Preoperative administration of controlled-release oxycodone as a transition opioid for total intravenous anaesthesia in pain control after laparoscopic cholecystectomy

Midazolam versus dexamethasone-ondansetron in preventing post-operative nausea-vomiting in patients undergoing laparoscopic surgeries

BACKGROUND

Midazolam reduces post-operative nausea and vomiting (PONV) when compared to a placebo or when used as an adjuvant to other antiemetics. The present study was designed to compare midazolam with a combination of dexamethasone-ondansetron in preventing PONV.

METHODS

One hundred and twenty patients undergoing laparoscopic surgeries having 2 or more risk factors for PONV (simplified Apfel score) were randomised into 2 groups of 60 each. Patients in group D received 8-mg dexamethasone and 4-mg ondansetron for PONV prophylaxis while those in group M received 2-mg midazolam towards the end of surgery. The proportion of patients (frequency) who had PONV, post-operative nausea (PON) and post-operative vomiting (POV) was noted over 24 hours over the following intervals: 0-2 hours, 2-24 hours and 0-24 hours.

RESULTS

The frequency of PONV at 24 hours in group D and group M was 30% and 33.3% respectively and was not significantly different (P = .70). There was no difference in the time to achieve post-anaesthesia discharge score of ≥9 between the two groups {5 minutes (5, 5) in group D; 5 minutes (1.25, 5) in group M, P = .48}. Ten patients in group D and 11 in group M required a rescue antiemetic over 24 hours (P = .81). The frequency of PON, POV and PONV as well as the median PONV score was similar at all time periods.

CONCLUSION

Midazolam does not result in significantly different frequency of PONV than a combination of dexamethasone-ondansetron.

Effective dose of intravenous oxycodone depending on sex and age for attenuation of intubation-related hemodynamic responses

Background/aim

Preoperative intravenous oxycodone may help to prevent or attenuate intubation-related hemodynamic responses (IRHRs), but its pharmacokinetics differs according to age and sex. Therefore, we investigated the 95% effective dose (ED₉₅) of intravenous oxycodone for attenuating all IRHRs, depending on the age and sex of the study population.

Materials and methods

All patients were allocated to one of 6 groups: 1) 20–40 year old males, 2) 41–65yearold males, 3) 66–80 year old males, 4) 20–40 year old females, 5) 41–65yearold females, and 6) 66–80 year old females (groups YM, OM, EM, YF, OF, and EF, respectively). Using Dixon’s up-and-down method, the first patient in each group was slowly injected with intravenous oxycodone (0.1 mg kg^-1) 20 min before intubation. The subsequent patient received the next oxycodone dose, which was decreased or increased by 0.01 mg kg^-1, depending on the “success” or “failure” of attenuation of all IRHRs to within 20% of the baseline values at 1 min after intubation in the previous patient. After obtaining 8 crossover points, predictive ED₉₅ was estimated with probit regression analysis.

Results

ED₉₅ varied greatly according to age and sex. ED₉₅was 0.133 mg kg^-1, 0.181 mg kg^-1, 0.332 mg kg^-1, 0.183 mg kg^-1, 0.108 mg kg^-1, and 0.147 mg kg^-1in groups YM, OM, EM, YF, OF, and EF, respectively.

Conclusion

ED₉₅ is higher in males with increasing age but is ambiguous for females. ED₉₅ is higher in males than in females over 40 years of age but is higher in females than in males under 41 years of age. However, after considering the age and sex of the study population, these results can be used as reference doses for further studies to verify the clinical effects of oxycodone for attenuating all IRHRs.

Preemptive oxycodone is superior to equal dose of sufentanil to reduce visceral pain and inflammatory markers after surgery: a randomized controlled trail

Background

Postoperative visceral pain is common after surgery and previous studies have demonstrated that oxycodone is an effective treatment. In this study, we compared the effects of preemptive oxycodone to equal dose of sufentanil on postoperative pain and serum level of inflammatory factors (TNF-α, IL-6, IL-10) after laparoscopic cholecystectomy.

Methods

Forty patients undergoing laparoscopic cholecystectomy were randomized into preemptive oxycodone group or preemptive sufentanil group.

