Revision of expert panel's guidelines on postoperative pain management

Aubrun, Frédéric; Nouette‐Gaulain, Karine; Fletcher, Dominique; Belbachir, A.; Beloeil, Hélène; Carlès, Michel; Cuvillon, Philippe; Dadure, Christophe; Lebuffe, Gilles; Marret, Emmanuel; Martinez, Valéria; Michel, Olivier; Sabourdin, Nada; Zetlaoui, Paul

doi:10.1016/j.accpm.2019.02.011

Cited by 72 publications

(42 citation statements)

References 63 publications

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“…110 The results of this review are not congruent with the American Pain Society recommendation for using gabapentinoids in the perioperative period, 22 as well as other societies suggesting that gabapentinoids may be beneficial in surgery associated with pronociceptive pain. 23,111 These recommendations are based on the results of a systematic review evaluating the perioperative use of pregabalin that included 33 trials. 34 Although interesting, this previous systematic review was designed to look at subgroups based on types of surgeries associated with potential pronociceptive pain mechanisms rather than using these subgroups to explain a potential overall effect.…”

Section: Quality Of the Evidencementioning

confidence: 99%

Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain

Verret¹,

Lauzier²,

Zarychanski³

et al. 2020

Anesthesiology

280

184

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Background Widely used for acute pain management, the clinical benefit from perioperative use of gabapentinoids is uncertain. The aim of this systematic review was to assess the analgesic effect and adverse events with the perioperative use of gabapentinoids in adult patients. Methods Randomized controlled trials studying the use of gabapentinoids in adult patients undergoing surgery were included. The primary outcome was the intensity of postoperative acute pain. Secondary outcomes included the intensity of postoperative subacute pain, incidence of postoperative chronic pain, cumulative opioid use, persistent opioid use, lengths of stay, and adverse events. The clinical significance of the summary estimates was assessed based on established thresholds for minimally important differences. Results In total, 281 trials (N = 24,682 participants) were included in this meta-analysis. Compared with controls, gabapentinoids were associated with a lower postoperative pain intensity (100-point scale) at 6 h (mean difference, −10; 95% CI, −12 to −9), 12 h (mean difference, −9; 95% CI, −10 to −7), 24 h (mean difference, −7; 95% CI, −8 to −6), and 48 h (mean difference, −3; 95% CI, −5 to −1). This effect was not clinically significant ranging below the minimally important difference (10 points out of 100) for each time point. These results were consistent regardless of the type of drug (gabapentin or pregabalin). No effect was observed on pain intensity at 72 h, subacute and chronic pain. The use of gabapentinoids was associated with a lower risk of postoperative nausea and vomiting but with more dizziness and visual disturbance. Conclusions No clinically significant analgesic effect for the perioperative use of gabapentinoids was observed. There was also no effect on the prevention of postoperative chronic pain and a greater risk of adverse events. These results do not support the routine use of pregabalin or gabapentin for the management of postoperative pain in adult patients. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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Section: Quality Of the Evidencementioning

confidence: 99%

Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain

Verret¹,

Lauzier²,

Zarychanski³

et al. 2020

Anesthesiology

280

184

View full text Add to dashboard Cite

show abstract

“…Furthermore, the analyzed literature, constrained mainly to the outpatient phase of perioperative care, has substantial methodological limitations, rendering the results deficient. Therefore, the available recommendations for outpatient use of opioids after surgery (24), are also based on insufficient evidence. Consequently, to formulate any putative recommendations against this backdrop, the necessity and distinct use of opioids by the various providers, and the differential risk of OUD at the various perioperative stages, must first be examined.…”

Section: Discussionmentioning

confidence: 99%

“…With literature broadly suggestive of high risk of OUD from prescription opioids for outpatient use (2,3,5) it may be useful to heed the proposed recommendations for outpatient analgesia after surgery, despite their unsubstantiated disposition. The latter generally endorse opioids of appropriate type and quantity prescribed commensurate to the nature of surgery and the expected duration of post-surgical pain, close monitoring of the patients' opioid consumption, and the preferential use of non-opioid analgesics (24). Following this pattern, weaning patients off opioids, and employing alternative non-opioid thera-…”

