Postoperative Fentanyl Research Articles

Evaluating the Effect of Intravenous Acetaminophen in Multimodal Analgesia After Total Hip Arthroplasty: A Randomized Controlled Trial

BackgroundPostoperative pain is a significant concern of patients before surgery. Multimodal pain management is an effective method of pain control after major orthopedic surgery. Acetaminophen is the most commonly used analgesic for the management of pain. It was hypothesized that 1000 mg of intravenous acetaminophen (IA) dosed every 6 hours would significantly reduce the postoperative pain score at rest and the opioid consumption volume in patients who would undergo total hip arthroplasty (THA) when compared to a control group. MethodsA single-center, prospective, open-label randomized control study was conducted. A total of 97 patients undergoing unilateral primary THA were divided into 2 groups: the study group (IA) (n = 45) and the control group (n = 52). The study group received administered IA after surgery, while the control group received only a standard pain control. Both groups received a preoperative femoral nerve block and postoperative intravenous fentanyl citrate. The primary outcome was the evaluation of the pain score at rest 24 hours after surgery. The pain score was measured using the Numerical Rating Scale. The primary outcome of this study was analyzed using generalized estimating equation. ResultsThe IA group had a significant improvement in Numerical Rating Scale score at rest 24 hours after THA compared to the control group (−0.91, 95% confidence interval −1.56 to −0.26, P = .006), suggesting a positive effect of IA usage for pain relief. The total fentanyl citrate consumption after surgery for 24 hours was significantly lower in the IA group than those of the control group (52.07 ± 7.64 vs 57.83 ± 12.44 mg, P < .001). ConclusionPostoperative administration of IA significantly reduced the postoperative pain score and opioid consumption volume after primary THA. IA was useful as one role of multimodal pain management after THA.Level of Evidence: Level 2.

Correlation of P2RX7 gene rs1718125 polymorphism with postoperative fentanyl analgesia in patients with lung cancer.

The aim of this study was to investigate the association between purinergic receptor P2X7 (P2RX7) gene rs1718125 polymorphism and analgesic effect of fentanyl after surgery among patients with lung cancer in a Chinese Han population.A total of 238 patients with lung cancer who received resection were enrolled in our study. The genotype distributions of P2RX7 rs1718125 polymorphism were detected by polymerase chain reaction and direct sequencing. Postoperative analgesia was performed by patient-controlled intravenous analgesia, and the consumption of fentanyl was recorded. The postoperative pain was measured by visual analog scale (VAS). Differences in postoperative VAS score and postoperative fentanyl consumption for analgesia in different genotype groups were analyzed by analysis of variance assay.The frequencies of GG, GA, and AA genotypes were 46.22%, 44.96%, and 8.82%, respectively. After surgery, the postoperative VAS score of GA group was significantly high in the period of analepsia after general anesthesia and at 6 hours after surgery (P = .041 and P = .030, respectively), while AA group exhibited obviously high in the period of analepsia after general anesthesia (P < .001), at postoperative 6 hours (P = .006) and 24 hours (P = .016). Moreover, the patients carrying GA and AA genotypes needed more fentanyl to control pain within 48 hours after surgery (P < .05 for all).P2RX7 gene rs1718125 polymorphism is significantly associated with postoperative pain and fentanyl consumption in patients with lung cancer.

Acetaminophen Does Not Reduce Postoperative Opiate Consumption in Patients Undergoing Craniotomy for Cerebral Revascularization: A Randomized Control Trial.

BackgroundPostoperative management in patients undergoing craniotomy is unique and challenging. We utilized a population of patients who underwent bilateral extracranial-to-intracranial (EC-IC bypass) revascularization procedures for moyamoya disease and hypothesized that 1 gram (gm) of intravenous (IV) acetaminophen given immediately after intubation and again 45 minutes prior to the end of craniotomy may be more effective than saline in minimizing opiate consumption and decreasing pain scores.MethodsIn a double-blind, randomized, placebo-controlled crossover pilot study, 40 craniotomies in 20 patients were studied. A random number generator assigned patients to receive either 1 gram of IV acetaminophen or an equal volume of normal saline immediately after intubation and again 45 minutes prior to the end of their first operation. For the second surgery, patients received the study drug (IV acetaminophen or normal saline) that they did not receive during their first surgery.ResultsIn the IV acetaminophen group, the average 24-hour postoperative fentanyl equivalent consumption was decreased but the difference was not statistically significant: 228 micrograms compared to 312 micrograms in the placebo group (Figure 1; p = 0.09). Pain scores did not significantly differ between the IV acetaminophen group and the placebo group in postoperative hours 0-12 (Figure 2; p = 0.44) or 24 (Figure 3; p = 0.77).ConclusionOur study demonstrates that in patients receiving bilateral craniotomies for moyamoya disease, IV acetaminophen when given immediately after intubation and again 45 minutes prior to closure does not significantly decrease 12- or 24-hour postoperative opiate consumption.

