Pain management after ambulatory surgery — Where is the disconnect?

Add dexmedetomidine to levobupivacaine for transversus abdominis plane block in elderly patients undergoing inguinal hernia repair: Could it make a difference? A randomised trial

BACKGROUND

Transversus abdominis plane block is becoming more common as part of multimodal analgesia for post-abdominal operation pain relief. This study compared the analgesic effects of adding dexmedetomidine to levobupivacaine (transversus abdominis plane) block in elderly patients undergoing inguinal hernia surgery to adding fentanyl.

METHODS

Overall, 90 elderly patients with a simple inguinal hernia repair were randomly assigned to one of three groups. After spinal anaesthesia, an ultrasound-guided transversus abdominis plane block was performed. Transversus abdominis plane block was accomplished with 0.25% levobupivacaine + 0.9% normal saline in Group L (n = 30) (20mL). Transversus abdominis plane block was accomplished with 0.25% levobupivacaine + 1 µg/kg dexmedetomidine in Group D (n = 30) (20mL). Transversus abdominis plane block was obtained with 0.25% levobupivacaine + 1 µg/kg fentanyl in Group F (n = 30) (20mL). The primary outcome was the first analgesic request, and the secondary outcomes were the visual analog scale, postoperative analgesic requirements, sedation, hemodynamic stability, and related complications 24 hours postoperatively. 1gm paracetamol intravenously was provided as rescue analgesia.

RESULTS

The time to first analgesic request in the dexmedetomidine group was substantially more prolonged than in the fentanyl and control groups (516.5±27.8, 451.2±11.1, and 403.9±10.5min, respectively; p < 0.05). Postoperative analgesic requirements were significantly decreased in dexmedetomidine 1(1-2) than control 2(1-3) and fentanyl 1.5(1-2) respectively (P<0.01). VAS was significantly lower in Group D and Group F than in Group L postoperatively. No significant difference in side effects was noted between the groups.

CONCLUSION

The transversus abdominis plane block is the best multimodal analgesia choice for inguinal hernia repair in older patients. Combining dexmedetomidine with levobupivacaine in the transversus abdominis plane block can improve the quality of postoperative analgesia while avoiding significant side effects.

Dexmedetomidine as an Adjuvant to Local Anesthetics in Transversus Abdominis Plane Block: A Systematic Review and Meta-analysis

OBJECTIVES

The objective of this meta-analysis was to evaluate the analgesic effects of dexmedetomidine (DEX) in transversus abdominis plane (TAP) blocks for abdominal surgery.

METHODS

Electronic databases, including PubMed, EMBASE, Chinese National Knowledge Infrastructure (CNKI), Wan Fang, and the Cochrane Library, were conducted to collect the randomized controlled trials (RCTs) from inception to March 2018. RCTs investigating the impact of adding DEX to local anesthetics for TAP blocks were included in this analysis. Pain scores (at rest and movement), opioid consumption, the duration of the TAP block and the common adverse effects were analyzed.

RESULTS

Twenty published trials including 1212 patients met the inclusion criteria. The addition of DEX significantly reduced pain scores 8 hours postoperatively at rest (WMD, -0.78; 95% CI, -1.27 to -0.30; P=0.001), 4 hours postoperatively on movement (WMD, -1.13; 95% CI, -1.65 to -0.60; P<0.001), and opioid consumption (WMD, -13.71; 95% CI, -17.83 to -9.60; P<0.001) when compared with control group. Furthermore, perineural DEX significantly prolonged the duration of the TAP block (WMD, 3.33; 95% CI, 2.85 to 3.82; P<0.001). It did not affect the incidence of postoperative nausea and vomiting, hypotension, bradycardia, somnolence, or pruritus.

CONCLUSIONS

DEX is a potential anesthetic adjuvant that can facilitate better postoperative analgesia, reduce postoperative analgesic requirements, and prolong the local anesthetic effect when administered in TAP blocks.

