The effect of intravenous paracetamol on postoperative pain after lumbar discectomy

The impact of magnesium on shivering incidence in cardiac surgery patients: A systematic review

Background and objective

This scientific review involves a sequential analysis of randomized trial research focused on the incidence of shivering in patients undergoing cardiac surgery. The study conducted a comprehensive search of different databases, up to the end of 2020. Only randomized trials comparing magnesium administration with either placebo or no treatment in patients expected to experience shivering were included. The primary objective was to evaluate shivering occurrence, distinguishing between patients receiving general anesthesia and those not. Secondary outcomes included serum magnesium concentrations, intubation time, post-anesthesia care unit stay, hospitalization duration, and side effects. Data collection included patient demographics and various factors related to magnesium administration.

Material and methods

This scientific review analyzed 64 clinical trials meeting inclusion criteria, encompassing a total of 4303 patients. Magnesium was administered via different routes, primarily intravenous, epidural, and intraperitoneal, and compared against placebo or control. Data included demographics, magnesium dosage, administration method, and outcomes. Heterogeneity was assessed using the I2 statistic. Some studies were excluded due to unavailability of data or non-responsiveness from authors.

Result

and discussion: Out of 2546 initially identified articles, 64 trials were selected for analysis. IV magnesium effectively reduced shivering, with epidural and intraperitoneal routes showing even greater efficacy. IV magnesium demonstrated cost-effectiveness and a favorable safety profile, not increasing adverse effects. The exact dose-response relationship of magnesium remains unclear. The results also indicated no significant impact on sedation, extubation time, or gastrointestinal distress. However, further research is needed to determine the optimal magnesium dose and to explore its potential effects on blood pressure and heart rate, particularly regarding pruritus prevention.

Conclusion

This study highlights the efficacy of intravenous (IV) magnesium in preventing shivering after cardiac surgery. Both epidural and intraperitoneal routes have shown promising results. The safety profile of magnesium administration appears favorable, as it reduces the incidence of shivering without significantly increasing costs. However, further investigation is required to establish the ideal magnesium dosage and explore its potential effects on blood pressure, heart rate, and pruritus prevention, especially in various patient groups.

Comparative Efficacy of Adjuvant Nonopioid Analgesia in Adult Cardiac Surgical Patients: A Network Meta-Analysis

OBJECTIVES

To compare the relative efficacy of adjuvant nonopioid analgesic regimens in adult cardiac surgical patients.

DESIGN

This frequentist, random-effects network meta-analysis (NMA) was prospectively registered on PROSPERO (CRD42021282913) and conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses for Network Meta-Analyses (PRISMA-NMA). The risk of bias (RoB) and confidence of evidence were assessed by RoB 2 and Confidence in Network Meta-Analysis, respectively. Relevant databases were searched from inception to October 9, 2021.

SETTING

A total of 124 (N = 26,257) randomized controlled trials were included, of which 110 were analyzed.

PARTICIPANTS

Trials enrolling adults (≥18 years of age) undergoing cardiac surgery that compared nonopioid analgesics against other nonopioid analgesics, placebo, or no additional treatment, as adjuvants to standard analgesic management, and reported at least 1 of the outcomes of interest.

MEASUREMENT AND MAIN RESULTS

Outcomes of interest included resting postoperative pain scores at 24 hours. Compared with standard care and/or placebo, pain scores were reduced significantly by 10 different regimens, including acetaminophen (N = 176; mean difference [MD] -0.66 points, 95% CI -1.16 to -0.15 points; high confidence), magnesium (N = 323; -0.05 points, 95% CI -0.07 to -0.02 points; high confidence), gabapentin (N = 96; MD -0.40 points, 95% CI -0.71 to -0.09; moderate confidence), and clonidine (N = 64; MD v0.38 points, 95% CI -0.73 to v0.04 points; moderate confidence). Indomethacin, diclofenac, magnesium, and gabapentin significantly reduced 24-hour opioid consumption. Four regimens significantly decreased the intensive care unit length of stay. Hydrocortisone, dexmedetomidine, and clonidine significantly decreased the duration of mechanical ventilation. Magnesium decreased, while methylprednisolone significantly increased, the risk of myocardial infarction.

CONCLUSIONS

Given the increasing emphasis on enhanced recovery after surgery(ERAS) protocols and the eventual goal of limiting opiate prescriptions postoperatively, the authors' data suggested far greater use of nonopioid adjuncts to minimize pain and enhance recovery following cardiac surgery.

