Perioperative Pregabalin Reduces Pain And Analgesic Consumption Nursing Essay

1: 2nd Department of Anaesthesiology, University of Athens, Attikon Hospital, Athens, Greece

2: Department of Anaesthesiology, Sismanoglion Hospital, Athens, Greece

3: Department of Thoracic Surgery, Sismanoglion Hospital, Athens, Greece

4: Department of Anaesthesiology, Alexandra Hospital, Athens, Greece

*Corresponding author: Rimini 1, Haidari, 12462, Athens, Greece

[email protected]

Summary

Background:

Methods:

Results:

Conclusions:

up to 250 words.

The Results section should contain data. It is important that the results and conclusion given in the Abstract are the same as in the whole article, as the Abstract may be used, as it stands, by abstracting journals. Perioperative Pregabalin Reduces Pain And Analgesic Consumption Nursing Essay. References are not included in this section.

Keywords

Pain, Postoperative; hyperalgesia; allodynia; analgesics, pregabalin; analgesics, morphine; thoracotomy; anesthetics, local;

Thoracotomy is one of the surgical procedures associated with most severe acute postoperative pain and it has a high incidence of eliciting persistent postsurgical pain, often lasting months or years.1 2 Pain may be related to the scar but can be experienced anywhere in the chest and back. A neuropathic component has been shown in about 35–80% of cases3 4 including allodynia, dysaesthesia, and burning. In a large study, Pluijms and colleagues5 found that chronic pain was associated with duration and severity of immediate postoperative pain and extent of surgery. Effective block of neural afferents reduces acute post-thoracotomypain and may thereby blunt the developmentof pain memory.Perioperative Pregabalin Reduces Pain And Analgesic Consumption Nursing Essay.

Pregabalin and gabapentin have been effectively used to treat acute postoperative pain and reduce the incidence of chronic post-surgical pain.6 7 Conversely, gabapentin has not been of analgesic benefit in the setting of post-thoracotomy patients. A single 1200 mg dose of gabapentin has not been effective in treating post-thoracotomy shoulder pain.8 A preoperative dose of 600 mg of gabapentin did not reduce pain scores or parenteral or oral opioid consumption in the first 48 hours following elective thoracotomy and did not influence the frequency of pain at 3 months post-thoracotomy.9

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Pregabalin however has a more reliable pharmacokinetic profile (≥ 90% bioavailability of a single dose) and may have a more promising and effective role in the prevention of chronic postsurgical pain.10 11 Perioperative use of pregabalin has been shown to efficiently decrease the incidence of neuropathic pain after knee replacement surgery12 but not after hysterectomy.13 The use of perioperative pregabalin consistently reduces opioid analgesic requirements after surgery.10 11 14 Anecdotic use of pregabalin in post-thoracotomy patients has shown to be effective in treating intercostal neuralgia.15

Local anaesthetics have become increasingly popular for management of surgical pain.16 17 In addition to providing good analgesia, local anaesthetic wound infiltration is simple, safe and inexpensive. A systematic review found that continuous wound instillation was safe, effective in reducing pain scores and had opioid-sparing effects for most surgical subgroups.18 However, the benefit of this technique remains controversial after thoracicsurgery 19-21, mainly because of its limited use. Perioperative Pregabalin Reduces Pain And Analgesic Consumption Nursing Essay.

In this study we aimed to determine the efficacy of perioperative pregabalin, with or without the addition of a local anaesthetic continuous wound infusion in the control of postoperative pain and the prevention of chronic post-thoracotomy pain in patients undergoing a procedure requiring thoracotomy.

Methods

This randomised controlled double-blind study obtained approval from the Institutional Ethics Committee and Scientific Council of the Attikon Hospital. The clinicaltrials.gov registration number of the trial is NCT01726205. During the time period between October 2008 and May 2012, 45 eligible patients undergoing thoracotomy were consecutively enrolled in the study after written informed consent was obtained. Subsequently they were randomly allocated (with a computer generated list of random numbers) in one of three groups and received placebo drug and saline infusion (group PLCB), pregabalin and saline wound infusion (group PRG), or pregabalin and ropivacaine wound infusion (PRG + CWI).