Pain relief after ambulatory surgery: Progress over the last decade

The concept of fast-track or ambulatory surgery appeared to facilitate early recovery and discharge from the hospital and early resumption of normal daily activities after elective surgical procedures as well to reduce the health-care costs. Multimodal/balanced analgesia is an increasingly popular approach for this. The use of conventional modalities including central neuraxial blockade and opioids cannot be extended to patients undergoing fast-track surgery. Hence, an aggressive perioperative analgesic regimen/protocol is required for effective pain relief, with minimal side effects and which could be managed easily by the patient or the relatives at home away from the hospital setting. Pharmacological therapy and regional anesthesia techniques have been utilized for postoperative pain management. The use of perineural, incisional, and intra-articular catheters and local anesthetic administration through elastomeric and electronic pumps is promising approach for effective pain management at home. The key to successful pain management of such procedures requires individually tailored education to patients or caregivers including information on treatment options for postoperative pain and use of multimodal analgesia. This review provides an overview of the current armamentarium of drugs and modalities available for effective management of patients undergoing day care surgeries and sheds light on newer modalities available.

Satisfactory Analgesia with Minimal Emesis in Day Surgeries (SAME DayS): a protocol for a randomised controlled trial of morphine versus hydromorphone

INTRODUCTION

There has been an exponential increase in the number of ambulatory surgeries (AS). Pain and postoperative nausea vomiting (PONV) affects the recovery, discharge and overall satisfaction of patients having AS. Opioids remain the primary modality for moderate to severe pain. Since there is no perfect opioid, physicians should ideally use the opioid that optimally balances benefits and risks. Present decisions on the choice between morphine (M) and hydromorphone (HM) are based on individual experience and observation. Our primary objective is to compare the proportion of patients having AS achieving satisfactory analgesia without significant PONV when using M compared with HM. Secondarily we will compare the proportion of patients with adverse events, analgesic used, patient satisfaction, time to discharge and postdischarge symptoms.

METHODS AND ANALYSIS

This is a two-arm, multicentre, parallel group, randomised controlled trial of 400 patients having AS. Eligible patients undergoing AS of the abdominal and pelvic regions with a potential to cause moderate to severe pain will be recruited in the preoperative clinic. Using a computer-generated randomization, with a 1:1 allocation ratio, patients will be randomised to M or HM. Patients, healthcare providers and research personnel will be blinded. Study interventions will be administered in the recovery using equianalgesic doses of M or HM in concealed syringes. Patients will be followed in hospital and up to 3 months. Intention-to-treat approach will be used for analysis.

ETHICS AND DISSEMINATION

This study has been approved by the Hamilton integrated research ethics board. We plan to publish our trial findings and present our findings at scientific meetings.

TRAIL REGISTRATION NUMBER

NCT02223377; Pre-results.

A Comparative Study of Oral Analgesics for Postoperative Pain After Minor Oral Surgery

We compared the effects of preoperative administration of diclofenac sodium, celecoxib, and acetaminophen on postoperative pain in patients undergoing minor oral surgery under general anesthesia. One hundred twenty-eight patients were randomly divided into 4 groups preoperatively treated with diclofenac sodium 50 mg, celecoxib 400 mg, acetaminophen 1000 mg, or placebo. Postoperative pain was managed using intravenous patient-controlled infusion of fentanyl. Assessments included levels of postoperative pain by using visual analog scale (VAS) scores at 4, 5, and 6 hours after administration of the test drug; consumption of fentanyl up to each time point; and time to first requirement for fentanyl. Our study demonstrated that, for diclofenac sodium and celecoxib in comparison with placebo, there were significantly lower VAS scores at 4, 5, and 6 hours after oral administration of the study drug; a longer period of time to first requirement for fentanyl after surgery; and less consumption of postoperative fentanyl. A similar analgesic effect versus placebo was noted for acetaminophen but only at the 5- and 6-hour time points. In contrast, no significant differences in VAS scores at 4 hours after administration or time to first requirement for fentanyl were observed between acetaminophen and placebo. Furthermore, no significant differences in measurements were observed between the study drugs at any time point. These findings suggest that oral administration of celecoxib 400 mg is suitable for controlling postoperative pain, and as effective as diclofenac sodium 50 mg. Acetaminophen 1000 mg also exerts analgesic effect with slower onset for postoperative pain.

