Evidence-based management of pain after laparoscopic cholecystectomy: a PROSPECT review update

Intravenous Ibuprofen Versus Ketorolac for Perioperative Pain Control in Patients with Morbid Obesity Undergoing Bariatric Surgery: A Randomized Controlled Trial

BACKGROUND

We aimed to compare the perioperative analgesic efficacy of intravenous ibuprofen versus ketorolac in patients with obesity undergoing bariatric surgery.

METHODS

This randomized controlled trial included adult patients with obesity undergoing bariatric surgery. Participants were randomized to receive either ibuprofen or ketorolac intravenously every 8 h. All patients received paracetamol intravenously 1 gm/6 h. Inadequate intraoperative analgesia was managed by fentanyl boluses, while inadequate postoperative analgesia was managed by nalbuphine boluses. The primary outcome was static visual analogue scale (VAS) 0.5 h postoperatively. Secondary outcomes were postoperative static and dynamic VAS, intra- and postoperative opioids consumption, postoperative nausea and vomiting, and patients' satisfaction.

RESULTS

Fifty-three patients were analyzed in each group. The median VAS (quartiles) at 0.5 h postoperatively was lower in the ketorolac group (3 [3, 6]) than in the ibuprofen group (7 [4, 8]), P-value < 0.001. The static and dynamic VAS were lower in the ketorolac group than in the ibuprofen group up to 6 h postoperatively. The intra- and postoperative opioid consumption was lower in the ketorolac group than in the ibuprofen group. The incidence of postoperative nausea and vomiting was also lower in the ketorolac group than in the ibuprofen group. Patients in the ketorolac group had higher level of satisfaction than patients in the ibuprofen group.

CONCLUSION

In patients with obesity undergoing bariatric surgery, perioperative administration of ketorolac provided improved pain control, reduced opioid consumption, and lowered the risk of postoperative nausea and vomiting, compared to ibuprofen. Additionally, patients reported higher satisfaction with ketorolac.

A meta analysis of efficacy and safety of nefopam for laparoscopic cholecystectomy pain management

Background

Nefopam is a safe analgesic with mild side effects including drowsiness, nausea, vomiting, and sweating. Nevertheless, research is scarce on the impact of nefopam in managing postoperative pain following laparoscopic cholecystectomy (LC), and the advantageous effects of nefopam remain unclear. In this research, the effectiveness of nefopam was compared to placebo for the treatment of postoperative pain following LC.

Methods

A literature search for randomized controlled trials (RCTs) was performed through June 2024 using online databases including Cochrane Library, PubMed/Medline, and Web of Science. The primary outcome assessed was the quality of postoperative patient pain, and the secondary outcome was side effects that occurred due to the use of nefopam. The Cochrane Risk of Bias (RoB) 2 tool was used to assess the RoB. The meta-analysis was conducted using Review Manager software version 5.4. The risk ratio (RR), mean difference (MD), and standardized mean difference (SMD) were calculated at 95% confidence intervals (CIs).

Results

Five RCTs comprising 254 participants were analyzed. The analysis revealed that compared to placebo, nefopam had no statistically significant effect on the reduction of postoperative pain severity at 30 min (SMD = -0.30, 95% CI: -0.61 to 0.01; P = 0.06) and 60 min (SMD = -0.31, 95% CI: -0.78 to 0.16; P = 0.20). Nefopam reduced the number of opioids taken, as shown in the meta-analysis (SMD = -0.94, 95 CI: -1.35 to -0.53; P < 00001), with minor heterogeneity (P = 0.24, I2 = 30%). This meta-analysis showed that nefopam lengthened the time to first rescue analgesia (MD = 23.003). and markedly reduced the number patients requiring analgesics compared to baseline (RR = 0.34, 95% CI: 0.22 to 0.54; P < 0.00001).

Conclusion

Nefopam did not cause any difference in total postoperative pain but was effective in reducing overall opioid consumption and the need for supplementary analgesics. It did not increase postoperative nausea and vomiting.

Sex-Related Analgesic Effects of Opioid-Based Anesthesia and Low-Opioid Anesthesia with Non-Opioid Postoperative Analgesia-A Clinical Observational Study

Background/Objectives: Sex is a crucial factor in modulating the perioperative aspects of anesthesia. A growing number of studies demonstrate that women and men experience pain differently and respond differentially to analgesics. Methods: This study evaluated the analgesic trajectory of low-opioid anesthesia (LOA) and opioid-based anesthesia (OBA) in women and men after laparoscopic cholecystectomy. The primary objective was to assess pain intensity at various time intervals after surgery (0-2, 2-6, 6-12, and 12-24 h) using the Numerical Rating Scale (NRS). The secondary objective was to assess the difference in mean pain intensity on the first postoperative day between the women and men. Results: The mean pain intensity did not differ significantly for men using LOA and OBA, but the value was significantly lower in the LOA group for women (p = 0.0002). The analgesic trajectory in women and men undergoing LOA presented a negative trend, but the pain intensity at 0-2, 2-6, 6-12, and 12-24 h in women was statistically lower than that of the OBA group (p = 0.01, p = 0.008, p = 0.002, and p = 0.001). Total fentanyl doses of 0.3 mg (sensitivity 44%, specificity 76%, AUC 0.55) and 0.35 mg achieved a mean NRS of <2 for pain intensity in the female and male OBA groups (sensitivity 33%, specificity 100%, AUC 0.53). Conclusions: A model combining low-opioid anesthesia and non-opioid postoperative analgesia presents a favorable therapeutic effect for women. OBA does not provide proper analgesic effects after laparoscopic cholecystectomy.

Ultrasound-guided vs. laparoscopic-guided transversus abdominis plane block for postoperative pain following laparoscopic cholecystectomy: a systematic review and meta-analysis

BACKGROUND

Postoperative pain following laparoscopic cholecystectomy (LC) is a major concern. The transversus abdominis plane block (TAPB) is one of the anesthetic techniques that has been developed to address this issue. The TAPB can be delivered by the guidance of either ultrasound (UTAPB) or laparoscopic (LTAPB). Our aim is to compare the efficacy of these guidance methods in reducing postoperative pain after LC.

METHODS

A systematic search was performed in PubMed, Scopus, Cochrane, and Web of Science databases from inception to June 2024 for randomized studies comparing the delivery of TAPB under ultrasound and laparoscopic guidance. Data analysis was conducted using Review Manager V5.4.

RESULTS

Five randomized studies were included in our study. UTAPB was significantly more effective in reducing postoperative pain after 6 h compared to LTAPB (MD =  - 0.38, 95% CI, - 0.67 to 0.09, p = 0.01). However, UTAPB was insignificantly more effective than LTAPB in reducing postoperative pain after 12 h (MD =  - 0.14, 95% CI, - 0.44 to 0.17, p = 0.39), 24 h (MD =  - 0.09, 95% CI, - 0.41 to 0.23, p = 0.60), and 48 h (MD =  - 0.12, 95% CI, - 0.44 to 0.19, p = 0.44). UTAPB insignificantly resulted in decreased opioid consumption (SMD: - 0.09; 95% CI: - 0.42, 0.25; p = 0.62) and less postoperative nausea and vomiting (OR = 0.73, 95% CI, 0.21 to 2.51, p = 0.62) in comparison with LTAPB.

CONCLUSION

Ultrasound guidance of TAPB offers superior pain relief in the setting of LC, especially in the early postoperative period. Further trials are needed to prove and support the results.

Comparison of the Effect of Adding Dexmedetomidine as an Adjuvant to Bupivacaine for Postoperative Pain Management in Patients Undergoing Shoulder Rotator Cuff Repair - A Randomized Clinical Trial

Background

Shoulder rotator cuff repair postoperative pain management is more critical than orthopedic surgeries in other limbs. This study aimed to investigate the effect of adding dexmedetomidine as an adjuvant to bupivacaine for postoperative pain management.

Materials and Methods

This double-blind, randomized clinical trial was performed on 80 patients aged 20 to 60 with ASA I and II who were candidates for elective shoulder rotator cuff repair. Forty candidates in the control group received 0.1% bupivacaine intra-articular and extra-articular before surgical wound closure, and 40 patients in the intervention group received 0.1% bupivacaine and dexmedetomidine 1 µg/kg intra-articular and extra-articular. Postoperative sleep disturbance and pain intensity were measured at recovery, 4, 8, 12, 18, and 24 hours after surgery. The results were analyzed by SPSS software version 23, and a P value ≤0.05 was considered significant.

Results

There were no significant differences between the two groups regarding the hemodynamic variations (P > 0.05), except 4 hours after surgery when the mean arterial pressure in the intervention group was significantly lower than the control group (P = 0.026). There was a significant reduction in pain scores at 8 and 12 hours after surgery in the intervention group. The night after surgery, sleep quality and the overall RCSQ score in the intervention group were significantly higher than those in the control group.

Conclusion

Administering 0.1% bupivacaine and dexmedetomidine 1 µg/kg intra-articular and extra-articular before surgical wound closure effectively reduced the pain intensity and analgesic consumption. Also, it maintained patients' hemodynamic stability and enhanced sleep quality without significant adverse effects.

Efficacy and Safety of Different Preemptive Analgesia Measures in Pain Management after Laparoscopic Cholecystectomy: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

INTRODUCTION

The purpose of this systematic review and network meta-analysis was to evaluate the efficacy and safety of different preemptive analgesia measures given before laparoscopic cholecystectomy (LC) for postoperative pain in patients.

