Opioid sparing strategies for perioperative pain management other than regional anaesthesia: A narrative review

Celecoxib-tramadol co-crystal in patients with moderate-to-severe pain following bunionectomy with osteotomy: Secondary analyses by baseline pain intensity and use of rescue medication of a phase 3, randomized, double-blind, factorial, active- and placebo-controlled trial

BACKGROUND

In the randomized, phase 3, SUSA-301 trial, celecoxib-tramadol co-crystal (CTC) provided significantly greater analgesia compared with celecoxib, tramadol, or placebo in adults with acute, moderate-to-severe, postoperative pain. This post hoc, secondary analysis further evaluated the use of rescue medication and the incidence of treatment-emergent adverse events (TEAEs).

METHODS

Patients (N = 637) were randomized 2:2:2:1 to receive oral CTC 200 mg twice daily (BID; n = 184), tramadol 50 mg four times daily (QID; n = 183), celecoxib 100 mg BID (n = 181), or placebo QID (n = 89). Post hoc analyses were conducted on the use of rescue medications up to 4 and 48 h post-study drug dose, stratified by baseline pain intensity (moderate/severe), and on the incidence of TEAEs, stratified by rescue medication use.

RESULTS

A significantly lower proportion of patients received any rescue medication within 4 h post-study dose with CTC (49.5%) versus tramadol (61.7%, p = 0.0178), celecoxib (65.2%, p = 0.0024), and placebo (75.3%, p = 0.0001); this was also seen for oxycodone use. Fewer patients in the CTC group received ≥3 doses of rescue medication compared with the other groups, irrespective of baseline pain intensity. In patients who did not receive opioid rescue medication, CTC was associated with a lower incidence of nausea and vomiting TEAEs versus tramadol alone. In patients who received rescue oxycodone, the incidence of nausea was similar in the CTC and tramadol groups, and higher versus celecoxib and placebo.

CONCLUSION

Celecoxib-tramadol co-crystal was associated with reduced rescue medication use and an acceptable tolerability profile compared with tramadol or celecoxib alone in adults with acute, moderate-to-severe, postoperative pain.

Navigating Opioid Alternatives in Spine Surgery: A Comprehensive Review

The opioid crisis has significantly impacted pain management practices in spine surgery, prompting a critical reassessment of traditional approaches. While opioids have historically been effective for post-operative pain relief, their widespread use has led to substantial public health challenges, including addiction and overdose. This review explores alternative strategies to opioids in spine surgery, emphasizing non-opioid pharmacological options [e.g., nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, local anesthetics] and non-pharmacological interventions (e.g., physical therapy, cognitive-behavioral therapy). These alternatives aim to mitigate opioid-related risks while optimizing patient outcomes. Key findings highlight these approaches' efficacy, safety considerations, and practical implications. Recommendations include personalized pain management plans and multidisciplinary collaboration to enhance care delivery. Future directions suggest advancing research in innovative pain management technologies and promoting evidence-based practices to mitigate opioid dependence. Ultimately, integrating these strategies into clinical practice is essential for addressing the opioid crisis and ensuring quality care in spine surgery.

High-frequency, high-intensity TENS compared to standard treatment with opioids for postoperative pain relief after laparoscopic cholecystectomy: A multicentre randomized controlled trial

BACKGROUND

Adverse effects of opioids could prolong the duration of stay in the post-anaesthesia care unit (PACU). This study aimed to assess time in the PACU and the pain-relieving effect of high-frequency, high-intensity transcutaneous electrical nerve stimulation (HFHI TENS) versus standard treatment with intravenous (IV) opioids.

METHODS

Patients undergoing laparoscopic cholecystectomy at two Swedish hospitals were invited to participate. Patients reporting postoperative pain intensity ≥3 according to the Numeric Rating Scale (NRS) in the PACU were randomized to receive standard treatment with IV opioids or HFHI TENS, administered with an intensity of 40-60 mA for 1 min, repeated once if insufficient pain relief. If NRS remained ≥3 after two TENS stimulation the patients received IV opioids.

