Perioperative prevention of chronic pain - Revision history

Mitchel.DeVita: cite

2022-02-27T23:48:28Z

cite

← Older revision		Revision as of 16:48, 27 February 2022
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	** Breast cancer surgery (89 patients): paravertebral block vs GA. Favored block OR .37 (95% CI .14-.94) NNT = 5<ref>Andreae MH, Andreae DA. Regional anaesthesia to prevent chronic pain after surgery: a Cochrane systematic review and meta-analysis. Br J Anaesth. 2013;111:711–720.</ref>.		** Breast cancer surgery (89 patients): paravertebral block vs GA. Favored block OR .37 (95% CI .14-.94) NNT = 5<ref>Andreae MH, Andreae DA. Regional anaesthesia to prevent chronic pain after surgery: a Cochrane systematic review and meta-analysis. Br J Anaesth. 2013;111:711–720.</ref>.
	** This evidence was graded as low-moderate quality		** This evidence was graded as low-moderate quality
	* A recent prospective RCT compared general anesthesia plus preoperative paravertebral block with ropivacaine vs saline placebo for partial or complete mastectomy.		* A recent prospective RCT compared general anesthesia plus preoperative paravertebral block with ropivacaine vs saline placebo for partial or complete mastectomy.<ref>Aline Albi-Feldzer, Sylvain Dureau, Abdelmalek Ghimouz, Julien Raft, Jean-Luc Soubirou, Guillaume Gayraud, Christian Jayr; Preoperative Paravertebral Block and Chronic Pain after Breast Cancer Surgery: A Double-blind Randomized Trial. ''Anesthesiology'' 2021; 135:1091–1103</ref>
	** Less acute postoperative pain was reported in the block group vs control group by VAS score (2.9 vs 4.3, P<.001) and by 73% less morphine use in the block group (OR .272, 95% CI .17-.43)		** Less acute postoperative pain was reported in the block group vs control group by VAS score (2.9 vs 4.3, P<.001) and by 73% less morphine use in the block group (OR .272, 95% CI .17-.43)
	** At 3 months chronic pain was reported in 52.2% in the paravertebral group vs 47.7% in the control group (OR 1.2, 95%CI .79-1.82)		** At 3 months chronic pain was reported in 52.2% in the paravertebral group vs 47.7% in the control group (OR 1.2, 95%CI .79-1.82)

Mitchel.DeVita: fixed error

2022-02-27T23:47:16Z

fixed error

← Older revision		Revision as of 16:47, 27 February 2022
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	** Breast cancer surgery (89 patients): paravertebral block vs GA. Favored block OR .37 (95% CI .14-.94) NNT = 5<ref>Andreae MH, Andreae DA. Regional anaesthesia to prevent chronic pain after surgery: a Cochrane systematic review and meta-analysis. Br J Anaesth. 2013;111:711–720.</ref>.		** Breast cancer surgery (89 patients): paravertebral block vs GA. Favored block OR .37 (95% CI .14-.94) NNT = 5<ref>Andreae MH, Andreae DA. Regional anaesthesia to prevent chronic pain after surgery: a Cochrane systematic review and meta-analysis. Br J Anaesth. 2013;111:711–720.</ref>.
	** This evidence was graded as low-moderate quality		** This evidence was graded as low-moderate quality
	* A recent prospective RCT compared preoperative paravertebral block with ropivacaine vs saline placebo ~~after~~ partial or complete mastectomy.		* A recent prospective RCT compared general anesthesia plus preoperative paravertebral block with ropivacaine vs saline placebo for partial or complete mastectomy.
	** ~~Greater~~ acute postoperative pain was reported in the block group vs control group by VAS score (2.9 vs 4.3, P<.001) and by 73% less morphine use in the block group (OR .272, 95% CI .17-.43)		** Less acute postoperative pain was reported in the block group vs control group by VAS score (2.9 vs 4.3, P<.001) and by 73% less morphine use in the block group (OR .272, 95% CI .17-.43)
	** At 3 months chronic pain was reported in 52.2% in the paravertebral group vs 47.7% in the control group (OR 1.2, 95%CI .79-1.82)		** At 3 months chronic pain was reported in 52.2% in the paravertebral group vs 47.7% in the control group (OR 1.2, 95%CI .79-1.82)
	** At 6 months chronic pain was reported in 58.4% in the paravertebral group vs 45.4% in the control group.		** At 6 months chronic pain was reported in 58.4% in the paravertebral group vs 45.4% in the control group.
			** Is is important to note that the paravertebral block may be insufficient for major breast surgery, as it misses key deep anatomic structures such as the pectoralis major and its fascia. This remains an important limitation to this study.

