Pre-emptive analgesia

Preemptive Analgesia in Thumb Basal Joint Arthroplasty: Immediate Postoperative Pain with Preincision versus Postincision Local Anesthesia

Purpose  Currently no guidelines exist for the timing of the injection of anesthetics in surgeries performed under general anesthesia to minimize postoperative pain. To better understand the role of timing of the injection of local anesthesia in hand surgery performed under general anesthesia, we evaluated the effect of pre- versus postincisional local analgesic injection on immediate postoperative pain experience. We hypothesize that the preincisional (preemptive) injection will result in decreased immediate postoperative pain experience and analgesic use when compared with postincisional injection. Methods  Consecutive cases of thumb basal joint arthroplasty performed over a 4-year period were retrospectively reviewed. During the first half of the study period, the surgical site was infiltrated with 0.5% bupivacaine at the completion of surgery following closure. During the second half of the study period, the surgical site was infiltrated with 0.5% bupivacaine prior to skin incision. Data collected included patient demographics, immediate postoperative recovery room (PACU) pain scores, and postoperative opioid consumption in morphine equivalents. Results  Two-tailed t -test identified no significant difference between the pre- and postincision cohorts relative to PACU entrance pain scores and time spent in the PACU. PACU exit pain scores were significantly lower in the preincision cohort. The mean PACU pain score was also significantly lower in the preincision cohort. PACU opioid consumption, converted into morphine equivalents, was found to be 211 mg in the preincision versus 299 mg in the postincision cohort. Conclusion  The preincisional (preemptive) injection of local anesthesia was found to result in lower pain scores during and upon exit of the PACU as compared with the postclosure group. In addition, the preincision cohort also trended toward lower opioid consumption while in the PACU. Consideration should be given to the routine use of preincision injection of local anesthesia to maximize pain relief in a multimodal pain strategy in hand surgical patients. Level of Evidence  Therapeutic level III.

Comparison of Pain Relief from Different Intravenous Doses of Ketorolac after Reduction of Mandibular Fractures

Introduction

Pain is an unpleasant feeling due to tissue destruction, which disturbs an individual's daily routines even at its lowest levels. The majority of surgeons and anaesthesiologists are increasingly trying to administer non-opioid analgesics because excessive use of opioids after surgery results in patient dissatisfaction.

Aim

To evaluate the analgesic effect of intravenous injection of different doses of ketorolac at different intervals in patients undergoing surgery for unilateral fractures of the mandible.

Materials and Methods

In the present randomized clinical trial (March 2016 to January 2017, in Tabriz Imam Reza Treatment/Educational Center), 50 patients were assigned to five groups with simple randomization method. In Group 1 and 2, immediately before the induction of general anaesthesia 30 and 60 mg of ketorolac and in Group 3 and 4, immediately before termination of surgery 30 and 60 mg of ketorolac was injected intravenously. In Group 5, ketorolac was not administered. After each patient regained complete consciousness, the severity of pain was determined using VAS up to 24 hours at baseline and at 2, 4, 6, 12 and 24-hours intervals. The total dose of the opioid analgesic agent (morphine-pethidine) and the time for the first request for an analgesic agent were recorded for each patient and their means were compared in each group with suitable statistical tests.

Results

The patients in Group 5 and 4 exhibited the highest and lowest mean pain scores (5.03±0.9 and 3.5±1), respectively. ANOVA for repeated measures and post-hoc Tukey tests showed significant differences only between Group 3 and 5 (p=0.002) and Group 4 and 5 (p=0.001), with no significant differences between the other groups (p>0.005). The highest dose of the analgesic agent was in Group 5 (5.3±1.4 mg) and the lowest dose was recorded in Group 4 (1.6±0.6 mg). Patients in the control group received significantly higher doses compared to the other groups (p<0.05). The patients in Group 1 and 2 received higher doses of analgesics compared to Group 3 and 4 (p<0.05). The longest time for the request for the first dose of analgesic agent after surgery was 73.4±12.03 minutes in Group 4 The patients in the control group had requested analgesics after surgery at a significantly shorter time compared to the patients in all the study groups (p<0.05). The patients in Group 1 and 2 had requested analgesics at a shorter time after surgery compared to the subjects in Group 3 and 4 (p<0.05).

Conclusion

Intravenous administration of 30 and 60 mg of ketorolac, immediately before termination of surgery, decreases the pain severity and the need for opioid analgesics after surgery.

A Comparative Randomized Trial on the Optimal Timing of Dexamethasone for Pain Relief after Endoscopic Submucosal Dissection for Early Gastric Neoplasm

Background/Aims

The aim of this study was to compare the clinical effects of preoperative and postoperative dexamethasone on pain after endoscopic submucosal dissection (ESD) for early gastric neoplasm.

Methods

Forty patients with early gastric neoplasm who were scheduled for ESD were randomized into two groups according to the timing of steroid administration: preoperative (“pre”, n=20) and postoperative (“post”, n=20) steroid administration. The pre group received 0.15 mg/kg dexamethasone before ESD and placebo after, and the post group received pre-ESD placebo and post-ESD dexamethasone. The present pain intensity (PPI) index and the short-form McGill pain (SF-MP) questionnaire were evaluated.

Results

The primary outcome was PPI score at 6 hours after ESD. There was a greater reduction in 6-hour PPI in the pre group than in the post group (2.1±0.8 vs 3.0±1.1, respectively; p=0.006). The immediate PPI was also significantly lower in the pre group than in the post group (1.6±0.6 vs 2.9±0.6, respectively; p<0.001), and the total SF-MP scores were significantly lower in the pre group than in the post group both immediately and at 6 hours after the operation.

