1
|
Guo X, Wang Z, Gao L, Ma W, Xing B, Lian W. Nonsteroidal antiinflammatory drugs versus tramadol in pain management following transsphenoidal surgery for pituitary adenomas: a randomized, double-blind, noninferiority trial. J Neurosurg 2022; 137:69-78. [PMID: 34826819 DOI: 10.3171/2021.8.jns211637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 08/18/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Opioid-minimizing or nonopioid therapy using nonsteroidal antiinflammatory drugs (NSAIDs) or tramadol has been encouraged for pain management. This study aimed to examine the noninferiority of NSAIDs to tramadol for pain management following transsphenoidal surgery for pituitary adenomas in terms of analgesic efficacy, adverse events, and rescue opioid use. METHODS This was a randomized, single-center, double-blind noninferiority trial. Patients 18-70 years old with planned transsphenoidal surgery for pituitary adenomas were randomly assigned (in a 1-to-1 ratio) to receive NSAIDs (parecoxib injection and subsequent loxoprofen tablets) or tramadol (tramadol injection and subsequent tramadol tablets). The primary outcome was pain score assessed by a visual analog scale (VAS) for 24 hours following surgery; the secondary outcomes were VAS scores for 48 and 72 hours. Other prespecified outcomes included nausea, vomiting, dizziness, upset stomach, skin rash, peptic ulcer, gastrointestinal bleeding, and pethidine use to control breakthrough pain. Noninferiority of NSAIDs to tramadol was established if the upper limit of the 95% confidence interval (CI) of the VAS score difference was < 1 point and the rate difference of adverse events and pethidine use < 5%. The superiority of NSAIDs was assessed when noninferiority was verified. All analyses were performed on an intention-to-treat basis. RESULTS Two hundred two patients were enrolled between November 1, 2020, and May 31, 2021 (101 in the NSAIDs group, 101 in the tramadol group). Baseline characteristics between groups were well balanced. Mean VAS scores for 24 hours following transsphenoidal surgery were 2.6 ± 1.8 in the NSAIDs group and 3.5 ± 2.1 in the tramadol group (-0.9 difference, 95% CI -1.5 to -0.4; p value for noninferiority < 0.001, p value for superiority < 0.001). Noninferiority and superiority were also achieved for both secondary outcomes. VAS scores improved over time in both groups. Incidences of nausea (39.6% vs 61.4%, p = 0.002), vomiting (3.0% vs 42.6%, p < 0.001), and dizziness (12.9% vs 47.5%, p < 0.001) were significantly lower, while incidence of upset stomach (9.9% vs 2.0%, p = 0.017) was slightly higher in the NSAIDs group compared with the tramadol group. The percentage of opioid use was 4.0% in the NSAIDs group and 15.8% in the tramadol group (-11.8% difference, 95% CI -19.9% to -3.7%; p value for noninferiority < 0.001, p value for superiority = 0.005). CONCLUSIONS NSAIDs significantly reduced acute pain following transsphenoidal surgery, caused few adverse events, and limited opioid use compared with tramadol.
