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1.
Nonopioid, Multimodal Analgesia as First-line Therapy After Otolaryngology Operations: Primer on Nonsteroidal Anti-inflammatory Drugs (NSAIDs).
Cramer, JD, Barnett, ML, Anne, S, Bateman, BT, Rosenfeld, RM, Tunkel, DE, Brenner, MJ
Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2021;(4):712-719
Abstract
OBJECTIVE To offer pragmatic, evidence-informed advice on nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy after surgery. This companion to the American Academy of Otolaryngology-Head & Neck Surgery (AAO-HNS) clinical practice guideline (CPG), "Opioid Prescribing for Analgesia After Common Otolaryngology Operations," presents data on potency, bleeding risk, and adverse effects for ibuprofen, naproxen, ketorolac, meloxicam, and celecoxib. DATA SOURCES National Guidelines Clearinghouse, CMA Infobase, National Library of Guidelines, NICE, SIGN, New Zealand Guidelines Group, Australian National Health and Medical, Research Council, TRIP database, PubMed, Guidelines International Network, Cochrane Library, EMBASE, CINAHL, BIOSIS Previews, ISI Web of Science, AHRQ, and HSTAT. REVIEW METHODS AAO-HNS opioid CPG literature search strategy, supplemented by PubMed/MEDLINE searches on NSAIDs, emphasizing systematic reviews and randomized controlled trials. CONCLUSION NSAIDs provide highly effective analgesia for postoperative pain, particularly when combined with acetaminophen. Inconsistent use of nonopioid regimens arises from common misconceptions that NSAIDs are less potent analgesics than opioids and have an unacceptable risk of bleeding. To the contrary, multimodal analgesia (combining 500 mg acetaminophen and 200 mg ibuprofen) is significantly more effective analgesia than opioid regimens (15 mg oxycodone with acetaminophen). Furthermore, selective cyclooxygenase-2 inhibition reliably circumvents antiplatelet effects. IMPLICATIONS FOR PRACTICE The combination of NSAIDs and acetaminophen provides more effective postoperative pain control with greater safety than opioid-based regimens. The AAO-HNS opioid prescribing CPG therefore prioritizes multimodal, nonopioid analgesia as first-line therapy, recommending that opioids be reserved for severe or refractory pain. This state-of-the-art review provides strategies for safely incorporating NSAIDs into acute postoperative pain regimens.
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2.
Are NSAIDs Safe? Assessing the Risk-Benefit Profile of Nonsteroidal Anti-inflammatory Drug Use in Postoperative Pain Management.
Chang, RW, Tompkins, DM, Cohn, SM
The American surgeon. 2021;(6):872-879
Abstract
In this article, we review controversies in assessing the risk of serious adverse effects caused by administration of nonsteroidal anti-inflammatory drugs (NSAIDs). Our focus is upon NSAIDs used in short courses for the management of acute postoperative pain. In our review of the literature, we found that the risks of short-term NSAID use may be overemphasized. Specifically, that the likelihood of renal dysfunction, bleeding, nonunion of bone, gastric complications, and finally, cardiac dysfunction do not appear to be significantly increased when NSAIDs are used appropriately after surgery. The importance of this finding is that in light of the opioid epidemic, it is crucial to be aware of alternative analgesic options that are safe for postoperative pain control.
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3.
Anesthesia Related to Breast Cancer Recurrence and Chronic Pain: A Review of Current Research.
Kujawa, E, Blau, A, Rametta, L
AANA journal. 2021;(4):291-298
Abstract
Patients with breast cancer often require several procedures requiring anesthesia, such as central venous catheter placements, mastectomies, lymph node dissections, and reconstructive surgeries. Recent research findings have suggested there may be a reduced risk of cancer recurrence and chronic pain with specific anesthetic techniques. Regional techniques, total intravenous anesthetics, and select adjuncts have been reviewed to identify their role in breast cancer recurrence and chronic pain. A review of the pathophysiology as it pertains to volatile anesthetics, propofol as a total intravenous anesthetic, paravertebral nerve blocks, dexmedetomidine, and ketorolac, as well as the role each of these plays in the prevention of chronic pain and cancer recurrence is provided. Current research and recommendations for practice are presented in the context of providing anesthesia to mitigate chronic pain and cancer recurrence in patients with breast cancer.
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4.
Review of nonopioid multimodal analgesia for surgical and trauma patients.