METHODS

We conducted a comprehensive search in databases including PubMed, Web of Science, Embase, and the Cochrane Library up to March 2024, and collected relevant research data on the 26 preemptive analgesia measures defined in this article in LC surgery. Outcomes included postoperative Visual Analogue Scores (VAS) at different times (2, 6, 12, and 24 h), opioid consumption within 24 h post-operation, time to first rescue analgesia, incidence of postoperative nausea and vomiting (PONV), and incidence of postoperative headache or dizziness.

RESULTS

Forty-nine articles involving 5987 patients were included. The network meta-analysis revealed that multimodal analgesia, nerve blocks, pregabalin, and gabapentin significantly reduced postoperative pain scores at all postoperative time points and postoperative opioid consumption compared to placebo. Tramadol, pregabalin, and gabapentin significantly extended the time to first rescue analgesia. Ibuprofen was the best intervention for reducing PONV incidence. Tramadol significantly reduced the incidence of postoperative headache or dizziness. Subgroup analysis of different doses of pregabalin and gabapentin showed that compared to placebo, pregabalin (300 mg, 150 mg) and gabapentin (600 mg, 300 mg, and 20 mg/kg) were all more effective without significant differences in efficacy between these doses. Higher doses increased the incidence of PONV and postoperative headache and dizziness, with gabapentin 300 mg having a lower adverse drug reaction (ADR) incidence.

CONCLUSIONS

Preemptive analgesia significantly reduced postoperative pain intensity, opioid consumption, extended the time to first rescue analgesia, and decreased the incidence of PONV and postoperative headache and dizziness. Multimodal analgesia, nerve blocks, pregabalin, and gabapentin all showed good efficacy. Gabapentin 300 mg given preoperatively significantly reduced postoperative pain and ADR incidence, recommended for preemptive analgesia in LC.

TRIAL REGISTRATION

PROSPERO CRD42024522185.

Pain management after laparoscopic cholecystectomy: A systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations

Laparoscopic cholecystectomy can be associated with significant postoperative pain that is difficult to treat. We aimed to evaluate the available literature and develop updated recommendations for optimal pain management after laparoscopic cholecystectomy. A systematic review was performed using the procedure-specific postoperative pain management (PROSPECT) methodology. Randomised controlled trials and systematic reviews published in the English language from August 2017 to December 2022 assessing postoperative pain after laparoscopic cholecystectomy using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases. From 589 full text articles, 157 randomised controlled trials and 31 systematic reviews met the inclusion criteria. Paracetamol combined with NSAIDs or cyclo-oxygenase-2 inhibitors should be given either pre-operatively or intra-operatively, unless contraindicated. In addition, intra-operative intravenous (i.v.) dexamethasone, port-site wound infiltration or intraperitoneal local anaesthetic instillation are recommended, with opioids used for rescue analgesia. As a second-line regional technique, the erector spinae plane block or transversus abdominis plane block may be reserved for patients with a heightened risk of postoperative pain. Three-port laparoscopy, a low-pressure pneumoperitoneum, umbilical port extraction, active aspiration of the pneumoperitoneum and saline irrigation are recommended technical aspects of the operative procedure. The following interventions are not recommended due to limited or no evidence on improved pain scores: single port or mini-port techniques, routine drainage, low flow insufflation, natural orifice transluminal endoscopic surgery (NOTES), infra-umbilical incision, i.v. clonidine, nefopam and regional techniques such as quadratus lumborum block or rectus sheath block. Several interventions provided better pain scores but are not recommended due to risk of side effects: spinal or epidural anaesthesia, gabapentinoids, i.v. lidocaine, i.v. ketamine and i.v. dexmedetomidine.

Preoperative Bilateral External Oblique Intercostal Plus Rectus Sheath Block for Postoperative Pain Management Following Laparoscopic Cholecystectomy: A Noninferior Double-Blind Placebo-Controlled Trial

OBJECTIVES

The transversus abdominis plane (TAP) block has proven efficacy and is an important component of multimodal analgesia in laparoscopic cholecystectomy (LC). The external oblique intercostal (EOI) block can provide a dermatomal sensory blockade of T6 to T10 using an anterior axillary line injection. The bilateral rectus sheath (RS) block can significantly reduce early postoperative pain caused by umbilical or periumbilical incisions. The current study aimed to compare the analgesic efficacies of ultrasound-guided subcostal TAP (UG-TAP) combined with the RS block and ultrasound-guided EOI (UG-EOI) combined with the RS block for LC.

METHODS

Patients were randomly assigned to TAP or EOI group. Patients in TAP group received UG-TAP combined with an RS block. Patients in EOI group received UG-EOI combined with an RS block. The primary outcome was postoperative 24-hour sufentanil consumption.

RESULTS

A total of 49 patients were included in the final analysis. The postoperative 24-hour sufentanil consumption in the EOI group was significantly lower than that in the TAP group (9.79±10.22 vs. 18.67±12.58 µg; P [noninferiority] <0.01; noninferiority confirmed). Fewer patients in the EOI versus TAP group had a numerical rating score of >3 during motion. Furthermore, the mean postoperative 48-hour sufentanil consumption was lower in the EOI versus TAP group (11.54±11.70 vs. 23.04±17.10 µg; P =0.01). The mean postoperative 24-hour Quality of Recovery-15 score was higher in the EOI versus TAP group (135.21±4.40 vs. 131.91±5.11; P =0.02).

DISCUSSION

These findings suggest that UG-EOI combined with an RS block was superior to UG-TAP combined with an RS block for postoperative pain management in patients undergoing LC.

Systemic lidocaine versus erector spinae plane block for improving quality of recovery after laparoscopic cholecystectomy: A randomized controlled trial

STUDY OBJECTIVE

To compare intravenous lidocaine, ultrasound-guided erector spinae plane block (ESPB), and placebo on the quality of recovery and analgesia after laparoscopic cholecystectomy.

DESIGN

A prospective, triple-arm, double-blind, randomized, placebo-controlled non-inferiority trial.

SETTING

A single tertiary academic medical center.

PATIENTS

126 adults aged 18-65 years undergoing elective laparoscopic cholecystectomy.

INTERVENTIONS

Patients were randomly allocated to one of three groups: intravenous lidocaine infusion (1.5 mg/kg bolus followed by 2 mg/kg/h) plus bilateral ESPB with saline (25 mL per side); bilateral ESPB with 0.25% ropivacaine (25 ml per side) plus placebo infusion; or bilateral ESPB with saline (25 ml per side) plus placebo infusion.

MEASUREMENTS

The primary outcome was the 24-h postoperative Quality of Recovery-15 (QoR-15) score. The non-inferiority of lidocaine versus ESPB was assessed with a margin of -6 points and 97.5% confidence interval (CI). Secondary outcomes included 24-h area under the curve (AUC) for pain scores, morphine consumption, and adverse events.

MAIN RESULTS

124 patients completed the study. Median (IQR) 24-h QoR-15 scores were 123 (117-127) for lidocaine, 124 (119-126) for ESPB, and 112 (108-117) for placebo. Lidocaine was non-inferior to ESPB (median difference  -1, 97.5% CI: -4 to ∞). Both lidocaine (median difference 9, 95% CI: 6-12, P < 0.001) and ESPB (median difference 10, 95% CI: 7-13, P < 0.001) were superior to placebo. AUC for pain scores and morphine use were lower with lidocaine and ESPB versus placebo (P < 0.001 for all), with no significant differences between lidocaine and ESPB. One ESPB patient reported a transient metallic taste; no other block-related complications occurred.

CONCLUSIONS

For patients undergoing laparoscopic cholecystectomy, intravenous lidocaine provides a non-inferior quality of recovery compared to ESPB without requiring specialized regional anesthesia procedures. Lidocaine may offer a practical and accessible alternative within multimodal analgesia pathways.

The Effect of Postoperative Analgesia on the Day-Case Rate of Laparoscopic Cholecystectomy: A Randomised Pilot Study of the Laparoscopic-Assisted Right Subcostal Transversus Abdominis Plane Block plus Local Anaesthetic Wound Infiltration versus Local Anaesthetic Wound Infiltration only

OBJECTIVE

The transversus abdominis plane (TAP) block and local anaesthetic infiltration (LAI) of port sites provide adequate analgesia after laparoscopic cholecystectomy (LC). Little is known if the two techniques affect the day-case (DC) rate of LC. We tested the appropriateness of the research design in view of a larger randomised controlled trial (RCT) - laparoscopic-assisted right subcostal TAP block plus local anaesthetic wound infiltration (STALA) versus LAI.

SUBJECTS AND METHODS

Sixty patients having DC LC were randomised into STALA and LAI. Participants received bupivacaine 0.5% 30 mL. Pain scores were evaluated with the Visual Analogue Scale (VAS) score, at 1 h post-surgery and at discharge. Need of postoperative intravenous (IV) opioids, DC rate, and Quality of Recovery-15 questionnaires were compared between groups and were considered as measures of efficacy of the interventions and follow-up in a definitive trial.

RESULTS

Twenty-nine participants were randomised to STALA, and 31 to LAI. Subjects in LAI group were all women (p = 0.0007) and younger (43.8 vs. 37.7 years, p = 0.023). Median VAS scores were 0 versus 1 at 1 h (p = 0.60), 0 versus 1.5 at discharge (p = 0.55). The need of IV opioids was 15/29 (51.7%) versus 13/31 (41.9%; p = 0.60). The DC rate was 93.1% versus 93.5% (p = 0.39). Fifty (83.3%) participants responded the questionnaires.

CONCLUSIONS

The laparoscopically guided right subcostal TAP block provided no additional benefit to LAI on pain control after LC and DC rate. Despite the appropriate design, our findings do not support a larger RCT.

