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Pandrangi VC, Araujo A, Buncke M, Olson B, Jorizzo M, Said-Al-Naief N, Sanusi O, Ciporen J, Shindo M, Schindler J, Colaianni CA, Clayburgh D, Andersen P, Flint P, Wax MK, Geltzeiler M, Li RJ. Patterns of virtual reality and Fitbit wearable activity device use after skull base surgery. Int Forum Allergy Rhinol 2024. [PMID: 38739098 DOI: 10.1002/alr.23364] [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: 03/27/2024] [Revised: 04/24/2024] [Accepted: 04/30/2024] [Indexed: 05/14/2024]
Abstract
KEY POINTS Virtual reality (VR) and Fitbit devices are well tolerated by patients after skull base surgery. Postoperative recovery protocols may benefit from incorporation of these devices. However, challenges including patient compliance may impact optimal device utilization.
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Affiliation(s)
- Vivek C Pandrangi
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Ana Araujo
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Michelle Buncke
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Brennan Olson
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Matthew Jorizzo
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Olabisi Sanusi
- Department of Neurosurgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Jeremy Ciporen
- Department of Neurosurgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Maisie Shindo
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Joshua Schindler
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - C Alessandra Colaianni
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Daniel Clayburgh
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Peter Andersen
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Paul Flint
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Mark K Wax
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Mathew Geltzeiler
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Ryan J Li
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
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2
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Xia Y, Sun M, Huang H, Jin WL. Drug repurposing for cancer therapy. Signal Transduct Target Ther 2024; 9:92. [PMID: 38637540 PMCID: PMC11026526 DOI: 10.1038/s41392-024-01808-1] [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: 02/06/2023] [Revised: 03/05/2024] [Accepted: 03/19/2024] [Indexed: 04/20/2024] Open
Abstract
Cancer, a complex and multifactorial disease, presents a significant challenge to global health. Despite significant advances in surgical, radiotherapeutic and immunological approaches, which have improved cancer treatment outcomes, drug therapy continues to serve as a key therapeutic strategy. However, the clinical efficacy of drug therapy is often constrained by drug resistance and severe toxic side effects, and thus there remains a critical need to develop novel cancer therapeutics. One promising strategy that has received widespread attention in recent years is drug repurposing: the identification of new applications for existing, clinically approved drugs. Drug repurposing possesses several inherent advantages in the context of cancer treatment since repurposed drugs are typically cost-effective, proven to be safe, and can significantly expedite the drug development process due to their already established safety profiles. In light of this, the present review offers a comprehensive overview of the various methods employed in drug repurposing, specifically focusing on the repurposing of drugs to treat cancer. We describe the antitumor properties of candidate drugs, and discuss in detail how they target both the hallmarks of cancer in tumor cells and the surrounding tumor microenvironment. In addition, we examine the innovative strategy of integrating drug repurposing with nanotechnology to enhance topical drug delivery. We also emphasize the critical role that repurposed drugs can play when used as part of a combination therapy regimen. To conclude, we outline the challenges associated with repurposing drugs and consider the future prospects of these repurposed drugs transitioning into clinical application.
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Affiliation(s)
- Ying Xia
- Center for Clinical Laboratories, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, PR China
- The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, 550001, PR China
- School of Clinical Laboratory Science, Guizhou Medical University, Guiyang, 550004, PR China
- Division of Gastroenterology and Hepatology, Department of Medicine and, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Ming Sun
- Center for Clinical Laboratories, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, PR China
- School of Clinical Laboratory Science, Guizhou Medical University, Guiyang, 550004, PR China
| | - Hai Huang
- Center for Clinical Laboratories, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, PR China.
- School of Clinical Laboratory Science, Guizhou Medical University, Guiyang, 550004, PR China.
| | - Wei-Lin Jin
- Institute of Cancer Neuroscience, Medical Frontier Innovation Research Center, The First Hospital of Lanzhou University, The First Clinical Medical College of Lanzhou University, Lanzhou, 730000, PR China.
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3
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Gu J, Chen X, Cheng X, Zou Y, Deng Z, Li D, Zhou Z, Jiang X. Headache alleviation with nasal irrigation following endoscopic endonasal surgery for pituitary adenomas. BMC Endocr Disord 2024; 24:45. [PMID: 38622616 PMCID: PMC11017480 DOI: 10.1186/s12902-024-01573-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 03/28/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND Headache is a common occurrence after endoscopic endonasal surgery (EES) for pituitary adenomas and significantly impacts the quality of life of patients. This study aims to investigate the effectiveness of nasal irrigation in relieving postoperative headache after EES. METHODS A retrospective analysis was conducted on a cohort of 101 patients (Cohort I) who underwent EES for pituitary adenomas to explore the risk factors associated with postoperative headache. Another cohort of 72 patients (Cohort II) who received adjuvant nasal irrigation following surgery was enrolled for further analysis. The Headache Impact Test (HIT-6) was used to score the severity of headache, and patients with a HIT score > 55 were classified as having headache. RESULTS In Cohort I, 21.78% of patients experienced headache one month after EES, which decreased to 5.94% at the three-month follow-up. Multivariate analysis revealed that postoperative nasal sinusitis (OR = 3.88, 95%CI 1.16-13.03, p = 0.028) and Hardy's grade C-D (OR = 10.53, 95%CI 1.02-109.19, p = 0.049) independently predicted the presence of postoperative headache at one month. At the three-month follow-up, patients with sinusitis had higher HIT-6 scores compared to those without sinusitis (44.43 ± 9.78 vs. 39.72 ± 5.25, p = 0.017). In Cohort II, the incidence of sinusitis at three months was significantly lower than that in Cohort I (p = 0.028). Importantly, both the incidence of headache and HIT-6 scores in Cohort II were significantly lower than those in Cohort I at the one- and three-month follow-ups. CONCLUSIONS Postoperative sinusitis is an independent risk factor for the development of headache following EES for pituitary adenomas. Prophylactic nasal irrigation helps relieve postoperative headache, possibly by preventing the occurrence of sinusitis.
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Affiliation(s)
- Jiayu Gu
- Department of Neurosurgery/Neuro-Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Xiaoqun Chen
- Department of Neurosurgery/Neuro-Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Xiaoman Cheng
- Department of Neurosurgery/Neuro-Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Yunzhi Zou
- Department of Neurosurgery/Neuro-Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Zekun Deng
- Department of Neurosurgery/Neuro-Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Depei Li
- Department of Neurosurgery/Neuro-Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Zhihuan Zhou
- Department of Neurosurgery/Neuro-Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.
| | - Xiaobing Jiang
- Department of Neurosurgery/Neuro-Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.
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4
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Potter T, Soni P, Krywyj M, Petitt J, Jarmula J, Obiri-Yeboah D, Oyem P, Momin A, Easley K, Sindwani R, Woodard T, Recinos PF, Kshettry VR. Predictive Factors for Postoperative Opioid Use in Elective Endoscopic Endonasal Skull Base Surgery. Laryngoscope 2023; 133:494-499. [PMID: 35353373 DOI: 10.1002/lary.30116] [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: 01/31/2022] [Revised: 03/14/2022] [Accepted: 03/21/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE In 2017, the United States opioid epidemic was declared a public health emergency. Increased efforts have been made to understand and reduce patient opioid use in neurosurgery. However, the factors associated with postoperative opioid use remain understudied in endoscopic endonasal skull base surgery (EESBS). We identified the demographic and surgical factors associated with postoperative opioid use in EESBS. METHODS A retrospective review was conducted of patients who underwent elective EESBS between January 2015 and December 2020. Patient demographics, relevant clinical history, and operative data were collected and analyzed. Total opioid use was calculated 24, 48, and 72 hours postoperatively. Multivariable linear regression analyses were performed to identify factors associated with opioid use. RESULTS There were 454 patients included. A history of anxiety/depression and younger patient age were associated with a significant increase in opioid use at 24 (28.2 MME, p < 0.001), 48 (53.4 MME, p < 0.001), and 72 (89.4 MME, p < 0.001) hours after surgery. Nasoseptal flap use was significantly associated with increased opioid use at 24 (12.8 MME, p < 0.49) and 48 (19.6 MME, p < 0.048) h postoperatively while controlling for intraoperative variables and surgical approach (trans-sellar vs. expanded). No significant association was observed for patient sex, history of migraines, preoperative opioid use, length of surgery, or surgical approach. CONCLUSION In patients undergoing EESBS, patient history of anxiety/depression, younger patient age, and nasoseptal flap use are associated with increased postoperative opioid use. Knowledge of these risk factors may guide perioperative prescribing patterns to both adequately control postoperative pain and reduce opioid use. LEVEL OF EVIDENCE 4 Laryngoscope, 133:494-499, 2023.
