Intraoperative fentanyl in endoscopic procedures and their impact on PACU time and costs

BACKGROUND

Extended stays in the postanesthesia care unit (PACU) pose challenges in high-volume endoscopies. This study investigates the impact of intraoperative fentanyl use on PACU duration, postoperative pain, and financial implications in outpatient endoscopy.

METHOD

A retrospective analysis of upper/lower endoscopies at our facility (2020-2022) was conducted, focusing on the relationship between fentanyl use, PACU duration, and pain scales. Financial impacts were also assessed.

RESULTS

Among 11,488 patients, 5787 (50.4%) received intraoperative fentanyl, and 5225 (45.5%) had a long stay at PACU (> 50 min). A larger proportion of patients in the long-stay group (> 50 min) received fentanyl (56.3% vs. 45.4%, P < 0.01), and they reported higher Numeric Rating Scale (NRS) pain scores (> 5 in 3.6% vs. 1.2%, P < 0.01). The median PACU time was longer for fentanyl recipients (52 vs. 48 min, P < 0.01). Multivariable analysis identified fentanyl use, older age, and higher ASA scores (≥ 3) as significant factors for prolonged PACU durations. Fentanyl did not significantly reduce postoperative pain (scores > 5: 2.8% for fentanyl users vs. 2.2% for nonusers). Furthermore, most patients reported no pain post-surgery (93.0% for fentanyl users vs. 95.2% for nonusers). Fentanyl recipients did not have shorter PACU stays within any pain scale category. Financial simulations suggest that fentanyl-free anesthesia management could notably decrease the financial burden within endoscopy operations. Specifically, our institution could have realized an annual saving of at least US $100,308.

CONCLUSION

Intraoperative fentanyl increases PACU duration by approximately 4 min per patient in endoscopies, without markedly improving pain management. Avoiding fentanyl could lead to significant time and cost savings.

Postoperative challenges addressed through nursing care of patients receiving lower extremity tumor prosthesis

BACKGROUND

Patients with primary Bone Sarcoma and Giant Cell Tumors in the lower extremities often require major surgery involving tumor prostheses. The postoperative course for this patient group can be complex and influenced by various factors and challenges that demand careful nursing care. This study aims to identify challenges related to the nursing care of individuals with primary bone tumors following surgery for tumor prostheses in the lower extremities.

METHODS

A retrospective cohort study of 15 patients treated at Rigshospitalet, Copenhagen, Denmark, between November 5. 2016, and April 1. 2020 was conducted by medical record review, focusing on challenges related to postoperative nursing care. All patients with the surgery code "Bone Excision" were identified within the surgery booking system and screened for eligibility.

RESULTS

Patients experienced postoperative challenges such as severe pain, prolonged time to mobilization (mean: 4 days), and defecation (mean: 5 days). The mean length of stay at the Rigshospitalet was 13 days. Furthermore, eleven patients (73%) reported disrupted sleep and nausea.

CONCLUSION

Patients undergoing tumor prosthesis surgery in the lower extremities face considerable postoperative challenges that contribute to a prolonged hospital stay. These challenges, including severe pain, delayed mobilization, and gastrointestinal issues, significantly impact recovery. The findings highlight the urgent need for targeted nursing interventions to address these issues effectively. Enhanced pain management protocols, early mobilization strategies, and comprehensive postoperative care plans are essential to improve patient outcomes and reduce the length of hospital stays. Addressing these challenges through dedicated nursing care is crucial for optimizing the recovery process for patients receiving lower extremity tumor prostheses.

Perioperative pain management with regional analgesia techniques for visceral cancer surgery: A systematic review and meta-analysis

STUDY OBJECTIVE

Regional analgesia following visceral cancer surgery might provide an advantage but evidence for best treatment options related to risk-benefit is unclear.

DESIGN

Systematic review of randomized controlled trials (RCT) with meta-analysis and GRADE assessment.

SETTING

Postoperative pain treatment.

PATIENTS

Adult patients undergoing visceral cancer surgery.

INTERVENTIONS

Any kind of peripheral (PRA) or epidural analgesia (EA) with/without systemic analgesia (SA) was compared to SA with or without placebo treatment or any other regional anaesthetic techniques.

