Systemic opioid regimens for postoperative pain in neonates.
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ABSTRACT:
SUBMITTER: Kinoshita M
PROVIDER: S-EPMC9841767 | biostudies-literature | 2023 Jan
REPOSITORIES: biostudies-literature
Publications
Systemic opioid regimens for postoperative pain in neonates.
Kinoshita Mari M Borges do Nascimento Israel Junior IJ Styrmisdóttir Lea L Bruschettini Matteo M
The Cochrane database of systematic reviews 20230116
<h4>Background</h4>Postoperative pain clinical management in neonates has always been a challenging medical issue. Worldwide, several systemic opioid regimens are available for pediatricians, neonatologists, and general practitioners to control pain in neonates undergoing surgical procedures. However, the most effective and safe regimen is still unknown in the current body of literature.<h4>Objectives</h4>To determine the effects of different regimens of systemic opioid analgesics in neonates su ...[more]
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Project description:ImportanceOpioids administered to treat postsurgical pain are a major contributor to the opioid crisis, leading to chronic use in a considerable proportion of patients. Initiatives promoting opioid-free or opioid-sparing modalities of perioperative pain management have led to reduced opioid administration in the operating room, but this reduction could have unforeseen detrimental effects in terms of postoperative pain outcomes, as the relationship between intraoperative opioid usage and later opioid requirements is not well understood.ObjectiveTo characterize the association between intraoperative opioid usage and postoperative pain and opioid requirements.Design, setting, and participantsThis retrospective cohort study evaluated electronic health record data from a quaternary care academic medical center (Massachusetts General Hospital) for adult patients who underwent noncardiac surgery with general anesthesia from April 2016 to March 2020. Patients who underwent cesarean surgery, received regional anesthesia, received opioids other than fentanyl or hydromorphone, were admitted to the intensive care unit, or who died intraoperatively were excluded. Statistical models were fitted on the propensity weighted data set to characterize the effect of intraoperative opioid exposures on primary and secondary outcomes. Data were analyzed from December 2021 to October 2022.ExposuresIntraoperative fentanyl and intraoperative hydromorphone average effect site concentration estimated using pharmacokinetic/pharmacodynamic models.Main outcomes and measuresThe primary study outcomes were the maximal pain score during the postanesthesia care unit (PACU) stay and the cumulative opioid dose, quantified in morphine milligram equivalents (MME), administered during the PACU stay. Medium- and long-term outcomes associated with pain and opioid dependence were also evaluated.ResultsThe study cohort included a total of 61 249 individuals undergoing surgery (mean [SD] age, 55.44 [17.08] years; 32 778 [53.5%] female). Increased intraoperative fentanyl and intraoperative hydromorphone were both associated with reduced maximum pain scores in the PACU. Both exposures were also associated with a reduced probability and reduced total dosage of opioid administration in the PACU. In particular, increased fentanyl administration was associated with lower frequency of uncontrolled pain; a decrease in new chronic pain diagnoses reported at 3 months; fewer opioid prescriptions at 30, 90, and 180 days; and decreased new persistent opioid use, without significant increases in adverse effects.Conclusions and relevanceContrary to prevailing trends, reduced opioid administration during surgery may have the unintended outcome of increasing postoperative pain and opioid consumption. Conversely, improvements in long-term outcomes might be achieved by optimizing opioid administration during surgery.
