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Dunworth S, Barbeito A, Nagavelli H, Higgins D, Edward S, Williams M, Pyati S. Transitional Pain Service: Optimizing Complex Surgical Patients. Curr Pain Headache Rep 2024; 28:141-147. [PMID: 38117461 DOI: 10.1007/s11916-023-01204-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2023] [Indexed: 12/21/2023]
Abstract
PURPOSE OF REVIEW The care of patients with complex postsurgical pain can be challenging and burdensome for the healthcare system. Transitional pain service (TPS) is a relatively new concept and has not been widely adopted in the USA. This article explores the benefits and barriers of transitional pain services and describes the development of a TPS at our institution. RECENT FINDINGS Evidence from a few institutions that have adopted TPS has shown decreased postsurgical opioid consumption for patients on chronic opioids and decreased incidence of chronic postsurgical opioid use for opioid-naïve patients. The development of a transitional pain service may improve outcomes for these complex patients by providing longitudinal and multidisciplinary perioperative pain care. In this article, we describe the implementation of a TPS at a tertiary medical center. Our TPS model involves a multidisciplinary team of anesthesiologists, pain psychologists, surgeons, and advanced practice providers. We provide longitudinal care, including preoperative education and optimization; perioperative multimodal analgesic care; and longitudinal follow-up for 90 days post-procedure. With our TPS service, we aim to reduce long-term opioid use and improve functional outcomes for our patients.
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Affiliation(s)
- Sophia Dunworth
- Department of Anesthesiology, Duke University School of Medicine, PO Box 3094, Durham, NC, 27701, USA
- Anesthesiology Service, Durham Veterans Affairs Healthcare Systems, Durham, NC, USA
| | - Atilio Barbeito
- Department of Anesthesiology, Duke University School of Medicine, PO Box 3094, Durham, NC, 27701, USA
- Anesthesiology Service, Durham Veterans Affairs Healthcare Systems, Durham, NC, USA
| | - Harika Nagavelli
- Department of Anesthesiology, Duke University School of Medicine, PO Box 3094, Durham, NC, 27701, USA
- Anesthesiology Service, Durham Veterans Affairs Healthcare Systems, Durham, NC, USA
| | - Diana Higgins
- Anesthesiology Service, Durham Veterans Affairs Healthcare Systems, Durham, NC, USA
| | - Shibu Edward
- Anesthesiology Service, Durham Veterans Affairs Healthcare Systems, Durham, NC, USA
| | - Melvania Williams
- Anesthesiology Service, Durham Veterans Affairs Healthcare Systems, Durham, NC, USA
| | - Srinivas Pyati
- Department of Anesthesiology, Duke University School of Medicine, PO Box 3094, Durham, NC, 27701, USA.
- Anesthesiology Service, Durham Veterans Affairs Healthcare Systems, Durham, NC, USA.
- Present address: Department of Anesthesiology, Duke University School of Medicine, Durham Veterans Affairs Healthcare System, PO Box 3094, Durham, NC, 27701, USA.
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Mainprize M, Yilbas A, Spencer Netto FAC, Svendrovski A, Katz J. Incidence of opioid use and early postoperative pain intensity after primary unilateral inguinal hernia repair at a single-center specialty hospital. Langenbecks Arch Surg 2023; 408:366. [PMID: 37726600 DOI: 10.1007/s00423-023-03111-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 09/14/2023] [Indexed: 09/21/2023]
Abstract
PURPOSE This research examined opioid use, pain intensity, and pain management after primary unilateral inguinal hernia repair (PUIHR) at a single-center specialty hospital. METHODS After research, ethics board approval, and informed consent, pain scores (0-10 numerical rating scale [NRS]) were obtained from survey-based questionnaires administered at the pre- and 3-day postoperative timepoints. Descriptive results are presented as frequency, mean, standard deviation, range, median, and interquartile ranges, as appropriate. Significance tests were conducted to compare participants who did and did not receive opioids after surgery. p-value <0.05 is considered statistically significant. As the standard of care, participants received nonopioid multimodal analgesia (acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs)) and opioids, when necessary. RESULTS A total of 414 and 331 participants completed the pre- and 3-day postoperative questionnaires, respectively. Out of the 414 participants, 38 (9.2%) received opioids during the postoperative stay. There was no significant difference between pain frequency or mean preoperative NRS pain intensity scores of those who did and did not receive opioids. Mean NRS pain intensity scores on day 3 after surgery were significantly higher for participants who received opioids (3.15±2.08) than those who did not (2.19±1.95), p=0.005. CONCLUSION Most participants did not receive opioids after PUIHR and had lower mean postoperative NRS pain intensity scores compared to those who did, most likely reflecting the need for opioids among the latter. Opioids were discontinued by day 3 for all participants who received them. Therefore, for most patients undergoing PUIHR, effective pain control can be achieved with nonopioid multimodal analgesia in the early postoperative period.
