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Kleinbart E, Tornberg H, Rivera-Pintado C, Hunter K, Kleiner MT, Miller LS, Pollard M, Fedorka CJ. Narcotic prescribing practices in shoulder surgery before and after the institution of narcotic e-prescribing. JSES Rev Rep Tech 2024; 4:208-212. [PMID: 38706676 PMCID: PMC11065727 DOI: 10.1016/j.xrrt.2024.01.004] [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] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Background Given the current opioid epidemic, it is crucial to highly regulate the prescription of narcotic medications for pain management. The use of electronic prescriptions (e-scripts) through the hospital's electronic medical record platform allows physicians to fill opioid prescriptions in smaller doses, potentially limiting the total quantity of analgesics patients have access to and decreasing the potential for substance misuse. The purpose of this study is to determine how the implementation of e-scripts changed the quantity of opioids prescribed following shoulder surgeries. Methods For this single-center retrospective study, data were extracted for all patients aged 18 years or more who received a shoulder procedure between January 2015 and December 2020. Total milligrams of morphine equivalents (MMEs) of opioids prescribed within the 90 days following surgery were compared between 3 cohorts: preimplementation of the 2017 New Jersey Opioid laws (Pre-NJ opioid laws), post-NJ Opioid Laws but pre-escripting, and postimplementation of e-scripting in 2019 (postescripting). Any patient prescribed preoperative opioids, prescribed opioids by nonorthopedic physicians, under the care of a pain management physician, or had a simultaneous nonshoulder procedure was excluded from this study. Results There were 1857 subjects included in this study; 796 pre-NJ opioid laws, 520 post-NJ opioid laws, pre-escripting, and 541 postescripting. Following implementation of e-scripting on July 1, 2019, there was a significant decrease in total MMEs prescribed (P < .001) from a median of 90 MME (interquartile range 65, 65-130) preimplementation to a median 45 MME (interquartile range 45, 45-90) MME postimplementation Additionally, there was a statistically significant decrease in opioids prescribed for all procedures (P < .001) and for 3 (P < .001) of the 4 orthopedic surgeons included in this study. Conclusion Our study demonstrated a significant reduction in total MMEs prescribed overall, for all shoulder surgeries, and for the majority of our institution's providers in the postoperative period following the e-scripting implementation in July 2019. E-scripting is a valuable tool in conjunction with education and awareness on the national, institutional, provider, and patient levels to combat the opioid epidemic.
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Affiliation(s)
- Emily Kleinbart
- Department of Orthopaedic Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Haley Tornberg
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | | | - Krystal Hunter
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Matthew T. Kleiner
- Department of Orthopaedic Surgery, Cooper University Hospital, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Lawrence S. Miller
- Department of Orthopaedic Surgery, Cooper University Hospital, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Mark Pollard
- Department of Orthopaedic Surgery, Cooper University Hospital, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Catherine J. Fedorka
- Department of Orthopaedic Surgery, Cooper University Hospital, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
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Kaye AD, Plaisance TR, Smith SA, Ragland AR, Alfred MJ, Nguyen CG, Chami AA, Kataria S, Dufrene K, Shekoohi S, Robinson CL. Peripheral Nerve Stimulation in Postoperative Analgesia: A Narrative Review. Curr Pain Headache Rep 2024:10.1007/s11916-024-01257-z. [PMID: 38642233 DOI: 10.1007/s11916-024-01257-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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2024] [Indexed: 04/22/2024]
Abstract
PURPOSE OF REVIEW Recent research has shown the effectiveness of peripheral nerve stimulators (PNS) in managing chronic pain conditions. Ongoing studies aim to explore its potential application in treating acute postoperative pain states. The purpose of this systematic review is to assess the role of PNS in providing relief for postoperative pain. RECENT FINDINGS Clinical studies investigating the use of peripheral nerve stimulators (PNS) for analgesia following various surgeries, such as total knee arthroplasty, anterior cruciate ligament repair, ankle arthroplasty, rotator cuff repair, hallux valgus correction, and extremity amputation, have shown promising results. Lead placement locations include the brachial plexus, sciatic, femoral, tibial, genicular, perineal, sural, radial, median, and ulnar nerves. These studies consistently report clinically significant reductions in pain scores, and some even indicate a decrease in opioid consumption following PNS for postoperative pain. PNS involves the subcutaneous placement of electrode leads to target peripheral nerve(s) followed by delivery of an electric current via an external pulse generator. While the precise mechanism is not fully understood, the theory posits that PNS modulates electrical stimulation, hindering the signaling of nociceptive pain. PNS presents itself as an alternative to opioid therapy, holding promise to address the opioid epidemic by offering a nonpharmacologic approach for both acute and chronic pain states.
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Affiliation(s)
- Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
- Department of Pharmacology, Toxicology, and Neurosciences, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
| | - Taylor R Plaisance
- School of Medicine, Louisiana State University Health Sciences Center at New Orleans, 2020 Gravier Street, New Orleans, LA, 70112, USA
| | - Summer A Smith
- School of Medicine, Louisiana State University Health Sciences Center at New Orleans, 2020 Gravier Street, New Orleans, LA, 70112, USA
| | - Amanda R Ragland
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Michael J Alfred
- School of Medicine, Louisiana State University Health Sciences Center at New Orleans, 2020 Gravier Street, New Orleans, LA, 70112, USA
| | - Catherine G Nguyen
- School of Medicine, Louisiana State University Health Sciences Center at New Orleans, 2020 Gravier Street, New Orleans, LA, 70112, USA
| | - Azem A Chami
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
| | - Saurabh Kataria
- Department of Neurology, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, 71103, USA
| | - Kylie Dufrene
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA.
| | - Christopher L Robinson
- Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
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McCrosson M, Jacob R, Chandler K, Scheinberg M, Baidwan N, Naranje S. Variations in opioid prescribing after total joint arthroplasty: An Observational study. J Clin Orthop Trauma 2024; 49:102353. [PMID: 38361510 PMCID: PMC10865388 DOI: 10.1016/j.jcot.2024.102353] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/30/2024] [Indexed: 02/17/2024] Open
Abstract
Background This study aimed to analyze the prescribing patterns of opioids by different categories of providers for postoperative pain after primary total hip and knee arthroplasty (THA, TKA) at a single institution. Methods A retrospective review was conducted on 1774 patients who underwent primary THA or TKA between 2014 and 2019 at a single, level one academic trauma center. Patients were excluded for additional procedures within 90 days of the index surgery. Patient demographics, operative variables, and opioid prescriptions were collected and analyzed. Generalized linear models accounting for within-person correlations were used to model the association between patient age, prescriber, etiology, opioid category, and mean morphine milligram equivalent (MME) prescribed. Results The mean MME prescribed per patient up to 90 days postoperatively was 1591. Significant variations were observed in prescribing habits based on patient gender, age, prescriber category, and drug type. Females were prescribed more MMEs than males (CI 8.58, 667.16; p = 0.0443) and patients 65 years or younger received higher MMEs compared to those above 65 (CI 231.11, 926.48; p = 0.0011). Non-orthopedic physicians prescribed higher MMEs than orthopedic surgeons (CI 402.76, 1219.48; p < 0.0001). Hydrocodone and oxycodone prescriptions had significantly higher MMEs than tramadol prescriptions (CI 446.33, 719.52; p < 0.0001 and CI 681.09, 1065.26; p < 0.0001, respectively). Conclusion These findings suggest the need for standardized guidelines and interventions to address variations in opioid prescribing practices for postoperative pain control. Understanding baseline prescription habits can help guide efforts to optimize pain management and reduce opioid overprescribing in the surgical setting.
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Affiliation(s)
- Matthew McCrosson
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13th Street S, Ste 226, Birmingham, AL, 35205, USA
| | - Roshan Jacob
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13th Street S, Ste 226, Birmingham, AL, 35205, USA
| | - Kelly Chandler
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13th Street S, Ste 226, Birmingham, AL, 35205, USA
| | - Mila Scheinberg
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13th Street S, Ste 226, Birmingham, AL, 35205, USA
| | - Navneet Baidwan
- Department of Family and Community Medicine, University of Alabama at Birmingham, 1201 11th Avenue South, Suite 410, Birmingham, AL, 35205, USA
| | - Sameer Naranje
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13th Street S, Ste 226, Birmingham, AL, 35205, USA
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Esteve-Pérez N, Perez-Herrero MA, Montes-Perez A, López-Alvarez S. Management of acute postoperative pain: Conditions to guarantee the safety and effectiveness of analgesic treatments. Rev Esp Anestesiol Reanim (Engl Ed) 2023:S2341-1929(23)00140-3. [PMID: 37683970 DOI: 10.1016/j.redare.2022.07.005] [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] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 07/07/2022] [Indexed: 09/10/2023]
Abstract
The evidence on postoperative pain management is of low or insufficient quality. The SEDAR Acute Pain Working Group has prepared this guideline-document to apply the best available scientific evidence to clinical practice, individualizing it based on factors specific to the patient and the procedure, and encompassing different organizational options, attempting to individualize it based on specific factors of the patient and the procedure, and encompassing the different organizational options for pain control. The document updates concepts and minimum requirements necessary for optimal postoperative analgesia, a multidisciplinary approach and the management of Acute Postoperative Pain. Strategic lines and different management models are defined. A general perioperative action plan is established based on collaboration with the surgical departments involved, on the joint review of the evidence and on preparation of protocols by the procedure. Finally, a follow-up plan and a series of minimum indicators necessary for quality control of postoperative pain are presented.
