Measuring acute postoperative pain using the visual analog scale: the minimal clinically important difference and patient acceptable symptom state

A prospective randomized open-label study of single injection versus continuous adductor canal block for postoperative analgesia after total knee arthroplasty

Aims

Adductor canal block (ACB) has emerged as an alternative to femoral nerve block (FNB) for analgesia after total knee arthroplasty (TKA). The optimal duration of maintenance of the ACB is still questionable. The purpose of this study was to compare the analgesic benefits and physiotherapy (PT) outcomes of single-shot ACB to two different regimens of infusion of the continuous ACB, 24-hour and 48-hour infusion.

Patients and Methods

This was a prospective, randomized, unblinded study. A total of 159 American Society of Anesthesiologists (ASA) physical status I to III patients scheduled for primary TKA were randomized to one of three study groups. Three patients did not complete the study, leaving 156 patients for final analysis. Group A (n = 53) was the single-shot group (16 female patients and 37 male patients with a mean age of 63.9 years (sd 9.6)), group B (n = 51) was the 24-hour infusion group (22 female patients and 29 male patients with a mean age of 66.5 years (sd 8.5)), and group C (n = 52) was the 48-hour infusion group (18 female patients and 34 male patients with a mean age of 62.2 years (sd 8.7)). Pain scores, opioid requirements, PT test results, and patient-reported outcome instruments were compared between the three groups.

Results

The proportion of patients reporting severe pain, defined as a pain score of between 7 and 10, on postoperative day number 2 (POD 2) were 21% for the single-shot group, 14% for the 24-hour block group, and 12% for the 48-hour block group (p = 0.05). Cumulative opioid requirements after 48 hours were similar between the groups. Functional outcomes were similar in all three groups in POD 1 and POD 2.

Conclusion

There was no clear benefit of the 24-hour or 48-hour infusions over the single-shot ACB for the primary endpoint of the study. Otherwise, there were marginal benefits for keeping the indwelling catheter for 48 hours in terms of reducing the number of patients with moderate pain and improving the quality of pain management. However, all three groups had similar opioid usage, length of hospital stay, and functional outcomes. Further studies with larger sample sizes are needed to confirm these findings. Cite this article: Bone Joint J 2019;101-B:340–347.

Effect of Intravenous Acetaminophen vs Placebo Combined With Propofol or Dexmedetomidine on Postoperative Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial

Importance

Postoperative delirium is common following cardiac surgery and may be affected by choice of analgesic and sedative.

Objective

To evaluate the effect of postoperative intravenous (IV) acetaminophen (paracetamol) vs placebo combined with IV propofol vs dexmedetomidine on postoperative delirium among older patients undergoing cardiac surgery.

Design, Setting, and Participants

Randomized, placebo-controlled, factorial clinical trial among 120 patients aged 60 years or older undergoing on-pump coronary artery bypass graft (CABG) surgery or combined CABG/valve surgeries at a US center. Enrollment was September 2015 to April 2018, with follow-up ending in April 2019.

Interventions

Patients were randomized to 1 of 4 groups receiving postoperative analgesia with IV acetaminophen or placebo every 6 hours for 48 hours and postoperative sedation with dexmedetomidine or propofol starting at chest closure and continued for up to 6 hours (acetaminophen and dexmedetomidine: n = 29; placebo and dexmedetomidine: n = 30; acetaminophen and propofol: n = 31; placebo and propofol: n = 30).

Main Outcomes and Measures

The primary outcome was incidence of postoperative in-hospital delirium by the Confusion Assessment Method. Secondary outcomes included delirium duration, cognitive decline, breakthrough analgesia within the first 48 hours, and ICU and hospital length of stay.

Results

Among 121 patients randomized (median age, 69 years; 19 women [15.8%]), 120 completed the trial. Patients treated with IV acetaminophen had a significant reduction in delirium (10% vs 28% placebo; difference, -18% [95% CI, -32% to -5%]; P = .01; HR, 2.8 [95% CI, 1.1-7.8]). Patients receiving dexmedetomidine vs propofol had no significant difference in delirium (17% vs 21%; difference, -4% [95% CI, -18% to 10%]; P = .54; HR, 0.8 [95% CI, 0.4-1.9]). There were significant differences favoring acetaminophen vs placebo for 3 prespecified secondary outcomes: delirium duration (median, 1 vs 2 days; difference, -1 [95% CI, -2 to 0]), ICU length of stay (median, 29.5 vs 46.7 hours; difference, -16.7 [95% CI, -20.3 to -0.8]), and breakthrough analgesia (median, 322.5 vs 405.3 µg morphine equivalents; difference, -83 [95% CI, -154 to -14]). For dexmedetomidine vs propofol, only breakthrough analgesia was significantly different (median, 328.8 vs 397.5 µg; difference, -69 [95% CI, -155 to -4]; P = .04). Fourteen patients in both the placebo-dexmedetomidine and acetaminophen-propofol groups (46% and 45%) and 7 in the acetaminophen-dexmedetomidine and placebo-propofol groups (24% and 23%) had hypotension.