The effects of adding dexamethasone to epidural bupivacaine for lower limb orthopedic surgery

Introduction Dexamethasone when given epidurally with local anesthetics is known to reduce postoperative pain and postoperative analgesic consumption in several types of surgical procedures. Objective The objective of this study was to evaluate the effect of epidural dexamethasone on postoperative analgesia in patients who were undergoing lower limb orthopedic surgery. Patients and methods It is a prospective, randomized, double-blinded comparative study carried out in Assiut University Hospital, Egypt. It included 50 patients divided into two equal groups (25 in each), who underwent lower limb orthopedic surgery. The saline group: who received 15 ml epidural plain bupivacaine (0.5%)+2 ml normal saline (BS) and the dexamethasone group: who received 15 ml epidural plain bupivacaine (0.5%)+8 mg dexamethasone (2 ml) (BD). Postoperatively, when the pain score of at least 4, the rescue analgesia was given in the form of fentanyl and bupivacaine epidurally and paracetamol (perfalgan) 1 g was given routinely for all patients intravenous drip/8 h. Pain was evaluated by visual analog scale every 4 h in the postoperative 24 h. Time to first request for analgesia and total dose of rescue analgesia (epidural fentanyl/bupivacaine) in the first, 24 h postoperative was recorded. Results Dexamethasone significantly reduced the first, 24 h postoperative pain score (visual analog scale), and postoperative epidural fentanyl consumption (70.00 vs. 43.40 μg) in the first, 24 h postoperative. Dexamethasone also significantly prolonged the time to first request for analgesia (3.38 ± 0.072 vs. 15.24 ± 2.03 h). Conclusion Epidural dexamethasone with bupivacaine offers favorable effects on postoperative analgesia in lower limb orthopedic surgery.

The Effect of the Modified Thoracolumbar Interfacial Nerve Plane Block on Postoperative Analgesia and Healing Quality in Patients Undergoing Lumbar Disk Surgery: A Prospective, Randomized Study.

Objective:The purpose of this study was to investigate the effect of the modified thoracolumbar interfascial plane block (TLIP) on postoperative analgesia and quality of recovery in patients undergoing lumbar disk surgery.Method:Ninety patients scheduled for lumbar disk surgery were divided into a control group (Group C) and a modified TLIP block group (Group T). Controlled analgesia was administered to both groups. Pain evaluation was performed at 30 min and at 1., 2., 4., 8.,12., and 24. hrs using a VAS scale, with patients at rest and duringand patients completed the QoR-40 quality of recovery inventory.Results:Fentanyl used during postoperative 24 hours was 742.5±220.3 mcg in Group C and 446.0±241.98 in Group T. Postoperative fentanyl consumption was statistically significantly lower in Group T (p<0.001) with a statistically significant intergroup difference. The patient’s pain, physical independence, physical comfort, psychological support, and emotional support were compared using the QoR-40 questionnaire survey. Significant differences in favor of Group T were observed (p<0.001, p=0.017, p=0.002, p=0.001 and p<0.001, respectively). Static and dynamic pain scores in Group C and Group T were recorded at 30 min and at 1, 2, 4, 8, 12, and 24h. Mean static scores were statistically significantly different in favor of Group T with the exception of 8th and 12h assessments (p<0.05). Dynamic scores were statistically significantly different in favor of Group T at all time points (p<0.05).Conclusion:Pain scores, opioid consumption and QoR-40 values after lumbar disk surgery were superior in the group undergoing TLIP. We think that the modified TLIP block may be an important method in terms of postoperative analgesia and patient recovery for lumbar spinal disk surgery.

Transmuscular Quadratus Lumborum Block Reduces Length of Stay in Patients Receiving Total Hip Arthroplasty

BackgroundTotal hip arthroplasty is a common procedure being performed at an increasing rate in the United States. Recovering from this surgery to the extent that one can participate in criteria for discharge relies heavily on effective postoperative analgesia. Many regional anesthetic techniques are deployed in this realm. The recent utilization of quadratus lumborum (QL) blocks with success in other procedures warrants investigation in the hip arthroplasty population.MethodsTwenty patients received general anesthesia for elective total hip arthroplasty. Ten cases included a preoperative ultrasound-guided transmuscular quadratus lumborum block with 30 cc 0.5% ropivacaine. Ten cases that lacked this regional procedure. The primary outcome was length of hospital stay. Secondary outcomes include total procedure time, intraoperative and postoperative fentanyl administration, and mean postoperative visual analog pain scores (VAS 1 - 10).ResultsLength of stay was shorter in patients receiving QL block (2.9 days) versus patients not receiving QL block (5.1 days) (P value 0.0146). Intra-operative use of fentanyl was lower in patients receiving QL block (183.5 mcg) versus patients not receiving QL block (240 mcg) (P value 0.0376). PACU narcotic utilization, 24-hour VAS score, and length of operative procedure lacked statistical significance, though the study was not powered for these outcomes.ConclusionsQL block employment in hip surgery produces significant reduction in length of stay and intraoperative fentanyl use. While quadratus lumborum blocks are rapidly becoming a popular option due to its quality and spread of analgesia, more adequately powered prospective research must be performed to appropriately elucidate significant trends.

