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Wang P, Zhou X, Wang S, Sheng F, Liu C, Wang Y, Jiang L, Wang J, Feng W. Opioid-free anesthesia improves postoperative recovery quality of small and medium-sized surgery: a prospective, randomized controlled study. Minerva Anestesiol 2024; 90:759-768. [PMID: 39279482 DOI: 10.23736/s0375-9393.24.18125-4] [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: 09/18/2024]
Abstract
BACKGROUND Opioid anesthesia (OA) is currently the predominant anesthetic method. However, its associated side effects, such as nausea and vomiting, coupled with the principle of enhanced recovery after surgery (ERAS), have spurred the adoption of opioid-free anesthesia (OFA) in select surgical procedures. For small and medium-sized operations, ERAS is particularly important. The aim of this study was to investigate the effect of OFA, utilizing esketamine in combination with dexmedetomidine and sevoflurane, on postoperative recovery quality following small and medium-sized surgical interventions. METHODS A total of 120 patients who underwent various small and medium-sized operations were randomly allocated to OFA and OA groups. The OA group received sufentanyl and sevoflurane, while the OFA group received esketamine, dexmedetomidine, and sevoflurane. The primary outcome measure was the postoperative quality of recovery-40 scores (QoR-40) 24 hours after surgery. Secondary outcomes included hemodynamic changes at different time intervals, the incidences of adverse events were recorded. RESULTS Patients in the OFA group exhibited a higher QoR-40 score of 184.0 (182.0, 186.2) compared to 182.0 (180.0, 184.0) in the OA group (P<0.001). The disparities were particularly noble in terms of Physical comfort and Emotional status. Multivariable analysis identified postoperative nausea and vomiting (PONV) as a significant independent factor impacting QoR-40 (β=-4.49 [-6.1, -2.87], P<0.001). Hemodynamic stability was more pronounced in the OFA than in the OA group. The incidence of PONV was substantially lower in the OFA group (one [1.6%] vs. 14 [25%], P<0.001), with a reduced need for vasoactive drugs (five [7.8%] vs. 15 [26.8%], P=0.005), and a lower incidence of respiratory depression (0 [0%] vs. six [10.7%], P=0.009). CONCLUSIONS OFA improves the postoperative recovery quality in small and medium-sized surgical procedures, potentially attributed to decreased incidence of PONV. Additionally, OFA facilitates the maintenance of more stable hemodynamics throughout the operation.
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Affiliation(s)
- Pei Wang
- Department of Anesthesiology, Affiliated Hospital of Qingdao University, University of Qingdao, Qingdao, China
| | - Xia Zhou
- Department of Anesthesiology, Affiliated Hospital of Qingdao University, University of Qingdao, Qingdao, China
| | - Shijie Wang
- Department of Pain Management, Affiliated Hospital of Qingdao University, University of Qingdao, Qingdao, China
| | - Fang Sheng
- Department of Anesthesiology, Affiliated Hospital of Qingdao University, University of Qingdao, Qingdao, China
| | - Cuicui Liu
- Department of Anesthesiology, Affiliated Hospital of Qingdao University, University of Qingdao, Qingdao, China
| | - Yanting Wang
- Department of Anesthesiology, Affiliated Hospital of Qingdao University, University of Qingdao, Qingdao, China
| | - Lili Jiang
- Department of Anesthesiology, Affiliated Hospital of Qingdao University, University of Qingdao, Qingdao, China
| | - Juntao Wang
- Department of Anesthesiology, Affiliated Hospital of Qingdao University, University of Qingdao, Qingdao, China
| | - Wei Feng
- Department of Anesthesiology, Affiliated Hospital of Qingdao University, University of Qingdao, Qingdao, China -
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Nicolì P, Biffi A, Boca GD, Vitagliano A, Silvestris E, Loizzi V, Naro ED, Cicinelli E, Damiani GR. Four-handed Technique for Total Laparoscopic Hysterectomy: An Italian Experience. Gynecol Minim Invasive Ther 2024; 13:161-167. [PMID: 39184247 PMCID: PMC11343349 DOI: 10.4103/gmit.gmit_50_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 09/23/2023] [Accepted: 11/09/2023] [Indexed: 08/27/2024] Open
Abstract
Objectives In our previous article, we proposed the novel four-handed technique (FHT) for total laparoscopic hysterectomy (TLH), which, according to us, is more helpful compared to the traditional TLH route. The objectives of the study were to analyze the FHT-TLH feasibility and efficiency by comparing some surgical outcomes recorded from 750 FHT-TLH performed in our hospital to literature data about the traditional TLH route and to underline the great opportunity this novel technique offers to the young specialists and residents to be more confident with gynecological laparoscopy. Materials and Methods This was a retrospective analysis carried out by collecting data regarding patient characteristics and surgical outcomes (operative time, blood loss, surgical complications, use of analgesics, and length of hospitalization) from 750 hospital records of women who underwent FHT-TLH (with or without adnexectomy) due to benign or malignant pathology from January 2015 to December 2021 at our hospital. Results We performed a total of 750 FHT-TLH, with or without adnexectomy. The mean skin-to-skin operative time for a FHT-TLH was 50 min, and the mean blood loss was 150 mL. No visceral damage was caused during surgeries. Only two patients underwent exploratory laparotomy with total abdominal hysterectomy due to the inability to proceed laparoscopically. Nonsteroidal anti-inflammatory drugs were administered only twice a day as analgesics, with advantage. The mean length of stay in the hospital after the procedure was 1.5 days, with discharge on the evening of the 1st day after surgery. No major postoperative complications occurred. The only minor postoperative complication described, in just three patients, was cellulitis of the vaginal vault. Conclusion Our FHT-TLH experience represents an alternative to the traditional TLH route, which allows to apply a minimally invasive approach with some advantages for patients compared to the traditional TLH route, such as early recovery and reduced operating time, blood loss, use of analgesics, and hospital stay. Moreover, it allows young specialists and residents to be more confident with gynecological laparoscopy, particularly when operating as the first assistant, to improve their laparoscopic surgical skills faster than the traditional TLH route allows them.
