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1.
Anaesthesia ; 75(1): 89-95, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31523801

RESUMEN

Quadratus lumborum block has been shown to provide satisfactory analgesia after caesarean section performed under neuraxial anaesthesia. However, its efficacy has not been demonstrated in patients who have received intrathecal morphine. The aim of this study was to assess the efficacy of quadratus lumborum block as part of a multimodal analgesic regimen including intrathecal morphine. This was a prospective, double-blind, placebo-controlled trial. Participants were randomly allocated to receive bilateral quadratus lumborum block (40 ml levobupivacaine 0.25%) or sham block (control) after undergoing elective caesarean section under spinal anaesthesia. The primary outcome was 24-h morphine consumption measured by patient-controlled analgesia. Secondary outcomes included pain scores and quality of recovery. Data from 86 women were analysed. Median (IQR [range]) 24-h morphine consumption was similar in patients receiving quadratus lumborum block and sham block (12 (8-29 [0-68]) mg vs. 14 (5-25 [0-90]) mg, respectively; p = 0.986). There was a reduction in median (IQR [range]) visual analogue scale pain scores at 6 h with quadratus lumborum block compared with sham block both at rest (6 (0-14 [0-98]) mm vs. 14 (3-23 [0-64]) mm (p = 0.019); and on movement: 23 (10-51 [0-99]) mm vs. 44 (27-61 [2-94]) mm; (p = 0.014)). There was no difference in pain scores at any other time-point up to 48 h. When used in conjunction with intrathecal morphine and spinal anaesthesia, bilateral quadratus lumborum block does not reduce 24-h morphine consumption after caesarean section.


Asunto(s)
Anestésicos Locales/administración & dosificación , Cesárea , Levobupivacaína/administración & dosificación , Bloqueo Nervioso/métodos , Dolor Postoperatorio/tratamiento farmacológico , Adulto , Método Doble Ciego , Femenino , Humanos , Embarazo , Estudios Prospectivos , Resultado del Tratamiento
2.
J Urol ; 203(1): 151-158, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31464563

RESUMEN

PURPOSE: Opioids are frequently overprescribed after surgery. The 2018 AUA position statement on opioid use suggests using the lowest dose and potency to achieve pain control but the lack of procedure specific prescribing guidelines contributes to wide variation in prescribing patterns. To address this gap we aimed to develop opioid prescribing recommendations through an expert panel consensus. MATERIALS AND METHODS: The 15-member multidisciplinary expert panel included representatives from 5 stakeholder groups. A 3-step modified Delphi method was used to develop recommendations for postoperative opioid prescribing. Recommendations were made for opioid naïve patients without chronic pain conditions. The panel used oxycodone 5 mg equivalents to define the number of prescribed tablets. RESULTS: Procedure specific recommendations were developed for 16 endourological and minimally invasive urological procedures. The panel agreed that not all patients desire or require opioids and, thus, the minimum recommended number of opioid tablets for all procedures was 0. Consensus ranges were identified to allow prescribed quantities to be aligned with expected needs. The maximum recommended quantity varied by procedure from 0 tablets (3 procedures) to 15 tablets (6 procedures) with a median of 10 tablets. Attending urologists typically voted for higher opioid quantities than nonattending panel members. The panel identified 8 overarching strategies for opioid stewardship, including contextualizing postoperative pain management with patient goals and preferences, and maximizing nonopioid therapies. CONCLUSIONS: Procedure specific guidelines for postoperative opioid prescribing may help align individual urologist prescribing habits with consensus recommendations. These guidelines can aid quality improvement efforts to reduce overprescribing in urology.


Asunto(s)
Analgésicos Opioides/uso terapéutico , Manejo del Dolor/métodos , Dolor Postoperatorio/tratamiento farmacológico , Pautas de la Práctica en Medicina/normas , Procedimientos Quirúrgicos Urológicos , Técnica Delfos , Humanos , Estados Unidos
3.
J Urol ; 203(1): 145-150, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31584849

RESUMEN

PURPOSE: North American studies have revealed that about 3% to 7% of opioid naïve surgical patients transition to chronic opioid use after a single prescription. We examined the risk of chronic opioid use following radical prostatectomy using nationwide Swedish data. MATERIALS AND METHODS: A total of 25,703 men in the National Prostate Cancer Register of Sweden who underwent radical prostatectomy were linked to the Prescribed Drug Register. Opioid use was assessed at 3 times, including baseline (13 months to 1 month preoperatively), perioperatively (1 month before and after) and postoperatively (1 to 12 months). Multivariable logistic regression was done to identify predictors of new late use (1 or more opioid prescriptions in 3 consecutive months more than 2 months after surgery). RESULTS: Overall 16,368 men (64%) filled an opioid prescription during the 13 months before or after surgery. The use of strong opioids increased with time and the use of weak opioids decreased. Of the men 1.9% had opioid prescriptions during the baseline period, followed by a spike to 59% around the time surgery, which sharply decreased in month 2 postoperatively. However, thereafter the proportion of men with opioid prescriptions remained slightly higher at 2.2% compared to the baseline before radical prostatectomy. Of chronic late users 57% were previous users and 43% were new chronic users. Higher cancer risk category, greater comorbidity, unmarried status and low educational level were associated with the risk of new chronic opioid use. CONCLUSIONS: Slightly more than half of male Swedish patients filled an opioid prescription after radical prostatectomy and less than 1% became chronic opioid users. These rates are lower than in previous studies of postoperative opioid use from North America.


