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Görges M, Sujan J, West NC, Sreepada RS, Wood MD, Payne BA, Shetty S, Gelinas JP, Sutherland AM. Postsurgical Pain Risk Stratification to Enhance Pain Management Workflow in Adult Patients: Design, Implementation, and Pilot Evaluation. JMIR Perioper Med 2024; 7:e54926. [PMID: 38954808 DOI: 10.2196/54926] [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: 11/28/2023] [Revised: 03/15/2024] [Accepted: 05/13/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Exposure to opioids after surgery is the initial contact for some people who develop chronic opioid use disorder. Hence, effective postoperative pain management, with less reliance on opioids, is critical. The Perioperative Opioid Quality Improvement (POQI) program developed (1) a digital health platform leveraging patient-survey-reported risk factors and (2) a postsurgical pain risk stratification algorithm to personalize perioperative care by integrating several commercially available digital health solutions into a combined platform. Development was reduced in scope by the COVID-19 pandemic. OBJECTIVE This pilot study aims to assess the screening performance of the risk algorithm, quantify the use of the POQI platform, and evaluate clinicians' and patients' perceptions of its utility and benefit. METHODS A POQI platform prototype was implemented in a quality improvement initiative at a Canadian tertiary care center and evaluated from January to September 2022. After surgical booking, a preliminary risk stratification algorithm was applied to health history questionnaire responses. The estimated risk guided the patient assignment to a care pathway based on low or high risk for persistent pain and opioid use. Demographic, procedural, and medication administration data were extracted retrospectively from the electronic medical record. Postoperative inpatient opioid use of >90 morphine milligram equivalents per day was the outcome used to assess algorithm performance. Data were summarized and compared between the low- and high-risk groups. POQI use was assessed by completed surveys on postoperative days 7, 14, 30, 60, 90, and 120. Semistructured patient and clinician interviews provided qualitative feedback on the platform. RESULTS Overall, 276 eligible patients were admitted for colorectal procedures. The risk algorithm stratified 203 (73.6%) as the low-risk group and 73 (26.4%) as the high-risk group. Among the 214 (77.5%) patients with available data, high-risk patients were younger than low-risk patients (age: median 53, IQR 40-65 years, vs median 59, IQR 49-69 years, median difference five years, 95% CI 1-9; P=.02) and were more often female patients (45/73, 62% vs 80/203, 39.4%; odds ratio 2.5, 95% CI 1.4-4.5; P=.002). The risk stratification was reasonably specific (true negative rate=144/200, 72%) but not sensitive (true positive rate=10/31, 32%). Only 39.7% (85/214) patients completed any postoperative quality of recovery questionnaires (only 14, 6.5% patients beyond 60 days after surgery), and 22.9% (49/214) completed a postdischarge medication survey. Interviewed participants welcomed the initiative but noted usability issues and poor platform education. CONCLUSIONS An initial POQI platform prototype was deployed operationally; the risk algorithm had reasonable specificity but poor sensitivity. There was a significant loss to follow-up in postdischarge survey completion. Clinicians and patients appreciated the potential impact of preemptively addressing opioid exposure but expressed shortcomings in the platform's design and implementation. Iterative platform redesign with additional features and reevaluation are required before broader implementation.
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Affiliation(s)
- Matthias Görges
- Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Vancouver, BC, Canada
- Research Institute, BC Children's Hospital, Vancouver, BC, Canada
| | - Jonath Sujan
- Research Institute, BC Children's Hospital, Vancouver, BC, Canada
| | - Nicholas C West
- Research Institute, BC Children's Hospital, Vancouver, BC, Canada
| | - Rama Syamala Sreepada
- Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Vancouver, BC, Canada
- Research Institute, BC Children's Hospital, Vancouver, BC, Canada
| | - Michael D Wood
- Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Vancouver, BC, Canada
- Research Institute, BC Children's Hospital, Vancouver, BC, Canada
| | - Beth A Payne
- Research Institute, BC Children's Hospital, Vancouver, BC, Canada
- School of Population and Public Health, The University of British Columbia, Vancouver, BC, Canada
| | - Swati Shetty
- MD Undergraduate Program, The University of British Columbia, Vancouver, BC, Canada
| | - Jean P Gelinas
- Department of Anesthesiology & Pain Medicine, University of Alberta, Edmonton, AB, Canada
- Department of Anesthesiology, Surrey Memorial Hospital, Surrey, BC, Canada
| | - Ainsley M Sutherland
- Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, St. Paul's Hospital, Vancouver, BC, Canada
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Park C, Reategui Via Y Rada ML, Pandhiri T, Davis S, Shipchandler T, Vernon D. Clinical and surgical factors associated with opioid refill rates following septorhinoplasty. Am J Otolaryngol 2024; 45:104268. [PMID: 38579507 DOI: 10.1016/j.amjoto.2024.104268] [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: 12/21/2023] [Revised: 03/16/2024] [Accepted: 03/18/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Septorhinoplasty is one the most common class of procedures performed worldwide, and opioids are frequently prescribed for post-operative pain [1]. OBJECTIVE The objective of this study was to examine the rate of post-operative opioid prescription refills following septorhinoplasty. METHODS This study was a case-control study of patients who underwent septoplasty and other secondary concomitant procedures. RESULTS Of the 249 patients included in this study, the majority of patients (94.8%) were prescribed 12 tablets of hydrocodone-acetaminophen 5 mg - 325 mg and only 31 patients (13.3%) received refills. The presence of osteotomies and history of prior opioid use were associated with refills. Nasal valve repair type, open versus closed approach, and presence of autologous auricular cartilage graft harvest were not. DISCUSSION Our study highlights factors that surgeons should consider when prescribing opioids after septorhinoplasty. Twelve tablets of an opioid are likely sufficient for the majority of patients, but if osteotomies are performed or the patient has a history of prior opioid use, more may be indicated to avoid the need for refills. Additional narcotics are not necessary for an open approach or for patients in which auricular cartilage is needed.
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Affiliation(s)
- Christopher Park
- Indiana University School of Medicine, Department of Otolaryngology - Head & Neck Surgery, Indianapolis, IN 46204, United States of America.
| | - Maria Laura Reategui Via Y Rada
- Indiana University School of Medicine, Department of Otolaryngology - Head & Neck Surgery, Indianapolis, IN 46204, United States of America
| | - Taruni Pandhiri
- Indiana University School of Medicine, Indianapolis, IN 46204, United States of America
| | - Seth Davis
- Stanford University School of Medicine, Stanford, CA 94304, United States of America
| | - Taha Shipchandler
- Indiana University School of Medicine, Department of Otolaryngology - Head & Neck Surgery, Indianapolis, IN 46204, United States of America
| | - Dominic Vernon
- Indiana University School of Medicine, Department of Otolaryngology - Head & Neck Surgery, Indianapolis, IN 46204, United States of America
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Katar MK, Turan UF. Efficacy and Safety of Paragastric Neural Blockade in Controlling Pain, Nausea, and Vomiting After Sleeve Gastrectomy: A Randomized Controlled Trial. Obes Surg 2024; 34:2383-2390. [PMID: 38713336 PMCID: PMC11217077 DOI: 10.1007/s11695-024-07255-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 04/21/2024] [Accepted: 04/24/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND There are difficulties in controlling the symptoms of pain, nausea, and vomiting after laparoscopic sleeve gastrectomy (LSG). This study aimed to evaluate the efficacy and safety of PGNB on pain and nausea and vomiting in the early postoperative period in patients who underwent LSG. METHODS In this prospective, randomized, controlled, double-blind study, the patients were divided into two equally formed groups: patients who underwent PGNB after LSG and the control group. Postoperative pain symptoms were evaluated using the visual analog scale (VAS) scores, and nausea and vomiting symptoms were evaluated using the postoperative nausea and vomiting (PONV) scores. RESULTS The study was completed with 90 patients, 45 patients in each group. The VAS scores measured at postoperative hours 1, 6, and 12 were statistically significantly lower in the PGNB group. There was no significant difference between the two groups in terms of the 24th hour VAS scores. The mean PONV scores of the PGNB and control groups were 0.47 ± 0.89 and 1.67 ± 1.95, respectively, revealing a significantly higher value for the controls. The mean time to first mobilization in the postoperative period was significantly shorter in the PGNB group. Upon the evaluation of patient satisfaction, it was determined that the satisfaction score of the PGNB group was significantly higher. CONCLUSIONS PGNB is an effective and safe method for managing pain, nausea, and vomiting that occur in the early period after LSG.
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Affiliation(s)
- Mehmet Kağan Katar
- General Surgery Department, Faculty of Medicine, Atlas University, Istanbul, 34450, Turkey.
| | - Umut Fırat Turan
- General Surgery Department, Faculty of Medicine, Atlas University, Istanbul, 34450, Turkey
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Carrascosa AJ, García-Gutiérrez MS, Saldaña R, Manzanares J. Additive antinociceptive action of intrathecal anandamide reuptake inhibitor and morphine in the management of post-incisional pain in rats. Biomed Pharmacother 2024; 177:117054. [PMID: 38943991 DOI: 10.1016/j.biopha.2024.117054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 06/19/2024] [Accepted: 06/26/2024] [Indexed: 07/01/2024] Open
Abstract
Spinal opioids have mixed efficacy and their adverse effects force treatment cessation of postoperative pain. Consequently, there is an ongoing search for new therapeutic strategies. Here, we evaluated the analgesic efficacy of intrathecal UCM707, an anandamide reuptake inhibitor, and morphine combination. Firstly, we assessed the effects of morphine (1, 5 and 10 μg), UCM707 (75 μg) and its combination in the hot plate. Then, morphine + UCM707 at sub-effective doses was evaluated in a rat post-incisional pain model. In addition, μ-, CB1r-, CB2r- and TRPV1-antagonists were pre-administered before the combination. Activation of μ-opioid and CB1r, and Cnr1, Cnr2, Oprm1 and TRPV1 expressions were evaluated in the lumbar sacra and periaqueductal grey by [35 S]-GTPγS binding autoradiography and qPCR studies. In the hot plate, morphine (1 μg) and UCM707 (75 μg) induced a more robust analgesic effect than each drug alone. Morphine plus UCM707 did not modify μ-opioid nor CB1 receptor function in the PAG or LS. Cnr1 and TRPV1 expression increased in the lumbar sacra (LS). Morphine plus UCM707 significantly reduced post-incisional pain at 1 and 4 days after surgery. Cnr1, Cnr2 and TRPV1 expressions increased in the LS. Blockade of μ-opioid receptor reduced combination effects on days 1 and 4. CB1r- and CB2r-antagonism reduced morphine + UCM707 effects on days 1 and 4, respectively. CB1r and TRPV1-antagonism improved their antinociceptive effects on day 4. These results revealed a synergistic/additive analgesic effect of UCM707 and morphine combination controlling postincisional pain. CB1r, CB2r and TRPV1 contribute differently as central sensitization occurs.
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Affiliation(s)
- Antonio J Carrascosa
- Department of Anesthesiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - María S García-Gutiérrez
- Instituto de Neurociencias, Campus de San Juan, Universidad Miguel Hernández-CSIC, San Juan de Alicante, Alicante, Spain; Red de Investigación en Atención Primaria de Adicciones, Instituto de Salud Carlos III, MICINN and FEDER, Madrid, Spain; Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - Raquel Saldaña
- Department of Anesthesiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Jorge Manzanares
- Instituto de Neurociencias, Campus de San Juan, Universidad Miguel Hernández-CSIC, San Juan de Alicante, Alicante, Spain; Red de Investigación en Atención Primaria de Adicciones, Instituto de Salud Carlos III, MICINN and FEDER, Madrid, Spain; Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain.
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Mogianos K, Undén J, Persson A. Effect of individualized anesthesia and analgesia on postoperative pain in patients stratified for pain sensitivity: A study protocol for the PeriOPerative individualization trial randomized controlled trial. Acta Anaesthesiol Scand 2024. [PMID: 38937954 DOI: 10.1111/aas.14487] [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: 06/04/2024] [Accepted: 06/14/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Despite advancements in surgical and anesthesia techniques, acute and persistent postoperative pain are still a common challenge. Postoperative pain has direct effects on individual patient care and outcome, as well as putting strain on limited health care resources. Several prediction methods for postoperative pain have been described. One such method is the assessment of pain during peripheral venous cannulation (VCP). It is not known if different approaches to anesthesia and analgesia, depending on the evaluation of risk for postoperative pain, can improve outcome. The aim of this study is to evaluate if individualized anesthesia and analgesia can affect postoperative pain and recovery after surgery, in patients stratified by VCP. METHODS Adult patients scheduled for laparoscopic surgery undergo pain-sensitivity stratification using VCP on the day of surgery. Patients scoring VCP ≥2.0 on the visual analogue scale (pain-sensitive) are randomized to multimodal anaesthesia and analgesia with opioids or standard of care. Patients scoring VCP ≤1.9 (pain-tolerant) are randomized to opioid-free anaesthesia or standard of care. The primary outcome is acute postoperative pain measured with numeric rating scale in the postoperative care unit. Secondary outcomes include analysis of pain after 24 h, persistent postoperative pain and quality of recovery. DISCUSSION Individualized perioperative pain management has the potential to improve patient care. This study will examine the impact of different anesthesia and analgesia regimes, in patients with differing pain sensitivity, on postoperative pain. TRIAL REGISTRATION Prospectively posted at ClinicalTrials.gov, identifier NCT04751812.
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Affiliation(s)
- Krister Mogianos
- Department of Anesthesiology and Intensive Care Medicine, Halland Hospital Halmstad, Halmstad, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Johan Undén
- Department of Anesthesiology and Intensive Care Medicine, Halland Hospital Halmstad, Halmstad, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Anna Persson
- Department of Anesthesiology and Intensive Care Medicine, Halland Hospital Halmstad, Halmstad, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
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Carrascosa AJ, Navarrete F, Saldaña R, García-Gutiérrez MS, Montalbán B, Navarro D, Gómez-Guijarro FM, Gasparyan A, Murcia-Sánchez E, Torregrosa AB, Pérez-Doblado P, Gutiérrez L, Manzanares J. Cannabinoid Analgesia in Postoperative Pain Management: From Molecular Mechanisms to Clinical Reality. Int J Mol Sci 2024; 25:6268. [PMID: 38892456 PMCID: PMC11172912 DOI: 10.3390/ijms25116268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/26/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
Postoperative pain (POP) is a challenging clinical phenomenon that affects the majority of surgical patients and demands effective management to mitigate adverse outcomes such as persistent pain. The primary goal of POP management is to alleviate suffering and facilitate a seamless return to normal function for the patient. Despite compelling evidence of its drawbacks, opioid analgesia remains the basis of POP treatment. Novel therapeutic approaches rely on multimodal analgesia, integrating different pharmacological strategies to optimize efficacy while minimizing adverse effects. The recognition of the imperative role of the endocannabinoid system in pain regulation has prompted the investigation of cannabinoid compounds as a new therapeutic avenue. Cannabinoids may serve as adjuvants, enhancing the analgesic effects of other drugs and potentially replacing or at least reducing the dependence on other long-term analgesics in pain management. This narrative review succinctly summarizes pertinent information on the molecular mechanisms, clinical therapeutic benefits, and considerations associated with the plausible use of various cannabinoid compounds in treating POP. According to the available evidence, cannabinoid compounds modulate specific molecular mechanisms intimately involved in POP. However, only two of the eleven clinical trials that evaluated the efficacy of different cannabinoid interventions showed positive results.
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Affiliation(s)
- Antonio J. Carrascosa
- Servicio de Anestesiologia y Reanimación, Hospital Universitario 12 de Octubre, Avda. Córdoba s/n, 28041 Madrid, Spain; (A.J.C.); (R.S.); (B.M.); (F.M.G.-G.); (E.M.-S.); (P.P.-D.)
| | - Francisco Navarrete
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda de Ramón y Cajal s/n, San Juan de Alicante, 03550 Alicante, Spain; (F.N.); (M.S.G.-G.); (D.N.); (A.G.); (A.B.T.); (L.G.)
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, 28029 Madrid, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), 03010 Alicante, Spain
| | - Raquel Saldaña
- Servicio de Anestesiologia y Reanimación, Hospital Universitario 12 de Octubre, Avda. Córdoba s/n, 28041 Madrid, Spain; (A.J.C.); (R.S.); (B.M.); (F.M.G.-G.); (E.M.-S.); (P.P.-D.)
| | - María S. García-Gutiérrez
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda de Ramón y Cajal s/n, San Juan de Alicante, 03550 Alicante, Spain; (F.N.); (M.S.G.-G.); (D.N.); (A.G.); (A.B.T.); (L.G.)
