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Ceban F, Yan E, Pivetta B, Saripella A, Englesakis M, Gan TJ, Joshi GP, Chung F. Perioperative adverse events in adult patients with obstructive sleep apnea undergoing ambulatory surgery: An updated systematic review and meta-analysis. J Clin Anesth 2024; 96:111464. [PMID: 38718686 DOI: 10.1016/j.jclinane.2024.111464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 03/10/2024] [Accepted: 04/01/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND The suitability of ambulatory surgery for patients with obstructive sleep apnea (OSA) remains controversial. This systematic review and meta-analysis aimed to evaluate the odds of perioperative adverse events in patients with OSA undergoing ambulatory surgery, compared to patients without OSA. METHODS Four electronic databases were searched for studies published between January 1, 2011 and July 11, 2023. The inclusion criteria were: adult patients with diagnosed or high-risk of OSA undergoing ambulatory surgery; perioperative adverse events; control group included; general and/or regional anesthesia; and publication on/after February 1, 2011. We calculated effect sizes as odds ratios using a random effects model, and additional sensitivity analyses were conducted. RESULTS Seventeen studies (375,389 patients) were included. OSA was associated with an increased odds of same-day admission amongst all surgery types (OR 1.94, 95% CI 1.46-2.59, I2:79%, P < 0.00001, 11 studies, n = 347,342), as well as when only orthopedic surgery was considered (OR 2.68, 95% CI 2.05-3.48, I2:41%, P < 0.00001, 6 studies, n = 132,473). Three studies reported that OSA was strongly associated with prolonged post anesthesia care unit (PACU) length of stay (LOS), while one study reported that the association was not statistically significant. In addition, four studies reported that OSA was associated with postoperative respiratory depression/hypoxia, with one large study on shoulder arthroscopy reporting an almost 5-fold increased odds of pulmonary compromise, 5-fold of myocardial infarction, 3-fold of acute renal failure, and 5-fold of intensive care unit (ICU) admission. CONCLUSIONS Ambulatory surgical patients with OSA had almost two-fold higher odds of same-day admission compared to non-OSA patients. Multiple large studies also reported an association of OSA with prolonged PACU LOS, respiratory complications, and/or ICU admission. Clinicians should screen preoperatively for OSA, optimize comorbidities, adhere to clinical algorithm-based management perioperatively, and maintain a high degree of vigilance in the postoperative period.
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Affiliation(s)
- Felicia Ceban
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ellene Yan
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Bianca Pivetta
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Aparna Saripella
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Marina Englesakis
- Library & Information Services, University Health Network, Toronto, ON, Canada
| | - Tong J Gan
- Division of Anesthesiology and Perioperative Medicine, Critical Care and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Frances Chung
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada.
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Huang L, Zhang T, Wang K, Chang B, Fu D, Chen X. Postoperative Multimodal Analgesia Strategy for Enhanced Recovery After Surgery in Elderly Colorectal Cancer Patients. Pain Ther 2024:10.1007/s40122-024-00619-0. [PMID: 38836984 DOI: 10.1007/s40122-024-00619-0] [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: 04/24/2024] [Accepted: 05/21/2024] [Indexed: 06/06/2024] Open
Abstract
Enhanced Recovery After Surgery (ERAS) protocols have substantially proven their merit in diminishing recuperation durations and mitigating postoperative adverse events in geriatric populations undergoing colorectal cancer procedures. Despite this, the pivotal aspect of postoperative pain control has not garnered the commensurate attention it deserves. Typically, employing a multimodal analgesia regimen that weaves together nonsteroidal anti-inflammatory drugs, opioids, local anesthetics, and nerve blocks stands paramount in curtailing surgical complications and facilitating reduced convalescence within hospital confines. Nevertheless, this integrative pain strategy is not devoid of pitfalls; the specter of organ dysfunction looms over the geriatric cohort, rooted in the abuse of analgesics or the complex interplay of polypharmacy. Revolutionary research is delving into alternative delivery and release modalities, seeking to allay the inadvertent consequences of analgesia and thereby potentially elevating postoperative outcomes for the elderly post-colorectal cancer surgery populace. This review examines the dual aspects of multimodal analgesia regimens by comparing their established benefits with potential limitations and offers insight into the evolving strategies of drug administration and release.
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Affiliation(s)
- Li Huang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Tianhao Zhang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Kaixin Wang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Bingcheng Chang
- The Second Affiliated Hospital of Guizhou, University of Traditional Chinese Medicine, Guiyang, 550003, China
| | - Daan Fu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China.
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Ministry of Education, Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Wuhan, China.
| | - Xiangdong Chen
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China.
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Ministry of Education, Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Wuhan, China.
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Blike GT, McGrath SP, Ochs Kinney MA, Gali B. Pro-Con Debate: Universal Versus Selective Continuous Monitoring of Postoperative Patients. Anesth Analg 2024; 138:955-966. [PMID: 38621283 DOI: 10.1213/ane.0000000000006840] [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: 04/17/2024]
Abstract
In this Pro-Con commentary article, we discuss use of continuous physiologic monitoring for clinical deterioration, specifically respiratory depression in the postoperative population. The Pro position advocates for 24/7 continuous surveillance monitoring of all patients starting in the postanesthesia care unit until discharge from the hospital. The strongest arguments for universal monitoring relate to inadequate assessment and algorithms for patient risk. We argue that the need for hospitalization in and of itself is a sufficient predictor of an individual's risk for unexpected respiratory deterioration. In addition, general care units carry the added risk that even the most severe respiratory events will not be recognized in a timely fashion, largely due to higher patient to nurse staffing ratios and limited intermittent vital signs assessments (e.g., every 4 hours). Continuous monitoring configured properly using a "surveillance model" can adequately detect patients' respiratory deterioration while minimizing alarm fatigue and the costs of the surveillance systems. The Con position advocates for a mixed approach of time-limited continuous pulse oximetry monitoring for all patients receiving opioids, with additional remote pulse oximetry monitoring for patients identified as having a high risk of respiratory depression. Alarm fatigue, clinical resource limitations, and cost are the strongest arguments for selective monitoring, which is a more targeted approach. The proponents of the con position acknowledge that postoperative respiratory monitoring is certainly indicated for all patients, but not all patients need the same level of monitoring. The analysis and discussion of each point of view describes who, when, where, and how continuous monitoring should be implemented. Consideration of various system-level factors are addressed, including clinical resource availability, alarm design, system costs, patient and staff acceptance, risk-assessment algorithms, and respiratory event detection. Literature is reviewed, findings are described, and recommendations for design of monitoring systems and implementation of monitoring are described for the pro and con positions.
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Affiliation(s)
- George T Blike
- From the Departments of Anesthesiology
- Community and Family Medicine, Geisel School of Medicine, Hanover, New Hampshire
- The Dartmouth Institute, Dartmouth College, Hanover, New Hampshire
- Surveillance Analytics Core, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Susan P McGrath
- From the Departments of Anesthesiology
- Surveillance Analytics Core, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Michelle A Ochs Kinney
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Bhargavi Gali
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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Green KW, Popovic G, Baitch L. Intraoperative methadone for day-case gynaecological laparoscopy: A double-blind, randomised controlled trial. Anaesth Intensive Care 2024; 52:168-179. [PMID: 38649297 PMCID: PMC11071594 DOI: 10.1177/0310057x231214551] [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] [Indexed: 04/25/2024]
Abstract
Optimal pain relief in day-case surgery is imperative to patient comfort and timely discharge from hospital. Short-acting opioids are commonly used for analgesia in modern anaesthesia, allowing rapid recovery after surgery. Plasma concentration fluctuations from repeated dosing of short-acting opioids can cause patients to oscillate between analgesia with potential adverse effects, and inadequate analgesia requiring rescue dosing. Methadone's unique pharmacology may offer effective and sustained analgesia with less opioid consumption, potentially reducing adverse effects. Using a double-blind, randomised controlled trial, we compared post-anaesthesia care unit opioid consumption between day-case gynaecological laparoscopy patients who received either intravenous methadone (10 mg), or short-acting opioids intraoperatively. The primary outcome was post-anaesthesia care unit opioid consumption in oral morphine equivalents. Secondary outcomes included total opioid consumption, discharge opioid consumption, pain scores (0-10) until discharge, adverse effects (respiratory depression, postoperative nausea and vomiting, excess sedation), and rate of admission. Seventy patients were randomly assigned. Patients who received methadone consumed on average 9.44 mg fewer oral morphine equivalents in the post-anaesthesia care unit than the short-acting group (18.02 mg vs 27.46 mg, respectively, 95% confidence interval 0.003 to 18.88, P = 0.050) and experienced lower postoperative pain scores at every time point, although absolute differences were small. There was no evidence of lower hospital or discharge opioid consumption. No significant differences between the methadone and short-acting groups in other outcomes were identified: respiratory depression 41.2% versus 31.4%, Padjusted >0.99; postoperative nausea and vomiting 29.4% versus 42.9%, Padjusted >0.99; overnight admission 17.7% versus 11.4%, Padjusted >0.99; excess sedation 8.82% versus 8.57%, Padjusted >0.99. This study provides evidence that, although modestly, methadone can reduce post-anaesthesia care unit opioid consumption and postoperative pain scores after day-case gynaecological laparoscopy. There were no significant differences in any secondary outcomes.
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Affiliation(s)
- Kyle W Green
- Albury Rural Clinical Campus, University of New South Wales, Albury, Australia
| | - Gordana Popovic
- UNSW Stats Central, University of New South Wales, Sydney, Australia
| | - Luke Baitch
- Albury Rural Clinical Campus, University of New South Wales, Albury, Australia
- Department of Anaesthesia, Albury Wodonga Health, Albury, Australia
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Chaudhry RA, Zarmer L, West K, Chung F. Obstructive Sleep Apnea and Risk of Postoperative Complications after Non-Cardiac Surgery. J Clin Med 2024; 13:2538. [PMID: 38731067 PMCID: PMC11084150 DOI: 10.3390/jcm13092538] [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: 02/21/2024] [Revised: 04/03/2024] [Accepted: 04/15/2024] [Indexed: 05/13/2024] Open
Abstract
Obstructive sleep apnea (OSA), a common sleep disorder, poses significant challenges in perioperative management due to its complexity and multifactorial nature. With a global prevalence of approximately 22.6%, OSA often remains undiagnosed, and increases the risk of cardiac and respiratory postoperative complications. Preoperative screening has become essential in many institutions to identify patients at increased risk, and experts recommend proceeding with surgery in the absence of severe symptoms, albeit with heightened postoperative monitoring. Anesthetic and sedative agents exacerbate upper airway collapsibility and depress central respiratory activity, complicating intraoperative management, especially with neuromuscular blockade use. Additionally, OSA patients are particularly prone to opioid-induced respiratory depression, given their increased sensitivity to opioids and heightened pain perception. Thus, regional anesthesia and multimodal analgesia are strongly advocated to reduce perioperative complication risks. Postoperative care for OSA patients necessitates vigilant monitoring and tailored management strategies, such as supplemental oxygen and Positive Airway Pressure therapy, to minimize cardiorespiratory complications. Health care institutions are increasingly focusing on enhanced monitoring and resource allocation for patient safety. However, the rising prevalence of OSA, heterogeneity in disease severity, and lack of evidence for the efficacy of costly perioperative measures pose challenges. The development of effective screening and monitoring algorithms, alongside reliable risk predictors, is crucial for identifying OSA patients needing extended postoperative care. This review emphasizes a multidimensional approach in managing OSA patients throughout the perioperative period, aiming to optimize patient outcomes and minimize adverse outcomes.