Patients were given either oxycodone 0.1 mg/kg (oxycodone group, n = 20) or sufentanil 0.1 μg/kg (sufentanil group, n = 20) for preemptive analgesia. We evaluated pain/sedation scores at 0 h, 0.5 h, 2 h, 4 h, 6 h, 8 h and 24 h after surgery and measured serum concentrations of TNF-α, IL-6 and IL-10 before surgery and at 0 h, 6 h and 24 h after surgery.

Results

Twenty patients were recruited in each group. Numerical rating scale (NRS) of visceral pain in the oxycodone group at 2 h when resting (0.5(0,2.75) vs 3(2,4), P = 0.008) and moving (0.5(0,3) vs 3(2.25,4), P = 0.015) and 4 h when moving (2(0,3) vs 3(0,4.75), P = 0.043) after surgery were significantly lower than the sufentanil group. Serum concentrations of TNF-α at 6 h (38.68 ± 10.49 vs 73.02 ± 16.27, P<0.001) and 24 h (43.12 ± 8.40 vs 74.00 ± 21.30, P<0.001) in the oxycodone group were lower than the sufentanil group.

Conclusions

Preemptive oxycodone 0.1 mg/kg administration could effectively suppress visceral pain at 2 h and 4 h after surgery and had lower inflammatory marker, serum TNF-α, level when compared to equal dose of sufentanil.

Trial registration

Clinical trials registration number: ChiCTR-IOR-17013738http://www.chictr.org.cn/showproj.aspx?proj=17346. Date of registration: 6th December 2017.

Effect of intravenous ketamine for postoperative analgesia in patients undergoing laparoscopic cholecystectomy: A meta-analysis

BACKGROUND

We conducted a meta-analysis to assess the efficacy and safety of ketamine for reducing pain and narcotic use for patients undergoing laparoscopic cholecystectomy (LC).

METHODS

PubMed, Embase, Web of science, Medline, and Cochrane library databases were systematically searched. Randomized controlled trials (RCTs) were regarded as eligible in our study. After testing the heterogeneity across RCTs, data were aggregated for fixed/random effect model according to the I statistic. The meta-analysis was conducted using Stata 11.0 software.

RESULTS

Five studies were included, with a total sample size of 212 patients. Current meta-analysis revealed that there were significant differences regarding postoperative pain score at 12 hours [standard mean difference (SMD) = -0.322, 95% confidence interval (95% CI): -0.594 to -0.050, P = .020], 24 hours (SMD = -0.332, 95% CI: -0.605 to -0.059, P = .017), and 48 hours (SMD = -0.340, 95% CI: -0.612 to -0.068, P = .014). Ketamine intervention was found to significantly decrease narcotic use at 12 hours (SMD = -0.296, 95% CI: -0.567 to -0.025, P = .033), 24 hours (SMD = -0.310, 95% CI: -0.581 to -0.039, P = .025), and 48 hours (SMD = -0.338, 95% CI: -0.609 to -0.066, P = .015).

CONCLUSION

Ketamine appeared to significantly reduce postoperative pain and narcotic use following LC. On the basis of the current evidence available, higher quality RCTs are still required for further research.

Effect of Multimodal Analgesia on Opioid Use After Open Ventral Hernia Repair

BACKGROUND

There is limited data on enhanced recovery after surgery (ERAS) protocols after ventral hernia repair (VHR). This study reports the impact of multimodal analgesia on opioid use after open VHR.

METHODS

Retrospective review of open VHR treated during the initial 6 months after ERAS implementation. Protocol focused on opioid sparing using intraoperative ketamine and/or lidocaine infusion, selective epidural anesthesia, and postoperative ketamine infusion, ketorolac, and acetaminophen. Four groups were analyzed: 1-ERAS protocol with epidural analgesia, 2-historical controls with epidural analgesia prior to ERAS, 3-ERAS protocol without epidural, and 4-historical controls without epidural analgesia, prior to ERAS. Continuous variables were analyzed using ANOVA or Kruskal-Wallis tests, and subgroup analysis using Student's t test or Mann-Whitney U test. Discrete variables were analyzed using Pearson's chi-square test or Fisher's exact test.