Asunto(s)
Analgésicos Opioides/uso terapéutico , Dolor Postoperatorio/tratamiento farmacológico , Prostatectomía , Neoplasias de la Próstata/cirugía , Anciano , Humanos , Masculino , Persona de Mediana Edad , Trastornos Relacionados con Opioides/epidemiología , Sistema de Registros , Suecia/epidemiología
4.
Einstein (Sao Paulo) ; 18: eAO4409, 2020.
Artículo en Inglés, Portugués | MEDLINE | ID: mdl-31618286

RESUMEN

OBJECTIVE: To compare the chest tube drainage by the same thoracotomy intercostal space with the traditional approach in patients undergoing muscle-sparing thoracotomy. METHODS: We evaluated 40 patients aged ≥18 years who underwent elective muscle sparing thoracotomies. Patients were divided into two groups of 20 patients. One group underwent thoracic drainage by the same intercostal space of thoracotomy and the other by traditional chest drainage approach. RESULTS: The mean length of hospital stay for the intercostal drainage group in the intensive care unit was 1.5 day (1.0 to 2.0 days) and 2.0 days (25.1 to 3.0 days) for the traditional chest drainage group (p=0.060). The intercostal drainage group had mean length of hospital stay (p=0.527) and drainage (p=0.547) of 4 days, and the traditional chest drainage group and 2 and 5.5 days, respectively. Dipirona and tramadol doses did not differ between groups (p=0.201 and p=0.341). The mean pain scale values on first postoperative was 4.24 in the drainage by the same intercostal group and 3.95 in the traditional chest drainage (p=0.733). In third postoperative day, mean was 3.18 for the first group and 3.11 for the traditional group (p=0.937). In the 15th day after surgery, drainage by the incision was 1.53 and the traditional chest drainage was 2.11 (p=0.440), 30th days after drainage by incision was 0.71 and traditional chest drainage was 0.84 (p=0.787). Complications, for both groups were similar with 30% in proposed drainage and 25% in traditional approach (p=0.723). CONCLUSION: Drainage by the same thoracotomy intercostal space was feasible and results 30 days after surgery were not inferior to those of the traditional chest drainage approach.


Asunto(s)
Tubos Torácicos , Drenaje/métodos , Toracotomía/métodos , Analgesia Epidural , Analgésicos/uso terapéutico , Fibrilación Atrial/etiología , Dipirona/uso terapéutico , Drenaje/estadística & datos numéricos , Disnea/etiología , Humanos , Tiempo de Internación , Dimensión del Dolor , Dolor Postoperatorio/tratamiento farmacológico , Periodo Posoperatorio , Estudios Prospectivos , Toracotomía/efectos adversos , Tramadol/uso terapéutico
5.
J Opioid Manag ; 15(5): 389-405, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31849030

RESUMEN

OBJECTIVE: Characterize changes in intraoperative opioid and non-opioid administration over time and to evaluate self-reported pain scores in the immediate postoperative period. DESIGN: Single-center retrospective longitudinal study. SETTING: Academic medical center. PATIENTS, PARTICIPANTS: All patients presenting for surgery between 2011 and 2017 in both an inpatient and outpatient setting. MAIN OUTCOME MEASURE(S): Determine total intraoperative opioid administration using intravenous oral morphine equivalents standardized to weight and intraoperative non-opioid use. Furthermore, postoperative self-reported pain scores within 2 hours of completion of surgery are reported. RESULTS: A total of 112,167 individual cases were identified from March 2011 to June 2017. There was a sustained and significant reduction in intraoperative mean and median opioid administration [2011: 0.16 ± 0.15 mg/kg and 0.13 (0-4.92) mg/kg vs 2017: 0.09 ± 0.09 mg/kg and 0.07 (0-4.17) mg/kg]. These effects are seen in emergent vs elective surgery, ambulatory vs inpatient, preoperative opioid use vs no preoperative opioid use, and those with and without intraoperative loco-regional procedures. Although median number of intraoperative non-opioid analgesic agents was unchanged over time, average difference in the number of intraoperative non-opioids increased over time. Finally, pain scores decreased over time [2011: mean (standard deviation) and median (range): 5.1 ± 2.62 and 5.4 (0-10) vs 2017: 3.29 ± 3.27 and 3 (0-10)]. CONCLUSION: This study confirms that intraoperative opioid use has decreased over time with increased utilization of non-opioid analgesic adjuncts and a commensurate decrease in immediate postoperative pain.


