Fentanyl-based Patient-controlled Analgesia Research Articles

Optimizing patient-controlled analgesia: a narrative review based on a single center audit process.

Intravenous patient-controlled analgesia (PCA) is valuable for delivering opioids in a flexible and timely manner. Although it is designed to offer personalized analgesia driven by the patients themselves, users often report insufficient pain relief, which can be addressed by optimizing its settings and multimodal analgesia. We adopted a systematic approach to modify PCA protocols by utilizing a serial audit process based on institutional PCA data. This review retrospectively examined the process, encompassing data from 13,230 patients who had used PCA devices. The two modifications to the fentanyl-based PCA protocols resulted in three distinct phases. In the first phase, high opioid consumption and unintended PCA withdrawal were the common issues. These were addressed in the second phase by omitting the routine use of basal infusion. However, this led to increased delivery-to-demand ratios, mitigated in the third phase by increasing the bolus dose from 15 μg to 20 μg. These serial protocol changes have produced varied outcomes across different surgical departments, underscoring the need for careful and gradual adjustments and thorough impact assessments. Drawing insights from this audit process, we incorporated findings from the literature on PCA settings and multimodal analgesic approaches. This review underscores the significance of iterative feedback and refinement of analgesic protocols to achieve optimal postoperative pain management. Additionally, it discusses critical considerations regarding the postoperative audit processes.

Comparison of intrathecal morphine versus erector spinae block for postoperative analgesia in patients with end-stage kidney disease undergoing kidney transplantation: A randomised clinical study.

Intrathecal morphine (ITM) or erector spinae plane (ESP) block reduces postsurgical pain in patients who underwent kidney transplantation surgeries. We aimed to compare the effectiveness of both modalities in terms of duration and quality of postoperative analgesia along with postoperative fentanyl consumption. We conducted a randomised study and analysed 60 patients posted for elective live-related kidney transplantation surgery. They were randomised into two groups. Group M patients received ITM, whereas Group E patients received ESP block. We standardised the postoperative analgesia for both groups with intravenous fentanyl-based patient-controlled analgesia. The primary outcome was to compare the quality of analgesia using the numerical rating scale score between the groups. The secondary outcome was to observe the effect of both modalities on the duration of analgesia, postoperative fentanyl consumption, rescue analgesics requirement, catheter-related bladder discomfort and any complications. We found significantly lower pain scores at rest and while coughing in Group M at all time intervals, except at 24 h while coughing. The mean time to first analgesia requirement was significantly longer in Group M than in Group E (P = 0.002). No significant difference was found in postoperative consumption of total fentanyl (P = 0.065) and rescue analgesia in both groups. In Group M, there was significantly more nausea, vomiting and pruritus (P = 0.001). ITM provides long-lasting postoperative analgesia at the cost of higher side effects than ESP block.

Effect of patient-controlled analgesia on development of postoperative nausea and vomiting in patients undergoing microvascular decompression: a prospective randomized controlled trial.

Postoperative nausea and vomiting (PONV) occurs frequently after microvascular decompression (MVD). Fentanyl, an opioid, is strongly related to the development of PONV, and ketorolac, a nonsteroidal anti-inflammatory drug, has been approved for postoperative pain management. However, how ketorolac-based patient-controlled analgesia (PCA) causes PONV or how its efficacy differs from that of fentanyl-based PCA after MVD is unclear. In this study, the authors compared ketorolac-based with fentanyl-based PCA in terms of the incidence and severity of PONV and analgesia after MVD. This prospective, double-blind, single-center, randomized controlled trial conducted from December 2021 to February 2023 included patients with MVD who were randomly allocated to the ketorolac- or fentanyl-based PCA group postoperatively. The incidence (primary outcome) and severity of PONV and rescue antiemetic requirements were determined during the first 48 hours postoperatively. Additionally, postoperative pain scores, rescue analgesic requirement, PCA usage, and satisfaction scores were assessed during the study period. PONV severity and postoperative pain scores were assessed using an 11-point numeric rating scale (0 = none, 10 = extremely). Satisfaction scores for PONV and pain were determined (0 = very dissatisfied, 10 = very satisfied). Categorical variables were analyzed using the chi-square or Fisher's exact test. Continuous variables were analyzed using the Student t-test or Mann-Whitney U-test based on normal distribution. Of 185 screened patients, 91 were excluded based on predetermined exclusion criteria; 87 patients (43 in the ketorolac group and 44 in the fentanyl group) were analyzed and showed no significant differences in demographic data between groups. PONV incidence (48.8% vs 79.5%, p = 0.003) and severity (p = 0.004) were lower in the ketorolac-based PCA group than in the fentanyl-based PCA group. In the ketorolac group, there was a significant reduction in rescue antiemetic requirements compared with the fentanyl group (p = 0.049). The number of discontinuations was lower in the ketorolac-based PCA group than in the fentanyl-based PCA group (p = 0.001), whereas no significant differences in postoperative pain were found between the two groups. In patients with MVD, ketorolac-based PCA resulted in a decrease in PONV incidence and severity compared with fentanyl-based PCA, with analgesic effects similar to those of fentanyl-based PCA. This study provides clinical evidence that ketorolac-based PCA may be a valid alternative to fentanyl-based PCA in postoperative care.

