Optimizing pain management to facilitate Enhanced Recovery After Surgery pathways

Adductor canal block combined with genicular nerve block versus local infiltration analgesia for total knee arthroplasty: a randomized noninferiority trial

OBJECTIVE

This randomized controlled and double-blind study aimed to investigate whether the analgesic effect of the adductor canal block (ACB) combined with the genicular nerve block (GNB) after total knee arthroplasty is noninferior to that of the adductor canal block combined with local infiltration analgesia (LIA).

METHODS

A total of 102 patients undergoing total knee arthroplasty under general anesthesia were included and randomly divided into: ACB + GNB and ACB + LIA groups; the ACB + LIA group received 80 mL of 0.2% ropivacaine with adrenaline 10 µg/mL for LIA, whereas the ACB + GNB group received 4 mL of 0.2% ropivacaine for the blockade of five peri-knee nerves. The primary outcome was the median difference in the visual analog scale scores at rest at 24 h between the two groups. Secondary outcomes involved the median differences in the pain scores at other time points. Other outcomes included the cumulative dosage of opioids calculated in morphine equivalents in the first 24 h and indicators related to knee joint functional recovery.

RESULTS

In total, 36 and 38 patients were included in the ACB + GNB and ACB + LIA groups, respectively. We found that the median difference (95% confidence internal) in postoperative rest pain at 24 h (noninferiority criteria, △ = 1) was - 0.5 (- 1 to 0, p = 0.002). The median difference in cumulative opioid consumption was 1 mg (- 1 to 3, p = 0.019), meeting the noninferiority criteria, △ = 7.7 mg.

CONCLUSIONS

ACB combined with GNB provides noninferior analgesia compared to ACB with LIA on the first day after total knee arthroplasty while significantly reducing local anesthetic use.

TRIAL REGISTRATION

Name of the Registry: Chinese Clinical Trial Registry; Trial Registration Number: ChiCTR2300074274; Date of Registration. August 2, 2023.

Virtual reality for postsurgical pain management: An explorative randomized controlled study

BACKGROUND

Virtual reality (VR) is a promising tool in a multimodal analgesic approach; however, evidence regarding virtual reality for postsurgical pain is limited. This study investigates the initial effectiveness and feasibility of self-administered virtual reality in postsurgical pain management.

METHODS

Patients reporting a postsurgical pain score ≥4 were randomized for control or VR, stratified for 3 interventions with varying levels of immersion and interaction. Subjects were instructed to use virtual reality as add-on treatment at least 3 times a day for 10 minutes on days 2 till 4 postoperatively. Primary outcome was the mean daily pain intensity. Results of pain scores were related to patient and intervention characteristics, to explore which characteristics interact with virtual reality effects. Secondary outcomes were analgesic use, anxiety, stress, and feasibility.

RESULTS

One hundred patients were included in the analyses: 37 in the control group and 63 for VR. VR did not demonstrate a significant effect on self-reported pain scores (P = .43), nor were specific patient or intervention characteristics associated with greater VR effects. Analgesic usage did not differ between groups. However, there was a trend toward greater cumulative percentages of patients achieving a 30% pain reduction, and significantly lower daily experienced stress (P = .01) and anxiety (P = .03) levels in VR intervention groups. VR was used less than prescribed, mainly because of illness and pain. Adverse events included disorientation, nausea, and fatigue.

CONCLUSIONS

This explorative study did not demonstrate initial effectiveness of VR as add-on pain treatment regarding pain and analgesic use; however, VR positively affected stress and anxiety. VR is safe and suitable for a wide target audience, and feasibility differed between interventions. Personalizing and improving VR technology may enhance its effectiveness.

Adjuvant Analgesics in Acute Pain - Evaluation of Efficacy

PURPOSE OF THE REVIEW

Acute postoperative pain impacts a significant number of patients and is associated with various complications, such as a higher occurrence of chronic postsurgical pain as well as increased morbidity and mortality.

RECENT FINDINGS

Opioids are often used to manage severe pain, but they come with serious adverse effects, such as sedation, respiratory depression, postoperative nausea and vomiting, and impaired bowel function. Therefore, most enhanced recovery after surgery protocols promote multimodal analgesia, which includes adjuvant analgesics, to provide optimal pain control. In this article, we aim to offer a comprehensive review of the contemporary literature on adjuvant analgesics in the management of acute pain, especially in the perioperative setting. Adjuvant analgesics have proven efficacy in treating postoperative pain and reducing need for opioids. While ketamine is an established option for opioid-dependent patients, magnesium and α2-agonists have, in addition to their analgetic effect, the potential to attenuate hemodynamic responses, which make them especially useful in painful laparoscopic procedures. Furthermore, α2-agonists and dexamethasone can extend the analgesic effect of regional anesthesia techniques. However, findings for lidocaine remain inconclusive.

Impact of Replacing Fentanyl With Hydromorphone as the First-Line Postoperative Opioid Among Patients Undergoing Outpatient Cancer Surgery

PURPOSE

In response to a nationwide fentanyl shortage, our institution assessed whether changing our first-line postoperative intravenous opioid from fentanyl to hydromorphone impacted patient outcomes. The primary research aim was to evaluate the association between first-line opioid and rapidity of recovery.

DESIGN

The study team retrospectively obtained data on all consecutive patients extracted from the electronic medical record. The rapidity of recovery was defined as the time from entry into the postanesthesia care unit to the transition to Phase 2 for ambulatory extended recovery patients and as the length of total postanesthesia care unit stay for outpatients.

METHODS

Following intent-to-treat-principles, we tested the association between study period and rapidity of recovery (a priori clinically meaningful difference: 20 minutes) using multivariable linear regression, adjusting for anesthesia type (general vs monitored anesthesia care), American Society of Anesthesiologst physical status (ASA) score (1-2 vs 3-4), age, service, robotic procedure, and surgery start time.

FINDINGS

Ambulatory extended recovery patients treated in the hydromorphone period had, on average, a 0.25 minute (95% confidence interval [CI] -6.5, 7.0), nonstatistically significant (P > .9) longer time to transition. For outpatient procedures, those who received hydromorphone had, on average, 8.5-minute longer stays (95% CI 3.7-13, P < .001). Although we saw statistical evidence of an increased risk of resurgery associated with receiving hydromorphone (0.5%; 95% CI -0.1%, 1.0%; P = .039 on univariate analysis), the size of the estimate is clinically and biologically implausible and is most likely a chance finding related either to multiple testing or confounding.

CONCLUSIONS

The multidisciplinary team concluded that the increase in postoperative length of stay associated with hydromorphone was not clinically significant and the decrease waste of prefilled syringes outweighed the small potential increased risk of resurgery compared to the shorter-acting fentanyl. We will therefore use hydromorphone moving forward.

CPL-01, an investigational long-acting ropivacaine, demonstrates safety and efficacy in open inguinal hernia repair

BACKGROUND

There is an unmet medical need for effective nonopioid analgesics that can decrease pain while reducing systemic opioid use. CPL-01, an extended-release injectable formulation of ropivacaine, is designed to safely provide analgesia and reduce or eliminate opioid use in the postoperative period.

METHODS

Subjects undergoing open inguinal hernia with mesh were prospectively randomized to 1 of 3 doses of CPL-01 (10, 20, or 30 ml of 2% CPL-01, n = 14, 12, and 14, respectively), Naropin (150 mg, n = 40), or saline placebo (n = 13) infiltrated into the surgical site prior to closure. Pain and rescue medication usage was assessed, and Numeric Rating Scale (NRS) pain scores were adjusted for opioid usage using windowed worst observation carried forward (wWOCF) imputation. The primary efficacy endpoint was the mean area under the curve (AUC) of the NRS pain intensity scores with activity.

RESULTS

Ninety-three subjects were treated, and 91 subjects completed 72 h of post-operative monitoring. Subjects who received the highest dose of CPL-01 in Cohort 3 showed a clinically meaningful reduction in postoperative pain intensity scores, which was the lowest value for any treatment in all cohorts, showing a trend towards statistical significance as compared to the pooled placebo group (p = 0.08), and numerically better than the 40 subjects who received Naropin. Opioid use through 72 h in subjects who received CPL-01 in Cohort 3 was approximately half of that shown in the placebo and Naropin groups; approximately 2/3 of the CPL-01 subjects (9/14) required no opioids at all through the first 72 h after the operation. More CPL-01 subjects avoided severe pain and were ready for discharge earlier than other groups. CPL-01 was safe and well-tolerated, with no clinically meaningful safety signals, and showed predictable and consistent extended-release pharmacokinetics.

CONCLUSION

Results suggest that CPL-01 may be the first long-acting ropivacaine to address postoperative pain while reducing the need for opioids.

Prevention and management of rebound pain after resolution of regional block: a systematic review

Background

An extreme pain known as rebound pain develops after regional blockage wears off. Patient, surgical, and anesthesia-related factors influence the occurrence and intensity of rebound pain. Prior to the peripheral nerve block (PNB) being resolved, multimodal therapy should use. The objective of this review was to explore rebound pain prevention and management following PNB resolution.

Methods

We conducted a thorough search across Pub Med, Hinari, Google Scholar, and Cochrane review databases, utilizing relevant keywords and search parameters to identify studies meeting our inclusion criteria. These studies aimed to provide sufficient evidence regarding the prevention and management of rebound pain following the resolution of regional blocks. Duplicate entries were removed using Endnote software. Screening of the literature was performed using a rigorous appraisal checklist. The findings of this review are reported in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement.

Results

Using an electronic search, 3526 items were found from databases and websites. After removing duplicates (n=500), 3026 articles remained. Of these, 2813 were excluded after going through their titles and abstracts. Of the 213 articles screened, 126 were removed for such reasons as ineligibility or similarity in objectives. Of the remaining 87 studies, 37 were excluded for such reasons as the inaccessibility of free full texts. Finally, 50 studies were included for review.

Conclusions and recommendation

Proper patient education about rebound pain, combined with the utilization of multimodal systemic analgesia before the resolution of PNBs, perineural dexamethasone, and employing a combination of nerve blocks, has been demonstrated to decrease the incidence of rebound pain. Therefore, clinicians should aim to prevent and manage rebound pain by implementing perioperative multimodal strategies before the resolution of regional blocks.