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Affiliation(s)
- Tamia Potter
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Pranay Soni
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Maria Krywyj
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jordan Petitt
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Jakub Jarmula
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Derrick Obiri-Yeboah
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Precious Oyem
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Arbaz Momin
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Kathryn Easley
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Raj Sindwani
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA.,Department of Otolaryngology-Head & Neck Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Troy Woodard
- Department of Otolaryngology-Head & Neck Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Pablo F Recinos
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA.,Department of Otolaryngology-Head & Neck Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Varun R Kshettry
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
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5
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Optimizing Perioperative Care in Transsphenoidal Pituitary Surgery: Considerations for Enhanced Recovery After Surgery. J Craniofac Surg 2023; 34:83-91. [PMID: 35968948 DOI: 10.1097/scs.0000000000008893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/04/2022] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To identify key recommendations for maximizing the efficiency and efficacy of perioperative care in transsphenoidal pituitary surgery. METHODS The authors performed a comprehensive literature search of Enhanced Recovery After Surgery protocols implemented for patients undergoing transsphenoidal adenomectomy (TSA); individual recommendations were abstracted, and the evidence base thoroughly reviewed. RESULTS The authors identified 19 individual recommendations pertinent to the care of patients undergoing TSA, which were subdivided into preoperative (n=6), intraoperative (n=6), and postoperative (n=7) interventions. Key factors recommended for minimizing length of stay, preventing readmission, and improving patient outcomes included comprehensive patient education, multidisciplinary evaluation, avoidance of routine lumbar drain placement and nasal packing, and rigorous postoperative monitoring of pituitary function and salt-water imbalances. The overall level of evidence for 7/19 (37%) implemented recommendations was found to be low, suggesting a need for continued research in this patient population. CONCLUSION Several key interventions should be considered in the development of Enhanced Recovery After Surgery protocols for TSA, which may aid in further decreasing length of stay and promoting positive patient outcomes.
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6
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Analgesic Efficacy of Intravenous Ibuprofen in the Treatment of Postoperative Acute Pain: A Phase III Multicenter Randomized Placebo-ControlledDouble-Blind Clinical Trial. Pain Res Manag 2023; 2023:7768704. [PMID: 36926379 PMCID: PMC10014159 DOI: 10.1155/2023/7768704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 01/05/2023] [Accepted: 02/07/2023] [Indexed: 03/12/2023]
Abstract
Objective To evaluate the analgesic efficacy and safety of different does of intravenous ibuprofen (IVIB) in the treatment of postoperative acute pain. Methods Patients with an intravenous (IV) patient-controlled analgesia device after abdominal or orthopedic surgery were randomly divided into placebo, IVIB 400 mg, and IVIB 800 mg groups. The first dosage of study medicines was given intravenously 30 minutes (min) before surgery ended, followed by six hours (h) intervals for a total of eight doses following surgery. The demographic characteristics and procedure data, cumulative morphine consumption, the visual analog scale (VAS), the area under the curve (AUC) of VAS, patient satisfaction score (PSS), the rates of treatment failure (RTF), and adverse events (AEs) and serious adverse event (SAEs) were recorded during the period of trial. Result A total of 345 patients were enrolled in the full analysis set (FAS), and of 326 participants were valid data set (VDS). Demographic characteristics, disease features, and medical history of patients were not significantly different between groups. Total morphine consumption of the IVIB 400 mg group (11.14 ± 7.14 mg; P = 0.0011) and the IVIB 800 mg group (11.29 ± 6.45 mg; P = 0.0014) was significantly reduced compared with the placebo group (14.51 ± 9.19 mg) for 24 h postoperatively, there was no significant difference between the IVIB 400 mg and IVIB 800 mg groups (P = 0.9997). The placebo group had significantly higher VAS and the AUCs of VAS than those in the IVIB 400 mg and the IVIB 800 mg groups at rest and movement for 24 h postoperatively (P < 0.05), and there was no significant difference between the IVIB 400 mg and IVIB 800 mg groups (P > 0.05). RTF was slightly higher in the placebo group than IVIB 400 mg group and 800 mg group, and no statistical significance (P < 0.690). PSS in the IVIB 400 mg (P = 0.0092) and the IVIB 800 mg groups (P = 0.0011) was higher than the placebo group for pain management, there was also no significant difference between the IVIB 400 mg and IVIB 800 mg groups (P = 0.456). The incidence of RTF (P = 0.690) and AEs (P > 0.05) were not different among the three groups. Conclusion Intermittent IV administration of ibuprofen 400 mg or 800 mg within 24 h after surgery in patients undergoing abdominal and orthopedic surgery significantly decreased morphine consumption and relieved pain, without increasing the incidence of AEs.
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7
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Abiri A, Patel TR, Nguyen E, Birkenbeuel JL, Tajudeen BA, Choby G, Wang EW, Schlosser RJ, Palmer JN, Adappa ND, Kuan EC. Postoperative protocols following endoscopic skull base surgery: An evidence-based review with recommendations. Int Forum Allergy Rhinol 2023; 13:42-71. [PMID: 35678720 DOI: 10.1002/alr.23041] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 05/30/2022] [Accepted: 05/31/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Postoperative management strategies for endoscopic skull base surgery (ESBS) vary widely because of limited evidence-based guidance. METHODS The PubMed, EMBASE, and Cochrane databases were systematically reviewed from January 1990 through February 2022 to examine 18 postoperative considerations for ESBS. Nonhuman studies, articles written in a language other than English, and case reports were excluded. Studies were assessed for levels of evidence, and each topic's aggregate grade of evidence was evaluated. RESULTS A total of 74 studies reporting on 18 postoperative practices were reviewed. Postoperative pain management, prophylactic antibiotics, and lumbar drain use had the highest grades of evidence (B). The literature currently lacks high quality evidence for a majority of the reviewed ESBS precautions. There were no relevant studies to address postoperative urinary catheter use and medical intracranial pressure reduction. CONCLUSION The evidence for postoperative ESBS precautions is heterogeneous, scarce, and generally of low quality. Although this review identified the best evidence available in the literature, it suggests the urgent need for more robust evidence. Therefore, additional high-quality studies are needed in order to devise optimal postoperative ESBS protocols.
