Balanced analgesia improves recovery and outcome after outpatient tubal ligation

Association between perioperative non-steroidal anti-inflammatory drug use and cardiovascular complications after non-cardiac surgery in older adult patients

BACKGROUND

We investigated in older adult non-cardiac surgical patients whether receipt of perioperative non-steroidal anti-inflammatory drugs (NSAIDs) is associated with increased incidence of postoperative cardiovascular complications.

METHODS

We retrospectively extracted the information for patients with age ≥  65 years who had inpatient non-cardiac surgery with a duration of ≥  1 h from the American College of Surgeons-National Surgical Quality Improvement Program registry data acquired at the University of Washington Medical Center. We compared patients who received NSAIDs perioperatively to those who did not receive NSAIDs, on the two composite outcomes: (1) the incidence of postoperative cardiovascular complications within 30 days of the surgery, and (2) the incidence of combined postoperative gastrointestinal and renal complications, and length of postoperative hospital stay. We used separate multivariable logistic regression models to analyze the two composite outcomes and a Poisson regression model for the length of hospital stay.

RESULTS

The receipt of perioperative NSAIDs was not associated with postoperative cardiovascular complications (estimated odds ratio (OR), 1.78; 95% confidence interval (CI), 0.97 to 3.25; P =  0.06), combined renal and gastrointestinal complications (estimated OR, 1.30; 95% CI, 0.53 to 3.20; P =  0.57), and length of postoperative hospital stay in days (incidence rate ratio, 1.06; 95% CI, 0.93 to 1.21; P =  0.39).

CONCLUSIONS

In older adult non-cardiac surgical patients, receipt of perioperative NSAIDs was not associated with increased incidences of postoperative cardiovascular complications, and renal and gastrointestinal complications within 30 days after surgery, or length of postoperative hospital stay.

Efficacy of Perioperative Intravenous Dexamethasone on Postoperative Analgesia in Scleral Buckle Surgery: A Randomized Clinical Trial

BACKGROUND AND OBJECTIVE

Postoperative pain is frequently reported following scleral buckle (SB) surgery. This study assessed the efficacy of perioperative dexamethasone on postoperative pain and opioid use following SB.

MATERIALS AND METHODS

Forty-five patients with rhegmatogenous retinal detachments undergoing SB or SB and pars plana vitrectomy were randomly assigned to either standard care of postoperative oral acetaminophen and oxycodone/acetaminophen as needed or standard care plus 8 mg single-dose peri-operative intravenous dexamethasone. A questionnaire was administered on postoperative days 0, 1, and 7 to determine visual analog scale 0 to 10 pain score and number of opioid tablets consumed.

RESULTS

Mean visual analog scale score and opioid use were significantly lower in the dexamethasone group on postoperative day 0 compared with control (2.76 ± 1.96 vs 5.64 ± 3.40, P = .002; 0.41 ± 0.92 vs 1.34 ± 1.43, P = .016). The dexamethasone group also demonstrated significantly lower total opioid use (0.97 ± 1.88 vs 3.69 ± 5.32, P = .047). No significant differences in pain score or opioid use were observed on days 1 or 7 (P = .078; P = .311; P = .326; P = .334).

CONCLUSION

Single-dose intravenous dexamethasone following SB can significantly reduce postoperative pain and opioid use. [Ophthalmic Surg Lasers Imaging Retina 2023;54(x):X-X.].

Minimal effective dose of ultrasound-guided rectus sheath block to reduce oral analgesic requirement after ambulatory laparoscopic tubal resection: a randomized controlled superiority trial

Background

The effective dose during ultrasound-guided rectus sheath block (URSB) for reducing pain after laparoscopic tubal ligation is reported to be 100 mg of 0.25% bupivacaine. We examined the minimal effective dose of 0.25% bupivacaine for URSB on oral analgesic requirement after ambulatory single-port laparoscopic tubal resection.

Methods

A prospective, randomized controlled, superiority trial was conducted among patients who had been scheduled for ambulatory laparoscopic tubal resection between September 2015 and January 2019 at a tertiary care hospital in southern Thailand. Anesthesia was induced following protocol. The intervention group was allocated to receive a bilateral URSB using 10 ml of 0.25% bupivacaine on either side after intubation (total 50 mg) while the control group did not receive the sham block. Patients and assessors were blinded to the study intervention. All patients received a multimodal analgesia regimen as follows: fentanyl and ketorolac intraoperatively and fentanyl and oral acetaminophen at the post-anesthetic care unit. Postoperative oral analgesic requirement (acetaminophen and/or ibuprofen) at home was the primary outcome. Postoperative time to first analgesic requirement, oral analgesia (acetaminophen/ibuprofen), and pain score at 6 and 24 h were accessed via telephone interviews. Percentage, effect size (ES), and 95% confidence interval (CI) were presented.

Results

A total of 66 out of 79 eligible patients were analyzed (32 intervention, 34 control). Intraoperative fentanyl consumption was significantly lower in the intervention group (ES [95% CI]: 0.58 [0.08, 1.07] mcg, p = 0.022). Time to first oral analgesia in the intervention group was significantly longer than that of the control group (ES [95% CI]: 0.66 [0.14, 1.16] h, p = 0.012). The proportion of oral analgesia requirement at 24 h after surgery in the control group was significantly higher than that in the intervention group (97% vs 75%, p = 0.012). Pain scores at 6 and 24 h were similar in both groups although slightly lower in the intervention group (ES [95% CI]: 0.22 [−0.26, 0.71], p = 0.368 and 0.33 [−0.16, 0.81], p = 0.184, respectively).