RESULTS

Patients differed in hernia width, but were similar in comorbidity and operative technique. There was no difference in length of stay or readmission. Use of ERAS nearly eliminated patient-controlled analgesia use (group 1, 2.7%; group 2, 68.4%; group 3, 0%; group 4, 65.7%; p < 0.001). ERAS significantly reduced narcotic requirements on postoperative days 0, 1, and 2 (p < 0.001). To account for the bias of selective epidural analgesia, groups 1 and 2 (epidural) and groups 3 and 4 (no epidural) were compared separately. Opioid requirement and PCA use remained significantly lower in patients in the ERAS pathway.

CONCLUSION

Implementation of multimodal analgesia in the perioperative and postoperative setting significantly reduced opioid use after VHR.

Effect of Preoperative Intravenous Oxycodone After Transurethral Resection of Prostate Under General Anesthesia

The objective of this study was to investigate the effect of intravenous oxycodone administered before transurethral resection of prostate (TURP) on postoperative pain and tramadol consumption. Preemptive analgesia can decrease postoperative pain and analgesic consumption. Sixty patients undergoing elective TURP were divided into 2 groups: group O (n = 30) received intravenous oxycodone (0.1 mg/kg) 10 minutes before surgery over 2 minutes and group C (n = 30) received normal saline as a placebo. A standardized general anesthesia method was performed with a laryngeal mask airway device. Data with respect to pain intensity, incidence of lower urinary tract discomfort, time to the first tramadol requirement, tramadol consumption, overall patient satisfaction, and adverse effects were collected. Preoperative oxycodone contributed to better analgesia at 1, 2, 6, and 12 hours after shifting the patients to the recovery room, a longer time interval to the first tramadol request, fewer patients requiring tramadol analgesia, and reduced tramadol consumption. Adverse effects were comparable between the 2 groups. Preoperative intravenous oxycodone (0.1 mg/kg) 10 minutes before TURP improves postoperative analgesia, prolongs time to the first tramadol request, and reduces tramadol consumption without an influence on lower urinary tract discomfort and adverse effects.

Effect of preemptive intravenous oxycodone on low-dose bupivacaine spinal anesthesia with intrathecal sufentanil

Objectives:

To evaluate the efficacy of preemptive intravenous oxycodone on low-dose bupivacaine spinal anesthesia with intrathecal sufentanil in patients undergoing transurethral resection of the prostate (TURP).

Methods:

In this randomized, double-blinded, placebo-controlled trial, 60 patients undergoing TURP were allocated into 2 groups: oxycodone group (group O, n=30) and a normal saline group (group N, n=30). Oxycodone 0.1 mg/kg, or normal saline 0.1 ml/kg was administered intravenously 10 minutes before surgical procedures in group O, or in group N. All patients received sufentanil 5 µg + bupivacaine 0.5% (0.8 ml) + normal saline 0.7 ml - in total, bupivacaine 0.25% (1.6 ml) intrathecally. Spinal block characteristics, hemodynamic values, the perioperative analgesic requirements, visual analogue scale (VAS) scores, Ramsay sedation scale, and side effects were assessed. The study was carried out at the First Hospital of Jilin University, Jilin, China between March and September 2014.

Results:

The time to 2-segment regression of sensory block, full recovery of sensory block, and first analgesic request was longer in group O. Fewer patients required postoperative analgesics, and the VAS pain scores at 4, 8, 16, and 24 hour after operation were significantly lower in group O.

Conclusion:

Preemptive intravenous oxycodone was an efficient and safe method to decrease postoperative pain and reduce tramadol analgesia in patients under low-dose dilute bupivacaine spinal anesthesia combined with intrathecal sufentanil.

Perioperative blood loss and gastrointestinal tolerability of etoricoxib and diclofenac in total hip arthroplasty (ETO-DIC study): a single-center, prospective double-blinded randomized controlled trial

OBJECTIVE

Non-selective NSAIDs can cause serious gastrointestinal side-effects. Selective COX-2 blockers are a reasonable alternative for pain treatment. They do not seem to affect platelet function and consequently cause a lower perioperative blood loss than non-selective NSAIDs. This study compared etoricoxib and diclofenac during a perioperative (9 days) period after THA to investigate total blood loss and gastrointestinal tolerability. The hypothesis was that etoricoxib is superior to diclofenac.

