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Hu L, Adegboye J, Chang AT, Hanna M, Jaremko K. Uncomplicated epidural removal in a patient on a therapeutic heparin infusion: a case report. Reg Anesth Pain Med 2024:rapm-2024-105577. [PMID: 38821537 DOI: 10.1136/rapm-2024-105577] [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: 04/18/2024] [Accepted: 05/16/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Unanticipated postoperative thrombotic complications can occur in complex patients who receive preoperative epidurals. Therefore, it is imperative that we consider the risks and benefits of epidural management in the setting of therapeutic anticoagulation. We present a case of epidural catheter removal on a heparin infusion, due to the extreme risk of holding anticoagulation for any duration. CASE REPORT A woman with hilar cholangiocarcinoma presented after uncomplicated hepatectomy, bile duct resection and hepaticojejunostomy, with a thoracic epidural for analgesia. On postoperative day 1, she developed a total portal vein thrombosis, requiring emergent open thrombectomy, transhepatic stenting and high-dose heparin infusion while the epidural was indwelling. The patient was deemed to have a profound risk of re-thrombosis if heparin were paused. Therefore, a multidisciplinary discussion between hepatobiliary surgery, critical care, neurosurgery, haematology, acute pain service and the patient's family ensued regarding epidural management. Options included catheter-directed thrombolytics to her stent while holding systemic anticoagulation, sterilely leaving the epidural catheter in place indefinitely, injecting prothrombotic agent into the epidural prior to removal, or removing the catheter without holding anticoagulation. Due to the risk of re-thrombosis in the portal vein and liver infarction, the heparin infusion was decreased to achieve the lowest therapeutic anti-Xa level, and the epidural was removed. The patient was continuously monitored in the intensive care unit without any adverse events. CONCLUSION A multidisciplinary discussion is paramount to weigh the risk of epidural haematoma if a catheter is removed on therapeutic anticoagulation against catastrophic thrombosis if anticoagulation is paused.
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Affiliation(s)
- Lizbeth Hu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Janet Adegboye
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Angela Tung Chang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Marie Hanna
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Kellie Jaremko
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
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Gu Y, Li X, Zhou Q, Deng H, Zhang F, Wei J, Lv X. Uniportal video-assisted thoracic surgery versus open thoracotomy for chronic pain after surgery: a prospective cohort study. J Anesth 2024:10.1007/s00540-024-03349-x. [PMID: 38767667 DOI: 10.1007/s00540-024-03349-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 05/09/2024] [Indexed: 05/22/2024]
Abstract
PURPOSE The potential of uniportal video-assisted thoracic surgery (U-VATS) to reduce chronic pain after thoracic surgery (CPTS) compared to open thoracotomy (OT) remains unexplored. This prospective study aims to assess the incidence of CPTS following U-VATS or OT and identify associated risk factors. METHODS Patients undergoing thoracic surgery were recruited from March 2021 to March 2022, categorized by surgical approach (U-VATS vs. OT). Standard clinical protocols for surgery, anesthesia, and analgesia were followed. Pain symptoms were assessed using the Short-form McGill Pain Questionnaire, with follow-ups up to 6 months. Perioperative factors influencing CPTS at 3 months were analyzed through univariate and multivariate methods. RESULTS A total of 694 patients were analyzed. Acute pain after thoracic surgery (APTS) was significantly less severe in the U-VATS group (p < 0.001). U-VATS patients exhibited a lower incidence of CPTS at 3 months (63.4% vs. 80.1%, p < 0.001), with reduced severity among those experiencing CPTS (p = 0.007) and a decreased occurrence of neuropathic pain (p = 0.014). Multivariate analysis identified OT incision, moderate to severe APTS (excluding moderate static pain at 24 h postoperative), nocturnal surgery, and lung surgery as risk factors for CPTS. CONCLUSION This study underscores the potential of U-VATS to reduce both the incidence and severity of CPTS at 3 months compared to OT. Furthermore, it highlights risk factors for CPTS, including OT incision, inadequately managed APTS, lung surgery, and nocturnal surgery. These findings emphasize the importance of considering surgical approach and perioperative pain management strategies to mitigate the burden of CPTS.
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Affiliation(s)
- Yang Gu
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 507 Zhengmin Rd, Yangpu, Shanghai, China
| | - Xiang Li
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 507 Zhengmin Rd, Yangpu, Shanghai, China
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Qing Zhou
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 507 Zhengmin Rd, Yangpu, Shanghai, China
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Huimin Deng
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 507 Zhengmin Rd, Yangpu, Shanghai, China
| | - Faqiang Zhang
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 507 Zhengmin Rd, Yangpu, Shanghai, China
| | - Juan Wei
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 507 Zhengmin Rd, Yangpu, Shanghai, China.
| | - Xin Lv
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 507 Zhengmin Rd, Yangpu, Shanghai, China.
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Hirai S, Ida M, Naito Y, Kawaguchi M. Comparison between the effects of epidural and intravenous patient-controlled analgesia on postoperative disability-free survival in patients undergoing thoracic and abdominal surgery: A post hoc analysis. Eur J Pain 2024. [PMID: 38511627 DOI: 10.1002/ejp.2266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/06/2024] [Accepted: 03/11/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Thoracic epidural analgesia (TEA) and intravenous patient-controlled analgesia (IV-PCA) are widely used to mitigate immediate postoperative pain; however, their effects on long-term disability-free survival are poorly documented. This study aimed to compare the effects of postoperative TEA and IV-PCA on disability-free survival in patients who underwent thoracic or abdominal surgery. METHODS This post hoc analysis of a prospective observational study included 845 inpatients aged ≥55 years that underwent elective thoracic and abdominal surgery between 1 April 2016 and 28 December 2018 in a tertiary care hospital. Inverse probability of treatment weighted (IPTW) using stabilized inverse propensity scores was adopted to minimize bias. The primary outcome in this study was disability-free survival, defined as survival with a 12-item World Health Organization Disability Assessment Schedule 2.0 score of <16%, assessed at 3 months and 1 year after surgery. RESULTS The final analysis included 601 patients who received TEA and 244 who received IV-PCA. After IPTW, the weighted incidence of disability-free survival at 3 months and 1 year was 60.5% and 61.4% in the TEA group and 78.3% and 66.2% in the IV-PCA group, respectively. The adjusted OR for disability-free survival at 3 months and 1 year was 0.84 (95% confidence interval [CI]: 0.50-1.39) and 1.21 (95% CI: 0.72-2.05), respectively, for the TEA group. CONCLUSION No significant differences were observed in the disability-free survival at 3 months and 1 year after elective thoracic and abdominal surgery in patients aged ≥55 years who received TEA or IV-PCA. SIGNIFICANCE STATEMENT This study is the first in our setting to document the long-term effects of patient-controlled analgesia. In a post hoc analysis of our prospective cohort study, we show that although differences in chronic postsurgical pain exist at 3 months post-surgery, disability-free survival rates at 1 year do not differ irrespective of the choice of patient-controlled analgesia. The findings of this study highlight the need for shared decision-making between clinicians and patients.
