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Ewing JK, Cassling KE, Hanneman MA, Broucek JR, Raymond BL, Pierce RA, Geiger TM, Bradley JF. Development of an Enhanced Recovery After Surgery Program in Ventral Hernia. Am Surg 2024:31348241268330. [PMID: 39096287 DOI: 10.1177/00031348241268330] [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: 08/05/2024]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) programs have spread after initial success in colorectal surgery decreasing length of stay (LOS) and decreasing opioid consumption. Adoption of ERAS specifically for ventral hernia patients remains in evolution. This study presents the development and implementation of an ERAS pathway for ventral hernia. METHODS A multidisciplinary team met weekly over 6 months to develop an ERAS pathway specific to ventral hernia patients. 75 process components and outcome measures were included, spanning multiple phases of care: Preoperative-Clinic, Preoperative Day of Surgery (DOS), Intraoperative, and Postoperative. Preoperative components included education and physiologic optimization. Pain control across phases of care focuses on nonopioid, multimodal analgesia. Postoperatively, the pathway emphasizes early diet advancement, early mobilization, and minimization of IV fluids. We compared compliance and outcome measures between a Pre Go-Live (PGL) period (9/1/2020-8/30/2021) and After Go-live (AGL) period (5/12/2022-5/19/2023). RESULTS There were 125 patients in the PGL group and 169 patients in the AGL group. Overall, ERAS compliance increased from 73.9% to 82.9% after implementation. Length of stay decreased from an average of 2.27 days PGL to 1.92 days AGL. Finally, the average daily postoperative opioid usage decreased from 25.4 to 13.5 MME after the implementation. DISCUSSION Enhanced Recovery After Surgery can be successfully applied to the care of hernia patients with improvements in LOS and decreased opioid consumption. Institutional support and multidisciplinary cooperation were key for the development of such a program.
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Affiliation(s)
- John K Ewing
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kyle E Cassling
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Michael A Hanneman
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joseph R Broucek
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Britany L Raymond
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Richard A Pierce
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Timothy M Geiger
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joel F Bradley
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Shiraishi M, Sowa Y, Inafuku N, Sunaga A, Yoshimura K, Okazaki M. Chronic Pain Following Breast Reconstruction: A Scoping Review. Ann Plast Surg 2024; 93:261-267. [PMID: 38980915 DOI: 10.1097/sap.0000000000003986] [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: 07/11/2024]
Abstract
BACKGROUND Breast cancer survival rates have increased significantly, underscoring the importance of enhancing long-term health-related quality of life. Breast reconstruction following mastectomy has emerged as a common approach that contributes to improved health-related quality of life. Nonetheless, chronic pain following breast reconstruction is a prevalent issue that has a negative impact on overall well-being. METHODS To examine recent findings on chronic pain after breast reconstruction and progress in pain management, we performed a review of the literature through independent searches using the MEDLINE database within NIH National Library of Medicine PubMed. RESULTS The review suggested that autologous reconstruction causes chronic postsurgical pain, especially at specific donor sites, whereas implant-based reconstruction does not seem to increase the risk of chronic pain. Moreover, certain operational and patient factors are also associated with chronic pain. Appropriate pain management can reduce chronic pain and prevent the transition from acute to chronic pain. CONCLUSION This scoping review evaluated the characteristics of long-term chronic pain after breast reconstruction. The findings provide patients with important treatment information and will assist with their decision on their preferred treatment.
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Affiliation(s)
- Makoto Shiraishi
- From the Department of Plastic and Reconstructive Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoshihiro Sowa
- Department of Plastic Surgery, Jichi Medical University, Tochigi, Japan
| | - Naoki Inafuku
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Ataru Sunaga
- Department of Plastic Surgery, Jichi Medical University, Tochigi, Japan
| | - Kotaro Yoshimura
- Department of Plastic Surgery, Jichi Medical University, Tochigi, Japan
| | - Mutsumi Okazaki
- From the Department of Plastic and Reconstructive Surgery, The University of Tokyo Hospital, Tokyo, Japan
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Qi Y, Zhou M, Dong Y, Zheng W, Jiang Q, Li Y, Wang X, Sun J, Zhou H, Hu Z, Wang L. Effect of esketamine on hypotension in women with preoperative anxiety undergoing elective cesarean section: a randomized, double-blind, controlled trial. Sci Rep 2024; 14:17088. [PMID: 39048628 PMCID: PMC11269714 DOI: 10.1038/s41598-024-68155-7] [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: 05/02/2024] [Accepted: 07/21/2024] [Indexed: 07/27/2024] Open
Abstract
To investigate the effect of low-doses esketamine on spinal anesthesia-induced hypotension in women with preoperative anxiety undergoing elective cesarean section, the randomized controlled trial enrolled 120 women aged 18-35 years who preoperative State-Trait Anxiety Inventory State scores > 40, conducted from September 2022 to August 2023 in Xuzhou Central Hospital, China. Women in the esketamine group received a single intravenous injection of 0.2 mg/kg esketamine after sensory block level achieved. The incidence of hypotension in the esketamine group was significantly lower than the control group at T2 (10% [6 of 60]; P < 0.001), T3 (5.0% [3 of 60]; P = 0.007) and T4(5.0% [3 of 60]; P = 0.004). Despite being higher in the esketamine group, the overall rates of hypertension (11.7% [7 of 60]; P = 0.186), tachycardia (23.3% [14 of 60]; P = 0.246), and bradycardia (0.0% [0 of 60]; P = 0.079) were no significantly difference between the two groups. STAI-S scores was significantly lower in the esketamine group (mean [SD] 37.52[7.14]) than in the control group (mean [SD] 41.03[9.66], P = 0.39) in postoperative day 1. Spinal anesthesia combined with intravenous low-doses esketamine infusion can significantly reduce the incidence of hypotension in women with preoperative anxiety undergoing elective cesarean section.
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Affiliation(s)
- Yu Qi
- The Xuzhou Clinical College of Xuzhou Medical University, No. 199, Jiefang South Road, 221009, Xuzhou, Jiangsu, China
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, Jiangsu, China
| | - Meiyan Zhou
- The Xuzhou Clinical College of Xuzhou Medical University, No. 199, Jiefang South Road, 221009, Xuzhou, Jiangsu, China
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, Jiangsu, China
| | - Yaqi Dong
- The Xuzhou Clinical College of Xuzhou Medical University, No. 199, Jiefang South Road, 221009, Xuzhou, Jiangsu, China
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, Jiangsu, China
| | - Wenting Zheng
- The Xuzhou Clinical College of Xuzhou Medical University, No. 199, Jiefang South Road, 221009, Xuzhou, Jiangsu, China
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, Jiangsu, China
| | - Qinyu Jiang
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, Jiangsu, China
| | - Yanyu Li
- Department of Obstetrics and Gynecology, Xuzhou Central Hospital, Xuzhou, Jiangsu, China
| | - Xinghe Wang
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, Jiangsu, China
| | - Jia Sun
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, Jiangsu, China
| | - Hai Zhou
- The Xuzhou Clinical College of Xuzhou Medical University, No. 199, Jiefang South Road, 221009, Xuzhou, Jiangsu, China
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, Jiangsu, China
| | - Zhengquan Hu
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, Jiangsu, China.
| | - Liwei Wang
- The Xuzhou Clinical College of Xuzhou Medical University, No. 199, Jiefang South Road, 221009, Xuzhou, Jiangsu, China.
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, Jiangsu, China.
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Palya M, Chevere JM, Drum M, Fowler S, Nusstein J, Reader A, Ni A. Pain Reduction of Ibuprofen Sodium Dihydrate Alone and in Combination with Acetaminophen in an Untreated Endodontic Pain Model: A Randomized, Double-blind Investigation. J Endod 2024; 50:881-888. [PMID: 38657900 DOI: 10.1016/j.joen.2024.04.005] [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: 01/18/2024] [Revised: 04/04/2024] [Accepted: 04/06/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION Most pain studies have been based on a postsurgical, third molar model using ibuprofen (IBU)/acetaminophen (APAP). Studies have found quicker onset of pain relief with a newer formulation of IBU - ibuprofen sodium dihydrate (ISD). The purpose of this study was to compare pain reduction of ISD/APAP to ISD in an acute endodontic pain model of untreated patients experiencing moderate to severe pain with symptomatic apical periodontitis. METHODS AND MATERIALS In this double-blind randomized study, 64 adult emergency patients in acute moderate to severe pain, a pulpal diagnosis of symptomatic irreversible pulpitis or necrosis, and symptomatic apical periodontitis participated. Each patient randomly received either one dose of 768 mg ISD/1000 mg APAP or one dose of 768 mg ISD. Pain intensity scores were recorded every 15 minutes over 240 minutes using the Heft-Parker VAS along with time to first sign of pain relief, time to meaningful pain relief, and time to 50% pain relief also recorded. The data were analyzed statistically. RESULTS Both ISD and ISD/APAP groups showed a progressive decrease in pain from baseline to 120 minutes after medication administration. Afterward, a relative plateau was seen in the patients' pain. There was no difference in the VAS scores between the ISD and ISD/APAP at any given time point, time to first sign of pain relief, time to meaningful pain relief, and time to 50% pain relief. CONCLUSIONS The addition of APAP to ISD for pain control in an untreated endodontic pain model did not differ significantly from ISD alone.
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Affiliation(s)
- Morgan Palya
- Former Graduate Student in Endodontics, Division of Endodontics, The Ohio State University, Pittsburg, Pennsylvania
| | - Janine Matos Chevere
- Former Graduate Student in Endodontics, Division of Endodontics, The Ohio State University, Holland and Muskegon, Michigan
| | - Melissa Drum
- Professor and Graduate Program Director, Division of Endodontics, The Ohio State University, Columbus, Ohio
| | - Sara Fowler
- Associate Professor and Predoctoral Director, Division of Endodontics, The Ohio State University, Columbus, Ohio
| | - John Nusstein
- Professor and Chair, Division of Endodontics, The Ohio State University, Columbus, Ohio
| | - Al Reader
- Emeritus Professor, Division of Endodontics, The Ohio State University, Columbus, Ohio.
| | - Andy Ni
- Assistant Professor, Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio
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Lee HJ, Choi S, Yoon S, Yoon S, Bahk JH. Effect of an intravenous acetaminophen/ibuprofen fixed-dose combination on postoperative opioid consumption and pain after video-assisted thoracic surgery: a double-blind randomized controlled trial. Surg Endosc 2024; 38:3061-3069. [PMID: 38609589 PMCID: PMC11133211 DOI: 10.1007/s00464-024-10821-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 03/22/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND Video-assisted thoracoscopic surgery (VATS) often induces significant postoperative pain, potentially leading to chronic pain and decreased quality of life. This study aimed to evaluate the acetaminophen/ibuprofen combination effectiveness in reducing analgesic requirements and pain intensity in patients undergoing VATS. STUDY DESIGN This is a double-blinded randomized controlled trial. METHODS Adult patients scheduled for elective VATS for lung resection were randomized to receive either intravenous acetaminophen and ibuprofen (intervention group) or 100 mL normal saline (control group). Treatments were administered post-anesthesia induction and every 6 h for three cycles. The primary outcome was total analgesic consumption at 24 h postoperatively. Secondary outcomes were cumulative analgesic consumption at 2 and 48 h; analgesic-related side effects at 2, 24, and 48 h; quality of recovery at 24 h and 48 h postoperatively; pain intensity at rest and during coughing; and rescue analgesics use. Chronic postsurgical pain (CPSP) was assessed through telephone interviews 3 months postoperatively. RESULTS The study included 96 participants. The intervention group showed significantly lower analgesic consumption at 24 h and 48 h postoperatively (24 h: median difference: - 100 µg equivalent intravenous fentanyl [95% confidence interval (CI) - 200 to - 5 μg], P = 0.037; 48 h: median difference: - 140 μg [95% CI - 320 to - 20 μg], P = 0.035). Compared to the controls, the intervention group exhibited a significantly lower quality of recovery 24 h post-surgery, with no significant difference at 48 h. All pain scores except for coughing at 48 h post-surgery were significantly lower in the intervention group compared to the controls. No significant differences were observed between the groups in postoperative nausea and vomiting occurrence, hospital stay length, and CPSP. CONCLUSION Perioperative administration of acetaminophen/ibuprofen significantly decreased analgesic needs in patients undergoing VATS, providing an effective postoperative pain management strategy, and potentially minimizing the need for stronger analgesics.
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Affiliation(s)
- Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Seungeun Choi
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Soohyuk Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Susie Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
| | - Jae-Hyon Bahk
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
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Fink PB, Wheeler AR, Smith WR, Brant-Zawadzki G, Lieberman JR, McIntosh SE, Van Tilburg C, Wedmore IS, Windsor JS, Hofmeyr R, Weber D. Wilderness Medical Society Clinical Practice Guidelines for the Treatment of Acute Pain in Austere Environments: 2024 Update. Wilderness Environ Med 2024; 35:198-218. [PMID: 38651342 DOI: 10.1177/10806032241248422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
The Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded based on the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians. This is an update of the 2014 version of the "WMS Practice Guidelines for the Treatment of Acute Pain in Remote Environments" published in Wilderness & Environmental Medicine 2014; 25:41-49.
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Affiliation(s)
- Patrick B Fink
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT
| | - Albert R Wheeler
- Department of Emergency Medicine, St. John's Health, Jackson, WY
| | - William R Smith
- Department of Emergency Medicine, St. John's Health, Jackson, WY
| | | | | | - Scott E McIntosh
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT
| | | | - Ian S Wedmore
- Uniformed Services University of the Health Sciences, Bethesda, MD
| | | | - Ross Hofmeyr
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - David Weber
- Mountain Rescue Collective, LLC, Park City, UT
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Steiness J, Hägi-Pedersen D, Lunn TH, Overgaard S, Brorson S, Graungaard BK, Lindberg-Larsen M, Varnum C, Lundstrøm LH, Beck T, Skettrup M, Pedersen NA, Bieder MJ, von Cappeln AG, Pleckaitiene L, Lindholm P, Bukhari SSH, Derby CB, Nielsen MG, Exsteen OW, Vinstrup LØ, Thybo KH, Gasbjerg KS, Nørskov AK, Jakobsen JC, Mathiesen O. Non-opioid analgesic combinations following total hip arthroplasty (RECIPE): a randomised, placebo-controlled, blinded, multicentre trial. THE LANCET. RHEUMATOLOGY 2024; 6:e205-e215. [PMID: 38458208 DOI: 10.1016/s2665-9913(24)00020-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Multimodal postoperative analgesia following total hip arthroplasty is recommended, but the optimal combination of drugs remains uncertain. The aim of the RECIPE trial was to investigate the relative benefit and harm of the different combinations of paracetamol, ibuprofen, and the analgesic adjuvant dexamethasone for treatment of postoperative pain following total hip arthroplasty. METHODS The RECIPE trial was a randomised, blinded, placebo-controlled trial conducted at nine Danish hospitals. Adults scheduled for total hip arthroplasty were randomly assigned (1:1:1:1) using a computer-generated list with stratification by site to receive combinations of oral paracetamol 1000 mg every 6 h, oral ibuprofen 400 mg every 6 h, or a single-dose of intravenous dexamethasone 24 mg in the following groups: paracetamol plus ibuprofen, ibuprofen plus dexamethasone, paracetamol plus dexamethasone, and paracetamol plus ibuprofen plus dexamethasone. The primary outcome was 24 h intravenous morphine consumption, analysed in a modified intention-to-treat population, defined as all randomly assigned participants who underwent total hip arthroplasty. The predefined minimal important difference was 8 mg. Safety outcomes included serious and non-serious adverse events within 90 days and 24 h. The trial was registered with ClinicalTrials.gov, NCT04123873. FINDINGS Between March 5, 2020, and Nov 15, 2022, we randomly assigned 1060 participants, of whom 1043 (589 [56%] women and 454 [44%] men) were included in the modified intention-to-treat population. 261 were assigned to paracetamol plus ibuprofen, 262 to ibuprofen plus dexamethasone, 262 to paracetamol plus dexamethasone, and 258 to paracetamol plus ibuprofen plus dexamethasone. Median 24 h morphine consumption was 24 mg (IQR 12-38) in the paracetamol plus ibuprofen group, 20 mg (12-32) in the paracetamol plus dexamethasone group, 16 mg (10-30) in the ibuprofen plus dexamethasone group, and 15 mg (8-26) in the paracetamol plus ibuprofen plus dexamethasone group. The paracetamol plus ibuprofen plus dexamethasone group had a significantly reduced 24 h morphine consumption compared with paracetamol plus ibuprofen (Hodges-Lehmann median difference -6 mg [99% CI -10 to -3]; p<0·0001) and paracetamol plus dexamethasone (-4 mg [-8 to -1]; p=0·0013), however, none of the comparisons showed differences reaching the minimal important threshold of 8 mg. 91 (35%) of 258 participants in the paracetamol plus ibuprofen plus dexamethasone group had one or more adverse events, compared with 99 (38%) of 262 in the ibuprofen plus dexamethasone group, 103 (39%) of 262 in the paracetamol plus dexamethasone group, and 165 (63%) of 261 in the paracetamol plus ibuprofen group. INTERPRETATION In adults undergoing total hip arthroplasty, a combination of paracetamol, ibuprofen, and dexamethasone had the lowest morphine consumption within 24 h following surgery and the most favourable adverse event profile, with a lower incidence of serious and non-serious adverse events (primarily driven by differences in nausea, vomiting, and dizziness) compared with paracetamol plus ibuprofen. FUNDING The Novo Nordisk Foundation and Næstved-Slagelse-Ringsted Hospitals' Research Fund.
