The role of COX-2 inhibitors in the treatment of postoperative pain

A new long-acting analgesic formulation for postoperative pain management

Local anesthetics (LA), as part of multimodal analgesia, have garnered significant interest for their role in delaying the initiation of opioid therapy, reducing postoperative opioid usage, and mitigating both hospitalization duration and related expenses. Despite numerous endeavors to extend the duration of local anesthetic effects, achieving truly satisfactory long-acting analgesia remains elusive. Drawing upon prior investigations, vesicular phospholipid gels (VPGs) emerge as promising candidates for extended-release modalities in small-molecule drug delivery systems. Therefore, we tried to use the amphiphilicity of phospholipids to co-encapsulate levobupivacaine hydrochloride and meloxicam, two drugs with different hydrophilicity, to obtain a long-term synergistic analgesic effect. Initially, the physicochemical attributes of the formulation were characterized, followed by an examination of its in vitro release kinetics, substantiating the viability of extending the release duration of the dual drugs. Sequentially, in vivo investigations encompassing pharmacokinetic profiling and assessment of analgesic efficacy were undertaken, revealing a prolonged release duration of up to 120 h and attainment of optimal postoperative analgesia. Subsequently, inquiries into the mechanism underlying synergistic analgesic effects and safety evaluations pertinent to the delivery strategy were pursued. In summation, we successfully developed a promising formulation to achieve long-acting analgesia.

Effects of benidipine, paracetamol, and their combination on postoperative and normal tissue pain thresholds

Introduction: In clinical practice, inadequate pain inhibition leads to increased morbidity and mortality. Increased intracellular calcium, oxidants, and proinflammatory cytokines are known to play a role in the pathogenesis of postoperative pain. Therefore, we investigated the analgesic effects of benidipine, paracetamol, and benidipine-paracetamol combination (BPC) on postoperative and normal pain thresholds in rats. Material and methods: Sixty-four male albino Wistar rats weighing 285-295 g were used. The without-incision rats were divided into 4 subgroups: healthy control, benidipine alone, paracetamol alone, and BPC. The scalpel-incision rats were divided into 4 subgroups: scalpel incision, scalpel incision + benidipine, scalpel incision + paracetamol, and scalpel incision + BPC. Paw pain thresholds of rats were measured using a Basile algesimeter. Biochemical analyses were performed on the paw tissues of 6 rats randomly taken from the experimental groups, each containing 8 rats. Rats were sacrificed immediately after the measurements. After the pain threshold tests were finished, the paw tissues were removed and malondialdehyde (MDA), total glutathione (tGSH), cyclooxygenase (COX), and interleukin-6 (IL-6) levels were measured. Results: There was no significant difference between the groups in paw pain threshold and measured biochemical parameters in rats without incision. The decrease in the pain threshold of the incised paw was also best prevented by BPC, followed by benidipine and then paracetamol. Furthermore, increases in scalpel-incised paw tissue MDA, COX-2, and IL-6 levels and the decrease in tGSH were significantly suppressed by benidipine and BPC, while paracetamol could only significantly inhibit the increase in IL-6 production. Conclusion: The combination of the L-type Ca2+ channel blocker benidipine and paracetamol (BPC) may provide potent analgesia. Our experimental results support that BPC may be useful in the treatment of severe pain that cannot be adequately inhibited by paracetamol.

Effectiveness of Bromelain in the control of postoperative pain after periodontal surgery: A crossover randomized clinical trial

Background

This study aimed to compare the analgesic effects of Ibuprofen and bromelain after periodontal surgery.

Methods

A double-blinded crossover clinical trial was conducted on 22 patients needing two crown lengthening surgeries without bone surgery or with limited bone surgery on two quadrants of the maxilla, with control and test sides. Each quadrant was randomly assigned to bromelain (500 GUD) or ibuprofen (400 mg). Immediately after the surgery and 6 hours after it, the first dose of the drugs was packaged in the same capsules in A and B. Postoperative pain was evaluated during the first 8 hours and on the following day using a visual analog scale (VAS).

