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International Journal of Surgery... Aug 2023The role of transversus thoracic muscle plane blocks (TTMPBs) during cardiac surgery is controversial. We conducted a systematic review to establish the effectiveness of... (Meta-Analysis)
Meta-Analysis
STUDY OBJECTIVE
The role of transversus thoracic muscle plane blocks (TTMPBs) during cardiac surgery is controversial. We conducted a systematic review to establish the effectiveness of this procedure.
DESIGN
Systematic review. We searched PubMed, Embase, Web of Science, CENTRAL, WanFang Data, and the China National Knowledge Infrastructure to June 2022, and followed the GRADE approach to evaluate the certainty of evidence.
STUDY ELIGIBILITY CRITERIA
Eligible studies enrolled adult patients scheduled to undergo cardiac surgery and randomized them to receive a TTMPB or no block/sham block.
MAIN RESULTS
Nine trials that enrolled 454 participants were included. Compared to no block/sham block, moderate certainty evidence found that TTMPB probably reduces postoperative pain at rest at 12 h [weighted mean difference (WMD) -1.51 cm on a 10 cm visual analogue scale for pain, 95% CI -2.02 to -1.00; risk difference (RD) for achieving mild pain or less (≤3 cm), 41%, 95% CI 17-65) and 24 h (WMD -1.07 cm, 95% CI -1.83 to -0.32; RD 26%, 95% CI 9-37). Moderate certainty evidence also supported that TTMPB probably reduces pain during movement at 12 h (WMD -3.42 cm, 95% CI -4.47 to -2.37; RD 46%, 95% CI 12-80) and at 24 h (WMD -1.73 cm, 95% CI -3.24 to -0.21; RD 32%, 95% CI 5-59), intraoperative opioid use [WMD -28 milligram morphine equivalent (MME), 95% CI -42 to -15], postoperative opioid consumption (WMD -17 MME, 95% CI -29 to -5), postoperative nausea and vomiting (absolute risk difference 255 less per 1000 persons, 95% CI 140-314), and intensive care unit (ICU) length of stay (WMD -13 h, 95% CI -21 to -6).
CONCLUSION
Moderate certainty evidence showed TTMPB during cardiac surgery probably reduces postoperative pain at rest and with movement, opioid consumption, ICU length of stay, and the incidence of nausea and vomiting.
Topics: Adult; Humans; Analgesics, Opioid; Pain, Postoperative; Postoperative Nausea and Vomiting; Cardiac Surgical Procedures; Muscles
PubMed: 37246971
DOI: 10.1097/JS9.0000000000000470 -
The Journal of Urology May 2022Opioid prescriptions after surgery are major contributors to the opioid abuse epidemic. Several measures designed to limit opioid prescriptions at discharge have been... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Opioid prescriptions after surgery are major contributors to the opioid abuse epidemic. Several measures designed to limit opioid prescriptions at discharge have been evaluated. We conducted a comprehensive review and meta-analysis of the effectiveness of various types of interventions in reducing opioid prescriptions after urological surgery.
MATERIALS AND METHODS
A systematic review including MEDLINE®, Web of Science™ and Cochrane databases was conducted to identify studies on opioid prescriptions and urological surgery. Twenty-two studies met the inclusion criteria, of which 19 were used for quantitative analysis for reduction in opioid prescriptions. Additional outcomes included opioid consumption and satisfaction with analgesia.
RESULTS
Of the 8,318 patients, 53% were in the pre- and 47% in the post-intervention cohort. Overall mean reduction/patient in prescribed opioids was -67.59 (95% CI 54.23 to 80.94) morphine milligram equivalents (MME). Direct interventions, implemented by providers within their local department or hospital, were more effective in reducing prescribed opioids compared to indirect, or systemic, interventions, at -76.68 MME (95% CI 60.04 to -93.31) vs -46.72 MME (95% CI 24.20 to -69.23; p=0.04). Opioid consumption significantly decreased post-intervention with a mean reduction of -18.31 MME (95% CI 7.89 to 28.72). Patient satisfaction with analgesia remained unchanged between the pre- and post-intervention groups.
CONCLUSIONS
Successful reduction in opioid prescriptions, without compromising pain control, can be achieved through a variety of interventions. Direct interventions appear to have a greater impact than indirect interventions in reducing opioid prescriptions. Despite the reduction, unused, excess prescription opioids were still noted, which provides an opportunity for further control on opioid prescriptions.
