Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI.
Department of Otolaryngology, William Beaumont Hospital, Royal Oak, MI.
Int Forum Allergy Rhinol. 2018 Jul;8(7):837-849. doi: 10.1002/alr.22107. Epub 2018 Apr 12.
Misuse and diversion of prescription opioids have been critical in facilitating the opioid epidemic. Our objective was to perform a systematic evidence-based review delineating perioperative regimens (including opioid alternatives) evaluated for endoscopic sinus surgery.
PubMed/MEDLINE, Cochrane Library, and EmBase databases were evaluated for studies detailing analgesics employed after endoscopic sinus surgery. Studies were assessed for level of evidence. Bias risk was evaluated using the Cochrane Bias tool and GRADE criteria. Medication, administration, adverse effects, pain scores, and rescue analgesic consumption were evaluated. A summary of evidence detailing benefits, harm, and cost was prepared.
Thirty-two studies encompassing 1812 patients were included. The GRADE criteria determined the overall evidence to be of moderate quality. Perioperative acetaminophen had few adverse events and reduced immediate need for opioid rescue after sinus surgery; studies evaluating acetaminophen demonstrate a preponderance of benefit over harm. Nonsteroidal anti-inflammatory drugs (NSAIDs) also reduce postoperative opioid consumption, although a small portion of patients undergoing sinus surgery harbor the potential for NSAID intolerance. The aggregate level of evidence for studies evaluating NSAIDs was grade A, whereas the aggregate grade of evidence for several other agents was grade B.
There is evidence supporting the use of NSAIDs and gabapentin for the control of pain after endoscopic sinus surgery. Acetaminophen, α-agonists, and local anesthetics are also viable options for postoperative analgesia. Familiarity with these data is essential to facilitate the use of opioid alternatives. Further large-scale, multi-institutional, randomized trials are needed to provide conclusive recommendations for these perioperative analgesics.
处方类阿片的滥用和转移是促成阿片类药物流行的关键因素。我们的目的是进行一项系统的循证综述，阐明用于内镜鼻窦手术的围手术期方案（包括阿片类药物替代品）。
评估了 PubMed/MEDLINE、Cochrane 图书馆和 EmBase 数据库中详细描述内镜鼻窦手术后使用的镇痛药的研究。研究的证据水平进行了评估。使用 Cochrane 偏倚工具和 GRADE 标准评估了偏倚风险。评估了药物、给药途径、不良反应、疼痛评分和急救镇痛药的消耗。准备了一份详细说明收益、危害和成本的证据摘要。
共纳入了 32 项研究，涵盖了 1812 名患者。GRADE 标准确定整体证据质量为中等。围手术期使用对乙酰氨基酚的不良反应较少，且术后即刻对阿片类药物急救的需求减少；评估对乙酰氨基酚的研究表明，其优势大于危害。非甾体抗炎药（NSAIDs）也可减少术后阿片类药物的消耗，但一部分接受鼻窦手术的患者存在 NSAIDs 不耐受的潜在风险。评估 NSAIDs 的研究的综合证据水平为 A 级，而评估其他几种药物的综合证据等级为 B 级。
有证据支持 NSAIDs 和加巴喷丁用于控制内镜鼻窦手术后的疼痛。对乙酰氨基酚、α-激动剂和局部麻醉剂也是术后镇痛的可行选择。熟悉这些数据对于促进阿片类药物替代品的使用至关重要。需要进一步开展大规模、多机构、随机临床试验，为这些围手术期镇痛药提供明确的推荐意见。
