Skip to main content
SpringerLink
Log in

Manage perioperative pain in morbidly obese patients by taking an all-round multimodal approach

  • Disease Management
  • Published:
Drugs & Therapy Perspectives Aims and scope Submit manuscript

Abstract

Morbidly obese individuals often require surgery, including bariatric (weight management) surgery. Acute pain management in the morbidly obese must consider the risk of chronic post-surgical pain, opioid dependence, and comorbidities (e.g. sleep-disordered breathing). A stepped, multimodal, opioid-sparing approach titrated to the type and severity of pain type should be taken, with co-administration of systemic and local anaesthetic agents when appropriate.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Nightingale CE, Margarson MP, Shearer E, et al. Peri-operative management of the obese surgical patient 2015: Association of Anaesthetists of Great Britain and Ireland Society for Obesity and Bariatric Anaesthesia. Anaesthesia. 2015;70:859–76.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Belcaid I, Eipe N. Perioperative pain management in morbid obesity. Drugs. 2019;79(11):1163–75.

    Article  PubMed  Google Scholar 

  3. Thorell A, MacCormick AD, Awad S, et al. Guidelines for perioperative care in bariatric surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations. World J Surg. 2016;40:2065–83.

    Article  CAS  PubMed  Google Scholar 

  4. Zeidan A, Al-Temyatt S, Mowafi H, et al. Gender-related difference in postoperative pain after laparoscopic Roux-En-Y gastric bypass in morbidly obese patients. Obes Surg. 2013;23:1880–4.

    Article  PubMed  Google Scholar 

  5. Chung F, Yang Y, Liao P. Predictive performance of the STOPBANG score for identifying obstructive sleep apnea in obese patients. Obes Surg. 2013;23:2050–7.

    Article  PubMed  Google Scholar 

  6. Raebel MA, Newcomer SR, Reifler LM, et al. Chronic use of opioid medications before and after bariatric surgery. JAMA. 2013;310:1369–76.

    Article  CAS  PubMed  Google Scholar 

  7. Weingarten TN, Sprung J, Flores A, et al. Opioid requirements after laparoscopic bariatric surgery. Obes Surg. 2011;21:1407–12.

    Article  PubMed  Google Scholar 

  8. Liu SS, Buvanendran A, Rathmell JP, et al. Predictors for moderate to severe acute postoperative pain after total hip and knee replacement. Int Orthop. 2012;36:2261–7.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Mei W, Seeling M, Franck M, et al. Independent risk factors for postoperative pain in need of intervention nearly after awakening from general anaesthesia. Eur J Pain. 2010;14(2):149.e1–e7.

    Article  Google Scholar 

  10. Yen CR, Tsou MY, Mandell MS, et al. An analysis of patient variables that influence intravenous patient-controlled analgesic use of morphine with quantile regression. Anesthesiology. 2010;112:688–95.

    Article  CAS  PubMed  Google Scholar 

  11. Ingrande J, Lemmens HJM. Dose adjustment of anaesthetics in the morbidly obese. Br J Anaesth. 2010;105:16–23.

    Article  CAS  Google Scholar 

  12. Budiansky AS, Margarson MP, Eipe N. Acute pain management in morbid obesity: an evidence based clinical update. Surg Obes Rel Dis. 2017;13:523–32.

    Article  Google Scholar 

  13. Bidgoli J, Delesalle S, De Hert SG, et al. A randomised trial comparing sufentanil versus remifentanil for laparoscopic gastroplasty in the morbidly obese patient. Eur J Anaesthesiol. 2011;28:120–4.

    Article  CAS  PubMed  Google Scholar 

  14. Ziemann-Gimmel P, Hensel P, Koppman J, et al. Multimodal analgesia reduces narcotic requirements and antiemetic rescue medication in laparoscopic Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis. 2013;9:975–80.

    Article  PubMed  Google Scholar 

  15. Zhang J, Ding EL, Song Y. Adverse effects of cyclooxygenase 2 inhibitors on renal and arrhythmia events: meta-analysis of randomized trials. JAMA. 2006;296:1619–32.

