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Martin LD, Franz AM, Rampersad SE, Ojo B, Low DK, Martin LD, Hunyady AI, Flack SH, Geiduschek JM. Outcomes for 41 260 pediatric surgical patients with opioid-free anesthesia: One center's experience. Paediatr Anaesth 2023; 33:699-709. [PMID: 37300350 DOI: 10.1111/pan.14705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 04/21/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Opioid use is common and associated with side effects and risks. Consequently, analgesic strategies to reduce opioid utilization have been developed. Regional anesthesia and multimodal strategies are central tenets of enhanced recovery pathways and facilitate reduced perioperative opioid use. Opioid-free anesthesia (OFA) protocols eliminate all intraoperative opioids, reserving opioids for postoperative rescue treatment. Systematic reviews show variable results for OFA. METHODS In a series of Quality Improvement (QI) projects, multidisciplinary teams developed interventions to test and spread OFA first in our ambulatory surgery center (ASC) and then in our hospital. Outcome measures were tracked using statistical process control charts to increase the adoption of OFA. RESULTS Between January 1, 2016, and September 30, 2022, 19 872 of 28 574 ASC patients received OFA, increasing from 30% to 98%. Post Anesthesia Care Unit (PACU) maximum pain score, opioid-rescue rate, and postoperative nausea and vomiting (PONV) treatment all decreased concomitantly. The use of OFA now represents our ambulatory standard practice. Over the same timeframe, the spread of this practice to our hospital led to 21 388 of 64 859 patients undergoing select procedures with OFA, increasing from 15% to 60%. Opioid rescue rate and PONV treatment in PACU decreased while hospital maximum pain scores and length of stay were stable. Two procedural examples with OFA benefits were identified. The use of OFA allowed relaxation of adenotonsillectomy admission criteria, resulting in 52 hospital patient days saved. Transition to OFA for laparoscopic appendectomy occurred concomitantly with a decrease in the mean hospital length of stay from 2.9 to 1.4 days, representing a savings of >500 hospital patient days/year. CONCLUSIONS These QI projects demonstrated that most pediatric ambulatory and select inpatient surgeries are amenable to OFA techniques which may reduce PONV without worsening pain.
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Affiliation(s)
- Lynn D Martin
- Department of Anesthesiology & Pain Medicine and Pediatrics, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Amber M Franz
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Sally E Rampersad
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Bukola Ojo
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Daniel K Low
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Lizabeth D Martin
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Agnes I Hunyady
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Sean H Flack
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Jeremy M Geiduschek
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
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Alrimy T, Alhalabi W, Malibari A, Alzahrani F, Alrajhi S, Yamani A, Ahmed H, Abduljawad A, Nasser E, ALattar S, Alharby B, Khalid H, Alhalabi M, Hoffman HG, Mason KP. Desktop Virtual Reality Offers a Novel Approach to Minimize Pain and Anxiety during Burn Wound Cleaning/Debridement in Infants and Young Children: A Randomized Crossover Pilot Study. J Clin Med 2023; 12:4985. [PMID: 37568388 PMCID: PMC10419830 DOI: 10.3390/jcm12154985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/14/2023] [Accepted: 07/24/2023] [Indexed: 08/13/2023] Open
Abstract
Although most scald burn injuries involve children under six, because of the challenges of using head mounted displays with young children there is very little research exploring the use of VR in children under six. The current clinical pilot study measured the analgesic effectiveness of our new desktop VR system (with no VR helmet) in children under six during burn wound care (a within-subjects design with randomized treatment order). Between December 2021-April 2022, nine children with burn injuries (10 months to 5 years age, mean = 18 months) participated. The mean burn size was 10% Total Body Surface Area, range 2-22%. Using nurse's ratings, VR significantly reduced children's pain during burn wound care by 40% on the observational Faces, Legs, Activity, Crying, and Consolability (FLACC) pain scale. Specifically, non-parametric within-subject sign tests compared nurse's ratings of the young patients' pain during burn wound care using usual pain medications with no VR = 6.67, (SD = 2.45) vs. adjunctive Animal Rescue World VR (VR = 4.00, SD = 2.24, p < 0.01). The observational Procedure-Behavior Checklist (PBCL) nurse's scale measured a 34% reduction in anxiety with VR as compared to pharmacologic treatment alone (p < 0.005). Similarly, when using single graphic rating scales the patients' parents reported a significant 36% decrease in their child's pain during VR (p < 0.05), a 38% (p < 0.005) decrease in their child's anxiety during VR, and a significant increase in patients' joy during VR. It can be concluded that during burn wound care with no distraction (traditional pain medications), children under 6 years old experienced severe pain during a 10 min burn wound cleaning session. During burn wound care combining desktop virtual reality and traditional pain medications, the same pediatric patients experienced only mild pain during burn wound cleaning/debridement. VR significantly reduced the children's pain and anxiety during burn wound care.