Asunto(s)
Analgésicos Opioides , Analgésicos , Dolor Postoperatorio , Analgésicos/administración & dosificación , Analgésicos Opioides/administración & dosificación , Femenino , Humanos , Estudios Longitudinales , Masculino , Dimensión del Dolor , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/prevención & control , Estudios Retrospectivos
6.
J Opioid Manag ; 15(6): 495-498, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31850511

RESUMEN

OBJECTIVE: Evaluate the accuracy of the Pennsylvania Prescription Drug Monitoring Program (PA PDMP) in patients undergoing upper extremity procedures. The authors hypothesized that the PA PDMP would provide an accurate account of the prescriptions that were filled. DESIGN: The authors prospectively collected post-operative pain prescription information of patients undergoing outpatient upper extremity surgery over a 2-week period. Patient-reported prescription-filling of opioid was cross-referenced with the PA PDMP information. SETTING: The study was performed at one private institution. PATIENTS: One hundred and thirty-nine consecutive patients undergoing upper extremity procedures. MAIN OUTCOME MEASURE(S): The PA PDMP information was cross-referenced with the post-operative prescription in the medical record to confirm the patient filled the surgeon's prescription. RESULTS: Of the 111 patients who reported filling their prescription, 107 (96.4 percent) of these were confirmed on the PA PDMP Web site (96.4 percent sensitivity; 95% confidence interval [CI]: 91.0-99.0 percent). None of 28 patients who did not fill their prescription appeared in the database search, resulting in 100 percent specificity (95% CI: 87.7-100 percent). Consequently, the overall accuracy of the PA PDMP was shown to be 97.1 percent (95% CI: 92.8-99.2 percent). CONCLUSIONS: The authors' results suggest that the PA PDMP and its many supplementary databases are accurate as it relates to monitoring opioid prescriptions.


Asunto(s)
Analgésicos Opioides/uso terapéutico , Dolor Postoperatorio/tratamiento farmacológico , Programas de Monitoreo de Medicamentos Recetados , Bases de Datos Factuales , Monitoreo de Drogas , Humanos , Programas de Monitoreo de Medicamentos Recetados/normas
7.
Medicine (Baltimore) ; 98(50): e18356, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31852139

RESUMEN

BACKGROUND: Total knee arthroplasty (TKA) is accompanied by moderate to severe postoperative pain. Multimodal analgesia, such as femoral nerve block, periarticular infiltration analgesia (PIA), and patient-controlled intravenous analgesia, have been used for postoperative analgesia. Recently, randomized controlled trials have compared the efficacy of the adductor canal block (ACB) and the PIA in patients undergoing TKA. However, there is no definite answer as to the efficacy and safety of the ACB compared with the PIA. METHOD: Randomized controlled trials about relevant studies were searched from PubMed (1996 to May 2019), Embase (1980 to May 2019), and Cochrane Library (CENTRAL, May 2019). Five studies which compared the ACB with the PIA methods were included in our meta-analysis. RESULTS: Five studies containing 413 patients met the inclusion criteria. There were no significant differences between the ACB and the PIA group in visual analog scale (VAS) score at rest (P = .14) and movement (P = .18), quadriceps muscle strength (P = .95), complications (P = .78), length of stay (LOS) (P = .54), and time up and go (TUG) test (P = .09), While patients in the ACB group had less equivalent morphine consumption (P < .05) compared with the PIA group. CONCLUSIONS: Our pooled data indicated the ACB group reduced the equivalent morphine consumption compared with the PIA group, with no statistically significant differences in the VAS score, quadriceps muscle strength, TUG test, complications, and LOS.


Asunto(s)
Analgesia/métodos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Bloqueo Nervioso/métodos , Manejo del Dolor/métodos , Dolor Postoperatorio/tratamiento farmacológico , Anestesia de Conducción/métodos , Femenino , Humanos , Articulación de la Rodilla/cirugía , Masculino , Persona de Mediana Edad , Fuerza Muscular/efectos de los fármacos , Dolor Postoperatorio/etiología , Músculo Cuádriceps/efectos de los fármacos , Ensayos Clínicos Controlados Aleatorios como Asunto , Muslo , Resultado del Tratamiento
8.
Orv Hetil ; 160(52): 2054-2060, 2019 Dec.
Artículo en Húngaro | MEDLINE | ID: mdl-31868008

RESUMEN

Introduction: Due to the increasing number of arthroplasties, the number of post-operative hospital days was reduced and the rate of rehabilitation accelerated. For this, proper postoperative analgesia is essential and the multimodal pain relief is an excellent tool. Aim: The aim of our study was to compare postoperative functional results, postoperative pain levels, and opioid analgesic needs of patients who received conventional and novel analgesic treatments. Method: In our prospective study, 81 patients were enrolled who underwent primary hip prosthesis surgery in our institution between February 2017 and January 2018. Of the randomized patients, 38 were in the control group and 43 in the multimodal pain group. We have tested their analgesic needs and the subjective pain levels of patients with the help of the visual analog scale (VAS). Results: Patients receiving multimodal pain relief had significantly lower opioid analgesic requirements and significantly lower VAS values assessed at 6 hours, and 3 and 4 days postoperatively. In addition, the patients in this group stayed in the hospital for a significantly shorter time after surgery. Conclusions: Based on our experience, multimodal pain relief in one-sided primary hip joint arthroplasty significantly reduced the patients' postoperative subjective pain sensation and pain killer consumptions. Orv Hetil. 2019; 160(52): 2054-2060.