Postoperative Pain after Laparoscopic Cholecystectomy in a Tertiary Care Center: A Descriptive Cross-sectional Study

INTRODUCTION

Laparoscopic cholecystectomy, being minimally invasive, is widely accepted in comparison to open cholecystectomy. The major benefits are small incision, less wound pain, rapid recovery, shorter hospital stay and earlier return to activities. Although, trauma and injury are limited in laparoscopic cholecystectomy; it is not a pain free surgery. Hence, we aimed to find the prevalence of pain at wound site after laparoscopic cholecystectomy at various time intervals in post-operative period.

METHODS

The descriptive cross-sectional study was conducted among 125 patients who belonged to American Society of Anesthesiologists grade I & II patients, with diagnosis of symptomatic gallstone disease from October, 2022 to September, 2023 in a tertiary care hospital after ethical approval was obtained from Institutional Review Board (Reference number: MEMG/483/IRC). Total sampling was done in this study. The post-operative pain at wound site was measured at 12, 24, 36 and 48 hours. Data were analyzed using Statistical Package of Social Sciences 21.0.

RESULTS

At 12 hours postoperatively, 2 (1.60%) patients complained of severe pain, 120 (96%) patients reported moderate pain and 3 (2.40%) patients expressed their pain as being mild. Likewise, at 24, 36 and 48 hours postoperatively, none of the patients suffered from severe pain. At 24 hours post-operative, 105 (84%) patients reported moderate pain which gradually declined over 48 hours. At 36 and 48 hours post-operative mild pain was reported by 85 (68%) and 117 (93.60%) patients. The moderate pain was complained by 40 (32%) and 8 (6.40%) patients.

CONCLUSIONS

The majority of patients suffered from mild to moderate pain after laparoscopic cholecystectomy, the intensity of which decreased over 48 hours.

Analgesic efficacy of erector spinae plane block versus transversus abdominis plane block for laparoscopic cholecystectomy: a systematic review and meta-analysis of randomized controlled trial

Background

Although laparoscopic cholecystectomy (LC) is a minimally invasive surgery, it can cause moderate to severe postoperative pain. Erector spinae plane (ESP) and transversus abdominis plane (TAP) blocks are considered effective means for pain management in such cases; however, there is inconclusive evidence regarding their analgesic efficacy. This meta-analysis aimed to compare the efficacy of ESP block and TAP block for pain control in LC.

Methods

We systematically searched Medline, PubMed, Scopus, Embase, and Google Scholar until 26 January 2024. All randomized clinical trials compared the efficacy of erector spinae plane block (ESPB) and transversus abdominis plane block (TAPB) for postoperative pain relief after LC. The primary outcomes were pain scores at rest and on movement at 1, 2, 6, 12, and 24 h postoperatively. The secondary outcomes were total opioid consumption, first analgesia request time, and rates of postoperative nausea and vomiting. We analyzed all the data using RevMan 5.4.

Results

A total of 8 RCTs, involving 542 patients (271 in the ESPB group and 271 in the TAPB group), were included in the analysis. The ESP block demonstrated statistically significant lower pain scores at rest and on movement than the TAP block at all-time points except at the 1st and 6th h on movement postoperatively; however, these differences were not considered clinically significant. Additionally, patients who received the ESP block required less morphine and had a longer time before requesting their first dose of analgesia. There were no significant differences in postoperative nausea and vomiting incidence between the two groups.

Conclusion

In patients undergoing LC, there is moderate evidence to suggest that the ESP block is effective in reducing pain severity, morphine equivalent consumption, and the time before the first analgesia request when compared to the TAP block during the early postoperative period.Systematic review registration: PROSPERO CRD42024505635, https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024505635.

Comparison of Analgesic Method in Laparoscopic Gastrectomy Using External Oblique Intercostal Block Versus Wound Infiltration: A Randomized Controlled Trial

Background: External oblique intercostal block (EOIB) is effective in relieving pain in the T6 to T10 dermatomes; however, there is limited evidence comparing EOIB with conventional regional anesthesia. In this randomized controlled trial, it was hypothesized that EOIB would provide more effective analgesia than wound infiltration (WI) in laparoscopic gastrectomy. Methods: Thirty-two patients (aged 20-85 years) with American Society of Anesthesiologists Performance Status of 1 to 2, scheduled for laparoscopic gastrectomy, were randomly divided into EOIB and WI groups. Both procedures were performed using 40 mL of 0.25% levobupivacaine. The primary outcome was the numerical rating scale (NRS) score 12 h postoperatively. Secondary outcomes were NRS at 2, 24, and 48 h postoperatively, variation in quality of recovery-15 score on postoperative days 1 and 2 from preoperative baseline, postoperative fentanyl consumption, and variation in World Health Organization Disability Assessment Scale 2.0 scores between baseline and 3 months postoperatively. Plasma concentrations of levobupivacaine and pinprick sensation in the T4-11 dermatomes post-EOIB were evaluated to determine the exploratory endpoints. Results: There were no differences in the NRS scores 12 h postoperatively at rest and during movement between the EOIB and WI groups (mean standard deviation 1.3 [1.1] vs. 1.5 [1.4] and 3.1 [1.6] vs. 3.8 [1.7], respectively). Secondary outcomes did not differ significantly between the groups. The time to peak plasma concentration of levobupivacaine following EOIB was 45 min. Conclusions: No significant differences in NRS scores were observed between the analgesic effects of EOIB and WI at 12 h postoperatively.

Analgesic effect of ultrasound-guided transversus abdominis plane block with or without rectus sheath block in laparoscopic cholecystectomy: a randomized, controlled trial

BACKGROUND

Ultrasound-guided transversus abdominis plane (TAP) block is commonly used for pain control in laparoscopic cholecystectomy. However, significant pain persists, affecting patient recovery and sleep quality on the day of surgery. We compared the analgesic effect of ultrasound-guided TAP block with or without rectus sheath (RS) block in patients undergoing laparoscopic cholecystectomy using the visual analog scale (VAS) scores.

METHODS

The study was registered before patient enrollment at the Clinical Research Information Service (registration number: KCT0006468, 19/08/2021). 88 American Society of Anesthesiologist physical status I-III patients undergoing laparoscopic cholecystectomy were divided into two groups. RS-TAP group received right lateral and right subcostal TAP block, and RS block with 0.2% ropivacaine (30 mL); Bi-TAP group received bilateral and right subcostal TAP block with same amount of ropivacaine. The primary outcome was visual analogue scale (VAS) for 48 h postoperatively. Secondary outcomes included the use of rescue analgesics, cumulative intravenous patient-controlled analgesia (IV-PCA) consumption, patient satisfaction, sleep quality, and incidence of adverse events.

RESULTS

There was no significant difference in VAS score between two groups for 48 h postoperatively. We found no difference between the groups in any of the secondary outcomes: the use of rescue analgesics, consumption of IV-PCA, patient satisfaction with postoperative pain control, sleep quality, and the incidence of postoperative adverse events.

CONCLUSION

Both RS-TAP and Bi-TAP blocks provided clinically acceptable pain control in patients undergoing laparoscopic cholecystectomy, although there was no significant difference between two combination blocks in postoperative analgesia or sleep quality.

Intravenous ibuprofen versus ketorolac for perioperative pain control in open abdominal hysterectomy: a randomized controlled trial

BACKGROUND

We aimed to compare the analgesic effects of intravenous ibuprofen to ketorolac after open abdominal hysterectomy.

METHODS

This randomized double-blinded controlled trial included adult women scheduled for elective open abdominal hysterectomy. Participants were randomized to receive either 30 mg ketorolac (n = 50) or 800 mg ibuprofen (n = 50) preoperatively, then every 8 h postoperatively for 24 h. All participants received paracetamol 1 gm/6 h. Rescue analgesic was given if the visual analogue scale (VAS) for pain assessment was > 3. The primary outcome was the mean postoperative dynamic VAS during the first 24 h. Secondary outcomes were static VAS, intraoperative fentanyl consumption, postoperative morphine consumption, time to independent movement, and patient's satisfaction.

RESULTS

Forty-six patients in the ibuprofen group and fifty patients in the ketorolac group were analyzed. The 24-h dynamic and static VAS were similar in the two groups. The median (quartiles) dynamic VAS was 1.1 (0.9, 1.9) in the ibuprofen group versus 1.0 (0.7, 1.3) in the ketorolac group, P-value = 0.116; and the median (quartiles) static VAS was 0.9 (0.6, 1.3) in the ibuprofen group versus 0.7 (0.4, 1.1) in the ketorolac group, P-value = 0.113. The intra- and postoperative analgesic requirements were also similar in the two groups. However, patient satisfaction was slightly higher in the ketorolac group than that in the ibuprofen group (median [quartiles]: 6 [5, 7] versus 5 [4, 7], respectively), P-value: 0.009.

CONCLUSION

The two drugs, intravenous ibuprofen and ketorolac produced similar analgesic profile in patients undergoing open abdominal hysterectomy receiving multimodal analgesic regimen. NCT05610384, Date of registration: 09/11/2022 CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05610384. https://clinicaltrials.gov/ct2/show/NCT05610384.

[Pain therapy in urology-overview of current S3 guideline recommendations]

Dealing efficiently with patients suffering from pain is a central medical task. Pain, as an important function in developmental physiology, warns against damage to the body caused by external noxious agents as well as internal malfunctions and requires special attention in modern medicine. Peri- and postoperative pain is known to have a negative influence on postoperative convalescence. Treatment of tumor-related pain represents another relevant challenge in uro-oncology and palliative medicine. The updated guideline on perioperative pain therapy and palliative medicine for patients with incurable diseases or cancer is dedicated to these two topics.

