Non-opioid Multimodal Analgesia Research Articles

Implementation of a nonopioid multimodal analgesia protocol significantly reduces opioids prescribed after total shoulder arthroplasty: a retrospective study

BackgroundThe purpose of this study was to evaluate the impact of a nonopioid multimodal pain protocol on the amount of opioids prescribed, pain level, and complications in patients undergoing total shoulder arthroplasty (TSA) compared to a standard opioid regimen. MethodsWe retrospectively reviewed 2 consecutive cohorts who underwent either primary anatomic or reverse TSA by a single surgeon. The opioid cohort included patients from 2016 to 2020 who received an intraoperative periarticular injection (Ropivacaine, Epinephrine, and Ketorolac cocktail) and were prescribed Oxycodone/Acetaminophen 5/325 mg on discharge. The nonopioid cohort included patients from 2020 to 2022, consisting of preoperative oral analgesics (Celecoxib, Pregabalin, and Tramadol); intraoperative intravenous Dexamethasone and Acetaminophen and periarticular injection; and postoperative oral Dexamethasone and oral analgesics (Pregabalin, Tizanidine, Magnesium, Ibuprofen, and Acetaminophen). The nonopioid cohort had the option to ask for an opioid prescription postoperatively if needed. Patient-reported outcomes collected included visual analog scale scores for pain and Patient-Reported Outcome Measurement Information System up to 1 year after surgery. Opioid consumption using Morphine Milligram Equivalents were compared up to 3 months postoperatively. ResultsThere were 232 patients in the opioid and 112 in the nonopioid cohorts, respectively. The nonopioid protocol had lower mean visual analog scale scores at preoperative (6.4 vs. 7.4, P < .05), 10-day (3.5 vs. 4.2, P < .05), and 6-week postoperative time points (2.1 vs. 2.8, P < .05), but no differences between the groups were noted 3 months postoperatively. No differences in Patient-Reported Outcome Measurement Information System–upper extremity, pain interference, or depression were found preoperatively and up to 1 year after surgery. Opioid consumption was lower in the nonopioid cohort at all time periods (P < .01). Patients in the nonopioid cohort had significantly lower Morphine Milligram Equivalents at discharge, 10-day, 6-week, and 90-day time periods (P < .01) when compared to the opioid cohort. When analyzing risk factors for continued opioid prescriptions for the whole cohort, preoperative opioid use within 90 days before surgery (relative risk 4.69 [95% confidence interval 3.18-6.91; P < .01) and current tobacco use (relative risk 2.61 [95% confidence interval 1.50-4.54]; P = .01) were associated with continued refills >30 days. Complications in the perioperative period and 90-day hospital readmissions were not significantly different between the groups. ConclusionA nonopioid postoperative regimen for patients undergoing TSA significantly reduces opioid prescriptions with similar patient-reported outcomes, subjective pain scores, and without increased complication rates compared to an opioid-only regimen.

Non-opioid multimodal analgesia in the immediate postoperative period

Objective. To increase the effectiveness of postoperative multimodal analgesia using contact LED exposure with Russian BASI bracelets emitting in blue range 470 ± 10 nm and including magnesium sulfate in the multimodal postoperative analgesia protocol.Material and methods. To achieve the goal set in the work, the effectiveness of contact LED blood irradiation in blue range of 470 ± 10 nm at the microcirculation state was analyzed in patients of the main group (n = 46) in the immediate postoperative period. We studied the percentage of oxygen, as well as the acid-base state of venous blood before and after contact LED exposure. In the comparison group (n = 42), patients did not have contact LED blood irradiation in the immediate postoperative period.To study the effectiveness of contact LED blood irradiation at blood coagulation parameters, a series of coagulograms of blood samples taken from patients of both groups was done: once (before surgery) in the preoperative period and once in the immediate postoperative period up to 6 hours, because after 6 hours, anticoagulant therapy was administered according to the protocol. Coagulological testing was performed using Sysmex CA-560 apparatus (Japan). The acid-base state of venous blood was evaluated using Gem Premier 3000 apparatus manufactured by Instrumentation Laboratory.Research results. Coagulation tests revealed a positive effect of contact LED blood irradiation in patients of the main group. This effect was manifested in the stable trend of shifts towards moderate hypocoagulation in postoperative hemostatic parameters in all studied stages, what indicates the prevention of possible complications like thromboembolism in the postoperative period.Conclusion. Contact LED blood irradiation in blue range 470 ± 10 nm prevents thromboembolism in the postoperative period and allows to achieve pain relief without narcotic analgesics on the first day after the surgery.