Conclusions and Relevance

Among older patients undergoing cardiac surgery, postoperative scheduled IV acetaminophen, combined with IV propofol or dexmedetomidine, reduced in-hospital delirium vs placebo. Additional research, including comparison of IV vs oral acetaminophen and other potentially opioid-sparing analgesics, on the incidence of postoperative delirium is warranted.

Trial Registration

ClinicalTrials.gov Identifier: NCT02546765.

Percutaneous periarticular multi-drug injection at one day after total knee arthroplasty as a component of multimodal pain management: a randomized control trial

Background

Although intraoperative periarticular multi-drug injection has been used for postoperative pain control after total knee arthroplasty (TKA), the injection has the inherent shortcoming of limited acting time. This randomized controlled trial was performed to assess whether adding percutaneous periarticular multi-drug injection at the day following TKA would improve the postoperative pain relief.

Methods

A total of 43 participants were randomly assigned to receive additional periarticular injection at 08:30, postoperative day 1 or no additional injection. The multi-drug solution including 40 mg of methylprednisolone, 150 mg of ropivacaine, and 0.1 mg of epinephrine was infiltrated into the muscle belly of the vastus medialis. In both groups, patients were treated with intraoperative periarticular multi-drug injection and postoperative intravenous and oral nonsteroidal anti-inflammatory drugs. We did not use any narcotic pain medications postoperatively. The primary outcome was the patients’ global assessment of postoperative pain at rest measured using a visual analog scale (VAS) and quantified as the area under the curve (AUC) of serial assessments until 20:00, postoperative day 5.

Results

The mean AUC for the postoperative pain VAS at rest was 1616 ± 1191 in patients received the additional periarticular injection versus 2808 ± 1494 in those received no injection (mean difference, − 1192; 95% confidence interval, − 2043 to − 340; p = 0.007). No wound complication or surgical site infection was observed in either groups.

Conclusions

Adding percutaneous periarticular multi-drug injection at the day following TKA may provide better postoperative pain relief. Further studies are needed to confirm the safety of the percutaneous injection.

Trial registration

University Hospital Medical Information Network UMIN000029003. Registered 5 September 2017.

Early stage periarticular injection during total knee arthroplasty may provide a better postoperative pain relief than late-stage periarticular injection: a randomized-controlled trial

PURPOSE

This study was performed to determine whether periarticular injection performed in the early stage of total knee arthroplasty (TKA) could provide a better postoperative pain relief than periarticular injection performed in the late stage of TKA. The hypothesis was based on the concept that analgesic intervention before the onset of noxious stimuli would be associated with less postoperative pain.

METHODS

A total of 105 participants were randomly assigned to receive superficial injection just prior to arthrotomy (early stage periarticular injection group) or superficial injection after implanting the prosthesis (late-stage periarticular injection group) in patients undergoing unilateral TKA with 1:1 treatment allocation. In both groups, deep injection was performed according to the same schedule (just prior to implanting prosthesis). The solution consisted of 300 mg of ropivacaine, 8 mg of morphine, 40 mg of methylprednisolone, 50 mg of ketoprofen, and 0.3 mg of epinephrine mixed with normal saline to a final volume of 60 mL. All surgeries were managed under general anesthesia without any regional blocks. Registry-specified primary outcome was postoperative pain score at rest measured at the recovery room using a 100-mm visual analog scale (VAS). The VAS score was compared between two groups and assessed to reach the reported threshold values for the minimal clinically important difference (MCID) of 10 mm for the postoperative VAS score.

RESULTS

The VAS score at the recovery room was significantly lower in the early stage periarticular injection group than the late-stage periarticular injection group (23 ± 25 mm versus 39 ± 34 mm, respectively; 95% confidence interval 4-28 mm; p = 0.0078). The mean difference in the primary outcome fulfilled the MCID value.

CONCLUSIONS

Bringing forward the timing of periarticular injection may provide significant and clinically meaningful improvement in pain following TKA under general anesthesia.

LEVEL OF EVIDENCE

I.

Postoperative pain after vitreo-retinal surgery is influenced by surgery duration and anesthesia conduction

BACKGROUND

The control of postoperative pain (POP) is a key component of perioperative care. POP after vitreo-retinal surgery (VRS) has been under-investigated, and its incidence remains elusive.

METHODS

In order to assess POP after VRS, the associated risk factors and efficacy of the analgesic protocol in use at our institution, we made a one-year retrospective study on patients undergoing VRS. Patients aged >18 years, ASA Class I-III undergoing VRS entered the study. POP was evaluated by measuring a Numerical Rating Scale (NRS), and analgesic consumption.

RESULTS

A total of 782 patients entered the study. Patients received locoregional (LRA) or general anesthesia (GA) with supplemental block. Twenty-two percent of patients needed analgesics (acetaminophen in 97% of cases), mostly between two and six hours after surgery. The univariate analysis showed a positive association between POP and duration of surgery (P<0.0001) and glaucoma (P=0.04), and a negative association with age (P=0.008), analgesic administration at the end of surgery (P=0.005) and the intraoperative administration of remifentanil for surgery under LRA (P=0.02); sedation to execute the block for LRA did not reduce POP. Patients treated with GA with supplemental block had less pain compared to those treated with LRA with/without remifentanil (P=0.03, P=0.002, respectively). The multivariate analysis confirmed a positive correlation between POP and duration of surgery (P=0.0007) and a negative correlation with the intraoperative remifentanil administration during LRA (P=0.04), and with GA with supplemental block (P=0.01).