A Randomized Comparison of Multimodal Analgesia and Fentanyl-Based Patient-Controlled Analgesia in Women Undergoing Robot-Assisted Bilateral Axillary Breast Approach Thyroidectomy

Opioid-free multimodal analgesia (MMA) emerges as a preferable approach for postoperative pain management compared to opioid-based patient-controlled analgesia (PCA) in robot-assisted bilateral axillary breast approach thyroidectomy, a procedure commonly undergone by young female patients. We compared the analgesic efficacy and other recovery profiles between MMA and PCA. In total, 88 female patients were administered fentanyl-based PCA or the combination of lidocaine continuous infusion and nefopam injection before recovery from general anesthesia. The visual analog scale score of postoperative pain was assessed at the post-anesthesia care unit and at 6, 12, and 24 h after the termination of surgery. Postoperative nausea and vomiting (PONV), rescue analgesic and anti-emetic agents, recovery profiles, and adverse events were also compared. The median numeric rating scores on postoperative pain at 6 h after recovery from general anesthesia were three in both groups, with no significant difference between the groups at any time point. The PONV incidence was significantly higher in the PCA group than in the MMA group. The combination of systemic lidocaine infusion and nefopam injection has an analgesic effect equivalent to that of fentanyl-based PCA without PONV.

Comparison of postoperative analgesic effects of erector spinae plane block and quadratus lumborum block in laparoscopic liver resection: study protocol for a randomized controlled trial

BackgroundCompared with open surgery, laparoscopic liver resection is a minimally invasive surgical technique. However, a number of patients experience moderate-to-severe postoperative pain after laparoscopic liver resection. This study aims to compare the postoperative analgesic effects of erector spinae plane block (ESPB) and quadratus lumborum block (QLB) in patients undergoing laparoscopic liver resection.MethodsOne hundred and fourteen patients undergoing laparoscopic liver resection will be randomly allocated to three groups (control, ESPB, or QLB) in a 1:1:1 ratio. In the control group, participants will receive systemic analgesia consisting of regular NSAIDs and fentanyl-based patient-controlled analgesia (PCA) according to the institutional postoperative analgesia protocol. In the two experimental groups (ESPB or QLB group), the participants will receive preoperative bilateral ESPB or bilateral QLB in addition to systemic analgesia according to the institutional protocol. ESPB will be performed at the 8th thoracic vertebra level with ultrasound guidance before surgery. QLB will be performed in the supine position on the posterior plane of the quadratus lumborum with ultrasound guidance before surgery. The primary outcome is cumulative opioid consumption 24 h after surgery. Secondary outcomes are cumulative opioid consumption, pain severity, opioid-related adverse events, and block-related adverse events at predetermined time points (24, 48, and 72 h after surgery). Differences in plasma ropivacaine concentrations in the ESPB and QLB groups would be investigated, and the quality of postoperative recovery among the groups will be compared.DiscussionThis study will reveal the usefulness of ESPB and QLB in terms of postoperative analgesic efficacy and safety in patients undergoing laparoscopic liver resection. Additionally, the study results will provide information on the analgesic superiority of ESPB versus QLB in the same population.Trial registrationProspectively registered with the Clinical Research Information Service on August 3, 2022; KCT0007599.