George, S, Johns, M
American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists. 2020;(24):2052-2063
Abstract
PURPOSE Pain is a frequent finding in surgical and trauma patients, and effective pain control remains a common challenge in the hospital setting. Opioids have traditionally been the foundation of pain management; however, these agents are associated with various adverse effects and risks of dependence and diversion. SUMMARY In response to the rising national opioid epidemic and the various risks associated with opioid use, multimodal pain management through use of nonopioid analgesics such as acetaminophen, nonsteroidal anti-inflammatory drugs, α 2 agonists, N-methyl-d-aspartate (NMDA) receptor antagonists, skeletal muscle relaxants, sodium channel blockers, and local anesthetics has gained popularity recently. Multimodal analgesia has synergistic therapeutic effects and can decrease adverse effects by enabling use of lower doses of each agent in the multimodal regimen. This review discusses properties of the various nonopioid analgesics and encourages pharmacists to play an active role in the selection, initiation, and dose-titration of multimodal analgesia. The choice of nonopioid agents should be based on patient comorbidities, hemodynamic stability, and the agents' respective adverse effect profiles. A multidisciplinary plan for management of pain should be formulated during transitions of care and is an area of opportunity for pharmacists to improve patient care. CONCLUSION Multimodal analgesia effectively treats pain while decreasing adverse effects. There is mounting evidence to support use of this strategy to decrease opioid use. As medication experts, pharmacists can play a key role in the selection, initiation, and dose-titration of analgesic agents based on patient-specific factors.
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Strategies of analgesic treatment after cesarean delivery. Current state and new alternatives.
Arroyo-Fernández, FJ, Calderón Seoane, JE, Torres Morera, LM
Revista espanola de anestesiologia y reanimacion. 2020;(3):167-175
Abstract
The number of caesarean sections performed worldwide is increasing, and with it, the need for the optimal analgesia strategies. Deficient postoperative analgesia increases the need for opioids, delays recovery, and is associated with chronic pain and postpartum depression. It is essential to find good postoperative pain control strategies that facilitate early mobility, early recovery, and early hospital discharge with minimal side effects on the mother and infant. Multimodal analgesia based on neuroaxial anaesthesia with morphine in combination with non-opioids such as non-steroidal anti-inflammatory drugs and paracetamol, gives the best post-caesarean analgesia outcome, and allows anaesthesiologists to reserve opioids, corticoids, gabapentin, magnesium or ketamine for situations where neuroaxial anaesthesia cannot be performed, for high-risk patients, or when pain is difficult to control. Peripheral nerve block techniques can also be added, such as transverse abdominis plane block, erector spinae block, or continuous wound infiltration.
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6.
Opioid Use and Misuse in Pregnancy.
Shatil, B, Landau, R
Clinics in perinatology. 2020;(4):769-777
Abstract
The rate of pregnant women with an opioid use disorder has risen drastically in the past 20 years, paralleling that in the general population. Pregnancies associated with opioid use, abuse, or dependence have significantly higher rates of complications, such as neonatal opioid withdrawal syndrome, intrauterine growth restriction, neural tube defects, stillbirth, increased maternal mortality, greater postpartum pain, and longer inpatient stays. Patient education about the risks and benefits of multimodal analgesia and empowering shared decision making may help curb the opioid epidemic. Tailoring pain management to individual needs might be the solution to the problem.
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7.
The Role of Exparel Plus Meloxicam for Postoperative Pain Management.
Kaye, AD, Novitch, MB, Carlson, SF, Fuller, MC, White, SW, Haroldson, AR, Kaiser, JA, Elkersh, MA, Brunk, AJ, Jeha, GM, et al
Current pain and headache reports. 2020;(3):6
Abstract
PURPOSE OF REVIEW Acute postoperative pain reduction is a major target against the opioid crisis. While opioids have traditionally been the mainstay for postoperative analgesia, current practice has focused on a multimodal approach to pain control, including ultrasound-guided blocks with longer acting local anesthetic agents. RECENT FINDINGS Non-steroidal anti-inflammatory drugs (NSAIDs), such as meloxicam, are an important class of medications utilized to manage pain in the perioperative period. An additional treatment used in perioperative or postoperative pain relief is Exparel, a bupivacaine (sodium channel blocker) liposomal injectable suspension with a 3-4-day duration of action. The long-acting mechanism and formulation of Exparel consistently has demonstrated decreased opioid use and pain scores in patients undergoing many different surgical procedures. A concern is that pH negatively alters the efficacy of bupivacaine, as in cases of inflamed tissue and acidic fluid pH. For this reason, a combination medication with both meloxicam and bupivacaine has been developed, which normalizes pH and has anti-inflammatory and anti-pain conduction properties. Clinical studies demonstrate that this combination agent can be extremely beneficial in treating postoperative pain. This manuscript summarizes the newest developments with regard to liposomal bupivacaine and the non-steroidal meloxicam, their roles in effective treatment of postoperative pain, contraindications, special considerations of using these medications, and future considerations. HTX-011 pairs up a new extended-release formulation of the local anesthetic bupivacaine with meloxicam, a well-established non-steroidal anti-inflammatory drug (NSAID).
