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Osorio D, Maldonado D, Rijs K, van der Marel C, Klimek M, Calvache JA. Efficacy of different routes of acetaminophen administration for postoperative pain in children: a systematic review and network meta-analysis. Can J Anaesth 2024:10.1007/s12630-024-02760-y. [PMID: 38622469 DOI: 10.1007/s12630-024-02760-y] [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: 10/10/2023] [Revised: 01/30/2024] [Accepted: 02/14/2024] [Indexed: 04/17/2024] Open
Abstract
PURPOSE Acetaminophen is the most common drug used to treat acute pain in the pediatric population, given its wide safety margin, low cost, and multiple routes for administration. We sought to determine the most efficacious route of acetaminophen administration for postoperative acute pain relief in the pediatric surgical population. METHODS We conducted a systematic review of randomized controlled trials (RCTs) that included children aged between 30 days and 17 yr who underwent any type of surgical procedure and that evaluated the analgesic efficacy of different routes of administration of acetaminophen for the treatment of postoperative pain. We searched MEDLINE, CENTRAL, Embase, CINAHL, LILACs, and Google Scholar databases for trials published from inception to 16 April 2023. We assessed the risk of bias in the included studies using the Cochrane Risk of Bias 1.0 tool. We performed a frequentist network meta-analysis using a random-effects model. Our primary outcome was postoperative pain using validated pain scales. RESULTS We screened 2,344 studies and included 14 trials with 829 participants in the analysis. We conducted a network meta-analysis for the period from zero to two hours, including six trials with 496 participants. There was no evidence of differences between intravenous vs rectal routes of administration of acetaminophen (difference in means, -0.28; 95% confidence interval [CI], -0.62 to 0.06; very low certainty of the evidence) and intravenous vs oral acetaminophen (difference in means, -0.60; 95% CI, -1.20 to 0.01; low certainty of the evidence). For the comparison of oral vs rectal routes, we found evidence favouring the oral route (difference in means, -0.88; 95% CI, -1.44 to -0.31; low certainty of the evidence). Few trials reported secondary outcomes of interest; when comparing the oral and rectal routes in the incidence of nausea and vomiting, there was no evidence of differences (relative risk, 1.20; 95% CI, 0.81 to 1.78). CONCLUSION The available evidence on the effect of the administration route of acetaminophen on postoperative pain in children is very uncertain. The outcomes of postoperative pain control and postoperative vomiting may differ very little between the oral and rectal route. Better designed and executed RCTs are required to address this important clinical question. STUDY REGISTRATION PROSPERO (CRD42021286495); first submitted 19 November 2021.
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Affiliation(s)
- Danilo Osorio
- Department of Anesthesiology, Universidad del Cauca, Popayán, Colombia
| | - Diana Maldonado
- Department of Anesthesiology, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Koen Rijs
- Department of Anesthesiology, Erasmus University MC, Rotterdam, The Netherlands
| | | | - Markus Klimek
- Department of Anesthesiology, Erasmus University MC, Rotterdam, The Netherlands
| | - Jose A Calvache
- Department of Anesthesiology, Universidad del Cauca, Popayán, Colombia.
- Department of Anesthesiology, Erasmus University MC, Rotterdam, The Netherlands.
- Department of Anesthesiology, Erasmus University MC, Dr. Molewaterplein 40, 3015 GD, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.
