1
|
Oh C, Chung W, Hong B. Optimizing patient-controlled analgesia: a narrative review based on a single center audit process. Anesth Pain Med (Seoul) 2024; 19:171-184. [PMID: 39118331 PMCID: PMC11317320 DOI: 10.17085/apm.24075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 07/06/2024] [Accepted: 07/08/2024] [Indexed: 08/10/2024] Open
Abstract
Intravenous patient-controlled analgesia (PCA) is valuable for delivering opioids in a flexible and timely manner. Although it is designed to offer personalized analgesia driven by the patients themselves, users often report insufficient pain relief, which can be addressed by optimizing its settings and multimodal analgesia. We adopted a systematic approach to modify PCA protocols by utilizing a serial audit process based on institutional PCA data. This review retrospectively examined the process, encompassing data from 13,230 patients who had used PCA devices. The two modifications to the fentanyl-based PCA protocols resulted in three distinct phases. In the first phase, high opioid consumption and unintended PCA withdrawal were the common issues. These were addressed in the second phase by omitting the routine use of basal infusion. However, this led to increased delivery-to-demand ratios, mitigated in the third phase by increasing the bolus dose from 15 μg to 20 μg. These serial protocol changes have produced varied outcomes across different surgical departments, underscoring the need for careful and gradual adjustments and thorough impact assessments. Drawing insights from this audit process, we incorporated findings from the literature on PCA settings and multimodal analgesic approaches. This review underscores the significance of iterative feedback and refinement of analgesic protocols to achieve optimal postoperative pain management. Additionally, it discusses critical considerations regarding the postoperative audit processes.
Collapse
Affiliation(s)
- Chahyun Oh
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Woosuk Chung
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Boohwi Hong
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, College of Medicine, Chungnam National University, Daejeon, Korea
| |
Collapse
|
2
|
Deshler BJ, Rockenbach E, Patel T, Monahan BV, Poggio JL. Current update on multimodal analgesia and nonopiate surgical pain management. Curr Probl Surg 2023; 60:101332. [PMID: 37302814 DOI: 10.1016/j.cpsurg.2023.101332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/08/2023] [Indexed: 06/13/2023]
Affiliation(s)
- Bailee J Deshler
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Emily Rockenbach
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Takshaka Patel
- Department of Surgery, General Surgery Resident Physician, Temple University Hospital, Philadelphia, PA
| | - Brian V Monahan
- Department of Surgery, General Surgery Resident Physician, Temple University Hospital, Philadelphia, PA
| | - Juan Lucas Poggio
- Division and System Chief, Colorectal Surgery, Department of Surgery, Professor of Surgery, Temple University Health System, Lewis Katz School of Medicine at Temple University, Philadelphia, PA.
| |
Collapse
|
3
|
Thepsoparn M, Prasitthipayong N, Pannangpetch P. Intravenous lidocaine bolus for reducing nefopam-induced venous pain: A randomized, intrasubject comparison trial. J Anaesthesiol Clin Pharmacol 2023; 39:245-249. [PMID: 37564839 PMCID: PMC10410043 DOI: 10.4103/joacp.joacp_224_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 07/25/2021] [Accepted: 08/28/2021] [Indexed: 08/12/2023] Open
Abstract
Background and Aims Intravenous nefopam reduces postoperative pain and opioid consumption but can cause infusion-related pain. We aimed to investigate whether lidocaine can effectively reduce this pain. Material and Methods This prospective, randomized, double-blind, controlled, intrasubject comparison trial included 42 patients (20-60 years) undergoing elective surgery under regional or peripheral anesthesia. In the postanesthesia care unit, two 50 mL syringes containing nefopam (20 mg) diluted in saline (100 mL) were sequentially infused in 15 min into venous catheters in the left and right arms. Patients were randomly assigned to the "left side" or "right side" group based on the arm in which a bolus of 1% lidocaine (2 mL) (study group) was administered before nefopam infusion. Normal saline (2 mL) was administered on the control side. Numerical Rating Scale scores and the incidence of pain (scores > 3) and nausea or vomiting were recorded at 1, 5, 10, and 15 min. Results The analysis included 42 patients (84 infusions). Compared with the placebo, lidocaine lowered the mean infusion-related pain at 1 (0.07 vs. 2.21, P < 0.001), 5 (2 vs. 4.21, P < 0.001), 10 (2.02 vs. 3.95, P < 0.001), and 15 min (1.62 vs. 3.16, P = 0.003). At 5 min, significantly higher percentages of infusion sites with moderate and higher pain scores (> 3) were observed on the control side (30.95% vs. 14.29%, P = 0.000). Seven patients exhibited nausea or vomiting (16.7%). Conclusion For the nefopam infusion rate and concentration that we used, a 20 mg lidocaine pretreatment bolus significantly reduces infusion-related pain.
