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Costa GB, Ferreira LA, Delgado MA, Soares AN, Junior CJC. Preoperative Gabapentin for Pain Control: A Randomized, Placebo-controlled Clinical Trial in Patients Undergoing Inguinal Hernioplasty. J Perianesth Nurs 2024:S1089-9472(24)00036-4. [PMID: 38935013 DOI: 10.1016/j.jopan.2024.01.018] [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: 08/16/2023] [Revised: 01/18/2024] [Accepted: 01/21/2024] [Indexed: 06/28/2024]
Abstract
PURPOSE The perioperative use of gabapentin has been suggested to reduce postoperative pain and opioid consumption. However, there is a variation in clinical practice, the type of surgery and the administration time seem to be distinct between the available studies. We assess whether gabapentin administered before surgery reduces postoperative pain in patients who have undergone inguinal hernioplasty. DESIGN This is a double-blind, randomized, and placebo-controlled trial. METHODS Seventy-seven patients scheduled for inguinal hernioplasty were randomized in two groups to receive gabapentin (900 mg) or placebo in the perioperative period. The primary outcome was analgesia measured by visual analog scale up to 30 days after surgery. The secondary outcomes such as morphine consumption, nausea, headache, and sedation have been also described. FINDINGS Patients who received gabapentin had lower postoperative pain scores compared to the control group, P < .001. The postoperative morphine use was significantly lower in the gabapentin (5.3%) versus placebo group (74.4%), P < .001. No significant difference between groups was observed for the occurrence of adverse events. CONCLUSIONS The perioperative administration of gabapentin was effective in reducing postoperative pain and had an important effect in decreasing morphine use. Together, our data reveal a long-lasting opioid-sparing effect of gabapentin in patients who underwent inguinal hernioplasty.
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Affiliation(s)
- Glaucio Boechat Costa
- Programa de Pós Graduação em Ciências da Saúde, Faculdade de Saúde Santa Casa BH, Belo Horizonte, Minas Gerais, Brazil
| | - Luana Assis Ferreira
- Programa de Pós Graduação em Ciências da Saúde, Faculdade de Saúde Santa Casa BH, Belo Horizonte, Minas Gerais, Brazil
| | - Marina Ayres Delgado
- Hospital das Clínicas de Belo Horizonte, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| | - Aleida Nazareth Soares
- Programa de Pós Graduação em Ciências da Saúde, Faculdade de Saúde Santa Casa BH, Belo Horizonte, Minas Gerais, Brazil
| | - Célio José Castro Junior
- Programa de Pós Graduação em Ciências da Saúde, Faculdade de Saúde Santa Casa BH, Belo Horizonte, Minas Gerais, Brazil
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2
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Giakas JA, Israel HA, Ali AH, Kaar SG. Does the addition of post-operative gabapentin reduce the use of narcotics after orthopedic surgery? PHYSICIAN SPORTSMED 2024; 52:283-290. [PMID: 37545473 DOI: 10.1080/00913847.2023.2246177] [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: 05/25/2023] [Revised: 07/27/2023] [Accepted: 08/06/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVES To evaluate the efficacy of post-operative gabapentin administration as an analgesic agent and its effect on narcotic use after orthopedic surgery in an outpatient sports medicine practice by comparing patients prior to and after initiating the routine use of gabapentin as part of a standardized post-operative pain medication regimen. We hypothesized that adding gabapentin to a multimodal post-operative pain regimen would decrease the number of requested pain medication refills and have no detrimental effect on Visual Analogue Scale and Single Assessment Numerical Evaluation scores at these early post-operative visits. METHODS All outpatient surgical patients, <90 years of age, undergoing outpatient orthopedic surgery by the study's senior author were included between 08/05/2021 and 02/22/2022. Patients were allowed 1 narcotic refill post-operatively and only in the first 3 weeks. The primary outcome was difference in percentage of patients who requested a narcotic refill within 3 weeks post-op. Two- and 6-week Visual Analogue Scale and Single Assessment Numerical Evaluation scores, and baseline health and demographic data. T-tests were run on continuous variables, Chi-Square or Fisher's Exact Test were run on dichotomous variables, and Mann-Whitney U test was run on all other categorical variables. Statistical significance was set at P < .05 for all tests. RESULTS There was a significant difference in narcotic refills at 3 weeks: 23 pre-gabapentin patients and 9 post-gabapentin patients (22.8% vs 9.0%, respectively: P = .006). There were no differences between 2- and 6-week Visual Analogue Scale and 2-week Single Assessment Numerical Evaluation scores. There was a significant difference in 6-week SANE between groups: mean difference = 6.4 (P = .027) though less than the established MCID. CONCLUSION Addition of gabapentin to a post-operative multimodal pain regimen reduced the use of narcotics after orthopedic sports medicine surgeries while also providing equivalent pain control.
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Affiliation(s)
- Julian A Giakas
- Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Heidi A Israel
- Department of Orthopedic Surgery, Division of Sports Medicine and Shoulder Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Ashley H Ali
- Department of Orthopedic Surgery, Division of Sports Medicine and Shoulder Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Scott G Kaar
- Department of Orthopedic Surgery, Division of Sports Medicine and Shoulder Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
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3
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Turk R, Hamid N. Postoperative Pain Control Following Shoulder Arthroplasty: Rethinking the Need for Opioids. Orthop Clin North Am 2023; 54:453-461. [PMID: 37718084 DOI: 10.1016/j.ocl.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
The use of opioid pain medication regimens to control perioperative pain has led to significant patient and societal consequences. There are several alternative, opioid-sparing and opioid-minimizing pain regimens that have been shown to provide equal, if not superior, pain relief with fewer secondary consequences. This article provides an in-depth review of the current evidence regarding efficacy, safety, and feasibility of a perioperative opioid-sparing clinical pathway for patients undergoing shoulder arthroplasty.
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Affiliation(s)
- Robby Turk
- Atrium Health Musculoskeletal Institute, Charlotte, NC, USA; Atrium Health, Carolinas Medical Center, 1000 Blythe Boulevard, Charlotte, NC 28203, USA.
| | - Nady Hamid
- Atrium Health Musculoskeletal Institute, Charlotte, NC, USA; Atrium Health, Carolinas Medical Center, 1000 Blythe Boulevard, Charlotte, NC 28203, USA; OrthoCarolina, Charlotte, NC, USA
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Osman BM, Tieu TG, Caceres YG, Hernandez VH. Current Trends and Future Directions for Outpatient Total Joint Arthroplasty: A Review of the Anesthesia Choices and Analgesic Options. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202309000-00001. [PMID: 37669101 PMCID: PMC10481314 DOI: 10.5435/jaaosglobal-d-22-00259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 07/11/2023] [Indexed: 09/06/2023]
Abstract
The aging population and the obesity epidemic have led to an increased rate of joint arthroplasty procedures, specifically total knee arthroplasty and total hip arthroplasty. These surgeries are associated with increased hospital length of stay and, consequently, higher costs. Despite the benefits of outpatient surgery, only a small percentage of total joint arthroplasties (TJAs) are done in this manner. We reviewed the most up-to-date trends for outpatient TJA and discussed essential factors for a successful outpatient program, including the proper patient selection process and best available anesthetic and analgesic options, along with their risks and benefits. Risk stratification tools, such as the Outpatient Arthroplasty Risk Assessment, are helpful for predicting outcomes regarding outpatient TJA, and neuraxial anesthesia should be considered to minimize complications and facilitate early discharge. A multimodal analgesia regimen could be effective for pain management in outpatient TJA, and the currently recommended peripheral nerve blocks for total hip arthroplasty and total knee arthroplasty are the fascia iliaca compartment block and adductor canal block, respectively. However, blocks should be carefully considered for outpatient procedures. Enhanced recovery after surgery (ERAS) protocols help to guide perioperative care teams and allow for improved patient recovery, decreased length of stay, and increased patient satisfaction.
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Affiliation(s)
- Brian M. Osman
- From the Perioperative Medicine and Pain Management, University of Miami Health System, University of Miami Miller School of Medicine, Miami, FL (Dr. Osman, Dr. Caceres, and Dr. Hernandez); Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL (Dr. Tieu)
| | - Tuan G. Tieu
- From the Perioperative Medicine and Pain Management, University of Miami Health System, University of Miami Miller School of Medicine, Miami, FL (Dr. Osman, Dr. Caceres, and Dr. Hernandez); Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL (Dr. Tieu)
| | - Yosira Guevara Caceres
- From the Perioperative Medicine and Pain Management, University of Miami Health System, University of Miami Miller School of Medicine, Miami, FL (Dr. Osman, Dr. Caceres, and Dr. Hernandez); Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL (Dr. Tieu)
| | - Victor H. Hernandez
- From the Perioperative Medicine and Pain Management, University of Miami Health System, University of Miami Miller School of Medicine, Miami, FL (Dr. Osman, Dr. Caceres, and Dr. Hernandez); Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL (Dr. Tieu)
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Berardino K, Carroll AH, Ricotti R, Popovsky D, Civilette MD, Urits I, Viswanath O, Sherman WF, Kaye AD. The Ramifications of Opioid Utilization and Outcomes of Alternative Pain Control Strategies for Total Knee Arthroplasties. Orthop Rev (Pavia) 2022; 14:37496. [PMID: 36045694 DOI: 10.52965/001c.37496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Morbidity and mortality related to opioid use has generated a public health crisis in the United States. Total knee arthroplasty (TKA) is an increasingly common procedure and is often accompanied by post-operative opioid utilization. Unfortunately, post-operative opioid usage after TKA has been shown to lead to higher rates of complications, longer hospital stays, increased costs, and more frequent need for revision surgery. Pre-operative opioid utilization has been shown to be one of the most important predictors of post-operative opioid usage. Additional risk factors for continued post-operative opioid utilization after TKA include pre-operative substance and tobacco use as well as higher post-operative prescription dosages, younger age, female gender, and Medicaid insurance. One method for mitigating excessive post-operative opioid utilization are Enhanced Recovery After Surgery (ERAS) protocols, which include a multidisciplinary approach that focuses on perioperative factors to optimize patient recovery and function after surgery. Additional strategies include multimodal pain regimens with epidural anesthetics, extended duration local anesthetics and adjuvants, and ultrasound guided peripheral nerve blocks. In recent years, opioid prescribing duration limitations have also been put into place by state and federal government, hospital systems, and ambulatory surgery centers making effective acute pain management imperative for all stakeholders. In this regard, as rates of TKA continue to increase across the United States, multidisciplinary efforts by all stakeholders are needed to ensure adequate pain control while preventing the negative sequalae of opioid medications.
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Affiliation(s)
| | | | | | | | | | - Ivan Urits
- Department of Anesthesiology, Louisiana State University Health Science Center Shreveport
| | - Omar Viswanath
- Innovative Pain and Wellness; Department of Anesthesiology, Creighton University School of Medicine
| | | | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Science Center Shreveport
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6
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Lavand'homme PM, Kehlet H, Rawal N, Joshi GP. Pain management after total knee arthroplasty: PROcedure SPEcific Postoperative Pain ManagemenT recommendations. Eur J Anaesthesiol 2022; 39:743-757. [PMID: 35852550 PMCID: PMC9891300 DOI: 10.1097/eja.0000000000001691] [Citation(s) in RCA: 70] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The PROSPECT (PROcedure SPEcific Postoperative Pain ManagemenT) Working Group is a global collaboration of surgeons and anaesthesiologists formulating procedure-specific recommendations for pain management after common operations. Total knee arthroplasty (TKA) is associated with significant postoperative pain that is difficult to treat. Nevertheless, pain control is essential for rehabilitation and to enhance recovery. OBJECTIVE To evaluate the available literature and develop recommendations for optimal pain management after unilateral primary TKA. DESIGN A narrative review based on published systematic reviews, using modified PROSPECT methodology. DATA SOURCES A literature search was performed in EMBASE, MEDLINE, PubMed and Cochrane Databases, between January 2014 and December 2020, for systematic reviews and meta-analyses evaluating analgesic interventions for pain management in patients undergoing TKA. ELIGIBILITY CRITERIA Each randomised controlled trial (RCT) included in the selected systematic reviews was critically evaluated and included only if met the PROSPECT requirements. Included studies were evaluated for clinically relevant differences in pain scores, use of nonopioid analgesics, such as paracetamol and nonsteroidal anti-inflammatory drugs and current clinical relevance. RESULTS A total of 151 systematic reviews were analysed, 106 RCTs met PROSPECT criteria. Paracetamol and nonsteroidal anti-inflammatory or cyclo-oxygenase-2-specific inhibitors are recommended. This should be combined with a single shot adductor canal block and peri-articular local infiltration analgesia together with a single intra-operative dose of intravenous dexamethasone. Intrathecal morphine (100 μg) may be considered in hospitalised patients only in rare situations when both adductor canal block and local infiltration analgesia are not possible. Opioids should be reserved as rescue analgesics in the postoperative period. Analgesic interventions that could not be recommended were also identified. CONCLUSION The present review identified an optimal analgesic regimen for unilateral primary TKA. Future studies to evaluate enhanced recovery programs and specific challenging patient groups are needed.