Effect of Intravenous Paracetamol on Opioid Consumption in Multimodal Analgesia After Lumbar Disc Surgery: A Meta-Analysis of Randomized Controlled Trials

Background: Intravenous paracetamol, as an adjunct to multimodal analgesia, has been shown to successfully reduce opioid consumption after joint arthroplasty, abdominal surgery, and caesarean delivery. However, there are limited data on the opioid-sparing effect of intravenous paracetamol on lumbar disc surgery. Objectives: The aim of this study was to investigate the effectiveness and safety of intravenous paracetamol for reducing opioid consumption in lumbar disc surgery. The primary outcome was cumulative opioid consumption within 24 h postoperatively. Method: We followed the PRISMA-P guidelines and used GRADE to assess the quality of evidence. The review was registered in PROSPERO under the registration number CRD42021288168. Two reviewers conducted electronic searches in PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science (Clarivate Analytics). Randomized controlled trials (RCTs) that compared the postoperative opioid consumption of intravenous paracetamol with placebo in lumbar discectomy were included. Results: Five trials comprising a total of 271 patients were included. The overall opioid consumption within 24 h postoperatively was reduced [mean difference (MD), -10.61 (95% CI, -16.00 to -5.22) mg, p = 0.0001, I2 = 90%] in patients with intravenous paracetamol. Intravenous paracetamol significantly reduced the postoperative pain scores at 1 h [MD, -2.37 (95%CI, -3.81 to -0.94), p = 0.001, I2 = 82%], 2 h [MD, -3.17 (95%CI, -3.85 to -2.48), p < 0.00001, I2 = 38%], 6 h [MD, -1.75 (95%CI, -3.10 to -0.40), p = 0.01], 12 h [MD, -0.96 (95%CI, -1.77 to -0.15), p = 0.02], and 24 h [MD, -0.97 (95%CI, -1.67 to -0.27), p = 0.006] compared with the placebo. There were no differences in postoperative adverse effects. Conclusion: Intravenous paracetamol reduced postoperative opioid consumption and decreased postoperative pain scores without increasing adverse effects. The overall GRADE quality of the evidence was rated as low to moderate. Intravenous paracetamol appears to be an applicable option as an important part of multimodal analgesia for postoperative analgesia after lumbar disc surgery. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, CRD42021288168.

Intravenous paracetamol infusion and tramadol as agents for post operative pain relief in urosurgical patient: A randomized control trial

Analgesia is one of the most important consideration in perioperative setting as it determines the recovery and discharge of a patient. Among the drugs used for analgesia, non steroidal anti-inflammatory drugs and opioids are the most commonly used ones in the current scenario. The aim of this study was to compare the efficacy of intravenous (IV) paracetamol and IV tramadol in alienating pain postoperatively. 100 adult patients of ASA grade I & II in the age group of 25-55 years were randomized into two groups of 50 patients , scheduled for elective urosurgical procedures and  were administered IV paracetamol and IV tramadol 30 minutes before the completion of surgery for postoperative analgesia and assessment was done with visual analog scale (VAS)score. In the present study, both the drugs showed effective pain relief. The onset of analgesia is faster in tramadol group. In paracetamol group, the onset of analgesia was slightly delayed but pain scores significantly decreased after 60 min, and this was observed up to 6 h with a statistically significant decrease in post operative nausea vomiting( PONV )with paracetamol group . 

Efficacy of erector spinae plane block on postoperative pain in patients undergoing lumbar spine surgery

BACKGROUND

Major lumbar spine surgery causes severe pain in the postoperative period. There are few studies regarding the effect of erector spinae plane block (ESPB) effect on lumbar surgery and its effect is still controversial. Therefore, the study aimed to investigate the effect of ultrasound-guided low thoracic ESPB on opioid consumption and postoperative pain score.

MATERIAL AND METHODS

Seventy-eight patients undergoing elective open lumbar spine surgery were randomized into two groups. In ESPB group (n = 35) received ultrasound-guided ESPB and in the control group (n = 35), there was no block. Postoperative opioid consumption as morphine equivalent dose, numerical rating scale, mobilization time, discharge time and side effects, bolus deliveries, rescue analgesia doses were evaluated.

RESULTS

Total opioid consumption as morphine equivalent was higher in the control group than the ESPB group (p = 0.000). Compare with the control group, the numeric rating scale scores were lower in the ESPB group at the 6th, 12th, and 24th hours (p < 0.05). The patient-controlled analgesia button pressing number in the postoperative 24-h period was lower in the ESPB group (p = 0.000). In the postoperative 24-h period, the need for paracetamol in the ESPB group was lower and the difference between the groups was statistically significant (p = 0.008). Rescue analgesia (diclofenac) doses were higher in the control group (p < 0.05). There was no statistically significant difference in terms of side effects and mobilization times.

