Caudal Morphine in Pediatric Patients: A Comparison of Two Different Doses in Children Undergoing Infraumbilical Surgery - A Prospective, Randomized, Double-Blind Study

Background

One of the most feared symptoms of any disease is PAIN. It is a complex phenomenal experience, especially in children. Various methods and medications have been administered through different routes. Regional anesthesia produces marvelous postoperative analgesia and cessation of stress response in infants and children. Caudal epidural analgesia is the most acceptable and popular method of providing intra- and postoperative analgesia for abdominal, perineal, and lower limb surgeries in children. The use of preservative-free morphine as an adjunct to ropivacaine increases the quality and duration of analgesia despite the various side effects. Various articles use various doses of morphine as an adjuvant in caudal epidural analgesia. Hence, we conducted the study to compare the two dosages of morphine that is 20 μg.kg-1 and 30 μg.kg-1 of caudal epidural morphine for infraumblical surgeries with regard to its efficacy and safety and side effect profiles.

Materials and Methods

The study is a prospective, randomized, double-blinded study. Sixty patients were divided into two groups. Group A: 20 μg.kg-1 of morphine was added to 0.2% ropivacaine 1 mL.kg-1 and the solution was made. Group B: 30 μg.kg-1 of morphine was added to 1 mL.kg-1 of 0.2% ropivacaine. Heart rate, systolic blood pressure, diastolic blood pressure, SPO2, pain score, and sedation score were recorded immediately, after 15 min, 30 min, 45 min, 1 h, 2 h, 4 h, 8 h, 12 h, 16 h, 18 h, and 24 h were recorded.

Results

The mean duration of analgesia is similar in both groups (P = 0.011). The mean duration was 20.517 ± 1.9143 h in Group A and 22.233 ± 1.6853 h in Group B. Children with the requirement of one dose of rescue analgesia in Group A was 83.3% which was higher than Group B being 66.7%. Children with no analgesic requirement were 16.7% in Group A and 33.3% in Group B. The incidence of side effects was more in Group B (8 [26.7%] children with nausea and vomiting; 1 [3.3%] children with urinary retention) than in Group A (2 [6.6%] children with nausea and vomiting.

Conclusion

From the above observations, it can be concluded that morphine of less dosage (20 μg.kg-1) when added to 0.2% ropivacaine for the caudal epidural block has better efficacy than morphine of higher dosage (30 μg.kg-1) as the duration of analgesia is similar with decreased incidence of side effects.

3D printing in orthopaedic surgery: a scoping review of randomized controlled trials

Aims

The use of 3D printing has become increasingly popular and has been widely used in orthopaedic surgery. There has been a trend towards an increasing number of publications in this field, but existing literature incorporates limited high-quality studies, and there is a lack of reports on outcomes. The aim of this study was to perform a scoping review with Level I evidence on the application and effectiveness of 3D printing.

Methods

A literature search was performed in PubMed, Embase, and Web of Science databases. The keywords used for the search criteria were ((3d print*) OR (rapid prototyp*) OR (additive manufactur*)) AND (orthopaedic). The inclusion criteria were: 1) use of 3D printing in orthopaedics, 2) randomized controlled trials, and 3) studies with participants/patients. Risk of bias was assessed with Cochrane Collaboration Tool and PEDro Score. Pooled analysis was performed.

Results

Overall, 21 studies were included in our study with a pooled total of 932 participants. Pooled analysis showed that operating time (p < 0.001), blood loss (p < 0.001), fluoroscopy times (p < 0.001), bone union time (p < 0.001), pain (p = 0.040), accuracy (p < 0.001), and functional scores (p < 0.001) were significantly improved with 3D printing compared to the control group. There were no significant differences in complications.

Conclusion

3D printing is a rapidly developing field in orthopaedics. Our findings show that 3D printing is advantageous in terms of operating time, blood loss, fluoroscopy times, bone union time, pain, accuracy, and function. The use of 3D printing did not increase the risk of complications.

Cite this article: Bone Joint Res 2021;10(12):807–819.

Long-term patient-reported outcomes for open surgery of the triangular fibrocartilage complex

Aims

Studies on long-term patient-reported outcomes after open surgery for triangular fibrocartilage complex (TFCC) are scarce. Surgeons and patients would benefit from self-reported outcome data on pain, function, complications, and satisfaction after this surgery to enhance shared decision-making. The aim of this study is to determine the long-term outcome of adults who had open surgery for the TFCC.

Methods

A prospective cohort study that included patients with open surgery for the TFCC between December 2011 and September 2015. In September 2020, we sent these patients an additional follow-up questionnaire, including the Patient-Rated Wrist Evaluation (PRWE), to score satisfaction, complications, pain, and function.

Results

A total of 113 patients were included in the analysis. At ≥ 60 months after an open TFCC reinsertion, we found a mean PRWE total score of 19 (SD 21), a mean PRWE pain score of 11 (SD 11), and a PRWE function score of 9 (SD 10). The percentage of patients obtaining minimum clinically important difference rose from 77% at 12 months to 83% at more than 60 months (p < 0.001). Patients reported fewer complications than surgeons, and overall complication rate was low.

Conclusion

Outcomes of patient-reported pain, function scores, and satisfaction are improved five years after open surgery for the TFCC.

Cite this article: Bone Jt Open 2021;2(11):981–987.