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Affiliation(s)
- Patricia M Lavand'homme
- From the Department of Anaesthesiology and Perioperative Pain Service, Cliniques Universitaires St Luc, University Catholic of Louvain (UCL), Brussels, Belgium (PML), Section of Surgical Pathophysiology 7621, Rigshospitalet, Copenhagen, Denmark (HK), Department of Anaesthesiology, Orebro University, Orebro, Sweden (NR) and Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, United States (GPJ)
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Pinsornsak P, Sukkarnkosol S, Boontanapibul K. Does Nefopam Provide Analgesic Effect and Reduce Morphine Consumption After Primary Total Knee Arthroplasty? A Prospective, Double-Blind, Randomized Controlled Trial. J Arthroplasty 2022; 37:845-850. [PMID: 35121091 DOI: 10.1016/j.arth.2022.01.079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND One of the most undesirable results after total knee arthroplasty (TKA) is severe immediate postoperative pain, resulting in patient dissatisfaction. We aimed to evaluate nefopam's analgesic efficacy after primary TKA along with related outcomes, including morphine consumption and adverse events. METHODS We conducted a double-blind, randomized controlled trial of patients undergoing unilateral primary TKA, comparing 24 hours of 80 mg of continuous intravenous nefopam to placebo infusion. A 100-mm Visual Analog Scale (VAS) for pain-at-rest and in-motion ≤48 hours was the primary outcome measure. Secondary outcomes were morphine and antiemetic consumption, adverse events, and functional outcomes: time-to-walk, timed up-and-go test, postoperative knee range of motion at 24 and 48 hours, time-to-discharge, and patient satisfaction scores. RESULTS Patients in the nefopam group had significantly lower VAS at rest 6 hours postop (20.3 ± 27.3 vs 35 ± 24.3, P = .01). Other timepoints and in-motion VAS did not significantly differ. Total morphine consumption (0-48 hours) was 37% less, significantly lower, in the nefopam group (5.3 ± 4.5 vs 8.4 ± 7.5 mg, P = .03). Antiemetic consumption was also 61% lower in the nefopam group but not statistically significant (0.8 ± 2.3 vs 2.0 ± 3.8 mg, P = .08). There were no variations in adverse events, functional outcomes, and satisfaction scores between groups. CONCLUSION Continuous nefopam administration as part of multimodal analgesia for 24 hours post-TKA produced a significant analgesic effect but only within the first 6 hours. However, there was a notable reduction in morphine use 48 hours postop. Nefopam is a useful agent for contemporary pain control after TKA. LEVEL OF EVIDENCE Therapeutic Level I.
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Affiliation(s)
- Piya Pinsornsak
- Department of Orthopaedic Surgery, Thammasat University, Pathum Thani, Thailand
| | | | - Krit Boontanapibul
- Department of Orthopaedic Surgery, Chulabhorn International College of Medicine Thammasat University, Pathum Thani, Thailand
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8
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Ishida Y, Okada T, Kobayashi T, Funatsu K, Uchino H. Pain Management of Acute and Chronic Postoperative Pain. Cureus 2022; 14:e23999. [PMID: 35547410 PMCID: PMC9086530 DOI: 10.7759/cureus.23999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2022] [Indexed: 12/04/2022] Open
Abstract
Inadequate management of acute postoperative pain is associated with effects related to both physiological and psychological function. Postoperative pain increases the risk of perioperative complications, so postoperative pain should be prevented. Postoperative pain management by sufficient analgesia is important while considering the use of various kinds of analgesics. Insufficient management of postoperative pain may lead to chronic postsurgical pain (CPSP). It is suggested that CPSP is dependent not only upon biological factors but also upon psychological factors, including the type of surgery, age, physical health, mental health, and preoperative pain. As CPSP is a severe complication that may prolong hospitalization and interferes with activities of daily living (ADL) and quality of life (QoL), its prevention of development is paramount. Therefore, in order to prevent the onset of CPSP, it is necessary to craft analgesic management to prevent CPSP during the perioperative period.
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9
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Lei Y, Huang Z, Huang Q, Pei F, Huang W. Dose optimization of intravenous dexamethasone for total knee arthroplasty: when two is not better than one. Arch Orthop Trauma Surg 2022; 142:665-672. [PMID: 33743063 DOI: 10.1007/s00402-021-03859-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/06/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND The optimal dose regimen of dexamethasone in total knee arthroplasty (TKA) has not been determined. This study was performed to evaluate the impact of a single preoperative high-dose dexamethasone compared with two perioperative low-dose dexamethasone in TKA. MATERIALS AND METHODS We prospectively studied three regimens on dexamethasone: no dexamethasone (A), a single preoperative dose of 20-mg dexamethasone (B), and two perioperative doses of 10-mg dexamethasone (C). The primary outcome was postoperative pain level. The incidence of postoperative nausea and vomiting (PONV), use of analgesic and antiemetic rescue, interleukin-6 (IL-6) and C-reactive protein (CRP) levels, range of motion (ROM), and complications were also compared. RESULTS The dynamic pain scores and CRP and IL-6 levels were significantly lower for Group B compared to Groups A and C on postoperative days 1 and 2 (POD 1 and 2). Such differences were also detected between Groups C and A. Besides, the pain scores at rest were significantly lower in Groups B and C than in Group A on POD 1 and 2. Patients in Groups B and C had a lower incidence of PONV, reduced use of analgesic and antiemetic rescue, and improved ROM than in Group A. No complications occurred in any group. CONCLUSION Dexamethasone in TKA provides short-term advantages in analgesic, antiemetic and anti-inflammatory effects. Besides, regarding the effects of pain and inflammatory control on POD 1 and 2, a single preoperative high dose of 20-mg dexamethasone was more effective than two perioperative low doses of 10-mg dexamethasone. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Yiting Lei
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Department of Orthopedics, West China Hospital, Sichuan University, 37# WainanGuoxue Road, Chengdu, 610041, People's Republic of China
| | - Zeyu Huang
- Department of Orthopedics, West China Hospital, Sichuan University, 37# WainanGuoxue Road, Chengdu, 610041, People's Republic of China
| | - Qiang Huang
- Department of Orthopedics, West China Hospital, Sichuan University, 37# WainanGuoxue Road, Chengdu, 610041, People's Republic of China
| | - Fuxing Pei
- Department of Orthopedics, West China Hospital, Sichuan University, 37# WainanGuoxue Road, Chengdu, 610041, People's Republic of China.
| | - Wei Huang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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10
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McGovern C, Quasim T, Puxty K, Shaw M, Ng W, Gilhooly C, Arkoulis N, Basler M, Macfarlane A, Paton L. Neuropathic agents in the management of pruritus in burn injuries: a systematic review and meta-analysis. Trauma Surg Acute Care Open 2021; 6:e000810. [PMID: 34722931 PMCID: PMC8547510 DOI: 10.1136/tsaco-2021-000810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 09/02/2021] [Indexed: 11/03/2022] Open
Abstract
Objectives Pruritus is a common and often distressing complication after a burn injury. The purpose of this review is to explore the efficacy of drugs classically used to treat neuropathic pain in the management of pruritus after burn injury. Methods A systematic literature search of medical databases was conducted to find studies investigating drugs listed in the National Institute for Health and Care Excellence (NICE) guideline (CG173, "neuropathic pain in adults") for the management of pruritus after burn injury in patients of any age. Controlled studies were stratified by the drug class studied and their risk of bias before conducting meta-analysis. A narrative review of case series or observational studies was presented. Severity of pruritus at any time point, with all quantitative and qualitative measures, was included. Results Fifteen studies were included in the final analysis, 10 investigated the use of gabapentinoids, 4 studied doxepin, and 1 local anesthetic agents. Meta-analysis of three randomized controlled trials (RCTs) demonstrated that the use of gabapentinoids was associated with an improvement in mean VAS (Visual Analog Scale) 0-10 scores of 2.96 (95% confidence interval (95% CI) 1.20 to 4.73, p<0.001) when compared with placebo or antihistamine. A meta-analysis of four RCTs investigating topical doxepin showed an improvement in mean VAS scores of 1.82 (95% CI 0.55 to 3.09, p<0.001). However, when excluding two studies found to be at high risk of bias, no such improvement was found (-0.32, 95% CI -1.64 to -0.99, p=0.83). Conclusion This study suggests that gabapentinoids are beneficial in the management of burn-related pruritus. There is a lack of evidence to suggest that doxepin is an effective treatment. Topical local anesthetic agents may be safe and beneficial, but studies are scarce. Level of evidence Systematic review, level II.
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Affiliation(s)
- Christopher McGovern
- Anaesthesia, Critical Care and Peri-operative Medicine, University of Glasgow, Glasgow, UK.,Anaesthesia & Critical Care, Glasgow Royal Infirmary, Glasgow, UK
| | - Tara Quasim
- Anaesthesia, Critical Care and Peri-operative Medicine, University of Glasgow, Glasgow, UK.,Anaesthesia & Critical Care, Glasgow Royal Infirmary, Glasgow, UK
| | - Kathryn Puxty
- Anaesthesia, Critical Care and Peri-operative Medicine, University of Glasgow, Glasgow, UK.,Anaesthesia & Critical Care, Glasgow Royal Infirmary, Glasgow, UK
| | - Martin Shaw
- Anaesthesia, Critical Care and Peri-operative Medicine, University of Glasgow, Glasgow, UK.,Department of Clinical Physics and Bioengineering, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Wijnand Ng
- Medical Student, University of Glasgow, Glasgow, UK
| | - Charlotte Gilhooly
- Anaesthesia, Critical Care and Peri-operative Medicine, University of Glasgow, Glasgow, UK.,Anaesthesia & Critical Care, Glasgow Royal Infirmary, Glasgow, UK
| | - Nikolaos Arkoulis
- Plastic and Burn Surgery, Glasgow Royal Infirmary, Glasgow, UK.,Honorary Clinical Senior Lecturer (Medicine), University of Glasgow, Glasgow, UK
| | - Michael Basler
- Anaesthesia and Pain Medicine, Glasgow Royal Infirmary, Glasgow, UK
| | - Alan Macfarlane
- Anaesthesia, Critical Care and Peri-operative Medicine, University of Glasgow, Glasgow, UK.,Anaesthesia and Pain Medicine, Glasgow Royal Infirmary, Glasgow, UK
| | - Lia Paton
- Anaesthesia & Critical Care, Glasgow Royal Infirmary, Glasgow, UK
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Karam JA, Schwenk ES, Parvizi J. An Update on Multimodal Pain Management After Total Joint Arthroplasty. J Bone Joint Surg Am 2021; 103:1652-1662. [PMID: 34232932 DOI: 10.2106/jbjs.19.01423] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ Multimodal analgesia has become the standard of care for total joint arthroplasty as it provides superior analgesia with fewer side effects than opioid-only protocols. ➤ Systemic medications, including nonsteroidal anti-inflammatory drugs, acetaminophen, corticosteroids, and gabapentinoids, and local anesthetics via local infiltration analgesia and peripheral nerve blocks, are the foundation of multimodal analgesia in total joint arthroplasty. ➤ Ideally, multimodal analgesia should begin preoperatively and continue throughout the perioperative period and beyond discharge. ➤ There is insufficient evidence to support the routine use of intravenous acetaminophen or liposomal bupivacaine as part of multimodal analgesia protocols.
