Flurbiprofen axetil provides a prophylactic benefit against mesenteric traction syndrome associated with remifentanil infusion during laparotomy

Risks of serious adverse events with non-steroidal anti-inflammatory drugs in gastrointestinal surgery: A systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly recommended for perioperative opioid-sparing multimodal analgesic treatments. Concerns regarding the potential for serious adverse events (SAEs) associated with perioperative NSAID treatment are especially relevant following gastrointestinal surgery. We assessed the risks of SAEs with perioperative NSAID treatment in patients undergoing gastrointestinal surgery.

METHODS

We conducted a systematic review of randomised clinical trials assessing the harmful effects of NSAIDs versus placebo, usual care or no intervention in patients undergoing gastrointestinal surgery. The primary outcome was an incidence of SAEs. We systematically searched for eligible trials in five major databases up to January 2024. We performed risk of bias assessments to account for systematic errors, trial sequential analysis (TSA) to account for the risks of random errors, performed meta-analyses using R and used the Grading of Recommendations Assessment, Development and Evaluation framework to describe the certainty of evidence.

RESULTS

We included 22 trials enrolling 1622 patients for our primary analyses. Most trials were at high risk of bias. Meta-analyses (risk ratio 0.78; 95% confidence interval [CI] 0.51-1.19; I2 = 4%; p = .24; very low certainty of evidence) and TSA indicated a lack of information on the effects of NSAIDs compared to placebo on the risks of SAEs. Post-hoc beta-binomial regression sensitivity analyses including trials with zero events showed a reduction in SAEs with NSAIDs versus placebo (odds ratio 0.73; CI 0.54-0.99; p = .042).

CONCLUSION

In adult patients undergoing gastrointestinal surgery, there was insufficient information to draw firm conclusions on the effects of NSAIDs on SAEs. The certainty of the evidence was very low.

Contribution of prophylactic administration of flurbiprofen for mesenteric traction syndrome to postoperative leakage or bleeding in gastrointestinal surgery: a retrospective observational study

PURPOSE

Mesenteric traction syndrome (MTS) sometimes occurs during abdominal surgery. Prophylactic administration of flurbiprofen, a non-steroidal anti-inflammatory drug, prevents the development of MTS. However, administration of non-steroidal anti-inflammatory drugs for postoperative pain increases the incidence of postoperative bleeding. Our aim was to examine the effect of prophylactic flurbiprofen administration on postoperative leakage or bleeding after gastrointestinal surgery.

METHODS

A retrospective observational study on patients who underwent open or laparoscopic abdominal surgery was conducted. Perioperative, anesthesia and medical records were reviewed. Patients who did (Flurbio-Group) or did not receive (Control-Group) prophylactic flurbiprofen administration were compared. Then, the Flurbio-Group and Control-Group were each divided into two groups according to whether the patients did or did not develop MTS (Flurbio-MTS-Group and Flurbio-no-MTS-Group, respectively, Control-MTS-Group and Control-no-MTS-Group, respectively).

RESULTS

This study included 188 patients (Flurbio-MTS-Group, 1 patient; Flurbio-no-MTS-Group, 31 patients; Control-MTS-Group, 59 patients; Control-no-MTS-Group, 97 patients). Seventeen patients developed postoperative leakage or bleeding. Eleven Flurbio-MTS-Group patients (18.6%), 4 Flurbio-no-MTS-Group patients (12.9%, 4/31), and only 2 Control-no-MTS-Group patients (2%, 2/97) developed postoperative leakage or bleeding. Multivariate logistic regression analysis demonstrated that there was a qualitative interaction effect between prophylactic administration of flurbiprofen and the development of MTS on postoperative leakage or bleeding.

CONCLUSION

Prophylactic flurbiprofen administration increased the risk of postoperative leakage or bleeding among patients who did not develop MTS.

Mesenteric traction syndrome - Incidence, impact, and treatment: A systematic scoping review of the literature

BACKGROUND

Mesenteric traction syndrome (MTS) is commonly seen during major abdominal surgery and is characterised by facial flushing, hypotension, and tachycardia 15 min into surgery. MTS also impacts the postoperative course, as severe MTS has been associated with increased postoperative morbidity. However, despite MTS being common and severe MTS causing increased postoperative morbidity, the gaps in the literature are not clearly defined. We aimed to examine the diagnostic criteria, incidence, intraoperative and postoperative impact, and potential preventative measures of MTS while highlighting potential gaps in the literature.

