Analgesic effect of preoperative versus intraoperative dexamethasone after laparoscopic cholecystectomy with multimodal analgesia

Pain management after laparoscopic cholecystectomy: A systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations

Laparoscopic cholecystectomy can be associated with significant postoperative pain that is difficult to treat. We aimed to evaluate the available literature and develop updated recommendations for optimal pain management after laparoscopic cholecystectomy. A systematic review was performed using the procedure-specific postoperative pain management (PROSPECT) methodology. Randomised controlled trials and systematic reviews published in the English language from August 2017 to December 2022 assessing postoperative pain after laparoscopic cholecystectomy using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases. From 589 full text articles, 157 randomised controlled trials and 31 systematic reviews met the inclusion criteria. Paracetamol combined with NSAIDs or cyclo-oxygenase-2 inhibitors should be given either pre-operatively or intra-operatively, unless contraindicated. In addition, intra-operative intravenous (i.v.) dexamethasone, port-site wound infiltration or intraperitoneal local anaesthetic instillation are recommended, with opioids used for rescue analgesia. As a second-line regional technique, the erector spinae plane block or transversus abdominis plane block may be reserved for patients with a heightened risk of postoperative pain. Three-port laparoscopy, a low-pressure pneumoperitoneum, umbilical port extraction, active aspiration of the pneumoperitoneum and saline irrigation are recommended technical aspects of the operative procedure. The following interventions are not recommended due to limited or no evidence on improved pain scores: single port or mini-port techniques, routine drainage, low flow insufflation, natural orifice transluminal endoscopic surgery (NOTES), infra-umbilical incision, i.v. clonidine, nefopam and regional techniques such as quadratus lumborum block or rectus sheath block. Several interventions provided better pain scores but are not recommended due to risk of side effects: spinal or epidural anaesthesia, gabapentinoids, i.v. lidocaine, i.v. ketamine and i.v. dexmedetomidine.

Higher Cardiovagal Baroreflex Sensitivity Predicts Increased Pain Outcomes After Cardiothoracic Surgery

Excessive postoperative pain can lead to extended hospitalization and increased expenses, but factors that predict its severity are still unclear. Baroreceptor function could influence postoperative pain by modulating nociceptive processing and vagal-mediated anti-inflammatory reflexes. To investigate this relationship, we conducted a study with 55 patients undergoing minimally invasive cardiothoracic surgery to evaluate whether cardiovagal baroreflex sensitivity (BRS) can predict postoperative pain. We assessed the spontaneous cardiovagal BRS under resting pain-free conditions before surgery. We estimated postoperative pain outcomes with the Pain, Enjoyment, and General Activity scale and pressure pain thresholds on the first (POD1) and second (POD2) postoperative days and persistent pain 3 and 6 months after hospital discharge. We also measured circulating levels of relevant inflammatory biomarkers (C-reactive protein, albumin, cytokines) at baseline, POD1, and POD2 to assess the contribution of inflammation to the relationship between BRS and postoperative pain. Our mixed-effects model analysis showed a significant main effect of preoperative BRS on postoperative pain (P = .013). Linear regression analysis revealed a significant positive association between preoperative BRS and postoperative pain on POD2, even after adjusting for demographic, surgical, analgesic treatment, and psychological factors. Moreover, preoperative BRS was linked to pain interfering with general activity and enjoyment but not with other pain parameters (pain intensity and pressure pain thresholds). Preoperative BRS had modest associations with postoperative C-reactive protein and IL-10 levels, but they did not mediate its relationship with postoperative pain. These findings indicate that preoperative BRS can independently predict postoperative pain, which could serve as a modifiable criterion for optimizing postoperative pain management. PERSPECTIVE: This article shows that preoperative BRS predicts postoperative pain outcomes independently of the inflammatory response and pain sensitivity to noxious pressure stimulation. These results provide valuable insights into the role of baroreceptors in pain and suggest a helpful tool for improving postoperative pain management.