	===== TIVA vs Gas =====		===== TIVA vs Gas =====

Mitchel.DeVita: added a new study

2022-02-27T23:39:50Z

added a new study

← Older revision		Revision as of 16:39, 27 February 2022
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	===== General vs regional =====		===== General vs regional =====

	* Regional anesthesia is well established for acute pain. Do these benefits extend to chronic pain?		* Regional/neuraxial anesthesia is well established for acute pain. Do these benefits extend to chronic pain?
	* A Cochrane meta-analysis Regional anesthesia to prevent chronic pain (23 RCTs) at 6 months		* A Cochrane meta-analysis Regional anesthesia to prevent chronic pain (23 RCTs) at 6 months
	** Thoracotomy (250 patients): Epidural vs GA. Favored epidural for prevention of chronic pain OR .33, (95% CI .2-.56) NNT = 4		** Thoracotomy (250 patients): Epidural vs GA. Favored epidural for prevention of chronic pain OR .33, (95% CI .2-.56) NNT = 4
	** Breast cancer surgery (89 patients): paravertebral block vs GA. Favored block OR .37 (95% CI .14-.94) NNT = 5<ref>Andreae MH, Andreae DA. Regional anaesthesia to prevent chronic pain after surgery: a Cochrane systematic review and meta-analysis. Br J Anaesth. 2013;111:711–720.</ref>		** Breast cancer surgery (89 patients): paravertebral block vs GA. Favored block OR .37 (95% CI .14-.94) NNT = 5<ref>Andreae MH, Andreae DA. Regional anaesthesia to prevent chronic pain after surgery: a Cochrane systematic review and meta-analysis. Br J Anaesth. 2013;111:711–720.</ref>.
			** This evidence was graded as low-moderate quality
			* A recent prospective RCT compared preoperative paravertebral block with ropivacaine vs saline placebo after partial or complete mastectomy.
			** Greater acute postoperative pain was reported in the block group vs control group by VAS score (2.9 vs 4.3, P<.001) and by 73% less morphine use in the block group (OR .272, 95% CI .17-.43)
			** At 3 months chronic pain was reported in 52.2% in the paravertebral group vs 47.7% in the control group (OR 1.2, 95%CI .79-1.82)
			** At 6 months chronic pain was reported in 58.4% in the paravertebral group vs 45.4% in the control group.

	===== TIVA vs Gas =====		===== TIVA vs Gas =====

Mitchel.DeVita at 15:42, 24 February 2022

2022-02-24T15:42:21Z

← Older revision		Revision as of 08:42, 24 February 2022
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	=== Modification of surgical technique ===		=== Modification of surgical technique ===
			'''Minimize risk of nerve damage, Less surgical trauma = less chronic pain'''
	~~=====~~ Minimize risk of nerve damage, Less surgical trauma = less chronic pain ~~=====~~

	* Cochrane review of 41 trials, Laparoscopic vs open inguinal hernia repair		* Cochrane review of 41 trials, Laparoscopic vs open inguinal hernia repair
	* Less persisting pain (pain of any severity at 12 months) in laparoscopic group – OR 0.54, 95% CI 0.46 to 0.64; p<0.0001)		* Less persisting pain (pain of any severity at 12 months) in laparoscopic group – OR 0.54, 95% CI 0.46 to 0.64; p<0.0001)
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	=== Control preoperative pain/risk factors ===		=== Control preoperative pain/risk factors ===
			'''Poorly controlled preop pain may be a trigger for central sensitization'''
	~~=====~~ Poorly controlled preop pain may be a trigger for central sensitization ~~=====~~

	* Karanikolas et al., Optimized perioperative analgesia reduces chronic phantom limb pain intensity, prevalence, and frequency		* Karanikolas et al., Optimized perioperative analgesia reduces chronic phantom limb pain intensity, prevalence, and frequency
	** Prospective, randomized, trial of 65 patients undergoing lower limb amputation		** Prospective, randomized, trial of 65 patients undergoing lower limb amputation

Mitchel.DeVita at 15:41, 24 February 2022

2022-02-24T15:41:35Z

← Older revision		Revision as of 08:41, 24 February 2022
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	== Preventive vs. Pre-emptive ==		== Preventive vs. Pre-emptive ==
			Pre-emptive Analgesia
	~~=====~~ Pre-emptive Analgesia ~~=====~~
	* Analgesia administered before incision targeting immediate perioperative period		* Analgesia administered before incision targeting immediate perioperative period
			Preventive Analgesia
	~~=====~~ Preventive Analgesia ~~=====~~
	* Reduce sensitization from the barrage of nociceptive afferent input to achieve neuroprotection from pathological changes in central pain pathways.		* Reduce sensitization from the barrage of nociceptive afferent input to achieve neuroprotection from pathological changes in central pain pathways.
	* The effects must outlast the expected pharmacokinetic effect of the drug itself		* The effects must outlast the expected pharmacokinetic effect of the drug itself

Mitchel.DeVita: adjusted formatting and updated things

2022-02-24T15:40:48Z

adjusted formatting and updated things

Show changes

Tony.Wang: Formatting

2021-08-30T17:44:49Z

Formatting

← Older revision		Revision as of 10:44, 30 August 2021
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	** Generalizability to other surgeries		** Generalizability to other surgeries

	==== Overview Summary Systematic Review<ref>Humble SR, Dalton AJ, Li L. A sythoracotomystematic review of therapeutic interventions to reduce acute and chronic post-surgical pain after amputation, or mastectomy. Eur J Pain. 2015;19(4):451-465. doi:10.1002/ejp.567</ref> ====		==== Overview Summary Systematic Review ====

