Effect of adding ketorolac to intravenous morphine patient-controlled analgesia on bowel function in colorectal surgery patients--a prospective, randomized, double-blind study

Risks of serious adverse events with non-steroidal anti-inflammatory drugs in gastrointestinal surgery: A systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly recommended for perioperative opioid-sparing multimodal analgesic treatments. Concerns regarding the potential for serious adverse events (SAEs) associated with perioperative NSAID treatment are especially relevant following gastrointestinal surgery. We assessed the risks of SAEs with perioperative NSAID treatment in patients undergoing gastrointestinal surgery.

METHODS

We conducted a systematic review of randomised clinical trials assessing the harmful effects of NSAIDs versus placebo, usual care or no intervention in patients undergoing gastrointestinal surgery. The primary outcome was an incidence of SAEs. We systematically searched for eligible trials in five major databases up to January 2024. We performed risk of bias assessments to account for systematic errors, trial sequential analysis (TSA) to account for the risks of random errors, performed meta-analyses using R and used the Grading of Recommendations Assessment, Development and Evaluation framework to describe the certainty of evidence.

RESULTS

We included 22 trials enrolling 1622 patients for our primary analyses. Most trials were at high risk of bias. Meta-analyses (risk ratio 0.78; 95% confidence interval [CI] 0.51-1.19; I2 = 4%; p = .24; very low certainty of evidence) and TSA indicated a lack of information on the effects of NSAIDs compared to placebo on the risks of SAEs. Post-hoc beta-binomial regression sensitivity analyses including trials with zero events showed a reduction in SAEs with NSAIDs versus placebo (odds ratio 0.73; CI 0.54-0.99; p = .042).

CONCLUSION

In adult patients undergoing gastrointestinal surgery, there was insufficient information to draw firm conclusions on the effects of NSAIDs on SAEs. The certainty of the evidence was very low.

Effect evaluation of different preventive measures for ileus after abdominal operation: A systematic review and network meta-analysis

Background

Different approaches to the prevention of postoperative ileus have been evaluated in numerous randomized controlled trials. This network meta-analysis aimed to investigate the relative effectiveness of different interventions in preventing postoperative ileus.

Methods

Randomized controlled trials (RCTS) on the prevention of postoperative ileus were screened from Chinese and foreign medical databases and compared. STATA software was used for network meta-analysis using the frequency method. Random-effects network meta-analysis was also used to compare all schemes directly and indirectly.

Results

A total of 105 randomized controlled trials with 18,840 participants were included in this report. The results of the network meta-analysis showed that intravenous analgesia was most effective in preventing the incidence of postoperative ileus, the surface under the cumulative ranking curve (SUCRA) is 90.5. The most effective intervention for reducing the first postoperative exhaust time was postoperative abdominal mechanical massage (SUCRA: 97.3), and the most effective intervention for reducing the first postoperative defecation time was high-dose opioid antagonists (SUCRA: 84.3). Additionally, the most effective intervention for reducing the time to initiate a normal diet after surgery was accelerated rehabilitation (SUCRA: 85.4). A comprehensive analysis demonstrated the effectiveness and prominence of oral opioid antagonists and electroacupuncture (EA) combined with gum.

Conclusion

This network meta-analysis determined that oral opioid antagonists and EA combined with chewing gum are the most effective treatments and optimal interventions for reducing the incidence of postoperative ileus. However, methods such as abdominal mechanical massage and coffee require further high-quality research.

Analgesic Patterns and Opioid Administration in Children Hospitalized With Acute Pancreatitis

BACKGROUND

Pain is the most common symptom of acute pancreatitis (AP), and opioids have been utilized as the cornerstone of treatment. Despite the adverse effects of opioids, data on effective analgesia in children with AP is lacking. We aimed to evaluate analgesia prescribing patterns in pediatric AP, identify factors associated with opioid administration, and test the associations between opioid administration and hospital length of stay (LOS).

METHODS

This is a retrospective cohort study of pediatric AP hospitalizations in a single institution from 2010 to 2020. Opioid administration was calculated for the first 48 hours of admission (morphine milligram equivalent; MME48). Data on multimodal analgesia [defined as the administration of acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs)] during hospitalization was captured.

RESULTS

The sample included 224 patients, mean age 12.0 years (standard deviation = 4.9) and 58.9% female. Median LOS was 4 days (interquartile range 2-9). Most patients (71.4%) were prescribed opioids, 77.7% acetaminophen, 40.2% NSAIDs, and 37.5% multimodal analgesia. Opioid administration decreased over the study period; in contrast, there was an increase in multimodal analgesia administration. Opioid administration did not differ by sex, age, biliary versus non-biliary etiology, or race/ethnicity. In a multivariate regression model, lower albumin values ( P < 0.01) and younger age ( P < 0.05) were significant predictors of increased LOS, while MME48 was not associated with increased LOS.

CONCLUSIONS

Opioids were commonly administered; only 37.5% of children were administered multimodal analgesia during their hospitalization for AP. Opioid administration was not associated with increased LOS. Prospective studies are needed to determine optimal pain management for pediatric AP.

Ketorolac Administration After Colorectal Surgery Increases Anastomotic Leak Rate: A Meta-Analysis and Systematic Review

Objective

This meta-analysis aimed to evaluate whether ketorolac administration is associated with an increased anastomotic leak rate after colorectal surgery.

Methods

The literature was searched using the Web of Science, Embase, and PubMed databases, and the search ended on May 31, 2020. The Newcastle–Ottawa Scale was used to assess methodological quality. Statistical heterogeneity was assessed using the Chi-square Q test and I² statistics. Subgroup analysis was performed, and Egger's test was used to assess publication bias.

Results

This meta-analysis included seven studies with 400,822 patients. Our results demonstrated that ketorolac administration after surgery increases the risk of anastomotic leak [OR = 1.41, 95% CI: 0.81–2.49, Z = 1.21, P = 0.23]. Low heterogeneity was observed across these studies (I² = 0%, P = 0.51). The results of subgroup analysis showed that the use of ketorolac in case–control and retrospective cohort studies significantly increased the risk of anastomotic leak (P < 0.05). Furthermore, the subgroup analysis revealed that ketorolac use increased anastomotic leak rate in patients in the United States and Canada, and ketorolac plus morphine use did not increase anastomotic leak rate in Taiwanese patients (P < 0.05). No significant publication bias was observed (P = 0.126). Moreover, the analysis of risk factors related to anastomotic leak rate indicated that the total use of ketorolac did not increase the risk of anastomotic leak similar to the control group (P > 0.05).

Conclusion

The meta-analysis indicates that the use of ketorolac increases the risk of anastomotic leak after colorectal surgery.

Systematic Review Registration

PROSPERO, identifier CRD42020195724.

Opioid Sparing Anesthesia and Enhanced Recovery After Surgery Protocol for Pancreaticoduodenectomy

Background

Opioid sparing anesthesia and enhanced recovery after surgery protocols are not innovative ideas. However, the utilization of pancreaticoduodenectomy is limited. With the rise in awareness of the opioid epidemic in the United States, we have created a multimodal approach to anesthesia and postoperative care to limit adverse effects of opioids and curb the use of opioids postoperatively.

Methods

We conducted a retrospective cohort study performed by chart review of an opioid-sparing anesthetic and enhanced recovery after surgery (ERAS) protocol initiated jointly by the anesthesiology departments and transplant surgery for pancreaticoduodenectomy from January 2017 to October 2019.

Results

Demographic data was found to be comparable between the control and protocol groups. Hospital length of stay, ICU length of stay, and opioid requirements significantly decreased in the protocol group. Hospital length of stay decreased from 8.92 to 5.72 days, ICU days decreased from 1.52 to 0.42 days, and narcotics for the first five hospital days were significantly decreased from 130.13 to 71.2 morphine milligram equivalents.

Conclusion

Proper postoperative pain management can improve patient satisfaction and decrease complication rates. Pancreaticoduodenectomy is a complicated procedure with relatively limited data regarding enhanced recovery after surgery protocols. Likewise, there is limited data regarding opioid-sparing anesthesia techniques. Our protocol produced promising hospital length of stay and reduced opioid administration during the first five hospital days without increasing 30-day readmission rates.

A Standardized Multimodal Analgesia Protocol Reduces Perioperative Opioid Use in Minimally Invasive Colorectal Surgery

BACKGROUND

Multimodal analgesia protocols are becoming a common part of enhanced recovery pathways after colorectal surgery. However, few protocols include a robust intraoperative component in addition to pre-operative and post-operative analgesics.

