Total knee replacement (TKR) is one of the most commonly done surgical procedures, with over 150,000 total knee replacements and THR performed annually in England and Wales in the National Health Service (NHS). In India although clear-cut data is not available but the incidence is increasing. In the US, 431,000 TKRs are performed yearly and the utilization of TKR has increased over the last two decades, especially among younger patients .TKR may be associated with severe post-operative pain. The International Association for the Study of Pain (IASP) has defined pain as “an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has made adequate pain management a priority and has deemed monitoring pain as the “fifth” vital sign.
CPSP is a new emerging disease but can be a silent epidemic.
Optimal perioperative management may reduce the incidence of CPSP.
Minimal invasive surgical techniques
Agressive perioperative multimodal analgesia, inluding epidural or nerve blocks.
Appropriate management of acute pain is therefore not only a humane obligation, but also may prevent of chronic pain!
Total knee replacement (TKR) is one of the most commonly done surgical procedures, with over 150,000 total knee replacements and THR performed annually in England and Wales in the National Health Service (NHS). In India although clear-cut data is not available but the incidence is increasing. In the US, 431,000 TKRs are performed yearly and the utilization of TKR has increased over the last two decades, especially among younger patients .TKR may be associated with severe post-operative pain. The International Association for the Study of Pain (IASP) has defined pain as “an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has made adequate pain management a priority and has deemed monitoring pain as the “fifth” vital sign.
CPSP is a new emerging disease but can be a silent epidemic.
Optimal perioperative management may reduce the incidence of CPSP.
Minimal invasive surgical techniques
Agressive perioperative multimodal analgesia, inluding epidural or nerve blocks.
Appropriate management of acute pain is therefore not only a humane obligation, but also may prevent of chronic pain!
Pain Physicians should consider nerve blocks when systemic analgesics are failing. (Adjuvant therapy)
Careful selection of patients
Benefits should outweigh the risks
Thorough knowledge of the limitations and side effects
Need for randomized controlled clinical trials.
Acute pain management requires a multimodal and multidisciplinary approach with a clear organization framework. Regional anesthesia techniques for surgical anesthesia are a highly effective component of acute pain management.
With the advancement of ultrasonographic technology with higher resolution and penetration imaging, there is increasing use of ultrasonography (US) in acute and chronic pain blocks.
Chronic pain after surgery. More than just a nuisance?
Chronic pain can complicate a third of even relatively minor surgical procedures with far-reaching consequences for patient and family. Why does it happen? What can be done to mitigate the problem?
A seminar in three movements held jointly with the Glasgow Southern Medical Society:
'Magnitude' Dr William Macrae, Dundee
'Molecules' Dr Mick Serpell, Glasgow
'Meaning' Dr David Craig, Glasgow
In this lecture, Dr Bill Macrae discusses the magnitude of the problem.
Surface anatomy and sonoanatomy for the occasional regional anesthesiologist Edward R. Mariano, MD
At the conclusion of this activity, learners will be able to: define optimal ultrasound transducer position for cross-sectional imaging of nerves; apply surface anatomic landmark identification in ultrasound transducer application; identify sonoanatomy of common peripheral nerves and surrounding structure; and discuss tips and tricks to improve ultrasound images and ultrasound-guided nerve block techniques.
Regional Anesthesia in the Prevention of Persistent Postsurgical PainEdward R. Mariano, MD
Persistent postsurgical pain (PPSP), or chronic pain that develops after surgery, occurs more frequently than one may expect: up to 50% after relatively common operations. For anesthesiologists, surgeons, and pain physicians, there is an urgent need to discover methods to prevent the development of PPSP which is considered one of the more dreaded adverse outcomes following elective surgery.
Trauma is one of the primary causes of mortality and morbidity worldwide, and pain is the most common symptom reported by patients entering the Emergency Department. More than 5 million people in the United States report long-term disabilities due to traumatic injuries. Safe intraoperative care and effective acute pain management are essential for successful outcomes in the trauma patient.
Interventional pain management by dr rajeev harsheRajeev Harshe
This is a brief presentation on how pain can be managed in a better way. Dr Rajeev Harshe is senior pain management consultant in western India. He is attached to Apollo Hospitals and has his private consulting room as well.Email: dr.harshe@gmail.com. If you are anaesthesiologist and if you wish to learn pain management,contact him.
