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Postoperative analgesic options after spine surgery: finding the optimal treatment strategies. Expert Rev Neurother 2024; 24:191-200. [PMID: 38155560 DOI: 10.1080/14737175.2023.2298824] [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: 06/03/2023] [Accepted: 12/20/2023] [Indexed: 12/30/2023]
Abstract
INTRODUCTION Spine surgery is one of the most common types of surgeries performed in the United States; however, managing postoperative pain following spine surgery has proven to be challenging. Patients with spine pathologies have higher incidences of chronic pain and resultant opioid use and potential for tolerance. Implementing a multimodal plan for postoperative analgesia after spine surgery can lead to enhanced recovery and outcomes. AREAS COVERED This review presents several options for analgesia following spine surgery with an emphasis on multimodal techniques to best aid this specific patient population. In addition to traditional therapeutics, such as acetaminophen, non-steroidal anti-inflammatory medications, and opioids, we discuss intrathecal morphine administration and emerging regional anesthesia techniques. EXPERT OPINION Several adjuncts to improve analgesia following spine surgery are efficacious in the postoperative period. Intrathecal morphine provides sustained analgesia and can be instilled intraoperatively by the surgical team under direct visualization. Local anesthetics deposited under ultrasound guidance by an anesthesiologist trained in regional techniques also provide the opportunity for single injections or continuous analgesia via an indwelling catheter.
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Opioid Sparing Analgesics in Spine Surgery. Adv Orthop 2022; 2022:1026547. [PMID: 35942400 PMCID: PMC9356873 DOI: 10.1155/2022/1026547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/17/2022] [Accepted: 07/06/2022] [Indexed: 11/28/2022] Open
Abstract
Combinations of various nonopioid analgesics have been used to decrease pain and opioid consumption postoperatively allowing for faster recovery, improved patient satisfaction, and decreased morbidity. These opioid alternatives include acetaminophen, NSAIDs, COX-2 specific inhibitors, gabapentinoids, local anesthetics, dexamethasone, and ketamine. Each of these drugs presents its own advantages and disadvantages which can make it difficult to implement universally. In addition, ambiguous administration guidelines for these nonopioid analgesics lead to a difficult implementation of standardization protocols in spine surgery. A focus on the efficacy of different pain modalities specifically within spine surgery was implemented to assist with this standardized protocol endeavor and to educate surgeons on limiting opioid prescribing in the postoperative period. The purpose of this review article is to investigate the various opioid sparing medications that have been used to decrease morbidity in spine surgery and better assist surgeons in managing postoperative pain. Methods. A narrative review of published literature was conducted using the search function in Google scholar and PubMed was used to narrow down search criteria. The keywords “analgesics,” “spine,” and “pain” were used.
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Gabapentin reduces postoperative pain and opioid consumption in patients who underwent lumbar laminectomy. J Am Pharm Assoc (2003) 2021; 61:e78-e83. [PMID: 34024754 DOI: 10.1016/j.japh.2021.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/22/2021] [Accepted: 05/02/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Postoperative pain management solely with opioids elevates the risk of opioid-related adverse events during hospitalization and after discharge from the hospital. Clinical trials have demonstrated gabapentinoids as viable adjunctive treatments for spinal surgeries. However, only a few practice-based studies have examined the efficacy of gabapentin as an opioid-sparing agent for patients undergoing lumbar laminectomy in rural hospital settings. OBJECTIVE To determine the effects of gabapentin on opioid consumption and pain perception in patients who underwent lumbar laminectomy at a rural community hospital. METHODS Data were collected by retrospective chart reviews of 99 patients who underwent lumbar laminectomy at Yavapai Regional Medical Center from January 1, 2017, to July 1, 2019. The patients were stratified into 2 groups: those who were taking gabapentin as outpatients before surgery and were continued on the same dose postoperatively (n = 50, gabapentin group) and those who were not taking gabapentin preoperatively or postoperatively (n = 49, usual-treatment group). The primary end points were opioid consumption in morphine milligram equivalents (MME) and pain for 24 hours postsurgery. RESULTS Outcomes from the mixed-model analysis of variance showed significant main effects of group and time for opioid consumption in MME (F1,97 = 4.3, P < 0.05 and F3,291 = 133.9, P < 0.001, respectively) and numerical pain scale scores (F1,99 = 4.0, P < 0.05 and F3,241 = 21.4, P < 0.001, respectively) and group-time interaction for opioid consumption in MME (F3,291 = 2.6, P = 0.05). Post hoc analyses showed that opioid consumption in MME was significantly lower in the gabapentin group than in the usual-treatment group for the first 6 hours postoperatively. The pain scores were significantly lower in the gabapentin group than in the usual-treatment group across all time periods. CONCLUSION Patients on gabapentin showed reductions in pain perception and postoperative opioid consumption. The results extend the findings from randomized trials to a real-world clinical setting. These data support using gabapentin in conjunction with opioids for pain management of patients undergoing lumbar laminectomy.