Conclusion

A dose of 0.25% bupivacaine 50 mg for URSB reduced the oral analgesic requirement at 24 h and prolonged the time to first analgesic requirement after ambulatory laparoscopic tubal resection.

Trial registration

Thaiclinicaltrials.orgTCTR20150921002. Registered on 18 September 2015

Bowel dysfunction after elective spinal surgery: etiology, diagnostics and management based on the medical literature and experience in a university hospital

BACKGROUND

Bowel dysfunction after spinal surgery is often underestimated and if not treated in a timely manner can lead to undesirable surgical interventions or fatal complications. The current medical literature primarily focuses on bowel dysfunction as a result of spinal injury.

OBJECTIVE

The purpose of this review is to explore this topic in evaluating current evidence regarding the causes of acute bowel dysfunction after elective spinal surgery, primarily the thoracolumbar spine. Since available evidence for recommendations of treatment is scarce, an interdisciplinary management approach for treatment of bowel dysfunction following spinal surgery is also formulated.

MATERIAL AND METHODS

An extensive literature search was carried out on PubMed. Keywords that were used in the search included bowel dysfunction, obstruction, postoperative ileus, spinal surgery, spinal fusion, constipation, opioid-induced constipation, colonic pseudo-obstruction, ischemic colitis, immobility-induced bowel changes, epidural anesthesia and diet. Relevant studies were chosen and included in the review. The treatment approach used in the spine center of a university hospital was included.

RESULTS

Current research mainly focuses on investigating the nature and symptomatology of chronic bowel dysfunction after spinal cord injury. Emphasis on the acute phase of bowel dysfunction in patients after elective spinal surgery is lacking. The comorbidities that exacerbate bowel dysfunction postoperatively are well-defined. There has been refinement and expansion of the pharmacological and nonpharmacological treatment that could be implemented. Enough evidence exists to provide sufficient care.

CONCLUSION

Management of acute bowel dysfunction after spinal surgery requires a comprehensive and individualized approach, encompassing comorbidities, behavioral changes, medications and surgery. Close supervision and timely treatment could minimize further complications. Research is required to identify patients who are at a higher risk of developing bowel dysfunction after specific spinal procedures.

Ultrasound-guided ilioinguinal-iliohypogastric block (ILIHB) or perifocal wound infiltration (PWI) in children: a prospective randomized comparison of analgesia quality, a pilot study

Background

Ilioinguinal-iliohypogastric block (ILIHB) is a well-established procedure for postoperative analgesia after open inguinal surgery in children. This procedure is effective and safe, especially when ultrasound is used. Data availability for comparing ultrasound-guided blocks versus wound infiltration is still weak. The study was designed to determine the efficacy of ultrasound-guided ILIHB (US-ILIHB) on postoperative pain control in pediatric patients following a inguinal daycase surgery, compared with perifocal wound infiltration (PWI) by the surgeon.

Methods

This randomized, double-blinded trail was conducted in pediatric patients aged from 6 months to 4 years. The total number of children included in the study was 103. Patients were allocated at random in two groups by sealed envelopes. The ILIHB group recieved 0,2% ropivacain for US-ILIHB after anesthesia induction. The PWI group recieved 0,2% ropivacain for PWI performed by a surgeon before wound closure. Parameters recorded included the postoperative pain score, pain frequency, time to first analgesics and consumption of analgesics.

Results: US-ILIHB significantly reduced the occurrence of pain within the first 24 h after surgery (7.7%, p = 0.01). Moreover, the pain-free interval until administration of the first dose of opioids was 21 min longer, on average (p = 0.003), following US-ILIHB compared to perifocal wound infiltration. 72% of children who received US-ILIHB did not require additional opioids, as compared to 56% of those who received PWI.

Conclusion

Thus our study demonstrates that US-ILIHB ensures better postoperative analgesia in children and should be prioritized over postoperative PWI.

Trail registration

UIHBOPWIIC, DRKS00020987. Registered 20 March 2020 – Retrospectivley registered.

Same-day discharge protocol for laparoscopic treatment of adnexal disease: management and acceptance

OBJECTIVE

Develop a 'same-day discharge' setting for laparoscopic treatment of adnexal disease.

SETTING

Preventive Gynecology, European Institute of Oncology, Milan, Italy.

POPULATION

Two hundred patients undergoing laparoscopic procedures.

MATERIAL AND METHODS

Data were retrospectively collected through clinical, surgical and laboratory reports. After discharge patients were contacted by phone and e-mail.

MAIN OUTCOME MEASURES

The rate of discharge, adverse events and readmission was measured. The need for adjunctive care provided by our on-call service or by a primary care physician and the acceptability of the same-day discharge protocol were also investigated.

RESULTS

One hundred and sixty-five patients out of 200 were discharged on the same day. Of the 35 patients hospitalized, the most frequent causes for overnight admission were: uncontrolled pain, surgical length or complexity of the procedure in nine patients, nausea/vomit in four patients. One hundred and one out of 200 patients answered the mailed questionnaire. None of the discharged patients were readmitted. Eighty-five percent of the answering patients evaluated the length of their hospital stay as adequate or moderately adequate. Ninety-two percent of the patients would recommend the day surgery to other patients.

CONCLUSIONS

our experience demonstrates that the same-day discharge protocol for laparoscopic treatment of adnexal disease is safe and acceptable.

