Comparison of three intraoperative analgesic strategies in laparoscopic bariatric surgery: a retrospective study of immediate postoperative outcomes

Abstract Introduction and objectives Multimodal Analgesia (MMA) has shown promising results in postoperative outcomes across a broad spectrum of surgeries, including bariatric surgery. We compared the analgesic effect immediately after Laparoscopic Bariatric Surgery (LBS) of the combined effect of MMA and methadone against two techniques that were based mainly on the use of high-potency medium-acting opioids. Methods Two hundred seventy-one patients were retrospectively reviewed. The primary outcome was postoperative pain score > 3/10 measured by the Verbal Numeric Scale (VNS) during the Postanesthetic Care Unit (PACU) stay. The three protocols of intraoperative analgesia were: (P1) sufentanil at anesthetic induction followed by remifentanil infusion; (P2) sufentanil at induction followed by dexmedetomidine infusion; and (P3) remifentanil at induction followed by MMA including dexmedetomidine, magnesium, lidocaine, and methadone. Only P1 and P2 patients received morphine toward the end of surgery. Poisson regression was used to adjust confounding factors and calculate Prevalence Ratio (PR). Results Postoperative VNS > 3 was recorded in 135 (49.81%) patients, of which 93 (68.89%) were subjected to P1, 25 (18.56%) to P2, and 17 (12.59%) to P3. In the final adjusted model, both anesthetic techniques (P3) (PR = 0.10; 95% CI [0.03-0.28]), and (P2) (PR = 0.42%; 95% CI [0.20-0.90]) were associated with lower occurrence of VNS > 3, whereas age range 20-29 was associated to higher occurrence of VNS > 3 (PR = 3.21; 95% CI [1.22-8.44]) in PACU. Postoperative Nausea and Vomiting (PONV) was distributed as follows: (P1) 20.3%, (P2) 31.25% and (P3) 6.77%; (P3 < P1, P2; p< 0.05). Intraoperative hypotension occurred more often in P3 (39%) compared to P2 (20.31%) and P1 (17.46%) (p< 0.05). Conclusion MMA + methadone was associated with higher incidence of intraoperative hypotension and lower incidence of moderate/severe pain in PACU after LBS.

Impact of educational strategies on pain control quality indicators at a tertiary hospital / Impacto de estratégias educativas nos indicadores de qualidade do controle de dor em um hospital de alta complexidade

ABSTRACT BACKGROUND AND OBJECTIVES: Pain management by the multidisciplinary team remains a challenge in the health field. The aim of this study was to analyze the impact of educational strategies for the implementation of pain as the fifth vital sign and its management in a highly complex hospital. METHODS: An interventional non-controlled study analyzed three different sequential educational processes: Pain training week (PW), educational visits by the pain nurse to guide professionals in relation to pain management and e-learning. The impact of the educational strategy was assessed through pain as the 5th vital sign and adequate pain management. RESULTS: For pain as the 5th vital sign, the audit previous to PW showed a median of compliance of 46.4% at the inpatient unit, 53.1% at the maternity ward and 16.7% at the emergency room. In the evaluations after PW, the median of compliance at the inpatient unit was 78.4%, at the maternity ward 79.62% and at the emergency room 32.9% (p<0.05). There was an improvement in pain management in all hospital sectors after subsequent training (p<0.05). CONCLUSION: The implementation of a continuing education program has improved pain care assistance and increased compliance to the institutional pain protocol.

