Effect of Nefopam-Based Patient-Controlled Analgesia with and without Fentanyl on Postoperative Pain Intensity in Patients Following Laparoscopic Cholecystectomy: A Prospective, Randomized, Controlled, Double-Blind Non-Inferiority Trial

A meta analysis of efficacy and safety of nefopam for laparoscopic cholecystectomy pain management

Background

Nefopam is a safe analgesic with mild side effects including drowsiness, nausea, vomiting, and sweating. Nevertheless, research is scarce on the impact of nefopam in managing postoperative pain following laparoscopic cholecystectomy (LC), and the advantageous effects of nefopam remain unclear. In this research, the effectiveness of nefopam was compared to placebo for the treatment of postoperative pain following LC.

Methods

A literature search for randomized controlled trials (RCTs) was performed through June 2024 using online databases including Cochrane Library, PubMed/Medline, and Web of Science. The primary outcome assessed was the quality of postoperative patient pain, and the secondary outcome was side effects that occurred due to the use of nefopam. The Cochrane Risk of Bias (RoB) 2 tool was used to assess the RoB. The meta-analysis was conducted using Review Manager software version 5.4. The risk ratio (RR), mean difference (MD), and standardized mean difference (SMD) were calculated at 95% confidence intervals (CIs).

Results

Five RCTs comprising 254 participants were analyzed. The analysis revealed that compared to placebo, nefopam had no statistically significant effect on the reduction of postoperative pain severity at 30 min (SMD = -0.30, 95% CI: -0.61 to 0.01; P = 0.06) and 60 min (SMD = -0.31, 95% CI: -0.78 to 0.16; P = 0.20). Nefopam reduced the number of opioids taken, as shown in the meta-analysis (SMD = -0.94, 95 CI: -1.35 to -0.53; P < 00001), with minor heterogeneity (P = 0.24, I2 = 30%). This meta-analysis showed that nefopam lengthened the time to first rescue analgesia (MD = 23.003). and markedly reduced the number patients requiring analgesics compared to baseline (RR = 0.34, 95% CI: 0.22 to 0.54; P < 0.00001).

Conclusion

Nefopam did not cause any difference in total postoperative pain but was effective in reducing overall opioid consumption and the need for supplementary analgesics. It did not increase postoperative nausea and vomiting.

Additive effect of a single intravenous dose of acetaminophen administered at the end of laparoscopic hysterectomy on postoperative pain control with nefopam and fentanyl-based patient-controlled analgesia: a double-blind, randomized controlled trial

BACKGROUND

Acetaminophen is a widely used analgesic for postoperative pain management. However, data on its combined use with nefopam for managing postoperative pain following laparoscopic hysterectomy are limited. This study evaluated the effects of a single intravenous dose of acetaminophen combined with fentanyl- and nefopam-based patient-controlled analgesia (PCA) in patients undergoing laparoscopic hysterectomy.

METHODS

In this prospective, double-blind, randomized controlled trial, 84 patients were randomized to receive either 1 g of intravenous acetaminophen (treatment group, n = 42) or normal saline (control group, n = 42) at the end of surgery. All patients received fentanyl and nefopam via PCA, postoperatively. PCA consumption, pain scores at rest, and postoperative nausea and vomiting (PONV) scores were assessed at 1, 6, and 24 h postoperatively. Patient satisfaction and opioid-related side effects were also evaluated. The primary outcome was the total PCA consumption within the first 24 h.

RESULTS

No significant difference in 24-h PCA consumption was observed between the control and treatment groups (27.9 ± 16.6 vs. 26.4 ± 11.2, P = 0.623). The pain scores at rest measured at 1, 6, and 24 h after surgery were also not significantly different between the two groups. There were no differences in the satisfaction scores, PONV scores, rescue analgesic use, adverse effects, or length of hospital stay between the groups.

CONCLUSIONS

A single intraoperative dose of intravenous acetaminophen, combined with nefopam- and fentanyl-based PCA, did not significantly reduce analgesic requirements, pain scores at rest, or opioid-related side effects compared with placebo in laparoscopic hysterectomy patients.

