Evolving the management of acute perioperative pain towards opioid free protocols: a narrative review

Opioid-free anesthesia reduces the severity of acute postoperative motion-induced pain and patient-controlled epidural analgesia-related adverse events in lung surgery: randomized clinical trial

Background

Opioids have been used as pain relievers for thousands of years. However, they may also cause undesirable side effects. We therefore performed this study to compare the effect of opioid-free anesthesia (OFA) versus opioid-sparing anesthesia (OSA) on postoperative pain and patient-controlled epidural analgesia (PCEA)-related events.

Methods

This is a single center randomized clinical trial that was recruited patients aged from 18 to 70 years who received video-assisted lung surgery between October 2021 and February 2022. Participants were 1:1 randomly assigned to OFA or OSA. Patients in the OFA group received propofol, rocuronium, esmolol, lidocaine, and magnesium sulfate intravenously with epidural ropivacaine. Patients in the OSA group received propofol, rocuronium, remifentanil, and sufentanil intravenously with epidural hydromorphone and ropivacaine.

Results

A total number of 124 patients were randomly allocated to the OFA or OSA group. In the OFA group, the severity of pain during coughs on the first postoperative days (PODs; VAS score 1.88 ± 0.88 vs. 2.16 ± 1.1, p = 0.044) was significantly lower than that in the OSA group. The total ratio of PCEA-related adverse events in the OFA group [11 (19.6%) vs. 26 (47.3%), p = 0.003] was significantly lower than in the OSA group.

Conclusion

OFA in patients who received video-assisted lung surgery led to lower severity of acute postoperative motion-induced pain and fewer PCEA-related adverse events on the first POD than in the patients in the OSA group.

Clinical trial registration

clinicaltrials.gov, identifier (NCT05063396).

Effect of opioid-free anesthesia on the incidence of postoperative nausea and vomiting: A meta-analysis of randomized controlled studies

BACKGROUND

Research on opioid-free anesthesia has increased in recent years; however, it has never been determined whether it is more beneficial than opioid anesthesia. This meta-analysis was primarily used to assess the effect of opioid-free anesthesia compared with opioid anesthesia on the incidence of postoperative nausea and vomiting.

METHODS

We searched the electronic databases of PubMed, the Cochrane Library, Web of Science and Embase from 2014 to 2022 to identify relevant articles and extract relevant data. The incidence of postoperative nausea and vomiting, time to extubation, pain score at 24 hours postoperatively, and time to first postoperative rescue analgesia were compared between patients receiving opioid-free anesthesia and those receiving standard opioid anesthesia. Differences in the incidence of postoperative nausea and vomiting were evaluated using risk ratios (95% confidence interval [CI]). The significance of the differences was assessed using mean differences and 95% CI. The heterogeneity of the subject trials was evaluated using the I2 test. Statistical analysis was performed using the RevMan 5.4 software.

RESULTS

Fourteen randomized controlled trials, including 1354 participants, were evaluated in the meta-analysis. As seen in the forest plot, the OFA group had a lower risk of postoperative nausea and vomiting than the control group (risk ratios = 0.41, 95% CI: 0.33-0.51, P < .00001; n = 1354), and the meta-analysis also found that the OFA group had lower postoperative analgesia scores at 24 hours (P < .000001), but time to extubation (P = .14) and first postoperative resuscitation analgesia time (P < .54) were not significantly different.

CONCLUSIONS

Opioid-free anesthesia reduces the incidence of postoperative nausea and vomiting while providing adequate analgesia without interfering with postoperative awakening.

Analgesic Efficacy of Intraoperative Superior Hypogastric Plexus (SHP) Block during Abdominal Hysterectomy: A Systematic Review and Meta-Analysis of Controlled Trials

Background and Objectives: Abdominal hysterectomy is a major surgery that is often associated with pronounced postsurgical pain. The objective of this research is to conduct a systematic review and meta-analysis of all randomized controlled trials (RCTs) and nonrandomized comparative trials (NCTs) that have surveyed the analgesic benefits and morbidity of intraoperative superior hypogastric plexus (SHP) block (intervention) compared with no SHP block (control) during abdominal hysterectomy. Materials and Methods: The Cochrane Central Register of Controlled Trials (CENTRAL), Google Scholar, Web of Science, PubMed, Scopus, and Embase were searched from inception until 8 May 2022. The Cochrane Collaboration tool and Newcastle-Ottawa Scale were used to evaluate the risk of bias of RCTs and NCTs, respectively. In a random effects mode, the data were pooled as risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI). Results: Five studies (four RCTs and one NCT) comprising 210 patients (SHP block = 107 and control = 103) were analyzed. The overall postsurgical pain score (n = 5 studies, MD = -1.08, 95% CI [-1.41, -0.75], p < 0.001), postsurgical opioid consumption (n = 4 studies, MD = -18.90 morphine milligram equivalent, 95% CI, [-22.19, -15.61], p < 0.001), and mean time to mobilization (n = 2 studies, MD = -1.33 h, 95% CI [-1.98, -0.68], p < 0.001) were significantly decreased in the SHP block group contrasted with the control arm. Nevertheless, there was no significant variance between both arms regarding operation time, intraoperative blood loss, postsurgical NSAID consumption, and hospital stay. There were no major side effects or sympathetic block-related aftermaths in both groups. Conclusions: During abdominal hysterectomy and receiving perioperative multimodal analgesia, the administration of intraoperative SHP block is largely safe and exhibits better analgesic effects compared to cases without administration of SHP block.