Pre-delivery angiogenic factors and their association with peripartum perceived stress and pain in pre-eclampsia with severe features and normotensive pregnancies

OBJECTIVE

To determine if any of maternal pre-delivery soluble fms-like tyrosine kinase-1 (sFlt-1), placental growth factor (PIGF), or sFlt-1/PIGF ratio correlate with either perceived stress scale (PSS) or verbal numeric rating scale (VNRS) pain scores.

METHODS

Among 50 pregnant women with severe pre-eclampsia and 90 normotensive pregnant women observed from 48 h or less before delivery until day 3 postpartum, correlations between the following were performed: (1) serum concentrations of each angiogenic factor (sFlt-1, PIGF, and sFlt-1/PIGF ratio) sampled within 48 h before childbirth and a four-item PSS (pre-delivery and one-off 48-72 h postpartum score); (2) the same angiogenic factors above and VNRS ranging from 0 to 10; and (3) PSS and VNRS (both pre-delivery and postpartum).

RESULTS

In the normotensive group, there was a positive correlation between sFlt-1 and postpartum PSS (ρ +0.214 and P = 0.043), and between sFlt-1/PIGF ratio and postpartum PSS (ρ +0.213 and P = 0.044). In the normotensive and severe pre-eclampsia groups there were non-significant negative correlations between PIGF and postpartum PSS (P > 0.096) and non-significant positive correlations between pre-delivery PSS and pre-delivery VNRS (P > 0.053). Other correlations were uninformative.

CONCLUSION

Maternal pre-delivery sFlt-1/PIGF ratio in normotensive pregnancy is a promising biomarker for identifying risk of increased postpartum PSS to enable early counselling.

Effect of tranexamic acid in arthroscopic anterior cruciate ligament repair: A systematic review and meta-analysis of randomised clinical trials

PURPOSE

Perioperative blood loss remains a major challenge to surgeons in anterior cruciate ligament reconstruction (ACLR) surgery, despite of the introduction of minimally invasive approach. Tranexamic acid (TXA) is believed to reduce blood loss, which may minimise the complication of postoperative haemarthrosis with insufficient evidence on its effectiveness in ACLR. The primary aim of this study was to examine the effect of TXA on postoperative blood loss and other secondary outcomes in patients undergoing arthroscopic ACLR surgery.

METHOD

PUBMED, EMBASE, MEDLINE and CENTRAL database were systematically searched from its inception until November 2020. All randomised clinical trials (RCTs) comparing TXA (intravenous or intra-articular) versus placebo in the arthroscopic ACLR surgery were included. Case series, case report and editorials were excluded.

RESULTS

Five RCTs comprising of a total of 580 patients (291 in TXA group, 289 in control group) were included for qualitative and quantitative meta-analysis. In comparison to placebo, TXA group was significantly associated with lower postoperative blood loss (mean difference (MD): -81.93 ml; 95% CI -141.80 to -22.05) and lower incidence of needing knee aspiration (odd ratio (OR): 0.19; 95% CI 0.08 to 0.44). Patients who randomised to TXA were also reported to have better range of movement (MD: 2.86; 95% CI 0.54 to 5.18), lower VAS Pain Score (MD: -1.39; 95% CI -2.54 to -0.25) and higher Lysholm Score (MD: 7.38; 95% CI 2.75 to 12.01).

CONCLUSION

In this meta-analysis, TXA reduced postoperative blood loss with lesser incidence of needing knee aspiration along with better range of knee movement and Lysholm score in patients undergoing arthroscopic ACLR surgery.

Comparing the efficacy and safety of Dexmedetomidine/Ketamine with Propofol/Fentanyl for sedation in colonoscopy patients: A double-blinded randomized clinical trial

BACKGROUND

In this double-blinded randomized clinical trial, we aimed to compare the safety and efficacy of a combination of dexmedetomidine and ketamine [DK] with propofol and fentanyl [PF] for sedation in colonoscopy patients.

METHODS

In this study, 64 patients who underwent colonoscopy were randomized into two groups: 1) A, which received PF, and 2) B, which received DK for sedation. Among 64 patients, 31 patients were included in PF, and 33 patients were included in the DK group. Both groups were similar in terms of demographics. Patients' sedation score (based on Ramsay sedation scale) and vital signs were recorded at 2, 5, 10, and 15 minutes. Complications including apnea, hypotension, hypoxia, nausea, and vomiting, along with gastroenterologist satisfaction and patients' pain score (based on Wong-Baker faces pain assessment scale), were recorded by a checklist. Data were analyzed by SPSS v.18 software, using chi-square, independent t-tests, and repeated measures analysis with p<0.05 as the criterion for significant differences.

RESULTS

The mean score of sedation was 4.82±0.49 in the DK group and 5.22±0.45 in the PF group [p value=0.001]. Serious complications, including hypotension [p value=0.005] and apnea [p value=0.10] were significantly higher in the PF group. Satisfaction of gastroenterologist [p value= 0.400] and patients' pain score [p value = 0.900] were similar among groups.

CONCLUSION

Combination of DK provides sufficient sedation with fewer complications in comparison with PF in colonoscopy patients.

Comparison of the efficacy of lotrafilcon B and comfilcon A silicone hydrogel bandage contact lenses after transepithelial photorefractive keratectomy

Background

At completion of transepithelial photorefractive keratectomy (t-PRK) surgery, the eye is usually fitted with a bandage contact lens to reduce discomfort and promote epithelial healing. This study aimed to compare the outcomes of eyes fitted with lotrafilcon B versus comfilcon A, silicone hydrogel bandage contact lenses after t-PRK for the correction of low to moderate myopia, with or without astigmatism.