TRIAL REGISTRATION

ClinicalTrials.gov (Identifier: NCT03644147 | August 21, 2018).

Pain management after laparoscopic cholecystectomy: A systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations

Laparoscopic cholecystectomy can be associated with significant postoperative pain that is difficult to treat. We aimed to evaluate the available literature and develop updated recommendations for optimal pain management after laparoscopic cholecystectomy. A systematic review was performed using the procedure-specific postoperative pain management (PROSPECT) methodology. Randomised controlled trials and systematic reviews published in the English language from August 2017 to December 2022 assessing postoperative pain after laparoscopic cholecystectomy using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases. From 589 full text articles, 157 randomised controlled trials and 31 systematic reviews met the inclusion criteria. Paracetamol combined with NSAIDs or cyclo-oxygenase-2 inhibitors should be given either pre-operatively or intra-operatively, unless contraindicated. In addition, intra-operative intravenous (i.v.) dexamethasone, port-site wound infiltration or intraperitoneal local anaesthetic instillation are recommended, with opioids used for rescue analgesia. As a second-line regional technique, the erector spinae plane block or transversus abdominis plane block may be reserved for patients with a heightened risk of postoperative pain. Three-port laparoscopy, a low-pressure pneumoperitoneum, umbilical port extraction, active aspiration of the pneumoperitoneum and saline irrigation are recommended technical aspects of the operative procedure. The following interventions are not recommended due to limited or no evidence on improved pain scores: single port or mini-port techniques, routine drainage, low flow insufflation, natural orifice transluminal endoscopic surgery (NOTES), infra-umbilical incision, i.v. clonidine, nefopam and regional techniques such as quadratus lumborum block or rectus sheath block. Several interventions provided better pain scores but are not recommended due to risk of side effects: spinal or epidural anaesthesia, gabapentinoids, i.v. lidocaine, i.v. ketamine and i.v. dexmedetomidine.

Nefopam as a multimodal analgesia in thoracoscopic surgery: a randomized controlled trial

Background

Video-assisted thoracoscopic surgery (VATS) is a minimally invasive procedure. However, some patients still experience severe pain after VATS. Pain after VATS can disturb deep breathing and coughing, and can increase postoperative pulmonary complications. Therefore, multidisciplinary pain management is emphasized for enhanced recovery after VATS. Nefopam is a centrally-acting, non-opioid, non-steroidal analgesic drug, and its pain reduction effect in many surgeries has been reported. We sought to determine whether administration of nefopam is effective as multimodal analgesia in VATS.

Methods

This study enrolled patients aged 19 years or older, and scheduled for elective VATS lobectomy with American Society of Anesthesiologists (ASA) physical class I-III. Forty-six participants were randomly divided into a group receiving nefopam (group N), and a control group (group O) in a 1:1 ratio. The study participants, and the researcher collecting the data were blinded to the group allocation. For the group N, nefopam 20 mg was administered before surgical incision and also at the end of surgery while chest tube was inserted. For the group O, normal saline 100 mL was administered. The primary outcome of this study was the pain score, by verbal numerical rating scale, at rest and upon coughing.

Results

Forty-five participants (group N =22, group O =23) were involved in the statistical analysis. Nefopam reduced pain at rest at 0 h [8 (IQR, 5-10) vs. 4 (IQR, 2-7), P=0.01], and at 0-1 h [5 (IQR, 5-8) vs. 3 (IQR, 2-5), P=0.001]. Pain upon coughing decreased with nefopam at 0 h [9 (IQR, 6-10) vs. 6 (IQR, 2-8), P=0.009], 0-1 h [6 (IQR, 5-8) vs. 5 (IQR, 2-6), P=0.001], and at 12-24 h [4 (IQR, 3-7) vs. 3 (IQR, 1-4), P=0.03]. Injection of 20 mg of nefopam before incision and at the end of surgery relieved postoperative pain at 0 h, 1 h at rest and at 0 h, 1 h, 12-24 h with coughing after VATS.

