Effect of intravenous ketamine for postoperative analgesia in patients undergoing laparoscopic cholecystectomy: A meta-analysis

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.

Is Multimodal Anesthesia Effecting Postoperative Nausea and Vomiting in Laparoscopic Cholecystectomy?

Background: Multimodal anesthesia represents a technique that can improve analgesia and lower the occurrence of opioid side effects in the postoperative period, such as postoperative nausea and vomiting (PONV). It can be achieved by providing different types of medication during the intraoperative period which can decrease the need for opioids. PONV happens more often in patients who have received large amounts of opioids during laparoscopic cholecystectomy. In this study, our aim was to observe the occurrence of PONV between three different groups of patients who received lidocaine, ketamine and magnesium sulfate in combination with fentanyl in the intraoperative period. We also observed any additional nausea and vomiting in the three groups as well as the amount of fentanyl given to these groups during operation. Materials and methods: 120 patients aged 20-65 years old were included in this randomized and prospective study, ASA classification 1 and 2, scheduled for laparoscopic cholecystectomy. Patients were classified into three groups randomly: Group 1 (lidocaine group-LG), these patients received lidocaine at 1 mg/kg during induction to general anesthesia and 2 mg/kg/h after intubation in continuous intravenous infusion; Group 2 (ketamine group-KG) these patients received ketamine at 0.5 mg/kg during induction to general anesthesia; and Group 3 (magnesium group-MG) these patients received magnesium sulfate at 1.5 gr/hr as a continuous intravenous infusion after intubation. In all three groups, patients additionally received bolus doses of fentanyl. Postoperative nausea and vomiting were monitored in all three groups at 1, 4, 8, 12, and 24 hours after surgery as a primary objective, and if patients had complainant of vomiting, they were treated with 10 mg of metoclopramid. Between the five control time points, additional nausea and vomiting was recorded as well, as a secondary objective. The third objective was to measure of the total amount of fentanyl given in the intraoperative period. Results: Patients from the lidocaine group experienced less PONV and they received less fentanyl compared to patients of ketamine and magnesium groups. Patients from the ketamine group had more nausea than other groups. In the magnesium group, the rate of vomiting was higher, and they received higher amounts of fentanyl during surgery. Additional nausea and vomiting occurred in 3 patients in the LG, 2 in the KG, and 3 in the MG between the five control time points. The patients from the magnesium group received the highest dose of fentanyl during surgery (307.50 ± 130.4), followed by the patients from the ketamine group (292.50 ± 60.5), and then patients from the lidocaine group (258.75 ± 60.9). The doses of fentanyl that patients received during surgery in all three groups were not statistically significant. Conclusion: Multimodal anesthesia has been shown to lower PONV 24 hours after laparoscopic cholecystectomy and can lower need for opioids during laparoscopic cholecystectomy.

Ketamine Use in the Surgical Patient: a Literature Review

PURPOSE OF REVIEW

While ketamine is an established anesthetic, its role in the management of acute surgical pain is less certain. Therefore, a literature review is warranted to examine the role of ketamine in acute pain management.

RECENT FINDINGS

The use of ketamine appears to be most efficacious in larger procedures that lead to increased systemic inflammation or extensive tissue damage. In addition, ketamine seems to be most successful when administered consistently throughout a procedure, such as by an infusion instead of a single bolus, in order to have adequate dosing for an analgesic effect. Therefore, the focus of research should be on procedures that lead to moderate to severe pain using frequent dosing to determine the most effective role of ketamine. Most importantly, the current literature shows that ketamine can be used as a successful part of multimodal anesthesia with few side effects in patients undergoing major procedures associated with moderate to severe pain.