CONCLUSIONS

The incidence of POP after VRS is low but not absent, especially for long procedures, it does not require postoperative opioids and can be modified by anesthesiologic choices.

Programmed intermittent epidural bolus versus continuous epidural infusion for postoperative analgesia after major abdominal and gynecological cancer surgery: a randomized, triple-blinded clinical trial

Background

Continuous epidural infusion (CEI) is the standard application setting for epidural infusion. A new mode, the programmed intermittent epidural bolus (PIEB) technique, showed reduced local anesthetic (LA) consumption and improved analgesia in obstetric analgesia. Goal of this trial was to evaluate the effects of PIEB versus CEI [combined with patient-controlled bolus (PCEA)] on LA consumption and pain scorings in major abdominal cancer surgery.

Methods

Following ethical approval, patients scheduled for major abdominal cancer surgery under general anesthesia in combination with epidural analgesia were randomized to receive either a PIEB mode of 6 mL/h or a CEI mode set at 6 mL/h of ropivacaine 0.2%, both combined with a PCEA mode set at a 4 mL bolus. LA consumptions and pain scorings were documented until the second postoperative evening.

Results

Eighty-four datasets were analyzed (CEI: n = 40, PIEB: n = 44). Regarding the primary endpoint, cumulative LA PCEA bolus volumes until day 2 differed significantly between the groups [PIEB 10 mL (2–28 mL) versus CEI, 28 mL (12–64 mL), median (25th–75th percentiles), p = 0.002]. Overall, LA consumption volumes were significantly lower in the PIEB group versus in the CEI group [PIEB: 329 mL (291–341 mL) vs. CEI: 350 mL (327–381 mL), p = 0.003]. Pain scores were comparable at each time point.

Conclusions

This trial demonstrates reduced needs for PCEA bolus in the PIEB group. There were no clinically relevant benefits regarding morphine consumption, pain scorings, or other secondary outcome parameters.

Trial registration

This study has been registered retrospectively in the ClinicalTrials.gov registry (NCT03378804), date of registration: December, 20th 2017.

Electronic supplementary material

The online version of this article (10.1186/s12871-018-0613-6) contains supplementary material, which is available to authorized users.

Effects of muscle energy technique on pain, range of motion and function in patients with post-surgical elbow stiffness: A randomized controlled trial

Background:

Elbow is a very functional joint. Elbow stiffness is a significant cause of disability hampering the function of the upper extremity as a whole. Muscle Energy Techniques (METs) are relatively pain-free techniques used in clinical practice for restricted range of motion (ROM).

Objective:

To study the effects of MET on pain, ROM and function given early in the rehabilitation in post-surgical elbow stiffness.

Methods:

An RCT was conducted on 30 patients post elbow fracture fixation. Group 1 was given MET immediately post removal of immobilization while Group 2 received MET 1 week later along with the rehabilitation protocol. Pain (Visual Analogue Scale), ROM (goniometry) and function (Disability of Arm, Shoulder and Hand questionnaire) were assessed pre and post 3 weeks.

Results:

Group 1 showed greater improvement than Group 2, mean flexion and extension change between groups being 11.7±2.8, 95%CI(5.9,17.4) and 8.5±2.0, 95%CI(4.4,12.7), respectively. VAS and DASH scores improved better in Group 1, mean change being 1.2±0.2, 95%CI(0.6,1.8) and 18.2±2.2, 95%CI(13.5,22.8) for VAS and DASH scores, respectively.

Conclusion:

MET can be used as an adjunct to the rehabilitation protocol to treat elbow stiffness and can be given safely in the early stages of post elbow fracture rehabilitation managed surgically with open reduction and rigid internal fixation.

Pain Management After Carpal Tunnel Release Surgery: A Prospective Randomized Double-Blinded Trial Comparing Acetaminophen, Ibuprofen, and Oxycodone

PURPOSE

Adequate postoperative pain control in hand surgery is a multifactorial issue affecting patient satisfaction, outcomes, and safety. However, prescription opioid abuse is becoming an increasingly prevalent problem in the Unites States. The purpose of this study was to determine if there was a difference in pain levels or pill consumption when using nonopioids, ibuprofen (IBU) and acetaminophen (ACE), versus an opioid, oxycodone (OXY), after carpal tunnel release (CTR) performed exclusively under local anesthesia without sedation.

METHODS

Patients scheduled for primary unilateral CTR under local anesthesia alone were randomized to receive 10 deidentified opaque capsules of either OXY 5 mg, IBU 600 mg, or ACE 500 mg after surgery. Both the patient and the surgeon were blinded to the distributed medication. Patients reported the worst pain experienced daily (0-10 scale), the number of pills consumed daily, and any adverse effects from postoperative days 0-5.