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Affiliation(s)
- Pierpaolo Nicolì
- Department of Obstetrics and Gynecology, University of Bari, Bari, Italy
| | - Anna Biffi
- Department of Obstetrics and Gynecology, Unit of Gynecology and Obstetrics, Leopldo Mandic Hospital, Merate, ASTT, Lecco, Italy
| | - Gregorio Del Boca
- Department of Obstetrics and Gynecology, Unit of Gynecology and Obstetrics, Leopldo Mandic Hospital, Merate, ASTT, Lecco, Italy
| | - Amerigo Vitagliano
- Department of Obstetrics and Gynecology, University of Bari, Bari, Italy
| | - Erica Silvestris
- Gynecologic Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Bari, Italy
| | - Vera Loizzi
- Gynecologic Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Bari, Italy
| | - Edoardo Di Naro
- Department of Obstetrics and Gynecology, University of Bari, Bari, Italy
| | - Ettore Cicinelli
- Department of Obstetrics and Gynecology, University of Bari, Bari, Italy
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Paradis T, Robitaille S, Wang A, Gervais C, Liberman AS, Charlebois P, Stein BL, Fiore JF, Feldman LS, Lee L. Predictive Factors for Successful Same-Day Discharge After Minimally Invasive Colectomy and Stoma Reversal. Dis Colon Rectum 2024; 67:558-565. [PMID: 38127647 DOI: 10.1097/dcr.0000000000003149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND Same-day discharge after minimally invasive colorectal surgery is a safe, effective practice in specific patients that can enhance the efficiency of enhanced recovery pathways. OBJECTIVE To identify predictive factors associated with success or failure of same-day discharge. DESIGN Prospective cohort study from January 2020 to March 2023. SETTINGS Tertiary colorectal center. PATIENTS Adult patients eligible for same-day discharge with remote postdischarge follow-up included those with minimal comorbidities, residing near the hospital, having sufficient home support, and owning a mobile device. INTERVENTIONS Patients were discharged on the day of surgery upon meeting specific criteria, including adequate pain control, tolerance of oral intake, independent mobility, urination, and the absence of complications. Successful same-day discharge was defined as discharge on the day of surgery without unplanned visits in the first 72 hours. MAIN OUTCOME MEASURES Factors associated with successful or failed same-day discharge after minimally invasive colorectal surgery. RESULTS A total of 175 patients (85.3%) were discharged on the day of surgery, with 14 patients (8%) having an unplanned visit within 72 hours. Overall, 161 patients (78.5%) were categorized as same-day discharge success and 44 patients (21.5%) as same-day discharge failure. The same-day discharge failure group had a higher Charlson Comorbidity Index (3.7 vs 2.8, p = 0.03). Mean length of stay (0.8 vs 3.0, p = 0.00), 30-day complications (10% vs 48%, p = 0.00), and readmissions (8% vs 27%, p = 0.00) were higher in the same-day discharge failure group. Regression analysis showed that failed same-day discharge was associated with higher comorbidities (OR 0.79; 95% CI, 0.66-0.95) and prolonged postanesthesia care unit time (OR 0.99; 95% CI, 0.99-0.99). Individuals who received a regional nerve block (OR 4.1; 95% CI, 1.2-14) and those who did not consume postoperative opioids (OR 4.6; 95% CI, 1-21) were more likely to have successful same-day discharge. LIMITATIONS Single-center study. CONCLUSIONS Our findings indicate that comorbidities and prolonged postanesthesia care unit stays were associated with same-day discharge failure, whereas regional nerve blocks and minimal postoperative opioids were related to success. These factors may inform future research aiming to enhance colorectal surgery recovery protocols. See Video Abstract . FACTORES PREDICTIVOS PARA UN ALTA EXITOSA EL MISMO DA DESPUS DE UNA COLECTOMA MNIMAMENTE INVASIVA Y REVERSIN DEL ESTOMA ANTECEDENTES:El alta el mismo día después de una cirugía colorrectal mínimamente invasiva es una práctica segura y eficaz en pacientes específicos que puede mejorar la eficiencia de las vías de recuperación mejoradas.OBJETIVO:Identificar factores predictivos asociados con el éxito o fracaso del alta el mismo día.DISEÑO:Estudio de cohorte prospectivo del 01/2020 al 03/2023.AJUSTES:Centro colorrectal terciario.PACIENTES:Los pacientes adultos elegibles para el alta el mismo día con seguimiento remoto posterior al alta incluyeron aquellos con comorbilidades mínimas, que residían cerca del hospital, tenían suficiente apoyo en el hogar y poseían un dispositivo móvil.INTERVENCIONES:Los pacientes fueron dados de alta el día de la cirugía al cumplir con criterios específicos, incluido un control adecuado del dolor, tolerancia a la ingesta oral, movilidad independiente, micción y ausencia de complicaciones. El alta exitosa el mismo día se definió como el alta el día de la cirugía sin visitas no planificadas en las primeras 72 horas.PRINCIPALES MEDIDAS DE RESULTADO:Factores asociados con el alta exitosa o fallida el mismo día después de una cirugía colorrectal mínimamente invasiva.RESULTADOS:Un total de 175 (85,3%) pacientes fueron dados de alta el día de la cirugía y 14 (8%) pacientes tuvieron una visita no planificada dentro de las 72 horas. En total, 161 (78,5%) pacientes se clasificaron como éxito del alta el mismo día y 44 (21,5%) pacientes como fracaso del alta el mismo día. El grupo de fracaso del alta el mismo día tuvo un índice de comorbilidad de Charlson más alto (3,7, 2,8, p = 0,03). La duración media de la estancia hospitalaria (0,8, 3,0, p = 0,00), las complicaciones a los 30 días (10%, 48%, p = 0,00) y los reingresos (8%, 27%, p = 0,00) fueron mayores en el mismo día grupo de fallo de descarga. El análisis de regresión mostró que el alta fallida el mismo día se asoció con mayores comorbilidades (OR 0,79; IC del 95 %: 0,66; 0,95) y tiempo prolongado en la unidad de cuidados postanestésicos (OR 0,99; IC del 95 %: 0,99; 0,99). Las personas que recibieron un bloqueo nervioso regional (OR 4,1; IC del 95 %: 1,2, 14) y aquellos que no consumieron opioides posoperatorios (OR 4,6, IC del 95 %: 1-21) tuvieron más probabilidades de tener éxito en el mismo día -descarga.LIMITACIONES:Estudio unicéntrico.CONCLUSIONES:Nuestros hallazgos indican que las comorbilidades y las estancias prolongadas en la unidad de cuidados postanestésicos se asociaron con el fracaso del alta el mismo día, mientras que los bloqueos nerviosos regionales y los opioides postoperatorios mínimos se relacionaron con el éxito. Estos factores pueden informar investigaciones futuras destinadas a mejorar los protocolos de recuperación de la cirugía colorrectal. (Traducción-Yesenia Rojas-Khalil ).
