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Young AM, Strobel RJ, Rotar EP, Kleiman A, McNeil JS, Teman NR, Hawkins RB, Raphael J, Mehaffey JH. Perioperative acetaminophen is associated with reduced acute kidney injury after cardiac surgery. J Thorac Cardiovasc Surg 2024; 167:1372-1380. [PMID: 36207161 DOI: 10.1016/j.jtcvs.2022.09.005] [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: 05/14/2022] [Revised: 08/19/2022] [Accepted: 09/03/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Cardiac surgery-associated acute kidney injury (AKI) is associated with increased postoperative morbidity and mortality. Evidence suggests an association between perioperative acetaminophen administration and decreased incidence of postoperative AKI in pediatric cardiac surgery patients; however, an effect in adults is unknown. METHODS All patients (n = 6192) undergoing coronary and/or valve surgery with a recorded Society of Thoracic Surgeons (STS) risk score at our institution between 2010 and 2018 were stratified by acetaminophen exposure on the day of surgery using institutional pharmacy records. AKI was determined using the Kidney Disease: Improving Global Outcomes (KDIGO) staging criteria. Logistic regression was used to analyze the association between perioperative acetaminophen and postoperative kidney injury or STS major morbidity. A sensitivity analysis using propensity score matching on the STS predicted risk of renal failure and cardiopulmonary bypass time was performed to account for time bias. RESULTS Perioperative acetaminophen exposure was associated with lower odds of stage 1 to 3 acute kidney injury (odds ratio [OR], 0.68; 95% CI, 0.56-0.83; P < .001) and decreased prolonged postoperative ventilation (OR, 0.53; 95% CI, 0.37-0.76; P < .001). A sensitivity analysis provided well-balanced (standard mean difference <0.10) groups of 401 pairs, in which acetaminophen was associated with a decreased incidence of postoperative AKI (OR, 0.7; 95% CI, 0.52-0.94; P = .016). CONCLUSIONS Exposure to acetaminophen on the day of surgery was associated with a decreased incidence of AKI in our patients undergoing cardiac surgery. These data serve as a measure of effect size to further explore the therapeutic potential of acetaminophen to reduce postoperative AKI after cardiac surgery and to elucidate the mechanisms involved.
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Affiliation(s)
- Andrew M Young
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Raymond J Strobel
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Evan P Rotar
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Amanda Kleiman
- Department of Anesthesiology, University of Virginia, Charlottesville, Va
| | - John S McNeil
- Department of Anesthesiology, University of Virginia, Charlottesville, Va
| | - Nicholas R Teman
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Robert B Hawkins
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Jacob Raphael
- Department of Anesthesiology, University of Virginia, Charlottesville, Va
| | - J Hunter Mehaffey
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa.
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2
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Grant MC, Chappell D, Gan TJ, Manning MW, Miller TE, Brodt JL. Pain management and opioid stewardship in adult cardiac surgery: Joint consensus report of the PeriOperative Quality Initiative and the Enhanced Recovery After Surgery Cardiac Society. J Thorac Cardiovasc Surg 2023; 166:1695-1706.e2. [PMID: 36868931 DOI: 10.1016/j.jtcvs.2023.01.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/07/2023] [Accepted: 01/19/2023] [Indexed: 01/30/2023]
Abstract
BACKGROUND Opioid-based anesthesia and analgesia is a traditional component of perioperative care for the cardiac surgery patient. Growing enthusiasm for Enhanced Recovery Programs (ERPs) coupled with evidence of potential harm associated with high-dose opioids suggests that we reconsider the role of opioids in cardiac surgery. METHODS An interdisciplinary North American panel of experts, using a structured appraisal of the literature and a modified Delphi method, derived consensus recommendations for optimal pain management and opioid stewardship for cardiac surgery patients. Individual recommendations are graded based on the strength and level of evidence. RESULTS The panel addressed 4 main topics: the harms associated with historical opioid use, the benefits of more targeted opioid administration, the use of nonopioid medications and techniques, and patient and provider education. A key principle that emerged is that opioid stewardship should apply to all cardiac surgery patients, entailing judicious and targeted use of opioids to achieve optimal analgesia with the fewest potential side effects. The process resulted in the promulgation of 6 recommendations regarding pain management and opioid stewardship in cardiac surgery, focused on avoiding the use of high-dose opioids, as well as encouraging more widespread application of foundational aspects of ERPs, such as the use of multimodal nonopioid medications and regional anesthesia techniques, formal patient and provider education, and structured system-level opioid prescription practices. CONCLUSIONS Based on the available literature and expert consensus, there is an opportunity to optimize anesthesia and analgesia for cardiac surgery patients. Although additional research is needed to establish specific strategies, core principles of pain management and opioid stewardship apply to the cardiac surgery population.
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Affiliation(s)
- Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md
| | | | - Tong J Gan
- Department of Anesthesiology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY
| | - Michael W Manning
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Timothy E Miller
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Jessica L Brodt
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, Calif.
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3
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Takeda Y, Tsujimoto K, Okamoto T, Nakai T, Fukunishi S, Tachibana T. Efficacy of Anterior Quadratus Lumborum Block and Pain After Total Hip Arthroplasty: A Randomized Controlled Trial. J Arthroplasty 2023; 38:2386-2392. [PMID: 37321519 DOI: 10.1016/j.arth.2023.05.044] [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: 02/13/2023] [Revised: 05/18/2023] [Accepted: 05/20/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Anterior quadratus lumborum block (AQLB) is one of the compartment blocks and has recently attracted attention as a new method of analgesia for postoperative hip surgery analgesia. This study aimed to compare the analgesic efficacy of AQLB in patients undergoing primary total hip arthroplasty (THA). METHODS There were 120 patients undergoing primary THA under general anesthesia randomly allocated to receive a femoral nerve block (FNB) or an AQLB. The primary outcome was total morphine consumption over the initial 24-hour postoperative period. Secondary outcomes included the pain score evaluation while at rest and during active and passive motion over the 2 days following surgery and the manual muscle testing of the quadriceps femoris. The numerical rating scale (NRS) score was used for evaluating the postoperative pain score. RESULTS There were no significant differences between the 2 groups concerning morphine consumption within 24 hours after surgery (P = .72). The NRS score at rest and passive motion were similar at all-time points (P > .05). However, there was a statistically significant difference in pain reported during the active motion for the FNB group compared to the AQLB (P = .04). No significant differences were found between the 2 groups concerning muscle weakness incidence. CONCLUSION Both AQLB and FNB demonstrated adequate efficacy for postoperative analgesia at rest in THA. However, based on our study, whether AQLB is inferior or noninferior to FNB as an analgesic method for THA was inconclusive.