Comparison between ketorolac- and fentanyl-based patient-controlled analgesia for acute kidney injury after robot-assisted radical prostatectomy: a retrospective propensity score-matched analysis.

It is unclear whether ketorolac-based patient-controlled analgesia (PCA) leads to acute kidney injury (AKI) after robot-assisted radical prostatectomy (RARP) in patients susceptible to AKI. We compared the postoperative AKI incidence with ketorolac- and fentanyl-based PCA after RARP. After medical record review, eligible patients were divided in ketorolac and fentanyl groups. We conducted propensity score matching of 3239 patients and assigned 641 matched patients to each group, and compared the AKI incidence. We investigated potential risk factors for postoperative AKI, defined according to the Kidney Disease Improving Global Outcomes criteria. We collected preoperative data (age, height, weight, body mass index, American Society of Anesthesiologists physical status, medical history, creatinine level, estimated glomerular filtration rate, and hemoglobin level) and intraoperative data (maintenance anesthetics, surgery duration, anesthesia duration, crystalloid amount, colloid use, total amount of fluid administered, estimated blood loss, norepinephrine use, phenylephrine use, and PCA type). The postoperative AKI incidence was significantly higher in the ketorolac than in the fentanyl group, both before (31.1% vs. 20.4%; p < 0.001) and after (31.5% vs. 22.6%; p < 0.001) matching. In the univariate analysis, ketorolac was significantly associated with postoperative AKI, both before (odds ratio [OR], 1.762; 95% confidence interval [CI], 1.475-2.105; p < 0.001) and after (OR, 1.574; 95% CI, 1.227-2.019; p < 0.001) matching. In the multivariate analysis, ketorolac-based PCA was independently associated with development of postoperative AKI in the matched groups (OR, 1.659; 95% CI, 1.283-2.147; p < 0.001). Ketorolac-based PCA may increase postoperative AKI incidence after RARP; thus, renal function should be monitored in these patients.

Factors influencing length of hospital stay in patients using patient-controlled analgesia after laparotomy surgery-retrospective observational study

Multiple factors influencing the length of hospital stay (LOS) were investigated in patients using patient-controlled analgesia (PCA) after surgical laparotomy for various abdominal pathologies. Charts of patients who underwent fentanyl-based PCA for pain control after different types of exploratory laparotomy were reviewed retrospectively between January and December of 2014. Data from the preoperative, perioperative, and postoperative period were statistically analyzed using the Pearson’s correlation coefficient (PCC) and a multiple linear regression in relation to LOS. In the subgroup analysis, a significant positive correlation was found between an increased PCA-fentanyl dosage (µg/kg) and LOS in the gynecologic laparotomy-cancer (GyLC) group (PCC = 0.408; p &lt; 0.05). In contrast, the PCA-fentanyl high dose (&gt;500 µg/day) had a significant negative correlation with LOS in the general surgery-laparotomy-liver transplant-donor (GLLTD) group (PCC = −0.402; p &lt; 0.05). Factors such as American Society of Anesthesiologists (ASA) classification, diabetes mellitus, hypertension, chronic kidney disease, age, surgical time, perioperative total fluid/urine/blood loss, blood transfusion, use of tetrastarch, vomit/pruritus during PCA use, and total amount of fentanyl use were demonstrated to be positively correlated with LOS in the various groups of patients. Only blood transfusion was a predictive variable for prolonged LOS in GyLC group. Chronic kidney disease, total perioperative fluid, and vomiting during PCA use were predictive of LOS in the gynecologic laparotomy-non-cancer (GyLNC) group. There are multiple factors that affect LOS in patients using PCA after laparotomy for various surgical procedures. Acute pain physicians should take the clinical situation into consideration when prescribing the postoperative opioid-PCA dosage.

Comparison of the Efficacy and Safety of Dinalbuphine Sebacate, Patient-Controlled Analgesia, and Conventional Analgesia After Laparotomy for Gynecologic Cancers: A Retrospective Study.

