Glucocorticoids for peri-operative analgesia: how far are we from general recommendations?

Perioperative intravenous dexamethasone did not reduce the severity of persistent postsurgical pain after total knee arthroplasty: a prospective, randomized, double-blind, placebo-controlled trial

BACKGROUND

Even with the great advancements in recent years in total knee arthroplasty (TKA), some patients continue to have persistent postsurgical pain (PPSP). The advantages of systemic corticosteroids in the perioperative context have been further supported by previously published trials. However, the impact of dexamethasone on the intensity of post-TKA PPSP is still unclear. We aimed to investigate its effect on the degree of PPSP and compare that with a placebo.

METHODS

In this randomized, double-blind, placebo-controlled study, 48 patients undergoing unilateral TKA were given intravenous dexamethasone 10 mg or saline just before spinal anesthesia was induced, and they also received two additional doses of dexamethasone 10 mg or saline 24 and 48 h after surgery. A standardized, multimodal analgesic regimen was administered to each patient. The modified WOMAC pain scores at 12 weeks postoperative were the main outcome. The secondary outcomes included pain during a walk of five meters, pain during active knee flexion at 45 degrees, maximum pain at rest during the previous 24 h, nausea visual analogue scale values, and use of rescue opioid and antiemetic medications.

RESULTS

There was no difference in modified WOMAC pain scores 12 weeks after surgery between patients who received and did not receive perioperative dexamethasone. At 24, 30, 48, 54, and 72 h following surgery, the dexamethasone group experienced considerably less pain during a five-meter walk and during 45 degrees active knee flexion (p < 0.01). At postoperative 0-24, 24-48, and 48-72 h, the dexamethasone group experienced less maximal pain at rest (p < 0.01). The dexamethasone group also had less visual analogue scale scores for nausea at 6, 24, 30, 48, and 54 h after surgery (p < 0.02). During the first 0-24 and 24-48 h, the dexamethasone group consumed fewer opioids and antiemetic medications (p < 0.01). All patients showed no signs of wound complications.

CONCLUSIONS

When compared to a placebo at 12 weeks after TKA, intravenous dexamethasone did not reduce PPSP. Nevertheless, early postoperative pain was relieved by perioperative intravenous dexamethasone, which also decreased the need for opioid and antiemetic medications and decreased postoperative nausea and vomiting.

TRIAL REGISTRATION

NCT02760459.

The application of low-dose dexamethasone in total knee arthroplasty: finding out the best route and dosage schedule

BACKGROUND

The use of dexamethasone as additive to multimodal analgesic regimen in total knee arthroplasty has been well established, but the most suitable route, effectiveness, safety and dose schedule of low-dose dexamethasone is not known.

METHODS

We conducted a prospective, randomized, double-blinded trial to investigate and compare the analgesic and antiemetic effects and safety of low-dose (8 mg) dexamethasone introduced as periarticular injection or intravenous (as a single dose or in two divided doses of 4 mg separated by 24 h) in unilateral total knee arthroplasty patients.

RESULTS

The single dose intravenous administration as well as the periarticular administration of dexamethasone had similar mean visual analogue scores which were significantly lower than divided dose group at 24 and 48 h postoperatively. The rate of postoperative nausea and vomiting was lowest among single intravenous dose group and highest among interval dose group at 24 h, while no difference was noted at 48 h. No significant differences were noted in terms of knee flexion angle at 48 h and modified Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score at 6 weeks.

CONCLUSION

Single low-dose intravenous dexamethasone is the most appropriate dose which can safely be given to TKA patients and is only moderately associated with rise in blood sugar not causing any significant complication. Alternatively, periarticular infiltration of low-dose dexamethasone can produce equivalent analgesic effect as SDIV in first 24 h without causing significant blood sugar rise and wound complications, but its antiemetic effect remains subtle. Therefore, it is recommended to further study the combination of intraoperative periarticular and postoperative intravenous dexamethasone for their possible additive effect.

Preoperative Single-dose Methylprednisolone Prevents Surgical Site Infections After Major Liver Resection: A Randomized Controlled Trial

OBJECTIVE

The primary aim of this study was to evaluate the efficacy of a single preoperative dose of methylprednisolone for preventing postoperative complications after major liver resections.

SUMMARY BACKGROUND DATA

Hepatic resections are associated with a significant acute systemic inflammatory response. This effect subsequently correlates with postoperative morbidity, mortality, and length of recovery. Multiple small trials have proposed that the administration of glucocorticoids may modulate this effect.