| S-EPMC10267849 | biostudies-literature
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| S-EPMC9732688 | biostudies-literature
Project description:BackgroundThis is an updated version of the original Cochrane review published in Issue 4, 2006. Patients may control postoperative pain by self administration of intravenous opioids using devices designed for this purpose (patient controlled analgesia or PCA). A 1992 meta-analysis by Ballantyne et al found a strong patient preference for PCA over non-patient controlled analgesia, but disclosed no differences in analgesic consumption or length of postoperative hospital stay. Although Ballantyne's meta-analysis found that PCA did have a small but statistically significant benefit upon pain intensity, a 2001 review by Walder et al did not find statistically significant differences in pain intensity or pain relief between PCA and groups treated with non-patient controlled analgesia.ObjectivesTo evaluate the efficacy and safety of patient controlled intravenous opioid analgesia (termed PCA in this review) versus non-patient controlled opioid analgesia of as-needed opioid analgesia for postoperative pain relief.Search methodsWe ran the search for the previous review in November 2004. For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 12), MEDLINE (1966 to 28 January 2015), and EMBASE (1980 to 28 January 2015) for randomized controlled trials (RCTs) in any language, and reference lists of reviews and retrieved articles.Selection criteriaWe selected RCTs that assessed pain intensity as a primary or secondary outcome. These studies compared PCA without a continuous background infusion with non-patient controlled opioid analgesic regimens. We excluded studies that explicitly stated they involved patients with chronic pain.Data collection and analysisTwo review authors independently extracted data, which included demographic variables, type of surgery, interventions, efficacy, and adverse events. We graded each included study for methodological quality by assessing risk of bias and employed the GRADE approach to assess the overall quality of the evidence. We performed meta-analysis of outcomes that included pain intensity assessed by a 0 to 100 visual analog scale (VAS), opioid consumption, patient satisfaction, length of stay, and adverse events.Main resultsForty-nine studies with 1725 participants receiving PCA and 1687 participants assigned to a control group met the inclusion criteria. The original review included 55 studies with 2023 patients receiving PCA and 1838 patients assigned to a control group. There were fewer included studies in our updated review due to the revised exclusion criteria. For the primary outcome, participants receiving PCA had lower VAS pain intensity scores versus non-patient controlled analgesia over most time intervals, e.g., scores over 0 to 24 hours were nine points lower (95% confidence interval (CI) -13 to -5, moderate quality evidence) and over 0 to 48 hours were 10 points lower (95% CI -12 to -7, low quality evidence). Among the secondary outcomes, participants were more satisfied with PCA (81% versus 61%, P value = 0.002) and consumed higher amounts of opioids than controls (0 to 24 hours, 7 mg more of intravenous morphine equivalents, 95% CI 1 mg to 13 mg). Those receiving PCA had a higher incidence of pruritus (15% versus 8%, P value = 0.01) but had a similar incidence of other adverse events. There was no difference in the length of hospital stay.Authors' conclusionsSince the last version of this review, we have found new studies providing additional information. We reanalyzed the data but the results did not substantially alter any of our previously published conclusions. This review provides moderate to low quality evidence that PCA is an efficacious alternative to non-patient controlled systemic analgesia for postoperative pain control.
| S-EPMC7387354 | biostudies-literature
Project description:BackgroundOpioids are commonly prescribed for postoperative pain, but may lead to prolonged use and addiction. Diabetes impairs nerve function, complicates pain management, and makes opioid prescribing particularly challenging.MethodsThis retrospective observational study included a cohort of postoperative patients from a multisite academic health system to assess the relationship between diabetes, pain, and prolonged opioid use (POU), 2008-2019. POU was defined as a new opioid prescription 3-6 months after discharge. The odds that a patient had POU was assessed using multivariate logistic regression controlling for patient factors (e.g., demographic and clinical factors, as well as prior pain and opiate use).FindingsA total of 43,654 patients were included, 12.4% with diabetes. Patients with diabetes had higher preoperative pain scores (2.1 vs 1.9, p<0.001) and lower opioid naïve rates (58.7% vs 68.6%, p<0.001). Following surgery, patients with diabetes had higher rates of POU (17.7% vs 12.7%, p<0.001) despite receiving similar opioid prescriptions at discharge. Patients with Type I diabetes were more likely to have POU compared to other patients (Odds Ratio [OR]: 2.22; 95% Confidence Interval [CI]:1.69-2.90 and OR:1.44, CI: 1.33-1.56, respectively).InterpretationIn conclusion, surgical patients with diabetes are at increased risk for POU even after controlling for likely covariates, yet they receive similar postoperative opiate therapy. The results suggest a more tailored approach to diabetic postoperative pain management is warranted.
