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

Reduction of postoperative pain and opioid consumption by VVZ-149, first-in-class analgesic molecule: A confirmatory phase 3 trial of laparoscopic colectomy

STUDY OBJECTIVE

VVZ-149 is a small molecule that inhibits the glycine transporter type 2 and the serotonin receptor 5-hydroxytryptamine 2 A. In this Phase 3 study, we investigated the efficacy and safety of VVZ-149 as a single-use injectable analgesic for treating moderate to severe postoperative pain after laparoscopic colectomy.

DESIGN

Randomized, parallel group, double-blind, Phase 3 clinical trial (Trial no. NCT05764525).

SETTING

5 tertiary referral centers in South Korea.

PATIENTS

284 patients undergoing laparoscopic colectomy.

INTERVENTIONS

A continuous 10-h intravenous infusion of VVZ-149 (n = 141) or placebo (n = 143) administered after emergence from anesthesia.

MEASUREMENTS

Pain intensity was assessed using a numeric rating scale (NRS) from the start of infusion for 48 h. The primary efficacy measure was the Sum of Pain Intensity Difference (SPID) for the first 12 h after the start of drug infusion. Other efficacy measures included SPID at other time points, opioid consumption via on-demand patient-controlled analgesia (PCA) and rescue medication, and proportion of patients who did not require rescue opioids for 48 h post-dose.

MAIN RESULTS

Pain relief as measured by SPID was significantly improved by 35 % in the VVZ-149 group compared to the placebo group at 6 h (p = 0.0193) and 12 h (p = 0.0047) after the start of infusion. Significantly lower pain intensity scores were observed between 4-10 h in the VVZ-149 group compared to the placebo group (p = 0.0007), reaching mild pain (mean NRS <4) at 8 h. VVZ-149 alleviated pain during the first 12 h post-dose with 30.8 % less opioid consumption and 60.2 % fewer PCA requests when compared with placebo. A higher proportion of patients receiving VVZ-149 were rescue opioid-free during 2-6 h (p = 0.0026) and 6-12 h (p = 0.0024) compared with the placebo group. VVZ-149 administration in post-colectomy patients was generally safe and well tolerated.

CONCLUSIONS

When compared to placebo, VVZ-149 infusion demonstrated a significant reduction of pain within the first 12 h after surgery with a substantial decrease in opioid use. VVZ-149 rapidly lowers the pain intensity starting at as early as 4 h post-dose, allowing subjects to experience mild pain levels from 8 h through 48 h. Therefore, the analgesic effect of VVZ-149 was shown to effectively relieve pain and reduce opioid use for treating moderate to severe pain in the early postoperative care setting.

REGISTRATION NUMBER

Trial Number NCT05764525.

Opioid-Sparing Anesthesia Versus Opioid-Free Anesthesia for the Prevention of Postoperative Nausea and Vomiting after Laparoscopic Bariatric Surgery: A Systematic Review and Network Meta-Analysis

BACKGROUND

Patients who undergo laparoscopic bariatric surgery (LBS) are susceptible to postoperative nausea and vomiting (PONV). Opioid-free anesthesia (OFA) or opioid-sparing anesthesia (OSA) protocols have been proposed as solutions; however, differences between the 2 alternative opioid protocols for anesthesia maintenance in obese patients remain uncertain. A network meta-analysis was conducted to compare the impacts of OFA and OSA on PONV.

METHODS

Systematic searches were conducted using Embase, PubMed, MEDLINE, and Cochrane Library databases to identify randomized controlled trials (RCTs) comparing OFA and OSA strategies. After screening according to the inclusion and exclusion criteria, we used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the credibility of the evidence. The main concern of this review was the difference between OFA and OSA in reducing PONV. The primary outcome was any PONV occurrence within 24 hours. Secondary outcomes included postoperative pain intensity, opioid consumption, opioid-related adverse events, and length of hospital stay.

RESULTS

Fifteen RCTs involving 1310 patients were identified for a network meta-analysis from 1776 articles that compared OFA, OSA, and traditional opioid-based anesthesia (OBA) strategies in LBS. Twelve RCTs (80%) with 922 participants (70%) were eligible for the occurrence of PONV. These included 199 (22%) patients who received OFA and 476 (52%) and 247 (27%) patients who received OSA and OBA, respectively. OFA was more effective at reducing PONV (relative risks [RR], 0.6, 95% confidence interval [CI], 0.5-0.9, moderate-quality evidence) compared to OSA. No differences were observed in postoperative pain control or opioid consumption between the OFA and OSA strategies (very low-to high-quality evidence). Notably, OFA is associated with a higher risk of bradycardia than OSA (RR, 2.6, 95% CI, 1.2-5.9, moderate-quality evidence).

CONCLUSIONS

OFA is more effective than OSA in reducing the occurrence of PONV during the early postoperative period of LBS, although it may associate with an increased risk of bradycardia. Patients who received either opioid-alternative strategy demonstrated similar effects in reducing postoperative opioid consumption and alleviating pain intensity.

Postoperative Cesarean Section Pain Management Using Transversus Abdominis Plane Block Versus Intrathecal Morphine: A Systematic Review and Meta-analysis

PURPOSE

Compare and evaluate the effectiveness of transversus abdominis plane (TAP) block versus intrathecal morphine (ITM) on elective postcesarean section pain, opioid consumption, and related side effects.

DESIGN

Systematic review and meta-analysis.

METHODS

A search for evidence was conducted in PubMed, Google Scholar, CINAHL, Cochrane Collaboration Database, UpToDate, Health Source, and gray literature. Only randomized controlled trials (RCTs) were included in the study. The methodological quality of evidence assessment was conducted using the Risk of Bias and Grades of Recommendation, Assessment, Development, and Evaluation system. The meta-analysis used Review Manager (RevMan 5.4, The Cochrane Collaboration).

FINDINGS

A total of 11 RCTs involving 1,129 patients were analyzed. Compared to ITM, TAP has a similar effect on static (mean difference [MD]; 0.37; 95% confidence interval [CI], -0.04 to 0.79; P = .08) and dynamic pain scores (MD, 0.43; 95% CI, -0.06 to 0.92; P = .09) within the first 48 hours after surgery. Additionally, the TAP block had a lower incidence of postoperative nausea and vomiting (risk ratio, 0.45; 95% CI, 0.31 to 0.66; P < .0001) and increased opioid consumption (MD, 6.78; 95% CI, 3.79 to 9.77; P < .00001). Overall, TAP block and ITM did not differ in the time to first to rescue analgesia, incidence of sedation, and pruritus.

CONCLUSIONS

Evidence suggests that TAP blocks are equivalent to ITM in pain scores and more effective at lowering the incidence of postoperative nausea and vomiting, yet ITM has been shown to be more effective in reducing postoperative opioid consumption.

The effect of intravenous lidocaine infusion on subarachnoid anesthesia in patients undergoing total knee replacement: a randomised controlled trial

PURPOSE

Intravenous lidocaine is a non-opioid analgesic adjunct for perioperative pain relief. The aim of our study was to explore whether concurrent administration of intravenous lidocaine prolongs the duration of sensory block during total knee replacement (TKR) under spinal anaesthesia.

METHODS

This prospective randomized double blind controlled trial was conducted on 28 patients (14 in lidocaine group and 14 in the control group) undergoing unilateral TKR under spinal anesthesia. In the lidocaine group, intravenous lidocaine 1.5 mg·kg-1 followed by an infusion of 1.5 mg·kg-1·h-1 was administered intraoperatively after spinal anesthesia. The primary outcome was the duration of sensory block of spinal anesthesia. Secondary outcomes included onset time of sensory and motor block, duration of motor block, time to first postoperative analgesic, postoperative visual analog scale (VAS) scores and postoperative analgesia requirement in 24 h after surgery.

RESULTS

The duration of sensory and motor block was longer in the lidocaine group (Mean ± SD; 112.50 ± 5.80 min versus 78.21 ± 9.12 min; p < 0.001 and 237.14 ± 9.14 min versus 215.00 ± 10.12 min; p < 0.001, respectively). Time to requirement of first rescue analgesia was 184.29 ± 9.38 min in the lidocaine group and 127.14 ± 23.35 min in the control group (p < 0.001). VAS scores were lower in the lidocaine group at 4, 8, 12 and 24 h after surgery (p < 0.00001, p < 0.00001, p < 0.00006, p = 0.032, respectively). Requirement of additional analgesia in the first 24 h was higher in the control group. There were no clinical signs to suggest lidocaine toxicity in any patient.

CONCLUSION

During unilateral TKR under spinal anaesthesia, concurrent use of intravenous lidocaine prolonged sensory block and reduced postoperative analgesic requirements.

Postoperative pain intensity and patient satisfaction: A multicentre observational study

BACKGROUND

Postoperative pain remains a prevalent issue, whose intensity is often inadequately controlled. This could lead to complications, longer hospital stays and unnecessary suffering. Understanding surgical patients' perspectives on pain management can help to identify areas for improvement.

OBJECTIVE

Determine postoperative pain prevalence and intensity, and satisfaction with pain management, of hospitalised patients.

METHODS

Multicentre, cross-sectional correlational study.

PARTICIPANTS

Aged over 18 years who underwent surgery, provided voluntary consent and were able to complete a survey.

VARIABLES

socio-demographic and clinical characteristics, surgical speciality, pain during hospitalisation, information, expectations and satisfaction with received care. An anonymous self-administered questionnaire adapted from the American Pain Society was used.

RESULTS

1327 patients answered the survey, 927 (69.9 %) reported postsurgery pain. The mean pain intensity at rest was 5.23 (SD = 2.75; 95%CI: 5.05-5.40), and was 5.7 (SD = 2.69; 95%CI: 5.53-5.87) when moving. Satisfaction with pain management was high, with 301 (22.7 %) patients feeling satisfied and 786 (59.2 %) very satisfied. In the multivariate linear regression, the factors that were statistically and significantly associated with higher pain intensity were presence of presurgical chronic pain, various surgical specialities and female gender. The belief that pain can be relieved was associated with lower intensity.

CONCLUSIONS

The percentage of patients who reported being satisfied or very satisfied with the way their pain was managed exceeded 80 %. Pain prevalence was high, with a mean intensity of 5.23 at rest and one of 5.7 when moving (0-10 scale).

