scholarly journals Pain Control: Opioid vs. Nonopioid Analgesia During the Immediate Postoperative Period

2021 ◽  
Author(s):  
Shamsie Lumpkin ◽  
Isaac Parrish ◽  
Austin Terrell ◽  
Dwayne Accardo
Keyword(s):  
Informed Consent ◽  
Surgical Procedures ◽  
Pain Control ◽  
Small Sample ◽  
Opioid Analgesia ◽  
Specific Patient ◽  
Pain Scores ◽  
Opioid Sparing ◽  
Opioid Medications ◽  
Written Informed Consent

Background Opioid analgesia has become the mainstay for acute pain management in the postoperative setting. However, the use of opioid medications comes with significant risks and side effects. Due to increasing numbers of prescriptions to those with chronic pain, opioid medications have become more expensive while becoming less effective due to the buildup of patient tolerance. The idea of opioid-free analgesic techniques has rarely been breached in many hospitals. Emerging research has shown that opioid-sparing approaches have resulted in lower reported pain scores across the board, as well as significant cost reductions to hospitals and insurance agencies. In addition to providing adequate pain relief, the predicted cost burden of an opioid-free or opioid-sparing approach is significantly less than traditional methods. Methods The following groups were considered in our inclusion criteria: those who speak the English language, all races and ethnicities, male or female, home medications, those who are at least 18 years of age and able to provide written informed consent, those undergoing inpatient or same-day surgical procedures. In addition, our scoping review includes the following exclusion criteria: those who are non-English speaking, those who are less than 18 years of age, those who are not undergoing surgical procedures while admitted, those who are unable to provide numeric pain score due to clinical status, those who are unable to provide written informed consent, and those who decline participation in the study. Data was extracted by one reviewer and verified by the remaining two group members. Extraction was divided as equally as possible among the 11 listed references. Discrepancies in data extraction were discussed between the article reviewer, project editor, and group leader. Results We identified nine primary sources addressing the use of ketamine as an alternative to opioid analgesia and post-operative pain control. Our findings indicate a positive correlation between perioperative ketamine administration and postoperative pain control. While this information provides insight on opioid-free analgesia, it also revealed the limited amount of research conducted in this area of practice. The strategies for several of the clinical trials limited ketamine administration to a small niche of patients. The included studies provided evidence for lower pain scores, reductions in opioid consumption, and better patient outcomes. Implications for Nursing Practice Based on the results of the studies’ randomized controlled trials and meta-analyses, the effects of ketamine are shown as an adequate analgesic alternative to opioids postoperatively. The cited resources showed that ketamine can be used as a sole agent, or combined effectively with reduced doses of opioids for multimodal therapy. There were noted limitations in some of the research articles. Not all of the cited studies were able to include definitive evidence of proper blinding techniques or randomization methods. Small sample sizes and the inclusion of specific patient populations identified within several of the studies can skew data in one direction or another; therefore, significant clinical results cannot be generalized to patient populations across the board.

scholarly journals THE COMPARISON OF ETOMIDATE AND PROPOFOL FOR ATTENUATION OF HAEMODYNAMIC RESPONSE TO INDUCTION AND ENDOTRACHEAL INTUBATION

2020 ◽  
Vol 4 (3) ◽  
Author(s):  
Virendra Singh Rathore ◽  
Suresh Pandey ◽  
S.P. Chittora
Keyword(s):  
Renal Failure ◽  
Informed Consent ◽  
General Anesthesia ◽  
Endotracheal Intubation ◽  
Surgical Procedures ◽  
Cardiac Surgical Procedures ◽  
Hemodynamic Instability ◽  
Hemodynamic Stability ◽  
Medical College ◽  
Written Informed Consent