The Impact of Preoperative Dexamethasone Administration on Quality of Recovery Following Laparoscopic Sleeve Gastrectomy: A Prospective Observational Study

INTRODUCTION

Recovery from anesthesia is complex and affected by multiple factors. In patient with obesity, the increased prevalence of anxiety and depressive disorders poses a challenge in achieving optimal patient satisfaction. Therefore, strategies to enhance the quality of recovery are crucial for this population. This study aimed to investigate whether administration of dexamethasone to patients undergoing laparoscopic sleeve gastrectomy (LSG) could improve recovery outcomes.

METHODS

This prospective observational study was conducted at a tertiary university hospital in Samsun, Turkey. Thirty patients who received dexamethasone prior to LSG (group D) and 30 patients who did not (group C) were included with convenience sampling method. The quality of recovery was assessed using the Quality of Recovery 40 questionnaire (QoR-40). The primary outcome measure was the QoR-40 score at 24 h postoperatively.

RESULTS

The dexamethasone group showed a significant improvement in QoR-40 scores (185.4 ± 6.0 vs. 172.0 ± 8.4, p < 0.001), exhibited reduced morphine consumption (11.8 ± 7.8 vs. 21.8 ± 10.9 mg, p < 0.001), opioid demand count (21.50 [9.50-49.00], p = 0.001), the number of patient used antiemetic drug (1 vs. 22, p < 0.001), and achieved earlier mobilization (3 [3-4] vs. 3 [3-4] h, p < 0.0001). However, no significant differences were observed between the two groups concerning intraoperative complications, postoperative wound infections, or time to discharge.

CONCLUSIONS

In patients undergoing laparoscopic sleeve gastrectomy, preoperative dexamethasone administration was associated with improved the recovery quality after discharge and reduced early postoperative need for antiemetic medications.

Regional anaesthesia for postoperative pain management following laparoscopic, visceral, non-oncological surgery a systematic review and meta-analysis

BACKGROUND

Postoperative pain management following laparoscopic, non-oncological visceral surgery in adults is challenging. Regional anaesthesia could be a promising component in multimodal pain management.

METHODS

We performed a systematic review and meta-analysis with GRADE assessment. Primary outcomes were postoperative acute pain intensity at rest/during movement after 24 h, the number of patients with block-related adverse events and the number of patients with postoperative paralytic ileus.

RESULTS

82 trials were included. Peripheral regional anaesthesia combined with general anaesthesia versus general anaesthesia may result in a slight reduction of pain intensity at rest at 24 h (mean difference (MD) - 0.72 points; 95% confidence interval (CI) - 0.91 to - 0.54; I2 = 97%; low-certainty evidence), which was not clinically relevant. The evidence is very uncertain regarding the effect on pain intensity during activity at 24 h (MD -0.8 points; 95%CI - 1.17 to - 0.42; I2 = 99%; very low-certainty evidence) and on the incidence of block-related adverse events. In contrast, neuraxial regional analgesia combined with general anaesthesia (versus general anaesthesia) may reduce postoperative pain intensity at rest in a clinical relevant matter (MD - 1.19 points; 95%CI - 1.99 to - 0.39; I2 = 97%; low-certainty evidence), but the effect is uncertain during activity (MD - 1.13 points; 95%CI - 2.31 to 0.06; I2 = 95%; very low-certainty evidence). There is uncertain evidence, that neuraxial regional analgesia combined with general anaesthesia (versus general anaesthesia) increases the risk for block-related adverse events (relative risk (RR) 5.11; 95%CI 1.13 to 23.03; I2 = 0%; very low-certainty evidence).

CONCLUSION

This meta-analysis confirms that regional anaesthesia might be an important part of multimodal postoperative analgesia in laparoscopic visceral surgery, e.g. in patients at risk for severe postoperative pain, and with large differences between surgical procedures and settings. Further research is required to evaluate the use of adjuvants and the additional benefit of regional anaesthesia in ERAS programmes.

PROTOCOL REGISTRATION

PROSPERO CRD42021258281.

Perioperative pain management for appendicectomy: A systematic review and Procedure-specific Postoperative Pain Management recommendations

BACKGROUND

Despite being a commonly performed surgical procedure, pain management for appendicectomy is often neglected because of insufficient evidence on the most effective treatment options.

OBJECTIVE

To provide evidence-based recommendations by assessing the available literature for optimal pain management after appendicectomy.

DESIGN AND DATA SOURCES

This systematic review-based guideline was conducted according to the PROSPECT methodology. Relevant randomised controlled trials, systematic reviews and meta-analyses in the English language from January 1999 to October 2022 were retrieved from MEDLINE, Embase and Cochrane Databases using PRISMA search protocols.

ELIGIBILITY CRITERIA

We included studies on adults and children. If articles reported combined data from different surgeries, they had to include specific information about appendicectomies. Studies needed to measure pain intensity using a visual analogue scale (VAS) or a numerical rating scale (NRS). Studies that did not report the precise appendicectomy technique were excluded.

RESULTS

Out of 1388 studies, 94 met the inclusion criteria. Based on evidence and consensus, the PROSPECT members agreed that basic analgesics [paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs)] should be administered perioperatively for open and laparoscopic appendicectomies. A laparoscopic approach is preferred because of lower pain scores. Additional recommendations for laparoscopic appendicectomies include a three-port laparoscopic approach and the instillation of intraperitoneal local anaesthetic. For open appendicectomy, a preoperative unilateral transverse abdominis plane (TAP) block is recommended. If not possible, preincisional infiltration with local anaesthetics is an alternative. Opioids should only be used as rescue analgesia. Limited evidence exists for TAP block in laparoscopic appendicectomy, analgesic adjuvants for TAP block, continuous wound infiltration after open appendicectomy and preoperative ketamine and dexamethasone. Recommendations apply to children and adults.

CONCLUSION

This review identified an optimal analgesic regimen for open and laparoscopic appendicectomy. Further randomised controlled trials should evaluate the use of regional analgesia and wound infiltrations with adequate baseline analgesia, especially during the recommended conventional three-port approach.

REGISTRATION

The protocol for this study was registered with the PROSPERO database (Registration No. CRD42023387994).

The Efficacy of Acupressure for Nausea and Vomiting After Laparoscopic Cholecystectomy: A Meta-analysis Study

OBJECTIVES

This meta-analysis aims to explore the impact of acupressure on nausea and vomiting for patients undergoing laparoscopic cholecystectomy (LC).

BACKGROUND

Acupressure may have some potential in managing nausea and vomiting after LC.

PATIENTS AND METHODS

PubMed, Embase, Web of Science, EBSCO, and Cochrane library databases were systematically searched, and we included randomized controlled trials assessing the effect of acupressure on nausea and vomiting for LC.

RESULTS

Six randomized controlled trials were finally included in the meta-analysis. Overall, compared with control intervention for LC, acupressure was associated with significantly reduced incidence of nausea at 2 hours [odds ratio (OR) = 0.37; 95% CI = 0.21-0.67; P = 0.001] and nausea at 6 hours (OR = 0.38; 95% CI = 0.22-0.66; P = 0.0006; Fig. 4), and decreased need of rescue antiemetic (OR = 0.41; 95% CI = 0.20-0.85; P = 0.02; Fig. 8), but demonstrated no obvious impact on vomiting at 2 hours (OR = 0.76; 95% CI = 0.28-2.10; P = 0.60), vomiting at 6 hours (OR = 0.49, 95% CI = 0.20-1.20; P = 0.12), nausea at 24 hours (OR = 0.71; 95% CI = 0.37-1.35; P = 0.30), or vomiting at 24 hours (OR = 0.81; 95% CI = 0.28-2.35; P = 0.69).

CONCLUSIONS

Acupressure is effective in controlling nausea and decreasing rescue antiemetics for LC.

Rapid screening and multicomponent quantifications of active components of oral syrup over-the-counter medications by Raman and UV-visible spectroscopy and multivariate regression analysis

Over-the-counter medications (OTCMs) are frequently recommended as a first-line treatment for common ailments, diseases, and illnesses. Oral liquid dosage forms are advantageous for rapid absorption with no dissolution time and are easier for pediatric and geriatric consumers to swallow. The production of these medicines by pharmaceutical industry makes them readily available to the public. Although the US Food and Drug Administration (FDA) provides strict guidelines to drug manufacturers of these products; the risk of counterfeiting is a global issue. This can lead to several adverse effects and health issues. Here, we report a fast screening and quality assurance method using Raman and UV-visible spectroscopy combined with Principal Component Analysis (PCA) and Partial-Least-Square (PLS) regression of commonly used OTCM oral syrups. PLS regressions of UV-visible absorption spectra were used for multicomponent quantifications of the active component (acetaminophen, guaifenesin, dextromethorphan HBr, and phenylephrine HCl) concentrations of OTMCs in flavored (sugar or sugar-free) oral syrups. Raman and UV-visible spectral responses varied based on the type and concentration of the active component analyzed. PCA of the spectral data provided pattern recognition of the oral syrup OTCM. The developed PLS method demonstrated good linearity with an R2 > 0.9784 and high sensitivity with a low detection limit of 0.02 mg/mL for acetaminophen and guaifenesin. Moreover, the simultaneous quantification of concentrations of all active components by the described method yielded good accuracies ranging from 88 to 94%. This study provides an example of the benefits of the combined use of Raman and UV-vis spectral profiling, PCA, and PLS regression for the quality analysis of oral syrups OTCM providing multicomponent quantification of active components with no need for sample extraction. The reported method can be easily adapted and scaled for online detection analysis used in the drug manufacturing industry, both in-situ and field analysis, and for the quality control of syrups OTCM by regulatory agencies and quality control officers.

