A Randomized Clinical Trial of Nefopam versus Ketorolac Combined With Oxycodone in Patient-Controlled Analgesia after Gynecologic Surgery

A Study of 57 Patients with Prostate Cancer to Compare Outcomes of Estimated Blood Loss and Postoperative Pain Between Robot-Assisted Laparoscopic Radical Prostatectomy and Standard Laparoscopic Radical Prostatectomy

BACKGROUND Robot-assisted radical prostatectomy (RARP) is becoming an increasingly common method for treatment of prostate cancer. This study aimed to compare outcomes of estimated blood loss and postoperative pain, determined by patient-controlled analgesia (PCA), between RARP and standard laparoscopic radical -prostatectomy (LRP). MATERIAL AND METHODS We enrolled 57 patients who had localized prostate cancer (28 patients in RARP, 29 patients in LRP). Primary outcomes were estimated blood loss (EBL) measured by gravimetric method for gauze and visual estimation for suction bottle, and PCA bolus count that the bolus doses were injected at the 1st, the 6th, the 24th, and the 48th hour after the operation. We recorded anesthesia and operation time, pneumoperitoneum duration, vital signs, fluid volume, and remifentanil use. Using the numeric rating scale (NRS), adverse effects were checked at the 1st, the 6th, the 24th, and the 48th hour and patient satisfaction was assessed at the 48th hour after the operation. RESULTS Anesthesia time, operation time, and gas insufflation time were longer (P=0.001, P=0.003, P=0.021), and patient-controlled analgesia (PCA) bolus counts at the 1st hour after the operation and volumes of administered crystalloid and remifentanil were higher in the RARP group than in the LRP group (P=0.013, P=0.011, P=0.031). There were no significant differences in EBL. CONCLUSIONS The RARP group required longer anesthetic time and more analgesics during the acute postoperative period compared to the LRP group. Regarding anesthesia, LRP is as good a surgical procedure as RARP until the operation time and the number of ports are reduced.

Postoperative analgesia of intraoperative nefopam in patients undergoing anterior cervical spine surgery: A prospective randomized controlled trial

BACKGROUND

Nefopam is a non-opioid, non-nonsteroidal anti-imflammatory drug, analgesic drug that inhibits the reuptake of serotonin, norepinephrine, and dopamine. It is widely used as an adjuvant for pain. This study investigated whether the intraoperative, intravenous infusion of nefopam (20 mg) reduces postoperative morphine consumption, pain scores, and alleviates neuropathic pain in patients undergoing cervical spine surgery.

METHODS

A prospective, paralleled design, randomized study was conducted on 50 patients (aged 18-75 years) in a university-based hospital. The patients were assigned to an intervention or a control group (25 patients in each). The intervention group received a 1-hour infusion of nefopam (20 mg) before the end of surgery. The control group received normal saline (NSS). The outcome measures were morphine consumption during the first 24 postoperative hours, numerical rating scale (NRS) pain scores, and scores for the Thai version of the Neuropathic Pain Symptom Inventory (NPSI-T) in patients with neuropathic pain and adverse drug reactions. The NPSI-T scores were assessed on the preoperative day, postoperative day 1, 3, 15, and 30. The outcome assessors were blinded to group allocation.

RESULTS

Fifty patients were analyzed. During the first 24 postoperative hours, morphine consumption was 8 mg (nefopam) and 12 mg (NSS; P = .130). The intervention and control groups demonstrated no significant differences in the median NRS scores or total NPSI-T scores or adverse drug reactions.

CONCLUSIONS

A single, intraoperative infusion of 20 mg of nefopam did not significantly reduce postoperative (24 hours) morphine consumption in patients undergoing anterior cervical spine surgery.

Perioperative Intravenous Patient-Controlled Analgesic Efficacy of Morphine with Combined Nefopam and Parecoxib versus Parecoxib in Gynecologic Surgery: A Randomized, Double-Blind Study

Background

Nefopam is a non-NSAIDs and opioid sparing centrally acting drug which is effective for a multimodal postoperative analgesia. The present study aimed to evaluate the analgesic efficacy of nefopam combined with parecoxib for gynecologic surgery.