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Affiliation(s)
- S Hirai
- Department of Perioperative Management Center, Nara Medical University Hospital, Nara, Japan
| | - M Ida
- Department of Anaesthesiology, Nara Medical University, Nara, Japan
| | - Y Naito
- Department of Anaesthesiology, Nara Medical University, Nara, Japan
| | - M Kawaguchi
- Department of Anaesthesiology, Nara Medical University, Nara, Japan
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Klotz R, Ahmed A, Tremmel A, Büsch C, Tenckhoff S, Doerr-Harim C, Lock JF, Brede EM, Köninger J, Schiff JH, Wittel UA, Hötzel A, Keck T, Nau C, Amati AL, Koch C, Diener MK, Weigand MA, Büchler MW, Knebel P, Larmann J. Thoracic Epidural Analgesia Is Not Associated With Improved Survival After Pancreatic Surgery: Long-Term Follow-Up of the Randomized Controlled PAKMAN Trial. Anesth Analg 2024:00000539-990000000-00740. [PMID: 38335141 DOI: 10.1213/ane.0000000000006812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
BACKGROUND Perioperative thoracic epidural analgesia (EDA) and patient-controlled intravenous analgesia (PCIA) are common forms of analgesia after pancreatic surgery. Current guidelines recommend EDA over PCIA, and evidence suggests that EDA may improve long-term survival after surgery, especially in cancer patients. The aim of this study was to determine whether perioperative EDA is associated with an improved patient prognosis compared to PCIA in pancreatic surgery. METHODS The PAKMAN trial was an adaptive, pragmatic, international, multicenter, randomized controlled superiority trial conducted from June 2015 to October 2017. Three to five years after index surgery a long-term follow-up was performed from October 2020 to April 2021. RESULTS For long-term follow-up of survival, 109 patients with EDA were compared to 111 patients with PCIA after partial pancreatoduodenectomy (PD). Long-term follow-up of quality of life (QoL) and pain assessment was available for 40 patients with EDA and 45 patients with PCIA (questionnaire response rate: 94%). Survival analysis revealed that EDA, when compared to PCIA, was not associated with improved overall survival (OS, HR, 1.176, 95% HR-CI, 0.809-1.710, P = .397, n = 220). Likewise, recurrence-free survival did not differ between groups (HR, 1.116, 95% HR-CI, 0.817-1.664, P = .397, n = 220). OS subgroup analysis including only patients with malignancies showed no significant difference between EDA and PCIA (HR, 1.369, 95% HR-CI, 0.932-2.011, P = .109, n = 179). Similar long-term effects on QoL and pain severity were observed in both groups (EDA: n = 40, PCIA: n = 45). CONCLUSIONS Results from this long-term follow-up of the PAKMAN randomized controlled trial do not support favoring EDA over PCIA in pancreatic surgery. Until further evidence is available, EDA and PCIA should be considered similar regarding long-term survival.
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Affiliation(s)
- Rosa Klotz
- From the Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- The Study Center of the German Surgical Society, Heidelberg University Hospital, Heidelberg, Germany
| | - Azaz Ahmed
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
- Translational Immunotherapy, German Cancer Research Center, Heidelberg, Germany
| | - Anja Tremmel
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christopher Büsch
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Solveig Tenckhoff
- The Study Center of the German Surgical Society, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Johan F Lock
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Elmar-Marc Brede
- General Medicine, Gemeinschaftspraxis für Allgemeinmedizin, Veitshöchheim, Germany
| | - Jörg Köninger
- Department of General, Visceral, Thorax and Transplantation Surgery, Stuttgart, Germany
| | - Jan-Henrik Schiff
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Stuttgart, Germany
- Department of Anesthesiology and Intensive Care, Philipps-University Marburg, Marburg, Germany
| | - Uwe A Wittel
- Department of General and Visceral Surgery, Medical Centre, University of Freiburg, Freiburg, Germany
| | - Alexander Hötzel
- Department of Anesthesiology and Critical Care, Medical Centre, University of Freiburg, Freiburg, Germany
| | - Tobias Keck
- Department of Surgery, University Medical Centre Schleswig-Holstein, Campus Lübeck, Germany
| | - Carla Nau
- Department of Anesthesiology and Intensive Care, University Medical Centre Schleswig-Holstein, Campus Lübeck, Germany
| | - Anca-Laura Amati
- Department of Visceral, Thoracic, Transplant and Pediatric Surgery, Justus Liebig University of Giessen, Giessen, Germany
| | - Christian Koch
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Giessen, Germany
| | - Markus K Diener
- Department of General and Visceral Surgery, Medical Centre, University of Freiburg, Freiburg, Germany
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus W Büchler
- From the Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Phillip Knebel
- From the Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan Larmann
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
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Eftekhar N, Eslami B, Orandi AH, Chabouk L, Ghotbizadeh Vahdani F, Mohammad khani H, Amoozadeh L. Effect of Local Ketamine Subcutaneous Injection at the Incision Site in Reducing the Postoperative Pain Score after Transabdominal Hysterectomy. Anesthesiol Res Pract 2023; 2023:7782847. [PMID: 37953884 PMCID: PMC10640139 DOI: 10.1155/2023/7782847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/06/2023] [Accepted: 10/18/2023] [Indexed: 11/14/2023] Open
Abstract
Background Pain control after operations is essential in decreasing the patient recovery period and potential morbidity. Prescribing opiates is very effective, but significant side effects accompany them. This study aims to examine the effect of local ketamine infiltration in decreasing pain intensity in patients undergoing transabdominal hysterectomy. Methods In this double-blind, randomized, controlled clinical trial, a total of 92 patients undergoing transabdominal hysterectomy aged 30-60 years were selected and divided into two intervention and control groups randomly. For the intervention group, ketamine was injected subcutaneously into the incision site at a dose of 0.5 mg/kg after the operation. In the control group, 5 mg normal saline was used in the same method. Postoperative pain intensity was measured using the visual analog scale (VAS: 0-10). The pain score and dose of administered opioids were documented at 1, 2, 4, 6, 12, and 24 hours and compared between the two groups. Results Postoperative pain intensity was significantly lower in the intervention group than in the control group, except for hour 24. The mean amounts of administered opioids were significantly lower in the intervention group at hours 6 and 12, as well as the total amount of used opioids, and no significant side effects were documented. Conclusion Local ketamine subcutaneous injection in the incisional site is effective and is a safe procedure for reducing pain scores in patients who underwent a transabdominal hysterectomy.
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Affiliation(s)
- Negar Eftekhar
- Department of Anesthesiology and Intensive Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Babak Eslami
- Department of Anesthesiology and Intensive Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Hossein Orandi
- Department of Anesthesiology and Intensive Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Leila Chabouk
- Imam Khomeini Medical Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Fahimeh Ghotbizadeh Vahdani
- Obstetrics and Gynecology Department, Imam Khomeini Medical Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Hoda Mohammad khani
- Obstetrics and Gynecology Department, Imam Khomeini Medical Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Laya Amoozadeh
- Department of Anesthesiology and Intensive Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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Casas-Arroyave FD, Osorno-Upegui SC, Zamudio-Burbano MA. Therapeutic efficacy of intravenous lidocaine infusion compared with thoracic epidural analgesia in major abdominal surgery: a noninferiority randomised clinical trial. Br J Anaesth 2023; 131:947-954. [PMID: 37758623 DOI: 10.1016/j.bja.2023.07.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 07/11/2023] [Accepted: 07/12/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Open major abdominal surgery is one of the most risky surgical procedures for acute postoperative pain. Thoracic epidural analgesia (TEA) has been considered the standard analgesic approach. In different reports, lidocaine i.v. has been shown to have an analgesic efficacy comparable with TEA. We compared the analgesic efficacy of i.v. lidocaine with thoracic epidural analgesia using bupivacaine in patients undergoing major abdominal surgery. METHODS In this noninferiority clinical trial, 210 patients were randomised to thoracic epidural bupivacaine with morphine or i.v. lidocaine. Dynamic pain at 24 h after surgery was measured using a numerical pain rating scale (NPR), and morphine consumption was also measured. A difference in i.v. the lidocaine-epidural bupivacaine NPR of ≤1 for dynamic pain was considered a noninferiority margin. RESULTS The NPR for dynamic pain in the lidocaine group at 24 h was between 5.7 (1.8) and 5.2 (1.9) in the epidural group, with a difference of 0.53 (95% confidence interval 0.0-1.0). In the first 24 h, the average difference in morphine consumption was 1.8 mg between the i.v. lidocaine and epidural groups (95% confidence interval 1-3 mg). No differences were found in adverse events or complications associated with the procedures. CONCLUSIONS Intravenous lidocaine is noninferior to thoracic epidural analgesia for acute postoperative pain control in major abdomial surgery at 24 h postoperatively. CLINICAL TRIALS REGISTRATION NCT04017013.