METHODS

A total of 100 patients (50 in each group) were included in this trial. Etoricoxib (90 mg) was administered once and diclofenac sodium (75 mg) twice daily for 9 days. Total blood loss during and after primary cementless THA was detected. The rate of adverse events (AEs) and serious adverse events (SAEs) was analyzed to detect gastrointestinal tolerability.

RESULTS

The mean total blood loss (calculated) was 1548 ± SD 468 ml in the etoricoxib (ETO) group and 1649 (SD 547) ml in the diclofenac (DIC) group. The mean duration of THA was 81 min (SD 29) in the DIC and 75 min (SD 30) in the ETO group. Hence, the mean calculated total blood loss was 101 ml higher in the DIC group. This difference was not statistically significant (p = 0.334). Fifty-six patients (28 in each group) received a cell saver retransfusion, but only one patient (ETO group) needed an additional red blood cell transfusion. The hidden blood loss was 1067 ml (SD 603) in the DIC group and 999 ml (SD 378) in the ETO group. The gastrointestinal tolerability (number of adverse and serious adverse events) was not significantly different between groups.

CONCLUSION

There was no statistically significant difference in perioperative blood loss after primary THA under etoricoxib (90 mg) compared to diclofenac (75 mg). Furthermore, no gastrointestinal superiority of etoricoxib could be detected during a short period of 9 days.

Effect of preemptive analgesia with intravenous oxycodone in the patients undergoing laparoscopic resection of ovarian tumor

Objective:

To evaluate the efficacy of preemptive intravenous oxycodone in the patients undergoing laparoscopic resection of ovarian tumor.

Methods:

Sixty ASA I or II patients undergoing elective laparoscopic resection of ovarian tumor were randomly allocated to one of two groups: Group O (n=30) received intravenous oxycodone (0.1 mg·kg^-1) 10 minutes before surgery over 2 minutes, and Group N (n=30) received an equivalent volume of normal saline. All patients received a standardized general anesthesia. MBP and HR at the time of arrival of the operating room (T1), 5 min before pneumoperitoneum (T2), 5 minutes (T3), 10 minutes (T4), and 15 minutes after pneumoperitoneum (T5), and VAS scores at postoperative 2, 4, 8, 12 and 24 hour were recorded. The tramadol consumption and side effects in 24 h after surgery were recorded.

Results:

VAS pain scores at 2, 4, 8 and 12 hour after operation were significantly lower in Group O (P<0.05). MBP and HR increased significantly due to pneumoperitoneum at T3, T4 and T5, compared with T1 and T2 within Group N, and were higher at T3, T4 and T5 in Group N than at the same time points in Group O. Tramadol consumption was statistically lower in Group O (P=0.0003).

Conclusions:

Preemptive intravenous oxycodone was an efficient and safe method to reduce intraoperative haemodynamic effect and postoperative pain.

Premedication and preoperative information reduces pain intensity and increases satisfaction in patients undergoing ablation for atrial fibrillation. A randomised controlled study

BACKGROUND

Pain and discomfort are common during radiofrequency ablation (RFA) for atrial fibrillation.

AIMS

To compare and evaluate the effect of premedication, standardised preoperative information and preoperative anxiety on pain intensity, drug consumption and patients' satisfaction.

METHODS

Preoperative anxiety at baseline, pain intensity during RFA, and patient satisfaction after the procedure were measured in 3 random groups. Group A (n=20) received standard pain management, group B (n=20) received premedication and group C (n=20) received premedication and standardised preoperative information.

RESULTS

Patients in groups B and C experienced less pain intensity (p<0.001) and needed fewer anxiolytics (p=0.023) and analgesics (p=0.031) compared to group A. Patient satisfaction was higher in group C (p=0.005) compared to group A. Increased preoperative anxiety is related to elevated drug demand (p<0.05).

CONCLUSION

Premedication alone or combined with preoperative information reduces and higher preoperative anxiety increases pain intensity and drug consumption during RFA. Preoperative information improves patient satisfaction.

