Preemptive Analgesia Reduces Pain After Radical Axillary Lymph Node Dissection

Analysis of in-hospital analgesic pharmacotherapy costs and regimen and impact on postoperative pain-related function in degenerative lumbar intervertebral disc disease

BACKGROUND

Pain medication may affect clinical and economic outcomes, and a detailed description of pain medication use is advocated in the literautre for better assessment of clinical outcomes of spine surgery, which otherwise clould be misleading.

OBJECTIVES

To analyze the impact of in-hospital analgesic pharmacotherapy after spine surgery on subjective quality of life and pain relief in patients with degenerative lumbar intervertebral disc disease (DLIVD), and also to analyze pharmacotherapy costs.

DESIGN

A single-center study included 50 patients with L5/S1 or L4/L5 DLIVD, eligible for spine surgery.

INTERVENTION

Neurosurgery for DLIVD.

MAIN ENDPOINTS

Outcomes in terms of postoperative pain and function were recorded prospectively using standardized questionnaires. Data for cost analysis and pharmcotherapy regimen were obtained retrospectively from case histories, doctors' request cards and hospital discharge summaries.

RESULTS

Mean total pharmacotherapy cost amounted to €453.42±49.09. Mean pharmacotherapy cost amounted to €314.76±54.21 preoperatively, and €138.66±25.54 postoperatively. The greatest improvement in function and quality of life was in patients treated with non-opioids.

CONCLUSION

This study supports the notion that analgesic pharmacotherapies could be differentiated in terms of overall impact on quality of life, and that pain-related distress might be the most relevant factor in this setting.

Effects of Single-Dose Preoperative Pregabalin on Postoperative Pain and Opioid Consumption in Cleft Orthognathic Surgery

BACKGROUND

Several studies have illustrated the efficacy of pregabalin in decreasing postoperative opioid use in adults undergoing orthognathic surgery. We aimed to study the effects of a single dose of preoperative pregabalin on total opioid consumption after orthognathic surgery in individuals with cleft lip and palate.

METHODS

This is a retrospective cohort study of consecutive patients who underwent Le Fort I midface advancement between June 2012 and July 2019. All patients had a diagnosis of cleft lip and palate. The treatment group received a 1-time preoperative dose of pregabalin; the control group did not. Total morphine milligram equivalent (MME) consumption was calculated by adding intraoperative and postoperative opioid use during admission.

RESULTS

Twenty-three patients were included in this study; 12 patients received pregabalin. The pregabalin group had significantly lower total opioid consumption (total MME 70.95 MME; interquartile range [IQR]: 24.65-150.17) compared to the control group (138.00 MME; IQR: 105.00-232.48) (MU = 31.00, P = 0.031). The difference in mean pain scores in the treatment group (3.21 ± 2.03) and the control group (3.71 ± 2.95) was not statistically significant (P = 0.651, 95% confidence interval -1.75 to 2.75).

CONCLUSIONS

A 1-time preoperative dose of pregabalin before orthognathic surgery in patients with cleft lip and palate reduced total opioid consumption during admission without increasing patient pain. A single preemptive dose of pregabalin should be considered an effective adjunct to pain management protocols in patients undergoing orthognathic surgery.

Using Intravenous Ibuprofen for Preventive Analgesia in Orthognathic Surgery

PURPOSE

Preventive analgesia aims to manage postoperative pain caused by nociceptive and central stimulation. The purpose of this study was to research the effect of a single-dose intravenous (IV) ibuprofen administration for preventive analgesia on postoperative pain management in orthognathic surgery.

MATERIALS AND METHODS

This prospective, double blind, and randomized study was performed on a total of 40 adult patients who planned to undergo bimaxillary osteotomy, between 2018 and 2019. Thirty minutes before the surgery, 800 mg of IV ibuprofen and 100 mL of saline were applied to group 1 (ibuprofen; n = 20) and group 2 (placebo; n = 20), respectively. Postoperative analgesia was maintained with tramadol infusion via a patient-controlled analgesia pump. Postoperative visual analog scale (VAS) scores at 1, 3, 6, 9, 12, and 24 hours after surgery, rescue analgesic requirement, total tramadol dose, and adverse effects were recorded.