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Affiliation(s)
- Fabian D Casas-Arroyave
- Department of Anaesthesiology, Faculty of Medicine, University of Antioquia, Medellin, Colombia; Department of Surgery, University Hospital of San Vicente Foundation, Medellín, Colombia.
| | - Susana C Osorno-Upegui
- Department of Anaesthesiology, Faculty of Medicine, University of Antioquia, Medellin, Colombia; Department of Anaesthesiology, Hospital Alma Mater de Antioquia, Medellín, Colombia
| | - Mario A Zamudio-Burbano
- Department of Anaesthesiology, Faculty of Medicine, University of Antioquia, Medellin, Colombia; Department of Anaesthesiology, Hospital Alma Mater de Antioquia, Medellín, Colombia
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Ishida Y, Okada T, Kobayashi T, Funatsu K, Uchino H. Pain Management of Acute and Chronic Postoperative Pain. Cureus 2022; 14:e23999. [PMID: 35547410 PMCID: PMC9086530 DOI: 10.7759/cureus.23999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2022] [Indexed: 12/04/2022] Open
Abstract
Inadequate management of acute postoperative pain is associated with effects related to both physiological and psychological function. Postoperative pain increases the risk of perioperative complications, so postoperative pain should be prevented. Postoperative pain management by sufficient analgesia is important while considering the use of various kinds of analgesics. Insufficient management of postoperative pain may lead to chronic postsurgical pain (CPSP). It is suggested that CPSP is dependent not only upon biological factors but also upon psychological factors, including the type of surgery, age, physical health, mental health, and preoperative pain. As CPSP is a severe complication that may prolong hospitalization and interferes with activities of daily living (ADL) and quality of life (QoL), its prevention of development is paramount. Therefore, in order to prevent the onset of CPSP, it is necessary to craft analgesic management to prevent CPSP during the perioperative period.
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Sciberras SC, Vella AP, Vella B, Spiteri J, Mizzi C, Borg-Xuereb K, LaFerla G, Grech G, Sammut F. A randomized, controlled trial on the effect of anesthesia on chronic pain after total knee arthroplasty. Pain Manag 2022; 12:711-723. [PMID: 35350864 DOI: 10.2217/pmt-2021-0081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: The study sought to evaluate the influence of anesthesia on chronic pain after total knee arthroplasty (TKA). Methods: This was a single-center, randomized controlled study, with patients receiving a spinal anesthetic (SP) alone or a general anesthetic (GA) with femoral block, with follow-up at 3 and at 6 months. The primary outcome was the WOMAC® score at 6 months. Results: 199 patients were enrolled. Group SP had better function (WOMAC: GA: 16.9 vs SP: 14.4, p = 0.015) and less pain (WOMAC pain: GA: 3.04 vs SP: 2.69, p = 0.02) at 3 months, but not at 6 months. Overall, 11% of patients had chronic postsurgical pain (CPSP), with Group GA having a higher incidence of CPSP at 6 months. Neuropathic pain increased during the follow-up and was more common in patients with CPSP. Conclusion: An SP reduces pain and incidence of CPSP after TKA. Clinical Trial Registration: NCT04206046 (ClinicalTrials.gov).
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Affiliation(s)
- Stephen C Sciberras
- Department of Surgery, Faculty of Medicine & Surgery, University of Malta, Msida, MSD, 2090, Malta
| | - Adrian P Vella
- Department of Surgery, Faculty of Medicine & Surgery, University of Malta, Msida, MSD, 2090, Malta.,Saint James Hospital, Sliema, SLM, 1807, Malta
| | - Bernice Vella
- Department of Anaesthesia, ITU & Pain Management, Mater Dei Hospital, Msida, MSD, 2080, Malta
| | - Jessica Spiteri
- Department of Anaesthesia, ITU & Pain Management, Mater Dei Hospital, Msida, MSD, 2080, Malta
| | - Christabel Mizzi
- Department of Anaesthesia, ITU & Pain Management, Mater Dei Hospital, Msida, MSD, 2080, Malta
| | - Keith Borg-Xuereb
- Department of Anaesthesia, ITU & Pain Management, Mater Dei Hospital, Msida, MSD, 2080, Malta
| | - Godfrey LaFerla
- Department of Surgery, Faculty of Medicine & Surgery, University of Malta, Msida, MSD, 2090, Malta
| | - Godfrey Grech
- Department of Pathology, Faculty of Medicine & Surgery, University of Malta, Msida, MSD, 2090, Malta
| | - Fiona Sammut
- Department of Statistics & Operations Research, Faculty of Science, University of Malta, Msida, MSD, 2090, Malta
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9
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Uyama K, Ida M, Wang X, Naito Y, Kawaguchi M. Association of Pre-operative Functional Disability with Chronic Postsurgical Pain: A Prospective Observational Study. Eur J Pain 2022; 26:902-910. [PMID: 35104389 DOI: 10.1002/ejp.1918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/23/2022] [Accepted: 01/28/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Chronic postsurgical pain negatively affects postoperative recovery. We aimed to assess the association between pre-operative functional disability and chronic postsurgical pain. METHODS This secondary analysis of a prospective observational study included 920 inpatients aged≥55 years undergoing elective abdominal surgery. We assessed functional disability using the 12-item World Health Organization Disability Assessment Schedule 2.0 before surgery and measured postoperative pain using a numerical rating scale at a postanaesthetic clinic 3 months and 1 year after surgery. We performed multiple logistic regression analysis to determine associations with chronic postsurgical pain 1 year after surgery. We analysed the sequential pain score using a mixed-effects model in patients with and without pre-operative functional disability. The primary outcome in this study was chronic postsurgical pain and its associated factors with a focus on preoperative functional disability. The secondary outcome was pain trajectories in patients with and without preoperative functional disability. RESULTS Of the 899 patients included in the analysis, 11.9% had chronic postsurgical pain 1 year later. The multiple logistic regression analysis revealed that pre-operative functional disability was associated with this outcome (OR 2.80, 95% CI, 1.70 to 4.59) as well as use of pre-operative pain medication (OR 2.74, 95% CI, 1.24 to 6.03) and pain numerical rating scale at the postanaesthetic clinic (OR 1.19, 95% CI 1.10 to 1.29). The pain trajectories were different in the presence or absence of functional disability (P<0.001) and the time of measurement (P<0.001). CONCLUSIONS Pre-operative functional disability was associated with chronic postsurgical pain and pain trajectories.
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Affiliation(s)
- Kayo Uyama
- Department of Anaesthesiology, Nara Medical University, Kashihara, Japan
| | - Mitsuru Ida
- Department of Anaesthesiology, Nara Medical University, Kashihara, Japan
| | - Xiaoying Wang
- Department of Anaesthesiology, Nara Medical University, Kashihara, Japan
| | - Yusuke Naito
- Department of Anaesthesiology, Nara Medical University, Kashihara, Japan
| | - Masahiko Kawaguchi
- Department of Anaesthesiology, Nara Medical University, Kashihara, Japan
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Abu Khudair H, Ramadan M, Obaid A, Yousef O, Sammour R. Prevalence of chronic postsurgical pain among cancer patients: A cross-sectional study. Anesth Essays Res 2022; 16:71-79. [PMID: 36249138 PMCID: PMC9558672 DOI: 10.4103/aer.aer_24_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/29/2022] [Accepted: 05/06/2022] [Indexed: 11/21/2022] Open
Abstract
Background: Cancer patients accept surgeries as part of their treatment. They may not be aware of the possibility of surgical pain persisting long after the surgery. Understanding chronic postsurgical pain is essential for effective pain management. Aims: We aimed to assess the prevalence of chronic postsurgical pain in cancer patients and the associated symptom burden. Settings and Design: This study was carried out at a tertiary cancer center. It was a cross-sectional study. Materials and Methods: Participants who underwent surgeries were asked to provide feedback on the MD Anderson Symptom Inventory at 3 months. Statistical Analysis Used: Descriptive statistics were used. Statistical tests included Kruskal–Wallis test, Chi-square test, Fisher's exact test, and Spearman's correlation. Logistic regression was used to assess the influence of variables on the presence or absence of chronic postsurgical pain. Results: Nine hundred and eighteen participants completed the study. Ninety-two percent (n = 840) were asymptomatic. Eight percent (n = 78) had postsurgical pain. Chronic postsurgical pain was influenced by the type of surgery (P = 0.01), specifically orthopedic and thoracic surgeries. Patients who receive epidurals are three times less likely to continue to have pain at 3 months. Conclusions: The prevalence of chronic postsurgical pain at 3 months in this study is lower than the rates in the literature. It is still associated with symptom burden that interferes with daily life. The risk of developing chronic postsurgical pain increases with thoracic and orthopedic surgeries. The risk may be lowered with epidural analgesia.