Conclusions

Preoperative administration of dexamethasone may produce a superior analgesic effect in patients who undergo ESD compared with the postoperative administration of dexamethasone.

Role of capsaicin- and heat-sensitive afferents in stimulation of acupoint-induced pain and analgesia in humans

We investigated role of capsaicin-sensitive afferents within and without the areas of Zusanli (ST36)/Shangjuxu (ST37) acupoints along the stomach (ST) meridian in the perception and modulation of pain assessed by visual analog scale of pain and its distribution rated by subjects, pressure pain threshold (PPT), and heat pain threshold (HPT) in humans. Compared with the treatment of non-acupoint area, capsaicin (100µg/50µl) administered into either ST36 or ST37 acupoint caused the strongest pain intensity and the most extensive pain distribution, followed by rapid onset, bilateral, long-lasting secondary mechanical hyperalgesia and slower onset secondary heat hypoalgesia (1day after the capsaicin treatment). Between treatments of different acupoints, capsaicin administrated into the ST36 acupoint exhibited the stronger pain intensity and more widespread pain distribution compared with the treatment of ST37 acupoint. A period of 30- to 45-min, but not 15-min, 43°C heating-needle stimulation applied to the ST36 acupoint significantly enhanced the HPT, and had no effect on PPT. Upon trapezius muscle pain elicited by the i.m. injection of 5.8% saline, pre-emptive treatment of the contralateral ST36 acupoint with 43°C heating-needle stimulation alleviated the ongoing muscle pain, reduced painful area, and reversed the decrease in HPT. It is suggested that (1) pain elicited from the acupoint and non-acupoint areas differs significantly, which are supposed to be dependent on the different distributions and contributions of capsaicin-sensitive afferents. (2) Non-painful heat stimulation is a valid approach in prevention of ongoing muscle pain with associated post-effects of peripheral and central sensitization.

Ethical use of animal models in musculoskeletal research

The use of animals in research is under increasing scrutiny from the general public, funding agencies, and regulatory authorities. Our ability to continue to perform in-vivo studies in laboratory animals will be critically determined by how researchers respond to this new reality. This Perspectives article summarizes recent and ongoing initiatives within ORS and allied organizations to ensure that musculoskeletal research is performed to the highest ethical standards. It goes on to present an overview of the practical application of the 3Rs (reduction, refinement, and replacement) into experimental design and execution, and discusses recent guidance with regard to improvements in the way in which animal data are reported in publications. The overarching goal of this review is to challenge the status quo, to highlight the absolute interdependence between animal welfare and rigorous science, and to provide practical recommendations and resources to allow clinicians and scientists to optimize the ways in which they undertake preclinical studies involving animals. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:740-751, 2017.

[Postoperative pain therapy in Germany. Status quo]

A great deal of progress has been made in the field of postoperative pain therapy in the last 20 years. Beginning from clinical trials on the effectiveness of individual procedures, such as epidural anesthesia and patient-controlled analgesia, a wide range of healthcare services research as well as basic research with human and animal experiments has been established. Whereas health services research in the 1980s and 1990s focused more on the implementation of acute pain services, outcome-oriented research approaches are nowadays the center of attention. Acute pain registries and pain certification projects initiated in Germany have to be mentioned particularly in this respect. Basic research papers from recent years increasingly address specific aspects of acute postoperative pain and have provided translational approaches that are applied around the world for studying neurobiological mechanisms of postoperative pain. At the same time, interdisciplinary cooperation in research projects has led to a better understanding of complex correlations regarding predictors and mechanisms (including psychosocial aspects) of acute and in recent times also chronic pain after surgery. In parallel, evidence-based medicine has found its way into acute pain medicine in Germany. In 2007, clinical acute pain therapy in Germany was enhanced by S3 level guidelines for the first time; however, the implementation is still incomplete. In future, questions concerning mechanism-based therapy of acute pain need to be equally in the center of attention of research, such as prevention of persisting pain after surgery and acute pain of different origins.

Pre-emptive analgesic effect of lornoxicam in mandibular third molar surgery: a prospective, randomized, double-blind clinical trial

The aim of this study was to establish whether the pre-emptive use of lornoxicam (16mg) in third molar surgery ensures successful postoperative analgesia and reduces rescue analgesic intake when compared to postoperative application, and in comparison with placebo. Ninety patients were split randomly into three groups: group A received lornoxicam 60min before surgery and placebo 60min after surgery; group B received placebo 60min before surgery and lornoxicam 60min after surgery; group C received placebo 60min before surgery and placebo 60min after surgery. Postoperative pain was recorded on a visual analogue scale and on a numerical rating scale at 1, 2, 4, 6, 8, 12, and 24h after surgery. The patients recorded total dose of paracetamol intake during the 24h after the procedure. The efficacy of postoperative analgesia was greater in lornoxicam groups when compared to the placebo group; there was no difference between the two lornoxicam groups (A and B). Patients in group C took their first rescue analgesic dose earlier after surgery than patients in the two lornoxicam groups. The average dose of paracetamol taken in group C was 1000mg, while it was500 mg in the lornoxicam groups.

Comparative Pre-Emptive Analgesic Efficacy Study of Novel Antiepileptic Agents Lamotrigine and Topiramate in Patients Undergoing Major Surgeries at a Tertiary Care Hospital: A Randomized Double Blind Clinical Trial

BACKGROUND

Central nervous sensitization, following surgical injury, leads to postoperative pain hypersensitivity due to lowered pain threshold in peripheral nociceptors and increased excitability of spinal neurons. Pre-emptive analgesia is intended to decrease pain perception and overall analgesic need by use of drug regimen, seizing CNS sensitization before exposure to painful stimuli. Few studies support pre-emptive analgesic efficacy of novel antiepileptic agent Gabapentin. Though Topiramate and Lamotrigine have been proven analgesic in animal models of chronic pain and clinical studies of Gabapentin-resistant neuropathic pain, literature search revealed scarce data on its pre-emptive analgesic efficacy.

