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Lirk P, Schreiber KL. Lessons learnt in evidence-based perioperative pain medicine: changing the focus from the medication and procedure to the patient. Reg Anesth Pain Med 2024; 49:688-691. [PMID: 38355216 DOI: 10.1136/rapm-2023-105235] [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] [Received: 12/15/2023] [Accepted: 02/01/2024] [Indexed: 02/16/2024]
Abstract
Over time, the focus of evidence-based acute pain medicine has shifted, from a focus on drugs and interventions (characterized by numbers needed to treat), to an appreciation of procedure-specific factors (characterized by guidelines and meta-analyses), and now anesthesiologists face the challenge to integrate our current approach with the concept of precision medicine. Psychometric and biopsychosocial markers can potentially guide clinicians on who may need more aggressive perioperative pain management, or who would respond particularly well to a given analgesic intervention. The challenge will be to identify an easily assessable set of parameters that will guide perioperative physicians in tailoring the analgesic strategy to procedure and patient.
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Affiliation(s)
- Philipp Lirk
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kristin L Schreiber
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Suleiman NN, Luedi MM, Joshi G, Dewinter G, Wu CL, Sauter AR. Perioperative pain management for cleft palate surgery: a systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations. Reg Anesth Pain Med 2024; 49:635-641. [PMID: 38124208 DOI: 10.1136/rapm-2023-105024] [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] [Received: 09/27/2023] [Accepted: 11/27/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND/IMPORTANCE Cleft palate surgery is associated with significant postoperative pain. Effective pain control can decrease stress and agitation in children undergoing cleft palate surgery and improve surgical outcomes. However, limited evidence often results in inadequate pain control after cleft palate surgery. OBJECTIVES The aim of this review was to evaluate the available evidence and to develop recommendations for optimal pain management after cleft palate surgery using procedure-specific postoperative pain management (PROSPECT) methodology. EVIDENCE REVIEW MEDLINE, Embase, and Cochrane Databases were searched for randomized controlled trials and systematic reviews assessing pain in children undergoing cleft palate repair published in English language from July 2002, through August 2023. FINDINGS Of 1048 identified studies, 19 randomized controlled trials and 4 systematic reviews met the inclusion criteria. Interventions that improved postoperative pain, and are recommended, include suprazygomatic maxillary nerve block or palatal nerve block (if maxillary nerve block cannot be performed). Addition of dexmedetomidine to local anesthetic for suprazygomatic maxillary nerve block or, alternatively, as intravenous administration perioperatively is recommended. These interventions should be combined with a basic analgesic regimen including acetaminophen and nonsteroidal anti-inflammatory drugs. Of note, pre-incisional local anesthetic infiltration and dexamethasone were administered as a routine in several studies, however, because of limited procedure-specific evidence their contribution to pain relief after cleft palate surgery remains unknown. CONCLUSION The present review identified an evidence-based analgesic regimen for cleft palate surgery in pediatric patients. PROSPERO REGISTRATION NUMBER CRD42022364788.
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Affiliation(s)
- Nergis Nina Suleiman
- Department of Plastic and Reconstructive Surgery, Oslo University Hospital, Oslo, Norway
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
- Department of Anaesthesiology, Cantonal Hospital of St Gallen, St Gallen, Switzerland
| | - Girish Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Geertrui Dewinter
- Department of Cardiovascular Sciences, Section Anesthesiology, KU Leuven and University Hospital Leuven, Leuven, Belgium
| | - Christopher L Wu
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Axel R Sauter
- Department of Anaesthesia and Intensive Care Medicine, Oslo University Hospital, Oslo, Norway
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Bourgeois C, Oyaert L, Van de Velde M, Pogatzki-Zahn E, Freys SM, Sauter AR, Joshi GP, Dewinter G. Pain management after laparoscopic cholecystectomy: A systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations. Eur J Anaesthesiol 2024:00003643-990000000-00210. [PMID: 39129451 DOI: 10.1097/eja.0000000000002047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
Laparoscopic cholecystectomy can be associated with significant postoperative pain that is difficult to treat. We aimed to evaluate the available literature and develop updated recommendations for optimal pain management after laparoscopic cholecystectomy. A systematic review was performed using the procedure-specific postoperative pain management (PROSPECT) methodology. Randomised controlled trials and systematic reviews published in the English language from August 2017 to December 2022 assessing postoperative pain after laparoscopic cholecystectomy using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases. From 589 full text articles, 157 randomised controlled trials and 31 systematic reviews met the inclusion criteria. Paracetamol combined with NSAIDs or cyclo-oxygenase-2 inhibitors should be given either pre-operatively or intra-operatively, unless contraindicated. In addition, intra-operative intravenous (i.v.) dexamethasone, port-site wound infiltration or intraperitoneal local anaesthetic instillation are recommended, with opioids used for rescue analgesia. As a second-line regional technique, the erector spinae plane block or transversus abdominis plane block may be reserved for patients with a heightened risk of postoperative pain. Three-port laparoscopy, a low-pressure pneumoperitoneum, umbilical port extraction, active aspiration of the pneumoperitoneum and saline irrigation are recommended technical aspects of the operative procedure. The following interventions are not recommended due to limited or no evidence on improved pain scores: single port or mini-port techniques, routine drainage, low flow insufflation, natural orifice transluminal endoscopic surgery (NOTES), infra-umbilical incision, i.v. clonidine, nefopam and regional techniques such as quadratus lumborum block or rectus sheath block. Several interventions provided better pain scores but are not recommended due to risk of side effects: spinal or epidural anaesthesia, gabapentinoids, i.v. lidocaine, i.v. ketamine and i.v. dexmedetomidine.
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Affiliation(s)
- Camille Bourgeois
- From the Department of Cardiovascular Sciences, Section Anaesthesiology, KU Leuven and University Hospital Leuven, Belgium (CB, LO, MvdV, GD), Department of Anaesthesiology, Intensive Care, and Pain Medicine, University Hospital Münster, Münster (EP-Z), Department of Surgery, DIAKO Ev. Diakonie-Krankenhaus, Bremen, Germany (SMF), Division of Emergencies and Critical Care, Department of Anaesthesiology and Department of Research and Development, Oslo University Hospital, Oslo, Norway (ARS), Department of Anaesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA (GPJ)
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Zaballos M, Reyes A, Cordero JM, Sánchez Hernández M, Hidalgo LA, Docobo Durantez F, Morales-Garcia D. Strategy for the management of acute postoperative pain in day surgery centres in Spain. DUCMA 2.0. project. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024:S2341-1929(24)00123-9. [PMID: 38972354 DOI: 10.1016/j.redare.2024.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/03/2024] [Accepted: 02/05/2024] [Indexed: 07/09/2024]
Abstract
INTRODUCTION Adequate treatment of acute postoperative pain is one of the quality requirements in ambulatory surgery and its suboptimal management is associated with delayed discharge, unplanned admissions and late admissions after home discharge. The aim of the present study was to learn about the organizational strategy for the management of postoperative pain in ambulatory surgery units (ASU) in Spain. METHODS A cross-sectional, multicenter study was carried out based on an electronic survey on aspects related to the management of acute postoperative pain in different ASUs in our country. RESULTS We recruited 133 ASUs of which 85 responded to the questions on the management of postoperative pain. Of the ASUs that responded, 80% had specific protocols for pain management and 37.6% provided preoperative information on the analgesic plan. The assessment of postoperative pain is carried out in 88.2% of the ASUs in the facility and only 56.5% at home. All ASUs use multimodal analgesia protocols; however, 68.2% report the use of opioids for the treatment of moderate to severe pain. Home invasive analgesia strategies are minimally used by the surveyed ASUs. CONCLUSIONS The DUCMA study highlights that the practice of pain treatment in day surgery remains a challenge in our country and is not always in agreement with national guidelines. The results suggest the need to establish strategies to improve clinical practice and homogenize pain management in ambulatory surgery.
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Affiliation(s)
- M Zaballos
- Servicio de Anestesiología y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Departamento de Medicina Legal, Psiquiatría y Patología, Universidad Complutense, Madrid, Spain.
| | - A Reyes
- Servicio de Anestesiología y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - J M Cordero
- Servicio de Anestesiología y Reanimación, Hospital Virgen del Rocío, Sevilla, Spain
| | - M Sánchez Hernández
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario de Salamanca, Salamanca, Spain
| | - L A Hidalgo
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Mataró, Barcelona, Spain
| | - F Docobo Durantez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - D Morales-Garcia
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Clínico Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
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Luxey X, Lemoine A, Dewinter G, Joshi GP, Le Ray C, Raeder J, Van de Velde M, Bonnet MP. Acute pain management after vaginal delivery with perineal tears or episiotomy. Reg Anesth Pain Med 2024:rapm-2024-105478. [PMID: 38772634 DOI: 10.1136/rapm-2024-105478] [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: 03/14/2024] [Accepted: 04/27/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND A vaginal delivery may be associated with acute postpartum pain, particularly after perineal trauma. However, pain management in this setting remains poorly explored. OBJECTIVE The aim of this systematic review was to evaluate the literature and to develop recommendations for pain management after a vaginal delivery with perineal trauma. EVIDENCE REVIEW MEDLINE, Embase, and Cochrane databases were searched for randomized controlled trials (RCTs) and systematic reviews assessing pain after a vaginal delivery with perineal tears or episiotomy until March 2023. Cochrane Covidence quality assessment generic tool and the RoB Vis 2 tool were used to grade the quality of evidence. FINDINGS Overall, 79 studies (69 RCTs and 10 systematic reviews and meta-analyses) of good quality of evidence were included. Acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line treatment. Epidural morphine (≤2 mg) is recommended among women with labor epidural analgesia and severe perineal tears, with adequate respiratory monitoring. Local anesthetic infiltration, topical local anesthetic, ointment application, and pudendal nerve block are not recommended due to insufficient or lack of evidence. Ice or chemical cold packs are recommended for postpartum pain first-line treatment due to their simplicity of use. Transcutaneous nerve stimulation and acupuncture are recommended as adjuvants. When a perineal suture is indicated, a continuous suture compared with an interrupted suture for the repair of episiotomy or second-degree perineal tears is recommended for the outcome of pain. For women with first-degree or second-degree perineal tears, no suturing or glue compared with suturing is recommended for the outcome of pain. CONCLUSIONS Postpartum pain management after a vaginal delivery with perineal trauma should include acetaminophen, NSAIDs, and ice or chemical cold packs. Epidural morphine should be reserved for severe perineal tears. A surgical repair technique should depend on perineal tear severity.
