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Rooney EM, Odum SM, Hamid N, Irwin TA. Opioid-Free Forefoot Surgery vs Traditional Perioperative Opiate Regimen: A Randomized Controlled Trial. Foot Ankle Int 2023; 44:21-31. [PMID: 36537761 DOI: 10.1177/10711007221140834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND In response to the opioid epidemic, the use of multimodal pain management in orthopaedic surgery is increasing. Efforts to decrease opioid prescribing and opioid consumption among foot and ankle surgical patients are needed. The purpose of this study was to compare the efficacy and adverse events between 2 multimodal pain management pathways for forefoot surgical patients: standard opioid-containing (OC) and opioid-free (OF). METHODS This is a single-center noninferior randomized controlled trial of 51 patients undergoing forefoot surgery allocated to one of 2 perioperative pain management treatments: opioid-free, multimodal (OF, n=27 patients), or traditional opioid-containing (OC, n=24 patients). Patient characteristics, creatine markers, pain (numeric rating scale [NRS]), general health (Veterans Rand 12-Item Health Survey [VR-12]), and depression were measured preoperatively. Postoperatively, pain was measured at 24-hour, 2-week, and 6-week time points. Satisfaction with pain control, complications, and general health were measured at 2 and 6 weeks. RESULTS The OF group is statistically noninferior to the OC group and reported lower median pain scores at 24 hours (2 [IQR 0, 3] vs 6 [IQR 3.5, 7]; p<.0001) and 2 weeks (2 [IQR 1, 4] vs 4 [IQR 0, 3]; p=.018]. By 6 weeks, pain levels were similar between groups. More than 85% of all patients reported satisfaction with pain level at 2 weeks, which increased to >90% at 6 weeks. The VR-12 scores were similar between groups across all time points. At 2 weeks, 8 patients in each group reported constipation. By 6 weeks, all but 2 OC patients reported resolution. No other adverse events of postoperative wound complications, readmissions, medication reactions, thrombosis, or persistent pain were documented. CONCLUSION In forefoot surgery, the opioid-free pain management protocol was statistically noninferior to the opioid-containing protocol in reducing postoperative pain. LEVEL OF EVIDENCE Level II, prospective cohort study.
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Affiliation(s)
| | - Susan M Odum
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Nady Hamid
- OrthoCarolina Foot and Ankle Institute, Charlotte, NC, USA.,Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Todd A Irwin
- OrthoCarolina Foot and Ankle Institute, Charlotte, NC, USA.,Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
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2
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Anciano Granadillo VJ, Werner BC, Moran TE, Park JS, Cooper MT. Perioperative Opioid Analgesics and Hallux Valgus Correction Surgery: Trends, Risk Factors for Prolonged Use and Complications. J Foot Ankle Surg 2022; 61:1152-1157. [PMID: 34810085 DOI: 10.1053/j.jfas.2021.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 05/13/2021] [Accepted: 10/11/2021] [Indexed: 02/03/2023]
Abstract
In the setting of an opioid epidemic, this study aims to provide evidence on opioid use trends, risk factors for prolonged use, and complications from perioperative opioid consumption in hallux valgus surgery. A national database was queried for patients who underwent hallux valgus correction. Regression analysis identified: (1) risk factors for prolonged postoperative narcotic use; and (2) association between preoperative/prolonged postoperative narcotic use and postoperative complications. A linear regression analysis was used to determine trends. About 20,749 patients were included, of which 3464 patients were prescribed narcotics preoperatively and 4339 were identified as prolonged postoperative narcotic prescription users. Preoperative prescriptions were identified as risk factors for prolonged use. Perioperative narcotic use was observed to be a risk factor for poor outcomes. About 21% of patients were identified as prolonged postoperative narcotic prescription users. Patients undergoing hallux valgus corrective surgery should be counseled regarding their increased risk of complications when using narcotics.
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Affiliation(s)
| | - Brian C Werner
- Associate Professor, Department of Orthopaedics, University of Virginia Health Systems, Charlottesville, VA
| | - Thomas E Moran
- Resident Physician, Department of Orthopaedics, University of Virginia Health Systems, Charlottesville, VA
| | - Joseph S Park
- Associate Professor, Department of Orthopaedics, University of Virginia Health Systems, Charlottesville, VA
| | - Minton T Cooper
- Associate Professor, Department of Orthopaedics, University of Virginia Health Systems, Charlottesville, VA.
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3
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The effect of NSAIDs on postfracture bone healing: a meta-analysis of randomized controlled trials. OTA Int 2021; 4:e092. [PMID: 34746650 PMCID: PMC8568409 DOI: 10.1097/oi9.0000000000000092] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/18/2020] [Accepted: 08/12/2020] [Indexed: 01/08/2023]
Abstract
To determine whether nonsteroidal anti-inflammatory drugs (NSAIDs) have an adverse effect on bone healing by evaluating all available human randomized controlled trials (RCTs) on this subject. Data Sources A comprehensive search of electronic databases (PubMed, MEDLINE, and Cross-References) until October 2018 comparing the occurrence of nonunion in patients who received NSAIDs to the control group through RCTs. Study Selection Inclusion criteria were English-only studies, and the type of studies was restricted to RCTs. Data Extraction Two authors independently extracted data from the selected studies, and the data collected were compared to verify agreement. Data Synthesis Nonunion was the main outcome evaluated in each study. Regression analysis was used to estimate the relative risk comparing the duration and the type of NSAIDs by calculating the odds ratio (OR) for dichotomous variables. Studies were weighed by the inverse of the variance of the outcome, and a fixed-effects model was used for all analyses. Conclusions Six RCTs (609 patients) were included. The risk of nonunion was higher in the patients who were given NSAIDs after the fracture with an OR of 3.47. However, once the studies were categorized into the duration of treatment with NSAIDs, those who received NSAIDs for a short period (<2 weeks) did not show any significant risk of nonunion compared to those who received NSAIDs for a long period (>4 weeks). Indomethacin was associated with a significant higher nonunion rate and OR ranging from 1.66 to 9.03 compared with other NSAIDs that did not show a significant nonunion risk.
