Role of Ketamine in Multimodal Analgesia Protocol for Bariatric Surgery

Efficacy of nonopioid analgesics and adjuvants in multimodal analgesia for reducing postoperative opioid consumption and complications in obesity: a systematic review and network meta-analysis

BACKGROUND

Managing postoperative pain in patients with obesity is challenging. Although multimodal analgesia has proved effective for pain relief, the specific impacts of different nonopioid i.v. analgesics and adjuvants on these patients are not well-defined. This study aims to assess the effectiveness of nonsteroidal antiinflammatory drugs, paracetamol, ketamine, α-2 adrenergic receptor agonists, lidocaine, magnesium, and oral gabapentinoids in reducing perioperative opioid consumption and, secondarily, in mitigating the occurrence of general and postoperative pulmonary complications (POPCs), nausea, vomiting, PACU length of stay (LOS), and hospital LOS among surgical patients with obesity.

METHODS

A systematic review and network meta-analysis was performed. PubMed, Scopus, Web of Science, CINAHL, and EMBASE were searched. Only English-language RCTs investigating the use of nonopioid analgesics and adjuvants in adult surgical patients with obesity were included. The quality of evidence and certainty were assessed using the RoB 2 tool and GRADE framework, respectively.

RESULTS

In total, 37 RCTs involving 3602 patients were included in the quantitative analysis. Compared with placebo/no intervention or a comparator, dexmedetomidine, ketamine, lidocaine, magnesium, and gabapentin significantly reduced postoperative opioid consumption after surgery. Ketamine/esketamine also significantly reduced POPCs. Ibuprofen, dexmedetomidine, and lidocaine significantly reduced postoperative nausea, whereas dexmedetomidine, either alone or combined with pregabalin, and lidocaine reduced postoperative vomiting. Dexmedetomidine significantly reduced PACU LOS, whereas both paracetamol and lidocaine reduced hospital LOS.

CONCLUSIONS

Intravenous nonopioid analgesics and adjuvants are crucial in multimodal anaesthesia, reducing opioid consumption and enhancing postoperative care in adult surgical patients with obesity.

SYSTEMATIC REVIEW PROTOCOL

CRD42023399373 (PROSPERO).

Opioid-Free Anesthesia in Bariatric Surgery: Is It the One and Only? A Comprehensive Review of the Current Literature

Opioid-free anesthesia (OFA) is a heterogeneous group of general anesthesia techniques in which the intraoperative use of opioids is eliminated. This strategy aims to decrease the risk of complications and improve the patient's safety and comfort. Such potential advantages are particularly beneficial for selected groups of patients, among them obese patients undergoing laparoscopic bariatric surgery. Opioids have been traditionally used as an element of balanced anesthesia, and replacing them requires using a combination of coanalgesics and various types of local and regional anesthesia, which also have their side effects, limitations, and potential disadvantages. Moreover, despite the growing amount of evidence, the empirical data on the superiority of OFA compared to standard anesthesia with multimodal analgesia are contradictory, and potential benefits in many studies are being questioned. Additionally, little is known about the long-term sequelae of such a strategy. Considering the above-mentioned issues, this study aims to present the potential benefits, risks, and difficulties of implementing OFA in bariatric surgery, considering the current state of knowledge and literature.

Non-Opioid Analgesics and Adjuvants after Surgery in Adults with Obesity: Systematic Review with Network Meta-Analysis of Randomized Controlled Trials

Background/Objectives: Managing postoperative pain in patients with obesity is challenging. Although using a combination of pain relief methods is recommended for these patients, the true effectiveness of various intravenous non-opioid analgesics and adjuvants in multimodal anesthesia needs to be better defined. Methods: A systematic review and network meta-analysis was performed to evaluate the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, ketamine, α-2 agonists, lidocaine, magnesium, and oral gabapentinoids in adult surgical patients with obesity. The analysis aimed to compare these treatments to a placebo/no treatment or alternative analgesics, with a primary focus on postoperative pain and secondary endpoints including rescue analgesia, postoperative nausea and vomiting (PONV), and recovery quality. English-language randomized controlled trials across PubMed, Scopus, Web of Science, CINAHL, and EMBASE were considered. Quality and evidence certainty were assessed with the RoB 2 tool and GRADE, and data was analyzed with R software. Results: NSAIDs, along with acetaminophen, lidocaine, α-2 agonists, ketamine, and oral gabapentinoids, effectively reduce early postoperative pain. NSAIDs, particularly ibuprofen, as well as acetaminophen, ketamine, and lidocaine, also show benefits in later postoperative stages. Intravenous non-opioid analgesics and adjuvants show some degree of benefit in reducing PONV and the need for rescue analgesic therapy when using α-2 agonists alone or combined with oral gabapentinoids, notably decreasing the likelihood of PONV. Ketamine, lidocaine, and α-2 agonists are shown to enhance postoperative recovery and care quality. Conclusions: Intravenous non-opioid analgesics and adjuvants are valuable in multimodal anesthesia for pain management in adult surgical patients suffering from obesity.