RESULTS

Analgesic pill-type distribution between the 105 patients who completed the study was 37 OXY, 34 IBU, and 34 ACE. For the endoscopic CTR group, mean total pills consumed from the day of surgery through postoperative day 5 for OXY, IBU, and ACE were 2.9, 4.2, and 2.7, respectively. The average worst daily pain scores for all days for the OXY, IBU, and ACE groups were 2.8, 2.5, and 2.8, respectively. For the open CTR group, mean total pills consumed from the day of surgery through postoperative day 5 for OXY, IBU, and ACE were 3.7, 5.1, and 4.2, respectively. The average worst daily pain scores for all days for the OXY, IBU, and ACE groups were 3.4, 2.5, and 2.3, respectively. Four of 5 adverse events were reported by OXY group patients, but all were minor with no reoperations or readmissions.

CONCLUSIONS

We recommend using nonopioids such as ACE and IBU in the postoperative management after CTR surgery, and regardless of the medication prescribed, we advise prescribing no more than 5-10 pills after surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Effect of patient-controlled epidural analgesia versus patient-controlled intravenous analgesia on postoperative pain management and short-term outcomes after gastric cancer resection: a retrospective analysis of 3,042 consecutive patients between 2010 and 2015

Background

Effective postoperative analgesia is essential for rehabilitation after surgery. Many studies have compared different methods of postoperative pain management for open abdominal surgery. However, the conclusions were inconsistent and controversial. In addition, few studies have focused on gastric cancer (GC) resection. This study aimed to determine the effects of patient-controlled epidural analgesia (PCEA) on postoperative pain management and short-term recovery after GC resection compared with those of patient-controlled intravenous analgesia (PCIA).

Methods

We analyzed retrospectively collected data on patients with non-metastatic GC diagnosed between 2010 and 2015 who underwent resection in a university hospital. PCIA and PCEA documented by the acute pain service team were retrospectively analyzed. A propensity score-matched analysis that incorporated preoperative variables was used to compare the short-term outcomes between the PCIA and PCEA groups.

Results

In total, 3,042 patients were identified for analysis. Propensity score matching resulted in 917 patients in each group. The PCEA group exhibited lower pain scores in the recovery room and on the first and second postoperative days (P=0.0005, P=0.0065, and P=0.0034 respectively). The time to the first passage of flatus after surgery was shorter in the PCEA group than in the PCIA group (P=0.032). The length of the hospital stay was 12.6±7.2 and 11.8±6.6 days in the PCEA and PCIA groups, respectively. No significant differences were observed in the length of hospital stay or the incidence of complications after surgery.

Conclusion

PCEA provided more effective postoperative pain management and a shorter time to the first passage of flatus than PCIA after GC resection. However, it did not have an effect on the length of hospital stay or the incidence of postoperative complications.

The use of 5% lidocaine medicated plaster for acute postoperative pain after gynecological surgery: A pilot randomized controlled feasibility trial

OBJECTIVES

To examine the feasibility and potential efficacy of 5% lidocaine medicated plaster for acute postoperative pain in a parallel, blinded, randomized controlled pilot trial.

METHODS

Twenty-eight women undergoing elective gynecological surgery with midline incisions were randomly allocated 5% lidocaine medicated patch (Lignopad) or placebo plasters. Postoperative pain at rest and on movement at 24 hours were the primary study endpoints, with secondary endpoints of postoperative pain within the first 48 hours, cumulative morphine consumption (mg), predicted peak flow rate (PFR) (%) and adverse effects. We assessed pain scores at rest and on movement using the visual analogue scale (0-100).

RESULTS

The lidocaine patch group had lower postoperative pain scores at rest at 24 hours (mean difference [MD] -15.1, 95% confidence interval [95% CI] -28.3 to -2.0; P = .024) but not on movement at 24 hours (MD -6.4, 95% CI -22.7 to 9.9; P = .445). Compared to placebo, lidocaine may slightly lower cumulative morphine consumption (mg) over time (MD -3.4, 95% CI -6.9 to 0.2; group*time interaction P = .065). The difference in improvement in the PFR over time after surgery between groups appeared small (group*time P = .0980). No adverse effects occurred.

CONCLUSIONS

Lidocaine patch may provide a clinically important reduction in postoperative pain intensity. A larger trial to confirm the efficacy and safety of lidocaine patch is feasible after modifying the inclusion criteria and collecting patient-centered outcomes, such as quality of recovery and patient satisfaction.

No Clinically Important Difference in Pain Scores After THA Between Periarticular Analgesic Injection and Placebo: A Randomized Trial

BACKGROUND

Periarticular analgesic injection (PAI) is being used more commonly for pain relief after orthopaedic surgeries. However, there is conflicting evidence regarding the effectiveness of PAI for post-THA pain relief.

QUESTIONS/PURPOSES

In a double-blind, randomized, controlled trial among patients undergoing same-day bilateral THA, with each patient serving as his or her own control, we asked: (1) Did the pain score as measured on a 100-mm VAS differ between the hips that received PAI versus placebo? (2) Were there differences in complications between the treatment and control hips in these patients?