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Affiliation(s)
- Yu Takeda
- Department of Orthopedic Surgery, Hyogo Medical University, Nishinomiya, Hyogo, Japan; Department of Orthopedic Surgery, Nishinomiya Kaisei Hospital, Nishinomiya, Hyogo, Japan
| | - Kazuyuki Tsujimoto
- Department of Anesthesia, Nishinomiya Kaisei Hospital, Nishinomiya, Hyogo, Japan
| | - Teru Okamoto
- Department of Anesthesia, Nishinomiya Kaisei Hospital, Nishinomiya, Hyogo, Japan
| | - Takuya Nakai
- Department of Orthopedic Surgery, Nishinomiya Kaisei Hospital, Nishinomiya, Hyogo, Japan
| | - Shigeo Fukunishi
- Department of Orthopedic Surgery, Nishinomiya Kaisei Hospital, Nishinomiya, Hyogo, Japan
| | - Toshiya Tachibana
- Department of Orthopedic Surgery, Hyogo Medical University, Nishinomiya, Hyogo, Japan
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Maeßen T, Korir N, Van de Velde M, Kennes J, Pogatzki-Zahn E, Joshi GP. Pain management after cardiac surgery via median sternotomy: A systematic review with procedure-specific postoperative pain management (PROSPECT) recommendations. Eur J Anaesthesiol 2023; 40:758-768. [PMID: 37501517 DOI: 10.1097/eja.0000000000001881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
BACKGROUND Pain after cardiac surgery via median sternotomy can be difficult to treat, and if inadequately managed can lead to respiratory complications, prolonged hospital stays and chronic pain. OBJECTIVES To evaluate available literature and develop recommendations for optimal pain management after cardiac surgery via median sternotomy. DESIGN A systematic review using PROcedure-SPECific Pain Management (PROSPECT) methodology. ELIGIBILITY CRITERIA Randomised controlled trials and systematic reviews published in the English language until November 2020 assessing postoperative pain after cardiac surgery via median sternotomy using analgesic, anaesthetic or surgical interventions. DATA SOURCES PubMed, Embase and Cochrane Databases. RESULTS Of 319 eligible studies, 209 randomised controlled trials and three systematic reviews were included in the final analysis. Pre-operative, intra-operative and postoperative interventions that reduced postoperative pain included paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), intravenous magnesium, intravenous dexmedetomidine and parasternal block/infiltration. CONCLUSIONS The analgesic regimen for cardiac surgery via sternotomy should include paracetamol and NSAIDs, unless contraindicated, administered intra-operatively and continued postoperatively. Intra-operative magnesium and dexmedetomidine infusions may be considered as adjuncts particularly when basic analgesics are not administered. It is not clear if combining dexmedetomidine and magnesium would provide superior pain relief compared with either drug alone. Parasternal block/surgical site infiltration is also recommended. However, no basic analgesics were used in the studies assessing these interventions. Opioids should be reserved for rescue analgesia. Other interventions, including cyclo-oxygenase-2 specific inhibitors, are not recommended because there was insufficient, inconsistent or no evidence to support their use and/or due to safety concerns.
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Affiliation(s)
- Timo Maeßen
- From the Department of Anaesthesiology, Intensive Care, and Pain Medicine, University Hospital Münster, Münster, Germany (TM, EP-Z), the Department of Cardiovascular Sciences, Section Anaesthesiology, KU Leuven and University Hospital Leuven, Leuven, Belgium (NK, MVdeV, JK), the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Centre, Dallas, Texas, USA (GPJ)
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Makkad B, Heinke TL, Sheriffdeen R, Khatib D, Brodt JL, Meng ML, Grant MC, Kachulis B, Popescu WM, Wu CL, Bollen BA. Practice Advisory for Preoperative and Intraoperative Pain Management of Cardiac Surgical Patients: Part 2. Anesth Analg 2023; 137:26-47. [PMID: 37326862 DOI: 10.1213/ane.0000000000006506] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Pain after cardiac surgery is of moderate to severe intensity, which increases postoperative distress and health care costs, and affects functional recovery. Opioids have been central agents in treating pain after cardiac surgery for decades. The use of multimodal analgesic strategies can promote effective postoperative pain control and help mitigate opioid exposure. This Practice Advisory is part of a series developed by the Society of Cardiovascular Anesthesiologists (SCA) Quality, Safety, and Leadership (QSL) Committee's Opioid Working Group. It is a systematic review of existing literature for various interventions related to the preoperative and intraoperative pain management of cardiac surgical patients. This Practice Advisory provides recommendations for providers caring for patients undergoing cardiac surgery. This entails developing customized pain management strategies for patients, including preoperative patient evaluation, pain management, and opioid use-focused education as well as perioperative use of multimodal analgesics and regional techniques for various cardiac surgical procedures. The literature related to this field is emerging, and future studies will provide additional guidance on ways to improve clinically meaningful patient outcomes.
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Affiliation(s)
- Benu Makkad
- From the Department of Anesthesiology, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Timothy Lee Heinke
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Raiyah Sheriffdeen
- Department of Anesthesiology, Medstar Washington Hospital Center, Washington, DC
| | - Diana Khatib
- Department of Anesthesiology, Weil Cornell Medical College, New York, New York
| | - Jessica Louise Brodt
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
| | - Marie-Louise Meng
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Michael Conrad Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bessie Kachulis
- Department of Anesthesiology, Columbia University, New York, New York
| | - Wanda Maria Popescu
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Christopher L Wu
- Department of Anesthesiology, Hospital of Special Surgery, Weill Cornell Medical College, New York, New York
| | - Bruce Allen Bollen
- Missoula Anesthesiology, Missoula, Montana
- The International Heart Institute of Montana, Missoula, Montana
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Heybati K, Zhou F, Lynn MJ, Deng J, Ali S, Hou W, Heybati S, Tzanis K, Krever M, Mughal R, Ramakrishna H. Comparative Efficacy of Adjuvant Nonopioid Analgesia in Adult Cardiac Surgical Patients: A Network Meta-Analysis. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00188-X. [PMID: 37088644 DOI: 10.1053/j.jvca.2023.03.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/10/2023] [Accepted: 03/11/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVES To compare the relative efficacy of adjuvant nonopioid analgesic regimens in adult cardiac surgical patients. DESIGN This frequentist, random-effects network meta-analysis (NMA) was prospectively registered on PROSPERO (CRD42021282913) and conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses for Network Meta-Analyses (PRISMA-NMA). The risk of bias (RoB) and confidence of evidence were assessed by RoB 2 and Confidence in Network Meta-Analysis, respectively. Relevant databases were searched from inception to October 9, 2021. SETTING A total of 124 (N = 26,257) randomized controlled trials were included, of which 110 were analyzed. PARTICIPANTS Trials enrolling adults (≥18 years of age) undergoing cardiac surgery that compared nonopioid analgesics against other nonopioid analgesics, placebo, or no additional treatment, as adjuvants to standard analgesic management, and reported at least 1 of the outcomes of interest. MEASUREMENT AND MAIN RESULTS Outcomes of interest included resting postoperative pain scores at 24 hours. Compared with standard care and/or placebo, pain scores were reduced significantly by 10 different regimens, including acetaminophen (N = 176; mean difference [MD] -0.66 points, 95% CI -1.16 to -0.15 points; high confidence), magnesium (N = 323; -0.05 points, 95% CI -0.07 to -0.02 points; high confidence), gabapentin (N = 96; MD -0.40 points, 95% CI -0.71 to -0.09; moderate confidence), and clonidine (N = 64; MD v0.38 points, 95% CI -0.73 to v0.04 points; moderate confidence). Indomethacin, diclofenac, magnesium, and gabapentin significantly reduced 24-hour opioid consumption. Four regimens significantly decreased the intensive care unit length of stay. Hydrocortisone, dexmedetomidine, and clonidine significantly decreased the duration of mechanical ventilation. Magnesium decreased, while methylprednisolone significantly increased, the risk of myocardial infarction. CONCLUSIONS Given the increasing emphasis on enhanced recovery after surgery(ERAS) protocols and the eventual goal of limiting opiate prescriptions postoperatively, the authors' data suggested far greater use of nonopioid adjuncts to minimize pain and enhance recovery following cardiac surgery.