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Pain management after laminectomy: a systematic review and procedure-specific post-operative pain management (prospect) recommendations. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 30:2925-2935. [PMID: 33247353 DOI: 10.1007/s00586-020-06661-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 10/09/2020] [Accepted: 11/07/2020] [Indexed: 01/06/2023]
Abstract
PURPOSE With lumbar laminectomy increasingly being performed on an outpatient basis, optimal pain management is critical to avoid post-operative delay in discharge and readmission. The aim of this review was to evaluate the available literature and develop recommendations for optimal pain management after one- or two-level lumbar laminectomy. METHODS A systematic review utilizing the PROcedure-SPECific Post-operative Pain ManagemenT (PROSPECT) methodology was undertaken. Randomised controlled trials (RCTs) published in the English language from 1 January 2008 until 31 March 2020-assessing post-operative pain using analgesic, anaesthetic and surgical interventions-were identified from MEDLINE, EMBASE and Cochrane Databases. RESULTS Out of 65 eligible studies identified, 39 RCTs met the inclusion criteria. The analgesic regimen for lumbar laminectomy should include paracetamol and a non-steroidal anti-inflammatory drug (NSAID) or cyclooxygenase (COX)-2 selective inhibitor administered preoperatively or intraoperatively and continued post-operatively, with post-operative opioids for rescue analgesia. In addition, surgical wound instillation or infiltration with local anaesthetics prior to wound closure is recommended. Some interventions-gabapentinoids and intrathecal opioid administration-although effective, carry significant risks and consequently were omitted from the recommendations. Other interventions were also not recommended because there was insufficient, inconsistent or lack of evidence. CONCLUSION Perioperative pain management for lumbar laminectomy should include paracetamol and NSAID- or COX-2-specific inhibitor, continued into the post-operative period, as well as intraoperative surgical wound instillation or infiltration. Opioids should be used as rescue medication post-operatively. Future studies are necessary to evaluate the efficacy of our recommendations.
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Systematic review and meta-analysis of the clinical utility of Enhanced Recovery After Surgery pathways in adult spine surgery. J Neurosurg Spine 2020; 34:325-347. [PMID: 33157522 DOI: 10.3171/2020.6.spine20795] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spine surgery has been identified as a significant source of healthcare expenditures in the United States. Prolonged hospitalization has been cited as one source of increased spending, and there has been drive from providers and payors alike to decrease inpatient stays. One strategy currently being explored is the use of Enhanced Recovery After Surgery (ERAS) protocols. Here, the authors review the literature on adult spine ERAS protocols, focusing on clinical benefits and cost reductions. They also conducted a quantitative meta-analysis examining the following: 1) length of stay (LOS), 2) complication rate, 3) wound infection rate, 4) 30-day readmission rate, and 5) 30-day reoperation rate. METHODS Using the PRISMA guidelines, a search of the PubMed/Medline, Web of Science, Cochrane Reviews, Embase, CINAHL, and OVID Medline databases was conducted to identify all full-text articles in the English-language literature describing ERAS protocol implementation for adult spine surgery. A quantitative meta-analysis using random-effects modeling was performed for the identified clinical outcomes using studies that directly compared ERAS protocols with conventional care. RESULTS Of 950 articles reviewed, 34 were included in the qualitative analysis and 20 were included in the quantitative analysis. The most common protocol types were general spine surgery protocols and protocols for lumbar spine surgery patients. The most frequently cited benefits of ERAS protocols were shorter LOS (n = 12), lower postoperative pain scores (n = 6), and decreased complication rates (n = 4). The meta-analysis demonstrated shorter LOS for the general spine surgery (mean difference -1.22 days [95% CI -1.98 to -0.47]) and lumbar spine ERAS protocols (-1.53 days [95% CI -2.89 to -0.16]). Neither general nor lumbar spine protocols led to a significant difference in complication rates. Insufficient data existed to perform a meta-analysis of the differences in costs or postoperative narcotic use. CONCLUSIONS Present data suggest that ERAS protocol implementation may reduce hospitalization time among adult spine surgery patients and may lead to reductions in complication rates when applied to specific populations. To generate high-quality evidence capable of supporting practice guidelines, though, additional controlled trials are necessary to validate these early findings in larger populations.
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Preoperative Gabapentin Administration Improves Acute Postoperative Analgesia in Patients Undergoing Craniotomy: A Randomized Controlled Trial. J Neurosurg Anesthesiol 2019; 31:392-398. [DOI: 10.1097/ana.0000000000000533] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Abstract
Multimodal analgesia (MMA) is the simultaneous use of multiple analgesic medications that work in a synergistic manner to provide pain control. In recent years, spine surgery has seen the growth of multimodal perioperative protocols for managing pain. Postoperative pain following spinal procedures is a common complaint, with persistent pain even after the immediate convalescent period leading to negative impacts on health. A multidisciplinary approach is essential in reducing postoperative morbidity and complication rates. This review demonstrates the efficacy in the combined use of opioid-alternative medications such as NSAIDs, gabapentinoids, local anesthetics, acetaminophen, and other neuromodulatory pharmacologic agents. Continued research will be essential in the optimization of the MMA protocol for treating patients who undergo spine procedures.
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Safety in Acute Pain Medicine-Pharmacologic Considerations and the Impact of Systems-Based Gaps. PAIN MEDICINE 2019; 19:2296-2315. [PMID: 29727003 DOI: 10.1093/pm/pny079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective In the setting of an expanding prevalence of acute pain medicine services and the aggressive use of multimodal analgesia, an overview of systems-based safety gaps and safety concerns in the setting of aggressive multimodal analgesia is provided below. Setting Expert commentary. Methods Recent evidence focused on systems-based gaps in acute pain medicine is discussed. A focused literature review was conducted to assess safety concerns related to commonly used multimodal pharmacologic agents (opioids, nonsteroidal anti-inflammatory drugs, gabapentanoids, ketamine, acetaminophen) in the setting of inpatient acute pain management. Conclusions Optimization of systems-based gaps will increase the probability of accurate pain assessment, improve the application of uniform evidence-based multimodal analgesia, and ensure a continuum of pain care. While acute pain medicine strategies should be aggressively applied, multimodal regimens must be strategically utilized to minimize risk to patients and in a comorbidity-specific fashion.