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Affiliation(s)
- Tiffany Paradis
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Stephan Robitaille
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Anna Wang
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Camille Gervais
- Department of Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - A Sender Liberman
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
- Department of General Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
| | - Patrick Charlebois
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
- Department of General Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
| | - Barry L Stein
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
- Department of General Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
| | - Julio F Fiore
- Department of Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Liane S Feldman
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
- Department of General Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
| | - Lawrence Lee
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
- Department of General Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
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Zhang S, Zhang J, Zhang R. Safety and effectiveness of opioid-free anaesthesia in thoracoscopic surgery: a preliminary retrospective cohort study. BMC Anesthesiol 2024; 24:60. [PMID: 38336669 PMCID: PMC10854143 DOI: 10.1186/s12871-024-02441-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 02/01/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND This study aimed to observe the effect of opioid-free anaesthesia (OFA) on intraoperative haemodynamic,postoperative analgesia and postoperative nausea and vomiting (PONV) in thoracoscopic surgery in order to provide more evidence for evaluating the safety and effectiveness of OFA technology. METHODS This was a single-centre retrospective observational study.Adult patients who underwent thoracoscopic surgery with the preoperative thoracic paravertebral block between January 2017 and June 2020 were included.A cohort of 101 thoracoscopic surgery patients who received the OFA technique were matched with 101 thoracoscopic surgery patients who received standard opioid-containing anaesthesia(SOA). Heart rate (HR) and mean arterial blood pressure (MAP) were measured before anaesthesia induction, immediately after endotracheal intubation, at the beginning of surgery, and 10, 20, and 30 min after surgery began.The total amount of intraoperative infusion, frequency of vasoactive drugs use, morphine ingested via the patient-controlled intravenous analgesia (PCIA) 24 h post-surgery,visual analogue scale (VAS) scores at rest and activity on the first day post-surgery, and frequency of nausea and vomiting within 24 h post-surgery were analysed. RESULTS There was no significant difference in intraoperative HR between the two groups (F = 0.889, P = 0.347); however, there was significant difference in intraoperative MAP (F = 16.709, P < 0.001), which was lower in SOA patients than in OFA patients. The frequency of vasoactive drug use and amount of infusion was less in OFA patients (P = 0.001). The consumption of morphine used by the PCIA 24 h post-surgery was significantly lower in OFA patients (OFA, 1.8 [0, 4.8] mg vs. SOA, 3.6 [0.6, 23] mg, P < 0.001). There was no significant difference in VAS scores at rest (P = 0.745) or during activity (P = 0.792) on the first day post-surgery. There was also no statistically significant difference in nausea and vomiting within 24 h post-surgery (P = 0.651). CONCLUSIONS This case-control study demonstrated that compared with SOA, OFA can effectively maintain the stability of intraoperative MAP, reduce the incidence of hypotension. Although OFA reduced morphine consumption via the PCIA pump 24 h post-surgery, postoperative pain scores and nausea and vomiting within 24 h post-surgery were similar between the groups.But this study was only a preliminary study and needed to confirm in a larger, more robust trial.
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Affiliation(s)
- Shanshan Zhang
- Department of Anesthesiology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Jianmin Zhang
- Department of Anesthesiology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Ran Zhang
- Department of Anesthesiology and Pain Medicine, Peking University People's Hospital, No.11 Xizhimen South Street, Xicheng District 100044, Beijing, China.
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Thalji NK, Patel SJ, Augoustides JG, Schiller RJ, Dalia AA, Low Y, Hamzi RI, Fernando RJ. Opioid-Free Cardiac Surgery: A Multimodal Pain Management Strategy With a Focus on Bilateral Erector Spinae Plane Block Catheters. J Cardiothorac Vasc Anesth 2022; 36:4523-4533. [PMID: 36184473 PMCID: PMC9745636 DOI: 10.1053/j.jvca.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Nabil K Thalji
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Saumil Jayant Patel
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Robin J Schiller
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA
| | - Adam A Dalia
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA
| | - Yinghui Low
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA
| | - Rawad I Hamzi
- Department of Anesthesiology, Regional Anesthesia and Acute Pain Management, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC
| | - Rohesh J Fernando
- Department of Anesthesiology, Cardiothoracic Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC.
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McLemore EC, Lee L, Hedrick TL, Rashidi L, Askenasy EP, Popowich D, Sylla P. Same day discharge following elective, minimally invasive, colorectal surgery : A review of enhanced recovery protocols and early outcomes by the SAGES Colorectal Surgical Committee with recommendations regarding patient selection, remote monitoring, and successful implementation. Surg Endosc 2022; 36:7898-7914. [PMID: 36131162 PMCID: PMC9491699 DOI: 10.1007/s00464-022-09606-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 08/28/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND As enhanced recovery programs (ERPs) have continued to evolve, the length of hospitalization (LOS) following elective minimally invasive colorectal surgery has continued to decline. Further refinements in multimodal perioperative pain management strategies have resulted in reduced opioid consumption. The interest in ambulatory colectomy has dramatically accelerated during the COVID-19 pandemic. Severe restrictions in hospital capacity and fear of COVID transmission forced surgical teams to rethink strategies to further reduce length of inpatient stay. METHODS Members of the SAGES Colorectal Surgery Committee began reviewing the emergence of SDD protocols and early publications for SDD in 2019. The authors met at regular intervals during 2020-2022 period reviewing SDD protocols, safe patient selection criteria, surrogates for postoperative monitoring, and early outcomes. RESULTS Early experience with SDD protocols for elective, minimally invasive colorectal surgery suggests that SDD is feasible and safe in well-selected patients and procedures. SDD protocols are associated with reduced opioid use and prescribing. Patient perception and experience with SDD is favourable. For early adopters, SDD has been the natural evolution of well-developed ERPs. Like all ERPs, SDD begins in the office setting, identifying the correct patient and procedure, aligning goals and objectives, and the perioperative education of the patient and their supporting significant others. A thorough discussion with the patient regarding expected activity levels, oral intake, and pain control post operatively lays the foundation for a successful application of SDD programs. These observations may not apply to all patient populations, institutions, practice types, or within the scope of an existing ERP. However, if the underlying principles of SDD can be incorporated into an existing institutional ERP, it may further reduce the incidence of post operative ileus, prolonged LOS, and improve the effectiveness of oral analgesia for postoperative pain management and reduced opioid use and prescribing. CONCLUSIONS The SAGES Colorectal Surgery Committee has performed a comprehensive review of the early experience with SDD. This manuscript summarizes SDD early results and considerations for safe and stepwise implementation of SDD with a specific focus on ERP evolution, patient selection, remote monitoring, and other relevant considerations based on hospital settings and surgical practices.
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Affiliation(s)
- Elisabeth C McLemore
- Bernard J. Tyson Kaiser Permanente School of Medicine, Los Angeles Medical Center, Los Angeles, CA, 90027, USA.
