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Bozorgmanesh M, Valibeik S, Shokrpour M, Maktabi M, Kamali A. Effect of combined paracetamol and dexamethasone vs. paracetamol on postoperative nausea vomiting after cesarean section. J Perinat Med 2022; 50:1067-1072. [PMID: 35589674 DOI: 10.1515/jpm-2021-0644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/11/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Postoperative nausea and vomiting (PONV) are common symptoms after cesarean delivery (CD) that affect patients outcomes and satisfaction. The treatment of choice is still evolving, therefore, we aimed to evaluate PONV of combined paracetamol-dexamethasone vs. paracetamol alone. METHODS This study is a double-blind randomized controlled trial on 100 patients undergoing cesarean delivery. Participants were randomly assigned into two groups of paracetamol or combined paracetamol-dexamethasone. Nausea and vomiting score, VAS score of pain, and chill were compared between the two groups. RESULTS The result of this study found that mild nausea 2nd h after surgery in the combined group was lesser than paracetamol group (0.03). However, there was no statistically significant difference in nausea and vomiting score in other periods of time between the two groups. VAS score of pain decreased 12th and 6th h after the surgery in the combined and paracetamol group, respectively. Chilling occurred in two patients of combined group and four patients of paracetamol group (p=0.432). CONCLUSIONS Dexamethasone added to paracetamol might not improve pain and vomiting after cesarean delivery comparison with just paracetamol. But it can be effective for reducing the score of nausea after the surgery.
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Affiliation(s)
| | - Shamim Valibeik
- Student Research Committee, Arak University of Medical Science, Arak, Iran
| | - Maryam Shokrpour
- Department of Obstetrics and Gynecology, Arak University of Medical Sciences Arak, Iran
| | - Maryam Maktabi
- Department of Obstetrics and Gynecology, Arak University of Medical Sciences Arak, Iran
| | - Alireza Kamali
- Department of Anesthesiology, Arak University of Medical Sciences, Arak, Iran
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The Current Consideration, Approach, and Management in Postcesarean Delivery Pain Control: A Narrative Review. Anesthesiol Res Pract 2021; 2021:2156918. [PMID: 34589125 PMCID: PMC8476264 DOI: 10.1155/2021/2156918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 09/04/2021] [Indexed: 12/25/2022] Open
Abstract
Optimal postoperative analgesia has a significant impact on patient recovery and outcomes after cesarean delivery. Multimodal analgesia is the core principle for cesarean delivery and pain management. For a standard analgesic regimen, the use of long-acting neuraxial opioids (e.g., morphine) and adjunct drugs, such as scheduled acetaminophen and nonsteroidal anti-inflammatory drugs, is recommended unless contraindicated. Oral or intravenous opioids should be reserved for breakthrough pain. In addition to the aforementioned use of multimodal analgesia, preoperative evaluation is critical to individualize the analgesic regimen according to the patient requirements. Risk factors for severe postoperative pain or analgesia-related adverse effects will require modifications to the standard analgesic regimen (e.g., the use of ketamine, gabapentinoids, or regional anesthetic techniques). Further investigation is required to determine analgesic drugs or dose alterations based on preoperative predictions for patients at risk of severe pain. Outcomes beyond pain and analgesic use, such as functional recovery, should be determined to evaluate analgesic treatment protocols.
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Sacha CR, Mortimer R, Hariton E, James K, Hosseini A, Gray M, Xuan C, Hammer K, Lange A, Mahalingaiah S, Wang J, Petrozza JC. Assessing efficacy of intravenous acetaminophen for perioperative pain control for oocyte retrieval: a randomized, double-blind, placebo-controlled trial. Fertil Steril 2021; 117:133-141. [PMID: 34548165 DOI: 10.1016/j.fertnstert.2021.08.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/29/2021] [Accepted: 08/23/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the effect of preoperative intravenous (IV) acetaminophen versus oral (PO) acetaminophen or placebo on postoperative pain scores and the time to discharge in women undergoing oocyte retrieval. DESIGN Randomized, double-blind, placebo-controlled trial. SETTING Single academic fertility center. PATIENT(S) Women aged 18-43 years undergoing oocyte retrieval. INTERVENTION(S) Randomization to preoperative 1,000 mg IV acetaminophen and PO placebo (group A), IV placebo and 1,000 mg PO acetaminophen (group B), or IV and PO placebo (group C) MAIN OUTCOME MEASURE(S): Difference in patient-reported postoperative visual analog scale pain scores from baseline and the time to discharge. RESULT(S) Of the 159 women who completed the study, there were no differences in the mean postoperative pain score differences or the time to discharge. Although not statistically significant, the mean postoperative opioid dose requirement in group A was lower than that in groups B and C (0.24 vs. 0.59 vs. 0.58 mg IV morphine equivalents, respectively) due to fewer women in group A requiring rescue pain medication (8% vs. 19% vs. 15%, respectively). Group A also reported less constipation when compared with groups B and C (19% vs. 33% vs. 40%, respectively). The rates of postoperative nausea were similar, and there were no differences in embryology or early pregnancy outcomes between the study groups. CONCLUSION(S) Preoperative IV acetaminophen for women undergoing oocyte retrieval did not reduce postoperative pain scores or shorten the time to discharge when compared with PO acetaminophen or placebo and, thus, cannot currently be recommended routinely in this patient population. CLINICAL TRIAL REGISTRATION NUMBER NCT03073980.
