Postoperative Pain Control
01 Sep 2013-Clinics in Colon and Rectal Surgery (Thieme Medical Publishers)-Vol. 26, Iss: 3, pp 191-196
TL;DR: Although traditionally the mainstay of postoperative analgesia is opioid based, increasingly more evidence exists to support a multimodal approach with the intent to reduce opioid side effects (such as nausea and ileus) and improve pain scores.
Abstract: The effective relief of pain is of the utmost importance to anyone treating patients undergoing surgery. Pain relief has significant physiological benefits; hence, monitoring of pain relief is increasingly becoming an important postoperative quality measure. The goal for postoperative pain management is to reduce or eliminate pain and discomfort with a minimum of side effects. Various agents (opioid vs. nonopioid), routes (oral, intravenous, neuraxial, regional) and modes (patient controlled vs. “as needed”) for the treatment of postoperative pain exist. Although traditionally the mainstay of postoperative analgesia is opioid based, increasingly more evidence exists to support a multimodal approach with the intent to reduce opioid side effects (such as nausea and ileus) and improve pain scores. Enhanced recovery protocols to reduce length of stay in colorectal surgery are becoming more prevalent and include multimodal opioid sparing regimens as a critical component. Familiarity with the efficacy of available agents and routes of administration is important to tailor the postoperative regimen to the needs of the individual patient.
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TL;DR: The National Academy of Sciences founded The National Academies Press (NAP) with the goal of publishing reports of all four national academies as mentioned in this paper, which publishes more than 200 books from the fields of science, engineering and medicine and offers more than 4000 titles in PDF on its website.
Abstract: The National Academy of Sciences founded The National Academies Press (NAP) with the goal of publishing reports of all four national academies. Annually, NAP publishes more than 200 books from the fields of science, engineering and medicine and offers more than 4000 titles in PDF on its website (http://www.nap.edu/) free of charge.
1,241 citations
TL;DR: In this paper, a 3-step modified Delphi method involving a multidisciplinary expert panel of 6 relevant stakeholder groups (surgeons, pain specialists, outpatient surgical nurse practitioners, surgical residents, patients, and pharmacists) was used to develop consensus ranges for outpatient opioid prescribing at the time of discharge after 20 common procedures in 8 surgical specialties.
Abstract: Background One in 16 surgical patients prescribed opioids becomes a long-term user. Overprescribing opioids after surgery is common, and the lack of multidisciplinary procedure-specific guidelines contributes to the wide variation in opioid prescribing practices. We hypothesized that a single-institution, multidisciplinary expert panel can establish consensus on ideal opioid prescribing for select common surgical procedures. Study Design We used a 3-step modified Delphi method involving a multidisciplinary expert panel of 6 relevant stakeholder groups (surgeons, pain specialists, outpatient surgical nurse practitioners, surgical residents, patients, and pharmacists) to develop consensus ranges for outpatient opioid prescribing at the time of discharge after 20 common procedures in 8 surgical specialties. Prescribing guidelines were developed for opioid-naive adult patients without chronic pain undergoing uncomplicated procedures. The number of opioid tablets was defined using oxycodone 5 mg oral equivalents. Results For all 20 surgical procedures reviewed, the minimum number of opioid tablets recommended by the panel was 0. Ibuprofen was recommended for all patients unless medically contraindicated. The maximum number of opioid tablets varied by procedure (median 12.5 tablets), with panel recommendations of 0 opioid tablets for 3 of 20 (15%) procedures, 1 to 15 opioid tablets for 11 of 20 (55%) procedures, and 16 to 20 tablets for 6 of 20 (30%) procedures. Overall, patients who had the procedures voted for lower opioid amounts than surgeons who performed them. Conclusions Procedure-specific prescribing recommendations may help provide guidance to clinicians who are currently overprescribing opioids after surgery. Multidisciplinary, patient-centered consensus guidelines for more procedures are feasible and may serve as a tool in combating the opioid crisis.
297 citations
TL;DR: It is suggested that oliceridine may provide effective, rapid analgesia in patients with moderate to severe postoperative pain, with an acceptable safety/tolerability profile and potentially wider therapeutic window than morphine.
