Paracetamol reduces postoperative pain and rescue analgesic demand after robot-assisted endoscopic thyroidectomy by the transaxillary approach

Paracetamol did not improve the analgesic efficacy with regional block after video assisted thoracoscopic surgery: a randomized controlled trial

BACKGROUND

Various analgesic techniques have been applied, the pain after video assisted thoracic surgery (VATS) is still challenging for anesthesiologists. Paracetamol provide analgesic efficacy in many surgeries. However, clinical evidence in the lung surgery with regional block remain limited. This monocentric double-blind randomized controlled trial investigates the efficacy of paracetamol after VATS with regional block.

METHODS

A total of 90 patients were randomized to receive paracetamol (1 g) or normal saline. Erector Spinae Plane Block and Intercostal Nerve block were applied during the surgery. The Visual Analogue Scales (VAS) pain score was measured in the PACU as well as 6, 12, 24, and 48 h postoperatively. And the total dose of rescue analgesics administered to patients in morphine milligram equivalents (MME), satisfaction score, length of hospital stays, and incidence of nausea and vomiting were also recorded.

RESULTS

The VAS pain score at each time point, the primary endpoint, did not differ between the groups (3.09 ± 2.14 vs. 2.53 ± 1.67, p = 0.174 at PACU; 4.56 ± 2.80 vs. 4.06 ± 2.46, p = 0.368 at 6 h; 3.07 ± 1.98 vs. 3.44 ± 2.48, p = 0.427 at 12 h; 2.10 ± 2.00 vs. 2.49 ± 2.07, p = 0.368 at 24 h; and 1.93 ± 1.76 vs. 2.39 ± 1.97, p = 0.251 at 48 h postoperatively). Satisfaction scores (4.37 ± 0.76 vs. 4.14 ± 0.88, p = 0.201), nausea (35.6% vs. 37.8%, p = 0.827), hypotension (2.2% vs. 0.0%, p = 0.317), and bradycardia (6.7% vs. 2.2%, p = 0.309) were also reported at similar rates.

CONCLUSIONS

The analgesic efficacy of one gram of paracetamol with ESPB and ICNB after VATS was not proven. Thus, caution should be exercised when prescribing paracetamol for pain control during VATS.

TRIAL REGISTRATION

this trial was registered on Clinical Research Information Service (CRIS), Republic of Korea (KCT0008710). Registration date: 17/08/2023.

Clinical Application of Pectoralis Nerve Block II for Flap Dissection-Related Pain Control after Robot-Assisted Transaxillary Thyroidectomy: A Preliminary Retrospective Cohort Study

Simple Summary

The main findings of the study are that pectoralis nerve block II (PECS II) may be a valuable analgesic option that alleviates flap dissection pain and stress during a robot-assisted transaxillary thyroidectomy (RATT) and reduces opioid consumption in the early recovery phase. Patients who received PECS II experienced a more comfortable recovery and required fewer painkillers. PECS II may serve as a valuable new pain relief modality in addition to the multimodal analgesic strategy for patients undergoing RATT. Although we have yet to investigate the optimal block duration, regions of sensory loss, optimal technique, and possible complications, our preliminary study suggests that PECS II reduces flap dissection pain and thus promotes recovery. Appropriate analgesia during RATT remains challenging, but is a key issue for postoperative recovery. A further prospective investigation is required to validate our results and establish the optimal pain control regimen for patients undergoing RATT.

Abstract

Few studies have examined the clinical utility of ultrasonography-guided pectoralis nerve block II (PECS II) during wide flap dissection of a robot-assisted transaxillary thyroidectomy (RATT). We assessed the ability of PECS II to reduce postoperative pain. We retrospectively reviewed 62 patients who underwent elective RATT from December 2021 to April 2022 at Seoul St. Mary’s Hospital (Seoul, Korea). The patients were divided into a block group (n = 28, 50.9%) and no-block group (n = 27, 49.1%). Pain was measured using a visual analog scale (VAS) at 4, 10, 20, 25, 35, and 45 h after surgery, and the requirements for rescue painkillers in the post-anesthesia care unit and ward were recorded. The VAS scores did not differ significantly between the two groups at 4 h postoperatively. The block group had significantly lower VAS scores at 10 and 25 h (p = 0.017 and p = 0.034, respectively). The block group required fewer painkillers in the post-anesthesia care unit than the no-block group, although the difference was not statistically significant in the ward. PECS II may serve as a new pain relief modality and valuable addition to the current multimodal analgesic strategy for patients undergoing RATT.