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Affiliation(s)
- Joakim Steiness
- Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark.
| | - Daniel Hägi-Pedersen
- Department of Anaesthesiology, Næstved-Slagelse-Ringsted Hospitals, Næstved, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Troels Haxholdt Lunn
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital, Bispebjerg Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Søren Overgaard
- Department of Orthopaedic Surgery and Traumatology, Copenhagen University Hospital, Bispebjerg Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Stig Brorson
- Department of Orthopaedic Surgery, Zealand University Hospital, Køge, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ben Kristian Graungaard
- Department of Anaesthesiology, Copenhagen University Hospital, Gentofte Hospital, Copenhagen, Denmark
| | - Martin Lindberg-Larsen
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark; Department of Orthopaedic Surgery, Odense University Hospital, Svendborg, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Claus Varnum
- Department of Orthopaedic Surgery, Lillebælt Hospital, Vejle, Denmark; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Lars Hyldborg Lundstrøm
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Torben Beck
- Department of Orthopaedic Surgery and Traumatology, Copenhagen University Hospital, Bispebjerg Hospital, Copenhagen, Denmark
| | - Michael Skettrup
- Department of Orthopaedic Surgery, Copenhagen University Hospital, Gentofte Hospital, Copenhagen, Denmark
| | | | - Manuel Josef Bieder
- Department of Orthopaedic Surgery, Næstved-Slagelse-Ringsted Hospitals, Næstved, Denmark
| | | | | | - Peter Lindholm
- Department of Anaesthesiology, Odense University Hospital, Odense, Denmark
| | | | | | - Maria Gantzel Nielsen
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital, Bispebjerg Hospital, Copenhagen, Denmark
| | - Oskar Wilborg Exsteen
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Louise Ørts Vinstrup
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital, Bispebjerg Hospital, Copenhagen, Denmark
| | - Kasper Højgaard Thybo
- Department of Anaesthesiology, Næstved-Slagelse-Ringsted Hospitals, Næstved, Denmark
| | - Kasper Smidt Gasbjerg
- Department of Anaesthesiology, Copenhagen University Hospital, Herlev Hospital, Copenhagen, Denmark
| | - Anders Kehlet Nørskov
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen, Denmark; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Ole Mathiesen
- Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Kouznetsov VV. Exploring acetaminophen prodrugs and hybrids: a review. RSC Adv 2024; 14:9691-9715. [PMID: 38525062 PMCID: PMC10958773 DOI: 10.1039/d4ra00365a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 03/17/2024] [Indexed: 03/26/2024] Open
Abstract
This critical review highlights the advances in developing new molecules for treating pain syndrome, an important issue for human health. Acetaminophen (APAP, known as paracetamol) and nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in clinical practice despite their adverse effects. Research is being conducted to develop innovative drugs with improved pharmaceutical properties to mitigate these effects. A more practical way to achieve that is to study well-known and time-tested drugs in their molecular combinations. Accordingly, the present work explores APAP and their combined chemical entities, i.e., prodrugs (soft drugs), codrugs (mutual prodrugs), and hybrids. Due to their molecular structure, APAP prodrugs or codrugs could be considered merged or conjugated hybrids; all these names are very fluid terms. This article proposed a structural classification of these entities to better analyze their advances. So, the following: carrier-linked O-modified APAP, -linked N-modified APAP derivatives (prodrugs), and direct- and spacer-N,O-linked APAP hybrids (codrugs) are the central parts of this review and are examined, especially ester and amide NSAID-APAP molecules. The C-linked APAP and nitric oxide (NO)-releasing APAP hybrids were also briefly discussed. Prime examples of APAP-based drugs such as propacetamol, benorylate, acetaminosalol, nitroparacetamol, and agent JNJ-10450232 weave well into this classification. The proposed classification is the first and original, giving a better understanding of the SAR studies for new pain relievers research and the design development for the analgesic APAP-(or NSAID)-based compounds.
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Affiliation(s)
- Vladimir V Kouznetsov
- Laboratorio de Química Orgánica y Biomolecular, Escuela de Química, Universidad Industrial de Santander Cl. 9 # Cra 27 A.A. 680006 Bucaramanga Colombia
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Sumphaongern T, Jansisyanont P. Single Dose Intravenous Paracetamol versus Placebo in Postorthognathic Surgery Pain: A Randomized Clinical Trial. Anesthesiol Res Pract 2024; 2024:8898553. [PMID: 38525206 PMCID: PMC10957247 DOI: 10.1155/2024/8898553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 02/21/2024] [Accepted: 03/09/2024] [Indexed: 03/26/2024] Open
Abstract
Background The postorthognathic surgery patients experienced moderate to severe pain and could be at risk for opioid-related side effects. The aim of this study was to evaluate the efficacy of a single dose of intravenous paracetamol to control postorthognathic surgery pain and reduce opioid consumption. Methods The patients were randomized into two groups. The study group received intravenous paracetamol and the control group received a placebo immediately postoperation. The visual analogue pain scale (VAS) at 1-, 4-, 8-, 12-, 16-, 20-, and 24 -h postoperatively, morphine consumption, side effects from morphine, and patient satisfaction were analyzed. Results Sixty-two patients (thirty-one patients in each group) were included. The postoperative VAS in the study group was significantly lower than those in the control group (p value <0.001) at all time points. The total postoperative morphine consumption in the study group (45.1 ± 21.2 mcg/kg) was significantly lower compared with the control group (136.5 ± 49.9 mcg/kg) (p value <0.001). Patient satisfaction was significantly higher in the study group (4.7 ± 0.5 out of 5 points) than in the control group (4.1 ± 0.7 out of 5 points) (p value <0.001). The incidence of nausea and vomiting was significantly lower in the study group compared with the control group (p value <0.001 and 0.002, respectively). Conclusion A single dose of intravenous paracetamol as part of multimodal analgesia was effective for postorthognathic surgery pain. It provided significant benefits to patients, including reduced pain scores, decreased opioid consumption, reduced nausea and vomiting, and improved satisfaction. This trial is registered with TCTR20210908002.
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Affiliation(s)
- Thunshuda Sumphaongern
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
| | - Pornchai Jansisyanont
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
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Freys JC, Bigalke SM, Mertes M, Lobo DN, Pogatzki-Zahn EM, Freys SM. Perioperative pain management for appendicectomy: A systematic review and Procedure-specific Postoperative Pain Management recommendations. Eur J Anaesthesiol 2024; 41:174-187. [PMID: 38214556 DOI: 10.1097/eja.0000000000001953] [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: 01/13/2024]
Abstract
BACKGROUND Despite being a commonly performed surgical procedure, pain management for appendicectomy is often neglected because of insufficient evidence on the most effective treatment options. OBJECTIVE To provide evidence-based recommendations by assessing the available literature for optimal pain management after appendicectomy. DESIGN AND DATA SOURCES This systematic review-based guideline was conducted according to the PROSPECT methodology. Relevant randomised controlled trials, systematic reviews and meta-analyses in the English language from January 1999 to October 2022 were retrieved from MEDLINE, Embase and Cochrane Databases using PRISMA search protocols. ELIGIBILITY CRITERIA We included studies on adults and children. If articles reported combined data from different surgeries, they had to include specific information about appendicectomies. Studies needed to measure pain intensity using a visual analogue scale (VAS) or a numerical rating scale (NRS). Studies that did not report the precise appendicectomy technique were excluded. RESULTS Out of 1388 studies, 94 met the inclusion criteria. Based on evidence and consensus, the PROSPECT members agreed that basic analgesics [paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs)] should be administered perioperatively for open and laparoscopic appendicectomies. A laparoscopic approach is preferred because of lower pain scores. Additional recommendations for laparoscopic appendicectomies include a three-port laparoscopic approach and the instillation of intraperitoneal local anaesthetic. For open appendicectomy, a preoperative unilateral transverse abdominis plane (TAP) block is recommended. If not possible, preincisional infiltration with local anaesthetics is an alternative. Opioids should only be used as rescue analgesia. Limited evidence exists for TAP block in laparoscopic appendicectomy, analgesic adjuvants for TAP block, continuous wound infiltration after open appendicectomy and preoperative ketamine and dexamethasone. Recommendations apply to children and adults. CONCLUSION This review identified an optimal analgesic regimen for open and laparoscopic appendicectomy. Further randomised controlled trials should evaluate the use of regional analgesia and wound infiltrations with adequate baseline analgesia, especially during the recommended conventional three-port approach. REGISTRATION The protocol for this study was registered with the PROSPERO database (Registration No. CRD42023387994).
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Affiliation(s)
- Jacob C Freys
- From the Department of Surgery, Agaplesion Bethesda Krankenhaus Hamburg (JCF), Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany (EMP-Z, MM), Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham (DNL), MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom (DNL), Department of Anaesthesiology, Intensive and Pain Medicine, Ruhr-University Bochum, BG-University Hospital Bergmannsheil gGmbH, Bochum (SMB) and Department of Surgery, DIAKO Ev. Diakonie-Krankenhaus, Bremen, Germany (SMF)
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Bieze M, van Haaps AP, Kapural L, Li S, Ferguson K, de Vries R, Schatman ME, Mijatovic V, Kallewaard JW. Spinal Cord Stimulation for Intractable Visceral Pain Originating from the Pelvic and Abdominal Region: A Narrative Review on a Possible New Indication for Patients with Therapy-Resistant Pain. J Pain Res 2024; 17:691-736. [PMID: 38405684 PMCID: PMC10887953 DOI: 10.2147/jpr.s445616] [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: 10/20/2023] [Accepted: 02/03/2024] [Indexed: 02/27/2024] Open
Abstract
Aim Visceral pain, characterized by pain that is diffuse and challenging to localize, occurs frequently and is difficult to treat. In cases where the pain becomes intractable despite optimal medical management, it can affect patients' Quality of Life (QoL). Spinal Cord Stimulation (SCS) has emerged as a potential solution for intractable visceral pain. Purpose In this narrative review, we collected all evidence regarding the efficacy of SCS for visceral pain across various underlying conditions. Methods A comprehensive literature search was conducted in PubMed, Embase, and Web of Science in which articles published from October 1st, 1963 up to March 7th, 2023 were identified. Results Seventy articles were included in this review of which most were retrospective cohort studies, case series and case reports. The studies, often with a small number of participants, reported on SCS for chronic pancreatitis, anorectal pain and bowel disorders, gynaecological diagnoses, visceral pelvic pain, urological disorders and finally general visceral pain. They found positive effects on pain and/or symptom relief, opioid consumption, anxiety and depression and QoL. Complications occurred frequently but were often minor and reversible. Conclusion Better screening and selection criteria need to be established to optimally evaluate eligible patients who might benefit from SCS. A positive outcome of a sympathetic nerve block appears to be a potential indicator of SCS effectiveness. Additionally, women receiving SCS for endometriosis had a better outcome compared to other indications. Finally, SCS could also relief functional symptoms such as voiding problems and gastroparesis. Complications could often be resolved with revision surgery. Since SCS is expensive and not always covered by standard health insurance, the incorporation of cost-analyses is recommended. In order to establish a comprehensive treatment plan, including selection criteria for SCS, rigorous prospective, possibly randomized and controlled studies that are diagnosis-oriented, with substantial follow-up and adequate sample sizes, are needed.
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Affiliation(s)
- Matthanja Bieze
- Department of Anesthesiology and Pain Management, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Annelotte Pauline van Haaps
- Department of Reproductive Medicine, Amsterdam University Medical Center location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Amsterdam Reproduction and Development, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Leonardo Kapural
- Carolina’s Pain Institute and Center for Clinical Research, Winston Salem, North Carolina, USA
| | - Sean Li
- National Spine and Pain Centers, Shrewsbury, New Jersey, USA
| | - Kris Ferguson
- Aspirus Langlade Hospital Pain Clinic, Antigo, Wisconsin, USA
| | - Ralph de Vries
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA
- Department of Population Health – Division of Medical Ethics, NYU Grossman School of Medicine, New York, New York, USA
| | - Velja Mijatovic
- Department of Reproductive Medicine, Amsterdam University Medical Center location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Amsterdam Reproduction and Development, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jan Willem Kallewaard
- Department of Anesthesiology and Pain Management, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
- Department of Anesthesiology and Pain Management, Rijnstate Ziekenhuis, Arnhem, the Netherlands
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Sethi V, Qin L, Cox E, Trocóniz IF, Della Pasqua O. Model-Based Meta-Analysis Supporting the Combination of Acetaminophen and Topical Diclofenac in Acute Pain: A Therapy for Mild-to-Moderate Osteoarthritis Pain? Pain Ther 2024; 13:145-159. [PMID: 38183573 PMCID: PMC10796861 DOI: 10.1007/s40122-023-00569-z] [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: 05/11/2023] [Accepted: 08/16/2023] [Indexed: 01/08/2024] Open
Abstract
INTRODUCTION Acetaminophen and topical diclofenac (AtopD) have complementary mechanisms of action and are therefore candidates for combination use in osteoarthritis (OA) pain. However, an evidence gap exists on their combination use in OA pain. This study aimed to assess the effects of this combination and compare its performance relative to monotherapies on pain score reduction and opioid-sparing effect by leveraging evidence from acute pain setting using a model-based meta-analysis (MBMA). METHODS A literature search was conducted using the MEDLINE database to identify randomized controlled trials (RCTs) studying the combination for acute pain. Subsequently, an MBMA of RCTs was implemented in conjunction with extrapolation principles to infer efficacy in the population of interest. Pain score reduction and opioid-sparing effect (OSE) were selected as the measures of efficacy. RESULTS A total of 11 RCTs encompassing 1396 patients were included. Exploratory evaluation revealed AtopD combination to show greater pain score reduction versus acetaminophen monotherapy. However, pain score reduction was more susceptible to confounding by opioid patient-controlled analgesia (PCA) than OSE. Therefore, a parsimonious MBMA evaluating OSE was developed from 5 of the 11 RCTs (n = 353 patients). The analysis revealed a statistically significant interaction coefficient, suggesting a reduction of 32% in opioid use with the combination versus acetaminophen monotherapy. Differences in the effect size of the combination were less conclusive versus diclofenac monotherapy. CONCLUSION Our results indicate greater pain reduction and opioid-sparing efficacy for the AtopD combination versus acetaminophen monotherapy. Given the similar pain pathways and mechanisms of action of the two drugs in acute and mild-to-moderate OA pain, comparable beneficial effects from the combination therapy may be anticipated following extrapolation to chronic OA pain. Prospective RCTs and real-world studies in OA pain are needed to confirm the differences in the efficacy of the combination treatment observed in our study.