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Affiliation(s)
- Taima Alrimy
- Computer Science Department, Faculty of Computing and Information Technology, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Wadee Alhalabi
- Computer Science Department, Faculty of Computing and Information Technology, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Immersive Virtual Reality Research Group, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Areej Malibari
- Computer Science Department, Faculty of Computing and Information Technology, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Fatma Alzahrani
- Paediatric Department, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Sharifah Alrajhi
- Statistics Department, Faculty of Science, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Ayman Yamani
- Department of Plastic Surgery and Burn, Alnoor Specialist Hospital, Makka 24241, Saudi Arabia
| | - Halah Ahmed
- Department of Plastic Surgery and Burn, Alnoor Specialist Hospital, Makka 24241, Saudi Arabia
| | - Amro Abduljawad
- Department of Plastic Surgery and Burn, Alnoor Specialist Hospital, Makka 24241, Saudi Arabia
| | - Essam Nasser
- Burn Unit, King Abdulaziz Hospital, Jeddah 22421, Saudi Arabia
| | - Samar ALattar
- Burn Unit, King Abdulaziz Hospital, Jeddah 22421, Saudi Arabia
| | | | - Hasna Khalid
- Plastic Surgery Department, International Medical Center, Jeddah 23214, Saudi Arabia
| | - Mohammed Alhalabi
- Immersive Virtual Reality Research Group, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Hunter G. Hoffman
- Computer Science Department, Faculty of Computing and Information Technology, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Department of Mechanical Engineering HPL, University of Washington, Seattle, WA 98195, USA
| | - Keira P. Mason
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children’s Hospital, Boston, MA 02115, USA
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Marchetti G, Vittori A, Cascella M, Mascilini I, Piga S, Petrucci E, Castellano A, Caruso R, Francia E, Stocchi F, Marinangeli F, Inserra A, Picardo SG. Pain prevalence and pain management in children and adolescents in an italian third level pediatric hospital: a cross-sectional study. Ital J Pediatr 2023; 49:41. [PMID: 36978099 PMCID: PMC10053721 DOI: 10.1186/s13052-023-01439-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/08/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND In 2016, we performed a one-day investigation to analyze the prevalence of pain, pain intensity, and pain therapy in the Departments of Surgery and Onco-Hematology of the Ospedale Pediatrico Bambino Gesù. To improve the knowledge gap highlighted in the previous study, refresher courses and even personalized audits have been carried out during these years. The purpose of this study is to evaluate if, after 5 years, there have been improvements in the management of pain. METHODS The study was conducted on 25 January 2020. Pain assessment, pain therapies, pain prevalence and intensity in the preceding 24 h and during the recovery period were recorded. Pain outcomes were compared with previous audit results. RESULTS Out of the 63 children with at least one documented pain assessment (starting from 100 eligible), 35 (55.4%) experienced pain: 32 children (50.7%) experienced moderate /severe pain while 3 patients (4%) felt mild pain. In the preceding 24 h, 20 patients (31.7%) reported moderate/severe pain while 10 (16%) reported moderate or severe pain during the interview. The average value of the Pain Management Index (PMI) was - 1.3 ± 0.9 with a minimum of -3 and a maximum of 0. 28 patients (87%) undergoing analgesic therapy for moderate/severe pain had a PMI of less than 0 (undertreated pain), while 3 patients (13%) scored value of 0 or higher (adequate pain therapy), 4 patients (12.5%) received multimodal analgesia with opioids and 2 patients (6%) opioids alone. Time-based therapy was prescribed to 20 patients (62.5%), intermittent therapy was prescribed to 7 patients (22%) and 5 patients (15.5%) did not receive any therapy. The prevalence of pain was higher during hospitalization and 24 h before the interview, while at the time of the interview, the proportion was the same. In this audit, the daily prescription modality of the therapy had some improvements (time-based: 62.5% vs. 44%; intermittent: 22%vs 25%; no therapy: 15.5% vs. 31%). CONCLUSION Pain management in hospitalized children constantly requires special daily attention from health professionals aimed at mitigating the components of intractable pain and resolving those of treatable pain. TRIAL REGISTRATION This study is registered with ClinicalTrials.gov, number (NCT04209764), registered 24 December 2019, https://clinicaltrials.gov/ct2/show/NCT04209764?term=NCT04209764&draw=2&rank=1 .