Collapse
Affiliation(s)
- Marvin Thepsoparn
- Pain Management Research Unit, Department of Anesthesia, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Chulalongkorn University, Bangkok, Thailand
| | - Nattha Prasitthipayong
- Pain Management Research Unit, Department of Anesthesia, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Chulalongkorn University, Bangkok, Thailand
| | - Patt Pannangpetch
- Pain Management Research Unit, Department of Anesthesia, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Chulalongkorn University, Bangkok, Thailand
| |
Collapse
|
4
|
Raksakietisak M, Rushatamukayanunt P, Wilaiwan K, Homprasert C, Nitising A, Sawasdiwipachai P, Pantubtim C. Postoperative analgesia of intraoperative nefopam in patients undergoing anterior cervical spine surgery: A prospective randomized controlled trial. Medicine (Baltimore) 2022; 101:e31296. [PMID: 36316913 PMCID: PMC9622578 DOI: 10.1097/md.0000000000031296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Nefopam is a non-opioid, non-nonsteroidal anti-imflammatory drug, analgesic drug that inhibits the reuptake of serotonin, norepinephrine, and dopamine. It is widely used as an adjuvant for pain. This study investigated whether the intraoperative, intravenous infusion of nefopam (20 mg) reduces postoperative morphine consumption, pain scores, and alleviates neuropathic pain in patients undergoing cervical spine surgery. METHODS A prospective, paralleled design, randomized study was conducted on 50 patients (aged 18-75 years) in a university-based hospital. The patients were assigned to an intervention or a control group (25 patients in each). The intervention group received a 1-hour infusion of nefopam (20 mg) before the end of surgery. The control group received normal saline (NSS). The outcome measures were morphine consumption during the first 24 postoperative hours, numerical rating scale (NRS) pain scores, and scores for the Thai version of the Neuropathic Pain Symptom Inventory (NPSI-T) in patients with neuropathic pain and adverse drug reactions. The NPSI-T scores were assessed on the preoperative day, postoperative day 1, 3, 15, and 30. The outcome assessors were blinded to group allocation. RESULTS Fifty patients were analyzed. During the first 24 postoperative hours, morphine consumption was 8 mg (nefopam) and 12 mg (NSS; P = .130). The intervention and control groups demonstrated no significant differences in the median NRS scores or total NPSI-T scores or adverse drug reactions. CONCLUSIONS A single, intraoperative infusion of 20 mg of nefopam did not significantly reduce postoperative (24 hours) morphine consumption in patients undergoing anterior cervical spine surgery.
