The Polyanalgesic Consensus Conference (PACC)®: Intrathecal Drug Delivery Guidance on Safety and Therapy Optimization When Treating Chronic Noncancer Pain.

INTRODUCTION: The International Neuromodulation Society convened a multispecialty group of physicians and scientists based on expertise with international representation to establish evidence-based guidance on intrathecal drug delivery in treating chronic pain. This Polyanalgesic Consensus Conference (PACC)® project, created more than two decades ago, intends to provide evidence-based guidance for important safety and efficacy issues surrounding intrathecal drug delivery and its impact on the practice of neuromodulation. MATERIALS AND METHODS: Authors were chosen on the basis of their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from 2017 (when PACC® last published guidelines) to the present. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on the strength of evidence or consensus when evidence is scant. RESULTS: The PACC® examined the published literature and established evidence- and consensus-based recommendations to guide best practices. Additional guidance will occur as new evidence is developed in future iterations of this process. CONCLUSIONS: The PACC® recommends best practices regarding intrathecal drug delivery to improve safety and efficacy. The evidence- and consensus-based recommendations should be used as a guide to assist decision-making when clinically appropriate.

Superiority of non-opioid postoperative pain management after thyroid and parathyroid operations: A systematic review and meta-analysis.

BACKGROUND: This meta-analysis aimed to evaluate the body of evidence investigating the post-operative use of non-opioid analgesic drugs and techniques in endocrine neck surgeries. Adequate pain control is crucial for successful recovery after thyroid and parathyroid surgery. Effective postoperative pain control can shorten hospital stay, improve postoperative outcomes, decrease morbidity and improve the overall patient experience. Traditionally, opioids have been the mainstay of postoperative analgesia after thyroid and parathyroid surgeries. However, the use of opioids has been linked to an increased incidence of postoperative complications. METHODS: A comprehensive systematic literature review via Medline, Embase, Web of Science and Cochrane Central Register for Controlled Trials from inception until December 26th, 2020 was conducted, followed by meta-analysis. Abstract and full-text screening, data extraction and quality assessment were independently conducted by 2 investigators. Odds ratios (OR), mean differences (MD) and 95% confidence intervals were calculated using RevMan 5.3. RESULTS: Sixty-five randomized control trials were identified from 486 unique publications. Pooled MD and 95% confidence interval for pain scores were higher for the control group at 24 h postoperatively both at rest (-0.65 [-0.92, -0.37]) and with swallowing (-0.77 [-1.37, -0.16]). These differences were statistically significant. The pooled MD and confidence interval for postoperative analgesic requirements was lower in the intervention group (-1.38 [-1.86, -0.90]). The incidence of PONV had a pooled OR of 0.67 [0.48, 0.94]. CONCLUSION: Non-opioid analgesia was superior to the control group for pain control in patients undergoing thyroid and parathyroid operations with no significant difference in complications.

Quality of meta-analyses of non-opioid, pharmacological, perioperative interventions for chronic postsurgical pain: a systematic review.

BACKGROUND: In an attempt to aggregate observations from clinical trials, several meta-analyses have been published examining the effectiveness of systemic, non-opioid, pharmacological interventions to reduce the incidence of chronic postsurgical pain. OBJECTIVE: To inform the design and reporting of future studies, the purpose of our study was to examine the quality of these meta-analyses. EVIDENCE REVIEW: We conducted an electronic literature search in Embase, MEDLINE, and the Cochrane Database of Systematic Reviews. Published meta-analyses, from the years 2010 to 2020, examining the effect of perioperative, systemic, non-opioid pharmacological treatments on the incidence of chronic postsurgical pain in adult patients were identified. Data extraction focused on methodological details. Meta-analysis quality was assessed using the A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2) critical appraisal tool. FINDINGS: Our search yielded 17 published studies conducting 58 meta-analyses for gabapentinoids (gabapentin and pregabalin), ketamine, lidocaine, non-steroidal anti-inflammatory drugs, and mexiletine. According to AMSTAR 2, 88.2% of studies (or 15/17) were low or critically low in quality. The most common critical element missing was an analysis of publication bias. Trends indicated an improvement in quality over time and association with journal impact factor. CONCLUSIONS: With few individual trials adequately powered to detect treatment effects, meta-analyses play a crucial role in informing the perioperative management of chronic postsurgical pain. In light of this inherent value and despite a number of attempts, high-quality meta-analyses are still needed. PROSPERO REGISTRATION NUMBER: CRD42021230941.