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Colon and Rectal Surgery, Los Angeles Medical Center, 4760 Sunset Blvd, 3rd Floor, Los Angeles, CA, 90027, USA.
| | - Lawrence Lee
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Traci L Hedrick
- Department of Surgery, University of Virginia Health, Charlottesville, VA, USA
| | | | - Erik P Askenasy
- Division of Colon and Rectal Surgery, University of Texas Health, Houston, TX, USA
| | - Daniel Popowich
- Division of Colon and Rectal Surgery, St. Francis Hospital, New York, NY, USA
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Tran-McCaslin M, Basam M, Rudikoff A, Thuraisingham D, McLemore EC. Reduced Opioid Use and Prescribing in a Same Day Discharge Pilot Enhanced Recovery Program for Elective Minimally Invasive Colorectal Surgical Procedures During the COVID-19 Pandemic. Am Surg 2022; 88:2572-2578. [PMID: 35771192 PMCID: PMC9253719 DOI: 10.1177/00031348221109467] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Purpose Enhanced recovery pathways (ERPs) are associated with reduced complications
and length of stay. The validation of the I-FEED scoring system, advances in
perioperative anesthesia, multimodal analgesia, and telehealth remote
monitoring have resulted in further evolution of ERPs setting the stage for
same day discharge (SDD). Pioneers and early adopters have demonstrated the
safety and feasibility of SDD programs. The aim of this study is to evaluate
the impact of a pilot SDD ERP on patient self-reported pain scoring and
narcotic usage. Methods A quality improvement pilot program was conducted to assess the impact of a
SDD ERP on post-operative pain score reporting and opioid use in healthy
patients undergoing elective colorectal surgery as an alternative to
post-operative hospitalization during the COVID-19 pandemic (May
2020-December 2021). Patients were monitored remotely with daily telephone
visits on POD 1-7 assessing the following variables: I-FEED score, pain
score, pain management, bowel function, dietary advancement, any
complications, and/or re-admissions. Results Thirty-seven patients met the highly selective eligibility criteria for
“healthy patient, healthy anastomosis.” SDD occurred in 70%. The remaining
30% were discharged on POD 1. Mean total narcotic usage was 5.2 tablets of
5 mg oxycodone despite relatively high reported pain scores. Conclusions In our initial experience, SDD is associated with significantly lower patient
narcotic utilization for postoperative pain management than hypothesized.
This pilot SDD program resulted in a change in clinical practice with
reduction of prescribed discharge oxycodone 5 mg quantity from #40 to #10
tablets.
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Affiliation(s)
- Marie Tran-McCaslin
- Department of Surgery, 23543Kaiser Permanente - Los Angeles Medical Center, Los Angeles, CA, USA
| | - Motahar Basam
- Department of Surgery, 23543Kaiser Permanente - Los Angeles Medical Center, Los Angeles, CA, USA
| | - Andrew Rudikoff
- Department of Anesthesia, 23543Kaiser Permanente - Los Angeles Medical Center, Los Angeles, CA, USA
| | - Dhilan Thuraisingham
- Department of Anesthesia, 23543Kaiser Permanente - Los Angeles Medical Center, Los Angeles, CA, USA
| | - Elisabeth C McLemore
- Department of Surgery, 23543Kaiser Permanente - Los Angeles Medical Center, Los Angeles, CA, USA
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Dong X, Burton BN, Rahman S. Response to Comment on: "Intraoperative opioid and analgesic adjuvant administration practice patterns following implementation of an enhanced recovery after surgery protocol for laparoscopic donor nephrectomy". J Clin Anesth 2022; 81:110916. [PMID: 35777288 DOI: 10.1016/j.jclinane.2022.110916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 06/15/2022] [Accepted: 06/22/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Xuezhi Dong
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095, USA; Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
| | - Brittany N Burton
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095, USA.
| | - Siamak Rahman
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095, USA.
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Inania M, Sharma P, Parikh M. Role of enhanced recovery after surgery in total laparoscopic hysterectomy. J Minim Access Surg 2022; 18:186-190. [PMID: 35046168 PMCID: PMC8973480 DOI: 10.4103/jmas.jmas_86_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Introduction: Enhanced recovery after surgery (ERAS) principles is an evidence-based surgical management approach that requires cooperation across various medical specialties. In this study, we applied ERAS principles in total laparoscopic hysterectomy (TLH) and the post-operative outcomes like post-operative pain, nausea and vomiting, opioid requirement, day of discharge, and any other complaints were studied. Methods: The study was conducted in a private healthcare setup in Jodhpur, Rajasthan, India. In this non-randomised controlled study 103 patients who underwent TLH over a period of 1 year were alternatively allocated to the study group and the control group. There were 51 patients in the study group in whom ERAS principles were applied and 52 patients in control group in whom traditional post-operative care was given. Results: Post-operative nausea and vomiting and opioid requirement were significantly reduced in the study group (P < 0.05). The post-operative pain was similar in both groups. The majority of patients in study group were discharged within 24 h as compared to the routine discharge after 48 h. Conclusion: Following ERAS principles in TLH results in decrease in post-operative nausea and vomiting, post-operative opioid requirement and hospital stay. Hence, the ERAS principles should be the standard practice in TLH even in a developing country setup.
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Affiliation(s)
- Mili Inania
- Department of OBG, Medipulse Hospital, Jodhpur, Rajasthan, India
| | - Priyanka Sharma
- Department of OBG, Medipulse Hospital, Jodhpur, Rajasthan, India
| | - Manoj Parikh
- Department of Anesthesia, Balaji Hospital, Jodhpur, Rajasthan, India
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Opioid-free TIVA Improves Post- operative Quality of Recovery (QOR) in Patients Undergoing Oocyte Retrieval. J Obstet Gynaecol India 2022; 72:59-65. [PMID: 35125739 PMCID: PMC8804050 DOI: 10.1007/s13224-021-01495-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 04/27/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Oocyte retrieval is a part of in vitro fertilisation (IVF) procedures performed on an ambulatory basis. Total intravenous anaesthesia (TIVA) with opioid is shown to improve quality of recovery (QOR) after ambulatory surgery. Opioid-free anaesthesia (OF) is gaining popularity in recent times as it is associated with lesser post-operative side effects related to opioids. Quality of recovery is considered as one of the principal end points in ambulatory surgery. AIM To compare quality of recovery using QOR-15 questionnaire between opioid-free TIVA and opioid-based TIVA at 24 h after oocyte retrieval. SETTINGS AND DESIGN A prospective randomised control study. PATIENTS AND METHODS Sixty six patients undergoing oocyte retrieval were prospectively selected. They were randomised into two equal group. OF TIVA group with dexmedetomidine (D) and propofol or opioid-based TIVA with fentanyl (F) and propofol. The primary outcome measured was quality of recovery using QOR-15 at 24 h after oocyte retrieval. Secondary outcomes measured were incidence of bradycardia, post-operative nausea and vomiting, usage of rescue analgesia and total consumption of propofol. RESULTS A statistically significant difference in total QOR-15 was observed between two groups (p value = 0.021) at 24 h post-operatively. Usage of rescue analgesia and incidence of post-operative nausea and vomiting was less in opioid-free TIVA. CONCLUSION Opioid-free TIVA improves post-operative QOR in patients undergoing oocyte retrieval.