METHOD

A prospective cohort study was performed in an urban teaching hospital in patients undergoing minimally invasive colorectal surgery before and after implementation of a multimodal analgesia protocol consisting of pre-operative (gabapentin, acetaminophen, celecoxib), intraoperative (lidocaine and magnesium infusions, ketorolac, transversus abdominis plane block), and post-operative (gabapentin, acetaminophen, celecoxib) opioid-sparing elements. The main outcome measure was use of morphine equivalents in the first 24-h post-operative period.

RESULTS

The study cohort (n = 71) included 41 patients before and 30 patients after implementation of a multimodal analgesia protocol. Mean age of the entire study cohort was 47 ± 19.7 years and 46% were male. Patients undergoing surgery post-multimodal analgesia vs. pre-multimodal analgesia had significantly lower use of IV morphine equivalents in first 24-h post-operative period (5.8 ± 6.4 mg vs. 22.8 ± 21.3 mg; p = 0.005) and first 48-h post-operative period (7.6 ± 9.4 mg vs. 42 ± 52.9 mg; p = 0.0008). This reduction in IV morphine equivalent use post-multimodal analgesia was coupled with improved pain scores in the post-operative period. Post-operative hospital length of stay, post-operative ileus, and overall complications were not significantly different between groups.

CONCLUSIONS

Multimodal analgesia incorporating pre-operative, intraoperative, and post-operative opioid-sparing agents is an effective method for reducing perioperative opioid utilization and pain after minimally invasive colorectal surgery.

Postoperative administration of non-steroidal anti-inflammatory drugs in colorectal cancer surgery does not increase anastomotic leak rate; A systematic review and meta-analysis

BACKGROUND

Evidence on the effect of non-steroidal anti-inflammatory drugs (NSAIDs) on anastomotic leak (AL) rate after colorectal surgery is conflicting. Effects of NSAIDs might depend on the underlying disease. This meta-analysis aimed to review the effect of NSAIDs on AL rate in a homogeneous colorectal cancer patient population.

METHODS

A systematic literature search using MEDLINE and EMBASE database was performed for studies with AL as primary outcome comparing NSAID use in the early postoperative phase with no NSAID administration in colorectal cancer patients undergoing surgical resection.

RESULTS

Nine studies including 10,868 patients met the inclusion criteria. The majority, 7689 patients (70.7%) underwent low anterior resection and 3050 patients (28.1%) underwent colonic resection. The pooled incidence of AL was 8.6% (95%CI 7.0-10.0). Overall AL rate after colorectal cancer surgery was not increased in patients using NSAIDs for postoperative analgesia compared to non-users (p = 0.34, RR 1.23; 95%CI 0.81-1.86). This effect remained non-significant after stratification for low anterior resections (p = 0.07). Stratification for colonic resections could not be performed because AL results for this subgroup were not reported separately. Neither non-selective NSAID use nor COX-2 selective NSAID use caused an increased AL rate (p = 0.19, p = 0.26). The results were robust throughout sensitivity analyses.

CONCLUSION

Use of NSAIDs in cohorts with patients undergoing surgical resection for colorectal cancer does not increase overall AL rate. Since results were robust throughout several subgroup and sensitivity analyses, prescription of NSAIDs after colorectal cancer surgery seems safe.

Postoperative non-steroidal anti-inflammatory drugs and anastomotic leakage after gastrointestinal anastomoses: Systematic review and meta-analysis

AIM

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to control postoperative pain; however, their postoperative use has been associated with anastomotic leakage after gastrointestinal surgery. This systematic review and meta-analysis aimed to determine the correlation between the use of NSAIDs and anastomotic leakage.

METHODS

We conducted a comprehensive electronic literature search up to August 2018 to identify studies comparing anastomotic leakage in patients with and without postoperative NSAID use following gastrointestinal surgery. We then carried out a meta-analysis using random-effects models to calculate odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

Twenty-four studies were included in this meta-analysis, including a total of 31 877 patients. Meta-analysis showed a significant association between NSAID use and anastomotic leakage (OR 1.73; 95% CI = 1.31-2.29, P < .0001). Subgroup analyses showed that non-selective NSAIDs, but not selective cyclooxygenase-2 inhibitors, were significantly associated with anastomotic leakage. However there was no significant subgroup difference between selective and non-selective NSAIDs.

CONCLUSION

Results of this meta-analysis indicate that postoperative NSAID use is associated with anastomotic leakage following gastrointestinal surgeries. Caution is warranted when using NSAIDs for postoperative analgesic control in patients with gastrointestinal anastomoses.

Trend and Economic Burden of Intravenous Narcotic Analgesic Utilization in Major Vascular Interventions in the United States

BACKGROUND

The use of IV narcotic analgesics (IVNA) within the context of vascular procedures is not fully described. We sought to evaluate the burden of IVNA including narcotic analgesia-related adverse drug events (NARADE), associated mortality and hospitalization cost in open and endovascular vascular procedures, and to compare it with nonnarcotic analgesia (IVNNA).

METHODS

Retrospective cross-sectional study in hospitals participating in Premier database (2009-2015). Logistic regression analysis was implemented to report the risks of NARADE and in-hospital mortality. Negative binomial regression was used to assess length of stay and generalized linear modeling was used to estimate the hospitalization cost.

RESULTS

A total of 171,473 patients were identified. NARADE occurred in 6.2% of the cohort. NARADE group was similar in gender and race but was slightly older (median age 71 vs. 70; P < 0.001). After risk-adjustment, NARADE risk was higher in patients who received IVNA-alone in carotid and lower extremity revascularization (LER) [OR (odds ratio) (95% confidence interval [CI]): 1.17 (1.02-1.34) and 1.31 (1.14-1.50)] or combined with IVNNA [OR (95% CI): 1.34 (1.13-1.59) and 1.81 (1.54-2.13)], respectively. Patients receiving aortic repair benefited from the use of IVNA + IVNNA [OR (95% CI): 0.82 (0.69-0.98)]. Occurrence of NARADE doubled the LOS, amplified mortality risk and increased cost in all domains. NARADE increased the odds of mortality by 24.3, 6.5 (4.9-8.68) and 16.6 times and added $5,368, $12,737 and $11,349 to the cost of carotid, aortic and LER interventions, respectively. In contrast, IVNNA was not associated with NARADE risk, increased LOS or cost and showed a survival benefit in patients undergoing open aortic repair [aOR (95% CI): 0.52 (0.36-0.75)].

CONCLUSIONS AND RELEVANCE

The use of opioid-based narcotics had increased the risk of NARADE, resources utilization and NARADE-related mortality. Yet the use of nonopioid-based analgesic was safe, did not increase the cost and reduced mortality in open AA repair. This entices shifting the paradigm toward exploring nonopioid-based analgesia options in order to replace or minimize opioid requirements.

Regional analgesia modalities in abdominal and lower limb surgery - comparison of efficacy

A significant component of all surgical procedures and postoperative treatment is pain management.Due to the physiological and psychological advantages of pain relief, it is one of the foremost indicators of quality of care. Today, there are various modalities of pain reduction, aimed to reduce patient discomfort andminimize side effects, which can be divided by therapeutic agents used (opioid or non-opioid), route of administration (intravenous, regional, oral, etc.) and modality (controlled by patients or "as needed"). Although opioids have proven to be very effective pain relief agents and are commonly used in postoperative analgesia, concerns about their side effects have spurred the development of modified, multimodal treatments that seek to minimize opioid use and associated drawbacks. Enhanced recovery protocols that emphasize sparing administration of opioids are growing in importance, andresulting in reduced length of hospital stay after abdominal and lower limb surgery. To further improve such protocols and optimize postoperative care for individual patient needs, it is imperative to fully assess the efficacy of available drugs and analgesia modalities.

Use of Ketorolac After Outpatient Urogynecologic Surgery: A Randomized Control Trial

OBJECTIVE

Patient surveys highlight a prevalence of moderate to severe pain in the postanesthesia care unit. Multimodal analgesia has been promoted to improve this with fewer opioid-induced adverse effects. The aim of this study was to evaluate the opioid sparing and analgesic effect of postoperative intravenous (IV) ketorolac after outpatient transvaginal surgery.