Results

Using the VAS, the Ibuprofen group showed significantly lower mean pain scores than the bromelain group at 4 hours (P=0.047). In contrast, there were no significant differences between the two groups at 2, 6, 8, 10, 12, 24, and 48 hours (P>0.05).

Conclusion

The effectiveness of bromelain for pain control following periodontal surgery was comparable to that of Ibuprofen. Therefore, bromelain can be an efficient replacement for ibuprofen in managing pain after periodontal surgery, especially in patients with gastric ulceration and increased bleeding tendency.

Parecoxib Reduced Postsurgical Pain and Facilitated Movement More Than Patient Controlled Analgesia

Background

Postoperative pain management is an imperative issue for patients undergoing lumbar spinal fusion surgery. Delayed pain relief is associated with poor clinical outcomes. This study compared the effects of intravenously administered patient-controlled analgesia (PCA) with intravenous parecoxib, both commonly used methods for analgesic pain control after surgery.

Methods

A non-randomized study was used to recruit 68 patients who were scheduled to receive lumbar spinal fusion surgery at a hospital in Taiwan from April through December of 2020. The group treated with parecoxib received an initial perioperative dose of parecoxib 40 mg during a 30-min period and then postoperative intravenous parecoxib at 40 mg per 12-h period, for 72 h. Those with PCA received morphine (0.4 mg/ml), droperidol (0.02 mg/ml), diphenhydramine (0.48 mg/ml), midazolam (0.02 mg/ml) and saline solution during the 3-day study course. Major outcomes, including visual scale pain score and Barthel index of activities of daily living, were collected via review of medical records at 4 times: 12, 24, 48 and 72 h after surgery. Comparative effects between two groups were assessed by the generalized estimating equations.

Results

After adjusting for potential confounders, the administration of parecoxib was associated with a significant decrease in pain scores and an increase in the Barthel Index, when compared with the PCA group (all p < 0.05). Notably, both effects would maintain for 72 h after surgery.

Discussion

This is the first trial of which the authors are aware, that supports intravenous parecoxib as significantly enhancing patient mobility, in addition to having pain control efficacy, when compared with PCA. This study could be used as a reference when instituting interventions to improve the adaptation process and clinical prognoses after lumbar spinal fusion surgery.

Comparative prospective randomized study of minimally invasive transpiriformis approach versus conventional posterolateral approach in total hip arthroplasty as measured by biology markers

Background

Minimally invasive surgery is becoming increasingly common, but evidence of the advantages of the minimally invasive transpiriformis approach in total hip arthroplasty is limited. Therefore, our single-centre randomized controlled trial evaluated the benefits of this approach versus the posterolateral approach.

Methods

Forty-nine patients undergoing the minimally invasive transpiriformis approach and 57 patients undergoing the posterolateral approach total hip arthroplasty were analyzed. The operative time, length of hospital stay, incision length, and peri-operative data related to the surgery were recorded. In both groups, serum CRP, IL-6, HGb, Hct, MB, CK-MB, and CK levels, Harris hip scores, and VAS scores were recorded.

Results

Patients who underwent the minimally invasive transpiriformis approach had a smaller surgical incision (9.10 ± 0.94 vs. 15.56 ± 1.20 cm, P = 0.00) and shorter hospital stay (6.20 ± 1.54 vs. 12.26 ± 2.97 days, P = 0.00) than those who underwent the posterolateral approach. Serum levels of CRP, IL-6, MB, CK-MB, and CK were also lower. According to the Harris hip score, the minimally invasive transpiriformis group showed significant improvement at one week and one month after surgery.

Conclusion

Compared to the posterolateral approach, the minimally invasive transpiriformis approach for total hip arthroplasty provided rapid functional recovery, elicited a significantly reduced post-operative inflammatory response, and caused less muscle damage.