METHODS

We followed the Prisma guidelines and performed a systematic literature search. We included only human studies examining MTS. All hits were screened for title and abstract, followed by a full-text review by at least two authors for determining eligibility for inclusion. Data were extracted and risk of bias was assessed by two independent reviewers.

RESULTS

A total of 37 studies, comprising 1102 patients were included in the review. The combined incidence of MTS during open abdominal surgery was found to be 76%, with 35% developing severe MTS. It was found that the development of MTS was associated with marked haemodynamic changes. It was also found that several different subjective diagnostic criteria exist and that severe MTS was associated with increased postoperative morbidity. Furthermore, several preventative measures for protecting against MTS have been examined, but only on the incidence of MTS and not on the postoperative course.

CONCLUSION

MTS occurs in 76% of patients undergoing major abdominal surgery and is associated with deleterious haemodynamic effects, which are more pronounced in patients developing severe MTS. Severe MTS is also associated with a worse postoperative outcome. However, gaps are still present in the current literature on MTS.

Mesenteric traction syndrome in pigs: A single-blinded, randomized controlled trial

Background

Mesenteric traction syndrome is commonly observed in patients undergoing upper abdominal surgery and is associated with severe postoperative complications. A triad of hypotension, tachycardia, and facial flushing seems provoked by prostacyclin (PGI2) release from the gut in response to mesenteric traction. The administration of nonsteroidal anti-inflammatory drugs (NSAID) inhibits PGI2 release, stabilizing the hemodynamic response. Here, we examined the effect of mesenteric traction on splanchnic blood flow in pigs randomized to NSAID or placebo treatment.

Materials and Methods

Twenty pigs were allocated to either ketorolac or placebo treatment. Five minutes of manual mesenteric traction was applied. Plasma 6-keto-PGF1α, a stable metabolite of PGI2, hemodynamic variables, and regional blood flow (laser speckle contrast imaging) to the liver, stomach, small intestine, upper lip, and snout (laser Doppler flowmetry) were recorded prior to traction and 5 and 30 minutes thereafter.

Results

Both groups of pigs presented a decrease in systemic vascular resistance (P = .01), mean arterial blood pressure (P = .001), and blood flow in the gastric antrum (P = .002). Plasma 6-keto-PGF1α did not increase in either group (P = .195), and cardiac output, heart rate, central venous pressure, and blood flow to the liver, small intestine, upper lip, and snout remained unchanged.

Conclusion

Mesenteric traction resulted in cardiovascular depression, including reduced blood flow in the gastric antrum. Plasma 6-keto-PGF1α did not increase, and ketorolac administration did not alter the response to mesenteric traction. Furthers studies are needed to identify which substance is responsible for eliciting the cardiovascular response to mesenteric traction in pigs.

Severe mesenteric traction syndrome is associated with increased systemic inflammatory response, endothelial dysfunction, and major postoperative morbidity

This study aimed to determine if mesenteric traction syndrome (MTS) triggers increased systemic inflammation and endothelial cell dysfunction. Patients developing severe MTS had pronounced early IL6 elevations followed by endothelial cell damage. Furthermore, these processes were associated with increased postoperative morbidity.

OBJECTIVE

To determine whether mesenteric traction syndrome (MTS) leads to increased systemic inflammation and dysfunction of the glycocalyx and endothelial cell and whether this correlates with the degree of postoperative morbidity.

INTRODUCTION

Severe MTS is associated with increased postoperative morbidity following major gastrointestinal surgery, but the pathophysiological mechanism has not been previously explored. Systemic inflammatory response and impaired glycocalyx and endothelial cells may be responsible for the development of symptoms.

METHODS

The study analyzed prospectively collected data from two cohorts (n = 67). The severity of the MTS response was graded intraoperatively and blood samples for PGI₂, catecholamines, IL6, and endothelial biomarkers obtained at predefined time points.