PURPOSE

This study is designed to study and compare the pre-emptive analgesic efficacy of Lamotrigine, Topiramate, and Diclofenac sodium in postoperative pain control.

METHODS

This randomized clinical trial included 90 patients of either sex, between 18 and 70 years undergoing major surgeries. Patients were randomly allocated to control and test groups and received respective treatment 30 min before induction of anesthesia. Aldrete's and pain scores were recorded using the Visual Analog Scale, Facial and Behavioral Rating Scale at awakening and at 1, 2, 4, 6, and 24 h. Postoperative rescue analgesic consumption for 24 h was recorded.

RESULTS

Significantly higher pain scores were observed in the Topiramate group postoperatively for 2 h on all pain scales (p < 0.05), whereas in the control group it was significantly higher at 1 h (p < 0.05). Lamotrigine-treated patients were more comfortable throughout the study with significantly less (p < 0.05) postoperative analgesic requirement.

CONCLUSIONS

Study results strongly suggest the pre-emptive analgesic efficacy of a single oral dose of Lamotrigine over Diclofenac and Topiramate in postoperative pain control.

Postoperative persistent chronic pain: what do we know about prevention, risk factors, and treatment

BACKGROUND AND OBJECTIVES

Postoperative persistent chronic pain (POCP) is a serious health problem, disabling, undermining the quality of life of affected patients. Although more studies and research have addressed the possible mechanisms of the evolution from acute pain to chronic postoperatively, there are still no consistent data about the risk factors and prevention. This article aims to bring what is in the panorama of the current literature available.

CONTENT

This review describes the definition, risk factors, and mechanisms of POCD, its prevention and treatment. The main drugs and techniques are exposed comprehensively.

CONCLUSION

Postoperative persistent chronic pain is a complex and still unclear etiology entity, which interferes heavily in the life of the subject. Neuropathic pain resulting from surgical trauma is still the most common expression of this entity. Techniques to prevent nerve injury are recommended and should be used whenever possible. Despite efforts to understand and select risk patients, the management and prevention of this syndrome remain challenging and inappropriate.

The effect of pre-emptive analgesia on the level of postoperative pain in women undergoing surgery for breast neoplasm

AIM OF THE STUDY

Dynamic development of research on pain has resulted in the formulation of the concept of pre-emptive analgesia, which involves administration of analgesics before the first pain-producing stimulus appears. It is meant to prevent increased sensitivity to pain in the postoperative period. The aim of this study was to assess the possibilities of modifying the intensity of postoperative pain evaluated with the visual analogue scale (VAS) in patients after surgical treatment for breast neoplasm offered by pre-emptive analgesia.

MATERIAL AND METHODS

The intensity of postoperative pain was measured immediately after the surgery as well as 6, 12, 18, and 24 hours later in 100 women who had undergone surgery for breast tumour. The correlation between experienced pain and the type of analgesic administered pre-emptively, including metamizole, tramadol, ketoprofen, and placebo was examined. The effect of other correlates such as the extensiveness of surgery, systolic and diastolic blood pressure, and heart rate on the level of experienced pain as well as the usefulness of physiological parameters for its assessment were also analysed.

RESULTS

The conducted study demonstrated the effectiveness of tramadol (p = 0.004) and ketoprofen (p = 0.039) administered half an hour before the beginning of surgery, but there was no similar effect in the case of metamizole (p = 1.0). A positive correlation was observed between the level of experienced pain and blood pressure values (p < 0.001). Heart rate does not seem to be significantly linked with the intensity of experienced pain (p = 0.157).

Invasive treatment of pain associated with pancreatic cancer on different levels of WHO analgesic ladder

Background

Pancreatic cancer is a malignant neoplasm with a high mortality rate, often associated with a delayed diagnosis, the early occurrence of metastasis and an overall, poor response to chemotherapy and radiotherapy. Pain management in pancreatic cancer consists mainly of pharmacological treatment according to the WHO analgesic ladder. Surgical treatment for pain relief, such as splanchnicectomy, is considered amongst the final step of pain management. It has been proven that splanchnicectomy is a safe procedure with a small percentage of complications, nevertheless, it is often used as a last resort, which can significantly decrease its effectiveness. Performance of thoracoscopic splanchnicectomy along the first step of the analgesic ladder may lead to long-lasting protection against the presence and severity of pain.

Methods/Design

A prospective, open label, 1:1 randomized, controlled trial, conducted at a single institution to determine the effectiveness of invasive treatment of pain via splanchnicectomy, in patients with advanced pancreatic cancer. The size of tested group will consist of 26 participants in each arm of the trial, to evaluate the level of pain relief and its impact on quality of life. To evaluate the influence on patients’ rate of overall survival, a sample size of 105 patients is necessary, in each trial arm. Assessments will not only include the usage of analgesic pharmacotherapy throughout the course of disease, and overall patient survival, but also subjective pain perception at rest, in movement, and after meals (measured by NRS score questionnaire), the patient’s quality of life (measured using the QLQ-C30 and FACIT questionnaires), and any pain-related suffering (measured with the PRISM projection test). The primary endpoint will consist of pain intensity. Questionnaires will be obtained upon the initial visit, the day of surgery, the day after surgery, as well as during long-term follow-up visits, held every two weeks thereafter.

Discussion

Earlier implementation of invasive treatment, such as thoracoscopic splanchnicectomy, can provide a higher efficacy of pain management, prevent deterioration in the patient’s quality of life, and lengthen their overall survival.