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Abstract
Anesthesia management during hallux valgus surgery trends toward multimodal pain control. Locoregional anesthesia with peripheral nerve blocks and wound instillation increase pain control. Peripheral nerve blocks as first-line analgesia are effective with minimal side effects. Local wound instillation has a variable but positive effect with minimal negative side effects. Nonsteroidal anti-inflammatory drugs in bone-to-bone healing remain controversial; however, they reduce opiate requirements and enhance patient satisfaction. Opiate agonists remain the mainstay for postoperative pain; long-acting formulations minimize pain crises. Multimodal analgesia with locoregional anesthesia facilitate the progress of hallux valgus surgery as an outpatient procedure.
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Affiliation(s)
- Max Seiter
- Sports Medicine Orthopaedic Surgery, Steadman Philippon Research Institute, 181 W Meadow Dr., Vail, CO 81657, USA
| | - Amiethab Aiyer
- Orthopaedic Surgery, University of Miami, Jackson Memorial Hospital, 900 NW 17th Street, Miami, FL 33136, USA.
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Rogero R, Fuchs D, Nicholson K, Shakked RJ, Winters BS, Pedowitz DI, Raikin SM, Daniel JN. Postoperative Opioid Consumption in Opioid-Naïve Patients Undergoing Hallux Valgus Correction. Foot Ankle Int 2019; 40:1267-1272. [PMID: 31319719 DOI: 10.1177/1071100719862606] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Postoperative pain management following orthopedic surgeries can be challenging, and the opioid epidemic has made it essential to better individualize opioid prescriptions by patient and procedure. The purpose of this subgroup analysis of a prospective study was to investigate immediate postoperative opioid pill consumption and prolonged use in patients undergoing operative correction of hallux valgus (HV). METHODS Patients undergoing outpatient HV correction procedures with 5 fellowship-trained foot and ankle surgeons over a 1-year period were included. Patients were excluded if they were being prescribed chronic opioid analgesics for an underlying condition prior to the date of initial injury or if they underwent concomitant nonforefoot procedures. At the patient's first postoperative visit, opioid pills were counted, and these were standardized to the equivalent number of 5-mg oxycodone pills. Linear regression analysis was performed to determine if any of the procedure categories or patient factors were independently associated with postoperative opioid consumption. Prolonged use of opioids 90 to 180 days after the procedure was also examined using our state's online Prescription Drug Monitoring Program (PDMP). One-hundred thirty-seven patients (86% female) were included. Thirty-six patients (26%) underwent primary chevron osteotomies, 78 (57%) underwent primary proximal osteotomies (Ludloff, scarf), 10 (7%) underwent soft tissue-only procedures with or without a first proximal phalanx osteotomy (modified McBride, Akin), and 13 (9%) underwent first metatarsophalangeal arthrodeses. RESULTS Overall, patients consumed a median of 27 pills. There was no significant difference in postoperative opioid intake between the 4 procedures, including when subdivided into those with and without lesser toe procedures. Higher preoperative visual analog scale pain levels (P = .028) and younger patient age (P = .042) were associated with higher opioid pill consumption. A total of 1.5% of patients demonstrated prolonged opioid use. CONCLUSION Our study demonstrated a lack of difference between HV procedures in terms of postoperative opioid consumption and an overall low rate of prolonged use in opioid-naïve patients. LEVEL OF EVIDENCE Level III, comparative study.
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Affiliation(s)
- Ryan Rogero
- Rothman Orthopaedic Institute, Philadelphia, PA, USA.,Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Daniel Fuchs
- Rothman Orthopaedic Institute, Philadelphia, PA, USA
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Analysis of quality of life after randomized controlled trial of alpha-1 adrenoceptor antagonist alone and in combination with cyclooxygenase-2 inhibitor in patients who underwent low-dose-rate brachytherapy for prostate cancer. J Contemp Brachytherapy 2019; 11:409-416. [PMID: 31749848 PMCID: PMC6854856 DOI: 10.5114/jcb.2019.88142] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 08/19/2019] [Indexed: 11/17/2022] Open
Abstract
Purpose The goal of this study was to evaluate the effect of cyclooxygenase-2 (COX-2) inhibitors on quality of life (QoL) of patients undergoing low-dose-rate (LDR) brachytherapy. Material and methods A total of 310 patients with prostate cancer who had undergone LDR brachytherapy were enrolled. The patients were randomized (1 : 1) to the monotherapy group (tamsulosin alone: 0.2 mg/day, n = 156) and the combination group (tamsulosin: 0.2 mg/day plus celecoxib: 200 mg/day, n = 154) without placebo. Using the expanded prostate cancer index composite (EPIC) and medical outcomes study 8-item short form health survey (SF-8) questionnaire, QoL was evaluated at baseline and at 1, 3, 6, and 12 months after seed implantation. Results The mean changes in scores from baseline to 1 and 3 months after seed implantation for the urinary (1M: –10.5, 3M: –10.9) and bowel (1M: –2.4, 3M: –4.2) domains of EPIC in the combination group were not significantly different from those (urinary 1M: –11.0, 3M: –11.4, bowel 1M: –2.3, 3M: –4.6) in the monotherapy group. The mean changes in scores from baseline to 1 and 3 months after seed implantation for the physical component summary (1M: 0.009, 3M: –0.32) and mental component summary (1M: 0.41, 3M: 0.36) of SF-8 in the combination group were not significantly different from those (physical component 1M: –0.89, 3M: –0.22, mental component 1M: 1.3, 3M: 1.1) in the monotherapy group. Conclusions Combination treatment with celecoxib and tamsulosin during the peri-operative period is not warranted for improving QoL in patients undergoing LDR brachytherapy.
