Effect of dexamethasone as an analgesic adjuvant to multimodal pain treatment after total knee arthroplasty: randomised clinical trial

Objective To investigate the effects of one and two doses of intravenous dexamethasone in patients after total knee arthroplasty. Design Randomised, blinded, placebo controlled trial with follow-up at 90 days. Setting Five Danish hospitals, September 2018 to March 2020. Participants 485 adult participants undergoing total knee arthroplasty. Intervention A computer generated randomised sequence stratified for site was used to allocate participants to one of three groups: DX1 (dexamethasone (24 mg)+placebo); DX2 (dexamethasone (24 mg)+dexamethasone (24 mg)); or placebo (placebo+placebo). The intervention was given preoperatively and after 24 hours. Participants, investigators, and outcome assessors were blinded. All participants received paracetamol, ibuprofen, and local infiltration analgesia. Main outcome measures The primary outcome was total intravenous morphine consumption 0 to 48 hours postoperatively. Multiplicity adjusted threshold for statistical significance was P<0.017 and minimal important difference was 10 mg morphine. Secondary outcomes included postoperative pain. Results 485 participants were randomised: 161 to DX1, 162 to DX2, and 162 to placebo. Data from 472 participants (97.3%) were included in the primary outcome analysis. The median (interquartile range) morphine consumptions at 0-48 hours were: DX1 37.9 mg (20.7 to 56.7); DX2 35.0 mg (20.6 to 52.0); and placebo 43.0 mg (28.7 to 64.0). Hodges-Lehmann median differences between groups were: −2.7 mg (98.3% confidence interval −9.3 to 3.7), P=0.30 between DX1 and DX2; 7.8 mg (0.7 to 14.7), P=0.008 between DX1 and placebo; and 10.7 mg (4.0 to 17.3), P<0.001 between DX2 and placebo. Postoperative pain was reduced at 24 hours with one dose, and at 48 hours with two doses, of dexamethasone. Conclusion Two doses of dexamethasone reduced morphine consumption during 48 hours after total knee arthroplasty and reduced postoperative pain. Trial registration Clinicaltrials.gov NCT03506789 .

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.

Dexamethasone and postoperative analgesia in minimally invasive thoracic surgery: a retrospective cohort study

Background Dexamethasone is commonly used for the prevention of postoperative nausea and vomiting (PONV), and recent reviews suggest a role for dexamethasone in postoperative analgesia. The aim of this study is to evaluate the efficacy of dexamethasone as an analgesic adjuvant in minimally invasive thoracic surgery. Primary outcome was morphine consumption 24 h after surgery; secondary outcomes were pain control, measured as numeric rating scale (NRS), glycemic changes, PONV, and surgical wound infection. Results We performed a retrospective cohort study considering 70 patients who underwent elective lobectomy, segmentectomy, or wedge resection surgery with a mini-thoracotomy approach or video-assisted thoracoscopic surgery (VATS). All patients received the same locoregional techniques and short-acting opioids during surgery; 46 patients received dexamethasone at induction. There were no significant differences in morphine consumption at 24 h (p = 0.09) and in postoperative pain scores. Nevertheless, a higher frequency of rescue therapy (p = 0.01) and a tendency for a higher attempted-PCA pushes count were observed in patients who did not receive dexamethasone. No cases of surgical wound infections were detected, and the incidence of PONV was similar in the two groups. Postoperative glycemia was transiently higher in the dexamethasone group (p = 0.004), but the need of hypoglycemic therapy was not significantly different. Conclusions Preoperative administration of dexamethasone did not cause a significant reduction in morphine consumption, but appears to be safe and plays a role in a multimodal anesthesia approach for patients undergoing elective minimally invasive thoracic surgery.

