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Flyger SSB, Sorenson S, Pingel L, Karlsen APH, Nørskov AK, Mathiesen O, Maagaard M. Primary outcomes and anticipated effect sizes in randomised clinical trials assessing adjuncts to peripheral nerve blocks: A scoping review. Acta Anaesthesiol Scand 2024. [PMID: 38978187 DOI: 10.1111/aas.14489] [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: 03/31/2024] [Revised: 05/29/2024] [Accepted: 06/18/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Prolonging effects of adjuncts to local anaesthetics in peripheral nerve blocks have been demonstrated in randomised clinical trials. The chosen primary outcome and anticipated effect size have major impact on the clinical relevance of results in these trials. This scoping review aims to provide an overview of frequently used outcomes and anticipated effect sizes in randomised trials on peripheral nerve block adjuncts. METHODS For our scoping review, we searched MEDLINE, Embase and CENTRAL for trials assessing effects of adjuncts for peripheral nerve blocks published in 10 major anaesthesia journals. We included randomised clinical trials assessing adjuncts for single-shot ultrasound-guided peripheral nerve blocks, regardless of the type of interventional adjunct and control group, local anaesthetic used and anatomical localization. Our primary outcome was the choice of primary outcomes and corresponding anticipated effect size used for sample size estimation. Secondary outcomes were assessor of primary outcomes, the reporting of sample size calculations and statistically significant and non-significant results related to the anticipated effect sizes. RESULTS Of 11,854 screened trials, we included 59. The most frequent primary outcome was duration of analgesia (35/59 trials, 59%) with absolute and relative median (interquartile range) anticipated effect sizes for adjunct versus placebo/no adjunct: 240 min (180-318) and 30% (25-40) and for adjunct versus active comparator: 210 min (180-308) and 17% (15-28). Adequate sample size calculations were reported in 78% of trials. Statistically significant results were reported for primary outcomes in 45/59 trials (76%), of which 22% did not reach the anticipated effect size. CONCLUSION The reported outcomes and associated anticipated effect sizes can be used in future trials on adjuncts for peripheral nerve blocks to increase methodological homogeneity.
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Affiliation(s)
- Sarah Sofie Bitsch Flyger
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Sandra Sorenson
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Lasse Pingel
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Anders Peder Højer Karlsen
- Department of Anaesthesia and Intensive Care Medicine, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Anders Kehlet Nørskov
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Mathias Maagaard
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
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Berthier F, Samain E, Vettoretti L, Maillot C, Besch G, Ferreira D. Impact of intravenous dexamethasone and perineural ropivacaine on axillary block duration: analysis of two single-centre randomised trials. Br J Anaesth 2024; 133:211-213. [PMID: 38679517 DOI: 10.1016/j.bja.2024.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/15/2024] [Accepted: 03/22/2024] [Indexed: 05/01/2024] Open
Affiliation(s)
- Francis Berthier
- Université de Franche-Comté, CHU Besançon, INSERM CIC 1431, SINERGIES, Département d'Anesthésie Réanimation Chirurgicale, Besançon, France.
| | - Emmanuel Samain
- Université de Franche-Comté, CHU Besançon, SINERGIES, Département d'Anesthésie Réanimation Chirurgicale, Besançon, France
| | - Lucie Vettoretti
- CHU Besançon, Département d'Anesthésie Réanimation Chirurgicale, Besançon, France
| | - Clémence Maillot
- CHU Besançon, Département d'Anesthésie Réanimation Chirurgicale, Besançon, France
| | - Guillaume Besch
- Université de Franche-Comté, CHU Besançon, INSERM CIC 1431, SINERGIES, Département d'Anesthésie Réanimation Chirurgicale, Besançon, France
| | - David Ferreira
- Université de Franche-Comté, CHU Besançon, LINC, Département d'Anesthésie Réanimation Chirurgicale, Besançon, France
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Xu C, Wang C, Hu Y, Gu F, Lu J, Zhou Q. Comparing preoperative and postoperative dexamethasone effects on analgesia duration in shoulder surgery. iScience 2024; 27:109019. [PMID: 38352222 PMCID: PMC10863306 DOI: 10.1016/j.isci.2024.109019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 12/24/2023] [Accepted: 01/22/2024] [Indexed: 02/16/2024] Open
Abstract
Dexamethasone is commonly used as an adjuvant to prolong peripheral nerve block analgesia, but the optimal timing is unclear. This randomized equivalence trial tested whether preoperative versus postoperative intravenous dexamethasone have equivalent analgesic effects when combined with interscalene brachial plexus block for shoulder surgery. 168 patients were randomized to receive 5 mg dexamethasone either preoperatively or postoperatively. The primary outcome was duration of analgesia, analyzed for equivalence with a 2-h margin. The mean durations were equivalent between groups (11.5 h preoperative versus 10.7 h postoperative). The confidence intervals fell within the equivalence margin. There were no other clinically significant differences in secondary outcomes like time to first analgesia, motor recovery, opioid consumption, blood glucose, or complications. In conclusion, as an adjuvant for nerve block, preoperative and postoperative intravenous dexamethasone provide equivalent analgesic duration, allowing for flexibility in clinical use. This addresses previous uncertainty about timing while demonstrating equivalent efficacy.