Asunto(s)
Analgesia/métodos , Analgésicos Opioides/administración & dosificación , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/prevención & control , Analgésicos Opioides/uso terapéutico , Humanos , Dolor Postoperatorio/etiología , Estudios Prospectivos , Factores de Tiempo , Resultado del Tratamiento
9.
Medicine (Baltimore) ; 98(44): e17708, 2019 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-31689803

RESUMEN

The aim of this study was to assess the effect of preoperative sleep quality on acute postoperative pain in breast cancer patients.The Pittsburgh Sleep Quality Index questionnaire (PSQI) was used to assess the overall sleep status of women scheduled for unilateral modified radical mastectomy in the past month. Based on the responses, patients were allocated to good sleep group or poor sleep group. Postoperatively, acute pain was assessed using the numerical rating score in the first 24 hours; in addition, the requirement of analgesics and the incidence of postoperative complications were recorded.A total of 108 breast surgery patients were enrolled. Based on the PSQI results, 55 (51%) patients were allocated to poor sleep group and 53 (49%) to good sleep group. Pain scores were similar in the 2 groups at the end of surgery (P = .589); however, poor sleep group reported higher postoperative pain scores than the good sleep group at 2 (P = .002), 6 (P < .001), 12 (P < .001), and 24 (P = .002) hours after surgery. The incidence of severe pain in the poor sleep group was higher than that in the good sleep group (27% vs 8%, P = .018), and the ratio of participants who required rescued analgesics was greater in the poor sleep group (52% vs 22%, P = .002). In addition, patients with poor sleep quality had more postoperative complications and longer hospital stay.In this study, breast cancer patients with poor preoperative sleep quality reported more severe postoperative pain, required more analgesics, experienced more complications, and had longer hospital stay.


Asunto(s)
Neoplasias de la Mama/cirugía , Mastectomía/efectos adversos , Dolor Postoperatorio/etiología , Trastornos del Inicio y del Mantenimiento del Sueño/complicaciones , Sueño , Adolescente , Adulto , Anciano , Analgésicos/uso terapéutico , Neoplasias de la Mama/complicaciones , Neoplasias de la Mama/fisiopatología , Femenino , Humanos , Tiempo de Internación , Persona de Mediana Edad , Dimensión del Dolor , Dolor Postoperatorio/tratamiento farmacológico , Periodo Preoperatorio , Estudios Prospectivos , Factores de Riesgo , Trastornos del Inicio y del Mantenimiento del Sueño/fisiopatología , Adulto Joven
10.
J Surg Oncol ; 120(8): 1456-1461, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31680250

RESUMEN

BACKGROUND AND OBJECTIVES: Remifentanil infusion is used as an intraoperative anesthetic for thyroidectomy, but has been associated with acute opioid tolerance and hyperalgesia. A national shortage of remifentanil provided an opportunity to study postoperative pain in patients undergoing thyroidectomy. METHODS: Retrospective review of prospectively collected data from an outpatient surgery center. Primary analysis compared patients treated before and after remifentanil shortage. RESULTS: Median postoperative opioid consumption was 20 morphine milligram equivalents (MMEs) among those treated in the high-dose period and 15 MMEs in the low-dose period. Remifentanil/weight received was a significant predictor of requiring a postoperative narcotic (P = .006). Total non-remifentanil narcotics administered were equivalent but patients in the low dose period received higher amounts of intraoperative long-acting narcotics. CONCLUSIONS: Remifentanil infusion for thyroid surgery is associated with higher postoperative pain and postoperative narcotics requirement. While a hyperalgesia state is possible, shifting of longer-acting narcotics from intraoperative to postoperatively is also supported.