Efficacy of Perioperative Administration of Intravenous Parecoxib on Postoperative Morphine Consumption after Video-Assisted Thoracoscopic Surgery

Background: Morphine is commonly used to relief pain after video-assisted thoracoscopic surgery (VATS), however high dose morphine is usually related with many complications. Parecoxib is a potent cyclo-oxygenase inhibitor for parenteral administration that has a role in acute pain management addition to opioid protocol. Objective: To investigate the potential benefits of intravenous parecoxib for relieving postoperative pain after VATS. Materials and Methods: The present study was a randomized controlled trial that assigned 22 patients undergoing VATS into two groups to received either parecoxib 40 mg as P group with 11 patients, or placebo using 2 mL of Normal Saline Solution as C group with 11 patients with an intravenous administration at 30 minutes prior to surgery and then 12 hours later. In the postoperative period, all patients received intravenous patient-controlled analgesia (PCA) with morphine. The primary outcome was the total morphine consumption for 24 hours postoperatively. The secondary outcomes were pain score at 2, 6, 12, and 24 hours postoperatively, using a numeric rating scale (NRS, 0 to 10) and the incidence of side effects. Results: The total morphine consumption was significantly lower in P group (26.64±4.41 mg) than C group (39.82±3.87 mg) at 24 hours postoperatively (p<0.001). The NRS pain score at rest and on coughing at 24 hours postoperatively between P group compared with C group were 1.09±1.04 versus 4.45±0.69 (p<0.001) and 2.91±0.83 versus 5.36±0.81 (p<0.001), respectively. The incidences of nausea and vomiting were found in both groups at 2, 6, and 12 hours, postoperatively, but there was no statistically significant difference between both groups (p>0.05). Other adverse events such as sedation, pruritus, dyspepsia, headache, hypotension, and respiratory depression were not found. Conclusion: Perioperative administration of parecoxib was safe and effectively decrease postoperative morphine consumption and pain score at rest and on coughing within 24 hours postoperatively after VATS. Keywords: Intravenous parecoxib; Video-assisted thoracoscopic surgery; Acute postoperative pain

Comparitive evaluation of different concentrations of alcohol in ultrasound guided coeliac plexus neurolysis for pain relief in upper abdominal malignancies

Patients suffering from advanced upper abdominal malignancies have pain as predominant symptom affects their quality of life and survival. USG guided coeliac plexus neurolysis become benevolence in these patients on part of their pain management and quality of life improvement. To compare the efficacy of USG guided coeliac plexus neurolysis for pain relief in upper abdominal malignancies by using different concentration of alcohol (50% vs 75%).This Prospective, comparative, randomised double blinded study was conducted during Sep 2019 – Aug 2020 at our tertiary care centre. Total 60 cases were taken as per following inclusion and exclusion criteria and randomly divided into 2 groups i.e. 30 each group, we compare Visual Analogue Scale (VAS) score, quality of life (QOL) and need of rescue analgesia profile between the groups to know the efficacy of USG guided coeliac plexus block. In our study, we observed that the baseline mean VAS score in group I was 8.26±0.78 while in group II was 8.03±0.76. No significant difference was found in mean VAS score at this time between the groups (p=0.24). The baseline mean QOL score in group-I was 77.46±3.40 while for the cases of group II the mean QOL score was 77.36±3.33. No significant difference was found in mean QOL score at baseline between the groups (p=0.90). The baseline mean morphine consumption in group-I was 113.33±39.24 mg while for the cases of group-II the mean morphine consumption was 120.33±38.37mg. No significant difference was found in mean morphine consumption at this time between the groups (p=0.48).Both groups having 50% alcohol and 75% alcohol decreases the VAS score from baseline in patients having upper abdominal malignancies along with QOL and dosages of rescue analgesia whereas no significant difference in VAS score in patients of both groups.