Incidence of opioid use and early postoperative pain intensity after primary unilateral inguinal hernia repair at a single-center specialty hospital.

This research examined opioid use, pain intensity, and pain management after primary unilateral inguinal hernia repair (PUIHR) at a single-center specialty hospital. After research, ethics board approval, and informed consent, pain scores (0-10 numerical rating scale [NRS]) were obtained from survey-based questionnaires administered at the pre- and 3-day postoperative timepoints. Descriptive results are presented as frequency, mean, standard deviation, range, median, and interquartile ranges, as appropriate. Significance tests were conducted to compare participants who did and did not receive opioids after surgery. p-value <0.05 is considered statistically significant. As the standard of care, participants received nonopioid multimodal analgesia (acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs)) and opioids, when necessary. A total of 414 and 331 participants completed the pre- and 3-day postoperative questionnaires, respectively. Out of the 414 participants, 38 (9.2%) received opioids during the postoperative stay. There was no significant difference between pain frequency or mean preoperative NRS pain intensity scores of those who did and did not receive opioids. Mean NRS pain intensity scores on day 3 after surgery were significantly higher for participants who received opioids (3.15±2.08) than those who did not (2.19±1.95), p=0.005. Most participants did not receive opioids after PUIHR and had lower mean postoperative NRS pain intensity scores compared to those who did, most likely reflecting the need for opioids among the latter. Opioids were discontinued by day 3 for all participants who received them. Therefore, for most patients undergoing PUIHR, effective pain control can be achieved with nonopioid multimodal analgesia in the early postoperative period.

Comparing Clinical Efficacy of Non-Opioid and Opioid-Based Analgesia Protocols [Letter

Letter for the article Comparison of a Non-Opioid Multimodal Analgesia Protocol with Opioid-Based Patient-Controlled Analgesia for Pain Control Following Robot-Assisted Radical Prostatectomy: A Randomized, Non-Inferiority Trial

Comparison of a Non-Opioid Multimodal Analgesia Protocol with Opioid-Based Patient-Controlled Analgesia for Pain Control Following Robot-Assisted Radical Prostatectomy: A Randomized, Non-Inferiority Trial.

Opioid use after surgery is a potential contributor to the opioid epidemic. An adequate pain control method after surgery while minimizing opioid exposure is needed. This study aimed to compare the effect of non-opioid multimodal analgesia (NOMA) protocol with opioid-based patient-controlled analgesia (PCA) for pain relief after robot-assisted radical prostatectomy (RARP). This prospective randomized, open, non-inferiority trial included 80 patients scheduled for RARP. The NOMA group received pregabalin, paracetamol, bilateral quadratus lumborum block, and pudendal nerve block. PCA group received PCA. Pain scores, postoperative nausea and vomiting, opioid requirements, and quality of recovery were recorded 48 hours after surgery. We found no significant differences in pain scores. The mean difference in pain score during rest at 24 h was 0.5 (95% CI -0.5 to 2.0). This result demonstrated the non-inferiority of NOMA protocol to PCA at our non-inferiority margin (-1). In addition, 23 patients in the NOMA group did not receive any opioid agonist for 48 h after surgery. Recovery of bowel function was also faster in the NOMA group than in the PCA group (25.0 hours vs 33.4 hours, p = 0.01). We did not evaluate whether our NOMA protocol could decrease the incidence of new continuous opioid use after surgery. NOMA protocol successfully controlled postoperative pain and was non-inferior to morphine-based PCA regarding patient-reported pain intensity. It also promoted recovery of bowel function and decreased postoperative nausea and vomiting.