Background: This study is designed to compare the degree of attenuation of hemodynamic response to induction, laryngoscopy and endotracheal intubation of etomidate with those of propofol in patients undergoing noncardiac surgical procedures. Methods:  The present study conducted in Non Cardiac Surgeries in the Department of Anaesthesiology, Jhalawar Medical College & Associated Hospitals, Jhalawar, Rajasthan.After institutional ethical committee’s approval and written informed consent from the patient’s attendant in the format as per proforma, the present study was conducted on 60  patients of ASA Grade I and II of either sex, aged 18 to 60 years, scheduled for a variety of non-cardiac surgical procedures requiring general anaesthesia. Results: The findings of the study suggest that use of etomidate as inducing agent provides more hemodynamic stability as compared to propofol and can be preffered in patients prone to hemodynamic instability, cardiovascular abnormalities, hypovolemia, prone to renal failure due to hypotension. Propofol may be preffered for induction where hypertension is contraindicated or hypotension is preffered and myoclonus is to be avoided. Conclusion: Etomidate provides a more stable hemodynamics during general anesthesia as compared to propofol. Keyword:- Etomidate, Propofol, Hemodynamic.

scholarly journals Comparing pain control using oral acetaminophen versus dorsal penile block in neonatal circumcision

2019 ◽  
Vol 15 (1) ◽  
Author(s):  
Olakayode O. Ogundoyin ◽  
Dare I. Olulana ◽  
Taiwo A. Lawal ◽  
Felix O. Kumolalo
Keyword(s):  
Surgical Procedures ◽  
Pain Control ◽  
Hospital Setting ◽  
Pain Scores ◽  
Lidocaine Injection ◽  
Group A ◽  
The Mean ◽  
Neonatal Circumcision ◽  
Group B ◽  
Penile Block

Abstract Background Circumcision is one of the commonest surgical procedures performed yet the most controversial worldwide. Although various reasons have been suggested in support of circumcision, the pain and stress that accompany it on both neonates and mothers are factors against the procedure. This study compared pain control using oral acetaminophen syrup versus 1% lidocaine injection given as dorsal penile block during neonatal circumcision. Results There were 191 neonates in group A and 195 in group B. The mean age at circumcision was 23.71 (SD ± 20.39) days, and mean weight was 3.33 (SD ± 0.74) kg. The mean pain scores for group A immediately and 1 h after circumcision were 4.26 (SD ± 2.48) and 0.37 (SD ± 1.35), respectively. In group B, the mean pain scores immediately and 1 h after circumcision were 3.31 (SD ± 2.59) and 0.35 (SD ± 1.19), respectively. Conclusion Penile block gives better pain control in comparison with oral acetaminophen syrup, but both agents are effective and can be combined to provide a long-lasting perioperative anaesthesia and analgesia for circumcision in the hospital setting.

scholarly journals OPIOID USE IN ADOLESCENTS FOLLOWING HIP AND KNEE ARTHROSCOPY

2019 ◽  
Vol 7 (3_suppl) ◽  
pp. 2325967119S0008
Author(s):  
S. Clifton Willimon ◽  
Michael Busch ◽  
Melissa Christino ◽  
Belinda Schaafsma ◽  
Crystal Perkins
Keyword(s):  
Risk Factors ◽  
Pain Control ◽  
Knee Arthroscopy ◽  
Medication Use ◽  
Pain Medication ◽  
Opioid Use ◽  
Pain Scores ◽  
Pain Medications ◽  
Post Operative Pain ◽  
Opioid Medications

