Intravenous Magnesium – Lidocaine - Ketorolac Cocktail for Postoperative Opioid Resistant Pain: A Case Series of Novel Rescue Therapy

2020 ◽  
Vol 15 ◽  
Author(s):  
Christian Zanza ◽  
Yaroslava Longhitano ◽  
Edwin Lin ◽  
Jerry Luo ◽  
Marco Artico ◽  
...  
Keyword(s):  
Postoperative Pain ◽  
Pain Score ◽  
Rescue Therapy ◽  
Visual Analogue Pain Score ◽  
Visual Analogue Pain ◽  
Pain Scores ◽  
Intravenous Magnesium ◽  
Severe Postoperative Pain ◽  
Opioid Induced Hyperalgesia ◽  
Antinociceptive Tolerance

Background: Severe postoperative pain is principally managed by opioids. While effective, opioids do not provide adequate relief in many patients and cause many side effects including antinociceptive tolerance and opioid-induced hyperalgesia. To evaluate if a combination of intravenous Magnesium, Lidocaine, Ketorolac (MLK cocktail) is a useful rescue therapy through synergistic pharmacological mechanisms for acute pain relief. We present the intravenous combination of magnesium, lidocaine, and ketorolac (MLK cocktail) as a possible rescue for opioid insensitive severe postoperative pain. Materials and Methods: The principal settings were the post-operative care unit (PACU) and the surgical ward. We retrospectively analyzed the electronic medical record and anesthesia documents of 14 patients experiencing severe postoperative pain, >7/10 visual-analogue pain score (VAS), despite receiving at least 8 mg of intravenous morphine milligram equivalents (MME) after arrival in the LAC+USC Medical Center PACU between September 2012 and January 2013. The data reviewed included patients’ demographics, disease etiology, surgical procedure, opioids received perioperatively, and visual-analogue pain scores before and after each analgesic received, and after the MLK cocktail. The a priori primary outcome and a posteriori secondary outcome of this study is mean visual-analogue pain score and morphine milligram equivalent dose administered per hour, respectively. The main tool evaluated has been VAS score. Results: In patients who failed to respond to opioid analgesics, administration of the MLK cocktail improved the VAS pain scores immediately from 9.4 ± 1.0 to 3.6 ± 3.5. The MLK cocktail also decreased the MME doses/hour in the immediate 12 hours postoperative period from 12.4 ± 5.6 to 1.1 ± 0.9. Conclusions: In patients experiencing opioid-resistant severe postoperative pain, the magnesium, lidocaine, and ketorolac combination may be an effective non opioid rescue therapy. Additionally, magnesium, lidocaine, and ketorolac may be utilized in cases complicated by either antinociceptive tolerance or opioid-induced hyperalgesia, and can restore opioid responsiveness.

The analgesic efficacy of liposomal bupivacaine compared with bupivacaine hydrochloride for the prevention of postoperative pain: a systematic review and meta-analysis with trial sequential analysis

2021 ◽  
pp. rapm-2020-102427
Author(s):  
Hanns-Christian Dinges ◽  
Thomas Wiesmann ◽  
Berit Otremba ◽  
Hinnerk Wulf ◽  
Leopold H Eberhart ◽  
...  
Keyword(s):  
Systematic Review ◽  
Postoperative Pain ◽  
Pain Score ◽  
Meta Analysis ◽  
End Points ◽  
Liposomal Bupivacaine ◽  
Bupivacaine Hydrochloride ◽  
Pain Scores ◽  
Score Difference ◽  
The Mean

Background/ImportanceLiposomal bupivacaine (LB) is a prolonged release formulation of conventional bupivacaine designed for prolonging local or peripheral regional single injection anesthesia. To this day, the benefit of the new substance on relevant end points is discussed controversial.ObjectiveThe objective was to determine whether there is a difference in postoperative pain scores and morphine consumption between patients treated with LB and bupivacaine hydrochloride in a systematic review and meta-analysis.Evidence reviewRandomized controlled trials (RCT) were identified in Embase, CENTRAL, MEDLINE and Web of Science up to May 2020. Risk of bias was assessed using Cochrane methodology. Primary end points were the mean pain score difference and the relative morphine equivalent (MEQ) consumption expressed as the ratio of means (ROM) 24 and 72 hours postoperatively.Findings23 RCTs including 1867 patients were eligible for meta-analysis. The mean pain score difference at 24 hours postoperatively was significantly lower in the LB group, at −0.37 (95% CI −0.56 to −0.19). The relative MEQ consumption after 24 hours was also significantly lower in the LB group, at 0.85 (0.82 to 0.89). At 72 hours, the pain score difference was not significant at −0.25 (−0.71 to 0.20) and the MEQ ratio was 0.85 (0.77 to 0.95).ConclusionThe beneficial effect on pain scores and opioid consumption was small but not clinically relevant, despite statistical significance. The effect was stable among all studies, indicating that it is independent of the application modality.