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Affiliation(s)
- Joseph A Karam
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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12
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Joshi GP, Kehlet H. Meta-analyses of gabapentinoids for pain management after knee arthroplasty: A caveat emptor? A narrative review. Acta Anaesthesiol Scand 2021; 65:865-869. [PMID: 33728646 DOI: 10.1111/aas.13820] [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] [Received: 11/06/2020] [Revised: 02/15/2021] [Accepted: 03/01/2021] [Indexed: 12/21/2022]
Abstract
The use of gabapentinoids for perioperative pain management after total knee arthroplasty has been the subject of nine systematic reviews and meta-analyses. A critical analysis of the clinical aspects of the methodology of these publications shows major flaws which limit the interpretation for the recommended use of perioperative gabapentinoids in pain management for unilateral primary total knee arthroplasty. Consequently, readers and authors of systematic reviews and meta-analyses should critically assess the clinical aspects of the included studies.
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Affiliation(s)
- Girish P. Joshi
- Anesthesiology and Pain Management University of Texas Southwestern Medical Center Dallas TX USA
| | - Henrik Kehlet
- Section of Surgical PathophysiologyRigshospitalet Copenhagen Denmark
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13
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A Narrative Review on Perioperative Pain Management Strategies in Enhanced Recovery Pathways-The Past, Present and Future. J Clin Med 2021; 10:jcm10122568. [PMID: 34200695 PMCID: PMC8229260 DOI: 10.3390/jcm10122568] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/05/2021] [Accepted: 06/08/2021] [Indexed: 12/14/2022] Open
Abstract
Effective pain management is a key component in the continuum of perioperative care to ensure optimal outcomes for surgical patients. The overutilization of opioids in the past few decades for postoperative pain control has been a major contributor to the current opioid epidemic. Multimodal analgesia (MMA) and enhanced recovery after surgery (ERAS) pathways have been repeatedly shown to significantly improve postoperative outcomes such as pain, function and satisfaction. The current review aims to examine the history of perioperative MMA strategies in ERAS and provide an update with recent evidence. Furthermore, this review details recent advancements in personalized pain medicine. We speculate that the next important step for improving perioperative pain management could be through incorporating these personalized metrics, such as clinical pharmacogenomic testing and patient-reported outcome measurements, into ERAS program.
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Tomaszek L, Fenikowski D, Maciejewski P, Komotajtys H, Gawron D. Perioperative Gabapentin in Pediatric Thoracic Surgery Patients-Randomized, Placebo-Controlled, Phase 4 Trial. PAIN MEDICINE 2021; 21:1562-1571. [PMID: 31596461 DOI: 10.1093/pm/pnz207] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To determine whether the use of perioperative gabapentin reduces postoperative pain and anxiety, decreases ropivacaine consumption and side effects, and improves patient satisfaction. DESIGN Randomized, placebo-controlled, phase 4 trial. BLINDING Participants, care providers, investigators, data analysts. SETTING Department of Thoracic Surgery of the Institute of Tuberculosis and Lung Disease, Rabka Zdrój Branch, Poland. SUBJECTS Forty patients undergoing the Ravitch procedure. METHODS Patients aged nine to 17 years were randomized into a gabapentin (preoperative 15 mg/kg, treatment) or placebo group. Postoperative analgesia included gabapentin (7.5 mg/kg) or placebo two times per day for three days, epidural ropivacaine + fentanyl, paracetamol, nonsteroidal anti-inflammatory drugs, and metamizol as a "rescue drug." Pain, anxiety, analgesic consumption, side effects, and patient satisfaction were recorded. RESULTS There was no statistically significant difference in median pain scores (numerical rating scale < 1/10) or incidence of adverse side effects between the gabapentin group (N = 20) and the placebo group (N = 20). Postoperative anxiety scores were significantly lower than before surgery in the gabapentin group (6 [4-8] vs 7 [6-8.5], P < 0.01) and remained unchanged in the placebo group (6 [5-6.5] vs 6 [5-7], P = 0.07). Gabapentin-treated patients received a lower number of doses of ondansetron when compared with the placebo group (6 [5-6] vs 7 [6-9], P = 0.02). A significant negative association was found between patient satisfaction and postoperative state anxiety in the gabapentin group (R = -0.51, P = 0.02). CONCLUSIONS Perioperative administration of gabapentin resulted in a decrease of postoperative anxiety in pediatric patients undergoing the Ravitch procedure.
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Affiliation(s)
- Lucyna Tomaszek
- Department of Thoracic Surgery, Institute of Tuberculosis and Lung Diseases, Rabka-Zdrój Branch, Rabka-Zdrój, Poland
| | - Dariusz Fenikowski
- Department of Thoracic Surgery, Institute of Tuberculosis and Lung Diseases, Rabka-Zdrój Branch, Rabka-Zdrój, Poland
| | - Piotr Maciejewski
- Department of Thoracic Surgery, Institute of Tuberculosis and Lung Diseases, Rabka-Zdrój Branch, Rabka-Zdrój, Poland
| | - Halina Komotajtys
- Department of Thoracic Surgery, Institute of Tuberculosis and Lung Diseases, Rabka-Zdrój Branch, Rabka-Zdrój, Poland
| | - Danuta Gawron
- Department of Thoracic Surgery, Institute of Tuberculosis and Lung Diseases, Rabka-Zdrój Branch, Rabka-Zdrój, Poland
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15
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Bykov K, Bateman BT, Franklin JM, Vine SM, Patorno E. Association of Gabapentinoids With the Risk of Opioid-Related Adverse Events in Surgical Patients in the United States. JAMA Netw Open 2020; 3:e2031647. [PMID: 33372975 PMCID: PMC7772715 DOI: 10.1001/jamanetworkopen.2020.31647] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE The use of gabapentinoids in multimodal postoperative analgesia is increasing; however, when coadministered with opioids, these drugs may potentiate central nervous system and respiratory depression. OBJECTIVE To evaluate the association between perioperative coadministration of gabapentinoids and opioids with inpatient opioid-related adverse events in surgical patients. DESIGN, SETTING, AND PARTICIPANTS This cohort study used propensity score trimming, stratification, and weighting of adults admitted for a major surgery between October 2007 and December 2017 who were treated with opioids on the day of surgery and included in the Premier Research database. Data analysis was conducted from February to April 2020. EXPOSURE Gabapentinoids (gabapentin or pregabalin) coadministered with opioids starting the day of surgery vs opioid therapy without gabapentinoids. MAIN OUTCOMES AND MEASURES Primary outcome was opioid overdose. Secondary outcomes included respiratory complications, unspecified adverse effects of opioid use, and a composite of these 3 outcomes. Patients were followed up for as long as 30 days from the day of surgery until deviation from the initial treatment regimen or discharge. RESULTS Gabapentinoids with opioids were administered to 892 484 of 5 547 667 eligible admissions (16.1%; mean [SD] age, 63.5 [11.8] years; 353 315 [39.6%] men). Among the 4 655 183 patients who received opioids only, the mean (SD) age was 63.7 (14.7) years, and 1 913 284 (41.1%) were men. Overall, 441 overdose events were identified, with absolute risks of 1.4 per 10 000 patients with gabapentinoid exposure and 0.7 per 10 000 patients receiving opioids only. Following propensity score trimming, the cohort included 737 383 patients exposed to gabapentinoids and 3 002 480 patients receiving opioids only. The primary analysis yielded the adjusted hazard ratio of 1.95 (95% CI, 1.49-2.55), and the number needed to treat for an additional overdose to occur was 16 914 patients (95% CI, 11 556-31 537 patients). Adjusted hazard ratios for secondary outcomes were 1.68 (95% CI, 1.59-1.78) for respiratory complications, 1.77 (95% CI, 1.61-1.93) for unspecified adverse effects of opioids, and 1.70 (95% CI, 1.62-1.79) for the composite outcome. The results were consistent across sensitivity analyses and subgroups identified by key clinical factors. CONCLUSIONS AND RELEVANCE In this real-world cohort study of patients who underwent major surgery, concomitant use of gabapentinoids with opioids was associated with increased risk of opioid overdose and other opioid-related adverse events; however, the absolute risk of adverse events was low.
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Affiliation(s)
- Katsiaryna Bykov
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Brian T. Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jessica M. Franklin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Seanna M. Vine
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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16
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Baos S, Rogers CA, Abbadi R, Alzetani A, Casali G, Chauhan N, Collett L, Culliford L, de Jesus SE, Edwards M, Goddard N, Lamb J, McKeon H, Molyneux M, Stokes EA, Wordsworth S, Gibbison B, Pufulete M. Effectiveness, cost-effectiveness and safety of gabapentin versus placebo as an adjunct to multimodal pain regimens in surgical patients: protocol of a placebo controlled randomised controlled trial with blinding (GAP study). BMJ Open 2020; 10:e041176. [PMID: 33444208 PMCID: PMC7682449 DOI: 10.1136/bmjopen-2020-041176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 10/14/2020] [Accepted: 10/16/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Gabapentin is an antiepileptic drug currently licensed to treat epilepsy and neuropathic pain but has been used off-label to treat acute postoperative pain. The GAP study will compare the effectiveness, cost-effectiveness and safety of gabapentin as an adjunct to standard multimodal analgesia versus placebo for the management of pain after major surgery. METHODS AND ANALYSIS The GAP study is a multicentre, double-blind, randomised controlled trial in patients aged 18 years and over, undergoing different types of major surgery (cardiac, thoracic or abdominal). Patients will be randomised in a 1:1 ratio to receive either gabapentin (600 mg just before surgery and 600 mg/day for 2 days after surgery) or placebo in addition to usual pain management for each type of surgery. Patients will be followed up daily until hospital discharge and then at 4 weeks and 4 months after surgery. The primary outcome is length of hospital stay following surgery. Secondary outcomes include pain, total opioid use, adverse health events, health related quality of life and costs. ETHICS AND DISSEMINATION This study has been approved by the Research Ethics Committee . Findings will be shared with participating hospitals and disseminated to the academic community through peer-reviewed publications and presentation at national and international meetings. Patients will be informed of the results through patient organisations and participant newsletters. TRIAL REGISTRATION NUMBER ISRCTN63614165.