Collapse
Affiliation(s)
- Manee Raksakietisak
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pranee Rushatamukayanunt
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- *Correspondence: Pranee Rushatamukayanunt, Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand (e-mail: )
| | - Kulanong Wilaiwan
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chakkarin Homprasert
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Akkapong Nitising
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Prasert Sawasdiwipachai
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chanitda Pantubtim
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| |
Collapse
|
5
|
The Lack of Analgesic Efficacy of Nefopam after Video-Assisted Thoracoscopic Surgery for Lung Cancer: A Randomized, Single-Blinded, Controlled Trial. J Clin Med 2022; 11:jcm11164849. [PMID: 36013087 PMCID: PMC9409862 DOI: 10.3390/jcm11164849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/17/2022] [Accepted: 08/17/2022] [Indexed: 11/17/2022] Open
Abstract
Nefopam is a centrally acting non-opioid analgesic, and its efficacy in multimodal analgesia has been reported. This study aimed to assess the analgesic efficacy of intraoperative nefopam on postoperative pain after video-assisted thoracoscopic surgery (VATS) for lung cancer. Participants were randomly assigned to either the nefopam or the control group. The nefopam group received 20 mg of nefopam after induction and 15 min before the end of surgery. The control group received saline. The primary outcome was cumulative opioid consumption during the 6 h postoperatively. Pain intensities, the time to first request for rescue analgesia, adverse events during the 72 h postoperatively, and the incidence of chronic pain 3 months after surgery were evaluated. Ninety-nine patients were included in the analysis. Total opioid consumption during the 6 h postoperatively was comparable between the groups (nefopam group [n = 50] vs. control group [n = 49], 19.8 [13.5–25.3] mg vs. 20.3 [13.9–27.0] mg; median difference: −1.55, 95% CI: −6.64 to 3.69; p = 0.356). Pain intensity during the 72 h postoperatively and the incidence of chronic pain 3 months after surgery did not differ between the groups. Intraoperative nefopam did not decrease acute postoperative opioid consumption or pain intensity, nor did it reduce the incidence of chronic pain after VATS.
Collapse
|
6
|
Ultrasound-guided bilateral subcostal transversus abdominis plane block in gastric cancer patients undergoing laparoscopic gastrectomy: a randomised-controlled double-blinded study. Surg Endosc 2021; 36:1044-1052. [PMID: 33638105 DOI: 10.1007/s00464-021-08370-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 02/09/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND The effectiveness of subcostal transversus abdominis plane block (TAPB) in laparoscopic gastric cancer surgery is unknown. We aimed to investigate its opioid-sparing and pain-relief effects in laparoscopic gastrectomy for gastric cancer. METHOD One hundred and twelve patients undergoing elective laparoscopic gastrectomy were randomised to the TAPB or control group. The TAPB group received ultrasound-guided bilateral subcostal TAPB at the end of surgery, while the control group did not. We investigated fentanyl consumption administered via intravenous patient-controlled analgesia and as a rescue analgesic, the numeric rating scale (NRS) pain scores at rest and during coughing, and the opioid-related side effects at 6, 12, 24, and 48 h postoperatively. The primary outcome was cumulative fentanyl consumption at 24 h postoperatively. RESULTS The study included 53 patients in each group. The cumulative fentanyl consumption 24 h postoperatively was significantly lower in the TAPB group than in the control group (median difference -170 mcg, P = 0.03, 95% CI -360 to -15 mcg). Subcostal TAPB also significantly reduced the resting NRS score at 48 h postoperatively (median difference -1, 95% CI -1 to 0, P = 0.01) and coughing NRS score at all time points (all median difference -1, 95% CI -2 to 0, P < 0.01, P = 0.02, 0.01, and 0.01, respectively). However, it did not reduce the occurrence of opioid-related side effects, except the use of antiemetics during the first 6 h postoperatively (TAPB, 1.9% vs. Control, 15.1%, P = 0.03). CONCLUSION Ultrasound-guided bilateral subcostal TAPB provides efficient postoperative analgesia with an opioid-sparing effect after laparoscopic gastrectomy.