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Affiliation(s)
- Vidhu Sethi
- Medical Affairs, Haleon (Formerly GSK Consumer Healthcare), GSK Asia House, Rochester Park, Singapore, 139234, Singapore
| | - Li Qin
- Quantitative Science, Certara, Princeton, USA
| | - Eugène Cox
- Quantitative Science, Certara, Princeton, USA
| | - Iñaki F Trocóniz
- Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain
| | - Oscar Della Pasqua
- Clinical Pharmacology and Therapeutics Group, University College London, BMA House, Tavistock Square, London, WC1H 9JP, UK.
- Clinical Pharmacology Modelling and Simulation, GlaxoSmithKline, Brentford, UK.
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Nasr Isfahani M, Etesami H, Ahmadi O, Masoumi B. Comparing the efficacy of intravenous morphine versus ibuprofen or the combination of ibuprofen and acetaminophen in patients with closed limb fractures: a randomized clinical trial. BMC Emerg Med 2024; 24:15. [PMID: 38273252 PMCID: PMC10809472 DOI: 10.1186/s12873-024-00933-y] [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: 08/31/2023] [Accepted: 01/11/2024] [Indexed: 01/27/2024] Open
Abstract
INTRODUCTION This study aims to investigate the effectiveness of intravenous ibuprofen or intravenous ibuprofen plus acetaminophen compared to intravenous morphine in patients with closed extremity fractures. METHODS A triple-blinded randomized clinical trial was conducted at a tertiary trauma center in Iran. Adult patients between 15 and 60 years old with closed, isolated limb fractures and a pain intensity of at least 6/10 on the visual analog scale (VAS) were eligible. Patients with specific conditions or contraindications were not included. Participants were randomly assigned to receive intravenous ibuprofen, intravenous ibuprofen plus acetaminophen, or intravenous morphine. Pain scores were assessed using the visual analog scale at baseline and 5, 15, 30, and 60 min after drug administration. The primary outcome measure was the pain score reduction after one hour. RESULTS Out of 388 trauma patients screened, 158 were included in the analysis. There were no significant differences in age or sex distribution among the three groups. The pain scores decreased significantly in all groups after 5 min, with the morphine group showing the lowest pain score at 15 min. The maximum effect of ibuprofen was observed after 30 min, while the ibuprofen-acetaminophen combination maintained its effect after 60 min. One hour after injection, pain score reduction in the ibuprofen-acetaminophen group was significantly more than in the other two groups, and pain score reduction in the ibuprofen group was significantly more than in the morphine group. CONCLUSION The study findings suggest that ibuprofen and its combination with acetaminophen have similar or better analgesic effects compared to morphine in patients with closed extremity fractures. Although morphine initially provided the greatest pain relief, its effect diminished over time. In contrast, ibuprofen and the ibuprofen-acetaminophen combination maintained their analgesic effects for a longer duration. The combination therapy demonstrated the most sustained pain reduction. The study highlights the potential of non-opioid analgesics in fracture pain management and emphasizes the importance of initiation of these medications as first line analgesic for patients with fractures. These findings support the growing trend of exploring non-opioid analgesics in pain management. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05630222 (Tue, Nov 29, 2022). The manuscript adheres to CONSORT guidelines.
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Affiliation(s)
- Mehdi Nasr Isfahani
- Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Trauma Data Registration Center, Al-Zahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hossein Etesami
- Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Student Research Committee, Vice Chancellery for Research, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Omid Ahmadi
- Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Babak Masoumi
- Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
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Feldman C, Fredericks-Younger J, Desjardins P, Malmstrom H, Miloro M, Warburton G, Ward B, Ziccardi V, Fine D, Greenberg P, Andrews T, Matheson P, Lu SE. The Opioid Analgesic Reduction Study (OARS) Pilot: A Double-Blind Randomized Multicenter Trial. JDR Clin Trans Res 2024; 9:72-84. [PMID: 36680313 PMCID: PMC10850879 DOI: 10.1177/23800844221144031] [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] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND With addiction rates and opioid deaths increasing, health care providers are obligated to help stem the opioid crisis. As limited studies examine the comparative effectiveness of fixed-dose combination nonopioid analgesia to opioid-containing analgesia, a comparative effectiveness study was planned and refined by conducting a pilot study. METHODS The Opioid Analgesic Reduction Study (OARS) pilot, a stratified, randomized, multisite, double-blind clinical trial, was designed to test technology and procedures to be used in the full OARS trial. Participants engaged in the full protocol, enabling the collection of OARS outcome data. Eligible participants reporting to 1 of 5 sites for partial or full bony impacted mandibular third molar extraction were stratified by biologic sex and randomized to 1 of 2 treatment groups, OPIOID or NONOPIOID. OPIOID participants were provided 20 doses of hydrocodone 5 mg/acetaminophen 300 mg. NONOPIOID participants were provided 20 doses of ibuprofen 400 mg/acetaminophen 500 mg. OARS outcomes data, including pain experience, adverse effects, sleep quality, pain interference, overall satisfaction, and remaining opioid tablets available for diversion, were collected via surveys, electronic medication bottles, eDiary, and activity/sleep monitor. RESULTS Fifty-three participants were randomized with 50 completing the OARS pilot protocol. Across all outcome pain domains, in all but 1 time period, NONOPIOID was better in managing pain than OPIOID (P < 0.05 level). Other outcomes suggest less pain interference, less adverse events, better sleep quality, better overall satisfaction, and fewer opioid-containing tablets available for diversion. DISCUSSION Results suggest patients requiring impacted mandibular third molar extraction would benefit from fixed-dose combination nonopioid analgesia. KNOWLEDGE TRANSFER STATEMENT Study results suggest fixed-dose nonopioid combination ibuprofen 400 mg/acetaminophen 500 mg is superior to opioid-containing analgesic (hydrocodone 5 mg/acetaminophen 500 mg). This knowledge should inform surgeons and patients in the selection of postsurgical analgesia.
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Affiliation(s)
- C.A. Feldman
- School of Dental Medicine, Rutgers University, Newark, NJ, USA
- School of Public Health, Rutgers University, Newark, NJ, USA
| | | | - P.J. Desjardins
- School of Dental Medicine, Rutgers University, Newark, NJ, USA
| | - H. Malmstrom
- Eastman Institute for Oral Health, University of Rochester, Rochester, NY, USA
| | - M. Miloro
- College of Dentistry, University of Illinois, IL, USA
| | - G. Warburton
- School of Dentistry, University of Maryland, MD, USA
| | - B. Ward
- School of Dentistry, University of Michigan, MI, USA
| | - V. Ziccardi
- School of Dental Medicine, Rutgers University, Newark, NJ, USA
| | - D.H. Fine
- School of Dental Medicine, Rutgers University, Newark, NJ, USA
| | - P. Greenberg
- School of Public Health, Rutgers University, Newark, NJ, USA
| | - T. Andrews
- School of Public Health, Rutgers University, Newark, NJ, USA
| | - P.B. Matheson
- School of Dental Medicine, Rutgers University, Newark, NJ, USA
| | - S.-E. Lu
- School of Public Health, Rutgers University, Newark, NJ, USA
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Bapodra A, Moy K, Nekola D, Schwartz GS. Neuraxial analgesia, nerve blocks, and special considerations for the parturient. Int Anesthesiol Clin 2024; 62:62-68. [PMID: 38063038 DOI: 10.1097/aia.0000000000000428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Anuj Bapodra
- Department of Anesthesiology, Maimonides Medical Center, Brooklyn, New York
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16
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Murdoch I, Carver AL, Sultan P, O’Carroll JE, Blake L, Carvalho B, Onwochei DN, Desai N. Comparison of different nonsteroidal anti-inflammatory drugs for cesarean section: a systematic review and network meta-analysis. Korean J Anesthesiol 2023; 76:597-616. [PMID: 37066603 PMCID: PMC10718621 DOI: 10.4097/kja.23014] [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: 01/05/2023] [Revised: 02/22/2023] [Accepted: 04/11/2023] [Indexed: 04/18/2023] Open
Abstract
BACKGROUND Cesarean section is associated with moderate to severe pain and nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly employed. The optimal NSAID, however, has not been elucidated. In this network meta-analysis and systematic review, we compared the influence of control and individual NSAIDs on the indices of analgesia, side effects, and quality of recovery. METHODS CDSR, CINAHL, CRCT, Embase, LILACS, PubMed, and Web of Science were searched for randomized controlled trials comparing a specific NSAID to either control or another NSAID in elective or emergency cesarean section under general or neuraxial anesthesia. Network plots and league tables were constructed, and the quality of evidence was evaluated with Grading of Recommendations Assessment, Development and Evaluation (GRADE) analysis. RESULTS We included 47 trials. Cumulative intravenous morphine equivalent consumption at 24 h, the primary outcome, was examined in 1,228 patients and 18 trials, and control was found to be inferior to diclofenac, indomethacin, ketorolac, and tenoxicam (very low quality evidence owing to serious limitations, imprecision, and publication bias). Indomethacin was superior to celecoxib for pain score at rest at 8-12 h and celecoxib + parecoxib, diclofenac, and ketorolac for pain score on movement at 48 h. In regard to the need for and time to rescue analgesia COX-2 inhibitors such as celecoxib were inferior to other NSAIDs. CONCLUSIONS Our review suggests the presence of minimal differences among the NSAIDs studied. Nonselective NSAIDs may be more effective than selective NSAIDs, and some NSAIDs such as indomethacin might be preferable to other NSAIDs.
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Affiliation(s)
- Iona Murdoch
- Department of Anesthesia, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Anthony L Carver
- Department of Anesthesia, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Pervez Sultan
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - James E O’Carroll
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Lindsay Blake
- University of Arkansas for Medical Sciences Library, Little Rock, AR, USA
| | - Brendan Carvalho
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Desire N. Onwochei
- Department of Anesthesia, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
- King’s College London, London, United Kingdom
| | - Neel Desai
- Department of Anesthesia, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
- King’s College London, London, United Kingdom
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Kovoor JG, Bacchi S, Gupta AK, Vo T, Lam C, Lam L, Jiang M, Stretton B, To MS, Nann S, Ovenden CD, Hewitt JN, Goh R, Reid JL, Hugh TJ, Dobbins C, Hewett PJ, Trochsler MI, Kette FE, Maddern GJ. Opioid prescribing, pain, and hospital stay of general surgery patients with oxycodone allergies in South Australia. ANZ J Surg 2023; 93:2631-2637. [PMID: 37837230 DOI: 10.1111/ans.18722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 09/16/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND The frequency of oxycodone adverse reactions, subsequent opioid prescription, effect on pain and patient care in general surgery patients are not well known. This study aimed to determine prevalence of documented oxycodone allergy and intolerances (independent variables) in a general surgical cohort, and association with prescribing other analgesics (particularly opioids), subjective pain scores, and length of hospital stay (dependent variables). METHODS This retrospective cohort study included general surgery patients from two South Australian hospitals between April 2020 and March 2022. Multivariable logistic regression evaluated associations between previous oxycodone allergies and intolerances, prescription records, subjective pain scores, and length of hospital stay. RESULTS Of 12 846 patients, 216 (1.7%) had oxycodone allergies, and 84 (0.7%) oxycodone intolerances. The 216 oxycodone allergy patients had lower odds of receiving oxycodone (OR 0.17, P < 0.001), higher odds of tramadol (OR 3.01, P < 0.001) and tapentadol (OR 2.87, P = 0.001), but 91 (42.3%) still received oxycodone and 19 (8.8%) morphine. The 84 with oxycodone intolerance patients had lower odds of receiving oxycodone (OR 0.23, P < 0.001), higher odds of fentanyl (OR 3.6, P < 0.001) and tramadol (OR 3.35, P < 0.001), but 42 (50%) still received oxycodone. Patients with oxycodone allergies and intolerances had higher odds of elevated subjective pain (OR 1.60, P = 0.013; OR 2.36, P = 0.002, respectively) and longer length of stay (OR 1.36, P = 0.038; OR 2.24, P = 0.002, respectively) than patients without these. CONCLUSIONS General surgery patients with oxycodone allergies and intolerances are at greater risk of worse postoperative pain and longer length of stay, compared to patients without. Many still receive oxycodone, and other opioids that could cause cross-reactivity.
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Affiliation(s)
- Joshua G Kovoor
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
- Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Stephen Bacchi
- University of Adelaide, Adelaide, South Australia, Australia
- Flinders Medical Centre, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Aashray K Gupta
- University of Adelaide, Adelaide, South Australia, Australia
- Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Tammy Vo
- Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Cindy Lam
- Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Lydia Lam
- University of Adelaide, Adelaide, South Australia, Australia
| | - Melinda Jiang
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Brandon Stretton
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Minh-Son To
- Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Silas Nann
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Christopher D Ovenden
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Joseph N Hewitt
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Rudy Goh
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jessica L Reid
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Thomas J Hugh
- University of Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Christopher Dobbins
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Peter J Hewett
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Markus I Trochsler
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Frank E Kette
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Guy J Maddern
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
- Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
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Ivascu R, Dutu M, Stanca A, Negutu M, Morlova D, Dutu C, Corneci D. Pain in Colorectal Surgery: How Does It Occur and What Tools Do We Have for Treatment? J Clin Med 2023; 12:6771. [PMID: 37959235 PMCID: PMC10648968 DOI: 10.3390/jcm12216771] [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: 09/10/2023] [Revised: 10/09/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023] Open
Abstract
Pain is a complex entity with deleterious effects on the entire organism. Poorly controlled postoperative pain impacts the patient outcome, being associated with increased morbidity, inadequate quality of life and functional recovery. In the current surgical environment with less invasive surgical procedures increasingly being used and a trend towards rapid discharge home after surgery, we need to continuously re-evaluate analgesic strategies. We have performed a narrative review consisting of a description of the acute surgical pain anatomic pathways and the connection between pain and the surgical stress response followed by reviewing methods of multimodal analgesia in colorectal surgery found in recent literature data. We have described various regional analgesia techniques and drugs effective in pain treatment, emphasizing their advantages and concerns. We have also tried to identify present knowledge gaps requiring future research. Our review concludes that surgical pain has peculiarities that make its management complex, implying a consistent, multimodal approach aiming to block both peripheral and central pain pathways.
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Affiliation(s)
- Robert Ivascu
- Department of Anesthesiology and Intensive Care, ‘Carol Davila’ University of Medicine and Pharmacy, 050474 Bucharest, Romania; (R.I.); (D.C.)
- Central Military Emergency University Hospital “Dr. Carol Davila”, 010825 Bucharest, Romania
| | - Madalina Dutu
- Department of Anesthesiology and Intensive Care, ‘Carol Davila’ University of Medicine and Pharmacy, 050474 Bucharest, Romania; (R.I.); (D.C.)