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Affiliation(s)
- Rabail Arif Chaudhry
- Department of Anesthesiology and Pain Medicine, Banner University Medical Center, University of Arizona COM-T, Tucson, AZ 85724, USA
| | - Lori Zarmer
- Department of Anesthesiology and Pain Medicine, Banner University Medical Center, University of Arizona COM-T, Tucson, AZ 85724, USA
| | - Kelly West
- Memorial Hermann Hospital—TMC, Department of Anesthesiology and Critical Care Medicine, McGovern Medical School, University of Texas at Houston, Houston, TX 77030, USA;
| | - Frances Chung
- University Health Network, Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada;
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
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Althans AR, Kumpati B, Lavage DR, Esper SA, Subramaniam K, Boisen ML, Holder-Murray J. Use of Perioperative Intravenous Lidocaine as Part of an Abdominal Surgery Enhanced Recovery Pathway Does Not Significantly Impact Postoperative Pain. Am Surg 2024; 90:624-630. [PMID: 37786239 DOI: 10.1177/00031348231204916] [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] [Indexed: 10/04/2023]
Abstract
BACKGROUND The utility of perioperative intravenous lidocaine in improving postoperative pain control remains unclear. We aimed to compare postoperative pain outcomes in ERP abdominal surgery patients who did vs did not receive intravenous lidocaine. We hypothesized that patients receiving lidocaine would have lower postoperative pain scores and consume fewer opioids. METHODS We performed a retrospective cohort study of patients undergoing elective abdominal surgery at a single institution via an ERP from 2017 to 2018. Patients who received lidocaine in the 6 months prior to a lidocaine shortage were compared to those who did not receive lidocaine for 6 months following the shortage. The primary outcome measures were pain scores as measured on the visual analogue scale and opioid consumption as measured by oral morphine equivalents (OME). RESULTS We identified 1227 consecutive ERP abdominal surgery patients for inclusion (519 patients receiving lidocaine and 708 patients not receiving lidocaine). Demographics between the two cohorts were similar, with the following exceptions: more females, and more patients with a history of psychiatric diagnoses in the group that did not receive lidocaine. Adjusted, mixed linear models for both OME (P = .23) and pain scores (P = .51) found no difference between the lidocaine and no lidocaine groups. DISCUSSION In our study of ERP abdominal surgery patients, perioperative intravenous lidocaine did not offer improvement in postoperative pain scores or OME consumed. We therefore do not recommend the use of intravenous lidocaine as part of an ERP multimodal pain management strategy in abdominal surgery patients.
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Affiliation(s)
- Alison R Althans
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Danielle R Lavage
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Stephen A Esper
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael L Boisen
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Rahman AA, Dell'Aniello S, Moodie EEM, Durand M, Coulombe J, Boivin JF, Suissa S, Ernst P, Renoux C. Gabapentinoids and Risk for Severe Exacerbation in Chronic Obstructive Pulmonary Disease : A Population-Based Cohort Study. Ann Intern Med 2024; 177:144-154. [PMID: 38224592 DOI: 10.7326/m23-0849] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND North American and European health agencies recently warned of severe breathing problems associated with gabapentinoids, including in patients with chronic obstructive pulmonary disease (COPD), although supporting evidence is limited. OBJECTIVE To assess whether gabapentinoid use is associated with severe exacerbation in patients with COPD. DESIGN Time-conditional propensity score-matched, new-user cohort study. SETTING Health insurance databases from the Régie de l'assurance maladie du Québec in Canada. PATIENTS Within a base cohort of patients with COPD between 1994 and 2015, patients initiating gabapentinoid therapy with an indication (epilepsy, neuropathic pain, or other chronic pain) were matched 1:1 with nonusers on COPD duration, indication for gabapentinoids, age, sex, calendar year, and time-conditional propensity score. MEASUREMENTS The primary outcome was severe COPD exacerbation requiring hospitalization. Hazard ratios (HRs) associated with gabapentinoid use were estimated in subcohorts according to gabapentinoid indication and in the overall cohort. RESULTS The cohort included 356 gabapentinoid users with epilepsy, 9411 with neuropathic pain, and 3737 with other chronic pain, matched 1:1 to nonusers. Compared with nonuse, gabapentinoid use was associated with increased risk for severe COPD exacerbation across the indications of epilepsy (HR, 1.58 [95% CI, 1.08 to 2.30]), neuropathic pain (HR, 1.35 [CI, 1.24 to 1.48]), and other chronic pain (HR, 1.49 [CI, 1.27 to 1.73]) and overall (HR, 1.39 [CI, 1.29 to 1.50]). LIMITATION Residual confounding, including from lack of smoking information. CONCLUSION In patients with COPD, gabapentinoid use was associated with increased risk for severe exacerbation. This study supports the warnings from regulatory agencies and highlights the importance of considering this potential risk when prescribing gabapentin and pregabalin to patients with COPD. PRIMARY FUNDING SOURCE Canadian Institutes of Health Research and Canadian Lung Association.
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Affiliation(s)
- Alvi A Rahman
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, and Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada (A.A.R., J.-F.B.)
| | - Sophie Dell'Aniello
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada (S.D.)
| | - Erica E M Moodie
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada (E.E.M.M.)
| | - Madeleine Durand
- Department of Medicine, Université de Montréal, and Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (M.D.)
| | - Janie Coulombe
- Department of Mathematics and Statistics, Université de Montréal, Montreal, Quebec, Canada (J.C.)
| | - Jean-François Boivin
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, and Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada (A.A.R., J.-F.B.)
| | - Samy Suissa
- Department of Epidemiology, Biostatistics and Occupational Health and Department of Medicine, McGill University, and Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada (S.S., P.E.)
| | - Pierre Ernst
- Department of Epidemiology, Biostatistics and Occupational Health and Department of Medicine, McGill University, and Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada (S.S., P.E.)
| | - Christel Renoux
- Department of Epidemiology, Biostatistics and Occupational Health; Department of Medicine; and Department of Neurology and Neurosurgery, McGill University, and Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada (C.R.)
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Razak A, Corman B, Servider J, Mavarez-Martinez A, Jin Z, Mushlin H, Bergese SD. Postoperative analgesic options after spine surgery: finding the optimal treatment strategies. Expert Rev Neurother 2024; 24:191-200. [PMID: 38155560 DOI: 10.1080/14737175.2023.2298824] [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: 06/03/2023] [Accepted: 12/20/2023] [Indexed: 12/30/2023]
Abstract
INTRODUCTION Spine surgery is one of the most common types of surgeries performed in the United States; however, managing postoperative pain following spine surgery has proven to be challenging. Patients with spine pathologies have higher incidences of chronic pain and resultant opioid use and potential for tolerance. Implementing a multimodal plan for postoperative analgesia after spine surgery can lead to enhanced recovery and outcomes. AREAS COVERED This review presents several options for analgesia following spine surgery with an emphasis on multimodal techniques to best aid this specific patient population. In addition to traditional therapeutics, such as acetaminophen, non-steroidal anti-inflammatory medications, and opioids, we discuss intrathecal morphine administration and emerging regional anesthesia techniques. EXPERT OPINION Several adjuncts to improve analgesia following spine surgery are efficacious in the postoperative period. Intrathecal morphine provides sustained analgesia and can be instilled intraoperatively by the surgical team under direct visualization. Local anesthetics deposited under ultrasound guidance by an anesthesiologist trained in regional techniques also provide the opportunity for single injections or continuous analgesia via an indwelling catheter.
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Affiliation(s)
- Alina Razak
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, USA
| | - Benjamin Corman
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | - John Servider
- Department of Neurological Surgery, Stony Brook University Health Science Center, Stony Brook, NY, USA
| | - Ana Mavarez-Martinez
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, USA
| | - Zhaosheng Jin
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, USA
| | - Harry Mushlin
- Department of Neurological Surgery, Stony Brook University Health Science Center, Stony Brook, NY, USA
| | - Sergio D Bergese
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, USA
- Department of Neurological Surgery, Stony Brook University Health Science Center, Stony Brook, NY, USA
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Ellis MS, Xu KY, Tardelli VS, Fidalgo TM, Buttram ME, Grucza RA. Gabapentin Use Among Individuals Initiating Buprenorphine Treatment for Opioid Use Disorder. JAMA Psychiatry 2023; 80:1269-1276. [PMID: 37672238 PMCID: PMC10483381 DOI: 10.1001/jamapsychiatry.2023.3145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/05/2023] [Indexed: 09/07/2023]
Abstract
Importance Gabapentin prescriptions have drastically increased in the US due to off-label prescribing in settings such as opioid use disorder (OUD) treatment to manage a range of comorbid conditions and withdrawal symptoms, despite a lack of evidence. Objective To assess the purpose and associated risks of off-label gabapentin use in OUD treatment. Design, Setting, and Participants This retrospective recurrent-event case-control study with a crossover design used administrative claims data from MarketScan Commercial and Multi-State Medicaid databases from January 1, 2006, to December 31, 2016. Individuals aged 12 to 64 years with an OUD diagnosis and filling buprenorphine prescriptions were included in the primary analysis conducted from July 1, 2022, through June 1, 2023. Unit of observation was the person-day. Exposures Days covered by filled gabapentin prescriptions. Main Outcomes and Measures Primary outcomes were receipt of gabapentin in the 90 days after initiation of buprenorphine treatment and drug-related poisoning. Drug-related poisonings were defined using codes from International Classification of Diseases, Ninth Revision, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. Results A total of 109 407 patients were included in the analysis (mean [SD] age, 34.0 [11.2] years; 60 112 [54.9%] male). Among the 29 967 patients with Medicaid coverage, 299 (1.0%) were Hispanic, 1330 (4.4%) were non-Hispanic Black, 23 112 (77.1%) were non-Hispanic White, and 3399 (11.3%) were other. Gabapentin was significantly less likely to be prescribed to Black or Hispanic patients, and more likely to be prescribed to female patients, those with co-occurring substance use or mood disorders, and those with comorbid physical conditions such as neuropathic pain. Nearly one-third of persons who received gabapentin (4336 [31.1%]) had at least 1 drug-related poisoning after initiating buprenorphine treatment, compared with 13 856 (14.5%) among persons who did not receive gabapentin. Adjusted analyses showed that days of gabapentin use were not associated with hospitalization for drug-related poisoning (odds ratio, 0.98 [95% CI, 0.85-1.13]). Drug-related poisoning risks did not vary based on dosage. Conclusions and Relevance Gabapentin is prescribed in the context of a myriad of comorbid conditions. Even though persons receiving gabapentin are more likely to have admissions for drug-related poisoning, these data suggest that gabapentin is not associated with an increased risk of drug-related poisoning alongside buprenorphine in adjusted analyses. More data on the safety profile of gabapentin in OUD settings are needed.
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Affiliation(s)
- Matthew S. Ellis
- Department of Psychiatry, Washington University in St Louis, School of Medicine, St Louis, Missouri
| | - Kevin Y. Xu
- Department of Psychiatry, Washington University in St Louis, School of Medicine, St Louis, Missouri
| | - Vitor S. Tardelli
- Department of Psychiatry, Universidade Federal de São Paulo, São Paulo, Brazil
- Translational Addictions Research Laboratory, Centre for Addictions and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Thiago M. Fidalgo
- Department of Psychiatry, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Mance E. Buttram
- Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville
| | - Richard A. Grucza
- Department of Family and Community Medicine, St Louis University, St Louis, Missouri
- Department of Health and Outcomes Research, St Louis University, St Louis, Missouri
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Hateruma Y, Nozaki-Taguchi N, Son K, Tarao K, Kawakami S, Sato Y, Isono S. Assessments of perioperative respiratory pattern with non-contact vital sign monitor in children undergoing minor surgery: a prospective observational study. J Anesth 2023; 37:714-725. [PMID: 37584687 DOI: 10.1007/s00540-023-03223-2] [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: 09/05/2022] [Accepted: 07/01/2023] [Indexed: 08/17/2023]
Abstract
PURPOSE Nurses routinely assess respiration of hospitalized children; however, respiratory rate measurements are technically difficult due to rapid and small chest wall movements. The aim of this study is to reveal the respiratory status of small children undergoing minor surgery with load cells placed under the bed legs, and to test the hypothesis that respiratory rate (primary variable) is slower immediately after arrival to the ward and recovers in 2 h. METHODS Continuous recordings of the load cell signals were performed and stable respiratory waves within the 10 discriminative perioperative timepoints were used for respiratory rate measurements. Apnea frequencies were calculated at pre and postoperative nights and 2 h immediately after returning to the ward after surgery. RESULTS Continuous recordings of the load cell signals were successfully performed in 18 children (13 to 119 months). Respiratory waves were appraisable for more than 70% of nighttime period and 40% of immediate postoperative period. There were no statistically significant differences of respiratory rate in any timepoint comparisons (p = 0.448), thereby not supporting the study hypothesis. Respiratory rates changed more than 5 breaths per minute postoperatively in 5 out of 18 children (28%) while doses of fentanyl alone did not explain the changes. Apnea frequencies significantly decreased 2 h immediately after returning to the ward and during the operative night compared to the preoperative night. CONCLUSION Respiratory signal extracted from load cell sensors under the bed legs successfully revealed various postoperative respiratory pattern change in small children undergoing minor surgery. CLINICAL TRAIL REGISTRATION UMIN (University Hospital Information Network) Clinical Registry: UMIN000045579 ( https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000052039 ).