METHODS

Forty patients were enrolled in this institutional review board-approved, randomized, double-blind, placebo-controlled study, to receive either 30 mg of IV ketorolac or IV saline placebo postoperatively. Pain was assessed by visual analog scale at timed intervals. Narcotic pain medication was provided upon request. Narcotic use was reassessed by telephone 5 to 7 days postoperatively. Categorical characteristics were compared by χ. Continuous variables were evaluated by Mann-Whitney U test.

RESULTS

Twenty patients were randomized to each group. Groups were similar in age, health, and operative factors. There was no significant difference in mean pain scores at any interval. The ketorolac group had a total morphine equivalent consumption median of 7.5 mg versus 4.0 mg for placebo, which was not significant (P = 0.17). Total use of narcotic pills postoperatively was equivalent (median, 5). There was no difference in postoperative nausea. One Dindo grade II complication was reported in the ketorolac group of a postoperative pelvic hematoma requiring transfusion.

DISCUSSION

Intravenous ketorolac administered after outpatient transvaginal surgery did not result in a reduction of pain scores or total morphine consumption. There was one Dindo grade II complication in the ketorolac group. Larger randomized control trials are needed to validate these findings.

Systematic Review and Meta-analysis of Nonsteroidal Anti-inflammatory Drugs to Improve GI Recovery After Colorectal Surgery

BACKGROUND

The management of delayed GI recovery after surgery is an unmet challenge. Uncertainty over its pathophysiology has limited previous research, but recent evidence identifies intestinal inflammation and activation of µ-opioid receptors as key mechanisms. Nonsteroidal anti-inflammatory drugs are recommended by enhanced recovery protocols for their opioid-sparing and anti-inflammatory properties.

OBJECTIVES

The purpose of this study was to explore the safety and efficacy of nonsteroidal anti-inflammatory drugs to improve GI recovery and to identify opportunities for future research.

DATA SOURCES

MEDLINE, Embase, and the Cochrane Library were systematically searched from inception up to January 2018.

STUDY SELECTION

Randomized controlled trials assessing the effect of nonsteroidal anti-inflammatory drugs on GI recovery after elective colorectal surgery were eligible.

MAIN OUTCOME MEASURES

Postoperative GI recovery, including first passage of flatus, stool, and oral tolerance, were measured.

RESULTS

Six randomized controlled trials involving 563 participants were identified. All of the participants received patient-controlled morphine and either nonsteroidal anti-inflammatory drug (nonselective: n = 4; cyclooxygenase-2 selective: n = 1; either: n = 1) or placebo. Patients receiving the active drug had faster return of flatus (mean difference: -17.73 h (95% CI, -21.26 to -14.19 h); p < 0.001), stool (-9.52 h (95% CI, -14.74 to -4.79 h); p < 0.001), and oral tolerance (-12.00 h (95% CI, -18.01 to -5.99 h); p < 0.001). Morphine consumption was reduced in the active groups of 4 studies (average reduction, 12.9-30.0 mg), and 1 study demonstrated significantly reduced measures of systemic inflammation. Nonsteroidal anti-inflammatory drugs were not associated with adverse events, but 1 study was temporarily suspended for safety.

LIMITATIONS

The data presented are relatively outdated but represent the best available evidence.

CONCLUSIONS

Nonsteroidal anti-inflammatory drugs may represent an effective and accessible intervention to improve GI recovery, but hesitancy over their use after colorectal surgery persists. Additional preclinical research to characterize their mechanisms of action, followed by well-designed clinical studies to test safety and patient-reported efficacy, should be considered.

Nonsteroidal anti-inflammatory drugs reduce the time to recovery of gut function after elective colorectal surgery: a systematic review and meta-analysis

AIM

Postoperative ileus causes significant patient morbidity after abdominal surgery. Some evidence suggests nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce time to gut recovery, but there has not been a meta-analysis to assess their efficacy. This systematic review and meta-analysis aimed to determine the benefit of NSAIDs for recovery of postoperative gut function in patients undergoing elective colorectal surgery.

METHOD

MEDLINE, EMBASE, CENTRAL and reference lists were searched with no date or language restrictions. Randomized controlled trials comparing the use of NSAIDs with placebo in the perioperative or postoperative period were identified. Included studies reported outcomes relevant to gut function: time to pass flatus or stool and time to tolerate an oral diet. The mean difference in time from surgery until passage of flatus, stool and tolerance of diet were meta-analysed using a random-effects model in RevMan 5.3.

RESULTS

This study identified 992 relevant articles. Five randomized controlled trials on patients undergoing elective colorectal surgery met our inclusion criteria and were meta-analysed. Compared with placebo, NSAIDs significantly improved the time to pass flatus (mean difference -9.44 h, 95% CI: -17.22, -1.65, I² = 70%, P = 0.02), time to pass stool (mean difference -12.09 h, 95% CI: -17.16, -7.02, I² = 0%, P < 0.001) and time to tolerate a diet (mean difference -11.95 h, 95% CI: -18.66, -5.24, I² = 0%, P < 0.001).

CONCLUSION

NSAIDs significantly improve time to gut recovery after elective colorectal surgery. Current evidence is not adequate to identify whether selective or nonselective drugs should be recommended. Further high-power studies using selective drugs are required.

Postoperative ileus following major colorectal surgery

BACKGROUND

Postoperative ileus (POI) is characterized by delayed gastrointestinal recovery following surgery. Current knowledge of pathophysiology, clinical interventions and methodological challenges was reviewed to inform modern practice and future research.

METHODS

A systematic search of MEDLINE and Embase databases was performed using search terms related to ileus and colorectal surgery. All RCTs involving an intervention to prevent or reduce POI published between 1990 and 2016 were identified. Grey literature, non-full-text manuscripts, and reanalyses of previous RCTs were excluded. Eligible articles were assessed using the Cochrane tool for assessing risk of bias.

RESULTS

Of 5614 studies screened, 86 eligible articles describing 88 RCTs were identified. Current knowledge of pathophysiology acknowledges neurogenic, inflammatory and pharmacological mechanisms, but much of the evidence arises from animal studies. The most common interventions tested were chewing gum (11 trials) and early enteral feeding (11), which are safe but of unclear benefit for actively reducing POI. Others, including thoracic epidural analgesia (8), systemic lidocaine (8) and peripheral μ antagonists (5), show benefit but require further investigation for safety and cost-effectiveness.

CONCLUSION

POI is a common condition with no established definition, aetiology or treatment. According to current literature, minimally invasive surgery, protocol-driven recovery (including early feeding and opioid avoidance strategies) and measures to avoid major inflammatory events (such as anastomotic leak) offer the best chances of reducing POI.

Initial Pain Management in Pediatric Acute Pancreatitis: Opioid Versus Non-opioid

Nearly all patients with acute pancreatitis (AP) experience some degree of abdominal pain that is severe enough to prompt medical evaluation and necessitate analgesia. Effective analgesia is a priority in caring for such patients. Despite its importance, strategies for pain management in AP have been poorly studied, particularly in the field of pediatrics. Presently, no published data examine the management of pain because of AP in children at the time of initial presentation. Management approaches are often extrapolated from adult practice and based on anecdotal experience in the absence of objective data. The aim of our study was to examine the initial provision of analgesia to children who presented to a pediatric emergency department with AP.

Consensus Statement for Clinical Pathway Development for Perioperative Pain Management and Care Transitions

The perioperative surgical home (PSH) model has been created with the intention to reduce costs and to improve efficiency of care and patient experience in the perioperative period. The PSH is a comprehensive model of care that is team-based and patient-centric. The team in each facility should be multidisciplinary and include the input of perioperative services leadership, surgical services, and support personnel in order to provide seamless care for the patient from the preoperative period when decision to undergo surgery is initially made to discharge and, if needed after discharge from the hospital, until full recovery is achieved. PSH is discussed in this consensus article with the emphasis on perioperative care coordination of patients with chronic pain conditions. Preoperative optimization can be successfully undertaken through patient evaluation, screening, and education. Many important positive implications in the PSH model, in particular for those patients with increased potential morbidity, mortality, and high-risk populations, including those with a history of substance abuse or anxiety, reflect a more modern approach to health care. Newer strategies, such as preemptive and multimodal analgesic techniques, have been demonstrated to reduce opioid consumption and to improve pain relief. Continuous catheters, ketamine, methadone, buprenorphine, and other modalities can be best delivered with the expertise of an anesthesiologist and a support team, such as an acute pain care coordinator. A physician-led PSH is a model of care that is patient-centered with the integration of care from multiple disciplines and is ideally suited for leadership from the anesthesia team. Optimum pain control will have a significant positive impact on the measures of the PSH, including lowering of complication rates, lowering of readmissions, improved patient satisfaction, reduced morbidity and mortality, and shortening of hospital stays. All stakeholders should work together and consider the PSH model to ensure the best quality of health care for patients undergoing surgery in the future. The pain management physician's role in the postoperative period should be focused on providing optimal analgesia associated with improved patient satisfaction and outcomes that result in reduced health care costs.