- Central Military Emergency University Hospital “Dr. Carol Davila”, 010825 Bucharest, Romania
| | - Alina Stanca
- Elias University Emergency Hospital, 011461 Bucharest, Romania
| | - Mihai Negutu
- Elias University Emergency Hospital, 011461 Bucharest, Romania
| | - Darius Morlova
- Bagdasar Arseni Clinical Emergency Hospital, 041915 Bucharest, Romania
| | - Costin Dutu
- Central Military Emergency University Hospital “Dr. Carol Davila”, 010825 Bucharest, Romania
| | - Dan Corneci
- Department of Anesthesiology and Intensive Care, ‘Carol Davila’ University of Medicine and Pharmacy, 050474 Bucharest, Romania; (R.I.); (D.C.)
- Central Military Emergency University Hospital “Dr. Carol Davila”, 010825 Bucharest, Romania
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Kim DH, Park JB, Kim SW, Stybayeva G, Hwang SH. Effect of Infraorbital and/or Infratrochlear Nerve Blocks on Postoperative Care in Patients with Septorhinoplasty: A Meta-Analysis. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1659. [PMID: 37763778 PMCID: PMC10535682 DOI: 10.3390/medicina59091659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/07/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: Through a comprehensive meta-analysis of the pertinent literature, this study evaluated the utility and efficacy of perioperative infraorbital and/or infratrochlear nerve blocks in reducing postoperative pain and related morbidities in patients undergoing septorhinoplasty. Materials and Methods: We reviewed studies retrieved from the PubMed, SCOPUS, Embase, Web of Science, and Cochrane databases up to August 2023. The analysis included a selection of seven articles that compared a treatment group receiving perioperative infraorbital and/or infratrochlear nerve blocks with a control group that either received a placebo or no treatment. The evaluated outcomes covered parameters such as postoperative pain, the amount and frequency of analgesic medication administration, the incidence of postoperative nausea and vomiting, as well as the manifestation of emergence agitation. Results: The treatment group displayed a significant reduction in postoperative pain (mean difference = -1.7236 [-2.6825; -0.7646], I2 = 98.8%), as well as a significant decrease in both the amount (standardized mean difference = -2.4629 [-3.8042; -1.1216], I2 = 93.0%) and frequency (odds ratio = 0.3584 [0.1383; 0.9287], I2 = 59.7%) of analgesic medication use compared to the control. The incidence of emergence agitation (odds ratio = 0.2040 [0.0907; 0.4590], I2 = 0.0%) was notably lower in the treatment group. The incidence of postoperative nausea and vomiting (odds ratio = 0.5393 [0.1309; 2.2218], I2 = 60.4%) showed a trend towards reduction, although it was not statistically significant. While no adverse effects reaching statistical significance were reported in the analyzed studies, hematoma (proportional rate = 0.2133 [0.0905; 0.4250], I2 = 76.9%) and edema (proportional rate = 0.1935 [0.1048; 0.3296], I2 = 57.2%) after blocks appeared at rates of approximately 20%. Conclusions: Infraorbital and/or infratrochlear nerve blocks for septorhinoplasty effectively reduce postoperative pain and emergence agitation without notable adverse outcomes.
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Affiliation(s)
- Do Hyun Kim
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (D.H.K.); (S.W.K.)
| | - Jun-Beom Park
- Department of Periodontics, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea;
| | - Sung Won Kim
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (D.H.K.); (S.W.K.)
| | - Gulnaz Stybayeva
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN 55905, USA;
| | - Se Hwan Hwang
- Department of Otolaryngology-Head and Neck Surgery, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
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20
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Muragizi J, Guptill M, Dumitriu BG, Henry MB, Aluisio AR, Nzabandora JP, Manirafasha A, Baird J, Morretti K, Karim N. Analgesia use in trauma patients at a university teaching hospital in Kigali, Rwanda. Afr J Emerg Med 2023; 13:147-151. [PMID: 37334174 PMCID: PMC10272278 DOI: 10.1016/j.afjem.2023.05.002] [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: 07/14/2022] [Revised: 04/26/2023] [Accepted: 05/11/2023] [Indexed: 06/20/2023] Open
Abstract
Introduction While trends in analgesia have been identified in high-income countries, little research exists regarding analgesia administration in low- and middle-income countries (LMIC). This study evaluates analgesia administration and clinical characteristics among patients seeking emergency injury care at University Teaching Hospital-Kigali in Kigali, Rwanda. Methods This retrospective, cross-sectional study utilized a random sample of emergency center (EC) cases accrued between July 2015 and June 2016. Data was extracted from the medical record for patients who had an injury and were ≥ 15 years of age. Injury-related EC visits were identified by presenting complaint or final discharge diagnosis. Sociodemographic information, injury mechanism and type, and analgesic medications ordered and administered were analyzed. Results Of the 3,609 random cases, 1,329 met eligibility and were analyzed. The study population was predominantly male (72%) with a median age of 32 years and range between 15 and 81 years. In the studied sample, 728 (54.8%) were treated with analgesia in the EC. In unadjusted logistic regression, only age was not a significant predictor of receiving pain medication and was excluded from the adjusted analysis. In the adjusted model, all predictors remained significant, with being male, having at least one severe injury, and road traffic accident (RTA) as injury mechanism being significant predictors of analgesia administration. Conclusion In the study setting of injured patients in Rwanda, being male, involved in RTA or having more than one serious injury was associated with higher odds of receiving pain medication. Approximately half of the patients with traumatic injuries received pain medications, predominantly opioids with no factors predicting whether a patient would receive opioids versus other medications. Further research on implementation of pain guidelines and drug shortages is warranted to improve pain management for injured patients in the LMIC setting.
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Affiliation(s)
- Jean Muragizi
- Department of Anesthesia, Emergency Medicine and Critical Care, University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| | - Mindi Guptill
- Department of Emergency Medicine, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Bogdan G. Dumitriu
- Department of Emergency Medicine, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Michael B. Henry
- Columbia University-Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Adam R. Aluisio
- Department of Emergency Medicine, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Jean Paul Nzabandora
- Department of Anesthesia, Emergency Medicine and Critical Care, University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| | - Appolinaire Manirafasha
- Department of Anesthesia, Emergency Medicine and Critical Care, University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| | - Janette Baird
- Department of Emergency Medicine, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Katelyn Morretti
- Department of Emergency Medicine, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Naz Karim
- Department of Emergency Medicine, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
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21
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Baratta JL, Deiling B, Hassan YR, Schwenk ES. Total joint replacement in ambulatory surgery. Best Pract Res Clin Anaesthesiol 2023; 37:269-284. [PMID: 37929822 DOI: 10.1016/j.bpa.2023.03.005] [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: 11/14/2022] [Revised: 03/08/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023]
Abstract
Total joint arthroplasty is one of the most commonly performed surgical procedures in the United States, and projected numbers are expected to double in the next ten years. From 2018 to 2020, total hip and knee arthroplasty were removed from the United States' Center for Medicare and Medicaid Services "inpatient-only" list, accelerating this migration to the ambulatory setting. Appropriate patient selection, including age, body mass index, comorbidities, and adequate social support, is critical for successful ambulatory total joint arthroplasty. General anesthesia and neuraxial anesthesia are both safe and effective anesthetic choices, and recent studies in this population have found no difference in outcomes. Multimodal analgesia, including acetaminophen, nonsteroidal anti-inflammatory drugs, local infiltration analgesia, and peripheral nerve blocks, is the foundation for adequate pain control. Common reasons for "failure to launch" include postoperative urinary retention, postoperative nausea and vomiting, inadequate analgesia, and hypotension.
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Affiliation(s)
- Jaime L Baratta
- Department of Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Gibbon Building, Suite 8290, Philadelphia, PA 19107, USA.
| | - Brittany Deiling
- Department of Anesthesiology, University of Virginia Health System, 1215 Lee Street, Charlottesville, VA 22908, USA.
| | - Yasser R Hassan
- Department of Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Gibbon Building, Suite 8290, Philadelphia, PA 19107, USA.
| | - Eric S Schwenk
- Department of Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Gibbon Building, Suite 8290, Philadelphia, PA 19107, USA.
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22
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Lee DJ, Grose E, Brenna CTA, Philteos J, Lightfoot D, Kirubalingam K, Chan Y, Palmer JN, Adappa ND, Lee JM. The benefits and risks of non-steroidal anti-inflammatory drugs for postoperative analgesia in sinonasal surgery: a systematic review and meta-analysis. Int Forum Allergy Rhinol 2023; 13:1738-1757. [PMID: 36762711 DOI: 10.1002/alr.23140] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/26/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) have emerged as an alternative to opioids for optimal postoperative pain management. However, the adoption of NSAIDs in sinonasal surgery has been impeded by a theoretical concern for postoperative bleeding. Our objective is to systematically review the efficacy and safety of NSAIDs for patients undergoing sinonasal surgery. METHODS MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, CINAHL, and the WHO International Clinical Trials Registry Platform were searched from inception to January 27, 2022. Randomized controlled trials (RCTs) and comparative observational studies in any language were considered. Screening, data extraction, and risk of bias assessment were performed in duplicate. Our outcomes were postoperative pain scores, requirement for rescue analgesia, and postoperative adverse events (epistaxis, nausea/vomiting). RESULTS Out of 4661 records, 15 RCTs (enrolling 1210 patients) and two observational studies were included. Following endoscopic sinus surgery, there was no difference in pain scores between NSAIDs and non-NSAIDs groups (standardized mean differences [SMD] 0.44 units better, 95% CI -0.18 to 1.05). Following septorhinoplasty, NSAIDs decreased pain scores compared to non-NSAID regimens (SMD 1.14 units better, 95% CI 0.61 to 1.67 units better). Overall, NSAIDs reduced the need for rescue medication with a relative risk (RR) of 0.45 (95% CI 0.24 to 0.84). In addition, NSAIDs decreased the risk of nausea with an RR of 0.62 (95% CI 0.42 to 0.91) and did not increase the risk of epistaxis (RR 0.72, 95% CI 0.23-2.22). CONCLUSION Among patients undergoing sinonasal surgery, NSAIDs are beneficial in postoperative pain management and avoidance of postoperative nausea without increasing the risk of postoperative epistaxis.
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Affiliation(s)
- Daniel J Lee
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elysia Grose
- Division of Rhinology, Department of Otolaryngology - Head & Neck Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Connor T A Brenna
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Justine Philteos
- Division of Rhinology, Department of Otolaryngology - Head & Neck Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - David Lightfoot
- St. Michael's Hospital Health Sciences Library, Unity Health Toronto, Toronto, Ontario, Canada
| | | | - Yvonne Chan
- Division of Rhinology, Department of Otolaryngology - Head & Neck Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - James N Palmer
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nithin D Adappa
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John M Lee
- Division of Rhinology, Department of Otolaryngology - Head & Neck Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
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23
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Osman BM, Tieu TG, Caceres YG, Hernandez VH. Current Trends and Future Directions for Outpatient Total Joint Arthroplasty: A Review of the Anesthesia Choices and Analgesic Options. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202309000-00001. [PMID: 37669101 PMCID: PMC10481314 DOI: 10.5435/jaaosglobal-d-22-00259] [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: 10/26/2022] [Accepted: 07/11/2023] [Indexed: 09/06/2023]
Abstract
The aging population and the obesity epidemic have led to an increased rate of joint arthroplasty procedures, specifically total knee arthroplasty and total hip arthroplasty. These surgeries are associated with increased hospital length of stay and, consequently, higher costs. Despite the benefits of outpatient surgery, only a small percentage of total joint arthroplasties (TJAs) are done in this manner. We reviewed the most up-to-date trends for outpatient TJA and discussed essential factors for a successful outpatient program, including the proper patient selection process and best available anesthetic and analgesic options, along with their risks and benefits. Risk stratification tools, such as the Outpatient Arthroplasty Risk Assessment, are helpful for predicting outcomes regarding outpatient TJA, and neuraxial anesthesia should be considered to minimize complications and facilitate early discharge. A multimodal analgesia regimen could be effective for pain management in outpatient TJA, and the currently recommended peripheral nerve blocks for total hip arthroplasty and total knee arthroplasty are the fascia iliaca compartment block and adductor canal block, respectively. However, blocks should be carefully considered for outpatient procedures. Enhanced recovery after surgery (ERAS) protocols help to guide perioperative care teams and allow for improved patient recovery, decreased length of stay, and increased patient satisfaction.
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Affiliation(s)
- Brian M. Osman
- From the Perioperative Medicine and Pain Management, University of Miami Health System, University of Miami Miller School of Medicine, Miami, FL (Dr. Osman, Dr. Caceres, and Dr. Hernandez); Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL (Dr. Tieu)
| | - Tuan G. Tieu
- From the Perioperative Medicine and Pain Management, University of Miami Health System, University of Miami Miller School of Medicine, Miami, FL (Dr. Osman, Dr. Caceres, and Dr. Hernandez); Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL (Dr. Tieu)
| | - Yosira Guevara Caceres
- From the Perioperative Medicine and Pain Management, University of Miami Health System, University of Miami Miller School of Medicine, Miami, FL (Dr. Osman, Dr. Caceres, and Dr. Hernandez); Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL (Dr. Tieu)
| | - Victor H. Hernandez
- From the Perioperative Medicine and Pain Management, University of Miami Health System, University of Miami Miller School of Medicine, Miami, FL (Dr. Osman, Dr. Caceres, and Dr. Hernandez); Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL (Dr. Tieu)
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24
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Orbay Yaşli S, Günay Canpolat D, Doğruel F, Demirbaş AE. Efficacy of Tenoxicam, Paracetamol, and Their Combination in Postoperative Pain After Double-Jaw Surgery. Cureus 2023; 15:e44195. [PMID: 37641729 PMCID: PMC10460537 DOI: 10.7759/cureus.44195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2023] [Indexed: 08/31/2023] Open
Abstract
Introduction Orthognathic surgical procedures include a series of surgical operations in which interventions are applied to the maxilla, mandible, or both for occlusal or aesthetic concerns due to facial skeletal development deformities. Double-jaw surgeries have the highest pain scores, in which both maxilla and mandible bones are intervened. This study aimed to compare the efficacy of individual applications of paracetamol and tenoxicam with their combined application on postoperative pain and opioid consumption in patients undergoing double-jaw surgery. Methods In this randomized, double-blind study, 60 patients undergoing double-jaw surgery were allocated into three groups, with each having 20 patients: the paracetamol group, the tenoxicam group, and the paracetamol-tenoxicam combination group. Pain intensity was evaluated using the visual analogue scale (VAS) at intervals of 30 minutes, 60 minutes, 120 minutes, and again at the 24th postoperative hour. Additionally, the consumption of opioids and other rescue analgesics was documented over the 24-hour postoperative period. Results The VAS values at 30 minutes, 60 minutes, and 24 hours were lower in the paracetamol-tenoxicam group compared to the other groups (p<0.001). The need for a rescue analgesic drug in the first 24 hours was not observed in the tenoxicam and paracetamol-tenoxicam groups. Conclusion It was concluded that both tenoxicam and paracetamol-tenoxicam combinations, especially the tenoxicam-paracetamol combination, were good options for postoperative analgesia in patients with double-jaw surgery.