The Effect of Dexamethasone on Postoperative Pain in Patients After Laparoscopic Cholecystectomy

Objectives The objective of the study was to determine the effect of a single dose of IV dexamethasone on postoperative pain in patients after laparoscopic cholecystectomy. The outcome will be measured in the terms of mean pain score. Study design and setting This is a prospective study. We did a randomized control trial to compare the outcome in two groups. This study was conducted in the Department of Surgery, Benazir Bhutto Hospital, Rawalpindi, from December 2021 to May 2022. The total duration of the study was six months. Methodology A total of 160 patients were randomly divided into group A and group B. We performed laparoscopic cholecystectomies on all the patients under standard general anesthesia. In group A (control group), 5 mL of normal saline was injected intravenously at the time of induction of anesthesia. In group B, the dexamethasone group, the inj. dexamethasone with a dose of 0.1 mg/kg diluted in 5 mL normal saline was given intravenously at the time of induction of anesthesia. Postoperatively, the median pain score was measured using visual analog scale (VAS) at 2, 6, 12, and 24 h on a specially made proforma. The results were further stratified according to gender and age. Results The postoperative VAS in group B was significantly low compared with group A when measured at 2, 6, 12, and 24 h. It means that the median pain score was markedly less in the study group than in the placebo one, and it was statistically significant (p<0.05). Conclusion Administration of a single dose of dexamethasone preoperatively in laparoscopic cholecystectomy patients is effective to control postoperative pain.

Evaluation of post laparoscopic cholecystectomy pain after subcutaneous injection of lidocaine at port site versus lidocaine spray on gallbladder bed after cholecystectomy: a randomized controlled trial

PURPOSE

The efficacy of intraperitoneal (IP) and incisional use of local anesthesia in laparoscopic cholecystectomy is a promising subject regarding post-operative pain control. In this study, we aim to compare these methods using lidocaine as the local anesthetic.

METHODS

This study was a double-blinded randomized controlled trial. Eighty-two patients, candidates for laparoscopic cholecystectomy, were included. Participants were randomly divided into two equal groups; the instillation group and the infiltration group. In the instillation group, a 2% lidocaine ampule was instilled in the gallbladder bed after removal of the gallbladder. In the infiltration group, a 2% lidocaine ampule was injected subcutaneously into the port sites before making the incisions for the insertion of laparoscopic ports.

RESULTS

The mean age of patients were 41.66 ± 14.44 and 48.05 ± 17.03 years in the instillation and infiltration groups, respectively. The etiologies recorded in this study were: acute calculous cholecystitis (29.3%), symptomatic gallstone (68.3%), and polyp (2.4). The pain severity, evaluated at six different times, from immediately after awakening from anesthesia to 24 h after the operation, was not significantly different between the two groups (p-value = 0.329). Consumption of nonsteroidal anti-inflammatory drugs and narcotics, were statistically lower in the instillation group (p-value = 0.013 and 0.003, respectively). However, hospitalization period, time spent to return to normal bowel movements and oral diet, and postoperative nausea/vomiting were not significantly significant between the groups.

CONCLUSION

IP instillation of lidocaine following laparoscopic cholecystectomy offers post-operative pain relief and is associated with lower analgesic consumption in comparison to subcutaneous injection of this agent at the port site.

What is the impact of dexamethasone on postoperative pain in adults undergoing general anaesthesia for elective abdominal surgery: a systematic review and meta-analysis

BACKGROUND

Previous meta-analysis of heterogeneous surgical cohorts demonstrated reduction in postoperative pain with perioperative intravenous dexamethasone, but none have addressed adults undergoing elective abdominal surgery. The aim of this study was to determine the impact of intravenous perioperative dexamethasone on postoperative pain in adults undergoing elective abdominal surgery under general anaesthesia.

METHODS

This review was prospectively registered on the international prospective register of systematic reviews (CRD42020176202). Electronic databases Medical Analysis and Retrieval System Online (MEDLINE), Exerpta Medica Database (EMBASE), (CINAHL) Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and trial registries were searched to January 28 2021 for randomised controlled trials, comparing dexamethasone to placebo or alternative antiemetic, that reported pain. The primary outcome was pain score, and secondary outcomes were time to first analgesia, opioid requirements and time to post-anaesthesia care unit (PACU) discharge.