Pharmacological interventions for prevention or treatment of postoperative pain in people undergoing laparoscopic cholecystectomy

BACKGROUND

While laparoscopic cholecystectomy is generally considered less painful than open surgery, pain is one of the important reasons for delayed discharge after day-surgery and overnight stay following laparoscopic cholecystectomy. The safety and effectiveness of different pharmacological interventions such as non-steroidal anti-inflammatory drugs, opioids, and anticonvulsant analgesics in people undergoing laparoscopic cholecystectomy is unknown.

OBJECTIVES

To assess the benefits and harms of different analgesics in people undergoing laparoscopic cholecystectomy.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index Expanded, and the World Health Organization International Clinical Trials Registry Platform portal (WHO ICTRP) to March 2013 to identify randomised clinical trials of relevance to this review.

SELECTION CRITERIA

We considered only randomised clinical trials (irrespective of language, blinding, or publication status) comparing different pharmacological interventions with no intervention or inactive controls for outcomes related to benefit in this review. We considered comparative non-randomised studies with regards to treatment-related harms. We also considered trials that compared one class of drug with another class of drug for this review.

DATA COLLECTION AND ANALYSIS

Two review authors collected the data independently. We analysed the data with both fixed-effect and random-effects models using Review Manager 5 analysis. For each outcome, we calculated the risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI).

MAIN RESULTS

We included 25 trials with 2505 participants randomised to the different pharmacological agents and inactive controls. All the trials were at unclear risk of bias. Most trials included only low anaesthetic risk people undergoing elective laparoscopic cholecystectomy. Participants were allowed to take additional analgesics as required in 24 of the trials. The pharmacological interventions in all the included trials were aimed at preventing pain after laparoscopic cholecystectomy. There were considerable differences in the pharmacological agents used and the methods of administration. The estimated effects of the intervention on the proportion of participants who were discharged as day-surgery, the length of hospital stay, or the time taken to return to work were imprecise in all the comparisons in which these outcomes were reported (very low quality evidence). There was no mortality in any of the groups in the two trials that reported mortality (183 participants, very low quality evidence). Differences in serious morbidity outcomes between the groups were imprecise across all the comparisons (very low quality evidence). None of the trials reported patient quality of life or time taken to return to normal activity. The pain at 4 to 8 hours was generally reduced by about 1 to 2 cm on the visual analogue scale of 1 to 10 cm in the comparisons involving the different pharmacological agents and inactive controls (low or very low quality evidence). The pain at 9 to 24 hours was generally reduced by about 0.5 cm (a modest reduction) on the visual analogue scale of 1 to 10 cm in the comparisons involving the different pharmacological agents and inactive controls (low or very low quality evidence).

AUTHORS' CONCLUSIONS

There is evidence of very low quality that different pharmacological agents including non-steroidal anti-inflammatory drugs, opioid analgesics, and anticonvulsant analgesics reduce pain scores in people at low anaesthetic risk undergoing elective laparoscopic cholecystectomy. However, the decision to use these drugs has to weigh the clinically small reduction in pain against uncertain evidence of serious adverse events associated with many of these agents. Further randomised clinical trials of low risk of systematic and random errors are necessary. Such trials should include important clinical outcomes such as quality of life and time to return to work in their assessment.

[Oral therapy algorithm for the treatment of postoperative pain. A prospective observational study]

BACKGROUND

Postoperative pain continues to be undermanaged, at least in part, due to inadequate organization and lack of use of opioids. Especially patients who do not receive consultation from an acute pain service and are therefore not eligible to receive regional anesthesia techniques or patient-controlled devices suffer from severe pain after surgery. The aim of the present prospective observational study was to assess the efficacy and feasibility of an analgesia algorithm for this subgroup of patients.

METHODS

An oral opioid concept including controlled-release (cr) oxycodone, immediate-release (ir) hydromorphone and a non-opioid analgesic was implemented at three different departments at the University Clinic of Muenster, Germany. Briefly, cr-oxycodon was administered preoperatively to patients undergoing ear nose and throat (ENT), general or elective trauma surgery on the day of surgery and every 12 h for a maximum of 4 days postoperatively. Inadequately managed pain above 3 on a visual analog scale (VAS 0-10) at rest and above 5 during movement was treated with ir-hydromorphone on patient request. After written informed consent, patients were assessed prospectively for up to 5 days perioperatively using a standardized questionnaire preoperatively, for 4 days postoperatively as well as 6 and 12 months after surgery.

