Dexmedetomidine, Ketamine and Lidocaine Infusion for Prevention of Postoperative Nausea and Vomiting in Laparoscopic Gynecological Surgery: Randomized Trial

Background: The intraoperative use of large bolus doses or continuous infusions of potent opioids may be associated with increased analgesic consumption postoperatively. In ambulatory surgery, opioid related side effects, such as postoperative nausea and vomiting (PONV), prolonged sedation, ileus and urinary retention may delay recovery and discharge or cause unanticipated hospital readmission. The aim was to evaluate the effect of opioid sparing technique via infusion of dexmedetomidine, ketamine and lidocaine on post-operative nausea and vomiting in laparoscopic gynecological surgery. Methods: A total of 80 patients were randomly allocated into 2 groups, 40 patients each. Control group (group c) received fentanyl while, Study group (group S) received infusion of a mixture of dexmedetomidine, ketamine and lidocaine. The PONV impact scale, intraoperative consumption of isoflurane and fentanyl and post operative 24 hr. morphine consumption were measured. Results: 18 (45%) patients of control group experienced PONV versus 7 (17.5%) patients of study group and it was clinically significant. Clinically significant vomiting was observed in10 (25%) patients of control group and 1 (2.5%) patient of study group. There was a marked reduction in fentanyl, isoflurane and 24 hours’ morphine consumption in group S compared to group C. Conclusion: Opioid sparing anesthesia with dexmedetomidine, ketamine and lidocaine infusion are superior to fentanyl for prevention of post-operative nausea and vomiting and reduction of isoflurane and, fentanyl consumption and provides better patient satisfaction in laparoscopic gynecological surgery.

Ultrasound-guided quadratus lumborum block for perioperative analgesia in robot-assisted partial nephrectomy: a randomized controlled trial

Background Recently, several case reports and limited randomized studies have shown that quadratus lumborum blocks (QLB) are effective in providing pain relief after intra-abdominal and retroperitoneal operations. Additionally, robot-assisted partial nephrectomy (RAPN) has been proposed as a promising operative treatment for renal carcinoma because it enables early recovery and ambulation. Therefore, we aimed to evaluate the analgesic and opioid-sparing effects of a single-injection QLB in patients undergoing RAPN to determine its role in an early recovery program. Methods Fifty-six patients undergoing elective RAPN under general anesthesia were randomized to two equally sized groups. Patients were randomly allocated to receive either a unilateral QLB (n = 28) with 0.375% bupivacaine 0.5 mL/kg (QLB group) or a conventional scheme (n = 28) (control group). The QLB technique, termed QLB2, was performed as first described by Blanco. The primary outcome was visual analog scale (VAS) scores with movement at 6 h postoperatively. The secondary endpoints were morphine consumption at different time periods after surgery, morphine-related side effects, and assessment of postoperative rehabilitation. Results Both the VAS pain scores and cumulative opioid consumption were significantly lower in the QLB group at 6 h after surgery as compared with results in the control group (all P < 0.05). There were significant differences in pain scores at all time points except at 4 h with movement and 48 h at rest. However, at 12–24 h no significant differences between the two groups were observed in cumulative opioid consumption or in the duration of PACU and hospital stays. The patient recovery scores were significantly higher in the QLB group. Conclusions Single-injection pre-emptive QLB applied to RAPN was effective and provided satisfactory analgesia and opioid-sparing effects in combination with typical patient-controlled analgesia. In addition, it may provide an effective technique for early recovery in the perioperative period for RAPN.

Evaluation of Postoperative Pain Management Using an Opioid-Sparing Protocol in Pediatric Surgical Patients

Background Since the 1990s, the U.S. has faced increasing rates of opioid overuse, misuse, and overdose deaths. To combat the opioid epidemic, there have been national initiatives to limit prescribing of opioids. At our institution, we implemented an opioid-sparing protocol in pediatric surgical patients and sought to evaluate its impact on postoperative opioid prescribing patterns. Methods A retrospective chart review of the electronic medical record was performed for 9- to 18-year-old patients who underwent a laparoscopic appendectomy or cholecystectomy before and after the implementation of an opioid-sparing protocol. Data on postoperative opioids administered during the hospitalization and prescribed at discharge, postoperative pain control, use of non-opioid analgesics, and safety were collected. Results A total of 81 patient charts were analyzed. The median amount of opioids administered during hospitalization was 8 MMEs and 15 MMEs in the pre-implementation and post-implementation, respectively ( P = 0.310). The median amount of opioids prescribed at discharge was 150 MMEs and 60 MMEs in the pre-implementation and post-implementation, respectively ( P = 0.006). Patients reported mild pain scores throughout the hospitalization in both groups. Discussion Among young patients who underwent laparoscopic appendectomy or cholecystectomy, the administration of opioids during hospitalization for postoperative pain was minimal. The opioid sparing protocol did not reduce the amount of inpatient postoperative opioids administered but found a decrease in the amount of opioids prescribed at discharge. The study findings identified further areas of intervention and education to optimize postoperative opioid prescribing after these common pediatric surgical procedures.