Editorial Acesso aberto Revisado por pares

Guidelines for perioperative pain management: need for re-evaluation

2017; Elsevier BV; Volume: 119; Issue: 4 Linguagem: Inglês

10.1093/bja/aex304

ISSN

1471-6771

Autores

Girish P. Joshi, Henrik Kehlet, Hélène Beloeil, Françis Bonnet, B. Fischer, Andrew G. Hill, Girish P. Joshi, Henrik Kehlet, Patricia Lavand’homme, Philipp Lirk, E.M. Pogatzki-Zhan, Johan Ræder, Narinder Rawal, Stephan A. Schug, M. Van de Velde,

Tópico(s)

Pain Management and Opioid Use

Resumo

Optimal perioperative pain management facilitates postoperative ambulation and rehabilitation, and is considered a prerequisite to enhancing recovery after surgery.1Joshi GP Schug S Kehlet H Procedure specific pain management and outcome strategies.Best Pract Res Clin Anaesthesiol. 2014; 28: 191-201Abstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar 2Kehlet H Dahl JB Anaesthesia, surgery, and challenges in postoperative recovery.Lancet. 2003; 362: 1921-1928Abstract Full Text Full Text PDF PubMed Scopus (1048) Google Scholar Despite well-documented benefits, postoperative pain continues to be inadequately treated.3Gan TJ Habib AS Miller TE White W Apfelbaum JL Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey.Curr Med Res Opin. 2014; 30: 149-160Crossref PubMed Scopus (443) Google Scholar, 4Chou R Gordon DB de Leon-Casasola OA et al.Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council.J Pain. 2016; 17: 131-157Abstract Full Text Full Text PDF PubMed Scopus (1550) Google Scholar, 5Schug SA Palmer GM Scott DA Halliwell R Trinca J APM: SE Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute Pain Management: Scientific Evidence. 4th Edn. ANZCA & FPM, Melbourne, Australia2015http://www.anzca.edu.au/resources/college-publicationsGoogle Scholar Although the reasons for the lack of appropriate pain management are not precisely known, conflicting and confusing evidence as well as lack of clear guidance could be contributing factors. The recently published clinical practice guidelines from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, the American Society of Anesthesiologists’ Committee on Regional Anesthesia4Chou R Gordon DB de Leon-Casasola OA et al.Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council.J Pain. 2016; 17: 131-157Abstract Full Text Full Text PDF PubMed Scopus (1550) Google Scholar and the Australian–New Zealand College of Anaesthetists5Schug SA Palmer GM Scott DA Halliwell R Trinca J APM: SE Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute Pain Management: Scientific Evidence. 4th Edn. ANZCA & FPM, Melbourne, Australia2015http://www.anzca.edu.au/resources/college-publicationsGoogle Scholar provide some excellent guidance with respect to preoperative assessment and patient education. However, the recommendations with regards to pharmacological therapy for pain are too broad and difficult to apply in day-to-day clinical practice.1Joshi GP Schug S Kehlet H Procedure specific pain management and outcome strategies.Best Pract Res Clin Anaesthesiol. 2014; 28: 191-201Abstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar The American guidelines suggest ‘considering’ almost every available analgesic [e.g. paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs)] and analgesic adjuncts (e.g. ketamine and gabapentinoids).4Chou R Gordon DB de Leon-Casasola OA et al.Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council.J Pain. 2016; 17: 131-157Abstract Full Text Full Text PDF PubMed Scopus (1550) Google Scholar However, the analgesic efficacy for a given analgesic depends on the type of surgical procedure.6Gray A Kehlet H Bonnet F Rawal N Predicting postoperative analgesia outcomes: NNT league tables or procedure-specific evidence?.Br J Anaesth. 2005; 94: 710-714Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar It is recommended that multimodal analgesic techniques should be offered, but there is no guidance with respect to appropriate combinations of analgesics for specific procedures.4Chou R Gordon DB de Leon-Casasola OA et al.Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council.J Pain. 2016; 17: 131-157Abstract Full Text Full Text PDF PubMed Scopus (1550) Google Scholar 5Schug SA Palmer GM Scott DA Halliwell R Trinca J APM: SE Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute Pain Management: Scientific Evidence. 4th Edn. ANZCA & FPM, Melbourne, Australia2015http://www.anzca.edu.au/resources/college-publicationsGoogle Scholar Therefore, it is not surprising that a recent analysis of data from 315 hospitals in the USA found that there was a wide variation in analgesic combinations in the 800 000 patients undergoing the four most common major surgical procedures.7Ladha KS Patorno E Huybrechts KF Liu J Rathmell JP Bateman BT Variations in the use of perioperative multimodal analgesic therapy.Anesthesiology. 