METHODS

This study was a parallel, dual-arm, double-blind randomized controlled trial. Adult patients undergoing elective major hepatic resection (≥3 segments) at a quaternary care institution were included (2013-2019). Patients were randomly assigned to receive a single preoperative 500 mg dose of methylprednisolone versus placebo. The main outcome measure was postoperative complications after liver resection, within 90 days of the index operation. Standard statistical methodology was employed (P < 0.05 = significant).

RESULTS

A total of 151 patients who underwent a major hepatic resection were randomized (mean age = 62.8 years; 57% male; body-mass-index = 27.9). No significant differences were identified between the intervention and control groups (age, sex, body-mass-index, preoperative comorbidities, hepatic function, ASA class, portal vein embolization rate) (P > 0.05). Underlying hepatic diagnoses included colorectal liver metastases (69%), hepatocellular carcinoma (18%), noncolorectal liver metastases (7%), and intrahepatic cholangiocarcinoma (6%). There was a significant reduction in the overall incidence of postoperative complications in the methylprednisolone group (31.2% vs 47.3%; P = 0.042). Patients in the glucocorticoid group also displayed less frequent organ space surgical site infections (6.5% vs 17.6%; P = 0.036), as well as a shorter length of hospital stay (8.9 vs 12.5 days; P = 0.015). Postoperative serum bilirubin and prothrombin timeinternational normalized ratio (PT-INR) levels were also lower in the steroid group (P = 0.03 and 0.04, respectively). Multivariate analysis did not identify any additional significant modifying factor relationships (estimated blood loss, duration of surgery, hepatic vascular occlusion (rate or duration), portal vein embolization, drain use, etc) (P > 0.05).

CONCLUSIONS

A single preoperative dose of methylprednisolone significantly reduces the length of hospital stay, postoperative serum bilirubin, and PT-INR, as well as infectious and overall complications following major hepatectomy.

The effect of pre-operative high doses of methylprednisolone on pain management and convalescence after total hip replacement in elderly: a double-blind randomized study

Purpose

The aim of the study was to assess whether administration of a single dose of methylprednisolone in the group patients above 65 years of age will be effective in complex analgesic management after total hip arthroplasty (THA).

Methods

Seventy-seven patients above 65 years old were double-blind randomized into two: the study and controls groups. Pre-operatively, the study group received as a single dose of 125 mg intravenous methylprednisolone, while the others saline solution as placebo. Peri-operatively, all the patients were administered opioid and nonopioid analgesic agents. We measured the levels of inflammatory markers (leukocytosis, C-reactive protein—CRP), pain intensity level (visual analog scale—VAS; numerical rating scale—NRS), the life parameters, and noted complications.

Results

Following administration of methylprednisolone were significantly lower levels of CRP on all the four post-operative days; leukocytosis on the second day; the VAS/NRS score at rest after six, 12, and 18 hours post-operatively, diminished the dose of parenteral opioid preparations (oxycodone hydrochloride), the duration of analgesia by peripheral nerve block was significantly higher as compared with the placebo group (p < 0.000001). No infectious complications were noted; there was one patient who developed post-operative delirium.

Conclusion

A single dose of methylprednisolone significantly reduces the level of post-operative pain at rest on the day of THA in the group patients above 65 years of age, decreases the dose of opioid analgesic agents, and significantly decreases the level of inflammatory markers, without infectious processes.

Perioperative pregabalin does not reduce opioid requirements in total knee arthroplasty

PURPOSE

The purpose of this prospective, randomized, double-blinded, placebo-controlled study was to determine if pregabalin, when given perioperatively in addition to patient-controlled analgesia morphine, paracetamol and etoricoxib, is effective in reducing morphine requirements and moderating pain scores after primary total knee arthroplasty. We hypothesize that there would be no difference in postoperative opioid requirements, postoperative pain scores, and functional scores with the use of perioperative pregabalin.

METHODS

Eighty-seven patients who underwent primary total knee arthroplasty were randomised and allocated to two groups. One group received capsules containing pregabalin 75 mg, and the other a placebo-one capsule before surgery and one capsule once per night up till postoperative day 2. Multimodal analgesia provided for all patients in this study included femoral nerve block, intravenous patient-controlled analgesia (morphine), paracetamol and etoricoxib. The primary outcome of patient's pain control was based on the measurement of cumulative morphine consumption during the first 72 h postoperatively.

RESULTS

Pregabalin did not reduce the cumulative or effective morphine consumption at 48 h and 72 h post-operation. There were also no significant differences noted in pain scores at 48 h and 72 h after surgery, functional range of motion of the operated knee at 72 h post-op, or outcomes recorded on the Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and 36-Item Short Form Survey (SF-36) questionnaires at 3 and 6 months post-op. None of the patients demonstrated common adverse reactions to pregabalin.

