Procedure-specific acute pain trajectory after elective total hip arthroplasty: systematic review and data synthesis

Pericapsular nerve group (PENG) block combined with local infiltration analgesia is not superior to local infiltration analgesia for the management of postoperative pain after primary elective total hip arthroplasty: A prospective, randomized, controlled, single-blind trial

Background

Local infiltration analgesia (LIA) has been advocated for the pain management after total hip arthroplasty (THA). The analgesic benefits of an added pericapsular nerve group (PENG) block remain questionable.

Methods

This randomized, single-blind trial enrolled patients undergoing elective THA under general anaesthesia and standardized postoperative analgesia. Patients were allocated to receive either a PENG block (20 mL of ropivacaine 0.475 %) combined with intraoperative LIA (PENG + LIA group, n = 32), or intraoperative LIA alone (LIA group, n = 32). The primary outcome was oral morphine equivalent (OME) consumption at day 1. Secondary outcomes were: pain scores at post anaesthesia care unit (PACU) discharge and on day 2, times for the Timed to Up and Go (TUG) test and measurement of adductor strength on day 1, and patients' satisfaction using the EVAN-G questionnaire.

Results

Compared with LIA alone, PENG + LIA resulted in similar OME consumption on day 1 (78 [51-91.5] mg vs 58 [30-80] mg respectively, median difference (95%CI) of -17 (-34 to 1) mg, p = 0.09). Pain scores and morphine consumption were not different between groups at any time point. TUG and thigh adduction tests were similar between LIA and PENG + LIA groups (respectively 35 [25-48.5] vs 31.5 [19.5-46.5] sec, p = 0.39; and 105 [85-150] vs 100 [80-125] mmHg, p = 0.61). No difference in the patients' satisfaction was found.

Conclusion

The addition of a PENG block to large-volume LIA did not significantly improve the analgesia for elective THA in the setting of an adequate basic postoperative analgesia regimen. The results of the lower limb functional tests confirmed the PENG block to be motor-sparing.

Clinical Efficacy of Intra-articular Tranexamic Acid Injection in the Management of Hemophilia with Total Hip Arthroplasty: A 24-month Retrospective Cohort Study

OBJECTIVE

Total hip arthroplasty (THA) effectively treats end-stage hemophilic hip arthropathy. Given hemophilia's unique characteristics, perioperative bleeding remains a significant risk for patients undergoing THA. Tranexamic acid (TXA), an efficient antifibrinolytic agent, may benefit the outcomes of THA for patients with hemophilia (PWH). This study aims to explore the clinical efficacy of intra-articular injection of TXA in treating perioperative bleeding in PWH and assess its additional clinical benefits.

METHODS

The retrospective study comprised data of PWH who received THA from January 2015 to December 2021 in the research center. A total of 59 individuals were included in the study, divided into a TXA group (n = 31) and a non-TXA group (n = 28). We compared various parameters, including total blood loss (TBL), visible blood loss (VBL), occult blood loss (OBL), intraoperative coagulation factor VIII (FVIII) consumption, perioperative total FVIII consumption, hemoglobin (HB), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), length of hospital stay, hospitalization costs, length of surgery, total protein, activated partial thromboplastin time (APTT), D-dimer, rate of joint swelling, hip joint range of motion (ROM), visual analogue scale (VAS), and Harris hip joint function scale (HHS) between the two groups. Follow-up assessments were conducted for up to 24 months. A Student's t test was utilized for the statistical analysis.

RESULTS

This study demonstrated that intra-articular TXA effectively reduced TBL (1248.19 ± 439.88 mL, p < 0.001), VBL (490.32 ± 344.34 mL, p = 0.003), and OBL (757.87 ± 381.48 mL, p = 0.004) in PWH who underwent THA. TXA demonstrated effectiveness in reducing VAS scores on POD1, POD7, and POD14 and joint swelling rates on POD1, POD7, POD14, and at discharge (p < 0.05). Additionally, the TXA group achieved higher HHS ratings at all follow-up time points (p < 0.05), showing superior hip joint mobility, lower postoperative inflammation levels, reduced factor VIII consumption during surgery, and less postoperative nutritional loss. No statistically significant differences were observed between the two groups in terms of hospital stay, hospitalization costs, surgery duration, and coagulation indicators.