Perioperative pain management and opioid-reduction in head and neck endocrine surgery: An American Head and Neck Society Endocrine Surgery Section consensus statement

BACKGROUND

This American Head and Neck Society (AHNS) consensus statement focuses on evidence-based comprehensive pain management practices for thyroid and parathyroid surgery. Overutilization of opioids for postoperative pain management is a major contributing factor to the opioid addiction epidemic however evidence-based guidelines for pain management after routine head and neck endocrine procedures are lacking.

METHODS

An expert panel was convened from the membership of the AHNS, its Endocrine Surgical Section, and ThyCa. An extensive literature review was performed, and recommendations addressing several pain management subtopics were constructed based on best available evidence. A modified Delphi survey was then utilized to evaluate group consensus of these statements.

CONCLUSIONS

This expert consensus provides evidence-based recommendations for effective postoperative pain management following head and neck endocrine procedures with a focus on limiting unnecessary use of opioid analgesics.

Perioperative Analgesia for Thyroid and Parathyroid Surgery: A Review of Current Practices

This article discusses the algorithms and published practice patterns on perioperative analgesia for thyroid and parathyroid surgery. This includes medications and techniques used for general anesthesia, local anesthesia including nerve block methods, and oral medication used for postoperative pain control. The authors also discuss multimodality pain control and the increased trend to reduce opioid analgesics without inadequate pain control or patient satisfaction.

A systematic review and trial sequential analysis of intravenous vs. oral peri-operative paracetamol

Postoperative pain might be different after intravenous vs. oral paracetamol. We systematically reviewed randomised controlled trials in patients >15 years that compared intravenous with oral paracetamol for postoperative pain. We identified 14 trials with 1695 participants. There was inconclusive evidence for an effect of route of paracetamol administration on postoperative pain at 0–2 h (734 participants), 2–6 h (766 participants), 6–24 h (1115 participants) and >24 h (248 participants), with differences in standardised mean (95%CI) pain scores for intravenous vs. oral of −0.17 (−0.45 to 0.10), −0.09 (−0.24 to 0.06), 0.06 (−0.12 to 0.23) and 0.03 (−0.22 to 0.28), respectively. Trial sequential analyses suggested that a total of 3948 participants would be needed to demonstrate a meaningful difference in pain or its absence at 0–2 h. There were no differences in secondary outcomes. Intravenous paracetamol is more expensive than oral paracetamol. Substitution of oral paracetamol in half the patients given intravenous paracetamol in our hospital would save around £ 38,711 (€ 43,960 or US$ 47,498) per annum.

Perioperative Analgesia for Patients Undergoing Thyroidectomy and Parathyroidectomy: An Evidence-Based Review

Objective:

To perform an evidence-based systematic review evaluating perioperative analgesia, including opioid alternatives, used for patients undergoing thyroidectomy and parathyroidectomy.

Methods:

A comprehensive literature search from 1997 to January 2018 of Pubmed, Cochrane, and EmBase libraries was performed for studies reporting analgesic administration following thyroid or parathyroid surgery. This systematic review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Studies were evaluated for level of evidence and given a Jadad score to assess for risk of bias. Outcomes gathered included postoperative pain scores, time to rescue analgesia, rescue analgesic consumption, and adverse events.

Results:

Thirty-eight randomized controlled trials met inclusion criteria. The GRADE criteria determined the overall evidence to be moderate-high. Studies utilizing NSAIDs reported reduced requirements for rescue analgesics. Acetaminophen studies presented with conflicting data on effectiveness. Gabapentinoid studies demonstrated lower pain scores and an increased time to rescue analgesic. Local anesthetics were effective at decreasing Visual Analogue Scale (VAS) and Numeric Rating Scale (NRS) pain scores while also reducing rescue analgesic consumption. Ketamine was shown to increased postoperative nausea and vomiting. NSAIDs and local anesthetic studies had an aggregate grade of evidence A, while all others had grade B evidence.