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Affiliation(s)
| | - Ayse Yilbas
- Department of Surgery, Shouldice Hospital, ON, Canada
| | | | | | - Joel Katz
- Department of Psychology, York University, ON, Canada
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Sng DDD, Uitenbosch G, de Boer HD, Carvalho HN, Cata JP, Erdoes G, Heytens L, Lois FJ, Pelosi P, Rousseau AF, Forget P, Nesvadba D. Developing expert international consensus statements for opioid-sparing analgesia using the Delphi method. BMC Anesthesiol 2023; 23:62. [PMID: 36849928 PMCID: PMC9969386 DOI: 10.1186/s12871-023-01995-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 01/25/2023] [Indexed: 03/01/2023] Open
Abstract
INTRODUCTION The management of postoperative pain in anaesthesia is evolving with a deeper understanding of associating multiple modalities and analgesic medications. However, the motivations and barriers regarding the adoption of opioid-sparing analgesia are not well known. METHODS We designed a modified Delphi survey to explore the perspectives and opinions of expert panellists with regard to opioid-sparing multimodal analgesia. 29 anaesthetists underwent an evolving three-round questionnaire to determine the level of agreement on certain aspects of multimodal analgesia, with the last round deciding if each statement was a priority. RESULTS The results were aggregated and a consensus, defined as achievement of over 75% on the Likert scale, was reached for five out of eight statements. The panellists agreed there was a strong body of evidence supporting opioid-sparing multimodal analgesia. However, there existed multiple barriers to widespread adoption, foremost the lack of training and education, as well as the reluctance to change existing practices. Practical issues such as cost effectiveness, increased workload, or the lack of supply of anaesthetic agents were not perceived to be as critical in preventing adoption. CONCLUSION Thus, a focus on developing specific guidelines for multimodal analgesia and addressing gaps in education may improve the adoption of opioid-sparing analgesia.
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Affiliation(s)
- Daniel Da Der Sng
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, AB25 2ZD, UK.
| | - Giulia Uitenbosch
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Hans D de Boer
- Department of Anesthesiology Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, Groningen, Netherlands
| | - Hugo Nogueira Carvalho
- Anesthesiology and Perioperative Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Jette, Belgium
| | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, USA
| | - Gabor Erdoes
- University Department of Anaesthesiology and Pain Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Luc Heytens
- Department of Anesthesia, Department of Neurology and Instituut Born-Bunge, University of Antwerp (UA), Antwerpen, Belgium
| | - Fernande Jane Lois
- Centre Hospitalier Universitaire de Liège, Anesthesiology, Liège, Belgium
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), IRCCS San Martino Policlinico Hospital, Genova GE, Italy
| | | | - Patrice Forget
- Department of Anaesthesia, Institute of Applied Health Sciences, Epidemiology Group, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen; NHS Grampian, Aberdeen, AB25 2ZD, UK.,Pain and Opioids After Surgery (PANDOS) European Society of Anaesthesiology and Intensive Care (ESAIC) Research Group, ESAIC, Brussels, Belgium
| | - David Nesvadba
- Department of Anaesthesia, NHS Grampian, Aberdeen, AB25 2ZD, UK
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Eichorn NL, Shult HT, Kracht KD, Berlau DJ. Making a joint decision: Cannabis as a potential substitute for opioids in obstetrics and gynecology. Best Pract Res Clin Obstet Gynaecol 2022; 85:59-67. [PMID: 35970747 DOI: 10.1016/j.bpobgyn.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 07/12/2022] [Indexed: 12/14/2022]
Abstract
There is a growing body of evidence that cannabis may be effective as an analgesic with potential to reduce opioid usage in chronic pain. This review synthesizes the available literature to elucidate the possible role that cannabis might play in reducing opioid use in gynecological disorders that may potentially lead to a recommendation of substituting opioids with cannabis. With reports of a decrease in opioid use after cannabis initiation, an opioid-sparing effect has been seen in gynecologic malignancies such as ovarian, uterine, endometrial, and cervical cancers, in addition to chronic pelvic pain (CPP). Though many studies have found an association between cannabis and various adverse maternal and neonatal outcomes, there is a lack of randomized controlled trials making it difficult to claim a directly causal relationship between cannabis and these adverse outcomes. Additionally, with increased use of cannabis during pregnancy, the evidence of possible benefits and risks to mothers and fetuses is examined.
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Affiliation(s)
- Nicole L Eichorn
- Departent of Pharmaceutical Sciences, Regis University School of Pharmacy, 3333 Regis Blvd. H-28, Denver, CO, 80221, USA
| | - Hannah T Shult
- Departent of Pharmaceutical Sciences, Regis University School of Pharmacy, 3333 Regis Blvd. H-28, Denver, CO, 80221, USA
| | - Kelsie D Kracht
- Departent of Pharmaceutical Sciences, Regis University School of Pharmacy, 3333 Regis Blvd. H-28, Denver, CO, 80221, USA
| | - Daniel J Berlau
- Departent of Pharmaceutical Sciences, Regis University School of Pharmacy, 3333 Regis Blvd. H-28, Denver, CO, 80221, USA.