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Affiliation(s)
- Sarah Baos
- Bristol Trials Centre, Clinical Trials and Evaluation Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Chris A Rogers
- Bristol Trials Centre, Clinical Trials and Evaluation Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Reyad Abbadi
- Department of Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Aiman Alzetani
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Gianluca Casali
- Department of Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Nilesh Chauhan
- Department of Anaesthesia, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Laura Collett
- Bristol Trials Centre, Clinical Trials and Evaluation Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Lucy Culliford
- Bristol Trials Centre, Clinical Trials and Evaluation Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Samantha E de Jesus
- Bristol Trials Centre, Clinical Trials and Evaluation Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Mark Edwards
- Department of Anaesthesia, University Hospital Southampton NHS FoundationTrust, Southampton, UK
- Acute, Critical & Perioperative Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
| | - Nicholas Goddard
- Department of Anaesthesia, University Hospital Southampton NHS FoundationTrust, Southampton, UK
| | - Jennifer Lamb
- Bristol Trials Centre, Clinical Trials and Evaluation Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Holly McKeon
- Bristol Trials Centre, Clinical Trials and Evaluation Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Mat Molyneux
- Department of Anaesthesia, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | | | - Sarah Wordsworth
- Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Ben Gibbison
- Department of Anaesthesia, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Maria Pufulete
- Bristol Trials Centre, Clinical Trials and Evaluation Unit, Bristol Medical School, University of Bristol, Bristol, UK
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17
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Roebke AJ, Via GG, Everhart JS, Munsch MA, Goyal KS, Glassman AH, Li M. Inpatient and outpatient opioid requirements after total joint replacement are strongly influenced by patient and surgical factors. Bone Jt Open 2020; 1:398-404. [PMID: 33215130 PMCID: PMC7659675 DOI: 10.1302/2633-1462.17.bjo-2020-0025.r1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Aims Currently, there is no single, comprehensive national guideline for analgesic strategies for total joint replacement. We compared inpatient and outpatient opioid requirements following total hip arthroplasty (THA) versus total knee arthroplasty (TKA) in order to determine risk factors for increased inpatient and outpatient opioid requirements following total hip or knee arthroplasty. Methods Outcomes after 92 primary total knee (n = 49) and hip (n = 43) arthroplasties were analyzed. Patients with repeat surgery within 90 days were excluded. Opioid use was recorded while inpatient and 90 days postoperatively. Outcomes included total opioid use, refills, use beyond 90 days, and unplanned clinical encounters for uncontrolled pain. Multivariate modelling determined the effect of surgery, regional nerve block (RNB) or neuraxial anesthesia (NA), and non-opioid medications after adjusting for demographics, ength of stay, and baseline opioid use. Results TKAs had higher daily inpatient opioid use than THAs (in 5 mg oxycodone pill equivalents: median 12.0 vs 7.0; p < 0.001), and greater 90 day use (median 224.0 vs 100.5; p < 0.001). Opioid refills were more likely in TKA (84% vs 33%; p < 0.001). Patient who underwent TKA had higher independent risk of opioid use beyond 90 days than THA (adjusted OR 7.64; 95% SE 1.23 to 47.5; p = 0.01). Inpatient opioid use 24 hours before discharge was the strongest independent predictor of 90-day opioid use (p < 0.001). Surgical procedure, demographics, and baseline opioid use have greater influence on in/outpatient opioid demand than RNB, NA, or non-opioid analgesics. Conclusion Opioid use following TKA and THA is most strongly predicted by surgical and patient factors. TKA was associated with higher postoperative opioid requirements than THA. RNB and NA did not diminish total inpatient or 90-day postoperative opioid consumption. The use of acetaminophen, gabapentin, or NSAIDs did not significantly alter inpatient opioid requirements. Cite this article: Bone Joint Open 2020;1-7:398–404.
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Affiliation(s)
- Austin J Roebke
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Garrhett G Via
- Department of Orthopaedic Surgery, Wright State University, Dayton, Ohio, USA
| | - Joshua S Everhart
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Maria A Munsch
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kanu S Goyal
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Andrew H Glassman
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Mengnai Li
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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18
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Wang J, Fu G, Liu J, Yu Y, Wang N. Effect of preoperative gabapentin after transurethral prostate resection under general anesthesia. A randomized double-blind, placebo-controlled trial. Saudi Med J 2020; 41:640-644. [PMID: 32518932 PMCID: PMC7502946 DOI: 10.15537/smj.2020.6.25132] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Objectives: To investigate whether preoperative oral gabapentin could reduce postoperative pain, analgesic consumption and the occurrence of catheter-related bladder discomfort (CRBD). Methods: In this study, participants randomly received either 600 mg gabapentin or placebo orally 2 h prior to transurethral prostate resection. Visual analogue scale and Ramsay sedation scale was utilized to assess pain intensity and sedation status after surgery. Intravenous 1.5 mg.kg-1 tramadol was used for postoperative analgesia. Pain intensity, sedation status, CRBD, tramadol consumption, side effects and the overall satisfaction degree were assessed and recorded for 48 h after tracheal extubation. Results: Ninety participants given gabapentin and 91 participants given placebo completed the study. Lower visual analogue scale scores, less tramadol consumption, longer time to the first analgesic requirement, lower incidence of CRBD and nausea and higher satisfaction degree were detected in the patients receiving gabapentin compared with the patients receiving placebo. Conclusion: Preoperative oral gabapentin reduced postoperative visual analogue scale scores, tramadol consumption and the occurrence rate of CRBD and nausea, and consequently, increased the degree of patients’ satisfaction after transurethral prostate resection.
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Affiliation(s)
- Jinguo Wang
- Department of Urology, The First Hospital of Jilin University, Jilin, China. E-mail.
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19
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George S, Johns M. Review of nonopioid multimodal analgesia for surgical and trauma patients. Am J Health Syst Pharm 2020; 77:2052-2063. [DOI: 10.1093/ajhp/zxaa301] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AbstractPurposePain is a frequent finding in surgical and trauma patients, and effective pain control remains a common challenge in the hospital setting. Opioids have traditionally been the foundation of pain management; however, these agents are associated with various adverse effects and risks of dependence and diversion.SummaryIn response to the rising national opioid epidemic and the various risks associated with opioid use, multimodal pain management through use of nonopioid analgesics such as acetaminophen, nonsteroidal anti-inflammatory drugs, α 2 agonists, N-methyl-d-aspartate (NMDA) receptor antagonists, skeletal muscle relaxants, sodium channel blockers, and local anesthetics has gained popularity recently. Multimodal analgesia has synergistic therapeutic effects and can decrease adverse effects by enabling use of lower doses of each agent in the multimodal regimen. This review discusses properties of the various nonopioid analgesics and encourages pharmacists to play an active role in the selection, initiation, and dose-titration of multimodal analgesia. The choice of nonopioid agents should be based on patient comorbidities, hemodynamic stability, and the agents’ respective adverse effect profiles. A multidisciplinary plan for management of pain should be formulated during transitions of care and is an area of opportunity for pharmacists to improve patient care.ConclusionMultimodal analgesia effectively treats pain while decreasing adverse effects. There is mounting evidence to support use of this strategy to decrease opioid use. As medication experts, pharmacists can play a key role in the selection, initiation, and dose-titration of analgesic agents based on patient-specific factors.
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Affiliation(s)
- Stephy George
- Department of Pharmacy, Texas Health Harris Methodist Hospital, Fort Worth, TX
| | - Meagan Johns
- Department of Pharmacy, University of Texas Southwestern Medical Center, Dallas, TX
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20
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Hannon CP, Fillingham YA, Browne JA, Schemitsch EH, Mullen K, Casambre F, Visvabharathy V, Hamilton WG, Della Valle CJ. The Efficacy and Safety of Gabapentinoids in Total Joint Arthroplasty: Systematic Review and Direct Meta-Analysis. J Arthroplasty 2020; 35:2730-2738.e6. [PMID: 32586656 DOI: 10.1016/j.arth.2020.05.033] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 05/18/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Gabapentinoids are commonly used as an adjunct to traditional pain management strategies after total joint arthroplasty (TJA). The purpose of this study is to evaluate the efficacy and safety of gabapentinoids in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management. METHODS The MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched for studies published prior to November 2018 on gabapentinoids in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of gabapentinoids. RESULTS In total, 384 publications were critically appraised to provide 13 high-quality studies regarded as the best available evidence for analysis. In the perioperative period prior to discharge, pregabalin reduces postoperative opioid consumption, but gabapentinoids do not reduce postoperative pain. After discharge, gabapentin does not reduce postoperative pain or opioid consumption, but pregabalin reduces both postoperative pain and opioid consumption. CONCLUSION Moderate evidence supports the use of pregabalin in TJA to reduce postoperative pain and opioid consumption. Gabapentinoids should be used with caution, however, as they may lead to an increased risk of sedation and respiratory depression especially when combined with other central nervous system depressants such as opioids.
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Affiliation(s)
- Charles P Hannon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Yale A Fillingham
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - James A Browne
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Emil H Schemitsch
- Department of Surgery, University of Western Ontario, London, Ontario, Canada
| | - Kyle Mullen
- Department of Research, Quality, and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Francisco Casambre
- Department of Research, Quality, and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Vidya Visvabharathy
- Department of Research, Quality, and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - William G Hamilton
- Department of Orthopaedic Surgery, Anderson Orthopedic Research Institute, Alexandria, VA
| | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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21
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Ramirez MF, Kamdar BB, Cata JP. Optimizing Perioperative Use of Opioids: A Multimodal Approach. CURRENT ANESTHESIOLOGY REPORTS 2020; 10:404-415. [PMID: 33281504 DOI: 10.1007/s40140-020-00413-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose of Review The main purpose of this article is to review recent literature regarding multimodal analgesia medications, citing their recommended doses, efficacy, and side effects. The second part of this report will provide a description of drugs in different stages of development which have novel mechanisms with less side effects such as tolerance and addiction. Recent Findings Multimodal analgesia is a technique that facilitates perioperative pain management by employing two or more systemic analgesics along with regional anesthesia, when possible. Even though opioids and non-opioid analgesics remain the most common medication used for acute pain management after surgery, they have many undesirable side effects including the potential for misuse. Newer analgesics including peripheral acting opioids, nitric oxide inhibitors, calcitonin gene-related peptide receptor antagonists, interleukin-6 receptor antagonists and gene therapy are under intensive investigation. Summary A patient's first exposure to opioids is often in the perioperative setting, a vulnerable time when multimodal therapy can play a large role in decreasing opioid exposure. Additionally, the current shift towards faster recovery times, fewer post-operative complications and improved cost-effectiveness during the perioperative period has made multimodal analgesia a central pillar of Enhanced Recovery After Surgery (ERAS) protocols.
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Affiliation(s)
- Maria F Ramirez
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Brinda B Kamdar
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
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22
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Kang J, Zhao Z, Lv J, Sun L, Lu B, Dong B, Ma J, Ma X. The efficacy of perioperative gabapentin for the treatment of postoperative pain following total knee and hip arthroplasty: a meta-analysis. J Orthop Surg Res 2020; 15:332. [PMID: 32799902 PMCID: PMC7429897 DOI: 10.1186/s13018-020-01849-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 07/30/2020] [Indexed: 01/07/2023] Open
Abstract
Background Postoperative pain after total knee arthroplasty (TKA) and total hip arthroplasty (THA) influence patients’ rehabilitation and life quality. Although gabapentin has been widely used for analgesia, its efficacy is still controversial in TKA and THA. This meta-analysis was performed to assess the efficacy and safety of gabapentin following TKA and THA. Method Electronic databases including PubMed, EMBASE, Cochrane Central Register of Controlled Trials, MEDLINE, and ClinicalTrials.gov were comprehensively retrieved for randomized controlled trials from their inception to June 2019. A total of 7 studies, which compared the administration of gabapentin with that of placebo for the treatment of postoperative pain, were included in our meta-analysis. The meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Result There was no difference in pain score at 24 (P = 0.87), 48 (P = 0.15), and 72 (P = 0.85) h associated with the use of gabapentin. Likewise, no difference in accumulative morphine consumption at 48 h following TKA or THA was found between gabapentin and placebo (DM = − 8.14, 95% CI − 18.55 to 2.28, P = 0.13). The incidence of opioid-related adverse effects, including nausea, pruritus, sedation, and dizziness, is no difference between gabapentin and placebo group. However, subgroup analysis indicated that gabapentin could reduce the incidence of pruritus after TKA (RR = 0.35, 95% CI 0.12 to 0.99, P = 0.05). Conclusion Based on our meta-analysis, gabapentin did not decrease postoperative pain, cumulative morphine consumption, and the incidence of adverse effects after TKA and THA. There was not enough evidence to support the administrations of gabapentin for postoperative pain after TKA and THA.