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Affiliation(s)
- Caitlin R Sacha
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Roisin Mortimer
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of OB/GYN, Brigham and Women's Hospital and Massachusetts General Hospital, Boston, Massachusetts
| | - Eduardo Hariton
- University of California San Francisco, Department of Obstetrics, Gynecology, and Reproductive Sciences, San Francisco, California
| | - Kaitlyn James
- Center for Outcomes Research, Department of OB/GYN, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Afrooz Hosseini
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Morgan Gray
- Boston University School of Medicine, Boston, Massachusetts
| | - Chengluan Xuan
- Department of Anesthesia, The First Hospital of Jilin University, Jilin, China; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Karissa Hammer
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Shruthi Mahalingaiah
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jingping Wang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - John C Petrozza
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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4
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Dolev A, Yaari L, Kittani M, Yassin M, Gbaren M, Feicht E, Shemesh S, Haviv B. Efficacy of Anti-inflammatory Treatment Versus Rescue Analgesia After Arthroscopic Partial Meniscectomy in Nonarthritic Knees: A 3-Arm Controlled Study. Orthop J Sports Med 2021; 9:2325967121991545. [PMID: 33796593 PMCID: PMC7983444 DOI: 10.1177/2325967121991545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 11/13/2020] [Indexed: 11/17/2022] Open
Abstract
Background There is currently no consensus regarding the appropriate treatment for postoperative pain after arthroscopic partial meniscectomy (APM). Prescribing a mild non-anti-inflammatory protocol of rescue analgesia may be sufficient to avoid the side effects of opioids or anti-inflammatories. Purpose/Hypothesis The purpose was to compare the efficacy of pain reduction after APM in nonarthritic knees using betamethasone or celecoxib as anti-inflammatory analgesics versus acetaminophen or tramadol as rescue analgesics. The hypothesis was that there is no advantage for anti-inflammatories in achieving postoperative immediate pain relief after APM in nonarthritic knees compared with a simple nonopioid treatment. Study Design Cohort study; Level of evidence, 2. Methods This 3-arm controlled study evaluated postoperative pain levels and analgesic consumption in patients who underwent primary APM (under general anesthesia) at a single institution from December 2018 to December 2019. Patients were prospectively divided into 3 treatment groups: (1) betamethasone injection at the end of the procedure, (2) oral celecoxib prescription, or (3) neither treatment (control). All groups were instructed to take supplementary acetaminophen as needed. Patients were also allowed to take tramadol as needed to evaluate the need for opioids. At postoperative weeks 1, 2, and 3, patients completed the Knee injury and Osteoarthritis Outcome Score (KOOS) Pain subscale, and results were compared between time points and groups. Results A total of 99 patients were included in the treatment groups: betamethasone group (32 patients), celecoxib group (30 patients), and control group (37 patients). At baseline, there were no statistically significant differences between the groups in age, sex, body mass index, level of activity, comorbidities, or surgical findings. KOOS Pain scores improved at every time point for all 3 groups (P < .001), and no differences in scores were observed among groups. The consumption of acetaminophen or tramadol as rescue analgesia throughout the follow-up period was negligible among groups. Conclusion During the first 3 postoperative weeks after APM in nonarthritic knees, pain was efficiently controlled by betamethasone or celecoxib; however, pain was also efficiently controlled by minimal consumption of acetaminophen with negligible use of tramadol. Therefore, acetaminophen could be prescribed as an effective first-line postoperative analgesic after APM.
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Affiliation(s)
- Amir Dolev
- Orthopedic Department, Hasharon Hospital, Rabin Medical Center, Petach Tikva, Israel.,Orthopedic Department, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lee Yaari
- Orthopedic Department, Hasharon Hospital, Rabin Medical Center, Petach Tikva, Israel.,Orthopedic Department, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mohamed Kittani
- Orthopedic Department, Hasharon Hospital, Rabin Medical Center, Petach Tikva, Israel.,Orthopedic Department, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mustafa Yassin
- Orthopedic Department, Hasharon Hospital, Rabin Medical Center, Petach Tikva, Israel.,Orthopedic Department, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mahmod Gbaren
- Orthopedic Department, Hasharon Hospital, Rabin Medical Center, Petach Tikva, Israel.,Orthopedic Department, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elia Feicht
- Orthopedic Department, Hasharon Hospital, Rabin Medical Center, Petach Tikva, Israel.,Orthopedic Department, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shai Shemesh
- Orthopedic Department, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Barak Haviv
- Orthopedic Department, Hasharon Hospital, Rabin Medical Center, Petach Tikva, Israel.,Orthopedic Department, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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6
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Tompkins DM, DiPasquale A, Segovia M, Cohn SM. Review of Intravenous Acetaminophen for Analgesia in the Postoperative Setting. Am Surg 2021; 87:1809-1822. [PMID: 33522265 DOI: 10.1177/0003134821989056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Acetaminophen is a non-opioid analgesic commonly utilized for pain control after several types of surgical procedures. METHODS This scoping primary literature review provides recommendations for intravenous (IV) acetaminophen use based on type of surgery. RESULTS Intravenous acetaminophen has been widely studied for postoperative pain control and has been compared to other agents such as NSAIDs, opioids, oral/rectal acetaminophen, and placebo. Some of the procedures studied include abdominal, gynecologic, orthopedic, neurosurgical, cardiac, renal, and genitourinary surgeries. Results of these studies have been conflicting and largely have not shown consistent clinical benefit. CONCLUSION Overall, findings from this review did not support the notion that IV acetaminophen has significant efficacy for postoperative analgesia. Given the limited clinical benefit of IV acetaminophen, especially when compared to the oral or rectal formulations, use is generally not justifiable.
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Affiliation(s)
- Danielle M Tompkins
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA.,Department of Pharmacy, 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Arielle DiPasquale
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA
| | - Michelle Segovia
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA
| | - Stephen M Cohn
- Department of Surgery, 3673Hackensack University Medical Center, Hackensack, NJ, USA
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Bremerich DH, Greve S. [The new S1 guidelines "Obstetric analgesia and anesthesia"-Presentation and comments]. Anaesthesist 2021; 70:229-236. [PMID: 33464374 DOI: 10.1007/s00101-020-00910-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Dorothee H Bremerich
- Klinik für Anästhesiologie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland.