Race, Ethnicity, and Insurance: the Association with Opioid Use in a Pediatric Hospital Setting

BACKGROUND

This study examined the association between race/ethnicity and health insurance payer type with pediatric opioid and non-opioid ordering in an inpatient hospital setting.

METHODS

Cross-sectional inpatient encounter data from June 2013 to June 2018 was retrieved from a pediatric children's hospital in Southern California (N = 55,944), and statistical analyses were performed to determine associations with opioid ordering.

RESULTS

There was a significant main effect of race/ethnicity on opioid and non-opioid orders. Physicians ordered significantly fewer opioid medications, but a greater number of non-opioid medications, for non-Hispanic African American children than non-Hispanic Asian, Hispanic/Latinx, and non-Hispanic White pediatric patients. There was also a main effect of health insurance payer type on non-opioid orders. Patients with government-sponsored plans (e.g., Medi-Cal, Medicare) received fewer non-opioid prescriptions compared with patients with both HMO and PPO coverage. Additionally, there was a significant race/ethnicity by insurance interaction on opioid orders. Non-Hispanic White patients with "other" insurance coverage received the greatest number of opioid orders. In non-Hispanic African American patients, children with PPO coverage received fewer opioids than those with government-sponsored and HMO insurance. For non-Hispanic Asian patients, children with PPO were prescribed more opioids than those with government-sponsored and HMO coverage.

CONCLUSION

Findings suggest that the relationship between race/ethnicity, insurance type, and physician decisions opioid prescribing is complex and multifaceted. Given that consistency in opioid prescribing should be seen regardless of patient background characteristics, future studies should continue to assess and monitor unequitable differences in care.

Comparison of Opioid Utilization Patterns After Major Head and Neck Procedures Between Hong Kong and the United States

Importance

The current opioid abuse epidemic in the United States requires evaluation of prescribing practices within all medical specialties. This examination includes a review of postoperative pain management for patients undergoing major head and neck procedures.

Objective

To report differences in postoperative pain regimens between an international and domestic head and neck surgical program.

Design, Setting, and Participants

Pain management patterns after head and neck surgery in the programs at Chinese University of Hong Kong (CUHK) and Oregon Health and Science University (OHSU) were compared with a focus on opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen or paracetamol, and anxiolytics. Cases from July 1, 2013, through August 31, 2017, were reviewed. Standing medication orders the day before surgery (PRE1), postoperative day 6 (POD6), and postoperative day 14 (POD14) were compared between institutions.

Exposures

Head and neck surgery.

Results

A total of 253 cases from CUHK and 567 cases from OHSU were analyzed (mean [SD] age, 59.4 [14.3] and 60.1 [16.4] years, respectively). Patients from OHSU had a significantly higher frequency of opioid orders on PRE1 (15.3% vs 1.6%; odds ratio [OR], 11.3; 95% CI, 4.09-31.10), POD6 (86.8% vs 0.4%; OR, 1653.12; 95% CI, 228.51-11 959.01), and POD14 (71.4% vs 0.8%; OR, 313.75; 95% CI, 77.12-1276.52). There were no significant differences in acetaminophen or paracetamol, NSAID, or anxiolytic orders between institutions. Institution was the most significant indicator for the presence of opioid orders on POD6 (OR, 4271.10; 95% CI, 380.04-47 999.70) and POD14 (OR, 330.35; 95% CI, 79.67-1369.82). In addition to treating institution, multivariate analysis showed that PRE1 opioid orders indicated a significant increase in likelihood of opioid orders on POD6 (OR, 4.77; 95% CI, 1.23-18.57) but not POD14. POD6 anxiolytic orders remained a significant indicator of opioid orders for POD6 (95% CI, 1.49-113.10) and POD14 (95% CI, 1.17-5.03), respectively.

