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Orthopaedic Surgery Oct 2019Total knee arthroplasty (TKA) is one of the most common surgeries performed to relieve joint pain in patients with end-stage osteoarthritis or rheumatic arthritis of the... (Review)
Review
Total knee arthroplasty (TKA) is one of the most common surgeries performed to relieve joint pain in patients with end-stage osteoarthritis or rheumatic arthritis of the knee. However, TKA is followed by moderate to severe postoperative pain that affects postoperative rehabilitation, patient satisfaction, and overall outcomes. Historically, opioids have been widely used for perioperative pain management of TKA. However, opioids are associated with undesirable adverse effects, such as nausea, respiratory depression, and retention of urine, which limit their application in daily clinical practice. The aim of this review was to discuss the current postoperative pain management regimens for TKA. Our review of the literature demonstrated that multimodal analgesia is considered the optimal regimen for perioperative pain management of TKA and improves clinical outcomes and patient satisfaction, through a combination of several types of medications and delivery routes, including preemptive analgesia, neuraxial anesthesia, peripheral nerve blockade, patient-controlled analgesia and local infiltration analgesia, and oral opioid/nonopioid medications. Multimodal analgesia provides superior pain relief, promotes recovery of the knee, and reduces opioid consumption and related adverse effects in patients undergoing TKA.
Topics: Arthroplasty, Replacement, Knee; Humans; Pain Management; Pain, Postoperative
PubMed: 31663286
DOI: 10.1111/os.12535 -
Hong Kong Medical Journal = Xianggang... Oct 2020Pain relief is an important component of modern obstetric care and can be produced by neuraxial, systemic, or inhalational analgesia or various physical techniques. We... (Review)
Review
Pain relief is an important component of modern obstetric care and can be produced by neuraxial, systemic, or inhalational analgesia or various physical techniques. We review the most recent evidence on the efficacy and safety of these techniques. Over the past decade, the availability of safer local anaesthetics, ultra-short acting opioids, combined spinal-epidural needles, patient-controlled analgesic devices, and ultrasound have revolutionised obstetric regional analgesia. Recent meta-analyses have supported epidural analgesia as the most efficacious technique, as it leads to higher maternal satisfaction and good maternal and fetal safety profiles. We examine the controversies and myths concerning the initiation, maintenance, and discontinuation of epidural analgesia. Recent evidence will also be reviewed to address concerns about the effects of epidural analgesia on the rates of instrumental and operative delivery, lower back pain, and breastfeeding. New developments in labour analgesia are also discussed.
Topics: Analgesia, Epidural; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Female; Humans; Labor Pain; Pain Management; Pregnancy
PubMed: 32943586
DOI: 10.12809/hkmj208632 -
BMC Anesthesiology Feb 2022Postpartum depression (PPD) is a common complication of cesarean section. S-ketamine given intravenously during surgery can help prevent PPD. However, whether S-ketamine... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Postpartum depression (PPD) is a common complication of cesarean section. S-ketamine given intravenously during surgery can help prevent PPD. However, whether S-ketamine in patient-controlled intravenous analgesia (PCIA) can reduce the incidence of PPD is unknown. This study assessed the effect of S-ketamine as an adjuvant in PCIA for preventing PPD in women undergoing cesarean delivery.
METHODS
A total of 375 parturients scheduled to undergo cesarean section and then receive PCIA were recruited from a single center and were randomly assigned to control (C) group (sufentanil 2 μg/kg + tropisetron 10 mg) or S-ketamine (S) group (S-ketamine 0.5 mg/kg + sufentanil 2 μg/kg + tropisetron 10 mg). The primary outcome was the incidence of PPD measured by the Edinburgh postnatal depression scale (EPDS) after surgery. The secondary outcomes were EPDS scores, visual analog scale (VAS) scores, Ramsay sedation scale (RSS) scores, and the rate of adverse events, including headache, nausea, dizziness, drowsiness, and vomit.
RESULTS
A total of 275 puerperal women were included in the study. The rate of depression in parturient on postoperative days 3, 14, 28 in the C group and S group were 17.6 and 8.2% (p < 0.05), 24.2 and 9.8% (p < 0.05), and 19.0 and 17.2% (p = 0.76) respectively. EPDS scores in the C group and S group on postoperative days 3,14, and 28 were 7.65 ± 3.14 and 6.00 ± 2.47 (p < 0.05), 7.62 ± 3.14 and 6.38 ± 2.67 (p < 0.05), and 7.35 ± 3.17 and 6.90 ± 2.78 (p = 0.15), respectively. The rate of adverse events in the C group and S group were headache 3.3 and 4.1% (p = 0.755), nausea 5.9 and 8.2% (p = 0.481), dizziness 9.2 and 12.3% (p = 0.434), drowsiness 6.5 and 10.7%(p = 0.274), and vomit 5.9 and 5.7% (p = 0.585).