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Affiliation(s)
- Seher Orbay Yaşli
- Anesthesiology in Oral and Maxillofacial Surgery, Erciyes University Faculty of Dentistry, Kayseri, TUR
| | - Dilek Günay Canpolat
- Anesthesiology in Oral and Maxillofacial Surgery, Erciyes University Faculty of Dentistry, Kayseri, TUR
| | - Fatma Doğruel
- Oral and Maxillofacial Surgery, Erciyes University Faculty of Dentistry, Kayseri, TUR
| | - Ahmet E Demirbaş
- Oral and Maxillofacial Surgery, Erciyes University Faculty of Dentistry, Kayseri, TUR
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25
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Silva F, Costa G, Veiga F, Cardoso C, Paiva-Santos AC. Parenteral Ready-to-Use Fixed-Dose Combinations Including NSAIDs with Paracetamol or Metamizole for Multimodal Analgesia-Approved Products and Challenges. Pharmaceuticals (Basel) 2023; 16:1084. [PMID: 37630999 PMCID: PMC10459253 DOI: 10.3390/ph16081084] [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: 05/25/2023] [Revised: 07/11/2023] [Accepted: 07/25/2023] [Indexed: 08/27/2023] Open
Abstract
The combination of non-steroidal anti-inflammatory drugs (NSAIDs) with non-opioid analgesics is common in clinical practice for the treatment of acute painful conditions like post-operative and post-traumatic pain. Despite the satisfactory results achieved by oral analgesics, parenteral analgesia remains a key tool in the treatment of painful conditions when the enteral routes of administration are inconvenient. Parenteral ready-to-use fixed-dose combinations of non-opioid analgesics combinations, including NSAIDs and paracetamol or metamizole, could play a central role in the treatment of painful conditions by combining the advantages of multimodal and parenteral analgesia in a single formulation. Surprisingly, only in 2020, a parenteral ready-to-use fixed-dose combination of ibuprofen/paracetamol was launched to the market. This review aims to investigate the current availability of combinations of NSAIDs with paracetamol or metamizole in both European and American markets, and how the combination of such drugs could play a central role in a multimodal analgesia strategy. Also, we explored how the parenteral formulations of NSAIDs, paracetamol, and metamizole could serve as starting elements for the development of new parenteral ready-to-use fixed-dose combinations. We concluded that, despite the well-recognized utility of combining NSAIDs with paracetamol or metamizole, several randomized clinical trial studies demonstrate no clear advantages concerning their efficacy and safety. Future clinical trials specifically designed to assess the efficacy and safety of pre-formulated fixed-dose combinations are required to generate solid evidence about their clinical advantages.
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Affiliation(s)
- Fernando Silva
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
- REQUIMTE/LAQV, Group of Pharmaceutical Technology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
| | - Gustavo Costa
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal
- Center for Innovative Biomedicine and Biotechnology (CIBB), Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal
- Laboratory of Pharmacognosy, Faculty of Pharmacy, University of Coimbra, Azinhaga de Santa Comba, Pólo das Ciências da Saúde, 3000-548 Coimbra, Portugal
| | - Francisco Veiga
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
- REQUIMTE/LAQV, Group of Pharmaceutical Technology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
| | - Catarina Cardoso
- Laboratórios Basi, Parque Industrial Manuel Lourenço Ferreira, Lote 15, 3450-232 Mortágua, Portugal
| | - Ana Cláudia Paiva-Santos
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
- REQUIMTE/LAQV, Group of Pharmaceutical Technology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
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26
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Ma CH, Tworek KB, Kung JY, Kilcommons S, Wheeler K, Parker A, Senaratne J, Macintyre E, Sligl W, Karvellas CJ, Zampieri FG, Kutsogiannis DJ, Basmaji J, Lewis K, Chaudhuri D, Sharif S, Rewa OG, Rochwerg B, Bagshaw SM, Lau VI. Systemic Nonsteroidal Anti-Inflammatories for Analgesia in Postoperative Critical Care Patients: A Systematic Review and Meta-Analysis of Randomized Control Trials. Crit Care Explor 2023; 5:e0938. [PMID: 37396930 PMCID: PMC10309528 DOI: 10.1097/cce.0000000000000938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023] Open
Abstract
While opioids are part of usual care for analgesia in the ICU, there are concerns regarding excess use. This is a systematic review of nonsteroidal anti-inflammatory drugs (NSAIDs) use in postoperative critical care adult patients. DATA SOURCES We searched Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, trial registries, Google Scholar, and relevant systematic reviews through March 2023. STUDY SELECTION Titles, abstracts, and full texts were reviewed independently and induplicate by two investigators to identify eligible studies. We included randomized control trials (RCTs) that compared NSAIDs alone or as an adjunct to opioids for systemic analgesia. The primary outcome was opioid utilization. DATA EXTRACTION In duplicate, investigators independently extracted study characteristics, patient demographics, intervention details, and outcomes of interest using predefined abstraction forms. Statistical analyses were conducted using Review Manager software Version 5.4. (The Cochrane Collaboration, Copenhagen, Denmark). DATA SYNTHESIS We included 15 RCTs (n = 1,621 patients) for admission to the ICU for postoperative management after elective procedures. Adjunctive NSAID therapy to opioids reduced 24-hour oral morphine equivalent consumption by 21.4 mg (95% CI, 11.8-31.0 mg reduction; high certainty) and probably reduced pain scores (measured by Visual Analog Scale) by 6.1 mm (95% CI, 12.2 decrease to 0.1 increase; moderate certainty). Adjunctive NSAID therapy probably had no impact on the duration of mechanical ventilation (1.6 hr reduction; 95% CI, 0.4 hr to 2.7 reduction; moderate certainty) and may have no impact on ICU length of stay (2.1 hr reduction; 95% CI, 6.1 hr reduction to 2.0 hr increase; low certainty). Variability in reporting adverse outcomes (e.g., gastrointestinal bleeding, acute kidney injury) precluded their meta-analysis. CONCLUSIONS In postoperative critical care adult patients, systemic NSAIDs reduced opioid use and probably reduced pain scores. However, the evidence is uncertain for the duration of mechanical ventilation or ICU length of stay. Further research is required to characterize the prevalence of NSAID-related adverse outcomes.
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Affiliation(s)
- Chen Hsiang Ma
- Department of Medicine, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Kimberly B Tworek
- Department of Medicine, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Janice Y Kung
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, AB, Canada
| | - Sebastian Kilcommons
- Department of Medicine, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Kathleen Wheeler
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Arabesque Parker
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Janek Senaratne
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Erika Macintyre
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Wendy Sligl
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Constantine J Karvellas
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Fernando G Zampieri
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Demetrios Jim Kutsogiannis
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - John Basmaji
- Department of Medicine, Division of Critical Care, Western University, London, ON, Canada
| | - Kimberley Lewis
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Dipayan Chaudhuri
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Sameer Sharif
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Oleksa G Rewa
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
- School of Public Health, University of Alberta, Edmonton, AB, Canada
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
| | - Vincent I Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
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Ali S, Dworsky-Fried Z, Moir M, Bharadia M, Rajagopal M, Gouin S, Sawyer S, Pellerin S, Bourrier L, Poonai N, Stang A, Leung J, van Manen M. Factors Influencing Parental Decision-Making Regarding Analgesia for Children with Musculoskeletal Injury-Related Pain: A Qualitative Study. J Pediatr 2023; 258:113405. [PMID: 37023945 DOI: 10.1016/j.jpeds.2023.113405] [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: 12/18/2022] [Revised: 03/05/2023] [Accepted: 03/27/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVES To explore and understand parental decision-making relating to acute pain management for their children presenting to the emergency department. STUDY DESIGN This study employed one-on-one semistructured interviews. Parents of children with acute musculoskeletal injuries were recruited from 3 Canadian pediatric emergency departments. Interviews were conducted via telephone from June 2019 to March 2021. Verbatim transcription and thematic analyses occurred concurrently with data collection, supporting data saturation and theory development considerations. RESULTS Twenty-seven interviews were completed. Five major themes regarding pain care emerged: (1) my child's comfort is a priority, (2) every situation is unique, (3) opioids only if necessary, (4) considerations when choosing opioids, and (5) pain research is important. Overall, parents were highly comfortable with their assessment of their child's pain. Participants' willingness to use opioid analgesia for their children was primarily dependent on perceptions of injury and pain severity. Opioid-averse and opioid-accepting families had similar considerations when making analgesic decisions but weighed risks and benefits differently. CONCLUSIONS Parents assess and manage their children's pain globally and multimodally, with comfort being prioritized. For most parents, the desire to relieve their children's pain outweighed concerns of substance use disorder, misuse, and adverse events when making decisions about opioid analgesia for short-term use. These results can inform evidence-based family-centered approaches to co-decision-making of analgesic plans for children with acute pain.
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Affiliation(s)
- Samina Ali
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada; Women and Children Health Research Institute, University of Alberta, Edmonton, Alberta, Canada.
| | - Zoë Dworsky-Fried
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Mackenzie Moir
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Manisha Bharadia
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Manasi Rajagopal
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Serge Gouin
- Division of Emergency Medicine, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Scott Sawyer
- Departments of Pediatrics and Emergency Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Stephanie Pellerin
- Division of Emergency Medicine, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Lise Bourrier
- Departments of Pediatrics and Emergency Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Naveen Poonai
- Departments of Paediatrics, Internal Medicine, Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Canada
| | - Antonia Stang
- Department of Pediatrics, Cummings School of Medicine, University of Calgary
| | - Julie Leung
- PEAK Research Team Family Representative, Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Michael van Manen
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada; Women and Children Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
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Miroshnychenko A, Azab M, Ibrahim S, Roldan Y, Diaz Martinez JP, Tamilselvan D, He L, Urquhart O, Tampi M, Polk DE, Moore PA, Hersh EV, Carrasco-Labra A, Brignardello-Petersen R. Analgesics for the management of acute dental pain in the pediatric population: A systematic review and meta-analysis. J Am Dent Assoc 2023; 154:403-416.e14. [PMID: 37105668 PMCID: PMC10911578 DOI: 10.1016/j.adaj.2023.02.013] [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: 08/26/2022] [Revised: 01/17/2023] [Accepted: 02/15/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND The authors assessed the clinical effectiveness of analgesics to manage acute pain after dental extractions and pain associated with irreversible pulpitis in children. TYPES OF STUDIES REVIEWED The authors searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and US Clinical Trials registry from inception through November 2020. They included randomized controlled trials comparing any pharmacologic interventions with each other and a placebo in pediatric participants undergoing dental extractions or experiencing irreversible pulpitis. After duplicate screening and data abstraction, the authors conducted random-effects meta-analyses. They assessed risk of bias using the Cochrane Risk of Bias 2.0 tool and certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS The authors included 6 randomized controlled trials reporting 8 comparisons. Ibuprofen may reduce pain intensity compared with acetaminophen (mean difference [MD], 0.27 points; 95% CI, -0.13 to 0.68; low certainty) and a placebo (MD, -0.19 points; 95% CI, -0.58 to 0.21; low certainty). Acetaminophen may reduce pain intensity compared with a placebo (MD, -0.13 points; 95% CI, -0.52 to 0.26; low certainty). Acetaminophen and ibuprofen combined probably reduce pain intensity compared with acetaminophen alone (MD, -0.75 points; 95% CI, -1.22 to -0.27; moderate certainty) and ibuprofen alone (MD, -0.01 points; 95% CI, -0.53 to 0.51; moderate certainty). There was very low certainty evidence regarding adverse effects. PRACTICAL IMPLICATIONS Several pharmacologic interventions alone or in combination may provide a beneficial effect when managing acute dental pain in children. There is a paucity of evidence regarding the use of analgesics to manage irreversible pulpitis.
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Zwolinski NM, Patel KS, Vadivelu N, Kodumudi G, Kaye AD. ERAS Protocol Options for Perioperative Pain Management of Substance Use Disorder in the Ambulatory Surgical Setting. Curr Pain Headache Rep 2023; 27:65-79. [PMID: 37079258 PMCID: PMC10116112 DOI: 10.1007/s11916-023-01108-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 04/21/2023]
Abstract
Even prior to the COVID-19 pandemic, rates of ambulatory surgeries and ambulatory patients presenting with substance use disorder were increasing, and the end of lockdown has further catalyzed the increasing rates of ambulatory patients presenting for surgery with substance use disorder (SUD). Certain subspecialty groups of ambulatory procedures have already established protocols to optimize early recovery after surgery (ERAS), and these groups have subsequently enjoyed improved efficiency and reduced adverse outcomes as a result. In this present investigation, we review the literature as it relates to substance use disorder patients, with a particular focus on pharmacokinetic and pharmacodynamic profiles, and their resulting impact on the acute- or chronic user ambulatory patient. The systematic literature review findings are organized and summarized. We conclude by identifying areas of opportunity for further study, specifically with the aim of developing a dedicated ERAS protocol for substance use disorder patients in the ambulatory surgery setting. - Healthcare in the USA has seen an increase in rates of both substance use disorder patients and separately in ambulatory surgery cases. - Specific perioperative protocols to optimize outcomes for patients who suffer from substance use disorder have been described in recent years. - Agents of interest like opioids, cannabis, and amphetamines are the top three most abused substances in North America. - A protocol and recommend further work should be done to integrate with concrete clinical data, in which strategies should be employed to confer benefits to patient outcomes and hospital quality metrics like those enjoyed by ERAS protocol in other settings.
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Affiliation(s)
- Nicholas M Zwolinski
- Department of Anesthesiology, Yale University School of Medicine, 333, Cedar Street, New Haven, CT, 06520, USA
| | - Kaiwal S Patel
- Department of Anesthesiology, Yale University School of Medicine, 333, Cedar Street, New Haven, CT, 06520, USA
| | - Nalini Vadivelu
- Department of Anesthesiology, Yale University School of Medicine, 333, Cedar Street, New Haven, CT, 06520, USA
| | - Gopal Kodumudi
- Department of Anesthesiology, LSU School of Medicine, 1542 Tulane Avenue Room 659, New Orleans, LA, 70112, USA
| | - Alan David Kaye
- Department of Anesthesiology, LSU School of Medicine, 1542 Tulane Avenue Room 659, New Orleans, LA, 70112, USA.
- Department of Anesthesiology, Louisiana State University Health Sciences Center, 1501 Kings Hwy, Shreveport, LA, 71103, USA.
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Nelson G, Fotopoulou C, Taylor J, Glaser G, Bakkum-Gamez J, Meyer LA, Stone R, Mena G, Elias KM, Altman AD, Bisch SP, Ramirez PT, Dowdy SC. Enhanced recovery after surgery (ERAS®) society guidelines for gynecologic oncology: Addressing implementation challenges - 2023 update. Gynecol Oncol 2023; 173:58-67. [PMID: 37086524 DOI: 10.1016/j.ygyno.2023.04.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/11/2023] [Accepted: 04/13/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Despite evidence supporting its use, many Enhanced Recovery After Surgery (ERAS) recommendations remain poorly adhered to and barriers to ERAS implementation persist. In this second updated ERAS® Society guideline, a consensus for optimal perioperative care in gynecologic oncology surgery is presented, with a specific emphasis on implementation challenges. METHODS Based on the gaps identified by clinician stakeholder groups, nine implementation challenge topics were prioritized for review. A database search of publications using Embase and PubMed was performed (2018-2023). Studies on each topic were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded by an international panel according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS implementation challenge topics are based on best available evidence. The level of evidence for each item is presented accordingly. CONCLUSIONS The updated evidence base and recommendations for stakeholder derived ERAS implementation challenges in gynecologic oncology are presented by the ERAS® Society in this consensus review.
