Efficacy of the intraoperative opioid-sparing anesthesia on quality of patients’ recovery in video-assisted thoracoscopic surgery: a randomized trial

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Abstract

Background

We aimed to explore the impact of opioid-sparing anesthesia on patients’ quality of recovery after video-assisted thoracoscopic surgery (VATS). We tested the primary hypothesis that our predefined opioid-sparing anesthesia provides better quality of patients’ recovery compared to routine anesthesia in VATS.

Methods

Patients between 18 and 70 years, scheduled for elective VATS, had an American Society of Anesthesiologists (ASA) class I–III under general anesthesia, were randomly allocated to: routine anesthesia group and opioid-sparing anesthesia group. Patients in the opioid-sparing anesthesia group were mainly given preoperative thoracic paravertebral blockade with intraoperative withholding longer acting opioids. Patients in routine anesthesia group received opioid-based anesthesia. The primary outcome was the Quality of Recovery-15 scale (QoR-15) at 6 hours after surgery. The secondary outcomes included QoR-15 at 24 and 48 hours after surgery, Overall Benefit of Analgesia Score Satisfaction with pain treatment (OBAS) and acute pain intensity at 6, 24 and 48 hours after surgery, and clinical outcomes of recovery after surgery.

Results

A total of 159 patients were included in final analysis. The median difference in QoR-15 between opioid-sparing anesthesia and routine anesthesia was 4 (95% CI: 1–6) at 6 hours, 8 (95% CI: 4–12) at 24 hours and 4.7 (95% CI: 1–6) at 48 hours after surgery respectively; 73.4% of patient showed good recovery in opioid-sparing anesthesia group, compared to 53.8% in routine anesthesia group at 24 hours after surgery (P=0.01). Patients demonstrated lower OBAS in opioid-sparing anesthesia group compared to routine anesthesia at all time points after surgery (P<0.05). The pain at most was significantly lower in opioid-sparing anesthesia group compared to routine anesthesia at 6 and 48 hours after surgery (P<0.05). Patients exhibited faster recovery with opioid-sparing anesthesia on time to mobilize and time to first flatus (P<0.01).

Conclusions

Our intraoperative opioid-sparing anesthesia cannot improve patients’ recovery at 6 hours after VATS lung surgery, but it demonstrates better outcomes at 24 hours after surgery compared to routine anesthesia, reaching to a clinically important difference.

Trial Registration

This study is registered in the Chinese Clinical Trial Registry, ChiCTR2000031609.

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Most cited references 36

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Enhanced Recovery After Surgery: A Review.

Michael E. Scott, Olle Ljungqvist, Kenneth Fearon (2017)

Enhanced Recovery After Surgery (ERAS) is a paradigm shift in perioperative care, resulting in substantial improvements in clinical outcomes and cost savings.

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Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council.

Roger Chou, Debra B Gordon, Oscar A de Leon-Casasola … (2016)

Most patients who undergo surgical procedures experience acute postoperative pain, but evidence suggests that less than half report adequate postoperative pain relief. Many preoperative, intraoperative, and postoperative interventions and management strategies are available for reducing and managing postoperative pain. The American Pain Society, with input from the American Society of Anesthesiologists, commissioned an interdisciplinary expert panel to develop a clinical practice guideline to promote evidence-based, effective, and safer postoperative pain management in children and adults. The guideline was subsequently approved by the American Society for Regional Anesthesia. As part of the guideline development process, a systematic review was commissioned on various aspects related to various interventions and management strategies for postoperative pain. After a review of the evidence, the expert panel formulated recommendations that addressed various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care. The recommendations are based on the underlying premise that optimal management begins in the preoperative period with an assessment of the patient and development of a plan of care tailored to the individual and the surgical procedure involved. The panel found that evidence supports the use of multimodal regimens in many situations, although the exact components of effective multimodal care will vary depending on the patient, setting, and surgical procedure. Although these guidelines are based on a systematic review of the evidence on management of postoperative pain, the panel identified numerous research gaps. Of 32 recommendations, 4 were assessed as being supported by high-quality evidence, and 11 (in the areas of patient education and perioperative planning, patient assessment, organizational structures and policies, and transitioning to outpatient care) were made on the basis of low-quality evidence.