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, 28029 Madrid, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), 03010 Alicante, Spain
| | - Belinda Montalbán
- Servicio de Anestesiologia y Reanimación, Hospital Universitario 12 de Octubre, Avda. Córdoba s/n, 28041 Madrid, Spain; (A.J.C.); (R.S.); (B.M.); (F.M.G.-G.); (E.M.-S.); (P.P.-D.)
| | - Daniela Navarro
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda de Ramón y Cajal s/n, San Juan de Alicante, 03550 Alicante, Spain; (F.N.); (M.S.G.-G.); (D.N.); (A.G.); (A.B.T.); (L.G.)
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, 28029 Madrid, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), 03010 Alicante, Spain
| | - Fernando M. Gómez-Guijarro
- Servicio de Anestesiologia y Reanimación, Hospital Universitario 12 de Octubre, Avda. Córdoba s/n, 28041 Madrid, Spain; (A.J.C.); (R.S.); (B.M.); (F.M.G.-G.); (E.M.-S.); (P.P.-D.)
| | - Ani Gasparyan
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda de Ramón y Cajal s/n, San Juan de Alicante, 03550 Alicante, Spain; (F.N.); (M.S.G.-G.); (D.N.); (A.G.); (A.B.T.); (L.G.)
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, 28029 Madrid, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), 03010 Alicante, Spain
| | - Elena Murcia-Sánchez
- Servicio de Anestesiologia y Reanimación, Hospital Universitario 12 de Octubre, Avda. Córdoba s/n, 28041 Madrid, Spain; (A.J.C.); (R.S.); (B.M.); (F.M.G.-G.); (E.M.-S.); (P.P.-D.)
| | - Abraham B. Torregrosa
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda de Ramón y Cajal s/n, San Juan de Alicante, 03550 Alicante, Spain; (F.N.); (M.S.G.-G.); (D.N.); (A.G.); (A.B.T.); (L.G.)
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, 28029 Madrid, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), 03010 Alicante, Spain
| | - Paloma Pérez-Doblado
- Servicio de Anestesiologia y Reanimación, Hospital Universitario 12 de Octubre, Avda. Córdoba s/n, 28041 Madrid, Spain; (A.J.C.); (R.S.); (B.M.); (F.M.G.-G.); (E.M.-S.); (P.P.-D.)
| | - Luisa Gutiérrez
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda de Ramón y Cajal s/n, San Juan de Alicante, 03550 Alicante, Spain; (F.N.); (M.S.G.-G.); (D.N.); (A.G.); (A.B.T.); (L.G.)
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, 28029 Madrid, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), 03010 Alicante, Spain
| | - Jorge Manzanares
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda de Ramón y Cajal s/n, San Juan de Alicante, 03550 Alicante, Spain; (F.N.); (M.S.G.-G.); (D.N.); (A.G.); (A.B.T.); (L.G.)
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, 28029 Madrid, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), 03010 Alicante, Spain
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Stephenson KJ, Krinock DJ, Vasquez IL, Shewmake CN, Spray BJ, Ketha B, Wolf LL, Dassinger MS. Implementation of Guidelines Limiting Postoperative Opioid Prescribing at a Children's Hospital. J Patient Saf 2024; 20:299-305. [PMID: 38240645 DOI: 10.1097/pts.0000000000001209] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
OBJECTIVES Variability in opioid-prescribing practices after common pediatric surgical procedures at our institution prompted the development of opioid-prescribing guidelines that provided suggested dose limitations for narcotics. The aims of this study were to improve opioid prescription practices through implementation of the developed guidelines and to assess compliance and identify barriers preventing guideline utilization. METHODS We conducted a single-center cohort study of all children who underwent the most common outpatient general surgery procedures at our institution from August 1, 2018, to February 1, 2020. We created guidelines designed to limit opioid prescription doses based on data obtained from standardized postoperative telephone interviews. Three 6-month periods were evaluated: before guideline implementation, after guideline initiation, and after addressing barriers to guideline compliance. Targeted interventions to increase compliance included modification of electronic medical record defaults and provider educations. Differences in opioid weight-based doses prescribed, filled, and taken, as well as protocol adherence between the 3 timeframes were evaluated. RESULTS A total of 1033 children underwent an outpatient procedure during the 1.5-year time frame. Phone call response rate was 72.22%. There was a significant sustained decrease in opioid doses prescribed ( P < 0.0001), prescriptions filled ( P = 0.009), and opioid doses taken ( P = 0.001) after implementation, without subsequent increase in reported pain on postoperative phone call ( P = 0.96). Protocol compliance significantly improved (62.39% versus 83.98%, P < 0.0001) after obstacles were addressed. CONCLUSIONS Implementation of a protocol limiting opioid prescribing after frequently performed pediatric general surgery procedures reduced opioids prescribed and taken postoperatively. Interventions that addressed barriers to application led to increased protocol compliance and sustained decreases in opioids prescribed and taken without a deleterious effect on pain control.
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Affiliation(s)
| | - Derek J Krinock
- From the Department of Surgery, University of Arkansas for Medical Sciences
| | - Isabel L Vasquez
- Department of Surgery, Arkansas Children's Hospital Research Institute
| | | | | | - Bavana Ketha
- Department of Pediatric Surgery, Arkansas Children's Hospital, Little Rock, Arizona
| | - Lindsey L Wolf
- Department of Pediatric Surgery, Arkansas Children's Hospital, Little Rock, Arizona
| | - Melvin S Dassinger
- Department of Pediatric Surgery, Arkansas Children's Hospital, Little Rock, Arizona
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Masood R, LeRoy TE, Moverman MA, Feldman MW, Rogerson A, Salzler MJ. Functional Somatic Syndromes Are Associated With Varied Postoperative Outcomes and Increased Opioid Use After Spine Surgery: A Systematic Review. Global Spine J 2024; 14:1601-1608. [PMID: 38124313 DOI: 10.1177/21925682231217706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
STUDY DESIGN Systematic Review. OBJECTIVE To perform a systematic review assessing the relationship between functional somatic syndromes (FSSs) and clinical outcomes after spine surgery. METHODS A systematic review of online databases (PubMed and Web of Science) through December 2021 was conducted via PRISMA guidelines to identify all studies investigating the impact of at least one FSS (fibromyalgia, irritable bowel syndrome (IBS), chronic headaches/migraines, interstitial cystitis, chronic fatigue syndrome, multiple chemical sensitivity) on outcomes after spine surgery. Outcomes of interest included patient reported outcome measures (PROMs), postoperative opioid use, cost of care, complications, and readmission rates. RESULTS A total of 207 records were identified. Seven studies (n = 40,011 patients) met inclusion criteria with a mean MINORS score of 16.6 out of 24. Four studies (n = 21,086) reported postoperative opioid use; fibromyalgia was a strong risk factor for long-term opioid use after surgery whereas the association with chronic migraines remains unclear. Two studies (n = 233) reported postoperative patient reported outcome measures (PROMs) with mixed results suggesting a possible association between fibromyalgia and less favorable PROMs. One study (n = 18,692) reported higher postoperative complications in patients with fibromyalgia. CONCLUSION Patients with fibromyalgia and possibly migraines are at higher risk for prolonged postoperative opioid use and less favorable PROMs after spine surgery. There is limited research on the relationship between other Functional somatic syndromes (FSSs) and outcomes following spine surgery. Growing evidence suggests the variation in outcomes after spine procedures may be attributed to non-identifiable organic patient factors such as FSSs.
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Affiliation(s)
- Raisa Masood
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA, United States
| | - Taryn E LeRoy
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA, United States
| | - Michael A Moverman
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA, United States
| | | | - Ashley Rogerson
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA, United States
| | - Matthew J Salzler
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA, United States
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Spears CA, Hodges SE, Liu B, Venkatraman V, Edwards RM, Than KD, Abd-El-Barr MM, Parente B, Lee HJ, Lad SP. Nationwide Analysis of Risk Factors Related to Opioid Weaning Following Lumbar Decompression Surgery - A Retrospective Database Study. World Neurosurg 2024; 186:e20-e34. [PMID: 38519019 DOI: 10.1016/j.wneu.2023.12.025] [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: 09/30/2023] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 03/24/2024]
Abstract
BACKGROUND Opioids are often prescribed for patients who eventually undergo lumbar decompression. Given the potential for opioid-related morbidity and mortality, postoperative weaning is often a goal of surgery. The purpose of this study was to examine the relationship between preoperative opioid use and postoperative complete opioid weaning among lumbar decompression patients. METHODS We surveyed the IBM Marketscan Databases for patients who underwent lumbar decompression during 2008-2017, had >30 days of opioid use in the year preceding surgery, and consumed a daily average of >0 morphine milligram equivalents in the 3 months preceding surgery. We used multivariable logistic regression and marginal standardization to examine the association between preoperative opioid use duration, average daily dose, and their interactions with complete opioid weaning in the 10-12 months after surgery. RESULTS Of the 11,114 patients who met inclusion criteria, most (54.7%, n = 6083) had a preoperative average daily dose of 1-20 morphine milligram equivalents. Postoperatively, 6144 patients (55.3%) remained on opioids. For patients with >180 days of preoperative use, the adjusted probability of weaning increased as the preoperative dose decreased. Obesity increased the likelihood of weaning, whereas older age, several comorbidities, female sex, and Medicaid decreased the odds of weaning. CONCLUSIONS Patients who used opioids for longer preoperatively were less likely to completely wean following surgery. Among patients with >180 days of preoperative use, those with lower preoperative doses were more likely to wean. Weaning was also associated with several clinical and demographic factors. These findings may help shape expectations regarding opioid use following lumbar decompression.
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Affiliation(s)
- Charis A Spears
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Sarah E Hodges
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Beiyu Liu
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Vishal Venkatraman
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Ryan M Edwards
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Khoi D Than
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Beth Parente
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Hui-Jie Lee
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA.
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10
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Khalil M, Woldesenbet S, Munir MM, Khan MMM, Rashid Z, Altaf A, Katayama E, Endo Y, Dillhoff M, Tsai S, Pawlik TM. Long-term Health Outcomes of New Persistent Opioid Use After Gastrointestinal Cancer Surgery. Ann Surg Oncol 2024:10.1245/s10434-024-15435-1. [PMID: 38762641 DOI: 10.1245/s10434-024-15435-1] [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: 02/26/2024] [Accepted: 04/24/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND New persistent opioid use (NPOU) after surgery has been identified as a common complication. This study sought to assess the long-term health outcomes among patients who experienced NPOU after gastrointestinal (GI) cancer surgery. METHODS Patients who underwent surgery for hepato-pancreato-biliary and colorectal cancer between 2007 and 2019 were identified using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. Mixed-effect multivariable logistic regression and Cox proportional hazard models were used to estimate the risk of mortality and hospital visits related to falls, respiratory events, or pain symptoms. RESULTS Among 15,456 patients who underwent GI cancer surgery, 967(6.6%) experienced NPOU. Notably, the patients at risk for the development of NPOU were those with a history of substance abuse (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.14-1.84), moderate social vulnerability (OR, 1.26; 95% CI, 1.06-1.50), an advanced disease stage (OR, 4.42; 95% CI, 3.51-5.82), or perioperative opioid use (OR, 3.07; 95% CI, 2.59-3.63. After control for competing risk factors, patients who experienced NPOU were more likely to visit a hospital for falls, respiratory events, or pain symptoms (OR, 1.45, 95% CI 1.18-1.78). Moreover, patients who experienced NPOU had a greater risk of death at 1 year (hazard ratio [HR], 2.15; 95% CI, 1.74-2.66). CONCLUSION Approximately 1 in 15 patients experienced NPOU after GI cancer surgery. NPOU was associated with an increased risk of subsequent hospital visits and higher mortality. Targeted interventions for individuals at higher risk for NPOU after surgery should be used to help mitigate the harmful effects of NPOU.
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Affiliation(s)
- Mujtaba Khalil
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Muhammad Muntazir Mehdi Khan
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Zayed Rashid
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Abdullah Altaf
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Erryk Katayama
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Susan Tsai
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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11
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Karlsen APH, Laigaard J, Pedersen C, Thybo KH, Gasbjerg KS, Geisler A, Lunn TH, Hägi-Pedersen D, Jakobsen JC, Mathiesen O. Minimal important difference in postoperative morphine consumption after hip and knee arthroplasty using nausea, vomiting, sedation and dizziness as anchors. Acta Anaesthesiol Scand 2024; 68:610-618. [PMID: 38380438 DOI: 10.1111/aas.14388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 01/05/2024] [Accepted: 01/30/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Morphine-sparing effects are often used to evaluate non-opioid analgesic interventions. The exact effect that would warrant the implementation of these interventions in clinical practice (a minimally important difference) remains unclear. We aimed to determine this with anchor-based methods. METHODS This was a post hoc analysis of three studies investigating pain management after hip or knee arthroplasty (PANSAID [NCT02571361], DEX-2-TKA [NCT03506789] and Pain Map [NCT02340052]). The overall population was median aged 70, median ASA 2, 54% female. We examined the correlation between 0 and 24 h postoperative iv morphine equivalent consumption and the severity of nausea, vomiting, sedation and dizziness. The anchor was different severity degrees of these opioid-related adverse events. The primary outcome was the difference in morphine consumption between patients experiencing no versus only mild events. Secondary outcomes included the difference in morphine consumption between patients with mild versus moderate and moderate versus severe events. We used Hodges-Lehmann median differences, exact Wilcoxon-Mann-Whitney tests and quantile regression. RESULTS The difference in iv morphine consumption was 6 mg (95% confidence interval: 4-8) between patients with no versus only mild events, 5 mg (2-8) between patients with mild versus moderate events and 0 mg (-4 to 4) between patients with moderate versus severe events. CONCLUSIONS In populations comparable to this post-hoc analysis (orthopaedic surgery, median age 70 and ASA 2), we suggest a minimally important difference of 5 mg for 0-24 h postoperative iv morphine consumption.
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Affiliation(s)
- Anders Peder Højer Karlsen
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospitals, Copenhagen, Denmark
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
| | - Jens Laigaard
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Casper Pedersen
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
| | - Kasper Højgaard Thybo
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
| | - Kasper Smidt Gasbjerg
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
- Research Centre of Anaesthesiology and Intensive Care Medicine, Department of Anaesthesiology, Næstved-Slagelse-Ringsted Hospitals, Denmark
| | - Anja Geisler
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Troels Haxholdt Lunn
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospitals, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Hägi-Pedersen
- Research Centre of Anaesthesiology and Intensive Care Medicine, Department of Anaesthesiology, Næstved-Slagelse-Ringsted Hospitals, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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12
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Segebarth PB, Schallmo M, Odum S, Hietpas K, Michalek C, Chapman TM, Leas D, Milam RA, Hamid N. Opioid-Free Analgesia is Safe and Effective in Anterior Cervical Spine Surgery: A Randomized Controlled Trial. Clin Spine Surg 2024; 37:138-148. [PMID: 38553433 DOI: 10.1097/bsd.0000000000001608] [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: 01/09/2024] [Accepted: 02/28/2024] [Indexed: 05/07/2024]
Abstract
STUDY DESIGN Randomized controlled trial (RCT). OBJECTIVE Compare the efficacy of a multimodal, opioid-free (OF) pain management pathway with a traditional opioid-containing (OC) pathway in patients undergoing anterior cervical procedures. SUMMARY OF BACKGROUND DATA Previous studies have compared opioid-based pain regimens to opioid-sparing regimens following cervical spine surgery, but have been limited by high rates of crossover, retrospective designs, reliance on indwelling pain catheters, opioid utilization for early postoperative analgesia, and/or a lack of patient-reported outcome measures. METHODS This is a RCT in which patients were allocated to either an OF or OC perioperative pain management protocol. Eligible study participants included adult (age up to 18 y) patients who underwent primary, 1-level or 2-level anterior cervical surgery [anterior cervical discectomy and fusion (ACDF), anterior cervical disc arthroplasty (ACDA), or hybrid (ACDF and ACDA at different levels)] for degenerative pathology. The primary outcome variable was subjective pain level at 24 hours postoperative. The final study cohort consisted of 50 patients (22 OF, 28 OC). RESULTS Patients in the OF group reported lower median postoperative pain levels at 6 hours (4 for OF vs. 7 for OC; P =0.041) and 24 hours (3 for OF vs. 5 for OC; P =0.032). At 2-week and 6-week follow-up, pain levels were similar between groups. Patients in the OF group reported greater comfort at 12 hours (9 for OF vs. 5 for OC; P =0.003) and 24 hours (9 for OF vs. 5 for OC; P =0.011) postoperatively. Notably, there were no significant differences in patients' reported pain satisfaction, overall surgical satisfaction, or overall sense of physical and mental well-being. In addition, there were no significant differences in falls, delirium, or constipation postoperatively. CONCLUSIONS A multimodal OF pain management pathway following anterior cervical surgery for degenerative disease results in statistically noninferior pain control and equivalent patient-reported outcome measures compared with a traditional OC pathway.
