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Eryilmaz NC, Eryilmaz T. Pain Levels Following Cosmetic Breast Surgery and An Easy-To-Use Pain Treatment Algorithm for Plastic Surgeons. Aesthetic Plast Surg 2024:10.1007/s00266-023-03831-z. [PMID: 38242977 DOI: 10.1007/s00266-023-03831-z] [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: 09/14/2023] [Accepted: 12/19/2023] [Indexed: 01/21/2024]
Abstract
INTRODUCTION The purpose of this study was to examine the degrees of pain experienced following various breast cosmetic surgery procedures and to evaluate the existing pain treatment methods. MATERIALS AND METHODS Patients who underwent subpectoral breast augmentation, mastopexy, or breast reduction between 2017 and 2022 were evaluated retrospectively. A total of 90 patients were randomly selected, with 30 patients in each group. The visual analog scale (VAS) was used to assess pain levels. The data were analyzed using the statistical program SPSS 22.0 (IBM Corp., Armonk, NY, USA). RESULTS The subpectoral breast augmentation group exhibited the highest recovery VAS score. Postoperative 1, 2, 4, 6, 12, and 24-h VAS values were higher in the breast augmentation group than in the breast reduction and mastopexy groups. No statistically significant difference observed between mastopexy and breast reduction in terms of VAS scores during the evaluation periods. Statistically significant higher VAS scores were observed for subpectoral breast augmentation at all times compared to the preoperative period. CONCLUSIONS Subpectoral breast augmentation is associated with higher levels of postoperative pain compared to breast reduction and mastopexy. Effective postoperative pain prevention is crucial following aesthetic breast surgeries. It not only helps to reduce hospital stays but also aids in patient recovery, facilitates a quicker return to daily activities, and enhances patient satisfaction. To achieve this objective, it is advantageous to utilize a practical pain treatment algorithm that is readily applicable. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Nuray Camgoz Eryilmaz
- Department of Anesthesia and Reanimation, Gazi University School of Medicine, Ankara, Turkey
| | - Tolga Eryilmaz
- Dr. Tolga Eryilmaz Plastic Surgery Clinic, Neorama Is Merkezi, Yasam Caddesi, 4th Floor, No:13, Bestepe, Ankara, Turkey.
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Boccella S, De Filippis L, Giorgio C, Brandolini L, Jones M, Novelli R, Amorizzo E, Leoni MLG, Terranova G, Maione S, Luongo L, Leone M, Allegretti M, Minnella EM, Aramini A. Combination Drug Therapy for the Management of Chronic Neuropathic Pain. Biomolecules 2023; 13:1802. [PMID: 38136672 PMCID: PMC10741625 DOI: 10.3390/biom13121802] [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: 11/01/2023] [Revised: 12/01/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Chronic neuropathic pain (NP) is an increasingly prevalent disease and leading cause of disability which is challenging to treat. Several distinct classes of drugs are currently used for the treatment of chronic NP, but each drug targets only narrow components of the underlying pathophysiological mechanisms, bears limited efficacy, and comes with dose-limiting side effects. Multimodal therapies have been increasingly proposed as potential therapeutic approaches to target the multiple mechanisms underlying nociceptive transmission and modulation. However, while preclinical studies with combination therapies showed promise to improve efficacy over monotherapy, clinical trial data on their efficacy in specific populations are lacking and increased risk for adverse effects should be carefully considered. Drug-drug co-crystallization has emerged as an innovative pharmacological approach which can combine two or more different active pharmaceutical ingredients in a single crystal, optimizing pharmacokinetic and physicochemical characteristics of the native molecules, thus potentially capitalizing on the synergistic efficacy between classes of drugs while simplifying adherence and minimizing the risk of side effects by reducing the doses. In this work, we review the current pharmacological options for the treatment of chronic NP, focusing on combination therapies and their ongoing developing programs and highlighting the potential of co-crystals as novel approaches to chronic NP management.
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Affiliation(s)
- Serena Boccella
- Research & Early Development (R&D), Dompé Farmaceutici S.p.A, Via De Amicis, 80131 Naples, Italy; (S.B.); (C.G.)
| | - Lidia De Filippis
- Research & Early Development (R&D), Dompé Farmaceutici S.p.A, Via S. Lucia, 20122 Milan, Italy; (L.D.F.); (R.N.); (M.L.); (E.M.M.)
| | - Cristina Giorgio
- Research & Early Development (R&D), Dompé Farmaceutici S.p.A, Via De Amicis, 80131 Naples, Italy; (S.B.); (C.G.)
| | - Laura Brandolini
- Research & Early Development (R&D), Dompé Farmaceutici S.p.A, Via Campo di Pile, 67100 L’Aquila, Italy; (L.B.); (M.A.)
| | - Meghan Jones
- Research & Early Development (R&D), Dompé US, 181 2nd Avenue, STE 600, San Mateo, CA 94401, USA;
| | - Rubina Novelli
- Research & Early Development (R&D), Dompé Farmaceutici S.p.A, Via S. Lucia, 20122 Milan, Italy; (L.D.F.); (R.N.); (M.L.); (E.M.M.)
| | - Ezio Amorizzo
- Pain Unit, San Paolo Hospital, 00053 Civitavecchia, Italy;
- Pain Clinic Roma, 00191 Rome, Italy
| | - Matteo Luigi Giuseppe Leoni
- Azienda USL di Piacenza, 29121 Piacenza, Italy;
- Department of Medical and Surgical Sciences and Translational Medicine, Sapienza University, 00185 Rome, Italy
| | | | - Sabatino Maione
- Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (S.M.); (L.L.)
| | - Livio Luongo
- Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (S.M.); (L.L.)
| | - Manuela Leone
- Research & Early Development (R&D), Dompé Farmaceutici S.p.A, Via S. Lucia, 20122 Milan, Italy; (L.D.F.); (R.N.); (M.L.); (E.M.M.)
| | - Marcello Allegretti
- Research & Early Development (R&D), Dompé Farmaceutici S.p.A, Via Campo di Pile, 67100 L’Aquila, Italy; (L.B.); (M.A.)
| | - Enrico Maria Minnella
- Research & Early Development (R&D), Dompé Farmaceutici S.p.A, Via S. Lucia, 20122 Milan, Italy; (L.D.F.); (R.N.); (M.L.); (E.M.M.)
| | - Andrea Aramini
- Research & Early Development (R&D), Dompé Farmaceutici S.p.A, Via Campo di Pile, 67100 L’Aquila, Italy; (L.B.); (M.A.)