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Affiliation(s)
- Giuliano Marchetti
- Department of Anesthesia and Critical care, ARCO Roma, Ospedale Pediatrico Bambino Gesù IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Alessandro Vittori
- Department of Anesthesia and Critical care, ARCO Roma, Ospedale Pediatrico Bambino Gesù IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy.
| | - Marco Cascella
- Department of Anesthesia and Critical Care, Istituto Nazionale Tumori-IRCCS, Fondazione Pascale, Naples, Italy
| | - Ilaria Mascilini
- Department of Anesthesia and Critical care, ARCO Roma, Ospedale Pediatrico Bambino Gesù IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Simone Piga
- Unit of Clinical Epidemiology, Ospedale Pediatrico Bambino Gesù IRCCS, Rome, Italy
| | - Emiliano Petrucci
- Department of Anesthesia and Intensive Care Unit, San Salvatore Academic Hospital of L'Aquila, L'Aquila, Italy
| | - Aurora Castellano
- Division of Oncohematology, Ospedale Pediatrico Bambino Gesù IRCCS, Rome, Italy
| | - Roberta Caruso
- Division of Oncohematology, Ospedale Pediatrico Bambino Gesù IRCCS, Rome, Italy
| | - Elisa Francia
- Department of Anesthesia and Critical care, ARCO Roma, Ospedale Pediatrico Bambino Gesù IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Francesca Stocchi
- Division of Oncohematology, Ospedale Pediatrico Bambino Gesù IRCCS, Rome, Italy
| | - Franco Marinangeli
- Department of Anesthesiology, Intensive Care and Pain Treatment, University of L'Aquila, L'Aquila, Italy
| | - Alessandro Inserra
- Surgical Department, General and Thoracic Unit, Ospedale Pediatrico Bambino Gesù IRCCS, Rome, Italy
| | - Sergio Giuseppe Picardo
- Department of Anesthesia and Critical care, ARCO Roma, Ospedale Pediatrico Bambino Gesù IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
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4
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Do U, Pook M, Najafi T, Rajabiyazdi F, El-Kefraoui C, Balvardi S, Barone N, Elhaj H, Nguyen-Powanda P, Lee L, Baldini G, Feldman LS, Fiore JF. S110-Opioid-free analgesia after outpatient general surgery: A qualitative study focused on the perspectives of patients and clinicians involved in a pilot trial. Surg Endosc 2023; 37:2269-2280. [PMID: 35918552 DOI: 10.1007/s00464-022-09472-8] [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: 03/26/2022] [Accepted: 07/12/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Opioid-free analgesia (OFA) may mitigate opioid-related harms after outpatient general surgery; however, the comparative effectiveness of this approach should be assessed in robust randomized controlled trials (RCTs). Undertaking an RCT on OFA raises important practical concerns, including surgeon and patient hesitation regarding pain management without opioids. We conducted a qualitative study to explore patients' and clinicians' perspectives and experiences with a pilot trial focused on OFA after outpatient general surgery. METHODS Patients undergoing outpatient abdominal and breast procedures were randomized to receive post-discharge opioid analgesia (OA) or OFA. Semi-structured interviews with patients and clinicians involved in the trial were conducted to elicit personal perspectives and experiences. Purposive sampling for maximum variation was used to recruit participants with diverse characteristics. Transcribed interviews were assessed using inductive thematic analysis. RESULTS Ten patients (5 abdominal, 5 breast) and 10 clinicians (6 surgeons, 2 anesthesiologists, 2 nurses) were interviewed. Five major themes emerged: readiness for trial engagement, pre-trial thoughts about the interventions, postoperative pain experiences, intervention acceptability, and trial refinement. Most patients were open to OFA. Clinicians expressed willingness to prescribe OFA, particularly after less invasive procedures and when using peripheral nerve blocks (PNBs). Concerns were raised regarding the adequacy of pain control and side effects of non-opioid drugs (e.g., NSAID-induced bleeding, kidney injury). Overall, participants were enthusiastic about the trial and recognized its relevance; clinicians praised the study design and organization; and patients valued the use of electronic questionnaires. Suggestions for improvements included preventing potential bias arising from the use of PNBs (i.e., via standardization or stratification) and reducing patient burden (i.e., decreasing postoperative questionnaires). CONCLUSION Patients and clinicians who participated in a pilot RCT generally accept the clinical equipoise between OA versus OFA after outpatient general surgery and recognize the need for methodologically robust trials to inform evidence-based analgesia prescribing.
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Affiliation(s)
- Uyen Do
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Makena Pook
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Tahereh Najafi
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Fateme Rajabiyazdi
- Department of Systems and Computer Engineering, Carleton University, Ottawa, ON, Canada
| | - Charbel El-Kefraoui
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Saba Balvardi
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Department of Surgery, McGill University, Montreal, QC, Canada
| | - Natasha Barone
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Hiba Elhaj
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Philip Nguyen-Powanda
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Lawrence Lee
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Division of Experimental Surgery, McGill University, Montreal, QC, Canada.,Department of Surgery, McGill University, Montreal, QC, Canada.,Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Gabriele Baldini
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Department of Anesthesia, McGill University, Montreal, QC, Canada
| | - Liane S Feldman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Division of Experimental Surgery, McGill University, Montreal, QC, Canada.,Department of Surgery, McGill University, Montreal, QC, Canada.,Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Julio F Fiore
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada. .,Division of Experimental Surgery, McGill University, Montreal, QC, Canada. .,Department of Surgery, McGill University, Montreal, QC, Canada. .,Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada. .,Montreal General Hospital, 1650 Cedar Ave, R2-104, Montreal, QC, H3G 1A4, Canada.
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5
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VanIderstine C. Opioid Prescribing Habits of Orthopedic Surgeons Following Total Hip Arthroplasty and Total Knee Arthroplasty: A Pilot Study. Can J Hosp Pharm 2022; 75:335-339. [PMID: 36246434 PMCID: PMC9524559 DOI: 10.4212/cjhp.3282] [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: 11/05/2022]
Abstract
Background Adequate pain management is important in patients' recovery from total hip arthroplasty (THA) and total knee arthroplasty (TKA). Objective To determine whether risk factors for prolonged opioid use are considered when discharge prescriptions for postoperative pain are written following THA and TKA. Methods Opioid prescriptions written between June 14 and July 9, 2021, for patients who underwent THA or TKA were analyzed. Data were also collected on the patients' age, sex, type of surgery, type of anesthesia (regional or general), preoperative use of opioids, and preoperative use of antidepressants. Results Among the 59 patients included in the study, the most common prescriptions were for hydromorphone 2 mg (n = 15, 25%) and hydromorphone 1 mg (n = 15, 25%). At discharge, patients received a median of 400 morphine milligram equivalents (MMEs). There was no significant difference in the quantity of opioids (MMEs) prescribed at discharge in relation to surgery type (p = 0.63), sex (p = 0.44), preoperative antidepressant use (p = 0.22), or preoperative opioid use (p = 0.97). There also appeared to be no correlation between a patient's age and MMEs at discharge (p = 0.21; r 2 = 0.028). None of these variables could be used to predict which patients would receive more than 400 MMEs. Conclusions Patient-specific factors appeared not to be taken into consideration when opioids were prescribed for postoperative pain among patients who underwent THA or TKA.
