Discussion
postoperative pain, ’, Postoperative pain, pain, PONV
ADVERSE REACTIONS, MOTION SICKNESS, POSTOPERATIVE COMPLICATIONS
In this non-inferiority randomized controlled trial in patients undergoing gynecological laparoscopic surgery, under ERAS protocol, OFA with esketamine and dexmedetomidine was non-inferior to OA with sufentanil and remifentanil in pain scores calculated as the area under the curve for the first 48 h postoperatively. Furthermore, we found that no differences in the intraoperative HR and MAP and the number of rescue analgesia required between two groups, which supports our primary outcome. Meanwhile, lower incidence of PONV and preliminary improvement of PSQ were advantages of OFA which compared to OA. However, in terms of postoperative recovery time, OFA had certain disadvantage.Although minimally invasive surgery, such as laparoscopic surgery, has become an important part of ERAS in gynecologic surgery, postoperative pain caused by laparoscopic surgery still creates difficulties for anesthesia management in ERAS context. Opioid is gradually replaced by non-opioid medications because of opioid-related disadvantages. In this study, all patients were under ERAS protocol after discussing with surgeon and nurses team. We applied TIVA combined with ultrasound-guided TAP block and non-steroidal anti-inflammatory drug (NSAID) flurbiprofen axate, which was administered for postoperative rescue analgesia. In this context, we purely researched application of opioid and non-opioid medications in gynecological laparoscopic surgery. Patients’ postoperative VAS scores while coughing at different time points were evaluated and recorded. Use of the area under the curve is a common approach to the analysis of continuous variables because of its superiority in precision and bias [In our study, we administered esketamine and dexmedetomidine for OFA. In a previous placebo-controlled trial [PONV is another difficulty to be solved in the ERAS context. To reduce PONV, we adopted ERAS protocol which included preoperative carbohydrate loading, limiting fasting of clear liquids, intaking caffeine, chewing gum and postoperative early mobilization [PSD, which is related to type of surgery, duration of surgery, methods of anesthesia, anesthesia agents and other factors, has gradually drawn attention. Postoperative pain and opioids have significant effects on postoperative sleep quality. Opioids can lead to postoperative sleep disturbance, which may be related to the regulation mechanism of endogenous opioid activity [Times of awakening and orientation recovery in group OFA were longer than those in group OA in this study. Although several studies found that delayed recovery may lead to serious postoperative complications, in this study delayed recovery does not have apparent anesthesia related adverse reactions, the reason may be that our population was ranged from 18–65 years old, which reduced the possibility that elder patients are more susceptible to postoperative complications due to delayed recovery. Furthermore, dexmedetomidine has certain effect on delayed recovery, but its role is gentle and the efficacy is close to the physiological effect of sleep, It is also safe for elder patients [Esketamine has the effect of sympathetic activation that can increase heart rate, blood pressure and cardiac output [There are several limitations in the study. Firstly, although there was significant difference in incidence of PONV between two groups, we didn’t collect the history of PONV and motion sickness, which are also risk factors of PONV. In addition, the number of rescue antiemetics after surgery was not recorded, hence in subsequent study, we will focus on PONV and prepare to observe and record more comprehensive data, even consider testing PONV related blood indicators such as histamine and 5-hydroxytryptamine or serotonin if necessary [