Conclusions and Relevance

A significantly lower frequency of postoperative opioid orders was observed from CUHK compared with OHSU across similar major head and neck procedures. This contrast encourages a careful examination of (1) cultural and patient expectations of pain control, (2) the metrics by which control is assessed, (3) industry and economic drivers of opioid use, and (4) alternatives to opioid pain regimens. A thoughtful shift in postoperative pain protocols that deemphasizes opioid use may be an opportunity to counter the epidemic of opioid abuse in the United States.

The safety profile of parecoxib for the treatment of postoperative pain: a pooled analysis of 28 randomized, double-blind, placebo-controlled clinical trials and a review of over 10 years of postauthorization data

Background

Nonselective, nonsteroidal anti-inflammatory drugs (NSAIDs) and selective cyclooxygenase-2 (COX-2) inhibitors are associated with safety issues including cardiovascular, renal, and gastrointestinal (GI) events.

Objective

To examine the safety of parecoxib, a COX-2 inhibitor, for the management of postoperative pain.

Design

Pooled analysis of 28 placebo-controlled trials of parecoxib and review of postauthorization safety data.

Main outcome measures

Prespecified safety events commonly associated with COX-2 inhibitors and/or NSAIDs. In the clinical trial analysis, the frequency of each event was compared between treatment groups using a chi-square test. In the postauthorization review, the number of confirmed cases, along with outcome, was presented for each event.

Results

In the clinical trial analysis, GI-related events occurred in ~0.2% of patients in the parecoxib and placebo groups. Renal failure and impairment was similar between parecoxib (1.0%) and placebo (0.9%). The occurrence of arterial (parecoxib=0.3%; placebo=0.2%) and venous (parecoxib=0.2%; placebo=0.1%) cardiovascular embolic and thrombotic events was similar between groups. Hypersensitivity reactions including anaphylactic reactions (parecoxib=8.7%; placebo=8.6%), hypotension (parecoxib=2.6%; placebo=2.1%), angioedema (parecoxib=2.5%; placebo=2.8%), and severe cutaneous adverse reactions (0% in both groups) were similar between groups. Incision site or other skin/tissue infections occurred in <0.1% of patients in both groups. The occurrence of these events (total reports/serious reports) in the postauthorization database, based on 69,567,300 units of parecoxib, was as follows: GI ulceration-related events (35/35), renal failure and impairment (77/68), cardiovascular embolic and thrombotic events (66/64), hypersensitivity reactions including hypotension-related events (32/25) and severe cutaneous adverse events (17/17), and masking signs of inflammation (18/18). A majority of reported outcomes were classified as recovered or recovering.

Conclusions

Potentially serious safety events occur infrequently with parecoxib, which high-lights its safety in patients with postoperative pain.

Safety of parecoxib when used for more than 3 days for the management of postoperative pain

AIM

To assess parecoxib safety when used for >3 days for postoperative pain management.

METHODS

Treatment-emergent adverse event (TEAE) occurrence after day 3 was examined in a pooled analysis of three placebo-controlled trials of parecoxib following general or gynecologic surgery, or total hip arthroplasty. A total of 358 patients received parecoxib, and 318 placebo.

RESULTS

Mean treatment duration was similar between treatment groups. The overall frequency of all TEAEs after day 3 was also similar between treatment groups. Most TEAEs occurred in <1% of patients after day 3; frequencies were similar between treatment groups. Most TEAEs were considered mild or moderate in severity.

CONCLUSION

TEAE occurrence in patients receiving parecoxib for >3 days was low and similar to placebo after treatment day 3.

Nonsteroidal Anti-Inflammatory Drugs and Clinical Outcomes in Patients Undergoing Coronary Artery Bypass Surgery

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in perioperative pain management of patients undergoing coronary artery bypass graft surgery. However, the association of periprocedural use of NSAIDs and clinical outcomes after coronary artery bypass graft is understudied.