Opioid free analgesia after return home in ambulatory colonic surgery patients: a single-center observational study

BACKGROUND

Because of the adverse effects of morphine and its derivatives, non-opioid analgesia procedures are proposed after outpatient surgery. Without opioids, the ability to provide quality analgesia after the patient returns home may be questioned. We examined whether an opioid-free strategy could ensure satisfactory analgesia after ambulatory laparoscopic colectomy.

METHODS

We performed a retrospective observational single-center study (of prospective collected database) including all patients eligible for scheduled outpatient colectomy. Postoperative analgesia was provided by paracetamol and nefopam. Postoperative follow-up included pain at mobilization (assessed by a numerical rating scale, NRS), hemodynamic variables, temperature, resumption of transit and biological markers of postoperative inflammation. The primary outcome was the proportion of patients with moderate to severe pain (NRS > 4) the day after surgery.

RESULTS

Data from 144 patients were analyzed. The majority were men aged 59 ± 12 years with a mean BMI of 27 [25-30] kg/m2. ASA scores were 1 for 14%, 2 for 59% and 3 for 27% of patients. Forty-seven patients (33%) underwent surgery for cancer, 94 for sigmoiditis (65%) and 3 (2%) for another colonic pathology. Postoperative pain was affected by time since surgery (Q3 = 52.4,p < 0.001) and decreased significantly from day to day. The incidence of moderate to severe pain at mobilization (NRS > 4) on the first day after surgery was (0.19; 95% CI, 0.13-0.27).

CONCLUSION

Non-opioid analgesia after ambulatory laparoscopic colectomy seems efficient to ensure adequate analgesia. This therapeutic strategy makes it possible to avoid the adverse effects of opioids.

TRIAL REGISTRATION

The study was retrospectively registered and approved by the relevant institutional review board (CERAR) reference IRB 00010254-2018 - 188). All patients gave written informed consent for analysis of their data. The anonymous database was declared to the French Data Protection Authority (CNIL) (reference 221 2976 v0 of April 12, 2019).

Evaluation of Post-Operative Pain Management Techniques in Oral Surgery

Objective

This prospective research directed to estimate the efficacy and safety of different post-operative pain management techniques in oral surgery subjects.

Methods

Patients scheduled for various oral surgical procedures were recruited from a single oral surgery clinic between January 2022 and December 2023. Inclusion criteria encompassed adult subjects undergoing elective oral surgery under local or general anesthesia. Subjects were randomly assigned to one of three post-operative pain management protocols: Group A received standard analgesics, Group B received combination analgesics, and Group C received non-pharmacological interventions. Pain intensity scores, analgesic consumption, adverse events, and patient satisfaction were assessed at specified intervals post-operatively.

Results

Non-pharmacological interventions demonstrated lower pain intensity scores and analgesic consumption compared to standard and combination analgesics. Additionally, the incidence of adverse events was lower in the non-pharmacological intervention group. Statistical analysis revealed significant differences in pain outcomes among the three groups.

Conclusion

This prospective research suggests that non-pharmacological interventions may provide effective pain relief with fewer adverse events compared to traditional analgesics in post-operative oral surgery subjects. Implementation of multi-modal pain management approaches tailored to individual patient needs may improve overall pain control and enhance patient outcomes.

Hydromorphone combined with ropivacaine for erector spinae plane block in patients undergoing modified radical mastectomy: A prospective randomized controlled trial

BACKGROUND

Combining hydromorphone with ropivacaine in ultrasound-guided erector spinae plane blocks enhances postoperative analgesia and reduces interleukin-6 expression in breast surgery patients.

METHODS

In this study, breast cancer patients undergoing modified radical mastectomy were randomized into 3 groups for anesthesia (30 patients in each group): standard general (group C), Erector Spinae Plane Block (ESPB) with ropivacaine (group R), and ESPB with ropivacaine plus hydromorphone (group HR). Diagnosis: Breast cancer patients. Postsurgery, pain levels, IL-6, anesthetic doses, additional analgesia needs, and recovery milestones were compared to evaluate the efficacy of the ESPB enhancements.

RESULTS

The 3 groups were not significantly different in baseline characteristics, operation time, number of cases with postoperative nausea, and serum IL-6 concentrations at T1 (the time of being returned to the ward after surgery). At T2 (at 6:00 in the next morning after surgery), the serum IL-6 concentration in group HR was significantly lower than that in groups R and C (P < .05); the intraoperative doses of remifentanil, sufentanil, and propofol were significantly lower in groups HR and R than those in group C (P < .05); Groups HR and R had significantly lower visual analog scale scores at T3 (4 hours postoperatively), T4 (12 hours postoperatively), and T5 (24 hours postoperatively) than those in group C (P < .05); the proportions of patients receiving postoperative remedial analgesia were significantly lower in groups HR and R than in group C (P < .05); groups HR and R had significantly lower proportions of patients with postoperative nausea than group C (P < .05); the time to the first anal exhaust and the time to the first ambulation after surgery were significantly shorter in groups HR and R than those in group C (P < .05).

CONCLUSION

Hydromorphone combined with ropivacaine for ESPB achieved a greater postoperative analgesic effect for patients receiving MRM under general anesthesia. The combined analgesia caused fewer adverse reactions and inhibited the expression level of the inflammatory factor IL-6 more effectively, thereby facilitating postoperative recovery. ESPB using hydromorphone with ropivacaine improved pain control post-MRM, reduced adverse effects, and more effectively suppressed IL-6, enhancing recovery.

Effects of Different Volumes of Ropivacaine for Pericapsular Nerve Group Block on Incidence of Quadriceps Weakness and Analgesic Efficacy Following Hip Arthroplasty: A Randomized Controlled Trial

INTRODUCTION

The pericapsular nerve group (PENG) block has been shown to be an effective approach to alleviating pain and reducing the need for opioids among older adults following hip surgery, with possible motor-sparing effects. No reports to date, however, have described appropriate ropivacaine volumes for use in the context of PENG block. The present prospective randomized controlled study was thus developed to assess the quadriceps muscle strength and analgesic efficacy associated with PENG block performed using three different volumes of 0.33% ropivacaine following general anesthesia in older adults undergoing hip arthroplasty.

METHODS

In this prospective randomized double-blind controlled clinical study, 60 patients were assigned at random to undergo ultrasound-guided PENG block for hip arthroplasty using different volumes of ropivacaine. Specifically, these patients were administered 10 ml (Group A, n = 20), 20 ml (Group B, n = 20), or 30 ml (Group C, n = 20) of 0.33% ropivacaine. Quadriceps muscle strength was evaluated at 6 h post-surgery. Visual analog scale (VAS) scores at rest and with movement were assessed at 4, 6, 12, and 24 h post-surgery. Block duration, adverse event incidence, and patient satisfaction were evaluated at 24 h post-surgery.

RESULTS

Quadriceps motor block incidence rates at 6 h post-surgery in the 10 ml, 20 ml, and 30 ml groups were 5%, 20%, and 75%, respectively. Quadriceps muscle weakness at 6 h post-surgery was significantly more common in the 30 ml group relative to the others (p < 0.001). Patients administered 10 ml 0.33% ropivacaine exhibited significantly higher VAS pain scores at rest and with movement relative to those patients in the 20 ml and 30 ml treatment groups at all time points (p < 0.05). No apparent differences in analgesic efficacy were observed when comparing the 20 ml and 30 ml groups at 4, 6, 12, and 24 h post-surgery. No significant differences in block duration, satisfaction, or adverse event incidence were observed among groups.

CONCLUSIONS

The preservation of motor function in the 20 ml 0.33% ropivacaine group was superior to that in the 30 ml 0.33% ropivacaine group. Relative to the group that received 10 ml 0.33% ropivacaine during PENG block, those elderly patients administered 20 ml and 30 ml volumes of 0.33% ropivacaine experienced superior postoperative pain relief following hip arthroplasty.

Ultrasound‑guided erector spinae plane block in posterior lumbar surgery (Review)

The erector spinae plane block (ESPB) is a novel fascial planar block technique, which is used to reduce postoperative pain in several surgical procedures, including breast, thoracic, spine and hip surgery. Due to its recognizable anatomy and low complication rate, the application of ESPB has been significantly increased. However, it is rarely used in clinical practice for postoperative analgesia after posterior lumbar spine surgery, while the choice of adjuvant drugs, block levels and drug doses remain controversial. Based on the current literature review, ropivacaine and dexmedetomidine could be considered as the best available drug combination. The present review aimed to analyze the currently available clinical evidence and summarize the benefits and challenges of ESPB in spinal surgery, thus providing novel insights into the application of ESPB in the postoperative management of posterior lumbar surgery.

Liposomal bupivacaine in transversus abdominis plane blocks for lower abdominal surgery

BACKGROUND

Transversus abdominis plane blocks are an established method of postoperative analgesia for abdominopelvic surgeries. Liposomal bupivacaine is an extended-release formulation of bupivacaine providing up to 72 h of analgesia. This study aims to determine if transversus abdominis plane blocks performed with liposomal bupivacaine are associated with reduced opioid consumption and level of pain intensity compared to conventional bupivacaine in patients undergoing lower abdominal surgery.

METHODS

This retrospective cohort study was conducted at a single institution between December 2020 and December 2021. After institutional review board approval, we identified patients who underwent lower abdominopelvic surgery with transversus abdominis plane blocks done with liposomal or conventional bupivacaine and collected demographic, clinical, and procedural information for analysis. We compared total opioid consumption over 72-h postoperatively in milligram morphine equivalents (MME), frequency of opioid utilization, and average level of pain intensity between groups. These outcomes were also evaluated after adjusting for covariates. Data were presented as mean ± SD, median [IQR] or frequency (%), as appropriate; p < 0.05 was accepted as significant.

RESULTS

A total of 178 patients met inclusion criteria, with 79 patients receiving an admixture of liposomal bupivacaine and conventional bupivacaine and 99 patients receiving conventional bupivacaine. The liposomal bupivacaine group had a median opioid consumption 72-h postoperatively of 47.5 [18-91.8] MME compared to 88 [43.8-160] MME in the conventional bupivacaine group, p = 0.045. Differences in opioid consumption between the groups did not reach statistical significance after adjustment for demographic and clinical characteristics, p = 0.11. There was no significant difference in frequency of opioid use or average pain intensity.

