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Fernández Martin MT, Alvarez Lopez S, Aldecoa Alvarez-Santullano C. Role of adjuvants in regional anesthesia: A systematic review. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:97-107. [PMID: 36813032 DOI: 10.1016/j.redare.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 06/16/2021] [Indexed: 02/22/2023]
Abstract
The combination of drugs and routes of administration produces a synergistic effect, and one of the most important components of multimodal analgesic strategies are, therefore, nerve blocks for pain management. The effect of a local anaesthetic can be prolonged by administering an adjuvant. In this systematic review, we included studies on adjuvants associated with local anaesthetics in peripheral nerve blocks published in the last 5 years in order to evaluate their effectiveness. The results were reported according to the PRISMA guidelines. The 79 studies selected using our criteria showed a clear prevalence of dexamethasone (n=24) and dexmedetomidine (n=33) over other adjuvants. Different meta-analyses comparing adjuvants suggest that dexamethasone administered perineurally achieves superior blockade with fewer side effects than dexmedetomidine. Based on the studies reviewed, we found moderate evidence to recommend the use of dexamethasone as an adjuvant to peripheral regional anaesthesia in surgeries that can cause moderate to severe pain.
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Affiliation(s)
- M T Fernández Martin
- Servicio de Anestesiología y Reanimación, Hospital Universitario Río Hortega, Valladolid, Spain.
| | - S Alvarez Lopez
- Servicio de Anestesiología y Reanimación, Hospital Abente y Lago, A Coruña, Spain
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Gupta AK, Mena S, Jin Z, Gan TJ, Bergese S. Postoperative pain: a review of emerging therapeutic options. Expert Rev Neurother 2021; 21:1085-1100. [PMID: 34461794 DOI: 10.1080/14737175.2021.1974840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Postoperative pain is often managed by opioid medications, even though they carry a risk of adverse effects such as vomiting, constipation, sedation, respiratory depression and physical dependence. Furthermore, opioid use in the healthcare setting has likely contributed to the epidemic. However, the mismanagement of postoperative pain can result in delayed recovery time, impaired physical function, increased risk of morbidity and mortality, chronic pain, and higher healthcare costs. AREAS COVERED This review explores emerging therapeutic options and strategies in the management of acute postoperative pain and focuses on opioid-sparing, multimodal analgesia. This includes regional anesthetic techniques, non opioid pharmacotherapy, novel opioids and non-pharmacologic therapy. We have also discussed examples of novel analgesics and formulations which have potential benefits in reducing postoperative pain and opioid use after surgery. EXPERT OPINION The development of novel regional anesthesia techniques allows for opioid minimization in increasing number of surgical procedures. This synergizes with the availability of novel non-opioid analgesic adjucts. In addition, several novel opioid drugs have been developed which may be pathway selective and associated with less adverse effect than conventional opioids.
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Affiliation(s)
- Abhishek K Gupta
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, United States
| | - Shayla Mena
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, United States
| | - Zhaosheng Jin
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, United States
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, United States
| | - Sergio Bergese
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, United States.,Department of Neurological Surgery, Stony Brook University Health Science Center, Stony Brook, United States
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Bigalke S, Maeßen TV, Schnabel K, Kaiser U, Segelcke D, Meyer-Frießem CH, Liedgens H, Macháček PA, Zahn PK, Pogatzki-Zahn EM. Assessing outcome in postoperative pain trials: are we missing the point? A systematic review of pain-related outcome domains reported in studies early after total knee arthroplasty. Pain 2021; 162:1914-1934. [PMID: 33492036 DOI: 10.1097/j.pain.0000000000002209] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/21/2020] [Indexed: 01/04/2023]
Abstract
ABSTRACT The management of acute postoperative pain remains suboptimal. Systematic reviews and Cochrane analysis can assist with collating evidence about treatment efficacy, but the results are limited in part by heterogeneity of endpoints in clinical trials. In addition, the chosen endpoints may not be entirely clinically relevant. To investigate the endpoints assessed in perioperative pain trials, we performed a systematic literature review on outcome domains assessing effectiveness of acute pain interventions in trials after total knee arthroplasty. We followed the Cochrane recommendations for systematic reviews, searching PubMed, Cochrane, and Embase, resulting in the screening of 1590 potentially eligible studies. After final inclusion of 295 studies, we identified 11 outcome domains and 45 subdomains/descriptors with the domain "pain"/"pain intensity" most commonly assessed (98.3%), followed by "analgesic consumption" (88.8%) and "side effects" (75.3%). By contrast, "physical function" (53.5%), "satisfaction" (28.8%), and "psychological function" (11.9%) were given much less consideration. The combinations of outcome domains were inhomogeneous throughout the studies, regardless of the type of pain management investigated. In conclusion, we found that there was high variability in outcome domains and inhomogeneous combinations, as well as inconsistent subdomain descriptions and utilization in trials comparing for effectiveness of pain interventions after total knee arthroplasty. This points towards the need for harmonizing outcome domains, eg, by consenting on a core outcome set of domains which are relevant for both stakeholders and patients. Such a core outcome set should include at least 3 domains from 3 different health core areas such as pain intensity, physical function, and one psychological domain.
