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Amin S, Hasanin A, Attia OA, Mostafa M, Elzayat NS, Elsherbiny M, Eissa AA. Intravenous ibuprofen versus ketorolac for perioperative pain control in open abdominal hysterectomy: a randomized controlled trial. BMC Anesthesiol 2024; 24:202. [PMID: 38849734 PMCID: PMC11157756 DOI: 10.1186/s12871-024-02571-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 05/21/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND We aimed to compare the analgesic effects of intravenous ibuprofen to ketorolac after open abdominal hysterectomy. METHODS This randomized double-blinded controlled trial included adult women scheduled for elective open abdominal hysterectomy. Participants were randomized to receive either 30 mg ketorolac (n = 50) or 800 mg ibuprofen (n = 50) preoperatively, then every 8 h postoperatively for 24 h. All participants received paracetamol 1 gm/6 h. Rescue analgesic was given if the visual analogue scale (VAS) for pain assessment was > 3. The primary outcome was the mean postoperative dynamic VAS during the first 24 h. Secondary outcomes were static VAS, intraoperative fentanyl consumption, postoperative morphine consumption, time to independent movement, and patient's satisfaction. RESULTS Forty-six patients in the ibuprofen group and fifty patients in the ketorolac group were analyzed. The 24-h dynamic and static VAS were similar in the two groups. The median (quartiles) dynamic VAS was 1.1 (0.9, 1.9) in the ibuprofen group versus 1.0 (0.7, 1.3) in the ketorolac group, P-value = 0.116; and the median (quartiles) static VAS was 0.9 (0.6, 1.3) in the ibuprofen group versus 0.7 (0.4, 1.1) in the ketorolac group, P-value = 0.113. The intra- and postoperative analgesic requirements were also similar in the two groups. However, patient satisfaction was slightly higher in the ketorolac group than that in the ibuprofen group (median [quartiles]: 6 [5, 7] versus 5 [4, 7], respectively), P-value: 0.009. CONCLUSION The two drugs, intravenous ibuprofen and ketorolac produced similar analgesic profile in patients undergoing open abdominal hysterectomy receiving multimodal analgesic regimen. NCT05610384, Date of registration: 09/11/2022 CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05610384. https://clinicaltrials.gov/ct2/show/NCT05610384.
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Affiliation(s)
- Sarah Amin
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Hasanin
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt.
| | - Ola A Attia
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Maha Mostafa
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Nashwa S Elzayat
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Mona Elsherbiny
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Amany A Eissa
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
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Laconi G, Coppens S, Roofthooft E, Van De Velde M. High dose glucocorticoids for treatment of postoperative pain: A systematic review of the literature and meta-analysis. J Clin Anesth 2024; 93:111352. [PMID: 38091865 DOI: 10.1016/j.jclinane.2023.111352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 10/30/2023] [Accepted: 11/22/2023] [Indexed: 01/14/2024]
Abstract
STUDY OBJECTIVE Glucocorticoids as a component of multimodal analgesia have been studied for many years and their post-operative analgesic effects appear to be dose-dependent. We conducted a systematic review of randomized controlled trials (RCTs) to evaluate the evidence of peri-operative high dose corticosteroid therapy in comparison to placebo (placebo drug) or control group (no treatment) for improving the quality of post-operative analgesia as indicated by a reduction of 10 mm in 100 mm Visual Analogue Scale (VAS) or reduction of 1 point in a 0-10 point VAS scale, or a reduction of 1 point in an 11-point Numerical Rating Scale (NRS) score, or reduction of rescue opioid analgesia, in patients undergoing all types of surgery. DESIGN Systematic review of RCTs with meta-analysis. SETTING Acute postoperative pain treatment in non-obese adult population. INTERVENTIONS Perioperative administration of high dose of Dexamethasone (≥ 0,2 mg/Kg or ≥ 15 mg), or a corresponding dose of a systemic glucocorticoid. MEASUREMENTS Primary outcomes were postoperative pain measured in 0-100 mm VAS score at 24 h after surgery upon rest and movement. Secondary outcomes were postoperative pain 0-100 mm VAS score 48 h after surgery, postoperative rescue analgesic requirement, postoperative nausea and vomiting (PONV), relevant adverse events. MAIN RESULTS 47 RCT's were included (3943 patients). The Mean Difference (MD) of 100 mm VAS scores for pain at rest 24 h after surgery was -6.18 mm 95% CI [-8.53, -3.83], at motion -8.86 mm 95% CI [-11.82, -5.89]. Opioid analgesic requirements evaluated in Oral Morphine Equivalents (OME) was -10.00 mg 95% CI [-13.65, -6.34]. PONV events Odds Ratio of 0.29 95%CI [0.24, 0.36]. Major adverse events OR was 0.88 95% CI [0.65, 1.19]. Minor adverse events OR 1.29 95% CI [0.86, 1.92]. CONCLUSION High doses of glucocorticoids are one of the many possible tools available in multimodal postoperative analgesia, possibly reducing opioids consumption and recurrence of PONV but with no relevant effects in terms of reduction of postoperative VAS score. Available data show a safe therapeutic profile, without increase adverse events. PROTOCOL REGISTRATION CRD42020137119.
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Affiliation(s)
- Giulia Laconi
- Anesthesia and Intensive Care Unit, AOU Sant'Anna, Ferrara, Italy.
| | - Steve Coppens
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Biomedical Sciences Group, University of Leuven, Leuven, Belgium
| | - Eva Roofthooft
- Department of Anesthesia, GZA Hospitals, Antwerp, Belgium and Department of Cardiovascular sciences, KULeuven, Leuven, Belgium
| | - Marc Van De Velde
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Biomedical Sciences Group, University of Leuven, Leuven, Belgium
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Lohmöller K, Carstensen V, Pogatzki-Zahn EM, Freys SM, Weibel S, Schnabel A. Regional anaesthesia for postoperative pain management following laparoscopic, visceral, non-oncological surgery a systematic review and meta-analysis. Surg Endosc 2024; 38:1844-1866. [PMID: 38307961 DOI: 10.1007/s00464-023-10667-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/29/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Postoperative pain management following laparoscopic, non-oncological visceral surgery in adults is challenging. Regional anaesthesia could be a promising component in multimodal pain management. METHODS We performed a systematic review and meta-analysis with GRADE assessment. Primary outcomes were postoperative acute pain intensity at rest/during movement after 24 h, the number of patients with block-related adverse events and the number of patients with postoperative paralytic ileus. RESULTS 82 trials were included. Peripheral regional anaesthesia combined with general anaesthesia versus general anaesthesia may result in a slight reduction of pain intensity at rest at 24 h (mean difference (MD) - 0.72 points; 95% confidence interval (CI) - 0.91 to - 0.54; I2 = 97%; low-certainty evidence), which was not clinically relevant. The evidence is very uncertain regarding the effect on pain intensity during activity at 24 h (MD -0.8 points; 95%CI - 1.17 to - 0.42; I2 = 99%; very low-certainty evidence) and on the incidence of block-related adverse events. In contrast, neuraxial regional analgesia combined with general anaesthesia (versus general anaesthesia) may reduce postoperative pain intensity at rest in a clinical relevant matter (MD - 1.19 points; 95%CI - 1.99 to - 0.39; I2 = 97%; low-certainty evidence), but the effect is uncertain during activity (MD - 1.13 points; 95%CI - 2.31 to 0.06; I2 = 95%; very low-certainty evidence). There is uncertain evidence, that neuraxial regional analgesia combined with general anaesthesia (versus general anaesthesia) increases the risk for block-related adverse events (relative risk (RR) 5.11; 95%CI 1.13 to 23.03; I2 = 0%; very low-certainty evidence). CONCLUSION This meta-analysis confirms that regional anaesthesia might be an important part of multimodal postoperative analgesia in laparoscopic visceral surgery, e.g. in patients at risk for severe postoperative pain, and with large differences between surgical procedures and settings. Further research is required to evaluate the use of adjuvants and the additional benefit of regional anaesthesia in ERAS programmes. PROTOCOL REGISTRATION PROSPERO CRD42021258281.
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Affiliation(s)
- Katharina Lohmöller
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Albert-Schweitzer Campus 1 A, 48149, Münster, Germany
| | - Vivian Carstensen
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Albert-Schweitzer Campus 1 A, 48149, Münster, Germany
| | - Esther M Pogatzki-Zahn
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Albert-Schweitzer Campus 1 A, 48149, Münster, Germany
| | - Stephan M Freys
- Department of Surgery, DIAKO Diakonie Hospital, Bremen, Germany
| | - Stephanie Weibel
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Alexander Schnabel
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Albert-Schweitzer Campus 1 A, 48149, Münster, Germany.
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Miao L, Chen Q, Wang Y, Wang D, Zhou M. Effect of intraperitoneal infusion of ropivacaine combined with dexmedetomidine in patients undergoing total laparoscopic hysterectomy: a single-center randomized double-blinded controlled trial. Arch Gynecol Obstet 2024; 309:1387-1393. [PMID: 37004537 PMCID: PMC10894115 DOI: 10.1007/s00404-023-07020-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 03/21/2023] [Indexed: 04/04/2023]
Abstract
PURPOSE To investigate the effect of intraperitoneal infusion of ropivacaine combined with dexmedetomidine and ropivacaine alone on the quality of postoperative recovery of patients undergoing total laparoscopic hysterectomy (TLH). METHODS Female patients scheduled to undergo a TLH under general anesthesia at Fujian Maternity and Child Health Hospital were included. Before the end of pneumoperitoneum, patients were laparoscopically administered an intraperitoneal infusion of 0.25% ropivacaine 40 ml (R group) or 0.25% ropivacaine combined with 1 µg/kg dexmedetomidine 40 ml (RD group). The primary outcome was QoR-40, which was assessed before surgery and 24 h after surgery. Secondary outcomes included postoperative NRS scores, postoperative anesthetic dosage, the time to ambulation, urinary catheter removal, and anal exhaust. The incidence of dizziness, nausea, and vomiting was also analyzed. RESULTS A total of 109 women were recruited. The RD group had higher QoR scores than the R group at 24 h after surgery (p < 0.05). Compared with the R group, NRS scores in the RD group decreased at 2, 6, 12, and 24 h after surgery (all p < 0.05). In the RD group, the time to the first dosage of postoperative opioid was longer and the cumulative and effective times of PCA compression were less than those in the R group (all p < 0.05). Simultaneously, the time to ambulation (p = 0.033), anal exhaust (p = 0.002), and urethral catheter removal (p = 0.018) was shortened in the RD group. The RD group had a lower incidence of dizziness, nausea, and vomiting (p < 0.05). CONCLUSION Intraperitoneal infusion of ropivacaine combined with dexmedetomidine improved the quality of recovery in patients undergoing TLH. TRIAL REGISTRATION ChiCTR2000033209, Registration Date: May 24, 2020.
