Opioid-Free Analgesia for Supratentorial Craniotomies: A Systematic Review

• Published in: Canadian journal of neurological sciences 2019-07, Vol.46 (4), p.415-422
• Main Authors: Darmawikarta, Denise, Sourour, Michel, Couban, Rachel, Kamath, Sriganesh, Reddy, Kesava KV, Shanthanna, Harsha
• Format: Article
• Language: English
• Subjects: Analgesics, Non-Narcotic - therapeutic use; Analgesics, Opioid - therapeutic use; Aneurysms; Craniotomy - adverse effects; Data collection; Gastrointestinal surgery; Humans; Morphine; Narcotics; Original Article; Pain; Pain Management - methods; Pain, Postoperative - drug therapy; Patients; Performance evaluation; Supratentorial Neoplasms - surgery; Systematic review
• ISSN: 0317-1671; 2057-0155
• DOI: 10.1017/cjn.2019.57

Background: Post-craniotomy pain can be severe and is often undermanaged. Opioids can interfere with neurological monitoring and are associated with adverse effects. This systematic review aimed to identify measures of opioid-free analgesia and compare their effectiveness with opioid analgesia for post-craniotomy pain in patients with supratentorial tumors. Methods: EMBASE, MEDLINE, and Cochrane databases were searched from their inception to February 14, 2017, for randomized controlled trials (RCTs) evaluating opioid versus non-opioid analgesia post-supratentorial craniotomy. Two reviewers independently carried out study selection and data extraction. Risk of bias assessment was performed using the Cochrane Collaboration’s tool. Outcomes were pain control (changes to pain scores or use of rescue analgesia) and adverse effects. Considering the number of studies and heterogeneity, a narrative synthesis was done without pooling and results were summarized using tables. Non-opioids were assessed for the potential to be equivalent to opioid-based analgesics for pain relief and adverse effects. Results: Of 467 RCTs, 4 met our inclusion criteria (n = 186 patients). Patients with scalp blocks (2 RCTs) had less post-operative nausea and vomiting (PONV), but scalp block was not superior to morphine for analgesia. Acetaminophen (1 RCT) was less likely to induce PONV but provided inadequate pain relief compared to morphine and sufentanil. Dexmedetomidine (1 RCT) was not superior to remifentanil for analgesia although it delayed time to rescue analgesia. Conclusions: Limited evidence suggests that scalp blocks and dexmedetomidine have the potential to eliminate the need for opioid analgesia. Multimodal analgesia should be considered as significant opioid-sparing effects have been shown. Analgésie sans opioïdes dans les craniotomies supratentorielles: revue systématique. Contexte: La douleur post-craniotomie peut être sévère et n’est souvent pas maintenue. Les opioïdes peuvent interférer avec la surveillance neurologique et sont associés à des effets indésirables. Cette revue systématique visait à identifier les mesures d’analgésie sans opioïdes et à comparer leur efficacité à celle des analgésiques opioïdes pour le traitement de la douleur post-craniotomie chez les patients atteints de tumeurs supratentorielles. Méthodes: Les bases de données EMBASE, MEDLINE et Cochrane ont été explorées depuis leur création jusqu’au 14 février 2017 dans le cadre d’essais contrôlés ra