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Ren Y, Nie X, Zhang F, Ma Y, Hua L, Zheng T, Xu Z, Gao J, Zhang J. Ultrasound-guided erector spinae plane block versus thoracic epidural block for postoperative analgesia in pediatric Nuss surgery: a randomized noninferiority trial. J Anesth 2024; 38:600-608. [PMID: 38829406 DOI: 10.1007/s00540-024-03354-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 05/24/2024] [Indexed: 06/05/2024]
Abstract
PURPOSE Thoracic epidural anesthesia (TEA) is often used for analgesia after thoracic surgery. Erector spinae plane block (ESPB) has been proposed to provide adequate analgesia. We hypothesized that ESPB would be noninferior to TEA as a part of multimodal analgesia in pediatric patients undergoing the Nuss procedure. METHODS Patients aged 7-18 years and scheduled for the Nuss procedure were randomly allocated to receive bilateral single-shot ESPB or TEA and a multimodal analgesic regimen including parent-controlled intravenous analgesia (PCIA). At 6 h, 12 h, 18 h, and 24 h postoperatively, pain was evaluated using the numeric rating scale (NRS) and opioid consumption was assessed by counting the number of PCIA boluses. The joint primary outcomes were the average pain score and opioid consumption at 24 h after surgery. The secondary outcomes were the NRS scores and the number of opioid boluses administered at different postoperative time points, adverse events, and recovery quality. RESULTS Three hundred patients underwent randomization, and 286 received ESPB (147 patients) or TEA (139 patients). At 24 h postoperatively, ESPB was noninferior to TEA in terms of the average NRS score (mean difference, - 0.1, 95% confidence interval [CI], - 0.3-0.1, margin = 1, P for noninferiority < 0.001) and the number of opioid boluses administered (mean difference, - 1.1, 95% CI, - 2.8-0.6, margin = 7, P for noninferiority < 0.001). Adverse events and patient recovery were comparable between groups. CONCLUSIONS The results demonstrate that combined with a multimodal analgesia, ESPB provides noninferior analgesia compared to TEA with respect to pain score and opioid consumption among pediatric patients undergoing the Nuss procedure.
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Affiliation(s)
- Yi Ren
- Department of Anesthesiology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56, South Lishi Road, Beijing, 100045, China
| | - Xiaolu Nie
- Center for Clinical Epidemiology and Evidence-Based Medicine, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, 100045, China
| | - Fuzhou Zhang
- Department of Anesthesiology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56, South Lishi Road, Beijing, 100045, China
| | - Yangwei Ma
- Department of Anesthesiology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56, South Lishi Road, Beijing, 100045, China
| | - Lei Hua
- Department of Anesthesiology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56, South Lishi Road, Beijing, 100045, China
| | - Tiehua Zheng
- Department of Anesthesiology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56, South Lishi Road, Beijing, 100045, China
| | - Zenghua Xu
- Department of Anesthesiology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56, South Lishi Road, Beijing, 100045, China
| | - Jia Gao
- Department of Anesthesiology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56, South Lishi Road, Beijing, 100045, China
| | - Jianmin Zhang
- Department of Anesthesiology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56, South Lishi Road, Beijing, 100045, China.
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Pantalone KM, Rogen B, Zirm P, Xiao H, Bena J, Barnard G, Borukh E, Peechakara S, Griebeler ML, Young JB, Burguera B. An Obesity-Centric Approach with and Without Anti-Obesity Medications Compared to the Usual-Care Approach to Management of Patients with Obesity and Type 2 Diabetes in an Employer Setting: A Pragmatic Randomized Controlled Trial (EMPOWER-T2D). Diabetes Ther 2024; 15:1201-1214. [PMID: 38573466 PMCID: PMC11043250 DOI: 10.1007/s13300-024-01563-0] [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: 02/05/2024] [Accepted: 03/04/2024] [Indexed: 04/05/2024] Open
Abstract
INTRODUCTION This study aimed to compare weight loss and glycated hemoglobin (HbA1c)-reduction effects of two obesity-centric, weight-loss management approaches (with or without anti-obesity medication) versus usual glucose-centric care in patients with obesity and type 2 diabetes. METHODS Single-center, randomized, open-label, 3-armed, parallel-group, pragmatic, noninferiority trial, July 2020 to August 2022. Adults enrolled in the Cleveland Clinic Employee Health Plan (body mass index [BMI] ≥ 30 kg/m2, type 2 diabetes diagnosis, HbA1c > 7.5%) were randomized to usual glucose-centric management ("Usual-Care" group) or one of two obesity-centric management strategies: participation in a weight management program plus anti-obesity medication ("WMP + AOM" group), or WMP participation without anti-obesity medication ("WMP-Only" group). Primary endpoints were changes in weight and HbA1c, baseline to month 12. RESULTS Due to enrollment and retention challenges, largely related to COVID-19, only 74/300 planned participants were randomized and the study was terminated early. Participants were predominantly female (59%), median (interquartile range [IQR]) age 53.5 (47, 60) years, 68% white, with baseline median (IQR) BMI and HbA1c of 37.4 (34.2, 42.7) kg/m2 and 8.8% (7.9%, 10.4%), respectively. At month 12, mean (90% confidence interval [CI]) percentage weight change in the Usual-Care, WMP-Only, and WMP + AOM groups was - 4.5% (- 6.5%, - 2.5%), - 6.7% (- 8.7%, - 4.7%), and - 8.7% (- 10.7%, - 6.8%), respectively; mean (90% CI) HbA1c change was - 1.7% (- 2.1%, - 1.2%), - 2.2% (- 2.7%, - 1.8%), and - 2.2% (- 2.6%, - 1.7%), respectively. WMP + AOM was superior to Usual-Care for weight change (P = 0.02); both WMP + AOM and WMP-Only were noninferior (P ≤ 0.01) to Usual-Care for change in HbA1c. CONCLUSIONS Including anti-obesity medication was associated with superior weight loss with noninferior HbA1c reductions, warranting further evaluation in larger study populations of obesity-focused approaches to type 2 diabetes management. Graphical abstract available for this article. TRIAL REGISTRATION ClinicalTrials.gov NCT03799198.
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Affiliation(s)
- Kevin M Pantalone
- Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic, Cleveland, OH, USA
| | - Bruce Rogen
- Employee Health Plan, Cleveland Clinic, Cleveland, OH, USA
| | - Patty Zirm
- Employee Health Plan, Cleveland Clinic, Cleveland, OH, USA
| | - Huijun Xiao
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - James Bena
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Gretchen Barnard
- Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic, Cleveland, OH, USA
| | - Elena Borukh
- Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic, Cleveland, OH, USA
| | - Seenia Peechakara
- Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic, Cleveland, OH, USA
| | - Marcio L Griebeler
- Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic, Cleveland, OH, USA
| | - James B Young
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, OH, USA
| | - Bartolome Burguera
- Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic, Cleveland, OH, USA.
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Kumar S, Kesavan R, Sistla SC, Penumadu P, Natarajan H, Nair S, Chakradhara Rao US, Venkatesan V, Kundra P. Impact of Genetic Variants on Postoperative Pain and Fentanyl Dose Requirement in Patients Undergoing Major Breast Surgery: A Candidate Gene Association Study. Anesth Analg 2023; 137:409-417. [PMID: 36538471 DOI: 10.1213/ane.0000000000006330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Postoperative analgesia is crucial for the early and effective recovery of patients undergoing surgery. Although postoperative multimodal analgesia is widely practiced, opioids such as fentanyl are still one of the best analgesics. The analgesic response of fentanyl varies widely among individuals, probably due to genetic and nongenetic factors. Among genetic factors, single nucleotide polymorphisms (SNPs) may influence its analgesic response by altering the structure or function of genes involved in nociceptive, fentanyl pharmacodynamic, and pharmacokinetic pathways. Thus, it is necessary to comprehensively ascertain if the SNPs present in the aforementioned pathways are associated with interindividual differences in fentanyl requirement. In this study, we evaluated the association between 10 candidate SNPs in 9 genes and 24-hour postoperative fentanyl dose (primary outcome) and also with postoperative pain scores and time for first analgesia (secondary outcomes). METHODS A total of 257 South Indian women, aged 18-70 years, with American Society of Anesthesiologists (ASA) physical status I-III, undergoing major breast surgery under general anesthesia, were included in the study. Patients were genotyped for candidate SNPs using real-time polymerase chain reaction. All patients received a standardized intravenous fentanyl infusion through a patient-controlled analgesic (PCA) pump, and the 24-hour postoperative fentanyl dose requirement was measured using PCA. RESULTS The median 24-hour postoperative fentanyl requirement was higher in rs1799971 carriers (G/G versus A/A + A/G-620 μg [500-700] vs 460 μg [400-580]) with a geometric mean (GM) ratio of 1.91 (95% confidence interval [CI], 1.071-1.327). The median 24-hour pain scores were higher in rs4680 carriers (A/G + A/A versus G/G-34 [30-38] vs 31 [30-38]) with a GM ratio of 1.059 (95% CI, 1.018-1.101) and were lower in rs1045642 carriers (A/A + A/G versus G/G-34 [30-38] vs 30 [30-34]) with a GM ratio of 0.936 (95% CI, 0.889-0.987). The median time for first analgesic was lower in rs734784 carriers [C/C versus T/T + C/T-240 minutes (180-270) vs 240 minutes (210-270)] with a GM ratio of 0.902 (95% CI, 0.837-0.972). Five of 9 clinical factors, namely, history of diabetes, hypertension, hypothyroidism, anesthesia duration, and intraoperative fentanyl requirement were associated with different outcomes individually ( P < .05) and were used to adjust the respective associations. CONCLUSIONS The SNP opioid receptor mu-1 ( OPRM1 ) (rs1799971) was associated with higher postoperative fentanyl requirement in South Indian patients undergoing major breast surgery. Twenty-four hour postoperative pain scores were higher in catechol-O-methyl transferase ( COMT ) (rs4680) carriers and lower in ATP binding cassette subfamily B member 1 ( ABCB1 ) (rs1045642) carriers, whereas time for first analgesic was lower in potassium channel subunit 1 ( KCNS1 ) (rs734784) carriers. However, these exploratory findings must be confirmed in a larger study.
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Affiliation(s)
- Shathish Kumar
- From the Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Ramasamy Kesavan
- From the Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Sarath Chandra Sistla
- Department of General Surgery, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India; Departments of
| | | | - Harivenkatesh Natarajan
- From the Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | | | - Uppugunduri S Chakradhara Rao
- Faculty of Medicine, CANSEARCH Research Platform in Pediatric Oncology and Hematology, Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, Geneva, Switzerland
| | - Vasuki Venkatesan
- Indian Council of Medical Research-Vector Control Research Centre, Department of Health Research, Ministry of Health & Family Welfare, GOI, Puducherry, India
| | - Pankaj Kundra
- Department of Anaesthesiology, JIPMER, Puducherry, India
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Xu ZZ, Li X, Chen BL, Yang KL, Wang J, Li XY, Zhang H, Wang DX. A randomised controlled trial of the non-inferiority of erector spinae plane block vs. thoracic paravertebral block for laparoscopic nephro-ureterectomy. Anaesthesia 2023; 78:442-448. [PMID: 36599621 DOI: 10.1111/anae.15959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 01/06/2023]
Abstract
Erector spinae plane block and paravertebral block can provide analgesia for abdominal surgery. It is unclear whether erector spinae block is inferior to paravertebral block. We aimed to determine whether sufentanil dose and pain intensity (11-point scale) to 24 h after erector spinae block exceeded those after paravertebral block by no more than 5 μg and 1 point, respectively. We randomly allocated 166 adults to 0.4 ml.kg-1 ropivacaine 0.375% before scheduled laparoscopic nephroureterectomy, 83 each to erector spinae or paravertebral injection. We measured incision pain and intra-abdominal pain at rest and on movement 0.5 h, 2 h, 6 h, 18 h, 24 h and 48 h after surgery. Median (IQR [range]) cumulative sufentanil dose after erector spinae block was 15 (5-30 [0-105]) μg vs. 20 (10-50 [0-145]) μg after paravertebral block, median (95%CI) difference 5 μg (0-10), erector spinae non-inferiority p < 0.001. Median (IQR [range]) pain were 1.5 (1.0-2.0 [0.0-5.3]) after erector spinae block vs. 2.0 (1.0-2.5 [0.0-6.0]) after paravertebral block, median (95% CI) difference 0.3 (0.0-0.5), erector spinae non-inferiority p < 0.001. Adverse events did not differ between groups. Erector spinae block analgesia was not inferior to paravertebral block analgesia after laparoscopic nephroureterectomy.