METHODS

Over a 1-year period at one center, 45 patients underwent same-day bilateral THA; three were excluded for prespecified reasons, and two declined participation in this randomized, controlled trial, leaving 40 patients (80 THAs) in the study. Patients randomly received PAI in one hip and placebo in the contralateral hip; patients, surgeons, and nurses were blinded in terms of which hip received the PAI and which hip received a placebo saline injection. The PAI solution included ropivacaine, morphine hydrochloride hydrate, methylprednisolone, ketoprofen, and epinephrine. The primary outcome was the VAS for pain at rest 24 hours after THA, measured using a 100-mm horizontal VAS. The VAS score was compared between two groups and assessed to reach the reported threshold values for the minimum clinically important difference (MCID) of 20 mm for the postoperative VAS score. No patients were lost to followup, and there were no missing data for the primary outcome. Complications that occurred during the trial were recorded prospectively with emphasis on infection, wound complications, nerve palsy and allergic reactions to the injections.

RESULTS

There were no clinically important differences between hips treated with the PAI and those treated with the placebo injection at any point. The hips that received PAI had less pain than those receiving placebo 24 hours after THA (16 ± 17 mm versus 22 ± 20 mm; mean difference, 6 mm; 95% confidence interval [CI], 2-9 mm; p = 0.006), but this effect size was below the MCID of 20 mm and thus is unlikely to be clinically important. The hips that received PAI also had better VAS scores in the recovery room (38 ± 29 mm versus 52 ± 33 mm; mean difference 14 mm; 95% CI, 5-23 mm; p = 0.004) and 3 hours after THA than placebo controls (28 ± 22 mm versus 37 ± 24 mm; mean difference 9 mm; 95% CI, 2-16 mm; p = 0.010). Neither of these differences exceeded the MCID and likewise were unlikely to be clinically important. No complications, including surgical site infections, were observed in either group.

CONCLUSIONS

Periarticular analgesic injection for pain control after THA did not result in a clinically important reduction in pain at any point examined. Given the expense associated with this PAI mixture and the lack of effectiveness outside this timeframe, we cannot recommend its use. Other mixtures or concentrations of drugs may be helpful in short-stay admissions for THA, but this will require further research.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Epidural analgesia versus patient-controlled intravenous analgesia for pain following intra-abdominal surgery in adults

BACKGROUND

Intravenous patient-controlled analgesia (IVPCA) with opioids and epidural analgesia (EA) using either continuous epidural administration (CEA) or patient-controlled (PCEA) techniques are popular approaches for analgesia following intra-abdominal surgery. Despite several attempts to compare the risks and benefits, the optimal form of analgesia for these procedures remains the subject of debate.

OBJECTIVES

The objective of this review was to update and expand a previously published Cochrane Review on IVPCA versus CEA for pain after intra-abdominal surgery with the addition of the comparator PCEA. We have compared both forms of EA to IVPCA. Where appropriate we have performed subgroup analysis for CEA versus PCEA.

SEARCH METHODS

We searched the following electronic databases for relevant studies: Cochrane Central Register of Controlled Trials (CENTRAL) (2017; Issue 8), MEDLINE (OvidSP) (1966 to September 2017), and Embase (OvidSP) (1988 to September 2017) using a combination of MeSH and text words. We searched the following trial registries: Australian New Zealand Clinical Trials Registry, ClinicalTrials.gov, and the EU Clinical Trials Register in September 2017, together with reference checking and citation searching to identify additional studies.We included only randomized controlled trials and used no language restrictions.

SELECTION CRITERIA

We included all parallel and cross-over randomized controlled trials (RCTs) comparing CEA or PCEA (or both) with IVPCA for postoperative pain relief in adults following intra-abdominal surgery.

DATA COLLECTION AND ANALYSIS

Two review authors (JS and EY) independently identified studies for eligibility and performed data extraction using a data extraction form. In cases of disagreement (three occasions) a third review author (MB) was consulted. We appraised each included study to assess the risk of bias as outlined in Section 8.5 of the Cochrane Handbook for Systematic Reviews of Interventions. We used GRADE to assess the quality of the evidence.