Background: The use and misuse of opioid medications has been declared an epidemic and public health emergency by the Centers for Disease Control. From 1999 – 2016, there was a 5-fold increase in overdose deaths secondary to opioids1. Pain control is an important component of post-operative care following orthopaedic surgery and opioid medications are commonly prescribed. The purpose of this study is to describe the average opioid use among adolescents following hip and knee arthroscopy. Methods: All patients less than 21 years of age undergoing ACL reconstruction, simple knee arthroscopy (plica and fat pad debridement, loose body removal, partial meniscectomy, or chondroplasty), and hip arthroscopy for femoroacetabular impingement were prospectively enrolled in this IRB-approved study. This is an interim report for an ongoing study with anticipated completion of enrollment in December 2018. All patients received hydrocodone-acetaminophen 5-325 mg for post-operative pain control. The number of pills prescribed was based on physician preference and was not dictated by the study. Patients and their families completed a medication logbook to track all doses of pain medication and associated pain scores. Risk factors for hydrocodone use following surgery were analyzed, including age, sex, race, pre-operative use of narcotic pain medications, surgical factors, and post-operative VAS pain scores. Results: A total of 65 patients were enrolled and completed the medication logbook, including 37 females and 28 males with a mean age of 15.6 years (range 7 – 20 years). Patients received a prescription for an average of 28 hydrocodone tablets (range 10 – 60) and 64 patients (98%) filled the prescription. The mean number and range of hydrocodone tablets consumed and remaining at the end of treatment and VAS pain scores at the time the patients consumed the pain medication are listed in the figure below. Forty-two patients (65%) reported one or more side effects from the hydrocodone, with the most common being drowsiness and constipation. There were no risk factors that predicted increased use of hydrocodone following ACL reconstruction or knee arthroscopy. Female sex and higher post-operative VAS pain scores predicted greater use of hydrocodone in patients following hip arthroscopy. Conclusions: Opioid medication use in adolescents following hip and knee arthroscopy is significantly less than the quantity of tablets prescribed, with 60% of the medication we prescribed remaining unused in the post-operative period. We recommend orthopaedic surgeons responsibly prescribe pain medications using evidence-based data or the results of their own experience monitoring medication consumption. Additionally, and important in the setting of the “opioid epidemic,” physicians must counsel patients and families of post-operative pain expectations and appropriate medication use. This study will provide the framework for the future development of educational resources regarding prescribing and use of pain medications for healthcare providers, patients, and caregivers. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2017 [Table: see text]

Risk Minimization Measures in Off-Label Drug Use: A Survey of Community Pharmacists in Malaysia

2020 ◽  
Vol 15 (3) ◽  
pp. 181-189
Author(s):  
Omotayo Fatokun
Keyword(s):  
Informed Consent ◽  
Drug Use ◽  
Perceived Risk ◽  
Adverse Drug Events ◽  
Community Pharmacists ◽  
Risk Minimization ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Off Label ◽  
Written Informed Consent

Background: While off-label drug use is common and sometimes necessary, it also presents considerable risks. Therefore, measures intended to prevent or reduce the potential exposure to off-label risks have been recommended. However, little is known about community pharmacists’ beliefs regarding these measures in Malaysia. Objectives: This study examined community pharmacists’ beliefs towards risk minimization measures in off-label drug use in Malaysia and assessed the relationship between perceived risk of off-label drug use and beliefs towards risk minimization measures. Methods: A cross-sectional survey was conducted among 154 pharmacists practicing in randomly selected community pharmacies in Kuala Lumpur and the State of Selangor, Malaysia. Results: The majority agreed or strongly agreed that adverse drug events from the off-label drug should be reported to the regulatory authority (90.9%) and the off-label drug should only be used when the benefit outweighs potential risks (88.3%). Less than half (48.1%) agreed or strongly agreed that written informed consent should be obtained before dispensing off-label drugs and a majority (63.7%) agreed or strongly agreed that the informed consent process will be burdensome to healthcare professionals. Beliefs towards risk minimization measures were significantly associated with perceived risk of off-label drug use regarding efficacy (p = 0. 033), safety (p = 0.001), adverse drug rection (p = 0.001) and medication errors (p = 0.002). Conclusion: The community pharmacists have positive beliefs towards most of the risk minimization measures. However, beliefs towards written informed consent requirements are not encouraging. Enhancing risk perception may help influence positive beliefs towards risk minimization measures.