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Affiliation(s)
- Z-Z Xu
- Department of Anaesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - X Li
- Department of Anaesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - B-L Chen
- Department of Anaesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - K-L Yang
- Department of Urology, Peking University First Hospital, Beijing, China
| | - J Wang
- Department of Anaesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - X-Y Li
- Department of Biostatistics, Peking University First Hospital, Beijing, China
| | - H Zhang
- Department of Anaesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - D-X Wang
- Department of Anaesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
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Son J, Jeong H, Yun J, Jeon YJ, Lee J, Shin S, Kim HK, Choi YS, Kim J, Zo JI, Shim YM, Cho JH, Ahn HJ. Enhanced Recovery After Surgery Program and Opioid Consumption in Pulmonary Resection Surgery: A Retrospective Observational Study. Anesth Analg 2023; 136:719-727. [PMID: 36753445 DOI: 10.1213/ane.0000000000006385] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Pulmonary resection surgery causes severe postoperative pain and usually requires opioid-based analgesia, particularly in the early postoperative period. However, the administration of large amounts of opioids is associated with various adverse events. We hypothesized that patients who underwent pulmonary resection under an enhanced recovery after surgery (ERAS) program consumed fewer opioids than patients who received conventional treatment. METHODS A total of 2147 patients underwent pulmonary resection surgery between August 2019 and December 2020. Two surgeons (25%) at our institution implemented the ERAS program for their patients. After screening, the patients were divided into the ERAS and conventional groups based on the treatment they received. The 2 groups were then compared after the stabilized inverse probability of treatment weighting. The primary end point was the total amount of opioid consumption from surgery to discharge. The secondary end points included daily average and highest pain intensity scores during exertion, opioid-related adverse events, and clinical outcomes, such as length of intensive care unit (ICU) stay, hospital stay, and postoperative complication grade defined by the Clavien-Dindo classification. Additionally, the number of patients discharged without opioids prescription was assessed. RESULTS Finally, 2120 patients were included in the analysis. The total amount of opioid consumption (median [interquartile range]) after surgery until discharge was lower in the ERAS group (n = 260) than that in the conventional group (n = 1860; morphine milligram equivalents, 44 [16-122] mg vs 208 [146-294] mg; median difference, -143 mg; 95% CI, -154 to -132; P < .001). The number of patients discharged without opioids prescription was higher in the ERAS group (156/260 [60%] vs 329/1860 [18%]; odds ratio, 7.0; 95% CI, 5.3-9.3; P < .001). On operation day, both average pain intensity score during exertion (3.0 ± 1.7 vs 3.5 ± 1.8; mean difference, -0.5; 95% CI, -0.8 to -0.3; P < .001) and the highest pain intensity score during exertion (5.5 ± 2.1 vs 6.4 ± 1.7; mean difference, -0.8; 95% CI, -1.0 to -0.5; P < .001) were lower in the ERAS group than in the conventional group. There were no significant differences in the length of ICU stay, hospital stay, or Clavien-Dindo classification grade. CONCLUSIONS Patients who underwent pulmonary resection under the ERAS program consumed fewer opioids than those who received conventional management while maintaining no significant differences in clinical outcomes.
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Affiliation(s)
- Jongbae Son
- From the Departments of Thoracic and Cardiovascular Surgery
| | - Heejoon Jeong
- Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeonghee Yun
- From the Departments of Thoracic and Cardiovascular Surgery
| | | | - Junghee Lee
- From the Departments of Thoracic and Cardiovascular Surgery
| | - Sumin Shin
- From the Departments of Thoracic and Cardiovascular Surgery
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Ewha Womans University, Mokdong Hospital, Seoul, South Korea
| | - Hong Kwan Kim
- From the Departments of Thoracic and Cardiovascular Surgery
| | - Yong Soo Choi
- From the Departments of Thoracic and Cardiovascular Surgery
| | - Jhingook Kim
- From the Departments of Thoracic and Cardiovascular Surgery
| | - Jae Ill Zo
- From the Departments of Thoracic and Cardiovascular Surgery
| | - Young Mog Shim
- From the Departments of Thoracic and Cardiovascular Surgery
| | - Jong Ho Cho
- From the Departments of Thoracic and Cardiovascular Surgery
| | - Hyun Joo Ahn
- Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Cummings LC, Liang C, Mascha EJ, Saager L, Smith ZL, Bhavani S, Vargo JJ, Cummings KC. Incidence of sedation-related adverse events during ERCP with anesthesia assistance: a multicenter observational study. Gastrointest Endosc 2022; 96:269-281.e1. [PMID: 35381231 DOI: 10.1016/j.gie.2022.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 03/25/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Anesthesia assistance is commonly used for ERCP. General anesthesia (GA) may provide greater airway protection but may lead to hypotension. We aimed to compare GA versus sedation without planned intubation (SWPI) on the incidence of hypoxemia and hypotension. We also explored risk factors for conversion from SWPI to GA. METHODS This observational study used data from the Multicenter Perioperative Outcomes Group. Adults with American Society of Anesthesiologists physical status class I to IV undergoing ERCP between 2006 and 2019 were included. We compared GA and SWPI on incidence of hypoxemia (oxygen saturation <90% for ≥3 minutes) and hypotension (mean arterial pressure <65 mm Hg for ≥5 minutes) using joint hypothesis testing. The association between anesthetic approach and outcomes was assessed using logistic regression. The noninferiority delta for hypoxemia and hypotension was an odds ratio of 1.20. One approach was deemed better if it was noninferior on both outcomes and superior on at least 1 outcome. To explore risk factors associated with conversion from SWPI to GA, we constructed a logistic regression model. RESULTS Among 61,735 cases from 42 institutions, 38,830 (63%) received GA and 22,905 (37%) received SWPI. The GA group had 1.27 times (97.5% confidence interval, 1.19-1.35) higher odds of hypotension but .71 times (97.5% confidence interval, .63-.80) lower odds of hypoxemia. Neither group was noninferior to the other on both outcomes. Conversion from SWPI to GA occurred in 6.5% of cases and was associated with baseline comorbidities and higher institutional procedure volume. CONCLUSIONS GA for ERCP was associated with less hypoxemia, whereas SWPI was associated with less hypotension. Neither approach was better on the combined incidence of hypotension and hypoxemia.
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Affiliation(s)
- Linda C Cummings
- Division of Gastroenterology and Liver Disease, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA; Department of Medicine, Case Western Reserve University School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Chen Liang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA; Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Edward J Mascha
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA; Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Leif Saager
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany; Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Zachary L Smith
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sekar Bhavani
- Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - John J Vargo
- Department of Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA; Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kenneth C Cummings
- Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA; Department of Anesthesiology, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
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Ilfeld BM. Why science is less scientific than we think (and what to do about it): The 2022 Gaston Labat Award Lecture. Reg Anesth Pain Med 2022; 47:395-400. [PMID: 35365548 PMCID: PMC9132860 DOI: 10.1136/rapm-2021-103331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 12/01/2021] [Indexed: 01/12/2023]
Affiliation(s)
- Brian M Ilfeld
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
- Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
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Zhang H, Qu Z, Miao Y, Jia R, Li F, Hua Z. Comparison Between Subparaneural Upper Trunk and Conventional Interscalene Blocks for Arthroscopic Shoulder Surgery: A Randomized Noninferiority Trial. Anesth Analg 2022; 134:1308-1317. [PMID: 35343933 DOI: 10.1213/ane.0000000000005990] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Although interscalene nerve block is the standard for shoulder analgesia, the risk of hemidiaphragmatic paralysis restricts its use in patients with compromised pulmonary function. We hypothesized that a novel subparaneural upper trunk block would provide noninferior postoperative analgesia but superior diaphragmatic sparing effect compared to interscalene block. METHODS This randomized controlled trial comprised 96 patients who underwent arthroscopic shoulder surgery under either subparaneural upper trunk block (5 mL of 0.5% ropivacaine) or interscalene block (15 mL of 0.5% ropivacaine), followed by supraclavicular nerve block (5 mL of 0.5% ropivacaine). General anesthesia was standardized. The coprimary outcomes were (1) recovery room resting pain score at 30 minutes, measured on an 11-point numerical rating scale, with a prespecified noninferiority margin of 1 point and (2) the incidence of hemidiaphragmatic paralysis, diagnosed using ultrasound. Among secondary outcomes, resting pain scores were assessed with numerical rating scale at 4, 8, and 24 hours postoperatively. RESULTS Recovery room resting pain scores at 30 minutes were 0 (0-1) in the subparaneural upper trunk group versus 0 (0-0) in the interscalene group, with a median difference of 0 (95% CI, 0-0); the upper 95% CI limit was lower than the prespecified noninferiority margin (noninferiority P < .001). Hemidiaphragmatic paralysis was observed in 16.7% of patients in the subparaneural upper trunk group versus 100% of those in the interscalene group (RR, 0.17; 95% CI, 0.09-0.31; P < .001), with complete paralysis occurring in 6.3% and 93.7% of patients, respectively. In this study, any reported differences in pain scores at 4, 8, and 24 hours postoperatively were not clinically important. CONCLUSIONS The subparaneural upper trunk block compared to interscalene block provided noninferior analgesia at 30 minutes in the recovery room after arthroscopic shoulder surgery but resulted in less hemidiaphragmatic paralysis.
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Affiliation(s)
- Hongye Zhang
- From the Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
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Ayad SS, Makarova N, Niazi AK, Khoshknabi DS, Stang T, Raza S, Kim DD. Effects of Gabapentin Enacarbil on Postoperative Pain After Hip and Knee Arthroplasty: A Placebo-controlled Randomized Trial. Clin J Pain 2022; 38:250-256. [PMID: 35132024 DOI: 10.1097/ajp.0000000000001024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 12/24/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Total joint arthroplasties are among the most common elective procedures performed in the United States, and they are associated with postoperative pain. Gabapentin enacarbil is a prodrug with an extended-release formulation that has been proposed for multimodal postoperative analgesia, but the drug's efficacy for major arthroplasties remains unclear. MATERIALS AND METHODS We enrolled 60 adult patients scheduled for primary knee or hip arthroplasty expected to remain hospitalized for at least 3 days. Eligible patients were randomly assigned to placebo or gabapentin enacarbil 600 mg twice daily starting the day before surgery continuing for 3 days thereafter.The primary outcome was analyzed using a joint hypothesis framework of pain (0 to 10 verbal response scores) and cumulative opioid consumption (mg of morphine equivalent) within the first 72 hours. Secondary outcomes were nausea and vomiting, pain persisting 90 days after surgery, duration of hospitalization, and early postoperative health status using quality of recovery score (QoR-15). RESULTS Twenty-eight patient in gabapentin enacarbil group and 32 in placebo group were analyzed. Since pain scores did not differ significantly (difference of means: -0.2 in pain scores; 95% confidence interval: -1.1, 0.7), nor did opioid consumption, conditions for joint hypothesis testing were not met. Moreover, there were no significant differences between groups for secondary outcomes. DISCUSSION We did not identify statistically significant or clinically meaningful differences in our primary and secondary outcomes related to perioperative use of gabapentin enacarbil in patients having primary hip or knee arthroplasties.
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Affiliation(s)
- Sabry S Ayad
- Anesthesia Institute, Fairview Hospital
- Departments of Outcomes Research
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Ren Y, Zheng T, Hua L, Zhang F, Ma Y, Zhang J. The Effect of Ultrasound-Guided Erector Spinae Plane Block versus Thoracic Epidural Block on Postoperative Analgesia After Nuss Surgery in Paediatric Patients: Study Protocol of a Randomized Non-Inferiority Design Trial. J Pain Res 2021; 14:3047-3055. [PMID: 34611435 PMCID: PMC8487277 DOI: 10.2147/jpr.s332078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/23/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose The Nuss procedure is a recognized treatment for adolescent pectus excavatum that results in severe postoperative pain. Erector spinae plane block (ESPB) is a novel technique that provides postoperative analgesia and reduces opioid consumption. Our aim is to explore whether ESPB produces analgesia similar to thoracic epidural anaesthesia (TEA) in paediatric patients undergoing Nuss procedure. Study Design and Methods This randomized, controlled, non-inferiority trial will enrol 300 paediatric patients undergoing Nuss surgery. Participants will be randomly assigned 1:1 to receive ESPB or TEA preoperatively. The primary, joint endpoint is the average numeric rating scale (NRS) score and cumulative sufentanil consumption. The secondary endpoints are pain scores and sufentanil consumption at different time points after surgery, analgesia-related side effects, and other postoperative complications. Data will be analysed by the intention-to-treat principle. Discussion This study investigates the effect of ESPB on postoperative opioid consumption and pain scores and intend to provide a new strategy of analgesia management for Nuss procedure in paediatric patients.
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Affiliation(s)
- Yi Ren
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, People's Republic of China
| | - Tiehua Zheng
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, People's Republic of China
| | - Lei Hua
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, People's Republic of China
| | - Fuzhou Zhang
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, People's Republic of China
| | - Yangwei Ma
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, People's Republic of China
| | - Jianmin Zhang
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, People's Republic of China
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11
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Ilfeld BM, Plunkett A, Vijjeswarapu AM, Hackworth R, Dhanjal S, Turan A, Cohen SP, Eisenach JC, Griffith S, Hanling S, Sessler DI, Mascha EJ, Han Y, Boggs JW, Wongsarnpigoon A, Gelfand H. Percutaneous Neuromodulation of the Brachial Plexus and Sciatic Nerve for the Treatment of Acute Pain Following Surgery: Secondary Outcomes From a Multicenter, Randomized, Controlled Pilot Study. Neuromodulation 2021; 26:638-649. [PMID: 34343394 DOI: 10.1111/ner.13492] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/20/2021] [Accepted: 06/14/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVES We recently reported that percutaneous peripheral nerve stimulation (PNS or "neuromodulation") decreased pain and opioid consumption within the first two weeks following ambulatory surgery. However, the anatomic lead locations were combined for the analysis, and benefits for each location remain unknown. We therefore now report the effects of percutaneous PNS for brachial plexus and sciatic nerve leads separately. MATERIALS AND METHODS Before surgery, leads were implanted percutaneously to target the brachial plexus (N = 21) for rotator cuff repair or sciatic nerve (N = 40) for foot/ankle surgery, followed by a single injection of local anesthetic. Postoperatively, subjects were randomized in a double masked fashion to 14 days of electrical stimulation (N = 30) or sham/placebo (N = 31) using an external pulse generator. The primary outcome of interest was opioid consumption and pain scores evaluated jointly. Thus, stimulation was deemed effective if superior on either outcome and at least noninferior on the other. RESULTS For brachial plexus leads, during the first seven postoperative days pain measured with the numeric rating scale in participants given active stimulation was a median [interquartile range ] of 0.8 [0.5, 1.6] versus 3.2 [2.7, 3.5] in patients given sham (p < 0.001). For this same group, opioid consumption in participants given active stimulation was 10 mg [5, 20] versus 71 mg [35, 125] in patients given sham (p = 0.043). For sciatic nerve leads, pain scores for the active treatment group were 0.7 [0, 1.4] versus 2.8 [1.6, 4.6] in patients given sham (p < 0.001). During this same period, participants given active stimulation consumed 5 mg [0, 30] of opioids versus 40 mg [20, 105] in patients given sham (p = 0.004). Treatment effects did not differ statistically between the two locations. CONCLUSIONS Ambulatory percutaneous PNS of both the brachial plexus and sciatic nerve is an effective treatment for acute pain free of systemic side-effects following painful orthopedic surgery.