RESULTS

In total, 163 patients were randomized to receive HFHI TENS (n = 85) or IV opioids (n = 78). There was no difference between the HFHI TENS group versus the opioid group regarding time in the PACU (138 min [SD 69] vs. 142 min [SD 95], mean difference -4.42 [95% CI-30:22], p = 0.74), time to pain relief NRS < 3 (median 10 min) and pain intensity at PACU discharge (NRS 1.7 [SD 1.45] vs. 1.6 [SD 1.20], p = 0.58). In the HFHI TENS group, 39 patients (46%) needed additional treatment with IV opioids. Mean opioid consumption was significantly lower in the HFHI TENS group than in the opioid group (4.5 vs. 11.0 morphine equivalents; p < 0.001).

CONCLUSIONS

HFHI TENS may be an opioid-sparing alternative for postoperative pain relief.

SIGNIFICANCE STATEMENT

In this multicentre, RCT time in the PACU and the pain-relieving effect of HFHI TENS was compared to standard treatment with IV opioids. There were no differences between the groups regarding time in the PACU, time to pain relief and side effects but opioid consumption in the HFHI TENS group was significantly lower. Both groups reported high satisfaction with pain treatment and care. In summary, HFHI TENS should be considered a safe, fast-onsetting, opioid-sparing option for postoperative pain relief.

Transcutaneous Electrical Nerve Stimulation Integrated into Pants for the Relief of Postoperative Pain in Hip Surgery Patients: A Randomized Trial

Background

The effect of transcutaneous electrical nerve stimulation (TENS) on pain and impression of change was assessed during a 2.5-hour intervention on the first postoperative days following hip surgery in a randomized, single-blinded, placebo-controlled trial involving 30 patients.

Methods

Mixed-frequency TENS (2 Hz/80 Hz) was administered using specially designed pants integrating modular textile electrodes to facilitate stimulation both at rest and during activity. The treatment outcome was assessed by self-reported pain Numerical Rating Scale (NRS) and Patient Global Impression of Change (PGIC) scores at four time points. The ability to perform a 3-meter walk test and the use of analgesics were also evaluated. Group comparison and repeated-measure analysis were carried out using nonparametric statistics.

Results

The active TENS group exhibited significantly higher PGIC scores after 30 minutes, which persisted throughout the intervention (all p ≤ 0.001). A reduction in NRS appeared after one hour of active TENS, persisting throughout the intervention (all p ≤ 0.05). The median group differences in pain ratings were greater than the minimum clinically important difference, and the analysis of pain trajectories confirmed clinical significance at the individual level. Moreover, patients in the active TENS group were more likely able to perform a 3-meter walk test by the end of the intervention (p = 0.04). Analysis of the opioid-sparing effect of TENS was inconclusive (p = 0.066). No postoperative surgical complications or TENS-related side effects were observed during the study.

Conclusion

Mixed-frequency TENS integrated in pants could potentially be an interesting addition to the arsenal of treatments for multimodal analgesia following hip surgery. This trial is registered with NCT05678101.

Acupoint Stimulation for Pain Control in Enhanced Recovery After Surgery: Systematic Review and Meta-Analysis

Introduction: Postoperative pain control is a challenge in enhanced recovery after surgery (ERAS). The current study reviewed the efficacy and safety of incorporating acupoint stimulation for postoperative pain control in ERAS. Methods: Ten databases for relevant randomized controlled trials (RCTs) published in English or Mandarin Chinese were searched from 1997 to 2022. The quality of each article was appraised using the Cochrane Collaboration Risk of Bias Criteria and the modified Jadad Scale. The primary outcome was pain control, measured using the visual analog scale 24 h after surgery. Results: Eleven trials met the eligibility criteria and were included in the study. Acupoint stimulation was found more effective than control treatments in terms of pain intensity (standardized mean difference [SMD] -0.94; 95% confidence interval [CI] -1.35 to -0.53), analgesic drug consumption (SMD -1.87; 95% CI -2.98 to -0.75), postoperative nausea (PON; SMD 0.31; 95% CI 0.13 to 0.73), postoperative vomiting (POV; SMD 0.57; 95% CI 0.11 to 2.92), and PON and POV (PONV; SMD 0.29; 95% CI 0.16 to 0.53). The Zusanli (ST36) and Neiguan (PC6) were the most-used acupoints in the included trials (8/11). The reported adverse reaction was only one case of bruising. Discussion: Acupoint stimulation improved pain control in patients undergoing ERAS more than control treatments. The findings provide an evidence-based premise for incorporating acupoint stimulation into ERAS strategies. More rigorous RCTs are needed in the future.