Pain Physicians should consider nerve blocks when systemic analgesics are failing. (Adjuvant therapy)
Careful selection of patients
Benefits should outweigh the risks
Thorough knowledge of the limitations and side effects
Need for randomized controlled clinical trials.
Acute pain management requires a multimodal and multidisciplinary approach with a clear organization framework. Regional anesthesia techniques for surgical anesthesia are a highly effective component of acute pain management.
With the advancement of ultrasonographic technology with higher resolution and penetration imaging, there is increasing use of ultrasonography (US) in acute and chronic pain blocks.
Chronic pain after surgery. More than just a nuisance?
Chronic pain can complicate a third of even relatively minor surgical procedures with far-reaching consequences for patient and family. Why does it happen? What can be done to mitigate the problem?
A seminar in three movements held jointly with the Glasgow Southern Medical Society:
'Magnitude' Dr William Macrae, Dundee
'Molecules' Dr Mick Serpell, Glasgow
'Meaning' Dr David Craig, Glasgow
In this lecture, Dr Bill Macrae discusses the magnitude of the problem.
Surface anatomy and sonoanatomy for the occasional regional anesthesiologist Edward R. Mariano, MD
At the conclusion of this activity, learners will be able to: define optimal ultrasound transducer position for cross-sectional imaging of nerves; apply surface anatomic landmark identification in ultrasound transducer application; identify sonoanatomy of common peripheral nerves and surrounding structure; and discuss tips and tricks to improve ultrasound images and ultrasound-guided nerve block techniques.
Regional Anesthesia in the Prevention of Persistent Postsurgical PainEdward R. Mariano, MD
Persistent postsurgical pain (PPSP), or chronic pain that develops after surgery, occurs more frequently than one may expect: up to 50% after relatively common operations. For anesthesiologists, surgeons, and pain physicians, there is an urgent need to discover methods to prevent the development of PPSP which is considered one of the more dreaded adverse outcomes following elective surgery.
Trauma is one of the primary causes of mortality and morbidity worldwide, and pain is the most common symptom reported by patients entering the Emergency Department. More than 5 million people in the United States report long-term disabilities due to traumatic injuries. Safe intraoperative care and effective acute pain management are essential for successful outcomes in the trauma patient.
Interventional pain management by dr rajeev harsheRajeev Harshe
This is a brief presentation on how pain can be managed in a better way. Dr Rajeev Harshe is senior pain management consultant in western India. He is attached to Apollo Hospitals and has his private consulting room as well.Email: dr.harshe@gmail.com. If you are anaesthesiologist and if you wish to learn pain management,contact him.
Peran Fentanyl pada balance anestesia -> telah banyak diteliti hasilnya adanya potensiasi fentanyl dengan obat anestesia baik inhalasi maupun intravena. Berikut ini kami mencoba menelaah beberapa penelitian dari luar maupun penelitian yang kami lakukan sendiri.
Transcranial Magnetic Stimulation ( TMS) for Chronic PainDr. Rafael Higashi
Aula sobre avanço no tratamento da dor crônica com o uso de Estimulação Magnética Transcraniana (EMT) ministrada por Dr. Rafael Higashi, médico neurologista, no departamento de tratamento da dor do Centro Médico da Universidade de Nova York, NYU, EUA.
www.estimulacaoneurologica.com.br
The essential use of parecoxib in post operative pain management speaker (1)Setyadi Soeroyo
Presentasi ini tentang obat nyeri yang aman untuk lambung, selain itu obat ini tidak mengganggu pembekuan darah. Parecoxib adalah jenis analgetik cox2. Penggunaan untuk pasien dengan kelainan jantung dan pada penderita kelainan ginjal harus hati-hati.
Nora e reversal colorato slideshare; NaPoli i SIA 2016Claudio Melloni
Non operating room anesthesia and reversal of muscle relaxation.Respiratory complications due to residual paralysis.Mechanism of action of residual paralysis .Sugammadex.Calabadion New discoveries.
