Multimodal Analgesic Regimen for Spine Surgery

Abstract Background Various multimodal analgesic approaches have been proposed for spine surgery. The authors evaluated the effect of using a combination of four nonopioid analgesics versus placebo on Quality of Recovery, postoperative opioid consumption, and pain scores. Methods Adults having multilevel spine surgery who were at high risk for postoperative pain were double-blind randomized to placebos or the combination of single preoperative oral doses of acetaminophen 1,000 mg and gabapentin 600 mg, an infusion of ketamine 5 µg/kg/min throughout surgery, and an infusion of lidocaine 1.5 mg/kg/h intraoperatively and during the initial hour of recovery. Postoperative analgesia included acetaminophen, gabapentin, and opioids. The primary outcome was the Quality of Recovery 15-questionnaire (0 to 150 points, with 15% considered to be a clinically important difference) assessed on the third postoperative day. Secondary outcomes were opioid use in morphine equivalents (with 20% considered to be a clinically important change) and verbal-response pain scores (0 to 10, with a 1-point change considered important) over the initial postoperative 48 h. Results The trial was stopped early for futility per a priori guidelines. The average duration ± SD of surgery was 5.4 ± 2.1 h. The mean ± SD Quality of Recovery score was 109 ± 25 in the pathway patients (n = 150) versus 109 ± 23 in the placebo group (n = 149); estimated difference in means was 0 (95% CI, –6 to 6, P = 0.920). Pain management within the initial 48 postoperative hours was not superior in analgesic pathway group: 48-h opioid consumption median (Q1, Q3) was 72 (48, 113) mg in the analgesic pathway group and 75 (50, 152) mg in the placebo group, with the difference in medians being –9 (97.5% CI, –23 to 5, P = 0.175) mg. Mean 48-h pain scores were 4.8 ± 1.8 in the analgesic pathway group versus 5.2 ± 1.9 in the placebo group, with the difference in means being –0.4 (97.5% CI; –0.8, 0.1, P = 0.094). Conclusions An analgesic pathway based on preoperative acetaminophen and gabapentin, combined with intraoperative infusions of lidocaine and ketamine, did not improve recovery in patients who had multilevel spine surgery. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Download Full-text

Influence of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain, and quality of recovery after adult spine surgery

Journal of Neurosurgery Spine ◽

10.3171/2017.5.spine1734 ◽

2018 ◽

Vol 28 (1) ◽

pp. 119-126 ◽

Cited By ~ 42

Author(s):

Lauren K. Dunn ◽

Marcel E. Durieux ◽

Lucas G. Fernández ◽

Siny Tsang ◽

Emily E. Smith-Straesser ◽

...

Keyword(s):

Spine Surgery ◽

Rating Scale ◽

Psychological Intervention ◽

Opioid Consumption ◽

Anxiety And Depression ◽

Opioid Use ◽

Quality Of Recovery ◽

Pain Scores ◽

The Impact

OBJECTIVEPerception of perioperative pain is influenced by various psychological factors. The aim of this study was to determine the impact of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain scores, and quality of recovery in adults who underwent spine surgery.METHODSPatients undergoing spine surgery were enrolled in this study, and the preoperatively completed questionnaires included the verbal rating scale (VRS), Pain Catastrophizing Scale (PCS), Hospital Anxiety and Depression Scale (HADS), and Oswestry Disability Index (ODI). Quality of recovery was assessed using the 40-item Quality of Recovery questionnaire (QoR40). Opioid consumption and pain scores according to the VRS were recorded daily until discharge.RESULTSOne hundred thirty-nine patients were recruited for the study, and 101 completed the QoR40 assessment postoperatively. Patients with higher catastrophizing scores were more likely to have higher maximum pain scores postoperatively (estimate: 0.03, SE: 0.01, p = 0.02), without increased opioid use (estimate: 0.44, SE: 0.27, p = 0.11). Preoperative anxiety (estimate: 1.18, SE: 0.65, p = 0.07) and depression scores (estimate: 1.06, SE: 0.71, p = 0.14) did not correlate with increased postoperative opioid use; however, patients with higher preoperative depression scores had lower quality of recovery after surgery (estimate: −1.9, SE: 0.56, p < 0.001).CONCLUSIONSCatastrophizing, anxiety, and depression play important roles in modulating postoperative pain. Preoperative evaluation of these factors, utilizing a validated tool, helps to identify patients at risk. This might allow for earlier psychological intervention that could reduce pain severity and improve the quality of recovery.