Effect of opioid-free versus opioid-based strategies during multimodal anaesthesia on postoperative morphine consumption after bariatric surgery: a randomised double-blind clinical trial

Background

The efficacy and safety of opioid-free anaesthesia during bariatric surgery remain debated, particularly when administering multimodal analgesia. As multimodal analgesia has become the standard of care in many centres, we aimed to determine if such a strategy coupled with either dexmedetomidine (opioid-free anaesthesia) or remifentanil with a morphine transition (opioid-based anaesthesia), would reduce postoperative morphine requirements and opioid-related adverse events.

Methods

In this prospective double-blind study, 172 class III obese patients having laparoscopic gastric bypass surgery were randomly allocated to receive either sevoflurane-dexmedetomidine anaesthesia with a continuous infusion of lidocaine and ketamine (opioid-free group) or sevoflurane-remifentanil anaesthesia with a morphine transition (opioid-based group). Both groups received at anaesthesia induction a bolus of magnesium, lidocaine, ketamine, paracetamol, diclofenac, and dexamethasone. The primary outcome was 24-h postoperative morphine consumption. Secondary outcomes included postoperative quality of recovery (QoR40), incidence of hypoxaemia, bradycardia, and postoperative nausea and vomiting (PONV).

Results

Eighty-six patients were recruited in each group (predominantly women, 70% had obstructive sleep apnoea). There was no significant difference in postoperative morphine consumption (median [inter-quartile range]: 16 [13-26] vs 15 [10-24] mg, P=0.183). The QoR40 up to postoperative day 30 did not differ between groups, but PONV was less frequent in the opioid-free group (37% vs 59%, P=0.005). Hypoxaemia and bradycardia were not different between groups.

Conclusions

During bariatric surgery, a multimodal opioid-free anaesthesia technique did not decrease postoperative morphine consumption when compared with a multimodal opioid-based strategy. Quality of recovery did not differ between groups although the incidence of PONV was less in the opioid-free group.

Clinical trial registration

NCT05004519.

Effect of three modalities on emergence agitation among post-traumatic stress disorder patients undergoing laparoscopy: a randomized controlled study

BACKGROUND AND AIM

Emergence agitation (EA) after general anesthesia is common in patients with post-traumatic stress disorder (PTSD). Due to the recent worldwide events such as the Covid-19 pandemic and wars, PTSD is not rare. Accordingly, a reliable, cost-effective anesthetic protocol to lower the incidence of EA is crucial. Therefore, we aimed to compare three different interventions for avoiding EA in PTSD patients undergoing gynecological laparoscopic surgery. Participants were divided into four groups: 1: performing pre-operative relaxation techniques (deep breathing exercise and progressive muscle relaxation [PMR]); 2: administrating intra-operative Ketamine; 3: applying both previously mentioned strategies and 4 as controls.

METHODS

This study was carried out on 144 adult women scheduled for gynecological laparoscopy, randomly allocated into four groups: three intervention groups and a control group (36 each). Women aged 18-45 years old, with a diagnosis of PTSD were included in the study. Patients with a positive history of major neurological, cardiovascular, metabolic, respiratory, or renal disease were excluded. Any patient who reported the use of psychiatric drugs were also excluded from the study. Data was analyzed using IBM SPSS Statistics software version 26. Kolmogorov- Smirnov was used to verify the normality of the distribution of variables. Odds ratio was calculated to clarify the strength and direction of the association between intervention groups and control. Data was deemed significant at a p-value ≤0.05.