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Anyaehie KB, Duryea E, Wang J, Echebelem C, Macias D, Sunna M, Ogunkua O, Joshi GP, Gasanova I. Multimodal opioid-sparing pain management for emergent cesarean delivery under general anesthesia: a quality improvement project. BMC Anesthesiol 2022; 22:239. [PMID: 35896959 PMCID: PMC9327409 DOI: 10.1186/s12871-022-01780-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 07/18/2022] [Indexed: 11/11/2022] Open
Abstract
Background Opioid-sparing multimodal analgesic approach has been shown to provide effective postoperative pain relief and reduce postoperative opioid consumption and opioid-associated adverse effects. While many studies have evaluated analgesic strategies for elective cesarean delivery, few studies have investigated analgesic approaches in emergent cesarean deliveries under general anesthesia. The primary aim of this quality improvement project is to evaluate opioid consumption with the use of a multimodal opioid-sparing pain management pathway in patients undergoing emergent cesarean delivery under general anesthesia. Methods Seventy-two women (age > 16 years) undergoing emergent cesarean delivery under general anesthesia before (n = 36) and after (n = 36) implementation of a multimodal opioid-sparing pain management pathway were included. All patients received a standardized general anesthetic. Prior to implementation of the pathway, postoperative pain management was primarily limited to intravenous patient-controlled opioid administration. The new multimodal pathway included scheduled acetaminophen and non-steroidal anti-inflammatory medications and ultrasound-guided classic lateral transversus abdominis plane blocks with postoperative opioids reserved only for rescue analgesia. Data obtained from electronic records included demographics, intraoperative opioid use, and pain scores and opioid consumption upon arrival to the recovery room, at 2, 6, 12, 24, 48, and 72 h postoperatively. Results Patients receiving multimodal opioid sparing analgesia (AFTER group) had lower opioid use for 72 h, postoperatively. Only 2 of the 36 patients (5.6%) in the AFTER group required intravenous opioids through patient-controlled analgesia while 30 out of 36 patients (83.3%) in the BEFORE group required intravenous opioids. Conclusions Multimodal opioid-sparing analgesia is associated with reduced postoperative opioid consumption after emergent cesarean delivery.
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Affiliation(s)
- Kelechi B Anyaehie
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9068, USA.
| | - Elaine Duryea
- Department of Obstetrics and Gynecology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9159, USA
| | - Jenny Wang
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9068, USA
| | - Chinedu Echebelem
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9068, USA
| | - Devin Macias
- Department of Obstetrics and Gynecology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9159, USA
| | - Mary Sunna
- Parkland Health and Hospital System, 5200 Harry Hines Blvd, Dallas, TX, 75235, USA
| | - Olutoyosi Ogunkua
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9068, USA
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9068, USA
| | - Irina Gasanova
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9068, USA
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Huang C, Huang Q, Shen Y, Liu K, Wu J. General anaesthesia with double-lumen intubation compared to opioid-sparing strategies with laryngeal mask for thoracoscopic surgery: A randomised trial. Anaesth Crit Care Pain Med 2022; 41:101083. [PMID: 35472588 DOI: 10.1016/j.accpm.2022.101083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/05/2021] [Accepted: 01/22/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND General anaesthesia for thoracoscopic lung surgery can be performed with the opioid-sparing strategies without intubation and may reduce the risk of glottic injury and enhance recovery after surgery. We therefore tested the primary hypothesis that avoiding intubation reduces glottic injury. METHODS Adults having elective thoracoscopic lung resections were randomised to: (1) intubated group: routine general anaesthesia with a double-lumen tube intubation; or, (2) non-intubated group: a bundle of opioid-sparing strategies, which included paravertebral blocks and total intravenous anaesthesia with minimal remifentanil infusion from 0.05 to 1.0 ng/mL (avoid sufentanil unless the respiratory rate exceeds 25/min or the systolic blood pressure exceeds 30% of the baseline value), no muscle relaxation, and spontaneous ventilation through a laryngeal mask. The primary outcome was glottal injury as determined by transnasal bronchoscopy one hour after removal of the laryngeal mask or double-lumen tube. RESULTS Two hundred seventeen patients were assessed for the primary outcome. Sufentanil use was reduced 96% and remifentanil was reduced 40% in non-intubated opioid-sparing patients. The incidence of glottal injury was 9% (10/109) in the non-intubated vs. 37% (40/108) in the intubated patients (RR: 0.25; 95%CI: 0.13-0.47, P < 0.001). The non-intubated group also had less postoperative sore throat (8% vs. 39%; P < 0.001) and hoarseness (3% vs. 19%; P < 0.001). Postoperative pulmonary complications and lung injury biomarkers did not differ between the groups. Compared to the intubated group, the non-intubated group had less postoperative pain, faster recovery, and improved quality-of-life scores. CONCLUSIONS Non-intubated opioid-sparing strategies for video-assisted lung resections reduce airway injury and promote postoperative recovery. CLINICAL TRIAL NUMBER AND REGISTRY URL ChiCTR1800018198 https://www.chictr.org.cn/showproj.aspx?proj=30780.
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Affiliation(s)
- Chengya Huang
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, China
| | - Qi Huang
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, China
| | - Yaofeng Shen
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, China
| | - Kun Liu
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, China
| | - Jingxiang Wu
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, China; Outcomes Research Consortium, Cleveland, OH, USA.
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Abstract
Opioid-based analgesia in the perioperative period can provide excellent pain control, but this approach exposes the patient to avoidable side effects and possible harm. Optimal analgesia, an approach that targets the fastest functional recovery with adequate pain control while minimizing side effects, can be achieved with opioid minimization. Many different options for nonopioid multimodal analgesia exist and have been shown to be efficacious, with certain modalities being more beneficial for specific surgeries. This review will present the evidence and practical tips for these management strategies.
