A Survey on the Effect of Oral Gabapentin on Hemodynamic Changes During Direct Laryngoscopy and Tracheal Intubation and Intraoperative Bleeding in Patients Undergoing Septorhinoplasty

The Effects of Hypocapnia and Hypercapnia on Intraoperative Bleeding, Surgical Field Quality, and Surgeon Satisfaction Level in Septorhinoplasty: A Prospective Randomized Clinical Study

BACKGROUND

Septorhinoplasty (SRP) is one of the most commonly performed procedures in the world for functional and aesthetic purposes. The present study was aimed to compare the effects of hypocapnia and hypercapnia regarding the total amount of intraoperative bleeding, surgical field quality, and surgeon satisfaction level.

METHODS

In this randomized prospective clinical study, eighty patients with American Society of Anesthesiologists I-II and were 18-45 years old scheduled for septorhinoplasty were randomly allocated to group hypocapnia [end-tidal carbon dioxide (EtCO2) 30 ± 2 mmHg] and group hypercapnia (EtCO2 40 ± 2 mmHg). We evaluated the total amount of intraoperative bleeding, the surgical field quality, surgeon satisfaction level, hemodynamics and peri- and postoperative adverse events.

RESULTS

Group hypocapnia significantly reduced the total amount of intraoperative bleeding (p < 0.001). The surgical field quality and surgeon satisfaction level in group hypocapnia were significantly better than group hypercapnia (p < 0.001). EtCO2 levels of group hypocapnia were significantly lower than group hypercapnia at all time points (p < 0.001 for all time points). There were no significant differences between the groups in terms of heart rate and mean arterial pressure at all time points. There were no significant differences between the groups in terms of adverse events CONCLUSIONS: The results of this double-blind randomized clinical trial showed that reducing the amount of intraoperative bleeding for patients with hypocapnia undergoing SRP through known methods (e.g., reverse Trendelenburg head-up position, positive end-expiratory pressure limiting, controlled hypotension, and use of topical vasoconstrictors, corticosteroids, and tranexamic acid) would improve the quality of the surgical field and raise the surgeon satisfaction level.

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 of Gabapentin + Dexamethasone for Postoperative Analgesia Following Septoplasty: A Prospective Randomized Placebo-Controlled Trial

AIMS

This study aimed to compare the efficacy of gabapentin, dexamethasone, and gabapentin + dexamethasone for pain control after septoplasty.

MATERIALS AND METHODS

This prospective randomized trial included 120 patients that underwent septoplasty and were randomly divided into 4 groups: group G (preoperative gabapentin 600 mg p.o.); group D (intraoperative dexamethasone 8 mg i.v.); group GD (preoperative gabapentin 600 mg p.o. + intraoperative dexamethasone 8 mg i.v.); group C (placebo control).

RESULTS

The median VAS score was significantly lower in groups G and GD at 1, 2, 4, 6, 12, and 24 hours postsurgery than in group C (P < .008 for all). The median VAS score was significantly lower in group D than in group C at 1, 2, and 4 hours postsurgery (P < .008 for all). There weren't any significant differences in the VAS score between groups D, G, and GD at any time point. Groups G, D, and GD had a significantly lower frequency of rescue analgesic use than group C; however, there were no differences between groups G, GD, and C (P < .001 and P = .108, respectively).

CONCLUSION

Gabapentin, dexamethasone, and gabapentin + dexamethasone are equally more effective analgesics during the first 4 hours postsurgery than placebo. The addition of dexamethasone to gabapentin does not provide extra analgesia. Both gabapentin and gabapentin + dexamethasone have a more prolonged analgesic effect than dexamethasone alone.

Lesser Known Uses of γ-Aminobutyric Acid Analogue Medications in Otolaryngology

OBJECTIVES/HYPOTHESIS

In otolaryngology, γ-aminobutyric acid (GABA) analogues have been previously analyzed for their roles in neuropathic pain, chronic cough, tinnitus, and perioperative analgesia. The primary aim of this study is to comprehensively summarize and synthesize the existing evidence for lesser known uses of gabapentin and pregabalin in otolaryngology.

STUDY DESIGN

A scoping review conducted of the available English-language literature was performed by two authors through April 1, 2021.