RESULTS

Fifty-two studies (5768 participants) were included in the meta-analysis. Pain scores ≤ 4 hour (h) were reduced in patients who received dexamethasone at rest (mean difference (MD), - 0.54, 95% confidence interval (CI) - 0.72 to - 0.35, I2 = 81%) and on movement (MD - 0.42, 95% CI - 0.62 to - 0.22, I2 = 35). In the dexamethasone group, 4-24 h pain scores were less at rest (MD - 0.31, 95% CI - 0.47 to - 0.14, I2 = 96) and on movement (MD - 0.26, 95% CI - 0.39 to - 0.13, I2 = 29) and pain scores ≥ 24 h were reduced at rest (MD - 0.38, 95% CI - 0.52 to - 0.24, I2 = 88) and on movement (MD - 0.38, 95% CI - 0.65 to - 0.11, I2 = 71). Time to first analgesia (minutes) was increased (MD 22.92, 95% CI 11.09 to 34.75, I2 = 98), opioid requirements (mg oral morphine) decreased (MD - 6.66, 95% CI - 9.38 to - 3.93, I2 = 88) and no difference in time to PACU discharge (MD - 3.82, 95% CI - 10.87 to 3.23, I2 = 59%).

CONCLUSIONS

Patients receiving dexamethasone had reduced pain scores, postoperative opioid requirements and longer time to first analgesia. Dexamethasone is an effective analgesic adjunct for patients undergoing abdominal surgery.

Preoperative Administration of Extended-Release Dinalbuphine Sebacate Compares with Morphine for Post-Laparoscopic Cholecystectomy Pain Management: A Randomized Study

Purpose

Perioperative pain management plays a critical role in the effort to promote enhanced recovery after surgery (ERAS). Pain is also the most concern for patients after laparoscopic cholecystectomy (LC). Naldebain (extended-release dinalbuphine sebacate, DS) is an oil-based formulation for intramuscular injection that has been designed for extended release and can be used for preoperative analgesia over a 7-day period. This study was aimed to compare the efficacy of DS injection with that of regular postoperative morphine administered when necessary for the management of post-laparoscopic cholecystectomy pain.

Patients and Methods

Forty-four patients scheduled for elective laparoscopic cholecystectomy were included in this prospective study. The patients were allocated randomly into two groups, with equal numbers receiving preoperative DS versus post-operative morphine. A total of 21 and 22 patients completed the study within the preoperative DS and post-operative morphine group, respectively.

Results

There were no statistically significant differences between two treatment groups with respect to length of surgery, anesthetics used during operation, or the average visual analog scale pain score in the post-operative anesthesia care unit (PACU), and at 4, 24, 48, and 72 hours post-procedure. Morphine was required only during the first postoperative day among those in the DS group. Safety was comparable in both DS and morphine groups.

Conclusion

A single preoperative dose of DS provides sufficient analgesia along with a manageable safety profile and no interference with surgical anesthetics when compared to control cases that underwent surgery without preoperative DS treatment. This pilot study suggests that preoperative administration of DS is safe and may decrease the need for postoperative opioid use after laparoscopic cholecystectomy.

Registration

ClinicalTrials.gov Identifier: NCT03713216.

Evaluation of postoperative analgesic efficacy and perioperative hemodynamic changes with low dose intravenous dexmedetomidine infusion in patients undergoing laparoscopic cholecystectomy - A randomised, double-blinded, placebo-controlled trial

Background and Aim:

Dexmedetomidine is a α2-agonist with sedative, sympatholytic and analgesic properties and hence, it can be a very useful adjuvant in anesthesia as stress response buster, sedative and analgesic. We aimed to evaluate the effects of low dose dexmedetomidine infusion (0.5 mcg/kg/h) on postoperative analgesic efficacy along with the perioperative hemodynamic changes in patients undergoing laparoscopic cholecystectomy.

Material and Methods:

Eighty patients of American Society of Anesthesiologists (ASA) physical grades I and II undergoing laparoscopic cholecystectomy were randomly allocated into two groups of 40 patients each. Group I (Normal Saline group) patients received normal saline and group II (Dexmedetomidine group) patients received dexmedetomidine infusion at 0.5 mcg/kg/h respectively, starting 15 min before induction and continued till the end of surgery. Parameters noted were heart rate, mean arterial pressure, oxygen saturation, post-operative pain was evaluated using VAS and analgesic requirement. Statistical tests such as ANOVA test for continuous variables, post-hoc test for intergroup comparison, and Chi-square test for discrete values were applied.

