Opioid-free versus opioid-based anesthesia in pancreatic surgery

Abstract Background Opioid-free anesthesia (OFA) is associated with significantly reduced cumulative postoperative morphine consumption in comparison with opioid-based anesthesia (OBA). Whether OFA is feasible and may improve outcomes in pancreatic surgery remains unclear. Methods Perioperative data from 77 consecutive patients who underwent pancreatic resection were included and retrospectively reviewed. Patients received either an OBA with intraoperative remifentanil (n = 42) or an OFA (n = 35). OFA included a combination of continuous infusions of dexmedetomidine, lidocaine, and esketamine. In OBA, patients also received a single bolus of intrathecal morphine. All patients received intraoperative propofol, sevoflurane, dexamethasone, diclofenac, neuromuscular blockade. Postoperative pain management was achieved by continuous wound infiltration and patient-controlled morphine. The primary outcome was postoperative pain (Numerical Rating Scale, NRS). Opioid consumption within 48 h after extubation, length of stay, adverse events within 90 days, and 30-day mortality were included as secondary outcomes. Episodes of bradycardia and hypotension requiring rescue medication were considered as safety outcomes. Results Compared to OBA, NRS (3 [2–4] vs 0 [0–2], P < 0.001) and opioid consumption (36 [24–52] vs 10 [2–24], P = 0.005) were both less in the OFA group. Length of stay was shorter by 4 days with OFA (14 [7–46] vs 10 [6–16], P < 0.001). OFA (P = 0.03), with postoperative pancreatic fistula (P = 0.0002) and delayed gastric emptying (P < 0.0001) were identified as only independent factors for length of stay. The comprehensive complication index (CCI) was the lowest with OFA (24.9 ± 25.5 vs 14.1 ± 23.4, P = 0.03). There were no differences in demographics, operative time, blood loss, bradycardia, vasopressors administration or time to extubation among groups. Conclusions In this series, OFA during pancreatic resection is feasible and independently associated with a better outcome, in particular pain outcomes. The lower rate of postoperative complications may justify future randomized trials to test the hypothesis that OFA may improve outcomes and shorten length of stay.

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Opioid-Free Versus Opioid-Based Anesthesia in Pancreatic Surgery

10.21203/rs.3.rs-664866/v1 ◽

2021 ◽

Author(s):

Hublet Stéphane ◽

Galland Marianne ◽

Navez Julie ◽

Loi Patrizia ◽

Closset Jean ◽

...

Keyword(s):

Length Of Stay ◽

Pancreatic Resection ◽

Pancreatic Surgery ◽

Rating Scale ◽

Numerical Rating Scale ◽

Intrathecal Morphine ◽

Postoperative Nausea And Vomiting ◽

Opioid Consumption ◽

Comprehensive Complication Index ◽

Wound Infiltration

Abstract Background: Opioid-free anesthesia (OFA) is associated with significantly reduced cumulative postoperative morphine consumption and postoperative nausea and vomiting in comparison with opioid-based anesthesia (OBA). Whether OFA is feasible and may improve outcomes in pancreatic surgery remains unclear. Hence, we retrospectively reviewed a consecutive cohort of patients undergoing pancreatic surgery. Methods: Perioperative data from 77 consecutive patients who underwent pancreatic resection under OBA or OFA were included. Patients received either an OBA with intraoperative remifentanil (n=42) or an OFA (n=35) with a combination of continuous infusions of dexmedetomidine, lidocaine, and esketamine. In OBA, patients also received a single bolus of intrathecal morphine. All patients received intraoperative propofol, sevoflurane, dexamethasone, diclofenac, neuromuscular blockade, postoperative continuous wound infiltration, and patient-controlled morphine. The primary outcome was postoperative pain (Numerical Rating Scale, NRS). Opioid consumption within 48h after extubation, length of stay (LOS), adverse events within 90 days, and 30-day mortality were included as secondary outcomes. Episodes of bradycardia and hypotension requiring rescue medication were considered as safety outcomes.Results: Compared to OBA, NRS (3 [2-4] vs 0 [0-2], P<0.001) and opioid consumption (36 [24-52] vs 10 [2-24], P=0.005) were both less in the OFA group. LOS was shorter by 4 days with OFA (14 [7-46] vs 10 [6-16], P<0.001). OFA (P=0.03), postoperative pancreatic fistula (P=0.0002) and delayed gastric emptying (P<0.0001) were identified as only independent factors for LOS. The comprehensive complication index (CCI) was the lowest with OFA (24.9±25.5 vs 14.1±23.4, P=0.03). There were no differences in demographics, operative time, blood loss, bradycardia, vasopressors administration or time to extubation among groups.Conclusions: In this series, OFA during pancreatic resection is feasible and independently associated with a better outcome, in particular pain outcomes. The lower rate of postoperative complications may justify future randomized trials to test the hypothesis that OFA may improve outcomes and shorten length of stay.

