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Myler CS, Chapman MR, Eden BD, Lehman EB, Karamchandani K. Oral versus intravenous acetaminophen for perioperative pain management in adult patients undergoing non-cardiac surgery: A quantile segmented regression analysis. J Clin Anesth 2023; 90:111220. [PMID: 37499316 DOI: 10.1016/j.jclinane.2023.111220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 07/14/2023] [Accepted: 07/18/2023] [Indexed: 07/29/2023]
Abstract
STUDY OBJECTIVE Determine whether preferential use of perioperative enteral acetaminophen is associated with changes in perioperative pain, narcotic administration, or time to meeting criteria for post anesthesia care unit (PACU) discharge, compared to preferential parenteral administration. DESIGN Retrospective Cohort with quantile segmented regression analysis. Groups determined by date of surgery, one year pre-initiative and one year post-initiative. SETTING Operating room and PACU of a tertiary academic medical center. PATIENTS Adult (age > 18 years), ASA status 1-5, non-pregnant patients undergoing non-cardiac surgery of less than six hours duration admitted to the PACU postoperatively. INTERVENTIONS A multidisciplinary initiative to preferentially utilize enteral over parenteral acetaminophen. MEASUREMENTS The primary outcome was narcotic consumption in the PACU. Secondary outcomes were intraoperative narcotic administration, pain score on PACU admission and discharge, and time to meeting criteria for PACU discharge. RESULTS 24,701 patients were included in the analysis; 12,379 had surgery prior to the initiative and 12,322 after. Enteral acetaminophen administration increased preoperatively from 13.49% to 26.84%, and postoperatively from 43.16% to 51.45%, while intraoperative parenteral APAP use dropped from 43.23% to 6.81%. Quantile Segmented regression analysis after adjusting for period (pre versus postintervention), day, age, gender, inpatient status, and ASA class demonstrated a decrease in adjusted median perioperative acetaminophen dose (-175 mg P < 0.001), with no significant difference in level change of intraoperative or PACU narcotic administration. There was no significant difference in median time to meet criteria for PACU discharge, though there was a significant change in the slope, (-0.36, p = 0.007.) Median pain scores measured on a standard 0-10 numeric rating scale at PACU admission did not change, while median pain scores at PACU discharge decreased slightly (-0.24 p < 0.001). There was no change in the probability of PONV. CONCLUSION In adult patients undergoing non-cardiac surgery of <6 h duration, preferential use of enteral rather than parenteral acetaminophen is associated with non-inferior outcomes in narcotic requirements, pain scores, time to PACU discharge, and probability of PONV when compared with routine parenteral administration. Further studies are needed to validate these findings.
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Affiliation(s)
- Conrad S Myler
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA.
| | | | | | - Erik B Lehman
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Kunal Karamchandani
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Ibrahim T, Gebril A, Nasr MK, Samad A, Zaki HA. Unlocking the Optimal Analgesic Potential: A Systematic Review and Meta-Analysis Comparing Intravenous, Oral, and Rectal Paracetamol in Equivalent Doses. Cureus 2023; 15:e41876. [PMID: 37581156 PMCID: PMC10423591 DOI: 10.7759/cureus.41876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2023] [Indexed: 08/16/2023] Open
Abstract
Paracetamol (acetaminophen) is an extensively used analgesic for acute and chronic pain management. Currently, paracetamol is manufactured for oral, rectal, and intravenous (IV) use. Research has shown varied results on the analgesic properties of IV paracetamol compared to oral and rectal paracetamol; however, research on the same doses of paracetamol is limited. Therefore, this review was constructed to explore the analgesic properties of IV paracetamol compared with oral and rectal paracetamol administered in equivalent doses. A broad and thorough literature search was performed on five electronic databases, including PubMed, ScienceDirect, Medline, Scopus, and Google Scholar. Statistical analysis of all outcomes in our review was then performed using the Review Manager software. Outcomes were categorized as primary (pain relief and time to request rescue analgesia) and secondary (adverse events after analgesia). An extensive quality appraisal was also done using the Review Manager software's Cochrane risk of bias tool. The literature survey yielded 2,945 articles, of which 12 were used for review and analysis. The pooled analysis for patients undergoing surgical procedures showed that IV paracetamol had statistically similar postoperative pain scores at two (mean difference (MD) = -0.14; 95% confidence interval (CI) -0.58-0.29; p = 0.51), 24 (MD = 0.09; 95% CI = -0.02-0.21; p = 0.12), and 48 (MD = 0.04; 95% CI = -0.08-0.16; p = 0.52) hours as oral paracetamol. Similarly, the data on time to rescue analgesia showed no considerable difference between the IV and oral paracetamol groups (MD = -1.58; 95% CI = -5.51-2.35; p = 0.43). On the other hand, the pooled analysis for patients presenting non-surgical acute pain showed no significant difference in the mean pain scores between patients treated with IV and oral paracetamol (MD = -0.35; 95% CI = -2.19-1.48; p = 0.71). Furthermore, a subgroup analysis of analgesia-related adverse events showed that the incidences of vomiting/nausea and pruritus did not differ between patients receiving IV and oral paracetamol (odds ratio (OR) = 0.71; 95% CI = 0.45-1.11; p = 0.13 and OR = 0.48; 95% CI = 0.18-1.29; p = 0.05, respectively). A review of information from two trials comparing equal doses of IV and rectal paracetamol suggested that the postoperative pain scores were statistically similar between the groups. IV paracetamol is not superior to oral or rectal paracetamol administered in equal doses. Therefore, we cannot recommend or refute IV paracetamol as the first-line analgesia for acute and postoperative pain.
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Affiliation(s)
| | - Amr Gebril
- Emergency Medicine, NMC Royal Hospital, Khalifa City, ARE
| | - Mohammed K Nasr
- Emergency Medicine, Dr. Sulaiman Al Habib Hospital, Dubai, ARE
| | - Abdul Samad
- Acute Medicine/Emergency, NMC Royal Hospital, Khalifa City, ARE
| | - Hany A Zaki
- Emergency Medicine, Hamad Medical Corporation, Doha, QAT
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Cao Q, Fan C, Yuan R, Dong H, Zhang S, Meng H. Comparison of intravenous and oral administration of acetaminophen in adults undergoing general anesthesia. Pain Pract 2021; 22:405-413. [PMID: 34775679 DOI: 10.1111/papr.13092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Acetaminophen is a widely clinically used analgesic. However, the clinical effect of the route of administration on postoperative analgesia as well as on postoperative nausea and vomiting in patients undergoing general anesthesia remains unclear. This study aimed to explore whether the route of administration of acetaminophen affects postoperative analgesia, nausea, and vomiting in patients undergoing general anesthesia. METHODS We included all randomized controlled trials investigating the effects of the route of administration of acetaminophen on postoperative pain, nausea, and vomiting in patients undergoing general anesthesia. Independent examiners reviewed the literature and extracted data, with disagreements resolved through negotiation or the involvement of a third party. The Cochrane risk assessment tool was used to evaluate the quality of the included randomized controlled trials. A narrative synthesis was conducted to summarize the qualitative information from the included studies. A meta-integration of quantitative data was performed using RevMan 5.4. RESULTS Ten studies met the inclusion criteria. Eight studies assessed postoperative pain, whereas two assessed postoperative nausea and vomiting. Data from the eight studies assessing postoperative pain confirmed that there was no difference between intravenously and orally administered acetaminophen in adults (OR = -0.13; 95% CI, -0.36 to 0.11; p = 0.3). Data from the two studies assessing postoperative nausea and vomiting revealed no difference between intravenously and orally administered acetaminophen in adults (OR = 0.89; 95% CI, 0.64-1.25; p = 0.51). The included studies were of poor quality, with a heterogeneity of 68%. CONCLUSIONS No differences in postoperative analgesia or postoperative nausea and vomiting were observed between the routes of administration (intravenous vs. oral) of acetaminophen in adult patients undergoing general anesthesia. There is a need for future large sample studies to increase the reliability of the results.