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Multimodal Analgesia for Perioperative Management of Patients presenting for Spinal Surgery. Curr Pharm Des 2019; 25:2123-2132. [PMID: 31298146 DOI: 10.2174/1381612825666190708174639] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 06/26/2019] [Indexed: 11/22/2022]
Abstract
Multimodal, non-opioid based analgesia has become the cornerstone of ERAS protocols for effective analgesia after spinal surgery. Opioid side effects, dependence and legislation restricting long term opioid use has led to a resurgence in interest in opioid sparing techniques. The increasing array of multimodal opioid sparing analgesics available for spinal surgery targeting novel receptors, transmitters, and altering epigenetics can help provide an optimal perioperative experience with less opioid side effects and long-term dependence. Epigenetic mechanisms of pain may enhance or suppress gene expression, without altering the genome itself. Such mechanisms are complex, dynamic and responsive to environment. Alterations that occur can affect the pathophysiology of pain management at a DNA level, modifying perceived pain relief. In this review, we provide a brief overview of epigenetics of pain, systemic local anesthetics and neuraxial techniques that continue to remain useful for spinal surgery, neuropathic agents, as well as other common and less common target receptors for a truly multimodal approach to perioperative pain management.
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The influence of pre- and perioperative administration of gabapentin on pain 3-4 years after total knee arthroplasty. Scand J Pain 2019; 18:237-245. [PMID: 29794296 DOI: 10.1515/sjpain-2018-0027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 02/14/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIMS Approximately 20% of patients having total knee arthroplasty (TKA) will experience chronic postoperative pain. Recently, preoperative pain facilitation has been associated with chronic pain after TKA, and gabapentin has been shown to decrease pain facilitation. The current study is a secondary follow-up of a primary RCT investigating the effect of gabapentin on acute postoperative pain after TKA and exploring the effect of pre- and perioperative administration of gabapentin on chronic postoperative pain and psychological state 3-4 years after TKA. METHODS Patients scheduled for TKA were randomized to either gabapentin 1,300 mg/day, gabapentin 900 mg/day, or placebo daily from 2-h before and 6 days after operation. Pre- and 3-4 years postoperatively pain scores related to pain while walking, at rest, when flexing the hip or the knee were collected. At the same time, the pain catastrophizing scale (PCS) and hospital anxiety and depression scale subscales for anxiety (HADS-A) and depression (HADS-D) were collected. RESULTS Lower postoperative pain while walking, flexing the hip, and at rest were found compared with preoperative scores (p<0.03), but these were not associated with gabapentin treatment (p>0.19). Significantly lower postoperative PCS and HADS-A scores were seen compared with preoperative scores (p<0.001), but these were not associated with gabapentin treatment (p>0.55). CONCLUSIONS The current study found that pre- and perioperative administrations of gabapentin do not influence the pain or psychological state 3-4 years after TKA. IMPLICATIONS The current study does not support that short-term pre- and perioperative use of gabapentin can reduce the development of chronic postoperative pain after TKA.
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Laminektomi operasyonu olan ileri yaş hastalarda genel anestezi ile spinal anestezinin postoperatif ağrı ve analjezik tüketimi üzerine etkileri: retrospektif deneyimlerimiz. DICLE MEDICAL JOURNAL 2019. [DOI: 10.5798/dicletip.420540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Effects of a single dose of preoperative pregabalin and gabapentin for acute postoperative pain: a network meta-analysis of randomized controlled trials. J Pain Res 2018; 11:2633-2643. [PMID: 30519075 PMCID: PMC6233947 DOI: 10.2147/jpr.s170810] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background Pregabalin (PGB) and gabapentin (GBP) are current and emerging drugs in the field of pre-emptive preoperative analgesia. However, the role of PGB or GBP in acute postoperative pain management still remains elusive. Materials and methods We conducted a comprehensive literature search of articles published by December 3, 2017. A total of 79 randomized controlled trials with 6,201 patients receiving single-dose premedication were included. Through a network meta-analysis (NMA), we validated the analgesic effect and incidence of adverse events by using various doses of PGB or GBP administration. Results NMA results suggested that the analgesic effect may be dose related. For 24-hour opioid consumption, a consistent decrease was found with the increase in the dose of PGB or GBP. For 24-hour pain score at rest, a high dose (≥150 mg) of PGB was more effective in decreasing pain score than a dose of 75 mg, and a high dose (≥900 mg) of GBP reduced pain intensity than doses of 300 or 600 mg. Moreover, the incidence of adverse reactions varied with varying doses of PGB or GBP. Conclusion A dose-response relationship was detected in opioid consumption and postoperative pain for a single-dose preoperative administration of PGB and GBP. Making reasonable choice of drugs and dosage may prevent the occurrence of adverse reactions.
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Evidence-Based Multimodal Analgesia for Perioperative Management of Spinal Instrumentation. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0287-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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A review of anesthetic considerations and postoperative pain control after the Nuss procedure. Semin Pediatr Surg 2018; 27:156-160. [PMID: 30078486 DOI: 10.1053/j.sempedsurg.2018.05.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Dose-related beneficial and harmful effects of gabapentin in postoperative pain management - post hoc analyses from a systematic review with meta-analyses and trial sequential analyses. J Pain Res 2017; 10:2547-2563. [PMID: 29138592 PMCID: PMC5677383 DOI: 10.2147/jpr.s138519] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background During the last 15 years, gabapentin has become an established component of postoperative pain treatment. Gabapentin has been employed in a wide range of doses, but little is known about the optimal dose, providing the best balance between benefit and harm. This systematic review with meta-analyses aimed to explore the beneficial and harmful effects of various doses of gabapentin administered to surgical patients. Materials and methods Data in this paper were derived from an original review, and the subgroup analyses were predefined in an International Prospective Register of Systematic Reviews published protocol: PROSPERO (ID: CRD42013006538). The methods followed Cochrane guidelines. The Cochrane Library’s CENTRAL, PubMed, EMBASE, Science Citation Index Expanded, Google Scholar, and FDA database were searched for relevant trials. Randomized clinical trials comparing gabapentin versus placebo were included. Four different dose intervals were investigated: 0–350, 351–700, 701–1050, and >1050 mg. Primary co-outcomes were 24-hour morphine consumption and serious adverse events (SAEs), with emphasis put on trials with low risk of bias. Results One hundred and twenty-two randomized clinical trials, with 8466 patients, were included. Sixteen were overall low risk of bias. No consistent increase in morphine-sparing effect was observed with increasing doses of gabapentin from the trials with low risk of bias. Analyzing all trials, the smallest and the highest dose subgroups demonstrated numerically the most prominent reduction in morphine consumption. Twenty-seven trials reported 72 SAEs, of which 83% were reported in the >1050 mg subgroup. No systematic increase in SAEs was observed with increasing doses of gabapentin. Conclusion Data were sparse, and the small number of trials with low risk of bias is a major limitation for firm conclusions. Taking these limitations into account, we were not able to demonstrate a clear relationship between the dosage of gabapentin and opioid-sparing or harmful effects. These subgroup analyses are exploratory and hypothesis-generating for future trialists.