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Lee JE, Park HJ, Chung YJ, Ahn HJ, Sim WS, Lee JY. Analgesic effect of dexmedetomidine in colorectal cancer patients undergoing laparoscopic surgery. Saudi Med J 2022; 43:1096-1102. [PMID: 36261202 PMCID: PMC9994502 DOI: 10.15537/smj.2022.43.10.20220526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/15/2022] [Indexed: 06/16/2023] Open
Abstract
OBJECTIVES To evaluate the analgesic efficacy of intraoperative dexmedetomidine (DEX) for acute postoperative pain in colorectal cancer patients undergoing laparoscopic surgery. METHODS We retrospectively analyzed data of 190 colorectal cancer patients who had undergone laparoscopic surgery between October 2020 and May 2021 at Samsung Medical Center, Seoul, Korea, with (n=74) or without intraoperative DEX (n=85) administration. The demographic, clinical, anesthetic, and postoperative data were compared. RESULTS In total, 159 patients were enrolled. Demographic and clinical data were not different between the groups. The mean arterial pressure (p<0.001) and heart rate (p<0.001) were lower in the DEX group at the end of surgery and after extubation (p=0.003, p=0.001). The minimum alveolar concentration of sevoflurane was lower in the DEX group during surgery. At the post-anesthesia care unit (PACU) admission and discharge, pain scores (p<0.001, p=0.027) and fentanyl consumption (p<0.001) were significantly lower in the DEX group. On postoperative days 1-3, pain scores and opioid consumption were not different between the groups. The incidence of postoperative complications was not different between the groups. CONCLUSION Continuous intraoperative DEX administration had an intraoperative analgesic effect as indicated by lower hemodynamic and fentanyl consumption. Furthermore, there was immediate postoperative analgesia as suspected by the lower pain scores and fentanyl dose during the PACU. However, pain scores and opioid consumption after the PACU remained unaffected.
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Affiliation(s)
- Ja E. Lee
- From the Department of Anesthesiology and Pain Medicine (JE. Lee, Chung, Ahn, Sim, JY. Lee), Samsung Medical Center, School of Medicine, Sungkyunkwan University, and from the Department of Anesthesiology and Pain Medicine (Park), Seoul St. Mary’s hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
| | - Hue J. Park
- From the Department of Anesthesiology and Pain Medicine (JE. Lee, Chung, Ahn, Sim, JY. Lee), Samsung Medical Center, School of Medicine, Sungkyunkwan University, and from the Department of Anesthesiology and Pain Medicine (Park), Seoul St. Mary’s hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
| | - Yoon J. Chung
- From the Department of Anesthesiology and Pain Medicine (JE. Lee, Chung, Ahn, Sim, JY. Lee), Samsung Medical Center, School of Medicine, Sungkyunkwan University, and from the Department of Anesthesiology and Pain Medicine (Park), Seoul St. Mary’s hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
| | - Hyun J. Ahn
- From the Department of Anesthesiology and Pain Medicine (JE. Lee, Chung, Ahn, Sim, JY. Lee), Samsung Medical Center, School of Medicine, Sungkyunkwan University, and from the Department of Anesthesiology and Pain Medicine (Park), Seoul St. Mary’s hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
| | - Woo S. Sim
- From the Department of Anesthesiology and Pain Medicine (JE. Lee, Chung, Ahn, Sim, JY. Lee), Samsung Medical Center, School of Medicine, Sungkyunkwan University, and from the Department of Anesthesiology and Pain Medicine (Park), Seoul St. Mary’s hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
| | - Jin Y. Lee