Effect of Intraoperative Infusion of Esketamine on Quality of Postoperative Recovery in Patients Undergoing Laparoscopic Bariatric Surgery: A Randomized Controlled Trial

INTRODUCTION

This study aims to evaluate the efficacy of esketamine on postoperative recovery quality after laparoscopic bariatric surgery.

METHODS

Patients (n = 74) scheduled for laparoscopic bariatric surgery were randomly divided into two groups: the esketamine group (group E: 0.5 mg/kg/h infusion, i.e., 0.2 mL/kg/h) or the control group (group C: 0.2 mL/kg/h normal saline infusion). The infusions were stopped 20 min before the end of the procedure. The primary outcome was the Quality of Recovery-40 (QoR-40) score on postoperative day 1 (POD 1). The secondary outcomes included QoR-40 scores on PODs 2 and 7, Numeric Rating Scale (NRS) on PODs 1, 2, and 7, time to extubation, additional postoperative analgesic use, length of hospital stay, and time to first exhaust. Additonally, the safety indices were also recorded, including hemodynamic profile, perioperative anesthesia index (Ai), utilization of vasoactive drugs or urapidil, and side effects.

RESULTS

All in all, 70 of the 74 patients completed the study, 35 in each group. The difference of QoR-40 scores on POD 1 was both statistically and clinically significant [difference 7.21, 95% confidence interval (CI) 5.17, 9.25, p < 0.001]. The difference of QoR-40 on POD 2 was statistically significant but clinically insignificant (difference 4.81, 95% CI 2.69, 6.92, p < 0.001). The difference of NRS scores on POD 1 was statistically significant (difference -1.23, 95% CI -2.36, -0.10, p = 0.033). Compared with group C, group E had a lower utilization rate of phenylephrine and higher Ai values (p < 0.05). There was no statistical difference between the two groups on other measures.

CONCLUSION

Continuous ketamine infusion seems to be safe and well tolerated in laparoscopic bariatric surgery. It improved the quality of postoperative recovery and reduced pain on POD 1. In spite of the increased Ai value during the surgery, it also provided better hemodynamics with less usage of phenylephrine.

Opioid Sparing Analgesics in Spine Surgery

Combinations of various nonopioid analgesics have been used to decrease pain and opioid consumption postoperatively allowing for faster recovery, improved patient satisfaction, and decreased morbidity. These opioid alternatives include acetaminophen, NSAIDs, COX-2 specific inhibitors, gabapentinoids, local anesthetics, dexamethasone, and ketamine. Each of these drugs presents its own advantages and disadvantages which can make it difficult to implement universally. In addition, ambiguous administration guidelines for these nonopioid analgesics lead to a difficult implementation of standardization protocols in spine surgery. A focus on the efficacy of different pain modalities specifically within spine surgery was implemented to assist with this standardized protocol endeavor and to educate surgeons on limiting opioid prescribing in the postoperative period. The purpose of this review article is to investigate the various opioid sparing medications that have been used to decrease morbidity in spine surgery and better assist surgeons in managing postoperative pain. Methods. A narrative review of published literature was conducted using the search function in Google scholar and PubMed was used to narrow down search criteria. The keywords “analgesics,” “spine,” and “pain” were used.

Ketamine as a component of multimodal analgesia for pain management in bariatric surgery: A systematic review and meta-analysis of randomized controlled trials

Introduction

Anaesthesia in morbidly obese people is challenging with a high dose of opioid consumption. This systematic review and meta-analysis of randomised controlled trials (RCTs) summaries evidence comparing ketamine to placebo for pain management after bariatric surgery.

Methods

We used PRISMA 2020 and AMSTAR 2 guidelines to conduct this study. The random-effects model was adopted using Review Manager Version 5.3 for pooled estimates.

Results

Seven RCTs published between 2009 and 2021 were eligible, including a total of 412 patients (202 patients in the ketamine group and 210 patients in the control group). In the ketamine group total opioid consumption during the first 24 h postoperatively was reduced (mean difference, MD = −5.89; 95% CI [-10.39, −1.38], p = 0.01), lower pain score at 4 h (MD = −0.81; 95% CI [-1.52, −0.10], p = 0.03), pain score at 8 h (MD = −1.00; 95% CI [-1.21, −0.79], p < 0.01), and shorter hospital stay (MD = −0.10; 95% CI [-0.20, −0.01], p = 0.03). There was no significant difference between the two groups regarding duration of anaesthesia (MD = −3.42; 95% CI [-8.62, 1.82], p = 0.20), or sedation score (MD = −0.02; 95% CI [-0.21, 0.17], p = 0.84). As concern the postoperative complications, risks of postoperative nausea and vomiting(OR = 0.75; 95% CI [0.27, 2.04], p = 0.56), hallucinations (OR = 5.47; 95% CI [0.26, 117.23], p = 0.28), dizziness (OR = 1.05; 95% CI [0.14, 7.78], p = 0.96), and euphoria (OR = 5.77; 95% CI [0.65, 51.52], p = 0.12) were not different between the two groups either.

