Abstract:Background
Opioid‐induced hyperalgesia is a state of nociceptive sensitisation secondary to opioid administration. The objective of this meta‐analysis was to test the hypothesis that high‐dose intraoperative opioids contribute to increased post‐operative pain and hyperalgesia when compared with a low‐dose regimen in patients under general anaesthesia.
Methods
We followed the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses statement guidelines and rated the certainty of evidence with the Grad… Show more
“…Seventhly, we recognise that the risk of remifentanil administered to patients operated on under general anaesthesia might result in postoperative opioid induced hyperalgesia, although the clinical effect is debateable. 42 43 Eighthly, we did not systematically involve patients or patient unions in the construction of the trial and trial protocol, which might have improved the choice of trial outcomes. Ninthly, the pragmatic design might introduce a small difference in how each patient was treated, from the type of operation to the way in which rehabilitation at the ward was handled.…”
Objective
To investigate the effects of one and two doses of intravenous dexamethasone in patients after total knee arthroplasty.
Design
Randomised, blinded, placebo controlled trial with follow-up at 90 days.
Setting
Five Danish hospitals, September 2018 to March 2020.
Participants
485 adult participants undergoing total knee arthroplasty.
Intervention
A computer generated randomised sequence stratified for site was used to allocate participants to one of three groups: DX1 (dexamethasone (24 mg)+placebo); DX2 (dexamethasone (24 mg)+dexamethasone (24 mg)); or placebo (placebo+placebo). The intervention was given preoperatively and after 24 hours. Participants, investigators, and outcome assessors were blinded. All participants received paracetamol, ibuprofen, and local infiltration analgesia.
Main outcome measures
The primary outcome was total intravenous morphine consumption 0 to 48 hours postoperatively. Multiplicity adjusted threshold for statistical significance was P<0.017 and minimal important difference was 10 mg morphine. Secondary outcomes included postoperative pain.
Results
485 participants were randomised: 161 to DX1, 162 to DX2, and 162 to placebo. Data from 472 participants (97.3%) were included in the primary outcome analysis. The median (interquartile range) morphine consumptions at 0-48 hours were: DX1 37.9 mg (20.7 to 56.7); DX2 35.0 mg (20.6 to 52.0); and placebo 43.0 mg (28.7 to 64.0). Hodges-Lehmann median differences between groups were: −2.7 mg (98.3% confidence interval −9.3 to 3.7), P=0.30 between DX1 and DX2; 7.8 mg (0.7 to 14.7), P=0.008 between DX1 and placebo; and 10.7 mg (4.0 to 17.3), P<0.001 between DX2 and placebo. Postoperative pain was reduced at 24 hours with one dose, and at 48 hours with two doses, of dexamethasone.
Conclusion
Two doses of dexamethasone reduced morphine consumption during 48 hours after total knee arthroplasty and reduced postoperative pain.
Trial registration
Clinicaltrials.gov
NCT03506789
.
“…Seventhly, we recognise that the risk of remifentanil administered to patients operated on under general anaesthesia might result in postoperative opioid induced hyperalgesia, although the clinical effect is debateable. 42 43 Eighthly, we did not systematically involve patients or patient unions in the construction of the trial and trial protocol, which might have improved the choice of trial outcomes. Ninthly, the pragmatic design might introduce a small difference in how each patient was treated, from the type of operation to the way in which rehabilitation at the ward was handled.…”
Objective
To investigate the effects of one and two doses of intravenous dexamethasone in patients after total knee arthroplasty.
Design
Randomised, blinded, placebo controlled trial with follow-up at 90 days.
Setting
Five Danish hospitals, September 2018 to March 2020.
Participants
485 adult participants undergoing total knee arthroplasty.
Intervention
A computer generated randomised sequence stratified for site was used to allocate participants to one of three groups: DX1 (dexamethasone (24 mg)+placebo); DX2 (dexamethasone (24 mg)+dexamethasone (24 mg)); or placebo (placebo+placebo). The intervention was given preoperatively and after 24 hours. Participants, investigators, and outcome assessors were blinded. All participants received paracetamol, ibuprofen, and local infiltration analgesia.