- From the Department of Anesthesiology and Pain Medicine (JE. Lee, Chung, Ahn, Sim, JY. Lee), Samsung Medical Center, School of Medicine, Sungkyunkwan University, and from the Department of Anesthesiology and Pain Medicine (Park), Seoul St. Mary’s hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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7
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Do U, El-Kefraoui C, Pook M, Balvardi S, Barone N, Nguyen-Powanda P, Lee L, Baldini G, Feldman LS, Fiore JF. Feasibility of Prospectively Comparing Opioid Analgesia With Opioid-Free Analgesia After Outpatient General Surgery: A Pilot Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2221430. [PMID: 35849399 PMCID: PMC9294998 DOI: 10.1001/jamanetworkopen.2022.21430] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE The overprescription of opioids to surgical patients is recognized as an important factor contributing to the opioid crisis. However, the value of prescribing opioid analgesia (OA) vs opioid-free analgesia (OFA) after postoperative discharge remains uncertain. OBJECTIVE To investigate the feasibility of conducting a full-scale randomized clinical trial (RCT) to assess the comparative effectiveness of OA vs OFA after outpatient general surgery. DESIGN, SETTING, AND PARTICIPANTS This parallel, 2-group, assessor-blind, pragmatic pilot RCT was conducted from January 29 to September 3, 2020 (last follow-up on October 2, 2020). at 2 university-affiliated hospitals in Montreal, Quebec, Canada. Participants were adult patients (aged ≥18 years) undergoing outpatient abdominal (ie, cholecystectomy, appendectomy, or hernia repair) or breast (ie, partial or total mastectomy) general surgical procedures. Exclusion criteria were contraindications to drugs used in the trial, preoperative opioid use, conditions that could affect assessment of outcomes, and intraoperative or early complications requiring hospitalization. INTERVENTIONS Patients were randomized 1:1 to receive OA (around-the-clock nonopioids and opioids for breakthrough pain) or OFA (around-the-clock nonopioids with increasing doses and/or addition of nonopioid medications for breakthrough pain) after postoperative discharge. MAIN OUTCOMES AND MEASURES Main outcomes were a priori RCT feasibility criteria (ie, rates of surgeon agreement, patient eligibility, patient consent, treatment adherence, loss to follow-up, and missing follow-up data). Secondary outcomes included pain intensity and interference, analgesic intake, 30-day unplanned health care use, and adverse events. Between-group comparison of outcomes followed the intention-to-treat principle. RESULTS A total of 15 surgeons were approached; all (100%; 95% CI, 78%-100%) agreed to have patients recruited and adhered to the study procedures. Rates of patient eligibility and consent were 73% (95% CI, 66%-78%) and 57% (95% CI, 49%-65%), respectively. Seventy-six patients were randomized (39 [51%] to OA and 37 [49%] to OFA) and included in the intention-to-treat analysis (mean [SD] age, 55.5 [14.5] years; 50 [66%] female); 40 (53%) underwent abdominal surgery, and 36 (47%) underwent breast surgery. Seventy-five patients (99%; 95% CI, 93%-100%) adhered to the allocated treatment; 1 patient randomly assigned to OFA received an opioid prescription. Seventeen patients (44%) randomly assigned to OA consumed opioids after discharge. Seventy-three patients (96%; 95% CI, 89%-99%) completed the 30-day follow-up. The rate of missing questionnaires was 37 of 3724 (1%; 95% CI, 0.7%-1.4%). All the a priori RCT feasibility criteria were fulfilled. CONCLUSIONS AND RELEVANCE The findings of this pilot RCT support the feasibility of conducting a robust, full-scale RCT to inform evidence-based prescribing of analgesia after outpatient general surgery. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04254679.
