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ABSTRACT: Pain management in the postanesthesia care unit (PACU) is continually evolving, with several new nonopioids expanding the list of available agents. Pain in the PACU is not an inevitable outcome of surgery. With careful planning, multimodal analgesic techniques instituted preoperatively will reduce pain in the PACU. Accurate assessment of the characteristics of pain will direct rational drug choices while minimizing side effects. Better management of pain in the PACU setting will likely improve patient satisfaction and facilitate shorter PACU stays.
Anesthesiology Clinics 09/2012; 30(3):e1-15.
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ASA Refresher Courses in Anesthesiology. 08/2012; 39(1):149–155.
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Regional anesthesia and pain medicine 11/2011; 36(6):632-3. · 4.16 Impact Factor
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ABSTRACT: From the time that Sinatra et al. (Anesthesiology. 2005;102:822) was published to FDA apaproval of intravenous (IV) acetaminophen, an expanded analysis of the original raw study data became necessary for the regulatory submission. The following analyses were conducted: (1) sum of pain intensity differences over 24 hours (SPID24) using currently accepted imputation methods to account for both missing data and the effects of rescue; (2) efficacy results after the first 6 hours; (3) effects of gender, race/ethnicity, age, weight, surgical site, ASA Class, and serotonin antagonists; and (4) a stepwise regression analysis of why adverse events of nausea and vomiting were numerically (although not statistically) higher in the IV acetaminophen group compared with placebo.
Sum of pain intensity differences over 24 hours using a 0- to 100-mm visual analog scale was statistically significantly (P < 0.001) in favor of IV acetaminophen (n = 49) compared with placebo (n = 52). Time to rescue was found to be 3.9 and 2.1 hours, respectively, for total hip and knee arthroplasty compared with 0.8 hours for the placebo group. Rescue medication consumption, requests, and actual administration were all significantly lower in the IV acetaminophen group compared with placebo for each dosing interval, except in the 6- to 12-hours interval where a numerical trend was observed. Analysis of various subset variables demonstrated similar efficacy for each variable. A stepwise regression analysis demonstrated that AE reports of nausea and vomiting were most likely due to prerandomization events, particularly opioid consumption and presence of nausea prior to randomization.
Repeated-dose 24-hours end points were found to be as robust as previously published results. IV acetaminophen efficacy and safety appeared to be unaffected by specific subset variables.▪
Pain Practice 10/2011; 12(5):357-65. · 2.21 Impact Factor
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ABSTRACT: The coexistence of diabetes, hypertension, obesity, and dyslipidemia is defined as metabolic syndrome. Studies show substantial cardiovascular risks among these patients. The risk of patients with metabolic syndrome undergoing total joint arthroplasty (TJA) is unknown. Patients with and without metabolic syndrome undergoing TJA during a 3-year period were analyzed for postoperative complications. Metabolic syndrome was defined by having 3 of the following 4 criteria: obesity (body mass index ≥30 kg/m(2)), dyslipidemia, hypertension, and diabetes. Patients with metabolic syndrome had a significantly higher risk of cardiovascular complications compared with controls (P = .017). The risk of an adverse event increased by 29% and 32%, respectively, when there were 3 or 4 syndrome components. Patients with metabolic syndrome undergoing TJA have increased risk for cardiovascular complications. Our results show that metabolic syndrome may have a clustering effect and pose increased risk when individual risks factors are combined.
The Journal of arthroplasty 09/2011; 27(4):514-9. · 1.79 Impact Factor
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ABSTRACT: The management of acute pain remains challenging, with many patients suffering inadequate pain control following surgery. Certain populations are at unique risk for unrelieved pain. Evidence-based approaches taking into account patients' specific needs and problems will likely substantially improve their perioperative experience. These patients must be identified in the preoperative process, and an anesthetic/analgesic plan discussed and formulated. A targeted multimodal approach to pain management should be considered the best clinical practice. The most challenging patients may benefit most from the surveillance of an acute pain service that is able to monitor and coordinate care into the postoperative period.
Anesthesiology Clinics 06/2011; 29(2):291-309.
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Spencer S. Liu,
Christopher L. Wu,
Jane C. Ballantyne,
Asokumar Buvanendran,
James P. Rathmell,
Daniel T. Warren, Eugene R. Viscusi,
Brian Ginsberg,
Richard W. Rosenquist,
Jacques Y. Yadeau,
Gregory A. Liguori
Regional Anesthesia and Pain Medicine 04/2011; 36(3):289. · 4.08 Impact Factor
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ABSTRACT: Current guidelines from the American Society of Regional Anesthesia state that an international normalized ratio (INR) of 1.4 is the upper limit of warfarin anticoagulation for safe removal of an epidural catheter. However, these guidelines are based primarily on expert consensus, and there is controversy regarding this recommendation as being "too conservative."