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Xu C, Li M, Wang C, Li H, Liu H. Perioperative analgesia with a buprenorphine transdermal patch for hallux valgus surgery: a prospective, randomized, controlled study. J Pain Res 2018; 11:867-873. [PMID: 29731664 PMCID: PMC5927186 DOI: 10.2147/jpr.s153456] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Hallux valgus surgery often results in significant postoperative pain. Adequate control of pain is essential for patient satisfaction and improves the outcome of the procedure. This study aimed to investigate the perioperative analgesic effect of a buprenorphine transdermal patch in patients who underwent hallux valgus surgery. Patients and methods A total of 90 patients were randomly divided into the following three groups based on the perioperative analgesic method: flurbiprofen axetil intravenous injection (Group F), oral celecoxib (Group C), and buprenorphine transdermal delivery system (BTDS) (Group BTDS). The pain status, degree of satisfaction, adverse effects, and administration of tramadol hydrochloride for uncontrolled pain were recorded on the night before surgery, postoperative day 1, postoperative day 2, and postoperative day 3. Results The BTDS could effectively control perioperative pain for patients undergoing hallux valgus surgery. The analgesic effect of the BTDS was better than that of oral celecoxib. In addition, statistically significant differences were not observed in the visual analog scale (VAS) scores, adverse effects, and rescue analgesia between the patients who received the BTDS and the patients who received the flurbiprofen axetil intravenous injection. However, the degree of patient satisfaction of the BTDS group was significantly higher (P<0.05) than that of the other two groups. Conclusion The BTDS (a preemptive analgesia regimen) could exert an analgesic effect during the perioperative period for patients who had received hallux valgus surgery, and this effect is beneficial for sustaining postoperative physiological and psychological states and promoting functional rehabilitation.
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Affiliation(s)
- Can Xu
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan Province, People's Republic of China
| | - Mingqing Li
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan Province, People's Republic of China
| | - Chenggong Wang
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan Province, People's Republic of China
| | - Hui Li
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan Province, People's Republic of China
| | - Hua Liu
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan Province, People's Republic of China
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Braito M, Dammerer D, Schlager A, Wansch J, Linhart C, Biedermann R. Continuous Wound Infiltration After Hallux Valgus Surgery. Foot Ankle Int 2018; 39:180-188. [PMID: 29073780 DOI: 10.1177/1071100717736292] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hallux valgus surgery is associated with significant early postoperative pain. The aim of this study was to investigate the use of continuous wound infiltration (CWI) with ropivacaine for pain management after hallux valgus surgery. METHODS In this prospective, randomized, double-blind, and placebo-controlled single-center trial, 50 patients undergoing distal metatarsal osteotomy for idiopathic hallux valgus were allocated to CWI with ropivacaine 2 mg/mL at a rate of 2 mL/h or placebo for 24 hours postoperatively. Average and peak pain levels on the verbal numeric rating scale (NRS; 1-10) during the first 48 hours after surgery were recorded as primary outcome parameters. Secondary outcome parameters included consumption of narcotics, clinical outcome, incidence of postoperative complications, and patient satisfaction. RESULTS No significant difference in mean ( P = .596) and peak ( P = .353) postoperative pain level was found for CWI with either ropivacaine (mean NRS 1.9 ± 0.8; peak NRS 3.5 ± 2.0) or placebo (mean NRS 2.0 ± 0.7; peak NRS 3.9 ± 1.7) during the early postoperative course. Furthermore, no significant difference between both groups was detected regarding narcotic consumption ( P = .354) and all other secondary outcome parameters. Two severe complications (local dysesthesia with CWI, catheter accidentally fixed by a suture) and 5 catheter dislocations were observed. CONCLUSION CWI with ropivacaine 2 mg/mL at a rate of 2 mL/h for 24 hours after hallux valgus surgery did not reduce postoperative pain level in an inpatient setting. LEVEL OF EVIDENCE Level I, prospective randomized trial.
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Affiliation(s)
- Matthias Braito
- 1 Department of Orthopedic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Dammerer
- 1 Department of Orthopedic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Andreas Schlager
- 2 Department of Anesthesiology and Critical Care, Medical University of Innsbruck, Innsbruck, Austria
| | - Jürgen Wansch
- 1 Department of Orthopedic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Caroline Linhart
- 3 Department of Medical Statistics, Medical University of Innsbruck, Innsbruck, Austria
| | - Rainer Biedermann
- 1 Department of Orthopedic Surgery, Medical University of Innsbruck, Innsbruck, Austria
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Ribeiro H, Sesterhenn RB, de Souza A, de Souza AC, Alves M, Machado JC, Burger NB, Torres ILDS, Stefani LC, Fregni F, Caumo W. Preoperative transcranial direct current stimulation: Exploration of a novel strategy to enhance neuroplasticity before surgery to control postoperative pain. A randomized sham-controlled study. PLoS One 2017; 12:e0187013. [PMID: 29190741 PMCID: PMC5708693 DOI: 10.1371/journal.pone.0187013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Accepted: 09/25/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND An imbalance in the excitatory/inhibitory systems in the pain networks may explain the persistent chronic pain after hallux valgus surgery. Thus, to contra-regulate this dysfunction, the use of transcranial direct current stimulation (tDCS) becomes attractive. OBJECTIVE We tested the hypothesis that two preoperative active(a)-tDCS sessions compared with sham(s)-tDCS could improve the postoperative pain [as indexed by Visual Analogue Scale (VAS) at rest and during walking (primary outcomes)]. To assess their effect on the change in the Numerical Pain Scale (NPS0-10) during Conditioned Pain Modulation (CPM-task), disability related to pain (DRP) and analgesic consumption (secondary outcomes). Also, we assessed if the brain derived neurotrophic factor (BDNF) in the cerebral spinal fluid (CSF) after tDCS could predict the intervention's effect on the DRP. METHODS It is a prospective, double blind, sham-controlled, randomized single center, 40 women (18-70 years-old) who had undergone hallux valgus surgery were randomized to receive two sessions (20 minutes each) of anodal a-tDCS or s-tDCS on the primary motor cortex at night and in the morning before the surgery. To assess the DRP was used the Brazilian Profile of Chronic Pain: Screen (B-PCP:S). RESULTS A-tDCS group showed lower scores on VAS at rest and during walking (P<0.001). At rest, the difference between groups was 2.13cm (95%CI = 1.59 to 2.68) while during walking was 1.67cm (95%CI = 1.05 to 2.28). A-tDCS, when compared to s-tDCS reduced analgesic doses in 73.25% (P<0.001), produced a greater reduction in B-PCP:S (mean difference of 9.41 points, 95%CI = 0.63 to 18.21) and higher function of descending pain modulatory system (DPMS) during CPM-task. CONCLUSION A-tDCS improves postoperative pain, the DRP and the function of DPMS. Also, the CSF BDNF after a-tDCS predicted the improvement in the DRP. In overall, these findings suggest that a-tDCS effects may be mediated by top-down regulatory mechanisms associated with the inhibitory cortical control. TRIAL REGISTRATION ClinicalTrials.gov NCT02360462.