CONCLUSION

This study showed no reduction in postoperative opioid requirements, or improvement in early postoperative pain scores or functional outcomes at 6 months, with perioperative use of pregabalin. Orthopaedic surgeons may consider this when selecting an analgesic regimen for their patients.

LEVEL OF EVIDENCE

II.

Effects of anaesthesia and analgesia on long-term outcome after total knee replacement: A prospective, observational, multicentre study

BACKGROUND

Perioperative regional anaesthesia may protect from persistent postsurgical pain (PPSP) and improve outcome after total knee arthroplasty (TKA).

OBJECTIVES

Aim of this study was to evaluate the impact of regional anaesthesia on PPSP and long-term functional outcome after TKA.

DESIGN

A web-based prospective observational registry.

SETTING

Five Italian Private and University Hospitals from 2012 to 2015.

PATIENTS

Undergoing primary unilateral TKA, aged more than 18 years, informed consent, American Society of Anesthesiologists (ASA) physical status classes 1 to 3, no previous knee surgery.

INTERVENTION(S)

Personal data (age, sex, BMI and ASA class), preoperative pain assessed by numerical rating scale (NRS) score, and risk factors for PPSP were registered preoperatively. Data on anaesthetic and analgesic techniques were collected. Postoperative pain (NRS), analgesic consumption, major complications and patient satisfaction were registered up to the time of discharge. PPSP was assessed by a blinded investigator during a phone call after 1, 3 and 6 months, together with patient satisfaction, quality of life (QOL) and walking ability.

MAIN OUTCOME MEASURES

Experience of PPSP according to the type of peri-operative analgesia.

RESULTS

Five hundred sixty-three patients completed the follow-up. At 6 months, 21.6% of patients experienced PPSP, whereas autonomy was improved only in 56.3%; QOL was worsened or unchanged in 30.7% of patients and improved in 69.3%. Patients receiving continuous regional anaesthesia (epidural or peripheral nerve block) showed a lower NRS through the whole peri-operative period up to 1 month compared with both single shot peripheral nerve block and those who did not receive any type of regional anaesthesia. No difference was found between these latter two groups. Differences in PPSP at 3 or 6 months were not significantly affected by the type of anaesthesia or postoperative analgesia. A higher NRS score at 1 month, younger age, history of anxiety or depression, pro-inflammatory status, higher BMI and a lower ASA physical status were associated with a higher incidence of PPSP and worsened QOL at 6 months.

CONCLUSION

Continuous regional anaesthesia provides analgesic benefit for up to 1 month after surgery, but did not influence PPSP at 6 months. Better pain control at 1 month was associated with reduced PPSP. Patients with higher expectations from surgery, enhanced basal inflammation and a pessimistic outlook are more prone to develop PPSP.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02147730.

High-dose methylprednisolone in video-assisted thoracoscopic surgery lobectomy: a randomized controlled trial

OBJECTIVES

The optimal postoperative analgesic strategy after video-assisted thoracoscopic surgery lobectomy remains undetermined. We hypothesized that high-dose preoperative methylprednisolone (MP) would improve analgesia compared to placebo.

METHODS

A total of 120 adult patients were randomized equally to 125 mg MP or placebo before the start of their elective video-assisted thoracoscopic surgery lobectomy. Group allocation was blinded to patients, investigators and caregivers, and all patients received standardized multimodal, opioid-sparing analgesia. Our primary outcome was area under the curve on a numeric rating scale from 0 to 10, for pain scores on the day of surgery and on postoperative days 1 and 2. Clinical follow-up was 2-3 weeks, and telephone follow-up was 12 weeks after surgery.

RESULTS

Ninety-six patients were included in the primary analysis. Methylprednisolone significantly decreased median pain scores on the day of surgery: at rest (numeric rating scale 1.6 vs 2.0, P = 0.019) and after mobilization to a sitting position (numeric rating scale 1.7 vs 2.5, P = 0.004) but not during arm abduction and coughing (P = 0.052 and P = 0.083, respectively). Nausea and fatigue were reduced on the day of surgery (P = 0.04 and 0.03), whereas no outcome was improved on postoperative Days 1 and 2. Methylprednisolone did not increase the risk of complications but increased blood glucose levels on the day of surgery (P < 0.0001).

CONCLUSIONS

High-dose preoperative MP significantly reduced pain at rest and after mobilization to a sitting position on the day of surgery, without later analgesic effects. Nausea and fatigue were improved without side effects, except transient higher postoperative blood glucose levels.