scholarly journals Artrodese posterolateral vs artrodese circunferencial no tratamento da espondilolistese degenerativa: avaliação clínica e impacto do IMC nos resultados

2013 ◽  
Vol 12 (3) ◽  
pp. 204-208
Author(s):  
Filipe Rodrigues Duarte ◽  
António Manuel Santos Nogueira de Sousa ◽  
Frederico José Antunes Raposo ◽  
Luís Filipe Almeida Valente ◽  
António Moura Gonçalves ◽  
...  
Keyword(s):  
Pain Score ◽  
Oswestry Disability Index ◽  
Visual Analogue Pain Score ◽  
Visual Analogue Pain

OBJETIVO: O tratamento cirúrgico da espondilolistese degenerativa (ED) apresenta vantagens quando comparado com o tratamento conservador. As técnicas cirúrgicas evoluíram no sentido de optimizar a fixação vertebral após descompressão, com o intuito de aumentar a taxa de artrodese. A fixação pedicular associada à fusão intersomática permite aumentar a área de contacto ósseo e assim a taxa de fusão, mas serão os resultados clínicos e funcionais superiores? MÉTODOS: Estudo retrospectivo incluindo 51 indivíduos (idade média de 61,2 anos) submetidos a artrodese posterolateral (APL) (19) e artrodese circunferencial (360º) (32) de 1996 até 2009 com acompanhamento médio de 5,8 anos (2 a 14 anos). Incluídas apenas descompressões de um nível. Avaliação clínica (VAS - Visual Analogue Pain Score), satisfação global e avaliação funcional (Oswestry disability Index modificado). Cálculo do IMC (índice de massa corporal) - avaliação clínica e funcional IMC ≥30 vs IMC <30. Estudo estatístico com SPSS®. RESULTADOS: Os resultados mostram franca melhoria clínica e funcional no tratamento cirúrgico da espondilolistese degenerativa, independentemente das técnicas estudadas. A taxa de satisfação é igualmente elevada. No confronto entre as duas técnicas de fixação não houve diferenças estatisticamente significativas. Relativamente ao IMC, os pacientes não obesos tiveram melhores resultados clínicos (p<0,05), não havendo diferenças relativas à função entre os dois grupos. CONCLUSÃO: A descompressão seguida de instrumentação vertebral é um tratamento eficaz para os pacientes com espondilolistese degenerativa. A técnica de artrodese utilizada não influencia os resultados clínicos e funcionais

Early postoperative patient-controlled analgesia ratio predicts 24-hour morphine consumption and pain in children undergoing scoliosis surgery

2014 ◽  
Vol 10 (1) ◽  
pp. 39 ◽  
Author(s):  
Clyde T. Matava, MBCHB ◽  
Mark W. Crawford, MBBS ◽  
Carolyne Pehora, RN ◽  
Basem Naser, MD ◽  
Conor McDonnell, MBCHB
Keyword(s):  
Side Effects ◽  
Postoperative Pain ◽  
Hospital Stay ◽  
Univariate Analysis ◽  
Morphine Consumption ◽  
Scoliosis Surgery ◽  
Patient Controlled Analgesia ◽  
Duration Of Hospital Stay ◽  
Pain Scores ◽  
Severe Postoperative Pain

