Background & Aims
Patients who undergo bariatric surgery generally experience pain, which can be intense in the immediate postoperative period and persistent after this period. Pain control during and after surgery is essential and can affect the surgery success rate. The persistence and recurrence of pain can result in increased morbidity, compromised physical function and quality of life, delayed recovery, increased hospital costs, prolonged use of opioids during hospitalization and after discharge and higher rates of hospital readmission. A nociception monitor (NOL) allows individualizing analgesia, guiding therapy as needed for a given patient. However, there is still a gap of specific studies that evaluate a group at higher risk for adverse events from the inappropriate use of opioids, the obese patients.
Methods
Clinical, prospective, randomized, interventional study, partially blinded as it is an intervention guided by the nociception index (NOL monitor), in patients of both sexes undergoing elective sleeve gastroplasty and laparoscopic bypass surgeries, for the treatment of obesity under general anesthesia. Patients were randomly divided into control and intervention groups. Inclusion criteria were patients aged between 18 and 65 years, diagnosed with obesity. Exclusion criteria were ASA 3 or 4, chronic pain or a history of cognitive, psychiatric, renal, oncological or neurological disorders. Data were collected in the surgery center, intensive care unit and ward of a Brazilian quaternary hospital. In the control group, the remifentanil infusion rate was controlled according to the nociceptive stimuli and hemodynamic changes perceived by the anesthetist. In the intervention group, the infusion was guided by the nociception level, remifentanil was adjusted according to the NOL monitor.
Results
19 participants were randomized (NOL = 7, Control =12). Two were excluded due to breach of intraoperative analgesic protocol and one did not record the outcome due to failure in data collection. Therefore, 16 participants were enrolled (NOL = 6, Control = 10). BMI ranged from 35.3 to 55.5 kg/m2 with the majority of patients classified as grade 3 obesity. The gastroplasty techniques evaluated were bypass and sleeve, with the former predominating. NOL reduced intraoperative remifentanil consumption, but without a statistically significant difference between groups (Control: median 2280 [P25: 2280, P75: 2920], NOL: median 803 [P25: 803, P75: 1190] p=0.10). Regarding secondary objectives, the length of stay was shorter in the NOL group, with a statistically significant difference between the groups. In the NOL group, fewer patients required the use of rescue analgesics. Morphine consumption in the NOL group was lower intraoperatively, however, the consumption in this group was higher in the anesthetic recovery room, at 6 hours, at 24 hours and at 48 hours, but without statistical significance. The incidence of nausea and vomiting in the first 48 hours did not differ between groups.
Conclusions
The use of the nociception monitor did not show a reduction in intraoperative remifentanil consumption. However, there was a significant result in reducing the length of hospital stay, which has positive relevance on hospital management and hospitalization costs. The study had limitations related to monitoring patients post-operatively, during which the responsibility of gathering data was assigned to professionals not directly related to the research. Another limitation was not reaching the number of patients proposed at the beginning of the study to achieve more statistically significant results. This was due to the decrease in the number of bariatric surgeries per week, which initially was five and in the last month of the study, one per week and, in addition, the availability of the monitor, which depended on the company providing it for each surgery. The third limitation was the disproportion between groups which was due to the simple randomization that was chosen for the study.
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Presenting Author
Georgiana Freire
Poster Authors
Topics
- Assessment and Diagnosis