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Affiliation(s)
- N Esteve-Pérez
- Servicio de Anestesiología y Reanimación, Hospital Sant Joan de Déu. Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa), Palma de Mallorca, Spain; Grupo de Trabajo de Dolor Agudo SEDAR, Spain.
| | - M A Perez-Herrero
- Grupo de Trabajo de Dolor Agudo SEDAR, Spain; Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario de Valladolid. Coordinadora del Grupo de Trabajo de Dolor Agudo SEDAR, Valladolid, Spain
| | - A Montes-Perez
- Grupo de Trabajo de Dolor Agudo SEDAR, Spain; Servicio de Anestesiología y Reanimación, Hospital del Mar. Jefe de Sección de la Unidad de Dolor. Vice-Presidente de la Sección Dolor Agudo y Crónico SEDAR, Barcelona, Spain
| | - S López-Alvarez
- Grupo de Trabajo de Dolor Agudo SEDAR, Spain; Servicio de Anestesiología y Reanimación, Hospital Abente y Lago. Presidente AGARyD. Vocal de la Sección Dolor Agudo y Crónico SEDAR, A Coruña, Spain
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Levy BE, Castle JT, Ebbitt LM, Kennon C, McAtee E, Davenport DL, Evers BM, Bhakta A. Opioid Use After Colorectal Resection: Identifying Preoperative Risk Factors for Postoperative Use. J Surg Res 2023; 283:296-304. [PMID: 36423479 DOI: 10.1016/j.jss.2022.10.051] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 09/30/2022] [Accepted: 10/17/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Appropriate prescribing practices are imperative to ensure adequate pain control, without excess opioid dispensing across colorectal patients. METHODS National Surgical Quality Improvement Program, Kentucky All Scheduled Prescription Electronic Reporting, and patient charts were queried to complete a retrospective study of elective colorectal resections, performed by a fellowship-trained colorectal surgeon, from January 2013 to December 2020. Opioid use at 14 d and 30 d posthospital discharge converted into morphine milligram equivalents (MMEs) were analyzed and compared across preadmission and inpatient factors. RESULTS One thousand four hundred twenty seven colorectal surgeries including 56.1% (N = 800) partial colectomy, 24.1% (N = 344) low anterior resection, 8.3% (N = 119) abdominoperineal resection, 8.4% (N = 121) sub/total colectomy, and 3.0% (N = 43) total proctocolectomy. Abdominoperineal resection and sub/total colectomy patients had higher 30-day postdischarge MMEs (P < 0.001, P = 0.041). An operative approach did not affect postdischarge MMEs (P = 0.440). Trans abdominal plane blocks do not predict postdischarge MMEs (0.616). Epidural usage provides a 15% increase in postdischarge MMEs (P = 0.020). Age (P < 0.001), smoking (P < 0.001), chronic obstructive pulmonary disease (P = 0.006, < 0.001), dyspnea (P = 0.001, < 0.001), albumin < 3.5 (P = 0.085, 0.010), disseminated cancer (P = 0.018, 0.001), and preadmission MMEs (P < 0.001) predict elevated 14-day and 30-day postdischarge MMEs. CONCLUSIONS We conclude that perioperative analgesic procedures, as enhanced recovery pathway suggests, are neither predictive nor protective of postoperative discharge MMEs in colorectal surgery. Provider should account for preoperative risk factors when prescribing discharge opioid medications. Furthermore, providers should identify appropriate adjunct procedures to improve discharge opioid prescription stewardship.
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Affiliation(s)
- Brittany E Levy
- Department of Surgery, General Surgery Residency Program, University of Kentucky, Lexington, Kentucky
| | - Jennifer T Castle
- Department of Surgery, General Surgery Residency Program, University of Kentucky, Lexington, Kentucky
| | - Laura M Ebbitt
- College of Pharmacy, University of Kentucky, Lexington, Kentucky
| | - Caleb Kennon
- Department of Anesthesiology Residency Program, University of Kentucky, Lexington, Kentucky
| | - Erin McAtee
- Division of UK Healthcare Outcomes and Optimal Patient Services, University of Kentucky, Lexington, Kentucky
| | - Daniel L Davenport
- Department of Surgery, General Surgery Residency Program, University of Kentucky, Lexington, Kentucky; Division of UK Healthcare Outcomes and Optimal Patient Services, University of Kentucky, Lexington, Kentucky
| | - B Mark Evers
- Department of Surgery, General Surgery Residency Program, University of Kentucky, Lexington, Kentucky; Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - Avinash Bhakta
- Department of Surgery, General Surgery Residency Program, University of Kentucky, Lexington, Kentucky; Division of Colon and Rectal Surgery, University of Kentucky, Lexington, Kentucky.
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Zeiner S, Haider T, Zotti O, Thüringer K, Höbart P, Kimberger O, Knolle E. Intravenous diclofenac and orphenadrine for the treatment of postoperative pain after remifentanil-based anesthesia : A double-blinded, randomized, placebo-controlled study. Wien Klin Wochenschr 2023; 135:67-74. [PMID: 36576555 DOI: 10.1007/s00508-022-02131-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 11/14/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Postoperative intravenous diclofenac reduces patient opioid demand and is commonly used in surgical units. Orphenadrine is mainly used in combination with diclofenac for musculoskeletal injuries and postoperative pain control. The objective of this study was to compare the analgesic efficacy of diclofenac-orphenadrine, diclofenac alone and saline. METHODS We performed a double-blind, randomized, placebo-controlled, parallel-group, single-center clinical study investigating the opioid-sparing effect of a combination of diclofenac and orphenadrine versus diclofenac alone versus isotonic saline solution. Initially 72 patients were included and received total intravenous anesthesia during cruciate ligament surgery. All patients were postoperatively treated with a patient-controlled analgesia (PCA) device containing hydromorphone. Pharmacological safety was assessed by laboratory parameters, vital signs, and delirium detection scores. RESULTS There was no significant difference between the groups in cumulative dose of PCA analgesics required after 24 h postsurgery, with 5.90 mg (SD ± 2.90 mg) in the placebo group, 5.73 mg (SD ± 4.75 mg) in the diclofenac group, and 4.13 mg (SD ± 2.57 mg) in the diclofenac-orphenadrine group. Furthermore, there was no significant difference between the groups in cumulative dose of PCA analgesics required 2 h postsurgery (n = 65). Mean dose of hydromorphone required after 2 h was 1.54 mg (SD ± 0.57 mg) in the placebo group, 1.56 mg (SD ± 1.19 mg) in the diclofenac-only group, and 1.37 mg (SD ± 0.78 mg) in the diclofenac-orphenadrine group. However, when comparing the diclofenac-orphenadrine group and the diclofenac group combined to placebo there was a significant reduction in PCA usage in the first 24 h postsurgery. In total, there were 25 adverse events reported, none of which were rated as severe. CONCLUSION Orphenadrine-diclofenac failed to significantly reduce postoperative opioid requirements. However, in an exploratory post hoc analysis the diclofenac-orphenadrine and the diclofenac group combined versus placebo showed a tendency to reduce opioid demand in postoperative pain control. Further research is required to determine the value of orphenadrine as an adjuvant in a multimodal approach for postoperative pain management.