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Regional anaesthesia for postoperative pain management after liver resection

Acta medica Lituanica ◽

10.6001/actamedica.v19i3.2434 ◽

2012 ◽

Vol 19 (3) ◽

pp. 126-129

Author(s):

Darius Trepenaitis ◽

Tadas Česnaitis ◽

Andrius Macas

Keyword(s):

Pain Management ◽

Liver Resection ◽

Postoperative Pain ◽

Adverse Effects ◽

Rating Scale ◽

Numerical Rating Scale ◽

Postoperative Pain Management ◽

Control Group ◽

Wound Infiltration ◽

Adequate Treatment

Background. Pain is the most common complication in the postoperative period. If adequate treatment is not taken, it can transform to chronic pain. Postoperative pain brings a lot of social, psychological and financial problems for patients and their families. Materials and methods. This prospective study included 30 patients after laparatomic liver resection operation. Patients were randomly assign ed to Infiltrated or Control groups. An infiltration of 40 ml levobupivacaine 0.25% solution to the operation cut edges was performed to the Infiltrated group. The pain was evaluated using the numerical rating scale after 2, 5, 12, 24, 48 hours and 1 month after the operation. Our aim was to determine the effect of local anesthesia in the operation wound. The total usage of morphine and any side effects were registered. Results. A statistically significant reduction in pain was observed in the Infiltrated group in all evaluation periods. Opioids usage was higher in the Control group almost by 4 times and adverse effects were 9 to 1 compared to the Infiltrated group. Conclusions. Surgical wound infiltration with local anesthetic for postoperative pain management after liver resection operations has a positive effect on postoperative pain reduction and leads to lesser usage of opioid analgetics. As a result, there is a less chance of opioids induced adverse effects.

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Comparison of Analgesic Effect of Levobupivacaine with Dexmedetomidine and Levobupivacaine for Scalp Block before Supratentorial Craniotomy: A Randomized Controlled Trial

Journal of the Medical Association of Thailand ◽

10.35755/jmedassocthai.2020.10.11547 ◽

2020 ◽

Vol 103 (10) ◽

pp. 1028-1035

Keyword(s):

Postoperative Pain ◽

Rating Scale ◽

Numerical Rating Scale ◽

Control Group ◽

Study Group ◽

Analgesic Requirement ◽

Supratentorial Craniotomy ◽

Numerical Rating ◽

Fentanyl Consumption ◽

Scalp Block

Background: Craniotomy causes acute and chronic pain. Uncontrolled postoperative pain may lead to adverse events. Perioperative scalp nerves block is not only effective in reducing intraoperative hemodynamic response, but it also reduces postoperative pain and postoperative analgesia requirement. Objective: To compare the benefits of adding dexmedetomidine to levobupivacaine in scalp nerves block before craniotomy for the duration of analgesia in supratentorial craniotomy. Materials and Methods: After approval by the Committee for Research, 50 supratentorial craniotomy patients were randomized into two groups. The control group received 30 mL scalp nerves block with 0.25% levobupivacaine with adrenaline 1:200,000, whereas the study group received 30 mL scalp nerves block with 0.25% levobupivacaine with adrenaline 1:200,000 plus dexmedetomidine 1 mcg/kg. The primary outcome was the time to first analgesic requirement postoperatively. The secondary outcomes included intraoperative fentanyl consumption, verbal numerical rating scale, tramadol consumption, and complications during the first 24 hours postoperatively. Results: Patients in the study group had significantly increase time to the first analgesic requirement in postoperative period and reduced intraoperative fentanyl consumption. The median time to first analgesic requirement was 555 (360 to 1,035) minutes in the study group versus 405 (300 to 520) minutes in the control group (p=0.023). Intraoperative fentanyl consumption 125 (75 to 175) mcg in the study group was significantly lower than 200 (150 to 250) mcg in the control group (p=0.02). The verbal numerical rating scale at 1, 4, 8, 12 and 24 hours postoperatively, tramadol consumption, and complications during the first 24 hours postoperatively were not statistically significant different. Conclusion: Preoperative scalp nerves block with 0.25% levobupivacaine with adrenaline (1:200,000) with dexmedetomidine 1 mcg/kg significantly increased the time to first analgesic requirement and reduced intraoperative fentanyl consumption compared to 0.25% levobupivacaine with adrenaline (1:200,000) without perioperative complications. Keywords: Scalp block, Dexmedetomidine, Post-craniotomy analgesia, Supratentorial tumor, Levobupivacaine

