anti-inflammatory, and antiemetic effects, as well as improved range of motion and shortened hospital stay. While it will not increase the risk of continued high glucose, postoperative wound infection and venous thrombosis.
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Affiliation(s)
- Fangyan Liu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Mei Duan
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Huiqun Fu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China.
- National Clinical Research Center for Geriatric Diseases, Beijing, China.
- Beijing Institute for Brain Disorders, Beijing, China.
- Center for Sleep and Consciousness Disorders, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China.
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8
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Bohlen KE, Bieger R. [Unicondylar knee arthroplasty-trigger for outpatient arthroplasty]. ORTHOPADIE (HEIDELBERG, GERMANY) 2024; 53:284-290. [PMID: 38451275 DOI: 10.1007/s00132-024-04485-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 03/08/2024]
Abstract
The combination of a reduction in surgical trauma in unicondylar knee arthroplasty compared to total knee arthroplasty and the introduction of a standardised enhanced recovery concept leads to a pre-, peri- and postoperative improvement in the patient's condition, which results in a reduction of the length of stay in hospital. In healthy, motivated patients, day-case or outpatient surgical treatment is possible under these circumstances.
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Affiliation(s)
- Karina E Bohlen
- Allgemeine Orthopädie und Zentrum für Endoprothetik, Schön Klinik Hamburg Eilbek, Dehnhaide 120, 22081, Hamburg, Deutschland.
| | - Ralf Bieger
- Zentrum für Knie‑, Hüft‑, Schulter- und Ellenbogenchirurgie, Schön Klinik München Harlaching, München, Deutschland
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9
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Li B, Yang X, Liu F, Huang H, Zhang B, Li X, Lu Q, Liu P, Fan L. Effect of Perineural or Intravenous Betamethasone on Femoral Nerve Block Outcomes in Knee Arthroplasty: A Randomized, Controlled Study. Orthop Surg 2024; 16:873-881. [PMID: 38384178 PMCID: PMC10984829 DOI: 10.1111/os.14018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 01/23/2024] [Accepted: 01/27/2024] [Indexed: 02/23/2024] Open
Abstract
OBJECTIVES Despite the use of multimodal analgesia, patients undergoing knee arthroplasty still encounter residual moderate pain. The addition of betamethasone to local anesthetic has been shown to improve postoperative pain. However, it remains uncertain whether the positive effects of perineural or intravenous administration of betamethasone on analgesia outcomes lead to better early mobility and postoperative recovery. METHODS Between June 2022 and February 2023, a total of 159 patients who were undergoing knee arthroplasty were included in this study. These patients were allocated randomly into three groups: (i) the NS group, received ropivacaine 0.375% and intravenous 3mL 0.9% normal saline; (ii) the PNB group, received ropivacaine 0.375% plus perineural betamethasone (12mg) 3mL and intravenous 3mL 0.9% normal saline; and (iii) the IVB group, received ropivacaine 0.375% and intravenous betamethasone (12mg) 3mL. RESULTS Both perineural and intravenous administration of betamethasone led to improved median (IQR) numeric rating scale (NRS) scores on the 6-meter walk test, with a score of 1.0 (1.0-2.0) for both groups, compared with 2.0 (1.0-2.0) for the NS group (p = 0.003). Compared to the NS group, both the PNB and IVB groups showed significant reductions in NRS scores at 24 and 36 h after surgery, along with a significant increase in ROM at 24, 36, and 48 h post-operation. Additionally, it exhibited lower levels of cytokine IL-1β and TNF-α in fluid samples, as well as lower level of HS-CRP in blood samples in the PNB and IVB groups compared to the NS group. CONCLUSION The administration of perineural and intravenous betamethasone demonstrated an enhanced analgesic effect following knee arthroplasty. Furthermore, it was associated with reduced levels of IL-1β, TNF-α, and HS-CRP, as well as enhanced knee ROM, which is conducive to early ambulation and postoperative rehabilitation after knee arthroplasty.
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Affiliation(s)
- Binglong Li
- Department of OrthopedicsQilu Hospital of Shandong UniversityJinanChina
- Shandong University Cheeloo College of MedicineJinanChina
| | - Xiaomei Yang
- Shandong University Cheeloo College of MedicineJinanChina
- Department of Anaesthesiology, Qilu HospitalShandong UniversityJinanChina
- Department of Cardiology, the Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, the State and Shandong Province Joint Key Laboratory of Translational Cardiovascular MedicineQilu Hospital of Shandong UniversityJinanChina
| | - Fang Liu
- Shandong University Cheeloo College of MedicineJinanChina
- Department of Anaesthesiology, Qilu HospitalShandong UniversityJinanChina
| | - Huang Huang
- Institute for In Vitro SciencesGaithersburgMDUSA
| | - Baoqing Zhang
- Department of OrthopedicsQilu Hospital of Shandong UniversityJinanChina
| | - Xuezhou Li
- Department of OrthopedicsQilu Hospital of Shandong UniversityJinanChina
| | - Qunshan Lu
- Department of OrthopedicsQilu Hospital of Shandong UniversityJinanChina
| | - Peilai Liu
- Department of OrthopedicsQilu Hospital of Shandong UniversityJinanChina
| | - Lixia Fan
- Department of Anaesthesiology, Qilu HospitalShandong UniversityJinanChina
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10
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郑 宇, 李 杨, 田 华. [Evaluation of early effectiveness of local infiltration anesthesia with compound betamethasone in total knee arthroplasty]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2024; 38:9-14. [PMID: 38225834 PMCID: PMC10796226 DOI: 10.7507/1002-1892.202309081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/16/2023] [Indexed: 01/17/2024]
Abstract
Objective To evaluate the early effectiveness of local infiltration anesthesia (LIA) with compound betamethasone in total knee arthroplasty (TKA). Methods The clinical data of 102 patients with knee osteoarthritis who were treated by TKA and met the selection criteria between May 2022 and March 2023 were retrospectively analyzed. They were divided into control group and study group according to whether LIA preparation was added with compound betamethasone, with 51 cases in each group. There was no significant difference of baseline data, such as age, gender, body mass index, operative side, preoperative range of motion (ROM), Knee Society Score (KSS), white blood cell (WBC), and hematocrit between the two groups ( P>0.05). The intraoperative total blood loss and hidden blood loss were recorded, and WBC was recorded on the 1st, 2nd, and 3rd days after operation. Pain was assessed by visual analogue scale (VAS) score on the 1st, 2nd, and 3rd days after operation and morphine intake milligrames equivalent within 48 hours after operation. Passive ROM, maximum extension and flexion angles of knee joint were measured on the 3rd day after operation; the early postoperative complications were recorded. Results There was no significant difference in total blood loss and hidden blood loss between the two groups ( P>0.05). The postoperative pain levels in both groups were relatively mild, and there was no significant difference in VAS scores in the first 3 days after operation and in morphine intake milligrams equivalent within 48 hours after operation between the two groups ( P>0.05). The WBC in the first 3 days after operation was significantly improved in both groups ( P<0.05). The WBC in the study group was significantly higher than that in the control group on the 1st and 2nd days after operation ( P<0.05), but there was no significant difference between the two groups on the 3rd day after operation ( P>0.05). On the 3rd day after operation, the maximum extension angle of knee joint in the study group was smaller than that in the control group, while the maximum flexion angle and passive ROM of knee joint in the study group were larger than those in the control group, and the differences were significant ( P<0.05). There were 6 cases of fever and 17 cases of deep venous thrombosis in the control group, and 1 case and 14 cases in the study group, respectively. There was no poor wound healing and periprosthetic joint infection in the two groups, and there was no significant difference in the incidence of complications between the two groups ( P>0.05). Conclusion The application of compound betamethasone in LIA during TKA is a safe and optimal strategy to promote the early postoperative rehabilitation of patients.
