Efficacy of Perioperative Administration of Intravenous Parecoxib on Postoperative Morphine Consumption after Video-Assisted Thoracoscopic Surgery

Background: Morphine is commonly used to relief pain after video-assisted thoracoscopic surgery (VATS), however high dose morphine is usually related with many complications. Parecoxib is a potent cyclo-oxygenase inhibitor for parenteral administration that has a role in acute pain management addition to opioid protocol. Objective: To investigate the potential benefits of intravenous parecoxib for relieving postoperative pain after VATS. Materials and Methods: The present study was a randomized controlled trial that assigned 22 patients undergoing VATS into two groups to received either parecoxib 40 mg as P group with 11 patients, or placebo using 2 mL of Normal Saline Solution as C group with 11 patients with an intravenous administration at 30 minutes prior to surgery and then 12 hours later. In the postoperative period, all patients received intravenous patient-controlled analgesia (PCA) with morphine. The primary outcome was the total morphine consumption for 24 hours postoperatively. The secondary outcomes were pain score at 2, 6, 12, and 24 hours postoperatively, using a numeric rating scale (NRS, 0 to 10) and the incidence of side effects. Results: The total morphine consumption was significantly lower in P group (26.64±4.41 mg) than C group (39.82±3.87 mg) at 24 hours postoperatively (p<0.001). The NRS pain score at rest and on coughing at 24 hours postoperatively between P group compared with C group were 1.09±1.04 versus 4.45±0.69 (p<0.001) and 2.91±0.83 versus 5.36±0.81 (p<0.001), respectively. The incidences of nausea and vomiting were found in both groups at 2, 6, and 12 hours, postoperatively, but there was no statistically significant difference between both groups (p>0.05). Other adverse events such as sedation, pruritus, dyspepsia, headache, hypotension, and respiratory depression were not found. Conclusion: Perioperative administration of parecoxib was safe and effectively decrease postoperative morphine consumption and pain score at rest and on coughing within 24 hours postoperatively after VATS. Keywords: Intravenous parecoxib; Video-assisted thoracoscopic surgery; Acute postoperative pain

Efficacy of a Combination of Ketamine and Morphine for Intravenous Patient Controlled-Analgesia in Upper Abdominal Surgery: A Prospective, Double-blind, Randomized Controlled Trial

Background: Most postoperative upper abdominal pain is severe, and various methods can be employed to control it. Presently, morphine is the main drug used for anesthesia, but it may contribute to the occurrence of many uncomfortable side effects. Ketamine is an analgesic drug that inhibits NMDA receptors, making it a synergistic effect of morphine. Objective: To investigate the efficacy of a combination of ketamine and morphine in controlling postoperative upper abdominal pain. Materials and Methods: Informed consents were obtained from patients enrolled into the present double-blind randomized study that divided into two groups, (i) the M group, which received 1 mg/mL of morphine, and (ii) the MK group, which received 1 mg of ketamine plus 1 mg/mL of morphine as intravenous patient-controlled analgesia (IV-PCA) post-operation. All patients were assessed based on postoperative morphine consumption, a numeric rating scale (NRS) used to rate pain, and the presence of side effects. Results: Sixty-seven patients completed the study including 34 patients in the MK group and 33 patients in the M group. Cumulative postoperative morphine consumption at 24 and 48 hours was significantly lower in the MK group at 27.91±11.11 and 46.44±15.21 mg compared to the M group at 43.24±15.32 and 71.33±19.67 mg, respectively (p<0.001). NRS were similar between the two groups and no observable differences regarding to side effects. Conclusion: A combination of ketamine and morphine via IV PCA is effective in controlling postoperative upper abdominal pain. Keywords: Ketamine; Morphine; Upper abdominal surgery; Intravenous patient-controlled analgesia

Intrathecal Morphine for Analgesia in Minimally Invasive Cardiac Surgery: A Randomized, Placebo-controlled, Double-blinded Clinical Trial