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11
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Kristiansen P, Oreskov JO, Ekeloef S, Gögenur I, Burcharth J. Patient perceptive focus on recovery: An exploratory study on follow-up after major emergency abdominal surgery. Acta Anaesthesiol Scand 2021; 65:1259-1266. [PMID: 34028006 DOI: 10.1111/aas.13925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 05/05/2021] [Accepted: 05/11/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Optimal recovery can be defined as the adequate in-hospital length of stay with minimal postoperative complications and readmissions. The quality of recovery beyond the immediate postoperative period after major emergency abdominal surgery is yet to be fully described. We hypothesized that long-term measures of overall recovery were affected after surgery. The study aimed to investigate patient-focused recovery-related parameters 1 year after major emergency abdominal surgery. METHOD This is a prospective study including patients undergoing major emergency abdominal surgery at a Danish secondary referral center. Three questionnaires were answered regarding the recovery following the procedure; Activities Assessment Scale (AAS); Quality of Recovery-15 (QoR-15), and Self-complete Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS). All questionnaires were answered at postoperative days (PODs) 14, 30, 90, and 365. RESULTS Eighty-two patients were included, and 68 were available for follow-up until 1 year after surgery. The response rates differed between the follow-up time points, with a response rate of 85% (n = 59) at POD30 and 50% (n = 36) at POD365. A decrease in the level of physical function following surgery was observed in 60% of the patients at POD14, which improved to 36% at POD365. Twenty-four patients (48%) reported postoperative pain at POD14, which declined to 9 (26%) at POD365. The maximum overall recovery was reached at POD30, which remained stable throughout the study period. CONCLUSION One in three patients reported physical functional impairment, and one in four patients reported pain 1 year after their surgical procedure.
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Affiliation(s)
- Puk Kristiansen
- Center for Surgical Science Department of Surgery Zealand University Hospital Køge Denmark
| | - Jakob Ohm Oreskov
- Center for Surgical Science Department of Surgery Zealand University Hospital Køge Denmark
| | - Sarah Ekeloef
- Center for Surgical Science Department of Surgery Zealand University Hospital Køge Denmark
| | - Ismail Gögenur
- Center for Surgical Science Department of Surgery Zealand University Hospital Køge Denmark
| | - Jakob Burcharth
- Center for Surgical Science Department of Surgery Zealand University Hospital Køge Denmark
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Abstract
Recent decades have demonstrated significant strides in cancer screening, diagnostics and therapeutics. As such there have been dramatic changes in survival following a diagnosis of cancer.
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Affiliation(s)
- Matthew R D Brown
- The Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ, UK
| | | | - David J Magee
- The Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK.
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Abstract
The entire field of medicine, not just anesthesiology, has grown comfortable with the risks posed by opioids; but these risks are unacceptably high. It is time for a dramatic paradigm shift. If used at all for acute or chronic pain management, they should be used only after consideration and maximizing the use of nonopioid pharmacologic agents, regional analgesia techniques, and nonpharmacologic methods. Opioids poorly control pain, their intraoperative use may increase the risk of recurrence of some types of cancer, and they have a large number of both minor and serious side effects. Furthermore, there are a myriad of alternative analgesic strategies that provide superior analgesia, decrease recovery time, and have fewer side effects and risks associated with their use. In this article the negative consequences of opioid use for pain, appropriate alternatives to opioids for analgesia, and the available evidence in pediatric populations for both are described.
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Pan ZY, Hu ZH, Zhang F, Xie WX, Tang YZ, Liao Q. The effect of transversus abdominis plane block on the chronic pain after colorectal surgery: a retrospective cohort study. BMC Anesthesiol 2020; 20:116. [PMID: 32423381 PMCID: PMC7236315 DOI: 10.1186/s12871-020-01032-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 05/05/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Chronic postsurgical pain (CPSP) is common and would reduce the quality of life of patients. Transversus abdominal plane (TAP) block has been widely used in lower abdominal surgery and many researches demonstrated that it could improve acute postsurgical pain. We aim to determine whether TAP block could improve chronic postoperative pain at 3 months and 6 months after colorectal surgery. METHODS A total of 307 patients received selective colorectal surgery under general anesthesia between January, 2015 and January, 2019 in a single university hospital were included: 128 patients received TAP block combined with patient-controlled intravenous analgesia (PCIA) for postsurgical analgesia (group TP) and 179 only administrated with PCIA (group P). Main outcome was the NRS score of pain at 3 months after colorectal surgery. The data was analyzed by two-way repeated measures anova and the chi-square test. RESULTS The NRS score at rest and during movement was decreased significantly at 24 h after surgery (rest NRS 1.07 ± 1.34 vs 1.65 ± 1.67, movement NRS 3.00 ± 1.45 vs 3.65 ± 1.89; all P = 0.003) in group TP than those of group P. There was no significant difference of NRS score at 48 h after surgery (P > 0.05). At 3 months after surgery, the NRS score during movement was also lower in group TP than that in group P (0.59 ± 1.23 vs 0.92 ± 1.65, P = 0.045). There was no significant difference of NRS score at 6 months after surgery (P > 0.05). The prevalence of CPSP was 19.5% (25/128) in group TP and 20.7% (37/179) in group P at 3 months after surgery. 13.2% (17/128) of patients suffered from CPSP in group TP and 13.9% (25/179) in group P at 6 months after surgery. Both at 3 months and 6 months after surgery, there was no statistical difference of the prevalence of CPSP between the two groups (all P > 0.05) . CONCLUSIONS TAP block reduced NRS during movement at 3 months after surgery but did not reduce the incidence of CPSP at 3 months and 6 months after selective colorectal surgery.
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Affiliation(s)
- Zi-Ye Pan
- Department of Anesthesiology, The Third Xiangya Hospital of Central South University, Changsha, 410013, Hunan, China
| | - Zhong-Hua Hu
- Department of Anesthesiology, The Third Xiangya Hospital of Central South University, Changsha, 410013, Hunan, China
| | - Fan Zhang
- Department of Anesthesiology, The Third Xiangya Hospital of Central South University, Changsha, 410013, Hunan, China
| | - Wen-Xiu Xie
- Department of Anesthesiology, The Third Xiangya Hospital of Central South University, Changsha, 410013, Hunan, China
| | - Yong-Zhong Tang
- Department of Anesthesiology, The Third Xiangya Hospital of Central South University, Changsha, 410013, Hunan, China.
| | - Qin Liao
- Department of Anesthesiology, The Third Xiangya Hospital of Central South University, Changsha, 410013, Hunan, China.
