A Review of Opioid-Sparing Modalities in Perioperative Pain Management: Methods to Decrease Opioid Use Postoperatively

Kumar, Kanupriya; Kirksey, Meghan A.; Duong, Silvia; Wu, Christopher L.

doi:10.1213/ane.0000000000002497

Cited by 260 publications

(150 citation statements)

References 125 publications

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“…Back in 2010, the Italian Society of Anesthesia, Analgesia and Intensive Care (SIAARTI) already recommended the adoption of multimodal analgesic strategies and underlined the importance of their adjustment to fast-track surgical settings (10). Recent reviews on analgesic care in ERAS protocols report the same concept, highlighting the necessity of combining systemic and loco-regional analgesia to favour opioidsparing strategies (4,5,11). The latter goal is extremely important, to minimize not only the side effects of this pharmacological class, but also the risk of respiratory complications of patients undergoing thoracic surgery.…”

Section: Multimodal Analgesia Strategymentioning

confidence: 99%

Enhanced recovery pathways in thoracic surgery from Italian VATS Group: perioperative analgesia protocols

Piccioni¹,

Segat²,

Falini³

et al. 2018

J. Thorac. Dis.

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Enhanced Recovery After Surgery (ERAS) is a multimodal, multidisciplinary approach to surgical patients with the aim of enhancing the quality of recovery after surgery (1,2). This strategy translates into faster post-operative recovery and improvements of outcomes. All the ERAS Society guidelines (freely available at www.erassociety.org) take into consideration the perioperative management of analgesia. The role of pain management in ERAS pathways is fundamental, considering the importance of containing surgical stress, reducing pain-related complications and speeding recovery (2-5). Correspondence to: Carlo Del Naja, MD. Casa Sollievo della Sofferenza Hospital, viale Cappuccini, 1, 71013 San Giovanni Rotondo (FG), Italy.Email: c.delnaja@operapadrepio.it.Abstract: Video-assisted thoracoscopic surgery (VATS) is a minimally invasive technique that allows a faster recovery after thoracic surgery. Although enhanced recovery after surgery (ERAS) principles seem reasonably applicable to thoracic surgery, there is little literature on the application of such a strategy in this context. In regard to pain management, ERAS pathways promote the adoption of a multimodal strategy, tailored to the patients. This approach is based on combining systemic and loco-regional analgesia to favour opioid-sparing strategies. Thoracic paravertebral block is considered the first-line loco-regional technique for VATS. Other techniques include intercostal nerve block and serratus anterior plane block. Nonsteroidal anti-inflammatory drugs and paracetamol are essential part of the multimodal treatment of pain. Also, adjuvant drugs can be useful as opioid-sparing agents. Nevertheless, the treatment of postoperative pain must take into account opioid agents too, if necessary. All above is useful for careful planning and execution of a multimodal analgesic treatment to enhance the recovery of patients. This article summarizes the most recent evidences from literature and authors' experiences on perioperative multimodal analgesia principles for implementing an ERAS program after VATS lobectomy.

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Section: Multimodal Analgesia Strategymentioning

confidence: 99%

Enhanced recovery pathways in thoracic surgery from Italian VATS Group: perioperative analgesia protocols

Piccioni¹,

Segat²,

Falini³

et al. 2018

J. Thorac. Dis.

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“…Multimodal pain management focuses on the combination of several analgesic agents and techniques to modulate pain at both central and peripheral sites, thereby enhancing analgesia and lessening opioid use and opioid‐related adverse effects . However, peripheral nerve blockade has been to play the major role in postoperative multimodal pain regimens .…”

Section: Discussionmentioning

confidence: 99%

“…Our primary outcome showed that pretreatment with peripheral nerve blockade was superior to pretreatment with periincisional LA infiltration on significant low-pain intensity and low-impact Multimodal pain management focuses on the combination of several analgesic agents and techniques to modulate pain at both central and peripheral sites, thereby enhancing analgesia and lessening opioid use and opioid-related adverse effects. 8,9 However, peripheral nerve blockade has been to play the major role in postoperative multimodal pain regimens. 10,11 The conventional nerve block techniques for forefoot surgery are popliteal sciatic nerve block 12 or ankle nerve blocks.…”

Section: Discussionmentioning

confidence: 99%

“…The disturbance of sleep quality and mood changes were also assessed on the coming morning with NRS, which rated from 0 to 10, while the 0 means "the pain totally not disturbed the sleep quality and not changed the mood status" , and 10 means "the sleep quality and mood status was completely affected by the pain". The severities of side effects including itching, nausea, and vomiting were categorized into four grades by NRS as none (0), mild (1-3), moderate (4)(5)(6), and severe (7)(8)(9)(10). Patients were allowed to intake oral medications after being able to tolerate drinking water.…”