Regional Versus General Anesthesia and the Incidence of Unplanned Health Care Resource Utilization for Postoperative Pain After Wrist Fracture Surgery: Results From a Retrospective Quality Improvement Project.

BACKGROUND AND OBJECTIVES: The establishment at our center of a dedicated regional anesthesia service in 2008-2009 has resulted in a marked increase in single-shot brachial plexus blocks (sBPBs) for ambulatory wrist fracture surgery. Despite the documented benefits of regional over general anesthesia (GA), there has been a perceived increase among sBPB patients in postoperative return rates for pain at our institution. We conducted a retrospective quality improvement project to examine this. METHODS: After exemption from human ethics board review, we sought to identify and contact all wrist fracture surgery patients treated at our center between 2003 and 2012. Our primary outcome was the incidence of unplanned physician visits (office/clinic or emergency department) for pain in the first 48 hours after surgery. Other main outcomes included the incidence of seeking any form of medical attention for pain and self-reporting of severe pain in the first 48 hours. RESULTS: Of 1008 identified patients, 419 could be contacted; 195 qualified for analysis. The incidence of unplanned physician visits in the first 48 hours was 12% (13 of 118) among sBPB patients versus 4% (3 of 77) in GA patients (odds ratio [OR], 3.1; 95% confidence interval [95% CI], 0.8-11.1; P = 0.11). More sBPB versus GA patients sought any form of medical attention for pain (20% vs 5%; OR, 4.7; 95% CI, 1.4-10.9; P = 0.003). Similarly, more sBPB patients reported severe postoperative pain (41% vs 10%; OR, 5.9; 95% CI, 2.6-13.4; P < 0.0001). CONCLUSIONS: Patients who received sBPBs for ambulatory wrist fracture surgery had a higher rate of unplanned health care resource utilization caused by pain after hospital discharge than those undergoing GA. These findings warrant confirmation in a prospective trial and emphasize the need for a defined postdischarge analgesic pathway as well as the potential merits of perineural home catheters.

Pharmacological risk factors for delirium after cardiac surgery: a review.

PURPOSE: The objective of this review is to evaluate the literature on medications associated with delirium after cardiac surgery and potential prophylactic agents for preventing it. SOURCE: Articles were searched in MEDLINE, Cumulative Index to Nursing and Allied Health, and EMBASE with the MeSH headings: delirium, cardiac surgical procedures, and risk factors, and the keywords: delirium, cardiac surgery, risk factors, and drugs. Principle inclusion criteria include having patient samples receiving cardiac procedures on cardiopulmonary bypass, and using DSM-IV-TR criteria or a standardized tool for the diagnosis of delirium. PRINCIPAL FINDINGS: Fifteen studies were reviewed. Two single drugs (intraoperative fentanyl and ketamine), and two classes of drugs (preoperative antipsychotics and postoperative inotropes) were identified in the literature as being independently associated with delirium after cardiac surgery. Another seven classes of drugs (preoperative antihypertensives, anticholinergics, antidepressants, benzodiazepines, opioids, and statins, and postoperative opioids) and three single drugs (intraoperative diazepam, and postoperative dexmedetomidine and rivastigmine) have mixed findings. One drug (risperidone) has been shown to prevent delirium when taken immediately upon awakening from cardiac surgery. None of these findings was replicated in the studies reviewed. CONCLUSION: These studies have shown that drugs taken perioperatively by cardiac surgery patients need to be considered in delirium risk management strategies. While medications with direct neurological actions are clearly important, this review has shown that specific cardiovascular drugs may also require attention. Future studies that are methodologically consistent are required to further validate these findings and improve their utility.