| S-EPMC10449216 | biostudies-literature
Project description:BackgroundEpidural analgesia offers greater pain relief compared to systemic opioid-based medications, but its effect on morbidity and mortality is unclear. This review was originally published in 2006 and was updated in 2012 and again in 2016.ObjectivesTo assess the benefits and harms of postoperative epidural analgesia in comparison with postoperative systemic opioid-based analgesia for adults undergoing elective abdominal aortic surgery.Search methodsIn the updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and five trial registers in November 2014, together with reference checking to identify additional studies.Selection criteriaWe included all randomized controlled trials comparing postoperative epidural analgesia and postoperative systemic opioid-based analgesia for adults who underwent elective open abdominal aortic surgery.Data collection and analysisTwo authors independently assessed trial quality and extracted data. We contacted study authors for additional information and data when required. We assessed the level of evidence according to the scale provided by the GRADE working group.Main resultsWe included 15 trials published from 1987 to 2009 with 1498 participants in this updated review. Participants had a mean age between 60.5 and 71.3 years. The percentage of women in the included studies varied from 0% to 28.1%. Adding an epidural to general anaesthesia for people undergoing abdominal aortic repair reduced myocardial infarction (risk ratio (RR) 0.54 (95% confidence interval (CI) 0.30 to 0.97); I(2) statistic = 0%; number needed to treat for one additional beneficial outcome (NNTB) 28 (95% CI 19 to 1423), visual or verbal analogical scale (VAS) scores up to three days after the surgery (mean difference (MD) -1.78 (95% CI -2.32 to -1.25); I(2) statistic = 0% for VAS scores on movement at postoperative day one), time to tracheal extubation (standardized mean difference (SMD) -0.42 (95% CI -0.70 to -0.15); I(2) statistic = 83%; equivalent to a mean reduction of 36 hours), postoperative respiratory failure (RR 0.69 (95% CI 0.56 to 0.85); I(2) statistic = 0%; NNTB 8 (95% CI 6 to 16)), gastrointestinal bleeding (OR 0.20 (95% CI 0.06 to 0.65); I(2) statistic = 0%; NNTB 32 (95% CI 27 to 74)) and time spent in the intensive care unit (SMD -0.23 (95% CI -0.41 to -0.06); I(2) statistic = 0%; equivalent to a mean reduction of six hours). We did not demonstrate a reduction in the mortality rate up to 30 days (RR 1.06 (95% CI 0.60 to 1.86); I(2) statistic = 0%). The level of evidence was low for mortality and time before tracheal extubation; moderate for myocardial infarction, respiratory failure and intensive care unit length of stay; and high for gastrointestinal bleeding and VAS scores.Authors' conclusionsEpidural analgesia provided better pain management, reduced myocardial infarction, time to tracheal extubation, postoperative respiratory failure, gastrointestinal bleeding, and intensive care unit length of stay compared with systemic opioid-based drugs. For mortality, we did not find a difference at 30 days.
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Project description:IntroductionFilling an opioid prescription after a minor urologic procedure increases patient risk of overdose and misuse. Strategies to reduce the number of opioids reaching the community are critical. This study evaluates opioid use after minor urologic procedures at a Canadian academic center and guides future prescribing recommendations.MethodsWe prospectively evaluated patients over 18 years old undergoing minor urologic procedures (penile, scrotal, urethral, etc.) from September 2020 to May 2022. Consenting participants were given a pain diary and postoperative pain questionnaire. Patients on chronic pain medications or those who had major surgery within six months were excluded. Response rate, pain on visual analog scale, pain control satisfaction, quantity of opioids prescribed, and consumption of opioid and non-opioid medication were collected and analyzed.ResultsNinety-five patients met the inclusion criteria. The mean age was 61.7 years (range 20- 87) and 96% of patients identified as male. The response rate for the opioid diary and pain questionnaire was 57%. Forty-two patients (78%) were offered an opioid prescription following their surgery, but only 12 of those patients (22%) filled and consumed any opioids analgesics. Forty-two patients (78%) used no postoperative opioids, and the mean oral morphine equivalents (OME) consumed was 5.87 (standard deviation 16.7). There was a total of 259 OME unused from post-procedure prescriptions. The mean overall pain score for patients who did and did not fill opioid prescriptions were 3.18/10 and 1.79/10 (p<0.01), respectively, with mean overall pain management satisfaction score of 8.63/10 and 8.58/10 (p=0.94), respectively.ConclusionsMost patients undergoing minor urologic procedures do not require opioids to manage postoperative pain. Based on our data, we suggest that a prescription for 39 OME would adequately treat postoperative pain in 95% of patients undergoing minor urologic procedures. Education around pain management with non-narcotic modalities is imperative, and practice changes are warranted to address the opioid crisis within our specialty.