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Affiliation(s)
- Jiayu Kang
- Department of Orthopedics, Jinhua Municipal Central Hospital, Jinhua, Zhejiang Province, People's Republic of China.,Tianjin Hospital, Tianjin University, Tianjin, 300211, People's Republic of China.,Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital, Tianjin, People's Republic of China
| | - Zhihu Zhao
- Tianjin Hospital, Tianjin University, Tianjin, 300211, People's Republic of China
| | - Jianwei Lv
- Tianjin Hospital, Tianjin University, Tianjin, 300211, People's Republic of China
| | - Lei Sun
- Tianjin Hospital, Tianjin University, Tianjin, 300211, People's Republic of China.,Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital, Tianjin, People's Republic of China
| | - Bin Lu
- Tianjin Hospital, Tianjin University, Tianjin, 300211, People's Republic of China.,Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital, Tianjin, People's Republic of China
| | - Benchao Dong
- Tianjin Hospital, Tianjin University, Tianjin, 300211, People's Republic of China.,Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital, Tianjin, People's Republic of China
| | - Jianxiong Ma
- Tianjin Hospital, Tianjin University, Tianjin, 300211, People's Republic of China. .,Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital, Tianjin, People's Republic of China.
| | - Xinlong Ma
- Tianjin Hospital, Tianjin University, Tianjin, 300211, People's Republic of China. .,Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital, Tianjin, People's Republic of China. .,Department of Orthopedics, Tianjin Hospital, No. 155, Munan Road, Hexi District, Tianjin City, People's Republic of China.
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Abstract
OBJECTIVE To evaluate opioid prescribing patterns following cochlear implantation (CI) and assess factors associated with recurrent opioid use. STUDY DESIGN Retrospective cohort study. SETTING National pharmaceutical database recording opioid fulfillment (Truven Health Marketscan Commercial Claims and Encounters and Medicare Claims and Encounters database) PARTICIPANTS:: CI recipients who filled opioid prescriptions between January 2011 and December 2016. All patients had no previous opioid prescriptions filled 60 days before implantation and filled at least one opioid prescription within 1 week after surgery. Cohort 1 filled only one prescription and cohort 2 filled more than one prescription in the 12 months following CI. Univariate/multivariate analysis was performed to assess for associations with recurrent opioid use. MAIN OUTCOME MEASURE(S) Opioid prescription details and recurrent opioid use. RESULTS The study included 98 patients (cohort 1 = 57, cohort 2 (recurrent opioid use) = 41). Hydrocodone 5 mg was most frequently used. The average duration opioids were prescribed was 5.49 days with an average quantity of tablets of 36.1. Recurrent opioid use in cohort 2 was associated with both total morphine milligram equivalents (MME) prescribed/day in the first postoperative week (OR = 1.03, p = 0.01) and use of stronger MME opioids (OR = 7.20, p = 0.05). CONCLUSION Prescribing patterns following CI can influence recurrent opioid use in patients. Each additional tablet of hydrocodone 5 mg beyond 8 tablets/d or oxycodone 5 mg beyond 5.33 tablets/d, increases the likelihood of recurrent opioid use by 15 or 22.5%, respectively. Limiting opioids prescribed per day to no more than 40 MME could lower the likelihood of patients becoming recurrent opioid users postoperatively.
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24
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Portenoy RK. A Practical Approach to Using Adjuvant Analgesics in Older Adults. J Am Geriatr Soc 2020; 68:691-698. [PMID: 32216151 DOI: 10.1111/jgs.16340] [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] [Received: 11/21/2019] [Revised: 12/24/2019] [Accepted: 12/30/2019] [Indexed: 12/26/2022]
Abstract
The adjuvant analgesics are a large and diverse group of drugs that were developed for primary indications other than pain and are potentially useful analgesics for one or more painful conditions. The "adjuvant" designation reflects their early use as opioid co-analgesics for cancer pain. During the past 3 decades, their role in pain management has changed with the advent of many new entities, emerging data from numerous analgesic trials, and growing clinical experience. Many of these drugs are now used as primary analgesics for specific types of chronic pain. With proper patient selection and cautious administration, they can potentially contribute meaningfully to the management of chronic pain in older adults. A practical approach categorizes the many adjuvant analgesics by broad indications: multipurpose drugs and drugs that target neuropathic pain, musculoskeletal pain, and cancer pain, respectively. This article reviews the status of the evidence supporting the analgesic potential of the adjuvant analgesics and discusses best practices in terms of drug selection and dosing. J Am Geriatr Soc 68:691-698, 2020.
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Affiliation(s)
- Russell K Portenoy
- MJHS Institute for Innovation in Palliative Care, New York, New York.,Albert Einstein College of Medicine, The Bronx, New York
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Cai AL, Liu SJ, Wu B, Liu G. Intrathecal versus local infiltration analgesia for pain control in total joint arthroplasty. J Orthop Surg Res 2020; 15:110. [PMID: 32188483 PMCID: PMC7079456 DOI: 10.1186/s13018-020-01627-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/09/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this meta-analysis was to assess the efficacy of intrathecal morphine (ITM) analgesia and local infiltration analgesia (LIA) for pain control in total joint arthroplasty (TJA). METHODS Embase, PubMed, the Cochrane Library, and Web of Science were systematically searched for randomized controlled trials (RCTs). All RCTs were comparing intrathecal analgesia and local infiltration analgesia in TJA. Primary outcomes were the visual analog scale (VAS) score with rest or mobilization up to 72 h. Secondary outcomes were the total morphine consumption, length of hospital stay, and morphine-related complications. RESULTS Compared with the intrathecal analgesia group, the LIA group was associated with a reduction in VAS score with rest up to 72 h. Moreover, LIA was associated with a decrease in VAS score with mobilization at 6 h, 12 h, 48 h, and 72 h. Moreover, LIA significantly reduced total morphine consumption (weighted mean difference (WMD) = - 15.37, 95% CI - 22.64 to - 8.83, P = 0.000), length of hospital stay (WMD = - 1.39, 95% CI - 1.67 to - 1.11, P = 0.000), and morphine-related complications (nausea and pruritus). CONCLUSIONS Local infiltration provided superior analgesia and morphine-sparing effects within the first 72 h compared with ITM following TJA.
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Affiliation(s)
- Ai-Lan Cai
- Anesthesiology Department, Liaocheng People's Hospital, No.67 DongChang West Road, Liaocheng, 252000, Shandong, China
| | - Sheng-Jie Liu
- Anesthesiology Department, Liaocheng People's Hospital, No.67 DongChang West Road, Liaocheng, 252000, Shandong, China
| | - Bin Wu
- Anesthesiology Department, Liaocheng People's Hospital, No.67 DongChang West Road, Liaocheng, 252000, Shandong, China
| | - Geng Liu
- Anesthesiology Department, Liaocheng People's Hospital, No.67 DongChang West Road, Liaocheng, 252000, Shandong, China.
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Wainwright TW, Gill M, McDonald DA, Middleton RG, Reed M, Sahota O, Yates P, Ljungqvist O. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS ®) Society recommendations. Acta Orthop 2020; 91:3-19. [PMID: 31663402 PMCID: PMC7006728 DOI: 10.1080/17453674.2019.1683790] [Citation(s) in RCA: 325] [Impact Index Per Article: 81.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background and purpose - There is a large volume of heterogeneous studies across all Enhanced Recovery After Surgery (ERAS®) components within total hip and total knee replacement surgery. This multidisciplinary consensus review summarizes the literature, and proposes recommendations for the perioperative care of patients undergoing total hip replacement and total knee replacement with an ERAS program.Methods - Studies were selected with particular attention being paid to meta-analyses, randomized controlled trials, and large prospective cohort studies that evaluated the efficacy of individual items of the perioperative treatment pathway to expedite the achievement of discharge criteria. A consensus recommendation was reached by the group after critical appraisal of the literature.Results - This consensus statement includes 17 topic areas. Best practice includes optimizing preoperative patient education, anesthetic technique, and transfusion strategy, in combination with an opioid-sparing multimodal analgesic approach and early mobilization. There is insufficient evidence to recommend that one surgical technique (type of approach, use of a minimally invasive technique, prosthesis choice, or use of computer-assisted surgery) over another will independently effect achievement of discharge criteria.Interpretation - Based on the evidence available for each element of perioperative care pathways, the ERAS® Society presents a comprehensive consensus review, for the perioperative care of patients undergoing total hip replacement and total knee replacement surgery within an ERAS® program. This unified protocol should now be further evaluated in order to refine the protocol and verify the strength of these recommendations.
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Affiliation(s)
- Thomas W Wainwright
- Orthopaedic Research Institute, Bournemouth Univesity, Bournemouth, UK
- The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, UK
| | - Mike Gill
- Golden Jubilee National Hospital, Glasgow, Scotland
| | - David A McDonald
- Scottish Government, Glasgow, Scotland
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, Scotland
| | - Robert G Middleton
- Orthopaedic Research Institute, Bournemouth Univesity, Bournemouth, UK
- The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, UK
- Poole Hospital NHS Foundation Trust, Poole, UK
| | - Mike Reed
- Northumbria Healthcare NHS Foundational Trust, Northumbria, UK
- Health Sciences, University of York, York, UK
| | - Opinder Sahota
- Nottingham University Hospital, Nottingham, UK
- Nottingham University, Nottingham, UK
| | - Piers Yates
- University of Western Australia, Perth, Australia
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Chin KK, Carroll I, Desai K, Asch S, Seto T, McDonald KM, Curtin C, Hernandez-Boussard T. Integrating Adjuvant Analgesics into Perioperative Pain Practice: Results from an Academic Medical Center. PAIN MEDICINE 2020; 21:161-170. [PMID: 30933284 PMCID: PMC10147384 DOI: 10.1093/pm/pnz053] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Opioid-sparing postoperative pain management therapies are important considering the opioid epidemic. Total knee arthroplasty (TKA) is a common and painful procedure accounting for a large number of opioid prescriptions. Adjuvant analgesics, nonopioid drugs with primary indications other than pain, have shown beneficial pain management and opioid-sparing effects following TKA in clinical trials. We evaluated the adjuvant analgesic gabapentin for its usage patterns and its effects on opioid use, pain, and readmissions. METHODS This retrospective, observational study included 4,046 patients who received primary TKA between 2009 and 2017 using electronic health records from an academic tertiary care medical institute. Descriptive statistics and multivariate modeling were used to estimate associations between inpatient gabapentin use and adverse pain outcomes as well as inpatient oral morphine equivalents per day (OME). RESULTS Overall, there was an 8.72% annual increase in gabapentin use (P < 0.001). Modeled estimates suggest that gabapentin is associated with a significant decrease in opioid consumption (estimate = 0.63, 95% confidence interval = 0.49-0.82, P < 0.001) when controlling for patient characteristics. Patients receiving gabapentin had similar discharge pain scores, follow-up pain scores, and 30-day unplanned readmission rates compared with patients receiving no adjuvant analgesics (P > 0.05). CONCLUSIONS When assessed in a real-world setting over a large cohort of TKA patients, gabapentin is an effective pain management therapy that is associated with reduced opioid consumption-a national priority in this time of opioid crisis-while maintaining the same quality of pain management.