METHODS

We conducted a retrospective analysis using pooled data from 2 multicenter randomized controlled trials (PREVENT IV [n = 3014] and MEND-CABG II [n = 3023]). Rates of death, death or myocardial infarction, and death, myocardial infarction, or stroke in the 30 days following coronary artery bypass graft surgery were compared in patients using or not using perioperative NSAIDs. Inverse probability of treatment weighting and Cox proportional hazards regression models were used to adjust for confounding.

RESULTS

A total of 5887 patients were studied. Median age was 65 years, 78% were male, and 91% were White. NSAIDs were used in 2368 (40.2%) patients. The majority of patients (1822 [30.9%]) received NSAIDs after coronary artery bypass graft surgery; 289 (4.9%) used them prior to and after the surgery; and 257 (4.4) received NSAIDs prior to the surgery only. Adjusted 30-day outcomes were similar in patients receiving and not receiving NSAIDs (death: hazard ratio [HR] 1.18; 95% confidence interval [CI], 0.48-2.92; death or myocardial infarction: HR 0.87; 95% CI, 0.42-1.79; death, myocardial infarction, or stroke: HR 0.87; 95% CI, 0.46-1.65).

CONCLUSION

In this pooled data analysis, perioperative NSAID use was common among patients undergoing coronary artery bypass graft surgery and was not associated with an increased short-term risk for major adverse clinical outcomes.

Perioperative Optimization of Autologous Breast Reconstruction

The authors recently showed that fast-track surgery could reduce the length of stay after a deep inferior epigastric perforator flap procedure from 7.4 days to 6.2 days without increasing complication rates or flap loss. This study improves the protocol and identifies specific factors that kept patients in the hospital. The authors present their results from the first 16 consecutive cases. Multimodal opioid-sparing analgesia was used. Nurses removed suction drains, without consulting the doctors. Fulfillment of functional discharge criteria (e.g., flap monitoring, ambulation) was assessed twice daily, and specified reasons for not allowing discharge were registered. All patients were discharged to home after approximately 72 hours, on the third postoperative day, except one patient who was discharged on day 4. Drains were removed on postoperative day 2 (n = 3) or 3 (n = 13). All patients had normal gastrointestinal tract function and minimal pain, and were eating and managing personal hygiene on the morning of postoperative day 2. All were mobilized by the afternoon of postoperative day 2. Median visual analogue scale score at discharge was 1 (range, 0 to 4). There were no reoperations and no major complications. Length of stay after autologous breast reconstruction using deep inferior epigastric perforator flaps can be reduced to approximately 3 days using the fast-track methodology.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Investigation of mucus obtained from different fish species on the acute pain induced with scalpel incision in paw of rats

No comparative study could be found for the analgesic activity of mucuses from the Oncorhynchus mykiss (OM), Salvelinus fontinalis (SF), Salmo coruhensis (SC), Acipenser gueldenstaedtii (AG), and Acipenser baerii (AB) fish species in the literature. We aimed to investigate the effects of mucuses obtained from the abovementioned fish species on scalpel incision-induced pain in the rat paw and to examine the role of oxidant/antioxidant parameters and COX-2 gene expression in the analgesic activities. Animals were divided into groups: SIC (scalpel incision; SI), SIDS (SI+25 mg/kg diclofenac sodium), SOM (SI+25 mg/kg OM mucus), SFM (SI+25 mg/kg SF mucus), SCM (SI+25 mg/kg SC mucus), SAgM (SI+25 mg/kg AG mucus), SAbM (SI+25 mg/kg AB mucus), and HG (healthy). The paw pain thresholds were measured with a Basile algesimeter before and after diclofenac sodium (DS) or mucus administration, and then the rats were euthanized with thiopental sodium. Oxidant/antioxidant and COX-2 gene expression parameters were measured in paw tissues. OM, SC, AG, and AB fish mucuses could not decrease the SI-induced pain. However, SF fish mucus prevented this pain by 69% after the first hour and by 58.3% after the third hour. DS was shown to suppress pain more weakly than SF, preventing the pain by 62.1% and 50.0% after the first and third hours, respectively. SF mucus and DS significantly inhibited increase of COX-2 gene expression, while other fish mucuses could not. None of the fish mucuses except SF mucus in conjunction with DS could significantly inhibit the increase in oxidant parameters and decrease in antioxidants. SF fish mucus should be comparatively assessed in clinical practice for treatment of postoperative pain.