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Affiliation(s)
- Brian M Ilfeld
- Department of Anesthesiology, University California San Diego, San Diego, CA, USA.,Outcomes Research Consortium, Cleveland, OH, USA
| | - Anthony Plunkett
- Department of Anesthesiology, Womack Army Medical Center, Fayetteville, NC, USA
| | | | - Robert Hackworth
- Department of Anesthesiology, Naval Medical Center San Diego, San Diego, CA, USA
| | - Sandeep Dhanjal
- Department of Anesthesiology, Brooke Army Medical Center, San Antonio, TX, USA
| | - Alparslan Turan
- Outcomes Research Consortium, Cleveland, OH, USA.,Departments of General Anesthesiology and Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Steven P Cohen
- Department of Anesthesiology, Johns Hopkins, Baltimore, MD, USA
| | - James C Eisenach
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Scott Griffith
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Steven Hanling
- Department of Physical Medicine and Rehabilitation, Columbia Veterans Affairs Health Care System, Columbia, SC, USA
| | - Daniel I Sessler
- Outcomes Research Consortium, Cleveland, OH, USA.,Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Edward J Mascha
- Outcomes Research Consortium, Cleveland, OH, USA.,Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Yanyan Han
- Outcomes Research Consortium, Cleveland, OH, USA.,Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Harold Gelfand
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, USA
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12
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Lee HM, Park JH, Park SJ, Choi H, Lee JR. Comparison of Monotherapy Versus Combination of Intravenous Ibuprofen and Propacetamol (Acetaminophen) for Reduction of Postoperative Opioid Administration in Children Undergoing Laparoscopic Hernia Repair: A Double-Blind Randomized Controlled Trial. Anesth Analg 2021; 133:168-175. [PMID: 33181557 DOI: 10.1213/ane.0000000000005284] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Extensive efforts have been made toward reducing postoperative opioid use in children. In this study, we assessed whether propacetamol, or a nonsteroidal anti-inflammatory drug (NSAID), or their combination could effectively reduce opioid use in children after laparoscopic inguinal hernia repair. METHODS This randomized, double-blind clinical trial included 159 children aged 6 months to 6 years. Children were allocated into 1 of the following 3 groups: group I was treated with 10 mg·kg-1 ibuprofen, group P was treated with 30 mg·kg-1 propacetamol, and group I + P was treated with both drugs in their respective concentrations. If the face-legs-activity-crying-consolability (FLACC) score was ≥4 during the postanesthesia care unit stay, 1.0 µg·kg-1 fentanyl was administered as a rescue analgesic. The number of patients who received rescue fentanyl in the postanesthesia care unit was defined as the primary outcome; this was analyzed using the χ2 test. The secondary outcomes included the FLACC and the parents' postoperative pain measure (PPPM) scores until the 24-hour postoperative period. RESULTS Among the 144 enrolled patients, 28.6% in group I, 66.7% in group P, and 12.8% in group I + P received rescue fentanyl in the postanesthesia care unit (P < .001). The highest FLACC score was lower in group I + P than in either group I or P (P = .007 and P < .001, respectively). Group I + P presented significantly lower PPPM scores than group P at 4 and 12 hours postoperative (P = .03 and .01, respectively). CONCLUSIONS The use of ibuprofen plus propacetamol immediately following laparoscopic hernia repair surgery in children resulted in the reduced use of an opioid drug compared with the use of propacetamol alone.
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Affiliation(s)
- Hye-Mi Lee
- From the Department of Anesthesiology and Pain Medicine.,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji-Hoon Park
- Department of Anesthesiology and Pain Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Su-Jung Park
- From the Department of Anesthesiology and Pain Medicine.,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Haegi Choi
- From the Department of Anesthesiology and Pain Medicine.,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Rim Lee
- From the Department of Anesthesiology and Pain Medicine.,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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13
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Percutaneous Peripheral Nerve Stimulation (Neuromodulation) for Postoperative Pain: A Randomized, Sham-controlled Pilot Study. Anesthesiology 2021; 135:95-110. [PMID: 33856424 DOI: 10.1097/aln.0000000000003776] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Percutaneous peripheral nerve stimulation is an analgesic technique involving the percutaneous implantation of a lead followed by the delivery of electric current using an external pulse generator. Percutaneous peripheral nerve stimulation has been used extensively for chronic pain, but only uncontrolled series have been published for acute postoperative pain. The current multicenter study was undertaken to (1) determine the feasibility and optimize the protocol for a subsequent clinical trial and (2) estimate the treatment effect of percutaneous peripheral nerve stimulation on postoperative pain and opioid consumption. METHODS Preoperatively, an electrical lead was percutaneously implanted to target the sciatic nerve for major foot/ankle surgery (e.g., hallux valgus correction), the femoral nerve for anterior cruciate ligament reconstruction, or the brachial plexus for rotator cuff repair, followed by a single injection of long-acting local anesthetic along the same nerve/plexus. Postoperatively, participants were randomized to 14 days of either electrical stimulation (n = 32) or sham stimulation (n = 34) using an external pulse generator in a double-masked fashion. The dual primary treatment effect outcome measures were (1) cumulative opioid consumption (in oral morphine equivalents) and (2) mean values of the "average" daily pain scores measured on the 0 to 10 Numeric Rating Scale within the first 7 postoperative days. RESULTS During the first 7 postoperative days, opioid consumption in participants given active stimulation was a median (interquartile range) of 5 mg (0 to 30) versus 48 mg (25 to 90) in patients given sham treatment (ratio of geometric means, 0.20 [97.5% CI, 0.07 to 0.57]; P < 0.001). During this same period, the average pain intensity in patients given active stimulation was a mean ± SD of 1.1 ± 1.1 versus 3.1 ± 1.7 in those given sham (difference, -1.8 [97.5% CI, -2.6 to -0.9]; P < 0.001). CONCLUSIONS Percutaneous peripheral nerve stimulation reduced pain scores and opioid requirements free of systemic side effects during at least the initial week after ambulatory orthopedic surgery. EDITOR’S PERSPECTIVE
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14
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Xu ZZ, Li X, Zhang Z, Liu ZY, Song LL, Li XY, Zhang H. Ultrasound-guided erector spinae plane block versus thoracic paravertebral block on postoperative analgesia after laparoscopic nephroureterectomy: study protocol of a randomized, double-blinded, non-inferiority design trial. Trials 2021; 22:249. [PMID: 33823924 PMCID: PMC8022408 DOI: 10.1186/s13063-021-05173-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 03/06/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction Erector spinae plane block (ESPB) is a novel inter-fascial plane block, which is applied more and more in postoperative pain control, especially in chest surgery. Regional block is advocated in order to decrease opioid consumption and improve analgesia in urological surgery. Therefore, we aimed to explore whether ESPB would have similar analgesia compared with thoracic paravertebral block (TPVB) in laparoscopic nephroureterectomy. Methods and analysis This prospective, randomized, double-blinded, non-inferiority trial will enroll 166 patients undergoing laparoscopic nephroureterectomy. Participants will be randomly assigned 1:1 into receiving ESPB or TPVB before surgery. Both ultrasound-guided ESPB and TPVB will be performed with an injection of 0.375% ropivacaine 0.4 ml/kg before anesthesia induction. Standardized patients controlled intravenous analgesia (PCIA) will be applied for each patient. The primary endpoint is the joint of cumulative 24 h opioid (sufentanil) consumption and average pain score via numeric rating scale (NRS) at 24 h after surgery. Secondary endpoints include rescued analgesic demand, cumulative opioid consumption, and pain NRS scores at different preset timepoints within 48 h after surgery. Other predefined outcomes include clinical features of blockage, quality of recovery, subjective sleep quality, time to ambulation and diet, and adverse events, as well as length of stay in hospital and anesthesia cost. Discussion Previous studies investigating the analgesic efficacy of ESPB only concentrated on a single endpoint for postoperative pain evaluation, while studies focusing on the direct comparison between ESPB and TPVB in urological surgery are still lacking. Our study is the first trial in non-inferiority design of comparing ESPB and TPVB in patient undergoing laparoscopic nephroureterectomy, and the primary outcome is the joint endpoint of opioid consumption and pain NRS score. Trial registration Chinese Clinical Trial Registry ChiCTR 2000031916. Registered on 14 April 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05173-0.
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Affiliation(s)
- Zhen-Zhen Xu
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No. 8, Xishiku Street, Beijing, 100034, China
| | - Xue Li
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No. 8, Xishiku Street, Beijing, 100034, China
| | - Zhen Zhang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No. 8, Xishiku Street, Beijing, 100034, China
| | - Zheng-Ye Liu
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No. 8, Xishiku Street, Beijing, 100034, China.,Department of Anesthesiology, Civil Aviation General Hospital, Beijing, China
| | - Lin-Lin Song
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No. 8, Xishiku Street, Beijing, 100034, China
| | - Xue-Ying Li
- Department of Biostatistics, Peking University First Hospital, Beijing, China
| | - Hong Zhang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No. 8, Xishiku Street, Beijing, 100034, China.
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15
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Elsharkawy H, Ahuja S, Sessler DI, Maheshwari K, Mao G, Sakr Esa WA, Soliman LM, Ayad S, Khoshknabi D, Khan MZ, Raza S, DeGrande S, Turan A. Subcostal Anterior Quadratus Lumborum Block Versus Epidural Block for Analgesia in Open Nephrectomy: A Randomized Clinical Trial. Anesth Analg 2021; 132:1138-1145. [PMID: 33617181 DOI: 10.1213/ane.0000000000005382] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Epidural block are often used for analgesia after open nephrectomy surgery. Subcostal anterior quadratus lumborum block may be an alternative. We therefore tested the hypothesis that the continuous subcostal anterior quadratus lumborum block is noninferior to epidural block for analgesia in patients having open partial nephrectomies. METHODS Adults having open partial nephrectomies were randomly allocated to epidural or unilateral subcostal anterior quadratus lumborum block. The joint primary outcomes were opioid consumption measured in morphine equivalents and pain measured on a numeric rating scale (0-10) from postanesthesia care unit (PACU) until 72 hours after surgery. The noninferiority deltas were 30% for opioid consumption and 1 point on a 0-10 scale for pain. Secondary outcomes included patient global assessment of pain management on the third postoperative day, the number of antiemetic medication doses through the third postoperative day, duration of PACU stay, and postoperative duration of hospitalization. RESULTS Twenty-six patients were randomized to anterior quadratus lumborum block and 29 to epidural analgesia. Neither pain scores nor opioid consumption in the quadratus lumborum patients were noninferior to epidural analgesia. At 72 hours, mean ± standard deviation pain scores in subcoastal anterior quadratus lumborum block and epidural group were 4.7 ± 1.8 and 4.1 ± 1.7, with an estimated difference in pain scores of 0.62 (95% confidence interval [CI], 0.74-1.99; noninferiority P = .21). The median [Q1, Q3] opioid consumption was more than doubled in quadratus lumborum patients at 70 mg [43, 125] versus 30 mg [18, 75] in the epidural group with an estimated ratio of geometric means of 1.69 (95% CI, 0.66-4.33; noninferiority P = .80). Patient global assessment and duration of PACU and hospital stays did not differ significantly in the 2 groups. CONCLUSIONS We were unable to show that subcostal anterior quadratus lumborum block are noninferior to epidural analgesia in terms of pain scores and opioid consumption for open partial nephrectomies. Effectiveness of novel blocks should be rigorously tested in specific surgical setting before widespread adoption.