High-dose intraoperative remifentanil infusion increases early postoperative analgesic consumption: a prospective, randomized, double-blind controlled study.

The purpose of this study was to determine whether intraoperative infusion of remifentanil induces acute tolerance to opioids, and compare the postoperative pain and opioid consumption by the effect site concentrations of remifentanil. One hundred and ninety-eight patients undergoing gastrectomy were randomly assigned to maintain target effect site concentrations of remifentanil at 0 (Group 1, n = 39), 2 (Group 2, n = 40), 4 (Group 3, n = 39), 8 (Group 4, n = 40), or 12ng/ml (Group 5, n = 40) during operation. Postoperative pain intensities and fentanyl requirement were recorded at postoperative 2, 6, 24, and 48h. Fentanyl requirement for postoperative 2h was significantly greater in Group 5 compared to Group 1 (376 ± 116 vs. 283 ± 129µg, P = 0.03). However, there were no differences in fentanyl requirements among the groups after postoperative 2h. Also, total fentanyl consumption for 48h was similar in all groups (Group 1; 3106 ± 629, Group 2; 2970 ± 705, Group 3; 3017 ± 555, Group 4; 3151 ± 606, and Group 5; 2984 ± 443 µg, P = 0.717). Pain scores at rest and during deep breathing were comparable in all groups at the time of each examination. Intraoperative infusion of remifentanil with 12ng/ml of effect site concentration in patients undergoing gastrectomy increases early postoperative fentanyl requirement. Acute opioid tolerance would be developed by higher concentration of remifentanil than dosage of common anesthetic practice.

Preemptive intravenous ibuprofen application reduces pain and opioid consumption following thyroid surgery

ObjectiveThe primary aim of this study was to investigate the effects of preemptive a single dose IV ibuprofen on postoperative 48 h opioid consumption and postoperative pain in patients undergoing thyroidectomy. MethodsThe study included 40 patients aged 18 to 65, scheduled for elective thyroidectomy. Patients were randomly divided into 2 groups. Control group (n = 20) received 100 mL saline solution 15 min before surgery, while study group (n = 20) received 800 mg IV ibuprofen in 100 mL saline. The same general anesthesia protocol was applied in both groups, and all operations were performed by the same surgical team using the same technique. Postoperative analgesia was assessed using a visual analogue scale (VAS) and the amount of consumption of 48 h postoperative fentanyl with patient-controlled analgesia (PCA) and additional analgesia requirements were recorded. When additional analgesia was required, 1000 mg IV paracetamol was used. ResultsVAS scores in the ibuprofen group were found lower than the control group in the all-time points (p < 0.05). Opioid consumption in the 48 h was significantly higher in the control group than the ibuprofen group (p < 0.001). Using of rescue analgesia was significantly higher in the control group than the ibuprofen group, statistically (p < 0.05). A significant difference was observed between two groups in terms of side effects of fentanyl consumption (nausea and vomiting) (p < 0.001). ConclusionTo use preemptive a single dose IV ibuprofen decreases pain scores and postoperative opioid consumption in patients following thyroidectomy. Additionally, this application increase the patient comfort reducing nausea and vomiting in early postoperative period.

Effects of propofol/remifentanil-based total intravenous anesthesia versus sevoflurane-based inhalational anesthesia on the release of VEGF-C and TGF-\u03b2 and prognosis after breast cancer surgery: a prospective, randomized and controlled study

BackgroundVascular endothelial growth factor (VEGF) and transforming growth factor-β (TGF-β) have been involved in tumor growth and metastasis. Sevoflurane may promote angiogenesis, whereas propofol can present an anti-angiogenic effect. In this study, we compared the effects of propofol/remifentanil-based total intravenous anesthesia (TIVA) and sevoflurane-based inhalational anesthesia on the release of VEGF-C and TGF-β, as well as recurrence- free survival (RFS) rates in the patients undergoing breast cancer surgery.MethodsEighty female patients undergoing breast cancer resection were enrolled and randomized to receive either sevoflurane-based inhalational anesthesia (SEV group) or propofol/remifentanil-based TIVA (TIVA group). The serum concentrations of VEGF-C and TGF-β before and 24 h after surgery were measured and RFS rates over a two-year follow-up were analyzed in both groups. The postoperative pain scores assessed using a visual analogue scale (VAS) and the use of perioperative opioids were also evaluated.ResultsAlthough VAS scores at 2 h and 24 h after surgery were comparable between the two groups, there were more patients receiving postoperative fentanyl in the TIVA group (16[40%]) compared with the SEV group (6[15%], p = 0.023). VEGF-C serum concentrations increased after surgery from 105 (87–193) pg/ml to174 (111–281) pg/ml in the SEV group (P = 0.009), but remained almost unchanged in the TIVA group with 134 (80–205) pg/ml vs.140(92–250) pg/ml(P = 0.402). The preoperative to postoperative change for VEGF-C of the SEV group (50 pg/ml) was significantly higher than that of the TIVA group (12 pg/ml) with a difference of 46 (− 11–113) pg/ml (P = 0.008). There were also no significant differences in the preoperative and postoperative TGF-β concentrations between the two groups. The two-year RFS rates were 78% and 95% in the SEV and TIVA groups (P = 0.221), respectively.ConclusionIn comparison with sevoflurane-based inhalational anesthesia, propofol/remifentanil -based total intravenous anesthesia can effectively inhibit the release of VEGF-C induced by breast surgery, but didn’t seem to be beneficial in the short-term recurrence rate of breast cancer.Trial registrationChictr.org.cn ChiCTR1800017910. Retrospectively Registered (Date of registration: August 20, 2018).