CONCLUSIONS
S-ketamine (0.01 mg/kg/h) as an adjuvant in PCIA significantly reduces the incidence of PPD within 14 days and relieves pain within 48 h after cesarean delivery, without increasing the rate of adverse reactions.
TRIAL REGISTRATION
Registered in the Chinese Clinical Trial Registry ( ChiCTR2100050263 ) on August 24, 2021.
Topics: Adult; Analgesia, Patient-Controlled; Antidepressive Agents; Cesarean Section; Depression, Postpartum; Female; Humans; Ketamine; Young Adult
PubMed: 35172727
DOI: 10.1186/s12871-022-01588-7 -
JAMA Surgery Jul 2020Morbidity is still high in pancreatic surgery, driven mainly by gastrointestinal complications such as pancreatic fistula. Perioperative thoracic epidural analgesia... (Comparative Study)
Comparative Study Randomized Controlled Trial
IMPORTANCE
Morbidity is still high in pancreatic surgery, driven mainly by gastrointestinal complications such as pancreatic fistula. Perioperative thoracic epidural analgesia (EDA) and patient-controlled intravenous analgesia (PCIA) are frequently used for pain control after pancreatic surgery. Evidence from a post hoc analysis suggests that PCIA is associated with fewer gastrointestinal complications.
OBJECTIVE
To determine whether postoperative PCIA decreases the occurrence of gastrointestinal complications after pancreatic surgery compared with EDA.
DESIGN, SETTING, AND PARTICIPANTS
In this adaptive, pragmatic, international, multicenter, superiority randomized clinical trial conducted from June 30, 2015, to October 1, 2017, 371 patients at 9 European pancreatic surgery centers who were scheduled for elective pancreatoduodenectomy were randomized to receive PCIA (n = 185) or EDA (n = 186); 248 patients (124 in each group) were analyzed. Data were analyzed from February 22 to April 25, 2019, using modified intention to treat and per protocol.
INTERVENTIONS
Patients in the PCIA group received general anesthesia and postoperative PCIA with intravenous opioids with the help of a patient-controlled analgesia device. In the EDA group, patients received general anesthesia and intraoperative and postoperative EDA.
MAIN OUTCOMES AND MEASURES
The primary end point was a composite of pancreatic fistula, bile leakage, delayed gastric emptying, gastrointestinal bleeding, or postoperative ileus within 30 days after surgery. Secondary end points included 30-day mortality, other complications, postoperative pain levels, intraoperative or postoperative use of vasopressor therapy, and fluid substitution.
RESULTS
Among the 248 patients analyzed (147 men; mean [SD] age, 64.9 [10.7] years), the primary composite end point did not differ between the PCIA group (61 [49.2%]) and EDA group (57 [46.0%]) (odds ratio, 1.17; 95% CI, 0.71-1.95 P = .54). Neither individual components of the primary end point nor 30-day mortality, postoperative pain levels, or intraoperative and postoperative substitution of fluids differed significantly between groups. Patients receiving EDA gained more weight by postoperative day 4 than patients receiving PCIA (mean [SD], 4.6 [3.8] vs 3.4 [3.6] kg; P = .03) and received more vasopressors (46 [37.1%] vs 31 [25.0%]; P = .04). Failure of EDA occurred in 23 patients (18.5%).
CONCLUSIONS AND RELEVANCE
This study found that the choice between PCIA and EDA for pain control after pancreatic surgery should not be based on concerns regarding gastrointestinal complications because the 2 procedures are comparable with regard to effectiveness and safety. However, EDA was associated with several shortcomings.
TRIAL REGISTRATION
German Clinical Trials Register: DRKS00007784.
Topics: Aged; Analgesia, Epidural; Analgesia, Patient-Controlled; Female; Gastrointestinal Diseases; Humans; Male; Middle Aged; Pain, Postoperative; Pancreaticoduodenectomy; Postoperative Complications
PubMed: 32459322
DOI: 10.1001/jamasurg.2020.0794 -
Medicine Nov 2022The aim of this randomized double-blind placebo controlled clinical trial was to investigate the effects of different doses of esketamine combined with sufentanil for... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
The aim of this randomized double-blind placebo controlled clinical trial was to investigate the effects of different doses of esketamine combined with sufentanil for postoperative intravenous controlled analgesia after cesarean section and the incidence of postpartum depression.