274 Tumoral and peripheral immunophenotype of refractory vs relapse to PD-(L)1 blockade in patients with advanced non-small cell lung cancer

2020 ◽  
Vol 8 (Suppl 3) ◽  
pp. A299-A299
Author(s):  
Maria Ascierto ◽  
Matthew Hellmann ◽  
Nathan Standifer ◽  
Song Wu ◽  
Han Si ◽  
...  
Keyword(s):  
Gene Expression ◽  
Informed Consent ◽  
Checkpoint Inhibitors ◽  
Patient Response ◽  
Calcium Dependent ◽  
Immune Exhaustion ◽  
Previously Treated ◽  
Expression Pathways ◽  
Relapsed Disease ◽  
Written Informed Consent

BackgroundDespite the encouraging successes of immune checkpoint inhibitors, many patients do not benefit and are either refractory or relapse. The mechanisms of refractory or relapsed disease following PD-(L)1 blockade are largely unknown. To identify characteristics associated with refractory or relapsed disease we explored the immune and genomic landscape of samples derived from NSCLC patients who previously received PD-(L)1 blockade and had blood and fresh tumor biopsies collected at the time of progression.MethodsPatient response categories were defined prospectively; ‘refractory’ defined as progression within 16 weeks of initiating PD-(L)1 and ‘relapse’ defined as initial clinical benefit (CR, PR, SD) followed by progression. RNAseq (n=52) and PD-L1 IHC (n=22) were performed on tumor tissue. Immune profiling of whole blood was assessed using flow cytometry or Biomark HD (Fluidigm) gene expression panel (n=54 and n=62, respectively). Differential gene expression was defined as unadjusted p<0.05 and fold-difference >1.5. Pathways analysis was conducted by David tool. Patient samples were collected during screening for clinical trial of second line immunotherapy. Written informed consent was obtained from the patients for publication of this abstract.ResultsIn patients with NSCLC previously treated with PD-(L)1 blockade, tumors of relapsed patients were characterized by increased expression of genes associated with interferon signaling (e.g. CXCL9, SPIC, IFNg), immune suppression (e.g. ARG1, TGFB), immune exhaustion (e.g. ADORA2A), and increased PD-L1 expression (by gene expression and IHC). Refractory disease was associated with increased cadherin signaling and calcium-dependent-cell-adhesion gene expression pathways. In the periphery, reduced quantities of B cells and activated (HLA-DR+ or CD38+) or proliferating (Ki67+) CD8+ T cells were observed in refractory patients.ConclusionsThe tumor and peripheral compartments of patients with NSCLC previously treated with PD-(L)1 blockade differ based on prior response. Relapsed patients tend to have signals of sturdy immune activation and chronic inflammation thus ultimately leading to immune exhaustion. These results may help inform rational therapeutic strategies to overcome resistance to PD-(L)1 blockade in NSCLC.Trial RegistrationNCT02000947Ethics ApprovalResearch on human samples here analyzed have been performed in accordance with the Declaration of Helsinki.ConsentWritten informed consent was obtained from the patient for publication of this abstract.

Pain perception in chronic knee osteoarthritis with varying levels of pain inhibitory control: an exploratory study

2020 ◽  
Vol 20 (4) ◽  
pp. 651-661
Author(s):  
Paulo E. P. Teixeira ◽  
Hanan I. Zehry ◽  
Swapnali Chaudhari ◽  
Laura Dipietro ◽  
Felipe Fregni
Keyword(s):  
Knee Osteoarthritis ◽  
Pain Intensity ◽  
Pain Perception ◽  
Small Sample Size ◽  
Linear Regression Analysis ◽  
Small Sample ◽  
Pain Modulation ◽  
Clinical Variables ◽  
Pain Scores ◽  
Intensity Perception

AbstractBackground and aimsPain is a disabling symptom in knee osteoarthritis (KOA) and its underlying mechanism remains poorly understood. Dysfunction of descending pain modulatory pathways and reduced pain inhibition enhance pain facilitation in many chronic pain syndromes but do not fully explain pain levels in chronic musculoskeletal conditions. The objective of this study is to explore the association of clinical variables with pain intensity perception in KOA individuals with varying levels of Conditioned Pain Modulation (CPM) response.MethodsThis is a cross-sectional, exploratory analysis using baseline data of a randomized clinical trial investigating the effects of a non-invasive brain stimulation treatment on the perception of pain and functional limitations due to KOA. Sixty-three subjects with KOA were included in this study. Data on pain perception, mood perception, self-reported depression, physical function, quality of life, and quantitative sensory testing was collected. Multiple linear regression analysis was performed to explore the association between the clinical variables with pain perception for individuals with different levels of CPM response.ResultsFor KOA patients with limited CPM response, perception of limitations at work/other activities due to emotional problems and stress scores were statistically significantly associated with pain scores, F(2, 37) = 7.02, p < 0.01. R-squared = 0.275. For KOA patients with normal CPM response, general health perception scores were statistically significantly associated with pain scores, F(1, 21) = 5.60, p < 0.05. R-squared = 0.2104. Limitations of this study include methodology details, small sample size and study design characteristics.ConclusionsPain intensity perception is associated differently with clinical variables according to the individual CPM response. Mechanistic models to explain pain perception in these two subgroups of KOA subjects are discussed.