Friday, September 28, 2018 4:05 PM–5:05 PM abstracts: basic science of spinal fusion: 233. Opioids delay healing of spinal fusion: a rabbit posterolateral lumbar fusion model

BACKGROUND CONTEXT Opioid use is prevalent for management of pre- and postoperative pain in patients undergoing spinal fusion. There is evidence that opioids downregulate osteoblasts in-vitro, and one previous study found that morphine delays the maturation and remodeling of callus in a rat femur fracture model. However, the effect of opioids on healing of spinal fusion has not been investigated before. Isolating the effect of opioid exposure in humans would be limited by the numerous confounding factors that affect fusion healing. Therefore, we have used a well-established rabbit model to study the process of spinal fusion healing that closely mimics humans. PURPOSE To study the effect of systemic opioids on the process of healing of spinal fusion in a rabbit posterolateral spinal fusion model. STUDY DESIGN/SETTING Preclinical animal study. PATIENT SAMPLE A total of 24 adult New Zealand white rabbits. OUTCOME MEASURES Assessment of fusion was done by manual palpation, plain radiographs, micro-computed tomography (microCT), and histology. METHODS A total of 24 adult New Zealand white rabbits were studied in two groups after approval from the Institutional Animal Care and Use Committee (IACUC). The opioid group (n=12) received four-weeks preoperative and six-weeks postoperative transdermal fentanyl. Serum fentanyl levels were measured just before surgery and four-weeks postoperatively to ensure adequate levels. The control group (n=12) received only perioperative pain control as necessary. All animals received a bilateral L5-L6 posterolateral spinal fusion using iliac crest autograft. Animals were euthanized at the six-week postoperative time point for analysis. RESULTS A total of 12 animals in control group and 11 animals in the opioid group were available for analysis at the end of six weeks. The fusion scores on manual palpation, radiographs, and microCT were not statistically different. Three-dimensional microCT morphometry found that the fusion mass in the opioid group had a lower bone volume (p=.09), lower trabecular number (p=.02) and higher trabecular separation (p=.02) as compared to control. Histological analysis found areas of incorporation of autograft, and unincorporated graft fragments in both groups. In the control group, there was remodeling of de-novo woven bone to lamellar organization with incorporation of osteocytes, formation of mature marrow, and relative paucity of hypertrophied osteoblasts lining new bone. Sections from the opioid group showed formation of de-novo woven bone, and hypertrophied osteoblasts seen lining the new bone. There were no sections showing lamellar organization and development of mature marrow elements in the opioid group. Less dense trabeculae on microCT correlated with histological findings of relatively immature fusion mass in the opioid group. CONCLUSIONS Systemic opioids led to an inferior quality fusion mass with delay in maturation and remodeling at six-weeks in this rabbit spinal fusion model. These preliminary results lay foundation for further research to investigate underlying cellular mechanisms, temporal fusion process, and dose-duration relationship of opioids responsible for our findings.

The predictive value of the heart rate variability-derived Analgesia Nociception Index in children anaesthetized with sevoflurane: An observational pilot study.

BackgroundThe heart rate variability (HRV)‐derived Analgesia Nociception Index (ANI™) is a continuous noninvasive tool to assess the nociception/antinociception balance in unconscious patients. It has been shown to be superior to haemodynamic variables in detecting insufficient antinociception in children, while little is known about its predictive value.MethodsThe primary objective of this prospective observational pilot study in paediatric surgical patients under sevoflurane anaesthesia was to compare the predictive value of the ANI and heart rate to help decide to give additional opioids. The paediatric anaesthesiologist in charge was blinded to ANI values.ResultsIn patients with an ANI value <50 (indicating insufficient antinociception) at the moment of decision, ANI values dropped from ±55 (indicating sufficient antinociception) to ±35, starting 60 s before decision. Within 120 s after administration of fentanyl (1 μg/kg), ANI values returned to ±60. This phenomenon was only observed in the ANI values derived from HRV data averaged over 2 min. Heart rate remained unchanged. In patients with ANI values ≥50 at the time of decision, opioid administration had no effect on ANI or heart rate. The same accounts for morphine for postoperative analgesia and fentanyl in case of intraoperative movement.ConclusionsThis study provides evidence of a better predictive value of the ANI in detecting insufficient antinociception in paediatric surgical patients than heart rate. The same accounts for depicting re‐establishment of sufficient antinociception after opioid drug administration.SignificanceIn paediatric surgical patients anaesthetized with sevoflurane, the heart rate variability‐derived Analgesia Nociception Index (ANI) appears to be a better predictor of insufficient antinociception than heart rate. The ANI also appears to depict re‐establishment of sufficient antinociception better than heart rate.