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Affiliation(s)
- Hesham Elsharkawy
- From the Department of Anesthesiology, Pain and Healing Center, Case Western Reserve University, MetroHealth, Cleveland, Ohio.,Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Sanchit Ahuja
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio.,Department of Anesthesiology, Pain Management & Perioperative Medicine, Henry Ford Health System, Detroit, Michigan
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Kamal Maheshwari
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio.,Department of General Anesthesiology and
| | - Guangmei Mao
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio.,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Sabry Ayad
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Syed Raza
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Sean DeGrande
- Department of Anesthesia, Seven Hills Anesthesia, Edgewood, Kentucky
| | - Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio.,Department of General Anesthesiology and
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16
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Potnuru PP, Patel SD, Birnbach DJ, Epstein RH, Dudaryk R. Effects of State Law Limiting Postoperative Opioid Prescription in Patients After Cesarean Delivery. Anesth Analg 2021; 132:752-760. [PMID: 32639388 DOI: 10.1213/ane.0000000000004993] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The impact of the Florida State law House Bill 21 (HB 21) restricting the duration of opioid prescriptions for acute pain in patients after cesarean delivery is unknown. Our objective was to assess the association of the passage of Florida State law HB 21 with trends in discharge opioid prescription practices following cesarean delivery, necessity for additional opioid prescriptions, and emergency department visits at a large tertiary care center. METHODS This was a retrospective cohort study conducted at a large, public hospital. The 2 cohorts represented the period before and after implementation of the law. Using a confounder-adjusted segmented regression analysis of an interrupted time series, we evaluated the association between HB 21 and trends in the proportions of patients receiving opioids on discharge, duration of opioid prescriptions, total opioid dose prescribed, and daily opioid dose prescribed. We also compared the need for additional opioid prescriptions within 30 days of discharge and the prevalence of emergency department visits within 7 days after discharge. RESULTS Eight months after implementation of HB 21, the mean duration of opioid prescriptions decreased by 2.9 days (95% confidence interval [CI], 5.2-0.5) and the mean total opioid dose decreased by 20.1 morphine milligram equivalents (MME; 95% CI, 4-36.3). However, there was no change in the proportion of patients receiving discharge opioids (95% CI of difference, -0.1 to 0.16) or in the mean daily opioid dose (mean difference, 5.3 MME; 95% CI, -13 to 2.4). After implementation of the law, there were no changes in the proportion of patients who required additional opioid prescriptions (2.1% vs 2.3%; 95% CI of difference, -1.2 to 1.5) or in the prevalence of emergency department visits (2.4% vs 2.2%; 95% CI of difference, -1.6 to 1.1). CONCLUSIONS Implementation of Florida Law HB 21 was associated with a lower total prescribed opioid dose and a shorter duration of therapy at the time of hospital discharge following cesarean delivery. These reductions were not associated with the need for additional opioid prescriptions or emergency department visits.
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Affiliation(s)
- Paul P Potnuru
- From the Department of Anesthesiology, University of Texas, McGovern Medical School, Houston, Texas
| | - Selina D Patel
- Department of Anesthesiology and Perioperative Medicine, University of Miami, Miller School of Medicine, Jackson Memorial Hospital, Miami, Florida
| | - David J Birnbach
- Department of Anesthesiology and Perioperative Medicine, University of Miami, Miller School of Medicine, Jackson Memorial Hospital, Miami, Florida
| | - Richard H Epstein
- Department of Anesthesiology and Perioperative Medicine, University of Miami, Miller School of Medicine, Jackson Memorial Hospital, Miami, Florida
| | - Roman Dudaryk
- Department of Anesthesiology and Perioperative Medicine, University of Miami, Miller School of Medicine, Jackson Memorial Hospital, Miami, Florida
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17
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Kim JH, Jwa EK, Choung Y, Yeon HJ, Kim SY, Kim E. Comparison of Pupillometry With Surgical Pleth Index Monitoring on Perioperative Opioid Consumption and Nociception During Propofol-Remifentanil Anesthesia: A Prospective Randomized Controlled Trial. Anesth Analg 2020; 131:1589-1598. [PMID: 33079883 DOI: 10.1213/ane.0000000000004958] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Intraoperative monitoring with pupillometry has shown promising results for nociception/antinociception balance monitoring. However, its benefits in clinical practice remain unproven. The aim of this study was to evaluate the efficacy of intraoperative pupillometry monitoring on intraoperative opioid consumption and postoperative pain compared to surgical pleth index (SPI), another widely investigated monitoring. METHODS American Society of Anesthesiologists (ASA) I-II patients scheduled for elective laparoscopic cholecystectomy were included. This prospective, parallel-arm, single-center study was conducted in 2 steps. First, we evaluated the feasibility of using pupillometry and SPI monitoring compared with conventional hemodynamic monitoring. Next, a parallel-arm, double-blind randomized study compared the peak postoperative pain measured with numerical rating scale (NRS) from 0 (no pain) to 10 (extreme pain) as a primary outcome between pupillometry (pupillometry group, n = 43) and SPI monitoring (SPI group, n = 43) using Mann-Whitney U test. Secondary outcomes included intraoperative remifentanil consumption, postoperative opioid responsiveness (a decrease in NRS by ≥1 after fentanyl administrations), number of analgesic administrations, and opioid-related complications. RESULTS In the preliminary study (n = 50), remifentanil consumption was less under pupillometry monitoring compared to SPI monitoring, and peak postoperative pain was lower under pupillometry compared to conventional monitoring. In the main study (n = 86), peak postoperative pain and intraoperative remifentanil consumption were lower in the pupillometry group (median [first to third quartile], 5 [4-6]; mean ± standard deviation [SD], 0.078 ± 0.019 μg·kg·minute) compared to the SPI group (7 [5-8] and 0.0130 ± 0.051 μg·kg·minute; P < .001), with the median difference in peak postoperative pain of -1 and its 95% confidence interval between -2 and -0.5. The pupillometry group had better responsiveness to fentanyl (84.6% vs 61.0%; P = .005) and lower number of analgesic administrations (2 [1-2] vs 2 [1-3]; P = .048) compared to the SPI group. CONCLUSIONS Intraoperative pupillometry monitoring reduced intraoperative remifentanil consumption and postoperative pain. It may be an alternative option for intraoperative opioid control under general anesthesia in adult patients.
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Affiliation(s)
- Jong Hae Kim
- From the Department of Anesthesiology and Pain Medicine, Daegu Catholic University Medical Center, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
| | - Eun Kyung Jwa
- Division of Hepatobiliary Surgery, Department of Surgery, Daegu Catholic University Medical Center, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
| | - Youjin Choung
- Department of Anesthesiology and Pain Medicine, Hanyang University Medical Center, Seoul, Republic of Korea
| | - Hyo Jin Yeon
- Department of Anesthesiology and Pain Medicine, Hanyang University Medical Center, Seoul, Republic of Korea
| | - Soo Yeon Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Medical Center, Seoul, Republic of Korea
| | - Eugene Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Medical Center, College of Medicine, Hanyang University, Seoul, Republic of Korea
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18
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Chen J, Sun D, Zhang S, Shi Y, Qiao F, Zhou Y, Liu J, Ren C. Effects of home-based telerehabilitation in patients with stroke. Neurology 2020; 95:e2318-e2330. [DOI: 10.1212/wnl.0000000000010821] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 05/08/2020] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo determine the effects of a 12-week home-based motor training telerehabilitation program in patients with subcortical stroke by combining motor function assessments and multimodality MRI analysis methods.MethodsFifty-two patients with stroke and hemiplegia were randomly assigned to either a home-based motor training telerehabilitation (TR) group or a conventional rehabilitation (CR) group for 12 weeks. The Fugl-Meyer assessment (FMA) for upper and lower extremities and the modified Barthel Index were used as primary outcomes. The secondary outcomes included resting-state functional connectivity (rsFC) between the bilateral M1 areas, gray matter volumes of the primary motor cortex (M1) areas, and white matter integrity of the corticospinal tract. Analysis of covariance was applied to examine the effects of the home-based motor training TR program on neural function recovery and brain plasticity.ResultsCompared with the CR group, the TR group showed significant improvement in the FMA (p = 0.011) and significantly increased M1-M1 rsFC (p = 0.031) at the end of the rehabilitation. The M1-M1 rsFC change was significantly positively correlated with the FMA change in the TR group (p = 0.018).ConclusionThis study showed a beneficial effect of the home-based motor training telerehabilitation program on motor function in patients with stroke, which was accompanied by enhanced interhemispheric functional connectivity of the M1 areas. We inferred that it is feasible, safe, and efficacious for patients with stroke to receive professional rehabilitation training at home. The combined use of imaging biomarkers should be encouraged in motor training clinical studies in patients with stroke.Classification of evidenceThis study provides Class II evidence that for patients with stroke with hemiplegia, home-based telerehabilitation compared to conventional rehabilitation significantly improves some motor function tests.
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19
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Marciniak DA, Alfirevic A, Hijazi RM, Ramos DJ, Duncan AE, Gillinov AM, Ahmad U, Murthy SC, Raymond DP. Intercostal Blocks with Liposomal Bupivacaine in Thoracic Surgery: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2020; 35:1404-1409. [PMID: 33067088 DOI: 10.1053/j.jvca.2020.09.116] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Assess the efficacy of adding liposomal bupivacaine (LB) to bupivacaine-containing intercostal nerve blocks (ICNBs) to improve analgesia and decrease opioid consumption and hospital length of stay compared with bupivacaine-only ICNBs. DESIGN This retrospective, observational investigation compared pain intensity scores and cumulative opioid consumption within the first 72 postoperative hours in patients who received ICNBs with bupivacaine plus LB (LB group) versus bupivacaine only (control group) after minimally invasive anatomic pulmonary resection. LB was tested for noninferiority on pain scores and opioid consumption. If LB was noninferior, superiority of LB was tested on both outcomes. SETTING Academic tertiary care medical center. PARTICIPANTS Adult patients undergoing minimally invasive anatomic pulmonary resection. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS For the secondary analysis, hospital length of stay was compared through the Cox regression model. Of 396 patients, 178 (45%) received LB and 218 (55%) did not. The mean (standard deviation) pain score was three (one) in the LB group and three (one) in the control group, with a difference of -0.10 (97.5% confidence interval [-0.39 to 0.18]; p = 0.41). The mean (standard deviation) cumulative opioid consumption (intravenous morphine equivalents) was 198 (208) mg in the LB group and 195 (162) mg in the control group. Treatment effect in opioid consumption was estimated at a ratio of geometric mean of 0.94 (97.5% confidence interval [0.74-1.20]; p = 0.56). Pain control and opioid consumption were noninferior with LB but not superior. Hospital discharge was not different between groups. CONCLUSIONS LB with bupivacaine in ICNBs did not demonstrate superior postoperative analgesia or affect the rate of hospital discharge.
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Affiliation(s)
- Donn A Marciniak
- Department of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, OH.
| | - Andrej Alfirevic
- Department of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, OH
| | - Ryan M Hijazi
- Department of General Anesthesia, Cleveland Clinic, Cleveland, OH
| | - Daniel J Ramos
- Department of General Anesthesia, Cleveland Clinic, Cleveland, OH
| | - Andra E Duncan
- Department of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, OH
| | - A Marc Gillinov
- Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH
| | - Usman Ahmad
- Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH
| | - Sudish C Murthy
- Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH
| | - Daniel P Raymond
- Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH
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Hussain N, Costache I, Kumar N, Essandoh M, Weaver T, Wong P, Tierney S, Rose P, McCartney CJL, Abdallah FW. Is Supraclavicular Block as Good as Interscalene Block for Acute Pain Control Following Shoulder Surgery? A Systematic Review and Meta-analysis. Anesth Analg 2020; 130:1304-1319. [PMID: 32102013 DOI: 10.1213/ane.0000000000004692] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Interscalene block (ISB) is the acute pain management technique of choice for shoulder surgery, but its undesirable respiratory side effects have prompted seeking alternatives. Supraclavicular block (SCB) is proposed as an ISB alternative, but evidence of comparative analgesic and respiratory-sparing effects is inconsistent. We compared the analgesic and respiratory effects of SCB and ISB for shoulder surgery. METHODS Trials comparing ISB to SCB for shoulder surgery were sought. We decided a priori that SCB would be an acceptable alternative if it were noninferior for (1) postoperative 24-hour cumulative oral morphine equivalent consumption (primary outcome, noninferiority margin Δ = -25 mg) and (2) postoperative pain (secondary outcome, noninferiority margin Δ = 4.0 cm·hour); and superior for (3) postblock respiratory dysfunction (primary outcome). Opioid-related side effects and block-related complications were also evaluated. RESULTS Fifteen studies (1065 patients) were analyzed. In single-injection blocks, SCB was noninferior to ISB for 24-hour morphine consumption (mean difference for SCB-ISB, MD [95% confidence interval {CI}] = -3.11 mg [-9.42 to 3.19], Δ = -25 mg); it was also noninferior for 24-hour pain scores (MD = 0.78 cm·hour [0.07-1.49], Δ = 4.0 cm·hour); and decreased the odds of respiratory dysfunction (odds ratio [OR] [95% CI] = 0.08 [0.01-0.68]). Similarly, in continuous blocks, SCB was noninferior to ISB for 24-hour morphine consumption (MD = 0.46 mg [-6.08 to 5.15], Δ = -25 mg), and decreased the odds of respiratory dysfunction (OR = 0.22 [0.08-0.57]). SCB also decreased odds of minor block-related complications (OR = 0.36 [0.20-0.68] and OR = 0.25 [0.15-0.41] for single-injection and continuous blocks, respectively). Consequently, the null joint-hypothesis was rejected, and SCB can be considered an acceptable alternative to ISB. CONCLUSIONS For acute pain control following shoulder surgery, high-quality evidence indicates that SCB can be used as an effective ISB alternative. SCB is noninferior for postoperative opioid consumption and acute pain, and it reduces the odds of postblock respiratory dysfunction.
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Affiliation(s)
- Nasir Hussain
- From the Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Ioana Costache
- Department of Anesthesiology and Pain Medicine, and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Nicolas Kumar
- From the Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, Ohio.,Faculty of Medicine, The Ohio State University College of Medicine, Columbus, Ohio
| | - Michael Essandoh
- From the Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Tristan Weaver
- From the Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Patrick Wong
- Department of Anesthesiology and Pain Medicine, and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Sarah Tierney
- Department of Anesthesiology and Pain Medicine, and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Rose
- Department of Anesthesiology and Pain Medicine, and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Colin J L McCartney
- Department of Anesthesiology and Pain Medicine, and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Faraj W Abdallah
- Department of Anesthesiology and Pain Medicine, and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.,Department of Anesthesia, and the Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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21
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Abstract
Abstract
Background
Various multimodal analgesic approaches have been proposed for spine surgery. The authors evaluated the effect of using a combination of four nonopioid analgesics versus placebo on Quality of Recovery, postoperative opioid consumption, and pain scores.