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Affiliation(s)
- Qinqin Cao
- Department of Anesthesiology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Chengjuan Fan
- Department of Urology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Ran Yuan
- Department of Anesthesiology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Hemin Dong
- Department of Anesthesiology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Shouxin Zhang
- Department of Anesthesiology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Haihong Meng
- Department of Anesthesiology, Affiliated Hospital of Jining Medical University, Jining, China
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Esmat IM, Mohamed MM, Abdelaal WA, El-Hariri HM, Ashoor TM. Postspinal anesthesia shivering in lower abdominal and lower limb surgeries: a randomized controlled comparison between paracetamol and dexamethasone. BMC Anesthesiol 2021; 21:262. [PMID: 34717535 PMCID: PMC8556952 DOI: 10.1186/s12871-021-01483-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 10/21/2021] [Indexed: 12/01/2022] Open
Abstract
Background Shivering is known to be a frequent complication in patients undergoing surgery under neuraxial anesthesia with incidence of 40–70%. Although many pharmacological agents have been used to treat or prevent postspinal anesthesia shivering (PSAS), the ideal treatment wasn’t found. This study evaluated the efficacy of paracetamol and dexamethasone to prevent PSAS in patients undergoing lower abdominal and lower limb surgeries. Methods Three hundred patients scheduled for surgeries under spinal anesthesia (SA) were allocated into three equal groups to receive a single preoperative dose of oral paracetamol 1 g (P group), dexamethasone 8 mg intravenous infusion (IVI) in 100 ml normal saline (D group) or placebo (C group), 2 h preoperatively, in a randomized, double-blind trial. The primary endpoint was the incidence of clinically significant PSAS. Secondary endpoints included shivering score, the change in hemodynamics, adverse events (e.g., nausea, vomiting and pruritis) and patients` satisfaction. Results Clinically significant PSAS was recorded as (15%) in P group, (40%) in D group and (77%) in C group (P < 0.001). The mean blood pressure values obtained over a 5-25 min observation period were significantly higher in the D group (P < 0.001). Core temperature 90 min after SA was significantly lower in the 3 groups compared to prespinal values (P < 0.001). Nausea, vomiting and pruritis were significantly higher in the C group (P < 0.001). P and D groups were superior to C group regarding the patients’ satisfaction score (P < 0.001). Conclusion Paracetamol and dexamethasone were effective in prevention of PSAS in patients undergoing lower abdominal and lower limb surgeries compared to placebo controls. Trial registration ClinicalTrials.gov Identifier: NCT03679065 / Registered 20 September 2018 - Retrospectively registered, http://www.ClinicalTrial.gov.
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Affiliation(s)
- Ibrahim M Esmat
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Marwa M Mohamed
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Wail A Abdelaal
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Hazem M El-Hariri
- Community Medicine Department, National Research Centre, Cairo, Egypt
| | - Tarek M Ashoor
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Ain-Shams University, Cairo, Egypt.
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Son J, Tran T, Yao M, Michener CM. Factors Associated With Unplanned Admission in Patients Intended for Same Day Discharge After Minimally Invasive Hysterectomy for Endometrial Cancer. Surg Innov 2021; 29:336-342. [PMID: 34470516 DOI: 10.1177/15533506211041882] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives. To identify factors that lead to successful same-day discharge compared with unplanned and planned admission after minimally invasive hysterectomy for endometrial cancer. Methods. Patients undergoing laparoscopic or robotic hysterectomy for endometrial cancer between 2016 and 2019 were retrospectively reviewed. 3 groups were created: same-day discarge (SDD), unplanned admission (UA), and planned admission(PA). Demographic/perioperative factors and encounters after discharge were compared. A multivariable logistic regression was performed. Results. 262 patients were included. By year, the success of SDD increased from 59.1% to 82.5%. Patients who underwent SDD compared with admission were younger (62.2 vs 66.2, P = .003) and had a lower Charlson Comorbidity Index (4 vs 5, P < .001). BMI was not significant. Comparing SDD and UA, shorter operative time (100.3 min vs 130.6 min, P = .037) was associated with SDD. Postoperative pain scores were not significant (3.8 vs 4.7, P = .086). The rate of unscheduled encounters within 30 days of discharge was not significantly different. On multivariable analysis, the odds of SDD decreased by 4% with each 1-year increase in age (OR .96, P = .017). Each 1-minute increase in operative time decreased the odds of SDD by 2% (OR .98, P < .001). Intraoperative acetaminophen (OR 2.78, P = .003) and ketorolac (OR 2.27, P = .031) were predictive of SDD. Conclusion. SDD can be safely incorporated into clinical practice in gynecologic oncology patients undergoing minimally invasive hysterectomy, even for patients older than previously reported. Shorter operative time was associated with SDD. The role of perioperative acetaminophen and ketorolac should be further investigated.
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Affiliation(s)
- Ji Son
- Department of OBGYN, Women's Health Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Thang Tran
- 12304Case Western University School of Medicine, Cleveland, OH, USA
| | - Meng Yao
- Section of Biostatistics, Quantitative Health Sciences, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Chad M Michener
- Division of Gynecologic Oncology, Women's Health Institute, 2569Cleveland Clinic, Cleveland, OH, USA
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Freo U, Ruocco C, Valerio A, Scagnol I, Nisoli E. Paracetamol: A Review of Guideline Recommendations. J Clin Med 2021; 10:jcm10153420. [PMID: 34362203 PMCID: PMC8347233 DOI: 10.3390/jcm10153420] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/11/2021] [Accepted: 07/28/2021] [Indexed: 02/06/2023] Open
Abstract
Musculoskeletal pain conditions are age-related, leading contributors to chronic pain and pain-related disability, which are expected to rise with the rapid global population aging. Current medical treatments provide only partial relief. Furthermore, non-steroidal anti-inflammatory drugs (NSAIDs) and opioids are effective in young and otherwise healthy individuals but are often contraindicated in elderly and frail patients. As a result of its favorable safety and tolerability record, paracetamol has long been the most common drug for treating pain. Strikingly, recent reports questioned its therapeutic value and safety. This review aims to present guideline recommendations. Paracetamol has been assessed in different conditions and demonstrated therapeutic efficacy on both acute and chronic pain. It is active as a single agent and is additive or synergistic with NSAIDs and opioids, improving their efficacy and safety. However, a lack of significant efficacy and hepatic toxicity have also been reported. Fast dissolving formulations of paracetamol provide superior and more extended pain relief that is similar to intravenous paracetamol. A dose reduction is recommended in patients with liver disease or malnourished. Genotyping may improve efficacy and safety. Within the current trend toward the minimization of opioid analgesia, it is consistently included in multimodal, non-opioid, or opioid-sparing therapies. Paracetamol is being recommended by guidelines as a first or second-line drug for acute pain and chronic pain, especially for patients with limited therapeutic options and for the elderly.