Methods

This randomized double-blinded control trial recruited participants (n = 72) who underwent gynecologic surgeries and divided them into either a nefopam or control group. The study group received parecoxib 40 mg plus nefopam 20 mg, while the control group received parecoxib 40 mg plus normal saline solution intravenously during open abdominal gynecological surgery. Both groups then received either nefopam or normal saline every 6 hours postoperatively for 24 hours. Intravenous patient-controlled analgesia with morphine was given for breakthrough pain within 24 h. The participants were evaluated for morphine consumption within 24 hours and postoperative pain using a verbal numerical rating scale (VNRS) at a postanesthetic care unit, at 6-, 12-, and 24-hour postoperative periods. Adverse effects were recorded.

Results

Morphine consumption within 24 hours and adverse effects were not significantly different between both groups. Mean difference and 95% confident interval of morphine consumption between both groups was 1.00 (−4.56, 4.76), P=0.97. The VNRS on movement at 6 hours after surgery of the nefopam group was significantly different from that of the control group [mean (SD), 4.14 (2.11) vs. 5.14 (1.80), P=0.04]. The VNRS of the nefopam group at 12 hours after operation during resting and on movement was significantly different from that of the control group ([mean (SD), 1.47 (1.80) vs. 2.54 (2.15), P=0.03], [mean (SD), 3.22 (1.84) vs 4.17 (1.74), P=0.03]), respectively.

Conclusions

The combined administration of nefopam and parecoxib during gynecologic surgery slightly reduced the VNRS at 6 and 12 hours postoperatively more than treatment with parecoxib.

Nefopam hydrochloride as a component of multimodal analgesia in the postoperative period

The modern approach to the multimodal scheme of postoperative analgesia includes the mandatory use of drugs that have a small number of side effects and at the same time have a polymodal effect on the pathogenetic links of pain development. Nefopam hydrochloride is able to prevent the development of: opioid hyperalgesia, stop pain stimuli without respiratory depression, affect platelet aggregation and the condition of the mucous membrane and motility of the gastrointestinal tract, which distinguishes it from classical NSAIDs. Nefopam hydrochloride is characterized by a low risk of addiction with prolonged use, a pronounced anti-sensory effect, especially significant at the stage of awakening and in the early postoperative period. Postoperative analgesia based on nefopam hydrochloride as a component of multimodal analgesia is effective and safe in the absence of absolute contraindications. The planned use of nefopam hydrochloride for the correction of pain reduces complications in the postoperative period and improves the quality of life of patients. Nefopam hydrochloride is one of the most effective drugs for the correction of postoperative tremor syndrome. The use of nefopam hydrochloride as a drug, which is a part of premedication before surgical interventions and a component of multimodal analgesia, improves the quality of the postoperative period due to: reduction of pain syndrome, planned correction of postoperative tremor syndrome and correction of complications arising from inadequate treatment of pain syndrome.

Molecular Basis of Cancer Pain Management: An Updated Review

Pain can have a significantly negative impact on the quality of life of patients. Therefore, patients may resort to analgesics to relieve the pain. The struggle to manage pain in cancer patients effectively and safely has long been an issue in medicine. Analgesics are the mainstay treatment for pain management as they act through various methods on the peripheral and central pain pathways. However, the variability in the patient genotypes may influence a drug response and adverse drug effects that follow through. This review summarizes the observed effects of analgesics on UDP-glucuronosyl (UGT) 2B7 isoenzyme, cytochrome P450 (CYP) 2D6, μ-opioid receptor μ 1 (OPRM1), efflux transporter P-glycoprotein (P-gp) and ATP-binding cassette B1 ABCB1/multiple drug resistance 1 (MDR1) polymorphisms on the mechanism of action of these drugs in managing pain in cancer. Furthermore, this review article also discusses the responses and adverse effects caused by analgesic drugs in cancer pain management, due to the inter-individual variability in their genomes.

Comparison of patient-controlled epidural analgesia with patient-controlled intravenous analgesia for laparoscopic radical prostatectomy

Background

Patient-controlled epidural analgesia (PCEA) is known to provide good postoperative analgesia in many types of surgery including laparoscopic surgery. However, no study has compared PCEA with patient-controlled intravascular analgesia (PCIA) in laparoscopic radical prostatectomy (LARP). In this study, the efficacy and side effects of PCEA and PCIA after LARP were compared.