ObjectiveWe aimed to investigate the effects of dinalbuphine sebacate (DNS), fentanyl-based patient-controlled analgesia (PCA), and conventional analgesia (CA) for pain management after laparotomy for gynecologic cancers.MethodsA total of 137 eligible patients who underwent laparotomy through a midline incision wound for gynecologic cancer between July 2019 and June 2020 were retrospectively evaluated. The patients were divided into three groups as follows: the intramuscular DNS, intravenous PCA, and CA groups. Postoperative pain (POP) intensity as measured with a numerical rating scale (NRS), total consumption of analgesics, and incidence of treatment-emergent adverse events were compared between the three groups.ResultsThe DNS group showed significant reduction in NRS pain intensity than the PCA and CA groups on day 1 (4.8 vs 6.2, p < 0.01 and 6.2, p < 0.05, respectively), day 2 (3.0 vs 4.7, p < 0.01 and 4.8, p < 0.001, respectively), day 3 (2.0 vs 3.9, p < 0.001 and 3.5, p < 0.001, respectively), day 4 (1.1 vs 3.1, p < 0.001 and 2.9, p < 0.001, respectively), and day 5 (0.7 vs 2.3, p < 0.001 and 2.4, p < 0.001, respectively). The total consumption of morphine equivalents per day was similar between the DNS and PCA groups (142.8 ± 7.3 mg vs 137.7 ± 70.0 mg, p = 0.8032) and lowest in the CA group (11.7 ± 30.7 mg, p < 0.0001). The overall safety profile was comparable between the DNS, PCA, and CA groups. The patients in the DNS group complained less of dizziness postoperatively than those in the PCA group (27% vs 47%) and had less nausea than those in the CA group (13% vs 33%).ConclusionA single DNS injection was more effective for relieving POP than PCA and CA in the patients who had a longitudinal incision for gynecologic cancer surgery. DNS was well tolerated and had less adverse effects than PCA and CA.

Comparison of Analgesic and Adverse Effects of Oxycodone- and Fentanyl-Based Patient-Controlled Analgesia in Patients Undergoing Robot-Assisted Laparoscopic Gastrectomy Using a 55:1 Potency Ratio of Oxycodone to Fentanyl: A Retrospective Study.

PurposeOxycodone has affinities for both kappa- and mu-opioid receptors. Therefore, it has been used for postoperative analgesia of surgeries in which visceral pain is expected to be the main cause of pain. However, there are few studies of the 55:1 potency ratio of oxycodone to fentanyl when using it as intravenous patient-controlled analgesia (IV-PCA). Thus, we compared the analgesic and adverse effects of IV-PCA using the 55:1 potency ratio of oxycodone to fentanyl in patients who underwent robot-assisted laparoscopic gastrectomy.Patients and MethodsThis retrospective study included 100 patients using an automatic PCA pump with oxycodone or fentanyl who underwent robot-assisted laparoscopic gastrectomy between January and November 2017. All patients were provided with an IV-PCA consisting of 20 μg/kg of fentanyl or 1.1 mg/kg of oxycodone mixed with 0.9% normal saline solution to a total volume of 250 mL, which was infused basally at a rate of 0.1 mL/h with a bolus dose of 1 mL and lockout time of 6 min. The primary and secondary endpoints were to evaluate the efficacies of IV-PCA using the 55:1 potency ratio of oxycodone to fentanyl on analgesic and adverse effects.ResultsPain intensity on arrival at the post-anesthesia care unit (PACU; 3.6±1.4 vs 4.4±2.0, P=0.031) and additional analgesic requirement within an hour after surgery (including the PACU period) (12% vs 37%; P=0.005) were significantly lower in the oxycodone group (n=49) than in the fentanyl group (n=51). Regarding adverse effects, the rate of postoperative nausea within 1 h after surgery (2% vs 16%; P=0.031) was also significantly lower in the oxycodone group than that in the fentanyl group.ConclusionOxycodone-based IV-PCA by dose calculations with a 55:1 potency ratio may achieve better analgesia without any significant adverse effects, when using IV-PCA in patients undergoing robot-assisted laparoscopic gastrectomy.