Methods

In this comparative, prospective study, patients with myopia < -6 D with or without astigmatism (< 1.75 D), who underwent t-PRK between January and June 2018, were randomly allocated to the lotrafilcon B and comfilcon A groups. Preoperative characteristics, including age, sex, eye treated, uncorrected visual acuity (UCVA), best-corrected visual acuity, mesopic pupil size, central corneal thickness, and refractive error were recorded. Postoperatively, pain score, UCVA, and corneal epithelial defect size on days 1, 4, and 7 were compared between the two groups.

Results

Twenty-nine eyes were included in each group. Demographic characteristics and preoperative measurements were similar between the two groups. UCVA was significantly improved on day 7 as compared to day 1 in the comfilcon A group (P = 0.03), but remained the same in the lotrafilcon B group (P = 0.70) as on day 1 postoperatively. There was no significant difference in UCVA between the two groups at any follow-up visits (all P > 0.05). The pain score on the first postoperative day was significantly higher in the lotrafilcon B-fitted eyes than in the comfilcon A group (P < 0.001), but was significantly reduced in both groups compared to day 1 (both P < 0.001). The epithelial defect in the comfilcon A group was significantly greater than in the lotrafilcon B group (P < 0.001) at day 1 postoperatively, with significant improvement in both groups (both P < 0.001).

Conclusions

Healing responses were better with lotrafilcon B than with comfilcon A bandage contact lenses. The patients had a greater mean pain score with lotrafilcon B than with comfilcon A lenses on the first postoperative day, yet the final outcome was comparable between the two groups. We did not encounter any postoperative complications related to contact lens wear.

Acute Pain Management for Patients with Substance Use Disorder Receiving Buprenorphine or Methadone Compared to Patients without Opioid-Dependence Disorder

This single-center retrospective study assessed pain management between patients being treated for SUD and compared them to those without SUD who underwent orthopedic surgery. Patients with SUD could be admitted for any reason, while the control arm consisted of patients undergoing total knee arthroplasty or hip arthroplasty surgery. Primary endpoints were average pains scores and morphine milligram equivalents (MME) over the first 48h. Secondary endpoints include adjuvant pain medications and the average MME prescribed upon discharge. A total of the 60 patients were enrolled, 30 patients had history of SUD and 30 patients in the control arm. Average MME between the SUD and control was not significantly different (139.9 mg vs. 96.6 mg, p = 0.889). Average pain scores between the groups were significantly different (7.46 vs. 5.94, p = 0.002). Patients with SUD were not given a statistically different amount of MME for acute pain and experienced higher pain scores than patients without SUD. However, this study had a small population size, and further case-control studies are needed to confirm this result.

Pre-Hospital Pain Management in Children with Injuries: A Retrospective Cohort Study

Background: The all-too-frequent failure to rate pain intensity, resulting in the lack of or inadequacy of pain management, has long ceased to be an exclusive problem of the young patient, becoming a major public health concern. This study aimed to evaluate the methods used for reducing post-traumatic pain in children and the frequency of use of such methods. Additionally, the methods of pain assessment and the frequency of their application in this age group were analysed. Methods: A retrospective analysis of 2452 medical records of emergency medical teams dispatched to injured children aged 0–18 years in the area around Warsaw (Poland). Results: Of all injured children, 1% (20 out of 2432) had their pain intensity rated, and the only tool used for this assessment was the numeric rating scale (NRS). Children with burns most frequently received a single analgesic drug or cooling (56.2%), whereas the least frequently used method was multimodal treatment combining pharmacotherapy and cooling (13.5%). Toddlers constituted the largest percentage of patients who were provided with cooling (12%). Immobilisation was most commonly used in adolescents (29%) and school-age children (n = 186; 24%). Conclusions: Low frequency of pain assessment emphasises the need to provide better training in the use of various pain rating scales and protocols. What is more, non-pharmacological methods (cooling and immobilisation) used for reducing pain in injured children still remain underutilized.

A comparative study of epidural labor analgesia and natural delivery without analgesia

OBJECTIVE

To investigate the effects of epidural labor analgesia and natural delivery without analgesia on labor duration, pain, uterine continuous contraction time, abnormal labor process and complications.

METHODS

A total of 220 primiparas in our hospital were selected and divided into two groups according to whether they accepted epidural labor analgesia, including 146 cases in the study group and 74 cases in the blank group. Primiparas in the study group received epidural block analgesia, and those in the blank group received routine labor without analgesia. Duration of the first, second and third stages of labor was observed and recorded. The NRS pain score and uterine continuous contraction time were detected before and after the analgesia. The abnormal situation and complications of primiparas in the two groups were recorded.

RESULTS

Compared with those in the blank group, the duration of the first stage of labor and the amount of postpartum hemorrhage in the study group were decreased (all P<0.001). The primiparas' NRS score in the study group was lower than that in the blank group at 10 min, 15 min, 30 min, 60 min and 120 min after analgesia (all P<0.001). The duration of uterine contractions in the study group was lower than that in the blank group at 15 min, 30 min and 60 min after analgesia (all P<0.01). Compared with those in the blank group, primiparas in the study group had a higher probability of active phase arrest in the process of labor (P<0.05). Compared with the blank group, the probability of urinary retention in the study group increased (P<0.05).

