94 results on '"Girish, P."'
Search Results
2. Pain management after elective craniotomy: A systematic review with procedure-specific postoperative pain management (PROSPECT) recommendations.
- Author
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Mestdagh FP, Lavand'homme PM, Pirard G, Joshi GP, Sauter AR, and Van de Velde M
- Subjects
- Humans, Acetaminophen, Analgesics therapeutic use, Pain, Postoperative diagnosis, Pain, Postoperative drug therapy, Pain, Postoperative etiology, Craniotomy adverse effects, Anti-Inflammatory Agents, Non-Steroidal therapeutic use, Pain Management methods, Dexmedetomidine
- Abstract
Background: Pain after craniotomy can be intense and its management is often suboptimal., Objectives: We aimed to evaluate the available literature and develop recommendations for optimal pain management after craniotomy., Design: A systematic review using procedure-specific postoperative pain management (PROSPECT) methodology was undertaken., Data Sources: Randomised controlled trials and systematic reviews published in English from 1 January 2010 to 30 June 2021 assessing pain after craniotomy using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases., Eligibility Criteria: Each randomised controlled trial (RCT) and systematic review was critically evaluated and included only if met the PROSPECT requirements. Included studies were evaluated for clinically relevant differences in pain scores, use of nonopioid analgesics, such as paracetamol and NSAIDs, and current clinical relevance., Results: Out of 126 eligible studies identified, 53 RCTs and seven systematic review or meta-analyses met the inclusion criteria. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, NSAIDs, intravenous dexmedetomidine infusion, regional analgesia techniques, including incision-site infiltration, scalp nerve block and acupuncture. Limited evidence was found for flupirtine, intra-operative magnesium sulphate infusion, intra-operative lidocaine infusion, infiltration adjuvants (hyaluronidase, dexamethasone and α-adrenergic agonist added to local anaesthetic solution). No evidence was found for metamizole, postoperative subcutaneous sumatriptan, pre-operative oral vitamin D, bilateral maxillary block or superficial cervical plexus block., Conclusions: The analgesic regimen for craniotomy should include paracetamol, NSAIDs, intravenous dexmedetomidine infusion and a regional analgesic technique (either incision-site infiltration or scalp nerve block), with opioids as rescue analgesics. Further RCTs are required to confirm the influence of the recommended analgesic regimen on postoperative pain relief., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the European Society of Anaesthesiology and Intensive Care.)
- Published
- 2023
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3. Rational Multimodal Analgesia for Perioperative Pain Management.
- Author
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Joshi GP
- Subjects
- Humans, Analgesics therapeutic use, Acetaminophen, Analgesics, Opioid therapeutic use, Pain, Postoperative drug therapy, Pain Management methods, Analgesia methods
- Abstract
Purpose of Review: A multimodal analgesic approach improves postoperative pain relief and reduces opioid use; however, it is not universally implemented. This review presents the evidence assessing multimodal analgesic regimens and recommends optimal analgesic combinations., Recent Findings: The evidence for best combinations of individual patients undergoing specific procedures is lacking. Nevertheless, an optimal multimodal regimen may be determined based on identifying efficacious, safe, and inexpensive analgesics interventions. Key components of an optimal multimodal analgesic regimen include the preoperative identification of patients at high risk for postoperative pain in addition to patient and caregiver education. Unless contraindicated, all patients should receive a combination of acetaminophen, non-steroidal anti-inflammatory drug or cycoxygenase-2-specific inhibitor, dexamethasone, and procedure-specific regional analgesic technique and/or surgical site local anesthetic infiltration. Opioids should be administered as rescue adjuncts. Non-pharmacological interventions are important components of an optimal multimodal analgesic technique. It is imperative to integrate multimodal analgesia regimens within a multidisciplinary enhanced recovery pathway., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)
- Published
- 2023
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4. Pain management after total knee arthroplasty: PROcedure SPEcific Postoperative Pain ManagemenT recommendations.
- Author
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Lavand'homme PM, Kehlet H, Rawal N, and Joshi GP
- Subjects
- Acetaminophen, Analgesics therapeutic use, Analgesics, Opioid therapeutic use, Anesthetics, Local, Anti-Inflammatory Agents, Humans, Pain, Postoperative diagnosis, Pain, Postoperative drug therapy, Pain, Postoperative etiology, Systematic Reviews as Topic, Arthroplasty, Replacement, Knee adverse effects, Arthroplasty, Replacement, Knee methods, Pain Management methods
- Abstract
Background: The PROSPECT (PROcedure SPEcific Postoperative Pain ManagemenT) Working Group is a global collaboration of surgeons and anaesthesiologists formulating procedure-specific recommendations for pain management after common operations. Total knee arthroplasty (TKA) is associated with significant postoperative pain that is difficult to treat. Nevertheless, pain control is essential for rehabilitation and to enhance recovery., Objective: To evaluate the available literature and develop recommendations for optimal pain management after unilateral primary TKA., Design: A narrative review based on published systematic reviews, using modified PROSPECT methodology., Data Sources: A literature search was performed in EMBASE, MEDLINE, PubMed and Cochrane Databases, between January 2014 and December 2020, for systematic reviews and meta-analyses evaluating analgesic interventions for pain management in patients undergoing TKA., Eligibility Criteria: Each randomised controlled trial (RCT) included in the selected systematic reviews was critically evaluated and included only if met the PROSPECT requirements. Included studies were evaluated for clinically relevant differences in pain scores, use of nonopioid analgesics, such as paracetamol and nonsteroidal anti-inflammatory drugs and current clinical relevance., Results: A total of 151 systematic reviews were analysed, 106 RCTs met PROSPECT criteria. Paracetamol and nonsteroidal anti-inflammatory or cyclo-oxygenase-2-specific inhibitors are recommended. This should be combined with a single shot adductor canal block and peri-articular local infiltration analgesia together with a single intra-operative dose of intravenous dexamethasone. Intrathecal morphine (100 μg) may be considered in hospitalised patients only in rare situations when both adductor canal block and local infiltration analgesia are not possible. Opioids should be reserved as rescue analgesics in the postoperative period. Analgesic interventions that could not be recommended were also identified., Conclusion: The present review identified an optimal analgesic regimen for unilateral primary TKA. Future studies to evaluate enhanced recovery programs and specific challenging patient groups are needed., (Copyright © 2022 European Society of Anaesthesiology and Intensive Care. Unauthorized reproduction of this article is prohibited.)
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- 2022
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5. Multimodal opioid-sparing pain management for emergent cesarean delivery under general anesthesia: a quality improvement project.
- Author
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Anyaehie KB, Duryea E, Wang J, Echebelem C, Macias D, Sunna M, Ogunkua O, Joshi GP, and Gasanova I
- Subjects
- Adolescent, Analgesia, Patient-Controlled, Anesthesia, General, Female, Humans, Pain, Postoperative drug therapy, Pregnancy, Quality Improvement, Analgesics, Opioid, Pain Management
- Abstract
Background: Opioid-sparing multimodal analgesic approach has been shown to provide effective postoperative pain relief and reduce postoperative opioid consumption and opioid-associated adverse effects. While many studies have evaluated analgesic strategies for elective cesarean delivery, few studies have investigated analgesic approaches in emergent cesarean deliveries under general anesthesia. The primary aim of this quality improvement project is to evaluate opioid consumption with the use of a multimodal opioid-sparing pain management pathway in patients undergoing emergent cesarean delivery under general anesthesia., Methods: Seventy-two women (age > 16 years) undergoing emergent cesarean delivery under general anesthesia before (n = 36) and after (n = 36) implementation of a multimodal opioid-sparing pain management pathway were included. All patients received a standardized general anesthetic. Prior to implementation of the pathway, postoperative pain management was primarily limited to intravenous patient-controlled opioid administration. The new multimodal pathway included scheduled acetaminophen and non-steroidal anti-inflammatory medications and ultrasound-guided classic lateral transversus abdominis plane blocks with postoperative opioids reserved only for rescue analgesia. Data obtained from electronic records included demographics, intraoperative opioid use, and pain scores and opioid consumption upon arrival to the recovery room, at 2, 6, 12, 24, 48, and 72 h postoperatively., Results: Patients receiving multimodal opioid sparing analgesia (AFTER group) had lower opioid use for 72 h, postoperatively. Only 2 of the 36 patients (5.6%) in the AFTER group required intravenous opioids through patient-controlled analgesia while 30 out of 36 patients (83.3%) in the BEFORE group required intravenous opioids., Conclusions: Multimodal opioid-sparing analgesia is associated with reduced postoperative opioid consumption after emergent cesarean delivery., (© 2022. The Author(s).)
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- 2022
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6. Pain management after laminectomy: a systematic review and procedure-specific post-operative pain management (prospect) recommendations.
- Author
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Peene L, Le Cacheux P, Sauter AR, Joshi GP, and Beloeil H
- Subjects
- Analgesics therapeutic use, Anesthetics, Local, Humans, Pain, Postoperative drug therapy, Laminectomy adverse effects, Pain Management
- Abstract
Purpose: With lumbar laminectomy increasingly being performed on an outpatient basis, optimal pain management is critical to avoid post-operative delay in discharge and readmission. The aim of this review was to evaluate the available literature and develop recommendations for optimal pain management after one- or two-level lumbar laminectomy., Methods: A systematic review utilizing the PROcedure-SPECific Post-operative Pain ManagemenT (PROSPECT) methodology was undertaken. Randomised controlled trials (RCTs) published in the English language from 1 January 2008 until 31 March 2020-assessing post-operative pain using analgesic, anaesthetic and surgical interventions-were identified from MEDLINE, EMBASE and Cochrane Databases., Results: Out of 65 eligible studies identified, 39 RCTs met the inclusion criteria. The analgesic regimen for lumbar laminectomy should include paracetamol and a non-steroidal anti-inflammatory drug (NSAID) or cyclooxygenase (COX)-2 selective inhibitor administered preoperatively or intraoperatively and continued post-operatively, with post-operative opioids for rescue analgesia. In addition, surgical wound instillation or infiltration with local anaesthetics prior to wound closure is recommended. Some interventions-gabapentinoids and intrathecal opioid administration-although effective, carry significant risks and consequently were omitted from the recommendations. Other interventions were also not recommended because there was insufficient, inconsistent or lack of evidence., Conclusion: Perioperative pain management for lumbar laminectomy should include paracetamol and NSAID- or COX-2-specific inhibitor, continued into the post-operative period, as well as intraoperative surgical wound instillation or infiltration. Opioids should be used as rescue medication post-operatively. Future studies are necessary to evaluate the efficacy of our recommendations., (© 2020. The Author(s).)
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- 2021
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7. Pain management after complex spine surgery: A systematic review and procedure-specific postoperative pain management recommendations.