Comparison of the Effects of Sufentanil and Fentanyl in Intravenous Patient-Controlled Analgesia after Pediatric Moyamoya Surgery: A Retrospective Study

Introduction: Intravenous patient-controlled analgesia (PCA) has been one of the most popular modalities for postoperative pain management in orthopedic surgery, plastic surgery, or neurosurgery in children. Objective: We compared the effects of fentanyl and sufentanil used in intravenous PCA on postoperative pain management and opioid-related side effects in pediatric moyamoya disease. Methods: This retrospective study included 97 pediatric patients who underwent surgery for moyamoya disease. Preoperative and perioperative parameters were assessed. The PCA regimen was as follows: fentanyl group (0.2 μg/kg/mL, 1 mL of loading volume, 0.1 μg/kg/h of basal infusion, a bolus of 0.2 μg/kg on demand, “lock-out” interval of 15 min); sufen­tanil group (0.04 μg/kg/mL, 1 mL of loading volume, 0.02 μg/kg/h of basal infusion, a bolus of 0.04 μg/kg on demand, 15 min lock-out), 10 μg/kg (up to 300 μg) of ramosetron for prophylaxis of postoperative nausea and vomiting with the same loading dose in both groups. Peripheral nerve blocks were performed. Pain was assessed by numeric rating scale or revised Faces Pain Scale. Side effects were reviewed. Results: The two groups showed similar pain scores and incidence of nausea or vomiting during the first 48 h postoperatively. Additional analgesics were more frequent in the fentanyl group, and PCA was discontinued more frequently in the sufentanil group. Conclusions: Postoperatively, sufen­tanil in PCA provided more analgesia than fentanyl with less additional analgesics in moyamoya disease. However, PCA with sufentanil was more frequently discontinued due to nausea or vomiting compared to fentanyl-based PCA.

Dose-Ranging Study of Ramosetron for the Prevention of Nausea and Vomiting after Laparoscopic Gynecological Surgery: A Prospective Randomized Study.

Patients undergoing laparoscopic gynecologic surgery and receiving postoperative analgesia with opioids have a high risk of postoperative nausea and vomiting (PONV). We compared the antiemetic efficacy of three doses of ramosetron in this high-risk population. In this prospective, double-blind trial, 174 patients randomly received ramosetron 0.3 mg (R0.3 group; n = 58), 0.45 mg (R0.45 group; n = 58), or 0.6 mg (R0.6 group; n = 58) at the end of surgery. The primary outcome was the incidence of PONV during the first postoperative 48 h. Nausea severity, pain scores, adverse events, and patient satisfaction (1–4; 4, excellent) were assessed. The incidence of PONV was not different between groups (35%, 38%, and 35% in R0.3, R0.45, and R0.6 groups; p = 0.905). Nausea severity, pain scores, and incidence of adverse events (dizziness, headache, or sedation) were similar between groups. Compared to the R0.3 group, the R0.45 and R0.6 groups had lower incidence of premature discontinuation of fentanyl-based patient-controlled analgesia primarily because of intractable PONV (9% and 5% vs. 24%; p = 0.038), and higher satisfaction scores (3.4 ± 0.8 and 3.3 ± 0.7 vs. 2.4 ± 0.9; p = 0.005). Compared to ramosetron 0.3 mg, ramosetron 0.45 and 0.6 mg did not reduce PONV, but reduced premature discontinuation of patient-controlled analgesia and increased patient satisfaction, without increasing adverse events.

Perioperative management of adult cadaveric and live donor renal transplantation in the UK: a survey of national practice

BackgroundThere is a limited evidence base and no national consensus regarding the perioperative management of patients undergoing renal transplantation. We developed an electronic survey to capture an overview of renal transplant perioperative practice across UK renal transplant centres and determine the need for future guidelines on patient management. MethodsA 29-question survey was developed to encompass the entire renal transplant perioperative pathway and input was sought from clinicians with expertise in renal transplant surgery, anaesthesia, nephrology and intensive care. The survey was sent to lead renal anaesthetists at each of the 23 transplant centres across the UK. ResultsA 96% response rate was achieved with 22 out of 23 centres returning complete responses. There was limited evidence of guideline-based approaches to preoperative workup. Questions regarding intraoperative fluid management, blood pressure targets, vasopressor administration and central venous pressure (CVP) monitoring identified a broad range of practice. Of note, the routine use of goal-directed fluid therapy based on cardiac output estimation was reported in six (27.3%) centres, while nine centres (40.9%) continue to target a specific CVP intraoperatively. In all, 12 (54.5%) centres perform transversus abdominis plane blocks with fentanyl-based patient-controlled analgesia as the most common mode of postoperative analgesia. A single centre reported a renal transplant-specific Enhanced Recovery after Surgery programme for cadaveric organ recipients. ConclusionsThis questionnaire highlighted a high degree of heterogeneity in current UK practice as regards the perioperative management of renal transplant recipients. Development of evidence-based national consensus guidelines to standardize the perioperative care of these patients is recommended in order to improve patient outcomes and focus areas of future research.