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Affiliation(s)
- Hugo Ribeiro
- Department of Clinical Research Center, Laboratory of Pain & Neuromodulation, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- Surgery Department, Hospital Independência, Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Andressa de Souza
- Department of Clinical Research Center, Laboratory of Pain & Neuromodulation, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Ana Claudia de Souza
- Department of Clinical Research Center, Laboratory of Pain & Neuromodulation, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Monique Alves
- Surgery Department, Hospital Independência, Porto Alegre, Rio Grande do Sul, Brazil
| | - Jessica Catarina Machado
- Postgraduate Program in Health and Human Development, La Salle University Center, Canoas, Rio Grande do Sul, Brazil
| | | | - Iraci Lucena da Silva Torres
- Department of Clinical Research Center, Laboratory of Pain & Neuromodulation, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- Pharmacology Department, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Luciana Cadore Stefani
- Department of Clinical Research Center, Laboratory of Pain & Neuromodulation, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- Surgery Department, Anesthesia and Perioperative Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Felipe Fregni
- Physical Medicine & Rehabilitation Department, Center of Neuromodulation & Center for Clinical Research Learning, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Wolnei Caumo
- Department of Clinical Research Center, Laboratory of Pain & Neuromodulation, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- Surgery Department, Anesthesia and Perioperative Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- Pain and Palliative Care Service, Laboratory of Pain & Neuromodulation, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- * E-mail:
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Abstract
Progress in surgical acute pain management has allowed most foot and ankle surgery to be performed in ambulatory outpatient surgical centers. Multimodal analgesia focuses on improving postoperative pain by combining pharmacologic and other modalities, addressing multiple pain mechanisms and receptor pathways while reducing adverse effects through lower doses of oral medications. Local anesthesia techniques provide excellent pain relief with few adverse events. Multimodal analgesia in foot and ankle surgery provides superior pain relief, and reduced opioid dependence and opioid-related side effects, improving patient satisfaction, safety, and timely return to function.
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Affiliation(s)
- Jessica M Kohring
- Department of Orthopaedics, The University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA.
| | - Nathan G Orgain
- Department of Anesthesiology, The University of Utah, SOM 3C444, 30 North 1900 East, Salt Lake City, UT 84132, USA
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Rose B, Kunasingam K, Barton T, Walsh J, Fogarty K, Wines A. A Randomized Controlled Trial Assessing the Effect of a Continuous Subcutaneous Infusion of Local Anesthetic Following Elective Surgery to the Great Toe. Foot Ankle Spec 2017; 10:116-124. [PMID: 27613814 DOI: 10.1177/1938640016666923] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
UNLABELLED Local anesthetic use for wound infusions, single injection, and continuous nerve blocks for postoperative analgesia is well established. No study has investigated the effect of a continuous block of the saphenous and superficial peroneal nerves at the level of the ankle joint following first ray surgery. A double blind randomized controlled trial was designed. One hundred patients with hallux valgus and rigidus requiring surgical correction were recruited and randomized to receive a postoperative continuous infusion at the ankle of normal saline or ropivacaine for 24 hours. Pain scores were recorded on postoperative days 1 and 7. There were more females than males. Follow-up was 100%. There were no significant differences in demographic data between the 2 randomized groups. There was no significant difference between the absolute visual analog scale scores on day 1 (P = .14) and day 7 (P = .16); nor was there a significant difference in reduction in scores between days 1 and 7 (P = .70). This study has shown no benefit to postoperative analgesia with the use of a continuous infusion of ropivacaine at the ankle. We, therefore, cannot currently recommend its use in the way described. Further studies may still identify a role for continuous local anesthetic infusions at the ankle to improve postoperative analgesia. LEVELS OF EVIDENCE Level I : Prospective randomised control trial.
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Affiliation(s)
- Barry Rose
- Royal North Shore Hospital, Reserve Road, Sydney, New South Wales, Australia (BR, KK, TB, JW, KF, AW).,Royal United Hospital, Combe Park, Bath, United Kingdom (TB).,Cappagh National Orthopaedic Hospital, Finglas, Republic of Ireland (JW).,North Sydney Orthopaedic Sports Medicine, Sydney, New South Wales, Australia (AW)
| | - Kumar Kunasingam
- Royal North Shore Hospital, Reserve Road, Sydney, New South Wales, Australia (BR, KK, TB, JW, KF, AW).,Royal United Hospital, Combe Park, Bath, United Kingdom (TB).,Cappagh National Orthopaedic Hospital, Finglas, Republic of Ireland (JW).,North Sydney Orthopaedic Sports Medicine, Sydney, New South Wales, Australia (AW)
| | - Tristan Barton
- Royal North Shore Hospital, Reserve Road, Sydney, New South Wales, Australia (BR, KK, TB, JW, KF, AW).,Royal United Hospital, Combe Park, Bath, United Kingdom (TB).,Cappagh National Orthopaedic Hospital, Finglas, Republic of Ireland (JW).,North Sydney Orthopaedic Sports Medicine, Sydney, New South Wales, Australia (AW)
| | - James Walsh
- Royal North Shore Hospital, Reserve Road, Sydney, New South Wales, Australia (BR, KK, TB, JW, KF, AW).,Royal United Hospital, Combe Park, Bath, United Kingdom (TB).,Cappagh National Orthopaedic Hospital, Finglas, Republic of Ireland (JW).,North Sydney Orthopaedic Sports Medicine, Sydney, New South Wales, Australia (AW)
| | - Karen Fogarty
- Royal North Shore Hospital, Reserve Road, Sydney, New South Wales, Australia (BR, KK, TB, JW, KF, AW).,Royal United Hospital, Combe Park, Bath, United Kingdom (TB).,Cappagh National Orthopaedic Hospital, Finglas, Republic of Ireland (JW).,North Sydney Orthopaedic Sports Medicine, Sydney, New South Wales, Australia (AW)
| | - Andrew Wines
- Royal North Shore Hospital, Reserve Road, Sydney, New South Wales, Australia (BR, KK, TB, JW, KF, AW).,Royal United Hospital, Combe Park, Bath, United Kingdom (TB).,Cappagh National Orthopaedic Hospital, Finglas, Republic of Ireland (JW).,North Sydney Orthopaedic Sports Medicine, Sydney, New South Wales, Australia (AW)
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Andersson V, Bergman S, Henoch I, Ene KW, Otterström-Rydberg E, Simonsson H, Ahlberg K. Pain and pain management in hospitalized patients before and after an intervention. Scand J Pain 2017; 15:22-29. [DOI: 10.1016/j.sjpain.2016.11.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 11/11/2016] [Accepted: 11/13/2016] [Indexed: 11/30/2022]
Abstract
Abstract
Background and aim
Studies have shown that pain is common among hospitalized patients and that there is a lack of compliance with pain management guidelines. Improving pain management does not only involve developing new drugs or technology; even more important is an effective organisation that utilises existing expertise. The aim of this study was to investigate whether pain in hospitalized patients can be reduced by implementing evidence-based pain management guidelines, providing education for staff and an organisation that includes pain responsibility nurses.