Ten days of supplementation with a standardized Boswellia serrata extract attenuates soreness and accelerates recovery after repeated bouts of downhill running in recreationally active men

Extracts derived from Indian frankincense (Boswellia serrata) effectively reduce the pain and swelling associated with osteoarthritis. It is unknown whether the anti-inflammatory and analgesic properties of B. serrata extend to muscle and joint pain resulting from high-impact eccentric exercise. This pilot study evaluated the efficacy of a standardized B. serrata extract LI51202F1 (SBS) to decrease soreness and improve recovery after repeated bouts of downhill running (DHR) compared to placebo (PLA). In total, 50 men (mean age 28 ± 4) were randomly allocated to consume 60 mg SBS or PLA once per day for 10 days (6 days before, the day of, and 3 days after DHR). On day 7, delayed soreness was induced by three 15-min DHR episodes on a 10% declined treadmill. Visual analog scale (VAS) scores of joint and muscle soreness, in addition to the maximal weight lifted for a one-repetition leg extension (1RM-LE) were assessed at baseline (pre-supplementation) and on days 8, 9, and 10. Blood and urine samples collected at baseline, before, and after DHR were analyzed for inflammation-related biomarkers. VAS scores significantly increased while muscle strength decreased from baseline measures after DHR regardless of group assignment (main effect of time p < 0.001). However, the subjects who received the supplement reported reduced muscle soreness on days 8, 9, and 10 compared to those who received the PLA. On day 9, peak soreness scores were lower in the SBS group than in the PLA group (p = 0.001). On day 10, the SBS group's VAS scores were 8.0 ± 1.6 mm lower than the PLA group (p < 0.001). Supplementation improved recovery time as the 1RM-LE returned to baseline strength by day 10, with the subjects who received the supplement lifting 3.4 ± 1.2 kg more than the PLA group (p = 0.006). The SBS-supplemented subjects reported less knee joint pain after DHR than the PLA group (p < 0.05 on days 8, 9, and 10). C-reactive protein and interleukin-6 increased after DHR, but by day 10, SBS reduced these markers compared to the PLA (p < 0.05). This study suggests that SBS, a novel, standardized extract derived from the gum resin of B. serrata, improves recovery and reduces soreness following high-impact eccentric exercise.

Clinical Trial Registration

https://ctri.nic.in/Clinicaltrials/pubview2.php, Clinical Trial Registry of India (CTRI/2019/07/020323).

Dual-Task Resistance Training Improves Strength and Reduces Pain More Than Resistance Exercise Alone in Elbow Fracture Rehabilitation: A Randomized Controlled Trial

OBJECTIVE

To examine the effects on strength, pain intensity, range of motion (ROM), and functionality of a 12-week dual-task resistance exercise program in patients undergoing rehabilitation from elbow fractures.

DESIGN

Randomized controlled trial.

SETTING

Rehabilitation hospital.

PARTICIPANTS

Individuals undergoing elbow fracture rehabilitation (N=32).

INTERVENTION

Randomization was performed sequentially using numbered envelopes containing assignments to either an intervention group (dual-task resistance training using a mathematical task with self-regulation, N=18) or a control group (traditional resistance training, N=14) for 12 weeks.

MAIN OUTCOME MEASURES

The primary outcomes were muscle strength for elbow flexors and extensors and pain assessed by the visual analog scale from 0 to 100 mm. The secondary outcomes were kinesiophobia assessed by the Tampa Scale-11 and disability using the Disabilities of the Arm, Shoulder, and Hand questionnaire and passive ROM.

RESULTS

Dual-task resistance training improved strength and reduced pain more than resistance training alone (P<.05), and only the dual-task group improved in kinesiophobia (P<.05). The linear regression showed a significant negative association between kinesiophobia and increased elbow strength in the dual-task group (flexion, r=-0.53, P=.024; extension, r=-0.65, P=.004) but not in the control group (P>.05). No significant differences were observed between the group for disability and passive ROM (P>.05).

CONCLUSIONS

Dual-task resistance training and traditional resistance training both enhance strength, reduce pain, improve functionality, and increase ROM after 12 weeks of elbow fracture rehabilitation. However, dual-task resistance training is superior to resistance training alone in enhancing strength and reducing pain.

Battlefield Acupuncture Does Not Provide Additional Improvement in Pain When Combined With Standard Physical Therapy After Shoulder Surgery: A Randomized Clinical Trial

INTRODUCTION

Shoulder stabilization surgery is common among military personnel, causing severe acute postoperative pain that may contribute to the development of chronic pain, thereby reducing military readiness. Battlefield Acupuncture (BFA) has shown promise as a non-pharmaceutical intervention for acute postoperative pain. The purpose of this study was to determine the effectiveness of BFA combined with standard physical therapy on pain, self-reported mood, self-reported improvement, and medication use in patients after shoulder stabilization surgery.

MATERIALS AND METHODS

The study design was a single-blind, randomized clinical trial, approved by the Naval Medical Center Portsmouth Institutional Review Board and registered with ClinicalTrials.gov (NCT04094246). Ninety-five participants were recruited after shoulder stabilization surgery. Participants were randomized via concealed allocation into a standard physical therapy (PT) group or a group receiving standard PT and BFA. Both groups received standard postoperative pain medication. The BFA intervention followed a standard protocol with the insertion of gold aiguille d'acupuncture emiermanente needles at 5 specific points in the ear. At 4 time points (baseline [24-48 hours], 72 hours, 1 week, and 4 weeks post-surgery), participants reported worst and average pain using a Visual Analog Scale (VAS), self-reported mood using the Profile of Mood States (POMS), self-recorded medication intake between study visits, and self-reported improvement in symptoms using a Global Rating of Change (GROC) Scale. Outcome assessors were blinded to treatment allocation. An alpha level of 0.05 was set a priori. For pain, a mixed-model analysis of variance was used to analyze the interaction effect between group and time. Differences in baseline data, total opioid usage, and pain change scores between groups were analyzed using independent t-tests.

RESULTS

Of the 95 participants enrolled, 7 failed to provide complete study visits after the baseline, leaving 88 patients (43 BFA, 45 control, mean age 21.8 (2.1) years, 23% female). There were no significant group-by-time interactions for VAS worst pain (F = 0.70, P = .54), VAS average pain (F = 0.99, P = .39), the POMS (F = 1.04, P = .37), or GROC (F = 0.43, P = 0.63). There was a significant main effect of time for VAS worst pain (F = 159.7, P < .001), VAS average pain (F = 122.4, P < .001), the POMS (F = 11.4, P < .001), and the GROC (F = 78.5, P < .001). While both groups demonstrated statistically significant and clinically meaningful improvements in pain and self-reported mood over time, BFA did not provide any additional benefit compared to standard physical therapy alone. There was no significant difference in opioid usage between groups at 4 weeks (t = 0.49, P = .63). Finally, both groups also demonstrated statistically significant and clinically meaningful self-reported improvements in function, but again, there was no additional benefit when adding BFA to standard physical therapy.

CONCLUSION

The results of this study do not support the effectiveness of BFA for postsurgical pain management as there were no significant differences in pain, self-reported mood, self-reported improvement, and medication use between participants who received BFA and those who did not. As this is the only known study of BFA in postsurgical participants, continued research is needed to determine if BFA is effective for pain reduction in that setting.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT04094246. Registered September 16, 2019, http://clinicaltrials.gov/NCT04094246.

Comparison of different pain management strategies during the perioperative period of esophageal squamous cell carcinoma: a retrospective cohort study

OBJECTIVE

This retrospective cohort study aims to evaluate and compare different postoperative pain management strategies for esophageal squamous cell carcinoma (ESCC), in order to provide scientific evidence for clinical practice and decision-making.

METHODS

A total of 274 ESCC patients who underwent surgery at the Affiliated Huai'an No. 1 People's Hospital of Nanjing Medical University were included in the study. Of these, 127 received conventional nursing decisions for postoperative pain management, and 147 received the "5 + nursing" postoperative pain management strategy. The main observation indicators of both groups included postoperative pain score, analgesic dosage, postoperative analgesic side effects, and length of hospital stays.

RESULTS

The "5 + nursing" postoperative pain management group showed significantly lower postoperative pain score and significantly shorter length of hospital stays than the conventional nursing group. There was no significant difference in postoperative analgesic side effects between the two groups. Multiple logistic regression analysis showed that the postoperative pain score is an independent risk factor for predicting postoperative arrhythmias in ESCC patients. When the daily average dose of opioids used postoperatively was between 37.5 and 50 mg, the patient's postoperative pain score dropped the fastest.

CONCLUSION

The "5 + nursing" pain management strategy can effectively reduce the degree of postoperative pain and shorten the length of hospital stays, improving patient's quality of life. Our research emphasizes the importance of opioids in postoperative pain management, as well as the need for individualized perioperative pain management strategies.

Immunocyte profiling changes in patients received epidural versus intravenous analgesia after pancreatectomy: A randomized controlled trial

BACKGROUND

Perioperative immunosuppressants, such as surgical stress and opioid use may downregulate anti-cancer immunocytes for patients undergoing pancreatectomy. Thoracic epidural analgesia (TEA) may attenuate these negative effects and provide better anti-cancer immunocyte profile change than intravenous analgesia using opioid.

METHODS

We randomly assigned 108 adult patients undergoing pancreatectomy to receive one of two 72-h postoperative analgesia protocols: one was TEA, and the other was intravenous patient-controlled analgesia (IV-PCA). The perioperative proportional changes of immunocytes relevant to anticancer immunity-namely natural killer (NK) cells, cytotoxic T cells, helper T cells, mature dendritic cells, and regulatory T (Treg) cells were determined at 1 day before surgery, at the end of surgery and on postoperative day 1,4 and 7 using flow cytometry. In addition, the progression-free survival and overall survival between the two groups were compared.

RESULTS

After surgery, the proportions of NK cells and cytotoxic T cells were significantly decreased; the proportion of B cells and mature dendritic cells and Treg cells were significantly increased. However, the proportions of helper T cells exhibited no significant change. These results were comparable between the two groups. Furthermore, there were no significant differences in progression-free survival (52.75 [39.96] and 57.48 [43.66] months for patients in the TEA and IV-PCA groups, respectively; p = 0.5600) and overall survival (62.71 [35.48] and 75.11 [33.10] months for patients in the TEA and IV-PCA groups, respectively; p = 0.0644).

CONCLUSION

TEA was neither associated with favorable anticancer immunity nor favorable oncological outcomes for patients undergoing pancreatectomy.

Challenges of perioperative pain control in opioid use disorder patients following intramedullary nail fixation

BACKGROUND

Outcomes of patients with opioid use disorder undergoing elective procedures have been well studied, but research is lacking in the orthopaedic trauma population.

AIM

The aim was to compare perioperative pain and morphine equivalents required by patients with versus without opioid use disorder following intramedullary nail fixation of femoral or tibial fractures.