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Affiliation(s)
- Arash Abiri
- Department of Otolaryngology, Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Tirth R Patel
- Department of Otolaryngology, Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Emily Nguyen
- Department of Otolaryngology, Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Jack L Birkenbeuel
- Department of Otolaryngology, Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Bobby A Tajudeen
- Department of Otolaryngology, Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Garret Choby
- Department of Otolaryngology, Head and Neck Surgery and Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric W Wang
- Department of Otolaryngology, Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Rodney J Schlosser
- Department of Otolaryngology, Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - James N Palmer
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nithin D Adappa
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Edward C Kuan
- Department of Otolaryngology, Head and Neck Surgery, University of California Irvine, Orange, California, USA
- Department of Neurological Surgery, University of California Irvine, Orange, California, USA
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8
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Simon É, Csipkés C, Andráskó D, Kovács V, Szabó-Maák Z, Tankó B, Buchholcz G, Fülesdi B, Molnár C. Preoperatively administered single dose of dexketoprofen decreases pain intensity on the first 5 days after craniotomy: A single-centre placebo-controlled, randomized trial. Transl Neurosci 2023; 14:20220323. [PMID: 38152091 PMCID: PMC10751892 DOI: 10.1515/tnsci-2022-0323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 10/30/2023] [Accepted: 10/30/2023] [Indexed: 12/29/2023] Open
Abstract
Background and purpose Headache attributed to craniotomy is an underestimated and under-treated condition. Previous studies confirmed the efficacy of preemptive analgesia with non-steroidal anti-inflammatory agents. The aim of the present work was to test the hypothesis of whether a single preoperatively administered dose of dexketoprofen (DEX) has the potency to decrease postcraniotomy headache (PCH) as compared to placebo (PL). Patients and methods This is a single-centre, randomized, PL-controlled trial comparing the effect of a single oral dose of 25 mg DEX to PL on the intensity of PCH. Patients undergoing craniotomy were randomly allocated to DEX and PL groups. Patients rated their actual and worst daily pain using visual analogue scale (VAS) scores during intrahospital treatment (0-5 days) and 30 and 90 days postoperatively. Results Two hundred patients were included. DEX decreased the worst daily pain intensity in the first 24 h only; the 5-days cumulative score of actual pain was 9.7 ± 7.9 cm for the DEX group and 12.6 ± 10.5 cm for the PL group, respectively (p = 0.03). This difference disappeared in the late, 30-, and 90-day follow-up period. No differences in VAS scores could be detected in supra- and infratentorial cases among the DEX and PL groups. Conclusions A single preoperative dose of 25 mg of DEX slightly decreases the intensity of PCH in the first 5 days after craniotomy but it does not have an effect on chronic headaches and postoperative analgesic requirements.
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Affiliation(s)
- Éva Simon
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Csaba Csipkés
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Dániel Andráskó
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Veronika Kovács
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Szabó-Maák
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Béla Tankó
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Gyula Buchholcz
- University Pharmacy, Clinical Centre, University of Debrecen, Debrecen, Hungary
| | - Béla Fülesdi
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Csilla Molnár
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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9
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Parikh KP, Motiwala M, Beer-Furlan A, Michael LM, Rangarajan SV, Choby GW, Kshettry VR, Saleh S, Mukherjee D, Kirsch C, McKean E, Sorenson JM. Skull Base Registries: A Roadmap. J Neurol Surg B Skull Base 2022; 83:561-578. [PMID: 36393883 PMCID: PMC9653294 DOI: 10.1055/a-1934-9191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 08/29/2022] [Indexed: 01/17/2023] Open
Abstract
Hospitals, payors, and patients increasingly expect us to report our outcomes in more detail and to justify our treatment decisions and costs. Although there are many stakeholders in surgical outcomes, physicians must take the lead role in defining how outcomes are assessed. Skull base lesions interact with surrounding anatomy to produce a complex spectrum of presentations and surgical challenges, requiring a wide variety of surgical approaches. Moreover, many skull base lesions are relatively rare. These factors and others often preclude the use of prospective randomized clinical trials, thus necessitating alternate methods of scientific inquiry. In this paper, we propose a roadmap for implementing a skull base registry, along with expected benefits and challenges.
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Affiliation(s)
- Kara P. Parikh
- Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Mustafa Motiwala
- Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Andre Beer-Furlan
- Department of Neurosurgery, Moffitt Cancer Center, Tampa, Florida, United States
| | - L. Madison Michael
- Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Sanjeet V. Rangarajan
- Department of Otolaryngology-Head and Neck Surgery, The University of Tennessee Health Science Center College of Medicine Memphis, Memphis, Tennessee, United States
| | - Garret W. Choby
- Department of Otorhinolaryngology, Mayo Clinic Rochester, Rochester, Minnesota, United States
| | - Varun R. Kshettry
- Brain Tumor and Neuro-Oncology Center Cleveland Clinic, Cleveland, Ohio, United States
| | - Sara Saleh
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, United States
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland, United States
| | - Claudia Kirsch
- Yale University School of Medicine Department of Radiology and Biomedical Imaging, New Haven, Connecticut, United States
- Department of Clinical Dentistry, University of Sheffield, Sheffield, South Yorkshire, England
- Mount Sinai Biomedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Erin McKean
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, United States
- Department of Otolaryngology–Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, United States
| | - Jeffrey M. Sorenson
- Department of Neurosurgery, University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee, United States
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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.
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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
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11
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Sarris CE, Brigeman ST, Doris E, Bobrowitz M, Rowe T, Duran EM, Santarelli GD, Rehl RM, Ovanessoff G, Rodriguez MC, Buddhdev K, Yuen KCJ, Little AS. Effects of a transsphenoidal surgery quality improvement program on patient outcomes and hospital financial performance. J Neurosurg 2022; 137:59-68. [PMID: 34798599 DOI: 10.3171/2021.7.jns21286] [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: 02/02/2021] [Accepted: 07/12/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE A comprehensive quality improvement (QI) program aimed at all aspects of patient care after pituitary surgery was initiated at a single center. This initiative was guided by standard quality principles to improve patient outcomes and optimize healthcare value. The programmatic goal was to discharge most elective patients within 1 day after surgery, improve patient safety, and limit unplanned readmissions. The program is described, and its effect on patient outcomes and hospital financial performance over a 5-year period are investigated. METHODS Details of the patient care pathway are presented. Foundational elements of the QI program include evidence-based care pathways (e.g., for hyponatremia and pain), an in-house research program designed to fortify care pathways, patient education, expectation setting, multidisciplinary team care, standard order sets, high-touch postdischarge care, outcomes auditing, and a patient navigator, among other elements. Length of stay (LOS), outcome variability, 30-day unplanned readmissions, and hospital financial performance were identified as surrogate endpoints for healthcare value for the surgical epoch. To assess the effect of these protocols, all patients undergoing elective transsphenoidal surgery for pituitary tumors and Rathke's cleft cysts between January 2015 and December 2019 were reviewed. RESULTS A total of 609 adult patients who underwent elective surgery by experienced pituitary surgeons were identified. Patient demographics, comorbidities, and payer mix did not change significantly over the study period (p ≥ 0.10). The mean LOS was significantly shorter in 2019 versus 2015 (1.6 ± 1.0 vs 2.9 ± 2.2 midnights, p < 0.001). The percentage of patients discharged after 1 midnight was significantly higher in 2019 versus 2015 (75.4% vs 15.6%, p < 0.001). The 30-day unplanned hospital readmission rate decreased to 2.8% in 2019 from 8.3% in 2015. Per-patient hospital profit increased 71.3% ($10,613 ± $19,321 in 2015; $18,180 ± $21,930 in 2019), and the contribution margin increased 42.3% ($18,925 ± $19,236 in 2015; $26,939 ± $22,057 in 2019), while costs increased by only 3.4% ($18,829 ± $6611 in 2015; $19,469 ± $4291 in 2019). CONCLUSIONS After implementation of a comprehensive pituitary surgery QI program, patient outcomes significantly improved, outcome variability decreased, and hospital financial performance was enhanced. Future studies designed to evaluate disease remission, patient satisfaction, and how the surgeon learning curve may synergize with other quality efforts may provide additional context.