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13
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Garcia S, Mali M, Grewal A. Pro: Methadone Should Be Used as a Part of Enhanced Recovery After Cardiac Surgery Protocol. J Cardiothorac Vasc Anesth 2024; 38:1268-1271. [PMID: 38458828 DOI: 10.1053/j.jvca.2024.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 03/10/2024]
Affiliation(s)
- Shelby Garcia
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Mitali Mali
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Ashanpreet Grewal
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD.
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14
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Bates JN, Baby SM, Getsy PM, Coffee GA, Hsieh YH, Knauss ZT, Dahan A, Bubier JA, MacFarlane PM, Mueller D, Lewis SJ. L-NAC and L-NAC methyl ester prevent and overcome physical dependence to fentanyl in male rats. Sci Rep 2024; 14:9091. [PMID: 38643270 PMCID: PMC11032344 DOI: 10.1038/s41598-024-59551-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 04/11/2024] [Indexed: 04/22/2024] Open
Abstract
N-acetyl-L-cysteine (L-NAC) is a proposed therapeutic for opioid use disorder. This study determined whether co-injections of L-NAC (500 μmol/kg, IV) or its highly cell-penetrant analogue, L-NAC methyl ester (L-NACme, 500 μmol/kg, IV), prevent acquisition of acute physical dependence induced by twice-daily injections of fentanyl (125 μg/kg, IV), and overcome acquired dependence to these injections in freely-moving male Sprague Dawley rats. The injection of the opioid receptor antagonist, naloxone HCl (NLX; 1.5 mg/kg, IV), elicited a series of withdrawal phenomena (i.e. behavioral and cardiorespiratory responses, hypothermia and body weight loss) in rats that received 5 or 10 injections of fentanyl and similar numbers of vehicle co-injections. With respect to the development of dependence, the NLX-precipitated withdrawal phenomena were reduced in rats that received had co-injections of L-NAC, and more greatly reduced in rats that received co-injections of L-NACme. In regard to overcoming established dependence, the NLX-precipitated withdrawal phenomena in rats that had received 10 injections of fentanyl (125 μg/kg, IV) were reduced in rats that had received co-injections of L-NAC, and more greatly reduced in rats that received co-injections of L-NACme beginning with injection 6 of fentanyl. This study provides compelling evidence that co-injections of L-NAC and L-NACme prevent the acquisition of physical dependence and overcome acquired dependence to fentanyl in male rats. The higher efficacy of L-NACme is likely due to its greater cell penetrability in brain regions mediating dependence to fentanyl and interaction with intracellular signaling cascades, including redox-dependent processes, responsible for the acquisition of physical dependence to fentanyl.
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Affiliation(s)
- James N Bates
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Atelerix Life Sciences Inc., 300 East Main Street, Suite 202, Charlottesville, VA, USA
| | - Santhosh M Baby
- Section of Biology, Galleon Pharmaceuticals, Inc, Horsham, PA, USA
- Translational Sciences Treatment Discovery, Galvani Bioelectronics, Inc, 1250 S Collegeville Rd, Collegeville, PA, USA
| | - Paulina M Getsy
- Department of Pediatrics, Division of Pulmonology, Allergy, and Immunology, Case Western Reserve University, Cleveland, OH, USA
| | - Gregory A Coffee
- Department of Pediatrics, Division of Pulmonology, Allergy, and Immunology, Case Western Reserve University, Cleveland, OH, USA
| | - Yee-Hsee Hsieh
- Division of Pulmonary, Critical Care and Sleep Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Zackery T Knauss
- Department of Biological Sciences, Kent State University, Kent, OH, USA
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Peter M MacFarlane
- Department of Pediatrics, Division of Pulmonology, Allergy, and Immunology, Case Western Reserve University, Cleveland, OH, USA
| | - Devin Mueller
- Department of Biological Sciences, Kent State University, Kent, OH, USA
| | - Stephen J Lewis
- Department of Pediatrics, Division of Pulmonology, Allergy, and Immunology, Case Western Reserve University, Cleveland, OH, USA.
- Department of Pharmacology, Case Western Reserve University, Cleveland, OH, USA.
- Functional Electrical Stimulation Center, Case Western Reserve University, Cleveland, OH, USA.
- Department of Pediatrics, Division of Pulmonology, Allergy and Immunology, School of Medicine,, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, USA.
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15
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Sutton KF, Cabell GH, Ashley LW, Lentz TA, Lewis BD, Olson SA, Mather RC. Does psychological distress predict risk of orthopaedic surgery and postoperative opioid prescribing in patients with hip pain? A retrospective study. BMC Musculoskelet Disord 2024; 25:304. [PMID: 38643071 PMCID: PMC11031887 DOI: 10.1186/s12891-024-07418-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 04/05/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND Clinicians and public health professionals have allocated resources to curb opioid over-prescription and address psychological needs among patients with musculoskeletal pain. However, associations between psychological distress, risk of surgery, and opioid prescribing among those with hip pathologies remain unclear. METHODS Using a retrospective cohort study design, we identified patients that were evaluated for hip pain from January 13, 2020 to October 27, 2021. Patients' surgical histories and postoperative opioid prescriptions were extracted via chart review. Risk of hip surgery within one year of evaluation was analyzed using multivariable logistic regression. Multivariable linear regression was employed to predict average morphine milligram equivalents (MME) per day of opioid prescriptions within the first 30 days after surgery. Candidate predictors included age, gender, race, ethnicity, employment, insurance type, hip function and quality of life on the International Hip Outcome Tool (iHOT-12), and psychological distress phenotype using the OSPRO Yellow Flag (OSPRO-YF) Assessment Tool. RESULTS Of the 672 patients, n = 350 (52.1%) underwent orthopaedic surgery for hip pain. In multivariable analysis, younger patients, those with TRICARE/other government insurance, and those with a high psychological distress phenotype had higher odds of surgery. After adding iHOT-12 scores, younger patients and lower iHOT-12 scores were associated with higher odds of surgery, while Black/African American patients had lower odds of surgery. In multivariable analysis of average MME, patients with periacetabular osteotomy (PAO) received opioid prescriptions with significantly higher average MME than those with other procedures, and surgery type was the only significant predictor. Post-hoc analysis excluding PAO found higher average MME for patients undergoing hip arthroscopy (compared to arthroplasty or other non-PAO procedures) and significantly lower average MME for patients with public insurance (Medicare/Medicaid) compared to those with private insurance. Among those only undergoing arthroscopy, older age and having public insurance were associated with opioid prescriptions with lower average MME. Neither iHOT-12 scores nor OSPRO-YF phenotype assignment were significant predictors of postoperative mean MME. CONCLUSIONS Psychological distress characteristics are modifiable targets for rehabilitation programs, but their use as prognostic factors for risk of orthopaedic surgery and opioid prescribing in patients with hip pain appears limited when considered alongside other commonly collected clinical information such as age, insurance, type of surgery pursued, and iHOT-12 scores.
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Affiliation(s)
- Kent F Sutton
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA.
| | - Grant H Cabell
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Lucas W Ashley
- Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Trevor A Lentz
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Brian D Lewis
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Steven A Olson
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Richard C Mather
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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16
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Hermans SMM, Lantinga-Zee AAG, Droeghaag R, van Santbrink H, van Hemert WLW, Reinders MK, Hoofwijk DMN, van Kuijk SMJ, Rijkers K, Curfs I. A Randomized Controlled Trial Using Epidural Analgesia for Pain Relief After Lumbar Interlaminar Decompressive Spine Surgery: The RAPID trial. Spine (Phila Pa 1976) 2024; 49:456-462. [PMID: 38214681 DOI: 10.1097/brs.0000000000004921] [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: 11/13/2023] [Accepted: 12/29/2023] [Indexed: 01/13/2024]
Abstract
STUDY DESIGN Prospective, double-blind randomized controlled trial. OBJECTIVE If an intraoperative single bolus of epidural bupivacaine can result in less postoperative pain following lumbar spinal decompression surgery. SUMMARY OF BACKGROUND DATA Adequate postoperative pain management following lumbar spinal decompression surgery is important, as it will lead to early mobilization, less complications, and a shorter hospital stay. Opioid consumption should be limited due to their frequently accompanied side effects and their addictive nature. During the final phase of lumbar decompression surgery, the epidural space becomes easily accessible. This might be an ideal moment for surgeons to administer an epidural bolus of analgesia as a safe and effective method for postoperative pain relief. MATERIALS AND METHODS In this trial, we compared a single intraoperative bolus of epidural analgesia using bupivacaine 0.25% to placebo (NaCl 0.9%) and its effect on postoperative pain following lumbar spinal decompression surgery. The primary outcome was the difference in Numeric (Pain) Rating Scale between the intervention and placebo groups during the first 48 hours after surgery. RESULTS Both the intervention group and the placebo group consisted of 20 randomized patients (N=40). Statistically significant lower mean Numeric (Pain) Rating Scale pain scores were observed in the intervention group in comparison with the control group (main effect group: -2.35±0.77, P =0.004). The average pain score was lower in the intervention group at all postoperative time points. No study-related complications occurred. CONCLUSION This randomized controlled trial shows that administrating a bolus of intraoperative epidural bupivacaine is a safe and effective method for reducing early postoperative pain following lumbar decompression surgery.
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Affiliation(s)
- Sem M M Hermans
- Department of Orthopaedic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | | | - Ruud Droeghaag
- Department of Orthopaedic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Henk van Santbrink
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Neurosurgery, Zuyderland Medical Center, Heerlen, The Netherlands
- Care and Public Health Research Institute (CAPHRI) Maastricht University, Maastricht, The Netherlands
| | - Wouter L W van Hemert
- Department of Orthopaedic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Mattheus K Reinders
- Department of Clinical Pharmacy, Pharmacology and Toxicology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Daisy M N Hoofwijk
- Department of Anaesthesiology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Kim Rijkers
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Neurosurgery, Zuyderland Medical Center, Heerlen, The Netherlands
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Inez Curfs
- Department of Orthopaedic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
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17
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Siebenmorgen JP, Goree JH, Siegel ER, Norman SE, Stronach BM, Stambough JB, Mears SC. Hospital-Wide Adherence to Postsurgical Opioid Prescribing Guidelines: A Retrospective Cohort Study. J Surg Res 2024; 296:571-580. [PMID: 38340491 DOI: 10.1016/j.jss.2024.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 01/10/2024] [Accepted: 01/18/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION Lowering opioid prescription doses and quantity decreases the risk of chronic opioid usage. A tool was inserted into the brief operative note for the surgeon to assess the severity of pain associated with the procedure. We studied surgeon adherence to current opioid-prescribing recommendations. METHODS Retrospective cohort study with 5486 patients were included in the study population. Each patient's prescription was scored yes or no for adherence on total morphine milligram equivalents (MMEs) and days prescribed with the selection in the brief operative note. The entire study population was tested for an increase from the null-hypothesis "benchmark" value of 75% using a one-sided exact binomial test of a single proportion with P < 0.05. This procedure was repeated for subgroups, with P < 0.01. RESULTS Adherence to guidelines was higher than the 75% benchmark for "total MMEs prescribed" (79.5%; P < 0.001), but lower for "number of days prescribed" (63.5%; P > 0.999). Surgeries with severe predicted pain showed the highest adherence toward total MMEs prescribed at 87.1%, followed by moderate (80.5%) and mild (74.5%). Severe cases also showed the highest adherence in number of days prescribed (92.4%). Adherence to total MMEs prescribed was highest among attending physicians (88.1%) and lowest among residents/fellows (76.6%). CONCLUSIONS Adherence to current guidelines was 79.5% for MMEs prescribed but only 63.5% for days prescribed. Compliance with guidelines was better for severe procedures than mild or moderate. Differences were seen across surgical departments. While an improvement from previous reports, further improvement is needed to reduce the number of days of opioids prescribed and increase compliance with recommended guidelines.
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Affiliation(s)
- Jacob P Siebenmorgen
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Johnathan H Goree
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Eric R Siegel
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Sarah E Norman
- The College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Benjamin M Stronach
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jeffrey B Stambough
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Simon C Mears
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
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Kaiser D, Hoch A, Dimitriou D, Groeber T, Bomberg H, Aguirre JA, Eichenberger U, Zingg PO. Perioperative Intravenous Dexamethasone Significantly Reduces Postoperative Opioid Requirement and Nausea After Unilateral Elective Hip Arthroscopy: A Randomized Double-blinded Placebo-controlled Trial. Am J Sports Med 2024; 52:1165-1172. [PMID: 38456291 PMCID: PMC10986151 DOI: 10.1177/03635465241232157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 12/20/2023] [Indexed: 03/09/2024]
Abstract
BACKGROUND Previous studies have shown that dexamethasone has a positive effect on postoperative pain control, opioid consumption, nausea, and vomiting and length of hospital stay after arthroplasty surgery. PURPOSE/HYPOTHESIS The purpose of this study was to assess whether adding perioperative dexamethasone to our current pain regimen after hip arthroscopy is more effective than a placebo. It was hypothesized that dexamethasone would reduce postoperative pain, reduce opioid consumption, improve subjective pain and nausea scores, and reduce the number of vomiting events. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS A total of 50 patients requiring unilateral elective hip arthroscopy were randomized to receive intravenous dexamethasone immediately before induction of anesthesia and at 8 am on the first postoperative day (2 ×12 mg) or a placebo (sodium chloride 0.9%). The patient, the surgeons, the treating anesthesiologist, and the involved nursing and physical therapy personnel were blinded to group assignment. The primary outcome was postoperative pain, and secondary outcomes were opioid consumption and nausea scores-assessed using a translated revised version of the American Pain Society Patient Outcome Questionnaire 6 hours postoperatively and on days 1 and 2-and vomiting events. A clinical follow-up was performed 12 weeks postoperatively to assess adverse events. RESULTS The mean age at inclusion was 29 years in both groups. Postoperative pain levels did not differ significantly in most instances. Opioid requirements during the hospitalization in the dexamethasone group were significantly lower than those in the placebo group (31.96 ± 20.56 mg vs 51.43 ± 38 mg; P = .014). Significantly fewer vomiting events were noted in the dexamethasone group (0.15 ± 0.59 vs 0.65 ± 0.91; P = .034). Descriptive data and surgical parameters did not differ significantly. CONCLUSION Perioperative intravenous dexamethasone significantly reduced postoperative opioid consumption by 40% without compromising pain level and safety, as no corticosteroid-related side effects were observed. Dexamethasone may be a valuable adjuvant to a multimodal systemic pain regimen after hip arthroscopy. REGISTRATION NCT04610398 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Dominik Kaiser
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Armando Hoch
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Dimitris Dimitriou
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Tanja Groeber
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Hagen Bomberg
- Department of Anaesthesiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - José A. Aguirre
- Department of Anaesthesiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Urs Eichenberger
- Department of Anaesthesiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Patrick O. Zingg
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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McCracken A, Kim RS, Laframboise S, Maganti M, Bernardini MQ, Ferguson S, Hogen L, May T, McCluskey SA, Bouchard-Fortier G. Sustainability of an enhanced recovery pathway after minimally invasive gynecologic oncology surgery. Int J Gynecol Cancer 2024:ijgc-2024-005342. [PMID: 38531541 DOI: 10.1136/ijgc-2024-005342] [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: 03/28/2024] Open
Abstract
OBJECTIVE Same day discharge is safe after minimally invasive gynecology oncology surgery. Our quality improvement peri-operative program based on enhanced recovery after surgery principles led to an increase in same day discharge from 30% to 75% over a 12 month period. Twelve months after program implementation, we assessed the sustainability of same day discharge rates, determined post-operative complication rates, and evaluated factors affecting same day discharge rates. METHODS A retrospective chart review was conducted of 100 consecutive patients who underwent minimally invasive surgery at an academic cancer center from January to 2021 to December 2021. This cohort was compared with the active intervention cohort (n=102) from the implementation period (January 2020 to December 2020). Same day discharge rates and complications were compared. Multivariable analysis was performed to assess which factors remained associated with same day discharge post-intervention. RESULTS Same day discharge post-intervention was 72% compared with 75% during active intervention (p=0.69). Both cohorts were similar in age (p=0.24) and body mass index (p=0.27), but the post-intervention cohort had longer operative times (p=0.001). There were no significant differences in 30-day complications, readmission, reoperation, or emergency room visits (p>0.05). There was a decrease in 30-day post-operative clinic visits from 18% to 5% in the post-intervention cohort (p=0.007), and unnecessary bowel prep use decreased from 35% to 14% (p<0.001). On multivariable analysis, start time (second case of the day) (OR 0.06; 95% CI 0.01 to 0.35), and ward narcotic use (OR 0.12; 95% CI 0.03 to 0.42) remained associated with overnight admission. CONCLUSION Same day discharge rate was sustained at 72%, 12 months after the implementation of a quality improvement program to optimize same day discharge rate after minimally invasive surgery, while maintaining low post-operative complications and reducing unplanned clinic visits. To maximize same day discharge, minimally invasive gynecologic oncology surgery should be prioritized as the first case of the day, and post-operative narcotic use should be limited.