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Patient-controlled Intravenous Analgesia With Combination of Dexmedetomidine and Sufentanil on Patients After Abdominal Operation: A Prospective, Randomized, Controlled, Blinded, Multicenter Clinical Study. Clin J Pain 2019; 34:155-161. [PMID: 28654556 PMCID: PMC5898784 DOI: 10.1097/ajp.0000000000000527] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective: To investigate the effect of combination of dexmedetomidine and sufentanil on patient-controlled intravenous analgesia (PCIA) in patients after abdominal operation and to assess the safety and validity of this treatment. Methods: This is a prospective, randomized controlled, blinded, multicenter clinical study. A total of 210 patients from 9 clinical research centers underwent selective abdominal operation with general anesthesia were enrolled in the study, including laparoscopic-assisted abdominal operation on stomach, intestines or open surgery on stomach, intestines, kidneys and liver, the American Society of Anesthesiologists status I to II. Patients were randomly assigned into 2 groups: control group (group C) sufentanil 100 μg+normal saline 100 mL in total and test group (group D) sufentanil 100 μg+ dexmedetomidine 200 μg+normal saline 100 mL in total. PCIA was set as follow: background infusion of sufentanil 2 μg/h, bolus dose of sufentanil 2 μg, lockout interval 5 minutes. Main measure indices were analgesic consumption, pressing times and effective pressing times of analgesic pump, usage count, and consumption of remedy drug. Validity indices were visual analog scale (VAS) scores and patient satisfaction. Drug safety indices were hemodynamic parameters, drug side effects, and anal exhaust time. Results: In total, 203 cases were analyzed. Seven cases were eliminated for incomplete data record. The total consumption of sufentanil (μg) in 24 hours after operation of group C and group D were 56.9±21.5 and 49.8±15.5, respectively, and the difference was statistically significant (P<0.05). Pressing times of analgesic pump in 24 hours after operation of group C and group D were 9.47±16.07 and 5.02±5.56 times, respectively, and the difference was statistically significant (P<0.05). Effective pressing times of analgesic pump in 24 hours after operation of group C and group D were 7.8±9.7 and 4.57±5.02 times, respectively, and the difference was statistically significant (P<0.05). Resting VAS scores and movement VAS scores at 2, 4, 8, and 24 hours postoperatively were statistically different (P<0.05). Usage times of rescue drug (pethidine) of group C and group D were 9 and 1, mean rank 118.13 and 85.71, respectively, and the difference was statistically significant (P<0.05). Mean rank of general satisfaction of group C and group D were 98.99 and 105.04, respectively, and the difference was statistically significant (P<0.05). Incidence rate of nausea in group C and group D within 24 hours after surgery was 25% and 12.5%, and of vomiting 18.2% and 6.25%, respectively and of vomiting and the difference was statistically significant. Conclusions: Compared with sufentanil PCIA alone, the combination of dexmedetomidine and sufentanil for PCIA after abdominal operation could reduce sufentanil consumption, decrease VAS scores, lower the rate of nausea and vomiting, and improve patient satisfaction.
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Yao YY, Zhou QH, Yu LN, Yan M. Additional femoral nerve block analgesia does not reduce the chronic pain after total knee arthroplasty: A retrospective study in patients with knee osteoarthritis. Medicine (Baltimore) 2019; 98:e14991. [PMID: 30921213 PMCID: PMC6456102 DOI: 10.1097/md.0000000000014991] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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
Femoral nerve block analgesia was deemed to the gold standard for acute pain management after total knee arthroplasty (TKA). But effect on chronic pain management is not investigated fully. We conducted a retrospective study to explore the effect of single-injection femoral nerve block on postsurgical chronic pain.All medical records of patients undertaking TKA between January, 2013 and June, 2014 were reviewed via the Docare anesthesia database. Patients who administrated with the self-controlled intravenous analgesia were assigned to group P. Patients who received a single-injection femoral never block combined with patient self-controlled intravenous analgesia were assigned to group N + P. The visual analog scale (VAS) score before surgery, the first postoperative day (POD 1), POD 2, 3 months, 6 months, and 12 months after surgery were extracted from medical records. Pain score was compared over these 2 groups to investigate treatment outcomes.In all, 470 patients met the selection criteria for group P and 266 patients met the selection criteria for group N + P. Compared with group P, the VAS score decreased significantly in group N + P at POD 1 (P < .001), and the same was observed at POD 2 (P < .001); the moderate to severe pain incidence rate decreased significantly in group N + P at POD 1 (P < .01) and POD 2 (motion, P < .001). The rescued anesthesia rate reduced significantly in group N + P in POD 1 (P = .001), whereas no difference was found in POD 2 (P = .864). No difference was found at 3, 6, and 12 months after surgery (all P > .05).The single-injection femoral nerve block could relieve the acute postsurgical pain in a short period of time. But no evidence was found that it could reduce the chronic pain between 3 and 12 months after TKA.
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Affiliation(s)
- Yuan-yuan Yao
- The Second Affiliated Hospital, School of Medicine, Zhejiang University
| | - Qing-he Zhou
- The Second Affiliated Hospital of Jiaxing University, Hangzhou, Zhejiang, China
| | - Li-na Yu
- The Second Affiliated Hospital, School of Medicine, Zhejiang University
| | - Min Yan
- The Second Affiliated Hospital, School of Medicine, Zhejiang University
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17
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Edney JC, Lam H, Raval MV, Heiss KF, Austin TM. Implementation of an enhanced recovery program in pediatric laparoscopic colorectal patients does not worsen analgesia despite reduced perioperative opioids: a retrospective, matched, non-inferiority study. Reg Anesth Pain Med 2019; 44:123-129. [DOI: 10.1136/rapm-2018-000017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 06/12/2018] [Accepted: 06/18/2018] [Indexed: 12/15/2022]
Abstract
Background and objectivesEnhanced recovery protocols (ERPs) decrease length of stay and postoperative morbidity, but it is important that these benefits do not come at a cost of sacrificing proper perioperative analgesia. In this retrospective, matched cohort study, we evaluated postoperative pain intensity in pediatric patients who underwent laparoscopic colorectal surgeries before and after ERP implementation.MethodsPatients in each cohort were randomly matched based on age, diagnosis, American Society of Anesthesiologists classification, and surgical procedure. The primary outcome was average daily postoperative pain score, while the secondary outcomes included postoperative hospital length of stay, complication rate, and 30-day readmissions. Since our hypothesis was non-inferior analgesia in the postprotocol cohort, a non-inferiority study design was used.ResultsAfter matching, 36 pairs of preprotocol and postprotocol patients were evaluated. ERP patients had non-inferior recovery room pain scores (difference 0 (−1.19, 0) points, 95% CI −0.22 to 0.26 points, p valuenon-inferiority <0.001) and 4-day postoperative pain scores (difference −0.3±1.9 points, 95% CI −0.82 to 0.48 points, p valuenon-inferiority <0.001) while receiving less postoperative opioids (difference −0.15 [−0.21, –0.05] intravenous morphine equivalents/kg/day, p<0.001). ERP patients also had reduced postoperative hospital stays (difference −1.5 [−4.5, 0] days, p<0.001) and 30-day readmissions (2.8% vs 27.8%, p=0.008).ConclusionsImplementation of our ERP for pediatric laparoscopic colorectal patients was associated with less perioperative opioids without worsening postoperative pain scores. In addition, patients who received the protocol had faster return of bowel function, shorter postoperative hospital stays, and a lower rate of 30-day hospital readmissions. In pediatric laparoscopic colorectal patients, the incorporation of an ERP was associated with a pronounced decrease in perioperative morbidity without sacrificing postoperative analgesia.