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Affiliation(s)
| | | | | | | | | | | | - Griffin D Santarelli
- 3Otolaryngology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | | | - Garineh Ovanessoff
- 5Department of Endocrinology, Dignity Health Medical Group, Phoenix, Arizona
| | - Monica C Rodriguez
- 5Department of Endocrinology, Dignity Health Medical Group, Phoenix, Arizona
| | - Kajalben Buddhdev
- 5Department of Endocrinology, Dignity Health Medical Group, Phoenix, Arizona
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12
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Potter T, Soni P, Krywyj M, Obiri-Yeboah D, Oyem P, Momin A, Easley K, Recinos PF, Kshettry VR. Predictive Factors for Postoperative Opioid Use in Elective Skull Base Craniotomies. Skull Base Surg 2022; 83:594-601. [DOI: 10.1055/s-0042-1744452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 02/11/2022] [Indexed: 10/17/2022]
Abstract
Abstract
Objective In 2017, the United States officially declared opioid overuse a public health emergency. Due to a paucity of published benchmark data in skull base neurosurgery, we quantified postoperative opioid use in patients undergoing skull base craniotomies and identified factors that influence postoperative opioid use.Setting Tertiary academic medical center.
Participants Patients who underwent elective craniotomies by two skull base neurosurgeons between January 2015 and May 2020.Main Outcome Measures Demographic and perioperative data were retrospectively extracted from the electronic medical record. Surgical approaches were categorized as having either “significant” or “minimal” muscle dissection. Univariate and multivariate linear regression analyses were performed to identify predictors of postoperative opioid use at 24, 48, and 72 hours.
Results We included 300 craniotomies, 206 were supratentorial and 94 were infratentorial. This included 195 women and 105 men, with a mean age of 54.9 years. In multivariable analysis, a history of anxiety or depression, preoperative opioid use, and a history of migraines independently predicted a significantly greater opioid use at 24, 48, and 72 hours. Increased age and minimal muscle dissection independently predicted lower opioid consumption. Sex, infratentorial versus supratentorial approach, length of surgery, and postoperative steroid use did not impact total opioid use.
Conclusion Younger age, history of anxiety or depression, preoperative opioid consumption, preexisting history of migraines, and significant intraoperative muscle dissection were associated with higher postoperative opioid consumption. These risk factors provide insight on potential targets for minimizing postoperative opioids in craniotomies.
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Affiliation(s)
- Tamia Potter
- Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
- Department of Neurological Surgery, Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Pranay Soni
- Department of Neurological Surgery, Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Maria Krywyj
- Department of Neurological Surgery, Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Derrick Obiri-Yeboah
- Department of Neurological Surgery, Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, United States
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, United States
| | - Precious Oyem
- Department of Neurological Surgery, Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, United States
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, United States
| | - Arbaz Momin
- Department of Neurological Surgery, Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, United States
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, United States
| | - Kathryn Easley
- Department of Neurological Surgery, Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Pablo F. Recinos
- Department of Neurological Surgery, Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, United States
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, United States
| | - Varun R. Kshettry
- Department of Neurological Surgery, Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, United States
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, United States
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13
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Kuan EC, Birkenbeuel JL, Kovacs AJ, Abiri A, Goshtasbi K, Lehrich BM, Golshani K, Chen JW, Cadena G, Hsu FPK. Patterns of Opioid Usage and Predictors of Utilization Following Endoscopic Skull Base Surgery. Laryngoscope 2022; 132:1939-1945. [PMID: 35543275 DOI: 10.1002/lary.30164] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/02/2022] [Accepted: 04/26/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Pain control is an important topic that has not been extensively studied in patients undergoing endoscopic skull base surgery (ESBS). The purpose of this study is to identify opioid requirements after ESBS and the risk factors predictive of increased use. METHODS This study was a retrospective review of all patients undergoing ESBS at a tertiary academic skull base surgery program between July 2018 and August 2020. The primary outcome variable was total morphine equivalent dose (MED) requirements after surgery, calculated as the sum of all morphine milligram equivalents over a 24-h period, and summated across the duration of each participant's hospital course. RESULTS 94 patients were included in this review. Average daily MED requirements were 14.00 ± 6.79 mg. Average total MED requirements were 83.78 ± 92.99 mg during hospitalization. Average length of stay (LOS) was 5.71 ± 4.42 days, with 22 (23.4%) patients not requiring opioid use upon discharge. On multivariate analysis, female sex (β = 49.62; 95% CI [13.53, 85.71], p = 0.008), nasoseptal flap (NSF) reconstruction (β = 49.56; 95% CI [13.51, 85.61], p = 0.008) and LOS (β = 4.02; 95% CI [0.001, 8.04], p = 0.050) were independently associated with higher total MED requirements. CONCLUSIONS We report average total MED requirements of 83.78 mg after ESBS, with female sex, intraoperative use of an NSF, and increased LOS as predictors of higher MED use. This data indicates a subset of patients who may benefit from more aggressive pain control strategies upfront, including consideration of non-opioid, multimodal pain regimens. LEVEL OF EVIDENCE 3 Laryngoscope, 2022.
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Affiliation(s)
- Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A.,Department of Neurological Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Jack L Birkenbeuel
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Alexander J Kovacs
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Arash Abiri
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Khodayar Goshtasbi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Brandon M Lehrich
- Medical Scientist Training Program, University of Pittsburgh and Carnegie Mellon University, Pittsburgh, Pennsylvania, U.S.A
| | - Kiarash Golshani
- Department of Neurological Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Jefferson W Chen
- Department of Neurological Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Gilbert Cadena
- Department of Neurological Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Frank P K Hsu
- Department of Neurological Surgery, University of California, Irvine, Orange, California, U.S.A
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14
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Aurilio C, Pace MC, Sansone P, Giaccari LG, Coppolino F, Pota V, Barbarisi M. Multimodal analgesia in neurosurgery: a narrative review. Postgrad Med 2021; 134:267-276. [PMID: 34872428 DOI: 10.1080/00325481.2021.2015221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Pain following brain surgery can compromise the result of surgery. Several pharmacological interventions have been used to prevent postoperative pain in adults undergoing brain surgery. Pain following craniotomy is considered to be moderate to severe during the first two post-operative days. Opioids have been historically the mainstay and are the current prominent strategy for pain treatment. They produce analgesia but may alter respiratory, cardiovascular, gastrointestinal, and neuroendocrine functions. All these side effects may affect the normal postoperative course of craniotomy by affecting neurological function and increasing intracranial pressure. Therefore, their use in neurosurgery is limited, and opioids are used in case of strict necessity or as rescue medication. In addition to opioids, drugs with differing mechanisms of actions target pain pathways, resulting in additive and/or synergistic effects. Some of these agents include acetaminophen/non-steroidal anti-inflammatory drugs (NSAIDs), alpha-2 agonists, NMDA receptor antagonists, gabapentinoids, and local anesthesia techniques. Multimodal analgesia should be a balance between adequate analgesia and less drug-induced sedation, respiratory depression, hypercapnia, nausea, and vomiting, which may increase intracranial pressure. Non-opioid analgesics can be an useful pharmacological alternative in multimodal regimes to manage post-craniotomy pain. This narrative review aims to outline the current clinical evidence of multimodal analgesia for post craniotomy pain control.
