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1.
Med Care ; 60(1): 75-82, 2022 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-34812786

RESUMO

BACKGROUND: In response to concerns about opioid addiction following surgery, many states have implemented laws capping the days supplied for initial postoperative prescriptions. However, few studies have examined changes in the risk of prolonged opioid use associated with the initial amount prescribed. OBJECTIVE: The objective of this study was to estimate the risk of prolonged opioid use associated with the length of initial opioid prescribed and the potential impact of prescribing limits. RESEARCH DESIGN: Using Medicare insurance claims (2007-2017), we identified opioid-naive adults undergoing surgery. Using G-computation methods with logistic regression models, we estimated the risk of prolonged opioid use (≥1 opioid prescription dispensed in 3 consecutive 30-d windows following surgery) associated with the varying initial number of days supplied. We then estimate the potential reduction in cases of prolonged opioid use associated with varying prescribing limits. RESULTS: We identified 1,060,596 opioid-naive surgical patients. Among the 70.0% who received an opioid for postoperative pain, 1.9% had prolonged opioid use. The risk of prolonged use increased from 0.7% (1 d supply) to 4.4% (15+ d). We estimated that a prescribing limit of 4 days would be associated with a risk reduction of 4.84 (3.59, 6.09)/1000 patients and would be associated with 2255 cases of prolonged use potentially avoided. The commonly used day supply limit of 7 would be associated with a smaller reduction in risk [absolute risk difference=2.04 (-0.17, 4.25)/1000]. CONCLUSIONS: The risk of prolonged opioid use following surgery increased monotonically with increasing prescription duration. Common prescribing maximums based on days supplied may impact many patients but are associated with relatively low numbers of reduced cases of prolonged use. Any prescribing limits need to be weighed against the need for adequate pain management.


Assuntos
Analgésicos Opioides/administração & dosagem , Fatores de Tempo , Adulto , Idoso , Analgésicos Opioides/uso terapêutico , Correlação de Dados , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/etiologia , Manejo da Dor/efeitos adversos , Manejo da Dor/métodos , Manejo da Dor/estatística & dados numéricos , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/epidemiologia , Cuidados Pós-Operatórios/normas , Cuidados Pós-Operatórios/estatística & dados numéricos , Padrões de Prática Médica/normas , Padrões de Prática Médica/estatística & dados numéricos , Estados Unidos/epidemiologia
2.
Trials ; 22(1): 858, 2021 Nov 27.
Artigo em Inglês | MEDLINE | ID: mdl-34838101

RESUMO

BACKGROUND: Orthopedic trauma patients face complex pain management needs and are frequently prescribed opioids, leaving them at-risk for prolonged opioid use. To date, post-trauma pain management research has placed little emphasis on individualized risk assessments for misuse and systematically implementing non-pharmacologic pain management strategies. Therefore, a community-academic partnership was formed to design a novel position in the healthcare field (Life Care Specialist (LCS)), who will educate patients on the risks of opioids, tapering usage, safe disposal practices, and harm reduction strategies. In addition, the LCS teaches patients behavior-based strategies for pain management, utilizing well-described techniques for coping and resilience. This study aims to determine the effects of LCS intervention on opioid utilization, pain control, and patient satisfaction in the aftermath of orthopedic trauma. METHODS: In total, 200 orthopedic trauma patients will be randomized to receive an intervention (LCS) or a standard-of-care control at an urban level 1 trauma center. All patients will be assessed with comprehensive social determinants of health and substance use surveys immediately after surgery (baseline). Follow-up assessments will be performed at 2, 6, and 12 weeks postoperatively, and will include pain medication utilization (morphine milligram equivalents), pain scores, and other substance use. In addition, overall patient wellness will be evaluated with objective actigraphy measures and patient-reported outcomes. Finally, a survey of patient understanding of risks of opioid use and misuse will be collected, to assess the influence of LCS opioid education. DISCUSSION: There is limited data on the role of individualized, multimodal, non-pharmacologic, behavioral-based pain management intervention in opioid-related risk-mitigation in high-risk populations, including the orthopedic trauma patients. The findings from this randomized controlled trial will provide scientific and clinical evidence on the efficacy and feasibility of the LCS intervention. Moreover, the final aim will provide early evidence into which patients benefit most from LCS intervention. TRIAL REGISTRATION: ClinicalTrials.gov NCT04154384 . Registered on 11/6/2019 (last updated on 6/10/2021).


Assuntos
Analgésicos Opioides , Transtornos Relacionados ao Uso de Opioides , Analgésicos Opioides/efeitos adversos , Humanos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Manejo da Dor/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Inquéritos e Questionários
3.
Medicine (Baltimore) ; 100(42): e27462, 2021 Oct 22.
Artigo em Inglês | MEDLINE | ID: mdl-34678876

RESUMO

ABSTRACT: As interventional pain management has been growing rapidly worldwide and chronic pain management is provided by a diverse range of practitioners, malpractice litigation has increased. Therefore, we examined the characteristics of medical disputes related to chronic pain management from 2009 to 2019 in South Korea.In this retrospective study, we analyzed the Korean Society of Anesthesiologists database covering case files from July 2009 to June 2019. We compared characteristics of patients, treatment details, mechanisms of injury, specific complications, clinical manifestations of injury, and outcomes between the first half (2009-2014, n = 33) and the second half (2014-2019, n = 65) of the study period using the Korean Society of Anesthesiologists Legislation Committee database.During the 10-year study period, the proportion of cases for chronic pain management in cases referred for surgical anesthesia or chronic pain management increased annually by 2.9% (R2 = 0.489, 95% confidence interval: 0.5%-5.2%, P = .024). While invasive procedure-related cases decreased from 63.6% in the first half to 38.5% in the second half (P = .019), complex regional pain syndrome-associated cases increased from 30.3% (10/33) to 55.4% (36/65) during this period (P = .019). The proportion of cases involving non-anesthesiologists in invasive procedure-related cases increased from 14.3% in the first half to 64.0% in the second half (P = .002). The majority of invasive procedure-related cases (82.6%, 38/46) were determined as 'directly related to the procedure'. Of these, the 3 most common damaging events were bleeding, intrathecal injection of local anesthetics, and infectious complications (each n = 6).During a recent decade, there were several typical changes in the characteristics of medical dispute cases related to chronic pain management, including an increasing trend of cases for chronic pain management relative to surgical anesthesia-related cases, a higher severity of complications in cervical procedures, an increase in complex regional pain syndrome-related cases, and an increase in cases involving non-anesthesiologists.