    Article  CAS  PubMed  Google Scholar 

  16. Bhala N, Emberson J, Merhi A, et al. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. Lancet. 2013;382:769–79.

    Article  CAS  PubMed  Google Scholar 

  17. Murphy JD, Yan D, Hanna MN, et al. Comparison of the postoperative analgesic efficacy of intravenous patient-controlled analgesia with tramadol to intravenous patient-controlled analgesia with opioids. J Opioid Manag. 2010;6:141–7.

    Article  PubMed  Google Scholar 

  18. Hollingshead J, Duhmke RM, Cornblath DR. Tramadol for neuropathic pain. Cochrane Database Syst Rev. 2006;3:CD003726.

  19. Nehoda H, Lanthaler M, Labeck B, et al. A study of pain after laparoscopic gastric banding. Obes Surg. 2001;11:208–11.

    Article  CAS  PubMed  Google Scholar 

  20. Ng JJ, Leong WQ, Tan CS, et al. A multimodal analgesic protocol reduces opioid-related adverse events and improves patient outcomes in laparoscopic sleeve gastrectomy. Obes Surg. 2017;27:3075–81.

    Article  PubMed  Google Scholar 

  21. Lam KKY, Mui WLM. Multimodal analgesia model to achieve low postoperative opioid requirement following bariatric surgery. Hong Kong Med J. 2016;22(22):428–34.

    PubMed  Google Scholar 

  22. Ultram® (tramadol hydrochloride) tablets: US prescribing information. Titusville (NJ): Janssen Pharmaceuticals, Inc.; 2019.

  23. Bamgbade OA, Oluwole O, Khaw RR. Perioperative analgesia for fast-track laparoscopic bariatric surgery. Obes Surg. 2017;27:1828–34.

    Article  PubMed  Google Scholar 

  24. Stamer UM, Lehnen K, Hothker F, et al. Impact of CYP2D6 genotype on postoperative tramadol analgesia. Pain. 2003;105:231–8.

    Article  CAS  PubMed  Google Scholar 

  25. Avila C, Holloway A, Hahn M, et al. An overview of links between obesity and mental health. Curr Obes Rep. 2015;4:303–10.

    Article  PubMed  Google Scholar 

  26. Ahmad S, Nagle A, McCarthy RJ, et al. Postoperative hypoxemia in morbidly obese patients with and without obstructive sleep apnea undergoing laparoscopic bariatric surgery. Anesth Analg. 2008;107:138–43.

    Article  PubMed  Google Scholar 

  27. Tawfic QA. A review of the use of ketamine in pain management. J Opioid Manag. 2013;9:379–88.

    Article  PubMed  Google Scholar 

  28. Kamal HM. Ketamine as an adjuvant to morphine for patient controlled analgesia in morbidly obese patients. J Med Sci. 2008;8:364–70.

    Article  CAS  Google Scholar 

  29. Chaparro LE, Smith SA, Moore RA, et al. Pharmacotherapy for the prevention of chronic pain after surgery in adults. Cochrane Database Syst Rev. 2013;7:CD008307.

  30. Mathews TJ, Churchhouse AM, Housden T, et al. Does adding ketamine to morphine patient-controlled analgesia safely improve post-thoracotomy pain? Interact Cardiovasc Thorac Surg. 2012;14:194–9.

    Article  PubMed  Google Scholar 

  31. Hasanein R, El-Sayed W, Nashwa N, et al. The effect of combined remifentanil and low dose ketamine infusion in patients undergoing laparoscopic gastric bypass. Egypt J Anaesthesiol. 2011;27:255–60.

    Article  CAS  Google Scholar 

  32. Feld JM, Laurito CE, Beckerman M, et al. Non-opioid analgesia improves pain relief and decreases sedation after gastric bypass surgery. Can J Anaesth. 2003;50:336–41.

    Article  PubMed  Google Scholar 

  33. Sollazzi L, Modesti C, Vitale F, et al. Preinductive use of clonidine and ketamine improves recovery and reduces postoperative pain after bariatric surgery. Surg Obes Relat Dis. 2009;5:67–71.

  34. Hassani V, Pazouki A, Nikoubakht N, et al. The effect of gabapentin on reducing pain after laparoscopic gastric bypass surgery in patients with morbid obesity: a randomized clinical trial. Anesth Pain Med. 2015;5:e22372.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Hilvering B, Draaisma WA, van der Bilt JD, et al. Randomized clinical trial of combined preincisional infiltration and intraperitoneal instillation of levobupivacaine for postoperative pain after laparoscopic cholecystectomy. Br J Surg. 2011;98:784–9.