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Affiliation(s)
- Xavier Luxey
- Anesthesiology and Intensive Care Medicine, Hôpital Armand-Trousseau, DMU DREAM, AP-HP, Paris, Île-de-France, France
- Hôpital de la Timone service d'anesthésie réanimation 1, Marseille, Provence-Alpes-Côte d'Azur, France
| | - Adrien Lemoine
- Anesthesia, Intensive Care and Perioperative Medicine, Tenon Hospital, DMU DREAM, AP-HP, Paris, France
| | - Geertrui Dewinter
- Biomedical Sciences Group, Department of Cardiovascular Sciences, Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
| | - Camille Le Ray
- Port Royal Maternity Unit, Cochin Hospital, Université Paris Cité, APHP, Paris, Île-de-France, France
- Centre for Epidemiology and StatisticS (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, INSERM, Paris, Île-de-France, France
| | - Johan Raeder
- Institute of Clinical Medicine, department of Anesthesiology, Oslo University Hospital, Oslo, Norway
| | - Marc Van de Velde
- Biomedical Sciences Group, department of cardiovascular sciences, Department of anesthesiolgy, University Hospitals Leuven, Leuven, Vlaams-Brabant, Belgium
| | - Marie-Pierre Bonnet
- Centre for Epidemiology and StatisticS (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, INSERM, Paris, Île-de-France, France
- Department of Anesthesiology and Intensive Care Medicine, Armand Trousseau Hospital, DMU DREAM, GRC29, Sorbonne University, APHP, Paris, Île-de-France, France
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Suresh V, Magoon R. 'Ten'der points of perioperative analgesia research. J Anaesthesiol Clin Pharmacol 2024; 40:181-184. [PMID: 38919419 PMCID: PMC11196048 DOI: 10.4103/joacp.joacp_39_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 01/31/2024] [Indexed: 06/27/2024] Open
Affiliation(s)
- Varun Suresh
- Department of Anesthesia and Intensive Care, Jaber Al Ahmad Al Sabah Hospital, Kuwait Arabian Gulf, Kuwait
| | - Rohan Magoon
- Department of Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, India
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, India
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Beloeil H, Joshi GP. Opioid-free anaesthesia: should we all adopt it? An overview of current evidence: a reply. Eur J Anaesthesiol 2024; 41:319-320. [PMID: 38426254 DOI: 10.1097/eja.0000000000001906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Affiliation(s)
- Helene Beloeil
- From the Anaesthesia and Intensive Care Department, Univ Rennes, CHU Rennes, Inserm, COSS 1242, CIC 1414, F-35000 Rennes, France (HB) and Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA (GPJ)
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Wynne R, Fredericks S, Hyde EK, Matthews S, Bowden T, O'Keefe-McCarthy S, Martorella G, Magboo R, Gjeilo KH, Jedwab RM, Keeping-Burke L, Murfin J, Bruneau J, Lie I, Sanders J. Multimodal Analgesic Effectiveness on Acute Postoperative Pain Management After Adult Cardiac Surgery: Protocol for a Systematic Review. J Cardiovasc Nurs 2024; 39:E21-E28. [PMID: 37052583 DOI: 10.1097/jcn.0000000000000989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
BACKGROUND Many patients report moderate to severe pain in the acute postoperative period. Enhanced recovery protocols recommend multimodal analgesics, but the optimal combination of these is unknown. PURPOSE The aim of this study was to synthesize the best available evidence about effectiveness of multimodal analgesics on pain after adult cardiac surgery. METHODS A systematic review to determine the effect of multimodal postoperative analgesics is proposed (International Prospective Register of Systematic Reviews Registration CRD42022355834). Multiple databases including the Cochrane Library, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, American Psychological Association, the Education Resources Information Centre, the Excerpta Medica database, the Medical Literature Analysis and Retrieval System Online, Scopus, Web of Science, and clinical trials databases will be searched. Screening in Covidence and quality assessment will be conducted by 2 authors. A grading of recommendations, assessment, development, and evaluation summary of findings will be presented if meta-analysis is possible.
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Lirk P, Badaoui J, Stuempflen M, Hedayat M, Freys SM, Joshi GP. PROcedure-SPECific postoperative pain management guideline for laparoscopic colorectal surgery: A systematic review with recommendations for postoperative pain management. Eur J Anaesthesiol 2024; 41:161-173. [PMID: 38298101 DOI: 10.1097/eja.0000000000001945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
Colorectal cancer is the second most common cancer diagnosed in women and third most common in men. Laparoscopic resection has become the standard surgical technique worldwide given its notable benefits, mainly the shorter length of stay and less postoperative pain. The aim of this systematic review was to evaluate the current literature on postoperative pain management following laparoscopic colorectal surgery and update previous procedure-specific pain management recommendations. The primary outcomes were postoperative pain scores and opioid requirements. We also considered study quality, clinical relevance of trial design, and a comprehensive risk-benefit assessment of the analgesic intervention. We performed a literature search to identify randomised controlled studies (RCTs) published before January 2022. Seventy-two studies were included in the present analysis. Through the established PROSPECT process, we recommend basic analgesia (paracetamol for rectal surgery, and paracetamol with either a nonsteroidal anti-inflammatory drug or cyclo-oxygenase-2-specific inhibitor for colonic surgery) and wound infiltration as first-line interventions. No consensus could be achieved either for the use of intrathecal morphine or intravenous lidocaine; no recommendation can be made for these interventions. However, intravenous lidocaine may be considered when basic analgesia cannot be provided.
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Affiliation(s)
- Philipp Lirk
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital (PL, JB, MS), Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA (MH), Department of Surgery, DIAKO Ev. Diakonie-Krankenhaus, Bremen, Germany (SMF) and Department of Anesthesiology, UT Southwestern Medical Center, Dallas, Texas, USA (GPJ)
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Casas Reza P, Gestal Vázquez M, Sampayo Rodríguez L, Vilar Castro A, López-López D, García Romar A. Retrospective analysis of regional anaesthesia in hip surgery: A clinical audit. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:160-170. [PMID: 38354775 DOI: 10.1016/j.redare.2024.02.011] [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: 10/07/2022] [Accepted: 07/08/2023] [Indexed: 02/16/2024]
Abstract
INTRODUCTION Total hip arthroplasty is one of the most frequent surgical interventions in the hospital setting. Nonetheless, the ideal method to manage post-operative pain is still unknown. Multimodal analgesia techniques based on regional anaesthesia are amongst the most promising solutions. OBJECTIVES The aim of this study was to evaluate postoperative pain after total hip arthroplasty according to whether peripheral nerve block was performed (femoral block, fascia iliaca block and pericapsular nerve group block). Intravenous morphine consumption during the patient's stay in the post-anaesthesia care unit was measured, as well as the number of opioid rescues at 24 and 48 h post intervention. As secondary objectives, the prevalence of nerve injury, prolonged quadricipital block, and morphine consumption were established according to other variables of interest. MATERIALS AND METHODS In this observational retrospective study, data was collected from the electronic medical record of 656 traumatological surgery patients from April 2018 to August 2020, with the following inclusion criteria: over 18 years old, ASA I-III, primary total hip arthroplasty under general anaesthesia or subarachnoid anaesthesia (only with hyperbaric bupivacaine) and use of levobupivacaine for peripheral nerve block. RESULTS A total of 362 patients were selected. The main surgical indication was coxarthrosis (61.3%), followed by hip fracture (22.6%). Peripheral nerve blocks were performed on 169 patients (66.3% femoral, 27.7% PENG, and 6.0% fascia iliaca). Mean postoperative opioid consumption in PACU was lower in patients in who received a PENG (2.2 mg) or a femoral (3.27 mg) block, compared to those who received neither (6.69 mg). There were no differences in opioid rescues at 24 and 48 h after the procedure. Nerve injury incidence was low (.8%), and not associated with nerve blocks. The incidence of prolonged quadricipital paralysis was also low (1.3%), and was mainly associated with femoral nerve block (75% of cases). CONCLUSIONS This retrospective study supports the use of regional blocks as opioid-sparing techniques, highlighting their role in rapid functional recovery with no motor impairment.
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MESH Headings
- Humans
- Retrospective Studies
- Pain, Postoperative/prevention & control
- Pain, Postoperative/epidemiology
- Pain, Postoperative/drug therapy
- Arthroplasty, Replacement, Hip
- Male
- Female
- Nerve Block/methods
- Aged
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/therapeutic use
- Middle Aged
- Anesthesia, Conduction/methods
- Morphine/administration & dosage
- Morphine/therapeutic use
- Clinical Audit
- Femoral Nerve
- Anesthetics, Local/administration & dosage
- Aged, 80 and over
- Hip Fractures/surgery
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Affiliation(s)
- P Casas Reza
- Departamento de Anestesiología, Reanimación y Terapéutica del Dolor, Complexo Hospitalario Universitario de A Coruña, A Coruña, Galicia, Spain.
| | - M Gestal Vázquez
- Departamento de Anestesiología, Reanimación y Terapéutica del Dolor, Complexo Hospitalario Universitario de A Coruña, A Coruña, Galicia, Spain
| | - L Sampayo Rodríguez
- Departamento de Anestesiología, Reanimación y Terapéutica del Dolor, Complexo Hospitalario Universitario de A Coruña, A Coruña, Galicia, Spain
| | - A Vilar Castro
- Departamento de Anestesiología, Reanimación y Terapéutica del Dolor, Complexo Hospitalario Universitario de A Coruña, A Coruña, Galicia, Spain
| | - D López-López
- Departamento de Anestesiología, Reanimación y Terapéutica del Dolor, Complexo Hospitalario Universitario de A Coruña, A Coruña, Galicia, Spain
| | - A García Romar
- Departamento de Anestesiología, Reanimación y Terapéutica del Dolor, Complexo Hospitalario Universitario de A Coruña, A Coruña, Galicia, Spain
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Freys JC, Bigalke SM, Mertes M, Lobo DN, Pogatzki-Zahn EM, Freys SM. Perioperative pain management for appendicectomy: A systematic review and Procedure-specific Postoperative Pain Management recommendations. Eur J Anaesthesiol 2024; 41:174-187. [PMID: 38214556 DOI: 10.1097/eja.0000000000001953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
BACKGROUND Despite being a commonly performed surgical procedure, pain management for appendicectomy is often neglected because of insufficient evidence on the most effective treatment options. OBJECTIVE To provide evidence-based recommendations by assessing the available literature for optimal pain management after appendicectomy. DESIGN AND DATA SOURCES This systematic review-based guideline was conducted according to the PROSPECT methodology. Relevant randomised controlled trials, systematic reviews and meta-analyses in the English language from January 1999 to October 2022 were retrieved from MEDLINE, Embase and Cochrane Databases using PRISMA search protocols. ELIGIBILITY CRITERIA We included studies on adults and children. If articles reported combined data from different surgeries, they had to include specific information about appendicectomies. Studies needed to measure pain intensity using a visual analogue scale (VAS) or a numerical rating scale (NRS). Studies that did not report the precise appendicectomy technique were excluded. RESULTS Out of 1388 studies, 94 met the inclusion criteria. Based on evidence and consensus, the PROSPECT members agreed that basic analgesics [paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs)] should be administered perioperatively for open and laparoscopic appendicectomies. A laparoscopic approach is preferred because of lower pain scores. Additional recommendations for laparoscopic appendicectomies include a three-port laparoscopic approach and the instillation of intraperitoneal local anaesthetic. For open appendicectomy, a preoperative unilateral transverse abdominis plane (TAP) block is recommended. If not possible, preincisional infiltration with local anaesthetics is an alternative. Opioids should only be used as rescue analgesia. Limited evidence exists for TAP block in laparoscopic appendicectomy, analgesic adjuvants for TAP block, continuous wound infiltration after open appendicectomy and preoperative ketamine and dexamethasone. Recommendations apply to children and adults. CONCLUSION This review identified an optimal analgesic regimen for open and laparoscopic appendicectomy. Further randomised controlled trials should evaluate the use of regional analgesia and wound infiltrations with adequate baseline analgesia, especially during the recommended conventional three-port approach. REGISTRATION The protocol for this study was registered with the PROSPERO database (Registration No. CRD42023387994).
