Pain in High-Dose-Rate Brachytherapy for Cervical Cancer: A Retrospective Cohort Study

High-dose-rate brachytherapy (HDR) is part of the main treatment for locally advanced uterine cervical cancer. Our aim was to evaluate the incidence and intensity of pain and patients' satisfaction during HDR. Risk factors for suffering pain were also analyzed. A retrospective study was carried out by extracting data from patients who had received HDR treatment for five years. Postoperative analgesia had been administered using pre-established analgesic protocols for 48 h. Pain assessment was collected according to a protocol by the acute pain unit. Analgesic assessment was compared according to analgesic protocol administered, number of needles implanted, and type of anesthesia performed during the procedure. From 172 patients treated, data from 247 treatments were analyzed. Pain was considered moderate in 18.2% of the patients, and 43.3% of the patients required at least one analgesic rescue. Patients receiving major opioids reported worse pain control. No differences were found regarding the analgesic management according to the intraprocedural anesthesia used or the patients' characteristics. The number of inserted needles did not influence the postoperative analgesic assessment. Continuous intravenous infusion of tramadol and metamizole made peri-procedural pain during HDR mild in most cases. Many patients still suffered from moderate pain.

A Retrospective Comparison of Three Patient-Controlled Analgesic Strategies: Intravenous Opioid Analgesia Plus Abdominal Wall Nerve Blocks versus Epidural Analgesia versus Intravenous Opioid Analgesia Alone in Open Liver Surgery

Background: Adequate pain control is of crucial importance to patient recovery and satisfaction following abdominal surgeries. The optimal analgesia regimen remains controversial in liver resections. Methods: Three groups of patients undergoing open hepatectomies were retrospectively analyzed, reviewing intravenous patient-controlled analgesia (IV-PCA) versus IV-PCA in addition to bilateral rectus sheath and subcostal transversus abdominis plane nerve blocks (IV-PCA + NBs) versus patient-controlled thoracic epidural analgesia (TEA). Patient-reported pain scores and clinical data were extracted and correlated with the method of analgesia. Outcomes included total morphine consumption and numerical rating scale (NRS) at rest and on movement over the first three postoperative days, time to remove the nasogastric tube and urinary catheter, time to commence on fluid and soft diet, and length of hospital stay. Results: The TEA group required less morphine over the first three postoperative days than IV-PCA and IV-PCA + NBs groups (9.21 ± 4.91 mg, 83.53 ± 49.51 mg, and 64.17 ± 31.96 mg, respectively, p < 0.001). Even though no statistical difference was demonstrated in NRS scores on the first three postoperative days at rest and on movement, the IV-PCA group showed delayed removal of urinary catheter (removal on postoperative day 4.93 ± 5.08, 3.87 ± 1.31, and 3.70 ± 1.30, respectively) and prolonged length of hospital stay (discharged on postoperative day 12.71 ± 7.26, 11.79 ± 5.71, and 10.02 ± 4.52, respectively) as compared to IV-PCA + NBs and TEA groups. Conclusions: For postoperative pain management, it is expected that the TEA group required the least amount of opioid; however, IV-PCA + NBs and TEA demonstrated comparable postoperative outcomes, namely, the time to remove nasogastric tube/urinary catheter, to start the diet, and the length of hospital stay. IV-PCA with NBs could thus be a reliable analgesic modality for patients undergoing open liver resections.

Evaluating the Effect of Dexmedetomidine Intravenous Infusion on Labour Pain Management in Primipara Pregnant Women: A Nonrandomised Clinical Trial Study

Background and aims

The pain of labour is very severe. Most women prefer painless labour to routine labour if they are aware of the methods of analgesia. The aim of this study was to evaluate the effect of dexmedetomidine intravenous infusion on labour pain management in primipara term pregnant women.

Methods

In this nonrandomised clinical trial with control group, all primipara term pregnant women from August 2019 to March 2020 were included. In the intervention group, after the active phase of labour, dexmedetomidine was given according to the protocol and continued until phase 2 of labour. The control group received no intervention to reduce pain. Patients in both groups were evaluated for fetal heart rate, Apgar scores, vital signs, pain intensity, and sedation score.

Results

There were no significant differences in primary fetal heart rate, primary maternal hemodynamics, and mean Apgar scores at 1 and 5 minutes between the two groups (p > .05). There was no significant difference in the mean fetal heart rate in different stages between the two groups. Intragroup analysis in the intervention group showed that mean systolic and diastolic blood pressures were significantly decreased after drug administration but were in the normal range. The active phase of labour in the intervention group was significantly shorter than in the control group (p = 0.002). The mean Visual Analogue Scale (VAS) score after dexmedetomidine administration decreased significantly from 9.25 at baseline to 4.61 after drug administration, 3.88 during labour, and 1.88 after placental expulsion. The mean Ramsay Sedation Scale score after dexmedetomidine administration increased significantly from 1.00 at baseline to 2.05 after drug administration, 2.22 during labour, and 2.05 after placental expulsion.