RESULTS

Heart rate (HR) and Mean Arterial Blood Pressure (MABP) intra-operative and post-operative till 24 hours were significantly lower in groups 1, 2, and 3 compared to group 4 (p<0.001). There was a significant statistical difference in the intraoperative HR percentage decrease. MABP percentage decrease post-operative was higher in all the intervention groups with no statistically significant difference, except for group 1 compared to group 4, which was statistically significant (12.28 ± 11.77 and 6.10 ± 7.24, p=0.025). Visual Analogue Scale measurements were significantly less in the intervention groups 1, 2, and 3 compared to group 4. On Riker sedation-agitation scores, group 1 was 85 times more likely to be non-agitated (85 (15.938 - 453.307), p<0.001), group 2 was 175 times more likely to be non-agitated (175 (19.932-1536.448), p<0.001) and group 3 was protected against agitation.

CONCLUSION

Pre-operative relaxation techniques (breathing exercises and PMR) significantly lowered HR, MABP, VAS score, and EA than controls. These effects were not significantly different from intra-operative ketamine injection or the combination of both (relaxation techniques and ketamine). We recommend routine pre-operative screening for PTSD and the application of relaxation techniques (breathing exercises and PMR) in the pre-operative preparation protocol of PTSD-positive cases as well as routine practical application of preoperative relaxation techniques. Further studies on using pre-operative relaxation techniques in general could be cost-effective.

Lipid-Based Nanotechnology: Liposome

Over the past several decades, liposomes have been extensively developed and used for various clinical applications such as in pharmaceutical, cosmetic, and dietetic fields, due to its versatility, biocompatibility, and biodegradability, as well as the ability to enhance the therapeutic index of free drugs. However, some challenges remain unsolved, including liposome premature leakage, manufacturing irreproducibility, and limited translation success. This article reviews various aspects of liposomes, including its advantages, major compositions, and common preparation techniques, and discusses present U.S. FDA-approved, clinical, and preclinical liposomal nanotherapeutics for treating and preventing a variety of human diseases. In addition, we summarize the significance of and challenges in liposome-enabled nanotherapeutic development and hope it provides the fundamental knowledge and concepts about liposomes and their applications and contributions in contemporary pharmaceutical advancement.

Research trends from 1992 to 2022 of acupuncture anesthesia: a bibliometric analysis

Background

Acupuncture anesthesia is a significant technical development that originated in China in 1958 and was introduced to the West in the early 1970s. Due to its relative novelty, it has been the subject of intense scrutiny and contestation. Since the early 1970s, the use of acupuncture as a complementary treatment for opioid analgesics has been accepted. Research on acupuncture anesthesia has helped to reduce clinical opioid abuse. However, only a few articles have focused on previous publications that reflect the trend of the study, the main investigators, reciprocal collaboration, and other information in this field. In view of this, we utilized bibliographic analysis methods to objectively analyze current trends and research hotspots in this field, aiming to provide a foundation and reference for future studies.

Methods

The Web of Science database was searched for publications related to acupuncture anesthesia between 1992 and 2022. The CiteSpace and VOSviewer were used to analyze the annual publications, authors, Co-cited authors, and their countries (regions) and institutions, co-occurrence keywords, burst keywords, Co-citation references and Co-citation journals.

Results

A total of 746 eligible publications were retrieved from the database for the analysis, including 637 articles and 109 reviews. And the trend of annual publications continued to grow. Aashish J. Kumar, Daniel I. Sessler, Baoguo Wang, and Paul F. White published the most papers in this field (7), and all authors, had a very low centrality (<0.01). China (252) and the University of California System (21) were the most productive country (region) and institution, respectively, while the United States (0.62) and University of California System (0.16) had the highest centrality. After removing keywords related to the search strategy, the three most frequent were pain (115), electroacupuncture (109), and stimulation (91). The six most recent burst keywords were recovery, transcutaneous electrical acupoint stimulation, systematic review, quality, general anesthesia, and surgery. Wang et al.'s article had the highest co-citation count (20), whereas Zhang et al.'s articles had the highest centrality (0.25). The Journal of Anesthesia and Analgesia was the most influential one (408 co-citations).

Conclusion

This research provides valuable information for the study of acupuncture anesthesia. In recent years, frontier topics in acupuncture anesthesia research have been the promotion of perioperative rehabilitation, anesthesia management, and quality improvement.