Use of Scheduled Nonopioid Analgesia to Decrease Inpatient Opioid Consumption After Scheduled Cesarean Birth

ObjectiveTo compare opioid use and pain scores in women who had scheduled cesarean birth before and after implementing a scheduled nonopioid analgesia practice guideline. DesignQuality improvement project with a comparison of pre-/postintervention. Setting/Local ProblemA 170-bed community hospital where the administration of postcesarean pain medications was unstandardized. ParticipantsConvenience sample of 175 individuals who were scheduled for cesarean birth (106 in preintervention group and 69 in postimplementation group). Intervention/MeasurementsAll participants had received a dose of 150 mcg of intrathecal morphine intraoperatively. Care of participants in the postimplementation group included a new practice guideline using preoperative oral acetaminophen 1 g and postoperative intravenous ketorolac 30 mg that transitioned to ibuprofen 600 mg orally every 6 hours until discharge. Acetaminophen 1 g every 6 hours also continued until discharge. For breakthrough pain, oxycodone 5 mg to 10 mg was available. ResultsResults were analyzed using the chi-square and t test. There was a statistical difference in the mean milligram morphine equivalent consumed after scheduled cesarean birth (preintervention = 21.15 vs. postintervention = 3.91, p < .001). Postimplementation, 84.1% of participants did not consume any opioids beyond the intrathecal dose compared to 47.2% of participants preintervention. Mean pain scores decreased from 2.49 to 1.62 (p < .001), and there was an observed decrease of the highest reported pain score from 5.39 to 4.03 (p < .001). ConclusionThe results of this project support the current literature indicating that the administration of a scheduled nonopioid multimodal analgesia regimen to individuals with scheduled cesarean birth is an effective postoperative pain management strategy. This approach to managing surgical birth pain can decrease subjective reports of pain and overall opioid consumption during the hospital stay.

Elective surgery in ankle and foot disorders-best practices for management of pain: a guideline for clinicians.

Complex elective foot and ankle surgeries are often associated with severe pain pre- and postoperatively. When inadequately managed, chronic postsurgical pain and long-term opioid use can result. As no standards currently exist, we aimed to develop best practice pain management guidelines. A local steering committee (n = 16) surveyed 116 North American foot and ankle surgeons to understand the "current state" of practice. A multidisciplinary expert panel (n = 35) was then formed consisting of orthopedic surgeons, anesthesiologists, chronic pain physicians, primary care physicians, pharmacists, registered nurses, physiotherapists, and clinical psychologists. Each expert provided up to three pain management recommendations for each of the presurgery, intraoperative, inpatient postoperative, and postdischarge periods. These preliminary recommendations were reduced, refined, and sent to the expert panel and "current state" survey respondents to create a consensus document using a Delphi process conducted from September to December 2020. One thousand four hundred and five preliminary statements were summarized into 51 statements. Strong consensus (≥ 80% respondent agreement) was achieved in 53% of statements including the following: postsurgical opioid use risk should be assessed preoperatively; opioid-naïve patients should not start opioids preoperatively unless non-opioid multimodal analgesia fails; and if opioids are prescribed at discharge, patients should receive education regarding importance of tapering opioid use. There was no consensus regarding opioid weaning preoperatively. Using multidisciplinary experts and a Delphi process, strong consensus was achieved in many areas, showing considerable agreement despite limited evidence for standardized pain management in patients undergoing complex elective foot and ankle surgery. No consensus on important issues related to opioid prescribing and cessation highlights the need for research to determine best practice.

Bupivacaine/meloxicam ER: A New Dual-acting Extended-Release Local Anesthetic for Opioid-Sparing Postoperative Pain Management.