Comparitive evaluation of different concentrations of alcohol in ultrasound guided coeliac plexus neurolysis for pain relief in upper abdominal malignancies

Patients suffering from advanced upper abdominal malignancies have pain as predominant symptom affects their quality of life and survival. USG guided coeliac plexus neurolysis become benevolence in these patients on part of their pain management and quality of life improvement. To compare the efficacy of USG guided coeliac plexus neurolysis for pain relief in upper abdominal malignancies by using different concentration of alcohol (50% vs 75%).This Prospective, comparative, randomised double blinded study was conducted during Sep 2019 – Aug 2020 at our tertiary care centre. Total 60 cases were taken as per following inclusion and exclusion criteria and randomly divided into 2 groups i.e. 30 each group, we compare Visual Analogue Scale (VAS) score, quality of life (QOL) and need of rescue analgesia profile between the groups to know the efficacy of USG guided coeliac plexus block. In our study, we observed that the baseline mean VAS score in group I was 8.26±0.78 while in group II was 8.03±0.76. No significant difference was found in mean VAS score at this time between the groups (p=0.24). The baseline mean QOL score in group-I was 77.46±3.40 while for the cases of group II the mean QOL score was 77.36±3.33. No significant difference was found in mean QOL score at baseline between the groups (p=0.90). The baseline mean morphine consumption in group-I was 113.33±39.24 mg while for the cases of group-II the mean morphine consumption was 120.33±38.37mg. No significant difference was found in mean morphine consumption at this time between the groups (p=0.48).Both groups having 50% alcohol and 75% alcohol decreases the VAS score from baseline in patients having upper abdominal malignancies along with QOL and dosages of rescue analgesia whereas no significant difference in VAS score in patients of both groups.

A Comparative Study of Preemptive Effect of Pregabalin and Gabapentin on Postoperative Pain After Coronary Artery Bypass Graft Surgery

Background Pain that pursues coronary artery bypass graft (CABG) surgery is usually associated with increased both recovery duration and hospital stay. Patient outcome could be worsened owing to large doses of opioids for pain control through over sedation, and prolonged mechanical ventilation. This study was designed to evaluate the effect of preemptive gabapentinoids on post CABG surgery pain control. Objective to evaluate the effect of pre-operative administration of pregabalin and gabapentin in limiting the post-operative pain in coronary artery bypass surgeries. Patients and Methods Type of Study: Prospective double – blinded, randomized controlled Trial. After Approval is obtained from the research ethics committee of anesthesia and intensive care department, Ain Shams University. Study Setting: National Heart Institute, Egypt. Study Period: 6 months. Study Population: adult undergoing coronary artery bypass graft surgeries. Results The primary outcome of this study was to compare the effect of gabapentinoids on post CABG pain as reflected by morphine consumption. The secondary outcome was to address the influence of gabapentinoids on patient satisfaction post CABG, the incidence of respiratory depression, nausea, vomiting, ventilatory hours and length of hospital stay. Conclusion Pregabalin, and gabapentin both can be effective for reduction of post CABG morphine consumption and have better patient satisfaction if given preemptively with single dose preoperatively.

Comparing the Efficacy of Postoperative Pain Control Between Intravenous Parecoxib and Oral Diclofenac in ACL Reconstruction

Background: A nonsteroidal anti-inflammatory drug such as oral diclofenac is normally used to relieve postoperative pain after anterior cruciate ligament reconstruction (ACLR), but most patients continue to have moderate-to-severe pain that disturbs their rehabilitation. Some orthopaedists prefer to use intravenous (IV) parecoxib for postoperative pain control. Purpose: To compare the efficacy of IV parecoxib and oral diclofenac for postoperative pain control in ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: We retrospectively collected and analyzed postoperative pain in patients who underwent both single- and double-bundle ACLR; pain was reported on a 10-point visual analog scale (VAS; 10 = worst pain). After the operation, each patient was given either IV parecoxib twice a day or oral diclofenac 3 times a day, and all patients received paracetamol 6 times per day for 24 hours postoperatively. If the patient complained of moderate or severe pain (VAS >3) after surgery, 3 mg of morphine would be given intravenously every 3 hours and 1 mg of morphine as a rescue analgesic every 1 hour for 24 hours postoperatively. Postoperative VAS and morphine consumption were recorded every 4 hours for 24 hours. Data were analyzed using paired t test, analysis of variance, and chi-square test. Results: Overall, 161 patients were included in this study, of whom 47 received IV parecoxib and 114 received oral diclofenac. The mean VAS scores at 4 and 8 hours postoperatively were 3.5 and 3.4, respectively, in the parecoxib group, and 4.4 and 4.7, respectively, in the diclofenac group. The parecoxib group had significantly lower mean VAS than the diclofenac group at 4 hours ( P = .047) and 8 hours ( P = .005), and the mean cumulative morphine consumption in the parecoxib group was significantly lower than in the diclofenac group at all time points ( P < .05) except 4 hours postoperatively. Conclusion: This study found that IV parecoxib was more effective than oral diclofenac in controlling postoperative pain and resulted in lower postoperative morphine consumption within the first 24 hours after ACLR.