Section: Possible Risk Of Oud At Various Perioperative Stagesmentioning

confidence: 99%

Risk of Opioid Use Disorder from Exposure to Opioids in the Perioperative Period: A Systematic Review

et al. 2020

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Opioid use disorder, a major source of morbidity and mortality globally, is regularly linked to opioids given around the time of surgery. Perioperative period, however, is markedly heterogeneous, with the diverse providers using opioids distinctively, and the various drivers of opioid misuse at-play dissimilarly, throughout the perioperative period. The risk of opioid use disorder may, therefore, be different from opioids given at the various phases of perioperative care, and the ensuing recommendations for their use may also be dissimilar. Systematic search and analysis of the pertinent literature, following the accepted standards, showed an overall increased risk of misuse from the perioperative opioids. However, the analyzed studies had significant methodological limitations, and were constrained mainly to the outpatient phase of the perioperative period. Lacking any data, this risk, therefore, is unknown for intraoperative and postoperative recovery periods. Consequently, no firm recommendations can be extended to anesthesia providers generally managing these perioperative stages. Furthermore, with significant methodological limitations, the current recommendations for opioid use after surgery are also arbitrary. Thus, though proposals for perioperative opioid use are formulated in this article, substantive recommendations would require clear delineation of these risks, while avoiding the limitations noted in this review.

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“…A lack of significant use in in shoulder procedures may be related to proximity to sensitive structures in the neck, making precise needle placement necessary. Many practitioners may believe this procedure requires ultrasound guidance, as suggested by Veneziano et al [19]. However, the lower use of RA might also be explained by the fact that practitioners may not be as familiar with its use.…”

Section: Discussionmentioning

confidence: 99%

The Utilization of Regional Anesthesia Among Pediatric Patients: A Retrospective Study

et al. 2020

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Background The use of regional anesthesia (RA) in pediatric patients remains understudied, although evidence suggests benefits over general anesthesia. Questions/Purposes We sought to identify factors associated with RA use in patients under the age of 21 years undergoing ambulatory orthopedic surgery. Methods Patients under the age of 21 who underwent anterior cruciate ligament (ACL) repair or reconstruction, knee arthroscopy (KA), or shoulder arthroscopy (SA) were identified from the NY Statewide Planning and Research Cooperative System (SPARCS) database (2005–2015). Frequencies of RA use (defined by femoral nerve block, spinal, epidural, caudal, or brachial plexus anesthesia) were calculated. Multivariable regression analysis identified patient- and healthcare system–related factors associated with the use of RA. Odds ratios (OR) and 95% confidence intervals (CI) were reported. Results We identified 87,273 patients who underwent the procedures of interest (ACL n = 28,226; SA n = 18,155; KA n = 40,892). In our primary analysis, 14.4% (n = 1404) had RA as their primary anesthetic; this percentage increased for patients who had ACL or KA. When adjusting for covariates, Hispanic ethnicity (OR 0.78; CI 0.65–0.94) and Medicaid insurance (OR 0.75; CI 0.65–0.87) were associated with decreased odds for the provision of RA. Further, we identified increasing age (OR 1.10; CI 1.08–1.11), ACL versus SA (OR 1.91; CI 1.74–2.10), and sports injuries (OR 1.20; CI 1.10–1.31) as factors associated with increased odds of RA use. Conclusion In this analysis, RA was used in a minority of patients under the age of 21 undergoing ambulatory orthopedic surgery. Older age was associated with increased use while Hispanic ethnicity and lower socioeconomic status were associated with lower use.

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Revision of expert panel's guidelines on postoperative pain management

Cited by 72 publications

References 63 publications

Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain

Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain

Risk of Opioid Use Disorder from Exposure to Opioids in the Perioperative Period: A Systematic Review

The Utilization of Regional Anesthesia Among Pediatric Patients: A Retrospective Study

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