| | - Susanne Greve
- Klinik für Anästhesiologie und Intensivmedizin, Medizinische Hochschule Hannover, Hannover, Deutschland
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Hilleman DE, Malesker MA, Aurit SJ, Morrow L. Evidence for the Efficacy of an Opioid-Sparing Effect of Intravenous Acetaminophen in the Surgery Patient: A Systematic Review. PAIN MEDICINE 2020; 21:3301-3313. [PMID: 32869091 DOI: 10.1093/pm/pnaa256] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Intravenous (IV) acetaminophen is used in multimodal analgesia to reduce the amount and duration of opioid use in the postoperative setting. METHODS A systematic review of published randomized controlled trials was conducted to define the opioid-sparing effect of IV acetaminophen in different types of surgeries. Eligible studies included prospective, randomized, double-blind trials of IV acetaminophen compared with either a placebo- or active-treatment group in adult (age ≥18 years) patients undergoing surgery. Trials had to be published in English in a peer-reviewed journal. RESULTS A total of 44 treatment cohorts included in 37 studies were included in the systematic analysis. Compared with active- or placebo-control treatments, IV acetaminophen produced a statistically significant opioid-sparing effect in 14 of 44 cohorts (32%). An opioid-sparing effect was more common in placebo-controlled comparisons. Of the 28 placebo treatment comparisons, IV acetaminophen produced an opioid-sparing effect in 13 (46%). IV acetaminophen produced an opioid-sparing effect in only 6% (one out of 16) of the active-control groups. Among the 16 active-control groups, opioid consumption was significantly greater with IV acetaminophen than the active comparator in seven cohorts and not significantly different than the active comparator in eight cohorts. CONCLUSIONS The results of this systematic analysis demonstrate that IV acetaminophen is not effective in reducing opioid consumption compared with other adjuvant analgesic agents in the postoperative patient. In patients where other adjuvant analgesic agents are contraindicated, IV acetaminophen may be an option.
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Affiliation(s)
- Daniel E Hilleman
- Department of Pharmacy Practice, Creighton University School of Pharmacy and Health Professions, Omaha, Nebraska
| | - Mark A Malesker
- Department of Pharmacy Practice, Creighton University School of Pharmacy and Health Professions, Omaha, Nebraska
| | - Sarah J Aurit
- Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Lee Morrow
- Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA
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Wilson SH, Wolf BJ, Robinson SM, Nelson C, Hebbar L. Intravenous vs Oral Acetaminophen for Analgesia After Cesarean Delivery: A Randomized Trial. PAIN MEDICINE 2020; 20:1584-1591. [PMID: 30561704 DOI: 10.1093/pm/pny253] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Examination of postoperative analgesia with intravenous and oral acetaminophen. DESIGN Prospective, three-arm, nonblinded, randomized clinical trial. SETTING A single academic medical center. SUBJECTS Parturients scheduled for elective cesarean delivery. METHODS This trial randomized 141 parturients to receive intravenous acetaminophen (1 g every eight hours, three doses), oral acetaminophen (1 g every eight hours, three doses), or no acetaminophen. All patients received a standardized neuraxial anesthetic with intrathecal opioids and scheduled postoperative ketorolac. The primary outcome, 24-hour opioid consumption, was evaluated using the Kruskal-Wallace test and Tukey-Kramer adjustment for multiple comparisons. Secondary outcomes included 48-hour opioid consumption, first opioid rescue, pain scores, patient satisfaction, times to ambulation and discharge, and side effects. RESULTS Over 18 months, 141 parturients with similar demographic variables completed the study. Median (interquartile range) opioid consumption in intravenous morphine milligram equivalents at 24 hours was 0 (5), 0 (7), and 5 (7) for the intravenous, oral, and no groups, respectively, and differed between groups (global P = 0.017). Opioid consumption and other secondary outcomes did not differ between the intravenous vs oral or oral vs no groups. Opioid consumption was reduced at 24 hours with intravenous vs no acetaminophen (P = 0.015). Patients receiving no acetaminophen had 5.8 times the odds of consuming opioids (P = 0.036), consumed 40% more opioids controlling for time (P = 0.041), and had higher pain scores with ambulation (P = 0.004) compared with the intravenous group. CONCLUSIONS Intravenous acetaminophen did not reduce 24-hour opioid consumption or other outcomes compared with oral acetaminophen. Intravenous acetaminophen did decrease opioid consumption and pain scores compared with no acetaminophen.
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Affiliation(s)
| | | | - Stefanie M Robinson
- Departments of Anesthesia and Perioperative Medicine.,East Carolina Anesthesia Associates, Greenville, North Carolina, USA
| | - Cecil Nelson
- Obstetrics and Gynecology, Medical University of South Carolina, Charleston, South Carolina, USA.,Regional Obstetrical Consultants, Chattanooga, Tennessee, USA
| | - Latha Hebbar
- Departments of Anesthesia and Perioperative Medicine
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10
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Neuroanesthesia Guidelines for Optimizing Transcranial Motor Evoked Potential Neuromonitoring During Deformity and Complex Spinal Surgery: A Delphi Consensus Study. Spine (Phila Pa 1976) 2020; 45:911-920. [PMID: 32539292 DOI: 10.1097/brs.0000000000003433] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Expert opinion-modified Delphi study. OBJECTIVE We used a modified Delphi approach to obtain consensus among leading spinal deformity surgeons and their neuroanesthesiology teams regarding optimal practices for obtaining reliable motor evoked potential (MEP) signals. SUMMARY OF BACKGROUND DATA Intraoperative neurophysiological monitoring of transcranial MEPs provides the best method for assessing spinal cord integrity during complex spinal surgeries. MEPs are affected by pharmacological and physiological parameters. It is the responsibility of the spine surgeon and neuroanesthesia team to understand how they can best maintain high-quality MEP signals throughout surgery. Nevertheless, varying approaches to neuroanesthesia are seen in clinical practice. METHODS We identified 19 international expert spinal deformity treatment teams. A modified Delphi process with two rounds of surveying was performed. Greater than 50% agreement on the final statements was considered "agreement"; >75% agreement was considered "consensus." RESULTS Anesthesia regimens and protocols were obtained from the expert centers. There was a large amount of variability among centers. Two rounds of consensus surveying were performed, and all centers participated in both rounds of surveying. Consensus was obtained for 12 of 15 statements, and majority agreement was obtained for two of the remaining statements. Total intravenous anesthesia was identified as the preferred method of maintenance, with few centers allowing for low mean alveolar concentration of inhaled anesthetic. Most centers advocated for <150 μg/kg/min of propofol with titration to the lowest dose that maintains appropriate anesthesia depth based on awareness monitoring. Use of adjuvant intravenous anesthetics, including ketamine, low-dose dexmedetomidine, and lidocaine, may help to reduce propofol requirements without negatively effecting MEP signals. CONCLUSION Spine surgeons and neuroanesthesia teams should be familiar with methods for optimizing MEPs during deformity and complex spinal cases. Although variability in practices exists, there is consensus among international spinal deformity treatment centers regarding best practices. LEVEL OF EVIDENCE 5.