Laparoscopic surgery: a narrative review of pharmacotherapy in pain management

Laparoscopic surgery is widespread, and an increasing number of surgeries are performed laparoscopically. Early pain after laparoscopy can be similar or even more severe than that after open surgery. Thus, proactive pain management should be provided. Pain after laparoscopic surgery is derived from multiple origins; therefore, a single agent is seldom sufficient. Pain is most effectively controlled by a multimodal, preventive analgesia approach, such as combining opioids with non-opioid analgesics and local anaesthetics. Wound and port site local anaesthetic injections decrease abdominal wall pain by 1-1.5 units on a 0-10 pain scale. Inflammatory pain and shoulder pain can be controlled by NSAIDs or corticosteroids. In some patient groups, adjuvant drugs, ketamine and α2-adrenergic agonists can be helpful, but evidence on gabapentinoids is conflicting. In the present review, the types of pain that need to be taken into account while planning pain management protocols and the wide range of analgesic options that have been assessed in laparoscopic surgery are critically assessed. Recommendations to the clinician will be made regarding how to manage acute pain and how to prevent persistent postoperative pain. It is important to identify patients at the highest risk for severe and prolonged post-operative pain, and to have a proactive strategy in place for these individuals.

The Effect of Pre-operative Lornoxicam and Ketoprofen Application on the Morphine Consumption of Post-operative Patient-controlled Analgesia

We compared the efficacy of preoperative intramuscular lornoxicam and ketoprofen for post-operative analgesia in patients undergoing abdominal hysterectomy. This randomized, double-blind, placebo-controlled, parallel-group study investigated 60 patients who received lornoxicam (group L, 8 mg), ketoprofen (group K, 100 mg) or saline (group C) 60 min before standard anaesthesia. All patients received patient-controlled analgesia (intravenous morphine) during the post-operative period. Visual analogue scale (VAS) scores recorded 2, 4, 6 and 12 h after surgery in groups L and K patients were significantly lower than in group C patients, and VAS scores at 2, 4 and 6 h in group L patients were significantly lower than those in group K patients. Morphine consumption in groups L and K was significantly lower than in group C. Pre-emptive administration of lornoxicam and ketoprofen effectively reduced post-operative pain and morphine consumption, and lornoxicam was more effective than ketoprofen in the early post-operative period.

Morphine after tubal ligation with bupivacaine: dosage versus body weight

Background and Objectives:

We investigated whether there was a statistically significant difference in patient need for postoperative analgesia based on adjusted body weight between heavier and lighter women who underwent laparoscopic tubal ligation with bupivacaine injection at the skin incision.

Methods:

We examined 49 records of women who underwent laparoscopic tubal ligation at Oklahoma State University Medical Center between 2000 and 2005 and received an injection of bupivacaine at the surgical site during the procedure. Postsurgical morphine was measured as doses per kilogram of body weight against total body weight and as total milligrams per kilogram of body weight against total body weight. A regression was performed for each measurement.

Results:

Heavier women required significantly fewer total milligrams of morphine per kilogram of body weight and fewer total doses of morphine per kilogram of body weight than lighter women (2-tailed P = .0035 and P = .0018, respectively).

Conclusion:

Our data may suggest that lipophilic bupivacaine injected at a surgical site is held in place better and works for a longer period when more fat is present.

Postarthroscopy analgesia using intraarticular levobupivacaine and intravenous dexketoprofen trometamol

PURPOSE

The aim of this prospective study was to determine the efficacy of intraarticular levobupivacaine with and without intravenous dexketoprofen trometamol for postarthroscopy analgesia.

METHODS

Sixty patients who underwent arthroscopic knee surgery were randomly assigned to three treatment groups. When the surgical procedure was completed, patients received the following treatments: group I (n = 20) patients received 20 mL intraarticular normal saline and 2 mL intravenous dexketoprofen trometamol (50 mg); group II (n = 20) patients received 20 mL intraarticular 0.5 % levobupivacaine (100 mg) and 2 mL intravenous normal saline; and group III (n = 20) patients received 20 mL intraarticular 0.5 % levobupivacaine (100 mg) and 2 mL intravenous dexketoprofen trometamol (50 mg). The visual analogue scale (VAS) was used, and the total analgesic consumption was assessed at 1, 2, 4, 6, 12, and 24 h post-operatively.

RESULTS

The VAS scores at 1, 2, 4, 6, 12, and 24 h post-operatively were significantly increased in group I and group II compared with group III (p < 0.05). The average VAS score during the first 24 h post-operatively was significantly lower in group III than in group I and group II (p < 0.001). Total meperidine consumption was significantly lower in group III than in groups I and II (p < 0.001).

CONCLUSION

Intraarticular levobupivacaine with adjuvant intravenous dexketoprofen trometamol administration provided better pain relief and less analgesic requirement after arthroscopic knee surgery during the first 24 h than that induced by dexketoprofen alone or levobupivacaine intraarticular alone.

LEVEL OF EVIDENCE

II.

Reducing postoperative pain after tubal ligation with rings or clips: a systematic review and meta-analysis

OBJECTIVE

To assess the effectiveness of using local anesthesia during interval laparoscopic tubal ligation to control postoperative pain.

DATA SOURCES

We searched MEDLINE, PubMed, and Cochrane databases and found additional articles from bibliographies of relevant studies.

METHODS OF STUDY SELECTION

We included only randomized, double-blind, placebo-controlled trials reporting postoperative pain after interval laparoscopic tubal ligation under general anesthesia (n=20). The trials compared the application of topical or injectable local anesthetic with placebo and used a visual analog scale (VAS) (scores 0-100) or the Modified McGill Pain Intensity Scale (subsequently converted to a VAS) to assess pain.