MEASUREMENTS

Primary outcome measures were postoperative acute pain intensity at rest and during activity 24 h after surgery, the number of patients with block-related adverse events and postoperative paralytic ileus.

MAIN RESULTS

59 RCTs (4345 participants) were included. EA may reduce pain intensity at rest (mean difference (MD) -1.05; 95% confidence interval (CI): -1.35 to -0.75, low certainty evidence) and during activity 24 h after surgery (MD -1.83; 95% CI: -2.34 to -1.33, very low certainty evidence). PRA likely results in little difference in pain intensity at rest (MD -0.75; 95% CI: -1.20 to -0.31, moderate certainty evidence) and pain during activity (MD -0.93; 95% CI: -1.34 to -0.53, moderate certainty evidence) 24 h after surgery compared to SA. There may be no difference in block-related adverse events (very low certainty evidence) and development of paralytic ileus (very low certainty of evidence) between EA, respectively PRA and SA.

CONCLUSIONS

Following visceral cancer surgery EA may reduce pain intensity. In contrast, PRA had only limited effects on pain intensity at rest and during activity. However, we are uncertain regarding the effect of both techniques on block-related adverse events and paralytic ileus. Further research is required focusing on regional analgesia techniques especially following laparoscopic visceral cancer surgery.

Enhanced Recovery After Aesthetic Breast Surgery Under Sedation, Intercostal Block and Tumescent Anaesthesia: A Prospective Cohort Study of the Early Postoperative Phase

BACKGROUND

Comfort and recovery are major concerns of patients seeking aesthetic surgery. This study aimed to assess postoperative pain and recovery after outpatient breast surgery under sedation, intercostal block, and local anaesthesia.

METHODS

This prospective cohort study included all consecutive patients who underwent aesthetic breast surgery between April 2021 and August 2022. Epidemiological data, anaesthesia, pain, and patients' satisfaction were systematically assessed with standardized self-assessment questionnaires.

RESULTS

Altogether, 48 patients [median (IQR) age: 30 (36-25)] were included. The most frequent surgery was mastopexy. 69% of surgeries involved additional procedures. The mean intercostal block and local anaesthesia time was 15 min. Patients received a median (IQR) of 19 (34-2) mg/kg lidocaine and 2.3 (2.5-2.0) mg/kg ropivacaine. The median (IQR) consumption of propofol and alfentanil was, respectively, 4.89 (5.48-4.26) mg/kg/h and 0.27 (0.39-0.19) µg/kg/min. No conversion to general anaesthesia or unplanned hospital admission occurred. Patients were discharged after a median (IQR) of 2:40 (3:43-1:58) hours. Within the first 24 postoperative hours, 17% required once an antiemetic medication and 38% an opioid. Patients were very satisfied with the anaesthesia and 90% of the patients had not wished more analgesia in the first 24 h.

CONCLUSIONS

Aesthetic breast surgery under sedation, intercostal block, and tumescent anaesthesia can safely be performed as an ambulatory procedure and is associated with minimal intra- and postoperative opioid consumption and high patient satisfaction. These data may be used to inform patients and clinicians and improve the overall quality of care.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The efficacy and safety of an adapted opioid-free anesthesia regimen versus conventional general anesthesia in gynecological surgery for low-resource settings: a randomized pilot study

INTRODUCTION

There is scarce data on the safety and efficacy of opioid-free anesthesia (OFA), in resource-limited settings due to the non-availability of dexmedetomidine, the reference OFA agent. We aimed to demonstrate the feasibility, efficacy and safety of a practical OFA protocol not containing dexmedetomidine, adapted for low-resource environments in very painful surgeries like gynecological surgery.

METHODS

We conducted a randomized pilot study on ASA I and II women undergoing elective gynecological surgery at a tertiary care hospital in Cameroon. Patients were matched in a ratio of 1:1 into an OFA and a conventional general anesthesia (CGA) group. The OFA protocol entailed the intravenous (IV) magnesium sulfate, lidocaine, ketamine, dexamethasone, propofol, and rocuronium, followed by isoflurane and a continuous infusion of a calibrated mixture of magnesium sulfate, ketamine and clonidine. The CGA protocol was IV dexamethasone, diazepam, fentanyl, propofol, and rocuronium, followed by isoflurane and reinjections of fentanyl propofol and a continuous infusion of normal saline as placebo. The primary endpoints were the success rate of OFA, isoflurane consumption and intraoperative anesthetic complications. The secondary endpoints were postoperative pain intensity, postoperative complications, patient satisfaction assessed using the QoR-40 questionnaire and the financial cost of anesthesia.