RESULTS

Patients undergoing either esophagectomy (n = 45) or gastrectomy (n = 22) were included. Surgery led to significantly increased plasma concentrations of all biomarkers. Yet, patients who developed severe MTS had higher baseline epinephrine levels (p < 0.05) and higher levels of PGI₂ (p < 0.05), Syndecan-1 (p < 0.001), and sVEGFR1 (p < 0.001). Peak values of IL6, Syndecan-1, sVEGFR1, and sTM all correlated to peak PGI₂. Lastly, patients with high postoperative morbidity had higher baseline epinephrine (p = 0.009) and developed higher plasma IL6 (p = 0.007) and sTM (p = 0.022).

CONCLUSION

The development of severe MTS during upper gastrointestinal surgery is associated with preoperative elevated plasma epinephrine and further a more pronounced proinflammatory response and damage to the vascular endothelium. The increased postoperative morbidity seen in patients with severe MTS may thus, in part, be explained by an inherent susceptibility towards an inappropriate secretion of PGI₂, which leads to an increased surgical stress response and endothelial damage. These findings must be confirmed in a new prospective cohort.

Hypotension Associated with MTS is Aggravated by Early Activation of TEA During Open Esophagectomy

Objective

A mesenteric traction syndrome (MTS) is elicited by prostacyclin (PGI₂)-induced vasodilation and identified by facial flushing, tachycardia, and hypotension during abdominal surgery. We evaluated whether thoracic epidural anesthesia (TEA) influences the incidence of MTS.

Design

Randomized, blinded controlled trial.

Setting

Single-center university hospital.

Participants

Fifty patients undergoing open esophagectomy.

Interventions

Patients were randomized to either early (EA, after induction of general anesthesia) or late activation of TEA (LA, after re-established gastric continuity). Plasma 6-keto-PGF_1α, a stable metabolite of PGI₂ and interleukine-6 (IL6) were measured in plasma during surgery along with hemodynamic variables and MTS graded according to facial flushing together with plasma C-reactive protein on the third post-operative day.

Results

Forty-five patients met the inclusion criteria. Development of MTS tended to be more prevalent with EA (n=13/25 [52%]) than with LA TEA (n=5/20 [25%], p=0.08). For patients who developed MTS, there was a transient increase in plasma 6-keto-PGF_1α by 15 min of surgery and plasma IL6 (p<0.001) as C-reactive protein (P<0.009) increased. EA TEA influenced the amount of phenylephrine needed to maintain mean arterial pressure >60 mmHg in patients who developed MTS (0.16 [0.016–0.019] mg/min vs MTS and LA TEA 0.000 [0.000–0.005] mg/min, p<0.001).

Conclusion

The incidence of MTS is not prevented by TEA in patients undergoing open esophagectomy. On the contrary, the risk of hypotension is increased in patients exposed to TEA during surgery, and the results suggest that it is advantageous to delay activation of TEA. Also, MTS seems to be associated with a systemic inflammatory response, maybe explaining the aggravated post-operative outcome.

Efficacy of flurbiprofen axetil for preventing postanesthetic shivering in patients undergoing gynecologic laparotomy surgeries

Background

Postanesthetic shivering is an unpleasant adverse event in surgical patients. A nonsteroidal anti-inflammatory drug has been reported to be useful in preventing postanesthetic shivering in several previous studies. The aim of this study was to evaluate the efficacy of flurbiprofen axetil being a prodrug of a nonsteroidal anti-inflammatory drug for preventing postanesthetic shivering in patients undergoing gynecologic laparotomy surgeries.

Method

This study is a retrospective observational study. I collected data from patients undergoing gynecologic laparotomy surgeries performed between October 1, 2019, and September 30, 2020, at Kumamoto City Hospital. All the patients were managed with general anesthesia with or without epidural analgesia. The administration of intravenous 50 mg flurbiprofen axetil for postoperative pain control at the end of the surgery was left to the individual anesthesiologist. The patients were divided into two groups: those who had received intravenous flurbiprofen axetil (flurbiprofen group) and those who had not received intravenous flurbiprofen axetil (non-flurbiprofen group), and I compared the frequency of postanesthetic shivering between the two groups. Additionally, the factors presumably associated with postanesthetic shivering were collected from the medical charts. Intergroup differences were assessed with the χ² test with Yates’ correlation for continuity category variables. The Student’s t test was used to test for differences in continuous variables. Furthermore, a multivariate logistic regression analysis was performed to elucidate the relationship between the administration of flurbiprofen axetil and the incidence of PAS.