RESULTS

VAS scores between the groups at 1, 6, 9, and 24 hours and also the average of 24-hour VAS scores were similar (P > .05). However, VAS scores at 3 hours were significantly higher in group 2 (P = 0.06). Also, rescue analgesic intake of paracetamol was significantly higher in group 2 in the third hour (P = .08). Rescue analgesic intake of paracetamol and tramadol consumption during the postoperative 24 hours were similar (P > .05).

CONCLUSIONS

Using single-dose IV ibuprofen administration just before orthognathic surgery for preventive analgesia reduced VAS scores and postoperative opioid consumption in patients. However, further studies in a large population are needed to estimate the preventive analgesia effect of ibuprofen in orthognathic surgery.

The efficacy of parecoxib for pain control after hysterectomy: a meta-analysis of randomized controlled studies

Introduction: The efficacy of parecoxib for pain control after hysterectomy remains controversial. We conduct a systematic review and meta-analysis to explore the influence of parecoxib versus placebo on pain intensity after hysterectomy.Methods: We search PubMed, Embase, Web of Science, EBSCO, and Cochrane Library databases through March 2019 for randomized controlled trials (RCTs) assessing the effect of parecoxib versus placebo on pain intensity after hysterectomy. This meta-analysis is performed using the random-effect model.Results: Six RCTs are included in the meta-analysis. Overall, compared with control group after hysterectomy, parecoxib treatment is associated with substantially reduced pain scores in 4-6 h at rest (MD = -0.98; 95%CI = -1.14 to -0.81; p < .00001), pain scores in 12 h at rest (MD = -0.70; 95%CI = -0.77 to -0.63; p < .00001), pain scores in 12 h on sitting up (MD = -0.90; 95%CI = -1.03 to -0.77; p < .00001), pain scores in 24 h on sitting up (MD = -1.19; 95%CI = -1.94 to -0.44; p = .002), dose of analgesic need in parecoxib group is notably lower than that in control group (std. MD = -2.54; 95%CI = -3.97 to -1.10; p = .0005), but shows no obvious effect on pain scores in 24 h at rest (MD = -0.40; 95%CI = -1.47-0.67; p = .47), pain scores in 4-6 h on sitting up (MD = -0.54; 95%CI = -2.50-1.42; p = .59), first time to analgesic requirement between two groups (std. MD = -0.10; 95%CI = -0.47-0.26; p = .57), nausea or vomiting (RR = 0.92; 95%CI = 0.59-1.43; p = .70), and adverse events (RR = 0.86; 95%CI = 0.64-1.17; p = .34).Conclusions: Parecoxib treatment provides additional benefits for pain control after hysterectomy.

Nonsteroidal anti-inflammatory drugs for postoperative pain control after lumbar spine surgery: A meta-analysis of randomized controlled trials

STUDY OBJECTIVE

Nonsteroidal anti-inflammatory drugs (NSAIDs) play a role in pain relief, especially in postoperative pain caused by inflammation. They have demonstrated significant opioid dose-sparing effects, which help in reducing postoperative effects and opioid side effects. The objective of this meta-analysis was to explore the role of NSAIDs in reducing postoperative pain at different time intervals and provide reference for medication after lumbar spine surgery by a meta-analysis of randomized controlled trials (RCT).

DESIGN

A meta-analysis study of randomized controlled trials.

SETTING

Postoperative recovery area.

PATIENTS

Adult patients who have undergone lumbar spine surgery.

INTERVENTION

Patients received NSAIDs for pain control after lumbar spine surgery.

MEASUREMENTS

Standardized mean difference (SMD) and 95%CI were used to evaluate the visual analog scale of postoperative pain.

MAIN RESULTS

Four hundred and eight participants from eight studies were included in this study. The difference between the NSAIDs group and placebo is significant in 0-6, 12, and 24h groups (overall: SMD=-0.72, 95%CI -0.98 to -0.45; 0-6h: SMD=0.50, 95%CI -0.81 to -0.19; 12h: SMD=-1.07, 95%CI -1.45 to -0.70; 24h: SMD=-1.16, 95%CI -1.87 to -0.45). Heterogeneity and publication bias were observed in the 0-6 and 24h groups.

CONCLUSION

NSAIDs are effective in postoperative analgesia after lumbar spine surgery. The study type, NSAID dose, different surgery types, and analgesic type might influence the efficacy of NSAIDs.