CONCLUSION

Transversus abdominis plane blocks using an admixture of liposomal bupivacaine conventional bupivacaine are not associated with decreased opioid consumption or reduced pain up to 72 h following elective abdominopelvic surgery.

Modified Thoracolumbar Interfascial Plane Block Versus Erector Spinae Plane Block in Patients Undergoing Spine Surgeries: A Randomized Controlled Trial

BACKGROUND

Lumbar spine surgery is associated with significant postoperative pain. Interfascial plane blocks, such as erector spinae plane (ESP) and thoracolumbar interfascial plane (TLIP) blocks, can play a significant role in multimodal analgesic regimens.

METHODS

Sixty patients aged 18 to 60 years undergoing elective single or double-level lumbar discectomy or primary lumbar laminoplasty were recruited into this randomized double‑blind study. All patients received general anesthesia and were randomly allocated to either modified TLIP (mTLIP) block (group M) or ESP block (group E). Postoperative and intraoperative fentanyl consumption, and postoperative pain scores, were recorded.

RESULTS

Total 48 h postoperative fentanyl consumption was higher in Group M (189.66±141.11 µg) than in Group E (124.16±80.83 µg; P =0.031). In the first 24 postoperative hours, fentanyl consumption was higher in Group M (150.3±120.9 µg) than in group E (89.9±65.3 µg; P =0.01) but was similar between groups in postoperative hours 24to 48 (39.0±20.2 µg versus 34.7±17.1 µg in group M and group E, respectively; P =0.37). Additional intraoperative fentanyl requirement was 57.66±21.76 µg in group M compared with 40.33±21.89 µg in group E ( P <0.01). Postoperative pain scores were higher in group M than in group E at 1, 2, 4, 6, 12, and 24 hours postoperatively ( P <0.001), but similar at 48 hours ( P =0.164).

CONCLUSION

Compared with the mTLIP block, the ESP block was associated with lower pain scores and a small decrease in perioperative fentanyl consumption in patients undergoing lumbar spine surgeries. Both blocks could form a part of a multimodal analgesic regimen in spine surgery patients.

Opioid-free anesthesia using a combination of ketamine and dexmedetomidine in patients undergoing laparoscopic cholecystectomy: a randomized controlled trial

BACKGROUND

Opioids administered as bolus doses or continuous infusions are widely used for major and daycare surgeries. Opioid-free anesthesia is multimodal anesthesia and analgesia that does not use opioids, benefiting patients from opioid-related adverse effects. We compared the postoperative analgesic requirements of patients scheduled for elective laparoscopic cholecystectomy under opioid-free and opioid-based anesthesia.

METHODS

Study included 88 patients aged 18-60 years with American Society of Anesthesiologists physical status 1 and 2 who underwent elective laparoscopic cholecystectomy. Participants were randomly divided into two groups with 44 in each. The opioid-free group was administered an intravenous bolus of ketamine and dexmedetomidine, whereas fentanyl was used in opioid group. Primary outcome was to compare the total amount of fentanyl consumed by both groups during 6 h postoperative period. Episodes of postoperative nausea and vomiting (PONV) and vital signs were noted throughout the postoperative period to analyze the secondary outcomes.

RESULTS

Both groups had similar demographic characteristics. The opioid-free group required lesser analgesia within the first 2 h (61.4 ± 17.4 vs. 79.0 ± 19.4 of fentanyl, P < 0.001), which was statistically significant. However, fentanyl consumption was comparable between the groups at 6 h (152 ± 28.2 vs. 164 ± 33.4, P = 0.061). Compared with 4.5% of the participants in the opioid-free group, 34% of those in the opioid-based group developed moderate PONV.

CONCLUSIONS

Opioid-free anesthesia in patients undergoing laparoscopic cholecystectomy reduced the requirement of analgesia in first two-hour postoperative period and was associated with decreased PONV.

Co-crystal of Tramadol-Celecoxib Versus Tramadol or Placebo for Acute Moderate-to-Severe Pain After Oral Surgery: Randomized, Double-Blind, Phase 3 Trial (STARDOM1)

INTRODUCTION

Co-crystal of tramadol-celecoxib (CTC) is the first analgesic co-crystal for acute pain. This completed phase 3 multicenter, double-blind trial assessed the efficacy and safety/tolerability of CTC in comparison with that of tramadol in the setting of moderate-to-severe pain up to 72 h after elective third molar extraction requiring bone removal.

METHODS

Adults (n = 726) were assigned randomly to five groups (2:2:2:2:1): orally administered twice-daily CTC 100 mg (44 mg rac-tramadol hydrochloride/56 mg celecoxib; n = 164), 150 mg (66/84 mg; n = 160) or 200 mg (88/112 mg; n = 160); tramadol 100 mg four times daily (n = 159); or placebo four times daily (n = 83). Participants in CTC groups also received twice-daily placebo. The full analysis set included all participants who underwent randomization. The primary endpoint was the sum of pain intensity differences over 0 to 4 h (SPID0-4; visual analog scale). Key secondary endpoints included 4-h 50% responder and rescue medication use rates. Safety endpoints included adverse events (AEs), laboratory measures, and Opioid-Related Symptom Distress Scale (OR-SDS) score.

RESULTS

All CTC doses were superior to placebo (P < 0.001) for primary and key secondary endpoints. All were superior to tramadol for SPID0-4 (analysis of covariance least squares mean differences [95% confidence interval]: - 37.1 [- 56.5, - 17.6], - 40.2 [- 59.7, - 20.6], and - 41.7 [- 61.2, - 22.2] for 100, 150, and 200 mg CTC, respectively; P < 0.001) and 4-h 50% responder rate. Four-hour 50% responder rates were 32.9% (CTC 100 mg), 33.8% (CTC 150 mg), 40.6% (CTC 200 mg), 20.1% (tramadol), and 7.2% (placebo). Rescue medication use was lower in the 100-mg (P = 0.013) and 200-mg (P = 0.003) CTC groups versus tramadol group. AE incidence and OR-SDS scores were highest for tramadol alone.

CONCLUSIONS

CTC demonstrated superior pain relief compared with tramadol or placebo, as well as an improved benefit/risk profile versus tramadol.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT02982161; EudraCT number, 2016-000592-24.

Additional low-pressure pulmonary recruitment for reducing post-laparoscopic shoulder pain in gynecologic laparoscopy: a randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of additional low-pressure pulmonary recruitment in reducing postoperative shoulder pain.

METHODS

A double-blind randomized controlled trial was conducted at Srinagarind Hospital between May 2021 and October 2021. Forty patients who underwent laparoscopic gynecologic surgery were randomized into either an intervention group that received additional low-pressure pulmonary recruitment (30 cmH2O) (n=20) or a control group (n=20). Shoulder pain was evaluated using a numerical rating scale from 0 to 10, 24, and 48 hours after the operation.

RESULTS

The mean±standard deviation of shoulder pain at 24 hours after the operation of both the intervention and control groups were 2.10±2.27 and 1.45±1.73 points, respectively. The shoulder pain at 48 hours after the operation of the intervention and control groups were 1.15±1.46 and 0.85±1.73 points, respectively. There were no statistical differences in the mean difference between the two groups at 24 and 48 hours after operation (P=0.49; 95% confidence interval [CI], -0.61 to 1.91 and P=1.00; 95% CI, -0.96 to 1.56, respectively). No statistically significant differences were observed in additional analgesic medications used in either group, such as intravenous morphine or oral acetaminophen.

CONCLUSION

Additional low-pressure pulmonary recruitment to reduce shoulder pain after laparoscopic surgery for benign gynecologic diseases did not show a significant benefit compared to the control group, especially when administering postoperative around-the-clock analgesia.

Comparison of Pain Management Strategies to Reduce Opioid Use Postoperatively in Free Flap Breast Reconstruction: Pain Catheter versus Nerve Block in Addition to Refinements in the Oral Pain Management Regime

Background  Perioperative management in autologous breast reconstruction has gained focus in recent years. This study compares two pain management protocols in patients undergoing abdominal-based free flap breast reconstruction: a past protocol (PP) and a current protocol (CP)-both intended to reduce opioid consumption postoperatively. The PP entails use of a pain catheter in the abdominal wound and the CP consists of an intraoperative nerve block in addition to refinements in the oral pain management. We hypothesize that the CP reduces opioid consumption compared to PP. Methods  From December 2017 to January 2020, 102 patients underwent breast reconstruction with an abdominal-based free flap. Two postoperative pain management strategies were used during the period; from December 2017 to September 2018, the PP was used which entailed the use of a pain catheter with ropivacaine applied in the abdominal wound with continuous distribution postoperatively in addition to paracetamol orally and oxycodone orally pro re nata (PRN). From October 2018 to January 2020, the CP was used. This protocol included a combination of intraoperative subfascial nerve block and a postoperative oral pain management regime that consisted of paracetamol, celecoxib, and gabapentin as well as oxycodone PRN. Results  The CP group ( n  = 63) had lower opioid consumption compared to the PP group ( n  = 39) when examining all aspects of opioid consumption, including daily opioid usage in morphine milligram equivalents and total opioid usage during the stay ( p  < 0.001). The CP group had shorter length of hospital stay (LOS). Conclusion  Introduction of the CP reduced opioid use and LOS was shorter.

Wireless patient monitoring and Efficacy Safety Score in postoperative treatment at the ward: evaluation of time consumption and usability

To evaluate objective time consumption and how nurses perceived introducing wireless patient monitoring (WPM) and a validated score on patient quality and safety, the Efficacy Safety Score (ESS), at a mixed surgery ward. After fulfilling a randomised controlled trial combining the ESS and WPM, we addressed time consumption and conducted a questionnaire survey among nurses who participated in the study. The questionnaire appraised the nurses' evaluation of introducing these tools for postoperative management. Of 28 invited nurses, 24 responded to the questionnaire, and 92% reported the ESS and WPM-systems to increase patient safety and quality of care. 67% felt the intervention took extra time, but objective workload measurements revealed reduced time to 1/3 using ESS and WPM compared to standard manual assessment. Improved confidence when using the systems was reported by 83% and improved working situation by 75%. In a test situation to measure time consumption, the ESS and pre-attached WPM-systems require less time than the conventional standard of care, and may allow for more frequent clinical monitoring at the post-surgical ward. The combination of the ESS and the WPM systems was perceived as positive by participating nurses and further clinical development and research is warranted.