CLINICAL TRIAL REGISTRATION

Registered at clinicaltrialsregister.eu [7 November 2012, EudraCT 2012-004451-37; https://www.clinicaltrialsregister.eu/ctr-search/trial/2012-004451-37/DK].

Postoperative Pain After Abdominal Hysterectomy: A Randomized, Double-Blind, Controlled Trial Comparing the Effects of Tramadol and Gabapentin as Premedication

Background:

Uncontrolled postoperative pain, characteristic to abdominal hysterectomy, results in multiple complications. One of the methods for controlling postoperative pain is preemptive analgesia. Gabapentin and tramadol are both used for this purpose.

Objectives:

This study aims to compare the effects of tramadol and gabapentin, as premedication, in decreasing the pain after hysterectomy.

Patients and Methods:

This clinical trial was performed on 120 eligible elective abdominal hysterectomy patients, divided in three groups of 40, receiving tramadol, gabapentin and placebo, respectively. Two hours before the surgery, the first group was given 300 mg gabapentin, the second one was given 100 mg tramadol, while the other group was given placebo, with 50 ml water. After the surgery, in case of visual analog pain scale (VAS) > 3, up to 3 mg of diclofenac suppository would be used. Pain score, nausea, vomiting, sedation, patient’s satisfaction and the number of meperidine administered during 24 hours (1 - 4 - 8 - 12 - 16 - 20 - 24 hours) were recorded. If patients had VAS > 3, despite using diclofenac, intravenous meperidine (0.25 mg/kg) would be prescribed. Data were analyzed using SPSS 21 software, chi-square test, general linear model and repeated measurement.

Results:

The three groups were similar regarding age and length of surgery (up to 2 hours). The average VAS, in the placebo group, was higher than in the other two groups (P = 0.0001) and the average received doses of meperidine during 24-hour time were considerably higher in placebo group, compared to the other two groups (55.62 mg in placebo, 18.75 mg in gabapentin and 17.5 mg in tramadol groups, P = 0.0001). Nausea, vomiting and sedation, in the tramadol group, were higher than in the other two groups, although they were not significant. Patients’ dissatisfaction, in the placebo group, during initial hours, especially in the fourth hour, was higher (P = 0.0001). In the gabapentin and tramadol groups, the trend of changes in satisfaction score was similar. However, satisfaction in the gabapentin group, during the initial 4 hours was higher, in comparison to the tramadol group (P = 0.0001).

Conclusions:

This study revealed that prescribing gabapentin or tramadol, as premedication, was effective in reducing postoperative pain, without any concerning side-effects.

The effect of a single dose of preemptive pregabalin administered with COX-2 inhibitor: a trial in total knee arthroplasty

We sought to compare a group (Group L) (n=21) of patients that underwent total knee arthroplasty and received a single preoperative dose of pregabalin combined with a COX-2 inhibitor with a control group (Group C) (n=20) that only received a COX-2 inhibitor in terms of (1) acute postoperative pain intensity, (2) analgesic consumption, and (3) functional recovery. Mean cumulative fentanyl consumption during the first 48 hours was lower in Group L than in Group C (P<0.05). The pain scores at rest were lower in Group L at 6 and 12 hours after surgery (P<0.05). No significant intergroup difference was noted in functional recovery. The addition of pregabalin led to an additive reduction in early postoperative pain and analgesic consumption.

Use of pre-operative steroids in liver resection: a systematic review and meta-analysis

BACKGROUND

By attenuating the systemic inflammatory response to major surgery, the pre-operative administration of steroids may reduce the incidence of complications.

METHODS

A systematic review was conducted to identify randomized controlled trials (RCT) comparing pre-operative steroid administration with placebo during a liver resection. Meta-analyses were performed.

RESULTS

Five RCTs were identified including a total of 379 patients. Pre-operative steroids were associated with statistically significant reductions in the levels of serum bilirubin and interleukin 6 (IL-6) on post-operative day one. There was a trend towards a lower incidence of post-operative complications and prothrombin time (PT), but this did not reach statistical significance.

CONCLUSION

Pre-operative steroids may be associated with a clinically significant benefit in liver resection.

Effect of pregabalin and dexamethasone addition to multimodal analgesia on postoperative analgesia following rhinoplasty surgery

BACKGROUND

We investigated the effect of a combination of pregabalin and dexamethasone, when used as part of a multimodal analgesic regimen, on pain control after rhinoplasty operations.