Assuntos
Dor Crônica/terapia , Dissidências e Disputas , Manejo da Dor/efeitos adversos , Manejo da Dor/métodos , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , República da Coreia/epidemiologia , Estudos Retrospectivos , Índice de Gravidade de Doença
4.
Anesth Analg ; 133(5): 1296-1302, 2021 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-34473654

RESUMO

BACKGROUND: The erector spinae block is an efficacious analgesic option for the management of rib fracture--related pain. Despite there being minimal published data specifically addressing the safety profile of this block, many societies have made statements regarding its safety and its use as an alternative to traditional regional anesthesia techniques in patients at risk of complications. The primary aim of this study was to characterize the safety profile of erector spinae plane block catheters by determining the incidence of early complications. The secondary aim of this study was to characterize the incidence of late adverse events, as well as the erector spinae plane block catheter failure rate. METHODS: We analyzed electronic medical record data of patients who had an erector spinae plane block catheter inserted for the management of rib fractures between November 2017 and September 2020. To assess early adverse events, data collection included hypotension, hypoxemia, local anesthetic systemic toxicity, and pneumothorax thought to be associated with erector spinae plane block catheter insertion. Late complications included catheter site infection and catheter site hematoma. RESULTS: A total of 224 patients received 244 continuous erector spinae catheters during the study period. After insertion of the erector spinae, there were no immediate complications such as hypotension, hypoxia, local anesthetic toxicity, or pneumothorax. Of all blocks inserted, 7.7% were removed due to catheter failure (8.4 per 100 catheters; 95% confidence interval [CI], 5.1-13.9 per 100 catheters). This resulted in a failure rate of 1.9 per 1000 catheter days (95% CI, 1.1-6.7 catheter days). Late complications included 2 erythematous catheter sites and 2 small hematomas not requiring intervention. The incidence of a minor late complication was 16.7 per 1000 catheters (95% CI, 6.1-45.5 per 1000 catheters). CONCLUSIONS: This study supports the statements made by regional anesthesia societies regarding the safety of the erector spinae plane block. Based on the results presented in this population of trauma patients, the erector spinae plane block catheter is a low-risk analgesic technique that may be performed in the presence of abnormal coagulation status or systemic infection.


Assuntos
Anestésicos Locais/administração & dosagem , Cateteres de Demora , Bloqueio Nervoso/instrumentação , Manejo da Dor/instrumentação , Fraturas das Costelas/terapia , Idoso , Anestésicos Locais/efeitos adversos , Infecções Relacionadas a Cateter/etiologia , Cateteres de Demora/efeitos adversos , Remoção de Dispositivo , Registros Eletrônicos de Saúde , Falha de Equipamento , Feminino , Hematoma/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso/efeitos adversos , Manejo da Dor/efeitos adversos , Segurança do Paciente , Estudos Retrospectivos , Fraturas das Costelas/diagnóstico por imagem , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
6.
PLoS One ; 16(7): e0253641, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34214098

RESUMO

BACKGROUND: The purpose of this study was to assess the efficacy of duloxetine as an alternative to opioid treatment for postoperative pain management following total knee arthroplasty (TKA). METHODS: Among 944 patients, 290 (30.7%) of patients received opioid or duloxetine for pain control for 6 weeks when the pain Visual Analogue Scale (VAS) score was greater than 4 out of 10 at the time of discharge. 121 patients in the Opioid group and 118 in the Duloxetine group were followed up for more than one year. Preoperative and postoperative patient reported outcome measures (pain VAS score, Western Ontario and McMaster Universities OA Index (WOMAC) score were compared. The rate of further drug prescription (opioid or duloxetine) after 6 weeks of first prescription, 30-day readmission rate, and side effects were also investigated. RESULTS: There was no significant difference in pain VAS score, WOMAC Pain and Function score, at each time point between before and after surgery (all p>0.05). Fifteen (9.8%) patients in the opioid group and six (4.4%) patients in the duloxetine group were prescribed additional medication after first 6 weeks, showing no significant (p>0.05) difference in proportion. The 30-day readmission rate and the incidence of side effects were also similar (all p>0.05). There was no difference in the incidence of side effects between the two groups (p>0.05). CONCLUSION: Duloxetine and opioid did not show any difference in pain control, function, and side effects for up to one year after TKA. Although large-scale randomized controlled trials are still required to further confirm the side effects of duloxetine, it can be considered as an alternative to opioid for postoperative pain control following TKA.


