British journal of anaesthesia
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Review
The prescription opioid crisis: role of the anaesthesiologist in reducing opioid use and misuse.
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?
- 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!).
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...
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Randomized Controlled Trial Multicenter Study Comparative Study
Clinical impact of peripherally inserted central catheters vs implanted port catheters in patients with cancer: an open-label, randomised, two-centre trial.
Centrally inserted totally implanted vascular access ports (PORTs) and peripherally inserted central catheters (PICCs) are widely used for the administration of chemotherapy. Our aim was to study the incidence of catheter-related deep venous thrombosis in patients with cancer receiving chemotherapy through either a PICC or a PORT. ⋯ NCT01971021.
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Analgesic design and evaluation have been driven by the desire to create high-affinity high-selectivity mu (μ)-opioid peptide (MOP) receptor agonists. Such ligands are the mainstay of current clinical practice, and include morphine and fentanyl. Advances in this sphere have come from designing pharmacokinetic advantage, as in rapid metabolism for remifentanil. ⋯ Recent development has been to move towards low-selectivity multifunctional 'mixed ligands', such as cebranopadol, or ligand mixtures, such as Targinact®. Moreover, the observation that β-arrestin coupling underlies the side-effect profile for MOP ligands (from knockout animal studies) led to the discovery of biased (to G-protein and away from β-arrestin intracellular signalling) MOP ligands, such as oliceridine. There is sufficient excitement in the opioid field to suggest that opioid analgesics without significant side-effects may be on the horizon, and the 'opioid Holy Grail' might be in reach.
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Opioids are potent painkillers but come with serious adverse effects ranging from addiction to potentially lethal respiratory depression. A variety of drugs with separate mechanisms of action are available to prevent or reverse opioid-induced respiratory depression (OIRD). ⋯ Model-based drug development is needed to design an 'ideal' reversal agent-that is, one that is not influenced by opioid receptor kinetics, does not interfere with opioid analgesia, has a rapid onset of action with long-lasting effects, and is devoid of adverse effects.
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Randomized Controlled Trial
Reduced perioperative blood loss in children undergoing craniosynostosis surgery using prolonged tranexamic acid infusion: a randomised trial.
Tranexamic acid (TXA) reduces intraoperative blood loss and transfusion during paediatric craniosynostosis surgery. Additional reduction of postoperative blood loss may further reduce exposure to allogeneic blood products. We studied the effect of combined intra- and postoperative TXA treatment on postoperative blood loss in children. ⋯ Combined intra- and postoperative tranexamic acid treatment reduced postoperative and overall blood loss and transfusion requirements. Improved clot stability represents a possible mechanism for blood loss reduction.