European Journal of Anaesthesiology最新文献

Laparoscopic cholecystectomy can be associated with significant postoperative pain that is difficult to treat. We aimed to evaluate the available literature and develop updated recommendations for optimal pain management after laparoscopic cholecystectomy. A systematic review was performed using the procedure-specific postoperative pain management (PROSPECT) methodology. Randomised controlled trials and systematic reviews published in the English language from August 2017 to December 2022 assessing postoperative pain after laparoscopic cholecystectomy using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases. From 589 full text articles, 157 randomised controlled trials and 31 systematic reviews met the inclusion criteria. Paracetamol combined with NSAIDs or cyclo-oxygenase-2 inhibitors should be given either pre-operatively or intra-operatively, unless contraindicated. In addition, intra-operative intravenous (i.v.) dexamethasone, port-site wound infiltration or intraperitoneal local anaesthetic instillation are recommended, with opioids used for rescue analgesia. As a second-line regional technique, the erector spinae plane block or transversus abdominis plane block may be reserved for patients with a heightened risk of postoperative pain. Three-port laparoscopy, a low-pressure pneumoperitoneum, umbilical port extraction, active aspiration of the pneumoperitoneum and saline irrigation are recommended technical aspects of the operative procedure. The following interventions are not recommended due to limited or no evidence on improved pain scores: single port or mini-port techniques, routine drainage, low flow insufflation, natural orifice transluminal endoscopic surgery (NOTES), infra-umbilical incision, i.v. clonidine, nefopam and regional techniques such as quadratus lumborum block or rectus sheath block. Several interventions provided better pain scores but are not recommended due to risk of side effects: spinal or epidural anaesthesia, gabapentinoids, i.v. lidocaine, i.v. ketamine and i.v. dexmedetomidine.

Background: Catheter-related bladder discomfort (CRBD) is problematic in patients with a urinary catheter. Transcutaneous electrical nerve stimulation (TENS) is a non-invasive analgesic modality used to relieve various types of pain.

Objectives: We evaluated the effect of TENS on CRBD after transurethral resection of bladder tumours (TURBT).

Design: A randomised controlled trial.

Setting: A large university tertiary hospital, from October 2022 to March 2023.

Patients: Patients requiring urinary catheterisation after TURBT.

Intervention: In this randomised controlled trial, patients were randomly allocated to the TENS ( n   =  56) or control ( n   =  56) groups. CRBD manifests as a burning sensation with an urge to void or discomfort in the suprapubic area. Moderate to severe CRBD was defined as patients self-reporting CRBD symptoms with or without behavioural response, including attempts to remove the urinary catheter, intense verbal reactions, and flailing limbs. TENS was performed from the end of surgery to 1 h postoperatively.

Main outcome measure: The primary endpoint was considered moderate to severe CRBD immediately postoperatively. Secondary endpoints included moderate to severe CRBD at 1, 2 and 6 h postoperatively. Additionally, postoperative pain, patient satisfaction, and TENS-related adverse effects were evaluated.

Results: Moderate to severe CRBD immediately postoperatively was significantly less frequent in the TENS group than in the control group: 10 (17.9%) vs. 34 (60.7%); P  < 0.001; relative risk (95% CI) = 0.294 (0.161 to 0.536); absolute risk reduction = 0.43; number needed to treat = 2.3. Moderate to severe CRBD differed between the two groups at 1 h postoperatively: 1 (1.8%) vs. 16 (28.6%); P  < 0.001; relative risk = 0.06 (95% CI 0.01 to 0.46); absolute risk reduction = 0.27; number needed to treat = 3.7. The TENS group exhibited a significantly lower score for postoperative pain at 1 h (1.8 ± 0.6 vs. 2.2 ± 0.4; P  < 0.001, mean difference (95% CI) = 0.4 (0.2 to 0.6) and a higher score for patient satisfaction, 5.0 (4.0 to 6.0) vs. 3.0 (3.0 to 4.0); P  < 0.001; median difference (95% CI) = 2.0 (1.0 to 2.0).