Assuntos
Analgésicos Opioides/administração & dosagem , Artroplastia do Joelho/efeitos adversos , Cloridrato de Duloxetina/administração & dosagem , Osteoartrite do Joelho/cirurgia , Dor Pós-Operatória/tratamento farmacológico , Idoso , Analgésicos Opioides/efeitos adversos , Cloridrato de Duloxetina/efeitos adversos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Ontário , Manejo da Dor/efeitos adversos , Manejo da Dor/métodos , Medição da Dor/estatística & dados numéricos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Readmissão do Paciente/estatística & dados numéricos , Medidas de Resultados Relatados pelo Paciente , Estudos Retrospectivos , Resultado do Tratamento
7.
Pediatr Blood Cancer ; 68(11): e29272, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34331510

RESUMO

BACKGROUND: Sedation for lumbar punctures (LPs) in pediatric acute lymphoblastic leukemia (ALL) patients has been the standard for decades to reduce pain and anxiety. Recent studies on the potential long-term neurocognitive effects of cumulative propofol exposure have raised concerns about this practice. The recent pandemic introduced additional burdens to patients, with the requirement of a negative COVID-19 test prior to each sedated procedure. PROCEDURE: These factors prompted a quality improvement intervention at our institution where we aimed to reduce postinduction sedated LPs by 50%. Our intervention included patient and family education, followed by a simulation of the procedure for selected patients. Those converted to unsedated LPs were queried for their preference. Comparative cost, clinical time, and LP success rates were collected for sedated and unsedated LPs. RESULTS: Following the intervention, the percentage of LPs performed with sedation dropped from 100% to 48%. All LPs were successful using both techniques. Most patients who experienced the unsedated LP technique, and their guardians, strongly preferred this approach. Unsedated LPs significantly reduced clinical time (169 vs. 83 minutes) for families, decreased expenditures ($5736 reduction per procedure), and improved institutional opportunity cost due to a decrease in last-minute cancelations. CONCLUSION: We have shown that it is feasible to significantly reduce the use of sedation for LPs in patients with ALL, which has the potential to improve health and patient experience at a lower cost.


Assuntos
Hipnóticos e Sedativos/uso terapêutico , Manejo da Dor , Leucemia-Linfoma Linfoblástico de Células Precursoras/diagnóstico , Punção Espinal , Adolescente , Adulto , COVID-19/diagnóstico , Criança , Feminino , Humanos , Hipnóticos e Sedativos/efeitos adversos , Masculino , Manejo da Dor/efeitos adversos , Manejo da Dor/métodos , Propofol/efeitos adversos , Propofol/uso terapêutico , SARS-CoV-2/isolamento & purificação , Punção Espinal/métodos , Adulto Jovem
8.
Anesth Analg ; 133(4): 1019-1027, 2021 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-34314392

RESUMO

BACKGROUND: We recently reported that a 6-day continuous peripheral nerve block reduced established postamputation phantom pain 3 weeks after treatment ended. However, the immediate effects of perineural infusion (secondary outcomes) have yet to be reported. METHODS: Participants from 5 enrolling academic centers with an upper or lower limb amputation and established phantom pain received a single-injection ropivacaine peripheral nerve block(s) and perineural catheter insertion(s). They were subsequently randomized to receive a 6-day ambulatory perineural infusion of either ropivacaine 0.5% or normal saline in a double-masked fashion. Participants were contacted by telephone 1, 7, 14, 21, and 28 days after the infusion started, with pain measured using the Numeric Rating Scale. Treatment effects were assessed using the Wilcoxon rank-sum test at each time point. Adjusting for 4 time points (days 1, 7, 14, and 21), P < .0125 was deemed statistically significant. Significance at 28 days was reported using methods from the original, previously published article. RESULTS: Pretreatment average phantom and residual pain scores were balanced between the groups. The day after infusion initiation (day 1), average phantom, and residual limb pain intensity was lower in patients receiving local anesthetic (n = 71) versus placebo (n = 73): median [quartiles] of 0 [0-2.5] vs 3.3 [0-5.0], median difference (98.75% confidence interval [CI]) of -1.0 (-3.0 to 0) for phantom pain (P = .001) and 0 [0-0] vs 0 [0-4.3], and median difference 0.0 (-2.0 to 0.0) for residual limb pain (P < .001). Pain's interference with physical and emotional functioning as measured with the interference domain of the Brief Pain Inventory improved during the infusion on day 1 for patients receiving local anesthetic versus placebo: 0 [0-10] vs 10 [0-40], median difference (98.75% CI) of 0.0 (-16.0 to 0.0), P = .002. Following infusion discontinuation (day 6), a few differences were found between the active and placebo treatment groups between days 7 and 21. In general, sample medians for average phantom and residual limb pain scores gradually increased after catheter removal for both treatments, but to a greater degree in the control group until day 28, at which time the differences between the groups returned to statistical significance. CONCLUSIONS: This secondary analysis suggests that a continuous peripheral nerve block decreases phantom and residual limb pain during the infusion, although few improvements were again detected until day 28, 3 weeks following catheter removal.


Assuntos
Amputação/efeitos adversos , Anestésicos Locais/administração & dosagem , Bloqueio Nervoso , Manejo da Dor , Dor Pós-Operatória/tratamento farmacológico , Sistema Nervoso Periférico/efeitos dos fármacos , Membro Fantasma/tratamento farmacológico , Ropivacaina/administração & dosagem , Humanos , Bloqueio Nervoso/efeitos adversos , Manejo da Dor/efeitos adversos , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Membro Fantasma/diagnóstico , Membro Fantasma/etiologia , Ropivacaina/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
9.
J Clin Oncol ; 39(26): 2948-2958, 2021 09 10.
Artigo em Inglês | MEDLINE | ID: mdl-34292766