Conclusion

Ketamine could be an effective and safe technique for pain management following bariatric surgery. It reduces opioid consumption, postoperative pain, and hospital stay.

RegistrationThis review was registered in PROSPERO (CRD42022296484).

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This study comparing ketamine infusion or bolus with placebo when used with morphine, paracetamol or tramadol for pain management following bariatric surgery demonstrated that:

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Ketamine was associated with lower opioid consumption during the 24 h postoperatively.

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Ketamine decreased VAS scores at H4 and H8, and shorten the hospital stay.

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Ketamine ensure a similar duration of anaesthesia, postoperative sedation scores, PONV, and postoperative complications rate (hallucinations, headache, euphoria and dizziness).

Anesthesia and Enhanced Recovery After Surgery in Bariatric Surgery

The Enhanced Recovery After Surgery Society published guidelines for bariatric surgery reviewing the evidence and providing specific care recommendations. These guidelines emphasize preoperative nutrition, multimodal analgesia, postoperative nausea and vomiting prophylaxis, anesthetic technique, nutrition, and mobilization. Several studies have since evaluated these pathways, showing them to be safe and effective at decreasing hospital length of stay and postoperative nausea and vomiting. This article emphasizes anesthetic management in the perioperative period and outlines future directions, including the application of Enhanced Recovery After Surgery principles in patients with extreme obesity, diabetes, and metabolic disease and standardization of the pathways to decrease heterogeneity.

Patients with sleep-disordered breathing for bariatric surgery

The prevalence of patients with obesity continues to rise worldwide and has reached epidemic proportions. There is a strong correlation between obesity and sleep-disordered breathing (SDB), and, in particular, obstructive sleep apnea (OSA). OSA is often undiagnosed in the surgical population. Bariatric surgery has been recognized as an effective treatment option for both obesity and OSA. Laparoscopic bariatric procedures, particularly laparoscopic sleeve gastrectomy (LSG), have become the most frequently performed procedures. OSA has been identified as an independent risk factor for perioperative complications and failure to recognize and prepare for patients with OSA is a major cause of postoperative adverse events, suggesting that all patients undergoing bariatric surgery should be screened preoperatively for OSA. These patients should be treated with an opioid-sparing analgesic plan and continuous positive airway pressure (CPAP) perioperatively to minimize respiratory complications. With the number of bariatric surgical patients with SDB likely to continue rising, it is critical to understand the best practices to manage this patient population.

Impact of Intraoperative Ketamine on Postoperative Analgesic Requirement Following Bariatric Surgery: a Meta-analysis of Randomized Controlled Trials

This meta-analysis aimed at exploring the impact of intravenous ketamine on pain relief and analgesic consumption in patients undergoing bariatric surgery (BS). Literature searches identified nine eligible trials with 458 participants. Forest plot revealed a significantly lower pain score [mean difference (MD) =  - 1.06, p = 0.005; 390 patients) and morphine consumption (MD =  - 3.85 mg, p = 0.01; 212 patients) immediately after BS in patients with intravenous ketamine than in those without. In contrast, pooled analysis showed comparable pain score (p = 0.28), morphine consumption (p = 0.45) within 24 h, and risk of postoperative nausea/vomiting (p = 0.67) between the two groups. In conclusion, the meta-analysis demonstrated improvements in pain outcomes immediately after surgery through perioperative intravenous ketamine administration despite the absence of analgesic benefit in the late postoperative period and a positive impact on postoperative nausea/vomiting.

Efficacy of intraoperative intravenous lidocaine for postoperative analgesia following bariatric surgery: a meta-analysis of randomized controlled studies

BACKGROUND

The impact of intravenous lidocaine in adults undergoing laparoscopic bariatric surgeries (LBS) remains unclear.

OBJECTIVES

This study aimed at investigating the effect of intravenous lidocaine on postoperative opioid consumption and recovery following LBS.

SETTING

Meta-analysis.

METHODS

We searched databases including MEDLINE, Embase, Google Scholar, and the Cochrane Library for randomized controlled trials that evaluated the use of intravenous lidocaine compared to placebo only prior to May 2021. The primary outcome was 24-hour postoperative opioid consumption, while secondary outcomes included pain score, quality of recovery (QOR)-40 score, length of hospital stay (LOS), and postoperative nausea/vomiting (PONV).

