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British Journal of Anaesthesia Sep 2014In recent years, there has been an increasing interest in local infiltration analgesia (LIA) as a technique to control postoperative pain. We conducted a systematic... (Review)
Review
In recent years, there has been an increasing interest in local infiltration analgesia (LIA) as a technique to control postoperative pain. We conducted a systematic review of randomized clinical trials investigating LIA for total knee arthroplasty (TKA) and total hip arthroplasty (THA) to evaluate the analgesic efficacy of LIA for early postoperative pain treatment. In addition, the analgesic efficacy of wound catheters and implications for length of hospital stay (LOS) were evaluated. Twenty-seven randomized controlled trials in 756 patients operated on with THA and 888 patients operated on with TKA were selected for inclusion in the review. In THA, no additional analgesic effect of LIA compared with placebo was reported in trials with low risk of bias when a multimodal analgesic regimen was administered perioperatively. Compared with intrathecal morphine and epidural analgesia, LIA was reported to have similar or improved analgesic efficacy. In TKA, most trials reported reduced pain and reduced opioid requirements with LIA compared with a control group treated with placebo/no injection. Compared with femoral nerve block, epidural or intrathecal morphine LIA provided similar or improved analgesia in the early postoperative period but most trials had a high risk of bias due to different systemic analgesia between groups. Overall, the use of wound catheters for postoperative administration of local anaesthetic was not supported in the included trials, and LOS was not related to analgesic efficacy. Despite the many studies of LIA, final interpretation is hindered by methodological insufficiencies in most studies, especially because of differences in use of systemic analgesia between groups. However, LIA provides effective analgesia in the initial postoperative period after TKA in most randomized clinical trials even when combined with multimodal systemic analgesia. In contrast, LIA may have limited additional analgesic efficacy in THA when combined with a multimodal analgesic regimen. Postoperative administration of local anaesthetic in wound catheters did not provide additional analgesia when systemic analgesia was similar and LOS was not related to use of LIA with a fast-track set-up.
Topics: Analgesics; Anesthesia, Local; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Humans; Length of Stay; Pain, Postoperative; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 24939863
DOI: 10.1093/bja/aeu155 -
PloS One 2014Neuraxial application of dexmedetomidine (DEX) as adjuvant analgesic has been invetigated in some randomized controlled trials (RCTs) but not been approved because of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Neuraxial application of dexmedetomidine (DEX) as adjuvant analgesic has been invetigated in some randomized controlled trials (RCTs) but not been approved because of the inconsistency of efficacy and safety in these RCTs. We performed this meta-analysis to access the efficacy and safety of neuraxial DEX as local anaesthetic (LA) adjuvant.
METHODS
We searched PubMed, PsycINFO, Scopus, EMBASE, and CENTRAL databases from inception to June 2013 for RCTs that investigated the analgesia efficacy and safety for neuraxial application DEX as LA adjuvant. Effects were summarized using standardized mean differences (SMDs), weighed mean differences (WMDs) or odds ratio (OR) with suitable effect model. The primary outcomes were postoperative pain intensity and analgesic duration, bradycardia and hypotension.
RESULTS
Sixteen RCTs involving 1092 participants were included. Neuraxial DEX significantly decreased postoperative pain intensity (SMD, -1.29; 95% confidence interval (CI), -1.70 to -0.89; P<0.00001), prolonged analgesic duration (WMD, 6.93 hours; 95% CI, 5.23 to 8.62; P<0.00001) and increased the risk of bradycardia (OR, 2.68; 95% CI, 1.18 to 6.10; P = 0.02). No evidence showed that neuraxial DEX increased the risk of other adverse events, such as hypotension (OR, 1.54; 95% CI, 0.83 to 2.85; P = 0.17). Additionally, neuraxial DEX was associated with beneficial alterations in postoperative sedation scores and number of analgesic requirements, sensory and motor block characteristics, and intro-operative hemodynamics.
CONCLUSION
Neuraxial DEX is a favorable LA adjuvant with better and longer analgesia. The greatest concern is bradycardia. Further large sample trials with strict design and focusing on long-term outcomes are needed.