Collapse
Affiliation(s)
- Xiaopeng Guo
- 1Department of Neurosurgery and
- 2Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College
- 3China Pituitary Disease Registry Center; and
- 4China Pituitary Adenoma Specialist Council, Beijing, China
| | - Zihao Wang
- 1Department of Neurosurgery and
- 2Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College
- 3China Pituitary Disease Registry Center; and
- 4China Pituitary Adenoma Specialist Council, Beijing, China
| | - Lu Gao
- 1Department of Neurosurgery and
- 2Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College
- 3China Pituitary Disease Registry Center; and
- 4China Pituitary Adenoma Specialist Council, Beijing, China
| | - Wenbin Ma
- 1Department of Neurosurgery and
- 2Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College
- 3China Pituitary Disease Registry Center; and
- 4China Pituitary Adenoma Specialist Council, Beijing, China
| | - Bing Xing
- 1Department of Neurosurgery and
- 2Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College
- 3China Pituitary Disease Registry Center; and
- 4China Pituitary Adenoma Specialist Council, Beijing, China
| | - Wei Lian
- 1Department of Neurosurgery and
- 2Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College
- 3China Pituitary Disease Registry Center; and
- 4China Pituitary Adenoma Specialist Council, Beijing, China
| |
Collapse
|
2
|
The Impact of Preventative Multimodal Analgesia on Postoperative Opioid Requirement and Pain Control in Patients Undergoing Lumbar Fusions. Clin Spine Surg 2020; 33:E135-E140. [PMID: 31693519 DOI: 10.1097/bsd.0000000000000913] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN A prospective observational study with a historical reference group. OBJECTIVES The main objectives of this study were to determine the impact of preventative multimodal analgesia (PMA) on postoperative opioid requirements and analgesic effectiveness in patients undergoing lumbar fusion surgery. SUMMARY OF BACKGROUND DATA PMA addresses the multiple pathways of acute and chronic pain by interfering with peripheral and central sensitization and should provide a way to achieve safer and more effective pain management with reduced opioid medication use. MATERIALS AND METHODS This study compared postoperative opioid requirement and analgesic effect in a total of 101 patients undergoing elective, 1-level or 2-level transforaminal lumbar interbody fusion surgeries for symptomatic lumbar degenerative disk disease. The PMA patient group included 51 consecutive patients who received 1000 mg of acetaminophen, 300-900 mg of gabapentin, and 200-400 mg of celecoxib 1 hour before their index procedure. The reference group included 50 patients who received 15 mg of morphine-equivalent dose (MED) preoperatively.Multiple linear regression was used to evaluate the effect of PMA on postoperative pain and MED over 4 postoperative days, while controlling for all variables likely to influence these outcomes, including age, sex, baseline opioid use, duration of surgery, postoperative intrathecal morphine use and the administration of muscle relaxants and anticonvulsants. RESULTS The differences in opioid requirement and postoperative pain scores were statistically significant on all 4 postoperative days. The effect size varied from -0.54 to -0.99 (34.8%-54.2% MED reduction) for the postoperative opioid requirement and from -0.59 to -1.16 (28.9%-37.3% visual analog scale reduction) for postoperative pain indicating that these measures were reduced by about ½ to 1 SD in the PMA patient group. CONCLUSIONS PMA is a highly effective and safe method for postoperative pain management in patients undergoing elective lumbar fusion surgeries by improving pain control and reducing opioid requirement. LEVEL OF EVIDENCE Level III.
Collapse
|
3
|
Liu S, Gnjidic D, Nguyen J, Penm J. Effectiveness of interventions on the appropriate use of opioids for noncancer pain among hospital inpatients: A systematic review. Br J Clin Pharmacol 2020; 86:210-243. [PMID: 31863503 DOI: 10.1111/bcp.14203] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 11/27/2019] [Accepted: 12/02/2019] [Indexed: 12/31/2022] Open
Abstract
AIMS To summarise the effectiveness of interventions on appropriate opioid use for noncancer pain among hospital inpatients. METHODS Two reviewers independently searched 6 databases up to March 2018 original research articles reporting on quantitative outcomes of interventions on appropriate opioid use among hospital inpatients. Appropriate opioid use was measured by changes in prescribing, such as the lowest effective opioid dose and duration, or clinical outcomes such as adequate pain control. Quality and intervention complexity assessments were performed by 2 independent reviewers. The full methodological approach was published on PROSPERO (ID: CRD42019145947). RESULTS Of 398 full-text articles assessed for eligibility, 37 articles were included in the review. Most articles had a moderate or high risk of bias (27 of 37 studies). Thirty-one articles primarily addressed appropriate opioid use and 6 articles targeted opioid safety as a secondary outcome. A multifaceted approach was the most common primary intervention (16 studies) and adequate pain control was the main outcome measured (14 studies). Health provider education, reinforced by hard-copy material and feedback, was associated with a 13.0 to 29.5% increase in the proportion of opioid prescriptions written in concordance with local guidelines and reduced pain scores ranging from 7.0 to 34.5%. Interventions to improve opioid safety in patient-controlled analgesia reduced medication errors by up to 89.1%. CONCLUSION Interventions involving academic detailing and education, especially when reinforced by feedback, show positive effects on appropriate opioid use among hospital inpatients. Future studies investigating the impact of administrative interventions on opioid use and related outcomes are warranted.