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Affiliation(s)
- Cheng Xu
- Department of Anaesthesiology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, China
| | - Chengyu Wang
- Department of Anaesthesiology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, China
| | - Yanling Hu
- Department of Anaesthesiology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, China
| | - Fei Gu
- Department of Anaesthesiology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, China
| | - Jie Lu
- Department of Anaesthesiology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, China
| | - Quanhong Zhou
- Department of Critical Care, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, China
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Albaum JM, Abdallah FW, Ahmed MM, Siddiqui U, Brull R. What Is the Risk of Postoperative Neurologic Symptoms After Regional Anesthesia in Upper Extremity Surgery? A Systematic Review and Meta-analysis of Randomized Trials. Clin Orthop Relat Res 2022; 480:2374-2389. [PMID: 36083846 PMCID: PMC10538904 DOI: 10.1097/corr.0000000000002367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/29/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The risk of neurologic symptoms after regional anesthesia in orthopaedic surgery is estimated to approach 3%, with long-term deficits affecting 2 to 4 per 10,000 patients. However, current estimates are derived from large retrospective or observational studies that are subject to important systemic biases. Therefore, to harness the highest quality data and overcome the challenge of small numbers of participants in individual randomized trials, we undertook this systematic review and meta-analysis of contemporary randomized trials. QUESTIONS/PURPOSES In this systematic review and meta-analysis of randomized trials we asked: (1) What is the aggregate pessimistic and optimistic risk of postoperative neurologic symptoms after regional anesthesia in upper extremity surgery? (2) What block locations have the highest and lowest risk of postoperative neurologic symptoms? (3) What is the timing of occurrence of postoperative neurologic symptoms (in days) after surgery? METHODS We searched Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, Web of Science, Scopus, and PubMed for randomized controlled trials (RCTs) published between 2008 and 2019 that prospectively evaluated postoperative neurologic symptoms after peripheral nerve blocks in operative procedures. Based on the Grading of Recommendations, Assessment, Development, and Evaluation guidance for using the Risk of Bias in Non-Randomized Studies of Interventions tool, most trials registered a global rating of a low-to-intermediate risk of bias. A total of 12,532 participants in 143 trials were analyzed. Data were pooled and interpreted using two approaches to calculate the aggregate risk of postoperative neurologic symptoms: first according to the occurrence of each neurologic symptom, such that all reported symptoms were considered mutually exclusive (pessimistic estimate), and second according to the occurrence of any neurologic symptom for each participant, such that all reported symptoms were considered mutually inclusive (optimistic estimate). RESULTS At any time postoperatively, the aggregate pessimistic and optimistic risks of postoperative neurologic symptoms were 7% (915 of 12,532 [95% CI 7% to 8%]) and 6% (775 of 12,532 [95% CI 6% to 7%]), respectively. Interscalene block was associated with the highest risk (13% [661 of 5101] [95% CI 12% to 14%]) and axillary block the lowest (3% [88 of 3026] [95% CI 2% to 4%]). Of all symptom occurrences, 73% (724 of 998) were reported between 0 and 7 days, 24% (243 of 998) between 7 and 90 days, and 3% (30 of 998) between 90 and 180 days. Among the 31 occurrences reported at 90 days or beyond, all involved sensory deficits and four involved motor deficits, three of which ultimately resolved. CONCLUSION When assessed prospectively in randomized trials, the aggregate risk of postoperative neurologic symptoms associated with peripheral nerve block in upper extremity surgery was approximately 7%, which is greater than previous