Results

I retrospectively examined the cases of 141 patients aged 49 ± 13 (range 21-84) years old. The overall postanesthetic shivering rate was 21.3% (30 of the 141 patients). The frequency of postanesthetic shivering in the flurbiprofen group (n = 31) was 6.5%, which was significantly lower than that in the non-flurbiprofen group (n = 110), 25.5% (p value = 0.022). A multivariate logistic regression analysis showed that administration of flurbiprofen axetil was independently associated with a reduced incidence of postanesthetic shivering (odds ratio 0.12; 95% confidence interval, 0.02-0.66, p value = 0.015).

Conclusions

My result suggests that intraoperative 50 mg flurbiprofen axetil administration for postoperative pain control is useful to prevent postanesthetic shivering in patients undergoing gynecologic laparotomy surgeries.

Quantitative fluorescence angiography detects dynamic changes in gastric perfusion

INTRODUCTION

The use of Indocyanine green (ICG) fluorescence angiography (ICG-FA) is an applied method to assess visceral perfusion during surgical procedures worldwide. Further development has entailed quantification of the fluorescence signal; however, whether quantified ICG-FA can detect intraoperative changes in perfusion after hemorrhage has not been investigated previously. In this study, we investigated whether a quantification method, developed and validated in our department (q-ICG), could detect changes in gastric perfusion induced by hemorrhage and resuscitation.

METHODS

Ten pigs were included in the study. Specific regions of interest of the stomach were chosen, and three q-ICG measurements of gastric perfusion obtained: 20 min after completion of the laparoscopic setup (baseline), after reducing the circulating blood volume by 30%, and after reinfusion of the withdrawn blood volume. Hemodynamic variables were recorded, and blood samples were collected every 10 min during the procedure.

RESULTS

The reduction in blood volume generated decreased gastric perfusion (q-ICG) from baseline (p = 0.023), and gastric perfusion subsequently increased (p < 0.001) after the reintroduction of the withdrawn blood volume. Cardiac output (CO) and mean arterial blood pressure (MAP) shifted correspondingly and the gastric perfusion correlated to CO (r = 0.575, p = 0.001) and MAP (r = 0.436, p = 0.018).

CONCLUSION

We present a novel study showing that the q-ICG method can detect dynamic changes in local tissue perfusion induced by hemorrhage and resuscitation. As regional gastrointestinal perfusion may be significantly reduced, while hemodynamic variables such as MAP or heart rate remain stable, q-ICG may provide an objective, non-invasive method for detecting regional early ischemia, strengthening surgical decision making.

Dexmedetomidine aggravates hypotension following mesenteric traction during total gastrectomy: a randomized controlled trial

BACKGROUND

Mesenteric traction syndrome (MTS), which is characterized by arterial hypotension and tachycardia following mesenteric traction (MT), frequently occurs during abdominal surgery. Dexmedetomidine, commonly used in general anesthesia during major surgery, has a sympatholytic effect and attenuates the compensatory response to hypotension.

OBJECTIVE

Assess the effect of dexmedetomidine on hypotension following mesenteric traction.

DESIGN

Prospective, randomized, controlled clinical trial.

SETTING

Department of Anesthesiology, Zhenjiang First People's Hospital in China.

PATIENTS AND METHODS

Patients were randomly divided into three groups. Dexmedetomidine, 0.5 or 1.0 µg/kg, was intravenously administered over 15 minutes before skin incision followed by a maintenance rate of 0.5 µg/kg/h in groups D1 and D2, respectively; saline was administered in group C.

MAIN OUTCOME MEASURE(S)

The duration of hypotension, heart rate and plasma norepinephrine level in patients with MTS were recorded within 60 minutes following MT.

SAMPLE SIZE

75 patients.