Conclusion

Based on the study's results, the administration of dexmedetomidine to manage labour pain with careful monitoring of mother and fetus is recommended.

Intravenous versus Epidural Routes of Patient-Controlled Analgesia in Abdominal Surgery: Systematic Review with Meta-Analysis

OBJECTIVE

To compare the intravenous and epidural routes of patient-controlled anesthesia in abdominal surgery.

METHODS

We searched for randomized clinical trials that compared the intravenous and epidural modes of patient-controlled anesthesia in intra-abdominal surgery in adults. Data analysis was performed in RevMan 5.4. Heterogeneity was measured using I2 statistic. Risk of bias was assessed using the Jadad/Oxford quality scoring system.

RESULTS

Seven studies reporting 529 patients were included into the meta-analysis. For pain at rest, the mean difference with 95% confidence interval (CI) was -0.00 [-0.79, 0.78], p-value 0.99, while for pain on coughing, it was 0.43 [-0.02, 0.88], p-value 0.06, indicating that patient-controlled epidural analgesia (PCEA) was superior. For the sedation score, the mean difference with 95% CI was 0.26 [-0.37, 0.89], p-value 0.42, slightly favoring PCEA. For the length of hospital stay, the mean difference with 95% CI was 1.13 [0.29, 1.98], p-value 0.009, favoring PCEA. For postoperative complications, the risk ratio with 95% CI was 0.8 [0.62, 1.03], p-value 0.08, slightly favoring patient-controlled intravenous analgesia (PCIVA). A significant effect was observed for hypotension, favoring PCIVA.

CONCLUSIONS

Patient-controlled intravenous analgesia compared with patient-controlled epidural analgesia was associated with fewer episodes of hypotension. PCEA, on other hand, was associated with a shorter length of hospital stay. Pain control and other side effects did not differ significantly. Only three studies out of seven had an acceptable methodological quality. Thus, these conclusions should be taken with caution.

Intraoperative Multimodal Approach for Pain After Thoracoscopic Pulmonary Resection

BACKGROUND

The optimal preemptive analgesia for thoracoscopic surgery remains unclear. We evaluated the utility of intraoperative intravenous analgesia on postoperative pain and the postoperative course in patients who underwent thoracoscopic lobectomy.

METHODS

We retrospectively reviewed 228 consecutive patients who underwent single-lobe thoracoscopic lobectomy for malignant pulmonary tumors between October 2017 and December 2019. Instead of epidural anesthesia, intercostal nerve blocks were performed from the thoracic cavity. We assessed the differences in the clinical and perioperative parameters including postoperative pain among the following: (1) N group (nonintraoperative intravenous analgesia), (2) A group (1000 mg acetaminophen), and (3) AF group (1000 mg acetaminophen with 50 mg flurbiprofen axetil). The numerical rating scale (NRS) was used to assess pain.

RESULTS

Receiver operating characteristic curve analysis revealed that the optimal cutoff pain score for the additional analgesic within 12 h postsurgery was 3.5 (area under the curve = 0.771; sensitivity = 63%; specificity = 19.4%; 95% confidence interval [CI] = 0.703-0.839; p < 0.01). Less pain scores on the surgical day were related to the AF group (NRS; N, 3 ± 2.6; A, 3 ± 2.4; AF, 2 ± 1.9; p = 0.008, respectively). No pain or mild pain (NRS = 0-2) on the operative day was strongly associated with the AF group (N = 36.4%; A = 46.4%; AF = 70.5%; p = 0.005). None of the patients experienced complications associated with intraoperative intravenous analgesia.

CONCLUSION

The combined use of intravenous analgesics (acetaminophen and flurbiprofen axetil) and intercostal nerve blocks is a safe and feasible preemptive analgesic approach for thoracoscopic lobectomy.

