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Dean C, McCullough I, Papangelou A. An update on the perioperative management of postcraniotomy pain. Curr Opin Anaesthesiol 2024; 37:478-485. [PMID: 39011673 DOI: 10.1097/aco.0000000000001409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Abstract
PURPOSE OF REVIEW Pain after craniotomy is often severe and undertreated. Providing adequate analgesia while avoiding medication adverse effects and physiological complications of pain remains a perioperative challenge. RECENT FINDINGS Multimodal pain management includes regional anesthesia and analgesic adjuncts. Strategies aim to reduce or eliminate opioids and the associated side effects. Many individual pharmacologic interventions have been studied with beneficial effects on acute pain following craniotomy. Evidence has been accumulating in support of scalp blockade, nonsteroidal anti-inflammatory drugs (NSAIDs), dexmedetomidine, paracetamol, and gabapentinoids. The strongest evidence supports scalp block in reducing postcraniotomy pain and opioid requirements. SUMMARY Improving analgesia following craniotomy continues to be a challenge that should be managed with multimodal medications and regional techniques. Additional studies are needed to identify the most effective regimen, balancing efficacy and adverse drug effects.
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MESH Headings
- Humans
- Pain, Postoperative/etiology
- Pain, Postoperative/prevention & control
- Pain, Postoperative/therapy
- Pain, Postoperative/diagnosis
- Pain, Postoperative/drug therapy
- Craniotomy/adverse effects
- Pain Management/methods
- Perioperative Care/methods
- Perioperative Care/standards
- Analgesics/administration & dosage
- Analgesics/therapeutic use
- Analgesics/adverse effects
- Anesthesia, Conduction/methods
- Anesthesia, Conduction/adverse effects
- Nerve Block/methods
- Nerve Block/adverse effects
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Anti-Inflammatory Agents, Non-Steroidal/administration & dosage
- Analgesics, Opioid/adverse effects
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/therapeutic use
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Affiliation(s)
- Cassandra Dean
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
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2
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Naik BI, Lele AV, Sharma D, Akkermans A, Vlisides PE, Colquhoun DA, Domino KB, Tsang S, Sun E, Dunn LK. Variability in Intraoperative Opioid and Nonopioid Utilization During Intracranial Surgery: A Multicenter, Retrospective Cohort Study. J Neurosurg Anesthesiol 2024:00008506-990000000-00102. [PMID: 38546217 PMCID: PMC11436478 DOI: 10.1097/ana.0000000000000960] [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: 10/27/2023] [Accepted: 02/16/2024] [Indexed: 09/29/2024]
Abstract
BACKGROUND Key goals during intracranial surgery are to facilitate rapid emergence and extubation for early neurologic evaluation. Longer-acting opioids are often avoided or administered at subtherapeutic doses due to their perceived risk of sedation and delayed emergence. However, inadequate analgesia and increased postoperative pain are common after intracranial surgery. In this multicenter study, we describe variability in opioid and nonopioid administration patterns in patients undergoing intracranial surgery. METHODS This was a multicenter, retrospective observational cohort study using the Multicenter Perioperative Outcomes Group database. Opioid and nonopioid practice patterns in 31,217 cases undergoing intracranial surgery across 11 institutions in the United States are described. RESULTS Across all 11 institutions, total median [interquartile range] oral morphine equivalents, normalized to weight and anesthesia duration was 0.17 (0.08 to 0.3) mg.kg.min-1. There was a 7-fold difference in oral morphine equivalents between the lowest (0.05 [0.02 to 0.13] mg.kg.min-1) and highest (0.36 [0.18 to 0.54] mg.kg.min-1) prescribing institutions. Patients undergoing supratentorial surgery had higher normalized oral morphine equivalents compared with those having infratentorial surgery [0.17 [0.08-0.31] vs. 0.15 [0.07-0.27] mg/kg/min-1; P<0.001); however, this difference is clinically small. Nonopioid analgesics were not administered in 20% to 96.8% of cases across institutions. CONCLUSION This study found wide variability for both opioid and nonopioid utilization at an institutional level. Future work on practitioner-level opioid and nonopioid use and its impact on outcomes after intracranial surgery should be conducted.
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Affiliation(s)
- Bhiken I Naik
- Department of Anesthesiology, University of Virginia, Charlottesville, VA
| | - Abhijit V Lele
- Department of Anesthesiology University of Washington, WA
| | - Deepak Sharma
- Department of Anesthesiology University of Washington, WA
| | | | | | | | - Karen B Domino
- Department of Anesthesiology University of Washington, WA
| | - Siny Tsang
- Department of Anesthesiology, University of Virginia, Charlottesville, VA
| | - Eric Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, CA
| | - Lauren K Dunn
- Department of Anesthesiology, University of Virginia, Charlottesville, VA
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3
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Abhinav K, Jadhav D, Andar UB, Karmarkar V, Agrawal R, Agrawal A. Management of Post-craniotomy Pain in Elective Cases: A Randomized Controlled Trial. Cureus 2023; 15:e46189. [PMID: 37905293 PMCID: PMC10613341 DOI: 10.7759/cureus.46189] [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: 07/22/2023] [Accepted: 09/28/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Craniotomy is associated with significant postoperative discomfort. Standardized pain management and enhanced recovery after surgery (ERAS) protocol could improve patient-reported outcomes and lower medical expenses. AIM The aim of this study is to prospectively assess the effectiveness of an ERAS protocol for neurosurgery in the treatment of postoperative pain following elective craniotomies. METHODS AND MATERIALS A total of 128 patients were assigned to the ERAS group and received care in accordance with the neurosurgical ERAS regulations, while 130 other participants were assigned to the control group and received traditional postoperative assistance. The participants' postoperative pain ratings using the numerical rating scale (NRS) were this study's main outcome of interest. The verbal NRS uses the numbers 0 to 10, with 0 indicating no sensation of pain and 10 indicating the most severe pain. On postoperative day (POD) 1, the patients' postoperative pain level at the surgical site was evaluated using the NRS. This was repeated every day until the patient either reported feeling no sensation of pain or was discharged home. RESULTS The mean value of pain on the day of surgery was 4.43 ± 0.43 and 4.72 ± 0.68 for patients in the ERAS and control groups, respectively. The pain values were higher in the control group compared to the ERAS group. However, the difference was not statistically significant (p = 0.478). The mean value of pain on POD1 was 3.13 ± 0.21 and 4.45 ± 0.95 for patients in the ERAS and control groups, respectively. These pain values were higher in the control group compared to the ERAS group, and the difference was statistically significant (p = 0.011). The mean value of pain on POD2 was 2.86 ± 0.3 and 4.33 ± 0.37 for patients in the ERAS and control groups, respectively. The values of pain were higher in the control group compared to the ERAS group, and the difference was statistically significant (p = 0.003). The mean value of pain on POD3 was 2.33 ± 0.52 and 4.04 ± 0.15 for patients in the ERAS and control groups, respectively. The pain values were higher in the control group compared to the ERAS group. The difference was meaningful statistically (p < 0.001). The mean value of pain on POD4 was 2.26 ± 0.9 and 2.84 ± 0.13 for the ERAS and control groups, respectively. However, the difference was not statistically significant (p = 0.274). The ERAS group had a significantly higher proportion of participants rating their pain between 1 and 3 (68.9%) and a lower proportion rating their pain between 4 and 7 (28.2%), compared to the control group (p < 0.001). Differences in the highest pain ratings (8-10) between the groups were not statistically significant. The duration of hospital stay, beginning from surgery to discharge, was lesser among study participants in the ERAS group, and this finding was statistically significant (p < 0.001). CONCLUSION The findings of this study imply that the ERAS protocol may aid pain management following elective craniotomies. Additionally, the ERAS protocol decreased the overall expense of medical care and the cumulative/postoperative length of hospital stay.
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Affiliation(s)
- Kumar Abhinav
- Department of Neurosurgery, Lilavati Hospital and Research Centre, Mumbai, IND
| | - Dikpal Jadhav
- Department of Neurosurgery, King Edward Memorial (KEM) Hospital, Mumbai, IND
| | - Uday B Andar
- Department of Neurosurgery, Bai Jerbai Wadia Hospital for Children, Mumbai, IND
| | - Vikram Karmarkar
- Department of Neurosurgery, Bombay Hospital and Medical Research Centre, Mumbai, IND
| | - Rama Agrawal
- Department of Physiology, Patna Medical College and Hospital, Patna, IND
| | - Ankita Agrawal
- Department of Conservative and Endodontics, Buddha Institute of Dental Sciences & Hospital, Patna, IND
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Wilson BR, Grogan TR, Schulman NJ, Kim W, Gabel E, Wang AC. Early Postoperative Opioid Requirement Is Associated With Later Pain Control Needs After Supratentorial Craniotomies. J Neurosurg Anesthesiol 2023; 35:307-312. [PMID: 35470325 DOI: 10.1097/ana.0000000000000842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 03/09/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite a renewed focus in recent years on pain management in the inpatient hospital setting, postoperative pain after elective craniotomy remains under investigated. This study aims to identify which perioperative factors associate most strongly with postoperative pain and opioid medication requirements after inpatient craniotomy. MATERIALS AND METHODS Using an existing dataset, we selected a restricted cohort of patients who underwent elective craniotomy surgery requiring an inpatient postoperative stay during a 7-year period at our institution (n=1832). We examined pain scores and opioid medication usage and analyzed the relative contribution of specific perioperative risk factors to postoperative pain and opioid medication intake (morphine milligram equivalents). RESULTS Postoperative pain was found to be highest on postoperative day 1 and decreased thereafter (up to day 5). Factors associated with greater postoperative opioid medication requirement were preoperative opioid medication use, duration of anesthesia, degree of pain in the preoperative setting, and patient age. Notably, the most significant factor associated with a higher postoperative pain score and Morphine milligram equivalents requirement was the time elapsed between the end of general anesthesia and a patient's first intravenous opioid medication. CONCLUSION Postcraniotomy patients are at higher risk for requiring opioid pain medications if they have a history of preoperative opioid use, are of younger age, or undergo a longer surgery. Moreover, early requirement of intravenous opioid medications in the postoperative period should alert treating physicians that a patient's pain may require additional or alternative methods of pain control than routinely administered, to avoid over-reliance on opioid medications.
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Affiliation(s)
| | | | - Nathan J Schulman
- Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA
| | | | - Eilon Gabel
- Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA
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Fiore G, Porto E, Pluderi M, Ampollini AM, Borsa S, Legnani FG, Giampiccolo D, Miserocchi A, Bertani GA, DiMeco F, Locatelli M. Prevention of Post-Operative Pain after Elective Brain Surgery: A Meta-Analysis of Randomized Controlled Trials. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050831. [PMID: 37241063 DOI: 10.3390/medicina59050831] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/02/2023] [Accepted: 04/20/2023] [Indexed: 05/28/2023]
Abstract
Background and Objective: To analyze the effects of several drug for pain prevention in adults undergoing craniotomy for elective brain surgery. Material and Methods: A systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The inclusion criteria were limited to randomized controlled trials (RCTs) that evaluated the effectiveness of pharmacological treatments for preventing post-operative pain in adults (aged 18 years or older) undergoing craniotomies. The main outcome measures were represented by the mean differences in validated pain intensity scales administered at 6 h, 12 h, 24 h and 48 h post-operatively. The pooled estimates were calculated using random forest models. The risk of bias was evaluated using the RoB2 revised tool, and the certainty of evidence was assessed according to the GRADE guidelines. Results: In total, 3359 records were identified through databases and registers' searching. After study selection, 29 studies and 2376 patients were included in the meta-analysis. The overall risk of bias was low in 78.5% of the studies included. The pooled estimates of the following drug classes were provided: NSAIDs, acetaminophen, local anesthetics and steroids for scalp infiltration and scalp block, gabapentinoids and agonists of adrenal receptors. Conclusions: High-certainty evidence suggests that NSAIDs and acetaminophen may have a moderate effect on reducing post-craniotomy pain 24 h after surgery compared to control and that ropivacaine scalp block may have a bigger impact on reducing post-craniotomy pain 6 h after surgery compared to control. Moderate-certainty evidence indicates that NSAIDs may have a more remarkable effect on reducing post-craniotomy pain 12 h after surgery compared to control. No moderate-to-high-certainty evidence indicates effective treatments for post-craniotomy pain prevention 48 h after surgery.