Methods
A cross-sectional study was carried out between 2009 and 2010 at two hospitals in southwest Sweden, comprising a baseline survey followed by an intervention. The study involved 306 patients, who answered questions about pain intensity at rest and while moving, disturbed sleep due to pain and whether they had used a pain rating scale while in hospital. Medical records were scrutinised for analgesic prescriptions. An intervention then took place, involving implementation of evidence-based guidelines, staff education and the introduction of pain responsibility nurses. A follow-up survey was carried out in 2012, in which 293 patients answered the same questions and their medical records were also reviewed. The baseline results were then compared with those of the follow-up survey.
Results
When compared with the baseline survey, the follow-up survey revealed significant differences in the use of validated pain rating instruments as well as the prescription of more appropriate analgesics. Prescription of paracetamol increased significantly in the follow-up survey; 56% of the patients were prescribed paracetamol on a regular basis, compared with 42% at baseline. There was also a significant increase in the use of strong opioids, from 38% at baseline to 55% at follow-up. Prescriptions of weak opioids decreased from 16% at baseline to 4% at follow-up. No significant differences were observed in patient pain levels in the follow-up survey. At baseline, 29% of the patients reported moderate to severe pain at rest (NRS 4–10) and at follow-up that figure was 24% (NRS 4–10). In both surveys, 41% reported moderate to severe pain (NRS 5–10) during movement. Thirty-nine percent reported disturbed sleep at night at both baseline and follow-up.
Conclusions
This study demonstrates that evidence-based guidelines made accessible to all staff as a pocket size booklet and on the intranet, in combination with staff education, pain responsibility nurses who informed other staff on their own wards, improved the prescription of analgesics in the hospitals studied. In order to achieve a noticeable effect for patients, i.e., reduced pain levels, an intervention containing more components than those employed in the present study is required.
Implications
Nurses and physicians need greater knowledge about the importance of pain rating. A vital part of pain management at hospitals is continuous evaluation of treatment outcomes to prevent severe pain and disturbed sleep. The complexity of pain and pain management requires commitment, time and knowledge on the part of healthcare staff. Multi-professional pain teams that support ward staff in pain management are necessary in order to reduce suffering and unnecessary pain in hospitalized patients.
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Affiliation(s)
- Viveka Andersson
- The Sahlgrenska Academy , University of Gothenburg , Institute of Health and Care Sciences , Box 457, 405 30 Gothenborg , Gothenburg , Sweden
- Department of Medicine , Hallands Hospital Varberg , Träslövsvägen 68, 432 37 , Varberg , Sweden
| | - Stefan Bergman
- Primary Health Care Unit, Department of Public Health and Community Medicine , Institute of Medicine, The Sahlgrenska Academy , University of Gothenburg , Box 457, 405 30 , Gothenborg , Sweden
- Spenshult Research and Development Centre , Bäckagårdsvägen 47, 302 74 , Halmstad , Sweden
| | - Ingela Henoch
- The Sahlgrenska Academy , University of Gothenburg , Institute of Health and Care Sciences , Box 457, 405 30 Gothenborg , Gothenburg , Sweden
- Angered Local Hospital , Halmtorget 1, 424 65 , Gothenburg , Sweden
| | - Kerstin Wickström Ene
- Department of Research, Development and Education , Hallands Hospital , Varberg , Träslövsvägen 68, 432 37 Varberg , Sweden
| | - Eva Otterström-Rydberg
- Department of Anesthesia and Intensive Care , Hallands Hospital , Varberg , Träslövsvägen 68, 432 37 Varberg , Sweden
| | - Hanna Simonsson
- Department of Surgery , Hallands Hospital , Halmstad , Lasarettsvägen, 302 33 Halmstad , Sweden
| | - Karin Ahlberg
- The Sahlgrenska Academy , University of Gothenburg , Institute of Health and Care Sciences , Box 457, 405 30 Gothenborg , Gothenburg , Sweden
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13
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Salgado FLL, Artigiani-Neto R, Lopes-Filho GDJ. GROWTH FACTORS AND COX2 IN WOUND HEALING: AN EXPERIMENTAL STUDY WITH EHRLICH TUMORS. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2017; 29:223-226. [PMID: 28076474 PMCID: PMC5225859 DOI: 10.1590/0102-6720201600040003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 08/30/2016] [Indexed: 11/21/2022]
Abstract
Background Healing is an innate biological phenomenon, and carcinogenesis acquired, but with common humoral and cellular elements. Carcinogenesis interferes negatively in healing. Aim To evaluate the histological changes in laparotomy scars of healthy Balb/c mice and with an Ehrlich tumor in its various forms of presentation. Methods Fifty-four mice were divided into three groups of 18 animals. First group was the control; the second had Ehrlich tumor with ascites; and the third had the subcutaneous form of this tumor. Seven days after tumor inoculation, all 54 mice were submitted to laparotomy. All of the animals in the experiment were operated on again on 7th day after surgery, with resection of the scar and subsequent euthanasia of the animal. The scars were sent for histological assessment using immunohistochemical techniques to evaluate Cox-2 (cyclooxygenase 2), VEGF (vascular endothelial growth factor) and FGF (fibroblast growth factor). Semi-quantitatively analysis was done in the laparotomy scars and in the abdominal walls far away from the site of the operation. Results Assessing the weight of the animals, the correct inoculation of the tumor and weight gain in the group with tumoral ascites was observed. The histological studies showed that groups with the tumor showed a statistically significant higher presence of Cox-2 compared to the control. In the Cox-2 analysis of the abdominal wall, the ascites group showed the most significant difference. VEGF did not present any significant differences between the three groups, regardless of the site. The FGF showed a significant increase in animals with the tumor. Conclusion Histological findings in both laparotomy scar and the abdominal wall showed that with Ehrlich's neoplasia there was an exacerbated inflammatory response, translated by more intense expression of Cox-2 and greater fibroblast proliferation, translated by more intense expression of FGF, that is, it stimulated both the immediate inflammatory reactions, observed with Cox-2 reactions, and late scarring by fibroblasts and FGF.