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Lien W, Zhou X, Liang Y, Ching CT, Wang C, Lu F, Chang H, Lin F, Wang HD. Therapeutic potential of nanoceria pretreatment in preventing the development of urological chronic pelvic pain syndrome: Immunomodulation via reactive oxygen species scavenging and SerpinB2 downregulation. Bioeng Transl Med 2023; 8:e10346. [PMID: 36684074 PMCID: PMC9842028 DOI: 10.1002/btm2.10346] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/23/2022] [Accepted: 05/10/2022] [Indexed: 01/25/2023] Open
Abstract
Urological chronic pelvic pain syndrome (UCPPS) manifests as pelvic pain with frequent urination and has a 10% prevalence rate without effective therapy. Nanoceria (cerium oxide nanoparticles [CNPs]) were synthesized in this study to achieve potential long-term pain relief, using a commonly used UCPPS mouse model with cyclophosphamide-induced cystitis. Transcriptome sequencing analysis revealed that serpin family B member 2 (SerpinB2) was the most upregulated marker in mouse bladder, and SerpinB2 was downregulated with CNP pretreatment. The transcriptome sequencing analysis results agreed with quantitative polymerase chain reaction and western blot analysis results for the expression of related mRNAs and proteins. Analysis of Gene Expression Omnibus (GEO) datasets revealed that SerpinB2 was a differentially upregulated gene in human UCPPS. In vitro SerpinB2 knockdown downregulated proinflammatory chemokine expression (chemokine receptor CXCR3 and C-X-C motif chemokine ligand 10) upon treatment with 4-hydroperoxycyclophosphamide. In conclusion, CNP pretreatment may prevent the development of UCPPS, and reactive oxygen species (ROS) scavenging and SerpinB2 downregulation may modulate the immune response in UCPPS.
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Affiliation(s)
- Wei‐Chih Lien
- Department of Physical Medicine and RehabilitationNational Cheng Kung University Hospital, College of Medicine, National Cheng Kung UniversityTainanTaiwan, Republic of China
- Department of Physical Medicine and Rehabilitation, College of MedicineNational Cheng Kung UniversityTainanTaiwan, Republic of China
- Ph.D. Program in Tissue Engineering and Regenerative MedicineNational Chung Hsing UniversityTaichung CityTaiwan, Republic of China
| | - Xin‐Ran Zhou
- Institute of Biomedical Engineering, College of Medicine and College of EngineeringNational Taiwan UniversityTaipeiTaiwan, Republic of China
| | - Ya‐Jyun Liang
- Institute of Biomedical Engineering, College of Medicine and College of EngineeringNational Taiwan UniversityTaipeiTaiwan, Republic of China
| | - Congo Tak‐Shing Ching
- Ph.D. Program in Tissue Engineering and Regenerative MedicineNational Chung Hsing UniversityTaichung CityTaiwan, Republic of China
- Graduate Institute of Biomedical EngineeringNational Chung Hsing UniversityTaichung CityTaiwan, Republic of China
| | - Chia‐Yih Wang
- Department of Cell Biology and Anatomy, College of MedicineNational Cheng Kung UniversityTainanTaiwan, Republic of China
- Institute of Basic Medical Sciences, College of MedicineNational Cheng Kung UniversityTainanTaiwan, Republic of China
| | - Fu‐I Lu
- Department of Biotechnology and Bioindustry Sciences, College of Bioscience and BiotechnologyNational Cheng Kung UniversityTainanTaiwan, Republic of China
- The iEGG and Animal Biotechnology CenterNational Chung Hsing UniversityTaichung CityTaiwan, Republic of China
| | - Huei‐Cih Chang
- Department of Physical Medicine and Rehabilitation, College of MedicineNational Cheng Kung UniversityTainanTaiwan, Republic of China
| | - Feng‐Huei Lin
- Ph.D. Program in Tissue Engineering and Regenerative MedicineNational Chung Hsing UniversityTaichung CityTaiwan, Republic of China
- Institute of Biomedical Engineering, College of Medicine and College of EngineeringNational Taiwan UniversityTaipeiTaiwan, Republic of China
- Institute of Biomedical Engineering and NanomedicineNational Health Research InstitutesZhunan, MiaoliTaiwan, Republic of China
| | - Hui‐Min David Wang
- Ph.D. Program in Tissue Engineering and Regenerative MedicineNational Chung Hsing UniversityTaichung CityTaiwan, Republic of China
- Graduate Institute of Biomedical EngineeringNational Chung Hsing UniversityTaichung CityTaiwan, Republic of China
- Graduate Institute of Medicine, College of MedicineKaohsiung Medical UniversityKaohsiungTaiwan, Republic of China
- Department of Medical Laboratory Science and BiotechnologyChina Medical UniversityTaichung CityTaiwan, Republic of China
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Ghai B, Jafra A, Bhatia N, Chanana N, Bansal D, Mehta V. Opioid sparing strategies for perioperative pain management other than regional anaesthesia: A narrative review. J Anaesthesiol Clin Pharmacol 2022; 38:3-10. [PMID: 35706649 PMCID: PMC9191794 DOI: 10.4103/joacp.joacp_362_19] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 03/14/2020] [Accepted: 10/14/2020] [Indexed: 11/04/2022] Open
Abstract
Opioids play a crucial role in pain management in spite of causing increased hospital morbidity and related costs. It may also cause significant risks such as postoperative nausea and vomiting (PONV), sedation, sleep disturbances, urinary retention and respiratory depression (commonly referred to as opioid related adverse effects) in postoperative patients. In order to evade these opioid related side effects and also improve pain management, multimodal analgesia i.e., combination of different analgesics, was introduced more than a decade ago. Both pharmacological and non-pharmacological techniques are available as opioid sparing analgesia. Research from around the world have proved pharmacological techniques ranging from acetaminophen, NSAIDs (non-steroidal anti-inflammatory drugs), N-methyl-D-aspartate receptor antagonists (NDMA), alpha-2 agonists, anticonvulsants such as gamma aminobutyric acid analogues, beta-blockers, capsaicin, lignocaine infusion to glucocorticoids to be effective. On the other hand, non-pharmacological methods include techniques such as cognitive behavioral therapy, transcutaneous electrical nerve stimulation (TENS), electroanalgesia, acupuncture and hypnosis. However, research regarding the effect of these non-pharmacological techniques on pain management is still needed.