Download Full-text

Evaluation of ultrasound-guided rhomboid intercostal nerve block for postoperative analgesia in breast cancer surgery: a prospective, randomized controlled trial

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2019-101114 ◽

2020 ◽

Vol 45 (4) ◽

pp. 277-282 ◽

Cited By ~ 2

Author(s):

Başak Altıparmak ◽

Melike Korkmaz Toker ◽

Ali Ihsan Uysal ◽

Özcan Dere ◽

Bakiye Uğur

Keyword(s):

Postoperative Analgesia ◽

Radical Mastectomy ◽

Opioid Consumption ◽

Control Group ◽

Axillary Lymph ◽

Ultrasound Guided ◽

Rescue Analgesia ◽

Quality Of Recovery ◽

Pain Scores

Background and objectivesMastectomy has many potential sources of pain. Rhomboid intercostal block (RIB) is a recently described plane block. The primary hypothesis of the study is that ultrasound-guided RIB combined with general anesthesia would accelerate global quality of recovery scores of patients following mastectomy surgery. Secondary hypothesis is that RIB would reduce postoperative opioid consumption, pain scores, and the need for rescue analgesia.MethodsPatients aged between 18 and 70 years, with American Society of Anesthesiologists physical status I–II and scheduled for an elective unilateral modified radical mastectomy surgery with axillary lymph node dissection were enrolled to the study. Following endotracheal intubation, patients were randomly allocated into two groups. Patients in the first group (group R) received ultrasound-guided RIB with 30 mL 0.25% bupivacaine. In the control group (group C), no block intervention was applied. All patients received intravenous dexamethasone 8 mg, dexketoprofen trometamol 50 mg intraoperatively and tramadol 1 mg/kg 30 min before the end of surgery for postoperative analgesia. All patients received intravenous morphine patient-controlled analgesia device at the arrival to the recovery room.ResultsThe descriptive variables of the patients were comparable between group R and group C. Mean quality of recovery-40 score at 24 hours was 164.8±3.9 in group R and 153.5±5.2 in group C (mean difference 11.4 (95% CI 8.8 to 13.9; p<0.001). At 24th hour, median morphine consumption was 5 mg (IQR 4–7 mg) in group R and 10 mg (IQR 8–13 mg) in group C, p<0.001. Intraoperative fentanyl administration, pain scores and the need for rescue postoperative analgesia was similar between groups.ConclusionsIn the current study, ultrasound-guided RIB promoted enhanced recovery and decreased opioid consumption after mastectomy surgery.Trial registration numberACTRN12619000879167.

Download Full-text

Comparative study of hemodynamic effects, quality of extubation and emergence - agitation response of the patients with dexmedetomidine versus lignocaine during and following the endotracheal extubation

MedPulse International Journal of Anesthesology ◽

10.26611/10151939 ◽

2021 ◽

Vol 19 (3) ◽

pp. 91-95

Author(s):

Manasi Panat ◽

Keyword(s):

Comparative Study ◽

Stress Responses ◽

Tracheal Extubation ◽

Emergence Agitation ◽

Quality Of Recovery ◽

Group 12 ◽

The Difference ◽

Group D ◽

Endotracheal Extubation

Background: Endotracheal extubation is the translaryngeal removal of a tube from the trachea via the nose or mouth. It is associated with hemodynamic changes because of reflex sympathetic discharge caused by epipharyngeal and laryngopharyngeal stimulation. Various drugs and techniques have been tried to attenuate the airway and stress responses during tracheal extubation. In present study, we have compared the effects of dexmedetomidine and intravenous lignocaine on the hemodynamic and recovery profiles during endotracheal extubation. Material and Methods: Present study was prospective randomised comparative study, conducted in patients from age group of 18-45 years, ASA grade I/II, scheduled for elective abdominal surgeries. The patients were categorised into two different groups using the sealed envelope method as Group D and group L. Results: In present study, patients were divided in following 2 groups with 50 patients in each group as group D (Dexmedetomidine) and group L (Lignocaine). Age, gender, mean BMI were comparable in both groups and difference was not significant statistically. The difference between mean heart rate, systolic BP, diastolic BP and mean arterial BP during extubation, after extubation at 1, 3, 5, 10, 15, 20, 25, 30 minutes in dexmedetomidine group and lignocaine group was statistically significant. In Dexmedetomidine group, 12% of the patients had no cough during extubation, 72% of the patients had smooth extubation with minimal cough while in Lignocaine group, 22% of the patients had smooth extubation with minimal cough, 74 % of the patients had moderate cough during extubation. Statistical analysis of the Emergence agitation score shows better results in group D. Conclusion: Administration of Dexmedetomidine before tracheal extubation was more effective in maintaining the hemodynamic stability, facilitated smooth tracheal extubation and had a better quality of recovery as compared to Lignocaine.

