The effect of methadone on postoperative quality of recovery in patients undergoing laparoscopic cholecystectomy: A prospective, randomized, double blinded, controlled clinical trial

Effect of intraoperative methadone in robot-assisted cystectomy on postoperative opioid requirements: A randomized clinical trial

BACKGROUND

Postoperative pain management is a challenge after robot-assisted cystectomy (RAC). Methadone has a long duration of action, and we therefore hypothesized that a single dose of intraoperative methadone would reduce postoperative opioid requirements and pain intensity in bladder cancer patients undergoing RAC.

METHODS

We conducted a blinded randomized controlled clinical trial from July 2020 to August 2023. Patients scheduled to undergo RAC because of bladder cancer were randomized to receive intraoperative methadone (0.15 mg/kg-1) or morphine (0.15 mg kg-1) 1 h before endotracheal extubation. The primary outcome was opioid requirements after 24 h. Secondary outcomes were opioid requirements after 3 h, pain intensity at rest and during coughing, postoperative nausea and vomiting (PONV), sedation, hypoxemia, hypoventilation, time spent in the post-anesthetic care unit, and patient satisfaction.

RESULTS

A total of 114 patients were randomized. Data from 99 patients (14 females, 85 males; mean age 69.8 ± 8.9 years) were available for analysis; 52 received methadone and 47 received morphine. Opioid consumption was similar between the methadone group and morphine group at 3 h (median, mg, 45 (IQR 30 to 75) vs. 45 (IQR 15 to 82.5) p = .97) and at 24 h (median, mg, 125 (IQR 75 to 198.5) versus 105 (IQR 72 to 157.5), p = .29). Pain intensity was significantly lower in the morphine group at 48 h compared with the methadone group. Patient satisfaction at 24 h was increased in the methadone group compared with the morphine group (median, (IQR), NRS; 9 (IQR 7 to 10) versus 7 (IQR 4 to 9), p = .020). There were no differences between treatment groups in terms of time spent in the post-anesthetic care unit and the occurrence of opioid-related side effects.

CONCLUSION

A single dose of intraoperative methadone does not reduce postoperative opioid requirements compared with a single dose of morphine in bladder cancer patients undergoing RAC.

Intraoperative methadone administration for total mastectomy: A single center retrospective study

BACKGROUND

Breast cancer is the most frequent type of cancer and the second leading cause of cancer-related mortality in women. Mastectomies remain a key component of the treatment of non-metastatic breast cancer, and strategies to treat acute postoperative pain, a complication affecting nearly all patients undergoing surgery, continues to be an important clinical challenge. This study aimed to determine the impact of intraoperative methadone administration compared to conventional short-acting opioids on pain-related perioperative outcomes in women undergoing a mastectomy.

METHODS

This single-center retrospective study included adult women undergoing total mastectomy. The primary outcome of this study was postoperative pain intensity on day 1 after surgery. Secondary outcomes included perioperative opioid consumption, perioperative non-opioid analgesics use, duration of surgery and anesthesia, time to extubation, pain intensity in the postanesthesia care unit (PACU), anti-emetic use in PACU, and length of stay in hospital. We used the propensity score-based nearest matching with a 1:3 ratio to balance the patient baseline characteristics.

RESULTS

133 patients received methadone, and 2192 patients were treated with short-acting opioids. The analysis demonstrated that methadone was associated with significantly lower intraoperative and postoperative opioid consumption as measured by oral morphine equivalents and lower average pain intensity scores in the postanesthesia care unit. Moreover, methadone was also shown to reduce the use of non-opioid analgesia during surgery.

CONCLUSION

Our study suggests that the unique pharmacological properties of methadone, including a short onset of action when given intravenously, long-acting pharmacokinetics, and multimodal effects, are associated with better acute pain management after a total mastectomy.