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Affiliation(s)
- Ulderico Freo
- Anesthesiology and Intensive Care, Department of Medicine—DIMED, University of Padua, 35122 Padua, Italy;
- Correspondence: ; Tel.: +39-049-821-3090
| | - Chiara Ruocco
- Center for the Study and Research on Obesity, Department of Biomedical Technology and Translational Medicine, University of Milan, 20129 Milan, Italy; (C.R.); (E.N.)
| | - Alessandra Valerio
- Department of Molecular and Translational Medicine, University of Brescia, 25100 Brescia, Italy;
| | - Irene Scagnol
- Anesthesiology and Intensive Care, Department of Medicine—DIMED, University of Padua, 35122 Padua, Italy;
| | - Enzo Nisoli
- Center for the Study and Research on Obesity, Department of Biomedical Technology and Translational Medicine, University of Milan, 20129 Milan, Italy; (C.R.); (E.N.)
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Stagg K. Intravenous versus oral paracetamol for postoperative analgesia: A systematic review. J Perioper Pract 2020; 31:373-378. [PMID: 33345698 DOI: 10.1177/1750458920950652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Paracetamol is a widely used analgesic agent that can be given by several different routes of administration. In the surgical setting, intravenous infusions of paracetamol are used, but an alternative is using oral paracetamol as a premedication. This systematic review is the first to compare the relative efficacy of intravenous and oral paracetamol at providing postoperative analgesia. Nine relevant studies were identified. Intravenous paracetamol resulted in a postoperative pain score of 0.5 points lower than in those receiving oral paracetamol premedication. Patients receiving intravenous paracetamol also had a small reduction in postoperative opioid requirements, but the time at which rescue analgesia was required did not differ. These results suggest that intravenous paracetamol may offer a small advantage over oral paracetamol premedication at providing postoperative analgesia.
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Abstract
BACKGROUND Total knee arthroplasty (TKA) is gradually emerging as the treatment of choice for end-stage osteoarthritis. In the past, intravenous (IV) versus oral acetaminophen (APAP) treatment is still a controversial subject in TKA. Therefore, we write this systematic review and meta-analysis to evaluate the efficacy of IV versus oral APAP on pain and recovery after TKA. METHODS Embase, Pubmed, and Cochrane Library were comprehensively searched. Randomized controlled trials, cohort studies were included in our meta-analysis. Five studies that compared IV APAP groups with oral APAP groups were included in our meta-analysis. The research was reported according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines to ensure the reliability and verity of results. RESULTS Pooled results indicated that no significant difference between the IV APAP groups and oral APAP groups in term of VAS score at 24 hours (P = .67), 48 hours (P = 0.08), and total morphine consumption at 24 hours (P = .07), but there was a significant difference in terms of length of hospital stay (LOS) (P = .0004). CONCLUSION IV APAP was not found to be superior to oral APAP in patients undergoing TKA in terms of VAS scores at 24 hours, 48 hours, and total morphine consumption at 24 hours. However, it can significantly reduce the LOS. We still need a large of high-quality research to verify the relationship between the oral and the IV APAP to give the conclusion.
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Affiliation(s)
| | - Yan Zhang
- Department of Nephrology, Weifang People's Hospital, Shandong, PR China
| | - Baojie Li
- Department of Orthopedics and Trauma
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Mallama M, Valencia A, Rijs K, Rietdijk WJR, Klimek M, Calvache JA. A systematic review and trial sequential analysis of intravenous vs. oral peri-operative paracetamol. Anaesthesia 2020; 76:270-276. [PMID: 32557588 PMCID: PMC7818191 DOI: 10.1111/anae.15163] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2020] [Indexed: 12/13/2022]
Abstract
Postoperative pain might be different after intravenous vs. oral paracetamol. We systematically reviewed randomised controlled trials in patients >15 years that compared intravenous with oral paracetamol for postoperative pain. We identified 14 trials with 1695 participants. There was inconclusive evidence for an effect of route of paracetamol administration on postoperative pain at 0–2 h (734 participants), 2–6 h (766 participants), 6–24 h (1115 participants) and >24 h (248 participants), with differences in standardised mean (95%CI) pain scores for intravenous vs. oral of −0.17 (−0.45 to 0.10), −0.09 (−0.24 to 0.06), 0.06 (−0.12 to 0.23) and 0.03 (−0.22 to 0.28), respectively. Trial sequential analyses suggested that a total of 3948 participants would be needed to demonstrate a meaningful difference in pain or its absence at 0–2 h. There were no differences in secondary outcomes. Intravenous paracetamol is more expensive than oral paracetamol. Substitution of oral paracetamol in half the patients given intravenous paracetamol in our hospital would save around £ 38,711 (€ 43,960 or US$ 47,498) per annum.
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Affiliation(s)
- M Mallama
- Department of Anaesthesiology, Universidad del Cauca, Popayán, Colombia
| | - A Valencia
- Department of Anaesthesiology, Universidad del Cauca, Popayán, Colombia
| | - K Rijs
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - W J R Rietdijk
- Department of Intensive Care, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - M Klimek
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - J A Calvache
- Department of Anaesthesiology, Universidad del Cauca, Popayán, Colombia.,Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Eggerstedt M, Stenson KM, Ramirez EA, Kuhar HN, Jandali DB, Vaughan D, Al-Khudari S, Smith RM, Revenaugh PC. Association of Perioperative Opioid-Sparing Multimodal Analgesia With Narcotic Use and Pain Control After Head and Neck Free Flap Reconstruction. JAMA FACIAL PLAST SU 2020; 21:446-451. [PMID: 31393513 DOI: 10.1001/jamafacial.2019.0612] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance An increase in narcotic prescription patterns has contributed to the current opioid epidemic in the United States. Opioid-sparing perioperative analgesia represents a means of mitigating the risk of opioid dependence while providing superior perioperative analgesia. Objective To assess whether multimodal analgesia (MMA) is associated with reduced narcotic use and improved pain control compared with traditional narcotic-based analgesics at discharge and in the immediate postoperative period after free flap reconstructive surgery. Design, Setting, and Participants This retrospective cohort study assessed a consecutive sample of 65 patients (28 MMA, 37 controls) undergoing free flap reconstruction of a through-and-through mucosal defect within the head and neck region at a tertiary academic referral center from June 1, 2017, to November 30, 2018. Patients and physicians were not blinded to the patients' analgesic regimen. Patients' clinical courses were followed up for 30 days postoperatively. Interventions Patients were administered a preoperative, intraoperative, and postoperative analgesia regimen consisting of scheduled and as-needed neuromodulating and anti-inflammatory medications, with narcotic medications reserved for refractory cases. Control patients were administered traditional narcotic-based analgesics as needed. Main Outcomes and Measures Narcotic doses administered during the perioperative period and at discharge were converted to morphine-equivalent doses (MEDs) for comparison. Postoperative Defense and Veterans Pain Rating Scale pain scores (ranging from 0 [no pain] to 10 [worst pain imaginable]) were collected for the first 72 hours postoperatively as a patient-reported means of analyzing effectiveness of analgesia. Results A total of 28 patients (mean [SD] age, 64.1 [12.3] years; 17 [61%] male) were included in the MMA group and 37 (mean [SD] age, 65.0 [11.0] years; 22 [59%] male) in the control group. The number of MEDs administered postoperatively was 10.0 (interquartile range [IQR], 2.7-23.1) in the MMA cohort and 89.6 (IQR, 60.0-104.5) in the control cohort (P < .001). Mean (SD) Defense and Veterans Pain Rating Scale pain scores postoperatively were 2.05 (1.41) in the MMA cohort and 3.66 (1.99) in the control cohort (P = .001). Median number of MEDs prescribed at discharge were 0 (IQR, 0-18.8) in the MMA cohort and 300.0 (IQR, 262.5-412.5) in the control cohort (P < .001). Conclusions and Relevance The findings suggest that after free flap reconstruction, MMA is associated with reduced narcotic use at discharge and in the immediate postoperative period and with superior analgesia as measured by patient-reported pain scores. Patients receiving MMA achieved improved pain control, and the number of narcotic prescriptions in circulation were reduced. Level of Evidence 3.