Methods
Adults having multilevel spine surgery who were at high risk for postoperative pain were double-blind randomized to placebos or the combination of single preoperative oral doses of acetaminophen 1,000 mg and gabapentin 600 mg, an infusion of ketamine 5 µg/kg/min throughout surgery, and an infusion of lidocaine 1.5 mg/kg/h intraoperatively and during the initial hour of recovery. Postoperative analgesia included acetaminophen, gabapentin, and opioids. The primary outcome was the Quality of Recovery 15-questionnaire (0 to 150 points, with 15% considered to be a clinically important difference) assessed on the third postoperative day. Secondary outcomes were opioid use in morphine equivalents (with 20% considered to be a clinically important change) and verbal-response pain scores (0 to 10, with a 1-point change considered important) over the initial postoperative 48 h.
Results
The trial was stopped early for futility per a priori guidelines. The average duration ± SD of surgery was 5.4 ± 2.1 h. The mean ± SD Quality of Recovery score was 109 ± 25 in the pathway patients (n = 150) versus 109 ± 23 in the placebo group (n = 149); estimated difference in means was 0 (95% CI, –6 to 6, P = 0.920). Pain management within the initial 48 postoperative hours was not superior in analgesic pathway group: 48-h opioid consumption median (Q1, Q3) was 72 (48, 113) mg in the analgesic pathway group and 75 (50, 152) mg in the placebo group, with the difference in medians being –9 (97.5% CI, –23 to 5, P = 0.175) mg. Mean 48-h pain scores were 4.8 ± 1.8 in the analgesic pathway group versus 5.2 ± 1.9 in the placebo group, with the difference in means being –0.4 (97.5% CI; –0.8, 0.1, P = 0.094).
Conclusions
An analgesic pathway based on preoperative acetaminophen and gabapentin, combined with intraoperative infusions of lidocaine and ketamine, did not improve recovery in patients who had multilevel spine surgery.
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
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Massouh F, Martin R, Chan B, Ma J, Patel V, Geary MP, Laffey JG, Wijeysundera DN, Abdallah FW. Is Activity Tracker-Measured Ambulation an Accurate and Reliable Determinant of Postoperative Quality of Recovery? A Prospective Cohort Validation Study. Anesth Analg 2020; 129:1144-1152. [PMID: 30379677 DOI: 10.1213/ane.0000000000003913] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Quality of recovery (QOR) instruments measure patients' ability to return to baseline health status after surgery. Whether, and the extent to which, postoperative ambulation contributes to QOR is unclear, in part due to the lack of valid tools to measure ambulation in clinical settings. This cohort study of the cesarean delivery surgical model examines the accuracy and reliability of activity trackers in quantifying early postoperative ambulation and investigates the correlation between ambulation and QOR. METHODS A prospective cohort of 200 parturients undergoing cesarean delivery between July 2015 and June 2017 was fitted with wrist-worn activity trackers immediately postpartum. The trackers were collected 24 hours later, along with QOR assessments (QoR-15 scale). The relationship between QOR and various covariates, including ambulation, was explored using multivariable linear regression and Spearman correlation (ρ). Forty-eight parturients fitted with 2 trackers also completed a walk exercise accompanied by a step-counting assessor, to evaluate accuracy, inter-, and intradevice reliability using interclass correlation (ICC). RESULTS Compared to step counting, activity trackers had high accuracy (ICC = 0.93) and excellent inter- and intradevice reliability (ICC = 0.98 and 0.96, respectively). Correlation analysis suggested that early ambulation is moderately correlated with postcesarean QoR-15 scores, with a ρ (95% confidence interval) equivalent to 0.56 (0.328-0.728). Regression analysis suggested that ambulation is a determinant of postcesarean QoR-15 scores, with an effect estimate (95% confidence interval) equivalent to 0.002 (0.001-0.003). Ambulation was also associated with all QoR-15 domains, except psychological support. The patient's acceptable symptom state (subjective threshold for good ambulation) in the first 24 hours was 287 steps. CONCLUSIONS This study demonstrated the accuracy and reliability of activity trackers in measuring ambulation in clinical settings and suggested that postoperative ambulation is a determinant of postoperative QOR. A hypothetical implication of our findings is that interventions that improve ambulation may also help to enhance QOR, but further research is needed to establish a causal relationship.
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Affiliation(s)
- Faraj Massouh
- From the Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Rachel Martin
- From the Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Bokman Chan
- From the Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Julia Ma
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Vikita Patel
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada.,Department of Interdisciplinary Medical Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Michael P Geary
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - John G Laffey
- From the Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia, School of Medicine, National University of Ireland, Galway, Ireland
| | - Duminda N Wijeysundera
- From the Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia and Pain Management, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Faraj W Abdallah
- From the Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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Turan A, Cohen B, Whitlock RP, Essber H, Niazi A, Makarova N, Saasouh W, Alfirevic A, Marciniak D, Sessler DI. Methylprednisolone Does Not Reduce Acute Postoperative Pain After Cardiac Surgery: Subanalysis of a Randomized Clinical Trial. Anesth Analg 2019; 129:1468-1473. [PMID: 31743165 DOI: 10.1213/ane.0000000000004061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pain after cardiac surgery is largely treated with opioids, but their poor safety profile makes nonopioid medications attractive as part of multimodal pathways. Anti-inflammatory drugs reduce acute postoperative pain, but the role of steroids in reducing acute poststernotomy pain is unclear. We evaluated the association between the intraoperative administration of methylprednisolone and postoperative analgesia, defined as a composite of pain scores and opioid consumption, during the initial 24 hours after cardiac surgery. METHODS We conducted a post hoc retrospective analysis of a large clinical trial in which adults having cardiac surgery were randomized 1:1 to receive 2 intraoperative doses of 250 mg IV methylprednisolone or placebo. Pain scores and opioid consumption were collected during the initial 24 hours after surgery. Methylprednisolone was considered to be associated with better pain control than placebo if proven noninferior (not worse) on both pain scores (defined a priori with delta of 1 point) and opioid consumption (delta of 20%) and superior to placebo in at least 1 of the 2 outcomes. This test was repeated in the opposite direction (testing whether placebo is better than methylprednisolone on postoperative pain management). RESULTS Of 251 eligible patients, 127 received methylprednisolone and 124 received placebo. Methylprednisolone was noninferior to placebo on pain with difference in mean (CI) pain scores of -0.25 (-0.71 to 0.21); P < .001. However, methylprednisolone was not noninferior to placebo on opioid consumption (ratio of geometric means [CI]: 1.11 [0.64-1.91]; P = .37). Because methylprednisolone was not noninferior to placebo on both outcomes, we did not proceed to superiority testing based on the a priori stopping rules. Similar results were found when testing the opposite direction. CONCLUSIONS In this post hoc analysis, we could not identify a beneficial analgesic effect after cardiac surgery associated with methylprednisolone administration. There are currently no data to suggest that methylprednisolone has significant analgesic benefit in adults having cardiac surgery.
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Affiliation(s)
- Alparslan Turan
- From the Departments of Outcomes Research
- General Anesthesia, Cleveland Clinic, Cleveland, Ohio
| | - Barak Cohen
- From the Departments of Outcomes Research
- Division of Anesthesia, Critical Care and Pain Management, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Richard P Whitlock
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | - Andrej Alfirevic
- Department of Cardiothoracic Anesthesia Cleveland Clinic, Cleveland, Ohio
| | - Donn Marciniak
- Department of Cardiothoracic Anesthesia Cleveland Clinic, Cleveland, Ohio
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Machado FC, Vieira JE, de Orange FA, Ashmawi HA. Intraoperative Methadone Reduces Pain and Opioid Consumption in Acute Postoperative Pain: A Systematic Review and Meta-analysis. Anesth Analg 2019; 129:1723-1732. [PMID: 31743194 DOI: 10.1213/ane.0000000000004404] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Methadone is a potent opioid exerting an analgesic effect through N-methyl-D-aspartate receptor antagonism and the inhibition of serotonin and noradrenaline reuptake. It has also been used in several procedures to reduce postoperative pain and opioid use. This meta-analysis aimed to determine whether the intraoperative use of methadone lowers postoperative pain scores and opioid consumption in comparison to other opioids. METHODS Double-blinded, controlled trials without language restrictions were included from MEDLINE, Embase, LILACS, The Cochrane Central Register of Controlled Trials (CENTRAL), and CINAHL via EBSCOhost. The included studies tracked total opioid consumption, postoperative pain scores, opioid-related side effects, and patient satisfaction until 72 hours postoperatively. Mean difference (MD) was used for effect size. RESULTS In total, 476 articles were identified and 13 were considered eligible for inclusion in the meta-analysis. In 486 patients (7 trials), pain at rest (MD, 1.09; 95% confidence interval (CI), 1.47-0.72; P < .00001) and at movement (MD, 2.48; 95% CI, 3.04-1.92; P = .00001) favored methadone 24 hours after surgery. In 374 patients (6 trials), pain at rest (MD, 1.47; 95% CI, 3.04-1.02; P < .00001) and at movement (MD, 2.03; 95% CI, 3.04-1.02; P < .00001) favored methadone 48 hours after surgery. In 320 patients (4 trials), pain at rest (MD, 1.02; 95% CI, 1.65-0.39; P = .001) and at movement (MD, 1.34; 95% CI, 1.82-0.87; P < .00001) favored methadone 72 hours after surgery. A Trial Sequential Analysis was performed and the Z-cumulative curve for methadone crossed the monitoring boundary at all evaluations, additionally crossing Required Information Size at 24 and 48 hours at rest. Methadone group also showed lower postoperative opioid consumption in morphine equivalent dosage (mg) at 24 hours (MD, 8.42; 95% CI, 12.99-3.84 lower; P < .00001), 24-48 hours (MD, 14.33; 95% CI, 26.96-1.91 lower; P < .00001), 48-72 hours (MD, 3.59; 95% CI, 6.18-1.0 lower; P = .007) postoperatively. CONCLUSIONS Intraoperative use of methadone reduced postoperative pain scores compared to other opioids, and Trial Sequential Analysis suggested that no more trials are required to confirm pain reduction at rest until 48 hours after surgery. Methadone also reduced postoperative opioid consumption and led to better patient satisfaction scores through 72 hours postoperatively compared to other opioids.
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Affiliation(s)
- Felipe C Machado
- From the Anesthesia Department, Universidade de Sao Paulo, São Paulo, Brazil
| | - Joaquim E Vieira
- From the Anesthesia Department, Universidade de Sao Paulo, São Paulo, Brazil
| | - Flávia A de Orange
- Anesthesia Department, Institute of Integral Medicine Prof. Fernando Figueira (IMIP), Recife, Brazil
| | - Hazem A Ashmawi
- From the Anesthesia Department, Universidade de Sao Paulo, São Paulo, Brazil
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Cohen B, Ahuja S, Schacham YN, Chelnick D, Mao G, Ali-Sakr Esa W, Maheshwari K, Sessler DI, Turan A. Intraoperative Hyperoxia Does Not Reduce Postoperative Pain: Subanalysis of an Alternating Cohort Trial. Anesth Analg 2019; 128:1160-1166. [PMID: 31094783 DOI: 10.1213/ane.0000000000004002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Postoperative pain is common and promotes opioid use. Surgical wounds are hypoxic because normal perfusion is impaired. Local wound ischemia and acidosis promote incisional pain. Some evidence suggests that improving oxygen supply to surgical wounds might reduce pain. We therefore tested the hypothesis that supplemental (80% inspired) intraoperative oxygen reduces postoperative pain and opioid consumption. METHODS We conducted a post hoc analysis of a large, single-center alternating cohort trial allocating surgical patients having general anesthesia for colorectal surgery to either 30% or 80% intraoperative oxygen concentration in 2-week blocks for a total of 39 months. Irrespective of allocation, patients were given sufficient oxygen to maintain saturation ≥95%. Patients who had regional anesthesia or nerve blocks were excluded. The primary outcome was pain and opioid consumption during the initial 2 postoperative hours, analyzed jointly. The secondary outcome was pain and opioid consumption over the subsequent 24 postoperative hours. Subgroup analyses of the primary outcome were conducted for open versus laparoscopic procedures and for patients with versus without chronic pain. RESULTS A total of 4702 cases were eligible for analysis: 2415 were assigned to 80% oxygen and 2287 to 30% oxygen. The groups were well balanced on potential confounding factors. Average pain scores and opioid consumption were similar between the groups (mean difference in pain scores, -0.01 [97.5% CI, -0.16 to 0.14; P = .45], median difference in opioid consumption, 0.0 [97.5% CI, 0 to 0] mg morphine equivalents; P = .82). There were also no significant differences in the secondary outcome or subgroup analyses. CONCLUSIONS Supplemental intraoperative oxygen does not reduce acute postoperative pain or reduce opioid consumption.
