Lower Background Infusion of Oxycodone for Patient-Controlled Intravenous Analgesia, Combined with Ropivacaine Intercostal Nerve Block, in Patients Undergoing Thoracoscopic Lobectomy for Lung Cancer: A Randomized, Double-Blind, Controlled Clinical Trial

Deep learning models for the prediction of acute postoperative pain in PACU for video-assisted thoracoscopic surgery

BACKGROUND

Postoperative pain is a prevalent symptom experienced by patients undergoing surgical procedures. This study aims to develop deep learning algorithms for predicting acute postoperative pain using both essential patient details and real-time vital sign data during surgery.

METHODS

Through a retrospective observational approach, we utilized Graph Attention Networks (GAT) and graph Transformer Networks (GTN) deep learning algorithms to construct the DoseFormer model while incorporating an attention mechanism. This model employed patient information and intraoperative vital signs obtained during Video-assisted thoracoscopic surgery (VATS) surgery to anticipate postoperative pain. By categorizing the static and dynamic data, the DoseFormer model performed binary classification to predict the likelihood of postoperative acute pain.

RESULTS

A total of 1758 patients were initially included, with 1552 patients after data cleaning. These patients were then divided into training set (n = 931) and testing set (n = 621). In the testing set, the DoseFormer model exhibited significantly higher AUROC (0.98) compared to classical machine learning algorithms. Furthermore, the DoseFormer model displayed a significantly higher F1 value (0.85) in comparison to other classical machine learning algorithms. Notably, the attending anesthesiologists' F1 values (attending: 0.49, fellow: 0.43, Resident: 0.16) were significantly lower than those of the DoseFormer model in predicting acute postoperative pain.

CONCLUSIONS

Deep learning model can predict postoperative acute pain events based on patients' basic information and intraoperative vital signs.

Optimizing patient-controlled analgesia: a narrative review based on a single center audit process

Intravenous patient-controlled analgesia (PCA) is valuable for delivering opioids in a flexible and timely manner. Although it is designed to offer personalized analgesia driven by the patients themselves, users often report insufficient pain relief, which can be addressed by optimizing its settings and multimodal analgesia. We adopted a systematic approach to modify PCA protocols by utilizing a serial audit process based on institutional PCA data. This review retrospectively examined the process, encompassing data from 13,230 patients who had used PCA devices. The two modifications to the fentanyl-based PCA protocols resulted in three distinct phases. In the first phase, high opioid consumption and unintended PCA withdrawal were the common issues. These were addressed in the second phase by omitting the routine use of basal infusion. However, this led to increased delivery-to-demand ratios, mitigated in the third phase by increasing the bolus dose from 15 μg to 20 μg. These serial protocol changes have produced varied outcomes across different surgical departments, underscoring the need for careful and gradual adjustments and thorough impact assessments. Drawing insights from this audit process, we incorporated findings from the literature on PCA settings and multimodal analgesic approaches. This review underscores the significance of iterative feedback and refinement of analgesic protocols to achieve optimal postoperative pain management. Additionally, it discusses critical considerations regarding the postoperative audit processes.

Programmed Intermittent Bolus for Erector Spinae Plane Block Versus Intercostal Nerve Block With Patient-controlled Intravenous Analgesia in Video-assisted Thoracoscopic Surgery: A Randomized Controlled Noninferiority Trial

OBJECTIVE

Postoperative analgesia is crucial after video-assisted thoracoscopic surgery (VATS). This study was designed to investigate whether the analgesic effect of programmed intermittent bolus (PIB) erector spinae plane block (ESPB) is noninferior to that of intercostal nerve block with patient-controlled intravenous analgesia (ICNB-PCIA) for VATS.

METHODS

The study was a single-center, open labeled, randomized noninferiority trial. A total of 80 patients (American Society of Anesthesiologists I to III) undergoing elective video-assisted thoracoscopic lobectomy or bulla resection were randomly allocated to the ICNB-PCIA (n=40) or the ESPB (n=40) group using a PIB injection. The primary outcome was pain intensity at movement at 4 hours postoperatively using the Numeric Rating Scale (NRS). Secondary outcomes included pain scores at rest and movement in the recovery room, at 8, 24, and 48 hours postoperatively, perioperative analgesics, adverse effects, hospital stay, and patient satisfaction.