Trial registration

ClinicalTrials.gov identifier: NCT02424279. Date of registration January 2, 2015.

Pain in an era of armed conflicts: Prevention and treatment for warfighters and civilian casualties

Chronic pain is a common squealae of military- and terror-related injuries. While its pathophysiology has not yet been fully elucidated, it may be potentially related to premorbid neuropsychobiological status, as well as to the type of injury and to the neural alterations that it may evoke. Accordingly, optimized approaches for wounded individuals should integrate primary, secondary and tertiary prevention in the form of thorough evaluation of risk factors along with specific interventions to contravene and mitigate the ensuing chronicity. Thus, Premorbid Events phase may encompass assessments of psychological and neurobiological vulnerability factors in conjunction with fostering preparedness and resilience in both military and civilian populations at risk. Injuries per se phase calls for immediate treatment of acute pain in the field by pharmacological agents that spare and even enhance coping and adaptive capabilities. The key objective of the Post Injury Events is to prevent and/or reverse maladaptive peripheral- and central neural system's processes that mediate transformation of acute to chronic pain and to incorporate timely interventions for concomitant mental health problems including post-traumatic stress disorder and addiction We suggest that the proposed continuum of care may avert more disability and suffering than the currently employed less integrated strategies. While the requirements of the armed forces present a pressing need for this integrated continuum and a framework in which it can be most readily implemented, this approach may be also instrumental for the care of civilian casualties.

A Randomized Double-Blind Placebo-Controlled Study to Compare Preemptive Analgesic Efficacy of Novel Antiepileptic Agent Lamotrigine in Patients Undergoing Major Surgeries

BACKGROUND

If postoperative acute pain remains unrelieved, it may result in significant morbidity and mortality. Preemptive analgesic initiated before surgery offers premature analgesia even before exposure to an initial noxious stimulus bestowing effective postoperative analgesia. In developed countries, it is regularly practiced as a part of well-defined protocol. In our country however, only a few centers practice it and that too irregularly and with undefined protocol. Few studies support preemptive analgesic efficacy of novel antiepileptic agent gabapentin. Though lamotrigine is a proven analgesic in animal models of chronic pain and clinical studies of gabapentin-resistant neuropathic pain, a literature search revealed scarce data on its preemptive analgesic efficacy.

AIMS

The present study is designed to study the preemptive analgesic efficacy of lamotrigine in comparison with diclofenac sodium in postoperative pain control.

MATERIALS AND METHODS

This randomized clinical trial included 90 patients of both sexes, between 18 years and 70 years undergoing major surgeries. Patients were randomly allocated into placebo, control, and test groups and received the respective treatment 30 min before the induction of anesthesia. Aldrete score and pain score were recorded using visual analog scale (VAS), facial rating scale (FRS), and behavioral rating scale (BRS) at awakening and at 1 h, 2 h, 4 h, 6 h, and 24 h. Postoperative rescue analgesic consumption for 24 h was recorded.

RESULTS

Significantly higher pain scores were observed in the placebo group postoperatively for 2 h on all pain scales (P < 0.05), whereas in the control group it was significantly higher at 1 h (P < 0.05). The test group patients were more comfortable throughout the study and postoperative analgesic requirement was significantly less (P < 0.05).

CONCLUSIONS

The study recommends the use of single oral dose lamotrigine as preemptive analgesic for effective postoperative pain control.

Randomized controlled trial on preemptive analgesia for acute postoperative pain management in children

BACKGROUND

Preemptive analgesia is an anti-nociceptive treatment that starts before surgery and prevents the establishment of central sensitization. Whether preemptive analgesia is more effective than conventional regimens for managing postoperative pain remains controversial. This study evaluated the efficacy of intravenous preemptive analgesia for acute postoperative pain control in pediatric patients.

METHODS

In this prospective randomized controlled trial, 51 children aged 3-7 years, scheduled for corrective osteotomy were randomized into control (group C) or preemptive (group P) group. Both groups received standardized general anesthesia, including intravenous patient-controlled analgesia (IV-PCA) with fentanyl, which was started before skin incision in group P or 5 min thereafter in group C. IV-PCA data, pain scores using verbal rating scale (VRS) and Wong-Baker FACES(®) pain rating scale (WBFS), emergence agitation score (EAS) using the Pediatric Anesthesia Emergence Delirium (PAED) scale, analgesic requirements, and complications were recorded.

RESULTS

The primary outcome, pain score at postoperative 1 h, showed no difference between the groups. Both groups did not demonstrate emergence agitation (PAED cutoff value ≥ 12), although the EAS at admission to the postanesthetic care unit (PACU) was lower in group P than in group C (P = 0.002; mean difference 4.85, 95% CI 1.97-7.73). There were no differences in the delivered volume of IV-PCA, frequency of pushing the IV-PCA button, effective push attempts, VRS, WBFS, EAS at discharge from the PACU, additional analgesic requirements, and complications.

CONCLUSION

Preemptive analgesia using IV-PCA with fentanyl showed no significant advantages for postoperative analgesia after corrective osteotomy in pediatric patients.

Pain Part 3: Acute Orofacial Pain

Acute trigeminal pain is a common presentation in the dental surgery, with a reported 22% of the US adult population experiencing orofacial pain more than once during a 6-month period. This article discusses the mechanisms underlying the pain experience, diagnosis and subsequent management of acute trigeminal pain, encompassing pre-, peri- and post-operative analgesia. The dental team spend most of their working lives managing patients and acute pain. The patient may present to the clinician in existing pain, which may often provide a diagnostic challenge. Prevention and managing intra-operative and post-surgical pain are implicit in providing your patient with optimum care. CPD/CLINICAL RELEVANCE: This paper aims to provide an overview of conditions that may present with acute orofacial pain and their management using the most recent evidence base. Intra-operative and post-surgical pain management are also scrutinized and evidence based treatment is recommended.