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Affiliation(s)
- Kiyan Heybati
- Mayo Clinic Alix School of Medicine, Mayo Clinic - Rochester, Rochester, MN
| | - Fangwen Zhou
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Matthew Joseph Lynn
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jiawen Deng
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Saif Ali
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Wenteng Hou
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
| | - Shayan Heybati
- Faculty of Science, Queen's University, Kingston, ON, Canada
| | - Kosta Tzanis
- Faculty of Science, University of Toronto, Toronto, ON, Canada
| | - Magnus Krever
- Faculty of Science, Wilfrid Laurier University, Waterloo, ON, Canada
| | - Rafay Mughal
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Gregory AJ, Noss CD, Chun R, Gysel M, Prusinkiewicz C, Webb N, Raymond M, Cogan J, Rousseau-Saine N, Lam W, van Rensburg G, Alli A, de Vasconcelos Papa F. Perioperative Optimization of the Cardiac Surgical Patient. Can J Cardiol 2023; 39:497-514. [PMID: 36746372 DOI: 10.1016/j.cjca.2023.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 01/16/2023] [Accepted: 01/29/2023] [Indexed: 02/06/2023] Open
Abstract
Perioperative optimization of cardiac surgical patients is imperative to reduce complications, utilize health care resources efficiently, and improve patient recovery and quality of life. Standardized application of evidence-based best practices can lead to better outcomes. Although many practices should be applied universally to all patients, there are also opportunities along the surgical journey to identify patients who will benefit from additional interventions that will further ameliorate their recovery. Enhanced recovery programs aim to bundle several process elements in a standardized fashion to optimize outcomes after cardiac surgery. A foundational concept of enhanced recovery is attaining a better postsurgical end point for patients, in less time, through achievement and maintenance in their greatest possible physiologic, functional, and psychological state. Perioperative optimization is a broad topic, spanning multiple phases of care and involving a variety of medical specialties and nonphysician health care providers. In this review we highlight a variety of perioperative care topics, in which a comprehensive approach to patient care can lead to improved results for patients, providers, and the health care system. A particular focus on patient-centred care is included. Although existing evidence supports all of the elements reviewed, most require further improvements in implementation, as well as additional research, before their full potential and usefulness can be determined.
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Affiliation(s)
- Alexander J Gregory
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada.
| | - Christopher D Noss
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Rosaleen Chun
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Michael Gysel
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Prusinkiewicz
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Nicole Webb
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Meggie Raymond
- Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Jennifer Cogan
- Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | | | - Wing Lam
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Gerry van Rensburg
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Ahmad Alli
- Department of Anesthesia, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Ward CT, Moll V, Boorman DW, Ooroth L, Groff RF, Gillingham TD, Pyronneau L, Prabhakar A. The impact of a postoperative multimodal analgesia pathway on opioid use and outcomes after cardiothoracic surgery. J Cardiothorac Surg 2022; 17:342. [PMID: 36581941 PMCID: PMC9801617 DOI: 10.1186/s13019-022-02067-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 12/08/2022] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE The Enhanced Recovery after Surgery Cardiac Society recommends using multimodal analgesia (MMA) for postoperative pain however, evidence-based guidelines have yet to be established. This study examines the impact of a standardized postoperative MMA pathway in reducing opioid consumption and related complications after cardiothoracic surgery (CTS). METHODS Within a multicenter healthcare system, a postoperative MMA pathway was developed and implemented at two CTS intensive care units (ICU) while the other CTS ICU opted to maintain the existing opioid-based pathway. A retrospective chart review was conducted on patients admitted to a CTS ICU within this healthcare system after conventional coronary artery bypass grafting and/or valve surgery from September 1, 2018, to June 30, 2019. Comparative analysis was conducted on patients prescribed MMA versus those managed with an opioid-based pathway. The primary outcome was total opioid consumption, converted to morphine milligram equivalents, 72-h post-surgery. Secondary outcomes included mobility within one-day post-surgery, ICU length of stay (LOS), time to first bowel movement (BM), and time to first zero Richmond Agitation-Sedation Scale (RASS). RESULTS Seven hundred sixty-two adults were included for final analysis. The MMA group had a higher body mass index, higher percentage of females, were more likely classified as African American and had higher scores for risk-adjusted complications. General Linear Model analysis revealed higher opioid consumption in the MMA group (Est. 0.22, p < 0.0009); however, this was not statistically significant after adjusting for differences in fentanyl usage. The MMA group was more likely to have mobility within one-day post-surgery (OR 0.44, p < 0.0001), have longer time to first BM (OR 1.93, p = 0.0011), and longer time to first zero RASS (OR 1.62, p = 0.0071). The analgesia groups were not a predictor for ICU LOS. CONCLUSIONS Opioid consumption was not reduced secondary to this postoperative MMA pathway. The MMA group was more likely to have mobility within one-day post-surgery. Patients in the MMA group were also more likely to have prolonged time to first BM and first zero RASS. Development and evaluation of a perioperative MMA pathway should be considered.
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Affiliation(s)
- Ceressa T. Ward
- Convergent Genomics, 425 Eccles Avenue, South San Francisco, CA 94080 USA ,grid.505042.6Potrero Medical, Hayward, CA USA
| | - Vanessa Moll
- grid.189967.80000 0001 0941 6502Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA USA ,grid.505042.6Potrero Medical, Hayward, CA USA
| | - David W. Boorman
- grid.189967.80000 0001 0941 6502Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA USA
| | - Lijo Ooroth
- grid.259906.10000 0001 2162 9738Mercer University College of Pharmacy, Atlanta, GA USA
| | - Robert F. Groff
- grid.189967.80000 0001 0941 6502Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA USA
| | - Trent D. Gillingham
- grid.462222.20000 0004 0382 6932Office of Quality, Emory Healthcare, Atlanta, GA USA
| | | | - Amit Prabhakar
- grid.189967.80000 0001 0941 6502Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA USA
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Intravenous acetaminophen with morphine versus intravenous morphine alone for acute pain in the emergency room: protocol for a multicenter, randomized, placebo-controlled, double-blinded study (ADAMOPA). Trials 2022; 23:1016. [PMID: 36522767 PMCID: PMC9756523 DOI: 10.1186/s13063-022-06943-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 11/18/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND In emergency medicine, pain is a frequent reason for consultation. However, there is a great variation in its management which is often insufficient. The use intravenous morphine alone or multimodal analgesia with paracetamol is recommended for severe pain. But robust data are lacking to justify the association of paracetamol with morphine versus morphine alone for pain management in the emergency room (ER). The aim of our study is therefore to assess if in patients with acute pain of moderate to severe intensity with a numerical verbal scale (NVS) ≥5 in the ER, the intravenous administration of morphine alone is not inferior to the administration of intravenous morphine combined with paracetamol at 30 min from the first administration of the study drug. METHODS ADAMOPA is a prospective, non-inferiority, multicenter, placebo-controlled, parallel-group, randomized (1:1), double-blind trial. Subjects will be enrolled in the ER if they experience moderate to severe, acute, non-traumatic, and traumatic pain, defined as an NVS ≥5. The primary endpoint will be the between-group difference in mean change in NVS pain scores among patients receiving the combination of intravenous morphine plus paracetamol or intravenous morphine given alone, measured from the time before administration of the study medication to 30 min later. DISCUSSION This trial will determine the clinical utility of the association of paracetamol with morphine for pain management in the emergency room. The ADAMOPA trial will be conducted in accordance with the International Council on Harmonization Good Clinical Practices. TRIAL REGISTRATION EudraCT number: 2019-002149-39. CLINICALTRIALS gov identifier: NCT04148495. Date of trial registration: November 1, 2019.