Prospective (3211) and retrospective (1154) patients undergoing total joint replacement followed by daily warfarin thromboprophylaxis were enrolled in this observational study. All nonsteroidal anti-inflammatory drugs and anticoagulants were held before surgery, and all patients had normal coagulation test results before surgery. Patients were followed twice a day by the acute pain service, no other anticoagulants except nonsteroidal anti-inflammatory drugs were administered, and epidural analgesia was discontinued per institutional protocol. Only patients with INR greater than 1.4 at the time of removal of epidural catheter were included. Neurologic checks were performed for 24 hrs after removal.
A total of 4365 patients were included, and 79% underwent knee replacement and 18% hip replacement. Mean age was 68 yrs, and mean weight was 81 kg. Mean (SD) duration of epidural analgesia was 2.1 (0.6) days. Mean (SD) INR at the time of epidural removal was 1.9 (0.4), ranging from 1.5 to 7.1. No spinal hematomas were observed (0% incidence with 95% confidence interval, 0%-0.069%).
Our series of 4365 patients had uncomplicated removal of epidural catheters despite INRs ranging from 1.5 to 5.9. Removal was only during initiation of warfarin therapy (up to approximately 50 hrs after warfarin intake) when several vitamin K factors are likely to still be adequate for hemostasis.
Regional anesthesia and pain medicine 03/2011; 36(3):231-5. · 4.16 Impact Factor
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ABSTRACT: All patients undergoing bowel resection experience postoperative ileus, a transient cessation of bowel motility that prevents effective transit of intestinal contents or tolerance of oral intake, to varying degrees. An anesthesiologist plays a critical role, not only in the initiation of surgical anesthesia, but also with the selection and transition to effective postoperative analgesia regimens. Attempts to reduce the duration of postoperative ileus have prompted the study of various preoperative, perioperative, and postoperative regimens to facilitate gastrointestinal recovery. These include modifiable variables such as epidural anesthesia and analgesia, opioid-sparing anesthesia and analgesia, fluid restriction, colloid versus crystalloid combinations, prokinetic drugs, and use of the new peripherally acting mu-opioid receptor (PAM-OR) antagonists. Review and appropriate adaptation of these multiple modifiable interventions by anesthesiologists and their surgical colleagues will facilitate implementation of a best-practice management routine for bowel resection procedures that will benefit the patient and the healthcare system.
Advances in preventive medicine. 01/2011; 2011:976904.
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ABSTRACT: Minimally invasive surgical techniques have many benefits, including reduced postoperative pain. Despite this, most patients require opioid analgesia, which can have significant side effects and toxicity. We report the first urologic study using multimodal analgesia with pregabalin, a gabapentinoid.
The present retrospective study included 60 patients who underwent robotic-assisted laparoscopic radical prostatectomy. Of the 60 patients, 30 received multimodal treatment with pregabalin 150 mg, acetaminophen 975 mg, and celecoxib 400 mg orally 2 hours before the start of the procedure and continued postoperatively. These patients were compared with 30 consecutive previous patients, who had received a standard postoperative analgesic regimen with intravenous ketorolac 15 mg every 6 hours with oxycodone 5 mg and acetaminophen 325 mg, 1 to 2 tablets, every 4 hours as needed for pain.
The patients in the multimodal treatment group had a significantly reduced intraoperative opioid requirement, as measured by the mean morphine equivalent dose administered (38.4 ± 2.73 mg vs 49.1 ± 2.65 mg; P < .01). The mean postoperative opioid use was also significantly reduced (10.7 ± 2.82 mg vs 26.2 ± 6.56 mg; P = .034), as was the mean total morphine equivalent dose administered (49.1 ± 2.7 mg vs 75.3 ± 4.6 mg; P < .001). The operative time, estimated operative blood loss, antiemetic use, postoperative creatinine and hemoglobin levels, and length of stay were similar in the 2 groups. No operative or treatment complications occurred in either group.
The present retrospective review has indicated that a multimodal analgesic approach with pregabalin and celecoxib administered preoperatively decreases intraoperative and postoperative opioid use in patients undergoing robotic-assisted laparoscopic radical prostatectomy.
Urology 11/2010; 76(5):1122-4. · 2.43 Impact Factor
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ABSTRACT: A pooled post hoc responder analysis was performed to assess the clinical benefit of alvimopan, a peripherally acting mu-opioid receptor (PAM-OR) antagonist, for the management of postoperative ileus after bowel resection.