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Affiliation(s)
| | - Rachel Soyoun Kim
- University Health Network, Toronto, Ontario, Canada
- Division of Gynecologic Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Stephane Laframboise
- University Health Network, Toronto, Ontario, Canada
- Division of Gynecologic Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Manjula Maganti
- Biostatistics, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | - Marcus Q Bernardini
- University Health Network, Toronto, Ontario, Canada
- Division of Gynecologic Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Ferguson
- University Health Network, Toronto, Ontario, Canada
- Division of Gynecologic Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Liat Hogen
- University Health Network, Toronto, Ontario, Canada
- Division of Gynecologic Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Taymaa May
- University Health Network, Toronto, Ontario, Canada
- Division of Gynecologic Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Stuart A McCluskey
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
| | - Geneviève Bouchard-Fortier
- University Health Network, Toronto, Ontario, Canada
- Division of Gynecologic Oncology, University of Toronto, Toronto, Ontario, Canada
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20
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Li L, Chang Y, Smith NA, Losina E, Costenbader KH, Laidlaw TM. Nonsteroidal anti-inflammatory drug "allergy" labeling is associated with increased postpartum opioid utilization. J Allergy Clin Immunol 2024; 153:772-779.e4. [PMID: 38040042 PMCID: PMC10939859 DOI: 10.1016/j.jaci.2023.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 11/15/2023] [Accepted: 11/17/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Current guidelines recommend a stepwise approach to postpartum pain management, beginning with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), with opioids added only if needed. Report of a prior NSAID-induced adverse drug reaction (ADR) may preclude use of first-line analgesics, despite evidence that many patients with this allergy label may safely tolerate NSAIDs. OBJECTIVE We assessed the association between reported NSAID ADRs and postpartum opioid utilization. METHODS We performed a retrospective cohort study of birthing people who delivered within an integrated health system (January 1, 2017, to December 31, 2020). Study outcomes were postpartum inpatient opioid administrations and opioid prescriptions at discharge. Statistical analysis was performed on a propensity score-matched sample, which was generated with the goal of matching to the covariate distributions from individuals with NSAID ADRs. RESULTS Of 38,927 eligible participants, there were 883 (2.3%) with an NSAID ADR. Among individuals with reported NSAID ADRs, 49.5% received inpatient opioids in the postpartum period, compared to 34.5% of those with no NSAID ADRs (difference = 15.0%, 95% confidence interval 11.4-18.6%). For patients who received postpartum inpatient opioids, those with NSAID ADRs received a higher total cumulative dose between delivery and hospital discharge (median 30.0 vs 22.5 morphine milligram equivalents [MME] for vaginal deliveries; median 104.4 vs 75.0 MME for cesarean deliveries). The overall proportion of patients receiving an opioid prescription at the time of hospital discharge was higher for patients with NSAID ADRs compared to patients with no NSAID ADRs (39.3% vs 27.2%; difference = 12.1%, 95% confidence interval 8.6-15.6%). CONCLUSION Patients with reported NSAID ADRs had higher postpartum inpatient opioid utilization and more frequently received opioid prescriptions at hospital discharge compared to those without NSAID ADRs, regardless of mode of delivery.
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Affiliation(s)
- Lily Li
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
| | - Yuchiao Chang
- Harvard Medical School, Boston, Mass; Division of General Internal Medicine, Massachusetts General Hospital, Boston, Mass
| | - Nicole A Smith
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Elena Losina
- Harvard Medical School, Boston, Mass; Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Karen H Costenbader
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Tanya M Laidlaw
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
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21
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Foppiani J, Alvarez AH, Stearns SA, Taritsa IC, Weidman AA, Valentine L, Escobar-Domingo MJ, Foster L, Schuster KA, Ho OA, Rinker B, Lee BT, Lin SJ. Utilization of patient-reported outcome measures in plastic surgery clinical trials: A systematic review. J Plast Reconstr Aesthet Surg 2024; 90:215-223. [PMID: 38387418 DOI: 10.1016/j.bjps.2024.01.036] [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: 11/06/2023] [Revised: 12/14/2023] [Accepted: 01/29/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND Patient-reported outcomes (PROs) have evolved to validated questionnaires assessing health-related quality of life. This systematic review evaluates the utilization of PROs in United States plastic and reconstructive surgery (PRS) clinical trials (CTs). METHODS A medical librarian conducted a search strategy for PRS CTs from 2012 to 2022. CTs were identified and assessed for PRO utilization. Summary statistics were performed, and Fisher's exact test was used for subgroup analysis. RESULTS Of the 3609 studies initially identified, 154 were PRS CTs. Approximately half (80 studies) employed PROs, encompassing 13,190 participants, 95% (12,229) of whom were female. Among the CTs, 37 (48%) were in the field of reconstruction, while 25 (32%) were cosmetic. Pain (35%) and patient satisfaction (24%) were the most common primary outcomes. Validated PROs were the main outcome in 61% of these trials, with the visual analog scale (19%) and BREAST-Q (15%) as the top instruments. Funding was primarily private (34%) or not reported (49%). No significant trend in validated PRO usage was observed over the examined decade. CONCLUSIONS The use of PROs is relevant for healthcare delivery and improvement as they provide insight into the efficacy of treatments from a patient-centered viewpoint. PROs are reported in just over half of PRS CTs, and within those CTs, the use of validated questionnaires is inconsistent. Therefore, emerging CTs should strive to incorporate PRO measures and utilize the existing validated tools to assess novel interventions and ensure that the data reported is objective.
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Affiliation(s)
- Jose Foppiani
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Angelica Hernandez Alvarez
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Stephen A Stearns
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Iulianna C Taritsa
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Allan A Weidman
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Lauren Valentine
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Maria J Escobar-Domingo
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Lacey Foster
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Kirsten A Schuster
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Olivia A Ho
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Brian Rinker
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Bernard T Lee
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Samuel J Lin
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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22
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Curry J, Coaston T, Vadlakonda A, Sakowitz S, Mallick S, Chervu N, Khoraminejad B, Benharash P. Trends, outcomes, and factors associated with in-hospital opioid overdose following major surgery. Surg Open Sci 2024; 18:111-116. [PMID: 38523845 PMCID: PMC10957460 DOI: 10.1016/j.sopen.2024.03.002] [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: 02/20/2024] [Accepted: 03/06/2024] [Indexed: 03/26/2024] Open
Abstract
Background With the growing opioid epidemic across the US, in-hospital utilization of opioids has garnered increasing attention. Using a national cohort, this study sought to characterize trends, outcomes, and factors associated with in-hospital opioid overdose (OD) following major elective operations. Methods We identified all adult (≥18 years) hospitalizations entailing select elective procedures in the 2016-2020 National Inpatient Sample. Patients who experienced in-hospital opioid overdose were characterized as OD (others: Non-OD). The primary outcome of interest was in-hospital OD. Multivariable logistic and linear regression models were developed to evaluate the association between in-hospital OD and mortality, length of stay (LOS), hospitalization costs, and non-home discharge. Results Of an estimated 11,096,064 hospitalizations meeting study criteria, 5375 (0.05 %) experienced a perioperative OD. Compared to others, OD were older (66 [57-73] vs 64 [54-72] years, p < 0.001), more commonly female (66.3 vs 56.7 %, p < 0.001), and in the lowest income quartile (26.4 vs 23.2 %, p < 0.001). After adjustment, female sex (Adjusted Odds Ratio [AOR] 1.68, 95 % Confidence Interval [CI] 1.47-1.91, p < 0.001), White race (AOR 1.19, CI 1.01-1.42, p = 0.04), and history of substance use disorder (AOR 2.51, CI 1.87-3.37, p < 0.001) were associated with greater likelihood of OD. Finally, OD was associated with increased LOS (β +1.91 days, CI [1.60-2.21], p < 0.001), hospitalization costs (β +$7500, CI [5900-9100], p < 0.001), and greater odds of non-home discharge (AOR 2.00, CI 1.61-2.48, p < 0.001). Conclusion Perioperative OD remains a rare but costly complication after elective surgery. While pain control remains a priority postoperatively, protocols and recovery pathways must be re-examined to ensure patient safety.
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Affiliation(s)
- Joanna Curry
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Troy Coaston
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Amulya Vadlakonda
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles, CA, USA
| | - Baran Khoraminejad
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles, CA, USA
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23
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Marcolin P, Amaral S, Motter SB, Brandão GR, de Oliveira Trindade B, Messer N, Poli de Figueiredo SM. Quadratus lumborum block versus transversus abdominis plane block for inguinal hernia repair: A systematic review and meta-analysis with trial sequential analysis. World J Surg 2024; 48:610-621. [PMID: 38265244 DOI: 10.1002/wjs.12064] [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: 10/06/2023] [Accepted: 12/18/2023] [Indexed: 01/25/2024]
Abstract
INTRODUCTION Postoperative pain management is crucial for patient recovery with Quadratus Lumborum Block (QLB) and Transversus Abdominis Plane Block (TAPB) emerging as potential techniques. We aimed to compare the analgesic efficacy of QLB and TAPB in patients undergoing inguinal hernia repair. METHODS We performed a systematic review of Cochrane, EMBASE, and MEDLINE databases to identify randomized controlled trials comparing QLB and TAPB in patients undergoing inguinal hernia repair. Outcomes included postoperative pain and opioid consumption. Statistical analysis was performed using RevMan 5.4. The review protocol was registered at PROSPERO (CRD42023445513). RESULTS We included five RCTs encompassing 255 patients. QLB was associated with a significant decrease in postoperative pain (MD -0.45; 95% CI -0.75 to -0.14; and p = 0.004; I2 = 94%). However, we found no difference in 24-h opioid consumption between QLB and TAPB groups. CONCLUSION QLB may offer superior pain reduction. However, its effect on opioid consumption remains unclear.
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Affiliation(s)
- Patrícia Marcolin
- Division of Medicine, Federal University of the Southern Border (Universidade Federal da Fronteira Sul), Passo Fundo, Brazil
| | - Sara Amaral
- Affonso Guizzo Regional Hospital (Hospital Regional Affonso Guizzo), Araranguá, Brazil
| | - Sarah Bueno Motter
- Division of Medicine, Federal University of Health Sciences of Porto Alegre (Universidade Federal de Ciências da Saúde de Porto Alegre), Porto Alegre, Brazil
| | - Gabriela R Brandão
- Division of Medicine, Federal University of Health Sciences of Porto Alegre (Universidade Federal de Ciências da Saúde de Porto Alegre), Porto Alegre, Brazil
| | - Bruna de Oliveira Trindade
- Division of Medicine, Federal University of Health Sciences of Porto Alegre (Universidade Federal de Ciências da Saúde de Porto Alegre), Porto Alegre, Brazil
| | - Nir Messer
- Division of Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Stringfield SB, Waddimba AC, Criss KM, Burgess B, Dosselman LJ, Fichera A, Wells KO, Fleshman J. Ketamine intolerance in patients on enhanced recovery after surgery protocols undergoing colorectal operations. J Gastrointest Surg 2024:S1091-255X(24)00342-1. [PMID: 38523035 DOI: 10.1016/j.gassur.2024.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/12/2024] [Accepted: 02/24/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Ketamine is used in enhanced recovery after surgery (ERAS) protocols because of its beneficial antihyperalgesic and antitolerance effects. However, adverse effects such as hallucinations, sedation, and diplopia could limit ketamine's utility. The main objective of this study was to identify rates of ketamine side effects in postoperative patients after colorectal surgery and, secondarily, to compare short-term outcomes between patients receiving ketamine analgesia and controls. METHODS This was a retrospective observational cohort study. Subjects were adults who underwent ERAS protocol-guided colorectal surgery at a large, integrated health system. Patients were grouped into ketamine-receiving and preketamine cohorts. Patients receiving ketamine were divided into tolerant and intolerant groups. Propensity score-adjusted models tested multivariate associations of ketamine tolerance/intolerance vs control group. RESULTS A total of 732 patients underwent colorectal surgery within the ERAS program before ketamine's introduction (control). After ketamine's introduction, 467 patients received the medication. Intolerance was seen in 29% of ketamine recipients, and the most common side effect was diplopia. Demographics and surgical variables did not differ between cohorts. Multivariate models revealed no significant differences in hospital stays. Pain scores in the first 24 hours after surgery were slightly higher in patients receiving ketamine. Opiate consumption after surgery was lower for both ketamine tolerant and ketamine intolerant cohorts than for controls. CONCLUSION Rates of ketamine intolerance are high, which can limit its use and potential effectiveness. Ketamine analgesia significantly reduced opiate consumption without increasing hospital stays after colorectal surgery, regardless of whether it was tolerated.
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Affiliation(s)
- Sarah B Stringfield
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, United States.
| | - Anthony C Waddimba
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, United States; Baylor Scott and White Research Institute, Dallas, Texas, United States
| | - Keirsyn M Criss
- College of Medicine, Texas A & M University Health Science Center, Dallas, Texas, United States
| | - Brooke Burgess
- College of Medicine, Texas A & M University Health Science Center, Dallas, Texas, United States
| | - Luke J Dosselman
- University of Texas (UT) Southwestern Medical School, Dallas, Texas, United States
| | - Alessandro Fichera
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, United States
| | - Katerina O Wells
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, United States
| | - James Fleshman
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, United States
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Madden K, Pallapothu S, Young Shing D, Adili A, Bhandari M, Carlesso L, Khan M, Kleinlugtenbelt YV, Krsmanovic A, Nowakowski M, Packham T, Romeril E, Tarride JE, Thabane L, Tushinski DM, Wallace C, Winemaker M, Shanthanna H. Opioid reduction and enhanced recovery in orthopaedic surgery (OREOS): a protocol for a feasibility randomised controlled trial in patients undergoing total knee arthroplasty. Pilot Feasibility Stud 2024; 10:30. [PMID: 38360686 PMCID: PMC10868001 DOI: 10.1186/s40814-024-01457-9] [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: 01/26/2023] [Accepted: 01/25/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Knee arthritis is a leading cause of limited function and long-term disability in older adults. Despite a technically successful total knee arthroplasty (TKA), around 20% of patients continue to have persisting pain with reduced function, and low quality of life. Many of them continue using opioids for pain control, which puts them at risk for potential long-term adverse effects such as dependence, overdose and risk of falls. Although persisting pain and opioid use after TKA have been recognised to be important issues, individual strategies to decrease their burden have limitations and multi-component interventions, despite their potential, have not been well studied. In this study, we propose a multi-component pathway including personalized pain management, facilitated by a pain management coordinator. The objectives of this pilot trial are to evaluate feasibility (recruitment, retention, and adherence), along with opioid-free pain control at 8 weeks after TKA. METHODS This is a protocol for a multicentre pilot randomised controlled trial using a 2-arm parallel group design. Adult participants undergoing unilateral total knee arthroplasty will be considered for inclusion and randomised to control and intervention groups. Participants in the intervention group will receive support from a pain management coordinator who will facilitate a multicomponent pain management pathway including (1) preoperative education on pain and opioid use, (2) preoperative risk identification and mitigation, (3) personalized post-discharge analgesic prescriptions and (4) continued support for pain control and recovery up to 8 weeks post-op. Participants in the control group will undergo usual care. The primary outcomes of this pilot trial are to assess the feasibility of participant recruitment, retention, and adherence to the interventions, and key secondary outcomes are persisting pain and opioid use. DISCUSSION The results of this trial will determine the feasibility of conducting a definitive trial for the implementation of a multicomponent pain pathway to improve pain control and reduce harms using a coordinated approach, while keeping an emphasis on patient centred care and shared decision making. TRIAL REGISTRATION Prospectively registered in Clinicaltrials.gov (NCT04968132).