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Is gabapentin effective and safe in open hysterectomy? A PRISMA compliant meta-analysis of randomized controlled trials. J Clin Anesth 2017; 41:76-83. [DOI: 10.1016/j.jclinane.2017.07.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 06/29/2017] [Accepted: 07/08/2017] [Indexed: 11/20/2022]
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A meta-analysis of the preoperative use of gabapentinoids for the treatment of acute postoperative pain following spinal surgery. Medicine (Baltimore) 2017; 96:e8031. [PMID: 28906391 PMCID: PMC5604660 DOI: 10.1097/md.0000000000008031] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Gabapentinoid drugs, which include gabapentin and pregabalin, play an established role in the management of neuropathic pain. However, whether preoperative administration of gabapentinoids has a beneficial role in controlling acute pain after spinal surgery is unknown. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the efficacy and safety of the preoperative use of gabapentinoids (gabapentin and pregabalin) for the treatment of acute postoperative pain following spinal surgery. METHODS In March 2017, a systematic computer-based search was conducted in PubMed, EMBASE, Web of Science, Cochrane Library, and Google databases. RCTs comparing gabapentinoids (gabapentin and pregabalin) with placebo in patients undergoing spine surgery were retrieved. The primary endpoint was the visual analogue scale (VAS) score with rest or mobilization at 6, 12, 24, and 48 hours and cumulative morphine consumption at 24 and 48 hours. The secondary outcomes were complications of nausea, vomiting, sedation, dizziness, headache, urine retention, pruritus, and visual disturbances. After tests for publication bias and heterogeneity among studies were performed, data were aggregated for random-effects models when necessary. RESULTS Sixteen clinical studies (gabapentin group n = 8 and pregabalin group n = 8) were ultimately included in the meta-analysis. Gabapentinoids were associated with reduced pain scores at 6, 12, 24, and 48 hours. Similarly, gabapentinoids were associated with a reduction in cumulative morphine consumption at 24 and 48 hours. Furthermore, gabapentinoids can significantly reduce the occurrence of nausea, vomiting, and pruritus. There were no significant differences in the occurrence of sedation, dizziness, headache, visual disturbances, somnolence, or urine retention. CONCLUSIONS Preoperative use of gabapentinoids was able to reduce postoperative pain, total morphine consumption, and morphine-related complications following spine surgery. Further studies should determine the optimal dose and whether pregabalin is superior to gabapentin in controlling acute pain after spine surgery.
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Abstract
BACKGROUND As part of an effort to maximize value in the perioperative setting, a paradigm shift is underway in the way that patients are cared for preoperatively, on the day of surgery, and postoperatively-a setting collectively known as the perioperative care. Enhanced Recovery After Surgery (ERAS®) is an evidence-based, patient-centered team approach to delivering high-quality perioperative care to surgical patients. METHODS This review focuses on anesthesiologists, with their unique purview of perioperative setting, who are important drivers of change in the delivery of valuable perioperative care. ERAS care pathways begin in the preoperative setting by both preparing the patient for the psychological stress of surgery and optimizing the patient's medical and physiologic status so the body is ready for the physical demands of surgery. RESULTS Minimization of perioperative fasting is important to maintain volume status-decreasing reliance on intravenous fluid administration, and to reduce protein catabolism around the time of surgery. Intraoperative management in ERAS pathways relies on goal-directed fluid therapy and opioid-sparing multimodal analgesia. Postoperatively, early feeding and ambulation, as well as discontinuation of extraneous lines and catheters facilitate patients' functional recovery. CONCLUSION The laparoscopic approach to surgery, when possible, compliments ERAS techniques by reducing abdominal wall trauma and the resultant milieu of inflammatory, neurohumoral, and pain responses. Anesthesiologists driving change in the perioperative setting, in collaboration with surgeons and other disciplines, can improve value in healthcare and provide optimal outcomes that matter most to patients and healthcare providers alike.
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Gabapentin in procedure-specific postoperative pain management - preplanned subgroup analyses from a systematic review with meta-analyses and trial sequential analyses. BMC Anesthesiol 2017. [PMID: 28637424 PMCID: PMC5480107 DOI: 10.1186/s12871-017-0373-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background It has been argued that postoperative pain treatment should be “procedure-specific”, since different analgesics may have specific effects dependent on the surgical procedure. The aim of the present subgroup analysis was to compare the beneficial and harmful effects of perioperative gabapentin treatment in different surgical procedures. Methods Relevant databases were searched for randomized clinical trials (RCTs) comparing gabapentin versus placebo. Two authors independently screened titles and abstracts, extracted data and assessed risk of bias. The primary outcomes were differences in 24-h morphine consumption, and serious adverse events (SAE) between surgical procedures. These subgroup analyses were predefined in a PRISMA compliant systematic review registered at PROSPERO (ID: CRD42013006538). It was predefined that conclusions should primarily be based on trials classified as overall low risk of bias. Results Seventy-four RCTs with 5645 patients were included, assessing benefit and harm in cholecystectomy, hysterectomy, mastectomy, and arthroplasty surgery, spinal surgery, and thoracic surgery. Only eight of 74 trials were classified as overall low risk of bias limiting our ability to conclude on the estimates in most meta-analyses. The differences between surgical procedures in these trials were not statistically significant when tested for subgroup differences. Fifteen trials with 1377 patients reported a total of 59 SAEs, most of which were observed in the thoracic surgery group. Conclusion Both beneficial and harmful effects in these subgroup analyses were influenced by bias and insufficient data, limiting conclusions. With these limitations, we could not adequately test for differences in beneficial or harmful outcomes between six surgical subgroups undergoing perioperative gabapentin treatment. Electronic supplementary material The online version of this article (doi:10.1186/s12871-017-0373-8) contains supplementary material, which is available to authorized users.