Background: The identification of patients at risk for developing severe postoperative pain and/or opioid-related side effects is difficult due to a lack of sensitive indicators. The patient-controlled analgesia (PCA) ratio of demands to deliveries is a potential tool for early identification of patients who experience severe postoperative pain. The authors hypothesized that the PCA ratio is able to predict morphine requirement in the first 24 hours after scoliosis surgery.Methods: The authors performed a retrospective study of adolescents who had surgery for idiopathic scoliosis. They collected data describing PCA demands and deliveries, morphine consumption, numerical rating scale (NRS) pain scores, opioidrelated side effects, and duration of hospital stay. Spearman rank analysis assessed association among 4-hour PCA ratios, NRS pain score, and 24-hour morphine consumption. Patients were divided into groups on the basis of PCA ratios <1.5 and ≥1.5. Univariate analysis and multiple regression were used to identify independent factors predictive for increased 24-hour morphine. Mann-Whitney rank-sum and Fisher exact tests were used to compare data. p < 0.05 was considered statistically significant.Results: One hundred forty-seven patients were included in the analysis, mean (SD) age and weight were 15 (1.8) years and 55 (27) kg, respectively. There was a significant positive correlation between the 4-hour PCA ratio and initial 24-hour cumulative morphine consumption (r = 0.33, p = 0.0002). Patients with a 4-hour PCA ratio ≥1.5 demonstrated a significantly greater initial 24-hour morphine consumption (p = 0.0002), greater pain scores at 24 hours after surgery (p = 0.02), a greater incidence of at least one opioid-related side effect within the initial 24 hours after surgery, and a longer duration of hospital stay (p = 0.04) compared with those patients with a 4-hour PCA ratio <1.5. PCA ratio ≥1.5, age, and patient sex were predictive for 24-hour morphine consumption.Conclusions: The authors have demonstrated that a PCA ratio of demands/deliveries ≥1.5 is predictive of increased opioid requirements and is associated with greater pain scores in the initial 24 hours after surgery, an increased incidence of opioid-related side effects, and duration of hospital stay.

One visual analogue pain score is sufficient after laparoscopic cholecystectomy

2002 ◽  
Vol 89 (1) ◽  
pp. 114-115 ◽  
Author(s):  
W. Schwenk ◽  
J. W. Mall ◽  
J. Neudecker ◽  
J. M. Müller
Keyword(s):  
Laparoscopic Cholecystectomy ◽  
Pain Score ◽  
Visual Analogue Pain Score ◽  
Visual Analogue Pain

scholarly journals Examining the Effects of Ketamine on Reducing the Incidence of Opiod-induced Hyperalgesia in the Perioperative Phase

2019 ◽  
Author(s):  
Marie Rahme
Keyword(s):  
Systematic Review ◽  
Postoperative Pain ◽  
Patient Outcomes ◽  
Perioperative Period ◽  
Opioid Consumption ◽  
Emotional Impact ◽  
Perioperative Phase ◽  
Pain Scores ◽  
Gate Control Theory ◽  
Opioid Induced Hyperalgesia

Pain in the postoperative period is a serious issue that can have a negative physical and emotional impact on patient outcomes. Complications from postoperative pain can have detrimental outcomes for patient’s health and wellbeing as well as the increased economic burden of continued treatment. Better management of pain in the perioperative phase can result in improved patient outcomes, fewer postoperative complications, and increased patient satisfaction. Although opioids are the mainstay of treatment in the perioperative period for pain management, abnormal pain responses such as hyperalgesia may be induced by administration of opioids. The purpose of this systematic review is to examine the effect of ketamine on reducing the phenomenon of opioid-induced hyperalgesia. After a comprehensive literature search, the PRISMA Statement was used to frame this systematic review and elevate the validity of the results by providing transparency and clarity of the findings. The theoretical framework that guided this systematic review was Melzack and Wall’s (1965) Gate Control Theory of Pain which encompassed the physiologic and emotional responses of pain. Studies incorporated in this systematic review were critically appraised to evaluate reliability of randomized control trials. Variables such as intraoperative doses of opioids, intraoperative ketamine doses, postoperative pain scores, postoperative opioid consumption, and evidence of hyperalgesia were evaluated and put into tables for comparison. The results of this systematic review support the use of ketamine in decreasing postoperative opioid consumption, decreasing postoperative pain scores, and decreasing the incidence of opioid induced hyperalgesia.

scholarly journals Intraoperative Dexmedetomidine has no Effect on Postoperative Pain Scores for Posterior Spinal Fusion