scholarly journals The Association between Implementation an Enhanced Recovery after Cesarean Pathway with Standardized Discharge Prescriptions and Opioid Use and Pain Experience after Cesarean Delivery

2021 ◽  
Author(s):  
Jennifer A. McCoy ◽  
Sarah Gutman ◽  
Rebecca F. Hamm ◽  
Sindhu K. Srinivas
Keyword(s):  
Cesarean Delivery ◽  
Pain Control ◽  
Enhanced Recovery ◽  
Median Number ◽  
Baseline Survey ◽  
Quality Improvement Initiative ◽  
Opioid Use ◽  
Pain Scores ◽  
Patient Reported ◽  
Hospital Patients

Objective This study was aimed to evaluate opioid use after cesarean delivery (CD) and to assess implementation of an enhanced recovery after CD (ERAS-CD) pathway and its association with inpatient and postdischarge pain control and opioid use. Study Design We conducted a baseline survey of women who underwent CD from January to March 2017 at a single, urban academic hospital. Patients were called 5 to 8 days after discharge and asked about their pain and postdischarge opioid use. An ERAS-CD pathway was implemented as a quality improvement initiative, including use of nonopioid analgesia and standardization of opioid discharge prescriptions to ≤25 tablets of oxycodone of 5 mg. From November to January 2019, a postimplementation survey was conducted to assess the association between this initiative and patients' pain control and postoperative opioid use, both inpatient and postdischarge. Results Data were obtained from 152 women preimplementation (PRE) and 137 women post-implementation (POST); complete survey data were obtained from 102 women PRE and 98 women POST. The median inpatient morphine milligram equivalents consumed per patient decreased significantly from 141 [range: 90–195] PRE to 114 [range: 45–168] POST (p = 0.002). On a 0- to 10-point scale, median patient-reported pain scores at discharge decreased significantly (PRE: 7 [range: 5–8] vs. POST 5 [range: 3–7], p < 0.001). The median number of pills consumed after discharge also decreased significantly (PRE: 25 [range: 16–30] vs. POST 17.5 [range: 4–25], p = 0.001). The number of pills consumed was significantly associated with number prescribed (p < 0.001). The median number of leftover pills and number of refills did not significantly differ between groups. Median patient-reported pain scores at the week after discharge were lower in the POST group (PRE: 4 [range: 2–6] vs. POST 3[range: 1–5], p = 0.03). Conclusion Implementing an ERAS-CD pathway was associated with a significant decrease in inpatient and postdischarge opioid consumption while improving pain control. Our data suggest that even fewer pills could be prescribed for some patients. Key Points

Perceptions and Understanding of Diabetes Mellitus Technology in Adults with Type 1 or Type 2 DM: A Pilot Survey from Pakistan

2021 ◽  
pp. 193229682110111
Author(s):  
Sarah Nadeem ◽  
Uswah Siddiqi ◽  
Russell Seth Martins ◽  
Kaleemullah Badini
Keyword(s):  
Diabetes Mellitus ◽  
Pilot Study ◽  
Diabetes Care ◽  
Online Survey ◽  
Small Sample Size ◽  
Developed Countries ◽  
Small Sample ◽  
Cost Of Care ◽  
Cross Sectional ◽  
Specific Patient