Abstract: BACKGROUND Oliceridine (TRV130), a novel μ-receptor G-protein pathway selective (μ-GPS) modulator, was designed to improve the therapeutic window of conventional opioids by activating G-protein signaling while causing low β-arrestin recruitment to the μ receptor. This randomized, double-blind, patient-controlled analgesia Phase IIb study was conducted to investigate the efficacy, safety, and tolerability of oliceridine compared with morphine and placebo in patients with moderate to severe pain following abdominoplasty (NCT02335294; oliceridine is an investigational agent not yet approved by the US Food and Drug Administration). METHODS Patients were randomized to receive postoperative regimens of intravenous oliceridine (loading/patient-controlled demand doses [mg/mg]: 1.5/0.10 [regimen A]; 1.5/0.35 [regimen B]), morphine (4.0/1.0), or placebo with treatment initiated within 4 hours of surgery and continued as needed for 24 hours. RESULTS Two hundred patients were treated (n=39, n=39, n=83, and n=39 in the oliceridine regimen A, oliceridine regimen B, morphine, and placebo groups, respectively). Patients were predominantly female (n=198 [99%]) and had a mean age of 38.2 years, weight of 71.2 kg, and baseline pain score of 7.7 (on 11-point numeric pain rating scale). Patients receiving the oliceridine regimens had reductions in average pain scores (model-based change in time-weighted average versus placebo over 24 hours) of 2.3 and 2.1 points, respectively (P=0.0001 and P=0.0005 versus placebo); patients receiving morphine had a similar reduction (2.1 points; P<0.0001 versus placebo). A lower prevalence of adverse events (AEs) related to nausea, vomiting, and respiratory function was observed with the oliceridine regimens than with morphine (P<0.05). Other AEs with oliceridine were generally dose-related and similar in nature to those observed with conventional opioids; no serious AEs were reported with oliceridine. CONCLUSION These results suggest that oliceridine may provide effective, rapid analgesia in patients with moderate to severe postoperative pain, with an acceptable safety/tolerability profile and potentially wider therapeutic window than morphine.
129 citations
Additional excerpts
...TEAEs in ≥10% of patients Patients with ≥1 TEAE 24 (62%) [48] 26 (67%) [54] 32 (82%) [67] 78 (94%) [238] Gastrointestinal disorders Nausea Vomiting 7 (18%) [7] 3 (8%) [3] 16 (41%) [17] 6 (15%) [6] 18 (46%) [18] 6 (15%) [6] 60 (72%) [63] 35 (42%) [35] Nervous system disorders Headache Dizziness Somnolence 5 (13%) [5] 1 (3%) [1] 0 6 (15%) [6] 1 (3%) [1] 0 6 (15%) [6] 4 (10%) [4] 2 (5%) [2] 14 (17%) [14] 7 (8%) [7] 10 (12%) [10] Vascular disorders Hypotension Phlebitis 1 (3%) [1] 4 (10%) [4] 6 (15%) [6] 0 3 (8%) [3] 2 (5%) [2] 7 (8%) [7] 1 (1%) [2] Respiratory, thoracic, and mediastinal disorders Hypoventilation 4 (10%) [5] 4 (10%) [4] 12 (31%) [12] 34 (41%) [34]...
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TL;DR: Surgical trainees are relying almost exclusively on opioids for postoperative analgesia, often in excessive amounts, pointing to a great need for increased resident education on postoperative pain and opioid management to help change prescribing habits.
106 citations
TL;DR: Liposomal bupivacaine is a safe method for postoperative pain control in the setting of plastic surgery and may represent an alternative to more invasive pain management systems such as patient-controlled analgesia, epidurals, peripheral nerve catheters, or intravenous narcotics.
Abstract: Background:Management of postoperative pain often requires multimodal approaches. Suboptimal dosages of current therapies can leave patients experiencing periods of insufficient analgesia, often requiring rescue therapy. With absence of a validated and standardized approach to pain management, furth
102 citations