TABULATION, INTEGRATION, AND RESULTS

Pain scores were evaluated at the following times after extubation: 30 minutes, 1 hour, 2 hours, 4 hours, 8 hours, and 24 hours. The meta-analysis was based on random-effects methods for pooled data using RevMan. Postoperative pain decreased with the use of local anesthetic compared with placebo as follows (mean VAS decrease in millimeters, 95% confidence interval): 30 minutes 18.6 (11.7-25.5); 1 hour 16.6 (9.3-24.0); 2 hours 17.4 (9.6-25.2); 4 hours 12.5 (5.1-19.9); 8 hours 11.9 (6.7-17.1); and 24 hours 3.9 (-1.4 to 9.2). There was moderate heterogeneity in the data across studies (I statistic ranging from 55% to 75%). The effect size was similar for the following subgroups: pain scores reported as means or medians and use of McGill compared with VAS pain scales. A stratified analysis of trials including ring tubal ligation compared with clip tubal ligation showed the use of local anesthetic decreased pain substantially for both. No eligible studies assessed tubal ligation with cautery.

CONCLUSION

Use of local anesthetic during laparoscopic tubal ligation substantially reduces postoperative pain up to 8 hours after surgery.

Pain management in ambulatory surgery-a review

Day surgery, coming to and leaving the hospital on the same day as surgery as well as ambulatory surgery, leaving hospital within twenty-three hours is increasingly being adopted. There are several potential benefits associated with the avoidance of in-hospital care. Early discharge demands a rapid recovery and low incidence and intensity of surgery and anaesthesia related side-effects; such as pain, nausea and fatigue. Patients must be fit enough and symptom intensity so low that self-care is feasible in order to secure quality of care. Preventive multi-modal analgesia has become the gold standard. Administering paracetamol, NSIADs prior to start of surgery and decreasing the noxious influx by the use of local anaesthetics by peripheral block or infiltration in surgical field prior to incision and at wound closure in combination with intra-operative fast acting opioid analgesics, e.g., remifentanil, have become standard of care. Single preoperative 0.1 mg/kg dose dexamethasone has a combined action, anti-emetic and provides enhanced analgesia. Additional α-2-agonists and/or gabapentin or pregabalin may be used in addition to facilitate the pain management if patients are at risk for more pronounced pain. Paracetamol, NSAIDs and rescue oral opioid is the basic concept for self-care during the first 3–5 days after common day/ambulatory surgical procedures.

Ketorolac tromethamine - routes and clinical implications

Opioids have long been used for analgesic purposes for a wide range of procedures. However, the binding of these drugs to opiate receptors has created various challenges to the clinician due to unfavorable side effect profiles and the potential for tolerance and abuse. In 1989, ketorolac became an approved nonsteroidal inflammatory drug (NSAID) for injectable use as an analgesic. Over the last 20 years, numerous studies have been conducted involving ketorolac. These studies have provided additional information about various routes of administration and their effect on the efficacy and the side effect profile of ketorolac. Moreover, ketorolac has been compared with several widely used analgesics. This review evaluates both the potential benefits and potential drawbacks of ketorolac generally, and specifically discusses routes of administration, including their advantages and disadvantages when compared to several traditional analgesics in both inpatient and outpatient settings.

Pre-emptive triple analgesia protocol for tonsillectomy pain control in children: double-blind, randomised, controlled, clinical trial

Introduction:

This double-blind, controlled, parallel-group study was designed to determine the efficacy of pre-emptive triple analgesia for paediatric post-tonsillectomy pain management.

Materials and methods:

One hundred and thirty-five children were randomised into two groups: pre-emptive triple analgesia (n = 55) and control (n = 80). Pain was assessed using a visual analogue scale (in hospital) and the Parent's Postoperative Pain Measure (at home), and scores recorded.

Results:

Visual analogue scale scores on awakening and for 6 hours post-surgery were significantly better in the study group than the control group (p < 0.05). The Parent's Postoperative Pain Measure scores of control group children were significantly higher within the first 3 post-operative days (p = 0.000), with a greater percentage of children experiencing significant pain and requiring more analgesia.

Conclusion:

The proposed multimodal, pre-emptive analgesia protocol for paediatric post-tonsillectomy pain results in less post-operative pain, both in hospital or at home.

Systematic review and metaanalysis of intraperitoneal instillation of local anesthetics for reduction of pain after gynecologic laparoscopy

We reviewed the effectiveness of intraperitoneal instillation of local anesthetic on pain after gynecologic laparoscopic surgery. Sources included the Cochrane Central Register of Controlled Trials, MEDLINE/PubMed, EMBASE, and Ovid MEDLINE In-Process & Other Non-Indexed Citations databases, and abstracts, reference lists, and randomized controlled trial (RCT) registries. The 7 included RCTs compared pain scores after administration of intraperitoneal analgesics or placebo/control during gynecologic laparoscopic surgery with benign indications. Outcome measures were pain scores (per visual analog scale) at 1 to 2, 4 to 6, and 24 hours postoperatively. Pain scores were significantly lower in the groups receiving local anesthesia at 1 to 2 hours (weighted mean difference [WMD], -1.82; 95% confidence interval [CI], -2.55 to -1.08]) and 4 to 6 hours postoperatively (WMD, -2.00; 95% CI, -3.64 to -0.35), but were similar at 24 hours (WMD, -1.43; 95% CI, -1.15 to 0.96). Local analgesia instilled intraperitoneally significantly decreased pain during a 6-hour interval after gynecologic laparoscopy.