RESULTS

The duration of hypotension in the MTS patients in group D1 and D2 was significantly longer than that in groups C (D1 vs. C, P<.05; D2 vs. C, P<.01). Significantly more phenylephrine was required to treat hypotension in group D1 and D2 than was required for patients in group C (P<.05). The increase in heart rate during the first 15 minutes of MT in group D2 was significantly attenuated compared to that in group C (P<.0083). The increases in norepinephrine levels during the first 15 minutes of MT in group C were significantly higher than those in groups D1 and D2 (P<.0167).

CONCLUSION

Adjunctive dexmedetomidine in general anesthesia aggravates hypotension during MTS in open total gastrectomy.

LIMITATIONS

Postoperative complications were not evaluated.

CONFLICT OF INTEREST

None.

Development of a severe mesenteric traction syndrome during major abdominal surgery is associated with increased postoperative morbidity: Secondary data analysis on prospective cohorts

PURPOSE

MTS is elicited during open abdominal surgery and is characterized by facial flushing, hypotension, and tachycardia in response to the release of prostacyclin (PGI₂) to plasma. MTS seems to affect postoperative morbidity, but data from larger cohorts are lacking. We aimed to determine the impact of severe mesenteric traction syndrome (MTS) on postoperative morbidity in patients undergoing open upper gastrointestinal surgery.

METHODS

The study was a secondary analysis of data from three cohorts (n = 137). The patients were graded for severity of MTS intraoperatively, and hemodynamic variables and blood samples for plasma 6-keto-PGF_1α, a stable metabolite of PGI₂, were obtained at defined time points. Postoperative morbidity was evaluated by the comprehensive complication index (CCI) and the Dindo-Clavien classification (DC).

RESULTS

Patients undergoing either esophagectomy (n = 70), gastrectomy (n = 22), liver- (n = 23), or pancreatic resection (n = 22) were included. Severe MTS was significantly associated with increased postoperative morbidity, i.e., CCI ≥ 26.2 (OR 3.06 [95% CI 1.1-6.6]; p = 0.03) and risk of severe complications, i.e., DC ≥3b (OR 3.1 [95% CI 1.2-8.2]; p = 0.023). Furthermore, patients with severe MTS had increased length of stay (OR 10.1 [95% CI 1.9-54.3]; p = 0.007) and were more likely to be admitted to the intensive care unit (OR = 7.3 [95% CI 1.3-41.9]; p = 0.027), but there was no difference in 1-year mortality.

CONCLUSION

Occurrence of severe MTS during upper gastrointestinal surgery is associated with increased postoperative morbidity as indicated by an increased rate of severe complications, length of stay, and admission to the ICU. It remains to be determined whether inhibition of MTS enhances postoperative recovery.

Laser speckle contrast imaging for quantitative assessment of facial flushing during mesenteric traction syndrome in upper gastrointestinal surgery

The mesenteric traction syndrome (MTS) is associated with prostacyclin (PGI₂) facilitated systemic vasodilatation during surgery and is identified by facial flushing. We hypothesized that severe facial flushing would be related to the highest concentrations of plasma PGI₂ and accordingly to the highest levels of skin blood flow measured by laser speckle contrast imaging (LSCI). Patients scheduled for major upper abdominal surgery were consecutively included. Within the first hour of the procedure, facial flushing was scored according to a standardized scale, and skin blood flow (LSPU) was continuously measured on the forehead and the cheeks by LSCI. Arterial blood samples for 6-keto-PGF_1α (stable metabolite of PGI₂) and hemodynamic variables were obtained at defined time points. Overall, 66 patients were included. After 15 min of surgery, patients with severe flushing demonstrated the highest plasma 6-keto-PGF_1α concentration and the most significant decrease in systemic vascular resistance. Accordingly, the skin blood flow on the forehead (238 [201-372] to 562 LSPU [433-729]) and the cheeks (341 [239-355] to 624 LSPU [468-917]) increased and were significantly higher than for patients with moderate or no flushing (both, P = 0.04). A cut-off value for skin blood flow could be defined for both the cheeks and the forehead for patients with severe flushing vs. no flushing (425/456 LSPU, sensitivity 75/76% and specificity 80/85%). MTS is linked to an increase in facial skin blood flow during upper gastrointestinal surgery. By applying LSCI, it is possible to quantitatively register facial blood flow, and thereby provide an objective tool for intraoperative verification of MTS.