Combination of gabapentin and ramosetron for the prevention of postoperative nausea and vomiting after gynecologic laparoscopic surgery: a prospective randomized comparative study

BackgroundAs a drug originally introduced for its anticonvulsant effects, gabapentin has been recently shown to be effective in the treatment of nausea and vomiting in various clinical settings. This study compared the antiemetic efficacy of oral gabapentin, intravenous ramosetron and gabapentin plus ramosetron in patients receiving fentanyl-based patient-controlled analgesia after laparoscopic gynecologic surgery.MethodsOne hundred and thirty two patients undergoing laparoscopic gynecologic surgery under general anesthesia were allocated randomly into three groups: group G received 300 mg oral gabapentin 1 h before anesthesia, group R received 0.3 mg intravenous ramosetron at the end of surgery, and group GR received a combination of 300 mg oral gabapentin 1 h before anesthesia and 0.3 mg intravenous ramosetron at the end of surgery. Postoperative nausea, retching, vomiting, rescue antiemetic drug use, pain, rescue analgesic requirements and adverse effects were assessed at 0–2, 2–24 and 24–48 h after surgery. Postoperative nausea and vomiting (PONV) was defined as the presence of nausea, retching or vomiting.ResultsThe incidence of complete response (no PONV and no rescue antiemetics up to 48 h postoperatively) was significantly higher in group GR (26/40, 65%) than group G (16/40, 40%; P = 0.025) and group R (18/44, 41%; P = 0.027), whereas there was no significant difference between group G and group R (P = 0.932). There were no significant between-group differences in the incidence of emetic episodes, use of rescue antiemetics, severe emesis, use of rescue analgesics or any adverse effects. Postoperative pain scores were also similar among groups.ConclusionsThe combination with gabapentin and ramosetron is superior to either drug alone for prevention of PONV after laparoscopic gynecologic surgery.Trial registrationClinicalTrials.gov NCT02617121, registered November 25, 2015.

Dexmedetomidine added to an opioid-based analgesic regimen for the prevention of postoperative nausea and vomiting in highly susceptible patients: A randomised controlled trial.

Dexmedetomidine, an α2 adrenergic receptor agonist, has analgesic, sedative and sympatholytic properties, with a lack of respiratory depression. It is licensed only for intensive care sedation. The objective of this study is to investigate whether intravenous (i.v.) patient-controlled analgesia (PCA) with dexmedetomidine added to a fentanyl-based drug mixture could reduce postoperative nausea and vomiting (PONV) in highly susceptible patients undergoing lumbar spinal surgery. A randomised, double-blinded study. At a tertiary university hospital between September 2012 and September 2013. One hundred and eight patients undergoing level 1 or 2 posterior lumbar spinal fusion who had at least three risk factors for PONV (female, nonsmoker, use of postoperative opioids) were randomised into two groups. Three patients were excluded from analysis and 105 patients completed the study. Patients received either dexmedetomidine 0.5 μg kg⁻¹ i.v. (dexmedetomidine group) or 0.9% normal saline (control group) 30 min before the completion of surgery followed by fentanyl 0.5 μg kg⁻¹ and 4 mg ondansetron. Postoperatively, the PCA (fentanyl 10 μg kg⁻¹ with 120 mg ketorolac, with or without dexmedetomidine 10 μg kg⁻¹ made up to a total volume of 100 ml) was programmed to deliver 1 ml bolus (lockout 15 min) with a continuous background infusion of 2 ml h⁻¹. The PCA was used for the first 48 h postoperatively. The incidence and severity of PONV, cumulative dose of PCA fentanyl consumed and pain scores were assessed for 48 h. The dexmedetomidine group experienced less nausea during the time interval 1 to 3 h postoperatively compared with the control group [odds ratio (OR) 0.32; 95% confidence interval (CI) 0.13 to 0.77; P = 0.019]. The intensity of nausea between the groups during the first 48 h was comparable, but the dexmedetomidine group had a lower incidence of moderate to severe nausea (OR 0.28; 95% CI 0.12 to 0.67; P < 0.003). Pain scores were not significantly different between the groups, but patients in the dexmedetomidine group required less fentanyl and less rescue analgesia in the first 12 h. Compared with the control group, patients in the dexmedetomidine group experienced almost twice as many episodes of hypotension and bradycardia, but this failed to reach statistical significance. Adding dexmedetomidine to a fentanyl-based PCA drug mixture reduces the frequency and severity of acute postoperative nausea in highly susceptible patients. Clinicaltrials.gov identifier: NCT01840254.