Asunto(s)
Analgésicos Opioides/administración & dosificación , Utilización de Medicamentos/estadística & datos numéricos , Dolor Postoperatorio/tratamiento farmacológico , Remifentanilo/administración & dosificación , Tiroidectomía , Adulto , Procedimientos Quirúrgicos Ambulatorios , Femenino , Humanos , Infusiones Intravenosas , Cuidados Intraoperatorios , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Alta del Paciente , Periodo Posoperatorio , Estudios Retrospectivos
11.
Medicine (Baltimore) ; 98(41): e17503, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31593120

RESUMEN

BACKGROUND: The local injection of multimodal cocktail is currently commonly used in the treatment of postoperative pain after total knee arthroplasty (TKA). It is still inconclusive whether the morphine added to the intraoperative injection mixture could make some difference. This meta-analysis aimed to evaluate the efficacy and safety of additional morphine injection on postoperative analgesia in TKA, and provide some useful information on morphine usage in clinical practice. METHODS: The randomized controlled trials (RCTs) in databases including PubMed, Web of Science, Embase, Cochrane Library, Chinese biomedical literature database (CBM), and Chinese National Knowledge Infrastructure (CNKI) databases were systematically searched. Of 623 records identified, 8 RCTs involving 1093 knees were eligible for data extraction and meta-analysis according to criteria included. RESULTS: Meta-analysis showed that the use of local morphine injection was not associated with significant pain relief within 48 hours postoperatively at rest and on motion (P > .05, all). The use of morphine reduced postoperative total systemic opioids consumption (P < .05). This study found no significant differences in other outcomes including knee flexion range of motion (ROM) (P > .05), extension ROM (P > .05), The Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores (P > .05), Post-operative nausea and vomiting occurrence (P > .05) regardless of the presence of morphine or not in the injections. CONCLUSION: Additional morphine added to multimodal cocktail did not decrease the postoperative pain scores significantly based on our outcomes, but it reduced the systemic postoperative opioids consumption in total knee arthroplasty.


Asunto(s)
Analgesia/métodos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Morfina/uso terapéutico , Dolor Postoperatorio/tratamiento farmacológico , Anciano , Anciano de 80 o más Años , Analgesia/efectos adversos , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/uso terapéutico , Anestesia Local/métodos , Artroplastia de Reemplazo de Rodilla/métodos , Terapia Combinada/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Morfina/administración & dosificación , Dimensión del Dolor/efectos de los fármacos , Dimensión del Dolor/métodos , Náusea y Vómito Posoperatorios/epidemiología , Ensayos Clínicos Controlados Aleatorios como Asunto , Rango del Movimiento Articular/efectos de los fármacos
12.
Medicine (Baltimore) ; 98(42): e17545, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31626118

RESUMEN

BACKGROUND: Controversy still exists regarding the efficiency and safety of ilioinguinal/iliohypogastric nerve (II/IH) block versus transversus abdominis plane (TAP) block for pain management after inguinal hernia repair. The purpose of the current meta-analysis was to perform a relatively credible and comprehensive assessment to compare the efficiency and safety of II/IH versus TAP for pain management after inguinal hernia repair. METHODS: The PUBMED, CENTRAL, and EMBASE were systematically searched. Studies comparing II/IH versus TAP for pain management in adult patients undergoing inguinal herniorrhaphy were included. The results of this study are synthesized and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. RESULTS: Six studies with 632 patients were included in this study. No statistically significant difference was observed between the II/IH and TAP groups in postoperative opioid use, the time to first request for rescue analgesia, the incidence of postoperative nausea and vomiting (PONV), incidence of complication related with nerve blocks and patient satisfaction. The TAP group had a significantly higher pain score at 6 and 8 hours postoperatively (6 hours: mean difference [MD] = 0.94, 95% confidence interval [CI] 0.67-1.22, I = 0%, P < .01; 8 hours: MD = 1.02, 95% CI 0.3-1.74, I = 59%, P < .01). However, no statistically significant difference was observed at 1, 2, 4, 12, 24, 48 hours, and 6 months postoperatively. CONCLUSIONS: In general, this meta-analysis revealed that both approaches have similar postoperative opioid consumption and no significant difference in postoperative complication and patient satisfaction. The II/IH block provides excellent analgesic effects at 6 and 8 hours after inguinal herniorrhaphy in compared with the TAP block. However, more high-quality randomized controlled trials with long-term follow-up are still required to make the conclusion.


Asunto(s)
Hernia Inguinal/cirugía , Herniorrafia/efectos adversos , Bloqueo Nervioso/métodos , Neuralgia/tratamiento farmacológico , Dolor Postoperatorio/tratamiento farmacológico , Músculos Abdominales/inervación , Adulto , Anciano , Analgésicos Opioides/uso terapéutico , Femenino , Herniorrafia/métodos , Humanos , Plexo Hipogástrico , Masculino , Persona de Mediana Edad , Neuralgia/etiología , Manejo del Dolor/métodos , Dolor Postoperatorio/etiología , Ensayos Clínicos Controlados Aleatorios como Asunto , Resultado del Tratamiento
13.
Medicine (Baltimore) ; 98(42): e17621, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31626143