To review data for bupivacaine/meloxicam extended-release (ER) solution for management of postoperative pain and opioid-sparing effects. Literature search of PubMed (1946 to August 2021) and ProQuest (1946 to August 2021) was performed using the terms: Zynrelef, HTX-011, and "bupivacaine AND meloxicam." Additional information sources include ClinicalTrials.gov, prescribing information, Heron Therapeutics' Clinical and Economic Evidence Dossier, meeting abstracts, and references of identified articles. Clinical trials and articles evaluating bupivacaine/meloxicam ER for postoperative pain management. Bupivacaine is a short-acting local anesthetic. Its efficacy is negatively impacted by the acidic environment of surgical sites. Meloxicam, a nonsteroidal antiinflammatory, reduces inflammation at the surgical site and increases pH propagating bupivacaine movement into the neurons. In Phase 2 and Phase 3 clinical trials, bupivacaine/meloxicam ER was compared with bupivacaine HCl, bupivacaine ER, and meloxicam ER with and without scheduled nonopioid multimodal analgesia (MMA) in bunionectomies, herniorrhaphies, total knee arthroplasty and abdominoplasty. Postoperative pain was well controlled for 72 hours and consistently superior to placebo, with minimal or no opioid use. Wound healing was not impacted and adverse effects were similar to placebo (most commonly nausea, dizziness, constipation, and headaches). Bupivacaine/meloxicam ER is a viable, safe, nonopioid local anesthetic for sustained 72-hour postoperative pain management mitigating opioid consumption. Bupivacaine/meloxicam ER is the only dual-acting, extended-release local anesthetic available. It provides effective analgesia in the postoperative setting and successfully reduces or eliminates postoperative opioid consumption.

Opioid-Sparing Perioperative Analgesia Within Enhanced Recovery Programs.

Opioid-based analgesia in the perioperative period can provide excellent pain control, but this approach exposes the patient to avoidable side effects and possible harm. Optimal analgesia, an approach that targets the fastest functional recovery with adequate pain control while minimizing side effects, can be achieved with opioid minimization. Many different options for nonopioid multimodal analgesia exist and have been shown to be efficacious, with certain modalities being more beneficial for specific surgeries. This review will present the evidence and practical tips for these management strategies.

Bupivacaine/Meloxicam Prolonged Release: A Review in Postoperative Pain.

Prolonged-release (PR; as ascribed in the EU) or extended-release (as ascribed in the USA) bupivacaine/meloxicam (HTX-011; hereafter referred to as bupivacaine/meloxicam PR; Zynrelef®) is a synergistic fixed-dose combination (FDC) of the local anaesthetic bupivacaine and the NSAID meloxicam. It is approved in the EU and the USA to treat postoperative pain. After needle-free application at the surgical site, the novel polymer technology allows simultaneous diffusion of bupivacaine and meloxicam over 72h. In clinical trials, bupivacaine/meloxicam PR significantly reduced postoperative pain and opioid consumption relative to bupivacaine hydrochloride (HCl) and placebo in patients undergoing bunionectomy, herniorrhaphy or total knee arthroplasty (TKA). When used as the foundation of a scheduled non-opioid multimodal analgesia (MMA) regimen, bupivacaine/meloxicam PR further improved pain control and reduced the need for opioids following surgery. Bupivacaine/meloxicam PR was generally well tolerated, with a lower incidence of opioid-related adverse events than bupivacaine HCl and placebo. Although additional data would be beneficial, current evidence indicates that bupivacaine/meloxicam PR is a promising non-opioid treatment option for the management of postoperative pain.

Opioid-Free Recovery from Bunionectomy with HTX-011, a Dual-Acting Local Anesthetic Combining Bupivacaine and Meloxicam, as the Foundation of Non-Opioid Multimodal Analgesia.