Background Intrathecal morphine decreases postoperative pain in standard cardiac surgery. Its safety and effectiveness have not been adequately evaluated in minimally invasive cardiac surgery. The authors hypothesized that intrathecal morphine would decrease postoperative morphine consumption after minimally invasive cardiac surgery. Methods In this randomized, placebo-controlled, double-blinded clinical trial, patients undergoing robotic totally endoscopic coronary artery bypass received either intrathecal morphine (5 mcg/kg) or intrathecal saline before surgery. The primary outcome was postoperative morphine equivalent consumption in the first 24 h after surgery; secondary outcomes included pain scores, side effects, and patient satisfaction. Pain was assessed via visual analog scale at 1, 2, 6, 12, 24, and 48 h after intensive care unit arrival. Opioid-related side effects (nausea/vomiting, pruritus, urinary retention, respiratory depression) were assessed daily. Patient satisfaction was evaluated with the Revised American Pain Society Outcome Questionnaire. Results Seventy-nine patients were randomized to receive intrathecal morphine (n = 37) or intrathecal placebo (n = 42), with 70 analyzed (morphine 33, placebo 37). Intrathecal morphine patients required significantly less median (25th to 75th percentile) morphine equivalents compared to placebo during first postoperative 24 h (28 [16 to 46] mg vs. 59 [41 to 79] mg; difference, –28 [95% CI, –40 to –18]; P &lt; 0.001) and second postoperative 24 h (0 [0 to 2] mg vs. 5 [0 to 6] mg; difference, –3.3 [95% CI, –5 to 0]; P &lt; 0.001), exhibited significantly lower visual analog scale pain scores at rest and cough at all postoperative timepoints (overall treatment effect, –4.1 [95% CI, –4.9 to –3.3] and –4.7 [95% CI, –5.5 to –3.9], respectively; P &lt; 0.001), and percent time in severe pain (10 [0 to 40] vs. 40 [20 to 70]; P = 0.003) during the postoperative period. Mild nausea was more common in the intrathecal morphine group (36% vs. 8%; P = 0.004). Conclusions When given before induction of anesthesia for totally endoscopic coronary artery bypass, intrathecal morphine decreases use of postoperative opioids and produces significant postoperative analgesia for 48 h. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Effects of opioid-reduced anesthesia during scoliosis surgery in children: a prospective observational study

Aims: Opioid-reduced anesthesia (ORA) was suggested to decrease morphine consumption after adolescent idiopathic scoliosis (AIS) surgery and incidence of chronic pain. Materials & methods: A prospective analysis using the ORA in AIS surgery was performed. Two cohorts were compared: a control group (opioid-based anesthesia) and the ORA group. The main outcome was morphine consumption at day 1. Results: 33 patients operated for AIS using ORA were compared with 36 with opioid-based anesthesia. Morphine consumption was decreased in the ORA group (1.1 mg.kg-1 [0.2–2] vs 0.8 mg.kg-1 [0.3–2]; p = 0.02) at day 1. Persistent neuropathic pain at 1 year was decreased in the ORA group (p = 0.02). Conclusion: The ORA protocol is efficient to reduce postoperative morphine consumption in AIS surgery and preventing neuropathic pain.

Comparison between femoral block and PENG block in femoral neck fractures: A cohort study

Background Regional analgesia is worth performing in the multimodal postoperative management of hip fracture (HF) because it reduces hospital morbidity and mortality. The aim of this study is to compare the efficacy and side effects of the recently described “Pericapsular Nerve Group (PENG) Block” with those of the femoral block, which is considered the standard of care for postoperative pain control after femoral neck fracture. Materials and methods We conducted a comparative observational study at a university hospital (Saint Antoine Hospital, Sorbonne University, Paris, France), where the PENG block was introduced in August 2019. We include all patients from June to October 2019, who were coming for femoral neck fractures and who had an analgesic femoral block or PENG block before their surgery. The primary outcome was the comparison of cumulative postoperative morphine consumption 48 hours after surgery. Results Demographics, medical charts, and perioperative data of 42 patients were reviewed: 21 patients before (Femoral group) and 21 patients after the introduction of PENG block (PENG group) in clinical practice. Thirteen total hip arthroplasties (THA) and eight hemi arthroplasties (HA) were included in each group. Demographics were also comparable. The median, postoperative, morphine equivalent consumption at 48 hours was 10 [0–20] mg and 20 [0–50] mg in Femoral and PENG groups respectively (p = 0.458). No statistically significant differences were found in postoperative pain intensity, time to ambulation, incidence of morphine-related side effects, or length of hospital stay. The postoperative muscle strength of the quadriceps was greater in the PENG group than in the Femoral group (5/5 vs. 2/5, p = 0.001). Conclusion In the management of hip fractures, PENG block is not associated in our study with a significant change in postoperative morphine consumption, compared to femoral block. However, it does significantly improve the immediate mobility of the operated limb, making it appropriate for inclusion in enhanced recovery programs after surgery.