RESULTS

The mean difference in NRS scores at movement at 4 hours postoperatively between the ESPB (n=39) and the ICNB-PCIA (n=37) groups was under the noninferiority margin. NRS scores were significantly higher in the ICNB-PCIA group than the ESPB group at movement postoperatively. At rest, NRS scores were significantly elevated in the ICNB-PCIA at 4, 8, and 24 hours. The postoperative opioids consumption was decreased in the ESPB group. No difference was found in rescue analgesics, hospital stay, and patient satisfaction.

DISCUSSION

ESPB using a PIB injection offers noninferior analgesia to ICNB-PCIA after VATS.

Prevalence and risk factors of emergence agitation among pediatric patients undergo ophthalmic and ENT Surgery: a cross-sectional study

BACKGROUND

Some studies reported that pediatric patients undergoing otorhinolaryngology (ENT) and ophthalmic surgeries have higher incidences of emergence agitation (EA). Children with EA tend to carry the risk of self-harm, have longer periods of recovery and delayed hospital discharge. Consequently, EA needs to be monitored and risk factors ought to be emphasized to implement preventative measures. The objective of this study was to describe EA and to identify risk factors after pediatric ophthalmic or ENT surgery.

METHODS

Between September 2021 and December 2021, a cross-sectional study was conducted in 100 children aged of 0-12 years who underwent ophthalmic or ENT surgery. The Watcha scale was used to observe and record EA, which was defined at levels of 3 or 4 at any time in the post-anesthesia care unit (PACU). The pain intensity was graded with the Face, Legs, Activity, Cry, Consolability (FLACC) Scale after surgery. Patient and surgery-related characteristics, the behavioral criteria of EA, the pharmacologic and non-pharmacologic interventions and recovery outcomes were objectively recorded. A binary logistic regression model was constructed to identify the associated factors of EA.

RESULTS

From the 100 analyzed children, 58 were males and 42 were females, and 44 patients received ophthalmic surgery and 56 ENT surgery. The median age was 6 (IQR 4-7) years. The overall incidence of EA among pediatrics was 30% (34.5% for ENT and 24.4% for ophthalmic surgery). High preoperative modified Yale Preoperative Anxiety scale (m-YPAS) grade (OR = 1.19, 95%CI 1.06-1.33, P = 0.003) and high postoperative FLACC score (OR = 3.36, 95%CI 1.88-6.02, P < 0.001) were risk factors for EA.

CONCLUSIONS

This study identified that preoperative anxiety and postoperative pain are associated with EA in children after ophthalmic or ENT surgery. Preoperative anxiety assessment and management, and administration of adjunct analgesic treatments should be considered in the routine care.

Effect of oxycodone combined with ultrasound-guided thoracic paravertebral nerve block on postoperative analgesia in patients with lung cancer undergoing thoracoscopic surgery: protocol for a randomised controlled study

INTRODUCTION

Postoperative pain is a main component influencing the recovery of patients with lung cancer. The combination of patient-controlled intravenous analgesia (PCIA) and paravertebral nerve block for postoperative analgesia in patients undergoing thoracoscopic lobectomy for lung cancer can achieve a satisfactory analgesic effect and promote early rehabilitation of patients. The objective is to investigate the optimal dose of oxycodone for PCIA combined with paravertebral nerve block, to achieve effective multimodal analgesia management in patients undergoing thoracoscopic lung cancer lobectomy.

METHODS AND ANALYSIS

This prospective, double-blind, single-centre, parallel-group, superiority study from 7 April 2023 to 31 December 2024 will include 160 participants scheduled for thoracoscopic lobectomy for lung cancer. Participants will be randomly assigned to four groups in a 1:1:1:1 ratio: OCA group (oxycodone: 0.5 mg/kg), OCB group (oxycodone: 1.0 mg/kg), OCC group (oxycodone: 1.5 mg/kg) and one sufentanil group (sufentanil: 2 µg/kg). Flurbiprofen 50 mg and ondansetron 16 mg are added to each group. All the drugs are diluted with 0.9% saline in a 100 mL volume, with a background infusion rate of 2 mL/hour, a bolus dose of 0.5 mL and a lockout interval of 15 min. The primary outcome is pain scores at rest and dynamic at 24 hours after surgery using a Numeric Rating Scale (NRS). Dynamic NRS scores are defined as NRS when coughing. NRS scores will be assessed at 2, 4, 12, 24 and 48 hours postoperatively. The secondary outcomes include the following variables: (1) NRS score at rest and dynamic at 2, 4, 12 and 48 hours postoperatively; (2) total dose of sufentanil or oxycodone consumption in PCIA; (3) the times of patient-controlled analgesia; (4) Ramsay Sedation Score (RSS) at 2, 4, 12, 24 and 48 hours after the surgery; (5) extubation time; (6) serum C-reactive protein and interleukin six levels; (7) incidence of postoperative nausea and vomiting; (8) incidence of itching; (9) incidence of respiratory depression and (10) gastrointestinal recovery (exhaust time).