- Author
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Waelkens P, Alsabbagh E, Sauter A, Joshi GP, and Beloeil H
- Subjects
- Analgesics, Opioid, Anesthetics, Local, Humans, Pain, Postoperative diagnosis, Pain, Postoperative drug therapy, Pain, Postoperative etiology, Analgesia, Epidural, Pain Management
- Abstract
Background: Complex spinal procedures are associated with intense pain in the postoperative period. Adequate peri-operative pain management has been shown to correlate with improved outcomes including early ambulation and early discharge., Objectives: We aimed to evaluate the available literature and develop recommendations for optimal pain management after complex spine surgery., Design and Data Sources: A systematic review using the PROcedure SPECific postoperative pain managemenT methodology was undertaken. Randomised controlled trials and systematic reviews published in the English language from January 2008 to April 2020 assessing postoperative pain after complex spine surgery using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, EMBASE and Cochrane Databases., Results: Out of 111 eligible studies identified, 31 randomised controlled trials and four systematic reviews met the inclusion criteria. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, cyclo-oxygenase (COX)-2 specific-inhibitors or non-steroidal anti-inflammatory drugs (NSAIDs), intravenous ketamine infusion and regional analgesia techniques including epidural analgesia using local anaesthetics with or without opioids. Limited evidence was found for local wound infiltration, intrathecal and epidural opioids, erector spinae plane block, thoracolumbar interfascial plane block, intravenous lidocaine, dexmedetomidine and gabapentin., Conclusions: The analgesic regimen for complex spine surgery should include pre-operative or intra-operative paracetamol and COX-2 specific inhibitors or NSAIDs, continued postoperatively with opioids used as rescue analgesics. Other recommendations are intra-operative ketamine and epidural analgesia using local anaesthetics with or without opioids. Although there is procedure-specific evidence in favour of intra-operative methadone, it is not recommended as it was compared with shorter-acting opioids and due to its limited safety profile. Furthermore, the methadone studies did not use non-opioid analgesics, which should be the primary analgesics to ultimately reduce overall opioid requirements, including methadone. Further qualitative randomised controlled trials are required to confirm the efficacy and safety of these recommended analgesics on postoperative pain relief., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the European Society of Anaesthesiology and Intensive Care.)
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- 2021
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8. Pain management after open liver resection: Procedure-Specific Postoperative Pain Management (PROSPECT) recommendations.
- Author
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Dieu A, Huynen P, Lavand'homme P, Beloeil H, Freys SM, Pogatzki-Zahn EM, Joshi GP, and Van de Velde M
- Subjects
- Analgesics, Opioid, Humans, Liver, Pain, Postoperative diagnosis, Pain, Postoperative drug therapy, Pain, Postoperative etiology, Nerve Block, Pain Management
- Abstract
Background and Objectives: Effective pain control improves postoperative rehabilitation and enhances recovery. The aim of this review was to evaluate the available evidence and to develop recommendations for optimal pain management after open liver resection using Procedure-Specific Postoperative Pain Management (PROSPECT) methodology., Strategy and Selection Criteria: Randomized controlled trials (RCTs) published in the English language from January 2010 to October 2019 assessing pain after liver resection using analgesic, anesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane databases., Results: Of 121 eligible studies identified, 31 RCTs and 3 systematic reviews met the inclusion criteria. Preoperative and intraoperative interventions that improved postoperative pain relief were non-steroidal anti-inflammatory drugs, continuous thoracic epidural analgesia, and subcostal transversus abdominis plane (TAP) blocks. Limited procedure-specific evidence was found for intravenous dexmedetomidine, intravenous magnesium, intrathecal morphine, quadratus lumborum blocks, paravertebral nerve blocks, continuous local anesthetic wound infiltration and postoperative interpleural local anesthesia. No evidence was found for intravenous lidocaine, ketamine, dexamethasone and gabapentinoids., Conclusions: Based on the results of this review, we suggest an analgesic strategy for open liver resection, including acetaminophen and non-steroidal anti-inflammatory drugs, combined with thoracic epidural analgesia or bilateral oblique subcostal TAP blocks. Systemic opioids should be considered as rescue analgesics. Further high-quality RCTs are needed to confirm and clarify the efficacy of the recommended analgesic regimen in the context of an enhanced recovery program., Competing Interests: Competing interests: GJ has received honoraria from Baxter and Pacira Pharmaceuticals. FB has received honoraria from Pfizer, The Medicine Company, Abbott France, Nordic Pharma France, Heron therapeutics, AMBU and Grunenthal. MVdV has received honoraria from Sintetica, Grunenthal, Vifor Pharma, MSD, Nordic Pharma, Janssen Pharmaceuticals, Heron Therapeutics and Aguettant. EP-Z has received honoraria form Mundipharma, Grunenthal, MSD, Janssen-Cilag GmbH, Fresenius Kabi and AcelRx., (© American Society of Regional Anesthesia & Pain Medicine 2021. Re-use permitted under CC BY-NC. No commercial re-use. Published by BMJ.)
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- 2021
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9. Interfascial plane blocks.
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Machi A and Joshi GP
- Subjects
- Humans, Pain, Postoperative therapy, Ultrasonography, Interventional, Nerve Block methods, Pain Management methods
- Abstract
Many novel interfascial plane blocks have been developed in the last 10 years in the effort to improve perioperative pain management that are safe, efficacious, efficient, and inexpensive. These blocks have been widely adopted into clinical practice despite relatively few high-quality clinical investigations of the techniques and how they affect perioperative outcomes. This article defines interfascial plane blocks, discusses the potential benefits, reviews the most common techniques and evidence supporting their indication, and guides clinicians in selecting an appropriate interfascial plane block for different types of surgical procedures., (Copyright © 2019 Elsevier Ltd. All rights reserved.)
- Published
- 2019
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10. Perioperative use of opioids: Current controversies and concerns.
- Author
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Alexander JC, Patel B, and Joshi GP
- Subjects
- Humans, Narcotic-Related Disorders epidemiology, Opioid-Related Disorders, Pain, Postoperative drug therapy, Analgesics, Opioid adverse effects, Analgesics, Opioid therapeutic use, Pain Management methods, Perioperative Care methods
- Abstract
In the midst of an epidemic of opioid abuse and overdose-related morbidity and mortality, the use of opioids remains the most common means of providing analgesia in the perioperative period. In this article, we review the risks and benefits of opioid use in preoperative, intraoperative and post-operative phases of care. Furthermore, we describe the role that surgeons and anaesthesiologists can play in reducing perioperative opioid use and mitigate their adverse effects, from both an individual and a population health perspective., (Copyright © 2019 Elsevier Ltd. All rights reserved.)
- Published
- 2019
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11. Postoperative pain management in the era of ERAS: An overview.
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Joshi GP and Kehlet H
- Subjects
- Humans, Perioperative Care, Enhanced Recovery After Surgery, Pain Management methods, Pain, Postoperative drug therapy, Postoperative Care methods
- Abstract
Enhanced recovery after surgery (ERAS) programmes are increasingly becoming standard of care for several surgical procedures. However, compliance with ERAS protocols including pain management protocols remains poor. The PROSPECT (PROcedure-SPEcific Postoperative Pain ManagemenT) collaboration provides evidence-based, procedure-specific pain management recommendations presented as preoperative, intraoperative and postoperative interventions as well as surgical interventions that are easy to access, transparent and relevant to clinicians. This approach should facilitate incorporation of pain management recommendations in an ERAS protocol and improve compliance with the protocols. This article presents an improved approach to developing pain management guidelines as well as a pragmatic approach to procedure-specific perioperative pain management that could be incorporated in an ERAS pathway., (Copyright © 2019 Elsevier Ltd. All rights reserved.)
- Published
- 2019
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12. Pain Management for Ambulatory Arthroscopic Anterior Cruciate Ligament Reconstruction: Evidence-Based Recommendations From the Society for Ambulatory Anesthesia.
- Author
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Abdallah FW, Brull R, and Joshi GP
- Subjects
- Acetaminophen therapeutic use, Ambulatory Care, Ambulatory Surgical Procedures, Analgesics therapeutic use, Anesthesia standards, Anesthesia, Conduction methods, Anti-Inflammatory Agents, Non-Steroidal therapeutic use, Evidence-Based Medicine, Femoral Nerve, Humans, Meta-Analysis as Topic, Nerve Block, Pain Management standards, Pain, Postoperative drug therapy, Practice Guidelines as Topic, Risk, Societies, Medical, Systematic Reviews as Topic, Anesthesia methods, Anterior Cruciate Ligament Reconstruction, Arthroscopy, Pain Management methods
- Abstract
Ambulatory arthroscopic anterior cruciate ligament reconstruction is associated with moderate pain, even when nonopioid oral analgesics such as acetaminophen and nonsteroidal anti-inflammatory drugs are used. Regional analgesia can supplement nonopioid oral analgesics and reduce postoperative opioid requirements, but the choice of regional analgesia technique for anterior cruciate ligament reconstruction remains controversial. Femoral nerve block, adductor canal block, and local instillation analgesia have all been proposed and are supported by some evidence from randomized controlled trials. Consequently, regional analgesia practice in patients undergoing anterior cruciate ligament reconstruction remains mixed. Published systematic reviews were used to identify the regional analgesia modality that would provide a balance between analgesic efficacy and associated potential risks in the setting of nonopioid multimodal analgesic strategies. Based on the evidence available, local instillation analgesia provides the best balance of analgesic efficacy and associated risks (strong recommendation, moderate level of evidence) when used as a component of multimodal analgesic technique in the first 24 hours after outpatient arthroscopic anterior cruciate ligament reconstruction. In the absence of local instillation analgesia, clinicians might use adductor canal block or femoral nerve block (weak recommendation, weak level of evidence). These recommendations have been endorsed by the Society of Ambulatory Anesthesia and approved by its board of directors.
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- 2019
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13. Pain management after laparoscopic hysterectomy: systematic review of literature and PROSPECT recommendations.
- Author
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Lirk P, Thiry J, Bonnet MP, Joshi GP, and Bonnet F
- Subjects
- Acetaminophen therapeutic use, Analgesics therapeutic use, Anesthetics, Local therapeutic use, Anti-Inflammatory Agents, Non-Steroidal therapeutic use, Bupivacaine therapeutic use, Dexamethasone therapeutic use, Humans, Laparoscopy, Randomized Controlled Trials as Topic, Analgesics, Non-Narcotic therapeutic use, Analgesics, Opioid therapeutic use, Pain Management methods, Pain, Postoperative drug therapy
- Abstract
Background and Objectives: Laparoscopic hysterectomy is increasingly performed because it is associated with less postoperative pain and earlier recovery as compared with open abdominal hysterectomy. The aim of this systematic review was to evaluate the available literature regarding the management of pain after laparoscopic hysterectomy., Strategy and Selection Criteria: Randomized controlled trials evaluating postoperative pain after laparoscopic hysterectomy published between January 1996 and May 2018 were retrieved, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, from the EMBASE and MEDLINE databases and the Cochrane Register of Controlled Trials. Efficacy and adverse effects of analgesic techniques were assessed., Results: Of the 281 studies initially identified, 56 were included. Of these, 31 assessed analgesic or anesthetic interventions and 25 assessed surgical interventions. Acetaminophen, non-steroidal anti-inflammatory drugs, and dexamethasone reduced opioid consumption. Limited evidence hindered recommendations on alpha-2-agonists. Inconsistent evidence was found in the studies investigating pregabalin and transversus abdominis plane block, and no evidence was found for intraperitoneal local anesthetics, port site infiltration, or single-port laparoscopy. Measures to lower peritoneal insufflation pressure or humidify or heat insufflated gas seem to reduce the incidence of shoulder pain, but not abdominal pain., Conclusions: The baseline analgesic regimen for laparoscopic hysterectomy should include acetaminophen, a non-steroidal anti-inflammatory drug, dexamethasone, and opioids as rescue analgesics., Competing Interests: Competing interests: GPJ has received honoraria from Baxter, Mallinckrodt, Pacira, and Merck Pharmaceuticals. FB has received honoraria from Pfizer, The Medicines Company, Abbott France, and Nordic Pharma France. Henrik Kehlet has received honoraria from Pfizer and Grunenthal. The Anesthesiology Unit of the University of Western Australia, but not Stephan Schug privately, has received research and travel funding and speaking and consulting honoraria from bioCSL, Eli Lilly, Indivior, iX Biopharma, and Pfizer within the last 2 years. Narinder Rawal has received honoraria from Baxter and Sintetica., (© American Society of Regional Anesthesia & Pain Medicine 2019. No commercial re-use. See rights and permissions. Published by BMJ.)