CONCLUSION

The effect of epidural labor analgesia is better, which is conducive to shorten the time of the first stage of labor, good analgesic effect, shorter duration of the uterine contraction and higher safety.

Analgesic effects of erector spinae plane block for patients after breast surgery: a systematic review and meta-analysis

OBJECTIVE

This meta-analysis investigated the analgesic effects of erector spinae plane block (ESPB) in patients undergoing breast surgery.

METHODS

PubMed, Embase, Web of Science, and the Cochrane Library were searched from database establishment to January 31, 2020. Two reviewers independently extracted the data. The primary outcomes were pain scores and opioid consumption during the first 24 hours after surgery. The risk of bias of the included studies was assessed according to the Cochrane Handbook.

RESULTS

Six randomized controlled trials of 415 patients were included. Compared with the control value, the pain score was significantly lower in the ESPB group at different time points postoperatively. Patients who underwent ESPB required lower opioid consumption (standardized mean difference = -2.02, 95% confidence interval [CI] = -2.85 to -1.20, I²= 91%. The rates of postoperative nausea (risk ratio [RR] = 0.79, 95% CI = 0.48-1.30, I² = 47%) and postoperative vomiting (RR = 0.76, 95% CI = 0.30-1.96, I² = 33%) did not differ between the groups. The quality of evidence was low or very low.

CONCLUSIONS

ESPB significantly alleviated pain and reduced opioid consumption after breast surgery. Further research is needed to expand its clinical application.PROSPERO registration number CRD42020167900.

Local Ketorolac Injection vs Popliteal Sciatic Nerve Blockade as an Adjuvant to a Spinal Block in Hindfoot Arthrodesis

BACKGROUND

Popliteal nerve blocks reduce pain and markedly improve postoperative outcomes during foot and ankle surgery; however, several potential complications may arise from nerve block procedures. The purpose of this study was to investigate local infiltration analgesia with ketorolac as a convenient alternative for pain relief.

METHODS

A total of 80 patients scheduled for hindfoot arthrodesis were randomly allocated to one of 2 anesthetic groups: a spinal block augmented with either a popliteal nerve block (n = 40) or local ketorolac and Marcaine infiltration (n = 40). Clinical assessment included postoperative visual analog scale (VAS) pain scores at 4, 8, 12, 24, and 48 hours, total morphine consumption, time to incision (time in operating room to incision), operative time, length of hospital stay, and complications.

RESULTS

Despite similar morphine consumption between groups (P = .28), VAS scores were significantly lower at 24 hours (1.6 ± 2.2 cm vs 2.7 ± 3.0 cm, P = .01) and 48 hours (0.2 ± 0.7 cm vs 1.0 ± 1.5 cm, P < .01) after surgery using local ketorolac injection. Although time from entry into the operating room to incision was also reduced after local ketorolac injection (19.0 ± 5.3 minutes vs 31.4 ± 14.6 minutes, P < .001), the length of operative time (P = .38), hospital stay (P = .43), and number of complications (P = .24) were similar between groups.

CONCLUSION

Ketorolac local injection provided effective pain control in hindfoot arthrodesis and markedly reduced VAS pain scores up to 48 hours after surgery compared with popliteal nerve block. In addition, ketorolac local injection also reduced time in the operating room compared with popliteal nerve blockade.

LEVEL OF EVIDENCE

Level 1, randomized controlled trial.

A Comparison of Pain Scores in Dysmenorrheic Patients With or Without Dyspeptic Symptoms

Introductıon: Dysmenorrhea attacks may be accompanied by extragenital symptoms such as nausea, vomiting, diarrhea, headache and leg pain and by emotional symptoms such as tension and irritability. Therefore, we think that dysmenorrheic symptoms may be more severe in patients with dyspeptic symptoms. The purpose of this study was to determine whether pain scores would differ between dysmenorrheic patients with or without dyspeptic symptoms.

METHODS

Patients presenting to the emergency department with dysmenorrhea attacks and volunteering to participate were included in this case-control study. Subjects with dyspeptic symptoms were enrolled as the case group and those without dyspeptic symptoms were enrolled as the control group. Participants were administered the Faces Pain Scale and a questionnaire involving demographic characteristics.

RESULTS

Pain scores on arrival were higher in the case group than in the control group (4.20 ± 0.71, 3.70 ± 0.74, n=30, p=0.011). A significant difference was observed between pain scores on arrival and at discharge in both the control and case groups. A decrease in pain scores was determined in all the subjects in the case group, while no change was observed in three volunteers in the control group.

CONCLUSIONS

We conclude that pain is significantly more severe in dysmenorrheic patients with dyspeptic symptoms.

Effects of acupoint catgut embedding on the postmenopausal osteoporosis patients and related mechanism

OBJECTIVE

To study the effect and mechanism of acupoint catgut embedding on patients of postmenopausal osteoporosis (PMOP).

METHODS

In this prospective study, 90 patients with PMOP who received treatment in our hospital were randomly divided into the drug treatment group (n=45) and drug treatment + catgut embedding group (n=45) according to SPSS random table method. The drug treatment group was given conventional western medicine treatment, and the drug treatment + catgut embedding group was given point embedding therapy. Bone mineral density (BMD), calcium (Ca²⁺), osteoprotegerin (OPG), estrogen (E₂), receptor activator of nuclear factor-kB ligand (RANKL), liver and kidney function and blood lipids were detected before treatment in the two groups, and visual analogue score (VAS) and PMOP symptom score were evaluated. The above-mentioned indexes were detected again 3 months and 6 months after treatment.