Exclusion criteria from the study were age >70 years, BMI > 30, preexistent chronic pain, neurologic disease, alcohol or opioid abuse, preexisting treatment with analgesics, anxiolytics, sedatives, antidepressants, calcium channel inhibitors or any contraindication for the use of patient controlled analgesia (PCA). The placebo drug was manufactured identical in size and color to pregabalin in our hospital pharmacy. Perioperative Pregabalin Reduces Pain And Analgesic Consumption Nursing Essay. A hospital nurse, in charge of the study randomisation administered the medication to the patients. The medication (drug or placebo) was packed in sealed envelopes were only the patient number was visible and the name of the study. The same person prepared the postoperative wound infusions (normal saline or local anesthetic) and was not otherwise involved in the study.Patients were advised to assume pregabalin 75 mg (group PRG and PRG+CWI) or placebo (group PLCB) every 12 hours, starting the afternoon before surgery (8.00 pm) and continuing for the first five postoperative days.

Patients were not premedicated. Intraoperatively anaesthesia was induced with propofol (2-2.5 mg/kg) and fentanyl (5 μg/kg) and tracheal intubation was facilitated with cis-atracurium (0.15-0.20 mg/kg). Anaesthesia was maintained with sevoflurane in an O2/air mixture. All patients received the same anaesthetic drugs; however modifications in drug dosage were at the discretion of the anaesthesist in charge. A left double lumen tube was placed in all patients. Standard monitoring with invasive blood pressure measurement was applied in all patients. To monitor the depth of anaesthesia, a Bispectral Index (BIS) sensor was attached to the patient’s forehead and connected to a BIS monitor (BIS A-2000, Aspect Medical Systems Inc., USA). Thirty minutes before the end of surgery all patients received ondasetron 4 mg and paracetamol 1 gr intravenously. Before wound closure the surgeon placed a 20-gauge multi-orifice catheter (PAINfusor Catheter Baxter, France) just above the sutured lattisimus dorsi muscle layer. The catheter had a distribution length for local anesthetics of 15 cm.The catheter was attached to the postoperative infusion via an elastomeric pump (SV2 Infusor, Baxter, France) which distributed either normal saline or ropivacaine 0.75% for the first 48 hours postoperatively with a flow rate of 5 ml/hr. After this period the catheter was removed aseptically. Patient-controlled analgesia via a PCA device (RythmicTM Plus – Medical Devices, Greece) with morphine 1 mg/mL set at boluses of 1 mg each with a lockout period of 7 min was granted in all patients. Maximum morphine consumption at 4 h was set at 16 mg. In the third postoperative day (POD#3) the PCA device was discontinued and patients were transitioned to oral Lonalgal® tablets (paracetamol 500 mg and codeine 30 mg) (Boehringer Ingelheim, Germany) until POD#5. The tablets were given as needed for adequate pain control every time the patient complained of pain (VAS ≥30mm) up to a maximum of 4 tablets daily. Perioperative Pregabalin Reduces Pain And Analgesic Consumption Nursing Essay.

Pain levels were assessed at rest and during cough with a visual analogue scale (0-10 cm) together with potential side-effects such as sedation, nausea, vomiting, dizziness, postoperative headache, stipsis, urinary retention, vertigo, and blurred vision. Data were collected at 2, 4, 8 hours postoperatively and then each day from POD#1 to POD#5. Morphine consumption was collected via the device’s internal memory at the same time periods as VAS scores. Sedation levels were documented by using an in-house score (0, awake; 1, sleeping, but easily arousable; 2, sleeping, hardly arousable; 3, not arousable). At POD#5 a patient satisfaction score for the analgesic efficacy was also collected (1-insufficient, 2-sufficient, 3-good, 4-very good). Subsequently patients were interviewed at one and three months after surgery in a regular surgical visit or by telephone regarding the development of neuropathic pain and analgesic consumption. Clinical symptoms of neuropathic pain were assessed, using the self-report version of the Leeds Assessmentof Neuropathic Symptoms and Signs pain scale (S-LANSS), to determine the presence of neuropathic pain in the operated side at two time points (1 and 3 months respectively).22 These time points mark the transition from acute, late pain to chronic pain. S-LANSS is a validated, weighted 7-item assessment tool for neuropathic pain (yes/ no for each pain measure) with a maximum score of 24. Perioperative Pregabalin Reduces Pain And Analgesic Consumption Nursing Essay. The 7 variables included twoself-examination items: allodynia (painful sensation to gentle stroking of the affected area) and altered pin-prick threshold (very painful or blunt sensation to pin-prick in the affected area) and 5 pain symptoms: tingling, skin color change, sensitivity to touch, electric shocks, and burning.An S-LANSS score of 12 or more was an indication of chronic neuropathic pain. Patients who had persistent post-thoracotomy pain 3 months after surgery were referred to our ambulatory Pain Service for follow up.