Valut az rischio anest sia napoli dic 2008;italian + bibliografyClaudio Melloni
evaluation of operative risk for non cardiac surgery ;for anesthesia and surgery.Cardiac conditions,including heart failure ,use of betablockers,stains.Diabetes risk,including difficult intubation.Thromboembolic risk,
lowest heart rate
lowest mean arterial pressure
estimated blood loss
A score built from these 3 predictors has proved strongly predictive of the risk of major postoperative complications and death in general and vascular surgery
A new dantrolene formulation for the treatment of Malignant hyperthermia(MH).Receptors,pharmacokinetics,dosages,preparation of dantrolene,practical tips,advantages.
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Navigating the Health Insurance Market_ Understanding Trends and Options.pdfEnterprise Wired
From navigating policy options to staying informed about industry trends, this comprehensive guide explores everything you need to know about the health insurance market.
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
Welcome to Secret Tantric, London’s finest VIP Massage agency. Since we first opened our doors, we have provided the ultimate erotic massage experience to innumerable clients, each one searching for the very best sensual massage in London. We come by this reputation honestly with a dynamic team of the city’s most beautiful masseuses.
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
Telehealth Psychology Building Trust with Clients.pptx
Update on NSAID's,Coxibs(2008???)
1. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Il trattamento del dolore
postoperatorio;
update on NSAIDs and Coxibs….
C.Melloni
Consulente di Anestesia Villa Torri e
Villa Chiara ,Bologna
2. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Practice guidelines in the perioperative
setting
unless contraindicated, all patients
should receive around-the-clock
regimen of NSAIDs, coxibs, or
acetaminophen’
– Ashburn MA, Caplan RA, Carr DB, et al. Practice
guidelines for acute pain management in the
perioperative setting. An updated report by the
American Society of Anesthesiologists task force on
acute pain management. Anesthesiology 2004;
100:1573–1581.
4. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Curr Opinion
Tissue injury leads to pain transmission by direct mechanical and thermal
damage to nerve endings, as well as the release of inflammatory mediators
[10]. These inflammatory mediators include arachidonic cascade metabolites
that sensitize peripheral nerve endings, resulting in hyperalgesia and thus
facilitating pain transmission.
Prostaglandins, including prostaglandin (PG)E2, are responsible for reducing
the pain threshold at the site of injury (primary hyperalgesia), resulting in
central sensitization and a lower pain threshold in the surrounding uninjured
tissue (secondary hyperalgesia) [11].
Traditionally, the primary site of action of NSAIDs has been attributed to their
inhibition of prostaglandin synthesis in the periphery although recent
research indicates that central inhibition of cyclooxygenase (COX)-2 may
also play an important role in modulating nociception [12]. Peripheral
inflammation has been shown also to induce a widespread increase in COX-
2 [13] and PGE synthase (PGES) expression in the CNS. The pro-
inflammatory cytokine interleukin 1b (IL-Ib) is upregulated at the site of
inflammation and plays a major role in inducing COX-2 in local inflammatory
cells by activating the
transcription factor NF-kB [14]. IL-1b is also responsible for the induction of
COX-2 in the central nervous system in response to peripheral inflammation
5. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Thus,
there appear to be two forms of input from peripheral
inflamed tissue to the central nervous system. The first is
mediated by electrical activity in sensitized nerve fibers
innervating the inflamed area, which signals the location
of the inflamed tissue, as well as the onset, duration and
nature of any stimuli applied to this tissue [15,16]. This
input is sensitive to peripherally acting COX-2 inhibitors
and to neural blockade with local anesthetics, as with
epidural or spinal anesthesia [15]. The second is a
humoral signal originating from the inflamed tissue,
which acts to produce a widespread induction of COX-
2 in the central nervous system. This input is not affected
by regional anesthesia and will only be blocked by
centrally acting COX-2 inhibitors [15,18]. One implication
of this is that patients who receive neuraxial anesthesia
for surgery might also need a centrally acting COX-2
inhibitor to optimally reduce postoperative pain and the
postoperative stress response [15,18,19]. Therefore the
permeability of the blood–brain barrier to currently used
NSAIDs and COX-2 inhibitors becomes important [20].
6. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Advantages of Nsaids
significant opioid-sparing effect [24].
lack of sedation
Lack of respiratory depression
low abuse potential,
no interference with bowel or bladder
function
Comparable efficacy for both pain at rest
and with movement [26],
7. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Disadvantages of Nsaids
Ceiling effect
Insufficient analgesia following major
surgery
8. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Differential expression of COX 1 & 2 isoenzymes in
different tissues
Arachidonic acid
COX 1 COX 2
Prostaglandin(s) Pgs
G.I tract:gastric mucosa,intestine
Platelet
Kidney
Most tissues
Inflammatory cells
Female reproduction
Spinal cord,brain
kidney
cancer
IL 1 Beta
TNF alfa
NSAIDs COxibs
paracetamol COX 3
?
?
9. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Choice criteria from bibliography and
efficacy analysis
Oxford league table of analgesics in acute pain
This league table was constructed for analgesics in acute
pain.
Information was from systematic reviews of randomised,
double-blind, single-dose studies,placebo controlled.
in patients with moderate to severe pain.
For each review the outcome was identical - that is at
least 50% pain relief over 4-6 hours.
The pain measurements were standardised, and have
been validated.
10. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
NNT
A measure of analgesic efficacy
Number of patients who need to receive
the active drug for one to achieve at
least 50% relief of pain compared with
placebo over a 4-6 h treatment period
The most effective drugs have a low NNT,i.e. just
over 2
The NNT is drug,dose,context specific
11. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Analgesics not efficacious
Codeina 60 mg da sola non è un analgesico efficace!
NNT 16.7
Destropropossifene (liberen) 65 mg da solo non è un
analgesico efficace
Diidrocodeina da sola (30-60 mg) non è un
analgesico efficace
Petidina 50 mg im non è un analgesico efficace.
12. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Aspirina !
0,00
10,00
20,00
30,00
40,00
50,00
60,00
70,00
% paz con
sollievo >50%
aspirina placebo NNT
500
600-650
1000
1200
650+codeina60
Dosi in mg
13. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Adverse effects for aspirin 650 mg plus codeine 60
mg compared with placebo
Adverse effect
Harmed on
Active
Harmed on
Control
Relative risk
(95%CI)
NNH (95%CI)
Dizziness 18/309 15/714 2.8 (1.4 to 5.4) 25 (15 to 110)
Drowsiness/som
nolence
58/309 48/714 2.8 (2.0 to 4.0) 8.3 (6 to 14)
Headache 18/309 41/714 1.0 (0.5 to 1.7) not calculated
Nausea 35/309 31/714 2.6 (1.6 to 4.2) 14 (9 to 32)
Vomiting 3/309 6/714 1.2 (0.3 to 4.6) not calculated
14. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Celecoxib:Artilog,Artrid,Celebrex,Solexa
0
10
20
30
40
50
60
% paz con
sollievo > 50%
celecoxib placebo NNT
200
400
Durata:6 h!
15. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Celecoxib vs placebo:orthopedic and
dental surgery
16. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Characteristics of excluded studies
Study Reason for exclusion
Doyle 2002 No evaluable data: analysed as pain relief plus
pain intensity difference
Ekman 2002 Not postoperative pain
Fort 1999 Review (no data)
Hubbard 1996 Abstract (no data)
Issioui 2002 Pre-operative drug administration (insufficient
baseline pain)
Khan 2002 Analgesic administered pre-operatively
Reuben 2000 Pre-operative drug administration and
concurrent morphine titration (insufficient baseline pain)
Salo 2003 No placebo group; included patients with
musculoskeletal injuries, not postoperative pain.
17. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Diclofenac:Algosenac,artrofenac,dealgic,deflamat,diclofan,dicloreu
m,fenadol,fender,flogofenac,forgenac,lisiflen,novapirina,ribex,voltaren,vol
tfast
0
10
20
30
40
50
60
70
% di paz con
sollievo>50%
diclofenac placebo NNT
25
50
100
mg
18. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Studies with diclofenac
Cochrane review
III molar extraction
Ahlstrom 1993,Bakshi 1992, Bakshi 1994, Mehlisch 1994,
Nelson 1994
Gynaecological surgery
Herbertson 1994
Post-episiotomy
Olson 1997
19. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
NNTs for diclofenac at different
doses
Number of
Percent with at least 50% pain
relief
Dose
(mg)
Trial
s
Patien
ts
Diclofenac Placebo
Relative
benefit
(95% CI)
NNT
(95% CI)
25 4 502 53 15
3.6 (2.6 to
5.0)
2.6 (2.2 to
3.3)
50 12 1296 57 19
3.0 (2.5 to
3.6)
2.7 (2.4 to
3.1)
100 5 545 69 14
4.9 (3.6 to
6.6)
1.8 (1.6 to
2.1)
20. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
There was a dose response for diclofenac
with higher doses producing lower (better)
NNTs
(Figure 1). With diclofenac 25 mg 54% of
patients
with initial pain of moderate or severe
intensity
had at least 50% pain relief over 4-6 hours,
as did 63% with diclofenac 50 mg and 67%
with diclofenac 100 mg.
21. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
NNTs for diclofenac at different
doses
22. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Etoricoxib:algix,arcoxia,tauxib
0
10
20
30
40
50
60
70
80
90
100
% di paz con
sollievo>50%
etoricoxib placebo NNT
60
120
180
240
mg
23. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Lumiracoxib
Characteristics of included studies
total knee or hip arthroplasty surgery
»Study Chan 2005
dental surgery, third molar extraction
»Study Kellstein 2004, Zelenakas 2004
26. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Ibuprofen:algofen,antalgil,antalisin,arfen,brufen,buscofen,calmine,c
ibalgina,dolocyl,faspic,ganaprofene,moment,nureflex,nurofen
0
10
20
30
40
50
60
70
80
90
100
% paz con
sollievo >50%
ibuprofen placebo NNT
50
100
200
400
600
800
mg
27. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Percentage of patients with at least 50%
pain relief at different doses
28. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
NNTs for ibuprofen at different doses
29. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Ketorolac:lixidol,toradol
0
10
20
30
40
50
60
70
80
% paz con
sollievo> 50%
Ketorolac placebo NNT
10 im
30 im
60 im
10 iv
5 os
10 os
20 os
30. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
NAPROXEN:aleve,algonapril,axer,floginax,floxalin,gibixen,laser,momend
ol,naprius,napronex,naprosyn, neo
eblimon,prexan,synalgo,synflex,ticoflrx,xenar.
0
5
10
15
20
25
30
35
40
45
50
% paz con
solievo > 50%
naproxen placebo NNT
naproxen 220
naproxen 400
naproxen 550
31. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Naproxen
major abdominal or orthopaedic surgery
» Brown 1997
3rd molar extraction
» Forbes 1986, Fricke 1993, Kiersch 1993,
Kiersch 1994
removal of 2 or more 3rd molars, one of which
was impacted
» Gottesdiener 1999, Merck 1997a ,Merck
1997b
orthopaedic or general surgery
» Mahler 1976
32. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
exclusion
Angle 2002 :Inappropriate pain scales and no 4-6 hour
efficacy data
Aromaa 1978 :No placebo arm
Baumgartner 1987: No placebo arm and not double blind
Brown 1984 :Inappropriate pain scales and no extractable
efficacy data
Brown 1990 :No extractable data
Bucheli 1994 :No placebo arm
Bunemann 1994: Baseline pain includes mild pain and no 4-6
hour efficacy data
Buttram 1984: No placebo arm
Coli 1992 :No placebo arm
33. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
A D D I T I O N A L T A B
L E S
Table 01. Remedication data - placebo
Study No. patients Time to remed. (hrs)
% remed. by 12 h
Gottesdiener 1999 25 1.6 92 (by 24 hrs)
Forbes 1986 42 5.29 81
Reicin 2001 53 2.8 93
Merck 1997a 38 1.6 57
Merck 1997b 47 1.5 76
Table 02. Remedication data - naproxen
sodium 550 mg
36. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Paracetamol indications
Opioid sparing
Pazients in whom salycilates are
contraindicated
» Asthmatics
» Allergic
» Peptic ulcer
» Children with febrile viral ilnesses
37. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Paracetamol toxicity
50% of cases of liver failure in UK
38. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
NNTs for paracetamol at different doses
39. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Studies with paracetamol
Cochrane review
3rd Molar removal (Bony Impacted)or other
teeth
» Bentley 1987, Cooper 1980 ,Cooper 1981,Cooper1986,Cooper 1988, Cooper
1989,Cooper1991a, Cooper 1998 , Forbes 1982 , Forbes 1984 , Forbes 1989 ,Forbes
1990a , Forbes 1990b , Hersch 2000 , Kiersch 1994 , Lehnert 1990 , Mehlisch 1995 ,
Moller 2000 , Seymour 1996 , Sunshine 1986 ,
Oral surgery (involving bone removal)
» Mehlisch 1984, Mehlisch 1990 , Winter 1983
Dental, gynaecologic and orthopaedic pain patients