RESULTS

Seven trials (496 participants) were included. Intraoperative intravenous lidocaine significantly reduced 24-hour equivalent morphine consumption (mean difference [MD]: -11.97 mg; 95% confidence interval [CI]: -23.12 to -.83), pain score at 1 to 3 hours (MD: -.77; 95% CI: -1.5 to -.04), and LOS (MD: -8.93 hr; 95% CI: -13.41 to -4.44) without positive impact on 24-hour pain score and PONV. There was also an increase in time to first opioid requirement (MD: 20.23 min; 95% CI: 11.76-28.7) and QOR-40 score (MD: 24.38; 95% CI: 5.57-43.18). However, sensitivity analysis demonstrated evidence supporting the beneficial effect of lidocaine only for time to first opioid requirement and QOR-40. The associations of intraoperative intravenous lidocaine with reductions in morphine consumption, pain score at 1 to 3 hours, and LOS after LBS were also weak.

CONCLUSION

Intraoperative intravenous lidocaine during LBS prolonged time to first opioid requirement and improved quality of recovery postoperatively without 24-hour pain or nausea/vomiting benefits. Due to the small number of trials, larger studies are warranted to verify our findings.

Low-Dose Ketamine Infusion for Perioperative Pain Management in Patients Undergoing Laparoscopic Gastric Bypass: A Prospective Randomized Controlled Trial

Introduction

Obesity is a common comorbidity seen in the perioperative setting and is associated with many diseases including cardiovascular disease and obstructive sleep apnea. Laparoscopic Roux-en-Y gastric bypass is the gold standard surgical treatment for patients whose weight is refractory to diet and exercise. Caring for these patients perioperatively presents unique challenges to anesthesiologists and is associated with an increased risk of adverse respiratory events. In our study, we hypothesize that a low-dose perioperative ketamine infusion will reduce opioid consumption and improve analgesia when compared to standard therapy.

Methods

This is a single-center, prospective randomized controlled study enrolling 35 patients in total. Patients were randomized equally into the ketamine and control group. Preop, intraop, and postop management regimens were standardized. The ketamine group received a 0.3 mg/kg ideal body weight ketamine bolus after induction followed by a 0.2 mg/kg/hr ketamine infusion continued into the postop setting for up to 24 hours. Data collected included total perioperative opioids used converted to oral morphine equivalents (ME), pain scores, side effects, hospital length of stay, and patient satisfaction captured via postoperative questionnaires.

Results

The use of perioperative opioid consumption was significantly lower in the ketamine group when compared with the control group (179.9 ME versus 248.7 ME, P=0.03). There was no statistically significant difference in pain scores or hospital length of stay postoperatively between the two groups. There were also no reported adverse respiratory events, prolonged sedation, agitation, or other side effects reported in either group. The patient satisfaction questionnaires showed a significant difference with the ketamine group reporting lower maximum pain scores, a decrease in how pain limited activities of daily living once discharged, and increased hospital pain management satisfaction scores.

Conclusions

Perioperative low-dose ketamine infusions significantly reduced opioid consumption in morbidly obese patients undergoing laparoscopic gastric bypass surgery.

Ultrasound-guided transversus abdominis plane block for postoperative analgesia in laparoscopic cholecystectomy: A retrospective study

OBJECTIVE:

This study aimed to investigate the effects on postoperative pain of ketamine and dexmedetomidine addition to bupivacaine in a transversus abdominis plane (TAP) block in laparoscopic cholecystectomy.

METHODS:

A retrospective study was conducted patients who underwent ultrasound-guided TAP block in laparoscopic cholecystectomy. The patients were divided into three groups: Group BD (Bupivacaine+Dexmedetomidine), Group BK (Bupivacaine+Ketamine), and Group B (Bupivacaine). Our primary outcomes were pain scores with Visual Analogue Scale (VAS), postoperative first analgesic time and tramadol consumption in 24 hours postoperatively. Secondary outcomes were intraoperative hemodynamic changes, rescue analgesic requirement and side effects.

RESULTS:

The first analgesic administration time was significantly shorter in Group B and significantly longer in Group BD than the other two groups. Pain score at rest in Group B at 0^th hours was significantly higher than that of Group BD and VAS pain score Group BD at 2^nd hours was significantly lower than the other two groups. There was no significant difference between the groups regarding tramadol consumption and the requirement of rescue analgesics.

CONCLUSION:

Dexmedetomidine and ketamine can be added to the bupivacaine for the TAP block without major side-effects. The combination of dexmedetomidine and bupivacaine provides better analgesia in the first postoperative 2^nd hour than other groups and hence extends the time to the first analgesic demand.