CONCLUSION

Intra-articular injection of TXA reduces perioperative bleeding in PWH undergoing THA while also improving joint mobility, post-operative rehabilitation, and quality of life. This may provide value for the future application of TXA in PWH.

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.

Lumbar erector spinae plane block versus infrainguinal fascia iliaca compartment block for pain management after total hip arthroplasty: a randomized clinical trial

OBJECTIVE

We aimed to evaluate the effectiveness of ultrasound-guided facia iliaca compartment (FIC) and erector spinae plane (ESP) blocks in managing postoperative pain after total hip arthroplasty surgery.

METHODS

A total of 60 patients were randomized into 2 groups (n = 30): one that received FIC blocks and one that received ESP blocks. FIC and ESP blocks were performed with 30 mL 0.25% bupivacaine at the end of the surgery. The patients received intravenous tramadol and patient-controlled postoperative analgesia. The pain scores, opioid consumption, and adverse events were recorded.

RESULTS

The dynamic pain scores on movement in the postoperative first hour were significantly lower in the ESP block group than in the FIC block group (3 [2-4] vs 4 [2-5], respectively; P = .035). Data are expressed as median (25th-75th percentiles). Postoperative opioid consumption within the first postoperative 8 hours was significantly higher in the FIC block group than in the ESP block group (80 mg [61-100] vs 100 mg [80-120], respectively; P = .010). The adverse effects of opioids did not differ between the 2 groups.

CONCLUSION

ESP and infrainguinal FIC blocks provided similar postoperative analgesia 24 hours after total hip arthroplasty. The ESP block is more beneficial than the FIC block in terms of pain scores and opioid consumption in the early hours of the postoperative period.

TRIAL REGISTRATION

www.ClinicalTrials.gov (ID: NCT05621161).

A Randomized Controlled Trial to Evaluate the Analgesic Effectiveness of Periarticular Injections and Pericapsular Nerve Group Block for Patients Undergoing Total Hip Arthroplasty

Pericapsular nerve group (PENG) block and periarticular injection (PAI) provide motor-sparing analgesia following hip surgery. We hypothesized that PAI offers non-inferior pain relief compared with PENG block in patients undergoing primary total hip arthroplasty (THA). In this randomized trial, 66 patients who underwent primary THA under spinal anesthesia were assigned to the PENG or PAI groups. The primary endpoint was the resting pain score 24 h postoperatively. The secondary endpoints included pain scores at rest and during movement at 6 and 48 h postoperatively, quadriceps strength at 24 h postoperatively, and opioid consumption at 24 and 48 h postoperatively. The mean difference in pain scores at rest between the two groups was 0.30 (95% confidence interval [CI], -0.78 to 1.39) at 24 h postoperatively. The upper 95% CI was lower than the non-inferiority margin, indicating non-inferior performance. No significant between-group differences were observed in the pain scores at 6 and 48 h postoperatively. Additionally, no significant differences in quadriceps strength and opioid consumption were observed between the two groups. The PAI and PENG blocks provided comparable postoperative analgesia during the first 48 h after primary THA. Further investigation is required to determine the optimal PAI technique and local anesthetic mixture.

Lessons learnt in evidence-based perioperative pain medicine: changing the focus from the medication and procedure to the patient

Over time, the focus of evidence-based acute pain medicine has shifted, from a focus on drugs and interventions (characterized by numbers needed to treat), to an appreciation of procedure-specific factors (characterized by guidelines and meta-analyses), and now anesthesiologists face the challenge to integrate our current approach with the concept of precision medicine. Psychometric and biopsychosocial markers can potentially guide clinicians on who may need more aggressive perioperative pain management, or who would respond particularly well to a given analgesic intervention. The challenge will be to identify an easily assessable set of parameters that will guide perioperative physicians in tailoring the analgesic strategy to procedure and patient.