METHODS

We conducted a retrospective review of all patients with isolated femoral or tibial diaphyseal fractures treated with intramedullary nail fixation. Outcomes were compared between patients with diagnosed opioid use disorder and controls without, including daily morphine equivalents and patient-reported pain scores.

RESULTS

Patients with opioid use disorder (n = 42) required greater morphine equivalents and reported higher pain than controls (n = 42) at all time points but did not differ in change of morphine equivalents over the perioperative period.

CONCLUSION

This highlights the challenge of perioperative pain control in this population and need for improved specific pain management protocols.

Therapeutic Effectiveness of Microneedling Radio Frequency in Different Areas of Periorbital Static Wrinkles: A Self-Controlled Study

BACKGROUND

Periocular static wrinkles, which are common cosmetic concerns, lack an established effective treatment. Microneedling radio frequency (MNRF) has shown promise in skin rejuvenation; however, there is limited objective information on its long-term effectiveness with regard to periocular static wrinkles.

AIMS

This study aimed to evaluate the clinical efficacy and safety of MNRF treatment for periocular static wrinkles.

METHOD

Eighteen participants with moderate to severe wrinkles were enrolled in this study. MNRF treatment was applied to the periocular skin using MicroRF9 microneedles, which have a depth of 0.5-1.5 mm and a pulse width of 200-300 ms. MNRF treatment was administered twice with a 1-month interval, and the participants were followed up for 6 months. The evaluation included four areas, namely the outer canthi, lower eyelid, inner canthi, and upper eyelid, by using clinical assessments and Antera 3D measurements by digitalized images and grading by clinicians.

RESULTS

The results showed significant improvement in all four areas assessed. Participants expressed high satisfaction with the treatment, and any adverse events, such as mild pain and redness, were temporary and resolved within a week.

CONCLUSION

These findings confirm that MNRF is a safe and effective method for reducing periocular static wrinkles.

Perioperative intravenous lidocaine infusion improves postoperative analgesia after hysterectomy: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The effectiveness of intravenous lidocaine in reducing acute pain after hysterectomy remains uncertain. The authors conducted a meta-analysis of randomized controlled trials (RCTs) to investigate the impact of intravenous lidocaine on posthysterectomy recovery.

METHODS

This study was completed based on the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. A systematic search was conducted in PubMed/MEDLINE, the Cochrane Controlled Trials Register (CENTRAL), and Embase up to 27 July 2023. The authors identified RCTs involving hysterectomy patients comparing lidocaine to a placebo. Outcome measures included postoperative pain scores at rest and during movement, opioid consumption, postoperative nausea and vomiting (PONV), improvements in functional gastrointestinal recovery, and Quality of Recovery scores.

RESULTS

Nine RCTs were included in the meta-analysis, comprising 352 patients who received intravenous lidocaine and 354 controls. The analysis revealed that intravenous lidocaine significantly reduced postoperative pain scores at rest at 2, 6, 8, and 24 h following hysterectomy, as well as postoperative opioid consumption within 24 h and PONV rates. Furthermore, no observed benefit was noted in shortening the time to first flatus with intravenous lidocaine administration posthysterectomy.

CONCLUSION

Intravenous lidocaine administration effectively reduces acute postoperative pain, opioid consumption, and PONV rates following hysterectomy. Lidocaine serves as an opioid-sparing agent, reducing the morphine equivalent dose while maintaining a similar degree of postoperative pain.

Anterior quadratus lumborum blocks for postoperative pain treatment following intra-abdominal surgery: A systematic review with meta-analyses and trial sequential analyses

BACKGROUND

The anterior quadratus lumborum (QL) block may be used for postoperative pain management for intra-abdominal surgeries, but the evidence is uncertain. We aimed to investigate the benefit and harm of the anterior QL block compared to placebo/no block for intra-abdominal surgery.

METHODS

We searched Medline, Embase, and CENTRAL for randomized controlled trials investigating anterior QL block for postoperative pain management for adult patients undergoing any intra-abdominal surgery. The two co-primary outcomes were cumulative 24-h opioid consumption and serious adverse events. We performed meta-analysis, trial sequential analysis (TSA), assessed the risk of bias, and present the certainty of evidence with the Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

Thirty-five trials randomizing 2418 patients were included in the meta-analyses. Anterior QL block may reduce cumulative 24-h intravenous opioid consumption compared to placebo/no block (MD -10.42 mg, 96.7% CI -14.83 to -6.01, TSA-adjusted CI -17.03 to -3.82, p < .01). Two trials reported on SAEs. Anterior QL block may have little to no effect on the number of serious adverse events compared to placebo (RR 1.49, 96.7% CI 0.19 to 11.47, p = .68), but the evidence is very uncertain. All trial results were assessed as being high risk of bias.

CONCLUSIONS

The anterior QL block may reduce cumulative 24-h opioid consumption. Reported serious adverse events were few and the anterior QL block may have little to no effect on the number of SAEs, but the evidence was very uncertain.

Ultrasound-Guided Double-Point Versus Single-Point Serratus Anterior Plane Block for Modified Radical Mastectomy: A Randomized Controlled Trial

OBJECTIVES

The double-point serratus anterior plane block (SAPB) covers more area, including the axilla, than the single-point approach, potentially offering better pain relief after modified radical mastectomy (MRM). The objective of this study were to evaluate the clinical outcomes of these 2 procedures for patients treated with MRMs.

METHODS

Sixty women were randomly assigned to double- or single-point groups. Double-point received SAPB at the third and fifth ribs, single-point at the fifth rib. The primary outcome includes pain numeric rating scale (NRS) at rest and movement 24 hours postsurgery. The secondary outcomes are axilla comfort NRS, recovery quality, and adverse events.

RESULTS

At 24 hours postsurgery, the double-point group compared with the single-point group showed movement pain NRS of 3 (2 to 3) versus 3 (3 to 4) ( P =0.011) and rest pain NRS of 1 (1 to 1) versus 2 (1 to 3) ( P =0.037). The difference between them did not exceed the minimum clindically important difference (MCID). The axillary comfort NRS in the double-point group was lower than the single-point group at 6 and 12 hours postsurgery, at 1 (1 to 2) versus 2 (2 to 4) ( P =0.001) and 1 (1 to 2) versus 2 (2 to 4) ( P =0.01), respectively, but there were no statistically significant differences at 24 and 48 hours postsurgery. At 48 hours postsurgery, pain scores and opioid use were similar in both groups. Recovery scores, rescue analgesia timing, adverse events, and hospital stay length were similar in both groups.

DISCUSSION

Double-point SAPB offers wider anesthetic spread but shows no significant clinical advantage in pain or axillary comfort over single-point SAPB after MRM.

Photobiomodulation as part of multimodal analgesia to improve pain relief and wound healing after elective caesarean section: A protocol for randomized controlled trial

BACKGROUND

Caesarean section (CS) is the most common inpatient surgical procedure performed in Canada. CS is known to cause moderate-to-severe pain, which is suggested to be associated with postpartum depression and persistent pain. Existing limitations in multimodal analgesia and conscious attempts to avoid opioids highlight the need for non-pharmacological strategies. Photobiomodulation therapy (PBMT) uses light-emitting diode (LED) and laser and has suggested potential for improving pain control and wound healing. This study aims to evaluate the effectiveness of PBMT as part of existing multimodal analgesia after elective CSs.

METHODS

This placebo-controlled, two-arm, multi-centre, parallel-design randomized controlled trial includes women aged ≥16 years with planned CS under spinal anesthesia (Clinical Trials Registration: NCT05738239). Patients will be randomized post-CS to intervention (n = 90) or placebo (n = 90). Study interventions will be carried out using equipment supported by Meditech International Incorporated (approved by Health Canada for pain relief). Patients will receive a maximum of 5 post-surgical treatment sessions of active PBMT (intervention: LED therapy: DUO 240 [red at 660nm and near-infrared at 840nm] applied parallel to the abdominal incision scar, followed by BIOFLEX LDR-100 laser probe (660nm red light) and the LD1-200 laser probe (825nm near-infrared light), applied at the incision wound edges) or non-effective doses of LED array and laser therapy (placebo), 4-6 hrs post-CS, and at 8am and 7pm of postoperative days 1 and 2. Patients, research assistants involved in patient recruitment and follow-up, health care providers, and data analysts will be blinded. All patients will have access to routine multimodal analgesia. Patients will be followed up in hospital on the evening of surgery and on postoperative days 1 and 2 (morning, noon, and evening); at 6 weeks; and at 3 months by telephone. Primary outcome is pain intensity with movement (elicited by asking the patient to move from supine to sitting position) using 0-10 Numerical Rating Scale (0 = no pain, 10 = worst possible pain).

SIGNIFICANCE

The results of this study may result in improved pain control, maternal satisfaction and wound healing; decrease the use of perioperative opioids; potentially decrease the incidence of postpartum depression and persistent pain; and overall lead to better postoperative outcomes thereby decreasing healthcare costs.

Impact of dexmedetomidine-ropivacaine versus sufentanil-ropivacaine combination for epidural labour analgesia on neonatal outcomes: a pilot randomised clinical trial

OBJECTIVE

To investigate the impact of dexmedetomidine-ropivacaine combination versus sufentanil-ropivacaine combination for epidural labour analgesia on neonatal and maternal outcomes and test the feasibility of a future large, randomised trial.

DESIGN

A randomised, double-blind, pilot clinical trial from 16 March 2023 to 15 June 2023.

SETTING

A tertiary-care hospital in Beijing, China.

PARTICIPANTS

200 women aged≥18 years who had full-term single pregnancy and were scheduled for vaginal delivery with epidural analgesia.

INTERVENTIONS

Eligible participants were randomly assigned in a 1:1 ratio to receive self-controlled epidural labour analgesia using ropivacaine supplemented with either dexmedetomidine (0.45 µg/mL for induction and 0.36 µg/mL for maintenance) or sufentanil (0.45 µg/mL for induction and 0.36 µg/mL for maintenance).

MAIN OUTCOMES AND MEASURES

The primary endpoint was a composite of neonatal morbidity, including 1- or 5 min Apgar score<7, umbilical artery PH<7.1, requirement for immediate assisted ventilation and admission to neonatal ward or intensive care unit within 24 hours. Secondary and other endpoints included effect of analgesia and occurrence of adverse events. The feasibility of implementing the protocol was evaluated.