Conclusions

Therefore, nefopam can serve as a useful component of multimodal analgesia for pain management after VATS.

Trial Registration

ClinicalTrials.gov (NCT05173337).

Comparison of Nefopam-Based Patient-Controlled Analgesia with Opioid-Based Patient-Controlled Analgesia for Postoperative Pain Management in Immediate Breast Reconstruction Surgery: A Randomized Controlled Trial

Background/Objectives: Immediate breast reconstruction surgery (BRS) often leads to significant postoperative pain, necessitating effective analgesia. This study aimed to compare the analgesic efficacy of patient-controlled analgesia (PCA) containing nefopam with that of PCA containing opioids alone in patients undergoing BRS. Methods: A prospective, double-blind, randomized controlled trial was conducted on 120 patients undergoing immediate BRS after mastectomy. Patients were randomly allocated to receive PCA with fentanyl alone (Group F: fentanyl 10 mcg/kg), fentanyl and nefopam (Group FN: fentanyl 5 mcg/kg + nefopam 1 mg/kg), or nefopam alone (Group N: nefopam 2 mg/kg). Pain intensity (expressed in VASr and VASm), opioid consumption, and opioid-related complications were assessed. Results: PCA with nefopam, either alone or in combination with opioids, demonstrated non-inferior analgesic efficacy compared to PCA with fentanyl alone. At 24 h postoperatively, the VASr scores were 2.9 ± 1.0 in Group F, 3.1 ± 1.2 in Group FN, and 2.8 ± 0.9 in Group N (p = 0.501). At the same timepoint, the VASm scores were 4.1 ± 1.2 in Group F, 4.5 ± 1.5 in Group FN, and 3.8 ± 1.4 in Group N (p = 0.129). Significant differences among the three groups were observed at all timepoints except for PACU in terms of the total opioid consumption (p < 0.0001). However, there were no significant differences in opioid-related complications among the three groups. Conclusions: PCA with nefopam, whether alone or in combination with opioids, offers non-inferior analgesic efficacy compared to PCA with fentanyl alone in patients undergoing immediate BRS.

Prevention of postoperative nausea and vomiting after orthognathic surgery: a scoping review

INTRODUCTION

Postoperative nausea and vomiting (PONV) is one of the most common adverse events following orthognathic surgery. It's a distressing feeling for patients and continues to be the cause of postoperative complications such as bleeding, delayed healing, and wound infection. This scoping review aims to identify effective PONV prophylaxis strategies during orthognathic surgery that have emerged in the past 15 years.

METHODS

We searched Pubmed, Cochrane Controlled Register of Trials, and Embase from 2008 to May 2023. Studies meeting the following criteria were eligible for inclusion: (1) recruited patients undergo any orthognathic surgery; (2) evaluated any pharmacologic or non-pharmacologic method to prevent PONV. Studies meeting the following criteria were excluded: (1) case series, review papers, or retrospective studies; (2) did not report our prespecified outcomes.

RESULTS

Twenty-one studies were included in this review. Pharmacological methods for PONV prevention include ondansetron and dexamethasone (3 studies), peripheral nerve block technique (4 studies), dexmedetomidine (1 study), pregabalin (2 studies), nefopam (2 studies), remifentanil (1 study), propofol (2 studies), and penehyclidine (1 study). Non-pharmacologic methods include capsicum plaster (1 study), throat packs (2 studies) and gastric aspiration (2 studies).

CONCLUSIONS

Based on current evidence, we conclude that prophylactic antiemetics like dexamethasone, ondansetron, and penehyclidine are the first defense against PONV. Multimodal analgesia with nerve block techniques and non-opioid analgesics should be considered due to their notable opioid-sparing and PONV preventive effect. For the non-pharmacological methods, throat packs are not recommended for routine use because of their poor effect and serious complications. More prospective RCTs are required to confirm whether gastric aspiration can prevent PONV effectively for patients undergoing orthognathic surgery.