Trajectory of pain threshold and its association with acute pain after thoracic surgery: a prospective observational study

BACKGROUND

Postoperative analgesic management is an ongoing challenge. The pain threshold (PT) is an objective index that reflects the body's sensitivity to pain and can be used for quantitative pain assessment. We hypothesized that the PT is correlated with postoperative pain and can thus be used to guide postoperative pain management.

METHODS

This study involved 93 patients who underwent thoracoscopic surgery from December 2019 to February 2020. The PT was measured with transcutaneous electrical stimulation before surgery (T0) and at 1 h (T1), 6 h (T6), and 24 h (T24) after surgery. The visual analogue scale (VAS) score was used to evaluate the severity of postoperative pain at the same time. The PT variation (PTV) after surgery was calculated as the ratio of the postoperative PT to preoperative PT.

RESULTS

The postoperative PT was higher than the preoperative PT and showed a downward trend within 24 h after surgery; the PTV also showed a downward trend within 24 h after surgery. PT-T1 was negatively correlated with VAS-T1 at rest and during motion (rest: VAS-T1r = - 0.274, P = 0.008; motion: VAS-T1r = - 0.298, P = 0.004). PTV-T1 was negatively correlated with VAS-T1 during motion (r = - 0.213, P = 0.04). Lower VAS-T1 scores (< 4) at rest and during motion were associated with higher PT-T1 (rest: t = 2.452, P = 0.016; motion: t = 2.138, P = 0.035). The intraoperative sufentanil dose was associated with a postoperative increase in PTV-T1. Increased rescue analgesic administration was associated with PTV elevation. However, the incidence of dizziness in patients with moderate PTV-T24 was lower than that in patients with high or low PTV-T24 (χ2 = 8.297, P = 0.015).

CONCLUSIONS

The postoperative PT was higher than the preoperative PT and showed a downward trend within 24 h after surgery; PTV also showed a downward trend within 24 h after surgery. The PT and PTV were negatively correlated with the pain intensity at rest and during motion and were associated with perioperative analgesic consumption and the incidence of adverse events.

Improved perioperative narcotic usage patterns in patients undergoing robotic-assisted compared to manual total hip arthroplasty

BACKGROUND

Robot-assisted total hip arthroplasty (RA-THA) improves accuracy in achieving the planned acetabular cup positioning compared to conventional manual THA (mTHA), but optimal dosage for peri-RA-THA and mTHA pain relief remains unclear. This study aimed to compare pain control with opioids between patients undergoing direct anterior approach THA with the use of a novel, fluoroscopic-assisted RA-THA system compared to opioid consumption associated with fluoroscopic-assisted, manual technique.

METHODS

Retrospective cohort analysis was performed on a consecutive series of patients who received mTHA and fluoroscopy-based RA-THA. The average amount of postoperative narcotics in morphine milligram equivalents (MME) given to each cohort was compared, including during the in-hospital and post-discharge periods. Analyses were performed on the overall cohort, as well as stratified by opioid-naïve and opioid-tolerant patients.

RESULTS

The RA-THA cohort had significantly lower total postoperative narcotic use compared to the mTHA cohort (103.7 vs. 127.8 MME; P < 0.05). This difference was similarly seen amongst opioid-tolerant patients (123.6 vs. 181.3 MME; P < 0.05). The RA-THA cohort had lower total in-hospital narcotics use compared to the mTHA cohort (42.3 vs. 66.4 MME; P < 0.05), consistent across opioid-naïve and opioid-tolerant patients. No differences were seen in post-discharge opioid use between groups.

CONCLUSIONS

Fluoroscopy-based RA-THA is associated with lower postoperative opioid use, including during the immediate perioperative period, when compared to manual techniques. This may have importance in rapid recovery protocols and mitigating episode burden of care.