CONCLUSION

ESPB is adequate for postoperative analgesia in patients undergoing lumbar spine surgery and can reduce opioid consumption compared with standard analgesia.

Multimodal Analgesic Management for Lumbar Decompression Surgery in the Ambulatory Setting: Clinical Case Series and Review of the Literature

BACKGROUND

Effective pain control is vital for successful surgery in the ambulatory setting. Our study aims to characterize a case series of patients who underwent lumbar decompression (LD) in the ambulatory surgical center (ASC) with the use of a multimodal analgesic (MMA) protocol.

METHODS

A prospective surgical registry was retrospectively assessed for patients who underwent single or multilevel LD in an ASC using MMA from 2013 to 2019. Observation in excess of 23 hours was not permitted at the ASC, and patients were required to be discharged the same day. Length of stay, patient-reported visual analog scale pain scores before discharge, and the quantity of narcotic medications administered to patients before discharge were recorded. Quantity of narcotic medications were converted into units of oral morphine equivalents and summed across all types of narcotic medications prescribed.

RESULTS

A total of 499 patients were included. In total, 86.0% (429) of the patients underwent a single-level decompression procedure, 13.8% (69) of patients underwent a 2-level, and 0.2% (1) of the patients underwent a 3-level procedure; 83.6% (417) of the patients in this study underwent a primary LD, and 14.0% (70) underwent a revision decompression.

CONCLUSIONS

This is the largest clinical case series focused on LD procedures within an ASC requiring no planned 23-hour observation. This study demonstrates the feasibility of performing LD surgery in an ASC with proper patient selection, surgical technique, and MMA protocol. All patients were discharged from the surgical center on the same day of surgery.

The effect of preoperative sublingual buprenorphine on postoperative pain after lumbar discectomy: A randomized controlled trial

Background

Lumbar discectomy is one of the most common surgical procedures performed to manage pain caused by the protrusion of an intervertebral disc. Postoperative pain management can be challenging and might lead to increased intake of opioids. Objective: The aim of this study was to determine the effect of preoperative sublingual buprenorphine on severity of pain after lumbar disc surgery and postoperative intake of morphine.

Methods

This Randomized clinical trial study was performed on 78 patients who were selected for lumbar discectomy surgery. Patients were randomly divided into two groups of 39 patients, each. Patients in the buprenorphine and placebo group received 2 mg buprenorphine sublingual, and placebo 1 h before surgery. Severity of pain, nausea, vomiting and pruritus and intake of opioids in the two groups were evaluated and recorded 1, 6, 12 and 24 h after surgery. Data were analyzed using SPSSv21.

Results

There was a significant difference in pain score in buprenorphine group at 1, 6, 12, and compared with placebo (P < 0.005). In the control group, the use of analgesics was more than the buprenorphine group. In the first hours after surgery (1–6 h), the incidence of nausea in the buprenorphine group was significantly lower than of the control group (P < 0.05). However, at 12 and 24 h, this difference was not observed, p > 0.05. There was no significant difference in incidence of side effects (nausea, vomiting, pruritus) in the two groups (P > 0.05).

Conclusion

Sublingual buprenorphine in postoperative pain management is an effective and low dose drug. Due to its simpler administration, it is recommended to relief postoperative pain after lumbar disc surgery.

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Lumbar discectomy is one of the most common surgical procedures performed to manage pain.

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Postoperative pain management can be challenging and might lead to increased intake of opioids.

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Sublingual buprenorphine in postoperative pain management is an effective and low dose drug.

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It is recommended to relief postoperative pain after lumbar disc surgery.

Perioperative and Anesthetic Considerations for Patients with Degenerative Spine Disease

The demand for spine surgery has dramatically increased over the last 2 decades. As the population ages and surgical and anesthetic techniques advance, the perioperative care of spine surgery patients poses challenges to anesthesiologists. Perioperative outcomes in terms of a decrease in complication rates and total health care expenditures have directed perioperative care to focus on enhanced recovery after surgery protocols, which many institutions have adopted. The role of anesthesiologists in the care of patients undergoing spine surgery is expanding beyond intraoperative care; consequently, a multidisciplinary approach is the best direction for optimal patient care.

Anesthetic management of complex spine surgery in adult patients: a review based on outcome evidence

PURPOSE OF REVIEW

The aim of this article is to review the evidence regarding the anesthetic management of blood loss, pain control, and position-related complications of adult patients undergoing complex spine procedures.