Suppression of mICAT in Mouse Small Intestinal Myocytes by General Anaesthetic Ketamine and its Recovery by TRPC4 Agonist (-)-englerin A

A better understanding of the negative impact of general anesthetics on gastrointestinal motility requires thorough knowledge of their molecular targets. In this respect the muscarinic cationic current (mI_CAT carried mainly via TRPC4 channels) that initiates cholinergic excitation-contraction coupling in the gut is of special interest. Here we aimed to characterize the effects of one of the most commonly used “dissociative anesthetics”, ketamine, on mI_CAT. Patch-clamp and tensiometry techniques were used to investigate the mechanisms of the inhibitory effects of ketamine on mI_CAT in single mouse ileal myocytes, as well as on intestinal motility. Ketamine (100 µM) strongly inhibited both carbachol- and GTPγS-induced mI_CAT. The inhibition was slow (time constant of about 1 min) and practically irreversible. It was associated with altered voltage dependence and kinetics of mI_CAT. In functional tests, ketamine suppressed both spontaneous and carbachol-induced contractions of small intestine. Importantly, inhibited by ketamine mI_CAT could be restored by direct TRPC4 agonist (-)-englerin A. We identified mI_CAT as a novel target for ketamine. Signal transduction leading to TRPC4 channel opening is disrupted by ketamine mainly downstream of muscarinic receptor activation, but does not involve TRPC4 per se. Direct TRPC4 agonists may be used for the correction of gastrointestinal disorders provoked by general anesthesia.

Overview of multimodal analgesia initiated in the perioperative setting

Despite progress in pain management in the perioperative setting, the literature is full of evidence that managing postoperative pain is suboptimal. Since the mechanism of pain is complex, the use of multimodal technique allows clinicians to use a combination of two or more drugs targeting different areas of pain transmission because of surgery. As part of enhanced recovery initiatives after surgery, healthcare and professional organisations incorporate the use of multimodal analgesia in surgical guidelines to improve patient satisfaction. This review aims to understand and summarise the current body of evidence involving the most common pharmacological therapies to manage postoperative pain in the preoperative setting.

A review on the recent application of ketamine in management of anesthesia, pain, and health care

Ketamine is considered as a promising drug for many clinical applications even after five decades since its discovery. Ketamine is a dissociative anesthetic agent with a variety of pharmacological effects from anesthetic induction and maintenance to analgesic and sedative depending on the consuming dose. It can be used solely or in combination with other co-adjuvant drugs, increasing their efficacy. Many therapeutic properties of ketamine have been attributed to its antagonism mechanism to N-Methyl-D-aspartate receptor. Identifying new properties of ketamine such as neuroprotective, antiinflammatory, and antitumor effects, on one hand, and taking advantage of subanesthetic regimens of ketamine, on the other hand, have resulted in a widespread use of ketamine in various clinical applications. Ketamine is solvable in aqueous and lipid solutions, providing convenient administration via multiple routes, including oral, nasal, rectal, intravenous, intramuscular, subcutaneous, transdermal, sublingual, and intraosseous administration. Application of ketamine has some advantages over other sedative and anesthetic agents. It produces bronchodilation status, allowing for most secure induction of anesthesia in patients with life-threatening asthma and intense acute bronchial constriction. Ketamine has an excellent hemodynamic profile, makes it the agent of choice for patients with unstable hemodynamics, such as shocked or hypotensive patients. Ketamine usage has been associated with a lower risk of respiratory depression and relatively more conserved airway reflexes. Although being an anesthetic agent, ketamine has been increasingly used in subanesthetic doses for acute and chronic pain as well as depression. Using ketamine in pre and postoperative pain management is well established. However, the studies on ketamine performance in pain management demonstrated contradicting results. On the other hand, various side effects along with no confirmatory data on long-term treatment demand great caution when using ketamine for treating complex chronic pains. The present study aimed to provide a general review on the recent applications of ketamine in anesthesia, pain management, and critical care.