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Affiliation(s)
- Uyen Do
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Charbel El-Kefraoui
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Makena Pook
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Saba Balvardi
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Natasha Barone
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Philip Nguyen-Powanda
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Lawrence Lee
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Gabriele Baldini
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Anesthesia, McGill University, Montreal, Quebec, Canada
| | - Liane S. Feldman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Julio F. Fiore
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
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Fiore JF, El-Kefraoui C, Chay MA, Nguyen-Powanda P, Do U, Olleik G, Rajabiyazdi F, Kouyoumdjian A, Derksen A, Landry T, Amar-Zifkin A, Bergeron A, Ramanakumar AV, Martel M, Lee L, Baldini G, Feldman LS. Opioid versus opioid-free analgesia after surgical discharge: a systematic review and meta-analysis of randomised trials. Lancet 2022; 399:2280-2293. [PMID: 35717988 DOI: 10.1016/s0140-6736(22)00582-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 03/12/2022] [Accepted: 03/18/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Excessive opioid prescribing after surgery has contributed to the current opioid crisis; however, the value of prescribing opioids at surgical discharge remains uncertain. We aimed to estimate the extent to which opioid prescribing after discharge affects self-reported pain intensity and adverse events in comparison with an opioid-free analgesic regimen. METHODS In this systematic review and meta-analysis, we searched MEDLINE, Embase, the Cochrane Library, Scopus, AMED, Biosis, and CINAHL from Jan 1, 1990, until July 8, 2021. We included multidose randomised controlled trials comparing opioid versus opioid-free analgesia in patients aged 15 years or older, discharged after undergoing a surgical procedure according to the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity definition (minor, moderate, major, and major complex). We screened articles, extracted data, and assessed risk of bias (Cochrane's risk-of-bias tool for randomised trials) in duplicate. The primary outcomes of interest were self-reported pain intensity on day 1 after discharge (standardised to 0-10 cm visual analogue scale) and vomiting up to 30 days. Pain intensity at further timepoints, pain interference, other adverse events, risk of dissatisfaction, and health-care reutilisation were also assessed. We did random-effects meta-analyses and appraised evidence certainty using the Grading of Recommendations, Assessment, Development, and Evaluations scoring system. The review was registered with PROSPERO (ID CRD42020153050). FINDINGS 47 trials (n=6607 patients) were included. 30 (64%) trials involved elective minor procedures (63% dental procedures) and 17 (36%) trials involved procedures of moderate extent (47% orthopaedic and 29% general surgery procedures). Compared with opioid-free analgesia, opioid prescribing did not reduce pain on the first day after discharge (weighted mean difference 0·01cm, 95% CI -0·26 to 0·27; moderate certainty) or at other postoperative timepoints (moderate-to-very-low certainty). Opioid prescribing was associated with increased risk of vomiting (relative risk 4·50, 95% CI 1·93 to 10·51; high certainty) and other adverse events, including nausea, constipation, dizziness, and drowsiness (high-to-moderate certainty). Opioids did not affect other outcomes. INTERPRETATION Findings from this meta-analysis support that opioid prescribing at surgical discharge does not reduce pain intensity but does increase adverse events. Evidence relied on trials focused on elective surgeries of minor and moderate extent, suggesting that clinicians can consider prescribing opioid-free analgesia in these surgical settings. Data were largely derived from low-quality trials, and none involved patients having major or major-complex procedures. Given these limitations, there is a great need to advance the quality and scope of research in this field. FUNDING The Canadian Institutes of Health Research.