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Affiliation(s)
- Yuki Hateruma
- Department of Anesthesiology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana-Cho, Chuo-Ku, Chiba, 260-8670, Japan.
| | - Natsuko Nozaki-Taguchi
- Department of Anesthesiology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kyongsuk Son
- Department of Anesthesiology, Chiba University Hospital, Chiba, Japan
| | - Kentaroh Tarao
- Department of Anesthesiology, Chiba University Hospital, Chiba, Japan
| | | | - Yasunori Sato
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Shiroh Isono
- Department of Anesthesiology, Graduate School of Medicine, Chiba University, Chiba, Japan
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11
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Chen O, Cadwell JB, Matsoukas K, Hagen J, Afonso AM. Perioperative gabapentin usage in pediatric patients: A scoping review. Paediatr Anaesth 2023; 33:598-608. [PMID: 37073498 PMCID: PMC10464522 DOI: 10.1111/pan.14674] [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: 07/18/2022] [Revised: 03/08/2023] [Accepted: 04/01/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND There has been a recent focus among anesthesiologists on reducing the use of perioperative opioids in favor of multimodal analgesic regimens. Gabapentin has played an integral role in this evolution of practice. This comprehensive review assesses the current clinical evidence on the efficacy of perioperative gabapentin regarding postoperative pain and opioid requirements among the pediatric surgery population. DATA SOURCES Pubmed, CINAHL, Embase, Scopus, and Web of Science Review. METHODS This scoping review of the above databases includes all studies examining the use of gabapentin perioperatively in pediatric patients and its association with postoperative pain intensity and postoperative opioid consumption through July 2021. The inclusion criteria encompassed all studies evaluating gabapentin in the perioperative pediatric population through randomized controlled trials (RCTs) and retrospective studies. Relevant metadata from each study were abstracted and descriptive statistics were used to summarize the results. RESULTS Fifteen papers met the inclusion criteria for this review, including 11 RCTs and 4 retrospective studies. Sample sizes ranged from 20 to 144 patients. Administered doses varied widely, mainly between 5 and 20 mg/kg. The studies included primarily orthopedic (10) and neck surgery cases (3). Seven papers had gabapentin provided preoperatively only, two postoperative only, and six both pre- and postoperatively. Of the studies assessing postoperative pain, 6/11 studies saw a decrease in postoperative pain in at least one period for the gabapentin group. Of the studies considering opioid requirements, 6/10 reported a reduction, 1/10 an increase, and 3/10 no difference in opioid requirements for the gabapentin groups. Yet, most of these pain and opioid requirement findings were only significant at one to two time points in the study follow-up periods, and the actual decreases had minimal clinical significance. CONCLUSIONS The current data on perioperative gabapentin in pediatric patients are insufficient to support the routine use of gabapentin in pediatric patients. Additional high-quality RCTs with more standardized protocols for gabapentin administration and outcome measures are necessary to provide more definitive conclusions.
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Affiliation(s)
- Olivia Chen
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joshua B. Cadwell
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Konstantina Matsoukas
- Medical Library, Information Systems, Memorial Sloan Kettering Cancer Center, New York, NY
| | - John Hagen
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anoushka M. Afonso
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
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12
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Sood A, Kuo YF, Sharma G, Raji MA. Author's Reply "Considerations Regarding a Cohort Study on Concomitant Use of Central Nervous System-Active Medications in Patients With COPD". Ann Pharmacother 2023; 57:995-996. [PMID: 36373620 DOI: 10.1177/10600280221136243] [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] [Indexed: 07/20/2023] Open
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13
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Jin Z, Rismany J, Gidicsin C, Bergese SD. Frailty: the perioperative and anesthesia challenges of an emerging pandemic. J Anesth 2023; 37:624-640. [PMID: 37311899 PMCID: PMC10263381 DOI: 10.1007/s00540-023-03206-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 05/22/2023] [Indexed: 06/15/2023]
Abstract
Frailty is a complex and multisystem biological process characterized by reductions in physiological reserve. It is an increasingly common phenomena in the surgical population, and significantly impacts postoperative recovery. In this review, we will discuss the pathophysiology of frailty, as well as preoperative, intraoperative, and postoperative considerations for frailty care. We will also discuss the different models of postoperative care, including enhanced recovery pathways, as well as elective critical care admission. With discoveries of new effective interventions, and advances in healthcare information technology, optimized pathways could be developed to provide the best care possible that meets the challenges of perioperative frailty.
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Affiliation(s)
- Zhaosheng Jin
- Department of Anesthesiology, Stony Brook University Health Science Center, Level 4, Room 060, Stony Brook, NY, 11794-8480, USA
| | - Joshua Rismany
- Department of Anesthesiology, Stony Brook University Health Science Center, Level 4, Room 060, Stony Brook, NY, 11794-8480, USA
| | - Christopher Gidicsin
- Department of Anesthesiology, Stony Brook University Health Science Center, Level 4, Room 060, Stony Brook, NY, 11794-8480, USA
| | - Sergio D Bergese
- Department of Anesthesiology, Stony Brook University Health Science Center, Level 4, Room 060, Stony Brook, NY, 11794-8480, USA.
- Department of Neurosurgery, Stony Brook University Health Science Center, Stony Brook, NY, 11794-8480, USA.
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14
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Fair L, Duggan E, Dellinger EP, Bedros N, Godawa K, Krusinski C, Curran R, Hart C, Zhu A, Peters W, Fleshman J, Fichera A. Sixth Annual Enhanced Recovery After Surgery Symposium highlights: work in progress or standard care? Proc AMIA Symp 2023; 36:651-656. [PMID: 37614867 PMCID: PMC10443985 DOI: 10.1080/08998280.2023.2221112] [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: 05/18/2023] [Accepted: 05/25/2023] [Indexed: 08/25/2023] Open
Abstract
Enhanced Recovery After Surgery (ERAS) protocols have demonstrated effectiveness in accelerating patient recovery and improving outcomes. Since the systemwide implementation of ERAS protocols at Baylor Scott & White Health, an annual multidisciplinary conference has provided a review of outcomes and advancements in the ERAS program. This meeting, coined the ERAS symposium, allows providers who utilize recovery protocols to collaborate with national and international leaders in the field to improve the clinical care of patients. The sixth annual ERAS symposium was held on February 10, 2023, and provided key presentations that discussed the latest results from ERAS efforts across multiple surgical specialties along with updates in anesthesia, nursing, and nutrition. A summary of those presentations, which included perioperative glycemic control, misconceptions in pain management, and emerging ERAS protocols in different surgical specialties, is provided to document the system progress.
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Affiliation(s)
- Lucas Fair
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, USA
- Research Institute, Baylor Scott and White Health, Dallas, Texas, USA
| | - Elizabeth Duggan
- Department of Anesthesiology and Perioperative Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Evan P. Dellinger
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Nicole Bedros
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, USA
| | - Kimberly Godawa
- Baylor Scott & White Regional Medical Center, Plano, Texas, USA
| | - Cynthia Krusinski
- Baylor Scott & White Regional Medical Center – Grapevine and Baylor Scott & White All Saints Medical Center, Fort Worth, Texas, USA
| | - Rachel Curran
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, USA
| | - Charlette Hart
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, USA
| | - Alex Zhu
- NeuroTexas, Baylor Scott & White Health, Lakeway, Texas, USA
| | - Walter Peters
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, USA
| | - James Fleshman
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, USA
| | - Alessandro Fichera
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, USA
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15
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Rivas E, Cohen B, Saasouh W, Mao G, Yalcin EK, Rodriguez-Patarroyo F, Ruetzler K, Turan A. Hypoventilation in the PACU is associated with hypoventilation in the surgical ward: Post-hoc analysis of a randomized clinical trial. J Clin Anesth 2023; 84:110989. [PMID: 36370589 DOI: 10.1016/j.jclinane.2022.110989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 09/14/2022] [Accepted: 10/27/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the association between early postoperative hypoventilation in the last hour of the post-anesthesia care unit (PACU) stay and hypoventilation during the rest of the first 48 postoperative hours in the surgical ward. DESIGN Sub-analysis of a clinical trial. SETTING PACU and surgical wards of a single medical center. PATIENTS Adults having abdominal surgery under general anesthesia. INTERVENTIONS Monitoring with a respiratory volume monitor from admission to PACU until the earlier of 48 h after surgery or discharge. MEASUREMENTS The exposure was having at least one low minute-ventilation (MV) event during the last hour of PACU stay, defined as MV lower than 40% the predicted value lasting at least 1 min. The primary outcome was low MV events lasting at least 2 min during the rest of the first 48 postoperative hours, while in the surgical ward. The secondary outcome was the rate of low MV events per monitored hour. MAIN RESULTS Data of 292 patients were analyzed, of which 20 (6.8%) patients had a low MV event in PACU. Low MV events in the surgical ward were found in 81 (28%) patients. All patients who had low MV events in PACU had events again in the ward, while 61/272 (22%) had an event in the ward but not in PACU. The incidence rate of low MV events per hour was 24 (95% CI: 13, 46) among patients having an event in the PACU, and 2 (1, 4) among those who did not. CONCLUSIONS In adults recovering from abdominal surgery, events of hypoventilation during the first postoperative hour are associated with similar events during the rest of the first 48 postoperative hours, with positive predictive value approaching 100%. Sixty-one patients had ward hypoventilation that was not preceded by hypoventilation in PACU.
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16
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Valencia Morales DJ, Laporta ML, Johnson RL, Schroeder DR, Sprung J, Weingarten TN. A Case-Control Study of Accidental Falls During Surgical Hospitalizations. Am Surg 2023; 89:61-68. [PMID: 33870764 DOI: 10.1177/00031348211011114] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Postoperative falls are preventable complications. The study aims were to describe the rate and circumstances surrounding postoperative falls and explore potential associations with patient and procedural characteristics with emphasis on the use of sedative medications. METHODS Medical records of hospitalized patients undergoing non-lower extremity surgery under general anesthesia from January 1, 2010, through April 30, 2018 were reviewed for falls within 72 postoperative hours. Perioperative use of sedatives, sleep aids, gabapentinoids, and opioids were abstracted. Each fall case was matched with two controls on age, sex, and procedure type. Descriptive statistics and multivariable analysis accounting for the matched design were performed. RESULTS There were 343 falls among 200 186 hospitalized surgical patients (incidence of 17.1 [95% CI: 15.4, 19.0] falls per 10 000 procedures) with largest proportion of falls occurring on postoperative day 2 (n = 134, 39.1%). Most falls occurred in the general hospital wards (n = 304, 88.6%) and were unwitnessed (n = 186, 55.9%). The incidence of major injuries was 1.0 (95% CI: .1 - 3.6) per 100 000 procedures. Home use of non-benzodiazepine hypnotics (odds ratio 2.68, 95% CI: 1.47, 4.88, P=.001) and blood transfusions were associated with increased fall risk. Hospital stay was longer in patients who fall (7 [4, 15] vs. 5 [3, 9] days, P < .001). CONCLUSIONS The rate of postoperative falls in our institution was low and frequently unwitnessed. The use of non-benzodiazepine hypnotics is a modifiable risk factor associated with postoperative falls. Serious complications after falls were rare.