Topics: Analgesics, Opioid; Humans; Pain Management; Pain, Postoperative; Practice Patterns, Physicians'; Prescriptions
PubMed: 35393897
DOI: 10.1097/JU.0000000000002447 -
Cureus Apr 2023Intraosseous basivertebral nerve ablation has shown sustained efficacy in treating chronic axial low back pain (LBP) in patients with type 1 or 2 Modic changes. This... (Review)
Review
Intraosseous basivertebral nerve ablation has shown sustained efficacy in treating chronic axial low back pain (LBP) in patients with type 1 or 2 Modic changes. This systematic review aims to determine the efficacy of intraosseous basivertebral nerve radiofrequency ablation in treating nonradiating axial chronic LBP compared to standard therapy, sham, or without contrast. The population of interest is individuals greater than or equal to 18 years old with chronic nonradiating vertebrogenic pain. The key outcome was the percentage of patients with greater than or equal to 50% pain reduction, greater than or equal to 10-point improvement in function and disability measured by the Oswestry Disability Index (ODI), greater than or equal to two-point pain reduction in the visual analog scale (VAS) or numerical pain rating scale, and a decrease in opioid utilization by 10 morphine milligram equivalents. Three databases, PubMed, MEDLINE, and Google Scholar, were used to retrieve the studies for the review. Two independent reviewers assessed the studies for inclusion using the validated tools for quality appraisal. There were 286 articles in total; however, only 11 publications with extensive data on 413 participants matched the inclusion criteria and were used for this review. At three months, a majority of the participants reported greater than or equal to 10-point improvement in the ODI, a measure of functional and disability improvement on a 10-point scale, and greater than or equal to two-point improvement in the VAS. A good number of patients in the basivertebral nerve ablation (BVNA) arm reported complete pain resolution demonstrating therapy success and the superiority of BVNA over sham and standard treatment. Basivertebral nerve radiofrequency ablation, among other criteria, is a safe and minimally invasive therapy that significantly lowers pain and impairment in individuals with vertebrogenic pain with distinct Modic type 1 and 2 changes at lumbar vertebra three-sacral vertebra one (L3-S1) vertebral levels. Proper patient selection and exact procedural methods are essential to the success of basivertebral nerve neurotomy. The findings of the existing investigations require confirmation by nonindustry-funded, large-scale, high-quality trials using generalizable study participants.
PubMed: 37034146
DOI: 10.7759/cureus.37114 -
Pain Physician Aug 2022Postoperative pain management in breast surgery and video-assisted thoracic surgeries (VATS) remains challenging. Oral or intravenous infusion of opioids were early... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Postoperative pain management in breast surgery and video-assisted thoracic surgeries (VATS) remains challenging. Oral or intravenous infusion of opioids were early treatments, but they can result in gastrointestinal reactions, respiratory inhibition, and other adverse reactions. In recent years, various regional block techniques have been employed for postoperative analgesia of these surgeries. However, a pair-wise meta-analysis cannot comprehensively rank and evaluate the analgesic effects and adverse events of various regional blocks.
OBJECTIVE
The purpose of this network meta-analysis (NMA) was to compare the analgesic effects and adverse events of different regional block techniques after breast surgery and VATS.
STUDY DESIGN
NMA of randomized controlled trials (RCTs) for comparing multiple regional block techniques in breast surgery and VATS.
METHODS
Pubmed, Embase, and Cochrane databases were searched systematically for RCTs comparing analgesic effects and adverse events after breast surgery and VATS. After critical appraisal, a random-effects NMA was mainly used to compare all the regional blocks' analgesic effects and adverse events. The Population, Interventions, Comparators, Outcomes, and Study design (PICOS) framework was used to build the search strategies and present the results according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. The primary endpoint was opioid consumption within 24 hours after the operation; secondary endpoints included dynamic and static pain scores and the incidence of nausea and vomiting. This study is registered in the Prospective Register of Systematic Reviews (PROSPERO) with a PROSPERO number of CRD42021283907.
RESULTS
A total of 21 clinical trials, including 1,284 patients and 6 different regional block techniques (paravertebral block pectoral nerve block serratus anterior plane block [SAPB], intercostal nerve block [ICNB], erector spinal plane block and thoracic epidural anesthesia), were included and analyzed. There was no significant difference between the consistent and the inconsistent models. Based on limited evidence, SAPB may be the most effective regional block technique for relieving postoperative pain, while ICNB had the lowest probability of nausea and vomiting. There was no significant difference in the pair-wise comparisons. In this study, we found no obvious publication bias.