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Gabapentin can decrease acute pain and morphine consumption in spinal surgery patients: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2017; 96:e6463. [PMID: 28403075 PMCID: PMC5403072 DOI: 10.1097/md.0000000000006463] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Approximately 80% of patients who underwent spinal surgeries experience moderate to extreme postoperative pain. Gabapentin was used as an adjunct for the management of acute pain in approximately half of enhanced recovery programs. This meta-analysis aimed to illustrate the efficacy and safety of gabapentin for pain management following spinal surgery. METHODS In January 2017, a systematic computer-based search was conducted in PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews, and Google database. Data on patients prepared for spine surgery in studies that compared gabapentin versus placebo were retrieved. The primary endpoint was the visual analog scale (VAS) at 12 hours and 24 hours and total morphine consumption. The secondary outcomes were complications that included nausea, dizziness, somnolence, headache, pruritus, urine retention, and vomiting. After testing for publication bias and heterogeneity between studies, data were aggregated for random-effects models when necessary. RESULTS Seven clinical studies with 581 patients (gabapentin group=383, control group=198) were ultimately included in the meta-analysis. Gabapentin was associated with reduced pain scores at 12 hours and 24 hours, corresponding to a reduction of 11.18 points (95% CI, -13.85 to -8.52 points) at 12 hours and 9.94 points (95% CI, -13.99 to -5.89 points) at 24 hours on a 100-point VAS. Similarly, gabapentin was associated with a reduction in total morphine consumption (-2.04, 95% CI -2.71, -1.37). Furthermore, gabapentin can reduce the occurrence of vomiting (risk ratio [RR] 0.46, 95% CI 0.27, 0.78, P = 0.004), urine retention (RR = 0.57, 95% CI 0.34, 0.98, P = 0.041, NNT = 11.9) and pruritus (RR = 0.38, 95% CI 0.22, 0.66, P = 0.001, NNT = 5.6) and the number needed to treat (NNT = 20.1). There were no significant differences in the occurrence of nausea, dizziness, somnolence, or headache. CONCLUSIONS Gabapentin was efficacious in the reduction of postoperative pain, total morphine consumption, and morphine-related complications following spine surgery. In addition, a high dose (≥900 mg/d) of gabapentin is more effective than a low dose (<900 mg/d). The number of included studies is limited, and more studies are needed to verify the effects of gabapentin in spinal surgery patients.
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Gabapentin for post-operative pain management - a systematic review with meta-analyses and trial sequential analyses. Acta Anaesthesiol Scand 2016; 60:1188-208. [PMID: 27426431 DOI: 10.1111/aas.12766] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 05/31/2016] [Accepted: 06/07/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Perioperative pain treatment often consist of combinations of non-opioid and opioid analgesics, 'multimodal analgesia', in which gabapentin is currently used. The aim was to document beneficial and harmful effects of perioperative gabapentin treatment. METHODS Randomized clinical trials comparing gabapentin vs. placebo or active placebo in adult surgical patients receiving gabapentin perioperatively were included. This review was conducted using Cochrane standards, trial sequential analysis (TSA), and Grading of Recommendations Assessment, Development, and Evaluation (GRADE). The primary outcomes were 24-h opioid consumption and incidence of serious adverse events (SAE). RESULTS One hundred and thirty-two trials with 9498 patients were included. Thirteen trials with low risk of bias reported a reduction in 24-h opioid consumption of 3.1 mg [0.5, 5.6] [corrected]. In the analysis of gabapentin as add-on analgesic to another non-opioid analgesic regimen found a mean reduction in 24-h morphine consumption of 1.2 mg [-0.3, 2.6; TSA-adjusted CI: -0.3, 2.6] in trials with low risk of bias. [corrected]. Nine trials with low risk of bias reported a risk ratio of SAEs of 1.61 [0.91; 2.86; TSA-adjusted CI: 0.57, 4.57]. CONCLUSION Based on GRADE assessment of the primary outcomes in trials with low risk of bias, the results are low or very low quality of evidence due to imprecision, inconsistency, and in some outcomes indirectness. Firm evidence for use of gabapentin is lacking as clinically relevant beneficial effect of gabapentin may be absent and harm is imminent, especially when added to multimodal analgesia.
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The Effect of Preoperative Gabapentin on Postoperative Nausea and Vomiting: A Meta-Analysis. Anesth Analg 2016; 122:976-85. [PMID: 26991615 DOI: 10.1213/ane.0000000000001120] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Preoperative gabapentin has been shown to improve postoperative pain and limit reliance on opioid analgesia. On the basis of an alternative mechanism, our group investigated the ability of preoperative gabapentin to prevent postoperative nausea and vomiting (PONV). METHODS We performed a meta-analysis of trials that reported outcomes on the effect of preoperative gabapentin on PONV end points in patients undergoing general anesthesia. In our primary analysis, we calculated the pooled antiemetic effects of preoperative gabapentin in studies with PONV as the primary end point. In our secondary analysis, we calculated the pooled effects in trials involving preoperative gabapentin that reported on the side effects, nausea and vomiting. RESULTS Among the trials designed with PONV as a primary end point (8 trials; n = 838), preoperative gabapentin was associated with a significant reduction in PONV (risk ratio [RR] = 0.60; 99% confidence interval [CI], 0.50-0.72; P < 0.0001), nausea (RR = 0.34; 99% CI, 0.20-0.56; P < 0.0001), and vomiting (RR = 0.34; 99% CI, 0.19-0.61; P = 0.0002) at 24 hours. Among all included trials (44 trials; n = 3489) that reported on the side effects, nausea and vomiting, similar reductions were noted in PONV with preoperative gabapentin administration. Subgroup analysis of trials excluding repeat dosing, thiopental induction, and nitrous oxide maintenance and including high-risk surgery resulted in similar PONV efficacy. Preoperative gabapentin is also associated with significantly increased rates of postoperative sedation (RR = 1.22; 95% CI, 1.02-1.47; P = 0.03) compared with control. CONCLUSIONS Preoperative gabapentin is associated with a significant reduction in PONV among studies designed to investigate this end point. Preoperative gabapentin should be considered not only as part of a multimodal approach to postoperative analgesia, but also for prevention of PONV.