» Edwards 2002
General, Gynaecological or orthopaedic surgery)
» Forbes 1984b,F orbes 1983, Jain 1986
40. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Studies with paracetamol Cochrane
review
Episiotomy
» Bhounsule 1990, Berry 1975 , Sunshine 1989
Caesarean section
» Bjune 1996, Sunshine 1993
Post partum (post episiotomy and post-surgical)
» Laska 1983 (Study 3), Rubin 1984, Schachtel 1989
Elective orthopaedic surgery
» McQuay 1988, Sakata 1986 , Santos Pereira 1986 , Winnem 1981
Tonsillectomy
» Pinto 1984
Urological
» Rubinstein 1986
41. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
NNTs for paracetamol +codeine at
different doses
43. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Parecoxib:
0
10
20
30
40
50
60
70
80
% paz con
sollievo >50%
parecoxib placebo NNT
parecoxib 20 iv
parecoxib 20 im
parecoxib 40 iv
parecoxib 40 im
44. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Tempo medio dalla somminmistrazione fino alla
necessità di una nuova dose di analgesico
45. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Piroxicam:algoxan,antiflog,artroxicam,brexin,brexivel,bruxicam,cicl
adol,dexicam,euroxi,feldene,flodol,lampoflex,polipirox,reucam,reudene,re
umagil,riacen,roxene,roxenil,roxiden.
0
0,5
1
1,5
2
2,5
3
piroxicam placebo NNT
piroxicam os 20
Piroxicam os 40
Solo 15 vs 15
46. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
ROFECOXIB:Arofex,Coxxil,dolcoxx,dolostop,miraxx,vioxx
0
10
20
30
40
50
60
% paz con
sollievo > 50%
rofecoxib placebo NNT
rofecoxib 50
48. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Tempo medio dalla somministrazione fino alla
necessità di una nuova dose di analgesico
49. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Tempo medio dalla somminmistrazione fino alla
necessità di una nuova dose di analgesico
50. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Rofecoxib,celebrex
Characteristics of included studies
Third molar removal
»Study Chang 2001, Chang 2002, Ehrich 1999,
Fricke 2002, ,Morrison 1999
Major orthopedic surgery (total hip replacement,
knee replacement or femoral fracture repair)
» Reicin 2001
51. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Rofecoxib
Characteristics of excluded studies
Study Reason for exclusion
Gimbel 2001 Did not include rofecoxib in
active treatment arms
Huang 2001 Study drug administration before
operation therefore insufficient baseline pain
intensity
Jeske 1999 Review
Mehlisch 1998 Abstract
Morrison 1999a Not postoperative pain
Morrison2000 Review, no identifiable unique
trial data
Pickering 2002 Children, not adult participants
52. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
event:
Chang 2001
Placebo 10/31
Rofecoxib 50 mg 60/182
Paracetamol 600 mg plus codeine 60 mg
83/180
Nausea:
Placebo 3/31
Rofecoxib 50 mg 11/182
Paracetamol 600 mg plus codeine 60 mg mg
45/180
Vomiting:
53. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Rofecoxib
Drug-related adverse events Chang 2002
seen in 13 (10.7%) of rofecoxib patients,
27 (22.3%) of diclofenac patients and
11 (17.5%) of placebo patients.
Notes Median time to remedication: > 24
hrs for rofecoxib 50 mg, 1.35 hrs for
diclofenac 50 mg and placebo.
54. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
1999
Specific adverse events:
Nausea -
Placebo 9/45
Rofecoxib 50 mg 8/90
Celecoxib 200 mg 11/91
Ibuprofen 400 mg 8/46
Vomiting -
Placebo 6/45
Remedication within 24 hours:
91% of placebo
49% of rofecoxib 50 mg
55. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Rofecoxib
» Morrison 1999
Notes Remedication within 24 hours:
92% of placebo
56% of rofecoxib 50 mg
82% of ibuprofen 400 mg
Median time to remedication:
2.4 hours for placebo
9.5 hours for rofecoxib 50.