Topics: Analgesia; Analgesics, Non-Narcotic; Anesthesia; Anesthetics, Local; Bradycardia; Chemotherapy, Adjuvant; Dexmedetomidine; Humans; Hypotension; Pain Management; Pain, Postoperative; Randomized Controlled Trials as Topic
PubMed: 24671181
DOI: 10.1371/journal.pone.0093114 -
Annals of Cardiac Anaesthesia 2023Ultrasound-guided erector spinae plane block (ESPB) has been used in many studies for providing opioid-sparing analgesia after various cardiac surgeries. We performed a... (Meta-Analysis)
Meta-Analysis Review
Ultrasound-guided erector spinae plane block (ESPB) has been used in many studies for providing opioid-sparing analgesia after various cardiac surgeries. We performed a systematic review and meta-analysis of randomized controlled trials to assess the efficacy of ESPB in cardiac surgeries. We searched PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar to identify the studies in which ESPB was compared with the control group/sham block in patients undergoing cardiac surgeries. The primary outcomes were postoperative opioid consumption and postoperative pain scores. The secondary outcomes were intraoperative opioid consumption, ventilation time, time to the first mobilization, length of ICU and hospital stay, and adverse events. Out of 607 studies identified, 16 studies (n = 1110 patients) fulfilled inclusion criteria and were used for qualitative and quantitative analysis. Although, 24-hr opioid consumption were comparable in both groups group (MD, -18.74; 95% CI, -46.85 to 9.36, P = 0.16), the 48-hr opioid consumption was significantly less in ESPB group than control ((MD, -11.01; 95% CI, -19.98 to --2.04, P = 0.02). The pain scores at various time intervals and intraoperative opioid consumption were significantly less in ESPB group. Moreover, duration of ventilation, time to the first mobilization, and length of ICU and hospital were also less in ESPB group (P < 0.00001, P < 0.00001, P < 0.00001, and P < 0.0001, respectively). This systematic review and meta-analysis demonstrated that ESPB provides opioid-sparing perioperative analgesia, facilitates early extubation and mobilization, leads to early discharge from ICU and hospital, and has lesser pruritus when compared to control in patients undergoing cardiac surgeries.
Topics: Humans; Analgesics, Opioid; Pain, Postoperative; Airway Extubation; Nerve Block; Analgesia
PubMed: 37470522
DOI: 10.4103/aca.aca_148_22 -
International Journal of Surgery... Jul 2022To compare the analgesic efficacy and feasibility of erector spinae plane block (ESPB) with non-block care or other blocks in patients undergoing liver surgery. (Meta-Analysis)
Meta-Analysis Review
Ultrasound-guided erector spinae plane block for postoperative analgesia in patients after liver surgery: A systematic review and meta-analysis on randomized comparative studies.
OBJECTIVE
To compare the analgesic efficacy and feasibility of erector spinae plane block (ESPB) with non-block care or other blocks in patients undergoing liver surgery.
METHOD
A meta-analysis of randomized controlled trials (RCTs) that compared ESPB to non-block care or local infiltration analgesia (LIA), intrathecal morphine (ITM) and quadratus lumborum block (QLB) for postoperative analgesia in liver surgery patients.
RESULTS
Six RCTs containing 392 patients were included. This meta-analysis found that ESPB did not significantly reduce postoperative 8 h [mean standard (MD) 0.20; 95% (confidence interval) CI: -1.62, 2.01; P = 0.83; I = 99%] and 24 h [MD 0.10; 95% CI: -0.91, 1.11; P = 0.84; I = 97%] resting pain scores in patients undergoing liver surgery compared to control groups. Furthermore, ESPB had no effect on postoperative 24 h cumulative opioid consumption [MD 1.74; 95% CI: 3.43, 6.91; P = 0.51; I = 95%] or sleep quality [OR 1.00; 95% CI: 0.43, 2.35; P 0.99; I = 0%]. In contrast, ESPB reduced postoperative 48 h resting pain score [MD -0.77; 95% CI -1.56, 0.02; P = 0.05; I = 96%], the incidence of postoperative nausea and vomiting (PONV) [OR 0.29; 95% CI 0.18, 0.48; P = 0.001; I = 0%]. Interestingly, in two RCTs, ESPB showed a higher incidence of shoulder pain compared to ITM [OR 2.89; 95%CI 1.03 to 8.09; P = 0.04; I = 0%]. There have been no reports of complications from ESPB or other blocks.