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Mullins C, O'Loughlin L, Albus U, Skelly JR, Smith J. Managing epidural catheters in critical care beds: An observation analysis in the Republic of Ireland. J Perioper Pract 2018; 29:228-236. [PMID: 30372362 DOI: 10.1177/1750458918808153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In certain hospitals, epidural analgesia is restricted to critical care beds. Due to critical care bed strain, it is likely that many patients are unable to avail of epidural analgesia. The aims of the study were to retrospectively review the number of patients admitted to critical care beds for epidural analgesia over a two-year period 2015–16, to determine the duration of epidural analgesia, to identify the average critical care bed occupancy during this period, to get updated information on the implementation of acute pain service in the Republic of Ireland and the availability of ward-based epidural analgesia. One hundred and sixty patients had a midline laparotomy, 40 of which had an epidural (25%). Forty-two patients were admitted to a critical care bed for epidural analgesia. Aside from epidural analgesia, 12% had other indications for ICU admission. Median duration epidural analgesia was 1.64 days (IQR 0.98–2.14 days). ICU bed occupancy rates were 88.7% in 2015 and 85.1% in 2016. Acute pain service and ward-based epidural analgesia were available in 46 and 42% of hospitals, respectively. Restricting epidural use to a critical care setting is likely to result in reduced access to epidural analgesia. The implementation of acute pain service and availability of ward-based epidural analgesia in the Republic of Ireland are suboptimal.
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Affiliation(s)
- Cormac Mullins
- Department of Anaesthesia, Sligo University Hospital, Sligo, Ireland
| | - Lauren O'Loughlin
- Department of Anaesthesia, Sligo University Hospital, Sligo, Ireland
| | - Ulrich Albus
- Department of Anaesthesia, Sligo University Hospital, Sligo, Ireland
| | - J R Skelly
- Department of Anaesthesia, Sligo University Hospital, Sligo, Ireland
| | - Jeremy Smith
- Department of Anaesthesia, Sligo University Hospital, Sligo, Ireland
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19
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Is epidural analgesia still a viable option for enhanced recovery after abdominal surgery. Curr Opin Anaesthesiol 2018; 31:622-629. [DOI: 10.1097/aco.0000000000000640] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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21
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Epidural Against Systemic Analgesia: An International Registry Analysis on Postoperative Pain and Related Perceptions After Abdominal Surgery. Clin J Pain 2017; 33:189-197. [PMID: 27258998 DOI: 10.1097/ajp.0000000000000393] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The PAIN OUT registry collected data from >30,000 patients on pain on the first postoperative day in hospitals worldwide. Utilizing the database, we compared systemic and epidural analgesia (EA) on postoperative pain and related side-effects in patients after abdominal surgeries (ASs). METHODS ASs were identified through the ICD9-Code and subgrouped into laparoscopic surgery and open surgery. After identifying patients in this subset with and without EA, propensity-score matching was performed on the basis of demographics and comorbidities. Primary outcomes were different qualities of pain, and secondary outcomes were pain-related sensations and treatment-related side effects measured with the numeric rating scale. They were calculated as the risk ratio (RR) using the median as the divisor. RESULTS The database contained 29,108 cases, with 5365 AS, and 646 cases remained after matching. A risk analysis revealed that for the AS group, EA posed a significantly lower risk for the perception of worst pain (RR, 0.75; confidence interval [CI], 0.64-0.87), least pain (RR, 0.61; CI, 0.5-0.75), time in severe pain (RR, 0.61; CI, 0.5-0.75), in-bed activity interference of pain (RR, 0.71; CI, 0.59-0.85), pain interference with coughing (RR, 0.68; CI, 0.57-0.82) or sleeping (RR, 0.73; CI, 0.61-0.87), and a higher chance of pain relief (RR, 1.5; CI, 1.23-1.83). The risk for itchiness (RR, 2.23; CI, 1.62-3.07) appeared to be higher, as did the probability of satisfaction (RR, 1.25; CI, 1.03-1.51). The risk for feeling helpless (RR, 0.83; CI, 0.7-0.99) and drowsiness (RR, 0.74; CI, 0.63-0.88) was reduced. Both subgroups showed similar tendencies. DISCUSSION Regarding the pain intensity, satisfaction, and relatable side-effects, EA seems to be superior compared with systemic analgesia after AS.
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Brown M, Farquhar-Smith P. Pain in cancer survivors; filling in the gaps. Br J Anaesth 2017; 119:723-736. [DOI: 10.1093/bja/aex202] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Nimmo SM, Foo ITH, Paterson HM. Enhanced recovery after surgery: Pain management. J Surg Oncol 2017; 116:583-591. [PMID: 28873505 DOI: 10.1002/jso.24814] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 07/13/2017] [Indexed: 12/13/2022]
Abstract
Effective pain management is fundamental to enhanced recovery after surgery. Selection of strategies should be tailored to patient and operation. As well as improving the quality of recovery, effective analgesia reduces the host stress response, facilitates mobilization and allows resumption of oral intake. Multi-modal regimens combining paracetamol, non-steroidal anti-inflammatory agents where indicated, a potent opioid and a local anaesthetic technique achieve effective analgesia while limiting the dose and thereby side effects of any one agent.
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Affiliation(s)
- Susan M Nimmo
- Department of Anaesthesia, Critical Care and Pain Medicine, Western General Hospital, Edinburgh, Scotland
| | - Irwin T H Foo
- Department of Anaesthesia, Critical Care and Pain Medicine, Western General Hospital, Edinburgh, Scotland
| | - Hugh M Paterson
- Colorectal Surgery Unit, Western General Hospital, University of Edinburgh, Edinburgh, Scotland
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Han C, Ge Z, Jiang W, Zhao H, Ma T. Incidence and risk factors of chronic pain following hysterectomy among Southern Jiangsu Chinese Women. BMC Anesthesiol 2017; 17:103. [PMID: 28800726 PMCID: PMC5553861 DOI: 10.1186/s12871-017-0394-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 07/31/2017] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Chronic post-surgical pain (CPSP) after hysterectomy has been recognized as a major clinical problem in the Western World. Reports on post-hysterectomy pain are relatively scarce in China. The aim of the current study was to prospectively investigate the incidence and the potential risk factors of CPSP at 3 months following hysterectomy in Chinese population. METHODS We assessed and collected data on preoperative socio-demographic characteristics, preexisting pain, anxiety and depression, sexual satisfaction, intra-operative variables, and acute postoperative pain intensity in a cohort of 870 women undergoing hysterectomy. The participants were interviewed to determine their suitability to diagnostic criteria of CPSP 3 months later. Logistic regression analyses were subsequently performed to identify predictors for CPSP. RESULTS The incidence of CPSP at 3 months after hysterectomy was 27.7%. Most of the women with CPSP suffered from mild pain and had a slight impact on daily life with sleep and emotion functional limitation. Risk factors for CPSP after hysterectomy were preoperative anxiety, depression, pelvic pain, preexisting pain, very-moderate sexual dissatisfaction, and acute postoperative pain at movement. Intra-operative dexmedetomidine infusion with 0.5 μg/kg/h was associated with a decreased incidence rate of chronic post-hysterectomy pain. CONCLUSION Twenty-eight percent of patients after hysterectomy in southern Jiangsu china had CPSP with 92% of those women describing it as mild with sleep and emotion functional limitation. Patients with preoperative anxiety and depression, poor sexual satisfaction, preexisting pain, and acute postoperative pain on movement have been identified to be at risk to develop CPSP.
