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M. Sean Kincaid and Arthur M. Lam

Object

Opioid administration after major intracranial surgery is often limited by a presumed lack of need and a concern that opioids will adversely affect the postoperative neurological examination. The authors conducted a prospective study to evaluate the incidence, severity, and treatment of postoperative pain in patients who underwent major intracranial surgery.

Methods

One hundred eighty-seven patients (77 men and 110 women, mean age 52 ± 15 years, mean weight 78.1 ± 19.9 kg) underwent either supratentorial (129 patients) or infratentorial (58 patients) procedures. Sixty-nine percent of the patients reported experiencing moderate to severe pain (≥ 4 on a 0–10 scale) during the 1st postoperative day. Pain scores greater than or equal to 4 persisted in 48% on the 2nd postoperative day. Approximately 80% of patients were treated with acetaminophen on the 1st postoperative day, whereas opioids (primarily intravenous fentanyl) were administered to 58%. Compared with patients who underwent supratentorial procedures, those who underwent infratentorial procedures reported more severe pain at rest (mean score 4.9 ± 2.2 compared with 3.8 ± 2.6; p = 0.015) and with movement (mean score 6.3 ± 2.6 compared with 4.5 ± 2.7; p <0.001) on the 1st postoperative day. On both the 1st and 2nd postoperative days, patients who underwent infratentorial procedures received greater quantities of opioid (p ≤ 0.019) and nonopioid (p ≤ 0.013) analgesics than those who underwent supratentorial procedures. Patients' dissatisfaction with analgesic therapy was significantly associated with elevated pain levels on the first 2 postoperative days (p <0.001).

Conclusions

In contrast to prevailing assumptions, the study findings reveal that most patients undergoing elective major intracranial surgery will experience moderate to severe pain for the first 2 days after surgery and that this pain is often inadequately treated.

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Kevin E. Vorenkamp and Marcel E. Durieux

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Athir H. Morad, Bradford D. Winters, Myron Yaster, Robert D. Stevens, Elizabeth D. White, Richard E. Thompson, Jon D. Weingart and Allan Gottschalk

Object

Opioid administration following major intracranial surgery is often limited by a presumed lack of need and a concern that opioids will adversely affect postoperative outcome and interfere with the neurological examination. Nevertheless, evidence is accumulating that these patients suffer moderate to severe postoperative pain and that this pain is often undertreated. The authors hypothesized that intravenous patient-controlled analgesia (PCA) would safely and more effectively treat postoperative supratentorial craniotomy pain than conventional as needed (PRN) therapy.

Methods

Following a standardized course of general anesthesia, adult patients who underwent elective supratentorial intracranial surgery were randomized in the neurosciences intensive care unit to receive either PRN intravenous fentanyl 25–50 μg every 30 minutes or PCA intravenous fentanyl 0.5 μg/kg every 15 minutes (maximum 4 doses/hour). The authors measured pain (self-reported scale score [0–10]), sedation (Ramsay Sedation Scale score), Glasgow Coma Scale score, fentanyl use, and major adverse events (excessive sedation, respiratory depression, pruritus, nausea, or vomiting) hourly.

Results

Sixty-four patients with a mean age of 48 years (range 22–77 years) were randomized to intravenous PCA (29 patients) or PRN fentanyl (35 patients) groups. There were no statistically significant demographic differences between the 2 groups. Patients receiving intravenous PCA had significantly lower pain scores than those receiving intravenous PRN fentanyl (2.53 ± 1.96 vs 3.62 ± 2.11 [p = 0.039]) and received significantly more fentanyl than the PRN group (44.1 ± 34.5 vs 23.6 ± 23.7 μg/hour [p = 0.007]). There were no differences between the 2 groups regarding the number of patients with adverse events.

Conclusions

Intravenous PCA more effectively treats the pain of supratentorial intracranial surgery than PRN fentanyl, and patients in the former group did not experience any untoward events related to the self-administration of opioids.

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Allan Gottschalk, Lauren C. Berkow, Robert D. Stevens, Marek Mirski, Richard E. Thompson, Elizabeth D. White, Jon D. Weingart, Donlin M. Long and Myron Yaster

Object

Opioid administration after major intracranial surgery is often limited by a presumed lack of need and a concern that opioids will adversely affect the postoperative neurological examination. The authors conducted a prospective study to evaluate the incidence, severity, and treatment of postoperative pain in patients who underwent major intracranial surgery.

Methods

One hundred eighty-seven patients (77 men and 110 women, mean age 52 ± 15 years, mean weight 78.1 ± 19.9 kg) underwent either supratentorial (129 patients) or infratentorial (58 patients) procedures. Sixty-nine percent of the patients reported experiencing moderate to severe pain (≥ 4 on a 0–10 scale) during the 1st postoperative day. Pain scores greater than or equal to 4 persisted in 48% on the 2nd postoperative day. Approximately 80% of patients were treated with acetaminophen on the 1st postoperative day, whereas opioids (primarily intravenous fentanyl) were administered to 58%. Compared with patients who underwent supratentorial procedures, those who underwent infratentorial procedures reported more severe pain at rest (mean score 4.9 ± 2.2 compared with 3.8 ± 2.6; p = 0.015) and with movement (mean score 6.3 ± 2.6 compared with 4.5 ± 2.7; p < 0.001) on the 1st postoperative day. On both the 1st and 2nd postoperative days, patients who underwent infratentorial procedures received greater quantities of opioid (p ≤ 0.019) and nonopioid (p ≤ 0.013) analgesics than those who underwent supratentorial procedures. Patients’ dissatisfaction with analgesic therapy was significantly associated with elevated pain levels on the first 2 postoperative days (p < 0.001).

Conclusions

In contrast to prevailing assumptions, the study findings reveal that most patients undergoing elective major intracranial surgery will experience moderate to severe pain for the first 2 days after surgery and that this pain is often inadequately treated.

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Marcel E. Durieux and Sabine Himmelseher