Collapse
Affiliation(s)
- Shania Liu
- Sydney Pharmacy School, The University of Sydney, Camperdown, NSW, Australia
| | - Danijela Gnjidic
- Sydney Pharmacy School, The University of Sydney, Camperdown, NSW, Australia.,Charles Perkins Centre, The University of Sydney, Camperdown, NSW, Australia
| | - Jessica Nguyen
- Sydney Pharmacy School, The University of Sydney, Camperdown, NSW, Australia
| | - Jonathan Penm
- Sydney Pharmacy School, The University of Sydney, Camperdown, NSW, Australia
| |
Collapse
|
4
|
Walker CT, Gullotti DM, Prendergast V, Radosevich J, Grimm D, Cole TS, Godzik J, Patel AA, Whiting AC, Little A, Uribe JS, Kakarla UK, Turner JD. Implementation of a Standardized Multimodal Postoperative Analgesia Protocol Improves Pain Control, Reduces Opioid Consumption, and Shortens Length of Hospital Stay After Posterior Lumbar Spinal Fusion. Neurosurgery 2019; 87:130-136. [DOI: 10.1093/neuros/nyz312] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 05/30/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Multimodal analgesia regimens have been suggested to improve pain control and reduce opioid consumption after surgery.
OBJECTIVE
To institutionally implement an evidence-based quality improvement initiative to standardize and optimize pain treatment following neurosurgical procedures. Our goal was to objectively evaluate efficacy of this multimodal protocol.
METHODS
A retrospective cohort analysis of pain-related outcomes after posterior lumbar fusion procedures was performed. We compared patients treated in the 6 mo preceding (PRE) and 6 mo following (POST) protocol execution.
RESULTS
A total of 102 PRE and 118 POST patients were included. The cohorts were well-matched regarding sex, age, surgical duration, number of segments fused, preoperative opioid consumption, and baseline physical status (all P > .05). Average patient-reported numerical rating scale pain scores significantly improved in the first 24 hr postoperatively (5.6 vs 4.5, P < .001) and 24 to 72 hr postoperatively (4.7 vs 3.4, P < .001), PRE vs POST, respectively. Maximum pain scores and time to achieving appropriate pain control also significantly improved during these same intervals (all P < .05). A concomitant decrease in opioid consumption during the first 72 hr was seen (110 vs 71 morphine milligram equivalents, P = .02). There was an observed reduction in opioid-related adverse events per patient (1.31 vs 0.83, P < .001) and hospital length of stay (4.6 vs 3.9 days, P = .03) after implementation of the protocol.
CONCLUSION
Implementation of an evidence-based, multimodal analgesia protocol improved postoperative outcomes, including pain scores, opioid consumption, and length of hospital stay, after posterior lumbar spinal fusion.