2016; 124: 837-845Crossref PubMed Scopus (69) Google Scholar In fact, use of regional anaesthetic techniques, which are considered the basis of an optimal analgesic technique,1Joshi GP Schug S Kehlet H Procedure specific pain management and outcome strategies.Best Pract Res Clin Anaesthesiol. 2014; 28: 191-201Abstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar was low. Further, opioid administration was the primary analgesic, despite their significant limitations.8Kharasch ED Brunt LM Perioperative opioids and public health.Anesthesiology. 2016; 124: 960-965Crossref PubMed Scopus (98) Google Scholar Because many randomized controlled trials (RCTs) assessing analgesic interventions are underpowered, data from several RCTs are frequently combined to perform meta-analyses. However, the conclusions of such meta-analyses have been questioned.9Kehlet H Joshi GP Systematic reviews and meta-analyses of randomized controlled trials on perioperative outcomes: an urgent need for critical reappraisal.Anesth Analg. 2015; 121: 1104-1107Crossref PubMed Scopus (44) Google Scholar 10Sivakumar H Peyton PJ Poor agreement in significant findings between meta-anaylses and subsequent large randomized trials in perioperative medicine.Br J Anaesth. 2016; 117: 431-441Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar Although there has been an emphasis on performing trial sequential analysis and assessing heterogeneity between RCTs,11Espitalier F Tavernier E Remerand F Laffon M Fusciardi J Giraudeau B Heterogeneity in meta-analyses of treatment of acute postoperative pain: a review.Br J Anaesth. 2013; 111: 897-906Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar 12Fabritius ML Geisler A Petersen PL et al.Gabapentin for post-operative pain management—a systematic review with meta-analyses and trial sequential analyses.Acta Anaesthesiol Scand. 2016; 60: 1188-1208Crossref PubMed Scopus (71) Google Scholar investigators often focus on ‘bias’ between RCTs without considering many other clinically relevant factors that could influence decision making.13Fabritius ML Geisler A Petersen PL Wtterslev J Mathiesen O Dahl JB Gabapentin in procedure-specific postoperative pain management—preplanned subgroup analyses from a systematic review with meta-analyses and trial sequential analyses.BMC Anesthesiol. 2017; 17: 85Crossref PubMed Scopus (18) Google Scholar The aggregation of RCTs usually does not take into account the nature, location and severity of surgical injury, as studies from several surgical procedures are often grouped together when performing a meta-analysis. Also, many RCTs are placebo controlled with the control group receiving only opioids as rescue. This might be appropriate for assessing a new analgesic intervention,14Cooper SA Desjardins PJ Turk DC et al.Research design considerations for single-dose analgesic clinical trials in acute pain: IMMPACT recommendations.Pain. 2016; 157: 288-301Crossref PubMed Scopus (67) Google Scholar but once the efficacy of an analgesic intervention has been established, it is necessary to assess its role as a component of the currently considered ‘optimal’ or ‘best practice’ multimodal analgesic technique. In other words, it is necessary to assess if addition of an analgesic intervention would further improve pain control or allow replacement of another analgesic intervention to improve cost effectiveness and/or safety. Also, they do not take into consideration that many analgesic interventions might not have relevance in the rapidly changing clinical practice.1Joshi GP Schug S Kehlet H Procedure specific pain management and outcome strategies.Best Pract Res Clin Anaesthesiol. 2014; 28: 191-201Abstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar In recent years, traditional meta-analyses have been replaced by network meta-analyses, and are considered to be the best approach for evaluating available evidence and providing guidelines for evidence-based decision making.15Hoaglin DC Hawkins N Jansen JP et al.Conducting indirect-treatment-comparison and network-meta-analysis studies: report of the ISPOR Task Force on Indirect Treatment Comparisons Good Research Practices: Part 2.Value Health. 2011; 14: 429-437Abstract Full Text Full Text PDF PubMed Scopus (525) Google Scholar, 16Hutton B Salanti G Caldwell DM et al.The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: Checklist and explanations.Ann Intern Med. 2015; 162: 777-784Crossref PubMed Scopus (3282) Google Scholar, 17Leucht S Chaimani A Cipriani AS Davis JM Furukawa TA Salanti G Network meta-analyses should be the highest level of evidence in treatment guidelines.Eur Arch Psychiatry Clin Neurosci. 