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Affiliation(s)
- Liyan Miao
- Department of Anesthesiology, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, 18 Daoshan Road, Gulou District, Fuzhou, Fujian, China
| | - Qiuchun Chen
- Department of Anesthesiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yuping Wang
- Department of Anesthesiology, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, 18 Daoshan Road, Gulou District, Fuzhou, Fujian, China
| | - Denggui Wang
- Department of Anesthesiology, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, 18 Daoshan Road, Gulou District, Fuzhou, Fujian, China.
| | - Min Zhou
- Department of Anesthesiology, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, 18 Daoshan Road, Gulou District, Fuzhou, Fujian, China.
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Majumdar JR, Grbic J, Carlsson S, Barreiro D, Marte M, Laudone V, Assel MJ, Masson G. Impact of Replacing Fentanyl With Hydromorphone as the First-Line Postoperative Opioid Among Patients Undergoing Outpatient Cancer Surgery. J Perianesth Nurs 2024:S1089-9472(23)01051-1. [PMID: 38493405 DOI: 10.1016/j.jopan.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 11/10/2023] [Accepted: 11/11/2023] [Indexed: 03/18/2024]
Abstract
PURPOSE In response to a nationwide fentanyl shortage, our institution assessed whether changing our first-line postoperative intravenous opioid from fentanyl to hydromorphone impacted patient outcomes. The primary research aim was to evaluate the association between first-line opioid and rapidity of recovery. DESIGN The study team retrospectively obtained data on all consecutive patients extracted from the electronic medical record. The rapidity of recovery was defined as the time from entry into the postanesthesia care unit to the transition to Phase 2 for ambulatory extended recovery patients and as the length of total postanesthesia care unit stay for outpatients. METHODS Following intent-to-treat-principles, we tested the association between study period and rapidity of recovery (a priori clinically meaningful difference: 20 minutes) using multivariable linear regression, adjusting for anesthesia type (general vs monitored anesthesia care), American Society of Anesthesiologst physical status (ASA) score (1-2 vs 3-4), age, service, robotic procedure, and surgery start time. FINDINGS Ambulatory extended recovery patients treated in the hydromorphone period had, on average, a 0.25 minute (95% confidence interval [CI] -6.5, 7.0), nonstatistically significant (P > .9) longer time to transition. For outpatient procedures, those who received hydromorphone had, on average, 8.5-minute longer stays (95% CI 3.7-13, P < .001). Although we saw statistical evidence of an increased risk of resurgery associated with receiving hydromorphone (0.5%; 95% CI -0.1%, 1.0%; P = .039 on univariate analysis), the size of the estimate is clinically and biologically implausible and is most likely a chance finding related either to multiple testing or confounding. CONCLUSIONS The multidisciplinary team concluded that the increase in postoperative length of stay associated with hydromorphone was not clinically significant and the decrease waste of prefilled syringes outweighed the small potential increased risk of resurgery compared to the shorter-acting fentanyl. We will therefore use hydromorphone moving forward.
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Affiliation(s)
- Jennifer R Majumdar
- Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY; Hunter-Bellevue School of Nursing, Hunter College, City University of New York, New York, NY.
| | - John Grbic
- Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sigrid Carlsson
- Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY; Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY; Urology, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Donna Barreiro
- Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Marie Marte
- Advanced Practice Providers, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Vincent Laudone
- Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Melissa J Assel
- Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Geema Masson
- Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY
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Suzuka T, Tanaka N, Kadoya Y, Ida M, Iwata M, Ozu N, Kawaguchi M. Comparison of Quality of Recovery between Modified Thoracoabdominal Nerves Block through Perichondrial Approach versus Oblique Subcostal Transversus Abdominis Plane Block in Patients Undergoing Total Laparoscopic Hysterectomy: A Pilot Randomized Controlled Trial. J Clin Med 2024; 13:712. [PMID: 38337406 PMCID: PMC10856699 DOI: 10.3390/jcm13030712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
Modified thoracoabdominal nerves block through a perichondrial approach (M-TAPA) provides a wide analgesic range. Herein, we examined the quality of recovery (QoR) of M-TAPA for total laparoscopic hysterectomy (TLH) compared with oblique subcostal transversus abdominis plane block (OSTAPB) and measured plasma levobupivacaine concentrations (PClevo). Forty female patients undergoing TLH were randomized to each group. Nerve blocks were performed bilaterally with 25 mL of 0.25% levobupivacaine administered per side. The primary outcome was changes in QoR-15 scores on postoperative days (POD) 1 and 2 from the preoperative baseline. The main secondary outcomes were PClevo at 15, 30, 45, 60, and 120 min after performing nerve block. Group differences (M-TAPA-OSTAPB) in mean changes from baseline in QoR-15 scores on POD 1 and 2 were -11.3 (95% confidence interval (CI), -24.9 to 2.4, p = 0.104; standard deviation (SD), 22.8) and -7.0 (95% CI, -20.5 to 6.6, p = 0.307; SD, 18.7), respectively. Changes in PClevo were similar in both groups. The post hoc analysis using Bayesian statistics revealed that posterior probabilities of M-TAPA being clinically more effective than OSTAPB were up to 22.4 and 24.4% for POD 1 and 2, respectively. In conclusion, M-TAPA may not be superior to OSTAPB for TLH.
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Affiliation(s)
- Takanori Suzuka
- Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.S.); (M.I.); (M.K.)
| | - Nobuhiro Tanaka
- Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.S.); (M.I.); (M.K.)
| | - Yuma Kadoya
- Department of Anesthesiology, Ikeda City Hospital, 3-1-18 Jonan, Ikeda 635-8501, Osaka, Japan;
| | - Mitsuru Ida
- Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.S.); (M.I.); (M.K.)
| | - Masato Iwata
- Department of Anesthesiology, Yamatotakada Municipal Hospital, 1-1, Isonokita-cho, Yamatotakada 635-8501, Nara, Japan;
| | - Naoki Ozu
- Institute for Clinical and Translational Science, Nara Medical University Hospital, 840 Shijocho, Kashihara 634-8522, Nara, Japan;
| | - Masahiko Kawaguchi
- Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.S.); (M.I.); (M.K.)
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Wu Q, Zhou Y, Sun S, Li H, Cao S, Shou H. Clinical analysis of acute postoperative pain after total laparoscopic hysterectomy for adenomyosis and uterine fibroids - a prospective observational study. Ann Med 2023; 55:2281510. [PMID: 37994446 PMCID: PMC10836289 DOI: 10.1080/07853890.2023.2281510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 11/04/2023] [Indexed: 11/24/2023] Open
Abstract
OBJECTIVE To investigate the outcome of total laparoscopic hysterectomy (TLH) and postoperative pain characteristics and compare the pain severity after TLH for adenomyosis or uterine fibroids. METHODS This prospective observational study collected 101 patients received TLH for adenomyosis (AD group) including 41 patients were injected goserelin (3.6 mg) 28 days before TLH, while other adenomyosis patients received TLH without preoperative treatment, and 113 patients received TLH for uterine fibroids (UF group). Pain scores were evaluated at different time sites from operation day to postoperative 72 h using the numeric rating scale. Clinical data were collected from clinical record. RESULTS Operative time and anaesthetic time were longer in the AD group than those in the UF group (66.88 ± 8.65 vs. 64.46 ± 7.21, p = 0.04; 83.95 ± 10.05 vs. 79.77 ± 6.88, p < 0.01), severe endometriosis was quite more common in AD group (23.76% vs. 2.65%, p < 0.01). Postoperative usage of Flurbiprofen in AD group were more than that of UF group (15.48 ± 38.00 vs. 4.79 ± 18.16, p = 0.02). Total pains and abdominal visceral pains of AD group were more severe compared with UF group in motion and rest pattern at several time sites, while incision pain and shoulder pain were similar. The total postoperative pains after goserelin preoperative treatment in AD group were less than that without goserelin preoperative treatment (p < 0.05). The levels of serum NPY, PGE2 and NGF after laparoscopic hysterectomy of adenomyosis reduced with GnRH agonist pretreatment. CONCLUSIONS Acute postoperative pain for adenomyosis and uterine fibroids showed considerably different severity, postoperative total pain and abdominal visceral pains of TLH for adenomyosis were more severe compared with uterine fibroids. While patients received goserelin before laparoscopic hysterectomy of adenomyosis suffered from less severity of postoperative total pain than that without goserelin preoperative treatment.
