Effect of intravenous methylprednisolone on pain after intertrochanteric femoral fracture surgery

The positive impact of a quality improvement collaborative on process indicators for geriatric hip fracture care

Adherence to guidelines for geriatric patients with a hip fracture is challenging. With this study, adherence to important quality indicators in geriatric hip fracture care was improved. A quality improvement collaborative including benchmarking and knowledge sharing showed to be effective in improving quality of care.

BACKGROUND

Adherence to guidelines for geriatric patients with an osteoporotic hip fracture is challenging. Therefore, the aim of this study was to improve the adherence to quality indicators (QIs) for these patients using benchmarking and knowledge sharing.

METHOD

A prospective multicenter study was initiated throughout 19 hospitals in Flanders, Belgium. Adherence to 23 QIs was measured. Two retrospective audits (based on patient record analyses) were conducted in 2018-2019 (measurement period (MP) 1) and 2021 (MP 2). Between both audits, anonymous benchmarking was provided to the participating centers and three educative sessions on specific topics were performed.

RESULTS

A total of 1044 patients were included in the study. At MP 1, QIs showing the lowest adherence rates were the administration of nerve blocks, steroids, and tranexamic acid, applied in only 8.0%, 9.7% and 22.2% of the patients, respectively. At MP 2, these adherence rates significantly improved up to 25.4%, 26.4% and 30.7%, respectively (p < 0.001). The indication of the start of discharge planning also significantly improved between both periods (89.3% in MP 1 vs. 93.7% in MP 2, p = 0.043), while the avoidance of intra-operative hypotension was less well realized (56.2% in MP 1 vs. 52% in MP2, p = 0.026). Overall adherence significantly increased from 61.7 to 64.5% (p < 0.001). Delirium was significantly reduced (from 22.1% in MP 1 to 17.4% in MP 2, p = 0.030).

CONCLUSION

Benchmarking in combination with a peer-reviewed and knowledge sharing intervention increases the adherence to quality indicators for patients with a geriatric hip fracture.

Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: a network meta-analysis

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common adverse effect of anaesthesia and surgery. Up to 80% of patients may be affected. These outcomes are a major cause of patient dissatisfaction and may lead to prolonged hospital stay and higher costs of care along with more severe complications. Many antiemetic drugs are available for prophylaxis. They have various mechanisms of action and side effects, but there is still uncertainty about which drugs are most effective with the fewest side effects.

OBJECTIVES

• To compare the efficacy and safety of different prophylactic pharmacologic interventions (antiemetic drugs) against no treatment, against placebo, or against each other (as monotherapy or combination prophylaxis) for prevention of postoperative nausea and vomiting in adults undergoing any type of surgery under general anaesthesia • To generate a clinically useful ranking of antiemetic drugs (monotherapy and combination prophylaxis) based on efficacy and safety • To identify the best dose or dose range of antiemetic drugs in terms of efficacy and safety SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), ClinicalTrials.gov, and reference lists of relevant systematic reviews. The first search was performed in November 2017 and was updated in April 2020. In the update of the search, 39 eligible studies were found that were not included in the analysis (listed as awaiting classification).

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing effectiveness or side effects of single antiemetic drugs in any dose or combination against each other or against an inactive control in adults undergoing any type of surgery under general anaesthesia. All antiemetic drugs belonged to one of the following substance classes: 5-HT₃ receptor antagonists, D₂ receptor antagonists, NK₁ receptor antagonists, corticosteroids, antihistamines, and anticholinergics. No language restrictions were applied. Abstract publications were excluded.

DATA COLLECTION AND ANALYSIS

A review team of 11 authors independently assessed trials for inclusion and risk of bias and subsequently extracted data. We performed pair-wise meta-analyses for drugs of direct interest (amisulpride, aprepitant, casopitant, dexamethasone, dimenhydrinate, dolasetron, droperidol, fosaprepitant, granisetron, haloperidol, meclizine, methylprednisolone, metoclopramide, ondansetron, palonosetron, perphenazine, promethazine, ramosetron, rolapitant, scopolamine, and tropisetron) compared to placebo (inactive control). We performed network meta-analyses (NMAs) to estimate the relative effects and ranking (with placebo as reference) of all available single drugs and combinations. Primary outcomes were vomiting within 24 hours postoperatively, serious adverse events (SAEs), and any adverse event (AE). Secondary outcomes were drug class-specific side effects (e.g. headache), mortality, early and late vomiting, nausea, and complete response. We performed subgroup network meta-analysis with dose of drugs as a moderator variable using dose ranges based on previous consensus recommendations. We assessed certainty of evidence of NMA treatment effects for all primary outcomes and drug class-specific side effects according to GRADE (CINeMA, Confidence in Network Meta-Analysis). We restricted GRADE assessment to single drugs of direct interest compared to placebo.