The relation between the effect of a subhypnotic dose of thiopental on claw pain threshold in rats and adrenalin, noradrenalin and dopamine levels

Thiopental sodium (TPS) needs to be applied together with adrenalin in order to establish its analgesic effect in general anesthesia. We aimed to investigate the effect of TPS on the claw pain threshold in rats and evaluated its relationship with endogenous adrenalin (ADR), noradrenalin (NDR), and dopamine (DOP) levels. Intact and adrenalectomized rats were used in the experiment. Intact animals were divided into the following groups: 15 mg/kg TPS (TS), 0.3 mg/kg ADR+15 mg/kg TPS (ATS) and 0.3 mg/kg ADR alone (ADR). Adrenalectomized animals were divided into the following groups: 15 mg/kg TPS (A-TS), 0.3 mg/kg ADR+15 mg/kg TPS (A-ATS) and 0.3 mg/kg ADR alone (A-ADR). Claw pain threshold and blood ADR, NDR, and DOP levels were measured. The TS group’s claw pain threshold was found low. However, the claw pain thresholds of the ATS and ADR groups increased significantly. In the A-TS group, the pain threshold decreased compared with normal, and in the A-ATS and A-ADR groups, the pain threshold increased. TPS reduced the blood ADR levels in intact rats; however, no significant changes were observed in the NDR and DOP levels. #TPS provides hyperalgesia by reducing the production of ADR in rats. The present study shows that to achieve analgesic activity, TPS needs to be applied together with ADR.

Introducing the fast track surgery principles can reduce length of stay after autologous breast reconstruction using free flaps: A case control study

INTRODUCTION

The concept of fast-track surgery (FTS) is a peri- and postoperative care concept developed to reduce length of hospital stay (LOS) and morbidity after surgery. FTS programmes have been reported from other surgical specialities, but there are few reports of FTS in plastic surgery.

MATERIALS AND METHODS

Autologous breast reconstructions have been performed with abdominal free flaps since 1994. In 2006, an FTS program was introduced. Important changes in procedure were: early mobilisation, fewer/faster removal of drains and urinary catheter, discontinuation of epidural analgesia, planned early discharge, and multimodal opioid-sparing analgesia. The results from all unilateral, breast reconstructions in the first 5 years after the implementation of the FTS (n = 177) were compared to results prior to the FTS (n = 292). Flap type, operating time, blood loss and ischaemic time, LOS, early flap related and systemic complications (< 30 days) were analysed.

RESULTS

FTS significantly reduced mean LOS from 7.4 days to 6.2 days (p = 0.0002). When compared to pre-FTS results, similar flap types, operating time, blood loss and ischaemic time were found. LOS > 7 days were due to complications, the most common being haematoma. Prevalence of complications (6.5 vs 7.9%) and flap loss (2 vs 2%) did not increase. Haematomas seemed more frequent with the use of NSAID than with COX-2 inhibitors (9 vs 4%); however, the difference was not statistically significant.

CONCLUSION

By introducing a simple, peri- and postoperative care concept it is possible to reduce LOS after microsurgery by at least 1 day without an increase in complications or flap loss.

Acute pain management in the opioid-tolerant patient

SUMMARY Opioid use is increasing worldwide leading to an increasing number of opioid-tolerant patients requiring acute pain management after surgery, trauma and acute diseases. Provision of analgesia in opioid-tolerant patients is complex due to the pharmacological effects of long-term opioid exposure, but also due to pre-existing pain states, comorbidities and psychosocial issues. Acute pain management in these patients is governed by the principles of provision of good analgesia, avoidance of withdrawal and organized discharge. Pain relief needs to be achieved by the use of multimodal analgesia, including regional anesthetic techniques and, if needed, opioids in increased doses. Withdrawal is best prevented by ongoing opioid substitution at previously established doses. Discharge planning requires multidisciplinary input and good communication with all healthcare providers involved.

