Postoperative pain management following minimally invasive abdominal cancer surgeries -An audit.

BACKGROUND: There is limited data comparing pain management following various minimally invasive oncological surgeries (MIOS). This retrospective audit was planned to determine the severity of pain and to study the analgesic modalities offered to these patients. Secondary objectives included studying opioid requirements, non-opioid analgesics, their side effects, and the influence of comorbidities on the choice of pain modalities. METHODS: Following approval and registration of trial (CTRI/2018/10/016220), data were collected retrospectively from adult patients who underwent elective MIOS for abdominal tumors from August 2017 to July 2018. Pain scores (PS) on the day of surgery, and the average, worst PS, and the morphine equivalent (ME) dose in the perioperative period was recorded. Emergency surgeries and thoracic-abdominal MIOS were excluded. The association between the type of surgery, pain modalities, and PS were compared using Chi-square test. ME dose consumption of patients and type of surgery were compared using ANOVA with Bonferroni's correction. RESULTS: Out of the 349 patients' data that were analyzed, 76% had mild, 22% had moderate, and 2% had severe pain after surgery. Port site infiltration was done in 27% of cases and epidural analgesia in 46 patients (13%). PS and opioid consumption (ME = 5.7 ± 5.2 mg) was significantly higher following pelvic surgeries when compared to other urological and diagnostic MIOS. American Society of Anesthesiologists Physical Status did not affect PS or choice of pain management technique. CONCLUSION: Most of the patients experience mild pain at movement in the immediate postoperative period, pelvic MIOS (abdominoperineal resection/exenteration surgeries) have higher PS and opioid consumption than other MIOS.

Predicting clinical entry point for thoracic epidural catheter insertion during paramedian approach: A prospective observational study.

Background and Aims: Thoracic epidural insertion has high failure rates in the mid-thoracic region due to steep angulation of oblique bending of spinous processes. The preferred skin puncture point for epidural needle insertion in the paramedian sagittal plane with respect to the superior/inferior tip of spinous process or inter-spinous cleft in the mid-thoracic region (T5-8) is not standard. The primary objective of this prospective observational study was to find the skin puncture point which had the best success rate for a successful epidural catheterization. Secondary objectives were to study the number of attempts and passes required to locate epidural space, incidence of failed epidural, and its relationship with patient characteristics and demographics. Material and Methods: After informed consent, 155 patients planned for general anesthesia with epidural analgesia in the mid-thoracic region were included in the trial. Patient demographics, the details of epidural attempts with respect to anatomical landmarks, distance from the midline, and number of passes in each attempt were noted. Epidural catheterization was considered successful after demonstrating dermatomal band of sensory blockade. Results: The success rate at different skin puncture sites was not statistically significant (P = 0.58). We found a failure rate of 12.9%. Failed epidural catheterization was significantly high in the age group >56 years (n = 62 and P = 0.007). Conclusion: In our study, none of the skin puncture points had a significant association with successful epidural insertion in mid-thoracic segments using a para-median approach.

Correction to: Audit of Pain Management After Colorectal Surgeries in a Tertiary Care Cancer Hospital.

[This corrects the article DOI: 10.1007/s13193-023-01865-y.].

Audit of Pain Management After Colorectal Surgeries in a Tertiary Care Cancer Hospital.

Surgery for gastrointestinal malignancy is associated with severe post-operative pain, which if inadequately treated, can lead to pulmonary complications and, in addition, delayed mobilization leading to delayed recovery and discharge. We audited our practices looking at the various pain modalities used and their effects on the post-operative recovery in colorectal surgeries, in a tertiary care cancer centre during the era of ERAS. The primary aim of the study was to assess the average pain score on movement in the first 72 h of post-operative period among patients. The secondary aim was to study the various modalities of pain management used and complications, perioperative vasopressor requirement, post-operative resumption of enteral feeding, ambulation, duration of hospital stay, duration of ICU/HDU stay, and worst pain scores in the first 72 h. We analyzed a total of 174 patients who underwent colorectal surgeries for the period of 1 year from 1st January 2018 till 31st December 2018. Out of the 174 patients, 86 (49.4%) patients received epidural analgesia and 88 (50.6%) patients who did not receive epidural analgesia, belong to the non-epidural group. Average pain scores on movement at 72 h in the epidural group was 2 [2, 3] and 2 [1, 2] in the non-epidural group (p < 0.001). Worst pain score at post-operative 72 h in epidural group was 3 [3, 4] and 3 [2, 4] in the non-epidural group (p = 0.016). In conclusion, we conclude, that the analgesic efficacy of epidural analgesia was not found to be superior in our study in patients undergoing major colorectal surgeries.