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Affiliation(s)
- Babita Ghai
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, India
| | - Anudeep Jafra
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, India
| | - Nidhi Bhatia
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, India
| | - Neha Chanana
- Department of Community Medicine, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, India
| | - Dipika Bansal
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research, Mohali, Punjab, India
| | - Vivek Mehta
- Consultant in Pain Medicine and Clinical Network Director Pain, St. Bartholomews Hospital, Barts Health NHS Trust West field, London
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Zanza C, Longhitano Y, Lin E, Luo J, Artico M, Savarese B, Bonato V, Piccioni A, Franceschi F, Taurone S, Abenavoli L, Berger JM. Intravenous Magnesium - Lidocaine - Ketorolac Cocktail for Postoperative Opioid Resistant Pain: A Case Series of Novel Rescue Therapy. Rev Recent Clin Trials 2021; 16:288-293. [PMID: 33267764 DOI: 10.2174/1574887115666201202105620] [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: 08/07/2020] [Revised: 10/17/2020] [Accepted: 10/19/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Severe postoperative pain is principally managed by opioids. While effective, opioids do not provide adequate relief in many patients and cause many side effects, including antinociceptive tolerance and opioid-induced hyperalgesia. To evaluate if a combination of intravenous Magnesium, Lidocaine, Ketorolac (MLK cocktail) is a useful rescue therapy through synergistic pharmacological mechanisms for acute pain relief. We present the intravenous combination of magnesium, lidocaine, and ketorolac (MLK cocktail) as a possible rescue for opioid insensitive severe post-operative pain. MATERIALS AND METHODS The principal settings were the post-operative care unit (PACU) and the surgical ward. We retrospectively analyzed the electronic medical record and anesthesia documents of 14 patients experiencing severe postoperative pain, >7/10 visual-analogue pain score (VAS), despite receiving at least 8 mg of intravenous morphine milligram equivalents (MME) after arrival in the LAC+USC Medical Center PACU between September 2012 and January 2013. The data reviewed included patients' demographics, disease etiology, surgical procedure, opioids received perioperatively, and visual-analogue pain scores before and after each analgesic received, and after the MLK cocktail. The a priori primary outcome and a posteriori secondary outcome of this study are mean visual-analogue pain score and morphine milligram equivalent dose administered per hour, respectively. The main tool evaluated has been VAS score. RESULTS In patients who failed to respond to opioid analgesics, administration of the MLK cocktail improved the VAS pain scores immediately from 9.4 ± 1.0 to 3.6 ± 3.5. The MLK cocktail also decreased the MME doses/hour in the immediate 12 hours postoperative period from 12.4 ± 5.6 to 1.1 ± 0.9. CONCLUSION In patients experiencing opioid-resistant severe postoperative pain, the magnesium, lidocaine, and ketorolac combination may be an effective nonopioid rescue therapy. Additionally, magnesium, lidocaine, and ketorolac may be utilized in cases complicated by either antinociceptive tolerance or opioid-induced hyperalgesia and can restore opioid responsiveness.
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Affiliation(s)
- Christian Zanza
- Department of Emergency Medicine, Policlinico Agostino Gemelli, Catholic University of Sacred Heart, Rome, Italy
| | - Yaroslava Longhitano
- Department of Anesthesiology, Keck Medical School of University of Southern California, Los Angeles, United States
| | - Edwin Lin
- Department of Anesthesiology, Keck Medical School of University of Southern California, Los Angeles, United States
| | - Jerry Luo
- Department of Anesthesiology, Keck Medical School of University of Southern California, Los Angeles, United States
| | - Marco Artico
- Department of Sensory Organs, Sapienza University of Rome/Policlinico Umberto I, Rome, Italy
| | - Benedetta Savarese
- Department of Anesthesiology and Critical Care, St. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Valeria Bonato
- Department of Anesthesiology and Critical Care, St. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Andrea Piccioni
- Department of Emergency Medicine, Policlinico Agostino Gemelli, Catholic University of Sacred Heart, Rome, Italy
| | - Francesco Franceschi
- Department of Emergency Medicine, Policlinico Agostino Gemelli, Catholic University of Sacred Heart, Rome, Italy
| | - Samanta Taurone
- Department of Sensory Organs, Sapienza University of Rome/Policlinico Umberto I, Rome, Italy
| | - Ludovico Abenavoli
- Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Jack Marshall Berger
- Department of Anesthesiology, Keck Medical School of University of Southern California, Los Angeles, United States
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Optimal analgesic dose of ketorolac for use in the perioperative period. J Clin Anesth 2020; 68:110081. [PMID: 33011670 DOI: 10.1016/j.jclinane.2020.110081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 09/22/2020] [Indexed: 11/22/2022]
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Intravenous Patient-controlled Analgesia Versus Thoracic Epidural Analgesia After Open Liver Surgery: A Prospective, Randomized, Controlled, Noninferiority Trial. Ann Surg 2020; 270:193-199. [PMID: 30676382 DOI: 10.1097/sla.0000000000003209] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE We conducted a randomized, controlled, noninferiority trial to investigate if intravenous, multimodal, patient-controlled analgesia (IV-PCA) could be noninferior to multimodal thoracic epidural analgesia (TEA) in patients undergoing open liver surgery. SUMMARY BACKGROUND DATA The increasing use of minimally invasive techniques and fast track protocols have questioned the position of epidural analgesia as the optimal method of pain management after abdominal surgery. METHODS Patients operated with open liver resection between February 2012 and February 2016 were randomly assigned to receive either IV-PCA enhanced with ketorolac/diclofenac (IV-PCA, n = 66) or TEA (n = 77) within an enhanced recovery after surgery protocol. Noninferiority would be declared if the mean pain score on the numeric rating scale (NRS) for postoperative days (PODs) 0 to 5 in the IV-PCA group was no worse than the mean pain score in the TEA group by a margin of <1 point on an 11-point scale (0-10). RESULTS The primary endpoint, mean NRS pain score was 1.7 in the IV-PCA group and 1.6 in the TEA group, establishing noninferiority. Pain scores were lower in the TEA group on PODs 0 and 1, but higher or equal on PODs 2 and 5. Postoperative hospital stay was significantly shorter for patients in the IV-PCA group (74 vs 104 h, P < 0.001). The total opioid consumption during the first 3 days was significantly lower in the IV-PCA group. CONCLUSIONS IV-PCA was noninferior to TEA for the treatment of postoperative pain in patients undergoing open liver resection.
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Postoperative Ketorolac Administration Is Not Associated with Hemorrhage in Cranial Vault Remodeling for Craniosynostosis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2401. [PMID: 31592008 PMCID: PMC6756670 DOI: 10.1097/gox.0000000000002401] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 06/28/2019] [Indexed: 11/25/2022]
Abstract
Nonsteroidal anti-inflammatory drugs have been used as part of multimodal postoperative analgesic regimens to reduce the necessity of opioids. However, due to its effect on platelet function, there is a hesitation to utilize ketorolac postoperatively. The goal of this study is to analyze our experience utilizing ketorolac in patients who underwent major cranial vault remodeling (CVR) for craniosynostosis with an emphasis on postoperative hemorrhage and complications.
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White PF. Expanding role of multimodal analgesia in facilitating recovery after surgery: From fast-tracking to enhanced recovery. J Clin Anesth 2019; 55:105-107. [PMID: 30622044 DOI: 10.1016/j.jclinane.2018.12.050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 12/26/2018] [Indexed: 12/16/2022]
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Moulder JK, Boone JD, Buehler JM, Louie M. Opioid Use in the Postoperative Arena: Global Reduction in Opioids After Surgery Through Enhanced Recovery and Gynecologic Surgery. Clin Obstet Gynecol 2019; 62:67-86. [PMID: 30407228 DOI: 10.1097/grf.0000000000000410] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Enhanced recovery programs aim to reduce surgical stress to improve the patient perioperative experience. Through a combination of multimodal analgesia and maintaining a physiological state, postoperative recovery is improved. Many analgesic adjuncts are available that improve postoperative pain control and limit opioid analgesia requirements. Adjuncts are often used in combination, but different interventions may be incorporated for patient-specific and procedure-specific needs. Postoperative pain control can be optimized by continuing nonopioid adjuncts, and prescribing opioid analgesia to address breakthrough pain. Prescribing practices should balance optimizing pain relief, minimizing the risk of chronic pain, while limiting the potential for opioid misuse.