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Affiliation(s)
- Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University School of Medicine, 1301 Medical Center Drive, TVC 4619, Nashville, TN 37221, USA; Perioperative Medicine Fellowship, Hi-RiSE Perioperative Optimization Clinic, Perioperative Consult Service, VUMC ERAS Executive Steering Committee, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN 37232, USA.
| | - Britany L Raymond
- Department of Anesthesiology, Vanderbilt University School of Medicine, 1301 Medical Center Drive, TVC 4619, Nashville, TN 37221, USA; Perioperative Medicine Fellowship, Hi-RiSE Perioperative Optimization Clinic, Perioperative Consult Service, VUMC ERAS Executive Steering Committee, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN 37232, USA
| | - Anton Krige
- Department of Anaesthesia and Critical Care, Royal Blackburn Teaching Hospital, Haslingden Road, Blackburn BB2 3HH, UK
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Yip W, Chen AB, Malekyan C, Widjaja W, Yan K, Stankey M, Sun X, Ashrafi AN, Graham JN, Dickerson SC, Eloustaz MH, Desai MM, Gill IS, Aron M, Kim MP. An Enhanced Recovery After Surgery protocol for robotic-assisted laparoscopic nephrectomies utilizing a quadratus lumborum block. J Robot Surg 2022. [PMID: 35142979 DOI: 10.1007/s11701-022-01379-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 01/29/2022] [Indexed: 12/29/2022]
Abstract
Enhanced Recovery After Surgery (ERAS) protocols have been developed in several fields to reduce hospitalization lengths and overall costs. There have also been developments in multimodal analgesia methods to curtail opioid usage after surgery. Herein, we present the results of our initiation of an ERAS protocol for robotic-assisted laparoscopic partial and radical nephrectomies, employing a quadratus lumborum (QL) regional anesthetic block. We retrospectively reviewed 614 patients in our Institutional Review Board approved database who underwent robotic-assisted laparoscopic partial or radical nephrectomies from January 2017 to February 2020. An ERAS protocol utilizing multimodal analgesia (acetaminophen and gabapentin) and a QL block was developed and introduced in February 2019. We then compared the opioid consumption and perioperative outcomes of patients before and after ERAS protocol initiation. 192 ERAS patients (February 2019 to February 2020) were compared to 422 non-ERAS patients (January 2017 to January 2019). Baseline characteristics and the proportion of preoperative opioids users were similar between the two groups. There were no statistically significant differences in surgery length, hospitalization length, or complication rates. There were statistically significant differences in our primary endpoint, opioid consumption, on post-operative days 0 (p < 0.001), 1 (p < 0.001), and 2 (p < 0.001). The total opioid requirements over the course of admission were lower in the ERAS group compared to the non-ERAS group (p = 0.03). The initiation of an ERAS protocol employing multimodal analgesia and a QL block, for patients undergoing robotic-assisted laparoscopic partial or radical nephrectomies, can decrease opioid requirements without compromising perioperative outcomes.
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Ashrafi AN, Yip W, Graham JN, Yu V, Titus M, Widjaja W, Dickerson S, Berger AK, Desai MM, Gill IS, Aron M, Kim MP. Implementation of a multimodal opioid-sparing enhanced recovery pathway for robotic-assisted radical prostatectomy. J Robot Surg 2021; 16:715-721. [PMID: 34431025 DOI: 10.1007/s11701-021-01268-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 06/13/2021] [Indexed: 12/24/2022]
Abstract
The purpose of the study is to evaluate the impact of a multimodal Enhanced Recovery After Surgery (ERAS) protocol on perioperative opioid consumption and hospital length of stay (LOS) after robotic-assisted radical prostatectomy (RARP). We compared the first 176 patients enrolled in the protocol (ERAS group) with the previous 176 patients (non-ERAS group) at a single quaternary institution from December 2017 to June 2019. The ERAS protocol included a multimodal opioid-sparing regimen utilizing acetaminophen, gabapentin, celecoxib, and liposomal bupivacaine. Demographic data, co-morbidities, post-operative pain scores, post-operative opiate consumption measured by morphine milligram equivalents (MME), operating time, and LOS were collected. The two groups were compared using chi-squared, Fisher exact, or Student t tests as appropriate. Multivariable logistic regression analysis was performed to identify predictors of prolonged LOS (> 1 day). The ERAS and non-ERAS groups were equivalent in terms of baseline characteristics and pathological data. The ERAS group had lower post-operative pain scores, post-operative opiate consumption (MME 15 vs. 46, p < 0.01), and LOS (1.2 vs. 1.7 days, p < 0.01) compared to the non-ERAS group. Only 22% in the ERAS cohort had a prolonged LOS compared to 39% of the non-ERAS group (p < 0.01). The ERAS protocol was a negative predictor of prolonged LOS on multivariable logistic regression analysis (odds ratio 0.39, 95% confidence interval 0.22-0.70, p < 0.01). A limitation of this study is its single-center retrospective design. The implementation of a multimodal opioid-sparing ERAS protocol was associated with improved pain control, reduced perioperative opioid usage, and shorter LOS after RARP.
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Affiliation(s)
- Akbar N Ashrafi
- Keck School of Medicine, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA. .,Department of Urology, Northern Adelaide Local Health Network, South Australia Health, Adelaide, Australia. .,Adelaide Medical School, The University of Adelaide, Adelaide, Australia. .,College of Medicine and Public Health, Flinders University, Adelaide, Australia.