Comparison of analgesic effects of pericapsular nerve group block and fascia iliaca compartment block during hip arthroplasty: A systematic review and meta-analysis of randomised controlled trials

Background and Aims

Postoperative pain for patients having hip arthroplasty ranges from moderate to severe. Many regional anaesthesia procedures treat postoperative pain to improve functional ability and quality of life. Evidence comparing the analgesic effects of the pericapsular nerve group (PENG) block and fascia iliaca compartment block (FICB) remains unclear. The analgesic efficacies of PENG and FICB in hip arthroplasty were compared to determine which technique is associated with superior analgesia.

Methods

The electronic databases (PubMed, Cochrane Library, Google Scholar and Web of Sciences) were searched for published randomised controlled trials (RCTs) till 5 April 2023 comparing PENG block vs. FICB following hip arthroplasty. The primary outcome was pain scores [numerical rating scale (NRS) or visual analogue scale (VAS)] between 0 and 10 at rest and during movement at 24 h. Secondary outcomes included pain scores at rest and during movement within 30 min, at 6 h and 12 h, time to first rescue analgesia and cumulative postoperative opioid use in 24 h. We assessed the risk of bias using the Cochrane Collaboration Risk-of-Bias 2 tool. Using Grading of Recommendations Assessment, Development, and Evaluation (GRADE), the certainty of the evidence was assessed. Subgroup analysis was performed to explore the source of heterogeneity.

Results

We included 12 RCTs examining 644 patients. Pain scores at rest at 24 h (standardised mean differences (SMDs): 0.17; 95% confidence interval (CI): -0.90 to 1.23; P = 0.76, moderate certainty) and during movement at 24 h (SMD: -0.58, 95% CI: -1.53 to 0.38, P = 0.24, moderate certainty) were not different in both PENG block and FICB. Pain scores at rest and during movement within 30 min may be lower with PENG block than FICB. However, the pain score at rest and during movement at 6 h and the time to first rescue analgesia were not different between the two treatment arms. The mean opioid consumption in oral morphine equivalents (mg) in 24 h may be lower with PENG than FICB.

Conclusion

We observed no difference between the PENG block and the FICB at 24 h for pain at rest and movement with a moderate degree of certainty. However, PENG block showed improved analgesia within 30 min at rest and during movement, and reduce postoperative opioid consumption in 24 h with moderate certainty of evidence. Further large-scale and high-quality RCTs are required to supplement the present findings.

Chronic pain patients and time to sustained acceptable pain scores after major surgery - A retrospective registry analysis

STUDY OBJECTIVE

We tested the hypothesis that pre-existing chronic pain is associated with prolonged time to reach sustained acceptable pain scores after major surgery.

DESIGN

Retrospective study using the German Network for Safety in Regional Anaesthesia and Acute Pain Therapy registry.

SETTING

Operating rooms and surgical wards.

PATIENTS

107,412 patients recovering from major surgery who were cared for by an acute pain service. 3.3% of the treatments were in patients who reported chronic pain with functional or psychological impairment.

INTERVENTIONS AND MEASUREMENT

We compared time to sustained adequacy of postoperative pain control defined by numeric rating scores <4 at rest and with movement in patients with and without chronic pain using an adjusted cox proportional hazard regression model and Kaplan-Meier analysis. The observation period was censored at 10 days and propensity score matching was used as a sensitivity analysis.

MAIN RESULTS

Postoperative pain at rest took significantly longer to resolve in patients with chronic pain than in those without (adjusted hazard ratio HR 1.42, 95% CI 1.36-1.49, P < 0.001). Postoperative pain with movement took even longer to resolve in patients with chronic pain (adjusted HR 1.65, 95%CI 1.56-1.75, P < 0.001).

CONCLUSIONS

Patients with chronic pain sustain more surgical pain than those without, and the pain takes longer to resolve. Clinicians providing postoperative pain management should consider the special needs of chronic pain patients.