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Early postoperative pain as a marker of anastomotic leakage in colorectal cancer surgery

International Journal of Colorectal Disease ◽

10.1007/s00384-021-03984-w ◽

2021 ◽

Author(s):

Petrus Boström ◽

Johan Svensson ◽

Camilla Brorsson ◽

Martin Rutegård

Keyword(s):

Colorectal Cancer ◽

Postoperative Pain ◽

Colorectal Surgery ◽

Anastomotic Leakage ◽

Rating Scale ◽

Numerical Rating Scale ◽

Population Based ◽

Colorectal Cancer Surgery ◽

Increased Risk ◽

Independent Marker

Abstract Purpose Even though anastomotic leakage after colorectal surgery is a major clinical problem in need of a timely diagnosis, early indicators of leakage have been insufficiently studied. We therefore conducted a population-based observational study to determine whether the patient’s early postoperative pain is an independent marker of anastomotic leakage. Methods By combining the Swedish Colorectal Cancer Registry and the Swedish Perioperative Registry, we retrieved prospectively collected data on 3084 patients who underwent anastomotic colorectal surgery for cancer in 2014–2017. Postoperative pain, measured with the numerical rating scale (NRS), was considered exposure, while anastomotic leakage and reoperation due to leakage were outcomes. We performed logistic regression to evaluate associations, estimating odds ratios (ORs) and 95% confidence intervals (CIs), while multiple imputation was used to handle missing data. Results In total, 189 patients suffered from anastomotic leakage, of whom 121 patients also needed a reoperation due to leakage. Moderate or severe postoperative pain (NRS 4–10) was associated with an increased risk of anastomotic leakage (OR 1.69, 95% CI 1.21–2.38), as well as reoperation (OR 2.17, 95% CI 1.41–3.32). Severe pain (NRS 8–10) was more strongly related to leakage (OR 2.38, 95% CI 1.44–3.93). These associations were confirmed in multivariable analyses and when reoperation due to leakage was used as an outcome. Conclusion In this population-based retrospective study on prospectively collected data, increased pain in the post-anaesthesia care unit is an independent marker of anastomotic leakage, possibly indicating a need for further diagnostic measures.

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Study of Pain Level Control Targets After Arthroscopic Surgery

10.21203/rs.3.rs-253532/v2 ◽

2021 ◽

Author(s):

Wang Xin ◽

Liu Congying ◽

Zhang Xiaole ◽

Wang Hong ◽

Xu Yan ◽

...

Keyword(s):