A Comparison of Multimodal Analgesic Approaches in Institutional Enhanced Recovery After Surgery Protocols for Colorectal Surgery: Pharmacological Agents

INTRODUCTION

Enhanced Recovery After Surgery (ERAS^®) protocols are the cornerstone of improved recovery after colorectal surgery. Their implementation leads to reduced morbidity and shorter hospital stays while attenuating the surgical stress response. Multimodal analgesia is an important part of ERAS protocols. We compared and contrasted protocols from 15 institutions to test our hypothesis that there is a fundamental consensus among them.

MATERIALS AND METHODS

ERAS protocols for open and laparoscopic colorectal surgery were compared from 15 different healthcare facilities. We examined each institution's approach to multimodal analgesia related to the use of oral and intravenous analgesics. Preoperative, intraoperative, and postoperative management was examined.

RESULTS

All but three protocols used preoperative multimodal analgesics, with acetaminophen, celecoxib, and gabapentin being the most common. Intraoperative recommendations included the use of ketamine, lidocaine, magnesium, and ketorolac. Some protocols advocated for the use of opiates, while others aimed to minimize total opioid dose. In the postoperative period, the three most utilized agents were acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids.

CONCLUSIONS

There were many similarities and some significant differences among ERAS protocols examined. Acetaminophen was the most widely used nonopioid agent and along with NSAIDs offers a benefit with respect to postoperative analgesia, opioid-sparing effects, earlier ambulation, and reduction in postoperative ileus. Gabapentin was widely used as it may reduce opioid consumption within the first 24 hours postoperatively. Lidocaine infusion was recommended if there were contraindications to or failure of epidural anesthesia. Ketamine is frequently recommended due to its analgesic, antihyperalgesic, antiallodynic, and antitolerance properties. Differences in approaches may be due to both institutional- and provider-level factors.

Influence of perioperative nonsteroidal anti-inflammatory drugs on complications after gastrointestinal surgery: A meta-analysis

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are a key part of multimodal perioperative analgesia. This study aimed to evaluate the influence of perioperative NSAIDs application on complications after gastrointestinal surgery by using meta-analysis.

METHODS

A systematic review of published literature was conducted by searching computerized databases including PubMed, CBM, Springer, Chinese Academic Journals, and China Info since the databases were published until June 2015. The articles and retrospective references regarding complications after gastrointestinal surgery were collected to compare postoperative complications associated with NSAIDs or other analgesics. After they were assessed by randomized controlled trials and extracted by the standard of the Jadad systematic review, the homogeneous studies were pooled using RevMan 5.3 software. The meta-analysis was performed on five postoperative complications: postoperative anastomotic leak, cardiovascular events, surgical site infection, nausea and vomiting, and intestinal obstruction.

RESULTS

Twelve randomized controlled trials involving 3829 patients met the inclusion criteria. The results of meta-analyses showed the following: (1) postoperative anastomotic leak: NSAIDs (including selective and nonselective NSAIDs) increased the incidence of anastomotic leak [odds ratio (OR)=3.02, 95% confidence interval (CI): 2.16-4.23, p=0.00001]. Further results showed that nonselective NSAIDs significantly increased the incidence of anastomotic leak (OR=2.96, 95% CI: 1.99-4.42, p<0.00001), and selective NSAIDs had no significant difference as compared with the control group using other analgesics (OR=2.27, 95% CI: 0.68-7.56, p=0.18); (2) postoperative cardiovascular events: NSAIDs (selective and nonselective NSAIDs) had no difference when compared with other analgesics (OR=0.50, 95% CI: 0.23-1.12, p=0.09); (3) postoperative surgical site infection: NSAIDs (selective and nonselective NSAIDs) and other analgesics had no difference in surgical site infection (OR=0.77, 95% CI: 0.52-1.15, p=0.20); (4) postoperative nausea and vomiting: NSAIDs (selective and nonselective NSAIDs) decreased the incidence of nausea and vomiting (OR=0.53, 95% CI: 0.34-0.81, p=0.003); (5) postoperative intestinal obstruction: NSAIDs (selective and nonselective NSAIDs) decreased the incidence of intestinal obstruction (OR=0.35, 95% CI: 0.13-0.89, p=0.03).

CONCLUSIONS

The meta-analysis suggests that postoperative NSAIDs, especially nonselective NSAIDs, could increase the incidence of anastomotic leak. NSAIDs could decrease postoperative nausea and vomiting and intestinal obstruction, but showed no difference in cardiovascular events and surgical site infection as compared with other analgesics.

Effects of dexmedetomidine in combination with fentanyl-based intravenous patient-controlled analgesia on pain attenuation after open gastrectomy in comparison with conventional thoracic epidural and fentanyl-based intravenous patient-controlled analgesia

Background: This study was investigated the effects of dexmedetomidine in combination with fentanyl-based intravenous patient-controlled analgesia (IV-PCA) on pain attenuation in patients undergoing open gastrectomy in comparison with conventional thoracic epidural patient-controlled analgesia (E-PCA) and IV-PCA. Methods: One hundred seventy-one patients who planned open gastrectomy were randomly distributed into one of the 3 groups: conventional thoracic E-PCA (E-PCA group, n = 57), dexmedetomidine in combination with fentanyl-based IV-PCA (dIV-PCA group, n = 57), or fentanyl-based IV-PCA only (IV-PCA group, n = 57). The primary outcome was the postoperative pain intensity (numerical rating scale) at 3 hours after surgery, and the secondary outcomes were the number of bolus deliveries and bolus attempts, and the number of patients who required additional rescue analgesics. Mean blood pressure, heart rate, and adverse effects were evaluated as well. Results: One hundred fifty-three patients were finally completed the study. The postoperative pain intensity was significantly lower in the dIV-PCA and E-PCA groups than in the IV-PCA group, but comparable between the dIV-PCA group and the E-PCA group. Patients in the dIV-PCA and E-PCA groups needed significantly fewer additional analgesic rescues between 6 and 24 hours after surgery, and had a significantly lower number of bolus attempts and bolus deliveries during the first 24 hours after surgery than those in the IV-PCA group. Conclusions: Dexmedetomidine in combination with fentanyl-based IV-PCA significantly improved postoperative analgesia in patients undergoing open gastrectomy without hemodynamic instability, which was comparable to thoracic E-PCA. Furthermore, this approach could be clinically more meaningful owing to its noninvasive nature.

Postoperative Nonsteroidal Anti-inflammatory Drug Use and Intestinal Anastomotic Dehiscence: A Systematic Review and Meta-Analysis

BACKGROUND

Nonsteroidal anti-inflammatory drugs are commonly used analgesics in colorectal surgery. Controversy exists regarding the potential association between these drugs and anastomotic dehiscence.

OBJECTIVE

This study aimed to determine whether postoperative nonsteroidal anti-inflammatory drug use is associated with intestinal anastomotic dehiscence.

DATA SOURCES

PubMed, EMBASE, CENTRAL, and references of included articles were searched without date or language restriction.

STUDY SELECTION

Randomized controlled trials and observational studies that compared postoperative nonsteroidal anti-inflammatory drug use with nonuse and reported on intestinal anastomotic dehiscence were selected.

INTERVENTION

The use of postoperative nonsteroidal anti-inflammatory drugs relative to placebo or nonuse was investigated.

MAIN OUTCOME MEASURES

Risk ratios and adjusted or unadjusted odds ratios for anastomotic dehiscence were pooled across randomized controlled trials and observational studies using DerSimonian and Laird random-effects models.

