Comparison of three intraoperative analgesic strategies in laparoscopic bariatric surgery – a retrospective study of immediate postoperative outcomes
Comparação de três estratégias analgésicas intraoperatórias em cirurgia bariátrica laparoscópica: um estudo retrospectivo dos resultados pós-operatórios imediatos
Leopoldo Muniz da Silva; Anthony M.H. Ho; Daniel Rodrigues de Oliveira; Arthur de Campos Vieira Abib; Saullo Queiroz Silveira; Anna Beatriz Aranha; Vitor Oliveira André; Patrícia Rennó Pinto; Rafael Souza Fava Nersessian; Glenio B. Mizubuti
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.
Keywords
Resumo
Introdução e objetivos: A analgesia multimodal (AMM) tem mostrado resultados promissores nos resultados pós-operatórios em um amplo espectro de cirurgias, incluindo a cirurgia bariátrica. Comparamos o efeito analgésico imediatamente após a cirurgia bariátrica laparoscópica (LBS) do efeito combinado de AMM e metadona com duas técnicas baseadas principalmente no uso de opioides de média ação de alta potência. Métodos: Duzentos e setenta e um pacientes foram revisados retrospectivamente. O desfecho primário foi escore de dor pós-operatória > 3/10 medido pela escala numérica verbal (ENV) durante a permanência na unidade de recuperação pós-anestésica (SRPA). Os três protocolos de analgesia intraoperatória foram: (P1) sufentanil na indução anestésica seguida de infusão de remifentanil; (P2) sufentanil na indução seguida de infusão de dexmedetomidina; e (P3) remifentanil na indução seguido de AMM incluindo dexmedetomidina, magnésio, lidocaína e metadona. Apenas os pacientes P1 e P2 receberam morfina no final da cirurgia. A regressão de Poisson foi utilizada para ajustar os fatores de confusão e calcular a razão de prevalência (RP). Resultados: VNS pós-operatório > 3 foi registrado em 135 (49,81%) pacientes, dos quais 93 (68,89%) foram submetidos a P1, 25 (18,56%) a P2 e 17 (12,59%) a P3. No modelo final ajustado, ambas as técnicas anestésicas (P3) [RP = 0,10; IC 95% (0,03–0,28)], e (P2) [RP = 0,42%; IC 95% (0,20–0,90)] foram associados à menor ocorrência de VNS > 3, enquanto a faixa etária de 20 a 29 foi associada a maior ocorrência de VNS > 3 [RP = 3,21; IC 95% (1,22–8,44)] na SRPA. Náuseas e vômitos pós-operatórios (NVPO) distribuíram-se da seguinte forma: (P1) 20,3%, (P2) 31,25% e (P3) 6,77%; (P3 < P1, P2; p < 0,05). A hipotensão intraoperatória ocorreu mais frequentemente em P3 (39%) em comparação a P2 (20,31%) e P1 (17,46%) (p < 0,05). Conclusão: AMM + metadona foi associado a maior incidência de hipotensão intraoperatória e menor incidência de dor moderada/severa na SRPA após LBS.
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References
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