Assessing a patient’s level of frailty before an operation can provide important insight into which individuals might develop postoperative complications.
A study by Dr. Balzer and his colleagues conducted a review of patients 65 years of age or older who were seen in the outpatient anesthesiology department for elective surgery from Jan. 14, 2016 through April 30, 2016. A frailty assessment was administered to 196 patients, consisting of a grip strength measurement, timed up-and-go test, a hemoglobin test, and a body mass index or serum albumin level as a test for malnutrition.
The patients were assigned 1 point for each pathologic test result. Patients scoring 0 to 1 point were designated “non-frail” (reference group; 68%); those with 2 points were “pre-frail” (23%) and those with 3 to 4 points were “frail” (9%). Postoperative complications were analyzed via ICD-10 diagnosis codes, and European Society of Cardiology/European Society of Anaesthesiology (ESC/ESA) guidelines were used to estimate operative risk.
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Surgery is on the move: With enhanced recovery protocols, procedures that once required several days of in-hospital recovery are shifting to the outpatient setting without compromising patient care. However, there are still major barriers to consider | Anesthesiology News
At the Interdisciplinary Conference on Orthopedic Value-Based Care, Tong Joo (T.J.) Gan, MD, FRCA, MHS, assessed the feasibility of outpatient arthroplasty and selected spine procedures. “Carefully selected patients in combination with enhanced recovery principles and pathways enable total knee replacement and spinal surgery to be done on an outpatient basis,” said Dr. Gan, who is professor and chairman of the Department of Anesthesiology, Stony Brook Medicine, in New York, “but pain management, postoperative nausea and vomiting (PONV) and rehabilitation are major constraints.”
In a narrative review by Henrik Kehlet, MD, the so-called “father of enhanced recovery after surgery” (ERAS), several potential barriers to outpatient total knee arthroplasty were delineated, including the patient’s social network and comorbidity profile, but pain was the major limiting factor (Bone Joint J 2015;97-B[10 Suppl A]:40-44). “Severity of pain was shown to be one of the main causes of increased length of stay,” Dr. Gan said. “Approximately 50% of patients reported moderate to major pain following surgery, and 30% had either severe or extreme pain.”
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Nikolajsen, L. (20170 Pain. 158(5) pp.769–770
In this issue of PAIN, Martinez and co-workers publish a systemic review with a meta-analysis of randomized trials on the effect of perioperative pregabalin for the prevention of chronic postsurgical pain (CPSP).12 The primary outcome was CPSP after 3 months. Secondary outcomes included CPSP after 6 and 12 months and CPSP with a neuropathic pain component (CPSPNP) after 3, 6, and 12 months. The review comprises 18 studies, of which only 15 studies presented data on the primary outcome. Nine of the 15 studies, accounting for 1492 out of 1884 patients (79%), were unpublished and mainly identified through registry searches and personal communication with the authors. Martinez et al. conclude that there is no evidence to support the use of perioperative pregabalin for the reduction of CPSP. The quality of evidence for reduction of CPSPNP was too low to make any recommendations.
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The original research article is available to download here
Guay, J. et al. Anesthesia & Analgesia. Published online: November 2 2016
Background: The aim of this review was to compare the effects of postoperative epidural analgesia with local anesthetics to postoperative systemic or epidural opioids in terms of return of gastrointestinal transit, postoperative pain control, postoperative vomiting, incidence of gastrointestinal anastomotic leak, hospital length of stay, and cost after abdominal surgery.
Methods: Trials were identified by computerized searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 12), Medical Literature Analysis and Retrieval System Online (MEDLINE) (from 1950 to December, 2014) and Excerpta Medica dataBASE (EMBASE) (from 1974 to December 2014) and by checking the reference lists of trials retained. We included parallel randomized controlled trials comparing the effects of postoperative epidural local anesthetic with regimens based on systemic or epidural opioids. The quality of the studies was rated according to the Cochrane tool. Two authors independently extracted data. We judged the quality of evidence according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) working group scale.
Results: Based on 22 trials including 1138 participants, an epidural containing a local anesthetic will decrease the time required for return of gastrointestinal transit as measured by time required to observe the first flatus after an abdominal surgery standardized mean difference (SMD) -1.28 (95% confidence interval [CI], -1.71 to -0.86; high quality of evidence; equivalent to 17.5 hours). The effect is proportional to the concentration of local anesthetic used. Based on 28 trials including 1559 participants, we also found a decrease in time to first feces (stool): SMD -0.67 (95% CI, -0.86 to -0.47; low quality of evidence; equivalent to 22 hours). Based on 35 trials including 2731 participants, pain on movement at 24 hours after surgery is also reduced: SMD -0.89 (95% CI, -1.08 to -0.70; moderate quality of evidence; equivalent to 2.5 on a scale from 0 to 10). Based on 22 trials including 1154 participants, we did not find a difference in the incidence of vomiting within 24 hours: risk ratio 0.84 (95% CI, 0.57-1.23); low quality of evidence. Based on 17 trials including 848 participants we did not find a difference in the incidence of gastrointestinal anastomotic leak: risk ratio 0.74 (95% CI, 0.41-1.32; low quality of evidence). Based on 30 trials including 2598 participants, epidural analgesia reduces length of hospital stay for an open surgery: SMD -0.20 (95% CI, -0.35 to -0.04; very low quality of evidence; equivalent to 1 day). Data on cost were very limited.