The nuts and bolts of multimodal anaesthesia in the 21st century: a primer for clinicians

PURPOSE OF REVIEW

This review article explores the application of multimodal anaesthesia in general anaesthesia, particularly in conjunction with locoregional anaesthesia, specifically focusing on the importance of EEG monitoring. We provide an evidence-based guide for implementing multimodal anaesthesia, encompassing drug combinations, dosages, and EEG monitoring techniques, to ensure reliable intraoperative anaesthesia while minimizing adverse effects and improving patient outcomes.

RECENT FINDINGS

Opioid-free and multimodal general anaesthesia have significantly reduced opioid addiction and chronic postoperative pain. However, the evidence supporting the effectiveness of these approaches is limited. This review attempts to integrate research from broader neuroscientific fields to generate new clinical hypotheses. It discusses the correlation between high-dose intraoperative opioids and increased postoperative opioid consumption and their impact on pain indices and readmission rates. Additionally, it explores the relationship between multimodal anaesthesia and pain processing models and investigates the potential effects of nonpharmacological interventions on preoperative anxiety and postoperative pain.

SUMMARY

The integration of EEG monitoring is crucial for guiding adequate multimodal anaesthesia and preventing excessive anaesthesia dosing. Furthermore, the review investigates the impact of combining regional and opioid-sparing general anaesthesia on perioperative EEG readings and anaesthetic depth. The findings have significant implications for clinical practice in optimizing multimodal anaesthesia techniques (Supplementary Digital Content 1: Video Abstract, http://links.lww.com/COAN/A96 ).

Impact of Enhanced Recovery Protocols on Short-Term Outcomes in Esophagectomy: A Retrospective Cohort Study from Cancer Research Institute, Uttarakhand, India

OBJECTIVE

Surgery for esophageal cancer is associated with high mortality and morbidity, especially in low and middle-income countries. The recent enhanced recovery after surgery guidelines for esophagectomy (2018) which attempt to reduce complications and length of stay (LOS) have rarely been validated in these settings. This study aimed to analyse the effect of this protocol on short-term outcomes in our subset of patients.

METHODS

A retrospective review was conducted to investigate the outcomes of enhanced recovery protocol (ERP) compared to standard pre-protocol care (PP) in patients who underwent esophagectomy for cancer (31 in ERP vs 61 in PP group) at Cancer Research Institute, Uttarakhand, India. The main outcomes measured were 30-day mortality, morbidity and LOS. Risk assessment was stratified as per Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) systems while complications were classified as per the Clavien-Dindo scale.

RESULTS

Preoperative clinical characteristics were similar between groups. Though the predicted POSSUM mortality and morbidity were significantly higher in the ERP group (p = 0.007), 30-day morbidity (19.35% vs 42.62%, p = 0.027) as well as median LOS (12 vs 15 days, p < 0.001) was significantly lower in ERP group. The PP group reported 4 deaths within 30 days as compared to none in the ERP group (p = 0.296). Furthermore, the ERP group reported lower occurrence of pulmonary complications (6.4%vs24.6%,p = 0.046), hemodynamic instability (0%vs14.75%,p = 0.026) as well as need for prolonged postoperative ventilation (> 24 h; 0% vs 11.48%, p = 0.004). Both minor and major complications as assessed by the Clavien-Dindo scale were lower in the group ERP though these differences were not statistically significant (0.059).

CONCLUSIONS

Implementation of ERP improved short-term outcomes; hence can be strongly recommended in patients undergoing esophagectomy.

Reconceptualizing Acute Pain Management in the 21st Century

Acute pain can have many etiologies that include surgical procedures, trauma (motor vehicle accident), musculoskeletal injuries (rib fracture) and, burns among others. Valuable components of a multimodal approach to acute pain management include both opioid and non-opioid medications, procedure specific regional anesthesia techniques (peripheral nerve blocks and neuraxial approaches), and interventional approaches (eg, peripheral nerve stimulation and cryo-neurolysis). Overall, successful acute perioperative pain management requires a multimodal, multidisciplinary approach that involves a coordinated effort between the surgical team, the anesthesia team, nursing, and pharmacy staff using Enhanced Recovery After Surgery (ERAS) protocols.

Gabapentin May Not Decrease Opioid Use in Pediatric Enhanced Recovery After Surgery Protocols

INTRODUCTION

In adults, the use of gabapentin in Enhanced Recovery After Surgery (ERAS) protocols is associated with increased morbidity and clinically insignificant improvement in postoperative pain control. Furthermore, there are limited data supporting its use in pediatric ERAS protocols.

METHODS

A single-institution retrospective study was performed to examine the correlation of gabapentin use and postoperative outcomes among children who underwent elective general, urologic, and orthopedic surgeries. Because gabapentin was removed from our institutional ERAS protocols in August 2020, we compared eligible patients from January 2018 to September 2021 using univariate and multivariable analysis. Due to heterogeneity between the treatment groups, a propensity score-matched analysis was also performed. Significance was defined as P < 0.05.

RESULTS

In this study, 196 patients were included, with 91 (46.4%) who received gabapentin and 105 (53.6%) who did not. When used in combination with opioids, gabapentin was not associated with a reduction in the amount of opioids consumed (β = -0.4, 95% confidence interval = -1.9, 1.1). Instead, children who received gabapentin had increased odds of requiring oxygen supplementation (odds ratio = 3.1, 95% confidence interval = 1.2, 9.0), but this finding did not persist after propensity score-matched analysis.

CONCLUSIONS

The use of gabapentin in multimodal pain regimens in children following elective surgery was not associated with a decrease in postoperative narcotic use. Inclusion of gabapentin in perioperative pain medication protocols should be further evaluated with prospective studies.

Impact of modified-release opioid use on clinical outcomes following total hip and knee arthroplasty: a propensity score-matched cohort study

Modified-release opioids are often prescribed for the management of moderate to severe acute pain following total hip and knee arthroplasty, despite recommendations against their use due to increasing concerns regarding harm. The primary objective of this multicentre study was to examine the impact of modified-release opioid use on the incidence of opioid-related adverse events compared with immediate-release opioid use, among adult inpatients following total hip or knee arthroplasty. Data for total hip and knee arthroplasty inpatients receiving an opioid analgesic for postoperative analgesia during hospitalisation were collected from electronic medical records of three tertiary metropolitan hospitals in Australia. The primary outcome was the incidence of opioid-related adverse events during hospital admission. Patients who received modified with or without immediate-release opioids were matched to those receiving immediate-release opioids only (1:1) using nearest neighbour propensity score matching with patient and clinical characteristics as covariates. This included total opioid dose received. In the matched cohorts, patients given modified-release opioids (n = 347) experienced a higher incidence of opioid-related adverse events overall, compared with those given immediate-release opioids only (20.5%, 71/347 vs. 12.7%, 44/347; difference in proportions 7.8% [95%CI 2.3-13.3%]). Modified-release opioid use was associated with an increased risk of harm when used for acute pain during hospitalisation after total hip or knee arthroplasty.

Intraoperative Methadone in Next-day Discharge Outpatient Surgery: A Randomized, Double-blinded, Dose-finding Pilot Study

BACKGROUND

Contemporary perioperative practice seeks to use less intraoperative opioid, diminish postoperative pain and opioid use, and enable less postdischarge opioid prescribing. For inpatient surgery, anesthesia with intraoperative methadone, compared with short-duration opioids, results in less pain, less postoperative opioid use, and greater patient satisfaction. This pilot investigation aimed to determine single-dose intraoperative methadone feasibility for next-day discharge outpatient surgery, determine an optimally analgesic and well-tolerated dose, and explore whether methadone would result in less postoperative opioid use compared with conventional short-duration opioids.

METHODS

This double-blind, randomized, dose-escalation feasibility and pilot study in next-day discharge surgery compared intraoperative single-dose IV methadone (0.1 then 0.2, 0.25 and 0.3 mg/kg ideal body weight) versus as-needed short-duration opioid (fentanyl, hydromorphone) controls. Perioperative opioid use, pain, and side effects were assessed before discharge. Patients recorded pain, opioid use, and side effects for 30 days postoperatively using take-home diaries. Primary clinical outcome was in-hospital (intraoperative and postoperative) opioid use. Secondary outcomes were 30-day opioid consumption, pain, opioid side effects, and leftover opioid counts.

RESULTS

Median (interquartile range) intraoperative methadone doses were 6 (5 to 7), 11 (10 to 12), 14 (13 to 16), and 18 (15 to 19) mg in 0.1, 0.2, 0.25, and 0.3 mg/kg ideal body weight groups, respectively. Anesthesia with single-dose methadone and propofol or volatile anesthetic was effective. Total in-hospital opioid use (IV milligram morphine equivalents [MME]) was 25 (20 to 37), 20 (13 to 30), 27 (18 to 32), and 25 (20 to 36) mg, respectively, in patients receiving 0.1, 0.2, 0.25 and 0.3 mg/kg methadone, compared to 46 (33 to 59) mg in short-duration opioid controls. Opioid-related side effects were not numerically different. Home pain and opioid use were numerically lower in patients receiving methadone.

CONCLUSIONS

The most effective and well-tolerated single intraoperative induction dose of methadone for next-day discharge surgery was 0.25 mg/kg ideal body weight (median, 14 mg). Single-dose intraoperative methadone was analgesic and opioid-sparing in next-day discharge outpatient surgery.

EDITOR’S PERSPECTIVE

Impact of enhanced recovery pathways on patient-reported outcomes after abdominal surgery: a systematic review

INTRODUCTION

Evidence supports that enhanced recovery pathways (ERPs) reduce length of stay and complications; however, these measures may not reflect the perspective of patients who are the main stakeholders in the recovery process. This systematic review aimed to appraise the evidence regarding the impact of ERPs on patient-reported outcomes (PROs) after abdominal surgery.

METHODS

Five databases (Medline, Embase, Biosis, Cochrane, and Web of Science) were searched for randomized controlled trials (RCTs) addressing the impact of ERPs on PROs after abdominal surgery. We focused on distinct periods of recovery: early (within 7 days postoperatively) and late (beyond 7 days). Risk of bias was assessed using Cochrane's RoB 2.0. Results were appraised descriptively as heterogeneity hindered meta-analysis. Certainty of evidence was evaluated using GRADE.