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Affiliation(s)
- Stephan Bigalke
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
- Clinic for Anaesthesiology, Intensive and Pain Medicine, Ruhr-University Bochum, BG-University Hospital Bergmannsheil gGmbH, Bochum, Germany
| | - Timo V Maeßen
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
| | - Kathrin Schnabel
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
| | - Ulrike Kaiser
- University Pain Centre, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Daniel Segelcke
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
| | - Christine H Meyer-Frießem
- Clinic for Anaesthesiology, Intensive and Pain Medicine, Ruhr-University Bochum, BG-University Hospital Bergmannsheil gGmbH, Bochum, Germany
| | | | - Philipp A Macháček
- Faculty of Electrical Engineering and Information Technology, Ruhr-University Bochum, Bochum, Germany
| | - Peter K Zahn
- Clinic for Anaesthesiology, Intensive and Pain Medicine, Ruhr-University Bochum, BG-University Hospital Bergmannsheil gGmbH, Bochum, Germany
| | - Esther M Pogatzki-Zahn
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
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Lalonde S, Wood GC. Short stay total joint arthroplasty program: patient factors predicting readmission. Can J Surg 2019; 62:1-7. [PMID: 30900435 PMCID: PMC6738504 DOI: 10.1503/cjs.009218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2018] [Indexed: 11/01/2022] Open
Abstract
Background The aim of this study was to evaluate the effectiveness of our short stay arthroplasty program as measured by 30-day readmission rate and the rate of transfer to inpatient care. Risk factors for readmission/transfer were also evaluated and contrasted with current patient screening criteria. Methods We retrospectively reviewed 297 charts for all primary total joint arthroplasties completed in the short stay program during an 18-month period. Data included readmission and patient characteristics such as age, sex, comorbidities, the American Society of Anesthesiologists (ASA) physical classification grade, body mass index (BMI) and the number of preoperative medications. Results The 30-day readmission rate was 2.6% (n = 8). With the inclusion of patients transferred to the inpatient hospital, the overall failure rate of our short stay program was 6.7% (n = 20). Multivariable modelling controlling for age, BMI and ASA suggested that those with an in-hospital complication were 11.4 times more likely to be readmitted or transferred to inpatient care (p < 0.001) with a trend for patients who were taking more medications (p = 0.09). Conclusion The current readmission rate from this program is comparable to previously published data in the arthroplasty literature. However, several patients required transfer to inpatient care, which significantly impacted the effectiveness of the short stay program. Risk factors for readmission/transfer are not completely accounted for by current presurgical screening criteria. Further evaluation of the Blaylock Risk Assessment Screening Score is required to determine its value for predicting hospital readmission.
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Affiliation(s)
- Sebastien Lalonde
- From the Department of Surgery, Kingston Health Sciences Centre, Queens University, Kingston, Ont
| | - Gavin C.A. Wood
- From the Department of Surgery, Kingston Health Sciences Centre, Queens University, Kingston, Ont
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Emelife PI, Eng MR, Menard BL, Myers AS, Cornett EM, Urman RD, Kaye AD. Adjunct medications for peripheral and neuraxial anesthesia. Best Pract Res Clin Anaesthesiol 2018; 32:83-99. [PMID: 30322466 DOI: 10.1016/j.bpa.2018.06.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 06/18/2018] [Indexed: 02/06/2023]
Abstract
Regional and neuraxial anesthesia can provide a safer perioperative experience, greater satisfaction, reduced opioid consumption, and reduction of pain, while minimizing side effects. Ultrasound technology has aided clinicians in depositing local anesthetic medication in precise proximity to targeted peripheral nerves. There are a plethora of adjuvants that have been utilized to prolong local anesthetic actions and enhance effects in peripheral nerve blocks. This manuscript describes the current state of the use of adjuncts, e.g., dexmedetomidine, dexamethasone, clonidine, epinephrine, etc., in regional anesthesia. Additionally, evidence behind dosing and block prolongation is summarized along with patient outcomes, adverse effects, and future directions.
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Affiliation(s)
- Patrick Ifesinachi Emelife
- Department of Anesthesiology, LSU Health Sciences Center, Room 653, 1542 Tulane Ave., New Orleans, LA, 70112, USA.
| | - Matthew R Eng
- Department of Anesthesiology, LSU Health Sciences Center, Room 656, 1542 Tulane Ave., New Orleans, LA, 70112, USA.
| | - Bethany L Menard
- Department of Anesthesiology, LSU Health Sciences Center, Room 656, 1542 Tulane Ave., New Orleans, LA, 70112, USA.
| | - Andrew S Myers
- LSU Health Sciences Center, 433 Bolivar St., New Orleans, LA, 70112, USA.
| | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
| | - Alan D Kaye
- Department of Anesthesiology, LSU Health Sciences Center, Room 653, 1542 Tulane Ave., New Orleans, LA, 70112, USA.
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Hirschmann MT, Kort N, Kopf S, Becker R. Fast track and outpatient surgery in total knee arthroplasty: beneficial for patients, doctors and hospitals. Knee Surg Sports Traumatol Arthrosc 2017; 25:2657-2658. [PMID: 28831572 DOI: 10.1007/s00167-017-4660-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 07/25/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), 4101, Bruderholz, Switzerland. .,University of Basel, 4000, Basel, Switzerland.
| | - Nanne Kort
- Department of Orthopedics and Traumatology, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - Sebastian Kopf
- Department of Orthopedics and Traumatology, Centre of Joint Replacement, Hospital Brandenburg and "Theodor Fontane" Medical School, 14770, Brandenburg/Havel, Germany
| | - Roland Becker
- Department of Orthopedics and Traumatology, Centre of Joint Replacement, Hospital Brandenburg and "Theodor Fontane" Medical School, 14770, Brandenburg/Havel, Germany
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