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Affiliation(s)
- Barak Cohen
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Division of Anesthesia, Critical Care and Pain Management, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Sanchit Ahuja
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Yehoshua N Schacham
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Internal Medicine C, Sheba Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - David Chelnick
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Kamal Maheshwari
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- General Anesthesia, Cleveland Clinic, Cleveland, Ohio
| | - Daniel I Sessler
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Alparslan Turan
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- General Anesthesia, Cleveland Clinic, Cleveland, Ohio
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Kim DH, Oh YJ, Lee JG, Ha D, Chang YJ, Kwak HJ. Efficacy of Ultrasound-Guided Serratus Plane Block on Postoperative Quality of Recovery and Analgesia After Video-Assisted Thoracic Surgery: A Randomized, Triple-Blind, Placebo-Controlled Study. Anesth Analg 2019; 126:1353-1361. [PMID: 29324496 DOI: 10.1213/ane.0000000000002779] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The optimal regional technique for analgesia and improved quality of recovery after video-assisted thoracic surgery (a procedure associated with considerable postoperative pain) has not been established. The main objective in this study was to compare quality of recovery in patients undergoing serratus plane block (SPB) with either ropivacaine or normal saline on the first postoperative day. Secondary outcomes were analgesic outcomes, including postoperative pain intensity and opioid consumption. METHODS Ninety patients undergoing video-assisted thoracic surgery were randomized to receive ultrasound-guided SPB with 0.4 mL/kg of either 0.375% ropivacaine (SPB group) or normal saline (control group) after anesthetic induction. The primary outcome was the 40-item Quality of Recovery (QoR-40) score at 24 hours after surgery. The QoR-40 questionnaire was completed by patients the day before surgery and on postoperative days 1 and 2. Pain scores, opioid consumption, and adverse events were assessed for 2 days postoperatively. RESULTS Eighty-five patients completed the study: 42 in the SPB group and 43 in the control group. The global QoR-40 scores on both postoperative days 1 and 2 were significantly higher in the SPB group than in the control group (estimated mean difference 8.5, 97.5% confidence interval [CI], 2.1-15.0, and P = .003; 8.5, 97.5% CI, 2.0-15.1, and P = .004, respectively). The overall mean difference between the SPB and control groups was 8.5 (95% CI, 3.3-13.8; P = .002). Pain scores at rest and opioid consumption were significantly lower up to 6 hours after surgery in the SPB group than in the control group. Cumulative opioid consumption was significantly lower up to 24 hours postoperatively in the SPB group. CONCLUSIONS Single-injection SPB with ropivacaine enhanced the quality of recovery for 2 days postoperatively and improved postoperative analgesia during the early postoperative period in patients undergoing video-assisted thoracic surgery.
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Affiliation(s)
- Do-Hyeong Kim
- From the Departments of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute
| | - Young Jun Oh
- From the Departments of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute
| | | | - Donghun Ha
- Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Jin Chang
- Department of Anesthesiology and Pain Medicine, Gil Medical Center, Gachon University, Incheon, Republic of Korea
| | - Hyun Jeong Kwak
- Department of Anesthesiology and Pain Medicine, Gil Medical Center, Gachon University, Incheon, Republic of Korea
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Sneyd JR, Colvin LA, Columb MO, Nightingale T. Perioperative statins surgery and postoperative pain. Br J Anaesth 2019; 119:712-715. [PMID: 29121300 DOI: 10.1093/bja/aex248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- J R Sneyd
- Peninsula Medical School, Plymouth University, Plymouth PL6 8BU, UK
| | - L A Colvin
- Department of Anaesthesia, Critical Care & Pain Medicine, Western General Hospital, Edinburgh, UK
| | - M O Columb
- Intensive Care Unit, Wythenshawe Hospital, Manchester M23 9LT, UK
| | - T Nightingale
- Peninsula Medical School, Plymouth University, Plymouth PL6 8BU, UK
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Saasouh W, Leung S, Yilmaz HO, Koyuncu O, You J, Zimmerman NM, Ruetzler K, Turan A. Are perioperative therapeutic doses of statins associated with postoperative pain and opioid consumption after hip surgery under spinal anaesthesia? Br J Anaesth 2019; 119:803-811. [PMID: 29121296 DOI: 10.1093/bja/aex232] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2017] [Indexed: 12/25/2022] Open
Abstract
Background The anti-inflammatory effects of statins have been suggested to relieve postoperative pain. This retrospective study tested the association between the perioperative routine use of statins in therapeutic doses, and opioid requirements and pain scores, after hip replacement surgery. Methods With IRB approval, data was obtained for adult patients who had elective hip replacement surgery under spinal anaesthesia at Cleveland Clinic between 2005 and 2015. Patients were compared using a joint hypothesis framework. We used the inverse probability of treatment weighting method to control for observed confounding factors (a total of 26). Results We included 611 statin users and 780 non-statin users. Pain score during the initial 72 h after surgery was 0.07 higher (95% CI: -0.02, 0.17) in statin users (noninferiority test in both directions P<0.001). The estimated ratio of geometric means in the cumulative i.v. morphine equivalent opioid consumption was 1.01 (95% CI: 0.93, 1.10) for statin vs non-statin users (noninferiority test P=0.001 in the hypothesized direction and<0.001 in the other direction) during the initial 72 h after surgery. The statin and non-statin patients were deemed equivalent on postoperative opioid consumption and pain score. Conclusions This is the first large retrospective clinical study that investigates the effects of statin use on postoperative pain and opioid consumption. We observed no difference between statin users and non-users during the initial 72 h after hip surgery. Our findings do not support the routine use of statins as part of an analgesic regimen.
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Affiliation(s)
- W Saasouh
- Department of Outcomes Research, Anaesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, P-77, Cleveland, OH 44195, USA.,Department of General Anaesthesiology, Anaesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - S Leung
- Department of Outcomes Research, Anaesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, P-77, Cleveland, OH 44195, USA
| | - H O Yilmaz
- Department of Anesthesiology and Reanimation, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey.,Outcomes Research Consortium, Cleveland, OH, USA
| | - O Koyuncu
- Outcomes Research Consortium, Cleveland, OH, USA.,Department of Anaesthesiology and Reanimation, Tayfur Ata Sökmen Medical Faculty, Mustafa Kemal University, Hatay, Turkey
| | - J You
- Department of Outcomes Research, Anaesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, P-77, Cleveland, OH 44195, USA.,Department of Quantitative Health Sciences, Cleveland Clinic, Ohio, USA
| | - N M Zimmerman
- Department of Outcomes Research, Anaesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, P-77, Cleveland, OH 44195, USA.,Department of Quantitative Health Sciences, Cleveland Clinic, Ohio, USA
| | - K Ruetzler
- Department of Outcomes Research, Anaesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, P-77, Cleveland, OH 44195, USA
| | - A Turan
- Department of Outcomes Research, Anaesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, P-77, Cleveland, OH 44195, USA
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Too Deep or Not Too Deep?: A Propensity-Matched Comparison of the Analgesic Effects of a Superficial Versus Deep Serratus Fascial Plane Block for Ambulatory Breast Cancer Surgery. Reg Anesth Pain Med 2019; 43:480-487. [PMID: 29932431 DOI: 10.1097/aap.0000000000000768] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Serratus fascial plane block can reduce pain following breast surgery, but the question of whether to inject the local anesthetic superficial or deep to the serratus muscle has not been answered. This cohort study compares the analgesic benefits of superficial versus deep serratus plane blocks in ambulatory breast cancer surgery patients at Women's College Hospital between February 2014 and December 2016. We tested the joint hypothesis that deep serratus block is noninferior to superficial serratus block for postoperative in-hospital (pre-discharge) opioid consumption and pain severity. METHODS One hundred sixty-six patients were propensity matched among 2 groups (83/group): superficial and deep serratus blocks. The cohort was used to evaluate the effect of blocks on postoperative oral morphine equivalent consumption and area under the curve for rest pain scores. We considered deep serratus block to be noninferior to superficial serratus block if it were noninferior for both outcomes, within 15 mg morphine and 4 cm·h units margins. Other outcomes included intraoperative fentanyl requirements, time to first analgesic request, recovery room stay, and incidence of postoperative nausea and vomiting. RESULTS Deep serratus block was associated with postoperative morphine consumption and pain scores area under the curve that were noninferior to those of the superficial serratus block. Intraoperative fentanyl requirements, time to first analgesic request, recovery room stay, and postoperative nausea and vomiting were not different between blocks. CONCLUSIONS The postoperative in-hospital analgesia associated with deep serratus block is as effective (within an acceptable margin) as superficial serratus block following ambulatory breast cancer surgery. These new findings are important to inform both current clinical practices and future prospective studies.
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The relative effects of dexmedetomidine and propofol on cerebral blood flow velocity and regional brain oxygenation: A randomised noninferiority trial. Eur J Anaesthesiol 2018; 34:732-739. [PMID: 28891839 DOI: 10.1097/eja.0000000000000662] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dexmedetomidine constricts cerebral blood vessels without a concomitant reduction in cerebral metabolic oxygen consumption. Its safety as a sedative in patients with neurological diseases thus remains uncertain. OBJECTIVE Our primary objective was to test the hypothesis that dexmedetomidine is noninferior to propofol as regards cerebral blood flow (CBF) velocity and brain oxygenation. DESIGN Unblinded randomised trial. SETTING Cleveland Clinic Hospital, Cleveland, from November 2010 to July 2013. PATIENTS Forty-four patients scheduled for insertion of a deep-brain stimulating electrodes. INTERVENTIONS Patients were randomised to receive either dexmedetomidine or propofol sedation during deep-brain stimulating electrode insertion. MAIN OUTCOME MEASURES Intraoperative CBF velocity was measured with transcranial Doppler, and brain oxygenation was assessed with near-infrared spectroscopy. Noninferiority of dexmedetomidine to propofol was defined as a less than 20% difference in means. RESULTS Twenty-three patients were given dexmedetomidine and 21 propofol. Baseline characteristics and operative management were similar in each group. Dexmedetomidine was noninferior to propofol on both CBF and brain oxygenation, confirming our primary hypothesis. For cerebral flood flow, the estimated ratio of means (dexmedetomidine/propofol) was 0.94 [90% CI: 0.84 to 1.05], P = 0.011 for noninferiority. For brain oxygenation, the estimated ratio of means was 0.99 [90% CI: 0.96 to 1.02], P < 0.001 for noninferiority. Superiority was not found for either primary outcome. Dexmedetomidine provided deeper sedation than propofol, with a difference of medians of 1 [90% CI: 0 to 2], P < 0.001 on the Observer's Assessment of Alertness/Sedation scale. No significant differences were observed in pulsatility index, cerebral perfusion pressure, number of hypertensive or apnoeic episodes. CONCLUSION Regional brain oxygenation and CBF velocity are comparably preserved during dexmedetomidine and propofol sedation. Thus, the use of dexmedetomidine in patients with movement disorders appears reasonable. TRIAL REGISTRATION The trial was registered at ClinicalTrials.gov (NCT 01200433).
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Optimal Weighted Wilcoxon–Mann–Whitney Test for Prioritized Outcomes. NEW FRONTIERS OF BIOSTATISTICS AND BIOINFORMATICS 2018. [DOI: 10.1007/978-3-319-99389-8_1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Abdallah FW, MacLean D, Madjdpour C, Cil T, Bhatia A, Brull R. Pectoralis and Serratus Fascial Plane Blocks Each Provide Early Analgesic Benefits Following Ambulatory Breast Cancer Surgery: A Retrospective Propensity-Matched Cohort Study. Anesth Analg 2017; 125:294-302. [PMID: 28328756 DOI: 10.1213/ane.0000000000001975] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pectoralis and serratus blocks have been described recently for use in breast surgery, but evidence supporting their analgesic benefits is limited. This cohort study evaluates the benefits of adding a pectoralis or serratus block to conventional opioid-based analgesia (control) in patients who underwent ambulatory breast cancer surgery at Women's College Hospital between July 2013 and May 2015. We tested the joint hypothesis that adding a pectoralis or serratus block reduced postoperative in-hospital (predischarge) opioid consumption and nausea and vomiting (PONV). We also examined the 2 block types for noninferiority. METHODS A total of 225 patients were propensity matched on 5 potential confounders among 3 study groups (75 per group): (1) pectoralis; (2) serratus; and (3) control. The propensity-matched cohort was used to evaluate the effect of the study group on postoperative in-hospital oral morphine equivalent consumption and PONV. We considered pectoralis noninferior to serratus block if it was noninferior for both outcomes, within 10 mg morphine and 17.5% in PONV incidence margins. Other outcomes included intraoperative fentanyl requirements, pain scores, time to first analgesic request, and duration of recovery room stay. RESULTS Both pectoralis and serratus blocks were each associated with reduced postoperative in-hospital opioid consumption and PONV compared with control. Pectoralis was noninferior to serratus block for these 2 outcomes. Pectoralis and serratus blocks were each associated with reduced intraoperative fentanyl requirements, prolonged time to first analgesic request, and expedited recovery room discharge compared with control; there were no differences for the remaining outcomes. CONCLUSIONS Pectoralis and serratus blocks were each associated with a reduction in postoperative in-hospital opioid consumption and PONV compared with conventional opioid-based analgesia after ambulatory breast cancer surgery.
