Pain control in outpatient surgery

Most effective pain-control procedure for open liver surgery: a network meta-analysis

BACKGROUND

To determine the most effective pain-control procedure for open liver surgery through a network meta-analysis and provide a best developing direction in this field.

METHODS

PubMed, Embase and Cochrane Library database were searched for randomized controlled trials up to 1 July 2016. We extracted data on post-operative pain score at the 4th-8th hour and 24th hour from studies that compared various pain-control strategies. Network meta-analysis was conducted in Aggregate Data Drug Information System software by evaluating the parametric pain score at rest and on movement. Cumulative probability value was utilized to rank the procedures under examination. The inconsistency would also be tested by node-splitting models.

RESULTS

Twelve articles containing 661 patients were included. Intrathecal analgesia plus intravenous analgesia played the most effective role in pain controlling at post-operative 4-8 h (both at rest and on movement, P = 0.49 and P = 0.62, respectively) and at post-operative 24 h (both at rest and on movement, P = 0.46 and P = 0.29, respectively). Node-splitting models test revealed that no significant inconsistency existed in this research.

CONCLUSIONS

Intrathecal analgesia plus intravenous analgesia revealed the most effective clinical pain-control value for open liver surgery. More importantly, we believed that creating a better comprehensive and systematic combined pain-control procedure should be considered as the developing direction in this field.

Does dexmedetomidine improve analgesia of superficial cervical plexus block for thyroid surgery?

Background and Aims:

Bilateral superficial cervical plexus block (BSCPB) is effective in reducing pain following thyroid surgeries. We studied the effect of dexmedetomidine on duration and quality of analgesia produced by BSCPB with 0.5% ropivacaine in patients undergoing thyroid surgeries.

Methods:

In this prospective double-blinded study, 60 adults undergoing thyroid surgeries were randomised into two equal groups to receive BSCPB, either with 20 ml 0.5% ropivacaine (Group A) or 20 ml 0.5% ropivacaine with 0.5 μg/kg dexmedetomidine (Group B) after induction of anaesthesia. Visual analogue scale (VAS) was used to assess analgesia postoperatively at 0, 2, 4, 6, 12 and 24 h and patient satisfaction at 24 h. Haemodynamics were recorded peri-operatively. Wilcoxon signed rank test and Mann–Whitney U-test were applied for VAS and sedation scores. Unpaired t-test was applied for age, weight, duration of surgery and duration of post-operative analgesia.

Results:

There was significantly longer duration of analgesia in Group B (1696.2 ± 100.2 vs. 967.8 ± 81.6 min; P < 0.001) and higher patient satisfaction at 24 h (7 [7–9] vs. 5 [4–6]; P < 0.001). While VAS score for pain were similar up to 6 h, they were lower in Group B at 12 h (0 [0–1] vs. 2 [1–2]; P < 0.001) and 24 h (2 [2–2] vs. 5 [5–6]; P < 0.001). Haemodynamic stability and sedation scores were similar across the groups. There were no adverse events. However, pain during swallowing persisted in both the groups.

Conclusion:

Combination of 0.5% ropivacaine and dexmedetomidine for BSCPB provided significantly prolonged and better quality of postoperative analgesia and patient satisfaction than with 0.5% ropivacaine alone in patients undergoing thyroidectomy.

Advances in perioperative pain management: use of medications with dual analgesic mechanisms, tramadol & tapentadol

Recovery from ambulatory surgical procedures can be limited by postoperative pain. Inadequate analgesia may delay or prevent patient discharge and can result in readmission. More frequently, postoperative pain produces discomfort and interrupts sleep, contributing to postoperative fatigue. The development of effective analgesic regimens for the management of postoperative pain is a priority especially in patients with impaired cardiorespiratory, hepatic, or renal function. Tramadol and tapentadol hydrochloride are novel in that their analgesic actions occur at multiple sites. Both agents are reported to be mu-opioid receptor agonists and monoamine-reuptake inhibitors. In contrast to pure opioid agonists, both drugs are believed to have lower risks of respiratory depression, tolerance, and dependence. The Food and Drug Administration has approved both drugs for the treatment of moderate-to-severe acute pain in adults. This article provides an evidence-based account of the role of tramadol and tapentadol in modern clinical practice.

Effects of low-level laser therapy on pain and scar formation after inguinal herniation surgery: a randomized controlled single-blind study

OBJECTIVE

The aim of this study was to investigate the efficacy of an infrared GaAlAs laser operating with a wavelength of 830 nm in the postsurgical scarring process after inguinal-hernia surgery.