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Green S, Karunakaran KD, Labadie R, Kussman B, Mizrahi-Arnaud A, Morad AG, Berry D, Zurakowski D, Micheli L, Peng K, Borsook D. fNIRS brain measures of ongoing nociception during surgical incisions under anesthesia. NEUROPHOTONICS 2022; 9:015002. [PMID: 35111876 PMCID: PMC8794294 DOI: 10.1117/1.nph.9.1.015002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 12/10/2021] [Indexed: 06/14/2023]
Abstract
Significance: Functional near-infrared spectroscopy (fNIRS) has evaluated pain in awake and anesthetized states. Aim: We evaluated fNIRS signals under general anesthesia in patients undergoing knee surgery for anterior cruciate ligament repair. Approach: Patients were split into groups: those with regional nerve block (NB) and those without (non-NB). Continuous fNIRS measures came from three regions: the primary somatosensory cortex (S1), known to be involved in evaluation of nociception, the lateral prefrontal cortex (BA9), and the polar frontal cortex (BA10), both involved in higher cortical functions (such as cognition and emotion). Results: Our results show three significant differences in fNIRS signals to incision procedures between groups: (1) NB compared with non-NB was associated with a greater net positive hemodynamic response to pain procedures in S1; (2) dynamic correlation between the prefrontal cortex (PreFC) and S1 within 1 min of painful procedures are anticorrelated in NB while positively correlated in non-NB; and (3) hemodynamic measures of activation were similar at two separate time points during surgery (i.e., first and last incisions) in PreFC and S1 but showed significant differences in their overlap. Comparing pain levels immediately after surgery and during discharge from postoperative care revealed no significant differences in the pain levels between NB and non-NB. Conclusion: Our data suggest multiple pain events that occur during surgery using devised algorithms could potentially give a measure of "pain load." This may allow for evaluation of central sensitization (i.e., a heightened state of the nervous system where noxious and non-noxious stimuli is perceived as painful) to postoperative pain levels and the resulting analgesic consumption. This evaluation could potentially predict postsurgical chronic neuropathic pain.
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Affiliation(s)
- Stephen Green
- Boston Children’s Hospital, Harvard Medical School, The Center for Pain and the Brain, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, United States
| | - Keerthana Deepti Karunakaran
- Boston Children’s Hospital, Harvard Medical School, The Center for Pain and the Brain, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, United States
| | - Robert Labadie
- Boston Children’s Hospital, Harvard Medical School, The Center for Pain and the Brain, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, United States
| | - Barry Kussman
- Boston Children’s Hospital, Harvard Medical School, Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, United States
| | - Arielle Mizrahi-Arnaud
- Boston Children’s Hospital, Harvard Medical School, Division of Perioperative Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, United States
| | - Andrea Gomez Morad
- Boston Children’s Hospital, Harvard Medical School, Division of Perioperative Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, United States
| | - Delany Berry
- Boston Children’s Hospital, Harvard Medical School, The Center for Pain and the Brain, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, United States
| | - David Zurakowski
- Boston Children’s Hospital, Harvard Medical School, Division of Biostatistics, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, United States
| | - Lyle Micheli
- Boston Children’s Hospital, Harvard Medical School, Sports Medicine Division, Department of Orthopedic Surgery, Boston, Massachusetts, United States
| | - Ke Peng
- Université de Montréal, Département en Neuroscience, Centre de Recherche du CHUM, Montréal, Quebec, Canada
| | - David Borsook
- Massachusetts General Hospital, Harvard Medical School, Departments of Psychiatry and Radiology, Boston, Massachusetts, United States
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Johnston DF, Turbitt LR. Defining success in regional anaesthesia. Anaesthesia 2021; 76 Suppl 1:40-52. [PMID: 33426663 DOI: 10.1111/anae.15275] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2020] [Indexed: 12/13/2022]
Abstract
Utilisation of regional anaesthesia is increasing globally; however, it remains challenging to determine the overall benefit of individual regional anaesthesia procedures. Like any peri-operative intervention, the benefit to the patient and healthcare system must outweigh any patient risk or resource implications. This review aims to identify markers of success in regional anaesthesia, categorise these into an objective framework and rationalise suggestions on how measuring outcomes in regional anaesthesia can be used to develop the widespread performance of this evolving subspecialty. This framework of measuring success of regional anaesthesia contains four pillars: patient-centred, population-centred, healthcare-centred and training-centred outcomes. Each pillar of success contains several outcomes which provide a structure for the measurement and development of regional anaesthesia success on a global scale.