MAIN RESULTS

We included 585 studies (97,516 randomized participants). Most of these studies were small (median sample size of 100); they were published between 1965 and 2017 and were primarily conducted in Asia (51%), Europe (25%), and North America (16%). Mean age of the overall population was 42 years. Most participants were women (83%), had American Society of Anesthesiologists (ASA) physical status I and II (70%), received perioperative opioids (88%), and underwent gynaecologic (32%) or gastrointestinal surgery (19%) under general anaesthesia using volatile anaesthetics (88%). In this review, 44 single drugs and 51 drug combinations were compared. Most studies investigated only single drugs (72%) and included an inactive control arm (66%). The three most investigated single drugs in this review were ondansetron (246 studies), dexamethasone (120 studies), and droperidol (97 studies). Almost all studies (89%) reported at least one efficacy outcome relevant for this review. However, only 56% reported at least one relevant safety outcome. Altogether, 157 studies (27%) were assessed as having overall low risk of bias, 101 studies (17%) overall high risk of bias, and 327 studies (56%) overall unclear risk of bias. Vomiting within 24 hours postoperatively Relative effects from NMA for vomiting within 24 hours (282 RCTs, 50,812 participants, 28 single drugs, and 36 drug combinations) suggest that 29 out of 36 drug combinations and 10 out of 28 single drugs showed a clinically important benefit (defined as the upper end of the 95% confidence interval (CI) below a risk ratio (RR) of 0.8) compared to placebo. Combinations of drugs were generally more effective than single drugs in preventing vomiting. However, single NK₁ receptor antagonists showed treatment effects similar to most of the drug combinations. High-certainty evidence suggests that the following single drugs reduce vomiting (ordered by decreasing efficacy): aprepitant (RR 0.26, 95% CI 0.18 to 0.38, high certainty, rank 3/28 of single drugs); ramosetron (RR 0.44, 95% CI 0.32 to 0.59, high certainty, rank 5/28); granisetron (RR 0.45, 95% CI 0.38 to 0.54, high certainty, rank 6/28); dexamethasone (RR 0.51, 95% CI 0.44 to 0.57, high certainty, rank 8/28); and ondansetron (RR 0.55, 95% CI 0.51 to 0.60, high certainty, rank 13/28). Moderate-certainty evidence suggests that the following single drugs probably reduce vomiting: fosaprepitant (RR 0.06, 95% CI 0.02 to 0.21, moderate certainty, rank 1/28) and droperidol (RR 0.61, 95% CI 0.54 to 0.69, moderate certainty, rank 20/28). Recommended and high doses of granisetron, dexamethasone, ondansetron, and droperidol showed clinically important benefit, but low doses showed no clinically important benefit. Aprepitant was used mainly at high doses, ramosetron at recommended doses, and fosaprepitant at doses of 150 mg (with no dose recommendation available). Frequency of SAEs Twenty-eight RCTs were included in the NMA for SAEs (10,766 participants, 13 single drugs, and eight drug combinations). The certainty of evidence for SAEs when using one of the best and most reliable anti-vomiting drugs (aprepitant, ramosetron, granisetron, dexamethasone, ondansetron, and droperidol compared to placebo) ranged from very low to low. Droperidol (RR 0.88, 95% CI 0.08 to 9.71, low certainty, rank 6/13) may reduce SAEs. We are uncertain about the effects of aprepitant (RR 1.39, 95% CI 0.26 to 7.36, very low certainty, rank 11/13), ramosetron (RR 0.89, 95% CI 0.05 to 15.74, very low certainty, rank 7/13), granisetron (RR 1.21, 95% CI 0.11 to 13.15, very low certainty, rank 10/13), dexamethasone (RR 1.16, 95% CI 0.28 to 4.85, very low certainty, rank 9/13), and ondansetron (RR 1.62, 95% CI 0.32 to 8.10, very low certainty, rank 12/13). No studies reporting SAEs were available for fosaprepitant. Frequency of any AE Sixty-one RCTs were included in the NMA for any AE (19,423 participants, 15 single drugs, and 11 drug combinations). The certainty of evidence for any AE when using one of the best and most reliable anti-vomiting drugs (aprepitant, ramosetron, granisetron, dexamethasone, ondansetron, and droperidol compared to placebo) ranged from very low to moderate. Granisetron (RR 0.92, 95% CI 0.80 to 1.05, moderate certainty, rank 7/15) probably has no or little effect on any AE. Dexamethasone (RR 0.77, 95% CI 0.55 to 1.08, low certainty, rank 2/15) and droperidol (RR 0.89, 95% CI 0.81 to 0.98, low certainty, rank 6/15) may reduce any AE. Ondansetron (RR 0.95, 95% CI 0.88 to 1.01, low certainty, rank 9/15) may have little or no effect on any AE. We are uncertain about the effects of aprepitant (RR 0.87, 95% CI 0.78 to 0.97, very low certainty, rank 3/15) and ramosetron (RR 1.00, 95% CI 0.65 to 1.54, very low certainty, rank 11/15) on any AE. No studies reporting any AE were available for fosaprepitant. Class-specific side effects For class-specific side effects (headache, constipation, wound infection, extrapyramidal symptoms, sedation, arrhythmia, and QT prolongation) of relevant substances, the certainty of evidence for the best and most reliable anti-vomiting drugs mostly ranged from very low to low. Exceptions were that ondansetron probably increases headache (RR 1.16, 95% CI 1.06 to 1.28, moderate certainty, rank 18/23) and probably reduces sedation (RR 0.87, 95% CI 0.79 to 0.96, moderate certainty, rank 5/24) compared to placebo. The latter effect is limited to recommended and high doses of ondansetron. Droperidol probably reduces headache (RR 0.76, 95% CI 0.67 to 0.86, moderate certainty, rank 5/23) compared to placebo. We have high-certainty evidence that dexamethasone (RR 1.00, 95% CI 0.91 to 1.09, high certainty, rank 16/24) has no effect on sedation compared to placebo. No studies assessed substance class-specific side effects for fosaprepitant. Direction and magnitude of network effect estimates together with level of evidence certainty are graphically summarized for all pre-defined GRADE-relevant outcomes and all drugs of direct interest compared to placebo in http://doi.org/10.5281/zenodo.4066353.