Oral administration of aprepitant to prevent postoperative nausea in highly susceptible patients after gynecological laparoscopy

The use of opioids following surgery is associated with a high incidence of postoperative nausea and vomiting (PONV). We conducted a prospective, randomized, double-blind, placebo-controlled study to investigate the effect of orally administered aprepitant, a neurokinin-1 receptor antagonist, for reducing PONV in patients with fentanyl-based, patient-controlled analgesia (PCA) given intravenously after gynecological laparoscopy. One hundred and twenty female patients (ages 21-60) undergoing laparoscopic hysterectomy were randomly allocated to receive 80mg (A80 group, n=40) or 125mg aprepitant (A125 group, n=40) or placebo (control group, n=40) orally 2h before anesthesia induction. Anesthesia was maintained with isoflurane and remifentanil, and PCA IV using fentanyl and ketorolac were provided for 48h after surgery. Incidences of nausea, vomiting/retching, and use of rescue antiemetics were recorded at 2, 24, and 48h after surgery. Complete response was defined as no PONV and no need for rescue treatment. The incidence of complete response was significantly lower in the A80 and A125 groups than in controls, 56% and 63%, vs. 28%, respectively, P=0.007 and P=0.003, respectively, during the first 48h, and 65% and 65% vs. 38%, respectively, both P=0.025, during the first 2h. However, there were no statistically significant differences between A80 and A125 groups in the incidences of complete response and PONV during the study period. Aprepitant 80mg orally was effective in lowering the incidence of PONV in the first 48h after anesthesia in patients receiving fentanyl-based PCA after gynecological laparoscopy.

Anti-emetic effect of ondansetron and palonosetron in thyroidectomy: a prospective, randomized, double-blind study

Palonosetron is a new potent 5-hydroxytryptamine 3 antagonist. Although this drug is thought to be more effective in patients receiving opioid-based patient-controlled analgesia (PCA), clinical data are lacking. This study compared the effects of i.v. ondansetron and palonosetron administered at the end of surgery in preventing postoperative nausea and vomiting (PONV) in high-risk patients receiving i.v. PCA after thyroidectomy. A total of 100 female non-smoking subjects were randomly assigned into a palonosetron group or an ondansetron group. Ondansetron was given as an 8 mg bolus and 16 mg was added to the i.v. PCA mixture. In the palonosetron group, 0.075 mg was injected as a bolus only. Fentanyl-based PCA was provided for 24 h after operation. The incidence of nausea and vomiting, severity of nausea, requirement for rescue anti-emetics, and adverse effects were evaluated during 0-2 and 2-24 h. The incidence of PONV during the 24 h postoperative period was lower in the palonosetron group than in the ondansetron group (42% vs 62%, P=0.045). No differences were observed between the groups during the first 2 h. However, the incidence of nausea and vomiting and nausea severity were significantly lower in the palonosetron group than in the ondansetron group during 2-24 h. The only difference in the use of rescue anti-emetics was at 2-24 h (10% with palonosetron compared with 28% with ondansetron, P=0.02). Palonosetron is more effective than ondansetron for high-risk patients receiving fentanyl-based PCA after thyroidectomy, especially 2-24 h after surgery.