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Affiliation(s)
- 宇航 郑
- 北京大学第三医院骨科(北京 100191)Department of Orthopedics, Peking University Third Hospital, Beijing, 100191, P. R. China
- 骨与关节精准医学教育部工程研究中心(北京 100191)Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, 100191, P. R. China
| | - 杨 李
- 北京大学第三医院骨科(北京 100191)Department of Orthopedics, Peking University Third Hospital, Beijing, 100191, P. R. China
- 骨与关节精准医学教育部工程研究中心(北京 100191)Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, 100191, P. R. China
| | - 华 田
- 北京大学第三医院骨科(北京 100191)Department of Orthopedics, Peking University Third Hospital, Beijing, 100191, P. R. China
- 骨与关节精准医学教育部工程研究中心(北京 100191)Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, 100191, P. R. China
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11
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Mou P, Zhao XD, Cai XY, Liu ZH, He CQ. The effect of preoperative different dexamethasone regimens on postoperative glycemic control in patients with type 2 diabetes mellitus undergoing total joint arthroplasty: a retrospective cohort study. J Orthop Surg Res 2024; 19:14. [PMID: 38167107 PMCID: PMC10763206 DOI: 10.1186/s13018-023-04485-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/16/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Concerns have been raised regarding the impact of preoperative intravenous dexamethasone on postoperative glycemic control in diabetic patients undergoing total joint arthroplasty (TJA). This study aimed to determine relationships between preoperative different dexamethasone regimens and postoperative fasting blood glucose (FBG), as well as to identify risk factors for postoperative FBG ≥ 200 mg/dl in diabetic patients undergoing TJA. METHODS This retrospective study included 1216 diabetic patients undergoing TJA and categorized into group A (dexamethasone = 0 mg), group B (dexamethasone = 5 mg), and group C (dexamethasone = 10 mg). All dexamethasone was administered before skin incision. FBG levels were monitored until postoperative day (POD) 3. Analyses were conducted for periprosthetic joint infection (PJI) and wound complications during 90 days postoperatively. And the risk factors for postoperative FBG ≥ 200 mg/dl were identified. RESULTS Preoperative dexamethasone administration resulted in a transiently higher FBG on POD 0 and POD 1 (all P < 0.001). However, no differences were observed on POD 2 (P = 0.583) and POD 3 (P = 0.131) among three groups. While preoperative dexamethasone led to an increase in postoperative mean FBG and postoperative maximum FBG (all P < 0.001), no differences were found in wound complications (P = 0.548) and PJI (P = 1.000). Increased HbA1c and preoperative high FBG, but not preoperative dexamethasone, were identified as risk factors for postoperative FBG ≥ 200 mg/dl. Preoperative HbA1c level of ≥ 7.15% was associated with an elevated risk of postoperative FBG ≥ 200 mg/dl. CONCLUSIONS Although preoperative intravenous administration of 5 mg or 10 mg dexamethasone in diabetic patients showed transient effects on postoperative FBG after TJA, no differences were found in the rates of PJI and wound complications during 90 days postoperatively. Notably, patients with a preoperative HbA1c level of ≥ 7.15% and elevated preoperative FBG may encountered postoperative FBG ≥ 200 mg/dl.
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Affiliation(s)
- Ping Mou
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Xiao-Dan Zhao
- Department of Orthopaedic Surgery, Trauma Medical Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Xin-Yu Cai
- Rehabilitation Medicine Department, Medical Technology Institute, West China Clinical Medical College, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Zun-Han Liu
- Department of Sports Medicine Center, State Key Laboratory of Trauma, Burn and Combined Injury, Southwest Hospital of the Army Military Medical University, Chongqing, 400038, People's Republic of China
| | - Cheng-Qi He
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China.
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China.
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Derby CB, Gasbjerg KS, Hägi-Pedersen D, Lunn TH, Pedersen NA, Lindholm P, Brorson S, Schrøder HM, Thybo KH, Bagger J, Lindberg-Larsen M, Overgaard S, Jakobsen JC, Mathiesen O. Prolonged effects of dexamethasone following total knee arthroplasty: A pre-planned sub-study of the DEX-2-TKA trial. Acta Anaesthesiol Scand 2024; 68:35-42. [PMID: 37709280 DOI: 10.1111/aas.14319] [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: 02/23/2023] [Revised: 07/31/2023] [Accepted: 08/08/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVES The DEX-2-TKA trial demonstrated that one and two doses of 24 mg intravenous dexamethasone reduced opioid consumption and pain after total knee arthroplasty (TKA). We aimed to investigate the prolonged effects of dexamethasone after the 48-h intervention period. DESIGN This was a prospective, pre-planned questionnaire follow-up on postoperative days 3-7 of patients in the DEX-2-TKA trial that randomly received: DX1 (dexamethasone 24 mg + placebo), DX2 (dexamethasone 24 mg + dexamethasone 24 mg), and placebo (placebo + placebo) perioperatively and 24 h later. SETTING A multicenter trial performed at five Danish hospitals. PARTICIPANTS We analyzed 434 of 485 adult participants enrolled in the DEX-2-TKA trial. OUTCOME MEASURES Primary outcome was difference between groups in average of all numerical rating scale (NRS) pain scores reported in the morning, at bedtime, and the daily average pain on postoperative days 3-7. Secondary outcomes were sleep quality and patient satisfaction. RESULTS The median (interquartile range) pain intensity levels for postoperative days 3-7 were: DX2 3.2 (2.1-4.3); DX1 3.3 (2.3-4.1); and placebo 3.3 (2.5-4.7). Hodges-Lehmann median differences between groups were: 0 (95% confidence interval - 0.54 to 0.2), P = 0.38 between DX1 and placebo; 0.1 (-0.47 to 0.33), p = .87 between DX1 and DX2; and 0.1 (-0.6 to 0.13), p = .20 between DX2 and placebo. We found no relevant differences between groups on sleep quality on postoperative days 3-7 nor for patient satisfaction with the analgesic treatment. CONCLUSIONS We found that neither one nor two doses of 24 mg intravenous dexamethasone demonstrated prolonged effects on overall pain or sleep quality on postoperative days 3-7 after total knee arthroplasty. We also found that dexamethasone had no effect on patient satisfaction. TRIAL REGISTRATION NUMBER Clinicaltrials.gov NCT03506789 (main result trial).