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Affiliation(s)
- Jacob C Freys
- From the Department of Surgery, Agaplesion Bethesda Krankenhaus Hamburg (JCF), Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany (EMP-Z, MM), Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham (DNL), MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom (DNL), Department of Anaesthesiology, Intensive and Pain Medicine, Ruhr-University Bochum, BG-University Hospital Bergmannsheil gGmbH, Bochum (SMB) and Department of Surgery, DIAKO Ev. Diakonie-Krankenhaus, Bremen, Germany (SMF)
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Verma A, Chauhan A, Islam MM, Kahlon MS, Singh A. Navigating the Opioid Crisis: Exploring Innovative Approaches to Pain Management. Curr Pharm Biotechnol 2024; 25:1629-1631. [PMID: 38093445 DOI: 10.2174/0113892010277968231127072017] [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] [Received: 08/18/2023] [Revised: 10/25/2023] [Accepted: 10/31/2023] [Indexed: 09/04/2024]
Affiliation(s)
- Abhishek Verma
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, Punjab, 142001, India
| | - Abhishek Chauhan
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, Punjab, 142001, India
| | - Md Moidul Islam
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, Punjab, 142001, India
| | - Milan Singh Kahlon
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, Punjab, 142001, India
| | - Amandeep Singh
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, Punjab, 142001, India
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Tee ZH, Tsoi EHC, Lee Q, Wong YS, Gibson A, Parsons N, Shaikh S, Forget P. Intrathecal Morphine and Post-Operative Pain Relief in Robotic Surgeries: A Systematic Review and Meta-Analysis. J Clin Med 2023; 13:137. [PMID: 38202144 PMCID: PMC10779813 DOI: 10.3390/jcm13010137] [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: 12/05/2023] [Revised: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024] Open
Abstract
Despite the potential benefits of intrathecal morphine (ITM), the precise role and dosing of ITM in robotic assisted surgery (RAS) remains unclear. This systematic review explores real-world evidence to evaluate the efficacy and outcomes of ITM in patients undergoing RAS. In accordance with PRISMA guidelines, a comprehensive search was conducted on four databases: MEDLINE, Embase, Cochrane Library and APA PsycInfo. Primary outcomes included pain scores at rest and on exertion at 24- and 48-h time intervals, and secondary outcomes aimed to explore the side effects of ITM. A meta-analysis was conducted to determine mean differences. A risk of bias assessment was conducted via the Cochrane Risk of Bias 2 tool. A total of 9 RCTs involving 619 patients were included in this review, of which 298 patients were administered ITM. Significant pain score reductions were observed both at rest (MD = -27.15; 95% CI [-43.97, -10.33]; I2 = 95%; p = 0.002) and on exertion (MD = -25.88; 95% CI [-37.03, -14.72]; I2 = 79%; p = 0.0003) 24 h postoperatively in the ITM groups, accompanied by a notable decrease in postoperative IV morphine equivalent consumption at 24 h (MD = -20.13; 95% CI [-30.74, -9.52]; I2 = 77%; p = 0.0002). ITM improved pain scores both at rest and on exertion at 24 and 48 h intervals, concurrently reducing the need for postoperative opioid consumption, but at the cost of an increased incidence of adverse events.
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Affiliation(s)
- Zi Heng Tee
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK (S.S.); (P.F.)
| | - Erica Ho Ching Tsoi
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK (S.S.); (P.F.)
| | - Quinston Lee
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK (S.S.); (P.F.)
| | - Yen Sin Wong
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK (S.S.); (P.F.)
| | - Arron Gibson
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK (S.S.); (P.F.)
| | - Niamh Parsons
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK (S.S.); (P.F.)
| | - Shafaque Shaikh
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK (S.S.); (P.F.)
- Department of Surgery, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen AB25 2ZD, UK
| | - Patrice Forget
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK (S.S.); (P.F.)
- Epidemiology Group, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
- Department of Anaesthesia, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen AB25 2ZD, UK
- Pain and Opioids after Surgery (PANDOS) Research Group, European Society of Anaesthesiology and Intensive Care, B-1000 Brussels, Belgium
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Joshi GP, Albrecht E, Van de Velde M, Kehlet H, Lobo DN. PROSPECT methodology for developing procedure-specific pain management recommendations: an update. Anaesthesia 2023; 78:1386-1392. [PMID: 37751453 DOI: 10.1111/anae.16135] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 09/28/2023]
Abstract
The procedure-specific postoperative pain management (PROSPECT) working group develops evidence-based pain management recommendations. PROSPECT methodology is unique and rigorous. However, several limitations were recognised that needed to be addressed, and several new factors were identified that improved PROSPECT methodology. The aim of this article is to present updated PROSPECT methodology for development of recommendations for procedure-specific pain management, focusing on the methodological revisions we will implement. In future, included randomised clinical trials will need to be prospectively registered on a publicly accessible clinical trials database and the study design, including the primary outcome in the registration, should coincide with that in the published manuscript. Placebo-controlled studies in which the analgesic intervention of interest is solely paracetamol, non-steroidal anti-inflammatory drugs, cyclo-oxygenase-2-specific inhibitors or opioids will not be included. Studies comparing one drug in a particular class with another in the same class will also not be included. Future projects will use the Cochrane Collaboration risk of bias tool for quality of reporting of methodology and results. A modified Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach will be used for grading of level of evidence and strength of recommendations. Finally, the updated PROSPECT methodology addresses several other limitations and implements new factors that all add rigour and transparency to developing procedure-specific pain management recommendations.
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Affiliation(s)
- G P Joshi
- Department of Anaesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - E Albrecht
- Program Director of Regional Anaesthesia, Department of Anaesthesia, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - M Van de Velde
- Department of Cardiovascular Sciences, Section Anaesthesiology, KU Leuven and University Hospital Leuven, Belgium
| | - H Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - D N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, Division of Translation Medical Sciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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15
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Mija D, Kehlet H, Joshi GP. Basic analgesic use in randomised trials assessing local and regional analgesic interventions for mastectomy: a critical appraisal and clinical implications. Br J Anaesth 2023; 131:921-924. [PMID: 37716888 DOI: 10.1016/j.bja.2023.08.025] [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] [Received: 06/29/2023] [Revised: 07/25/2023] [Accepted: 08/15/2023] [Indexed: 09/18/2023] Open
Abstract
Regional analgesia is a core component of an optimal multimodal analgesia technique. Several advanced regional analgesic techniques have been evaluated for mastectomy; however, the optimal choice remains unclear. Many randomised clinical trials (RCTs) evaluating various local/regional analgesic techniques do not include basic analgesics (i.e. paracetamol, non-steroidal anti-inflammatory drugs, cyclooxygenase-2 specific inhibitors, and dexamethasone) which precludes objective evaluation of their efficacy. The aim of this scoping review was to assess the use of basic analgesics in RCTs evaluating efficacy of local and regional analgesic techniques in patients undergoing mastectomy. PubMed was searched to identify relevant articles from January 1, 2010 to May 31, 2023. The key finding of this study is that almost 90% (n=82/92) of the RCTs evaluating local/regional analgesic techniques in patients undergoing mastectomy did not administer well accepted basic analgesics in the comparator groups. Consequently, the conclusions of the RCTs assessing local/regional analgesic techniques for mastectomy should be interpreted with caution. Also, clinical guidelines based on meta-analyses of these RCTs could be inadequate or inappropriate.
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Affiliation(s)
- Dan Mija
- Medical Graduate, Dallas, TX, USA
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen, Denmark
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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16
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Pellegrino PR, Are M. Pain management in cancer surgery: Global inequities and strategies to address them. J Surg Oncol 2023; 128:1032-1037. [PMID: 37818914 DOI: 10.1002/jso.27441] [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] [Received: 08/31/2023] [Accepted: 09/02/2023] [Indexed: 10/13/2023]
Abstract
Among patients undergoing surgical oncologic operations, patients in low- and middle-income countries are at particularly high risk for inadequate perioperative analgesia. This article reviews some of the guiding pillars of pain management for cancer surgery, including use of regional analgesia and acute pain service consultation, multimodal adjunctive analgesia, and judicious opioid use while presenting data on international disparities for each pillar and proposing strategies to address these inequities.
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Affiliation(s)
- Peter Ricci Pellegrino
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Madhuri Are
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
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17
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Maeßen T, Korir N, Van de Velde M, Kennes J, Pogatzki-Zahn E, Joshi GP. Pain management after cardiac surgery via median sternotomy: A systematic review with procedure-specific postoperative pain management (PROSPECT) recommendations. Eur J Anaesthesiol 2023; 40:758-768. [PMID: 37501517 DOI: 10.1097/eja.0000000000001881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
BACKGROUND Pain after cardiac surgery via median sternotomy can be difficult to treat, and if inadequately managed can lead to respiratory complications, prolonged hospital stays and chronic pain. OBJECTIVES To evaluate available literature and develop recommendations for optimal pain management after cardiac surgery via median sternotomy. DESIGN A systematic review using PROcedure-SPECific Pain Management (PROSPECT) methodology. ELIGIBILITY CRITERIA Randomised controlled trials and systematic reviews published in the English language until November 2020 assessing postoperative pain after cardiac surgery via median sternotomy using analgesic, anaesthetic or surgical interventions. DATA SOURCES PubMed, Embase and Cochrane Databases. RESULTS Of 319 eligible studies, 209 randomised controlled trials and three systematic reviews were included in the final analysis. Pre-operative, intra-operative and postoperative interventions that reduced postoperative pain included paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), intravenous magnesium, intravenous dexmedetomidine and parasternal block/infiltration. CONCLUSIONS The analgesic regimen for cardiac surgery via sternotomy should include paracetamol and NSAIDs, unless contraindicated, administered intra-operatively and continued postoperatively. Intra-operative magnesium and dexmedetomidine infusions may be considered as adjuncts particularly when basic analgesics are not administered. It is not clear if combining dexmedetomidine and magnesium would provide superior pain relief compared with either drug alone. Parasternal block/surgical site infiltration is also recommended. However, no basic analgesics were used in the studies assessing these interventions. Opioids should be reserved for rescue analgesia. Other interventions, including cyclo-oxygenase-2 specific inhibitors, are not recommended because there was insufficient, inconsistent or no evidence to support their use and/or due to safety concerns.