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Affiliation(s)
- Giorgio Fiore
- Unit of Neurosurgery, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK
| | - Edoardo Porto
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, 20133 Milan, Italy
- Department of Neurosurgery, School of Medicine, Emory University, Atlanta, GA 30322, USA
| | - Mauro Pluderi
- Unit of Neurosurgery, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | | | - Stefano Borsa
- Unit of Neurosurgery, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | | | - Davide Giampiccolo
- Institute of Neuroscience, Cleveland Clinic London, Grosvenor Place, London SW1X 7HY, UK
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College, London WC1E 6BT, UK
| | - Anna Miserocchi
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK
| | - Giulio Andrea Bertani
- Unit of Neurosurgery, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Francesco DiMeco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, 20133 Milan, Italy
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Marco Locatelli
- Unit of Neurosurgery, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
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Sane S, Mahoori A, Abdulabbas HS, Alshahrani SH, Qasim MT, Abosaooda M, Nozad P, Khanahmadi S, Golabi P, Kazemi Haki B, Darvishzadehdaledari S. Investigating the effect of pregabalin on postoperative pain in non-emergency craniotomy. Clin Neurol Neurosurg 2023; 226:107599. [PMID: 36764099 DOI: 10.1016/j.clineuro.2023.107599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/10/2023] [Accepted: 01/16/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND Surgical procedures performed in the suboccipital and subtemporal regions are associated with severe pain. The present study was designed to determine pregabalin's effect on postoperative pain in elective craniotomy. METHOD This double-blind prospective randomized clinical trial was conducted on 50 patients aged 20-60 with ASA classifications I and II. The patients who qualified for elective craniotomies were split into intervention (two capsules =300 mg pregabalin) and control groups (two capsule starch). Patients were also assessed at recovery, 2, 6, 12, and 24 h after surgery for their pain and level of sedation. Data were analyzed by SPSS software version 23, and a P-value ≤ 0.05 was considered significant. RESULTS The mean pain score in the intervention group was lower than the control group at recovery (p = 0.224), 2 h (p = 0.001), 6 h (p = 0.011), and 12 h (p = 0.032) after surgery. The methadone consumption in the control group was significantly higher than the intervention group (p < 0.05). There was no significant difference between the two groups regarding the level of sedation (p > 0.05). The mean heart rate at induction (p = 0.01), 15 min (p = 0.01), 30 min (p = 0.025), recovery (p = 0.031), and 2 h (p = 0.021) after surgery and the MAP at recovery, 2 h, and 6 h after surgery was significantly lower than the control group (p = 0.029), (p = 0.013), and (p = 0.038), respectively. CONCLUSION Our investigation demonstrated the effectiveness of pregabalin two hours before surgery on decreasing postoperative pain and analgesic consumption without disturbance in neurological examinations and any specific adverse effects.
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Affiliation(s)
- Shahryar Sane
- Department of Anesthesiology, Urmia Imam Khomeini Hospital, Urmia University of Medical Sciences, Urmia, Iran
| | - Alireza Mahoori
- Department of Anesthesiology, Urmia Imam Khomeini Hospital, Urmia University of Medical Sciences, Urmia, Iran
| | - Hadi Sajid Abdulabbas
- Continuous Education Department, Faculty of Dentistry, University of Al-Ameed, Karbala 56001, Iraq
| | | | - Maytham T Qasim
- Department of Anesthesia, College of Health and Medical Technololgy, Al-Ayen University, Thi-Qar, Iraq
| | | | - Payam Nozad
- Department of Anesthesiology, Urmia Imam Khomeini Hospital, Urmia University of Medical Sciences, Urmia, Iran
| | - Shima Khanahmadi
- Department of Anesthesiology, Urmia Imam Khomeini Hospital, Urmia University of Medical Sciences, Urmia, Iran
| | - Parang Golabi
- Department of Anesthesiology, Omid Charity Hospital, Urmia University of Medical Sciences, Urmia, Iran
| | - Behzad Kazemi Haki
- Department of Anesthesiology, Urmia Imam Khomeini Hospital, Urmia University of Medical Sciences, Urmia, Iran
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Opioid-Free Anesthesia for Craniotomy. J Neurosurg Anesthesiol 2023; 35:80-85. [PMID: 34469414 DOI: 10.1097/ana.0000000000000797] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/26/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Perioperative opioids are problematic following craniotomy as they can impede neurological examination because of excessive sedation and mask surgical complications. Multimodal anesthetic techniques including nerve blocks have been used successfully to deliver opioid-free anesthesia in other surgical populations; however, no clinical data evaluating opioid-free anesthesia for craniotomy exists within the current body of literature. MATERIALS AND METHODS Six prospectively identified patients underwent supratentorial craniotomy at Emory University Hospital using a multimodal opioid-free anesthetic (OFA) technique consisting of preoperative scalp block, dexmedetomidine and intravenous acetaminophen. These opioid-free patients were matched by age, sex, incision length, and incision location to 18 retrospectively identified control patients who underwent craniotomy using conventional, opioid-based anesthetic techniques. Postoperative opioid consumption and pain scores were compared and analyzed for noninferiority. RESULTS Noninferiority of the OFA technique was demonstrated for opioid consumption at all measured intervals from postanesthesia care unit arrival to 24 hours postoperatively. Noninferiority was also demonstrated with respect to average postoperative pain scores from 0 to 12 hours, 0 to 24 hours, as well as length of postanesthesia care unit stay. Noninferiority was not shown for time to first rescue opioid postoperatively, pain scores for the 12 to 24 hours postoperative period, or time to emergence from anesthesia. CONCLUSIONS This pilot study demonstrates the feasibility of an OFA technique for patients undergoing supratentorial craniotomy and suggests that larger prospective randomized controlled trials are indicated to examine the role of multimodal anesthetic techniques for craniotomy.
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King H, Reiber M, Philippi V, Stirling H, Aulehner K, Bankstahl M, Bleich A, Buchecker V, Glasenapp A, Jirkof P, Miljanovic N, Schönhoff K, von Schumann L, Leenaars C, Potschka H. Anesthesia and analgesia for experimental craniotomy in mice and rats: a systematic scoping review comparing the years 2009 and 2019. Front Neurosci 2023; 17:1143109. [PMID: 37207181 PMCID: PMC10188949 DOI: 10.3389/fnins.2023.1143109] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/27/2023] [Indexed: 05/21/2023] Open
Abstract
Experimental craniotomies are a common surgical procedure in neuroscience. Because inadequate analgesia appears to be a problem in animal-based research, we conducted this review and collected information on management of craniotomy-associated pain in laboratory mice and rats. A comprehensive search and screening resulted in the identification of 2235 studies, published in 2009 and 2019, describing craniotomy in mice and/or rats. While key features were extracted from all studies, detailed information was extracted from a random subset of 100 studies/year. Reporting of perioperative analgesia increased from 2009 to 2019. However, the majority of studies from both years did not report pharmacologic pain management. Moreover, reporting of multimodal treatments remained at a low level, and monotherapeutic approaches were more common. Among drug groups, reporting of pre- and postoperative administration of non-steroidal anti-inflammatory drugs, opioids, and local anesthetics in 2019 exceeded that of 2009. In summary, these results suggest that inadequate analgesia and oligoanalgesia are persistent issues associated with experimental intracranial surgery. This underscores the need for intensified training of those working with laboratory rodents subjected to craniotomies. Systematic review registration https://osf.io/7d4qe.
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Affiliation(s)
- Hannah King
- Institute of Pharmacology, Toxicology, and Pharmacy, Ludwig Maximilian University of Munich, Munich, Germany
| | - Maria Reiber
- Institute of Pharmacology, Toxicology, and Pharmacy, Ludwig Maximilian University of Munich, Munich, Germany
| | - Vanessa Philippi
- Institute of Pharmacology, Toxicology, and Pharmacy, Ludwig Maximilian University of Munich, Munich, Germany
| | - Helen Stirling
- Institute of Pharmacology, Toxicology, and Pharmacy, Ludwig Maximilian University of Munich, Munich, Germany
| | - Katharina Aulehner
- Institute of Pharmacology, Toxicology, and Pharmacy, Ludwig Maximilian University of Munich, Munich, Germany
| | - Marion Bankstahl
- Hannover Medical School, Institute for Laboratory Animal Science, Hanover, Germany
| | - André Bleich
- Hannover Medical School, Institute for Laboratory Animal Science, Hanover, Germany
| | - Verena Buchecker
- Institute of Pharmacology, Toxicology, and Pharmacy, Ludwig Maximilian University of Munich, Munich, Germany
| | - Aylina Glasenapp
- Hannover Medical School, Institute for Laboratory Animal Science, Hanover, Germany
| | - Paulin Jirkof
- Office for Animal Welfare and 3Rs, University of Zurich, Zurich, Switzerland
| | - Nina Miljanovic
- Institute of Pharmacology, Toxicology, and Pharmacy, Ludwig Maximilian University of Munich, Munich, Germany
| | - Katharina Schönhoff
- Institute of Pharmacology, Toxicology, and Pharmacy, Ludwig Maximilian University of Munich, Munich, Germany
| | - Lara von Schumann
- Institute of Pharmacology, Toxicology, and Pharmacy, Ludwig Maximilian University of Munich, Munich, Germany
| | - Cathalijn Leenaars
- Hannover Medical School, Institute for Laboratory Animal Science, Hanover, Germany
| | - Heidrun Potschka
- Institute of Pharmacology, Toxicology, and Pharmacy, Ludwig Maximilian University of Munich, Munich, Germany
- *Correspondence: Heidrun Potschka,
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Buchecker V, Koska I, Pace C, Talbot SR, Palme R, Bleich A, Potschka H. Toward Evidence-Based Severity Assessment in Mouse Models with Repeated Seizures: (II.) Impact of Surgery and Intrahippocampal Kainate. Eur Surg Res 2023; 64:89-107. [PMID: 35073547 PMCID: PMC9808668 DOI: 10.1159/000522156] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 01/05/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Chronic epilepsy models require neurosurgical procedures including depth electrode implants. The intrahippocampal kainate model is a frequently used chronic paradigm, which is based on chemoconvulsant administration and status epilepticus induction during the surgical procedure. This experimental approach raises the question of the extent to which this approach affects postsurgical recovery. In addition to the short- and long-term impact of the surgical intervention, a potential impact of highly frequent electrographic seizure events needs to be considered in the context of severity assessment. METHODS Various behavioral, biochemical, and telemetric parameters were analyzed in four experimental groups of mice: 1st naive, 2nd with transmitter implants, 3rd with transmitter and electrode implants, and 4th with transmitter implants, electrode implants, and kainate-induced status epilepticus. RESULTS During the early postsurgical phase, transmitter implants caused a transient impact on Mouse Grimace scores and intragroup increase of fecal corticosterone metabolites. Additional craniotomy was associated with an influence on total heart rate variability and fecal corticosterone metabolites. Heart rate and Irwin score increases as well as a prolonged increase in Mouse Grimace scores pointed to an added burden related to the induction of a nonconvulsive status epilepticus. Data from the chronic phase argued against a relevant influence of frequent electrographic seizures on behavioral patterns, fecal corticosterone metabolites, heart rate, and its variability. However, Irwin scores indicated long-term changes in some animals with increased reactivity, body tone, and Straub tail. Interestingly, selected behavioral and telemetric data from the early post-status epilepticus phase correlated with the frequency of electrographic seizure events in the chronic phase. CONCLUSION In conclusion, our findings argue against the pronounced impact of highly frequent electrographic seizures on the well-being of mice. However, an increased level of nervousness in a subgroup of animals should be considered for handling procedures and refinement measures. In the early postsurgical phase, several parameters indicate an influence of the interventions with evidence that the nonconvulsive status epilepticus can negatively affect the recovery. Thus, the development and validation of refinement efforts should focus on this experimental phase. Finally, the datasets suggest that simple readout parameters may predict the long-term consequences of the epileptogenic insult. Respective biomarker candidates require further validation in the follow-up studies in models with subgroups of animals with or without epilepsy development.