Collapse
Affiliation(s)
- Corey T Walker
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - David M Gullotti
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Virginia Prendergast
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - John Radosevich
- Department of Pharmacy, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Doneen Grimm
- Department of Pharmacy, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Jakub Godzik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Arpan A Patel
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Alexander C Whiting
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Andrew Little
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Udaya K Kakarla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Jay D Turner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| |
Collapse
|
5
|
Abstract
BACKGROUND Post-craniotomy pain can be severe and is often undermanaged. Opioids can interfere with neurological monitoring and are associated with adverse effects. This systematic review aimed to identify measures of opioid-free analgesia and compare their effectiveness with opioid analgesia for post-craniotomy pain in patients with supratentorial tumors. METHODS EMBASE, MEDLINE, and Cochrane databases were searched from their inception to February 14, 2017, for randomized controlled trials (RCTs) evaluating opioid versus non-opioid analgesia post-supratentorial craniotomy. Two reviewers independently carried out study selection and data extraction. Risk of bias assessment was performed using the Cochrane Collaboration's tool. Outcomes were pain control (changes to pain scores or use of rescue analgesia) and adverse effects. Considering the number of studies and heterogeneity, a narrative synthesis was done without pooling and results were summarized using tables. Non-opioids were assessed for the potential to be equivalent to opioid-based analgesics for pain relief and adverse effects. RESULTS Of 467 RCTs, 4 met our inclusion criteria (n = 186 patients). Patients with scalp blocks (2 RCTs) had less post-operative nausea and vomiting (PONV), but scalp block was not superior to morphine for analgesia. Acetaminophen (1 RCT) was less likely to induce PONV but provided inadequate pain relief compared to morphine and sufentanil. Dexmedetomidine (1 RCT) was not superior to remifentanil for analgesia although it delayed time to rescue analgesia. CONCLUSIONS Limited evidence suggests that scalp blocks and dexmedetomidine have the potential to eliminate the need for opioid analgesia. Multimodal analgesia should be considered as significant opioid-sparing effects have been shown.
Collapse
|
6
|
Sivakumar W, Jensen M, Martinez J, Tanana M, Duncan N, Hoesch R, Riva-Cambrin JK, Kilburg C, Ansari S, House PA. Intravenous acetaminophen for postoperative supratentorial craniotomy pain: a prospective, randomized, double-blinded, placebo-controlled trial. J Neurosurg 2019; 130:766-722. [PMID: 29676689 DOI: 10.3171/2017.10.jns171464] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 10/30/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Acute pain control after cranial surgery is challenging. Prior research has shown that patients experience inadequate pain control post-craniotomy. The use of oral medications is sometimes delayed because of postoperative nausea, and the use of narcotics can impair the evaluation of brain function and thus are used judiciously. Few nonnarcotic intravenous (IV) analgesics exist. The authors present the results of the first prospective study evaluating the use of IV acetaminophen in patients after elective craniotomy. METHODS The authors conducted a randomized, double-blinded, placebo-controlled investigation. Adults undergoing elective, supratentorial craniotomies between September 2013 and June 2015 were randomized into two groups. The experimental group received 1000 mg/100 ml IV acetaminophen every 8 hours for 48 hours. The placebo group received 100 ml of 0.9% normal saline on the same schedule. Both groups were also treated with a standardized pain control algorithm. The study was powered to detect a 30% difference in the primary outcome measures: narcotic consumption (morphine equivalents, ME) at 24 and 48 hours after surgery. Patient-reported pain scores immediately postoperatively and 48 hours after surgery were also recorded. RESULTS A total of 204 patients completed the trial. No significant differences were found in narcotic consumption between groups at either time point (in the treatment and placebo groups, respectively, at 24 hours: 84.3 ME [95% CI 70.2–98.4] and 85.5 ME [95% CI 73–97.9]; and at 48 hours: 123.5 ME [95% CI 102.9–144.2] and 134.2 ME [95% CI 112.1–156.3]). The difference in improvement in patient-reported pain scores between the treatment and placebo groups was significant (p < 0.001). CONCLUSIONS Patients who received postoperative IV acetaminophen after craniotomy did not have significantly decreased narcotic consumption but did experience significantly lower pain scores after surgery. The drug was well tolerated and safe in this patient population.