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Elshafie MA, Khalil MK, ElSheikh ML, Mowafy NI. Erector Spinae Block with Opioid Free Anesthesia in Cirrhotic Patients Undergoing Hepatic Resection: A Randomized Controlled Trial. Local Reg Anesth 2022; 15:1-10. [PMID: 35115825 PMCID: PMC8801329 DOI: 10.2147/lra.s343347] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 01/08/2022] [Indexed: 01/01/2023] Open
Abstract
Background Hepatic resection is a major abdominal surgery with challenging pain management. We aimed to investigate the effect of erector spinae plane block (ESPB) with opioid free anesthesia (OFA) in cirrhotic patients scheduled for liver resection on perioperative pain management in terms of hemodynamic stability. Secondarily, we assessed time to first request for analgesia and perioperative fentanyl consumption, nausea and vomiting within 24 hours after surgery. Methods Forty patients were randomized to block group (n = 20): OFA with ESPB and conventional group (n = 20): conventional balanced anesthesia with opioids (OFA associated non-opioid drugs [dexmedetomidine, magnesium sulfate, xylocaine, and acetaminophen] and ESPB). Bilateral ESP block was done with ultrasound guidance at the level of thoracic vertebrae T 6–7, the local anesthetic dose was 20 mL Bupivacaine 0.25% with adjuvant dexmedetomidine (0.5 µg/kg) on each side. We monitored hemodynamic stability as the primary endpoint (heart rate, mean arterial blood pressure, and cardiac output). Results Bilateral ESPB offered somatic and visceral analgesia for hepatic resection patients with no intraoperative fentanyl required. Postoperatively, the block group with dexmedetomidine adjuvant to the local anesthesia drugs showed delay in the first request for analgesia (p = 0.092) and decreased fentanyl requirement (p < 0.001), so no patient in the ESP group suffered from postoperative nausea and vomiting compared to 50% in the conventional group (p < 0.001). Conclusion Bilateral ESP block with OFA is an effective approach for intra- and postoperative analgesia in cirrhotic patients undergoing liver resection.
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Affiliation(s)
- Minatallah A Elshafie
- Department of Anesthesia and Intensive Care, National Liver Institute, Menoufia University, Sheeben Elkom City, Egypt
- Correspondence: Minatallah A Elshafie, Department of Anesthesia and Intensive Care, National Liver Institute, Menoufia University, Sheeben Elkom City, Egypt, Tel +20 111 224 8935, Email
| | - Magdy K Khalil
- Department of Anesthesia and Intensive Care, National Liver Institute, Menoufia University, Sheeben Elkom City, Egypt
| | - Maha L ElSheikh
- Department of Anesthesia and Intensive Care, National Liver Institute, Menoufia University, Sheeben Elkom City, Egypt
| | - Nagwa I Mowafy
- Department of Anesthesia and Intensive Care, National Liver Institute, Menoufia University, Sheeben Elkom City, Egypt
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INFLUENCE OF DIFFERENT TYPES OF ANESTHESIA FOR LAPAROSCOPIC HYSTERECTOMY ON THE DYNAMICS OF STRESS HORMONES. EUREKA: HEALTH SCIENCES 2021. [DOI: 10.21303/2504-5679.2021.001598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The aim of the study – to evaluate the influence of different variants of anesthesia, including low-opioid (LOA) and opioid-free anesthesia (OFA), on the dynamics of the stress response during laparoscopic hysterectomy.
Materials and methods: 102 patients were randomly allocated into 3 groups: 37 women assigned to receive a standard opioid-based anesthesia (OBA group), 33 women – LOA group and 32 patients OFA group.
Results: The patients of OFA group after induction and intubation of the trachea showed a significant (p<0.05) increase in cortisol level by 155.4 % and 160.9 % compared with the OBA group and LOA group. After completion of the hysterectomy, regardless of the variant of anesthesia, the level of cortisol exceeded the preoperative one (pOBA=0.116, pLOA=0.049, pOFA=0.043). Two hours after surgery with standard anesthesia (OBA group) there was a further increase in the concentration of cortisol in the blood, exceeding the initial values by 142.9 % (p=0.043). Patients in the LOA group and OFA group tended to decrease cortisolemia. The changes in adrenaline & glucose levels were somewhat similar.
Conclusion: Use of OFA is accompanied by an aggravation of the stress response at the stage of hysterectomy, which is manifested by an increase in the level of adrenaline and cortisol. The most adequate perioperative protection is inherent in low-opioid anesthesia, which is accompanied by a lower release of stress hormones during hysterectomy and in the postoperative period. Opioid-based anesthesia provides adequate intraoperative protection, but is accompanied by insufficient postoperative analgesia.
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Improving the cost, quality, and safety of perioperative care: A systematic review of the literature on implementation of the perioperative surgical home. J Clin Anesth 2020; 63:109760. [DOI: 10.1016/j.jclinane.2020.109760] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/17/2020] [Accepted: 02/28/2020] [Indexed: 12/14/2022]
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Patel A, Rojas A, Samson D, Fakas S, Gachabayov M, L Xu J, Latifi R, Bergamaschi R. Postoperative opioid-free analgesia in elective bowel resection: Changes over time. J Perioper Pract 2020; 31:255-260. [PMID: 32600187 DOI: 10.1177/1750458920936065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In the pain management evolution, opioid-free analgesia and multimodal analgesia strategies have emerged as feasible in many surgical settings including colorectal surgery. This was a retrospective cohort study including patients having undergone elective bowel resection between February 2012 and June 2018 aiming to evaluate whether there was reduction in opioid use after implementation of opioid-free analgesia in one medical centre. Trend analysis was conducted using Joinpoint regression employing nine-month intervals. The primary outcome for each interval was the proportion of patients receiving postoperative opioid-free analgesia, defined as forgoing all opioid analgesics after the day of surgery. This study showed a significant increasing trend in opioid-free analgesia in elective bowel resection from 0 to 42.5% over 4.5 years.
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Affiliation(s)
- Ankoor Patel
- Department of Surgery, 8138Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Aram Rojas
- Department of Surgery, 8138Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - David Samson
- Department of Surgery, 8138Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Steliana Fakas
- Department of Surgery, 8138Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Mahir Gachabayov
- Department of Surgery, 8138Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Jeff L Xu
- Department of Surgery, 8138Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Rifat Latifi
- Department of Surgery, 8138Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Roberto Bergamaschi
- Department of Surgery, 8138Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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Allen BF, Jablonski PM, McEvoy MD, Ehrenfeld JM, Shi H, King AB, Wanderer JP. Implementation of an Enhanced Recovery Protocol (ERP) is associated with an increase in the perioperative use of non-opioid multimodal analgesia for non-ERP patients. J Clin Anesth 2020; 62:109694. [DOI: 10.1016/j.jclinane.2019.109694] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/24/2019] [Accepted: 12/14/2019] [Indexed: 01/13/2023]
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Nair S, McGuinness S, Masood F, Boylan JF, Conlon NP. Erector Spinae Plane Blocks in Major Hepatopancreaticobiliary Surgery: A Case Series. A A Pract 2020; 13:332-334. [PMID: 31361665 DOI: 10.1213/xaa.0000000000001069] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hepatopancreaticobiliary (HPB) surgery is major upper abdominal surgery with considerable risk of pulmonary complications related to postoperative pain. While epidural analgesia remains an effective analgesic technique for upper abdominal surgery, HPB surgery poses challenges to its use due to coagulopathy. Erector spinae plane (ESP) blocks are a promising alternative to epidurals. Injection of local anesthetic deep to the erector spinae muscle plane and placement of a catheter for prolonged effect provide both somatic and visceral analgesia for both thoracic and abdominal surgery. We describe a series of 3 cases that illustrate the efficacy of ESP blocks after major HPB surgery.