Pain management after laparoscopic cholecystectomy: A systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations

Laparoscopic cholecystectomy can be associated with significant postoperative pain that is difficult to treat. We aimed to evaluate the available literature and develop updated recommendations for optimal pain management after laparoscopic cholecystectomy. A systematic review was performed using the procedure-specific postoperative pain management (PROSPECT) methodology. Randomised controlled trials and systematic reviews published in the English language from August 2017 to December 2022 assessing postoperative pain after laparoscopic cholecystectomy using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases. From 589 full text articles, 157 randomised controlled trials and 31 systematic reviews met the inclusion criteria. Paracetamol combined with NSAIDs or cyclo-oxygenase-2 inhibitors should be given either pre-operatively or intra-operatively, unless contraindicated. In addition, intra-operative intravenous (i.v.) dexamethasone, port-site wound infiltration or intraperitoneal local anaesthetic instillation are recommended, with opioids used for rescue analgesia. As a second-line regional technique, the erector spinae plane block or transversus abdominis plane block may be reserved for patients with a heightened risk of postoperative pain. Three-port laparoscopy, a low-pressure pneumoperitoneum, umbilical port extraction, active aspiration of the pneumoperitoneum and saline irrigation are recommended technical aspects of the operative procedure. The following interventions are not recommended due to limited or no evidence on improved pain scores: single port or mini-port techniques, routine drainage, low flow insufflation, natural orifice transluminal endoscopic surgery (NOTES), infra-umbilical incision, i.v. clonidine, nefopam and regional techniques such as quadratus lumborum block or rectus sheath block. Several interventions provided better pain scores but are not recommended due to risk of side effects: spinal or epidural anaesthesia, gabapentinoids, i.v. lidocaine, i.v. ketamine and i.v. dexmedetomidine.

Ultrasound-Guided Suprazygomatic Maxillary Nerve Block Is Effective in Reducing Postoperative Opioid Use Following Bimaxillary Osteotomy

BACKGROUND

Ultrasound-guided maxillary nerve block has recently been described, though its impact upon bimaxillary osteotomy has not been formally investigated.

PURPOSE

The present study was carried out to determine whether the addition of ultrasound-guided maxillary nerve block in subjects undergoing bimaxillary osteotomy reduces opioid use.

STUDY DESIGN, SETTING, SAMPLE

A randomized clinical trial was carried out in adults undergoing bimaxillary osteotomy between April 2019 and January 2020 at Teknon Medical Center (Barcelona, Spain).

PREDICTOR VARIABLE

The predictor variable was the treatment technique used (maxillary nerve block or no block). The subjects were randomized to either receive (test group) or not receive (control group) bilateral ultrasound-guided suprazygomatic maxillary nerve block (5 ml of 0.37% ropivacaine) before surgery.

MAIN OUTCOME VARIABLE(S)

The primary outcome variable was the intravenous methadone requirements in the first two postoperative hours. The secondary outcome variables were postoperative pain, rescue subcutaneous methadone, intravenous remifentanil used intraoperatively, the incidence of postoperative nausea-vomiting, and complications derived from maxillary nerve block.

COVARIATES

Subject age, sex, weight, height, and anesthetic risk, and the duration of surgery were recorded.

ANALYSES

Descriptive and inferential analyses were performed using the χ2 test and Mann-Whitney U test. Statistical significance was considered for P < .05.

RESULTS

The baseline sample consisted of 68 subjects scheduled for bimaxillary osteotomy. The follow-up sample comprised 60 subjects: 30 in the control group (10 females and 20 males, aged 34.0 ± 10.2 years) and 30 in the test group (13 females and 17 males, aged 29.8 ± 10.8 years). The subjects who received maxillary nerve block showed less intravenous methadone use in the first 2 hours postsurgery (median 2.0 mg control group vs 0 mg test group; P < .001), lower pain levels at any time during the first 18 hours postsurgery (median visual analog score 4 control group vs 2 test group; P < .001), and a lesser percentage required methadone (33.3% control group vs 0% test group; P < .01) at 4-18 hours postsurgery.