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Affiliation(s)
| | - Ian Carroll
- Department of Medicine, Stanford University, Stanford, CA USA
| | - Karishma Desai
- Department of Medicine, Stanford University, Stanford, CA USA
| | - Steven Asch
- Department of Medicine, Stanford University, Stanford, CA USA.,VA Palo Alto Health Care System, Center for Innovation to Implementation, Palo Alto, CA
| | - Tina Seto
- Stanford School of Medicine IRT Research Technology, Stanford, CA USA
| | - Kathryn M McDonald
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA USA
| | - Catherine Curtin
- Department of Surgery, VA Palo Alto Health Care System, Palo Alto, CA
| | - Tina Hernandez-Boussard
- Department of Medicine, Stanford University, Stanford, CA USA.,VA Palo Alto Health Care System, Center for Innovation to Implementation, Palo Alto, CA.,Department of Biomedical Data Science, Stanford University, Stanford, CA USA
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Pinto Filho WA, Silveira LDHJ, Vale ML, Fernandes CR, Alves Gomes J. The Effect of Gabapentin on Postoperative Pain of Orthopedic Surgery of Lower Limb by Sciatic and Femoral Blockage in Children: A Clinical Trial. Anesth Pain Med 2019; 9:e91207. [PMID: 31754608 PMCID: PMC6825328 DOI: 10.5812/aapm.91207] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 06/04/2019] [Accepted: 06/29/2019] [Indexed: 11/16/2022] Open
Abstract
Background There are meta-analyzes in adults demonstrating the benefits of using gabapentin to improve postoperative pain in orthopedic surgeries. In pediatrics, it has never been studied. Objectives The aim of this study was to evaluate the use of gabapentin 10 mg/kg, orally, in postoperative analgesia, hemodynamic stability and its pre/postoperative anxiolytic effect in children subjected to unilateral inferior limb surgery. Methods We performed a double-blinded, randomized study. 84 patients in Albert Sabin Children's Hospital were selected for elective surgery that were divided into 2 groups: gabapentin group, who received gabapentin 1 to 2 hours before the procedure and the control group. Both groups were submitted to the same general anesthesia protocol with 0.125% bupivacaine femoral and sciatic block. Patients received scheduled dipyrone and morphine was used as the rescue analgesic up to 2/2 h. Postoperative pain was assessed using a scale appropriate for age (CRIES, CHIPPS or Wong-Baker face scale). We registered hemodynamic parameters, analgesic consumption and pre/postoperative anxiolytics. Results A decrease in pain intensity in the 4th and 8th postoperative hours was observed in gabapentin group, both groups had the same opioid consumption. Children in the gabapentin group had an odds ratio of 25.6 for preoperative sedation and gabapentin promoted reduction of postoperative agitation. During orotracheal intubation the gabapentin group exhibited attenuation of the hemodynamic response. Conclusions Gabapentin was superior to placebo in reducing postoperative pain. Children who received gabapentin were more sedated in the operating room, less agitated in the postoperative period and the autonomic response to intubation was reduced.
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Affiliation(s)
- Washington Aspilicueta Pinto Filho
- Department of Pharmacology, Federal University of Ceara, Fortaleza, Brazil
- Corresponding Author: Department of Pharmacology, Federal University of Ceará, Fortaleza, Brazil, Tel: +55-85999580971,
| | | | - Mariana Lima Vale
- Department of Pharmacology, Federal University of Ceara, Fortaleza, Brazil
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Eckhard L, Jones T, Collins JE, Shrestha S, Fitz W. Increased postoperative dexamethasone and gabapentin reduces opioid consumption after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2019; 27:2167-2172. [PMID: 30826856 DOI: 10.1007/s00167-019-05449-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/25/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE Dexamethasone and gabapentin are used in multimodal pain management protocols to reduce postoperative pain after total knee arthroplasty. For both analgesic adjuvants, the optimal dose regimen to reduce opioid usage is still unclear. METHODS The opioid consumption of patients undergoing primary TKA before and after a change of the analgesic adjuvant medication in our protocol (old protocol: 4 mg of dexamethasone daily for 2 days, 600 mg gabapentin daily for 1 week; new protocol: 10 mg dexamethasone daily for 2 days, 300 mg gabapentin every 8 h for 1 week) were retrospectively compared. All surgeries were performed under spinal anesthesia. Peri- and postoperative pain medication remained unchanged. RESULTS A total of 186 patients who received TKA between 11/29/2016 and 06/09/2017 were screened. Six patients who received general anesthesia, 4 patients who underwent simultaneous bilateral TKA, and 16 patients with ongoing opioid consumption at the time of surgery were excluded, leaving 80 patients in each group. Opioid consumption within 24 h [morphine equivalents in mg: mean 50.5, standard deviation (SD) 30.0 (old) vs. 39.8, SD 24.2 (new); P = 0.0470], cumulative consumption over 48 h (97.3, SD 64.4 vs. 70.4, SD 51.2; P = 0.0040) and cumulative consumption over 72 h (108.1, SD 79.5 vs. 82.5, SD 72.6; P = 0.0080), were all significantly lower in the new protocol. CONCLUSION Increased postoperative administration of dexamethasone and gabapentin after TKA is associated with lower opioid consumption. Within the first 48 h, up to about 25% of opioids can be spared, comparing high-dose to low-dose protocols. LEVEL OF EVIDENCE Therapeutic Level III.
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Affiliation(s)
- Lukas Eckhard
- Department of Orthopedics and Traumatology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany.
- Department of Orthopedic Surgery, Brigham and Women's Hospital, 850 Boylston Street, Chestnut Hill, MA, 02467, USA.
| | - Todd Jones
- Department of Orthopedic Surgery, Brigham and Women's Hospital, 850 Boylston Street, Chestnut Hill, MA, 02467, USA
| | - Jamie E Collins
- Orthopedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham and Women's Hospital, 75 Francis Street, BTM 5016, Boston, MA, 02115, USA
| | - Swastina Shrestha
- Orthopedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham and Women's Hospital, 75 Francis Street, BTM 5016, Boston, MA, 02115, USA
| | - Wolfgang Fitz
- Department of Orthopedic Surgery, Brigham and Women's Hospital, 850 Boylston Street, Chestnut Hill, MA, 02467, USA
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Affiliation(s)
- J. P. A. M. Loon
- Department of Equine Sciences Faculty of Veterinary Medicine Utrecht University Utrecht The Netherlands
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Jiang Y, Li J, Lin H, Huang Q, Wang T, Zhang S, Zhang Q, Rong Z, Xiong J. The efficacy of gabapentin in reducing pain intensity and morphine consumption after breast cancer surgery: A meta-analysis. Medicine (Baltimore) 2018; 97:e11581. [PMID: 30235654 PMCID: PMC6160249 DOI: 10.1097/md.0000000000011581] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The purpose of this meta-analysis from randomized controlled trials (RCTs) was to determine the efficacy and safety of the preoperative use of gabapentin for the treatment of acute and chronic postoperative pain following breast cancer surgery. METHODS In November 2017, a systematic computer-based search was conducted in PubMed, Embase, Web of Science, Cochrane Library, and Google databases. RCTs comparing gabapentin with placebo in patients undergoing breast cancer surgery were retrieved. The primary endpoint was the visual analog scale (VAS) after surgery and 24 hours after surgery and total morphine consumption. The secondary outcomes were incidence of chronic pain and complications (the incidence of nausea). Software Stata 12.0 was used for meta-analysis. RESULTS Finally, 9 RCTs were included in the meta-analysis. Results indicated that gabapentin was associated with reduced pain scores after surgery and 24 hours after surgery. Meanwhile, oral gabapentin was associated with a reduction of the total morphine consumption after breast cancer surgery. Similarly, gabapentin was associated with a reduction in the incidence of chronic pain and the incidence of nausea. CONCLUSIONS Preoperative use of gabapentin was able to reduce acute and chronic postoperative pain, total morphine consumption and the occurrence of nausea following breast cancer surgery. Further studies should determine the optimal dose of gabapentin for pain control after breast cancer surgery.
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Affiliation(s)
- Yunfeng Jiang
- Oncology Department, The First Affiliated Hospital of Guangxi University of Chinese Medicine
| | | | - Huasheng Lin
- Department of Spleen and Stomach Liver Disease, Nanning, Guangxi
| | - Qiaotong Huang
- Oncology Department, The First Affiliated Hospital of Guangxi University of Chinese Medicine
| | - Tongbiao Wang
- Oncology Department, The First Affiliated Hospital of Guangxi University of Chinese Medicine
| | - Shijie Zhang
- Oncology Department, The First Affiliated Hospital of Guangxi University of Chinese Medicine
| | - Qing Zhang
- College of Education Science, Guangxi Teachers Education University, Nanning
| | - Zheng Rong
- Oncology Department, The First Affiliated Hospital of Guangxi University of Chinese Medicine
| | - Jun Xiong
- Department of Acupuncture and Moxibustion, The Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, Nanchang, Jiangxi, China
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Soffin EM, YaDeau JT. Enhanced recovery after surgery for primary hip and knee arthroplasty: a review of the evidence. Br J Anaesth 2018; 117:iii62-iii72. [PMID: 27940457 DOI: 10.1093/bja/aew362] [Citation(s) in RCA: 184] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) protocols produce significant clinical and economic benefits in a range of surgical subspecialties. There is a long tradition of applying clinical pathways to the perioperative care of joint arthroplasty patients. Enhanced recovery after surgery represents the next step in the evolution of standardized care. To date, reports of full ERAS pathways for hip or knee arthroplasty are lacking. In this narrative review, we present the evidence base that can be usefully applied to constructing ERAS pathways for hip or knee arthroplasty. The history and rationale for applying ERAS to joint arthroplasty are explained. Evidence demonstrates improved outcomes after joint arthroplasty when a standardized approach to care is implemented. The efficacy of individual ERAS components in hip or knee replacement is considered, including preoperative education, intraoperative anaesthetic techniques, postoperative analgesia, and early mobilization after joint arthroplasty. Interventions lacking high-quality evidence are identified, together with recommendations for future research. Based on currently available evidence, we present a model ERAS pathway that can be applied to perioperative care of patients undergoing hip or knee arthroplasty.
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Affiliation(s)
- E M Soffin
- Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY 10021, USA
| | - J T YaDeau
- Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY 10021, USA
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Slavova S, Miller A, Bunn TL, White JR, Kirschke D, Light T, Christy D, Thompson G, Winecker R. Prevalence of gabapentin in drug overdose postmortem toxicology testing results. Drug Alcohol Depend 2018; 186:80-85. [PMID: 29554591 DOI: 10.1016/j.drugalcdep.2018.01.018] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 12/30/2017] [Accepted: 01/22/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND The goal of this study was to establish and compare baseline data on the prevalence of gabapentin identified through postmortem toxicology testing among drug overdose decedents in several geographically diverse states/jurisdictions with differing levels of drug overdose fatality burdens in 2015. METHODS Death certificates and postmortem toxicology result reports from five U.S. jurisdictions were used to identify residents who died from drug overdoses in year 2015 and to calculate prevalence rates of gabapentin in postmortem toxicology by jurisdiction. RESULTS On average, 22% of all drug overdose decedents in our study tested positive for gabapentin. The percentage of gabapentin-positive overdose deaths varied significantly among jurisdictions: 4% in Northeast Tennessee, 7% in Maricopa County, 15% in West Virginia, 20% in North Carolina, and 41% in Kentucky (p < 0.0001). Among the drug overdose decedents who tested positive for opioids (including heroin), 26% also tested positive for gabapentin, with significant variation among states/jurisdictions (p < 0.0001). There was a significant difference in the gender distribution among drug overdose decedents who tested positive for gabapentin (46% male) vs. those who tested negative for gabapentin (65% male) (p < 0.0001). In Kentucky, gabapentin was listed as a contributing drug on the death certificate in 40% of the overdose deaths with gabapentin-positive toxicology; in North Carolina this percentage was 57%. CONCLUSIONS Routine gabapentin postmortem testing and linking of death certificate, medical examiner, coroner, toxicology, and prescription history data will provide more reliable information on the extent of gabapentin misuse, diversion, and implications for clinical care.