Effect of innovative nursing practice on stress response of patients undergoing laparoscopic cholecystectomy

BACKGROUND

Laparoscopic surgery has the advantages of less trauma, less bleeding, fewer complications, and faster postoperative recovery. Although laparoscopic surgery has become mature, many patients still show unique characteristics of high psychological sensitivity and strong surgical stress, and worry about postoperative syndrome, such as poor appetite, diarrhea and so on. The concept of homogeneous medical care is a team jointly established by medical staff to carry out clinical medical care. In this study, the innovative nursing model based on the concept of homogeneous medical care was applied to the actual nursing of patients undergoing cholecystectomy in order to provide a reference for clinical staff.

AIM

To explore the influence of innovative nursing practice on stress response of patients undergoing laparoscopic cholecystectomy.

METHODS

A total of 80 patients who underwent laparoscopic cholecystectomy at Yiwu Central Hospital of Zhejiang Province from April 2017 to April 2019 were selected as the subjects of the study. The patients were randomly divided into either a control group or an observation group with 40 cases each. Both groups were given routine nursing care, such as health education, psychological counseling, diet nursing, preoperative nursing and evaluation, condition nursing, medication nursing, intraoperative and postoperative routine nursing, and vital sign monitoring. The observation group was additionally given innovative nursing care based on the homogeneous medical concept. Changes in stress indicators, including heart rate (HR), mean arterial pressure (MAP), and blood glucose, were observed at one day before surgery (T₀), 10 min after pneumoperitoneum (T₁), and 5 min after surgery (T₂) in the two groups, and venous blood was collected to detect plasma noradrenaline (NE), adrenaline (E), and cortisol levels.

RESULTS

In the control group, HR, MAP, and blood glucose at T₁ and T₂ were all significantly higher than those at T₀ (P < 0.05), but their levels at T₂ were slightly lower those at T1 and still higher than those at T₀ (P < 0.05). The change trends of HR, MAP, and blood glucose in the observation group were similar to those in the control group, but the differences were not statistically significant among different time points (P > 0.05). HR, MAP, and blood glucose at T₁ and T₂ in the observation group were all significantly lower than those in the control group (P < 0.05). Compared with those at T₀, the concentrations of NE, E, and cortisol in the control group significantly increased at T₁ and T₂ (P < 0.05). In the observation group, the concentrations of NE, E, and cortisol increased at T₁ (P < 0.05) and decreased at T₂ (P < 0.05). Compared with the control group, the concentrations of NE, E, and cortisol at T₁ and T₂ were all decreased in the observation group (P < 0.05).

CONCLUSION

Innovative nursing care based on the concept of homogenous medical treatment can significantly reduce the perioperative stress response of patients undergoing laparoscopic cholecystectomy, which is beneficial to promote the postoperative physical recovery of patients.

Analgesic efficacy and safety of ketamine after total knee or hip arthroplasty: a meta-analysis of randomised placebo-controlled studies

OBJECTIVE

To examine the analgesic efficacy and safety of ketamine after total knee or hip arthroplasty.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, EMBASE and Cochrane Library from inception to 22 May 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials comparing the efficacy and safety of ketamine with placebo for postoperative pain relief in patients undergoing total knee or hip arthroplasty.

DATA EXTRACTION AND SYNTHESIS

Data (ie, pain intensity, morphine consumption, gastrointestinal and psychotic adverse effects) were extracted by two reviewers independently. The Cochrane Collaboration's recommended tool was used to determine the methodological quality of included studies.

RESULTS

A total of 10 studies were included. One of them was rated as low quality. Compared with placebo, intravenous ketamine was effective for pain relief during 0-8-hour (weighted mean difference (WMD) -1.21, 95% CI -1.45 to -0.98, p<0.001; three studies, 149 participants) but not during 8-24-hour postoperative periods, and effective for reduction of cumulative morphine consumption during both 0-24-hour (WMD -17.76, 95% CI -31.25 to -4.27, p=0.01; five studies, 366 participants) and 0-48-hour (WMD -21.79, 95% CI -25.46 to -18.11, p<0.001; four studies, 252 participants) postoperative periods, without increasing risks of gastrointestinal or psychotic adverse effects. The limited data available for intra-articular (WMD -0.49, 95% CI -0.70 to -0.29, p<0.001; two studies, 83 participants) and epidural (WMD -2.10, 95% CI -3.30 to -0.90, p<0.001; one study, 20 participants) ketamine pointed to a significant reduction in pain intensity during 8-24-hour postoperative period.