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Tips and tricks in achieving zero peri-operative opioid used in onco-urologic surgery. World J Urol 2020; 40:1343-1350. [PMID: 32556676 DOI: 10.1007/s00345-020-03305-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 06/08/2020] [Indexed: 10/24/2022] Open
Abstract
PURPOSE To review non-opioid based protocols in urologic oncologic surgery and describe our institutional methods of eliminating peri-operative opioids. METHODS A thorough literature review was performed using PUBMED to identify articles pertaining to reducing or eliminating narcotic use in genitourinary cancer surgery. Studies were analyzed pertaining to protocols utilized in genitourinary cancer surgery, major abdominal and/or pelvic non-urologic surgery. RESULTS Reducing or eliminating peri-operative narcotics should begin with an institutionalized protocol made in conjunction with the anesthesia department. Pre-operative regimens should consist of appropriate counseling, gabapentin, and acetaminophen with or without a non-steroidal anti-inflammatory medications. Prior to incision, a regional block or local anesthetic should be delivered. Anesthesiologists may develop opioid-free protocols for achieving and maintaining general anesthesia. Post-operatively, patients should be on a scheduled regimen of ketorolac, gabapentin, and acetaminophen. CONCLUSION Eliminating peri-operative narcotic use is feasible for major genitourinary oncologic surgery. Patients not only have improved peri-operative outcomes but also are at significantly reduced risk of developing long-term opioid use. Through the implementation of a non-opioid protocol, urologists are able to best serve their patients while positively contributing to reducing the opioid epidemic.
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12
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Wang B, Yang X, Yu H, Man X. The comparison of ibuprofen versus acetaminophen for blood pressure in preeclampsia: a meta-analysis of randomized controlled studies. J Matern Fetal Neonatal Med 2020; 35:592-597. [PMID: 32508173 DOI: 10.1080/14767058.2020.1720641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction: The comparison of ibuprofen with acetaminophen for blood pressure (BP) in preeclampsia remains controversial. We conduct a systematic review and meta-analysis to compare the impact of ibuprofen versus acetaminophen on BP for preeclampsia.Methods: We search PubMed, Embase, Web of Science, EBSCO, and Cochrane Library databases through October 2019 for randomized controlled trials (RCTs) assessing the effect of ibuprofen versus acetaminophen on BP for preeclampsia. This meta-analysis is performed using the random-effect model.Results: Four RCTs are included in the meta-analysis. Overall in preeclampsia patients, ibuprofen and acetaminophen show similar systolic BP (SBP) (standard mean difference [SMD] = 0.04; 95% CI = -0.26-0.34; p= .81), diastolic BP (DBP) (SMD = 0.15; 95% CI = -0.18-0.48; p = 0.38), mean BP (MAP) (SMD = 0.02; 95% CI = -0.29-0.33; p = .91), severe range BP (SMD = -0.10; 95% CI = -0.40-0.19; p = .50), severe hypertension (SMD = 1.18; 95% CI = 0.85-1.62; p = .32), and satisfaction level (SMD = 1.2; 95% CI = 0.95-1.53; p = .13).Conclusions: Ibuprofen and acetaminophen may have no significant influence on BP for preeclampsia.
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Affiliation(s)
- Baogang Wang
- Department of Cardiac Surgery, The First Hospital of Jilin University, Changchun, P. R. China
| | - Xiaolin Yang
- Department of Geriatrics, The First Hospital of Jilin University, Changchun, P. R. China
| | - Hongbo Yu
- Department of Cardiac Surgery, The First Hospital of Jilin University, Changchun, P. R. China
| | - Xiaxia Man
- Department of Oncological Gynecology, The First Hospital of Jilin University, Changchun, P. R. China
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13
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Mian P, Dallmann A, van den Anker JN, Tibboel D, Allegaert K. Intravenous or Oral Acetaminophen for Analgesia After Cesarean Section: Exposure Drives Pain Relief. PAIN MEDICINE 2020; 20:2329-2331. [PMID: 31211382 DOI: 10.1093/pm/pnz136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Paola Mian
- Department of Paediatric Surgery and Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Development and Regeneration, Paediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital Basel, Basel, Switzerland; Division of Clinical Pharmacology, Children's National Medical Center, Washington, DC; Division of Neonatology, Department of Paediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - André Dallmann
- Department of Paediatric Surgery and Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Development and Regeneration, Paediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital Basel, Basel, Switzerland; Division of Clinical Pharmacology, Children's National Medical Center, Washington, DC; Division of Neonatology, Department of Paediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - John N van den Anker
- Department of Paediatric Surgery and Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Development and Regeneration, Paediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital Basel, Basel, Switzerland; Division of Clinical Pharmacology, Children's National Medical Center, Washington, DC; Division of Neonatology, Department of Paediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Dick Tibboel
- Department of Paediatric Surgery and Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Development and Regeneration, Paediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital Basel, Basel, Switzerland; Division of Clinical Pharmacology, Children's National Medical Center, Washington, DC; Division of Neonatology, Department of Paediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Karel Allegaert
- Department of Paediatric Surgery and Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Development and Regeneration, Paediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital Basel, Basel, Switzerland; Division of Clinical Pharmacology, Children's National Medical Center, Washington, DC; Division of Neonatology, Department of Paediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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Talwar R, Xia L, Serna J, Ding J, Lee DJ, Ziemba JB, Guzzo TJ. Preventing Excess Narcotic Prescriptions in New Robotic Surgery Discharges: The PENN Prospective Cohort Quality Improvement Initiative. J Endourol 2020; 34:48-53. [DOI: 10.1089/end.2019.0362] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ruchika Talwar
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Leilei Xia
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Juan Serna
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James Ding
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel J. Lee