RESULTS

Among 4395 citations identified, 6 randomized controlled trials (n = 473 patients) and 11 observational studies (n > 20,184 patients) were included. Pooled analyses revealed that nonsteroidal anti-inflammatory drug use was nonsignificantly associated with anastomotic dehiscence in randomized controlled trials (risk ratio, 1.96; 95% CI, 0.74-5.16; I = 0%) and significantly associated with anastomotic dehiscence in observational studies (OR, 1.46; 95% CI, 1.14-1.86; I = 54%). In stratified analyses of observational study data, the pooled OR for anastomotic dehiscence was statistically significant for studies of nonselective nonsteroidal anti-inflammatory drug use (6 studies; > 4900 patients; OR, 2.09; 95% CI, 1.65-2.64; I = 0%), but was not statistically significant for studies of cyclooxygenase-2 selective nonsteroidal anti-inflammatory drug use (3 studies; >697 patients; OR, 1.34; 95% CI, 0.78-2.31; I = 0%).

LIMITATIONS

Studies varied by patient selection criteria, drug exposures, and definitions of anastomotic dehiscence. Analyses of randomized controlled trials and cyclooxygenase-2 selective nonsteroidal anti-inflammatory drugs were potentially underpowered.

CONCLUSIONS

Pooled observational data suggest an association between postoperative nonsteroidal anti-inflammatory drug use and intestinal anastomotic dehiscence. Caution may be warranted in using these medications in patients at risk for this complication.

Efficacy and tolerability of oxycodone versus fentanyl for intravenous patient-controlled analgesia after gastrointestinal laparotomy: A prospective, randomized, double-blind study

BACKGROUND

It has been suggested that oxycodone is effective in relieving acute postoperative pain. The aim of this study was to investigate the efficacy and tolerability of oxycodone (O) versus fentanyl (F), and the adequate potency ratio of oxycodone and fentanyl in patients with intravenous patient-controlled analgesia after gastric laparotomy.

METHODS

In this double-blinded, randomized, controlled study, 60 patients undergoing elective gastric laparotomy were allocated to receive either oxycodone or fentanyl for postoperative intravenous patient-controlled analgesia (potency ratio 60:1). The patients received ketorolac 60 mg before the end of anesthesia and then continued with patient-controlled analgesia for 48 hours postsurgery. Pain severity, side effects and respiration rate were recorded 30 minutes, 3, 6, 12, 24, and 48 hours after the surgery. Cumulative opioid requirements and patient satisfaction were also measured.

RESULTS

The median consumption more than 48 hours after operation of oxycodone was 50 mg (range: 40.0-62.4 mg) and fentanyl was 0.8 mg (range: 0.6-1.1 mg), and the percentage of patients requiring rescue medication was not statistically significant. Numeric rating scores at rest and upon movement were significantly lower in group O than in F (P < 0.05). Whereas the incidences of adverse events were similar between the groups (33.3% vs 27.6%, P = 0.64), a significant higher sedation scores were found in patients given fentanyl at 30 minutes after the surgery (P = 0.04).

CONCLUSION

Oxycodone was comparable to fentanyl in the relief of postoperative pain following gastric laparotomy. Oxycodone not only provides better postoperative pain relief and less sedation, but also there was a tendency toward more side effects with oxycodone.

Opioid-sparing effect of selective cyclooxygenase-2 inhibitors on surgical outcomes after open colorectal surgery within an enhanced recovery after surgery protocol

AIM: To evaluate the opioid-sparing effect of selective cyclooxygenase-2 (COX-2) inhibitors on short-term surgical outcomes after open colorectal surgery.

METHODS: Patients undergoing open colorectal resection within an enhanced recovery after surgery protocol from 2011 to 2015 were reviewed. Patients with combined general anesthesia and epidural anesthesia, and those with acute colonic obstruction or perforation were excluded. Patients receiving selective COX-2 inhibitor were compared with well-matched individuals without such a drug. Outcome measures included numeric pain score and morphine milligram equivalent (MME) consumption on postoperative day (POD) 1-3, gastrointestinal recovery (time to tolerate solid diet and time to defecate), complications and length of postoperative stay.

RESULTS: There were 75 patients in each group. Pain score on POD 1-3 was not significantly different between two groups. However, MME consumption and MME consumption per kilogram body weight on POD 1-3 was significantly less in patients receiving a selective COX-2 inhibitor (P < 0.001). Median MME consumption per kilogram body weight on POD 1-3 was 0.09, 0.06 and nil, respectively in patients receiving a selective COX-2 inhibitor and 0.22, 0.25 and 0.07, respectively in the comparative group (P < 0.001), representing at least 59% opioid reduction. Patients prescribing a selective COX-2 inhibitor had a shorter median time to resumption of solid diet [1 (IQR 1-2) d vs 2 (IQR 2-3) d; P < 0.001] and time to first defecation [2 (IQR 2-3) d vs 3 (IQR 3-4) d; P < 0.001]. There was no significant difference in overall postoperative complications between two groups. However, median postoperative stay was significantly 1-d shorter in patients prescribing a selective COX-2 inhibitor [4 (IQR 3-5) d vs 5 (IQR 4-6) d; P < 0.001].

CONCLUSION: Perioperative administration of oral selective COX-2 inhibitors significantly decreased intravenous opioid consumption, shortened time to gastrointestinal recovery and reduced hospital stay after open colorectal surgery.

Double-blind, randomized, double-dummy clinical trial comparing the efficacy of ketorolac trometamol and naproxen for acute low back pain

Background

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most common type of medication used in the treatment of acute pain. Ketorolac trometamol (KT) is a nonnarcotic, peripherally acting nonsteroidal anti-inflammatory drug with analgesic effects comparable to certain opioids.

Objective

The aim of this study was to compare the efficacy of KT and naproxen (NA) in the treatment of acute low back pain (LBP) of moderate-to-severe intensity.

Patients and methods

In this 10-day, Phase III, randomized, double-blind, double-dummy, noninferiority trial, participants with acute LBP of moderate-to-severe intensity as determined through a visual analog scale (VAS) were randomly assigned in a 1:1 ratio to receive sublingual KT 10 mg three times daily or oral NA 250 mg three times daily. From the second to the fifth day of treatment, if patient had VAS >40 mm, increased dosage to four times per day was allowed. The primary end point was the reduction in LBP as measured by VAS. We also performed a post hoc superiority analysis.

Results

KT was not inferior to NA for the reduction in LBP over 5 days of use as measured by VAS scores (P=0.608 for equality of variance; P=0.321 for equality of means) and by the Roland–Morris Disability Questionnaire (P=0.180 for equality of variance test; P=0.446 for equality of means) using 95% confidence intervals. The percentage of participants with improved pain relief 60 minutes after receiving the first dose was higher in the KT group (24.2%) than in the NA group (6.5%; P=0.049). The most common adverse effects were heartburn, nausea, and vomiting.

Conclusion

KT is not inferior in efficacy and delivers faster pain relief than NA.

Ketorolac Use and Postoperative Complications in Gastrointestinal Surgery

OBJECTIVE

To study the association between ketorolac use and postoperative complications.

BACKGROUND

Nonsteroidal anti-inflammatory drugs may impair wound healing and increase the risk of anastomotic leak in colon surgery. Studies to date have been limited by sample size, inability to identify confounding, and a focus limited to colon surgery.

METHODS

Ketorolac use, reinterventions, emergency department (ED) visits, and readmissions in adults (≥ 18 years) undergoing gastrointestinal (GI) operations was assessed in a nationwide cohort using the MarketScan Database (2008-2012).

RESULTS

Among 398,752 patients (median age 52, 45% male), 55% underwent colorectal surgery, whereas 45% had noncolorectal GI surgery. Five percent of patients received ketorolac. Adjusting for demographic characteristics, comorbidities, surgery type/indication, and preoperative medications, patients receiving ketorolac had higher odds of reintervention (odds ratio [OR] 1.20, 95% confidence interval [CI] 1.08-1.32), ED visit (OR 1.44, 95% CI 1.37-1.51), and readmission within 30 days (OR 1.11, 95% CI 1.05-1.18) compared to those who did not receive ketorolac. Ketorolac use was associated with readmissions related to anastomotic complications (OR 1.20, 95% CI 1.06-1.36). Evaluating only admissions with ≤ 3 days duration to exclude cases where ketorolac might have been used for complication-related pain relief, the odds of complications associated with ketorolac were even greater.

CONCLUSIONS

Use of intravenous ketorolac was associated with greater odds of reintervention, ED visit, and readmission in both colorectal and noncolorectal GI surgery. Given this confirmatory evaluation of other reports of a negative association and the large size of this cohort, clinicians should exercise caution when using ketorolac in patients undergoing GI surgery.

