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Bukhari S, Leth MF, Laursen CCW, Larsen ME, Tornøe AS, Eriksen VR, Hovmand AEK, Jakobsen JC, Maagaard M, Mathiesen O. Risks of serious adverse events with non-steroidal anti-inflammatory drugs in gastrointestinal surgery: A systematic review with meta-analysis and trial sequential analysis. Acta Anaesthesiol Scand 2024; 68:871-887. [PMID: 38629348 DOI: 10.1111/aas.14425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 03/19/2024] [Accepted: 03/21/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly recommended for perioperative opioid-sparing multimodal analgesic treatments. Concerns regarding the potential for serious adverse events (SAEs) associated with perioperative NSAID treatment are especially relevant following gastrointestinal surgery. We assessed the risks of SAEs with perioperative NSAID treatment in patients undergoing gastrointestinal surgery. METHODS We conducted a systematic review of randomised clinical trials assessing the harmful effects of NSAIDs versus placebo, usual care or no intervention in patients undergoing gastrointestinal surgery. The primary outcome was an incidence of SAEs. We systematically searched for eligible trials in five major databases up to January 2024. We performed risk of bias assessments to account for systematic errors, trial sequential analysis (TSA) to account for the risks of random errors, performed meta-analyses using R and used the Grading of Recommendations Assessment, Development and Evaluation framework to describe the certainty of evidence. RESULTS We included 22 trials enrolling 1622 patients for our primary analyses. Most trials were at high risk of bias. Meta-analyses (risk ratio 0.78; 95% confidence interval [CI] 0.51-1.19; I2 = 4%; p = .24; very low certainty of evidence) and TSA indicated a lack of information on the effects of NSAIDs compared to placebo on the risks of SAEs. Post-hoc beta-binomial regression sensitivity analyses including trials with zero events showed a reduction in SAEs with NSAIDs versus placebo (odds ratio 0.73; CI 0.54-0.99; p = .042). CONCLUSION In adult patients undergoing gastrointestinal surgery, there was insufficient information to draw firm conclusions on the effects of NSAIDs on SAEs. The certainty of the evidence was very low.
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Affiliation(s)
- Shaheer Bukhari
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Morten F Leth
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Christina C W Laursen
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Mia E Larsen
- Department of Anesthesiology, Nykøbing Falster Hospital, Nykøbing Falster, Denmark
| | - Anders S Tornøe
- Department of Anesthesiology, Nordland Hospital Trust, Bodø, Norway
| | - Vibeke R Eriksen
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Alfred E K Hovmand
- Department of Anesthesiology, University Hospital Northern Norway, Tromsø, Norway
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Mathias Maagaard
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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Lirk P, Badaoui J, Stuempflen M, Hedayat M, Freys SM, Joshi GP. PROcedure-SPECific postoperative pain management guideline for laparoscopic colorectal surgery: A systematic review with recommendations for postoperative pain management. Eur J Anaesthesiol 2024; 41:161-173. [PMID: 38298101 DOI: 10.1097/eja.0000000000001945] [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: 02/02/2024]
Abstract
Colorectal cancer is the second most common cancer diagnosed in women and third most common in men. Laparoscopic resection has become the standard surgical technique worldwide given its notable benefits, mainly the shorter length of stay and less postoperative pain. The aim of this systematic review was to evaluate the current literature on postoperative pain management following laparoscopic colorectal surgery and update previous procedure-specific pain management recommendations. The primary outcomes were postoperative pain scores and opioid requirements. We also considered study quality, clinical relevance of trial design, and a comprehensive risk-benefit assessment of the analgesic intervention. We performed a literature search to identify randomised controlled studies (RCTs) published before January 2022. Seventy-two studies were included in the present analysis. Through the established PROSPECT process, we recommend basic analgesia (paracetamol for rectal surgery, and paracetamol with either a nonsteroidal anti-inflammatory drug or cyclo-oxygenase-2-specific inhibitor for colonic surgery) and wound infiltration as first-line interventions. No consensus could be achieved either for the use of intrathecal morphine or intravenous lidocaine; no recommendation can be made for these interventions. However, intravenous lidocaine may be considered when basic analgesia cannot be provided.