Adult patients who underwent laparotomy for bowel resection scheduled for opioid-based intravenous patient-controlled analgesia received oral alvimopan or placebo preoperatively and twice daily postoperatively until hospital discharge or for 7 postoperative days. The proportion of responders and numbers needed to treat (NNT) were examined on postoperative days (POD) 3-8 for GI-2 recovery (first bowel movement, toleration of solid food) and hospital discharge order (DCO) written.
Alvimopan significantly increased the proportion of patients with GI-2 recovery and DCO written by each POD (P < 0.001 for all). More patients who received alvimopan achieved GI-2 recovery on or before POD 5 (alvimopan, 80%; placebo, 66%) and DCO written before POD 7 (alvimopan, 87%; placebo, 72%), with corresponding NNTs equal to 7.
On each POD analyzed, alvimopan significantly increased the proportion of patients who achieved GI-2 recovery and DCO written versus placebo and was associated with relatively low NNTs. The results of these analyses provide additional characterization and support for the overall clinical benefit of alvimopan in patients undergoing bowel resection.
World Journal of Surgery 09/2010; 34(9):2185-90. · 2.36 Impact Factor
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ABSTRACT: An extended-release epidural morphine (EREM) has been introduced to improve postoperative pain management. Studies have shown the effectiveness of this agent in providing better pain control and patient satisfaction for patients undergoing total joint arthroplasty. We evaluated postoperative pain relief by comparing average daily pain scores and opioid use with those of the control group. Safety was measured by comparing the occurrence of postoperative complications, nausea and vomiting, pruritus, and respiratory depression between the two groups. Between February 2006 and March 2008, we selected 203 patients to receive EREM for THA. These patients were matched in a 2:1 ratio with patients undergoing THA and receiving spinal anesthesia. We retrospectively reviewed all major and minor postoperative complications from a prospective database. Patients receiving EREM had lower pain scores than patients not receiving EREM on Postoperative Day 1 (POD 1) but not POD 2, or POD 3. Patients receiving EREM experienced a slightly higher incidence of pulmonary embolism and supraventricular tachycardia. Patients receiving EREM also experienced more nausea and vomiting and pruritus. We found EREM provided better pain relief on POD 1 at the expense of a slightly higher incidence of side effects compared with spinal anesthesia alone. Level of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
Clinical Orthopaedics and Related Research 12/2009; 468(4):1082-7. · 2.53 Impact Factor
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ABSTRACT: Postoperative ileus (POI), a transient cessation of coordinated bowel function after surgery, is an important health care problem. The etiology of POI is multifactorial and related to both the surgical and anesthetic pathways chosen. Opioids used to manage surgical pain can exacerbate POI, delaying gastrointestinal (GI) recovery. Peripherally acting mu-opioid receptor (PAM-OR) antagonists are designed to mitigate the deleterious effects of opioids on GI motility. This new class is investigational for POI management with the goal of accelerating the recovery of upper and lower GI tract function after bowel resection. In this review, we summarize the mechanisms by which POI occurs and the role of opioids and opioid receptors in the enteric nervous system, discuss the mechanism of action of PAM-OR antagonists, and review clinical pharmacology and Phase II/III POI trial results of methylnaltrexone and alvimopan. Finally, the role of anesthesiologists in managing POI in the context of a multimodal approach is discussed.
Anesthesia and analgesia 07/2009; 108(6):1811-22. · 3.08 Impact Factor
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ABSTRACT: A pooled analysis of six clinical studies was conducted to describe the pharmacokinetics of extended-release epidural morphine sulfate.
Data from six clinical studies evaluating extended-release epidural morphine sulfate in volunteers and abdominal or hip surgery patients were pooled and analyzed. Participants age 18 years or older received extended-release epidural morphine sulfate (2.5-40 mg) within 30 minutes of surgery initiation. Most participants received a test dose of 1.5% lidocaine with 1:200,000 epinephrine for epidural space identification 15 minutes before study drug administration. Blood samples were generally collected at 0.5, 2, 4, 8, 12, 18, 24, and 48 hours postinjection.
Standard epidural morphine sulfate exhibited a spike in drug release, producing higher peak concentrations (C(max)) than 5-mg extended-release epidural morphine sulfate, which produced more prolonged serum morphine concentrations. Using labeled doses of extended-release epidural morphine sulfate (10-20 mg), the C(max) was comparable to that for 5-mg standard epidural morphine sulfate, whereas the apparent terminal elimination half-life and area under the serum concentration-time curve were twofold to fourfold greater and consistent with dose-proportional exposure. The mean dose-normalized C(max) for extended-release epidural morphine sulfate was 25% higher for women versus men. Administering extended-release epidural morphine sulfate 15 minutes after the test dose mitigated any pharmacokinetic interaction. Extended-release epidural morphine sulfate demonstrated dose- related reductions in postoperative fentanyl consumption and pain intensity.