METHODS

The Preferred Reporting Items for Systematic Review and Meta-Analysis criteria were followed, and a quality assessment of included studies was performed using the Methodological Index for Non-Randomized Studies.

RESULTS

Ten studies met inclusion criteria. Three studies found that gabapentin may reduce gastrostomy tube usage and improve swallowing function in head and neck cancer patients undergoing radiation therapy (RT). Three studies suggested that gabapentin may help reduce opiate use when used as a primary analgesic in patients with radiation-induced mucositis. One study demonstrated that pregabalin-reduced trismus severity in patients with radiotherapy-induced trismus. One study demonstrated gabapentin may be useful in patients with phonasthenia. Two studies demonstrated that GABA analogues may be a useful adjunct in patients with globus pharyngeus in the context of likely laryngeal sensory neuropathy.

CONCLUSIONS

The most promising potential uses for GABA analogues identified in this review are for improving swallowing, trismus, and narcotic overuse after RT. The benefit of GABA analogues for improving nonorganic voice disorders is also promising while the benefit for globus pharyngeus when possibly related to laryngeal sensory neuropathy is inconclusive. Laryngoscope, 2021.

Preoperative gabapentin versus bisoprolol for haemodynamic and surgical field optimisation during endoscopic sinus surgery: A randomised controlled trial

Background and Aims:

Appropriate premedication can optimise haemodynamics and hence surgical field visibility during endoscopic sinus surgery (ESS). This study aimed to compare the intraoperative effect of gabapentin 1200 mg versus bisoprolol 2.5 mg, given 2 hours before ESS.

Methods:

Patients were assigned into one of three groups. Patients of gabapentin group received preoperative oral gabapentin 1200 mg while, patients of bisoprolol and control groups received oral bisoprolol 2.5 mg and placebo respectively 2 hours before ESS. Primary outcome: reduction of blood loss and surgical field quality. Secondary outcome: haemodynamic control. mean arterial pressure (MAP) and heart rate (HR) were recorded as baseline, before and after induction of anaesthesia, at 1, 5, 10, 15 minutes after intubation and then every 15 minutes until the end of surgery. Data also included Fromm and Boezaart category scale (assessed every 15 min), intraoperative blood loss, surgeon satisfaction score, intraoperative anaesthetic/analgesic and vasoactive medications requirements.

Results:

Out of 66 eligible patients, 60 patients completed the study. Intraoperative MAP and HR were significantly lower and more stable in gabapentin and bisoprolol groups compared to control group (p < 0.05). The volume of blood loss was significantly lower (p 0.000) and operative field was more visible in gabapentin and bisoprolol groups than those in control group (p 0.000).

Conclusion:

The beneficial effect of gabapentin 1200 mg on intraoperative haemodynamic control and surgical field visibility is comparable to that of bisoprolol 2.5 mg when either of them is given as a single oral dose 2 hours before ESS.

Perioperative Analgesia for Patients Undergoing Septoplasty and Rhinoplasty: An Evidence-Based Review

OBJECTIVES/HYPOTHESIS

Opioid misuse and diversion is a pressing topic in today's healthcare environment. The objective of this study was to conduct a review of non-opioid perioperative analgesic regimens following septoplasty, rhinoplasty, and septorhinoplasty.

STUDY DESIGN

Evidence-based systematic review.

METHODS

PubMed, MEDLINE, Cochrane Library, and Embase databases were reviewed for articles related to perioperative analgesic use in septoplasty, rhinoplasty, and septorhinoplasty. Quality of studies were assessed via the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria, Jadad scores, and the Cochrane bias tool. Patient demographic data and clinical outcomes, including medication type, dose, administration time, pain scores, and adverse events, were obtained from included studies. Summary tables detailing the benefits and harms of each investigated regimen are included.

RESULTS

Thirty-seven studies met inclusion criteria for this evidence-based review. The quality of the studies was determined to be of moderate quality based off of GRADE standardized criteria with a mean Jadad score of 3.1. A preponderance of evidence showed reduced perioperative pain scores and rescue analgesic requirements, supporting the use of local anesthetics for analgesic control. Nonsteroidal anti-inflammatory drugs (NSAIDs) demonstrated similar decreased visual analog scores and postoperative analgesic demand; however, increased adverse events in this class warrant caution.