METHODS

Sixty patients were enrolled in this study. They were randomly assigned into three groups: Group C (placebo + placebo), Group P (pregabalin + placebo), and Group PD (pregabalin + dexamethasone). Patients received either pregabalin 300 mg orally 1 h before surgery, dexamethasone 8 mg intravenously during induction, or placebo according to their allocation. Postoperative pain was treated with intravenous patient-controlled analgesia (tramadol, 20-mg bolus dose, 45-min lockout time). The numeric rating scale (NRS), side effects, and consumption of tramadol, pethidine, and ondansetron were assessed.

RESULTS

The median NRS scores at 0, 1, and 6 h after surgery were significantly higher in Group C than in Group PD (p < 0.001 for all). The 24-h consumption of tramadol and pethidine was significantly reduced in Groups P and PD compared to Group C (p < 0.01 and p < 0.01). The total tramadol consumption was decreased by 54.5 % in Group P and 81.9 % in Group PD compared to Group C (p < 0.001 for both). The incidence of nausea was higher in Group C than in Groups P and PD between the postoperative 0-2 and 0-24-h periods (p < 0.05 for both). The frequency of blurred vision was significantly higher in Groups P and PD than in Group C within the 0-24-h period (p < 0.05 for both).

CONCLUSION

We found that the addition of a single dose of pregabalin and dexamethasone to multimodal analgesia in rhinoplasty surgeries provided efficient analgesia and thus decreased opioid consumption.

LEVEL OF EVIDENCE I

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Perioperative glucocorticoids in hip and knee surgery - benefit vs. harm? A review of randomized clinical trials

Glucocorticoids are frequently used to prevent post-operative nausea and vomiting (PONV), and may be part of multimodal analgesic regimes. The objective of this review was to evaluate the overall benefit vs. harm of perioperative glucocorticoids in patients undergoing hip or knee surgery. A wide search was performed in PubMed, Embase, and Cochrane Central to identify relevant randomized clinical trials. A systematic approach was used, starting from the PRISMA recommendations. The Cochrane Collaboration's tool was used for risk of bias assessment. Studies were divided into three groups: systemic glucocorticoid administration analogous to > 10 mg or ≤ 10 mg dexamethasone, and local glucocorticoid administration. Seventeen studies with data from 1081 patients were included in the final qualitative synthesis. Benefit (of any kind) with glucocorticoid vs. placebo was reported in 15 studies. PONV was reduced with systemic glucocorticoid. Pain was reduced with high-dose systemic and local glucocorticoid, but not with low-dose systemic glucocorticoid. Systemic inflammatory markers were reduced with low-dose and high-dose systemic glucocorticoid, and with local glucocorticoid. Functional recovery was improved with local glucocorticoid. All studies were small-sized and none sufficiently powered to meaningfully evaluate uncommon adverse events. Most of the local administration studies had poor scientific quality (high risk of bias). Due to clinical heterogeneity and poor scientific quality, no meta-analysis was performed. In conclusion, in addition to PONV reduction with low-dose systemic glucocorticoid, this review supports high-dose systemic glucocorticoid to ameliorate post-operative pain after hip and knee surgery. However, large-scale safety and dose-finding studies are warranted before final recommendations.

Fast-track hip and knee arthroplasty: clinical and organizational aspects

Fast-track hip and knee arthroplasty aims at giving the patients the best available treatment at all times, being a dynamic entity. Fast-track combines evidence-based, clinical features with organizational optimization including a revision of traditions resulting in a streamlined pathway from admission till discharge – and beyond. The goal is to reduce morbidity, mortality and functional convalescence with an earlier achievement of functional milestones including functional discharge criteria with subsequent reduced length of stay and high patient satisfaction. Outcomes are traditionally measured as length of stay; safety aspects in the form of morbidity/mortality; patient satisfaction; and – as a secondary parameter – economic savings. Optimization of the clinical aspects include focusing on analgesia; DVT-prophylaxis; mobilization; care principles including functional discharge criteria; patient-characteristics to predict outcome; and traditions which may be barriers in optimizing outcomes. Patients should be informed and motivated to be active participants and their expectations should be modulated in order to improve satisfaction. Also, organizational aspects need to be analyzed and optimized. New logistical approaches should be implemented; the ward ideally (re)structured to only admit arthroplasties; the staff educated to have a uniform approach; extensive preoperative information given including discharge criteria and intended length of stay. This thesis includes 9 papers on clinical and organizational aspects of fast-track hip and knee arthroplasty (I–IX). A detailed description of the fast-track set-up and its components is provided. Major results include identification of patient characteristics to predict length of stay and satisfaction with different aspects of the hospital stay (I); how to optimize analgesia by using a compression bandage in total knee arthroplasty (II); the clinical and organizational set-up facilitating or acting as barriers for early discharge (III); safety aspects following fast-track in the form of few readmissions in general (IV) and few thromboembolic complications in particular (V); feasibility studies showing excellent outcomes following fast-track bilateral simultaneous total knee arthroplasty (VI) and non-septic revision knee arthroplasty (VII); how acute pain relief in total hip arthroplasty is not enhanced by the use of local infiltration analgesia when multi-modal opioid-sparing analgesia is given (VIII); and a detailed description of which clinical and organizational factors detain patients in hospital following fast-track hip and knee arthroplasty (IX). Economic savings following fast-track hip and knee arthroplasty is also documented in studies, reviews, metaanalyses and Cochrane reviews – including the present fast-track (ANORAK). In conclusion, the published results (I–IX) provide substantial, important new knowledge on clinical and organizational aspects of fast-track hip and knee arthroplasty – with concomitant documented high degrees of safety (morbidity/mortality) and patient satisfaction. Future research strategies are multiple and include both research strategies as efforts to implement the fast-track methodology on a wider basis. Research areas include improvements in pain treatment, blood saving strategies, fluid plans, reduction of complications, avoidance of tourniquet and concomitant blood loss, improved early functional recovery and muscle strengthening. Also, improvements in information and motivation of the patients, preoperative identification of patients needing special attention and detailed economic studies of fast- track are warranted.