Postoperative Pain ◽

Pain Score ◽

Pain Control ◽

Rating Scale ◽

Numerical Rating Scale ◽

Arthroscopic Surgery ◽

Daily Activities ◽

Pain Level ◽

Convenience Sampling ◽

The Impact

Abstract Objective: To explore the goal of pain control in patients after arthroscopic surgery.Design: Investigation. Postoperative pain, pain control satisfaction and the effect of pain on daily activities were investigated and evaluated.Setting: Department of Sports Medicine,Peking University 3rd Hospital,Beijing, P.R.ChinaSubjects: 514 patients selected by convenience sampling from patients hospitalized in a level A hospital in Beijing from 2020.06-2020.11. The patient inclusion criteria were an age of at least 18 years, no history of diagnosis of mental illness, the ability to clearly express his or her pain and an agreement to voluntarily cooperate with the investigators. The exclusion criteria were patients who were unable to complete follow-up.Methods: Postoperative pain, pain control satisfaction and the effect of pain on daily activities were investigated and evaluated by administering a homemade questionnaire to 514 patients selected by convenience sampling from patients hospitalized in a level A hospital in Beijing from 2020.06-2020.11. Pain was assessed using a digital pain numerical rating scale (NRS) (0-10), and a digital score ranging from 0 to 10 was used for satisfaction with pain control and the impact of pain on aspects of daily living.Results: The pain level was most severe in patients 6-24 hours after arthroscopic surgery, during which pain control satisfaction was at its worst. The pain score was significantly related to the effects of pain on aspects of daily life, and the degree of these effects changed significantly for pain scores greater than 2 points.Conclusion: Pain control 6 to 24 hours after surgery is not satisfactory. It is recommended that a pain score of 2 points is used as the goal for pain control after arthroscopic surgery to guide both doctors and patients to effectively control postoperative pain.

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Postendodontic Pain after Pulpotomy or Root Canal Treatment in Mature Teeth with Carious Pulp Exposure: A Multicenter Randomized Controlled Trial

Pain Research and Management ◽

10.1155/2020/5853412 ◽

2020 ◽

Vol 2020 ◽

pp. 1-14

Author(s):

Mohammad Jafar Eghbal ◽

Ali Haeri ◽

Arash Shahravan ◽

Ali Kazemi ◽

Fariborz Moazami ◽

...

Keyword(s):

Postoperative Pain ◽

Pain Relief ◽

Root Canal ◽

Rating Scale ◽

Numerical Rating Scale ◽

Controlled Trial ◽

Mineral Trioxide Aggregate ◽

Preoperative Pain ◽

Multicenter Randomized Controlled Trial ◽

The Mean

This equivalence, randomized, clinical trial aimed to compare the postoperative pain of root canal therapy (RCT) with pulpotomy with mineral trioxide aggregate (PMTA) or calcium-enriched mixture (PCEM) in permanent mature teeth. In seven academic centers, 550 cariously exposed pulps were included and randomly allocated into PMTA (n = 188), PCEM (n = 194), or RCT (n = 168) arms. Preoperative “Pain Intensity” (PI) on Numerical Rating Scale and postoperative PIs until day 7 were recorded. Patients’ demographic and pre-/intra-/postoperative factors/conditions were recorded/analysed. The arms were homogeneous in terms of demographics. The mean preoperative PIs were similar (P=0.998), the mean sum PIs recorded during 10 postoperative intervals were comparable (P=0.939), and the trend/changes in pain relief were parallel (P=0.821) in all study arms. The incidences of preoperative moderate-severe pain in RCT, PMTA, and PCEM arms were 56.5%, 55.7%, and 56.7%, which after 24 hours considerably decreased to 13.1%, 10.6%, and 12.9%, respectively (P=0.578). The time span of endodontic procedures was statistically different; RCT = 69.73, PMTA = 35.37, and PCEM = 33.62 minutes (P<0.001). Patients with greater preoperative pain, symptomatic apical periodontitis, or presence of PDL widening suffered more pain (P=0.002, 0.035, and 0.023, resp.); however, other pre-/intra-/postoperative factors/conditions were comparable. Pulpotomy with MTA/CEM and RCT demonstrate comparable and effective postoperative pain relief.

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Electroacupuncture to alleviate postoperative pain after a laparoscopic appendectomy: study protocol for a three-arm, randomised, controlled trial

BMJ Open ◽

10.1136/bmjopen-2016-015286 ◽

2017 ◽

Vol 7 (8) ◽

pp. e015286 ◽

Cited By ~ 3

Author(s):

Seunghoon Lee ◽

Dongwoo Nam ◽

Minsoo Kwon ◽

Won Seo Park ◽

Sun Jin Park

Keyword(s):