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Affiliation(s)
- Cecilie Bauer Derby
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Kasper Smidt Gasbjerg
- Research Centre of Anaesthesiology and Intensive Care Medicine, Department of Anesthesiology, Naestved, Slagelse and Ringsted Hospitals, Naestved, Denmark
| | - Daniel Hägi-Pedersen
- Research Centre of Anaesthesiology and Intensive Care Medicine, Department of Anesthesiology, Naestved, Slagelse and Ringsted Hospitals, Naestved, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, 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
| | | | - Peter Lindholm
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Stig Brorson
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Orthopaedic Surgery, Zealand University Hospital, Køge, Denmark
| | | | - Kasper Højgaard Thybo
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Jens Bagger
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, 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
| | - 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, Copenhagen, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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He R, Li X, Zhang S, Liu Y, Xue Q, Luo Y, Yu B, Li X, Liu Z. Dexamethasone inhibits IL-8 via glycolysis and mitochondria-related pathway to regulate inflammatory pain. BMC Anesthesiol 2023; 23:317. [PMID: 37723417 PMCID: PMC10506226 DOI: 10.1186/s12871-023-02277-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 09/11/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Dexamethasone (Dexa) has been recently found to exert an analgesic effect, whose action is closely related to IL-8. However, whether dexamethasone induces antinociception via glycolysis and mitochondria-related pathways is still unclear. METHODS Right hind paw inflammatory pain in mice was induced by intraplantar injection of Freund's Complete Adjuvant (FCA). Von Frey test was then used to measure the paw withdrawal threshold. The detection of glycolysis and mitochondrial pathway-related proteins and IL-8 were determined by Western blot and ELISA. The potential interaction between Dexa and fructose-1,6-bisphosphate (FBP, a PKM2 activator) was examined by simulation predictions using molecular docking. RESULTS Intrathecal administration of Dexa (20 µg/20 µL) had an obvious analgesic effect in FCA-treated mice, which was counteracted by the glycolysis inhibitor 2-deoxyglucose (2-DG, 5 mg/20 µL) or the mitochondria-related pathway inhibitor oligomycin complex (Oligo, 5 µg/20 µL). In the glycolysis pathway, Dexa decreased GLUT3 and had no impact on HIF-1α expression during FCA-induced inflammation. Additionally, Dexa further increased the PKM2 level, accompanied by the formation of hydrogen bonds between Dexa and the PKM2 activator fructose-1,6-bisphosphate (FBP). In the mitochondrial pathway, Dexa downregulated the expression of Mfn2 protein but not the PGC-1α and SIRT-1 levels in the spinal cord. Moreover, both 2-DG and Oligo decreased Mfn2 expression. Finally, IL-8 level was reduced by the single or combined administration of Dexa, 2-DG, and Oligo. CONCLUSION Dexa attenuated IL-8 expression via glycolysis and mitochondrial pathway-related proteins, thus mediating the analgesic effect during inflammatory pain.
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Affiliation(s)
- Ren He
- Department of Anesthesiology, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Health Science Center, No. 3002, Futian District, Shenzhen, Guangdong Province, 518035, China
| | - Xiaohan Li
- Department of Anesthesiology, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Health Science Center, No. 3002, Futian District, Shenzhen, Guangdong Province, 518035, China
| | - Silun Zhang
- Department of Anesthesiology, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Health Science Center, No. 3002, Futian District, Shenzhen, Guangdong Province, 518035, China
| | - Yuqiang Liu
- Department of Anesthesiology, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Health Science Center, No. 3002, Futian District, Shenzhen, Guangdong Province, 518035, China
| | - Qingsheng Xue
- Department of Anesthesiology, Ruijin Hospital Affiliated to Shanghai Jiaotong University, Shanghai, 200025, China
| | - Yan Luo
- Department of Anesthesiology, Ruijin Hospital Affiliated to Shanghai Jiaotong University, Shanghai, 200025, China
| | - Buwei Yu
- Department of Anesthesiology, Ruijin Hospital Affiliated to Shanghai Jiaotong University, Shanghai, 200025, China
| | - Xiongjuan Li
- Department of Anesthesiology, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Health Science Center, No. 3002, Futian District, Shenzhen, Guangdong Province, 518035, China.
| | - Zhiheng Liu
- Department of Anesthesiology, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Health Science Center, No. 3002, Futian District, Shenzhen, Guangdong Province, 518035, China.
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Hui H, Miao H, Qiu F, Lin Y, Li H, Zhang Y, Jiang B. Adjunctive dexamethasone palmitate use for intercostal nerve block after video-assisted thoracoscopic surgery: A prospective, randomized control trial. Heliyon 2023; 9:e19156. [PMID: 37662806 PMCID: PMC10474424 DOI: 10.1016/j.heliyon.2023.e19156] [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: 02/14/2023] [Revised: 08/12/2023] [Accepted: 08/14/2023] [Indexed: 09/05/2023] Open
Abstract
Objectives The efficacy of dexamethasone palmitate in extending durations of local anesthetic blocks is uncertain. In a randomized, double-blind study of patients undergoing video-assisted thoracoscopic surgery, we tested whether intravenous or perineural dexamethasone palmitate caused prolonged analgesia after intercostal nerve block. Methods A total of 90 patients subjected to video-assisted thoracoscopic surgery between May and December 2022 were randomly assigned to one of three intercostal nerve blocks study arms (n = 30 each), requiring the addition of 0.5% ropivacaine (23 ml) as follows: controls (C group), 2 ml saline; IV-DXP group, 2 ml saline + 2 ml (8 mg) intravenous dexamethasone palmitate; and PN-DXP group, 2 ml (8 mg) perineural dexamethasone palmitate. Time to first postoperative remedial analgesia served as primary outcome measure. Secondary endpoints included postoperative opioid consumption, pain scores by Visual Analog Scale, analgesia satisfaction, and related adverse effects. Results Compared with controls or the IV-DXP group, time to first postoperative remedial analgesia was longer and postoperative opioid consumption for rescue analgesia was lower in the PN-DXP group (p < 0.01). Similarly, the Visual Analog Scale scores in patients at 8, 12, 18, and 24 h postoperatively were lower in the PN-DXP group than in controls and the IV-DXP group (p < 0.01). Patient satisfaction was statistically lower in the PN-DXP group, compared with either the control or IV-DXP group (p < 0.05). Clinically, the three groups did not differ significantly in occurrences of adverse effects during the 48-h postoperative monitoring period (p > 0.05). Conclusions Perineural dexamethasone palmitate is a promising adjunct to ropivacaine intercostal nerve block by prolonging analgesia with almost no related adverse effects.