CONCLUSION
Current literature supported that ESPB had no significant difference in analgesic efficacy in liver surgery patients compared to LIA, ITM, and QLB. More evidences, preferably from high quality RCTs are required to confirm these finding.
Topics: Analgesia; Analgesics; Humans; Liver; Morphine; Nerve Block; Pain, Postoperative; Ultrasonography, Interventional
PubMed: 35662584
DOI: 10.1016/j.ijsu.2022.106689 -
Anaesthesia Oct 2008The PROSPECT Working Group, a collaboration of anaesthetists and surgeons, conducts systematic reviews of postoperative pain management for different surgical procedures... (Review)
Review
The PROSPECT Working Group, a collaboration of anaesthetists and surgeons, conducts systematic reviews of postoperative pain management for different surgical procedures (http://www.postoppain.org). Evidence-based consensus recommendations for the effective management of postoperative pain are then developed from these systematic reviews, incorporating clinical practice observations, and transferable evidence from other relevant procedures. We present the results of a systematic review of pain and other outcomes following analgesic, anaesthetic and surgical interventions for total knee arthroplasty (TKA). The evidence from this review supports the use of general anaesthesia combined with a femoral nerve block for surgery and postoperative analgesia, or alternatively spinal anaesthesia with local anaesthetic plus spinal morphine. The primary technique, together with cooling and compression techniques, should be supplemented with paracetamol and conventional non-steroidal anti-inflammatory drugs or COX-2-selective inhibitors, plus intravenous strong opioids (high-intensity pain) or weak opioids (moderate- to low-intensity pain).
Topics: Analgesia; Analgesics; Anesthesia, Conduction; Arthroplasty, Replacement, Knee; Humans; Pain, Postoperative; Physical Therapy Modalities; Postoperative Care; Randomized Controlled Trials as Topic
PubMed: 18627367
DOI: 10.1111/j.1365-2044.2008.05565.x -
Pain Physician Jul 2016Offset analgesia (OA) is an increasingly described phenomenon to measure endogenous pain inhibition, in which a greater decrease in pain intensity is experienced than... (Review)
Review
BACKGROUND
Offset analgesia (OA) is an increasingly described phenomenon to measure endogenous pain inhibition, in which a greater decrease in pain intensity is experienced than would be predicted by the decrease in painful stimulation. The temporal filtering in this OA phenomenon differs from the spatial filtering in the commonly described conditioned pain modulation (CPM). Yet, the knowledge on the efficacy of OA in chronic pain patients is scarce, compared to CPM efficacy.
OBJECTIVE
This systematic review has been conducted to provide an overview of the current knowledge regarding OA, and to compare it to CPM.
STUDY DESIGN
A systematic review of research studies that investigated the application or mechanisms of OA.
SETTING
The present study took place at Ghent University and the University of Antwerp.
METHODS
This systematic review follows the PRISMA guidelines. The electronic databases Pubmed and Web of Science were searched in January 2015. Full text clinical reports addressing OA were included. The checklists for randomized controlled trials, case-control studies, and cohort-studies provided by the Dutch Institute for Healthcare Improvement and the Dutch Cochrane Centre were used to assess methodological quality. The articles received a level of evidence A1, A2, B, C, or D, based on study design and risk of bias. These levels were used to determine the strength of conclusion (level 1 to 4).
RESULTS
Seventeen articles met the inclusion criteria. Sixteen studies used quantitative sensory testing to provoke OA; however, differences in protocols are present. OA can function as a non-opioid mediated assessment tool for endogenous pain inhibition, and activates brain regions such as periaqueductal gray (PAG), dorsolateral prefontral cortex, insula, medulla, pons and cerebellum, indicating strong brain derived pain modulation. The primary somatosensory cortex is, conversely, less activated during OA. OA is decreased in neuropathic patients. Nonetheless, evidence for the influence of individual factors on OA is limited. OA and CPM seem to rely on different mechanisms.