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Affiliation(s)
- Michael Eggerstedt
- Section of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois
| | - Kerstin M Stenson
- Section of Head and Neck Surgical Oncology, Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois
| | - Emily A Ramirez
- Section of Head and Neck Surgical Oncology, Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois
| | - Hannah N Kuhar
- Rush Medical College, Rush University Medical Center, Chicago, Illinois
| | - Danny B Jandali
- Section of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois
| | - Deborah Vaughan
- Section of Head and Neck Surgical Oncology, Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois
| | - Samer Al-Khudari
- Section of Head and Neck Surgical Oncology, Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois
| | - Ryan M Smith
- Section of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois
| | - Peter C Revenaugh
- Section of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois
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Ridderikhof ML, Saanen J, Goddijn H, Van Dieren S, Van Etten-Jamaludin F, Lirk P, Goslings JC, Hollmann MW. Paracetamol versus other analgesia in adult patients with minor musculoskeletal injuries: a systematic review. Emerg Med J 2019; 36:493-500. [DOI: 10.1136/emermed-2019-208439] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 05/17/2019] [Accepted: 05/20/2019] [Indexed: 12/26/2022]
Abstract
ObjectivesPain treatment in acute musculoskeletal injuries usually consists of paracetamol, non-steroidal antiinflammatory drugs (NSAIDs) or opioids. It would be beneficial to determine whether paracetamol is as effective as other analgesics. The objective of this study was to evaluate available evidence regarding efficacy of paracetamol in these patients.MethodsEmbase, MEDLINE, Cochrane and relevant trial registers were searched from inception to 14 February 2018 by two independent reviewers to detect all randomised studies with adult patients with acute minor musculoskeletal injuries treated with paracetamol as compared with other analgesics. There were no language or date restrictions. Two independent reviewers evaluated risk of bias and quality of evidence. Primary outcome was decrease in pain scores during the first 24 hours, and secondary outcomes included pain decrease beyond 24 hours, need for additional analgesia and occurrence of adverse events.ResultsSeven trials were included, evaluating 2100 patients who were treated with paracetamol or NSAIDs or the combination of both as comparisons, of which only four studies addressed the primary outcome. No studies were found comparing paracetamol with opioids. There were no differences in analgesic effectiveness within and beyond 24 hours, nor in need for additional analgesia and occurrence of adverse events. Overall, quality of evidence was low. Because of methodological inconsistencies, a meta-analysis was not possible.ConclusionsBased on available evidence, paracetamol is as effective as NSAIDs or the combination of both in treating pain in adult patients with minor musculoskeletal injuries in the acute setting. The quality of evidence is low.
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Nimmaanrat S, Jongjidpranitarn M, Prathep S, Oofuvong M. Premedication with oral paracetamol for reduction of propofol injection pain: a randomized placebo-controlled trial. BMC Anesthesiol 2019; 19:100. [PMID: 31185906 PMCID: PMC6560875 DOI: 10.1186/s12871-019-0758-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 05/14/2019] [Indexed: 11/20/2022] Open
Abstract
Background To compare the effect of premedication with 2 different doses of oral paracetamol to prevent pain at propofol intravenous injection. Methods We conducted a double-blind randomized controlled trial in which patients scheduled for induction of general anesthesia with intravenous propofol received either a placebo, 500 mg or 1000 mg of oral paracetamol (P500 and P1000, respectively) 1 h prior to induction. Two mg/kg of propofol was injected at a rate of 600 ml/hr. After 1/4 of the full dose had been injected, the syringe pump was paused, and patients were asked to rate pain at the injection site using a verbal numerical rating score (VNRS) from 0 to 10. Results Three hundred and twenty-four patients were included. Pain intensity was lower in both P500 and P1000 groups (median VNRS [interquartile range] = 2 [0–3] and 4 [2–5], respectively) than in the placebo group (8 [7–10]; P < 0.001)*. The rate of pain was lower in the P1000 group (70.4%) than in both the P500 and the placebo group (86.1 and 99.1%, respectively; P < 0.001)*. The respective rates of mild (VNRS 1–3), moderate (VNRS 4–6) and severe pain (VNRS 7–10) were 47.2, 23.2 and 0% in the P1000 group, 28.7, 50 and 7.4% in the P500 group, and 0, 22.2 and 76.9% in the placebo group (P < 0.001* for between group comparisons). Tolerance was similar in the 3 groups. Conclusions A premedication with oral paracetamol can dose-dependently reduce pain at propofol intravenous injection. To avoid this common uncomfortable concern for the patients, this well-tolerated, available and cheap treatment appears as an option to be implemented in the current practice. Trial registration TCTR20150224002. Prospectively registered on 24 February 2015.
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Affiliation(s)
- Sasikaan Nimmaanrat
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla, 90110, Thailand.
| | - Manasanun Jongjidpranitarn
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla, 90110, Thailand
| | - Sumidtra Prathep
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla, 90110, Thailand
| | - Maliwan Oofuvong
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla, 90110, Thailand
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Johnson RJ, Nguyen DK, Acosta JM, O'Brien AL, Doyle PD, Medina-Rivera G. Intravenous Versus Oral Acetaminophen in Ambulatory Surgical Center Laparoscopic Cholecystectomies: A Retrospective Analysis. P T 2019; 44:359-363. [PMID: 31160871 PMCID: PMC6534170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
STUDY OBJECTIVE The primary aim was to compare postoperative pain scores in patients undergoing laparoscopic cholecystectomy and receiving intravenous (IV) or oral (PO) acetaminophen (APAP) as part of a multimodal analgesic regimen to examine whether PO APAP is non-inferior to IV APAP. DESIGN Retrospective analysis. SETTING Ambulatory surgical center (ASC) in an academic setting. PATIENTS 579 patients (18-70 years old), American Society of Anesthesiologists physical status I-III, undergoing laparoscopic cholecystectomy. INTERVENTIONS Patients received 1,000 mg IV APAP intraoperatively (n = 319) or 1,000 mg PO APAP preoperatively (n = 260). MEASUREMENTS The primary outcome was the median difference in post-anesthesia care unit (PACU) end-pain scores between the groups. Median pain scores were also compared on PACU admission, and at 15, 30, 45, and 60 minutes. Additional measures include PACU rescue-analgesia consumption, time to first PACU rescue analgesia, intraoperative use of opioid and nonopioid analgesics, PACU length of stay, and PACU rescue nausea and vomiting therapy. MAIN RESULTS In both groups, the PACU median end-pain score was 2. The 90% confidence interval (CI) for difference in median pain scores between groups was [0, 0]; the CI upper limit was below the non-inferior margin of 1 pain-score point, indicating PO APAP's non-inferiority to IV APAP. There were no statistically significant differences in the percentages of patients receiving PACU hydromorphone equivalents between the IV and PO groups (75% vs. 77%, P = 0.72) or in the mean dose received (0.5 mg vs. 0.5 mg, P = 0.66). CONCLUSION Single-dose PO APAP is non-inferior to IV APAP for postoperative analgesia in ASC laparoscopic cholecystectomy patients. The value of single-dose IV APAP in this population should be further explored.