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Affiliation(s)
- Kim Madden
- Department of Surgery, McMaster University, Hamilton, Canada.
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada.
- Department of Health Research Methods, McMaster University, Hamilton, Canada.
| | | | | | - Anthony Adili
- Department of Surgery, McMaster University, Hamilton, Canada
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Mohit Bhandari
- Department of Surgery, McMaster University, Hamilton, Canada
- Department of Health Research Methods, McMaster University, Hamilton, Canada
| | - Lisa Carlesso
- School of Rehabilitation Science, McMaster University, Hamilton, Canada
| | - Moin Khan
- Department of Surgery, McMaster University, Hamilton, Canada
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | | | - Adrijana Krsmanovic
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada
| | - Matilda Nowakowski
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada
| | - Tara Packham
- School of Rehabilitation Science, McMaster University, Hamilton, Canada
| | - Eric Romeril
- Hamilton Health Sciences-Juravinski Hospital, Hamilton, Canada
| | - Jean-Eric Tarride
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Health Research Methods, McMaster University, Hamilton, Canada
- Center for Health Economics and Policy Analyses, McMaster University, Hamilton, Canada
| | - Lehana Thabane
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Health Research Methods, McMaster University, Hamilton, Canada
| | - Daniel M Tushinski
- Department of Surgery, McMaster University, Hamilton, Canada
- Hamilton Health Sciences-Juravinski Hospital, Hamilton, Canada
| | - Christine Wallace
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | | | - Harsha Shanthanna
- Department of Surgery, McMaster University, Hamilton, Canada
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Anesthesia, McMaster University, Hamilton, Canada
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26
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Froehlich KA, Deleon ZG, Tubog TD. Effects of Gabapentin on Postoperative Pain and Opioid Consumption Following Laparoscopic Cholecystectomy: A Systematic Review and Meta-analysis. J Perianesth Nurs 2024; 39:132-141. [PMID: 37855760 DOI: 10.1016/j.jopan.2023.06.005] [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: 09/29/2022] [Revised: 02/27/2023] [Accepted: 06/02/2023] [Indexed: 10/20/2023]
Abstract
PURPOSE Examine the efficacy of gabapentin on postoperative pain scores and opioid consumption in laparoscopic cholecystectomy. DESIGN Systematic review and meta-analysis. METHODS PubMed, EBSCO, CINAHL, the Cochrane Central Register of Controlled Trials, Google Scholar, and gray literature was used to search the literature. Only randomized controlled trials were included. Outcomes were reported using the risk ratio and mean difference (MD). Risk of bias and the grades of recommendation, assessment, development, and evaluation (GRADE) system was used to the assessed quality of evidence. FINDINGS Nineteen trials involving 2,068 patients were analyzed. Compared to placebo, gabapentin reduced the cumulative pain scores in the first 24 hours after surgery (MD, -1.19; 95% CI, -1.39-0.99; P < .00011), opioid consumption (MD, -3.51; 95% CI, -4.67 to -2.35; P < .00001), and the incidence of postoperative nausea and vomiting (risk ratio, 0.64; 95% CI, 0.52-0.78; P < .00001) with prolonged time to first analgesic rescue (MD, 210.9; 95% CI, 76.90-344.91; P = .002). However, gabapentin has little to no effect on the incidence of sedation, somnolence, and respiratory depression. CONCLUSIONS Gabapentin can be added as part of the multimodal pain management for patients undergoing laparoscopic cholecystectomy. Extrapolation of these findings to clinical settings must take into consideration the limitations identified in this review.
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Affiliation(s)
| | - Zeus G Deleon
- Graduate Programs of Nurse Anesthesia, Texas Wesleyan University, Fort Worth, Texas
| | - Tito D Tubog
- Graduate Programs of Nurse Anesthesia, Texas Wesleyan University, Fort Worth, Texas.
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Huffman C, Olson J, Evans JK, Brady T, Huff S, Bishop B, Abbott E, Wishon K, Washburn K, Coeytaux R. Nurse initiated auricular acupressure for post-operative pain control in patients undergoing TKA or THA: A randomized controlled trial. Int J Orthop Trauma Nurs 2024; 52:101035. [PMID: 37429783 PMCID: PMC10921186 DOI: 10.1016/j.ijotn.2023.101035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/14/2023] [Accepted: 06/17/2023] [Indexed: 07/12/2023]
Affiliation(s)
- Carolyn Huffman
- Center for Nursing Research, Atrium Health Wake Forest Baptist, Medical Center Blvd, Winston Salem, NC, 27157, USA.
| | - Juli Olson
- Integrative Health Coordinating Center, Veterans Health Administration, Des Moines, IA, 50325, USA
| | - Joni K Evans
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Teresa Brady
- Comprehensive Cancer Center, Atrium Health Wake Forest Baptist, Medical Center Blvd, Winston Salem, NC, 27157, USA
| | - Sonia Huff
- Atrium Health Wake Forest Baptist, Davie Medical Center, 329 NC Highway 801 North, Bermuda Run, NC, 27006, USA
| | - Brie Bishop
- Atrium Health Wake Forest Baptist Davie Medical Center, USA
| | - Ellen Abbott
- Atrium Health Wake Forest Baptist Davie Medical Center, USA
| | - Karen Wishon
- Atrium Health Wake Forest Baptist Davie Medical Center, USA
| | - Kyle Washburn
- Atrium Health Wake Forest Baptist Pain Center, 605 Cotton Street, NC, 27101, USA
| | - Remy Coeytaux
- Former Professor of Family Medicine and Former Director of Center for Integrative Medicine at Wake Forest University School of Medicine, USA
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Kim SY, Lim YC, Seo BK, Nam D, Ha IH, Lee YS, Lee YJ. A study on the 10-year trend of surgeries performed for lumbar disc herniation and comparative analysis of prescribed opioid analgesics and hospitalization duration: 2010-2019 HIRA NPS Data. BMC Musculoskelet Disord 2024; 25:65. [PMID: 38218767 PMCID: PMC10787428 DOI: 10.1186/s12891-024-07167-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 01/02/2024] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND This study, utilizing the claims data from the Health Insurance Review and Assessment Service of Korea, aimed to examine the 10-year (2010-2019) trends in various types of lumbar spine surgeries performed on patients diagnosed with lumbar herniated intervertebral disc (HIVD), and the current status of opioid prescriptions, as well as the duration of postoperative hospital stays based on the type of surgery performed. METHOD This retrospective cross-sectional study examined patients with one or more national health insurance claims carrying a primary or secondary diagnosis of HIVD (ICD-10 codes: M511, M518, M519) over a 10-year period (2010-2019). From the patients undergoing lumbar spine surgery, we selected those who did not require reoperation within 30 days following the initial lumbar surgery. Our final study sample comprised patients who underwent only one type of surgery. RESULTS Among the patients diagnosed with HIVD and subsequently undergoing lumbar surgery between 2010 and 2019, a slight downward trend was observed in those undergoing open discectomy (OD); however, OD persistently accounted for the highest proportion over the 10 years. Percutaneous endoscopic lumbar discectomy (PELD) demonstrated a consistent upward trend from 2016 to 2018. When inspecting trends, we noted a consistent escalation over the decade in the postoperative opioid prescription rates of strong opioids (50.7% in 2010 to 77.8% in 2019) and tramadol (50.9% in 2010 to 76.8% in 2019). Analyzing these trends by surgery type, spinal fusion exhibited a slightly higher rate of opioid prescriptions than other lumbar surgeries. Regarding the length of postoperative hospital stays, patients undergoing PELD recorded the shortest stay (7.04 ± 6.78 days), while spinal fusion necessitated the longest (20.14 ± 12.18 days). CONCLUSION This study analyzed the trends in types of lumbar spine surgeries, opioid analgesic prescriptions, and length of hospital stays over 10 years (2010-2019) among patients with HIVD in Korea. Our data and findings provide valuable evidence that may prove beneficial for clinicians and researchers involved in HIVD-related practices.
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Affiliation(s)
- Sang Yoon Kim
- Jaseng Hospital of Korean Medicine, 536 Gangnam-daero, Gangnam-gu, Seoul, 06110, Republic of Korea
| | - Yu-Cheol Lim
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, 2F, 540 Gangnam-daero, Gangnam-gu, Seoul, 06110, Republic of Korea
| | - Byung-Kwan Seo
- Department of Acupuncture and Moxibustion, Kyung Hee University Korean Medicine Hospital at Gangdong, Seoul, 05278, Republic of Korea
| | - Dongwoo Nam
- Department of Acupuncture and Moxibustion, Kyung Hee University, Seoul, Republic of Korea
| | - In-Hyuk Ha
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, 2F, 540 Gangnam-daero, Gangnam-gu, Seoul, 06110, Republic of Korea
| | - Ye-Seul Lee
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, 2F, 540 Gangnam-daero, Gangnam-gu, Seoul, 06110, Republic of Korea.
| | - Yoon Jae Lee
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, 2F, 540 Gangnam-daero, Gangnam-gu, Seoul, 06110, Republic of Korea.
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Muhammad QUA, Sohail MA, Azam NM, Bashir HH, Islam H, Ijaz R, Aquil S, Mansoor T, Dhakal B, Fatima T, Noor J, Khan AS, Iqbal A, Khatri M, Kumar S. Analgesic efficacy and safety of erector spinae versus serratus anterior plane block in thoracic surgery: a systematic review and meta-analysis of randomized controlled trials. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:3. [PMID: 38217050 PMCID: PMC10785351 DOI: 10.1186/s44158-023-00138-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/23/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Erector spinae plane block (ESPB) and serratus anterior plane block (SAPB) are regional anesthesia techniques that have shown favorable results in pain management following thoracic surgeries; however, their relative superiority is unclear. This review (PROSPERO: CRD42023443018) aims to compare the analgesic efficacy of ESPB and SAPB in patients undergoing thoracic surgeries through the pooled analysis of co-primary outcomes: postoperative oral-morphine-equivalent (mg) consumption in 24 h and pain scores (static) at 24 h. METHODS A literature search was conducted across PubMed, Cochrane Library, and Google Scholar to identify randomized controlled trials (RCTs) from inception to May 2023, comparing ESPB and SAPB in thoracic surgeries. Statistical pooling was done using Review Manager 5.4.1. Bias assessment employed the Cochrane Collaboration Risk-of-Bias 2.0 tool. The strength of evidence was assessed using the guidelines from the GRADE working group. RESULTS Nine RCTs (485 patients) were included in the study. Postoperative pain scores (static) at 24 h (mean difference (MD) = - 0.31 [- 0.57, 0.05], p = 0.02) and postoperative oral-morphine-equivalent (mg) consumption in 24 h (MD = - 19.73 [- 25.65, - 13.80], p < 0.00001) were significantly lower in the ESBP group. However, the MDs did not exceed the set threshold for clinical importance. No significant differences were observed in the opioid-related adverse effects and block-related complications. CONCLUSION Our statistically significant results imply that ESPB has superior analgesic efficacy compared to SAPB; however, this difference is clinically unimportant. The safety profile of the two blocks is comparable; hence, current evidence cannot define the relative superiority of one block over the other. Our findings warrant further research with standardized methodologies and a longer duration of analgesic efficacy assessment to yield robust evidence for better clinical applications.
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Affiliation(s)
- Qurat Ul Ain Muhammad
- Rawalpindi Medical University, Chamanzar Colony, Tipu Road, Rawalpindi, 46000, Pakistan.
| | | | - Noor Mahal Azam
- Rawalpindi Medical University, Chamanzar Colony, Tipu Road, Rawalpindi, 46000, Pakistan
| | | | - Hira Islam
- Karachi Medical and Dental College, Karachi, Pakistan
| | - Rana Ijaz
- Services Institute of Medical Sciences, Lahore, Pakistan
| | - Sakina Aquil
- Dow University of Health Sciences, Karachi, Pakistan
| | | | - Bishal Dhakal
- Nepalese Army Institute of Medical Sciences, Kathmandu, Nepal
| | | | - Javeria Noor
- Rawalpindi Medical University, Chamanzar Colony, Tipu Road, Rawalpindi, 46000, Pakistan
| | - Alina Sami Khan
- Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Arham Iqbal
- Dow University of Health Sciences, Karachi, Pakistan
| | - Mahima Khatri
- Dow University of Health Sciences, Karachi, Pakistan
| | - Satesh Kumar
- Shaheed Mohtarma Benazir Bhutto Medical College, Karachi, Pakistan
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Garcia V, Wallet J, Leroux-Bromberg N, Delbrouck D, Hannebicque K, Ben Oune F, Léguillette C, Le Deley MC, Ahmeidi A. Incidence and characteristics of chronic postsurgical pain at 6 months after total mastectomy under pectoserratus and interpectoral plane block combined with general anesthesia: a prospective cohort study. Reg Anesth Pain Med 2024; 49:36-40. [PMID: 37280082 DOI: 10.1136/rapm-2022-104185] [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: 11/24/2022] [Accepted: 05/19/2023] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Chronic postsurgical pain (CPSP) occurs in 20%-30% of patients who undergo total mastectomy (TM) performed under general anesthesia alone and significantly affects the quality of life. Pectoserratus and interpectoral plane block have been reportedly combined with general anesthesia to control immediate postoperative pain after TM. Our prospective cohort study aimed to evaluate the incidence of CPSP after TM when pectoserratus and interpectoral plane block were combined with general anesthesia. METHODS We recruited adult women scheduled to undergo TM for breast cancer. Patients planned for TM with flap surgery, those who underwent breast surgery in the past 5 years, or those presenting with residual chronic pain after prior breast surgery were excluded. After general anesthesia induction, an anesthesiologist performed pectoserratus and interpectoral plane block with a ropivacaine (3.75 mg/mL) and clonidine (3.75 µg/mL) in 40 mL of 0.9% sodium chloride. The primary endpoint was the occurrence of CPSP-defined as pain with a Numeric Rating Scale Score of ≥3, either at the breast surgical site and/or at axilla, without other identifiable causes-evaluated during a pain medicine consultation at 6 months post TM. RESULTS Overall, 43/164 study participants had CPSP (26.2%; 95% CI: 19.7 to 33.6); of these, 23 had neuropathic type of pain (53.5%), 19 had nociceptive (44.2%), and 1 had mixed (2.3%) type of pain. CONCLUSION Although postoperative analgesia has significantly improved in the last decade, there is still need for improvement to reduce CPSP after oncologic breast surgery. TRIAL REGISTRATION NUMBER NCT03023007.