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Affiliation(s)
- Diana J Valencia Morales
- Departments of Anesthesiology and Perioperative Medicine, and Health Sciences Research, Rochester, MN, USA6915
| | - Mariana L Laporta
- Departments of Anesthesiology and Perioperative Medicine, and Health Sciences Research, Rochester, MN, USA6915
| | - Rebecca L Johnson
- Departments of Anesthesiology and Perioperative Medicine, and Health Sciences Research, Rochester, MN, USA6915
| | - Darrell R Schroeder
- Division of Biomedical Statistics and Informatics, 6915Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Juraj Sprung
- Departments of Anesthesiology and Perioperative Medicine, and Health Sciences Research, Rochester, MN, USA6915
| | - Toby N Weingarten
- Departments of Anesthesiology and Perioperative Medicine, and Health Sciences Research, Rochester, MN, USA6915
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17
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Review of Postoperative Respiratory Depression: From Recovery Room to General Care Unit. Anesthesiology 2022; 137:735-741. [DOI: 10.1097/aln.0000000000004391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Contemporary evidence suggests that episodes of respiratory depression during anesthesia recovery are associated with subsequent respiratory complications in general care units.
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18
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AUGS-IUGA Joint Clinical Consensus Statement on Enhanced Recovery After Urogynecologic Surgery: Developed by the Joint Writing Group of the International Urogynecological Association and the American Urogynecologic Society. Individual writing group members are noted in the Acknowledgements section. UROGYNECOLOGY (HAGERSTOWN, MD.) 2022; 28:716-734. [PMID: 36288110 DOI: 10.1097/spv.0000000000001252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Enhanced recovery after surgery (ERAS) evidence-based protocols for perioperative care can lead to improvements in clinical outcomes and cost savings. This article aims to present consensus recommendations for the optimal perioperative management of patients undergoing urogynecological surgery. METHODS A review of meta-analyses, randomized clinical trials, large nonrandomized studies, and review articles was conducted via PubMed and other databases for ERAS and urogynecological surgery. ERAS protocol components were established, and then quality of the evidence was both graded and used to form consensus recommendations for each topic. These recommendations were developed and endorsed by the writing group, which is comprised of the American Urogynecologic Society and the International Urogynecological Association members. RESULTS All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. The components of ERAS with a high level of evidence to support their use include fasting for 6 h and taking clear fluids up to 2 h preoperatively, euvolemia, normothermia, surgical site preparation, antibiotic and antithrombotic prophylaxis, strong antiemetics and dexamethasone to reduce postoperative nausea and vomiting, multimodal analgesia and restrictive use of opiates, use of chewing gum to reduce ileus, removal of catheter as soon as feasible after surgery and avoiding systematic use of drains/vaginal packs. CONCLUSIONS The evidence base and recommendations for a urogynecology-relevant ERAS perioperative care pathway are presented in this consensus review. There are several elements of ERAS with strong evidence of benefit in urogynecological surgery.
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Park CM, Inouye SK, Marcantonio ER, Metzger E, Bateman BT, Lie JJ, Lee SB, Levin R, Kim DH. Perioperative Gabapentin Use and In-Hospital Adverse Clinical Events Among Older Adults After Major Surgery. JAMA Intern Med 2022; 182:1117-1127. [PMID: 36121671 PMCID: PMC9486639 DOI: 10.1001/jamainternmed.2022.3680] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 07/03/2022] [Indexed: 12/14/2022]
Abstract
Importance Gabapentin has been increasingly used as part of a multimodal analgesia regimen to reduce opioid use in perioperative pain management. However, the safety of perioperative gabapentin use among older patients remains uncertain. Objective To examine in-hospital adverse clinical events associated with perioperative gabapentin use among older patients undergoing major surgery. Design, Setting, and Participants This retrospective cohort study using data from the Premier Healthcare Database included patients aged 65 years or older who underwent major surgery at US hospitals within 7 days of hospital admission from January 1, 2009, to March 31, 2018, and did not use gabapentin before surgery. Data were analyzed from June 14, 2021, to May 23, 2022. Exposures Gabapentin use within 2 days after surgery. Main Outcomes and Measures The primary outcome was delirium, identified using diagnosis codes, and secondary outcomes were new antipsychotic use, pneumonia, and in-hospital death between postoperative day 3 and hospital discharge. To reduce confounding, 1:1 propensity score matching was performed. Risk ratios (RRs) and risk differences (RDs) with 95% CIs were estimated. Results Among 967 547 patients before propensity score matching (mean [SD] age, 76.2 [7.4] years; 59.6% female), the rate of perioperative gabapentin use was 12.3% (119 087 patients). After propensity score matching, 237 872 (118 936 pairs) gabapentin users and nonusers (mean [SD] age, 74.5 [6.7] years; 62.7% female) were identified. Compared with nonusers, gabapentin users had increased risk of delirium (4040 [3.4%] vs 3148 [2.6%]; RR, 1.28 [95% CI, 1.23-1.34]; RD, 0.75 [95% CI, 0.75 [0.61-0.89] per 100 persons), new antipsychotic use (944 [0.8%] vs 805 [0.7%]; RR, 1.17 [95% CI, 1.07-1.29]; RD, 0.12 [95% CI, 0.05-0.19] per 100 persons), and pneumonia (1521 [1.3%] vs 1368 [1.2%]; RR, 1.11 [95% CI, 1.03-1.20]; RD, 0.13 [95% CI, 0.04-0.22] per 100 persons), but there was no difference in in-hospital death (362 [0.3%] vs 354 [0.2%]; RR, 1.02 [95% CI, 0.88-1.18]; RD, 0.00 [95% CI, -0.04 to 0.05] per 100 persons). Risk of delirium among gabapentin users was greater in subgroups with high comorbidity burden than in those with low comorbidity burden (combined comorbidity index <4 vs ≥4: RR, 1.20 [95% CI, 1.13-1.27] vs 1.40 [95% CI, 1.30-1.51]; RD, 0.41 [95% CI, 0.28-0.53] vs 2.66 [95% CI, 2.08-3.24] per 100 persons) and chronic kidney disease (absence vs presence: RR, 1.26 [95% CI, 1.19-1.33] vs 1.38 [95% CI, 1.27-1.49]; RD, 0.56 [95% CI, 0.42-0.69] vs 1.97 [95% CI, 1.49-2.46] per 100 persons). Conclusion and Relevance In this cohort study, perioperative gabapentin use was associated with increased risk of delirium, new antipsychotic use, and pneumonia among older patients after major surgery. These results suggest careful risk-benefit assessment before prescribing gabapentin for perioperative pain management.
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Affiliation(s)
- Chan Mi Park
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Sharon K. Inouye
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Edward R. Marcantonio
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Eran Metzger
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Brian T. Bateman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jessica J. Lie
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of General Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Su Been Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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20
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Grauer JS, Cramer JD. Association of State-Imposed Restrictions on Gabapentin with Changes in Prescribing in Medicare. J Gen Intern Med 2022; 37:3630-3637. [PMID: 35018568 PMCID: PMC9585149 DOI: 10.1007/s11606-021-07314-2] [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] [Received: 08/07/2021] [Accepted: 12/03/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Between August 2016 and July 2018, three states classified gabapentin as a Schedule V drug and nine states implemented prescription drug monitoring program (PDMP) regulation for gabapentin. It is highly unusual for states to take drug regulation into their own hands. The impact of these changes on gabapentin prescribing is unclear. OBJECTIVE To determine the effect of state-imposed regulation on gabapentin prescribing for Medicare Part D enrollees from 2013 to 2018. DESIGN Population-based difference-in-difference(DID) analysis study utilizing the Medicare Part D Prescriber Public Use File. PARTICIPANTS All eligible Medicare Part D prescribers excluding those outside of the fifty states and the District of Columbia were included in our analysis. Prescriber data and key sociodemographic variables were organized by state and year. States with a gabapentin schedule change or PDMP regulation enacted before 2019 were included in the intervention group. For the Schedule V DID analysis, a control group of the ten highest opioid-prescribing states was used. INTERVENTIONS States with gabapentin schedule changes or PDMP regulation before January 1, 2019, were included and compared to control states that did not implement these policies. MAIN MEASURES Total days' supply of gabapentin per enrollee per year was the primary outcome variable. KEY RESULTS The mean total days' supply of gabapentin per enrollee increased 41% from 19.71 to 27.81 total days' supply per enrollee per year between 2013 and 2018. After adjustment, Schedule V gabapentin regulation resulted in a reduction of 8.37 total days of gabapentin prescribed per enrollee (95% confidence interval of - 10.34 to - 6.39). In contrast, PDMP regulation resulted in a reduction of 1.01 total days of gabapentin prescribed per enrollee (95% confidence interval of - 1.74 to - 0.29). CONCLUSIONS Classifying gabapentin as a Schedule V drug results in substantial reduction in total days prescribed whereas PDMP regulation results in modest reduction.
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Affiliation(s)
- Jordan S Grauer
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University School of Medicine, 4201 St Antoine St, UHC 5E, Detroit, MI, 48201, USA
| | - John D Cramer
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University School of Medicine, 4201 St Antoine St, UHC 5E, Detroit, MI, 48201, USA.
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21
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Johnson S, Haywood C. Perioperative medication management for older people. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2022. [DOI: 10.1002/jppr.1834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Samuel Johnson
- Aged Care Services, Austin Health Heidelberg Repatriation Hospital Heidelberg Heights Australia
| | - Cilla Haywood
- Aged Care Services, Austin Health Heidelberg Repatriation Hospital Heidelberg Heights Australia
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22
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AUGS-IUGA Joint clinical consensus statement on enhanced recovery after urogynecologic surgery. Int Urogynecol J 2022; 33:2921-2940. [DOI: 10.1007/s00192-022-05223-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 02/19/2022] [Indexed: 10/14/2022]
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23
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Vecchione TM, Agarwal R, Monitto CL. Error traps in acute pain management in children. Paediatr Anaesth 2022; 32:982-992. [PMID: 35751474 DOI: 10.1111/pan.14514] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 06/14/2022] [Accepted: 06/19/2022] [Indexed: 11/28/2022]
Abstract
Providing effective acute pain management to hospitalized children can help improve outcomes, decrease length of stay, and increase patient and parental satisfaction. Error traps (circumstances that lead to erroneous actions or undesirable consequences) can result in inadequately controlled pain, unnecessary side effects, and adverse events. This article highlights five error traps encountered when managing acute pain in children. They include failure to appropriately assess pain, optimally utilize regional anesthesia, select suitable systemic analgesics, identify and treat medication-related side effects, and consider patient characteristics when choosing medication or dosing route. These issues are easily addressed when the clinician is cognizant of ways to anticipate, identify, and mitigate or avoid these errors.