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Affiliation(s)
| | | | - Jason M Buehler
- Anesthesiology, University of Tennessee Medical Center Knoxville, Graduate School of Medicine, Knoxville, Tennessee
| | - Michelle Louie
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
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Creighton DW, Kumar AH, Grant SA. Perioperative Multimodal Pain Management: an Evidence-Based Update. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00340-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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12
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Use of Ketorolac After Outpatient Urogynecologic Surgery: A Randomized Control Trial. Female Pelvic Med Reconstr Surg 2019; 24:281-286. [PMID: 28914700 DOI: 10.1097/spv.0000000000000459] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Patient surveys highlight a prevalence of moderate to severe pain in the postanesthesia care unit. Multimodal analgesia has been promoted to improve this with fewer opioid-induced adverse effects. The aim of this study was to evaluate the opioid sparing and analgesic effect of postoperative intravenous (IV) ketorolac after outpatient transvaginal surgery. METHODS Forty patients were enrolled in this institutional review board-approved, randomized, double-blind, placebo-controlled study, to receive either 30 mg of IV ketorolac or IV saline placebo postoperatively. Pain was assessed by visual analog scale at timed intervals. Narcotic pain medication was provided upon request. Narcotic use was reassessed by telephone 5 to 7 days postoperatively. Categorical characteristics were compared by χ. Continuous variables were evaluated by Mann-Whitney U test. RESULTS Twenty patients were randomized to each group. Groups were similar in age, health, and operative factors. There was no significant difference in mean pain scores at any interval. The ketorolac group had a total morphine equivalent consumption median of 7.5 mg versus 4.0 mg for placebo, which was not significant (P = 0.17). Total use of narcotic pills postoperatively was equivalent (median, 5). There was no difference in postoperative nausea. One Dindo grade II complication was reported in the ketorolac group of a postoperative pelvic hematoma requiring transfusion. DISCUSSION Intravenous ketorolac administered after outpatient transvaginal surgery did not result in a reduction of pain scores or total morphine consumption. There was one Dindo grade II complication in the ketorolac group. Larger randomized control trials are needed to validate these findings.
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White PF. An alternative approach to solving the opioid epidemic: is there a role for non-pharmacologic analgesic therapies? Postgrad Med 2018; 131:1-5. [PMID: 30232921 DOI: 10.1080/00325481.2018.1520589] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Paul F White
- a Department of Anesthesiology & Pain Management , Cedars Sinai Medical Center , Los Angeles , CA , USA.,b The White Mountain Institute , The Sea Ranch , CA , USA
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Zhang B, Wang G, Liu X, Wang TL, Chi P. The Opioid-Sparing Effect of Perioperative Dexmedetomidine Combined with Oxycodone Infusion during Open Hepatectomy: A Randomized Controlled Trial. Front Pharmacol 2018; 8:940. [PMID: 29354054 PMCID: PMC5758592 DOI: 10.3389/fphar.2017.00940] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 12/11/2017] [Indexed: 12/17/2022] Open
Abstract
Background: A large right subcostal incision performed by open hepatectomy is associated with significant post-operative pain and distress. However, post-operative analgesia solutions still need to be devised. We investigated the effects of intra- and post-operative infusion of dexmedetomidine (Dex) combined with oxycodone during open hepatectomy. Methods: In this prospective, randomized and double-blind investigation, 52 patients undergoing selective open hepatectomy were divided into Dex group (DEX infusion at an initial loading dose of 0.5 μg⋅kg-1 over 10 min before intubation then adjusted to a maintenance dose of 0.3 μg⋅kg-1⋅h-1 until incision suturing) or control (Con) group (0.9% sodium chloride was administered). Patient-controlled analgesia was administered for 48 h after surgery (Dex group: 60 mg oxycodone and 360 μg DEX diluted to 120 ml and administered at a bolus dose of 2 ml, with 5 min lockout interval and a 1 h limit of 20 ml. Con group: 60 mg oxycodone alone with the same regimen). The primary outcome was post-operative oxycodone consumption. The secondary outcomes included requirement of narcotic and vasoactive drugs, hemodynamics, incidence of adverse effects, satisfaction, first exhaust time, pain intensity, and the Ramsay Sedation Scale. Results: Post-operative oxycodone consumption was significantly reduced in Dex group from 4 to 48 h after surgery (P < 0.05). Heart rate in Dex group was statistically decreased from T1 (just before intubation) to T6 (20 min after arriving at the post-anesthesia care unit), while mean arterial pressure was significantly decreased from T1 to T3 (during surgical incision; P < 0.05). The consumption of propofol and remifentanil were significantly decreased in Dex group (P < 0.05). The VAS scores at rest at 1, 4, and 8 h and with cough at 24, and 48 h after surgery were lower, the first exhaust time were shorter, satisfaction with pain control was statistically higher and the incidence of nausea and vomiting was less in Dex group than in Con group (all P < 0.05). Conclusion: The combination of DEX and oxycodone could reduce oxycodone consumption and the incidence of nausea and vomiting, enhance the analgesic effect, improves patient satisfaction and shorten the first exhaust time.
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Affiliation(s)
- Benhou Zhang
- Department of Anesthesiology, Xuan Wu Hospital, Capital Medical University, Beijing, China.,Department of Anesthesiology, Beijing You An Hospital, Capital Medical University, Beijing, China
| | - Guifang Wang
- Department of Medical Insurance, Beijing You An Hospital, Capital Medical University, Beijing, China
| | - Xiaopeng Liu
- Department of Anesthesiology, Beijing You An Hospital, Capital Medical University, Beijing, China
| | - Tian-Long Wang
- Department of Anesthesiology, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Ping Chi
- Department of Anesthesiology, Beijing You An Hospital, Capital Medical University, Beijing, China
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Tan P, Martin M, Shank N, Myers L, Wolfe E, Lindsey J, Metzinger S. A Comparison of 4 Analgesic Regimens for Acute Postoperative Pain Control in Breast Augmentation Patients. Ann Plast Surg 2017; 78:S299-S304. [PMID: 28459704 PMCID: PMC6686898 DOI: 10.1097/sap.0000000000001132] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Patients undergoing breast augmentation are treated with multiple combinations of medications for pain control including ketorolac, liposomal bupivacaine, bupivacaine, and intravenous and oral narcotics. There is no current consensus on the optimal combination; therefore, all are used at the discretion of the surgeon. METHODS This was a single-center, retrospective study. The total number of patients included was 132. Comparisons were made between 4 groups: bupivacaine only (B); bupivacaine and liposomal bupivacaine (BL); bupivacaine and liposomal bupivacaine plus intraoperative ketorolac (BLKi); and bupivacaine and liposomal bupivacaine plus postoperative ketorolac (BLKp). Average pain scores immediately postoperative and before discharge were recorded and correlated to percentage of patients who received narcotic in the post-anesthesia care unit (PACU). Additional end points noted were side effects including nausea and time spent in PACU postoperatively. RESULTS Those receiving intraoperative ketorolac had the lowest pain on discharge (P < 0.0001) and the lowest percentage of patients receiving narcotics (P = 0.009) out of all 4 groups. There was no significant difference between the 4 groups in terms of time spent in PACU, pain immediately after the procedure, or amount of antiemetic given. No bleeding complications were noted for those who did or did not receive ketorolac. CONCLUSIONS When given options for pain control in breast augmentation, intraoperative ketorolac should be considered, because its inclusion was significant in decreasing use of narcotics and pain upon discharge. Addition of other costly drugs such as liposomal bupivacaine may not provide additional benefit in the immediate postoperative setting for procedures with a short recovery period such as breast augmentation.