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Affiliation(s)
- Timo Maeßen
- From the Department of Anaesthesiology, Intensive Care, and Pain Medicine, University Hospital Münster, Münster, Germany (TM, EP-Z), the Department of Cardiovascular Sciences, Section Anaesthesiology, KU Leuven and University Hospital Leuven, Leuven, Belgium (NK, MVdeV, JK), the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Centre, Dallas, Texas, USA (GPJ)
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18
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Kehlet H. Prediction of postoperative pain: are we missing the target? Anaesthesia 2023; 78:1301-1302. [PMID: 37314728 DOI: 10.1111/anae.16063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 06/15/2023]
Affiliation(s)
- H Kehlet
- Rigshospitalet, Copenhagen, Denmark
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19
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Xu Y, Ye M, Liu F, Hong Y, Kang Y, Li Y, Li H, Xiao X, Yu F, Zhou M, Zhou L, Jiang C. Efficacy of prolonged intravenous lidocaine infusion for postoperative movement-evoked pain following hepatectomy: a double-blinded, randomised, placebo-controlled trial. Br J Anaesth 2023:S0007-0912(23)00169-1. [PMID: 37202261 DOI: 10.1016/j.bja.2023.03.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 03/04/2023] [Accepted: 03/11/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND The analgesic effect of intravenous lidocaine varies with the duration of lidocaine infusion and surgery type. We tested the hypothesis that prolonged lidocaine infusion alleviates postoperative pain in patients recovering from hepatectomy over the first 3 postoperative days. METHODS Patients undergoing elective hepatectomy were randomly assigned to receive prolonged i.v. lidocaine treatment or placebo. The primary outcome was incidence of moderate-to-severe movement-evoked pain at 24 h postoperatively. The secondary outcomes included incidence of moderate-to-severe pain during movement and at rest throughout the first 3 postoperative days, postoperative opioid consumption, and pulmonary complications. Plasma lidocaine concentration was also monitored. RESULTS We enrolled 260 subjects. Intravenous lidocaine lowered the incidence of moderate-to-severe movement-evoked pain at 24 h and 48 h postoperatively (47.7% vs 67.7%, P=0.001; 38.5% vs 58.5%, P=0.001) and reduced movement-evoked pain scores (3.7 [1.7] vs 4.2 [1.6]; mean difference 0.5 [95% confidence interval {CI}: 0.1-0.9]; P=0.018) and morphine equivalent consumption (47.2 [16.7] mg vs 52.6 [19.2] mg; mean difference 5.4 mg [95% CI: 1.0-9.8]; P=0.016) at 24 h postoperatively. Lidocaine also lowered the incidence of postoperative pulmonary complications (23.1% vs 38.5%; P=0.007). Median plasma lidocaine concentrations were 1.5, 1.9, and 1.1 μg ml-1 (inter-quartile ranges: 1.1-2.1, 1.4-2.6, and 0.8-1.6, respectively) after bolus injection, at the end of the surgery, and 24 h postoperatively. CONCLUSIONS Prolonged intravenous lidocaine infusion reduced the incidence of moderate-to-severe movement-evoked pain for 48 h after hepatectomy. However, the reduction in pain scores and opioid consumption by lidocaine was below the minimal clinically important difference. CLINICAL TRIAL REGISTRATION NCT04295330.
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Affiliation(s)
- Yan Xu
- Department of Anaesthesiology, West China Hospital, Sichuan University & The Research Units of West China, Chinese Academy of Medical Sciences, Chengdu, China
| | - Mao Ye
- Department of Anaesthesiology, West China Hospital, Sichuan University & The Research Units of West China, Chinese Academy of Medical Sciences, Chengdu, China
| | - Fei Liu
- Department of Anaesthesiology, West China Hospital, Sichuan University & The Research Units of West China, Chinese Academy of Medical Sciences, Chengdu, China
| | - Ying Hong
- Department of Anaesthesiology, West China Hospital, Sichuan University & The Research Units of West China, Chinese Academy of Medical Sciences, Chengdu, China
| | - Yi Kang
- Department of Anaesthesiology and Translational Neuroscience Centre, Laboratory of Anaesthesia and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yue Li
- Department of Anaesthesiology, West China Hospital, Sichuan University & The Research Units of West China, Chinese Academy of Medical Sciences, Chengdu, China
| | - Huan Li
- Department of Anaesthesiology, Affiliated Hospital of Xiangnan University, Chenzhou, China
| | - Xiao Xiao
- Department of Anaesthesiology, West China Hospital, Sichuan University & The Research Units of West China, Chinese Academy of Medical Sciences, Chengdu, China
| | - Feng Yu
- Department of Anaesthesiology, West China Hospital, Sichuan University & The Research Units of West China, Chinese Academy of Medical Sciences, Chengdu, China
| | - Mengmeng Zhou
- Department of Anaesthesiology, West China Hospital, Sichuan University & The Research Units of West China, Chinese Academy of Medical Sciences, Chengdu, China
| | - Li Zhou
- Department of Anaesthesiology, West China Hospital, Sichuan University & The Research Units of West China, Chinese Academy of Medical Sciences, Chengdu, China.
| | - Chunling Jiang
- Department of Anaesthesiology, West China Hospital, Sichuan University & The Research Units of West China, Chinese Academy of Medical Sciences, Chengdu, China.
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20
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Abstract
PURPOSE OF REVIEW The acute inflammatory reaction induced by tissue trauma causes pain but also promotes recovery. Recovery is highly variable among peoples. Effective acute pain (AP) management is very important but remains suboptimal what could affect long term outcomes. The review questions the impact of either failure or effectiveness of AP treatments and the choice of analgesic drugs on different long-term outcomes after tissue trauma. RECENT FINDINGS Pain control during mobilization is mandatory to reduce the risk of complications which exacerbate and prolong the inflammatory response to trauma, impairing physical recovery. Common analgesic treatments show considerable variability in effectiveness among peoples what argues for an urgent need to develop personalized AP management, that is, finding better responders to common analgesics and targeting challenging patients for more invasive procedures. Optimal multimodal analgesia to spare opioids administration remains a priority as opioids may enhance neuroinflammation, which underlies pain persistence and precipitates neurocognitive decline in frail patients. Finally, recent findings demonstrate that AP treatments which modulate nociceptive and inflammatory pain should be used with caution as drugs which inhibit inflammation like nonsteroidal antiinflammatory drugs and corticoids might interfere with natural recovery processes. SUMMARY Effective and safe AP management is of far greater importance than previously realized. Evidence of suboptimal AP management in many patients and recent reports pointing out the impact of current treatments on long term outcomes argue for further research in the field.
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Affiliation(s)
- Simon Delande
- Department of Anesthesiology, Cliniques Universitaires St Luc - University Catholic of Louvain, Brussels, Belgium
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21
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Dieu A, Momeni M. Pain management after robot-assisted thoracic surgery for mediastinal disease: a first step towards randomized control trials. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:187. [PMID: 37007539 PMCID: PMC10061491 DOI: 10.21037/atm-23-1095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 03/09/2023] [Indexed: 03/17/2023]
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22
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Zaslansky R, Baumbach P, Edry R, Chetty S, Min LS, Schaub I, Cruz JJ, Meissner W, Stamer UM. Following Evidence-Based Recommendations for Perioperative Pain Management after Cesarean Section Is Associated with Better Pain-Related Outcomes: Analysis of Registry Data. J Clin Med 2023; 12:jcm12020676. [PMID: 36675605 PMCID: PMC9864952 DOI: 10.3390/jcm12020676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 11/23/2022] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
Women who have had a Cesarean Section (CS) frequently report severe pain and pain-related interference. One reason for insufficient pain treatment might be inconsistent implementation of evidence-based guidelines. We assessed the association between implementing three elements of care recommended by guidelines for postoperative pain management and pain-related patient-reported outcomes (PROs) in women after CS. The analysis relied on an anonymized dataset of women undergoing CS, retrieved from PAIN OUT. PAIN OUT, an international perioperative pain registry, provides clinicians with treatment assessment methodology and tools for patients to assess multi-dimensional pain-related PROs on the first postoperative day. We examined whether the care included [i] regional anesthesia with a neuraxial opioid OR general anesthesia with wound infiltration or a Transvesus Abdominis Plane block; [ii] at least one non-opioid analgesic at the full daily dose; and [iii] pain assessment and recording. Credit for care was given only if all three elements were administered (= “full”); otherwise, it was “incomplete”. A “Pain Composite Score-total” (PCStotal), evaluating outcomes of pain intensity, pain-related interference with function, and side-effects, was the primary endpoint in the total cohort (women receiving GA and/or RA) or a sub-group of women with RA only. Data from 5182 women was analyzed. “Full” care was administered to 20% of women in the total cohort and to 21% in the RA sub-group. In both groups, the PCStotal was significantly lower compared to “incomplete” care (p < 0.001); this was a small-to-moderate effect size. Administering all three elements of care was associated with better pain-related outcomes after CS. These should be straightforward and inexpensive for integration into routine care after CS. However, even in this group, a high proportion of women reported poor outcomes, indicating that additional work needs to be carried out to close the evidence-practice gap so that women who have undergone CS can be comfortable when caring for themselves and their newborn.
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Affiliation(s)
- Ruth Zaslansky
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Jena, 07747 Jena, Germany
- Correspondence: (R.Z.); (U.M.S.)
| | - Philipp Baumbach
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Jena, 07747 Jena, Germany
| | - Ruth Edry
- Acute Pain Service, Department of Anesthesiology, Rambam Health Care Campus, Haifa 3109601, Israel
| | - Sean Chetty
- Department of Anaesthesiology& Critical Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7500, South Africa
| | - Lim Siu Min
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Isabelle Schaub
- Department of Anesthesiology and Pain Clinic, Clinique St Jean, 1000 Brussels, Belgium
| | - Jorge Jimenez Cruz
- Department of Obstetrics and Gynecology, Bonn University Hospital, 53127 Bonn, Germany
| | - Winfried Meissner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Jena, 07747 Jena, Germany
| | - Ulrike M. Stamer
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Correspondence: (R.Z.); (U.M.S.)
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23
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Crush J, Levy N, Knaggs RD, Lobo DN. The pitfalls of labelling opioids as weak or strong. Response to Br J Anaesth 2022; 129:e150-e153. Br J Anaesth 2023; 130:e16-e17. [PMID: 36939496 DOI: 10.1016/j.bja.2022.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jos Crush
- Department of Anaesthesia and Perioperative Medicine, West Suffolk Hospital NHS Foundation Trust, Bury St Edmunds, UK
| | - Nicholas Levy
- Department of Anaesthesia and Perioperative Medicine, West Suffolk Hospital NHS Foundation Trust, Bury St Edmunds, UK
| | - Roger D Knaggs
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK; Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - Dileep N Lobo
- Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK.