RECENT FINDINGS

The most recent evidence of the anesthetic management of complex spine surgery was identified with a systematic search and graded. In our review, prophylactic tranexamic acid and optimal prone positioning were shown to be effective blood conservation strategies with minimal risks to the patients. Cell saver was cost-effective in complex surgeries with expected blood loss of greater than 500 ml. As for pain control, most interventions only produced mild analgesic effects, suggesting a multimodal approach is necessary to achieve optimal pain control after spine surgery. Regional techniques and NSAIDs were effective but because of their risks, their usage should be discussed with the surgical team. Further studies are required to assess the effectiveness, cost-effectiveness, and risks associated with combined uses of different analgesic interventions. On the basis of the available evidence, we recommend a combined use of gabapentinoids, ketamine, and opioids to achieve optimal analgesia. Lastly, literature for position-related injuries is heavily relied on case reports and the Anesthesia Closed Claim Study because of their rarity. Therefore, we advocate for a structured team-based approach with checklists to minimize position-related complications.

SUMMARY

As the number and complexity of spine procedures are being performed worldwide is increasing, we suggested to bundle the aforementioned effective interventions as part of an ERAS spine protocol to improve the patient outcome of spine surgery.

Anesthetic considerations in spine surgery: What orthopaedic surgeon should know!

With clinical innovation and technological advancement, the paradigm of surgical procedures on the spine and spinal cord along with the perioperative management are rapidly evolving. Irrespective of different modes the anesthetic management of spine surgery is challenging in view of significant blood loss, prolong procedure, position-related complications, and complex pain management. The enhanced recovery after surgery (ERAS) for this kind of surgery is yet to be finalized. The aim of this article is to highlight the current evidence-based major perioperative considerations for patients undergoing spine surgery.

Comparison of tramadol versus tramadol with paracetamol for efficacy of postoperative pain management in lumbar discectomy: A randomised controlled study

PURPOSE

Despite developments in the treatment of pain, the availability of new drugs or increased knowledge of pain management, postoperative pain control after different surgeries remains inadequate. We aimed to compare the postoperative analgesic efficacy of tramadol versus tramadol with paracetamol after lumbar discectomy.

DESIGN, SETTING, PARTICIPANTS

Sixty patients undergoing lumbar discectomy were randomly assigned into two groups.

METHODS

Patients in Group T (n = 30) received tramadol (1 mg/kg), and patients in Group TP (n = 30) received tramadol (1 mg/kg) with paracetamol (1 g) 30 minutes before the end of surgery and paracetamol was continued during the postoperative period at 6 hours intervals for the first 24 hours. Patient-controlled analgesia with tramadol was used during the postoperative period.

MAIN OUTCOME MEASURES

Duration, postoperative pain scores, Ramsay sedation scores, analgesic consumption, and side effects were recorded in all patients during the postoperative period. Continuous random variables were tested for normal distribution using the Kolmogorov-Smirnov test, than Student's t-test was used for means comparisons between groups. For discrete random variables chi-square tests and McNemar test was used.

RESULTS

Demographic data, mean duration of anaesthesia and surgery were similar in both groups. Postoperative pain scores were significantly higher in Group T than Group TP at 5; 15; 20; and 30 minutes (P = .021, P = .004, P = .002, P = .018). Late postoperative pain scores were similar. Total tramadol consumption in Group T (106.12 ± 4.84 mg) was higher than Group TP (81.20 ± 2.53) during the 24 hours postoperative period. However, continuing the paracetamol at 6 hours interval did not change late postoperative pain scores.

CONCLUSION

The administration of tramadol with paracetamol was more effective than tramadol alone for early acute postoperative pain therapy following lumbar discectomy. Therefore, while adding paracetamol in early pain management is recommended, continuing paracetamol for the late postoperative period is not advised.

Endogenous Opiates and Behavior: 2015

This paper is the thirty-eighth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2015 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.

Single dose intravenous paracetamol or intravenous propacetamol for postoperative pain

BACKGROUND

This is an updated version of the original Cochrane review published in Issue 10, 2011. Paracetamol (acetaminophen) is the most commonly prescribed analgesic for the treatment of acute pain. It may be administered orally, rectally, or intravenously. The efficacy and safety of intravenous (IV) formulations of paracetamol, IV paracetamol, and IV propacetamol (a prodrug that is metabolized to paracetamol), compared with placebo and other analgesics, is unclear.

OBJECTIVES

To assess the efficacy and safety of IV formulations of paracetamol for the treatment of postoperative pain in both adults and children.