RESUMO

PURPOSE: Heightened regulations have decreased opioid prescribing across the United States, yet little is known about trends in opioid access among patients dying of cancer. METHODS: Among 270,632 Medicare fee-for-service decedents with poor prognosis cancers, we used part D data to examine trends from 2007 to 2017 in opioid prescription fills and opioid potency (morphine milligram equivalents per day [MMED]) near the end-of-life (EOL), defined as the 30 days before death or hospice enrollment. We used administrative claims to evaluate trends in pain-related emergency department (ED) visits near EOL. RESULTS: Between 2007 and 2017, the proportion of decedents with poor prognosis cancers receiving ≥ 1 opioid prescription near EOL declined 15.5% (relative percent difference [RPD]), from 42.0% (95% CI, 41.4 to 42.7) to 35.5% (95% CI, 34.9 to 36.0) and the proportion receiving ≥ 1 long-acting opioid prescription declined 36.5% (RPD), from 18.1% (95% CI, 17.6 to 18.6) to 11.5% (95% CI, 11.1 to 11.9). Among decedents receiving opioids near EOL, the mean daily dose fell 24.5%, from 85.6 MMED (95% CI, 82.9 to 88.3) to 64.6 (95% CI, 62.7 to 66.6) MMED. Overall, the total amount of opioids prescribed per decedent near EOL (averaged across those who did and did not receive an opioid) fell 38.0%, from 1,075 morphine milligram equivalents per decedent (95% CI, 1,042 to 1,109) to 666 morphine milligram equivalents per decedent (95% CI, 646 to 686). Simultaneously, the proportion of patients with pain-related ED visits increased 50.8% (RPD), from 13.2% (95% CI, 12.7 to 13.6) to 19.9% (95% CI, 19.4 to 20.4). Sensitivity analyses demonstrated similar declines in opioid utilization in the 60 and 90 days before death or hospice, and suggested that trends in opioid access were not confounded by secular trends in hospice utilization. CONCLUSION: Opioid use among patients dying of cancer has declined substantially from 2007 to 2017. Rising pain-related ED visits suggests that EOL cancer pain management may be worsening.


Assuntos
Analgésicos Opioides/uso terapêutico , Dor do Câncer/tratamento farmacológico , Acesso aos Serviços de Saúde/tendências , Manejo da Dor/tendências , Padrões de Prática Médica/tendências , Assistência Terminal/tendências , Demandas Administrativas em Assistência à Saúde , Idoso , Idoso de 80 Anos ou mais , Analgésicos Opioides/efeitos adversos , Dor do Câncer/diagnóstico , Dor do Câncer/epidemiologia , Morte , Prescrições de Medicamentos , Uso de Medicamentos/tendências , Serviço Hospitalar de Emergência/tendências , Feminino , Humanos , Seguro de Serviços Farmacêuticos/tendências , Masculino , Medicare , Manejo da Dor/efeitos adversos , Prevalência , Fatores de Tempo , Estados Unidos/epidemiologia
10.
Anesth Analg ; 133(4): 940-948, 2021 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-34283040

RESUMO

BACKGROUND: Patient satisfaction is an important element of high-quality health care. Virtual reality has been studied for its sedative and analgesic effects, as it immerses the patient into an artificial interactive environment. Deriving from this concept, we hypothesized that an immersive experience that engulfs the senses with noninteractive visual and auditory stimuli would have a positive effect on satisfaction and anxiety in patients undergoing spinal anesthesia. METHODS: We enrolled and randomized 90 patients undergoing spinal anesthesia for arthroscopic knee surgery into an immersive experience arm and an intravenous midazolam sedation arm. The immersive experience was provided through a mobile phone-based head-mounted display showing binocular monoscopic video and noise-canceling headphones playing audio. The primary outcome measure was postoperative satisfaction, measured using a visual analog scale and compared using the Mann-Whitney U test; secondary outcomes included anxiety score (measured using the 6-item State-Trait Anxiety Inventory), hemodynamic stability, and additional sedative requirement. RESULTS: The visual analog scale satisfaction score with immersive experience was significantly higher than with midazolam (median [interquartile range {IQR}] of 93 [82-98] and 80 [73-93], respectively, P = .004), with Hodges-Lehmann median difference estimate of 7 (95% confidence interval, 3-14). The change in anxiety scores from the preoperative to postoperative period between the groups was not significantly different (P = .08), with a Hodges-Lehmann median difference estimate of 3.3 (95% confidence interval, 0-6.7). All patients were hemodynamically stable, were without significant adverse events, and did not require additional sedatives. CONCLUSIONS: We have found that an immersive experience is an effective and acceptable intraoperative alternative to pharmacological sedation in patients undergoing arthroscopic knee surgery under spinal anesthesia, with higher satisfaction levels and no detected difference in preoperative to postoperative anxiolytic effect.


Assuntos
Raquianestesia , Ansiedade/prevenção & controle , Artroscopia , Telefone Celular , Articulação do Joelho/cirurgia , Manejo da Dor/instrumentação , Satisfação do Paciente , Óculos Inteligentes , Realidade Virtual , Estimulação Acústica , Administração Intravenosa , Adulto , Raquianestesia/efeitos adversos , Ansiedade/etiologia , Ansiedade/psicologia , Artroscopia/efeitos adversos , Feminino , Humanos , Hipnóticos e Sedativos/administração & dosagem , Índia , Masculino , Midazolam/administração & dosagem , Manejo da Dor/efeitos adversos , Estimulação Luminosa , Estudos Prospectivos , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
11.
Plast Reconstr Surg ; 148(1): 121-130, 2021 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-34181608

RESUMO

BACKGROUND: Currently, opioids are the standard of care for postoperative pain management. Avoiding unnecessary opioid exposure in patients is of current interest because of widespread abuse. METHODS: This is a prospective cohort study in which wide-awake, local anesthesia, no-tourniquet (WALANT) technique was used for 94 hand/upper extremity surgical patients and compared to patient cohorts undergoing similar procedures under monitored anesthesia care. Patients were not prescribed opioids postoperatively but were instead directed to use over-the-counter pain relievers. Pain scores on a visual analogue scale were collected from patients preoperatively, and on postoperative days 1 and 14. WALANT visual analogue scale scores were compared to those of the two patient cohorts who either did or did not receive postoperative opioids after undergoing similar procedures under monitored anesthesia care. Electronic medical records and New York State's prescription monitoring program, Internet System for Tracking Over-Prescribing, were used to assess prescription opioid-seeking. Information on sex, age, comorbidity burden, previous opioid exposure, and insurance coverage was also collected. RESULTS: Decreased pain was reported by WALANT patients 14 days postoperatively compared to preoperatively and 1 day postoperatively, with a total group mean pain score of 0.37. This is lower than mean scores of monitored anesthesia care patients with and without postoperative opioids. Only two WALANT patients (2.1 percent) sought opioid prescriptions from outside providers. There was little evidence suggesting factors including sex, age, comorbidity burden, previous opioid exposure, or insurance status alter these results. CONCLUSION: WALANT may be a beneficial technique hand surgeons may adopt to mitigate use of postoperative opioids and reduce risk of abuse in patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.