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Thalji NK, Patel SJ, Augoustides JG, Schiller RJ, Dalia AA, Low Y, Hamzi RI, Fernando RJ. Opioid-Free Cardiac Surgery: A Multimodal Pain Management Strategy With a Focus on Bilateral Erector Spinae Plane Block Catheters. J Cardiothorac Vasc Anesth 2022; 36:4523-4533. [PMID: 36184473 PMCID: PMC9745636 DOI: 10.1053/j.jvca.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Nabil K Thalji
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Saumil Jayant Patel
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Robin J Schiller
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA
| | - Adam A Dalia
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA
| | - Yinghui Low
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA
| | - Rawad I Hamzi
- Department of Anesthesiology, Regional Anesthesia and Acute Pain Management, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC
| | - Rohesh J Fernando
- Department of Anesthesiology, Cardiothoracic Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC.
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Subramaniam K, Esper SA, Mallikarjun K, Dickson A, Ruppert K, Drabek T, Wong H, Murray JH. The Effect of Scheduled Intravenous Acetaminophen in an Enhanced Recovery Protocol Pathway in Patients Undergoing Major Abdominal Procedures: A Prospective, Randomized, and Placebo-Controlled Clinical Trial. PAIN MEDICINE 2021; 23:10-18. [PMID: 34498068 DOI: 10.1093/pm/pnab272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 06/30/2021] [Accepted: 09/01/2021] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Enhanced recovery protocols (ERPs) utilize multi-modal analgesia regimens. Individual regimen components should be evaluated for their analgesic efficacy. We evaluated the effect of scheduled intravenous (IV) acetaminophen within an ERP on analgesia and recovery after a major abdominal surgery. DESIGN This study is a prospective, randomized, double-blinded clinical trial. SETTING The study setting was a tertiary care, academic medical center. SUBJECTS Adult patients scheduled for elective major abdominal surgical procedures. METHODS Patients in group A received 1g IV acetaminophen, while patients in group P received IV placebo every six hours for 48 hours postoperatively within an ERP. Pain scores, opioid requirements, nausea and vomiting, time to oral intake and mobilization, length of stay, and patient satisfaction scores were measured and compared. RESULTS From 412 patients screened, 154 patients completed the study (Group A: 76, Group P: 78). Primary outcome was the number of patients with unsatisfactory pain relief, defined as a composite of average Numeric Rating Scale (NRS) scores above 5 and requirement of IV patient-controlled analgesia for pain relief during the first 48 hours postoperatively, and was not significantly different between the two groups (33 (43.4%) in group A versus 42 (53.8%) patients in group P, p=0.20). Opioid consumption was comparable between two groups. Group A utilized significantly less postoperative rescue antiemetics compared to group P (41% vs. 58%, p= 0.02). CONCLUSIONS Scheduled administration of IV acetaminophen did not improve postoperative analgesia or characteristics of postoperative recovery in patients undergoing major abdominal surgery within an ERP pathway.
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Affiliation(s)
- Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh PA
| | - Stephen A Esper
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh PA
| | - Kushanth Mallikarjun
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO
| | - Alec Dickson
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh PA
| | - Kristin Ruppert
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh PA
| | - Tomas Drabek
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh PA
| | - Hesper Wong
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh PA
| | - Jennifer Holder Murray
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh PA
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12
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Krakowski JC, Hallman MJ, Smeltz AM. Persistent Pain After Cardiac Surgery: Prevention and Management. Semin Cardiothorac Vasc Anesth 2021; 25:289-300. [PMID: 34416847 PMCID: PMC8669213 DOI: 10.1177/10892532211041320] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Persistent postoperative pain (PPP) after cardiac surgery is a significant complication that negatively affects patient quality of life and increases health care system burden. However, there are no standards or guidelines to inform how to mitigate these effects. Therefore, in this review, we will discuss strategies to prevent and manage PPP after cardiac surgery. Adequate perioperative analgesia may prove instrumental in the prevention of PPP. Although opioids have historically been the primary analgesic approach to cardiac surgery, an opioid-sparing strategy may prove advantageous in reducing side effects, avoiding secondary hyperalgesia, and decreasing risk of PPP. Implementing a multimodal analgesic plan using alternative medications and regional anesthetic techniques may offer superior efficacy while reducing adverse effects.
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Affiliation(s)
| | | | - Alan M Smeltz
- University of North Carolina at Chapel Hill, NC, USA
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13
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Sychev DA, Morozova TE, Shatskiy DA, Shikh EV. Efficiency and safety of pharmacotherapy for postoperative pain in cardiac surgery. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2021. [DOI: 10.15829/1728-8800-2021-2683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Intraoperative injury with the formation of a sternotomy wound is inevitably accompanied by postoperative pain, which has a negative effect on the postoperative period and prognosis of patients. Today, moderate and severe pain affects at least half of patients in the early postoperative period after cardiac surgery. Inadequate pain relief in the early postoperative period can lead to chronic pain, which significantly reduces the quality of life of patients. The concept of multimodal analgesia with different painkillers is a priority, effective and safe technique both after cardiac surgery and in other areas of surgery. The current review article is devoted to the analysis of efficacy and safety of various drug groups for postoperative pain relief in cardiac surgery.
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Affiliation(s)
- D. A. Sychev
- Russian Medical Academy of Continuous Professional Education
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14
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Nazarnia S, Subramaniam K. Nonopioid Analgesics in Postoperative Pain Management After Cardiac Surgery. Semin Cardiothorac Vasc Anesth 2021; 25:280-288. [PMID: 33899581 DOI: 10.1177/1089253221998552] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Opioid analgesia is still considered the standard of practice for cardiac surgery. In recent years, combinations of several nonnarcotic analgesics and regional analgesia have shown promise in restricting opioid use during and after cardiac surgery. Ketamine infusion, dexmedetomidine infusion, acetaminophen, ketorolac, and gabapentin are useful adjuvants in cardiac anesthesia practice and have opioid-sparing properties. The beneficial effects of nonnarcotic multimodal analgesia on intraoperative stress response, recovery profile, postoperative pain, and persistent opioid use after cardiac surgery are yet to be established, and further randomized clinical trials are required.