Conclusions: An epidural containing a local anesthetic, with or without the addition of an opioid, accelerates the return of the gastrointestinal transit (high quality of evidence). An epidural containing a local anesthetic with an opioid decreases pain after an abdominal surgery (moderate quality of evidence). An epidural containing a local anesthetic does not affect the incidence of vomiting or anastomotic leak (low quality of evidence). For an open surgery, an epidural containing a local anesthetic would reduce the length of hospital stay (very low quality of evidence).
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Grant, M. et al. (2016) Anesthesia & Analgesia. 123(5) pp. 1100–1107
Background: Nonopioid adjuvant medications are increasingly included among perioperative Enhanced Recovery After Surgery protocols. Preoperative pregabalin has been shown to improve postoperative pain and limit reliance on opioid analgesia. Our group investigated the ability of preoperative pregabalin to also prevent postoperative nausea and vomiting (PONV).
Methods: Our group performed a meta-analysis of randomized trials that report outcomes on the effect of preoperative pregabalin on PONV endpoints in patients undergoing general anesthesia.
Results: Among all included trials (23 trials; n = 1693), preoperative pregabalin was associated with a significant reduction in PONV (risk ratio [RR] = 0.53; 95% confidence interval [CI], 0.39–0.73; P = 0.0001), nausea (RR = 0.62; 95% CI, 0.46–0.83; P = 0.002), and vomiting (RR = 0.68; 95% CI, 0.52–0.88; P = 0.003) at 24 hours. Subgroup analysis designed to account for major PONV confounders, including the exclusion trials with repeat dosing, thiopental induction, nitrous oxide maintenance, and prophylactic antiemetics and including high-risk surgery, resulted in similar antiemetic efficacy. Preoperative pregabalin is also associated with significantly increased rates of postoperative visual disturbance (RR = 3.11; 95% CI, 1.34–7.21; P = 0.008) compared with a control.
Conclusions: Preoperative pregabalin is associated with significant reduction of PONV and should not only be considered as part of a multimodal approach to postoperative analgesia but also for prevention of PONV.
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Joshi, G. (2016) Journal of Clinical Anesthesia. 35, pp. 524–529
- Peripheral nerve block (PNB) improves pain control and reduces opioid requirements compared with opioids alone.
- Continuous PNB prolongs analgesia but introduces significant risks and challenges.
- The ideal PNB technique would have a sufficient duration of action and minimal risk of complications.
Peripheral nerve blocks (PNBs) are increasingly used as a component of multimodal analgesia and may be administered as a single injection (sPNB) or continuous infusion via a perineural catheter (cPNB). We undertook a qualitative review focusing on sPNB and cPNB with regard to benefits, risks, and opportunities for optimizing patient care. Meta-analyses of randomized controlled trials have shown superior pain control and reductions in opioid consumption in patients receiving PNB compared with those receiving intravenous opioids in a variety of upper and lower extremity surgical procedures. cPNB has also been associated with a reduction in time to discharge readiness compared with sPNB. Risks of PNB, regardless of technique or block location, include vascular puncture and bleeding, nerve damage, and local anesthetic systemic toxicity. Site-specific complications include quadriceps weakness in patients receiving femoral nerve block, and pleural puncture or neuraxial blockade in patients receiving interscalene block. The major limitation of sPNB is the short (12-24 hours) duration of action. cPNB may be complicated by catheter obstruction, migration, and leakage of local anesthetic as well as accidental removal of catheters. Potential infectious complications of catheters, although rare, include local inflammation and infection. Other considerations for ambulatory cPNB include appropriate patient selection, education, and need for 24/7 availability of a health care provider to address any complications. The ideal PNB technique would have a duration of action that is sufficiently long to address the most intense period of postsurgical pain; should be associated with minimal risk of infection, neurologic complications, bleeding, and local anesthetic systemic toxicity; and should be easy to perform, convenient for patients, and easy to manage in the postoperative period.
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Davidson, F. et al. (2016) Pain. 157(9). pp. 1872–1886
Pediatric surgeries are common and painful for children. Postoperative pain is commonly managed with analgesics; however, pain is often still problematic. Despite evidence for psychological interventions for procedural pain, there is currently no evidence synthesis for psychological interventions in managing postoperative pain in children.
The purpose of this review was to assess the efficacy of psychological interventions for postoperative pain in youth. Psychological interventions included Preparation/education, distraction/imagery, and mixed. Four databases (PsycINFO, PubMed, EMBASE, and Certified Index to Nursing and Allied Health Literature) were searched to July 2015 for published articles and dissertations.
We screened 1401 citations and included 20 studies of youth aged 2 to 18 years undergoing surgery. Two reviewers independently screened articles, extracted data, and assessed risk of bias. Standardized mean differences (SMDs) and 95% confidence intervals (CIs) were calculated using RevMan 5.3. Fourteen studies (1096 participants) were included in meta-analyses. Primary outcome was pain intensity (0-10 metric).
Results indicated that psychological interventions as a whole were effective in reducing children’s self-reported pain in the short term (SMD = −0.47, 95% CI = −0.76 to −0.18). Subgroup analysis indicated that distraction/imagery interventions were effective in reducing self-reported pain in the short term (24 hours, SMD = −0.63, 95% CI = −1.04 to −0.23), whereas preparation/education interventions were not effective (SMD = −0.27, 95% CI = −0.61 to 0.08).
Data on the effects of interventions on longer term pain outcomes were limited. Psychological interventions may be effective in reducing short-term postoperative pain intensity in children, as well as longer term pain and other outcomes (eg, adverse events) require further study.
Read the full review here