Postoperative Pain ◽

Laparoscopic Appendectomy ◽

Pain Control ◽

Rating Scale ◽

Acupuncture Treatment ◽

Numerical Rating Scale ◽

Controlled Trial ◽

Control Group ◽

Acupuncture Points ◽

Postoperative Pain Control

BackgroundThe purpose of this study is to evaluate the efficacy and safety of electroacupuncture (EA) for postoperative pain after laparoscopic appendectomy compared with sham electroacupuncture (SEA) and no acupuncture treatment.Methods and analysisThis study is a protocol for a three-arm, randomised, patient-assessor-blinded (to the type of acupuncture treatment), controlled, parallel trial. 138 participants diagnosed with appendicitis and scheduled for laparoscopic appendectomy will be randomly assigned to the EA group (n=46), SEA group (n=46) or control group (n=46). The EA group will receive acupuncture treatment at both regional and distal acupuncture points with electrostimulation. The SEA group will receive sham acupuncture treatment with mock electrostimulation. Both EA and SEA groups will receive a total of four treatments 1 hour preoperative, 1 hour postoperative and during the morning and afternoon the day after surgery with the same routine postoperative pain control. The control group will receive only routine postoperative pain control. The primary outcome is the 11-point Pain Intensity Numerical Rating Scale (PI-NRS) at 24 hours after surgery. The secondary outcomes are the PI-NRS, analgesic consumption, opioid-related side effects, time to first passing flatus, quality of life and adverse events evaluated 6, 12, 24 and 36 hours and 7 days after surgery.Ethics and disseminationThe study was planned in accordance with the Helsinki Declaration and the Korean Good Clinical Practice Guidelines to protect the participants and was approved by the institutional review board (IRB) of Kyung Hee University Medical Center (KMC IRB-1427–02). The results will be disseminated in peer-reviewed journals and presented at international conferences.Trial registration numberClinical Research Information Service (KCT0001328).

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Patient-controlled Analgesia with Target-controlled Infusion of Hydromorphone in Postoperative Pain Therapy

Anesthesiology ◽

10.1097/aln.0000000000000937 ◽

2016 ◽

Vol 124 (1) ◽

pp. 56-68 ◽

Cited By ~ 10

Author(s):

Christian Jeleazcov ◽

Harald Ihmsen ◽

Teijo I. Saari ◽

Doris Rohde ◽

Jan Mell ◽

...

Keyword(s):

Postoperative Pain ◽

Pain Therapy ◽

Rating Scale ◽

Numerical Rating Scale ◽

Plasma Concentrations ◽

Maximum Plasma ◽

Patient Controlled Analgesia ◽

Postoperative Pain Therapy ◽

Target Controlled Infusion ◽

Plasma Target

Abstract Background Patient-controlled analgesia (PCA) is a common method for postoperative pain therapy, but it is characterized by large variation of plasma concentrations. PCA with target-controlled infusion (TCI-PCA) may be an alternative. In a previous analysis, the authors developed a pharmacokinetic model for hydromorphone. In this secondary analysis, the authors investigated the feasibility and efficacy of TCI-PCA for postoperative pain therapy with hydromorphone. Methods Fifty adult patients undergoing cardiac surgery were enrolled in this study. Postoperatively, hydromorphone was applied intravenously during three sequential periods: (1) as TCI with plasma target concentrations of 1 to 2 ng/ml until extubation; (2) as TCI-PCA with plasma target concentrations between 0.8 and 10 ng/ml during the following 6 to 8 h; and (3) thereafter as PCA with a bolus dose of 0.2 mg until the next morning. During TCI-PCA, pain was regularly assessed using the 11-point numerical rating scale (NRS). A pharmacokinetic/pharmacodynamic model was developed using ordinal logistic regression based on measured plasma concentrations. Results Data of 43 patients aged 40 to 81 yr were analyzed. The hydromorphone dose during TCI-PCA was 0.26 mg/h (0.07 to 0.93 mg/h). The maximum plasma target concentration during TCI-PCA was 2.3 ng/ml (0.9 to 7.0 ng/ml). The NRS score under deep inspiration was less than 5 in 83% of the ratings. Nausea was present in 30%, vomiting in 9%, and respiratory insufficiency in 5% of the patients. The EC50 of hydromorphone for NRS of 4 or less was 4.1 ng/ml (0.6 to 12.8 ng/ml). Conclusion TCI-PCA with hydromorphone offered satisfactory postoperative pain therapy with moderate side effects.