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Affiliation(s)
- D F Johnston
- Department of Anaesthesia, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - L R Turbitt
- Department of Anaesthesia, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
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Hamilton GM, MacMillan Y, Benson P, Memtsoudis S, McCartney CJL. Regional anaesthesia quality indicators for adult patients undergoing non-cardiac surgery: a systematic review. Anaesthesia 2021; 76 Suppl 1:89-99. [PMID: 33426666 DOI: 10.1111/anae.15311] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2020] [Indexed: 11/26/2022]
Abstract
Improvement in healthcare delivery depends on the ability to measure outcomes that can direct changes in the system. An overview of quality indicators within the field of regional anaesthesia is lacking. This systematic review aims to synthesise available quality indicators, as per the Donabedian framework, and provide a concise overview of evidence-based quality indicators within regional anaesthesia. A systematic literature search was conducted using the databases MEDLINE, Embase, CINAHL and Cochrane from 2003 to present, and a prespecified search of regional anaesthesia society websites and healthcare quality agencies. The quality indicators relevant to regional anaesthesia were subdivided into peri-operative structure, process and outcome indicators as per the Donabedian framework. The methodological quality of the indicators was determined as per the Oxford Centre for Evidence-Based Medicine's framework. Twenty manuscripts met our inclusion criteria and, in total, 68 unique quality indicators were identified. There were 4 (6%) structure, 12 (18%) process and 52 (76%) outcome indicators. Most of the indicators were related to the safety (57%) and effectiveness (19%) of regional anaesthesia and were general in nature (60%). In addition, most indicators (84%) were based on low levels of evidence. Our study is an important first step towards describing quality indicators for the provision of regional anaesthesia. Future research should focus on the development of structure and process quality indicators and improving the methodological quality and usability of these indicators.
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Affiliation(s)
- G M Hamilton
- Department of Anaesthesiology and Pain Medicine, University of Ottawa, ON, Canada
| | - Y MacMillan
- Department of Medicine, University of Ottawa, ON, Canada
| | - P Benson
- Department of Medicine, University of Ottawa, ON, Canada
| | - S Memtsoudis
- Department of Anaesthesiology, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA
| | - C J L McCartney
- Department of Anaesthesiology and Pain Medicine, University of Ottawa, ON, Canada
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Puljak L, Boric K, Dosenovic S. Pain assessment in clinical trials: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:188. [PMID: 33569490 PMCID: PMC7867958 DOI: 10.21037/atm-20-3451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Pain is a symptom measured in many clinical trials. For pain as an outcome domain, trialists need to choose adequate outcome measure(s), as there are myriad outcome measures for pain to choose from. To ensure consistency and uniformity in clinical trials and systematic reviews, core outcome sets (COS) have been defined; COS includes a predefined minimal list of core outcomes that should be measured within a trial, to ensure their consistency and comparability. COS is defined via consensus procedure, which includes relevant stakeholders such as experts from a specific field and patients. Along with outcomes, outcome measures for each outcome need to be defined to make sure that the outcomes will be measured consistently and uniformly. Hereby we reviewed studies that have examined use of recommended core outcome domains and outcome measures in clinical trials that would be expected to measure pain. Despite the existence of COS and defined core outcome measures (COMs), multiple studies have shown that these are not necessarily used in clinical trials, or in the relevant systematic reviews, which further increases heterogeneity of existing evidence, hinders evidence synthesis and trial comparability, and assessment of comparative effectiveness of interventions. Trialists are encouraged to use COS and COMs when designing clinical trials. Research community is encouraged to design interventions that will help with identifying barriers for using COS and COMs and interventions to foster their uptake. Use of consistent pain outcomes and pain outcome measures is in the interest of patients, research community, healthcare workers and decision-makers. For clinical conditions for which there are no COS and COMs, efforts to design them would be beneficial.