- Published
- 2019
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14. Ultrasound-guided suprainguinal fascia iliaca compartment block versus periarticular infiltration for pain management after total hip arthroplasty: a randomized controlled trial.
- Author
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Gasanova I, Alexander JC, Estrera K, Wells J, Sunna M, Minhajuddin A, and Joshi GP
- Subjects
- Adult, Aged, Female, Humans, Male, Middle Aged, Pain, Postoperative diagnostic imaging, Anesthesia, Local methods, Arthroplasty, Replacement, Hip adverse effects, Nerve Block methods, Pain Management methods, Pain, Postoperative therapy, Ultrasonography, Interventional methods
- Abstract
Background and Objectives: Fascia iliaca compartment block (FICB) has been shown to provide excellent pain relief in patients undergoing total hip arthroplasty (THA). However, the analgesic efficacy of FICB, in comparison with periarticular infiltration (PAI) for THA, has not been evaluated. This randomized, controlled, observer-blinded study was designed to compare suprainguinal FICB (SFICB) with PAI in patients undergoing THA via posterior approach., Methods: After institutional review board approval, 60 consenting patients scheduled for elective THA were randomized to one of two groups: ultrasound-guided SFICB block or PAI. The local anesthetic solution for both the groups included 60 mL ropivacaine 300 mg and epinephrine 150 µg. The remaining aspects of perioperative care, including general anesthetic and non-opioid multimodal analgesic techniques, were standardized. An investigator blinded to group allocation documented pain scores at rest and with movement and supplemental opioid requirements at various time points. Patients were evaluated for sensory changes and quadriceps weakness in the operated extremity., Results: There were no differences between the groups with respect to demographics, intraoperative opioid use, duration of surgery, recovery room stay, nausea scores, need for rescue antiemetics, time to ambulation and time to discharge readiness as well as 48 hours postoperative opioid requirements. The pain scores at rest and with movement also were similar at all time points. Significantly more patients in the SFICB group experienced muscle weakness at 6 hours after surgery., Conclusions: Under the circumstances of our study, in patients undergoing THA, SFICB provided the similar pain relief compared with PAI, but was associated with muscle weakness at 6 hours postoperatively., Trial Registration Number: NCT02658240., Competing Interests: Competing interests: GPJ has received honoraria from Pacira Pharmaceuticals (Exparel), Baxter Pharmaceuticals, Mallinckrodt Pharmaceuticals, and Merck Pharmaceuticals., (© American Society of Regional Anesthesia & Pain Medicine 2019. No commercial re-use. See rights and permissions. Published by BMJ.)
- Published
- 2019
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15. Procedure-Specific Pain Management (PROSPECT) - An update.
- Author
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Lee B, Schug SA, Joshi GP, and Kehlet H
- Subjects
- Clinical Decision-Making methods, Evidence-Based Medicine methods, Evidence-Based Medicine trends, Humans, Pain Management methods, Anesthesiologists trends, Pain Management trends, Pain, Postoperative prevention & control
- Abstract
Post-operative pain management protocols may be optimised by examining procedure-specific evidence and outcomes. This recognition led to the formation of the PROcedure-SPECific Pain ManagemenT (PROSPECT) collaboration of anaesthesiologists and surgeons. The aim of PROSPECT is to provide practical and evidence-based recommendations to prevent and treat post-operative pain after specific surgical procedures, thereby overcoming the limitations of generic, non-specific guidelines. Updates in the methodology of PROSPECT in 2017 have placed an increased emphasis on the clinical relevance of studies, including a focus on interventions in the context of multimodal analgesia strategies and consideration of risks and benefits of interventions in specific surgical settings. Evidence-based reviews of analgesic measures, including advice on surgical techniques and adjuvants after diverse surgical procedures, have been completed by the PROSPECT collaboration and are accessible on the website (www.postoppain.org) and published in the peer-reviewed literature. These reviews continue to identify significant gaps in clinically relevant research on post-operative analgesia and are possibly leading to a closing of some of these gaps., (Copyright © 2018 Elsevier Ltd. All rights reserved.)
- Published
- 2018
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16. Transversus Abdominis Plane Block Versus Surgical Site Infiltration for Pain Management After Open Total Abdominal Hysterectomy.
- Author
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Gasanova I, Alexander J, Ogunnaike B, Hamid C, Rogers D, Minhajuddin A, and Joshi GP
- Subjects
- Adult, Female, Humans, Hysterectomy methods, Middle Aged, Pain, Postoperative diagnosis, Single-Blind Method, Abdominal Muscles surgery, Hysterectomy adverse effects, Nerve Block methods, Pain Management methods, Pain, Postoperative prevention & control
- Abstract
Background: Surgical site infiltration and transversus abdominis plane (TAP) blocks are commonly used to improve pain relief after lower abdominal surgery. This randomized, observer-blinded study was designed to compare the analgesic efficacy of TAP blocks with surgical site infiltration in patients undergoing open total abdominal hysterectomy via a Pfannenstiel incision., Methods: Patients were randomized to receive either bilateral ultrasound-guided TAP blocks using bupivacaine 0.5% 20 mL on each side (n = 30) or surgical site infiltration with liposomal bupivacaine 266 mg diluted to 60 mL injected in the preperitoneal, subfascial, and subcutaneous planes (n = 30). The remaining aspects of the perioperative care were standardized. An investigator blinded to the group allocation documented pain scores at rest and with coughing, opioid requirements, nausea, vomiting, and rescue antiemetics in the postanesthesia care unit and at 2, 6, 12, 24, and 48 hours postoperatively. The primary outcome measure was pain scores on coughing at 6 hours postoperatively., Results: One patient in each group was excluded from the analysis because of reoperation within 24 hours in the TAP block group and change of incision type in the infiltration group. The pain scores at rest and with coughing were significantly lower in the surgical site infiltration group at all postoperative time points (P < 0.0001) except at rest in the postanesthesia care unit. The opioid requirements between 24 and 48 hours were significantly lower in the infiltration group (P = 0.009). The nausea scores, occurrence of vomiting, and need for rescue antiemetics were similar., Conclusions: Surgical site infiltration provided superior pain relief at rest and on coughing, as well as reduced opioid consumption for up to 48 hours. Future studies need to compare TAP blocks with liposomal bupivacaine with surgical site infiltration with liposomal bupivacaine.
- Published
- 2015
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17. Pain Management for Elective Foot and Ankle Surgery: A Systematic Review of Randomized Controlled Trials.
- Author
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Wang J, Liu GT, Mayo HG, and Joshi GP
- Subjects
- Elective Surgical Procedures, Humans, Pain Measurement, Randomized Controlled Trials as Topic, Ankle surgery, Foot surgery, Pain Management methods, Pain, Postoperative prevention & control
- Abstract
Pain after foot and ankle surgery can significantly affect the postoperative outcomes. We performed a systematic review of randomized controlled trials assessing postoperative pain after foot and ankle surgery, because the surgery will lead to moderate-to-severe postoperative pain, but the optimal pain therapy has been controversial. A systematic review of randomized controlled trials in English reporting on pain after foot and ankle surgery in adults published from January 1946 to February 2013 was performed. The primary outcome measure was the postoperative pain scores. The secondary outcome measures included supplemental analgesic requirements and other recovery outcomes. With 953 studies identified, 45 met the inclusion criteria. The approaches improving pain relief (reduced pain scores or opioid requirements) included peripheral nerve blocks, wound infiltration, intravenous dexamethasone, acetaminophen, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 selective inhibitors, and opioids. Wound instillation, intra-articular injection, and intravenous regional analgesia had variable analgesia. The lack of homogeneous study design precluded quantitative analyses. Optimal pain management strategies included locoregional analgesic techniques plus acetaminophen and nonsteroidal anti-inflammatory drugs or cyclooxygenase-2 selective inhibitors, with opioids used for "rescue," and 1 intraoperative dose of parenteral dexamethasone. Popliteal sciatic nerve blocks would be appropriate when expecting severe postoperative pain (extensive surgical procedure), and ankle blocks and surgical incision infiltration would be appropriate when expecting moderate postoperative pain (less extensive and minimally invasive surgical procedures). Additional studies are needed to assess multimodal analgesia techniques., (Copyright © 2015 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)
- Published
- 2015
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18. Procedure-specific pain management and outcome strategies.
- Author
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Joshi GP, Schug SA, and Kehlet H
- Subjects
- Evidence-Based Medicine, Humans, Analgesia methods, Pain Management methods, Pain, Postoperative therapy
- Abstract
Optimal dynamic pain relief is a prerequisite for optimizing post-operative recovery and reducing morbidity and convalescence. Procedure-specific pain management initiative aims to overcome the limitations of conventional guidelines and provide health-care professionals with practical recommendations formulated in a way that facilitates clinical decision making across all the stages of the perioperative period. The procedure-specific evidence is supplemented with data from other similar surgical procedures and clinical practices to balance benefits and risks of each analgesic technique. There is emphasis on the use of multimodal analgesia and preventive analgesia aimed at reducing central sensitization. Importantly, the benefits of dynamic pain relief may only be realized if other aspects of perioperative care such as the use of minimally invasive surgery, approaches to reduce stress responses, optimizing fluid therapy and optimizing post-operative nursing care with early mobilization and oral feeding are utilized., (Copyright © 2014 Elsevier Ltd. All rights reserved.)
- Published
- 2014
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19. Defining new directions for more effective management of surgical pain in the United States: highlights of the inaugural Surgical Pain Congress™.