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The use of gabapentin in the management of postoperative pain after total hip arthroplasty: a meta-analysis of randomised controlled trials. J Orthop Surg Res 2016; 11:79. [PMID: 27405805 PMCID: PMC4941035 DOI: 10.1186/s13018-016-0412-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 07/03/2016] [Indexed: 12/29/2022] Open
Abstract
Background Pain management after total hip arthroplasty (THA) varies and has been widely studied in recent years. Gabapentin as a third-generation antiepileptic drug that selectively affects the nociceptive process has been used for pain relief after THA. This meta-analysis was conducted to examine the efficacy of gabapentin in THA. Methods An electronic-based search was conducted using the following databases: PubMed, EMBASE, Ovid MEDLINE, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials (CENTRAL). Randomised controlled trials (RCTs) involving gabapentin and a placebo for THA were included. The meta-analysis was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Results Five trials met the inclusion criteria. The cumulative narcotic consumption and the visual analogue scale (VAS) scores at 24 and 48 h postoperatively were used for postoperative pain assessment. There was a significant decrease in morphine consumption at 24 h (P = 0.00). Compared with the control group, the VAS score (at rest) at 48 h was less in the gabapentin group (P = 0.00). Conclusion The administration of gabapentin is effective in decreasing postoperative narcotic consumption and the VAS score.
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The use of gabapentin in the management of postoperative pain after total knee arthroplasty: A PRISMA-compliant meta-analysis of randomized controlled trials. Medicine (Baltimore) 2016; 95:e3883. [PMID: 27281103 PMCID: PMC4907681 DOI: 10.1097/md.0000000000003883] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Pain management after total knee arthroplasty (TKA) varies and has been widely studied in recent years. Some randomized controlled studies have carried out to evaluate the effects of gabapentin on pain relief after TKA. However, no solid result was made about it. The purpose of this Meta-Analysis of Randomized Controlled Trials (RCTs) was to estimate the overall effect of pain control of gabapentin versus placebo after a TKA. An electronic-based search using the following databases: PubMed, EMBASE, Ovid MEDLINE, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trial from 1966 to June 2015. RCTs involving gabapentin and placebo for total knee arthroplasty were included. The meta-analysis was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Six trials with 859 participants met the inclusion criteria. The primary endpoint was cumulative narcotic consumption and the visual analog scale scores at 12 hours, 24 hours, and 48 hours, postoperatively. The knee flexion degree and treatment side effects were also compiled to evaluate the safety of gabapentin. After testing for the heterogeneity and publication bias among studies, data were aggregated for random-effects modeling when necessary. There was a significant decrease in morphine consumption at 12 hours (MD = -4.69, 95% CI: -7.18 to -2.21, P = 0.0002), 24 hours (MD = -5.30, 95% CI: -9.94 to -0.66, P = 0.03), and 48 hours (MD = -17.80, 95% CI: -31.95 to -3.64, P = 0.01), respectively. Compared with the control group, the rate of pruritus was less in the gabapentin group (RR 0.20, 95% CI 0.10 to 0.38, P = 0.00). In summary, the administration of gabapentin was effective in decreasing postoperative narcotic consumption and the incidence of pruritus. There was a high risk of selection bias and a higher heterogeneity of knee flexion range in this analysis. More high-quality large randomized controlled trials with long follow-up period are necessary for proper comparisons of the efficacy and safety of gabapentin with placebo.Systematic review registration number: No.
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Non-opioid analgesics: Novel approaches to perioperative analgesia for major spine surgery. Best Pract Res Clin Anaesthesiol 2016; 30:79-89. [DOI: 10.1016/j.bpa.2015.11.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 10/27/2015] [Accepted: 11/16/2015] [Indexed: 01/07/2023]
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A systematic review and meta-regression analysis of prophylactic gabapentin for postoperative pain. Anaesthesia 2015; 70:1186-204. [DOI: 10.1111/anae.13179] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2015] [Indexed: 12/11/2022]
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Perioperative nonopioid agents for pain control in spinal surgery. Am J Health Syst Pharm 2015; 71:1845-57. [PMID: 25320134 DOI: 10.2146/ajhp130688] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
PURPOSE Commonly used nonopioid analgesic agents that are incorporated into multimodal perioperative pain management protocols in spinal surgery are reviewed. SUMMARY Spinal procedures constitute perhaps some of most painful surgical interventions, as they often encompass extensive muscle dissection, tissue retraction, and surgical implants, as well as prolonged operative duration. Perioperative nonopioid analgesics frequently used in multimodal protocols include gabapentin, pregabalin, acetaminophen, dexamethasone, ketamine, and nonsteroidal antiinflammatory drugs (NSAIDs). There is evidence to suggest that gabapentin is safe and effective in reducing opioid consumption and pain scores at optimal doses of 600-900 mg orally administered preoperatively. Pregabalin 150-300 mg orally perioperatively has been shown to reduce both pain and narcotic consumption. Most reports concur that a single 1-g i.v. perioperative dose is safe in adults and that this dose has been shown to reduce pain and attenuate narcotic requirements. Dexamethasone's influence on postoperative pain has primarily been investigated for minor spinal procedures, with limited evidence for spinal fusions. Ketamine added to a patient-controlled analgesia regimen appears to be efficacious for 24 hours postoperatively when implemented for microdiskectomy and laminectomy procedures at doses of 1 mg/mL in a 1:1 mixture with morphine. For patients undergoing laminectomy or diskectomy, NSAIDs appear to be safe and effective in reducing pain scores and decreasing opioid consumption. CONCLUSION Preemptive analgesic therapy combining nonopioid agents with opioids may reduce narcotic consumption and improve patient satisfaction after spinal surgery. Such therapy should be considered for patients undergoing various spinal procedures in which postoperative pain control has been historically difficult to achieve.