The impact of loco-regional anaesthesia on postoperative opioid use in elderly hip fracture patients: an observational study

Purpose Hip fractures are a common health problem among the elderly with an increasing incidence. They are associated with high mortality and morbidity. Optimal pain management remains challenging and inadequate pain control is known for negatively affecting outcomes. Loco-regional anaesthetics (LRA) have been proven to benefit pain management and to lower the risks of opioid use and -related side effects. We aimed to evaluate the use and efficacy of different LRA in elderly hip fracture patients. Methods Single-center cohort study of elderly hip fracture patients, who were treated in central Switzerland. We compared patients who received LRA in the form of a femoral nerve block (FNB) or a continuous femoral nerve catheter (CFNC) with patients who did not receive LRA. Primary outcomes were pain—as measured in perioperative morphine use—hospital length of stay (HLOS), postoperative complications, postoperative falls and mortality. Results 407 patients were included for analysis. Mean age was 85.2 (SD6.3). There was a significant difference in intraoperative morphine use between the groups (p = 0.007). Postoperative morphine use differed significantly and was lowest in patients with FNB and highest in patients without LRA (p < 0.001). The use of LRA was a significant predictor for postoperative morphine use for postoperative morphine use at the recovery room and for postoperative morphine use 48 h after surgery. No significant differences were found in postoperative complications, a significant difference was found in 1-year mortality. Conclusions This article shows that LRA in the form of FNB and CFNC causes a significant decrease in postoperative opioid consumption. Differences between single-shot FNB or CFNC were minimal. There were no significant differences in clinical outcomes such as HLOS, delirium, 30-day and 90-day mortality and postoperative falls. We suggest that use of LRA should be incorporated in the perioperative treatment of elderly patients with a hip fracture. For future research, we recommend evaluating the number of postoperative complications and mortality.

A Prospective Randomized Comparison of Postoperative Pain and Complications after Thyroidectomy under Different Anesthetic Techniques: Volatile Anesthesia versus Total Intravenous Anesthesia

While the postoperative outcome is favorable, post-thyroidectomy pain is considerable. Reducing the postoperative acute pain, therefore, is considered important. This study investigated whether the pain intensity and need for rescue analgesics during the immediate postoperative period after thyroidectomy differ according to the methods of anesthesia. Seventy-two patients undergoing total thyroidectomy under general anesthesia were examined. Patients were randomly assigned to undergo either total intravenous anesthesia with remifentanil and propofol (TIVA, n = 35) or propofol induction and maintenance with desflurane and nitrous oxide (volatile anesthesia [VA], n = 37). The mean administered dose of remifentanil was 1977.7 ± 722.5 μg in the TIVA group, which was approximately 0.268 ± 0.118 μg/min/kg during surgery. Pain scores based on a numeric rating scale (NRS) and the need for rescue analgesics were compared between groups at the postoperative anesthetic care unit (PACU). The immediate postoperative NRS values of the TIVA and VA groups were 5.7 ± 1.7 and 4.7 ± 2.3, respectively ( P = 0.034). Postoperative morphine equianalgesic doses in the PACU were higher in the TIVA group than in the VA group (16.7 ± 3.8 mg vs. 14.1 ± 5.9 mg, P = 0.027). The incidence of immediate postanesthetic complications did not differ significantly between groups. In conclusion, more rescue analgesics were required in the TIVA group than in the VA group to adequately manage postoperative pain while staying in the PACU after thyroidectomy.