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Affiliation(s)
- Svetla Slavova
- Council of State and Territorial Epidemiologists Overdose Subcommittee, USA; Kentucky Injury Prevention and Research Center, University of Kentucky College of Public Health, Lexington, KY, USA.
| | - Alison Miller
- Council of State and Territorial Epidemiologists Overdose Subcommittee, USA; North Carolina Office of the Chief Medical Examiner, Raleigh, NC, USA
| | - Terry L Bunn
- Council of State and Territorial Epidemiologists Overdose Subcommittee, USA; Kentucky Injury Prevention and Research Center, University of Kentucky College of Public Health, Lexington, KY, USA
| | - Jessica R White
- Council of State and Territorial Epidemiologists Overdose Subcommittee, USA; Office of Epidemiology, Maricopa County Department of Public Health, Phoenix, AZ, USA
| | - David Kirschke
- Council of State and Territorial Epidemiologists Overdose Subcommittee, USA; Tennessee Department of Health, Northeast Regional Health Office, Johnson City, TN, USA
| | - Tom Light
- Council of State and Territorial Epidemiologists Overdose Subcommittee, USA; West Virginia Health Statistics Center, A Unit of The West Virginia Bureau for Public Health, Department of Health and Human Resources, Charleston, WV, USA
| | - Daniel Christy
- Council of State and Territorial Epidemiologists Overdose Subcommittee, USA; West Virginia Health Statistics Center, A Unit of The West Virginia Bureau for Public Health, Department of Health and Human Resources, Charleston, WV, USA
| | - Gary Thompson
- Council of State and Territorial Epidemiologists Overdose Subcommittee, USA; West Virginia Health Statistics Center, A Unit of The West Virginia Bureau for Public Health, Department of Health and Human Resources, Charleston, WV, USA
| | - Ruth Winecker
- Council of State and Territorial Epidemiologists Overdose Subcommittee, USA; University of North Carolina, School of Medicine, Department of Pathology and Laboratory Medicine, Chapel Hill, NC, USA
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Kumar K, Kirksey MA, Duong S, Wu CL. A Review of Opioid-Sparing Modalities in Perioperative Pain Management. Anesth Analg 2017; 125:1749-1760. [DOI: 10.1213/ane.0000000000002497] [Citation(s) in RCA: 176] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Liu X, Liu J, Sun G. Preoperative intravenous glucocorticoids can reduce postoperative acute pain following total knee arthroplasty: A meta-analysis. Medicine (Baltimore) 2017; 96:e7836. [PMID: 28858092 PMCID: PMC5585486 DOI: 10.1097/md.0000000000007836] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The ability of preoperative intravenous glucocorticoids to control pain after total knee arthroplasty (TKA) has been examined in many studies, but it remains controversial. Therefore, we undertook a meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of preoperative intravenous glucocorticoids for postoperative pain management after TKA. METHODS We systematically searched RCTs from electronic databases, including PubMed, Embase, Web of Science, the Cochrane Library, the Chinese Wanfang Database, and the China National Knowledge Infrastructure database. The outcomes included visual analogue scale (VAS) scores at 6, 12, 24, 48, and 72 hours after TKA; the occurrence of postoperative nausea and vomiting (PONV); blood glucose at 6 and 24 hours after TKA; and the occurrence of infection. RESULTS Of the identified studies, a total of 11 RCTs involving 1000 patients (glucocorticoids = 501, control = 499) were included in this meta-analysis. Compared with a placebo, preoperative intravenous glucocorticoids significantly reduced VAS scores at 6, 12, 24, and 48 hours, with decreases of 3.63 points, 6.81 points, 10.40 points, and 3.15 points, respectively, on a 110-point VAS. Moreover, intravenous glucocorticoids were associated with significant decreases of 19.4% and 16.8% in the occurrence of nausea and vomiting, respectively. However, intravenous glucocorticoids were also associated with increased blood glucose with no clinical importance at 6 hours after TKA. No significant difference was found in the occurrence of infection or in blood glucose at 24 hours after TKA. CONCLUSION Preoperative intravenous glucocorticoids are an effective and safe method to reduce postoperative pain and PONV in patients following TKA. More studies are necessary to identify the optimal dose and type of glucocorticoids for maximal pain control.
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Wang L, Dong Y, Zhang J, Tan H. The efficacy of gabapentin in reducing pain intensity and postoperative nausea and vomiting following laparoscopic cholecystectomy: A meta-analysis. Medicine (Baltimore) 2017; 96:e8007. [PMID: 28906382 PMCID: PMC5604651 DOI: 10.1097/md.0000000000008007] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND It is unknown whether gabapentin is effective in reducing acute pain following laparoscopic cholecystectomy. The purpose of the current meta-analysis was to evaluate the efficacy of gabapentin in reducing pain intensity and postoperative nausea and vomiting (PONV) after laparoscopic cholecystectomy. METHODS All randomized controlled trials (RCTs) evaluating the efficacy of gabapentin in reducing pain intensity and PONV after laparoscopic cholecystectomy were searched on the following databases: PubMed, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), the Google database, the Chinese Wanfang database, and the China National Knowledge Infrastructure (CNKI). The most recent literature search was conducted on March 21, 2017. Outcomes including visual analog scale (VAS) at 12 and 24 hours, total morphine consumption, and the occurrence of PONV. Continuous outcomes were expressed as the weighted mean difference (WMD) and 95% confidence interval (CI), and the one discontinuous outcome was expressed as risk ratio (RR) and 95% CI. Stata 12.0 software was used for meta-analysis. RESULTS A total of 9 studies involving 966 patients were identified. In total, there were 484 gabapentin subjects and 482 controls. Compared with the control group, gabapentin was associated with lower VAS at 12 hours (WMD = -10.18, 95% CI: -17.36 to -2.80, P = .007) and 24 hours (WMD = -6.33, 95% CI: -8.41 to -4.25, P = .000), which was equivalent on a 110-point VAS scale to 10.18 points at 12 hours and 6.33 points at 24 hours. Compared with the control group, gabapentin was associated with less total morphine consumption by approximately 110.83 mg (WMD = -110.83, 95% CI: -183.25 to -38.42, P = .003). In addition, the occurrence of nausea and vomiting in gabapentin was decreased (25.2% vs 47.6, RR = 0.53, 95% CI: 0.44-0.63, P = .000). CONCLUSION Gabapentin was efficacious in reducing postoperative pain, total morphine consumption, and morphine-related complications following laparoscopic cholecystectomy. In addition, there was a negative correlation between the gabapentin dosage and the occurrence of nausea and vomiting. The number of included studies is limited, and more studies are needed to verify the effects of gabapentin in laparoscopic cholecystectomy patients.
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Affiliation(s)
| | | | - Jiling Zhang
- Department of Gastroenterology, Linyi People's Hospital, Shandong Province, China
| | - Hongwu Tan
- Department of Gastroenterology, Linyi People's Hospital, Shandong Province, China
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Rai A, Meng H, Weinrib A, Englesakis M, Kumbhare D, Grosman-Rimon L, Katz J, Clarke H. A Review of Adjunctive CNS Medications Used for the Treatment of Post-Surgical Pain. CNS Drugs 2017; 31:605-615. [PMID: 28577135 DOI: 10.1007/s40263-017-0440-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Inadequate post-operative pain management can have significant impacts on patients' quality of life. Effective management of acute pain after surgery is important for early mobilization and discharge from hospital, patient satisfaction, and overall well-being. Utilizing multimodal analgesic strategies has become the mainstay of acute post-operative pain management. A comprehensive search was performed, assessing the published or otherwise publically available literature on different central nervous system (CNS) drugs [excluding opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and acetaminophen] and their uses to treat acute post-surgical pain. Included among the drugs evaluated in this review are anticonvulsants, N-methyl-D-aspartic acid (NMDA) agonists, local anesthetics, α2-agonists, cannabinoids, serotonin-noradrenaline reuptake inhibitors (SNRIs), and serotonin-noradrenaline-dopamine reuptake inhibitors (SNDRIs). Timing, dosing, routes of administration, as well as mechanisms of action are discussed for these CNS drugs.
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Affiliation(s)
- Ajit Rai
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, 3 EB-317, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada
| | - Howard Meng
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, 3 EB-317, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada.,Department of Anesthesia, University of Toronto, RM 1200, 12th floor, 123 Edward St., Toronto, Ontario, M5G 1E2, Canada
| | - Aliza Weinrib
- Department of Anesthesia, University of Toronto, RM 1200, 12th floor, 123 Edward St., Toronto, Ontario, M5G 1E2, Canada.,Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada.,Department of Psychology, York University, 4700, Keele St., BSB 232, Toronto, ON, M3J 1P3, Canada
| | - Marina Englesakis
- Library and Information Services, Toronto General HospitalUniversity Health Network, 1 EN-418, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada
| | - Dinesh Kumbhare
- Division of Physical Medicine and Rehabilitation, Department of Medicine, Toronto Rehabilitation Institute, University Health Network, 550 University Ave, Toronto, ON, M5G 2A2, Canada
| | - Liza Grosman-Rimon
- Division of Physical Medicine and Rehabilitation, Department of Medicine, Toronto Rehabilitation Institute, University Health Network, 550 University Ave, Toronto, ON, M5G 2A2, Canada
| | - Joel Katz
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, 3 EB-317, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada.,Department of Anesthesia, University of Toronto, RM 1200, 12th floor, 123 Edward St., Toronto, Ontario, M5G 1E2, Canada.,Department of Psychology, York University, 4700, Keele St., BSB 232, Toronto, ON, M3J 1P3, Canada
| | - Hance Clarke
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, 3 EB-317, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada. .,Department of Anesthesia, University of Toronto, RM 1200, 12th floor, 123 Edward St., Toronto, Ontario, M5G 1E2, Canada. .,Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada.
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Xing LZ, Li L, Zhang LJ. Can intravenous steroid administration reduce postoperative pain scores following total knee arthroplasty?: A meta-analysis. Medicine (Baltimore) 2017; 96:e7134. [PMID: 28614237 PMCID: PMC5478322 DOI: 10.1097/md.0000000000007134] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The purpose of this systematic review and meta-analysis of randomized controlled trials (RCTs) was to evaluate whether intravenous steroids would result in reduced acute pain and postoperative nausea and vomiting (PONV) among patients undergoing total knee arthroplasty (TKA). METHODS Electronic databases, including PubMed, Embase, Web of Science, and the Cochrane Library, were searched to identify articles published from database inception to July 2016. RCTs that compared the effects of intravenous steroids with the effects of placebo among patients undergoing TKA were included in this meta-analysis. The primary outcomes were visual analogue scale (VAS) scores after 12, 24, and 48 hours of rest and PONV incidence. The secondary outcomes were blood glucose levels and incidence of infection. We calculated the risk ratio (RR) with its corresponding 95% confidence interval (CI) for dichotomous outcomes and the mean difference (MD) with its corresponding 95% CI for continuous outcomes. RESULTS Seven clinical trials involving 434 patients were included in the final meta-analysis. The pooled results indicated that intravenous steroids were associated with decreased VAS scores after 24 hours (MD = -10.21, 95%CI = -18.80 to -1.63, P = .020) and 48 hours (MD = -2.60, 95%CI = -4.70 to -0.50, P = .015) of rest. Moreover, intravenous steroids were also associated with decreased risk of nausea (RR = 0.58, 95% CI 0.44-0.77, P = .000) and vomiting (RR = 0.46, 95% CI = 0.24-0.88, P = .019). However, intravenous steroids were also associated with increased blood glucose levels. No significant difference in the risk of infection was identified between the 2 groups. CONCLUSION Intravenous steroids may be associated with decreased pain intensity and decreased risk of nausea and vomiting during the early period following TKA. However, evidence supporting its use is limited by the low quality of and variations in dosing regimens between the included RCTs. Thus, more high-quality RCTs are needed to identify the optimal drug administration intervals for maximal pain control.