SEARCH METHODS

We ran the search for the previous review in May 2010. For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 1), MEDLINE (May 2010 to 16 February 2016), EMBASE (May 2010 to 16 February 2016), LILACS (2010 to 2016), a clinical trials registry, and reference lists of reviews for randomized controlled trials (RCTs) in any language and we retrieved articles.

SELECTION CRITERIA

Randomized, double-blind, placebo- or active-controlled single dose clinical trials of IV paracetamol or IV propacetamol for acute postoperative pain in adults or children.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, which included demographic variables, type of surgery, interventions, efficacy, and adverse events. We contacted study authors for additional information. We graded each included study for methodological quality by assessing risk of bias and employed the GRADE approach to assess the overall quality of the evidence.

MAIN RESULTS

We included 75 studies (36 from the original review and 39 from our updated review) enrolling a total of 7200 participants.Among primary outcomes, 36% of participants receiving IV paracetamol/propacetamol experienced at least 50% pain relief over four hours compared with 16% of those receiving placebo (number needed to treat to benefit (NNT) = 5; 95% confidence interval (CI) 3.7 to 5.6, high quality evidence). The proportion of participants in IV paracetamol/propacetamol groups experiencing at least 50% pain relief diminished over six hours, as reflected in a higher NNT of 6 (4.6 to 7.1, moderate quality evidence). Mean pain intensity at four hours was similar when comparing IV paracetamol and placebo, but was seven points lower on a 0 to 100 visual analog scale (0 = no pain, 100 = worst pain imaginable, 95% CI -9 to -6, low quality evidence) in those receiving paracetamol at six hours.For secondary outcomes, participants receiving IV paracetamol/propacetamol required 26% less opioid over four hours and 16% less over six hours (moderate quality evidence) than those receiving placebo. However, this did not translate to a clinically meaningful reduction in opioid-induced adverse events.Meta-analysis of efficacy comparisons between IV paracetamol/propacetamol and active comparators (e.g., opioids or nonsteroidal anti-inflammatory drugs) were either not statistically significant, not clinically significant, or both.Adverse events occurred at similar rates with IV paracetamol or IV propacetamol and placebo. However, pain on infusion occurred more frequently in those receiving IV propacetamol versus placebo (23% versus 1%). Meta-analysis did not demonstrate clinically meaningful differences between IV paracetamol/propacetamol and active comparators for any adverse event.

AUTHORS' CONCLUSIONS

Since the last version of this review, we have found 39 new studies providing additional information. Most included studies evaluated adults only. We reanalyzed the data but the results did not substantially alter any of our previously published conclusions. This review provides high quality evidence that a single dose of either IV paracetamol or IV propacetamol provides around four hours of effective analgesia for about 36% of patients with acute postoperative pain. Low to very low quality evidence demonstrates that both formulations are associated with few adverse events, although patients receiving IV propacetamol have a higher incidence of pain on infusion than both placebo and IV paracetamol.

Effect of Intravenous Acetaminophen (Paracetamol) on Hemodynamic Parameters Following Endotracheal Tube Intubation and Postoperative Pain in Caesarian Section Surgeries

BACKGROUND

Use of analgesics, especially opioids, before delivery during cesarean section for preventing hemodynamic changes after endotracheal intubation and postoperative analgesia is limited due to their adverse effects on the neonate.

OBJECTIVES

The aim of this study was to investigate the effect of intravenous acetaminophen (paracetamol) in blunting hemodynamic responses to endotracheal intubation and postoperative pain in parturient undergoing cesarean section by general anesthesia.

PATIENTS AND METHODS

Eighty parturients undergoing cesarean section by general anesthesia were randomly divided to receive either 15 mg/kg intravenous paracetamol (n = 40) or normal saline (n = 40) fifteen minutes before endotracheal intubation. Mean arterial blood pressure (MAP) and pulse rates were compared at baseline and after intubation at one minute interval for five minutes between the two groups. The patients were also compared for postoperative pain intensity and analgesic requirement.

RESULTS

Patients in the saline group experienced more pain in the recovery room (VAS 7.0 ± 1.24 vs. 6.15 ± 2.27; P value = 0.041) and required more fentanyl intraoperatively (150 µg vs. 87.7 ± 75; P value < 0.01) and meperidine postoperatively (12.88 ± 20.84 mg vs. 1.35 ± 5.73; P value = 0.002) than the paracetamol group. Mean arterial pressure (MAP) changes were similar after intubation in the both groups (P value = 0.71), however, pulse rates showed greater changes following intubation in the saline group (P value = 0.01).

CONCLUSIONS

Intravenous acetaminophen administered before caesarean section reduced tachycardia after intubation, narcotic drugs administration during and after the operation and reduced pain in PACU.