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24
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Opioid-sparing anesthesia and patient-reported outcomes after open gynecologic surgery: a historical cohort study. Can J Anaesth 2022; 69:1477-1492. [PMID: 36224506 DOI: 10.1007/s12630-022-02336-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 04/13/2022] [Accepted: 05/30/2022] [Indexed: 11/06/2022] Open
Abstract
PURPOSE Dexmedetomidine and ketamine may be administered intraoperatively as continuous infusions to provide opioid-sparing anesthesia. Recent evidence has yielded controversial results regarding the impact of opioid-free anesthesia on postoperative complications, and there is a gap in knowledge regarding patient-reported outcomes (PROs). This study aimed to determine the impact of opioid-sparing anesthesia and opioid-based anesthesia on PROs among gynecologic patients within an enhanced recovery after surgery (ERAS) program. METHODS We formed a single-center historical cohort from patients enrolled in another study who underwent open gynecologic surgery on an ERAS program from November 2014 to December 2020 (n = 2,095). We identified two cohorts based on the type of balanced anesthesia administered: 1) opioid-sparing anesthesia defined as the continuous infusion of dexmedetomidine and ketamine (adjuvants) during surgery or 2) opioid-based anesthesia (no adjuvants). We measured the quality of postoperative recovery using the MD Anderson Symptom Inventory (MDASI), a 29-item validated tool that was administered preoperatively, daily while admitted, and weekly after discharge until week 6. The primary outcome was interference with walking. We matched both cohorts and used a multilevel linear mixed-effect model to evaluate the effect of opioid-sparing anesthesia on the primary outcome. RESULTS In total, 498 patients were eligible (159 in the opioid-sparing anesthesia cohort and 339 in the opioid-based anesthesia cohort), of whom 149 matched pairs were included in the final analysis. Longitudinal assessment showed no significant or clinically important difference in interference with walking (P = 0.99), general activity (P = 0.99), or other PROs between cohorts. Median [interquartile range (IQR)] intraoperative opioid administration (expressed as morphine milligram equivalents [MME]) among matched patients in the opioid-sparing anesthesia cohort was 30 [25-55] mg vs 58 [8-70] mg in the opioid-based anesthesia cohort (P < 0.01). Patients in the opioid-sparing anesthesia cohort had a lower opioid consumption in the postanesthesia care unit than those in the opioid-based anesthesia cohort (MME, 3 [0-10] mg vs 5 [0-15] mg; P < 0.01), but there was no significant difference between cohorts in total postoperative opioid consumption (MME, 23 [0-94] mg vs 35 [13-95] mg P = 0.053). CONCLUSIONS In this single-center historical cohort study, opioid-sparing anesthesia had no significant or clinically important effects on interference with walking or other PROs in patients undergoing gynecologic surgery compared with opioid-based anesthesia. Opioid-sparing anesthesia was associated with less short-term opioid consumption than opioid-based anesthesia.
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25
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Abstract
PURPOSE OF REVIEW Also in ambulatory surgery, there will usually be a need for analgesic medication to deal with postoperative pain. Even so, a significant proportion of ambulatory surgery patients have unacceptable postoperative pain, and there is a need for better education in how to provide proper prophylaxis and treatment. RECENT FINDINGS Postoperative pain should be addressed both pre, intra- and postoperatively. The management should be with a multimodal nonopioid-based procedure specific guideline for the routine cases. In 10-20% of cases, there will be a need to adjust and supplement the basic guideline with extra analgesic measures. This may be because there are contraindications for a drug in the guideline, the procedure is more extensive than usual or the patient has extra risk factors for strong postoperative pain. Opioids should only be used when needed on top of multimodal nonopioid prophylaxis. Opioids should be with nondepot formulations, titrated to effect in the postoperative care unit and eventually continued only when needed for a few days at maximum. SUMMARY Multimodal analgesia should start pre or per-operatively and include paracetamol, nonsteroidal anti-inflammatory drug (NSAID), dexamethasone (or alternative glucocorticoid) and local anaesthetic wound infiltration, unless contraindicated in the individual case. Paracetamol and NSAID should be continued postoperatively, supplemented with opioid on top as needed. Extra analgesia may be considered when appropriate and needed. First-line options include nerve blocks or interfascial plane blocks and i.v. lidocaine infusion. In addition, gabapentinnoids, dexmedetomidine, ketamine infusion and clonidine may be used, but adverse effects of sedation, dizziness and hypotension must be carefully considered in the ambulatory setting.
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26
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Newton K, Dumville J, Briggs M, Law J, Martin J, Pearce L, Kirwan C, Pinkney T, Needham A, Jackson R, Winn S, McCulloch H, Hill J. Postoperative Packing of Perianal Abscess Cavities (PPAC2): randomized clinical trial. Br J Surg 2022; 109:951-957. [PMID: 35929816 PMCID: PMC10364677 DOI: 10.1093/bjs/znac225] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/16/2022] [Accepted: 05/31/2022] [Indexed: 08/02/2023]
Abstract
BACKGROUND Perianal abscess is common. Traditionally, postoperative perianal abscess cavities are managed with internal wound packing, a practice not supported by evidence. The aim of this randomized clinical trial (RCT) was to assess if non-packing is less painful and if it is associated with adverse outcomes. METHODS The Postoperative Packing of Perianal Abscess Cavities (PPAC2) trial was a multicentre, RCT (two-group parallel design) of adult participants admitted to an NHS hospital for incision and drainage of a primary perianal abscess. Participants were randomized 1:1 (via an online system) to receive continued postoperative wound packing or non-packing. Blinded data were collected via symptom diaries, telephone, and clinics over 6 months. The objective was to determine whether non-packing of perianal abscess cavities is less painful than packing, without an increase in perianal fistula or abscess recurrence. The primary outcome was pain (mean maximum pain score on a 100-point visual analogue scale). RESULTS Between February 2018 and March 2020, 433 participants (mean age 42 years) were randomized across 50 sites. Two hundred and thirteen participants allocated to packing reported higher pain scores than 220 allocated to non-packing (38.2 versus 28.2, mean difference 9.9; P < 0.0001). The occurrence of fistula-in-ano was low in both groups: 32/213 (15 per cent) in the packing group and 24/220 (11 per cent) in the non-packing group (OR 0.69, 95 per cent c.i. 0.39 to 1.22; P = 0.20). The proportion of patients with abscess recurrence was also low: 13/223 (6 per cent) in the non-packing group and 7/213 (3 per cent) in the packing group (OR 1.85, 95 per cent c.i. 0.72 to 4.73; P = 0.20). CONCLUSION Avoiding abscess cavity packing is less painful without a negative morbidity risk. REGISTRATION NUMBER ISRCTN93273484 (https://www.isrctn.com/ISRCTN93273484). REGISTRATION NUMBER NCT03315169 (http://clinicaltrials.gov).
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Affiliation(s)
- Katy Newton
- Correspondence to: Katy Newton, Department of Surgery, Manchester Royal Infirmary, Oxford Road, Manchester, M14 9WL, UK (e-mail: )
| | - Jo Dumville
- School of Midwifery, Nursing and Social Work, University of Manchester, UK
| | - Michelle Briggs
- School of Midwifery, Nursing and Social Work, University of Manchester, UK
| | | | | | - Lyndsay Pearce
- Department of General Surgery, Salford Royal NHS Foundation Trust, UK
| | - Cliona Kirwan
- Department of Academic Surgery, Wythenshawe Hospital, Manchester University NHS Foundation Trust, UK
| | - Thomas Pinkney
- Academic Department of Surgery, University of Birmingham, UK
| | | | | | | | | | - James Hill
- Department of General Surgery, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, UK
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Abstract
Perioperative pain management is one of the domains in which Anesthesiologists are intricately involved, and which is immensely important. Adequate postoperative analgesia is central to avoid both the acute as well as chronic complications of uncontrolled postoperative pain. Preventive analgesia has been identified as an approach to mitigate the phenomenon of central sensitization, which plays an important role in the development of chronic pain after surgery. As an over-reliance on opioids for peri- and postoperative pain control is associated with opioid dependence and hyperalgesia, multimodal analgesia has taken center stage. Multimodal analgesia, in theory, will optimize perioperative pain control, reduce the chance of central sensitization, and avoid the detrimental effects of opioid overuse. Multiple classes of systemic analgesic medications have been used to accomplish these tasks, and the aim of this article is to outline these medications, their mechanisms of action, as well as the evidence behind their individual roles in multimodal analgesia. Regional anesthesia has also been embraced as a key component of multimodal analgesia in orthopedic surgery; however, over the past several years, local infiltration analgesia (LIA) emerged as a viable alternative, particularly in total knee arthroplasty.
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Affiliation(s)
- Archana O'Neill
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Philipp Lirk
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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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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Psychiatric Comorbidities Associated with Persistent Postoperative Opioid Use. Curr Pain Headache Rep 2022; 26:701-708. [PMID: 35960447 DOI: 10.1007/s11916-022-01073-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW This review outlines the psychiatric comorbidities associated with persistent opioid use in the postoperative period. We finish our analysis with evidence-based, patient-centered interventions that can be rendered in the perioperative setting to decrease postoperative opioid requirements. RECENT FINDINGS Opioids are overprescribed in the USA, especially in the postoperative setting. Excess opioids can result in diversion and contribute to the ongoing opioid epidemic. Mental health and substance use disorders can contribute to persistent postoperative opioid use. Adequately managing these disorders preoperatively promises to reduce persistent postoperative opioid use. Due to the lack of homogenous, evidence-based recommendations on the appropriate quantity and duration of postoperative opioid therapy, there is wide variability in provider prescribing habits. Further research is needed to establish surgery-specific postoperative opioid therapy protocols. Opioids continue to be a mainstay in the treatment of postoperative pain. Unmonitored postoperative opioid use can lead to opioid use disorder. Mental health disorders increase susceptibility to persistent postoperative opioid use. By managing these psychiatric illnesses preoperatively, clinicians have the ability to decrease opioid consumption postoperatively. Lastly, given the healthcare burden of opioid misuse and abuse, it is important to establish concrete protocols to guide provider-prescribing habits.
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Yu H, Tian W, Xu Z, Jiang R, Jin L, Mao W, Chen Y, Yu H. Patient-controlled intravenous analgesia with opioids after thoracoscopic lung surgery: a randomized clinical trial. BMC Anesthesiol 2022; 22:253. [PMID: 35941536 PMCID: PMC9358799 DOI: 10.1186/s12871-022-01785-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 07/25/2022] [Indexed: 11/21/2022] Open
Abstract
Background Opioids remain the mainstream therapy for post-surgical pain. The choice of opioids administered by patient-controlled intravenous analgesia (PCIA) for thoracoscopic lung surgery is unclear. This study compared 3 opioid analgesics for achieving satisfactory analgesia with minimal emesis (SAME). Methods This randomized clinical trial enrolled patients scheduled for thoracoscopic lung surgery randomized to receive 1 of 3 opioids for PCIA: oxycodone (group O), hydromorphone (group H), and sufentanil (group S). The primary outcome was the proportion of subjects achieving SAME, i.e., no-to-mild pain (pain score < 4/10) with minimal nausea/vomiting (PONV score < 2/4) when coughing during the pulmonary rehabilitation exercise in the first 3 postoperative days. Results Of 555 enrolled patients, 184 patients in group O, 186 in group H and 184 in group S were included in the final analysis. The primary outcome of SAME was significantly different among group O, H and S (41.3% vs 40.3% vs 29.9%, P = 0.043), but no difference was observed between pairwise group comparisons. Patients in groups O and H had lower pain scores when coughing on the second day after surgery than those in group S, both with mean differences of 1 (3(3,4) and 3(3,4) vs 4(3,4), P = 0.009 and 0.039, respectively). The PONV scores were comparable between three groups (P > 0.05). There were no differences in other opioid-related side effects, patient satisfaction score, and QoR-15 score among three groups. Conclusions Given clinically relevant benefits detected, PCIA with oxycodone or hydromorphone is superior to sufentanil for achieving SAME as a supplement to multimodal analgesia in patients undergoing thoracoscopic lung surgery. Trial registration This study was registered at (ChiCTR2100045614, 19/04/2021). Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01785-4.