Conclusion:

There is significant evidence supporting the use of NSAIDs and local anesthetics in the perioperative period for pain management for thyroid and parathyroid surgeries. Acetaminophen, gabapentinoid and ketamine have some supporting evidence and may serve as adequate alternatives. Further multi-institutional RCTs are warranted to delineate optimal analgesic regimens.

Level of Evidence:

NA

Robotic-assisted breast-axillo insufflation thyroidectomy (RABIT): a retrospective case series of thyroid carcinoma

OBJECTIVE

To evaluate the feasibility and safety of robotic-assisted breast-axillo insufflation thyroidectomy (RABIT) for differentiated thyroid cancer.

METHODS

In this retrospective case series, patients with differentiated thyroid carcinoma were enrolled in our hospital from January 2018 to December 2018. All patients underwent indirect laryngoscopy to assess the status of vocal cord preoperatively. RABIT was performed with five separate breast-axillo incisions. All the procedures were performed using da Vinci Xi Robotic Surgical System, a single docking method using CO₂ insufflation.

RESULTS

Twelve patients completed RABIT, in which one case needed conversion to open thyroidectomy. The mean age was 30.25 ± 7 with male to female ratio being 1:1. Preoperative diagnosis showed papillary carcinoma (n = 9) and follicular neoplasm (n = 3). The mean operative time for RABIT was 140 ± 50.45 min and average blood loss during surgery was 22.92 ± 9 mL. Mean hospital stay was 4.42 ± 1.08 days. Final pathology confirmed classical papillary thyroid carcinoma (n = 10; 83.3%) and follicular variant of papillary carcinoma (n = 2; 16.7%). None of the cases reported injury or paralysis to the recurrent laryngeal nerves.

CONCLUSION

RABIT is a safe and feasible approach for thyroidectomy. It has several advantages in that it provides similar symmetrical view to conventional open surgery and enables to maintain specimen integrity and use of assistant port permits better handling of the gland. Additionally, the largest operating angles with this technique prevent collision between the robotic arms and provide excellent cosmetic satisfaction due to very small, five separate breast-axillo incisions.

Robotic Thyroidectomy Decreases Postoperative Pain Compared With Conventional Thyroidectomy

BACKGROUND

This retrospective study compared postoperative pain between patients undergoing open thyroidectomy (OT) and bilateral axillo-breast approach (BABA) robotic thyroidectomy (RT).

MATERIALS AND METHODS

We analyzed the electronic medical records of 1269 patients who underwent OT or RT at Chung-Ang University Hospital between January 1, 2010 and April 30, 2016. On the basis of the surgical procedure performed, patients were categorized into an OT (n=1128) and a BABA RT (BRT) group (n=141). On the basis of covariates, patients in these groups were matched using propensity score matching (n=86 in each group).

RESULTS

After propensity score matching, no intergroup differences were observed in the covariates. The visual analogue scale scores for pain on postoperative day 0 were lower in the BRT than in the OT group (2.57±0.95 vs. 2.28±0.95, P=0.040). However, no statistically significant differences were observed in the use of rescue analgesics, the numerical rating scale score for nausea, and the use of rescue antiemetics.

CONCLUSIONS

Pain on postoperative day 0 was lesser in the BRT than in the OT group. Similarly, the severity of nausea was lesser in the BRT group, despite longer operation time and broad dissection performed for docking the robotic arms.

Association between intravenous acetaminophen and reduction in intraoperative opioid consumption during transsphenoidal surgery for pituitary tumors

Background and Aims

Pain during and after transsphenoidal surgeries originates from stimulation of branches of the trigeminal cranial nerve that supply the inner aspect of the nose cavity and dura mater. Thereby, patients undergoing transsphenoidal surgery may require moderate-to-large amounts of analgesics including opioids. Intravenous acetaminophen provides analgesia and reduces opioid consumption for a wide variety of surgeries. We hypothesized that the use of intravenous acetaminophen is associated with a reduction in intraoperative opioid consumption and provides significant analgesia during and after transsphenoidal surgery.