RESUMEN

While the pain after gynecological laparoscopy is assumed to be minor, many women suffer from unexpected postoperative pain in the post-anesthesia care unit (PACU). Prior identification of these patients is significant for effective analgesia. Therefore, we sought to determine the predictors for acute postoperative pain after gynecological laparoscopy. The data of 280 patients undergoing gynecological laparoscopy were analyzed. Data included demographic characteristics, previous obstetric/gynecologic surgical history, menstruation pattern including dysmenorrhea severity, gynecological hormone administration history, and surgical data (surgical time, endometriosis severity, adhesion, drainage insertion, and surgery type). Univariate analysis and binary logistic regression were used to evaluate predictors for substantial pain in the PACU after gynecologic laparoscopy. Among the 280 patients, 115 (41%) suffered from substantial postoperative pain in the PACU. Whenever the level of dysmenorrhea became more severe (none → mild → moderate → severe), the risk of substantial pain in the PACU increased 2.9-fold (odds ratio [OR] 2.92, 95% confidence interval [CI] 2.11-4.03, P < .001). Moreover, patients undergoing laparoscopy for ectopic pregnancy had a higher risk of substantial pain compared with the others (OR 3.11, 95% CI 1.36-7.12, P = .007). Other factors did not show a significant association with substantial pain. Patients with preoperative severe dysmenorrhea and those undergoing laparoscopy for ectopic pregnancy should be considered to have a high risk of substantial postoperative pain in the PACU so that they receive prompt and aggressive analgesic intervention. In particular, dysmenorrhea severity is clinically valuable as a useful predictor for substantial pain after gynecological laparoscopy.


Asunto(s)
Dolor Agudo/diagnóstico , Analgésicos/uso terapéutico , Enfermedades de los Genitales Femeninos/cirugía , Procedimientos Quirúrgicos Ginecológicos/efectos adversos , Laparoscopía/efectos adversos , Dimensión del Dolor/métodos , Dolor Postoperatorio/diagnóstico , Dolor Agudo/tratamiento farmacológico , Dolor Agudo/etiología , Adulto , Femenino , Procedimientos Quirúrgicos Ginecológicos/métodos , Humanos , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/etiología , Estudios Retrospectivos
15.
Medicine (Baltimore) ; 98(39): e17358, 2019 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-31574881

RESUMEN

OBJECTIVES: Previous studies comparing adductor canal block (ACB) with femoral nerve block (FNB) are inconclusive with regard to patient-controlled analgesia (PCA) induced by opioids. Moreover, some postoperative pain severity results differ between previous randomized controlled trials (RCTs). The primary aim of the current study was to compare total intravenous morphine consumption administered via PCA during the first postoperative day in continuous FNB and ACB groups after total knee arthroplasty (TKA). Secondary aims included evaluation of postoperative pain via a visual analog scale, degree of knee extension, quadriceps muscle strength, and ability to sit, stand upright, and walk. METHODS: The study was a RCT. Inclusion criteria were presence of gonarthrosis, age >18 and <75 years, and scheduled for TKA under single-shot spinal anesthesia. RESULTS: A number of morphine uses was lower in the FNB group than in the ACB group (14, range 12-15 vs 20, range 18-22; P = .0001), and they perceived less severe pain at the 8th (P = .00003) and 24th hours. However, ACB was significantly superior with regard to most of the other parameters pertaining to mobility, including muscle strength at the 8th and 24th hours, degree of knee extension at the 8th hour, sitting at the 8th hour, standing upright at the 24th hour, and walking at the 24th and 48th hours. DISCUSSION: FNB was associated with the perception of less severe pain after TKAs. However, ACB was associated with earlier mobility rehabilitation.


Asunto(s)
Artroplastia de Reemplazo de Rodilla/efectos adversos , Nervio Femoral/efectos de los fármacos , Bloqueo Nervioso/métodos , Manejo del Dolor/métodos , Dolor Postoperatorio/tratamiento farmacológico , Anciano , Anciano de 80 o más Años , Método Doble Ciego , Femenino , Humanos , Masculino , Morfina/uso terapéutico , Fuerza Muscular/efectos de los fármacos , Dimensión del Dolor , Dolor Postoperatorio/etiología , Músculo Cuádriceps , Rango del Movimiento Articular/efectos de los fármacos , Recuperación de la Función/efectos de los fármacos , Resultado del Tratamiento
16.
J Opioid Manag ; 15(4): 333-341, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31637685

RESUMEN

BACKGROUND: The use of opioid analgesics in the United States has increased nearly fourfold since 1999 resulting in a similar increase in opioid-related overdose deaths. Although the Centers for Disease Control published guidelines for prescribing chronic opioids, there is a lack of guidance for prescribing postoperative opioids. OBJECTIVE: To offer an evidence-based approach to prescribing opioids for post-operative pain management in the orthopedic setting. METHODS: A narrative review was performed of studies evaluating and quantifying opioid use in orthopedic patients in the postoperative setting, as well as studies analyzing patient satisfaction and perception with regards to opioid use. RESULTS: Studies show that postoperative pain may not be the largest contributing factor to developing an opioid use disorder, but rather patient factors such as tobacco and substance use disorder, mental health disorders, anxiety, mood disorders, pre-existing chronic pain, and recent opioid use may play a role. The review also found that most patients do not utilize significant portions of prescribed opioids and most do not require a refill. This trend leaves patients with thousands of unused pills, which are either retained, shared, or diverted. Although there is no guideline for prescribing opioids postoperatively, data suggest that clinicians can prescribe smaller dosages and fewer quantities of opioids initially. There are also non-opioid strategies that can be employed to reduce opioid consumption. CONCLUSION: There is a need for more high quality research to be conducted to standardize postoperative opioid prescribing patterns and create best practice guidelines to guide clinicians. Orthopedic practices should consider creating institutional guidelines to reduce the amount of opioids prescribed.