Influence of Preoperative Anxiety Level on Postoperative Pain After Cardiac Surgery

IntroductionPreoperative anxiety is generally neglected in evaluation of cardiac surgery patients due to various reasons including insufficient literature and lack of simple assessment tool. In addition, association between anxiety and postoperative complications including pain has been scarcely studied.Present study was designed, to assess preoperative anxiety levels in all patients coming for cardiac surgery and then evaluate the effect of different levels of anxiety on postoperative pain scores. MethodsThis prospective cohort study was conducted in a single university hospital, from March 2018 to December 2019. 100 consecutive cardiac surgery patients between the ages of 18-65 year were enrolled in this study. Level of preoperative anxiety ( assessed by State Anxiety Inventory) and its effect on postoperative pain and morphine consumption was assessed.ResultsThe average age of the patients was 58.24±10.03 year in which 68% were male and 32% female. Preoperative mild anxiety was observed in 64% patients and moderate to severe anxiety in 36% patients. Post-operative mean pain score was significantly high in moderate to severe anxiety group as compared to mild anxiety group [Mean pain difference =1.64 (95%CI: 1.38-1.89) p=0.0005], [Mean pain difference =0.51 (95%CI: 0.29-0.73) p=0.0005] at 12 hour and 24 hour respectively. Intraoperative and postoperative morphine consumption was significantly high in patients with moderate to severe anxiety group.ConclusionsPatients with moderate to severe anxiety before cardiac surgery experienced higher pain scores at post-operative period which is significantly different from mild anxiety group. Intraoperative and postoperative analgesic requirements were also significantly increased.

Post-Cesarean Opioid Use after Implementation of Enhanced Recovery after Surgery Protocol

Objective This study aimed to evaluate whether implementation of an enhanced recovery after surgery (ERAS) protocol is associated with lower maternal opioid use after cesarean delivery (CD). Study Design We performed a pre- and postimplementation (PRE and POST, respectively) study of an ERAS protocol for cesarean deliveries. ERAS is a multimodal, multidisciplinary perioperative approach. The four pillars of our protocol include education, pain management, nutrition, and early ambulation. Patients were counseled by their outpatient providers and given an educational booklet. Pain management included gabapentin and acetaminophen immediately prior to spinal anesthesia. Postoperatively patients received scheduled acetaminophen and ibuprofen. Oxycodone was initiated as needed 24 hours after spinal analgesia. Preoperative diet consisted of clear carbohydrate drink consumed 2 hours prior to scheduled operative time with advancement as tolerated immediately postoperation. Women with a body mass index (BMI) <40 kg/m2 and scheduled CD were eligible for ERAS. PRE patients were randomly selected from repeat cesarean deliveries (RCDs) at a single site from October 2017 to September 2018, BMI <40 kg/m2, without trial of labor. The POST cohort included women who participated in ERAS from October 2018 to June 2019. PRE and POST demographic and clinical characteristics were compared. Primary outcome was total postoperative morphine milligram equivalents (MMEs). Secondary outcomes included length of stay (LOS) and maximum postoperative day 2 (POD2) pain score. Results All women in PRE (n = 70) had RCD compared with 66.2% (49/74) in POST. Median total postoperative MMEs were 140.0 (interquartile range [IQR]: 87.5–182.5) in PRE compared with 0.0 (IQR: 0.0–72.5) in POST (p < 0.001). Median LOS in PRE was 4.02 days (IQR: 3.26–4.27) compared with 2.37 days (IQR: 2.21–3.26) in POST (p < 0.001). Mean maximum POD2 pain score was 5.28 (standard deviation [SD] = 1.86) in PRE compared with 4.67 (SD = 1.63) in POST (p = 0.04). Conclusion ERAS protocol was associated with decreased postoperative opioid use, shorter LOS, and decreased pain after CD. Key Points