CONCLUSION AND RELEVANCE

The results obtained suggest that ultrasound-guided maxillary nerve block is a promising anesthetic technique capable of reducing intraoperative and postoperative opioid use, with greater patient comfort in bimaxillary osteotomy.

Clinical effectiveness and safety of intraoperative methadone in patients undergoing laparoscopic hysterectomy: a randomised, blinded clinical trial

Background

Laparoscopic hysterectomy is often carried out as day-stay surgery. Minimising postoperative pain is therefore of utmost importance to ensure timely discharge from hospital. Methadone has several desirable pharmacological features, including a long elimination half-life. Therefore, a single intraoperative dose could provide long-lasting pain relief.

Methods

Patients scheduled to undergo laparoscopic hysterectomy were randomly allocated to receive methadone (0.2 mg kg-1) or morphine (0.2 mg kg-1) intraoperatively, 60 min before tracheal extubation. Primary outcomes were opioid consumption (oral morphine equivalents in milligrams) at 6 and 24 h. Secondary outcomes included pain intensity at rest and during coughing, patient satisfaction, postoperative nausea and vomiting, and adverse events up to 72 h after completion of surgery.

Results

The postoperative median opioid consumption was reduced in the methadone group compared with the morphine group at 6 h (35.5 [0-61] mg vs 48 [31-74.5] mg; P=0.01) and 24 h (42 [10-67] mg vs 54.5 [31-83] mg; P=0.03). On arrival at the PACU, pain at rest was significantly lower in patients receiving methadone (numeric rating scale: 3 [2-5] vs 5 [3-6]), whereas pain scores at rest and coughing were not significantly different throughout the rest of the observation period. No differences in other secondary outcomes were found.

Conclusions

In this randomised, blinded, controlled trial, opioid consumption was reduced during the first 24 postoperative hours in patients receiving methadone without causing an increase in adverse events. The difference observed might be considered as small and of limited clinical relevance.

Clinical trial registration

NCT03908060; EudraCT no. 2018-004351-20.

Postoperative recovery: how and when is it assessed: a scoping review

BACKGROUND

There is no consensus about the type of instrument with which to assess postoperative recovery or the time points when assessments are most appropriate. It is also unclear whether instruments measure the four dimensions of postoperative recovery, that is physical, psychological, social, and habitual recovery. This scoping review had three objectives: (1) to identify and describe instruments used in clinical trials to assess postoperative recovery; (2) to determine how, when, and the number of times postoperative recovery was measured; and (3) to explore whether the four dimensions of postoperative recovery are represented in the identified instruments.

METHODS

A literature search was conducted in CINAHL, MEDLINE, and Web of Science. The search terms were related to three search strands: postoperative recovery, instrument, and clinical trials. The limits were English language and publication January 2010 to November 2021. In total, 5015 studies were identified.

RESULTS

A total of 198 studies were included in the results. We identified 20 instruments measuring postoperative recovery. Different versions of Quality of Recovery represented 81.8% of the included instruments. Postoperative recovery was often assessed at one time point (47.2%) and most often on postoperative day 1 (81.5%). Thirteen instruments had items covering all four dimensions of postoperative recovery.

CONCLUSIONS

Assessing recovery is important to evaluate and improve perioperative care. We emphasise the importance of choosing the right instrument for the concept studied and, if postoperative recovery is of interest, of assessing more than once. Ideally, instruments should include all four dimensions to cover the whole recovery process.

Type of anesthesia and quality of recovery in male patients undergoing lumbar surgery: a randomized trial comparing propofol-remifentanil total i.v. anesthesia with sevoflurane anesthesia

Background

Previous studies have shown that women achieve a better quality of postoperative recovery from total intravenous anesthesia (TIVA) than from inhalation anesthesia, but the effect of anesthesia type on recovery in male patients is unclear. This study therefore compared patient recovery between males undergoing lumbar surgery who received TIVA and those who received sevoflurane anesthesia.