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Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS)

Timothy Batchelor, Neil J. Rasburn, Etienne Abdelnour-Berchtold … (2019)

Enhanced recovery after surgery is well established in specialties such as colorectal surgery. It is achieved through the introduction of multiple evidence-based perioperative measures that aim to diminish postoperative organ dysfunction while facilitating recovery. This review aims to present consensus recommendations for the optimal perioperative management of patients undergoing thoracic surgery (principally lung resection). A systematic review of meta-analyses, randomized controlled trials, large non-randomized studies and reviews was conducted for each protocol element. Smaller prospective and retrospective cohort studies were considered only when higher-level evidence was unavailable. The quality of the evidence base was graded by the authors and used to form consensus recommendations for each topic. Development of these recommendations was endorsed by the Enhanced Recovery after Surgery Society and the European Society for Thoracic Surgery. Recommendations were developed for a total of 45 enhanced recovery items covering topics related to preadmission, admission, intraoperative care and postoperative care. Most are based on good-quality studies. In some instances, good-quality data were not available, and subsequent recommendations are generic or based on data extrapolated from other specialties. In other cases, no recommendation can currently be made because either equipoise exists or there is a lack of available evidence. Recommendations are based not only on the quality of the evidence but also on the balance between desirable and undesirable effects. Key recommendations include preoperative counselling, nutritional screening, smoking cessation, prehabilitation for high-risk patients, avoidance of fasting, carbohydrate loading, avoidance of preoperative sedatives, venous thromboembolism prophylaxis, prevention of hypothermia, short-acting anaesthetics to facilitate early emergence, regional anaesthesia, nausea and vomiting control, opioid-sparing analgesia, euvolemic fluid management, minimally invasive surgery, early chest drain removal, avoidance of urinary catheters and early mobilization after surgery. These guidelines outline recommendations for the perioperative management of patients undergoing lung surgery based on the best available evidence. As the recommendation grade for most of the elements is strong, the use of a systematic perioperative care pathway has the potential to improve outcomes after surgery.

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Author and article information

Journal

Journal ID (nlm-ta): J Thorac Dis

Journal ID (iso-abbrev): J Thorac Dis

Journal ID (publisher-id): JTD

Title: Journal of Thoracic Disease

Publisher: AME Publishing Company

ISSN (Print): 2072-1439

ISSN (Electronic): 2077-6624

Publication date (Print and electronic): July 2022

Publication date (Print): July 2022

Volume: 14

Issue: 7

Pages: 2544-2555

Affiliations

[1 ]deptDepartment of Anesthesiology, Shanghai Chest Hospital , Shanghai Jiao Tong University School of Medicine , Shanghai, China;

[2 ]Outcomes Research Consortium , Cleveland, OH, USA;

[3 ]deptDepartment of Statistics Center, Shanghai Chest Hospital , Shanghai Jiao Tong University School of Medicine , Shanghai, China

Author notes

Contributions: (I) Conception and design: Y Qiu, J Wu; (II) Administrative support: J Wu; (III) Provision of study materials or patients: Y Qiu, X Lu; (IV) Collection and assembly of data: X Chen, X Lu; (V) Data analysis and interpretation: Y Qiu, Y Liu, J Wu; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

[#]

These authors contributed equally to this work.

Correspondence to: Professor Jingxiang Wu, MD. Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, No. 241, West Huaihai Rd., Shanghai, China. Email: wjx1132@ 123456163.com .

Article

Publisher ID: jtd-14-07-2544

DOI: 10.21037/jtd-22-50

PMC ID: 9344409

PubMed ID: 35928625

SO-VID: 7e578286-7239-41c1-bc4a-7ef2b3f6de60

License:

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0.

Efficacy of the intraoperative opioid-sparing anesthesia on quality of patients’ recovery in video-assisted thoracoscopic surgery: a randomized trial

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Abstract

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Most cited references 36

Enhanced Recovery After Surgery: A Review.

Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council.

Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS)

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