Therapeutic effects of flurbiprofen axetil on mesenteric traction syndrome: randomized clinical trial

Background

This study aimed to reveal the appropriate timing for the intravenous administration of flurbiprofen axetil for preventing mesenteric traction syndrome (MTS), caused by prostacyclin release.

Methods

In this prospective, randomized, clinical study, forty-five patients who were undergoing elective surgery for colorectal cancer via laparotomy were enrolled. Patients were randomly divided into 3 groups: a preoperative group (n = 16) receiving flurbiprofen axetil directly before surgery; a post-MTS group (n = 14) receiving following MTS onset; and a control group (n = 15) who were not administered flurbiprofen axetil. 6-keto-PGF1α, a stable metabolite of prostacyclin, levels were measured and mean blood pressures were recorded.

Results

In the preoperative group, 6-keto-PGF1α levels did not increase, blood pressure levels did not decrease, and no facial flushing was observed. In both the post-MTS and control groups, 6-keto-PGF1α levels increased markedly after mesenteric traction and blood pressure decreased significantly. The post-MTS group exhibited a faster decreasing trend in 6-keto-PGF1α levels and quick restore of the mean blood pressure, and the use of vasopressors and phenylephrine were lower than that in the control group.

Conclusions

Even therapeutic administration of flurbiprofen axetil after the onset of MTS has also effects on MTS by suppressing prostacyclin production.

Trial registration

Clinical trial number: UMIN000009111. (Registered 14 October 2012)

A mesenteric traction syndrome affects near-infrared spectroscopy evaluated cerebral oxygenation because skin blood flow increases

During abdominal surgery manipulation of internal organs may induce a "mesenteric traction syndrome" (MTS) including a triad of flushing, hypotension, and tachycardia that lasts for about 30 min. We evaluated whether MTS affects near-infrared spectroscopy (NIRS) assessed frontal lobe oxygenation (S_cO₂) by an increase in forehead skin blood flow (SkBF). The study intended to include 10 patients who developed MTS during pancreaticoduodenectomy and 22 patients were enrolled (age 61 ± 8 years; mean ± SD). NIRS determined ScO₂, laser Doppler flowmetry determined SkBF, cardiac output (CO) was evaluated by pulse-contour analysis (Modelflow), and transcranial Doppler assessed middle cerebral artery mean flow velocity (MCA V_mean). MTS was identified by flushing within 60 min after start of surgery. MTS developed 20 min (12-24; median with range) after the start of surgery and heart rate (78 ± 16 vs. 68 ± 17 bpm; P = 0.0032), CO (6.2 ± 1.4 vs. 5.3 ± 1.1 L min^-1; P = 0.0086), SkBF (98 ± 35 vs. 80 ± 23 PU; P = 0.0271), and S_cO₂ (71 ± 6 vs. 67 ± 8%; P < 0.0001), but not MCA V_mean (32 ± 8 vs. 32 ± 7; P = 0.1881) were largest in the patients who developed MTS. In some patients undergoing abdominal surgery NIRS-determined S_cO₂ is at least temporarily affected by an increase in extra-cranial perfusion independent of cerebral blood flow as indicated by MCA V_mean. Thus, NIRS evaluation of S_cO₂ may overestimate cerebral oxygenation if patients flush during surgery.

Hemodynamics of mesenteric traction syndrome measured by FloTrac sensor

BACKGROUND

Mesenteric traction syndrome (MTS) develops in the early phase of laparotomy, which is triggered by pulling of the mesentery. We attempted to analyze the circulatory dynamics of MTS by using the FloTrac sensor.

METHODS

Prospective randomized control study, the MTS trial, was conducted with or without prophylactic administration of flurbiprofen axetil in order to control MTS development in 57 elective open colorectal surgeries. None of the Flurbipurofen group patients (n = 23) develop MTS and were allocated to the non-MTS group. Among the non-flurbiprofen group, 28 patients (82%) developed MTS and were categorized into the MTS group. For these patients, in addition to blood pressure, stroke volume variation (SVV) and systemic vascular resistance index (SVRI) were measured by FloTrac sensor.