Postoperative nonsteroidal anti-inflammatory drugs and risk of anastomotic leak: meta-analysis of clinical and experimental studies

BACKGROUND

Enhanced recovery programs following colorectal resection recommend the use of nonsteroidal anti-inflammatory drugs (NSAIDs) as part of multimodal analgesia. The present study aimed to assess whether postoperative NSAID use increased the risk of anastomotic leak.

METHODS

A systematic review of published literature was performed for studies comparing anastomotic leak following NSAID administration versus control. Meta-analysis was conducted for studies in human patients and experimental animal models. The primary endpoint was anastomotic leak.

RESULTS

The final analysis included 8 studies in humans and 12 experimental animal studies. Use of NSAIDs was significantly associated with anastomotic leak in humans (8 studies, 4,464 patients, odds ratio [OR] 2.14; p < 0.001). This effect was seen with nonselective NSAIDs (6 studies, 3,074 patients, OR 2.37; p < 0.001), but not with selective NSAIDs (4 studies, 1,223 patients, OR 2.32; p = 0.170). There was strong evidence of selection bias from all clinical studies, with additional inconsistent definitions and outcomes assessment. From experimental animal models, anastomotic leak was more likely with NSAID use (ten studies, 575 animals, OR 9.51; p < 0.001). Bursting pressures at day 7 were significantly lower in NSAID versus controls (7 studies, 168 animals, weighted mean difference -35.7 mmHg; p < 0.001).

CONCLUSIONS

Emerging data strongly suggest that postoperative NSAIDs are linked to anastomotic leak, although most studies are flawed and may be describing pre-existing selection bias. However, when combined with experimental data, these increasing concerns suggest caution is needed when prescribing NSAIDs to patients with pre-existing risk factors for leak, until more definitive evidence emerges.

Butorphanol and ketamine combined in infusion solutions for patient-controlled analgesia administration: a long-term stability study

BACKGROUND

Ketamine in subanesthetic dose added to butorphanol has been reported to give superior pain control when used for intravenous patient-controlled analgesia (PCA) after surgery. However, this admixture is not available commercially and stability data applicable to hospital practice are limited.

MATERIAL/METHODS

The butorphanol-ketamine admixtures were prepared in polyolefin bags and stored in the dark at 4°C, 25°C, or 37°C for 15 days. The initial concentrations were 50-150 microgram/ml for butorphanol and 1-4 mg/ml for ketamine, respectively. The stabilities were determined by visual inspection, pH measurement, and high-pressure liquid chromatography (HPLC) assay of drug concentrations.

RESULTS

Over the 15 days, all solutions were clear in appearance, and no color change or precipitation was observed among the three temperatures. The percentages of initial concentration of each drug were over 95% during the study period, and the pH value did not change significantly.

CONCLUSIONS

The results indicate that the drug mixtures of butorphanol and ketamine in 0.9% sodium chloride injection were stable for 15 days when stored in polyolefin bags at 4°C, 25°C, or 37°C.

Analgesic opioid dose is an important indicator of postoperative ileus following radical cystectomy with ileal conduit: experience in the robotic surgery era

PURPOSE

Postoperative ileus (POI) is common following bowel resection for radical cystectomy with ileal conduit (RCIC). We investigated perioperative factors associated with prolonged POI following RCIC, with specific focus on opioid-based analgesic dosage.

MATERIALS AND METHODS

From March 2007 to January 2013, 78 open RCICs and 26 robot-assisted RCICs performed for bladder carcinoma were identified with adjustment for age, gender, American Society of Anesthesiologists grade, and body mass index (BMI). Perioperative records including operative time, intraoperative fluid excess, estimated blood loss, lymph node yield, and opioid analgesic dose were obtained to assess their associations with time to passage of flatus, tolerable oral diet, and length of hospital stay (LOS). Prior to general anaesthesia, patients received epidural patient-controlled analgesia (PCA) consisted of fentanyl with its dose adjusted for BMI. Postoperatively, single intravenous injections of tramadol were applied according to patient desire.

RESULTS

Multivariate analyses revealed cumulative dosages of both PCA fentanyl and tramadol injections as independent predictors of POI. According to surgical modality, linear regression analyses revealed cumulative dosages of PCA fentanyl and tramadol injections to be positively associated with time to first passage of flatus, tolerable diet, and LOS in the open RCIC group. In the robot-assisted RCIC group, only tramadol dose was associated with time to flatus and tolerable diet. Compared to open RCIC, robot-assisted RCIC yielded shorter days to diet and LOS; however, it failed to shorten days to first flatus.

CONCLUSION

Reducing opioid-based analgesics shortens the duration of POI. The utilization of the robotic system may confer additional benefit.

Perioperative nonselective non-steroidal anti-inflammatory drugs are not associated with anastomotic leakage after colorectal surgery

INTRODUCTION

Recent evidence raises concern about the use of perioperative non-steroidal anti-inflammatory drug (NSAID) use after colorectal resection. The purpose of this retrospective cohort study was to investigate the relationship between perioperative ketorolac use and anastomotic leakage after colorectal surgery.

METHODS

A retrospective review (2004-2011) was performed on patients who underwent elective colorectal surgery. Univariate analysis and multivariate logistic regression were used to evaluate the association between patients who did not receive any NSAIDs and those who received ketorolac within the first 5 days perioperatively and leak rate.

RESULTS

A total of 731 patients were identified as having resection with primary anastomosis: 376 (51.4 %) received no NSAIDs and 355 (48.6 %) received ketorolac perioperatively within 5 days after their surgery. There were 24 (3.3 %) leaks, with 12 in both the no NSAIDs (3.2 %) and ketorolac (3.4 %) groups, odds ratio (OR) 1.06 (0.43, 2.62; p = 0.886). Adjusting for smoking, steroid use, and age, there remained no significant difference between ketorolac use and leakage, OR 1.21 (0.52, 2.84; p = 0.660). In our multivariate model, only smoking was a significant predictor of postoperative leak, OR 3.34 (1.30, 8.62; p = 0.021).

CONCLUSIONS

There does not appear to be a significant association between perioperative ketorolac use and anastomotic leakage after colorectal surgery. However, further prospective studies are needed to confirm our findings before definitive guidelines on NSAID use perioperatively can be recommended.

Postoperative pain control

The effective relief of pain is of the utmost importance to anyone treating patients undergoing surgery. Pain relief has significant physiological benefits; hence, monitoring of pain relief is increasingly becoming an important postoperative quality measure. The goal for postoperative pain management is to reduce or eliminate pain and discomfort with a minimum of side effects. Various agents (opioid vs. nonopioid), routes (oral, intravenous, neuraxial, regional) and modes (patient controlled vs. "as needed") for the treatment of postoperative pain exist. Although traditionally the mainstay of postoperative analgesia is opioid based, increasingly more evidence exists to support a multimodal approach with the intent to reduce opioid side effects (such as nausea and ileus) and improve pain scores. Enhanced recovery protocols to reduce length of stay in colorectal surgery are becoming more prevalent and include multimodal opioid sparing regimens as a critical component. Familiarity with the efficacy of available agents and routes of administration is important to tailor the postoperative regimen to the needs of the individual patient.

Nonopioid versus opioid based general anesthesia technique for bariatric surgery: A randomized double-blind study

OBJECTIVE

The objective of this study was to evaluate the efficacy and safety of giving general anesthesia without the use of any opioids either systemic or intraperitoneal in bariatric surgery.

METHODS

Prospective randomized controlled trial. Obese patients (body mass index >50 Kg/m(2)) undergoing laparoscopic sleeve gastrectomies were recruited and provided an informed signed consent. Patients were randomized using a computer generated randomization table to receive either opioid or non-opioid based anesthesia. The patient and the investigator scoring patient outcome after surgery were blinded to the anesthetic protocol. Primary outcomes were hemodynamics in the form of "heart rate, systolic, diastolic, and mean arterial blood pressure" on induction and ½ hourly thereafter. Pain monitoring through visual analog scale (VAS) 30 min after recovery, hourly for 2 h and every 4 h for 24 h was also recorded. Pain monitoring through VAS and post-operative nausea and vomiting 30 min after recovery were also recorded and finally patient satisfaction and acute pain nurse satisfaction.

RESULTS

There was no difference in background characteristics in both groups. There were no statistically significant differences in different outcomes as heart rate, mean blood pressure, O2 saturation in different timings between groups at any of the determined eight time points but pain score and nurse satisfaction showed a trend to better performance with non-opioid treatment.