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Affiliation(s)
| | | | | | - Yangui Lin
- Department of Thoracic Cardiovascular Surgery, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, Guangdong, China
| | - Huaming Li
- Department of Thoracic Cardiovascular Surgery, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, Guangdong, China
| | - Yiqian Zhang
- Department of Thoracic Cardiovascular Surgery, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, Guangdong, China
| | - Bo Jiang
- Department of Thoracic Cardiovascular Surgery, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, Guangdong, China
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Yu B, Wang B, Shrestha N, Luo F. Pre-emptive coinfiltration of dexamethasone palmitate emulsion with ropivacaine for postoperative pain in patients undergoing major spine surgery: a study protocol for a prospective, randomised controlled, multicentre trial. BMJ Open 2023; 13:e072162. [PMID: 37225277 DOI: 10.1136/bmjopen-2023-072162] [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: 05/26/2023] Open
Abstract
INTRODUCTION Patients undergoing major spine surgery usually experience moderate-to-severe postoperative pain. It has been shown that dexamethasone as an adjunct to local anaesthesia (LA) infiltration presented a superior analgesic benefit compared with LA alone in various types of surgeries. However, a recent meta-analysis reported that the overall benefits of dexamethasone infiltration were marginal. Dexamethasone palmitate (DXP) emulsion is a targeted liposteroid. Compared with dexamethasone, DXP has a stronger anti-inflammatory effect, longer duration of action and fewer adverse effects. We hypothesised that the additive analgesic effects of DXP on local incisional infiltration in major spine surgery may have better postoperative analgesic effect, compared with local anaesthetic alone. However, no study has evaluated this so far. The purpose of this trial is to determine whether pre-emptive coinfiltration of DXP emulsion and ropivacaine at surgical site incision will further reduce postoperative opioid requirements and pain scores after spine surgery than that with ropivacaine alone. METHODS AND ANALYSIS This is a prospective, randomised, open-label, blinded endpoint, multicentre study. 124 patients scheduled for elective laminoplasty or laminectomy with no more than three levels will be randomly allocated in a 1:1 ratio into two groups: the intervention group will receive local incision site infiltration with ropivacaine plus DXP; the control group will receive infiltration with ropivacaine alone. All participants will complete a 3 months follow-up. The primary outcome will be the cumulative sufentanil consumption within 24 hours after surgery. The secondary outcomes will include further analgesia outcome assessments, steroid-related side effects and other complications, within the 3 months follow-up period. ETHICS AND DISSEMINATION This study protocol has been approved by the Institutional Review Board of Beijing Tiantan Hospital (KY-2019-112-02-3). All participants will provide a written informed consent. The results will be submitted for publication in a peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT05693467.
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Affiliation(s)
- Bin Yu
- Department of Day Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Baoguo Wang
- Department of Anesthesiology, Capital Medical University Sanbo Brain Hospital, Haidian District, Beijing, China
| | - Niti Shrestha
- Department of Pain Management, Beijing Tiantan Hospital, Beijing, China
| | - Fang Luo
- Department of Pain Management, Beijing Tiantan Hospital, Beijing, China
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Arraut J, Thomas J, Oakley C, Schmicker T, Aggarwal VK, Schwarzkopf R, Rozell JC. Effects of Dexamethasone on Postoperative Glycemic Control in Diabetic Patients Following Primary Total Joint Arthroplasty: A Retrospective Cohort Study. J Arthroplasty 2023:S0883-5403(23)00348-0. [PMID: 37040822 DOI: 10.1016/j.arth.2023.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 03/24/2023] [Accepted: 04/03/2023] [Indexed: 04/13/2023] Open
Abstract
INTRODUCTION Concerns regarding the effects of dexamethasone on diabetics' glucose control have stymied its use following total joint arthroplasty (TJA). This study aimed to evaluate the effects of two intravenous (IV) perioperative doses of dexamethasone on glucose levels, pain scores, and inpatient opioid consumption following TJA in diabetic patients. METHODS A retrospective review of 523 diabetic patients who underwent primary elective THA and 953 diabetic patients who underwent primary elective TKA between May 6, 2020 and December 17, 2021. Patients who received one dose (1D) of perioperative dexamethasone 10 mg IV were compared to patients who received two doses (2D). Primary outcomes included postoperative glucose levels, opioid consumption as morphine milligram equivalences (MMEs), postoperative pain as Verbal Rating Scale (VRS) pain scores, and postoperative complications. RESULTS The 2D TKA cohort had significantly greater average and maximum blood glucose levels from 24 to 60 hours compared to the 1D TKA cohort. The 2D THA cohort had significantly greater average blood glucose levels at 24 to 36 hours compared to the 1D THA cohort. However, the 2D TKA group had significantly reduced opioid consumption from 24 to 72 hours and reduced total consumption compared to the 1D TKA group. VRS pain scores did not differ between cohorts for both TKA and THA at any interval. CONCLUSION Administration of a second perioperative dose of dexamethasone was associated with increased postoperative blood glucose levels. However, the observed effect on glucose control may not outweigh the clinical benefits of a second perioperative dose of glucocorticoids.
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Affiliation(s)
- Jerry Arraut
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Jeremiah Thomas
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Christian Oakley
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Thomas Schmicker
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Vinay K Aggarwal
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Joshua C Rozell
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York.
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Khan J, Ashraf RA, Bilal Shabbir HM, Haider A, Saeed S, Rauf Khalid A, Shabbir H, Haider Kazmi SN, Abbas K, Basit J. The Effect of Dexamethasone on Postoperative Pain Management in Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Trial. Cureus 2023; 15:e37052. [PMID: 37143623 PMCID: PMC10153787 DOI: 10.7759/cureus.37052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2023] [Indexed: 04/05/2023] Open
Abstract
Objective The objective of this study was to evaluate the effectiveness of dexamethasone in treating postoperative pain in patients undergoing total knee arthroplasty (TKA). Methodology This randomized controlled trial (RCT) was completed over the course of two years (September 7, 2015, to September 6, 2017). In the course of their treatment for osteoarthritis of the knee, all of the patients who had primary unilateral total knee replacement (TKR) participated in the research. Under spinal anesthesia, each patient had medial para-patellar approach medial orthopedic surgery. Patients were assigned to group A or group B based on a random selection. Each of the groups consisted of 79 individuals. Group A was given dexamethasone through intravenous administration at a dose of 0.1 mg/kg before the operation. During the subsequent period of 24 hours, no more treatment was administered (control group). On a predesigned questionnaire, postoperative pain was measured using the visual analog scale (VAS) for pain. Functional results, duration of hospital stay, and complications were all recorded on the questionnaire (VAS). Analysis of data was carried out using the Statistical Package for the Social Sciences (SPSS) version 23 (IBM SPSS Statistics, Armonk, NY, USA). Results There were 158 patients in total in the study, out of which 98 were females and 60 were males in the group. The patients' average body mass index (BMI) was 26.94 ± 3.14 kg/m2. Patients in group A had lower postoperative analgesic and antiemetic needs and higher VAS scores and spent less time in the hospital than patients in group B. There were no postoperative problems in either group. Conclusion In patients undergoing TKA, the use of dexamethasone during and after surgery decreases pain, the need for analgesics, and the duration of hospital stay.