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Affiliation(s)
- Chao Han
- The Affiliated Yixing Hospital of Jiangsu University, 75 Tongzhenguan Road, Yixing, Jiangsu 214200 People’s Republic of China
| | - Zhijun Ge
- The Affiliated Yixing Hospital of Jiangsu University, 75 Tongzhenguan Road, Yixing, Jiangsu 214200 People’s Republic of China
| | - Wenjie Jiang
- The Affiliated Yixing Hospital of Jiangsu University, 75 Tongzhenguan Road, Yixing, Jiangsu 214200 People’s Republic of China
| | - Hailong Zhao
- The Affiliated Yixing Hospital of Jiangsu University, 75 Tongzhenguan Road, Yixing, Jiangsu 214200 People’s Republic of China
| | - Tieliang Ma
- The Affiliated Yixing Hospital of Jiangsu University, 75 Tongzhenguan Road, Yixing, Jiangsu 214200 People’s Republic of China
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Masgoret P, Gomar C, Tena B, Taurá P, Ríos J, Coca M. Incidence of persistent postoperative pain after hepatectomies with 2 regimes of perioperative analgesia containing ketamine. Medicine (Baltimore) 2017; 96:e6624. [PMID: 28403113 PMCID: PMC5403110 DOI: 10.1097/md.0000000000006624] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/21/2017] [Accepted: 03/26/2017] [Indexed: 11/24/2022] Open
Abstract
Studies designed to assess persistent postoperative pain (PPP) incidence after hepatectomies are lacking. Our aim was to assess PPP incidence 6 months after hepatectomies with intravenous (IV) or epidural (EPI) analgesia containing ketamine.Prospective observational comparative study between 2 cohorts of patients submitted to hepatectomy. Patients received 1 of 2 analgesic regimes containing ketamine: EPI group or IV group. Visual analog scale (VAS), Neuropathic Pain Symptom Inventory (NPSI), Pain Catastrophizing Scale (PCS), and quantitative sensorial testing (QST: to determine area of hyperalgesia/allodynia) were assessed preoperatively and postoperatively at 2 h, 24 h, 7 days, 1 month, and 6 months. VAS ≥ 1 at 1 and 6 months was considered indicative of PPP and VAS > 3 was considered as not controlled pain. Side effects and complications were registered.Forty-four patients were included: 23 in EPI group and 21 in IV group. Patients in IV group were older and had more comorbidities. No patient presented VAS > 3 at 1 or 6 months. VAS ≥ 1 at 1 and 6 months was 36.4% and 22.7%, respectively. No differences in VAS, NPSI, or PCS were found between groups. Allodynia/hyperalgesia area did not differ between groups and was infrequent and slight. Pain pressure threshold in the wound vertical component was significantly higher in EPI group after 7 days. IV group showed more cognitive side effects.Incidence of PPP at 6 months after open hepatectomies with EPI or IV analgesia containing ketamine was lower than previously reported for other abdominal surgeries.Ketamine influence on low PPP incidence and hyperalgesia cannot be discarded.
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Affiliation(s)
- Paula Masgoret
- Department of Anesthesiology, Hospital Clinic, University of Barcelona
| | - Carmen Gomar
- Department of Anesthesiology, Hospital Clinic, University of Barcelona
| | - Beatriz Tena
- Department of Anesthesiology, Hospital Clinic, University of Barcelona
| | - Pilar Taurá
- Department of Anesthesiology, Hospital Clinic, University of Barcelona
| | - José Ríos
- Laboratory of Biostatistics and Epidemiology, Universitat Autonoma de Barcelona, Biostatistics and Data Management Platform, IDIBAPS, Hospital Clinic, Barcelona, Spain
| | - Miquel Coca
- Department of Anesthesiology, Hospital Clinic, University of Barcelona
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Lee JY, Kim HC, Huh JW, Sim WS, Lim HY, Lee EK, Park HG, Bang YJ. Incidence and risk factors for rectal pain after laparoscopic rectal cancer surgery. J Int Med Res 2017; 45:781-791. [PMID: 28415928 PMCID: PMC5536646 DOI: 10.1177/0300060517693421] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 01/21/2017] [Indexed: 12/25/2022] Open
Abstract
Objective This study was performed to investigate the incidence of and potential risk factors for rectal pain after laparoscopic rectal cancer surgery. Methods We retrospectively analyzed data from 300 patients who underwent laparoscopic rectal cancer surgery. We assessed the presence of rectal pain and categorized patients into Group N (no rectal pain) or Group P (rectal pain). Results In total, 288 patients were included. Of these patients, 39 (13.5%) reported rectal pain and 14 (4.9%) had rectal pain that persisted for >3 months. Univariate analysis revealed that patients in Group P had more preoperative chemoradiotherapy, more ileostomies, longer operation times, more anastomotic margins of <2 cm from the anal verge, more anastomotic leakage, and longer hospital stays. Multivariate analysis identified an anastomotic margin of <2 cm from the anal verge and a long operation time as risk factors. The presence of diabetes mellitus was a negative predictor of rectal pain. Conclusions In this study, the incidence of rectal pain after laparoscopic rectal cancer surgery was 13.5%. An anastomotic margin of <2 cm from the anal verge and a long operation time were risk factors for rectal pain. The presence of diabetes mellitus was a negative predictor of rectal pain. Thus, the possibility of postoperative rectal pain should be discussed preoperatively with patients with these risk factors.
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Affiliation(s)
- Jin Young Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Korea
| | - Hee Cheol Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Korea
| | - Jung Wook Huh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Korea
| | - Woo Seog Sim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Korea
| | - Hyun Young Lim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Korea
| | - Eun Kyung Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Korea
| | - Hui Gyeong Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Korea
| | - Yu Jeong Bang
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Korea
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Prevention of chronic post-surgical pain: the importance of early identification of risk factors. J Anesth 2017; 31:424-431. [PMID: 28349202 DOI: 10.1007/s00540-017-2339-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 03/17/2017] [Indexed: 01/30/2023]
Abstract
Chronic post-surgical pain (CPSP) is currently an inevitable surgical complication. Despite the advances in surgical techniques and the development of new modalities for pain management, CPSP can affect 15-60% of all surgical patients. The development of chronic pain represents a burden to both the patient and to the community. In order to have a meaningful impact on this debilitating condition it is essential to identify those at risk. Early identification of patients at risk will help to reduce the percentage of patients who go on to develop CPSP. Unfortunately, evidence about any effective actions to reduce this condition is limited. This review will focus on providing context to the challenging problem of CPSP. The possible role of both the surgeon and anesthesiologist in reducing the incidence of this problem will be explored.
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Abstract
OBJECTIVES To determine the effect of spinal anesthesia (SA) on short-term outcomes when compared with general anesthesia in operatively managed tibial plateau fractures. DESIGN This is an institutional review board-approved retrospective review of prospectively collected data. SETTING Two level-1 trauma centers. PARTICIPANTS One hundred twelve patients with a surgically managed tibial plateau fracture were identified within a registry of patients. INTERVENTION Of these, 29 (25.9%) received SA and 83 (74.1%) received general anesthesia in a nonrandomized fashion. MAIN OUTCOME MEASURES Short Musculoskeletal Functional Assessment scores, pain levels, knee range of motion, complications, and reoperations. RESULTS SA was found to be a predictor of lower pain scores at 3 months (odds ratio, 0.32; 95% confidence interval, 0.12-0.95; P = 0.039) but not at 6 months (P = 0.266) or the latest follow-up (P = 0.056). In the multivariate Short Musculoskeletal Functional Assessment model, although anesthesia type was not found to be a statistically significant predictor, other predictors were identified. Anesthesia type was not a predictor of complications or reoperations. In the univariate analysis, SA was associated with an increased knee range of motion at 3 months (121 vs. 111 degrees; P = 0.048) but not at 6 months (P = 0.31) or the latest follow-up (P = 0.053). CONCLUSION In patients who undergo surgical management of a tibial plateau fracture, the use of SA is associated with decreased pain levels in the early postoperative period; however, there was no effect on functional assessment scores. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Lins L, Carvalho FM. SF-36 total score as a single measure of health-related quality of life: Scoping review. SAGE Open Med 2016; 4:2050312116671725. [PMID: 27757230 PMCID: PMC5052926 DOI: 10.1177/2050312116671725] [Citation(s) in RCA: 473] [Impact Index Per Article: 59.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 08/10/2016] [Indexed: 12/12/2022] Open
Abstract
According to the 36-Item Short Form Health Survey questionnaire developers, a global measure of health-related quality of life such as the “SF-36 Total/Global/Overall Score” cannot be generated from the questionnaire. However, studies keep on reporting such measure. This study aimed to evaluate the frequency and to describe some characteristics of articles reporting the SF-36 Total/Global/Overall Score in the scientific literature. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses method was adapted to a scoping review. We performed searches in PubMed, Web of Science, SCOPUS, BVS, and Cochrane Library databases for articles using such scores. We found 172 articles published between 1997 and 2015; 110 (64.0%) of them were published from 2010 onwards; 30.0% appeared in journals with Impact Factor 3.00 or greater. Overall, 129 (75.0%) out of the 172 studies did not specify the method for calculating the “SF-36 Total Score”; 13 studies did not specify their methods but referred to the SF-36 developers’ studies or others; and 30 articles used different strategies for calculating such score, the most frequent being arithmetic averaging of the eight SF-36 domains scores. We concluded that the “SF-36 Total/Global/Overall Score” has been increasingly reported in the scientific literature. Researchers should be aware of this procedure and of its possible impacts upon human health.