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Abstract
Pain control is an integral part of Enhanced Recovery after Surgery (ERAS) protocols for colorectal surgery. While opioid therapy remains the mainstay of therapy for postsurgical pain, opioids have undesired side effects including delayed recovery of bowel function, respiratory depression, and postoperative nausea and vomiting. A variety of nonopioid systemic medical therapies as well as regional and neuraxial techniques have been described as improving pain control while reducing opioid use. Multimodal and preemptive analgesia as part of an ERAS protocol facilitates early mobility and early return of bowel function and decreases postoperative morbidity. In this review, we examine several multimodal therapies and their impact on postoperative analgesia, opioid use, and recovery for patients undergoing colorectal surgery.
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Affiliation(s)
- J Creswell Simpson
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Xiaodong Bao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Aalok Agarwala
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Wang VC, Preston MA, Kibel AS, Xu X, Gosnell J, Yong RJ, Urman RD. A Prospective, Randomized, Double-Blind, Placebo-Controlled Trial to Evaluate Intravenous Acetaminophen Versus Placebo in Patients Undergoing Robotic-Assisted Laparoscopic Prostatectomy. J Pain Palliat Care Pharmacother 2019; 32:82-89. [DOI: 10.1080/15360288.2018.1513436] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Plunkett A, Haley C, McCoart A, Beltran T, Highland KB, Berry-Caban C, Lamberth S, Bartoszek M. A Preliminary Examination of the Comparative Efficacy of Intravenous vs Oral Acetaminophen in the Treatment of Perioperative Pain. Pain Med 2018; 18:2466-2473. [PMID: 28034981 DOI: 10.1093/pm/pnw273] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objective The management of postoperative pain is a major health care issue. While the cost of intravenous acetaminophen (IVA) is significantly greater than its oral acetaminophen (OA) counterpart, less is known regarding comparative effectiveness of these routes. The purpose of this study was to determine whether perioperative IVA is equivalent in reducing postoperative pain compared with perioperative OA for laparoscopic cholecystectomy (LapChole). Design Double-blinded, prospective, randomized placebo-controlled trial. Setting Womack Army Medical Center, Fort Bragg, North Carolina. Subjects Adults (age > 18 years) active duty military, veterans, and beneficiaries receiving a laparoscopic cholecystectomy. Methods This study was conducted at Womack Army Medical Center (WAMC), Fort Bragg, North Carolina, between January 2013 and June 2015. Sixty-seven subjects with symptomatic cholelithiasis were randomly assigned to receive two doses (1,000 mg each) of either IVA or OA. A numerical rating scale (NRS) score of pain was obtained preoperatively and every six hours for 24 hours postoperation. The primary objective was to assess whether treatment groups had significantly different 24-hour postoperative sum of pain intensity differences (SPID24) using an analysis of covariance test. Results Sixty subjects completed the study and were included in the analysis. Treatment groups did not differ in SPID24, even when controlling for age, gender, and preoperative pain levels (F(1,55) = 0.39, P = 0.54, partial η2 = 0.007), nor did 24-hour opioid consumption when controlling for age, gender, and operation time (F(1, 46) = 0.47, P = 0.50, partial η2 = 0.01). Furthermore, treatment groups were equally as likely to report average postoperative NRS scores of 4 or higher (β = 0.24, Exp(B) = 1.28, P = 0.68). Conclusions The results show no evidence of differences between IVA or OA in pain or opioid consumption among a sample of patients undergoing LapChole. Due to low sample size, these descriptive findings warrant larger studies, which may have a significant economic impact.
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Affiliation(s)
| | - Chelsey Haley
- Defense and Veterans Center for Integrative Pain Management, Henry M. Jackson Foundation, Womack Army Medical Center, Fort Bragg, North Carolina
| | - Amy McCoart
- Defense and Veterans Center for Integrative Pain Management, Henry M. Jackson Foundation, Womack Army Medical Center, Fort Bragg, North Carolina
| | | | - Krista Beth Highland
- Defense and Veterans Center for Integrative Pain Management, Henry M. Jackson Foundation, Uniformed Services University of the Health Sciences, Rockville, Maryland, USA
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Sirintawat N, Sawang K, Chaiyasamut T, Wongsirichat N. Pain measurement in oral and maxillofacial surgery. J Dent Anesth Pain Med 2017; 17:253-263. [PMID: 29349347 PMCID: PMC5766084 DOI: 10.17245/jdapm.2017.17.4.253] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 11/28/2017] [Accepted: 11/30/2017] [Indexed: 12/04/2022] Open
Abstract
Regardless of whether it is acute or chronic, the assessment of pain should be simple and practical. Since the intensity of pain is thought to be one of the primary factors that determine its effect on a human's overall function and sense, there are many scales to assess pain. The aim of the current article was to review pain intensity scales that are commonly used in dental and oral and maxillofacial surgery (OMFS). Previous studies demonstrated that multidimensional scales, such as the McGill Pain Questionnaire, Short form of the McGill Pain Questionnaire, and Wisconsin Brief Pain Questionnaire were suitable for assessing chronic pain, while unidimensional scales, like the Visual Analogue Scales (VAS), Verbal descriptor scale, Verbal rating scale, Numerical rating Scale, Faces Pain Scale, Wong-Baker Faces Pain Rating Scale (WBS), and Full Cup Test, were used to evaluate acute pain. The WBS is widely used to assess pain in children and elderly because other scales are often difficult to understand, which could consequently lead to an overestimation of the pain intensity. In dental or OMFS research, the use of the VAS is more common because it is more reliable, valid, sensitive, and appropriate. However, some researchers use NRS to evaluate OMFS pain in adults because this scale is easier to use than VAS and yields relatively similar pain scores. This review only assessed pain scales used for post-operative OMFS or dental pain.