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Affiliation(s)
- Shrijit Nair
- From the Department of Anesthesia and Intensive Care Medicine, St Vincent's University Hospital, Elm Park, Dublin, Ireland
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Beiler B, Barraud D, Vigneron J, Demoré B. Physicochemical stability of an admixture of lidocaine and ketamine in polypropylene syringe used in opioid-free anaesthesia. Eur J Hosp Pharm 2020; 27:e79-e83. [PMID: 32296511 PMCID: PMC7147561 DOI: 10.1136/ejhpharm-2019-001976] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 08/26/2019] [Accepted: 09/23/2019] [Indexed: 11/04/2022] Open
Abstract
Objectives Opioid-free anaesthesia is a treatment strategy of pain management based on the use of drugs such as lidocaine, ketamine and dexmedetomidine that do not interact significantly with opioid receptors. In particular, these drugs are used by anaesthesiologists to ensure adequate levels of analgesia during surgical procedures for burn patients such as daily wound dressings and graft surgeries. Furthermore, for hypothermia prevention and wound-healing purposes, ambient temperature must be kept high for these patients, usually between 27°C and 30°C. To facilitate the use of this technique, clinicians want to mix lidocaine and ketamine in the same syringe. No stability data is available to determine the feasibility of this admixture and at this temperature. The objective was to study the physicochemical stability of lidocaine 20 mg/mL with ketamine 2.5 mg/mL diluted with 0.9% sodium chloride (0.9% NaCl) stored at 28°C in polypropylene syringe for 48 hours. Methods Physical stability was evaluated by visual examination and by measuring turbidity with a spectrophotometer. Chemical stability was determined after preparation and after 6, 24 and 48 hours of conservation with a high performance liquid chromatography and pH measurements. The method was validated according to International Conference on Harmonisation Q2(R1) guidelines. Results Both lidocaine (99.98%±1.44%) and ketamine (100.70%±0.95%) retained more than 95% of their initial concentration after 48 hours storage. pH measurements remained stable over the course of the study (less than 0.21 point of variation). No signs of physical instability were observed after visual and subvisual inspections. Conclusions The physicochemical stability of lidocaine 20 mg/mL and ketamine 2.5 mg/mL diluted with 0.9% NaCl in a polypropylene syringe stored at 28°C protected from light was demonstrated for 48 hours. This infusion technique is therefore feasible from a pharmaceutical point of view in burn-unit settings.
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Affiliation(s)
- Benoît Beiler
- Pharmacy, Centre Hospitalier Universitaire de Nancy, Vandoeuvre-les-Nancy, France
| | - Damien Barraud
- Burn Critical Care Unit, Centre Hospitalier Regional de Metz-Thionville, Metz, France
| | - Jean Vigneron
- Pharmacy, Centre Hospitalier Universitaire de Nancy, Vandoeuvre-lès-Nancy, France
| | - Béatrice Demoré
- Pharmacy, Centre Hospitalier Universitaire de Nancy, Vandoeuvre-lès-Nancy, France
- APEMAC, Vandoeuvre les Nancy, France
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Ferari CS, Katsevman GA, Dekeseredy P, Sedney CL. Implications of Drug Use Disorders on Spine Surgery. World Neurosurg 2020; 136:e334-e341. [PMID: 31926361 DOI: 10.1016/j.wneu.2019.12.177] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 12/30/2019] [Accepted: 12/30/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND The opioid crisis has been declared a "public health emergency." Spine surgeons are treating more patients with substance use disorders (SUDs). OBJECTIVE To investigate the outcomes of patients with SUD who undergo spine surgery. METHODS A retrospective chart review was performed on patients with SUD who underwent nonelective spine surgery by orthopedic or neurosurgical staff from 2012 to 2017 at a level 1 trauma center and spine referral center. Three elective cases were excluded. RESULTS A total of 49 patients undergoing 72 surgeries were reviewed. The most common substances of abuse were opioids (44/49 patients; 90%). Of 31 patients using multisubstances (63%), 29 misused opioids. The most common indications for surgery were infection (26/49, 53%), trauma (13/49, 27%), and myelopathy (7/49, 14%). Fusions (35/49, 71%) and irrigation and debridement surgeries (12/49, 24%) predominated. Twenty-nine percent (14/49) of patients had complications, the most common being hardware failure (7/49, 14%). Twenty percent (10/49) of patients left against medical advice and 22% (11/49) did not follow up after hospital discharge. The average length of hospital stay was 22 days. Forty-five percent (22/49) of patients were known to be in a drug program preoperatively versus 39% (19/49) postoperatively. Sixty-five percent (32/49) were prescribed opioids in the immediate postoperative period and 47% (23/49) continued to abuse drugs postoperatively. CONCLUSIONS Patients with SUD are at increased risk of complications and inadequate follow-up. Additional studies are warranted to determine whether additional perioperative education, psychiatry consultations, or prescription of opioid addiction treatment regimens will improve drug use cessation and outcomes.
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Affiliation(s)
| | - Gennadiy A Katsevman
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia, USA.
| | - Patricia Dekeseredy
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia, USA
| | - Cara L Sedney
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia, USA
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Fernández-Ginés FD, Cortiñas-Sáenz M, Agudo-Ponce D, Navajas-Gómez de Aranda A, Morales-Molina JA, Fernández-Sánchez C, Sierra-García F, Mateo-Carrasco H. Pain reduction of topical sevoflurane vs intravenous opioids in pressure ulcers. Int Wound J 2019; 17:83-90. [PMID: 31762163 DOI: 10.1111/iwj.13235] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 09/06/2019] [Accepted: 09/13/2019] [Indexed: 11/29/2022] Open
Abstract
Recently, it has been reported that topical irrigations of liquid sevoflurane on the bed of painful wounds produce a rapid, intense, and lasting analgesic effect. In this paper, A cohort of 112 patients with painful pressure ulcers who were refractory to opioids (or who exhibited undesirable adverse events to them) was treated with topical sevoflurane as per local institutional policy. These patients were recruited from an intensive care unit for a period of 3 years. The main aim was to determine the effectiveness of topical sevoflurane in reducing the pain of PUs and reducing the ulcer area. Study findings are reported and discussed herein and suggest that sevoflurane is a viable and promising treatment option for PUs.