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Affiliation(s)
- G Nelson
- Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - C Fotopoulou
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - J Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Glaser
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - J Bakkum-Gamez
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - L A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R Stone
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - G Mena
- Department of Anesthesiology, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - K M Elias
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - A D Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - S P Bisch
- Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - P T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, TX, USA
| | - S C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
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Anderson BJ, Cortinez LI. Perioperative Acetaminophen Dosing in Obese Children. CHILDREN 2023; 10:children10040625. [PMID: 37189874 DOI: 10.3390/children10040625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/14/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023]
Abstract
Acetaminophen is a commonly used perioperative analgesic drug in children. The use of a preoperative loading dose achieves a target concentration of 10 mg/L associated with a target analgesic effect that is 2.6 pain units (visual analogue scale 1–10). Postoperative maintenance dosing is used to keep this effect at a steady-state concentration. The loading dose in children is commonly prescribed per kilogram. That dose is consistent with the linear relationship between the volume of distribution and total body weight. Total body weight is made up of both fat and fat-free mass. The fat mass has little influence on the volume of distribution of acetaminophen but fat mass should be considered for maintenance dosing that is determined by clearance. The relationship between the pharmacokinetic parameter, clearance, and size is not linear. A number of size metrics (e.g., fat-free and normal fat mass, ideal body weight and lean body weight) have been proposed to scale clearance and all consequent dosing schedules recognize curvilinear relationships between clearance and size. This relationship can be described using allometric theory. Fat mass also has an indirect influence on clearance that is independent of its effects due to increased body mass. Normal fat mass, used in conjunction with allometry, has proven a useful size metric for acetaminophen; it is calculated using fat-free mass and a fraction (Ffat) of the additional mass contributing to total body weight. However, the Ffat for acetaminophen is large (Ffat = 0.82), pharmacokinetic and pharmacodynamic parameter variability high, and the concentration–response slope gentle at the target concentration. Consequently, total body weight with allometry is acceptable for the calculation of maintenance dose. The dose of acetaminophen is tempered by concerns about adverse effects, notably hepatotoxicity associated with use after 2–3 days at doses greater than 90 mg/kg/day.
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Mallet C, Desmeules J, Pegahi R, Eschalier A. An Updated Review on the Metabolite (AM404)-Mediated Central Mechanism of Action of Paracetamol (Acetaminophen): Experimental Evidence and Potential Clinical Impact. J Pain Res 2023; 16:1081-1094. [PMID: 37016715 PMCID: PMC10066900 DOI: 10.2147/jpr.s393809] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 03/14/2023] [Indexed: 03/30/2023] Open
Abstract
Paracetamol remains the recommended first-line option for mild-to-moderate acute pain in general population and particularly in vulnerable populations. Despite its wide use, debate exists regarding the analgesic mechanism of action (MoA) of paracetamol. A growing body of evidence challenged the notion that paracetamol exerts its analgesic effect through cyclooxygenase (COX)-dependent inhibitory effect. It is now more evident that paracetamol analgesia has multiple pathways and is mediated by the formation of the bioactive AM404 metabolite in the central nervous system (CNS). AM404 is a potent activator of TRPV1, a major contributor to neuronal response to pain in the brain and dorsal horn. In the periaqueductal grey, the bioactive metabolite AM404 activated the TRPV1 channel-mGlu5 receptor-PLC-DAGL-CB1 receptor signaling cascade. The present article provides a comprehensive literature review of the centrally located, COX-independent, analgesic MoA of paracetamol and relates how the current experimental evidence can be translated into clinical practice. The evidence discussed in this review established paracetamol as a central, COX-independent, antinociceptive medication that has a distinct MoA from non-steroidal anti-inflammatory drugs (NSAIDs) and a more tolerable safety profile. With the establishment of the central MoA of paracetamol, we believe that paracetamol remains the preferred first-line option for mild-to-moderate acute pain for healthy adults, children, and patients with health concerns. However, safety concerns remain with the high dose of paracetamol due to the NAPQI-mediated liver necrosis. Centrally acting paracetamol/p-aminophenol derivatives could potentiate the analgesic effect of paracetamol without increasing the risk of hepatoxicity. Moreover, the specific central MoA of paracetamol allows its combination with other analgesics, including NSAIDs, with a different MoA. Future experiments to better explain the central actions of paracetamol could pave the way for discovering new central analgesics with a better benefit-to-risk ratio.
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Affiliation(s)
- Christophe Mallet
- Université Clermont Auvergne, INSERM, NEURO-DOL Basics & Clinical Pharmacology of Pain, Clermont-Ferrand, France
| | - Jules Desmeules
- Faculty of Medicine and The School of Pharmaceutical Sciences, Faculty of Sciences, Geneva University, Geneva, Switzerland
| | | | - Alain Eschalier
- Université Clermont Auvergne, INSERM, NEURO-DOL Basics & Clinical Pharmacology of Pain, Clermont-Ferrand, France
- Correspondence: Alain Eschalier, Faculté de Médecine, UMR Neuro-Dol, 49 Bd François Mitterrand, Clermont-Ferrand, 63000, France, Email
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Diana K, Teh MS, Islam T, Lim WL, Beh ZY, Taib NAM. Benefits of PECS Block as Part of the Enhanced Recovery After Surgery (ERAS) Protocol for Breast Cancer Surgery in an Asian Institution: A Retrospective Cohort Study. World J Surg 2023; 47:564-572. [PMID: 36599951 DOI: 10.1007/s00268-022-06881-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Regional analgesia techniques have been increasingly used for post-operative pain management following mastectomy. We aim to evaluate analgesic benefits of pectoral nerve (PECS2) block incorporated as part of the enhanced recovery after surgery (ERAS) protocol in patients undergoing mastectomy in University Malaya Medical Centre, Malaysia. MATERIAL AND METHODS A single centre, cohort study evaluating 335 women who have undergone unilateral mastectomy between January 2017 and March 2020 in Malaysia. Regional anaesthesia were given pre-operatively via ultrasound guided pectoral and intercostal nerves block (PECSII). RESULTS Utilization of regional anaesthesia increased from 11% in 2017 to 43% in 2020. Types and duration of surgeries were comparable. Opiod consumption was 3 mg lower in those who had PECS2 block ((27 [24-30] mg), in comparison with those who received general anaesthesia only (30 [26-34] mg), p < 0.001, and length of stay was half a day shorter in the regional anaesthesia group and these were statistically significant. However, pain score (2 [1-3]; 2 [1-3], p=0.719) and post-operative nausea and vomiting (PONV) (32.6-32.5%, p = 0.996) were similar. CONCLUSION This study highlights the importance of PECS2 block as a component of ERAS protocol for mastectomy in an Asian hospital. This study also inferred that patients may be safely discharged within 24 h of surgery and therefore, same day surgery may be feasible in selected group of patients undergoing mastectomy and this could imply overall cost benefits.
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Affiliation(s)
- Kavinya Diana
- Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Mei-Sze Teh
- Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia.
| | - Tania Islam
- Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Woon-Lai Lim
- Department of Anaestesiology, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Zhi-Yuan Beh
- Department of Anaestesiology, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Nur Aishah Mohd Taib
- Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia.
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Jasani B, Weisz DE, Reese J, Jain A. Combination pharmacotherapy for patent ductus arteriosus: Rationale and evidence. Semin Perinatol 2023; 47:151720. [PMID: 36914507 DOI: 10.1016/j.semperi.2023.151720] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
While cyclooxygenase inhibitors have been the most common medications used to facilitate earlier closure of patent ductus arteriosus in preterm infants, adverse effects and low efficacy in extremely low gestational age neonates (ELGANs) have highlighted a need for alternative options. Combination therapy with acetaminophen and ibuprofen is a novel strategy for PDA treatment in ELGANs, as it may facilitate higher ductal closure rates via additive action on two separate pathways inhibiting prostaglandin production. Initial small observational studies and pilot randomized clinical trials indicate potentially higher efficacy of the combination regime to induce ductal closure in comparison to treatment with ibuprofen alone. In this review, we examine the potential clinical impact of treatment failure in ELGANs with significant PDA, highlight the biological rationale in support of studying combination therapy, and review the randomized and non-randomized studies to date. With the rising number of ELGANs receiving neonatal intensive care, who are vulnerable to PDA-related morbidities, there is an urgent need for adequately powered clinical trials to systematically investigate the efficacy and safety of combination therapy for PDA treatment.
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Affiliation(s)
- Bonny Jasani
- Division of Neonatology, Hospital for Sick Children, Toronto, Canada; Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Dany E Weisz
- Department of Pediatrics, University of Toronto, Toronto, Canada; Department of Newborn and Developmental Pediatrics, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jeff Reese
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amish Jain
- Department of Pediatrics, University of Toronto, Toronto, Canada; Department of Pediatrics, Mount Sinai Hospital, Toronto, Canada.
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Analgesic use and favourable patient-reported outcome measures after paediatric surgery: an analysis of registry data. Br J Anaesth 2023; 130:74-82. [PMID: 36470745 DOI: 10.1016/j.bja.2022.09.028] [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: 07/04/2022] [Revised: 08/30/2022] [Accepted: 09/26/2022] [Indexed: 12/09/2022] Open
Abstract
BACKGROUND Pain after paediatric appendectomy and tonsillectomy is often undertreated. Benchmarking of hospitals could reveal which measures are associated with improved patient- or parent-reported pain-related outcomes. METHODS A total of 898 anonymised cases from 11 European hospitals participating in PAIN OUT infant were analysed. The children completed a questionnaire on patient-reported outcomes (PROs) 24 h after surgery. According to a composite PRO measure, including pain intensity and pain-related interference, hospitals were allocated to Group I (favourable results), II (average results), and III (unfavourable results). Benchmarking of hospital groups was performed investigating process variables (dosing of non-opioid analgesics, opioids, and dexamethasone) associated with PROs, side-effects, and children's perception of care. Variables associated with PROs were analysed using multinomial regression analysis with the PRO score-related hospital group as a dependent variable (estimated odds ratios [OR], 95% confidence interval [CI]). RESULTS During the first 24 h after surgery, 1.2 (1.1-1.3) full daily doses of non-opioid analgesics (non-steroidal anti-inflammatory drug [NSAID], paracetamol, metamizole) were administered in group I and 0.7 (0.6-0.8) in group III (P<0.001). Intraoperative dexamethasone was administered to 70.1 and 52.6% of the children in Group I and Group III, respectively (P<0.001). A lower number of full daily doses of non-opioid analgesics: 0.22 [0.15-0.31]), less dexamethasone (0.49 [0.33-0.71]), fewer non-opioid analgesics before the end of surgery (0.37 [0.22-0.62]) and higher opioid doses were associated with hospital allocation to group III vs group I (Nagelkerke's R2=0.433). CONCLUSIONS The results indicated substantial deficits in the concept, application, and dosing of analgesics in paediatric patients after surgery. Timely administration of adequate analgesic doses can easily be introduced into daily clinical practice. CLINICAL TRIAL REGISTRATION clinicaltrials.gov NCT02083835.
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Hastings G, Brahler T, Howles-Banerji G, Kotton M, Price A, Singer D, Wrenn SJ. Pain, Nausea, and Hospital Admission after Uterine Fibroid Embolization: A Comparison of 2 Protocols. J Vasc Interv Radiol 2022; 34:585-590.e2. [PMID: 36521791 DOI: 10.1016/j.jvir.2022.12.018] [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: 07/06/2022] [Revised: 10/07/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022] Open
Abstract
Uterine fibroid embolization (UFE) procedures performed from 2013 to 2019 were reviewed. Seventy-two patients were treated with a standard protocol consisting of sedation, ketorolac, ondansetron, and overnight parenteral analgesics and antiemetics. Ninety-six patients were treated with a new protocol, which added transdermal scopolamine, lorazepam, and intravenous acetaminophen. Outpatient uterine fibroid embolization (OP-UFE) not requiring hospitalization was successful in 81.4% and 2.7% of patients treated with the new and old protocols, respectively (odds ratio [OR], 141.4; P < .0001). Procedural fentanyl doses were lower with the new protocol than with the old one (mean, 148 vs 186 mcg; P = .0016). In the new protocol subset, patients were 1.01 times more likely to fail OP-UFE for every microgram increase in procedural fentanyl (OR, 0.99, P = .009), and those presenting with pain were less likely to succeed with OP-UFE than those with bleeding or bulk symptoms (OR, 0.31, P = .04). In conclusion, decreasing the opioid dose while increasing the antiemetic and nonopioid analgesic medications improves the chances of same day discharge after UFE.
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Affiliation(s)
- Geoffrey Hastings
- Department of Radiology, Kaiser Permanente Oakland Medical Center, Oakland, California; Department of Radiology, Kaiser Permanente Richmond Medical Center, Richmond, California.
| | - Thomas Brahler
- Department of Radiology, Kaiser Permanente Oakland Medical Center, Oakland, California; Department of Radiology, Kaiser Permanente Richmond Medical Center, Richmond, California
| | - Gabriel Howles-Banerji
- Department of Radiology, Kaiser Permanente Oakland Medical Center, Oakland, California; Department of Radiology, Kaiser Permanente Richmond Medical Center, Richmond, California
| | - Michael Kotton
- Department of Radiology, Kaiser Permanente Oakland Medical Center, Oakland, California; Department of Radiology, Kaiser Permanente Richmond Medical Center, Richmond, California
| | - Adi Price
- Department of Radiology, Kaiser Permanente Oakland Medical Center, Oakland, California; Department of Radiology, Kaiser Permanente Richmond Medical Center, Richmond, California
| | - Daniel Singer
- Department of Psychology, George Mason University, Fairfax, Virginia
| | - S Jarrett Wrenn
- Department of Radiology, Kaiser Permanente Oakland Medical Center, Oakland, California; Department of Radiology, Kaiser Permanente Richmond Medical Center, Richmond, California
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Swenson JD, Conrad KM, Pace NL, Phillips K, Saltzman CL. Scheduled, Simultaneous Dosing of Pregabalin, Celecoxib, and Acetaminophen Markedly Reduces or Eliminates Opioid Use After ACL Reconstruction Using Allograft or Hamstring Tendon Autograft: A Randomized Clinical Trial. Orthop J Sports Med 2022; 10:23259671221140837. [PMID: 36518729 PMCID: PMC9743025 DOI: 10.1177/23259671221140837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 09/13/2022] [Indexed: 09/05/2023] Open
Abstract
BACKGROUND Opioid analgesics continue to be prescribed after ambulatory surgery despite untoward adverse effects, risk of overdose, and association with substance use disorder. PURPOSE/HYPOTHESIS The purpose was to investigate the use of a novel system to provide scheduled and simultaneous dosing of acetaminophen, celecoxib, and pregabalin after anterior cruciate ligament reconstruction (ACLR). It was hypothesized that this system would markedly reduce pain and opioid use compared with existing best practice. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS Included were 100 patients scheduled for elective, primary ACLR using allograft or hamstring tendon autograft. Selection criteria included age between 18 and 65 years and weight between 65 and 120 kg. Exclusion criteria were a known allergy to any drug used in the study or the use of opioid analgesics before surgery. Patients in the intervention group received a blister pack with scheduled, simultaneous doses of acetaminophen, celecoxib, and pregabalin; patients were also given oxycodone 5 mg as needed for breakthrough pain. Patients in the control group were prescribed ibuprofen and oxycodone 5 mg/acetaminophen 325 mg as needed for pain. The primary outcome measure was pain. Secondary outcomes were nausea, itching, and daily oxycodone use. Patients were asked to quantify their average pain at rest, nausea, and itching on an 11-point verbal scale (from 0 to 10). These data were recorded for 6 days during daily telephone contacts with patients after hospital discharge. RESULTS Cumulative results for 6 days showed significantly lower values in the intervention group compared with the control group for pain (median [interquartile range], 28 [14-35] vs 35 [28-41], respectively; P = .009) and oxycodone use (median [interquartile range] number of tablets, 0 [0-2] vs 8 [1.25-16], respectively; P < .001). Based on these data, the upper tolerance limits for the number of oxycodone tablets required by 90% of patients in the intervention and control groups were 8 tablets and 30 tablets, respectively. Cumulative results for nausea and itching were also significantly lower for the intervention group. Most patients in the intervention group used no opioids during recovery. CONCLUSION Simultaneous dosing of 3 nonopioid analgesics resulted in reduced postoperative pain and markedly lower opioid use. REGISTRATION NCT04015908 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Jeffrey D. Swenson
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah, USA
| | - Kevin M. Conrad
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah, USA
| | - Nathan L. Pace
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah, USA
| | - Kathleen Phillips
- Department of Pharmacy, University of Utah, Salt Lake City, Utah, USA
| | - Charles L. Saltzman
- Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah, USA
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Cesarean delivery using an ERAS-CD process for nonopioid anesthesia and analgesia drug/medication management. Best Pract Res Clin Obstet Gynaecol 2022; 85:35-52. [PMID: 35995654 DOI: 10.1016/j.bpobgyn.2022.07.004] [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: 05/24/2022] [Accepted: 07/13/2022] [Indexed: 12/14/2022]
Abstract
Cesarean delivery (CD) is a surgical delivery of a neonate with surgical access through the maternal abdominal and uterine structures. The Enhanced Recovery After Surgery (ERAS) protocol is a standardized perioperative care program and surgery quality improvement process that has had global spread across numerous surgical disciplines. The medical and surgical use of opioids for pain management and the nonmedical opioid use, over the last three decades, have significantly increased the prevalence of abuse and addiction to opioids. This review summarizes pain, pregnancy substance use, and ERAS-directed analgesia and anesthesia for opioid use reduction or elimination in the operative and postoperative periods. Enhanced recovery (quality and safety) in the surgical CD context requires collaboration, consensus, and appropriate clinical prioritization to allow for the identification of 'the right patient, in the right clinical situation, with the right informed consent, and the right clinical care team and health system'.