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Bagheri Fard A, Jabalameli M, Khorrami AM, Ghaderi MT, Mohammadpour M, Gharanizadeh K. The Effect of Adding Corticosteroid to the Periarticular Injection Cocktail for Pain Control after Total Hip and Total Knee Arthroplasty: A Double-Blinded Randomized Clinical Trial. Arch Bone Jt Surg 2022; 10:1049-1055. [PMID: 36721657 PMCID: PMC9846724 DOI: 10.22038/abjs.2022.50610.2509] [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] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/15/2022] [Indexed: 02/02/2023]
Abstract
Background The impact of periarticular corticosteroid injection for pain control after total joint arthroplasty (TJA) is controversial. The present study aimed to investigate this controversy in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods A total of 42 THA and 42 TKA patients were included in this study. The patients of each group were randomly allocated into group A (cocktail+Depo-Medrol) and group B (cocktail alone). The outcome measures were a Visual Analog Scale (VAS) for pain at five different time points for both THA and TKA, as well as the knee range of motion (ROM) and straight leg raise (SLR) for the TKA group only. Patients were followed for three months to observe infection, wound complications, and any venous thromboembolic event. Results In the THA group, the preoperative VAS, 12, 24, 48, and 72h postoperative VAS were not statistically different between groups A and B (P=0.49, P=0.5, P=0.96, P=0.15, and P=0.11, respectively). In the TKA group, the preoperative VAS, 12, 24 48h, and 72h postoperative VAS were not statistically different between groups A and B (P=1.0, P=0.47, P=0.82, P=0.92, P=0.5, respectively). The mean scores of knee range of motion and ability to perform SLR were not significantly different between TKA patients in the steroid and non-steroid groups (P=0.18 and P=0.58, respectively). The only observed complication was one surgical site infection in the non-steroid group of the TKA. Conclusion The obtained results did not support the benefit of including a steroid (Depo-Medrol) in the periarticular injection cocktail for pain control after the THA and TKA.
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Affiliation(s)
- Abolfazl Bagheri Fard
- Bone and Joint Reconstruction Research Center, Department of Orthopedics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mahmoud Jabalameli
- Bone and Joint Reconstruction Research Center, Department of Orthopedics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Amir Mohsen Khorrami
- Bone and Joint Reconstruction Research Center, Department of Orthopedics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Taher Ghaderi
- Bone and Joint Reconstruction Research Center, Department of Orthopedics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mehdi Mohammadpour
- Bone and Joint Reconstruction Research Center, Department of Orthopedics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Kaveh Gharanizadeh
- Bone and Joint Reconstruction Research Center, Department of Orthopedics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
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Chen IC, Kang YN, Wang HJ, Chiu WK, Chen C. The Efficacy of Local Anesthesia for Postoperative Pain Control in Breast Augmentation Surgery: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials. Aesthetic Plast Surg 2022; 46:1106-1115. [PMID: 35274178 DOI: 10.1007/s00266-022-02815-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 10/23/2021] [Accepted: 01/27/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND Breast augmentation can cause severe postoperative pain; therefore, some surgeons perform wound infiltration with a local anesthetic solution. This study investigated the postoperative pain relief of local analgesics in breast augmentation surgery. METHODS We searched three databases for randomized controlled trials evaluating the outcomes of local wound irrigation with local analgesics during or after breast augmentation surgery. The solutions included ropivacaine, bupivacaine, bupivacaine plus ketorolac. The control groups may be saline alone or no irrigation. Network meta-analysis was further employed based on the frequentist approach. Outcomes were reported as weighted mean differences with 95% confidence intervals. RESULTS Comparisons between the interventions of our included studies revealed that only bupivacaine plus ketorolac (versus placebo) significantly reduced pain at 1 h postoperatively, as indicated by the visual analog scale pain score reduction of 2.22 (- 3.98, - 0.47). Other comparisons showed no significant differences. Moreover, three of the included studies reported postoperative medication use. Two of them reported that postoperative narcotic use was reduced, but the others did not report any such reduction. CONCLUSIONS Our results showed possibility that local irrigation with bupivacaine plus ketorolac might reduce pain 1 h after surgery. In addition, local anesthesia might reduce postoperative narcotic use. However, due to the small number of included studies, the clinical benefits of local anesthesia in breast augmentation surgery require further confirmation. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- I-Chun Chen
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, 110, Taiwan
| | - Yi-No Kang
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
- Evidence-Based Medicine Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Research Center of Big Data and Meta-analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Hsian-Jenn Wang
- Division of Plastic Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Wen-Kuan Chiu
- Division of Plastic Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
| | - Chiehfeng Chen
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.
- Evidence-Based Medicine Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
- Division of Plastic Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
- Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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Dong L. Comment on "Effectiveness of local anesthetic application methods in postoperative pain control in laparoscopic cholecystectomies; a randomised controlled trial". Int J Surg 2022; 98:106211. [PMID: 34999286 DOI: 10.1016/j.ijsu.2021.106211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/16/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Lingna Dong
- Center for Geriatrics, The Affiliated Hospital of Medical College of Ningbo University, Ningbo, 315000, Zhejiang, China
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Zhong C, He R, Lu X, Zhong L, Lin DK, Liu J, Guo D. Would high-dose corticosteroid addition to multimodal cocktail periarticular injection contribute to prolonged pain control and better recovery following total knee arthroplasty?: study protocol for a randomized controlled trial. Trials 2021; 22:703. [PMID: 34654469 PMCID: PMC8518286 DOI: 10.1186/s13063-021-05655-1] [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: 03/31/2021] [Accepted: 09/24/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Enhanced recovery following total knee arthroplasty (TKA) has been advocated to enhance postoperative recovery. Multimodal cocktail periarticular injection (MCPI) use for pain control in TKA has gained wide acceptance. MCPI-containing corticosteroids are believed to be an effective solution owing to their local anti-inflammatory effects and ability to reduce the local stress response postoperatively. However, there is conflicting evidence regarding its benefits. This trial aims to compare MCPI with a high dose of corticosteroid, normal dose of corticosteroid, and non-corticosteroid during TKA, to assess the effectiveness of MCPI containing corticosteroids in postoperative pain relief, functional improvement, rescue analgesia, and side effects and provide evidence that high-dose corticosteroids result in prolonged pain control and better recovery following TKA. METHODS This is a double-blinded, randomized, placebo-controlled study. A total of 234 patients scheduled for TKA will be recruited. During surgery, before wound closure, 80 ml of the cocktail analgesic will be injected into the muscle and joint capsule for local infiltration analgesia; the participants will be randomly assigned to three groups to receive a high dose of betamethasone MCPI (group H), normal dose of betamethasone MCPI (group N), and non-betamethasone MCPI (group C). The following indices will be recorded and analyzed: the strongest knee pain experienced during 90° flexion at 6 h, 24 h, 48 h, 72 h, 5 days, 14 days, and 30 days after surgery; 1 min walking ability; and circumference around the patella at 2, 5, 14, and 30 days after surgery; Knee Society knee score at 14 days and 30 days after surgery; C-reactive protein and blood sedimentation; blood sugar 2, 5, 14, and 30 days following surgery; rescue analgesic consumption; and adverse events. If any participant withdraws from the trial, an intention-to-treat analysis will be performed. DISCUSSION The results of this study will provide clinical evidence on the effectiveness of MCPI-containing corticosteroids in postoperative pain relief, functional improvement, rescue analgesia, and adverse events, as well as provide evidence on the efficacy of high-dose corticosteroids in prolonged pain control and better recovery following TKA. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR2000038671 . Registered on September 27, 2020.
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Affiliation(s)
- Chengfan Zhong
- Department of Orthopedic Surgery, People's Hospital of Gaozhou, No. 89, Xiguan Road, Gaozhou City, 525200, Guangdong, China
| | - Rong He
- Department of Orthopedic Surgery, Maoming People's Hospital, No.101, Weimin Road, Maoming City, 525000, Guangdong, China
| | - Xiaomin Lu
- Clinical Medical College of Acupuncture Moxibustion and Rehabilitation, Guangzhou University of Chinese Medicine, No. 12, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong, China
| | - Lilun Zhong
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 111 Dade Road, Guangzhou, 510120, Guangdong, China
| | - Ding-Kun Lin
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 111 Dade Road, Guangzhou, 510120, Guangdong, China
| | - Jun Liu
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 111 Dade Road, Guangzhou, 510120, Guangdong, China
| | - Da Guo
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 111 Dade Road, Guangzhou, 510120, Guangdong, China.