Perioperative care for the older outpatient undergoing ambulatory surgery

As the number of ambulatory surgery procedures continues to grow in an aging global society, the implementation of evidence-based perioperative care programs for the elderly will assume increased importance. Given the recent advances in anesthesia, surgery, and monitoring technology, the ambulatory setting offers potential advantages for elderly patients undergoing elective surgery. In this review article we summarize the physiologic and pharmacologic effects of aging and their influence on anesthetic drugs, the important considerations in the preoperative evaluation of elderly outpatients with coexisting diseases, the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and offer recommendations regarding the management of common postoperative side effects (including delirium and cognitive dysfunction, fatigue, dizziness, pain, and gastrointestinal dysfunction) after ambulatory surgery. We conclude with a discussion of future challenges related to the growth of ambulatory surgery practice in this segment of our surgical population. When information specifically for the elderly population was not available in the peer-reviewed literature, we drew from relevant information in other ambulatory surgery populations.

Expert panel consensus recommendations for the pharmacological treatment of acute pain in the Middle East region

The findings of an expert panel convened to review critically how best to apply evidence-based guidelines for the treatment of acute pain in the Middle East region are presented. The panel recommended a three-step treatment protocol. Patients with mild-to-moderate levels of acute pain should be treated with paracetamol (step 1). If analgesia is insufficient after 1-2 days, a selective cyclo-oxygenase-2 inhibitor or, if gastrointestinal safety and bleeding risk are not an issue, a non-specific nonsteroidal anti-inflammatory drug, should be used (step 2). If analgesia remains inadequate, treatment with tramadol, or paracetamol plus codeine/tramadol is recommended (step 3). Patients reporting severe pain should be referred to a pain clinic or specialist for opioid analgesic treatment. Measures of pain and functioning that have been validated in Arabic, with culturally appropriate and easy to understand descriptors, should be used. Early and aggressive acute pain management is important to reduce the risk of pain becoming chronic, especially in the presence of neuropathic features.

Multimodal therapies for postoperative nausea and vomiting, and pain

Postoperative nausea and vomiting (PONV) and pain are two of the major concerns for patients presenting for surgery. The causes of PONV are multifactorial and can largely be categorized as patient risk factors, anaesthetic technique, and surgical procedure. Antiemetics work on several different receptor sites to prevent or treat PONV. This is probably why numerous studies have now demonstrated that using more than one antiemetic is usually more effective and results in fewer side-effects than simply increasing the dose of a single antiemetic. A multimodal approach to PONV should not be limited to drug therapy alone but should involve a holistic approach starting before operation and continuing intraoperatively with risk reduction strategies to which are added prophylactic antiemetics according to the assessed patient risk for PONV. With the increasing understanding of the pathophysiology of acute pain, especially the occurrence of peripheral and central hypersensitization, it is unlikely that a single drug or intervention is sufficiently broad in its action to be adequately effective, especially with moderate or greater pain. Although morphine and its congeners are usually the foundation of pain management regimens, as their dose increases so does the incidence of side-effects. Thus, the approach for the management of acute postoperative pain is to use multiple drugs or modalities (e.g. regional anaesthesia) to maximize pain relief and reduce side-effects.

Mechanisms of pain transmission and pharmacologic management

BACKGROUND

Pain sensation involves multiple signaling and modulatory pathways, employing a variety of neurotransmitters and other mediators. Inhibitory and facilitatory mechanisms affect the perception of stimuli as painful or non-painful, and in addition may affect the perceived intensity of pain. Endogenous opioids are key mediators in the descending pain suppression pathways. Additionally, monoaminergic neurotransmitters such as norepinephrine, serotonin and dopamine positively or negatively modulate pain signaling, depending on receptor type and location. The various mediators involved in pain signaling provide potential targets for pharmacological interventions. Single analgesic therapies may be limited in their ability to comprehensively target these complex pain signaling pathways. Therapeutic approaches acting on multiple pain transmission pathways through different mechanisms of action provide an opportunity to maximize efficacy and tolerability in the treatment of pain.

SCOPE

This article discusses the various physiologic processes involved in pain signaling and modulation, describes the mechanisms by which various classes of analgesic agents are believed to produce their clinical effects, and explores the potential benefits of a multiple-mechanism approach to analgesia. Published articles describing the physiologic processes involved in pain signaling and modulation and the mechanisms of analgesia for different drug classes were reviewed. MEDLINE searches were conducted to identify relevant studies published through August 2009 that evaluated the efficacy and tolerability of multiple-mechanism analgesic regimens. English language-only randomized controlled trials and meta-analyses of randomized controlled trials were considered.

FINDINGS/CONCLUSION

Multiple neurotransmitters and other mediators are involved in the endogenous modulation of pain signaling, providing numerous opportunities for intervention with different classes of analgesics. Data from numerous clinical trials indicate that multiple-mechanism approaches to analgesia provide comparable or superior analgesic efficacy with lower doses of the individual agents and reduced incidence of side effects. These data support current guidelines which endorse multiple-mechanism strategies for both acute and chronic pain management.

Postoperative pain management after ambulatory surgery: role of multimodal analgesia

Multimodal (or balanced) analgesia represents an increasingly popular approach to preventing postoperative pain. The approach involves administering a combination of opioid and nonopioid analgesics. Nonopioid analgesics are increasingly being used as adjuvants before, during, and after surgery to facilitate the recovery process after ambulatory surgery. Early studies evaluating approaches to facilitating the recovery process have demonstrated that the use of multimodal analgesic techniques can improve early recovery as well as other clinically meaningful outcomes after ambulatory surgery. The potential beneficial effects of local anesthetics, NSAIDs, and gabapentanioids in improving perioperative outcomes continue to be investigated.

Intravenous paracetamol reduced the use of opioids, extubation time, and opioid-related adverse effects after major surgery in intensive care unit

BACKGROUND

This study assessed the analgesic efficacy, side effects, and time to extubation of intravenous paracetamol when administered as an adjuvant to intravenous meperidine after major surgery in intensive care unit (ICU).