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Abstract
Appropriate perioperative pain control is essential to aid in patients' recovery after surgery; however, acute postsurgical pain remains poorly treated and there continues to be an overreliance on opiates. Perioperative pain control starts in the operating room, and opiate-free anesthesia (OFA), where no opiates are used intraoperatively, has been proposed as a feasible strategy to further minimize opiates in the perioperative period. In this article, we address the potential benefits and shortcomings of OFA, while exploring tools available to accomplish multimodal anesthesia and ideally OFA, and the evidence behind the techniques proposed.
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AUGS-IUGA Joint Clinical Consensus Statement on Enhanced Recovery After Urogynecologic Surgery: Developed by the Joint Writing Group of the International Urogynecological Association and the American Urogynecologic Society. Individual writing group members are noted in the Acknowledgements section. UROGYNECOLOGY (HAGERSTOWN, MD.) 2022; 28:716-734. [PMID: 36288110 DOI: 10.1097/spv.0000000000001252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Enhanced recovery after surgery (ERAS) evidence-based protocols for perioperative care can lead to improvements in clinical outcomes and cost savings. This article aims to present consensus recommendations for the optimal perioperative management of patients undergoing urogynecological surgery. METHODS A review of meta-analyses, randomized clinical trials, large nonrandomized studies, and review articles was conducted via PubMed and other databases for ERAS and urogynecological surgery. ERAS protocol components were established, and then quality of the evidence was both graded and used to form consensus recommendations for each topic. These recommendations were developed and endorsed by the writing group, which is comprised of the American Urogynecologic Society and the International Urogynecological Association members. RESULTS All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. The components of ERAS with a high level of evidence to support their use include fasting for 6 h and taking clear fluids up to 2 h preoperatively, euvolemia, normothermia, surgical site preparation, antibiotic and antithrombotic prophylaxis, strong antiemetics and dexamethasone to reduce postoperative nausea and vomiting, multimodal analgesia and restrictive use of opiates, use of chewing gum to reduce ileus, removal of catheter as soon as feasible after surgery and avoiding systematic use of drains/vaginal packs. CONCLUSIONS The evidence base and recommendations for a urogynecology-relevant ERAS perioperative care pathway are presented in this consensus review. There are several elements of ERAS with strong evidence of benefit in urogynecological surgery.
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Gazendam A, Ekhtiari S, Horner NS, Simunovic N, Khan M, de Sa DL, Madden K, Ayeni OR. Effect of a Postoperative Multimodal Opioid-Sparing Protocol vs Standard Opioid Prescribing on Postoperative Opioid Consumption After Knee or Shoulder Arthroscopy: A Randomized Clinical Trial. JAMA 2022; 328:1326-1335. [PMID: 36194219 PMCID: PMC9533185 DOI: 10.1001/jama.2022.16844] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE In arthroscopic knee and shoulder surgery, there is growing evidence that opioid-sparing protocols may reduce postoperative opioid consumption while adequately addressing patients' pain. However, there are a lack of prospective, comparative trials evaluating their effectiveness. OBJECTIVE To evaluate the effect of a multimodal, opioid-sparing approach to postoperative pain management compared with the current standard of care in patients undergoing arthroscopic shoulder or knee surgery. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was performed at 3 clinical sites in Ontario, Canada, and enrolled 200 patients from March 2021 to March 2022 with final follow-up completed in April 2022. Adult patients undergoing outpatient arthroscopic shoulder or knee surgery were followed up for 6 weeks postoperatively. INTERVENTIONS The opioid-sparing group (100 participants randomized) received a prescription of naproxen, acetaminophen (paracetamol), and pantoprazole; a limited rescue prescription of hydromorphone; and a patient educational infographic. The control group (100 participants randomized) received the current standard of care determined by the treating surgeon, which consisted of an opioid analgesic. MAIN OUTCOMES AND MEASURES The primary outcome was postoperative oral morphine equivalent (OME) consumption at 6 weeks after surgery. There were 5 secondary outcomes, including pain, patient satisfaction, opioid refills, quantity of OMEs prescribed at the time of hospital discharge, and adverse events at 6 weeks all reported at 6 weeks after surgery. RESULTS Among the 200 patients who were randomized (mean age, 43 years; 73 women [38%]), 193 patients (97%) completed the trial; 98 of whom were randomized to receive standard care and 95 the opioid-sparing protocol. Patients in the opioid-sparing protocol consumed significantly fewer opioids (median, 0 mg; IQR, 0-8.0 mg) than patients in the control group (median, 40.0 mg; IQR, 7.5-105.0; z = -6.55; P < .001). Of the 5 prespecified secondary end points, 4 showed no significant difference. The mean amount of OMEs prescribed was 341.2 mg (95% CI, 310.2-372.2) in the standard care group and 40.4 mg (95% CI, 39.6-41.2) in the opioid-sparing group (mean difference, 300.8 mg; 95% CI, 269.4-332.3; P < .001). There was no significant difference in adverse events at 6 weeks (2 events [2.1%] in the standard care group vs 3 events [3.2%] in the opioid-sparing group), but more patients reported medication-related adverse effects in the standard care group (32% vs 19%, P = .048). CONCLUSIONS AND RELEVANCE Among patients who underwent arthroscopic knee or shoulder surgery, a multimodal opioid-sparing postoperative pain management protocol, compared with standard opioid prescribing, significantly reduced postoperative opioid consumption over 6 weeks. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04566250.
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Affiliation(s)
| | - Aaron Gazendam
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Seper Ekhtiari
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Nolan S Horner
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Nicole Simunovic
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Moin Khan
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Darren L de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kim Madden
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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AUGS-IUGA Joint clinical consensus statement on enhanced recovery after urogynecologic surgery. Int Urogynecol J 2022; 33:2921-2940. [DOI: 10.1007/s00192-022-05223-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 02/19/2022] [Indexed: 10/14/2022]
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Coccolini F, Corradi F, Sartelli M, Coimbra R, Kryvoruchko IA, Leppaniemi A, Doklestic K, Bignami E, Biancofiore G, Bala M, Marco C, Damaskos D, Biffl WL, Fugazzola P, Santonastaso D, Agnoletti V, Sbarbaro C, Nacoti M, Hardcastle TC, Mariani D, De Simone B, Tolonen M, Ball C, Podda M, Di Carlo I, Di Saverio S, Navsaria P, Bonavina L, Abu-Zidan F, Soreide K, Fraga GP, Carvalho VH, Batista SF, Hecker A, Cucchetti A, Ercolani G, Tartaglia D, Galante JM, Wani I, Kurihara H, Tan E, Litvin A, Melotti RM, Sganga G, Zoro T, Isirdi A, De'Angelis N, Weber DG, Hodonou AM, tenBroek R, Parini D, Khan J, Sbrana G, Coniglio C, Giarratano A, Gratarola A, Zaghi C, Romeo O, Kelly M, Forfori F, Chiarugi M, Moore EE, Catena F, Malbrain MLNG. Postoperative pain management in non-traumatic emergency general surgery: WSES-GAIS-SIAARTI-AAST guidelines. World J Emerg Surg 2022; 17:50. [PMID: 36131311 PMCID: PMC9494880 DOI: 10.1186/s13017-022-00455-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/16/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Non-traumatic emergency general surgery involves a heterogeneous population that may present with several underlying diseases. Timeous emergency surgical treatment should be supplemented with high-quality perioperative care, ideally performed by multidisciplinary teams trained to identify and handle complex postoperative courses. Uncontrolled or poorly controlled acute postoperative pain may result in significant complications. While pain management after elective surgery has been standardized in perioperative pathways, the traditional perioperative treatment of patients undergoing emergency surgery is often a haphazard practice. The present recommended pain management guidelines are for pain management after non-traumatic emergency surgical intervention. It is meant to provide clinicians a list of indications to prescribe the optimal analgesics even in the absence of a multidisciplinary pain team. MATERIAL AND METHODS An international expert panel discussed the different issues in subsequent rounds. Four international recognized scientific societies: World Society of Emergency Surgery (WSES), Global Alliance for Infection in Surgery (GAIS), Italian Society of Anesthesia, Analgesia Intensive Care (SIAARTI), and American Association for the Surgery of Trauma (AAST), endorsed the project and approved the final manuscript. CONCLUSION Dealing with acute postoperative pain in the emergency abdominal surgery setting is complex, requires special attention, and should be multidisciplinary. Several tools are available, and their combination is mandatory whenever is possible. Analgesic approach to the various situations and conditions should be patient based and tailored according to procedure, pathology, age, response, and available expertise. A better understanding of the patho-mechanisms of postoperative pain for short- and long-term outcomes is necessary to improve prophylactic and treatment strategies.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124, Pisa, Italy.
| | | | | | - Raul Coimbra
- Trauma Surgery Department, Riverside University Health System Medical Center, Loma Linda, CA, USA
| | - Igor A Kryvoruchko
- Department of Surgery No2, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Ari Leppaniemi
- General Surgery Department, Helsinki University Hospital, Helsinki, Finland
| | - Krstina Doklestic
- Clinic of Emergency Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Elena Bignami
- ICU Department, Parma University Hospital, Parma, Italy
| | | | - Miklosh Bala
- Trauma and Acute Care Surgery Unit Hadassah, Hebrew University Medical Center, Jerusalem, Israel
| | - Ceresoli Marco
- General Surgery Department, Monza University Hospital, Monza, Italy
| | - Dimitris Damaskos
- General and Emergency Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Walt L Biffl
- Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Paola Fugazzola
- General Surgery Department, Pavia University Hospital, Pavia, Italy
| | | | | | | | - Mirco Nacoti
- ICU Department Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Timothy C Hardcastle
- Trauma and Burn Service, Inkosi Albert Luthuli Central Hospital, Mayville, Durban, South Africa
| | - Diego Mariani
- General Surgery Department, Legnano Hospital, Legnano, Milano, Italy
| | - Belinda De Simone
- Emergency and Colorectal Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy, France
| | - Matti Tolonen
- Emergency Surgery, HUS Helsinki University Hospital, Meilahti Tower Hospital, Helsinki, Finland
| | - Chad Ball
- Trauma and Acute Care Surgery, Foothills Medical Center, Calgary, AB, Canada
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | | | - Salomone Di Saverio
- General Surgery Department, San Benedetto del Tronto Hospital, San Benedetto del Tronto, Italy
| | - Pradeep Navsaria
- Trauma Center, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Luigi Bonavina
- General Surgery Department, San Donato Hospital, Milan, Italy
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, University of Bergen, Bergen, Norway
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | | | | | - Andreas Hecker
- General Surgery, Giessen University Hospital, Giessen, Germany
| | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences - DIMEC, Alma Mater Studiorum - University of Bologna, General Surgery of the Morgagni - Pierantoni Hospital, Forlì, Italy
| | - Giorgio Ercolani
- Department of Medical and Surgical Sciences - DIMEC, Alma Mater Studiorum - University of Bologna, General Surgery of the Morgagni - Pierantoni Hospital, Forlì, Italy
| | - Dario Tartaglia
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124, Pisa, Italy
| | - Joseph M Galante
- General Surgery Department, UCLA Davis University Hospital, Los Angeles, CA, USA
| | - Imtiaz Wani
- General Surgery Department, Government Gousiua Hospital, Srinagar, India
| | - Hayato Kurihara
- Emergency and Trauma Surgery Department, Milano University Hospital, Milan, Italy
| | - Edward Tan
- Emergency Department, Nijmegen Hospital, Nijmegen, The Netherlands
| | - Andrey Litvin
- Department of Surgical Disciplines, Immanuel Kant Baltic Federal University, Regional Clinical Hospital, Kaliningrad, Russia
| | | | - Gabriele Sganga
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Tamara Zoro
- ICU Department, Pisa University Hospital, Pisa, Italy
| | | | - Nicola De'Angelis
- Service de Chirurgie Digestive Et Hépato-Bilio-Pancréatique, Hôpital Henri Mondor, Université Paris Est, Créteil, France
| | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Adrien M Hodonou
- Faculty of Medicine of Parakou, University of Parakou, Parakou, Benin
| | - Richard tenBroek
- General Surgery Department, Nijmegen Hospital, Nijmegen, The Netherlands
| | - Dario Parini
- General Surgery Department, Santa Maria Della Misericordia Hospital, Rovigo, Italy
| | - Jim Khan
- University of Portsmouth, Portsmouth Hospitals University NHS Trust UK, Portsmouth, UK
| | | | | | | | | | - Claudia Zaghi
- General, Emergency and Trauma Surgery Department, Vicenza Hospital, Vicenza, Italy
| | - Oreste Romeo
- Trauma and Surgical Critical Care, East Medical Center Drive, University of Michigan Health System, Ann Arbor, MI, USA
| | - Michael Kelly
- Department of General Surgery, Albury Hospital, Albury, Australia
| | | | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124, Pisa, Italy
| | | | - Fausto Catena
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Manu L N G Malbrain
- First Department Anaesthesiology Intensive Therapy, Medical University Lublin, Lublin, Poland.,International Fluid Academy, Lovenjoel, Belgium
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Abstract
Perioperative pain management is one of the domains in which Anesthesiologists are intricately involved, and which is immensely important. Adequate postoperative analgesia is central to avoid both the acute as well as chronic complications of uncontrolled postoperative pain. Preventive analgesia has been identified as an approach to mitigate the phenomenon of central sensitization, which plays an important role in the development of chronic pain after surgery. As an over-reliance on opioids for peri- and postoperative pain control is associated with opioid dependence and hyperalgesia, multimodal analgesia has taken center stage. Multimodal analgesia, in theory, will optimize perioperative pain control, reduce the chance of central sensitization, and avoid the detrimental effects of opioid overuse. Multiple classes of systemic analgesic medications have been used to accomplish these tasks, and the aim of this article is to outline these medications, their mechanisms of action, as well as the evidence behind their individual roles in multimodal analgesia. Regional anesthesia has also been embraced as a key component of multimodal analgesia in orthopedic surgery; however, over the past several years, local infiltration analgesia (LIA) emerged as a viable alternative, particularly in total knee arthroplasty.