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8.
Perioperative Opioid-sparing Strategies: Utility of Conventional NSAIDs in Adults.
Martinez, L, Ekman, E, Nakhla, N
Clinical therapeutics. 2019;(12):2612-2628
Abstract
PURPOSE Opioids have long been used to treat acute postsurgical and postprocedural pain; however, opioid-related adverse events (AEs) contribute to poor patient outcomes. In addition, perisurgical exposure to opioids can potentially increase the risk for opioid-use disorder. NSAIDs reduce pain and inflammation by a mechanism different from that of opioid analgesics and may be useful in reducing the need for opioid drugs as part of a multimodal analgesia strategy. We conducted this review to assess the effectiveness and tolerability of adjunctive conventional NSAIDs given systemically in the perioperative setting in terms of opioid-sparing effects observed postoperatively. METHODS Clinical trials published since 2000 that have assessed the opioid-sparing effects of conventional, nonselective NSAIDs were identified by a literature search using the PubMed search engine. Search terms were identified for the treatment of interest, the timing of the intervention, and the drugs of interest (NSAIDs). Data from studies that assessed opioid consumption outcomes with systemic NSAID administration were included in the review; data from studies in which NSAIDs were administered topically or via periarticular injection, local infiltration, or regional block were excluded. FINDINGS Upon full-text review of the search results, 32 studies were chosen for inclusion in this literature review. These studies included those that assessed diclofenac, ketorolac, ibuprofen, ketoprofen, dexketoprofen, flurbiprofen, lornoxicam, tenoxicam, meloxicam, and piroxicam. In studies in which NSAIDs were associated with opioid-sparing effects within the setting of patient-controlled analgesia, opioid use was reduced by 17%-∼50% with diclofenac, 9%-66% with ketorolac, 22%-46% with ibuprofen, 34%-66% with ketoprofen, 36%-50% with dexketoprofen, 38%-41% with tenoxicam, 36%-54% with lornoxicam, and ∼50% with flurbiprofen. No opioid-sparing effect was noted with meloxicam (1 study). The majority of studies that reported on pain-score changes revealed either pain reductions with NSAIDs versus placebo or similar pain scores between groups, indicating that NSAIDs did not compromise pain control. Although many studies found no difference in the prevalence of AEs in NSAID-treated patients compared with controls, several studies noted lower rates of nausea, vomiting, sedation, and pruritus with NSAIDs versus placebo. Conversely, NSAID-related AEs were few overall but included gastrointestinal bleeding, injection site reactions, transient oliguric renal failure, and dizziness. No surgery-related bleeding complications were observed. IMPLICATIONS NSAIDs have the potential to play an important role in reducing postoperative opioid requirements. Reducing the amount of opioids used could be expected to reduce opioid-related side effects and contribute to reversing the opioid epidemic.
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Adjuvants in clinical regional anesthesia practice: A comprehensive review.
Prabhakar, A, Lambert, T, Kaye, RJ, Gaignard, SM, Ragusa, J, Wheat, S, Moll, V, Cornett, EM, Urman, RD, Kaye, AD
Best practice & research. Clinical anaesthesiology. 2019;(4):415-423
Abstract
Adjuvants are medications that work synergistically with local anesthetics to help enhance the duration and quality of analgesia in regional techniques. Regional anesthesia has become more prevalent as evidence continues to show efficacy, enhancement of patient care, increased patient satisfaction, and improved patient safety. Practitioners in the perioperative setting need to not only be familiar with regional techniques but also the medications used for them. Some examples of adjuvant medications for regional techniques include dexamethasone, alpha 2 agonists such as clonidine and dexmedetomidine, midazolam, buprenorphine, NMDA antagonists, including ketamine and magnesium, neostigmine, sodium bicarbonate, epinephrine, and non-steroidal anti-inflammatory drugs. The aim of the present investigation, therefore, is to provide a comprehensive review of the most commonly used non-opioid adjuvants in clinical practice today. Regional adjuvants can improve patient safety, increase patient satisfaction, and enhance clinical efficacy. Future studies and best practice techniques can facilitate standardization of regional anesthesia adjuvant dosing when providing nerve blocks in clinical practice.
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10.