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Affiliation(s)
- Qing Wu
- Center for Reproductive Medicine, Department of Gynecology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China
| | - Yun Zhou
- Department of Obstetrics and Gynecology, Shengli Clinical Medical College of Fujian Medical University and Fujian Provincial Hospital, Fuzhou, China
| | - Saijun Sun
- Tiantai People’s Hospital of Zhejiang Province, Zhejiang, China
| | - Hui Li
- Center for Reproductive Medicine, Department of Gynecology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China
| | - Shanshan Cao
- Tiantai People’s Hospital of Zhejiang Province, Zhejiang, China
| | - Huafeng Shou
- Center for Reproductive Medicine, Department of Gynecology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China
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She H, Qin Y, Peng W, Zhou Y, Dai Y, Wang Y, Jiang P, Wu J. Anterior Quadratus Lumborum Block for Total Laparoscopic Hysterectomy: A Randomized, Double-Blind, Placebo-Controlled Trial. Clin J Pain 2023; 39:571-579. [PMID: 37712228 DOI: 10.1097/ajp.0000000000001156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 08/11/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVES This study aimed to investigate the perioperative analgesic effects of anterior quadratus lumborum block (QLB) for total laparoscopic hysterectomy (TLH). MATERIALS AND METHODS One hundred patients undergoing TLH were randomized to receive an anterior QLB or placebo before general anesthesia. The primary and secondary outcomes were postoperative sufentanil consumption, intraoperative remifentanil demand, time to first opioid demand, numeric rating scale (NRS) pain scores, heart rate, mean arterial pressure, and complications within 24 hours after surgery. RESULTS No significant intergroup differences were observed in sufentanil consumption within 24 hours after surgery. Remifentanil consumption during surgery was lower in the QLB group than in the placebo group. At 1 hour after surgery, the NRS scores of abdominal visceral pain at rest and during activity were 1.26 and 1.41 points lower than those in the placebo group. In other time points, the differences in abdominal visceral pain were neither statistically significant nor clinically significant (pain difference <1) or both. No significant differences in NRS scores of shoulder pain, abdominal incisional pain, and perineal pain were observed between the 2 groups, at rest or during activity. There were no significant differences in other secondary outcome variables between the 2 groups. DISCUSSION Preoperative bilateral anterior QLB only reduced intraoperative opioid demand and postoperative abdominal visceral pain scores at 1 hour after surgery. Thus, the clinical significance of anterior QLB in TLH may be limited.
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Affiliation(s)
- Huiyu She
- Department of Anesthesiology, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Yifan Qin
- Department of Anesthesiology, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Wenrui Peng
- Department of Anesthesiology, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Yali Zhou
- Department of Surgery, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Ying Dai
- Department of Surgery, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Yiting Wang
- Department of Anesthesiology, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Peng Jiang
- Department of Anesthesiology, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Jin Wu
- Department of Anesthesiology, Affiliated Hospital of Jiangsu University, Zhenjiang, China
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Qin Y, She H, Peng W, Zhou X, Wang Y, Jiang P, Wu J. The Effect of Caudal Ropivacaine and Morphine on Postoperative Analgesia in Total Laparoscopic Hysterectomy: A Prospective, Double-Blind, Randomized Controlled Trial. J Pain Res 2023; 16:3379-3390. [PMID: 37817757 PMCID: PMC10560628 DOI: 10.2147/jpr.s426820] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/26/2023] [Indexed: 10/12/2023] Open
Abstract
Purpose Multiple regional nerve blocks proved no additional benefit in total laparoscopic hysterectomy in multimodal analgesia, as postoperative pain may mainly originate from the vaginal cuff. Theoretically, caudal block can relieve pain from the vaginal cuff by a sacral spinal nerve block. We aimed to verify whether a caudal block with ropivacaine and morphine can achieve an analgesic effect without additional adverse effects after a total laparoscopic hysterectomy. Patients and Methods Forty-eight patients undergoing total laparoscopic hysterectomy were randomly allocated to receive preoperative caudal block with 20 mL of mixture including 0.25% ropivacaine and 2 mg morphine (caudal block group) or sham block (sham group). The primary outcome was the postoperative 24 h cumulative sufentanil consumption. Results Median (IQR) sufentanil consumption in the first 24 postoperative hours of the caudal block group and the sham group was 0.00 (0.00 to 0.05) μg/kg vs 0.13 (0.04 to 0.21) μg/kg, respectively, p < 0.001. The majority of patients felt that visceral pain was more intense than incisional pain at 1, 6, 12, and 24 h post-surgery in the sham group (95.8% at 1 h, 95.8% at 6 h, 95.8% at 12 h, and 75% at 24 h post-surgery). Compared to the sham group, the caudal block reduced visceral pain scores at rest and during movement at 1 h (p < 0.001), 6 h (p < 0.001), 12 h (p < 0.001), and 24 h (p < 0.001) post-surgery. Intraoperative remifentanil consumption was significantly lower in the caudal block group than in the sham group (p = 0.004). There were no significant differences in other secondary outcomes between the two groups. Conclusion A caudal block with ropivacaine and morphine could provide a satisfactory analgesic effect for 24 h postoperatively without additional adverse effects after total laparoscopic hysterectomy.
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Affiliation(s)
- Yifan Qin
- Department of Anesthesiology, Affiliated Hospital of Jiangsu University, Zhenjiang, People’s Republic of China
| | - Huiyu She
- Department of Anesthesiology, Affiliated Hospital of Jiangsu University, Zhenjiang, People’s Republic of China
| | - Wenrui Peng
- Department of Anesthesiology, Affiliated Hospital of Jiangsu University, Zhenjiang, People’s Republic of China
| | - Xiaofeng Zhou
- Department of Anesthesiology, Affiliated Hospital of Jiangsu University, Zhenjiang, People’s Republic of China
| | - Yiting Wang
- Department of Anesthesiology, Affiliated Hospital of Jiangsu University, Zhenjiang, People’s Republic of China
| | - Peng Jiang
- Department of Anesthesiology, Affiliated Hospital of Jiangsu University, Zhenjiang, People’s Republic of China
| | - Jin Wu
- Department of Anesthesiology, Affiliated Hospital of Jiangsu University, Zhenjiang, People’s Republic of China
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Larsen MHH, Kehlet H, von Buchwald C. Transoral robotic surgery - time for consensus on pain assessment. A review. Acta Otolaryngol 2023; 143:902-911. [PMID: 37991140 DOI: 10.1080/00016489.2023.2282149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/02/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND In Head and Neck surgery Transoral Robotic Surgery (TORS) is evolving as a key treatment option for benign and malignant lesions in the oropharynx. Even so, postoperative pain is one of the primary early complaints following TORS. Well established evidence-based procedure specific pain treatment guidelines are available for a variety of other surgical specialties. However, there are no guidelines for TORS. AIM This review describes the available data of early pain intensity following TORS during rest and procedure related activity. METHODS Literature concerning pain in the immediate postoperative phase following TORS were obtained from two literature databases. RESULTS Most data on pain intensity following TORS are based upon a numeric rating scale, e.g. the Visual Analogue Scale and/or analgesic demands. Only one randomized clinical trial is available reflecting that the literature is mainly based on retrospective and a few prospective studies. Only one study analyzed pain during relevant functionality, i.e. swallowing. Overall, the studies suffer from a non-standardized approach and there is a need for transparent information concerning the timing of pain ratings and methodology. CONCLUSIONS The evidence for optimal pain control is limited, particularly during surgical relevant activity. Postoperative pain rating during activity is a fundamental element in pain trials in order to enhance recovery thereby calling for future consensus on assessment methodology.
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Affiliation(s)
- Mikkel Hjordt Holm Larsen
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian von Buchwald
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
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Friesgaard KD, Brix LD, Kristensen CB, Rian O, Nikolajsen L. Clinical effectiveness and safety of intraoperative methadone in patients undergoing laparoscopic hysterectomy: a randomised, blinded clinical trial. BJA OPEN 2023; 7:100219. [PMID: 37638083 PMCID: PMC10457492 DOI: 10.1016/j.bjao.2023.100219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/19/2023] [Accepted: 07/12/2023] [Indexed: 08/29/2023]
Abstract
Background Laparoscopic hysterectomy is often carried out as day-stay surgery. Minimising postoperative pain is therefore of utmost importance to ensure timely discharge from hospital. Methadone has several desirable pharmacological features, including a long elimination half-life. Therefore, a single intraoperative dose could provide long-lasting pain relief. Methods Patients scheduled to undergo laparoscopic hysterectomy were randomly allocated to receive methadone (0.2 mg kg-1) or morphine (0.2 mg kg-1) intraoperatively, 60 min before tracheal extubation. Primary outcomes were opioid consumption (oral morphine equivalents in milligrams) at 6 and 24 h. Secondary outcomes included pain intensity at rest and during coughing, patient satisfaction, postoperative nausea and vomiting, and adverse events up to 72 h after completion of surgery. Results The postoperative median opioid consumption was reduced in the methadone group compared with the morphine group at 6 h (35.5 [0-61] mg vs 48 [31-74.5] mg; P=0.01) and 24 h (42 [10-67] mg vs 54.5 [31-83] mg; P=0.03). On arrival at the PACU, pain at rest was significantly lower in patients receiving methadone (numeric rating scale: 3 [2-5] vs 5 [3-6]), whereas pain scores at rest and coughing were not significantly different throughout the rest of the observation period. No differences in other secondary outcomes were found. Conclusions In this randomised, blinded, controlled trial, opioid consumption was reduced during the first 24 postoperative hours in patients receiving methadone without causing an increase in adverse events. The difference observed might be considered as small and of limited clinical relevance. Clinical trial registration NCT03908060; EudraCT no. 2018-004351-20.
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Affiliation(s)
- Kristian D. Friesgaard
- Department of Anaesthesiology and Intensive Care, Horsens Regional Hospital, Horsens, Denmark
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Lone D. Brix
- Department of Anaesthesiology and Intensive Care, Horsens Regional Hospital, Horsens, Denmark
| | | | - Omar Rian
- Department of Anaesthesiology and Intensive Care, Horsens Regional Hospital, Horsens, Denmark
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Lone Nikolajsen
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
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Fuad Hetta D, Abdelfatah Mohamed M, Elmorabaa HA, Ahmed MI, Elgalaly NA, Kamal SM. Efficacy of perioperative duloxetine as a part of multimodal analgesia in laparoscopic colorectal cancer surgeries. BMC Anesthesiol 2023; 23:166. [PMID: 37194004 DOI: 10.1186/s12871-023-02119-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 04/30/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Although laparoscopic surgery provides earlier recovery, less morbidity and hospital stay, however, severe pain is still a problem after it. Duloxetine has been recently used in postoperative pain management. We tested perioperative duloxetine to evaluate its effect on patients undergoing laparoscopic colorectal cancer surgery. METHODS Sixty patients were enrolled in this study divided into two equal groups; duloxetine group each patient received an oral duloxetine capsule (60 mg) 1st dose at night before surgery, the 2nd dose 1 h preoperative, and the 3rd dose 24 h postoperative. Placebo group received placebo capsules at the same times. The cumulative morphine consumption in 48 h, postoperative VAS score, quality of recovery (QoR-40 score), sedation, and adverse effects were evaluated. RESULTS Duloxetine group had lower VAS scores compared to placebo group, (3 ± 0.69) VS. (4.17 ± 0.83), (2.5 ± 0.6) VS. (4.3 ± 0.9), (2.2 ± 0.7) VS. (3.9 ± 0.6), (1.6 ± 0.7) VS. (3.6 ± 0.8), (1.1 ± 0.8) VS. (3.7 ± 0.7), (0.7 ± 0.7) VS. (3.5 ± 0.8), (0.6 ± 0.7) VS. (3.5 ± 0.8) respectively, P ˂0.01. The cumulative morphine consumption was significantly reduced in the Duloxetine group compared to the placebo group (4.6 ± 2.9 vs. 11.3 ± 1.7 mg), P < 0.01. The total QoR-40 score for duloxetine group was (180.8 ± 4.5) vs. (156 ± 5.9) in placebo group (P < 0.01). Patients in Duloxetine group were more sedated in all the 48 h postoperatively in comparison to placebo group. CONCLUSIONS Perioperative duloxetine had reduced postoperative pain, decreased opioid consumption, and improved the quality of recovery in patients undergoing laparoscopic colorectal surgery.