The incidence of post cholecystectomy pain (PCP) syndrome at 12 months following laparoscopic cholecystectomy: a prospective evaluation in 200 patients

OBJECTIVES

Post cholecystectomy pain syndrome can cause significant distress, impairs quality of life and exacerbations often result in emergency visits. Poorly controlled postoperative pain is a recognized cause of persistent postsurgical pain. Abdominal myofascial pain syndrome is an underdiagnosed cause of persistent pain in this cohort. The objective was to estimate the incidence of poorly controlled postoperative pain in the first 48 h after surgery and the likelihood of developing persistent pain at 12 months.

METHODS

The patients undergoing laparoscopic cholecystectomy at a tertiary unit were consented for participation in a prospective service evaluation. A telephone review was performed at three, six and twelve months after surgery. Incidence of poorly controlled pain in the first 48 h after surgery was assessed. Patients with persistent pain were referred to the pain clinic.

RESULTS

Over a six-month period, 200 patients were assessed. Eleven patients were excluded (5.5 %). Twelve patients were lost to follow-up (6.6 %, 12/189). Patient satisfaction with acute postoperative pain management was low in 40 % (76/189). Poorly controlled postoperative pain was reported by 36 % (68/189) of patients. Incidence of persistent pain was 29 % (54/189) at 12 months post-surgery. Over half of patients with persistent pain (63 %, 34/54) reported poorly controlled postoperative pain. A somatic source was diagnosed in 54 % (29/54) with post cholecystectomy pain syndrome.

CONCLUSIONS

Poorly controlled postoperative pain was reported by a third of patients. Persistent pain was present in 29 % at twelve months post-surgery. Abdominal myofascial pain syndrome should be considered as a differential diagnosis in post cholecystectomy pain syndrome.

The effect of the addition of nefopam to intraoperative ketoprofen and acetaminophen on postoperative morphine requirements after laparoscopic cholecystectomy: a randomized controlled trial

BACKGROUND

Few studies investigated the use of nefopam for pain control after laparoscopic cholecystectomy in the context of multimodal analgesia. The aim of this study was to evaluate the effect of adding nefopam to ketoprofen and acetaminophen given before the end of laparoscopic cholecystectomy.

METHODS

In this double-blind, controlled study, 90 patients undergoing laparoscopic cholecystectomy during sevoflurane-dexmedetomidine-based anesthesia were randomized to receive either ketoprofen and acetaminophen or nefopam, ketoprofen, and acetaminophen for postoperative pain control before the end of surgery. The primary outcome was total morphine consumption in the Postanesthesia Care Unit (PACU).

RESULTS

PACU morphine consumption was significantly lower in the experimental group compared to the control group (0.9±1.8 mg vs. 2.3±2.4 mg, respectively; P=0.004, Cohen's d=0.63). In the experimental group, a smaller proportion of patients received morphine in PACU (24% vs. 60%, respectively; P=0.001), morphine during the first 24 hours after surgery (47% vs. 77%, respectively; P=0.004), and acetaminophen on the floor (76% vs. 93%, respectively; P=0.039) compared with the control group. The average pain score during PACU stay was also significantly lower in the experimental group (1.7±2.0 vs. 2.7±2.0, P=0.01). Median time to first morphine requirement (44.0 minutes, 95% CI [(31.96 to, 52.21)] was shorter in the control group than in the experimental group (higher than the 90 minutes-last time point taken in PACU).

CONCLUSIONS

Adding nefopam to ketoprofen and acetaminophen before the end of laparoscopic cholecystectomy provides a reduction in morphine consumption with superior analgesia in PACU.

Analgesic benefits of pre-operative versus postoperative transversus abdominis plane block for laparoscopic cholecystectomy: a frequentist network meta-analysis of randomized controlled trials

BACKGROUND

Transversus abdominis plane (TAP) block has been utilized to alleviate pain following laparoscopic cholecystectomy (LC). However, the optimal timing of administration remains uncertain. This study aimed to compare the efficacy of pre-operative and postoperative TAP blocks as analgesic options after LC.

METHODS

A frequentist network meta-analysis of randomized controlled trials (RCTs) was conducted. We systematically searched PubMed (via the National Library of Medicine), EMBASE, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science up to March 2023. The study included RCTs that enrolled adult patients (≥ 18 years) who underwent LC and received either pre-operative or postoperative TAP blocks. The primary outcome assessed was 24-hour postoperative morphine consumption (mg). Additionally, pain rest scores within 3 hours, 12 hours, and 24 hours, as well as postoperative nausea and vomiting (PONV), were considered as pre-specified secondary outcomes.

RESULTS

A total of 34 trials with 2317 patients were included in the analysis. Postoperative TAP block demonstrated superiority over the pre-operative TAP block in reducing opioid consumption (MD 2.02, 95% CI 0.87 to 3.18, I2 98.6%, p < 0.001). However, with regards to postoperative pain, neither pre-operative nor postoperative TAP blocks exhibited superiority over each other at any of the assessed time points. The postoperative TAP block consistently ranked as the best intervention using SUCRA analysis. Moreover, the postoperative TAP block led to the most significant reduction in PONV.

CONCLUSIONS

The findings suggest that the postoperative TAP block may be slightly more effective in reducing 24-hour postoperative opioid consumption and PONV when compared to the pre-operative TAP block.

TRIAL REGISTRATION

PROSPERO, CRD42023396880 .

Peri-Incisional Infiltration and Intraperitoneal Instillation of Local Anesthetic for Reducing Pain After Laparoscopic Donor Nephrectomy: A Prospective, Randomized, Double-Blind Control Trial

BACKGROUND

The analgesic efficacy of peri-incisional infiltration and intraperitoneal instillation of ropivacaine in laparoscopic donor nephrectomy has not been clearly established.

METHODS

This randomized, controlled, double-blind trial allocated living donors undergoing left-sided laparoscopic donor nephrectomy to one of the following 4 groups: peri-incisional normal saline (NS) and intraperitoneal NS (group A, n = 30), peri-incisional 0.375% ropivacaine and intraperitoneal NS (group B, n = 31), peri-incisional NS and intraperitoneal 0.15% ropivacaine (group C, n = 31), and peri-incisional 0.375% and intraperitoneal 0.15% ropivacaine (group D, n = 32). Pain status was assessed using the visual analog scale at rest and during coughing at 2, 12, 24, and 48 hours postoperatively. Patient-controlled analgesia and additional rescue analgesic consumption were calculated by conversion to an equivalent dosage of morphine. This study did not include prisoners or those individuals who were coerced or paid as study participants.

RESULTS

The patient demographics and perioperative outcomes, including operative time, blood loss, and incision length, were comparable between the groups. The pain scores and number of patients who experienced shoulder pain at all postoperative time points did not differ significantly among the 4 groups. Postoperative analgesic consumption was similar in all groups, and there was no difference in the length of hospital stay.

CONCLUSION

Peri-incisional infiltration and intraperitoneal instillation of ropivacaine did not reduce postoperative pain or analgetic consumption.

The Effect of Various Combinations of Peripheral Nerve Blocks on Postoperative Pain in Laparoscopic Cholecystectomy: A Comparative Prospective Study

Objectives

Most patients who undergo laparoscopic cholecystectomy (LC) experience moderate to severe pain in the first 24 hours after surgery. The transversus abdominal plane (TAP) is currently used for post-LC analgesia. Posterior, subcostal, or rectus sheath TAP blocks are the conventional approaches used. The aim of the current study was to compare the efficacy of combinations of various peripheral blocks on pain intensity and the use of pain killers, shortly after LC.

Methods

This was a prospective, double-blind study, in which 200 patients who were about to undergo a LC procedure were recruited and randomized into 4 groups: patients receiving one of the following: TAP block alone, subcostal Tap block alone, subcostal TAP block with a TAP block, or subcostal TAP with a rectus sheath block. The intensity of pain (VAS score) and the use of painkillers were monitored in the recovery unit and in the department for up to 24 hours after surgery.

Results

Pain levels decreased with time from 3.6 ± 3.2 at 30 minutes to 0.9 ± 2.0 at 24 hours after the surgery. Nevertheless, no difference between the various block types groups was noted. The percentage of patients who consumed analgesic medications decreased over time, from 83% at 30 to 21% at 24 hours after surgery. The mean/median number of medications consumed by each of the patients was lower among the patients who received a combination of 2 blocks compared to those who received a single one (mean/median of 2.7/3 and 2.8/3 for the TAP or subcostal TAP blocks, respectively; 2.5/2 and 2.3/2 for the subcostal TAP + TAP or subcostal TAP + rectus sheath blocks, respectively).

Conclusion

A combination of peripheral nerve blocks reduced the use of analgesic consumption during the 24 hours after LC surgery, compared to standalone blocks.

Opioid-Free Anesthesia for Pain Relief After Laparoscopic Cholecystectomy: A Prospective Randomized Controlled Trial

Purpose

To compare the efficacies of opioid-free anesthesia (OFA) and opioid-based anesthesia (OBA) in laparoscopic cholecystectomy (LC).

Patients and Methods

A total of 150 patients who underwent 3-port LC procedures were randomly divided into an OFA group with esketamine, dexmedetomidine and lidocaine intravenous combined with local anesthetic incision infiltration or an OBA group with remifentanil combined with local anesthetic incision infiltration. The primary outcome was the consumption of rescue analgesics within 24 hrs after surgery. Secondary outcomes included time to LMA removal, time to orientation recovery, time to unassisted walking, sleep quality on the night of surgery, time to first flatus, hemodynamics during induction of general anesthesia, postoperative pain level on the visual analog scale (VAS), incidence of postoperative nausea and vomiting (PONV) and global satisfaction score (GSS) within 24 hrs after surgery.