LIMITATIONS
Limitations include: morphine milligram equivalents were not used to calculate opioid consumption; the scales used in the studies were different; the number of studies and total sample size included was limited; non-English literature and gray literature were not included; more databases were not searched.
CONCLUSIONS
After a comprehensive evaluation of postoperative analgesic effects and adverse events based on the NMA, we hypothesize that SAPB and ICNB have distinct advantages in postoperative analgesia and reduce the incidence of nausea and vomiting, respectively. However, conclusions drawn from more RCTs may be more convincing.
Topics: Analgesics, Opioid; Breast Neoplasms; Female; Humans; Nausea; Network Meta-Analysis; Pain, Postoperative; Vomiting
PubMed: 35901474
DOI: No ID Found -
Medicina (Kaunas, Lithuania) May 2023Abdominal hysterectomy is a major surgery that is often associated with pronounced postsurgical pain. The objective of this research is to conduct a systematic review... (Meta-Analysis)
Meta-Analysis Review
Abdominal hysterectomy is a major surgery that is often associated with pronounced postsurgical pain. The objective of this research is to conduct a systematic review and meta-analysis of all randomized controlled trials (RCTs) and nonrandomized comparative trials (NCTs) that have surveyed the analgesic benefits and morbidity of intraoperative superior hypogastric plexus (SHP) block (intervention) compared with no SHP block (control) during abdominal hysterectomy. The Cochrane Central Register of Controlled Trials (CENTRAL), Google Scholar, Web of Science, PubMed, Scopus, and Embase were searched from inception until 8 May 2022. The Cochrane Collaboration tool and Newcastle-Ottawa Scale were used to evaluate the risk of bias of RCTs and NCTs, respectively. In a random effects mode, the data were pooled as risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI). Five studies (four RCTs and one NCT) comprising 210 patients (SHP block = 107 and control = 103) were analyzed. The overall postsurgical pain score (n = 5 studies, MD = -1.08, 95% CI [-1.41, -0.75], < 0.001), postsurgical opioid consumption (n = 4 studies, MD = -18.90 morphine milligram equivalent, 95% CI, [-22.19, -15.61], < 0.001), and mean time to mobilization (n = 2 studies, MD = -1.33 h, 95% CI [-1.98, -0.68], < 0.001) were significantly decreased in the SHP block group contrasted with the control arm. Nevertheless, there was no significant variance between both arms regarding operation time, intraoperative blood loss, postsurgical NSAID consumption, and hospital stay. There were no major side effects or sympathetic block-related aftermaths in both groups. During abdominal hysterectomy and receiving perioperative multimodal analgesia, the administration of intraoperative SHP block is largely safe and exhibits better analgesic effects compared to cases without administration of SHP block.
Topics: Female; Humans; Hypogastric Plexus; Nerve Block; Analgesics; Pain, Postoperative; Analgesics, Opioid; Hysterectomy; Randomized Controlled Trials as Topic
PubMed: 37241125
DOI: 10.3390/medicina59050893 -
Integrative Cancer Therapies 2023Safe and effective management of cancer-related pain is a worldwide challenge. In the search for treatment options, natural products used in Chinese herbal medicines... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND OBJECTIVES
Safe and effective management of cancer-related pain is a worldwide challenge. In the search for treatment options, natural products used in Chinese herbal medicines (CHMs) have received attention in clinical studies for their effects on cancer-related pain. The objective of this systematic review is to evaluate the clinical evidence for topically applied CHMs as adjunctive treatments for cancer pain management.
METHODS
Nine biomedical databases and 4 clinical trial registries were searched for randomized-controlled trials (RCTs) that reported measures of pain and/or quality of life. Risk of bias was assessed using the Cochrane tool. Meta-analysis employed mean difference (MD) with 95% confidence intervals (random effects).
RESULTS
Twenty (20) RCTs (1636 participants) met the inclusion criteria. Meta-analyses were grouped based on the comparisons and outcome measures. For pain intensity, there was a greater reduction in the topical CHM group versus placebo (MD -0.72 [-1.04, -0.40]), no difference when compared to tramadol (MD -0.15 [-0.38, 0.08]), and a greater reduction when topical CHMs were combined with conventional analgesic medications (MD -0.67 [-0.93, -0.40]). Analgesic onset time was reduced in the CHM group compared to tramadol (MD -26.02 [-27.57, -24.47] minutes), and for CHMs combined with conventional medications (MD -19.17 [-21.83, -16.52] minutes). When CHMs were combined with analgesic medications, improvements were found for duration of analgesia (MD 1.65 [0.78, 2.51] hours), analgesic maintenance dose (MD -31.72 [-50.43, -13.01] milligrams/day), and quality of life.