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Affiliation(s)
| | - Manuel Cortiñas-Sáenz
- Anesthesiology and Pain Management Department, Torrecárdenas Hospital, Almería, Spain
| | - Desirée Agudo-Ponce
- Anesthesiology and Pain Management Department, Torrecárdenas Hospital, Almería, Spain
| | | | | | | | | | - Héctor Mateo-Carrasco
- Department of Clinical Pharmacy, Division of Oncology, University College London Hospital, London, UK
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Thota RS, Ramkiran S, Garg R, Goswami J, Baxi V, Thomas M. Opioid free onco-anesthesia: Is it time to convict opioids? A systematic review of literature. J Anaesthesiol Clin Pharmacol 2019; 35:441-452. [PMID: 31920226 PMCID: PMC6939563 DOI: 10.4103/joacp.joacp_128_19] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The epidemic of opioid crisis started getting recognised as a public health emergency in view of increasing opioid-related deaths occurring due to undetected respiratory depression. Prescribing opioids at discharge has become an independent risk factor for chronic opioid use, following which, prescription practices have undergone a radical change. A call to action has been voiced recently to end the opioid epidemic although with the pain practitioners still struggling to make opioids readily available. American Society of Anesthesiologist (ASA) has called for reducing patient exposure to opioids in the surgical setting. Opioid sparing strategies have emerged embracing loco-regional techniques and non-opioid based multimodal pain management whereas opioid free anesthesia is the combination of various opioid sparing strategies culminating in complete elimination of opioid usage. The movement away from opioid usage perioperatively is a massive but necessary shift in anesthesia which has rationalised perioperative opioid usage. Ideal way moving forward would be to adapt selective low opioid effective dosing which is both procedure and patient specific while reserving it as rescue analgesia, postoperatively. Many unknowns persist in the domain of immunologic effects of opioids, as complex interplay of factors gets associated during real time surgery towards outcome. At present it would be too premature to conclude upon opioid-induced immunosuppression from the existing evidence. Till evidence is established, there are no recommendations to change current clinical practice. At the same time, consideration for multimodal opioid sparing strategies should be initiated in each patient undergoing surgery.
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Affiliation(s)
- Raghu S. Thota
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre (Homi Bhabha National Institute), E Borges Road, Parel, Mumbai, Maharashtra, India
- Address for correspondence: Dr. Raghu S. Thota, Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre (Homi Bhabha National Institute), E Borges Road, Parel, Mumbai - 400 012, Maharashtra, India. E-mail:
| | - Seshadri Ramkiran
- Department of Anaesthesiology Critical Care and Pain, Homi Bhabha Cancer Hospital and Research Centre, Aganampudi, Gajuwaka Mandalam, Vishakapatnam, Andhra Pradesh, India
| | - Rakesh Garg
- Department of Onco-Anaesthesiology and Palliative Medicine, Dr. BRAIRCH, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Jyotsna Goswami
- Department of Anaesthesia and Critical Care, Tata Medical Centre, New Town, Rajarhat, Kolkata, West Bengal, India
| | - Vaibhavi Baxi
- Department of Anaesthesiology, Lilavati Hospital and Research Centre, A-791, Bandra Reclamation, Bandra, Mumbai, Maharashtra, India
| | - Mary Thomas
- Regional Cancer Centre, Medical College Campus, Post Bag No. 2417, Thiruvananthapuram, Kerala, India
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Opioid-free anaesthesia: Pro: damned if you don't use opioids during surgery. Eur J Anaesthesiol 2019; 36:247-249. [PMID: 30817359 DOI: 10.1097/eja.0000000000000966] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Bicket MC, Brat GA, Hutfless S, Wu CL, Nesbit SA, Alexander GC. Optimizing opioid prescribing and pain treatment for surgery: Review and conceptual framework. Am J Health Syst Pharm 2019; 76:1403-1412. [DOI: 10.1093/ajhp/zxz146] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
AbstractPurposeMillions of Americans who undergo surgical procedures receive opioid prescriptions as they return home. While some derive great benefit from these medicines, others experience adverse events, convert to chronic opioid use, or have unused medicines that serve as a reservoir for potential nonmedical use. Our aim was to investigate concepts and methods relevant to optimal opioid prescribing and pain treatment in the perioperative period.MethodsWe reviewed existing literature for trials on factors that influence opioid prescribing and optimization of pain treatment for surgical procedures and generated a conceptual framework to guide future quality, safety, and research efforts.ResultsOpioid prescribing and pain treatment after discharge from surgery broadly consist of 3 key interacting perspectives, including those of the patient, the perioperative team, and, serving in an essential role for all patients, the pharmacist. Systems-based factors, ranging from the organizational environment’s ability to provide multimodal analgesia and participation in enhanced recovery after surgery programs to other healthcare system and macro-level trends, shape these interactions and influence opioid-related safety outcomes.ConclusionsThe severity and persistence of the opioid crisis underscore the urgent need for interventions to improve postoperative prescription opioid use in the United States. Such interventions are likely to be most effective, with the fewest unintended consequences, if based on sound evidence and built on multidisciplinary efforts that include pharmacists, nurses, surgeons, anesthesiologists, and the patient. Future studies have the potential to identify the optimal amount to prescribe, improve patient-focused safety and quality outcomes, and help curb the oversupply of opioids that contributes to the most pressing public health crisis of our time.
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Affiliation(s)
- Mark C Bicket
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, and Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Gabriel A Brat
- Harvard Medical School, Boston, MA, and Division of Acute Care Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Susan Hutfless
- Gastrointestinal Epidemiology Research Center, Department of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher L Wu
- Department of Anesthesiology, Hospital for Special Surgery, and Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Suzanne A Nesbit
- Department of Pharmacy, Johns Hopkins Hospital, and Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins Hospital, Baltimore, MD
| | - G Caleb Alexander
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, and Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Landry E, Burns S, Pelletier MP, Muehlschlegel JD. A Successful Opioid-Free Anesthetic in a Patient Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 33:2517-2520. [DOI: 10.1053/j.jvca.2018.11.040] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Indexed: 11/11/2022]
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Bhardwaj N. Enhanced recovery after surgery. J Anaesthesiol Clin Pharmacol 2019; 35:S3-S4. [PMID: 31142952 PMCID: PMC6515718 DOI: 10.4103/joacp.joacp_57_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Neerja Bhardwaj
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Delayed recovery following thoracic surgery: persistent issues and potential interventions. Curr Opin Anaesthesiol 2019; 32:3-9. [PMID: 30507683 DOI: 10.1097/aco.0000000000000669] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Lung and esophageal surgery remain a curative option for resectable cancers. However, despite advances in surgical and anesthesia practices, the inclusion of patients with comorbidities that would have previously not been offered curative resection presents additional concerns and challenges. RECENT FINDINGS Perioperative complication rates remain high and prolonged and/or painful recovery are common. Further, many patients face a permanent decline in their functional status, which negatively affects their quality of life. Examination of the variables associated with high complications following thoracic surgery reveals patient, physician, and institutional factors in the forefront. Anesthesiologist training, Enhanced Recovery After Surgery protocols, and preparations to minimize "failure to rescue" when a complication does arise are key strategies to address adverse outcomes. SUMMARY Delayed and complicated recovery after thoracic noncardiac surgery persist in current practice. This review analyzes the diverse factors that can impact complications and quality of life after lung surgery and the interventions that can help decrease length of stay and improve return to baseline conditions.