LIMITATIONS
Search strategy was taken wide, wherefore a large variety of research perspectives were included.
CONCLUSIONS
This systematic review displays OA as a temporal filtering mechanisms that is more brain-derived compared to the spatial assessment method CPM. There is strong evidence for reduced OA in neuropathic patients, however, evidence regarding OA in (sub)acute and central sensitization patients, and the influence of personal factors on OA is currently scarce and needs further investigation.
Topics: Analgesia; Central Nervous System Sensitization; Chronic Pain; Humans; Pain Management; Pain Measurement
PubMed: 27454261
DOI: No ID Found -
Deutsches Arzteblatt International Nov 2017Suitable analgesic drugs and techniques are needed for the acute care of the approximately 18 200-18 400 seriously injured patients in Germany each year. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Suitable analgesic drugs and techniques are needed for the acute care of the approximately 18 200-18 400 seriously injured patients in Germany each year.
METHODS
This systematic review and meta-analysis of analgesia in trauma patients was carried out on the basis of randomized, controlled trials and observational studies. A systematic search of the literature over the 10-year period ending in February 2016 was carried out in the PubMed, Google Scholar, and Springer Link Library databases. Some of the considered trials and studies were included in a meta-analysis. Mean differences (MD) of pain reduction or pain outcome as measured on the Numeric Rating Scale were taken as a summarizing measure of treatment efficacy.
RESULTS
Out of 685 studies, 41 studies were considered and 10 studies were included in the meta-analysis. Among the drugs and drug combinations studied, none was clearly superior to another with respect to pain relief. Neither fentanyl versus morphine (MD -0.10 with a 95% confidence interval of [-0.58; 0.39], p = 0.70) nor ketamine versus morphine (MD -1.27 [-3.71; 1.16], p = 0.31), or the combination of ketamine and morphine versus morphine alone (MD -1.23 [-2.29; -0.18], p = 0.02) showed clear superiority regarding analgesia.
CONCLUSION
Ketamine, fentanyl, and morphine are suitable for analgesia in spontaneously breathing trauma patients. Fentanyl and ketamine have a rapid onset of action and a strong analgesic effect. Our quantitative meta-analysis revealed no evidence for the superiority of any of the three substances over the others. Suitable monitoring equipment, and expertise in emergency procedures are prerequisites for safe and effective analgesia by healthcare professionals..
Topics: Analgesia; Analgesics, Opioid; Emergency Medicine; Germany; Humans; Observational Studies as Topic; Pain Management; Pain Measurement
PubMed: 29229039
DOI: 10.3238/arztebl.2017.0785 -
Gynecologic and Obstetric Investigation 2017Low back pain (LBP) is commonly experienced during pregnancy and is often poorly managed. There is much ambiguity in diagnostic work-up, appropriate management and... (Review)
Review
BACKGROUND
Low back pain (LBP) is commonly experienced during pregnancy and is often poorly managed. There is much ambiguity in diagnostic work-up, appropriate management and decision-making regarding the use of neuraxial analgesia and anaesthesia during labour and delivery in these patients. This systematic review summarises the evidence regarding investigations, management strategies and considerations around performing neuraxial blocks for pregnant women with LBP.
METHODS
We searched 3 databases and reviewed literature concerning LBP in pregnancy with regards to diagnostic modalities, management strategies and use of neuraxial techniques for facilitating labour and delivery.
RESULTS
In all, we included 78 studies in this review, with 32 studies concerning diagnostic investigations, 56 studies involving management strategies, and 4 studies regarding the use of neuraxial techniques for labour and delivery.
SUMMARY
MRI is the safest investigative modality for LBP in pregnancy. Antenatal educational programmes, exercise and steroid injections into the epidural space or sacroiliac joints may help with pain management. Worsening neurological deficits, vertebral fractures and tumours may need surgical management. There is limited evidence on challenges of performing neuraxial blocks in the peripartum period for analgesia and anaesthesia, but there is a potential for increased risk of neurological complications in parturients with pre-existing neurological deficits.