Esketamine-based opioid-free anaesthesia alleviates postoperative nausea and vomiting in patients who underwent laparoscopic surgery: study protocol for a randomized, double-blinded, multicentre trial

BACKGROUND

Although opioids are commonly prescribed in clinical anaesthesia, the significant side effects attributed to their overuse are raising increasing concerns. One way to reduce perioperative opioid consumption is to apply opioid-reduced anaesthesia (ORA) and even opioid-free anaesthesia (OFA), which involves regional techniques, neuraxial anaesthesia, nonopioid analgesics or combined use. The aim of this study was to investigate whether the application of OFA by using esketamine in intraoperative analgesia could minimize the side effects of postoperative nausea and vomiting (PONV), as well as other short-term side effects related to anaesthesia.

METHODS/DESIGN

The study was designed as a prospective, randomized, controlled, multicentre trial. A total of 278 patients were enrolled; participants were nonsmoking female patients aged 18-50 years and scheduled for laparoscopic appendectomy or cholecystectomy, ASA at I-III, with no serious physical or mental diseases. Both groups received usual perioperative care except for the analgesic medication of either esketamine or sufentanil. The primary outcome was the incidence of PONV 3 days after surgery. Secondary outcomes included recovery status, pain, sedation level and overall recovery, delirium and cognition, anxiety and depression and total consumption of analgesic agents.

DISCUSSION

This trial may show that the synergy of esketamine and propofol anaesthesia reduces PONV as well as other short-term adverse events, thereby providing a better safety and satisfaction profile of ERAS for laparoscopic appendectomy and cholecystectomy.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2100047169. Registered on June 9, 2021.

A Comprehensive Assessment of The Eight Vital Signs

The term “vital sign” has been assigned to various phenomena with the presumptive intent to emphasize their importance in health care resulting in the emergence of eight vital signs with multiple designations and overlapping terms. This review developed a case definition for vital signs and identified and described the fifth through eighth vital signs. PubMed/Medline, Google and biographical databases were searched using the individual Medical Subject Headings (MeSH) terms, vital sign and fifth, vital sign and sixth, vital sign and seventh, and vital sign eighth. The search was limited to human clinical studies written in English literature from 1957 up until November 30, 2021. Excluded were articles containing the term vital sign if used alone without the qualifier fifth, sixth, seventh, or eighth or about temperature, blood pressure, pulse, and respiratory rate. One hundred ninety-six articles (122 for the fifth vital sign, 71 for the sixth vital sign, two for the seventh vital sign, and one for the eighth vital sign) constituted the final dataset. The vital signs consisted of 35 terms, classified into 17 categories compromising 186 unique papers for each primary authored article with redundant numbered vital signs for glucose, weight, body mass index, and medication compliance. Eleven terms have been named the fifth vital sign, 25 the sixth vital sign, three the seventh, and one as the eighth vital sign. There are four time-honored vital signs based on the case definition, and they represent an objective bedside measurement obtained noninvasively that is essential for life. Based on this case definition, pulse oximetry qualifies as the fifth while end-tidal CO2 and cardiac output as the sixth. Thus, these terms have been misappropriated 31 times. Although important to emphasize in patient care, the remainder are not vital signs and should not be construed in this manner.

Feasibility of Opioid-Free Anesthesia for Cervical Rib Excision: A Case Series and Review of Literature

Background Perioperative pain management following cervical rib excision can be compounded in the background of chronic pain disorder caused by the neurovascular compression. The former mandates an enhanced analgesic requirement wherein the perioperative opioid use, in particular, can be associated with a peculiar adverse-effect profile and abuse potential. Appropriate to the context, an opioid-free anesthesia (OFA) protocol can be instrumental in minimizing the incidence of the aforementioned.

Case Series While two patients necessitated OFA owing to opioid contraindication, the formulated protocol was evaluated in another six consecutive patients posted for elective cervical rib excision. A combined paravertebral block and superficial cervical plexus block was employed alongside general anesthesia. Intravenous dexmedetomidine and lignocaine assisted the conduct of OFA, and paracetamol dosing was continued into the postoperative period. Intraoperative rescue analgesia was ensured by a ketofol bolus (1:1 mixture of ketamine and propofol) whereas intravenous diclofenac was used for postoperative rescue analgesia.