RESUMO JUSTIFICATIVA E OBJETIVOS: O manejo da dor pela equipe multidisciplinar continua como um desafio na saúde. O objetivo deste estudo foi analisar o impacto de estratégias educacionais para efetivação da dor como 5º sinal vital e seu gerenciamento em um hospital de alta complexidade. MÉTODOS: Estudo não controlado de intervenção por meio de análise de três diferentes estratégias educativas sequenciais: Semana de treinamentos sobre Dor (SD), visitas educacionais pelo enfermeiro da dor para orientar os profissionais em relação à dor e treinamento eletrônico virtual de revisão. A análise do impacto das estratégias educativas foi realizada por meio de indicadores em relação à dor como 5º sinal vital e tratamento adequado da dor. RESULTADOS: Na avaliação da dor como 5° sinal vital, a auditoria prévia à SD mostrou mediana de conformidade de 46,4% na unidade de internação, de 53,1% na maternidade e de 16,7% no Pronto Socorro. Nas avaliações após a SD, a mediana de conformidade na unidade de internação foi de 78,4%, na maternidade de 79,62% e no pronto atendimento de 32,9% (p<0,05). Houve melhora no tratamento da dor em todos os setores após avaliações subsequentes aos treinamentos (p<0,05). CONCLUSÃO: A implantação de um programa de educação continuada se mostrou efetivo em promover melhora na assistência no cuidado ao paciente com dor e dos resultados dos indicadores assistenciais em relação ao protocolo de dor institucional.

Fatores associados à dor pós-operatória na recuperação pós-anestésica em pacientes submetidos à gastroplastia laparoscópica / Factors associated to postoperative pain in the post-anesthetic care unit in patients submitted to laparoscopic gastroplasty

JUSTIFICATIVA E OBJETIVOS: A dor pós-operatória em pacientes obesos é um evento prejudicial para sua recuperação, retardando a alta e aumentando a chance de complicações. O objetivo deste estudo foi determinar a frequência de dor na sala de recuperação pós-anestésica e averiguar os fatores associados à ocorrência de dor moderada ou intensa em obesos submetidos a gastroplastia, relacionando-os a possíveis complicações. MÉTODOS: Estudo observacional prospectivo incluindo 84 pacientes submetidos a anestesia geral com sevoflurano para gastroplastia laparoscópica. Na sala de recuperação pós-anestésica, os pacientes foram avaliados quanto à intensidade da dor pela escala numérica e verbal, sedação (escala de Ramsay), ocorrência de náuseas, vômitos e complicações respiratórias. O modelo de regressão logística foi utilizado para determinar as variáveis independentes associadas à dor. RESULTADOS: Na sala de recuperação pós-anestésica, a ausência de dor na admissão ocorreu em 61,63% dos pacientes. Na análise multivariada, o uso do opioide fentanil em comparação ao sufentanil foi o único fator independentemente associado à dor (RR 3,07 - IC95% 1,17-6,4). Não houve diferença entre o tipo de opioide utilizado e a ocorrência de náuseas e vômitos (p>0,05). Os escores da escala de Ramsay não diferiram entre os tipos de opioides utilizados no intraoperatório (p>0,05). CONCLUSÃO: O único fator independentemente associado à dor na sala de recuperação pós-anestésica foi o tipo de opioide utilizado na indução anestésica. A dor pós-operatória ainda é um evento frequente que acomete a maioria dos pacientes e protocolos de analgesia precisam ser implementados para minimizar os efeitos que a dor subtratada pode causar.

BACKGROUND AND OBJECTIVES: Postoperative pain in obese patients is a noxious event for their recovery delaying hospital discharge and increasing the chance of complications. This study aimed at determining pain frequency in the post-anesthetic care unit and at investigating factors associated to moderate to severe pain in obese patients submitted to gastroplasty, relating them to potential complications. METHODS: This is an observational and prospective study including 84 patients submitted to general anesthesia with sevoflurane for laparoscopic gastroplasty. Patients were evaluated in the post-anesthetic care unit for pain intensity by the verbal and numerical scale (Ramsay scale), presence of nausea, vomiting and respiratory complications. Logistic regression model was used to determine pain-related independent variables. RESULTS: There has been no pain at admission to the post-anesthetic care unit in 61.63% of patients. In the multivariate analysis, fentanyl as compared to sufentanil was the only independent factor associated to pain (OR 3.07 - IC95% 1.17 - 6.4). There has been no difference between the type of opioid used and the presence of nausea and vomiting (p>0.05). Ramsay scale scores were not different between opioids used in the intraoperative period (p>0.05). CONCLUSION: The only independent factor associated to pain in the post-anesthetic care unit was the type of opioid used for anesthetic induction. Postoperative pain is still a frequent event affecting most patients, and analgesic protocols have to be implemented to minimize the effects that undertreated pain may induce.