Comparison between ketorolac- and fentanyl-based patient-controlled analgesia for acute kidney injury after robot-assisted radical prostatectomy: a retrospective propensity score-matched analysis

PURPOSE

It is unclear whether ketorolac-based patient-controlled analgesia (PCA) leads to acute kidney injury (AKI) after robot-assisted radical prostatectomy (RARP) in patients susceptible to AKI. We compared the postoperative AKI incidence with ketorolac- and fentanyl-based PCA after RARP.

METHODS

After medical record review, eligible patients were divided in ketorolac and fentanyl groups. We conducted propensity score matching of 3239 patients and assigned 641 matched patients to each group, and compared the AKI incidence. We investigated potential risk factors for postoperative AKI, defined according to the Kidney Disease Improving Global Outcomes criteria. We collected preoperative data (age, height, weight, body mass index, American Society of Anesthesiologists physical status, medical history, creatinine level, estimated glomerular filtration rate, and hemoglobin level) and intraoperative data (maintenance anesthetics, surgery duration, anesthesia duration, crystalloid amount, colloid use, total amount of fluid administered, estimated blood loss, norepinephrine use, phenylephrine use, and PCA type).

RESULTS

The postoperative AKI incidence was significantly higher in the ketorolac than in the fentanyl group, both before (31.1% vs. 20.4%; p < 0.001) and after (31.5% vs. 22.6%; p < 0.001) matching. In the univariate analysis, ketorolac was significantly associated with postoperative AKI, both before (odds ratio [OR], 1.762; 95% confidence interval [CI], 1.475-2.105; p < 0.001) and after (OR, 1.574; 95% CI, 1.227-2.019; p < 0.001) matching. In the multivariate analysis, ketorolac-based PCA was independently associated with development of postoperative AKI in the matched groups (OR, 1.659; 95% CI, 1.283-2.147; p < 0.001).

CONCLUSION

Ketorolac-based PCA may increase postoperative AKI incidence after RARP; thus, renal function should be monitored in these patients.

Effect of Transcutaneous Electrical Acupoint Stimulation Combined with Transversus Abdominis Plane Block on Postoperative Recovery in Elderly Patients Undergoing Laparoscopic Gastric Cancer Surgery: A Randomized Controlled Trial

INTRODUCTION

This study assessed the influence of transcutaneous electrical acupoint stimulation (TEAS) combined with transversus abdominis plane block (TAPB) on the recovery of elderly patients undergoing laparoscopic gastric cancer surgery.

METHODS

Ninety patients (age ≥ 60 years) undergoing laparoscopic gastric cancer surgery were randomly divided into general anesthesia group (group G), TAPB group (group NG), and TEAS combined with TAPB group (group NTG). Patients in the NTG group received TEAS at PC6, LI4, and ST36 acupoints and TAPB. Patients in the NG group received TAPB. The quality of recovery (QoR) was assessed using the QoR-15 questionnaire. The percentages of T lymphocyte subsets were determined. Consumption of anesthetics, extubation time, visual analog scale (VAS) scores, time of first postoperative ambulation and flatus, and postoperative adverse events were also recorded.

RESULTS

QoR-15 scores on postoperative day (POD) 3 and POD 7 were higher in the NTG group than in the G and NG groups (P < 0.05). On POD 1 and POD 3, the percentages of CD3⁺ and CD4⁺ T cells and the CD4⁺/CD8⁺ ratio were higher and the percentage of CD8⁺ T cells was lower in the NTG group than in the G and NG groups (P < 0.05). Remifentanil consumption, and the incidence of postoperative nausea and vomiting (PONV) were lower and extubation time and time of first postoperative flatus were shorter in the NTG group than in the G and NG groups (P < 0.05). Compared with the G group, the VAS scores on POD 1 were lower in the NG group and those on POD 2 were lower in the NTG group (P < 0.05).

CONCLUSION

The combination of TEAS and TAPB ameliorated postoperative pain, improved immune and gastrointestinal function, reduced the incidence of PONV, and effectively promoted postoperative recovery in elderly patients undergoing laparoscopic gastric cancer surgery.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2100042119).