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11
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Van Boerum MS, Mann SL, Veith JP, Collier W, Hosein RC, Manum JS, Agarwal J, Kwok AC. Patient-reported opioid use for tissue expander-based breast reconstruction. J Plast Reconstr Aesthet Surg 2021; 74:2899-2905. [PMID: 34078588 DOI: 10.1016/j.bjps.2021.03.114] [Citation(s) in RCA: 3] [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: 09/24/2020] [Revised: 01/07/2021] [Accepted: 03/18/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION There is limited evidence for appropriate post-operative opioid prescribing in breast reconstruction patients. We sought to describe postoperative outpatient prescription opioid use patterns (quantity and duration) following discharge after immediate breast reconstruction with tissue expanders (TE) and to identify demographic and/or clinical risk factors associated with postoperative outpatient opioid use. METHODS Patients 18 years and older undergoing immediate TE-based breast reconstruction were given a 28-day postoperative pain medication log book. Descriptive statistics were performed to describe the quantity and duration of opioid use. Preoperative, intraoperative, and postoperative characteristics were examined and tested for their associations with postoperative opioid use. RESULTS A total of 45 logbooks were completed. On average, patients used opioids for 7.42 days (SD = 6.45) after discharge home and used 15.9 (SD = 18.71) oxycodone 5 mg tablet equivalents (119.3 morphine milligram equivalents, SD = 140.31). The total number of oxycodone 5 mg equivalents consumed prior to discharge was associated with the amount of post-discharge opioid consumption (IRR=1.08, p<0.01). Each additional year of age was associated with a reduction in the days-to-opioid cessation by a factor of 0.97 (p=0.01). Each additional oxycodone 5mg equivalent consumed prior to hospital discharge was associated with an increase in the days-to-cessation after discharge by a factor of 1.04 (p=0.026). CONCLUSIONS These patient-reported data will provide a benchmark which plastic surgeons can use to minimize narcotic use in patients and will help prevent issues of dependence, misuse, and diversion, while being mindful of adequate pain control. For patients discharging home after a one-night stay for immediate TE breast reconstruction, we recommend a prescription for 10 oxycodone 5 mg tablets, or 15 tablets if they are less than age 49 or have had high inpatient opioid use. Patients should also be counseled that the expected duration of outpatient opioid use is 7-11 days, and that 20 % of patients did not use any opioids following hospital discharge, making nonnarcotic pain regimens a real possibility.
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Affiliation(s)
- Melody S Van Boerum
- Department of Surgery, Division of Plastic Surgery, University of Utah School of Medicine, 30 North 1900 East, 3B400, Salt Lake City, Utah 84132
| | - Sara L Mann
- University of Utah School of Medicine, 30 North 1900 East, 3B400, Salt Lake City, Utah 84132
| | - Jacob P Veith
- Department of Surgery, Division of Plastic Surgery, University of Utah School of Medicine, 30 North 1900 East, 3B400, Salt Lake City, Utah 84132
| | - Willem Collier
- Department of Population Health Sciences, University of Utah School of Medicine, Williams Building, Room 1N490 295 Chipeta Way, Salt Lake City, UT 84108
| | - Rayaad C Hosein
- Department of Surgery, Division of Plastic Surgery, University of Utah School of Medicine, 30 North 1900 East, 3B400, Salt Lake City, Utah 84132
| | - Joanna S Manum
- Department of Surgery, Division of Plastic Surgery, University of Utah School of Medicine, 30 North 1900 East, 3B400, Salt Lake City, Utah 84132
| | - Jayant Agarwal
- Department of Surgery, Division of Plastic Surgery, University of Utah School of Medicine, 30 North 1900 East, 3B400, Salt Lake City, Utah 84132
| | - Alvin C Kwok
- Department of Surgery, Division of Plastic Surgery, University of Utah School of Medicine, 30 North 1900 East, 3B400, Salt Lake City, Utah 84132.
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Takahashi R, Kajita Y, Harada Y, Iwahori Y, Deie M. Post-operative pain control following arthroscopic rotator cuff repair: Intravenous acetaminophen versus interscalene brachial plexus block; A prospective randomized study. J Orthop 2021; 25:6-9. [PMID: 33897133 DOI: 10.1016/j.jor.2021.03.010] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/23/2021] [Indexed: 11/19/2022] Open
Abstract
Background With the increasing number of patients undergoing arthroscopic rotator cuff repair (ARCR), postoperative pain control in these patients has become an important issue. We investigated and compared post-operative pain relief with intravenous acetaminophen (IA) and interscalene brachial plexus block (IBPB) after ARCR. Methods This prospective study involved 66 consecutive patients who underwent ARCR in 2019-2020 at our hospital. Overall, 23 and 43 shoulders were assigned to the IA and IBPB groups, respectively. We evaluated the visual analog scale (VAS) pain scores at rest, during activity, and at night for the first 72 h postoperatively. We compared the results statistically between the groups. A p-value <0.05 was considered statistically significant. Results VAS scores for night pain in the IBPB group were significantly lower than those in the IA group for the first 24 h postoperatively (p = 0.017). In contrast, the same scores were significantly lower in the IA group than in the IBPB group at 72 h postoperatively (p = 0.024). Other scores were not significantly different between the groups. Conclusions IBPB provides superior night pain control during the first 24 h postoperatively, and IA provides superior night pain control at 72 h postoperatively. However, there were no significant differences in other pain scores between the two groups.
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Affiliation(s)
| | - Yukihiro Kajita
- Department of Orthopaedic Surgery, Ichinomiya Nishi Hospital, Japan
- Department of Orthopaedic Surgery, Aichi Medical University, Japan
| | - Yohei Harada
- Department of Orthopaedic Surgery, Aichi Medical University, Japan
| | - Yusuke Iwahori
- Department of Orthopaedic Surgery, Asahi Hospital, Japan
| | - Masataka Deie
- Department of Orthopaedic Surgery, Aichi Medical University, Japan
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13
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Pathonsamit C, Onklin I, Hongku N, Chaiyakit P. Randomized Double-Blind Controlled Trial Comparing 0.2 mg, 0.1 mg, and No Intrathecal Morphine Combined With Periarticular Injection for Unilateral Total Knee Arthroplasty. Arthroplast Today 2020; 7:253-259. [PMID: 33786350 PMCID: PMC7987934 DOI: 10.1016/j.artd.2020.11.008] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 10/27/2020] [Accepted: 11/15/2020] [Indexed: 12/22/2022] Open
Abstract
Background The addition of intrathecal morphine (ITM) to neuraxial anesthesia during total knee arthroplasty (TKA) to achieve postoperative analgesia can elicit opioid-related side effects. The other methods of pain alleviation and side effect reduction, including multimodal analgesia, are challenging. This study aimed to determine the efficacy of various ITM dosages for primary unilateral TKA with periarticular injection (PI). Methods This randomized double-blind controlled trial was conducted at Vajira Hospital between April 2018 and March 2019. Patients undergoing TKA were randomized into 3 groups: no ITM (M0), ITM 0.1 mg (M1), and ITM 0.2 mg (M2). All patients received PI. Postoperative pain scores, side effects of ITM, and orthopedic outcomes were compared. Results The trial enrolled 102 patients: M0 (n = 32), M1 (n = 35), and M2 (n = 35). The postoperative pain scores and rescue analgesic consumption of groups M1 and M2 did not differ significantly within the first 24 hours and were significantly lower than those in group M0. Nausea and vomiting were observed more frequently 4 hours postoperatively in M2 than in groups M1 and M0 (77%, 51%, and 6%, respectively; P < .05), which required second-line antiemetic administration (29%, 9%, and 13%, respectively; P = .09). Conclusion Postoperative pain control achieved with PI combined with ITM 0.1 mg after primary unilateral TKA was comparable to that achieved with ITM 0.2 mg. PI without ITM resulted in higher pain scores and rescue analgesic consumption. The frequency and severity of nausea and vomiting 4 hours postoperatively were also lower in patients administered 0.1 mg of ITM than those in patients administered 0.2 mg of ITM.
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Affiliation(s)
- Chompunoot Pathonsamit
- Department of Anesthesiology, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Ittiwat Onklin
- Department of Orthopedics, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Natthapong Hongku
- Department of Orthopedics, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Pruk Chaiyakit
- Department of Orthopedics, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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McCarthy E, Felte R, Urban D, Zhang Z, Halbert C. Community hospital decreases narcotic usage in postoperative bariatric patients. Surg Obes Relat Dis 2020; 16:1810-1815. [PMID: 32741726 DOI: 10.1016/j.soard.2020.06.021] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/29/2020] [Accepted: 06/20/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Opioids have long been used as an effective form of analgesia for pain in the postoperative setting; however, their addictive potential and associated complications have become a detriment. There has been an increasing movement to decrease opioid prescribing. OBJECTIVE The aim of this study was to look at common bariatric surgery procedures at a single institution and compare opioid usage before and after the implementation of a multimodal pain regimen. SETTING Community program, hospital-employed, and private practice, United States. METHODS Six hundred twelve laparoscopic gastric bypass and laparoscopic sleeve gastrectomy patients were included in this single-institution retrospective cohort study. Data were obtained from chart review. Comparison was made between patients from 2016 and patients from a 3-month period in 2017 when the new pain management protocol had been instituted. RESULTS The postoperative opioid usage of 516 patients from 2016 was compared with that of 96 patients from a 3-month period in 2017 after initiating the new pain management protocol. The mean intravenous hydromorphone usage of the control group, 16.0 ± 14.6 morphine milligram equivalent (or 4.0 mg ± .2), over the postoperative inpatient stay decreased to 7.3 ± 6.7 morphine milligram equivalent (or 1.8 mg ± .2) in the study group. This represents a 55% decrease. The study group did show less 30-day postoperative complications compared with the control, 1.04% and 2.13%, respectively, although this was not statistically significant. CONCLUSION A multimodal pain regimen is an effective way to cut opioid usage with no statistical difference in overall 30-day complications.