RESULTS

The lowest blood pressure was noted within 30 minutes from the beginning of the intra-abdominal examination; in the non-MTS group, the mean blood pressure decreased by 16.7%, and in the MTS group, it decreased by 34.2% (P < .01). SVV of the 28 MTS patients was as follows: <9% in 10 patients (35.7%), >9% and <13% in 8 patients (28.6%), and >13% in 10 patients (35.7%). SVRI rose in the non-MTS group by 5.1%, whereas it fell in the MTS group by 15.1% (P < .01), indicating the close relationship between MTS and SVRI.

CONCLUSIONS

The SVV results indicate that fluid loading is not that optimal treatment against hypotension of MTS and that it is also important to consider the use of a vasoconstrictor. FloTrac is therefore useful for making an appropriate decision on the treatment strategy for MTS.

Intravenous flurbiprofen axetil enhances analgesic effect of opioids in patients with refractory cancer pain by increasing plasma β-endorphin

BACKGROUND

The study aimed to investigate the analgesic effect of a combination of intravenous flurbiprofen axetil and opioids, and evaluate the relationship between refractory pain relief and plasma β-endorphin levels in cancer patients.

MATERIALS AND METHODS

A total of 120 cancer patients was randomly divided into two groups, 60 patients took orally morphine sulfate sustained-release tablets in group A, and another 60 patients receiving the combination treatment of intravenous flurbiprofen axetil and opioid drugs in group B. After 7 days, pain relief, quality of life improvement and side effects were evaluated. Furthermore, plasma β-endorphin levels were measured by radioimmunoassay.

RESULTS

With the combination treatment of intravenous intravenous flurbiprofen axetil and opioids, the total effective rate of pain relief rose to 91.4%, as compared to 82.1% when morphine sulfate sustained-release tablet was used alone. Compared with that of group A, the analgesic effect increased in group B (p=0.031). Moreover, satisfactory pain relief was associated with a significant increase in plasma β-endorphin levels. After the treatment, plasma β-endorphin level in group B was 62.4±13.5 pg/ml, which was higher than that in group A (45.8±11.2 pg/ml) (p<0.05).

CONCLUSIONS

Our results suggest the combination of intravenous flurbiprofen axetil and opioids can enhance the analgesic effect of opioid drugs by increasing plasma β-endorphin levels, which would offer a selected and reliable strategy for refractory cancer pain treatment.

Intravenous flurbiprofen axetil can stabilize the hemodynamic instability due to mesenteric traction syndrome--evaluation with continuous measurement of the systemic vascular resistance index using a FloTrac® sensor

OBJECTIVE

Evaluation of the stabilizing effect of intravenous flurbiprofen axetil against hemodynamic instability due to mesenteric traction syndrome (MTS) by continuous measurement of systemic vascular resistance index (SVRI) using a FloTrac(®) sensor was evaluated.

DESIGN

Prospective randomized trial.

SETTING

A single-center study performed in an educational hospital.

PARTICIPANTS

Two prospective studies were carried out, each with 40 patients scheduled for elective open abdominal surgery.

INTERVENTION

Twenty patients received 50 mg of flurbiprofen axetil after the recognition of MTS by the anesthesiologist (group FT). The remaining patients served as controls (groups CP and CT).

MEASUREMENTS AND MAIN RESULTS

SVRI data was collected every 20 seconds for 1 hour after starting the laparotomy. The average SVRI prior to skin incision was taken as the baseline. Following 3 values were devised to evaluate MTS: the S-value (sum total of changes in SVRI from baseline), the T-value (period during which SVRI remained 20% or more below baseline), and the M-value (maximum change in SVRI from baseline). In group FP, decrease in SVRI was smaller than in group CP, and statistical differences in the 3 values were found. In group FT, SVRI recovered earlier than in group CT, and statistical differences were found in S-value and T-value. However, the M-value had no statistical differences.

CONCLUSIONS

Intravenous flurbiprofen axetil can stabilize the hemodynamic instability due to MTS.