Article Notes
- Identify patients at risk of opioid dependence.
- Use multi-modal non-opioid analgesia perioperatively.
- Educate patients on realistic expectations for post-operative pain.
- Consider regional techniques intraoperatively when appropriate.
- Limit discharge prescribing of opioids (42-71% of all postop opioid tablets go unused!).
Why should I care?
Misuse of opioids is a growing global problem, well established in the US and quickly appearing in many high-resource countries. One person dies every 15 minutes in the US from opioid overdose.
For many affected, the perioperative period is the first exposure event. In the US ~6% of previously opioid-naive patients progress to persistent opioid use after surgery.
What can anaesthetists and anesthesiologists do?
The bigger picture...
Although inidividual practice changes are important, real impact will come through anesthesiologists as integrators of care (eg. ERAS interventions) and contributions to institutional strategies, patient and provider education.
Take a long view, this problem is not going away in a hurry...
Daniel Jolley
Metajournal now automatically tracks and can filter for retracted articles – simply hit search in your article view and filter by article type. Easily check if there are any retracted articles among those you’ve favourited or read previously.
It’s a sad indictment on a minority in the medical community that this kind of technology is now necessary...
Daniel Jolley
Calabadions are heterocyclics molecule that offers rapid and complete reversal of both aminosteroids, such as rocuronium and vecuronium, and benzylisoquinoline NMBDS, such as atracurium and cisatracurium.
Notably, calabadion 2 binds rocuronium 89 times stronger than sugammadex. Additionally it also binds etomidate and ketamine.
Calabadions are still undergoing pre-human animal testing, and so are some time away from entering clinical practice.
Daniel Jolley
We’re still doing too many unnecessary general anaesthetic cesarean sections. It is not enough to be confident that we can conduct a ‘safe’ GA CS (ie. misperceived as meaning a low mortality risk), when avoidable GA CS are still associated with a spectrum of morbidity.
Definitely falls into the category of ‘just because we can, doesn’t mean we should’...
Daniel Jolley
Although there is reasonable confidence that a single general anaesthetic before three years of age has no consequences for intelligence development, there is an association between multiple exposures and learning and behavioural difficulties, possibly including ADHD. Animal studies have demonstrated ADHD-like changes in juvenile rats exposed to general anaesthetics.
There is a plausible physiological explanation for how general anaesthesia may induce ADHD, involving disruption of the prefrontal cortex and basal ganglia via dopaminergic, glutaminergic and neutrophic factor mechanisms.
Nonetheless, evidence to date linking general anaesthetic exposure in young children and ADHD development is far from conclusive and – as with many areas of practice – requires further research.
Daniel Jolley
The remifentanil PCA for labour analgesia controversy continues...
Those advocating its first-line use point to reassuring evidence of maternal satisfaction and acceptability, reduced epidural rates, and some suggestion of reduced instrumental delivery rates.
For the negative, the ongoing safety concerns created by routine use of remifentanil PCAs are foremost, particularly given how uneven hospitals can be at implementing best safety practices. Observed rates of significant desaturation range from 25-70%, in addition to potential neonatal effects.
The greatest challenge facing the remiPCA advocates, is that the labour epidural is still the most effective form of labour analgesia, and has only improved over the decades as safety has been both maintained and increased.
Daniel Jolley
A narrative article describing the myths can be found here:
Neuromuscular myths: we need to do better!
Daniel Jolley
Pholcodine is an opioid anti-tussive (ie. cough suppressant). It is a common component of over-the-counter cough medications. However it has a special significance to anesthesiologists in relation to anaphylaxis risk, particularly related to neuromuscular agents.
Florvaag et al's 2009 review covers this issue very comprehensively. Earlier 2006 research from Florvaag et al attempting to explain some of the regional variability in anaphylaxis rates showed that exposure to pholcodine causes an 60-105 times increase in IgE levels!
Countries where pholcodine use is common (eg Norway) seem to have experienced higher levels of anaphylaxis to neuromuscular blocking agents than countries where it is not common (eg Sweden). In fact, in Norway rocuronium anaphylaxis was such a problem that its use was restricted to modified rapid sequence inductions. A pholcodine containing cough syrup has been withdrawn from the market in Norway because of this (and levels of sensitisation seem to be dropping although it is still too early to draw conclusions). It will be interesting to see if there are other compounds that have a similar effect on IgE sensitisation and whether other countries will consider withdrawing pholcodine products.
In addition to the two articles from Florvaag that specifically look at Pholcodine and it's effects, there is also an interesting review looking at recent insights into anaphylaxis in the anaesthetic setting from Dewachter and team.
Also interesting is Lee et al.'s 2016 case report describing two patients with pholcodine anaphylaxis who then when tested also showed NMBD sensitivity.
Helen Crilly & Michael Rose's 2014 review in Australian Prescriber Anaphylaxis and anaesthesia – can treating a cough kill? is another great summary of the issue.
Daniel Jolley
It’s notable how poor the evidence base is for many drugs for use in children. This is indicative of the lack of studies rather than efficacy, though is always worth remembering. Even from Germany, the Land of Tramadol, this Cochrane review could not unearth significant evidence for using tramadol for pediatric post-operative pain.
Daniel Jolley
Post-operative cognitive problems are a growing worldwide concern, especially with our aging surgical population – but as this Cochrane review points out, we still don’t know the answers to even some simple questions, like ‘Is there a difference between TIVA and volatile anesthesia?’
Continue to watch this space...
Daniel Jolley