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Affiliation(s)
| | - Robert Felte
- Christiana Care Surgical Residency Program, Newark, Delaware
| | - DaKota Urban
- Christiana Care Surgical Residency Program, Newark, Delaware
| | - Zugui Zhang
- Christiana Care Value Institute, Newark, Delaware
| | - Caitlin Halbert
- Christiana Care Wilmington Chief Surgical Services, Wilmington, Delaware
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Ladanyi C, Sticco P, Blevins M, Boyd S, Gutmann D, Holcombe J, Mohling S. Efficacy and Safety of a Surgeon-Performed Laparoscopic-Guided, 4-point Transversus Abdominis Plane Block: A retrospective review. J Minim Invasive Gynecol 2020; 28:124-130. [PMID: 32562766 DOI: 10.1016/j.jmig.2020.06.012] [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: 10/27/2019] [Revised: 05/28/2020] [Accepted: 06/10/2020] [Indexed: 11/19/2022]
Abstract
We performed a retrospective chart review from October 2017 to March 2019 to demonstrate the safety and efficacy of a surgeon-performed, laparoscopically guided, transversus abdominis plane (TAP) blocks for robot-assisted gynecologic procedures. A total of 116 patients who underwent robot-assisted gynecologic surgery, at 1 academic hospital, with administration of a 4-point TAP block were included. A 4-point TAP block was performed under laparoscopic visualization, by the same surgeon, after induction of anesthesia and immediately after placement of the laparoscope. Liposomal bupivacaine (20 mL) and 0.5% bupivacaine (20 mL) mixed with saline were used as the injectant. All information from the surgical admission and the postoperative follow-up were reviewed. Data were presented in our descriptive study. A total of 116 patients were included with a mean age of 40.6 years (19-80 years) and a mean body mass index of 30.6 kg/m2 (17.2-53.3 kg/m2). Of the patients, 70.7% were discharged to home on the day of surgery. Of the 29.3% of patients who were admitted, 20.6% were admitted because of pain control. Those who were admitted for pain control comprised 6.0% of the total of all study participants. There were no adverse events in our cohort and no readmissions because of pain control. A surgeon-performed TAP block, under laparoscopic visualization, is a safe and efficacious intervention to reduce postoperative pain and may add to a multimodal approach for enhanced recovery protocols.
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Affiliation(s)
- Camille Ladanyi
- Minimally Invasive Gynecologic Surgery Fellow, Department of Obstetrics and Gynecology, Erlanger Hospital, University of Tennessee College of Medicine, 979 E 3rd St #725, Chattanooga, TN 37403 (Drs. Ladanyi and Sticco).
| | - Peter Sticco
- Minimally Invasive Gynecologic Surgery Fellow, Department of Obstetrics and Gynecology, Erlanger Hospital, University of Tennessee College of Medicine, 979 E 3rd St #725, Chattanooga, TN 37403 (Drs. Ladanyi and Sticco)
| | - Miranda Blevins
- Department of Obstetrics and Gynecology, Erlanger Hospital, University of Tennessee College of Medicine, 979 E 3rd St #725, Chattanooga, TN 37403 (Drs. Blevins and Boyd)
| | - Sarah Boyd
- Department of Obstetrics and Gynecology, Erlanger Hospital, University of Tennessee College of Medicine, 979 E 3rd St #725, Chattanooga, TN 37403 (Drs. Blevins and Boyd)
| | - Daniel Gutmann
- Clinical Assistant Professor, Department of Emergency Medicine, Erlanger Hospital, University of Tennessee College of Medicine, 975 E 3rd St, Chattanooga, TN 37403 (Dr. Gutmann)
| | - Jenny Holcombe
- University of Tennessee School of Nursing & School of Education, University of Tennessee Health Science Center College of Medicine, 615 McCallie Ave, chattanooga, TN 37403 (Dr. Holcombe)
| | - Shanti Mohling
- Directory of Gynecology, Pearl Women's Center, 140 NW 14th Ave, Portland, OR 97209 (Dr. Mohling)
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Hernandez MC, Finnesgard EJ, Aho JM, Zielinski MD, Schiller HJ. Reduced Opioid Prescription Practices and Duration of Stay after TAP Block for Laparoscopic Appendectomy. J Gastrointest Surg 2020; 24:418-425. [PMID: 30671804 DOI: 10.1007/s11605-018-04100-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 12/28/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND We evaluated whether TAP blocks performed at the time of appendectomy resulted in reduced total oral morphine equivalent (OME) prescribed and fewer 30-day opioid prescription (OP) refills. STUDY DESIGN Single institution review of historical data (2010-2016) was performed. Adults (≥ 18 years) that underwent appendectomy for appendicitis with uniform disease severity (AAST EGS grades I, II) were included. Opioid tolerance was defined as any preoperative OP ordered 1-3 months prior to appendectomy or < 1 month unrelated to appendicitis; opioid naïve patients were without OP. Intraoperative TAP blocks (admixture of liposomal/regular bupivacaine) were performed at surgeon discretion. Risk factors for discharge prescription > 200 OME were assessed using logistic regression and quantified using odds ratios (OR) and 95% confidence intervals (CI). RESULT There were 960 patients with uniform appendicitis severity. During appendectomy, 145 (15%) patients received TAP blocks. There were 46 patients that were opioid tolerant (5%) and the majority of the cohort received discharge OP (n = 914, 95%) with a median prescription OME volume of 225 [150-300]. Only 76 patients required 30-day opioid prescription refill. On regression, factors associated with a discharge prescription > 200 OME included ≥ 65 years of age (OR 0.64 (95%CI 0.41-0.98)) and no TAP block (OR 1.7 (95%CI 1.2-2.5)) but not preoperative opioid utilization. CONCLUSIONS TAP blocks in low-grade appendicitis were associated with reduced OME prescribed, hospital duration of stay, and fewer refills without impacting operative time or total hospital costs.
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Affiliation(s)
- Matthew C Hernandez
- Department of Trauma, Critical Care, and General Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55901, USA.
| | | | - Johnathon M Aho
- Department of Trauma, Critical Care, and General Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55901, USA
| | - Martin D Zielinski
- Department of Trauma, Critical Care, and General Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55901, USA
| | - Henry J Schiller
- Department of Trauma, Critical Care, and General Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55901, USA
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Patterson DC, Cagle PJ, Poeran J, Zubizarreta N, Mazumdar M, Galatz LM, Anthony SG. Effectiveness of intravenous acetaminophen for postoperative pain management in shoulder arthroplasties: A population-based study. J Orthop Translat 2019; 18:119-127. [PMID: 31508315 PMCID: PMC6718947 DOI: 10.1016/j.jot.2018.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 09/14/2018] [Accepted: 09/18/2018] [Indexed: 10/29/2022] Open
Abstract
Background Intravenous acetaminophen (IV APAP) is an option in multimodal postoperative analgesia. Prior trials focus on hip and knee arthroplasties, whereas large-scale data on utilization and effectiveness in shoulder arthroplasties are lacking. Methods Data on 67,494 (452 hospitals) partial/total shoulder arthroplasties were extracted from the Premier claims database (2011-2016). Patients were categorized by receipt and dosage of IV APAP. Multilevel models measured associations between IV APAP and opioid utilization (in oral morphine equivalents), length/cost of stay and opioid-related complications. Effect estimates (adjusted % change) with 95% confidence intervals (CIs) are reported. Results IV APAP was used in 17.7% (n = 11,949) of patients with an increasing utilization trend. Most patients received only one dose on the day of surgery (69.5%; n = 8308). When adjusting for relevant covariates, IV APAP was not associated with meaningful effects on outcomes. Specifically, its use (versus no use) was not associated with decreased (but rather somewhat increased) opioid utilization: + 5.4% (CI 3.6-7.1%; P < 0.05). Conclusion In this first large-scale study that assesses IV APAP in shoulder arthroplasties, IV APAP use was not associated with decreased opioid utilization or the length/cost of stay. These results do not support routine use of IV APAP in this cohort, especially given its high cost. The translational potential for this article Multimodal pain control to assist in reducing the opioid pain medications are seen as a route to improved postoperative patient outcomes, better pain control and expedited hospital discharge. Acetaminophen plays a significant role in these protocols in many institutions, but it is not established if this expensive IV formulation is superior to the oral formulation. This study evaluates the use and effectiveness of IV acetaminophen following shoulder arthroplasty at a large number of institutions.