Postoperative pain management practices and their effectiveness after major gynecological surgery: An observational study in a tertiary care hospital

Background and Aims:

Despite advances in postoperative pain management, patients continue to experience moderate to severe pain. This study was designed to assess the strategy, effectiveness, and safety of postoperative pain management in patients undergoing major gynecological surgery.

Material and Methods:

This observational study included postoperative patients having major gynecological surgery from February 2016 to July 2016. Data collected on a predesigned data collection sheet included patient's demographics, postoperative analgesia modality, patient satisfaction, acute pain service assessment of numeric rating scale (NRS), number of breakthrough pains, number of rescue boluses, time required for the pain relief after rescue analgesia, and any complication for 48 h.

Results:

Among 154 patients reviewed, postoperative analgesia was provided with patient-controlled intravenous analgesia in 91 (59.1%) patients, intravenous opioid infusion in 42 (27%), and epidural analgesia in 21 (13.6%) patients with no statistically significant difference in NRS between different analgesic modalities. On analysis of breakthrough pain, 103 (66.8%) patients experienced moderate pain at one time and 53 (51.4%) at two or more times postoperatively. There were 2 (0.6%) patients experiencing severe breakthrough pain due to gaps in service provision and inadequate patient's knowledge. Moderate-to-severe pain perception was irrespective of type of incision and surgery. Vomiting was significantly higher (P = 0.049) in patients receiving opioids.

Conclusion:

Adequacy of postoperative pain is not solely dependent on drugs and techniques but on the overall organization of pain services. However, incidence of nausea and vomiting was significantly higher in patients receiving opioids.

Perioperative Care of Elderly Surgical Outpatients

The ambulatory setting offers potential advantages for elderly patients undergoing elective surgery due to the advancement in both surgical and anesthetic techniques resulting in quicker recovery times, fewer complications, higher patient satisfaction, and reduced costs of care. This review article aims to provide a practical guide to anesthetic management of elderly outpatients. Important considerations in the preoperative evaluation of elderly outpatients with co-existing diseases, as well as the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and recommendations regarding the management of common postoperative complications (e.g., pain, postoperative nausea and vomiting [PONV], delirium and cognitive dysfunction, and gastrointestinal dysfunction) are discussed. The role of anesthesiologists as perioperative physicians is important for optimizing surgical outcomes for elderly patients undergoing ambulatory surgery. The implementation of high-quality, evidence-based perioperative care programs for the elderly on an ambulatory basis has assumed increased importance. Optimal management of perioperative pain using opioid-sparing multimodal analgesic techniques and preventing PONV using prophylactic antiemetics are key elements for achieving enhanced recovery after surgery.

An update on pain management for elderly patients undergoing ambulatory surgery

PURPOSE OF REVIEW

The aim of this review is to provide an overview of the drugs and techniques used for multimodal postoperative pain management in the older population undergoing surgery in the ambulatory setting.

RECENT FINDINGS

Interest has grown in the possibility of adding adjuncts to a single shot nerve block in order to prolong the local anesthetic effect. The rapid and short-acting local anesthetics for spinal anesthesia are potentially beneficial for day-case surgery in the older population because of shorter duration of the motor block, faster recovery, and less transient neurologic symptoms. Another recent advance is the introduction of intravenous acetaminophen, which can rapidly achieve rapid peak plasma concentration (<15 min) following infusion and analgesic effect in ∼5 min with a duration of action up to 4 h.

SUMMARY

The nonopioid analgesic therapies will likely assume an increasingly important role in facilitating the recovery process and improving the satisfaction for elderly ambulatory surgery patients. Strategies to avoid the use of opioids and minimize opioid-related side-effects is an important advance as we expand on the use of ambulatory surgery for the aging population.