2016; 266: 477-480Crossref PubMed Scopus (104) Google Scholar Network meta-analyses assess the relative treatment effects through direct and indirect comparisons of available evidence. This approach allows comparisons between competing interventions that have not been directly compared head-to-head. Thus, a network meta-analysis provides not only the relative treatment effect for pairwise comparisons, but also a ranking of treatments. Although network meta-analyses are considered to be an improvement over the traditional meta-analyses, they too suffer from some of the same limitations of traditional meta-analyses. This is illustrated from the conclusions of a recent network meta-analysis assessing postoperative analgesic interventions that evaluated pain management modalities for total knee arthroplasty surgery from a total of 170 RCTs comparing 17 treatment modalities.18Terkawi AS Mavridis D Sessler DI et al.Pain management modalities after total knee arthroplasty: a network meta-analysis of 170 randomized controlled trials.Anesthesiology. 2017; 126: 923-937Crossref PubMed Scopus (99) Google Scholar The authors concluded that multiple nerve blocks are preferable to single nerve blocks, periarticular infiltration and epidural analgesia. Furthermore, they recommended that a combination of femoral nerve block and sciatic nerve block is the optimal approach. It is clear that the results of this study are not currently clinically applicable, because the recommended best approach has been questioned because of concerns of safety and delayed time to safe ambulation. Also, it did not compare other relevant non-opioid multimodal interventions. Thus, this network meta-analysis might be an interesting methodological exercise, but misleading to the clinician. Another network meta-analysis assessed 135 RCTs assessing 14 non-opioid analgesics.19Martinez V Beloeil H Marret E Fletcher D Ravaud P Trinquart L Non-opioid analgesics in adults after major surgery: systematic review with network meta-analysis of randomized trials.Br J Anaesth. 2017; 118: 22-31Abstract Full Text Full Text PDF PubMed Scopus (128) Google Scholar The authors concluded that a combination of paracetamol and NSAIDs or nefopam had superior opioid-sparing effects compared with non-opioid analgesics alone. Furthermore, if used alone NSAIDs, cyclooxygenase (COX)-2-specific inhibitors and α-2 agonists provided the best analgesic efficacy, whereas tramadol and paracetamol alone had the least analgesic efficacy. Here again, the authors combined studies from different surgical procedures and in most studies the comparator groups received only opioids as rescue and failed to consider combination of other non-opioid techniques or other outcomes. Given the aforementioned limitations of traditional approaches to assessing evidence (i.e. use of meta-analyses and network meta-analyses), it is necessary to modify the process by which recommendations are formulated. The methodological process for critical analysis of evidence and development of recommendations for procedure-specific analgesic interventions starts with performing a systematic review based on the protocol of the Cochrane Collaboration. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines are used to perform the literature search and assess quality and level of evidence of included studies. Importantly, the process of inclusion/exclusion of RCTs is critical and should be clearly defined. For studies to be grouped together they should have uniformity in analgesic technique(s) utilized. However, a critical interpretation of ‘bias’ in the available RCTs can lead to only a few ‘low-risk bias’ studies13Fabritius ML Geisler A Petersen PL Wtterslev J Mathiesen O Dahl JB Gabapentin in procedure-specific postoperative pain management—preplanned subgroup analyses from a systematic review with meta-analyses and trial sequential analyses.BMC Anesthesiol. 2017; 17: 85Crossref PubMed Scopus (18) Google Scholar and limit the possibility for a proper procedure-specific analysis. Thus, there is an urgent need for procedure-specific RCTs with fewer variables such that pain-related confounders are controlled while perioperative care is based upon the most updated evidence. In addition, welldesigned, highly standardized prospective cohort studies, designed to minimize bias and confounding factors, could address a relevant clinical question. In addition to considering the quality of available procedure-specific evidence, it is necessary to assess current clinical relevance and safety (e.g. adverse effects and impact on rehabilitation) of the analgesic techniques assessed in included studies. Thus, it is necessary to determine if the analgesic intervention would further improve postoperative pain relief and/or outcome when added to current ‘best practice’ analgesic regimens. For example, adding i.v. lidocaine infusion or transversus abdominis plane blocks to patients undergoing laparoscopic cholecystectomy might not be beneficial over the analgesic regimen of paracetamol + NSAIDs or COX-2-specific inhibitors + port site infiltration.1Joshi GP Schug S Kehlet H Procedure specific pain management and outcome strategies.Best Pract Res Clin Anaesthesiol. 