A pooled analysis of six studies revealed that extended-release epidural morphine sulfate provided a more prolonged release of morphine compared with standard epidural morphine sulfate. Extended-release epidural morphine sulfate displayed a consistent pharmacokinetic profile among adults, with only slight variability between men and women in C(max), which appeared to be mainly caused by differences in body weight.
American journal of health-system pharmacy: AJHP: official journal of the American Society of Health-System Pharmacists 07/2009; 66(11):1020-30. · 2.10 Impact Factor
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ABSTRACT: This multicenter, multiple-dose, randomized, double-blind, parallel-group study compared the analgesic efficacy and safety of two dosing regimens of parecoxib sodium (parecoxib) versus placebo after total hip arthroplasty.
On study Day 1, 490 patients received a postoperative initial loading dose of IV parecoxib 40 mg, followed by a re-dose of parecoxib 20 mg in 484 of 490 patients. Subsequently, 479 randomized patients received double-blind treatment with parecoxib 20 mg bid (n = 159), parecoxib 20 mg qd (n = 159) followed by placebo, or placebo (n = 161) on Day 2.
Patients treated with parecoxib 20 mg bid reported significantly lower summed pain intensity over 24 h (SPI-24) scores and improved patients' global evaluation of study medication (PGESM) ratings compared with placebo-treated patients on Days 2 to 5 (P < 0.05). For patients treated with parecoxib 20 mg qd, SPI-24 scores were significantly lower on Days 3 and 4 (P < 0.05), and PGESM ratings significantly improved on Day 5 compared with placebo. The incidence of adverse events was similar in all treatment groups with the exception of fever, vomiting and impaired concentration, which were significantly more common in the placebo group compared with one or other of the parecoxib treatment groups (P < 0.05).
Multiple-day administration of parecoxib 20 mg once or twice daily is effective and generally well tolerated after total hip arthroplasty.
Anesthesia and analgesia 08/2008; 107(2):652-60. · 3.08 Impact Factor
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ABSTRACT: Postoperative pain is often managed using IV patient-controlled analgesia (PCA). In this analysis of pooled data, we compared the safety and efficacy of the fentanyl iontophoretic transdermal system (ITS) with morphine IV PCA.
Data were obtained from three multicenter, randomized, active-controlled trials (N = 1941). The primary efficacy measure was success ("good"/"excellent" ratings) on the 24-h patient global assessment of the method of pain control. Pain intensity, relative dosing ratios, discontinuation rates, and adverse events were assessed. Efficacy was evaluated across age, surgery type, and body mass index (BMI).
Comparable percentages of patients reported success on the 24-h patient global assessment of the method of pain control (fentanyl ITS, 80.5%; morphine IV PCA, 81.0%; difference = -0.5%; 95% confidence interval, -4.0% to 3.0%). Mean last pain intensity scores in the first 24 h were comparable (fentanyl ITS, 3.1; morphine IV PCA, 3.0; difference = 0.07; 95% confidence interval, -0.14 to 0.29). Relative dosing ratios of fentanyl to morphine overall and in subpopulations (age, BMI) were comparable over 6, 12, and 24 h. Fentanyl ITS was equally effective when compared with morphine IV PCA for patient subpopulations (age, surgery type, and BMI). Discontinuation rates and the incidence of adverse events were similar between groups.
These pooled data represent one of the largest head-to-head comparisons of fentanyl versus morphine in a postoperative acute pain setting. Results suggest that fentanyl ITS is effective across subpopulations defined by age and BMI, and support a consistent safety and efficacy profile of fentanyl delivered by fentanyl ITS for postoperative pain management.
Anesthesia and analgesia 12/2007; 105(5):1428-36, table of contents. · 3.08 Impact Factor
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ABSTRACT: Postoperative ileus (POI), a transient cessation of coordinated bowel motility, occurs to some extent after all major abdominal operations. This analysis examines gastrointestinal (GI) recovery and hospital discharge history in patients undergoing partial bowel resection (BR) or total abdominal hysterectomy (TAH) by laparotomy in the placebo arms of recent phase III alvimopan trials.
This was a pooled post hoc analysis of placebo groups from randomized, double-blind, parallel-group, multicenter trials. All patients were uniformly managed with a standardized accelerated postoperative care pathway to facilitate GI recovery.