Introduction: Diabetes mellitus technology (DMT) is increasingly used for routine management in developed countries, yet its uptake in developing countries is not as consistent. Multiple factors may influence this, including country specific patient perception regarding DMT. We conducted a pilot study in Pakistan to understand this important question which has not been studied yet. Methods: A cross-sectional pilot study was conducted in Pakistan. An anonymous survey exploring perceptions of diabetes technology was circulated on social media platforms, collecting responses over 2 weeks. Target population included adults (≥18 years) living in Pakistan, with DM1 or 2. Results: A total of 40 responses were received. The majority (36/40) reported using conventional glucometers. Nine used continuous glucose monitoring (CGM). Thirty-two of 40 patients believed DMT improved diabetes care, 22 felt it helped decreased risk of Diabetes-related complications. 15/40 stated that DMT results in increased cost of care. Sixteen reported their diabetes care teams had never discussed wearable DMT options whereas 11 disliked them because they did not want a device on their self. Conclusion: In our pilot study we have identified broad themes of opportunity and challenges to DMT use in Pakistan. Patients’ perceptions regarding DMT were generally positive but significant barriers to its acceptance included high cost, lack of discussion between doctor and patient about available technology and personal hesitation. Limitations of our study include sampling bias (online survey) and small sample size, but this data can help inform larger studies, to look at this important topic in greater detail.

scholarly journals Written Informed Consent—Translating into Plain Language. A Pilot Study

Healthcare ◽  
2021 ◽  
Vol 9 (2) ◽  
pp. 232
Author(s):  
Agnieszka Zimmermann ◽  
Anna Pilarska ◽  
Aleksandra Gaworska-Krzemińska ◽  
Jerzy Jankau ◽  
Marsha N. Cohen
Keyword(s):  
Informed Consent ◽  
Plain Language ◽  
Consent Forms ◽  
Software Analysis ◽  
Informed Consent Form ◽  
Education Levels ◽  
Polish Language ◽  
University Degree ◽  
Study Participants ◽  
Written Informed Consent

Background: Informed consent is important in clinical practice, as a person’s written consent is required prior to many medical interventions. Many informed consent forms fail to communicate simply and clearly. The aim of our study was to create an easy-to-understand form. Methods: Our assessment of a Polish-language plastic surgery informed consent form used the Polish-language comprehension analysis program (jasnopis.pl, SWPS University) to assess the readability of texts written for people of various education levels; and this enabled us to modify the form by shortening sentences and simplifying words. The form was re-assessed with the same software and subsequently given to 160 adult volunteers to assess the revised form’s degree of difficulty or readability. Results: The first software analysis found the language was suitable for people with a university degree or higher education, and after revision and re-assessment became suitable for persons with 4–6 years of primary school education and above. Most study participants also assessed the form as completely comprehensible. Conclusions: There are significant benefits possible for patients and practitioners by improving the comprehensibility of written informed consent forms.

Lumbosacral paraspinal interfascial plane blocks for pain control after feminizing genital gender affirmation surgery

2021 ◽  
Author(s):  
Sudipta Sen ◽  
Johanna B de Haan ◽  
Grace Guvernator ◽  
Andrzej P Kwater ◽  
Xuan T Langridge ◽  
...  
Keyword(s):  
Postoperative Pain ◽  
Pain Control ◽  
Case Series ◽  
Erector Spinae ◽  
Anesthetic Techniques ◽  
Pain Scores ◽  
Gender Affirmation ◽  
The Usa ◽  
Gender Affirmation Surgery ◽  
Regional Anesthetic

Aim: Feminizing genital gender affirmation surgery (fgGAS) is increasing in prevalence in the USA. Management of postoperative pain following fgGAS is challenging. We report a series of patients where post-fgGAS pain was adequately controlled with paraspinal blocks. Materials & methods: This is a case series of three patients who received bilateral lumbar and sacral erector spinae plane blocks after fgGAS. Block techniques, medications administered, opioid requirements and pain scores were reviewed. Results: Erector spinae plane blocks provided adequate analgesia for 24–48 h following the block. Conclusion: Currently, there are two regional anesthetic techniques described for the treatment of postoperative pain after fgGAS. We describe two additional approaches as options for improved pain management in this patient population.

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