A comparison between dexamethasone and methylprednisolone for vomiting prophylaxis after tonsillectomy in inpatient children: a randomized trial

BACKGROUND

The frequent incidence of postoperative vomiting in children undergoing tonsillectomy, in addition to the occurrence of severe pain, may delay postoperative oral intake and lead to increased risk of dehydration. Thus, prophylactic therapy is indicated in this high-risk group. Glucocorticoids, such as dexamethasone and methylprednisolone, have anti-inflammatory and antiemetic properties with dexamethasone being frequently used. We hypothesized that methylprednisolone should be noninferior to dexamethasone for the prevention of vomiting in children after tonsillectomy.

METHODS

We designed a randomized double-blind trial to compare the efficacy of a single prophylactic dose of 0.5 mg/kg dexamethasone with a dose of 2.5 mg/kg methylprednisolone on the incidence of postoperative vomiting during the first 24 hours (primary outcome) in children undergoing total or partial tonsillectomy with a noninferiority margin set at 9%. One hundred sixty children undergoing total or partial tonsillectomy under general anesthesia were randomly assigned to receive either IV dexamethasone 0.5 mg/kg (n = 79) or methylprednisolone 2.5 mg/kg (n = 81) after induction of anesthesia. Secondary analysis of all studied outcomes was also performed according to the type of surgery.

RESULTS

An intention-to-treat analysis showed an overall incidence of vomiting of 30% in the dexamethasone group and of 22% in the methylprednisolone group (difference: 8%, 95% confidence interval [CI]: -5% to 21%). A per protocol analysis showed an incidence of vomiting of 32% and 23%, respectively (difference: 9%, and 95% CI of the difference: -5 to 23%, P(sup) = 0.28). The time and quality of oral intake and the duration of IV hydration, as well as pain and satisfaction scores and the need for analgesics, were similar between the 2 groups. The incidence of vomiting was also similar in patients who had total versus partial tonsillectomy; however, time to first oral intake, duration of IV hydration, and the need for analgesics were less with better satisfaction scores in partial versus total tonsillectomy patients.

CONCLUSION

Methylprednisolone is at worst 5% less effective than dexamethasone by the intention-to-treat analysis, and by the per protocol analysis. Thus, it is noninferior to dexamethasone in preventing vomiting after tonsillectomy in children.

Evidence-based management of postoperative pain in adults undergoing open inguinal hernia surgery

Background

Open inguinal hernia repair is associated with moderate postoperative pain, but optimal analgesia remains controversial. The aim of this systematic review was to evaluate the available literature on the management of pain after open hernia surgery.

Methods

Randomized studies, in English, published between January 1966 and March 2009, assessing analgesic and anaesthetic interventions in adult open hernia surgery, and reporting pain scores, were retrieved from the Embase and MEDLINE databases. In addition to published evidence, clinical practice was taken into account to ensure that the recommendations had clinical validity.

Results

Of the 334 randomized studies identified, 79 were included. Quantitative analysis suggested that regional anaesthesia was superior to general anaesthesia for reducing postoperative pain. Spinal anaesthesia was associated with a higher incidence of urinary retention and increased time to home-readiness compared with regional anaesthesia.