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Affiliation(s)
- Pamela Tan
- Tulane University Division of Plastic and Reconstructive Surgery, New Orleans, LA
| | - Morgan Martin
- Tulane University Division of Plastic and Reconstructive Surgery, New Orleans, LA
| | - Nina Shank
- Tulane University Division of Plastic and Reconstructive Surgery, New Orleans, LA
| | - Leann Myers
- Tulane University Department of Biostatistics and Bioinformatics, New Orleans, LA
| | - Emily Wolfe
- Tulane University Division of Plastic and Reconstructive Surgery, New Orleans, LA
| | - John Lindsey
- Tulane University Division of Plastic and Reconstructive Surgery, New Orleans, LA
| | - Stephen Metzinger
- Tulane University Division of Plastic and Reconstructive Surgery, New Orleans, LA
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16
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Välitalo PA, Kemppainen H, Kulo A, Smits A, van Calsteren K, Olkkola KT, de Hoon J, Knibbe CAJ, Allegaert K. Body weight, gender and pregnancy affect enantiomer-specific ketorolac pharmacokinetics. Br J Clin Pharmacol 2017; 83:1966-1975. [PMID: 28429492 DOI: 10.1111/bcp.13311] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 02/23/2017] [Accepted: 04/15/2017] [Indexed: 12/20/2022] Open
Abstract
AIMS Although ketorolac analgesia is linked only to the S-enantiomer, there is limited information on the stereo-selective pharmacokinetics of this agent. We studied the stereo-selective pharmacokinetics of ketorolac in a pooled dataset of two studies, with women at delivery and 4-5 months postpartum, and males and nonpregnant females. METHODS Nonlinear mixed-effect modelling was used to evaluate the stereo-selective pharmacokinetics of ketorolac tromethamine after a single intravenous injection immediately after delivery (n = 41), 4-5 months postpartum (n = 8, paired), and in male (n = 12) and nonpregnant female (n = 14) subjects. All of the males and six of the nonpregnant females were recruited from another study, in which they were undergoing blood sampling for 24 h. All remaining cases underwent blood sampling for 8 h. RESULTS For both the R- and S-enantiomers, body weight affected ketorolac clearance. In addition, clearance for both enantiomers was 36% [95% confidence interval (CI) 15%, 58%] higher in male than in female subjects of the same body weight, and 55% (95% CI 33%, 78%) higher in women at delivery than in nonpregnant women of the same body weight. Women at delivery also had a 27% (95% CI 8%, 46%) higher distribution volume than nonpregnant women. The proportional effects of the covariates were not significantly different for the two ketorolac enantiomers. CONCLUSIONS Besides the anticipated impact of body weight on clearance, R- and S-ketorolac clearance is increased in male subjects and in women at delivery. To reach an exposure equivalent to that in nonpregnant women, males should receive a 36% increased ketorolac dose and pregnant women a 55% increased dose, in addition to a dose adjustment by body weight.
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Affiliation(s)
- Pyry A Välitalo
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, the Netherlands
| | - Heidi Kemppainen
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, the Netherlands.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Aida Kulo
- Institute of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Anne Smits
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Kristel van Calsteren
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, University Hospitals Leuven, Leuven, Belgium
| | - Klaus T Olkkola
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jan de Hoon
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Belgium.,Center for Clinical Pharmacology, University Hospitals Leuven, Leuven, Belgium
| | - Catherijne A J Knibbe
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, the Netherlands.,Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Karel Allegaert
- Department of Development and Regeneration, University Hospitals Leuven, Leuven, Belgium.,Department of Pediatric Surgery and Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
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17
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An update on pain management for elderly patients undergoing ambulatory surgery. Curr Opin Anaesthesiol 2017; 29:674-682. [PMID: 27820738 DOI: 10.1097/aco.0000000000000396] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to provide an overview of the drugs and techniques used for multimodal postoperative pain management in the older population undergoing surgery in the ambulatory setting. RECENT FINDINGS Interest has grown in the possibility of adding adjuncts to a single shot nerve block in order to prolong the local anesthetic effect. The rapid and short-acting local anesthetics for spinal anesthesia are potentially beneficial for day-case surgery in the older population because of shorter duration of the motor block, faster recovery, and less transient neurologic symptoms. Another recent advance is the introduction of intravenous acetaminophen, which can rapidly achieve rapid peak plasma concentration (<15 min) following infusion and analgesic effect in ∼5 min with a duration of action up to 4 h. SUMMARY The nonopioid analgesic therapies will likely assume an increasingly important role in facilitating the recovery process and improving the satisfaction for elderly ambulatory surgery patients. Strategies to avoid the use of opioids and minimize opioid-related side-effects is an important advance as we expand on the use of ambulatory surgery for the aging population.
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18
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Kulo A, Smits A, Maleškić S, Van de Velde M, Van Calsteren K, De Hoon J, Verbesselt R, Deprest J, Allegaert K. Enantiomer-specific ketorolac pharmacokinetics in young women, including pregnancy and postpartum period. Bosn J Basic Med Sci 2017; 17:54-60. [PMID: 27968707 DOI: 10.17305/bjbms.2016.1515] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 09/27/2016] [Accepted: 09/27/2016] [Indexed: 11/16/2022] Open
Abstract
Racemic ketorolac clearance (CL) is significantly higher at delivery, but S-ketorolac disposition determines the analgesic effects. The aim of this study was to investigate the effect of pregnancy and postpartum period on enantiomer-specific (S and R) intravenous (IV) ketorolac pharmacokinetics (PKs). Data in women shortly following cesarean delivery (n=39) were pooled with data in a subgroup of these women that was reevaluated in the later postpartum period (postpartum group, n=8/39) and with eight healthy female volunteers. All women received single IV bolus of 30 mg ketorolac tromethamine. Five plasma samples were collected at 1, 2, 4, 6, and 8 hours and plasma concentrations were determined using high performance liquid chromatography. Enantiomer-specific PKs were calculated using PKSolver. Unpaired analysis showed that distribution volume at steady state (Vss, L/kg) for S- and R-ketorolac was significantly higher in women shortly following cesarean delivery (n=31) compared to postpartum group (n=8) or to healthy female volunteers (n=8). CL, CL to body weight, and CL to body surface area (CL/BSA) for S- and R-ketorolac were also significantly higher in women following delivery. In addition, S/R-ketorolac CL/BSA ratio was significantly higher at delivery. Paired PK analysis in eight women shortly following delivery and in postpartum group showed the same pattern. Finally, the simultaneous increase in CL and Vss resulted in similar estimates for elimination half-life in both unpaired and paired analysis. In conclusion, pregnancy affects S-, R-, and S/R-ketorolac disposition. This is of clinical relevance since S-ketorolac (analgesia) CL is even more increased compared to R-ketorolac CL, and S/R-ketorolac CL ratio is higher following delivery compared to postpartum period or to healthy female volunteers.