Collapse
Affiliation(s)
| | | | - Julie Martinez
- 3Neurosciences Clinical Program, Intermountain Healthcare, Murray
| | - Michael Tanana
- 4Department of Biostatistics, Biosocial Research Institute, University of Utah, Salt Lake City, Utah; and
| | | | - Robert Hoesch
- 2Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City
- 3Neurosciences Clinical Program, Intermountain Healthcare, Murray
| | - Jay K Riva-Cambrin
- Departments of1Neurosurgery and
- 5Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | | | - Safdar Ansari
- 2Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City
| | | |
Collapse
|
7
|
Kerezoudis P, Alvi MA, Ubl DS, Hanson KT, Krauss WE, Meyer FB, Spinner RJ, Habermann EB, Bydon M. The impact of spine disease, relative to cranial disease, on perception of health and care experience: an analysis of 1484 patients in a tertiary center. J Neurosurg 2018; 129:1630-1640. [PMID: 29372876 DOI: 10.3171/2017.7.jns17991] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 07/24/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEPatient-reported outcomes have been increasingly mandated by regulators and payers to evaluate hospital and physician performance. The purpose of this study is to delineate the differences in patient-reported experience of hospital care for cranial and spinal operations.METHODSThe authors selected all patients who underwent inpatient, elective cranial or spinal procedures and completed the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey at a single, high-volume, tertiary care institution between October 2012 and September 2015. The association of the surgical procedure and diagnosis with various HCAHPS composite measures, calculated across 9 domains using standard top-box methodology, was investigated. Multivariable logistic regression models were fitted for outcomes that were significant with procedure type and diagnosis group on univariate analysis, adjusting for age, sex, case complexity, overall health rating, and education level.RESULTSA total of 1484 patients met criteria and returned an HCAHPS survey. Overall, patients undergoing a cranial procedure gave top-box (most favorable) scores more often in pain management measure (66.3% vs 59.6%, p = 0.01) compared with those undergoing spine surgery. Furthermore, despite better discharge scores (93.1% vs 87.1%, p < 0.001), spinal patients were less likely to report excellent health (7.4% vs 12.7%). Lastly, patients with a primary diagnosis of brain or spinal tumor compared with those with degenerative spinal disease and those with other neurosurgical diagnoses provided top-box scores more often regarding communication with doctors (82.7% vs 76.4% vs 75.2%, p = 0.04), pain management (71.8% vs 60.9% vs 59.1%, p = 0.002), and global rating (90.4% vs 84.0% vs 87.3%, p = 0.02). On multivariable analysis, spinal patients had significantly lower odds of reporting top-box scores in pain management (OR 0.67, 95% CI 0.52-0.85; p = 0.001), staff responsiveness (OR 0.68, 95% CI 0.53-0.87; p = 0.002), and global rating (OR 0.59, 95% CI 0.42-0.82; p = 0.002), and significantly higher odds of top-box scoring in discharge information (OR 2.15, 95% CI 1.45-3.18; p < 0.001) than cranial patients. Similarly, brain tumor cases were associated with significantly higher odds of top-box scoring in communication with doctors (OR 1.46, 95% CI 1.01-2.12; p = 0.04), pain management (OR 1.81, 95% CI 1.29-2.55; p < 0.001), staff responsiveness (OR 1.88, 95% CI 1.33-2.66; p < 0.001), and global rating (OR 2.00, 95% CI 1.26-3.17; p = 0.003) compared with degenerative spine cases.CONCLUSIONSSignificant differences in patient-reported experience with hospital care exist across different cranial and spine surgery patient populations. Overall, spinal patients, particularly those with degenerative spine disease, rated their health and their hospital experience lower relative to cranial patients. Identifying weaker areas of hospital performance in target populations can stimulate quality initiatives that aim to increase the overall hospital score.