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Affiliation(s)
- Diab Fuad Hetta
- Anesthesia and intensive care and pain management department, South Egypt Cancer Institiue, Assiut University, Assiut, Egypt
| | - Montaser Abdelfatah Mohamed
- Anesthesia and intensive care and pain management department, South Egypt Cancer Institiue, Assiut University, Assiut, Egypt
| | - Hany Ahmed Elmorabaa
- Anaesthesia, Intensive care and pain management department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mirna Ismail Ahmed
- Anesthesia and intensive care and pain management department, South Egypt Cancer Institiue, Assiut University, Assiut, Egypt
| | - Nourhan Alaa Elgalaly
- Anesthesia and intensive care and pain management department, South Egypt Cancer Institiue, Assiut University, Assiut, Egypt
| | - Shereen Mamdouh Kamal
- Anesthesia and intensive care and pain management department, South Egypt Cancer Institiue, Assiut University, Assiut, Egypt.
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Kaiser K, Valsamidis AN, Karstensen SH, Strøm T, Gögenur I, Balsevicius L, Lauszus FF. Effect of 24 mg dexamethasone preoperatively on surgical stress, pain and recovery in robotic-assisted laparoscopic hysterectomy. Contemp Clin Trials Commun 2023; 33:101109. [PMID: 36969986 PMCID: PMC10030906 DOI: 10.1016/j.conctc.2023.101109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/26/2023] [Accepted: 03/10/2023] [Indexed: 03/13/2023] Open
Abstract
Background Robotic-assisted hysterectomy is an alternative to laparoscopic surgery as part of a minimal invasive regimen. Several treatment strategies are followed to improve the overall outcome and minimize surgical stress. Glucocorticoids provide significant analgesic and antiemetic effects but their role in reducing inflammatory stress in a fast-track, multi-modal setting in patients undergoing minimally invasive surgery remains to be investigated in details. Methods This study will evaluate in a randomized trial the effect of a single dose of 24 mg dexamethasone on 100 women undergoing robotic-assisted hysterectomy with regard to surgical stress, measured by c-reactive protein as primary outcome and, further, other stress markers like white blood cell subtypes. The postoperative recovery will be registered in validated charts and questionnaires for pain and analgesic use, quality of recovery, incontinence, sexual and work life. Furthermore, in a sub-analysis, transcriptional profiling will be performed to explore the mechanism of systemic innate and adaptive immune system perturbation induced by surgical stress. Conclusion The study will provide solid evidence on markers of immunomodulation biomarkers and in addition the subjective effects and underlying mechanisms of perioperative glucocorticoid in women undergoing robotic hysterectomy. These include important aspects of life quality like pain, fatigue, freedom of medications, resuming work and sexual activities.
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Affiliation(s)
- Karsten Kaiser
- Department of Gynecology and Obstetrics, Aabenraa Hospital, Sygehus Sonderjylland, Denmark
| | | | - Sven Hoedt Karstensen
- Department of Gynecology and Obstetrics, Aabenraa Hospital, Sygehus Sonderjylland, Denmark
| | - Thomas Strøm
- Aabenraa Hospital, Sygehus Sønderjylland, Department of Anesthesia and Critical Care Medicine, Hospital Sønderjylland, University of Southern Denmark, Denmark
- Department of Intensive Care, Odense University Hospital, Denmark
| | - Ismail Gögenur
- Department of Surgery, Zealand University Hospital, Denmark
- University of Copenhagen, Denmark
- Center of Surgical Science, Zealand University Hospital, Denmark
| | - Lukas Balsevicius
- Department of Surgery, Zealand University Hospital, Denmark
- University of Copenhagen, Denmark
- Center of Surgical Science, Zealand University Hospital, Denmark
| | - Finn Friis Lauszus
- Department of Gynecology and Obstetrics, Aabenraa Hospital, Sygehus Sonderjylland, Denmark
- Corresponding author. Dept. of Gynecology and Obstetrics, Aabenraa Hospital, Sygehus Sønderjylland Kresten Phillipsensvej 15, DK- 6200, Aabenraa, Denmark.
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Kim K, Biskupiak JE, Babin JL, Ilham S. Positive Association between Peri-Surgical Opioid Exposure and Post-Discharge Opioid-Related Outcomes. Healthcare (Basel) 2022; 11:healthcare11010115. [PMID: 36611576 PMCID: PMC9819163 DOI: 10.3390/healthcare11010115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 01/04/2023] Open
Abstract
Background: Multiple studies have investigated the epidemic of persistent opioid use as a common postsurgical complication. However, there exists a knowledge gap in the association between the level of opioid exposure in the peri-surgical setting and post-discharge adverse outcomes to patients and healthcare settings. We analyzed the association between peri-surgical opioid exposure use and post-discharge outcomes, including persistent postsurgical opioid prescription, opioid-related symptoms (ORS), and healthcare resource utilization (HCRU). Methods: A retrospective cohort study included patients undergoing cesarean delivery, hysterectomy, spine surgery, total hip arthroplasty, or total knee arthroplasty in an academic healthcare system between January 2015 and June 2018. Peri-surgical opioid exposure was converted into morphine milligram equivalents (MME), then grouped into two categories: high (>median MME of each surgery cohort) or low (≤median MME of each surgery cohort) MME groups. The rates of persistent opioid use 30 and 90 days after discharge were compared using logistic regression. Secondary outcomes, including ORS and HCRU during the 180-day follow-up, were descriptively compared between the high and low MME groups. Results: The odds ratios (95% CI) of high vs. low MME for persistent opioid use after 30 and 90 days of discharge were 1.38 (1.24−1.54) and 1.41 (1.24−1.61), respectively. The proportion of patients with one or more ORS diagnoses was greater among the high-MME group than the low-MME group (27.2% vs. 21.2%, p < 0.01). High vs. low MME was positively associated with the rate of inpatient admission, emergency department admissions, and outpatient visits. Conclusions: Greater peri-surgical opioid exposure correlates with a statistically and clinically significant increase in post-discharge adverse opioid-related outcomes. The study findings warrant intensive monitoring for patients receiving greater peri-surgical opioid exposure.
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Affiliation(s)
- Kibum Kim
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL 60564, USA
- Department of Pharmacotherapy, University of Utah Health, Salt Lake City, UT 84112, USA
- Correspondence: ; Tel.: +1-312-413-0152; Fax: +1-312-996-2954
| | - Joseph E. Biskupiak
- Department of Pharmacotherapy, University of Utah Health, Salt Lake City, UT 84112, USA
- Pharmacotherapy Outcomes Research Center, University of Utah Health, Salt Lake City, UT 84112, USA
| | - Jennifer L. Babin
- Department of Pharmacotherapy, University of Utah Health, Salt Lake City, UT 84112, USA
| | - Sabrina Ilham
- Pharmacotherapy Outcomes Research Center, University of Utah Health, Salt Lake City, UT 84112, USA
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Bougie O, Blom J, Zhou G, Murji A, Thurston J. Use and misuse of opioid after gynecologic surgery. Best Pract Res Clin Obstet Gynaecol 2022; 85:23-34. [PMID: 35973919 DOI: 10.1016/j.bpobgyn.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 05/25/2022] [Accepted: 07/06/2022] [Indexed: 12/14/2022]
Abstract
Postoperative opioid use following gynecologic surgery may be necessary for effective treatment of pain; however, it can result in significant side effects, adverse reactions, and negative health consequences, including prolonged problematic use. Surgeons and healthcare providers of patients recovering from gynecologic procedures should be aware of effective strategies that can decrease the need for opioid use, while providing high-quality pain management. These include adherence to Enhanced Recovery After Surgery Protocols, particularly the use of multimodal analgesia management. When prescribing opioids, providers should adhere to responsible prescribing practices to minimize the risk of inappropriate and/or long-term opioid use.
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Affiliation(s)
- Olga Bougie
- Department of Obstetrics & Gynecology, Queen's University, Kingston Health Sciences Centre, Kingston, ON, USA.
| | - Jessica Blom
- Department of Obstetrics & Gynecology, Queen's University, Kingston Health Sciences Centre, Kingston, ON, USA
| | - Grace Zhou
- Department of Obstetrics & Gynecology, Mount Sinai Hospital and University of Toronto, Toronto, ON, USA
| | - Ally Murji
- Department of Obstetrics & Gynecology, Mount Sinai Hospital and University of Toronto, Toronto, ON, USA
| | - Jackie Thurston
- Department of Obstetrics & Gynecology, University of Calgary, Calgary, Alberta, USA
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Abstract
PURPOSE OF REVIEW Also in ambulatory surgery, there will usually be a need for analgesic medication to deal with postoperative pain. Even so, a significant proportion of ambulatory surgery patients have unacceptable postoperative pain, and there is a need for better education in how to provide proper prophylaxis and treatment. RECENT FINDINGS Postoperative pain should be addressed both pre, intra- and postoperatively. The management should be with a multimodal nonopioid-based procedure specific guideline for the routine cases. In 10-20% of cases, there will be a need to adjust and supplement the basic guideline with extra analgesic measures. This may be because there are contraindications for a drug in the guideline, the procedure is more extensive than usual or the patient has extra risk factors for strong postoperative pain. Opioids should only be used when needed on top of multimodal nonopioid prophylaxis. Opioids should be with nondepot formulations, titrated to effect in the postoperative care unit and eventually continued only when needed for a few days at maximum. SUMMARY Multimodal analgesia should start pre or per-operatively and include paracetamol, nonsteroidal anti-inflammatory drug (NSAID), dexamethasone (or alternative glucocorticoid) and local anaesthetic wound infiltration, unless contraindicated in the individual case. Paracetamol and NSAID should be continued postoperatively, supplemented with opioid on top as needed. Extra analgesia may be considered when appropriate and needed. First-line options include nerve blocks or interfascial plane blocks and i.v. lidocaine infusion. In addition, gabapentinnoids, dexmedetomidine, ketamine infusion and clonidine may be used, but adverse effects of sedation, dizziness and hypotension must be carefully considered in the ambulatory setting.