Results:

Post-operative efficacy was found to be limited in the dexmedetomidine group in terms of VAS score. The analgesic requirement in 24-hour was observed to be reduced in dexmedetomidine group when compared to the NS group; however, not statistically significant. In group NS, significant hemodynamic stress response was seen following laryngoscopy, tracheal intubation, creation of pneumoperitoneum and extubation. On intergroup comparison, the hemodynamic response was significantly attenuated in the dexmedetomidine group when compared to the NS group. No significant side effects were noted.

Conclusion:

Dexmedetomidine IV in an infusion dose of 0.5 μg/kg/hr is effective in providing postoperative analgesia in terms of significant reduction in analgesic consumption in 24 hours and in addition to the effective obtundation of the pneumoperitoneum-induced hemodynamic changes.

A meta-analysis of dexamethasone for pain management in patients with total knee arthroplasty

BACKGROUND

Pain management after a total-knee arthroplasty (TKA) has become an important issue in the field of medicine. This study conducted a meta-analysis from randomized controlled trials (RCTs) to assess the efficacy and safety of dexamethasone for pain management after TKA.

METHODS

PubMed, Medline, Embase, ScienceDirect, and the Cochrane Library were searched up to December 2017 for comparative RCTs involving dexamethasone and placebo for pain control after TKA. Primary outcomes were postoperative pain scores and opioid consumption. Secondary outcomes were length of hospital stay, adverse effects, and postoperative complications. We assessed statistical heterogeneity for each RCT with the use of a standard Chi-squared test and the I statistic. All data were carried out with Stata 14.0 software.

RESULTS

A total of 6 RCTs were included. The present meta-analysis indicated that there were significant differences between dexamethasone-treated groups and placebo groups regarding postoperative pain scores at 12, 24, and 48 hours after TKA. Administering dexamethasone could significantly reduce opioid consumption at 12 hours after TKA. However, no significant difference was found in opioid consumption at 24 and 48 hours after TKA. There was a decreased risk of adverse effects in dexamethasone groups.

CONCLUSION

Use of dexamethasone could result in a significant reduction in postoperative pain while minimizing adverse effects after TKA. Based on the current evidence available, more RCTs are needed for further investigation.

Hydrocortisone relieves the immediate post-operative scrotal edema after inguinal varicocelectomy: A prospective clinical trial

This study aimed to assess the effect of a single IM injection of hydrocortisone succinate in relieving the immediate post-varicocelectomy scrotal edema. In all, 117 patients with grades II and III varicocele who developed post-varicocelectomy scrotal edema were randomly classified into group A (n = 59) that received a single IM hydrocortisone sodium succinate injection plus ordinary post-operative treatment and Group B (n = 58), which received the post-operative treatment alone. All patients were followed up to assess; changes in scrotal edema, the day of return to work and emergence of complications. Post-operative scrotal edema was assessed using a scrotal edema rating grades (SERG = 0–3) score. In group A, scrotal edema disappeared 1 day after steroid injection in 33 patients (55.9%), and after 2 days in the remaining 26 patients (44.1%), and all patients were returned to work within 5–7 days. In group B, the edema remained large in 36 patients (62.1%), moderate in 22 patients (37.9%), and disappeared after 9–12 days; and those patients returned to work within 11–13 days. It is concluded that a single IM hydrocortisone injection could be effective to reduce the immediate post-operative scrotal edema after inguinal varicocelectomy without obvious side effects.

Cost Effectiveness of a Fast-Track Protocol for Urgent Laparoscopic Cholecystectomies and Appendectomies

BACKGROUND

Fast-track protocols (FTPs) are used to decrease length of stay (LOS) and hospital costs for elective outpatient procedures. Few institutions have implemented FTP for urgent procedures such as laparoscopic cholecystectomy (LC) and laparoscopic appendectomy (LA).