Post-Operative Pain Management in Patients Undergoing Robotic Urological Surgery

Robotic urological surgery is being increasingly performed worldwide. The main focus currently is on the operative technique but post operative patient care is an essential part of the process to make this technique safe and successful. We present a review on multiple analgesic techniques available to prevent and treat pain specifically caused after by urological robotic surgery; this article will explain the mechanism of pain pathways involved in laparoscopic procedures and review current evidence pertaining to systemic and regional analgesia methods.

Effects of postoperative administration of celecoxib on pain management in patients after total knee arthroplasty: study protocol for an open-label randomized controlled trial

Background

Multimodal analgesia is achieved by combining different analgesics and different methods of analgesic administration, synergistically providing superior pain relief when compared with conventional analgesia. Multimodal analgesia can also result in reductions in the side effects and complications of analgesia, thereby improving patient safety. Preventive analgesia, treatment before initiation of the surgical procedure, has a potential to be more effective in reducing pain sensitization than treatment initiated after surgery. Multimodal analgesia that includes prophylactic administration of selective cyclooxygenase-2 (COX-2) inhibitors can improve postoperative pain and reduce opioid analgesic consumption after total knee arthroplasty (TKA). However COX-2 inhibitors are not approved for use as preventive analgesia in Japan. Thus, assessing the effectiveness of COX-2 inhibitors during the early postoperative period is important to establish clinical practice guidelines in Japan. This study was designed to examine the effects of celecoxib administration immediately after surgery, in addition to multimodal analgesia, on postoperative pain management after TKA.

Methods/Design

This randomized, prospective, open-label controlled study will include 120 patients undergoing unilateral TKA. All patients will routinely receive single injections of femoral and sciatic nerve blocks, along with postoperative patient-controlled analgesia (PCA) with fentanyl. Patients will be randomly assigned to receive or not receive immediate postoperative administration of celecoxib. The primary outcome is a visual analog scale (VAS) pain score the second day after surgery. Secondary outcomes include opioid consumption, VAS pain score for 7 days after surgery, range of knee motion, evaluation of sleep quality, overall evaluations by patients and physicians, rates of postoperative nausea and vomiting, and consumption of rescue analgesics.

Discussion

The objective of this study is to evaluate the effects of celecoxib administration immediately after surgery on pain after TKA surgery. A randomized controlled trial design will address the hypothesis that administration of oral celecoxib immediately after surgery, along with multimodal analgesia that includes peripheral nerve block and PCA, could reduce VAS pain score after TKA surgery.

Trial Registration

UMIN-CTR 000014624 (23 July 2014)

Pain control of thoracoscopic major pulmonary resection: is pre-emptive local bupivacaine injection able to replace the intravenous patient controlled analgesia?

BACKGROUND

The aim of this open-label, non-inferiority trial was to evaluate whether pre-emptive local bupivacaine injection (PLBI) can replace intravenous patient controlled analgesia (IV PCA) in video-assisted thoracic surgery (VATS) major pulmonary resection.

METHODS

A total of 86 patients scheduled for VATS segmentectomy/lobectomy were randomly assigned into two groups. The PLBI group (n=42) received 0.5% bupivacaine wound infiltration before skin incision, and the IV PCA group (n=44) received a continuous infusion of fentanyl with a basal rate of 10 µg/mL/h. Visual analogue scale (VAS; range, 0-10) was measured as the primary endpoint. The secondary endpoint was an additional use of analgesics and drug induced side effects.

RESULTS

Both groups showed no difference in terms of age, sex, disease entity, operation time, chest tube indwelling time, and hospital stay. Serial pain scores between the PLBI and IV PCA groups demonstrated no statistical differences (non-inferiority margin; ΔVAS =1.0) (Recovery room: 8.3±2.1 vs. 8.5±1.7; Day 0: 5.1±1.6 vs. 5.2±1.4; Day 1: 3.5±1.6 vs. 3.3±1.2; Day 2: 2.7±1.3 vs. 2.5±1.2; Day 3: 2.3±1.3 vs. 2.1±1.5; 1 week after discharge: 3.0±1.7 vs. 2.8±1.5; 1 month: 1.9±1.2 vs. 2.3±1.4 and 2 months: 1.5±1.2 vs. 1.3±1.2; 95% confidential interval (CI) of ΔVAS <1.0; P>0.05). The mean one-additional usage of IV analgesics was needed in the PLBI group (3.3±2.1 vs. 2.3±1.3; P=0.03). The occurrence of nausea/vomiting was higher in the IV PCA group (12.5% vs. 38.9%; P=0.026) and 41.7% of IV PCA patients experienced drug side effects that required IV PCA removal within postoperative day (POD) 1.

CONCLUSIONS

PLBI is a simple, safe, effective, and economical method, which is not inferior to IV PCA in VATS major pulmonary resection.

The opioid abuse and misuse epidemic: implications for pharmacists in hospitals and health systems

PURPOSE

The current epidemic of prescription opioid abuse and misuse in the United States is discussed, with an emphasis on the pharmacist's role in ensuring safe and effective opioid use.