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Affiliation(s)
- Verena Buchecker
- Institute of Pharmacology, Toxicology, and Pharmacy, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Ines Koska
- Institute of Pharmacology, Toxicology, and Pharmacy, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Claudia Pace
- Institute of Pharmacology, Toxicology, and Pharmacy, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Steven R. Talbot
- Institute for Laboratory Animal Science, Hannover Medical School, Hannover, Germany
| | - Rupert Palme
- Department of Biomedical Sciences, University of Veterinary Medicine, Vienna, Austria
| | - Andre Bleich
- Institute for Laboratory Animal Science, Hannover Medical School, Hannover, Germany
| | - Heidrun Potschka
- Institute of Pharmacology, Toxicology, and Pharmacy, Ludwig-Maximilians-University Munich, Munich, Germany
- *Heidrun Potschka,
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Simon É, Csipkés C, Andráskó D, Kovács V, Szabó-Maák Z, Tankó B, Buchholcz G, Fülesdi B, Molnár C. Preoperatively administered single dose of dexketoprofen decreases pain intensity on the first 5 days after craniotomy: A single-centre placebo-controlled, randomized trial. Transl Neurosci 2023; 14:20220323. [PMID: 38152091 PMCID: PMC10751892 DOI: 10.1515/tnsci-2022-0323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 10/30/2023] [Accepted: 10/30/2023] [Indexed: 12/29/2023] Open
Abstract
Background and purpose Headache attributed to craniotomy is an underestimated and under-treated condition. Previous studies confirmed the efficacy of preemptive analgesia with non-steroidal anti-inflammatory agents. The aim of the present work was to test the hypothesis of whether a single preoperatively administered dose of dexketoprofen (DEX) has the potency to decrease postcraniotomy headache (PCH) as compared to placebo (PL). Patients and methods This is a single-centre, randomized, PL-controlled trial comparing the effect of a single oral dose of 25 mg DEX to PL on the intensity of PCH. Patients undergoing craniotomy were randomly allocated to DEX and PL groups. Patients rated their actual and worst daily pain using visual analogue scale (VAS) scores during intrahospital treatment (0-5 days) and 30 and 90 days postoperatively. Results Two hundred patients were included. DEX decreased the worst daily pain intensity in the first 24 h only; the 5-days cumulative score of actual pain was 9.7 ± 7.9 cm for the DEX group and 12.6 ± 10.5 cm for the PL group, respectively (p = 0.03). This difference disappeared in the late, 30-, and 90-day follow-up period. No differences in VAS scores could be detected in supra- and infratentorial cases among the DEX and PL groups. Conclusions A single preoperative dose of 25 mg of DEX slightly decreases the intensity of PCH in the first 5 days after craniotomy but it does not have an effect on chronic headaches and postoperative analgesic requirements.
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Affiliation(s)
- Éva Simon
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Csaba Csipkés
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Dániel Andráskó
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Veronika Kovács
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Szabó-Maák
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Béla Tankó
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Gyula Buchholcz
- University Pharmacy, Clinical Centre, University of Debrecen, Debrecen, Hungary
| | - Béla Fülesdi
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Csilla Molnár
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Zhang W, Li C, Zhao C, Ji N, Luo F. Pre-incisional infiltration with ropivacaine plus dexamethasone palmitate emulsion for postoperative pain in patients undergoing craniotomy: study protocol for a prospective, randomized controlled trial. Trials 2022; 23:996. [PMID: 36510271 PMCID: PMC9743637 DOI: 10.1186/s13063-022-06936-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 11/15/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Post-craniotomy pain is a common occurrence which is associated with poor outcomes. Pre-emptive scalp infiltration with dexamethasone and ropivacaine has been proven effective in previous studies but with limited clinical significance. Dexamethasone palmitate emulsion (D-PAL) is a pro-drug incorporating dexamethasone into lipid microspheres with greater anti-inflammatory activity and fewer side effects than free dexamethasone. However, its effects in post-craniotomy pain management remain unknown. This study hypothesizes that pre-emptive scalp infiltration with ropivacaine plus D-PAL emulsion can achieve superior analgesic effects to ropivacaine alone in adult patients undergoing craniotomy. METHODS/DESIGN This is a single center, randomized controlled trial enrolling 130 patients scheduled for supratentorial craniotomy, which is expected to last longer than 4 h. We compare the efficacy and safety for postoperative pain relief of ropivacaine plus D-PAL group and ropivacaine alone group following pre-emptive scalp infiltration. Primary outcome will be pain Numerical Rating Scale at 24 h postoperatively. Secondary outcomes will include further analgesia evaluations and drug-related complications within a follow-up period of 3 months. DISCUSSION This is the first randomized controlled trial aiming to assess the possible benefits or disadvantages of D-PAL emulsion for incisional pain in craniotomy. It may provide an alternative to optimize pain outcome for neurosurgical patients. TRIAL REGISTRATION ClinicalTrials.gov (NCT04488315). Registered on 19 July 2020.
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Affiliation(s)
- Wei Zhang
- grid.24696.3f0000 0004 0369 153XDepartment of Day Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 People’s Republic of China
| | - Chunzhao Li
- grid.24696.3f0000 0004 0369 153XDepartment of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 100070 Beijing, People’s Republic of China
| | - Chunmei Zhao
- grid.24696.3f0000 0004 0369 153XDepartment of Day Surgery and Pain Management, Beijing Tiantan Hospital, Capital Medical University, 100070 Beijing, People’s Republic of China
| | - Nan Ji
- grid.24696.3f0000 0004 0369 153XDepartment of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 100070 Beijing, People’s Republic of China
| | - Fang Luo
- grid.24696.3f0000 0004 0369 153XDepartment of Day Surgery and Pain Management, Beijing Tiantan Hospital, Capital Medical University, 100070 Beijing, People’s Republic of China
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12
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Ning L, Jiang L, Zhang Q, Luo M, Xu D, Peng Y. Effect of scalp nerve block with ropivacaine on postoperative pain in pediatric patients undergoing craniotomy: A randomized controlled trial. Front Med (Lausanne) 2022; 9:952064. [PMID: 36160174 PMCID: PMC9489944 DOI: 10.3389/fmed.2022.952064] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 07/15/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundScalp nerve block (SNB) is widely used for postoperative pain control, intraoperative hemodynamic control, and opioid-sparing in adult craniotomies. However, there are few studies of SNB in pediatric patients undergoing craniotomy. In the present study, we aimed to investigate the effect of SNB on postoperative pain, intraoperative hemodynamic stability, and narcotic consumption in pediatric craniotomy under general anesthesia.MethodsThis trial is a single-center, prospective, randomized, and double-blind study. A total of 50 children aged between 2 and 12 years who are undergoing elective brain tumor surgery will be randomly allocated in a 1:1 ratio to receive either 0.2% ropivacaine for SNB (group SNB, intervention group, n = 25) or the same volume of saline (group Ctrl, control group, n = 25). The primary outcome was to assess the score of postoperative pain intensity at time 1, 4, 8, 12, 24, and 48 h postoperatively using the FLACC score method. Secondary outcomes were to record intraoperative hemodynamic variables (MAP and HR) during skull-pin fixation, skin incision and end of skin closure, intraoperative total consumption of remifentanil and propofol, postoperative opioid consumption, and the incidence of postoperative nausea and vomiting.ResultsFifty patients were analyzed (n = 25 in SNB group; n = 25 in control group). Compared to the control group, postoperative pain intensity was significantly relieved in the SNB group up to 8 h post-operatively. In addition, SNB provided good intraoperative hemodynamic stability, reduced intraoperative overall propofol and remifentanil consumption rate, and postoperative fentanyl consumption compared to the control group. However, the incidence of postoperative nausea and vomiting was not different between SNB and the control group.ConclusionsIn pediatric craniotomies, SNB with 0.2% ropivacaine provides adequate postoperative pain control and good intraoperative hemodynamic stability during noxious events compared to the control group.Clinical trial registrationChinese Clinical Trial Registry [No: ChiCTR2100050594], Prospective registration.
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Affiliation(s)
- Li Ning
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lai Jiang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Qingqing Zhang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Mengqiang Luo
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
- Mengqiang Luo
| | - Daojie Xu
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
- Daojie Xu
| | - Yuanzhi Peng
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- *Correspondence: Yuanzhi Peng
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13
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Zeng M, Li R, Xu X, Wang D, Dong J, Li S, Kass IS, Peng Y, Jia W. Ultrasound-guided superficial cervical plexus block reduces opioid consumption in patients undergoing craniotomy via suboccipital retrosigmoid approach: a randomized controlled trial. Reg Anesth Pain Med 2022; 47:rapm-2022-103534. [PMID: 35768167 DOI: 10.1136/rapm-2022-103534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 06/20/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The effectiveness of superficial cervical plexus block (SCPB) at decreasing opioid use and improving hemodynamic stability during suboccipital retrosigmoid craniotomy has not been established. The aim of this study is to evaluate the analgesic effect of preoperative ultrasound-guided SCPB for craniotomy via a suboccipital retrosigmoid approach. METHODS This was a prospective, single-center, randomized, double-blind, parallel-group controlled trial. One hundred and six adult patients undergoing suboccipital retrosigmoid craniotomy were randomly allocated into either the SCPB group (n=53) to receive 10 mL of 0.5% ropivacaine or the control group (n=53) to receive 0.9% normal saline injected into the superficial layer of prevertebral fascia guided by ultrasound. The primary outcome was the cumulative consumption of sufentanil with patient-controlled intravenous analgesia (PCIA) within 24 hours. Secondary outcomes included the overall perioperative consumption of opioids, the area under the curve of the pain score from 1 hour to 48 hours (AUC1-48), intraoperative hemodynamic parameters, and anesthesia depth. RESULTS The mean PCIA pump cumulative consumption of sufentanil in the first 24 hour postoperative period was significantly lowered by SCPB (5.0 µg vs 9.8 µg, 95% CI: -8.0 to -2.4; p=0.001). The total perioperative consumption of sufentanil (45.0 µg vs 54.5 µg, 95% CI: -14.8 to -4.1; p=0.001) was also significantly decreased by SCPB. The incidence of severe pain within 24 hours was decreased by SCPB (7.5% vs 26.4%, p=0.01). SCPB significantly decreased the AUC1-48 of the pain score. Intraoperative hemodynamic parameters and anesthesia depth were similar between groups (p>0.05). DISCUSSION SCPB provides effective analgesia in patients undergoing craniotomy and tumor resection via suboccipital retrosigmoid approach. SCPB demonstrates an opioid-sparing effect and allows for the maintenance hemodynamic stability at an appropriate depth of anesthesia. TRIAL REGISTRATION NUMBER NCT04036812.
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Affiliation(s)
- Min Zeng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Ruowen Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Xin Xu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Dexiang Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Jia Dong
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Shu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Ira S Kass
- Anesthesiology and Physiology & Pharmacology Departments, SUNY Downstate Health Sciences University, Brooklyn, New York, USA
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Wang Jia
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
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Abstract
Purpose of Review Postcraniotomy headache (PCH) is a highly underappreciated and very common adverse event following craniotomy. Recent Findings Analgetic medication with opioids often interferes with neurologic evaluation in the acute phase of recovery and should be kept to a minimal, in general, in the treatment of chronic pain as well. We provide an update on the latest evidence for the management of acute and chronic PCH. Summary Especially in the neurosurgical setting, enhanced recovery after surgery protocols need to include a special focus on pain control. Patients at risk of developing chronic pain must be identified and treated as early as possible.
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Kvolik S, Koruga N, Skiljic S. Analgesia in the Neurosurgical Intensive Care Unit. Front Neurol 2022; 12:819613. [PMID: 35185756 PMCID: PMC8848763 DOI: 10.3389/fneur.2021.819613] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 12/23/2021] [Indexed: 11/13/2022] Open
Abstract
Acute pain in neurosurgical patients is an important issue. Opioids are the most used for pain treatment in the neurosurgical ICU. Potential side effects of opioid use such as oversedation, respiratory depression, hypercapnia, worsening intracranial pressure, nausea, and vomiting may be problems and could interfere with neurologic assessment. Consequently, reducing opioids and use of non-opioid analgesics and adjuvants (N-methyl-D-aspartate antagonists, α2 -adrenergic agonists, anticonvulsants, corticosteroids), as well as non-pharmacological therapies were introduced as a part of a multimodal regimen. Local and regional anesthesia is effective in opioid reduction during the early postoperative period. Among non-opioid agents, acetaminophen and non-steroidal anti-inflammatory drugs are used frequently. Adverse events associated with opioid use in neurosurgical patients are discussed. Larger controlled studies are needed to find optimal pain management tailored to neurologically impaired neurosurgical patients.