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Affiliation(s)
- Vincent Garcia
- Department of Anesthesiology, Intensive Care, Centre Oscar Lambret, Lille, Hauts-de-France, France
| | - Jennifer Wallet
- Department of Clinical Research and Innovation, Centre Oscar Lambret, Lille, Hauts-de-France, France
| | - Nathalie Leroux-Bromberg
- Department of Anesthesiology, Intensive Care, Centre Oscar Lambret, Lille, Hauts-de-France, France
| | - Didier Delbrouck
- Department of Anesthesiology, Intensive Care, Centre Oscar Lambret, Lille, Hauts-de-France, France
| | - Karine Hannebicque
- Department of Breast Surgery, Centre Oscar Lambret, Lille, Hauts-de-France, France
| | - Fanny Ben Oune
- Department of Clinical Research and Innovation, Centre Oscar Lambret, Lille, Hauts-de-France, France
| | - Clémence Léguillette
- Department of Clinical Research and Innovation, Centre Oscar Lambret, Lille, Hauts-de-France, France
| | - Marie-Cécile Le Deley
- Department of Clinical Research and Innovation, Centre Oscar Lambret, Lille, Hauts-de-France, France
| | - Abesse Ahmeidi
- Department of Anesthesiology, Intensive Care, Centre Oscar Lambret, Lille, Hauts-de-France, France
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Burns ML, Hilliard P, Vandervest J, Mentz G, Josifoski A, Varghese J, Fisher C, Kheterpal S, Shah N, Bicket MC. Variation in Intraoperative Opioid Administration by Patient, Clinician, and Hospital Contribution. JAMA Netw Open 2024; 7:e2351689. [PMID: 38227311 DOI: 10.1001/jamanetworkopen.2023.51689] [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: 01/17/2024] Open
Abstract
Importance The opioid crisis has led to scrutiny of opioid exposures before and after surgical procedures. However, the extent of intraoperative opioid variation and the sources and contributing factors associated with it are unclear. Objective To analyze attributable variance of intraoperative opioid administration for patient-, clinician-, and hospital-level factors across surgical and analgesic categories. Design, Setting, and Participants This cohort study was conducted using electronic health record data collected from a national quality collaborative database. The cohort consisted of 1 011 268 surgical procedures at 46 hospitals across the US involving 2911 anesthesiologists, 2291 surgeons, and 8 surgical and 4 analgesic categories. Patients without ambulatory opioid prescriptions or use history undergoing an elective surgical procedure between January 1, 2014, and September 11, 2020, were included. Data were analyzed from January 2022 to July 2023. Main Outcomes and Measures The rate of intraoperative opioid administration as a continuous measure of oral morphine equivalents (OMEs) normalized to patient weight and case duration was assessed. Attributable variance was estimated in a hierarchical structure using patient, clinician, and hospital levels and adjusted intraclass correlations (ICCs). Results Among 1 011 268 surgical procedures (mean [SD] age of patients, 55.9 [16.2] years; 604 057 surgical procedures among females [59.7%]), the mean (SD) rate of intraoperative opioid administration was 0.3 [0.2] OME/kg/h. Together, clinician and hospital levels contributed to 20% or more of variability in intraoperative opioid administration across all analgesic and surgical categories (adjusting for surgical or analgesic category, ICCs ranged from 0.57-0.79 for the patient, 0.04-0.22 for the anesthesiologist, and 0.09-0.26 for the hospital, with the lowest ICC combination 0.21 for anesthesiologist and hosptial [0.12 for the anesthesiologist and 0.09 for the hospital for opioid only]). Comparing the 95th and fifth percentiles of opioid administration, variation was 3.3-fold among anesthesiologists (surgical category range, 2.7-fold to 7.7-fold), 4.3-fold among surgeons (surgical category range, 3.4-fold to 8.0-fold), and 2.2-fold among hospitals (surgical category range, 2.2-fold to 4.3-fold). When adjusted for patient and surgical characteristics, mean (square error mean) administration was highest for cardiac surgical procedures (0.54 [0.56-0.52 OME/kg/h]) and lowest for orthopedic knee surgical procedures (0.19 [0.17-0.21 OME/kg/h]). Peripheral and neuraxial analgesic techniques were associated with reduced administration in orthopedic hip (51.6% [95% CI, 51.4%-51.8%] and 60.7% [95% CI, 60.5%-60.9%] reductions, respectively) and knee (48.3% [95% CI, 48.0%-48.5%] and 60.9% [95% CI, 60.7%-61.1%] reductions, respectively) surgical procedures, but reduction was less substantial in other surgical categories (mean [SD] reduction, 13.3% [8.8%] for peripheral and 17.6% [9.9%] for neuraxial techniques). Conclusions and Relevance In this cohort study, clinician-, hospital-, and patient-level factors had important contributions to substantial variation of opioid administrations during surgical procedures. These findings suggest the need for a broadened focus across multiple factors when developing and implementing opioid-reducing strategies in collaborative quality-improvement programs.
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Affiliation(s)
- Michael L Burns
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Paul Hilliard
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - John Vandervest
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Graciela Mentz
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Ace Josifoski
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Jomy Varghese
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Clark Fisher
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Nirav Shah
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Mark C Bicket
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
- Opioid Prescribing Engagement Network, Institute for Healthcare Innovation and Policy, University of Michigan, Ann Arbor
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Yau B, Shenoy A. Outcomes of liver transplant in patients with alcohol use disorders and opioid use disorders. Clin Liver Dis (Hoboken) 2024; 23:e0175. [PMID: 38919869 PMCID: PMC11199006 DOI: 10.1097/cld.0000000000000175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 04/07/2024] [Indexed: 06/27/2024] Open
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Lerner DK, Gray M, Liu K, Al-Awady A, Omorogbe A, Ninan S, Goldrich DY, Schaberg M, Del Signore A, Govindaraj S, Iloreta AM. Gabapentin and postoperative pain and opioid consumption: A double-blind randomized controlled trial of perioperative pain management for sinus surgery. Am J Otolaryngol 2024; 45:104108. [PMID: 37948826 DOI: 10.1016/j.amjoto.2023.104108] [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: 08/19/2023] [Accepted: 10/29/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND The link between post-operative narcotic prescription and opioid misuse has spurred a nationwide effort to reduce perioperative opioid use. Previous work has suggested that perioperative gabapentin may reduce post-operative pain and opioid consumption across different procedures, although the optimal regimen remains to be defined. METHODS Chronic rhinosinusitis (CRS) patients undergoing functional endoscopic sinus surgery (FESS) with or without septoplasty were randomized to receive a 7-day pre- and post-operative course of placebo or gabapentin, starting at 300 mg daily and titrated to 300 mg three times daily, in a double-blind fashion. Primary endpoint was pain level using a validated visual analog scale (VAS). Secondary endpoints included post-operative opioid consumption and side effects, as well as modified Lund-Kennedy endoscopy, Lund-Mackay, and SNOT-22 scores. RESULTS Analysis of 35 patients (20 gabapentin, 15 control) showed no significant difference in mean postoperative VAS (p = 0.18) or postoperative opioid consumption between the placebo and gabapentin groups (2.3 and 4.8 oxycodone tablets respectively, p = 0.18). 15 of 35 patients did not require any post-operative oxycodone tablets, and only two patients required more than six tablets. CONCLUSION Preliminary results show no significant change in pain after FESS with or without septoplasty in patients taking 7-day pre- and post-operative gabapentin versus placebo. Results also showed no significant difference in opioid consumption between the treatment and placebo groups. Post-operative pain scores and opioid requirements are both quite low following FESS. Many patients do not need opioids at all, suggesting that routine initial post-operative opioid prescriptions can be limited accordingly.
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Affiliation(s)
- David K Lerner
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mingyang Gray
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Katherine Liu
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Abdurrahman Al-Awady
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Aisosa Omorogbe
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sen Ninan
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David Y Goldrich
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Madeleine Schaberg
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anthony Del Signore
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Satish Govindaraj
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alfred Marc Iloreta
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Clark RC, Alving-Trinh A, Becker M, Leach GA, Gosman A, Reid CM. Moving the needle: a narrative review of enhanced recovery protocols in breast reconstruction. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:414. [PMID: 38213812 PMCID: PMC10777219 DOI: 10.21037/atm-23-1509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/07/2023] [Indexed: 01/13/2024]
Abstract
Background and Objective After a relatively late introduction to the literature in 2015, enhanced recovery protocols for breast reconstruction have flourished into a wealth of reports. Many have since described unique methodologies making improved offerings with superior outcomes attainable. This is a particularly interesting procedure for the study of enhanced recovery as it encompasses two dissident approaches. Compared to implant-based reconstruction, autologous free-flap reconstruction has demonstrated superiority in a range of long-term metrics at the expense of historically increased peri-operative morbidity. This narrative review collates reports of recovery protocols for both approaches and examines methodologies surrounding the key pieces of a comprehensive pathway. Methods All primary clinical reports specifically describing enhanced recovery protocols for implant-based and autologous breast reconstruction through 2022 were identified by systematic review of PubMed and Embase libraries. Twenty-five reports meeting criteria were identified, with ten additional reports included for narrative purpose. Included studies were examined for facets of innovation from the pre-hospital setting through outpatient follow-up. Notable findings were described in the context of a comprehensive framework with attention paid to clinical and basic scientific background. Considerations for implementation were additionally discussed. Key Content and Findings Of 35 included studies, 29 regarded autologous reconstruction with majority focus on reduction of peri-operative opioid requirements and length of stay. Six regarded implant-based reconstruction with most discussing pathways towards ambulatory procedures. Eighty percent of included studies were published after the 2017 consensus guidelines with many described innovations to this baseline. Pathways included considerations for pre-hospital, pre-operative, intra-operative, inpatient, and outpatient settings. Implant-based studies demonstrated that safe ambulatory care is accessible. Autologous studies demonstrated a trend towards discharge before post-operative day three and peri-operative opioid requirements equivalent to those of implant-based reconstructions. Conclusions Study of enhanced recovery after breast reconstruction has inspired paradigm shift and pushed limits previously not thought to be attainable. These protocols should encompass a longitudinal care pathway with optimization through patient-centered approaches and multidisciplinary collaboration. This framework should represent standard of care and will serve to expand availability of all methods of breast reconstruction.
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Affiliation(s)
- Robert Craig Clark
- Division of Plastic Surgery, UC San Diego School of Medicine, La Jolla, CA, USA
| | | | - Miriam Becker
- Division of Plastic Surgery, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Garrison A Leach
- Division of Plastic Surgery, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Amanda Gosman
- Division of Plastic Surgery, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Chris M Reid
- Division of Plastic Surgery, UC San Diego School of Medicine, La Jolla, CA, USA
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Bates JN, Getsy PM, Coffee GA, Baby SM, MacFarlane PM, Hsieh YH, Knauss ZT, Bubier JA, Mueller D, Lewis SJ. L-cysteine ethyl ester prevents and reverses acquired physical dependence on morphine in male Sprague Dawley rats. Front Pharmacol 2023; 14:1303207. [PMID: 38111383 PMCID: PMC10726967 DOI: 10.3389/fphar.2023.1303207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 10/31/2023] [Indexed: 12/20/2023] Open
Abstract
The molecular mechanisms underlying the acquisition of addiction/dependence on morphine may result from the ability of the opioid to diminish the transport of L-cysteine into neurons via inhibition of excitatory amino acid transporter 3 (EAA3). The objective of this study was to determine whether the co-administration of the cell-penetrant L-thiol ester, L-cysteine ethyl ester (L-CYSee), would reduce physical dependence on morphine in male Sprague Dawley rats. Injection of the opioid-receptor antagonist, naloxone HCl (NLX; 1.5 mg/kg, IP), elicited pronounced withdrawal phenomena in rats which received a subcutaneous depot of morphine (150 mg/kg) for 36 h and were receiving a continuous infusion of saline (20 μL/h, IV) via osmotic minipumps for the same 36 h period. The withdrawal phenomena included wet-dog shakes, jumping, rearing, fore-paw licking, 360° circling, writhing, apneas, cardiovascular (pressor and tachycardia) responses, hypothermia, and body weight loss. NLX elicited substantially reduced withdrawal syndrome in rats that received an infusion of L-CYSee (20.8 μmol/kg/h, IV) for 36 h. NLX precipitated a marked withdrawal syndrome in rats that had received subcutaneous depots of morphine (150 mg/kg) for 48 h) and a co-infusion of vehicle. However, the NLX-precipitated withdrawal signs were markedly reduced in morphine (150 mg/kg for 48 h)-treated rats that began receiving an infusion of L-CYSee (20.8 μmol/kg/h, IV) at 36 h. In similar studies to those described previously, neither L-cysteine nor L-serine ethyl ester (both at 20.8 μmol/kg/h, IV) mimicked the effects of L-CYSee. This study demonstrates that 1) L-CYSee attenuates the development of physical dependence on morphine in male rats and 2) prior administration of L-CYSee reverses morphine dependence, most likely by intracellular actions within the brain. The lack of the effect of L-serine ethyl ester (oxygen atom instead of sulfur atom) strongly implicates thiol biochemistry in the efficacy of L-CYSee. Accordingly, L-CYSee and analogs may be a novel class of therapeutics that ameliorate the development of physical dependence on opioids in humans.
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Affiliation(s)
- James N. Bates
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Paulina M. Getsy
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States
| | - Gregory A. Coffee
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States
| | - Santhosh M. Baby
- Section of Biology, Galleon Pharmaceuticals, Inc., Horsham, PA, United States
| | - Peter M. MacFarlane
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States
| | - Yee-Hsee Hsieh
- Division of Pulmonary, Critical Care and Sleep Medicine, Case Western Reserve University, Cleveland, OH, United States
| | - Zackery T. Knauss
- Department of Biological Sciences, Kent State University, Kent, OH, United States
| | | | - Devin Mueller
- Department of Biological Sciences, Kent State University, Kent, OH, United States
| | - Stephen J. Lewis
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States
- Department of Pharmacology, Case Western Reserve University, Cleveland, OH, United States
- Functional Electrical Stimulation Center, Case Western Reserve University, Cleveland, OH, United States
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Fearon NJ, Kurtzman J, Benfante N, Assel M, Vickers A, Carlsson S, Laudone VP, Levine M, Simon BA, Mehrara BJ, Nelson JA. Reducing opioid prescribing after ambulatory breast reconstruction surgery. J Surg Oncol 2023; 128:1235-1242. [PMID: 37653689 PMCID: PMC10841230 DOI: 10.1002/jso.27427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 08/03/2023] [Accepted: 08/15/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND The lack of evidence-based guidelines for postoperative opioid prescriptions following breast reconstruction contributes to a wide variation in prescribing practices and increases potential for misuse and abuse. METHODS Between August and December 2019, women who underwent outpatient breast reconstruction were surveyed 7-10 days before (n = 97) and after (n = 101) implementing a standardized opioid prescription reduction initiative. We compared postoperative opioid use, pain control, and refills in both groups. Patient reported outcomes were compared using the BREAST-Q physical wellbeing of the chest domain and a novel symptom Recovery Tracker. RESULTS Before changes in prescriptions, patients were prescribed a median of 30 pills and consumed three pills (interquartile range [IQR: 1,9]). After standardization, patients were prescribed eight pills and consumed three pills (IQR: 1,6). There was no evidence of a difference in the proportion of patients experiencing moderate to very severe pain on the Recovery Tracker or in the early BREAST-Q physical wellbeing of the chest scores (p = 0.8 and 0.3, respectively). CONCLUSION Standardizing and reducing opioid prescriptions for patients undergoing reconstructive breast surgery is feasible and can significantly decrease the number of excess pills prescribed. The was no adverse impact on early physical wellbeing, although larger studies are needed to obtain further data.
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Affiliation(s)
- Nkechi J. Fearon
- Josie Robertson Surgical Center, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joey Kurtzman
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nicole Benfante
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Melissa Assel
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrew Vickers
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sigrid Carlsson
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Sweden
| | - Vincent P. Laudone
- Josie Robertson Surgical Center, Memorial Sloan Kettering Cancer Center, New York, NY
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Marcia Levine
- Josie Robertson Surgical Center, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brett A. Simon
- Josie Robertson Surgical Center, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Babak J. Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonas A. Nelson
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Darville-Beneby R, Lomanowska AM, Yu HC, Jobin P, Rosenbloom BN, Gabriel G, Daudt H, Negraeff M, Di Renna T, Hudspith M, Clarke H. The Impact of Preoperative Patient Education on Postoperative Pain, Opioid Use, and Psychological Outcomes: A Narrative Review. Can J Pain 2023; 7:2266751. [PMID: 38126044 PMCID: PMC10732618 DOI: 10.1080/24740527.2023.2266751] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/30/2023] [Indexed: 12/23/2023]
Abstract
Background Recent studies have shown that preoperative education can positively impact postoperative recovery, improving postoperative pain management and patient satisfaction. Gaps in preoperative education regarding postoperative pain and opioid use may lead to increased patient anxiety and persistent postoperative opioid use. Objectives The objective of this narrative review was to identify, examine, and summarize the available evidence on the use and effectiveness of preoperative educational interventions with respect to postoperative outcomes. Method The current narrative review focused on studies that assessed the impact of preoperative educational interventions on postoperative pain, opioid use, and psychological outcomes. The search strategy used concept blocks including "preoperative" AND "patient education" AND "elective surgery," limited to the English language, humans, and adults, using the MEDLINE ALL database. Studies reporting on preoperative educational interventions that included postoperative outcomes were included. Studies reporting on enhanced recovery after surgery protocols were excluded. Results From a total of 761 retrieved articles, 721 were screened in full and 34 met criteria for inclusion. Of 12 studies that assessed the impact of preoperative educational interventions on postoperative pain, 5 reported a benefit for pain reduction. Eight studies examined postoperative opioid use, and all found a significant reduction in opioid consumption after preoperative education. Twenty-four studies reported on postoperative psychological outcomes, and 20 of these showed benefits of preoperative education, especially on postoperative anxiety. Conclusion Preoperative patient education interventions demonstrate promise for improving postoperative outcomes. Preoperative education programs should become a prerequisite and an available resource for all patients undergoing elective surgery.