Analgesic efficacy of the inferior alveolar nerve block for maxillofacial cancer surgery under general anaesthesia - A randomised controlled study.

Background and Aims: Mandibular resection during maxillofacial cancer surgery evokes a strong sympathetic response requiring high doses of opioids. We studied the effect of the inferior alveolar nerve block (IANB) for analgesia in maxillofacial cancer surgeries. Methods: This randomised controlled study was conducted over five months in a tertiary care cancer hospital following Institutional Ethics approval and trial registration. Fifty consenting adult patients belonging to the American Society of Anesthesiologists (ASA) physical status I and II requiring maxillofacial cancer surgery with unilateral mandibular resection were recruited. Twenty-five patients in the study arm received ipsilateral IANB; a mock injection was given to the control group. Fentanyl requirement and haemodynamic parameters during primary tumour excision were the primary and secondary endpoints. Student's t-test was applied to compare primary and secondary endpoints. Results: Forty-nine patients completed the study. Both arms were comparable with respect to age, gender distribution, ASA physical status and baseline heart rate (HR) and blood pressure (BP). The mean (standard deviation) intravenous fentanyl requirement during primary tumour excision in the IANB arm was 70(32) µg, significantly lower than 183(48) µg in the control arm, P < 0.001. The mean maximum HR during primary tumour excision was 82 and 99 per minute in the IANB and control arms, respectively (P < 0.001) whereas the maximum mean BP was 88 and 101 mm Hg, respectively (P < 0.001). Conclusion: IANB significantly reduced intraoperative fentanyl requirement and caused fewer haemodynamic changes during maxillofacial cancer surgery requiring unilateral mandibular excision.

Predicting postoperative pain by using preoperative pain threshold in response to electrical stimulus in women undergoing gynaecological cancer surgery - Single-arm, prospective, observational study.

Background and Aims: Individual variability leading to different pain experiences makes pain prediction challenging. This study aimed to evaluate whether preoperative electrical pain threshold testing is predictive of postoperative pain. Methods: Following ethics committee approval and registration of the trial, 40 consenting patients undergoing open laparotomy (interval debulking surgery) for ovarian cancer were included in the study. Electrical stimulus (maximum of 256 µA) was used preoperatively to determine the current perception threshold (CPT) and pain equivalent current (PEC). A numerical rating scale (NRS; 0-10, with 0 indicating no pain and 10 indicating severe pain) was used to assess pain. All patients received intravenous paracetamol in accordance to body weight, diclofenac (1 mg/kg, maximum 50 mg), and tramadol (1 mg/kg, maximum 50 mg) eight hourly for 24 hours. The preoperative PEC was compared with worst pain score (PS) at movement at the end of 24 hours. PEC was also compared with average PS at rest, at movement, and with opioid requirement (24 hours). Results: The median values of CPT and PEC were 12.51 (45 [10.1-14.6]) µA and 94.75 (174 [48.8-94.7]) µA, respectively. A moderate correlation was observed between PEC and worst PS (P = 0.01, r = -0.402), with patients having PEC less than 60 µA being associated with moderate-to-severe PS. There was no correlation between PEC and average PS at rest (P = 0.16, r = 0.225), at movement (P = 0.46, r = 0.119), and the postoperative opioid consumption in the first 24 hours (P = 0.50, r = -0.110). Conclusion: There is a moderate association between preoperative pain threshold in response to electrical stimulus and worst PS in the postoperative period following interval debulking surgery for ovarian cancer.