CONCLUSIONS

Intravenous administration of ketamine is effective and safe for postoperative pain relief in patients undergoing total knee or hip arthroplasty. Nevertheless, the analgesic efficacy and safety of ketamine in such patients seem to vary by different administration routes and still warrant further studies to explore.

Acupuncture for the postcholecystectomy syndrome: Protocol for a systematic review and meta-analysis

BACKGROUND

Postcholecystectomy syndrome (PCS) is a term used to describe the persistence of biliary colic or right upper quadrant abdominal pain with a variety of postoperative gastrointestinal symptoms. Acupuncture and related treatments have shown clinical effects for PCS in many studies. But the systematic reviews and meta-analyses for them are lacking. We aim to evaluate the efficacy and safety of acupuncture on the treatment of PCS.

METHODS

We will search 8 electronic databases, including the Web of Science, PubMed, Cochrane Library, Embase, and 4 Chinese databases (CBM, Wanfang, VIP, and CNKI databases), and additional sources (WHO ICTRP, ChiCTR, Clinical Trials, Grey Literature Database), for potentially eligible studies. Literature retrieval, screening, and data extraction will be conducted by 2 researchers independently. In case of disagreement, a 3rd party shall be consulted to assist judgment. We will use RevmanV.5.3 to perform a fixed effect meta-analysis on the data of clinical homogeneity studies, and evidence's level will be assessed through the method for GRADE.

RESULTS

This systematic review and meta-analysis will put a high-quality synthesis of the efficacy and safety of acupuncture treatment in PCS.

CONCLUSION

The conclusion of this systematic review will provide evidence to assess acupuncture therapy is an efficacy and safe intervention to treat and control PCS.

ETHICS AND DISSEMINATION

Since this article does not involve patients' private data, no ethical approval is required. The agreement will be disseminated by peer-reviewed journals or conference reports.

TRIAL REGISTRATION NUMBER

PROSPERO CRD4201929287.

The Influence of Etoricoxib on Pain Control for Laparoscopic Cholecystectomy: A Meta-analysis of Randomized Controlled Trials

INTRODUCTION

The efficacy of etoricoxib on pain control for laparoscopic cholecystectomy remains controversial. We conduct a systematic review and meta-analysis to explore the impact of etoricoxib on pain intensity after laparoscopic cholecystectomy.

MATERIALS AND METHODS

We searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through September 2018 for randomized controlled trials assessing the effect of etoricoxib versus placebo on pain management after laparoscopic cholecystectomy. This meta-analysis was performed using the random-effect model.

RESULTS

Four randomized controlled trials involving 351 patients are included in the meta-analysis. Overall, compared with control group for laparoscopic cholecystectomy, etoricoxib has no important impact on pain scores within 4 hours [mean difference (MD)=-1.48; 95% confidence interval (CI)=-3.54 to 0.58; P=0.16] and 8 hours (MD=-0.65; 95% CI=-1.43 to 0.12; P=0.10), but can significantly decrease pain intensity within 12 hours (MD=-1.16; 95% CI=-1.93 to -0.38; P=0.003) and 24 hours (MD=-1.10; 95% CI=-1.98 to -0.22; P=0.01), as well as postoperative analgesic consumption (standard MD=-1.21; 95% CI=-2.19 to -0.23; P=0.02), with no increase in nausea and vomiting (risk ratio=0.68; 95% CI=0.42-1.10; P=0.11), and headache (risk ratio=0.96; 95% CI=0.44-2.09; P=0.92).

CONCLUSIONS

Etoricoxib can substantially reduce pain intensity in patients with laparoscopic cholecystectomy.

Ketamine for pain management

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