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Affiliation(s)
| | - Li Li
- Department of Hepatobiliary Surgery, Linyi People's Hospital, Linyi, Shandong, China
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Li S, Guo J, Li F, Yang Z, Wang S, Qin C. Pregabalin can decrease acute pain and morphine consumption in laparoscopic cholecystectomy patients: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2017; 96:e6982. [PMID: 28538404 PMCID: PMC5457884 DOI: 10.1097/md.0000000000006982] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Pregabalin has been used as an adjunct for the management of acute pain in laparoscopic cholecystectomy. This meta-analysis aimed to illustrate the efficacy and safety of pregabalin for pain management following laparoscopic cholecystectomy. METHODS In March 2017, a systematic computer-based search was conducted in PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews, and Google databases. Data on patients prepared for laparoscopic cholecystectomy in studies that compared pregabalin versus placebo were retrieved. The primary endpoints were the visual analog scale (VAS) score with rest or mobilization at 6, 12, and 24 hours and total morphine consumption. The secondary outcomes were the morphine-related complications (i.e., nausea, vomiting, dizziness, somnolence, headache, pruritus, urine retention, respiratory depression, and blurred vision). Continuous outcomes were expressed as the weighted mean difference (WMD) with a corresponding 95% confidence interval (CI), and discontinuous outcomes were expressed as a risk ratio (RR) with a corresponding 95% CI. RESULTS Twelve clinical studies with 938 patients (gabapentin group = 536, control group = 402) were ultimately included in the meta-analysis. Pregabalin was associated with reduced pain scores with rest at 6, 12, and 24 hours, which corresponded to a reduction of 11.27 points at 6 hours, 9.46 points at 12 hours, and 3.99 points at 24 hours on a 100-point VAS. Moreover, pregabalin was associated with reduced pain scores with mobilization at 6, 12, and 24 hours, which corresponded to a reduction of 8.74 points, 5.80 points and 6.37 points at 6, 12, and 24 hours, respectively, on a 110-point VAS. Furthermore, pregabalin reduced the occurrence of nausea and vomiting. There were no significant differences in the occurrence of respiratory depression, pruritus, dizziness, blurred vision, and headache. CONCLUSIONS Pregabalin was efficacious in the reduction of postoperative pain, total morphine consumption, and morphine-related complications following laparoscopic cholecystectomy. In addition, a high dose of pregabalin was more effective than a low dose. The dose of pregabalin differed across the studies, and the heterogeneity was large. More studies are needed to verify the optimal dose of pregabalin in laparoscopic cholecystectomy patients.
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Affiliation(s)
| | | | | | | | | | - Changjiang Qin
- Department of General Surgery, Huaihe Hospital, Henan University, Kaifeng, China
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Peng C, Li C, Qu J, Wu D. Gabapentin can decrease acute pain and morphine consumption in spinal surgery patients: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2017; 96:e6463. [PMID: 28403075 PMCID: PMC5403072 DOI: 10.1097/md.0000000000006463] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Approximately 80% of patients who underwent spinal surgeries experience moderate to extreme postoperative pain. Gabapentin was used as an adjunct for the management of acute pain in approximately half of enhanced recovery programs. This meta-analysis aimed to illustrate the efficacy and safety of gabapentin for pain management following spinal surgery. METHODS In January 2017, a systematic computer-based search was conducted in PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews, and Google database. Data on patients prepared for spine surgery in studies that compared gabapentin versus placebo were retrieved. The primary endpoint was the visual analog scale (VAS) at 12 hours and 24 hours and total morphine consumption. The secondary outcomes were complications that included nausea, dizziness, somnolence, headache, pruritus, urine retention, and vomiting. After testing for publication bias and heterogeneity between studies, data were aggregated for random-effects models when necessary. RESULTS Seven clinical studies with 581 patients (gabapentin group=383, control group=198) were ultimately included in the meta-analysis. Gabapentin was associated with reduced pain scores at 12 hours and 24 hours, corresponding to a reduction of 11.18 points (95% CI, -13.85 to -8.52 points) at 12 hours and 9.94 points (95% CI, -13.99 to -5.89 points) at 24 hours on a 100-point VAS. Similarly, gabapentin was associated with a reduction in total morphine consumption (-2.04, 95% CI -2.71, -1.37). Furthermore, gabapentin can reduce the occurrence of vomiting (risk ratio [RR] 0.46, 95% CI 0.27, 0.78, P = 0.004), urine retention (RR = 0.57, 95% CI 0.34, 0.98, P = 0.041, NNT = 11.9) and pruritus (RR = 0.38, 95% CI 0.22, 0.66, P = 0.001, NNT = 5.6) and the number needed to treat (NNT = 20.1). There were no significant differences in the occurrence of nausea, dizziness, somnolence, or headache. CONCLUSIONS Gabapentin was efficacious in the reduction of postoperative pain, total morphine consumption, and morphine-related complications following spine surgery. In addition, a high dose (≥900 mg/d) of gabapentin is more effective than a low dose (<900 mg/d). The number of included studies is limited, and more studies are needed to verify the effects of gabapentin in spinal surgery patients.
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Improving Pain Management and Long-Term Outcomes Following High-Energy Orthopaedic Trauma (Pain Study). J Orthop Trauma 2017; 31 Suppl 1:S71-S77. [PMID: 28323806 DOI: 10.1097/bot.0000000000000793] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Poor pain control after orthopaedic trauma is a predictor of physical disability and numerous negative long-term outcomes. Despite increased awareness of the negative consequences of poorly controlled pain, analgesic therapy among hospitalized patients after orthopaedic trauma remains inconsistent and often inadequate. The Pain study is a 3 armed, prospective, double-blind, multicenter randomized trial designed to evaluate the effect of standard pain management versus standard pain management plus perioperative nonsteroidal anti-inflammatory drugs or pregabalin in patients of ages 18-85 with extremity fractures. The primary outcomes are chronic pain, opioid utilization during the 48 hours after definitive fixation and surgery for nonunion in the year after fixation. Secondary outcomes include preoperative and postoperative pain intensity, adverse events and complications, physical function, depression, and post-traumatic stress disorder. One year treatment costs are also compared between the groups.
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Khezri MB, Nasseh N, Soltanian G. The comparative preemptive analgesic efficacy of addition of vitamin B complex to gabapentin versus gabapentin alone in women undergoing cesarean section under spinal anesthesia: A prospective randomized double-blind study. Medicine (Baltimore) 2017; 96:e6545. [PMID: 28403084 PMCID: PMC5403081 DOI: 10.1097/md.0000000000006545] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Development of new multimodal analgesic regimens have led to substantial improvement in postoperative pain relief. We designed this study to compare the effect of combined vitamin B complex-gabapentin versus gabapentin alone on postoperative pain in women undergoing cesarean section under spinal anesthesia. METHODS One hundred twenty-eight women who underwent cesarean section under spinal anesthesia were randomized to receive orally 300 mg gabapentin (group G) or 300 mg of gabapentin plus 2 vitamin B complex (group GB) tablets 30 minutes before surgery. Postoperative pain intensity and total analgesic consumption during 12 hours after surgery, vomiting, and drowsiness during recovery were assessed. RESULTS The pain intensity in the gabapentin plus vitamin B complex group was lower than gabapentin group during 12 hours after surgery (95% CI: 1.4-2.2; P < .001). Meanwhile, the total analgesic consumption in this group was less than gabapentin alone (95% CI: 1.07-1.24; P = 0.034). The incidence of vomiting in patients who receive combined gabapentin-vitamin B complex group was similar to gabapentin alone (P = .206). The difference of the distribution of the relative frequency of sedation according to Ramsay sedation scores in patients between 2 groups were insignificant (P = .82). All newborns in our study were free of any adverse effects. CONCLUSION Addition of vitamin B complex to gabapentin reduced intensity of postoperative pain and also the total amount of analgesic consumption within the first 12 hours postoperative following cesarean section.
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Liu SQ, Chen X, Yu CC, Weng CW, Wu YQ, Xiong JC, Xu SH. Comparison of periarticular anesthesia with liposomal bupivacaine with femoral nerve block for pain control after total knee arthroplasty: A PRISMA-compliant meta-analysis. Medicine (Baltimore) 2017; 96:e6462. [PMID: 28353580 PMCID: PMC5380264 DOI: 10.1097/md.0000000000006462] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Periarticular anesthesia (PAI) with liposomal bupivacaine (LB) and femoral nerve block (FNB) were 2 common type of pain management after total knee arthroplasty (TKA). There is no consensus about PAI with LB shows better clinical outcome than FNB. Thus, we performed a systematic review and meta-analysis to compare the efficacy and safety of PAI with LB and FNB for patients prepared for TKA. METHODS Randomized controlled trials (RCTs) and non-RCTs from PubMed (1966-2017.2), EMBASE (1980-2017.2), and the Cochrane Central Register of Controlled Trials (CENTRAL, 2017.2), Web of Science (1966-2017.2), and Chinese Wanfang database (1980-2017.2) were searched. Continuous outcomes including visual analogue scale (VAS) at 24, 48, and 72 hours, total morphine consumption, length of hospital, and range of motion (ROM) were reported as the weighted mean difference with 95% and confidence interval (CI) and discontinuous outcomes (the occurrence of postoperative nausea and vomiting [PONV]) were presented as relative risk with 95% CI. Random-effects model was adopted to analyze the relevant data. RESULTS According to the inclusion and exclusion criteria, 8 studies with 2407 patients were eligible and finally included in this meta-analysis (LB = 1114, FNB = 1293). There was no significant difference between VAS at 24, 4, and 72 hours, ROM, and the occurrence of PONV between PAI with LB group versus FNB group (P > 0.05). Compared with the FNB group, PAI with LB was associated with a significant decrease in length of hospital stay by 0.43 day (MD = -0.43; 95% CI -0.60 to -0.27; P = 0.001) and the total dose of total morphine consumption by (MD = -29.32; 95% CI -57.55 to -1.09; P = 0.042). CONCLUSIONS The review of trials found that PAI with LB provided a significant beneficial effect over FNB in improving the pain or decreased the total morphine consumption in patients who underwent TKA. However, PAI with LB associated with less LOS than FNB. More high quality RCTs are still needed to identify the effects and optimal dose of LB for pain management after TKA.
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Affiliation(s)
- Shu-qun Liu
- Department of Anaesthesiology, Wenzhou People's Hospital, Canghou Xiang, Wenzhou, Zhejiang province, China
| | - Xiang Chen
- Department of Anaesthesiology, Wenzhou People's Hospital, Canghou Xiang, Wenzhou, Zhejiang province, China
| | - Chen-chen Yu
- Department of Anaesthesiology, Wenzhou People's Hospital, Canghou Xiang, Wenzhou, Zhejiang province, China
| | - Cheng-wei Weng
- Department of Anaesthesiology, Wenzhou People's Hospital, Canghou Xiang, Wenzhou, Zhejiang province, China
| | - Yan-qin Wu
- Department of Anaesthesiology, Wenzhou People's Hospital, Canghou Xiang, Wenzhou, Zhejiang province, China
| | - Jun-cheng Xiong
- Department of Anaesthesiology, Wenzhou People's Hospital, Canghou Xiang, Wenzhou, Zhejiang province, China
| | - Shi-hao Xu
- Department of Anaesthesiology, Wenzhou Central Hospital, Dajian Xiang, Wenzhou, Zhejiang Province, China
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Yung L, Lee KC, Hsu C, Furnish T, Atayee RS. Patterns of naloxone use in hospitalized patients. Postgrad Med 2016; 129:40-45. [DOI: 10.1080/00325481.2017.1263139] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Lisa Yung
- Department of Pharmacy, UC San Diego Health, San Diego, CA, USA
| | - Kelly C. Lee
- Department of Pharmacy, UC San Diego Health, San Diego, CA, USA
- UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA, USA
| | - Chih Hsu
- Department of Pharmacy, UC San Diego Health, San Diego, CA, USA
| | - Timothy Furnish
- Department of Anesthesiology, UC San Diego Health, San Diego, CA, USA
| | - Rabia S. Atayee
- Department of Pharmacy, UC San Diego Health, San Diego, CA, USA
- UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA, USA
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