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Affiliation(s)
- Flávio L L Salgado
- Postgraduate Program in Interdisciplinary Surgical Science, Paulista School of Medicine, Federal University of São Paulo - UNIFESP, São Paulo, SP, Brazil
| | - Ricardo Artigiani-Neto
- Postgraduate Program in Interdisciplinary Surgical Science, Paulista School of Medicine, Federal University of São Paulo - UNIFESP, São Paulo, SP, Brazil
| | - Gaspar de Jesus Lopes-Filho
- Postgraduate Program in Interdisciplinary Surgical Science, Paulista School of Medicine, Federal University of São Paulo - UNIFESP, São Paulo, SP, Brazil
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Meyr AJ, Mirmiran R, Naldo J, Sachs BD, Shibuya N. American College of Foot and Ankle Surgeons ® Clinical Consensus Statement: Perioperative Management. J Foot Ankle Surg 2017; 56:336-356. [PMID: 28231966 DOI: 10.1053/j.jfas.2016.10.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Indexed: 02/07/2023]
Abstract
A wide range of factors contribute to the complexity of the management plan for an individual patient, and it is the surgeon's responsibility to consider the clinical variables and to guide the patient through the perioperative period. In an effort to address a number of important variables, the American College of Foot and Ankle Surgeons convened a panel of experts to derive a clinical consensus statement to address selected issues associated with the perioperative management of foot and ankle surgical patients.
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Affiliation(s)
- Andrew J Meyr
- Committee Chairperson and Clinical Associate Professor, Department of Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA.
| | | | - Jason Naldo
- Assistant Professor, Department of Orthopedic Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Brett D Sachs
- Private Practice, Rocky Mountain Foot & Ankle Center, Wheat Ridge, CO; Faculty, Podiatric Medicine and Surgery Program, Highlands-Presbyterian St. Luke's Medical Center, Denver, CO
| | - Naohiro Shibuya
- Professor, Department of Surgery, Texas A&M, College of Medicine, Temple, TX
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15
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Acetaminophen, nonsteroidal anti-inflammatory drugs, and cyclooxygenase-2 selective inhibitors: an update. Plast Reconstr Surg 2016; 134:24S-31S. [PMID: 25255003 DOI: 10.1097/prs.0000000000000672] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
SUMMARY Plastic and cosmetic surgery is often performed as an ambulatory procedure, and pain is often mild to moderate. Good pain relief is central to patient comfort and satisfaction. Analgesics used should ensure rapid onset and adequate pain relief lasting a sufficiently long duration with minimal or no side effects. Acetaminophen is well tolerated by patients, efficacious, and associated with only minor side effects, when used in the minimal effective doses. Nonsteroidal anti-inflammatory drugs (NSAIDs) are more efficacious, having lower numbers needed to treat compared with acetaminophen, but have several side effects and contraindications. However, when used in the correct doses in healthy patients, NSAIDs are excellent for pain management with one caveat that there is an increased risk for oozing or bleeding. In contrast, cyclooxygenase inhibitors (Coxibs) are equally efficacious as NSAIDs but have the added advantage that they have minimal or no effect on platelet function, and therefore, the risk for bleeding complications is minimal. However, there has been some concern about the risk of vascular events in patients with ischemic heart disease, specifically when using Coxibs, but even some NSAIDs, for example, diclofenac. In conclusion, acetaminophen should be given postoperatively to all patients undergoing plastic surgical procedures. For patients undergoing moderately invasive surgery, the addition of Coxibs to acetaminophen would be an advantage except in the patient with ischemic heart disease where NSAIDs could have a place in management of pain. Side effects and contraindications of NSAIDs, however, restrict their use to the healthy patient with mild comorbidities.
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16
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Revisión sistemática de pautas analgésicas para el postoperatorio en cirugías de pie y tobillo. REVISTA ESPAÑOLA DE PODOLOGÍA 2016. [DOI: 10.1016/j.repod.2016.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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17
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Merivirta R, Pitkänen M, Alanen J, Haapoja E, Koivisto M, Kuusniemi K. Postoperative pain management with transdermal fentanyl after forefoot surgery: a randomized, placebo-controlled study. J Pain Res 2015; 8:39-45. [PMID: 25653553 PMCID: PMC4303394 DOI: 10.2147/jpr.s69511] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Quality of life is decreased in patients with hallux valgus deformity, mainly because of pain. Significant improvement is usually achieved by surgery. However, postoperative pain can be moderate to severe for 2–3 days. The aim of the present study was to evaluate the use of transdermal fentanyl for postoperative pain management after forefoot surgery. Methods Sixty patients undergoing hallux valgus or hallux rigidus surgery were allocated to receive a patch delivering either fentanyl 12 μg/hour or placebo for postoperative pain. The consumption of rescue opioid oxycodone, the primary outcome measure, was evaluated daily until the fourth postoperative day. Total consumption of oxycodone during the study period was also assessed. Pain scores and possible adverse effects were evaluated every 6 hours during the first 24 hours and on the fourth postoperative day. Results The use of rescue opioid was low in both groups, the median (range) consumption of oxycodone being 10 (0–50) mg on the day of surgery (no difference between the groups, P=0.31) and 0 (0–35) mg thereafter. The total combined consumption was 10 (0–105) mg in the fentanyl group and 20 (0–70) mg in the placebo group (P=0.23). There were no statistically significant differences in pain scores or adverse effects between the groups. Conclusion As a part of multimodal analgesia with ibuprofen and acetaminophen, a patch delivering fentanyl 12 μg/hour did not significantly decrease the consumption of rescue opioid or pain scores after forefoot surgery.