MAIN RESULTS

We included 32 studies (1716 participants) in our review. There are 10 studies awaiting classification and one ongoing study. A total of 869 participants (51%) received EA and 847 (49%) received IVPCA. The EA trials included 16 trials with CEA (418 participants) and 16 trials with PCEA (451 participants). The studies included a broad range of surgical procedures (including hysterectomies, radical prostatectomies, Caesarean sections, colorectal and upper gastrointestinal procedures), a wide range of adult ages, and were performed in several different countries.Our pooled analyses suggested a benefit with regard to pain scores (using a visual analogue scale between 0 and 100) in favour of EA techniques at rest. The mean pain reduction at rest from waking to six hours after operation was 5.7 points (95% confidence interval (CI) 1.9 to 9.5; 7 trials, 384 participants; moderate-quality evidence). From seven to 24 hours, the mean pain reduction was 9.0 points (95% CI 4.6 to 13.4; 11 trials, 558 participants; moderate-quality evidence). From 24 hours the mean pain reduction was 5.1 points (95% CI 0.9 to 9.4; 7 trials, 393 participants; moderate-quality evidence). Due to high statistical heterogeneity, no pooled analysis was possible for the estimation of pain on movement at any time. Two single studies (one using CEA and one PCEA) reported lower pain scores with EA compared to IVPCA at 0 to 6 hours and 7 to 24 hours. At > 24 hours the results from 2 studies (both CEA) were conflicting.We found no difference in mortality between EA and IVPCA, although the only deaths reported were in the EA group (5/287, 1.7%). The risk ratio (RR) of death with EA compared to using IVPCA was 3.37 (95% CI 0.72 to 15.88; 9 trials, 560 participants; low-quality evidence).A single study suggested that the use of EA may result in fewer episodes of respiratory depression, with an RR of 0.47 (95% CI 0.04 to 5.69; 1 trial; low-quality evidence). The successful placement of an epidural catheter can be technically challenging. The improvements in pain scores above were accompanied by an increase in the risk of failure of the analgesic technique with EA (RR 2.48, 95% CI 1.13 to 5.45; 10 trials, 678 participants; moderate-quality evidence); the occurrence of pruritus (RR 2.36, 95% CI 1.67 to 3.35; 8 trials, 492 participants; moderate-quality evidence); and episodes of hypotension requiring intervention (RR 7.13, 95% CI 2.87 to 17.75; 6 trials, 479 participants; moderate-quality evidence). There was no clear evidence of an advantage of one technique over another for other adverse effects considered in this review (Venous thromboembolism with EA (RR 0.32, 95% CI 0.03 to 2.95; 2 trials, 101 participants; low-quality evidence); nausea and vomiting (RR 0.94, 95% CI 0.69 to 1.27; 10 trials, 645 participants; moderate-quality evidence); sedation requiring intervention (RR 0.87, 95% CI 0.40 to 1.87; 4 trials, 223 participants; moderate-quality evidence); or episodes of desaturation to less than 90% (RR 1.29, 95% CI 0.71 to 2.37; 5 trials, 328 participants; moderate-quality evidence)).

AUTHORS' CONCLUSIONS

The additional pain reduction at rest associated with the use of EA rather than IVPCA is modest and unlikely to be clinically important. Single-trial estimates provide low-quality evidence that there may be an additional reduction in pain on movement, which is clinically important. Any improvement needs to be interpreted with the understanding that the use of EA is also associated with an increased chance of failure to successfully institute analgesia, and an increased likelihood of episodes of hypotension requiring intervention and pruritus. We have rated the evidence as of moderate quality given study limitations in most of the contributing studies. Further large RCTs are required to determine the ideal analgesic technique. The 10 studies awaiting classification may alter the conclusions of the review once assessed.

Efficacy of Pectoral Nerve Block Type II for Breast-Conserving Surgery and Sentinel Lymph Node Biopsy: A Prospective Randomized Controlled Study

Objectives

The pectoral nerve block type II (PECS II block) is widely used for postoperative analgesia after breast surgery. This study evaluated the analgesic efficacy of PECS II block in patients undergoing breast-conserving surgery (BCS) and sentinel lymph node biopsy (SNB).

Methods

Patients were randomized to the control group (n=40) and the PECS II group (n=40). An ultrasound-guided PECS II block was performed after induction of anesthesia. The primary outcome measure was opioid consumption, and the secondary outcome was pain at the breast and axillary measured using the Numerical Rating Scale (NRS) 24 hours after surgery. Opioid requirement was assessed according to tumor location.

Results

Opioid requirement was lower in the PECS II than in the control group (43.8 ± 28.5 µg versus 77.0 ± 41.9 µg, p < 0.001). However, the frequency of rescue analgesics did not differ between these groups. Opioid consumption in the PECS II group was significantly lower in patients with tumors in the outer area than that in patients with tumors in the inner area (32.5 ± 23.0 µg versus 58.0 ± 29.3 µg, p=0.007). The axillary NRS was consistently lower through 24 hr in the PECS II group.

Conclusion

Although the PECS II block seemed to reduce pain intensity and opioid requirements for 24 h after BCS and SNB, these reductions may not be clinically significant. This trial is registered with Clinical Research Information Service KCT0002509.

Establishing the minimal clinically important difference for the Questionnaire of Olfactory Disorders

BACKGROUND

Olfactory-specific quality of life (QOL) can be measured using the Questionnaire of Olfactory Disorders Negative Statements (QOD-NS). Changes in the QOD-NS after treatment can be difficult to interpret since there is no standardized definition of clinically meaningful improvement.

METHODS

Patients with chronic rhinosinusitis (CRS) completed the QOD-NS. Four distribution-based methods were used to calculate the minimal clinically important difference (MCID): (1) one-half standard deviation (SD); (2) standard error of the mean (SEM); (3) Cohen's effect size (d) of the smallest unit of change; and (4) minimal detectable change (MDC). We also averaged all 4 of the scores together. Finally, the likelihood of achieving a MCID after sinus surgery using these methods, as well as average QOD-NS scores, was stratified by normal vs abnormal baseline QOD-NS scores.

RESULTS

Outcomes were examined on 128 patients. The mean ± SD improvement in QOD-NS score after surgery was 4.3 ± 11.0 for the entire cohort and 9.6 ± 12.9 for those with abnormal baseline scores (p < 0.001). The MCID values using the different techniques were: (1) SD = 6.5; (2) SEM = 3.1; (3) d = 2.6; and (4) MDC = 8.6. The MCID score was 5.2 on average. For the total cohort analysis, the likelihood of reporting a MCID ranged from 26% to 51%, and 49% to 70% for patients reporting preoperative abnormal olfaction.