Results

Both the consumption of rescue analgesics and the time to first flatus in the OFA group were significantly lower than those in the OBA group (P < 0.001 and P = 0.029, respectively). However, the time to LMA removal and the time to orientation recovery were significantly longer in the OFA group than in the OBA group (P < 0.001). In addition, the VAS scores at 2 hrs and 8 hrs after surgery and HR at laryngeal mask airway insertion in the OFA group were significantly lower than those in the OBA group (P = 0.002 and P = 0.001, and P =0.016, respectively).

Conclusion

OFA may be beneficial for patients undergoing LC in that it could decrease the dosage of postoperative analgesics and pain intensity and even shorten the time to first flatus after surgery.

Transoral robotic surgery - time for consensus on pain assessment. A review

BACKGROUND

In Head and Neck surgery Transoral Robotic Surgery (TORS) is evolving as a key treatment option for benign and malignant lesions in the oropharynx. Even so, postoperative pain is one of the primary early complaints following TORS. Well established evidence-based procedure specific pain treatment guidelines are available for a variety of other surgical specialties. However, there are no guidelines for TORS.

AIM

This review describes the available data of early pain intensity following TORS during rest and procedure related activity.

METHODS

Literature concerning pain in the immediate postoperative phase following TORS were obtained from two literature databases.

RESULTS

Most data on pain intensity following TORS are based upon a numeric rating scale, e.g. the Visual Analogue Scale and/or analgesic demands. Only one randomized clinical trial is available reflecting that the literature is mainly based on retrospective and a few prospective studies. Only one study analyzed pain during relevant functionality, i.e. swallowing. Overall, the studies suffer from a non-standardized approach and there is a need for transparent information concerning the timing of pain ratings and methodology.

CONCLUSIONS

The evidence for optimal pain control is limited, particularly during surgical relevant activity. Postoperative pain rating during activity is a fundamental element in pain trials in order to enhance recovery thereby calling for future consensus on assessment methodology.

Adjuvants for balanced anesthesia in ambulatory surgery

Balanced anesthesia relies on the simultaneous administration of different drugs to attain an anesthetic state. The classic triad of anesthesia is a combination of a hypnotic, an analgesic, and a neuromuscular blocker. It is predominantly the analgesic pillar of this triad that became more and more supported by adjuvant therapy. The aim of this approach is to evolve into an opioid-sparing technique to cope with undesirable side effects of the opioids and is fueled by the opioid epidemic. The optimal strategy for balanced general anesthesia in ambulatory surgery must aim for a transition to a multimodal analgesic regimen dealing with acute postoperative pain and ideally reduce the most common adverse effects patients are faced with at home; sore throat, delayed awakening, memory disturbances, headache, nausea and vomiting, and negative behavioral changes. Over the years, this continuum of "multimodal general anesthesia" adopted many drugs with different modes of action. This review focuses on the most recent evidence on the different adjuvants that entered clinical practice and gives an overview of the different mechanisms of action, the potential as opioid-sparing or hypnotic-sparing drugs, and the applicability specifically in ambulatory surgery.

Effect of a Local Anesthetic Injection Kit on Pain Relief and Postoperative Recovery After Transumbilical Single-Incision Laparoscopic Cholecystectomy

Purpose

This study was conducted to explore whether incisional infiltration using a local anesthetic injection kit could better relieve postoperative pain and enhance the quality of recovery compared with ultrasound-guided rectus sheath block (RSB) or conventional local anesthetic infiltration in patients undergoing transumbilical single-incision laparoscopic cholecystectomy (SILC).

Patients and Methods

A total of 60 patients undergoing SILC with American Society of Anesthesiology functional status scores of I-II were randomized into the rectus sheath block group (RSB group), conventional local wound infiltration group (LAI-I group) and incisional infiltration using a local anesthetic injection kit group (LAI-II group). The primary outcomes were the patient-controlled intravenous analgesia (PCIA) demand frequency within 48 hours after the operation and postoperative pain measured by a visual analog scale (VAS) at 2 h, 4 h, 8 h, 24 h, and 48 h after surgery. Secondary outcomes were the total procedure times, cumulative consumption of anesthetic drugs, duration of surgery, duration and awaking time of anesthesia, early recovery indicator and side effects.

Results

The PCIA demand frequency in LAI-II group was significantly lower compared with patients in the RSB and LAI-I group (both P < 0.001). Moreover, the total procedure times in LAI-I and LAI-II group was significantly shorter than that in the RSB group (P < 0.001, respectively), but it was comparable between LAI-I and LAI-II group (P = 0.471). Though lower at 2h and 4h postoperative in LAI-II group, pain scores at each time point had no statistical differences among three groups. There were no significant differences among three groups for other outcomes as well.

Conclusion

The effect of ultrasound-guided RSB and conventional local anesthetic infiltration in SILC patients were found to be similar in terms of relieving postoperative pain and promoting recovery. Incisional infiltration using a local anesthetic injection kit can significantly reduce the demand frequency of PCIA, which serves as a rescue analgesic.

Efficacy and safety of an extended-release sebacoyl dinalbuphine ester for laparoscopic cholecystectomy: A randomized controlled trial

BACKGROUND

A long-acting κreceptor agonist parenteral analgesic may theoretically improve acute pain and reduce incidence of chronic postsurgical pain (CPSP) after laparoscopic cholecystectomy with minimal drug-related side effects of the traditional μreceptor opioids.

METHODS

Eighty adult patients undergoing elective laparoscopic cholecystectomy were randomly assigned to receive single intramuscular injection of an extended-release sebacoyl dinalbuphine ester (SDE, Naldebain 150 mg; n = 40) or placebo (n = 40) after anesthesia induction. Standard multimodal analgesia (MMA) was administered for postoperative pain control. The primary endpoint was pain intensity within 7 days after surgery. The secondary endpoints were incidence CPSP at 3 months and adverse reactions up to 7 days after surgery.

RESULTS

The highest visual analogue scale (VAS) and area under the curve of VAS 0 to 48 hours after operation were not different between the two groups and a similar proportion of patients requested rescue parenteral analgesics. Average pain intensities were also not different at 72 hours and 7 days after surgery. Incidence of CPSP was 22.5% and 13.1% in patients who received placebo and SDE treatment, respectively (P = .379). Significantly higher incidence of drug-related adverse events, including dizziness, nausea and injection site reactions, were recorded in the SDE group.

CONCLUSION

A single dose of extended-release analgesic SDE given intraoperatively did not provide sufficient add-on effect for acute and chronic pain management after laparoscopic cholecystectomies in patients who received standard postoperative MMA. Intramuscular injection of 150 mg SDE in patients with average body mass causes adverse events that could have been overlooked. More clinical studies are warranted to determine the target populations who may benefit from SDE injections for improvement of acute and chronic postsurgical pain management.

Ultrasound-guided erector spinae plane block versus port site infiltration for postoperative pain and quality of recovery in adult patients undergoing laparoscopic cholecystectomy: An assessor-blinded randomised controlled trial

Background and Aim

Pain following laparoscopic cholecystectomy (LC) is common and results in poor quality of recovery. Our study aimed to compare the analgesic efficacy of port site local infiltration, novel erector spinae plane (ESP) block, and standard regimen in patients undergoing LC and its impact on functional recovery.

Methods

After ethical approval and registering the trial, we randomly allocated 105 adult patients undergoing LC to three groups: Group I (n = 35), received multimodal analgesia; Group II (n = 35), received pre-incisional port site infiltration with 20 ml of 0.375% bupivacaine; and Group III (n = 35), preoperative bilateral ESP block with 20 ml of 0.375% bupivacaine bilaterally was administered. Pain severity, fentanyl consumption, and time to first rescue analgesia were recorded over 24 h. Quality of recovery (QoR-15) was assessed at baseline and 24 h postoperatively.

Results

Pain in the first 6 h was lowest in the ESP group (P < 0.001). Although static pain in the infiltration group was comparable with that in the ESP group after 6 h (P > 0.05), dynamic pain was better in the ESP group till 20 h postoperatively (P < 0.05). Fentanyl consumption was significantly lower in the ESP group (P < 0.001). Global and sub-dimensional QoR-15 scores were significantly higher only in the ESP group at 24 h compared to the other two groups (P < 0.001). The infiltration group did better than the control group in terms of total opioid requirement (P < 0.001) and Visual Analogue Scale (VAS) score after 6 h (P < 0.001).

Conclusion

ESP block provided lower postoperative pain scores with opioid-sparing and better quality of recovery in patients undergoing LC.

Anesthesia and analgesia for experimental craniotomy in mice and rats: a systematic scoping review comparing the years 2009 and 2019

Experimental craniotomies are a common surgical procedure in neuroscience. Because inadequate analgesia appears to be a problem in animal-based research, we conducted this review and collected information on management of craniotomy-associated pain in laboratory mice and rats. A comprehensive search and screening resulted in the identification of 2235 studies, published in 2009 and 2019, describing craniotomy in mice and/or rats. While key features were extracted from all studies, detailed information was extracted from a random subset of 100 studies/year. Reporting of perioperative analgesia increased from 2009 to 2019. However, the majority of studies from both years did not report pharmacologic pain management. Moreover, reporting of multimodal treatments remained at a low level, and monotherapeutic approaches were more common. Among drug groups, reporting of pre- and postoperative administration of non-steroidal anti-inflammatory drugs, opioids, and local anesthetics in 2019 exceeded that of 2009. In summary, these results suggest that inadequate analgesia and oligoanalgesia are persistent issues associated with experimental intracranial surgery. This underscores the need for intensified training of those working with laboratory rodents subjected to craniotomies.

Systematic review registration

https://osf.io/7d4qe.