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Affiliation(s)
- Caterina Aurilio
- Department of Women, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Maria Caterina Pace
- Department of Women, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Pasquale Sansone
- Department of Women, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Luca Gregorio Giaccari
- Department of Women, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Francesco Coppolino
- Department of Women, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Vincenzo Pota
- Department of Women, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Manlio Barbarisi
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
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15
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Wu TJ, Kianian R, Villalpando EG, Nakhla MN, Wells C, Heaney AP, Bergsneider M, Wang MB. Opiate Use After Endoscopic Endonasal Transsphenoidal Surgery. Am J Rhinol Allergy 2021; 36:339-347. [PMID: 34881667 DOI: 10.1177/19458924211061990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The literature on opiate use after endoscopic endonasal transsphenoidal surgery (EETS) is limited. OBJECTIVE To determine the risk factors for higher opiate use following EETS and the quantity of opiates used after discharge. METHODS A retrospective review of 144 patients undergoing EETS from July 2018 to July 2020 was conducted. Patient, tumor, and surgical factors were documented. Pain scores and medications used on postoperative days (POD) 0 and 1, and discharge prescriptions, were recorded. Opiate use was quantified using morphine milligram equivalents (MME) dose. Multiple linear regression determined risk factors independently associated with POD0 to 1 opiate use. RESULTS On POD 0 to 1, mean pain score was 4.9/10 (standard deviation [SD] ± 2.0). Mean acetaminophen use was 3.4 tablets (SD ± 1.6; 650 mg per tablet). Mean opiate use was 35.6 MME (SD ± 36.3), equivalent to 4.7 tablets (SD ± 4.8) of oxycodone 5 mg. Multiple linear regression showed that current smokers required an additional 37.1 MME (P = .011), and patients with grade 3 intraoperative cerebrospinal fluid leaks required an additional 36.7 MME (P = .046) on POD0 to 1. On discharge, mean opiate prescription was 117.7 MME (SD ± 102.1), equivalent to 15.7 tablets (SD ± 13.6) of oxycodone 5 mg. Thirty-nine patients (27.1%) did not require prescriptions. Only 10 patients (6.9%) required opiate refill(s) within 30 days after surgery. CONCLUSION Patients undergoing EETS have higher opiate needs compared to those undergoing endoscopic sinus surgery, although the overall requirements are still considered low. Independent risk factors associated with higher opiate use in the immediate postoperative period included current smokers and grade 3 intraoperative cerebrospinal fluid leaks.
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Affiliation(s)
- Tara J Wu
- David Geffen School of Medicine at the University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Reza Kianian
- David Geffen School of Medicine at the University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Emmanuel G Villalpando
- David Geffen School of Medicine at the University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Morcos N Nakhla
- David Geffen School of Medicine at the University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Christine Wells
- 8783University of California, Los Angeles (UCLA) Statistical Consulting Group, Los Angeles, CA, USA
| | - Anthony P Heaney
- David Geffen School of Medicine at the University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Marvin Bergsneider
- David Geffen School of Medicine at the University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Marilene B Wang
- David Geffen School of Medicine at the University of California, Los Angeles (UCLA), Los Angeles, CA, USA
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16
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Thakur JD, Corlin A, Mallari RJ, Yawitz S, Eisenberg A, Sivakumar W, Griffiths C, Carrau RL, Rettinger S, Cohan P, Krauss H, Araque KA, Barkhoudarian G, Kelly DF. Complication avoidance protocols in endoscopic pituitary adenoma surgery: a retrospective cohort study in 514 patients. Pituitary 2021; 24:930-942. [PMID: 34215990 PMCID: PMC8252985 DOI: 10.1007/s11102-021-01167-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2021] [Indexed: 12/02/2022]
Abstract
PURPOSE To evaluate the impact of using consistent complication-avoidance protocols in patients undergoing endoscopic pituitary adenoma surgery including techniques for avoiding anosmia, epistaxis, carotid artery injury, hypopituitarism, cerebrospinal fluid leaks and meningitis. METHODS All patients undergoing endoscopic adenoma resection from 2010 to 2020 were included. Primary outcomes included 90-day complication rates, gland function outcomes, reoperations, readmissions and length of stay. Secondary outcomes were extent of resection, short-term endocrine remission, vision recovery. RESULTS Of 514 patients, (mean age 51 ± 16 years; 78% macroadenomas, 19% prior surgery) major complications occurred in 18(3.5%) patients, most commonly CSF leak (9, 1.7%) and meningitis (4, 0.8%). In 14 of 18 patients, complications were deemed preventable. Four (0.8%) had complications with permanent sequelae (3 before 2016): one unexplained mortality, one stroke, one oculomotor nerve palsy, one oculoparesis. There were no internal carotid artery injuries, permanent visual worsening or permanent anosmia. New hypopituitarism occurred in 23/485(4.7%). Partial or complete hypopituitarism resolution occurred in 102/193(52.8%) patients. Median LOS was 2 days; 98.3% of patients were discharged home. Comparing 18 patients with major complications versus 496 without, median LOS was 7 versus 2 days, respectively p < 0.001. Readmissions occurred in 6%(31/535), mostly for hyponatremia (18/31). Gross total resection was achieved in 214/312(69%) endocrine-inactive adenomas; biochemical remission was achieved in 148/209(71%) endocrine-active adenomas. Visual field or acuity defects improved in 126/138(91.3%) patients. CONCLUSION This study suggests that conformance to established protocols for endoscopic pituitary surgery may minimize complications, re-admissions and LOS while enhancing the likelihood of preserving gland function, although there remains opportunity for further improvements.
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Affiliation(s)
| | - Alex Corlin
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Regin Jay Mallari
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Samantha Yawitz
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Amalia Eisenberg
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Walavan Sivakumar
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Chester Griffiths
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA
| | | | - Sarah Rettinger
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Pejman Cohan
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Howard Krauss
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Katherine A Araque
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Daniel F Kelly
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA.
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA.
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17
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Hoke AT, Malfitano M, Zanation AM, Ebert CS, Senior BA, Kimple AJ, Thorp BD. Postoperative Pain Management and Perceived Patient Outcomes following Endoscopic Pituitary Surgery. J Neurol Surg B Skull Base 2021; 83:397-404. [DOI: 10.1055/a-1692-9879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 11/06/2021] [Indexed: 10/19/2022] Open
Abstract
Abstract
Objectives Pain management remains a point of emphasis given the ongoing opioid crisis. There are no studies in the literature interrogating opioid prescribing and use following endoscopic pituitary surgery. This study investigates provider prescribing tendency, patient utilization of analgesics, and patient outcomes regarding pain management after endoscopic pituitary surgery.
Methods We identified 100 patients undergoing endoscopic pituitary surgery at one institution from 2016 to 2018 in the electronic medical record (EMR) and state narcotic database to determine postoperative analgesic regimens. A telephone survey was used to characterize postoperative analgesic use and satisfaction with prescribed regimen.
Results Fifty-two different pain control regimens were prescribed to the study patients. Also, 93% of study patients were prescribed an opioid postoperatively. The average quantity of opioids prescribed per patient in morphine milligram equivalents (MMEs) was 625 (equivalent 83 oxycodone 5-mg tablets) with an average MME/day of 59 (equivalent 8 oxycodone 5-mg tablets). A total of 71% survey respondents who used opioids reported using <25% of their prescription. The majority of prescription narcotic users consumed >50% of their postoperative opioid intake in the first 24 to 48 hours after discharge. There were no significant differences in pain outcome between opioid users and nonopioid users.
Conclusion Vast heterogeneity exists in narcotic prescribing by providers at our institution following endoscopic pituitary surgery. Narcotic prescribing patterns exceeded most patients' analgesic needs. Opioid analgesics were not superior to nonopioids regimens in patient-reported pain outcomes in this study population.
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Affiliation(s)
- Austin T.K. Hoke
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel, North Carolina, United States
| | - Madison Malfitano
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel, North Carolina, United States
| | - Adam M. Zanation
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel, North Carolina, United States
| | - Charles S. Ebert
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel, North Carolina, United States
| | - Brent A. Senior
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel, North Carolina, United States
| | - Adam J. Kimple
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel, North Carolina, United States
| | - Brian D. Thorp
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel, North Carolina, United States
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18
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Abstract
PURPOSE OF REVIEW Pituitary adenoma resections comprise a large proportion of intracranial tumor surgeries. This patient population is medically and physiologically complex and requires careful perioperative planning and management on the part of the anesthesiologist. This review will summarize anesthetic considerations for pre, intra, and postoperative management of patients undergoing transsphenoidal pituitary surgery. RECENT FINDINGS An endoscopic approach is favored for patients undergoing transsphenoidal pituitary surgery. Hemodynamic monitoring is important to maintain cerebral perfusion and avoid risk of bleeding; however, 'controlled' hypotension may have adverse effects. Multimodal analgesia is effective for the management of postoperative pain and may reduce the risk of postoperative complications, including respiratory depression and postoperative nausea and vomiting. SUMMARY Transsphenoidal pituitary surgery is a preferred approach for the surgical management of nonfunctioning pituitary macroadenomas with symptoms of mass effect and functioning adenomas that cannot be otherwise managed medically. Understanding tumor pathologies and systemic effects are essential for preoperative planning and providing safe anesthetic care during the perioperative period.