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Joshi GP, Beck DE, Emerson RH, Halaszynski TM, Jahr JS, Lipman AG, Nihira MA, Sheth KR, Simpson MH, and Sinatra RS
- Subjects
- Analgesics therapeutic use, Analgesics, Opioid therapeutic use, Congresses as Topic, Drug Therapy, Combination, Female, Humans, Male, Pain Measurement, Practice Guidelines as Topic, Risk Assessment, Severity of Illness Index, Treatment Outcome, United States, Analgesia methods, Pain Management methods, Pain, Postoperative diagnosis, Pain, Postoperative drug therapy
- Abstract
Despite advances in pharmacologic options for the management of surgical pain, there appears to have been little or no overall improvement over the last two decades in the level of pain experienced by patients. The importance of adequate and effective surgical pain management, however, is clear, because inadequate pain control 1) has a wide range of undesirable physiologic and immunologic effects; 2) is associated with poor surgical outcomes; 3) has increased probability of readmission; and 4) adversely affects the overall cost of care as well as patient satisfaction. There is a clear unmet need for a national surgical pain management consensus task force to raise awareness and develop best practice guidelines for improving surgical pain management, patient safety, patient satisfaction, rapid postsurgical recovery, and health economic outcomes. To comprehensively address this need, the multidisciplinary Surgical Pain Congress™ has been established. The inaugural meeting of this Congress (March 8 to 10, 2013, Celebration, Florida) evaluated the current surgical pain management paradigm and identified key components of best practices.
- Published
- 2014
20. Ultrasound-guided transversus abdominal plane block with multimodal analgesia for pain management after total abdominal hysterectomy.
- Author
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Gasanova I, Grant E, Way M, Rosero EB, and Joshi GP
- Subjects
- Abdominal Muscles diagnostic imaging, Acetaminophen therapeutic use, Adult, Analgesia, Patient-Controlled, Analgesics, Non-Narcotic therapeutic use, Analgesics, Opioid administration & dosage, Anesthetics, Local, Anti-Inflammatory Agents, Non-Steroidal therapeutic use, Bupivacaine, Drug Therapy, Combination adverse effects, Female, Humans, Ketorolac therapeutic use, Middle Aged, Morphine administration & dosage, Nausea chemically induced, Pain Management adverse effects, Single-Blind Method, Ultrasonography, Interventional, Vomiting chemically induced, Hysterectomy adverse effects, Nerve Block, Pain Management methods, Pain, Postoperative drug therapy
- Abstract
Background: Transversus abdominis plane (TAP) block has been shown to provide pain relief after abdominal procedures. However, TAP block combined with multimodal analgesia technique have not been assessed in a randomized controlled trial. This randomized, controlled, observer-blinded study was designed to evaluate the analgesic efficacy of bilateral ultrasound-guided TAP blocks with or without acetaminophen and non-steroidal anti-inflammatory drug (NSAID) combination., Methods: Patients undergoing total abdominal hysterectomy were randomized to one of three groups. Group 1 (n = 25) received a TAP block and ketorolac 30 mg, IV at the end of surgery and then ketorolac plus paracetamol 650 mg, orally, every 6 h for 24 h. Group 2 (n = 24) received only TAP block at the end of surgery. Group 3 (n = 25) received ketorolac 30 mg, IV at the end of surgery and then ketorolac plus paracetamol 650 mg, orally, every 6 h for 24 h. All patients received IV-PCA morphine for 24-h, postoperatively. All patients received a standardized general anaesthetic technique and dexamethasone 4 mg and ondansetron 4 mg, IV for antiemetic prophylaxis., Results: There were no statistically significant differences in pain at rest between the groups. However, the pain on coughing (dynamic pain) in Group 1 was significantly less variable, compared with the other two groups (P = 0.012). Opioid consumption and occurrences of nausea, vomiting, and rescue antiemetic were similar in three the groups., Conclusions: The combination of TAP block and acetaminophen and NSAID provided less variability in dynamic pain compared with either treatment alone.
- Published
- 2013
- Full Text
- View/download PDF
21. The state of the art in preventing postthoracotomy pain.
- Author
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Romero A, Garcia JE, and Joshi GP
- Subjects
- Combined Modality Therapy, Drug Therapy, Combination, Humans, Length of Stay, Pain Measurement, Pain, Postoperative diagnosis, Pain, Postoperative etiology, Recovery of Function, Thoracotomy rehabilitation, Time Factors, Treatment Outcome, Analgesics therapeutic use, Anesthesia, Conduction, Pain Management methods, Pain, Postoperative prevention & control, Thoracotomy adverse effects
- Abstract
Pain after thoracic surgery can be intense and prolonged. Inadequate pain management can have several detrimental effects, including increased postoperative morbidity and delayed recovery as well as occurrence of postthoracotomy syndrome. Therefore, establishing an adequate analgesic regimen for thoracic surgery is critical. Thoracic paravertebral block or thoracic epidural analgesia is recommended as the first-choice therapies for postthoracotomy analgesia. When these techniques are either contraindicated or not possible, intercostal analgesia or intrathecal opioids are recommended. These techniques should be combined with nonopioid analgesics, such as acetaminophen, nonsteroidal anti-inflammatory drugs, or cyclooxygenase-2-specific inhibitors, administered on a regular "round-the-clock" basis, with opioids used as "rescue" analgesics. Finally, the integration of multimodal analgesia techniques with multidisciplinary rehabilitation program can enhance recovery, reduce hospital stay, and facilitate early convalescence., (Copyright © 2013 Elsevier Inc. All rights reserved.)
- Published
- 2013
- Full Text
- View/download PDF
22. Evaluating therapeutic benefit in postsurgical analgesia requires global assessment: an example from liposome bupivacaine in hemorrhoidectomy.
- Author
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Schmidt WK, Patou G, and Joshi GP
- Subjects
- Analgesics, Opioid administration & dosage, Anesthetics, Local administration & dosage, Bupivacaine administration & dosage, Humans, Liposomes, Outcome Assessment, Health Care, Pain Measurement, Patient Satisfaction, Randomized Controlled Trials as Topic, Anesthetics, Local therapeutic use, Bupivacaine therapeutic use, Hemorrhoids surgery, Pain Management methods, Pain, Postoperative drug therapy
- Abstract
Background and Objective: Interpreting analgesic efficacy based solely on measures of pain intensity can be misleading. Here, we use data from an adult hemorrhoidectomy study to demonstrate the importance of evaluating pain intensity scores with other outcome measures in interpreting analgesic study results., Methodology: We looked for coordinated outcome measures including pain intensity at rest using a numeric rating scale (NRS), postsurgical consumption of rescue medication, subject-reported results from the Brief Pain Inventory, subject satisfaction with postsurgical analgesia, and adverse events., Results: The analgesic efficacy of liposome bupivacaine was reflected in a significant reduction in pain intensity scores at each timed assessment during the first 12 to 24 hours after surgery (mean NRS at 12 hours: liposome bupivacaine, 2.2; placebo, 2.9; P = 0.04), and less consumption of opioid rescue medications thereafter through 72 hours postsurgery (mean total amount of opioids consumed: liposome bupivacaine, 10 mg; placebo, 18 mg; P = 0.0006). These observations are supported by results of other outcome measures, including time to first use of opioid rescue medication, pain-related interference of subject functionality, and subject satisfaction with postsurgical analgesia., Conclusion: Liposome bupivacaine produced superior analgesia when compared with placebo at early postoperative time points, but appropriate use of rescue medication diminished this effect after 12 hours. However, based on our assessment of multiple outcome measures used in the study, it appears that the therapeutic benefit associated with the tested analgesic lasted throughout the 72-hour study period.
- Published
- 2012
- Full Text
- View/download PDF
23. Pain management in COVID-19 pediatric patients—An evidence- based review
- Author
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Priyanka Mishra, Anupama Tomar, Ajit Kumar, Amborish Nath, Suresh K Sharma, and Girish Kumar Singh
- Subjects
analgesia ,analgesic safety ,covid-19 ,pain management ,pediatric ,Anesthesiology ,RD78.3-87.3 - Abstract
Despite our growing knowledge about the COVID pandemic, not much concern has been focused upon the effective pain management in pediatric patients suffering from this SARS CoV2 virus. Symptoms with pain like myalgia (10%–40%), sore throat (5%–30%), headache (14%–40%) and abdominal pain (10%) are common in children suffering from COVID. (3-5) We conducted a systematic review regarding analgesia for COVID positive pediatric patients. Cochrane, PubMed, and Google scholar databases were searched for relevant literature. Owing to the novel status of COVID-19 with limited literature, we included randomized controlled trials (RCTs), observational studies, case series and case reports in the descending order of consideration. Articles in languages other than English, abstract only articles and non-scientific commentaries were excluded. The Primary outcome was evaluation of pain related symptoms and best strategies for their management. Our review revealed that a multidisciplinary approach starting from non-pharmacological techniques like drinking plenty of water, removing triggers like inadequate sleep, specific foods and psychotherapy including distraction, comfort and cognitive behavioural strategies should be used. Pharmacological approaches like acetaminophen, NSAIDS, spasmolytics etc. can be used if non-pharmacological therapy is inadequate. As per the current strength of evidence, acetaminophen and ibuprofen can be safely administered for pain management in children with COVID-19. Undertreated pain is a significant contributor to increased morbidity and poor prognosis. Integration of evidence based non-pharmacotherapies in the multidisciplinary pain management will contribute towards improved functioning, early recovery and better quality care for pediatric patients suffering from COVID.
- Published
- 2021
- Full Text
- View/download PDF
24. Ultrasound-guided erector spinae plane blocks for pain management after open lumbar laminectomy.
- Author
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Stewart, Jesse W., Dickson, Douglas, Van Hal, Michael, Aryeetey, Lemuelson, Sunna, Mary, Schulz, Cedar, Alexander, John C., Gasanova, Irina, and Joshi, Girish P.
- Subjects
SPINAL surgery ,ERECTOR spinae muscles ,PAIN management ,LAMINECTOMY ,COMBINED modality therapy ,PERIOPERATIVE care - Abstract
Purpose: Lumbar spine surgery is associated with significant postoperative pain. The benefits of erector spinae plane blocks (ESPBs) combined with multimodal analgesia has not been adequately studied. We evaluated the analgesic effects of bilateral ESPBs as a component of multimodal analgesia after open lumbar laminectomy. Methods: Analgesic effects of preoperative, bilateral, ultrasound-guided ESPBs combined with standardized multimodal analgesia (n = 25) was compared with multimodal analgesia alone (n = 25) in patients undergoing one or two level open lumbar laminectomy. Other aspects of perioperative care were similar. The primary outcome measure was cumulative opioid consumption at 24 h. Secondary outcomes included opioid consumption, pain scores, and nausea and vomiting requiring antiemetics on arrival to the post-anesthesia care unit (PACU), at 24 h, 48 h, and 72 h after surgery, as well as duration of the PACU and hospital stay. Results: Opioid requirements at 24 h were significantly lower with ESPBs (31.9 ± 12.3 mg vs. 61.2 ± 29.9 mg, oral morphine equivalents). Pain scores were significantly lower with ESPBs in the PACU and through postoperative day two. Patients who received ESPBs required fewer postoperative antiemetic therapy (n = 3, 12%) compared to those without ESPBs (n = 12, 48%). Furthermore, PACU duration was significantly shorter with ESPBs (49.7 ± 9.5 vs. 79.9 ± 24.6 min). Conclusions: Ultrasound-guided, bilateral ESPBs, when added to an optimal multimodal analgesia technique, reduce opioid consumption and pain scores, the need for antiemetic therapy, and the duration of stay in the PACU after one or two level open lumbar laminectomy. [ABSTRACT FROM AUTHOR]
- Published
- 2024
- Full Text
- View/download PDF
25. Critical appraisal of randomised trials assessing regional analgesic interventions for knee arthroplasty: implications for postoperative pain guidelines development
- Author
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Girish P. Joshi, Jesse Stewart, and Henrik Kehlet
- Subjects
Analgesics, Opioid ,Analgesics ,Pain, Postoperative ,Anesthesiology and Pain Medicine ,Humans ,Pain Management ,Analgesia ,Arthroplasty, Replacement, Knee - Abstract
Guidelines are increasingly being used for clinical decision-making. Such guidelines are usually based on meta-analyses, which are generally derived from RCTs. However, their interpretations are often hindered as they do not always consider current clinical relevance. Analyses of RCTs assessing analgesic efficacy of advanced regional analgesic techniques in knee arthroplasty show that the majority of trials do not include a package of basic analgesics such as paracetamol, NSAIDs or cyclooxygenase-2 specific inhibitors, dexamethasone, and local infiltration analgesia in the comparator group. Consequently, the current approach to analyse meta-analyses of pain interventions is not optimal, and may lead to inadequate or inappropriate conclusions and clinical guidance.