Effect of intraperitoneal magnesium sulfate in the prevention of postoperative pain in daycare laparoscopic cholecystectomy - A prospective randomized controlled trial

This study evaluated the efficacy of intraperitoneal magnesium sulfate (MgSO4) in preventing postoperative pain after elective laparoscopic cholecystectomy (LC). It is a prospective, double-blinded, placebo-controlled, randomized trial which included 64 patients who underwent LC. Patients were equally randomized into Groups A and B. MgSO4 and normal saline were instilled in subdiaphragmatic space in Groups A and B, respectively, after creating pneumoperitoneum and before starting dissection. The Visual analogue Scale (VAS) was used to determine postoperative pain. Patients who received intraperitoneal MgSO4 had lower average VAS scores for the first 6 h postoperatively, and also, the time for the requirement of first analgesic was longer (3.6 ± 0.4 vs. 2.3 ± 1.0 h). The incidence of vomiting and the requirement for rescue antiemetic was also lower in Group A. Intraperitoneal instillation of MgSO4 reduces postoperative pain and vomiting following elective LC without incurring additional side effects.

Comparing ultrasound-guided modified thoracoabdominal nerves block through perichondrial approach with oblique subcostal transversus abdominis plane block for patients undergoing laparoscopic cholecystectomy: a randomized, controlled trial

BACKGROUND

Laparoscopic cholecystectomy(LC) causes significant postoperative pain. Oblique subcostal transversus abdominis plane(OSTAP) block was described for postoperative analgesia, especially for upper abdominal surgeries. Modified thoracoabdominal nerves block through perichondrial approach(M-TAPA) block is a new technique defined by the modification of the thoracoabdominal nerves through perichondrial approach (TAPA) block, in which local anesthetics are delivered only to the underside of the perichondral surface. The primary aim of this study was to evaluate the effect of M-TAPA and OSTAP blocks as part of multimodal analgesia on postoperative opioid consumption in patients undergoing LC.

METHOD

The present study was designed as a randomized, controlled, prospective study. Seventy-six adult patients undergoing LC were randomly assigned to receive either bilaterally M-TAPA or OSTAP block after the induction of anesthesia and before surgery using bupivacaine 0.25%, 25 ml. The primary outcome was assessed as postoperative 24 h opioid consumption, between groups were compared. Secondary outcomes were Numerical Rational scale(NRS) scores, time to first opioid analgesia, patient recovery, using the Quality of Recovery-15 (QoR-15) scale, nausea and vomiting, sedation score, metoclopramide consumption, and evaluating the analgesic range of dermatome.

RESULTS

The mean tramadol consumption at the postoperative 24th hour was higher in the group OSTAP than in group M-TAPA (P = 0.047). NRS movement score at 12th hour was statistically significantly lower in group M-TAPA than in group OSTAP (P = 0.044). Dermatomes showed intense sensory analgesia between T7-11 in both groups, and it was determined that there was proportionally more involvement in the group M-TAPA. There were no differences between the groups in terms of other results.

CONCLUSIONS

After the LC surgery, ultrasound-guided M-TAPA block effectively reduced opioid consumption, postoperative pain, and QoR-15 scores similar to OSTAP block.

CLINICAL TRIAL REGISTRATION

The study was registered prospectively at clinicaltrials.gov (trial ID: NCT05108129 on 4/11/2021).

Is intravenous magnesium sulphate a suitable adjuvant in postoperative pain management? - A critical and systematic review of methodology in randomized controlled trials

A growing worldwide focus on opioid-free anaesthesia entails multimodal analgesic strategies involving non-opioids such as magnesium sulphate (MgSO4). Several systematic reviews have concluded there is beneficial analgesic effect of MgSO4 administration but do not take considerable heterogeneity among the studies into consideration. Medical literature published until June 2021 was searched in PubMed/Medline, Embase, Central and Web of Science: The final search yielded a total of 5,672 articles. We included only randomised controlled trials assessing the effect of intravenous MgSO4 on opioid consumption and acute postoperative pain when compared to either placebo or standardized analgesic treatment. The primary aim was to compare the homogeneity of essential variables and confounders. A post-hoc meta-analysis demonstrated a reduction in both postoperative morphine consumption (-6.12 mg) and pain score (-12.32 VAS points) in favour of the MgSO4-groups. Data for meta-analysis was missing from 19 studies (45%) on morphine consumption and 29 studies (69%) for pain score, the majority of which reports no effect for either morphine consumption or pain score. The calculated heterogeneity among the included studies was considerable for both outcomes; I 2=91% for morphine consumption and I 2=96% for pain score. Although we found a per se reduction in opioid consumption and pain score, methodological heterogeneity and clinical shortcomings of pre-, intra-, and post anaesthetic data precludes conclusions on clinical importance of intraoperative intravenous MgSO4. In addition, the reduction is likely less than what can be gained from using standardized analgesic treatment.

"I Prefer to Stay Away": A Qualitative Study of Patients in an Opioid-Sparing Pain Management Protocol

OBJECTIVE

The aim of this study was to explore beliefs and behaviors of opioid pain medications among patients undergoing elective surgery.

BACKGROUND

Opioid dependence after surgery is a major contributor to the ongoing opioid epidemic. Recent efforts by surgeons and health systems have sought to improve the education patients receive regarding safe opioid use after surgery; however, little is known about patients' pre-existing beliefs surrounding opioids.

METHODS

Semistructured interviews were conducted with patients who underwent 1 of 4 common elective surgical procedures at 1 institution. Patients were specifically asked about their knowledge and beliefs about opioids before surgery and their opinions of opioid-sparing recovery after surgery. Coding was conducted through iterative steps, beginning with an initial cycle of rapid analysis, followed by focused coding, and thematic analysis.

RESULTS

Twenty-one patients were interviewed. Three major themes emerged regarding patient opinions about using opioids after surgery. First, there was widespread awareness among patients about opioid medications, and preoperatively, patients had specific intentions about using opioids, often informed by this awareness. Second, patients described a spectrum of opioid related behavior which both aligned and conflicted with preoperative intentions. Third, there was tension among patients about opioid-free postoperative recovery, with patients expressing support, opposition, and emphasis on tailoring recovery to patient needs.

CONCLUSIONS

Patients undergoing common surgical procedures often arrive at their surgical encounter with strong, pre-formed opinions about opioids. Eliciting these preexisting opinions may help surgeons better counsel patients about safe opioid use after surgery.

Analgesic efficacy of modified thoracoabdominal nerves block through the perichondrial approach in laparoscopic cholecystectomy: A retrospective study with propensity analysis

Modified thoracoabdominal nerves block through the perichondral approach (M-TAPA) was recently reported to provide broad analgesia with only a single injection of local anesthetics (LA) on each side. However, the effectiveness of M-TAPA in laparoscopic cholecystectomy (LC) is not often reported. We retrospectively evaluated the analgesic efficacy of M-TAPA in patients who underwent LC and compared it with conventional LA infiltration (LAI) by calculating the propensity score. The primary outcome was the frequency of analgesic use after surgery. Although there was no difference in the frequency of analgesic use within 48 hours (P = .063), there was significantly less analgesic use 24-48 hours after surgery in the TAPA group (P = .02). Intraoperative remifentanil administration also significantly decreased in the TAPA group (P < .001). We found that pre-incisional M-TAPA may have an advantage over LAI with respect to analgesia on postoperative day 1.

Ultrasound-guided erector spinae plane block for postoperative analgesia in Chinese patients undergoing laparoscopic cholecystectomy: a double-blind randomized controlled trial

PURPOSE

Pain management after laparoscopic cholecystectomy (LC) is a main concern for Chinese clinicians. This study aims to explore the effect of erector spinae plane block (ESPB) on the postoperative analgesia of patients undergoing LC in China.

METHODS

In this randomized controlled trial (RCT), 220 patients were randomized into the ESPB group and control group. Patients in the ESPB group received a bilateral ESPB, and patients in the control group were injected saline. Lornoxicam (0.08 mg/mL, 100 mL) was used as routine analgesia for both groups after the surgery. Visual analog scale (VAS) score at rest state at 12 h postoperative was the primary outcome and divided into no pain, mild pain, moderate pain, and severe pain.

RESULTS

Finally, 197 patients were included for analysis. At postoperative 12 h, ESPB group observed less patients with moderate pain (0% vs. 8.91%) and severe pain (0% vs. 0.99%) than the control group (P < 0.001). Moreover, ESPB group found less dose of additional sufentanil (5.55 ± 1.37 μg vs. 10.67 ± 5.05 μg), less requirement for rescue analgesia (13.54% vs. 31.68%), earlier first time to leave bed (10 h vs. 18 h), and earlier first exhaust time (17.5 h vs. 25 h), less adverse reactions (5.21% vs. 17.82%), and higher satisfaction degree (78.13% vs. 31.68%) (all P < 0.05).

CONCLUSIONS

ESPB was followed by better postoperative analgesia and less opioid consumption.

Single-shot regional anesthesia for laparoscopic cholecystectomies: a systematic review and network meta-analysis

BACKGROUND

Different regional anesthesia (RA) techniques have been used for laparoscopic cholecystectomy (LC), but there is no consensus on their comparative effectiveness. Our objective was to evaluate the effect of RA techniques on patients undergoing LC using a network meta-analysis approach.

METHODS

We conducted a systematic review and network meta-analysis. We searched PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science (Science and Social Science Citation Index) using the following PICOS criteria: (P) adult patients undergoing LC; (I) any RA single-shot technique with injection of local anesthetics; (C) placebo or no intervention; (O) postoperative opioid consumption expressed as morphine milligram equivalents (MME), rest pain at 12 h and 24 h post-operation, postoperative nausea and vomiting (PONV), length of stay; and (S) randomized controlled trials.