Assuntos
Anestesia Local/métodos , Anti-Inflamatórios não Esteroides/administração & dosagem , Mãos/cirurgia , Procedimentos Ortopédicos/efeitos adversos , Manejo da Dor/métodos , Dor Pós-Operatória/terapia , Analgésicos Opioides/efeitos adversos , Anestésicos Locais/administração & dosagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medicamentos sem Prescrição/administração & dosagem , Epidemia de Opioides/prevenção & controle , Procedimentos Ortopédicos/métodos , Manejo da Dor/efeitos adversos , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Estudos Prospectivos , Resultado do Tratamento
12.
Medicine (Baltimore) ; 100(25): e26348, 2021 Jun 25.
Artigo em Inglês | MEDLINE | ID: mdl-34160400

RESUMO

BACKGROUND: With the promotion of the concept of "minimally invasive" surgery, the advantages of laparoscopic surgery are increasingly manifested. However, the postoperative pain of laparoscopic surgery brings difficulties and challenges to patients' rehabilitation. Transcutaneous electrical acupoint stimulation (TEAS) is a non-invasive treatment, which can exert the dual efficacy of acupuncture and electrical stimulation. The efficacy and safety of TEAS for postoperative pain after laparoscopy based on randomized controlled trials (RCTs) need to further evaluate. METHODS: A comprehensive and systematic literature searching will mainly perform on 7 electronic databases (PubMed, the Cochrane Library, Embase, China National Knowledge Infrastructure, Chongqing VIP Information, WanFang Data, and Chinese Biomedical Database) from their inception up to November 30, 2020. We will also search for ongoing or unpublished studies from other websites (eg, PROSPERO, ClinicalTrials.gov, and Chinese Clinical Trial Registry) and do manual retrieval for potential gray literature. Only the relevant RCTs published in English or Chinese were included. Two independent investigators will independently complete literature selection, assessment of risk bias, and data extraction, the disagreements will be discussed with the third party for final decisions. The primary outcome measures: the pain intensity (eg, VAS) and the consumption of postoperative analgesics. The secondary outcome measures: the postoperative quality of life, the duration of hospitalization, and the incidence of adverse reactions and serious events. Assessment of bias risk will follow the Cochrane risk of bias tool. Data processing will be conducted by Stata 15.0 software. RESULTS: We will evaluate the efficacy and safety of TEAS for postoperative pain after laparoscopy based on RCTs. CONCLUSION: This study can provide more comprehensive and strong evidence of whether TEAS is efficacy and safe for postoperative pain in laparoscopic surgery.


Assuntos
Pontos de Acupuntura , Eletroacupuntura/métodos , Laparoscopia/efeitos adversos , Manejo da Dor/métodos , Dor Pós-Operatória/terapia , Eletroacupuntura/efeitos adversos , Humanos , Tempo de Internação/estatística & dados numéricos , Metanálise como Assunto , Manejo da Dor/efeitos adversos , Medição da Dor/estatística & dados numéricos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/psicologia , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Revisões Sistemáticas como Assunto , Resultado do Tratamento
13.
Medicine (Baltimore) ; 100(25): e26400, 2021 Jun 25.
Artigo em Inglês | MEDLINE | ID: mdl-34160424

RESUMO

BACKGROUND: Femur Head Necrosis (FHN) is a common clinical joint orthopedic-related disease, and its incidence is increasing year by year. Symptoms include dull pain and dull pain in the affected hip joint or its surrounding joints. More severely, it can lead to limited joint movement and inability to walk autonomously. Surgical treatment has many sequelae. The high cost makes it unaffordable for patients, and the side effects of drug treatment are unknown. A large number of clinical studies have shown that acupuncture is effective in treating femoral head necrosis. Therefore, this systematic review aims to explore the safety and effectiveness of acupuncture in the treatment of femoral head necrosis. METHODS: We will conduct a comprehensive literature search in Medline, PubMed, Cochrane Database of Systematic Reviews, Embase, Chinese Biomedical Literatures Database (CBM), China National Knowledge Infrastructure (CNKI), Wang FangDatabase (WF), Chinese Scientific Journal Database (VIP) from inception to May 2021 without any language restriction. In addition, we will retrieve the unpublished studies and the references of initially included literature manually. The two reviewers will identify studies, extract data, and assess the quality independently. The outcomes of interest include: total effective rate; the total nasal symptom score; Hip function (Hip Harris joint score, WOMAC hip score, hip joint Lequesne index score, Merle D 'Aubigne and hip joint Postel score); Adverse events. Randomized clinical trials will be collected, methodological quality will be evaluated using the Cochrane risk-of-bias assessment tool, and the level of evidence will be rated using the Grading of Recommendations, Assessment, Development and Evaluation approach. Meta-analysis will be performed using RevMan 5.4.0 software. The heterogeneity test will be conducted between the studies, P < .1 and I2 > 50% are the thresholds for the tests. We will utilize the fixed effects model or the random effects model according to the size of heterogeneity. RESULTS: The meta-analysis program will systematically evaluate the efficacy and safety of acupuncture in the treatment of FHN patients. CONCLUSION: This study will investigate whether acupuncture can be used as one of the non-surgical and non-pharmacological therapies for the prevention or treatment of FHN. TRIAL REGISTRATION NUMBER: INPLASY202150035.