Preoperative screening for illicit drug use in patients undergoing emergency surgery: A prospective observational study

Knowledge of illicit drug users (IDUs) is important because of the comorbidity related to drug use. In this prospective, observational study, we screened 1007 patients undergoing emergency surgery and found that 75 of them (7.5%) were IDUs The results of preoperative screening showed that the rates of HIV and syphilis infection were significantly higher in IDUs (HIV (+) 2.6%, syphilis (+) 10.7%) than in non-IDUs (HIV (+) 0, syphilis (+) 0.5%). Intraoperative consumption of remifentanil (IDUs: 1.85 ± 1.30 vs. non-IDUs: 1.31 ± 0.86, p = 0.009), midazolam (IDUs: 4.82 ± 1.52 vs. non-IDUs: 4.15 ± 1.81, p = 0.002), and atracurium (IDUs: 31.5 ± 15.1 vs. non-IDUs: 25.5 ± 11.9, p = 0.006) and the proportion of patients requiring postoperative fentanyl (IDUs: 15 (20.0%) vs. non-IDUs: 95 (1.2%), p = 0.031) were significantly increased in IDUs compared to non-IDUs. Postoperative complications were observed in 22.7% (17/75) of patients who were IDUs, which was significantly increased when compared with non-IDUs (6.0%, 56/932, p < 0.001). The mortality rate within 30 days after surgery was similar between the two groups. These findings suggested that the IDUs were associated with increased rates of HIV and syphilis infection; greater consumption of intraoperative opioids, sedatives, and muscle relaxants; increased postoperative complications and a similar mortality rate within 30 days after surgery when compared with non-IDUs.

Opioids delay healing of spinal fusion: a rabbit posterolateral lumbar fusion model

Background ContextOpioid use is prevalent in the management of pre- and postoperative pain in patients undergoing spinal fusion. There is evidence that opioids downregulate osteoblasts in vitro, and a previous study found that morphine delays the maturation and remodeling of callus in a rat femur fracture model. However, the effect of opioids on healing of spinal fusion has not been investigated before. Isolating the effect of opioid exposure in humans would be limited by the numerous confounding factors that affect fusion healing. Therefore, we have used a well-established rabbit model to study the process of spinal fusion healing that closely mimics humans. PurposeThe objective of this work was to study the effect of systemic opioids on the process of healing of spinal fusion in a rabbit posterolateral spinal fusion model. Study Design/SettingThis is a preclinical animal study. Materials and MethodsTwenty-four adult New Zealand white rabbits were studied in two groups after approval from the Institutional Animal Care and Use Committee (IACUC). The opioid group (n=12) received 4 weeks' preoperative and 6 weeks' postoperative transdermal fentanyl. Serum fentanyl levels were measured just before surgery and 4 weeks postoperatively to ensure adequate levels. The control group (n=12) received only perioperative pain control as necessary. All animals underwent a bilateral L5–L6 posterolateral spinal fusion using iliac crest autograft. Animals were euthanized at the 6-week postoperative time point, and assessment of fusion was done by manual palpation, plain radiographs, microcomputed tomography (microCT), and histology. ResultsTwelve animals in the control group and 11 animals in the opioid group were available for analysis at the end of 6 weeks. The fusion scores on manual palpation, radiographs, and microCT were not statistically different. Three-dimensional microCT morphometry found that the fusion mass in the opioid group had a lower bone volume (p=.09), a lower trabecular number (p=.02), and a higher trabecular separation (p=.02) compared with the control group. Histologic analysis found areas of incorporation of autograft and unincorporated graft fragments in both groups. In the control group, there was remodeling of de novo woven bone to lamellar organization with incorporation of osteocytes, formation of mature marrow, and relative paucity of hypertrophied osteoblasts lining new bone. Sections from the opioid group showed formation of de novo woven bone, and hypertrophied osteoblasts were seen lining the new bone. There were no sections showing lamellar organization and development of mature marrow elements in the opioid group. Less dense trabeculae on microCT correlated with histologic findings of relatively immature fusion mass in the opioid group. ConclusionsSystemic opioids led to an inferior quality fusion mass with delay in maturation and remodeling at 6 weeks in this rabbit spinal fusion model. These preliminary results lay the foundation for further research to investigate underlying cellular mechanisms, the temporal fusion process, and the dose-duration relationship of opioids responsible for our findings.