CONCLUSION

Distribution-based MCID values of the QOD-NS range between 2.6 and 8.6 points, with an average of 5.2. When stratified by preoperative QOD-NS scores the majority of patients reporting abnormal preoperative QOD-NS scores achieved a MCID.

Patient Comfort with Yellow (577 nm) vs. Green (532 nm) Laser Panretinal Photocoagulation for Proliferative Diabetic Retinopathy

PURPOSE

Pain associated with panretinal photocoagulation (PRP) can adversely affect the number and quality of retinal burns delivered and subsequently increase the number of treatment sessions required to achieve regression of proliferative diabetic retinopathy (PDR). We assessed comfort in patients undergoing treatment with yellow (577 nm) vs. green (532 nm) PRP for PDR.

DESIGN

Prospective, single-center, randomized crossover clinical trial.

SUBJECTS

Patients with PDR with high-risk characteristics.

METHODS

Subjects were equally randomized to first receive PRP with a laser indirect ophthalmoscope with either green (IQ 532; IRIDEX, Mountain View, CA) or yellow (IQ 577; IRIDEX) laser, followed by additional treatment with the opposite laser using standardized settings in the superior hemisphere of a single treatment eye per patient. Topical anesthetic was used in all study eyes before each treatment and power was titrated until moderate grey-white retinal burns were achieved.

MAIN OUTCOME MEASURES

The primary outcome measure was patient's perceived pain as measured with a standardized 10-point pain scale. Secondary outcome measures included laser power, treatment time, number of treatment shots with each laser, and physician ease-of-use score with each laser on a 10-point scale.

RESULTS

Forty patients (40 eyes) with a mean age of 54.0 years were enrolled. Mean pain scores were similar when comparing treatment with yellow and green laser (3.1 ± 2.3 vs. 2.8 ± 2.6; P = 0.40). No significant difference was seen in visual acuity (P = 0.44) or central macular thickness (P = 0.39) 1 month after PRP. Additionally, there were no significant differences when comparing minimum power required (243.2 ± 74.2 vs. 234.0 ± 59.6 mW; P = 0.55), treatment time (5.1 ± 3.6 vs. 5.6 ± 3.9 minutes; P = 0.384), and number of treatment shots (257.6 ± 12.6 vs. 258.0 ± 2.3; P = 0.68). Six of 7 co-investigators (85%) preferred using yellow laser over green and reported ease-of-use scores of 9.0 ± 1.2 and 7.6 ± 1.4, respectively (P = 0.07). No severe adverse events occurred.

CONCLUSIONS

Patient comfort during PRP for PDR utilizing laser indirect ophthalmoscopy is similar for green and yellow wavelengths.

Periarticular Injection Versus Femoral Nerve Block for Pain Relief After Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial

PURPOSE

To compare the effectiveness and safety of periarticular injection (PI) with those of femoral nerve block (FNB) after anterior cruciate ligament (ACL) reconstruction.

METHODS

A total of 129 patients scheduled for ACL reconstruction were randomly assigned to receive PI or FNB. Other perioperative interventions were identical for all patients. The primary outcome was the postoperative pain score 24 hours after surgery, which was measured using a 100-mm visual analog scale (VAS). The pain scores were also assessed to determine whether the VAS score would reach the threshold values reported for the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS).

RESULTS

The PI group had significantly lower VAS scores 24 hours after ACL reconstruction than the FNB group (21 mm vs 39 mm; P < .0001). Consequently, the primary outcome reached the level of clinical significance as indicated by the threshold values of an MCID of 9.9 and a PASS of 33. The PI group also had a significantly lower VAS score at rest at 4 hours, 8 hours, and 2 days after surgery (30 mm vs 39 mm [P = .025], 25 mm vs 33 mm [P = .022], and 22 mm vs 32 mm [P = .0022], respectively). The opioid consumption during the initial 24 hours was significantly lower in the PI group (354 μg vs 503 μg; P = .0003). The complication rate, including opioid-related complications, was not significantly different between groups.

CONCLUSION

The patients treated with PI had significantly better pain scores and lower opioid consumption than those treated with FNB without elevating the complication rate.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Cryotherapy Treatment After Unicompartmental and Total Knee Arthroplasty: A Review

BACKGROUND

Cryotherapy is widely utilized to enhance recovery after knee surgeries. However, the outcome parameters often vary between studies. Therefore, the purpose of this review is to compare (1) no cryotherapy vs cryotherapy; (2) cold pack cryotherapy vs continuous flow device cryotherapy; (3) various protocols of application of these cryotherapy methods; and (4) cost-benefit analysis in patients who had unicompartmental knee arthroplasty (UKA) or total knee arthroplasty (TKA).

METHODS

A search for "knee" and "cryotherapy" using PubMed, EBSCO Host, and SCOPUS was performed, yielding 187 initial reports. After selecting for RCTs relevant to our study, 16 studies were included.