Collapse
Affiliation(s)
| | - Mohammed Ali Alvi
- 1Mayo Clinic Neuro-Informatics Laboratory
- 2Department of Neurosurgery; and
| | - Daniel S Ubl
- 3Surgical Outcomes Program, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Kristine T Hanson
- 3Surgical Outcomes Program, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Elizabeth B Habermann
- 3Surgical Outcomes Program, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Mohamad Bydon
- 1Mayo Clinic Neuro-Informatics Laboratory
- 2Department of Neurosurgery; and
| |
Collapse
|
8
|
Abstract
PURPOSE OF REVIEW This review reports an update of the evidence on practices applied for the prevention and management of the most common complications after craniotomy surgery. RECENT FINDINGS Latest guidelines support the combined thromboprophylaxis with the use of both mechanical and chemical modalities, preferably applied within 24 h after craniotomy. Nevertheless, a heightened risk of minor hemorrhagic events remains an issue of concern. Postoperative nausea and vomiting (PONV) and pain constitute the complications most commonly encountered during the first 24 h postcraniotomy. Recently, neurokinin type-1 receptor antagonists have been tested as adjuncts for PONV prophylaxis with encouraging results, whereas dexmedetomidine and gabapentinoids emerge as promising alternatives for postcraniotomy pain management. The available data for seizure prophylaxis following craniotomy lacks scientific quality; thus, this remains still a debatable issue. Significantly, a growing body of evidence supports the superiority of levetiracetam over the older antiepileptic drugs (AEDs), in terms of efficacy and safety. SUMMARY Optimum management of postoperative complications is incorporated as an integral part of the augmented quality of care in patients undergoing craniotomy surgery, aiming to improve outcomes. This review may serve as a benchmark for neuroanesthetists for heightened clinical awareness and prompt institution of well-documented practices.
Collapse
|
9
|
Abstract
OBJECTIVE To describe the existing science of palliative care in surgery within three priority areas and expose specific gaps within the field. BACKGROUND Given the acute and often life-limiting nature of surgical illness, as well as the potential for treatment to induce further suffering, surgical patients have considerable palliative care needs. Yet these patients are less likely to receive palliative care than their medical counterparts and palliative care consultations often occur when death is imminent, reflecting poor quality end-of-life care. METHODS The National Institutes of Health and the National Palliative Care Research Center convened researchers from several medical subspecialties to develop a national agenda for palliative care research. The surgeon work group reviewed the existing surgical literature to identify critical knowledge gaps. RESULTS To date, evidence to support the role of palliative care in surgical practice is sparse and palliative care research in surgery is encumbered by methodological challenges and entrenched cultural norms that impede appropriate provision of palliative care. Priorities for future research on palliative care in surgery include: 1) measuring outcomes that matter to patients, 2) communication and decision making, and 3) delivery of palliative care to surgical patients. CONCLUSIONS Surgical patients would likely benefit from early palliative care delivered alongside surgical treatment to promote goal-concordant decision making and to improve patients' physical, emotional, social and spiritual well-being and quality of life. We propose a research agenda to address major gaps in the literature and provide a road map for future investigation.
Collapse
|
10
|
Vacas S, Van de Wiele B. Designing a pain management protocol for craniotomy: A narrative review and consideration of promising practices. Surg Neurol Int 2017; 8:291. [PMID: 29285407 PMCID: PMC5735429 DOI: 10.4103/sni.sni_301_17] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 10/02/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Craniotomy is a relatively common surgical procedure with a high incidence of postoperative pain. Development of standardized pain management and enhanced recovery after surgery (ERAS) protocols are necessary and crucial to optimize outcomes and patient satisfaction and reduce health care costs. METHODS This work is based upon a literature search of published manuscripts (between 1996 and 2017) from Pubmed, Cochrane Central Register, and Google Scholar. It seeks to both synthesize and review our current scientific understanding of postcraniotomy pain and its part in neurosurgical ERAS protocols. RESULTS Strategies to ameliorate craniotomy pain demand interventions during all phases of patient care: preoperative, intraoperative, and postoperative interventions. Pain management should begin in the perioperative period with risk assessment, patient education, and premedication. In the intraoperative period, modifications in anesthesia technique, choice of opioids, acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), regional techniques, dexmedetomidine, ketamine, lidocaine, corticosteroids, and interdisciplinary communication are all strategies to consider and possibly deploy. Opioids remain the mainstay for pain relief, but patient-controlled analgesia, NSAIDs, standardization of pain management, bio/behavioral interventions, modification of head dressings as well as patient-centric management are useful opportunities that potentially improve patient care. CONCLUSIONS Future research on mechanisms, predictors, treatments, and pain management pathways will help define the combinations of interventions that optimize pain outcomes.