AUTHORS' CONCLUSIONS

We found high-certainty evidence that five single drugs (aprepitant, ramosetron, granisetron, dexamethasone, and ondansetron) reduce vomiting, and moderate-certainty evidence that two other single drugs (fosaprepitant and droperidol) probably reduce vomiting, compared to placebo. Four of the six substance classes (5-HT₃ receptor antagonists, D₂ receptor antagonists, NK₁ receptor antagonists, and corticosteroids) were thus represented by at least one drug with important benefit for prevention of vomiting. Combinations of drugs were generally more effective than the corresponding single drugs in preventing vomiting. NK₁ receptor antagonists were the most effective drug class and had comparable efficacy to most of the drug combinations. 5-HT₃ receptor antagonists were the best studied substance class. For most of the single drugs of direct interest, we found only very low to low certainty evidence for safety outcomes such as occurrence of SAEs, any AE, and substance class-specific side effects. Recommended and high doses of granisetron, dexamethasone, ondansetron, and droperidol were more effective than low doses for prevention of vomiting. Dose dependency of side effects was rarely found due to the limited number of studies, except for the less sedating effect of recommended and high doses of ondansetron. The results of the review are transferable mainly to patients at higher risk of nausea and vomiting (i.e. healthy women undergoing inhalational anaesthesia and receiving perioperative opioids). Overall study quality was limited, but certainty assessments of effect estimates consider this limitation. No further efficacy studies are needed as there is evidence of moderate to high certainty for seven single drugs with relevant benefit for prevention of vomiting. However, additional studies are needed to investigate potential side effects of these drugs and to examine higher-risk patient populations (e.g. individuals with diabetes and heart disease).

Comparison of intraperitoneal bupivacaine, acetazolamide, and placebo on pain relief after laparoscopic cholecystectomy surgery: A clinical trial

Background: Given the importance of patients' pain after laparoscopic surgeries, this study was conducted to compare the effectiveness of intraperitoneal bupivacaine, acetazolamide, and placebo on pain relief after laparoscopic cholecystectomy surgery. Methods: Patients admitted to Rasool Akram hospital with physical status I or II, based on the American Society of Anesthesiologists (ASA) system, who were candidates for laparoscopic cholecystectomy surgery due to gallstones, were included in this study. Patients were divided into 3 groups (each group containing 20 patients) using block randomization with foursome blocks. Group 1 received bupivacaine, group 2 acetazolamide, and group 3 intravenous saline as placebo. After surgery, pain score was assessed by visual analogue scale, and shoulder pain and analgesic doses were also measured. The mentioned parameters were assessed at 1, 4, 8, 12, and 24 hours after surgery. Results: In this study, 60 patients were included in 3 groups. The mean pain recorded (VAS) at 1, 4, and 8 hours after surgery was not significantly different between acetazolamide and bupivacaine groups, but their score was significantly lower than the placebo group (p<0.05). However, the score recorded at 12 and 24 hours after surgery was not significantly different between the 3 groups (p>0.05). Mean of pain reliever (acetaminophen) injected to the patients when needed was not significantly different among the 3 intervention groups (p<0.05). The highest prevalence of shoulder pain (70%) belonged to the placebo group and the lowest (25%) to acetazolamide (p<0.05). Mean heart rate, systolic blood pressure, diastolic blood pressure, and the respiratory rate were not significantly different among intervention groups in 1, 4, 8, 12, and 24 hours after surgery (p>0.05). Conclusion: According to the results, acetazolamide and bupivacaine injection reduced pain in early hours after laparoscopy. However, pain intensity was not different between intervention groups and the control group after 12 hours, so re-prescription seems to be appropriate at this time. Acetazolamide injection significantly reduces shoulder pains after surgery.