Conclusion

Field block with, or without wound infiltration, either as a sole anaesthetic/analgesic technique or as an adjunct to general anaesthesia, is recommended to reduce postoperative pain. Continuous local anaesthetic infusion of a surgical wound provides a longer duration of analgesia. Conventional non-steroidal anti-inflammatory drugs or cyclo-oxygenase 2-selective inhibitors in combination with paracetamol, administered in time to provide sufficient analgesia in the early recovery phase, are optimal. In addition, weak opioids are recommended for moderate pain, and strong opioids for severe pain, on request.

An expert opinion on postoperative pain management, with special reference to new developments

IMPORTANCE OF THE FIELD

Recently, much attention has been directed towards the effect of opioid-sparing strategies on postoperative morbidity and hospitalization, and on different nociceptive mechanisms involved in various postoperative pain states and surgical procedures. This has resulted in an increased interest in secondary, or adjunct, analgesics and procedure-specific analgesic methods.

AREAS COVERED IN THIS REVIEW

The present paper aims to review and discuss recent developments within the field of various adjunct, systemic analgesics and local/regional anesthetic methods for management of postoperative pain, based on evidence from randomized, clinical trials published within the last 5 years.

WHAT THE READER WILL GAIN

The reader will gain insight into the current role of pregabalin, glucocorticoids and systemic lidocaine for the management of postoperative pain. In addition, the current status of local infiltration analgesia for hip and knee arthroplasty, transversus abdominis plane block for abdominal operations, and the analgesic effect of wound instillation of capsaicin are reviewed.

TAKE HOME MESSAGE

The evidence of a substantial analgesic effect of pregabalin on acute postoperative pain is questionable, and more convincing evidence of the role of glucocorticoids and systemic lidocaine is needed before they should be recommended as analgesics in daily clinical practice. Local infiltration analgesia after hip and knee arthroplasty, transversus abdominis plane block after abdominal operations and local application of capsaicin lend some promise, but there is still a lack of well-performed RCTs to draw any firm conclusions. Procedure-specific analgesic combinations within well-defined rehabilitation paradigms should be explored further to reduce adverse effects associated with the use of conventional analgesic treatment protocols, and to improve postoperative outcome.

Sedation: not quite that simple

The number of diagnostic and therapeutic interventions performed under sedation is growing rapidly. While providing patients with an improved experience secondary to anxiolysis, analgesia, and amnesia, sedation also puts them at risk for associated cardiorespiratory and other complications. Several medications are available for sedation, all of which have unique advantages and disadvantages. The combination of patient characteristics, procedural factors, and side effects associated with each medication places each patient at risk and therefore, vigilance during sedation cannot be overemphasized. Due vigilance includes proper monitoring, training, staffing, and equipment, all of which are essential to the safe delivery of sedation.

Evidence-based management of pain after haemorrhoidectomy surgery

BACKGROUND

Haemorrhoidectomy is associated with intense postoperative pain, but optimal evidence-based pain therapy has not been described. The aim of this systematic review was to evaluate the available literature on the management of pain after haemorrhoidal surgery.

METHODS

Randomized studies published in the English language from 1966 to June 2006, assessing analgesic and anaesthetic interventions in adult haemorrhoidal surgery, and reporting pain scores, were retrieved from the Embase and MEDLINE databases.

RESULTS

Of the 207 randomized studies identified, 106 met the inclusion criteria, with mixed methodological quality. Of these, 41 studies evaluating surgical and alternative interventions were excluded. Quantitative analyses were not performed, as there were limited numbers of trials with a sufficiently homogeneous design.

CONCLUSION

Local anaesthetic infiltration, either as a sole technique or as an adjunct to general or regional anaesthesia, and combinations of analgesics (non-steroidal anti-inflammatory drugs, paracetamol and opiates) are recommended. If appropriate, a stapled operation may be preferable.

Effect of preoperative single-dose corticosteroid administration on postoperative morbidity following esophagectomy

BACKGROUND

Eight clinical trials involving the administration of preoperative i.v. methylprednisolone have been undertaken in order to decrease the considerable inflammatory response to esophageal resection, in an effort to decrease the supposedly associated morbidity and mortality

METHOD

A meta-analysis was performed for eight clinical end-points. Due to quality problems in seven of the eight included studies, a Bayesian meta-analysis using a skeptical prior derived from the results of the classical analysis was also performed.

RESULTS

The end-points including any organ dysfunction (OR = 0.30), respiratory complication (OR = 0.41), sepsis (OR = 0.37), liver dysfunction (OR = 18), cardiovascular dysfunction (OR = 0.28), and surgical anastomotic leak (OR = 0.42) were significantly decreased by methylprednisolone pretreatment. Following the Bayesian analysis, despite the use of skeptical priors, there is a 95% probability to obtain a relative risk reduction of at least 23% to 54%, depending of the end-point, by methylprednisolone pretreatment.