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Affiliation(s)
- Soheyla Nazarnia
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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15
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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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16
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Maldonado Y, Mehta AR, Skubas NJ. Enhanced Recovery After Cardiac Surgery: Are More (and Which) Opioid-Sparing Interventions Better? Anesth Analg 2020; 131:1850-1851. [PMID: 33186170 DOI: 10.1213/ane.0000000000005238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Yasdet Maldonado
- From the Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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17
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Lu SY, Lai Y, Dalia AA. Implementing a Cardiac Enhanced Recovery After Surgery Protocol: Nuts and Bolts. J Cardiothorac Vasc Anesth 2020; 34:3104-3112. [DOI: 10.1053/j.jvca.2019.12.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/02/2019] [Accepted: 12/11/2019] [Indexed: 12/17/2022]
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18
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Del Rio JM, Abernathy JJ, Taylor MA, Habib RH, Fernandez FG, Bollen BA, Lauer RE, Nussmeier NA, Glance LG, Petty JV, Mackensen GB, Vener DF, Kertai MD. The Adult Cardiac Anesthesiology Section of STS Adult Cardiac Surgery Database: 2020 Update on Quality and Outcomes. Anesth Analg 2020; 131:1383-1396. [PMID: 33079860 DOI: 10.1213/ane.0000000000005093] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- J Mauricio Del Rio
- From the Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - James Jake Abernathy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark A Taylor
- Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert H Habib
- STS Research Center, The Society of Thoracic Surgeons, Chicago, Illinois
| | - Felix G Fernandez
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Bruce A Bollen
- International Heart Institute of Montana, Missoula Anesthesiology, PC, Missoula, Montana
| | - Ryan E Lauer
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California
| | - Nancy A Nussmeier
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Joseph V Petty
- CHI Health Clinic Physician Enterprise Anesthesia, CHI Health Nebraska Heart, Omaha, Nebraska
| | - G Burkhard Mackensen
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology & Pain Medicine, University of Washington Medical Center, Seattle, Washington
| | - David F Vener
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Miklos D Kertai
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
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19
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Del Rio JM, Jake Abernathy J, Taylor MA, Habib RH, Fernandez FG, Bollen BA, Lauer RE, Nussmeier NA, Glance LG, Petty JV, Mackensen GB, Vener DF, Kertai MD. The Adult Cardiac Anesthesiology Section of STS Adult Cardiac Surgery Database: 2020 Update on Quality and Outcomes. J Cardiothorac Vasc Anesth 2020; 35:22-34. [PMID: 33008722 DOI: 10.1053/j.jvca.2020.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The Society of Cardiovascular Anesthesiologists, in partnership with The Society of Thoracic Surgeons, has developed the Adult Cardiac Anesthesiology Section of the Adult Cardiac Surgery Database. The goal of this landmark collaboration is to advance clinical care, quality, and knowledge, and to demonstrate the value of cardiac anesthesiology in the perioperative care of cardiac surgical patients. Participation in the Adult Cardiac Anesthesiology Section has been optional since its inception in 2014 but has progressively increased. Opportunities for further growth and improvement remain. In this first update report on quality and outcomes of the Adult Cardiac Anesthesiology Section, we present an overview of the clinically significant anesthesia and surgical variables submitted between 2015 and 2018. Our review provides a summary of quality measures and outcomes related to the current practice of cardiothoracic anesthesiology. We also emphasize the potential for addressing high-impact research questions as data accumulate, with the overall goal of elucidating the influence of cardiac anesthesiology contributions to patient outcomes within the framework of the cardiac surgical team.
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Affiliation(s)
- J Mauricio Del Rio
- Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - James Jake Abernathy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark A Taylor
- Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert H Habib
- STS Research Center, The Society of Thoracic Surgeons, Chicago, Illinois
| | - Felix G Fernandez
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Bruce A Bollen
- International Heart Institute of Montana, Missoula Anesthesiology, PC, Missoula, Montana
| | - Ryan E Lauer
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California
| | - Nancy A Nussmeier
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Joseph V Petty
- CHI Health Clinic Physician Enterprise Anesthesia, CHI Health Nebraska Heart, Omaha, Nebraska
| | - G Burkhard Mackensen
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology & Pain Medicine, University of Washington Medical Center, Seattle, Washington
| | - David F Vener
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Miklos D Kertai
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.
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20
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Del Rio JM, Abernathy JJ, Taylor MA, Habib RH, Fernandez FG, Bollen BA, Lauer RE, Nussmeier NA, Glance LG, Petty JV, Mackensen GB, Vener DF, Kertai MD. The Adult Cardiac Anesthesiology Section of STS Adult Cardiac Surgery Database: 2020 Update on Quality and Outcomes. Ann Thorac Surg 2020; 110:1447-1460. [PMID: 33008569 DOI: 10.1016/j.athoracsur.2020.05.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 10/23/2022]
Abstract
The Society of Cardiovascular Anesthesiologists, in partnership with The Society of Thoracic Surgeons, has developed the Adult Cardiac Anesthesiology Section of the Adult Cardiac Surgery Database. The goal of this landmark collaboration is to advance clinical care, quality, and knowledge, and to demonstrate the value of cardiac anesthesiology in the perioperative care of cardiac surgical patients. Participation in the Adult Cardiac Anesthesiology Section has been optional since its inception in 2014 but has progressively increased. Opportunities for further growth and improvement remain. In this first update report on quality and outcomes of the Adult Cardiac Anesthesiology Section, we present an overview of the clinically significant anesthesia and surgical variables submitted between 2015 and 2018. Our review provides a summary of quality measures and outcomes related to the current practice of cardiothoracic anesthesiology. We also emphasize the potential for addressing high-impact research questions as data accumulate, with the overall goal of elucidating the influence of cardiac anesthesiology contributions to patient outcomes within the framework of the cardiac surgical team.
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Affiliation(s)
- J Mauricio Del Rio
- Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - James Jake Abernathy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark A Taylor
- Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert H Habib
- STS Research Center, The Society of Thoracic Surgeons, Chicago, Illinois
| | - Felix G Fernandez
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Bruce A Bollen
- International Heart Institute of Montana, Missoula Anesthesiology, PC, Missoula, Montana
| | - Ryan E Lauer
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California
| | - Nancy A Nussmeier
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Joseph V Petty
- CHI Health Clinic Physician Enterprise Anesthesia, CHI Health Nebraska Heart, Omaha, Nebraska
| | - G Burkhard Mackensen
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology & Pain Medicine, University of Washington Medical Center, Seattle, Washington
| | - David F Vener
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Miklos D Kertai
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.
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21
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Ochroch J, Usman A, Kiefer J, Pulton D, Shah R, Grosh T, Patel S, Vernick W, Gutsche JT, Raiten J. Reducing Opioid Use in Patients Undergoing Cardiac Surgery - Preoperative, Intraoperative, and Critical Care Strategies. J Cardiothorac Vasc Anesth 2020; 35:2155-2165. [PMID: 33069556 DOI: 10.1053/j.jvca.2020.09.103] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/01/2020] [Accepted: 09/09/2020] [Indexed: 02/08/2023]
Abstract
Patients undergoing cardiothoracic surgery are exposed to opioids in the operating room and intensive care unit and after hospital discharge. Opportunities exist to reduce perioperative opioid use at all stages of care and include alternative oral and intravenous medications, novel intraoperative regional anesthetic techniques, and postoperative opioid-sparing sedative and analgesic strategies. In this review, currently used and investigational strategies to reduce the opioid burden for cardiothoracic surgical patients are explored.
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Affiliation(s)
- Jason Ochroch
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Asad Usman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jesse Kiefer
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Danielle Pulton
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ro Shah
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Taras Grosh
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Saumil Patel
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - William Vernick
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jesse Raiten
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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22
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Stefanos R, Graziella D'A, Giovanni T. Methodological aspects of superiority, equivalence, and non-inferiority trials. Intern Emerg Med 2020; 15:1085-1091. [PMID: 32705494 DOI: 10.1007/s11739-020-02450-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/15/2020] [Indexed: 12/13/2022]
Abstract
Depending on the scientific hypothesis to be addressed, randomized-controlled trials (RCT) are accordingly designed. RCTs that aim to determine whether a novel, experimental therapeutic intervention (either a drug or a treatment) is superior to a placebo or control intervention, are called superiority trials. Less common are the non-inferiority RCTs, designed to assess whether a new intervention is not unacceptably worse than an already existing reference intervention. An equivalence RCT is designed to investigate whether a novel treatment is equivalently effective to another, already existing, control intervention. In equivalence and non-inferiority RCTs, the efficacy of the reference intervention (active comparator) is already established, and therefore, an untreated control group would not be ethical. In this review, using a series of examples derived from equivalence and non-inferiority/superiority RCTs, we describe the main differences and methodological aspects among these three different types of RCTs.
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Affiliation(s)
- Roumeliotis Stefanos
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, School of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, St. Kyriakidi 1, 54636, Thessaloniki, Greece.