Asunto(s)
Analgésicos Opioides , Prescripciones de Medicamentos/estadística & datos numéricos , Trastornos Relacionados con Opioides , Pautas de la Práctica en Medicina , Analgésicos Opioides/efectos adversos , Analgésicos Opioides/uso terapéutico , Humanos , Trastornos Relacionados con Opioides/prevención & control , Procedimientos Ortopédicos , Manejo del Dolor/métodos , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/prevención & control , Pautas de la Práctica en Medicina/estadística & datos numéricos , Estados Unidos
17.
Am Surg ; 85(9): 956-960, 2019 Sep 01.
Artículo en Inglés | MEDLINE | ID: mdl-31638506

RESUMEN

Postoperative pain managed with opioids has contributed to the opioid crisis through overprescribing practices. We assessed opioid-prescribing habits and their use by patients undergoing surgery for cutaneous malignancies. An Institutional Review Board-approved retrospective analysis was conducted for patients who underwent skin cancer resection between January 2018 and June 2018. Data were collected from the electronic medical record, and opioid-related data were collected from patient interviews and state registries. There were 120 study participants (42 females and 78 males) with a median age of 67 years (range, 21-94 years). All received preincision local anesthetic: 64 had liposomal bupivacaine (LB) (53%) and 56 had non-LB bupivacaine (47%). Most participants (n = 88) used 0 opioids (73%), including 43 LB-anesthetic (67%) and 45 non-LB-anesthetic (80%). No significance was seen between those with a diagnosis of chronic pain, narcotic tolerance, an area of resection, and nodal sampling groups in opioid use. Four patients (3%) requested a refill. Of 105 prescriptions written for opioids, 99 had leftover opioids for an overprescribing rate of 94 per cent. This study suggests pain after skin cancer surgery is manageable with very limited opioid requirements. Our results support prescribing no more than five opioid tablets for postoperative pain control in patients undergoing resection for skin malignancies.


Asunto(s)
Procedimientos Quirúrgicos Ambulatorios/efectos adversos , Analgésicos Opioides/uso terapéutico , Prescripción Inadecuada/estadística & datos numéricos , Dolor Postoperatorio/tratamiento farmacológico , Neoplasias Cutáneas/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Anestésicos Locales/administración & dosificación , Bupivacaína/administración & dosificación , Femenino , Humanos , Liposomas , Masculino , Persona de Mediana Edad , Manejo del Dolor/métodos , Estudios Retrospectivos , Sudeste de Estados Unidos , Adulto Joven
18.
Am Surg ; 85(9): 1013-1016, 2019 Sep 01.
Artículo en Inglés | MEDLINE | ID: mdl-31638516

RESUMEN

Transversus abdominis plane (TAP) blocks are a safe and effective way to provide immediate postoperative pain relief in surgical patients, and have been shown to decrease narcotic requirements. Concerns about complications of narcotics, increase in hospital length of stay (LOS), and health-care costs make this of particular interest. We compared standard bupivacaine TAP blocks with those carried out using liposomal bupivacaine to evaluate postoperative outcomes. Fifty patients undergoing elective laparoscopic colectomy received laparoscopic liposomal bupivacaine TAP blocks using 80 cc of local anesthetic, and data were collected prospectively during hospitalization. Data collected included amount of narcotic medication used during hospitalization, number of days to ambulation, number of days to bowel function, and LOS. These patients were compared with the last 50 patients recruited to the control/bupivacaine TAP block arm of the study. The same data parameters were collected and all patients were on an enhanced recovery protocol, which included scheduled acetaminophen, ibuprofen, and gabapentin by mouth, as well as clear liquid diet starting on postoperative day zero. Statistical analysis was performed using Student's t test and Fisher's exact test; P < 0.05 was considered statistically significant. Patients treated with liposomal bupivacaine needed less narcotics (5.06 vs 18.75 mg, P = 0.0002), had earlier bowel function (1.7 vs 2.4 days, P = 0.0002), and shorter LOS (2.7 vs 3.4 days, P = 0.0146). Patients undergoing laparoscopic colon resections seem to require fewer narcotics and have better patient outcomes with liposomal bupivacaine TAP blocks. Based on our data, liposomal bupivacaine seems to be superior to bupivacaine for TAP blocks.