Effects of different analgesia regimens on early post-operative cognitive dysfunction in elderly patients undergoing radical resection of cervical carcinoma

This study was designed to compare the effects of epidural and intravenous analgesia on early post-operative cognitive dysfunction (POCD) in elderly patients undergoing radical resection of cervical cancer. For this purpose, 74 patients aged 60-78 years [body mass index (BMI), 18-25 kg/m²; American Society of Anesthesiologists (ASA) classification score of I-III) undergoing radical resection of cervical cancer were divided into the epidural group (group E) and parenteral group (group P) groups (37 patients in each group). All patients underwent their surgical procedures under epidural anesthesia and intravenously-delivered general anesthesia. Patient-controlled analgesia (PCA) was supplied for 72 h after the surgery. Epidural analgesia was provided for the patients in group E and intravenous analgesia was provide for those in group P. General patient information was recorded and peripheral blood neutrophil counts, C-reactive protein (CRP) levels and interleukin (IL)-6 concentrations were measured immediately prior to the surgery (T₀), and at 24, 48 and 72 h after the procedure (T₁, T₂ and T₃, respectively). Visual analog scale (VAS) scores were also recorded at T₁, T₂ and T₃, and the mini-mental state evaluation (MMSE) scores at T₀, T₁, T₂, and T₃ were calculated. Patients were diagnosed as having POCD according to their MMSE score differences between the peri-operative and post-operative values. The results revealed that the levels of CRP and IL-6 significantly increased in both groups after the surgery (T_1-3). However, the CRP and IL-6 levels in group E were significantly lower than those in group P at all time points examined (P<0.05). The VAS scores in group E at T₁, T₂ and T₃ were significantly lower than those in group P (P<0.05). Finally, the incidence of POCD in group E was significantly lower than that in group P (P<0.05). On the whole, the post-operative epidural analgesia reduced the systemic inflammatory response, the perceived pain, and the incidence of POCD in patients undergoing radical resection of cervical cancer, when compared with the effects of intravenous analgesia.

Cost of Intravenous Analgesia for the Management of Acute Pain in the Emergency Department is Substantial in the United States

Background: Pain is a leading cause of admission to the emergency department (ED) and moderate-to-severe acute pain in medically supervised settings is often treated with intravenous (IV) opioids. With novel noninvasive analgesic products in development for this indication, it is important to assess the costs associated with IV administration of opioids. Materials and Methods: A retrospective observational study of data derived from the Premier database was conducted. All ED encounters of adult patients treated with IV opioids during a 2-year time period, who were charged for at least one IV opioid administration in the ED were included. Hospital reported costs were used to estimate the costs to administer IV opioids. Results: Over a 24 month-period, 7.3 million encounters, which included the administration of IV opioids took place in 614 US EDs. The mean cost per encounter of IV administration of an initial dose of the three most frequently prescribed opioids were: morphine $145, hydromorphone $146, and fentanyl $147. The main driver of the total costs is the cost of nursing time and equipment cost to set up and maintain an IV infusion ($140 ± 60). Adding a second dose of opioid, brings the average costs to $151-$154. If costs associated with the management of opioid-related adverse events and IV-related complications are also added, the total costs can amount to $269-$273. Of these 7.3 million encounters, 4.3 million (58%) did not lead to hospital admission of the patient and, therefore, the patient may have only required an IV catheter for opioid administration. Conclusions: IV opioid use in the ED is indicated for moderate-to-severe pain but is associated with significant costs. In subjects who are discharged from the ED and may not have required an IV for reasons other than opioid administration, rapid-onset analgesics for moderate-to-severe pain that do not require IV administration could lead to direct cost reductions and improved care.

Analgesia for Medically Induced Second Trimester Termination of Pregnancy: A Randomized Trial

OBJECTIVE

To compare the efficacy between intravenous patient-controlled analgesia (IVPCA) and patient-controlled epidural analgesia (PCEA) in women undergoing medically induced second trimester termination of pregnancy (TOP).

METHODS

We conducted a randomized trial in a Canadian quaternary care hospital. We included in the study women of gestational age 12 weeks to 23+6 weeks who were undergoing second trimester induction of labour between June 2012 and January 2014. Participants were computer-randomized to receive either IVPCA with fentanyl or PCEA with bupivacaine and fentanyl, with the option to cross over between treatment groups. We administered Quality of Recovery-40 (QoR-40) questionnaires pre-procedure, at the time of discharge, and 24 hours after discharge. Pain scores, satisfaction scores, and obstetrical complications also were noted.

RESULTS

One hundred thirty-eight women were approached for participation in the study; 80 declined and 16 were ineligible, leaving 42 participants. Three women subsequently withdrew consent, and two were not included in the results because of protocol violations. A total of 37 women completed the study. Twenty (54%) were allocated to the IVPCA group and 17 (46%) to the PCEA group. Although the QoR-40 values at the time of discharge and at 24 hours after discharge were significantly higher in the PCEA group, they also were significantly higher before the procedure in that group. The within-group differences in QoR-40 (between QoR-40 at discharge and QoR pre-procedure, and between QoR-40 at 24 hours after discharge and QoR pre-procedure), maximum pain scores, satisfaction, and obstetrical complication rates did not differ significantly between the two groups.

CONCLUSION

IVPCA and PCEA provide similar quality of recovery, quality of analgesia, and satisfaction for women undergoing second trimester TOP.