Sample size calculation was based on the null hypothesis of no pain difference across all groups. Assuming a baseline pain intensity of 5 on a 0-10 VAS scale and a pain variance of 2.5 we calculated that a sample of 14 patients per group would provide an 80% chance of detecting a mean difference of 2 among treatment groups on a 0-10 scale. To account for three treatment groups we used the Bonferroni inequality to calculate sample size (where the level of significance is divided by the number of groups α/3 = 0.0167). We enrolled 15 patients per group to allow for dropouts.

Demographic, intraoperative and postoperative continuous data were analyzed with the Kruscal-Wallis test for k samples (a non parametric analysis of variance for data measured at one single point). If a significant result was found we performedpairwise comparisons with the Mann Whitney-U test.Nominaland ordinal data were analyzed using the Pearson’schi square test and confirmed with exact probability tests because of the small sample size. Perioperative Pregabalin Reduces Pain And Analgesic Consumption Nursing Essay.Repeated measures such as pain, morphine consumption, oral analgesics and sedation scores were analyzed using a linear mixed model with treatment, time and their interaction as fixed effects. If a significant result was obtained then the treatment groups were compared at each time point in pairwise comparisons.The Bonferroni correction was applied for multiple comparisons. Descriptive statistics are reported as mean and SD for continuous variables, median (range) for ordinal variables, and count and/or percentages (%) for dichotomous variables. Statistics were performed using the SPSS v17.0 (SPSS Inc, Chicago,USA).

Results

Forty-five patients completed the study. One patient from the pregabalin (PRG) group developed severe but transient diplopia during the second postoperative day and therefore pregabalin administration was discontinued. However this patient continued to receive opioid analgesia and postoperative data were collected and included in the analysis (intention to treat). Interestingly at our 1- and 3-month visit the patient did not develop chronic neuropathic pain.

There were no significant differences in patient demographic and intraoperative data (Table 1). A significant effect of time and treatment was found in visual analogue scale (VAS) scores at rest (time: p<0.001, treatment: p=0.015) and after cough (time: p<0.001, treatment: p<0.001) but their interaction (treatment*time) was not significant in any instance. Subsequent pairwise analysis revealed that VAS scores were significantly lower in the PRG+CWI group at rest while during cough the placebo group had higher scores than both treatment groups (Table 2). Perioperative Pregabalin Reduces Pain And Analgesic Consumption Nursing Essay. The same model used for morphine consumption resulted in a significant effect of time and treatment (p<0.001 and p<0.001 respectively) but not their interaction (Figure 2). Cumulative morphine consumption measured at 48 hr revealed a significant difference in total morphine between the three groups; PLCB: 49.2 ± 11.4 mg, PRG: 32.9 ± 10mg and PRG+CWI: 28.5 ± 10.8mg (p<0.001 between placebo and the other two groups).LONALGAL

Incidence of side effects was similar among groups with the exception of nausea and vomitus which were lower in the treatment groups (Table 3). No differences were observed in sedation scores throughout the study period. Patients in the placebo group were less satisfied than patients in the treatment groups (Table 3).