SUMMARY

U.S. sales of prescription opioids increased fourfold from 1999 to 2010, with an alarming rise in deaths and emergency department visits associated with the use of fentanyl, hydrocodone, oxycodone, and other opioid medications. Signs and symptoms of opioid toxicity may include altered mental status, hypoventilation, decreased bowel motility, central nervous system and respiratory depression, peripheral vasodilation, pulmonary edema, hypotension, bradycardia, and seizures. In patients receiving long-term opioid therapy for chronic pain, urine drug testing is an important tool for monitoring and assessment of therapy; knowledge of opioid metabolic pathways and assay limitations is essential for appropriate use and interpretation of screening and confirmatory tests. In recent years, there has been an increase in federal enforcement actions against pharmacies and prescription drug wholesalers involved in improper opioid distribution, as well as increased reliance on state-level prescription drug monitoring programs to track patterns of opioid use and improper sales. Pharmacies are urged to implement or promote appropriate guidelines on opioid therapy, including the use of pain management agreement plans; policies to ensure adequate oversight of opioid prescribing, dispensing, and waste disposal; and educational initiatives targeting patients as well as hospital and pharmacy staff.

CONCLUSION

Pharmacists in hospitals and health systems can play a key role in recognizing the various forms of opioid toxicity and in preventing inappropriate prescribing and diversion of opioids.

Intra- and postoperative low-dose ketamine for adolescent idiopathic scoliosis surgery: a randomized controlled trial

BACKGROUND

In this randomized controlled trial, we examined whether intra- and postoperative infusion of low-dose ketamine decreased postoperative morphine requirement and morphine-related adverse effects as nausea and vomiting after scoliosis surgery.

METHODS

After IRB approval and informed consent, 36 patients, aged 10-19 years, undergoing posterior correction surgery for adolescent idiopathic scoliosis, were randomly allocated into two groups: intra- and postoperative ketamine infusion at a rate of 2 μg/kg/min until 48 h after surgery (ketamine group, n = 17) or infusion of an equal volume of saline (placebo group, n = 19). All patients were administered total intravenous anesthesia with propofol and remifentanil during surgery and intravenous morphine using a patient-controlled analgesia device after surgery. The primary outcome was cumulative morphine consumption in the initial 48 h after surgery. Pain scores (Numerical Rating Scale, NRS, 0-10), sedation scales, incidence of postoperative nausea and vomiting (PONV), and antiemetic consumption were recorded by nurses blinded to the study protocol for 48 h after surgery.

RESULTS

Patient characteristics did not differ between the two groups. Cumulative morphine consumption for 48 h after surgery was significantly lower in the ketamine group compared to the placebo group (0.89 ± 0.08 mg/kg vs. 1.16 ± 0.07 mg/kg, 95% confidence interval for difference between the means, 0.03-0.48 mg/kg, P = 0.019). NRS pain, sedation scales, and incidence of PONV did not differ between the two groups. Antiemetic consumption was significantly smaller in ketamine group.

CONCLUSIONS

Intra- and postoperative infusion of low-dose ketamine reduced cumulative morphine consumption and antiemetic requirement for 48 h after surgery.

Electronic Ordering System Improves Postoperative Pain Management After Total Knee or Hip Arthroplasty

OBJECTIVES

The authors investigated the impact of computerized provider order entry (CPOE) on the delivery times of analgesia and subsequent patient outcomes. We hypothesized that patients would report less pain and use less pain medications compared with the previous paper-based system.

METHODS

Two groups of patients after a total hip (THA) or knee arthroplasty (TKA) were retrospectively compared: one comprising 106 patients when the paper-based ordering system was in effect (conventional group), and one comprising 96 patients after CPOE was installed (electronic group). All patients received a regional anaesthetic at surgery (combined spinal-epidural). TKA patients also received a single-injection femoral nerve block. After transfer to the postoperative anaesthesia care unit (PACU), a patient-controlled epidural analgesia (PCEA) infusion was initiated. The following data was collected from the PACU record: time to initiation of analgesia, visual analog scale (VAS) pain scores at initiation of analgesia and hourly for the first postoperative day (POD), volume of pain medication used, length of stay (LOS) in the PACU and the hospital.

RESULTS

The time to initiation of analgesia from arrival in the PACU was significantly lower in the electronic group compared to the conventional group (24.5 ± 28.3 minutes vs. 51.1 ± 26.2 minutes; mean ± SD, p < 0.001), as were VAS pain scores (0.82 ± 1.08 vs. 1.5 ± 1.52, p < 0.001) and the volume of PCEA needed to control pain (27.9 ± 20.2 ml vs. 34.8 ± 20.3 ml, p = 0.001) at 4 hours postoperatively. PACU LOS and hospital LOS did not significantly differ in the two groups.

CONCLUSIONS

After implementation of CPOE, patients received their postoperative analgesia faster, had less pain, and required less medication.

Does the Preemptive Use of Oral Nonsteroidal Anti-inflammatory Drugs Reduce Postoperative Pain in Surgical Removal of Third Molars? A Meta-analysis of Randomized Clinical Trials

The purpose of this study was to investigate the effectiveness of preemptive analgesia with nonsteroidal anti-inflammatory drugs (NSAIDs) in third-molar surgery. A PubMed literature search was conducted for articles restricted to the English language using the following terms (DeCS/MeSH) or combinations: analgesia, third molar, and preemptive. From a total of 704 articles, 6 (n=420 subjects) were selected. All studies presented a low risk of bias (Cochrane criteria) but exhibited high heterogeneity of methods. Two studies were excluded from the meta-analysis because they did not have adequate numeric values (dichotomous data) for the calculations. Preemptive analgesia showed no significant benefit (n=298, P=.2227, odds ratio: 2.30, 0.60-8.73) in reducing postoperative pain after removal of lower impacted third molars. However, there was a probable direct relationship between the effectiveness of NSAIDs in preemptive analgesia for removal of third molars and its selectivity for the cyclooxygenase-2 (COX-2). Preemptive analgesia did not have a significant effect in reducing postoperative pain after removal of lower impacted third molars. More homogeneous and well-delineated clinical studies are necessary to determine a possible association between NSAIDs' selectivity for COX-2 and treatment effectiveness.

