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1.
Dis Colon Rectum ; 61(10): 1196-1204, 2018 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-30192328

RESUMEN

BACKGROUND: Multimodal pain management is an integral part of enhanced recovery pathways. The most effective pain management strategies have not been determined. OBJECTIVE: The purpose of this study was to compare liposomal bupivacaine transversus abdominis plane block with epidural analgesia in patients undergoing colorectal surgery. DESIGN: This is a single-institution, open-label randomized (1:1) trial. SETTING: This study compared liposomal bupivacaine transversus abdominis plane block with epidural analgesia in patients undergoing elective open and minimally invasive colorectal surgery in an enhanced recovery pathway. PATIENTS: Two hundred were enrolled. Following randomization, allocation, and follow-up, there were 92 patients with transversus abdominis plane block and 87 patients with epidural analgesia available for analysis. INTERVENTIONS: The interventions comprised liposomal bupivacaine transversus abdominis plane block versus epidural analgesia. MAIN OUTCOME MEASURES: The primary outcomes measured were numeric pain scores and the overall benefit of analgesia scores. RESULTS: There were no significant differences in the Numeric Pain Scale and Overall Benefit of Analgesia Score between groups. Time trend analysis revealed that patients with transversus abdominis plane block had higher numeric pain scores on the day of surgery, but that the relationship was reversed later in the postoperative period. Opioid use was significantly less in the transversus abdominis plane block group (206.84 mg vs 98.29 mg, p < 0.001). There were no significant differences in time to GI recovery, hospital length of stay, and postoperative complications. Cost was considerably more for the epidural analgesia group. LIMITATIONS: This study was conducted at a single institution. CONCLUSIONS: This randomized trial shows that perioperative pain management with liposomal bupivacaine transversus abdominis plane block is as effective as epidural analgesia and is associated with less opioid use and less cost. These data and the more favorable risk profile suggest that liposomal bupivacaine transversus abdominis plane block is a viable multimodal perioperative pain management option for this patient population in an established enhanced recovery pathway. CLINICAL TRIAL REGISTRATION: http://www.clinicaltrials.gov (NCT02591407). See Video Abstract at http://links.lww.com/DCR/A737.


Asunto(s)
Músculos Abdominales/efectos de los fármacos , Analgesia Epidural/métodos , Bupivacaína/farmacología , Colon/cirugía , Cirugía Colorrectal/normas , Bloqueo Nervioso/métodos , Dolor Postoperatorio/tratamiento farmacológico , Músculos Abdominales/inervación , Músculos Abdominales/fisiopatología , Adulto , Analgesia Epidural/economía , Analgesia Epidural/estadística & datos numéricos , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/uso terapéutico , Anestésicos Locales/administración & dosificación , Anestésicos Locales/farmacología , Bupivacaína/administración & dosificación , Procedimientos Quirúrgicos del Sistema Digestivo/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Manejo del Dolor/métodos , Manejo del Dolor/normas , Dimensión del Dolor/métodos , Atención Perioperativa/normas , Periodo Posoperatorio
2.
J Am Pharm Assoc (2003) ; 57(2S): S92-S98, 2017.
Artículo en Inglés | MEDLINE | ID: mdl-28292507

RESUMEN

OBJECTIVES: The benefits of a pharmacist's involvement in medication reconciliation and discharge counseling are well documented in the literature as improving patient outcomes. In contrast, no studies have focused on the initiation of a pharmacist-led opioid exit plan (OEP) for acute postoperative pain management. This paper summarizes a pharmacist-led OEP practice model and the potential role that pharmacists and student pharmacists can have at the point of admission, during postoperative recovery, and on discharge in acute pain management patients. SETTING: The pain management team at St. Joseph Mercy Hospital in Ann Arbor, MI, has developed and implemented a pharmacist-led OEP to better manage acute postoperative pain in neurosurgery and orthopedic and colorectal surgery in an effort to ensure appropriate patient and provider education and understanding of pain management. PRACTICE DESCRIPTION: OEP is a tool with the potential to expand the role of pharmacists in managing acute pain in postoperative patients at the point of admission, during the postoperative inpatient stay, and on discharge. Its benefits include medication reconciliation review and prescription drug-monitoring program search before admission, interdisciplinary rounds with the medical team to provide optimal inpatient postoperative pain management, clinical assessment of outpatient prescriptions with opioid discharge counseling, and medication evaluation of prescribed pain regimen and opioid discontinuation status at the post-discharge follow-up appointment. CONCLUSION: A hospital pain management team operating a pharmacist-led OEP can be key to guiding the appropriate prescribing practice of opioids and assisting with transitions of care on discharge. Further outcomes-based evaluations of the practice model are planned and encouraged to validate and improve the pharmacist-led OEP practice.


Asunto(s)
Dolor Agudo/tratamiento farmacológico , Analgésicos Opioides/administración & dosificación , Dolor Postoperatorio/tratamiento farmacológico , Farmacéuticos/organización & administración , Humanos , Conciliación de Medicamentos/métodos , Admisión del Paciente , Grupo de Atención al Paciente/organización & administración , Alta del Paciente , Educación del Paciente como Asunto/métodos , Transferencia de Pacientes/organización & administración , Servicio de Farmacia en Hospital/organización & administración , Pautas de la Práctica en Medicina/estadística & datos numéricos , Rol Profesional , Estudiantes de Farmacia
3.
J Opioid Manag ; 10(5): 337-44, 2014.
Artículo en Inglés | MEDLINE | ID: mdl-25350475

RESUMEN

OBJECTIVE: To determine whether an educational intervention combined with a voluntary decision support system improves inpatient pain control. DESIGN: Retrospective serial cross-sectional study. SETTING: Community teaching hospital. PATIENTS: Patients admitted to internal medicine teaching service from October to December 2011 and 2012. The study cohorts consisted of a random sample of 75 patients each from both time periods. INTERVENTIONS: Beginning in August 2012, internal medicine residents participated in an interactive training session on the use of opioids for hospitalized patients and concurrently, a user initiated voluntary computerized decision support system (CDSS), in the form of computer order entry (COE) and pocket cards were introduced. The COE options correspond to the standardized opioid dosing regimen on the pocket card. Pain scores and opioid doses and demographic information were obtained from administrative databases. Additional covariates were abstracted via programmed electronic medical record (EMR) review. MAIN OUTCOME MEASURES: Pre- and postintervention, maximum reported pain score in every 8-hour period from first analgesic dose, to 72 hours after the first analgesic dose, were compared by fitting a multivariable linear mixed model. Naloxone use was a surrogate measure for secondary outcome of opioid overdose. RESULTS: The intervention had no effect on maximum pain score (MPS) over time, p = 0.0930. The estimated mean MPS (95% confidence interval) was 4.7 (3.9, 5.5) preintervention and 5.2 (4.4, 6.0) postintervention. CONCLUSIONS: A combination of a resident educational intervention, CDSS, and pocket cards did not improve MPSs over time for patients on an internal medicine teaching service.


Asunto(s)
Analgésicos Opioides/uso terapéutico , Sistemas de Apoyo a Decisiones Clínicas , Manejo del Dolor/métodos , Adulto , Anciano , Estudios Transversales , Femenino , Hospitalización , Humanos , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Estudios Retrospectivos
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