RESULTS

Fifty-six RCTs were identified [colorectal (n = 18), hepatopancreaticobiliary (HPB) (n = 11), upper gastrointestinal (UGI) (n = 10), gynecological (n = 7), urological (n = 7), general surgery (n = 3)]. Most trials had 'some concerns' (n = 30) or 'high' (n = 25) risk of bias. In the early postoperative period, ERPs improved patient-reported general health (colorectal, HPB, UGI, urological; very low to low certainty), physical health (colorectal, gynecological; very low to low certainty), mental health (colorectal, gynecological; very low certainty), pain (all specialties; very low to moderate certainty), and fatigue (colorectal; low certainty). In the late postoperative period, ERPs improved general health (HPB, UGI, urological; very low certainty), physical health (UGI, gynecological, urological; very low to low certainty), mental health (UGI, gynecological, urological; very low certainty), social health (gynecological; very low certainty), pain (gynecological, urological; very low certainty), and fatigue (gynecological; very low certainty).

CONCLUSION

This review supports that ERPs may have a positive impact on patient-reported postoperative health status (i.e., general, physical, mental, and social health) and symptom experience (i.e., pain and fatigue) after abdominal surgery; however, data were largely derived from low-quality trials. Although these findings contribute important knowledge to inform evidence-based ERP implementation, there remains a great need to improve PRO assessment in studies focused on postoperative recovery.

Risks and benefits of oral modified-release compared with oral immediate-release opioid use after surgery: a systematic review and meta-analysis

Prescription of modified-release opioids for acute postoperative pain is widespread despite evidence to show their use may be associated with an increased risk of adverse effects. This systematic review and meta-analysis aimed to examine the available evidence on the safety and efficacy of modified-release, compared with immediate-release, oral opioids for postoperative pain in adults. We searched five electronic databases from 1 January 2003 to 1 January 2023. Published randomised clinical trials and observational studies on adults who underwent surgery which compared those who received oral modified-release opioids postoperatively with those receiving oral immediate-release opioids were included. Two reviewers independently extracted data on the primary outcomes of safety (incidence of adverse events) and efficacy (pain intensity, analgesic and opioid use, and physical function) and secondary outcomes (length of hospital stay, hospital readmission, psychological function, costs, and quality of life) up to 12 months postoperatively. Of the eight articles included, five were randomised clinical trials and three were observational studies. The overall quality of evidence was low. Modified-release opioid use was associated with a higher incidence of adverse events (n = 645, odds ratio (95%CI) 2.76 (1.52-5.04)) and worse pain (n = 550, standardised mean difference (95%CI) 0.2 (0.04-0.37)) compared with immediate-release opioid use following surgery. Our narrative synthesis concluded that modified-release opioids showed no superiority over immediate-release opioids for analgesic consumption, length of hospital stay, hospital readmissions or physical function after surgery. One study showed that modified-release opioid use is associated with higher rates of persistent postoperative opioid use compared with immediate-release opioid use. None of the included studies reported on psychological function, costs or quality of life.

Impact of an enhanced recovery after surgery program with a multimodal analgesia care pathway on opioid prescribing and clinical outcomes for patients undergoing colorectal surgery

Background

Opioids are a mainstay for acute pain management, but their side effects can adversely impact patient recovery. Multimodal analgesia (MMA) is recommended for treatment of postoperative pain and has been incorporated in enhanced recovery after surgery (ERAS) protocols. The objective of this quality improvement study was to implement an MMA care pathway as part of an ERAS program for colorectal surgery and to measure the effect of this intervention on patient outcomes and costs.

Methods

This pre-post study included 856 adult inpatients who underwent an elective colorectal surgery at three hospitals within an integrated healthcare system. The impact of ERAS program implementation on opioid prescribing practices, outcomes, and costs was examined after adjusting for clinical and demographic confounders.

Results

Improvements were seen in MMA compliance (34.0% vs 65.5%, P < 0.0001) and ERAS compliance (50.4% vs 57.6%, P < 0.0001). Reductions in mean days on opioids (4.2 vs 3.2), daily (51.6 vs 33.4 mg) and total (228.8 vs 112.7 mg) morphine milligram equivalents given during hospitalization, and risk-adjusted length of stay (4.3 vs 3.6 days, P < 0.05) were also observed.

Conclusions

Implementing ERAS programs that include MMA care pathways as standard of care may result in more judicious use of opioids and reduce patient recovery time.

The impact of PECS II blockade in patients undergoing minimally invasive cardiac surgery-a prospective, randomized, controlled, and triple-blinded trial

BACKGROUND

Classic neuraxial techniques, such as thoracic epidural anesthesia, or alternative approaches like the paravertebral block, are not indicated in cardiac surgery due to increased bleeding risk. To provide satisfactory analgesia without the need for excessive opioid use, novel ultrasound techniques gained popularity and are of growing interest. The pectoralis nerve block II (PECS II) has been shown to provide good postoperative analgesia in modified radical mastectomy and might also be suitable for minimally invasive cardiac surgery.

METHODS

In a single center, prospective, triple-blinded, two-group randomized trial, 60 patients undergoing elective, unilateral minimal invasive cardiac surgery will be randomized to receive a PECS II with 30 ml of ropivacaine 0.5% (intervention group) or sodium chloride 0.9% (placebo group). The primary outcome parameter is the overall opioid demand given as intravenous morphine milligram equivalents (MME) during the first 24 h after extubation. Secondary endpoints are the visual analog scale (VAS) 2, 4, 6, 8, 12, and 24 h after extubation, the Overall Benefit of Analgesia Score (OBAS) after 24 h, the interval until extubation, and intensive care unit (ICU) discharge within 24 h, as well as the length of hospital stay (LOS).

DISCUSSION

This prospective randomized, controlled, and triple-blinded trial aims to assess if a PECS II with ropivacaine 0.5% helps to decrease the opioid demand in the first 24 h and increases postoperative pain control after minimally invasive cardiac surgery.

TRIAL REGISTRATION

www.clinicaltrialsregister.eu ; EudraCT Nr: 2021-005452-11; Lukas Gasteiger MD, November 18, 2021.

Preoperative flurbiprofen diminishes the rate of reoperation after free flap reconstruction: A retrospective study

This study aimed to evaluate the association between preoperative flurbiprofen, a non-selective COX inhibitor, and reoperation for flap crisis after free flap reconstruction. In this retrospective study, patients who underwent head and neck surgery with free flap reconstructions were collected. To identify risk factors for reoperation from demographic features and perioperative variables, univariate and multivariate logistic analyses were conducted. After propensity score matching (PSM), univariate and adjusted multivariate analyses were employed to explore the impact of preoperative flurbiprofen on reoperation after free flap reconstruction. This study comprised 437 patients, 33 of whom underwent reoperations for flap crisis. After multivariate analysis, radiotherapy history (P = 0.005; odds ratio [OR] = 0.225; 95% CI, 0.080-0.636) and preoperative flurbiprofen (P = 0.038; OR = 5.059; 95% CI, 1.094-23.386) were identified as independent factors for reoperation. PSM was achieved, and preoperative flurbiprofen was found to diminish the reoperation rate (P = 0.046; OR = 4.765; 95% CI, 1.029-22.202) without increasing bleeding complications. Within the limitations of the study, flurbiprofen should be administered preoperatively to reduce the rate of reoperations for flap crisis whenever appropriate.

Rhomboid intercostal block or thoracic paravertebral block for postoperative recovery quality after video-assisted thoracic surgery: A prospective, non-inferiority, randomised controlled trial

BACKGROUND

The analgesic characteristics of rhomboid intercostal block (RIB) remain unclear. Before it can be fully recommended, we compared the recovery quality and analgesic effects of RIB and thoracic paravertebral block (TPVB) for video-assisted thoracoscopic surgery (VATS).

OBJECTIVE

The current study aimed to investigate whether there is a difference in postoperative recovery quality between TPVB and RIB.

DESIGN

A prospective, non-inferiority, randomised controlled trial.

SETTING

Affiliated Hospital of Jiaxing University in China from March 2021 to August 2022.

PATIENTS

Eighty patients aged 18 to 80 years, with ASA physical status I to III, and scheduled for elective VATS were enrolled in the trial.

INTERVENTION

Ultrasound-guided TPVB or RIB was performed with 20 ml 0.375% ropivacaine.

MAIN OUTCOME MEASURES

The primary outcome of the study was the mean difference of quality of recovery-40 scores 24 h postoperatively. The non-inferiority margin was defined as 6.3. Numeric rating scores (NRS) for pain at 0.5, 1, 3, 6, 12, 24 and 48 h postoperatively in all patients were also recorded.

RESULTS

A total of 75 participants completed the study. The mean difference of quality of recovery-40 scores 24 h postoperatively was -1.6 (95% CI, -4.5 to 1.3), demonstrating the non-inferiority of RIB to TPVB. There was no significant difference between the two groups in the area under the curve for pain NRS over time, at rest and on movement, at 6, 12, 24 and 48 h postoperatively (all P  > 0.05), except for the area under the curve pain NRS over time on movement at 48 h postoperatively ( P  = 0.046). There were no statistical differences between the two groups in the postoperative sufentanil use at 0 to 24 h or 24 to 48 h (all P  > 0.05).

CONCLUSION

Our study suggests that RIB was non-inferior to TPVB for the quality of recovery, with almost the same postoperative analgesic effect as TPVB after VATS.

CLINICAL TRIAL REGISTRATION

chictr.org.cn: ChiCTR2100043841.

Practice Advisory for Preoperative and Intraoperative Pain Management of Cardiac Surgical Patients: Part 2

Pain after cardiac surgery is of moderate to severe intensity, which increases postoperative distress and health care costs, and affects functional recovery. Opioids have been central agents in treating pain after cardiac surgery for decades. The use of multimodal analgesic strategies can promote effective postoperative pain control and help mitigate opioid exposure. This Practice Advisory is part of a series developed by the Society of Cardiovascular Anesthesiologists (SCA) Quality, Safety, and Leadership (QSL) Committee's Opioid Working Group. It is a systematic review of existing literature for various interventions related to the preoperative and intraoperative pain management of cardiac surgical patients. This Practice Advisory provides recommendations for providers caring for patients undergoing cardiac surgery. This entails developing customized pain management strategies for patients, including preoperative patient evaluation, pain management, and opioid use-focused education as well as perioperative use of multimodal analgesics and regional techniques for various cardiac surgical procedures. The literature related to this field is emerging, and future studies will provide additional guidance on ways to improve clinically meaningful patient outcomes.

