Preoperative glycosylated haemoglobin as a predictor of postoperative analgesic requirements in diabetic patients: A prospective observational study

Effect of an opioid-free anesthetic on postoperative opioid consumption after laparoscopic bariatric surgery: a prospective, single-blinded, randomized controlled trial

INTRODUCTION

Opioid administration has the benefit of providing perioperative analgesia but is also associated with adverse effects. Opioid-free anesthesia (OFA) may reduce postoperative opioid consumption and adverse effects after laparoscopic bariatric surgery. In this randomized controlled study, we hypothesized that an opioid-free anesthetic using lidocaine, ketamine, and dexmedetomidine would result in a clinically significant reduction in 24-hour postoperative opioid consumption when compared with an opioid-inclusive technique.

METHODS

Subjects presenting for laparoscopic or robotic bariatric surgery were randomized in a 1:1 ratio to receive either standard opioid-inclusive anesthesia (group A: control) or OFA (group B: OFA). The primary outcome was opioid consumption in the first 24 hours postoperatively in oral morphine equivalents (OMEs). Secondary outcomes included postoperative pain scores, patient-reported incidence of opioid-related adverse effects, hospital length of stay, patient satisfaction, and ongoing opioid use at 1 and 3 months after hospital discharge.

RESULTS

181 subjects, 86 from the control group and 95 from the OFA group, completed the study per protocol. Analysis of the primary outcome showed no significant difference in total opioid consumption at 24 hours between the two treatment groups (control: 52 OMEs vs OFA: 55 OMEs, p=0.49). No secondary outcomes showed statistically significant differences between groups.

CONCLUSIONS

This study demonstrates that an OFA protocol using dexmedetomidine, ketamine, and lidocaine for laparoscopic or robotic bariatric surgery was not associated with a reduction in 24-hour postoperative opioid consumption when compared with an opioid-inclusive technique using fentanyl.

Factors Affecting Upper Limb Fracture Opioid Requirements

Introduction Understanding the different opioid pain relief requirements between patients with upper limb fractures can be useful in forming specific evidence-based guidelines and balancing patient-clinician prescribing discussions with opioid stewardship. We investigated the predictors for opioid requirements in upper limb fractures. Methods We retrospectively investigated all upper limb fractures from the shoulder to the wrist treated at a major trauma center from January 2015 to January 2022. The data collected consisted of fracture location, demographics, comorbidities, and management options. Post-injury opioid prescriptions in the first post-injury year were calculated every month up to six months and then grouped from the seventh to the 12th month and converted to morphine milligram equivalents (MMEs). We then calculated days requiring at least one medication (representing the "coverage") and relative "strength" in each time period. Results Six thousand four hundred thirteen patients sustaining a combined 9125 fractures were included in the study, with an MME mean of 436. Fracture locations of the scapula, proximal humerus, humeral shaft, distal humerus, and proximal ulna all had significantly higher MME requirements (p<0.05) at the one-year level. The radius shaft and distal radius had significantly lower MME requirements (p<0.05). The patients with depression, diabetes, drug abuse history, obesity, pulmonary circulatory disorder, and rheumatological conditions required higher strength of opioids at the one-year level (p<0.05). The patients with chronic kidney disease, depression, pulmonary circulation disorder, and rheumatological conditions required higher coverage of opioids at the one-year level (p<0.05). Conclusion Our study presents a high-resolution breakdown of the post-injury opioid requirements for patients with upper limb injuries. Fractures of the scapula, proximal humerus, and shaft of the humerus were associated with increases in both opioid strength and coverage. Depression, pulmonary disease, and rheumatological conditions were all associated with increased opioid strength and coverage. This provides a framework for which clinicians and patients can more accurately anticipate the course of the rehabilitation journey and risk stratify appropriately at the outset of injury.

Postoperative opioid prescribing patients with diabetes: Opportunities for personalized pain management

BACKGROUND

Opioids are commonly prescribed for postoperative pain, but may lead to prolonged use and addiction. Diabetes impairs nerve function, complicates pain management, and makes opioid prescribing particularly challenging.