RESULTS

Of the 8 studies that compared the immediate postoperative outcomes between patients who did and did not receive cryotherapy, 5 studies favored cryotherapy (2 cold packs and 3 continuous cold flow devices). Of the 6 studies comparing the use of cold packs and continuous cold flow devices in patients who underwent UKA or TKA, 3 favor the use of continuous flow devices. There was no difference in pain, postoperative opioid consumption, or drain output between 2 different temperature settings of continuous cold flow device.

CONCLUSION

The optimal device to use may be one that offers continuous circulating cold flow, as there were more studies demonstrating better outcomes. In addition, the pain relieving effects of cryotherapy may help minimize pain medication use, such as with opioids, which are associated with numerous potential side effects as well as dependence and addiction. Meta-analysis on the most recent RCTs should be performed next.

Laparoscopic versus open resection for sigmoid diverticulitis

BACKGROUND

Diverticular disease is a common condition in Western industrialised countries. Most individuals remain asymptomatic throughout life; however, 25% experience acute diverticulitis. The standard treatment for acute diverticulitis is open surgery. Laparoscopic surgery - a minimal-access procedure - offers an alternative approach to open surgery, as it is characterised by reduced operative stress that may translate into shorter hospitalisation and more rapid recovery, as well as improved quality of life.

OBJECTIVES

To evaluate the effectiveness of laparoscopic surgical resection compared with open surgical resection for individuals with acute sigmoid diverticulitis.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2) in the Cochrane Library; Ovid MEDLINE (1946 to 23 February 2017); Ovid Embase (1974 to 23 February 2017); clinicaltrials.gov (February 2017); and the World Health Organization (WHO) International Clinical Trials Registry (February 2017). We reviewed the bibliographies of identified trials to search for additional studies.

SELECTION CRITERIA

We included randomised controlled trials comparing elective or emergency laparoscopic sigmoid resection versus open surgical resection for acute sigmoid diverticulitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed the domains of risk of bias from each included trial, and extracted data. For dichotomous outcomes, we calculated risk ratios (RRs) with 95% confidence intervals (CIs). For continuous outcomes, we planned to calculate mean differences (MDs) with 95% CIs for outcomes such as hospital stay, and standardised mean differences (SMDs) with 95% CIs for quality of life and global rating scales, if researchers used different scales.

MAIN RESULTS

Three trials with 392 participants met the inclusion criteria. Studies were conducted in three European countries (Switzerland, Netherlands, and Germany). The median age of participants ranged from 62 to 66 years; 53% to 64% were female. Inclusion criteria differed among studies. One trial included participants with Hinchey I characteristics as well as those who underwent Hartmann's procedure; the second trial included only participants with "a proven stage II/III disease according to the classification of Stock and Hansen"; the third trial considered for inclusion patients with "diverticular disease of sigmoid colon documented by colonoscopy and 2 episodes of uncomplicated diverticulitis, one at least being documented with CT scan, 1 episode of complicated diverticulitis, with a pericolic abscess (Hinchey stage I) or pelvic abscess (Hinchey stage II) requiring percutaneous drainage."We determined that two studies were at low risk of selection bias; two that reported considerable dropouts were at high risk of attrition bias; none reported blinding of outcome assessors (unclear detection bias); and all were exposed to performance bias owing to the nature of the intervention.Available low-quality evidence suggests that laparoscopic surgical resection may lead to little or no difference in mean hospital stay compared with open surgical resection (3 studies, 360 participants; MD -0.62 (days), 95% CI -2.49 to 1.25; I² = 0%).Low-quality evidence suggests that operating time was longer in the laparoscopic surgery group than in the open surgery group (3 studies, 360 participants; MD 49.28 (minutes), 95% CI 40.64 to 57.93; I² = 0%).We are uncertain whether laparoscopic surgery improves postoperative pain between day 1 and day 3 more effectively than open surgery. Low-quality evidence suggests that laparoscopic surgery may improve postoperative pain at the fourth postoperative day more effectively than open surgery (2 studies, 250 participants; MD = -0.65, 95% CI -1.04 to -0.25).Researchers reported quality of life differently across trials, hindering the possibility of meta-analysis. Low-quality evidence from one trial using the Short Form (SF)-36 questionnaire six weeks after surgery suggests that laparoscopic intervention may improve quality of life, whereas evidence from two other trials using the European Organization for Research and Treatment of Cancer core quality of life questionnaire (EORTC QLQ-C30) v3 and the Gastrointestinal Quality of Life Index score, respectively, suggests that laparoscopic surgery may make little or no difference in improving quality of life compared with open surgery.We are uncertain whether laparoscopic surgery improves the following outcomes: 30-day postoperative mortality, early overall morbidity, major and minor complications, surgical complications, postoperative times to liquid and solid diets, and reoperations due to anastomotic leak.

AUTHORS' CONCLUSIONS

Results from the present comprehensive review indicate that evidence to support or refute the safety and effectiveness of laparoscopic surgery versus open surgical resection for treatment of patients with acute diverticular disease is insufficient. Well-designed trials with adequate sample size are needed to investigate the efficacy of laparoscopic surgery towards important patient-oriented (e.g. postoperative pain) and health system-oriented outcomes (e.g. mean hospital stay).