High dose dexamethasone in high pain responders undergoing total hip arthroplasty: A randomized controlled trial

BACKGROUND

Postoperative pain after total hip arthroplasty (THA) may delay postoperative mobilization and discharge. Postoperative pain has been shown to be higher in pain catastrophisers and patients receiving opioids. A single dose of glucocorticoid reduces pain after THA, and an increased dose of glucocorticoids has been found to be effective in patients at high risk of postoperative pain after total knee arthroplasty (TKA), however, the ideal dose in THA remains unknown.

OBJECTIVE

To evaluate the effect of a high dose (1 mg kg -1 ) vs. intermediate dose (0.3 mg kg -1 ) of dexamethasone on pain after THA.

DESIGN

A randomized double-blind controlled study.

SETTING

A two-centre study including two large arthroplasty sites in Denmark was conducted from February 2019 to August 2020.

PATIENTS

A total of 160 patients undergoing THA by neuraxial block with multimodal analgesia, having a Pain Catastrophising Scale score >20 and/or preoperative opioid use were included.

INTERVENTION

Patients were randomly assigned to receive dexamethasone 1 mg kg -1 or 0.3 mg kg -1 before THA.

MAIN OUTCOME MEASURES

Primary outcome was percentage of patients experiencing moderate to severe pain (visual analogue scale, VAS > 30 mm on a 0 to 100 mm scale) on ambulating 24 h after surgery. Secondary outcomes included cumulated pain scores, C-reactive protein (CRP), opioid use, postoperative recovery scores, length of stay, complications, and re-admission within 30 and 90 days.

RESULTS

No difference was found in percentage of VAS >30 mm 24 h after surgery in the 5-m walk test (VAS > 30/VAS ≤ 30%); 33/42 (44%) vs. 32/43 (43%), relative risk = 1.04 (95% confidence interval 0.72-1.51; P  = 0.814) in 1 mg kg -1vs. 0.3 mg kg -1 respectively. No differences were found in CRP and opioid use between groups. Also, no intergroup differences were found in recovery scores, re-admissions, or complications.

CONCLUSION

1 mg kg -1vs. 0.3 mg kg -1 dexamethasone improved neither postoperative pain nor recovery in THA in a cohort of predicted high pain responders.

TRIAL REGISTRATION

ClinicalTrials.gov ID-number NCT03763760 and EudraCT-number 2018-2636-25.

Comparison between supra-inguinal fascia iliaca and pericapsular nerve group blocks on postoperative pain and functional recovery after total hip arthroplasty: A noninferiority randomised clinical trial

BACKGROUND

Pain after a posterolateral approach for total hip arthroplasty (THA) may affect early functional recovery. Supra-inguinal fascia iliaca (SFIB) and pericapsular nerve group (PENG) blocks have been proposed as promising analgesia techniques.

OBJECTIVES

This trial was conducted to compare a PENG with a SFIB for controlling postoperative pain and for providing functional recovery.

DESIGN

Noninferiority monocentric randomised controlled study.

SETTING

One hundred and two patients scheduled for a total hip arthroplasty via the posterolateral approach under spinal anaesthesia were prospectively allocated to two groups. Data acquisition occurred between October 2021 and July 2022 at the University Hospital of Liege.

PATIENTS

One hundred and two patients completed the trial.

INTERVENTIONS

Group SFIB received supra-inguinal fascia iliaca block (SFIB) (40 ml ropivacaine 0.375%), whereas group PENG received a PENG block (20 ml ropivacaine 0.75%).

MAIN OUTCOME MEASURES

Rest and mobilisation pain on a 0 to 10 numeric rating scale at fixed time points: 1 and 6 h after surgery, on day-1 and day-2 at 8 a.m.,1 p.m. and 6 p.m. On day-1 and day-2, evolution of quality-of-recovery-15 score was assessed, and timed-up-and-go, 2 and 6 min-walking tests. The noninferiority margin was set as 1 numeric rating scale point 6 h after surgery.