- Published
- 2022
26. PROSPECT guidelines for video‐assisted thoracoscopic surgery: a systematic review and procedure‐specific postoperative pain management recommendations
- Author
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Francis Bonnet, J Lubach, S Feray, Pain Therapy, Girish P. Joshi, and M. Van de Velde
- Subjects
medicine.medical_treatment ,Postoperative pain ,Analgesic ,DOUBLE-BLIND ,GENERAL-ANESTHESIA ,SINGLE-INJECTION ,LUNG-CANCER ,systematic review ,Anesthesiology ,medicine ,THORACIC PARAVERTEBRAL BLOCK ,Paravertebral Block ,Thoracotomy ,Dexmedetomidine ,Science & Technology ,business.industry ,analgesia ,PATIENT-CONTROLLED ANALGESIA ,Evidence-based medicine ,Pain management ,EFFICACY ,video-assisted thoracoscopic surgery ,Anesthesiology and Pain Medicine ,DEXMEDETOMIDINE ,Anesthesia ,ANTERIOR PLANE BLOCK ,Video-assisted thoracoscopic surgery ,CONTINUOUS EPIDURAL BLOCK ,evidence-based medicine ,postoperative pain ,business ,Life Sciences & Biomedicine ,medicine.drug - Abstract
Video-assisted thoracoscopic surgery has become increasingly popular due to faster recovery times and reduced postoperative pain compared with thoracotomy. However, analgesic regimens for video-assisted thoracoscopic surgery vary significantly. The goal of this systematic review was to evaluate the available literature and develop recommendations for optimal pain management after video-assisted thoracoscopic surgery. A systematic review was undertaken using procedure-specific postoperative pain management (PROSPECT) methodology. Randomised controlled trials published in the English language, between January 2010 and January 2021 assessing the effect of analgesic, anaesthetic or surgical interventions were identified. We retrieved 1070 studies of which 69 randomised controlled trials and two reviews met inclusion criteria. We recommend the administration of basic analgesia including paracetamol and non-steroidal anti-inflammatory drugs or cyclo-oxygenase-2-specific inhibitors pre-operatively or intra-operatively and continued postoperatively. Intra-operative intravenous dexmedetomidine infusion may be used, specifically when basic analgesia and regional analgesic techniques could not be given. In addition, a paravertebral block or erector spinae plane block is recommended as a first-choice option. A serratus anterior plane block could also be administered as a second-choice option. Opioids should be reserved as rescue analgesics in the postoperative period. ispartof: ANAESTHESIA vol:77 issue:3 pages:311-325 ispartof: location:England status: published
- Published
- 2021
27. PROSPECT guideline for total hip arthroplasty: a systematic review and procedure‐specific postoperative pain management recommendations
- Author
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Johan Raeder, Pain Therapy, M Anger, Girish P. Joshi, Philipp Lirk, T Valovska, M. Van de Velde, and H Beloeil
- Subjects
total hip arthroplasty ,DIRECT LATERAL APPROACH ,Arthroplasty, Replacement, Hip ,Analgesic ,MEDLINE ,DIRECT ANTERIOR ,evidence‐ ,ILIACA COMPARTMENT BLOCK ,CONTINUOUS WOUND INFUSION ,DOUBLE-BLIND ,03 medical and health sciences ,chemistry.chemical_compound ,0302 clinical medicine ,systematic review ,Anesthesiology ,030202 anesthesiology ,Humans ,Pain Management ,Medicine ,pain ,030212 general & internal medicine ,Adverse effect ,PRIMARY TOTAL KNEE ,Dexamethasone ,LOCAL INFILTRATION ANALGESIA ,Pain, Postoperative ,Science & Technology ,based medicine ,business.industry ,analgesia ,PATIENT-CONTROLLED ANALGESIA ,Guideline ,Evidence-based medicine ,RANDOMIZED CLINICAL-TRIAL ,Regimen ,Anesthesiology and Pain Medicine ,chemistry ,Anesthesia ,Practice Guidelines as Topic ,FEMORAL NERVE BLOCK ,business ,Life Sciences & Biomedicine ,Gabapentinoid ,medicine.drug - Abstract
The aim of this systematic review was to develop recommendations for the management of postoperative pain after primary elective total hip arthroplasty, updating the previous procedure-specific postoperative pain management (PROSPECT) guidelines published in 2005 and updated in July 2010. Randomised controlled trials and meta-analyses published between July 2010 and December 2019 assessing postoperative pain using analgesic, anaesthetic, surgical or other interventions were identified from MEDLINE, Embase and Cochrane databases. Five hundred and twenty studies were initially identified, of which 108 randomised trials and 21 meta-analyses met the inclusion criteria. Peri-operative interventions that improved postoperative pain include: paracetamol; cyclo-oxygenase-2-selective inhibitors; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone. In addition, peripheral nerve blocks (femoral nerve block; lumbar plexus block; fascia iliaca block), single-shot local infiltration analgesia, intrathecal morphine and epidural analgesia also improved pain. Limited or inconsistent evidence was found for all other approaches evaluated. Surgical and anaesthetic techniques appear to have a minor impact on postoperative pain, and thus their choice should be based on criteria other than pain. In summary, the analgesic regimen for total hip arthroplasty should include pre-operative or intra-operative paracetamol and cyclo-oxygenase-2-selective inhibitors or non-steroidal anti-inflammatory drugs, continued postoperatively with opioids used as rescue analgesics. In addition, intra-operative intravenous dexamethasone 8-10 mg is recommended. Regional analgesic techniques such as fascia iliaca block or local infiltration analgesia are recommended, especially if there are contra-indications to basic analgesics and/or in patients with high expected postoperative pain. Epidural analgesia, femoral nerve block, lumbar plexus block and gabapentinoid administration are not recommended as the adverse effects outweigh the benefits. Although intrathecal morphine 0.1 mg can be used, the PROSPECT group emphasises the risks and side-effects associated with its use and provides evidence that adequate analgesia may be achieved with basic analgesics and regional techniques without intrathecal morphine. ispartof: ANAESTHESIA vol:76 issue:8 pages:1082-1097 ispartof: location:England status: published
- Published
- 2021
28. Erector spinae plane block versus thoracic paravertebral block for pain management after total bilateral mastectomies
- Author
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Mary Sunna, Deborah Farr, Abu Minhajuddin, John C. Alexander, Irina Gasanova, Cedar Schulz, Rachel Wooldridge, Jesse Stewart, Jenny R.B. Ringqvist, and Girish P. Joshi
- Subjects
business.industry ,Opioid consumption ,medicine.medical_treatment ,Postoperative pain ,Analgesic ,General Medicine ,Pain management ,Anesthesia ,medicine ,In patient ,Paravertebral Block ,Clinical quality ,business ,Mastectomy ,Original Research - Abstract
This prospectively designed, clinical quality improvement project compared pain scores and opioid consumption between ultrasound-guided, erector spinae plane blocks (ESPB) and thoracic paravertebral blocks (PVB) in patients undergoing total bilateral mastectomies without reconstruction. Twenty-five patients were included in an enhanced recovery pathway and received an ESPB on one side and a PVB on the contralateral side. Numeric rating scores at rest and with movement for each side were recorded in the recovery room at 2, 6, 12, 24, and 48 hours and on days 3 to 7. There were no significant differences in the resting or movement-evoked pain scores between sides receiving ESPB or PVB at any time point up to day 7 after surgery. Both ESPB and PVB confer equal analgesic effects in patients undergoing mastectomies. ESPB provides an alternative to PVB in reducing postoperative pain in patients undergoing mastectomy as part of an enhanced recovery pathway.
- Published
- 2021
29. Multimodal opioid-sparing pain management for emergent cesarean delivery under general anesthesia: a quality improvement project
- Author
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Kelechi B, Anyaehie, Elaine, Duryea, Jenny, Wang, Chinedu, Echebelem, Devin, Macias, Mary, Sunna, Olutoyosi, Ogunkua, Girish P, Joshi, and Irina, Gasanova
- Subjects
Analgesics, Opioid ,Pain, Postoperative ,Anesthesiology and Pain Medicine ,Adolescent ,Pregnancy ,Humans ,Pain Management ,Analgesia, Patient-Controlled ,Female ,Anesthesia, General ,Quality Improvement - Abstract
Background Opioid-sparing multimodal analgesic approach has been shown to provide effective postoperative pain relief and reduce postoperative opioid consumption and opioid-associated adverse effects. While many studies have evaluated analgesic strategies for elective cesarean delivery, few studies have investigated analgesic approaches in emergent cesarean deliveries under general anesthesia. The primary aim of this quality improvement project is to evaluate opioid consumption with the use of a multimodal opioid-sparing pain management pathway in patients undergoing emergent cesarean delivery under general anesthesia. Methods Seventy-two women (age > 16 years) undergoing emergent cesarean delivery under general anesthesia before (n = 36) and after (n = 36) implementation of a multimodal opioid-sparing pain management pathway were included. All patients received a standardized general anesthetic. Prior to implementation of the pathway, postoperative pain management was primarily limited to intravenous patient-controlled opioid administration. The new multimodal pathway included scheduled acetaminophen and non-steroidal anti-inflammatory medications and ultrasound-guided classic lateral transversus abdominis plane blocks with postoperative opioids reserved only for rescue analgesia. Data obtained from electronic records included demographics, intraoperative opioid use, and pain scores and opioid consumption upon arrival to the recovery room, at 2, 6, 12, 24, 48, and 72 h postoperatively. Results Patients receiving multimodal opioid sparing analgesia (AFTER group) had lower opioid use for 72 h, postoperatively. Only 2 of the 36 patients (5.6%) in the AFTER group required intravenous opioids through patient-controlled analgesia while 30 out of 36 patients (83.3%) in the BEFORE group required intravenous opioids. Conclusions Multimodal opioid-sparing analgesia is associated with reduced postoperative opioid consumption after emergent cesarean delivery.