2021 ◽  
Vol 15 (1) ◽  
pp. 1-6
Author(s):  
Rebecca A. Hong ◽  
Aleda Leis ◽  
James Weinberg ◽  
G. Ying Li
Keyword(s):  
Postoperative Pain ◽  
Idiopathic Scoliosis ◽  
Spinal Fusion ◽  
Intrathecal Morphine ◽  
Posterior Spinal Fusion ◽  
P Value ◽  
Pain Scores ◽  
Significant Difference ◽  
Severe Postoperative Pain ◽  
Secondary Analyses

Background: Posterior Spinal Fusion (PSF) for idiopathic scoliosis results in severe postoperative pain. At our institution, a protocol for postoperative analgesia is followed, but anesthetic maintenance is decided by the anesthesiologist. Previous studies have shown that postoperative use of dexmedetomidine may improve analgesia for these patients, but the effect of intraoperative dexmedetomidine on postoperative pain scores remains unknown. Purpose: We sought to retrospectively compare pain scores from the Postoperative Anesthesia Care Unit (PACU) and from PACU discharge until midnight between PSF patients who did and did not receive intraoperative dexmedetomidine. Methods: After obtaining IRB approval, we retrospectively identified 79 patients aged 10-17 years who had undergone PSF for idiopathic scoliosis from June 2015-August 2018 and who received intrathecal morphine. Patients were then divided into two groups based on whether or not they received intraoperative dexmedetomidine. A multivariable linear regression model was constructed with the dependent variable of highest PACU pain score and exposure of interest intraoperative dexmedetomidine use. Secondary analyses were conducted similarly within those who received dexmedetomidine to examine the effects of dose on PACU pain scores, using a p-value < 0.05. Results: After adjusting for age, weight, sex, levels fused, intrathecal morphine, diazepam, and ketamine doses, there was no statistically significant difference in average PACU pain scores between those who did and did not receive intraoperative dexmedetomidine (β = -0.85, 95% CI: -2.48, 0.68; p = 0.31). Conclusion: Intraoperative use of dexmedetomidine during posterior spinal fusion for adolescent idiopathic scoliosis appears to have no effect on postoperative pain scores.

Treatment with Buttress Plate Technique for Symptomatic Ulnar Styloid Base Nonunion

2021 ◽  
Author(s):  
Ömer Faruk Kümbüloğlu ◽  
Necmi Cam ◽  
Hacı Mustafa Özdemir
Keyword(s):  
Pain Score ◽  
Mean Value ◽  
Dash Score ◽  
Visual Analogue Pain Score ◽  
Ulnar Styloid ◽  
Level Of Evidence ◽  
Visual Analogue Pain ◽  
Plate Technique ◽  
Buttress Plate

Abstract Background Surgical treatment options for symptomatic ulnar styloid base nonunion can be divided into two groups: styloid excision and styloid fixation methods. Styloid fixation is commonly performed using tension band wiring or distal ulna hook plate. However, these methods are more suitable for large styloids than small ones. For this reason, fixation of small styloids still remains a problem. Purpose To present the surgical details and results of patients operated using the buttress plate technique, due to the symptomatic ulnar styloid base nonunion. Patients and Methods In this study, 11 patients who underwent surgery for symptomatic ulnar styloid base nonunion using buttress plate technique were evaluated retrospectively. The patients were evaluated with the help of forearm and wrist range of motion, grip strength, disabilities of the arm, shoulder, and hand (DASH) score and visual analogue pain score. Results The mean follow-up period was 15 months (range: 13–21 months). Union was achieved in 10 patients. At the final follow-up, the forearm supination and pronation active range of motions were significantly higher than those in the preoperative period, the visual analogue pain score mean value was 0.7 (range: 0–5), and the DASH score mean value was 7 (range: 1–32). Conclusion We conclude that good results can be achieved with the buttress plate technique in patients with both large and small fragmented ulnar styloid base nonunions and no distal radioulnar joint instability. Level of Evidence This is a Level IV, therapeutic study.

scholarly journals Characterization of  self-anticipated surgical pain prior to general anesthesia - a prospective observational study

2021 ◽  
Author(s):  
Wei-Shu Chang ◽  
Yi-Ting Hsieh ◽  
Moa-Chu Chen ◽  
Shu-Ching Chang ◽  
Tzu-Shan Chen ◽  
...  
Keyword(s):  
Pain Management ◽  
Postoperative Pain ◽  
Observational Study ◽  
General Anesthesia ◽  
Pain Intensity ◽  
Pain Score ◽  
Prospective Observational Study ◽  
Rating Scale ◽  
Perioperative Period ◽  
Pain Scores