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Affiliation(s)
- Nattapong Sirintawat
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Mahidol University, Bangkok, Thailand
| | - Kamonpun Sawang
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Mahidol University, Bangkok, Thailand
| | - Teeranut Chaiyasamut
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Mahidol University, Bangkok, Thailand
| | - Natthamet Wongsirichat
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Mahidol University, Bangkok, Thailand
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O'Neal JB, Freiberg AA, Yelle MD, Jiang Y, Zhang C, Gu Y, Kong X, Jian W, O'Neal WT, Wang J. Intravenous vs Oral Acetaminophen as an Adjunct to Multimodal Analgesia After Total Knee Arthroplasty: A Prospective, Randomized, Double-Blind Clinical Trial. J Arthroplasty 2017; 32:3029-3033. [PMID: 28690041 PMCID: PMC5605416 DOI: 10.1016/j.arth.2017.05.019] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 05/05/2017] [Accepted: 05/10/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The efficacy of intravenous (IV) acetaminophen compared with its oral formulation for postoperative analgesia is unknown. We hypothesized that the addition of acetaminophen to a multimodal analgesia regimen would provide improved pain management in patients after total knee arthroplasty (TKA) and that the effect of acetaminophen would be variable based on the route of delivery. METHODS The study was a single-center, randomized, double-blinded, placebo-controlled clinical trial on the efficacy of IV vs oral acetaminophen in patients undergoing unilateral TKA. One hundred seventy-four subjects were randomized to one of the 3 groups: IV acetaminophen group (IV group, n = 57) received 1 g IV acetaminophen and oral placebo before postanesthesia care unit (PACU) admission; oral acetaminophen group (PO group, n = 58) received 1 g oral acetaminophen and volume-matched IV normal saline; placebo group (Placebo group, n = 59) received oral placebo and volume-matched IV normal saline. Pain scores were obtained every 15 minutes during PACU stay. Average pain scores, maximum pain score, and pain scores before physical therapy were compared among the 3 groups. Secondary outcomes included total opiate consumption, time to PACU discharge, time to rescue analgesia, and time to breakthrough pain. RESULTS The average PACU pain score was similar in the IV group (0.56 ± 0.99 [mean ± standard deviation]) compared with the PO group (0.67 ± 1.20; P = .84) and Placebo group (0.58 ± 0.99; P = .71). Total opiate consumption at 6 hours (0.47 mg hydromorphone equivalents ± 0.56 vs 0.54 ± 0.53 vs 0.54 ± 0.61; P = .69) and at 24 hours (1.25 ± 1.30 vs 1.49 ± 1.34 vs 1.36 ± 1.31; P = .46) were also similar between the IV, PO, and Placebo groups. No significant differences were found between all groups for any other outcome. CONCLUSION Neither IV nor oral acetaminophen provides additional analgesia in the immediate postoperative period when administered as an adjunct to multimodal analgesia in patients undergoing TKA in the setting of a spinal anesthetic.
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Affiliation(s)
- Jason B. O'Neal
- Vanderbilt University Medical Center, Department of Anesthesiology, Nashville, TN, USA
| | - Andrew A. Freiberg
- Massachussetts General Hospital, Harvard Medical School, Department of Orthopedic Surgery, Boston, MA, USA
| | - Marc D. Yelle
- Duke University Medical Center, Department of Anesthesiology, Durham, NC, USA
| | - Yandong Jiang
- Vanderbilt University Medical Center, Department of Anesthesiology, Nashville, TN, USA
| | - Chengwei Zhang
- Department of Anesthesiology, The Second Hospital of Jilin University, Changchun, China
| | - Yin Gu
- Shenzhen Maternal & Child Care Hospital, Department of Anesthesia, Shenzhen, Guangdong, China
| | - Xiangyi Kong
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences NO.1 Shuaifuyuan Hutong of Dongcheng District, Beijing, China
| | - Wenling Jian
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Wesley T. O'Neal
- Emory University School of Medicine, Department of Medicine, Atlanta, GA, USA
| | - Jingping Wang
- Massachussetts General Hospital, Harvard Medical School, Department of Anesthesiology, Boston, MA, USA
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Helander EM, Webb MP, Bias M, Whang EE, Kaye AD, Urman RD. A Comparison of Multimodal Analgesic Approaches in Institutional Enhanced Recovery After Surgery Protocols for Colorectal Surgery: Pharmacological Agents. J Laparoendosc Adv Surg Tech A 2017; 27:903-908. [PMID: 28742427 DOI: 10.1089/lap.2017.0338] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Enhanced Recovery After Surgery (ERAS®) protocols are the cornerstone of improved recovery after colorectal surgery. Their implementation leads to reduced morbidity and shorter hospital stays while attenuating the surgical stress response. Multimodal analgesia is an important part of ERAS protocols. We compared and contrasted protocols from 15 institutions to test our hypothesis that there is a fundamental consensus among them. MATERIALS AND METHODS ERAS protocols for open and laparoscopic colorectal surgery were compared from 15 different healthcare facilities. We examined each institution's approach to multimodal analgesia related to the use of oral and intravenous analgesics. Preoperative, intraoperative, and postoperative management was examined. RESULTS All but three protocols used preoperative multimodal analgesics, with acetaminophen, celecoxib, and gabapentin being the most common. Intraoperative recommendations included the use of ketamine, lidocaine, magnesium, and ketorolac. Some protocols advocated for the use of opiates, while others aimed to minimize total opioid dose. In the postoperative period, the three most utilized agents were acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids. CONCLUSIONS There were many similarities and some significant differences among ERAS protocols examined. Acetaminophen was the most widely used nonopioid agent and along with NSAIDs offers a benefit with respect to postoperative analgesia, opioid-sparing effects, earlier ambulation, and reduction in postoperative ileus. Gabapentin was widely used as it may reduce opioid consumption within the first 24 hours postoperatively. Lidocaine infusion was recommended if there were contraindications to or failure of epidural anesthesia. Ketamine is frequently recommended due to its analgesic, antihyperalgesic, antiallodynic, and antitolerance properties. Differences in approaches may be due to both institutional- and provider-level factors.
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Affiliation(s)
- Erik M Helander
- 1 Department of Anesthesiology, LSU School of Medicine , New Orleans, Louisiana
| | - Michael P Webb
- 2 Department of Anesthesiology, North Shore Hospital , Auckland, New Zealand
| | - Meghan Bias
- 3 Department of Surgery, LSU School of Medicine , New Orleans, Louisiana
| | - Edward E Whang
- 4 Department of Surgery, Brigham and Women's Hospital , Harvard Medical School, Boston, Massachusetts
| | - Alan D Kaye
- 1 Department of Anesthesiology, LSU School of Medicine , New Orleans, Louisiana
| | - Richard D Urman
- 5 Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital , Harvard Medical School, Boston, Massachusetts
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McEvoy MD, Scott MJ, Gordon DB, Grant SA, Thacker JKM, Wu CL, Gan TJ, Mythen MG, Shaw AD, Miller TE. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on optimal analgesia within an enhanced recovery pathway for colorectal surgery: part 1-from the preoperative period to PACU. Perioper Med (Lond) 2017; 6:8. [PMID: 28413629 PMCID: PMC5390366 DOI: 10.1186/s13741-017-0064-5] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 03/14/2017] [Indexed: 01/01/2023] Open
Abstract
Background Within an enhanced recovery pathway (ERP), the approach to treating pain should be multifaceted and the goal should be to deliver “optimal analgesia,” which we define in this paper as a technique that optimizes patient comfort and facilitates functional recovery with the fewest medication side effects. Methods With input from a multi-disciplinary, international group of clinicians, and through a structured review of the literature and use of a modified Delphi method, we achieved consensus surrounding the topic of optimal analgesia in the perioperative period for colorectal surgery patients. Discussion As a part of the first Perioperative Quality Improvement (POQI) workgroup meeting, we sought to develop a consensus document describing a comprehensive, yet rational and practical, approach for developing an evidence-based plan for achieving optimal analgesia, specifically for a colorectal surgery ERP. The goal was two-fold: (a) that application of this process would lead to improved patient outcomes and (b) that investigation of the questions raised would identify knowledge gaps to aid the direction for research into analgesia within ERPs in the years to come. This document details the evidence for a wide range of analgesic components, with particular focus from the preoperative period to the post-anesthesia care unit. The overall conclusion is that the combination of analgesic techniques employed in the perioperative period is not important as long as it is effective in delivering the goal of optimal analgesia as set forth in this document.