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Affiliation(s)
- Slavica Kvolik
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
- Department of Anesthesiology and Critical Care, Osijek University Hospital, Osijek, Croatia
- *Correspondence: Slavica Kvolik
| | - Nenad Koruga
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
- Department of Neurosurgery, Osijek University Hospital, Osijek, Croatia
| | - Sonja Skiljic
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
- Department of Anesthesiology and Critical Care, Osijek University Hospital, Osijek, Croatia
- Sonja Skiljic
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16
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Gehlaut P, Bala R, Mittal K, Singh I. Ropivacaine instillation through subgaleal drain: A novel approach for acute post-craniotomy pain. Indian J Anaesth 2022; 66:498-504. [PMID: 36111089 PMCID: PMC9468998 DOI: 10.4103/ija.ija_646_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 07/04/2022] [Accepted: 07/05/2022] [Indexed: 11/07/2022] Open
Abstract
Background and Aims: Post-craniotomy pain has often been overlooked and undertreated. Various classes of analgesic drugs have been used, not without limitations. Therefore, we planned to study the novel technique of wound instillation of ropivacaine through the surgical drain in patients undergoing supratentorial craniotomy to study its effect on post-craniotomy pain, analgesic requirement in the post-operative period along with the recovery profile of the patient and the side effects. Methods: This prospective, randomised, placebo-controlled, double-blinded study enroled 50 patients of either gender, scheduled to undergo elective craniotomy, under general anaesthesia. They were randomly divided into two groups and received either 12 ml of 0.25% ropivacaine (group R) or 12 ml of normal saline (group NS), through the subgaleal drain, after the closure of the dura. Pain scores were assessed at 1, 2, 4, 8 and 24 hours post-operatively. Student’s t-test was used for comparison of continuous variables and the Chi-square test or Fisher’s exact test was used for comparing the nominal categorical data. Results: The visual analogue scale score was higher in group NS than in group R, and the difference was statistically significant (P = 0.012, 0.016, and 0.005 at 0, 1, and 2 post-operative hours, respectively). The difference in the mean emergence time in the two groups was 1.12 minutes (P = 0.024). Conclusion: Single-time wound instillation of ropivacaine (12 ml of 0.25%) through surgical (subgaleal) drain during wound closure is an effective and simple technique for reducing post-operative pain and analgesic consumption and early emergence in neurosurgical patients undergoing supratentorial craniotomy.
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Modulation of nociception and pain-evoked neurobehavioral responses by levetiracetam in a craniotomy pain model. Behav Brain Res 2021; 420:113728. [PMID: 34952028 DOI: 10.1016/j.bbr.2021.113728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 12/06/2021] [Accepted: 12/18/2021] [Indexed: 11/23/2022]
Abstract
Traditional and novel analgesic modalities have been extensively tested for post-craniotomy pain management, yet the role of newer antiepileptic drugs in this area remains obscure. This study investigates the impact of levetiracetam (LEV) on pain modulation and neurobehavioral performance in a craniotomy model. Fifty-six Wistar rats were randomly assigned into seven groups: no intervention (CTRL), administration of placebo or LEV with no further intervention (PBO and LEV, respectively), and sham-operation or craniotomy in placebo (PBO-SHAM and PBO-CR, respectively) or LEV-treated rats (LEV-SHAM and LEV-CR, respectively). Pain was assessed by the rat grimace scale before, and at 8 and 24 h after craniotomy, following intraperitoneal injections of LEV (100 mg/kg twice daily) or normal saline two consecutive days before and on the craniotomy day. Elevated plus-maze and olfactory social memory tests were performed at 24- and 48 h post-craniotomy, respectively. Upon testing conclusion blood samples were collected for cytokines estimation. Levetiracetam administration enhanced antinociception in sham and craniotomy groups. In the elevated plus-maze test, LEV-CR rats spent more time in investigating open arms and performed more open arm entries than PBO-SHAM and PBO-CR animals. The olfactory test revealed no between-groups difference in acquisition time during first contact with a juvenile rat, while LEV-CR rats spent less time to recognize the same juvenile rat compared to PBO-SHAM and PBO-CR groups. Furthermore, LEV-treatment attenuated cortisol, interleukin-6 and TNF-a release, in sham and craniotomy animals. In conclusion, preemptive use of LEV decreases nociception, improves pain-evoked behavior and attenuates stress response in rats subjected to craniotomy.
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18
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Wang L, Cai H, Wang Y, Liu J, Chen T, Liu J, Huang J, Guo Q, Zou W. Enhanced recovery after elective craniotomy: A randomized controlled trial. J Clin Anesth 2021; 76:110575. [PMID: 34739947 DOI: 10.1016/j.jclinane.2021.110575] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 12/11/2022]
Abstract
STUDY OBJECTIVES Enhanced recovery after surgery (ERAS) protocols have been proven to improve outcomes but have not been widely used in neurosurgery. The purpose of this study was to design a multidisciplinary enhanced recovery after elective craniotomy protocol and to evaluate its clinical efficacy and safety after implementation. DESIGN A prospective randomized controlled trial. SETTING The setting is at an operating room, a post-anesthesia care unit, and a hospital ward. PATIENTS This randomized controlled trial (RCT) prospectively analyzed 151 patients who underwent elective craniotomy between January 2019 and June 2020. INTERVENTIONS The neurosurgical ERAS group was cared for with evidence-based systematic optimization approaches, while the control group received routine care. MEASUREMENTS The primary outcomes were the postoperative length of stay (LOS) and hospitalization costs. The secondary outcomes included 30-day readmission rates, postoperative complications, postoperative pain scores, length of intensive care unit (ICU) stay, duration of the drainage tube, time to oral intake, time to ambulation, and postoperative functional recovery status. MAIN RESULTS After ERAS protocol implementation, the median postoperative LOS (4 days to 3 days, difference [95% confidence interval, CI], 2 [1 to 2], P < 0.0001) and hospitalization costs (6266 USD to 5880 USD, difference [95% CI], 427.0 [234.8 to 633.6], P < 0.0001) decreased. Compared to routine perioperative care, the ERAS protocol reduced the incidence of postoperative nausea and vomiting (PONV) (28.0% to 9.2%, adjusted odds ratio [OR] 0.3, 95% CI 0.1-0.7, P = 0.003), shortened urinary catheter removal time by 24 h (64.0% to 83.0%, adjusted OR 2.9, 95% CI 1.3-6.5, P = 0.031), improved ambulation on postoperative day 1 (POD 1) (30.7% to 75.0%, adjusted OR 7.5, 95% CI 3.6-15.8, P < 0.0001), shortened the time to oral intake (15 h to 13 h, difference [95% CI], 3 [1 to 4], P < 0.001), and improved perioperative pain management. CONCLUSIONS Implementation of an enhanced recovery after elective craniotomy protocol had significant benefits over conventional perioperative management. It was associated with a significant reduction in postoperative length of stay, medical cost, and postoperative complications.
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Affiliation(s)
- Lei Wang
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Hongwei Cai
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yanjin Wang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jian Liu
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Tiange Chen
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jing Liu
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY, United States of America
| | - Qulian Guo
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Wangyuan Zou
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China.
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Zhao C, Jia Z, Shrestha N, Luo F. REDUCE trial: the effects of perineural dexamethasone on scalp nerve blocks for relief of postcraniotomy pain-a study protocol for a randomized controlled trial. Trials 2021; 22:772. [PMID: 34736497 PMCID: PMC8567555 DOI: 10.1186/s13063-021-05747-y] [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: 04/07/2021] [Accepted: 10/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pain is common in the first 2 days after major craniotomy. Inadequate analgesia may lead to an increased risk of postoperative complications. Most pain following craniotomy arises from the pericranial muscles and soft tissues of the scalp. Scalp nerve blocks with local anesthesia seem to provide effective, safe, however, transient postoperative analgesia which does not seem to meet the requirements of craniotomy. Currently, peripheral dexamethasone has been observed to significantly prolong the duration of analgesia of nerve blocks (e.g., saphenous nerve block, adductor canal block, thoracic paravertebral block, brachial plexus nerve block). On the contrary, a study reported that perineural dexamethasone did not appear to prolong the analgesic time after supratentorial craniotomy. However, all patients in this study were given 24 mg of oral or intravenous dexamethasone regularly for at least 7 days during the perioperative period, which possibly masked the role of single local low doses of perineural dexamethasone. Therefore, the analgesic effect of single dexamethasone for scalp nerve blocks without the background of perioperative glucocorticoid deserves further clarification. METHODS The REDUCE trial is a prospective, single-center, parallel-group randomized controlled trial involving a total of 156 adults scheduled for elective craniotomy with general anesthesia. Patients will be randomly divided among two groups: the control group (n = 78) will receive scalp nerve blocks with 0.5% bupivacaine, plus normal saline with epinephrine at 1:200,000; the DEX4mg group (n = 78) will receive scalp nerve blocks with 0.5% bupivacaine, plus 4 mg dexamethasone with epinephrine at 1:200,000. The primary outcome will be the duration of analgesia, defined as the time between the performance of the block and the first analgesic request. DISCUSSION The REDUCE trial aims to further assess the analgesic effect of single dexamethasone as an adjuvant to scalp nerve blocks for relief of postcraniotomy pain without the background of perioperative glucocorticoid. TRIAL REGISTRATION ClinicalTrials.gov NCT04648358 . Registered on November 30, 2020.
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Affiliation(s)
- Chunmei Zhao
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Zipu Jia
- Department of Day Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Niti Shrestha
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Fang Luo
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.
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Patel KS, Sun MZ, Willis SL, Alemnew M, De Jong R, Evans AS, Duong C, Gopen Q, Yang I. Selective scalp block decreases short term post-operative pain scores and opioid use after craniotomy: A case series. J Clin Neurosci 2021; 93:183-187. [PMID: 34656245 DOI: 10.1016/j.jocn.2021.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/12/2021] [Accepted: 09/06/2021] [Indexed: 10/20/2022]
Abstract
There is no consensus on the management of post-craniotomy pain. Several randomized controlled trials have examined the use of a regional scalp block for post-craniotomy pain. We aim to investigate whether scalp block affected short or long-term pain levels and opioid use after craniotomy. This study prospectively administered selective scalp blocks (lesser occipital, preauricular nerve block + pin site block) in 20 consecutive patients undergoing craniotomy for semicircular canal dehiscence. Anesthesia, pain, and opioid outcomes in these patients were compared to 40 consecutive historic controls. There was no significant difference in patient demographics between the two groups and no complications related to selective scalp block. The time between the end of procedure and end of anesthesia decreased in the scalp block group (16 vs 21 min, P = 0.047). Pain scores were significantly less in the scalp block group for the first 4 h, after which there was no statistically significant difference. Time to opioid rescue was longer in the scalp block group (3.6 vs 1.8 h, HR 0.487, P = 0.0361) and opioid use in the first 7 h was significantly less in the scalp block group. Total opioid use, outpatient opioid use, and length of stay did not differ. Selective scalp block is a safe and effective tool for short-term management of postoperative pain after craniotomy and decreases the medication requirement during emergence and recovery. Selective scalp block can speed up OR turnover but is not efficacious in the treatment of postoperative pain beyond this point.
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Affiliation(s)
- Kunal S Patel
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, United States
| | - Matthew Z Sun
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, United States
| | - Shelby L Willis
- Department of Head & Neck Surgery, University of California Los Angeles, Los Angeles, CA, United States
| | - Mahlet Alemnew
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, United States
| | - Russell De Jong
- Department of Head & Neck Surgery, University of California Los Angeles, Los Angeles, CA, United States
| | - Audree S Evans
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, United States
| | - Courtney Duong
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, United States
| | - Quinton Gopen
- Department of Head & Neck Surgery, University of California Los Angeles, Los Angeles, CA, United States
| | - Isaac Yang
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, United States; Department of Head & Neck Surgery, University of California Los Angeles, Los Angeles, CA, United States; Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, United States; Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, CA, United States; Department of Surgery, Harbor-UCLA Los Angeles, Los Angeles, CA, United States; Los Angeles Biomedical Research Center, Harbor-UCLA Los Angeles, Los Angeles, CA, United States.
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21
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Role of Craniectomy Versus Craniotomy via the Retrosigmoid Approach in Decreasing the Incidence of Postoperative Headache. Int Surg 2021. [DOI: 10.9738/intsurg-d-21-00011.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Postoperative headache is a major complaint after RS surgery. PH affected the patient’s quality of life. The role of craniotomy in the prevention of such headaches. We aimed to evaluate the role of craniectomy versus craniotomy via the retrosigmoid approach in reducing the incidence of postoperative headaches. Materials and methods: Patients who underwent surgery between January 2012 and December 2018 were retrospectively assessed and were classified into the craniectomy and craniotomy groups. Clinical data, such as those on age, sex, type of surgery, surgical repair technique, development of infection, postoperative cerebrospinal fluid leak, postoperative meningitis, size of the bone flap, and wound infection, were collected. The severity of headache in all patients was clinically assessed using the Catalano grading system. Results: Overall, 95 patients underwent microsurgery via the retrosigmoid approach. Of these, 48 were men and 47 were women. In total, 34 patients underwent craniectomy, and 61 patients underwent craniotomy. On discharge, postoperative headache was observed in 47% (16/34) and 21% (13/61) of patients who underwent craniectomy and craniotomy, respectively ( P =.01). The incidence of headache decreased at follow-up. At 12 months after surgery, 15% of patients in the craniectomy group (5/34) and 2% of patients in the craniotomy group (2/61) experienced headache ( P =.01). Of the 61 patients in the craniotomy group, 2 (2%) had less severe headache at 12 months of follow-up. Conclusion: The severity of headache after surgery and upon discharge significantly decreased in patients who underwent craniotomy than in those who underwent craniectomy.