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Affiliation(s)
- Rasheeda Darville-Beneby
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management Pain Research Unit, Toronto General Hospital, Toronto, Ontario, Canada
- Transitional Pain Service, Toronto General Hospital, Toronto, Ontario, Canada
| | - Anna M. Lomanowska
- Department of Anesthesia and Pain Management Pain Research Unit, Toronto General Hospital, Toronto, Ontario, Canada
- Transitional Pain Service, Toronto General Hospital, Toronto, Ontario, Canada
| | - Hai Chuan Yu
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Parker Jobin
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Brittany N. Rosenbloom
- Transitional Pain Service, Toronto General Hospital, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gretchen Gabriel
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management Pain Research Unit, Toronto General Hospital, Toronto, Ontario, Canada
- Transitional Pain Service, Toronto General Hospital, Toronto, Ontario, Canada
| | - Helena Daudt
- Pain BC/Pain Canada, Vancouver, British Columbia, Canada
| | - Michael Negraeff
- Pain BC/Pain Canada, Vancouver, British Columbia, Canada
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Tania Di Renna
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Toronto Academic Pain Medicine Institute, Toronto, Ontario, Canada
| | - Maria Hudspith
- Pain BC/Pain Canada, Vancouver, British Columbia, Canada
| | - Hance Clarke
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management Pain Research Unit, Toronto General Hospital, Toronto, Ontario, Canada
- Transitional Pain Service, Toronto General Hospital, Toronto, Ontario, Canada
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Liu R, Gutiérrez R, Mather RV, Stone TAD, Santa Cruz Mercado LA, Bharadwaj K, Johnson J, Das P, Balanza G, Uwanaka E, Sydloski J, Chen A, Hagood M, Bittner EA, Purdon PL. Development and prospective validation of postoperative pain prediction from preoperative EHR data using attention-based set embeddings. NPJ Digit Med 2023; 6:209. [PMID: 37973817 PMCID: PMC10654400 DOI: 10.1038/s41746-023-00947-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/13/2023] [Indexed: 11/19/2023] Open
Abstract
Preoperative knowledge of expected postoperative pain can help guide perioperative pain management and focus interventions on patients with the greatest risk of acute pain. However, current methods for predicting postoperative pain require patient and clinician input or laborious manual chart review and often do not achieve sufficient performance. We use routinely collected electronic health record data from a multicenter dataset of 234,274 adult non-cardiac surgical patients to develop a machine learning method which predicts maximum pain scores on the day of surgery and four subsequent days and validate this method in a prospective cohort. Our method, POPS, is fully automated and relies only on data available prior to surgery, allowing application in all patients scheduled for or considering surgery. Here we report that POPS achieves state-of-the-art performance and outperforms clinician predictions on all postoperative days when predicting maximum pain on the 0-10 NRS in prospective validation, though with degraded calibration. POPS is interpretable, identifying comorbidities that significantly contribute to postoperative pain based on patient-specific context, which can assist clinicians in mitigating cases of acute pain.
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Affiliation(s)
- Ran Liu
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Rodrigo Gutiérrez
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Rory V Mather
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Harvard-MIT Program in Health Sciences and Technology, Cambridge, MA, US
| | - Tom A D Stone
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Laura A Santa Cruz Mercado
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kishore Bharadwaj
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jasmine Johnson
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Proloy Das
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Gustavo Balanza
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Ekenedilichukwu Uwanaka
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Justin Sydloski
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Andrew Chen
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Mackenzie Hagood
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Edward A Bittner
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Patrick L Purdon
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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Canizares M, Power JD, Perruccio AV, Veillette C, Mahomed N, Rampersaud YR. Time trends and patterns in opioid prescription use following orthopaedic surgery in Ontario, Canada, from 2004/2005 to 2017/2018: a population-based study. BMJ Open 2023; 13:e074423. [PMID: 37963700 PMCID: PMC10649703 DOI: 10.1136/bmjopen-2023-074423] [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: 04/05/2023] [Accepted: 10/26/2023] [Indexed: 11/16/2023] Open
Abstract
OBJECTIVES Increased use of opioids and their associated harms have raised concerns around prescription opioid use for pain management following surgery. We examined trends and patterns of opioid prescribing following elective orthopaedic surgery. DESIGN Population-based study. SETTING Ontario, Canada. PARTICIPANTS Ontario residents aged 66+ years who had elective orthopaedic surgery from April 2004 to March 2018. PRIMARY AND SECONDARY OUTCOME MEASURES Postoperative opioid use (short term: within 90 days of surgery, prolonged: within 180 days and chronic: within 1 year), specific opioids prescribed, average duration (days) and amount (morphine milligram equivalents) of the initial prescription by year of surgery. RESULTS We included 464 460 elective orthopaedic surgeries in 2004/2005-2017/2018: 80% of patients used opioids within 1 year of surgery-25.1% were chronic users. There was an 8% increase in opioid use within 1 year of surgery, from 75.1% in 2004/2005 to 80.9% in 2017/2018: a 29% increase in short-term use and a decline in prolonged (9%) and chronic (22%) use. After 2014/2015, prescribed opioid amounts initially declined sharply, while the duration of the initial prescription increased substantially. Across categories of use, there was a steady decline in coprescription of benzodiazepines and opioids. CONCLUSIONS Most patients filled opioid prescriptions after surgery, and many continued filling prescriptions after 3 months. During a period of general increase in awareness of opioid harms and dissemination of guidelines/policies aimed at opioid prescribing for chronic pain, we found changes in prescribing practices following elective orthopaedic surgery. Findings illustrate the potential impact of guidelines/policies on shaping prescription patterns in the surgical population, even in the absence of specific guidelines for surgical prescribing.
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Affiliation(s)
- Mayilee Canizares
- Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
| | - J Denise Power
- Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
| | - Anthony V Perruccio
- Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
| | - Christian Veillette
- Department of Orthopaedic Surgery, University Health Network, Toronto, Ontario, Canada
| | - Nizar Mahomed
- Department of Orthopaedic Surgery, University Health Network, Toronto, Ontario, Canada
| | - Y Raja Rampersaud
- Department of Orthopaedic Surgery, University Health Network, Toronto, Ontario, Canada
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Milkias M, Mekonnen S, Ahmed S, Getachew H, Adamu Y, Mola S, Gugsa T. Evidence-based guideline on chronic postsurgical pain management in adult patients in resource-restricted setting, 2023: systematic review and guideline. Ann Med Surg (Lond) 2023; 85:5593-5603. [PMID: 37915690 PMCID: PMC10617887 DOI: 10.1097/ms9.0000000000001258] [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: 08/01/2023] [Accepted: 08/22/2023] [Indexed: 11/03/2023] Open
Abstract
Background Chronic postsurgical pain (CPSP) after tissue trauma is frequent and may have a long-lasting impact on the functioning and quality of life. The development of CPSP increases the burden on both the patient and the community. This review aims to systematically review articles and, lastly, pull an evidence-based guideline for CPSP management in adult patients in resource-limited areas. Methodology The review was reported based on preferred reporting items for the systemic review and meta-analysis (PRISMA) protocol. A literature search was conducted from the Cochrane, PubMed/Medline, and Google Scholar databases, and other gray literature from 2010 to 2022. The conclusion was made based on the level of evidence. Results A total of 3521 articles were identified through the database by searching strategies. Finally, by filtering duplicates unrelated to the topics, 22 articles (9 meta-analyses and systematic reviews, 12 systematic reviews, and one cohort study) were selected on the management of CPSP in adult patients. Filtering was made based on the intervention, outcome data of the population, and methodological quality. Conclusion Given the complexity and multidimensional nature of chronic postsurgical pain, effective assessment, and management require a comprehensive, multiaxial approach. Adequate preoperative preparation and counseling, potential risk identification and optimization, and use of a multimodal approach, and noninvasive surgical techniques are crucial in reducing the development of chronic postsurgical pain.
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Affiliation(s)
| | | | | | | | | | | | - Tesfaye Gugsa
- Surgery Department, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia
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Cleary C, Li YH, Jain A, Kainkaryam P, Shah P, Divinagracia T, Gallagher J, Aitcheson E, Ayach M, Finkel K, Glotzer O, Gifford E. Rectus Sheath Block Improves Patient Recovery Following Open Aortic Surgery. Ann Vasc Surg 2023; 97:27-36. [PMID: 38054410 DOI: 10.1016/j.avsg.2023.04.012] [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: 02/25/2023] [Revised: 04/03/2023] [Accepted: 04/11/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND Postoperative pain management remains a barrier to recovery following aortic surgery. Although epidural catheters help in adjunctive pain management, less is known about the use of rectus sheath blocks. We compared patient recovery following open abdominal aortic surgery (OAS) with and without adjunctive rectus block. METHODS Adult patients undergoing open abdominal aortic aneurysm repair and aortobifemoral or aortoiliac bypass for occlusive disease were identified and stratified by use of general anesthesia alone (GA) versus adjunctive use of a rectus sheath block (GA + RB). A small number of patients with GA and concomitant epidural analgesia, along with patients that had retroperitoneal repairs, were not included in further analysis. Outcomes included time to extubation, intraoperative and postoperative morphine milligram equivalents (MME) utilization, length of stay, discharge MME, and postoperative complications. Categorial data were compared with Person Chi-Square tests or Fisher's exact tests. Continuous data were tested with independent t-tests or Mann-Whitney U-tests. RESULTS From January 2017 to April 2022, there were 106 patients who underwent open aortic surgery, 55 patients with GA alone, 39 with GA + RB, and 12 patients who had a GA with concomitant epidural analgesia. Between GA and GA + RB, patients were comparable in both groups in terms of age, BMI (body mass index), smoking history, hypertension, diabetes, CAD (coronary artery disease), COPD (chronic obstructive pulmonary disease), and ASA (American Society of Anesthesiologists) class and prior opioid use. Patients with GA + RB were more likely to have scheduled elective procedures (80% GA cohort vs. 94.9% RB, P = 0.040), and a lower incidence of retroperitoneal exposure (14.5% GA cohort vs. 0% RB, P = 0.019). Patients with GA + RB had shorter time to extubation than GA (84.6% < 12 hr vs. 44.4%, P < 0.001), greater rate of procedural ketamine usage (GA + RB: 61.5% vs. GA: 40.0%, P = 0.049), lower MME at first postoperative day (median MME GA + RB: 25.0 vs. GA: 67.5, P = 0.002), lower discharge MME (median MME GA + RB: 142.5 vs. GA: 225.0, P = 0.036), and overall shorter length of stay (median stay GA + RB: 5 vs. GA: 6 days, P = 0.006). Postoperative complications were similar between groups. Similar findings were found in the comparison between elective-only GA and GA + RB patients and after exclusion of patients who only had a single shot of regional anesthesia. CONCLUSIONS Patients that receive adjunctive rectus sheath blocks for pain control following OAS utilize fewer opioid medications during hospital stay and at discharge. Rectus sheath blocks represent an alternative option to other periprocedural analgesia following open aortic surgery.
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Affiliation(s)
- Colin Cleary
- University of Connecticut School of Medicine, Farmington, CT
| | - Ya-Huei Li
- Hartford Hospital Clinical Research Center, Hartford, CT
| | - Akhilesh Jain
- Division of Vascular Surgery, Hartford Hospital, Hartford, CT
| | | | - Parth Shah
- Division of Vascular Surgery, Hartford Hospital, Hartford, CT
| | | | - James Gallagher
- Division of Vascular Surgery, Hartford Hospital, Hartford, CT
| | | | - Mouhanad Ayach
- Division of Vascular Surgery, Hartford Hospital, Hartford, CT
| | | | - Owen Glotzer
- Division of Vascular Surgery, Hartford Hospital, Hartford, CT
| | - Edward Gifford
- Division of Vascular Surgery, Hartford Hospital, Hartford, CT.
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Weinerman J, Vazquez A, Schurhoff N, Shatz C, Goldenberg B, Constantinescu D, Hernandez GM. The impacts of anxiety and depression on outcomes in orthopaedic trauma surgery: a narrative review. Ann Med Surg (Lond) 2023; 85:5523-5527. [PMID: 37920654 PMCID: PMC10619579 DOI: 10.1097/ms9.0000000000001307] [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: 05/24/2023] [Accepted: 09/06/2023] [Indexed: 11/04/2023] Open
Abstract
Introduction The impact of anxiety and depression on outcomes in orthopaedic trauma surgery is a topic of growing research interest. Patients and methods Orthopaedic trauma patients often experience high rates of psychiatric disorders, with anxiety and depression being the most prevalent. Mental health disorders have been shown to increase the risk of negative surgical outcomes and morbidity. This narrative review seeks to summarize the current literature surrounding the impacts of anxiety and depression on orthopaedic trauma surgery outcomes. Discussion There is a bidirectional relationship between chronic pain and mental health disorders, involving overlapping brain regions and neurotransmitter pathways. Anxiety and depression have been identified as predictors of negative surgical outcomes in orthopaedic trauma patients. Screening tools like the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder Screener-7 (GAD-7), and Medical Outcomes Study 36-item Short Form (SF-36) can assess mental health status and help tailor interventions. Psychological distress, chronic pain, and traumatic limb amputation are factors that contribute to adverse mental health outcomes in orthopaedic trauma patients. Opioid use for pain management is common in orthopaedic surgery, but it can worsen symptoms of depression and lead to dependency. Non-opioid pain management strategies may improve postoperative outcomes by reducing the impact of opioid-exacerbated depression. Conclusion Mental health interventions, both preoperative and postoperative, are crucial in optimizing surgical outcomes and improving patient quality of life. Multidisciplinary approaches that address both physical and mental health are recommended for orthopaedic trauma patients. Further research is needed to develop effective interventions for improving mental health outcomes in this patient population.
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Affiliation(s)
- Jonathan Weinerman
- Department of Education, The University of Miami Leonard M. Miller School of Medicine
| | - Arianna Vazquez
- Department of Education, The University of Miami Leonard M. Miller School of Medicine
| | - Nicolette Schurhoff
- Department of Education, The University of Miami Leonard M. Miller School of Medicine
| | - Connor Shatz
- Department of Education, The University of Miami Leonard M. Miller School of Medicine
| | - Brandon Goldenberg
- Department of Orthopaedic Surgery, University of Miami Hospital, Miami, Florida, USA
| | - David Constantinescu
- Department of Orthopaedic Surgery, University of Miami Hospital, Miami, Florida, USA
| | - Giselle M. Hernandez
- Department of Orthopaedic Surgery, University of Miami Hospital, Miami, Florida, USA
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McCauley JL, Ward RC, Taber DJ, Basco WT, Gebregziabher M, Reitman C, Moran WP, Cina RA, Lockett MA, Ball SJ. Surgical prescription opioid trajectories among state Medicaid enrollees. J Opioid Manag 2023; 19:465-488. [PMID: 38189189 DOI: 10.5055/jom.0832] [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: 01/09/2024]
Abstract
OBJECTIVE The objective of this study was to evaluate opioid use trajectories among a sample of 10,138 Medicaid patients receiving one of six index surgeries: lumbar spine, total knee arthroplasty, cholecystectomy, appendectomy, colon resection, and tonsillectomy. DESIGN Retrospective cohort. SETTING Administrative claims data. PATIENTS AND PARTICIPANTS Patients, aged 13 years and older, with 15-month continuous Medicaid eligibility surrounding index surgery, were selected from single-state Medicaid medical and pharmacy claims data for surgeries performed between 2014 and 2017. INTERVENTIONS None. MAIN OUTCOME MEASURES Baseline comorbidities and presurgery opioid use were assessed in the 6 months prior to admission, and patients' opioid use was followed for 9 months post-discharge. Generalized linear model with log link and Poisson distribution was used to determine risk of chronic opioid use for all risk factors. Group-based trajectory models identified groups of patients with similar opioid use trajectories over the 15-month study period. RESULTS More than one in three (37.7 percent) patients were post-surgery chronic opioid users, defined as the dichotomous outcome of filling an opioid prescription 90 or more days after surgery. Key variables associated with chronic post-surgery opioid use include presurgery opioid use, 30-day post-surgery opioid use, and comorbidities. Latent trajectory modeling grouped patients into six distinct opioid use trajectories. Associates of trajectory group membership are reported. CONCLUSIONS Findings support the importance of surgeons setting realistic patient expectations for post-surgical opioid use, as well as the importance of coordination of post-surgical care among patients failing to fully taper off opioids within 1-3 months of surgery.