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Retrospective observational comparative study of Hemilaminectomy versus Laminectomy for intraspinal tumour resection; Shorter Stays, Lower Analgesic Usage and Less Kyphotic Deformity. Br J Neurosurg 2015; 29:390-5. [PMID: 25622650 DOI: 10.3109/02688697.2014.1003026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Intraspinal tumours are rare and principally managed surgically. Laminectomy, employed for access to the spinal canal, destroys the posterior tension band leading to a risk of kyphosis. Hemilaminectomy as an alternative may be less destructive, potentially reducing the risk of deformity and causing less post-operative pain. METHOD We investigated this hypothesis by retrospectively reviewing a case series of 56 surgeries for a disparate and unselected group of intraspinal tumours utilizing a laminectomy or hemilaminectomy approach. RESULTS No difference was found in length of operation, completeness of resection, complication rate and Frankel-score improvements. Hemilaminectomy (n = 22) is associated with reduced hospital stay (post-op days) 4.5 (2-6) versus 6 (3-8), (p = 0.026, Mann-Whitney), and a reduction in post-operative morphine use (mg) 10 (3.5-28) versus 30 (10-90), (p = 0.005, Mann-Whitney). Post-operative kyphosis was measured with the Harrison posterior tangent method on T2-weighted sagittal MR images. The average change in kyphosis angle was greater in the laminectomy group compared with the hemilaminectomy group, 3.6 (0.8-6.2) versus 0.4 (-0.2-1.2), statistically significant (p = 0.004, Mann-Whitney). CONCLUSION Hemilaminectomy is as effective an access procedure for the resection of unselected intraspinal tumours as laminectomy, but is associated with shorter post-operative stays, lower analgesic requirements and less post-operative kyphosis.
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Optimizing pain management to facilitate Enhanced Recovery After Surgery pathways. Can J Anaesth 2014; 62:203-18. [DOI: 10.1007/s12630-014-0275-x] [Citation(s) in RCA: 145] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 11/10/2014] [Indexed: 01/30/2023] Open
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Gabapentin significantly decreases posthemorrhoidectomy pain: a prospective study. Int J Colorectal Dis 2014; 29:1565-9. [PMID: 25269619 DOI: 10.1007/s00384-014-2018-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/16/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE Surgery for hemorrhoidectomy remains a painful procedure despite advances in pain management. Gabapentin is widely used for control of acute and chronic pain. Our aim was to evaluate the effect of gabapentin on posthemorrhoidectomy pain and opioid use. METHODS A prospective, open-label study. Patients requiring hemorrhoid surgery were recruited to be in control (standard of care) or treatment group (standard of care plus daily gabapentin). RESULTS Twenty-one treatment and 18 control patients were recruited. One patient from study group and two patients from control group were excluded due to failure to follow up. Pain levels for gabapentin group were significantly lower on postoperative days 1, 7, and 14 compared to the standard treatment group (3.68 vs. 6.82 p < 0.01, 2.68 vs. 5 p = 0.02 and 0.75 vs. 3.64 p < 0.001 respectively). There was a trend toward less opioids taken in gabapentin group for postoperative days 1, 7, and 14 (4.69 vs. 6.36; 2.13 vs. 2.73, and 0.125 vs. 0.9) but it did not reach statistical significance. The average hemorrhoidal grade and number of hemorrhoidal complexes removed was slightly higher in gabapentin group. Five control group patients experienced postoperative complications versus two gabapentin group patients. No gabapentin related complications were seen in the treatment group. The average cost of gabapentin course was $5.34 per patient. CONCLUSIONS Daily use of gabapentin in perioperative period significantly decreased reported levels of postoperative pain. This effective, inexpensive addition improves pain after hemorrhoid surgery. Randomized placebo-controlled studies would better define the usefulness of this medication for posthemorrhoidectomy pain.
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Perioperative gabapentinoids: choice of agent, dose, timing, and effects on chronic postsurgical pain. Anesthesiology 2013; 119:1215-21. [PMID: 24051389 DOI: 10.1097/aln.0b013e3182a9a896] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Abstract
This article summarizes the current evidence for the use of gabapentinoids in the perioperative setting and provides useful clinical recommendations regarding dosing, timing, and choice of agent.