- Institute of Clinical Physiology (IFC-CNR), Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Ospedali Riuniti, via Vallone Petrara, Reggio Calabria, Italy.
| | - D 'Arrigo Graziella
- Institute of Clinical Physiology (IFC-CNR), Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Ospedali Riuniti, via Vallone Petrara, Reggio Calabria, Italy
| | - Tripepi Giovanni
- Institute of Clinical Physiology (IFC-CNR), Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Ospedali Riuniti, via Vallone Petrara, Reggio Calabria, Italy
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23
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Grant MC, Isada T, Ruzankin P, Whitman G, Lawton JS, Dodd-o J, Barodka V, Grant MC, Isada T, Ibekwe S, Mihocsa AB, Ruzankin P, Gottschalk A, Liu C, Whitman G, Lawton JS, Mandal K, Dodd-o J, Barodka V. Results from an enhanced recovery program for cardiac surgery. J Thorac Cardiovasc Surg 2020; 159:1393-1402.e7. [DOI: 10.1016/j.jtcvs.2019.05.035] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 04/19/2019] [Accepted: 05/10/2019] [Indexed: 11/29/2022]
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Mattern HP, Reichert JC, McConnell KJ. The Effect of Intravenous Acetaminophen on Patient Outcomes within a Large Integrated Delivery Network. Pharmacotherapy 2020; 40:301-307. [PMID: 31994206 DOI: 10.1002/phar.2372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To evaluate the impact of intravenous acetaminophen on patient outcomes. METHODS In this retrospective observational analysis, 54,742 patients were identified from 19 Catholic Health Initiatives hospitals during a 12-month period. Charges were used to identify patients who received intravenous acetaminophen during their encounter. The control group included patients who did not receive intravenous acetaminophen. Five outcomes were measured: total length of stay, intensive care unit (ICU) length of stay, total narcotic use (in morphine milligram equivalents [MME]), likelihood of receiving a narcotic prescription at discharge, and 30-day readmission rate. Patients undergoing five procedures were evaluated: total knee replacements, total hip replacements, cesarean section, coronary artery bypass graft (CABG), and gallbladder resection. These patients were also evaluated in a combined group. RESULTS After matching, population imbalances for patient characteristics were addressed. Combined with the five outcomes, 25 populations had a sufficient number of matched pairs for analysis. Six of the 25 tests showed a significant difference favoring the control group. Total length of stay was shorter for the control group in the combined population (-0.18 days [4 hours], 95% confidence interval (CI) -0.26 to -0.11). Total narcotic use was lower for the control group in the caesarean section (-10 MME, 95% CI -16 to -5), CABG (-26 MME, 95% CI -41 to -12), and combined (-13 MME, 95% CI -16 to -11) populations. The control group was less likely to be discharged with a narcotic prescription for the caesarean section (odds ratio (OR) -1.39, 95% CI -1.00 to -1.92) and combined (OR -1.14, 95% CI -1.04 to -1.24) populations. CONCLUSIONS Intravenous acetaminophen was not associated with improvement in the following patient outcomes: total length of stay, ICU length of stay, total narcotic use, likelihood of receiving a discharge narcotic prescription, and 30-day readmission rate. Based on these findings, clinicians may reconsider the routine use of intravenous acetaminophen.
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Intravenous Acetaminophen Reduces Length of Stay Via Mediation of Postoperative Opioid Consumption After Posterior Spinal Fusion in a Pediatric Cohort. Clin J Pain 2019; 34:593-599. [PMID: 29200016 DOI: 10.1097/ajp.0000000000000576] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Since approval of intravenous acetaminophen (IV APAP), its use has become quite common without strong positive evidence. Our goal was to determine the effect of IV APAP on length of hospital stay (LOS) via mediation of opioid-related side effects in pediatric patients. MATERIALS AND METHODS After Institutional Review Board approval, 114 adolescents undergoing posterior spinal fusion were prospectively recruited and managed postoperatively with patient-controlled analgesia and adjuvant therapy. Patients were divided into 2 groups based on the use of IV APAP: control (n=70) and treatment (n=44). Association of IV APAP use with opioid outcomes was analyzed using inverse probability of treatment weighting (IPTW)-adjusted propensity scores to balance the 2 groups for all significant covariates except postoperative opioid consumption. Mediation analysis was carried out for LOS with IV APAP as the independent variable and morphine consumption as the mediator. RESULTS Oral intake was delayed by ∼1 day (P<0.001) and LOS was 0.6 days longer in the control group (P=0.044). After IPTW, time to oral intake remained significantly longer in the control group (P=0.014). The mediation model with IPTW revealed a significant negative association between IV APAP and morphine consumption (P<0.001), which significantly increased LOS (P<0.003). IV APAP had a significant opioid-sparing effect associated with shorter LOS. DISCUSSION IV APAP hastens oral intake and is associated with decreased LOS in an adolescent surgery population likely through decreased opioid consumption. Through addition of IV APAP in this population, LOS may be decreased, an important implication in the setting of escalating health care costs.
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Weingarten TN, Taenzer AH, Elkassabany NM, Le Wendling L, Nin O, Kent ML. Safety in Acute Pain Medicine-Pharmacologic Considerations and the Impact of Systems-Based Gaps. PAIN MEDICINE 2019; 19:2296-2315. [PMID: 29727003 DOI: 10.1093/pm/pny079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective In the setting of an expanding prevalence of acute pain medicine services and the aggressive use of multimodal analgesia, an overview of systems-based safety gaps and safety concerns in the setting of aggressive multimodal analgesia is provided below. Setting Expert commentary. Methods Recent evidence focused on systems-based gaps in acute pain medicine is discussed. A focused literature review was conducted to assess safety concerns related to commonly used multimodal pharmacologic agents (opioids, nonsteroidal anti-inflammatory drugs, gabapentanoids, ketamine, acetaminophen) in the setting of inpatient acute pain management. Conclusions Optimization of systems-based gaps will increase the probability of accurate pain assessment, improve the application of uniform evidence-based multimodal analgesia, and ensure a continuum of pain care. While acute pain medicine strategies should be aggressively applied, multimodal regimens must be strategically utilized to minimize risk to patients and in a comorbidity-specific fashion.
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Affiliation(s)
- Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Andreas H Taenzer
- Departments of Anesthesiology.,Pediatrics, The Dartmouth Institute, Dartmouth Hitchcock Medical Center, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Nabil M Elkassabany
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda Le Wendling
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Olga Nin
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Michael L Kent
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
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Routine intravenous acetaminophen for postcardiac surgery analgesia: High costs and questionable benefits. J Thorac Cardiovasc Surg 2019; 153:149. [PMID: 27986252 DOI: 10.1016/j.jtcvs.2016.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 09/08/2016] [Indexed: 11/22/2022]
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Takeda Y, Fukunishi S, Nishio S, Yoshiya S, Hashimoto K, Simura Y. Evaluating the Effect of Intravenous Acetaminophen in Multimodal Analgesia After Total Hip Arthroplasty: A Randomized Controlled Trial. J Arthroplasty 2019; 34:1155-1161. [PMID: 30898388 DOI: 10.1016/j.arth.2019.02.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 02/13/2019] [Accepted: 02/15/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Postoperative pain is a significant concern of patients before surgery. Multimodal pain management is an effective method of pain control after major orthopedic surgery. Acetaminophen is the most commonly used analgesic for the management of pain. It was hypothesized that 1000 mg of intravenous acetaminophen (IA) dosed every 6 hours would significantly reduce the postoperative pain score at rest and the opioid consumption volume in patients who would undergo total hip arthroplasty (THA) when compared to a control group. METHODS A single-center, prospective, open-label randomized control study was conducted. A total of 97 patients undergoing unilateral primary THA were divided into 2 groups: the study group (IA) (n = 45) and the control group (n = 52). The study group received administered IA after surgery, while the control group received only a standard pain control. Both groups received a preoperative femoral nerve block and postoperative intravenous fentanyl citrate. The primary outcome was the evaluation of the pain score at rest 24 hours after surgery. The pain score was measured using the Numerical Rating Scale. The primary outcome of this study was analyzed using generalized estimating equation. RESULTS The IA group had a significant improvement in Numerical Rating Scale score at rest 24 hours after THA compared to the control group (-0.91, 95% confidence interval -1.56 to -0.26, P = .006), suggesting a positive effect of IA usage for pain relief. The total fentanyl citrate consumption after surgery for 24 hours was significantly lower in the IA group than those of the control group (52.07 ± 7.64 vs 57.83 ± 12.44 mg, P < .001). CONCLUSION Postoperative administration of IA significantly reduced the postoperative pain score and opioid consumption volume after primary THA. IA was useful as one role of multimodal pain management after THA. LEVEL OF EVIDENCE Level 2.