METHODS
One hundred and sixty patients undergoing elective cesarean section, with a singleton term pregnancy and American Society of Anesthesiologists physical status II were selected. All patients were treated by a combined epidural with spinal anesthesia. They were randomly divided into 4 groups according to patient controlled intravenous analgesia formula. The consumption of sufentanil, times of effective press and remediate analgesia at 48 hours after cesarean section, incidence of postpartum depression (PPD) at 1 week and 6 weeks after the operation were recorded.
RESULTS
Comparison of cumulated dosage of sufentanil, times of effective press and rescue analgesia at 48 hours after operation: Group H was significantly lower than Group M, Group L, and Group C (P < .05), Group M significantly lower than group L and Group C (P < .05), and Group L significantly lower than Group C (P < .05). Comparison of the incidence of PPD at 1 week and 6 weeks later: Group H was significantly lower than Group M, Group L, and Group C (P < .01), Group M significantly lower than Group L and Group C (P < .01) and Group L significantly lower than Group C (P < .01). Compared with Group C, the incidence of nausea and vomiting was significantly reduced in Group H, Group M, and Group L (P < .05).
CONCLUSION
Esketamine combined with sufentanil used for patient controlled intravenous analgesia after elective cesarean section can reduce the consumption of sufentanil, improve postoperative analgesia, decrease the incidence of PPD at 1 week and 6 weeks and postoperative nausea and vomiting.
Topics: Female; Humans; Pregnancy; Analgesia, Patient-Controlled; Cesarean Section; Depression, Postpartum; Postoperative Nausea and Vomiting; Sufentanil; Antidepressive Agents; Pain, Postoperative
PubMed: 36451452
DOI: 10.1097/MD.0000000000032010 -
British Journal of Anaesthesia Sep 2022Laparoscopic hepatectomy is associated with trauma and severe pain. We examined whether bilateral, ultrasound-guided, single-injection erector spinae plane block (ESPB)... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Laparoscopic hepatectomy is associated with trauma and severe pain. We examined whether bilateral, ultrasound-guided, single-injection erector spinae plane block (ESPB) could improve on postoperative analgesia compared with patient-controlled intravenous analgesia in patients undergoing laparoscopic hepatectomy.
METHODS
Fifty adults were randomly allocated to receive patient-controlled intravenous analgesia alone or combined with bilateral single-injection ESPB (ropivacaine 0.5%, 15 ml on each side). Primary outcome was resting pain scores at 3 h postoperatively assessed with visual analogue scale (VAS). Secondary outcomes included VAS scores at rest and during movement at 6, 12, 16, 20, 24, 48, and 72 h postoperatively; use of intraoperative opioids; postoperative rescue analgesia; sleep quality; time of first ambulation; ESPB-related complications; and ropivacaine concentration in plasma.
RESULTS
The ESPB group showed lower resting VAS scores at 3 h postoperatively (mean [standard deviation]), 2.0 (0.5) vs 4.3 (0.7), P<0.001, and significantly lower scores at rest and during movement at 6-24 h postoperatively. The ESPB group showed lower intraoperative opioid use, lower consumption of rescue analgesia within 72 h postoperatively, and better sleep quality. ESPB subjects began to ambulate 10 h earlier than control subjects. None of the ESPB subjects showed ESPB-related complications, and analysis of a subset of subjects showed that ropivacaine concentrations in plasma decreased gradually over time.
CONCLUSIONS
Compared with patient-controlled intravenous analgesia only, preoperative ultrasound-guided erector spinae plane block can improve postoperative analgesia, reduce opioid demand, and accelerate recovery in patients undergoing laparoscopic hepatectomy.
CLINICAL TRIAL REGISTRATION
Chinese Clinical Trial Registry ChiCTR1900020961.
Topics: Adult; Analgesia, Patient-Controlled; Analgesics, Opioid; Hepatectomy; Humans; Laparoscopy; Nerve Block; Pain, Postoperative; Ropivacaine; Ultrasonography, Interventional
PubMed: 35803754
DOI: 10.1016/j.bja.2022.05.013 -
BMJ (Clinical Research Ed.) Dec 2020To investigate the effect of therapeutic suggestions played to patients through earphones during surgery on postoperative pain and opioid use. (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
To investigate the effect of therapeutic suggestions played to patients through earphones during surgery on postoperative pain and opioid use.
DESIGN
Blinded randomised controlled study.
SETTING
Five tertiary care hospitals in Germany.
PARTICIPANTS
385 of 400 patients consecutively recruited from January to December 2018 who were to undergo surgery for 1-3 hours under general anaesthesia. In the per protocol analysis 191 patients were included in the intervention group and 194 patients in the control group.
INTERVENTION
The intervention comprised an audiotape of background music and positive suggestions based on hypnotherapeutic principles, which was played repeatedly for 20 minutes followed by 10 minutes of silence to patients through earphones during general anaesthesia. Patients in the control group were assigned to a blank tape.