Research Status and Prospects of Acupuncture in Perioperative Medicine Over the Past Decade: A Bibliometric Analysis

Background

Over the past decade, acupuncture in the perioperative period has attracted great interest, and a growing number of related literature has been published.

Purpose

To analyze the general information and identify the research hotspots and trends of acupuncture in perioperative medicine in the last 10 years by bibliometric analysis.

Methods

We searched the Web of Science Core Collection for publications on acupuncture in perioperative medicine from 2013 to 2023. The articles and reviews were collected with no language restriction. CiteSpace and VOSviewer software were used for bibliometric and visual analysis of relevant literature.

Results

A total of 814 bibliographic records were retrieved. Overall, the annual number of publications showed an increasing trend. China and its institutions were in a leading position regarding the publication number. With comparatively more scientific collaboration with China, the USA ranked second. Shanghai University of Traditional Chinese Medicine was the most prolific institution. Ha, In-Hyuk had the most publications, and Han JS and Lee A were the most cited authors. Medicine was the most popular journal and Journal of Clinical Oncology had the highest impact factor. "Acupuncture", "electroacupuncture" and "postoperative pain" were the top three keywords. The most popular topics were postoperative pain, postoperative ileus, and postoperative nausea and vomiting according to the keywords and references. And the clusters of postoperative cognitive dysfunction, anxiety, and breast cancer attracted relatively more attention recently.

Conclusion

This study summarized the research status, hotspots, and trends of acupuncture in perioperative medicine in the past decade, which may aid researchers in better understanding this field. The research hotspots primarily focused on postoperative pain management and postoperative gastrointestinal function. The research of acupuncture for postoperative cognitive dysfunction, cancer-related surgery, and psychological states were the main frontiers topics and may be the focus in the future.

Intravenous lidocaine bolus for reducing nefopam-induced venous pain: A randomized, intrasubject comparison trial

Background and Aims

Intravenous nefopam reduces postoperative pain and opioid consumption but can cause infusion-related pain. We aimed to investigate whether lidocaine can effectively reduce this pain.

Material and Methods

This prospective, randomized, double-blind, controlled, intrasubject comparison trial included 42 patients (20-60 years) undergoing elective surgery under regional or peripheral anesthesia. In the postanesthesia care unit, two 50 mL syringes containing nefopam (20 mg) diluted in saline (100 mL) were sequentially infused in 15 min into venous catheters in the left and right arms. Patients were randomly assigned to the "left side" or "right side" group based on the arm in which a bolus of 1% lidocaine (2 mL) (study group) was administered before nefopam infusion. Normal saline (2 mL) was administered on the control side. Numerical Rating Scale scores and the incidence of pain (scores > 3) and nausea or vomiting were recorded at 1, 5, 10, and 15 min.

Results

The analysis included 42 patients (84 infusions). Compared with the placebo, lidocaine lowered the mean infusion-related pain at 1 (0.07 vs. 2.21, P < 0.001), 5 (2 vs. 4.21, P < 0.001), 10 (2.02 vs. 3.95, P < 0.001), and 15 min (1.62 vs. 3.16, P = 0.003). At 5 min, significantly higher percentages of infusion sites with moderate and higher pain scores (> 3) were observed on the control side (30.95% vs. 14.29%, P = 0.000). Seven patients exhibited nausea or vomiting (16.7%).

Conclusion

For the nefopam infusion rate and concentration that we used, a 20 mg lidocaine pretreatment bolus significantly reduces infusion-related pain.

How does the ERAS protocol work in patients who underwent cesarean section? (HERMES study)

OBJECTIVE

To assess the effect of the enhanced recovery after surgery (ERAS) protocol for cesarean deliveries (CD) on postoperative outcomes.

METHODS

This multicenter prospective cohort study was conducted in six different centers between September 2020 and March 2021 and involved women who underwent either planned or unplanned CD. The primary outcome was time to the first passage of flatus following CD. Secondary outcomes included postoperative pain score, postoperative complications, and patient satisfaction. The protocol included early postoperative oral intake of ice cream and coffee, multimodal analgesia, antiemetic medications, and early ambulation.

RESULTS

A total of 448 patients were included. The median time to the first passage of flatus was 10 h in the Hermes group and 18 hours in the control group (P < 0.001). Postoperative visual analog scale scores were significantly higher in the control group. Patient satisfaction scores and the frequency of postoperative complications did not differ between the groups (P = 0.08, P = 0.604, respectively).

CONCLUSIONS

The ERAS protocol, including early serving of ice cream and coffee in the early postoperative period, enabled early discharge and a faster return of bowel function. Implementation of the ERAS protocol for patients who underwent planned and unplanned CD appeared to be safe and effective.

Effects of thoracic paravertebral nerve block on postoperative pain and postoperative delirium in elderly patients undergoing thoracoscopic lobectomy

OBJECTIVES

To evaluate the effects of ultrasound-guided thoracic paravertebral nerve block on perioperative pain and postoperative delirium in elderly patients undergoing thoracoscopic lobotomy.

METHODS

Patients aged 60 to 80 years who underwent the surgery of thoracoscopic lobectomy were selected; ASA grades I to III and New York Heart Association (NYHA) grades I to II. Patients were randomly divided into two groups: group C (group Compaired) and group T (group Thoracic Paravertebral Nerve Block TPVB). Patients in group T received ultrason-guided TPVB while those in group C didn't received TPVB. Postoperative patient-controlled intravenous analgesia was administered to all the patients. The consumption of intraoperative opioids, cases of hipoxemia, operative time, and extubation time was also recorded. Pain scores (static and dynamic) were assessed at 2, 4, 6, 24, 48, 72, 96, and 120 hours point after the operation. Pain scores, occurrence of postoperative delirium occurrence, postoperative complications, total amount of analgesic drugs, length of hospital stay, rescue analgesic requirement, and side effects were recorded within 5 days.

RESULTS

Intraoperative dosages of sufentanil and remifentanil were significantly lower in group T (Table 1). The postoperative recovery time in group T was significantly shortened (Table 1). The VAS pain scores of group T at 2, 4, 6, and 24 hours after surgery were much lower. The consumption of intraoperative opioids, number of rescue analgesic requirements, and the occurrence of postoperative delirium incidence in group T was significantly reduced (Table 2). There were no differences in hipoxemia events, postoperative nausea, vomiting and pulmonary complications between the two groups (Table 2).

CONCLUSION

Preoperative ultrasound-guided thoracic paravertebral nerve block (TPVB) can obviously decrease the intraoperative and postoperative opioids consumption, shorten the recovery time, reduce the number of rescue analgesia and the incidence of postoperative delirium in elderly patients undergoing thoracoscopic lobotomy.

Peripheral Regional Anesthesia Using Local Anesthetics: Old Wine in New Bottles?

During the past decade, numerous efforts were undertaken aiming at prolonging the analgesic effect of regional anesthesia. With the development of extended-release formulations and enhanced selectivity for nociceptive sensory neurons, a very promising contribution to the development of pain medications has been achieved. At present, liposomal bupivacaine is the most popular, non-opioid, controlled drug delivery system, but its duration of action, which is still controversially discussed, and its expensiveness have decreased initial enthusiasm. Continuous techniques can be seen as an elegant alternative for providing a prolonged duration of analgesia, but for logistic or anatomical reasons, they are not always the best choice. Therefore, focus has been directed towards the perineural and/or intravenous addition of old and established substances. As for perineural application, most of these so-called 'adjuvants' are used outside their indication, and their pharmacological efficacy is often not or only poorly understood. This review aims to summarize the recent developments for prolonging the duration of regional anesthesia. It will also discuss the potential harmful interactions and side effects of frequently used analgesic mixtures.

How to teach ERAS protocols: surgical residents' perspectives and perioperative practices for breast surgery patients

Purpose

Breast enhanced recovery after surgery (ERAS) protocols emphasize multimodal analgesia to expedite home recovery, but variable implementation remains. This study examines how residents learn and use ERAS protocols, how they conceptualize pain management, and what influences breast surgery patients' same-day discharges.

Methods

Interviews were conducted with surgical residents following their breast surgery rotation using an interview guide adapted from existing pain management literature. Interviews were transcribed, de-identified, and independently inductively coded by two researchers. A codebook was developed and refined using the constant comparative method. Codes were grouped into categories and explored for thematic analysis.

Results

Twelve interviews were completed with plastic and general surgery residents. Ultimately, 365 primary codes were organized into 26 parent codes, with a Cohen's kappa of 0.93. A total of six themes were identified. Three themes described how participants learn through a mixture of templated care, formal education, and informal experiential learning. Two themes delineated how residents would teach breast surgery ERAS: by emphasizing buy-in and connecting the impetus behind ERAS with daily workflow implementation. One theme illustrated how a patient-centered culture impacts postoperative management and same-day discharges.

Conclusions

Residents describe learning breast surgery ERAS and postoperative pain management by imitating their seniors, observing patient encounters, completing templated orders, and translating concepts from other ERAS services more so than from formal lectures. When implementing breast ERAS protocols, it is important to consider how informal learning and local culture influence pain management and discharge practices. Ultimately, residents believe in ERAS and often request further educational tools to better connect the daily how-to of breast ERAS pathways with the why behind the enhanced recovery principles.

The Efficiency of Ultrasound-Guided Pericapsular Nerve Group Block for Pain Management after Hip Surgery: A Meta-analysis

INTRODUCTION

Patients with hip surgery often experience moderate to severe postoperative pain, and need large doses of opioids to relieve it, which is not conducive to patient rehabilitation. Pericapsular nerve group (PENG) block is a new regional block technique that is considered to reduce postoperative pain and the use of opioids. The purpose of this study was to evaluate the efficacy and safety of PENG block for postoperative analgesia after hip surgery.