CONCLUSION

Nonopioid based general anesthesia for Bariatric surgery is as effective as opioid one. There is no need to use opioids for such surgery especially that there was a trend to less pain in non-opioid anesthesia.

The beneficial effect of ST-36 (Zusanli) acupressure on postoperative gastrointestinal function in patients with colorectal cancer

PURPOSE/OBJECTIVES

To evaluate the effectiveness of ST-36 (Zusanli) acupressure on recovery of postoperative gastrointestinal function in patients with colorectal cancer.

DESIGN

A longitudinal, randomized, controlled trial design.

SETTING

An urban medical center in Taiwan.

SAMPLE

60 patients with colorectal cancer who had undergone abdominal surgery.

METHODS

Patients were randomly assigned to two groups, the ST-36 acupressure group (n = 30) and a sham acupressure group (n = 30). Patients in the ST-36 group received an acupressure procedure in a three-minute cycle performed three times per day during the five days after surgery. Patients in the control group received routine postoperative care and sham acupressure. Generalized estimating equations (GEEs) were used to gauge longitudinal effects of the two groups of patients.

MAIN RESEARCH VARIABLES

Frequency of bowel sounds, the time to first flatus passage, first liquid intake, solid intake, and defecation.

FINDINGS

Patients who received acupressure had significantly earlier flatus passage and time to liquid intake as compared to patients in the control group. Other main variables, including the first time to solid intake and defecation, did not show significant difference between the two groups. The GEE method revealed that all patients had increasing bowel sounds over time, and the experimental group had greater improvement of bowel motility than the control group within the period of 2-3 days postoperatively.

CONCLUSIONS

ST-36 acupressure was able to shorten the time to first flatus passage, oral liquid intake, and improve gastrointestinal function in patients after abdominal surgery.

IMPLICATIONS FOR NURSING

ST-36 acupressure can be integrated into postoperative adjunct nursing care to assist patients' postoperative gastrointestinal function.

KNOWLEDGE TRANSLATION

Few studies have explored the effectiveness of acupressure techniques on promoting bowel sounds. Evidence from this study suggests stimulation of the ST-36 acupressure point can increase bowel sound frequency for patients with colorectal cancer in the first three days after surgery. Application of this technique may improve a patient's comfort after surgery.

Defining postoperative ileus: results of a systematic review and global survey

BACKGROUND

There is a lack of an internationally accepted standardised clinical definition for postoperative ileus (POI). This has made it difficult to estimate incidence and identify risk factors and has compromised external validity of clinical trials.

AIM

To clarify terminology of POI and propose concise, clinically quantifiable definitions.

METHODS

A systematic review extracted definitions from randomised trials published between 1996 and 2011 investigating POI after abdominal surgery. This was followed by a global survey seeking opinions of those who have published in the field.

RESULTS

Definitions were extracted from 52 identified trials. Responses were received in the survey from 45 of 118 corresponding authors. Data were amalgamated to synthesise the following definitions: postoperative ileus (POI) "interval from surgery until passage of flatus/stool AND tolerance of an oral diet"; prolonged POI "two or more of nausea/vomiting, inability to tolerate oral diet over 24 h, absence of flatus over 24 h, distension, radiologic confirmation occurring on or after day 4 postoperatively without prior resolution of POI"; recurrent POI "two or more of nausea/vomiting, inability to tolerate oral diet over 24 h, absence of flatus over 24 h, distension, radiologic confirmation, occurring after apparent resolution of POI". Concordance of the latter two definitions with survey responses were ≥75 %.

CONCLUSION

We have proposed standardised endpoints for use in future studies to facilitate objective comparison of competing interventions.

Nonsteroidal anti-inflammatory drugs and anastomotic dehiscence in bowel surgery: systematic review and meta-analysis of randomized, controlled trials

BACKGROUND

Nonsteroidal anti-inflammatory drugs are a key component of contemporary perioperative analgesia. Recent experimental and observational clinical data suggest an associated increased incidence of anastomotic dehiscence in bowel surgery.

OBJECTIVE

The aim of this study was to conduct a systematic review and meta-analysis of anastomotic dehiscence in randomized, controlled trials of perioperative nonsteroidal anti-inflammatory drugs.

DATA SOURCES

Published and unpublished trials in any language reported 1990 or later were identified by searching electronic databases, bibliographies, and relevant conference proceedings.

STUDY SELECTION

Trials of adults undergoing bowel surgery randomly assigned to perioperative nonsteroidal anti-inflammatory drugs or control were included. The number of patients with a bowel anastomosis and the incidence of anastomotic dehiscence had to be reported or be available from authors for the study to be included.

INTERVENTION

At least 1 dose of a nonsteroidal anti-inflammatory drug was given perioperatively within 48 hours of surgery.

MAIN OUTCOME MEASURES

The primary outcome measured was 30-day incidence of anastomotic dehiscence as defined by authors.

RESULTS

Six trials comprising 480 patients having a bowel anastomosis met inclusion criteria. In 4 studies, anastomotic dehiscence rates were higher in the intervention groups. Overall rates were 14/272 participants (5.1%) in intervention arms vs 5/208 (2.4%) in control arms. Peto OR was 2.16 (95% CI 0.85, 5.53; p = 0.11), and there was no heterogeneity between studies (I statistic 0%).

LIMITATIONS

Sizes of available trials were small, preventing firm conclusions and subset analysis of drugs of different cyclooxygenase specificity. A precise and consistent definition of anastomotic dehiscence was not used across trials.

CONCLUSIONS

A statistically significant difference in incidence of anastomotic dehiscence was not demonstrated. However, the Peto OR of 2.16 (0.85, 5.53) and lack of heterogeneity between trials suggest that this finding may be due to a lack of power of the available data rather than a lack of effect.

Anesthesia and perioperative management of colorectal surgical patients - A clinical review (Part 1)

Colorectal surgery is commonly performed for colorectal cancer and other pathology such as diverticular and inflammatory bowel disease. Despite significant advances, such as laparoscopic techniques and multidisciplinary recovery programs, morbidity and mortality remain high and vary among surgical centers. The use of scoring systems and assessment of functional capacity may help in identifying high-risk patients and predicting complications. An understanding of perioperative factors affecting colon blood flow and oxygenation, suppression of stress response, optimal fluid therapy, and multimodal pain management are essential. These fundamental principles are more important than any specific choice of anesthetic agents. Anesthesiologists can significantly contribute to enhance recovery and improve the quality of perioperative care.

Peri-operative ketamine with the ambulatory elastometric infusion pump as an adjuvant to manage acute postoperative pain after spinal fusion in adults: a prospective randomized trial

Background

In this study, we assessed the effectiveness of ketamine as an alternative to non-steroidal anti-inflammatory drugs (NSAID), to manage acute postoperative pain after spinal fusion when given intravenously via a patient-controlled analgesia (PCA) pump in which the dose was proportional to that of fentanyl.

Methods

Forty patients undergoing 1-2 level spinal fusion were enrolled in this study. Patients were intraoperatively randomized into two groups to receive intravenous PCA consisting either of fentanyl 0.4 µg/ml/kg (control group) or fentanyl 0.4 µg/ml/kg with ketamine 30 µg/ml/kg (ketamine group) after intravenous injection of a loading dose. The loading dose in the control group was fentanyl 1 µg/kg with normal saline equal to ketamine volume and in the ketamine group it was fentanyl 1 µg/kg with ketamine 0.2 mg/kg. The verbal numerical rating scale (NRS), fentanyl and ketamine infusion rate, and side effects were evaluated at 1, 24, and 48 hours after surgery.

Results

There were no significant differences in patient demographics, duration of surgery and anesthesia or intra-operative opioids administration. We did not find any significant differences in the mean infusion rate of intraoperative remifentanil or postoperative fentanyl or in the side effects between the groups, but we did find a significant difference in the NRS between the groups.

Conclusions

Based on our results, we conclude that a small dose of ketamine (0.5-2.5 µg/kg/min) proportional to fentanyl is not only safe, but also lowers postoperative pain intensity in patients undergoing spinal fusion, although the opioid-sparing effects of ketamine were not demonstrated.