RESULTS

At 3 and 6 months after treatment, the BMD and the levels of Ca²⁺ and E₂ in the two groups were increased, while the levels of OPG and RANKL were decreased, and the improvement in the drug treatment + catgut embedding group was significantly better than that in the drug treatment group (P<0.05). The symptom scores of VAS and PMOP in the drug treatment + catgut embedding group were significantly lower than those in the drug treatment group (all P<0.001). There was no significant difference in the levels of alanine aminotransferase (ALT), total bilirubin (TBil), albumin (ALB), blood urea nitrogen (BUN), serum creatinine (SCr) and serum uric acid (SUA) between the two groups, but the levels of total cholesterol (TC) and triglyceride (TG) in the drug treatment + catgut embedding group were significantly lower than those in the drug treatment group (all P<0.001).

CONCLUSION

Acupoint catgut embedding has a good effect on PMOP, and it can increase BMO and improve the clinical symptoms of patients, which is worthy of clinical promotion.

Transrectal ultrasound guided prostate biopsy in university of Benin teaching hospital: effect of prostate volume on pain amongst Nigerian patients

Prostate volume has been reported to have an effect on the severity of pain during prostate biopsy. This study assessed the effect of prostate volume on pain during TRUS guided prostate biopsy when apical peri-prostatic block is compared with intra-rectal xylocaine gel. This was a prospective randomized study which involved 90 patients. Group (A) had 2% intra-rectal plain xylocaine gel instillation, while Group (B) had peri-prostatic block with 1% plain xylocaine infiltration. Both groups were further stratified into prostate volume of < 50 mls and ≥50 mls. An 11 point visual analogue scale was used to assess pain during probe insertion, biopsy and 1 hour after biopsy. The mean pain score analyzed for each group. The mean pain score for Group (A) patients with prostate volume < 50 mls was 3.22.2, 7.31.7 and 2.11.4 during probe insertion, biopsy, and one hour after biopsy respectively. For Group (A) patients with prostate volume ≥50 mls, the mean pain score recorded was 2.81.8, 5.71.6, and 2.31.8 during probe insertion, biopsy and one hour after biopsy respectively (P{during biopsy} = 0.003). For Group B patients, the mean pain score during probe insertion, biopsy and one hour after biopsy for patients with prostate volume < 50 mls was 3.11.8, 2.81.7, 1.00.6 respectively. While for patients with prostate volumes ≥50 mls, the mean pain scores were 2.91.8, 3.21.8 and 1.30.9 respectively. This study revealed that prostate volume did not affect the severity of pain during prostate biopsy when apical peri-prostatic block was used as the anesthetic agent. Significantly reduced pain during trans-rectal ultrasound guided biopsy of the prostate for all prostate volumes. Intra-rectal xylocaine though inferior to peri-prostatic block was more effective for patients with prostate volume ≥50 mls.

Ultrasound guided central line insertion in neonates: Pain score results from a prospective study

BACKGROUND

Central lines can be placed through different techniques, either peripherally or centrally. Although they have the same aim, decision to use one of these modalities depends on the patient outcomes. The aim is to compare pain scores between ultrasound-guided central line insertion and peripherally inserted catheter in neonates in a prospective randomized single center study.

METHODS

A randomized controlled trial was conducted in neonates requiring central venous access for any of the following reasons: total parenteral nutrition (TPN), antibiotics treatment for at least 7 days and having poor or difficult venous access. The study compared pain difference, in neonates, that were randomized between peripherally and ultra-sound guided centrally placed central lines using the validated pain score N - PASS.

RESULTS

61 neonates were enrolled in the study. US-guided CICC was associated with less pain as reported by the statistically significant lower pain score difference (p-value <0.001) than the standard PICC. Additionally, the US-guided CICC had a higher rate of successful first attempt (p = 0.012), lower overall number of attempts (p < 0.001), and shorter procedure duration (p < 0.001) as compared to standard PICC.

CONCLUSION

US-guided CICC is a less painful technique than PICC line insertion associated with higher rate of successful first attempt, lower overall number of attempts and shorter procedure duration.

An investigation of the effects of dexmedetomidine and fentanyl as an adjuvant to ropivacaine on pain scores and hemodynamic changes following laparoscopic cholecystectomy

Postoperative pain control is recognized as a challenging surgical issue receiving high priority in the healthcare system, and opioids are routinely prescribed for anesthesia and pain relief. This study aimed to investigate the effects of ropivacaine administered intraperitoneally alone or combined with dexmedetomidine or fentanyl on postoperative pain control following laparoscopic cholecystectomy. This randomized double-blind clinical trial recruited three equal-size block-randomized groups of patients (n = 138) scheduled for elective laparoscopic cholecystectomy at Valiasr Hospital, Arak, Iran, in 2019–2020 who received ropivacaine (40 mL/0.5%), ropivacaine (40 mL/0.5%) + dexmedetomidine (1 μg/kg), and ropivacaine (40 mL/0.5%) + fentanyl (1 μg/kg). No significant differences were observed among the three groups according to the vital signs (mean arterial pressure/heart-rate/oxygen saturation) in the study period and during surgery (P > 0.05). Lower pain was revealed in the ropivacaine + dexmedetomidine group (P = 0.001), with the lowest opioid dose in postoperative 24 hours (P = 0.001). Moreover, no clinically significant differences were observed in complications among the three groups (P = 0.483), and no patient developed ileus. Intraperitoneal ropivacaine administered with dexmedetomidine could relieve pain and reduce opioid use in postoperative 24 hours, without any complication and ileus. Therefore, intraperitoneal ropivacaine administered with dexmedetomidine is recommended for postoperative pain control in patients undergoing laparoscopic cholecystectomy. This study was approved by the Ethical Committee of Arak University of Medical Sciences (approval No. IR.ARAKMU.REC.1397.267) on December 30, 2018 and was registered in the Iranian Registry of Clinical Trials (No. IRCT 20141209020258N117) on July 13, 2019.