RESULTS

All 200 women were included in the intention-to-treat analysis. Composite neonatal morbidity occurred in 14.0% (14/100) of women with dexmedetomidine versus 17.0% (17/100) of women with sufentanil: relative risk 0.82, 95% CI 0.43 to 1.58. Women in the dexmedetomidine group had a comparable area under curve of pain intensity (median difference -2.0 point⋅h, 95% CI -9.9 to 5.9, p=0.638), required more self-controlled boluses (median difference two boluses, 95% CI 0 to 3, p=0.040) and epidural analgesics (median difference 17 mL, 95% CI 4 to 29, p=0.007), and experienced less pruritus (0.0% (0/100) vs 30.0% (30/100), p<0.001) but more lower limb weakness (13.0% (13/100) vs 1.0% (1/100), p<0.001). Recruitment rate was satisfactory (87.7%); the protocol was well accepted by anaesthesiologists and nurses.

CONCLUSIONS

Compared with sufentanil-ropivacaine combination, use of dexmedetomidine-ropivacaine combination for epidural labour analgesia was associated with a 18% decrease in composite neonatal endpoint and deserve further investigation. The dexmedetomidine-ropivacaine combination provided comparable analgesia but increased mild motor block. The conduct of a large, randomised trial using same protocol requires careful re-evaluation.

TRIAL REGISTRATION NUMBER

NCT05698407.

Addition of Ketorolac to Local Anesthesia for Wound Infiltration in Multilevel Posterior Lumbar Spinal Fusion: A Randomized, Double-Blinded, Placebo-Controlled Trial

STUDY DESIGN

Randomized double-blind controlled trial.

OBJECTIVE

The purpose of this study was to determine the efficacy of pain control and opioid consumption after administration of ketorolac directly to paraspinal muscle after spinal fusion.

SUMMARY OF BACKGROUND DATA

Ketorolac is added to multimodal analgesia regimens to improve pain control, reduce opioid consumption following orthopaedics and spine surgery. However, evidence of the efficacy of adding ketorolac to local anesthesia for intrawound infiltration after spine surgery is still limited.

MATERIALS AND METHODS

The patients who underwent multilevel lumbar decompression and posterolateral fusion were recruited and randomized to the control group which received 0.5% bupivacaine hydrochloride injected into paraspinal muscles before wound closure, and the ketorolac group which received 30 mg ketorolac in addition to 0.5% bupivacaine hydrochloride. Postoperative numerical rating scale (NRS) for back pain, leg pain, morphine consumption, and adverse events were recorded.

RESULTS

A total of 47 patients were randomized (24 in the ketorolac group and 23 in the control group). The mean age was 60.9±6.9 years old. The mean NRS for back pain at 6 hours after surgery was 5.8±3.0 points for the control group and 3.3±2.1 points for the ketorolac group ( P <0.01). The ketorolac group consumed lesser morphine than the control group by 9.1 mg in the first 24 hours, 13.8 mg at 48 hours, 14.3 mg at 72 hours, and 13.9 mg at 96 hours after the surgery ( P <0.05). Postoperative complications were not different between the two groups.

CONCLUSIONS

The addition of ketorolac to bupivacaine for wound infiltration after posterior lumbar spine decompression and fusion reduces early postoperative pain and total morphine consumption as compared with bupivacaine alone.

Effects of Continuous Erector Spinae Plane Block on the Postoperative Sleep Quality for Patients Undergoing Thoracoscopic Lung Lobe Resection Surgery: A Prospective, Randomized Controlled Trial

Purpose

To investigate the effect of continuous erector spinae plane block (ESPB) on postoperative sleep in patients undergoing thoracoscopic lung lobe resection surgery.

Patients and Methods

Eighty-six patients were randomly assigned into two groups: ESPB group (Group E) or control group (Group P). Group E received ESPB before induction, followed by continuous ESPB analgesia, while Group P received postoperative intravenous controlled analgesia. The Pittsburgh Sleep Quality Index (PSQI) questionnaire was used to assess postoperative sleep disturbance (PSD) on the postoperative day 3 (POD3). The St. Mary's Hospital Sleep Questionnaire (SMH) evaluated sleep quality on the day of surgery and postoperative day 1 (POD1) and postoperative day 2 (POD2). The Identity Consequence Fatigue Scale-10 (ICFS-10) was utilized to evaluate postoperative fatigue status. Numeric Rating Scale (NRS) scores at resting and coughing were recorded at extubation, 6 h, 24 h, 48 h, 72 h after surgery. Consumption of propofol, remifentanil, and remedial analgesics (bucinazine), hospital duration, occurrence of postoperative adverse reactions were documented. Interleukin-6 (IL-6) and interleukin-10 (IL-10) serum levels were measured before surgery, 12 h, 24 h, 48 h after surgery.

Results

The incidence of PSD in group E on POD3 was significantly lower than group P (75% vs 25%). Patients in group E had higher SMH scores than group P on the day of surgery and POD2. Compared with group P, the NRS scores of resting and coughing at all time points, remifentanil and bucinazine consumption, postoperative ICFS-10 scores, the incidence of nausea and vomiting, IL-6 serum levels in group E were significantly decreased. The IL-10 serum levels in group E were significantly higher than those in group P.

Conclusion

The continuous ESPB can improve postoperative sleep quality, alleviate pain, fatigue and inflammation, and reduce the incidence of postoperative nausea and vomiting.

Efficacy of generic versus branded diacerein for treatment of knee osteoarthritis: A randomized control trial

BACKGROUND

Several studies have proved that diacerein effectively treats knee osteoarthritis (OA). All studies used branded diacerein. Recently, generic diacerein has been available in several countries, with limited studies comparing the efficacy of generic and branded diacerein for knee OA treatment.

METHODS

Among 200 eligible patients, 94 were randomized to take a daily 50 mg of generic diacerein (Diaceric®); group A or branded diacerein (Artrodar®); group B for treating mild to moderate knee OA. All patients were assigned 5-visit assessments and followed until 24 weeks. The primary outcome was a visual analog scale (VAS) on the motion. The secondary outcomes were 2 patient-report outcome measures (PROMs): the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index and the Short Form-12 (SF-12), as well as 3 performance-based measures (PBMs): 5-time sit to stand test (5 × SST), the time up and go test (TUGT), and the 3-minute walk test (3MWT).

RESULTS

There were 47 patients in group A and 47 in group B, with no patients lost for FU. Among all patients, 79.8% were female with a mean age of 63.2 years in group A and 64.8 years in group B. The Kellgren and Lawrence (KL) grade II was the most common in both groups. There were no differences in all demographic data. At 24-week follow-up (FU), both groups had significantly improved VAS, with a 12-week earlier improvement in the branded diacerein. In addition, the PBMs, including 5 × SST and 3MWT, significantly improved from 12-week FU in both groups, with insignificantly improved WOMAC and SF-12 and no serious adverse events in either group.

CONCLUSION

After a 24-week FU, the generic diacerein had similar efficacy as the branded diacerein in significantly improving VAS and PBMs: 5 × SST and 3MWT. However, the latter had a faster statistically improved VAS than the former.

Effectiveness of adductor canal block combined with posterior capsular infiltration on pain and return to walking after total knee arthroplasty: comparative analysis with femoral and popliteal sciatic nerves blocks

INTRODUCTION

Perioperative analgesia after total knee arthroplasty (TKA) reduces morphine consumption and speeds up rehabilitation. The primary objective of this study was to compare the pain experienced by patients with an adductor canal and posterior capsule block with those with a continuous femoral nerve block combined with a popliteal sciatic nerve block. The secondary objectives were to analyze the time to recovery from early walking, length of hospital stay, and block-related complications between the two groups.

HYPOTHESIS

Patients with an adductor canal block and posterior capsular infiltration had less pain 24 h after TKA.

MATERIAL AND METHODS

This single-center retrospective study included 774 TKA between January 2020 and March 2023. Two types of locoregional blocks were evaluated: patients who had a continuous femoral nerve block with a single-shot popliteal sciatic nerve block (FN-PSN group) operated on before March 2022 and those who had a single-shot adductor canal block combined with posterior capsular infiltration (ACB-PI group) operated on after March 2022. One patient in the ACB-PI group was matched to two patients in the NF-BS group according to sex, age, and BMI. A total of 725 TKA were included: 500 in the FN-PSN group and 225 in the ACB-PI group. The primary endpoint was pain assessed using the numerical pain rating scale (NPRS) and opioid consumption at 24 h after TKA. Resumption of walking, defined as getting up for the first time and walking ten steps until discharge from the hospital, and complications between the two groups were also assessed. The study population consisted of 471 women (64.9%) with a mean age of 72.2 ± 8.2 years and a mean BMI of 28.2 ± 4.6.

RESULTS

Patients in the FN-PSN group had less pain at NPRS (1.3 versus 1.9; p < 0.001), and fewer patients required morphine titration (13.8% versus 6.8%, p = 0.02) within the first 8 h of surgery with no difference at 24 h, 48 h and 72 h. The mean doses of morphine administered were similar between the groups. Resumption of walking was significantly longer in the FN-PSN group (1.5 versus 2.0 days, p = 0.003), and hospitalization times and complications were similar between the groups.

CONCLUSION

Adductor canal block combined with posterior capsular infiltration did not reduce postoperative pain compared with femoral and popliteal sciatic block at 24 h after TKA. Opioid consumption and pain were similar between the groups, with more patients requiring morphine in the first eight hours in the ACB-PI group but with a faster return to walking.

LEVEL OF EVIDENCE

III; comparative study.

Treatment of Arthrogenic-Muscle-Inhibition in patients after knee-surgery with Motion-Activated-Neuromuscular stimulation - a case-series

Arthrogenic muscle inhibition (AMI) presents a persistent challenge in postoperative knee rehabilitation and is often resistant to standard care. This case series examines the efficacy of Motion-Activated Neuromuscular Electrical Stimulation (mNMES) in addressing AMI refractory to rehabilitation after ACL (revision) surgery, patellar dislocation, trochleoplasty, or conservative treatment of the patellofemoral pain syndrome. Eight patients who had undergone extensive unsuccessful rehabilitation received six weeks of a novel mNMES treatment regimen. Outcome assessments included patient-reported outcome measures (PROMs) and AMI classification. Results revealed significant improvements in pain reduction, knee function, and AMI reduction. Despite study limitations, mNMES demonstrated promising outcomes and could be used as an adjunct to standard rehabilitation, offering potential for enhancing postoperative outcomes in patients refractory to conventional therapy. Further research is required to validate these findings and optimise treatment protocols.

Postoperative analgesic effectiveness of ultrasound-guided bilateral erector spinae plane block vs. rectus sheath block for midline abdominal surgery in a low- and middle-income country: a randomised controlled trial

INTRODUCTION

The use of erector spinae plane block and rectus sheath block for postoperative analgesia in midline abdominal procedures is becoming more common. However, the most effective and appropriate method remains unclear. We aimed to compare the postoperative analgesic effecacy of ultrasound-guided bilateral erector spinae plane blocks with rectus sheath blocks for midline abdominal surgery in a low- and middle-income country.