Conclusions: TENS reduced moderate to severe CRBD, decreased postoperative pain, and increased patient satisfaction after TURBT.

Clinical trial registry: Clinical Research Information Service (KCT0007450).

Background: The administration of intravenous lidocaine during the peri-operative period may improve pain management after paediatric surgery.

Objective: To explore the decrease in postoperative pain intensity and opioid consumption associated with peri-operative lidocaine administration in the paediatric population.

Design: A systematic review with meta-analysis of randomised controlled trials and a Grading of Recommendations Assessment, Development and Evaluation (GRADE) analysis.

Data sources: Extensive literature review.

Eligibility criteria: This study includes clinical trials conducted during surgery that examined the effect of intravenous lidocaine compared with placebo on postoperative pain management.

Results: Lidocaine administration decreased pain intensity in PACU (standardised mean difference (SMD) = -1.89 [-3.75, -0.03], I2  = 97%, P of I2  < 0.001) and on postoperative day 1 (SMD = -2.02 [-3.37, -0.66], I2  = 96%, P of I2  < 0.001, number of studies = 5). Lidocaine was associated with a decrease in opioid consumption on postoperative day 1 (SMD = -1.2 [-2.19, -0.2], I2  = 93%, P of I2  < 0.001) but not on postoperative day 2 (SMD = -1.73 [-3.9, 0.44], I2  = 96%, P of I2  < 0.001). GRADE analyses resulted in low-quality results. Subgroup analyses revealed that pain intensity in PACU and opioid consumption on postoperative day 1 decreased when lidocaine was administered during both the intra-operative and postoperative periods.

Conclusions: The use of lidocaine is associated with improved pain management. However, further studies are needed to increase the level of evidence and determine the optimal administration regimen for pain management.

Background: Caesarean section is a widely performed surgical procedure that often results in moderate-to-severe postoperative pain. If left untreated, this pain can lead to short-term and long-term consequences. Transversalis fascia plane (TFP) block and transversus abdominis plane (TAP) block are among the regional anaesthesia techniques employed for managing pain after a caesarean section.

Objective: We aimed to compare the impact of these two blocks on the quality of recovery in patients undergoing elective caesarean section under spinal anaesthesia.

Design: A single-centre, double-blind, randomised trial.

Settings: Operating room, postanaesthesia recovery unit, and ward in a tertiary hospital.

Participants: Ninety-three patients (ASA 2 to 3) were recruited. After exclusion, 79 patients were included in the final analysis: 40 in the TFP block group and 39 in the TAP block group.

Interventions: After surgery, participants received either TFP block (20 ml 0.25% bupivacaine for each side) or TAP block (20 ml 0.25% bupivacaine for each side).

Main outcome measures: The primary outcome was the difference in obstetric quality of recovery 11-Turkish (ObsQoR-11T) scores between groups. Secondary outcomes included pain scores, opioid consumption and incidence of opioid-related complications.

Results: The mean ObsQoR-11T score was higher in the TFP block group compared with the TAP block group (97.13 ± 6.67 points vs. 87.10 ± 9.84 points, respectively; P  < 0.001). The pain scores in the TFP block group were slightly lower between postoperative 4 and 24 h. The mean total morphine consumption was 15.08 ± 2.21 mg in the TFP block group and 22.21 ± 3.04 mg in the TAP block group ( P  < 0.001). More patients required rescue analgesia between 4 and 8 h in the TAP block group [2.00 (5.00%) vs. 9.00 (23.08%), P  = 0.02]. No significant differences were observed between groups in terms of opioid-related side effects.

Conclusion: TFP block used for analgesic purposes yielded a better quality recovery period than TAP block and also reduced opioid consumption.

Trial registration: Clinicaltrials.gov (NCT05999981).

Visual abstract: http://links.lww.com/EJA/B6 .