Assuntos
Terapia por Acupuntura/efeitos adversos , Necrose da Cabeça do Fêmur/terapia , Dor Musculoesquelética/terapia , Manejo da Dor/métodos , Estudos de Viabilidade , Necrose da Cabeça do Fêmur/complicações , Necrose da Cabeça do Fêmur/diagnóstico , Humanos , Metanálise como Assunto , Dor Musculoesquelética/diagnóstico , Dor Musculoesquelética/etiologia , Manejo da Dor/efeitos adversos , Medição da Dor/estatística & dados numéricos , Ensaios Clínicos Controlados Aleatórios como Assunto , Índice de Gravidade de Doença , Revisões Sistemáticas como Assunto , Resultado do Tratamento
14.
Medicine (Baltimore) ; 100(18): e25667, 2021 May 07.
Artigo em Inglês | MEDLINE | ID: mdl-33950945

RESUMO

INTRODUCTION: Blunt chest trauma (BCT) accounts for up to 65% of polytrauma patients. In patients with 0 to 2 rib fractures, treatment interventions are typically limited to oral analgesics and breathing exercises. Patients suffering from BCT experience symptoms of severe pain, poor sleep, and inability to perform simple daily life activities for an extended period of time thereafter. In this trial, we aim to investigate the efficacy of acupuncture as a functional and reliable treatment option for blunt chest trauma patients. METHODS: The study is designed as a double-blind randomized control trial. We will include 72 patients divided into 2 groups; the acupuncture group (Acu) and placebo group (Con). The acupuncture group will receive true acupuncture using a uniquely designed press tack needle. The control group will receive placebo acupuncture treatment through the use of a similarly designed press tack needle without the needle element. The acupoints selected for both groups are GB 34, GB 36, LI 4, LU 7, ST 36, and TH 5. Both groups will receive 1 treatment only following the initial visit to the medical facility and upon diagnosis of BCT. Patient outcome measurements include: Numerical Rating Scale, Face Rating Scale, respiratory function flowmeter, Verran Snyder-Halpern sleep scale, and the total amount of allopathic medication used. Follow-up time will be scheduled at 4 days, 2 weeks, and lastly 3 months. EXPECTED OUTCOME: The results of this study can potentially provide a simple and cost-effective analgesic solution to blunt chest trauma patients. This novel study design can serve as supporting evidence for future double-blind studies within the field of acupuncture. OTHER INFORMATION: The study will be conducted in the thoracic surgical department and acupuncture department in China Medical University Hospital, Taichung, Taiwan. The study will be conducted on blunt chest trauma patients and is anticipated to have minimum risk of adverse events. Enrollment of the patients and data collection will start from March 2020. Study completion time is expected in March 2022. PROTOCOL REGISTRATION: (CMUH109-REC1-002), (NCT04318496).


Assuntos
Terapia por Acupuntura/métodos , Traumatismo Múltiplo/terapia , Manejo da Dor/métodos , Dor/diagnóstico , Traumatismos Torácicos/terapia , Ferimentos não Penetrantes/terapia , Terapia por Acupuntura/efeitos adversos , Terapia por Acupuntura/instrumentação , Adulto , Idoso , Idoso de 80 Anos ou mais , Método Duplo-Cego , Feminino , Seguimentos , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Traumatismo Múltiplo/complicações , Traumatismo Múltiplo/diagnóstico , Agulhas , Dor/etiologia , Manejo da Dor/efeitos adversos , Manejo da Dor/instrumentação , Medição da Dor/estatística & dados numéricos , Ensaios Clínicos Controlados Aleatórios como Assunto , Traumatismos Torácicos/complicações , Traumatismos Torácicos/diagnóstico , Resultado do Tratamento , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/diagnóstico , Adulto Jovem
15.
Anesth Analg ; 133(4): 991-999, 2021 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-34029273

RESUMO

BACKGROUND: Safe postoperative pain relief with opioids is an unmet critical medical need in children. There is a lack of objective, noninvasive bedside tool to assess central nervous system (CNS) effects of intraoperative opioids. Proactive identification of children at risk for postoperative respiratory depression (RD) will help tailor analgesic therapy and significantly improve the safety of opioids in children. Quantitative pupillometry (QP) is a noninvasive, objective, and real-time tool for monitoring CNS effect-time relationship of opioids. This exploratory study aimed to determine the association of QP measures with postoperative RD, as well as to identify the best intraoperative QP measures predictive of postoperative RD in children. METHODS: After approval from the institutional review board and informed parental consent, in this prospective, observational study of 220 children undergoing tonsillectomy, QP measures were collected at 5 time points: awake preoperative baseline before anesthesia induction (at the time of enrollment [T1]), immediately after anesthesia induction before morphine administration (T2), 3 minutes after intraoperative morphine administration (T3), at the end of surgery (T4), and postoperatively when awake in postanesthesia recovery unit (PACU) (T5). Intraoperative use of opioid and incidence of postoperative RD were collected. Analyses were aimed at exploring correlations of QP measures with the incidence of RD and, if found significant, to develop a predictive model for postoperative RD. RESULTS: Perioperative QP measures of percentage pupil constriction (CONQ, P = .027), minimum pupillary diameter (MIN, P = .027), and maximum pupillary diameter (MAX, P = .034) differed significantly among children with and without postoperative RD. A predictive model including the minimum pupillary diameter 3 minutes after morphine administration (MIN3), minimum pupillary diameter normalized to baseline (MIN31), and percentage pupillary constriction after surgery (T4) standardized to baseline (T1) (CONQ41), along with the weight-based morphine dose performed the best to predict postoperative RD in children (area under the curve [AUC], 0.76). CONCLUSIONS: A model based on pre- and intraoperative pupillometry measures including CONQ, MIN, along with weight-based morphine dose-predicted postoperative RD in our cohort of children undergoing tonsillectomy. More studies with a larger sample size are required to validate this finding.