	* A systematic review of therapeutic interventions to reduce acute and chronic post-surgical pain after amputation, thoracotomy or mastectomy		* A systematic review of therapeutic interventions to reduce acute and chronic post-surgical pain after amputation, thoracotomy or mastectomy<ref>Humble SR, Dalton AJ, Li L. A sythoracotomystematic review of therapeutic interventions to reduce acute and chronic post-surgical pain after amputation, or mastectomy. Eur J Pain. 2015;19(4):451-465. doi:10.1002/ejp.567</ref>
	** 32 RCTs: Overall high heterogeneity in studies. •Gabapentinoids: reduced chronic pain after mastectomy, but single preop doses not effective •Ketamine: found no impact on chronic pain •RA: reduced chronic pain after amputation and thoracotomy		** 32 RCTs: Overall high heterogeneity in studies. •Gabapentinoids: reduced chronic pain after mastectomy, but single preop doses not effective •Ketamine: found no impact on chronic pain •RA: reduced chronic pain after amputation and thoracotomy

	== Summary ==		== Summary ==

Tony.Wang: Formatting

2021-08-30T17:44:11Z

Formatting

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	== Summary ==		== Summary ==
			'''Chronic surgical pain is commonly overlooked as a surgical complication that can lead to significant functional limitation and psychological distress'''
	~~===~~ Chronic surgical pain is commonly overlooked as a surgical complication that can lead to significant functional limitation and psychological distress ~~===~~

	# Evaluate for risk factors and aggressive control of preoperative and postoperative pain		# Evaluate for risk factors and aggressive control of preoperative and postoperative pain
	# Minimize surgical trauma where possible		# Minimize surgical trauma where possible

Tony.Wang: Formatting

2021-08-30T17:43:45Z

Formatting

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	== Intro: ==		== Intro ==
	Chronic surgical pain is a commonly overlooked surgical complication that can lead to significant functional limitations and psychological distress		Chronic surgical pain is a commonly overlooked surgical complication that can lead to significant functional limitations and psychological distress

	== Acute Pain ==		== Acute Pain ==
			'''Noxious stimulus ->local inflammatory mediators -> peripheral sensitization and hyperexcitability'''
	~~===~~ Noxious stimulus ->local inflammatory mediators -> peripheral sensitization and hyperexcitability ~~ ===~~

	* Typically short lived and resolves with injury healing		* Typically short lived and resolves with injury healing
	* Pain appears to be a mix of mostly nociceptive with some neuropathic pain		* Pain appears to be a mix of mostly nociceptive with some neuropathic pain
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	####* Subgroup of IV ketamine only RCTs however did show significant reduction of CPSP •at 3 months RR of 0.75 (P = 0.01), NNT 12, and 6 months RR .7 (P = .04)		####* Subgroup of IV ketamine only RCTs however did show significant reduction of CPSP •at 3 months RR of 0.75 (P = 0.01), NNT 12, and 6 months RR .7 (P = .04)
	####* Recommend bolus of .2mg/kg followed by infusion .2-.3mg/kg/hr<ref>MCNICOL, E.D., SCHUMANN, R. and HAROUTOUNIAN, S. (2014), Ketamine for prevention of PPSP. Acta Anaesthesiol Scand, 58: 1199-1213. <nowiki>https://doi-org.proxy1.library.jhu.edu/10.1111/aas.12377</nowiki>		####* Recommend bolus of .2mg/kg followed by infusion .2-.3mg/kg/hr<ref>MCNICOL, E.D., SCHUMANN, R. and HAROUTOUNIAN, S. (2014), Ketamine for prevention of PPSP. Acta Anaesthesiol Scand, 58: 1199-1213. <nowiki>https://doi-org.proxy1.library.jhu.edu/10.1111/aas.12377</nowiki>

	</ref>		</ref>
	*### Suzuki and colleagues, administering ketamine by infusion for 3 days, but at only 0.05 mg/kg/h. (n=49)Despite the small dose – they saw a reduction in CPSP at 3 months, but not at 6 months following thoracotomy		*### Suzuki and colleagues, administering ketamine by infusion for 3 days, but at only 0.05 mg/kg/h. (n=49)Despite the small dose – they saw a reduction in CPSP at 3 months, but not at 6 months following thoracotomy
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	# Incorporate regional anesthesia when possible		# Incorporate regional anesthesia when possible
	# Consider adjuncts like gabapentin and ketamine, however more research is required		# Consider adjuncts like gabapentin and ketamine, however more research is required

			== References ==
			<references />

Tony.Wang: Tony.Wang moved page Perioperative Prevention of Chronic Pain to Perioperative prevention of chronic pain without leaving a redirect: Consistent capitalization

2021-08-30T17:41:29Z

Tony.Wang moved page Perioperative Prevention of Chronic Pain to Perioperative prevention of chronic pain without leaving a redirect: Consistent capitalization

← Older revision	Revision as of 10:41, 30 August 2021
(No difference)