Intravenous lidocaine for postmastectomy pain treatment: randomized, blind, placebo controlled clinical trial

BACKGROUND AND OBJECTIVE

Postoperative pain treatment in mastectomy remains a major challenge despite the multimodal approach. The aim of this study was to investigate the analgesic effect of intravenous lidocaine in patients undergoing mastectomy, as well as the postoperative consumption of opioids.

METHODS

After approval by the Human Research Ethics Committee of the Instituto de Medicina Integral Prof. Fernando Figueira in Recife, Pernambuco, a randomized, blind, controlled trial was conducted with intravenous lidocaine at a dose of 3mg/kg infused over 1h in 45 women undergoing mastectomy under general anesthesia. One patient from placebo group was.

RESULTS

Groups were similar in age, body mass index, type of surgery, and postoperative need for opioids. Two of 22 patients in lidocaine group and three of 22 patients in placebo group requested opioid (p=0.50). Pain on awakening was identified in 4/22 of lidocaine group and 5/22 of placebo group (p=0.50); in the post-anesthetic recovery room in 14/22 and 12/22 (p=0.37) of lidocaine and placebo groups, respectively. Pain evaluation 24h after surgery showed that 2/22 and 3/22 patients (p=0.50) of lidocaine and placebo groups, respectively, complained of pain.

CONCLUSION

Intravenous lidocaine at a dose of 3mg/kg administered over a period of an hour during mastectomy did not promote additional analgesia compared to placebo in the first 24h, and has not decreased opioid consumption. However, a beneficial effect of intravenous lidocaine in selected and/or other therapeutic regimens patients cannot be ruled out.

Lidocaine patch for acute pain management: a meta-analysis of prospective controlled trials

BACKGROUND

Local anesthetic is one of the cornerstones of multimodal analgesia. We investigated the efficacy of the lidocaine patch for acute pain management.

METHODS

We searched MEDLINE, CINAHL, Scopus, and the Cochrane Controlled Trials Register for published prospective controlled clinical trials that evaluated the analgesic effect of the lidocaine patch for acute or postoperative pain management (1966--2014). The outcomes were postoperative opioid consumption, pain intensity and length of hospital stay.

RESULTS

Five trials comparing the lidocaine patch with control (no treatment/placebo) for acute or postoperative pain treatment/management were included in this meta-analysis. Data was analyzed on 251 patients. Between the lidocaine patch group and the control group, no significant difference was found for all three outcomes (all p > 0.05). For postoperative opioid consumption, mean difference (MD) was -8.2 mg morphine equivalent (95% CI -28.68, 12.24). For postoperative pain intensity, MD was -9.1 mm visual analog scale or equivalent (95% CI -23.31, 5.20). For length of hospital stay, MD was -0.2 days (95% CI -0.80, 0.43).

CONCLUSION

Application of a lidocaine patch may not be an effective adjunct for acute and postoperative pain management, in terms of pain intensity, opioid consumption and length of hospital stay.

LIMITATIONS

The limitations were a small number of included studies, potential biases from some unblinded studies, clinical heterogeneity between studies, and incomplete reported data for adjunct analgesics.

No evidence of real progress in treatment of acute pain, 1993-2012: scientometric analysis

Over the past 2 decades, many new techniques and drugs for the treatment of acute pain have achieved widespread use. The main aim of this study was to assess the progress in their implementation using scientometric analysis. The following scientometric indices were used: 1) popularity index, representing the share of articles on a specific technique (or a drug) relative to all articles in the field of acute pain; 2) index of change, representing the degree of growth in publications on a topic compared to the previous period; and 3) index of expectations, representing the ratio of the number of articles on a topic in the top 20 journals relative to the number of articles in all (>5,000) biomedical journals covered by PubMed. Publications on specific topics (ten techniques and 21 drugs) were assessed during four time periods (1993–1997, 1998–2002, 2003–2007, and 2008–2012). In addition, to determine whether the status of routine acute pain management has improved over the past 20 years, we analyzed surveys designed to be representative of the national population that reflected direct responses of patients reporting pain scores. By the 2008–2012 period, popularity index had reached a substantial level (≥5%) only with techniques or drugs that were introduced 30–50 years ago or more (epidural analgesia, patient-controlled analgesia, nerve blocks, epidural analgesia for labor or delivery, bupivacaine, and acetaminophen). In 2008–2012, promising (although modest) changes of index of change and index of expectations were found only with dexamethasone. Six national surveys conducted for the past 20 years demonstrated an unacceptably high percentage of patients experiencing moderate or severe pain with not even a trend toward outcome improvement. Thus, techniques or drugs that were introduced and achieved widespread use for acute pain management within the past 20 years have produced no changes in scientometric indices that would indicate real progress and have failed to improve national outcomes for relief of acute pain. Two possible reasons for this are discussed: 1) the difference between the effectiveness of old and new techniques is not clinically meaningful; and 2) resources necessary for appropriate use of new techniques in routine pain management are not adequate.