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Justin B. Ziemba
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas J. Guzzo
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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A Quality Improvement Initiative to Reduce Opioid Consumption after Cesarean Birth. MCN Am J Matern Child Nurs 2019; 44:250-259. [DOI: 10.1097/nmc.0000000000000549] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ng QX, Loke W, Yeo WS, Chng KYY, Tan CH. A Meta-Analysis of the Utility of Preoperative Intravenous Paracetamol for Post-Caesarean Analgesia. ACTA ACUST UNITED AC 2019; 55:medicina55080424. [PMID: 31370298 PMCID: PMC6723542 DOI: 10.3390/medicina55080424] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 07/02/2019] [Accepted: 07/29/2019] [Indexed: 01/18/2023]
Abstract
Background and objectives: Worldwide, the number of caesarean sections performed has increased exponentially. Some studies have reported better pain control and lower postoperative requirements for opioids when intravenous (IV) paracetamol was administered preoperatively. This meta-analysis thus aimed to investigate the utility of preoperative IV paracetamol for post-caesarean analgesia. Materials and Methods: By using the keywords (paracetamol OR acetaminophen) AND [cesarea* OR caesarea* OR cesaria* OR caesaria*], a systematic literature search was conducted using PubMed, Medline, Embase, Google Scholar and ClinicalTrials.gov databases for papers published in English between January 1, 1960 and March 1, 2019. Grey literature was searched as well. Results: Seven clinical trials were reviewed, while five randomized, placebo-controlled, double-blind studies were included in the final meta-analysis. Applying per-protocol analysis and a random-effects model, there was a significant reduction in postoperative opioid consumption and pain score in the group that received preoperative IV paracetamol, compared to placebo, as the standardized mean difference (SMD) were −0.460 (95% CI −0.828 to −0.092, p = 0.014) and −0.719 (95% CI: −1.31 to −0.13, p = 0.018), respectively. However, there was significant heterogeneity amongst the different studies included in the meta-analysis (I2 = 70.66%), perhaps owing to their diverse protocols. Some studies administered IV paracetamol 15 min before induction while others gave it before surgical incision. Conclusion: This is the first review on the topic. Overall, preoperative IV paracetamol has convincingly demonstrated useful opioid-sparing effects and it also appears safe for use at the time of delivery. It should be considered as a component of an effective multimodal analgesic regimen. Future studies could be conducted on other patient groups, e.g., those with multiple comorbidities or chronic pain disorders, and further delineate the optimal timing to administer the drug preoperatively.
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Affiliation(s)
- Qin Xiang Ng
- MOH Holdings Pte Ltd., 1 Maritime Square, Singapore 099253, Singapore.
- KK Women's and Children's Hospital, Department of Women's Anaesthesia, 100 Bukit Timah Rd, Singapore 229899, Singapore.
| | - Wayren Loke
- MOH Holdings Pte Ltd., 1 Maritime Square, Singapore 099253, Singapore
- Singapore General Hospital, Department of Anaesthesiology, Outram Rd, Singapore 169608, Singapore
| | - Wee Song Yeo
- National University Hospital, National University Health System, Singapore 119074, Singapore
| | - Kelvin Yong Yan Chng
- MOH Holdings Pte Ltd., 1 Maritime Square, Singapore 099253, Singapore
- KK Women's and Children's Hospital, Department of Women's Anaesthesia, 100 Bukit Timah Rd, Singapore 229899, Singapore
| | - Chin How Tan
- KK Women's and Children's Hospital, Department of Women's Anaesthesia, 100 Bukit Timah Rd, Singapore 229899, Singapore
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Hamburger J, Beilin Y. Systemic adjunct analgesics for cesarean delivery: a narrative review. Int J Obstet Anesth 2019; 40:101-118. [PMID: 31350096 DOI: 10.1016/j.ijoa.2019.06.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 05/24/2019] [Accepted: 06/28/2019] [Indexed: 01/12/2023]
Abstract
It is critical to adequately treat postoperative cesarean delivery pain. The use of parenteral or neuraxial opioids has been a mainstay, but opioids have side effects that can be troubling and the opioid crisis in the United States has highlighted the necessity to utilize analgesics other than opioids. Other analgesic options include neuraxial analgesics, nerve blocks such as the transversus abdominis plane block, and non-opioid parenteral and oral medications. The goal of this article is to review non-opioid systemic analgesic adjuncts following cesarean delivery, focusing on their efficacy and side effects as well as their impact on reduction of opioid requirements after surgery.
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Affiliation(s)
- J Hamburger
- Department of Anesthesiology, Pain and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, USA.
| | - Y Beilin
- Department of Anesthesiology, Pain and Perioperative Medicine, Department of Obstetrics, Genecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, USA
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Dafna L, Herman HG, Ben-Zvi M, Bustan M, Sasson L, Bar J, Kovo M. Comparison of 3 protocols for analgesia control after cesarean delivery: a randomized controlled trial. Am J Obstet Gynecol MFM 2019; 1:112-118. [DOI: 10.1016/j.ajogmf.2019.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/29/2019] [Accepted: 04/03/2019] [Indexed: 12/21/2022]
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Soens MA, He J, Bateman BT. Anesthesia considerations and post-operative pain management in pregnant women with chronic opioid use. Semin Perinatol 2019; 43:149-161. [PMID: 30791974 DOI: 10.1053/j.semperi.2019.01.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The prevalence of opioid use disorder in pregnancy has escalated markedly in recent years. Chronic opioid use during pregnancy poses several challenges for providing adequate analgesia and anesthesia in the peripartum period. These challenges include the potential for withdrawal, opioid tolerance and opioid-induced hyperalgesia. Here we discuss alterations in analgesic pharmacokinetics and pharmacodynamics that are associated with chronic opioid use. In addition, when treating pain in patients with opioid use disorder it is important to distinguish between different subgroups. In this review, we will discuss practical management strategies for parturients with (1) untreated opioid use disorder, (2) parturients on medication-assisted treatment (methadone, buprenorphine) and (3) patients recovering from opioid use disorder that are currently abstinent. Finally, we offer an overview of non-opioid strategies that may be utilized as part of a multimodal approach to providing optimal analgesia in this patient population.