Material and Methods

This retrospective study included 413 patients who underwent transsphenoidal surgery for pituitary adenomas. The primary outcome of this study was intraoperative opioid consumption. Secondary outcomes included pain intensity, Richmond Agitation Sedation Scale scores, and nausea and vomiting upon arrival to postoperative anesthesia care unit. Patients were divided into two groups based on the intraoperative acetaminophen use. A prospensity score matching analysis was used to balance for important variables between the two groups of treatment. Regression models were fitted after matching the covariates. A P < 0.05 was considered statistically significant.

Results

After matching, 126 patients were included in each group of treatment. Patients in the acetaminophen group required significantly less amount (a decrease by 14.9%) of opioids during surgery than those in the non-acetaminophen group. Postoperative pain, postoperative nausea and vomiting, and sedation scores were not significantly different between patients who received intravenous acetaminophen and those who did not.

Conclusion

Intravenous acetaminophen is associated with a reduction in intraoperative opioids during transsphenoidal pituitary surgery.

Efficacy of ketamine for postoperative pain following robotic thyroidectomy: A prospective randomised study

Objective

Although robotic thyroidectomy (RoT) is a minimally invasive surgery, percutaneous tunneling causes moderate to severe pain immediately postoperatively. We evaluated the efficacy of ketamine for postoperative pain management in patients following RoT.

Methods

Sixty-four patients scheduled for RoT were randomly divided into two groups. In the ketamine group (n = 32), ketamine was infused from induction of anaesthesia until the end of the procedure (0.15-mg/kg bolus with continuous infusion at 2 µg/kg/min). In the control group (n = 32), the same volume of saline was infused. Visual analogue scale (VAS) scores for acute and chronic pain, the incidence of hypoesthesia, postoperative analgesic requirements, and complications related to opioids or ketamine were compared between the two groups.

Results

The VAS pain scores were significantly lower in the ketamine group up to 24 h postoperatively. The VAS pain score when coughing was significantly higher in the control group than in the ketamine group at 24 h postoperatively. A significantly greater proportion of patients in the control group required rescue analgesics. Complications were comparable in both groups.

Conclusions

Ketamine infusion decreased pain scores for 24 h postoperatively and reduced analgesic requirements without serious complications in patients following RoT.

Trial Registration: Clinicaltrials.gov Identifier: NCT01997801

Transoral robotic thyroidectomy: lessons learned from an initial consecutive series of 24 patients

BACKGROUND

Transoral thyroid surgery is an ideal method for minimally invasive thyroidectomy, as there is less flap dissection during the procedure and no postoperative scars. Nonetheless, technical obstacles have precluded the wide dissemination of this procedure. We present the surgical procedures and outcomes of transoral robotic thyroidectomy (TORT).

METHODS

From September 2012 to June 2016, we performed TORT at Korea University Hospital. We used three intraoral ports and a single axillary port for the system's four robotic arms. The surgical outcomes were retrospectively reviewed.

RESULTS

Twenty-four female patients (mean age 39.6 ± 11.6 years; mean tumor size 1.0 ± 1.3 cm) underwent unilateral thyroid lobectomies with or without ipsilateral central neck dissection. Twenty patients had papillary thyroid carcinomas (PTC), three had benign nodules, and one had a follicular thyroid carcinoma. The mean surgical time was 232 ± 41 min; the mean hospital stay was 3.3 ± 0.8 days. The number of retrieved central lymph nodes in the PTC patients was 4.7 ± 3.2. There were no reports of transient or permanent vocal cord palsy, recurrence, or mortality during the median follow-up period of 16.8 months. Paresthesia of the lower lip and the chin due to mental nerve injury was observed in nine of the first 12 patients (six transient, three permanent), but no further reports of paresthesia were recorded after patient 12, when the locations of the intraoral incisions were modified.

CONCLUSIONS

TORT is feasible and safe for selected patients after technical refinements, and can be a potential alternative approach for scarless thyroid surgery.