estimates described in large retrospective and observational trials. Most occurrences were reported within the first week and were associated with an interscalene block. Few occurrences were reported after 90 days, and they primarily involved sensory deficits. Although these findings cannot inform causation, they can help inform risk discussions and clinical decisions, as well as bolster our understanding of the evolution of postoperative neurologic symptoms after regional anesthesia in upper extremity surgery. Future prospective trials examining the risks of neurologic symptoms should aim to standardize descriptions of symptoms, timing of evaluation, classification of severity, and diagnostic methods. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Jordan M. Albaum
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Faraj W. Abdallah
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, ON, Canada
- Women’s College Hospital Research Institute, Women’s College Hospital, Toronto, ON, Canada
| | - M. Muneeb Ahmed
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Urooj Siddiqui
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, Mount Sinai Hospital, Toronto, ON, Canada
| | - Richard Brull
- Women’s College Hospital Research Institute, Women’s College Hospital, Toronto, ON, Canada
- Department of Anesthesia, Women’s College Hospital and Toronto Western Hospital, Toronto, ON, Canada
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5
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Termpornlert S, Vijitpavan A, Ngodngamthaweesuk M, Sangkum L, Saeaeh L, Pipatpongsa B, Leurcharusmee P, Wanishpongpan S, Sakura S. Analgesic Efficacy of Intravenous Dexamethasone as an Adjunct to Ultrasound-Guided Paravertebral Block with Bupivacaine in Video-Assisted Thoracoscopic Surgery. J Pain Res 2022; 15:2351-2361. [PMID: 35996452 PMCID: PMC9391992 DOI: 10.2147/jpr.s372780] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 07/29/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose Thoracic paravertebral block (TPVB) is a recommended regional analgesia during video-assisted thoracoscopic surgery (VATS). However, single-injection TPVB does not last long enough to provide sufficient acute postoperative pain relief. Continuous TPVB through a catheter is technically challenging and often unreliable. Intravenous dexamethasone extends the analgesic duration with some peripheral nerve blocks. However, data on the effect of intravenous dexamethasone on pain relief with TPVB are limited. This study aimed to assess the analgesic efficacy of intravenous dexamethasone in patients who received TPVB for VATS. Patients and Methods In this multicenter prospective randomized controlled trial, we recruited patients aged between 18 and 80 years with the American Society of Anesthesiologists of physical status class 1–3 and underwent elective VATS. Patients under general anesthesia randomly received 8 mg of intravenous dexamethasone (group D) or normal saline (group C). Ultrasound-guided TPVB (USG-TPVB) was performed at the T4–T5 and T6-T7 spaces. Multimodal analgesia was achieved via paracetamol, tramadol and intravenous morphine for both study groups. The primary outcome was time for the first analgesic requirement. Postoperative pain in terms of numeric rating score (NRS), total morphine consumption and postoperative nausea and vomiting (PONV) were assessed. Results After excluding one patient, 59 patients were analyzed. There were no intergroup differences in baseline characteristics. The time to first analgesic requirement was longer in group D (305 [240, 510] minutes) than in group C (270 [180, 300] minutes) (P value = 0.02). The NRS at rest and on movement was lower in group D than in group C at 12 hours but did not differ at other time points. Postoperative morphine consumption was significantly lower in group D than in group C at 6,12,24 and 48 hours. Incidences of PONV were comparable between the groups. Conclusion Intravenous dexamethasone, used as an adjunct to a single-injection USG-TPVB prolonged analgesic duration, had an opioid-sparing effect and provided better postoperative pain relief after VATS.