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Affiliation(s)
- Diana C Patterson
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY, USA
| | - Paul J Cagle
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY, USA
| | - Jashvant Poeran
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nicole Zubizarreta
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Madhu Mazumdar
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Leesa M Galatz
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY, USA
| | - Shawn G Anthony
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY, USA
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Cairo SB, Calabro KA, Bowdish E, Reilly C, Watt S, Rothstein DH. Variation in postoperative narcotic prescribing after pediatric appendectomy. J Pediatr Surg 2019; 54:1866-71. [PMID: 30819545 DOI: 10.1016/j.jpedsurg.2018.11.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 11/27/2018] [Accepted: 11/29/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Overuse of prescription opioids by both pediatric and adult patients has garnered significant attention in recent years. Educational interventions have been shown to decrease prescription opioids post-operatively in the adult population; similar data have not previously been reported in pediatrics. METHODS Educational interventions included staff education, institution of opioid standardization protocol, and distribution of educational materials to families. Chart review was performed pre- and post-intervention to compare prescribing practices following appendectomy in patients less than 19 years of age. Follow-up phone calls were used to assess patient satisfaction and pain control. RESULTS Three hundred thirteen cases were identified pre-intervention [PRE] and compared to 119 cases postintervention [POST]. 84.3% of patients were given a prescription for opioids at time of discharge in the PRE cohort compared to 6.7% (p < 0.001) POST. There was a significant increase in non-opioid analgesia (p < 0.001) POST. There was no significant variability in opioid usage by type of surgery performed, attending provider, or patients' gender or age. Of the patients in the POST cohort, 60.5% were available for telephone follow-up. More than 80% of patients were given acetaminophen and/or ibuprofen POST and 94.4% reported adequate pain control; 88.9% reported that they would agree to avoid opioids again in the future. On follow-up survey, there was no increase in emergency department visits or phone calls for poorly controlled pain following the intervention. CONCLUSION Low-fidelity educational interventions and creation of a standardized pathway is an effective tool to reduce opioid prescribing and promote alternative means of analgesia without an increase in readmissions or presentation for pain. LEVEL OF EVIDENCE III.
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Felder L, Saccone G, Scuotto S, Monks DT, Carvalho JCA, Zullo F, Berghella V. Perioperative gabapentin and post cesarean pain control: A systematic review and meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol 2018; 233:98-106. [PMID: 30583095 DOI: 10.1016/j.ejogrb.2018.11.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 11/26/2022]
Abstract
Cesarean delivery occurs in roughly one third of pregnancies. Effective postoperative pain control is a goal for patients and physicians. Limiting opioid use in this period is important as some percentage of opioid naïve individuals will develop persistent use. Gabapentin is a non-opioid medication that has been used perioperatively to improve postoperative pain and limit opioid requirements. The goal of this study is to determine the efficacy of perioperative gabapentin in improving post cesarean delivery pain control. The following data sources were searched from their inception through October 2018: MEDLINE, Ovid, ClinicalTrials.gov, Sciencedirect, and the Cochrane Library at the CENTRAL Register of Controlled Trials. A systematic review of the literature was performed to include all randomized trials examining the effect of perioperative gabapentin on post cesarean delivery pain control and other postoperative outcomes. The primary outcome was the analgesic effect of gabapentin on post cesarean delivery pain, measured by visual analog scale (VAS; 0-100) or Numerical Rating Scale (NRS; 0-10) on movement 24 hours (h) postoperative. These scores were directly compared by multiplying all NRS scores by a factor of 10. Meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of mean difference (MD) with 95% confidence interval (CI). Six placebo controlled trials (n = 645) were identified as relevant and included in the meta-analysis. All studies included only healthy pregnant women (American Society of Anesthesiologist (ASA) physical status I or II) undergoing spinal anesthesia for cesarean delivery at term. Participants were randomized to either 600 mg oral gabapentin or placebo preoperatively and in one study the medications were also continued postoperatively. Pooled data showed that women who received gabapentin prior to cesarean delivery had significantly lower VAS pain scores at 24 h on movement (MD -11.58, 95% CI -23.04 to -0.12). VAS pain scores at other time points at rest or on movement were not significantly different for those who received gabapentin and placebo although there was a general trend toward lower pain scores for women receiving gabapentin. There was no significant between-group difference in use of additional pain medications, supplemental opioids, and maternal or neonatal side effects. There was higher pain control satisfaction at 12 and 24 h in the gabapentin versus placebo groups.
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Affiliation(s)
- Laura Felder
- Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Sergio Scuotto
- Department of Anesthesiology, School of Medicine, University of Siena, Siena, Italy
| | - David T Monks
- Department of Anesthesia, Washington University School of Medicine, St. Louis, MO, USA
| | - Jose C A Carvalho
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Fulvio Zullo
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA.
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Kang C, Lee GS, Kim SB, Won YG, Lee JK, Jung YS, Cho HJ. Comparison of postoperative pain control methods after bony surgery in the foot and ankle. Foot Ankle Surg 2018; 24:521-524. [PMID: 29409271 DOI: 10.1016/j.fas.2017.06.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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] [Received: 12/12/2016] [Revised: 06/14/2017] [Accepted: 06/16/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND We performed a prospective study to evaluate and compare the effectiveness of postoperative pain control methods after bone surgery in the foot and ankle. METHODS Among the patients who underwent foot and ankle surgery from June 2014 to September 2015 with an ultrasound-guided nerve block, 84 patients who fully completed a postoperative pain survey were enrolled. An opioid patch (fentanyl patch, 25mg) was applied in group A (30 patients). Diluted anesthetic (0.2% ropivacaine, 30ml) was injected into the sciatic nerve once, about 12h after the preoperative nerve block, in group B (27 patients). Periodic intramuscular injection of an analgesic (ketorolac [Tarasyn], 30mg) was performed in group C (27 patients). The visual analogue scale (VAS) pain scores at 6, 12, 18, 24, and 48h after surgery were checked, and the complications of all methods were monitored. RESULTS The mean VAS pain score was lower in group B, with a statistically significant difference (P<.05) between groups A, B, and C at 12 and 18h after surgery. Four patients in group A experienced nausea and vomiting; however, no other patients complained of any complications or adverse effects. CONCLUSION The ultrasound-guided injection of a diluted anesthetic into the sciatic nerve seemed to be the most useful method for controlling pain in the acute phase after bone surgery in the foot and ankle. The injection of the diluted anesthetic once on the evening of the day of surgery resulted in less postoperative pain in the patients. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Chan Kang
- Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Republic of Korea
| | - Gi-Soo Lee
- Department of Orthopedic Surgery, Konyang University College of Medicine, Daejeon, Republic of Korea; Konyang University Myunggok Medical Research Institute, Daejeon, Republic of Korea.
| | - Sang-Bum Kim
- Department of Orthopedic Surgery, Konyang University College of Medicine, Daejeon, Republic of Korea
| | - You-Gun Won
- Department of Orthopedic Surgery, Konyang University College of Medicine, Daejeon, Republic of Korea
| | - Jeong-Kil Lee
- Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Republic of Korea
| | - You-Sun Jung
- Department of Orthopedic Surgery, Konyang University College of Medicine, Daejeon, Republic of Korea
| | - Hyung-June Cho
- Department of Orthopedic Surgery, Konyang University College of Medicine, Daejeon, Republic of Korea
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Ortega-García FJ, García-Del-Pino I, Auñon-Martín I, Carrascosa-Fernández AJ. Utility of percutaneous catheters for local anaesthetics infusion for postoperative pain control in lumbar arthrodesis. A prospective cohort study. Rev Esp Cir Ortop Traumatol (Engl Ed) 2018; 62:365-372. [PMID: 29784500 DOI: 10.1016/j.recot.2018.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 08/23/2017] [Revised: 12/27/2017] [Accepted: 01/10/2018] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To evaluate whether postoperative continuous wound infiltration of levobupivacaine through two submuscular catheters connected to two elastomeric pumps after lumbar instrumented arthrodesis is more effective than intravenous patient-controlled analgesia. MATERIAL AND METHODS An observational, prospective cohorts study was carried out. The visual analogue scale, the need for additional rescue analgesia and the onset of adverse effects were recorded. RESULTS Pain records measured with visual analogue scale scale were significantly lower in the 48hours postoperative record at rest (p=.032). The other records of visual analogue scale showed a clear tendency to lower levels of pain in the group treated with the catheters. No statistically significant differences were found in the rescue analgesia demands of the patients. The adverse effects were lower in the catheter group (6 cases versus 11 cases) but without statistical differences. CONCLUSIONS A trend to lower pain records was found in the group treated with catheters, although differences were not statistically significant.