Collapse
Affiliation(s)
- Susana Vacas
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, UCLA, Los Angeles, California, USA
| | - Barbara Van de Wiele
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, UCLA, Los Angeles, California, USA
| |
Collapse
|
11
|
Valero R, Carrero E, Fàbregas N, Iturri F, Saiz-Sapena N, Valencia L. National survey on postoperative care and treatment circuits in neurosurgery. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2017; 64:441-452. [PMID: 28318531 DOI: 10.1016/j.redar.2017.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 01/18/2017] [Indexed: 06/06/2023]
Abstract
INTRODUCTION The analysis of surgical processes should be a standard of health systems. We describe the circuit of care and postoperative treatment for neurosurgical interventions in the centres of our country. MATERIAL AND METHODS From June to October 2014, a survey dealing with perioperative treatments and postoperative circuits after neurosurgical procedures was sent to the chiefs of Anaesthesiology of 73 Spanish hospitals with neurosurgery and members of the Neuroscience Section of SEDAR. RESULTS We obtained 45 responses from 30 centres (41.09%). Sixty percent of anaesthesiologists perform preventive locoregional analgesic treatment. Pain intensity is systematically assessed by 78%. Paracetamol, non-steroidal anti-inflammatory and morphine combinations are the most commonly used. A percentage of 51.1 are aware of the incidence of postoperative nausea after craniotomy and 86.7% consider multimodal prophylaxis to be necessary. Dexamethasone is given as antiemetic (88.9%) and/or anti-oedema treatment (68.9%). A percentage of 44.4 of anaesthesiologists routinely administer anticonvulsive prophylaxis in patients with supratentorial tumours (levetiracetam, 88.9%), and 73.3% of anaesthesiologists have postoperative surveillance protocols. The anaesthesiologist (73.3%) decides the patient's destination, which is usually ICU (83.3%) or PACU (50%). Postoperative neurological monitoring varied according to the type of intervention, although strength and sensitivity were explored in between 70-80%. CONCLUSIONS There is great variability in the responses, probably attributable to the absence of guidelines, different structures and hospital equipment, type of surgery and qualified personnel. We need consensual protocols to standardize the treatment and the degree of monitoring needed during the postoperative period.
Collapse
Affiliation(s)
- R Valero
- Servicio de Anestesiología, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, España.
| | - E Carrero
- Servicio de Anestesiología, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, España
| | - N Fàbregas
- Servicio de Anestesiología, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, España
| | - F Iturri
- Servicio de Anestesiología, Hospital Universitario Cruces, Bilbao, Vizcaya, España
| | - N Saiz-Sapena
- Servicio de Anestesiología, Hospital 9 de Octubre, Valencia, España
| | - L Valencia
- Servicio de Anestesiología, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Las Palmas, España
| |
Collapse
|
12
|
Leveraging the electronic health record to improve quality and safety in rheumatology. Rheumatol Int 2017; 37:1603-1610. [PMID: 28852846 DOI: 10.1007/s00296-017-3804-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 08/17/2017] [Indexed: 12/13/2022]
Abstract
During the last two decades, improving the quality and safety of healthcare has become a focus in rheumatology. Widespread use of electronic health records (EHRs) and the availability of digital data have the potential to drive quality improvement, improve patient outcomes, and prevent adverse events. In the coming years, developing and leveraging tools within the EHR will be the key to making the next big strides in improving the health of patients with rheumatoid arthritis and other rheumatic diseases, including building EHR infrastructure to capture patient outcomes and developing automated methods to retrieve information from free text of clinical notes.