METHODS

We allocated randomly 72 patients aged 18-65 y undergoing midline abdominal surgery to an erector spinae plane block (n = 36) or a rectus sheath block (n = 36) utilising a prospective, parallel study design. Patients, care providers and outcome assessors were blinded to the interventions. The primary outcome measures were total postoperative analgesia consumption, postoperative pain severity and time to first rescue analgesic administration. Secondary outcomes included the incidence of postoperative complications and adverse events.

RESULTS

Of 78 patients assessed for eligibility, six were excluded, leaving 72 for analysis. Patients allocated to erector spinae plane block had a lower mean (SD) postoperative opioid consumption compared with those allocated to rectus sheath block (3.5 (8.7) morphine milligram equivalents vs. 8.2 (2.8) morphine milligram equivalents, respectively; p = 0.003). Time to first analgesic request was greater in patients allocated to erector spinae plane block compared with those allocated to rectus sheath block (mean (95%CI) 16 (13-17) h vs. 12 (11-13) h, respectively; p < 0.001). There were no block-related complications in either group.

DISCUSSION

Erector spinae plane blocks are more effective than rectus sheath blocks for the management of postoperative pain following midline abdominal surgery. Integration of erector spinae plane blocks into multimodal opioid-sparing analgesic strategies after midline abdominal surgeries may promote enhanced patient recovery in low-and middle-income countries.

Effects of transcutaneous electrical nerve stimulation on acute postoperative breast augmentation pain: study protocol

The aim of this study is to describe a protocol for evaluating the effects of transcutaneous electrical nerve stimulation (TENS) on pain following breast augmentation surgery. Fifty-four women will be randomly allocated into two groups: active TENS and placebo. Pain will be assessed at rest and during movement, before and immediately after TENS application. Secondary outcomes include pain one-hour post-treatment, respiratory muscle strength, patient satisfaction, and analgesic use in the first four hours post-surgery. The results of this clinical trial could enhance the management of post-operative pain in breast augmentation surgery using non-pharmacological interventions, potentially reducing costs and improving patient experience.Clinical Trial Registration: RBR-96h3k97.

Patient-Perceived Outcomes of Recovery After Trigger Digit Release

PURPOSE

Trigger finger release (TFR) is one of the most commonly performed hand surgeries; nevertheless, the time until patients subjectively feel recovered has not been well documented. The limited literature on patient perceptions of recovery after any type of surgery has described that patients and surgeons may have differing views on the time until full recovery. Our primary study question was to determine how long it takes for patients to subjectively feel fully recovered after TFR.

METHODS

In this prospective study, patients who underwent isolated TFR completed questionnaires before surgery and at multiple time points following surgery until they reported full recovery. Patients completed visual analog scale (VAS) pain scores and QuickDASH (Disabilities of the Arm, Shoulder, and Hand) and were asked if they felt fully recovered at 4 weeks, 6 weeks, and 3, 6, 9, and 12 months.

RESULTS

The average time to self-reported full recovery was 6.2 months (SD 2.6), and the median time to self-reported full recovery was 6 months (IQR 4 months). At 12 months, four out of 50 patients (8%) did not feel fully recovered. QuickDASH and VAS pain scores improved significantly from preoperative assessment to final follow-up. All patients reported improvement in both VAS pain scores and QuickDASH scores greater than the minimal clinically important difference between 6 weeks and 3 months after surgery. Higher preoperative VAS and QuickDASH scores were associated with failure to fully recover by 12 months after surgery.

CONCLUSIONS

The length of time after surgery until patients felt fully recovered after isolated TFR is longer than the senior authors' expectations. This suggests that patients and surgeons may consider distinctly different parameters when discussing recovery. Surgeons should be aware of this discrepancy when discussing recovery after surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Evaluation of Pain Relief and Opioid Consumption With the Addition of an Erector Spinae Plane Catheter Block After an Interscalene Nerve Block in Arthroscopic Rotator Cuff Repair

Background

The effects of the erector spinae plane (ESP) block and interscalene nerve block (ISNB) on arthroscopic rotator cuff repair (RCR) have been investigated separately.

Purpose

To evaluate whether additional catheterization for the ESP block can decrease acute postoperative pain and opioid consumption above the ISNB and multimodal oral analgesics in patients after arthroscopic RCR.

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were patients who underwent primary arthroscopic RCR between January 1 and December 31, 2021, and received either ISNB (ISNB group) or additional ESP block catheterization (ESP block group) as part of their pain management. Patients who underwent concomitant shoulder procedures were excluded. Patient characteristics, surgical details, pre- and postoperative numerical pain rating scale (NPRS) scores, rescue analgesic use, and possible opioid-related side effects were recorded. The primary outcome was the NPRS score immediately after surgery; secondary outcomes included rescue opioid use and opioid-related side effects until patients were discharged the next day. The Mann-Whitney U test or the chi-square test was used for between-group comparisons. Multiple linear regression analysis was conducted to examine predictors for total opioid consumption.

Results

A total of 54 patients were included-21 in the ISNB group and 33 in the ESP block group. The ESP block group exhibited significantly lower postoperative NPRS scores (2 ± 0.3 vs 3 ± 1.6 for ISNB; P = .003), reduced opioid consumption during hospitalization (0.5 ± 1.3 vs 6.1 ± 8.3 morphine milligram equivalent [MME] for ISNB; P < .001), and fewer opioid-related side effects (0 vs 3 for ISNB; P = .022). Multiple linear regression analysis indicated that the analgesic protocol (β = 5.750; P < .001) and the number of anchors used (β = 1.609; P = .022) were independently correlated with higher opioid consumption. Subgroup analysis revealed that additional ESP block significantly reduced opioid consumption during repairs involving ≥2 tendons (7.6 ± 9 vs 0.5 ± 1.4 MME; P < .001).

Conclusion

The study findings indicated that additional catheterization for the ESP block reduced postoperative pain, opioid consumption, and opioid-related side effects during the acute postoperative period of arthroscopic RCR when the ISNB and multimodal oral analgesics had already been administered. Future studies are needed to evaluate this treatment protocol.

Paravertebral versus Pectoralis-II (Interpectoral and Pectoserratus) Nerve Blocks for Postoperative Analgesia after Nonmastectomy Breast Surgery: A Randomized, Controlled, Observer-masked Noninferiority Trial

BACKGROUND

Pectoralis-II and paravertebral nerve blocks are both used to treat pain after breast surgery. Most previous studies involving mastectomy identified little difference of significance between the two approaches. Whether this is also accurate for nonmastectomy procedures remains unknown.

METHODS

Participants undergoing uni- or bilateral nonmastectomy breast surgery anticipated to have at least moderate postoperative pain were randomized to a pectoralis-II or paravertebral block (90 mg ropivacaine per side for both). Surgeons and recovery room staff were masked to treatment group assignment, and participants were not informed of their treatment group. Injectate for pectoralis-II blocks was ropivacaine 0.3% (30 ml) per side. Injectate for paravertebral blocks was ropivacaine 0.5% (9 ml in each of two levels) per side. This study hypothesized that pectoralis-II blocks would have noninferior analgesia (numeric rating scale) and noninferior cumulative opioid consumption within the operating and recovery rooms combined (dual primary outcomes). The study was adequately powered with n = 100, but the target enrollment was raised to n = 150 to account for higher-than-anticipated variability.

RESULTS

The trial was ended prematurely with 119 (79%) of the original target of 150 participants enrolled due to (masked) surgeon preference. Within the recovery room, pain scores were higher in participants with pectoralis-II (n = 60) than paravertebral blocks (n = 59): median [interquartile range], 3.3 [2.3, 4.8] versus 1.3 [0, 3.6] (95% CI, 0.5 to 2.6; P < 0.001). Similarly, intravenous morphine equivalents were higher in the pectoralis-II group: 17.5 [12.5, 21.9] versus 10.0 mg [10, 20] (95% CI, 0.1 to 7.5; P = 0.004). No block-related adverse events were identified in either group.

CONCLUSIONS

After nonmastectomy breast surgery, two-level paravertebral blocks provided superior analgesia and opioid sparing compared with pectoralis-II blocks. This is a contrary finding to the majority of studies in patients having mastectomy, in which little significant difference was identified between the two types of blocks.

EDITOR’S PERSPECTIVE

Comparison of 2 Types of Local Anesthetic Techniques in the Reduction of Distal Radius Fracture: A Prospective Cohort Study

BACKGROUND

The treatment of distal radius fractures may require manipulation of the fracture assisted by finger traction, causing pain both at the fracture site and at the fingers. The usual type of anesthesia used does not anesthetize the fingers.

METHODS

We conducted a prospective cohort study with two groups, hematoma block (HB) and hematoma with associated median nerve block (MHB). Characteristic variables of the patients were collected. The main variable for the analysis was pain, measured using the Visual Analogical Scale (VAS). It was measured prior to the injection (VAS1), during fracture reduction (VAS2), and 30 minutes after the injection (VAS3) in both groups.

RESULTS

The study included a total of 140 fractures (70 anesthetized with HB), 78% were women. There were no significant differences in the variables age, sex, Elixhauser index. and need for surgery between the groups. In the HB group, the VAS means were VAS1 5.23 cm (SD 2.31), VAS2 5.80 cm (SD 2.52), and VAS3 1.89 cm (SD 1.94); while in the MHB group, VAS1 5.13 cm (SD 2.36), VAS2 3.15 cm (SD 1.70), and VAS3 1.09 cm (SD 1.38). Area of greatest pain during fracture reduction in the HB group was finger traction in 78% cases (p < .05), while in the MHB group it was the manipulation of the fracture site in 71% cases (p < .05).

CONCLUSIONS

The study demonstrates that the use of hematoma with associated median nerve block decreases pain perception in patients with distal radius fracture that needs closed reduction, when compared to HB alone.