METHODS

This retrospective observational study included a cohort of postoperative patients from a multisite academic health system to assess the relationship between diabetes, pain, and prolonged opioid use (POU), 2008-2019. POU was defined as a new opioid prescription 3-6 months after discharge. The odds that a patient had POU was assessed using multivariate logistic regression controlling for patient factors (e.g., demographic and clinical factors, as well as prior pain and opiate use).

FINDINGS

A total of 43,654 patients were included, 12.4% with diabetes. Patients with diabetes had higher preoperative pain scores (2.1 vs 1.9, p<0.001) and lower opioid naïve rates (58.7% vs 68.6%, p<0.001). Following surgery, patients with diabetes had higher rates of POU (17.7% vs 12.7%, p<0.001) despite receiving similar opioid prescriptions at discharge. Patients with Type I diabetes were more likely to have POU compared to other patients (Odds Ratio [OR]: 2.22; 95% Confidence Interval [CI]:1.69-2.90 and OR:1.44, CI: 1.33-1.56, respectively).

INTERPRETATION

In conclusion, surgical patients with diabetes are at increased risk for POU even after controlling for likely covariates, yet they receive similar postoperative opiate therapy. The results suggest a more tailored approach to diabetic postoperative pain management is warranted.

Current practice in the perioperative management of patients with diabetes mellitus: a narrative review

The prevalence of diabetes is increasing, and patients with diabetes mellitus have both an increased likelihood of requiring surgery and of developing postoperative complications when they do. We summarise available evidence underpinning current guidelines on preoperative assessment and optimisation, perioperative management of prescribed insulin and oral hypoglycaemic medication, intraoperative glycaemic control, and postoperative patient care.

Predictive factors of postoperative fentanyl consumption in patients with inflammatory bowel disease: a retrospective cohort study

Background

Patients with inflammatory bowel disease (IBD), including Crohn’s disease and ulcerative colitis, might present difficulties in achieving postoperative analgesia. Prior studies have suggested that patients with IBD undergoing major abdominal surgery require higher doses of perioperative opioids than do patients without IBD. Considering patients with IBD potentially require high-dose opioids, identifying those requiring higher opioid doses will allow clinicians to optimize the perioperative opioid dose and avoid insufficient pain management or complications of opioid overdose. Therefore, we conducted this study to identify predictive factors that might influence postoperative opioid consumption in patients with IBD.

Methods

This single-center, historical cohort study reviewed the medical records of all patients admitted to the IBD center of our institution for surgery and who used intravenous fentanyl patient-controlled analgesia (PCA) after open abdominal surgery between June 2013 and April 2017. Ultimately, 179 patients were enrolled in the analysis. Variables expected to influence and/or represent pain, analgesia, inflammation, disease condition, and extent of surgery were selected as potential explanatory variables for predicting postoperative opioid consumption. Multivariable linear regression analysis was used to examine the effect of independent variables on postoperative fentanyl consumption.

Results

Of the nine predictive variables selected using the stepwise-selection method, eight were significant. Intraoperative fentanyl consumption, current smoking, ulcerative colitis, administration of biologics during the month before surgery, and the use of supplementary analgesics had a significant increasing effect on postoperative fentanyl consumption, whereas droperidol concentration in the PCA solution, age, and diabetes mellitus had a significant decreasing effect. Preoperative use of opioids was a non-significant variable. The adjusted coefficient of determination was 0.302.

Conclusions

Intraoperative fentanyl consumption, current smoking, ulcerative colitis, administration of biologics during the month before surgery, and the use of supplementary analgesics had a significant increasing effect, whereas droperidol concentration in the PCA solution, age, and diabetes mellitus had a significant decreasing effect on postoperative fentanyl consumption. These factors should be considered when adopting postoperative intravenous fentanyl PCA administration for patients with IBD.

Trial registration

Registry: UMIN Clinical Trials Registry.

Clinical Trial Number: UMIN000031198.

Date of registration: February 8, 2018.