CONCLUSIONS

Contemporary literature supports the use of NSAIDs, gabapentin, local anesthetics, and α-agonists as effective perioperative analgesic opioid alternatives for septoplasty and septorhinoplasty. Local anesthetic use is a cost-effective option resulting in decreased postoperative pain scores and rescue analgesic requirements. Further large-scale, multi-institutional, controlled studies are needed to provide definitive recommendations.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:E200-E212, 2019.

Dose-related beneficial and harmful effects of gabapentin in postoperative pain management - post hoc analyses from a systematic review with meta-analyses and trial sequential analyses

Background

During the last 15 years, gabapentin has become an established component of postoperative pain treatment. Gabapentin has been employed in a wide range of doses, but little is known about the optimal dose, providing the best balance between benefit and harm. This systematic review with meta-analyses aimed to explore the beneficial and harmful effects of various doses of gabapentin administered to surgical patients.

Materials and methods

Data in this paper were derived from an original review, and the subgroup analyses were predefined in an International Prospective Register of Systematic Reviews published protocol: PROSPERO (ID: CRD42013006538). The methods followed Cochrane guidelines. The Cochrane Library’s CENTRAL, PubMed, EMBASE, Science Citation Index Expanded, Google Scholar, and FDA database were searched for relevant trials. Randomized clinical trials comparing gabapentin versus placebo were included. Four different dose intervals were investigated: 0–350, 351–700, 701–1050, and >1050 mg. Primary co-outcomes were 24-hour morphine consumption and serious adverse events (SAEs), with emphasis put on trials with low risk of bias.

Results

One hundred and twenty-two randomized clinical trials, with 8466 patients, were included. Sixteen were overall low risk of bias. No consistent increase in morphine-sparing effect was observed with increasing doses of gabapentin from the trials with low risk of bias. Analyzing all trials, the smallest and the highest dose subgroups demonstrated numerically the most prominent reduction in morphine consumption. Twenty-seven trials reported 72 SAEs, of which 83% were reported in the >1050 mg subgroup. No systematic increase in SAEs was observed with increasing doses of gabapentin.

Conclusion

Data were sparse, and the small number of trials with low risk of bias is a major limitation for firm conclusions. Taking these limitations into account, we were not able to demonstrate a clear relationship between the dosage of gabapentin and opioid-sparing or harmful effects. These subgroup analyses are exploratory and hypothesis-generating for future trialists.

Gabapentin for post-operative pain management - a systematic review with meta-analyses and trial sequential analyses

BACKGROUND

Perioperative pain treatment often consist of combinations of non-opioid and opioid analgesics, 'multimodal analgesia', in which gabapentin is currently used. The aim was to document beneficial and harmful effects of perioperative gabapentin treatment.

METHODS

Randomized clinical trials comparing gabapentin vs. placebo or active placebo in adult surgical patients receiving gabapentin perioperatively were included. This review was conducted using Cochrane standards, trial sequential analysis (TSA), and Grading of Recommendations Assessment, Development, and Evaluation (GRADE). The primary outcomes were 24-h opioid consumption and incidence of serious adverse events (SAE).

RESULTS

One hundred and thirty-two trials with 9498 patients were included. Thirteen trials with low risk of bias reported a reduction in 24-h opioid consumption of 3.1 mg [0.5, 5.6] [corrected]. In the analysis of gabapentin as add-on analgesic to another non-opioid analgesic regimen found a mean reduction in 24-h morphine consumption of 1.2 mg [-0.3, 2.6; TSA-adjusted CI: -0.3, 2.6] in trials with low risk of bias. [corrected]. Nine trials with low risk of bias reported a risk ratio of SAEs of 1.61 [0.91; 2.86; TSA-adjusted CI: 0.57, 4.57].

CONCLUSION

Based on GRADE assessment of the primary outcomes in trials with low risk of bias, the results are low or very low quality of evidence due to imprecision, inconsistency, and in some outcomes indirectness. Firm evidence for use of gabapentin is lacking as clinically relevant beneficial effect of gabapentin may be absent and harm is imminent, especially when added to multimodal analgesia.