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Gabapentin and pregabalin in the management of postoperative pain after lumbar spinal surgery: a systematic review and meta-analysis. Spine (Phila Pa 1976) 2013; 38:1947-52. [PMID: 23921329 DOI: 10.1097/brs.0b013e3182a69b90] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVE To review the literature systematically and make a comprehensive understanding of the efficacy of these 2 drugs in the management of postoperative pain after lumbar spinal surgery. SUMMARY OF BACKGROUND DATA Several trials that evaluated the efficacy of gabapentin and pregabalin in the management of postoperative pain after lumbar spinal surgery have been published. METHODS PubMed (1980 to present), adapted for EMBASE (1980 to present), and Cochrane databases were searched for randomized placebo-controlled trials. Random effect model was used in our meta-analysis, and standard mean difference (SMD) was chosen as the pooled estimate. RESULTS Seven trials were included in our study. All included studies could be considered to be of high quality in methodology. The pooled results from meta-analysis demonstrated that compared with placebo, both gabapentin and pregabalin could significantly reduce the postoperative narcotic consumption (SMD, -1.54, and -1.16, respectively). Oral gabapentin was efficacious in the management of postoperative pain at all time points during the first day after surgery (SMD, -1.91 at 0-6 hr, -1.30 at 6-12 hr, -1.05 at 12-24 hr, respectively). Pregabalin seemed to be also efficacious in the management of postoperative pain at 0 to 6 hours (SMD, -1.05), at 6 to 12 hours (SMD, -0.62), and at 12 to 24 hours (SMD, -0.43). Both drugs could be well tolerated in our included trials, compared with placebo. CONCLUSION This work suggested that both gabapentin and pregabalin were efficacious in reduction of postoperative pain and narcotic requirements after lumbar spinal surgery, whereas more trials were needed to further assess the efficacy of pregabalin in the management of postoperative pain after lumbar spinal surgery. LEVEL OF EVIDENCE 1.
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Effects of Preoperative Gabapentin on Postoperative Pain after Radical Retropubic Prostatectomy. J Int Med Res 2012; 40:2362-9. [DOI: 10.1177/030006051204000635] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: The impact of preoperative gabapentin on tramadol consumption using patient-controlled analgesia (PCA) and postoperative pain was assessed in patients undergoing radical retropubic prostatectomy (RRP). Methods: In this prospective, randomized trial, 51 patients undergoing RRP were randomized into two groups: the gabapentin group received 900 mg gabapentin orally 2 h before surgery; the control group did not receive gabapentin. Postoperative analgesia was provided by tramadol PCA. Pain was assessed using a visual analogue scale for 24 h, postoperatively. Results: Mean cumulative tramadol consumption at 24 h was comparable in the two groups. Pain scores at 45 min, 60 min and 2 h postoperatively, and the number of patients who required rescue analgesia, were significantly lower in the gabapentin group than in the control group. Side-effects were similar in the two groups. Conclusions: Preoperative administration of 900 mg gabapentin did not decrease tramadol consumption, but was associated with lower pain scores in the early postoperative phase and a reduced need for rescue analgesia, compared with controls, in patients undergoing RRP.
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Postoperative gabapentin to prevent postoperative pain: a randomized clinical trial. Anesth Pain Med 2012; 2:77-80. [PMID: 24223342 PMCID: PMC3821121 DOI: 10.5812/aapm.4744] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Revised: 05/05/2012] [Accepted: 05/08/2012] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Gabapentin is an anticonvulsant that has postoperative analgesic effects but there are limited studies on its postoperative administration. OBJECTIVES The present study was conducted to evaluate the effect of the postoperative oral gabapentin on pain and morphine consumption. PATIENTS AND METHODS In a double blind, randomized study, 64 patients undergoing internal fixation of tibia under spinal anesthesia were randomly assigned to receive oral gabapentin or placebo immediately after the surgery. Pain scores were recorded at time points of 2, 12 and 24 hours postoperatively using visual analog scale (VAS). Time duration from the end of surgery until morphine administration and total morphine requirement in the first 24 hours were recorded. RESULTS The estimated duration of surgeries was 120-150 minutes. VAS score was not significantly different between the two groups at 2, 12 and 24 hours after surgery. There was no significant morphine consumption difference between the groups. CONCLUSIONS Our study showed no significant analgesic efficacy of oral gabapentin 300 mg immediately after tibia internal fixation surgery under spinal anesthesia at time points of 2, 12 and 24 hours postoperatively.
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Postoperative Gabapentin to Prevent Postoperative Pain: A Randomized Clinical Trial. Anesth Pain Med 2012. [DOI: 10.5812/anesthpain.4744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
Greater understanding of the pathophysiology and mechanism of acute pain has led to advances in pharmacologic therapy. Understanding the principles of multimodal therapy along with surgical-specific protocols leads to improved outcome in patients. However, further large-scale randomized trials need to be performed to further establish and demonstrate the long-term benefit of multimodal therapy for patients undergoing surgery.
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Effects of gabapentin on postoperative pain, nausea and vomiting after abdominal hysterectomy: a double blind randomized clinical trial. Arch Gynecol Obstet 2011; 285:677-82. [PMID: 21818576 DOI: 10.1007/s00404-011-2023-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Accepted: 07/13/2011] [Indexed: 01/07/2023]
Abstract
PURPOSE Gabapentin has demonstrated analgesic effects in some studies. This double blind randomized clinical trial (RCT) was conducted to evaluate whether the pre-emptive use of gabapentin 600 mg could reduce postoperative pain, nausea and vomiting, and meperidine consumption in patients after hysterectomy. METHODS Between 2009 and 2010, a total of 170 patients who were candidates for abdominal hysterectomy were assessed for eligibility to enter the study. Thirty patients were excluded for different reasons; and 140 included patients were randomly assigned to one of two groups according to the method of treatment, gabapentin or placebo, in a double-blind manner before hysterectomy. Postoperatively, the pain was assessed on a visual analogue scale (VAS) at 1, 4, 8, 12 and 24 h at rest. Meperidine intramuscularly was used to treat postoperative pain on VAS score and patients demand. Total meperidine and anti emetic drug consumption in the first 24 h after surgery was also recorded. The trial is registered at irct.ir, number IRCT201106186829N1. RESULTS Patients in the gabapentin group had significantly lower VAS scores at all time intervals, than those in the placebo group. The total meperidine consumed in the gabapentin group was significantly less than in the placebo group. Postoperative nausea and vomiting (PONV) and anti emetic drug consumption were significantly decreased in gabapentin group. CONCLUSION Pre-emptive use of gabapentin 600 mg orally, significantly decreases postoperative pain and PONV, and also rescues analgesic and anti emetic drug requirements in patients who undergo abdominal hysterectomy.
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