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Affiliation(s)
- Tricia M Vecchione
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Rita Agarwal
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, Stanford University School of Medicine, Stanford, California, USA
| | - Constance L Monitto
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Shahi P, Vaishnav AS, Melissaridou D, Sivaganesan A, Sarmiento JM, Urakawa H, Araghi K, Shinn DJ, Song J, Dalal SS, Iyer S, Sheha ED, Dowdell JE, Qureshi SA. Factors Causing Delay in Discharge in Patients Eligible for Ambulatory Lumbar Fusion Surgery. Spine (Phila Pa 1976) 2022; 47:1137-1144. [PMID: 35797654 DOI: 10.1097/brs.0000000000004380] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 04/14/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of prospectively collected data. OBJECTIVE To analyze the postoperative factors that led delayed discharge in patients who would have been eligible for ambulatory lumbar fusion (ALF). SUMMARY OF BACKGROUND DATA Assessing postoperative inefficiencies is vital to increase the feasibility of ALF. MATERIALS AND METHODS Patients who underwent single-level minimally invasive transforaminal lumbar interbody fusion and would have met the eligibility criteria for ALF were included. Length of stay (LOS); time in postanesthesia recovery unit (PACU); alertness and neurological examination, and pain scores at three and six hours; type of analgesia; time to physical therapy (PT) visit; reasons for PT nonclearance; time to per-oral (PO) intake; time to voiding; time to readiness for discharge were assessed. Time taken to meet each discharge criterion was calculated. Multiple regression analyses were performed to study the effect of variables on postoperative parameters influencing discharge. RESULTS Of 71 patients, 4% were discharged on the same day and 69% on postoperative day 1. PT clearance was the last-met discharge criterion in 93%. Sixty-six percent did not get PT evaluation on the day of surgery. Seventy-six percent required intravenous opioids and <60% had adequate pain control. Twenty-six percent had orthostatic intolerance. The median postoperative LOS was 26.9 hours, time in PACU was 4.2 hours, time to PO intake was 6.5 hours, time to first void was 6.3 hours, time to first PT visit was 17.7 hours, time to PT clearance was 21.8 hours, and time to discharge readiness was 21.9 hours. Regression analysis showed that time to PT clearance, time to PO intake, time to voiding, time in PACU, and pain score at three hours had a significant effect on LOS. CONCLUSIONS Unavailability of PT, surgery after 1 pm , orthostatic intolerance, inadequate pain control, prolonged PACU stay, and long feeding and voiding times were identified as modifiable factors preventing same-day discharge. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Pratyush Shahi
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Avani S Vaishnav
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | | | - Ahilan Sivaganesan
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA
| | - Jose M Sarmiento
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Hikari Urakawa
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Kasra Araghi
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Daniel J Shinn
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Junho Song
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Sidhant S Dalal
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Sravisht Iyer
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Evan D Sheha
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - James E Dowdell
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Sheeraz A Qureshi
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
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Perioperative considerations for adult patients with obstructive sleep apnea. Curr Opin Anaesthesiol 2022; 35:392-400. [PMID: 35671031 DOI: 10.1097/aco.0000000000001125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Obstructive sleep apnea (OSA) is a common, but often undiagnosed, sleep breathing disorder affecting approximately a third of adult surgical patients. OSA patients have increased sensitivity to anesthetic agents, sedatives, and opioid analgesics. RECENT FINDINGS Newer technologies (e.g., bedside capnography) have demonstrated that OSA patients have repetitive apneic spells, beginning in the immediate postoperative period and peaking in frequency during the first postoperative night. Compared to patients without OSA, OSA patients have double the risk for postoperative pulmonary as well as other complications, and OSA has been linked to critical postoperative respiratory events leading to anoxic brain injury or death. Patients with OSA who have respiratory depression during anesthesia recovery have been found to be high-risk for subsequent pulmonary complications. Gabapentinoids have been linked to respiratory depression in these patients. SUMMARY Surgical patients should be screened for OSA and patients with OSA should continue using positive airway pressure devices postoperatively. Use of shorter acting and less sedating agents and opioid sparing anesthetic techniques should be encouraged. In particular, OSA patients exhibiting signs of respiratory depression in postanesthesia recovery unit should receive enhancer respiratory monitoring following discharge to wards.
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Hamilton C, Alfille P, Mountjoy J, Bao X. Regional anesthesia and acute perioperative pain management in thoracic surgery: a narrative review. J Thorac Dis 2022; 14:2276-2296. [PMID: 35813725 PMCID: PMC9264080 DOI: 10.21037/jtd-21-1740] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/24/2022] [Indexed: 12/11/2022]
Abstract
Background and Objective Thoracic surgery causes significant pain which can negatively affect pulmonary function and increase risk of postoperative complications. Effective analgesia is important to reduce splinting and atelectasis. Systemic opioids and thoracic epidural analgesia (TEA) have been used for decades and are effective at treating acute post-thoracotomy pain, although both have risks and adverse effects. The advancement of thoracoscopic surgery, a focus on multimodal and opioid-sparing analgesics, and the development of ultrasound-guided regional anesthesia techniques have greatly expanded the options for acute pain management after thoracic surgery. Despite the expansion of surgical techniques and analgesic approaches, there is no clear optimal approach to pain management. This review aims to summarize the body of literature regarding systemic and regional anesthetic techniques for thoracic surgery in both thoracotomy and minimally invasive approaches, with a goal of providing a foundation for providers to make individualized decisions for patients depending on surgical approach and patient factors, and to discuss avenues for future research. Methods We searched PubMed and Google Scholar databases from inception to May 2021 using the terms “thoracic surgery”, “thoracic surgery AND pain management”, “thoracic surgery AND analgesia”, “thoracic surgery AND regional anesthesia”, “thoracic surgery AND epidural”. We considered articles written in English and available to the reader. Key Content and Findings There is a wide variety of strategies for treating acute pain after thoracic surgery, including multimodal opioid and non-opioid systemic analgesics, regional anesthesia including TEA and paravertebral blocks (PVB), and a recent expansion in the use of novel fascial plane blocks especially for thoracoscopy. The body of literature on the effectiveness of different approaches for thoracotomy and thoracoscopy is a rapidly expanding field and area of active debate. Conclusions The optimal analgesic approach for thoracic surgery may depend on patient factors, surgical factors, and institutional factors. Although TEA may provide optimal analgesia after thoracotomy, PVB and emerging fascial plane blocks may offer effective alternatives. A tailored approach using multimodal systemic therapies and regional anesthesia is important, and future studies comparing techniques are necessary to further investigate the optimal approach to improve patient outcomes.
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Affiliation(s)
- Casey Hamilton
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Paul Alfille
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jeremi Mountjoy
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Xiaodong Bao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
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Non-opioid analgesics and post-operative pain following transoral robotic surgery for oropharyngeal cancer. The Journal of Laryngology & Otology 2022; 136:527-534. [DOI: 10.1017/s0022215121004734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjectiveTo investigate associations between multimodal analgesia and post-operative pain among patients undergoing transoral robotic surgery for oropharyngeal squamous cell carcinoma.MethodsRecords of patients who underwent surgery from 5 September 2012 to 30 November 2016 were abstracted. Associations were assessed using multivariable analysis.ResultsA total of 216 patients (mean age of 59.1 years, 89.4 per cent male) underwent transoral robotic surgery (92.6 per cent were human papilloma virus positive, 87.5 per cent had stage T1–T2 tumours, and 82.9 per cent had stage N0–N1 nodes). Gabapentin (n = 86) was not associated with a reduction in severe pain. Ibuprofen (n = 72) was administered less often in patients with severe pain. Gabapentin was not associated with increased post-operative sedation (p = 0.624) and ibuprofen was not associated with increased bleeding (p = 0.221). Post-operative opioid usage was not associated with surgical duration, pharyngotomy, bilateral neck dissections, tumour stage, tumour size, subsite or gabapentin.ConclusionScheduled low-dose gabapentin was not associated with improved pain control or increased respiratory depression. Ibuprofen was not associated with an increased risk of bleeding and may be under-utilised.
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Fernández-Liz E, Barceló-Colomer ME, Gómez-Ganda L, Varon-Galcera C, Lalueza-Broto P, Medel-Rebollo FJ, Hortelano-García MA, Martín-Gracia E. Prevalence of Gabapentinoids and Central Nervous System Depressant Drugs, and Their Association with Risk Factors for Respiratory Depression in Primary Care Patients. Clin Drug Investig 2022; 42:417-426. [PMID: 35446006 DOI: 10.1007/s40261-022-01144-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Warnings have been published regarding an increased risk of severe respiratory depression in patients receiving gabapentinoids either alone or in combination with opioids and/or anxiolytics/hypnotics, especially in individuals with a respiratory risk factor. The aim is to report the prevalence of the use of gabapentinoids alone and associated with central nervous system depressant drugs, and possible associated risk factors for respiratory depression, in order to identify the most fragile population and establish intervention strategies. METHODS We performed a cross-sectional study using computerized prescription records from the northern area of Barcelona at Catalan Institute of Health for 363,007 inhabitants registered during 2021. Patients aged ≥ 18 years with one or more gabapentinoid prescription were included. Age, gender, polypharmacy, adjusted morbidity groups, quantity of chronic diseases, and the number of consultations per year were independent variables. Four age categories were defined (18-64 years, then 64-74, 75-84, and those aged 85 years or older). Descriptive and inferential statistics were employed. Level of statistical significance was 5% (p ≤ 0.05). For the analysis, the SPSS program (version 22) was employed. RESULTS Of the study sample, 9218 were prescribed gabapentidoids. Overall prevalence of use was 3.0% (women 3.6%, men 2.4%). On the whole, women used more drugs than men. In contrast to their younger counterparts, consumption increased 2.6 times, 3.8 times, and 4.0 times in the 65-74 age group, 75-84 age group, and those aged ≥ 85 years, respectively. Mean age was 65.59 (±15.80) years. Polypharmacy (5-9 drugs) was present in 41.7% of the patients and extreme polypharmacy (≥ 10 drugs) was present in 39.3% of the patients. Regarding renal function, 2396 patients (25.9%) had glomerular filtration that required dose adjustment (76.1% with gabapentin and 23.8% with pregabalin). In 141 patients (5.9%), a total daily dose higher than that authorized (109 with gabapentin, 29 with pregabalin) had been prescribed. The prescription of gabapentinoids combined with opioids and/or anxiolytics/hypnotics was significantly associated with (i) polypharmacy (5-9 drugs, OR: 3.42 [95% CI 3.00-3.88]; ≥ 10 drugs, OR 8.72 [95% CI 7.42-10.25]); (ii) quantity of chronic diseases, OR: 1.14 (95% CI 1.11-1.17); (iii) augmented number of consultations/year, OR: 1.01 (95% CI 1.00-1.01); (iv) female gender, OR: < 1 for men, OR: 0.66 (95% CI 0.60-0.73); (v) being elderly: 65-74 years, OR: 0.71 (95% CI 0.62-0.81); 75-84 years, OR: 0.62 (95% CI 0.54-0.71); ≥85 years, OR: 0.68 (95% CI 0.58-0.81); and (vi) adjusted morbidity groups, OR: 0.90 (95% CI 0.88-0.92), (p < 0.0001). CONCLUSION Exposure to gabapentinoids occurs in a non-negligible percentage of the population. Greater numbers of combinations of gabapentinoids and opioids and/or anxiolytics/hypnotics were associated with polypharmacy, quantity of chronic diseases, and augmented number of consultations, but not with male gender, older age, and adjusted morbidity groups.
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Affiliation(s)
- Eladio Fernández-Liz
- Primary Health Care Barcelona, Gerència Territorial de Barcelona, Catalan Institute of Health, CAP Poble Nou. Carrer Lope de Vega 138, 6a planta, 08005, Barcelona, Spain.
| | - Maria Estrella Barceló-Colomer
- Primary Health Care Barcelona, Gerència Territorial de Barcelona, Catalan Institute of Health, CAP Poble Nou. Carrer Lope de Vega 138, 6a planta, 08005, Barcelona, Spain
| | - Laura Gómez-Ganda
- Pharmacy Department, Vall d'Hebron Hospital Universari, Vall d'Hebron Barcelona Hospital Campus, Passeig de la Vall d'Hebron, 119, 08035, Barcelona, Spain
| | - Carlota Varon-Galcera
- Pharmacy Department, Vall d'Hebron Hospital Universari, Vall d'Hebron Barcelona Hospital Campus, Passeig de la Vall d'Hebron, 119, 08035, Barcelona, Spain
| | - Pilar Lalueza-Broto
- Pharmacy Department, Vall d'Hebron Hospital Universari, Vall d'Hebron Barcelona Hospital Campus, Passeig de la Vall d'Hebron, 119, 08035, Barcelona, Spain
| | - Francisco Javier Medel-Rebollo
- Pain Unit, Anaesthesia, Resuscitation and Pain Management Department, Vall d'Hebron Hospital Universari, Vall d'Hebron Barcelona Hospital Campus, Passeig de la Vall d'Hebron, 119, 08035, Barcelona, Spain
| | - Maria Angeles Hortelano-García
- Primary Health Care Center Chafarinas, Gerencia Territorial de Barcelona, Catalan Institute of Health, Carrer Chafarinas, 2-8, 08033, Barcelona, Spain
| | - Elisabeth Martín-Gracia
- Primary Health Care Service Muntanya, Gerència Territorial de Barcelona, Catalan Institute of Health, Avenida Meridiana, 428, 08030, Barcelona, Spain
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Affiliation(s)
- Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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30
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Seet E, Saw CJ, Kumar CM. Obstructive sleep apnea and perioperative management of the difficult airway. Int Anesthesiol Clin 2022; 60:35-42. [PMID: 35261344 DOI: 10.1097/aia.0000000000000358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Edwin Seet
- Department of Anaesthesia, Khoo Teck Puat Hospital, Singapore
- Department of Anaesthesia, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Harbell MW, Barendrick LN, Mi L, Quillen J, Millstine DM. Patient Attitudes Toward Acupuncture in the Perioperative Setting. JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE 2022; 28:349-354. [PMID: 35426737 DOI: 10.1089/jicm.2021.0311] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Introduction: Acupuncture is a potential treatment option for pain, nausea, vomiting, anxiety, and agitation in the perioperative period. Patient preference for participating in acupuncture in the perioperative period is not well understood. The aim of this study was to quantify patient interest in perioperative acupuncture, explore the relationship between acupuncture interest, insurance coverage and patient cost, and identify clinical factors associated with patient interest in acupuncture. Materials and Methods: Adult patients evaluated in the Preoperative Evaluation Clinic at the Mayo Clinic in Phoenix, AZ, between June 2019 and July 2019, received a voluntary survey to assess their attitudes toward receiving acupuncture in the perioperative period. Patient interest in acupuncture to help treat pain, anxiety, and postoperative nausea and vomiting, as well as their willingness to pay for such services, were assessed. Demographic data, American Society of Anesthesiologists (ASA) physical class, scheduled procedure, and insurance coverage were extracted from the medical record. Univariate analysis was performed to estimate interest in acupuncture. Results: Three hundred and seven respondents were included in this study with a response rate of 60.4%. A total of 68.4% of study participants were interested in receiving perioperative acupuncture. Of those interested in acupuncture, 86.7% were interested if acupuncture was offered at no cost (either free or fully covered by insurance). A total of 47.1% of those patients interested in acupuncture would be interested if the cost of acupuncture was between 20 and 50 U.S. dollars. A total of 8.6% would be interested in acupuncture if patients were expected to pay the full cost of treatment (estimated 175 U.S. dollars). Age, sex, ASA status, type of surgery, risk of procedure, and Medicare/Medicaid coverage were not statistically associated with interest in acupuncture. Conclusions: When there is little to no direct cost to the patient, the majority of patients are interested in acupuncture in the perioperative period.