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Lindberg-Larsen M, Varnum C, Jakobsen T, Andersen MR, Sperling K, Overgaard S, Hansen TB, Jørgensen CC, Kehlet H, Gromov K. Study protocol for discharge on day of surgery after hip and knee arthroplasty from the Center for Fast-track Hip and Knee Replacement. Acta Orthop 2023; 94:121-127. [PMID: 36942664 PMCID: PMC10028556 DOI: 10.2340/17453674.2023.11636] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 03/04/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND AND PURPOSE Limited data exists on the implementation process and safety of discharge on the day of surgery after primary hip and knee arthroplasty in a multicenter setting. We report our study protocol on the investigation of the feasibility, safety, and socioeconomic aspects following discharge on day of surgery after hip and knee arthroplasty across 8 fast-track centers. PATIENTS AND METHODS This is a study protocol for a prospective cohort study on discharge on day of surgery from the Center for Fast-track Hip and Knee Replacement. The collaboration includes 8 centers covering 40% of the primary hip and knee arthroplasty procedures undertaken in Denmark. All patients scheduled for surgery are screened for eligibility using well-defined inclusion and exclusion criteria. Eligible patients fulfilling discharge criteria will be discharged on day of surgery. We expect to screen 9,000 patients annually. Duration and outcome: Patients will be enrolled over a 3-year period from September 2022 and reporting of results will run continuously until December 2025. We shall report the proportion of eligible patients and patients discharged on day of surgery as well as limiting factors. Readmissions and complications within 30 days are recorded with real-time follow-up by research staff. Furthermore, patient-reported information on willingness to repeat discharge on day of surgery, contacts with the healthcare system, complications, and workability is registered 30 days postoperatively. EQ-5D, Oxford Knee Score, and Oxford Hip Score are completed preoperatively and after 3 months and 1 year. Finally, outcome data will be used in the development of a prediction model for successful discharge on the day of surgery.
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Affiliation(s)
- Martin Lindberg-Larsen
- Center for Fast-track Hip and Knee Replacement; Department of Orthopaedic Surgery and traumatology, Odense University Hospital and Svendborg.
| | - Claus Varnum
- Center for Fast-track Hip and Knee Replacement; Department of Orthopaedic Surgery, Lillebaelt Hospital-Vejle
| | - Thomas Jakobsen
- Center for Fast-track Hip and Knee Replacement; Department of Orthopaedic Surgery, Aalborg University Hospital
| | - Mikkel Rathsach Andersen
- Center for Fast-track Hip and Knee Replacement; Department of Orthopaedic Surgery, Copenhagen University Hospital, Herlev-Gentofte
| | - Kim Sperling
- Center for Fast-track Hip and Knee Replacement; Department of Orthopaedic Surgery, Næstved, Slagelse and Ringsted Hospitals
| | - Søren Overgaard
- Center for Fast-track Hip and Knee Replacement; Department of Orthopaedic Surgery and Traumatology, Copenhagen University Hospital, Bispebjerg
| | - Torben Bæk Hansen
- Center for Fast-track Hip and Knee Replacement; University Clinic for Hand, Hip and Knee Surgery, Hospital Unit West Jutland and Aarhus University
| | - Christoffer Calov Jørgensen
- Center for Fast-track Hip and Knee Replacement; Department of Anaesthesia, Hospital of Northern Zeeland, Hillerød
| | - Henrik Kehlet
- Center for Fast-track Hip and Knee Replacement; Section of Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet
| | - Kirill Gromov
- Center for Fast-track Hip and Knee Replacement; Department of Orthopaedic Surgery, Hvidovre University Hospital, Denmark
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19
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Stocks GW, Odoemene M, Gex J, Vidal EA, Sawyer K, Jones SL, Thompson B, Laughlin MS. Quadriceps Strain and TKA: Contribution of the Tourniquet and Intramedullary Rod to Postoperative Thigh Pain: A Randomized Controlled Trial. J Bone Joint Surg Am 2023; 105:455-461. [PMID: 36728455 DOI: 10.2106/jbjs.22.00703] [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] [Indexed: 02/03/2023]
Abstract
BACKGROUND Thigh pain is relatively common after total knee arthroplasty (TKA) and has been attributed to compression of the thigh muscles by the tourniquet used during surgery. Thigh pain that occurs after a TKA that was performed without a tourniquet may be due to a strain of the quadriceps muscle or insertion of the intramedullary (IM) rod. The purpose of the present study was to determine the cause of thigh pain after TKA in a randomized controlled trial evaluating tourniquet use, IM rod use, and quadriceps strain. METHODS This prospective randomized controlled trial enrolled 97 subjects undergoing primary knee arthroplasty into 4 groups according to tourniquet use (yes or no) and IM rod use (yes or no). Quadriceps strain was evaluated with magnetic resonance imaging (MRI) on postoperative day 1 (POD 1). Data collected preoperatively, intraoperatively, and postoperatively until the 6-week clinical visit included pain levels for the knee and thigh (recorded separately) and knee range of motion. RESULTS Regardless of tourniquet or IM rod use, 73 (75%) of the 97 patients reported thigh pain on POD 1. Thigh pain at 2 weeks postoperatively was indicative of a quadriceps strain. Use of a tourniquet and patient-reported thigh pain at 2 weeks increased the odds of a quadriceps strain, whereas IM rod use did not significantly contribute to thigh pain. CONCLUSIONS The etiology of thigh pain after TKA may be multifactorial; however, an iatrogenic quadriceps strain is one source of thigh pain after TKA, especially if the pain persists 2 weeks after surgery. LEVEL OF EVIDENCE Prognostic Level I . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Gregory W Stocks
- Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, Texas.,Fondren Orthopedic Research Institute (FORI), Houston, Texas
| | - Melissa Odoemene
- Fondren Orthopedic Research Institute (FORI), Houston, Texas.,McGovern Medical School, Houston, Texas
| | - Julia Gex
- Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, Texas.,Fondren Orthopedic Research Institute (FORI), Houston, Texas
| | - Emily A Vidal
- Fondren Orthopedic Research Institute (FORI), Houston, Texas
| | | | | | - Brandon Thompson
- Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, Texas
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20
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Systemic glucocorticoids as an adjunct to treatment of postoperative pain after total hip and knee arthroplasty: A systematic review with meta-analysis and trial sequential analysis. Ugeskr Laeger 2023; 40:155-170. [PMID: 36325886 DOI: 10.1097/eja.0000000000001768] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Postoperative analgesic effects of systemic glucocorticoids given as an adjunct to treatment are largely undetermined in alloplastic procedures. OBJECTIVES To investigate the beneficial and harmful effects of peri-operative systemic glucocorticoid treatment for pain after total hip arthroplasty (THA) or total knee arthroplasty (TKA). DESIGN A systematic review of randomised clinical trials (RCTs) with meta-analyses, trial sequential analyses and GRADE. Primary outcome was 24 h intravenous (i.v.) morphine (or equivalent) consumption with a predefined minimal important difference (MID) of 5 mg. Secondary outcomes included pain at rest and during mobilisation (MID, VAS 10 mm), adverse and serious adverse events (SAEs). DATA SOURCES We searched EMBASE, Cochrane CENTRAL, PubMed and Google Scholar up to October 2021. ELIGIBILITY CRITERIA RCTs investigating peri-operative systemic glucocorticoid versus placebo or no intervention, for analgesic pain management of patients at least 18 years undergoing planned THA or TKA, irrespective of publication date and language. RESULTS We included 32 RCTs with 3521 patients. Nine trials were at a low risk of bias. Meta-analyses showed evidence of a reduction in 24 h cumulative morphine consumption with glucocorticoids by 5.0 mg (95% CI 2.2 to 7.7; P = 0.0004). Pain at rest was reduced at 6 h by 7.8 mm (95% CI 5.5 to 10.2; P < 0.00001), and at 24 h by 6.3 mm (95% CI 3.8 to 8.8; P < 0.00001). Pain during mobilisation was reduced at 6 h by 9.8 mm (95% CI 6.9 to 12.8; P < 0.00001), and at 24 h by 9.0 mm (95% CI 5.5 to 12.4, P < 0.00001). Incidence of adverse events was generally lower in the glucocorticoid treatment group. SAEs were rarely reported. The GRADE rated quality of evidence was low to very low. CONCLUSION Peri-operative systemic glucocorticoid treatment reduced postoperative morphine consumption to an individually relevant level following hip and knee arthroplasty. Pain levels were reduced but were below the predefined MID. The quality of evidence was generally low. REGISTRATION PROSPERO ID: CRD42019135034.