Assuntos
Analgésicos Opioides/efeitos adversos , Morfina/efeitos adversos , Manejo da Dor/efeitos adversos , Dor Pós-Operatória/tratamento farmacológico , Testes Imediatos , Reflexo Pupilar/efeitos dos fármacos , Insuficiência Respiratória/diagnóstico , Tonsilectomia/efeitos adversos , Adolescente , Fatores Etários , Analgésicos Opioides/administração & dosagem , Criança , Feminino , Humanos , Cuidados Intraoperatórios , Masculino , Morfina/administração & dosagem , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Valor Preditivo dos Testes , Estudos Prospectivos , Insuficiência Respiratória/induzido quimicamente , Insuficiência Respiratória/fisiopatologia , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
16.
Medicine (Baltimore) ; 100(20): e25740, 2021 May 21.
Artigo em Inglês | MEDLINE | ID: mdl-34011032

RESUMO

INTRODUCTION: The efficacy of gabapentin for pain management of arthroscopy remains controversial. We conduct a systematic review and meta-analysis to explore the influence of gabapentin versus placebo on the postoperative pain intensity of arthroscopy. METHODS: We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through April 2020 for randomized controlled trials assessing the effect of gabapentin versus placebo on pain control of arthroscopy. This meta-analysis is performed using the random-effect model. RESULTS: Five randomized controlled trials are included in the meta-analysis. Overall, compared with control group for arthroscopy, gabapentin remarkably decreases pain scores at 24 hour (standard mean difference [SMD]=-0.68; 95% confidence interval [CI]=-1.15 to -0.02; P = .21), analgesic consumption (SMD = -18.24; 95% CI=-24.61 to -11.88; P < .00001), nausea and vomiting (OR = 0.42; 95% CI = 0.21 to 0.84; P = .01), but has no obvious influence on pain scores at 6 h (SMD = -1.30; 95% CI = -2.92 to 0.31; P = .11) or dizziness (OR = 1.12; 95% CI = 0.56 to 2.24; P = .75). CONCLUSIONS: Gabapentin is effective for pain control after arthroscopy.


Assuntos
Artroscopia/efeitos adversos , Gabapentina/administração & dosagem , Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Náusea e Vômito Pós-Operatórios/epidemiologia , Gabapentina/efeitos adversos , Humanos , Manejo da Dor/efeitos adversos , Medição da Dor/estatística & dados numéricos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Placebos/administração & dosagem , Náusea e Vômito Pós-Operatórios/etiologia , Náusea e Vômito Pós-Operatórios/prevenção & controle , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
17.
Elife ; 102021 04 13.
Artigo em Inglês | MEDLINE | ID: mdl-33847561

RESUMO

Despite the high burden of pain experienced by hospitalised neonates, there are few analgesics with proven efficacy. Testing analgesics in neonates is experimentally and ethically challenging and minimising the number of neonates required to demonstrate efficacy is essential. EEG (electroencephalography)-derived measures of noxious-evoked brain activity can be used to assess analgesic efficacy; however, as variability exists in neonate's responses to painful procedures, large sample sizes are often required. Here, we present an experimental paradigm to account for individual differences in noxious-evoked baseline sensitivity which can be used to improve the design of analgesic trials in neonates. The paradigm is developed and tested across four observational studies using clinical, experimental, and simulated data (92 neonates). We provide evidence of the efficacy of gentle brushing and paracetamol, substantiating the need for randomised controlled trials of these interventions. This work provides an important step towards safe, cost-effective clinical trials of analgesics in neonates.


Assuntos
Encéfalo/efeitos dos fármacos , Eletroencefalografia , Comportamento do Lactente/efeitos dos fármacos , Manejo da Dor , Medição da Dor , Percepção da Dor/efeitos dos fármacos , Limiar da Dor/efeitos dos fármacos , Dor/prevenção & controle , Acetaminofen/uso terapêutico , Fatores Etários , Analgésicos não Narcóticos/uso terapêutico , Coleta de Amostras Sanguíneas/efeitos adversos , Encéfalo/fisiopatologia , Ensaios Clínicos como Assunto , Simulação por Computador , Determinação de Ponto Final , Feminino , Humanos , Recém-Nascido , Masculino , Dor/diagnóstico , Dor/etiologia , Dor/fisiopatologia , Manejo da Dor/efeitos adversos , Valor Preditivo dos Testes , Estudos Prospectivos , Projetos de Pesquisa , Estudos Retrospectivos , Toque Terapêutico , Resultado do Tratamento , Vacinação/efeitos adversos
18.
Int J Mol Sci ; 22(8)2021 Apr 09.
Artigo em Inglês | MEDLINE | ID: mdl-33918736

RESUMO

Fibromyalgia is a syndrome characterized by chronic and widespread musculoskeletal pain, often accompanied by other symptoms, such as fatigue, intestinal disorders and alterations in sleep and mood. It is estimated that two to eight percent of the world population is affected by fibromyalgia. From a medical point of view, this pathology still presents inexplicable aspects. It is known that fibromyalgia is caused by a central sensitization phenomenon characterized by the dysfunction of neuro-circuits, which involves the perception, transmission and processing of afferent nociceptive stimuli, with the prevalent manifestation of pain at the level of the locomotor system. In recent years, the pathogenesis of fibromyalgia has also been linked to other factors, such as inflammatory, immune, endocrine, genetic and psychosocial factors. A rheumatologist typically makes a diagnosis of fibromyalgia when the patient describes a history of pain spreading in all quadrants of the body for at least three months and when pain is caused by digital pressure in at least 11 out of 18 allogenic points, called tender points. Fibromyalgia does not involve organic damage, and several diagnostic approaches have been developed in recent years, including the analysis of genetic, epigenetic and serological biomarkers. Symptoms often begin after physical or emotional trauma, but in many cases, there appears to be no obvious trigger. Women are more prone to developing the disease than men. Unfortunately, the conventional medical therapies that target this pathology produce limited benefits. They remain largely pharmacological in nature and tend to treat the symptomatic aspects of various disorders reported by the patient. The statistics, however, highlight the fact that 90% of people with fibromyalgia also turn to complementary medicine to manage their symptoms.