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Affiliation(s)
- Monica W Harbell
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Lindsay N Barendrick
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Lanyu Mi
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, AZ, USA
| | - Jaxon Quillen
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, AZ, USA
| | - Denise M Millstine
- Divisions of Women's Health Internal Medicine and Mayo Clinic, Scottsdale, AZ, USA
- Divisions of Medicine, Mayo Clinic, Scottsdale, AZ, USA
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Wilson SH, Wilson PR, Bridges KH, Bell LH, Clark CA. Nonopioid Analgesics for the Perioperative Geriatric Patient: A Narrative Review. Anesth Analg 2022; 135:290-306. [PMID: 35202007 DOI: 10.1213/ane.0000000000005944] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Management of acute perioperative pain in the geriatric patient can be challenging as the physiologic and pharmacokinetic changes associated with aging may predispose older patients to opioid-related side effects. Furthermore, elderly adults are more susceptible to postoperative delirium and postoperative cognitive dysfunction, which may be exacerbated by both poorly controlled postoperative pain and commonly used pain medications. This narrative review summarizes the literature published in the past 10 years for several nonopioid analgesics commonly prescribed to the geriatric patient in the perioperative period. Nonopioid analgesics are broken down as follows: medications prescribed throughout the perioperative period (acetaminophen and nonsteroidal anti-inflammatory drugs), medications limited to the acute perioperative setting (N-methyl-D-aspartate receptor antagonists, dexmedetomidine, dexamethasone, and local anesthetics), and medications to be used with caution in the geriatric patient population (gabapentinoids and muscle relaxants). Our search identified 1757 citations, but only 33 specifically focused on geriatric analgesia. Of these, only 21 were randomized clinical trials' and 1 was a systematic review. While guidance in tailoring pain regimens that focus on the use of nonopioid medications in the geriatric patient is lacking, we summarize the current literature and highlight that some nonopioid medications may extend benefits to the geriatric patient beyond analgesia.
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Affiliation(s)
- Sylvia H Wilson
- From the Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina
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Impact of timing of preoperative gabapentin administration on postoperative somnolence. J Osteopath Med 2022; 122:303-311. [DOI: 10.1515/jom-2021-0256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/25/2022] [Indexed: 11/15/2022]
Abstract
Abstract
Context
Enhanced Recovery After Surgery (ERAS) is a multimodal protocol aimed to improve quality of postoperative recovery, minimize complications, and optimize overall self-regulation. Preoperative gabapentin decreases postoperative pain but can be associated with prolonged postoperative somnolence and respiratory depression risk. Although it is known that gabapentin affects the postoperative course, it is unclear if the timing of preoperative administration affects this finding.
Objectives
This study aims to assess the optimal preoperative timing for gabapentin administration in patients undergoing gynecologic surgery to minimize postoperative somnolence risk.
Methods
A retrospective cohort study evaluated patients who underwent major gynecologic surgery and received preoperative gabapentin. Patients were grouped based on timing from gabapentin administration to surgical incision (<4 h group vs. ≥4 h group). Preoperative, intraoperative, and postoperative data were abstracted and compared. Univariate associations between the timing of gabapentin administration and the patient and surgical characteristics and outcomes were tested utilizing two-sample equal-variance t-tests, linear model ANOVA, or Fisher’s exact tests. Associations between the timing of gabapentin administration and the time until the Richmond Agitation Sedation Scale (RASS) score of 0 were modeled utilizing linear regression, adjusted for age, initial postoperative anesthesia care unit (PACU), RASS score, and postoperative narcotics.
Results
Each group contained 127 patients. Demographics were similar except for age (<4 h group mean=44.2 years; ≥4 h group mean=40.5 years; p=0.021), chronic pain (<4 h group=17.6%; ≥4 h group=43.3%; p<0.001), and surgical indication (<4 h group=pelvic pain [29.1%]; ≥4 h group=pelvic pain [51.2%]; p=0.007). The <4 h group had a similar postoperative narcotic administration (<4 h group mean morphine milligram equivalents [MME]=3.667; ≥4 h group mean MME=4.833; p=0.185). The minutes from surgical closure until the patient received a RASS score of 0 and initial PACU pain score (Visual Analogue Scale [VAS]) were similar. The initial PACU oxygen administration volume, hours from surgical closure until the patient transitioned to room air, and initial PACU respiratory rate were similar. The PACU duration, admission secondary to somnolence, and initial PACU Glasgow Coma Scale (GCS) score showed no difference. Postoperative nausea/vomiting was decreased in the ≥4 h group (<4 h group=24.4%; ≥4 h group=13.4%; p-value=0.036), and urinary retention (<4 h group=14.2%; ≥4 h group=5.5%; p-value=0.033) was decreased in the ≥4 h group.
Conclusions
The timing of gabapentin administration less than or more than 4 h preoperatively in patients ≥18 years does not significantly affect postoperative somnolence or respiratory depression. Further, it does not have a significant effect on GCS scores or VAS scores.
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Ayad SS, Makarova N, Niazi AK, Khoshknabi DS, Stang T, Raza S, Kim DD. Effects of Gabapentin Enacarbil on Postoperative Pain After Hip and Knee Arthroplasty: A Placebo-controlled Randomized Trial. Clin J Pain 2022; 38:250-256. [PMID: 35132024 DOI: 10.1097/ajp.0000000000001024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 12/24/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Total joint arthroplasties are among the most common elective procedures performed in the United States, and they are associated with postoperative pain. Gabapentin enacarbil is a prodrug with an extended-release formulation that has been proposed for multimodal postoperative analgesia, but the drug's efficacy for major arthroplasties remains unclear. MATERIALS AND METHODS We enrolled 60 adult patients scheduled for primary knee or hip arthroplasty expected to remain hospitalized for at least 3 days. Eligible patients were randomly assigned to placebo or gabapentin enacarbil 600 mg twice daily starting the day before surgery continuing for 3 days thereafter.The primary outcome was analyzed using a joint hypothesis framework of pain (0 to 10 verbal response scores) and cumulative opioid consumption (mg of morphine equivalent) within the first 72 hours. Secondary outcomes were nausea and vomiting, pain persisting 90 days after surgery, duration of hospitalization, and early postoperative health status using quality of recovery score (QoR-15). RESULTS Twenty-eight patient in gabapentin enacarbil group and 32 in placebo group were analyzed. Since pain scores did not differ significantly (difference of means: -0.2 in pain scores; 95% confidence interval: -1.1, 0.7), nor did opioid consumption, conditions for joint hypothesis testing were not met. Moreover, there were no significant differences between groups for secondary outcomes. DISCUSSION We did not identify statistically significant or clinically meaningful differences in our primary and secondary outcomes related to perioperative use of gabapentin enacarbil in patients having primary hip or knee arthroplasties.
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Affiliation(s)
- Sabry S Ayad
- Anesthesia Institute, Fairview Hospital
- Departments of Outcomes Research
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Gabapentinoid Use in Perioperative Care and Current Controversies. Curr Pain Headache Rep 2022; 26:139-144. [PMID: 35084656 DOI: 10.1007/s11916-022-01012-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW This review summarizes the risks and benefits of gabapentinoids (gabapentin and pregabalin) for perioperative pain control and the controversies surrounding their use in a variety of settings. We review current literature with the goal of providing patient-centric and procedure-specific recommendations for the use of these medications. RECENT FINDINGS Gabapentinoids are among the most prescribed medications in the USA, and typically for off-label indications such as postoperative pain. In the perioperative setting, multimodal analgesic or "opioid-sparing" regimens have become the standard of care-and some clinical protocols include gabapentinoids. At the same time, guidelines regarding the perioperative use of gabapentinoids are conflicting and evidence supporting their broad use is lacking. Gabapentinoids administered perioperatively reduce opioid requirements and pain scores for a variety of surgeries. The extent of opioid and pain reduction, however, is not always clinically significant. These medications reduce postoperative nausea and vomiting as well as pruritis, likely as a feature of reducing opioid intake, but are associated with side effects such as dizziness, ataxia, and cognitive dysfunction. Gabapentinoids also increase the risk of respiratory depression, in particular when paired with opioids. There is thus evidence suggesting that the routine use of these medications for perioperative pain management is not recommended. An individualized, patient- and surgery-specific approach should be used, although research is still needed to determine risks and benefits during perioperative use.
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Cheung CK, Adeola JO, Beutler SS, Urman RD. Postoperative Pain Management in Enhanced Recovery Pathways. J Pain Res 2022; 15:123-135. [PMID: 35058714 PMCID: PMC8765537 DOI: 10.2147/jpr.s231774] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/30/2021] [Indexed: 12/05/2022] Open
Abstract
Postoperative pain is a common but often inadequately treated condition. Enhanced recovery pathways (ERPs) are increasingly being utilized to standardize perioperative care and improve outcomes. ERPs employ multimodal postoperative pain management strategies that minimize opioid use and promote recovery. While traditional opioid medications continue to play an important role in the treatment of postoperative pain, ERPs also rely on a wide range of non-opioid pharmacologic therapies as well as regional anesthesia techniques to manage pain in the postoperative setting. The evidence for the use of these interventions continues to evolve rapidly given the increasing focus on enhanced postoperative recovery. This article reviews the current evidence and knowledge gaps pertaining to commonly utilized modalities for postoperative pain management in ERPs.