Collapse
|
7
|
Analgesic Efficacy of Nefopam as an Adjuvant in Patient-Controlled Analgesia for Acute Postoperative Pain After Laparoscopic Colorectal Cancer Surgery. J Clin Med 2021; 10:jcm10020270. [PMID: 33450926 PMCID: PMC7828424 DOI: 10.3390/jcm10020270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/28/2020] [Accepted: 01/08/2021] [Indexed: 11/24/2022] Open
Abstract
Despite rapid advancements in laparoscopic surgical techniques and perioperative management, postoperative pain remains a significant clinical issue. We examined the analgesic efficacy of nefopam as an adjuvant in patient-controlled analgesia (PCA) for acute postoperative pain in patients undergoing laparoscopic colorectal cancer surgery. We retrospectively analyzed the medical records of 120 patients who did or did not receive 80 mg of nefopam as an adjuvant in fentanyl PCA; they were allocated to the nefopam (n = 60) or non-nefopam group (n = 60). The demographic, clinical, and anesthetic data, with data on pain severity and opioid administration at the postoperative anesthesia care unit (PACU) on postoperative days (PODs) 1, 3, and 5, were compared between the groups. The pain score and opioid administration did not differ at the PACU or on PODs 1, 3, or 5. The day of PCA discontinuation, time to pass flatus, length of the hospital stay, and incidence of nausea/vomiting, dizziness, and headache also did not differ between the groups. Fentanyl PCA with 80 mg of nefopam as an adjuvant did not have a superior analgesic effect after laparoscopic colorectal cancer surgery.
Collapse
|
8
|
Di Lorenzo N, Antoniou SA, Batterham RL, Busetto L, Godoroja D, Iossa A, Carrano FM, Agresta F, Alarçon I, Azran C, Bouvy N, Balaguè Ponz C, Buza M, Copaescu C, De Luca M, Dicker D, Di Vincenzo A, Felsenreich DM, Francis NK, Fried M, Gonzalo Prats B, Goitein D, Halford JCG, Herlesova J, Kalogridaki M, Ket H, Morales-Conde S, Piatto G, Prager G, Pruijssers S, Pucci A, Rayman S, Romano E, Sanchez-Cordero S, Vilallonga R, Silecchia G. Clinical practice guidelines of the European Association for Endoscopic Surgery (EAES) on bariatric surgery: update 2020 endorsed by IFSO-EC, EASO and ESPCOP. Surg Endosc 2020; 34:2332-2358. [PMID: 32328827 PMCID: PMC7214495 DOI: 10.1007/s00464-020-07555-y] [Citation(s) in RCA: 221] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/07/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgery for obesity and metabolic diseases has been evolved in the light of new scientific evidence, long-term outcomes and accumulated experience. EAES has sponsored an update of previous guidelines on bariatric surgery. METHODS A multidisciplinary group of bariatric surgeons, obesity physicians, nutritional experts, psychologists, anesthetists and a patient representative comprised the guideline development panel. Development and reporting conformed to GRADE guidelines and AGREE II standards. RESULTS Systematic review of databases, record selection, data extraction and synthesis, evidence appraisal and evidence-to-decision frameworks were developed for 42 key questions in the domains Indication; Preoperative work-up; Perioperative management; Non-bypass, bypass and one-anastomosis procedures; Revisional surgery; Postoperative care; and Investigational procedures. A total of 36 recommendations and position statements were formed through a modified Delphi procedure. CONCLUSION This document summarizes the latest evidence on bariatric surgery through state-of-the art guideline development, aiming to facilitate evidence-based clinical decisions.
