Intraoperative pharmacologic opioid minimisation strategies and patient-centred outcomes after surgery: a scoping review

Michael Verret; Nhat H Lam; Manoj Lalu; Stuart G Nicholls; Alexis F Turgeon; Daniel I McIsaac; Myriam Hamtiaux; John Bao Phuc Le; Ian Gilron; Lucy Yang; Mahrukh Kaimkhani; Alexandre Assi; David El-Adem; Makenna Timm; Peter Tai; Joelle Amir; Sriyathavan Srichandramohan; Abdulaziz Al-Mazidi; Nicholas A Fergusson; Brian Hutton; Fiona Zivkovic; Megan Graham; Maxime Lê; Allison Geist; Mélanie Bérubé; Patricia Poulin; Risa Shorr; Helena Daudt; Guillaume Martel; Jason McVicar; Husein Moloo; Dean A Fergusson; Perioperative Anesthesia Clinical Trials (PACT) group

doi:10.1016/j.bja.2024.01.006

Intraoperative pharmacologic opioid minimisation strategies and patient-centred outcomes after surgery: a scoping review

Br J Anaesth. 2024 Apr;132(4):758-770. doi: 10.1016/j.bja.2024.01.006. Epub 2024 Feb 8.

Authors

Michael Verret¹, Nhat H Lam², Manoj Lalu³, Stuart G Nicholls⁴, Alexis F Turgeon⁵, Daniel I McIsaac³, Myriam Hamtiaux², John Bao Phuc Le², Ian Gilron⁶, Lucy Yang⁷, Mahrukh Kaimkhani⁷, Alexandre Assi⁸, David El-Adem⁹, Makenna Timm¹⁰, Peter Tai⁹, Joelle Amir⁹, Sriyathavan Srichandramohan², Abdulaziz Al-Mazidi², Nicholas A Fergusson¹¹, Brian Hutton¹², Fiona Zivkovic¹³, Megan Graham¹³, Maxime Lê¹³, Allison Geist¹³, Mélanie Bérubé¹⁴, Patricia Poulin¹², Risa Shorr¹⁵, Helena Daudt¹⁶, Guillaume Martel¹², Jason McVicar¹⁷, Husein Moloo¹², Dean A Fergusson²; Perioperative Anesthesia Clinical Trials (PACT) group

Affiliations

¹ Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, Civic Campus, The Ottawa Hospital, Ottawa, ON, Canada; Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec City, QC, Canada. Electronic address: mverr051@uottawa.ca.
² Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
³ Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, Civic Campus, The Ottawa Hospital, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
⁴ Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Ottawa Methods Centre, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
⁵ Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec City, QC, Canada; Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du CHU de Québec-Université Laval, Université Laval, Québec City, QC, Canada.
⁶ Department of Anesthesiology & Perioperative Medicine, Biomedical & Molecular Sciences, Centre for Neuroscience Studies and School of Policy Studies, Queen's University, Kingston, ON, Canada.
⁷ Faculty of Medicine, University of Calgary, Calgary, AB, Canada.
⁸ School of Medicine, Trinity College Dublin, Dublin, Ireland.
⁹ Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada.
¹⁰ Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
¹¹ Department of Anesthesiology, Perioperative & Pain Medicine, University of Calgary, Calgary, AB, Canada.
¹² Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada.
¹³ Patient partner, The Ottawa Hospital, Ottawa, ON, Canada.
¹⁴ Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du CHU de Québec-Université Laval, Université Laval, Québec City, QC, Canada; Faculty of Nursing, Université Laval, Québec City, QC, Canada; Quebec Pain Research Network, Sherbrooke, QC, Canada.
¹⁵ Library Services, The Ottawa Hospital, Ottawa, ON, Canada.
¹⁶ Pain Canada, Pain BC, Vancouver, BC, Canada.
¹⁷ Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, Civic Campus, The Ottawa Hospital, Ottawa, ON, Canada.

Abstract

Background: Postoperative patient-centred outcome measures are essential to capture the patient's experience after surgery. Although a large number of pharmacologic opioid minimisation strategies (i.e. opioid alternatives) are used for patients undergoing surgery, it remains unclear which strategies are most promising in terms of patient-centred outcome improvements. This scoping review had two main objectives: (1) to map and describe evidence from clinical trials assessing the patient-centred effectiveness of pharmacologic intraoperative opioid minimisation strategies in adult surgical patients, and (2) to identify promising pharmacologic opioid minimisation strategies.

Methods: We searched MEDLINE, Embase, CENTRAL, Web of Science, and CINAHL databases from inception to February 2023. We included trials investigating the use of opioid minimisation strategies in adult surgical patients and reporting at least one patient-centred outcome. Study screening and data extraction were conducted independently by at least two reviewers.

Results: Of 24,842 citations screened for eligibility, 2803 trials assessed the effectiveness of intraoperative opioid minimisation strategies. Of these, 457 trials (67,060 participants) met eligibility criteria, reporting at least one patient-centred outcome. In the 107 trials that included a patient-centred primary outcome, patient wellbeing was the most frequently used domain (55 trials). Based on aggregate findings, dexmedetomidine, systemic lidocaine, and COX-2 inhibitors were promising strategies, while paracetamol, ketamine, and gabapentinoids were less promising. Almost half of the trials (253 trials) did not report a protocol or registration number.

Conclusions: Researchers should prioritise and include patient-centred outcomes in the assessment of opioid minimisation strategy effectiveness. We identified three potentially promising pharmacologic intraoperative opioid minimisation strategies that should be further assessed through systematic reviews and multicentre trials. Findings from our scoping review may be influenced by selective outcome reporting bias.

Study registration: OSF - https://osf.io/7kea3.

Keywords: adult anaesthesia; clinical pharmacology; opioid minimisation strategies; pain management; patient-centred outcomes.

Publication types

Review

MeSH terms

Adult
Analgesics, Opioid* / therapeutic use
Humans
Lidocaine*
Outcome Assessment, Health Care

Substances

Analgesics, Opioid
Lidocaine