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Predictors of chronic neuropathic pain after scoliosis surgery in children

Scandinavian Journal of Pain ◽

10.1016/j.sjpain.2017.09.002 ◽

2017 ◽

Vol 17 (1) ◽

pp. 339-344 ◽

Cited By ~ 6

Author(s):

Florence Julien-Marsollier ◽

Raphaelle David ◽

Julie Hilly ◽

Christopher Brasher ◽

Daphné Michelet ◽

...

Keyword(s):

Chronic Pain ◽

Logistic Regression ◽

Neuropathic Pain ◽

Rating Scale ◽

Numerical Rating Scale ◽

Univariate Analysis ◽

Opioid Consumption ◽

Multivariate Logistic Regression Model ◽

Scoliosis Surgery ◽

Preoperative Pain

AbstractBackgroundNumerous publications describe chronic pain following surgery in both adults and children. However, data in the paediatric population are still sparse and both prevalence of chronic pain after surgery and risk factors of this complication still undetermined.MethodsWe prospectively evaluated the prevalence of chronic pain and its neuropathic pain component at 1 year following correction of idiopathic scoliosis in children less than 18 years of age. Pain was defined as the presence of pain (numerical rating scale – NRS ≥4), the presence of signs of neurologic damage within the area of surgery and the presence of the neuropathic symptoms as a DN4 (Douleur Neuropathique 4) questionnaire ≥4. Factors investigated as potentially associated with the presence of a persistent neuropathic pain were: age, weight, the presence of continuous preoperative pain over the 3 months before surgery, surgical characteristics, pain scores during the first five postoperative days, and DN4 at day 3. Statistical analysis employed univariate analysis and a multivariate logistic regression model.ResultsThirty six patients were included in the study. Nineteen (52.8%) had pain at one year after surgery. Among them 17 (48.2%) had neuropathic pain. Logistic regression found continuous pain over the 3 months preceding surgery and day 1 morphine consumption ≥0.5 mg kg-1 as independent predictors of persistent chronic pain with a neuropathic component. The overall model accuracy was 80.6 and the area under the curve of the model was 0.89 (95% confidence interval 0.78–0.99).ConclusionsThe present study found a high proportion of paediatric patients developing chronic persistent pain after surgical correction of scoliosis diformity. It allows identifying two factors associated with the occurrence of persistent chronic pain with a neuropathic component: the presence of persistent preoperative pain during the 3 months preceeding surgery and postoperative opioid consumption at day 1 –;0.5 mg kg-1ImplicationPatients scheduled for spine surgery and presenting with preoperative pain should be considered at risk of chronic pain after surgery and managed accordingly by the chronic and/or acute pain team. Postoperative opioid consumption should be lowered as possible by using multimodal analgesia and regional analgesia such as postoperative epidural analgesia.

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Proportion of immediate severe postoperative pain in laparoscopic sterilization under general anaesthesia: A cross-sectional study (postoperative pain in laparoscopic sterilization)

Serbian Journal of Anesthesia and Intensive Therapy ◽

10.5937/sjait2106111m ◽

2021 ◽

Vol 43 (5-6) ◽

pp. 111-116

Author(s):

Girijanandan Menon ◽

Manjit George

Keyword(s):

Postoperative Pain ◽

General Anaesthesia ◽

Rating Scale ◽

Numerical Rating Scale ◽

Cross Sectional Study ◽

Cross Sectional ◽

Post Operative Pain ◽

Severe Postoperative Pain ◽

Numerical Rating ◽

Laparoscopic Sterilization

Background: Effective control of immediate post operative abdominal pain following laparoscopic sterilization is challenging. The objective of the study was to estimate the incidence of immediate severe postoperative pain following laparoscopic sterilization under general anaesthesia by the proportion of patients with the pain assessed on a numerical rating scale. Methods: A cross sectional study was conducted with the approval of institutional review board and ethics committee. Fifty seven participants with written informed consent underwent the study over a period of six months. Pain was assessed by a trained recovery nurse and data was collected and analyzed. The main outcome measure was immediate severe post operative pain on numerical rating scale (NRS). Results: Among the 57 participants, 14 (24.6%) had immediate severe post operative pain with median score of five in the inter quartile range of 0 to 5.75 and 43 (75.4%) participants had no severe pain. Conclusion: The incidence of immediate severe postoperative abdominal pain after laparoscopic sterilization under general anaesthesia is high. Therefore, the management of pain following laparoscopic sterilization requires individually based multimodal analgesia.

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