Collapse
Affiliation(s)
- Nicola Di Lorenzo
- Department of Surgical Sciences, University of Rome "Tor Vergata", Rome, Italy
| | - Stavros A Antoniou
- Department of Surgery, European University of Cyprus, Nicosia, Cyprus
- Department of Surgery, Mediterranean Hospital of Cyprus, Limassol, Cyprus
| | - Rachel L Batterham
- Centre for Obesity Research, University College London, London, UK
- Biomedical Research Centre, National Institute of Health Research, London, UK
| | - Luca Busetto
- Internal Medicine 3, Department of Medicine, DIMED, Center for the Study and the Integrated Treatment of Obesity, University Hospital of Padua, Padua, Italy
| | - Daniela Godoroja
- Department of Anesthesiology, Ponderas Academic Hospital Regina Maria, Bucharest, Romania
| | - Angelo Iossa
- Department of Medical-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, "La Sapienza" University of Rome-Polo Pontino, Bariatric Centre of Excellence IFSO-EC, Via F. Faggiana 1668, 04100, Latina, Italy
| | - Francesco M Carrano
- Department of Endocrine and Metabolic Surgery, University of Insubria, Ospedale di Circolo and Fondazione Macchi, ASST Sette Laghi, Varese, Italy
| | | | - Isaias Alarçon
- Unit of Innovation in Minimally Invasive Surgery, Department of General and Digestive Surgery, University Hospital "Virgen del Rocío", 41010, Sevilla, Spain
| | | | - Nicole Bouvy
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Maura Buza
- Department of General Surgery, Ponderas Academic Hospital Regina Maria, Bucharest, Romania
| | - Catalin Copaescu
- Department of General Surgery, Ponderas Academic Hospital Regina Maria, Bucharest, Romania
| | - Maurizio De Luca
- Division of General Surgery, Castelfranco and Montebelluna Hospitals, Treviso, Italy
| | - Dror Dicker
- Department of Internal Medicine D, Hasharon Hospital, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Angelo Di Vincenzo
- Internal Medicine 3, Department of Medicine, DIMED, Center for the Study and the Integrated Treatment of Obesity, University Hospital of Padua, Padua, Italy
| | - Daniel M Felsenreich
- Division of General Surgery, Department of Surgery, Vienna Medical University, Vienna, Austria
| | - Nader K Francis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
| | - Martin Fried
- Center for Treatment of Obesity and Metabolic Disorders, OB Klinika, Prague, Czech Republic
| | | | - David Goitein
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Surgery C, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Jason C G Halford
- Department of Psychological Sciences, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Jitka Herlesova
- Center for Treatment of Obesity and Metabolic Disorders, OB Klinika, Prague, Czech Republic
| | | | - Hans Ket
- VU Amsterdam, Amsterdam, Netherlands
| | - Salvador Morales-Conde
- Unit of Innovation in Minimally Invasive Surgery, Department of General and Digestive Surgery, University Hospital "Virgen del Rocío", 41010, Sevilla, Spain
| | - Giacomo Piatto
- Division of General Surgery, Castelfranco and Montebelluna Hospitals, Treviso, Italy
| | - Gerhard Prager
- Division of General Surgery, Department of Surgery, Vienna Medical University, Vienna, Austria
| | - Suzanne Pruijssers
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Andrea Pucci
- Centre for Obesity Research, University College London, London, UK
- Biomedical Research Centre, National Institute of Health Research, London, UK
| | - Shlomi Rayman
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Surgery C, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Eugenia Romano
- Department of Psychological Sciences, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | | | - Ramon Vilallonga
- Endocrine, Metabolic and Bariatric Unit, General Surgery Department, Vall D'Hebron University Hospital, Center of Excellence for the EAC-BC, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Gianfranco Silecchia
- Department of Medical-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, "La Sapienza" University of Rome-Polo Pontino, Bariatric Centre of Excellence IFSO-EC, Via F. Faggiana 1668, 04100, Latina, Italy.
| |
Collapse
|
9
|
Kendall MC, Castro-Alves LJ. Postoperative Pain and Opioid Consumption in the Acute Postoperative Period after Laparoscopic Gastrectomy. J Gastrointest Surg 2018; 22:1134. [PMID: 29644556 DOI: 10.1007/s11605-018-3776-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 04/03/2018] [Indexed: 01/31/2023]
Affiliation(s)
- Mark C Kendall
- Department of Anesthesiology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA.
| | - Lucas J Castro-Alves
- Department of Anesthesiology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
| |
Collapse
|