Aqueous Chlorhexidine Compared with Povidone-Iodine as Ocular Antisepsis before Intravitreal Injection: A Randomized Clinical Trial

PURPOSE

Topical povidone-iodine (PI) is widely used as an ocular surface antiseptic for intravitreal injections (IVIs). Although PI is generally well tolerated, it can be associated with significant ocular irritation. Aqueous chlorhexidine (AqCHX) has been described as a possibly better tolerated antimicrobial for ophthalmic procedures. We compared patient pain scores, ocular surface characteristics, and antimicrobial efficacy between PI 5% and AqCHX 0.1% during IVIs.

DESIGN

Prospective single-center, randomized clinical trial.

PARTICIPANTS

Patients receiving same-day bilateral intravitreal anti-vascular endothelial growth factor (VEGF) injections.

METHODS

Each patient had 1 eye randomized to PI or AqCHX, and the second eye received the other agent. Both eyes received topical proparacaine 0.5%.

MAIN OUTCOME MEASURES

After IVIs, participants rated their pain (Wong-Baker, scale 0-10) for each eye 1 minute after PI or AqCHX instillation and 1 day after the procedure. Each eye was assessed using a standardized quantitative grading system of corneal epitheliopathy (ocular staining score). Microbial swab cultures of the conjunctiva both before instillation of topical antisepsis and 10 minutes after IVIs were given.

RESULTS

A total of 100 eyes of 50 patients were included. The mean patient age was 68 years (range, 39-92), and 30 of 50 (60%) were male. Compared with AqCHX, eyes receiving PI had a greater mean pain score immediately after injection (1.44 vs. 0.44, P < 0.001) but not on postprocedure day 1 (1.04 vs. 0.48, P = 0.06). Eyes that received PI had a higher ocular staining score indicating worse corneal epitheliopathy (4.22 vs. 3.10, P < 0.001). There was no difference in rates of positive microbial cultures between groups. There was no difference in rates of adverse events between groups (P = 0.99), and no cases of endophthalmitis occurred.

CONCLUSIONS

Povidone-iodine demonstrated greater ocular surface discomfort and corneal epitheliopathy compared with AqCHX during same-day bilateral IVIs. The 2 agents otherwise demonstrated no difference in positive microbial cultures or adverse events. Aqueous chlorhexidine may be a better tolerated alternative to PI for antimicrobial prophylaxis during IVIs for some patients.

Histone Deacetylase Inhibitors Prevented the Development of Morphine Tolerance by Decreasing IL6 Production and Upregulating μ-Opioid Receptors

BACKGROUND

Morphine tolerance on long-term usage leads to chronic pain conditions. Preclinical studies demonstrated that the upregulation of HDACs is associated with a decrease in the sensitivity of μ-opioid receptors, which results in morphine tolerance.

OBJECTIVE

The present study was designed to assess the influence of the selected known HDAC inhibitors (NMJ2 and NMJ3) on the pain tolerance induced by chronic administration of morphine in Balb/c mice.

METHODS

In the present study, morphine was administered in incremental doses 1, 2, 3.6, 6.5, 11.2, 21, and 21 mg/kg daily for seven days to develop morphine tolerance. The nociceptive thresholds, analgesia, and tolerance were assessed 30 min after morphine administration alternatively from 1st day to 7th day using the hot plate and mechanical allodynia methods.

RESULTS

The morphine control group showed a reduction in the Paw Withdrawal Threshold (PWT) and the percentage Maximum Possible Effects (MPEs). In contrast, the combination of SAHA and test drugs with morphine increased the PWT and MPEs as compared to the morphine alone group. Administration of morphine alone also showed an increase in the production of the pro-inflammatory mediator, IL-6, and down-regulation of the μ-opioid receptor in the brain tissues. Treatment with HDAC inhibitors, SAHA, and test drugs showed a reversal in these changes.

CONCLUSION

Results indicated that HDAC inhibitors were involved in the prevention of morphine tolerance in normal mice by inhibiting pro-inflammatory marker production and by increasing the sensitivity of neurons towards morphine in producing an analgesic effect in morphine tolerated mice.

Postoperative Pain Scores After Open Inguinal Hernia Repair: Comparison of Three Postoperative Analgesic Regimens

INTRODUCTION

Pain management after open inguinal hernia repair has become an issue that physicians deal with on a daily basis.

AIM

The purpose of this study was to investigate the analgesic effect of three different regimens of analgesics administered to patients undergoing open inguinal hernia repair.