RESULTS

A total of 275 patients were included in the present prospective observational study: (ENT surgery: 163, trauma surgery 82 and general surgery 30). Median resting and evoked numeric rating scale (NRS) pain scores were equal or less than 3 and 5, respectively. Less patients received cr-oxycodone after ENT and general surgery compared to trauma surgery (p < 0.001). Constipation was more frequent after general and trauma surgery compared to ENT surgery. Vomiting decreased from 20 %-30 % on the day of surgery to 10 % or less regardless of the type of operation. No severe adverse events were observed. Additionally, patients with an increased depression score before surgery reported greater immediate postoperative pain than non-depressed patients. Of the patients 11 (15.7 %) and 7 (14.9 %) complained about persistent postoperative pain 6 and 12 months after surgery, respectively and these patients had increased acute pain ratings during the first postoperative days.

CONCLUSIONS

The present study has demonstrated that the implementation of an oral opioid algorithm for patients without patient-controlled intravenous or regional analgesia is effective and feasible on surgical wards. Patients who underwent trauma surgery needed more cr-oxycodone. Side effects were similar regardless of the operation with the exception of obstipation which was more frequent after trauma and general surgery compared to ENT surgery.

Liver cancer: effects, safety, and cost-effectiveness of controlled-release oxycodone for pain control after TACE

PURPOSE

To evaluate the analgesic effect, safety, and cost-effectiveness of controlled-release oxycodone (CRO) to control postoperative pain in patients with liver cancer who are undergoing transarterial chemoembolization.

MATERIALS AND METHODS

This randomized, double-blind, placebo-controlled, prospective clinical study received institutional review board approval. After written informed consent was obtained, 210 patients with liver cancer were randomized into three groups of 70 patients. Group 1 received 20 mg of CRO, group 2 received 10 mg of CRO, and group 3 received a placebo at 1 hour before transarterial chemoembolization (T(0)) and 12 (T(12)) and 24 (T(24)) hours after T(0). Pain intensity on a numeric rating scale, percentage of patients with each degree of pain, quality of life, adverse reactions, analgesic costs, and hospital stays were evaluated and compared among the three groups.

RESULTS

Numeric rating scale scores for pain intensity in group 1 and group 2 were significantly lower than those in group 3 at T(0-12) (P < .001); T(12-24) (P < .001); and T(24-48) (P < .001). When group 1 with group 2 were compared, numeric rating scale scores were significantly lower in group 1 than in group 2 during the period of T(0-12) (P < .001) but were not significantly different at T(12-24) (P = .68) and T(24-48) (P = .10). Analgesic cost and hospital stay were significantly lower in treated groups than in the placebo group. No significant difference was observed in quality of life and adverse events between the treated groups and the placebo group.

CONCLUSION

CRO is effective, safe, and cost-effective in the control of postoperative pain after transarterial chemoembolization for patients with inoperable liver cancer.

A systematic review of interventions to facilitate ambulatory laparoscopic cholecystectomy

OBJECTIVES

  We aimed to perform a systematic review of the literature to identify interventions that may facilitate ambulatory laparoscopic cholecystectomy (LC).

METHODS

The PubMed and CENTRAL databases were interrogated for key MeSH headings. To be eligible for systematic review, trials were required to include outcome measures of postoperative pain, nausea or vomiting and time to discharge following LC. Interventions were subsequently assessed for the level of evidence and grade of recommendation given.

RESULTS

A total of 331 trials were identified, 68 of which met the predefined study inclusion criteria. Interventions which met Level I, Grade A recommendation included the administration of 8 mg i.v. dexamethasone, preoperative administration of analgesia including the use of non-steroidal anti-inflammatory or COX II inhibitors, intraoperative use of an anti-emetic, pre-incisional use of bupivacaine, administration of intraperitoneal bupivacaine on establishment of pneumoperitoneum, and avoidance of drains.

CONCLUSIONS

  High-quality evidence describing interventions that minimize barriers to ambulatory LC exists. Further studies will be required to determine the optimal combination of these interventions.