    Article  CAS  PubMed  Google Scholar 

  36. Bouhassira D, Attal N, Alchaar H, et al. Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain. 2005;114:29–36.

    Article  PubMed  Google Scholar 

  37. DeBaerdemaeker LE, Jacobs S, Pattyn P, et al. Influence of intraoperative opioid on postoperative pain and pulmonary function after laparoscopic gastric banding: remifentanil TCI vs sufentanil TCI in morbid obesity. Br J Anaesth. 2007;99:404–11.

    Article  CAS  Google Scholar 

  38. Gaszynski TM, Strzelczyk JM, Gaszynski WP. Post-anesthesia recovery after infusion of propofol with remifentanil or alfentanil or fentanyl in morbidly obese patients. Obes Surg. 2004;14:498–503.

    Article  PubMed  Google Scholar 

  39. Machado FC, Palmeira CCDA, Torres JNL, et al. Intraoperative use of methadone improves control of postoperative pain in morbidly obese patients: a randomized controlled study. J Pain Res. 2018;11:2123–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. De Oliveira GS, Duncan K, Fitzgerald P, et al. Systemic lidocaine to improve quality of recovery after laparoscopic bariatric surgery: a randomized double-blinded placebo-controlled trial. Obes Surg. 2014;24:212–8.

    Article  PubMed  Google Scholar 

  41. Blaudszun G, Lysakowski C, Elia N, et al. Effect of perioperative systemic α2 agonists on postoperative morphine consumption and pain intensity: systematic review and meta-analysis of randomized controlled trials. Anesthesiology. 2012;116:1312–22.

    Article  CAS  PubMed  Google Scholar 

  42. Singh PM, Panwar R, Borle A, et al. Perioperative analgesic profile of dexmedetomidine infusions in morbidly obese undergoing bariatric surgery: a meta-analysis and trial sequential analysis. Surg Obes Relat Dis. 2017;13:1434–46.

    Article  PubMed  Google Scholar 

  43. Vigneault L, Turgeon AF, Cote D, et al. Perioperative intravenous lidocaine infusion for postoperative pain control: a meta-analysis of randomized controlled trials. Can J Anaesth. 2011;58:22–37.

    Article  PubMed  Google Scholar 

  44. Sun Y, Li T, Wang N, et al. Perioperative systemic lidocaine for postoperative analgesia and recovery after abdominal surgery: a meta-analysis of randomized controlled trials. Dis Colon Rectum. 2012;55:1183–94.

    Article  PubMed  Google Scholar 

  45. Dholakia C, Beverstein G, Garren M, et al. The impact of perioperative dexmedetomidine infusion on postoperative narcotic use and duration of stay after laparoscopic bariatric surgery. J Gastrointest Surg. 2007;11:1556–9.

    Article  PubMed  Google Scholar 

  46. Raffa RB, Buschmann H, Christoph T, et al. Mechanistic and functional differentiation of tapentadol and tramadol. Expert Opin Pharmacother. 2012;13:1437–49.

    Article  CAS  PubMed  Google Scholar 

  47. Schumann R. Anaesthesia for bariatric surgery. Best Pract Res Clin Anaesthesiol. 2011;25:83–93.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

    Consortia

    Adis Medical Writers

    Ethics declarations

    Conflict of interest

    The article was adapted from Drugs 2019;79(11):1163-75 [2] by employees of Adis International Ltd./Springer Nature, who are responsible for the article content and declare no conflicts of interest.

    Funding

    The preparation of this review was not supported by any external funding.

    Rights and permissions

    Reprints and permissions

    About this article

    Check for updates. Verify currency and authenticity via CrossMark

    Cite this article

    Adis Medical Writers. Manage perioperative pain in morbidly obese patients by taking an all-round multimodal approach. Drugs Ther Perspect 36, 139–145 (2020). https://doi.org/10.1007/s40267-020-00705-1

    Download citation

    • Published:

    • Issue Date:

    • DOI: https://doi.org/10.1007/s40267-020-00705-1

    Search

    Navigation