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Affiliation(s)
- Matthew D McEvoy
- Department of Anesthesiology, CIPHER (Center for Innovation in Perioperative Health, Education, and Research) Vanderbilt University Medical Center, 2301VUH, Nashville, TN 37232 USA
| | - Michael J Scott
- Anaesthesia & Intensive Care Medicine, Royal Surrey County NHS Foundation Hospital, Surrey, UK.,Department of Anaesthesia, University of Surrey, Surrey, UK.,University College London, London, UK
| | - Debra B Gordon
- Harborview Integrated Pain Care Program, Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, USA
| | - Stuart A Grant
- Division of Regional Division, Department of Anesthesiology, Duke University Medical Center, Durham, USA
| | - Julie K M Thacker
- Division of Advanced Oncologic and GI Surgery, Department of Surgery, Duke University Medical Center, Durham, USA
| | - Christopher L Wu
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University School of Medicine, Suffolk, USA
| | - Monty G Mythen
- UCL/UCLH National Institute of Health Research Biomedical Research Centre, London, UK
| | - Andrew D Shaw
- Department of Anesthesiology, Vanderbilt University, Nashville, USA
| | - Timothy E Miller
- Division of General, Vascular and Transplant Anesthesia, Duke University Medical Center, Durham, USA
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Medico CJ, King MW, Cole G, Albright D, Kowalek E, Bickert T, Venditti D. Improving patients' pain experience in a large rural hospital. Am J Health Syst Pharm 2017; 74:528-533. [PMID: 28336763 DOI: 10.2146/ajhp160009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Ozmete O, Bali C, Cok OY, Ergenoglu P, Ozyilkan NB, Akin S, Kalayci H, Aribogan A. Preoperative paracetamol improves post-cesarean delivery pain management: a prospective, randomized, double-blind, placebo-controlled trial. J Clin Anesth 2016; 33:51-7. [PMID: 27555133 DOI: 10.1016/j.jclinane.2016.02.030] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 01/28/2016] [Accepted: 02/18/2016] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE To evaluate the analgesic effect of preoperative single dose intravenous paracetamol on postoperative pain and analgesic consumption within 24hours after elective cesarean surgery. DESIGN Prospective, randomized, double-blind, placebo-controlled clinical trial. SETTING University Teaching Hospital. PATIENTS American Society of Anesthesiologists (ASA) I and II 60 patients between 18-40years of age who were scheduled to undergo elective cesarean section. INTERVENTIONS Patients were randomized into two groups to receive either intravenous 1g paracetamol (100mL) (Group P) or 0.9% NaCl solution (100mL) (Group C) 15minutes before the induction of general anesthesia. After delivery of newborn 0.15mg kg(-1) morphine was administered to all patients in both groups. Postoperative analgesia was provided with patient-controlled intravenous analgesia with morphine in the postoperative period. MEASUREMENTS Pain which is the primary outcome measure was assessed at 15th, 30th minutes and 1st, 2nd, 4th, 6th, 12th, 24th hours by the Visual Analogue Scale. Patients' demographics, hemodynamics, Apgar score, additional analgesic requirement, side effects, patients' satisfaction and postoperative total morphine consumption within 24hours were recorded. MAIN RESULTS Median visual analogue scale for pain in Group P was significantly lower compared to Group C at all time points except for the score at 24th h postoperatively (P<.05). Additional analgesic requirement during postoperative first hour was lower in Group P (P<.05). Total morphine consumption was higher in Group C compared with Group P (P<.05). There was no difference between groups with respect to Apgar scores, side effects, and patient satisfaction (P>.05). CONCLUSIONS Preoperative use of single-dose intravenous 1g paracetamol was found to be effective in reducing the severity of pain and opioid requirements within 24hours after cesarean section.
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Affiliation(s)
- Ozlem Ozmete
- Baskent University School of Medicine, Anesthesiology and Reanimation Department, Adana, Turkey.
| | - Cagla Bali
- Baskent University School of Medicine, Anesthesiology and Reanimation Department, Adana, Turkey.
| | - Oya Yalcin Cok
- Baskent University School of Medicine, Anesthesiology and Reanimation Department, Adana, Turkey.
| | - Pinar Ergenoglu
- Baskent University School of Medicine, Anesthesiology and Reanimation Department, Adana, Turkey.
| | - Nesrin Bozdogan Ozyilkan
- Baskent University School of Medicine, Anesthesiology and Reanimation Department, Adana, Turkey.
| | - Sule Akin
- Baskent University School of Medicine, Anesthesiology and Reanimation Department, Adana, Turkey.
| | - Hakan Kalayci
- Baskent University School of Medicine, Obstetrics and Gynecology Department, Adana, Turkey.
| | - Anis Aribogan
- Baskent University School of Medicine, Anesthesiology and Reanimation Department, Adana, Turkey.
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Sabry N, Dawoud D, Alansary A, Hounsome N, Baines D. Evaluation of a protocol-based intervention to promote timely switching from intravenous to oral paracetamol for post-operative pain management: an interrupted time series analysis. J Eval Clin Pract 2015; 21:1081-8. [PMID: 26489529 DOI: 10.1111/jep.12463] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2015] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Timely switching from intravenous to oral therapy ensures optimized treatment and efficient use of health care resources. Intravenous (IV) paracetamol is widely used for post-operative pain management but not always switched to the oral form in a timely manner, leading to unnecessary increase in expenditure. This study aims to evaluate the impact of a multifaceted intervention to promote timely switching from the IV to oral form in the post-operative setting. METHODS An evidence-based prescribing protocol was designed and implemented by the clinical pharmacy team in a single district general hospital in Egypt. The protocol specified the criteria for appropriate prescribing of IV paracetamol. Doctors were provided with information and educational sessions prior to implementation. A prospective, quasi-experimental study was undertaken to evaluate its impact on IV paracetamol utilization and costs. Data on monthly utilization and costs were recorded for 12 months before and after implementation (January 2012 to December 2013). Data were analysed using interrupted time series analysis. RESULTS Prior to implementation, in 2012, total spending on IV paracetamol was 674 154.00 Egyptian Pounds (L.E.) ($23,668.00). There was a non-significant (P > 0.05) downward trend in utilization (-32 ampoules per month) and costs [reduction of 632 L.E. ($222) per month]. Following implementation, immediate decrease in utilization and costs (P < 0.05) and a trend change over the follow-up period were observed. Average monthly reduction was 26% (95% CI: 24% to 28%, P < 0.001). CONCLUSION A multifaceted, protocol-based intervention to ensure timely switching from IV-to-oral paracetamol achieved significant reduction in utilization and cost of IV paracetamol in the first 5 months of its implementation.