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Affiliation(s)
- Jenna L McCauley
- Addiction Science Division, Department of Psychiatry, The Medical University of South Carolina, Charleston, South Carolina. ORCID: https://orcid.org/0000-0001-8406-2329
| | - Ralph C Ward
- Public Health Sciences, The Medical University of South Carolina, Charleston, South Carolina
| | - David J Taber
- The Medical University of South Carolina, Charleston, South Carolina
| | - William T Basco
- The Medical University of South Carolina, Charleston, South Carolina
| | - Mulugeta Gebregziabher
- Public Health Sciences, The Medical University of South Carolina, Charleston, South Carolina
| | - Charles Reitman
- Department of Orthopaedics and Physical Medicine, The Medical University of South Carolina, Charleston, South Carolina
| | - William P Moran
- College of Medicine, The Medical University of South Carolina, Charleston, South Carolina
| | - Robert A Cina
- The Medical University of South Carolina, Charleston, South Carolina
| | - Mark A Lockett
- The Medical University of South Carolina, Charleston, South Carolina
| | - Sarah J Ball
- College of Medicine, The Medical University of South Carolina, Charleston, South Carolina
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Brooke BS, Bayless K, Anderson Z, Holeman TA, Zhang C, Hales J, Buys MJ. Opioid tapering after surgery and its association with patient-reported outcomes and behavioral changes: a mixed-methods analysis. Reg Anesth Pain Med 2023:rapm-2023-104807. [PMID: 37865394 DOI: 10.1136/rapm-2023-104807] [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: 06/30/2023] [Accepted: 10/02/2023] [Indexed: 10/23/2023]
Abstract
INTRODUCTION Opioid tapering after surgery is recommended among patients with chronic opioid use, but it is unclear how this process affects their quality of life. The objective of this study was to evaluate how opioid tapering following surgery was associated with patient-reported outcome measures related to pain control and behavioral changes that affect quality of life. METHODS We conducted an explanatory sequential mixed-methods study at a VA Medical Center among patients with chronic opioid use who underwent a spectrum of orthopedic, vascular, thoracic, urology, otolaryngology, and general surgery procedures between 2018 and 2020. Patients were stratified based on the extent that opioid tapering was successful (complete, partial, and no-taper) by 90 days after surgery, followed by qualitative interviews of 10 patients in each taper group. Longitudinal patient-reported outcome measures related to pain intensity, interference, and catastrophizing were compared using Kruskal Wallis tests over the 90-day period after surgery. Qualitative interviews were conducted among patients in each taper group to identify themes associated with the impact of opioid tapering after surgery on quality of life. RESULTS We identified 211 patients with chronic opioid use (92% male, median age 66 years) who underwent surgery during the time period, including 42 (20%) individuals with complete tapering, 48 (23%) patients with partial tapering, and 121 (57%) patients with no taper of opioids following surgery. Patients who did not taper were more likely to have a history of opioid use disorder (10%-partial, 2%-complete vs 17%-no taper, p<0.05) and be discharged on a higher median morphine equivalent daily dose (52-partial, 30-complete vs 60-no taper; p<0.05) than patients in the partial and complete taper groups. Pain interference (-7.2-partial taper and -9.8-complete taper vs -3.5-no taper) and pain catastrophizing (-21.4-partial taper and -16.5-complete taper vs -1.7-no taper) scores for partial and complete taper groups were significantly improved at 90 days relative to baseline when compared with patients in the no-taper group (p<0.05 for both comparisons), while pain intensity was similar between groups. Finally, patients achieving complete and partial opioid tapering were more likely to report improvements in activity, mood, thinking, and sleep following surgery as compared with patients who failed to taper. CONCLUSIONS Partial and complete opioid tapering within 90 days after surgery among patients with chronic opioid use was associated with improved patient-reported measures of pain control as well as behaviors that impact a patient's quality of life.
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Affiliation(s)
- Benjamin Sands Brooke
- Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
- IDEAS 2.0, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Kimberlee Bayless
- Anesthesiology, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Zachary Anderson
- Anesthesiology, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Teryn A Holeman
- Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Chong Zhang
- Internal Medicine-Epidemiology, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Julie Hales
- Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
- IDEAS 2.0, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Michael J Buys
- Anesthesiology, Salt Lake City VA Medical Center, Salt Lake City, Utah, USA
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Aglio LS, Mezzalira E, Corey SM, Fields KG, Hauser BM, Susano MJ, Culley DJ, Schreiber KL, Kelly-Aglio NJ, Patton ME, Mekary RA, Edwards RR. Does the Association Between Psychosocial Factors and Opioid Use After Elective Spine Surgery Differ by Sex in Older Adults? J Pain Res 2023; 16:3477-3489. [PMID: 37873025 PMCID: PMC10590566 DOI: 10.2147/jpr.s415714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/01/2023] [Indexed: 10/25/2023] Open
Abstract
Purpose Psychosocial disorders have been linked to chronic postoperative opioid use and the development of postoperative pain. The potential interaction between sex and psychosocial factors with respect to opioid use after elective spine surgery in the elderly has not yet been evaluated. Our aim was to assess whether any observed association of anxiety or depression indicators with opioid consumption in the first 72 hours after elective spine surgery varies by sex in adults ≥65 years. Patients and Methods Secondary analysis of a retrospective cohort of 647 elective spine surgeries performed at Brigham and Women's Hospital, July 1, 2015-March 15, 2017, in patients ≥65. Linear mixed-effects models were used to test whether history of anxiety, anxiolytic use, history of depression, and antidepressant use were associated with opioid consumption 0-24, 24-48, and 48-72 post surgery, and whether these potential associations differed by sex. Results History of anxiety, anxiolytic use, history of depression, and antidepressant use were more common among women (51.3% of the sample). During the first 24 hours after surgery, men with a preoperative history of anxiety consumed an adjusted mean of 19.5 morphine milligram equivalents (MME) (99.6% CI: 8.1, 31.0) more than men without a history of anxiety; women with a history of anxiety only consumed an adjusted mean 2.9 MME (99.6% CI: -3.1, 8.9) more than women without a history of anxiety (P value for interaction between sex and history of anxiety <0.001). No other interactions were detected between sex and psychosocial factors with respect to opioid use after surgery. Conclusion Secondary analysis of this retrospective cohort study found minimal evidence that the association between psychosocial factors and opioid consumption after elective spine surgery differs by sex in adults ≥65.
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Affiliation(s)
- Linda S Aglio
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Computational Neurosurgical Outcome Center, Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Elisabetta Mezzalira
- Computational Neurosurgical Outcome Center, Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Sarah M Corey
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Kara G Fields
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Blake M Hauser
- Harvard-Massachusetts Institute of Technology Program in Health Sciences and Technology, Cambridge, MA, USA
| | - Maria J Susano
- Department of Anesthesiology, Emergency and Critical Care, Centro Hospitalar do Porto, Porto, Portugal
| | - Deborah J Culley
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Kristin L Schreiber
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Nicole J Kelly-Aglio
- Computational Neurosurgical Outcome Center, Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Megan E Patton
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Rania A Mekary
- Computational Neurosurgical Outcome Center, Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA, USA
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Robert R Edwards
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
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Mercadante S. Houston, we have a problem of opioid crisis… and Rome? JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2023; 3:36. [PMID: 37849004 PMCID: PMC10580571 DOI: 10.1186/s44158-023-00121-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 09/09/2023] [Indexed: 10/19/2023]
Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy.
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Jain S, Lapointe-Gagner M, Alali N, Elhaj H, Poirier AS, Kaneva P, Alhashemi M, Lee L, Agnihotram RV, Feldman LS, Gagner M, Andalib A, Fiore JF. Prescription and consumption of opioids after bariatric surgery: a multicenter prospective cohort study. Surg Endosc 2023; 37:8006-8018. [PMID: 37460817 DOI: 10.1007/s00464-023-10265-w] [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: 05/05/2023] [Accepted: 06/27/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION In the current opioid crisis, bariatric surgical patients are at increased risk of harms related to postoperative opioid overprescribing. This study aimed to assess the extent to which opioids prescribed at discharge after bariatric surgery are consumed by patients. METHODS This multicenter prospective cohort study included adult patients (≥ 18yo) undergoing laparoscopic bariatric surgery. Preoperative assessments included demographics and patient-reported measures. Information regarding surgical and perioperative care interventions (including discharge prescriptions) was obtained from medical records. Self-reported opioid consumption was assessed weekly up to 30 days post-discharge. Number of opioid pills prescribed and consumed was compared using Wilcoxon signed-rank test. Zero-inflated negative binomial regression was used to identify predictors of post-discharge opioid consumption. RESULTS We analyzed 351 patients (mean age 44 ± 11 years, BMI 45 ± 8.0 kg/m2, 77% female, 71% sleeve gastrectomy, length of stay 1.6 ± 0.6 days). The quantity of opioids prescribed at discharge (median 15 pills [IQR 15-16], 112.5 morphine milligram equivalents (MMEs) [IQR 80-112.5]) was significantly higher than patient-reported consumption (median 1 pill [IQR 0-5], 7.5 MMEs [IQR 0-37.5]) (p < 0.001). Overall, 37% of patients did not take any opioids post-discharge and 78.5% of the opioid pills prescribed were unused. Increased post-discharge opioid consumption was associated with male sex (IRR 1.54 [95%CI 1.14 to 2.07]), higher BMI (1.03 [95%CI 1.01 to 1.05]), preoperative opioid use (1.48 [95%CI 1.04 to 2.10]), current smoking (2.32 [95%CI 1.44 to 3.72]), higher PROMIS-29 depression score (1.03 [95% CI 1.01 to 1.04]), anastomotic procedures (1.33 [95%CI 1.01 to 1.75]), and number of pills prescribed (1.04 [95%CI 1.01 to 1.06]). CONCLUSION This study supports that most opioid pills prescribed to bariatric surgery patients at discharge are not consumed. Patient and procedure-related factors may predict opioid consumption. Individualized post-discharge analgesia strategies with minimal or no opioids may be feasible and should be further investigated in future research.
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Affiliation(s)
- Shrieda Jain
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Maxime Lapointe-Gagner
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Naser Alali
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Hiba Elhaj
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Anne-Sophie Poirier
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Pepa Kaneva
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Mohsen Alhashemi
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Lawrence Lee
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Ramanakumar V Agnihotram
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Liane S Feldman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Michel Gagner
- Clinique Michel Gagner (Westmount Square Surgical Center), Westmount, QC, Canada
| | - Amin Andalib
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
- Center for Bariatric Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Julio F Fiore
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada.
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada.
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada.
- Montreal General Hospital, 1650 Cedar Ave, R2-104, Montreal, QC, H3G 1A4, Canada.
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Ruckle DE, Chang AC, Wongworawat MD. The Effect of Upper Extremity Tourniquet Time on Postoperative Pain and Opiate Consumption. Hand (N Y) 2023; 18:1152-1155. [PMID: 35321573 PMCID: PMC10798213 DOI: 10.1177/15589447221084009] [Citation(s) in RCA: 2] [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: 11/15/2022]
Abstract
BACKGROUND There is widespread use of pneumatic tourniquet for both upper and lower extremity orthopedic surgeries. Tourniquet use improves visualization, decreases blood loss, and as a result, decreases operative time. Exceeding a certain amount of tourniquet time can cause lasting neuromuscular damage. Orthopedic procedures cause significant pain, and the perioperative narcotic prescriptions after orthopedic surgery have been identified as one of the major contributors to the opioid epidemic. Our aim was to determine whether increasing tourniquet time had a negative impact on immediate postoperative opiate usage in the upper extremity, and to determine other factors associated with increased immediate postoperative opiate usage. METHODS A retrospective medical record review was performed on patients who underwent volar pleading for fracture fixation between January 2014 and December 2019 at a single institution. Postoperative pain, morphine equivalent dose (MED) usage, and demographic variables were collected. Multivariable analysis was performed, with P < .05 considered significant. RESULTS Immediate postoperative MED consumed was not correlated with operative time, tourniquet time, preoperative substance usage, or sex. However, postoperative MED consumed was correlated with preoperative narcotic use, high body mass index (BMI), and fracture surgery complexity. CONCLUSIONS Tourniquet usage under current guidelines does not appear to have an effect on postoperative pain and narcotic usage. Preoperative narcotic usage, BMI, and surgery complexity are significant factors for postoperative opiate consumption.
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49
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Sabesan V, Lapica H, Fernandez C, Fomunung C. Evolution of Perioperative Pain Management in Shoulder Arthroplasty. Orthop Clin North Am 2023; 54:435-451. [PMID: 37718083 DOI: 10.1016/j.ocl.2023.04.004] [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: 09/19/2023]
Abstract
Historically, opioids have been used as a primary conservative treatment for pain related to glenohumeral osteoarthritis (GHOA). However, this practice is concerning as it often leads to overuse, which has contributed to the current epidemic of addiction and overdoses in the United States. Studies have shown that preoperative opioid use is associated with higher complication rates and worse outcomes following surgery, particularly for shoulder arthroplasty. To address these concerns, perioperative pain management for shoulder arthroplasty has evolved over the years to the use of multimodal analgesia.
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Affiliation(s)
- Vani Sabesan
- Department of Orthopedics, JFK/University of Miami, Palm Beach, FL, USA.
| | - Hans Lapica
- Department of Orthopedics, JFK/University of Miami, Palm Beach, FL, USA
| | - Carlos Fernandez
- Department of Orthopedics, JFK/University of Miami, Palm Beach, FL, USA
| | - Clyde Fomunung
- Department of Orthopedics, JFK/University of Miami, Palm Beach, FL, USA
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50
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Berger JH, Abdou W, Roberts JL, Leach M, Ryan JF, Attaluri SV, Finneran JJ, Sur RL, Monga M, Bechis SK. Erector spinae plane blocks for analgesia after percutaneous nephrolithotomy A pathway to reduce opioids. Can Urol Assoc J 2023; 17:E330-E335. [PMID: 37494322 PMCID: PMC10581734 DOI: 10.5489/cuaj.8323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Despite its minimally invasive nature, percutaneous nephrolithotomy (PCNL ) may be associated with significant pain. Challenges in pain control may prevent timely discharge (and expose patients to adverse effects of opioid use). We sought to evaluate whether our patients who underwent erector spinae plane (ESP) regional blocks experienced improved postoperative pain control and decreased opioid use after PCNL (compared with those who did not receive blocks). METHODS We retrospectively reviewed consecutive PCNL cases on patients admitted for greater than 24 hours without pre-existing opioid regimens for chronic pain. Cases were completed by a single high-volume surgeon. Patients who accepted an ESP block were compared to those who did not receive a block. Patients received either a single injection or a disposable pump delivering intermittent boluses of ropivacaine 0.2%. Demographic and perioperative data were analyzed. The primary outcomes were opioid use measured in morphine milligram equivalent (MME ) and patient-reported pain scores during the first 24 hours of hospitalization. RESULTS From March 2019 to August 2021, 44 patients were identified who met criteria - 28 of whom received an ESP block (including 14 continuous blocks). The patients who received blocks had significantly decreased opioid use (18.3 vs. 81.3 MME, p=0.004) and a longer mean time to first non-zero pain score (p=0.004). Continuous blocks had similar opioid use to single shot blocks (21.0 vs. 15.6 MME, p=0.952). CONCLUSIONS ESP regional blocks appear to offer an effective adjunct method for pain control after PCNL and may reduce post-PCNL opioid use while maintaining adequate patient analgesia.
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Affiliation(s)
- Jonathan H. Berger
- University of California, San Diego Department of Urology, San Diego, CA, United States
| | - Waseem Abdou
- University of California, San Diego School of Medicine, La Jolla, CA, United States
| | - Jacob L. Roberts
- University of California, San Diego Department of Urology, San Diego, CA, United States
| | - Michelle Leach
- University of California, San Diego Department of Urology, San Diego, CA, United States
| | - John F. Ryan
- University of California, San Diego School of Medicine, La Jolla, CA, United States
| | | | - John J. Finneran
- University of California, San Diego Department of Anesthesia, San Diego, CA, United States
| | - Roger L. Sur
- University of California, San Diego Department of Urology, San Diego, CA, United States
| | - Manoj Monga
- University of California, San Diego Department of Urology, San Diego, CA, United States
| | - Seth K. Bechis
- University of California, San Diego Department of Urology, San Diego, CA, United States
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