Endogenous opiates and behavior: 2021

This paper is the forty-fourth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2021 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonizts and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Comparative effectiveness of interventions for managing urological postoperative catheter-related bladder discomfort: a systematic review and network meta-analysis

BACKGROUND

Catheter-related bladder discomfort (CRBD) is a common postoperative bladder pain syndrome. Many drugs and interventions for managing CRBD have been studied, but their comparative effectiveness remains controversial. We made a study to assess the comparative effectiveness of interventions included Ketorolac, Lidocaine, Chlorpheniramine, Gabapentin, Magnesium, Nefopam, Oxycodone, Parecoxib, Solifenacin, Tolterodine, Bupivancaine, Dexmedetomidine, Hyoscine N-butyl bromide, Ketamine, Penile nerve block on urological postoperative CRBD.

METHODS

We performed a network meta-analysis via Aggregate Data Drug Inormation System software included 18 studies with 1816 patients and assessed the risk of bias by Cochrane Collaboration tool. The incidence of moderate to severe CRBD at 0, 1, and 6 h after surgery and the incidence severe CRBD at 1 h after surgery were compared.

RESULT

The number of best rank is 0.48(Nefopam) and 0.22(Nefopam) in the incidence of moderate to severe CRBD at 1 h and incidence severe CRBD at 1 h. More than half of studies at unclear or high risk of bias.

CONCLUSION

Nefopam reduced the incidence of CRBD and prevented severe events, but limited by the small number of studies for each intervention and heterogeneous patients.

A Comprehensive Review: Chronic Pain Sequelae in the Presence of Ehlers-Danlos Syndrome

PURPOSE OF REVIEW

Patients diagnosed with Ehlers-Danlos syndromes (EDS), and especially those with the hypermobility subtype, often experience a diverse range of acute and chronic pain conditions throughout their lifetime. These can present in a variety of different phenotypes and comorbidities, making it difficult to develop structured treatment protocols. This review seeks to summarize the current literature to address old and novel treatments for EDS.

RECENT FINDINGS

Historically, medications and surgery have been used to treat patients with EDS but with low efficacy. Newer therapies that have shown promising effects for both decreasing pain and increasing quality of life include physical/occupational therapy, transcutaneous electrical nerve stimulation units, trigger point injections, low-dose naltrexone, and laser therapy. In addition, addressing the psychosocial aspects of pain with EDS through methods like cognitive behavioral therapy and patient education has shown to be vital in minimizing pain. Most research also emphasizes that pain management should not only focus on pain reduction, but on helping reduce symptoms of hypermobility, central sensitization, and fatigue to make an impactful difference. Research on pain in EDS is still limited with good clinical practice guidelines often limited by poor sample size and lack of clinical studies. Treatment options should be structured based on the specific type of pain pathology and presenting symptoms of each patient and their comorbidities. Future research should attempt to prioritize larger sample sizes, clear definitions of EDS subtypes, randomized trials for treatment efficacy, and more studies dedicated to non-musculoskeletal forms of pain.

Analgesic Effects of Continuous Wound Infusion Combined with Intravenous Patient-Controlled Analgesia for Thoracic Surgery: A Retrospective Study

Continuous wound infusion analgesia (CWA) with local anesthetics is a loco-regional anesthetic approach for multimodal analgesia management in surgical procedures. This study analyzed whether the combination of intravenous patient-controlled analgesia (PCA) and CWA would be more effective than PCA alone for postoperative analgesia and in preventing chronic postsurgical pain syndrome (PSPS) after thoracic surgeries. We enrolled 166 patients after propensity score matching, the PCA alone (PCA group, n = 83) and the combination of PCA and CWA (PCA-CWA group, n = 83), through a review of electronic medical records. The primary endpoint was the numeric rating scale (NRS) at postoperative days 1, 2, 3, 4, and 5. The secondary endpoint was the presence of PSPS at 3 and 6 months postoperatively. The NRS were lower in the PCA-CWA group than in the PCA group throughout the postoperative period (p < 0.001). The sedation incidence was lower in the PCA-CWA group (1.2%) than in the PCA group (9.6%) (p = 0.034), and there was no significant difference in other postoperative complications or in the incidence of PSPS (p = 1.000). The combination of intravenous PCA and CWA is an effective postoperative analgesic modality for thoracic surgery.