MATERIAL

Patients were randomized postoperatively into 2 groups in ICU. Patients received either 100 mL of serum saline intravenous (IV) every 6 hours and IV meperidine (n = 20 group M) or IV paracetamol 1 g every 6 hours and IV meperidine (n = 20, group MP) into a peripheral vein for 24 hours. Behavioral Pain Scale (BPS) is used until extubation, and visual analog score (VAS) is used after extubation. When BPS and VAS values were more than 4, meperidine, 1 mg/kg IV, was administered and noted in 2 groups. Pain scores, total meperidine consumption, time to extubation, sedation scores, and side effects are 24-hour postoperatively noted.

RESULTS

Behavioral Pain Scale and VAS scores are significantly lower in group paracetamol-meperidine at 24 hours (P < .05). In group MP, postoperative meperidine consumption (76.75 ± 18.2 mg vs. 198 ± 66.4 mg) and extubation time (64.3 ± 40.6 min vs. 204.5 ± 112.7 min) were lower than in group M (P < .01). In addition to, postoperative nausea-vomiting and sedation scores were significantly lower in group MP when compared with group M (P < .05).

CONCLUSION

We have demonstrated important clinical benefits by the addition of 4 g/d of paracetamol to meperidine after major surgery. This benefit has been shown in a range of patients under routine clinical conditions and therefore has important practical consequences in ICU. These data suggest that intravenous paracetamol is a useful component of the multimodal analgesia model, especially after major surgery.

Effect of rectal diclofenac in reducing postoperative pain and rescue analgesia requirement after cardiac surgery

BACKGROUND

Adequate analgesic medication is mandatory after coronary artery bypass grafting (CABG) surgery. The aim of this study was to assess the analgesic efficacy, side effects, and need for rescue analgesia after CABG surgery comparing diclofenac and placebo rectal suppository.

METHODS

Thirty-seven consenting adults undergoing elective CABG surgery were randomly assigned in a double-blind fashion to receive either rectal diclofenac 100 mg (Group 1, n = 19) or placebo suppository (Group 2, n = 18) postoperatively, just after extubation. Both groups were given intravenous tramadol as a rescue analgesic. Pain scores in the two groups were assessed on a 10-cm visual analog scale at 0, 0.5, 1, 1.5, 2, 6, 12, 18, and 24 hours after suppository administration. Rescue analgesic consumption, sedation, nausea, and vomiting in both the groups were also recorded.

RESULTS

Twenty-four-hour tramadol consumption in Group 1 was 92.5 +/- 33.5 mg compared to 157.5 +/- 63.4 mg in Group 2 (P = 0.002). Patients in the placebo group had significantly greater pain scores 1.5 to 12 hours after extubation. Group 1 patients were significantly more awake compared to Group 2 (P < 0.05). The incidence of postoperative nausea was less in Group 1 than in Group 2 (P = 0.001). Though not statistically significant, three patients in Group 2 each had a single episode of vomiting, whereas no patient had vomiting in Group 1.

CONCLUSION

Rectal diclofenac suppository with tramadol provides adequate pain relief after cardiac surgery, and also reduces tramadol consumption and side effects commonly associated with tramadol.

Fast-track anesthetic techniques for ambulatory surgery

PURPOSE OF REVIEW

Improving perioperative efficiency and throughput has become increasingly important in facilitating the fast-track recovery process following ambulatory surgery. This review focuses on the important role played by the anesthesiologist as a perioperative physician in fast-track ambulatory surgery.

RECENT FINDINGS

A literature review of more than 200 peer-reviewed publications was used to develop evidence-based recommendations for optimizing recovery following ambulatory anesthesia. The choice of anesthetic technique should be tailored to the needs of the patient as well as the type of surgical procedure being performed in the ambulatory setting. The anesthetic decisions made by the anesthesiologist, as a key perioperative physician, are of critical importance in developing a successful fast-track ambulatory surgery program.

SUMMARY

The pivotal role played by the anesthesiologist as the key perioperative physician in facilitating the recovery process has assumed increased importance in the current outpatient fast-track recovery environment. The choice of premedication, anesthetic, analgesic and antiemetic drugs, as well as cardiovascular, hormonal and fluid therapies, can all influence the ability to fast-track outpatients after ambulatory surgery.

An evaluation of epidural analgesia following circumferential belt lipectomy

BACKGROUND

Belt lipectomy combines traditional abdominoplasty with a circumferential excision of skin and fat, with resultant buttock and lateral thigh lifts. Because of the extensive nature of the procedure, postoperative pain management can be difficult. Epidural analgesia has been shown to be efficacious in treating postoperative pain. This study compares the postoperative use of epidural analgesia with more traditional pain management regimens in a large series of belt lipectomy patients.

METHODS

Charts of 62 belt lipectomy patients were examined retrospectively. Postoperative pain control regimen, pain scores, total amount of opioids administered, and side effects encountered were recorded. Twenty-seven patients had traditional pain control regimens, opioids on demand, and pain control pumps. Thirty-five patients received epidural analgesia as their primary mode of postoperative pain control.

RESULTS

Pain scores and total nonepidural opioids used were lower in the epidural analgesia group on postoperative days 0 and 1 compared with the nonepidural group. The two groups converged on postoperative days 2 through 5, sharing similar pain scores and opioid use after discontinuation of epidural analgesia. The incidence of side effects was similar in the two groups, with the exception of pruritus, which was much more prominent in the epidural group. Eight of the 35 epidural patients (23 percent) experienced transient and minor complications associated with epidural therapy; several resolved spontaneously, whereas the balance resolved with cessation or modification of the epidural infusion.