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Edney JC, Lam H, Raval MV, Heiss KF, Austin TM. Implementation of an enhanced recovery program in pediatric laparoscopic colorectal patients does not worsen analgesia despite reduced perioperative opioids: a retrospective, matched, non-inferiority study. Reg Anesth Pain Med 2019; 44:123-129. [DOI: 10.1136/rapm-2018-000017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 06/12/2018] [Accepted: 06/18/2018] [Indexed: 12/15/2022]
Abstract
Background and objectivesEnhanced recovery protocols (ERPs) decrease length of stay and postoperative morbidity, but it is important that these benefits do not come at a cost of sacrificing proper perioperative analgesia. In this retrospective, matched cohort study, we evaluated postoperative pain intensity in pediatric patients who underwent laparoscopic colorectal surgeries before and after ERP implementation.MethodsPatients in each cohort were randomly matched based on age, diagnosis, American Society of Anesthesiologists classification, and surgical procedure. The primary outcome was average daily postoperative pain score, while the secondary outcomes included postoperative hospital length of stay, complication rate, and 30-day readmissions. Since our hypothesis was non-inferior analgesia in the postprotocol cohort, a non-inferiority study design was used.ResultsAfter matching, 36 pairs of preprotocol and postprotocol patients were evaluated. ERP patients had non-inferior recovery room pain scores (difference 0 (−1.19, 0) points, 95% CI −0.22 to 0.26 points, p valuenon-inferiority <0.001) and 4-day postoperative pain scores (difference −0.3±1.9 points, 95% CI −0.82 to 0.48 points, p valuenon-inferiority <0.001) while receiving less postoperative opioids (difference −0.15 [−0.21, –0.05] intravenous morphine equivalents/kg/day, p<0.001). ERP patients also had reduced postoperative hospital stays (difference −1.5 [−4.5, 0] days, p<0.001) and 30-day readmissions (2.8% vs 27.8%, p=0.008).ConclusionsImplementation of our ERP for pediatric laparoscopic colorectal patients was associated with less perioperative opioids without worsening postoperative pain scores. In addition, patients who received the protocol had faster return of bowel function, shorter postoperative hospital stays, and a lower rate of 30-day hospital readmissions. In pediatric laparoscopic colorectal patients, the incorporation of an ERP was associated with a pronounced decrease in perioperative morbidity without sacrificing postoperative analgesia.
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Effect of Intravenous Oxycodone in Combination With Different Doses of Dexmedetomdine on Sleep Quality and Visceral Pain in Patients After Abdominal Surgery. Clin J Pain 2018; 34:1126-1132. [DOI: 10.1097/ajp.0000000000000645] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Organization of Multidisciplinary Cancer Care for the Surgical Patient: Role of Anesthesiologists. CURRENT ANESTHESIOLOGY REPORTS 2018; 8:368-374. [PMID: 30559607 DOI: 10.1007/s40140-018-0291-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Purpose of review The purpose of this review is to describe significant recent trends or developments regarding the role of anesthesiologists in a multidisciplinary team approach to cancer care for the surgical patient. We also discuss our own institutional multidisciplinary approach as a comprehensive cancer center with high surgical volume. Recent findings Beyond the multidisciplinary team meeting concept, and local, institution-specific, or national programs, more formalized concepts and models of perioperative care have evolved. These provide a framework for robust involvement of anesthesiologists in cancer care for the surgical patient, with the goal of allowing for optimal individualized cancer outcomes. Summary Because of the wide-ranging nature of their perioperative expertise, anesthesiologists play an important role in multidisciplinary team cancer care for surgical patients. This role has been seen in the recent trends toward clinical models, such as the perioperative surgical home and enhanced recovery programs. Areas for future research include multidisciplinary assessment of the impact of such models on perioperative cancer outcomes through integration of data from national outcomes groups.
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Affiliation(s)
- Elizabeth B Habermann
- Departments of Surgery and Health Sciences Research, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Jing X, Zhang B, Xing S, Tian L, Wang X, Zhou M, Li J. Cost-benefit analysis of enhanced recovery after hepatectomy in Chinese Han population. Medicine (Baltimore) 2018; 97:e11957. [PMID: 30142819 PMCID: PMC6113004 DOI: 10.1097/md.0000000000011957] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programs have been proved effective for enhancing the clinical healing rate and reducing hospitalization cost in most countries of the world. It's a multi-model approach that designed to optimize perioperative pathway, attenuate the surgical stress response, and decrease postoperative complications. OBJECTIVE The economic benefit from the application of ERAS to colorectal surgery has been demonstrated in China. However, such economic benefit of ERAS programs for hepatectomy hasn't been clarified yet. This study was carried out to explore the clinical efficacy and cost effectiveness of ERAS in Chinese Han population after hepatectomy. METHODS ERAS program was implemented in our department for hepatectomy in December 2016. In total, 79 consecutive patients after hepatectomy were chosen as ERAS group (ERAS protocol) in coming half year while 121 consecutive patients after hepatectomy were chosen as Pre-ERAS group (traditional protocol) in past half year. The operation time, intraoperative blood loss, length of hospital stay (LOS), complication, readmission, and hospitalization cost of 2 groups were compared. RESULTS The LOS of ERAS group was 5.81 ± 1.79 days, significantly shorter than that of Pre-ERAS group (8.06 ± 3.40 d) (P = .000). The operation time was 168.03 ± 46.20 minutes for ERAS group and 175.41 ± 64.64 minutes for Pre-ERAS group respectively (P = .417). The intraoperative blood loss was 166.58 ± 194.13 mL (ERAS group) and 205.45 ± 279.63 mL (Pre-ERAS group) (P = .293). It should be noted that the hospitalization cost of ERAS group was 51556.18 ± 8926.05 Yuan (7835.05 ± 1355.45 US dollars), significantly less than that of Pre-ERAS group 60554.66 ± 15615.31 Yuan (9202.56 ± 2371.24 US dollars) (P = .000). The application of ERAS effectively saved 8998.48 Yuan (1367.51 US dollars) for each patient. CONCLUSIONS ERAS implementation for hepatectomy surgery is safe and feasible for Chinese Han population. It eventually enhanced the clinical healing rate. The benefits from such programs include a reduction of the LOS, complication, and readmission rates. So each patient has access to better medical service. It effectively relieved the financial burden of patients. The benefits from such programs include a reduction of the hospitalization cost, especially in medication cost. So each patient can afford the diseases.
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