Pain alleviation in patients undergoing cardiac surgery; presternal local anesthetic and magnesium infiltration versus conventional intravenous analgesia: a randomized double-blind study.

BackgroundMagnesium is one of the effective, safe local anesthetic adjuvants that can exert an analgesic effect in conditions presenting acute and chronic post-sternotomy pain. We studied the efficacy of continuous infusion of presternal magnesium sulfate with bupivacaine for pain relief following cardiac surgery.MethodsNinety adult patients undergoing valve replacement cardiac surgery randomly allocated into three groups. In all patients; a presternal catheter was placed for continuous infusion of either 0.125% bupivacaine and 5% magnesium sulfate (3 ml/h for 48 hours) in group 1, or 0.125% bupivacaine only in the same rate in group 2, versus conventional intravenous paracetamol and ketorolac in group 3. Rescue analgesia was iv 25 µg fentanyl. Postoperative Visual Analog Scale (VAS) and fentanyl consumption during the early two postoperative days were assessed. All patients were followed up over two months for occurrence of chronic post-sternotomy pain.ResultsVAS values showed high significant differences during the first 48 hours with the least pain scale in group 1 and significantly least fentanyl consumption (30.8 ± 7 µg in group 1 vs. 69 ± 18 µg in group 2, and 162 ± 3 in group 3 respectively). The incidence of chronic pain has not differed between the three groups although it was more pronounced in group 3.ConclusionsContinuous presternal bupivacaine and magnesium infusion resulted in better postoperative analgesia than both presternal bupivacaine alone or conventional analgesic groups.

Association between MDR1/CYP3A4/OPRM1 gene polymorphisms and the post-caesarean fentanyl analgesic effect on Chinese women

ObjectiveOur study aimed to evaluate the association between the multidrug resistance 1 (MDR1)/cytochrome P450 3A4 (CYP3A4)/μ-opioid receptor (OPRM1) gene polymorphisms and the post-caesarean analgesic effect of fentanyl on Chinese women. MethodsWe recruited 240 patients who received lower segment caesarean section surgeries. Sanger sequencing was used to analyze the MDR11236C > T/CYP3A4*1G/OPRM1A118G polymorphisms. We evaluated post-operative fentanyl consumption and the effect of intravenous analgesia in patients with different genotypes. Results1. Subjects with the TT genotype at the 1236C > T polymorphism in the MDR1 gene consumed significantly more fentanyl than that consumed by subjects with the CC and CT genotypes in the first post-operative 24 h and 48 h (P < 0.05), and the MAP/HR/Cor/Ang-1 levels gradually increased immediately after surgery and in the first post-operative 24 h. 2. Subjects with the CYP3A4*1G/*1G genotype needed less fentanyl to achieve pain control than that needed by subjects carrying the CYP3A4*1/*1 and CYP3A4*1/*1G genotypes in the first post-operative 24 h and 48 h (P < 0.05), and the MAP/HR/Cor/Ang-1 levels gradually decreased immediately after surgery and in the first post-operative 24 h. 3. Subjects with the GG genotype at the A118G polymorphism in the OPRM1 gene consumed significantly more fentanyl than that consumed by subjects with the AA and AG genotypes in the first post-operative 24 h and 48 h (P < 0.05), and the MAP/HR/Cor/Ang-1 levels gradually increased immediately after surgery and in the first post-operative 24 h. 4. There were no significant differences in the adverse reactions to fentanyl in patients with different genotypes (P > 0.05). ConclusionThese results indicated that the MDR1/CYP3A4/OPRM1 gene polymorphisms influenced the fentanyl consumption and the physiological effects of intravenous analgesia in the Chinese women who received lower segment caesarean section surgeries. Moreover, the present study provides an important foundation and theoretical evidence for the gene-directed rationalization and individualization of medication before caesarean section surgeries.

Ultrasound-guided pectoral nerve blocks versus serratus intercostal plane block in breast surgeries