2014; 28: 191-201Abstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar 9Kehlet H Joshi GP Systematic reviews and meta-analyses of randomized controlled trials on perioperative outcomes: an urgent need for critical reappraisal.Anesth Analg. 2015; 121: 1104-1107Crossref PubMed Scopus (44) Google Scholar Such a change in approach is necessary to gain evidence for improvements in multimodal pain management, and not to investigate alternative single treatment approaches. Analyses of the balance between invasiveness of the analgesic technique and the consequences of postoperative pain, as well as a balance between analgesic efficacy and adverse event profile of the intervention should be used to develop recommendations to ensure patient safety.20Fabritius ML Mathiesen O Wetterslev J Dahl JB Post-operative analgesia: focus has been on benefit—are we forgetting the harm?.Acta Anaesthesiol Scand. 2016; 60: 839-841Crossref PubMed Scopus (11) Google Scholar In addition, different relevant patient characteristics (e.g. opioid tolerance, psychiatric ailments) can be included to ensure not only procedure-specific but also patient-specific aspects of pain management. In summary, judgments about ‘best’ evidence for analgesic interventions and perioperative pain management recommendations are complex. Current guidelines for perioperative pain management are limited by their inability to be applied in a procedure-specific pathway. The current approach to traditional meta-analyses and network meta-analyses of RCTs of pain interventions is not optimal and can lead to inadequate or inappropriate conclusions and clinical guidance. Optimal recommendations for perioperative pain management should be based on a critical appraisal of evidence, focus on specific procedures and be interpreted against the backdrop of contemporary patterns of clinical practice. Therefore, in addition to experts in literature searches and/or data analysis, it is necessary to include specific expertise in the surgical procedure reviewed. Clinicians must be responsible for critical analysis of the design as well as relevance to current perioperative care in order to determine if RCTs identified in systematic reviews should be used in clinical decision making. The PROSPECT (PROcedure-SPEcific Postoperative Pain ManagemenT) Working Group, which consists of an international collaboration of anaesthesiologists and surgeons, is in the process of optimizing pain management recommendations based upon the aforementioned considerations. The PROSPECT initiative aims to provide healthcare professionals with practical procedure-specific pain management recommendations formulated in a way that facilitates clinical decision making across all stages of the perioperative period in a procedure-specific manner. The web-based (postoppain.org) recommendations are subject to formal review and updating within a prescribed time (usually every 3–5 yrs), so that they remain valid and clinically relevant. Finally, the main problem relates to the lack of high-quality procedure- and patient-specific data with sufficient information on efficacy vs safety of simple basic analgesia approaches integrated into fully implemented evidence-based enhanced recovery programmes. Hopefully, clinical pain researchers will fulfil these requirements in future trials in order to optimize perioperative pain management recommendations. All authors have made substantial contribution to conception and design of the editorial, drafting the article and revising it critically, final approval of the version to be published and agree to be accountable for all aspects of the work thereby ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. G. P. J. has received honoraria from Pacira, Baxter, Merck and Mallinckrodt pharmaceuticals. H. K. has received honoraria from Pfizer, Merck and Grunenthal. H. B. has received honoraria from BBraun. F. B. has received honoraria from Nordik Pharma, The Medicines Company and Ambu. E. M. P.-Z. has received honoraria from Mundipharma GmbH, Gruenenthal, The Medicine Company, Fresenius Kabi and ArcelRX. N. R. has received honoraria from Sintetica S. S.: The Anaesthesiology Department of the University of Western Australia, but not S. S. personally, has received research and honoraria from Aspen Australia, Gruenenthal, bioCSL/Seqirus, Indivior, Mundipharma, Pfizer, Pierre Fabre and iXBiopharma M. Van de V. has received honoraria from Smiths Medical, MSD, AstraZeneca, Baxter, Smiths Medical, BBraun, Abbvie, Kimberley Clarck and Fresenius, and a research grant from Air Liquide B. F., A. H., P. M. L. Jr, P. L. and J. R. do not have any conflicts. None declared.

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