CONCLUSION

We are in the presence of a potential benefit that cannot be accepted at face value due to the quality problems of the included studies. But in the presence of a remaining potential benefit after a Bayesian analysis starting from a skeptical prior, the best option would be the planning of a large multicenter prospective randomized study.

Pain following the repair of an abdominal hernia

Pain and other types of discomfort are frequent symptoms following the repair of an abdominal hernia. After 1 year, the incidence of light to moderate pain following inguinal hernia repair is as high as 10% and 2% for severe disabling chronic pain. Postoperative chronic pain not only affects the individual patient, but may also have a great impact on relatives and society, and may be a cause of concern for the responsible surgeon. This paper provides an overview of the anatomy, surgical procedures, and disposing factors (age, gender, ethnicity, genotype, previous hernia repair, pain prior to surgery, psychosocial characteristics, and surgical procedures) related to the postoperative pain conditions. Furthermore, the mechanisms for both acute and chronic pain are presented. We focus on inguinal hernia repair, which is the most frequent type of abdominal hernia surgery that leads to chronic pain. Finally, the paper provides an update on the diagnostic and treatment routines for postoperative pain.

Subacute pain and function after fast-track hip and knee arthroplasty

In a well-defined fast-track setup for total hip and knee arthroplasty, with a multimodal analgesic regimen consisting of intra-operative local anaesthetic infiltration and oral celecoxib, gabapentin and paracetamol for 6 days postoperatively, we conducted a prospective, consecutive, observational study. The purpose was to describe the prevalence and intensity of subacute postoperative pain and opioid related side effects, use of analgesics and functional ability 1-10 and 30 days postoperatively. Fast-track total hip and knee arthroplasty with early discharge (< 3 days) resulted in acceptable levels of pain and postoperative nausea and vomiting with concomitant low use of opioids in > 95% of patients after discharge before day 10 after total hip arthroplasty. However, after total knee arthroplasty 52% patients reported moderate pain (VAS 30-59 mm), and 16% severe pain (VAS > or = 60 mm) when walking 1 month after surgery with a concomitant increase in the use of strong opioids. These results emphasise the need for improvement in analgesia after discharge following total knee arthroplasty, to facilitate rehabilitation.

[New and evidence-based aspects of postoperative pain therapy]

Poorly managed postoperative pain has been recognised to delay patient recovery and hospital discharge. Recent metaanalyses support a multimodal approach with combinations of analgesics from different classes. The pharmacological options of commonly used opioids, nonsteroidal anti-inflammatory drugs, and other nonopioid analgesics in combination have been shown to provide effective pain relief and to reduce opioid consumption. Local, intraarticular, epidural, and, more importantly, modern peripheral regional techniques can be used successfully to enhance perioperative analgesia. The use of continuous perineural techniques with local anaesthetic infusion has been extended beyond hospital discharge in many European countries.

Evidence-based surgical care and the evolution of fast-track surgery

BACKGROUND

Optimization of postoperative outcome requires the application of evidence-based principles of care carefully integrated into a multimodal rehabilitation program.

OBJECTIVE

To assess, synthesize, and discuss implementation of "fast-track" recovery programs.

DATA SOURCES

Medline MBASE (January 1966-May 2007) and the Cochrane library (January 1966-May 2007) were searched using the following keywords: fast-track, enhanced recovery, accelerated rehabilitation, and multimodal and perioperative care. In addition, the synthesis on the many specific interventions and organizational and implementation issues were based on data published within the past 5 years from major anesthesiological and surgical journals, using systematic reviews where appropriate instead of multiple references of original work.

DATA SYNTHESIS

Based on an increasing amount of multinational, multicenter cohort studies, randomized studies, and meta-analyses, the concept of the "fast-track methodology" has uniformly provided a major enhancement in recovery leading to decreased hospital stay and with an apparent reduction in medical morbidity but unaltered "surgery-specific" morbidity in a variety of procedures. However, despite being based on a combination of evidence-based unimodal principles of care, recent surveys have demonstrated slow adaptation and implementation of the fast-track methodology.

CONCLUSION

Multimodal evidence-based care within the fast-track methodology significantly enhances postoperative recovery and reduces morbidity, and should therefore be more widely adopted. Further improvement is expected by future integration of minimal invasive surgery, pharmacological stress-reduction, and effective multimodal, nonopioid analgesia.