Comparison of Intraoperative Infusion of Remifentanil versus Fentanyl on Pain Management in Patients Undergoing Spine Surgery: A Double Blinded Randomized Clinical Trial

Background: Remifentanil is an ultra-short-acting opioid which facilitates hemodynamic management. However, there are concerns about postoperative Remifentanil hyperalgesia because of its potent fast onset and offset. Objectives: The aim of this study was to determine visual analog scale (VAS), postoperative pain, and morphine used in two groups after spine surgery. Methods: In this randomized clinical trial study, 60 patients aged 18 - 60 years old, according to the American Society of Anesthesiology (ASA) I - II, who underwent spinal canal stenosis or scoliosis surgery, were divided into two groups. In the control group, patients received 0.07 - 0.1 µg/kg/h intraoperative Fentanyl infusion, and in the intervention group 0.1 - 0.2 µg/kg/min remifentanil was infused during the surgery. Both groups received 15 mg/kg intravenous Acetaminophen 20 minutes before the end of the surgery. Postoperative pain score and morphine consumption were measured 6, 12, 24, and 48 hours after discharge from the post-anesthesia care unit (PACU). Results: During the first 12 hours, VAS and morphine consumption were significantly higher in remifentanil group (P < 0.001). However, no significant difference was found between the two groups in morphine consumption 12 - 48 hours after surgery. Conclusions: These findings suggest that Remifentanil infusion during surgery may increase postoperative pain. Also, VAS and morphine consumption were higher during the first 12 hours.

Efficacy of a Combination of Ketamine and Morphine for Intravenous Patient Controlled-Analgesia in Upper Abdominal Surgery: A Prospective, Double-blind, Randomized Controlled Trial

Background: Most postoperative upper abdominal pain is severe, and various methods can be employed to control it. Presently, morphine is the main drug used for anesthesia, but it may contribute to the occurrence of many uncomfortable side effects. Ketamine is an analgesic drug that inhibits NMDA receptors, making it a synergistic effect of morphine. Objective: To investigate the efficacy of a combination of ketamine and morphine in controlling postoperative upper abdominal pain. Materials and Methods: Informed consents were obtained from patients enrolled into the present double-blind randomized study that divided into two groups, (i) the M group, which received 1 mg/mL of morphine, and (ii) the MK group, which received 1 mg of ketamine plus 1 mg/mL of morphine as intravenous patient-controlled analgesia (IV-PCA) post-operation. All patients were assessed based on postoperative morphine consumption, a numeric rating scale (NRS) used to rate pain, and the presence of side effects. Results: Sixty-seven patients completed the study including 34 patients in the MK group and 33 patients in the M group. Cumulative postoperative morphine consumption at 24 and 48 hours was significantly lower in the MK group at 27.91±11.11 and 46.44±15.21 mg compared to the M group at 43.24±15.32 and 71.33±19.67 mg, respectively (p<0.001). NRS were similar between the two groups and no observable differences regarding to side effects. Conclusion: A combination of ketamine and morphine via IV PCA is effective in controlling postoperative upper abdominal pain. Keywords: Ketamine; Morphine; Upper abdominal surgery; Intravenous patient-controlled analgesia