Patients experiencing any adverse event:
Placebo 17/50
61. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Tramadol (contramal,fortradol,fraxidol,prontalgin,tradonal),per
os e studi comparativi
0
5
10
15
20
25
30
35
40
45
50
% paz con
sollievo >50%
placebo NNT
codeina 60
tramadol 50
tramadol 75
tramadol 100
tramadol 150
paracetamol 650+propossifene 100
aspirin 650+ codeina 60
62. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
VALDECOXIB per os
0
10
20
30
40
50
60
70
80
valdecoxib placebo NNT
valdecoxib 20
valdecoxib 40
63. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Oxford league table of analgesic efficacy/NNT
pag 91 MooreA,Edwards J,Barden J,McQuay H.Bandolier’s Little Book of pain.Oxford UNiversity Press
2004
0
1
2
3
4
5
6
ibuprofen
800ketorolac20
ketorolac60
imdiclofenac
100piroxicam
40
paracetam
ol1000+
codeine
60
paracetam
ol500+
O
xycodone
5brom
fenac25rofecoxib
50diclofenac
50naproxen
440
O
xycodone
15
ibuprofen
600ibuprofen
400aspirin
1200
dipyrone
1000dipyrone
500
lower confidence
higher confidence
NNT
64. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Ibuprofen
Oxford league table of analgesic efficacy/NNT
0
1
2
3
4
5
6
7
ib
uprofen
800ib
up
rofen
600ib
up
rofen
400ib
up
rofen
200ib
up
rofen
100
lower confidence
higher confidence
NNT
65. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Ketorolac
Oxford league table of analgesic efficacy/NNT
0
1
2
3
4
5
6
ketorolac 20 ketorolac 60 im ketorolac 10 ketorolac 30 im
lower confidence
higher confidence
NNT
66. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Paracetamol & Paracetamol +codeine
Oxford league table of analgesic efficacy/NNT
0
5
10
15
20
25
p
arq
acetam
o
l1000+
vcod
ein
e
60
p
aracetam
ol
1000+
oxycod
o
n
e
10
p
aracetam
ol
500
p
aracetam
ol
1500
p
aracetam
ol
1000
p
aracetam
ol
600/650+
cod
en
ed
60
P
aracetam
ol
1000+
oxycod
o
n
e
5
p
aracetam
ol
600/650
p
aracetam
ol
325+
o
xy
co
d
on
e
5
p
aracetam
ol
300+
cod
in
e
30
lower confidence
higher confidence
NNT
67. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Diclofenac
2007 League table of number needed to treat (NNT) for at least 50%
pain relief over 4-6 hours in patients with moderate to severe pain,
0
0,5
1
1,5
2
2,5
3
3,5
4
4,5
5
diclofenac 100 diclofenac 25
lower confidence
higher confidence
NNT
68. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
naproxen
2007 League table of number needed to treat (NNT) for at least 50% pain
relief over 4-6 hours in patients with moderate to severe pain,
0
1
2
3
4
5
6
naproxen 440 naproxen 550
lower confidence
higher confidence
NNT
69. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Tramadol,pethidine,morphine
2007 League table of number needed to treat (NNT) for at least 50%
pain relief over 4-6 hours in patients with moderate to severe pain,
0
2
4
6
8
10
12
14
pethidine
100 im
tramadol
150
morphine
10 im
tramadol
100
tramadol
75
tramadol
50
lower confidence
higher confidence
NNT
70. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Aspirine
2007 League table of number needed to treat (NNT) for at least 50%
pain relief over 4-6 hours in patients with moderate to severe pain,
0
1
2
3
4
5
6
7
8
aspirin 1200 aspirin 600/650 aspirin 650 +
codeine 60
lower confidence
higher confidence
NNT
71. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
piroxicam
2007 League table of number needed to treat (NNT) for at least 50% pain
relief over 4-6 hours in patients with moderate to severe pain,
0
1
2
3
4
5
6
piroxicam 40 piroxicam 20 ketorolac 10 ketorolac 30 im
lower confidence
higher confidence
NNT
72. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Etoricoxib,valdecoxib,rofecoxib
2007 League table of number needed to treat (NNT) for at least 50%
pain relief over 4-6 hours in patients with moderate to severe pain,
0
0,5
1
1,5
2
2,5
3
etoricoxib
180/240
etoricoxib
100/120
valdecoxib
40
valdecoxib
20
celecoxib
400
rofecoxib 50
lower confidence
higher confidence
NNT
73. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Oxford league table of analgesics in acute pain
2004
74. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Oxford league table of analgesics in acute pain
2004
75. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
eeded to
Number needed to treat (NNT) for at least 50% pain relief over 4-6
hours in patients with moderate to severe pain, all oral analgesics
except IM morphine and pethidine and ketorolac.Bandolier 2004
76. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
2007 League table of number needed to treat (NNT) for at least 50%
pain relief over 4-6 hours in patients with moderate to severe pain,
all oral analgesics except IM morphine
80. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Gajraj NM. Cyclooxygenase-2 inhibitors. Anesth Analg 2003;
96:1720–1738.