Prospective, randomized, and controlled trial on ketamine infusion during bilateral axillo-breast approach (BABA) robotic or endoscopic thyroidectomy: Effects on postoperative pain and recovery profiles: A consort compliant article

BACKGROUND

Robotic or endoscopic thyroidectomy using bilateral axillo-breast approach (BABA) is frequently performed for excellent cosmesis. However, postoperative pain is remained as concerns due to the extent tissue dissection and tension during the operation. Ketamine is a noncompetitive N-methyl-D-aspartate (NMDA) receptor antagonist that reduces acute postoperative pain. We evaluated the effects of intraoperative ketamine infusion on postoperative pain control and recovery profiles following BABA robotic or endoscopic thyroidectomy.

METHODS

Fifty-eight adult patients scheduled for BABA robotic or endoscopic thyroidectomy were randomized into a control group (n = 29) and ketamine group (n = 29). Following induction of anesthesia, patients in each group were infused with the same volume of saline or ketamine solution (1 mg/kg bolus, 60 μg/kg/h continuous infusion). Total intravenous anesthesia with propofol and remifentanil was used to induce and maintain anesthesia. Pain scores (101-point numerical rating scale, 0 = no pain, 100 = the worst imaginable pain), the consumption of rescue analgesics, and other postoperative adverse effects were assessed at 1, 6, 24, and 48 hours postoperatively.

RESULTS

Patients in the ketamine group reported lower pain scores than those in the control group at 6 hours (30 [30] vs 50 [30]; P = 0.017), 24 hours (20 [10] vs 30 [20]; P < 0.001), and 48 hours (10 [10] vs 20 [15]; P < 0.001) in neck area. No statistically significant differences were found between the 2 groups in terms of the requirements for rescue analgesics or the occurrence of adverse events.

CONCLUSION

Intravenous ketamine infusion during anesthesia resulted in lower postoperative pain scores following BABA robotic or endoscopic thyroidectomy, with no increase in adverse events.

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.

Benefits of Multimodal Enhanced Recovery Pathway in Patients Undergoing Open Ventral Hernia Repair

BACKGROUND

Use of Enhanced Recovery After Surgery (ERAS) pathways have evidenced improved outcomes in several surgical specialties. The effectiveness of ERAS pathways specific to hernia surgery, however, has not yet been investigated. We hypothesized that our ERAS pathway would accelerate functional recovery and shorten hospitalization in patients undergoing open ventral hernia repair (VHR).

STUDY DESIGN

Consecutive patients undergoing open major VHR using transversus abdominis release and sublay synthetic mesh placement, with use of our ERAS pathway, were compared with a historical cohort before ERAS implementation. Main outcomes measures were time to diet advancement, time to return of bowel function, time to oral narcotics, length of stay (LOS), and 90-day readmissions.

RESULTS

Between January 2014 and January 2015, 100 patients undergoing VHR with ERAS implementation were compared with a historical cohort. The ERAS group demonstrated significantly shorter times to liquid and regular diet: 1.1 vs 2.7 and 3.0 vs 4.8 days, respectively (p < 0.001). Furthermore, ERAS patients demonstrated significantly shorter times to flatus and bowel movement: 3.1 vs 3.9 and 3.6 vs 5.2 days, respectively (p < 0.001). Average LOS was reduced from 6.1 to 4.0 days (p < 0.001), and ERAS patients had significantly fewer 90-day readmissions, 4% vs 16% (p < 0.001).

CONCLUSIONS

A comprehensive ERAS pathway for major open VHR was implemented safely. Multimodal perioperative pain management, oral opioid-receptor blockade, and early feeding strategies resulted in accelerated intestinal recovery, shorter hospitalizations, and fewer readmissions. Use of our ERAS pathway appears to result in improved outcomes in patients undergoing open VHR.