Retrospective evaluation of inpatient celecoxib use after total hip and knee arthroplasty at a Veterans Affairs Medical Center

A retrospective cohort study (1.5 years) was performed to investigate the efficacy of celecoxib vs non-celecoxib use in patient who underwent total knee arthroplasty (TKA) and total hip arthroplasty (THA). Study time frame encompassed a pre and post period of a local policy decision opening access to short-term celecoxib use after TKA/THA. Primary end point was the amount of opioid use during their inpatient stay postprocedure. The TKA (n = 81) and THA (n = 60) groups were analyzed independently. Both celecoxib groups used significantly less opioids during their inpatient stay vs noncelecoxib groups, given in oral morphine milligram equivalents (TKA: 203 vs 337 mg, P = .002; THA: 214 vs 336 mg, P = .005). Other secondary outcome measures showed that the celecoxib groups also reported reduction in pain scores, total as needed (PRN) opioid doses, PRN opioid doses per day, average dose of PRN opioids, total PRN opioids, use of intravenous opioids, and rehabilitation facility admissions (in the TKA group only). Linear regression analysis showed a statistically significant inverse relationship between opioid consumption and age. Short-term celecoxib use after TKA/THA may lead to a reduction in overall opioid use and improved pain scores; however, further studies will be required to validate the results of this study.

Effect of ketamine on intravenous patient-controlled analgesia using hydromorphone and ketorolac after the Nuss surgery in pediatric patients

Background

Nuss surgery is preferred in pectus excavatum repair because this procedure produces excellent cosmetic results and prevents postoperative distressed pulmonary function. However, the procedure causes severe pain due to thoracic expansion. This study was designed to investigate the analgesic effect of small doses of ketamine on an intravenous patient-controlled analgesia (IV-PCA) using hydromorphone and ketorolac for pain control after Nuss surgery.

Methods

Forty-four patients undergoing elective Nuss surgery were randomly assigned to receive hydromorphone 3 µg/kg/hr, ketorolac 0.05 mg/kg/hr and ondansetron 0.1 mg/kg/day (Group HO, n = 22) or hydromorphone 3 µg/kg/hr, ketorolac 0.05 mg/kg/hr, ondansetron 0.1 mg/kg/day and ketamine 0.15 mg/kg/hr (Group HK, n = 22) via an IV-PCA pump after surgery. A blind observer evaluated each patient using the Modified Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) for the assessment of pain control. The total administered PCA volume, side effects and parents satisfaction with pain control were assessed at postoperative 1, 4, 8, 12, 24, and 48 hours.

Results

There were no significant differences in Modified CHEOPS between the groups during postoperative 48 hours. The total PCA volume in group HK was significantly lower than that in group HO (P < 0.05). The side effects in both groups did not significantly differ except for pruritus. The levels of satisfaction from the parents were not significantly different between the groups.

Conclusions

A small dose of ketamine on IV-PCA reduced the total administered dose of IV-PCA with hydromorphone and ketorolac and reduced the incidence of pruritus after the Nuss procedure in pediatric patients.

Postoperative ileus: strategies for reduction

Postoperative Ileus (POI) is a frequent, frustrating occurrence for patients and surgeons after abdominal surgery. Despite significant research investigating how to reduce this multi-factorial phenomenon, a single strategy has not been shown to reduce POI's significant effects on length of stay (LOS) and hospital costs. Perhaps the most significant cause of POI is the use of narcotics for analgesia. Strategies that target inflammation and pain reduction such as NSAID use, epidural analgesia, and laparoscopic techniques will reduce POI but are accompanied by a simultaneous reduction in opioid use. Pharmacologic means of stimulating gut motility have not shown a positive effect, and the routine use of nasogastric tubes only increases morbidity. Recent multi-site phase III trials with alvimopan, a peripherally acting mu-antagonist, have shown significant reductions in POI and LOS by 12 and 16 hours, respectively, by blunting the effects of narcotics on gut motility while sparing centrally mediated analgesia. Use of alvimopan, along with a multi-modal postoperative treatment plan involving early ambulation, feeding, and avoiding nasogastric tubes, will likely be the crux of POI treatment and prevention.

The opioid component of delayed gastrointestinal recovery after bowel resection

INTRODUCTION

Patients undergoing bowel resection or other major abdominal surgery experience a period of delayed gastrointestinal recovery associated with increased postoperative morbidity and longer hospital length of stay. Symptoms include nausea, vomiting, abdominal distension, bloating, pain, intolerance to solid or liquid food, and inability to pass stool or gas. The exact cause of delayed gastrointestinal recovery is not known, but several factors appear to play a central role, namely the neurogenic, hormonal, and inflammatory responses to surgery and the response to exogenous opioid analgesics and endogenous opioids.

DISCUSSION

Stimulation of opioid receptors localized to neurons of the enteric nervous system inhibits coordinated gastrointestinal motility and fluid absorption, thereby contributing to delayed gastrointestinal recovery and its associated symptoms. Given the central role of opioid analgesics in delayed gastrointestinal recovery, a range of opioid-sparing techniques and pharmacologic agents, including opioid receptor antagonists, have been developed to facilitate faster restoration of gastrointestinal function after bowel resection when used as part of a multimodal accelerated care pathway. This review discusses the etiology of opioid-induced gastrointestinal dysfunction as well as clinical approaches that have been evaluated in controlled clinical trials to reduce the opioid component of delayed gastrointestinal recovery.

Compatibility and stability of binary mixtures of ketorolac tromethamine and tramadol hydrochloride injection concentrate and diluted infusion solution

OBJECTIVE

Ketorolac added to tramadol as an injection mixture convenient for clinical use has been shown to be an effective balanced analgesic regimen in alleviating moderate-to-severe pain. However, analytical confirmation of the compatibility and stability of this combination is not available. This study examined the compatibility and stability of this combination.

METHODS

Two different mixtures containing ketorolac tromethamine and tramadol hydrochloride were examined: ketorolac (10 mg/mL) and tramadol (33.3 mg/mL) prepared as injection concentrate in ampoule mingled together in the ratio of one ampoule to one ampoule; diluted ketorolac (2 mg/mL) and tramadol (20 mg/mL) prepared in saline infusion solution, with or without pH adjustment. The mixtures were visually inspected for precipitation and color change. Quantitative chemical analysis was performed on days 0, 1, 3 and 7 by high-performance liquid chromatography.

RESULTS

When stored at room temperature under ambient light, the ketorolac (10 mg/mL)-tramadol (33.3 mg/mL) injection concentrate and ketorolac (2 mg/mL)-tramadol (20 mg/mL) solution, without pH adjustment and adjusted to pH 5-8, were physico-chemically stable, and neither visible precipitation nor loss of concentration was found. With the ketorolac (2 mg/mL)-tramadol (20 mg/mL) solution adjusted to pH 9, however, precipitation occurred immediately, resulting in a significant loss of tramadol.

CONCLUSION

This study suggests that a ready-to-use ketorolac-tramadol mixture, either undiluted or diluted in physiological saline solution, can be prepared, with a shelf life of at least 7 days when stored at room temperature under ambient light.

Intravenous patient-controlled analgesia to manage the postoperative pain in patients undergoing craniotomy

Background

This randomized controlled study evaluated the efficacy of intravenous patient-controlled analgesia (IV-PCA) with fentanyl and ketorolac for neurosurgical patients, and compared the effectiveness of IV-PCA with intermittent analgesics injection.

Methods

The patients undergoing craniotomy were randomly assigned to two groups. Patients of group P (n = 53) received fentanyl (0.2 µg/kg/hr) and ketorolac (0.3 mg/kg/hr) via IV-PCA, and those of group N (n = 53) received intermittent fentanyl or ketorolac injection as needed. Pain was evaluated using a 0-10 visual analogue scale (VAS) at postoperative 1, 4, and 24 hr. The amount of infused analgesic drugs, Glasgow Coma Scale (GCS) score, systolic arterial pressure, heart rate, respiratory rate, and the incidence of nausea and miosis were measured at the same time points.

Results

Although VAS of pain (VASp) was comparable at postoperative 1 hr (P = 0.168) between the two groups, the group P had significantly lower VASp at postoperative 4 hr (P = 0.007) and 24 hr (P = 0.017). In group P, less analgesic drugs were administered at postoperative 1 hr, and more analgesic drugs were administered at postoperative 24 hr. There were no differences between two groups with respect to nausea, GCS, systolic arterial pressure, and heart rate. IV-PCA did not further incur respiratory depression or miosis.

Conclusions

IV-PCA with fentanyl and ketorolac after craniotomy is more effective analgesic technique, without adverse events, than the intermittent administration of analgesics.