Assuntos
Fibromialgia/diagnóstico , Fibromialgia/etiologia , Fibromialgia/terapia , Animais , Antioxidantes/metabolismo , Biomarcadores , Dietoterapia , Gerenciamento Clínico , Suscetibilidade a Doenças , Epigênese Genética , Regulação da Expressão Gênica , Predisposição Genética para Doença , Humanos , Manejo da Dor/efeitos adversos , Manejo da Dor/métodos , Prognóstico , Testes Sorológicos
19.
J Surg Res ; 264: 510-533, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33862580

RESUMO

Background The opioid crisis has prompted surgeons to search for alternative postoperative methods of analgesia. Liposomal bupivacaine is a long-acting local anesthetic formulation used for pain, potentially reducing opioid use. Evaluation of liposomal bupivacaine as a viable alternative for pain management is needed. The objective was to assess the efficacy of randomized clinical trials (RCTs) of liposomal bupivacaine in postoperative pain management and opioid consumption. Material and Methods The authors extracted RCTs comparing liposomal bupivacaine versus placebo or active comparators for postoperative pain or opioid reduction from PubMED/MEDLINE, Cochrane Library, and ClinicalTrials.gov. Exclusion criteria included nonhuman studies, non-RCTs, pooled studies, and inability to access full text. The following variables were abstracted: surgical specialty, number of subjects, pain and opioid outcomes, and authors' financial conflicts of interest. Results We identified 77 published RCTs, of which 63 studies with a total of 6770 subjects met inclusion criteria. Liposomal bupivacaine did not demonstrate significant pain relief compared to placebo or active agents in 74.58% of RCTs. Of the studies evaluating narcotic use, liposomal bupivacaine did not show a reduction in opioid consumption in 85.71% of RCTs. Liposomal bupivacaine, when compared to standard bupivacaine or another active agent, yielded no reduction in opioid use in 83.33% and 100.00% of studies, respectively. Clinical trials with a financial conflict of interest relating to the manufacturer of liposomal bupivacaine were significantly more likely to show pain relief (OR: 14.31 [95% CI, 2.8, 73.10], P = 0.0001) and decreased opioid consumption (OR: 12.35 [95% CI 1.40, 109.07], P = 0.0237). Of the 265 unpublished RCTs on ClinicalTrials.gov, 47.54% were withdrawn, terminated, suspended, or completed without study results available. Conclusions The efficacy of liposomal bupivacaine for providing superior postoperative pain control relative to placebo or another active agent is not supported by a majority of RCTs. Underreporting of trial results and bias due to underlying financial relationships amongst authors are two major concerns that should be considered when evaluating the available evidence.


Assuntos
Analgésicos Opioides/administração & dosagem , Anestésicos Locais/administração & dosagem , Bupivacaína/administração & dosagem , Dor Pós-Operatória/tratamento farmacológico , Analgésicos Opioides/efeitos adversos , Humanos , Lipossomos , Epidemia de Opioides/prevenção & controle , Manejo da Dor/efeitos adversos , Manejo da Dor/métodos , Manejo da Dor/estatística & dados numéricos , Medição da Dor/estatística & dados numéricos , Dor Pós-Operatória/diagnóstico , Placebos/administração & dosagem , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
20.
J Surg Res ; 263: 124-129, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33652174

RESUMO

BACKGROUND: Current guidelines for severe rib fractures recommend neuraxial blockade in addition to multimodal pain therapies. While the guidelines for venous thromboembolism prevention recommend chemoprophylaxis, these medications must be held for neuraxial blockade placement. Erector spinae plane block (ESPB) is a newly described block for thoracic pain control. Advantages include its quick learning curve and potential for less bleeding complications. We describe the use of ESPB for rib fractures in patients on chemoprophylaxis. We hypothesize that ESPB can be performed in this patient population without holding chemoprophylaxis. MATERIALS AND METHODS: This was a retrospective observational cohort study of a level 1 trauma center from 9/2016 to 12/2018. All patients with trauma with rib fractures undergoing neuraxial blockade or ESPB were included. Demographics, chemoprophylaxis and anticoagulation regimens, outcomes, and complications were collected. RESULTS: Nine hundred sixty-four patients with rib fracture(s) were admitted. Of these, 73 had a pain management consult. Thirteen had epidural catheters and 25 had ESPBs placed. There was no difference in demographics, injury patterns, bleeding complications, or venous thromboembolism rates among the groups. Patients with ESPB were less likely to have a dose of chemoprophylaxis held because of placement of a catheter (25% versus 100%, P < 0.00001). Three patients with ESPB were on oral anticoagulation on admission, and two were able to continue their regimen during placement. CONCLUSIONS: ESPB can be safely placed in patients on chemoprophylaxis. It should be considered over traditional blocks in patients with blunt chest wall trauma because of its technical ease and ability to be performed with chemoprophylaxis.


Assuntos
Anticoagulantes/administração & dosagem , Hemorragia/epidemiologia , Bloqueio Nervoso/efeitos adversos , Manejo da Dor/efeitos adversos , Fraturas das Costelas/cirurgia , Tromboembolia Venosa/epidemiologia , Adulto , Anestésicos Locais/administração & dosagem , Anticoagulantes/efeitos adversos , Feminino , Hemorragia/etiologia , Hemorragia/prevenção & controle , Humanos , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso/métodos , Manejo da Dor/métodos , Manejo da Dor/normas , Músculos Paraespinais/inervação , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Fraturas das Costelas/complicações , Fraturas das Costelas/diagnóstico , Índices de Gravidade do Trauma , Resultado do Tratamento , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/prevenção & controle
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