Methods

Forty patients undergoing LARP were randomly divided into two groups: 1) a PCEA group, treated with 0.2% ropivacaine 3 ml and 0.1 mg morphine in the bolus; and 2) a PCIA group, treated with oxycodone 1 mg and nefopam 1 mg in the bolus. After the operation, a blinded observer assessed estimated blood loss (EBL), added a dose of rocuronium, performed transfusion, and added analgesics. The numeric rating scale (NRS), infused PCA dose, and side effects were assessed at 1, 6, 24, and 48 h.

Results

EBL, added rocuronium, and added analgesics in the PCEA group were less than those in the PCIA group. There were no significant differences in side-effects after the operation between the two groups. Patients were more satisfied with PCEA than with PCIA. The NRS and accumulated PCA count were lower in PCEA group.

Conclusions

Combined thoracic epidural anesthesia could induce less blood loss during operations. PCEA showed better postoperative analgesia and greater patient satisfaction than PCIA. Thus, PCEA may be a more useful analgesic method than PICA after LARP.

Association of nefopam use with postoperative nausea and vomiting in gynecological patients receiving prophylactic ramosetron: A retrospective study

Background

Postoperative nausea and vomiting (PONV) is a common adverse effect of opioid-based intravenous patient-controlled analgesia (IV PCA). Nefopam has been considered as a good candidate for inclusion in multimodal analgesia because of its opioid sparing effect, but it can be emetic. This study aims to examine whether the use of nefopam combined with fentanyl in IV PCA was associated with the higher incidence of PONV in patients receiving prophylactic ramosetron after gynecological surgery.

Methods

Data from 296 patients who underwent gynecological surgery were retrospectively reviewed. The patients received IV PCA containing either fentanyl 1500 μg and ketorolac 90 mg (Group K) or fentanyl 1500 μg and nefopam 80 mg (Group N). All patients in both groups received 0.3 mg of ramosetron at the end of surgery. The primary outcome measure was the incidence of PONV during the 3-day postoperative period.

Results

No difference was observed in the incidence of PONV during the 3-day postoperative period between the two groups. However, the incidence of nausea on postoperative day 2 was significantly higher in Group N (10.3%) than in Group K (2.8%) (P = 0.016). Multivariable logistic regression analysis showed that the use of nefopam was not associated with a higher incidence of PONV (adjusted odds ratio, 1.616; 95% confidence interval, 0.952–2.743, P = 0.076). There were no differences in postoperative pain scores between the two groups.

Conclusion

The combined use of nefopam with fentanyl in IV PCA was not associated with the higher incidence of PONV compared with the use of ketorolac and fentanyl combination in patients who received ramosetron as PONV prophylactic agent. However, prospective trials are required for a confirmative conclusion.

Intraoperative Nefopam Reduces Acute Postoperative Pain after Laparoscopic Gastrectomy: a Prospective, Randomized Study

BACKGROUND

We assessed whether intraoperative nefopam would reduce opioid consumption and relieve postoperative pain in patients undergoing laparoscopic gastrectomy.

METHODS

The 60 enrolled patients were randomly assigned to the control (n = 32) or nefopam (n = 28) group. All patients were blinded to their group assignment. We administered 100 ml of normal saline only (control group) or 20 mg of nefopam mixed in 100 ml normal saline (nefopam group) after anesthesia induction and at the end of surgery. The cumulative amount of fentanyl via intravenous patient-controlled analgesia (PCA), incidence of rescue analgesic medication, and numerical rating scale (NRS) for postoperative pain were evaluated along with the total remifentanil consumption.

RESULTS

The mean infusion rate of remifentanil was significantly lower in the nefopam group (0.08 ± 0.05 μg/kg/min) than in the control group (0.13 ± 0.06 μg/kg/min) (P < 0.001). Patients in the nefopam group required less fentanyl via intravenous PCA than those in the control group during the first 6 h after surgery (323.8 ± 119.3 μg vs. 421.2 ± 151.6 μg, P = 0.009). Additionally, fewer patients in the nefopam group than in the control group received a rescue analgesic during the initial 6 h postoperatively (78.6 vs. 96.9%, P = 0.028). The NRS measured while patients were in the post-anesthetic care unit was significantly lower in the nefopam group than in the control group (3.8 ± 1.1 vs. 4.8 ± 1.4, P = 0.012). The subsequent NRS obtained after patients had been transferred to the general ward was comparable between the two groups during the following postoperative period.

CONCLUSIONS

Intraoperative nefopam decreased postoperative pain and opioid consumption in the acute postoperative period after laparoscopic gastrectomy. Hence, nefopam may be considered as a component of multimodal analgesia after laparoscopic gastrectomy.