The incidence of neuropathic pain at 1- and 3-months postoperatively was more frequent in the placebo group than the PRG and PRG+CWI group. At 1-month 10 (67%) patients in the placebo group complained of symptoms of neuropathic pain versus none (0%) in the PRG group and only one (6.7%) patient in the PRG + CWI group (p <0.001). The incidence of allodynia alone in the operated side was also higher in the PLCB group (PLCB: 9 (60%) patients, PRG: 1 (6.7%) patient, PRG+CWI: 0 (0%) patients, p<0.001); the incidence of hyperalgesia in the operated side was also higher in the PLCB group (PLCB: 11 (73%) patients, PRG: 1 (6.7%) patient, PRG+CWI: 1 (6.7%) patients, p<0.001). At 3-months 5(33%) patients in the placebo group complained of symptoms of neuropathic pain versus none (0%) in the PRG and PRG + CWI group (p =0.001). The incidence of allodynia alone in the operated side was also higher in the PLCB group (PLCB: 5 (33%) patients, PRG:0 (0%) patient, PRG+CWI: 0 (0%) patients, p=0.007); the incidence of hyperalgesia in the operated side was also higher in the PLCB group (PLCB: 7 (46.7%) patients, PRG: 0(0%) patient, PRG+CWI: 0(0%) patients, p<0.001). Perioperative Pregabalin Reduces Pain And Analgesic Consumption Nursing Essay.

Discussion

In this study we found a significant effect of perioperative pregabalin administration in reducing pain scores and morphine consumption after thoracotomy. A distinct, clear effect of continuous infusion of local anesthetics was not evident from this study. Pregabalin was also effective in preventing the development of neuropathic pain as measured at 1 and 3 months postoperatively.

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Ειναι φοβερο, το είδαμε πρώτοι!!!!

State main findings
• How do they fit in with previous studies 
• Why are they different / same
• What it adds to knowledge of subject
• Weaknesses in study
• Future studies
• Conclusions Single vsmultimple doses

Pain neuropathic low scores but maybe our scale snot so sensitive

Post-thoracotomy pain syndrome or PTPS (chronic post-thoracotomy pain or postthoracotomy neuralgia) is defined by the International Association for the Study of Pain (IASP) as ‘pain that recurs or persists along a thoracotomy incision at least two months following the surgical procedure’. In general, it is burning and stabbing pain with dysesthesia and thus shares many features of neuropathic pain (29). PTPS is increasingly acknowledged byanesthesiologists and surgeons alike (30).

29. Koehler RP, Keenan RJ. Management of postthoracotomy pain: acute and chronic. ThoracSurgClin

2006 August;16(3):287–97. [PubMed: 17004557]

30. Gottschalk A, Cohen SP, Yang S, Ochroch EA. Preventing and treating pain after thoracic surgery.

Anesthesiology 2006 March;104(3):594–600. [PubMed: 16508407]

For example, incidence of long-term post-thoracotomy pain has been reported to be 80% at 3 months, 75% at 6 months, and 61% at one year after surgery; incidence of severe pain is 3–5%, and pain that interferes with normal life is reported by about50% of patients (31).

Up to half the chronic pain after thoracic surgery is not associated with a neuropathic component, which has not been reported to date. More extensive surgery and pleurectomy are predictive factors for chronic pain after thoracic surgery, suggesting a visceral component apart from nerve injury.

Pain is commonly reported at 3 months after elective thoracotomy but is generally mild, shows improvement with time, and does not usually require opioid analgesics. Patients who experience postthoracotomy pain at 3 months are at risk for significantly decreased physical functioning and vitality, but are not at risk for significantly decreased social, emotional, or mental health functioning compared with patients who do not experience postthoracotomy pain at 3 months. Perioperative Pregabalin Reduces Pain And Analgesic Consumption Nursing Essay.

Neuropathic pain, which is defined as pain initiated orcaused by a primary lesion or dysfunction in the nervoussystem,15has been implicated as a major contributor to thedevelopment of CPSP.16

2. Katz J, Seltzer Z. Transition from acute to chronic postsurgical pain: risk factors and protective factors. Expert Rev Neurother2009;9:723–44

15. Loeser JD, Treede RD. The Kyoto protocol of IASP basic pain terminology. Pain 2008;137:473–7

16. Costigan M, Scholz J, Woolf CJ. Neuropathic pain: a maladaptive response of the nervous system to damage. Ann Rev Neurosci 2009;32:1–32

Gottschalk A, Ochroch EA. Clinical and demographic characteristics of patients with chronic pain after major thoracotomy.Clin J Pain 2008; 24: 708–16

Niraj G, Rowbotham DJ. Persistent postoperative pain: where are we now? Br J Anaesth 2011; 107: 25–9

Perioperative Pregabalin Reduces Pain And Analgesic Consumption Nursing Essay