Improving pain control during transarterial chemoembolization for hepatocellular carcinoma performed under local anesthesia with multimodal analgesia

• Published in: Diagnostic and interventional imaging 2023-03, Vol.104 (3), p.123-132
• Main Authors: Vanderbecq, Quentin, Grégory, Jules, Dana, Jeremy, Dioguardi Burgio, Marco, Garzelli, Lorenzo, Raynaud, Lucas, Frémy, Sébastien, Paulatto, Luisa, Bouattour, Mohamed, Kavafyan-Lasserre, Juliette, Vilgrain, Valérie, Ronot, Maxime
• Format: Article
• Language: English
• Subjects: Abdominal Pain - etiology; Aged; Aged, 80 and over; Analgesia; Analgesics opioid; Anesthesia, Local; Carcinoma, Hepatocellular - pathology; Carcinoma, Hepatocellular - therapy; Chemoembolization; Chemoembolization, Therapeutic - methods; Female; Hepatocellular carcinoma; Humans; Liver cirrhosis; Liver Neoplasms - pathology; Liver Neoplasms - therapy; Male; Middle Aged; Non-narcotic analgesics; Pain measurement; Retrospective Studies; Treatment Outcome
• ISSN: 2211-5684; 2211-5684
• DOI: 10.1016/j.diii.2022.10.013

•Adding nefopam and tramadol reduces pain in patients undergoing conventional transarterial chemoembolization for hepatocellular carcinoma.•A reinforced analgesic protocol does not increase the rate of peri and post procedural adverse events.•Existing individual pain risk stratification criteria do not seem relevant for deciding on adding nefopam and tramadol for pain relief in transarterial chemoembolization for hepatocellular carcinoma. The purpose of this study was to assess the performance of a reinforced analgesic protocol (RAP) on pain control in patients undergoing conventional trans-arterial chemoembolization (cTACE) for hepatocellular carcinoma (HCC). Eighty-one consecutive patients (57 men, 24 women) with a mean age of 69 ± 10 (standard deviation) years (age range: 49–92 years) underwent 103 cTACEs. Standard antalgic protocol (50 mg hydroxyzine, 10 mg oxycodone, 8 mg ondansetron, and lidocaine for local anesthesia) was prospectively compared to a RAP (standard + 40 mg 2-h infusion nefopam and 50 mg tramadol). The individual pain risk was stratified based on age, the presence of cirrhosis and alcoholic liver disease, and patients were assigned to a low-risk group (standard protocol) or high-risk group (RAP). The primary endpoint was severe periprocedural abdominal pain (SAP), defined as a visual analog scale score ≥30/100. A predefined intermediate analysis was performed to monitor the benefit-risk of the RAP. Based on the intermediate analysis, all patients were treated with the RAP. The intermediate analysis performed after 52 cTACE showed that 2/17 (12%) high-risk patients (i.e., those receiving the RAP) experienced SAP compared to 15/35 (43%) low-risk patients (odds ratio [OR] = 0.18; 95% confidence interval [CI]: 0.02–0.98; P = 0.03). Analysis of all procedures showed that 12/67 (18%) patients in cTACE receiving the RAP experienced SAP compared to 15/36 (42%) patients who did not receive it (OR = 3.27; 95% CI: 1.32–8.14; P = 0.01). There were no statistical differences in adverse events, particularly for nausea, between groups. Reinforcing the analgesic protocol by combining non-opioid and opioid molecules reduces perioperative pain in patients undergoing cTACE for HCC.