Retrospective evaluation of inpatient celecoxib use after total hip and knee arthroplasty at a Veterans Affairs Medical Center

A retrospective cohort study (1.5 years) was performed to investigate the efficacy of celecoxib vs non-celecoxib use in patient who underwent total knee arthroplasty (TKA) and total hip arthroplasty (THA). Study time frame encompassed a pre and post period of a local policy decision opening access to short-term celecoxib use after TKA/THA. Primary end point was the amount of opioid use during their inpatient stay postprocedure. The TKA (n = 81) and THA (n = 60) groups were analyzed independently. Both celecoxib groups used significantly less opioids during their inpatient stay vs noncelecoxib groups, given in oral morphine milligram equivalents (TKA: 203 vs 337 mg, P = .002; THA: 214 vs 336 mg, P = .005). Other secondary outcome measures showed that the celecoxib groups also reported reduction in pain scores, total as needed (PRN) opioid doses, PRN opioid doses per day, average dose of PRN opioids, total PRN opioids, use of intravenous opioids, and rehabilitation facility admissions (in the TKA group only). Linear regression analysis showed a statistically significant inverse relationship between opioid consumption and age. Short-term celecoxib use after TKA/THA may lead to a reduction in overall opioid use and improved pain scores; however, further studies will be required to validate the results of this study.

Bupivacaine extended-release liposome injection for prolonged postsurgical analgesia in patients undergoing hemorrhoidectomy: a multicenter, randomized, double-blind, placebo-controlled trial

BACKGROUND

Bupivacaine extended-release liposome injection is a novel formulation of bupivacaine designed to achieve long-acting postoperative analgesia.

OBJECTIVE

The aim of this study was to compare the magnitude and duration of postoperative analgesia from a single dose of bupivacaine extended-release injection with placebo administered intraoperatively in patients undergoing hemorrhoidectomy.

DESIGN

This evaluation was a multicenter, randomized, double-blind, parallel-group, placebo-controlled phase 3 study.

SETTINGS

Data were obtained from 13 centers in the Republic of Georgia, Poland, and Serbia.

PATIENTS

Included in this study were patients aged 18 to 86 years undergoing excisional hemorrhoidectomy.

INTERVENTIONS

All patients received either a single dose of bupivacaine extended-release 300 mg or placebo administered intraoperatively via wound infiltration.

MAIN OUTCOME MEASURE

The cumulative pain score was assessed by measurement of the area under the curve of pain intensity through 72 hours after study drug administration.

RESULTS

One hundred eighty-nine patients were randomly assigned and treated; 186 completed the study. Pain intensity scores were significantly lower in the bupivacaine extended-release group in comparison with the group receiving placebo (141.8 vs 202.5, P < .0001). More patients in the bupivacaine extended-release group remained opioid free from 12 hours (59%) to 72 hours (28%) after surgery compared with patients receiving placebo (14% and 10%; P < .0008 through 72 h). The mean total amount of opioids consumed through 72 hours was 22.3 mg and 29.1 mg in the bupivacaine extended-release and placebo groups (P ≤ .0006). The median time to first opioid use was 14.3 hours in the bupivacaine extended-release group vs 1.2 hours in the placebo group (P < .0001). A greater proportion of patients in the bupivacaine extended-release group were satisfied with their postsurgical analgesia (95% vs 73%, P = .0007) than in the placebo group.

CONCLUSIONS

Bupivacaine extended-release demonstrated a statistically significant reduction in pain through 72 hours, decreased opioid requirements, delayed time to first opioid use, and improved patient satisfaction compared with placebo after hemorrhoidectomy.