There is a need for postoperative pain control that minimizes or eliminates opioid use during the first 72 hours following surgery, when pain is most severe. HTX-011 is an extended-release, dual-acting local anesthetic that demonstrated superior 72-hour analgesia over standard of care bupivacaine hydrochloride (HCl) and saline placebo in a phase 3 bunionectomy study (EPOCH-1). Having shown HTX-011 monotherapy is superior to bupivacaine HCl in reducing postoperative pain intensity and opioid use, this follow-on study evaluated the safety and efficacy of HTX-011 as the foundation of a multimodal analgesia (MMA) regimen using over-the-counter medications recommended by practice guidelines for pain management. Following regional anesthesia administered as a lidocaine block, patients underwent unilateral bunionectomy with osteotomy and internal fixation. Prior to closure, HTX-011 (up to 60 mg bupivacaine/1.8 mg meloxicam) was applied without a needle. Patients received scheduled postoperative MMA alternating ibuprofen (600 mg) and acetaminophen (1 g) every 3 hours for 72 hours. Efficacy was assessed based on pain intensity (numeric rating scale [NRS; 0-10]) and consumption of opioid rescue medication (intravenous morphine milligram equivalents [MME]). Adverse event and vital sign monitoring, plus laboratory and wound healing assessments, were used to determine safety. Over the 72-hour assessment period following bunionectomy, mean pain scores were mild in severity (NRS <4) and 22/31 patients (71%) experienced no severe pain (NRS ≥7) with HTX-011 as the foundation of scheduled, non-opioid MMA. Patients consumed an average of 1.61 MME total, with 24/31 (77%) requiring no opioid rescue medication (opioid-free). HTX-011 was well-tolerated and demonstrated no safety concerns with the inclusion of postoperative MMA. HTX-011 as the foundation of an MMA regimen including scheduled ibuprofen and acetaminophen maintained mean postoperative pain scores in the mild range and enabled opioid-free recovery for 77% of bunionectomy patients through the 28-day recovery period.

Review of nonopioid multimodal analgesia for surgical and trauma patients.

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. 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. 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.

Maximization of Non-Opioid Multimodal Analgesia in Ambulatory Surgery Centers

Ambulatory surgery centers aid the healthcare system by not only providing a cost-effective option for delivery of care but also by helping to reduce overwhelming case volumes at inpatient facilities. While outpatient protocols have been designed for an increasing number of surgical procedures, the inpatient to outpatient transition of surgery remains limited by both procedure type and patient comorbidities. This limitation stems in part from the heavy emphasis on accelerated discharge following outpatient procedures, given that prolonged recovery time is associated with delayed turnover and increased nursing care demands. Since its inception, enhanced recovery after surgery (ERAS) has aimed to primarily reduce the disruption of physiologic homeostasis that occurs secondary to surgery. More recently, the aim of ERAS has evolved to help transition inpatient procedures to outpatient settings and may even be useful in more emergent cases. It should be noted, however, that outpatient surgery even in combination with ERAS is not the best option for all patients, and the use of ERAS protocols should be complemented with predictive assessments of patient risk. Beyond augmenting the efficiency of outpatient surgery, ERAS protocols, when used in eligible patients and especially when combined with regional anesthetic techniques, are effective in delivering opioid-sparing pain management while increasing overall outcomes and patient satisfaction rates.

Can enhanced recovery protocols impact non-opioid multimodal analgesia use in all surgical patients?

• Multimodal analgesia is a key component of enhanced recovery pathways (ERPs). • Use of any element of non-opioid multimodal analgesia (NOMA) in non-ERP cases increased from 17.06% to 35.21%. • Patient, provider and procedure factors influenced increased adoption of multimodal analgesia • NOMA usage in non-ERP patients increased in conjunction with departmental education and implementation of ERP pathways.