Sinatra R. Role of COX-2 inhibitors in the evolution of acute pain
management.J Pain Symptom Manage 2002; 24:S18–S27.
Gilron I, Milne B, Hong M. Cyclooxygenase-2 inhibitors in
postoperative pain management. Anesthesiology 2003; 99:1198–
1208.
Stephens J, Laskins B, Pashos C, Wong J. The burden of acute
postoperative pain and the potential role of the COX-2 specific
inhibitors. Rheumatology 2003; 42:40–52.
Zemmel MH. The role of COX-2 inhibitors in the perioperative
setting:efficacy and safety – a systematic review. AANA J 2006;
74:49–60.
Straube S, Derry S, McQuay HJ, Moore RA. Effect of preoperative
COX-II selective NSAIDs (coxibs) on postoperative outcomes: a
81. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Acta Anaesthesiol Scand. 2005 May;49(5):601-13. Links
» Effect of preoperative Cox-II-selective NSAIDs (coxibs) on postoperative outcomes: a systematic review of
randomized studies.
» Straube S, Derry S, McQuay HJ, Moore RA.
» Pain Research and Nuffield Department of Anaesthetics, University of Oxford, Oxford Radcliffe Hospital, The Churchill,
Headington, Oxford OX3 7LJ, UK.
» BACKGROUND: Preoperative use of coxibs has been claimed to reduce postoperative pain and analgesic consumption,
and to affect other postoperative outcomes. METHODS: Systematic review of randomized trials comparing preoperative
coxib with preoperative placebo, or active comparator. Searching of PubMed and Cochrane Library to August 2004. A
qualitative and a quantitative analysis. RESULTS: Twenty-two included trials with 2246 patients had high reporting quality
and validity scores, though treatment group sizes were small, with a median size of 30 patients. Most trials used oral
preoperative rofecoxib (mainly 50 mg) or celecoxib (mainly 200 mg). Preoperative coxibs significantly reduced both
postoperative pain and analgesic consumption compared with preoperative placebo in 15/20 trials. In one further trial
postoperative pain was reduced and in one analgesic consumption. There was no significant difference in the incidence of
postoperative nausea and vomiting in 13/17 studies or when data were pooled. Postoperative antiemetic use was
significantly reduced in all five trials reporting it; the NNT to prevent one patient using postoperative antiemetic was 10 (5.5
to 66). No trial reported any significant difference in intraoperative blood loss or recovery from anaesthesia. Patient
satisfaction was significantly increased with preoperative coxib use. No conclusions could be drawn from the three trials
comparing preoperative coxib with preoperative NSAID. One study reported significantly improved cost-efficacy with
rofecoxib. CONCLUSIONS: Preoperative coxibs had clear benefits in terms of reduced postoperative pain, analgesic
consumption and patient satisfaction compared with placebo. Effects on postoperative nausea and vomiting remain
uncertain, as do those on recovery from surgery or economic benefit. Future trials should be larger and more pragmatic in
nature.
82. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
acetaminophen in the treatment of pain after
ambulatory orthopedic surgery in adults. Clin Ther
2001;23:228–41