The analgesic effect of continuous adductor canal block combined with popliteal plexus block for total knee arthroplasty: a randomized controlled trial

This study aimed to confirm the hypothesis that continuous ACB (CACB) combined with a popliteal plexus block (PPB) can improve posterior knee pain, reduce nalbuphine consumption, and shorten the length of hospital stay. Patients who underwent TKA were allocated to the CACB + sham block (SHAM) or CACB + PPB groups. The primary outcome was the maximum pain score originating from the posterior knee within 4 h after TKA. Secondary outcomes included the maximum pain score originating from the posterior and anterior knees within 72 h after TKA, range of motion on postoperative day (POD) 1-3, postoperative nalbuphine consumption within 72 h of surgery, length of hospital stay, and complications. The maximum pain score of the posterior knee was lower in the CACB + PPB group than in the CACB + SHAM group within 0-12 h after surgery. Nalbuphine consumption within 24 h after surgery was lower in the CACB + PPB group than in the CACB + SHAM group. The range of motion was better in the CACB + PPB group than in the CACB + SHAM group on POD1 and 2. The length of hospital stay was shorter in the CACB + PPB group than in the CACB + SHAM group. The incidence of clinical significant nausea and vomiting was lower in the CACB + PPB group than in the CACB + SHAM group. This study found that PPB combined with CACB could relieve pain in the posterior knee within at least 12 h after TKA, reduce nalbuphine consumption within 24 h after TKA, improve the range of motion on POD1 and 2, and shorten the length of hospital stay for patients who underwent TKA.

Efficacy of a computer vision-based system for exercise management in patients with knee osteoarthritis: a study protocol for a randomised controlled pilot trial

INTRODUCTION

This study aims to evaluate the efficacy of a computer vision system in guiding exercise management for patients with knee osteoarthritis (OA) by comparing functional improvement between a tele-rehabilitation versus an outpatient intervention program.

METHODS AND ANALYSIS

This is a prospective, single-blind, randomised controlled trial of 60 patients with knee OA who will be randomly assigned to exercise therapy (n=30) or control (n=30) . Both groups will receive treatment two times per week for 12 weeks. The primary outcome of the study will be assessed using the University of Western Ontario and McMaster University Osteoarthritis Index (WOMAC). The Knee Injury and Osteoarthritis Outcome Score will be assessed, as well as the visual analogue scale, quality of life score and physical fitness score. All observations will be collected at baseline and at weeks 4, 8 and 12 during the intervention period, as well as at weeks 4, 8, 12 and 24 during the follow-up visits after the end of the intervention.

ETHICS AND DISSEMINATION

This evaluator-blinded, prospective, randomised controlled study was approved by the Biomedical Ethics Review Committee of West China Hospital of Sichuan University.

TRIAL REGISTRATION NUMBER

ChiCTR2300070319.

Comparison of erector spinae plane and transversus abdominis plane block for postoperative analgesia after caesarean delivery under spinal anaesthesia: A randomised controlled trial

BACKGROUND

Truncal blocks contribute to multimodal analgesia that enhances early recovery after caesarean delivery. The transversus abdominis plane (TAP) block is an established technique that offers somatic abdominal wall analgesia. The erector spinae plane (ESP) block is a fascial plane technique that may offer additional visceral analgesic effects. This study hypothesized that ESP block would offer superior analgesic efficacy to TAP block in women undergoing caesarean delivery under spinal anaesthesia.

METHODS

Sixty-six ASA physical status grade 1-3 (≥18 years) patients undergoing elective caesarean delivery under spinal anaesthesia were randomly allocated to receive either bilateral ultrasound-guided TAP (N = 33) or ESP blocks at the T9 vertebral level (N = 35). The primary outcome measure was 24-hour cumulative morphine consumption. The secondary outcomes included time to first analgesic request, duration of block placement, numeric rating scale (NRS) pain scores at rest and movement, effect of pain on activities of daily living (ADLs) and care for the infant, patient analgesic satisfaction, frequency and severity of opioid-related side effects.

RESULTS

There was no statistically significant difference in mean (95% CI) 24-hour cumulative morphine consumption between groups: 32.0 (27.0 to 37.0) mg with TAP versus 27.0 (19.9 to 34.0) mg with ESP (p = 0.16). The mean (SD) duration of block placement was longer for ESP than for TAP blocks (10.7 (2.2) minutes versus 9.0 (2.5) minutes; p = 0.004). There were no significant differences in the other secondary outcomes.

CONCLUSION

This study found similar postoperative opioid use and analgesic efficacy between ESP and TAP block after caesarean delivery performed under spinal anaesthesia.

TRIAL REGISTRATION

South African National Clinical Trial Registry (DOH-27-102022-5278): https://sanctr.samrc.ac.za/TrialDisplay.aspx?TrialID=8100, Pan African Clinical Trials Registry (PACTR202301645957324): https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=24267.

Outcomes of cooled radiofrequency ablation of cervical nerves for the treatment of chronic pain

BACKGROUND

Chronic pain, defined as pain persisting for more than 3-6 months, has a mean one-year prevalence in the United States of 25.8% and is one of the most frequent reasons adults seek medical care. Treatment options include physical therapy, analgesics, anticonvulsants, exercise, and muscle relaxants. Even with conventional treatment modalities, in a subset of patients, pain may persist. Cooled radiofrequency ablation (c-RFA), a minimally invasive therapy, employs thermal energy generated by electrical currents to disrupt the transmission of pain stimuli along nociceptive pathways. This leads to an attenuation of pain impulses, primarily through nerve tissue necrosis. The potential of c-RFA to alleviate chronic pain for patients who struggle to find relief elsewhere accentuates the importance of rigorously investigating its outcomes. This study investigates whether patients receiving c-RFA for relief of chronic neck pain caused by cervical facet joint arthropathy experience a reduction in pain scores, the length of this reduction in pain scores, and the magnitude of this reduction in pain.

METHODS

This study was a retrospective analysis of data extracted from UW-Health Electronic Medical Health records (EMR), encompassing cervical c-RFA procedures performed from 2015 through 2022. Patient data were obtained, including diagnosis, pre-operative pain score, post-operative pain score, duration of relief, patient age, sex, and BMI. A two-tailed paired t-test was used to statistically analyze the pre-operative and post-operative pain scores, in which a p-value ≤0.05 was considered significant.

RESULTS

A total of 450 cervical c-RFA procedures were reviewed, 152 were excluded due to absent pre- or post-op pain scores. 298 were included in the analysis, comprising 203 unique patients: 129 females and 74 males with an average age of 56.03 ± 12.76 and a BMI of 28.76 ± 6.05. Improvement of pain symptoms was reported in 85.23% (n = 263), 6% (n = 19) reported complete pain remission, 8.72% (n = 26) reported no change, and 3.02% (n = 9) reported worsening symptoms. Patients reported an average pre-operative pain score of 6.15 (M = 6.15, SD = 1.55) and an average post-operative pain score of 3.64 (M = 3.64, SD = 2.09) this achieved significance (p < 0.0001). Of the 85.23% (n = 263) charts that noted improvement, there is an average of 48.04% ± 26.53 reduction from their pre-operative pain scores. The average duration of relief lasted 6.67 ± 4.84 months.

CONCLUSION

This study supports the potential efficacy of c-RFA as a minimally invasive treatment for chronic neck pain secondary to cervical facet joint arthropathy refractory to conventional treatment measures, demonstrating significant relief for a substantial length of time. Due to chronic pain's detrimental effect on one's quality of life, finding effective treatment options is essential, especially for those refractory to conventional treatments.

High-frequency, high-intensity TENS compared to standard treatment with opioids for postoperative pain relief after laparoscopic cholecystectomy: A multicentre randomized controlled trial

BACKGROUND

Adverse effects of opioids could prolong the duration of stay in the post-anaesthesia care unit (PACU). This study aimed to assess time in the PACU and the pain-relieving effect of high-frequency, high-intensity transcutaneous electrical nerve stimulation (HFHI TENS) versus standard treatment with intravenous (IV) opioids.

METHODS

Patients undergoing laparoscopic cholecystectomy at two Swedish hospitals were invited to participate. Patients reporting postoperative pain intensity ≥3 according to the Numeric Rating Scale (NRS) in the PACU were randomized to receive standard treatment with IV opioids or HFHI TENS, administered with an intensity of 40-60 mA for 1 min, repeated once if insufficient pain relief. If NRS remained ≥3 after two TENS stimulation the patients received IV opioids.

RESULTS

In total, 163 patients were randomized to receive HFHI TENS (n = 85) or IV opioids (n = 78). There was no difference between the HFHI TENS group versus the opioid group regarding time in the PACU (138 min [SD 69] vs. 142 min [SD 95], mean difference -4.42 [95% CI-30:22], p = 0.74), time to pain relief NRS < 3 (median 10 min) and pain intensity at PACU discharge (NRS 1.7 [SD 1.45] vs. 1.6 [SD 1.20], p = 0.58). In the HFHI TENS group, 39 patients (46%) needed additional treatment with IV opioids. Mean opioid consumption was significantly lower in the HFHI TENS group than in the opioid group (4.5 vs. 11.0 morphine equivalents; p < 0.001).

CONCLUSIONS

HFHI TENS may be an opioid-sparing alternative for postoperative pain relief.

SIGNIFICANCE STATEMENT

In this multicentre, RCT time in the PACU and the pain-relieving effect of HFHI TENS was compared to standard treatment with IV opioids. There were no differences between the groups regarding time in the PACU, time to pain relief and side effects but opioid consumption in the HFHI TENS group was significantly lower. Both groups reported high satisfaction with pain treatment and care. In summary, HFHI TENS should be considered a safe, fast-onsetting, opioid-sparing option for postoperative pain relief.

Preoperative Acetaminophen For Microsuspension Laryngoscopy Reduces Postoperative Opioid Use

OBJECTIVES

The opioid crisis has prompted consideration of analgesic prescriptions. This study explored the value of preoperative acetaminophen for pain control following microsuspension laryngoscopy (MSL) and compared the results with a previous study of pain and opioid use following MSL (Tsang et al.).

METHODS

A prospective open-label clinical trial was conducted in patients undergoing MSL. All patients were administered preoperative acetaminophen. Short-form McGill Pain Questionnaire (SF-MPQ), pain visual analogue scale (VAS), and present pain intensity (PPI) scores were collected preoperatively and on postoperative days (PODs) 1, 3, 7, and 14. Statistical analysis identified variables associated with opioid use or increased pain scores, and compared outcomes with Tsang et al. RESULTS: Eighty-nine patients were included (mean age 52.8 ± 17.3 years, 40 males). All patients received preoperative 1 g acetaminophen (77 (86.5%) orally) with no adverse effects. On POD1, opioid usage was 10%. Median [IQR] pain scores were 5 [2-11], 21 [12.3-56.8], and 3 [2-3.3] on SF-MPQ, VAS, and PPI, respectively. Post-Anesthesia Care Unit (PACU) opioid requirements significantly correlated with POD1 opioid consumption (τb = 0.214; p ≤ 0.05), and significant associations with PACU opioid administration were found for total anesthesia time (OR (95%CI) = 1.271 (1.043-1.548), p = 0.017) and total laryngoscope suspension time (OR (95%CI) = 0.791 (0.651-0.962, p = 0.019)). This cohort demonstrated reduced opioid usage on POD1 compared with Tsang et al (23%).