Effect of Parecoxib as an Adjunct to Patient-Controlled Epidural Analgesia after Abdominal Hysterectomy: A Multicenter, Randomized, Placebo-Controlled Trial

OBJECTIVE

This multicenter, randomized, placebo-controlled study evaluated the efficacy and side effects of parecoxib during patient-controlled epidural analgesia (PCEA) after abdominal hysterectomy.

METHODS

A total of 240 patients who were scheduled for elective abdominal hysterectomy under combined spinal-epidural anesthesia received PCEA plus postoperative intravenous parecoxib 40 mg or saline every 12 h for 48 h after an initial preoperative dose of parecoxib 40 mg or saline. An epidural loading dose of a mixture of 6 mL of 0.25% ropivacaine and 2 mg morphine was administered 30 min before the end of surgery, and PCEA was initiated using 1.25 mg/mL ropivacaine and 0.05 mg/mL morphine with a 2-mL/h background infusion and 2-mL bolus with a 15-min lockout. The primary end point of this study was the quantification of the PCEA-sparing effect of parecoxib.

RESULTS

Demographic data were similar between the two groups. Patients in the parecoxib group received significantly fewer self-administrated boluses (0 (0, 3) vs. 7 (2, 15), P < 0.001) and less epidural morphine (5.01 ± 0.44 vs. 5.95 ± 1.29 mg, P < 0.001) but experienced greater pain relief compared with the control group (P < 0.001). Patient global satisfaction was higher in the parecoxib group than the control group (P < 0.001). Length of hospitalization (9.50 ± 2.1, 95% CI 9.12~9.88 vs. 10.41 ± 2.6, 95% CI 9.95~10.87, P = 0.003) and postoperative vomiting (17% vs. 29%, P < 0.05) were also reduced in the parecoxib group. There were no serious adverse effects in either group.

CONCLUSION

Our data suggest that adjunctive parecoxib during PCEA following abdominal hysterectomy is safe and efficacious in reducing pain, requirements of epidural analgesics, and side effects.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT01566669).

Preemptive, preventive, multimodal analgesia: what do they really mean?

SUMMARY

To improve postoperative pain management, several concepts have been developed, including preemptive analgesia, preventive analgesia, and multimodal analgesia. This article will discuss the role of these concepts in improving perioperative pain management. Preemptive analgesia refers to the administration of an analgesic treatment before the surgical insult or tissue injury. Several randomized clinical trials have, however, provided equivocal evidence regarding the benefits of preincisional compared with postincisional analgesic administration. Current general consensus, therefore, indicates that use of preemptive analgesia does not translate into consistent clinical benefits after surgery. Preventive analgesia is a wider concept where the timing of analgesic administration in relation to the surgical incision is not critical. The aim of preventive analgesia is to minimize sensitization induced by noxious stimuli arising throughout the perioperative period. Multimodal analgesia consists of the administration of 2 or more drugs that act by different mechanisms for providing analgesia. These drugs may be administered via the same route or by different routes. Thus, the aim of multimodal analgesia is to improve pain relief while reducing opioid requirements and opioid-related adverse effects. Analgesic modalities currently available for postoperative pain control include opioids, local anesthetic techniques [local anesthetic infiltration, peripheral nerve blocks, and neuraxial blocks (epidural and paravertebral)], acetaminophen, nonsteroidal anti-inflammatory drugs, and cyclooxygenase-2-specific inhibitors as well as analgesic adjuncts such as steroids, ketamine, α-2 agonists, and anticonvulsants.

Pre-emptive parecoxib and post-operative cognitive function in elderly patients

BACKGROUND

To investigate the effect of pre-emptive parecoxib sodium, given in addition to routine analgesic treatment, on post-operative cognitive function in elderly patients.

METHODS

Seventy elderly patients were included, who were 65-82 years of age, 48-75 kg of weight, and ASA grade I-II. Preoperative mini mental state examination (MMSE) score was ≥21 points. Patients were randomly divided into two groups: control group (group C) and parecoxib sodium group (group P). Before induction of general anesthesia, 40 mg of parecoxib sodium was injected intravenously in group P and the same volume of saline was injected in group C. Patient-controlled intravenous analgesia (PCIA) containing fentanyl and tramadol was used for post-operative pain control. A 3 ml blood sample was obtained from the peripheral vein one day before surgery, 1, 4, 24, and 72 h after surgery, and plasma cortisol, IL-6 and S100β concentrations were measured. Cognitive function was evaluated by measuring the MMSE score and a neurological test battery within 72 h after surgery. The occurrence of post-operative cognitive dysfunction (POCD), the dosage of fentanyl and tramadol used in PCIA, and the rate of additional fentanyl administration were recorded.