CONCLUSIONS

Epidural analgesia is more effective than traditional pain control methods in reducing immediate postoperative pain in belt lipectomy patients. On the basis of these findings, epidural analgesia should also be considered for postoperative pain management in other truncal procedures.

The Role of the Anesthesiologist in Fast-Track Surgery: From Multimodal Analgesia to Perioperative Medical Care

BACKGROUND

Improving perioperative efficiency and throughput has become increasingly important in the modern practice of anesthesiology. Fast-track surgery represents a multidisciplinary approach to improving perioperative efficiency by facilitating recovery after both minor (i.e., outpatient) and major (inpatient) surgery procedures. In this article we focus on the expanding role of the anesthesiologist in fast-track surgery.

METHODS

A multidisciplinary group of clinical investigators met at McGill University in the Fall of 2005 to discuss current anesthetic and surgical practices directed at improving the postoperative recovery process. A subgroup of the attendees at this conference was assigned the task of reviewing the peer-reviewed literature on this topic as it related to the role of the anesthesiologist as a perioperative physician.

RESULTS

Anesthesiologists as perioperative physicians play a key role in fast-track surgery through their choice of preoperative medication, anesthetics and techniques, use of prophylactic drugs to minimize side effects (e.g., pain, nausea and vomiting, dizziness), as well as the administration of adjunctive drugs to maintain major organ system function during and after surgery.

CONCLUSION

The decisions of the anesthesiologist as a key perioperative physician are of critical importance to the surgical care team in developing a successful fast-track surgery program.

Perioperative pain management

The under-treatment of postoperative pain has been recognised to delay patient recovery and discharge from hospital. Despite recognition of the importance of effective pain control, up to 70% of patients still complain of moderate to severe pain postoperatively. The mechanistic approach to pain management, based on current understanding of the peripheral and central mechanisms involved in nociceptive transmission, provides newer options for clinicians to manage pain effectively. In this article we review the rationale for a multimodal approach with combinations of analgesics from different classes and different sites of analgesic administration. The pharmacological options of commonly used analgesics, such as opioids, NSAIDs, paracetamol, tramadol and other non-opioid analgesics, and their combinations is discussed. These analgesics have been shown to provide effective pain relief and their combinations demonstrate a reduction in opioid consumption. The basis for using non-opioid analgesic adjuvants is to reduce opioid consumption and consequently alleviate opioid-related adverse effects. We review the evidence on the opioid-sparing effect of ketamine, clonidine, gabapentin and other novel analgesics in perioperative pain management. Most available data support the addition of these adjuvants to routine analgesic techniques to reduce the need for opioids and improve quality of analgesia by their synergistic effect. Local anaesthetic infiltration, epidural and other regional techniques are also used successfully to enhance perioperative analgesia after a variety of surgical procedures. The use of continuous perineural techniques that offer prolonged analgesia with local anaesthetic infusion has been extended to the care of patients beyond hospital discharge. The use of nonpharmacological options such as acupuncture, relaxation, music therapy, hypnosis and transcutaneous nerve stimulation as adjuvants to conventional analgesia should be considered and incorporated to achieve an effective and successful perioperative pain management regimen.

A comparison of cyclizine and granisetron alone and in combination for the prevention of postoperative nausea and vomiting

We conducted a randomised double-blinded study of 960 women undergoing day-case surgery to determine whether combination anti-emetic therapy of granisetron and cyclizine was more effective at decreasing the incidence of postoperative nausea and vomiting than these agents used alone. The women were randomly allocated to three groups to receive intravenous granisetron 1 mg, cyclizine 50 mg or both before induction of general anaesthesia. The incidence of postoperative nausea and vomiting was 77/322 (24%) in the granisetron group, 73/316 (23%) in the cyclizine group and 53/322 (17%) in those women given both drugs (p = 0.04). There was no difference in the requirement for rescue anti-emetic drugs. There were no differences in the anaesthetic techniques used in the three groups. We conclude that the risk of postoperative nausea and vomiting is less with cyclizine and granisetron given together than with either given alone.

Anesthesia for laparoscopy: a review

Laparoscopy is the process of inspecting the abdominal cavity through an endoscope. Carbon dioxide is most universally used to insufflate the abdominal cavity to facilitate the view. However, several pathophysiological changes occur after carbon dioxide pneumoperitoneum and extremes of patient positioning. A thorough understanding of these pathophysiological changes is fundamental for optimal anesthetic care. Because expertise and equipment have improved, laparoscopy has become one of the most common surgical procedures performed on an outpatient basis and to sicker patients, rendering anesthesia for laparoscopy technically difficult and challenging. Careful choice of the anesthetic technique must be tailored to the type of surgery. General anesthesia using balanced anesthesia technique including several intravenous and inhalational agents with the use of muscle relaxants showed a rapid recovery and cardiovascular stability. Peripheral nerve blocks and neuraxial anesthesia were both considered as safe alternative to general anesthesia for outpatient pelvic laparoscopy without associated respiratory depression. Local anesthesia infiltration has shown to be effective and safe in microlaparoscopy for limited and precise gynecologic procedures. However, intravenous sedation is sometimes required. This article considers the pathophysiological changes during laparoscopy using carbon dioxide for intra-abdominal insufflation, outlines various anesthetic techniques of general and regional anesthesia, and discusses recovery and postoperative complications after laparoscopic abdominal surgery.