Topics: Adult; Analgesia, Obstetrical; Anesthesia, Obstetrical; Delivery, Obstetric; Female; Humans; Labor, Obstetric; Low Back Pain; Magnetic Resonance Imaging; Pain Management; Parturition; Pregnancy; Pregnancy Complications
PubMed: 28514779
DOI: 10.1159/000471764 -
Medicina Oral, Patologia Oral Y Cirugia... Sep 2021To assess the effectiveness of preemptive analgesia in dental implant surgery in randomized controlled trials (RCTs). (Meta-Analysis)
Meta-Analysis
BACKGROUND
To assess the effectiveness of preemptive analgesia in dental implant surgery in randomized controlled trials (RCTs).
MATERIAL AND METHODS
The present study was conducted in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and registered in PROSPERO database CRD42020168757. A search without restrictions regarding language or date of publication was conducted in six databases and gray literature. A random effect meta-analysis compared the efficacy of preemptive analgesia compared to placebo through pooled OR and 95%CI. The interpretation of results followed the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach together with the magnitude of the effect according to GRADE guidelines.
RESULTS
Four studies were included in the review and three were incorporated into the meta-analysis. All studies demonstrated that preemptive analgesia contributed to a significant improvement in the postoperative pain control. However, the overall pooled standard mean difference (SMD) showed that preemptive analgesia had small effects compared to placebo in reducing pain (SMD: -0.45; IC: -0.83; -0.08) with low certainty of the evidence. Our meta-analysis showed that the magnitude of the effect was bigger six to eight hours after the surgery (large effect), compared to the time of one to two hours after the surgery (small effect).
CONCLUSIONS
Preemptive analgesia may have a positive effect in reducing pain compared to not using preemptive medication, but the evidence is very uncertain.
Topics: Analgesia; Dental Implants; Humans; Randomized Controlled Trials as Topic
PubMed: 34415001
DOI: 10.4317/medoral.24639 -
Pain Practice : the Official Journal of... Sep 2022Premature neonates require regular ophthalmological examination, generally indirect ophthalmoscopy, to screen for retinopathy of prematurity (ROP). Conventional... (Review)
Review
BACKGROUND AND AIMS
Premature neonates require regular ophthalmological examination, generally indirect ophthalmoscopy, to screen for retinopathy of prematurity (ROP). Conventional analgesia is provided with topical anesthetic eyedrops and oral sugar solution, but neonates still experience significant pain. Here, the literature base was examined to evaluate the usefulness of other pharmacological analgesics.
MATERIALS AND METHODS
A systematic review was undertaken, adhering to a PROSPERO preregistered protocol in accordance with PRISMA guidelines (identifier CRD42022302459). Electronic databases were searched for primary research articles on pharmacological pain interventions used for ROP screening in neonates. The primary outcome measure was pain scores recorded using validated pain scoring tools, with and without pharmacological interventions in neonates during eye examination. For analysis, studies were separated into two categories: topical anesthesia and alternative pharmacological treatments.
RESULTS
Eleven studies met the inclusion criteria. Topical analgesia, oral paracetamol, and intranasal fentanyl were found to be effective in reducing the pain of eye examination. Oral morphine and inhaled nitrous oxide had no significant effect on premature infant pain profile (PIPP) scores during indirect ophthalmoscopy.
DISCUSSION
In addition to topical anesthesia, premedication with oral paracetamol is recommended during screening examination for ROP. The routine use of fentanyl is not recommended due to the risk of potential side effects. Non-pharmacological measures, such as sweet oral solutions and comfort techniques should also be employed. Further research is required to determine whether the use of nitrous oxide has a role, and to develop a safe and effective analgesic strategy to fully ameliorate the pain of ROP screening.
Topics: Acetaminophen; Analgesia; Fentanyl; Humans; Infant, Newborn; Nitrous Oxide; Pain; Pain Measurement; Retinopathy of Prematurity
PubMed: 35703418
DOI: 10.1111/papr.13138