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Affiliation(s)
- Kamilla Esfahani
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
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Ferguson MC, Schumann R, Gallagher S, McNicol ED. Single-dose intravenous ibuprofen for acute postoperative pain in adults. Cochrane Database Syst Rev 2021; 9:CD013264. [PMID: 34499349 PMCID: PMC8428326 DOI: 10.1002/14651858.cd013264.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Postoperative administration of non-steroidal anti-inflammatory drugs (NSAIDs) reduces patient opioid requirements and, in turn, may reduce the incidence and severity of opioid-induced adverse events (AEs). OBJECTIVES To assess the analgesic efficacy and adverse effects of single-dose intravenous (IV) ibuprofen, compared with placebo or an active comparator, for moderate-to-severe postoperative pain in adults. SEARCH METHODS We searched the following databases without language restrictions: CENTRAL, MEDLINE, Embase and LILACS on 10 June 2021. We checked clinical trials registers and reference lists of retrieved articles for additional studies. SELECTION CRITERIA We included randomized trials that compared a single postoperative dose of intravenous (IV) ibuprofen with placebo or another active treatment, for treating acute postoperative pain in adults following any surgery. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors independently considered trials for review inclusion, assessed risk of bias, and extracted data. Our primary outcome was the number of participants in each arm achieving at least 50% pain relief over a 4- and 6-hour period. Our secondary outcomes were time to, and number of participants using rescue medication; withdrawals due to lack of efficacy, adverse events (AEs), and for any other cause; and number of participants reporting or experiencing any AE, serious AEs (SAEs), and specific NSAID-related or opioid-related AEs. We were not able to carry out any planned meta-analysis. We assessed the certainty of the evidence using GRADE. MAIN RESULTS Only one study met our inclusion criteria, involving 201 total participants, mostly female (mean age 42 years), undergoing primary, unilateral, distal, first metatarsal bunionectomy (with osteotomy and internal fixation). Ibuprofen 300 mg, placebo or acetaminophen 1000 mg was administered intravenously to participants reporting moderate pain intensity the day after surgery. Since we identified only one study for inclusion, we did not perform any quantitative analyses. The study was at low risk of bias for most domains. We downgraded the certainty of the evidence due to serious study limitations, indirectness and imprecision. Ibuprofen versus placebo Findings of the single study found that at both the 4-hour and 6-hour assessment period, the proportion of participants with at least 50% pain relief was 32% (24/76) for those assigned to ibuprofen and 22% (11/50) for those assigned to placebo. These findings produced a risk ratio (RR) of 1.44 (95% confidence interval (CI) 0.77 to 2.66 versus placebo for at least 50% of maximum pain relief over the 4-hour and 6-hour period (very low-certainty evidence). Median time to rescue medication was 101 minutes for ibuprofen and 71 minutes for placebo (1 study, 126 participants; very low-certainty evidence). The number of participants using rescue medication was not reported within the included study. During the study (1 study, 126 participants), 58/76 (76%) of participants assigned to ibuprofen and 39/50 (78%) assigned to placebo reported or experienced any adverse event (AE), (RR 0.98, 95% CI 0.81 to 1.19; low-certainty evidence). No serious AEs (SAEs) were experienced (1 study, 126 participants; very low-certainty evidence). Ibuprofen versus active comparators Ibuprofen (300 mg) was similar to the active comparator, IV acetaminophen (1000 mg) at 4 hours and 6 hours (1 study, 126 participants). For those assigned to active control (acetaminophen), the proportion of participants with at least 50% pain relief was 35% (26/75) at 4 hours and 31% (23/75) at 6 hours. At 4 hours, these findings produced a RR of 0.91 (95% CI 0.58 to 1.43; very low-certainty evidence) versus active comparator (acetaminophen). At 6 hours, these findings produced a RR of 1.03 (95% CI 0.64 to 1.66; very low-certainty evidence) versus active comparator (acetaminophen). Median time to rescue medication was 101 minutes for ibuprofen and 125 minutes for the active comparator, acetaminophen (1 study, 151 participants; very low-certainty evidence). The number of participants using rescue medication was not reported within the included study. During the study, 8/76 (76%) of participants assigned to ibuprofen and 45/75 (60%) assigned to active control (acetaminophen) reported or experienced any AE, (RR 1.27, 95% CI 1.02 to 1.59; very low-certainty evidence). No SAEs were experienced (1 study, 151 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS There is insufficient evidence to support or refute the suggestion that IV ibuprofen is effective and safe for acute postoperative pain in adults.
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Affiliation(s)
- McKenzie C Ferguson
- Pharmacy Practice, Southern Illinois University Edwardsville, Edwardsville, Illinois, USA
| | - Roman Schumann
- Department of Anesthesia, Critical Care and Pain Medicine, VA Boston Healthcare System, West Roxbury, Massachusetts, USA
| | - Sean Gallagher
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ewan D McNicol
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, Massachusetts, USA
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Rimmer RA, Scott B, Pailet J, Farrell NF, Mace JC, Detwiller KY, Smith TL, Dogan A, Gupta S, Andersen P, Cetas J, Geltzeiler M. Opioid use after endoscopic skull base surgery: A descriptive, prospective, longitudinal cohort study. Int Forum Allergy Rhinol 2021; 12:160-171. [PMID: 34309220 DOI: 10.1002/alr.22871] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/11/2021] [Accepted: 07/01/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Opioid abuse is a public health crisis and the perioperative period can be a time of first opioid exposure. Little is known about postoperative pain management after endoscopic skull base surgery (ESBS). METHODS This investigation was a single-institution, longitudinal, prospective cohort study of adult patients undergoing ESBS between November 2019 and March 2020. Participants completed preoperative questionnaires and were contacted every 48 hours postoperatively to quantify pain and opioid consumption. RESULTS A total of 33 patients were enrolled and 28 of 33 patients (85%) underwent ESBS for sellar pathology. Mean total morphine milligram equivalents (MME) consumed was 381.9 ± 476.0. History of a headache disorder (p = 0.025) and previous opioid use within 60 days preoperatively (p < 0.001) were significantly associated with greater opioid use. Mean duration of opioid use was 6.7 ± 5.1 (range, 0-20) days. Headache disorder (p = 0.01), depression (p = 0.03), anxiety (p = 0.03), age ≤46 years (p = 0.029), and previous opioid use (p = 0.008) were all associated with longer mean opioid use. Patients with headache disorder also reported higher mean postoperative pain scores. Fewer than half of the participants required opioids by postoperative day 8. Prescription of nonsteroidal anti-inflammatory drugs at discharge was significantly associated with less outpatient opioid use (p = 0.032). At 2-month follow-up, 37% of patients reported keeping excess opioids. CONCLUSION After ESBS, greater total opioid use was significantly associated with history of headaches and previous opioid use within 60 days. Overall, opioid use declined among all patients in the postoperative period, but several factors may contribute to longer duration of use.