Intravenous acetaminophen vs. ketorolac for postoperative analgesia after ambulatory parathyroidectomy

Background and methods Minimally invasive parathyroidectomy requires limited analgesia and short recovery times. The preferred post-operative analgesic regimen for this patient population has not been established but non-narcotic components would be quite appropriate. The aim of the study was to determine whether intravenous (IV) acetaminophen (1 g) or ketorolac (30 mg) provide better pain control after parathyroidectomy. A parallel, randomized, double blind, comparative study was completed on 180 patients scheduled for outpatient parathyroidectomy utilizing general anesthesia. Patients were randomized to a blinded administration of either intravenous acetaminophen 1 g or ketorolac 30 mg intra-operatively. Upon arrival but before premedication, baseline pain scores were assessed in all patients. A consecutive series of postoperative pain scores were collected every 15 min using a 10 cm visual analog pain scale (VAS) upon arrival to the post anesthesia care unit (PACU) until discharge by blinded study personnel. Other data collected included: anesthesia time, surgical time, time to discharge, supplemental morphine and postoperative side effects. Results Overall mean postoperative VAS scores were not significantly different between the two treatment groups (p = 0.07). However, ketorolac produced significantly lower pain scores compared with acetaminophen in the later postoperative periods (3.9 ± 1.9 vs. 4.8 ± 2.4 at 45 min, p = 0.009; 3.4 ± 1.7 vs. 4.5 ± 2.1 at 60min, p = 0.04; and 3.2 ± 2.1 vs. 4.4 ± 2.1 at 75 min, p = 0.03). Supplemental morphine was administered to 3 patients in the ketorolac group and 9 patients in the acetaminophen group but total consumption was not significantly different between groups (p = 0.13). The occurrence of nausea was significantly lower in the ketorolac group compared with the IV acetaminophen group (3.4% vs. 14.6%, respectively; p = 0.02). The overall incidence of morphine supplementation, vomiting, headache, muscular pain, dizziness, and drowsiness were not significantly different when compared between the treatment groups. Conclusions Both postoperative regimens provided adequate analgesia but patients receiving ketorolac intraoperatively had significantly lower pain scores at later recovery time points and significantly lower occurrences of nausea. Implications The large volume of patients undergoing parathyroidectomies at our facility warranted a study to develop a standardized postoperative analgesic regimen. We conclude both medications can be utilized safely in this patient population, but there is a slight advantage in pain control with the usage of ketorolac for minimally invasive parathyroidectomies.

Intravenous acetaminophen: a review of pharmacoeconomic science for perioperative use

Hospitals are subject to more economic pressures than ever before. On the one hand, cost containment or cost reduction is paramount, particularly in relation to costly branded pharmaceuticals. On the other hand, quality measures and value-based reimbursement penalizes poor patient care. Multimodal analgesia sits squarely in this quandary, since its very nature requires use of multiple drugs with their associated costs, though this approach has the potential to improve quality of care. We undertook a comprehensive review of the pharmacoeconomics of IV acetaminophen, a new drug useful as part of a multimodal analgesic approach. While this new branded drug adds to direct drug costs, there is clear potential for IV acetaminophen to reduce the incidence of opioid-related adverse events and, in so doing, result in net hospital savings. This review describes many clinical studies showing significant improvements in postoperative nausea and vomiting, excessive sedation and pruritus. In addition, we describe studies demonstrating faster recovery times in the post-anesthesia care unit, intensive care unit and total hospital length of stay. Lastly, we summarize many studies demonstrating the robust effect of IV acetaminophen on patient satisfaction. A holistic view of total hospital performance should be adopted when reviewing drugs rather than a silo mentality within the pharmacy. While IV acetaminophen adds to drug costs, the body of evidence indicates this drug has the potential to improve outcomes and hospital efficiency.

Analgesic efficacy of bilateral superficial cervical plexus block in robot-assisted endoscopic thyroidectomy using a transaxillary approach

BACKGROUND

Nerve blocks and infiltration with local anesthetics are commonly employed methods for postoperative pain control. This prospective, randomized trial was conducted to determine whether bilateral superficial cervical plexus block (BSCPB) is effective for reducing acute postoperative pain after robot-assisted endoscopic thyroidectomy (RAET) and to compare its effects with that of local wound infiltration (LWI).

METHODS

Ninety-seven patients who were to undergo RAET were randomly assigned to one of three groups to receive BSCPB with either 20 mL of 0.525% ropivacaine (BSCPB group, n=32) or 20 mL of isotonic sodium chloride solution (Control group, n=32) or LWI with 20 mL of 0.525% ropivacaine (LWI group, n=33). Postoperative pain scores were assessed at the postoperative anesthesia care unit (PACU) and at 6, 24, and 48 h postoperatively using a visual analog scale (VAS). Patients with VAS scores of ≥40 were administered rescue analgesics according to a standardized protocol. The main outcome variables were pain scores during the first postoperative 24 h and the number of patients requiring postoperative analgesic rescue.