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Affiliation(s)
- Sivaporn Termpornlert
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Amorn Vijitpavan
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Montien Ngodngamthaweesuk
- Department of Cardiovascular Thoracic Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Lisa Sangkum
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Lalisa Saeaeh
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Benjaporn Pipatpongsa
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Prangmalee Leurcharusmee
- Department of Anesthesiology, Faculty of Medicine Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University, Chiang Mai, Thailand
| | - Samon Wanishpongpan
- Department of Anesthesiology, Faculty of Medicine Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University, Chiang Mai, Thailand
| | - Shinichi Sakura
- Department of Anesthesiology, University Hospital Shimane University Faculty of Medicine, Izumo, Japan
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6
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Sun Z, Liu L, Liu H, Luo F. Effect of CT-Guided Gasserian Ganglion Block with Local Anesthetics and Steroids on Acute/Subacute Zoster-Related Trigeminal Neuralgia: A Multicenter Retrospective Study. J Pain Res 2022; 15:2303-2313. [PMID: 35974906 PMCID: PMC9375984 DOI: 10.2147/jpr.s375257] [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: 05/28/2022] [Accepted: 07/29/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose To further evaluate the effects of gasserian ganglion block treatment with local anesthetics and steroids on patients with acute/subacute zoster-related trigeminal neuralgia. Patients and Methods This is a multicenteric retrospective study which included patients between the ages of 26–92 years, who suffered from acute/subacute zoster-related trigeminal neuralgia and had undergone CT-guided gasserian ganglion block. The medical records of these patients between January 13, 2016 and August 25, 2021 were retrieved, and the patients were followed up for 6 months. Follow-up outcomes were Numerical Rating Scale (NRS) scores, medications and dosage. The effective rate was defined as the number of cases with NRS score reduction of >50%/total number of cases×100% at 12 weeks postoperatively. Results The postoperative NRS scores were significantly decreased in all patients (P < 0.05), and NRS scores in acute zoster group were lower than those in subacute zoster group at different time points (P < 0.05). The percentage of patients who had a reduction of medication use value of >50% was 56.4% and the effective rate was 66.7% in all patients, at 3 months after the block treatment. There was no significant difference in the reduction of medication use value of >50% and the effective rates between the two groups. There were no intracranial hemorrhage, infection or other serious adverse effects in either groups. Conclusion CT-guided gasserian ganglion block with local anesthetics and steroids can be an effective and safe technique to relieve the pain of acute/subacute zoster-related trigeminal neuralgia.
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Affiliation(s)
- Zhe Sun
- Department of Day Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, People's Republic of China
| | - Lu Liu
- Department of Day Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, People's Republic of China
| | - Hongbing Liu
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, People's Republic of China
| | - Fang Luo
- Department of Day Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, People's Republic of China.,Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, People's Republic of China
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7
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Grelet T, Besch G, Puyraveau M, Assila L, Pascual M, Ferreira D, Vettoretti L, Pili-Floury S, Samain E, Berthier F. Minimum effective concentration of ropivacaine for 90% ultrasound-guided axillary brachial plexus block, with or without intravenous dexamethasone. J Clin Anesth 2021; 75:110468. [PMID: 34332494 DOI: 10.1016/j.jclinane.2021.110468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/16/2021] [Accepted: 07/20/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Tommy Grelet
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, Besancon, France
| | - Guillaume Besch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, Besancon, France; EA 3920, University of Franche-Comte, Besancon, France
| | - Marc Puyraveau
- Clinical Methodology Center, University Hospital of Besancon, Besancon, France; Laboratory Chrono-environment, UMR 6249 Centre National de la Recherche Scientifique, University of Franche-Comte, Besancon, France
| | - Loubena Assila
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, Besancon, France
| | - Mathieu Pascual
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, Besancon, France
| | - David Ferreira
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, Besancon, France; EA 481 University of Franche-Comte, Besancon, France
| | - Lucie Vettoretti
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, Besancon, France
| | - Sébastien Pili-Floury
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, Besancon, France; EA 3920, University of Franche-Comte, Besancon, France
| | - Emmanuel Samain
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, Besancon, France; EA 3920, University of Franche-Comte, Besancon, France
| | - Francis Berthier
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, Besancon, France.