Abstract Background: Current postoperative pain management principles are primarily based on the type and extent of surgical interventions. This clinical study measured patient’s self-anticipated pain score before surgery and compared the scores with the pain levels and analgesic requirements after surgery.Methods: This prospective observational study recruited consecutive patients who received general anesthesia for elective surgeries in E-Da Hospital (Taiwan) between June and August 2018. Patients were asked to subjectively rate their highest anticipated pain level (numerical rating scale, NRS 0-10) for their scheduled surgical intervention during their preoperative anesthesia assessment. After the operation, the actual pain intensity (NRS 0-10) experienced by the patient in the post-anesthesia care unit (PACU) and the total dose of opioids administered during the perioperative period were recorded. Pain scores ³4 on the NRS were regarded as being unacceptable levels of anticipated or postoperative pain.Results: A total of 857 patients were included in the study. The final database included 49.2% males, and 73.7% of them have had previous operations. The mean anticipated pain score was 4.9±2.5 and 72.2% of the patients reported an anticipated NRS ³4 before their operations. Females anticipated significantly higher overall pain intensities than male patients (adjusted odds ratio 1.695, 95% confidence interval 1.252-2.295; P=0.001). Patients over 40 years of age reported significantly lower overall anticipated NRS scores (4.78±2.49 vs 5.36±2.50; P=0.003). Patients scheduled to receive more invasive surgical procedures were more likely to anticipate high pain intensity in the preoperative period (P<0.001). Higher anticipated pain scores (preoperative NRS³4) were associated with higher actual postoperative pain levels (P=0.032) in the PACU and higher total equivalent opioid use (P=0.001) for acute pain management during the perioperative period.Conclusion: This observational study found that females, younger patients (£40 years), and patients scheduled for more invasive surgeries anticipate significantly higher surgery-related pain. Therefore, appropriate preoperative counseling for analgesic control and management of exaggerated pain expectation in these patients are necessary to improve the quality of anesthesia delivered and patient’s satisfaction.

scholarly journals Comparison of the effect of dexmedetomidine with remifentanil on pain after lumbar laminectomy in patients under general anesthesia

2021 ◽  
Author(s):  
Shahryar Sane ◽  
Rahman Abasi vash ◽  
Farzaneh Joshaghani ◽  
Gonash Alizadeh ◽  
behzad gholamveisi ◽  
...  
Keyword(s):  
Heart Rate ◽  
Postoperative Pain ◽  
Pain Score ◽  
Lumbar Vertebrae ◽  
Pain Scores ◽  
Arterial Blood ◽  
Recovery Times ◽  
Age Range ◽  
Group D ◽  
Remifentanil Group

Backgrounds and objectives: Acute postoperative pain is still an issue in patients undergoing lumbar laminectomy surgery. We compared the effects of remifentanil and dexmedetomidine on pain intensity as well as the analgesic requirements in patients undergoing spinal surgery. Methods: This randomized clinical trial study was conducted on 60 patients in the age range of 20 to 60 years with ASA class one and two of the American Anesthesia Association under elective lumbar vertebrae laminectomy. Patients were divided into two groups: Remifentanil (group R) and Dexmedetomidine (group D). Before induction of anesthesia in R group patients, 0.01 می g / kg / min remifentanil was used. In group D, 0.3 dexmedetomidine was injected from µg / min / 50kg using a syringe pump. Postoperative pain score, nausea, and vomiting, mean arterial blood pressure, and heart rate at recovery times, 6, 12, and 24 hours after surgery were recorded. Results: The propofol infusion rate was significantly lower in the DEX group than in group R (P = 0.001). Pain scores except for 6h after surgery was significantly lower in group DEX. Analgesic consumption was significantly lower in group DEX (P=0.021). Mean arterial pressure during surgery, after laryngoscopy, and recovery was significantly lower in group DEX (P<0.05). The mean heart rate after laryngoscopy was significantly lower in group DEX (P=0.033). Conclusion: Intraoperative infusion of DEX improved hemodynamic parameters during surgery and decreased pain score, morphine use after lumbar laminectomy surgery.

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