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21
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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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22
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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: 1] [Impact Index Per Article: 1.0] [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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23
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van der Weegen W, Das D, Vrints K, Agricola R, Siebelt M. A 20 mg dose of dexamethasone does not reduce the proportion of joint replacement patients needing rescue analgesia: a matched cohort study. ANNALS OF JOINT 2023; 8:4. [PMID: 38529231 PMCID: PMC10929338 DOI: 10.21037/aoj-22-34] [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: 09/09/2022] [Accepted: 12/23/2022] [Indexed: 03/27/2024]
Abstract
Background Consistent pain control after total joint replacement (TJR) has not yet been reached in all patients managed with a multimodal analgesia regime. Questions remain on dosage and timing of analgesics. Glucocorticoids such as dexamethasone are considered most powerful in reducing the surgery-induced inflammatory response with most pain studies using a 6-12 mg dose. Reviews agree that additional glucocorticoids may provide more analgesia, but a dose-finding analysis is limited. The primary aim of this study was to determine if a high, single preoperative dose of dexamethasone resulted in a reduced need for rescue analgesics during the first 24 hours after TJR when compared to a standard 8 mg dose of dexamethasone. Methods A cohort study in which 59 patients who received 20 mg dexamethasone intravenously just prior to incision were matched 1:1 to patients who received a standard 8 mg dose. Consecutive elective hip and knee replacement patients managed by one anaesthesiologist were included in the high dose group between June 2019 and March 2020. Patients were matched for arthroplasty type, gender, age, anaesthesia type and pre-operative pain. Patients with opioid use before surgery or with diabetes mellitus were excluded. Oxynorm rescues analgesics (number of times given and dosage) usage during hospitalization was retrieved from the electronic nursing files. Results There were no significant differences between groups in gender distribution, mean age and body mass index (BMI), in American Society of Anesthesiologists (ASA), type of arthroplasty, anaesthesia type and pre-operative pain score. In the 20 mg group 54 patients (91.5%) needed oxynorm during hospitalization versus 58 (98.3%) in the 8 mg group (P=0.09). High dose group patients received a median of 5 mg [interquartile range (IQR): 0] oxynorm versus 5 mg (IQR: 0) in the standard dose group (P=0.70). Conclusions In this matched cohort study there was no difference in the proportion of patients needing rescue analgesics during hospitalization between the group of patients who preoperatively received 20 mg dexamethasone and the group of patients who received 8 mg. Future blinded randomized controlled trials are needed to further investigate the effect of different glucocorticoids dosages on pain after joint replacement surgery.
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Affiliation(s)
| | - Dirk Das
- Sports & Orthopedics Research Centre, St. Anna Hospital, Geldrop, The Netherlands
| | - Katleen Vrints
- Department of Anesthesiology, Geldrop, St. Anna Hospital, Geldrop, The Netherlands
| | - Rintje Agricola
- Sports & Orthopedics Research Centre, St. Anna Hospital, Geldrop, The Netherlands
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Michiel Siebelt
- Sports & Orthopedics Research Centre, St. Anna Hospital, Geldrop, The Netherlands
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24
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Málek J. Year 2022 in review - Perioperative pain therapy. ANESTEZIOLOGIE A INTENZIVNÍ MEDICÍNA 2022. [DOI: 10.36290/aim.2022.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
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25
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Zhu M, Xu S, Ju X, Wang S, Yu X. Effects of the Different Doses of Esketamine on Postoperative Quality of Recovery in Patients Undergoing Modified Radical Mastectomy: A Randomized, Double-Blind, Controlled Trial. Drug Des Devel Ther 2022; 16:4291-4299. [PMID: 36561309 PMCID: PMC9766490 DOI: 10.2147/dddt.s392784] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022] Open
Abstract
Purpose This study aims to investigate the effects of the different doses of esketamine on postoperative quality of recovery in patients undergoing modified radical mastectomy. Methods Ninety-nine female patients were randomly allocated to three groups: the low-dose esketamine group (group E1) (0.5 mg/kg loading, 2 µg/kg/h infusion), the high-dose esketamine group (group E2) (0.5 mg/kg loading, 4 µg/kg/h infusion), the control group (group C) (received normal saline). The primary outcome was the quality of recovery-15 (QoR-15) scores on postoperative day 1 (POD1) and days 3 (POD3). The secondary outcomes were the sleep quality scores on POD1, bispectral index (BIS) value at 10, 30, and 60 min after operation, numeric rating scale (NRS) pain scores within 24 h after surgery, nausea, vomiting, drowsiness, nightmare, and intraoperative awareness. Results The total QoR-15 scores were higher in group E1 and group E2 than in group C on POD1 and POD3 (P<0.05). The sleep quality scores on POD1 and BIS value at 10, 30, and 60 min after operation were higher in group E1 and group E2 than in group C (P<0.05). The NRS pain scores at 2, 4 and 6 h after surgery in group E1 and at 2, 4, 6, 12 and 24 h after surgery in group E2 were lower than in group C (P<0.05). The NRS pain scores at 6, 12 and 24 h after surgery in group E2 were lower than in group E1 (P<0.05). The incidence of drowsiness was higher in group E1 and group E2 than in group C (P<0.05). Conclusion Esketamine infusion improved to some extent the quality of recovery on POD1 and POD3 in patients undergoing modified radical mastectomy, especially 4 µg/kg/h esketamine was better, but the BIS value and incidence of drowsiness were significantly increased.