Methods

Eighty male patients undergoing elective one- or two-level primary transforaminal lumbar interbody fusion (TLIF) were randomly divided into two groups: the TIVA group (maintenance was achieved with propofol and remifentanil) or sevoflurane group (SEVO group: maintenance was achieved with sevoflurane and remifentanil). The quality of recovery-40 questionnaire (QoR-40) was administered before surgery and on postoperative days 1 and 2 (POD1 and POD2). Pain scores, postoperative nausea and vomiting, postoperative hospital stay, anesthesia consumption, and adverse effects were recorded.

Results

The QoR-40 scores were similar on the three points (Preoperative, POD1 and POD2). Pain scores were significantly lower in the SEVO group than in the TIVA group on POD1 (30.6 vs 31.4; P = 0.01) and POD2 (32 vs 33; P = 0.002). There was no significant difference in the postoperative hospital stay or complications in the postanesthesia care unit between the TIVA group and the SEVO group.

Conclusions

This study demonstrates that the quality of recovery is not significantly different between male TLIF surgery patients who receive TIVA and those who receive sevoflurane anesthesia. Patients in the TIVA group had better postoperative analgesic effect on POD2.

Trial registration

This was registered at http://www.chictr.org.cn (registration number ChiCTR-IOR-16007987, registration date: 24/02/2016).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01519-y.

Effect of total intravenous anesthesia or inhalation anesthesia on postoperative quality of recovery in patients undergoing total laparoscopic hysterectomy: A randomized controlled trial

STUDY OBJECTIVE

To investigate the effect of propofol-based total intravenous anesthesia (TIVA) or sevoflurane-based inhalation anesthesia on postoperative quality of recovery in patients undergoing total laparoscopic hysterectomy.

DESIGN

A prospective randomized controlled trial.

SETTING

An operating room, a postoperative recovery area, and a hospital ward.

PATIENTS

A total of 102 female patients scheduled for elective total laparoscopic hysterectomy were randomly divided into two groups: the propofol group (group P) or sevoflurane group (group S).

INTERVENTIONS

Anesthesia in group P was induced by propofol, fentanyl and rocuronium, and maintained by intravenous infusion of propofol and remifentanil. Anesthesia in group S was induced by a tidal volume inhalation technique with sevoflurane and rocuronium and maintained with sevoflurane and remifentanil. Patients in group P did not receive any volatile drugs.

MEASUREMENTS

Quality of Recovery-40 (QoR-40), Pittsburgh Sleep Quality Index (PSQI) and Numerical Rating Scale (NRS) scores were assessed at 8, 24, 48, 72 h, 7 days and 30 days after surgery. Intraoperative hemodynamics, postoperative inflammatory indicators and adverse reactions were also recorded.

MAIN RESULTS

The QoR-40 score and its 5 dimensions were similar in the two groups at each point in time (P > 0.05). Group S had less consumption of remifentanil (P < 0.001) but increased use of phenylephrine (P = 0.001) intraoperatively. PSQI scores were also comparable between groups at each point in time (P > 0.05). NRS scores at 72 h (P = 0.023) and 7 days (P = 0.017) after surgery, postoperative NLR (P = 0.024) and hs-CRP (P = 0.042), and the incidence of abdominal distension (P = 0.017) were significantly lower in group P than in group S. Multiple linear regression analyses demonstrated that duration of pneumoperitoneum and sleep quality were associated with postoperative recovery.

CONCLUSIONS

The choice of intravenous or inhalation maintenance anesthesia did not affect overall postoperative recovery as measured by the QoR-40 in patients undergoing total laparoscopic hysterectomy. Reducing the duration of pneumoperitoneum and improving sleep quality were conducive to postoperative recovery.