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Affiliation(s)
- Riika Merivirta
- Department of Anaesthesiology, Intensive Care, Emergency Care and Pain Medicine of Turku University Hospital and University of Turku, Turku
| | - Mikko Pitkänen
- Department of Anaesthesia, Hospital Orton, Invalid Foundation, Helsinki, Finland
| | | | - Elina Haapoja
- Department of Anaesthesiology, Intensive Care, Emergency Care and Pain Medicine of Turku University Hospital and University of Turku, Turku
| | - Mari Koivisto
- Department of Biostatistics, University of Turku, Turku, Finland
| | - Kristiina Kuusniemi
- Department of Anaesthesiology, Intensive Care, Emergency Care and Pain Medicine of Turku University Hospital and University of Turku, Turku
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18
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Singla N, Barrett T, Sisk L, Kostenbader K, Young J. Assessment of the safety and efficacy of extended-release oxycodone/acetaminophen, for 14 days postsurgery. Curr Med Res Opin 2014; 30:2571-8. [PMID: 25157951 DOI: 10.1185/03007995.2014.957824] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To investigate the safety and satisfaction of patients treated ≤ 14 days after unilateral bunionectomy with extended-release oxycodone/acetaminophen (ER OC/APAP), a biphasic (ER and immediate release) fixed-dose combination analgesic being developed for moderate to severe acute pain. RESEARCH DESIGN AND METHODS This was an open-label extension (OLE) of a randomized, double-blind, placebo-controlled trial (DBRCT) of patients undergoing bunionectomy. Patients who consented to the OLE before entering the 48 hour DBRCT entered the OLE upon completing the DBRCT and during the OLE received two tablets of ER OC/APAP (15/650 mg total dose) every 12 hours for ≤ 14 days. ClinicalTrials identifier: NCT01484652. MAIN OUTCOME MEASURES Treatment-emergent adverse events, physical examinations, vital sign measurements, and clinical laboratory testing were assessed throughout the study. Global assessments of treatment satisfaction were made at the end of the DBRCT and at each clinic visit during the OLE. RESULTS A total of 146 patients consented to the OLE before entering the DBRCT and 129 completed the OLE. Tolerability of ER OC/APAP during the OLE was consistent with that of an opioid product. Adverse events occurred during the OLE in 64 patients (43.8%); the most common were gastrointestinal events including nausea (17.8%), vomiting (7.5%), and constipation (6.2%). No changes in vital signs or clinical laboratory tests were considered by the investigator to be clinically significant. At all visits during the OLE, the majority of patients were satisfied or very satisfied with their medication. Limitations include a 14 day postprocedure study duration that may be confounded with natural healing time, and lack of a placebo arm. CONCLUSIONS These results show that ER OC/APAP demonstrated an expected safety and tolerability profile and good patient satisfaction in a postsurgical model of acute pain.
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Affiliation(s)
- Neil Singla
- Lotus Clinical Research LLC, Huntington Hospital, Department of Anesthesia , Pasadena, CA , USA
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19
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Wang J, Liu GT, Mayo HG, Joshi GP. Pain Management for Elective Foot and Ankle Surgery: A Systematic Review of Randomized Controlled Trials. J Foot Ankle Surg 2014; 54:625-35. [PMID: 24954920 DOI: 10.1053/j.jfas.2014.05.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Indexed: 02/03/2023]
Abstract
Pain after foot and ankle surgery can significantly affect the postoperative outcomes. We performed a systematic review of randomized controlled trials assessing postoperative pain after foot and ankle surgery, because the surgery will lead to moderate-to-severe postoperative pain, but the optimal pain therapy has been controversial. A systematic review of randomized controlled trials in English reporting on pain after foot and ankle surgery in adults published from January 1946 to February 2013 was performed. The primary outcome measure was the postoperative pain scores. The secondary outcome measures included supplemental analgesic requirements and other recovery outcomes. With 953 studies identified, 45 met the inclusion criteria. The approaches improving pain relief (reduced pain scores or opioid requirements) included peripheral nerve blocks, wound infiltration, intravenous dexamethasone, acetaminophen, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 selective inhibitors, and opioids. Wound instillation, intra-articular injection, and intravenous regional analgesia had variable analgesia. The lack of homogeneous study design precluded quantitative analyses. Optimal pain management strategies included locoregional analgesic techniques plus acetaminophen and nonsteroidal anti-inflammatory drugs or cyclooxygenase-2 selective inhibitors, with opioids used for "rescue," and 1 intraoperative dose of parenteral dexamethasone. Popliteal sciatic nerve blocks would be appropriate when expecting severe postoperative pain (extensive surgical procedure), and ankle blocks and surgical incision infiltration would be appropriate when expecting moderate postoperative pain (less extensive and minimally invasive surgical procedures). Additional studies are needed to assess multimodal analgesia techniques.
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Affiliation(s)
- Jia Wang
- Resident, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX
| | - George T Liu
- Assistant Professor, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Helen G Mayo
- Research and Liaison Librarian, University of Texas Southwestern Health Sciences Digital Library and Learning Center, University of Texas Southwestern Medical Center, Dallas, TX
| | - Girish P Joshi
- Professor, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX.