Role of gabapentinoids in post-operative pain management in thoracic surgeries: A single-centre propensity score-matched audit.

Background and Aims: The analgesic role of gabapentinoids following thoracic surgeries is not clear. In this study, we evaluated the benefits of gabapentinoids for pain management in patients undergoing thoracic onco-surgery in terms of opioids and non-steroidal anti-inflammatory drugs (NSAIDs) sparing effect. We also compared pain scores (PSs), number of days of active surveillance by the acute pain service team, and side effects associated with gabapentinoids. Methods: After ethics-committee approval, data were retrieved retrospectively from clinical sheets, an electronic database, and nurses' charts from a tertiary cancer care hospital. Propensity score matching was performed for six covariates, that is, age, gender, American Society of Anesthesiologists grading, surgical approach, analgesia modality, and worst PS in the first 24 hours performed. A total of 272 patients were grouped into group N (not given gabapentinoids, n = 174) and group Y (given, n = 98). Results: The median opioid consumption in terms of fentanyl equivalent by group N was 800 µg [inter-quartile range (IQR): 280-900], and the median opioid consumption by group Y was 400 µg (IQR: 100-690) (p = 0.001). The median number of rescue doses of NSAIDs administered to group N was 8 (IQR = 4-10), and the median number of rescue doses to group Y was 3 (IQR = 2-5) (p = 0.001). No difference was found in subsequent PS and for the number of days under acute pain service surveillance for either group. Group Y had an increased incidence of giddiness compared to group N (p = 0.006), with a relative reduction in post-operative nausea and vomiting scores (p = 0.32). Conclusion: Gabapentinoids used following thoracic onco-surgeries result in a significant reduction in concomitant use of NSAIDs and opioids. There is an increased incidence of dizziness with the use of these drugs.

Inkk Trial - Intraoperative ketamine for perioperative pain management following total knee endoprosthetic replacement in oncology: a double-blinded randomized trial

Abstract Background There has been a growing interest in the use of ketamine following orthopedic surgeries. We hypothesized that low dose intravenous ketamine during surgery would help in mobilization following total knee replacement (TKR) in oncology patients as assessed by the timed to up and go (TUG) test at 72 hours post-surgery. Our secondary objectives were to compare the opioid requirement at the end of 72 hours, pain scores, satisfaction with pain management, adverse effects, range of joint movement achieved in the post-operative period and the functional recovery at the end of 1 month. Methods After the ethics commitee approval, registration of the trial with the Clinical Trial Registry - India (CTRI), and informed consent, this double-blinded trial was conducted. Using computer generated randomization chart, an independent team randomized the patients into ketamine group which received at induction, a ketamine bolus dose of 0.5 mg.kg-1 before the incision followed by 10 µg.kg-1min-1 infusion which was maintained intraoperatively till skin closure and the saline group received an equivalent volume of saline. Postoperatively, patient controlled morphine pumps were attached and the pain score with morphine usage were recorded for 72 hours. The TUG tests and range of motion were assessed by the physiotherapists until 72 hours. Results Fifty-two patients were enrolled in the trial. Demographics were comparable. No significant intraoperative hemodynamic changes and post-operative adverse events were noted between the groups. A decrease in the TUG test, along with decreased opioid usage with a better range of movements was noted in the ketamine group, but this was not statistically significant. Day of discharge, patient satisfaction score, and functional recovery assessed by Oxford Knee Score (OKS) were comparable between the groups. Conclusion In conclusion, low dose intraoperative ketamine infusion does not provide clinical benefit in perioperative pain management and postoperative rehabilitation following total knee endoprosthetic replacement in oncology.

Inkk Trial .Çô Intraoperative ketamine for perioperative pain management following total knee endoprosthetic replacement in oncology: a double-blinded randomized trial.