Post-operative analgesia for major abdominal surgery and its effectiveness in a tertiary care hospital

Background:

Post-operative pain is often inadequately treated. Optimal utilization of the available resources is essential for improving pain management.

Aims:

The aim of our study was to determine pain management strategies employed after major abdominal surgeries at our institute and their efficacy and safety.

Settings and Design:

Prospective observational study conducted at a tertiary care hospital.

Materials and Methods:

Patients undergoing elective major abdominal surgeries were included. Post-operative analgesic strategy, co-analgesics used, pain and sedation scores, motor block, nausea and vomiting were recorded and patient satisfaction was determined.

Results:

Data was collected on 100 patients. Epidural analgesia was used in 61, patient controlled intravenous analgesia (PCIA) in 25 and opioid infusion in 14 patients. Multimodal analgesia was employed in 98 patients. The level of epidural was between L1-L3 in 31, T10-L1 in 20 and T8-T10 in 10 patients. Pethidine was used in 80% of patients receiving PCIA. Patients with epidurals at T8-T10 had lower pain scores. Fifteen patients had motor block, 73% of which were with epidural at L1-L3. Fourteen patients complained of nausea. Ninety nine out of 100 patients were satisfied with their analgesia.

Conclusion:

Epidural, PCIA and opioid infusions are used for pain relief after major abdominal surgeries at our hospital. Although there is limited drug availability, regular assessments and appropriate dose adjustments by acute pain management service (APMS) and use of multimodal analgesia led to a high level of patient satisfaction. We recommend that feedback to the primary anesthesiologists by APMS is of utmost importance to enable improvement in practice.

The effect of preoperative intravenous dexketoprofen trometamol on postoperative pain in minor outpatient urologic surgery

OBJECTIVE

The aim of this prospective double-blind randomized study was to compare the effectiveness of preoperative dexketoprofen trometamol for acute postoperative pain in patients undergoing minor outpatient urologic surgery.

MATERIAL AND METHODS

Sixty male patients (ASA I and II) undergoing varicocelectomy and testicular sperm extraction (TESE) with standard laryngeal mask airway (LMA) anesthesia were randomly divided into two groups. Patients in Group I (n=30) received 50 mg of dexketoprofen trometamol iv before induction, whereas patients in Group II (n=30) received saline. All patients received standard LMA anesthesia (propofol, sevoflurane and N2O/O2). Analgesic efficacy was evaluated by self-assessment of pain intensity (VAS) at regular intervals. Vital signs, side effects and time to reach a postanesthesia discharge score (PADS) of ≥9 were also recorded. Paracetamol 1 gr iv and tramadol 100 mg iv were used for rescue analgesia.

RESULTS

Demographic data and duration of surgery were similar in both groups. There was no significant difference between groups with respect to postoperative pain scores and side effects. Although more patients in Group II (60%) required rescue analgesia compared to Group I (33.3%), the difference did not reach statistical significance.

CONCLUSION

Preoperative IV use of dexketoprofen trometamol iv did not decrease the need for rescue analgesia in patients undergoing minor outpatient urological surgery.

Perioperative celecoxib decreases opioid use in patients undergoing testicular surgery: a randomized, double-blind, placebo controlled trial

PURPOSE

We evaluated the effect of daily perioperative celecoxib on patient reported pain control and opioid use after testicular surgery.