STUDY DESIGN

This is a retrospective single-institution cohort study including all patients undergoing urgent LC or LA between July 1, 2010 and May 1, 2013. Exclusion criteria included conversion to open procedure, perforated appendicitis, or procedure related to intra-abdominal injury. Analysis included a comparison of the three study groups: (1) before (PRE) and after (POST) implementation of the fast-track protocol (FTP), (2) fast-track cohort (FT) and non-fast-track cohort (NFT), and (3) those completing the fast-track pathway (FT-C) and those who began but failed to complete the pathway (FT-F).

RESULTS

There were significant reductions in LOS between all study groups compared: between PRE (n = 256) and POST (n = 472) cohorts by half a day (2.0 vs. 1.5 days, p < 0.02); between FT and NFT (0.68 vs. 1.82 days, p < 0.01); and FT-C and FT-F (0.49 vs. 1.05 days, p < 0.01). Total hospital charges were significantly reduced in FT compared with NFT ($22,347 vs. $30,868, p < 0.01) with an average savings of $8521. Total hospital charges were decreased in the FT-C compared with FT-F cohorts ($21,971 vs. $22,939, p = 0.3) with an average savings of $968. Readmissions, complications, and satisfaction were similar for all comparison groups.

CONCLUSIONS

FTPs for urgent appendectomies and cholecystectomies can significantly reduce hospital costs by reducing LOS without compromising patient outcomes.

The effect of single-dose administration of dexamethasone on postoperative pain in patients undergoing laparoscopic cholecystectomy

Background:

Postoperative pain is considered as a reason of patient’s delay in discharge and disability aggravation. Therefore, multimodal approaches have been suggested in order to mitigate pain and decrease postoperative side effects.

Objectives:

The aim of this study was to evaluate analgesic effect of a single dose injection of dexamethasone on reducing postoperative pain in laparoscopic cholecystectomy.

Patients and Methods:

In this double-blind, prospective study, 122 patients aged 18-60 years old, whom were selected for laparoscopic cholecystectomy, were classified into two case and control groups, and 61 patients were included in each group. The case (D) group underwent general anesthesia and a single- dose intravenous injection of dexamethasone. The Control (C) group received general anesthesia and intravenous injection of normal saline. Total dose of consumed meperidine and pain intensity during first 24 hours were evaluated in both groups.

Results:

No significant difference existed between two groups regarding age, sex, weight and operation time. Pain intensity in group D was significantly less than group C (P < 0.01) after two, six and 12 hoursof surgery. No significant difference existed in pain intensity between two groups at the beginning of and 24 hours after the surgery (P > 0.05). Meperidine consumption in group D was significantly less than group C (P < 0.05).

Conclusions:

Findings of present study showed that single dose of intravenous dexamethasone, led to less pain intensity and amounts of meperidine consumption, in comparison with placebo.

Does dexmedetomidine reduce postoperative pain after laparoscopic cholecystectomy with multimodal analgesia?

Background

Pain after laparoscopy is multifactorial and different treatments have been proposed to provide pain relief. Multimodal analgesia is now recommended to prevent and treat post-laparoscopy pain. Dexmedetomidine, an α2 agonist, has well-known anesthetic and analgesic-sparing effects. We evaluated the analgesic effect of perioperative dexmedetomidine infusion during laparoscopic cholecystectomy with multimodal analgesia.

Methods

Forty-two patients aged 20 to 60 years old were allocated randomly into one of 2 groups (n = 21, in each). All patients underwent laparoscopic cholecystectomy under multimodal analgesia. The patients in group P received dexmedetomidine 1 µg/kg during 10 min before induction and then 0.5 µg/kg/h continuously until the removal of the gall bladder while the patients in the group C received saline by the same methods as group P. Total analgesic consumption and VAS score were recorded for the first 24 hr.

Results

There were no significant differences in VAS scores between group P and group C during 24 hr after laparoscopic cholecystectomy. VAS scores of group P were lower than that of group C during the 1st hr after operation. The amount of ketorolac required during the 24 hr after the operation was significantly less in group P compared to group C.

Conclusions

The administration of dexmedetomidine during laparoscopic cholecystectomy with multimodal analgesia has minimal benefits on the reduction of the postoperative pain score. The amount of ketorolac requirements during 24 hr after the operation showed significant difference. Dexmedetomidine might be helpful for the postoperative pain after laparoscopic cholecystectomy with multimodal analgesia.