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20
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Singla NK, Desjardins PJ, Chang PD. A comparison of the clinical and experimental characteristics of four acute surgical pain models: Dental extraction, bunionectomy, joint replacement, and soft tissue surgery. Pain 2014; 155:441-456. [DOI: 10.1016/j.pain.2013.09.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 08/27/2013] [Accepted: 09/02/2013] [Indexed: 11/30/2022]
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21
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Mei XP, Sakuma Y, Xie C, Wu D, Ho I, Kotani J, Xu LX. Depressing Interleukin-1� Contributed to the Synergistic Effects of Tramadol and Minocycline on Spinal Nerve Ligation-Induced Neuropathic Pain. Neurosignals 2014; 22:30-42. [DOI: 10.1159/000355071] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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22
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Zhang J, Wu D, Xie C, Wang H, Wang W, Zhang H, Liu R, Xu LX, Mei XP. Tramadol and propentofylline coadministration exerted synergistic effects on rat spinal nerve ligation-induced neuropathic pain. PLoS One 2013; 8:e72943. [PMID: 24009718 PMCID: PMC3756942 DOI: 10.1371/journal.pone.0072943] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Accepted: 07/16/2013] [Indexed: 01/22/2023] Open
Abstract
Neuropathic pain is an intractable clinical problem. Drug treatments such as tramadol have been reported to effectively decrease neuropathic pain by inhibiting the activity of nociceptive neurons. It has also been reported that modulating glial activation could also prevent or reverse neuropathic pain via the administration of a glial modulator or inhibitor, such as propentofylline. Thus far, there has been no clinical strategy incorporating both neuronal and glial participation for treating neuropathic pain. Therefore, the present research study was designed to assess whether coadministration of tramadol and propentofylline, as neuronal and glial activation inhibitors, respectively, would exert a synergistic effect on the reduction of rat spinal nerve ligation (SNL)-induced neuropathic pain. Rats underwent SNL surgery to induce neuropathic pain. Pain behavioral tests were conducted to ascertain the effect of drugs on SNL-induced mechanical allodynia with von-Frey hairs. Proinflammatory factor interleukin-1β (IL-1β) expression was also detected by Real-time RT-PCR. Intrathecal tramadol and propentofylline administered alone relieved SNL-induced mechanical allodynia in a dose-dependent manner. Tramadol and propentofylline coadministration exerted a more potent effect in a synergistic and dose dependent manner than the intrathecal administration of either drug alone. Real-time RT-PCR demonstrated IL-1β up-expression in the ipsilateral spinal dorsal horn after the lesion, which was significantly decreased by tramadol and propentofylline coadministration. Inhibiting proinflammatory factor IL-1β contributed to the synergistic effects of tramadol and propentofylline coadministration on rat peripheral nerve injury-induced neuropathic pain. Thus, our study provided a rationale for utilizing a novel strategy for treating neuropathic pain by blocking the proinflammatory factor related pathways in the central nervous system.
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Affiliation(s)
- Jin Zhang
- Department of Anesthesiology, School of Stomatology, Fourth Military Medical University, Xi'an, China
| | - Dan Wu
- Department of Prosthodontics, School of Stomatology, Fourth Military Medical University, Xi'an, China
| | - Cheng Xie
- Department of Prosthodontics, School of Stomatology, Fourth Military Medical University, Xi'an, China
| | - Huan Wang
- Department of Orthodontics, School of Stomatology, Fourth Military Medical University, Xi'an, China
| | - Wei Wang
- Department of Anesthesiology, School of Stomatology, Fourth Military Medical University, Xi'an, China
| | - Hui Zhang
- Department of Anesthesiology, School of Stomatology, Fourth Military Medical University, Xi'an, China
| | - Rui Liu
- Department of Anesthesiology, School of Stomatology, Fourth Military Medical University, Xi'an, China
- * E-mail: (RL); (LXX); (XPM)
| | - Li-Xian Xu
- Department of Anesthesiology, School of Stomatology, Fourth Military Medical University, Xi'an, China
- * E-mail: (RL); (LXX); (XPM)
| | - Xiao-Peng Mei
- Department of Anesthesiology, School of Stomatology, Fourth Military Medical University, Xi'an, China
- * E-mail: (RL); (LXX); (XPM)
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Renner B, Walter G, Strauss J, Fromm MF, Zacher J, Brune K. Preoperative administration of etoricoxib in patients undergoing hip replacement causes inhibition of inflammatory mediators and pain relief. Eur J Pain 2011; 16:838-48. [PMID: 22337568 PMCID: PMC3437501 DOI: 10.1002/j.1532-2149.2011.00062.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2011] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Administering cyclooxygenase-2 inhibitors preoperatively appears attractive since these drugs reduce post-operative pain, but do not increase the risk of post-operative bleeds, asthmatic attacks and stress-related gastrointestinal ulcers. In a former investigation, we could show that post-operative administration of etoricoxib reduces prostaglandin production in wound fluid, but the onset of action is variable due to delayed post-operative absorption. METHODS In this study, we investigated the preoperative administration of etoricoxib in patients undergoing hip replacement. They received 120 mg etoricoxib or placebo 2 h before surgery and 1 day after in a double-blinded, randomized, parallel group design. RESULTS A total of 11 patients were randomized (placebo n = 5; verum n = 6). We found high and constant levels of the drug in blood, central nervous system and wound fluid already at the end of surgery (t(max) < 2 h). This was accompanied by inhibition of prostaglandin production in the wound tissue (treatment p < 0.05), suppression of interleukin 6 increase in plasma (treatment p < 0.01), and - despite existing standard pain relief procedures - higher satisfaction with analgesics (time vs. treatment p < 0.05) and less demand for opioids (treatment p < 0.01) and intrathecal bupivacaine (treatment p = 0.05) administration. CONCLUSION Administration of etoricoxib 2 h before surgery allows for an effective drug concentration in critical tissues, a reduction of the production of pro-inflammatory mediators and for better pain relief.
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Affiliation(s)
- B Renner
- Institute of Experimental and Clinical Pharmacology and Toxicology, University of Erlangen-Nürnberg, Erlangen, Germany.
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Ambulatory anaesthesia: there is room for further improvements of safety and quality of care – is the way forward further simple but evidence-based risk scores? Curr Opin Anaesthesiol 2010; 23:679-81. [DOI: 10.1097/aco.0b013e32833ff3bc] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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