- Published
- 2022
30. Pain management after total knee arthroplasty: PROcedure SPEcific Postoperative Pain ManagemenT recommendations
- Author
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Patricia M, Lavand'homme, Henrik, Kehlet, Narinder, Rawal, and Girish P, Joshi
- Subjects
Analgesics, Opioid ,Analgesics ,Pain, Postoperative ,Anti-Inflammatory Agents ,Humans ,Pain Management ,Anesthetics, Local ,Arthroplasty, Replacement, Knee ,Acetaminophen ,Systematic Reviews as Topic - Abstract
The PROSPECT (PROcedure SPEcific Postoperative Pain ManagemenT) Working Group is a global collaboration of surgeons and anaesthesiologists formulating procedure-specific recommendations for pain management after common operations. Total knee arthroplasty (TKA) is associated with significant postoperative pain that is difficult to treat. Nevertheless, pain control is essential for rehabilitation and to enhance recovery.To evaluate the available literature and develop recommendations for optimal pain management after unilateral primary TKA.A narrative review based on published systematic reviews, using modified PROSPECT methodology.A literature search was performed in EMBASE, MEDLINE, PubMed and Cochrane Databases, between January 2014 and December 2020, for systematic reviews and meta-analyses evaluating analgesic interventions for pain management in patients undergoing TKA.Each randomised controlled trial (RCT) included in the selected systematic reviews was critically evaluated and included only if met the PROSPECT requirements. Included studies were evaluated for clinically relevant differences in pain scores, use of nonopioid analgesics, such as paracetamol and nonsteroidal anti-inflammatory drugs and current clinical relevance.A total of 151 systematic reviews were analysed, 106 RCTs met PROSPECT criteria. Paracetamol and nonsteroidal anti-inflammatory or cyclo-oxygenase-2-specific inhibitors are recommended. This should be combined with a single shot adductor canal block and peri-articular local infiltration analgesia together with a single intra-operative dose of intravenous dexamethasone. Intrathecal morphine (100 μg) may be considered in hospitalised patients only in rare situations when both adductor canal block and local infiltration analgesia are not possible. Opioids should be reserved as rescue analgesics in the postoperative period. Analgesic interventions that could not be recommended were also identified.The present review identified an optimal analgesic regimen for unilateral primary TKA. Future studies to evaluate enhanced recovery programs and specific challenging patient groups are needed.
- Published
- 2022
31. Meta‐analyses of gabapentinoids for pain management after knee arthroplasty: A caveat emptor? A narrative review
- Author
-
Girish P. Joshi and Henrik Kehlet
- Subjects
Pain, Postoperative ,medicine.medical_specialty ,business.industry ,medicine.medical_treatment ,Total knee arthroplasty ,030208 emergency & critical care medicine ,General Medicine ,Perioperative ,Pain management ,Arthroplasty ,03 medical and health sciences ,0302 clinical medicine ,Anesthesiology and Pain Medicine ,Systematic review ,030202 anesthesiology ,medicine ,Physical therapy ,Humans ,Pain Management ,Narrative review ,Arthroplasty, Replacement, Knee ,business ,Caveat emptor ,Systematic Reviews as Topic - Abstract
The use of gabapentinoids for perioperative pain management after total knee arthroplasty has been the subject of nine systematic reviews and meta-analyses. A critical analysis of the clinical aspects of the methodology of these publications shows major flaws which limit the interpretation for the recommended use of perioperative gabapentinoids in pain management for unilateral primary total knee arthroplasty. Consequently, readers and authors of systematic reviews and meta-analyses should critically assess the clinical aspects of the included studies.
- Published
- 2021
32. The systematic review/meta‐analysis epidemic: a tale of glucocorticoid therapy in total knee arthroplasty
- Author
-
H. Kehlet and Girish P. Joshi
- Subjects
Pain, Postoperative ,medicine.medical_specialty ,business.industry ,Total knee arthroplasty ,Perioperative Care ,law.invention ,Anesthesiology and Pain Medicine ,Meta-Analysis as Topic ,Randomized controlled trial ,Glucocorticoid therapy ,law ,Data Interpretation, Statistical ,Meta-analysis ,Internal medicine ,medicine ,Humans ,Pain Management ,Arthroplasty, Replacement, Knee ,business ,Glucocorticoids ,Randomized Controlled Trials as Topic ,Systematic Reviews as Topic - Published
- 2019
33. Surgical site infiltration: A neuroanatomical approach
- Author
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Anthony T. Machi and Girish P. Joshi
- Subjects
Bupivacaine ,Pain, Postoperative ,business.industry ,Ropivacaine ,medicine.medical_treatment ,Analgesic ,Surgical wound ,Liposomal Bupivacaine ,medicine.disease ,03 medical and health sciences ,0302 clinical medicine ,Anesthesiology and Pain Medicine ,030202 anesthesiology ,Anesthesia ,medicine ,Humans ,Pain Management ,Anesthetics, Local ,business ,Saline ,Infiltration (medical) ,030217 neurology & neurosurgery ,Anesthesia, Local ,Abdominal surgery ,medicine.drug - Abstract
Local anaesthetic administration into a surgical wound blocks the noxious stimuli that result from surgical insult at the site of origin. Surgical site infiltration (also known as local infiltration analgesia) is easy to perform, safe and inexpensive. In addition, it avoids motor blockade, which is particularly relevant for lower limb surgery. The best approach to surgical site infiltration includes meticulous, systematic and extensive surgical site local anaesthetic infiltration in the various tissue planes under direct visualisation before closure of the surgical wound. Local anaesthetic solutions that could be used include bupivacaine HCl, ropivacaine or liposomal bupivacaine diluted with preservative-free normal (0.9%) saline to a total volume depending on the size of the incision. Bupivacaine and ropivacaine are sometimes combined with additives, which have controversial benefits. Continuous wound infusion with preperitoneal wound catheters is an effective pain modality in abdominal surgery and can be used as an alternative for neuraxial analgesia. It is essential that surgical site infiltration is combined with other non-opioid analgesics such as paracetamol and non-steroidal anti-inflammatory drugs to attain the maximum analgesic efficacy.
- Published
- 2019
34. Postoperative pain management in the era of ERAS: An overview
- Author
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Henrik Kehlet and Girish P. Joshi
- Subjects
Postoperative Care ,Protocol (science) ,Pain, Postoperative ,medicine.medical_specialty ,business.industry ,Postoperative pain ,Psychological intervention ,Perioperative ,Evidence-based medicine ,Surgical procedures ,Pain management ,Perioperative Care ,03 medical and health sciences ,0302 clinical medicine ,Anesthesiology and Pain Medicine ,030202 anesthesiology ,medicine ,Humans ,Pain Management ,Enhanced Recovery After Surgery ,Intensive care medicine ,business ,Enhanced recovery after surgery ,030217 neurology & neurosurgery - Abstract
Enhanced recovery after surgery (ERAS) programmes are increasingly becoming standard of care for several surgical procedures. However, compliance with ERAS protocols including pain management protocols remains poor. The PROSPECT (PROcedure-SPEcific Postoperative Pain ManagemenT) collaboration provides evidence-based, procedure-specific pain management recommendations presented as preoperative, intraoperative and postoperative interventions as well as surgical interventions that are easy to access, transparent and relevant to clinicians. This approach should facilitate incorporation of pain management recommendations in an ERAS protocol and improve compliance with the protocols. This article presents an improved approach to developing pain management guidelines as well as a pragmatic approach to procedure-specific perioperative pain management that could be incorporated in an ERAS pathway.
- Published
- 2019
35. Tailoring postoperative pain management using a procedure-specific approach
- Author
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E. Roofthooft, Girish P. Joshi, M. Van de Velde, and Narinder Rawal
- Subjects
medicine.medical_specialty ,Pain, Postoperative ,Science & Technology ,business.industry ,Postoperative pain ,MEDLINE ,Anesthesiology and Pain Medicine ,Text mining ,Anesthesiology ,Physical therapy ,Medicine ,Humans ,Pain Management ,business ,Life Sciences & Biomedicine - Abstract
ispartof: ANAESTHESIA vol:76 issue:9 pages:1282-1282 ispartof: location:England status: published
- Published
- 2021
36. Pain management after open liver resection: Procedure-Specific Postoperative Pain Management (PROSPECT) recommendations
- Author
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Dieu, Audrey, Huynen, Philippe, Lavand'homme, Patricia, Beloeil, Hélène, Freys, Stephan M, Pogatzki-Zahn, Esther M, Joshi, Girish P, Van de Velde, Marc, PROSPECT Working Group of the European Society of Regional Anaesthesia and Pain Therapy (ESRA), Cliniques Universitaires Saint-Luc [Bruxelles], Catholic University of Leuven - Katholieke Universiteit Leuven (KU Leuven), Centre d'Investigation Clinique [Rennes] (CIC), Université de Rennes 1 (UR1), Université de Rennes (UNIV-RENNES)-Université de Rennes (UNIV-RENNES)-Hôpital Pontchaillou-Institut National de la Santé et de la Recherche Médicale (INSERM), Nutrition, Métabolismes et Cancer (NuMeCan), Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement (INRAE)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Rennes 1 (UR1), Université de Rennes (UNIV-RENNES)-Université de Rennes (UNIV-RENNES), CHU Pontchaillou [Rennes], DIAKO Ev. Diakonie-Krankenhaus [Bremen, Germany], University Hospital Münster - Universitaetsklinikum Muenster [Germany] (UKM), University of Texas Southwestern Medical Center, Unrestricted grant, European Society of Regional Anaesthesia and Pain Therapy, UCL - SSS/IONS/CEMO - Pôle Cellulaire et moléculaire, UCL - (SLuc) Service d'anesthésiologie, HAL UR1, Admin, Université de Rennes (UR)-Hôpital Pontchaillou-Institut National de la Santé et de la Recherche Médicale (INSERM), and Université de Rennes (UR)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement (INRAE)
- Subjects
medicine.drug_class ,[SDV]Life Sciences [q-bio] ,Analgesic ,Context (language use) ,Review ,law.invention ,03 medical and health sciences ,0302 clinical medicine ,Randomized controlled trial ,030202 anesthesiology ,law ,Medicine ,Humans ,postoperative ,Ketamine ,Local anesthesia ,pain ,Dexmedetomidine ,10. No inequality ,Pain, Postoperative ,business.industry ,Local anesthetic ,Nerve Block ,analgesia ,General Medicine ,3. Good health ,Acetaminophen ,[SDV] Life Sciences [q-bio] ,Analgesics, Opioid ,Anesthesiology and Pain Medicine ,Liver ,pain management ,030220 oncology & carcinogenesis ,Anesthesia ,business ,medicine.drug - Abstract
Background and objectivesEffective pain control improves postoperative rehabilitation and enhances recovery. The aim of this review was to evaluate the available evidence and to develop recommendations for optimal pain management after open liver resection using Procedure-Specific Postoperative Pain Management (PROSPECT) methodology.Strategy and selection criteriaRandomized controlled trials (RCTs) published in the English language from January 2010 to October 2019 assessing pain after liver resection using analgesic, anesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane databases.ResultsOf 121 eligible studies identified, 31 RCTs and 3 systematic reviews met the inclusion criteria. Preoperative and intraoperative interventions that improved postoperative pain relief were non-steroidal anti-inflammatory drugs, continuous thoracic epidural analgesia, and subcostal transversus abdominis plane (TAP) blocks. Limited procedure-specific evidence was found for intravenous dexmedetomidine, intravenous magnesium, intrathecal morphine, quadratus lumborum blocks, paravertebral nerve blocks, continuous local anesthetic wound infiltration and postoperative interpleural local anesthesia. No evidence was found for intravenous lidocaine, ketamine, dexamethasone and gabapentinoids.ConclusionsBased on the results of this review, we suggest an analgesic strategy for open liver resection, including acetaminophen and non-steroidal anti-inflammatory drugs, combined with thoracic epidural analgesia or bilateral oblique subcostal TAP blocks. Systemic opioids should be considered as rescue analgesics. Further high-quality RCTs are needed to confirm and clarify the efficacy of the recommended analgesic regimen in the context of an enhanced recovery program.