Gabapentin for the hemodynamic response to intubation: systematic review and meta-analysis

PURPOSE

Endotracheal intubation is the gold standard for securing the airway before surgery. Nevertheless, this procedure can produce an activation of the sympathetic nervous system and result in a hemodynamic response which, in high-risk patients, may lead to cardiovascular instability and myocardial ischemia. The aim of this review was to evaluate whether gabapentin can attenuate this response and whether such an attenuation could translate into reduced myocardial ischemia and mortality.

SOURCE

We searched MEDLINE(®), EMBASE™, CINAHL, AMED, and unpublished clinical trial databases for randomized-controlled trials that compared gabapentin with control, fentanyl, clonidine, or beta blockers for attenuating the hemodynamic response to intubation. Primary outcomes were mortality, myocardial infarction, and myocardial ischemia. Secondary outcomes were hemodynamic changes following intubation.

PRINCIPAL FINDINGS

We included 29 randomized trials with only two studies at low risk of bias. No data were provided for the primary outcomes and no studies included high-risk patients. The use of gabapentin resulted in attenuation in the rise in mean arterial blood pressure [mean difference (MD), -12 mmHg; 95% confidence interval (CI), -17 to -8] and heart rate (MD, -8 beats·min(-1); 95% CI, -11 to -5) one minute after intubation. Gabapentin also reduced the risk of hypertension or tachycardia requiring treatment (risk ratio, 0.15; 95% CI, 0.05 to 0.48). Data were limited on adverse hemodynamic events such as bradycardia and hypotension.

CONCLUSION

It remains unknown whether gabapentin improves clinically relevant outcomes such as death and myocardial infarction since studies failed to report on these. Nevertheless, gabapentin attenuated increases in heart rate and blood pressure following intubation when compared with the control group. Even so, the studies included in this review were at potential risk of bias. Moreover, they did not include high-risk patients or report adverse hemodynamic outcomes. Future studies are required to address these limitations.

Comparing Clonidine and Lidocaine on Attenuation of Hemodynamic Responses to Laryngoscopy and Tracheal Intubation in Controlled Hypertensive Patients: A Randomized, Double-Blinded Clinical Trial

BACKGROUND

Hemodynamic fluctuations in response to laryngoscopy and tracheal intubation and their potential hazards have been well-recognized, especially in hypertensive patients. Many drugs in various combinations have been used to attenuate these adverse responses.

OBJECTIVES

We conducted a study to compare lidocaine with clonidine on the attenuation of hemodynamic responses to laryngoscopy and tracheal intubation, in controlled hypertensive patients undergoing general anesthesia.

PATIENTS AND METHODS

Eighty-six patients of American society of anesthesiologists (ASA) class II, who were aged 18 to 65-years-old and were scheduled for elective surgeries under general anesthesia, were included. The patients were randomly divided into two equal groups. The clonidine group received 0.2 mg oral clonidine 90 minutes before surgery and the lidocaine group received a placebo tablet at the same time. All patients in both groups were anesthetized with the same technique, including: intravenous fentanyl 3 mcg/kg, sodium thiopental 5 mg/kg, and atracurium 0.5 mg/kg. The lidocaine group received 1.5 mg/kg lidocaine but the clonidine group received the same volume of saline ninety seconds before intubation. Hemodynamic parameters were recorded before intubation and 1, 3, 5, and 10 minutes after endotracheal intubation.

RESULTS

There were no significant differences between the two groups' hemodynamic parameters, including heart rate and systolic, diastolic, and mean arterial blood pressures at the measured points. There were also no significant differences within each group in hemodynamic responses at the measured points (P > 0.05). Twenty patients in the clonidine and three patients in the lidocaine group complained of mouth dryness (P = 0.001). Fourteen patients in the clonidine and four patients in the lidocaine group had bradycardia (P = 0.008). Nineteen patients in the clonidine and six patients in the lidocaine group had orthostatic hypotension (P = 0.002).

CONCLUSIONS

There were no statistical differences between oral clonidine and intravenous lidocaine regarding attenuation of hemodynamic responses after tracheal intubation in controlled hypertensive patients, although the rate of complications including mouth dryness, bradycardia, and orthostatic hypotension was significantly higher in the clonidine group before induction of anesthesia.