Main outcome measures
The primary outcome was total intravenous morphine consumption 0 to 48 hours postoperatively. Multiplicity adjusted threshold for statistical significance was P<0.017 and minimal important difference was 10 mg morphine. Secondary outcomes included postoperative pain.
Results
485 participants were randomised: 161 to DX1, 162 to DX2, and 162 to placebo. Data from 472 participants (97.3%) were included in the primary outcome analysis. The median (interquartile range) morphine consumptions at 0-48 hours were: DX1 37.9 mg (20.7 to 56.7); DX2 35.0 mg (20.6 to 52.0); and placebo 43.0 mg (28.7 to 64.0). Hodges-Lehmann median differences between groups were: −2.7 mg (98.3% confidence interval −9.3 to 3.7), P=0.30 between DX1 and DX2; 7.8 mg (0.7 to 14.7), P=0.008 between DX1 and placebo; and 10.7 mg (4.0 to 17.3), P<0.001 between DX2 and placebo. Postoperative pain was reduced at 24 hours with one dose, and at 48 hours with two doses, of dexamethasone.
Conclusion
Two doses of dexamethasone reduced morphine consumption during 48 hours after total knee arthroplasty and reduced postoperative pain.
Trial registration
Clinicaltrials.gov
NCT03506789
.
“…Previous studies on this subject have been heterogeneous with small sample sizes, suggesting fragile and inconsistent benefits. Recent meta-analyses have suggested limited benefits pertaining to the incidence of postoperative pain, nausea, and vomiting [ 4 , 5 , 6 ]. The weaknesses and methodological limitations of these meta-analyses have been highlighted [ 3 , 7 ].…”
Opioid-free anesthesia (OFA) is used in surgery to avoid opioid-related side effects. However, uncertainty exists in the balance between OFA benefits and risks. We searched for randomized controlled trials (RCTs) comparing OFA to opioid-based anesthesia (OBA) in five international databases. The co-primary outcomes were postoperative acute pain and morphine consumption at 2, 24, and 48 h. The secondary outcomes were the incidence of postoperative chronic pain, hemodynamic tolerance, severe adverse effects, opioid-related adverse effects, and specific adverse effects related to substitution drugs. Overall, 33 RCTs including 2209 participants were assessed. At 2 h, the OFA groups had lower pain scores at rest MD (0.75 (−1.18; −0.32)), which did not definitively reach MCID. Less morphine was required in the OFA groups at 2 and 24 h, but with very small reductions: 1.61 mg (−2.69; −0.53) and −1.73 mg (p < 0.05), respectively, both not reaching MCID. The reduction in PONV in the OFA group in the PACU presented an RR of 0.46 (0.38, 0.56) and an RR of 0.34 (0.21; 0.56), respectively. Less sedation and shivering were observed in the OFA groups with an SMD of −0.81 (−1.05; −0.58) and an RR of 0.48 (0.33; 0.70), respectively. Quantitative analysis did not reveal differences between the hemodynamic outcomes, although severe side effects have been identified in the literature. No clinically significant benefits were observed with OFA in terms of pain and opioid use after surgery. A clear benefit of OFA use was observed with respect to a reduction in PONV. However, more data on the safe use of OFAs should be collected and caution should be taken in the development of OFA.
“…Intraoperative use of opioids at a high dose leads to an increase in morphine use in the first two postoperative hours. Moreover, it is believed to cause an increase in pain scores between postoperative 2 and 24 hours [ 20 ]. In our study, remifentanil was used intraoperatively in the control group and fentanyl consumption at the postoperative one hour was higher.…”
Objective: Erector spinae plane (ESP) block can be a method to be used for postoperative pain control in lumbar herniated disc operations. The aim of this study is to investigate the effect of erector spinae block in lumbar herniated disc operation on intraoperative and postoperative opioid consumption.Methods: Sixty patients scheduled for lumbar herniated disc surgery were included in the study. Patients were randomized into two groups: ESP block and control. Ultrasound-guided ESP block with 20 ml 0.25% bupivacaine at the bilateral L3 vertebral level was applied preoperatively to all patients in the ESP group. Patients in both groups were provided with intravenous patient-controlled analgesia (PCA) device containing fentanyl for postoperative analgesia. Fentanyl consumption and visual analogue scale (VAS) score were recorded at 15 min, 1, 6, 12, and 24 hours postoperatively.
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