Comparative Study of Dezocine and Ketorolac Tromethamine in Patient-Controlled Intravenous Analgesia of Laparoscopic Cholecystectomy

Purpose

This study aimed to observe the application value of dezocine and ketorolac tromethamine in patient-controlled intravenous analgesia (PCIA) of patients undergoing laparoscopic cholecystectomy (LC).

Methods

A total of 154 patients who underwent LC surgery in our hospital and received PCIA after surgery from September 2020 to September 2021 were selected, they were divided into group A (n = 77) and group B (n = 77). Group A was given dezocine and group B was given ketorolac tromethamine. The analgesia, sedation, comfort, and adverse reactions of the two groups were closely observed at 4, 8, 12, and 24 h after surgery.

Results

At 4, 8, 12, and 24 h after surgery, the visual analog scale scores in group B were lower than those in group A (P &lt; 0.05). At 4, 8, 12, and 24 h after surgery, the Ramsay scores in group B were higher than those in group A (P &lt; 0.05). At 4, 8, 12, and 24 h after surgery, there was no significant difference in Bruggrmann comfort scale scores between the two groups (P &gt; 0.05). There was no significant difference in the incidence of adverse reactions between the two groups (P &gt; 0.05).

Conclusion

Both dezocine and ketorolac tromethamine have high clinical application value in patients who underwent LC surgery and received PCIA, with higher patient comfort and fewer adverse reactions. But compared with dezocine, ketorolac tromethamine can achieve better sedative and analgesic effects, which is worthy of clinical promotion.

Cutoff Values for Providing the Ideal Intravenous Patient-Controlled Analgesia According to the Intensity of Postoperative Pain—A Retrospective Observational Study

Background and Objectives: The cutoff values were analyzed for providing the ideal intravenous patient-controlled analgesia (PCA) that could reduce rescue analgesics or antiemetics requirements, based on the grades of postoperative pain intensity (PPI). Materials and Methods: PCA regimens of 4106 patients were retrospectively analyzed, and they were allocated into three groups with low, moderate, and high PPI grades (groups L, M, and H, respectively) based on numeric rating scores obtained 6 h postoperatively. Opioid and non-opioid analgesic doses were converted into fentanyl-equivalent doses (DOSE-FEN-OP and DOSE-FEN-NONOP, respectively). The primary endpoint was the cutoff values of these parameters. Results: With respect to the PCA settings to reduce rescue analgesic and antiemetic requirements, group L required a background infusion rate (BIR) of 1.75–3 mL/h, bolus volume of 0.5–1.25 mL, and lockout interval of ≤12.5 min. Group M required a BIR of 1.75 mL/h, bolus volume of 0.5–1.75 mL, and lockout interval of ≤5 min. Group H required a BIR of 1.75 mL/h, bolus volume of 0.5 mL, and lockout interval of ≤5 min. In assessments of the analgesic doses to reduce rescue analgesic requirement, the DOSE-FEN-OP was at least 950 μg of fentanyl regardless of group, while the DOSE-FEN-NONOP was ≥250 μg, ≥550 μg, and ≥700 μg for the L, M, and H groups, respectively. In assessments of the analgesic doses to reduce rescue antiemetic requirement, DOSE-FEN-OP was ≤950 μg for groups L and M and ≤850 μg for Group H, while DOSE-FEN-NONOP was ≤50 μg, ≤450 μg, and ≤700 μg for groups L, M, and H, respectively. Conclusion: The ideal PCA for reduction in rescue analgesics or antiemetics can be achieved by adjustment of PCA settings and drug dosages carefully with these cutoff values depending on the expected grades of PPI. Especially, the ideal PCA can be provided by adjusting the lockout interval and bolus volume rather than BIR and by applying smaller bolus doses and shorter lockout intervals with an increasing PPI grade.