Collapse
|
13
|
Davidson KW, Shaffer JA, Ye S, Falzon L, Emeruwa IO, Sundquist K, Inneh IA, Mascitelli SL, Manzano WM, Vawdrey DK, Ting HH. Interventions to improve hospital patient satisfaction with healthcare providers and systems: a systematic review. BMJ Qual Saf 2017; 26:596-606. [PMID: 27488124 PMCID: PMC5290224 DOI: 10.1136/bmjqs-2015-004758] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 07/07/2016] [Accepted: 07/14/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Many hospital systems seek to improve patient satisfaction as assessed by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. A systematic review of the current experimental evidence could inform these efforts and does not yet exist. METHODS We conducted a systematic review of the literature by searching electronic databases, including MEDLINE and EMBASE, the six databases of the Cochrane Library and grey literature databases. We included studies involving hospital patients with interventions targeting at least 1 of the 11 HCAHPS domains, and that met our quality filter score on the 27-item Downs and Black coding scale. We calculated post hoc power when appropriate. RESULTS A total of 59 studies met inclusion criteria, out of these 44 did not meet the quality filter of 50% (average quality rating 27.8%±10.9%). Of the 15 studies that met the quality filter (average quality rating 67.3%±10.7%), 8 targeted the Communication with Doctors HCAHPS domain, 6 targeted Overall Hospital Rating, 5 targeted Communication with Nurses, 5 targeted Pain Management, 5 targeted Communication about Medicines, 5 targeted Recommend the Hospital, 3 targeted Quietness of the Hospital Environment, 3 targeted Cleanliness of the Hospital Environment and 3 targeted Discharge Information. Significant HCAHPS improvements were reported by eight interventions, but their generalisability may be limited by narrowly focused patient populations, heterogeneity of approach and other methodological concerns. CONCLUSIONS Although there are a few studies that show some improvement in HCAHPS score through various interventions, we conclude that more rigorous research is needed to identify effective and generalisable interventions to improve patient satisfaction.
Collapse
Affiliation(s)
- Karina W. Davidson
- Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical College, New York, NY
- Value Institute, New York-Presbyterian Hospital, New York, NY
| | - Jonathan A. Shaffer
- Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical College, New York, NY
- Department of Psychology, University of Colorado Denver, Denver, CO
| | - Siqin Ye
- Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical College, New York, NY
| | - Louise Falzon
- Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical College, New York, NY
| | - Iheanacho O. Emeruwa
- Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical College, New York, NY
| | - Kevin Sundquist
- Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical College, New York, NY
| | - Ifeoma A. Inneh
- Value Institute, New York-Presbyterian Hospital, New York, NY
| | | | | | | | - Henry H. Ting
- Value Institute, New York-Presbyterian Hospital, New York, NY
| |
Collapse
|
14
|
Lilley EJ, Cooper Z, Schwarze ML, Mosenthal AC. Palliative Care in Surgery: Defining the Research Priorities. J Palliat Med 2017; 20:702-709. [PMID: 28339313 DOI: 10.1089/jpm.2017.0079] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Given the acute and often life-limiting nature of surgical illness, as well as the potential for treatment to induce further suffering, surgical patients have considerable palliative care needs. Yet, these patients are less likely to receive palliative care than their medical counterparts and palliative care consultations often occur when death is imminent, reflecting poor quality end-of-life care. Surgical patients would likely benefit from early palliative care delivered alongside surgical treatment to promote goal-concordant decision making and to improve patients' physical, emotional, social, and spiritual well-being and quality of life. To date, evidence to support the role of palliative care in surgical practice is sparse and palliative care research in surgery is encumbered by methodological challenges and entrenched cultural norms that impede appropriate provision of palliative care. The objective of this article was to describe the existing science of palliative care in surgery within three priority areas and expose specific gaps within the field. We propose a research agenda to address these gaps and provide a road map for future investigation.
Collapse
Affiliation(s)
- Elizabeth J Lilley
- 1 The Center for Surgery and Public Health at Brigham and Women's Hospital , Boston, Massachusetts
| | - Zara Cooper
- 1 The Center for Surgery and Public Health at Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts
| | - Margaret L Schwarze
- 3 Department of Surgery, University of Wisconsin , Madison, Wisconsin.,4 Department of Medical History and Bioethics, University of Wisconsin , Madison, Wisconsin
| | - Anne C Mosenthal
- 5 Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| |
Collapse
|
15
|
|
16
|
Velly L, Simeone P, Bruder N. Postoperative Care of Neurosurgical Patients. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0175-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|