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22
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Pain Quality Among Hospitalized Postcraniotomy Brain Tumor Patients. CLIN NURSE SPEC 2021; 35:129-137. [PMID: 33793175 DOI: 10.1097/nur.0000000000000594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE/AIMS The aim of this study was to describe how persons given a diagnosis of a brain tumor who have had a craniotomy describe the quality of their pain after surgery. DESIGN A qualitative descriptive design was used. METHODS Qualitative descriptive methods as described by Sandelowski guided this study. Semistructured interviews were conducted with patients hospitalized on a neurological step-down unit in an urban teaching hospital in the Midwestern United States. Interviews focused on the quality of participants' pain after surgery. Narratives were analyzed using standard content analysis. RESULTS Twenty-seven participants were interviewed. Most were White and female. Most underwent a craniotomy using an anterior approach with sedation. Participants described the quality of their pain with 6 different types of descriptors: pain as pressure, pain as tender or sore, pain as stabbing, pain as throbbing, pain as jarring, and pain as itching. CONCLUSIONS Participants' descriptions of their pain quality after surgery provide a different understanding than do numerical pain ratings. Clinicians should use questions to explore patients' individual pain experiences, seeking to understand the quality of patients' pain and their perceptions.
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23
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Efficacy of an opioid-sparing analgesic protocol in pain control after less invasive cranial neurosurgery. Pain Rep 2021; 6:e948. [PMID: 34368598 PMCID: PMC8341305 DOI: 10.1097/pr9.0000000000000948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 04/15/2021] [Accepted: 05/22/2021] [Indexed: 12/04/2022] Open
Abstract
An opioid-sparing protocol for postoperative pain management in less invasive cranial neurosurgery significantly lowered opioid usage while reducing pain scores. Introduction: Opioid overuse in postoperative patients is a worrisome trend, and potential alternatives exist which warrant investigation. Nonsteroidal anti-inflammatory drug use in treating postoperative cranial surgery pain has been hampered by concern for inadequate pain control and increased risk of hemorrhagic complications. A safe and effective alternative to opioid-based pain management is critical to improving postoperative care. Objective: The objective of this retrospective study was to determine whether an NSAID-based opioid-sparing pain management protocol (OSP) is effective in analgesic control of less invasive cranial surgery patients at 6-, 12-, and 24-hour postoperatively. Secondary aims included investigating differences in hemorrhagic complications. Methods: Five hundred sixty-six consecutive patients who underwent cranial surgery before and after implementation of the celecoxib-based OSP were eligible. Propensity score matching was used to match patients in each cohort. Results: The opioid-sparing cohort had lower pain scores at 6 hours (3.45 vs 4.19, P = 0.036), 12 hours (3.21 vs 4.00, P = 0.006), and 24 hours (2.90 vs 3.59, P = 0.010). Rates of postoperative hemorrhage were not significantly different (5% intervention vs 8% control, P = 0.527). The opioid-sparing pain management protocol provided comparable or better pain control in the first 24 hours after less invasive cranial surgery. Hemorrhage rates did not change with the use of an NSAID-based OSP. Conclusion: An effective alternative to the current standard opioid-based pain management is feasible for less invasive cranial surgery. Determinations of hemorrhage risk and more complex cranial surgery will require larger prospective randomized trials.
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24
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Foust Winton RE, Draucker CB, Von Ah D. Pain Management Experiences Among Hospitalized Postcraniotomy Brain Tumor Patients. Cancer Nurs 2021; 44:E170-E180. [PMID: 32657900 PMCID: PMC7794082 DOI: 10.1097/ncc.0000000000000851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Brain tumors account for the majority of central nervous system tumors, and most are removed by craniotomies. Many postcraniotomy patients experience moderate or severe pain after surgery, but patient perspectives on their experiences with pain management in the hospital have not been well described. OBJECTIVE The aim of this study was to describe how patients who have undergone a craniotomy for brain tumor removal experience pain management while hospitalized. METHODS Qualitative descriptive methods using semistructured interviews were conducted with patients on a neurological step-down unit in an urban teaching hospital in the Midwest United States. Interviews focused on how patients experienced postcraniotomy pain and how it was managed. Narratives were analyzed with standard content analytic procedures. RESULTS Twenty-seven participants (median age, 58.5 years; interquartile range, 26-41 years; range, 21-83 years) were interviewed. The majority were white (n = 25) and female (n = 15) and had an anterior craniotomy (n = 25) with sedation (n = 17). Their pain experiences varied on 2 dimensions: salience of pain during recovery and complexity of pain management. Based on these dimensions, 3 distinct types of pain management experiences were identified: (1) pain-as-nonsalient, routine pain management experience; (2) pain-as-salient, routine pain management experience; and (3) pain-as-salient, complex pain management experience. CONCLUSIONS Many postcraniotomy patients experience their pain as tolerable and/or pain management as satisfying and effective; others experience pain and pain management as challenging. IMPLICATIONS FOR PRACTICE Clinicians should be attuned to needs of patients with complex pain management experiences and should incorporate good patient/clinician communication.
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Affiliation(s)
- Rebecca E Foust Winton
- Author Affiliation: Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis
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25
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Zhao C, Wang S, Pan Y, Ji N, Luo F. Pre-Emptive Incision-Site Infiltration with Ropivacaine Plus Dexamethasone for Postoperative Pain After Supratentorial Craniotomy: A Prospective Randomized Controlled Trial. J Pain Res 2021; 14:1071-1082. [PMID: 33907455 PMCID: PMC8064677 DOI: 10.2147/jpr.s300943] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/22/2021] [Indexed: 01/23/2023] Open
Abstract
Background Incision-site infiltration with local anesthetics prevents pain on incision site, but pain relief is limited to the first few postoperative hours. Dexamethasone as an adjuvant to local infiltration successfully achieves better postoperative pain relief; however, this has not been studied in craniotomy patients yet. Study Design and Methods This is a prospective, single-center, blinded, randomized, controlled trial included patients aged between 18 and 64 years, ASA physical status of I–II, scheduled for elective supratentorial tumor craniotomy under general anesthesia. We screened patients for enrollment from April 4, 2019 through August 15, 2019. The final study visit of the last patient was conducted on February 13, 2020. We randomly assigned eligible participants (1:1) to either the dexamethasone group who received incision-site infiltration of 0.5% ropivacaine plus 0.033% dexamethasone (N=70) or the control group who received 0.5% ropivacaine alone (N=70). Primary outcome was the cumulative sufentanil consumption (μg) within 48 hours postoperatively. Primary analysis was performed based on the modified intention-to-treat (MITT) principle. Results Baseline characteristics were similar between the groups (p>0.05). Sufentanil consumption during the first 48 hours postoperatively was 29.0 (10.7) μg in the dexamethasone group and 38.3 (13.7) μg in the control group (mean difference −9.3, 95% CI −13.4 to −5.1; p<0.001). There was no serious adverse effect directly associated with incision-site infiltration or local dexamethasone use. Conclusion The addition of dexamethasone to pre-emptive incision-site infiltration with the local anesthetic can reduce about 27% of opioids consumption and the postoperative pain scores within 72 hours after craniotomy. Trial Registration ClinicalTrials.Gov (NCT03618264).
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Affiliation(s)
- Chunmei Zhao
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, People's Republic of China
| | - Shaoheng Wang
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, People's Republic of China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, 100070, People's Republic of China
| | - Nan Ji
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, People's Republic of China
| | - Fang Luo
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, People's Republic of China
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26
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Dupriest K, Rogers K, Thakur B, Venkatachalam AM, Stutzman SE. Postoperative Pain Management Is Influenced by Previous Cannabis Use in Neurosurgical Patients. J Neurosci Nurs 2021; 53:87-91. [PMID: 33538461 DOI: 10.1097/jnn.0000000000000577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT BACKGROUND: Cannabis use for medical and recreational purposes is growing. Cannabis may have drug-drug interactions for managing pain, anxiety, and seizures. The research regarding cannabis use in patients with craniotomy surgeries is sparse and often conducted in states where cannabis use is legal. This study compared 24-hour postoperative craniotomy pain levels in patients who reported cannabis use in a state where cannabis is not yet legal. METHODS: This is an observational prospective, nonrandomized, pilot study of postoperative craniotomy patients. Patients were consented and given a one-time self-report questionnaire regarding postoperative pain, pain management method, type of pain medication used at home (including cannabis), route of administration, and frequency of use. Subjects scored pain on both the numeric rating scale and the visual analog scale. Demographic data were collected from the electronic medical record. RESULTS: Forty-five patients with a mean age of 57 years, 62% female, participated in this study. There were 33% who reported previous cannabis use. One-way analysis of variance showed a significant difference in the mean postoperative pain scores for the cannabis users (4.58) and nonusers (3.89; P = .0056). There was no significant difference between age (P = .1894) and adequacy of pain control (P = .6584) between users and nonusers. CONCLUSION: In this pilot study, a one-time survey in critical care on the sensitive topic of cannabis use is feasible and seems to generate honest responses. One-third of patients reported home use of cannabis in a state where cannabis is illegal.
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27
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Carella M, Tran G, Bonhomme VL, Franssen C. Influence of Levobupivacaine Regional Scalp Block on Hemodynamic Stability, Intra- and Postoperative Opioid Consumption in Supratentorial Craniotomies: A Randomized Controlled Trial. Anesth Analg 2021; 132:500-511. [PMID: 33060491 DOI: 10.1213/ane.0000000000005230] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The anesthetic management of supratentorial craniotomy (CR) necessitates tight intraoperative hemodynamic control. This type of surgery may also be associated with substantial postoperative pain. We aimed at evaluating the influence of regional scalp block (SB) on hemodynamic stability during the noxious events of supratentorial craniotomies and total intravenous anesthesia, its influence on intraoperative anesthetic agents' consumption, and its effect on postoperative pain control. METHODS Sixty patients scheduled for elective CR were prospectively enrolled. Patient, anesthesiologist, and neurosurgeon were blind to the random performance of SB with either levobupivacaine 0.33% (intervention group [group SB], n = 30) or the same volume of saline (control group [group CO], placebo group, n = 30). General anesthesia was induced and maintained using target-controlled infusions of remifentanil and propofol that were adjusted according to hemodynamic parameters and state entropy of the electroencephalogram (SE), respectively. Mean arterial blood pressure (MAP), heart rate (HR), SE, and propofol and remifentanil effect-site concentrations (Ce) were recorded at the time of scalp block performance (Baseline), and 0, 1, 3, and 5 minutes after skull-pin fixation (SP), skin incision (SI), CR, and dura-mater incision (DM). Morphine consumption and postoperative pain intensity (0-10 visual analog scale [VAS]) were recorded 1, 3, 6, 24, and 48 hours after surgery. Propofol and remifentanil overall infusion rates were also recorded. Data were analyzed using 2-tailed Student unpaired t tests, 2-way mixed-design analysis of variance (ANOVA), and Tukey's honestly significant difference (HSD) tests for post hoc comparisons as appropriate. RESULTS Demographics and length of anesthetic procedure of group CO and SB were comparable. SP, SI, and CR were associated with a significantly higher MAP in group CO than in group SB, at least at one of the time points of recording surrounding those noxious events. This was not the case at DM. Similarly, HR was significantly higher in group CO than in group SB during SP and SI, at least at 1 of the points of recording, but not during CR and DM. Propofol and remifentanil Ce and overall infusion rates were significantly higher in group CO than in group SB, except for propofol Ce during SP. Postoperative pain VAS and cumulative morphine consumption were significantly higher in group CO than in group SB. CONCLUSIONS In supratentorial craniotomies, SB improves hemodynamic control during noxious events and provides adequate and prolonged postoperative pain control as compared to placebo.
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Affiliation(s)
- Michele Carella
- From the Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
| | - Gabriel Tran
- From the Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
| | - Vincent L Bonhomme
- From the Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium.,University Department of Anesthesia and Intensive Care Medicine, Centre Hospitalier Régional Citadelle, Liege, Belgium.,Anesthesia and Intensive Care Laboratory, Centre interdisciplinaire de recherche biomédicale de l'Université de Liège (GIGA)-Consciousness Thematic Unit, GIGA-Research, Liege University, Liege, Belgium
| | - Colette Franssen
- From the Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
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28
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Karaarslan N, Yilmaz I, Sirin DY. Toxicity of the acetyl-para-aminophenol group of medicines to intact intervertebral disc tissue cells. Exp Ther Med 2021; 21:147. [PMID: 33456514 PMCID: PMC7791924 DOI: 10.3892/etm.2020.9578] [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: 07/25/2020] [Accepted: 11/06/2020] [Indexed: 11/21/2022] Open
Abstract
The present study aimed to investigate the effects of paracetamol, an analgesic and antipyretic that is used in emergency departments and neurosurgery departments for postoperative pain management on intervertebral disc tissue. Paracetamol-treated human primary cell cultures and untreated cell cultures were compared using molecular analyses. Cell proliferation and gene expression were statistically analyzed. Cell proliferation was suppressed on days 10 (P=0.05) and 20 (P<0.05) in the paracetamol-treated groups. Gene expression of chondroadherin, matrix metalloproteinase (MMP)-7, MMP-13 and MMP-19 was higher in the paracetamol-treated samples while gene expression of Cartilage Oligomeric Matrix Protein and interleukin-1β was lower (P<0.05). Paracetamol, which appears innocuous compared with many analgesics, may increase the expression of MMPs, which serve a significant role in catabolic reactions and suppress the proliferation of intact intervertebral disc tissue cells.