| | - Wesley Yip
- Keck School of Medicine, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - John N Graham
- Keck School of Medicine, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Valerie Yu
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Micha Titus
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - William Widjaja
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Shane Dickerson
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Andre K Berger
- Keck School of Medicine, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Mihir M Desai
- Keck School of Medicine, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Inderbir S Gill
- Keck School of Medicine, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Monish Aron
- Keck School of Medicine, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Michael P Kim
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Ahmad S, Khanna R, Onyewuenyi AC, Panos N, Breslin R, Sani S. Efficacy of an opioid-sparing analgesic protocol in pain control after less invasive cranial neurosurgery. Pain Rep 2021; 6:e948. [PMID: 34368598 DOI: 10.1097/PR9.0000000000000948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 04/15/2021] [Accepted: 05/22/2021] [Indexed: 12/04/2022] Open
Abstract
An opioid-sparing protocol for postoperative pain management in less invasive cranial neurosurgery significantly lowered opioid usage while reducing pain scores. Introduction: Opioid overuse in postoperative patients is a worrisome trend, and potential alternatives exist which warrant investigation. Nonsteroidal anti-inflammatory drug use in treating postoperative cranial surgery pain has been hampered by concern for inadequate pain control and increased risk of hemorrhagic complications. A safe and effective alternative to opioid-based pain management is critical to improving postoperative care. Objective: The objective of this retrospective study was to determine whether an NSAID-based opioid-sparing pain management protocol (OSP) is effective in analgesic control of less invasive cranial surgery patients at 6-, 12-, and 24-hour postoperatively. Secondary aims included investigating differences in hemorrhagic complications. Methods: Five hundred sixty-six consecutive patients who underwent cranial surgery before and after implementation of the celecoxib-based OSP were eligible. Propensity score matching was used to match patients in each cohort. Results: The opioid-sparing cohort had lower pain scores at 6 hours (3.45 vs 4.19, P = 0.036), 12 hours (3.21 vs 4.00, P = 0.006), and 24 hours (2.90 vs 3.59, P = 0.010). Rates of postoperative hemorrhage were not significantly different (5% intervention vs 8% control, P = 0.527). The opioid-sparing pain management protocol provided comparable or better pain control in the first 24 hours after less invasive cranial surgery. Hemorrhage rates did not change with the use of an NSAID-based OSP. Conclusion: An effective alternative to the current standard opioid-based pain management is feasible for less invasive cranial surgery. Determinations of hemorrhage risk and more complex cranial surgery will require larger prospective randomized trials.
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Cheng XQ, Cheng J, Zhou YN, Zuo YM, Liu XS, Gu EW, Xu GH. Anti-nociceptive Effects of Dexmedetomidine Infusion Plus Modified Intercostal Nerve Block During Single-port Thoracoscopic Lobectomy: A Double-blind, Randomized Controlled Trial. Pain Physician 2021; 24:E565-E572. [PMID: 34323443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Multimodal general anesthesia based on modified intercostal nerve block (MINB) has been found as a novel method to achieve an intraoperative opioid-sparing effect. However, there is little information about the effective method to inhibit visceral nociceptive stress during single-port thoracoscopic surgery. OBJECTIVE To investigate whether a low-dose dexmedetomidine infusion followed by MINB might be an alternative method to blunt visceral stress effectively. STUDY DESIGN Double-blind, randomized control trial. SETTING Affiliated hospital from March 2020 through September 2020. METHODS Fifty-four patients were randomized (1:1), 45 patients were included to receive dexmedetomidine with a 0.4 microgram/kg bolus followed by 0.4 microgram/kg/h infusion (group Dex) or saline placebo (group Con). During the operation, an additional dose of remifentanil 0.05-0.25 microgram/kg/min was used to keep mean arterial pressure (MAP) or heart rate (HR) values around 20% below baseline values. The primary outcome was to evaluate remifentanil consumption. Secondary outcomes included intraoperative hemodynamics, the first time to press an analgesia pump, and adverse effects. RESULTS Remifentanil consumption during surgery was markedly decreased in the Dex group than in the Con group (0 [0-0] versus 560.0 [337.5-965.0] microgram; P = 0.00). MAP and HR in the Con group during the first 5 minutes after visceral exploration was significantly higher than in the Dex group (P < 0.05). Time to first opioid demand was significantly prolonged (P = 0.04) and postoperative length of stay was shortened slightly in the Dex group (P = 0.05). LIMITATIONS This study was limited by the measurement of nociception. CONCLUSIONS This study demonstrates that low-dose dexmedetomidine infusion combined with MINB might be an effective alternative method to blunt visceral stress in patients undergoing single-port thoracoscopic lobectomy. Furthermore, the analgesic effect of MINB was significantly prolonged after dexmedetomidine infusion.
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Affiliation(s)
- Xin-Qi Cheng
- Department of Anesthesiology, First Affiliated Hospital, Anhui Medical University, Hefei, Anhui, China
| | - Juan Cheng
- Department of Physiology, School of Basic Medical Sciences, Anhui Medical University, Hefei, China
| | - Yan-Nan Zhou
- Department of Anesthesiology, First Affiliated Hospital, Anhui Medical University, Hefei, Anhui, China
| | - You-Mei Zuo
- Department of Anesthesiology, First Affiliated Hospital, Anhui Medical University, Hefei, Anhui, China
| | - Xue-Sheng Liu
- Department of Anesthesiology, First Affiliated Hospital, Anhui Medical University, Hefei, Anhui, China
| | - Er-Wei Gu
- Department of Anesthesiology, First Affiliated Hospital, Anhui Medical University, Hefei, Anhui, China
| | - Guang-Hong Xu
- Department of Anesthesiology, First Affiliated Hospital, Anhui Medical University, Hefei, Anhui, China
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Decker H, Wu CL, Wick E. Multimodal Pain Control in Surgery 2020. Adv Surg 2021; 55:147-57. [PMID: 34389089 DOI: 10.1016/j.yasu.2021.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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13
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Han DS, Brockel MA, Boxley PJ, Dönmez Mİ, Saltzman AF, Wilcox DT, Rove KO. Enhanced recovery after surgery and anesthetic outcomes in pediatric reconstructive urologic surgery. Pediatr Surg Int 2021; 37:151-159. [PMID: 33161476 DOI: 10.1007/s00383-020-04775-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/22/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Enhanced recovery after surgery (ERAS) is a perioperative management strategy to hasten postoperative recovery. We examined the effects of a pilot implementation of ERAS for pediatric patients on anesthetic outcomes. METHODS We performed a prospective case-control study utilizing an ERAS protocol in patients aged < 18 years undergoing urologic reconstruction that included a bowel anastomosis. Protocol elements included: multimodal analgesia, opioid minimization, and routine nausea/vomiting prophylaxis. ERAS patients were propensity-matched with historical controls. Outcomes of interest included maximum PACU pain score, time to first opioid, opioid-free days, and need for opioids on day of discharge. RESULTS A total of 13 ERAS patients and 26 historical controls were included, with median ages 9.9 years (IQR 9.1-11) and 10.4 years (IQR 8.0-12.4), respectively. ERAS increased the percentage of patients who did not receive any intraoperative or postoperative opioids (0% vs 15%, p = 0.046 for both) and reduced maximum PACU pain score (3 vs 0, p < 0.001). The use of postoperative supplemental oxygen was decreased in the ERAS group (85% vs 38%, p = 0.013). CONCLUSIONS The implementation of an ERAS protocol appears to decrease postoperative pain, opioid usage, and positively impact other anesthetic outcomes in children undergoing urologic reconstructive surgery utilizing a bowel anastomosis.