Nerve Blocks in the Geriatric Patient With Hip Fracture: A Review of the Current Literature and Relevant Neuroanatomy

Introduction

Hip fracture is a common occurrence in the elderly population with high morbidity and mortality due to postoperative pain and opioid use. The goal of this article is to review the current literature on the neuroanatomy of the hip and the use of localized nerve block in controlling hip fracture pain.

Methods

A thorough search of MEDLINE/PubMed, Embase, and the Cochrane Database of Systematic Reviews was conducted using the search terms "hip fracture" and "fascia iliaca block (FICB)." An additional search was conducted utilizing multiple search terms including "hip fracture," "greater trochanter," "femur," "hip," "anatomy," "neuroanatomical," and "anatomic." Each search result was investigated for cadaveric studies on the innervation of the trochanteric region.

Results

Twenty-five clinical studies examining the use of FICBs in hip fracture patients were identified. These studies show that FICB is safe and effective in controlling perioperative pain. Additionally, FICB has been shown to decrease opioid requirement and opioid-related side effects. Neuroanatomical studies show that the hip capsule is innervated by contributions from the femoral, obturator, sciatic, and superior gluteal nerves. Imaging studies suggest that FICB anesthetizes these branches through localized spread along the fascia iliaca plane. Cadaveric evidence suggests that the greater trochanter region is directly innervated by a single branch from the femoral nerve.

Discussion

The proven efficacy of nerve blocks and their anatomic basis is encouraging to both the anesthesiologist and orthopedic surgeon. Their routine use in the hip fracture setting may improve patient outcomes, given the unacceptably high morbidity and mortality associated with opioid use.

Conclusions

Localized nerve blocks, specifically FICB, have been shown to be safe and effective in managing acute hip fracture pain in geriatric patients, leading to decreased opioid use. Knowledge of the hip neuroanatomy may help guide future development of hip fracture pain blockade.

The Effect of Intravenous Magnesium Sulfate Versus Intravenous Sufentanil on the Duration of Analgesia and Postoperative Pain in Patients with Tibia Fracture

BACKGROUND

In the recent decades controlling postoperative pain has become a popular topic as it leads to the patients' wellbeing and improved life quality, while it reduces the costs for both patients and medical facilities.

OBJECTIVES

This study aimed at comparing intravenous magnesium sulfate versus intravenous sufentanil on the duration of analgesia and postoperative pain in patients undergoing tibia fracture surgery.

METHODS

This double blind clinical trial study was performed on 70 candidates of tibia fractures between the ages of 18 and 55 years with American society of anesthesiologists (ASA) class I and II. The patients were randomly divided to 2 groups, 1 receiving magnesium sulfate (M) and another receiving sufentanil (S). Both of the groups underwent spinal anesthesia with 10 mg bupivacaine 0.5%. One hour after ensuring the sensorimotor blockade, in the S group 0.1 µg/kg/hour and in the M group 8 mg/kg/hour was diluted in 1 liter of Ringer's solution and infused. In this study, full weakness of the lower limb was considered as the sign of sensorimotor blockade initiation. The postoperative pain intensity was measured using the Visual Analog Scale (VAS), 0, 1, 4, 8, 16, and 24 hours after the end of anesthesia duration. In case of VAS ≥ 3, the patients received 0.3 mg/kg pethidine, intravenously. At last, the time of requesting the first narcotic drug and the total usage of pethidine were recorded.

RESULTS AND CONCLUSIONS

Sufentanil was found to be more effective than magnesium sulfate in reducing postoperative pain and the time of first narcotics request was later in patients receiving sufentanil (P < 0.05).