RESULTS

The BSCBP and LWI groups showed lower pain scores compared with the Control group at the PACU. The BSCPB group continued to show significantly lower pain scores compared with the LWI and Control groups at postoperative 6 and 24 h. The number of patients requiring analgesic rescue at the PACU was lower in the BSCPB and LWI groups than in the Control group. The number of patients requiring additional rescue analgesics after discharge from the PACU until the first 24 postoperative h was lower in the BSCPB group than in the LWI group.

CONCLUSIONS

BSCPB and LWI are effective for reducing pain scores and analgesic requirements during the immediate postoperative period in patients who undergo RAET, with BSCPB being superior to LWI at postoperative 6-24 h.

Intravenous acetaminophen reduces postoperative nausea and vomiting: a systematic review and meta-analysis

Opioids are a key risk factor for postoperative nausea and vomiting (PONV). As intravenous (i.v.) acetaminophen reduces postoperative pain and opioid requirements, one would expect i.v. acetaminophen to be associated with a lower incidence of opioid-induced side effects, including PONV. We conducted a systematic search using Medline and Cochrane databases supplemented with hand search of abstract proceedings to identify randomized-controlled trials of i.v. acetaminophen. Inclusion criteria were (a) randomized for i.v. acetaminophen vs a placebo control, (b) general anesthesia, and (c) reported or obtainable PONV outcomes. Primary outcome was postoperative nausea and secondary outcome was postoperative vomiting. We included 30 studies with 2364 patients (1223 in the acetaminophen group, 1141 in the placebo group). The relative risk (95% confidence interval) was 0.73 (0.60-0.88) for nausea and 0.63 (0.45-0.88) for vomiting. Data showed significant heterogeneity for both nausea (P=0.02, I(2)=38%) and vomiting (P=0.006, I(2)=47%), but were homogeneous when studies were grouped according to timing of first administration: i.v. acetaminophen reduced nausea when given prophylactically either before surgery, 0.54 (0.40-0.74), or before arrival in the postanesthesia care unit, 0.67 (0.55-0.83); but not when given after the onset of pain, 1.12 (0.85-1.48). When i.v. acetaminophen was given prophylactically, the reduction of nausea correlated with the reduction of pain (odds ratio 0.66, 0.47-0.93), but not with reduction in postoperative opioids (odds ratio 0.89, 0.64-1.22). Prophylactically administered i.v. acetaminophen reduced PONV, mainly mediated through superior pain control.

Comparison of the incidence of postoperative nausea and vomiting between women undergoing open or robot-assisted thyroidectomy

BACKGROUND

Open thyroidectomy is associated with a high incidence of postoperative nausea and vomiting (PONV) in up to 70 % of cases. Use of the recently introduced robot-assisted endoscopic thyroidectomy using a gasless transaxillary approach has been increasing because of its several advantages over open thyroidectomy. This study compared the incidence of PONV in the women who underwent open or robot-assisted thyroidectomy.

METHODS

This prospective, double-blinded study enrolled 170 women 20-60 years of age who were scheduled for conventional open thyroidectomy (group O) or robot-assisted thyroidectomy (group R). A standard anesthetic technique, including sevoflurane and air in oxygen, was used. During a 0-24-h postoperative period, the presence and severity of PONV (nausea, retching/vomiting), severity of pain, need for rescue antiemetics, and the degree of patient satisfaction were evaluated.

RESULTS

During the 0-6-h postoperative period, the incidence of PONV and mean pain score (40.0 vs. 51.8 %and 4.2 vs. 4.8 in groups R and O, respectively) were not significantly different. At 6-24 h postoperatively, the incidence of PONV (18.8 vs. 44.7 %), severe emesis (11.8 vs. 29.4 %) and mean pain score (2.8 vs. 3.8) were significantly lower in group R compared to group O, respectively. Overall, the incidence of PONV (42.4 vs. 63.5 %) and severe emesis (20.0 vs. 43.5 %) were significantly lower in group R compared to group O, respectively. The incidence of satisfied patients 6 and 24 h after the end of anesthesia (55.3 vs. 28.2 and 82.4 vs. 58.8 %) were significantly higher in group R compared to group O, respectively.