RESULTS

Compared to group C, post-operative plasma cortisol concentration decreased, the amount of fentanyl and tramadol used in PCIA was reduced, the rate of additional fentanyl administration decreased, and the rate of POCD was reduced in group P (P < 0.05).

CONCLUSION

Pre-emptive analgesia with 40 mg of parecoxib sodium can reduce the incidence of POCD in elderly patients.

The cyclooxygenase-2 inhibitor parecoxib inhibits surgery-induced proinflammatory cytokine expression in the hippocampus in aged rats

BACKGROUND

Neuroinflammatory response triggered by surgery has been increasingly reported to be associated with postoperative cognitive dysfunction. Proinflammatory cytokines, such as interleukin 1β (IL-1β) and tumor necrosis factor α (TNF-α), play a pivotal role in mediating surgery-induced neuroinflammation. The role of cyclooxygenase-2 (COX-2), a critical regulator in inflammatory response, in surgery-induced neuroinflammation is still unknown. The aim of the study was to investigate the changes of COX-2 expression and prostaglandin E2 (PGE2) production in the hippocampus in aged rats following partial hepatectomy. The effects of selective COX-2 inhibitor (parecoxib) on hippocampal proinflammatory cytokine expression were also evaluated.

METHODS

Aged rats were randomly divided into three groups: control (n = 10), surgery (n = 30), and parecoxib (n = 30). Control animals received sterile saline to control for the effects of injection stress. Rats in the surgery group received partial hepatectomy under isoflurane anesthesia and sterile saline injection. Rats in the parecoxib group received surgery and anesthesia similar to surgery group rats, and parecoxib treatment. On postanesthetic days 1, 3, and 7, animals were euthanized to assess levels of hippocampal COX-2 expression, PGE2 production, and cytokines IL-1β and TNF-α expression. The effects of parecoxib on proinflammatory cytokine expression were also assessed.

RESULTS

Partial hepatectomy significantly increased COX-2 expression, PGE2 production, and proinflammatory cytokine expression in the hippocampus in aged rats on postoperative days 1 and 3. Parecoxib inhibited hippocampal IL-1β and TNF-α expression through downregulation of the COX-2/PGE2 pathway.

CONCLUSION

COX-2 may play a critical role in surgery-induced neuroinflammation. The COX-2 inhibitor may be a promising candidate for treatment of neuroinflammation caused by surgical trauma.

Lack of preemptive analgesia by intravenous flurbiprofen in thyroid gland surgery: a randomized, double-blind and placebo-controlled clinical trial

BACKGROUND

Nowadays, increasingly more preemptive analgesia studies focus on postoperative pain; however, the impact of preemptive analgesia on perioperative opioid requirement is not well defined. This study was carried out in order to evaluate whether preoperative intravenous flurbiprofen axetil can reduce perioperative opioid consumption and provide postoperative analgesia in patients undergoing thyroid gland surgery.

METHODS

Ninety patients undergoing elective thyroid gland surgery were randomly assigned to three groups. Group A (Control) was administered Intralipid(®) 2 ml as a placebo 15 min before the cervical plexus block and at the end of the surgery; Group B (Routine analgesia) was administered a placebo 15 min before the cervical plexus block and flurbiprofen 50 mg at the end of the surgery; Group C (Preemptive analgesia) was administered intravenous flurbiprofen 50 mg 15 min before the cervical plexus block and a placebo at the end of the surgery. Sufentanil administration during the surgery and the 24 h satisfaction score on analgesic therapy were both recorded. The analgesic efficacy was assessed at 1, 2, 4, 6, 8, 12, and 24 hours after the surgery, based on visual analog scales.

RESULTS

Ninety patients were involved in the study. One patient from Group B did not have their scheduled surgery; eighty-nine patients completed the study. There were no significant differences in the patient demographics between the three groups. Visual analog scales: 1, 2, 4 h for Group A was significantly higher than Groups B and C (P<0.05); Sufentanil administration during surgery: Group C was obviously lower compared to Groups A and B (P<0.05); 24 h satisfaction score: Groups B and C were higher than Group A (P<0.05).

CONCLUSION

Preoperative administration of intravenous Flurbiprofen axetil reduced analgesic consumption during surgery, but not postoperative pain scores.