METHODS

A total of 259 patients undergoing open inguinal hernia repair were enrolled. Patients were randomly allocated to one of three groups on admission, which would determine the prescribed post-operative analgesic regimen. Patients allocated to group A receiving a combination of 1gr/8hours intravenous (IV) acetaminophen and 50mg/6hours intramuscular (IM) pethidine, patients in group B receiving a combination of 1gr/8hours IV acetaminophen and 40mg/12hours IV parecoxib, while patients of group C received 1gr/8hours IV acetaminophen monotherapy. All patients remained overnight at the hospital and discharged the day after. Analgesic therapy was administered at regular intervals. Pain was evaluated utilizing the numeric rating scale (NRS) at 5 time points: the first assessment was done at 45 minutes, the second at 2 hours, the third at 6 hours, the fourth at 12 hours and the fifth at 24 hours post-administration. The postoperative pain intensities measured by NRS within groups and between groups at each time were analyzed using one-way repeat measured ANOVA and Post Hoc Test-Bonferroni Correlation.

RESULTS

The analgesic regimens of groups A and B (combination regimens consisting of IV acetaminophen and intramuscular pethidine and IV acetaminophen and IV parecoxib, respectively) were found to be of equivalent efficacy (P-value=1.000). In contrast, patients in group C (acetaminophen monotherapy) had higher NRS scores, compared to both patients in groups A (P-value<0.0001) and B (P-value<0.0001).

CONCLUSION

The combinations of IV acetaminophen with either intramuscular pethidine or IV parecoxib are superior to IV acetaminophen monotherapy in achieving pain control in patients undergoing open inguinal hernia repair.

Robotic surgery enables safe and comfortable single-incision cholecystectomy: A comparison of robotic and laparoscopic approaches for single-incision surgery

Background:

Although single-incision robotic cholecystectomy (SIRC) overcomes various limitations of single-incision laparoscopic cholecystectomy (SILC), it is associated with high cost. In this study, we intended to investigate if SIRC is recommendable and advantageous to patients despite its high cost.

Materials and Methods:

We prospectively collected and analysed data of patients who had undergone either SILC (n = 25) or SIRC (n = 50) for benign gallbladder diseases, with identical inclusion criteria, between November 2017 and February 2019.

Results:

SILC and SIRC showed similar operative outcomes in terms of intra- and post-operative complications and verbal numerical rating scale (VNRS) for pain. However, the SIRC group exhibited significantly longer operation time than the SILC group (83.2 ± 32.6 vs. 66.4 ± 32.8, P = 0.002). The SIRC group also showed longer hospital stay (2.4 ± 0.7 vs. 2.2 ± 0.6, P = 0.053). Although the SILC and SIRC groups showed no significant difference in VNRS, the SIRC group required a higher amount (126.0 ± 88.8 mg vs. 87.5 ± 79.7 mg, P = 0.063) and frequency (3.0 ± 2.1 vs. 2.0 ± 1.8, P = 0.033) of intravenous opioid analgesic administration. During surgery, the critical view of safety (CVS), the prerequisite for safe cholecystectomy, was identified in only 24% (n = 6) of patients undergoing SILC and in 100% (n = 50) of patients undergoing SIRC (P < 0.05).

Conclusion:

We conclude that although SILC and SIRC have similar operative outcomes, SIRC is advantageous over SILC because of its potential to markedly enhance the safety of patients by proficiently acquiring CVS.

Treatment effect of oil-based contrast is related to experienced pain at HSG: a post-hoc analysis of the randomised H2Oil study

STUDY QUESTION

Does pain or volume of used contrast medium impact the effectiveness of oil-based contrast during hysterosalpingography (HSG)?

SUMMARY ANSWER

In women who report moderate to severe pain during HSG, the use of oil-based contrast resulted in more ongoing pregnancies compared to the use of water-based contrast, whereas in women who reported mild or no pain, no difference in ongoing pregnancies was found.

WHAT IS KNOWN ALREADY

We recently showed that in infertile women undergoing HSG, the use of oil-based contrast results in more ongoing pregnancies within 6 months as compared to the use of water-based contrast. However, the underlying mechanism of this fertility-enhancing effect remains unclear.

STUDY DESIGN, SIZE, DURATION

We performed a post-hoc analysis of the H2Oil study, a multicentre randomised controlled trial (RCT) evaluating the therapeutic effect of oil- and water-based contrast at HSG. Here, we evaluated the impact of pain experienced at HSG and volume of used contrast media during HSG on ongoing pregnancy.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In a subset of 400 participating women, pain during HSG by means of the Visual Analogue Scale (VAS) (range: 0.0–10.0 cm) was reported, while in 512 women, we registered the volume of used contrast (in millilitres). We used logistic regression analyses to assess whether pain and volume of used contrast media modified the effect of oil-based contrast on ongoing pregnancy rates. Data were analysed according to intention-to-treat principle.

MAIN RESULTS AND THE ROLE OF CHANCE

In 400 women in whom pain scores were reported, the overall median pain score was 5.0 (Interquartile range (IQR) 3.0–6.8) (oil group (n = 199) 4.8 (IQR 3.0–6.4); water group (n = 201) 5.0 (IQR 3.0–6.7); P-value 0.28). There was a significant interaction between pain (VAS ≤5 versus VAS ≥6) and the primary outcome ongoing pregnancy (P-value 0.047). In women experiencing pain (VAS ≥6), HSG with oil-based contrast resulted in better 6-month ongoing pregnancy rates compared to HSG with water-based contrast (49.4% versus 29.6%; RR 1.7; 95% CI, 1.1–2.5), while in women with a pain score ≤5, 6-month ongoing pregnancy rates were not significantly different between the use of oil- (28.8%) versus water-based contrast (29.2%) (RR 0.99; 95% CI, 0.66–1.5). In the 512 women in whom we recorded contrast, median volume was 9.0 ml (IQR 5.7–15.0) in the oil group versus 8.0 ml (IQR 5.9–13.0) in the water group, respectively (P-value 0.72). Volume of used contrast was not found to modify the effect of oil-based contrast on ongoing pregnancy (P-value for interaction 0.23).