Asunto(s)
Músculos Abdominales/inervación , Anestésicos Locales/administración & dosificación , Bupivacaína/administración & dosificación , Colectomía/efectos adversos , Laparoscopía/efectos adversos , Bloqueo Nervioso/métodos , Dolor Postoperatorio/tratamiento farmacológico , Analgésicos Opioides/uso terapéutico , Femenino , Humanos , Tiempo de Internación , Liposomas , Masculino , Persona de Mediana Edad , Manejo del Dolor/métodos
19.
Am Surg ; 85(10): 1155-1158, 2019 Oct 01.
Artículo en Inglés | MEDLINE | ID: mdl-31657314

RESUMEN

The utility of opioid-sparing multimodal analgesia protocols (OSMMAPs) in opioid-tolerant (OT) patients is unknown. We sought to determine the impact of a standardized OSMMAP in OT versus opioid-naïve (ON) patients after major colorectal surgery. Consecutive patients undergoing surgery before (January 2015-March 2017) and after OSMMAP implementation (April 2017-March 2018) were identified from a single-institution prospective colorectal surgery registry. OT was defined by the presence of an opioid on the preadmission medication record. Opioid use (measured in oral morphine equivalents (OMEs)) and surgical outcomes were compared between OT and ON patients pre- and post-OSMMAP. The study cohort of 201 patients included 59 OT patients (25 pre- and 34 post-OSMMAP) and 142 ON controls (34 pre- and 108 post-OSMMAP). The median age was 47.5 years (IQR 32), and 50% were male. 185 patients (92%) had a laparoscopic/robotic resection and 16 (8%) open. There were statistically significant reductions in OME required post-OSMMAP on each postoperative day (days 1 to 4) and cumulative OME for both OT and ON patients. The reduction in opioid requirements was significantly larger in OT than ON patients. We present the first study highlighting a larger opioid usage reduction in OT than in ON patients after OSMMAP implementation.


Asunto(s)
Analgésicos Opioides/uso terapéutico , Procedimientos Quirúrgicos del Sistema Digestivo , Tolerancia a Medicamentos , Morfina/uso terapéutico , Manejo del Dolor/métodos , Dolor Postoperatorio/tratamiento farmacológico , Adulto , Analgésicos no Narcóticos/administración & dosificación , Analgésicos no Narcóticos/uso terapéutico , Analgésicos Opioides/administración & dosificación , Estudios de Casos y Controles , Protocolos Clínicos , Procedimientos Quirúrgicos del Sistema Digestivo/estadística & datos numéricos , Femenino , Fentanilo/administración & dosificación , Fentanilo/uso terapéutico , Humanos , Laparoscopía/estadística & datos numéricos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Morfina/administración & dosificación , Medicación Preanestésica/efectos adversos , Estudios Retrospectivos , Procedimientos Quirúrgicos Robotizados/estadística & datos numéricos , Resultado del Tratamiento
20.
Am Surg ; 85(10): 1198-1203, 2019 Oct 01.
Artículo en Inglés | MEDLINE | ID: mdl-31657324

RESUMEN

Overdose of opioids is the number one cause of accidental death in the United States, and surgeons are overprescribing these medications. The aim of this study was to assess the feasibility of implementing postoperative opioid prescribing guidelines for general surgery procedures at a public hospital, where patients have lower socioeconomic status, public insurance, and limited access to care. We implemented a quality improvement project, which included in-service training for surgical staff and distribution of standardized guidelines. An infographic for patients was created to facilitate education on postoperative pain management. Pre- and postintervention opioid prescriptions and emergency room visits were compared for patients undergoing common general surgery procedures (inguinal hernia repair, appendectomy, and laparoscopic cholecystectomy). The median number of narcotic pills prescribed significantly decreased from 30 (n = 64) to 15 (n = 63) after the intervention (P < 0.0001). Morphine milligram equivalents decreased from a median [range] of 150 [20,600] to 90 [5,300] (P < 0.0001). The percentage of patients with postoperative pain-related emergency department visits remained low (1.6%). Standardization of postoperative opioid prescription practices was successfully implemented at a public hospital without an increase in the number of emergency room visits for pain.


Asunto(s)
Analgésicos Opioides/uso terapéutico , Manejo del Dolor/normas , Dolor Postoperatorio/tratamiento farmacológico , Mejoramiento de la Calidad , Adulto , Anciano , Anciano de 80 o más Años , Apendicectomía/efectos adversos , Colecistectomía Laparoscópica/efectos adversos , Prescripciones de Medicamentos/normas , Servicio de Urgencia en Hospital/estadística & datos numéricos , Estudios de Factibilidad , Femenino , Necesidades y Demandas de Servicios de Salud/estadística & datos numéricos , Herniorrafia/efectos adversos , Hospitales Públicos , Humanos , Masculino , Persona de Mediana Edad , Educación del Paciente como Asunto , Guías de Práctica Clínica como Asunto , Adulto Joven
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