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Prevalence, characteristics and risk factors of chronic postsurgical pain after laparoscopic colorectal surgery. Eur J Anaesthesiol 2015; 32:712-7. [DOI: 10.1097/eja.0000000000000268] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Piccioni F, Casiraghi C, Fumagalli L, Kusamura S, Baratti D, Deraco M, Arienti F, Langer M. Epidural analgesia for cytoreductive surgery with peritonectomy and heated intraperitoneal chemotherapy. Int J Surg 2015; 16:99-106. [PMID: 25771101 DOI: 10.1016/j.ijsu.2015.02.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 02/23/2015] [Indexed: 01/18/2023]
Abstract
PURPOSE To evaluate epidural analgesia role after cytoreductive surgery with peritonectomy combined with heated intraperitoneal chemotherapy. METHODS 101 patients were retrospectively studied (between 2008 and 2012) to evaluate epidural analgesia effectiveness, tolerability and safety in this surgical context through the assessment of pain, detection of adverse events (nausea, vomiting, itching), temporary motor block, respiratory failure and coagulation profile in the post-operative period. RESULTS The median duration of epidural analgesia was 5 [range 1-10] days. As regards pain relief, the median verbal numerical scale scores at rest and on movement were below 2 and 5 until the fifth post-operative day, respectively. 13% of patients suffered nausea, 4% vomit, and 1% itching. No bradycardia or respiratory failure event was reported. 9.9% of patients had hypotension episodes. Coagulation reached normality only 3-4 days after surgery. 5 risky accidental dislodgments of epidural catheter occurred (prothrombine time INR > 1.5) without neurological complications. CONCLUSIONS Epidural analgesia ensures adequate pain relief and is well tolerated by patients after cytoreductive surgery with peritonectomy combined with heated intraperitoneal chemotherapy. Hypotension is common in this context and careful monitoring of coagulation parameters, especially in the first 3 days after surgery, is advisable to reduce the risk of neuraxial complications.
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Affiliation(s)
- Federico Piccioni
- Department of Anesthesia, Intensive Care and Palliative Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan, 20080, Italy.
| | - Claudia Casiraghi
- School of Anesthesia and Intensive Care, University of Milan, Via Festa del Perdono 7, Milan, 20122, Italy
| | - Luca Fumagalli
- Department of Anesthesia, Intensive Care and Palliative Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan, 20080, Italy
| | - Shigeki Kusamura
- Colorectal Cancer Unit-Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan, 20080, Italy
| | - Dario Baratti
- Colorectal Cancer Unit-Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan, 20080, Italy
| | - Marcello Deraco
- Colorectal Cancer Unit-Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan, 20080, Italy
| | - Flavio Arienti
- Immunohematology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan, 20080, Italy
| | - Martin Langer
- Department of Anesthesia, Intensive Care and Palliative Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan, 20080, Italy; Department of Pathophysiology and Transplantation, University of Milan, Via Festa del Perdono 7, Milan, 20122, Italy
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McCarthy CJ, Tomasella E, Malet M, Seroogy KB, Hökfelt T, Villar MJ, Gebhart GF, Brumovsky PR. Axotomy of tributaries of the pelvic and pudendal nerves induces changes in the neurochemistry of mouse dorsal root ganglion neurons and the spinal cord. Brain Struct Funct 2015; 221:1985-2004. [PMID: 25749859 DOI: 10.1007/s00429-015-1019-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 02/24/2015] [Indexed: 12/31/2022]
Abstract
Using immunohistochemical techniques, we characterized changes in the expression of several neurochemical markers in lumbar 4-sacral 2 (L4-S2) dorsal root ganglion (DRG) neuron profiles (NPs) and the spinal cord of BALB/c mice after axotomy of the L6 and S1 spinal nerves, major tributaries of the pelvic (targeting pelvic visceral organs) and pudendal (targeting perineum and genitalia) nerves. Sham animals were included. Expression of cyclic AMP-dependent transcription factor 3 (ATF3), calcitonin gene-related peptide (CGRP), transient receptor potential cation channel subfamily V, member 1 (TRPV1), tyrosine hydroxylase (TH) and vesicular glutamate transporters (VGLUT) types 1 and -2 was analysed seven days after injury. L6-S1 axotomy induced dramatic de novo expression of ATF3 in many L6-S1 DRG NPs, and parallel significant downregulations in the percentage of CGRP-, TRPV1-, TH- and VGLUT2-immunoreactive (IR) DRG NPs, as compared to their expression in uninjured DRGs (contralateral L6-S1-AXO; sham mice); VGLUT1 expression remained unaltered. Sham L6-S1 DRGs only showed a small ipsilateral increase in ATF3-IR NPs (other markers were unchanged). L6-S1-AXO induced de novo expression of ATF3 in several lumbosacral spinal cord motoneurons and parasympathetic preganglionic neurons; in sham mice the effect was limited to a few motoneurons. Finally, a moderate decrease in CGRP- and TRPV1-like-immunoreactivities was observed in the ipsilateral superficial dorsal horn neuropil. In conclusion, injury of a mixed visceral/non-visceral nerve leads to considerable neurochemical alterations in DRGs matched, to some extent, in the spinal cord. Changes in these and potentially other nociception-related molecules could contribute to pain due to injury of nerves in the abdominopelvic cavity.
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Affiliation(s)
- Carly J McCarthy
- Faculty of Biomedical Sciences, School of Biomedical Sciences, Austral University, Av. Juan D. Perón 1500, Pilar, B1629AHJ, Buenos Aires, Argentina
| | - Eugenia Tomasella
- Faculty of Biomedical Sciences, School of Biomedical Sciences, Austral University, Av. Juan D. Perón 1500, Pilar, B1629AHJ, Buenos Aires, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina
| | - Mariana Malet
- Faculty of Biomedical Sciences, School of Biomedical Sciences, Austral University, Av. Juan D. Perón 1500, Pilar, B1629AHJ, Buenos Aires, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina
| | - Kim B Seroogy
- Department of Neurology, University of Cincinnati, Cincinnati, OH, 45267, USA
| | - Tomas Hökfelt
- Department of Neuroscience, Karolinska Institutet, 17177, Stockholm, Sweden
| | - Marcelo J Villar
- Faculty of Biomedical Sciences, School of Biomedical Sciences, Austral University, Av. Juan D. Perón 1500, Pilar, B1629AHJ, Buenos Aires, Argentina
| | - G F Gebhart
- Department of Anesthesiology, Center for Pain Research, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Pablo R Brumovsky
- Faculty of Biomedical Sciences, School of Biomedical Sciences, Austral University, Av. Juan D. Perón 1500, Pilar, B1629AHJ, Buenos Aires, Argentina. .,Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina. .,Department of Anesthesiology, Center for Pain Research, University of Pittsburgh, Pittsburgh, PA, 15213, USA.
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Nimmo SM, Harrington LS. What is the role of epidural analgesia in abdominal surgery? ACTA ACUST UNITED AC 2014. [DOI: 10.1093/bjaceaccp/mkt062] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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