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Affiliation(s)
- Faraj W Abdallah
- From the *Department of Anesthesia, University of Toronto, Ontario, Canada; †Department of Anesthesia and Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; ‡Department of Anesthesia, Women's College Hospital, Toronto, Ontario, Canada; §Department of Surgery, University of Toronto, Ontario, Canada; and ‖Department of Surgery, Women's College Hospital, Toronto, Ontario, Canada
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Quantitative Assessment of Statistical Reviews of Patient Safety Research Articles. J Patient Saf 2017; 15:184-190. [PMID: 28590949 DOI: 10.1097/pts.0000000000000391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES For 8.5 consecutive years, all patient safety articles of a journal underwent statistical review before publication. We sought to establish the prevalence of statistical themes in the statistical reviews, consideration of contemporary statistical methods, and their associations with time to journal receipt of authors' revision. METHODS An initial set of statistical themes was created using the statistical editor's notes. For example, for the statistical theme of "CONSORT checklist," the search term needed was "CONSORT." A complete (exhaustive) list of additional themes was obtained inductively. RESULTS Among the 273 subsequent reviews for manuscripts that were ultimately accepted, the number of paragraphs that included a theme of a statistical method was only weakly associated with longer revision times (Kendall τ = 0.139 ± 0.039, P = 0.0004). Among the total 3274 paragraphs of statistical reviews, 72.2% did not include a theme of a statistical method (e.g., the editor instead asked the authors to clarify what statistical method had been used) (95% confidence interval [CI] = 70.6%-73.7%, P < 0.0001 versus 50%).Among the 207 manuscripts with a review that included a statistical method, 47.3% included a contemporary topic (e.g., generalized pivotal methods) (95% CI = 40.4%-54.4%). However, among the 911 corresponding paragraphs of statistical review comments, only 16.0% included a contemporary theme (95% CI = 13.7%-18.6%). CONCLUSIONS The revised versions of patient safety articles, which are eventually to be accepted for publication, have many statistical limitations especially in the reporting (writing) of basic statistical methods and results. The results suggest a need for education of patient safety investigators to include statistical writing.
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Welsing PM, Oude Rengerink K, Collier S, Eckert L, van Smeden M, Ciaglia A, Nachbaur G, Trelle S, Taylor AJ, Egger M, Goetz I. Series: Pragmatic trials and real world evidence: Paper 6. Outcome measures in the real world. J Clin Epidemiol 2017; 90:99-107. [PMID: 28502810 DOI: 10.1016/j.jclinepi.2016.12.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 12/05/2016] [Accepted: 12/12/2016] [Indexed: 10/19/2022]
Abstract
Results from pragmatic trials should reflect the comparative treatment effects encountered in patients in real-life clinical practice to guide treatment decisions. Therefore, pragmatic trials should focus on outcomes that are relevant to patients, clinical practice, and treatment choices. This sixth article in the series (see Box) discusses different types of outcomes and their suitability for pragmatic trials, design choices for measuring these outcomes, and their implications and challenges. Measuring outcomes in pragmatic trials should not interfere with real-world clinical practice to ensure generalizability of trial results, and routinely collected outcomes should be prioritized. Typical outcomes include mortality, morbidity, functional status, well-being, and resource use. Surrogate endpoints are typically avoided as primary outcome. It is important to measure outcomes over a relevant time horizon and obtain valid and precise results. As pragmatic trials are often open label, a less subjective outcome can reduce bias. Methods that decrease bias or enhance precision of the results, such as standardization and blinding of outcome assessment, should be considered when a high risk of bias or high variability is expected. The selection of outcomes in pragmatic trials should be relevant for decision making and feasible in terms of executing the trial in the context of interest. Therefore, this should be discussed with all stakeholders as early as feasible to ensure the relevance of study results for decision making in clinical practice and the ability to perform the study.
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Affiliation(s)
- Paco M Welsing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands.
| | - Katrien Oude Rengerink
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands
| | - Sue Collier
- GSK, Respiratory R&D, Stockley Park West, Brentford, Middlesex TW89GS, UK
| | - Laurent Eckert
- Health Economics and Outcome Research, Sanofi, Avenue Pierre Brossolette, 91385, Chilly-Mazarin, France
| | - Maarten van Smeden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands
| | - Antonio Ciaglia
- International Alliance of Patients' Organizations, 49-51 East Road, London, N1 6AH, UK
| | - Gaelle Nachbaur
- Medical Department, GSK, 100 route de Versailles, Marly-le-Roi 78163, France
| | - Sven Trelle
- Department of Clinical Research, CTU, University of Bern, Finkenhubelweg 11, CH-3012, Bern, Switzerland
| | - Aliki J Taylor
- Global Outcomes Research, Takeda Development Centre Europe Ltd, 61 Aldwych, WC2B 4AE, London, UK
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, CH-3012, Bern, Switzerland
| | - Iris Goetz
- Global Patient Outcomes & Real World Evidence, Eli Lilly and Company Ltd, Erl Wood Manor, Sunninghill Road, Windlesham, Surrey, GU20 6PH, UK
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Naik BI, Tsang S, Knisely A, Yerra S, Durieux ME. Retrospective case-control non-inferiority analysis of intravenous lidocaine in a colorectal surgery enhanced recovery program. BMC Anesthesiol 2017; 17:16. [PMID: 28143397 PMCID: PMC5282801 DOI: 10.1186/s12871-017-0306-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 01/19/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programs typically utilizes multi-modal analgesia to reduce perioperative opioid consumption. Systemic lidocaine is used in several of these ERAS algorithms and has been shown to reduce opioid use after colorectal surgery. However it is unclear how much the other components of an ERAS protocol contribute to the final outcome. Using a noninferiority analysis we sought to assess the role of perioperative lidocaine in an ERAS program for colorectal surgery, using pain and opioid consumption as outcomes. METHODS We conducted a retrospective review of patients who had received intravenous lidocaine perioperatively during colorectal surgery. We matched them with patients who were managed using a multi-component ERAS protocol, which included perioperative lidocaine. We tested a joint hypothesis of noninferiority of lidocaine infusion to ERAS protocol in postoperative pain scores and opioid consumption. We assigned a noninferiority margin of 1 point (on an 11-point numerical rating scale) difference in pain and a ratio [mean (lidocaine) / mean (ERAS)] of 1.2 in opioid consumption, respectively. RESULTS Fifty-two patients in the lidocaine group were matched with patients in the ERAS group. With regards to opioid consumption, in the overall [1.68 (1.43-1.98)] [odds ratio (95% confidence interval)] analysis and on postoperative day (POD) 1 [2.38 (1.74-3.31)] lidocaine alone was inferior to multi-modal analgesia. On POD 2 and beyond, although the mean odds ratio for opioid consumption was 1.43 [1.43 (1.17-1.73)], the lower limit extended beyond the pre-defined cut-off of 1.2, rendering the outcome inconclusive. For pain scores lidocaine is non-inferior to ERAS [-0.17 (-1.08-0.74)] on POD 2 and beyond. Pain scores on POD 1 and in the overall cohort were inconclusive based on the noninferiority analysis. CONCLUSIONS The addition of a multi-component ERAS protocol to intravenous lidocaine incrementally reduces opioid consumption, most evident on POD 1. For pain scores the data is inconclusive on POD 1, however on POD 2 and beyond lidocaine alone is non-inferior to an ERAS program with lidocaine. Opioid-related complications, including return of bowel function, were not different between the groups despite reduced opioid use in the ERAS group.
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Affiliation(s)
- Bhiken I Naik
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA. .,Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA.
| | - Siny Tsang
- Department of Epidemiology, Columbia University, New York, NY, USA
| | - Anne Knisely
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Sandeep Yerra
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Marcel E Durieux
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA.,Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
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Matsouaka RA, Singhal AB, Betensky RA. An optimal Wilcoxon-Mann-Whitney test of mortality and a continuous outcome. Stat Methods Med Res 2016; 27:2384-2400. [PMID: 27920364 DOI: 10.1177/0962280216680524] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
We consider a two-group randomized clinical trial, where mortality affects the assessment of a follow-up continuous outcome. Using the worst-rank composite endpoint, we develop a weighted Wilcoxon-Mann-Whitney test statistic to analyze the data. We determine the optimal weights for the Wilcoxon-Mann-Whitney test statistic that maximize its power. We derive a formula for its power and demonstrate its accuracy in simulations. Finally, we apply the method to data from an acute ischemic stroke clinical trial of normobaric oxygen therapy.
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Affiliation(s)
- Roland A Matsouaka
- 1 Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA.,2 Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Aneesh B Singhal
- 3 Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Rebecca A Betensky
- 4 Department of Biostatistics, Harvard T.H. Chan School of Public Health.,5 Harvard NeuroDiscovery Center, Harvard Medical School
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A Clinical Comparison of Intravenous and Epidural Local Anesthetic for Major Abdominal Surgery. Reg Anesth Pain Med 2016; 41:28-36. [PMID: 26650426 DOI: 10.1097/aap.0000000000000332] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Epidural analgesia provides good pain control after many postoperative procedures, but it can lead to complications, has some contraindications, and occasionally fails. Intravenous lidocaine infusion has been suggested as an alternative. We assessed, in our clinical practice, the effects of perioperative intravenous lidocaine infusion compared with epidural analgesia for major abdominal surgery. METHODS We conducted a retrospective review of patients who had received intravenous lidocaine (1 mg/kg per hour) perioperatively after a major abdominal surgery. We matched them with patients who had received epidural analgesia. We tested a joint hypothesis of noninferiority of lidocaine infusion to epidural analgesia in postoperative pain scores and opioid consumption. We assigned a noninferiority margin of 1 point (on an 11-point numerical rating scale) difference in pain and a ratio [mean (lidocaine) / mean (epidural)] of 1.2 in opioid consumption, respectively. RESULTS Two hundred sixteen patients (108 in each group) were analyzed. Intravenous lidocaine was not inferior to epidural analgesia with respect to pain scores. Lidocaine infusion was inferior to epidural analgesia with respect to opioid consumption. Patients in the lidocaine group had fewer episodes of hypotension and less postoperative nausea and vomiting, pruritus, and urinary retention. Patients receiving lidocaine also had earlier urinary catheter removal and earlier first gastrointestinal function. Daily mental status assessment was similar between the 2 groups. CONCLUSIONS Patients who received systemic lidocaine infusions with the addition of PRN (as needed) opioids administered for breakthrough pain did not have clinically significant differences in pain scores on postoperative day 2 and beyond. Intravenous lidocaine infusion in major abdominal surgery was inferior to epidural analgesia with respect to opioid consumption. However, lidocaine was associated with improvements in several important aspects of recovery.
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Steiner J, Sessler D, Makarova N, Mascha E, Olomu P, Zhong J, Setiawan C, Handy A, Kravitz B, Szmuk P. Use of deep laryngeal oxygen insufflation during laryngoscopy in children: a randomized clinical trial. Br J Anaesth 2016; 117:350-7. [DOI: 10.1093/bja/aew186] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2016] [Indexed: 11/12/2022] Open
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Adductor Canal Block Provides Noninferior Analgesia and Superior Quadriceps Strength Compared with Femoral Nerve Block in Anterior Cruciate Ligament Reconstruction. Anesthesiology 2016; 124:1053-64. [PMID: 26938989 DOI: 10.1097/aln.0000000000001045] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND By targeting the distal branches of the femoral nerve in the mid-thigh, the adductor canal block (ACB) can preserve quadriceps muscle strength while providing analgesia similar to a conventional femoral nerve block (FNB) for inpatients undergoing major knee surgery. In this randomized, double-blind, noninferiority trial, the authors hypothesized that ACB provides postoperative analgesia that is at least as good as FNB while preserving quadriceps strength after outpatient anterior cruciate ligament reconstruction. METHODS A total of 100 patients were randomized to receive ACB or FNB with 20 ml ropivacaine 0.5% (with epinephrine). The authors sequentially tested the joint hypothesis that ACB is noninferior to FNB for cumulative oral morphine equivalent consumption and area under the curve for pain scores during the first 24 h postoperatively and also superior to FNB for postblock quadriceps maximal voluntary isometric contraction. RESULTS The authors analyzed 52 and 48 patients who received ACB and FNB, respectively. Compared with preset noninferiority margins, the ACB-FNB difference (95% CI) in morphine consumption and area under the curve for pain scores were -4.8 mg (-12.3 to 2.7) (P = 0.03) and -71 mm h (-148 to 6) (P < 0.00001), respectively, indicating noninferiority of ACB for both outcomes. The maximal voluntary isometric contraction for ACB and FNB at 45 min were 26.6 pound-force (24.7-28.6) and 10.6 pound-force (8.3-13.0) (P < 0.00001), respectively, indicating superiority of ACB. CONCLUSION Compared with FNB, the study findings suggest that ACB preserves quadriceps strength and provides noninferior postoperative analgesia for outpatients undergoing anterior cruciate ligament reconstruction.
