Opioid-Sparing Multimodal Analgesia Versus Opioid Analgesia for Postoperative Pain After Elective Craniotomy
Condition: Analgesia Post Craniotomy
MeSH terms: Agnosia; Pain, Postoperative
Study type: Interventional

Summary: 
      Several neurosurgical procedures can cause postoperative pain including craniotomies for
      tumor resections, epilepsy surgery and craniotomies for aneurysm clipping, penetrating
      traumatic brain injury, and neuroradiological procedures such as arteriovenous embolization
      procedures and aneurysm coiling's. Postoperative hematomas, elevation of intracranial
      pressures, cerebral infarctions, seizures, hypertension, development of air embolism, cranial
      nerve injury, and the development of cerebral edema and stroke can complicate the management
      of postoperative pain .

      Within the initial 24 hours post craniotomy, 60% of patients experienced moderate-to-severe
      pain. Most patients describe the pain as predominantly superficial suggesting a pathogenesis
      that is somatic instead of visceral. It is believed to originate from soft tissue and per
      cranial muscle, rather than the brain tissue itself .

      Majority of patients undergoing craniotomy experienced severe pain in surgical site after the
      procedure.Insufficient pain control after craniotomy can increase the intracranial pressure
      in patients with compromised cerebral auto regulation, and arterial or intracranial
      hypertension can lead to intracranial hemorrhage .

      Moreover, most neurosurgeons want to ascertain the neurological results as early as possible,
      so cautious postoperative pain management is required so as not to disturb the neurological
      assessment after craniotomy .

      As a consequence of these conflicting scenarios and emerging interest in avoiding opioids,
      there is greater emphasis on sparing -opioid alternatives, as well as growing interest in the
      use of opioid-free anesthesia and perioperative analgesia .

      If the need for opiates is eliminated for these patient it will improve post-operative
      neurological examination significantly and hopefully decrease the number of investigations
      (e.g. computed tomography [CT] scans) due to more reliable clinical examination .

      There is lack of consensus and evidence regarding the use of common systemic analgesics for
      post craniotomy pain. Analgesic adjuvants like Paracetamol, NSAIDs, gabapentin,
      dexmedetomedine, scalp block can be used alone or in combination. When various analgesic
      drugs of different classes, different mechanisms of action, and adverse-effect profiles are
      used in combination, this may result in synergism of the analgesic effects. This method is
      called Multimodal analgesia, it is considered very effective and optimum for management of
      post craniotomy pain, in addition to opioid sparing effect .

      Rationale Stress response to pain after craniotomy procedure in the form of hemodynamic
      changes (hypertension and tachycardia) and increase in intracranial tension, can cause
      serious intracranial complications.Opioids are the most commonly used agents for treating
      moderate to severe postoperative pain, however it usually associated with adverse effects
      such as postoperative nausea and vomiting, respiratory depression and excessive
      sedation.Previous studies showed that combined use of multimodal opioid sparing analgesics
      such as Paracetamol, NSAIDs, Gabapentin, Dexamdetomedine, scalp block offers the promise of
      improved pain and reduced opioid consumption while preserving the clinical neurologic
      examination. Research question: Is multimodal opioid sparing analgesia safer, beneficial and
      more effective than opioids for post craniotomy analgesia? Aim of the study Adequate
      analgesia with less opioid consumption and related side effects in patients with elective
      craniotomy.

      Objectives

        1. To compare the effectiveness of opioid- sparing and opioid analgesia in the treatment of
           post-craniotomy pain: regarding pain relief time to the first rescue analgesia and total
           dose of postoperative analgesia.

        2. To compare adverse effects between opioid and opioid- sparing analgesia groups such as
           postoperative nausea and vomiting and excessive sedation.
    


Intervention name(s): Morphine versus multimodal analgesia for post elective craniotomy pain
Intervention type(s): Drug
Intervention description(s): To compare the effectiveness of opioid- sparing multimodal analgesia and opioid analgesia in the treatment of post-craniotomy pain
Intervention MeSH terms: Morphine
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Treatment