Introduction Analgesia in breast surgeries can be delivered orally, intravenously, intramuscularly, neuroaxially, or using regional nerve blocks. Pectoral nerve block (Pecs) and serratus intercostal plane block (SIPB) are a recently introduced ultrasound-guided technique for providing intraoperative and postoperative analgesia. Aim The aim of the present study was to compare intraoperative and postoperative analgesic effect of Pecs versus SIPB in breast surgeries. Patients and methods The current study was carried out on 60 female patients of American Society of Anaesthesiologists class I or II. The patients were undergoing nonreconstructive breast surgery. The patients were randomly divided into two equal groups. The Pecs group included 30 patients who received ultrasound-guided Pecs with 40 ml of levobupivacaine with adrenaline 1 : 200 000. The SIPB group included 30 patients who received ultrasound-guided SIPB with 40 ml of levobupivacaine with adrenaline 1 : 200 000. After assessing the efficacy of the block using sensory block scale, standard general anesthesia was induced in both groups using intravenous fentanyl (1 µg/kg), propofol (2.5 mg/kg) and cisatracurium (0.15 mg/kg). Results The completion of block was significant shorter in SIPB group than Pecs group. The duration of paresthesia in the SIPB group extended to 8 h postoperatively, whereas in the Pecs group the duration extended to 3 h postoperatively. Visual analog scale at rest and in movement was significantly higher in the Pecs group compared with the SIPB group. The number of patients who received postoperative fentanyl was significantly increased in the Pecs group than in the SIPB group. The first request for postoperative fentanyl was significantly delayed in the SIPB group than in the Pecs group. There was no significant difference in the total dose of fentanyl consumption during 24 h postoperatively between the two groups. Conclusion The present study found that SIPB provided superior postoperative analgesia compared with Pecs in patients undergoing nonreconstructive breast surgeries.

Morphine versus fentanyl patient-controlled analgesia for postoperative pain control in major hepatic resection surgeries including living liver donors: A retrospective study.

Background:Liver resection surgery results in significant postoperative pain. However, it is still not clear which opioids used by patient-controlled analgesia (PCA) provides the best pain control and results in the least side effect in a patient with impaired liver function. Our hypothesis was that fentanyl is a better choice than morphine as it is a potent analgesic that its elimination half-life does not depend on the hepatic uptake and metabolism.The Study Purpose:Is to compare morphine and fentanyl PCA in liver resection patients as regards the degree of pain control, the consumption of opioids, and the side effects.Methods:A retrospective case–control study of hepatic resection patients who received postoperative morphine (Morph) or fentanyl (Fent) PCA. The study compared the pain scores, the morphine equivalent dose (MED), the number of demands requested as recorded by the PCA infusion pump, and the side effects every 12 h for 48 h.Results:This study yielded 40 patients; with the majority were living donor hepatic resection patients. There was no significant difference in the pain scores. However, the MED and the demands were significantly less in the Morph group. The P < 0.000, 0.0001, 0.0005, and 0.003, demands P < 0.002, 0.006, 0.014, and 0.013 at 12, 24, 48, and 36 h, respectively. The overall side effects were not different between the 2 groups at all time intervals measured; however, Morph patients were significantly more sedated in the first 12 h. There was one case of respiratory depression in the Morph group compared to two cases in the in the Fent group that needed treatment with naloxone.Conclusions:Although both groups had adequate pain control. The Morphine group reached faster pain control with less MED and PCA requests in liver resection patients, although it was more sedating in the first 12 h. However, fentanyl patients were less sedated; both drugs need close monitoring in the immediate postoperative period due to reported respiratory depressive effect and the need to use naloxone. The dosage of the PCA settings needs to be studied further to reach to the best dose with a reduced side effect. Further studies are recommended to reduce PCA dosages by introducing a multimodal approach of pain management relying on other methods with no additional sedative effects as regional anterior abdominal blocks.

Continuous Perioperative Thoracic Epidural Fentanyl-Bupivacaine Infusion vs. Continuous Perioperative Fentanyl Intravenous Infusion in Patients Undergoing Major Upper Abdominal Cancer Surgeries

Background: Major upper gastrointestinal cancer surgeries induce postoperative pain, that if not controlled may cause various organ dysfunctions and prolonged hospital and ICU stay. Thus an appropriate pain therapy to those patients must be applicated. Objective: To compares the effects of continuous perioperative thoracic epidural Fentanyl-bupivacaine infusion versus continuous perioperative Fentanyl intravenous infusion in patients undergoing major upper gastrointestinal cancer surgery. Methods: 60 patients (ASA II) of either sex were scheduled for elective upper gastrointestinal cancer surgeries. Patients were allocated randomly into two groups (30 patients each) to receive: continuous peri-operative epidural infusion with bupivacaine 0.132 and fentanyl (TEA group), or continuous peri-operative intravenous infusion with fentanyl (control group). Postoperative pain was assessed over 72 h using visual analogue scale (VAS). The intra and post-operative haemodynamic, sedation score and overall patient fentanyl consumption were recorded. Any concomitant events like nausea; vomiting, pruritus or respiratory complications were recorded postoperatively. Results: There was a significant decrease in pain sensation in TEA group during first day postoperative. Patient haemodynamics was significantly decreased in TEA group. As regard sedation scale, patients of the TEA group were significantly less sedated than control group at immediate postoperative only. Conclusion: Continuous perioperative thoracic epidural Fentanyl-bupivacaine infusion was much better in pain relief, less sedating effect and shorter duration of hospital and ICU stay than continuous perioperative fentanyl intravenous infusion in patients undergoing major upper gastrointestinal cancer surgery.