RESULTS

We enrolled a total of 36 women undergoing gynecological surgery; 18 in the OFA group and 18 in the CGA group. The success rate of OFA was 100% with significant lesser consumption of isoflurane in the OFA group, no significant intraoperative complication and better intraoperative hemodynamic stability in the OFA group. Postoperatively, compared to the CGA group, the OFA group had statistically significantly less pain during the first 24 h, no morphine consumption for pain relief, had less hypoxemia during the first six hours, less paralytic ileus, less nausea and vomiting, no pruritus and better satisfaction. The mean financial cost of this adapted OFA protocol was statistically significant lesser than that of CGA.

CONCLUSION

This OFA regimen without dexmedetomidine for a low-resource setting has a promising success rate with few perioperative complications including mild intraoperative hemodynamic changes, decrease postoperative complications, pain, and opioid consumption in patients undergoing elective gynecology surgery.

TRIAL REGISTRATION

This study was registered at clinicaltrials.gov on 03/02/2021 under the registration number NCT04737473.

Effect of opioid-free anesthesia on postoperative analgesia after laparoscopic gynecologic surgery

BACKGROUND

We performed this randomised controlled trial to evaluate the effect of opioid-free anesthesia (OFA) on postoperative analgesia after laparoscopic gynecologic surgery.

METHODS

78 patients undergoing laparoscopic gynecologic surgery were randomized to receive either OFA (Group OF) or opioid-inclusive anesthesia (Group C). Postoperative sufentanil consumption within the first 24 h, visual analogue scale (VAS) for pain, postoperative equivalent milligrams of morphine (EMM), severity of postoperative nausea (PN) and vomiting (PV), prevalence of PONV, use of antiemetics, time to first passage of flatus were compared by a two-tailed Student's t test, Wilcoxon rank-sum tests or Fisher's exact tests. Repeated measures ANOVA was used to assess the effect of allocation of groups over time.

RESULTS

The median [IQR] sufentanil consumption within 24 h was lower in Group OF (4[4.5]) than in Group C (6[8], mean difference [MD]=-2, 95% confidence interval [CI] [-4 to 0], P=0.029). The VAS scores at rest and during coughing at 6 h (P=0.009 at rest; P=0.002 during coughing), VAS scores during coughing at 2h (P=0.013) and 4 h (P=0.008), EMM (P=0.026), severities of PN (P=0.003) and PV (P=0.003), and the mean time to first passage of flatus (P=0.017) was significantly less in Group OF than that in Group C. The prevalence of PONV (26.3% [Group OF], 68.4% [Group C], OR=0.31, 95% CI [0.158 to 0.589], P <0.001), use of antiemetics (5.3% [Group OF], 28.9% [Group C], OR=0.136, 95% CI[0.028 to 0.667], P=0.012) was also significantly different between groups.

CONCLUSIONS

Compared to opioid-inclusive anesthesia during laparoscopic gynecologic surgery, OFA was associated with significant improvement in postoperative analgesia, reduced PONV incidenceprevalence and severity, and faster first passage of flatus.

Total opioid-free general anaesthesia can improve postoperative outcomes after surgery, without evidence of adverse effects on patient safety and pain management: A systematic review and meta-analysis

BACKGROUND

Opioid-based treatment is used to manage stress responses during surgery and postoperative pain. However, opioids have both acute and long-term side effects, calling for opioid-free anaesthetic strategies. This meta-analysis compares adverse events, postoperative recovery, discharge time from post-anaesthesia care unit, and postoperative pain, nausea, vomiting, and opioid consumption between strict opioid-free and opioid-based general anaesthesia.

METHODS

We conducted a systematic review and meta-analysis. We searched PubMed, Embase, Cinahl, Cochrane Library, selected reference lists, and Google Scholar. We included randomised controlled trials (RCTs) published between January 2000 and February 2021 with at least one opioid-free study arm, i.e. no opioids administered preoperatively, during anaesthesia induction, before skin closure, or before emergence from anaesthesia.