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Affiliation(s)
- Numan Karaarslan
- Department of Neurosurgery, School of Medicine, Namik Kemal University, Tekirdag 59100, Turkey
| | - Ibrahim Yilmaz
- Department of Medical Pharmacology, School of Medicine, Istanbul Medipol University, Istanbul 34810, Turkey
| | - Duygu Yasar Sirin
- Department of Molecular Biology and Genetics, Faculty of Arts and Sciences, Namik Kemal University, Tekirdag 59100, Turkey
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29
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Neuroanesthesiology Update. J Neurosurg Anesthesiol 2021; 33:107-136. [PMID: 33480638 DOI: 10.1097/ana.0000000000000757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 12/18/2020] [Indexed: 11/27/2022]
Abstract
This review summarizes the literature published in 2020 that is relevant to the perioperative care of neurosurgical patients and patients with neurological diseases as well as critically ill patients with neurological diseases. Broad topics include general perioperative neuroscientific considerations, stroke, traumatic brain injury, monitoring, anesthetic neurotoxicity, and perioperative disorders of cognitive function.
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30
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Xiong W, Li L, Bao D, Wang Y, Liang Y, Lu P, Zhang D, Liu G, Qiao L, Zheng N, Jin X. Postoperative analgesia of scalp nerve block with ropivacaine in pediatric craniotomy patients: a protocol for a prospective, randomized, placebo-controlled, double-blinded trial. Trials 2020; 21:580. [PMID: 32586348 PMCID: PMC7318534 DOI: 10.1186/s13063-020-04524-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 06/16/2020] [Indexed: 02/12/2023] Open
Abstract
Background Moderate-to-severe postoperative pain following craniotomy has a high incidence in pediatric patients. Such pain may cause agitation, intracranial hypertension, epileptic seizures, and postoperative hematoma, which affect morbidity and mortality. Although scalp nerve block (SNB) achieves satisfactory pain relief except for suboccipital mid-craniotomy in adults and ropivacaine is widely used as a long-acting peripheral nerve block agent in children, there are few studies of SNB with ropivacaine in pediatric patients undergoing craniotomy. In addition, the neurosurgery operation time is relatively long, but the duration of action of SNB is limited. It is generally believed that postoperative SNB is better than preoperative SNB for postoperative analgesia. However, considering the concept of preemptive analgesia, we believe that preoperative SNB may achieve a longer postoperative analgesia effect than we expected. Methods This trial is a single-institution, prospective, randomized, controlled, double-blind study. A total of 180 children aged between 1 and 12 years who are undergoing elective craniotomy will be randomly allocated in a 1:1:1 ratio to three groups: group B (preoperative ropivacaine block group), group A (postoperative ropivacaine block group), and group N (nonblocking control group). This randomization will be stratified by age in two strata (1–6 years and 7–12 years). The primary outcome is the total consumption of sufentanil within 24 h after surgery. The secondary outcomes include assessment of pain scores, total consumption of sufentanil and emergency-remedy medicine consumption at observation points, the occurrence of postoperative complications, and the length of hospitalization after surgery. Discussion This study is designed to explore the effect and feasibility of SNB with ropivacaine for postoperative analgesia in pediatric patients undergoing craniotomy. Further aims are to compare the effects of preoperative and postoperative SNB on postoperative analgesia in order to identify whether there is a preemptive analgesic effect and determine the better time to implement SNB in pediatric patients during craniotomy. Trial registration Chinese Clinical Trial Registry ChiCTR1800017386. Registered on 27 July 2018.
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Affiliation(s)
- Wei Xiong
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Lu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Di Bao
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Yaxin Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Yi Liang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Pengwei Lu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Di Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Gaifen Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, 100070, China
| | - Lanxin Qiao
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Na Zheng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Xu Jin
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.
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31
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Peng K, Zeng M, Dong J, Yan X, Wang D, Li S, Peng Y. Ultrasound-guided superficial cervical plexus block for analgesia in patients undergoing craniotomy via suboccipital retrosigmoid approach: study protocol of a randomised controlled trial. BMJ Open 2020; 10:e034003. [PMID: 32029493 PMCID: PMC7044881 DOI: 10.1136/bmjopen-2019-034003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Scalp nerve block has been proven to be an alternative choice to opioids in multimodal analgesia. However, for the infratentorial space-occupying craniotomy, especially the suboccipital retrosigmoid craniotomy, scalp nerve block is insufficient. METHODS AND ANALYSIS The study is a prospective, single-centre, randomised, paralleled-group controlled trial. Patients scheduled to receive elective suboccipital retrosigmoid craniotomy will be randomly assigned to the superficial cervical plexus block group or the control group. After anaesthesia induction, superficial cervical plexus nerve block will be performed under the guidance of ultrasound. The primary outcome is the cumulative consumption of sufentanil by the patient-controlled intravenous analgesia pump within 24 hours after surgery. Secondary outcomes include the cumulative consumption of sufentanil at other four time points and numerical rating scale pain severity score. ETHICS AND DISSEMINATION The protocol (version number: 2.0, 10 April 2019) has been approved by the Ethics Review Committee of China Registered Clinical Trials (Ethics Review No. ChiECRCT-20190047). The findings of this study will be disseminated in peer-reviewed journals and at scientific conferences. TRIAL REGISTRATION NUMBER NCT04036812.
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Affiliation(s)
- Kun Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Min Zeng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jia Dong
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiang Yan
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dexiang Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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32
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Qu L, Liu B, Zhang H, Sankey EW, Chai W, Wang B, Li Z, Niu J, Zhao B, Jiang X, Ye L, Zhao L, Zhang Y, Zheng T, Xue Y, Chen L, Chen L, Han H, Liu W, Li R, Gao G, Wang X, Wang Y, He S. Management of Postoperative Pain after Elective Craniotomy: A Prospective Randomized Controlled Trial of a Neurosurgical Enhanced Recovery after Surgery (ERAS) Program. Int J Med Sci 2020; 17:1541-1549. [PMID: 32669957 PMCID: PMC7359387 DOI: 10.7150/ijms.46403] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/09/2020] [Indexed: 12/13/2022] Open
Abstract
Objective: To prospectively evaluate the efficacy of a neurosurgical enhanced recovery after surgery (ERAS) protocol on the management of postoperative pain after elective craniotomies. Methods: This randomized controlled trial was conducted in the neurosurgical center of Tangdu Hospital (Fourth Military Medical University, Xi'an, China). A total of 129 patients undergoing craniotomies between October 2016 and July 2017 were enrolled in a randomized clinical trial comparing an ERAS protocol to a conventional postoperative care regimen. The primary outcome was the postoperative pain score assessed by a verbal numerical rating scale (NRS). Results: Patients in the ERAS group had a significant reduction in their postoperative pain scores on POD 1 compared to patients in the control group (p < 0.05). More patients (n = 44, 68.8%) in the ERAS group experienced mild pain (NRS: 1 to 3) on POD1 compared with patients (n = 23, 35.4%) in the control group (p < 0.05). A further reduction in pain scores was also observed on POD 2 and maintained on POD 3 in the ERAS group compared with that in the control group. In addition, the median postoperative length of hospital stay was significantly decreased with the incorporation of the ERAS protocol compared to controls (ERAS: 4 days, control: 7 days, P<0.001). Conclusion: The implementation of a neurosurgical ERAS protocol for elective craniotomy patients has significant benefits in alleviating postoperative pain and enhancing recovery leading to early discharge after surgery compared to conventional care. Further evaluation of this protocol in larger, multi-center studies is warranted.
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Affiliation(s)
- Liang Qu
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University. Xi'an, China
| | - Bolin Liu
- Department of Neurosurgery, Xi'an International Medical Center, Xi'an, Shaanxi, China
| | - Haitao Zhang
- Department of Respiratory and Critical Care Medicine, Tangdu Hospital, Fourth Military Medical University. Xi'an, China
| | | | - Wei Chai
- Department of Anesthesiology, Xi'an International Medical Center, Xi'an, Shaanxi, China
| | - Binrong Wang
- Department of Anesthesiology, Xi'an International Medical Center, Xi'an, Shaanxi, China
| | - Zhengmin Li
- Department of Anesthesiology, Tangdu Hospital, Fourth Military Medical University. Xi'an, China
| | - Jiangtao Niu
- Department of Anesthesiology, Tangdu Hospital, Fourth Military Medical University. Xi'an, China
| | - Binfang Zhao
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University. Xi'an, China
| | - Xue Jiang
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University. Xi'an, China
| | - Lin Ye
- Department of Nutrition, Tangdu Hospital, Fourth Military Medical University. Xi'an, China
| | - Lanfu Zhao
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University. Xi'an, China
| | - Yufu Zhang
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University. Xi'an, China
| | - Tao Zheng
- Department of Neurosurgery, Xi'an International Medical Center, Xi'an, Shaanxi, China
| | - Yafei Xue
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University. Xi'an, China
| | - Lei Chen
- Department of Neurosurgery, Xi'an International Medical Center, Xi'an, Shaanxi, China
| | - Long Chen
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University. Xi'an, China
| | - Haijing Han
- Department of Neurosurgery, Xi'an International Medical Center, Xi'an, Shaanxi, China
| | - Wenjuan Liu
- Department of Neurosurgery, Xi'an International Medical Center, Xi'an, Shaanxi, China
| | - Ruigang Li
- Department of Neurosurgery, Xi'an International Medical Center, Xi'an, Shaanxi, China
| | - Guodong Gao
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University. Xi'an, China
| | - Xuelian Wang
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University. Xi'an, China
| | - Yuan Wang
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University. Xi'an, China
| | - Shiming He
- Department of Neurosurgery, Xi'an International Medical Center, Xi'an, Shaanxi, China
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Galvin IM, Levy R, Day AG, Gilron I. Pharmacological interventions for the prevention of acute postoperative pain in adults following brain surgery. Cochrane Database Syst Rev 2019; 2019:CD011931. [PMID: 31747720 PMCID: PMC6867906 DOI: 10.1002/14651858.cd011931.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pain following brain surgery can compromise recovery. Several pharmacological interventions have been used to prevent pain after craniotomy; however, there is currently a lack of evidence regarding which interventions are most effective. OBJECTIVES The objectives are to assess the effectiveness of pharmacological interventions for prevention of acute postoperative pain in adults undergoing brain surgery; compare them in terms of additional analgesic requirements, incidence of chronic headache, sedative effects, length of hospital stay and adverse events; and determine whether these characteristics are different for certain subgroups. SEARCH METHODS We searched MEDLINE, Embase, CINAHL, CENTRAL, Web of Science and two trial registries together with reference checking and citation searching on 28th of November 2018. SELECTION CRITERIA We included blinded and non-blinded, randomized controlled trials evaluating pharmacological interventions for the prevention of acute postoperative pain in adults undergoing neurosurgery, which had at least one validated pain score outcome measure. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. We calculated mean differences for the primary outcome of pain intensity; any pain scores reported on a 0 to 100 scale were converted to a 0 to 10 scale. MAIN RESULTS We included 42 completed studies (3548 participants) and identified one ongoing study. Nonsteroidal anti-inflammatories (NSAIDs) Nonsteroidal anti-inflammatories (NSAIDs) reduce pain up to 24 hours (0 to 6 hours, MD -1.16, 95% CI -1.57 to -0.76; 12 hours, MD -0.62, 95% CI -1.11 to -0.14; 24 hours, MD -0.66, 95% CI -1.18 to -0.13; 6 studies, 742 participants; all high-quality evidence). Results for other outcomes were imprecise (additional analgesic requirements: MD 1.29 mg, 95% CI -5.0 to 2.46, 4 studies, 265 participants; nausea and vomiting RR 1.34, 95% CI 0.30 to 5.94, 2 studies, 345 participants; both low-quality evidence). Dexmedetomidine reduces pain up to 12 hours (0 to 6 hours, MD -0.89, 95% CI -1.27 to -0.51, moderate-quality evidence; 12 hours, MD -0.81, 95% CI -1.21 to -0.42, low-quality evidence). It did not show efficacy at 24 hours (MD -0.08, 95% CI -0.32 to 0.16; 2 studies, 128 participants; low-quality evidence). Dexmedetomidine may decrease additional analgesic requirements (MD -21.36 mg, 95% CI -34.63 to -8.1 mg, 2 studies, 128 participants, low-quality evidence). Results for other outcomes were imprecise (nausea and vomiting RR -0.43, 95% CI 0.06 to 3.08, 3 studies, 261 participants; hypotension RR 0.5, 95% CI 0.05 to 5.28, 3 studies, 184 participants; both low-quality evidence). Scalp blocks may reduce pain up to 48 hours (0 to 6 hours, MD -0.98, 95% CI -1.66 to -0.3, 10 studies, 414 participants; 12 hours, MD -0.95, 95% CI -1.53 to -0.37, 8 studies, 294 participants; 24 hours, MD -0.78, 95% CI -1.52 to -0.05, 9 studies, 433 participants, all low-quality evidence; 48 hours, MD -1.34, 95% CI -2.57 to -0.11, 4 studies, 135 participants, very low-quality evidence. When studies with high risk of bias were excluded, significance remained at 12 hours only. Scalp blocks may decrease additional analgesia requirements (SMD -1.11, 95% CI -1.97 to -0.25, 7 studies, 314 participants). Results for other outcomes were imprecise (nausea and vomiting RR 0.66, 95% CI 0.33 to 1.32, 4 studies, 165 participants, very low-quality evidence). Scalp Infiltration may reduce pain postoperatively but efficacy was inconsistent, with a significant effect at 12 and 48 hours only (12 hours, MD -0.71, 95% CI -1.34 to -0.08, 7 studies, 309 participants, low-quality evidence; 48 hours, MD - 1.09, 95% CI -2.13 to - 0.06, 3 studies, 128 participants, moderate-quality evidence). No benefit was observed at other times (0 to 6 hours, MD -0.64, 95% CI -1.28 to -0.00, 9 studies, 475 participants, moderate-quality evidence; 24 hours, MD -0.39, 95% CI -1.06 to 0.27,6 studies, 260 participants, low-quality evidence. Scalp infiltration may reduce additional analgesia requirements MD -9.56 mg, 95% CI -15.64 to -3.49, 6 studies, 345 participants, very low-quality evidence). When studies with high risk of bias were excluded, scalp infiltration lost the pain benefit at 12 hours and effects on additional analgesia requirements, but retained the pain-reducing benefit at 48 hours (MD -0.56, 95% CI -1.20 to -0.32, 2 studies, 100 participants, very low-quality evidence). Results for other outcomes were imprecise (nausea and vomiting, RR 0.74, 95% CI 0.48 to 1.41, 4 studies, 318 participants, low-quality evidence). Pregabalin or gabapentin may reduce pain up to 6 hours (2 studies, 202 participants), MD -1.15,95% CI -1.66 to -0.6, 2 studies, 202 participants, low-quality evidence). One study examined analgesic efficacy at 12 hours showing significant benefit. No analgesia efficacy was shown at later times (24 hours, MD -0.29, 95% CI -0.78 to -0.19; 48 hours, MD - 0.06, 95% CI -0.86 to 0.77, 2 studies, 202 participants, low-quality evidence). Additional analgesia requirements were not significantly less (MD -0.37 (95% CI -1.10 to 0.35, 3 studies, 234 participants, low-quality evidence). Risk of nausea and vomiting was significantly reduced (RR 0.51, 95% CI 0.29 to 0.89, 3 studies, 273 participants, low-quality evidence). Results for other outcomes were imprecise (additional analgesia requirements: MD -0.37, 95% CI -1.10 to 0.35, 3 studies, 234 participants, low-quality evidence). Acetaminophen did not show analgesic benefit (0 to 6 hours, MD -0.35, 95% CI -1.00 to 0.30; 12 hours, MD -0.51, 95% CI -1.04 to 0.03, 3 studies, 332 participants, moderate-quality evidence; 24 hours, MD -0.34, 95% CI -1.20 to 0.52, 4 studies, 439 participants, high-quality evidence). Results for other outcomes remained imprecise (additional analgesia requirements, MD 0.07, 95% CI -0.86 to 0.99, 4 studies, 459 participants, high-quality evidence; length of hospitalizations, MD -3.71, 95% CI -14.12 to 6.7, 2 studies, 335 participants, moderate-quality evidence). AUTHORS' CONCLUSIONS There is high-quality evidence that NSAIDs reduce pain up to 24 hours postoperatively. The evidence for reductions in pain with dexmedetomidine, pregabalin or gabapentin, scalp blocks, and scalp infiltration is less certain and of very low to moderate quality. There is low-quality evidence that scalp blocks and dexmedetomidine may reduce additional analgesics requirements. There is low-quality evidence that gabapentin or pregabalin may decrease nausea and vomiting, with the caveat that the total number of events for this comparison was low.
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Affiliation(s)
| | - Ron Levy
- Kingston General HospitalDepartment of NeurosurgeryDept of Surgery, Room 304 , Victory 3 ,76 Stuart StreetKingstonONCanadaK7L 2V7
| | - Andrew G Day
- Kingston General HospitalClinical Research CentreAngada 4, Room 5‐42176 Stuart StreetKingstonONCanadaK7L 2V7
| | - Ian Gilron
- Queen's UniversityDepartments of Anesthesiology & Perioperative Medicine & Biomedical & Molecular Sciences76 Stuart StreetVictory 2 PavillionKingstonONCanadaK7L 2V7
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Ghaffarpasand F, Dadgostar E, Ilami G, Shoaee F, Niakan A, Aghabaklou S, Ghadimi M, Goudarzi S, Dehghankhalili M, Alavi MH. Intravenous Acetaminophen (Paracetamol) for Postcraniotomy Pain: Systematic Review and Meta-Analysis of Randomized Controlled Trials. World Neurosurg 2019; 134:569-576. [PMID: 31756498 DOI: 10.1016/j.wneu.2019.11.066] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 11/12/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Acute pain control after supratentorial craniotomy is considered among the most important indicators of postoperative recovery. The aim of this study was to determine the effects of intravenous acetaminophen on postcraniotomy pain. METHODS We searched databases including Embase, Scopus, Medline, Cochrane Library, and Web of Science until April 2019. Cochran Q test and I2 statistic were used to assess the heterogeneity across included clinical trials. Standardized mean difference (SMD) and 95% confidence interval (CI) were used to estimate pooled effect sizes. RESULTS Out of 479 reports, 5 randomized controlled trials met the inclusion criteria and were appropriate for our meta-analysis, which included a total of 2635 patients. The pooled results of included clinical trials indicated that paracetamol intake significantly decreased rescue dose (SMD, -0.67; 95% CI, -1.15 to -0.19; P < 0.01; I2 = 90.0%), total dosage of rescue (SMD, -0.78; 95% CI, -1.18 to -0.37; P < 0.01; I2 = 86.0%), intensive care unit length of stay (SMD, -0.24; 95% CI, -0.44 to -0.04; P = 0.01; I2 = 0.0%), and visual analog scale score (SMD, -0.16; 95% CI, -0.31 to -0.00; P = 0.04; I2 = 71.7%) and increased patient satisfaction (SMD, 0.28; 95% CI, 0.14-0.43; P < 0.01; I2 = 10.2%) among patients with craniotomy. Time to rescue (SMD, 0.21; 95% CI, -0.42 to 0.85; P = 0.51; I2 = 94.3%) and hospital length of stay (SMD, -0.04; 95% CI, -0.24 to 0.16; P = 0.69; I2 = 0.0%) did not significantly change after paracetamol intake. CONCLUSIONS The results of this systematic review and meta-analysis indicate that preoperative intravenous administration of acetaminophen is associated with decreased postoperative pain, need for rescue analgesics, and dosages of analgesics after craniotomy surgery.
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Affiliation(s)
- Fariborz Ghaffarpasand
- Research Center for Neuromodulation and Pain, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ehsan Dadgostar
- Halal Research Center of IRI, Food and Drug Administration, Tehran, Iran
| | - Ghazal Ilami
- Research Center for Neuromodulation and Pain, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fatemeh Shoaee
- Department of Obstetrics and Gynecology, Shiraz Kowsar Hospital, Shiraz, Iran
| | - Amin Niakan
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Sara Aghabaklou
- Department of Preventive Medicine, University of Southern California, Los Angeles, California, USA
| | - Maryam Ghadimi
- Department of Radiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sogand Goudarzi
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical School, Harvard University, Boston, Massachusetts, USA
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Preoperative Gabapentin Administration Improves Acute Postoperative Analgesia in Patients Undergoing Craniotomy: A Randomized Controlled Trial. J Neurosurg Anesthesiol 2019; 31:392-398. [DOI: 10.1097/ana.0000000000000533] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Zheng W, Zhu XM, Zhang QE, Cai DB, Yang XH, Zhou YL, Ungvari GS, Ng CH, He SH, Peng XJ, Ning YP, Xiang YT. Adjunctive memantine for major mental disorders: A systematic review and meta-analysis of randomized double-blind controlled trials. Schizophr Res 2019; 209:12-21. [PMID: 31164254 DOI: 10.1016/j.schres.2019.05.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 05/05/2019] [Accepted: 05/06/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE As a non-competitive N-methyl-d-aspartate receptor antagonist, memantine has been used to treat major mental disorders including schizophrenia, bipolar disorder, and major depressive disorder (MDD). This meta-analysis systematically investigated the effectiveness and tolerability of adjunctive memantine for patients with schizophrenia, bipolar disorder, and MDD. METHODS Only randomized controlled trials (RCTs) were identified and included in the study. Data of the three disorders were separately synthesized using the RevMan 5.3 software. RESULTS Fifteen RCTs (n = 988) examining memantine (5-20 mg/day) as an adjunct treatment for schizophrenia (9 trials with 512 patients), bipolar disorder (3 trials with 319 patients), and MDD (3 trials with 157 patients) were analyzed. Memantine outperformed the comparator regarding total psychopathology with a standardized mean difference (SMD) of -0.56 [95% confidence interval (CI): -1.01, -0.11; I2 = 76%, P = 0.01] and negative symptoms with an SMD of -0.71 (95% CI: -1.09, -0.33; I2 = 74%, P = 0.0003) in schizophrenia, but no significant effects were found with regard to positive symptoms and general psychopathology in schizophrenia, or depressive and manic symptoms in bipolar disorder or depressive symptoms in MDD. Memantine outperformed the comparator in improving cognitive performance in schizophrenia with an SMD of 1.07 (95% CI: 0.53, 1.61; P < 0.0001, I2 = 29%). No group differences were found in the rates of adverse drug reactions and discontinuation due to any reason in the three major mental disorders. CONCLUSIONS Memantine as an adjunct treatment appears to have significant efficacy in improving negative symptoms in schizophrenia. The efficacy and safety of adjunctive memantine for bipolar disorder or MDD needs to be further examined. REVIEW REGISTRATION PROSPERO: 42018099045.
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Affiliation(s)
- Wei Zheng
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Xiao-Min Zhu
- Suzhou Guangji Hospital, Affiliated Guangji Hospital of Soochow University, Suzhou, China
| | - Qing-E Zhang
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Dong-Bin Cai
- Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Xin-Hu Yang
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Yan-Ling Zhou
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Gabor S Ungvari
- The University of Notre Dame Australia, Fremantle, Australia; Division of Psychiatry, School of Medicine, University of Western Australia, Perth, Australia
| | - Chee H Ng
- Department of Psychiatry, University of Melbourne, Melbourne, Victoria, Australia
| | | | | | - Yu-Ping Ning
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China.
| | - Yu-Tao Xiang
- Unit of Psychiatry, Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Macao SAR, China.
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Jia Y, Zhao C, Ren H, Wang T, Luo F. Pre-emptive scalp infiltration with dexamethasone plus ropivacaine for postoperative pain after craniotomy: a protocol for a prospective, randomized controlled trial. J Pain Res 2019; 12:1709-1719. [PMID: 31213883 PMCID: PMC6542215 DOI: 10.2147/jpr.s190679] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 03/18/2019] [Indexed: 12/14/2022] Open
Abstract
Background: Approximately 55–87% of the patients undergoing craniotomy experience moderate to severe pain during the first 48 hrs after surgery, which negatively influences patients’ postoperative rehabilitation. Recently, local infiltration of analgesia (LIA) has been widely performed clinically as a promising analgesic method that could avoid the side effects of analgesics but only has a short pain-free duration; researchers have clarified that the addition of dexamethasone to LIA could provide significant analgesic effects and significantly prolong the duration of analgesic effects without obvious complications for various types of surgeries. To date, no studies have evaluated the addition of dexamethasone to LIA for patients receiving craniotomy. The aim of the study was to test the hypothesis that pre-emptive scalp infiltration with a steroid (dexamethasone) plus a local anesthetic (ropivacaine) could achieve superior postoperative analgesic effects to a local anesthetic (ropivacaine) alone in adult patients undergoing a craniotomy. Study design and methods: This study is a randomized controlled trial that will include one intervention and one control group involving a total of 140 adults scheduled for elective craniotomy for resection of supratentorial tumors under general anesthesia and with an anticipated full recovery within 2 hrs postoperatively. The intervention will involve pre-emptive scalp infiltration with ropivacaine plus dexamethasone (the dexamethasone group) or ropivacaine alone (the control group), and the participants in both groups will complete a 6-month follow-up. The primary outcome will be the cumulative sufentanil consumption within 48 hrs postoperatively. Discussion: The intervention, if effective, this study will provide clinically important information on the role of dexamethasone in scalp infiltration for post-craniotomy pain management.