A split-mouth, randomized, triple-blind, placebo-controlled study to analyze the pre-emptive effect of etoricoxib 120 mg on inflammatory events following removal of unerupted mandibular third molars

Pain after third molar extraction has been considered the most suitable pharmaceutical model to evaluate acute pain. This study aimed to evaluate the pre-emptive analgesic/anti-inflammatory efficacy of etoricoxib 120 mg following mandibular third molar surgery. A split-mouth, randomized, triple-blind, placebo-controlled study was conducted with patients undergoing the surgical removal of mandibular third molars. All volunteers were allocated randomly to receive either etoricoxib 120 mg or placebo 1h preoperatively, and inflammatory events were evaluated. An estimated sample of 18 surgical units per group was required based on a pilot study (95% confidence level and 80% statistical power). Rescue medication was analyzed by Kaplan-Meier method through log-rank Mantel-Cox test and Pearson linear correlation (P<0.05). Pre-emptive etoricoxib reduced postoperative pain scores significantly in comparison to placebo (P<0.001), with a pain score peak at 6h after surgery (P<0.001). The mean rescue medication consumption was lower in the etoricoxib group compared to the placebo group over the study period (P<0.05). There was no statistically significant difference between groups related to swelling and trismus. The pre-emptive administration of etoricoxib 120 mg significantly reduced the postoperative pain intensity and the need for rescue medication, but did not reduce swelling or trismus.

The late effect of intraoperative wound infiltration with local anaesthetic in surgical patients; is there any? A randomized control trial

INTRODUCTION

Intraoperative wound infiltration with local anaesthetic is commonly used. Apart from the obvious immediate action it has been supported that a possible down regulation of pain receptors may lead to longer effects. Our aim was to compare the use of local anaesthetic versus placebo in order to assess if indeed there is a late beneficial effect.

METHODS

We conducted an RCT involving 400 consecutive general surgery patients randomized in 2 groups: Group A = placebo, Group B = wound infiltration with 15 ml of ropivacaine 10%. We recorded the preoperative and postoperative pain for the 1st week as well as the type and quantity of the analgesia used during the study period.

RESULTS

No significant difference was found between the groups in all known confounding factors recorded. No significant difference was found in the intensity of postoperative pain. More people of group A required NSAIDs during the first 3 PO days while more people of Group B required stronger painkillers. For those patients who underwent a non urgent operation and especially laparoscopic surgery higher pain score was recorded in the group B from the 3rd PO day onwards.

DISCUSSION

Intraoperative local infiltration of the wound with local anaesthetic offers no further benefit for the general surgery apart from that of the immediate PO period. There is no late effect for pain control. Considering that during the immediate postoperative period stronger systematic painkillers are given the intraoperative, infiltration of the wound with the local anaesthetic under study offers no obvious benefit.

The benefits of preincision ropivacaine infiltration for reducing postoperative pain after robotic bilateral axillo-breast approach thyroidectomy: a prospective, randomized, double-blind, placebo-controlled study

Purpose

The aim of this study was to evaluate the effects of preoperative ropivacaine infiltration in patients undergoing robotic thyroidectomy using the bilateral axillary breast approach method.

Methods

Using a randomized, double-blind study design, 34 consecutive female patients who underwent robotic thyroidectomy were randomly assigned to receive local infiltration to the skin flap site using either only 0.9% saline solution, 3 mL/kg (group C, n = 17) or 0.1% ropivacaine with saline, 3 mg/kg (group L, n = 17). Local anesthetic was administered prior to skin incision after the induction of general anesthesia. Postoperative pain was rated at 2, 6, 18, 30, 42, and 66 hours postoperatively by visual analogue scale (VAS) score. The bottom hit counts (BHC) from patient controlled analgesia and fentanyl consumption were evaluated. CRP levels, mean blood pressure (BP), and heart rate (HR) were also evaluated.

Results

VAS pain scores were significantly lower in group L than in group C from 2 to 42 hours (P < 0.05). Fentanyl use for analgesia and BHC were also significantly lower in group L compared with group C during the first postoperative 6 and 2 hours, respectively (P < 0.05). The total consumption of fentanyl was significantly lower in group L than in group C (P = 0.009). No significant differences were noted for baseline, postoperative mean BP, or HR.

Conclusion

Preoperative infiltration using ropivacaine with saline to all flap sites is a safe and effective method for reducing postoperative pain and postoperative fentanyl consumption in patients with robotic thyroidectomy.

Comparing early postoperative period analgesic effect of dexketoprofene trometamol and lornoxicam in mediastinoscopy cases

OBJECTIVE

In this study, we aimed comparing early postoperative period analgesic effectiveness and the effects on opioid consumption of intravenous dexketoprofen and lornoxicam that are given preemptively.

MATERIALS AND METHODS

Forty patients, planned elective mediastinoscopy, were included in this prospective randomized study. These patients were classified in two groups, group D for dexketoprofene trometamol and group L for lornoxicam, randomly. 20 minutes before the operation 50 mg dexketoprofene trometamol and 8 mg lornoxicam were injected intravenously for group D and group L respectively. In postoperative intensive care unit, pain scores, mean arterial pressures, heart rates and peripheric O2 saturations of patients were recorded at 0, 10, 20, 60, 90 and 120(th) minutes.

RESULTS

When we evaluate the VAS score of the groups, there was a significant decrease in group D in all measured timesstatistically compairing to group L (p<0.001). When both group were evaluated in itself according to 0 minute time, in group L there was a significant decrease at 10 minutes time (p<0.0001) but in group D there was not a significant decrease (p>0.05).

CONCLUSION

Since intravenous dexketoprofen, applied preemptively, has more potent analgesic effect and causing less opioid consumption in early postoperative period, is better than intravenous lornoxicam.