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- 2021
37. Answer to the letter to the editor of JY Li et al. concerning "Ultrasound-guided erector spinae plane blocks for pain management after open lumbar laminectomy" by Stewart et al. (Eur Spine J [2022]: https://doi.org/10.1007/s00586-023-07881-4).
- Author
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Stewart, Jesse and Joshi, Girish P.
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ERECTOR spinae muscles , *PAIN management , *LAMINECTOMY , *SURGICAL site , *SPINE - Abstract
This document is a response to a letter to the editor regarding a study on the use of erector spinae plane blocks (ESPBs) for pain management after open lumbar laminectomy. The authors address the concerns raised in the letter, stating that there was no surgical site infiltration in either group and that the only difference was the administration of ESPBs in the study group. They also discuss the limitations of surgical site infiltration and the need for further research comparing ESPBs with local wound infiltration. The authors acknowledge the need to assess functional pain in future studies and clarify that there is no evidence supporting the claim that pain scores of 3 or less are necessary for early mobilization. They also acknowledge a typographical error in one of the tables and state that they are working with the publishers to correct it. [Extracted from the article]
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- 2023
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38. Pain management after laminectomy: a systematic review and procedure-specific post-operative pain management (prospect) recommendations
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Hélène Beloeil, Laurens Peene, Pauline Le Cacheux, Axel R. Sauter, Girish P. Joshi, HAL UR1, Admin, University Hospitals Leuven [Leuven], CHU Pontchaillou [Rennes], Bern University Hospital [Berne] (Inselspital), University of Texas Southwestern Medical Center [Dallas], Nutrition, Métabolismes et Cancer (NuMeCan), Université de Rennes (UR)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement (INRAE), Centre d'Investigation Clinique [Rennes] (CIC), Université de Rennes (UR)-Hôpital Pontchaillou-Institut National de la Santé et de la Recherche Médicale (INSERM), European Society of Regional Anaesthesia and Pain Therapy, Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement (INRAE)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Rennes 1 (UR1), Université de Rennes (UNIV-RENNES)-Université de Rennes (UNIV-RENNES), Université de Rennes 1 (UR1), and Université de Rennes (UNIV-RENNES)-Université de Rennes (UNIV-RENNES)-Hôpital Pontchaillou-Institut National de la Santé et de la Recherche Médicale (INSERM)
- Subjects
GELFOAM ,Evidence-based medicine ,[SDV]Life Sciences [q-bio] ,medicine.medical_treatment ,Analgesic ,Clinical Neurology ,MEDLINE ,LUMBAR DECOMPRESSION SURGERY ,SPINE SURGERY ,PREGABALIN ,MORPHINE ,DOUBLE-BLIND ,ANALGESIA ,03 medical and health sciences ,0302 clinical medicine ,030202 anesthesiology ,medicine ,PARACETAMOL ,Humans ,Pain Management ,Orthopedics and Sports Medicine ,Anesthetics, Local ,Analgesics ,Pain, Postoperative ,Science & Technology ,business.industry ,Laminectomy ,Surgical wound ,Perioperative ,DEXAMETHASONE ,3. Good health ,[SDV] Life Sciences [q-bio] ,Regimen ,Orthopedics ,INFILTRATION ,Opioid ,Anesthesia ,Systematic review ,Surgery ,Neurosciences & Neurology ,Analgesia ,business ,Life Sciences & Biomedicine ,030217 neurology & neurosurgery ,medicine.drug - Abstract
Purpose With lumbar laminectomy increasingly being performed on an outpatient basis, optimal pain management is critical to avoid post-operative delay in discharge and readmission. The aim of this review was to evaluate the available literature and develop recommendations for optimal pain management after one- or two-level lumbar laminectomy. Methods A systematic review utilizing the PROcedure-SPECific Post-operative Pain ManagemenT (PROSPECT) methodology was undertaken. Randomised controlled trials (RCTs) published in the English language from 1 January 2008 until 31 March 2020—assessing post-operative pain using analgesic, anaesthetic and surgical interventions—were identified from MEDLINE, EMBASE and Cochrane Databases. Results Out of 65 eligible studies identified, 39 RCTs met the inclusion criteria. The analgesic regimen for lumbar laminectomy should include paracetamol and a non-steroidal anti-inflammatory drug (NSAID) or cyclooxygenase (COX)—2 selective inhibitor administered preoperatively or intraoperatively and continued post-operatively, with post-operative opioids for rescue analgesia. In addition, surgical wound instillation or infiltration with local anaesthetics prior to wound closure is recommended. Some interventions—gabapentinoids and intrathecal opioid administration—although effective, carry significant risks and consequently were omitted from the recommendations. Other interventions were also not recommended because there was insufficient, inconsistent or lack of evidence. Conclusion Perioperative pain management for lumbar laminectomy should include paracetamol and NSAID- or COX-2-specific inhibitor, continued into the post-operative period, as well as intraoperative surgical wound instillation or infiltration. Opioids should be used as rescue medication post-operatively. Future studies are necessary to evaluate the efficacy of our recommendations.
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- 2020
39. Breast surgery analgesia: a reply
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Girish P. Joshi, A. Lemoine, M. Van de Velde, A. Jacobs, and Francis Bonnet
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medicine.medical_specialty ,business.industry ,Breast surgery ,medicine.medical_treatment ,General surgery ,MEDLINE ,Breast Neoplasms ,Anesthesiology and Pain Medicine ,Medicine ,Humans ,Pain Management ,Analgesia ,business ,Mastectomy - Published
- 2020
40. Functional recovery after knee arthroplasty with regional analgesia
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Girish P. Joshi and Henrik Kehlet
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Anesthesiology and Pain Medicine ,business.industry ,medicine.medical_treatment ,Anesthesia ,Medicine ,Pain Management ,Analgesia ,business ,Functional recovery ,Arthroplasty, Replacement, Knee ,Arthroplasty - Published
- 2020
41. Preface
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Girish P. Joshi and Francis Bonnet
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Pain, Postoperative ,Anesthesiology and Pain Medicine ,Humans ,Pain Management ,Perioperative Care - Published
- 2019
42. Critical appraisal of randomised trials assessing regional analgesic interventions for knee arthroplasty: implications for postoperative pain guidelines development.
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Joshi, Girish P., Stewart, Jesse, and Kehlet, Henrik
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KNEE pain , *POSTOPERATIVE pain , *ARTHROPLASTY , *PAIN management , *ANALGESIA , *KNEE , *TOTAL knee replacement , *RESEARCH , *ANALGESICS , *RESEARCH methodology , *EVALUATION research , *COMPARATIVE studies , *RANDOMIZED controlled trials , *OPIOID analgesics - Abstract
Guidelines are increasingly being used for clinical decision-making. Such guidelines are usually based on meta-analyses, which are generally derived from RCTs. However, their interpretations are often hindered as they do not always consider current clinical relevance. Analyses of RCTs assessing analgesic efficacy of advanced regional analgesic techniques in knee arthroplasty show that the majority of trials do not include a package of basic analgesics such as paracetamol, NSAIDs or cyclooxygenase-2 specific inhibitors, dexamethasone, and local infiltration analgesia in the comparator group. Consequently, the current approach to analyse meta-analyses of pain interventions is not optimal, and may lead to inadequate or inappropriate conclusions and clinical guidance. [ABSTRACT FROM AUTHOR]
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- 2022
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43. Meta‐analyses of gabapentinoids for pain management after knee arthroplasty: A caveat emptor? A narrative review.
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Joshi, Girish P. and Kehlet, Henrik
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PAIN management , *KNEE pain , *TOTAL knee replacement , *ARTHROPLASTY , *KNEE , *AUTHOR-reader relationships - Abstract
The use of gabapentinoids for perioperative pain management after total knee arthroplasty has been the subject of nine systematic reviews and meta‐analyses. A critical analysis of the clinical aspects of the methodology of these publications shows major flaws which limit the interpretation for the recommended use of perioperative gabapentinoids in pain management for unilateral primary total knee arthroplasty. Consequently, readers and authors of systematic reviews and meta‐analyses should critically assess the clinical aspects of the included studies. [ABSTRACT FROM AUTHOR]
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- 2021
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44. Interfascial plane blocks
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Girish P. Joshi and Anthony T. Machi
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medicine.medical_specialty ,Pain, Postoperative ,business.industry ,Nerve Block ,Perioperative ,Pain management ,Surgical procedures ,Plane (Unicode) ,Clinical Practice ,03 medical and health sciences ,0302 clinical medicine ,Anesthesiology and Pain Medicine ,030202 anesthesiology ,Block (programming) ,Medicine ,Humans ,Pain Management ,Medical physics ,business ,030217 neurology & neurosurgery ,Ultrasonography, Interventional - Abstract
Many novel interfascial plane blocks have been developed in the last 10 years in the effort to improve perioperative pain management that are safe, efficacious, efficient, and inexpensive. These blocks have been widely adopted into clinical practice despite relatively few high-quality clinical investigations of the techniques and how they affect perioperative outcomes. This article defines interfascial plane blocks, discusses the potential benefits, reviews the most common techniques and evidence supporting their indication, and guides clinicians in selecting an appropriate interfascial plane block for different types of surgical procedures.