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Affiliation(s)
- Mieke A Soens
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
| | - Jingui He
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Brian T Bateman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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Liposome Bupivacaine Compared to Plain Local Anesthetics to Reduce Postsurgical Pain: An Updated Meta-Analysis of Randomized Controlled Trials. PAIN RESEARCH AND TREATMENT 2018; 2018:5710169. [PMID: 30112203 PMCID: PMC6077608 DOI: 10.1155/2018/5710169] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/09/2018] [Accepted: 05/15/2018] [Indexed: 12/01/2022]
Abstract
Objective Peripheral nerve blocks for postoperative analgesia have improved block success, but analgesia efficacy has been limited by the short duration of traditional local anesthetics. The results of randomized trials comparing liposome bupivacaine with conventional local anesthetic formulations (e.g., plain bupivacaine and ropivacaine) have generated conflicting results. This study was conducted to systematically review the effectiveness of analgesic efficacy of liposome bupivacaine infiltration at the surgical site versus plain local anesthetic bupivacaine or ropivacaine in patients undergoing surgery. Methods PRISMA statement guidelines were followed. A search of electronic databases National Library of Medicine's PubMed database, Cochrane Database of Systematic Reviews, Embase, and Google Scholar from January 2012 to September 2017 was performed. Among the 1,612 records identified, 9 randomized controlled trials involving 779 patients were eligible for data extraction and meta-analysis. Results Liposome bupivacaine did not reduce postsurgical pain at rest compared to plain local anesthetics at 24 and 48 hours after surgery. Moreover, liposome bupivacaine did not reduce postoperative opioid consumption at 24, 48, or 72 hours when compared to plain local anesthetics. Liposome bupivacaine did reduce postoperative nausea when compared to plain local anesthetics (P =<0.3). There was no significant difference in hospital length of stay between study groups, the use of plain bupivacaine or ropivacaine, or among orthopedic or nonorthopedic procedures. No manifestations of local anesthetic toxicity were reported. Conclusions Our results suggest that liposome bupivacaine does not have an analgesic advantage when compared to plain local anesthetics at the surgical site for patients undergoing surgical procedures.
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22
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Lefkowits C, Buss MK, Ramzan AA, Fischer S, Urban RR, Fisher CM, Duska LR. Opioid use in gynecologic oncology in the age of the opioid epidemic: Part I - Effective opioid use across clinical settings, a society of gynecologic oncology evidence-based review. Gynecol Oncol 2018; 149:394-400. [DOI: 10.1016/j.ygyno.2018.01.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 01/16/2018] [Accepted: 01/23/2018] [Indexed: 02/07/2023]
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Opioid-induced hyperalgesia in clinical anesthesia practice: what has remained from theoretical concepts and experimental studies? Curr Opin Anaesthesiol 2018; 30:458-465. [PMID: 28590258 DOI: 10.1097/aco.0000000000000485] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This article reviews the phenomenon of opioid-induced hyperalgesia (OIH) and its implications for clinical anesthesia. The goal of this review is to give an update on perioperative prevention and treatment strategies, based on findings in preclinical and clinical research. RECENT FINDINGS Several systems have been suggested to be involved in the pathophysiology of OIH with a focus on the glutaminergic system. Very recently preclinical data revealed that peripheral μ-opioid receptors (MORs) are key players in the development of OIH and acute opioid tolerance (AOT). Peripheral MOR antagonists could, thus, become a new prevention/treatment option of OIH in the perioperative setting. Although the impact of OIH on postoperative pain seems to be moderate, recent evidence suggests that increased hyperalgesia following opioid treatment correlates with the risk of developing persistent pain after surgery. In clinical practice, distinction among OIH, AOT and acute opioid withdrawal remains difficult, especially because a specific quantitative sensory test to diagnose OIH has not been validated yet. SUMMARY Since the immediate postoperative period is not ideal to initiate long-term treatment for OIH, the best strategy is to prevent its occurrence. A multimodal approach, including choice of opioid, dose limitations and addition of nonopioid analgesics, is recommended.
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Preoperative cesarean delivery intravenous acetaminophen treatment for postoperative pain control: a randomized double-blinded placebo control trial. Am J Obstet Gynecol 2018; 218:353.e1-353.e4. [PMID: 29274831 DOI: 10.1016/j.ajog.2017.12.203] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 12/14/2017] [Accepted: 12/14/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND The United States currently has an opioid use disorder epidemic and research evaluating ways to minimize the use of opioids postsurgery are needed. One of these options is intravenous acetaminophen. If the use of preoperative intravenous acetaminophen was found to be effective for cesarean delivery, this would be beneficial for both the mother and breast-feeding neonate. OBJECTIVE The primary study objective was to see if maternal opioid use was significantly less in the postoperative period for the study group that received 1 g of intravenous acetaminophen preoperatively compared with a control group that received placebo. The secondary objectives were to evaluate maternal length of stay and pain scores postoperatively, and assess the acetaminophen level in cord blood at delivery. STUDY DESIGN This study was a prospective double-blinded randomized placebo-controlled trial. All pregnant patients who entered labor and delivery for a scheduled cesarean from November 2015 through April 2017 were eligible. Once consented, the medication was supplied by the pharmacy department, which performed the blinded randomization. Both the study drug of 1000 mg (1 g) of acetaminophen and placebo of normal saline were distributed as unmarked 100-mL bags administered over 15 minutes just prior to incision. No study personnel from the obstetric or anesthesia departments had any access to the randomization. Based on a power analysis using the published surgical data results, the goal was to obtain a minimum of 100 patients (50 patients in each arm). Primary data collection included demographics, number of opioid doses and morphine milligram equivalents administered to the patient postoperatively, length of stay postdelivery, pain scores, and newborn cord blood acetaminophen levels. Exclusions were maternal acetaminophen allergy, receipt of acetaminophen in the prior 24 hours, opioid use disorder, and hepatitis/liver impairment. Statistics involved χ2, Fisher exact, and the Student t test where appropriate and a P value <.05 was considered significant with all tests considered against a 2-sided alternative hypothesis. RESULTS A total of 105 patients were evaluated with 51 who received intravenous acetaminophen and 54 who received placebo. The number of postoperative opioid medication doses administered to the study group was 11.1 (±8.9) compared with the number received by the control group of 10.5 (±8.5), P = .72. The morphine milligram equivalents in the study group was 94.2 (±40.4) compared with the control group of 90.7 (±42.1), P = .67. The length of stay and pain scores were not different between the groups. All of the umbilical cord blood values for acetaminophen were subtherapeutic. CONCLUSION These data demonstrate that for cesarean delivery, the use of a preoperative 1-g intravenous dose of acetaminophen does not decrease the number of opioid medication doses or the morphine milligram equivalents administered postoperatively, nor does it decrease length of stay postcesarean. The administration of 1-g intravenous acetaminophen preoperatively does not result in elevated newborn cord blood levels (ClinicalTrials.govNCT02694653).