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Affiliation(s)
- Christopher K Cheung
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Janet O Adeola
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Sascha S Beutler
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Correspondence: Richard D Urman Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, CWN L1, Boston, MA, 02115, USATel +1 617 732 8210Fax +1 617 264 6841 Email
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Zero Patient-controlled Analgesia is an Achievable Target for Postoperative Rapid Recovery Management of Adolescent Idiopathic Scoliosis Patients. Spine (Phila Pa 1976) 2021; 46:1448-1454. [PMID: 34618705 DOI: 10.1097/brs.0000000000004062] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE The objective of this study was to report on one institution's use of single bolus micro-dose intrathecal morphine as part of a rapid recovery pathway during posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and its comparison to patients whose pain was controlled with patient-controlled analgesia (PCA). SUMMARY OF BACKGROUND DATA Narcotic substance addiction has risen across all patient populations, including pediatrics. Narcotics have been historically used in complex spine surgeries as a measure of pain control, predominantly provided as PCA and additional take-home medication. METHODS AIS patients undergoing PSF from 2015 to 2019 were reviewed. In 2018, we instituted a standardized rapid recovery pathway for scoliosis patients undergoing PSF utilizing micro-dose intrathecal morphine (ITM-RRP). Before this, traditional protocol with PCA was used for postoperative management. Perioperative data, morphine consumption and prescription refill requests were compared. RESULTS There were 373 AIS patients total in this study, of which 250 patients were in the PCA group and 123 in the ITM-RRP Group. Preoperative Cobb angles (P = 0.195), as well as levels fused (P = 0.481) and body mass index (P = 0.075) were similar. 69.4% of ITM-RRP patients had a length of stay ≤3 days, significantly >11.6% of PCA patients (P < 0.001). ITM-RRP patients began ambulating significantly earlier with 84.6% patients out of bed by postoperative day 1 versus 8% PCA patients (P < 0.001). Additionally, ITM-RRP patients had significantly lower VAS pain scores with activity and earlier initial bowel movements (P < 0.001).Postoperative emesis was similar (P = 0.11). No patients had pruritus, respiratory depression, or required supplemental oxygenation. CONCLUSION This is the first study to show that a rapid recovery protocol utilizing single micro-dose ITM with oral analgesics have adequate recovery, significantly better postoperative pain control and superior perioperative outcomes to traditional protocols using PCA in the AIS population following PSF.Level of Evidence: 3.
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Verret M, Turgeon AF. Gabapentinoids: When Is the Right Moment to Stop? Anesth Analg 2021; 133:1116-1118. [PMID: 34673723 DOI: 10.1213/ane.0000000000005727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Michael Verret
- From the CHU de Québec-Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Québec City, Québec, Canada.,Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
| | - Alexis F Turgeon
- From the CHU de Québec-Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Québec City, Québec, Canada.,Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
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Gewandter JS, Smith SM, Dworkin RH, Turk DC, Gan TJ, Gilron I, Hertz S, Katz NP, Markman JD, Raja SN, Rowbotham MC, Stacey BR, Strain EC, Ward DS, Farrar JT, Kroenke K, Rathmell JP, Rauck R, Brown C, Cowan P, Edwards RR, Eisenach JC, Ferguson M, Freeman R, Gray R, Giblin K, Grol-Prokopczyk H, Haythornthwaite J, Jamison RN, Martel M, McNicol E, Oshinsky M, Sandbrink F, Scholz J, Scranton R, Simon LS, Steiner D, Verburg K, Wasan AD, Wentworth K. Research approaches for evaluating opioid sparing in clinical trials of acute and chronic pain treatments: Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials recommendations. Pain 2021; 162:2669-2681. [PMID: 33863862 PMCID: PMC8497633 DOI: 10.1097/j.pain.0000000000002283] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/23/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Randomized clinical trials have demonstrated the efficacy of opioid analgesics for the treatment of acute and chronic pain conditions, and for some patients, these medications may be the only effective treatment available. Unfortunately, opioid analgesics are also associated with major risks (eg, opioid use disorder) and adverse outcomes (eg, respiratory depression and falls). The risks and adverse outcomes associated with opioid analgesics have prompted efforts to reduce their use in the treatment of both acute and chronic pain. This article presents Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) consensus recommendations for the design of opioid-sparing clinical trials. The recommendations presented in this article are based on the following definition of an opioid-sparing intervention: any intervention that (1) prevents the initiation of treatment with opioid analgesics, (2) decreases the duration of such treatment, (3) reduces the total dosages of opioids that are prescribed for or used by patients, or (4) reduces opioid-related adverse outcomes (without increasing opioid dosages), all without causing an unacceptable increase in pain. These recommendations are based on the results of a background review, presentations and discussions at an IMMPACT consensus meeting, and iterative drafts of this article modified to accommodate input from the co-authors. We discuss opioid sparing definitions, study objectives, outcome measures, the assessment of opioid-related adverse events, incorporation of adequate pain control in trial design, interpretation of research findings, and future research priorities to inform opioid-sparing trial methods. The considerations and recommendations presented in this article are meant to help guide the design, conduct, analysis, and interpretation of future trials.
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Affiliation(s)
| | | | | | | | - Tong Joo Gan
- Stony Brook School of Medicine, Stony Brook, NY, USA
| | - Ian Gilron
- Queens University, Kingston, Ontario, Canada
| | - Sharon Hertz
- (Formally) U.S. Food and Drug Administration, Silver Spring, MD, USA
| | | | | | | | | | | | | | - Denham S. Ward
- University of Rochester Medical Center, Rochester, NY, USA
| | | | - Kurt Kroenke
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - James P. Rathmell
- Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, USA
| | | | | | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, USA
| | - Robert R. Edwards
- Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, USA
| | | | | | - Roy Freeman
- Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, USA
| | - Roy Gray
- GW Pharmaceuticals, Carlsbad, CA, USA
| | | | | | | | - Robert N. Jamison
- Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, USA
| | | | | | | | - Friedhelm Sandbrink
- U.S. Department of Veterans Affairs / George Washington University, Washington, DC, USA
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Pogatzki-Zahn EM, Freys SM. [Procedure Specific Pain Therapy - the PROSPECT Idea]. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56:586-598. [PMID: 34507382 DOI: 10.1055/a-1188-0945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Acute pain therapy following operative or interventional procedures has become a compulsory component of a modern perioperative patient management. A structured pain regimen has several clear advantages: it leads to an improvement of the patients' quality of life in the short term, it reduces perioperative morbidity in the medium term, it reduces pain chronification in the long term, at the same time improving the economic efficiency due to an accelerated mobilization, a reduction of the hospitalization and an avoidance of complication inherent costs.This article provides detailed information on the change of paradigm, away from a generalized and rather unspecific acute pain therapy towards a problem oriented procedure specific regimen. It points out two examples of the PROSPECT (PROcedure SPECific pain managemenT) methodology and explains its background.
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Waelkens P, Alsabbagh E, Sauter A, Joshi GP, Beloeil H. Pain management after complex spine surgery: A systematic review and procedure-specific postoperative pain management recommendations. Eur J Anaesthesiol 2021; 38:985-994. [PMID: 34397527 PMCID: PMC8373453 DOI: 10.1097/eja.0000000000001448] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Complex spinal procedures are associated with intense pain in the postoperative period. Adequate peri-operative pain management has been shown to correlate with improved outcomes including early ambulation and early discharge. OBJECTIVES We aimed to evaluate the available literature and develop recommendations for optimal pain management after complex spine surgery. DESIGN AND DATA SOURCES A systematic review using the PROcedure SPECific postoperative pain managemenT methodology was undertaken. Randomised controlled trials and systematic reviews published in the English language from January 2008 to April 2020 assessing postoperative pain after complex spine surgery using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, EMBASE and Cochrane Databases. RESULTS Out of 111 eligible studies identified, 31 randomised controlled trials and four systematic reviews met the inclusion criteria. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, cyclo-oxygenase (COX)-2 specific-inhibitors or non-steroidal anti-inflammatory drugs (NSAIDs), intravenous ketamine infusion and regional analgesia techniques including epidural analgesia using local anaesthetics with or without opioids. Limited evidence was found for local wound infiltration, intrathecal and epidural opioids, erector spinae plane block, thoracolumbar interfascial plane block, intravenous lidocaine, dexmedetomidine and gabapentin. CONCLUSIONS The analgesic regimen for complex spine surgery should include pre-operative or intra-operative paracetamol and COX-2 specific inhibitors or NSAIDs, continued postoperatively with opioids used as rescue analgesics. Other recommendations are intra-operative ketamine and epidural analgesia using local anaesthetics with or without opioids. Although there is procedure-specific evidence in favour of intra-operative methadone, it is not recommended as it was compared with shorter-acting opioids and due to its limited safety profile. Furthermore, the methadone studies did not use non-opioid analgesics, which should be the primary analgesics to ultimately reduce overall opioid requirements, including methadone. Further qualitative randomised controlled trials are required to confirm the efficacy and safety of these recommended analgesics on postoperative pain relief.
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Affiliation(s)
- Piet Waelkens
- From the Department of Anaesthesiology, KU Leuven and University Hospital Leuven, Leuven, Belgium (PW), CHU Rennes, Anesthesia and Intensive Care Department, Rennes, France (EA), the Department of Anaesthesiology and Pain Management, University of Oslo, Oslo, Norway (AS), the Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (AS), the Department of Anaesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA (GPJ), the University Rennes, CHU Rennes, Inserm, INRA, CIC 1414 NuMeCan, Anesthesia and Intensive Care Department, Rennes, France (HB)
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Macintyre PE. The opioid epidemic from the acute care hospital front line. Anaesth Intensive Care 2021; 50:29-43. [PMID: 34348484 DOI: 10.1177/0310057x211018211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Prescription opioid use has risen steeply for over two decades, driven primarily by advocacy for better management of chronic non-cancer pain, but also by poor opioid stewardship in the management of acute pain. Inappropriate prescribing, among other things, contributed to the opioid 'epidemic' and striking increases in patient harm. It has also seen a greater proportion of opioid-tolerant patients presenting to acute care hospitals. Effective and safe management of acute pain in opioid-tolerant patients can be challenging, with higher risks of opioid-induced ventilatory impairment and persistent post-discharge opioid use compared with opioid-naive patients. There are also increased risks of some less well known adverse postoperative outcomes including infection, earlier revision rates after major joint arthroplasty and spinal fusion, longer hospital stays, higher re-admission rates and increased healthcare costs. Increasingly, opioid-free/opioid-sparing techniques have been advocated as ways to reduce patient harm. However, good evidence for these remains lacking and opioids will continue to play an important role in the management of acute pain in many patients.Better opioid stewardship with consideration of preoperative opioid weaning in some patients, assessment of patient function rather than relying on pain scores alone to assess adequacy of analgesia, prescription of immediate release opioids only and evidence-based use of analgesic adjuvants are important. Post-discharge opioid prescribing should be contingent on an assessment of patient risk, with short-term only use of opioids. In partnership with pharmacists, nursing staff, other medical specialists, general practitioners and patients, anaesthetists remain ideally positioned to be involved in opioid stewardship in the acute care setting.
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Affiliation(s)
- Pamela E Macintyre
- Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
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Lee JT, Levine CG, Overdevest JB, Higgins TS, Manes RP, Myhill JA, Soler ZM. American Rhinologic Society expert practice statement: Postoperative pain management and opioid use after sinonasal surgery. Int Forum Allergy Rhinol 2021; 11:1296-1307. [PMID: 34251080 DOI: 10.1002/alr.22847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 05/20/2021] [Indexed: 02/06/2023]
Abstract
The goal of this American Rhinologic Society expert practice statement (EPS) is to provide clinically applicable, evidence-based recommendations regarding pain management in sinonasal surgery. This EPS was developed following the recommended methodology and approval process as previously outlined. The topics of interest included preoperative counseling, local anesthesia, use of opioids for postoperative pain, use of nonopioid medication for postoperative pain, nonsteroidal anti-inflammatory drugs and bleeding, and use of gabapentin for pain control. Following a modified Delphi approach, 6 statements were developed, 5 of which reached consensus and 1 that did not. These statements and accompanying evidence are summarized along with an assessment of future needs.