MATERIALS AND METHODS

Men scheduled to undergo elective outpatient microsurgical testicular sperm extraction were prospectively randomized to receive 200 mg celecoxib or placebo twice daily, which was initiated the night before surgery and continued for 6 days thereafter. Using an 11-point visual analog scale, participants self-reported the postoperative pain level and acetaminophen/hydrocodone use for supplemental pain control. We compared differences in pain scores and opioid use between the 2 patient groups using the Student t test with p<0.05 considered significant.

RESULTS

At 1-year interim analysis 35 of 78 eligible participants (45%) had returned the study questionnaire, of whom 34 were included in the final analysis. Of the 34 patients the 16 who received celecoxib had significantly lower postoperative opioid use than those on placebo (6 vs 16 pills, p=0.02). We noted a statistically significant difference in postoperative day 1 and 2 patient reported pain scores (4 vs 6, p<0.05 and 3 vs 5, p=0.03) and opioid use (1 vs 5 pills, p<0.01 and 2 vs 4, p=0.02) seen between the celecoxib and placebo groups, respectively. No study complications were identified. The trial was terminated early based on the results of interim analysis.

CONCLUSIONS

Twice daily celecoxib use started preoperatively significantly decreased patient reported postoperative pain and opioid use, especially in the early postoperative period. A short course of celecoxib is well tolerated and may be effective as part of multimodal postoperative analgesia in patients who undergo testicular surgery for sperm retrieval.

Prediction of post-operative pain following arthroscopic subacromial decompression surgery: an observational study

Background: Arthroscopic shoulder surgery is increasingly performed as a day case procedure. Optimal post-operative pain relief remains a challenge due to considerable variations in the level of pain experienced between individuals. Our aim was to examine whether the preoperative electrical pain threshold was a strong predictor of elevated postoperative pain levels following arthroscopic subacromial decompression (ASD) surgery. Methods: Forty consenting patients with American Society of Anesthesiologists (ASA) grade 1-2 presenting for elective ASD surgery were recruited. Patients’ electrical pain thresholds were measured preoperatively using a PainMatcher® (Cefar Medical AB, Lund, Sweden) device. Following surgery under general anaesthesia, the maximum pain experienced at rest and movement was recorded using a visual analogue scale until the end of postoperative day four. Results: In univariate analyses (t-test), the postoperative pain experienced (Area Under Curve) was significantly greater in patients with a low pain threshold as compared with a high pain threshold at both rest (mean 12.5, S.E. 1.7 v mean 6.5, S.E.1.2. P=0.008) and on movement (mean 18.7, S.E. 1.5 v mean 14.1, S.E.1.4. P=0.031). In multivariate analyses, adjusting for additional extra analgesia, the pain experienced postoperatively was significantly greater in the low pain threshold group both at rest (mean difference 4.9, 95% CI 1.5 to 8.4, P=0.007) and on movement (mean difference 4.1, 95%CI 0.03 to 8.2, P=0.049). Conclusions: Preoperative pain threshold can predict postoperative pain level following ASD of the shoulder. Trial registration: Clinicaltrials.gov identifier: NCT01351363 Level of Evidence: II

Pattern of postoperative pain management among adult surgical patients in a low-resource setting

Objective

Postoperative pain is one of the most common complications of surgery. The pattern of management varies between centers. The current study aimed to study the prescription pattern and the common drugs used in the management of postoperative pain in adult surgical patients at Ahmadu Bello University Teaching Hospital (ABUTH; Zaria, Nigeria).

Methods

Following ethical approval, a prospective observational study of consecutive adult patients who had surgery at the ABUTH Zaria was performed from January to December 2005. The data were entered into a proforma and analyzed using the Minitab statistical package.