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Affiliation(s)
- Ryan A Rimmer
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR
| | - Brian Scott
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR
| | - Jasmina Pailet
- School of Medicine, Oregon Health and Science University, Portland, OR
| | - Nyssa Fox Farrell
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, St. Louis, MO
| | - Jess C Mace
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR
| | - Kara Y Detwiller
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR
| | - Timothy L Smith
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR
| | - Aclan Dogan
- Department of Neurological Surgery, Oregon Health and Science University, Portland, OR
| | - Sachin Gupta
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR
| | - Peter Andersen
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR
| | - Justin Cetas
- Department of Neurological Surgery, Oregon Health and Science University, Portland, OR
| | - Mathew Geltzeiler
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR
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Scoville JP, Joyce E, Hunsaker J, Reese J, Wilde H, Arain A, Bollo RL, Rolston JD. Stereotactic Electroencephalography Is Associated With Reduced Pain and Opioid Use When Compared with Subdural Grids: A Case Series. Oper Neurosurg (Hagerstown) 2021; 21:6-13. [PMID: 33733680 DOI: 10.1093/ons/opab040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 12/25/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Minimally invasive surgery (MIS) has been shown to decrease length of hospital stay and opioid use. OBJECTIVE To identify whether surgery for epilepsy mapping via MIS stereotactically placed electroencephalography (SEEG) electrodes decreased overall opioid use when compared with craniotomy for EEG grid placement (ECoG). METHODS Patients who underwent surgery for epilepsy mapping, either SEEG or ECoG, were identified through retrospective chart review from 2015 through 2018. The hospital stay was separated into specific time periods to distinguish opioid use immediately postoperatively, throughout the rest of the stay and at discharge. The total amount of opioids consumed during each period was calculated by transforming all types of opioids into their morphine equivalents (ME). Pain scores were also collected using a modification of the Clinically Aligned Pain Assessment (CAPA) scale. The 2 surgical groups were compared using appropriate statistical tests. RESULTS The study identified 43 patients who met the inclusion criteria: 36 underwent SEEG placement and 17 underwent craniotomy grid placement. There was a statistically significant difference in median opioid consumption per hospital stay between the ECoG and the SEEG placement groups, 307.8 vs 71.5 ME, respectively (P = .0011). There was also a significant difference in CAPA scales between the 2 groups (P = .0117). CONCLUSION Opioid use is significantly lower in patients who undergo MIS epilepsy mapping via SEEG compared with those who undergo the more invasive ECoG procedure. As part of efforts to decrease the overall opioid burden, these results should be considered by patients and surgeons when deciding on surgical methods.
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Affiliation(s)
- Jonathan P Scoville
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, USA
| | - Evan Joyce
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, USA
| | - Joshua Hunsaker
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Jared Reese
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Herschel Wilde
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Amir Arain
- Department of Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Robert L Bollo
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, USA
| | - John D Rolston
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, USA.,Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, Utah, USA
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Abstract
PURPOSE OF REVIEW Acute pain management in the surgical ICU is imperative. Effective acute pain management hastens a patient's return to normal function and avoid the negative sequelae of untreated acute pain. Traditionally, opioids have been the mainstay of acute pain management strategies in the surgical ICU, but alternative medications and management strategies are increasingly being utilized. RECENT FINDINGS Extrapolating from lessons learned from enhanced recovery after surgery protocols, surgical intensivists are increasingly utilizing multimodal pain regimens (MMPRs) in critically ill surgical patients recovering from major surgical procedures and injuries. MMPRs incorporate both oral medications from several drug classes and regional blocks when feasible. In addition, although MMPRs may include opioids as needed, they are able to achieve effective pain control while minimizing opioid exposure. SUMMARY Even after major elective surgery or significant injury, opioid-minimizing MMPRs can effectively treat acute pain.
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Shao B, Tariq AA, Goldstein HE, Alexiades NG, Mar KM, Feldstein NA, Anderson RCE, Giordano M. Multimodal Analgesia After Posterior Fossa Decompression With and Without Duraplasty for Children With Chiari Type I. Hosp Pediatr 2020; 10:447-451. [PMID: 32321740 DOI: 10.1542/hpeds.2019-0298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Multimodal analgesia (MMA) may reduce opioid use after surgery for Chiari malformation type I. An MMA protocol was implemented after both posterior fossa decompression without dural opening (PFD) and posterior fossa decompression with duraplasty (PFDD). METHODS Scheduled nonsteroidal antiinflammatory drugs (ketorolac or ibuprofen) and diazepam were alternated with acetaminophen, and as-needed oxycodone or intravenous morphine. The primary outcome was total opioid requirement over postoperative days 0 to 2. RESULTS From 2012 to 2017, 49 PFD and 29 PFDD procedures were performed, and 46 of 78 patients used the protocol. Patients with PFD required less opioids than patients with PFDD. Among patients with PFDD, patients with MMA protocol usage had a lower mean opioid requirement than patients with no MMA protocol usage (0.53 ± 0.49 mgEq/kg versus 1.4 ± 1.0 mgEq/kg, P = .0142). In multivariable analysis, MMA protocol usage status independently predicted a mean decrease in opioid requirement of 0.146 mg equivalents/kg (P = .0497) after adjustment for procedure and surgeon. Statistically significant differences were not demonstrated in antiemetic requirements, discharge opioid prescriptions, total direct cost, and length of stay. CONCLUSIONS A protocol of scheduled nonsteroidal antiinflammatory drugs alternating with scheduled acetaminophen and diazepam was associated with opioid use reductions.
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Affiliation(s)
- Belinda Shao
- Departments of Neurological Surgery and.,Department of Neurosurgery, Brown University, Providence, Rhode Island
| | - Abdul A Tariq
- Value Institute, New York-Presbyterian Hospital, New York, New York; and
| | | | | | - Krista M Mar
- Department of Information Services and Technology, Jefferson Health, Philadelphia, Pennsylvania
| | | | | | - Mirna Giordano
- Pediatrics, Columbia University Irving Medical Center, Columbia University, New York, New York;
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Shao B, Tariq AA, Goldstein HE, Alexiades NG, Mar KM, Feldstein NA, Anderson RCE, Giordano M. Opioid-Sparing Multimodal Analgesia After Selective Dorsal Rhizotomy. Hosp Pediatr 2019; 10:84-89. [PMID: 31862854 DOI: 10.1542/hpeds.2019-0016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Multimodal analgesia (MMA) may reduce opioid use among children who are hospitalized, and may contribute toward enhanced recovery after selective dorsal rhizotomy (SDR) for patients with spasticity in pediatric cerebral palsy. In this retrospective cohort study, we assess an MMA protocol consisting of scheduled nonsteroidal antiinflammatory drug doses (ketorolac or ibuprofen), alternating with scheduled acetaminophen and diazepam doses, with as-needed opioids. It was hypothesized that protocol use would be associated with reductions in opioid requirements and other clinical improvements. METHODS Data were obtained for 52 patients undergoing SDR at an academic tertiary care pediatric hospital (2012-2017, with the protocol implemented in 2014). Using a retrospective cohort design, we compared outcomes between protocol and nonprotocol patients, employing both univariate t test and Wilcoxon rank test comparisons as well as multivariable regression methods. The primary outcome was total as-needed opioid requirements over postoperative days (PODs) 0 to 2, measured in oral morphine milligram equivalents per kilogram. Additional outcomes included antiemetic medication doses, discharge opioid prescriptions, total direct cost, and length of stay. RESULTS Twelve patients received the MMA protocol, and 40 patients did not. POD-0 MMA initiation was independently associated with a reduction of 0.14 morphine milligram equivalents per kilogram in mean opioid requirements over PODs 0 to 2 in the multiple regression analysis (95% confidence interval 0.01 to 0.28; P = .04). No statistically significant differences were demonstrated in doses of antiemetic medications, discharge opioid prescriptions, total direct cost, and length of stay. CONCLUSIONS This MMA protocol may help reduce opioid use after SDR. Improving protocol implementation in a prospective, multisite study will help elucidate further MMA effects on pain, costs, and recovery.