CONCLUSION
Addition of topical CHMs to conventional analgesic medications was associated with improved outcomes for pain intensity, some other pain-related outcomes, and measures of quality of life. Limitations included methodological issues in some studies and considerable heterogeneity in some pooled results.
Topics: Humans; Cancer Pain; Tramadol; Randomized Controlled Trials as Topic; Medicine, Chinese Traditional; Analgesics; Neoplasms
PubMed: 37962002
DOI: 10.1177/15347354231210870 -
Journal of Gynecology Obstetrics and... Mar 2022To evaluate the efficacy and safety of preoperative duloxetine on postoperative pain management after gynecologic laparoscopic surgeries. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To evaluate the efficacy and safety of preoperative duloxetine on postoperative pain management after gynecologic laparoscopic surgeries.
METHODS
A systematic search was done in Cochrane Library, PubMed, ISI web of science, and Scopus from inception to September 2021. We selected randomized clinical trials (RCTs) that compared preoperative duloxetine (intervention group) versus placebo (control group) among women undergoing gynecologic laparoscopic surgeries. Our primary outcomes were pain scores evaluated by the Visual Analog Scale (VAS) at 2, 6, 12, and 24 h postoperatively. Our secondary outcomes were the time required for the first analgesic request in minutes, postoperative analgesic consumption in milligrams, length of hospital stay in days, and side effects.
RESULTS
Four RCTs with a total number of 244 patients were included in our systematic review and meta-analysis. We found duloxetine was linked to a significant reduction in VAS pain scores at different time intervals. The first analgesic request was significantly earlier in the placebo group than in the duloxetine group (p = 0.03). In addition, duloxetine significantly reduced the postoperative analgesic consumption compared to placebo (MD= -41.97, 95% CI [-53.23, -30.72], p<0.001). However, both groups did not differ in the length of hospital stay and side effects.
CONCLUSIONS
Duloxetine administration prior to gynecological laparoscopic surgeries is safe and effective in improving postoperative pain and analgesia.
Topics: Duloxetine Hydrochloride; Female; Gynecologic Surgical Procedures; Humans; Laparoscopy; Pain, Postoperative; Randomized Controlled Trials as Topic
PubMed: 34974147
DOI: 10.1016/j.jogoh.2021.102305 -
The Clinical Journal of Pain May 2024Ultrasound-guided pericapsular nerve group (PENG) block is an emerging regional anesthesia technique that may provide analgesia for patients undergoing total hip... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Ultrasound-guided pericapsular nerve group (PENG) block is an emerging regional anesthesia technique that may provide analgesia for patients undergoing total hip arthroplasties (THA). There are clinical studies comparing this fascial plane block to other established methods; however, evidence on the actual efficacy of this block for THA continues to evolve.
OBJECTIVE
Available clinical studies conducted over the past 4 years were reviewed to evaluate the analgesic efficacy and effectiveness of PENG block in patients undergoing THAs.
METHODS
A meta-analysis of randomized controlled trials (RCTs) in patients undergoing THA, where PENG block was compared to no block, placebo/sham block (injection with saline), or other analgesic techniques including suprainguinal fascia iliaca block (FIB), or periarticular infiltration (PAI) was performed. Our primary outcome was opioid consumption during the first 24 hours. Secondary outcomes were postoperative rest and dynamic pain scores at 6-12, 24 and 48 hours, block performance time, sensory-motor assessment, quadriceps weakness, the incidence of postoperative falls, first analgesic request, block and opioid-related complications, surgical complications, patient satisfaction scores, postanesthesia care unit length of stay, hospital length of stay, and functional and quality of life outcomes.
RESULTS
We included 12 RCTs with a total of 705 patients. Data showed that PENG block decreased 24-hour oral morphine milligram equivalent consumption by a mean difference (MD) of 3.75 mg (95% CI: -5.96,-1.54; P =0.0009). No statistically significant differences in rest or dynamic pain were found, except for a modest MD reduction in dynamic pain score of 0.55 points (95% CI: -0.98, -0.12; P =0.01), measured 24 hours after surgery in favor of PENG block.