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De Oliveira GS, Rodes ME, Bialek J, Kendall MC, McCarthy RJ. Single dose systemic acetaminophen to improve patient reported quality of recovery after ambulatory segmental mastectomy: A prospective, randomized, double-blinded, placebo controlled, clinical trial. Breast J 2017; 24:240-244. [DOI: 10.1111/tbj.12950] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 03/10/2017] [Accepted: 03/15/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Gildasio S. De Oliveira
- Department of Anesthesiology; Feinberg School of Medicine; Northwestern University; Chicago IL USA
| | - Meghan E. Rodes
- Department of Anesthesiology; Feinberg School of Medicine; Northwestern University; Chicago IL USA
| | - Jane Bialek
- Department of Anesthesiology; Feinberg School of Medicine; Northwestern University; Chicago IL USA
| | - Mark C. Kendall
- Department of Anesthesiology; Feinberg School of Medicine; Northwestern University; Chicago IL USA
| | - Robert J. McCarthy
- Department of Anesthesiology; Feinberg School of Medicine; Northwestern University; Chicago IL USA
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De Oliveira GS, Bialek J, Rodes ME, Kendall MC, McCarthy RJ. The effect of sevoflurane compared to propofol maintenance on post-surgical quality of recovery in patients undergoing an ambulatory gynecological surgery: A prospective, randomized, double-blinded, controlled, clinical trial. J Clin Anesth 2017; 43:70-74. [PMID: 29032007 DOI: 10.1016/j.jclinane.2017.10.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 10/06/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The main objective of the current investigation was to evaluate the effect of propofol used as anesthetic maintenance compared to sevoflurane on global post-surgical quality of recovery in female patients undergoing ambulatory gynecological surgery. DESIGN The study was a prospective randomized double blinded, controlled, clinical trial. INTERVENTIONS Healthy female subjects were randomized to receive propofol or sevoflurane as anesthetic maintenance. MEASUREMENTS The primary outcome was the Quality of Recovery 40 (QOR-40) questionnaire at 24h after surgery. Other data collected included opioid consumption, pain scores and time to hospital discharge. P<0.05 was used to reject the null hypothesis for the primary outcome. MAIN RESULTS Ninety subjects were randomized and sixty seven completed the study. Patient's baseline characteristics and surgical factors were not different between study groups. There was not a clinically significant difference in the global QoR-40 scores between the sevoflurane and the propofol groups, median (IQR) of 175 (163 to 181) and 176 (163 to 184), respectively, P=0.97. There was an inverse relationship (ρ=-0.42) between the opioid consumption in PACU (IV morphine equivalents) and 24h postoperative quality of recovery (P<0.001) and an inverse relationship (ρ=-0.48) between the oral opioid consumption at home (oral morphine equivalents) and 24h postoperative quality of recovery, P<0.001. CONCLUSIONS Our current results do not support the use of total intravenous anesthesia as an efficacious strategy to improve global quality of recovery after ambulatory surgery. Opioid consumption in the PACU is an earlier surrogate that can be utilized to identify ambulatory patients with a high likelihood to develop poor global quality of recovery and who may benefit from more efficacious strategies to improve global quality of recovery. TRIAL REGISTRATION ClinicalTrial.gov; url: http://www.clinicaltrials.gov; registration identified: NCT 01755234.
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Affiliation(s)
- Gildasio S De Oliveira
- Department of Anesthesiology, Rhode Island Hospital, Brown University, Providence, RI, USA; Department of Surgery, Alpert School of Medicine, Brown University, United States; Department of Health Services Research, Practice and Policy, The School of Public health, Brown University, United States.
| | - Jane Bialek
- Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Meghan E Rodes
- Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Mark C Kendall
- Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Robert J McCarthy
- Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Allegaert K, van den Anker JN. Perinatal and neonatal use of paracetamol for pain relief. Semin Fetal Neonatal Med 2017; 22:308-313. [PMID: 28720398 DOI: 10.1016/j.siny.2017.07.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Paracetamol (acetaminophen) is the most widely used drug to treat pain or fever in pregnant women or neonates, but its pharmacokinetics (PK) and pharmacodynamics (PD) warrant a focused analysis. During pregnancy, there is an important increase in paracetamol clearance. Consequently, it is reasonable to anticipate that the analgesic effect of paracetamol will decrease faster, whereas higher doses may result in even higher oxidative toxic metabolites. Therefore, most peripartal PD data relate to multimodal analgesia strategies. In neonates, weight/size is the most relevant covariate of paracetamol PK. This resulted in proposed dosing regimens containing higher doses than currently prescribed in the label for term neonates. Using adequate dosing, paracetamol is a poor procedural analgesic, is effective for mild-to-moderate pain, and has morphine-sparing effects. Short-term safety has been well documented, and there is active research investigating the potential association between paracetamol exposure and atopy, fertility, and neurobehavior.