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17
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Relationship between the Use of Fentanyl-Based Intravenous Patient-Controlled Analgesia and Clinically Significant Events in Laparoscopic Gynecological Surgery: A Single-Center Retrospective Cohort Study. J Clin Med 2022; 11:jcm11113235. [PMID: 35683626 PMCID: PMC9181663 DOI: 10.3390/jcm11113235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 06/02/2022] [Accepted: 06/05/2022] [Indexed: 02/01/2023] Open
Abstract
Background: This study examined the relationship between the use of fentanyl-based intravenous patient-controlled analgesia (ivPCA) and the incidence of a clinically significant event (CSE), while considering both the analgesic effects and side effects in laparoscopic gynecological surgery. Methods: This study included 816 patients undergoing laparoscopic gynecological surgery under general anesthesia at Kyoto University Hospital between 2012 and 2018. The primary exposure was the use of fentanyl-based ivPCA. We defined an outcome measure—CSE—that integrates severe wound pain and vomiting assumed to negatively affect patient recovery. We performed multivariable logistic regression analysis to assess the independent relationship between ivPCA use and CSE. Results: Multivariable logistic regression analysis revealed that fentanyl-based ivPCA was independently associated with increased CSE (adjusted odds ratio (95% confidence interval): 1.80 (1.24−2.61), p = 0.002). Use of ivPCA was associated with a reduced incidence of postoperative severe wound pain (adjusted odds ratio (95% confidence interval): 0.50 (0.27−0.90), p = 0.022), but was also associated with an increased incidence of vomiting (adjusted odds ratio (95% confidence interval): 2.65 (1.79−3.92), p < 0.001). Conclusion: The use of fentanyl-based ivPCA in laparoscopic gynecological surgery is associated with increased CSE.
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18
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Delecourt C, Tourette C, Crochet P, Pivano A, Hamouda I, Agostini A. Benefits of AirSeal® System in Laparoscopic Hysterectomy for Benign Condition: A Randomized Controlled Trial. J Minim Invasive Gynecol 2022; 29:1003-1010. [DOI: 10.1016/j.jmig.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/05/2022] [Accepted: 05/07/2022] [Indexed: 10/18/2022]
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Nazemroaya B, Keleidari B, Arabzadeh A, Honarmand A. Comparison of Intraperitoneal Versus Intravenous Dexamethasone on Postoperative Pain, Nausea, and Vomiting After Laparoscopic Cholecystectomy. Anesth Pain Med 2022; 12:e122203. [PMID: 35991777 PMCID: PMC9375960 DOI: 10.5812/aapm-122203] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 11/20/2022] Open
Abstract
Background Despite all of the benefits provided by laparoscopic cholecystectomy, such as rapid recovery and shorter hospital stay for patients, the incidence of postoperative nausea and vomiting (PONV) and postoperative pain (POP) still remains high. Objectives This study was designed to compare the effects of intraperitoneal (IP) and intravenous (IV) dexamethasone on the reduction of PONV and POP. Methods This prospective, randomized, double-blind clinical trial was conducted on a study population of 86 adult patients who were scheduled for laparoscopic cholecystectomy with the American Society of Anesthesiologists class I-II. The patients were randomized into three groups, namely IP dexamethasone (n = 29), IV dexamethasone (n = 29), and control (n = 28) groups. The patients were followed for clinical outcomes, including PONV, POP, and consumption of antiemetics, and their hemodynamic status during the first 24 hours after the surgery. Results In the first 24 hours after the operation, no significant differences were observed in nausea (P = 0.41) and vomiting (P = 0.38) between the IP and IV dexamethasone groups. However, there was a lower severity of nausea in the IP group (P = 0.001). Additionally, the visual analog scale score representing POP was significantly reduced in the IP group (P = 0.02). No significant differences in the hemodynamic status were observed after the operation between all the three groups. Conclusions The administration of 8 mg IP dexamethasone was associated with significantly reduced pain and severity of nausea, but not PONV, after laparoscopic cholecystectomy.
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Affiliation(s)
- Behzad Nazemroaya
- Anesthesiology and Critical Care Department , Isfahan University of Medical Sciences, Isfahan, Iran
- Corresponding Author: Anesthesiology and Critical Care Department , Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Behrooz Keleidari
- Surgery Department, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Alireza Arabzadeh
- Anesthesiology Department, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Azim Honarmand
- Anesthesiology and Critical Care Department , Isfahan University of Medical Sciences, Isfahan, Iran
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Analgesia for Gynecologic Oncologic Surgeries: A Narrative Review. Curr Pain Headache Rep 2022; 26:1-13. [PMID: 35118596 DOI: 10.1007/s11916-022-00998-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Gynecologic oncologic malignancies are amongst the most common cancers affecting women across the world. This narrative review focuses on the current state of evidence around optimal perioperative pain management of patients undergoing surgeries for gynecologic malignancies with a specific focus on cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). RECENT FINDINGS Recent improvements in postoperative pain management following all types of gynecologic procedures, including minimally invasive, open-abdominal, or CRS + HIPEC, have been implemented through enhanced recovery after surgery (ERAS) protocols. These protocols encompass the use of preemptive analgesia, neuraxial and regional techniques, local anesthetic infiltration, and multimodal analgesia. The severity of postoperative pain varies for minimally invasive cancer surgery to open debulking procedures. Therefore, an individualized perioperative analgesic plan is critical depending on the surgical approach. For CRS + HIPEC, neuraxial techniques such as thoracic epidurals and opioid sparing multimodal analgesics have shown efficacy in the perioperative period. However, future research is needed as many of these patients develop chronic pain with very limited research done in this realm.
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López-Ruiz C, Orjuela JC, Rojas-Gualdrón DF, Jimenez-Arango M, Ríos JFDL, Vásquez-Trespalacios EM, Vargas C. Efficacy of Transversus Abdominis Plane Block in the Reduction of Pain and Opioid Requirement in Laparoscopic and Robot-assisted Hysterectomy: A Systematic Review and Meta-analysis. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:55-66. [PMID: 35092960 PMCID: PMC9948299 DOI: 10.1055/s-0041-1740595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To summarize the available evidence of TAP Block in efficacy in laparoscopic or robotic hysterectomy. DATA SOURCES We searched databases and gray literature for randomized controlled trials in which transversus abdominis plane (TAP) block was compared with placebo or with no treatment in patients who underwent laparoscopic or robot-assisted hysterectomy. METHOD OF STUDY SELECTION Two researchers independently evaluated the eligibility of the selected articles. TABULATION, INTEGRATION, AND RESULTS Seven studies were selected, involving 518 patients. Early postoperative pain showed a difference in the mean mean difference (MD): - 1.17 (95% confidence interval [CI]: - 1.87-0.46) in pain scale scores (I2 = 68%), which was statistically significant in favor of using TAP block, but without clinical relevance; late postoperative pain: DM 0.001 (95%CI: - 0.43-0.44; I2 = 69%); opioid requirement: DM 0.36 (95%CI: - 0.94-1.68; I2 = 80%); and incidence of nausea and vomiting with a difference of 95%CI = - 0.11 (- 0.215-0.006) in favor of TAP. CONCLUSION With moderate strength of evidence, due to the high heterogeneity and imbalance in baseline characteristics among studies, the results indicate that TAP block should not be considered as a clinically relevant analgesic technique to improve postoperative pain in laparoscopic or robotic hysterectomy, despite statistical significance in early postoperative pain scale scores. CLINICAL TRIAL NUMBER AND REGISTRY PROSPERO ID - CRD42018103573.
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Affiliation(s)
- Claudia López-Ruiz
- Department of Gynecology and Obstetrics, Clínica del Prado, Medellín, Colombia.,School of Graduate Studies, School of Medicine, CES University, Medellín, Colombia
| | | | | | | | | | | | - Claudia Vargas
- American Association of Gynecologic Laparoscopists, Medellín, Colombia
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22
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Evaluation of Opioid Prescribing Patterns and Use Following Hysterectomy for Benign Indication: A Prospective Cohort Study. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 44:240-246.e1. [PMID: 34656767 DOI: 10.1016/j.jogc.2021.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 09/08/2021] [Accepted: 09/09/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To evaluate surgeon opioid prescribing patterns for patients undergoing hysterectomy for benign indication, as well as patient use of postoperative medications and satisfaction with postoperative pain management. METHODS Patients undergoing hysterectomy for benign indications at Kingston Health Sciences Centre were invited to participate in a telephone survey 2 weeks post-surgery to review their analgesia use and pain management. Patient demographics, medical history, intraoperative surgical details, and postoperative prescriptions were gathered through patient record review. Opioid prescribing and utilization patterns were assessed, as was satisfaction with postoperative pain management. RESULTS Of 124 eligible patients 110 (89%) completed the telephone survey, a mean 15.9 ± 2.3 days after surgery. The mean age of participants was 51.6 ± 11.9 years. Most surgeries (84.5%) were minimally invasive, and 45.5% of patients were discharged within 24 hours of surgery. An opioid prescription was given to 71.8% of participants, and 52.7% used at least 1 dose of opioid medication after discharge. Most participants described very good or adequate postoperative pain management (88.2%). Satisfaction with postoperative pain control was not associated with receipt of an opioid prescription (P = 0.89). A greater proportion of those who used 1 or more doses of opioids versus none indicated poor or inadequate pain management (19.0% vs. 4.1%; P = 0.035). CONCLUSION Many patients do not use postoperative opioid analgesia following hospital discharge after hysterectomy, without experiencing poor pain management. Surgeons should assess each individual and tailor the analgesia plan as necessary, optimizing non-opioid options.