CONCLUSIONS

Robotic thyroidectomy reduces the incidence and severity of PONV compared to open thyroidectomy during a 0-24-h postoperative period.

Clinical and economic evidence for intravenous acetaminophen

Intravenous acetaminophen received United States Food and Drug Administration approval in November 2010 for the management of mild-to-moderate pain, management of moderate-to-severe pain with adjunctive opioid analgesics, and reduction of fever. Although intravenous acetaminophen generally improved pain relief and demonstrated opioid-sparing effects compared with placebo, it did not consistently reduce the frequency of opioid-related adverse events (e.g., postoperative nausea and vomiting). The safety and efficacy of intravenous acetaminophen as an antipyretic agent have been documented in adults and children; however, its cost is several-fold higher than that of the oral and rectal formulations. Although use of intravenous acetaminophen has reduced other postoperative resource utilization (e.g., hospital length of stay) in some studies outside the United States in patients undergoing abdominal surgery, a full economic evaluation in the United States has yet to be undertaken. In addition, its administration time (15-min infusion) and packaging (glass, single-use vial) have the potential to adversely affect patient flow in the postanesthesia care unit, create burden on patient care units, and lead to drug waste. Furthermore, 1 g of intravenous acetaminophen is formulated in 100 ml of solution, which may be an issue for patients with fluid restrictions. Given the clinical and economic evidence currently available, intravenous acetaminophen should not replace oral or rectal acetaminophen, but its use may be considered in a limited number of patients who cannot receive drugs orally and rectally and who cannot tolerate other parenteral nonopioid analgesic or antipyretic agents.

Continuous multimechanistic postoperative analgesia: a rationale for transitioning from intravenous acetaminophen and opioids to oral formulations

Good surgical outcomes depend in part on good pain relief, allowing for early mobilization, optimal recovery, and patient satisfaction. Postsurgical pain has multiple mechanisms, and multimechanistic approaches to postoperative analgesia are recommended and may be associated with improved pain relief, lowered opioid doses, and sometimes a lower rate of opioid-associated side effects. Acetaminophen (paracetamol) is a familiar agent for treating many types of pain, including postsurgical pain. Oral acetaminophen has been shown to be safe and effective in a variety of acute pain models. Combination products using a fixed-dose of acetaminophen and an opioid have also been effective in treating postsurgical pain. Combination products with acetaminophen have demonstrated an opioid-sparing effect, which inconsistently results in a reduced rate of opioid-associated side effects. Intravenous (IV) acetaminophen and an opioid analgesic administered in the perioperative period may be followed by an oral acetaminophen and opioid combination in the postoperative period. Transitioning from an IV acetaminophen and opioid formulation to a similar but oral formulation of the same drugs appears to be a reasonable step in that both analgesic therapies are known to be safe and effective. For postsurgical analgesia with any acetaminophen product, patient education is necessary to be sure that the patient does not concurrently take any over-the-counter products containing acetaminophen and accidentally exceed dose limits.

Intravenous acetaminophen

Acetaminophen has unique analgesic and antipyretic properties. It is globally recommended as a first-line agent for the treatment of fever and pain due to its few contraindications. Acetaminophen lacks the significant gastrointestinal and cardiovascular side effects associated with nonsteroidal anti-inflammatory drugs and narcotics. An intravenous formulation of acetaminophen is available in Europe and is currently undergoing extensive clinical development for use in the United States. This use may have important implications for management of postoperative pain and fever. This review summarizes recent clinical trial experiences with intravenous acetaminophen for the treatment of postoperative pain and fever in adult and pediatric subjects.

The evolution of robotic thyroidectomy: from inception to neck dissection

Over the past decade, the application of surgical robotics is bringing about dramatic changes in various surgical fields. Robotic thyroidectomy has achieved safe and accurate management of thyroid disease with remarkable cosmetic and functional benefits. As experiences with robotic techniques accumulate, its indications will expand to include more advanced cases with higher levels of difficulty.