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Affiliation(s)
- Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Intensive Care and Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - John N van den Anker
- Intensive Care and Department of Pediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands; Division of Clinical Pharmacology, Department of Pediatrics, Children's National Health System, Washington DC, USA; Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
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Ramos-Rangel GE, Ferrer-Zaccaro LE, Mojica-Manrique VL, González La Rotta M. Management of post-cesarean delivery analgesia: Pharmacologic strategies. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rcae.2017.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Ramos-Rangel GE, Ferrer-Zaccaro LE, Mojica-Manrique VL, González La Rotta M. Manejo analgésico durante el postoperatorio de cesárea: estrategias farmacológicas. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rca.2017.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Management of post-cesarean delivery analgesia: Pharmacologic strategies☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1097/01819236-201710000-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Altenau B, Crisp CC, Devaiah CG, Lambers DS. Randomized controlled trial of intravenous acetaminophen for postcesarean delivery pain control. Am J Obstet Gynecol 2017; 217:362.e1-362.e6. [PMID: 28455085 DOI: 10.1016/j.ajog.2017.04.030] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 04/17/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cesarean delivery is a common surgery in the United States, with 1.3 million performed during 2009.1 Obstetricians must balance the growing concern with opioid abuse, dependence, and side effects with optimal postoperative pain control. Intravenous acetaminophen may represent an additional method to decrease the reliance on opioid medications and improve postoperative pain following cesarean delivery. OBJECTIVE The objective of the study was to determine whether the administration of intravenous acetaminophen following routine scheduled cesarean delivery would decrease the need for narcotic medications to control postoperative pain. STUDY DESIGN This was an institutional review board-approved, double-blind, placebo-controlled, randomized trial, registered on clinicaltrials.gov (number 02046382). Women scheduled to undergo cesarean delivery with regional anesthesia at term were recruited. All perioperative and postpartum care was standardized via study order sets. Study patients were given all medications in a standardized manner receiving either acetaminophen 1000 mg intravenously or 100 mL saline (placebo) every 8 hours for 48 hours for a total of 6 doses. The pharmacy prepared intravenous acetaminophen and saline in identical administration bags labeled study drug to ensure blinding. The initial dose of study drug was given within 60 minutes of skin incision. Quantity of breakthrough and scheduled analgesic medications and self-reported pain levels on the Faces Pain Scale (0-10) before and after study drug administration were collected. Patient demographics were extracted from the chart. Power calculation determined that 45 patients per arm were required to detect a 30% reduction in postcesarean narcotic requirement with 80% power and a significance level of P = .05. RESULTS A total of 133 patients were consented for the study. Twenty-nine were excluded and 104 patients completed the study: 57 received intravenous acetaminophen and 47 received placebo. There were no differences in baseline demographic characteristics including patient age, body mass index, gravidity, parity, race, comorbidities, or number of prior cesarean deliveries. There were no differences between groups in estimated blood loss or length of stay. The total amount of oral narcotic medications consumed by patients receiving intravenous acetaminophen was significantly reduced when compared with the placebo group (47 mg vs 65 mg of oxycodone; P = .034). The total amount of ibuprofen used between groups was not different. There was no difference in pain scores between groups before and after study dose administration. There was no significant difference in narcotic side effects (nausea/emesis, respiratory depression, constipation) in either study arm. CONCLUSION Intravenous acetaminophen in the postoperative period following cesarean delivery resulted in a significant decrease in oral narcotic consumption for pain control.
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Affiliation(s)
- Brie Altenau
- Department of Obstetrics and Gynecology, TriHealth Hospitals, Cincinnati, OH
| | - Catrina C Crisp
- Division of Female Pelvic Medicine and Reconstructive Surgery, TriHealth Hospitals, Cincinnati, OH
| | - C Ganga Devaiah
- Hatton Research Institute, TriHealth Hospitals, Cincinnati, OH
| | - Donna S Lambers
- Department of Obstetrics and Gynecology, TriHealth Hospitals, Cincinnati, OH.
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Hansen RN, Pham AT, Lovelace B, Balaban S, Wan GJ. Comparative Analysis of Inpatient Costs for Obstetrics and Gynecology Surgery Patients Treated With IV Acetaminophen and IV Opioids Versus IV Opioid-only Analgesia for Postoperative Pain. Ann Pharmacother 2017; 51:834-839. [PMID: 28608722 DOI: 10.1177/1060028017715651] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Recovery from obstetrics and gynecology (OB/GYN) surgery, including hysterectomy and cesarean section delivery, aims to restore function while minimizing hospital length of stay (LOS) and medical expenditures. OBJECTIVE Our analyses compare OB/GYN surgery patients who received combination intravenous (IV) acetaminophen and IV opioid analgesia with those who received IV opioid-only analgesia and estimate differences in LOS, hospitalization costs, and opioid consumption. METHODS We performed a retrospective analysis of the Premier Database between January 2009 and June 2015, comparing OB/GYN surgery patients who received postoperative pain management with combination IV acetaminophen and IV opioids with those who received only IV opioids starting on the day of surgery and continuing up to the second postoperative day. We performed instrumental variable 2-stage least-squares regressions controlling for patient and hospital covariates to compare the LOS, hospitalization costs, and daily opioid doses (morphine equivalent dose) of IV acetaminophen recipients with that of opioid-only analgesia patients. RESULTS We identified 225 142 OB/GYN surgery patients who were eligible for our study of whom 89 568 (40%) had been managed with IV acetaminophen and opioids. Participants averaged 36 years of age and were predominantly non-Hispanic Caucasians (60%). Multivariable regression models estimated statistically significant differences in hospitalization cost and opioid use with IV acetaminophen associated with $484.4 lower total hospitalization costs (95% CI = -$760.4 to -$208.4; P = 0.0006) and 8.2 mg lower daily opioid use (95% CI = -10.0 to -6.4), whereas the difference in LOS was not significant, at -0.09 days (95% CI = -0.19 to 0.01; P = 0.07). CONCLUSION Compared with IV opioid-only analgesia, managing post-OB/GYN surgery pain with the addition of IV acetaminophen is associated with decreased hospitalization costs and reduced opioid use.
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Affiliation(s)
| | - An T Pham
- 2 Mallinckrodt Pharmaceuticals, Hampton, NJ, USA
| | | | | | - George J Wan
- 2 Mallinckrodt Pharmaceuticals, Hampton, NJ, USA
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