Nonopioid Analgesics for the Perioperative Geriatric Patient: A Narrative Review

Wilson, Sylvia H.; Wilson, Patty R.; Bridges, Kathryn H.; Bell, Linda; Clark, Carlee A.

doi:10.1213/ane.0000000000005944

Cited by 11 publications

(4 citation statements)

References 163 publications

(341 reference statements)

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“… 50 Santosa et al conducted a retrospective analysis of patients being co-prescribed opiates with muscle relaxants and benzodiazepines, and found that patients were significantly more likely to refill their opioid prescriptions even after controlling for preoperative opioid exposure. 51 Caution must be exercised when using muscle relaxants in patients at high risk of postoperative complications, including older patients (age >65 years), 52 morbidly obese patients (BMI >40 kg/m 2 ), those with sleep apnea, and those with significant comorbidities.…”

Section: Discussionmentioning

confidence: 99%

Use of Muscle Relaxants for Acute Postoperative Pain: A Practical Review

Farishta,

Iancau,

Janis

et al. 2024

Plastic and Reconstructive Surgery - Global Open

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Background: Skeletal muscle relaxants have emerged as a broad category of analgesic adjuncts, aiming to improve pain relief and reduce opioid reliance. These drugs induce muscle relaxation and reduce muscle spasms, and therefore, they are commonly used in surgical procedures involving muscle manipulation, such as abdominal surgery, breast surgery, and spine surgery. However, their analgesic efficacy and opioid-sparing effects are poorly explored. Methods: A scoping review of literature was performed with several electronic databases. We used a search string with a sequence of text words and word variants related to central muscle relaxants, pain management, postoperative pain, and specific muscle relaxants. Results: Review of literature shows significant heterogeneity among the studies in terms of surgical procedures, patient populations, choice of muscle relaxant, and timing and duration of administration, potentially limiting the generalizability of the findings and the ability for pooled analysis. Conclusions: Given the lack of evidence, we recommend that the use of skeletal muscle relaxants be reserved for patients in whom an optimal multimodal analgesic technique is not adequate. Also, there may be a limited role for these drugs in patients at high risk of postoperative pain undergoing surgical procedures with expected high opioid requirements. Due to the concerns of potential adverse effects, the decision to use muscle relaxants in vulnerable populations should be made carefully, weighing the benefits against the risks.

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Section: Discussionmentioning

confidence: 99%

Use of Muscle Relaxants for Acute Postoperative Pain: A Practical Review

Farishta,

Iancau,

Janis

et al. 2024

Plastic and Reconstructive Surgery - Global Open

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“…It has been suggested that non-narcotic analgesics may be the preferred approach to perioperative analgesia in the geriatric patient population ( Wilson et al, 2022 ) as opioid administration has been associated with increased rates of POCD ( Awada et al, 2019 ) and possibly POD ( Clegg and Young, 2011 ). Conversely, pain, especially severe pain, increases the risk for delirium [for review, see O’Gara et al (2021) ], and there is clearly a risk-benefit assessment that must be considered as opioid analgesics are highly effective in relieving acute pain.…”

Section: Managementmentioning

confidence: 99%

Mitigation of perioperative neurocognitive disorders: A holistic approach

Safavynia

Goldstein

Evered

2022

Front. Aging Neurosci.

