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Adequate analgesic regimen would be required after minimally invasive colorectal surgery

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Annals of Surgical Treatment and Research 155

pISSN 2288-6575 eISSN 2288-6796 http://dx.doi.org/10.4174/astr.2016.91.4.155 Annals of Surgical Treatment and Research

LETTERS TO THE EDITOR

Adequate analgesic regimen would be required after minimally invasive colorectal surgery

Chun-Seok Yang, Sung Hye Byun1, Taeha Ryu1

Department of Surgery, Daegu Catholic University Medical Center, 1Department of Anesthesiology and Pain Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea

To the editor:

Postoperative pain management is important not only in patient wellbeing, but in recovery. An appropriate strategy for pain management is required in the perioperative period. We read with interest the article on the necessity of intravenous patient controlled analgesia (IV-PCA) in patients undergoing mini mally invasive colorectal surgeries [1]. The authors sug- gested that IV-PCA may not be necessary in patients who under- went minimally invasive surgeries for colorectal cancer, because there were no significant differences on postoperative analgesia between opioid-based IV-PCA and intravenous tramadol on demand.

However, we cannot agree with their conclusion on some points. First, all patients in their study had suffered extremely severe pain at postoperative days 1 and 2. According to the methods of this study, the authors aimed to maintain scores less than visual analogue scale (VAS) 4 on a 10-point VAS, but the aim was not achieved and they failed to provide adequate analgesia for all patients during postoperative periods. It’s especially surprising that even the patients who had received IV-PCA treatment had suffered severe pain during postoperative periods. The main purpose of PCA is literally analgesia, but the IV-PCA regimen in this study failed to provide adequate analgesia. The main cause of inadequate analgesia in IV-PCA group was insufficient dosage of fentanyl, and inappropriate IV-PCA regimen. IV-PCA regimens consist of several variables, including the bolus dose, lockout time, and maintenance infu- sion. These variables can affect the analgesic efficacy of IV PCA.

Usually, the recommended IV-PCA regimen of fentanyl is 10–20 mg for bolus dose and 4–10 minutes of lockout interval [2]. Use of continuous maintenance infusion was not recommended for fentanyl IV-PCA. In their study, the PCA formulation contained 25 mg/kg fentanyl diluted to 100 mL in normal saline. The bolus volume was 0.5 mL with 10 minutes of lockout interval, and the maintenance rate was set at 0.5 mL/hr. For example, a patient weighing 50 kg received 6.25 mg of fentanyl as bolus dose with a maintenance rate of 6.25 mg/hr of fentanyl according to their IV-PCA regimen. Compared with the recommended regimen, the regimen in their study might be insufficient to provide ade- quate analgesia for their patients.

Second, their pharmacologic effect of tramadol may affect the results of the study. The authors said that tramadol is an anti-inflammatory drug, but it is not. Tramadol is a synthetic opioid that has weak m agonist activity and inhibits reuptake of sero tonin and norepinephrine [3]. Actually, the most common ad verse side effects of tramadol are dizziness, nausea, vomiting, seda tion, and constipation [3]. There was an interesting study showing that tramadol based PCA had more postoperative nausea and vomiting (PONV) than opioid based PCA, which had a comparable analgesic effect [4]. In the study of Choi et al. [1], the results of the incidence of PONV being significantly higher in PCA group than in the non-PCA group might have been in- fluenced by tramadol as rescue analgesics. The interaction bet- ween tramadol and fentanyl was highly suspicious for the cause of higher incidence of PONV in IV-PCA group.

In conclusion, even minimally invasive colorectal surgery Reviewed

January February March April May June July August September October November December

Received March 16, 2016, Reviewed March 30, 2016, Accepted August 4, 2016

Corresponding Author: Taeha Ryu

Department of Anesthesiology and Pain Medicine, Catholic University of Daegu School of Medicine, 33 Duryugongwon-ro 17-gil, Nam-gu, Daegu 42472, Korea

Tel: +82-53-650-4785, Fax: +82-53-650-4517 E-mail: anesryu@cu.ac.kr

Copyright ⓒ 2016, the Korean Surgical Society

cc Annals of Surgical Treatment and Research is an Open Access Journal. All articles are distributed under the terms of the Creative Commons Attribution Non- Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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156

Annals of Surgical Treatment and Research 2016;91(4):155-156

is not free from severe postoperative pain, and the severe pain lasted for 2 days postoperatively under their insufficient pain management in this study. We agree that opioid-based IV-PCA has some limitations because of its adverse effect.

More over, opioid-based IV-PCA is not the only modality for postoperative analgesic management and alternative stra te- gies including epidural PCA rather than opioid based IV PCA have been recommended in early recovery protocol. But the most important thing is that patients who undergo mini- mally invasive colorectal surgery have severe pain in the early postoperative period, and they have the right to receive ade-

quate postoperative pain management. Opioid-based IV-PCA can be omitted in patients undergoing laparoscopic surgeries for colorectal cancer. However, other alternative strategies such as combination of IV and regional analgesia, namely multimodal analgesia, should be considered to provide adequate analgesia for the patients.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

1. Choi YY, Park JS, Park SY, Kim HJ, Yeo J, Kim JC, et al. Can intravenous patient- con trolled analgesia be omitted in pa- tients undergoing laparoscopic surgery for colorectal cancer? Ann Surg Treat Res 2015;88:86-91.

2. Hurley RW, Murphy JD, Wu CL. Acute postoperative pain. In: Miller RD. Miller’s

anesthesia. 8th ed. Philadelphia: Elsevier Churchill Livingstone; 2015. p. 2974-98.

3. Vazzana M, Andreani T, Fangueiro J, Faggio C, Silva C, Santini A, et al. Tramadol hydrochloride: pharmacokinetics, phar- macodynamics, adverse side effects, co- ad ministration of drugs and new drug delivery systems. Biomed Pharmacother

2015;70:234-8.

4. Murphy JD, Yan D, Hanna MN, Bravos ED, Isaac GR, Eng CA, et al. Comparison of the postoperative analgesic efficacy of intra venous patient-controlled analgesia with tramadol to intravenous patient-con- trolled analgesia with opioids. J Opioid Manag 2010;6:141-7.

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