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Affiliation(s)
- Nirmeen Sabry
- Clinical Pharmacy Department, Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Dalia Dawoud
- Clinical Pharmacy Department, Faculty of Pharmacy, Cairo University, Cairo, Egypt.,Health Economics, Modelling and Systems Analysis (HeMaSa), Centre for Technology Enabled Health Research, Coventry University, Coventry, UK
| | - Adel Alansary
- Department of Anaesthesiology and Critical Care, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Natalia Hounsome
- Pragmatic Clinical Trials Unit (PCTU), Centre for Primary Care and Public Health, Queen Mary, University of London, London, UK
| | - Darrin Baines
- Health Economics, Modelling and Systems Analysis (HeMaSa), Centre for Technology Enabled Health Research, Coventry University, Coventry, UK
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Eftekharian H, Tabrizi R, Kazemi H, Nili M. Evaluation of a Single Dose Intravenous Paracetamol for Pain Relief After Maxillofacial Surgery: A Randomized Clinical Trial Study. J Maxillofac Oral Surg 2015. [PMID: 26225014 DOI: 10.1007/s12663-013-0557-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate, using a single dose of intravenous paracetamol, pain relief after maxillofacial surgery. MATERIALS AND METHODS This is a controlled, randomized, uni- blind, clinical trial study to evaluate using a single dose of IV paracetamol for pain relief after maxillofacial surgery. The subjects were randomly divided into two groups with 40 subjects in each: group I received paracetamol (Apotel)* as a single dose and group II received placebo. Subjects were randomly allocated according to randomization lists. Paracetamol was used as a single dose (20 mg/kg in 100 cc of normal saline which was infused for 10 min after surgery in recovery room just before discharging). We used a visual analogue scale to investigate pain relief at various times. RESULTS Analysis of the data, did not show any significant difference for age, sex and weight between the treatment group and the control group. Pain decreased 6 h after paracetamol infusion; then it increased mildly. In the control group, pain severity increased after operation, then it decreased mildly. Results showed a correlation between duration of surgery and pain severity in both the groups. CONCLUSION Paracetamol is effective on pain relief after maxillofacial surgeries. Operation time may be an important factor for induction of pain after the surgeries.
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Affiliation(s)
- Hamidreza Eftekharian
- Department of Maxillofacial Surgery, Shiraz University of Medical Science, Shiraz, Iran
| | - Reza Tabrizi
- Department of Maxillofacial Surgery, Shiraz University of Medical Science, Shiraz, Iran ; Chamran Hospital, CMF Ward, Chamran Avenue, Shiraz, Fars Iran
| | - Hamidreza Kazemi
- Department of Maxillofacial Surgery, Shiraz University of Medical Science, Shiraz, Iran
| | - Mahsa Nili
- Shiraz University of Medical Science, Shiraz, Iran
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Jibril F, Sharaby S, Mohamed A, Wilby KJ. Intravenous versus Oral Acetaminophen for Pain: Systematic Review of Current Evidence to Support Clinical Decision-Making. Can J Hosp Pharm 2015; 68:238-47. [PMID: 26157186 DOI: 10.4212/cjhp.v68i3.1458] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Intravenous (IV) acetaminophen is increasingly used around the world for pain control for a variety of indications. However, it is unclear whether IV administration offers advantages over oral administration. OBJECTIVE To identify, summarize, and critically evaluate the literature comparing analgesic efficacy, safety, and pharmacokinetics for IV and oral dosage forms of acetaminophen. DATA SOURCES A literature search of the PubMed, Embase, and International Pharmaceutical Abstracts databases was supplemented with keyword searches of Science Direct, Wiley Library Online, and Springer Link databases for the period 1948 to November 2014. The reference lists of identified studies were searched manually. STUDY SELECTION AND DATA EXTRACTION Randomized controlled trials comparing IV and oral dosage forms of acetaminophen were included if they assessed an efficacy, safety, or pharmacokinetic outcome. For each study, 2 investigators independently extracted data (study design, population, interventions, follow-up, efficacy outcomes, safety outcomes, pharmacokinetic outcomes, and any other pertinent information) and completed risk-of-bias assessments. DATA SYNTHESIS Six randomized clinical trials were included. Three of the studies reported outcomes pertaining to efficacy, 4 to safety, and 4 to pharmacokinetics. No clinically significant differences in efficacy were found between the 2 dosage forms. Safety outcomes were not reported consistently enough to allow adequate assessment. No evidence was found to suggest that increased bioavailability of the IV formulation enhances efficacy outcomes. For studies reporting clinical outcomes, the results of risk-of-bias assessments were largely unclear. CONCLUSIONS For patients who can take an oral dosage form, no clear indication exists for preferential prescribing of IV acetaminophen. Decision-making must take into account the known adverse effects of each dosage form and other considerations such as convenience and cost. Future studies should assess multiple-dose regimens over longer periods for patients with common pain indications such as cancer, trauma, and surgery.
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Affiliation(s)
- Farah Jibril
- BSc(Pharm), PharmD, is a Clinical Pharmacist at the National Center for Cancer Care and Research, Doha, Qatar
| | - Sherif Sharaby
- Sherif Sharaby, BSc(Pharm), is a Pharmacist with the San Joaquin Valley Rehabilitation Hospital, Fresno, California
| | - Ahmed Mohamed
- BSc(Pharm), PhD, is an Assistant Professor with the College of Pharmacy, Qatar University, Doha, Qatar
| | - Kyle J Wilby
- BSP, ACPR, PharmD, is an Assistant Professor - Clinical Pharmacy and Practice, College of Pharmacy, Qatar University, Doha, Qatar
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Abstract
OBJECTIVE This study aimed to determine if intravenous acetaminophen [paracetamol] (IV APAP) could decrease visual analog pain scores (VAS), opioid exposure and subsequent opioid related adverse effects (nausea, vomiting, constipation) in spinal surgery patients. METHODS Thirty four spinal surgery patients to date have received IV APAP since its addition to the formulary at our institution. The electronic medical record was accessed on all patients who received at least one dose pre or post operatively to collect postoperative opioid consumption (in morphine equivalents), number of antiemetic and laxative doses, use of naloxone, and VAS pain scores from arrival to surgical unit through postop day two. An equivalent number of patients who did not receive any IV APAP were selected and matched on the basis of opioid use prior to admission, surgery type, surgeon, age, and sex to constitute the control group. RESULTS The IV APAP group used significantly less opioids than the control group (p=0.015). Frequency of antiemetic and laxative use and VAS pain scores did not differ significantly between the two groups. CONCLUSIONS It appears IV APAP can be used effectively as an adjuvant pain management therapy in spinal surgery patients to decrease opioid exposure, but does not necessarily reduce the incidence of opioid related adverse effects or VAS pain scores.
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Affiliation(s)
- April N Smith
- Department of Pharmacy Practice, School of Pharmacy & Health Professions, Creighton University . Omaha, NE ( United States ).
| | - Vie C Hoefling
- School of Pharmacy & Health Professions, Creighton University . Omaha, NE ( United States )
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Abstract
Intravenous acetaminophen (IVA) has rapid and effective analgesic properties. Recent studies have shown several benefits of using IVA perioperatively. However, due to its relatively high cost and limited clinical data concerning its efficacy compared with other agents, physicians are hesitant to use IVA in the perioperative period. This brief review examines the utility of this medication in the perioperative period and highlights future areas of clinical and epidemiological research regarding its use.
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Affiliation(s)
- Jason B O'Neal
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School , Boston, MA , USA
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