METHODS

We searched multiple databases for randomized controlled trials (RCTs) published in English, which compared PENG block with fascia iliaca compartment block (FICB). The primary outcome was 24 h postsurgical opioid consumption (OC). The secondary outcomes were pain scores (PSs) at different timepoints after surgery and the incidence of postoperative nausea and vomiting (PONV).

RESULTS

Five RCTs involving 234 patients were selected for our analysis. Our results show that the 24 h OC was drastically lower in PENG block versus FICB patients (SMD -0.60, 95% CI -1.08 to -0.11); P < 0.05, I² = 69%). At the same time, there were no significant difference in postsurgical PSs between the two cohorts (6 h: MD -0.07, 95% CI -0.67 to 0.53; P = 0.82, I² = 43%; 12 h: MD -0.60, 95% CI -1.40 to 0.19; P = 0.14, I² = 31%; 24 h: MD 0.17, 95% CI -0.87 to 1.21; P = 0.75, I² = 76%; 36 h: MD 0.80, 95% CI -0.92 to 2.51; P = 0.36, I² = 73%; 48 h: MD -0.06, 95% CI -0.75 to 0.63; P = 0.86, I² = 0%) and the incidence of PONV (RR 1.00, 95% CI 0.40-2.50, P = 1.00, I² = 35%).

CONCLUSIONS

Our research shows that PENG block can reduce the use of opioids after hip surgery and is effective in postoperative analgesia. Future research should explore the injection method, concentration, and dosage.

Surgical Pharmacy for Optimizing Medication Therapy Management Services within Enhanced Recovery after Surgery (ERAS®) Programs

Drug-related problems (DRPs) are common among surgical patients, especially older patients with polypharmacy and underlying diseases. DRPs can potentially lead to morbidity, mortality, and increased treatment costs. The enhanced recovery after surgery (ERAS) system has shown great advantages in managing surgical patients. Medication therapy management for surgical patients (established as "surgical pharmacy" by Guangdong Province Pharmaceutical Association (GDPA)) is an important part of the ERAS system. Improper medication therapy management can lead to serious consequences and even death. In order to reduce DRPs further, and promote the rapid recovery of surgical patients, the need for pharmacists in the ERAS program is even more pressing. However, the medication therapy management services of surgical pharmacy and how surgical pharmacists should participate in ERAS programs are still unclear worldwide. Therefore, this article reviews the main perioperative medical management strategies and precautions from several aspects, including antimicrobial agents, antithrombotic agents, pain medication, nutritional therapy, blood glucose monitoring, blood pressure treatment, fluid management, treatment of nausea and vomiting, and management of postoperative delirium. Additionally, the way surgical pharmacists participate in perioperative medication management, and the relevant medication pathways are explored for optimizing medication therapy management services within the ERAS programs. This study will greatly assist surgical pharmacists' work, contributing to surgeons accepting that pharmacists have an important role in the multidisciplinary team, benefitting medical workers in treating, counseling, and advocating for their patients, and further improving the effectiveness, safety and economy of medication therapy for patients and promoting patient recovery.

Efficacy of pericapsular nerve group (PENG) block on perioperative pain management in elderly patients undergoing hip surgical procedures: a protocol for a systematic review with meta-analysis and trial sequential analysis

INTRODUCTION

An increasing number of elderly patients suffer from hip diseases associated with moderate to severe perioperative pain during the accelerating global ageing process. Optimal analgesia can decrease perioperative complications and facilitate elderly patients' perioperative recovery. Pericapsular nerve group (PENG) block is a relatively new, analgesia adequate and motor-sparing block technique for perioperative pain management of hip diseases. However, the efficacy of PENG block remains unclear as the limited clinical evidence. Then, we will perform a protocol for a systematic review and meta-analysis to identify the efficacy of PENG block for perioperative pain management.

METHODS AND ANALYSIS

PubMed, Ovid Medline, Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure, Chinese BioMedical Literature, Wanfang and VIP databases will be searched from inception to August 2022 to identify randomised controlled trials of elderly patients accepting PENG block for hip diseases. The primary outcome will be the pain intensity after pain management. Secondary outcomes will be quadriceps strength, perioperative rescue analgesia information and perioperative complications. Assessment of heterogeneity will be primarily inspected by forest plots. If there is no indication of funnel plot asymmetry, a random-effects meta-analysis will be performed. The Cochrane risk-of-bias tool, Grading of Recommendations Assessment, Development and Evaluation and trial sequential analysis will be conducted to evaluate the evidence quality and control the random errors. Funnel plots and Egger's regression test will be performed to evaluate publication bias.

ETHICS AND DISSEMINATION

Ethical approval was not required for this systematic review protocol. The results will be disseminated through peer-reviewed publications.

PROSPERO REGISTRATION NUMBER

CRD42022313895.

Acupuncture-assisted anaesthesia for catheter ablation of atrial fibrillation to reduce the consumption of morphine hydrochloride and postoperative nausea and vomiting (PONV): study protocol for a randomised controlled trial

BACKGROUND

Patients often experience postoperative nausea and vomiting (PONV) after catheter ablation of atrial fibrillation (AF) because of the use of opioids for anaesthesia and analgesia during the procedure. Some clinical trials have demonstrated that acupuncture-assisted anaesthesia (AAA) reduces opioid consumption and prevents PONV. Although several studies have been conducted on AAA, its safety and efficacy in AF catheter ablation remain unclear due to small sample sizes and a paucity of methodologically rigorous designs. Therefore, this trial was designed to evaluate the safety and efficacy of AAA in reducing PONV and morphine hydrochloride consumption during catheter ablation.

METHODS

This single-centre, patient-blinded, randomised, non-penetrating sham-controlled trial will be conducted in China. A total of 100 patients will be randomly assigned to the AAA and conventional anaesthesia (CA) groups in a ratio of 1:1. The patients will receive AAA or CA plus sham acupuncture during catheter ablation and will be followed up for 30 days. The primary outcomes include the total amount of morphine hydrochloride consumed during catheter ablation and PONV within the first 24 hours after the procedure. The secondary outcomes include pain, nausea and vomiting, anxiety, patient's ability to cope during catheter ablation, AF recurrence and quality of life, as assessed using the numeric rating scale. Adverse events will be recorded and their influence will be analysed at the end of the trial.

DISCUSSION

This study will help in evaluating the safety and efficacy of AAA applied for AF catheter ablation in reducing opioid doses during the procedure and the occurrence of PONV.

ETHICS AND DISSEMINATION

The study has been approved by the Medical Ethics Committee of Second Affiliated Hospital of Shandong University of Traditional Chinese Medicine. The results of the study will be published in peer-reviewed journals and presented at conferences if possible.

TRIAL REGISTRATION NUMBER

ChiCTR 2100042646; Chinese Clinical Trial Registry.

Magnitude and severity of rebound pain after resolution of peripheral nerve block and associated factors among patients undergoes surgery at university of gondar comprehensive specialized hospital northwest, Ethiopia, 2022. Longitudinal cross-sectional study

Background

Rebound pain is extreme pain that persists after the effects of regional anesthesia wear off. Rebound pain occurrence and intensity are influenced by patient, surgical, and anesthesia-related factors. The incidence and severity of rebound pain after peripheral nerve block resolution are both reduced by the use of perioperative multimodal strategy. The purpose of the current paper was to evaluate the frequency, seriousness, and risk factors for rebound pain following peripheral nerve block resolution.

Method

A cross-sectional study centred on 384 patients who had received peripheral nerve blocks was carried out from August 20, 2021, to June 30, 2022. A semi-structured questionnaire was used to gather information within 24 h following the block's performance. SPSS 25 was used to enter and analyze the data. The change from well-controlled pain while the block is operating to severe pain within 24 h of block performance is known as rebound pain. Both univariate and multivariable analyses were used to examine the relationship between various parameters (patient, surgical, and anesthetic-related factors) and rebound pain. In the multivariable analysis, a P-value of 0.05 or lower is regarded as statistically significant.

Results

The incidence of rebound pain after peripheral nerve block was resolved was 61.7% (95% CI: 56.5-66.7) with a mean rebound pain score of 4.19 ± 2. Of the total 237, 120(50.6%) had severe rebound pain after the peripheral nerve block was resolved. The use of preoperative intravenous dexamethasone (AOR: 2.6, 95%CI: 20.29-24.57), preoperative pain (AOR: 3.9, 95%CI: 41-57.4), type of surgery (AOR: 6.5, 95%CI: 1.45-11.7), post-operative NSAID (AOR: 2.2, 95%CI: 17.69-20.8), and opioid use (AOR: 2.2, 95%CI: 19.1-22.56) were independent risks associated with rebound pain.

Conclusions

and Recommendation: Rebound pain occurred in 61.7% of patients and had independent associations with preoperative pain, dexamethasone premedication, type of surgery, use of an adjuvant, use of postoperative opioids, and NSAIDs. Therefore, clinicians should continue to use preventative strategies, especially for patients at higher risk of experiencing rebound pain.

Intraoperative administration of systemic/epidural/intrathecal morphine on the quality of recovery following substitutional urethroplasty with buccal mucosal graft: A randomized control trial

Background and Aims

Substitutional urethroplasty with buccal mucosal grafting for urethral stricture is associated with significant pain, and thus inappropriate perioperative pain management could delay postoperative recovery. The objective of our research was to determine the effects of analgesia with systemic or epidural or intrathecal morphine on quality of recovery (QoR) in patients undergoing substitutional urethroplasty with buccal mucosal grafting.

Material and Methods

This prospective, double-blinded, randomized control trial was conducted over 2 years in ASA I and II patients who underwent substitutional urethroplasty with buccal mucosal graft. Patients were randomized into three groups, and Group A received systemic morphine (0.1 mg/kg), Group B received epidural morphine (3 mg), and Group C received intrathecal morphine (150 μg). The QoR between the groups were compared postoperatively using the 40-item QoR questionnaire, and the hemodynamic variations, time taken for ambulation, resumption of oral intake, and incidence of complications were also compared.

Results

Out of the recruited 93 patients, 88 patients were analyzed. The QoR score for each domain was comparable between the three groups. The total QoR score for systemic, epidural, and intrathecal morphine groups were 189 (185-191), 189 (187-191), and 185 (183-189), respectively. Additionally, the hemodynamic variations, time taken for ambulation, and resumption of oral intake were comparable between all three groups except the incidence of postoperative nausea and vomiting (PONV) and pruritis, which were higher in the intrathecal group.