Preventive analgesia in hip or knee arthroplasty: a systematic review

OBJECTIVE

To analyze the efficacy and safety of preventive analgesia in patients undergoing hip or knee arthroplasty due to osteoarthritis.

METHODS

A systematic literature review was performed, using a defined a sensitive strategy on Medline, Embase and Cochrane Library up to May 2013. The inclusion criteria were: patients undergoing knee and/or hip arthroplasty, adults with moderate or severe pain (≥4 on a Visual Analog Scale). The intervention, the use (efficacy and safety) of pharmacological treatment (preventive) close to surgery was recorded. Oral, topical and skin patch drugs were included. Systematic reviews, meta-analysis, controlled trials and observational studies were selected.

RESULTS

A total of 36 articles, of moderate quality, were selected. The patients included were representative of those undergoing knee and/or hip arthroplasty in Spain. They had a mean age >50 years, higher number of women, and reporting moderate to severe pain (≥4 on a Visual Analog Scale). Possurgical pain was mainly evaluated with a Visual Analog Scale. A wide variation was found as regards the drugs used in the preventive protocols, including acetaminophen, classic NSAID, Cox-2, opioids, corticosteroids, antidepressants, analgesics for neuropathic pain, as well as others, such as magnesium, ketamine, nimodipine or clonidine. In general, all of them decreased post-surgical pain without severe adverse events.

CONCLUSIONS

The use or one or more pre-surgical analgesics decreases the use of post-surgical drugs, at least for short term pain.

Efficacy of tramadol as a preincisional infiltration anesthetic in children undergoing inguinal hernia repair: a prospective randomized study

Background

Preincisional local anesthetic infiltration at the surgical site is a therapeutic option for postoperative pain relief for pediatric inguinal hernia. Additionally, tramadol has been used as an analgesic for postoperative pain in children. Recently, the local anesthetic effects of tramadol have been reported. The aim of this study was to determine both the systemic analgesic and the local anesthetic effects of tramadol and to determine how it differs from bupivacaine when administered preincisionally.

Methods

Fifty-two healthy children, aged 2–7 years, who were scheduled for elective herniorrhaphy were randomly allocated to receive either preincisional infiltration at the surgical site with 2 mg/kg tramadol (Group T, n=26) or 0.25 mL/kg 0.5% bupivacaine (Group B, n=26). At the time of anesthetic administration, perioperative hemodynamic parameters were recorded. The pain assessments were performed 10 minutes after the end of anesthesia and during the first 6-hour period, using pain scores. The time of first dose of analgesia and need for additional analgesia were recorded.

Results

Between T and B groups, the anesthesia time, perioperative hemodynamic changes, and pain scores were not statistically different. However, in group B, the postoperative analgesic requirement was higher than in group T.

Conclusion

Tramadol shows equal analgesic effect to bupivacaine and decreases additional analgesic requirement, when used for preincisional infiltration anesthesia in children undergoing inguinal herniorrhaphy.

Pre-emptive tramadol could reduce pain after ureteroscopic lithotripsy

PURPOSE

Optimal analgesia in ambulatory urology patients still remains a challenge. The aim of this study was to examine if the pre-emptive use of intravenous tramadol can reduce pain after ureteroscopic lithotripsy in patients diagnosed with unilateral ureteral stones.

MATERIALS AND METHODS

This prospective pilot cohort study included 74 patients diagnosed with unilateral ureteral stones who underwent ureteroscopic lithotripsy under general anesthesia in the Urology Clinic at the Clinical Center of Serbia from March to June 2012. All patients were randomly allocated to two groups: one group (38 patients) received intravenous infusion of tramadol 100 mg in 500 mL 0.9%NaCl one hour before the procedure, while the other group (36 patients) received 500 mL 0.9%NaCl at the same time. Visual analogue scale (VAS) scores were recorded once prior to surgery and two times after the surgery (1 h and 6 h, respectively). The patients were prescribed additional postoperative analgesia (diclofenac 75 mg i.m.) when required. Pre-emptive effects of tramadol were assessed measuring pain scores, VAS1 and VAS2, intraoperative fentanyl consumption, and postoperative analgesic requirement.

RESULTS

The average VAS1 score in the tramadol group was significantly lower than that in the non-tramadol group. The difference in average VAS2 score values between the two groups was not statistically significant; however, there were more patients who experienced severe pain in the non-tramadol group (p<0.01). The number of patients that required postoperative analgesia was not statistically different between the groups.

CONCLUSION

Pre-emptive tramadol did reduce early postoperative pain. The patients who received pre-emptive tramadol were less likely to experience severe post-operative pain.

Preventive analgesia for postoperative pain control: a broader concept

Pain from surgical procedures occurs as a consequence of tissue trauma and may result in physical, cognitive, and emotional discomfort. Almost a century ago, researchers first described a possible relationship between intraoperative tissue damage and an intensification of acute pain and long-term postoperative pain, now referred to as central sensitization. Nociceptor activation is mediated by chemicals that are released in response to cellular or tissue damage. Pre-emptive analgesia is an important concept in understanding treatment strategies for postoperative analgesia. Pre-emptive analgesia focuses on postoperative pain control and the prevention of central sensitization and chronic neuropathic pain by providing analgesia administered preoperatively but not after surgical incision. Additional research in pre-emptive analgesia is warranted to better determine good outcome measurements and a better appreciation with regard to treatment optimization. Preventive analgesia reduces postoperative pain and consumption of analgesics, and this appears to be the most effective means of decreasing postoperative pain. Preventive analgesia, which includes multimodal preoperative and postoperative analgesic therapies, results in decreased postoperative pain and less postoperative consumption of analgesics.