MAIN OUTCOME MEASURES
The main outcome was dose of opioid administered by patient controlled analgesia or nurse controlled analgesia within the first postoperative 24 hours, based on regular evaluation of pain intensity on a numerical rating scale (range 0-10, with higher scores representing more severe pain).
RESULTS
Compared with the control group, the intervention group required a significantly (P=0.002) lower opioid dose within 24 hours after surgery, with a median of 4.0 mg (interquartile range 0-8) morphine equivalents versus 5.3 (2-12), and an effect size (Cohen's d) of 0.36 (95% confidence interval 0.16 to 0.56). The number of patients who needed opioids postoperatively was significantly (P=0.001) reduced in the intervention group: 121 of 191 (63%, 95% confidence interval 45% to 70%) patients in the intervention group versus 155 of 194 (80%, 74% to 85%) in the control group. The number needed to treat to avoid postoperative opioids was 6. Pain scores were consistently and significantly lower in the intervention group within 24 hours after surgery, with an average reduction of 25%. No adverse events were reported.
CONCLUSIONS
Therapeutic suggestions played through earphones during general anaesthesia could provide a safe, feasible, inexpensive, and non-drug technique to reduce postoperative pain and opioid use, with the potential for more general use. Based on the finding of intraoperative perception by a considerable number of patients, surgeons and anaesthetists should be careful about background noise and conversations during surgery.
TRIAL REGISTRATION
German Clinical Trial Register DRKS00013800.
Topics: Adolescent; Adult; Aged; Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthesia, General; Female; Germany; Humans; Intraoperative Period; Male; Middle Aged; Music Therapy; Pain Management; Pain Measurement; Pain, Postoperative; Single-Blind Method; Suggestion; Treatment Outcome; Young Adult
PubMed: 33303476
DOI: 10.1136/bmj.m4284 -
Pharmacy (Basel, Switzerland) Jan 2022Patient-controlled analgesia (PCA) is an effective method for controlling acute pain, including postoperative pain in adults and in children from five years of age, pain... (Review)
Review
Patient-controlled analgesia (PCA) is an effective method for controlling acute pain, including postoperative pain in adults and in children from five years of age, pain resulting from labor, trauma, or other medical situations, or chronic and malignant pain. The treatment consists of a mini-computer-controlled infusion pump permitting the administration of on-demand, continuous, or combined doses of analgesic (mainly opioid) variations in response to therapy, which allows pain to be significantly controlled. Intravenous (IV)-PCA minimizes individual pharmacodynamics and pharmacokinetic differences and is widely accepted as a reference method for mild or severe postoperative pain. IV-PCA is the most studied route of PCA; other delivery methods have been extensively reported in the literature. In addition, IV-PCA usually voids the gap between pain sensation and analgesic administration, permitting better recovery and fewer side effects. The most commonly observed complications are nausea and vomiting, pruritus, respiratory depression, sedation, confusion and urinary retention. However, human factors such as pharmacy preparation and device programming can also be involved in the occurrence of these complications, while device failure is much less of an issue.
PubMed: 35202071
DOI: 10.3390/pharmacy10010022 -
Evidence-based Complementary and... 2021This meta-analysis evaluates the efficacy and safety regarding usage of butorphanol in patient-controlled analgesia (PCA). (Review)
Review
OBJECTIVE
This meta-analysis evaluates the efficacy and safety regarding usage of butorphanol in patient-controlled analgesia (PCA).
METHODS
Several databases such as PubMed, Cochrane Library, Embase, CNKI, and VIP were explored with the help of computer search and manual retrieval. Randomized controlled trial (RCT) was selected, and the meta-analysis was conducted using RevMan 5.1. The primary efficacy endpoint was the postoperative visual analog scale score, postoperative Ramsay sedation scale (RSS), and adverse events.
RESULTS
Nine RCTs met the inclusion criteria and were included in this meta-analysis. No significant differences were found between the butorphanol group and nonbutorphanol group at 12 h and 48 h. The postoperative RSS score at 12 h, 24 h, and 48 h was representative of the calming effect of butorphanol. No significant difference was found on the endpoint of the postoperative RSS score at 12 h, 48 h, and 24 h. The RSS score was lower in the butorphanol group in comparison to the nonbutorphanol group. The butorphanol group was also associated with lower rate of nausea, vomiting, itching, and dizziness compared to the nonbutorphanol group.
CONCLUSION
Butorphanol may be used in PCA as a successful postoperative analgesia and is also associated with lower side effects. Further research is needed to verify the efficacy and safety of butorphanol.
PubMed: 34335812
DOI: 10.1155/2021/5530441