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Affiliation(s)
- Jivianne T Lee
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA
| | - Corinna G Levine
- Department of Otolaryngology-Head and Neck Surgery, University of Miami School of Medicine, Miami, FL
| | - Jonathan B Overdevest
- Department of Otolaryngology-Head and Neck Surgery, Columbia University School of Medicine, New York, NY
| | - Thomas S Higgins
- Division of Otolaryngology-Head and Neck Surgery, University of Louisville School of Medicine, Louisville, KY
| | - R Peter Manes
- Department of Otolaryngology-Head and Neck Surgery, Yale School of Medicine, New Haven, CT
| | - Jeffrey A Myhill
- Otolaryngology and Allergy, North East Arkansas Baptist Clinic, Jonesboro, AR
| | - Zachary M Soler
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
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Multimodal Pain Control in Surgery 2020. Adv Surg 2021; 55:147-157. [PMID: 34389089 DOI: 10.1016/j.yasu.2021.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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L Laporta M, O Kinney M, R Schroeder D, Sprung J, Weingarten TN. Postoperative respiratory depression after hysterectomy. Bosn J Basic Med Sci 2021; 21:346-351. [PMID: 32937097 PMCID: PMC8112565 DOI: 10.17305/bjbms.2020.5026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/15/2020] [Indexed: 11/16/2022] Open
Abstract
To investigate if sex-specific physiologic characteristics could impact postoperative respiratory depression risks in women, we studied incidence and risk factors associated with postoperative respiratory depression in a gynecologic surgical cohort. Only hysterectomies performed under general anesthesia from 2012 to 2017 were included to minimize interprocedural variability. Respiratory depression was defined as episodes of apnea, hypopnea, hypoxemia, pain-sedation mismatch, unplanned positive airway pressure device application, or naloxone administration in the post-anesthesia care unit. Multivariable logistic regression was used to explore the association with clinical characteristics. From 1,974 hysterectomies, 253 had postoperative respiratory depression, yielding an incidence of 128 (95% confidence interval, 114-144) per 1,000 surgeries. Risk factors associated with respiratory depression were older age (odds ratio 1.22 [95% confidence interval 1.02-1.46] per decade increase, p = 0.03), lower body weight (0.77 [0.62-0.94] per 10 kg/m2, p = 0.01), and higher intraoperative opioid dose (1.05 [1.01-1.09] per 10 mg oral morphine equivalents, p = 0.01); while sugammadex use was associated with a reduced risk (0.48 [0.30-0.75], p = 0.002). Respiratory depression was not associated with increased hospital stay, postoperative complications, or mortality. Postoperative respiratory depression risk in women increased with age, lower weight, and higher intraoperative opioids and decreased with sugammadex use; however, it was not associated with postoperative pulmonary complications.
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Affiliation(s)
- Mariana L Laporta
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Michelle O Kinney
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Darrell R Schroeder
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Brzezinski M, Hammer GB, Candiotti KA, Bergese SD, Pan PH, Bourne MH, Michalsky C, Wase L, Demitrack MA, Habib AS. Low Incidence of Opioid-Induced Respiratory Depression Observed with Oliceridine Regardless of Age or Body Mass Index: Exploratory Analysis from a Phase 3 Open-Label Trial in Postsurgical Pain. Pain Ther 2021; 10:457-473. [PMID: 33502739 PMCID: PMC8119589 DOI: 10.1007/s40122-020-00232-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 12/22/2020] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Advanced age and obesity are reported to increase the risk of opioid-induced respiratory depression (OIRD). Oliceridine, an intravenous opioid, is a G-protein-biased agonist at the µ-opioid receptor that may provide improved safety. The recent phase 3 ATHENA open-label, multicenter study evaluated postoperative use of oliceridine in patients with moderate-to-severe acute pain. This exploratory analysis of the ATHENA data examined the incidence of OIRD in older (≥ 65 years) and/or obese (BMI ≥ 30 kg/m2) patients and analyzed risk factors of OIRD. METHODS Patients aged ≥ 18 years with a score ≥ 4 on an 11-point numeric pain rating scale (NPRS) received IV oliceridine as needed via bolus dosing and/or patient-controlled analgesia (PCA). OIRD occurring within 48 h of last dose of oliceridine was defined using two established definitions: (1) naloxone use, (2) respiratory rate < 10 breaths per minute and/or oxygen saturation < 90%. RESULTS A total of 724 surgical patients with a mean age of 54.5 ± 15.9 years and a mean NRS score of 6.2 ± 2.1 were included in this analysis; 33.3% (241/724) were ≥ 65 years of age and 46.3% (335/724) had BMI (body mass index) ≥ 30 kg/m2. The overall OIRD incidence was 13.7% with no patients requiring naloxone. The OIRD incidence was similar in the elderly and younger adults' cohorts [10.8 vs. 15.1%, OR 0.68 (0.42, 1.1), p = 0.11], and in obese and non-obese groups [14.0 vs. 13.4%, OR 1.06 (0.69, 1.62), p = 0.80]. In patients that were both elderly and obese (n = 120), the incidence was 10.8%. The multivariate analysis identified baseline NRS ≥ 6 [OR 1.6 (1.0, 2.4), p = 0.0499], PCA administration [OR 1.9 (1.2, 3.1), p = 0.005], and concomitant use of benzodiazepines and/or gabapentinoids [OR 1.6 (1.0, 2.6), p = 0.045], as being associated with OIRD. CONCLUSIONS Postoperative oliceridine use in patients with advanced age and/or increased BMI was not associated with increased risk of OIRD.
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Affiliation(s)
- Marek Brzezinski
- VA Medical Center, University of California San Francisco, San Francisco, CA, USA.
| | | | - Keith A Candiotti
- Department of Anesthesiology, University of Miami/Jackson Health System, Miami, FL, USA
| | - Sergio D Bergese
- School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Peter H Pan
- Wake Forest School of Medicine, Winston-Salem, NC, USA
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Cozowicz C, Memtsoudis SG. Perioperative Management of the Patient With Obstructive Sleep Apnea: A Narrative Review. Anesth Analg 2021; 132:1231-1243. [PMID: 33857965 DOI: 10.1213/ane.0000000000005444] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The prevalence of obstructive sleep apnea (OSA) has reached 1 billion people worldwide, implying significant risk for the perioperative setting as patients are vulnerable to cardiopulmonary complications, critical care requirement, and unexpected death. This review summarizes main aspects and considerations for the perioperative management of OSA, a condition of public health concern. Critical determinants of perioperative risk include OSA-related changes in upper airway anatomy with augmented collapsibility, diminished capability of upper airway dilator muscles to respond to airway obstruction, disparities in hypoxemia and hypercarbia arousal thresholds, and instability of ventilatory control. Preoperative OSA screening to identify patients at increased risk has therefore been implemented in many institutions. Experts recommend that in the absence of severe symptoms or additional compounding health risks, patients may nevertheless proceed to surgery, while heightened awareness and the adjustment of postoperative care is required. Perioperative caregivers should anticipate difficult airway management in OSA and be prepared for airway complications. Anesthetic and sedative drug agents worsen upper airway collapsibility and depress central respiratory activity, while the risk for postoperative respiratory compromise is further increased with the utilization of neuromuscular blockade. Consistently, opioid analgesia has proven to be complex in OSA, as patients are particularly prone to opioid-induced respiratory depression. Moreover, basic features of OSA, including intermittent hypoxemia and repetitive sleep fragmentation, gradually precipitate a higher sensitivity to opioid analgesic potency along with an increased perception of pain. Hence, regional anesthesia by blockade of neural pathways directly at the site of surgical trauma as well as multimodal analgesia by facilitating additive and synergistic analgesic effects are both strongly supported in the literature as interventions that may reduce perioperative complication risk. Health care institutions are increasingly allocating resources, including those of postoperative enhanced monitoring, in an effort to increase patient safety. The implementation of evidence-based perioperative management strategies is however burdened by the rising prevalence of OSA, the large heterogeneity in disease severity, and the lack of evidence on the efficacy of costly perioperative measures. Screening and monitoring algorithms, as well as reliable risk predictors, are urgently needed to identify OSA patients that are truly in need of extended postoperative surveillance and care. The perioperative community is therefore challenged to develop feasible pathways and measures that can confer increased patient safety and prevent complications in patients with OSA.
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Affiliation(s)
- Crispiana Cozowicz
- From the Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Stavros G Memtsoudis
- From the Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria.,Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York
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48
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Doufas AG, Weingarten TN. Pharmacologically Induced Ventilatory Depression in the Postoperative Patient: A Sleep-Wake State-Dependent Perspective. Anesth Analg 2021; 132:1274-1286. [PMID: 33857969 DOI: 10.1213/ane.0000000000005370] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pharmacologically induced ventilatory depression (PIVD) is a common postoperative complication with a spectrum of severity ranging from mild hypoventilation to severe ventilatory depression, potentially leading to anoxic brain injury and death. Recent studies, using continuous monitoring technologies, have revealed alarming rates of previously undetected severe episodes of postoperative ventilatory depression, rendering the recognition of such episodes by the standard intermittent assessment practice, quite problematic. This imprecise description of the epidemiologic landscape of PIVD has thus stymied efforts to understand better its pathophysiology and quantify relevant risk factors for this postoperative complication. The residual effects of various perianesthetic agents on ventilatory control, as well as the multiple interactions of these drugs with patient-related factors and phenotypes, make postoperative recovery of ventilation after surgery and anesthesia a highly complex physiological event. The sleep-wake, state-dependent variation in the control of ventilation seems to play a central role in the mechanisms potentially enhancing the risk for PIVD. Herein, we discuss emerging evidence regarding the epidemiology, risk factors, and potential mechanisms of PIVD.
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Affiliation(s)
- Anthony G Doufas
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, College of Medicine, Mayo Clinic, Rochester, Minnesota
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Tan HS, Frere Z, Krishnamoorthy V, Ohnuma T, Raghunathan K, Habib AS. Association of gabapentinoid utilization with postoperative pulmonary complications in gynecologic surgery: a retrospective cohort study. Curr Med Res Opin 2021; 37:821-828. [PMID: 33685298 DOI: 10.1080/03007995.2021.1900092] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To investigate gabapentinoid utilization and association with postoperative pulmonary complications after gynecologic surgery. METHODS After Institutional Review Board approval, we performed this retrospective cohort study using the Premier Healthcare Database. We used ICD-10 and charge codes to identify adults who underwent elective gynecologic surgery from 2015 to 2018 and received either gabapentin or pregabalin on the day of surgery. Our primary outcome was a composite of pulmonary complications: respiratory failure, pneumonia, reintubation, pulmonary edema, and non-invasive or invasive ventilation. Secondary outcomes included mortality, intensive care unit admission, mechanical or non-invasive ventilation, hospital length of stay, re-admission within 30 days, opioid consumption and antiemetic use. Multivariable generalized linear mixed models were utilized to examine the associations between gabapentinoids and our outcome measures, adjusted for all covariates. RESULTS Data from 253,013 patients were analyzed, with 19,121 (7.6%) receiving gabapentinoids. Gabapentinoid utilization increased from 3.9% in 2015 to 12.3% in 2018, and was associated with increased pulmonary complications (OR 1.19; 95% CI 1.03-1.38), non-invasive ventilation (odds ratio [OR] 1.53; 95% CI 1.29-1.81), duration of hospital stay (% change 1.75; 95% CI 0.92-2.59), daily antiemetic doses on day of surgery (mean difference [MD] 1.37; 95% CI 1.26-1.49) and subsequently (MD 1.61; 95% CI 1.30-1.99), and higher daily average (MD 4.59 mg; 95% CI 3.55-5.63) and total (MD 8.74 mg; 95% CI 6.83-10.62) parenteral morphine equivalents. CONCLUSIONS Gabapentinoid utilization in gynecologic surgery is increasing and is associated with postoperative pulmonary complications.
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Affiliation(s)
- Hon Sen Tan
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore, Singapore
| | - Zach Frere
- Critical Care and Perioperative Epidemiologic Research Unit, Duke University Medical Center, Durham, NC, USA
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Epidemiologic Research Unit, Duke University Medical Center, Durham, NC, USA
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Tetsu Ohnuma
- Critical Care and Perioperative Epidemiologic Research Unit, Duke University Medical Center, Durham, NC, USA
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Karthik Raghunathan
- Critical Care and Perioperative Epidemiologic Research Unit, Duke University Medical Center, Durham, NC, USA
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Ashraf S Habib
- Critical Care and Perioperative Epidemiologic Research Unit, Duke University Medical Center, Durham, NC, USA
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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Abstract
Opioids form an important component of general anesthesia and perioperative analgesia. Discharge opioid prescriptions are identified as a contributor for persistent opioid use and diversion. In parallel, there is increased enthusiasm to advocate opioid-free strategies, which include a combination of known analgesics and adjuvants, many of which are in the form of continuous infusions. This article critically reviews perioperative opioid use, especially in view of opioid-sparing versus opioid-free strategies. The data indicate that opioid-free strategies, however noble in their cause, do not fully acknowledge the limitations and gaps within the existing evidence and clinical practice considerations. Moreover, they do not allow analgesic titration based on patient needs; are unclear about optimal components and their role in different surgical settings and perioperative phases; and do not serve to decrease the risk of persistent opioid use, thereby distracting us from optimizing pain and minimizing realistic long-term harms.
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