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Mancel L, Van Loon K, Lopez AM. Role of regional anesthesia in Enhanced Recovery After Surgery (ERAS) protocols. Curr Opin Anaesthesiol 2021; 34:616-625. [PMID: 34325463 DOI: 10.1097/aco.0000000000001048] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Enhanced Recovery After Surgery (ERAS) protocols and interventional locoregional anesthesia (LRA) techniques continuously evolve. This review outlines the latest recommendations for the use of regional anesthesia in ERAS protocols and emerging interventional analgesia techniques. RECENT FINDINGS Research in ultrasound-guided regional anesthesia has led to a refinement of the traditional techniques and the introduction of a number of new approaches to complement ERAS strategies. The efficacy and versatility of LRA enable its use in an increasing number of ERAS indications. SUMMARY The implementation of ERAS protocols in different surgical procedures reduces overall complications and recovery time. Multimodal analgesia strategies with regional anesthesia techniques are some of the key interventions contributing to the improvement in postoperative outcomes.
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Affiliation(s)
- Leander Mancel
- Department of Anesthesiology, UZ Leuven, Leuven, Belgium
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Sacha CR, Mortimer R, Hariton E, James K, Hosseini A, Gray M, Xuan C, Hammer K, Lange A, Mahalingaiah S, Wang J, Petrozza JC. Assessing efficacy of intravenous acetaminophen for perioperative pain control for oocyte retrieval: a randomized, double-blind, placebo-controlled trial. Fertil Steril 2021; 117:133-141. [PMID: 34548165 DOI: 10.1016/j.fertnstert.2021.08.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/29/2021] [Accepted: 08/23/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the effect of preoperative intravenous (IV) acetaminophen versus oral (PO) acetaminophen or placebo on postoperative pain scores and the time to discharge in women undergoing oocyte retrieval. DESIGN Randomized, double-blind, placebo-controlled trial. SETTING Single academic fertility center. PATIENT(S) Women aged 18-43 years undergoing oocyte retrieval. INTERVENTION(S) Randomization to preoperative 1,000 mg IV acetaminophen and PO placebo (group A), IV placebo and 1,000 mg PO acetaminophen (group B), or IV and PO placebo (group C) MAIN OUTCOME MEASURE(S): Difference in patient-reported postoperative visual analog scale pain scores from baseline and the time to discharge. RESULT(S) Of the 159 women who completed the study, there were no differences in the mean postoperative pain score differences or the time to discharge. Although not statistically significant, the mean postoperative opioid dose requirement in group A was lower than that in groups B and C (0.24 vs. 0.59 vs. 0.58 mg IV morphine equivalents, respectively) due to fewer women in group A requiring rescue pain medication (8% vs. 19% vs. 15%, respectively). Group A also reported less constipation when compared with groups B and C (19% vs. 33% vs. 40%, respectively). The rates of postoperative nausea were similar, and there were no differences in embryology or early pregnancy outcomes between the study groups. CONCLUSION(S) Preoperative IV acetaminophen for women undergoing oocyte retrieval did not reduce postoperative pain scores or shorten the time to discharge when compared with PO acetaminophen or placebo and, thus, cannot currently be recommended routinely in this patient population. CLINICAL TRIAL REGISTRATION NUMBER NCT03073980.
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Affiliation(s)
- Caitlin R Sacha
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Roisin Mortimer
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of OB/GYN, Brigham and Women's Hospital and Massachusetts General Hospital, Boston, Massachusetts
| | - Eduardo Hariton
- University of California San Francisco, Department of Obstetrics, Gynecology, and Reproductive Sciences, San Francisco, California
| | - Kaitlyn James
- Center for Outcomes Research, Department of OB/GYN, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Afrooz Hosseini
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Morgan Gray
- Boston University School of Medicine, Boston, Massachusetts
| | - Chengluan Xuan
- Department of Anesthesia, The First Hospital of Jilin University, Jilin, China; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Karissa Hammer
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Shruthi Mahalingaiah
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jingping Wang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - John C Petrozza
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Jadon A, Ahmad A, Sahoo RK, Sinha N, Chakraborty S, Bakshi A. Efficacy of transmuscular quadratus lumborum block in the multimodal regimen for postoperative analgesia after total laparoscopic hysterectomy: A prospective randomised double-blinded study. Indian J Anaesth 2021; 65:362-368. [PMID: 34211193 PMCID: PMC8202790 DOI: 10.4103/ija.ija_1258_20] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/03/2020] [Accepted: 03/18/2021] [Indexed: 11/04/2022] Open
Abstract
Background and Aims Transmuscular Quadratus Lumborum Block (TQLB) is a novel regional anaesthesia technique, however, its analgesic efficacy as a component of multimodal analgesia (MMA) in Total Laparoscopic Hysterectomy (TLH) is not well studied. The aim of the study was to evaluate the analgesic efficacy of TQLB as a component of MMA for postoperative pain in TLH. Methods A prospective double-blind randomised controlled study was done after approval from the ethical committee and informed patient consent. After randomisation, 37 patients in Group-Q received 20 ml 0.375% ropivacaine and in Group-C, 37 patients received saline in TQLB bilaterally after TLH surgery. All patients received intravenous patient controlled analgesia (IV-PCA) with fentanyl along with diclofenac 75 mg every 12 h. All the patients were assessed at 2, 4, 6, 8, 12, 18, and 24 hours. The primary outcome was the time to first analgesic request. The secondary outcome measures were total fentanyl consumption in 24 hrs, pain scores during rest and movement, postoperative nausea-vomiting, sedation and complications related to local anaesthetic and TQLB procedure. Results The mean [standard deviation (SD)] time to first analgesic request was 7.8 (1.5) hours in Group-Q and 3.2 (1.0) hours in Group-C (P < 0.0001). The mean (SD) dose of fentanyl used in 24 hours was 167.3 (44) μg in Group-Q and 226.5 (41.9) μg in Group-C (P < 0.0001). Conclusion The ultrasound-guided TQLB provides effective postoperative analgesia after TLH surgery in a multimodal analgesia approach. It reduces the fentanyl consumption and improves the visual analogue scale (VAS) score.
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Affiliation(s)
- Ashok Jadon
- Department of Anaesthesia and Pain Relief Service, Tata Motors Hospital, Telco Colony, Jamshedpur, Jharkhand, India
| | - Asif Ahmad
- Department of Anaesthesia and Pain Relief Service, Tata Motors Hospital, Telco Colony, Jamshedpur, Jharkhand, India
| | - Rajendra K Sahoo
- Department of Anaesthesiology and Pain Management, Health World Hospitals, Durgapur, West Bengal, India
| | - Neelam Sinha
- Department of Anaesthesia and Pain Relief Service, Tata Motors Hospital, Telco Colony, Jamshedpur, Jharkhand, India
| | - Swastika Chakraborty
- Department of Anaesthesia and Pain Relief Service, Tata Motors Hospital, Telco Colony, Jamshedpur, Jharkhand, India
| | - Apoorva Bakshi
- Department of Anaesthesia and Pain Relief Service, Tata Motors Hospital, Telco Colony, Jamshedpur, Jharkhand, India
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Hirsch M, Tariq L, Duffy JM. Effect of Local Anesthetics on Postoperative Pain in Patients Undergoing Gynecologic Laparoscopy: A Systematic Review and Meta-analysis of Randomized Trials. J Minim Invasive Gynecol 2021; 28:1689-1698. [PMID: 33991671 DOI: 10.1016/j.jmig.2021.04.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 04/29/2021] [Accepted: 04/30/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Pain remains a common complication after gynecologic laparoscopy. Use of local anesthesia may be beneficial in reducing postoperative pain. We performed a systematic review and meta-analysis to assess whether local anesthetic decreases postoperative pain after laparoscopic gynecologic procedures. DATA SOURCES We searched Cumulative Index to Nursing and Allied Health Literature, Embase, and Medline from inception to November 2020 using Medical Subject Headings and free text combinations. METHODS OF TRIAL SELECTION We included randomized controlled trials of patients undergoing gynecologic laparoscopy receiving port site subcutaneous, subfascial, or intraperitoneal local anesthetic compared with placebo or no intervention. We included 20 trials (1861 participants) with size varying between 28 and 164 participants. TABULATIONS, INTEGRATION, AND RESULTS Meta-analysis was performed with RevMan 5.3 (Cochrane Collaboration, London, United Kingdom), with standard mean differences (SMDs) and random-effects model. Port site infiltration reduces postoperative pain at 4 hours (SMD -0.25; 95% confidence interval [CI], -0.44 to -0.06; 4 trials; 545 participants) and 6 hours (SMD -0.44; 95% CI, -0.82 to -0.06; 4 trials; 455 participants) after surgery. The administration of intraperitoneal local anesthetics reduces pain at 6 hours (-1.42; 95% CI, -3.22 to -0.30; 4 trials; 277 participants) after surgery. CONCLUSIONS The use of port site and intraperitoneal local anesthetic decreases immediate postoperative pain in patients undergoing gynecologic laparoscopy, although its impact on analgesia requirements is unclear. Routine usage of local anesthetics should be considered for people undergoing gynecologic laparoscopy.