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Affiliation(s)
- Daniel S Han
- Department of Pediatric Urology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E. 16th Ave, B-463, Aurora, CO, 80045, USA.
| | - Megan A Brockel
- Department of Anesthesiology, Children's Hospital Colorado, Aurora, CO, USA
| | - Peter J Boxley
- Department of Pediatric Urology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E. 16th Ave, B-463, Aurora, CO, 80045, USA
| | - M İ Dönmez
- Department of Urology, Division of Pediatric Urology, İstanbul University İstanbul Faculty of Medicine, İstanbul, Turkey
| | | | - Duncan T Wilcox
- Department of Pediatric Urology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E. 16th Ave, B-463, Aurora, CO, 80045, USA
| | - Kyle O Rove
- Department of Pediatric Urology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E. 16th Ave, B-463, Aurora, CO, 80045, USA
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Fei Y, Cui X, Chen S, Peng H, Feng B, Qian W, Lin J, Weng X, Huang Y. Continuous block at the proximal end of the adductor canal provides better analgesia compared to that at the middle of the canal after total knee arthroplasty: a randomized, double-blind, controlled trial. BMC Anesthesiol 2020; 20:260. [PMID: 33036554 PMCID: PMC7545931 DOI: 10.1186/s12871-020-01165-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 09/17/2020] [Indexed: 11/10/2022] Open
Abstract
Background The optimal position for continuous adductor canal block (ACB) for analgesia after total knee anthroplasty (TKA) remians controversial, mainly due to high variability in the localization of the the adductor canal (AC). Latest neuroanatomy studies show that the nerve to vastus medialis plays an important role in innervating the anteromedial aspect of the knee and dives outside of the exact AC at the proximal end of the AC. Therefore, we hypothesized that continuous ACB at the proximal end of the exact AC could provide a better analgesic effect after TKA compared with that at the middle of the AC (which appeared to only block the saphenous nerve). Methods Sixty-two adult patients who were scheduled for a unilateral TKA were randomized to receive continuous ACB at the proximal end or middle of the AC. All patients received patient-controlled intravenous analgesia with sufentanil postoperatively. The primary outcome measure was cumulative sufentanil consumption within 24 h after the surgery, which was analyzed using Mann-Whitney U tests. P-values < 0.05 (two-sided) were considered statistically significant. The secondary outcomes included postoperative sufentanil consumption at other time points, pain at rest and during passive knee flexion, quadriceps motor strength, and other recovery related paramaters. Results Sixty patients eventually completed the study (30/group). The 24-h sufentanil consumption was 0.22 μg/kg (interquartile range [IQR]: 0.15–0.40 μg/kg) and 0.39 μg/kg (IQR: 0.23–0.52 μg/kg) in the proximal end and middle groups (P = 0.026), respectively. There were no significant inter-group differences in sufentanil consumption at other time points, pain at rest and during passive knee flexion, quadriceps motor strength, and other recovery related paramaters. Conclusions Continuous ACB at the proximal end of the AC has a better opioid-sparing effect without a significant influence on quadriceps motor strength compared to that at the middle of the AC after TKA. These findings indicates that a true ACB may not produce the effective analgesia, instead, the proximal end AC might be a more suitable block to alleviate pain after TKA. Trial registration This study was registered at ClinicalTrials.gov (NCT03942133; registration date: May 06, 2019; enrollment date: May 11, 2019).
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Affiliation(s)
- Yuda Fei
- Anesthesiology Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, China
| | - Xulei Cui
- Anesthesiology Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, China.