Download Full-text

Effects of an opioid stewardship program on opioid consumption and related outcomes after multilevel lumbar spine fusion: a pre- and postimplementation analysis of 268 patients

Journal of Neurosurgery Spine ◽

10.3171/2021.8.spine21599 ◽

2021 ◽

pp. 1-9

Author(s):

Marie-Jacqueline Reisener ◽

Alexander P. Hughes ◽

Ichiro Okano ◽

Jiaqi Zhu ◽

Artine Arzani ◽

...

Keyword(s):

Side Effects ◽

Spine Surgery ◽

Effect Size ◽

Lumbar Fusion ◽

Opioid Consumption ◽

Opioid Use ◽

Chi Square ◽

Opioid Prescribing ◽

Pain Scores ◽

Stewardship Program

OBJECTIVE Opioid stewardship programs combine clinical, regulatory, and educational interventions to minimize inappropriate opioid use and prescribing for orthopedic and spine surgery. Most evaluations of stewardship programs quantify effects on prescriber behavior, whereas patient-relevant outcomes have been relatively neglected. The authors evaluated the impact of an opioid stewardship program on perioperative opioid consumption, prescribing, and related clinical outcomes after multilevel lumbar fusion. METHODS The study was based on a retrospective, quasi-experimental, pretest-posttest design in 268 adult patients who underwent multilevel lumbar fusion in 2016 (preimplementation, n = 141) or 2019 (postimplementation, n = 127). The primary outcome was in-hospital opioid consumption (morphine equivalent dose [MED], mg). Secondary outcomes included numeric rating scale pain scores (0–10), length of stay (LOS), incidence of opioid-induced side effects (gastrointestinal, nausea/vomiting, respiratory, sedation, cognitive), and preoperative and discharge prescribing. Outcomes were measured continuously during the hospital admission. Differences in outcomes between the epochs were assessed in bivariable (Wilcoxon signed-rank or Fisher’s exact tests) and multivariable (Wald’s chi-square test) analyses. RESULTS In bivariable analyses, there were significant decreases in preoperative opioid use (46% vs 28% of patients, p = 0.002), preoperative opioid prescribing (MED 30 mg [IQR 20–60 mg] vs 20 mg [IQR 11–39 mg], p = 0.003), in-hospital opioid consumption (MED 329 mg [IQR 188–575 mg] vs 199 mg [100–372 mg], p < 0.001), the incidence of any opioid-related side effect (62% vs 50%, p = 0.03), and discharge opioid prescribing (MED 90 mg [IQR 60–135 mg] vs 60 mg [IQR 45–80 mg], p < 0.0001) between 2016 and 2019. There were no significant differences in postanesthesia care unit pain scores (4 [IQR 3–6] vs 5 [IQR 3–6], p = 0.33), nursing floor pain scores (4 [IQR 3–5] vs 4 [IQR 3–5], p = 0.93), or total LOS (118 hours [IQR 81–173 hours] vs 103 hours [IQR 81–132 hours], p = 0.21). On multivariable analysis, the opioid stewardship program was significantly associated with decreased discharge prescribing (Wald’s chi square = 9.45, effect size −52.4, 95% confidence interval [CI] −86 to −19.0, p = 0.002). The number of lumbar levels fused had the strongest effect on total opioid consumption during the hospital stay (Wald’s chi square = 16.53, effect size = 539, 95% CI 279.1 to 799, p < 0.001), followed by preoperative opioid use (Wald’s chi square = 44.04, effect size = 5, 95% CI 4 to 7, p < 0.001). CONCLUSIONS A significant decrease in perioperative opioid prescribing, consumption, and opioid-related side effects was found after implementation of an opioid stewardship program. These gains were achieved without adverse effects on pain scores or LOS. These results suggest the major impact of opioid stewardship programs for spine surgery may be on changing prescriber behavior.

Download Full-text

The Quality of Recovery after Dexamethasone, Ondansetron, or Placebo Administration in Patients Undergoing Lower Limbs Orthopedic Surgery under Spinal Anesthesia Using Intrathecal Morphine. A Randomized Controlled Trial

Anesthesiology Research and Practice ◽

10.1155/2020/9265698 ◽

2020 ◽

Vol 2020 ◽

pp. 1-6

Author(s):

Eduardo Toshiyuki Moro ◽

Miguel Antônio Teixeira Ferreira ◽

Renyer dos Santos Gonçalves ◽

Roberta Costa Vargas ◽

Samira Joverno Calil ◽

...