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Affiliation(s)
- Martin Hirsch
- EGA Institute for Women's Health (Dr. Hirsch), University College London; Oxford University Hospitals (Dr. Hirsch), Headley way, Oxford, United Kingdom.
| | - Laiba Tariq
- University College London Medical School (Ms. Tariq)
| | - James Mn Duffy
- King's Fertility (Dr. Duffy), Fetal Medicine Research Institute
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Ni J, Jiang J, Mao S, Sun RF. Pregabalin does not decrease acute pain or postoperative nausea and vomiting after hysterectomy: a meta-analysis. J Int Med Res 2021; 48:300060520954720. [PMID: 33334230 PMCID: PMC7750779 DOI: 10.1177/0300060520954720] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Hysterectomy is associated with severe postoperative pain. The relative efficacy of pregabalin compared with other treatments for post-hysterectomy pain is unclear. METHODS We searched the PubMed, Cochrane Library, and Web of Science databases for studies that compared the use of pregabalin and placebo for reducing pain in patients undergoing hysterectomy. RESULTS This meta-analysis showed that pregabalin had limited pain-relieving effects at 2, 6, 24, and 48 hours after hysterectomy compared with placebo. Pregabalin significantly reduced postoperative nausea and vomiting. However, there was no significant difference in postoperative sedation or visual disturbances between patients treated with pregabalin and placebo. CONCLUSIONS Pregabalin is not clinically superior to placebo in terms of reducing pain intensity and morphine consumption in patients undergoing hysterectomy. However, the limitations of this meta-analysis mean that more high-quality randomized controlled trials are necessary to verify our pooled results.
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Affiliation(s)
- Jie Ni
- Department of Gynecology, Jingjiang People's Hospital, Taizhou, Jiangsu Province, China
| | - Juan Jiang
- Department of Gynecology, Jingjiang People's Hospital, Taizhou, Jiangsu Province, China
| | - Shiqin Mao
- Department of Gynecology, Jingjiang People's Hospital, Taizhou, Jiangsu Province, China
| | - Rui-Fang Sun
- Department of Gynecology, Jingjiang People's Hospital, Taizhou, Jiangsu Province, China
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Hamid HKS, Minas V. Interfascial plane blocks in laparoscopic hysterectomy: are they effective? Reg Anesth Pain Med 2021; 46:1115-1116. [PMID: 33479115 DOI: 10.1136/rapm-2020-102452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/08/2021] [Accepted: 01/12/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Hytham K S Hamid
- Department of Surgery, Soba University Hospital, Khartoum, Sudan
| | - Vasileios Minas
- Centre for Endometriosis and Minimally Invasive Gynaecology, Ashford and Saint Peter's Hospitals NHS Trust, Chertsey, Surrey, UK
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Zhu H, Chen Y, Huang S, Sun X. Interaction of Analgesic Effects of Dezocine and Sufentanil for Relief of Postoperative Pain: A Pilot Study. DRUG DESIGN DEVELOPMENT AND THERAPY 2020; 14:4717-4724. [PMID: 33177808 PMCID: PMC7650029 DOI: 10.2147/dddt.s270478] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/19/2020] [Indexed: 12/12/2022]
Abstract
Purpose The combination of dezocine and sufentanil is often used for postoperative analgesia in China and other areas, but the interaction of both two drugs is still unclear. The purpose of this study was to evaluate the interaction of the analgesic effects of dezocine and sufentanil in the patients after gynecological laparoscopic surgery. Patients and Methods We conducted a prospective, randomized, double-blinded clinical trial. A total of 150 patients were divided into 5 groups (30 in each group) in the post-anesthesia care unit, namely, dezocine group (Group D), sufentanil group (Group S) and dezocine mixed sufentanil groups (Group DS1-3). In group D and S, the initial dose of dezocine or sufentanil was 5mg and 5μg intravenously, respectively. In Group DS1, the initial dose was dezocine 5mg × 3/4 and sufentanil 5μg × 1/4. In Group DS2, the initial dose was dezocine 5mg × 1/2 and sufentanil 5μg × 1/2. In Group DS3, the initial dose was dezocine 5mg × 1/4 and sufentanil 5μg × 3/4. Results The median effective dose (ED50) of dezocine and sufentanil alone was 3.92 (95% confidence interval (CI) 3.01~4.64) mg and 3.71 (95% CI 2.78~4.39) μg, respectively. The isobolographic analysis showed that the combination of dezocine and sufentanil at 1:3, 1:1 or 3:1 appeared in the additive line. Conclusion In conclusion, when simultaneously administered intravenously, combined dezocine and sufentanil produce an additive effect for relieving the acute nociception after gynecological laparoscopic surgery.
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Affiliation(s)
- He Zhu
- Department of Anesthesiology, Tianjin Central Hospital of Gynecology and Obstetrics, Tianjin 300199, People's Republic of China
| | - Yaobing Chen
- Department of Anesthesiology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai 200093, People's Republic of China
| | - Shaoqiang Huang
- Department of Anesthesiology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai 200093, People's Republic of China
| | - Xingfeng Sun
- Department of Anesthesiology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai 200093, People's Republic of China
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Hansen C, Dam M, Nielsen MV, Tanggaard KB, Poulsen TD, Bendtsen TF, Børglum J. Transmuscular quadratus lumborum block for total laparoscopic hysterectomy: a double-blind, randomized, placebo-controlled trial. Reg Anesth Pain Med 2020; 46:25-30. [PMID: 33082286 DOI: 10.1136/rapm-2020-101931] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The population of patients scheduled for total laparoscopic hysterectomy at our surgical center is heterogeneous concerning a multitude of demographic variables such as age, collateral surgery and malign or benign pathogenesis. A common denominator is moderate to severe postoperative pain and a substantial opioid consumption. A recent procedure specific postoperative pain management (PROSPECT) review found no gain from the regional techniques included. The transmuscular quadratus lumborum (TQL) block has shown promising results in recent trials for other types of surgery. The aim of the current study was to investigate the analgesic efficacy of the ultrasound-guided TQL block for total laparoscopic hysterectomy. METHODS We enrolled 70 patients and randomly allocated participants to preoperative bilateral ultrasound-guided TQL block with either 60 mL 0.375% ropivacaine or 60 mL isotonic saline. Preoperatively, all patients received the TQL block (active or placebo) as well as a standardized multimodal analgesic regimen consisting of oral paracetamol, ibuprofen and dexamethasone. Intraoperatively, intravenous sufentanil 0.2 µg/kg was administered 30 min prior to emergence. PRIMARY OUTCOME Opioid consumption during the first 12 postoperative hours. SECONDARY OUTCOMES Pain scores, times to first opioid demand and first ambulation, nausea and vomiting, and total opioid consumption during the first 24 postoperative hours. RESULTS No significant intergroup differences were observed for any outcome. Mean (SD) oral morphine equivalent consumption the first 12 postoperative hours was 58.4 mg (48.3) vs 62.9 mg (48.5), p=0.70, for group ropivacaine versus group saline. CONCLUSION Preoperative bilateral ultrasound-guided TQL block did not reduce opioid consumption after total laparoscopic hysterectomy. TRIAL REGISTRATION NUMBERS NCT03650998, EudraCT (2017-004593-34).
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Affiliation(s)
- Christian Hansen
- Department of Anesthesiology and Intensive Care, Zealand University Hospital, Roskilde, Denmark
| | - Mette Dam
- Department of Anesthesiology and Intensive Care, Zealand University Hospital, Roskilde, Denmark
| | - Martin Vedel Nielsen
- Department of Anesthesiology and Intensive Care, Zealand University Hospital, Roskilde, Denmark
| | - Katrine B Tanggaard
- Department of Anesthesiology and Intensive Care, Zealand University Hospital, Roskilde, Denmark
| | - Troels Dirch Poulsen
- Department of Anesthesiology and Intensive Care, Zealand University Hospital, Roskilde, Denmark
| | | | - Jens Børglum
- Department of Anesthesiology and Intensive Care, Zealand University Hospital, Roskilde, Denmark .,Department of Clinical Medicine, Faculty of Health and Clinical Science, University of Copenhagen, Copenhagen, Denmark
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Procedure-specific and patient-specific pain management for ambulatory surgery with emphasis on the opioid crisis. Curr Opin Anaesthesiol 2020; 33:753-759. [PMID: 33027075 DOI: 10.1097/aco.0000000000000922] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Postoperative pain is frequent while, on the other hand, there is a grooving general concern on using effective opioid pain killers in view of the opioid crisis and significant incidence of opioid abuse. The present review aims at describing nonopioid measures in order to optimize and tailor perioperative pain management in ambulatory surgery. RECENT FINDINGS Postoperative pain should be addressed both preoperatively, intraoperatively and postoperatively. The management should basically be multimodal, nonopioid and procedure-specific. Opioids should only be used when needed on top of multimodal nonopioid prophylaxis, and then limited to a few days at maximum, unless strict control is applied. The individual patient should be screened preoperatively for any risk factors for severe postoperative pain and/or any abuse potential. SUMMARY Basic multimodal analgesia should start preoperatively or peroperatively and include paracetamol, cyclo-oxygenase (COX)-2 specific inhibitor or conventional nonsteroidal anti-inflammatory drug (NSAID) and in most cases dexamethasone and local anaesthetic wound infiltration. If any of these basic analgesics are contraindicated or there is an extra risk of severe postoperative pain, further measures may be considered: nerve-blocks or interfascial plane blocks, gabapentinnoids, clonidine, intravenous lidocaine infusion or ketamine infusion. In the abuse-prone patient, a preferably nonopioid perioperative approach should be aimed at.
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High-risk surgical procedures and semi-emergent surgical procedures for ambulatory surgery. Curr Opin Anaesthesiol 2020; 33:718-723. [PMID: 33002955 DOI: 10.1097/aco.0000000000000918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review evaluates more complex surgical procedures to see whether they might be suitable for ambulatory surgery. Operations that have shown an increasing daycase rate in England include thyroidectomy, joint arthroplasty, spinal surgery and hysterectomy, and these procedures are evaluated. Similarly, there have been recent developments in the management of nonelective ambulatory surgery with more timely throughput and home discharge for suitable patients. RECENT FINDINGS Caveats on patient selection with the development of focussed educational programmes about the proposed operation have assisted with the development of shorter discharge times. Strict antiemetic guidelines, multimodal analgesic protocols and postoperative multidisciplinary follow-up are core components of the pathway for effective ambulatory management. Communication after discharge should include phone calls from the Ambulatory Unit and easy access to the medical staff who conducted their operation. SUMMARY There should be no reason why more complex surgical operations could not be included in a day surgery armamentarium. Similarly, the evidence for more effective use of timely emergency care with shortened length of stay is increasing.