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William Morton introduced the world to ether anesthesia for use during surgery in the Bullfinch Building of the Massachusetts General Hospital on October 16, 1846. For nearly two centuries, the prevailing wisdom had been that the effects of general anesthetics were rapidly and fully reversible, with no apparent long-term adverse sequelae. Despite occasional concerns of a possible association between surgery and anesthesia with dementia since 1887 (Savage, 1887), our initial belief was robustly punctured following the publication in 1998 of the International Study of Post-Operative Cognitive Dysfunction [ISPOCD 1] study by Moller et al. (1998) in The Lancet, in which they demonstrated in a prospective fashion that there were in fact persistent adverse effects on neurocognitive function up to 3 months following surgery and that these effects were common. Since the publication of that landmark study, significant strides have been made in redefining the terminology describing cognitive dysfunction, identifying those patients most at risk, and establishing the underlying etiology of the condition, particularly with respect to the relative contributions of anesthesia and surgery. In 2018, the International Nomenclature Consensus Working Group proposed new nomenclature to standardize identification of and classify perioperative cognitive changes under the umbrella of perioperative neurocognitive disorders (PND) (Evered et al., 2018a). Since then, the new nomenclature has tried to describe post-surgical cognitive derangements within a unifying framework and has brought to light the need to standardize methodology in clinical studies and motivate such studies with hypotheses of PND pathogenesis. In this narrative review, we highlight the relevant literature regarding recent key developments in PND identification and management throughout the perioperative period. We provide an overview of the new nomenclature and its implications for interpreting risk factors identified by clinical association studies. We then describe current hypotheses for PND development, using data from clinical association studies and neurophysiologic data where appropriate. Finally, we offer broad clinical guidelines for mitigating PND in the perioperative period, highlighting the role of Brain Enhanced Recovery After Surgery (Brain-ERAS) protocols.

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“…[1][2][3] Despite their benefits, caution should be exercised, particularly in geriatric patients, due to potential side effects. [4][5][6] Among the NSAIDs used during the perioperative period after TKA, ketorolac is commonly administered. This drug has shown efficacy in providing analgesia; however, evidence suggests a ceiling effect for its potency.…”

Section: Introductionmentioning

confidence: 99%

“…1–3 Despite their benefits, caution should be exercised, particularly in geriatric patients, due to potential side effects. 4–6…”

Section: Introductionmentioning

confidence: 99%

Superior analgesic efficacy of preemptive low-dose ketorolac compared with parecoxib after total knee arthroplasty: A retrospective propensity score matching study

Iamthanaporn,

Rojjanasirisawat,

Yuenyongviwat

2024

J Orthop Surg (Hong Kong)

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Background Total knee arthroplasty (TKA) is a routine orthopedic procedure often associated with significant postoperative pain. Efficient pain management is paramount for patient recovery, with nonsteroidal anti-inflammatory drugs (NSAIDs) being a common choice. Nevertheless, the specific NSAID and its dosing regimen can have varying impacts on outcomes. Methods In this retrospective cohort study spanning from January 2016 to December 2020, we analyzed patients who underwent TKA. These patients were divided into two groups: one receiving preemptive low-dose ketorolac (15 mg) followed by 15 mg every 6 h for 48 h, and the other receiving parecoxib (40 mg) every 12 h for the same duration. We assessed pain scores, opioid consumption, and monitored adverse events. Results Our findings reveal that ketorolac yielded superior results compared to parecoxib. Specifically, patients receiving ketorolac reported significantly lower Visual Numeric Rating Scale (VNRS) scores at 8- and 20-h post-surgery. This trend was further confirmed by linear mixed models ( p = .0084). Additionally, ketorolac was associated with reduced opioid consumption during the initial 24 h. Importantly, the rates of adverse events were comparable between the two groups. Conclusion The utilization of preemptive low-dose ketorolac demonstrates promising potential in bolstering pain control within the initial 24 h post-TKA, potentially reducing the need for opioids. However, further exploration is required to thoroughly assess its prolonged analgesic effects and safety across various surgical contexts. These investigations could provide invaluable insights for optimizing pain management protocols.

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Nonopioid Analgesics for the Perioperative Geriatric Patient: A Narrative Review

Cited by 11 publications

References 163 publications

Use of Muscle Relaxants for Acute Postoperative Pain: A Practical Review

Use of Muscle Relaxants for Acute Postoperative Pain: A Practical Review

Mitigation of perioperative neurocognitive disorders: A holistic approach

Superior analgesic efficacy of preemptive low-dose ketorolac compared with parecoxib after total knee arthroplasty: A retrospective propensity score matching study

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