| | - Shaohui Chen
- Anesthesiology Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, China
| | - Huiming Peng
- Orthopaedic Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, China
| | - Bin Feng
- Orthopaedic Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, China
| | - Wenwei Qian
- Orthopaedic Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, China
| | - Jin Lin
- Orthopaedic Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, China
| | - Xisheng Weng
- Orthopaedic Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, China
| | - Yuguang Huang
- Anesthesiology Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, China
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Pardue B, Thomas A, Buckley J, Suggs WJ. An Opioid-Sparing Protocol Improves Recovery Time and Reduces Opioid Use After Laparoscopic Sleeve Gastrectomy. Obes Surg 2020; 30:4919-4925. [PMID: 32951136 DOI: 10.1007/s11695-020-04980-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 09/12/2020] [Accepted: 09/15/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE The current literature is sparse on post discharge pain management for bariatric surgical patients. This study aimed to determine if an opioid-sparing protocol could decrease opioid use during the postoperative period (hospital to home). MATERIALS AND METHODS In this retrospective cohort study, we implemented an opioid-sparing protocol in January 2018, for patients undergoing laparoscopic sleeve gastrectomy (LSG) at our institution. We compared recovery time, pain scores (in hospital and at home), and perioperative opioid use between the historic control group (February 2017 to December 2017) and the opioid-sparing group (January 2018 to December 2018). A p value of < .05 was considered statistically significant. RESULTS The study included 400 patients (200 in each group), and 165 participated in the phone survey. Baseline characteristics were similar, except the control group had a higher body mass index and body weight. The average recovery time was significantly shorter in the opioid-sparing group (18.9 versus 35.3 days, P = .043). There was no significant difference in mean postoperative pain scores in the hospital or at home. The opioid-sparing group required significantly fewer opioids postoperatively (10.4 versus 16.1 morphine milligram equivalents, P < .001). Only 1 out of the 200 patients in the opioid-sparing arm requested an opioid prescription after discharge. CONCLUSION Implementation of an opioid-sparing protocol improved recovery time and reduced postoperative opioid use in the hospital and after discharge without changing perceived pain in patients undergoing LSG.
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Affiliation(s)
- Benjamin Pardue
- Edward Via College of Osteopathic Medicine - Auburn Campus, 910 South Donahue Drive, Auburn, AL, 36832, USA
| | - Austin Thomas
- Edward Via College of Osteopathic Medicine - Auburn Campus, 910 South Donahue Drive, Auburn, AL, 36832, USA
| | - Jake Buckley
- Crestwood Medical Center, One Hospital Drive, Huntsville, AL, 35801, USA
| | - William J Suggs
- Crestwood Medical Center, One Hospital Drive, Huntsville, AL, 35801, USA.
- Alabama Bariatrics, 705 Bank Street, Decatur, AL, 35601, USA.
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16
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Blok Z, Ridderikhof ML, Goddijn H, Berendsen M, Hollmann MW. Intravenous acetaminophen does not have an opioid sparing effect in Emergency Department patients with painful conditions. Am J Emerg Med 2020; 39:1-5. [PMID: 32014373 DOI: 10.1016/j.ajem.2020.01.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/16/2020] [Accepted: 01/27/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Pain in the Emergency Department is common and is frequently treated with opioids. Due to the opioid epidemic, it is clinically helpful to decrease opioid usage. The purpose of this study was to evaluate opioid requirement in Emergency Department patients with painful conditions who receive intravenous acetaminophen. METHODS In this prospective cohort study, patients aged 18 years and older and treated with opioids in the acute phase were included. Patients receiving additional intravenous acetaminophen were compared to patients who did not. Primary outcome was opioid requirement, measured in Morphine Equivalent Units (MEU) during Emergency Department stay. Secondary outcomes were opioid requirement after discharge; decrease in pain scores; occurrence of adverse events and patient satisfaction. RESULTS A total of 116 patients were included of whom 76 received intravenous acetaminophen. Opioid consumption in the acute phase was not significantly different (p=0.53) between patients receiving (10.0 MEU (IQR 7.5; 15.0)) and those not receiving acetaminophen: 10.0 MEU (IQR 7.1; 15.0). After discharge these numbers were 15.0 MEU (IQR 7.5; 30.0) versus 30.0 MEU (IQR 15.0; 43.8), respectively (p=0.059). In both groups median NRS pain scores decreased from 9.0 to 4.0 and >80% of patients were satisfied regarding pain treatment. Nine minor adverse events were recorded, equally divided among the groups. CONCLUSIONS The additional use of intravenous acetaminophen did not decrease opioid requirement in adult patients with acute pain during Emergency Department stay. There was a trend towards decreased opioid requirement during 24 h after discharge.
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Affiliation(s)
- Z Blok
- Department of Emergency Medicine, Amsterdam University Center, location AMC, P.O. Box 22660, 1100 DD Amsterdam, the Netherlands
| | - M L Ridderikhof
- Department of Emergency Medicine, Amsterdam University Center, location AMC, P.O. Box 22660, 1100 DD Amsterdam, the Netherlands.