CONCLUSIONS
Our systematic review and meta-analysis suggest that PENG block provides better analgesia, measured as MME use, in the first 24 hours after THA, with no real impact on postoperative VAS scores. Despite statistical significance, the high heterogeneity across RCTs implies that PENG's benefits may not surpass the minimal clinically important difference threshold for us to recommend PENG as best practice in THA.
Topics: Humans; Arthroplasty, Replacement, Hip; Analgesics, Opioid; Pain, Postoperative; Nerve Block; Analgesics
PubMed: 38268183
DOI: 10.1097/AJP.0000000000001196 -
BMC Anesthesiology Dec 2022The objective of this systematic review and network meta-analysis was to compare the effects of single-shot ultrasound-guided regional anesthesia techniques on... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The objective of this systematic review and network meta-analysis was to compare the effects of single-shot ultrasound-guided regional anesthesia techniques on postoperative opioid consumption in patients undergoing open cardiac surgery.
METHODS
This systematic review and network meta-analysis involved cardiac surgical patients (age > 18 y) requiring median sternotomy. We searched PubMed, EMBASE, The Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science. The effects of the single-shot ultrasound-guided regional anesthesia technique were compared with those of placebo and no intervention. We conducted a risk assessment of bias for eligible studies and assessed the overall quality of evidence for each outcome.
RESULTS
The primary outcome was opioid consumption during the first 24 h after surgery. The secondary outcomes were pain after extubation at 12 and 24 h, postoperative nausea and vomiting, extubation time, intensive care unit discharge time, and length of hospital stay. Fifteen studies with 849 patients were included. The regional anesthesia techniques included pecto-intercostal fascial block, transversus thoracis muscle plane block, erector spinae plane (ESP) block, and pectoralis nerve block I. All the regional anesthesia techniques included significantly reduced postoperative opioid consumption at 24 h, expressed as morphine milligram equivalents (MME). The ESP block was the most effective treatment (-22.93 MME [-34.29;-11.56]).
CONCLUSIONS
In this meta-analysis, we concluded that fascial plane blocks were better than placebo when evaluating 24 h MMEs. However, it is still challenging to determine which is better, given the paucity of studies available in the literature. More randomized controlled trials are required to determine which regional anesthesia technique is better.
TRIAL REGISTRATION
PROSPERO; CRD42022315497.
Topics: Humans; Adult; Middle Aged; Analgesics, Opioid; Network Meta-Analysis; Pain, Postoperative; Anesthesia, Conduction; Cardiac Surgical Procedures; Ultrasonography, Interventional
PubMed: 36581838
DOI: 10.1186/s12871-022-01952-7 -
The Journal of Arthroplasty Jan 2022The opioid epidemic is a health crisis in the United States. Within orthopedic surgery, opioid misuse and incautious prescription remains a concern. In the last several...
BACKGROUND
The opioid epidemic is a health crisis in the United States. Within orthopedic surgery, opioid misuse and incautious prescription remains a concern. In the last several years, there has been a growing interest and public effort toward reducing opioid use in total joint arthroplasty (TJA) in response to the opioid epidemic in the United States. We aim to review opioid-limiting practices, policies, and legislations that are implemented at the state level and nationally that are relevant to TJA, as well as evaluate studies that measure the efficacy of these policies in the management of patients undergoing TJA.
METHODS
Two independent reviewers conducted a systematic review of national and state level opioid-limiting policies implemented in the United States and their effects on opioid prescription, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA).
RESULTS
We identified 3 national bills and 9 policies set forth by national organizations that imposed limits on opioid prescription. Opioid-reducing legislation was also identified in 24 states, with the majority specifying a 7-day limit on initial opioid prescription for acute pain management. Six research studies evaluating the impact of opioid-restricting policies on postoperative opioid prescription for TJA patients were found. Three studies assessed legislation at the state level while the others were institution-based guidelines. Overall, these studies demonstrated a significant decrease in mean morphine milligram equivalents of initial opioid prescription after implementing the policies.
CONCLUSION
Recent opioid-restricting legislation is effective in decreasing postoperative opioid prescriptions following TJA.
Topics: Analgesics, Opioid; Arthroplasty; Humans; Opioid-Related Disorders; Pain Management; Pain, Postoperative; Practice Patterns, Physicians'; Retrospective Studies; United States
PubMed: 34456092
DOI: 10.1016/j.arth.2021.07.013