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Affiliation(s)
- Hong Yu
- Department of Anesthesiology, West China Hospital, Sichuan University. No, 37 Guoxue Alley, Chengdu, 610041, China
| | - Wei Tian
- Department of Anesthesiology, The First People's Hospital of Neijiang, Neijiang, 641000, China
| | - Zhao Xu
- Department of Anesthesiology, West China Hospital, Sichuan University. No, 37 Guoxue Alley, Chengdu, 610041, China
| | - Rongjuan Jiang
- Department of Anesthesiology, Chengdu Second People's Hospital, Chengdu, 610017, China
| | - Liang Jin
- Department of Anesthesiology, The People's Hospital of Leshan, Leshan, 614099, China
| | - Wenjie Mao
- Department of Anesthesiology, The People's Hospital of Jianyang, Chengdu, 641499, China
| | - Ying Chen
- Department of Anesthesiology, Liangshan Hospital of Integrated Traditional and Western Medicine, Xichang, 615099, China
| | - Hai Yu
- Department of Anesthesiology, West China Hospital, Sichuan University. No, 37 Guoxue Alley, Chengdu, 610041, China.
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Albrecht E, Kehlet H, Raeder J, Joshi GP. Impact of country of origin on procedure-specific postoperative pain management (PROSPECT) recommendations. Anaesthesia 2022; 77:1057-1059. [PMID: 35776133 DOI: 10.1111/anae.15796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2022] [Indexed: 11/29/2022]
Affiliation(s)
- E Albrecht
- University Hospital of Lausanne, Lausanne, Switzerland
| | - H Kehlet
- Rigshospitalet, Copenhagen, Denmark
| | - J Raeder
- Oslo University Hospital, Oslo, Norway
| | - G P Joshi
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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32
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Veef E, Van de Velde M. Post-cesarean section analgesia. Best Pract Res Clin Anaesthesiol 2022; 36:83-88. [PMID: 35659962 DOI: 10.1016/j.bpa.2022.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 02/24/2022] [Indexed: 10/18/2022]
Abstract
Worldwide, the most performed surgical intervention is cesarean section. Hence, post-cesarean pain is a common problem with significant health and economic impact on the individual patient and society. Adequate treatment of post-cesarean pain is necessary to facilitate enhanced recovery, improve neonatal outcome by improving breastfeeding success and bonding between mother and child, and reduce pain-induced side effects. Therefore, optimal pain relief is important, but in the obstetric population, this is often complex due to the interplay of mother and neonate. To facilitate recovery and temper the side effects of potent analgesic drugs such as opioids, multimodal analgesia is currently advocated, and clear international guidelines and recommendations have recently been described. In the present overview, we will discuss the most recent guidelines and evaluate various analgesic interventions.
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Affiliation(s)
- Ellen Veef
- Department of Cardiovascular Sciences, KULeuven and Department of Anaesthesiology, UZLeuven, Herestraat 49, 3000 Leuven, Belgium
| | - Marc Van de Velde
- Department of Cardiovascular Sciences, KULeuven and Department of Anaesthesiology, UZLeuven, Herestraat 49, 3000 Leuven, Belgium.
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33
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Joshi GP, Bonnet F, Van de Velde M. PROSPECT guidelines for pain management after video-assisted thoracoscopic surgery: a reply. Anaesthesia 2022; 77:938. [PMID: 35388475 DOI: 10.1111/anae.15737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 03/26/2022] [Indexed: 11/28/2022]
Affiliation(s)
- G P Joshi
- Katholieke Universiteit Leuven Universitaire Ziekenhuizen, Leuven, Belgium
| | - F Bonnet
- Katholieke Universiteit Leuven Universitaire Ziekenhuizen, Leuven, Belgium
| | - M Van de Velde
- Katholieke Universiteit Leuven Universitaire Ziekenhuizen, Leuven, Belgium
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Analysis of Adverse Effects of Multimodal Gabapentin in Abdominal Wall Reconstruction. Plast Reconstr Surg 2022; 149:733-739. [PMID: 35041638 DOI: 10.1097/prs.0000000000008836] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Multimodal analgesia, a key component of enhanced recovery after surgery protocols, emphasizes the use of nonopioid analgesics. Preoperative and postoperative gabapentin is often included within multimodal analgesia because it has been shown to reduce postoperative opioid use. However, the role of gabapentin has been questioned because of concerns of adverse effects, particularly in the elderly. In an effort to better understand the specific role of gabapentin within the context of an established enhanced recovery after surgery protocol, the authors studied the prevalence of its adverse effects in patients undergoing abdominal wall reconstruction. METHODS Following institutional review board approval, a retrospective review of a prospectively collected database of 267 consecutive patients who underwent abdominal wall reconstruction performed by a single surgeon was conducted. Demographic variables; operative details; postoperative analgesic use; the presence of dizziness, lightheadedness, or altered mental status; hypotension; negative Richmond Agitation Sedation Scale scores; and postoperative falls were recorded and analyzed according to postoperative gabapentin administration. RESULTS Two hundred thirteen patients (80 percent) met inclusion criteria, of which 138 (65 percent) received postoperative gabapentin. Postoperative gabapentin use was not associated with dizziness, lightheadedness, or altered mental status; hypotension; negative Richmond Agitation Sedation Scale scores; or falls. Furthermore, even among those aged 65 years or older, postoperative gabapentin use was not significantly associated with these adverse events. CONCLUSIONS In patients undergoing abdominal wall reconstruction, postoperative gabapentin administration was not associated with an increase in adverse effects. Further prospective analysis may better allow the characterization of the adverse effects of perioperative gabapentin. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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35
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Rollins KE, Lobo DN, Joshi GP. Enhanced recovery after surgery: Current status and future progress. Best Pract Res Clin Anaesthesiol 2021; 35:479-489. [PMID: 34801211 DOI: 10.1016/j.bpa.2020.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 10/07/2020] [Indexed: 12/20/2022]
Abstract
Enhanced Recovery After Surgery (ERAS) pathways were first introduced almost a quarter of a century ago and represent a paradigm shift in perioperative care that reduced postoperative complications and hospital length of stay, improved postoperative quality of life, and reduced overall healthcare costs. Gradual recognition of the generalizability of the interventions and transferable improvements in postoperative outcomes, led them to become standard of care for several surgical procedures. In this article, we critically review the current status of ERAS pathways, address related controversies, and propose measures for future progress.
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Affiliation(s)
- Katie E Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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36
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Feray S, Lubach J, Joshi GP, Bonnet F, Van de Velde M. PROSPECT guidelines for video-assisted thoracoscopic surgery: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2021; 77:311-325. [PMID: 34739134 PMCID: PMC9297998 DOI: 10.1111/anae.15609] [Citation(s) in RCA: 99] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2021] [Indexed: 01/13/2023]
Abstract
Video‐assisted thoracoscopic surgery has become increasingly popular due to faster recovery times and reduced postoperative pain compared with thoracotomy. However, analgesic regimens for video‐assisted thoracoscopic surgery vary significantly. The goal of this systematic review was to evaluate the available literature and develop recommendations for optimal pain management after video‐assisted thoracoscopic surgery. A systematic review was undertaken using procedure‐specific postoperative pain management (PROSPECT) methodology. Randomised controlled trials published in the English language, between January 2010 and January 2021 assessing the effect of analgesic, anaesthetic or surgical interventions were identified. We retrieved 1070 studies of which 69 randomised controlled trials and two reviews met inclusion criteria. We recommend the administration of basic analgesia including paracetamol and non‐steroidal anti‐inflammatory drugs or cyclo‐oxygenase‐2‐specific inhibitors pre‐operatively or intra‐operatively and continued postoperatively. Intra‐operative intravenous dexmedetomidine infusion may be used, specifically when basic analgesia and regional analgesic techniques could not be given. In addition, a paravertebral block or erector spinae plane block is recommended as a first‐choice option. A serratus anterior plane block could also be administered as a second‐choice option. Opioids should be reserved as rescue analgesics in the postoperative period.
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Affiliation(s)
- S Feray
- Department of Anaesthesia, Intensive Care and Peri-operative Medicine, Hôpital Tenon, Paris, France
| | - J Lubach
- Department of Anaesthesiology, KU Leuven and University Hospital Leuven, Leuven, Belgium
| | - G P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - F Bonnet
- Department of Anaesthesia, Intensive Care and Peri-operative Medicine, Hôpital Tenon, Paris, France
| | - M Van de Velde
- Department of Cardiovascular Sciences, KU Leuven and University Hospital Leuven, Leuven, Belgium
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Chen S, Du W, Zhuang X, Dai Q, Zhu J, Fu H, Wang J, Huang L. Description and Comparison of Acute Pain Characteristics After Laparoscope-Assisted Vaginal Hysterectomy, Laparoscopic Myomectomy and Laparoscopic Adnexectomy. J Pain Res 2021; 14:3279-3288. [PMID: 34703303 PMCID: PMC8541747 DOI: 10.2147/jpr.s335089] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/07/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose To determine the characteristics of the acute pain after laparoscopic-assisted vaginal hysterectomy (LAVH), laparoscopic myomectomy (LM), and laparoscopic adnexectomy (LA) and compare them with each other. Patients and Methods Patients undergoing LAVH, LM, and LA under general anaesthesia at the First Affiliated Hospital of Wenzhou Medical University between December 2017 and December 2019 were selected. Their data were collected before, during, and after the surgery. We evaluated the degrees of pain in each group of patients and compared them. Results There were differences in the baseline characteristics of the patients in the LAVH, LM, and LA groups. The severity and incidence of postoperative pain were higher in the LAVH group than in the LM and LA groups, followed by the LM and LA groups. Compared with the LA group, the postoperative pain in the LAVH and LM groups was more complicated. The LA group had the lowest incidence of two or more types of moderate to severe pain. The LAVH and LM groups mainly had visceral pain and low back pain, and the LA group mainly had incisional pain. Shoulder pain had the lowest incidence in the three groups. Conclusion There were different postoperative pain characteristics after the LAVH, LM, and LA, and we should clinically adjust analgesia programs for different gynaecological laparoscopic surgeries.