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Affiliation(s)
- Archana O'Neill
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Philipp Lirk
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Forkin KT, Mitchell RD, Chiao SS, Song C, Chronister BNC, Wang XQ, Chisholm CA, Tiouririne M. Impact of timing of multimodal analgesia in enhanced recovery after cesarean delivery protocols on postoperative opioids: A single center before-and-after study. J Clin Anesth 2022; 80:110847. [PMID: 35468349 PMCID: PMC10813818 DOI: 10.1016/j.jclinane.2022.110847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 04/01/2022] [Accepted: 04/14/2022] [Indexed: 01/07/2023]
Abstract
STUDY OBJECTIVE Enhanced recovery after cesarean delivery (ERAC) programs aim to decrease maternal morbidity and aid in maternal recovery and return to baseline. Multimodal analgesia is an important element of ERAC protocols, but no consensus exists on the timing of medication administration. We compared maternal pain outcomes following scheduled cesarean delivery with modification of the timing of administration of multimodal analgesia with non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen. DESIGN Before-and-after study. SETTING Labor and delivery unit at a single academic institution. INTERVENTION NSAIDs and acetaminophen were administered as a fixed-interval alternating regimen every 3 h for the initial ERAC group (ERAC 1) and fixed-interval combined regimen every 6 h for the modified ERAC group (ERAC 2). ERAC 1 and ERAC 2 groups were compared to historical controls (Pre-ERAC). PATIENTS 520 women undergoing scheduled cesarean delivery (Pre-ERAC n = 179, ERAC 1 n = 179, and ERAC 2 n = 162). MEASUREMENTS The primary outcomes were postoperative total and daily opioid utilization as measured in morphine milligram equivalents (MME). Secondary outcomes included postoperative length of stay, maximum pain scores, and racial disparities in care. MAIN RESULTS The modified schedule of non-opioid analgesics involving combined administration (ERAC 2) versus alternating administration (ERAC 1) of multimodal analgesia resulted in decreased total postoperative opioid utilization (median = 26.3 vs 52.5 MME, Bonferroni corrected P = 0.002). Total postoperative opioid utilization among the ERAC 2 group was also significantly reduced compared to the Pre-ERAC group (median = 26.3 vs 105.0 MME, Bonferroni corrected P < 0.0001). CONCLUSIONS Multidisciplinary teams developing or modifying ERAC protocols for scheduled cesarean delivery should consider a combined administration at fixed intervals of NSAIDs and acetaminophen throughout the hospital stay to optimize postoperative pain management.
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Affiliation(s)
- Katherine T Forkin
- Department of Anesthesiology, University of Virginia Health System, P.O. Box 800710, Charlottesville, VA 22908, USA.
| | - Rochanda D Mitchell
- Department of Obstetrics and Gynecology, Howard University Hospital, Suite 3C, 2041 Georgia Avenue, Washington, DC 20060, USA.
| | - Sunny S Chiao
- Department of Anesthesiology, University of Virginia Health System, P.O. Box 800710, Charlottesville, VA 22908, USA.
| | - Chunzi Song
- Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9030, USA.
| | - Briana N C Chronister
- Department of Public Health, University of California San Diego, 9500 Gilman Dr., La Jolla, CA 92093, USA.
| | - Xin-Qun Wang
- Department of Public Health Services, University of Virginia Health System, P.O. Box 800717, Charlottesville, VA 22908, USA.
| | - Christian A Chisholm
- Department of Obstetrics and Gynecology, University of Virginia Health System, PO Box 800712, Charlottesville, VA 22908, USA.
| | - Mohamed Tiouririne
- Department of Anesthesiology, University of Virginia Health System, P.O. Box 800710, Charlottesville, VA 22908, USA.
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Steiness J, Hägi-Pedersen D, Lunn TH, Lindberg-Larsen M, Graungaard BK, Lundstrom LH, Lindholm P, Brorson S, Bieder MJ, Beck T, Skettrup M, von Cappeln AG, Thybo KH, Gasbjerg KS, Overgaard S, Jakobsen JC, Mathiesen O. Paracetamol, ibuprofen and dexamethasone for pain treatment after total hip arthroplasty: protocol for the randomised, placebo-controlled, parallel 4-group, blinded, multicentre RECIPE trial. BMJ Open 2022; 12:e058965. [PMID: 36190737 PMCID: PMC9438203 DOI: 10.1136/bmjopen-2021-058965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Multimodal analgesia with paracetamol, non-steroidal anti-inflammatory drug and glucocorticoid is recommended for hip arthroplasty, but with uncertain effects of the different combinations. We aim to investigate benefit and harm of different combinations of paracetamol, ibuprofen and dexamethasone following total hip arthroplasty. METHODS AND ANALYSIS RECIPE is a randomised, placebo-controlled, parallel 4-group, blinded trial with 90-day and 1-year follow-up performed at nine Danish hospitals. Interventions are initiated preoperatively and continued for 24 hours postoperatively. Eligible participants undergoing total hip arthroplasty are randomised to:group A: oral paracetamol 1000 mg × 4+oral ibuprofen 400 mg × 4+intravenous placebo; group B: oral paracetamol 1000 mg × 4+intravenous dexamethasone 24 mg+oral placebo; group C: oral ibuprofen 400 mg × 4+intravenous dexamethasone 24 mg+oral placebo; group D: oral paracetamol 1000 mg × 4+oral ibuprofen 400 mg × 4+intravenous dexamethasone 24 mg.Primary outcome is cumulative opioid consumption at 0-24 hours. Secondary outcomes are pain at rest, during mobilisation and during a 5 m walk and adverse events. Follow-up includes serious adverse events and patient reported outcome measures at 90 days and 1 year. A total of 1060 participants are needed to demonstrate a difference of 8 mg in 24-hour morphine consumption assuming an SD of 24.5 mg, a risk of type I errors of 0.0083 and a risk of type 2 errors of 0.2. Primary analysis will be a modified intention-to-treat analysis.With this trial we aim to verify recommendations for pain treatment after total hip arthroplasty, and investigate the role of dexamethasone as an analgesic adjuvant to paracetamol and ibuprofen. ETHICS AND DISSEMINATION This trial is approved by the Region Zealand Committee on Health Research Ethics (SJ-799). Plans for dissemination include publication in peer-reviewed journals and presentation at scientific meetings. TRIAL REGISTRATION NUMBER NCT04123873.
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Affiliation(s)
- Joakim Steiness
- Department of Anaesthesiology, Zealand University Hospital Koge Centre for Anaesthesiological Research, Koege, Denmark
- Department of Anaesthesiology, Nastved Hospital, Naestved, Denmark
| | - Daniel Hägi-Pedersen
- Department of Anaesthesiology, Slagelse Hospital, Slagelse, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Troels Haxholdt Lunn
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesiology and Intensive Care, Bispebjerg Hospital, Copenhagen, Denmark
| | - Martin Lindberg-Larsen
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
- Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
| | | | | | - Peter Lindholm
- Department of Anaesthesiology, Odense University Hospital, Odense, Denmark
| | - Stig Brorson
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Orthopaedic Surgery, Zealand University Hospital Koge, Koege, Denmark
| | | | - Torben Beck
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Michael Skettrup
- Department of Orthopaedic Surgery, Gentofte Hospital, Hellerup, Denmark
| | | | - Kasper Højgaard Thybo
- Department of Anaesthesiology, Zealand University Hospital Koge Centre for Anaesthesiological Research, Koege, Denmark
| | | | - Søren Overgaard
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
- Centre for Clinical Intervention Research, Rigshospitalet Copenhagen Trial Unit, Copenhagen, Denmark
| | - Ole Mathiesen
- Department of Anaesthesiology, Zealand University Hospital Koge Centre for Anaesthesiological Research, Koege, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Lavand'homme PM, Kehlet H, Rawal N, Joshi GP. Pain management after total knee arthroplasty: PROcedure SPEcific Postoperative Pain ManagemenT recommendations. Eur J Anaesthesiol 2022; 39:743-757. [PMID: 35852550 PMCID: PMC9891300 DOI: 10.1097/eja.0000000000001691] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The PROSPECT (PROcedure SPEcific Postoperative Pain ManagemenT) Working Group is a global collaboration of surgeons and anaesthesiologists formulating procedure-specific recommendations for pain management after common operations. Total knee arthroplasty (TKA) is associated with significant postoperative pain that is difficult to treat. Nevertheless, pain control is essential for rehabilitation and to enhance recovery. OBJECTIVE To evaluate the available literature and develop recommendations for optimal pain management after unilateral primary TKA. DESIGN A narrative review based on published systematic reviews, using modified PROSPECT methodology. DATA SOURCES A literature search was performed in EMBASE, MEDLINE, PubMed and Cochrane Databases, between January 2014 and December 2020, for systematic reviews and meta-analyses evaluating analgesic interventions for pain management in patients undergoing TKA. ELIGIBILITY CRITERIA Each randomised controlled trial (RCT) included in the selected systematic reviews was critically evaluated and included only if met the PROSPECT requirements. Included studies were evaluated for clinically relevant differences in pain scores, use of nonopioid analgesics, such as paracetamol and nonsteroidal anti-inflammatory drugs and current clinical relevance. RESULTS A total of 151 systematic reviews were analysed, 106 RCTs met PROSPECT criteria. Paracetamol and nonsteroidal anti-inflammatory or cyclo-oxygenase-2-specific inhibitors are recommended. This should be combined with a single shot adductor canal block and peri-articular local infiltration analgesia together with a single intra-operative dose of intravenous dexamethasone. Intrathecal morphine (100 μg) may be considered in hospitalised patients only in rare situations when both adductor canal block and local infiltration analgesia are not possible. Opioids should be reserved as rescue analgesics in the postoperative period. Analgesic interventions that could not be recommended were also identified. CONCLUSION The present review identified an optimal analgesic regimen for unilateral primary TKA. Future studies to evaluate enhanced recovery programs and specific challenging patient groups are needed.
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Affiliation(s)
- Patricia M Lavand'homme
- From the Department of Anaesthesiology and Perioperative Pain Service, Cliniques Universitaires St Luc, University Catholic of Louvain (UCL), Brussels, Belgium (PML), Section of Surgical Pathophysiology 7621, Rigshospitalet, Copenhagen, Denmark (HK), Department of Anaesthesiology, Orebro University, Orebro, Sweden (NR) and Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, United States (GPJ)
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Gostian M, Stilkerich L, Pauly A, Waldfahrer F, Balk M, Rupp R, Allner M, Iro H, Gostian AO. Pain management after tonsillectomy-by demand or by-the-clock-is there a difference? EAR, NOSE & THROAT JOURNAL 2022:1455613221116223. [PMID: 35861363 DOI: 10.1177/01455613221116223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To improve pain management after tonsillectomy (TE) by comparing individual analgesic management by demand versus a fixed-scheduled analgesic treatment protocol in a prospective trial. PATIENTS AND METHODS Forty consecutive patients received individual pain treatment by demand (control group) followed by 40 patients who were treated by a fixed-scheduled four-staged escalating analgesic protocol (intervention group) after TE. Minimum and maximum pain as well as pain on ambulation (NRS 0-10) on the first postoperative day were defined as primary objectives. Secondary endpoints comprised the analgesic score, treatment-related side effects/pain-associated impairments, wish for more pain medication, and patient satisfaction. Patients were surveyed using the standardized and validated "Quality Improvement in Postoperative Pain Treatment" (QUIPS) questionnaire. RESULTS Patients of the control group reported comparable minimum (2.03 ± 1.42 vs 2.38 ± 1.79, P = 0.337, r = 0.110) and maximum pain (6.65 ± 2.10 vs 6.93 ± 1.86, P = 0.536, r = 0.07) and pain on ambulation (4.73 ± 2.26 vs 5.18 ± 2.19, P = 0.370, r = 0.10) compared to the intervention group. Patients in both groups were comparably well satisfied with the pain treatment (7.53 ± 2.40 vs 7.73 ± 2.30, P = 0.704, r = 0.04), experienced similar side effects and functional impairments (P > 0.050, Φ < 0.3), and did not ask for much more analgesic medication (P = 0.152, Φ = 0.160). CONCLUSION Pain control following TE was not distinctly affected by applying a fixed-scheduled analgesic treatment protocol compared to individual analgesic therapy. In conclusion, analgesic treatment after TE remains unsatisfying. Consequently, further efforts are needed to achieve a standardized and effective approach to the underlying pathophysiological causes of pain following TE.
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Affiliation(s)
- Magdalena Gostian
- Department of Anesthesiology and Intensive Care Medicine, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany
| | - Lisa Stilkerich
- Department of Otolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-Europäische Metropolregion Nürnberg, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Anne Pauly
- Clinic Pharmacy, Friedrich-Alexander-University of Erlangen-Nuremberg, Erlangen, Germany
| | - Frank Waldfahrer
- Department of Otolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-Europäische Metropolregion Nürnberg, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Matthias Balk
- Department of Otolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-Europäische Metropolregion Nürnberg, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Robin Rupp
- Department of Otolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-Europäische Metropolregion Nürnberg, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Moritz Allner
- Department of Otolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-Europäische Metropolregion Nürnberg, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Heinrich Iro
- Department of Otolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-Europäische Metropolregion Nürnberg, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Antoniu-Oreste Gostian
- Department of Otolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-Europäische Metropolregion Nürnberg, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
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Hamilton C, Alfille P, Mountjoy J, Bao X. Regional anesthesia and acute perioperative pain management in thoracic surgery: a narrative review. J Thorac Dis 2022; 14:2276-2296. [PMID: 35813725 PMCID: PMC9264080 DOI: 10.21037/jtd-21-1740] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/24/2022] [Indexed: 12/11/2022]
Abstract
Background and Objective Thoracic surgery causes significant pain which can negatively affect pulmonary function and increase risk of postoperative complications. Effective analgesia is important to reduce splinting and atelectasis. Systemic opioids and thoracic epidural analgesia (TEA) have been used for decades and are effective at treating acute post-thoracotomy pain, although both have risks and adverse effects. The advancement of thoracoscopic surgery, a focus on multimodal and opioid-sparing analgesics, and the development of ultrasound-guided regional anesthesia techniques have greatly expanded the options for acute pain management after thoracic surgery. Despite the expansion of surgical techniques and analgesic approaches, there is no clear optimal approach to pain management. This review aims to summarize the body of literature regarding systemic and regional anesthetic techniques for thoracic surgery in both thoracotomy and minimally invasive approaches, with a goal of providing a foundation for providers to make individualized decisions for patients depending on surgical approach and patient factors, and to discuss avenues for future research. Methods We searched PubMed and Google Scholar databases from inception to May 2021 using the terms “thoracic surgery”, “thoracic surgery AND pain management”, “thoracic surgery AND analgesia”, “thoracic surgery AND regional anesthesia”, “thoracic surgery AND epidural”. We considered articles written in English and available to the reader. Key Content and Findings There is a wide variety of strategies for treating acute pain after thoracic surgery, including multimodal opioid and non-opioid systemic analgesics, regional anesthesia including TEA and paravertebral blocks (PVB), and a recent expansion in the use of novel fascial plane blocks especially for thoracoscopy. The body of literature on the effectiveness of different approaches for thoracotomy and thoracoscopy is a rapidly expanding field and area of active debate. Conclusions The optimal analgesic approach for thoracic surgery may depend on patient factors, surgical factors, and institutional factors. Although TEA may provide optimal analgesia after thoracotomy, PVB and emerging fascial plane blocks may offer effective alternatives. A tailored approach using multimodal systemic therapies and regional anesthesia is important, and future studies comparing techniques are necessary to further investigate the optimal approach to improve patient outcomes.
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Affiliation(s)
- Casey Hamilton
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Paul Alfille
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jeremi Mountjoy
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Xiaodong Bao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
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Rech MA, Griggs C, Lovett S, Motov S. Acute pain management in the Emergency Department: Use of multimodal and non-opioid analgesic treatment strategies. Am J Emerg Med 2022; 58:57-65. [DOI: 10.1016/j.ajem.2022.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/05/2022] [Accepted: 05/14/2022] [Indexed: 12/01/2022] Open
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