RESULTS

A total of 84 studies were included. With the exception of the rectus sheath block (P = 0.301), the RA techniques were superior to placebo at reducing opioid consumption. Regarding postoperative pain, the transversus abdominis plane (TAP) block (-1.80 on an 11-point pain scale) and erector spinae plane (ESP) block (-1.33 on an 11-point pain scale) were the most effective at 12 and 24 h. The TAP block was also associated with the greatest reduction in PONV.

CONCLUSIONS

RA techniques are effective at reducing intraoperative opioid use, postoperative pain, and PONV in patients undergoing LC. Patients benefit the most from the bilateral paravertebral, ESP, quadratus lumborum, and TAP blocks.

Effect of Acupuncture on Postoperative Pain in Patients after Laparoscopic Cholecystectomy: A Randomized Clinical Trial

Objective

To evaluate the efficacy and safety of acupuncture compared to that of parecoxib sodium on postoperative pain (POP), postoperative nausea and vomiting (PONV), and the Bruggemann Comfort Scale (BCS) in patients following laparoscopic cholecystectomy (LC).

Methods

Eligible patients admitted to the hospital for LC were randomly allocated to either acupuncture or control groups in a 1 : 1 ratio. The subjects in the acupuncture group received acupuncture while those in the control group were injected by parecoxib sodium at their requests. The pain score, PONV score, and BCS were assessed at 0 h, 6 h, 9 h, and 12 h after operation. The primary outcome was the pain score. The secondary outcomes included the number of patients asking for parecoxib sodium from the two groups at 0-6 h and 6-12 h, PONV score, and BCS score.

Results

The pain score of the acupuncture group were lower in acupuncture than that in the control group at 6 h and 9 h after operation (P=0.002, P=0.008). However, no difference was found at 12 h. Besides, the number of patients administered parecoxib sodium in acupuncture group was less than that in the control group both at 0-6 h and 6-12 h after operation (P=0.019, P < 0.001). Similarly, there were significantly lower levels of PONV score and higher levels of BCS at 6 h after operation in the acupuncture group than in the control group. However, no difference was found at 9 h and 12 h.

Conclusion

Acupuncture can clinically improve the short-term treatment of postoperative pain after LC and reduce the request for extra analgesics; therefore, acupuncture might be a potential method as one of multimodal analgesia techniques to treat POP following LC. Trial Registrations. This trial is registered with ChiCTR2000036885 (Chinese Clinical Trial Registry).

Effectiveness and safety of path-based analgesic regimens designed by clinical pharmacists based on the type of biliary and pancreatic surgery

WHAT IS KNOWN AND OBJECTIVE

As the incidence of postoperative pain in patients with biliary and pancreatic diseases has gradually increased, how to control postoperative pain has received increasing research attention. By reading pain management guidelines and multidisciplinary communication and cooperation, clinical pharmacists designed multi-mode analgesia regimens based on surgical types, in order to provide strong evidence for the effectiveness and safety of postoperative analgesia regimens and better serve patients.

METHODS

Data from biliary or pancreatic surgery performed at Nanjing Drum Tower Hospital from 2019 to 2021 were collected. Take October 2020 as the time point to compare the outcomes before and after the implementation of the path-based postoperative analgesic regimens. The primary outcomes were NRS pain scores, sleep quality, and incidence of adverse reactions. Length of stay was a secondary outcome.

RESULTS AND DISCUSSION

A total of 268 and 239 patients were enrolled in the study and control groups, respectively. Four path-based postoperative analgesic management regimens significantly reduced patients' static and dynamic NRS scores in the 24 h (p < 0.05). The patients' sleep quality were better than controls (p > 0.05). The incidence of adverse reactions and the length of stay in the study group were numerically lower than controls. Moderate analysis indicated that four analgesia regimens are more precise and better meet actual clinical needs.

WHAT IS NEW AND CONCLUSION

Effective and safe postoperative pain management is particularly important for clinical purposes. Path-based postoperative analgesia regimens based on different types of surgery overcome the disadvantages of overly broad and generalized traditional guidelines, which play an important role in providing personalized and precise clinical services. Further, study findings provide evidence that four path-based analgesic regimens can reduce postoperative pain and reduce the length of hospital stay, which may provide a better direction for clinical postoperative pain management.

Unilateral Right-Sided Ultrasound-Guided Erector Spinae Plane Block for Post-Laparoscopic Cholecystectomy Analgesia: A Randomized Control Trial

BACKGROUND

Post-laparoscopic cholecystectomy (LC) pain control is still an issue postoperatively.

OBJECTIVES

We investigated the effectiveness of the unilateral right-side ultrasound-guided erector spinae plane block (ESPB) on post-LC pain intensity and opioid consumption.

METHODS

This is a parallel-arm randomized control trial on 62 adult patients with an American Society of Anesthesiologists (ASA) physical status ≤ 2 who underwent LC. The patients were randomized into 2 groups (the block group [BG] and the control group [CG]; n = 31 per group). BG received a single-shot right-sided T7 ESPB with 20 mL of 0.2% ropivacaine at arrival time in the post-anesthesia care unit (PACU). CG) received no regional anesthesia. Both groups received patient-controlled intravenous fentanyl and rescue meperidine for analgesia. The primary outcome was the pain intensity determined using a Numerical Rating Scale (NRS) in the first 24 hours after surgery. Secondary outcomes included total fentanyl and meperidine consumption within 24 hours.

RESULTS

Median pain scores were significantly higher in CG at rest and with coughing up to 12 hours after surgery compared with BG. Pain scores were higher in CG with a cough at 24 hours compared with BG (median 1 [interquartile range (IQR) 1, 2] vs. 1 [1, 0]; P = 0.0005). Total fentanyl consumption and meperidine consumption within 24 hours were significantly lower in BG compared with CG (median 60 µg [IQR 60, 90] vs 250 µg [90, 300]; P < 0.0001 and median 20 µg [IQR 10, 20] vs 25 [20, 25]; P = 0.002, respectively).

CONCLUSIONS

A single-shot, right-sided, unilateral ESPB decreases post-LC opioid consumption and pain.

Evaluation of preoperative duloxetine use for postoperative analgesia following laparoscopic cholecystectomy: A randomized controlled trial

Background: The pain pattern after laparoscopic cholecystectomy (LC) is complex and distinct from postoperative pain after other laparoscopic procedures, suggesting that procedure-specific optimal analgesic management plans should be proposed. Duloxetine, a non-opioid neuromodulator, has been widely used to manage pain with dual central and peripheral analgesic properties.

Aims: To assess the effect of preoperative administration of duloxetine compared to placebo on postoperative pain control in patients undergoing LC.

Patients and Methods: This study was a randomized, parallel-group, placebo-controlled, double-blinded study performed on patients undergoing LC. Patients were randomly divided into two groups of 30 each on the day of surgery in the preoperative holding area, using a computer-generated random number to receive 60 mg duloxetine as a single oral dose 2 h before the procedure or placebo. The primary outcome was the difference in the mean of visual analogue scale (VAS) scores between the two studied groups, as measured by the area under the curve (AUC) of the VAS scores.

Results: The derived AUC of VAS scores in the duloxetine group (757.89 ± 326.01 mm × h) was significantly lower than that calculated for the control group (1005.1 ± 432.5 mm × h). The mean postoperative VAS scores recorded at 4 and 24 h were statistically different between the study groups (p = 0.041 and 0.003, respectively). As observed in the survival curve analysis, there was no significant difference (p = 0.665) for the time until the patient’s first request for rescue medications in the two groups. The frequency of postoperative nausea and vomiting (PONV) was lower in patients of the duloxetine group than that recorded in those allocated to the control group at 8 and 24-h time intervals (p = 0.734 and 0.572, respectively).

Conclusion: Preoperative use of duloxetine reduces postoperative pain significantly compared with placebo. In addition, its use is associated with a reduction in PONV. These preliminary findings suggest that duloxetine could play a role in the acute preoperative period for patients undergoing LC.

Clinical Trial Registration: [https://clinicaltrials.gov/ct2/show/NCT05115123, identifier NCT05115123],

Pain treatment and prophylaxis on pain

PURPOSE OF REVIEW

Also in ambulatory surgery, there will usually be a need for analgesic medication to deal with postoperative pain. Even so, a significant proportion of ambulatory surgery patients have unacceptable postoperative pain, and there is a need for better education in how to provide proper prophylaxis and treatment.

RECENT FINDINGS

Postoperative pain should be addressed both pre, intra- and postoperatively. The management should be with a multimodal nonopioid-based procedure specific guideline for the routine cases. In 10-20% of cases, there will be a need to adjust and supplement the basic guideline with extra analgesic measures. This may be because there are contraindications for a drug in the guideline, the procedure is more extensive than usual or the patient has extra risk factors for strong postoperative pain. Opioids should only be used when needed on top of multimodal nonopioid prophylaxis. Opioids should be with nondepot formulations, titrated to effect in the postoperative care unit and eventually continued only when needed for a few days at maximum.

SUMMARY

Multimodal analgesia should start pre or per-operatively and include paracetamol, nonsteroidal anti-inflammatory drug (NSAID), dexamethasone (or alternative glucocorticoid) and local anaesthetic wound infiltration, unless contraindicated in the individual case. Paracetamol and NSAID should be continued postoperatively, supplemented with opioid on top as needed. Extra analgesia may be considered when appropriate and needed. First-line options include nerve blocks or interfascial plane blocks and i.v. lidocaine infusion. In addition, gabapentinnoids, dexmedetomidine, ketamine infusion and clonidine may be used, but adverse effects of sedation, dizziness and hypotension must be carefully considered in the ambulatory setting.