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Hortu I, Turkay U, Terzi H, Kale A, Yılmaz M, Balcı C, Aydın U, Laganà AS. Impact of bupivacaine injection to trocar sites on postoperative pain following laparoscopic hysterectomy: Results from a prospective, multicentre, double-blind randomized controlled trial. Eur J Obstet Gynecol Reprod Biol 2020; 252:317-322. [PMID: 32653604 DOI: 10.1016/j.ejogrb.2020.07.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 06/30/2020] [Accepted: 07/02/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Ismet Hortu
- Department of Obstetrics and Gynaecology, Ege University School of Medicine, Izmir, Turkey; Department of Stem Cell, Ege University Institute of Health Sciences, Izmir, Turkey.
| | - Unal Turkay
- Department of Obstetrics and Gynaecology, University of Health Sciences Derince Education and Research Hospital, Kocaeli, Turkey
| | - Hasan Terzi
- Department of Obstetrics and Gynaecology, University of Health Sciences Derince Education and Research Hospital, Kocaeli, Turkey
| | - Ahmet Kale
- Department of Obstetrics and Gynaecology, University of Health Sciences Derince Education and Research Hospital, Kocaeli, Turkey
| | - Mehmet Yılmaz
- Department of Anaesthesiology, University of Health Sciences Derince Education and Research Hospital, Kocaeli, Turkey
| | - Canan Balcı
- Department of Anaesthesiology, University of Health Sciences Derince Education and Research Hospital, Kocaeli, Turkey
| | - Umit Aydın
- Department of Obstetrics and Gynaecology, University of Health Sciences Derince Education and Research Hospital, Kocaeli, Turkey
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynaecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
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De Oliveira GS. New blocks in regional anesthesia to improve patient recovery: Evidence still needed? J Clin Anesth 2020; 63:109791. [DOI: 10.1016/j.jclinane.2020.109791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/14/2020] [Indexed: 12/26/2022]
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Ohnesorge H, Günther V, Grünewald M, Maass N, Alkatout İ. Postoperative pain management in obstetrics and gynecology. J Turk Ger Gynecol Assoc 2020; 21:287-297. [PMID: 32500680 PMCID: PMC7726464 DOI: 10.4274/jtgga.galenos.2020.2020.0024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The efficiency and quality of postoperative pain management may be considered unsatisfactory in Europe, as well as in the United States. Notwithstanding our better understanding of the physiology of pain and the development of new analgesia procedures, the improvement in satisfaction of patients has not be enhanced to the same degree. Obstetrics and gynecology are no exception to this statement. In fact, obstetrics and gynecology are surgical departments in which patients experience the greatest severity of postoperative pain. Current concepts of postoperative pain management are largely based on the administration of systemic non-opioid and opioid analgesics, supplemented with regional analgesia procedures and/or peripheral nerve blockades and, in some cases, the administration of other pain-relieving pharmaceutical agents. Based on the existing body of evidence, it would be appropriate to develop procedure-related concepts of analgesia. The concepts are based on the special circumstances of the respective department, and the scheme of analgesia is aligned to the respective interventions. Generally, however, a surgeon’s individual experience in dealing with the procedures and substances could be more significant than the theoretical advantages demonstrated in preceding investigations.
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Affiliation(s)
- Henning Ohnesorge
- Clinic of Anesthesiology and Operative Intensive Medicine, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Veronika Günther
- Clinic of Obstetrics and Gynecology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Matthias Grünewald
- Clinic of Anesthesiology and Operative Intensive Medicine, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Nicolai Maass
- Clinic of Obstetrics and Gynecology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - İbrahim Alkatout
- Clinic of Obstetrics and Gynecology, University Medical Center Schleswig-Holstein, Kiel, Germany
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Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the most recent evidence-based interventions for perioperative pain management in minimally invasive gynecologic surgery. RECENT FINDINGS With particular emphasis on preemptive interventions in recent studies, we found preoperative counseling, nutrition, exercise, psychological interventions, and a combination of acetaminophen, celecoxib, and gabapentin are highly important and effective measures to reduce postoperative pain and opioid demand. Intraoperative local anesthetics may help at incision sites, as a paracervical block, and a transversus abdominus plane block. Postoperatively, an effort should be made to utilize non-narcotic interventions such as abdominal binders, ice packs, simethicone, bowel regimens, gabapentin, and scheduled NSAIDs and acetaminophen. When prescribing narcotics, providers should be aware of recommended amounts of opioids required per procedure so as to avoid overprescribing. SUMMARY Our findings emphasize the evolving importance of preemptive interventions, including prehabilitation and pharmacologic agents, to improve postoperative pain after minimally invasive gynecologic surgery. Additionally, a multimodal approach to nonnarcotic intraoperative and postoperative interventions decreases narcotic requirement and improves opioid stewardship.
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Zakalska K, Babiichuk O. Paracetamol as a basic component of a modern approach to adequate perioperative analgesia. PAIN MEDICINE 2020. [DOI: 10.31636/pmjua.v5i1.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The problem of adequate perioperative anesthesia is one of the most pressing in the current health care system, given its medical, humanistic and socio-economic aspects. Currently, the standard of postoperative analgesia is multimodal analgesia (MMA). One of the major and required components of MMA is paracetamol, which has antipyretic and analgesic effects with limited peripheral anti-inflammatory activity. Most authors consider intravenous paracetamol as a base drug in a multimodal analgesia strategy for a variety of surgical interventions, which reduces the need for opioids and reduces the side effects of the latter, which in turn significantly affects the results of treatment and the length of hospital stay.Numerous studies in many countries have created a broad evidence base for the clinical use of this drug. Due to its pharmacokinetic and pharmacodynamic properties, it has been shown that intravenous paracetamol has several advantages over oral and rectal forms: early and more effective onset of analgesia and stable maintenance of the therapeutic dose of paracetamol are explained by the formation of a faster and higher peak in the concentration of the drug. The side effects of using paracetamol can be compared with placebo. The mechanism of action of the drug is different from the mechanism of action of NSAIDs, however, is still not fully understood. It may possibly involve inhibition of cyclooxygenase, cannabinoid, or nitric oxide pathways in the central nervous system. Intravenous paracetamol is a safe and effective first-line drug for the treatment of moderate pain in the perioperative period.
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Zdravkovic M, Kamenik M. A prospective randomized controlled study of combined spinal-general anesthesia vs. general anesthesia for laparoscopic gynecological surgery: Opioid sparing properties. J Clin Anesth 2020; 64:109808. [PMID: 32305787 DOI: 10.1016/j.jclinane.2020.109808] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 02/20/2020] [Accepted: 04/04/2020] [Indexed: 12/11/2022]
Abstract
STUDY OBJECTIVE We aimed to determine the magnitude of peri-operative opioid sparing effect when general anesthesia is combined with spinal analgesia for laparoscopic gynecological surgery. DESIGN A prospective randomized controlled study; a three-group trial with two comparisons (each intervention group to control). SETTING Operating room and postoperative recovery area. PATIENTS Patients aged between 18 and 65 years with American Society of Anesthesiologists physical status 1 or 2 who were scheduled for inpatient elective laparoscopic gynecological surgery with expected pneumoperitoneum duration of at least 20 min. Of 102 randomized patients, 99 completed the study. INTERVENTIONS Patients were randomized to general anesthesia alone (control group) or combined with very-low-dose (levobupivacaine 3.75 mg; sufentanil 2.5 μg) or low-dose (levobupivacaine 7.5 mg; sufentanil 2.5 μg) spinal analgesia. MEASUREMENTS Primary endpoints were perioperative opioid consumption and pain scores (11-point numeric rating scale) at 30 min, 1 h, 2 h, 4 h and 24 h post-surgery. Secondary endpoints were patient satisfaction with anesthetic care and participation in research, sevoflurane consumption and adverse effects. MAIN RESULTS Intra-operative sufentanil (median [95% CI]) consumption was 16.1 (10.5-22.6) μg/h in the control group versus 4.7 (3.2-9.2) μg/h in the very-low-dose and versus 2.9 (0.0-4.0) μg/h in the low-dose spinal analgesia groups (p < 0.001, for both comparisons). Median (95% CI) piritramide consumption at 24 h post-surgery was 7.5 (3-8) mg in the control group versus 5 (0-7.5) mg in the very-low dose spinal analgesia group (p = 0.182) and versus 2 (0-2.5) mg in the low-dose spinal analgesia group (p = 0.001). Postoperative pain scores were consistently <3 only in the low dose spinal analgesia group. Patient satisfaction with anesthetic care and participation in research was very high in all groups. CONCLUSIONS Low-dose spinal analgesia in combination with general anesthesia reduces peri-operative opioid consumption in laparoscopic gynecological surgery in immediate postoperative period.
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Affiliation(s)
- Marko Zdravkovic
- Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Ljubljanska ulica 5, 2000 Maribor, Slovenia; Faculty of Medicine, University of Maribor, Taborska ulica 8, 2000 Maribor, Slovenia.
| | - Mirt Kamenik
- Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Ljubljanska ulica 5, 2000 Maribor, Slovenia; Faculty of Medicine, University of Maribor, Taborska ulica 8, 2000 Maribor, Slovenia
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Therapeutic Approaches for Peripheral and Central Neuropathic Pain. Behav Neurol 2019; 2019:8685954. [PMID: 31871494 PMCID: PMC6906810 DOI: 10.1155/2019/8685954] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 09/20/2019] [Accepted: 10/30/2019] [Indexed: 12/11/2022] Open
Abstract
Neuropathic pain is a chronic secondary pain condition, which is a consequence of peripheral or central nervous (somatosensory) system lesions or diseases. It is a devastating condition, which affects around 7% of the general population. Numerous etiological factors contribute to the development of chronic neuropathic pain. It can originate from the peripheral part of the nervous system such as in the case of trigeminal or postherpetic neuralgia, peripheral nerve injury, painful polyneuropathies, or radiculopathies. Central chronic neuropathic pain can develop as a result of spinal cord or brain injury, stroke, or multiple sclerosis. As first-line pharmacological treatment options, tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and gabapentinoids are recommended. In trigeminal neuralgia, carbamazepine and oxcarbazepine are the first-choice drugs. In drug-refractory cases, interventional, physical, and psychological therapies are available. This review was structured based on a PubMed search of papers published in the field from 2010 until May 2019.
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