RESULTS

The study comprised 1934 patients from 26 RCTs. Common interventions included laparoscopic gynaecological surgery, upper gastrointestinal surgery, and breast surgery. There is firm evidence that opioid-free anaesthesia significantly reduced adverse postoperative events (OR 0.32, 95% CI 0.22 to 0.46, I²  = 56%, p < 0.00001), mainly driven by decreased nausea (OR 0.27, (0.17 to 0.42), p < 0.00001) and vomiting (OR 0.22 (0.11 to 0.41), p < 0.00001). Postoperative opioid consumption was significantly lower in the opioid-free group (-6.00 mg (-8.52 to -3.48), p < 0.00001). There was no significant difference in length of post-anaesthesia care unit stay and overall postoperative pain between groups.

CONCLUSIONS

Opioid-free anaesthesia can improve postoperative outcomes in several surgical settings without evidence of adverse effects on patient safety and pain management. There is a need for more evidence-based non-opioid anaesthetic protocols for different types of surgery as well as postoperative phases.

Defining success in regional anaesthesia

Utilisation of regional anaesthesia is increasing globally; however, it remains challenging to determine the overall benefit of individual regional anaesthesia procedures. Like any peri-operative intervention, the benefit to the patient and healthcare system must outweigh any patient risk or resource implications. This review aims to identify markers of success in regional anaesthesia, categorise these into an objective framework and rationalise suggestions on how measuring outcomes in regional anaesthesia can be used to develop the widespread performance of this evolving subspecialty. This framework of measuring success of regional anaesthesia contains four pillars: patient-centred, population-centred, healthcare-centred and training-centred outcomes. Each pillar of success contains several outcomes which provide a structure for the measurement and development of regional anaesthesia success on a global scale.

Pupillometry pain index decreases intraoperative sufentanyl administration in cardiac surgery: a prospective randomized study

Pupillometry has proven effective for the monitoring of intraoperative analgesia in non-cardiac surgery. We performed a prospective randomized study to evaluate the impact of an analgesia-guided pupillometry algorithm on the consumption of sufentanyl during cardiac surgery. Fifty patients were included prior to surgery. General anesthesia was standardized with propofol and target-controlled infusions of sufentanyl. The standard group consisted of sufentanyl target infusion left to the discretion of the anesthesiologist. The intervention group consisted of sufentanyl target infusion based on the pupillary pain index. The primary outcome was the total intraoperative sufentanyl dose. The total dose of sufentanyl was lower in the intervention group than in the control group and (55.8 µg [39.7–95.2] vs 83.9 µg [64.1–107.0], p = 0.04). During the postoperative course, the cumulative doses of morphine (mg) were not significantly different between groups (23 mg [15–53] vs 24 mg [17–46]; p = 0.95). We found no significant differences in chronic pain at 3 months between the 2 groups (0 (0%) vs 2 (9.5%) p = 0.49). Overall, the algorithm based on the pupillometry pain index decreased the dose of sufentanyl infused during cardiac surgery.

Clinical trial number: NCT03864016.

Advances in regional anaesthesia and acute pain management: a narrative review

Regional anaesthesia has undergone several exciting advances in the past few decades. Ultrasound-guided techniques of peripheral nerve blockade have become the gold standard thanks to the associated improvements in efficacy, ease of performance and safety. This has increased the accessibility and utilisation of regional anaesthesia in the anaesthesia community at large and is timely given the mounting evidence for its potential benefits on various patient-centred outcomes, including major morbidity, cancer recurrence and persistent postoperative pain. Ultrasound guidance has also paved the way for refinement of the technical performance of existing blocks concerning simplicity and safety, as well as the development of new regional anaesthesia techniques. In particular, the emergence of fascial plane blocks has further broadened the application of regional anaesthesia in the management of painful conditions of the thorax and abdomen. The preliminary results of investigations into these fascial plane blocks are promising but require further research to establish their true value and role in clinical care. One of the challenges that remains is how best to prolong regional anaesthesia to maximise its benefits while avoiding undue harm. There is ongoing research into optimising continuous catheter techniques and their management, intravenous and perineural pharmacological adjuncts, and sustained-release local anaesthetic molecules. Finally, there is a growing appreciation for the critical role that regional anaesthesia can play in an overall multimodal anaesthetic strategy. This is especially pertinent given the current focus on eliminating unnecessary peri-operative opioid administration.