CONCLUSIONS

Preoperative acetaminophen is a safe intervention, resulting in decreased postoperative opioid use following MSL. Anesthesia time correlated with need for postoperative opioids.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:4625-4635, 2024.

The Analgesic Effect of Ultrasound-guided Erector Spinae Plane Block in Median Sternotomy Cardiac Surgery in Adults: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVES

To assess the analgesic effect of erector spinae plane block in adults undergoing median sternotomy cardiac surgery.

DESIGN AND SETTING

The Cochrane, Embase, and PubMed databases from inception to January 2024 were searched. The study has been registered in the International Prospective Register of Systematic Reviews (CRD42023470375).

PARTICIPANTS

Eight randomized controlled trials involving 543 patients, comparing with no block or sham block, were included, whether it was a single injection or continuous.

MEASUREMENTS AND MAIN RESULTS

The primary outcomes were pain scores and opioid consumption. Erector spinae plane block reduced pain scores immediately after extubation (mean difference [MD], -1.19; 95% confidence interval [CI], -1.67 to -0.71; p for heterogeneity = 0.10), at 6 hours after extubation (MD, -1.96; 95% CI, -2.85 to -1.08; p for heterogeneity < 0.0001), and at 12 hours after extubation (MD, -0.98; 95% CI, -1.55 to -0.40; p for heterogeneity < 0.00001). The decrease in pain scores reached the minimal clinically important difference within 6 hours. Opioid consumption 24 hours after surgery decreased by 35.72 mg of oral morphine equivalents (95% CI, -50.88 to -20.57; p for heterogeneity < 0.0001). Sensitivity analysis confirmed the stability of results. The quality of primary outcomes was rated as very low to moderate.

CONCLUSIONS

Erector spinae plane block decreased pain scores within 12 hours after extubation, reached the minimal clinically important difference within 6 hours, and decreased opioid consumption 24 hours after surgery, based on data of very low to moderate quality. However, high-quality randomized controlled trials are necessary to validate these findings.

Opioids and personalized analgesia in the perioperative setting: A protocol for five systematic reviews

BACKGROUND

Treatment with opioids is a mainstay in perioperative pain management. While the leading treatment paradigm has been procedure-specific pain management, efforts regarding personalized pain treatment are increasing. The OPI•AID project aims to develop personalized algorithms for perioperative pain management, taking demographic, surgical, and anaesthesiologic factors into account. We will undertake five parallel reviews to illuminate current evidence on different aspects of individual responses to perioperative opioid treatment.

METHODS

Inclusion of adult populations in English-written studies. Review-specific searches are developed for the following databases: CENTRAL, MEDLINE, Embase, clinicaltrials.gov, and clinicaltrial.eu. Two authors will independently screen citations, extract data, and assess the risks of bias in each review (QUIPS, PROBAST and RoB2, as relevant).

CONCLUSION

These reviews will evaluate various aspects of perioperative opioid treatment, including individualized treatment strategies, selection of specific opioids, and individual patient responses. These will guide future development of a personalized perioperative opioid treatment algorithm (OPI•AID) that will be validated and tested clinically against standard of care.

Posttraumatic stress disorder 2 months after cesarean delivery: a multicenter prospective study

BACKGROUND

The prevalence and risk factors of posttraumatic stress disorder after cesarean delivery, outside high-risk contexts, remain unclear.

OBJECTIVE

This study aimed to assess posttraumatic stress disorder prevalence and risk factors at 2 months postpartum among a general population of women with cesarean delivery.

STUDY DESIGN

This was a prospective ancillary cohort study of the Tranexamic Acid for Preventing Postpartum Hemorrhage after Cesarean Delivery (TRAAP2) trial, conducted in 27 French hospitals from 2018 to 2020, enrolling women expected to undergo cesarean delivery before or during labor at ≥34 weeks of gestation. After randomization, characteristics of the cesarean delivery and postpartum blood loss were prospectively collected. Two months after childbirth, posttraumatic stress disorder profile (presence of posttraumatic stress disorder symptoms) and provisional diagnosis (positive screening for diagnosis consistent with a posttraumatic stress disorder) were assessed by 2 self-administered questionnaires (Impact of Event Scale - Revised and Traumatic Event Scale). The corrected posttraumatic stress disorder prevalence was estimated with inverse probability weighting to take nonresponse into account. Associations between potential risk factors and posttraumatic stress disorder were analyzed by multivariate logistic or linear regression modeling according to the type of dependent variable.

RESULTS

In total, 2785 of 4431 women returned the Impact of Event Scale - Revised questionnaire and 2792 the Traumatic Event Scale (response rates of 62.9% and 63.0%). The prevalence of posttraumatic stress disorder profile was 9.0% (95% confidence interval, 7.8%-10.3%) and of provisional diagnosis 1.7% (95% confidence interval, 1.2%-2.4%). Characteristics associated with a higher risk of posttraumatic stress disorder profile were prepregnancy vulnerability factors (young age, high body mass index, and African-born migrant) and cesarean delivery-related obstetrical factors (cesarean delivery after induced labor [adjusted odds ratio, 1.81; 95% confidence interval, 1.14-2.87], postpartum hemorrhage [adjusted odds ratio, 1.61; 95% confidence interval, 1.04-2.46] and high-intensity pain during the postpartum stay [adjusted odds ratio, 1.90; 95% confidence interval, 1.17-3.11]). Women who had immediate skin-to-skin contact with their newborn were at lower risk of posttraumatic stress disorder (adjusted odds ratio, 0.66; 95% confidence interval, 0.46-0.98), and women with bad memories of delivery on day 2 postpartum were at higher risk (adjusted odds ratio, 3.20; 95% confidence interval, 1.97-5.12). The Impact of Event Scale - Revised and the Traumatic Event Scale yielded consistent results.

CONCLUSION

Approximately 1 in 11 women with cesarean deliveries had posttraumatic stress disorder symptoms at 2 months postpartum. Some obstetrical interventions and components of cesarean delivery management may influence this risk.

The cervico-ocular reflex changes following treatment in individuals with subclinical neck pain: a randomized control trial

Individuals with subclinical neck pain (SCNP) exhibit altered cerebellar processing, likely due to disordered sensorimotor integration of inaccurate proprioceptive input. This association between proprioceptive feedback and SMI has been captured in cervico-ocular reflex (COR) differences where SCNP showed higher gain than healthy participants. Previous neurophysiological research demonstrated improved cerebellar processing in SCNP participants following a single treatment session, but it is unknown whether these neurophysiological changes transfer to cerebellar function. In a parallel group, randomized control trial conducted at Ontario Tech University, 27 right-hand dominant SCNP participants were allocated to the 8-week chiropractic care (n = 15; 7M & 8 F) or 8-week control (n = 12; 6M & 6 F) group. COR gain (ratio of eye movement to trunk movement) was assessed using an eye-tracking device at baseline and at post 8-weeks (treatment vs. no treatment). COR gain (10 trials): participants gazed at a circular target that disappeared after 3 s, while a motorized chair rotated their trunk at a frequency of 0.04 Hz, with an amplitude of 5º, for 2 minutes. A 2 × 2 repeated measures ANOVA was performed. COR gain was significantly reduced following 8-weeks of chiropractic care compared to the SCNP control (8-weeks of no treatment) group (p = 0.012, ηp2 = 0.237). The decrease in COR gain following treatment is likely due to normalized proprioceptive feedback from the neck, enabling improved processing and integration within the flocculonodular lobe of the cerebellum.

Primary outcomes and anticipated effect sizes in randomised clinical trials assessing adjuncts to peripheral nerve blocks: A scoping review

BACKGROUND

Prolonging effects of adjuncts to local anaesthetics in peripheral nerve blocks have been demonstrated in randomised clinical trials. The chosen primary outcome and anticipated effect size have major impact on the clinical relevance of results in these trials. This scoping review aims to provide an overview of frequently used outcomes and anticipated effect sizes in randomised trials on peripheral nerve block adjuncts.

METHODS

For our scoping review, we searched MEDLINE, Embase and CENTRAL for trials assessing effects of adjuncts for peripheral nerve blocks published in 10 major anaesthesia journals. We included randomised clinical trials assessing adjuncts for single-shot ultrasound-guided peripheral nerve blocks, regardless of the type of interventional adjunct and control group, local anaesthetic used and anatomical localization. Our primary outcome was the choice of primary outcomes and corresponding anticipated effect size used for sample size estimation. Secondary outcomes were assessor of primary outcomes, the reporting of sample size calculations and statistically significant and non-significant results related to the anticipated effect sizes.

RESULTS

Of 11,854 screened trials, we included 59. The most frequent primary outcome was duration of analgesia (35/59 trials, 59%) with absolute and relative median (interquartile range) anticipated effect sizes for adjunct versus placebo/no adjunct: 240 min (180-318) and 30% (25-40) and for adjunct versus active comparator: 210 min (180-308) and 17% (15-28). Adequate sample size calculations were reported in 78% of trials. Statistically significant results were reported for primary outcomes in 45/59 trials (76%), of which 22% did not reach the anticipated effect size.

CONCLUSION

The reported outcomes and associated anticipated effect sizes can be used in future trials on adjuncts for peripheral nerve blocks to increase methodological homogeneity.

Evaluation of transcutaneous electrical acupoint stimulation for improving pain and cognitive function in elderly patients around the perioperative period of hip replacement surgery: A meta-analysis

PURPOSE

We aim to evaluate the efficacy and safety of transcutaneous electrical acupoint stimulation(TEAS) in elderly patients around the perioperative period of hip replacement surgery.

METHODS

The China National Knowledge Infrastructure(CNKI), Wangfang Data, VIP database, SinoMed, PubMed, and Embase databases were searched for relevant publications until August 2024. All randomized controlled studies evaluating the efficacy and safety of TEAS in patients around the perioperative period of hip replacement surgery. We calculated pooled risk ratio (RR) with 95% CIs for binary outcomes and standardized mean difference (SMD) for continuous outcomes. The Cochrane's Risk of Bias Tool were used to evaluate the quality of studies.

RESULTS

A total of 13 studies with 946 patients were included in this analysis. 1-day visual analogue scale (VAS) scores and 2-day VAS scores were significantly lower in the TEAS group compared to the control group (SMD: -0.78, 95% CI: -1.47, -0.09, P = 0.02 and SMD:-0.54, 95% CI:-1.00,-0.09,P = 0.02). Furthermore, 1-day mini-mental state examination (MMSE) scores and 3-day MMSE scores were significantly higher in the TEAS group compared to the control group (SMD: 1.60, 95% CI: 0.68, 2.51,P<0.001 and SMD:1.31, 95% CI:1.03,1.59,P<0.001), along with a lower postoperative cognitive dysfunction rate (RR: 0.55, 95% CI: 0.41, 0.73, P<0.001).