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- 2019
45. Development of evidence-based recommendations for procedure-specific pain management: PROSPECT methodology
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M. Van de Velde, Girish P. Joshi, H. Kehlet, Pogatzki-Zahn, E, Schug, S, Bonnet, F, Rawal, N, Delbos, A, Lavand'homme, P, Beloeil, H, Raeder, J, Sauter, A, Albrecht, E, Lirk, P, Lobo, D, and Freys, S
- Subjects
Evidence-based practice ,Delphi Technique ,media_common.quotation_subject ,education ,Clinical Decision-Making ,Guidelines as Topic ,Rigour ,Perioperative Care ,03 medical and health sciences ,0302 clinical medicine ,030202 anesthesiology ,Medicine ,Humans ,Pain Management ,Quality (business) ,030212 general & internal medicine ,health care economics and organizations ,media_common ,Pain Measurement ,Surgeons ,Medical education ,Pain, Postoperative ,evidence‐based medicine ,Evidence-Based Medicine ,Health professionals ,business.industry ,postoperative pain, analgesia ,methodology ,Evidence-based medicine ,Original Articles ,Pain management ,Transparency (behavior) ,Anesthesiologists ,Clinical Practice ,Anesthesiology and Pain Medicine ,recommendations ,Original Article ,business ,evidence-based medicine - Abstract
Effective peri-operative pain management is a prerequisite for optimal recovery after surgery. Despite published evidence-based guidelines from several professional groups, postoperative pain management remains inadequate. The procedure-specific pain management (PROSPECT) collaboration consists of anaesthetists and surgeons with broad international representation that provide healthcare professionals with practical and evidence-based recommendations formulated in a way that facilitates clinical decision-making across all stages of the peri-operative period on a procedure-specific basis. The aim of this manuscript is to provide a detailed description of the current PROSPECT methodology with the intention of providing the rigour and transparency in which procedure-specific pain management recommendations are developed. The high methodological standards of the recommendations should improve the quality of clinical practice. ispartof: ANAESTHESIA vol:74 issue:10 pages:1298-1304 ispartof: location:England status: published
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- 2019
46. Perioperative use of opioids: Current controversies and concerns
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Girish P. Joshi, Biral Patel, and John C. Alexander
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medicine.medical_specialty ,Pain, Postoperative ,business.industry ,Opioid use ,Opioid abuse ,Narcotic-Related Disorders ,Population health ,Perioperative ,Pain management ,Opioid-Related Disorders ,Perioperative Care ,Analgesics, Opioid ,03 medical and health sciences ,0302 clinical medicine ,Anesthesiology and Pain Medicine ,030202 anesthesiology ,medicine ,Humans ,Pain Management ,Intraoperative Period ,Risks and benefits ,Intensive care medicine ,Adverse effect ,business ,030217 neurology & neurosurgery - Abstract
In the midst of an epidemic of opioid abuse and overdose-related morbidity and mortality, the use of opioids remains the most common means of providing analgesia in the perioperative period. In this article, we review the risks and benefits of opioid use in preoperative, intraoperative and post-operative phases of care. Furthermore, we describe the role that surgeons and anaesthesiologists can play in reducing perioperative opioid use and mitigate their adverse effects, from both an individual and a population health perspective.
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- 2019
47. Procedure-specific acute pain trajectory after elective total hip arthroplasty: systematic review and data synthesis
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Claire X. Xu, James P. Rathmell, Girish P. Joshi, Paul Panzenbeck, Philipp Lirk, Arvind von Keudell, Kristin L. Schreiber, and Kamen Vlassakov
- Subjects
Clinical Trials as Topic ,Pain, Postoperative ,business.industry ,Arthroplasty, Replacement, Hip ,Analgesic ,Psychological intervention ,Chronic pain ,medicine.disease ,Regimen ,Anesthesiology and Pain Medicine ,Elective Surgical Procedures ,Anesthesia ,Data Interpretation, Statistical ,medicine ,Humans ,Pain Management ,General anaesthesia ,Adjuvant Analgesic ,business ,Acute pain ,Total hip arthroplasty ,Pain Measurement - Abstract
For most procedures, there is insufficient evidence to guide clinicians in the optimal timing of advanced analgesic methods, which should be based on the expected time course of acute postoperative pain severity and aimed at time points where basic analgesia has proven insufficient.We conducted a systematic search of the literature of analgesic trials for total hip arthroplasty (THA), extracting and pooling pain scores across studies, weighted for study size. Patients were grouped according to basic anaesthetic method used (general, spinal), and adjuvant analgesic interventions such as nerve blocks, local infiltration analgesia, and multimodal analgesia. Special consideration was given to high-risk populations such as chronic pain or opioid-dependent patients.We identified and analysed 71 trials with 5973 patients and constructed pain trajectories from the available pain scores. In most patients undergoing THA under general anaesthesia on a basic analgesic regimen, postoperative acute pain recedes to a mild level (4/10) by 4 h after surgery. We note substantial variability in pain intensity even in patients subjected to similar analgesic regimens. Chronic pain or opioid-dependent patients were most often actively excluded from studies, and never analysed separately.We have demonstrated that it is feasible to construct procedure-specific pain curves to guide clinicians on the timing of advanced analgesic measures. Acute intense postoperative pain after THA should have resolved by 4-6 h after surgery in most patients. However, there is a substantial gap in knowledge on the management of patients with chronic pain and opioid-dependent patients.
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- 2019
48. Pain Management for Ambulatory Arthroscopic Anterior Cruciate Ligament Reconstruction: Evidence-Based Recommendations From the Society for Ambulatory Anesthesia
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Girish P. Joshi, Richard Brull, and Faraj W. Abdallah
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Risk ,Anterior cruciate ligament reconstruction ,Adductor canal ,medicine.medical_treatment ,03 medical and health sciences ,Arthroscopy ,0302 clinical medicine ,Femoral nerve ,Meta-Analysis as Topic ,030202 anesthesiology ,Anesthesia, Conduction ,Ambulatory Care ,Medicine ,Humans ,Pain Management ,Anesthesia ,Societies, Medical ,Acetaminophen ,Analgesics ,Pain, Postoperative ,Evidence-Based Medicine ,medicine.diagnostic_test ,Anterior Cruciate Ligament Reconstruction ,business.industry ,Anti-Inflammatory Agents, Non-Steroidal ,Nerve Block ,Evidence-based medicine ,Ambulatory Surgical Procedure ,Anesthesiology and Pain Medicine ,medicine.anatomical_structure ,Ambulatory Surgical Procedures ,Ambulatory ,Practice Guidelines as Topic ,Nerve block ,business ,030217 neurology & neurosurgery ,Femoral Nerve ,Systematic Reviews as Topic - Abstract
Ambulatory arthroscopic anterior cruciate ligament reconstruction is associated with moderate pain, even when nonopioid oral analgesics such as acetaminophen and nonsteroidal anti-inflammatory drugs are used. Regional analgesia can supplement nonopioid oral analgesics and reduce postoperative opioid requirements, but the choice of regional analgesia technique for anterior cruciate ligament reconstruction remains controversial. Femoral nerve block, adductor canal block, and local instillation analgesia have all been proposed and are supported by some evidence from randomized controlled trials. Consequently, regional analgesia practice in patients undergoing anterior cruciate ligament reconstruction remains mixed. Published systematic reviews were used to identify the regional analgesia modality that would provide a balance between analgesic efficacy and associated potential risks in the setting of nonopioid multimodal analgesic strategies. Based on the evidence available, local instillation analgesia provides the best balance of analgesic efficacy and associated risks (strong recommendation, moderate level of evidence) when used as a component of multimodal analgesic technique in the first 24 hours after outpatient arthroscopic anterior cruciate ligament reconstruction. In the absence of local instillation analgesia, clinicians might use adductor canal block or femoral nerve block (weak recommendation, weak level of evidence). These recommendations have been endorsed by the Society of Ambulatory Anesthesia and approved by its board of directors.
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- 2019
49. Pain management after laparoscopic hysterectomy: systematic review of literature and PROSPECT recommendations
- Author
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Philipp, Lirk, Juliette, Thiry, Marie-Pierre, Bonnet, Girish P, Joshi, Francis, Bonnet, M, van de Velde, Brigham & Women’s Hospital [Boston] (BWH), Harvard Medical School [Boston] (HMS), Department of Biological Chemistry and Molecular Pharmacology [Harvard Medical School], Service des soins intensifs [CHU Tenon], Assistance publique - Hôpitaux de Paris (AP-HP) (APHP)-CHU Tenon [APHP], Sorbonne Université (SU), CHU Cochin [AP-HP], Université Paris Descartes - Paris 5 (UPD5), University of Texas Southwestern Medical Center [Dallas], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-CHU Tenon [AP-HP], Sorbonne Université (SU)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU), Hôpital Cochin [AP-HP], and Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)
- Subjects
Abdominal pain ,Analgesic ,Pregabalin ,[SDV.MHEP.CHI]Life Sciences [q-bio]/Human health and pathology/Surgery ,[SDV.MHEP.GEO]Life Sciences [q-bio]/Human health and pathology/Gynecology and obstetrics ,Dexamethasone ,law.invention ,03 medical and health sciences ,0302 clinical medicine ,Randomized controlled trial ,systematic review ,030202 anesthesiology ,Transversus Abdominis Plane Block ,law ,Humans ,Pain Management ,Medicine ,pain ,Anesthetics, Local ,Adverse effect ,Acetaminophen ,Randomized Controlled Trials as Topic ,Analgesics ,Pain, Postoperative ,030219 obstetrics & reproductive medicine ,business.industry ,Anti-Inflammatory Agents, Non-Steroidal ,analgesia ,General Medicine ,Evidence-based medicine ,Analgesics, Non-Narcotic ,Bupivacaine ,3. Good health ,Analgesics, Opioid ,Anesthesiology and Pain Medicine ,Systematic review ,Anesthesia ,Laparoscopy ,medicine.symptom ,laparoscopic hysterectomy ,business ,evidence-based medicine ,medicine.drug - Abstract
Background and objectivesLaparoscopic hysterectomy is increasingly performed because it is associated with less postoperative pain and earlier recovery as compared with open abdominal hysterectomy. The aim of this systematic review was to evaluate the available literature regarding the management of pain after laparoscopic hysterectomy.Strategy and selection criteriaRandomized controlled trials evaluating postoperative pain after laparoscopic hysterectomy published between January 1996 and May 2018 were retrieved, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, from the EMBASE and MEDLINE databases and the Cochrane Register of Controlled Trials. Efficacy and adverse effects of analgesic techniques were assessed.ResultsOf the 281 studies initially identified, 56 were included. Of these, 31 assessed analgesic or anesthetic interventions and 25 assessed surgical interventions. Acetaminophen, non-steroidal anti-inflammatory drugs, and dexamethasone reduced opioid consumption. Limited evidence hindered recommendations on alpha-2-agonists. Inconsistent evidence was found in the studies investigating pregabalin and transversus abdominis plane block, and no evidence was found for intraperitoneal local anesthetics, port site infiltration, or single-port laparoscopy. Measures to lower peritoneal insufflation pressure or humidify or heat insufflated gas seem to reduce the incidence of shoulder pain, but not abdominal pain.ConclusionsThe baseline analgesic regimen for laparoscopic hysterectomy should include acetaminophen, a non-steroidal anti-inflammatory drug, dexamethasone, and opioids as rescue analgesics.
- Published
- 2019
50. Correction to: Ultrasound‑guided erector spinae plane blocks for pain management after open lumbar laminectomy.
- Author
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Stewart, Jesse W., Dickson, Douglas, Van Hal, Michael, Aryeetey, Lemuelson, Sunna, Mary, Schulz, Cedar, Alexander, John C., Gasanova, Irina, and Joshi, Girish P.
- Subjects
ERECTOR spinae muscles ,LAMINECTOMY ,PAIN management - Abstract
This document is a correction notice for an article titled "Ultrasound-guided erector spinae plane blocks for pain management after open lumbar laminectomy" published in the European Spine Journal. The correction states that Table 3 data in the original publication were incorrect and provides the correct table. The table presents numerical rating scores over time for patients undergoing open lumbar laminectomy with or without erector spinae plane block (ESPB) as part of multimodal analgesic care. The correction notice concludes by stating that the original article has been corrected and that Springer Nature remains neutral regarding jurisdictional claims and institutional affiliations. [Extracted from the article]
- Published
- 2024
- Full Text
- View/download PDF
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