BACKGROUND

Low-level laser therapy (LLLT) has been shown to be beneficial in the tissue-repair process, as previously demonstrated in tissue culture and animal experiments. However, there is lack of studies on the effects of LLLT on postsurgical scarring of incisions in humans using an infrared 830-nm GaAlAs laser.

METHOD

Twenty-eight patients who underwent surgery for inguinal hernias were randomly divided into an experimental group (G1) and a control group (G2). G1 received LLLT, with the first application performed 24 h after surgery and then on days 3, 5, and 7. The incisions were irradiated with an 830-nm diode laser operating with a continuous power output of 40 mW, a spot-size aperture of 0.08 cm(2) for 26 s, energy per point of 1.04 J, and an energy density of 13 J/cm(2). Ten points per scar were irradiated. Six months after surgery, both groups were reevaluated using the Vancouver Scar Scale (VSS), the Visual Analog Scale, and measurement of the scar thickness.

RESULTS

G1 showed significantly better results in the VSS totals (2.14 +/- 1.51) compared with G2 (4.85 +/- 1.87); in the thickness measurements (0.11 cm) compared with G2 (0.19 cm); and in the malleability (0.14) compared with G2 (1.07). The pain score was also around 50% higher in G2.

CONCLUSION

Infra-red LLLT (830 nm) applied after inguinal-hernia surgery was effective in preventing the formation of keloids. In addition, LLLT resulted in better scar appearance and quality 6 mo postsurgery.

Preemptive sub-Tenon's anesthesia for pars plana vitrectomy under general anesthesia: is it effective?

BACKGROUND AND OBJECTIVES

To determine whether irrigation of the sub-Tenon's space with anesthetic agents during pars plana vitrectomy (PPV) involving general anesthesia decreases postoperative pain, analgesic use, or nausea.

PATIENTS AND METHODS

A prospective, controlled trial of 46 consecutive patients requesting general anesthesia for PPV who were randomized to receive or not receive a sub-Tenon's space injection prior to surgery. A mixture of 3 mL of 2% lidocaine with hyaluronidase and 3 mL of 0.5% bupivacaine was used to induce local blockade. Pain, postoperative nausea, and analgesia use were evaluated.

RESULTS

Local blockade did not significantly alter the proportion of reported pain at 30 minutes and 2, 4, and 24 hours after the operation. The local blockade had no effect on reducing postoperative nausea or the number of patients requiring pain medication.

CONCLUSIONS

Local blockade prior to surgery in patients undergoing PPV under general anesthesia does not significantly decrease postoperative pain, analgesic use, or nausea.

Is one-day hospitalization after open pyeloplasty possible and safe?

OBJECTIVES

A critical pathway was developed to determine whether open pyeloplasty could be performed in preadolescent and adolescent children with ureteropelvic junction (UPJ) obstruction with patients safely discharged after a 1-day hospitalization.

METHODS

Twenty-six consecutive children who underwent open dismembered pyeloplasty for the treatment of UPJ obstruction and followed a critical pathway for preoperative education, operative management, and postoperative care were evaluated. The patients received a caudal anesthetic for preventive analgesia unless not technically possible and postoperative ketorolac (Toradol) unless contraindicated. A child was required to fulfill five strict criteria to be discharged from the hospital.

RESULTS

The 26 patients with UPJ obstruction consisted of 18 boys and 8 girls (age range 2.4 months to 16.7 years). Of the 26 patients, 24 (92%) were discharged on the first postoperative day, with a mean length of hospitalization of 1.1 days (range 1 to 3). All patients younger than 6 years of age (19 patients) were discharged on the first postoperative day. Of the 25 patients who received a caudal block, 24 (96%) were discharged on the first postoperative day. All patients tolerated the procedure well without major complications.

CONCLUSIONS

This is the first study, to our knowledge, to describe a detailed critical pathway for open pyeloplasty to treat UPJ obstruction. This enabled all children younger than 6 years of age and more than 90% of all patients to be discharged uniformly on the first postoperative day.

Perioperative Pain Control: A Strategy for Management

A thorough understanding of the anatomy and neurophysiology of the pain response is necessary for the effective treatment of perioperative pain. This article describes the mechanisms that produce pain,including those related to inflammation. Other topics include the pharmacologies of nonopioid and opioid analgesics. Nonopioid analgesics can be separated into two categories: nonsteroidal anti-inflammatory drugs, such as salicylates, and acetaminophen. Opioids include morphine, fentanyl, and meperidine. The pharmacology of local anesthesia is discussed. The six major adverse reactions to local anesthetics are cardiac arrhythmias, hypertension, direct tissue toxicity, central nervous system toxicity, methemoglobinemia and allergic reactions. Methods for measuring pain are described.