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Affiliation(s)
- F J Ortega-García
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Doce de Octubre, Madrid, España.
| | - I García-Del-Pino
- Servicio de Medicina Familiar y Comunitaria, Hospital Doce de Octubre, Madrid, España
| | - I Auñon-Martín
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Doce de Octubre, Madrid, España
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Hinther A, Nakoneshny SC, Chandarana SP, Wayne Matthews T, Dort JC. Efficacy of postoperative pain management in head and neck cancer patients. J Otolaryngol Head Neck Surg 2018; 47:29. [PMID: 29720267 PMCID: PMC5932752 DOI: 10.1186/s40463-018-0274-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [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: 11/20/2017] [Accepted: 04/17/2018] [Indexed: 02/08/2023] Open
Abstract
Background Our study quantifies the effectiveness of perioperative pain control in a cohort of patients undergoing major head and neck surgery with free flap reconstruction. Our long-term goal is to improve pain control and thereby increase mobility, decrease postoperative complications and decrease hospital stay. Methods A retrospective analysis was performed at a tertiary, academic head and neck surgical oncology program in Calgary, Alberta, Canada from January 1, 2015 – December 31, 2015. Pain scores were recorded prospectively. Primary outcomes were frequency of postoperative pain assessments and pain intensity using the numeric rating scale. Results The cohort included 41 patients. Analysis was limited to pain scores recorded from postoperative days 1–14. There was an average of 7.3 pain measurements per day (SD 4.6, range 1–24) with the most frequent monitoring on postoperative days 1–4. Median pain scores ranged from 0 to 4.5 with the highest median score on postoperative day 6. The daily maximum pain scores recorded ranged from 8 to 10 with scores of 10 recorded on postoperative days 1, 2, 3, 5, 7, 8, and 10. Patients most frequently had inadequate pain control on postoperative days 1, 2, 4, and 5 with the majority occurring on postoperative day 1. Conclusions Postoperative pain control could be improved at our centre. The frequency of pain assessments is also highly variable. Ongoing measurement, audit, and feedback of analgesic protocol effectiveness is an excellent first step in improving perioperative pain management in patients undergoing major head and neck cancer surgery with free flap reconstruction.
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Affiliation(s)
- Ashley Hinther
- Department of Surgery, Section of Otolaryngology- Head and Neck Surgery, Cumming School of Medicine, University of Calgary, HRIC 2A02, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
| | - Steven C Nakoneshny
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Shamir P Chandarana
- Department of Surgery, Section of Otolaryngology- Head and Neck Surgery, Cumming School of Medicine, University of Calgary, HRIC 2A02, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada.,Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - T Wayne Matthews
- Department of Surgery, Section of Otolaryngology- Head and Neck Surgery, Cumming School of Medicine, University of Calgary, HRIC 2A02, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada.,Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Joseph C Dort
- Department of Surgery, Section of Otolaryngology- Head and Neck Surgery, Cumming School of Medicine, University of Calgary, HRIC 2A02, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada. .,Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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Zhang Z, Xu H, Zhang Y, Li W, Yang Y, Han T, Wei Z, Xu X, Gao J. Nonsteroidal anti-inflammatory drugs for postoperative pain control after lumbar spine surgery: A meta-analysis of randomized controlled trials. J Clin Anesth 2017; 43:84-89. [PMID: 29046234 DOI: 10.1016/j.jclinane.2017.08.030] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [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: 05/22/2017] [Revised: 08/24/2017] [Accepted: 08/29/2017] [Indexed: 01/11/2023]
Abstract
STUDY OBJECTIVE Nonsteroidal anti-inflammatory drugs (NSAIDs) play a role in pain relief, especially in postoperative pain caused by inflammation. They have demonstrated significant opioid dose-sparing effects, which help in reducing postoperative effects and opioid side effects. The objective of this meta-analysis was to explore the role of NSAIDs in reducing postoperative pain at different time intervals and provide reference for medication after lumbar spine surgery by a meta-analysis of randomized controlled trials (RCT). DESIGN A meta-analysis study of randomized controlled trials. SETTING Postoperative recovery area. PATIENTS Adult patients who have undergone lumbar spine surgery. INTERVENTION Patients received NSAIDs for pain control after lumbar spine surgery. MEASUREMENTS Standardized mean difference (SMD) and 95%CI were used to evaluate the visual analog scale of postoperative pain. MAIN RESULTS Four hundred and eight participants from eight studies were included in this study. The difference between the NSAIDs group and placebo is significant in 0-6, 12, and 24h groups (overall: SMD=-0.72, 95%CI -0.98 to -0.45; 0-6h: SMD=0.50, 95%CI -0.81 to -0.19; 12h: SMD=-1.07, 95%CI -1.45 to -0.70; 24h: SMD=-1.16, 95%CI -1.87 to -0.45). Heterogeneity and publication bias were observed in the 0-6 and 24h groups. CONCLUSION NSAIDs are effective in postoperative analgesia after lumbar spine surgery. The study type, NSAID dose, different surgery types, and analgesic type might influence the efficacy of NSAIDs.
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Affiliation(s)
- Zhifeng Zhang
- Department of Pain Treatment, the Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Haihua Xu
- Department of Urinary Surgery, the Children's Hospital in Tianjin, Tianjin 300074, China
| | - Yunhui Zhang
- Department of Anesthesia, the Second Hospital of Hebei Medical University, Shijiazhuang 050000, China
| | - Wei Li
- Department of Anesthesia, the Second Hospital of Hebei Medical University, Shijiazhuang 050000, China
| | - Yanjie Yang
- Department of Anesthesia, the Second Hospital of Hebei Medical University, Shijiazhuang 050000, China
| | - Tian Han
- Department of Anesthesia, Baoding NO.2 Central Hospital, Baoding 072750, China
| | - Zhihui Wei
- Department of Anesthesia, Baoding NO.2 Central Hospital, Baoding 072750, China
| | - Xue Xu
- Department of Anesthesia, the Second Hospital of Hebei Medical University, Shijiazhuang 050000, China
| | - Jingui Gao
- Department of Anesthesia, the Second Hospital of Hebei Medical University, Shijiazhuang 050000, China.
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Redmann AJ, Wang Y, Furstein J, Myer CM, de Alarcón A. The use of the FLACC pain scale in pediatric patients undergoing adenotonsillectomy. Int J Pediatr Otorhinolaryngol 2017; 92:115-118. [PMID: 28012511 DOI: 10.1016/j.ijporl.2016.11.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [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] [Received: 05/24/2016] [Revised: 11/16/2016] [Accepted: 11/16/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVES 1) Determine the usage rate of opioid pain medication after adenotonsillectomy (T&A). 2) Review the use of the Face, Legs, Activity, Cry, Consolability (FLACC) pain scale for T&A patients 3) Determine the rate of postoperative physician contacts for pain related complaints. METHODS A retrospective case series review was performed on 125 pediatric patients undergoing T&A and subsequent 23-hour postoperative observation at an academic tertiary care center from June-August of 2015. Postoperative pain scores using the FLACC pain scale, the utilization of opioid pain medications, and the number of postoperative contacts for pain were recorded. RESULTS Average age of patients was 5.7 years and 50% were female. 90% of T&A's were performed for adenotonsillar hypertrophy. The post-tonsillectomy hemorrhage rate was 4%. 70 (56%) patients required postoperative opioid pain medication, with (30) 43% of these patients requiring more than one dose. The mean number of opioid doses was 1.64 ± 0.9 and was not related to age, weight or gender. FLACC scores were highly associated (spearman correlation 0.77) with the amount of opioid medication given. Mean FLACC scores decreased over time after T&A. 20% of patients contacted a physician for unsatisfactory pain control postoperatively with 6% requiring emergency department visits and 14% contacting the office via phone call. CONCLUSIONS A significant portion of pediatric patients undergoing T&A require postoperative opioids for pain control. The FLACC scale is a valuable way of quantifying post-operative T&A pain in pediatric patients. Despite routine pain management postoperatively, a significant proportion of patients require contact with a physician postoperatively for pain management.