Section: Postoperative Carementioning

confidence: 99%

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Pretreatment of ankle nerve block provides better postoperative analgesia than peri‐incisional local anesthetic infiltration in hallux valgus correction surgery

Huang

Tseng

et al. 2019

The Kaohsiung J of Med Scie

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Adequate postoperative analgesia after hallux valgus (HV) correction surgery improves early mobilization and decreases hospital stay. Peripheral nerve block and peri‐incisional local anesthetic (LA) infiltration are both widely used for pain management in orthopedic surgeries. The aim of this study was to compare the analgesic effects between the ankle block and peri‐incisional infiltration technique in patients undergoing HV correction surgery. Ninety patients scheduled for hallux valgus correction surgery were randomly allocated into three groups. In group N, patients were pretreated with tibial and peroneal nerve blocks with 8‐10 mL of 0.25% bupivacaine before surgery. In group P, patients received the same LA for peri‐incisional infiltration preoperatively. In group C, patients underwent surgery without regional analgesic pretreatment. All patients had intravenous fentanyl patient control analgesia as part of multimodal postoperative pain management. Fentanyl consumption, rest and moving pain scale, and adverse effects were evaluated at postoperative 6 h (Poh6), Poh12, Poh 24, and Poh36, respectively. Patients receiving bilateral feet surgeries were excluded in this study. Seventy‐five patients were enrolled into final analysis. The patients in group N expressed lower resting and moving pain scores at Poh6, but the pain scores turned similarly among the three groups following Poh12 and then. The total fentanyl consumption was significantly less in group N than in group P. The postoperative activities and mood disturbance were not significantly different between groups after Poh12 and then. We conclude that ankle block is better than peri‐incisional LA infiltration in HV correction surgery in pain relief and fentanyl consumption.

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“…There is growing interest in opioid-sparing methods in perioperative pain management, given an ongoing epidemic of opioid use and misuse that is causing significant morbidity and mortality 1. While misuse occurs more frequently among chronic pain patients, the perioperative period is often the patient’s first exposure to these medications 2…”

Section: Introductionmentioning

confidence: 99%

Interfascial block at the serratus muscle plane versus conventional analgesia in breast surgery: a randomized controlled trial

Mazzinari

Rovira

Casasempere

et al. 2019

Regional Anesthesia &Amp; Pain Medicine

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Background and objectivesIn the context of opioid-sparing perioperative management, there is still little evidence from randomized controlled trials regarding the effectiveness of interfascial thoracic blocks. This study hypothesizes that receiving a serratus plane block reduces opioid requirements, pain scores, and rescue medication needs.MethodsThis double-blind, randomized controlled study was conducted on 60 adult females undergoing oncologic breast surgery. After general anesthesia, patients were randomly allocated to either conventional analgesia (control group, n=30) or single-injection serratus block with L-bupivacaine 0.25% 30mL (study group, n=30). First 24-hour total morphine consumption (primary outcome), pain scores at 1, 3, 6, 12, and 24 hours, time-to-first opioid rescue analgesia, and adverse effects were recorded.ResultsMedian 24 hours’ opioid dose was greater in the control group (median difference 9 mg (95% CI 4 to 14.5 mg); p<0.001). Proportional odds model showed that the study group has a lower probability of receiving opioid drugs (OR=0.26 (95% CI 0.10 to 0.68); p<0.001), while mastectomies have a higher probability of receiving them (OR=4.11 (95% CI 1.25 to 13.58); p=0.002). Pain scores in the study group were significantly lower throughout the follow-up period (p<0.001). Control group subjects needed earlier morphine rescue and had a higher risk of rescue dose requirement (p=0.002).ConclusionsInterfascial serratus plane block reduces opioid requirements and is associated with better pain scores and lower and later rescue analgesia needs in the first 24 hours, compared with conventional intravenous analgesia, in breast surgery.Trial registration numberNCT02905149.

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A Review of Opioid-Sparing Modalities in Perioperative Pain Management: Methods to Decrease Opioid Use Postoperatively

Cited by 260 publications

References 125 publications

Enhanced recovery pathways in thoracic surgery from Italian VATS Group: perioperative analgesia protocols

Enhanced recovery pathways in thoracic surgery from Italian VATS Group: perioperative analgesia protocols

Pretreatment of ankle nerve block provides better postoperative analgesia than peri‐incisional local anesthetic infiltration in hallux valgus correction surgery

Interfascial block at the serratus muscle plane versus conventional analgesia in breast surgery: a randomized controlled trial

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