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Affiliation(s)
- Livia Puljak
- Center for Evidence-Based Medicine and Health Care, Catholic University of Croatia, Zagreb, Croatia
| | - Krste Boric
- Department of Surgery, University Hospital Center Split, Split, Croatia
| | - Svjetlana Dosenovic
- Department of Anesthesiology and Intensive Care, University Hospital Center Split, Split, Croatia
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Muñoz-Leyva F, El-Boghdadly K, Chan V. Is the minimal clinically important difference (MCID) in acute pain a good measure of analgesic efficacy in regional anesthesia? Reg Anesth Pain Med 2020; 45:1000-1005. [DOI: 10.1136/rapm-2020-101670] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/26/2020] [Accepted: 07/30/2020] [Indexed: 02/06/2023]
Abstract
In the field of acute pain medicine research, we believe there is an unmet need to incorporate patient related outcome measures that move beyond reporting pain scores and opioid consumption. The term “minimal clinically important difference” (MCID) defines the clinical benefit of an intervention as perceived by the patient, as opposed to a mathematically determined statistically significant difference that may not necessarily be clinically significant. The present article reviews the concept of MCID in acute postoperative pain research, addresses potential pitfalls in MCID determination and questions the clinical validity of extrapolating MCID determined from chronic pain and non-surgical pain studies to the acute postoperative pain setting. We further suggest the concepts of minimal clinically important improvement, substantial clinical benefit and patient acceptable symptom state should also represent aspirational outcomes for future research in acute postoperative pain management.
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Bosanquet DC, Ambler GK, Waldron CA, Thomas-Jones E, Brookes-Howell L, Kelson M, Pickles T, Harris D, Milosevic S, Fitzsimmons D, Saxena N, Twine CP. Perineural local anaesthetic catheter after major lower limb amputation trial (PLACEMENT): results from a randomised controlled feasibility trial. BMJ Open 2019; 9:e029233. [PMID: 31719071 PMCID: PMC6858124 DOI: 10.1136/bmjopen-2019-029233] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES To determine the feasibility of undertaking a randomised controlled effectiveness trial evaluating the use of a perineural catheter (PNC) after major lower limb amputation with postoperative pain as the primary outcome. DESIGN Randomised controlled feasibility trial. SETTING Two vascular Centres in South Wales, UK. PARTICIPANTS 50 patients scheduled for major lower limb amputation (below or above knee) for complications of peripheral vascular disease. INTERVENTIONS The treatment arm received a PNC placed adjacent to the sciatic or tibial nerve at the time of surgery, with continuous infusion of levobupivacaine hydrochloride 0.125% for up to 5 days. The control arm received neither local anaesthetic nor PNC. Both arms received usual perioperative anaesthesia and postoperative analgesia. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcomes were the proportion of eligible patients who were randomised and the proportion of recruited patients who provided primary effectiveness outcome data. Secondary outcomes were: the proportion of recruited patients reaching 2 and 6 month follow-up and supplying pain data; identification of key cost drivers; development of an economic analysis framework for a future effectiveness trial; identification of barriers to recruitment and site set-up; and identification of the best way to measure postoperative pain. RESULTS Seventy-six of 103 screened patients were deemed eligible over a 10 month period. Fifty (64.5%) of these patients were randomised, with one excluded in the perioperative period. Forty-five (91.3%) of 49 recruited patients provided enough pain scores on a 4-point verbal rating scale to allow primary effectiveness outcome evaluation. Attrition rates were high; 18 patients supplied data at 6 month follow-up. Costs were dominated by length of hospital stay. Patients and healthcare professionals reported that trial processes were acceptable. CONCLUSIONS Recruitment of patients into a trial comparing PNC use to usual care after major lower limb amputation with postoperative pain measured on a 4-point verbal rating scale is feasible. Evaluation of longer-term symptoms is difficult. TRIAL REGISTRATION NUMBER ISRCTN: 85 710 690. EudraCT: 2016-003544-37.
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Affiliation(s)
- David C Bosanquet
- Department of Vascular Surgery, Aneurin Bevan University Health Board, Newport, UK
| | - Graeme K Ambler
- Department of Vascular Surgery, Aneurin Bevan University Health Board, Newport, UK
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | | | | | | | - Mark Kelson
- Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK
| | | | - Debbie Harris
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | | | - Deborah Fitzsimmons
- Swansea Centre for Health Economics, College of Human Health Sciences, Swansea University, Swansea, UK
| | - Neeraj Saxena
- Department of Anaesthetics, Royal Glamorgan Hospital, Cwm Taf University Health Board, Abercynon, UK
- CUBRIC, School of Psychology, Cardiff University, Cardiff, UK
| | - Christopher P Twine
- Department of Vascular Surgery, Aneurin Bevan University Health Board, Newport, UK
- Division of Population Medicine, Cardiff University, Cardiff, UK
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