CONCLUSIONS

Our meta-analysis demonstrated that TEAS significantly reduces pain and improves cognitive function in patients undergoing hip replacement surgery. Future studies should further investigate the optimal TEAS protocols to maximize these benefits across different population and surgical settings.

Impact of mini-dose dexmedetomidine supplemented analgesia on sleep structure in patients at high risk of obstructive sleep apnea: a pilot trial

Background

Obstructive sleep apnea (OSA) is common in surgical patients and associated with worse perioperative outcomes.

Objectives

To investigate the effect of mini-dose dexmedetomidine supplemented analgesia on postoperative sleep quality pattern in patients at high risk of OSA.

Design

A pilot randomized, double-blind, placebo-controlled trial.

Setting

A tertiary university hospital in Beijing, China.

Patients

One hundred and fifty-two adult patients who had a STOP-Bang score ≥3 and a serum bicarbonate level ≥28 mmol/L and were scheduled for major noncardiac surgery between 29 January 2021 and 20 September 2022.

Intervention

After surgery, patients were provided with high-flow nasal cannula and randomized in a 1:1 ratio to receive self-controlled opioid analgesia supplemented with either mini-dose dexmedetomidine (median 0.02 μg/kg/h) or placebo. We monitored polysomnogram from 9:00 pm to 6:00 am during the first night.

Main outcome measures

Our primary outcome was the percentage of stage 2 non-rapid eye movement (N2) sleep. Secondary and exploratory outcomes included other postoperative sleep structure parameters, sleep-respiratory parameters, and subjective sleep quality (Richards-Campbell Sleep Questionnaire; 0-100 score range, higher score better).

Results

All 152 patients were included in intention-to-treat analysis; 123 patients were included in sleep structure analysis. Mini-dose dexmedetomidine supplemented analgesia increased the percentage of stage N2 sleep (median difference, 10%; 95% CI, 1 to 21%; p = 0.029); it also decreased the percentage of stage N1 sleep (median difference, -10%; 95% CI, -20% to -1%; p = 0.042). Other sleep structure and sleep-respiratory parameters did not differ significantly between the two groups. Subjective sleep quality was slightly improved with dexmedetomidine on the night of surgery, but not statistically significant (median difference, 6; 95% CI, 0 to 13; p = 0.060). Adverse events were similar between groups.

Conclusion

Among patients at high risk of OSA who underwent noncardiac surgery, mini-dose dexmedetomidine supplemented analgesia may improve sleep quality without increasing adverse events.

Clinical trial registration

Clinicaltrials.gov, identifier NCT04608331.

Long-Term Effects of Individualized Acupuncture for Chronic Neck Pain : A Randomized Controlled Trial

BACKGROUND

Long-term effects of individualized acupuncture in persons with chronic neck pain (CNP) remain unknown.

OBJECTIVE

To evaluate the efficacy and safety of pressure pain, sensory-based individualized acupuncture for relieving CNP.

DESIGN

A 24-week multicenter randomized controlled clinical trial. (ChiCTR1800016371).

SETTING

Outpatient settings at 4 clinical centers in China from May 2018 to March 2020.

PARTICIPANTS

716 participants with CNP.

INTERVENTION

Participants were randomly assigned to a waiting list (WL) group or to 1 of 3 interventions, which consisted of 10 sessions over 4 weeks: higher sensitive acupoints (HSA), lower sensitive acupoints (LSA), and sham acupoints (SA) acupuncture groups.

MEASUREMENTS

The primary outcome was the change in the visual analogue scale (VAS) score for neck pain (range, 0 to 100) from baseline to 4 weeks, with a difference of 10 points considered the minimum clinically important threshold. The VAS was also assessed every 4 weeks through 24 weeks.

RESULTS

The modified intention-to-treat population included 683 participants. The mean baseline VAS was 50.36, 50.10, 49.24, and 49.16 for HSA, LSA, SA, and WL, respectively. Compared with a mean baseline to week 4 change of -12.16 in the HSA group, the mean changes were -10.19 in the LSA group (net difference [ND], -1.97 [95% CI, -5.03 to 1.09]), -6.11 in the SA group (ND, -6.05 [CI, -9.10 to -3.00]), and -2.24 in the WL group (ND, -9.93 [CI, -12.95 to -6.90]). The intervention effects persisted at 24-week follow-up.

LIMITATION

Lack of complete blinding and limited generalizability.

CONCLUSION

Individualized acupuncture interventions using high- or low-sensitivity acupuncture points were more effective in reducing CNP than SA and WL control groups sustained through 24 weeks, but the magnitude of relative improvement did not reach a minimal clinically important difference.

PRIMARY FUNDING SOURCE

National Natural Science Foundation of China.

Virtual reality exposure reduce acute postoperative pain in female patients undergoing laparoscopic gynecology surgery: A Randomized Control Trial (RCT) study

STUDY OBJECTIVE

Few studies have focused on the effect of virtual reality (VR) exposure on postoperative acute pain in adult female patients undergoing gynecology surgery.

DESIGN

A randomized control trial (RCT) study.

SETTING

At Beijing Fuxing Hospital.

PATIENTS

115 patients aged between 20 and 60 years, American Society of Anesthesiologists (ASA) physical status I - II were consecutively enrolled and randomly divided into VR group (n = 58) or control group (n = 57).

INTERVENTIONS

Patients in the VR group received 15 min of VR video viewing before surgery.

MEASUREMENTS

The primary outcome was acute postoperative pain at 8 h which was measured by the Visual Analogue Scale (VAS) scores. The secondary outcomes including the use of analgesic drugs, the incidence of moderate pain and postoperative recovery which were recorded 24 h after surgery. The Hospital Anxiety and Depression Scale (HADS) was also used to evaluate patients' emotional status before surgery.

MAIN RESULTS

The VAS scores at 30 min [2 (1,2) vs. 3 (2,3)], 2 h [2 (2,3) vs. 4 (3,4)], 4 h [3 (2,4) vs. 4 (4,5)], 8 h [3 (2,4) vs. 4 (4,5)], 12 h [2 (2,3) vs. 4 (3,4)], 24 h [1 (1,2) vs. 3 (2,3)] after surgery. Generalized estimation equation (GEE) indicated that VR intervention was negatively correlated with postoperative VAS values (β = -0.830, S.E = 0.199, 95%CI (-1.220,-0.439), Wald χ2 = 17.359, p<0.05), in the meanwhile, VR also lower the incidence of moderate pain (VAS > 4) at 8 h postoperatively (12.1% vs 31.0%, p = 0.013). However, the 24 h tramadol usage remained unchanged. Patients in the VR group had better sleep quality (6.33 ± 2.3 vs. 4.12 ± 2.5, p < 0.001) and lower incidence of nausea (43.1% vs. 63.2%, p < 0.05), dizziness (0% vs. 14.0%, p < 0.05), and headache (12.1% vs. 29.8%, p < 0.05). VR could reduce the median HADS scores (9.81 ± 6.1 vs 3.14 ± 3.9, p < 0.001) and blood pressure preoperatively.

CONCLUSIONS

VR intervention can reduce acute postoperative pain with better postoperative recovery and lower preoperative anxiety level in adult female patients undergoing laparoscopic gynecology surgery.

Association Between Single-Injection Regional Analgesia and Postoperative Pain in Cardiac Surgery Patients: A Single-Center Retrospective Cohort Study

OBJECTIVES

Effective pain control after cardiac surgery may facilitate recovery. This study aimed to assess the use and association of ultrasound-guided single-injection chest wall blocks with liposomal bupivacaine on postoperative pain scores and short-term opioid requirements after cardiothoracic surgery at a single institution.

DESIGN

Retrospective cohort study.

SETTING

Midwestern academic hospital.

PARTICIPANTS

Adult patients who underwent cardiothoracic surgery between July 1, 2020, and June 30, 2022.

INTERVENTIONS

Ultrasound-guided single-injection chest wall block with liposomal bupivacaine.

MEASUREMENTS AND MAIN RESULTS

Of the 1,038 patients included in this study, 301 (29%) received a perioperative nerve block for postoperative sternotomy pain, and 737 (71%) did not. Most of the single-shot blocks were bilateral parasternal intercostal plane blocks (n = 294 [98%]) performed after induction and before surgical incision (n = 280 [93%]). After adjusting for age, gender, American Society of Anesthesiologists status, select comorbidities, and surgical procedure type, mean postoperative pain scores were not significantly different between groups in the immediate postoperative period at all time points assessed (12 ± 2 hours, 24 ± 4 hours, 48 ± 8 hours, and 72 ± 12 hours). Similarly, there was no difference in mean opioid requirements (milligram morphine equivalents) at 72 hours between groups (68.6 [95% confidence interval, 56.3-83.4] vs 62.9 [95% confidence interval, 52.8-74.9], p = 0.195).

CONCLUSIONS

In this retrospective study, the implementation of single-shot chest wall nerve blocks with liposomal bupivacaine was not associated with decreased postoperative pain scores or opioid consumption at 72 hours in select cardiac surgical patients at one institution.

Effectiveness of intra-articular analgesia in reducing postoperative pain after minimally invasive sacroiliac joint fusion: a double-blind randomized controlled trial

During the first postoperative days following minimally invasive sacroiliac joint fusion (MISJF), patients often report serious pain, which contributes to high utilization of painkillers and prevention of early mobilization. This prospective, double-blind randomized controlled trial investigates the effectiveness of intraoperative SIJ infiltration with bupivacaine 0.50% versus placebo (NaCl 0.9%) in 42 patients in reducing postoperative pain after MISJF. The primary outcome was difference in pain between bupivacaine and placebo groups, assessed as fixed factor in a linear mixed model. Secondary outcomes were opioid consumption, patient satisfaction, adverse events, and length of hospital stay. We found that SIJ infiltration with bupivacaine did not affect postoperative pain scores in comparison with placebo, neither as group-effect (p = 0.68), nor dependent on time (group*time: p = 0.87). None of the secondary outcome parameters were affected in the postoperative period in comparison with placebo, including opioid consumption (p = 0.81). To conclude, intra-articular infiltration of the SIJ with bupivacaine at the end of MISJF surgery is not effective in reducing postoperative pain. Hence, we do not recommend routine use of intraoperative SIJ infiltration with analgesia in MISJF.