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Affiliation(s)
- Aida Kulo
- Center for Clinical Pharmacology, KU Leuven and University Hospitals Leuven, Leuven, Belgium; Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina.
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White PF. What are the advantages of non-opioid analgesic techniques in the management of acute and chronic pain? Expert Opin Pharmacother 2017; 18:329-333. [DOI: 10.1080/14656566.2017.1289176] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Paul F. White
- White Mountain Institute, The Sea Ranch, CA, USA
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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20
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Su S, Ren C, Zhang H, Liu Z, Zhang Z. The Opioid-Sparing Effect of Perioperative Dexmedetomidine Plus Sufentanil Infusion during Neurosurgery: A Retrospective Study. Front Pharmacol 2016; 7:407. [PMID: 27833559 PMCID: PMC5080288 DOI: 10.3389/fphar.2016.00407] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 10/13/2016] [Indexed: 12/20/2022] Open
Abstract
Background: Approximately 60% of patients experience moderate-to-severe pain after neurosurgery, which primarily occurs in the first 24–72 h. Despite this, improved postoperative analgesia solutions after neurosurgery have not yet been devised. This retrospective study was conducted to evaluate the effect of intra- and post-operative infusions of dexmedetomidine (DEX) plus sufentanil on the quality of postoperative analgesia in patients undergoing neurosurgery. Methods: One hundred and sixty-three post-neurosurgery patients were divided into two groups: Group D (DEX infusion at 0.5 μg·kg−1 for 10 min, then adjusted to 0.3 μg·kg−1·h−1 until incision suturing) and Group ND (no DEX infusion during surgery). Patient-controlled analgesia was administered for 72 h after surgery (Group D: sufentanil 0.02 μg·kg−1·h−1 plus DEX 0.02 μg·kg−1·h−1, Group ND: sufentanil 0.02 μg·kg−1·h−1) in this retrospective study. The primary outcome measure was postoperative sufentanil consumption. Hemodynamics, requirement of narcotic, and vasoactive drugs, recovery time and the incidence of concerning adverse effects were recorded. Pain intensity [Visual Analogue Scale (VAS)], Ramsay sedation scale (RSS) and Bruggemann comfort scale (BCS) were also evaluated at 1, 4, 8, 12, 24, 48, and 72 h after surgery. Results: Postoperative sufentanil consumption was significantly lower in Group D during the first 72 h after surgery (P < 0.05). Compared with Group ND, heart rate (HR) in Group D was significantly decreased from intubation to 20 min after arriving at post anesthesia care unit (PACU), while mean arterial pressure (MAP) in Group D was significantly decreased from intubation to 5 min after arriving at PACU (P < 0.05). The intraoperative requirements for sevoflurane, remifentanil, and fentanyl were approximately 35% less in Group D compared with Group ND. VAS at rest at 1, 4, and 8 h and with cough at 12, 24, 48, and 72 h after surgery were significantly lower in Group D (P < 0.05). Compared with Group ND, patients in Group D showed lower levels of overall incidence of tachycardia, hypertension, nausea, and vomiting (P < 0.05). There were no significant differences between the two groups in terms of baseline clinical characteristics, recovery time, RSS, and BCS (P > 0.05). Conclusions: DEX (0.02 μg·kg−1·h−1) plus sufentanil (0.02 μg·kg−1·h−1) could reduce postoperative opioid consumption and concerning adverse adverse effects, while improving pain scores. However, it did not influence RSS and BCS during the first 72 h after neurosurgery.
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Affiliation(s)
- Shiyu Su
- Department of Anaesthesiology, The Fifth People's Hospital of Jinan Jinan, China
| | - Chunguang Ren
- Department of Anaesthesiology, Liaocheng People's Hospital Liaocheng, China
| | - Hongquan Zhang
- Department of Anaesthesiology, Liaocheng People's Hospital Liaocheng, China
| | - Zhong Liu
- Department of Anaesthesiology, Liaocheng People's Hospital Liaocheng, China
| | - Zongwang Zhang
- Department of Anaesthesiology, Liaocheng People's Hospital Liaocheng, China
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21
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22
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Single-dose systemic acetaminophen to prevent postoperative pain: a meta-analysis of randomized controlled trials. Clin J Pain 2015; 31:86-93. [PMID: 25485955 DOI: 10.1097/ajp.0000000000000081] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The effect of a single-dose systemic acetaminophen to treat postoperative pain has been previously quantified, but the effect of systemic acetaminophen to prevent postoperative pain is currently not well defined. The preventive analgesic effect of acetaminophen has yet to be quantified in a meta-analysis. The objective of the current investigation was to evaluate the effect of a single preventive dose of systemic acetaminophen on postoperative pain outcomes. MATERIALS AND METHODS A wide search was performed to identify randomized controlled trials that evaluated the effects of a single dose of systemic acetaminophen on pain outcomes in a large variety of surgical procedures. Meta-analysis was performed using a random-effect model. RESULTS Eleven randomized clinical trials evaluating 740 patients were included in the analysis. The weighted mean difference (95% confidence interval [CI]) of the combined effects favored acetaminophen over control for early pain at rest (≤4 h, -1.1 (-2.0 to -0.2)) and early pain at movement (24 h, -1.9 (-2.8 to -1.0)) Postoperative opioid consumption was decreased in the systemic acetaminophen group compared with control. Weighted mean difference (95% CI) of -9.7 (-13.0 to -6.4) mg morphine intravenous equivalents systemic acetaminophen also reduced postoperative nausea and vomiting compared with control, odds ratio (95% CI) of 0.25 (0.13 to 0.47), numbers needed to treat (95% CI)=3.3 (2.3 to 5.9). DISCUSSION Systemic acetaminophen, when used as a single-dose preventive regimen, is an effective intervention to reduce postoperative pain. It also reduces postoperative nausea and/or vomiting. Doses >1 g were not associated with greater reduction in pain outcomes.