BACKGROUND: There has been a growing interest in the use of ketamine following orthopedic surgeries. We hypothesized that low dose intravenous ketamine during surgery would help in mobilization following total knee replacement (TKR) in oncology patients as assessed by the timed to up and go (TUG) test at 72.áhours post-surgery. Our secondary objectives were to compare the opioid requirement at the end of 72.áhours, pain scores, satisfaction with pain management, adverse effects, range of joint movement achieved in the post-operative period and the functional recovery at the end of 1 month. METHODS: After the ethics commitee approval, registration of the trial with the Clinical Trial Registry - India (CTRI), and informed consent, this double-blinded trial was conducted. Using computer generated randomization chart, an independent team randomized the patients into ketamine group which received at induction, a ketamine bolus dose of 0.5.ámg.kg-1 before the incision followed by 10.á..g.kg-1min-1 infusion which was maintained intraoperatively till skin closure and the saline group received an equivalent volume of saline. Postoperatively, patient controlled morphine pumps were attached and the pain score with morphine usage were recorded for 72.áhours. The TUG tests and range of motion were assessed by the physiotherapists until 72.áhours. RESULTS: Fifty-two patients were enrolled in the trial. Demographics were comparable. No significant intraoperative hemodynamic changes and post-operative adverse events were noted between the groups. A decrease in the TUG test, along with decreased opioid usage with a better range of movements was noted in the ketamine group, but this was not statistically significant. Day of discharge, patient satisfaction score, and functional recovery assessed by Oxford Knee Score (OKS) were comparable between the groups. CONCLUSION: In conclusion, low dose intraoperative ketamine infusion does not provide clinical benefit in perioperative pain management and postoperative rehabilitation following total knee endoprosthetic replacement in oncology.

Role of video-based learning on competency level of direct laryngoscopic skills of novice anaesthesiologists - A randomised clinical trial.

Background and Aims: Video laryngoscopes are often used for education and training of intubation skills. This study aimed to examine the influence of video-assisted guidance and video replay on intubation skills of novice anaesthesiologists. Methods: Adult patients of American Society of Anesthesiologists physical status grade I-II, with a normal airway and scheduled to undergo elective surgical procedures requiring general anaesthesia and orotracheal intubation were included in this randomised study. Ten trainee anaesthesiologists, with no prior experience of performing tracheal intubation were enroled and randomly divided into group STD (received traditional learning) and group VL (received video-based learning). After initial mannequin training, the first seven intubations in patients in both the groups were done under supervision. In group VL, in addition to traditional cues, posttracheal intubation, the trainee and instructor had a session of video replay to discuss the entire process of laryngoscopy and tracheal intubation with areas of improvement. For the subsequent 15 intubations in patients, the trainees intubated independently using a standard Macintosh blade. The primary objective was to compare time required to intubate (TTI) for both groups using Mann-Whitney U test. Secondary objectives included comparison of difficulty in intubation (using a 5-point Likert scale), self-confidence scores (1-10, 10 - most confident), and intubation-related trauma. Results: The mean TTI was significantly lower in group VL than in group STD - 40s [Interquartile range (IQR): 32-50] versus 52s [IQR: 39-76], P = 0.002. No difference was seen in self-assessed confidence levels, rating of difficulty in intubation, and airway trauma. Conclusion: Video replay of the intubation process has a positive impact on direct laryngoscopy learning.

"Prevalence of chronic pain following resection of pelvic bone tumours: A single centre prospective observational survey".

Background: Hemipelvectomy is a major surgery most often performed for pelvic malignancy. These complex surgeries often involve dissection around major neurovascular bundle and resection of tumour being bone along with involved tissues. This may result in short and long term morbidities. There is very little literature about incidence of chronic pain after pelvic resections. We conducted a prospective study at a tertiary cancer hospital to assess the prevalence of chronic pain post hemipelvectomy. Method: This is a single centre prospective observational study conducted over 30 months. Pain scores were recorded using Brief pain inventory (BPI) and pain detect questionnaire. The quality of life was assessed using musculoskeletal tumour society (MSTS) score. Intra-operative details like extent of surgical resection, nerves spared, details of intra-operative and post-operative analgesia were retrieved from the patient files. Data were analysed using SPSS 21 version. Results: Neuropathic pain post hemipelvectomy was uncommon. The prevalence of mild to moderate somatic pain was around 30%. Functional limitation was minimal as assessed by BPI and MSTS score. A high incidence of numbness was seen to persist in and around the area of surgical incision (50%). Conclusion: This is first study to report the incidence of chronic pain post hemipelvectomy done for pelvic tumour resections. Despite the extensive nature of resection involved, there is a low prevalence of neuropathic pain in this population. However, incidence of persistent somatic pain is high and there is a need for further studies for evaluating the causality.