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Affiliation(s)
- Yu Takeda
- Department of Orthopedic Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Shigeo Fukunishi
- Department of Orthopedic Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Shoji Nishio
- Department of Orthopedic Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Shinichi Yoshiya
- Department of Orthopedic Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Kazuma Hashimoto
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yuka Simura
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
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Nguyen LP, Nguyen L, Austin JP. A Quality Improvement Initiative to Decrease Inappropriate Intravenous Acetaminophen Use at an Academic Medical Center. Hosp Pharm 2019; 55:253-260. [PMID: 32742014 DOI: 10.1177/0018578719841054] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background: Following availability in the United States in 2011, intravenous acetaminophen (IV APAP) was added to many hospital formularies for multimodal pain control. In 2014, the price of IV APAP increased from $12/g to $33/g and became a top 10 medication expenditure at our institution. Objective: To promote appropriate IV APAP prescribing and reduce costs. Design, Setting, Participants: Quality improvement project at a 562-bed academic medical center involving all inpatient admissions from 2010 to 2017. Interventions: Using Plan-Do-Study-Act (PDSA) methodology, our Pharmacy & Therapeutics (P&T) committee aimed to reduce inappropriate use of IV APAP by refinement of restriction criteria, development of clinical decision support in the electronic medical record, education of clinical staff on appropriate use, and empowerment of hospital pharmacists to enforce restrictions. Measurements: Monthly IV APAP utilization and spending were assessed using statistical process control charts. Balancing measures included monthly usage of IV opioid, IV ketorolac, and oral ibuprofen. Results: Five PDSA cycles were conducted during the study period. Monthly spending on IV APAP decreased from the highest average of $56 038 per month to $5822 per month at study conclusion. Interventions resulted in an 80% annual cost savings, or an approximate savings of $600 000 per year. Usage of IV opioids, IV ketorolac, and oral ibuprofen showed no major changes during the study period. Conclusions: IV APAP can be restricted in a safe and cost effective manner without concomitant increase in IV opioid use.
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Affiliation(s)
| | - Lam Nguyen
- Oregon Health & Science University, Portland, USA
- Doernbecher Children's Hospital, Portland, OR, USA
| | - Jared P Austin
- Oregon Health & Science University, Portland, USA
- Doernbecher Children's Hospital, Portland, OR, USA
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Subramaniam B, Shankar P, Shaefi S, Mueller A, O’Gara B, Banner-Goodspeed V, Gallagher J, Gasangwa D, Patxot M, Packiasabapathy S, Mathur P, Eikermann M, Talmor D, Marcantonio ER. Effect of Intravenous Acetaminophen vs Placebo Combined With Propofol or Dexmedetomidine on Postoperative Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial. JAMA 2019; 321:686-696. [PMID: 30778597 PMCID: PMC6439609 DOI: 10.1001/jama.2019.0234] [Citation(s) in RCA: 169] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 01/16/2019] [Indexed: 01/04/2023]
Abstract
Importance Postoperative delirium is common following cardiac surgery and may be affected by choice of analgesic and sedative. Objective To evaluate the effect of postoperative intravenous (IV) acetaminophen (paracetamol) vs placebo combined with IV propofol vs dexmedetomidine on postoperative delirium among older patients undergoing cardiac surgery. Design, Setting, and Participants Randomized, placebo-controlled, factorial clinical trial among 120 patients aged 60 years or older undergoing on-pump coronary artery bypass graft (CABG) surgery or combined CABG/valve surgeries at a US center. Enrollment was September 2015 to April 2018, with follow-up ending in April 2019. Interventions Patients were randomized to 1 of 4 groups receiving postoperative analgesia with IV acetaminophen or placebo every 6 hours for 48 hours and postoperative sedation with dexmedetomidine or propofol starting at chest closure and continued for up to 6 hours (acetaminophen and dexmedetomidine: n = 29; placebo and dexmedetomidine: n = 30; acetaminophen and propofol: n = 31; placebo and propofol: n = 30). Main Outcomes and Measures The primary outcome was incidence of postoperative in-hospital delirium by the Confusion Assessment Method. Secondary outcomes included delirium duration, cognitive decline, breakthrough analgesia within the first 48 hours, and ICU and hospital length of stay. Results Among 121 patients randomized (median age, 69 years; 19 women [15.8%]), 120 completed the trial. Patients treated with IV acetaminophen had a significant reduction in delirium (10% vs 28% placebo; difference, -18% [95% CI, -32% to -5%]; P = .01; HR, 2.8 [95% CI, 1.1-7.8]). Patients receiving dexmedetomidine vs propofol had no significant difference in delirium (17% vs 21%; difference, -4% [95% CI, -18% to 10%]; P = .54; HR, 0.8 [95% CI, 0.4-1.9]). There were significant differences favoring acetaminophen vs placebo for 3 prespecified secondary outcomes: delirium duration (median, 1 vs 2 days; difference, -1 [95% CI, -2 to 0]), ICU length of stay (median, 29.5 vs 46.7 hours; difference, -16.7 [95% CI, -20.3 to -0.8]), and breakthrough analgesia (median, 322.5 vs 405.3 µg morphine equivalents; difference, -83 [95% CI, -154 to -14]). For dexmedetomidine vs propofol, only breakthrough analgesia was significantly different (median, 328.8 vs 397.5 µg; difference, -69 [95% CI, -155 to -4]; P = .04). Fourteen patients in both the placebo-dexmedetomidine and acetaminophen-propofol groups (46% and 45%) and 7 in the acetaminophen-dexmedetomidine and placebo-propofol groups (24% and 23%) had hypotension. Conclusions and Relevance Among older patients undergoing cardiac surgery, postoperative scheduled IV acetaminophen, combined with IV propofol or dexmedetomidine, reduced in-hospital delirium vs placebo. Additional research, including comparison of IV vs oral acetaminophen and other potentially opioid-sparing analgesics, on the incidence of postoperative delirium is warranted. Trial Registration ClinicalTrials.gov Identifier: NCT02546765.