LIMITATIONS, REASONS FOR CAUTION

This was a post-hoc analysis that should be considered as hypothesis generating. The RCT was restricted to infertile ovulatory women, younger than 39 years of age and with a low risk for tubal pathology. Therefore, our results should not be generalised to infertile women who do not share these features.

WIDER IMPLICATIONS OF THE FINDINGS

The underlying mechanism of the fertility-enhancing effect induced by HSG with the use of oil-based contrast remains unclear. However, these findings suggest a possible mechanistic pathway, that is increasing intrauterine pressure occurring prior to dislodging pregnancy hindering debris or mucus plugs from the proximal part of otherwise normal fallopian tubes. This information might help in the search of the underlying fertility-enhancing mechanism found by using oil-based contrast during HSG.

STUDY FUNDING/COMPETING INTEREST(S)

The original H2Oil RCT was an investigator-initiated study that was funded by the two academic institutions (AMC and VUmc) of the Amsterdam UMC. The funders had no role in study design, collection, analysis and interpretation of the data. K.D. reports consultancy for Guerbet. H.V. reports consultancy fees from Ferring. C.B.L. reports speakers’ fees from Ferring and research grants from Ferring, Merck and Guerbet. V.M. reports receiving travel and speakers fees as well as research grants from Guerbet. B.W.M. is supported by an NHMRC Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for ObsEva, Merck KGaA and Guerbet and travel and research grants from Merck KGaA and Guerbet. The other authors do not report conflict of interests.

TRIAL REGISTRATION NUMBER

The H2Oil study was registered at the Netherlands Trial Registry (NTR 3270).

TRIAL REGISTRATION DATE

1 February 2012.

DATE OF FIRST PATIENT’S ENROLMENT

3 February 2012.

Analgesic effect of extracorporeal shock-wave therapy for frozen shoulder: A randomized controlled trial protocol

BACKGROUND

Till date only a few studies have reported the efficacy and clinical improvements obtained by extracorporeal shock-wave therapy (ESWT) on frozen shoulder. Limited by small number of studies and insufficient outcomes, it is important and necessary to conduct a new randomized controlled trial. The purpose of the present study is to determine whether ESWT could be more effective than oral steroid in treatment of frozen shoulder.

METHODS

This randomized, single-blind, superiority clinical trial was approved by the institutional review board in The Third People's Hospital of Linyi. The inclusion criteria were patients aged >18 years with shoulder pain and restriction in range of motion. A symptom duration >3 months was required, with no radiographic findings on anteroposterior shoulder plain radiographs except for osteoporosis. Group 1 patients were given 30 mg of oral prednisolone daily for 2 weeks as a single morning dose and then 15 mg daily for another 2 weeks. Group 2 patients received 3 sessions of ESWT on the first, 14th, and 28th days. The primary outcome measure was shoulder pain score. The secondary outcomes included Disabilities of the Arm, Shoulder, and Hand score, range of motion, satisfaction rate, and complications.

RESULTS

It was hypothesized that there would be a significant difference between ESWT and control groups in improving shoulder pain and functions in frozen shoulder.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5736).

Comparison of preoperative versus postoperative transversus abdominis plane and rectus sheath block in patients undergoing minimally invasive colorectal surgery

AIM

Ultrasound-guided transversus abdominis plane and rectus sheath block (TAPRSB) decreases pain scores and narcotic use postoperatively after colorectal surgery (CRS). It is unclear if the effectiveness of TAPRSB varies according to whether it is performed preoperatively or postoperatively. Our aim was to investigate this.

METHOD

We compared patients who underwent preoperative TAPRSB or postoperative TAPRSB during minimally invasive CRS. Primary end-points were pain scores and oral morphine milligram equivalent (MME) use postoperatively. Secondary end-points included perioperative factors affecting pain scores and postoperative MME. Summary statistics and univariate analysis by nonparametric tests were utilized. The mixed-effect model was applied to model the repeatedly measured pain score.

RESULTS

From April 2015 until May 2018 168 patients received TAPRSB before (115) or after (53) minimally invasive CRS. The cohort included 79 (47.0%) women, and had an average age of 59.11 (±12.32) years and mean body mass index of 28.32 (±5.82) kg/m² . Indication for surgery was cancer in 66 (39.3%), polyp in 43 (25.6%) and diverticulitis in 43 (25.6%). Right colectomy was performed in 61 (36.3%), low anterior resection in 46 (27.4%) and sigmoid colectomy in 40 (23.8%) patients. The demographics of the groups were similar. Postoperative TAPRSB was only associated with lower pain scores at 12 h postoperatively. As secondary outcomes, average pain scores and MME were lower in patients who were older, had right colectomy or intracorporeal anastomosis.

CONCLUSIONS

Postoperative TAPRSB resulted in lower pain scores than preoperative TAPRSB 12 h after minimally invasive CRS, but otherwise no differences were seen in pain scores or MME use.