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Affiliation(s)
- Min Zhu
- Department of Anesthesiology, The Anqing Medical Center of Anhui Medical University, The Fifth Clinical Medical College of Anhui Medical University, Anqing, People’s Republic of China
| | - Siqi Xu
- Department of Anesthesiology, The Anqing Medical Center of Anhui Medical University, The Fifth Clinical Medical College of Anhui Medical University, Anqing, People’s Republic of China
| | - Xia Ju
- Department of Anesthesiology, The Anqing Medical Center of Anhui Medical University, The Fifth Clinical Medical College of Anhui Medical University, Anqing, People’s Republic of China,Correspondence: Xia Ju, Department of Anesthesiology, The Anqing Medical Center of Anhui Medical University, The Fifth Clinical Medical College of Anhui Medical University, Anqing, 246003, People’s Republic of China, Tel +86 13685563136, Email
| | - Shengbin Wang
- Department of Anesthesiology, The Anqing Medical Center of Anhui Medical University, The Fifth Clinical Medical College of Anhui Medical University, Anqing, People’s Republic of China
| | - Xitong Yu
- Department of Anesthesiology, The Anqing Medical Center of Anhui Medical University, The Fifth Clinical Medical College of Anhui Medical University, Anqing, People’s Republic of China
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26
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Jiang H, Ma Q, Dong J, Ye X. The effect of liposomal bupivacaine for surgical wound infiltration: A meta‐analysis of randomised controlled trials. Int Wound J 2022; 20:1591-1608. [PMID: 36345868 PMCID: PMC10088822 DOI: 10.1111/iwj.14015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 10/24/2022] [Accepted: 10/26/2022] [Indexed: 11/11/2022] Open
Abstract
Liposomal bupivacaine (LB) has consistently been considered a potential analgesic for surgical wound infiltration. However, the evidence of its analgesic effectiveness remains unclear. In this meta-analysis, we attempted to identify the potential clinical role of LB wound infiltration in different surgical procedures. Randomised controlled trials (RCTs) comparing LB with non-liposomal local anaesthetics and placebos were retrieved from six electronic databases. The primary outcome was cumulative morphine equivalent consumption within 24, 48, and 72 hours after surgery. Approximately 2659 patients from 22 studies were included in the meta-analysis. Compared to the control, LB-wound infiltration did not reduce the postoperative morphine consumption at 24 hours (weighted mean difference [WMD], -0.60 mg; 97.5% confidence interval [CI], -2.78 to 1.59 mg; P = 0.54), 48 hours (WMD, -1.00 mg; 97.5% CI, -3.23 to 1.24; P = 0.32) or 72 hours (WMD, 0.50 mg; 97.5% CI, -0.67 to 1.67; P = 0.33). Similarly, secondary outcome analysis did not reveal any additional benefits of LB in any other pain-related outcomes. LB was not associated with any adverse effects. Overall, LB does not appear to improve the postoperative analgesic, rehabilitation, or safety outcomes. Current evidence does not support the routine use of LB for wound infiltration following surgical procedures.
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Affiliation(s)
- Hua Jiang
- Hospital of Chengdu University of Traditional Chinese Medicine Chengdu China
| | - Qiong Ma
- Hospital of Chengdu University of Traditional Chinese Medicine Chengdu China
| | - Jing Dong
- Hospital of Chengdu University of Traditional Chinese Medicine Chengdu China
| | - Xin Ye
- Hospital of Chengdu University of Traditional Chinese Medicine Chengdu China
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27
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Comparison of Aseptic Partial- and Full-Component Revision Total Knee Arthroplasty. J Arthroplasty 2022. [PMID: 37343280 DOI: 10.1016/j.arth.2022.09.025] [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] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Revision total knee arthroplasty (rTKA) can be performed with isolated tibial, isolated femoral, and combined tibial and femoral component exchange for different indications. Replacement of only 1 fixed component in rTKA leads to shorter operative times and decreased complexity. We sought to compare functional outcomes and rates of rerevision in patients undergoing partial and full rTKA. METHODS This retrospective study examined all aseptic rTKA patients with a minimum follow-up of 2 years in a single center between September 2011 and December 2019. Patients were divided into two groups: full rTKA (F-rTKA) if both components (femoral and tibial) were revised and partial rTKA (P-rTKA) if only 1 component was revised. A total of 293 patients (P-rTKA = 76, F-rTKA = 217) were included. RESULTS P-rTKA patients had significantly shorter surgical time (109 ± 37 Versus. 141 ± 44 minutes, P < .001). At mean follow-up of 4.2 (range 2.2-6.2) years, rerevision rates did not significantly differ between groups (11.8 Versus. 16.1%, P = .358). Improvements in postoperative Visual Analogue Scale (VAS) pain and Knee Injury and Osteoarthritis Scale (KOOS), Joint Replacement scores were similar as well (P = .100 and P = .140, respectively). For patients undergoing rTKA due to aseptic loosening, freedom from rerevision due to aseptic loosening was similar between groups (100 Versus. 97.8%, P = .321). For patients undergoing rTKA due to instability, freedom from rerevision due to instability did not significantly differ as well (100 Versus. 98.1%, P = .683). In the P-rTKA cohort, freedom from all-cause and aseptic revision of preserved components was 96.1% and 98.7% at the 2-year follow-up. CONCLUSION Compared to F-rTKA, P-rTKA yielded similar functional outcomes and implant survivorship with shorter surgical time. When indications and component compatibility allow for such a procedure, surgeons can expect good outcomes when performing P-rTKA.
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Multimodal Pain Management in Orthopedic Surgery. J Clin Med 2022; 11:jcm11216386. [PMID: 36362617 PMCID: PMC9658297 DOI: 10.3390/jcm11216386] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 12/02/2022] Open
Abstract
Background: Orthopedic surgery typically results in moderate to severe pain in a majority of patients. Opioids were traditionally the primary medication to target mechanisms of pain transmission. Multimodal analgesia has become a preferred method of pain management in orthopedic practice. Utilizing more than one mode to address post-surgical pain by recruiting multiple receptors through different medications accelerates the recovery process and decreases the need for opioids. By implementing effective analgesic techniques and interventions, this practice, in turn, decreases the usage of perioperative opioids, and in the long term, prevents addiction to pain medications and risk of opioid overdose. In orthopedic surgeries, previous studies have found that multimodal analgesia has reduced early opioid usage in the postoperative course. Pain is the result of direct injury to the nervous system, with a wide variety of chemicals directly stimulating or sensitizing the peripheral nociceptors. The pathophysiology behind the mechanism of post-surgical pain, along with the importance of preoperative, perioperative, and postoperative pain regimens are emphasized. A brief overview of pain medications and their properties is provided. These medications are further categorized, with information on special considerations and typical dosage requirements. Pain management should address both neuropathic and subjective types of pain. Effective pain control requires constant reassessment with individualized strategies. Conclusion: By focusing on multimodal analgesia, anesthesiologists can now utilize newer techniques for postoperative pain relief from orthopedic surgery, with better short-term and long-term outcomes for the patient.