Effect of opioid-free anaesthesia on post-operative period in cardiac surgery: a retrospective matched case-control study

BACKGROUND

No study has been conducted to demonstrate the feasibility of an opioid-free anesthesia (OFA) protocol in cardiac surgery to improve patient care. The aim of the present study was to evaluate the effect of OFA on post-operative morphine consumption and the post-operative course.

METHODS

After retrospectively registering to clinicaltrial.gov (NCT03816592), we performed a retrospective matched cohort study (1:1) on cardiac surgery patients with cardiopulmonary bypass between 2018 and 2019. Patients were divided into two groups: OFA (lidocaine, dexamethasone and ketamine) or opioid anaesthesia (OA) (sufentanil). The main outcome was the total postoperative morphine consumption in the 48 h after surgery. Secondary outcomes were rescue analgesic use, a major adverse event composite endpoint, and ICU and hospital length of stay (LOS).

RESULTS

One hundred ten patients were matched (OFA: n = 55; OA: n = 55). On inclusion, demographic and surgical data for the OFA and OA groups were comparable. The total morphine consumption was higher in the OA group than in the OFA group (15 (6-34) vs 5 mg (2-18), p = 0.001). The pain score during the first 48 post-operative hours did not differ between the two groups. Creatinine values did not differ on the first post-operative day (80 (IQR: 66-115) vs 77 mmol/l (IQR: 69-95), p = 0.284). Incidence of the composite endpoint was lower in the OFA group (25 patients (43%) vs 38 patients (68%), p = 0.021). The time to extubation and the ICU stays were shorter in the OFA group (3 (1-5) vs 5 (3-6) hours, p = 0.001 and 2 (1-3) vs 3 (2-5) days, p = 0.037).

CONCLUSION

The use of OFA was associated with lower morphine consumption. OFA might be associated with shorter intubation time and ICU stays. Further randomized studies are needed to confirm these results.

TRIAL REGISTRATION

This study was retrospectively registered to ct2 (identifier: NCT03816592 ) on January 25, 2019.

Intra-operative analgesia with remifentanil vs. dexmedetomidine: a systematic review and meta-analysis with trial sequential analysis

Intra-operative remifentanil is associated with increased postoperative analgesic requirements and opioid consumption. Dexmedetomidine has characteristics suggesting it may substitute for intra-operative remifentanil during general anaesthesia, but existing literature has reported conflicting results. We undertook this meta-analysis to investigate whether general anaesthesia including dexmedetomidine would result in less postoperative pain than general anaesthesia including remifentanil. The MEDLINE and PubMed electronic databases were searched up to October 2018. Only randomised trials including patients receiving general anaesthesia and comparing dexmedetomidine with remifentanil administration were included. Meta-analyses were performed mostly employing a random effects model. The primary outcome was pain score at rest (visual analogue scale, 0-10) at two postoperative hours. The secondary outcomes included: pain score at rest at 24 postoperative hours; opioid consumption at 2 and 24 postoperative hours; and rates of hypotension, bradycardia, shivering and postoperative nausea and vomiting. Twenty-one randomised trials, including 1309 patients, were identified. Pain scores at rest at two postoperative hours were lower in the dexmedetomidine group, with a mean difference (95%CI) of -0.7 (-1.2 to -0.2), I2  = 85%, p = 0.004, and a moderate quality of evidence. Secondary pain outcomes were also significantly better in the dexmedetomidine group. Rates of hypotension, shivering and postoperative nausea and vomiting were at least twice as frequent in patients who received remifentanil. Time to analgesia request was longer, and use of postoperative morphine and rescue analgesia were less, with dexmedetomidine, whereas episodes of bradycardia were similar between groups. There is moderate evidence that intra-operative dexmedetomidine during general anaesthesia improves pain outcomes during the first 24 postoperative hours, when compared with remifentanil, with fewer side effects.