Keyword(s):

Spinal Anesthesia ◽

Orthopedic Surgery ◽

Intrathecal Morphine ◽

Controlled Trial ◽

Lower Limbs ◽

Postanesthesia Care Unit ◽

Quality Of Recovery ◽

Pain Scores ◽

To Receive

Intrathecal morphine is widely and successfully used to prevent postoperative pain after orthopedic surgery, but it is frequently associated with side effects. The aim of this study was to evaluate the effect of dexamethasone or ondansetron when compared to placebo to reduce the occurrence of these undesirable effects and, consequently, to improve the quality of recovery based on patient’s perspective. Methods. One hundred and thirty-five patients undergoing lower extremity orthopedic surgery under spinal anesthesia using bupivacaine and morphine were randomly assigned to receive IV dexamethasone, ondansetron, or saline. On the morning following surgery, a quality of recovery questionnaire (QoR-40) was completed. Results. No differences were detected in the global and dimensional QoR-40 scores following surgery; however, following postanesthesia care unit (PACU) discharge, pain scores were higher in patients receiving ondansetron compared with patients who received dexamethasone. Conclusion. Neither ondansetron nor dexamethasone improves the quality of recovery after lower limbs orthopedic surgery under spinal anesthesia using intrathecal morphine.

Download Full-text

Combined Opioid Free and Loco-Regional Anesthesia Enhances the Quality of Recovery in Sleeve Gastrectomy Done Under ERAS Protocol: A Randomized Controlled Trial

10.21203/rs.3.rs-558975/v1 ◽

2021 ◽

Author(s):

Mohamed Ibrahim ◽

Ali M Elnabtity ◽

Ahmed Hegab ◽

Omar A. Alnujaidi ◽

Osama El Sanea

Keyword(s):

Postoperative Pain ◽

Regional Anesthesia ◽

Oral Fluid ◽

Multimodal Analgesia ◽

Opioid Consumption ◽

P Value ◽

Rescue Analgesia ◽

Quality Of Recovery ◽

Eras Protocol

Abstract Background: There is still debate as to whether opioid-free anaesthsia (OFA) may offer additional benefit over multimodal analgesia to better achieve the goals of ERAS(Enhanced recovery after surgery) in bariatric surgery.Patients and method: Patients in the OFA group (n=51) were pre-medicated with IV dexmedetomidine 0.1 µg.kg-1 then induced with propofol (2 mg. kg-1) -ketamine (0.5 mg. kg-1) mixture and maintained on dexmedetomidine 0.5µg. kg-1.h-1, ketamine 0.5 mg.kg-1.h-1, and lidocaine 1 mg. kg-1.h-1. Patients in the MMA(Multimodal analgesia) group (n= 52) were induced using IV propofol 2 mg. kg-1, and fentanyl 1 µg. kg-1. Cisatracurium (0.15 mg.kg-1) was given to all patients for muscle relaxation. Ultrasound-guided bilateral oblique subcostal transverse abdominis plane (OSTAP) block was performed in all patients. The postoperative quality of recovery at 6 and 24 hours was measured as a primary outcome. Postoperative pain control; subsequent opioid consumption; time to ambulate; time to tolerate oral fluid; and time to readiness for discharge were measured as secondary outcomes Results: The total QoR-40 (quality of recovery-40) scores at 6 hours were significantly higher in the OFA group (184.84 versus 180.69 in the MMA group with an estimated difference in mean of -4.15, 95% CI, -5.78 to -2.5, and P ˂0.001. The OFA group tolerated oral fluid intake earlier (194.94, 95% CI, 162.59 to 227.30) versus (273, 95% CI, 223.65 to 322.27) for the MMA group (p value=0.009). Readiness for discharge was significantly quicker in the OFA group (447.49, 95% CI, 409.69 to 485.29 versus 544.56, 95% CI, 503.08 to 586.04 in the MMA group, P-value =0.001). The post-anesthesia care unit (PACU) (0 Hour) and the floor 2 and 6-hour numerical rating scales (NRS) for pain were significantly higher in the MMA group. The OFA group needed less opioid rescue analgesia in the PACU and at 24-hours (P value= 0.003 and 0.014; respectively).Conclusion: Combined Opioid free and loco-regional anesthesia provides better early recovery with reduced postoperative pain intensity, and opioid consumption when compared to multimodal analgesia; and is better suited to achieve the goals of ERAS protocol.Clinical trial number: registration number NCT04285255.