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Affiliation(s)
- Sijia Chen
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Wenwen Du
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Xiuxiu Zhuang
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Qinxue Dai
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Jingwen Zhu
- Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Haifeng Fu
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Junlu Wang
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Luping Huang
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
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Rutherford D, Massie EM, Worsley C, Wilson MS. Intraperitoneal local anaesthetic instillation versus no intraperitoneal local anaesthetic instillation for laparoscopic cholecystectomy. Cochrane Database Syst Rev 2021; 10:CD007337. [PMID: 34693999 PMCID: PMC8543182 DOI: 10.1002/14651858.cd007337.pub4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pain is one of the important reasons for delayed discharge after laparoscopic cholecystectomy. Use of intraperitoneal local anaesthetic for laparoscopic cholecystectomy may be a way of reducing pain. A previous version of this Cochrane Review found very low-certainty evidence on the benefits and harms of the intervention. OBJECTIVES To assess the benefits and harms of intraperitoneal instillation of local anaesthetic agents in people undergoing laparoscopic cholecystectomy. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and three other databases to 19 January 2021 together with reference checking of studies retrieved. We also searched five online clinical trials registries to identify unpublished or ongoing trials to 10 September 2021. We contacted study authors to identify additional studies. SELECTION CRITERIA We only considered randomised clinical trials (irrespective of language, blinding, publication status, or relevance of outcome measure) comparing local anaesthetic intraperitoneal instillation versus placebo, no intervention, or inactive control during laparoscopic cholecystectomy, for the review. We excluded non-randomised studies, and studies where the method of allocating participants to a treatment was not strictly random (e.g. date of birth, hospital record number, or alternation). DATA COLLECTION AND ANALYSIS Two review authors collected the data independently. Primary outcomes included all-cause mortality, serious adverse events, and quality of life. Secondary outcomes included length of stay, pain, return to activity and work, and non-serious adverse events. The analysis included both fixed-effect and random-effects models using RevManWeb. We performed subgroup, sensitivity, and meta-regression analyses. For each outcome, we calculated the risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CIs). We assessed risk of bias using predefined domains, graded the certainty of the evidence using GRADE, and presented outcome results in a summary of findings table. MAIN RESULTS Eighty-five completed trials were included, of which 76 trials contributed data to one or more of the outcomes. This included a total of 4957 participants randomised to intraperitoneal local anaesthetic instillation (2803 participants) and control (2154 participants). Most trials only included participants undergoing elective laparoscopic cholecystectomy and those who were at low anaesthetic risk (ASA I and II). The most commonly used local anaesthetic agent was bupivacaine. Methods of instilling the local anaesthetic varied considerably between trials; this included location and timing of application. The control groups received 0.9% normal saline (69 trials), no intervention (six trials), or sterile water (two trials). One trial did not specify the control agent used. None of the trials provided information on follow-up beyond point of discharge from hospital. Only two trials were at low risk of bias. Seven trials received external funding, of these three were assessed to be at risk of conflicts of interest, a further 17 trials declared no funding. We are very uncertain about the effect intraperitoneal local anaesthetic versus control on mortality; zero mortalities in either group (8 trials; 446 participants; very low-certainty evidence); serious adverse events (RR 1.07; 95% CI 0.49 to 2.34); 13 trials; 988 participants; discharge on same day of surgery (RR 1.43; 95% CI 0.64 to 3.20; 3 trials; 242 participants; very low-certainty evidence). We found that intraperitoneal local anaesthetic probably results in a small reduction in length of hospital stay (MD -0.10 days; 95% CI -0.18 to -0.01; 12 trials; 936 participants; moderate-certainty evidence). No trials reported data on health-related quality of life, return to normal activity or return to work. Pain scores, as measured by visual analogue scale (VAS), were lower in the intraperitoneal local anaesthetic instillation group compared to the control group at both four to eight hours (MD -0.99 cm VAS; 95% CI -1.19 to -0.79; 57 trials; 4046 participants; low-certainty of evidence) and nine to 24 hours (MD -0.68 cm VAS; 95% CI -0.88 to -0.49; 52 trials; 3588 participants; low-certainty of evidence). In addition, we found two trials that were still ongoing, and one trial that was completed but with no published results. All three trials are registered on the WHO trial register. AUTHORS' CONCLUSIONS We are very uncertain about the effect estimate of intraperitoneal local anaesthetic for laparoscopic cholecystectomy on all-cause mortality, serious adverse events, and proportion of patients discharged on the same day of surgery because the certainty of evidence was very low. Due to inadequate reporting, we cannot exclude an increase in adverse events. We found that intraperitoneal local anaesthetic probably results in a small reduction in length of stay in hospital after surgery. We found that intraperitoneal local anaesthetic may reduce pain at up to 24 hours for low-risk patients undergoing laparoscopic cholecystectomy. Future randomised clinical trials should be at low risk of systematic and random errors, should fully report mortality and side effects, and should focus on clinical outcomes such as quality of life.
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Affiliation(s)
| | | | - Calum Worsley
- Department of General Surgery, NHS Forth Valley, Larbert, UK
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Mena GE, Zorrilla-Vaca A, Vaporciyan A, Mehran R, Lasala JD, Williams W, Patel C, Woodward T, Kruse B, Joshi G, Rice D. Intraoperative Dexmedetomidine and Ketamine Infusions in an Enhanced Recovery After Thoracic Surgery Program: A Propensity Score Matched Analysis. J Cardiothorac Vasc Anesth 2021; 36:1064-1072. [PMID: 34690059 DOI: 10.1053/j.jvca.2021.09.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/15/2021] [Accepted: 09/22/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To assess the impact of intraoperative dexmedetomidine and ketamine on postoperative pain and opioid consumption within an ERAS program in thoracic pulmonary oncologic surgery. DESIGN Retrospective, propensity-score matched analysis SETTING: Enhanced Recovery After Surgery (ERAS) program. PARTICIPANTS Patients undergoing thoracic pulmonary oncologic surgery between March 2016 and April 2020. INTERVENTIONS Continuous infusion of dexmedetomidine and ketamine. MEASUREMENTS & MAIN RESULTS The authors initially analyzed data of 1,630 patients undergoing thoracic pulmonary oncologic surgery within their ERAS program. In total, 117 matched pairs were included in this analysis. Patients in the intraoperative dexmedetomidine + ketamine group were more likely to be opioid-free (76.6% vs 60.9%, P<0.01). Raw analysis showed lower pain scores at PACU admission (2.8±2.0 vs 3.4±2.0, P=0.03) and less opioid consumption at PACU admission (5 MED [0-10] vs 7.5 MED [0-15], P=0.03) in the dexmedetomidine + ketamine group; however, these differences were not present after adjusting for multiplicity. There were no significant differences in the length of PACU stay (1.9 hours [1.5-2.8] vs 2.0 hours [1.4-2.9], P=0.48) or hospital stay (three days [two-five] vs three days [two-five], P=0.08). Both groups had similar rates of pulmonary complications (5.9% vs 9.4%, P=0.326), ileus (0.9% vs 0.9%, P=1.00), and 30-day readmission (2.6% vs 4.3%, P=0.722). CONCLUSIONS There were no differences in postoperative pain scores and opioid consumption throughout their hospital stay between patients receiving concomitant dexmedetomidine and ketamine infusions versus patients who did not receive these infusions during thoracic surgery.
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Affiliation(s)
- Gabriel E Mena
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Andres Zorrilla-Vaca
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX; Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX; Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, MA.
| | - Ara Vaporciyan
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Reza Mehran
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Javier D Lasala
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Wendell Williams
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carla Patel
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - TaCharra Woodward
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brittany Kruse
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Girish Joshi
- Department of Anesthesiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - David Rice
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
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Pogatzki-Zahn EM, Freys SM. [Procedure Specific Pain Therapy - the PROSPECT Idea]. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56:586-598. [PMID: 34507382 DOI: 10.1055/a-1188-0945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Acute pain therapy following operative or interventional procedures has become a compulsory component of a modern perioperative patient management. A structured pain regimen has several clear advantages: it leads to an improvement of the patients' quality of life in the short term, it reduces perioperative morbidity in the medium term, it reduces pain chronification in the long term, at the same time improving the economic efficiency due to an accelerated mobilization, a reduction of the hospitalization and an avoidance of complication inherent costs.This article provides detailed information on the change of paradigm, away from a generalized and rather unspecific acute pain therapy towards a problem oriented procedure specific regimen. It points out two examples of the PROSPECT (PROcedure SPECific pain managemenT) methodology and explains its background.
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Waelkens P, Alsabbagh E, Sauter A, Joshi GP, Beloeil H. Pain management after complex spine surgery: A systematic review and procedure-specific postoperative pain management recommendations. Eur J Anaesthesiol 2021; 38:985-994. [PMID: 34397527 PMCID: PMC8373453 DOI: 10.1097/eja.0000000000001448] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Complex spinal procedures are associated with intense pain in the postoperative period. Adequate peri-operative pain management has been shown to correlate with improved outcomes including early ambulation and early discharge. OBJECTIVES We aimed to evaluate the available literature and develop recommendations for optimal pain management after complex spine surgery. DESIGN AND DATA SOURCES A systematic review using the PROcedure SPECific postoperative pain managemenT methodology was undertaken. Randomised controlled trials and systematic reviews published in the English language from January 2008 to April 2020 assessing postoperative pain after complex spine surgery using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, EMBASE and Cochrane Databases. RESULTS Out of 111 eligible studies identified, 31 randomised controlled trials and four systematic reviews met the inclusion criteria. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, cyclo-oxygenase (COX)-2 specific-inhibitors or non-steroidal anti-inflammatory drugs (NSAIDs), intravenous ketamine infusion and regional analgesia techniques including epidural analgesia using local anaesthetics with or without opioids. Limited evidence was found for local wound infiltration, intrathecal and epidural opioids, erector spinae plane block, thoracolumbar interfascial plane block, intravenous lidocaine, dexmedetomidine and gabapentin. CONCLUSIONS The analgesic regimen for complex spine surgery should include pre-operative or intra-operative paracetamol and COX-2 specific inhibitors or NSAIDs, continued postoperatively with opioids used as rescue analgesics. Other recommendations are intra-operative ketamine and epidural analgesia using local anaesthetics with or without opioids. Although there is procedure-specific evidence in favour of intra-operative methadone, it is not recommended as it was compared with shorter-acting opioids and due to its limited safety profile. Furthermore, the methadone studies did not use non-opioid analgesics, which should be the primary analgesics to ultimately reduce overall opioid requirements, including methadone. Further qualitative randomised controlled trials are required to confirm the efficacy and safety of these recommended analgesics on postoperative pain relief.
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Affiliation(s)
- Piet Waelkens
- From the Department of Anaesthesiology, KU Leuven and University Hospital Leuven, Leuven, Belgium (PW), CHU Rennes, Anesthesia and Intensive Care Department, Rennes, France (EA), the Department of Anaesthesiology and Pain Management, University of Oslo, Oslo, Norway (AS), the Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (AS), the Department of Anaesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA (GPJ), the University Rennes, CHU Rennes, Inserm, INRA, CIC 1414 NuMeCan, Anesthesia and Intensive Care Department, Rennes, France (HB)
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Stewart JW, Ringqvist J, Wooldridge RD, Farr DE, Sunna M, Schulz C, Alexander JC, Minhajuddin A, Gasanova I, Joshi GP. Erector spinae plane block versus thoracic paravertebral block for pain management after total bilateral mastectomies. Proc (Bayl Univ Med Cent) 2021; 34:571-574. [PMID: 34456475 DOI: 10.1080/08998280.2021.1919003] [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: 10/21/2022] Open
Abstract
This prospectively designed, clinical quality improvement project compared pain scores and opioid consumption between ultrasound-guided, erector spinae plane blocks (ESPB) and thoracic paravertebral blocks (PVB) in patients undergoing total bilateral mastectomies without reconstruction. Twenty-five patients were included in an enhanced recovery pathway and received an ESPB on one side and a PVB on the contralateral side. Numeric rating scores at rest and with movement for each side were recorded in the recovery room at 2, 6, 12, 24, and 48 hours and on days 3 to 7. There were no significant differences in the resting or movement-evoked pain scores between sides receiving ESPB or PVB at any time point up to day 7 after surgery. Both ESPB and PVB confer equal analgesic effects in patients undergoing mastectomies. ESPB provides an alternative to PVB in reducing postoperative pain in patients undergoing mastectomy as part of an enhanced recovery pathway.