The efficacy and safety of nefopam for pain relief during laparoscopic cholecystectomy: A meta-analysis

BACKGROUND

Pain control after laparoscopic cholecystectomy (LC) has become an important topic. We performed a meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of nefopam for pain management after LC.

METHODS

PubMed, Medline, Embase, ScienceDirect, and the Cochrane Library were searched up to November 2017 for comparative articles involving nefopam and placebo for reducing postoperative pain after LC. Primary outcomes were postoperative pain scores and opioid consumption. Secondary outcomes were length of hospital stay, opioid-related adverse effects, and postoperative complications. We assessed statistical heterogeneity for each RCT by using a standard Chi test and the I statistic. The meta-analysis was undertaken using Stata 12.0.

RESULTS

A total of 215 patients were analyzed across 4 RCTs. We found that there were significant differences between nefopam and placebo groups regarding the postoperative pain scores and opioid requirements at 6, 12, and 24 hours. Moreover, there was a decreased risk of opioid-related adverse effects in the nefopam groups. No significant differences were identified in terms of the incidence of postoperative complications.

CONCLUSION

Intravenous nefopam infusion resulted in significant reduction in postoperative pain scores and opioid requirements while decreasing opioid-related adverse effects. Additionally, no increased risk of venous thromboembolism was found. The current evidence suggests that more RCTs will be needed in further investigations.

Paracetamol Instead of Ketorolac in Post-Video-Assisted Thoracic Surgery Pain Management: A Randomized Trial

BACKGROUND

Video-assisted thoracic surgery (VATS) is a minimally invasive procedure that is growing more common around the world. Despite causing less pain compared open thoracic surgery, postoperative pain management is still important.

OBJECTIVES

The aim of the present study was to compare the analgesic effects of paracetamol and ketorolac in VATS patients.

METHODS

This was a double-blinded randomized clinical trial conducted on 70 patients undergoing lobectomy or segmentectomy due to lung masses, using video-assisted methods. The patients were randomly divided into two groups (each n = 35): the ketorolac (K) group and the paracetamol (P) group. The K group received ketorolac 30 mg IV stat at the end of surgery and then a 90 mg/24 h infusion. The P group received paracetamol 1 g IV stat at the end of surgery and then a 3 g/24 h infusion. Pain scores were recorded during recovery and 2, 4, 8, 12, and 24 hours after drug administration. Pain scores, total doses of rescue analgesics, and patient satisfaction levels were compared between the groups.

RESULTS

There was no significant difference between the K and P groups in pain scores in any of the evaluations. Seventeen (48.6 %) and 9 (25.7 %) patients in the K and P groups, respectively, did not require any rescue analgesia (P = 0.047). The mean doses of rescue analgesia in the K and P groups were 3.129 ± 4.27 mg and 4.38 ± 3.69 mg, respectively, which were similar (P = 0.144). There was no significant difference between the groups in satisfaction scores (P = 0.175).

CONCLUSIONS

Paracetamol 1 g stat + 3 g/24 h infusion is as effective as ketorolac 30 mg stat + 90 mg/24 h infusion in post-VATS pain management, with good tolerability and a low incidence of adverse effects.

Opioid sparing effect and safety of nefopam in patient controlled analgesia after laparotomy: A randomized, double blind study

OBJECTIVES

A double-blind randomised study to evaluate the opioid sparing effect and safety of nefopam when administered via intravenous patient controlled analgesia (PCA) with fentanyl.

METHODS

Patients planned for elective open laparotomy, were randomly assigned to receive into fentanyl 25 µg/ml (SF group) or nefopam 2.4 mg/ml plus fentanyl 25 µg/ml (NF group). Patients were assessed before surgery and for 24 h postoperatively.

RESULTS

Total PCA fentanyl consumption was significantly lower in the NF group (n = 35) than the SF group (n = 36). Pain scores were significantly lower and patients' satisfaction with treatment significantly better in the NF group than the SF group. Dry mouth and dizziness were significantly more frequent in the NF group than the SF group. There were no other statistically significant between-group differences in the incidence of adverse events.

CONCLUSIONS

Intravenous PCA using nefopam + fentanyl following laparotomy has an opioid sparing effect and is associated with a low incidence of some of the typical opioid related adverse events.

TRIAL REGISTRY

Clinicaltrials.gov Registration No: NCT02596269.