Comparison of double lumen tube insertion using the McGrath MAC versus direct laryngoscopy in adult patients with a limited glottis view: A prospective interventional study.

Background and Aims: Passage of double-lumen tubes (DLT) can be challenging in patients with limited glottis view. This study aims to determine the usefulness of McGrath® MAC videolaryngoscope (VL) in cases with limited glottis view on direct laryngoscopy with Macintosh blade. Material and Methods: After study approval and registration of trial, consent was sought from all adult patients planned for elective DLT insertion for lung isolation during the course of general anesthesia. Patients not consenting, less than 18 years, with anticipated difficult mask ventilation or need for rapid sequence induction were excluded. Following routine anesthetic induction, laryngoscopy was attempted by an experienced anesthesiologist using Macintosh scope. If the view obtained was Cormack and Lehane (CL) view IIB and above or the attempt at intubation using DLT failed despite a CL I/IIA view, the patient was included in the trial. The laryngoscope was removed and after ensuring adequate oxygenation and depth of anesthesia, intubation was attempted using McGrath® MAC VL. The percentage of glottis opening (POGO) score was noted for both the scopes. Results: DLT insertion was attempted in 76 patients in the study period. Eight patients were included in the trial on account of limited glottis view/failure with Macintosh scope. Insertion of DLT with McGrath MAC was tried only in six patients, in two patients, the VL was not available for use. The mean (standard deviation) POGO score with Macintosh scope was 9 (±20), which significantly improved with the use of VL to 71 (±24), P = 0.01. Conclusion: McGrath MAC is helpful in inserting DLT in patients with limited glottis view with Macintosh scope.

Effect of patient information leaflet on working pattern and patient satisfaction level in a busy Indian day care operative theater complex.

BACKGROUND AND AIMS: In a day care setting, communication of preprocedure instructions prior to general anesthesia (GA) is critical. Verbal information may be inadequate at times leading to unnecessary rescheduling. The aim of the study is to evaluate the use of patient information leaflet (PIL) and its impact on rescheduling and patients' satisfaction levels. MATERIAL AND METHODS: Adult ASA I-III patients scheduled for elective day care Head Neck procedures such as direct laryngoscopy, examination under anesthesia, and biopsy under GA were recruited. In the outpatient department (OPD), the attending surgeons verbally instructed the patients as well as handed them the PIL. The process was streamlined over a month and thereafter patients' satisfaction levels and rescheduling rates were captured over 2 months. This was compared to the data from the pre-PIL phase. RESULT: Prior to PIL, 12% cases were rescheduled due to avoidable causes. After introducing of the PIL, only 8% case were rescheduled (P = 0.02). There was a significant improvement seen in patient satisfaction with 89% patients reporting that the PIL was good or better while 77% were willing to recommend it to the others. CONCLUSION: PIL is an effective way of imparting perioperative instructions to patients which will improve not only satisfaction but also reduce patient rescheduling. The institution is in the process of implementing PIL to provide instructions to patient posted for day care procedures.

Preparation, validation, and evaluation of an information leaflet for patients undergoing day-care surgeries under general anesthesia at a busy tertiary care hospital.