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Affiliation(s)
- Philipp Lirk
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital (PL, JB, MS), Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA (MH), Department of Surgery, DIAKO Ev. Diakonie-Krankenhaus, Bremen, Germany (SMF) and Department of Anesthesiology, UT Southwestern Medical Center, Dallas, Texas, USA (GPJ)
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Abernethy EK, Aly EH. Postoperative Ileus after Minimally Invasive Colorectal Surgery: A Summary of Current Strategies for Prevention and Management. Dig Surg 2024; 41:79-91. [PMID: 38359801 PMCID: PMC11025667 DOI: 10.1159/000537805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 02/12/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Postoperative ileus (POI) is one of the most common postoperative complications after colorectal surgery and prolongs hospital stays. Minimally invasive surgery (MIS) has reduced POI, but it remains common. This review explores the current methods for preventing and managing POI after MIS. SUMMARY Preoperative interventions, including optimising nutrition, preoperative medicationn, and mechanical bowel preparation with oral antibiotics, may have a role in preventing POI. Transversus abdominis plane blocks and lidocaine could replace epidural analgesia in MIS. Fluid overload should be avoided; in some cases, goal-directed fluid therapy may aid in achieving this. Pharmacological agents, such as prucalopride and dexmedetomidine, could target mechanisms underlying POI. New strategies to stimulate vagal nerve activity may promote postoperative gastrointestinal motility. Preoperative bowel stimulation could potentially reduce POI following loop ileostomy closure. However, the evidence base for several interventions remains weak and requires further corroboration with robust studies. KEY MESSAGES Despite the increasing use of MIS, POI remains a major issue following colorectal surgery. Further strategies to prevent POI are rapidly emerging. Studies using standardised definitions and perioperative care will help validate these interventions and remove barriers to accurate meta-analysis. Future studies should focus on establishing the impact of these interventions on POI after MIS specifically.
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Affiliation(s)
| | - Emad H Aly
- University of Aberdeen, Aberdeen, UK
- Aberdeen Royal Infirmary, Aberdeen, UK
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Positive Patient Postoperative Outcomes with Pharmacotherapy: A Narrative Review including Perioperative-Specialty Pharmacist Interviews. J Clin Med 2022; 11:jcm11195628. [PMID: 36233497 PMCID: PMC9572852 DOI: 10.3390/jcm11195628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/15/2022] [Accepted: 09/21/2022] [Indexed: 11/19/2022] Open
Abstract
The influence of pharmacotherapy regimens on surgical patient outcomes is increasingly appreciated in the era of enhanced recovery protocols and institutional focus on reducing postoperative complications. Specifics related to medication selection, dosing, frequency of administration, and duration of therapy are evolving to optimize pharmacotherapeutic regimens for many enhanced recovery protocolized elements. This review provides a summary of recent pharmacotherapeutic strategies, including those configured within electronic health record (EHR) applications and functionalities, that are associated with the minimization of the frequency and severity of postoperative complications (POCs), shortened hospital length of stay (LOS), reduced readmission rates, and cost or revenue impacts. Further, it will highlight preventive pharmacotherapy regimens that are correlated with improved patient preparation, especially those related to surgical site infection (SSI), venous thromboembolism (VTE), nausea and vomiting (PONV), postoperative ileus (POI), and emergence delirium (PoD) as well as less commonly encountered POCs such as acute kidney injury (AKI) and atrial fibrillation (AF). The importance of interprofessional collaboration in all periprocedural phases, focusing on medication management through shared responsibilities for drug therapy outcomes, will be emphasized. Finally, examples of collaborative care through shared mental models of drug stewardship and non-medical practice agreements to improve operative throughput, reduce operative stress, and increase patient satisfaction are illustrated.
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Shavlovskaya O, Bokova I, Shavlovskiy N. Meloxicam clinical effects. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:36-42. [DOI: 10.17116/jnevro202212201136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Brooks C. Welcome to the 12th volume of Pain Management. Pain Manag 2021; 12:1-4. [PMID: 34670401 DOI: 10.2217/pmt-2021-0103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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