Implementation of an Enhanced Recovery Protocol (ERP) is associated with an increase in the perioperative use of non-opioid multimodal analgesia for non-ERP patients

Study objectiveIncorporation of multimodal, non-opioid analgesic medications into patient care pathways has become a common theme of enhanced recovery pathways (ERPs), which have been shown to improve patient outcomes such as complication rates and length of stay. With surgical care episodes, patients also incur a significant risk of persistent postoperative opioid use, whether the surgery is classified as major or minor surgery. One method that has been shown to reduce perioperative opioid administration is a structured non-opioid multimodal analgesic strategy, widely utilized in ERPs. Despite well-defined benefits, the time to translate evidence-based approaches into clinical practice can be prolonged. This study examines the effect of implementation of an Enhanced Recovery Protocol (ERP) on the adoption of intraoperative multimodal analgesia outside of the auspices of an ERP care pathway, describing factors influencing the clinical implementation of non-opioid multimodal analgesia (NOMA) in routine practice. DesignRetrospective cohort analysis. SettingWe identified all surgical cases between January 2013 and December 2016 at Vanderbilt University Medical Center (VUMC). InterventionsNone. MeasurementsUsing both segmented and logistic regression approaches, we compared non-ERP surgical cases before and after the initial ERP education and implementation in April 2014. Outcomes included provider, patient, and procedural factors associated with utilization of non-opioid multimodal analgesia (NOMA) in the immediate perioperative period. Main resultsWe studied 73,560 non-ERP cases. Cases utilizing any element of NOMA increased from 17.06% to 35.21% (X2 = 2358, df = 1, p < 0.01) before and after the initial ERP pathway implementation. Patient factors influencing this increased adoption of multimodal analgesia included lower American Society of Anesthesiologists Physical Status Class, younger age, and Caucasian race. Cases with in-room providers who were residents or trainees (as opposed to nurse anesthetists) or providers who had a greater number of prior ERP pathway cases were more likely to use multimodal. Procedure-specific factors favoring multimodal included use of laparoscopy. The gynecologic, neurosurgical, and orthopedic cases were more likely to utilize multimodal analgesics. ConclusionsFrom 2013 to 2016, NOMA usage in non-ERP patients increased significantly and in association with departmental education and concomitant implementation of an ERP pathway. Factors associated with increased uptake of multimodal analgesia included the presence of trainees, providers with a higher number of previous ERP pathway cases, patients who were younger, healthier, female, Caucasian race, and having specific types of surgery.

Cognitive Effects of Perioperative Pregabalin: Comment.

We read with interest the recent article by Myhre et al.1 concerning the effects of pregabalin on cognitive function in the perioperative period. The authors note that there were significant changes in several components of the battery of tests, thus leaving the reader with the conclusion that pregabalin may cause significant detriment and demonstrably raise the risk of harm, including an increased risk of fall or behavior that would increase “risk of re-injury” (presumably wound dehiscence or other injury).1As we routinely use nonopioid multimodal analgesia in our practice of perioperative pain management, we have several questions about this article and the data presented. First, was any reduction in dosage considered if the patient experienced side effects of the pregabalin? This is important as the patients were likely naïve to gabapentinoids and the dose utilized is the maximum dose that has been studied perioperatively (300 mg/day). Second, it would be helpful for the authors to note the test-retest reliability of this battery of tests and the correlation between them. The authors’ conclusions suggested a significant risk, yet only two of the five tests showed any change from baseline and all of the tests were only administered once at each time point. Additionally, with approximately 20% of the patients in the control group not participating at 24 h due to pain or postoperative nausea and vomiting, could the authors comment on how stable their results would be if they assumed that these patients displayed poor function due to increased pain or an opioid effect? Third, it is unclear to the reader that a fraction of an error in two of the tests is a meaningful clinical difference at 3 to 5 days. What is the significance of 0.28 or 0.43 errors in actual practice? Finally, as the authors associate the change in executive function with an increased risk of fall in both the introduction and the discussion sections, it would be helpful for the reader to know whether this is speculative or if this event actually occurred in any patient.The authors declare no competing interests.

Opioid Versus Nonopioid Analgesia After Carpal Tunnel Release: A Randomized, Prospective Study.