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8
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Chazapi A, Lepetsos P, Gambopoulou Z, Siafaka I, Argyra E, Vadalouka A. Analgesic Effect of the Topical Use of Dexamethasone in Ultrasound-Guided Axillary Brachial Plexus Blockade: A Prospective, Randomized, Double-Blind, Placebo-Controlled Study. Cureus 2021; 13:e12971. [PMID: 33654632 PMCID: PMC7913892 DOI: 10.7759/cureus.12971] [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] [Indexed: 11/10/2022] Open
Abstract
Introduction Increasing the duration of regional anesthesia in orthopedic surgery is of vital importance, as it prolongs postoperative analgesia, allowing faster rehabilitation of patients. Dexamethasone has been found to extend the block duration in animal and human studies. The aim of this study is the assessment of the effect of the addition of dexamethasone to ropivacaine on the onset and duration of axillary brachial plexus block, along with the intensity of postoperative pain. Methods Forty patients undergoing below-elbow surgery under ultrasound-guided axillary brachial plexus block were randomly allocated to receive either 30 mL ropivacaine 0.75% with 2 mL of saline (Group A, n = 20) or 30 mL ropivacaine 0.75% with 2 mL of dexamethasone (4 mg) (Group B, n = 20). Sensory and motor blockade were assessed, with the use of the pinprick test and the modified Bromage scale, at five, 10, 15, and 20 min after the block. The duration of analgesia, intensity of postoperative pain, postoperative opioid consumption, overall satisfaction, and perioperative complications were compared between the two groups. Results We found no difference at the mean onset time of the sensory and motor block between the two groups. The mean duration of postoperative analgesia was three hours higher in the dexamethasone group (15.85 ± 4.82 versus 11.75 ± 6.81, p-value = 0.035). Pain intensity was lower in the dexamethasone group, at six and 12 hours after surgery (3.45 ± 1.79 versus 4.65 ± 1.79, p-value = 0.040). Postoperative opioid consumption, patient overall satisfaction, and perioperative complications were not significantly different between groups. Conclusions Dexamethasone prolongs the duration of ropivacaine in an axillary brachial plexus block and decreases postoperative pain in patients subjected to below-elbow surgery.
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Affiliation(s)
| | | | | | - Ioanna Siafaka
- 1st Department of Anaesthesiology, University of Athens Medical School, Athens, GRC
| | - Erifylli Argyra
- 1st Department of Anaesthesiology, University of Athens Medical School, Athens, GRC
| | - Athina Vadalouka
- 1st Department of Anaesthesiology, University of Athens Medical School, Athens, GRC
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9
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Parrish JM, Jenkins NW, Brundage TS, Hrynewycz NM, Podnar J, Buvanendran A, Singh K. Outpatient Minimally Invasive Lumbar Fusion Using Multimodal Analgesic Management in the Ambulatory Surgery Setting. Int J Spine Surg 2020; 14:970-981. [PMID: 33560257 DOI: 10.14444/7146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND The transition of minimally invasive (MIS) spine surgery from the inpatient to outpatient setting has been aided by advances in multimodal analgesic (MMA) protocols. This clinical case series of patients demonstrates the feasibility of ambulatory MIS transforaminal lumbar interbody fusion (TLIF) and lateral lumbar interbody fusion (LLIF) procedures while using an enhanced MMA protocol. METHODS Consecutive MIS TLIF or LLIF procedures with percutaneous pedicle screw fixation and direct decompression in the ambulatory setting were reviewed. The procedures were performed using an MMA protocol. The ambulatory surgery center (ASC) did not allow for observation of patients for periods of time greater than 23 hours. We recorded patient demographics, perioperative, and postoperative characteristics. RESULTS Fifty consecutive patients were identified from September 2016 to July 2019. Forty-one patients (82%) underwent MIS TLIF, and 9 patients underwent MIS LLIF (18.0%). All patients were discharged on the same day of surgery. The mean length of stay was 4.5 hours and 3.8 hours for the TLIF and LLIF cohorts, respectively. Our review of medical records revealed no postoperative complications following either the TLIF or the LLIF procedures. CONCLUSIONS The present study of 50 consecutive patients is the largest clinical series of ASC patients undergoing lumbar fusion procedures in a stand-alone facility with no extended postoperative observation capability. While using MMA protocol within the ASC, no postoperative complications were observed for either MIS TLIF or LLIF procedures. All patients were discharged from the ambulatory surgical center on the day of surgery with well-controlled postoperative pain. LEVEL OF EVIDENCE 4. CLINICAL RELEVANCE The MMA protocol is an essential aspect in transitioning minimally invasive lumbar spine surgery to the ASC. Our findings indicate that MIS lumbar fusion spine surgery with an enhanced MMA protocol can lead to safe and timely ASC discharge while minimizing hospital admission.