Effect of intraoperative methadone vs other opioids on postoperative outcomes: a meta-analysis of randomized controlled studies

ABSTRACT

Recent randomized controlled trials comparing the efficacy between intraoperative methadone and other opioids on postoperative outcomes have been limited by their small sample sizes and conflicting results. We performed a meta-analysis on randomized controlled trials which investigated outcomes between methadone and an opioid control group. Primary outcome data included postoperative opioid consumption, number of patients who received postoperative opioids, time to first analgesic, and pain scores. Secondary outcomes included time to extubation and incidence of nausea, vomiting, and respiratory depression. Statistical analysis was performed using RevMan. A P < 0.05 was considered statistically significant. Nine studies comprising 632 patients were included. There was no statistically significant reduction in opioid consumption postoperatively between the groups. Forty-seven percentage of patients in the methadone group received a dose of opioid postoperatively compared with 55% in the other opioids control group, which was not statistically significant. (P = 0.25) There was no difference in average time to receiving first postoperative analgesic among the groups. Pain scores within 24 hours were significantly lower in the methadone group when compared with other opioids (8 studies, n = 622, -0.49 [-0.74, -0.23], P = 0.002). However, there was no difference between 24 and 72 hours. There was no difference among the groups with respect to extubation time, nausea, vomiting, or respiratory depression. This meta-analysis concludes that there is currently insufficient evidence for the use of intraoperative methadone, when compared with other opioids. Although there was a decrease in average pain scores with methadone when compared with controls at 24 hours, there was no difference between 24 and 72 hours.

The Effects of Preoperative and Postoperative Anxiety on the Quality of Recovery in Patients Undergoing Abdominal Surgery

PURPOSE

The aim of this study was to investigate the effect of preoperative and postoperative anxiety on the state of recovery in patients undergoing abdominal surgery.

DESIGN

This research is a descriptive and cross-sectional study.

METHODS

The study included a total of 82 patients undergoing elective abdominal surgery. Demographic data were collected. State-Trait Anxiety Inventory was the measure for anxiety. The quality of recovery (QoR) was assessed using Quality of Recovery Scale (QoR-40). Both have known validity and reliability and valid translations into Turkish. After obtaining consent from patients, 82 patients completed their demographic profile and State-Trait Anxiety Inventory before surgery, and after 24 hours of surgery completed the state anxiety and QoR.

FINDINGS

Patients who received general anesthesia had higher anxiety before and after surgery (P = .004 and P = .022). Patients who were not informed about the surgery had higher preoperative trait anxiety (P = .01). The QoR scores of the patients were negatively related to preoperative and postoperative state anxiety (P = .01 and P = .000). Preoperative state anxiety was positively related to preoperative trait and postoperative state anxiety (P = .000 and P = .000).

CONCLUSIONS

The results provided more evidence that patients need education before surgery as to what to expect both in the surgical suite and immediately after surgery to alleviate anxiety. This should also improve QoR.

The Effect of Intraoperative Methadone Compared to Morphine on Postsurgical Pain: A Meta-Analysis of Randomized Controlled Trials

Methods

We performed a quantitative systematic review of randomized controlled trials in PubMed, Embase, Cochrane Library, and Google Scholar electronic databases. Meta-analysis was performed using the random effects model, weighted mean differences (WMD), standard deviation, 95% confidence intervals, and sample size. Methodological quality was evaluated using Cochrane Collaboration's tool.

Results

Seven randomized controlled trials evaluating 337 patients across different surgical procedures were included. The aggregated effect of intraoperative methadone on postoperative opioid consumption did not reveal a significant effect, WMD (95% CI) of −0.51 (−1.79 to 0.76), (P=0.43) IV morphine equivalents. In contrast, the effect of methadone on postoperative pain demonstrated a significant effect in the postanesthesia care unit, WMD (95% CI) of −1.11 (−1.88 to −0.33), P=0.005, and at 24 hours, WMD (95% CI) of −1.35 (−2.03 to −0.67), P < 0.001.

Conclusions

The use of intraoperative methadone reduces postoperative pain when compared to morphine. In addition, the beneficial effect of methadone on postoperative pain is not attributable to an increase in postsurgical opioid consumption. Our results suggest that intraoperative methadone may be a viable strategy to reduce acute pain in surgical patients.