A Comparative Study on the Efficacy of Oral Memantine and Placebo for Acute Postoperative Pain in Patients Undergoing Dacryocystorhinostomy (DCR)

BACKGROUND

Memantine is an N-methyl-D-Aspartate (NMDA) antagonist. By transferring acute postoperative pain, the NMDA channels may lead to active excess and neuropathic pain. Objectives: This study attempted to investigate the effect of preoperative use of single oral dose of memantine in controlling Dacryocystorhinostomy (DCR) postoperative pain.

METHODS

A double-blind clinical trial was conducted on 60 patients undergoing DCR. On arrival at the operating room, the memantine group received 20 mg of oral memantine and the control group received placebo. The severities of pain by visual analogue scale (VAS) and sedation by Ramsy Scale were measured immediately 1, 2, and 6 hours after the operation. The drug's side effects were recorded.

RESULTS

The pain scores of patients in the recovery in 1, 2, and 6 hours after operation were significantly lower in the memantine group than the placebo group (P < 0.001). The sedation score, 1 hour after the operation, was significantly greater in the memantine group than the placebo (P < 0.001). The sedation scores did not have any statistically significant difference in recovery and 2 hours after surgery between the two groups. Moreover, the sedation scores in 6 hours after the surgery were identical in the two groups.

CONCLUSIONS

The oral single-dose 20 mg of memantine administered before DCR can reduce postoperative pain compared with placebo.

Ultrasound-guided fascia iliaca compartment block in orthopedic fractures: Bupivacaine 0.2% or 0.3%?

Background: Postoperative pain is one of the major problems in patients with femoral or hip fracture. Current study investigates the effect of 0.2% and 0.3% bupivacaine in ultrasound-guided fascia iliaca compartment block (FICB) on postoperative pain. Methods: This randomized clinical trial study was conducted in Rasoul Akram Hospital of Iran University of Medical Sciences. Forty-eight patients with femoral or hip fractures who were candidates for surgery underwent FICB, divided into two groups receiving bupivacaine in 0.2% and 0.3% concentrations. Pain was evaluated with Visual Analog Scale (VAS) at times 2, 6, 12, 24, and 48 hours after surgery. Need for opioids, nausea and vomiting after surgery, patients' satisfaction with pain control and motor block were also recorded. T-test or Mann- Whitney U test and Repeated measure ANOVA was used for analysis. Results: Pain score after surgery was significantly lower in groups receiving 0.3% than the group receiving 0.2% concentration. Patients' satisfaction with pain control in 0.2% group was significantly higher (p=0.04). Time to analgesic onset in both groups had no significant differences (p=0.5). The incidence of nausea and vomiting (p=0.5) and opioid consumption (p=0.1) between the two groups showed no significant difference. Conclusion: In femoral or hip fracture, bupivacaine with 0.3% concentration in fascia iliaca compartment block can cause lower pain score compared to bupivacaine with 0.2% concentration, but patients' satisfaction with pain control and severity of motor block is higher in bupivacaine 0.2%.

Diclofenac Suppository vs. IV Acetaminophen Combined With IV PCA for Postoperative Pain Management in Patients Undergoing Laminectomy: A Randomized, Double-Blinded Clinical Trial

Background

Tissue damage caused by surgical procedures nearly always results in pain. The effective management of postoperative pain remains a challenge because of its influence on the surgical outcome and its critical role in early mobilization and functionality. Recent research on postoperative pain management supports a treatment approach known as “multimodal analgesia,” which comprises the use of more than one method or modality of pain control and management.

Objectives

In the present study, we compared the effects of diclofenac suppository and intravenous (IV) acetaminophen combined with IV patient-controlled analgesia (PCA) for pain management after laminectomy surgery.

Patients and Methods

Our randomized, double-blinded controlled trial during 2013 at Besat hospital in Hamadan, Iran, included 102 ASA I-II patients aged 18 to 65 years who were candidates for laminectomy surgery. The patients were randomly assigned to receive the diclofenac suppository (100 mg) (n = 51) or IV acetaminophen (1 g in 100 mL normal saline) (n = 51) 10 minutes before completing surgery and 12 hours after the operation.

Results

The patients’ characteristics were the same in both study groups. The patients’ satisfaction levels were higher among those who received diclofenac when compared with the acetaminophen group, especially at the time points of 6 and 12 h after surgery. The consumed narcotic using the PCA pump within 24 h of surgery in the diclofenac group was significantly lower than that of the acetaminophen group (735.70 ± 59.61 µg vs. 819.70 ± 80.02 µg; P < 0.001).

Conclusions

The use of diclofenac suppository combined with IV PCA results in reduced narcotic usage and a higher level of patient satisfaction compared to the use of IV acetaminophen combined with IV PCA.