The Relationship between Postoperative Intravenous Patient-Controlled Fentanyl Analgesic Requirements and Severity of Liver Disease

PurposeDecreased inhalational anesthetic requirements during orthotopic liver transplantation (OLT) have been reported according to the severity of the pre-existent disease as well as decreased opioid requirements thereafter. The aim of the present study was to determine the relationship between postoperative opioid requirements and severity of liver disease among OLT patients. MethodsWe retrospectively reviewed 44 recipients who used intravenous fentanyl-based patient-controlled analgesia (PCA) after OLT from November 2009 to May 2010. The severity of liver disease was assessed using the model for end-stage liver disease (MELD) score. Recipients were divided into a low-MELD group (<20; n = 30) and a high-MELD group (≥20; n = 14). The amounts of PCA infusion and rescue opioid up to 3 postoperative days (POD) were compared between the 2 groups. The intensity of pain at rest and when coughing was assessed using visual analog scale (VAS) scores. ResultsThe cumulative opioid requirements via PCA on POD 1, 2, and 3 were significantly lower in the high-MELD than the low-MELD group. The amounts of rescue opioid were similar between the 2 groups. However, the intensity of pain at both rest and when coughing on POD 1, 2, and 3 were significantly less severe in the high-MELD than the low-MELD group. ConclusionsOLT patients with high MELD scores required less postoperative opioids and experienced less pain than those with low scores. Therefore, postoperative pain control after OLT should be carefully titrated according to the severity of the liver disease.

Efficacy comparison of ramosetron with ondansetron on preventing nausea and vomiting in high-risk patients following spine surgery with a single bolus of dexamethasone as an adjunct

BackgroundDespite the development of a new class of antiemetics, postoperative nausea and vomiting (PONV) still remains a frequent and distressing complication. We compared the prophylactic antiemetic effect of administering dexamethasone 5 mg as an adjunct to ramosetron and ondansetron in patients at high-risk for PONV following lumbar spinal surgery.MethodsIn this randomized, double-blind study, 120 female non-smoking patients with intravenous patient-controlled analgesia (PCA) received ramosetron 0.3 mg plus dexamethasone 5 mg (group R + D) or ondansetron 4 mg plus dexamethasone 5 mg (group O + D) intravenously. Fentanyl-based PCA was administered for 48 hr postoperatively; ramosetron 0.3 mg or ondansetron 12 mg was added to the PCA regimen according to the allocated group. The incidence of PONV and rescue antiemetic were assessed for 48 hr postoperatively at 0-6, 6-24, and 24-48 hr.ResultsThe overall incidence of PONV did not differ between the groups (50% vs. 60%, in groups R + D and O + D, respectively). The overall incidence of nausea was similar between groups (47% vs. 60%, in groups R + D and O + D, respectively). The overall frequency of vomiting was also similar between groups (8% vs. 12%, in groups R + D and O + D, respectively). The severity of nausea and the overall use of rescue antiemetic were not different between groups.ConclusionsThe antiemetic efficacy of ramosetron plus dexamethasone was similar to that of ondansetron plus dexamethasone on preventing PONV in high-risk patients undergoing lumbar spinal surgery.

The preventative effect of ramosetron on postoperative nausea and vomiting after total thyroidectomy.

BackgroundPostoperative nausea and vomiting (PONV) frequently develops in patients undergoing thyroidectomy, and propofol-based total intravenous anesthesia (TIVA) has been reported to reduce the incidence of PONV. The present study was undertaken to compare the effects of ramosetron on PONV in women following total thyroidectomy under TIVA.MethodsOne hundred and thirty women scheduled for thyroidectomy were allocated to either a control group (n = 65) or a ramosetron group (n = 65). Propofol in combination with remifentanil was used for TIVA in all patients. 2 ml of either intravenous saline (control group) or 0.3 mg of ramosetron (ramosetron group) were administered at the end of the surgery. Fentanyl-based patient-controlled analgesia was implemented for 48 h after surgery in all patients. The incidences and severities of PONV, pain scores, administrations of rescue antiemetics, and the side effects of the antiemetics were documented during the first 48 h after surgery.ResultsThe incidences of complete response (no PONV, no rescue) in the control and ramosetron groups were 71% and 88%, respectively, during the first 6 h (P = 0.029), 85% and 94% during the next 6 to 24 h period (P = 0.155), and 97% and 95% during the last 24 to 48 h period (P = 1.00). During the first 6 h, the severity of nausea and the use of rescue antiemetic medication were significantly lower in the ramosetron group.ConclusionsRamosetron was found to be effective at reducing the incidence and severity of postoperative nausea in women that underwent total thyroidectomy with propofol-based TIVA, especially during the first 6 hours postoperatively.