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Affiliation(s)
- James M Parrish
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Nathaniel W Jenkins
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Thomas S Brundage
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Nadia M Hrynewycz
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Jeffrey Podnar
- Department of Anesthesiology, Midwest Anesthesia Partners LLC, Naperville, Illinois
| | | | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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10
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Kendall MC, Alves L, Traill LL, De Oliveira GS. The effect of ultrasound-guided erector spinae plane block on postsurgical pain: a meta-analysis of randomized controlled trials. BMC Anesthesiol 2020; 20:99. [PMID: 32357842 PMCID: PMC7195766 DOI: 10.1186/s12871-020-01016-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 04/16/2020] [Indexed: 12/11/2022] Open
Abstract
Background The effect of erector spinae plane block has been evaluated by clinical trials leading to a diversity of results. The main objective of the current investigation is to compare the analgesic efficacy of erector spinae plane block to no block intervention in patients undergoing surgical procedures. Methods We performed a quantitative systematic review of randomized controlled trials in PubMed, Embase, Cochrane Library, and Google Scholar electronic databases from their inception through July 2019. Included trials reported either on opioid consumption or pain scores as postoperative pain outcomes. Methodological quality of included studies was evaluated using Cochrane Collaboration’s tool. Results Thirteen randomized controlled trials evaluating 679 patients across different surgical procedures were included. The aggregated effect of erector spinae plane block on postoperative opioid consumption revealed a significant effect, weighted mean difference of − 8.84 (95% CI: − 12.54 to − 5.14), (P < 0.001) IV mg morphine equivalents. The effect of erector spinae plane block on post surgical pain at 6 h compared to control revealed a significant effect weighted mean difference of − 1.31 (95% CI: − 2.40 to − 0.23), P < 0.02. At 12 h, the weighted mean difference was of − 0.46 (95% CI: − 1.01 to 0.09), P = 0.10. No block related complications were reported. Conclusions Our results provide moderate quality evidence that erector spinae plane block is an effective strategy to improve postsurgical analgesia.
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Affiliation(s)
- Mark C Kendall
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
| | - Lucas Alves
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Lauren L Traill
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Gildasio S De Oliveira
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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11
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Intravenous dexamethasone and peripheral nerve blocks: A systemic review and meta-analysis of randomized controlled trials. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020. [DOI: 10.1016/j.ijso.2020.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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12
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Bhatia A, Buvanendran A. Anesthesia and postoperative pain control-multimodal anesthesia protocol. JOURNAL OF SPINE SURGERY 2019; 5:S160-S165. [PMID: 31656870 DOI: 10.21037/jss.2019.09.33] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Multimodal analgesia (MMA) involves the use of additive or synergistic combinations of analgesics to achieve clinically required analgesia while minimizing significant side effects associated with higher dose of a single equianalgesic medication such as an opioid analgesic. MMA generally involves optimizing non-opioid pharmacologic and non-pharmacologic interventions and reserving opioid use to treat breakthrough pain. Patients receiving medications via MMA protocols are likely to have lower opioid consumption compared to those managed using primarily IV opioid patient-controlled analgesia. MMA pain management strategies have become important components of enhanced recovery after surgery (ERAS) protocols in an effort to optimize care by standardizing analgesic medications in the perioperative setting while minimizing adverse effects and improving quality and patient outcomes. Successful implementation of a MMA requires the input and cooperation of all of the stakeholders including the caregivers as well as the patients. Health system benefits can also be realized from the implementation of an effective MMA, as fewer opioid related side effects can improve patient recovery and lead to faster discharge and improved utilization of resources.
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Affiliation(s)
- Alisha Bhatia
- Rush University Medical Center, Department of Anesthesiology, Chicago, Illinois, USA
| | - Asokumar Buvanendran
- Rush University Medical Center, Department of Anesthesiology, Chicago, Illinois, USA
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