| | - H Goddijn
- Department of Emergency Medicine, Amsterdam University Center, location AMC, P.O. Box 22660, 1100 DD Amsterdam, the Netherlands
| | - M Berendsen
- Department of Emergency Medicine, Amsterdam University Center, location AMC, P.O. Box 22660, 1100 DD Amsterdam, the Netherlands
| | - M W Hollmann
- Department of Anesthesiology, Amsterdam University Center, location AMC, Amsterdam, the Netherlands
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Jessula S, Atkinson L, Casey P, Kwofie K, Stewart S, Lee MS, Smith M, Herman CR. Surgically positioned paravertebral catheters and postoperative analgesia after open abdominal aortic aneurysm repair. J Vasc Surg 2019; 70:1479-1487. [PMID: 31153699 DOI: 10.1016/j.jvs.2019.02.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 02/13/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare postoperative morphine equivalent intake after open abdominal aortic aneurysm (AAA) repair among analgesic modalities: systemic analgesia (SA) only with no regional anesthesia, surgically positioned paravertebral catheter (PVC), and thoracic epidural analgesia (TEA). METHODS This retrospective cohort study included patients undergoing elective open AAA at the Queen Elizabeth II Health Science Center, Halifax, Nova Scotia. Demographics, morphine equivalents, methods of analgesia administration, and outcomes data were collected on all patients from 2005 to 2016. Total morphine equivalent (MEQ) on postoperative days (PODs) 1, 2, and 3 were compared among patients with SA, PVC, and TEA. A multivariable zero-inflated log-linear regression was used to determine the association between analgesic modality and MEQ. Multivariable logistic regression models were used to determine associations between analgesic modality and postoperative pain, rates of discharge from intensive care within 1 day and opioid-related adverse events. RESULTS The study cohort included 355 patients: 177 retroperitoneal and 178 transperitoneal repairs; 173 patients underwent SA, 117 PVC, and 65 TEA. On POD1, median MEQs were 984 (interquartile range [IQR], 342-1525) for SA, 89 (33-246) for PVC, and 49 (0-90) for TEA. On POD2, the median MEQs were 105 (IQR, 57-210) for SA, 45 (15-99) for PVC, and 30 (0-64) for TEA. On POD3, the median MEQs were 45 (IQR, 15-120) for SA, 30 (0-60) for PVC, and 10 (0-45) for TEA. On multivariable log-linear regression, compared with SA, PVC and TEA were associated with increased odds of receiving no opioids on POD1 (odds ratio [OR], 66.85; 95% confidence interval [CI], 17.49-255.57; and OR, 214.68; 95% CI, 60.20-766.38; respectively), POD 2 (OR, 6.97; 95% CI, 3.61-13.46; and OR, 28.73; 95% CI, 15.68-52.62; respectively), and POD 3 (OR, 3.93; 95% CI, 2.72-5.67; and OR, 4.68; 95% CI, 3.20-6.86; respectively). If patients did receive opioids, compared with SA, PVC and TEA were associated with decreased consumption on POD1 (RR, 0.22; 95% CI, 0.18-0.27; and RR, 0.16; 95% CI, 0.12-0.20; respectively), POD2 (RR, 0.50; 95% CI, 0.42-0.58; and RR, 0.46; 95% CI, 0.37-0.56; respectively), and POD3 (RR, 0.78; 95% CI, 0.66-0.93; and RR, 0.76; 95% CI, 0.63-0.93; respectively). Compared with SA, PVC was associated with earlier discharge from intensive care (OR, 2.75; 95% CI, 1.17-6.45) and TEA was not (OR, 1.12; 95% CI, 0.56-2.2). Compared with TEA, PVC was not associated with increased rate of opioid-related adverse events (OR, 0.44; 95% CI, 0.08-2.44). CONCLUSIONS PVC and TEA are associated with decreased MEQ compared with SA. PVC is associated with earlier discharge from intensive care compared with SA and similar rates of opioid-related adverse events compared with TEA. Paravertebral analgesia appears to be a safe and effective analgesic modality in patients undergoing retroperitoneal approach for abdominal aneurysm repair.
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Affiliation(s)
- Samuel Jessula
- Division of General Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Logan Atkinson
- Department of Anesthesiology, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Patrick Casey
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kwesi Kwofie
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Samuel Stewart
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Min S Lee
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Matthew Smith
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Christine R Herman
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Division of Vascular Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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Diaz-Borjon E, Torres-Gomez A, Essex MN, Salomon P, Li C, Cheung R, Parsons B. Parecoxib Provides Analgesic and Opioid-Sparing Effects Following Major Orthopedic Surgery: A Subset Analysis of a Randomized, Placebo-Controlled Clinical Trial. Pain Ther 2017; 6:61-72. [PMID: 28255955 PMCID: PMC5447543 DOI: 10.1007/s40122-017-0066-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Indexed: 12/15/2022] Open
Abstract
Introduction Orthopedic surgeries are among the most common and most painful surgeries performed. A multimodal analgesic approach is recommended to reduce opioid consumption, provide effective pain relief, and improve outcomes following surgery. This study examined the efficacy and opioid-sparing effects of parecoxib following major orthopedic surgery. Methods This subset analysis of a large, multicenter, randomized, double-blind, placebo-controlled study of parecoxib examined treatment effects on postoperative pain severity, pain interference with function, opioid consumption, occurrence of opioid-related symptoms, safety, and patient satisfaction following major orthopedic surgery. Results Pain scores were significantly lower in the parecoxib group (n = 142) compared with placebo (n = 139) on day 2 (−22%; p < 0.001) and day 3 (−17%; p = 0.004). Pain interference with function scores were also significantly lower in the parecoxib group on day 2 (−32%; p < 0.001) and day 3 (−27%; p = 0.003) relative to placebo. Additionally, significantly less supplemental morphine was required in the parecoxib group relative to placebo through 24 h (−28%; p = 0.008) and 48 h (−33%; p < 0.001). Patients in the parecoxib group had a reduced risk of experiencing opioid-related symptoms including fatigue, drowsiness, inability to concentrate, confusion, nausea, constipation, and confusion on day 2 and/or day 3. Finally, more patients receiving parecoxib (42%) rated treatment as “excellent” compared to those receiving placebo (21%). Conclusions These findings support the use of parecoxib for the management of pain following major orthopedic surgery.
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Affiliation(s)
- Efrain Diaz-Borjon
- Orthopedics and Traumatology, Hospital Angeles Lomas, Huixquilucan, Mexico
| | | | | | - Patricia Salomon
- Pain Division for Latin America, Pfizer Inc, Mexico City, Mexico
| | | | | | - Bruce Parsons
- Global Medical Affairs, Pfizer Inc, New York, NY, USA
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