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Affiliation(s)
- Julio F Fiore
- Department of Surgery, McGill University, Montreal, QC, Canada; Division of Experimental Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada.
| | - Charbel El-Kefraoui
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | | | - Philip Nguyen-Powanda
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Uyen Do
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Ghadeer Olleik
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Fateme Rajabiyazdi
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Department of Systems and Computer Engineering, Carleton University, ON, Canada
| | - Araz Kouyoumdjian
- Department of Surgery, McGill University, Montreal, QC, Canada; Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Alexa Derksen
- Patient Representative, Université de Montréal, Montreal, QC, Canada
| | - Tara Landry
- Medical Libraries, McGill University Health Centre, Montreal, QC, Canada; Bibliothèque de la Santé, Université de Montréal, Montreal, QC, Canada
| | | | - Amy Bergeron
- Medical Libraries, McGill University Health Centre, Montreal, QC, Canada
| | - Agnihotram V Ramanakumar
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Marc Martel
- Faculty of Dentistry, McGill University, Montreal, QC, Canada; Department of Anaesthesia, McGill University, Montreal, QC, Canada
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, QC, Canada; Division of Experimental Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Gabriele Baldini
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada; Department of Anaesthesia, McGill University, Montreal, QC, Canada
| | - Liane S Feldman
- Department of Surgery, McGill University, Montreal, QC, Canada; Division of Experimental Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
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9
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Rudikoff AG, Tieu DD, Banzali FM, Nguyen CV, Rettig RL, Nashed MM, Mora-Marquez J, Chen Q, Conte AH, Mason KP. Perioperative Acetaminophen and Dexmedetomidine Eliminate Post-Operative Opioid Requirement following Pediatric Tonsillectomy. J Clin Med 2022; 11:jcm11030561. [PMID: 35160013 PMCID: PMC8836354 DOI: 10.3390/jcm11030561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/18/2022] [Accepted: 01/21/2022] [Indexed: 02/01/2023] Open
Abstract
Administration of post-operative opioids following pediatric tonsillectomy can elicit respiratory events in this patient population that often arise as central and obstructive sleep apnea. The primary objective of this study was to determine whether a perioperative combination of dexmedetomidine and acetaminophen could eliminate post-operative (in recovery and at home) opioid requirements. Following IRB approval and a waiver for informed consent, the medical records of 681 patients who underwent tonsillectomy between 1 January 2013 and 31 December 2018 were evaluated. Between 1 January 2013 and 31 December 2015, all patients received a fentanyl-sevoflurane-based anesthetic, without acetaminophen or dexmedetomidine, and received opioids in recovery and for discharge home. On 1 January 2016, an institution-wide practice change replaced this protocol with a multimodal perioperative regimen of acetaminophen (intravenous or enteral) and dexmedetomidine and eliminated post-operative opioids. This is the first time that the effect of an acetaminophen and dexmedetomidine combination on the perioperative and home opioid requirement has been reported. Primarily, we compared the need for rescue opioids in the post-anesthesia care period and after discharge. The multi-modal protocol eliminated the need for post-tonsillectomy opioid administration. Dexmedetomidine in combination with acetaminophen eliminated the need for post-operative opioids in the recovery period.
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Affiliation(s)
- Andrew G. Rudikoff
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA 90027, USA; (A.G.R.); (F.M.B.)
| | - David D. Tieu
- Department of Head & Neck Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA 90027, USA; (D.D.T.); (C.V.N.)
| | - Franklin M. Banzali
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA 90027, USA; (A.G.R.); (F.M.B.)
| | - Carolyn V. Nguyen
- Department of Head & Neck Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA 90027, USA; (D.D.T.); (C.V.N.)
| | - Robert L. Rettig
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA 90027, USA;
| | - Marlene M. Nashed
- Department of Pharmacy, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA 90027, USA;
| | - Janet Mora-Marquez
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Avenue, Pasadena, CA 91101, USA; (J.M.-M.); (Q.C.)
| | - Qiaoling Chen
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Avenue, Pasadena, CA 91101, USA; (J.M.-M.); (Q.C.)
| | - Antonio Hernandez Conte
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA 90027, USA; (A.G.R.); (F.M.B.)
- Correspondence: ; Tel.: +1-323-573-3900
| | - Keira P. Mason
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA;
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Hadzic A, Van Herreweghe I, Lopez AM, Vandebergh V. Editorial: Point-of-care ultrasound revolution in anesthesiology. Curr Opin Anaesthesiol 2021; 34:607-608. [PMID: 34342288 DOI: 10.1097/aco.0000000000001053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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