Conclusion

All three modalities, namely systemic morphine (0.1 mg/kg), epidural morphine (3 mg), and intrathecal morphine (150 μg), offer similar QoR after substitutional urethroplasty. However, the incidence of PONV and pruritis was higher with the administration of intrathecal morphine.

Optimization of anesthetic decision-making in ERAS using Bayesian network

Enhanced recovery after surgery (ERAS) can accelerate patient recovery. However, little research has been done on optimizing the ERAS-related measures and how the measures interact with each other. The Bayesian network (BN) is a graphical model that describes the dependencies between variables and is also a model for uncertainty reasoning. In this study, we aimed to develop a method for optimizing anesthetic decisions in ERAS and then investigate the relationship between anesthetic decisions and outcomes. First, assuming that the indicators used were independent, the effects of combinations of single indicators were analyzed based on BN. Additionally, the impact indicators for outcomes were selected with statistical tests. Then, based on the previously selected indicators, the Bayesian network was constructed using the proposed structure learning method based on Strongly Connected Components (SCC) Local Structure determination by Hill Climbing Twice (LSHCT) and adjusted according to the expert’s knowledge. Finally, the relationship is analyzed. The proposed method is validated by the real clinical data of patients with benign gynecological tumors from 3 hospitals in China. Postoperative length of stay (LOS) and total cost (TC) were chosen as the outcomes. Experimental results show that the ERAS protocol has some pivotal indicators influencing LOS and TC. Identifying the relationship between these indicators can help anesthesiologists optimize the ERAS protocol and make individualized decisions.

Opioid-Sparing Anesthesia: Gabapentin and Postoperative Pain

PURPOSE

Nonopioid analgesics are commonly used to augment or replace opioids in the perioperative setting. Perianesthesia nurses must consider timing and appropriateness when administering these medications to patients in the preoperative area or the postanesthesia care unit, particularly when other medications with sedative effects are being given. Gabapentin, originally proposed as an anticonvulsant medication, promotes analgesia and reduces risk for postoperative nausea and vomiting. This review examines the effect of gabapentin on postoperative pain.

DESIGN

A systematic review.

METHODS

CINAHL, PubMed, and Cochrane Review databases were searched to find a total of 93 sources that examined gabapentin and postoperative pain. After applying inclusion and exclusion criteria, four randomized controlled trials (RCT) were reviewed. Postoperative pain within the 24 hours of surgery was measured as the primary outcome using the visual analog scale in all sources FINDINGS: Three of the four reviewed RCTs determined gabapentin was both statistically and clinically significant in reducing postoperative pain, and all four sources showed a reduction in opioid consumption during the immediate postoperative period, which promoted patient satisfaction.

CONCLUSIONS

Further study of gabapentin and postoperative pain is needed employing rigorous and robust methodology and diversity of the sample selections.

Enhanced recovery after cardiac surgery protocol reduces perioperative opioid use

Objective

Enhanced Recovery After Surgery protocols are relatively new in cardiac surgery. Enhanced Recovery After Surgery addresses perioperative analgesia by implementing multimodal pain control regimens that include both opioid and nonopioid components. We investigated the effects of an Enhanced Recovery After Surgery protocol at our institution on postoperative outcomes with particular focus on analgesia.

Methods

Single-center retrospective study comparing perioperative opioid use before and after implementation of an Enhanced Recovery After Surgery protocol at our institution. Subjects were divided into 2 cohorts: Enhanced Recovery After Surgery (study group from year 2020) and pre-Enhanced Recovery After Surgery (control group from year 2018). Baseline and perioperative variables including total opioid use from the day of surgery to postoperative day 5 were collected. Opioid use was calculated as morphine milligram equivalents and compared between the 2 cohorts.

Results

A total of 466 patients were included: 250 in the Enhanced Recovery After Surgery group and 216 in the pre-Enhanced Recovery After Surgery group. Both groups had similar baseline characteristics, but the Enhanced Recovery After Surgery group had significantly more subjects with intravenous drug use history (P < .0001), endocarditis (P < .0001), and liver disease (P = .007) compared with the pre-Enhanced Recovery After Surgery group. Every day from the day of surgery to postoperative day 5, the Enhanced Recovery After Surgery group had significant reduction (57%) in opioid use compared with the pre-Enhanced Recovery After Surgery group. Total opioid use for the entire length of stay was 259 morphine milligram equivalents in the Enhanced Recovery After Surgery group versus 452 morphine milligram equivalents in the pre-Enhanced Recovery After Surgery group (P < .0001). Subgroup analysis of subjects with intravenous drug use history did not demonstrate a significant reduction in opioid use.

Conclusions

Enhanced Recovery After Surgery protocols with an emphasis on multimodal pain management throughout perioperative care are associated with a significant reduction in the postoperative use of opioid analgesics.

Laparoscopic rectal resection without epidural catheters-does it work?

PURPOSE

Placement of an epidural catheter (EC) in colorectal resections is still recommended as a valid measure to achieve a low level of pain. However, EC is associated with increased invasiveness and with an increased risk of bladder emptying disorders and a decrease in blood pressure, which all relate to delayed mobilization. Preliminary data shows that EC placement may not be necessary for laparoscopic colon resections. The aim of this prospective study was to investigate how the omission of EC placement influences short-term postoperative outcomes in laparoscopic rectal resections.

METHODS

All laparoscopic rectal resections occurring between 2013 and 2020 were prospectively examined. Resections from January 2013 to February 2018 (group A) were compared with resections from March 2018 to December 2020 (group B; after the internal change of the perioperative pain regime). In addition to EC placement, the other target parameters of our study were urinary catheter placement during the inpatient stay, postoperative pain > 3 days on a numerical rating scale (NRS), mobilization in the first 5 postoperative days, time until the first postoperative bowel movement, postoperative complications according to Clavien-Dindo, intermediate care unit stay (IMC stay) in days, and hospital length of stay in days.

RESULTS

In the entire study period, 221 laparoscopic rectal resections were performed: 122 in group A and 99 resections in group B. The frequency of EC placement and urinary catheter placement, postoperative IMC stay, and hospital length of stay was significantly lower in group B (p < 0.05). The postoperative mobilization of patients in group B was possible more quickly. There were no differences in the level of pain, time until the first postoperative bowel movement, and postoperative complications according to Clavien-Dindo.

CONCLUSION

Omission of EC placement in laparoscopic rectal resections led to faster mobilization, a shorter IMC stay, and a shorter hospital stay without increasing the pain level. Postoperative complications did not change when an EC was not placed. Therefore, routine EC placement in laparoscopic rectal resections is unnecessary.

Bilateral Erector Spinae Plane Block for Quality of Recovery Following Posterior Lumbar Interbody Fusion: A Randomized Controlled Trial

BACKGROUND

Erector spinae plane block, a novel ultrasound-guided fascial plane block, has become popular for perioperative pain management. This randomized controlled trial tested the hypothesis that preoperative bilateral erector spinae plane block improves the quality of recovery in patients undergoing posterior lumbar interbody fusion.

METHODS

Eighty-four patients scheduled for elective posterior lumbar interbody fusion were enrolled. Patients were randomly administered either ultrasound-guided bilateral erector spinae plane blocks using 20 ml of 0.375% ropivacaine on each side (ESPB group, n = 42) or no block (control group, n = 42) after anesthesia induction. The primary outcome was the quality of recovery 24 h postoperatively, assessed using the 15-item quality of recovery questionnaire.

RESULTS

The global postoperative 24-h quality of recovery-15 score was 117 [114-121] in the erector spinae plane block group and 108 [105-111] in the control group, with a median difference of 9 (95% confidence interval 7-12, P < 0.001). Compared with the control group, preoperative bilateral erector spinae plane blocks reduced the area under the curve of the numeric rating scale pain scores over 48 h, prolonged the time to first rescue analgesia, lessened postoperative 24 h morphine consumption, decreased the occurrence of postoperative nausea and vomiting, and improved patient satisfaction with postoperative analgesia. There were no block-related adverse events.

CONCLUSION

We found that preoperative bilateral erector spinae plane blocks provided superior early quality of recovery, postoperative analgesia, and patient satisfaction scores in patients undergoing posterior lumbar interbody fusion.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR1900027186, 4/11/2019.

Impact of timing of multimodal analgesia in enhanced recovery after cesarean delivery protocols on postoperative opioids: A single center before-and-after study

STUDY OBJECTIVE

Enhanced recovery after cesarean delivery (ERAC) programs aim to decrease maternal morbidity and aid in maternal recovery and return to baseline. Multimodal analgesia is an important element of ERAC protocols, but no consensus exists on the timing of medication administration. We compared maternal pain outcomes following scheduled cesarean delivery with modification of the timing of administration of multimodal analgesia with non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen.

DESIGN

Before-and-after study.

SETTING

Labor and delivery unit at a single academic institution.

INTERVENTION

NSAIDs and acetaminophen were administered as a fixed-interval alternating regimen every 3 h for the initial ERAC group (ERAC 1) and fixed-interval combined regimen every 6 h for the modified ERAC group (ERAC 2). ERAC 1 and ERAC 2 groups were compared to historical controls (Pre-ERAC).

PATIENTS

520 women undergoing scheduled cesarean delivery (Pre-ERAC n = 179, ERAC 1 n = 179, and ERAC 2 n = 162).

MEASUREMENTS

The primary outcomes were postoperative total and daily opioid utilization as measured in morphine milligram equivalents (MME). Secondary outcomes included postoperative length of stay, maximum pain scores, and racial disparities in care.

MAIN RESULTS

The modified schedule of non-opioid analgesics involving combined administration (ERAC 2) versus alternating administration (ERAC 1) of multimodal analgesia resulted in decreased total postoperative opioid utilization (median = 26.3 vs 52.5 MME, Bonferroni corrected P = 0.002). Total postoperative opioid utilization among the ERAC 2 group was also significantly reduced compared to the Pre-ERAC group (median = 26.3 vs 105.0 MME, Bonferroni corrected P < 0.0001).

CONCLUSIONS

Multidisciplinary teams developing or modifying ERAC protocols for scheduled cesarean delivery should consider a combined administration at fixed intervals of NSAIDs and acetaminophen throughout the hospital stay to optimize postoperative pain management.