ETHICS AND DISSEMINATION

The First Affiliated Hospital of Shandong First Medical University's Ethics Committee granted consent for this study (approval number: YXLL-KY-2022(116)). To enable widespread use of the data gathered, we plan to publish the trial's findings in an appropriate scientific journal after it is complete.

TRIAL REGISTRATION NUMBER

NCT05742256.

Endogenous opiates and behavior: 2021

This paper is the forty-fourth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2021 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonizts and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Effect of intercostal nerve block combined with oxycodone on the postoperative cognitive ability in elderly patients undergoing radical resection of lung cancer

OBJECTIVE

To explore the effect of intercostal nerve block (INB) combined with oxycodone on the postoperative cognitive ability in elderly patients undergoing radical resection of lung cancer (LC).

METHODS

A total of 135 elderly patients who underwent radical LC operations in our hospital from April 2019 to July 2021 were enrolled for retrospective analysis. There are 71 patients, who received INB with 0.5% ropivacaine 20 mL and oxycodone 5 mg (intravenous injection) before chest closure, were assigned to the observation group (OG), while 64 patients, who received a single oxycodone injection (5 mg) into the anterior thoracic vein, were assigned as the control group (CG). The cognitive function of patients was assessed by a mini mental state examination (MMSE) before and 24 h after operation. Also, the visual analogue scale (VAS), sedation score (Ramsay) and the occurrence of adverse reactions within 48 h after surgery were compared. Additionally, the changes of heart rate (HR), blood oxygen saturation (SpO₂) and central venous pressure (CAP) at 4 h, 8 h, 12 h and 24 h after operation were observed, and the pressure times of analgesia pump within 24 h and the satisfaction rates of postoperative analgesia were compared between the two groups.

RESULTS

After operation, compared with the CG, the MMSE in the OG was dramatically higher (P<0.05), while the incidence of adverse reactions (P<0.05) and the VAS score (P<0.05) in the OG were significantly lower. There was no remarkable difference in postoperative HR, SpO₂ and MAP between the two groups (P>0.05). The number of postoperative analgesia pump pressing in the OG was lower than that in the CG (P<0.05), and the satisfaction rate of postoperative analgesia in the OG was higher (P<0.05).

CONCLUSION

INB combined with oxycodone has a better application effect in senile LC radical operation. It can improve the postoperative cognitive function and reduce postoperative adverse reactions and pain with high safety.

Patient-controlled intravenous analgesia with opioids after thoracoscopic lung surgery: a randomized clinical trial

Background

Opioids remain the mainstream therapy for post-surgical pain. The choice of opioids administered by patient-controlled intravenous analgesia (PCIA) for thoracoscopic lung surgery is unclear. This study compared 3 opioid analgesics for achieving satisfactory analgesia with minimal emesis (SAME).

Methods

This randomized clinical trial enrolled patients scheduled for thoracoscopic lung surgery randomized to receive 1 of 3 opioids for PCIA: oxycodone (group O), hydromorphone (group H), and sufentanil (group S). The primary outcome was the proportion of subjects achieving SAME, i.e., no-to-mild pain (pain score < 4/10) with minimal nausea/vomiting (PONV score < 2/4) when coughing during the pulmonary rehabilitation exercise in the first 3 postoperative days.

Results

Of 555 enrolled patients, 184 patients in group O, 186 in group H and 184 in group S were included in the final analysis. The primary outcome of SAME was significantly different among group O, H and S (41.3% vs 40.3% vs 29.9%, P = 0.043), but no difference was observed between pairwise group comparisons. Patients in groups O and H had lower pain scores when coughing on the second day after surgery than those in group S, both with mean differences of 1 (3(3,4) and 3(3,4) vs 4(3,4), P = 0.009 and 0.039, respectively). The PONV scores were comparable between three groups (P > 0.05). There were no differences in other opioid-related side effects, patient satisfaction score, and QoR-15 score among three groups.

Conclusions

Given clinically relevant benefits detected, PCIA with oxycodone or hydromorphone is superior to sufentanil for achieving SAME as a supplement to multimodal analgesia in patients undergoing thoracoscopic lung surgery.

Trial registration

This study was registered at (ChiCTR2100045614, 19/04/2021).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01785-4.