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29
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Steiness J, Hägi-Pedersen D, Lunn TH, Lindberg-Larsen M, Graungaard BK, Lundstrom LH, Lindholm P, Brorson S, Bieder MJ, Beck T, Skettrup M, von Cappeln AG, Thybo KH, Gasbjerg KS, Overgaard S, Jakobsen JC, Mathiesen O. Paracetamol, ibuprofen and dexamethasone for pain treatment after total hip arthroplasty: protocol for the randomised, placebo-controlled, parallel 4-group, blinded, multicentre RECIPE trial. BMJ Open 2022; 12:e058965. [PMID: 36190737 PMCID: PMC9438203 DOI: 10.1136/bmjopen-2021-058965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Multimodal analgesia with paracetamol, non-steroidal anti-inflammatory drug and glucocorticoid is recommended for hip arthroplasty, but with uncertain effects of the different combinations. We aim to investigate benefit and harm of different combinations of paracetamol, ibuprofen and dexamethasone following total hip arthroplasty. METHODS AND ANALYSIS RECIPE is a randomised, placebo-controlled, parallel 4-group, blinded trial with 90-day and 1-year follow-up performed at nine Danish hospitals. Interventions are initiated preoperatively and continued for 24 hours postoperatively. Eligible participants undergoing total hip arthroplasty are randomised to:group A: oral paracetamol 1000 mg × 4+oral ibuprofen 400 mg × 4+intravenous placebo; group B: oral paracetamol 1000 mg × 4+intravenous dexamethasone 24 mg+oral placebo; group C: oral ibuprofen 400 mg × 4+intravenous dexamethasone 24 mg+oral placebo; group D: oral paracetamol 1000 mg × 4+oral ibuprofen 400 mg × 4+intravenous dexamethasone 24 mg.Primary outcome is cumulative opioid consumption at 0-24 hours. Secondary outcomes are pain at rest, during mobilisation and during a 5 m walk and adverse events. Follow-up includes serious adverse events and patient reported outcome measures at 90 days and 1 year. A total of 1060 participants are needed to demonstrate a difference of 8 mg in 24-hour morphine consumption assuming an SD of 24.5 mg, a risk of type I errors of 0.0083 and a risk of type 2 errors of 0.2. Primary analysis will be a modified intention-to-treat analysis.With this trial we aim to verify recommendations for pain treatment after total hip arthroplasty, and investigate the role of dexamethasone as an analgesic adjuvant to paracetamol and ibuprofen. ETHICS AND DISSEMINATION This trial is approved by the Region Zealand Committee on Health Research Ethics (SJ-799). Plans for dissemination include publication in peer-reviewed journals and presentation at scientific meetings. TRIAL REGISTRATION NUMBER NCT04123873.
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Affiliation(s)
- Joakim Steiness
- Department of Anaesthesiology, Zealand University Hospital Koge Centre for Anaesthesiological Research, Koege, Denmark
- Department of Anaesthesiology, Nastved Hospital, Naestved, Denmark
| | - Daniel Hägi-Pedersen
- Department of Anaesthesiology, Slagelse Hospital, Slagelse, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Troels Haxholdt Lunn
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesiology and Intensive Care, Bispebjerg Hospital, Copenhagen, Denmark
| | - Martin Lindberg-Larsen
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
- Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
| | | | | | - Peter Lindholm
- Department of Anaesthesiology, Odense University Hospital, Odense, Denmark
| | - Stig Brorson
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Orthopaedic Surgery, Zealand University Hospital Koge, Koege, Denmark
| | | | - Torben Beck
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Michael Skettrup
- Department of Orthopaedic Surgery, Gentofte Hospital, Hellerup, Denmark
| | | | - Kasper Højgaard Thybo
- Department of Anaesthesiology, Zealand University Hospital Koge Centre for Anaesthesiological Research, Koege, Denmark
| | | | - Søren Overgaard
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
- Centre for Clinical Intervention Research, Rigshospitalet Copenhagen Trial Unit, Copenhagen, Denmark
| | - Ole Mathiesen
- Department of Anaesthesiology, Zealand University Hospital Koge Centre for Anaesthesiological Research, Koege, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Mendes A. Dexamethasone as an adjunct to pain management following knee surgery. Br J Community Nurs 2022; 27:370-371. [PMID: 35924901 DOI: 10.12968/bjcn.2022.27.8.370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Aysha Mendes
- Freelance Journalist, specialising in Healthcare and Psychology
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Gantzel M, Gasbjerg KS, Hägi-Pedersen D, Meyhoff CS, Olsen MH, Mathiesen O, Jakobsen JC, Lunn TH. Effect of dexamethasone on intraoperative remifentanil dose in total knee arthroplasty surgery under general anaesthesia. Acta Anaesthesiol Scand 2022; 66:1070-1076. [PMID: 35908167 PMCID: PMC9543467 DOI: 10.1111/aas.14118] [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: 03/12/2022] [Revised: 07/01/2022] [Accepted: 07/13/2022] [Indexed: 11/30/2022]
Abstract
Background The effects of glucocorticoids may include both genomic and rapid nongenomic effects. The potential rapid analgesic effect during surgery has not previously been investigated. We aimed to explore the effect of dexamethasone on intraoperative infusion rate of remifentanil in patients undergoing total knee arthroplasty (TKA) surgery under general anaesthesia. Methods In this post hoc subgroup analysis, we included patients randomised in the DEX‐2‐TKA trial, who were operated under total intravenous anaesthesia with remifentanil and propofol. Trial medication, intravenous dexamethasone 24 mg or placebo, was administered immediately after anaesthesia onset. The primary outcome was the median weight‐corrected infusion rate of remifentanil during surgery. Secondary outcomes included median weight‐corrected infusion rate of propofol, median intraoperative bispectral index and time spent in the post‐anaesthesia care unit. Results Eighty‐seven patients were included in the analysis of the primary outcome. A significantly higher remifentanil infusion rate was observed in the dexamethasone group compared with the placebo group, p = .02. None of the secondary outcomes resulted in statistically significant differences between groups. Conclusion This explorative post hoc analysis of the randomised DEX‐2‐TKA trail showed that patients undergoing TKA surgery under general anaesthesia and who received dexamethasone seemed to have a higher remifentanil infusion rate compared with patients who received placebo. The clinical implications of the potentially increased remifentanil infusion rate need to be validated and explored further. Clinical trial registration ClinicalTrials.gov Identifier: NCT05002361 (12 August 2021).
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Affiliation(s)
- Maria Gantzel
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Kasper Smidt Gasbjerg
- Research Centre of Anaesthesiology and Intensive Care Medicine, Department of Anaesthesiology, Naestved-Slagelse- Ringsted Hospitals, Denmark
| | - Daniel Hägi-Pedersen
- Research Centre of Anaesthesiology and Intensive Care Medicine, Department of Anaesthesiology, Naestved-Slagelse- Ringsted Hospitals, Denmark.,Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Christian Sylvest Meyhoff
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark.,Department of Clinical Medicine, Copenhagen University, Copenhagen, 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
| | - Ole Mathiesen
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark.,Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Janus Christian Jakobsen
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark.,Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Troels Haxholdt Lunn
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark.,Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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Dexamethason verringert postoperativen Schmerz nach Knie-TEP. Dtsch Med Wochenschr 2022. [DOI: 10.1055/a-1750-0933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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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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