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Risparmio Degli Oppioidi o Modulazione?: Paolo Grossi, M.D
Risparmio Degli Oppioidi o Modulazione?: Paolo Grossi, M.D
Ritardata dimissione
• Bupivacaina, Ropivacaina,
A. locali Levobupivacaina
a
Examples of opioids include morphine, fentanyl, sufentanil
b
Examples of local anesthetics include bupivacaine, ropivacaine
Vie discendenti
Multimodal Approaches:
Evidence-based Summary
Multimodal Approaches:
Evidence-based Summary
• Acetaminophen – Parenteral
• Studied single dose, multiple dose over 24 hours compared with
placebo
• Orthopedic surgery, laminectomy, abdominal, gynecological,
cardiac, and thyroidectomy
• Dosing: 1 gram IV, either single dose or every 6 hours
• Summary APAP patients:
• Statistically significant shortened time to meaningful pain relief and in total
relief compared with placebo
• Improved patient satisfaction with pain control, lower morphine
consumption (up to 61%) and decreased incidence of vomiting
• No statistical significant difference in the rates of adverse events including
liver function abnormalities compared with placebo
• Nonselective NSAIDs
• Single dose oral ibuprofen1 – Summary 72 randomized clinical trials
(RCTs), 9168 patients
• ³ 50% pain relief in approximately half of patients with moderate to severe
postoperative pain, and adverse events were similar to placebo
• Single dose oral aspirin2 – Summary
• ³ 50% or greater reduction in pain in 39% of those with moderate to severe
pain, compared with 15% of those in the placebo group
• The efficacy of aspirin was considered equivalent to that of acetaminophen
• Adverse events were statistically similar for those taking a lower
aspirin dose, 600 mg to 650 mg, compared with placebo. However, patients
who took 900 mg to 1000 mg experienced adverse events at more than twice
the rate of patients receiving placebo (26% vs 12%). The most common events
in the aspirin group were drowsiness, dizziness, nausea, vomiting, and gastric
irritation
2Derry C et al. Cochrane Database Syst Rev. Published Online Jan 2012
Verso la Chirurgia Ortopedica Ambulatoriale - International Meeting Orthopea
Derry S et al. Cochrane Database Syst Rev. Published Online: 22 OCT 2013
Verso la Chirurgia Ortopedica Ambulatoriale - International Meeting Orthopea
• Injectable NSAIDs
• Ketorolac and ibuprofen studied in United States
• Indicated for short-term moderate to severe acute pain that
requires analgesia at the opioid level
• Studies (variety of surgery types) with ketorolac1,2 compared with placebo
suggest patients who received ketorolac:
• Significant reduction in pain
• Reduction in opioid consumption (~30%)
• Facilitation of quicker recovery and rehabilitation
• Studies with ibuprofen in orthopedic and abdominal surgery3
• At 800-mg dose, reduced morphine use by 22% in first 24 hours
• Significant reductions in pain at rest and with movement
• No significant increases compared with placebo in ADRs
Nel 2005
NSAIDs
Verso la Chirurgia Ortopedica Ambulatoriale - International Meeting Orthopea
Verso la Chirurgia Ortopedica Ambulatoriale - International Meeting Orthopea
• ABSTRACT
• Backgroung Local injection of multimodal cocktail including corticosteroid is commonly
used for postoperative pain following total knee arthroplasty (TKA). However, it is
inconclusive whether additional corticosteroid is beneficial. This meta-analysis of
randomized controlled trials aimed to evaluate the efficacy of an additional, local
injection of corticosteroid in terms of pain relief and knee function recovery after TKA.
• Methods: Randomized controlled trials (RCTs) in electronic literature database including
PubMed, Web of Science, Embase, and Cochrane Library were systematically searched.
Of 1628 records identified, 9 RCTs involving 727 knees were eligible for data extraction
and meta-analysis.
• Results: Local injection of multimodal cocktail including corticosteroid did not contribute
to pain relief within 12 hours postoperatively (p>0.05). However, from 24 hours to 72
hours, it significantly decreased pain score (p<0.05, all) at rest and reduced total rescue
opioids.
• consumption postoperatively (p<0.05). The knee range of motion (ROM) degree was
improved at postoperative day 1 (POD1) and POD2 (p<0.05), and hospital stay (p<0.05)
was shortened after local injection of corticosteroid. However, the other outcomes,
including knee ROM degree after POD2, C-reactive protein level, Knee Society score,
postoperative nausea and vomiting, and wound complication occurrences, were not
significantly different (p>0.05, all).
• Conclusions: Additional corticosteroid added to a multimodal cocktail improved the
postoperative pain, enhance knee functional recovery, and shorten the hospital stays
following TKA, but local injection of corticosteroids had no effect on reducing nausea
and vomiting based on our outcomes
Verso la Chirurgia Ortopedica Ambulatoriale - International Meeting Orthopea
Gabapentin
Multimodal Approaches:
Evidence-based Summary
Gabapentin
Verso la Chirurgia Ortopedica Ambulatoriale - International Meeting Orthopea
Perioperative Pain –
Analgesic Adjuvants
Opioid- Prevention of
Analgesic Opioid related Side Chronic
Drug Pain Intensity Consumption Effects Postsurgical Pain Side Effects
Ketamine Inconsistent Psychomimetic
(hallucinations,
dreams)
Strategie analgesiche
Spinal
Anaesthesia
Knee Intravenous
NSAID and
Analgesia
analgesia Opioids
Peripheral
nerve
Blocks
Verso la Chirurgia Ortopedica Ambulatoriale - International Meeting Orthopea
ANALGESIA
AIM FOR TOTAL KNEE POSTOPERATIVE
Verso la Chirurgia Ortopedica Ambulatoriale - International Meeting Orthopea
…2019
Better
analges
better t ia ,
oghete
r!
Verso la Chirurgia Ortopedica Ambulatoriale - International Meeting Orthopea
Verso la Chirurgia Ortopedica Ambulatoriale - International Meeting Orthopea
Verso la Chirurgia Ortopedica Ambulatoriale - International Meeting Orthopea
Verso la Chirurgia Ortopedica Ambulatoriale - International Meeting Orthopea
Verso la Chirurgia Ortopedica Ambulatoriale - International Meeting Orthopea
Verso la Chirurgia Ortopedica Ambulatoriale - International Meeting Orthopea
Conclusions: In a population at high risk for perioperative complications from OSA, multimodal analgesia was associated
with a stepwise reduction in opioid use and complications, including critical respiratory failure.
Verso la Chirurgia Ortopedica Ambulatoriale - International Meeting Orthopea
Multimodal Analgesia
NSAIDs
The state-of-the-art is multimodal therapy with:
Opioids
IV Opioids:
Intraspinal (IS) IV, Intraspinal, Acetaminophen
Oral route Oral Route
NSAIDs
APAP Multimodal
Local anesthetics Analgesia
Wound site infiltration or perfusion
Peripheral nerve infusions via catheters Peripheral Nerve
Epidural Adjuvants
Block: Continous
IV vs single shot
Preperitoneal catheters
Wound Site
Infiltration