Ketorolac for postoperative pain in children.
McNicol, ED, Rowe, E, Cooper, TE
The Cochrane database of systematic reviews. 2018;(7):CD012294
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Abstract
BACKGROUND Children who undergo surgical procedures in ambulatory and inpatient settings are at risk of experiencing acute pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) can reduce moderate to severe pain without many of the side effects associated with opioids. However, NSAIDs may cause bleeding, renal and gastrointestinal toxicity, and potentially delay wound and bone healing. Intravenous administration of ketorolac for postoperative pain in children has not been approved in many countries, but is routinely administered in clinical practise. OBJECTIVES To assess the efficacy and safety of ketorolac for postoperative pain in children. SEARCH METHODS We searched the following databases, without language restrictions, to November 2017: CENTRAL (The Cochrane Library 2017, Issue 10); MEDLINE, Embase, and LILACS. We also checked clinical trials registers and reference lists of reviews, and retrieved articles for additional studies. SELECTION CRITERIA We included randomised controlled trials that compared the analgesic efficacy of ketorolac (in any dose, administered via any route) with placebo or another active treatment, in treating postoperative pain in participants zero to 18 years of age following any type of surgery. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors independently considered trials for inclusion in the review, assessed risk of bias, and extracted data. We analyzed trials in two groups; ketorolac versus placebo, and ketorolac versus opioid. However, we performed limited pooled analyses. We assessed the overall quality of the evidence for each outcome using GRADE, and created a 'Summary of findings' table. MAIN RESULTS We included 13 studies, involving 920 randomised participants. There was considerable heterogeneity among study designs, including the comparator arms (placebo, opioid, another NSAID, or a different regimen of ketorolac), dosing regimens (routes and timing of administration, single versus multiple dose), outcome assessment methods, and types of surgery. Mean study population ages ranged from 356 days to 13.9 years. The majority of studies chose a dose of either 0.5 mg/kg (as a single or multiple dose regimen) or 1 mg/kg (single dose with 0.5 mg/kg for any subsequent doses). One study administered interventions intraoperatively; the remainder administered interventions postoperatively, often after the participant reported moderate to severe pain.There were insufficient data to perform meta-analysis for either of our primary outcomes: participants with at least 50% pain relief; or mean postoperative pain intensity. Four studies individually reported statistically significant reductions in pain intensity when comparing ketorolac with placebo, but the studies were small and had various risks of bias, primarily due to incomplete outcome data and small sample sizes.We found limited data available for the secondary outcomes of participants requiring rescue medication and opioid consumption. For the former, we saw no clear difference between ketorolac and placebo; 74 of 135 (55%) participants receiving ketorolac required rescue analgesia in the post-anaesthesia care unit (PACU) versus 81 of 127 (64%) receiving placebo (relative risk (RR) 0.85, 95% confidence interval (CI) 0.71 to 1.00, P = 0.05; 4 studies, 262 participants). For opioid consumption in the PACU, we saw no clear difference between ketorolac and placebo (P = 0.61). For the time period zero to four hours after administration of the interventions, participants receiving ketorolac received 1.58 mg less intravenous morphine equivalents than those receiving placebo (95% CI -2.58 mg to -0.57 mg, P = 0.002; 2 studies, 129 participants). However, we are uncertain whether ketorolac has an important effect on opioid consumption, as the data were sparse and the results were inconsistent. Only one study reported data for opioid consumption when comparing ketorolac with an opioid. There were no clear differences between the ketorolac and opioid group at any time point. There were no data assessing this outcome for the comparison of ketorolac with another NSAID.There were insufficient data to allow us to analyze overall adverse event or serious adverse event rates. Although the majority of serious adverse events reported in those receiving ketorolac involved bleeding, the number of events was too low to conclude that bleeding risk was increased in those receiving ketorolac perioperatively. There was not a statistically significant increase in event rates for any specific adverse event, either in pooled analysis or in single studies, when comparing ketorolac and placebo. When comparing ketorolac with opioids or other NSAIDs, there were too few data to make any conclusions regarding event rates. Lastly, withdrawals due to adverse events were vary rare in all groups, reflecting the acute nature of such studies.We assessed the quality of evidence for all outcomes for each comparison (placebo or active) as very low, due to issues with risk of bias in individual studies, imprecision, heterogeneity between studies, and low overall numbers of participants and events. AUTHORS' CONCLUSIONS Due to the lack of data for our primary outcomes, and the very low-quality evidence for secondary outcomes, the efficacy and safety of ketorolac in treating postoperative pain in children were both uncertain. The evidence was insufficient to support or reject its use.