Background: The purpose of this investigation was to compare pain control and patient satisfaction for conventional postoperative opioid analgesia and nonopioid multimodal analgesia after elective open or endoscopic carpal tunnel release (CTR). Methods: As part of a randomized, prospective study, patients undergoing primary, elective CTR were randomized to receive either postoperative opioids or nonopioid medications as part of a multimodal pain control strategy. Patients currently taking opioids were excluded. Patients completed a postoperative pain journal and completed the shortened version of the Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH), Boston Carpal Tunnel Questionnaire, Numeric Pain Rating Scale (NPRS), and satisfaction ratings at their 2-week visit. Results: A total of 68 patients were included. Preoperatively, there were no statistically significant differences between the 2 groups with respect to pain scores, coping skills, or carpal tunnel symptoms. At 2 weeks postoperatively, patients in the nonopioid group had lower average NPRS and QuickDASH scores. Patients who took opioids consumed an average of 5 pills. No patient randomized to the nonopioid group required any opioids. Patients in the nonopioid group demonstrated lower early postoperative NPRS scores. Patient satisfaction with their pain control regimen and outcome was not significantly different between the 2 groups at any time point. Conclusions: Nonopioid medications as part of a perioperative pain control strategy demonstrate improved pain scores compared with opioid medications with similar patient satisfaction and functional outcomes. Considering the risks associated with the use of opioid analgesics, we recommend against prescribing opioids after CTR, particularly in patients not currently taking narcotic medications.

Terapêutica anestésica para o alívio da dor aguda pós-colecistectomia videolaparoscópica: revisão sistemática.

Inappropriate therapy of postoperative pain in laparoscopic cholecystectomy may lead to late mobilization, patient dissatisfaction, delayed hospital discharge, and chronic pain development. Our objective was to identify the best therapeutic strategy available to the anesthesiologist for the acute postoperative pain of patients submitted to elective laparoscopic cholecystectomy. This is a systematic review that included 36 complete articles indexed in the Medline, Scopus, Web of Science and LILACS databases, with a five-year time cut (2012 to 2016), resulting from controlled and randomized studies that were submitted to qualitative analysis. In a proposal for multimodal analgesia, it is important to consider the contraindications, adverse effects, dose and optimal timing of interventions. Non-opioid drugs, such as non-steroidal anti-inflammatory drugs (NSAIDs)/cyclooxygenase-2 (COX-2) inhibitors, gabapentin/pregabalin, N-methyl-D-aspartate (NMDA) receptor antagonists, and others. Opioids may be used at low doses associated with multimodal therapy or are restricted to cases where non-opioid multimodal analgesia is insufficient. We conclude that there is no consensus as to the best analgesic strategy to be implemented in the acute postoperative pain of laparoscopic cholecystectomy, which requires its applicability in an individualized way, based on the scientific evidence found in the literature. As contribution to medical learning and practice, we point out the theoretical enrichment of the analgesic drug options available for the therapy of postoperative pain in patients submitted to elective laparoscopic cholecystectomy, and alert the team to consider the adverse effects of the interventions implemented.

Anesthesia for Ambulatory Major Total Joint Arthroplasty: The Future is Now!

The rapidly growing demands for total joint arthroplasty and changes in healthcare have resulted in these surgical procedures being performed in an outpatient/short-stay setting. For these procedures to be performed safely on an outpatient basis, it is necessary to implement multidisciplinary, multimodal protocols that improve functional outcomes, enhance recovery, and reduce the need for hospitalization. These protocols include appropriate patient selection, preoperative optimization of comorbid conditions, and patient education. In addition, use of minimally invasive surgical techniques along with fast-track anesthesia techniques as well as aggressive nonopioid multimodal analgesia and aggressive postoperative nausea and vomiting prophylaxis is necessary. Postoperatively, the focus is on early mobilization and accelerated physical therapy. Collectively, these fast-track methods result in an effective clinical pathway that improves outcomes and the patient experience. The purpose of this review article is to examine the perioperative considerations required for performing total hip and knee arthroplasties on an outpatient basis.