The Relationship Between Pre-Operative Glycosylated Haemoglobin and Opioid Consumption After Caesarean Section in Women With Gestational Diabetes Mellitus

INTRODUCTION

Women with Gestational diabetes mellitus (GDM) had a higher need and consumption of analgesics than women without GDM. The preoperative level of HbA1c was associated with the postoperative consumption for analgesics in diabetic patients. This prospective observational study go further to investigate the relationship between the pre-operative HbA1c and the post-operative consumption for analgesics in women with GDM.

METHODS

Women with GDM and a singleton pregnancy undergoing elective cesarean section under combined spinal-epidural anaesthesia were divided into two groups based on pre-operative HbA1c: group HbA1c < 6% and group HbA1c ≥ 6%. Analgesics consumption, number of patient-controlled analgesia (PCA) compression, and pain scores in 6 hours and 24 hours post-operation were compared between the two groups. Then Pearson's correlation coefficient and a stepwise multivariate linear regression were performed to investigate possible independentpredictors of post-operative 24-hour sufentanil consumption.

RESULTS

Analgesics consumption was significantly lower (18.8 ± 0.4 vs 23.2 ± 4.3; 82.7 ± 2.4 vs 115.8 ± 17.4, P < 0.001), and number of PCA compressions was significantly less frequent (1 [1-2] vs 3 [1-5]; 5 [3-7] vs 7 [3-15], P < 0.001), and in group HbA1c < 6% than in group HbA1c ≥ 6% in 6 hours and 24 hours post-operation.The univariate analysis showed that sufentanil consumption at 24 hours post-operation was significantly related to pre-operative HbA1c (r = 0.338, P < 0.001) and parity (r = 0.184, P = 0.03) and was related to blood glucose management methods (r = 0.172, P = 0.043). Multivariate linear regression analysis showed that HbA1c was the independent factor related to post-operative 24-hour sufentanil consumption (adjusted r2 = 0.246, P < 0.001).

CONCLUSIONS

This study demonstrated that in pregnant women with GDM, the pre-operative HbA1c is independently related to the need for and consumption of analgesics in 24 hours after CS.

Comparison of Postoperative Pain and Analgesia Requirement among Diabetic and Nondiabetic Patients undergoing Lower Limb Fracture Surgery - A Prospective Observational Study

Background:

Diabetic patients usually experience neuropathic pain and have a decreased response to opioids. Fractures are acute conditions and as such, they are very painful. No data is available related to fracture and postoperative pain in diabetics.

Aim:

This study was conducted to evaluate postoperative pain and analgesics requirement among diabetic and nondiabetic patients undergoing lower limb fracture surgery and the effect of glycosylated hemoglobin (HbA1c) on the postoperative pain.

Setting and Design:

This was a prospective observational study, conducted on 80 patients comprising of nondiabetic and diabetic, scheduled for elective lower limb fracture surgery under spinal anesthesia.

Materials and Methods:

HbA1c was done in all the patients who were included in the study. Postoperative Visual Analog Scale (VAS) and analgesic consumption were assessed by an anesthesiologist blinded to the diabetic or nondiabetic status of the patients. VAS was assessed every 2^nd hourly, for 24 h and rescue analgesia was given if the VAS was ≥4 and record was maintained. Sedation scores and adverse effects were also recorded postoperatively.

Statistical Analysis:

The Chi-square test was used for the analysis of categorical variables and Student's t-test was used for continuous variables.

Results:

Diabetic group of patients had a significantly high VAS score with P ≤ 0.05. Rescue analgesics requirement was significantly different in two groups with diabetic patients requiring more supplementation of analgesia with a P = 0.025. The overall patient satisfaction was lesser in diabetic group (P = 0.004). There was statistically significant correlation between glycosylated hemoglobin and VAS at 2^nd, 16^th, 18^th, 20^th, 22^nd, and 24^th h.

Conclusion:

Postoperative pain and analgesic requirement was significantly higher in diabetic patients with lower limb fracture. Glycosylated hemoglobin had good correlation with higher VAS.

Factors associated with successful response to neurolytic celiac plexus block in patients with upper abdominal cancer-related pain: a retrospective study

Background

Prior studies have reported that 40%-90% of the patients with celiac plexus-mediated visceral pain benefit from the neurolytic celiac plexus block (NCPB), but the predictive factors of response to NCPB have not been evaluated extensively. This study aimed to identify the factors associated with the immediate analgesic effectiveness of NCPB in patients with intractable upper abdominal cancer-related pain.