Download Full-text

Factors driving the difference in quality of recovery scores between scheduled and unscheduled Caesarean delivery patients

British Journal of Anaesthesia ◽

10.1016/j.bja.2021.11.026 ◽

2022 ◽

Author(s):

Cyrus Bhiladvala ◽

Robert ffrench-O’Carroll ◽

Yeganeh Dadkhah ◽

Susan Bright ◽

Anthony Chau ◽

...

Keyword(s):

Caesarean Delivery ◽

Quality Of Recovery ◽

The Difference

Download Full-text

Clinical Application of TCM-Characteristic Rehabilitation Program after Total Knee Arthroplasty

Acupuncture & Electro-Therapeutics Research ◽

10.3727/036012921x16298112109484 ◽

2021 ◽

Author(s):

Xin-Xia Gao ◽

Xiong Xiao ◽

Ying Chen ◽

Li Yang ◽

Yun-Xia Zhang ◽

...

Keyword(s):

Total Knee Arthroplasty ◽

Treatment Group ◽

Knee Arthroplasty ◽

Rehabilitation Program ◽

Control Group ◽

Pain Scores ◽

Total Knee ◽

Random Number Table ◽

The Difference

Objective: To evaluate the effect of traditional Chinese medicine (TCM)-characteristic rehabilitation program on levels of pain and swelling after total knee arthroplasty. Methods: A total of 72 in-patients who recovered from total knee arthroplasty in our department were selected as the study subjects. They were divided into two groups according to a random number table: the control group (n = 36) with routine nursing and the treatment group (n = 36) with TCM rehabilitation nursing. The pain scores and joint swelling were statistically analyzed. Results: The pain scores in the treatment group were lower than those in the control group, and the difference was statistically significant (P < 0.05).Conclusion: The implementation of a TCM rehabilitation program for patients after total knee arthroplasty can effectively and quickly reduce the pain and swelling of the affected limb, promote the local blood circulation, and promote the quality of life of patients after rehabilitation.

Download Full-text

Preoperative Dexamethasone Enhances Quality of Recovery after Laparoscopic Cholecystectomy

Anesthesiology ◽

10.1097/aln.0b013e3181ec642e ◽

2011 ◽

Vol 114 (4) ◽

pp. 882-890 ◽

Cited By ~ 98

Author(s):

Glenn S. Murphy ◽

Joseph W. Szokol ◽

Steven B. Greenberg ◽

Michael J. Avram ◽

Jeffery S. Vender ◽

...

Keyword(s):

Laparoscopic Cholecystectomy ◽

Length Of Stay ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Postanesthesia Care Unit ◽

Control Group ◽

Quality Of Recovery ◽

Pain Scores ◽

Dexamethasone Group

Background The effect of dexamethasone on quality of recovery after discharge from the hospital after laparoscopic surgery has not been examined rigorously in previous investigations. We hypothesized that preoperative dexamethasone would enhance patient-perceived quality of recovery on postoperative day 1 in subjects undergoing laparoscopic cholecystectomy. Methods One hundred twenty patients undergoing outpatient laparoscopic cholecystectomy were randomized to receive either dexamethasone (8 mg) or placebo-saline. A 40-item quality-of-recovery scoring system (QoR-40) was administered preoperatively and on postoperative day 1 to all subjects. Nausea, vomiting, fatigue, and pain scores were recorded at the time of discharge from the postanesthesia care unit and ambulatory surgical unit. Hospital length of stay was also assessed. Results Global QoR-40 scores on postoperative day 1 were higher in the dexamethasone group (median [range], 178 [130-195]) compared with the control group (161 [113-194]) (median difference [99% CI], -18 [-26 to -8]; P < 0.0001). Postoperative QoR-40 scores in the dimensions of emotional state, physical comfort, and pain were all improved in the dexamethasone group compared with the control group (P < 0.001). Nausea, fatigue, and pain scores were all reduced in the dexamethasone group during the hospitalization, as were postoperative analgesic requirements (P < 0.05). Total hospital length of stay was also reduced in subjects administered steroids (P = 0.003). Conclusions Among patients undergoing outpatient laparoscopic cholecystectomy surgery, the use of preoperative dexamethasone enhanced postdischarge quality of recovery and reduced nausea, pain, and fatigue in the early postoperative period.

Download Full-text