Results OFA could be successfully contemplated in all eight patients. A single bolus rescue dose of ketofol had to be administered in two patients intraoperatively and diclofenac had to be administered as postoperative rescue analgesic in two patients. There was no incidence of postoperative nausea/vomiting or any block-related complications. The postoperative stay was uneventful with an acceptable patient satisfaction.

Conclusion The index experience reiterates the fact that a prudent combination of nonopioid multimodal analgesics with case-based locoregional techniques can feature as a successful OFA protocol, albeit mandating future prospective studies in this novel area of clinical interest.

Factors influencing postoperative pain management among nurses in selected district hospitals in Ghana

BACKGROUND

Poorly managed postoperative pain is linked to numerous postoperative complications worldwide and in Ghana. This is due to the myriad of physical and psychological problems, such as lifelong chronic pain syndromes, impaired functionality and death.

PURPOSE

The aim of this study was to assess the barriers and factors influencing postoperative pain management by Ghanaian nurses working in four hospitals.

METHODS

A quantitative descriptive cross-sectional design was employed for this study. Participants were recruited using a multistage sampling technique by which 146 returned their questionnaires out of 194 participants. The statistical analysis of data was done with the Statistical Package of Social Sciences (SPSS) 20.0 version.

RESULTS

Findings revealed that some verbal and non-verbal cues from patients such as facial grimacing, restlessness, irritability and distress, lack of concentration and moaning or crying (verbalisation) influenced how nurses controlled postoperative pain with analgesia. The participants also identified several barriers to influence postoperative pain management by nurses.

CONCLUSION

In conclusion, postoperative pain control by nurses is influenced by several factors, and hence, nurses need to manage patients' pain effectively in Ghana and abroad using multiple approaches.

Experience of Pain and Satisfaction with Pain Management in Patients After a Lumbar Disc Herniation Surgery

PURPOSE

The descriptive study was performed to assess patients' pain experienced in the early postoperative period of a lumbar disc herniation surgery and their satisfaction with the pain management administered.

DESIGN

This was a descriptive and cross-sectional study conducted from May 8 to November 8, 2017.

METHODS

Data collection was performed during interviews through the Patient Information Form (20 questions), Turkish version of clinical quality indicators in the Postoperative Pain Management questionnaire (19 questions). The questionnaire included 14 items and 3 subdimensions named nursing interventions, pain management, and the environment. The remaining 5 questions were related to pain management satisfaction and pain severity. Questionnaire items scored on a 1 to 5 Likert scale. The higher the total score obtained from the questionnaire is the satisfaction with pain management increases.

FINDINGS

The mean score obtained from the total questionnaire was 51.4 (standard deviation: 6.6).Characteristics of patients with lumbar disc herniation did not influence the total score obtained from the instrument and its sub-dimensions (P > .05). Overall satisfaction with pain management was high (mean: 8.3; standard deviation: 1.6) on the 0 to 10 visual analog scale. There was a statistically significant difference between the length of hospital stay, the type of anesthesia used, having more pain than expected, and the satisfaction score of patients (P < .05). As the length of procedure increases, the average and current pain scores increase as well (P < .05).

CONCLUSIONS

Results of this study indicate that despite pain experienced after the lumbar disc herniation surgery, patients' satisfaction with pain management was high. Encouraging nurses to implement systematic and evidence-based practices in pain management may help alleviate patients' pain after surgery and reduce variety of pain management practices among nurses.

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations

OBJECTIVE

Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families.

PURPOSE

The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed.This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients.

ACTION STATEMENTS

The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method.The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.

Opioid free anesthesia: feasible?

PURPOSE OF REVIEW

The present review aims to address the feasibility of opioid free anesthesia (OFA). The use of opioids to provide adequate perioperative pain management has been a central practice of anesthesia, and only recently has been challenged. Understanding the goals and challenges of OFA is essential as the approach to intraoperative analgesia and postsurgical management of pain has shifted in response to the opioid epidemic in the United States.

RECENT FINDINGS

OFA is an opioid sparing technique, which focuses on multimodal or balanced analgesia, relying on nonopioid adjuncts and regional anesthesia. Enhanced recovery after surgery protocols, often under the auspices of a perioperative pain service, can help guide and promote opioid reduced and OFA, without negatively impacting perioperative pain management or recovery.

SUMMARY

The feasibility of OFA is evident. However, there are limitations of this approach that warrant discussion including the potential for adverse drug interactions with multimodal analgesics, the need for providers trained in regional anesthesia, and the management of pain expectations. Additionally, minimizing opioid use perioperatively also requires a change in current prescribing practices. Monitors that can reliably quantify nociception would be helpful in the titration of these analgesics and enable anesthesiologists to achieve the goal in providing personalized perioperative medicine.