Intravenous lidocaine infusions for 48 hours in open colorectal surgery: a prospective, randomized, double-blinded, placebo-controlled trial.

BackgroundAlthough intravenous (i.v.) lidocaine is used as a perioperative analgesic in abdominal surgery, evidence of efficacy is limited. The infusion dose and duration remain unclear. This study aimed to investigate the effect of a longer low-dose 48-hour infusion regimen on these outcomes.MethodsFifty-eight adults undergoing elective open colorectal surgery were randomized into the lidocaine group (1.5 mg/kg bolus followed by 1 mg/kg/h infusion for 48 hours) and control group. After surgery, patients were given a fentanyl patient-controlled analgesia machine and time to first bowel movement (primary outcome) and flatus were recorded. Postoperative pain scores and fentanyl consumption were assessed for 72 hours.ResultsThere was no significant difference in time to first bowel movement (80.1 ± 42.2 vs. 82.5 ± 40.4 hours; P = 0.830), time to first flatus (64.7 ± 38.5 vs. 70.0 ± 31.2 hours; P = 0.568), length of hospital stay (9 [8–13] vs. 11 [9–14) days; P = 0.531], nor postoperative pain scores in the lidocaine vs. control groups. Cumulative opioid consumption was significantly lower in the lidocaine vs. the control group from 24 hours onwards. At 72 hours, cumulative opioid consumption (µg fentanyl) in the lidocaine group (1,570 [825–3,587]) was over 40% lower than in the placebo group (2,730 [1,778–5,327]; P = 0.039).ConclusionsA 48-hour low-dose i.v. lidocaine infusion does not significantly speed the return of bowel function in patients undergoing elective open colorectal surgery. It was associated with reduced postoperative opioid consumption, but not with earlier hospital discharge, or lower pain scores.

Peri-operative Rectus Sheath Fentanyl-levobupivacaine Infusion vs. Thoracic Epidural Fentanyl Levobupvacaine Infusion in Patients Undergoing Major Abdominal Cancer Surgeries with Medline Incision

Background and Objectives: The gold standard for acute postoperative pain management in major abdominal surgeries is thoracic epidural analgesia (TEA) and this was proved by a lot of studies, systematic reviews and metaanalyses. However, TEA is sometimes contraindicated and may cause serious risks. Rectus Sheath Block (RSB) is effective for the abdominal surgeries with midline abdominal incisions as local anesthetics will be injected within the posterior rectus sheath bilaterally leading to intense pain relief for the middle anterior wall extending from the xiphoid process to the symphysis pubis. The aim of the study was to assess intra and post-operative RSB versus intra and post-operative TEA, in patients undergoing elective major abdominal cancer surgery with midline incisions. Methods: This randomized, blinded, was registered at www.clinicaltrials.gov at no.: “NCT03460561” and was approved by local ethics committee of South Egypt Cancer Institute, Assiut University, Egypt. One hundred adult patients, (ASA grade II and III), scheduled for major elective abdominal cancer surgery with Medline incision, were randomly divided into two groups, (50 patients each); TEA group: patients in this group received TEA with standard GA and intra-operative analgesia was started before skin incision by injecting epidural bolus dose of 0.1 ml/kg of (0.125% levo-bupivacaine+fentanyl 2 μg/ml). Postoperative analgesia was provided through PCEA by injecting a bolus dose of 3 ml then continuous infusion of 0.1 ml/kg of mixture of (0.0625% levo-bupivacaine+fentanyl 2 μg/ml) for 48 hours postoperative. RSB group: patients in this group received standard GA plus ultrasound (U/S) guided rectus sheath block by a volume of 20 mL of (0.25% levo-bupivacaine+fentanyl 30 μg) in saline on either side. Before end of surgery and before closure of abdominal wall, bilateral surgically placed catheters in rectus sheath plane aiming to provide post-operative analgesia using the following; 20 mL of (0.125% levo-bupivicaine+Fentanyl 30 μg) every 12 hours in to each catheter for 48 hours. Perioperative hemodynamics (MAP and HR) were recorded. Postoperative pain was assessed over 48 hour post operatively using (VAS). Total fentanyl consumption, Peak expiratory flow rate (PEFR), postoperative and side effects of the drugs and duration of ICU and hospital stay were recorded. Results: We found a significant reduction in VAS pain scores (at rest and during cough) in both group at all postoperative period but fentanyl consumption was significantly lower in TEA group. Also we found a significant reduction in intra-operative hemodynamics (mean arterial pressure and heart rate) in TEA group in comparison to RSB group while there was minimal statistically significant reduction in postoperative MAP and heart rate. The incidence of other postoperative complications such as sedation, nausea and vomiting were comparable in both groups. Conclusion: Rectus sheath block was not inferior to thoracic epidural analgesia in reduction of pain intensity after major abdominal cancer surgeries, and associated with hemodynamic stability along the 48 hours postoperative without procedure related adverse events or decreasing PEFR.