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Clarke E, Saidu Y, Adetifa JU, Adigweme I, Hydara MB, Bashorun AO, Moneke-Anyanwoke N, Umesi A, Roberts E, Cham PM, Okoye ME, Brown KE, Niedrig M, Chowdhury PR, Clemens R, Bandyopadhyay AS, Mueller J, Jeffries DJ, Kampmann B. Safety and immunogenicity of inactivated poliovirus vaccine when given with measles-rubella combined vaccine and yellow fever vaccine and when given via different administration routes: a phase 4, randomised, non-inferiority trial in The Gambia. LANCET GLOBAL HEALTH 2016; 4:e534-47. [PMID: 27364568 DOI: 10.1016/s2214-109x(16)30075-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 04/17/2016] [Accepted: 04/27/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The introduction of the inactivated poliovirus vaccine (IPV) represents a crucial step in the polio eradication endgame. This trial examined the safety and immunogenicity of IPV given alongside the measles-rubella and yellow fever vaccines at 9 months and when given as a full or fractional dose using needle and syringe or disposable-syringe jet injector. METHODS We did a phase 4, randomised, non-inferiority trial at three periurban government clinics in west Gambia. Infants aged 9-10 months who had already received oral poliovirus vaccine were randomly assigned to receive the IPV, measles-rubella, and yellow fever vaccines, singularly or in combination. Separately, IPV was given as a full intramuscular or fractional intradermal dose by needle and syringe or disposable-syringe jet injector at a second visit. The primary outcomes were seroprevalence rates for poliovirus 4-6 weeks post-vaccination and the rate of seroconversion between baseline and post-vaccination serum samples for measles, rubella, and yellow fever; and the post-vaccination antibody titres generated against each component of the vaccines. We did a per-protocol analysis with a non-inferiority margin of 10% for poliovirus seroprevalence and measles, rubella, and yellow fever seroconversion, and (1/3) log2 for log2-transformed antibody titres. This trial is registered with ClinicalTrials.gov, number NCT01847872. FINDINGS Between July 10, 2013, and May 8, 2014, we assessed 1662 infants for eligibility, of whom 1504 were enrolled into one of seven groups for vaccine interference and one of four groups for fractional dosing and alternative route of administration. The rubella and yellow fever antibody titres were reduced by co-administration but the seroconversion rates achieved non-inferiority in both cases (rubella, -4·5% [95% CI -9·5 to -0·1]; yellow fever, 1·2% [-2·9 to 5·5]). Measles and poliovirus responses were unaffected (measles, 6·8% [95% CI -1·4 to 14·9]; poliovirus serotype 1, 1·6% [-6·7 to 4·7]; serotype 2, 0·0% [-2·1 to 2·1]; serotype 3, 0·0% [-3·8 to 3·9]). Poliovirus seroprevalence was universally high (>97%) after vaccination, but the antibody titres generated by fractional intradermal doses of IPV did not achieve non-inferiority compared with full dose. The number of infants who seroconverted or had a four-fold rise in titres was also lower by the intradermal route. There were no safety concerns. INTERPRETATION The data support the future co-administration of IPV, measles-rubella, and yellow fever vaccines within the Expanded Programme on Immunization schedule at 9 months. The administration of single fractional intradermal doses of IPV by needle and syringe or disposable-syringe jet injector compromises the immunity generated, although it results in a high post-vaccination poliovirus seroprevalence. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Ed Clarke
- MRC Unit The Gambia, Fajara, Banjul, The Gambia.
| | - Yauba Saidu
- MRC Unit The Gambia, Fajara, Banjul, The Gambia
| | | | | | | | | | | | - Ama Umesi
- MRC Unit The Gambia, Fajara, Banjul, The Gambia
| | | | | | | | - Kevin E Brown
- Virus Reference Department, Public Health England, Colindale, UK
| | - Matthias Niedrig
- Centre for Biological Threats and Special Pathogens, Robert Koch Institut, Berlin, Germany
| | - Panchali Roy Chowdhury
- Centre for Biological Threats and Special Pathogens, Robert Koch Institut, Berlin, Germany
| | - Ralf Clemens
- Global Research in Infectious Diseases, Rio de Janeiro, Brazil
| | | | | | | | - Beate Kampmann
- MRC Unit The Gambia, Fajara, Banjul, The Gambia; Department of Medicine, Imperial College, London, UK
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Mamoun NF, Lin P, Zimmerman NM, Mascha EJ, Mick SL, Insler SR, Sessler DI, Duncan AE. Intravenous acetaminophen analgesia after cardiac surgery: A randomized, blinded, controlled superiority trial. J Thorac Cardiovasc Surg 2016; 152:881-889.e1. [PMID: 27236864 DOI: 10.1016/j.jtcvs.2016.04.078] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 03/14/2016] [Accepted: 04/23/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pain after cardiac surgery traditionally has been controlled by intravenous opioids and nonsteroidal antiinflammatory drugs. An intravenous analgesic with fewer adverse effects is needed. Therefore, we tested the primary hypothesis that intravenous acetaminophen is more effective than placebo for pain management, which was defined a priori as superior on either pain intensity score and/or opioid consumption and not worse on either. METHODS In this single-center, double-blind trial, 147 patients having cardiac surgery via median sternotomy were randomized to receive either 1 g of intravenous acetaminophen (73 patients) every 6 hours for 24 hours or comparable placebo (74 patients) starting in the operating room after sternal closure. Cumulative opioid consumption (in morphine equivalents) and pain intensity scores (on a 0-10 Numeric Rating Scale) were measured at 4, 6, 8, 12, 16, 20, and 24 hours after surgery. We estimated ratio of mean opioid consumption by using multivariable linear regression (noninferiority delta = 1.15) and pain score difference by using repeated measures regression (noninferiority delta = 1). RESULTS Acetaminophen was superior to placebo on mean pain intensity scores and noninferior on opioid consumption, with estimated difference in mean pain (95% confidence interval) of -0.90 (-1.39, -0.42), P < .001 (superior), and estimated ratio of means in opioid consumption (90% confidence interval) of 0.89 (0.73-1.10), P = .28 (noninferior; not superior). CONCLUSIONS Intravenous acetaminophen reduced pain after cardiac surgery, but not opioid consumption. Intravenous acetaminophen can be an effective analgesic adjunct in patients recovering from median sternotomy.
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Affiliation(s)
- Negmeldeen F Mamoun
- Department of Cardiothoracic Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Peirong Lin
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nicole M Zimmerman
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Edward J Mascha
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Stephanie L Mick
- Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Steven R Insler
- Department of Cardiothoracic Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Andra E Duncan
- Department of Cardiothoracic Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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Ayad S, Babazade R, Elsharkawy H, Nadar V, Lokhande C, Makarova N, Khanna R, Sessler DI, Turan A. Comparison of Transversus Abdominis Plane Infiltration with Liposomal Bupivacaine versus Continuous Epidural Analgesia versus Intravenous Opioid Analgesia. PLoS One 2016; 11:e0153675. [PMID: 27082959 PMCID: PMC4833354 DOI: 10.1371/journal.pone.0153675] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 04/01/2016] [Indexed: 02/02/2023] Open
Abstract
Epidural analgesia is considered the standard of care but cannot be provided to all patients Liposomal bupivacaine has been approved for field blocks such as transversus abdominis plane (TAP) blocks but has not been clinically compared against other modalities. In this retrospective propensity matched cohort study we thus tested the primary hypothesis that TAP infiltration are noninferior (not worse) to continuous epidural analgesia and superior (better) to intravenous opioid analgesia in patients recovering from major lower abdominal surgery. 318 patients were propensity matched on 18 potential factors among three groups (106 per group): 1) TAP infiltration with bupivacaine liposome; 2) continuous Epidural analgesia with plain bupivacaine; and; 3) intravenous patient-controlled analgesia (IV PCA). We claimed TAP noninferior (not worse) over Epidural if TAP was noninferior (not worse) on total morphine-equivalent opioid and time-weighted average pain score (10-point scale) within first 72 hours after surgery with noninferiority deltas of 1 (10-point scale) for pain and an increase less of 20% in the mean morphine equivalent opioid consumption. We claimed TAP or Epidural groups superior (better) over IV PCA if TAP or Epidural was superior on opioid consumption and at least noninferior on pain outcome. Multivariable linear regressions within the propensity-matched cohorts were used to model total morphine-equivalent opioid dose and time-weighted average pain score within first 72 hours after surgery; joint hypothesis framework was used for formal testing. TAP infiltration were noninferior to Epidural on both primary outcomes (p<0.001). TAP infiltration were noninferior to IV PCA on pain scores (p = 0.001) but we did not find superiority on opioid consumption (p = 0.37). We did not find noninferiority of Epidural over IV PCA on pain scores (P = 0.13) and nor did we find superiority on opioid consumption (P = 0.98). TAP infiltration with liposomal bupivacaine and continuous epidural analgesia were similar in terms of pain and opioid consumption, and not worse in pain compared with IV PCA. TAP infiltrations might be a reasonable alternative to epidural analgesia in abdominal surgical patients. A large randomized trial comparing these techniques is justified.
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Affiliation(s)
- Sabry Ayad
- Department of Anesthesiology and Pain Management, Fairview Hospital; Department of Outcomes Research, Cleveland Clinic, Anesthesiology Institute Cleveland, Ohio
| | - Rovnat Babazade
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas and Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Hesham Elsharkawy
- Departments of General Anesthesiology and Outcomes Research, Cleveland Clinic, Anesthesiology Institute, Cleveland, Ohio
| | - Vinayak Nadar
- Department of Outcomes Research, Cleveland Clinic, Anesthesiology Institute, Cleveland, Ohio
| | - Chetan Lokhande
- Department of Outcomes Research, Cleveland Clinic, Anesthesiology Institute, Cleveland, Ohio
| | - Natalya Makarova
- Departments of Qualitative Health Sciences and Outcomes Research, Cleveland Clinic, Anesthesiology Institute, Cleveland, Ohio
| | - Rashi Khanna
- Department of Outcomes Research, Cleveland Clinic, Anesthesiology Institute, Cleveland, Ohio
| | - Daniel I. Sessler
- Department of Outcomes Research, Cleveland Clinic, Anesthesiology Institute, Cleveland, Ohio
| | - Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Anesthesiology Institute, Cleveland, Ohio
- * E-mail:
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IV and Perineural Dexmedetomidine Similarly Prolong the Duration of Analgesia after Interscalene Brachial Plexus Block. Anesthesiology 2016; 124:683-95. [DOI: 10.1097/aln.0000000000000983] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Background
Perineural and IV dexmedetomidine have each been suggested to prolong the duration of analgesia when administered in conjunction with peripheral nerve blocks. In the first randomized, triple-masked, placebo-controlled trial to date, the authors aimed to define and compare the efficacy of perineural and IV dexmedetomidine in prolonging the analgesic duration of single-injection interscalene brachial plexus block (ISB) for outpatient shoulder surgery.
Methods
Ninety-nine patients were randomized to receive ISB using 15 ml ropivacaine, 0.5%, with 0.5 μg/kg dexmedetomidine administered perineurally (DexP group), intravenously (DexIV group), or none (control group). The authors sequentially tested the joint hypothesis that dexmedetomidine prolongs the duration of analgesia and reduces the 24-h cumulative postoperative morphine consumption. Motor blockade, pain severity, hemodynamic variations, opioid-related side effects, postoperative neurologic symptoms, and patient satisfaction were also evaluated.
Results
Ninety-nine patients were analyzed. The duration of analgesia was 10.9 h (10.0 to 11.8 h) and 9.8 h (9.0 to 10.6 h) for the DexP and DexIV groups, respectively, compared with 6.7 h (5.6 to 7.8) for the control group (P < 0.001). Dexmedetomidine also reduced the 24-h cumulative morphine consumption to 63.9 mg (58.8 to 69.0 mg) and 66.2 mg (60.6 to 71.8 mg) for the DexP and DexIV groups, respectively, compared with 81.9 mg (75.0 to 88.9 mg) for the control group (P < 0.001). DexIV was noninferior to DexP for these outcomes. Both dexmedetomidine routes reduced the pain and opioid consumption up to 8 h postoperatively and did not prolong the duration of motor blockade.
Conclusion
Both perineural and IV dexmedetomidine can effectively prolong the ISB analgesic duration and reduce the opioid consumption without prolonging motor blockade.
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Pei L, Zhou Y, Tan G, Mao F, Yang D, Guan J, Lin Y, Wang X, Zhang Y, Zhang X, Shen S, Xu Z, Sun Q, Huang Y. Ultrasound-Assisted Thoracic Paravertebral Block Reduces Intraoperative Opioid Requirement and Improves Analgesia after Breast Cancer Surgery: A Randomized, Controlled, Single-Center Trial. PLoS One 2015; 10:e0142249. [PMID: 26588217 PMCID: PMC4654480 DOI: 10.1371/journal.pone.0142249] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 10/18/2015] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES The contribution of ultrasound-assisted thoracic paravertebral block to postoperative analgesia remains unclear. We compared the effect of a combination of ultrasound assisted-thoracic paravertebral block and propofol general anesthesia with opioid and sevoflurane general anesthesia on volatile anesthetic, propofol and opioid consumption, and postoperative pain in patients having breast cancer surgery. METHODS Patients undergoing breast cancer surgery were randomly assigned to ultrasound-assisted paravertebral block with propofol general anesthesia (PPA group, n = 121) or fentanyl with sevoflurane general anesthesia (GA group, n = 126). Volatile anesthetic, propofol and opioid consumption, and postoperative pain intensity were compared between the groups using noninferiority and superiority tests. RESULTS Patients in the PPA group required less sevoflurane than those in the GA group (median [interquartile range] of 0 [0, 0] vs. 0.4 [0.3, 0.6] minimum alveolar concentration [MAC]-hours), less intraoperative fentanyl requirements (100 [50, 100] vs. 250 [200, 300]μg,), less intense postoperative pain (median visual analog scale score 2 [1, 3.5] vs. 3 [2, 4.5]), but more propofol (median 529 [424, 672] vs. 100 [100, 130] mg). Noninferiority was detected for all four outcomes; one-tailed superiority tests for each outcome were highly significant at P<0.001 in the expected directions. CONCLUSIONS The combination of propofol anesthesia with ultrasound-assisted paravertebral block reduces intraoperative volatile anesthetic and opioid requirements, and results in less post operative pain in patients undergoing breast cancer surgery. TRIAL REGISTRATION ClinicalTrial.gov NCT00418457.
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Affiliation(s)
- Lijian Pei
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Yidong Zhou
- Department of Breast Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Gang Tan
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Feng Mao
- Department of Breast Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Dongsheng Yang
- Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, OH, United States of America
| | - Jinghong Guan
- Department of Breast Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Yan Lin
- Department of Breast Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Xuejing Wang
- Department of Breast Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Yanna Zhang
- Department of Breast Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Xiaohui Zhang
- Department of Breast Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Songjie Shen
- Department of Breast Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Zhonghuang Xu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Qiang Sun
- Department of Breast Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, PR China
- * E-mail:
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