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23
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Ren C, Chi M, Zhang Y, Zhang Z, Qi F, Liu Z. Dexmedetomidine in Postoperative Analgesia in Patients Undergoing Hysterectomy: A CONSORT-Prospective, Randomized, Controlled Trial. Medicine (Baltimore) 2015; 94:e1348. [PMID: 26266386 PMCID: PMC4616704 DOI: 10.1097/md.0000000000001348] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Both dexmedetomidine and sufentanil modulate spinal analgesia by different mechanisms, and yet no human studies are available on their combination for analgesia during the first 72 hours after abdominal hysterectomy.This CONSORT-prospective, randomized, double-blinded, controlled trial sought to evaluate the safety and efficacy of the combination of dexmedetomidine and sufentanil in intravenous patient-controlled analgesia (PCA) for 72 hours after abdominal hysterectomy.Ninety women undergoing total abdominal hysterectomy were divided into 3 equal groups that received sufentanil (Group C; 0.02 μg/kg/h), sufentanil plus dexmedetomidine (Group D1; 0.02 μg/kg/h, each), or sufentanil (0.02 μg/kg/h) plus dexmedetomidine (0.05 μg/kg/h) (Group D2) for 72 hours after surgery in this double-blinded, randomized study. The primary outcome measure was the postoperative sufentanil consumption, whereas the secondary outcome measures were pain intensity (visual analogue scale), requirement of narcotic drugs during the operation, level of sedation, Bruggrmann comfort scale, and concerning adverse effects.The postoperative sufentanil consumption was significantly lower in Groups D1 and D2 than in Group C during the observation period (P < 0.05), but lower in Group D2 than in Group D1 at 24, 48, and 72 hours after surgery (P < 0.05). The heart rate after intubation and incision was lower in Groups D1 and D2 than in Group C (P < 0.05). On arrival at the recovery room, Groups D1 and D2 had lower mean blood pressure than Group C (P < 0.05). The intraoperative requirement of sevoflurane was 30% lesser in Groups D1 and D2 than in Group C. The sedation levels were greater in Groups D1 and D2 during the first hour (P < 0.05). Compared with Groups C and D1, Group D2 showed lower levels of the overall incidence of nausea and vomiting (P < 0.05).Among the tested PCA options, the addition of dexmedetomidine (0.05 μg/kg/h) and sufentanil (0.02 μg/kg/h) showed better analgesic effect and greater patient satisfaction without other clinically relevant side effects for patients undergoing hysterectomy during the first 72 hours after abdominal hysterectomy.
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Affiliation(s)
- Chunguang Ren
- From the Department of Anesthesiology (FQ), Qilu Hospital of Shandong University, Jinan; and Department of Anesthesiology (CR, MC, YZ, ZZ, ZL), Liaocheng People's Hospital, Liaocheng, PR China
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24
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Affiliation(s)
- Paul F White
- White Mountain Institute, The Sea Ranch, CA, USA
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25
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Kim SY, Huh KH, Roh YH, Oh YJ, Park J, Choi YS. Nefopam as an adjunct to intravenous patient-controlled analgesia after renal transplantation: a randomised trial. Acta Anaesthesiol Scand 2015; 59:1068-75. [PMID: 25903742 DOI: 10.1111/aas.12519] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 10/04/2014] [Accepted: 02/24/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Nefopam has been used as an adjuvant to opioid analgesia after operation. We investigated the efficacy of nefopam as an adjunct to fentanyl-based intravenous patient-controlled analgesia (IV PCA) on post-operative pain relief in patients undergoing renal transplantation. METHODS Ninety-eight patients undergoing elective renal transplantation were randomised into two groups: nefopam or control groups. The former received nefopam (160 mg in 200 ml at a rate of 4 ml/h) whereas the latter received normal saline during the first 48 h after reperfusion of grafted kidney. Pain intensity scores, cumulative dose of fentanyl, and the incidence of adverse events were assessed at 1, 6, 12, 24, and 48 h post-operatively. Serum creatinine and estimated glomerular filtration rate were evaluated on post-operative days 1, 2, 4, and 7. RESULTS The cumulative fentanyl consumption during the first 48 h after operation was 19% less in the nefopam group than that in the control group (1005 ± 344 μg vs. 1246 ± 486 μg, mean ± SD; P = 0.006). Pain intensity scores at rest and on coughing were significantly lower in the nefopam group throughout the first 12 and 48 h after operation, respectively. Adverse events and early graft function were comparable between the groups, except a significantly lower incidence of drowsiness observed in the nefopam group (4% vs. 21%, P = 0.027). CONCLUSION In combination with fentanyl PCA, nefopam reduced post-operative fentanyl consumption with superior analgesia after renal transplantation.
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Affiliation(s)
- S. Y. Kim
- Department of Anaesthesiology and Pain Medicine; Yonsei University College of Medicine; Seoul Korea
- Anaesthesia and Pain Research Institute; Yonsei University College of Medicine; Seoul Korea
| | - K. H. Huh
- Department of Surgery; Yonsei University College of Medicine; Seoul Korea
| | - Y. H. Roh
- Department of Research Affairs; Biostatistics Collaboration Unit; Severance Hospital; Yonsei University College of Medicine; Seoul Korea
| | - Y. J. Oh
- Department of Anaesthesiology and Pain Medicine; Yonsei University College of Medicine; Seoul Korea
- Anaesthesia and Pain Research Institute; Yonsei University College of Medicine; Seoul Korea
| | - J. Park
- Department of Anaesthesiology and Pain Medicine; Yonsei University College of Medicine; Seoul Korea
| | - Y. S. Choi
- Department of Anaesthesiology and Pain Medicine; Yonsei University College of Medicine; Seoul Korea
- Anaesthesia and Pain Research Institute; Yonsei University College of Medicine; Seoul Korea
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Determination of Racemic Ketorolac, Ketorolac Enantiomers and Their Metabolites in Human Plasma and Urine by LC–UV, Applied in Clinical Study During and After Pregnancy. Chromatographia 2014. [DOI: 10.1007/s10337-014-2670-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vadivelu N, Gowda AM, Urman RD, Jolly S, Kodumudi V, Maria M, Taylor R, Pergolizzi JV. Ketorolac tromethamine - routes and clinical implications. Pain Pract 2014; 15:175-93. [PMID: 24738596 DOI: 10.1111/papr.12198] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 01/27/2014] [Indexed: 11/29/2022]
Abstract
Opioids have long been used for analgesic purposes for a wide range of procedures. However, the binding of these drugs to opiate receptors has created various challenges to the clinician due to unfavorable side effect profiles and the potential for tolerance and abuse. In 1989, ketorolac became an approved nonsteroidal inflammatory drug (NSAID) for injectable use as an analgesic. Over the last 20 years, numerous studies have been conducted involving ketorolac. These studies have provided additional information about various routes of administration and their effect on the efficacy and the side effect profile of ketorolac. Moreover, ketorolac has been compared with several widely used analgesics. This review evaluates both the potential benefits and potential drawbacks of ketorolac generally, and specifically discusses routes of administration, including their advantages and disadvantages when compared to several traditional analgesics in both inpatient and outpatient settings.