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Affiliation(s)
- Belinda Shao
- Departments of Neurologic Surgery and.,Department of Neurosurgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Abdul A Tariq
- The Value Institute, NewYork-Presbyterian Hospital, New York, New York; and
| | | | | | - Krista M Mar
- Department of Data Science, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
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Galvin IM, Levy R, Day AG, Gilron I. Pharmacological interventions for the prevention of acute postoperative pain in adults following brain surgery. Cochrane Database Syst Rev 2019; 2019:CD011931. [PMID: 31747720 PMCID: PMC6867906 DOI: 10.1002/14651858.cd011931.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pain following brain surgery can compromise recovery. Several pharmacological interventions have been used to prevent pain after craniotomy; however, there is currently a lack of evidence regarding which interventions are most effective. OBJECTIVES The objectives are to assess the effectiveness of pharmacological interventions for prevention of acute postoperative pain in adults undergoing brain surgery; compare them in terms of additional analgesic requirements, incidence of chronic headache, sedative effects, length of hospital stay and adverse events; and determine whether these characteristics are different for certain subgroups. SEARCH METHODS We searched MEDLINE, Embase, CINAHL, CENTRAL, Web of Science and two trial registries together with reference checking and citation searching on 28th of November 2018. SELECTION CRITERIA We included blinded and non-blinded, randomized controlled trials evaluating pharmacological interventions for the prevention of acute postoperative pain in adults undergoing neurosurgery, which had at least one validated pain score outcome measure. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. We calculated mean differences for the primary outcome of pain intensity; any pain scores reported on a 0 to 100 scale were converted to a 0 to 10 scale. MAIN RESULTS We included 42 completed studies (3548 participants) and identified one ongoing study. Nonsteroidal anti-inflammatories (NSAIDs) Nonsteroidal anti-inflammatories (NSAIDs) reduce pain up to 24 hours (0 to 6 hours, MD -1.16, 95% CI -1.57 to -0.76; 12 hours, MD -0.62, 95% CI -1.11 to -0.14; 24 hours, MD -0.66, 95% CI -1.18 to -0.13; 6 studies, 742 participants; all high-quality evidence). Results for other outcomes were imprecise (additional analgesic requirements: MD 1.29 mg, 95% CI -5.0 to 2.46, 4 studies, 265 participants; nausea and vomiting RR 1.34, 95% CI 0.30 to 5.94, 2 studies, 345 participants; both low-quality evidence). Dexmedetomidine reduces pain up to 12 hours (0 to 6 hours, MD -0.89, 95% CI -1.27 to -0.51, moderate-quality evidence; 12 hours, MD -0.81, 95% CI -1.21 to -0.42, low-quality evidence). It did not show efficacy at 24 hours (MD -0.08, 95% CI -0.32 to 0.16; 2 studies, 128 participants; low-quality evidence). Dexmedetomidine may decrease additional analgesic requirements (MD -21.36 mg, 95% CI -34.63 to -8.1 mg, 2 studies, 128 participants, low-quality evidence). Results for other outcomes were imprecise (nausea and vomiting RR -0.43, 95% CI 0.06 to 3.08, 3 studies, 261 participants; hypotension RR 0.5, 95% CI 0.05 to 5.28, 3 studies, 184 participants; both low-quality evidence). Scalp blocks may reduce pain up to 48 hours (0 to 6 hours, MD -0.98, 95% CI -1.66 to -0.3, 10 studies, 414 participants; 12 hours, MD -0.95, 95% CI -1.53 to -0.37, 8 studies, 294 participants; 24 hours, MD -0.78, 95% CI -1.52 to -0.05, 9 studies, 433 participants, all low-quality evidence; 48 hours, MD -1.34, 95% CI -2.57 to -0.11, 4 studies, 135 participants, very low-quality evidence. When studies with high risk of bias were excluded, significance remained at 12 hours only. Scalp blocks may decrease additional analgesia requirements (SMD -1.11, 95% CI -1.97 to -0.25, 7 studies, 314 participants). Results for other outcomes were imprecise (nausea and vomiting RR 0.66, 95% CI 0.33 to 1.32, 4 studies, 165 participants, very low-quality evidence). Scalp Infiltration may reduce pain postoperatively but efficacy was inconsistent, with a significant effect at 12 and 48 hours only (12 hours, MD -0.71, 95% CI -1.34 to -0.08, 7 studies, 309 participants, low-quality evidence; 48 hours, MD - 1.09, 95% CI -2.13 to - 0.06, 3 studies, 128 participants, moderate-quality evidence). No benefit was observed at other times (0 to 6 hours, MD -0.64, 95% CI -1.28 to -0.00, 9 studies, 475 participants, moderate-quality evidence; 24 hours, MD -0.39, 95% CI -1.06 to 0.27,6 studies, 260 participants, low-quality evidence. Scalp infiltration may reduce additional analgesia requirements MD -9.56 mg, 95% CI -15.64 to -3.49, 6 studies, 345 participants, very low-quality evidence). When studies with high risk of bias were excluded, scalp infiltration lost the pain benefit at 12 hours and effects on additional analgesia requirements, but retained the pain-reducing benefit at 48 hours (MD -0.56, 95% CI -1.20 to -0.32, 2 studies, 100 participants, very low-quality evidence). Results for other outcomes were imprecise (nausea and vomiting, RR 0.74, 95% CI 0.48 to 1.41, 4 studies, 318 participants, low-quality evidence). Pregabalin or gabapentin may reduce pain up to 6 hours (2 studies, 202 participants), MD -1.15,95% CI -1.66 to -0.6, 2 studies, 202 participants, low-quality evidence). One study examined analgesic efficacy at 12 hours showing significant benefit. No analgesia efficacy was shown at later times (24 hours, MD -0.29, 95% CI -0.78 to -0.19; 48 hours, MD - 0.06, 95% CI -0.86 to 0.77, 2 studies, 202 participants, low-quality evidence). Additional analgesia requirements were not significantly less (MD -0.37 (95% CI -1.10 to 0.35, 3 studies, 234 participants, low-quality evidence). Risk of nausea and vomiting was significantly reduced (RR 0.51, 95% CI 0.29 to 0.89, 3 studies, 273 participants, low-quality evidence). Results for other outcomes were imprecise (additional analgesia requirements: MD -0.37, 95% CI -1.10 to 0.35, 3 studies, 234 participants, low-quality evidence). Acetaminophen did not show analgesic benefit (0 to 6 hours, MD -0.35, 95% CI -1.00 to 0.30; 12 hours, MD -0.51, 95% CI -1.04 to 0.03, 3 studies, 332 participants, moderate-quality evidence; 24 hours, MD -0.34, 95% CI -1.20 to 0.52, 4 studies, 439 participants, high-quality evidence). Results for other outcomes remained imprecise (additional analgesia requirements, MD 0.07, 95% CI -0.86 to 0.99, 4 studies, 459 participants, high-quality evidence; length of hospitalizations, MD -3.71, 95% CI -14.12 to 6.7, 2 studies, 335 participants, moderate-quality evidence). AUTHORS' CONCLUSIONS There is high-quality evidence that NSAIDs reduce pain up to 24 hours postoperatively. The evidence for reductions in pain with dexmedetomidine, pregabalin or gabapentin, scalp blocks, and scalp infiltration is less certain and of very low to moderate quality. There is low-quality evidence that scalp blocks and dexmedetomidine may reduce additional analgesics requirements. There is low-quality evidence that gabapentin or pregabalin may decrease nausea and vomiting, with the caveat that the total number of events for this comparison was low.
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Affiliation(s)
| | - Ron Levy
- Kingston General HospitalDepartment of NeurosurgeryDept of Surgery, Room 304 , Victory 3 ,76 Stuart StreetKingstonONCanadaK7L 2V7
| | - Andrew G Day
- Kingston General HospitalClinical Research CentreAngada 4, Room 5‐42176 Stuart StreetKingstonONCanadaK7L 2V7
| | - Ian Gilron
- Queen's UniversityDepartments of Anesthesiology & Perioperative Medicine & Biomedical & Molecular Sciences76 Stuart StreetVictory 2 PavillionKingstonONCanadaK7L 2V7
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Kendall MC, Castro-Alves LJ. Letter to the Editor. Multimodal opioid-minimizing pain management regimens following transsphenoidal surgery. J Neurosurg 2018; 129:561-562. [PMID: 29999449 DOI: 10.3171/2018.2.jns18392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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