Methods

A retrospective review was performed of 513 patients who underwent NCPB for upper abdominal cancer-related pain. Response to the procedure was defined as (1) a decrease of ≥ 50% or ≥ 4 points on the numerical rating scale (NRS) in pain intensity from the baseline without an increase in opioid requirement, or (2) a decrease of ≥ 30% or ≥ 2 points on the NRS from the baseline with simultaneously reduced opioid consumption after NCPB. Logistic regression analysis was performed to determine the factors associated with successful responses to NCPB.

Results

Among the 513 patients included in the analysis, 255 (49.8%) and 258 (50.2%) patients were in the non-responder and responder group after NCPB, respectively. Multivariable logistic regression analysis showed that diabetes (odds ratio [OR] = 0.644, P = 0.035), history of upper abdominal surgery (OR = 0.691, P = 0.040), and celiac metastasis (OR = 1.496, P = 0.039) were the independent factors associated with response to NCPB.

Conclusions

Celiac plexus metastases, absence of diabetes, and absence of prior upper abdominal surgery may be independently associated with better response to NCPB for upper abdominal cancer-related pain.

The effect of gestational diabetes mellitus on sufentanil consumption after cesarean section: a prospective cohort study

Background

Previous studies have shown that patients with long-term diabetes require more opioids after surgery than patients without diabetes. Gestational diabetes mellitus (GDM) normally only lasts for a brief period; nevertheless, its effect on sufentanil consumption after cesarean section is unknown.

Methods

This prospective cohort study included two groups: a GDM group (n = 32) and a matched non-GDM (NGDM) group (n = 32). All patients underwent routine combined spinal-epidural anesthesia for cesarean delivery. Sufentanil consumption through an intravenous patient-controlled analgesia (PCA) pump, the frequency of PCA requests, and visual analog scale (VAS) scores 6 and 24 h after surgery were compared between groups.

Results

Sufentanil consumption (μg) 6 h after surgery was higher in the GDM group than in the NGDM group (24.0 ± 6.6 vs 20.1 ± 5.7, P = 0.023). PCA was used more frequently 6 and 24 h after surgery by the GDM group than by the NGDM group (1[0–2] vs 0[0–1], P = 0.001; 6 [1–5] vs 3 [1, 2, 6–8], P = 0.001, respectively). The VAS score during activity 24 h after surgery was higher in the GDM group than in the NGDM group (5 [2, 3] vs 5 [1, 2], respectively, P = 0.03).

Conclusion

Pregnant women with GDM require more opioids during the immediate postoperative period after cesarean section than those without GDM.

Clinical trials registration

No. ChiCTR1800016014, ChenYang, May 6th 2018.

Perioperative management of adult diabetic patients. Intraoperative period

Perioperative hyperglycaemia (>1.80g/L or 10mmol/L) increases morbidity (particularly due to infection) and mortality. Hypoglycaemia can be managed in the perioperative period by decreasing blood sugar levels with insulin between 0.90 and 1.80g/L but it may occur more frequently when the goal is strict normoglycaemia. We propose continuous administration of insulin therapy via an electronic syringe (IVES) in type-1 diabetes (T1D) and type-2 diabetes (T2D) patients if required or in cases of stress hyperglycaemia. Stopping a personal insulin pump requires immediate follow on with IVES insulin. We recommend 4mg dexamethasone for the prophylaxis of nausea and vomiting, rather than 8mg, combined with another antiemetic drug. The use of regional anaesthesia (RA), when possible, allows for better control of postoperative pain and should be prioritised. Analgesic requirements are higher in patients with poorly controlled blood sugar levels than in those with HbA1c<6.5%. The struggle to prevent hypothermia, the use of RA and multimodal analgesia (which allow for a more rapid recovery of bowel movements), limitation of blood loss, early ambulation and minimally invasive surgery are the preferred measures to regulate perioperative insulin resistance. Finally, diabetes does not change the usual rules of fasting or of antibiotic prophylaxis.