BACKGROUND AND AIMS: It is essential that patients posted for day-care surgeries are adequately prepared preoperatively. Verbal information alone may not be always effective. This study aimed to prepare, validate, and evaluate the efficacy of a patient information leaflet (PIL) for patients undergoing day-care surgeries under general anesthesia (GA). MATERIAL AND METHODS: After approval from the hospital ethics committee a PIL was prepared in English. Readability and design of the leaflet were checked using standard tests: Flesch readability ease test (FRE), Flesch Kincaid grade level (FKGL), and Baker Able leaflet design (BALD). It was translated into three regional languages. The PIL was tested among patients using a questionnaire. Seventy-nine adult patients posted for elective day-care procedures were included while emergency surgeries were excluded. Patient knowledge pre and post-PIL was compared using paired 't' test. The influence of age, gender, and education level on the usefulness of PIL were analyzed using the Chi-square test and knowledge was compared using ANOVA. RESULTS: The English leaflet had an FRE Score of 63.9 and FKGL of 6.4, which is "standard". The BALD score for all leaflets was 25 ("above standard"). The overall knowledge scores significantly improved from 52.6% (preintervention) to 70.7% (postintervention), P < 0.001. Knowledge improvement was seen with the use of PIL in all four languages. Sixty eight percent of patients strongly recommended the PIL while 31% were willing to recommend it to others. CONCLUSION: The PILs developed in this study have standard readability, good design and validated for efficacy.

Influence of interpretation of pain scores on patients' perception of pain: A prospective study.

BACKGROUND AND AIMS: Assessment of pain using pain scales is essential. In the Numeric Rating Scale (NRS), patients are asked to score their pain intensity on a scale from 0 to 10 (10- worst pain). This requires some abstract thinking by the patient, also the pain scores (PS) may not essentially communicate the patients' need for more analgesia. We planned a study to evaluate the change in patients' self-assessed PS after understanding clinical interpretation of the NRS. METHODS: This prospective study was registered after approval from our hospital ethics board. Sample size estimated for the trial was 360 patients. All postoperative patients were recruited after informed consent. Patients having prolonged stay in Intensive Care Unit (more than 48 h), or those who underwent emergency surgeries were excluded. During Acute Pain Service (APS) rounds, patients were asked to rate their PS on the NRS. This was followed by a briefing about the clinical interpretation of the scale, and the patients were asked to re score their pain using the same scale. The change in pain severity was compared using Chi-square test. RESULTS: Following explanation, a change in severity was seen for PS at rest [X 2 (9, N- 360) = 441, P < 0.001] and at movement [X2 (9, N- 360) = 508, P < 0.001]. Overall, a change in PS severity was seen in 162 patients (45%). A decrease and an increase in the severity of pain was seen in 119 and 41 patients respectively. CONCLUSION: Explaining the clinical interpretation of PS on a NRS does lead to a change in patients' self-assessed PS.

A randomised controlled trial to evaluate the peri-operative role of intraoperative dexmedetomidine infusion in robotic-assisted laparoscopic oncosurgeries.

BACKGROUND: Robotic and minimal invasive surgeries pose challenges to the anaesthesiologists. Dexmedetomidine (dexmed), with distinct properties of sedation and analgesia has emerged as a promising drug. Our primary aim, in this double-blinded study, was to evaluate reduction in the intraoperative opioid requirement with the use of intravenous dexmed infusion. Secondary objectives included effect on intraoperative anaesthetic and postoperative analgesic requirement. METHODOLOGY: After approval from Ethics board and registration of the trial, 46 eligible patients planned for robotic oncosurgeries (abdomen) were included. As per computer generated randomisation chart, patients were randomised into either dexmed or saline group. Five minutes after insufflation of the abdomen, the study drug bolus-saline or dexmed (1 µg/kg) was given over 10 min and was followed by maintenance infusion (0.2 µg/kg/h) until release of pneumoperitoneum. Study drug titration, fentanyl boluses, and changes in minimum alveolar concentration (MAC) of inhalational agent were protocolised. RESULTS: The mean intraoperative fentanyl requirement was significantly lower in the dexmed group 192.6 µg (±66.4) versus the saline group 260.7 µg (±88.6), P = 0.013. The MAC requirement of inhalational agent was significantly lower in the dexmed group. Intraoperative episodes of hypotension and bradycardia were similar in both groups. First analgesic request, 24 h postoperative pain scores and side effects profile were comparable in both groups. CONCLUSION: Intraoperative dexmed (bolus of 1 µg/kg followed by 0.2 µg/kg/h infusion) has an opioid and inhalational anaesthetic sparing role during robotic oncosurgeries. However, no benefit of the infusion is seen in the postoperative period.