A "swing room" model based on regional anesthesia reduces turnover time and increases case throughput.

PURPOSE: Our centre recently implemented a new ambulatory care model featuring two alternate regional anesthesia "swing" operating rooms (RA-SRs) managed by a single anesthesiologist. We hypothesized that this model would be associated with decreased turnover times and improved recovery profiles when compared with a traditional model with a single operating room using general anesthesia. METHODS: We conducted a retrospective cohort study of 164 patients scheduled for hand and wrist surgery who were treated in the RA-SRs under brachial plexus blockade, and we compared the findings with a matched historical control group of patients who underwent general anesthesia in a single operating room (GA-OR). The primary endpoint was room turnover time. Secondary endpoints included home discharge time, postoperative interventions for nausea and pain, and number of cases possible per eight-hour day. RESULTS: Patients in the RA-SR group had faster turnover times than patients in the GA-OR group (median [interquartile range]: 15 min [8-22] vs 54 min [49-61], respectively) as well as faster home discharge times (28 min [20-46] vs 156 min [118-215], respectively) (P < 0.0001). In the RA-SR group, postoperative antiemetics were used in 3/164 patients (2%) vs 28/164 (17%) in the GA-OR group (P < 0.0001), and opioids were used in 1/164 (0.6%) vs 132/164 (80%), respectively (P < 0.0001). The median number of daily cases possible in the RA-SR group was 56% greater than in the GA-OR group (8.4 [7.5-9.4] vs 5.4 [5.1-5.8], respectively; P < 0.0001). CONCLUSION: Compared with a traditional model using general anesthesia in a single operating room, the implementation of a model using regional anesthesia with two swing operating rooms was associated with reduced room turnover times, improved recovery profiles, and a higher case throughput.

Prenatal ethanol exposure alters sensitivity to the effects of corticotropin-releasing factor (CRF) on behavior in the elevated plus-maze.

Animals prenatally exposed to ethanol (E) exhibit behavioral alterations in a wide variety of stressful or challenging tasks. The hypothalamic peptide corticotropin-releasing factor (CRF) is known to play a crucial role in integrating an organism's behavioral responses to environmental stressors or challenges. Previous research indicates that E animals exhibit increased hypothalamic-pituitary-adrenal (HPA) reactivity, including increased hypothalamic CRF expression under both basal and stress conditions. However, the possible role of CRF in mediating the behavioral changes observed in E animals remains to be determined. The current study investigated the hypothesis that E animals may be differentially sensitive to the effects of CRF on behavior in the elevated plus-maze, a task widely used to assess anxiety-like behavior in rodents. Sprague-Dawley offspring from prenatal E, pair-fed (PF), and ad lib-fed control (C) groups were tested at 60-90 days of age. Thirty minutes prior to a 5 min test on the elevated plus-maze, animals received an icv infusion of vehicle (VEH) or CRF (males: 0.75 microg or 1.5 microg ; females: 1.0 microg or 2.0 microg ). Under VEH conditions, E males showed greater activity (more total arm entries) than PF and C males and both E males and E and PF females showed less anxiety-like behavior (more open arm entries) than their PF and/or C counterparts. As expected, CRF treatment resulted in fewer open arm, closed arm and total arm entries, and total rears in both males and females in all prenatal groups, and increased time in the closed arms in males compared to that in their VEH-treated counterparts. Importantly, the effects of CRF were most pronounced in E animals. That is, when normalized for prenatal group differences following VEH treatment, CRF-treated E males showed fewer total arm entries and total rears than PF and C males, and CRF-treated E and PF females showed fewer open arm entries than C females. These results support and extend previous findings demonstrating that E animals show altered behavior in aversive or stressful situations. While some effects of CRF in females may be mediated partially by nutritional effects of ethanol, the data overall suggest that the behavioral alterations observed in E animals may be due, at least in part, to increased sensitivity to CRF.