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Affiliation(s)
- Nalini Vadivelu
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
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Tumber PS. Optimizing perioperative analgesia for the complex pain patient: medical and interventional strategies. Can J Anaesth 2013; 61:131-40. [PMID: 24242954 DOI: 10.1007/s12630-013-0073-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 10/25/2013] [Indexed: 12/11/2022] Open
Affiliation(s)
- Paul S Tumber
- University Health Network and Wasser Pain Centre, Mt. Sinai Hospital, University of Toronto, Toronto, ON, Canada,
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30
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Gerstein NS, Gerstein WH, Carey MC, Kong Lam NC, Ram H, Spassil NR, Schulman PM. The thrombotic and arrhythmogenic risks of perioperative NSAIDs. J Cardiothorac Vasc Anesth 2013; 28:369-78. [PMID: 24125630 DOI: 10.1053/j.jvca.2013.05.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Indexed: 01/12/2023]
Affiliation(s)
| | - Wendy Hawks Gerstein
- Department of Internal Medicine, Raymond G. Murphy VA Medical Center, Albuquerque, NM
| | | | | | - Harish Ram
- Department of Anesthesiology, University of New Mexico, Albuquerque, NM
| | | | - Peter Mark Schulman
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR
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Magni G, La Rosa I, Melillo G, Abeni D, Hernandez H, Rosa G. Intracranial hemorrhage requiring surgery in neurosurgical patients given ketorolac: a case-control study within a cohort (2001-2010). Anesth Analg 2013; 116:443-7. [PMID: 23302965 DOI: 10.1213/ane.0b013e3182746eda] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Ketorolac tromethamine (ketorolac) is a nonsedating drug with potent analgesic and moderate anti-inflammatory activity, which does not increase the sedation level. The safety of ketorolac with respect to risk of bleeding has been demonstrated in large numbers of patients undergoing general surgery, yet comparable safety data for neurosurgical patients are lacking. We studied the risk of symptomatic bleeding requiring surgery in patients undergoing elective neurosurgical procedures who received ketorolac as analgesic therapy. METHODS We established a cohort of patients who had elective intracranial procedures from January 2001 to August 2010 (excluding patients with urgent surgery, coagulopathy, history of anticoagulant or nonsteroidal, anti-inflammatory drug therapy) and verified the occurrence of postcraniotomy intracranial hemorrhage (ICH; detected by computed tomography and requiring surgery) in patients who received or did not receive ketorolac. Then, to control for potential confounders, we conducted a "nested" case-control study within the cohort: cases were defined as patients with ICH; controls were patients without ICH matched in a 2:1 ratio. RESULTS The cohort included 4086 craniotomy patients (mean age, 52.4±14.3 years, 2124 male, 52%). Of the 1571 patients who received ketorolac (mean dosage, 50±15 mg/d), 8 (0.5%) suffered ICH; of the 2515 patients who did not receive ketorolac, 35 (1.3%) had ICH (relative risk, 0.37; 95% confidence interval, 0.17-0.79; P=0.007). In the nested case-control study, the adjusted odds ratio for ketorolac administration between the 2 groups was 1.09 (95% confidence interval, 0.35-3.44; P=0.88). CONCLUSION Although the adjusted estimate for risk of symptomatic bleeding requiring surgery and ketorolac use is very close to the null effect, it may be not reproducible, and the width of the confidence interval is not conclusive evidence of the safety of ketorolac after elective neurosurgical procedures.
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Affiliation(s)
- Giuseppina Magni
- Department of Anesthesia and Intensive Care, Policlinico Umberto 1, University of Rome, La Sapienza, Rome, Italy.
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Retsky M, Demicheli R, Hrushesky WJM, Forget P, De Kock M, Gukas I, Rogers RA, Baum M, Sukhatme V, Vaidya JS. Reduction of breast cancer relapses with perioperative non-steroidal anti-inflammatory drugs: new findings and a review. Curr Med Chem 2013; 20:4163-76. [PMID: 23992307 PMCID: PMC3831877 DOI: 10.2174/09298673113209990250] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Revised: 03/26/2013] [Accepted: 03/31/2013] [Indexed: 12/21/2022]
Abstract
To explain a bimodal pattern of hazard of relapse among early stage breast cancer patients identified in multiple databases, we proposed that late relapses result from steady stochastic progressions from single dormant malignant cells to avascular micrometastases and then on to growing deposits. However in order to explain early relapses, we had to postulate that something happens at about the time of surgery to provoke sudden exits from dormant phases to active growth and then to detection. Most relapses in breast cancer are in the early category. Recent data from Forget et al. suggest an unexpected mechanism. They retrospectively studied results from 327 consecutive breast cancer patients comparing various perioperative analgesics and anesthetics in one Belgian hospital and one surgeon. Patients were treated with mastectomy and conventional adjuvant therapy. Relapse hazard updated Sept 2011 are presented. A common Non-Steroidal Anti-Inflammatory Drug (NSAID) analgesic used in surgery produced far superior disease-free survival in the first 5 years after surgery. The expected prominent early relapse events in months 9-18 are reduced 5-fold. If this observation holds up to further scrutiny, it could mean that the simple use of this safe, inexpensive and effective anti-inflammatory agent at surgery might eliminate early relapses. Transient systemic inflammation accompanying surgery could facilitate angiogenesis of dormant micrometastases, proliferation of dormant single cells, and seeding of circulating cancer stem cells (perhaps in part released from bone marrow) resulting in early relapse and could have been effectively blocked by the perioperative anti-inflammatory agent.
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Affiliation(s)
- Michael Retsky
- Harvard School of Public Health, BLDG I, Rm 1311, 665 Huntington, Ave, Boston, MA 02115, USA.
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Kulo A, van de Velde M, van Calsteren K, Smits A, de Hoon J, Verbesselt R, Deprest J, Allegaert K. Pharmacokinetics of intravenous ketorolac following caesarean delivery. Int J Obstet Anesth 2012; 21:334-8. [DOI: 10.1016/j.ijoa.2012.06.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Revised: 05/22/2012] [Accepted: 06/07/2012] [Indexed: 11/29/2022]
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White PF, White LM, Monk T, Jakobsson J, Raeder J, Mulroy MF, Bertini L, Torri G, Solca M, Pittoni G, Bettelli G. Perioperative care for the older outpatient undergoing ambulatory surgery. Anesth Analg 2012; 114:1190-215. [PMID: 22467899 DOI: 10.1213/ane.0b013e31824f19b8] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
As the number of ambulatory surgery procedures continues to grow in an aging global society, the implementation of evidence-based perioperative care programs for the elderly will assume increased importance. Given the recent advances in anesthesia, surgery, and monitoring technology, the ambulatory setting offers potential advantages for elderly patients undergoing elective surgery. In this review article we summarize the physiologic and pharmacologic effects of aging and their influence on anesthetic drugs, the important considerations in the preoperative evaluation of elderly outpatients with coexisting diseases, the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and offer recommendations regarding the management of common postoperative side effects (including delirium and cognitive dysfunction, fatigue, dizziness, pain, and gastrointestinal dysfunction) after ambulatory surgery. We conclude with a discussion of future challenges related to the growth of ambulatory surgery practice in this segment of our surgical population. When information specifically for the elderly population was not available in the peer-reviewed literature, we drew from relevant information in other ambulatory surgery populations.
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Affiliation(s)
- Paul F White
- Department of Anesthesia, Cedars-Sinai Medical Center, Los Angeles, California, USA.
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