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Affiliation(s)
- Andrew J Redmann
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, OH, United States.
| | - Yu Wang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - James Furstein
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Charles M Myer
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, OH, United States; Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Alessandro de Alarcón
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, OH, United States; Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
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El Chaar M, Stoltzfus J, Claros L, Wasylik T. IV Acetaminophen Results in Lower Hospital Costs and Emergency Room Visits Following Bariatric Surgery: a Double-Blind, Prospective, Randomized Trial in a Single Accredited Bariatric Center. J Gastrointest Surg 2016; 20:715-24. [PMID: 26842692 DOI: 10.1007/s11605-016-3088-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [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] [Received: 09/17/2015] [Accepted: 01/19/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Postoperative pain control in bariatric surgery is challenging, despite use of intravenous (IV) narcotics. IV acetaminophen is one pain control alternative. OBJECTIVE The aim of this study was to investigate the economic impact of IV acetaminophen in bariatric surgery and its effect on patients' pain, satisfaction, and hospital length of stay. METHODS In a randomized controlled trial, Group 1 (treatment) received IV acetaminophen plus IV narcotics 30 min before surgery, then medication plus IV narcotics/PO narcotics for the remaining 18 h. Group 2 (control) received IV normal saline plus IV/PO narcotics. Patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (SG). Primary outcomes included direct hospital costs, length of stay, postoperative pain, and patient satisfaction. Secondary outcomes included indirect costs, rescue narcotics dosage, and 30-day outcomes. RESULTS Mean direct hospital cost in the treatment group (n = 50) was $3089.18 versus $2991.62 for the control group (n = 50) (p > 0.05). Pain scores did not differ significantly (p = 0.61). After adjusting for surgery type, there was no significant difference in length of stay (p = 0.95). Significantly more control group patients incurred surgery-related indirect costs (10 versus 2%, p < 0.05), with greater presentation to the emergency department (ED) for abdominal pain (5/50 versus 1/50), yielding higher total indirect costs ($39,293 versus $13,185). CONCLUSIONS Using IV acetaminophen for postoperative pain management produced notable indirect cost savings and reduced ED visits in the first 30 days postoperatively, with good safety and tolerance. Decreased statistical power may have accounted for certain non-significant findings.
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Affiliation(s)
- Maher El Chaar
- Medical School of Temple University/St. Luke's University Health Network, 240 Cetronia Road, Suite 205, North Allentown, PA, 18104, USA.
| | - Jill Stoltzfus
- Medical School of Temple University/St. Luke's University Health Network, 240 Cetronia Road, Suite 205, North Allentown, PA, 18104, USA
| | - Leonardo Claros
- Medical School of Temple University/St. Luke's University Health Network, 240 Cetronia Road, Suite 205, North Allentown, PA, 18104, USA
| | - Tara Wasylik
- Medical School of Temple University/St. Luke's University Health Network, 240 Cetronia Road, Suite 205, North Allentown, PA, 18104, USA
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Lv N, Kong Y, Mu L, Pan T, Xie Q, Zhao M. Effect of perioperative parecoxib sodium on postoperative pain control for transcatheter arterial chemoembolization for inoperable hepatocellular carcinoma: a prospective randomized trial. Eur Radiol. 2016;26:3492-3499. [PMID: 26801163 DOI: 10.1007/s00330-016-4207-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 09/11/2015] [Accepted: 01/08/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Pain is one of the most common side effects of transcatheter arterial chemoembolization (TACE) treatment. This study aimed to assess the analgesic effect of parecoxib sodium for postoperative pain control in patients with inoperable hepatocellular carcinoma (HCC) undergoing TACE. MATERIALS AND METHODS This randomized placebo-controlled prospective clinical study was conducted at a single cancer centre. Patients were randomly assigned to receive parecoxib sodium (experimental group; n = 60) or 0.9 % sodium chloride (control group; n = 60) 1 h before TACE and once every 12 h for 2 days after TACE. Pain level, morphine consumption, adverse events, and quality of life were evaluated and compared between the two groups. RESULTS Pain scores, percentage distribution of pain categories, and morphine consumption were significantly lower in the experimental group than in the control group (P < 0.05). Fever score comparisons revealed significantly better body temperature balance in the experimental group than in the control group (P = 0.024). Quality-of-life scores in the experimental group were significantly better than those in the control group (P < 0.05). CONCLUSIONS Our results demonstrate that the perioperative administration of parecoxib significantly improved its effectiveness in the control of postoperative pain after TACE. KEY POINTS • Perioperative administration of parecoxib is effective for control of pain after TACE. • COX-2 inhibitors provide effective and safe pain control. • Parecoxib helps improve quality-of-life after TACE for patients with inoperable hepatocellular carcinoma.
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Abstract
This was judged to be the first place winning submission for the American Dental Society of Anesthesiology Student Essay Award. Acetaminophen is an old drug that is now available in an intravenous formulation. Its advantages and disadvantages are reviewed, including its potential role in multimodal postoperative pain therapy.
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Rouhani A, Tabrizi A, Elmi A, Abedini N, Mirza Tolouei F. Effects of preoperative non-steroidal anti-inflammatory drugs on pain mitigation and patients' shoulder performance following rotator cuff repair. Adv Pharm Bull 2014; 4:363-7. [PMID: 25436192 DOI: 10.5681/apb.2014.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 02/02/2014] [Accepted: 02/19/2014] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Pain is one of the most important factors adversely affecting clinical outcomes of operated patients. The present study aims at evaluating effects of preoperative COX2 non-steroidal anti-inflammatory inhibitors on pain mitigation and performance of patients with shoulder rotator cuff tear. METHODS This case-control study was conducted on 60 patients suffering from rotator cuff injury candidate for arthroscopic repair. The patients were classified in two parallel and matched groups. One group (case group) was treated using Celecoxib (200mg/12h) started 48 hours before surgery and continued for 10 days after operation. In the control group, the placebo was prescribed in the same way. Postoperative pain, side effects, sleep disturbance, and short-term outcomes were compared between two groups using DASH questionnaire. RESULTS Postoperative pain in the Celecoxib group significantly decreased in comparison with the control one. The difference was statistically meaningful (P<0.001). Well motion ability was seen in 80% of patients of the Celecoxib group. It was 26.6% in the placebo group since pain inhibited them from exercising more motions. In this regard, there was a statistically meaningful difference between these two groups (P=0.02). Sleep disturbance was meaningfully at higher levels in the placebo group (P=0.001). Following up the patients for three months, it was made clear that performance of the Celecoxib group was better than that of the placebo one. CONCLUSION COX2 inhibitors are well efficient in patients' pain management after arthroscopic rotator cuff repair surgery. It results in less life complications, less sleep disturbances, improvement of patients' short-term clinical outcome, and more quick recovery.
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Affiliation(s)
- Alireza Rouhani
- Shohada Educational Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ali Tabrizi
- Shohada Educational Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Asghar Elmi
- Shohada Educational Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Naghi Abedini
- Shohada Educational Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
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Oh JH, Rhee KY, Kim SH, Lee PB, Lee JW, Lee SJ. Comparison of analgesic efficacy between single interscalene block combined with a continuous intra-bursal infusion of ropivacaine and continuous interscalene block after arthroscopic rotator cuff repair. Clin Orthop Surg 2009; 1:48-53. [PMID: 19884997 PMCID: PMC2766686 DOI: 10.4055/cios.2009.1.1.48] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2008] [Accepted: 06/03/2008] [Indexed: 11/23/2022] Open
Abstract
Background This study evaluated the effectiveness of a continuous interscalene block (CISB) by comparing it with that of a single interscalene block combined with a continuous intra-bursal infusion of ropivacaine (ISB-IB) after arthroscopic rotator cuff repair. Methods Patients who had undergone CISB (CISB group; n = 25) were compared with those who had undergone ISB-IB (ISB-IB group; n = 25) for more than 48 hours after surgery. The visual analog scale (VAS) for pain, motor and/or sensory deficit, supplementary analgesics and adverse effects were recorded. Results There were no significant differences between the postoperative VAS of the CISB and ISB-IB groups, except at 1 hour after surgery. Their supplementary analgesics of the two groups were similar. Transient motor weakness (52%) and sensory disturbance (40%) of the affected arm were observed in patients in the CISB group. The catheters came out accidentally in 22% of the CISB group but in only 4% of the ISB-IB group. Conclusions ISB-IB provides similar analgesia to CISB. However, the ISB-IB group had a lower incidence of neurological deficits and better catheter retention.
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Affiliation(s)
- Joo Han Oh
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Korea
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