Spare Opioid Use Protocol Improved the Outcomes of the Enhanced Recovery after Surgery Protocol for Patients Undergoing Laparoscopic Sleeve Gastrectomy for Morbid Obese Patients

Background: Obesity and intraoperative (IO) opioid are risk-factors during bariatric surgery and require certain manipulations to deal with. Enhanced recovery after surgery (ERAS) and spare-opioid use protocol (SOUP) might aid to bypass these risk factors Objectives: Evaluation of the outcomes of ERAS protocol with SOUP application for morbid obese patients undergoing laparoscopic sleeve gastrectomy (LSG). Patients and methods: 60 obese patients were allocated into Group-C received conventional opioid-based anaesthesia and postoperative (PO) analgesia and Group-E received the ERAS protocol with SOUP application. All patients received balanced sevoflurane anesthesia 2% in oxygen 100% and rocuronium and 4-ports LSG. The study outcome is the efficacy of the applied protocol to provide IO and PO opioid-free analgesia during major surgeries for risky patients. Results: All surgeries were conducted without a shift to laparotomy or conventional opioid-based anesthesia. Group-E patients had significantly shorter PACU stays (P=0.035) and higher Aldrete scores at time of PACU discharge (P=0.023). Among Group-E patients, 5 required IO fentanyl shots and 3 patients received PO morphine shots. Group-E patients showed significantly lower PO nausea (P=0.032) and need for antiemetic therapy (P=0.005), earlier ambulation (P=0.020) and oral intake (P=0.034) and hospital discharge (P=0.014). Conclusion: Implementation of ERAS with SOUP protocols is a feasible, effective and safe anesthetic policy for high-risk patients undergoing major surgeries. The applied SOUP spared the need for opioid analgesia in about 90% of patients. The applied anesthetic policy improved immediate surgical outcomes, and reduced times for PACU discharge, ambulation, oral intake and PO hospital stay with cost reductions

Twenty-four-hour postoperative orphenadrine and ketorolac infusion efficiently precedes orphenadrine-diclofenac infusion as an opioid-sparing analgesic modality after mastectomy

ABSTRACTObjectives Determination of the efficacy of postoperative (PO) infusion of orphenadrine/ketorolac (O/KT) combination for 24-h as PO analgesia and its opioid-sparing rate (OSR) compared to orphenadrine/diclofenac (O/D) and Placebo infusions for women undergoing Modified Radical Mastectomy.Patients & Methods A total of 129 women with operable cancer breast received the same anesthetic procedure and were randomly divided into groups I–III according to the PO infusion. Infusions were started before skin closure for 60-min and were repeated for 8-hourly for 24-h. Pain severity was assessed using the numeric rating scale (NRS) and at NRS scores >4, morphine 5 mg was given. The OSR was defined as the number of patients who required no PO morphine in the study outcome.Results The OSR was significantly higher with O/KT than with O/D infusion (72.1% vs. 51.2%, respectively) and the frequency of requesting multiple doses of morphine was significantly lower with O/KT than other infusions with significant difference in favor of O/D infusion than placebo. The frequency of early requests of morphine was significantly lower with O/KT having a significantly longer duration till the first request. The average pain scores were significantly lower with O/KT infusion. PO morphine-related side effects were significantly higher, while patient and surgeon’s satisfaction scores were significantly lower among patients of the placebo group.Conclusion Cocktails of ketorolac or diclofenac with orphenadrine infusions for 24-h after mastectomy improve PO pain sensation with a reduction of opioid consumption. The O/KT infusion was superior to the O/D infusion with regard to OSR and pain scores

The use of laser assisted hatching of frozen/thawed embryos versus laser assisted hatching of fresh embryos in human intracytoplasmic sperm injection

Cryopreservation of human embryos has become an essential part of assisted reproduction. It limits the number of embryo transferred while supernumerary embryos can be transferred in subsequent cycles, however, it is associated with zonal hardening, which lowers the success rate in the majority of (ICSI) centres, associated with decreased implantation rate and clinical pregnancy rates. Assisted hatching has been used to induce microdissection of the zona pellucida. Many techniques have been used, such as mechanical, chemical, piezo and laser techniques. Aim: To compare the efficacy of laser assisted hatching of vitrified embryos and fresh embryos with regards to implantation rate and clinical pregnancy rate. Study design: Prospective randomised study. Patients and methods: One hundred twenty women with fresh embryos scheduled for (ICSI) were randomised in two groups; laser assisted hatching (LAH) group (test group), containing 60 women and the other is (non LAH) (control group). Second group with 120 women with frozen embryos were randomised in (LAH group) and (non LAH group). On the day of embryo transfer, 1.48 μm Infrared Diode laser, class 1 M, was used in test group to induce zonal microdissection, the quality and safety of embryos is assessed morphologically after hatching. On the other hand, the zona of the control group were left intact. Both clinical pregnancy and implantation rates were estimated. Results: Laser assisted hatching group had clinical pregnancy and implantation rates of 38% and 50%, respectively. Non laser assisted hatching group had lower clinical pregnancy and implantation rates; 30% (p = .442) and 33% (p = .095), respectively, with no statistically significant difference p < .05. Conclusion: LAH does not improve statistically both pregnancy rate and implantation rate in fresh embryos. However, there is improvement in both implantation and pregnancy rate in Vitrified group

Prospective randomized trial on the use of laser assisted hatching for transfer of frozen/thawed embryos in human Intracytoplasmic Sperm injection

Background: Cryopreservation of human embryos has become an essential part of assisted reproduction, however it might be associated with zonal hardening, which could reduce implantation rate and clinical pregnancy rates. Assisted hatching has been used to induce microdissection of the zona pellucida. Many techniques have been used, such as mechanical, chemical, piezo and laser techniques. Objective: To determine if laser assisted hatching improves both the implantation and clinical pregnancy rates in women using transferred frozen/thawed embryos. Study design: Prospective randomized study. Patients and methods: 160 women, scheduled for transfer of cryopreserved embryos, were randomized in two equal groups using sealed envelopes; a laser assisted hatching group (test group), and a control group, each included 80 women. On the day of embryo transfer, Diode laser was used in test group to induce zonal microdissection, the quality and safety of embryos is assessed morphologically after hatching. On the other hand, the zona of the control group were left intact. Both implantation and clinical pregnancy rates were estimated. Results: Laser assisted hatching group had implantation rates and clinical pregnancy of 50% and 37.5% respectively. Non laser assisted hatching group had lower implantation rates and clinical pregnancy; 47.27% (P value = 0.87) and 27.5% (P value = 0.237) respectively. Conclusion: Laser assisted hatching seems to improve both the clinical pregnancy and implantation rates amongst patients using frozen/thawed embryos, however that was statistically insignificant