The changing role of non-opioid analgesic techniques in the management of postoperative pain

Given the expanding role of ambulatory surgery and the need to facilitate an earlier hospital discharge, improving postoperative pain control has become an increasingly important issue for all anesthesiologists. As a result of the shift from inpatient to outpatient surgery, the use of IV patient-controlled analgesia and continuous epidural infusions has steadily declined. To manage the pain associated with increasingly complex surgical procedures on an ambulatory or short-stay basis, anesthesiologists and surgeons should prescribe multimodal analgesic regimens that use non-opioid analgesics (e.g., local anesthetics, nonsteroidal antiinflammatory drugs, cyclooxygenase inhibitors, acetaminophen, ketamine, alpha 2-agonists) to supplement opioid analgesics. The opioid-sparing effects of these compounds may lead to reduced nausea, vomiting, constipation, urinary retention, respiratory depression and sedation. Therefore, use of non-opioid analgesic techniques can lead to an improved quality of recovery for surgical patients.

Patient outcomes following ambulatory anesthesia

As the number and type of surgeries performed in the ambulatory setting have increased, outcomes research has allowed for better analysis of the safety and efficacy of care given to patients. Though this once involved measures of clinical morbidity and mortality alone, researchers have begun to focus their attention beyond these end points and take into account patients' postoperative functional status and satisfaction as a way to assess the overall quality of patient care. Also key in this move to a more global assessment of health care interventions has been an increased focus on economic outcomes. As new anesthetic drugs and techniques continue to develop, outcomes research will continue to evolve in new directions, providing further information for improvements in patient care.

A systematic approach to the management of postoperative nausea and vomiting

Postoperative nausea and vomiting (PONV), a common complication after anesthesia and surgery, often results in delayed discharge with the patient's unpleasant symptoms continuing at home. To effectively prevent and treat PONV, it is important to understand the factors implicated in PONV, the mechanisms of PONV, the pharmacology of the antiemetic agents, and the nonpharmacologic measures that have been shown to be effective. The cause of PONV is likely to be multifactorial, with important predictors being female gender, history of PONV, and history of motion sickness. The vomiting center can be triggered by activation of dopamine, serotonin (type 3), histamine (type 1), and muscarinic cholingergic receptors in the chemoreceptor trigger zone and the nucleus tractus solitarus, as well as acetylcholine receptors in the vestibular apparatus, vagal afferents from the periphery, and the endocrine environment. Antiemetic agents such as the serotonin antagonists (eg, ondansetron, dolasetron), droperidol, antihistamines (eg, diphenhydramine, dimenhydrinate), and promethazine can prevent and treat PONV effectively. Transdermal scopolamine and dexamethasone have a role in the prevention of PONV, particularly for certain high-risk patients. Nonpharmacologic measures and alternative treatments such as hydration, maintaining blood pressure, acupressure techniques, trancutaneous acupoint stimulation, and isopropyl alcohol must not be overlooked. Finally, an evidence-based algorithm for the prevention and treatment of PONV in adults is presented.

Outcome after regional anaesthesia in the ambulatory setting--is it really worth it?

Regional anaesthesia provides a continuum of perioperative care that includes perioperative pain management, decreased opioid requirements and decreased post-operative nausea and vomiting. In addition to these benefits, a wide variety of perioperative outcomes can be enhanced by utilizing regional anaesthesia in the ambulatory setting. Regional anaesthesia has been shown to improve the cardiovascular, pulmonary, gastrointestinal, coagulative, immunological and cognitive functions and to be of benefit in an economic context. These improvements are particularly advantageous in caring for elderly and high-risk patient populations undergoing surgery. In addition, regional anaesthesia can facilitate early recovery with excellent post-operative analgesia and few side-effects, which may decrease overall operative costs. This chapter identifies important perioperative outcomes that may be positively influenced by the use of regional anaesthesia in the ambulatory setting.

Preoperative administration of controlled-release oxycodone for the management of pain after ambulatory laparoscopic tubal ligation surgery

STUDY OBJECTIVE

To examine the analgesic efficacy of administering controlled-release (CR) oxycodone 10 mg before elective ambulatory laparoscopic tubal ligation surgery.

DESIGN

Randomized, double-blind study.

PATIENTS

50 healthy women presenting for elective ambulatory laparoscopic tubal ligation surgery.

SETTING

Ambulatory surgery center of a university hospital.

INTERVENTIONS

Fifty patients were administered either placebo (n = 25) or CR oxycodone 10 mg (n = 25) 1 hour before surgery. All patients were administered a similar general anesthetic. In the postanesthesia care unit (PACU), fentanyl 25 microg was administered for a verbal analog scale (VAS) pain score >or=3. Patients were discharged home when they were awake and alert, had stable vital signs, were able to void, tolerated oral fluids, experienced no side effects, had a VAS <or=3, and were able to ambulate without assistance. While at home, patients were instructed to take 1 to 2 acetaminophen 325 mg/oxycodone 5 mg tablets, every 3 hours as needed for a VAS >or=3.

MEASUREMENTS

VAS pain scores and the frequency of postoperative nausea and vomiting were recorded in the PACU. While at home, patients were contacted by telephone after surgery and asked about their pain score, time to first analgesic use, frequency of postoperative nausea and vomiting, and total acetaminophen/oxycodone use in the 24 hours following surgery.

MAIN RESULTS

Patients in the CR oxycodone group had a shorter time to discharge (p < 0.001), reported lower postoperative pain scores (p < 0.001), lower frequency of postoperative nausea and vomiting (p < 0.05), longer time to first analgesic use (p < 0.0,001), and required less fentanyl in the PACU (p < 0.01) and fewer acetaminophen/oxycodone tablets in the 24 hours following surgery.

CONCLUSION

The preoperative administration of CR oxycodone 10 mg is an effective analgesic technique in the management of pain following ambulatory laparoscopic tubal ligation surgery, and may facilitate earlier postoperative discharge.