| S-EPMC10697706 | biostudies-literature
Project description:ObjectiveTo implement Standard Opioid Prescribing Schedules (SOPS) based on opioid use following urologic surgeries and to evaluate how evidence-based prescribing schedules affect opioid use and patient reported outcomes.MethodsPatients who underwent urologic surgeries within 6 procedure subtypes at UNC Health during the 2 study time periods ("pre-SOPS": 7/2017-1/2018, "post-SOPS": 7/2018-1/2019) were invited to complete a survey analyzing postoperative opioid usage, storage and disposal, and patient reported outcomes (including pain interference using a validated questionnaire). A pharmacy database provided medication prescribing data and patient demographics. During the pre-SOPS time period, baseline outcomes were measured. Following the pre-SOPS period, usage amounts were analyzed and Standard Opioid Prescribing Schedules were developed to guide prescriptions during the post-SOPS period. Descriptive summary statistics and appropriate t test or r2 were calculated.ResultsA total of 438 patients within 6 procedure types completed the survey (pre-SOPS: 282 patients, post-SOPS: 156 patients). Pre-SOPS, patients were prescribed significantly more 5-mg oxycodone tablets than used (20.9 vs 7.8, P <.001). Post-SOPS, compared to pre-SOPS amounts, patients were prescribed significantly fewer tablets (12.7 vs 20.9, P <.001) and used fewer tablets (5.3 vs 7.8, P = .003). No difference was observed in pain interference (average t-score (standard deviation): 54.33 (10.9) pre-SOPS vs 55.89 (9.1) post-SOPS, P = .125) or patient satisfaction (95% pre-SOPS vs 94% post-SOPS).ConclusionAdherence to data-driven postoperative opioid prescribing schedules reduce opioid prescriptions and use without compromising pain interference or patient satisfaction. These results have important implications for urologists' ability to decrease opioid prescriptions and fight the opioid epidemic.
| S-EPMC10278587 | biostudies-literature
Project description:Previous studies have associated mu-opioid receptor (OPRM1) genotype with pain and analgesia responses in postoperative and patient populations. This study investigates the role of catechol-O-methyltransferase (COMT) and OPRM1 genotypes in acute postoperative pain scores, opioid use, and opioid-induced sedation after surgical procedures for orthopedic trauma in an otherwise healthy patient population. Verbal pain/sedation scores, opioid use, and physiologic responses in the immediate postoperative period were examined for association with genetic variants in Caucasians genotyped for OPRM1 single nucleotide polymorphisms (SNPs) A118G and C17T and COMT SNPs. The OPRM1 A118G genotype was associated with patients' postoperative Numerical Pain scale (NPS) ratings at 15 min in the postanesthesia care unit (PACU) (p = .01) and patients' sedation scores at 15 min in the PACU (p = .02). COMT genotype (rs4818) was associated with opioid consumption in the first 45 min in the PACU (p = .04). NPS ratings at 45 min were also higher in the group of patients with A/A genotype of rs4680 than in patients with the other two genotypes at this SNP (p = .03). Our haplotype trend analysis identified a COMT haplotype "GCGG" significantly associated with NPS at 15 min (p = .0013), amount of opioids consumed in the first 45 min (p = .0024), and heart rate at 45 min in the PACU (p = .017). The results indicate that genetic variations in COMT contribute to the acute postoperative pain and analgesia responses and physiologic responses in this group of otherwise healthy postoperative orthopedic trauma patients.
| S-EPMC3815675 | biostudies-literature