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Affiliation(s)
- Balachundhar Subramaniam
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Puja Shankar
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ariel Mueller
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Brian O’Gara
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Valerie Banner-Goodspeed
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jackie Gallagher
- Department of Medicine, Division of Gerontology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Doris Gasangwa
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Melissa Patxot
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Senthil Packiasabapathy
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Pooja Mathur
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Daniel Talmor
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Edward R. Marcantonio
- Department of Medicine, Division of Gerontology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Scheduled Intravenous Acetaminophen Improves Patient Satisfaction With Postcraniotomy Pain Management: A Prospective, Randomized, Placebo-controlled, Double-blind Study. J Neurosurg Anesthesiol 2018; 30:231-236. [PMID: 29117012 DOI: 10.1097/ana.0000000000000461] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Postcraniotomy pain can be difficult to manage with opioids due to opioid-related side effects, including drowsiness, nausea/vomiting, confusion, and pupillary changes, potentially masking the signs of postoperative neurological deterioration. Intravenous (IV) acetaminophen, a nonopioid analgesic, has been reported to have opioid-sparing effects after abdominal and orthopedic surgeries. This study investigates whether IV acetaminophen has similar effects after craniotomy. MATERIALS AND METHODS In this prospective, randomized, placebo-controlled, double-blind clinical trial, 100 adult patients scheduled to undergo supratentorial craniotomy for excision of a brain mass were randomized to receive either IV acetaminophen or placebo preincision and then every 6 hours for a total of 24 hours after surgery. Total 24-hour opioid consumption, pain scores, satisfaction with overall pain management, time to meet postanesthesia care unit discharge criteria, and incidence of opioid-related side effects were compared. RESULTS There was no difference in the 24-hour postoperative opioid consumption in morphine equivalents between the IV acetaminophen group (median, 11 mg; n=45) and the placebo group (median, 10.1 mg; n=41). No statistically significant difference of visual analog scale pain score was observed between 2 treatment groups. Patient satisfaction with overall postoperative pain management was significantly higher in the IV acetaminophen group than the placebo group on a 1 to 10 scale (8.1±0.4 vs. 6.9±0.4; P=0.03). There was no significant difference in secondary outcomes, including the incidence of opioid-related side effects. CONCLUSIONS IV acetaminophen, as adjunctive therapy for craniotomy procedures, did not show an opioid-sparing effect in patients for the 24 hours after craniotomy; however, it was associated with improved patient satisfaction regarding overall pain control.
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A Review of Perioperative Analgesic Strategies in Cardiac Surgery. Int Anesthesiol Clin 2018; 56:e56-e83. [PMID: 30204605 DOI: 10.1097/aia.0000000000000200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Age and pain as predictors of discomfort in patients undergoing transfemoral percutaneous coronary interventions. Heart Lung 2018; 47:576-583. [PMID: 30093164 DOI: 10.1016/j.hrtlng.2018.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 06/14/2018] [Accepted: 07/04/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Transfemoral percutaneous coronary intervention (PCI) requires strict bed rest, causing pain and discomfort in patients. However, no studies have investigated this issue. OBJECTIVES To investigate the predictors of discomfort in transfemoral PCI patients. METHODS A cross-sectional sample of 110 patients from two coronary care units completed questionnaires on demographic and clinical characteristics, visual analogue pain scale, and discomfort. RESULTS Eight factors predicted overall discomfort: physiologic pain, physiological discomfort, psychological discomfort, analgesic use after sheath removal, hemostasis method, and bed rest duration. Psychological discomfort was associated with age, chronic obstructive pulmonary disease, analgesic use after sheath removal, successful hemostasis, and hematoma >5 cm. A hierarchical regression model explained 70.5% of the variance in overall discomfort. CONCLUSIONS Age and physiologic pain are major predictors of overall discomfort, especially in patients aged <60 years having high pain sensitivity. Critical care providers should note patients' physiological and psychological issues throughout the PCI process.
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Chiam E, Bellomo R, Churilov L, Weinberg L. The hemodynamic effects of intravenous paracetamol (acetaminophen) vs normal saline in cardiac surgery patients: A single center placebo controlled randomized study. PLoS One 2018; 13:e0195931. [PMID: 29659631 PMCID: PMC5901786 DOI: 10.1371/journal.pone.0195931] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 03/09/2018] [Indexed: 11/18/2022] Open
Abstract
The hemodynamic effects of intravenous (IV) paracetamol in patients undergoing cardiac surgery are unknown. We performed a prospective single center placebo controlled randomized study with parallel group design in adult patients undergoing elective cardiac surgery. Participants received paracetamol (1 gram) IV or placebo (an equal volume of 0.9% saline) preoperatively followed by two postoperative doses 6 hours apart. The primary endpoint was the absolute change in systolic (SBP) 30 minutes after the preoperative infusion, analysed using an ANCOVA model. Secondary endpoints included absolute changes in mean arterial pressure (MAP) and diastolic blood pressure (DPB), and other key hemodynamic variables after each infusion. All other endpoints were analysed using random-effect generalized least squares regression modelling with individual patients treated as random effects. Fifty participants were randomly assigned to receive paracetamol (n = 25) or placebo (n = 25). Post preoperative infusion, paracetamol decreased SBP by a mean (SD) of 13 (18) mmHg, p = 0.02, compared to a mean (SD) of 1 (11) mmHg with saline. Paracetamol decreased MAP and DBP by a mean (SD) of 9 (12) mmHg and 8 (9) mmHg (p = 0.01 and 0.02), respectively, compared to a mean (SD) of 1 (8) mmHg and 0 (6) mmHg with placebo. Postoperatively, there were no significant differences in pressure or flow based hemodynamic parameters in both groups. This study provides high quality evidence that the administration of IV paracetamol in patients undergoing cardiac surgery causes a transient decrease in preoperative blood pressure when administered before surgery but no adverse hemodynamic effects when administered in the postoperative setting.
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Affiliation(s)
- Elizabeth Chiam
- Department of Surgery, The University of Melbourne, Austin Hospital, Heidelberg, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia
| | - Leonid Churilov
- The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Victoria, Australia
| | - Laurence Weinberg
- Department of Surgery, The University of Melbourne, Austin Hospital, Heidelberg, Victoria, Australia
- Anesthesia, Perioperative and Pain Medicine, The University of Melbourne, Victoria, Australia
- * E-mail:
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Therapeutic Advances in the Management of Older Adults in the Intensive Care Unit: A Focus on Pain, Sedation, and Delirium. Am J Ther 2018. [DOI: 10.1097/mjt.0000000000000685] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Turan A, Karimi N, Zimmerman NM, Mick SL, Sessler DI, Mamoun N. Intravenous Acetaminophen Does Not Decrease Persistent Surgical Pain After Cardiac Surgery. J Cardiothorac Vasc Anesth 2017; 31:2058-2064. [DOI: 10.1053/j.jvca.2017.05.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Indexed: 11/11/2022]
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Sousa-Uva M, Head SJ, Milojevic M, Collet JP, Landoni G, Castella M, Dunning J, Gudbjartsson T, Linker NJ, Sandoval E, Thielmann M, Jeppsson A, Landmesser U. 2017 EACTS Guidelines on perioperative medication in adult cardiac surgery. Eur J Cardiothorac Surg 2017; 53:5-33. [PMID: 29029110 DOI: 10.1093/ejcts/ezx314] [Citation(s) in RCA: 247] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Khelemsky Y, Evans AS. Pain in the ICU; Can We Adequately Treat What We Can't Hear? J Cardiothorac Vasc Anesth 2017; 31:1153-1154. [PMID: 28800980 DOI: 10.1053/j.jvca.2017.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Yury Khelemsky
- Department of Anesthesiology, Perioperative & Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Adam S Evans
- Department of Anesthesiology, Perioperative & Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Cardiothoracic Surgery, Perioperative & Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Mamoun NF. Intravenous acetaminophen: Can the benefit outweigh the cost in selected patients? J Thorac Cardiovasc Surg 2016; 153:149-150. [PMID: 27986251 DOI: 10.1016/j.jtcvs.2016.09.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 09/23/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Negmeldeen F Mamoun
- Departments of Cardiothoracic Anesthesia and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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