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Affiliation(s)
- Jesse W Stewart
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jenny Ringqvist
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rachel D Wooldridge
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Deborah E Farr
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mary Sunna
- Parkland Health and Hospital System, Dallas, Texas
| | - Cedar Schulz
- Parkland Health and Hospital System, Dallas, Texas
| | - John C Alexander
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Abu Minhajuddin
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Irina Gasanova
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
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Raeder J, Joshi GP. PROSPECT guidelines for total hip arthroplasty: a reply. Anaesthesia 2021; 77:1306. [PMID: 34390583 DOI: 10.1111/anae.15566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2021] [Indexed: 11/30/2022]
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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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Panzenbeck P, von Keudell A, Joshi GP, Xu CX, Vlassakov K, Schreiber KL, Rathmell JP, Lirk P. Procedure-specific acute pain trajectory after elective total hip arthroplasty: systematic review and data synthesis. Br J Anaesth 2021; 127:110-132. [PMID: 34147158 DOI: 10.1016/j.bja.2021.02.036] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 01/25/2021] [Accepted: 02/23/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND For most procedures, there is insufficient evidence to guide clinicians in the optimal timing of advanced analgesic methods, which should be based on the expected time course of acute postoperative pain severity and aimed at time points where basic analgesia has proven insufficient. METHODS We conducted a systematic search of the literature of analgesic trials for total hip arthroplasty (THA), extracting and pooling pain scores across studies, weighted for study size. Patients were grouped according to basic anaesthetic method used (general, spinal), and adjuvant analgesic interventions such as nerve blocks, local infiltration analgesia, and multimodal analgesia. Special consideration was given to high-risk populations such as chronic pain or opioid-dependent patients. RESULTS We identified and analysed 71 trials with 5973 patients and constructed pain trajectories from the available pain scores. In most patients undergoing THA under general anaesthesia on a basic analgesic regimen, postoperative acute pain recedes to a mild level (<4/10) by 4 h after surgery. We note substantial variability in pain intensity even in patients subjected to similar analgesic regimens. Chronic pain or opioid-dependent patients were most often actively excluded from studies, and never analysed separately. CONCLUSIONS We have demonstrated that it is feasible to construct procedure-specific pain curves to guide clinicians on the timing of advanced analgesic measures. Acute intense postoperative pain after THA should have resolved by 4-6 h after surgery in most patients. However, there is a substantial gap in knowledge on the management of patients with chronic pain and opioid-dependent patients.
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Affiliation(s)
- Paul Panzenbeck
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Arvind von Keudell
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, RX, USA
| | - Claire X Xu
- Department of Anesthesiology, Pain and Critical Care Medicine, Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA, USA
| | - Kamen Vlassakov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kristin L Schreiber
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - James P Rathmell
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Philipp Lirk
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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PROSPECT guidelines update for evidence-based pain management after prostatectomy for cancer. Anaesth Crit Care Pain Med 2021; 40:100922. [PMID: 34197976 DOI: 10.1016/j.accpm.2021.100922] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 02/03/2023]
Abstract
The aim of this review was to update the recommendations for optimal pain management after open and laparoscopic or robotic prostatectomy. Optimal pain management is known to influence postoperative recovery, but patients undergoing open radical prostatectomy typically experience moderate dynamic pain in the immediate postoperative day. Robot-assisted and laparoscopic surgery may be associated with decreased pain levels as opposed to open surgery. We performed a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) with PROcedure SPECific Postoperative Pain ManagemenT (PROSPECT) methodology. Randomised controlled trials (RCTs) published in English language, from January 2015 until March 2020, assessing postoperative pain, using analgesic, anaesthetic and surgical interventions, were identified from MEDLINE, EMBASE and Cochrane Databases. Of the 1797 studies identified, 35 RCTs and 3 meta-analyses met our inclusion criteria. NSAIDs and COX-2 selective inhibitors proved to lower postoperative pain scores. Continuous intravenous lidocaine reduced postoperative pain scores during open surgery. Local wound infiltration showed positive results in open surgery. Bilateral transversus abdominis plane (TAP) block was performed at the end of surgery and lowered pain scores in robot-assisted procedures, but results were conflicting for open procedures. Basic analgesia for prostatic surgery should include paracetamol and NSAIDs or COX-2 selective inhibitors. TAP block should be recommended as the first-choice regional analgesic technique for laparoscopic/robotic radical prostatectomy. Intravenous lidocaine should be considered for open surgeries.
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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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Anger M, Valovska T, Beloeil H, Lirk P, Joshi GP, Van de Velde M, Raeder J. PROSPECT guideline for total hip arthroplasty: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2021; 76:1082-1097. [PMID: 34015859 DOI: 10.1111/anae.15498] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2021] [Indexed: 12/11/2022]
Abstract
The aim of this systematic review was to develop recommendations for the management of postoperative pain after primary elective total hip arthroplasty, updating the previous procedure-specific postoperative pain management (PROSPECT) guidelines published in 2005 and updated in July 2010. Randomised controlled trials and meta-analyses published between July 2010 and December 2019 assessing postoperative pain using analgesic, anaesthetic, surgical or other interventions were identified from MEDLINE, Embase and Cochrane databases. Five hundred and twenty studies were initially identified, of which 108 randomised trials and 21 meta-analyses met the inclusion criteria. Peri-operative interventions that improved postoperative pain include: paracetamol; cyclo-oxygenase-2-selective inhibitors; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone. In addition, peripheral nerve blocks (femoral nerve block; lumbar plexus block; fascia iliaca block), single-shot local infiltration analgesia, intrathecal morphine and epidural analgesia also improved pain. Limited or inconsistent evidence was found for all other approaches evaluated. Surgical and anaesthetic techniques appear to have a minor impact on postoperative pain, and thus their choice should be based on criteria other than pain. In summary, the analgesic regimen for total hip arthroplasty should include pre-operative or intra-operative paracetamol and cyclo-oxygenase-2-selective inhibitors or non-steroidal anti-inflammatory drugs, continued postoperatively with opioids used as rescue analgesics. In addition, intra-operative intravenous dexamethasone 8-10 mg is recommended. Regional analgesic techniques such as fascia iliaca block or local infiltration analgesia are recommended, especially if there are contra-indications to basic analgesics and/or in patients with high expected postoperative pain. Epidural analgesia, femoral nerve block, lumbar plexus block and gabapentinoid administration are not recommended as the adverse effects outweigh the benefits. Although intrathecal morphine 0.1 mg can be used, the PROSPECT group emphasises the risks and side-effects associated with its use and provides evidence that adequate analgesia may be achieved with basic analgesics and regional techniques without intrathecal morphine.
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Affiliation(s)
- M Anger
- Service d'Anesthésie Réanimation et Médecine Péri-opératoire, CHU Rennes, Université Rennes, Rennes, France
| | - T Valovska
- Service d'Anesthésie Réanimation et Médecine Péri-opératoire, CHU Rennes, Université Rennes, Rennes, France
| | - H Beloeil
- Department of Anesthesiology, Henry Ford Health Systems, Wayne State School of Medicine, Detroit, MI, USA
| | - P Lirk
- Department of Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - G P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - M Van de Velde
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Anaesthesiology, UZLeuven, Leuven, Belgium
| | - J Raeder
- Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway.,Division of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
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Marty P, Chassery C, Rontes O, Vuillaume C, Basset B, Merouani M, Marquis C, Delussy A, Delbos MC, Ferre F, Bataille B, Joshi G, Delbos A. Obturator nerve block does not provide analgesic benefits in total hip arthroplasty under multimodal analgesic regimen: a randomized controlled trial. Reg Anesth Pain Med 2021; 46:657-662. [PMID: 33952684 DOI: 10.1136/rapm-2021-102531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/17/2021] [Accepted: 04/19/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVES Although regional analgesia is considered an important component of optimal pain management, use of peripheral nerve blocks for total hip arthroplasty remains controversial. Since the obturator nerve innervates the anteromedial part of the joint capsule, we hypothesized that an obturator nerve block would decrease the opioid consumption after total hip arthroplasty. METHODS In this single center, prospective, triple blinded study, we randomly allocated 60 patients undergoing total hip arthroplasty under opioid-sparing total intravenous general anesthesia to a preoperative obturator nerve block or a sham block (placebo group) using 20 mL of ropivacaine 0.2% or saline, respectively. All patients received a multimodal analgesic regimen with non-opioid analgesics including periarticular local infiltration analgesia. The primary outcome was the intravenous opioid consumption in the post-anesthesia care unit. RESULTS Median (IQR) intravenous oxycodone consumption in the post-anesthesia care unit was 4 (2, 7.5) mg in the obturator nerve block group and 3 (0, 4) mg in the placebo group (p=0.05). There were no differences in pain scores between groups in the first 24 hours except at arrival on the surgical ward with significant higher pain scores in the placebo group (p=0.03). The ability to stand up and walk within 24 hours was comparable between groups as was the time to first walk (180 (90, 720) vs 240 (120, 780) min for the obturator nerve block and placebo groups, respectively; p=0.62). CONCLUSIONS Obturator nerve block did not improve postoperative opioid consumption after total hip arthroplasty performed under general anesthesia with a multimodal analgesic regimen. TRIAL REGISTRATION NUMBER NCT04085640.
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Affiliation(s)
- Philippe Marty
- Department of Anesthesia, Clinique Medipole Garonne, Toulouse, Occitanie, France
| | - Clement Chassery
- Department of Anesthesia, Clinique Medipole Garonne, Toulouse, Occitanie, France
| | - Olivier Rontes
- Department of Anesthesia, Clinique Medipole Garonne, Toulouse, Occitanie, France
| | - Corine Vuillaume
- Department of Anesthesia, Clinique Medipole Garonne, Toulouse, Occitanie, France
| | - Bertrand Basset
- Department of Anesthesia, Clinique Medipole Garonne, Toulouse, Occitanie, France
| | - Mehdi Merouani
- Department of Anesthesia, Clinique Medipole Garonne, Toulouse, Occitanie, France
| | - Constance Marquis
- Department of Anesthesia, Clinique Medipole Garonne, Toulouse, Occitanie, France
| | - Anne Delussy
- Department of Anesthesia, Clinique Medipole Garonne, Toulouse, Occitanie, France
| | - Marie-Claude Delbos
- Department of Anesthesia, Clinique Medipole Garonne, Toulouse, Occitanie, France
| | - Fabrice Ferre
- Department of Anesthesia, Hôpital Purpan, Toulouse, Midi-Pyrénées, France
| | - Benoit Bataille
- Department of Anesthesia and Intensive Care, Narbonne Hospital Orthopedic and Trauma Surgery, Narbonne, Occitanie, France
| | - Girish Joshi
- Department of Anesthesiology, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
| | - Alain Delbos
- Department of Anesthesia, Clinique Medipole Garonne, Toulouse, Occitanie, France
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Roofthooft E, Joshi GP, Rawal N, Van de Velde M. Tailoring postoperative pain management using a procedure-specific approach. Anaesthesia 2021; 76:1282. [PMID: 33942900 DOI: 10.1111/anae.15505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2021] [Indexed: 11/30/2022]
Affiliation(s)
| | - G P Joshi
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - N Rawal
- Orebro University, Orebro, Sweden
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