Of the 727 BR patients and 140 TAH patients included in this analysis, POI as an adverse event was reported in approximately 14.7% of BR patients and 2.9% of TAH patients, and postoperative nasogastric tube insertion was required in 11.5% of BR patients and 0.8% of TAH patients. Time to first toleration of solid food was almost 2 days longer for BR patients than for TAH patients (BR, 4.1 days; TAH, 2.5 days). Approximately 34.4% of BR patients and 4.2% of TAH patients had discharge orders written 7 days or more after operation. Nearly half (40%) of patients undergoing TAH were discharged from the hospital before GI recovery was complete. Mean postoperative lengths of hospital stay after BR and TAH were 6.6 days and 3.4 days, respectively.
Despite the relatively fast recovery observed with standardized accelerated postoperative care pathway use, POI as an adverse event was still reported in approximately 15% of BR patients and 3% of TAH patients. This analysis provides important clinical insight into the differences in GI recovery patterns and the incidence and impact of POI after BR and TAH.
Journal of the American College of Surgeons 08/2007; 205(1):43-51. · 4.55 Impact Factor
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Eugene R Viscusi
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ABSTRACT: The advantages and disadvantages of intravenous patient-controlled analgesia (i.v. PCA) and epidural analgesia are discussed. New approaches to the management of patients with acute post-operative pain are described. The results of controlled clinical trials with these modalities are presented.
Intravenous patient-controlled analgesia, while effective, is a burdensome technology requiring approximately 125 steps and at least 6 staff members. Furthermore, medication and pump programming errors may lead to patient injury. Epidural analgesia via catheter has a high reported failure rate, causing analgesic gaps and requiring a high level of staff intervention. In a clinical trial involving hip arthroplasty, extended-release epidural morphine demonstrated a 48-hour duration of action with a marked reduction in need for supplemental analgesia. The fentanyl Iontophoretic Transdermal System has demonstrated therapeutic equivalence with morphine intravenous patient-controlled analgesia and similar safety. Selective opioid antagonists are under development that may selectively block gastrointestinal opioid receptors while preserving analgesia.
Recently approved agents and those in development may address a variety of unmet needs in the management of patients with post-operative pain.
American Journal of Health-System Pharmacy 04/2007; 64(6 Suppl 4):S6-S11. · 1.96 Impact Factor
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ABSTRACT: Epidural hypotensive anesthesia can, in addition to imparting numerous intraoperative benefits, provide excellent postoperative pain control for patients having joint arthroplasties. However, because of the risk of epidural hematoma, epidural anesthesia is not coadministered with anticoagulation in some centers. We retrospectively ascertained, by chart review, the incidence of epidural hematoma in 11,235 patients having 12,991 knee arthroplasties at our institution who received oral anticoagulation and epidural anesthesia for their surgery. Warfarin was administered on the day of surgery. With the exception of 212 patients, the epidural catheter was removed within 48 hours of surgery. Based on clinical examinations, we detected no epidural hematomas. For 1030 patients (1038 knees) whose charts were reviewed in detail, the mean international normalized ratio at the time of removal of the epidural catheter was 1.54 (range, 0.93-4.25). We identified no other complications related to the coadministration of epidural anesthesia and warfarin. Although administration of epidural anesthesia in patients with coagulopathy can be detrimental, we recognized no cases of epidural hematoma causing neurologic symptoms in patients receiving controlled oral anticoagulation after total knee arthroplasty.
Clinical Orthopaedics and Related Research 04/2007; 456:133-7. · 2.53 Impact Factor
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ABSTRACT: Perioperative pain management has drastically evolved over the years to satisfy current unmet needs. Intermittent delivery of drugs has been replaced by continuous delivery systems involving oral, neuraxial, and peripheral nerve block routes of administration. One current standard of perioperative pain management is an epidural injection of an opioid such as morphine, fentanyl, or hydromorphone, with or without the addition of a local anesthetic, such as bupivacaine. Although this method is extremely effective in controlling pain during the most critical 48-hour period postoperatively, it also has its disadvantages. Risks associated with indwelling epidural catheters include infection, adverse effects, and spinal hematoma. The development of extended- and controlled-release drug delivery systems has revolutionized perioperative pain management. This class of drugs comprises MS Contin (Purdue Pharma LP, Stamford, CT), OxyContin (Purdue Pharma LP), Opana ER (Endo Pharmaceuticals, Chadds Ford, PA), and DepoDur (Endo Pharmaceuticals). There are also phase II trials in progress examining controlled-release formulations of local anesthetics. This review discusses extended- and controlled-release agents administered perioperatively.
Current Pain and Headache Reports 03/2007; 11(1):33-7. · 1.66 Impact Factor