Postoperative pain management of the obese patient

In the obese patient, the goal of postoperative pain management is provision of comfort, early mobilisation and improved respiratory function without causing inadequate sedation and respiratory compromise. The pathophysiology of obesity, typical co-morbidities and the high prevalence of obstructive sleep apnoea (OSA) amongst obese patients make safe analgesic management difficult. In particular, pain control after bariatric surgery is a major challenge. Although several reviews covering anaesthesia and analgesia for obese patients are published, there is mainly expert opinion and a paucity of evidence-based recommendations. Advice on general management includes multimodal analgesic therapy, preference for regional techniques, avoidance of sedatives, non-invasive ventilation with supplemental oxygen, early mobilisation and elevation of the head of bed to 30 degrees. Finally, with regard to monitoring, sedation scoring is most relevant, but there should be a low threshold for continuous pulse oxymetry, arterial blood pressure measurement and placement in a high-dependency area for the postoperative period.

[Concepts for perioperative pain therapy. A critical stocktaking]

Despite numerous publications, new guidelines for the treatment of acute pain and efforts from a number of initiatives, there is still a tremendous need for improvement in postoperative pain therapy. One of the reasons for the shortcomings in the care of patients with postoperative pain is the lack of applicability of guidelines in daily clinical practice. Therefore, simple but effective and easy to implement concepts need to be developed. In the following review, different concepts that have been developed over recent years are presented and evaluated for their effectiveness. One of these is the notion of balanced analgesia, currently probably one of the most widely used perioperative therapy concepts. The idea of this concept is to reduce the doses of analgesics, e.g. opioids, through combinations of different classes of analgesics, thereby reducing their side effects. However, recent studies and essential meta-analyses indicate pitfalls using this concept. The pros and cons will be discussed and ideas on how to deal with balanced analgesia in daily practice will be given. Another pain concept of "procedure-specific postoperative pain therapy", is an appealing idea of an international initiative from surgeons and anaesthesiologists and an essential part of the German S3 guidelines for acute pain released last year. Critical evaluation of the available recommendations for procedure-specific analgesia together with the presentation of relatively simple but evidence-based algorithms for specific procedures may help to implement this concept in clinical routine.

Comparison of etoricoxib vs. ketorolac in postoperative pain relief

BACKGROUND

COX-2 inhibitors have been claimed to have equal analgesic efficacy as non-selective nonsteroidal anti-inflammatory drugs, but this has been disputed in animal experiments.

METHODS

One hundred thirty-three women scheduled for ambulatory, laparoscopic gynaecological surgery were included in this randomised, double-blind study. Group E received 120 mg etoricoxib orally as premedication. Group K received 30 mg ketorolac i.v. after induction of anaesthesia. General anaesthesia was induced and maintained with propofol and remifentanil. Fentanyl 0.5 microg/kg i.v. and local wound anaesthesia was administered at the end of surgery. Postoperatively, the patients received fentanyl 0.5 microg/kg i.v. if visual analogue scale (VAS) >or=30 mm. Before discharge, Group K received 30 mg ketorolac i.v. Twenty-four hours postoperatively, Group E received 120 mg etoricoxib.

RESULTS

The first 4 h postoperatively, Group K required 83+/-65 microg and Group E required 123+/-91 microg fentanyl [mean (SD), P=0.004]. After 30 min VAS in Group K was 31.3+/-19.7 mm and 43.8+/-16.9 mm in Group E [mean (SD), P<0.001]. Discharge readiness was significantly shorter in Group K (222+/-40 min) compared with Group E (244+/-47 min) [mean (SD), P=0.004]. There were no differences in pain scores or rescue pain medication at 24 or 48 h postoperatively. Less nausea was observed in the 4-24-h period in Group E.

CONCLUSIONS

Thirty milligram ketorolac i.v. after induction of anaesthesia resulted in significantly less immediate pain and opioid consumption during the first 4 h postoperatively compared with 120 mg etoricoxib preoperatively.