Results

One hundred and thirty-eight patients were included in the study. The age range was 17 to 80 years, with a mean age of 41 years. One hundred and thirty-two (95.7%) of the prescriptions were written solely by the surgeon or surgical resident; passive suggestions were given by the anesthetists for only six patients (4.3%). Intermittent intramuscular injections of opioids/opiates were prescribed for 126 patients (91.3%), while nine patients (6.5%) received intermittent intramuscular injections with non-steroidal anti-inflammatory drugs. Oral paracetamol was prescribed for six patients (4.3%), while three patients (2.1%) received no postoperative analgesic. Moderate pain was recorded in 48 patients (34.8%), and 90 patients (65.2%) had mild pain 8 hours after their operation before subsequent doses of analgesics were given. More females (81 patients [58.7%]), than males (42 patients [29.7%]) suffered moderate to severe pain. The reported side effects were nausea (reported by 32.6% of patients), dry mouth (21.7%), vomiting (13.0%), and urinary retention (6.5%), with 32.6% of patients experiencing no side effects. The three patients who received no analgesics experienced vomiting as a side effect. Despite the high incidence of pain and other side effects, 108 patients (78.2%) still reported that the methods of postoperative pain management were satisfactory.

Conclusion

Despite recent advances and the development of more effective techniques for postoperative pain control, a high proportion of patients still experience moderate to severe postoperative pain. Intermittent intramuscular injection of analgesic medication remains the mainstay of postoperative pain management at the ABUTH Zaria. Anesthetists should be more involved in postoperative analgesia prescriptions and should include other forms of multimodal pain management in their regimens. With proper application of current knowledge and training, postoperative pain management can be improved.

Control of postoperative pain with a wearable continuously operating pulsed radiofrequency energy device: a preliminary study

BACKGROUND

Pulsed radiofrequency energy (PRFE) has long been reported to have a therapeutic effect on postoperative pain. In this study, a portable, wearable, low-energy-emitting PRFE therapy device was used to determine the control of postoperative pain after breast augmentation surgery.

METHODS

The study enrolled 18 healthy women who underwent breast augmentation purely for aesthetic considerations. Postoperative pain after surgery was assessed with a 0- to 10-point visual analog scale (VAS). Baseline pain scores were taken at completion of the operation, and the patients were randomly assigned coded PRFE devices that were either active or placebo devices. For 7 days, VAS scores were recorded twice daily (a.m. and p.m.). Medication use also was logged for 7 days. The PRFE devices were left in place and in continuous operation for the 7 days of the study.

RESULTS

All the patients tolerated the PRFE therapy well, and no side effects were reported. The VAS scores for the active group were significantly lower on postoperative day 1. By day 7, the baseline VAS remaining in the active group was 7.9% versus 38% in the placebo group. Together with lower VAS scores, narcotic pain medication use was lower in the patient group that received PRFE therapy.

CONCLUSION

Postoperative pain is significantly lower with PRFE therapy. According to the findings, PRFE therapy in this form is an excellent, safe, drug-free method of postoperative pain control.

The role of multimodal analgesia in pain management after ambulatory surgery

PURPOSE OF REVIEW

As outpatient (day-case) surgery had continued to grow throughout the world, many more complex and potentially painful procedures are being routinely performed in the ambulatory setting. Opioid analgesics, once considered the standard approach to preventing acute postoperative pain, are being replaced by a combination of nonopioid analgesic drugs with diverse modes of action as part of a multimodal approach to preventing pain after ambulatory surgery. This review will provide an update on the topic of multimodal pain management for ambulatory (day-case) surgery.

RECENT FINDINGS

Efficacy of multimodal analgesic regimens continues to improve; opioid analgesics are increasingly taking on the role of 'rescue analgesics' for acute pain after day-case surgery. The use of multimodal analgesia is rapidly becoming the 'standard of care' for preventing pain after ambulatory procedures at most surgery centers throughout the world.

SUMMARY

This article discusses recent evidence from the peer-reviewed literature regarding the role of local anesthetics, NSAIDs, gabapentinoids, and acetaminophen, as well as alpha-2 agonists, ketamine, esmolol, and nonpharmacologic approaches (e.g., transcutaneous electrical stimulation) as parts of multimodal pain management strategies in day-case surgery.