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Affiliation(s)
- Yitong Jia
- Department of Anesthesiology and Pain Management, Beijing Tiantan Hospital, Capital Medical University
| | - Chunmei Zhao
- Department of Anesthesiology and Pain Management, Beijing Tiantan Hospital, Capital Medical University
| | - Hao Ren
- Department of Anesthesiology and Pain Management, Beijing Tiantan Hospital, Capital Medical University
| | - Tao Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University
| | - Fang Luo
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
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López-Alfaro MP, Echarte-Nuin I, Fernández-Sangil P, Moyano-Berardo BM, Goñi-Viguria R. Perception of pain in post-surgical patients in intensive care units. ENFERMERIA INTENSIVA 2019; 30:99-107. [PMID: 31010777 DOI: 10.1016/j.enfi.2018.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 12/09/2018] [Accepted: 12/17/2018] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Pain assessment and treatment are essential for ensuring quality of care as well as for improving patient's satisfaction and clinical outcomes. OBJECTIVES 1) To describe pain perception of surgical patients admitted to our Intensive Care Unit(ICU). 2) To compare the patients' pain perception with the assessment carried out by nurses. 3) To correlate International Pain Outcomes Questionnaire results with socio-demographical data. METHODOLOGY A prospective descriptive observational study was carried out in the ICU of a third level university hospital over a period of 3 months. Surgical patients' pain-perception was assessed 24hours after their admission to the ICU using the Spanish translation of International Pain Outcomes Questionnaire. RESULTS The highest pain score recorded among 109 patients by nurses was 4.47±2.75, while, the lowest was .69±1,25. However, the highest and lowest pain scores reported by patients were 5.59±2.72 and 2.13±2.03, which showed significant differences (P <0.001). The highest pain score seemed to be related to the type of surgery (P <0.027). There are significant variations in the lowest pain score depending on age (P=0.005 r=-0.270). Likewise, the worst pain score correlated with the patients' sex (P=0.004). Patients who reported that pain made them feel very anxious or helpless scored highest with the worst pain, 7.35±1.98, 7.44±1.85 respectively. These differences were statistically significant (P=0.001, P <0.001). Regarding to the score of less pain, there is an association with feeling anxiety (P=0.032) and not with feeling helpless (P=-0.088). CONCLUSIONS The post-surgical patients reported pain during the first 24hours following admission to ICU (max score 5.59±.26). The nurses underestimated the patients' reported pain. Improving nurses' education would provide them with assessment strategies for better pain management. Age, sex, anxiety and helplessness caused by pain, were variables that significantly influenced pain.
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Affiliation(s)
- M P López-Alfaro
- Unidad de Cuidados Intensivos, Clínica Universidad de Navarra, Pamplona, España
| | - I Echarte-Nuin
- Unidad de Cuidados Intensivos, Clínica Universidad de Navarra, Pamplona, España
| | - P Fernández-Sangil
- Unidad de Cuidados Intensivos, Clínica Universidad de Navarra, Pamplona, España
| | - B M Moyano-Berardo
- Unidad de Cuidados Intensivos, Clínica Universidad de Navarra, Pamplona, España
| | - R Goñi-Viguria
- Práctica Avanzada del Área de Críticos, Clínica Universidad de Navarra, Pamplona, España.
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Wyler D, Esterlis M, Dennis BB, Ng A, Lele A. Challenges of pain management in neurologically injured patients: systematic review protocol of analgesia and sedation strategies for early recovery from neurointensive care. Syst Rev 2018; 7:104. [PMID: 30041695 PMCID: PMC6058380 DOI: 10.1186/s13643-018-0756-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 06/13/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND A recent paradigm shift within the intensive care discipline has led to implementation of protocols to drive early recovery from the intensive care unit (ICU). These protocols belong to a large knowledge, translation and quality improvement initiative lead by the Society of Critical Care Medicine, aiming to "liberate" patients from the ICU. They "bundle" evidence-based elements shown to lower ICU stay and mortality and optimize pain management. The bundled elements focus on Assessing, preventing and managing pain; Both spontaneous awakening trials and spontaneous breathing trials; Choice of analgesia and sedation; assessment, prevention, and management of Delirium; Early mobility and exercise; and Family engagement and empowerment (ABCDEF). It is evident that analgesia and sedation protocols either directly relate to or influence most of the bundle elements. A paucity of literature exists for neurologically injured patients, who create unique challenges to bundle implementation and often have limited external validity in existent studies. We will systematically search the literature, present the unique challenges of neurointensive care patients, conduct a stratified analysis of subgroups of interest, and disseminate the evidence of analgesia and sedation protocols in the neurointensive care unit (NICU). We hope the relevant stakeholders can adapt this information through knowledge translation-to make formal recommendations in clinical practice guidelines or a position statement. METHODS/DESIGN The authors will search MEDLINE (PubMed), EMBASE, Cochrane Library, Cochrane Clinical Trials Registry, World Health Organization International Clinical Trials Registry Platform Search Portal, and the National Institutes for Health Clinical Trials Registry. The title, abstract, and full-text screening will be completed in duplicate, and a Cohen's Kappa coefficient of agreement will be reported. Provided the data retrieved from studies is suitable, results will be combined statistically using meta-analysis. We aim to evaluate the impact of ABCDEF bundle components on multiple endpoints of NICU recovery. Our primary outcomes will be time to successful discontinuation of mechanical ventilation and time to early mobility. The authors will guide the methodological design of the study using the PRISMA-statement and the checklist compliance will be available. DISCUSSION Using the evidence from this systematic review, we anticipate disseminating knowledge of analgesia and sedation protocols in the NICU. The results of this systematic review are imperative to close the knowledge gap in a patient population that is often excluded from studies, and to add to the body of literature aiming to enhance early recovery from the NICU and mitigate iatrogenic harm. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017078909.
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Affiliation(s)
- David Wyler
- Department of Anesthesiology and Pain Medicine, Thomas Jefferson University, 111 South 11th Street Suite 8490 Gibbon, Philadelphia, PA 19107 USA
- Department of Critical Care Medicine and Neurological Surgery, Thomas Jefferson University, 111 South 11th Street Suite 8490 Gibbon, Philadelphia, PA 19107 USA
| | - Michael Esterlis
- Department of Anesthesia, University of Toronto, Toronto, Canada
- St George’s University of London Medical School, London, UK
| | | | - Andrew Ng
- Department of Anesthesiology and Pain Medicine, Thomas Jefferson University, 111 South 11th Street Suite 8490 Gibbon, Philadelphia, PA 19107 USA
| | - Abhijit Lele
- Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, USA
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Mitra S, Carlyle D, Kodumudi G, Kodumudi V, Vadivelu N. New Advances in Acute Postoperative Pain Management. Curr Pain Headache Rep 2018; 22:35. [PMID: 29619627 DOI: 10.1007/s11916-018-0690-8] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Postoperative pain remains one of the most common challenges following inpatient and outpatient surgeries. With our advances in modern medicine, pain following surgical procedures still remains a challenge, though significant accomplishments have been made over the past few decades. This article highlights some of the promising new advances and approaches in postoperative pain management. RECENT FINDINGS Over the last decade, Enhanced Recovery after Surgery (ERAS) pathways and protocols are becoming the benchmark standards for enhancing postoperative recovery. Multimodal analgesia (MMA) is an essential component of such care. Further, in the wake of serious and persistent concern on the opioid epidemic in the USA, there has been a recent renewal of interest in non-opioid alternatives or adjuncts in controlling postoperative pain, often in the context of MMA. Intravenous (IV) acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), magnesium, ketamine, dexmedetomidine, liposomal bupivacaine, and newer neuraxial and peripheral regional techniques as well as patient-controlled modalities are gaining importance. Gabapentinoids have become popular but recent meta-analytic reviews have cast doubt on their routine use in perioperative settings. Among opioids, sublingual sufentanil, IV oxycodone, and iontophoretic transdermal fentanyl hold promise. Acupuncture and transcutaneous electrical nerve stimulation may be useful as adjuncts in MMA packages. Genetic testing, derivatives of herbal preparations, and an extended role of acute pain services may emerge as potential areas of importance in the future. There are, however, critical gaps in good quality evidence in many of the practice guideline recommendations. In the era of opioid epidemic, several lines of evidence have emerged to support non-opioid-based drugs and approaches along with a few newer opioid formulations for postoperative pain management, although more research is needed to find the right balance of efficacy and safety.
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Affiliation(s)
- Sukanya Mitra
- Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Sector 32, Chandigarh, 160030, India.
| | - Daniel Carlyle
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Gopal Kodumudi
- California Northstate University College of Medicine, Elk Grove, CA, USA
| | - Vijay Kodumudi
- University of Connecticut School of Medicine, Farmington, CT, USA
| | - Nalini Vadivelu
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
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Abstract
We conducted a systematic review and meta-analysis on whether memantine was beneficial for the treatment of depressive symptoms in major depressive disorder (MDD) and bipolar disorder (BD). The analysis included double-blind, randomized, placebo-controlled trials of memantine in MDD and BD. The primary outcome measures for efficacy and safety were response rate and all-cause discontinuation, respectively. Risk ratio (RR) and standardized mean difference with 95% confidence intervals (95% CI) were calculated. We identified six trials including 451 patients: MDD, four trials (n = 189), three of which studied memantine augmentation for antidepressants; BD, two trials (n = 262), both on memantine augmentation for mood stabilizers. The mean study duration was 8.33 weeks, and the mean age of patients was 39.9 years. Memantine was not superior to placebo with regard to response rate (RR = 0.92, 95% CI = 0.70-1.20, I2 = 72%), remission rate, improvement of depressive symptoms scale score, all-cause discontinuation (RR = 0.84, 95% CI = 0.60-1.18, I2 = 0%), discontinuation due to inefficacy and adverse events, or incidence of individual adverse events including decreased appetite, dizziness, nausea, and sedation. Although we conducted sensitivity analyses of the response rate to determine the reasons for the heterogeneity (diagnosis, age of patients, memantine dose, memantine augmentation, geographical region, and statistical population), we did not seek confounding factors. Memantine did not improve the treatment efficacy for depressive symptoms in MDD and BD patients. Long-term study of memantine for depression is required.
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Abstract
This review summarizes the added value of local anesthetics in patients undergoing craniotomy for brain tumor resection, which is a procedure that is carried out frequently in neurosurgical practice. The procedure can be carried out under general anesthesia, sedation with local anesthesia or under local anesthesia only. Literature shows a large variation in the postoperative pain intensity ranging from no postoperative analgesia requirement in two-thirds of the patients up to a rate of 96% of the patients suffering from severe postoperative pain. The only identified causative factor predicting higher postoperative pain scores is infratentorial surgery. Postoperative analgesia can be achieved with multimodal pain management where local anesthesia is associated with lower postoperative pain intensity, reduction in opioid requirement and prevention of development of chronic pain. In awake craniotomy patients, sufficient local anesthesia is a cornerstone of the procedure. An awake craniotomy and brain tumor resection can be carried out completely under local anesthesia only. However, the use of sedative drugs is common to improve patient comfort during craniotomy and closure. Local anesthesia for craniotomy can be performed by directly blocking the six different nerves that provide the sensory innervation of the scalp, or by local infiltration of the surgical site and the placement of the pins of the Mayfield clamp. Direct nerve block has potential complications and pitfalls and is technically more challenging, but mostly requires lower total doses of the local anesthetics than the doses required in surgical-site infiltration. Due to a lack of comparative studies, there is no evidence showing superiority of one technique versus the other. Besides the use of other local anesthetics for analgesia, intravenous lidocaine administration has proven to be a safe and effective method in the prevention of coughing during emergence from general anesthesia and extubation, which is especially appreciated after brain tumor resection.
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Affiliation(s)
| | - Markus Klimek
- Department of Anesthesiology, Erasmus MC, Rotterdam, The Netherlands
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