RESULTS

Six hours after surgery, pain scores in group PENG were noninferior to those of group SFIB, with a difference between medians at 0 (95% CI -0.93 to 0.93). There were no significant differences between the groups regarding rest and dynamic pain trajectories during the first 48 postoperative hours, with no significant effects of group (rest P  = 0.800; dynamic P  = 0.708) or interaction between group and time (rest P  = 0.803; dynamic P  = 0.187). Similarly, no significant differences were observed regarding motor and functional recovery as assessed by timed-up-and-go ( P  = 0.197), 2 min ( P  = 0.364), and 6 min walking ( P  = 0.347) tests and quality-of-recovery-15 ( P  = 0.417) score.

CONCLUSION

Following a total hip arthroplasty via the posterolateral approach, a PENG block is noninferior to SFIB regarding postoperative pain control 6 h after surgery, and functional recovery.

TRIAL REGISTRATION

European Clinical Trial Register under EudraCT-number 2020-005126-28 ( https://www.clinicaltrialsregister.eu/ctr-search/trial/2020-005126-28/BE ).

Pain Trajectory after Short-Stay Anorectal Surgery: A Prospective Observational Study

The evolution of pain after anorectal surgery has not been well characterized. The main objective of this study is to evaluate patterns in acute postoperative pain in patients undergoing short-stay anorectal surgery. A total of 217 patients were included in the study, which used group-based trajectory modeling to estimate postoperative pain and then examined the relationships between sociodemographic or surgical factors and pain trajectories. Three distinct postoperative pain trajectories were determined: hemorrhoidectomy (OR, 0.15), higher anxiety (OR, 3.26), and a higher preoperative pain behavior score (OR, 3.15). In multivariate analysis, they were associated with an increased likelihood of being on the high pain trajectory. The pain trajectory group was related to postoperative analgesic use (p < 0.001), with the high-low group needing more nonsteroidal analgesics. The study showed that there were three obvious pain trajectories after anorectal surgery, including an unreported low-moderate-low type. More than 60% of patients maintained moderate to severe pain within 7 days after the operation. These postoperative pain trajectories were predominantly defined by surgery factors and patient factors.

Erector spinae block: beyond the torso

PURPOSE OF REVIEW

This article aims to summarize the current literature describing the application of erector spinae plane (ESP) blocks for regional anesthesia of upper and lower limbs and to discuss the advantages and limitations.

RECENT FINDINGS

Investigations are still at an early stage but results are promising. High thoracic ESP blockade can relieve acute and chronic shoulder pain through local anesthetic diffusion to cervical nerve roots, although it may not be as effective as direct local anesthetic injection around the brachial plexus. It does, however, preserve motor and phrenic nerve function to a greater extent. It will also block the T2 innervation of the axilla which can be a source of pain in complex arthroscopic shoulder surgery. Lumbar ESP blocks provide effective analgesia following hip arthroplasty and arthroscopy, and appear comparable to lumbar plexus, quadratus lumborum, and fascia iliaca blocks. Unlike the latter, they are motor-sparing and are associated with improved postoperative ambulation.

SUMMARY

High thoracic and lumbar ESP blocks have the potential to provide adequate analgesia of the upper and lower limbs respectively, without causing significant motor block. They are thus alternative methods of regional anesthesia when other techniques are not feasible or have undesirable adverse effects.

Rebound Pain After Peripheral Nerve Blockade-Bad Timing or Rude Awakening?

Patients who have perioperatively benefited from regional anesthesia frequently report moderate to severe pain when the nerve block effects fade away. Over the past years, the term "rebound pain" has been introduced, suggesting a specific pathologic process. It is debated whether significant pain on block resolution reflects a separate and distinct pathologic mechanism potentially involving proinflammatory and neurotoxic effects of local anesthetics, or is simply caused by the recovery of sensory function at a timepoint when nociceptive stimuli are still intense, and moderate to severe pain should be anticipated. In that latter case, the phenomenon referred to as rebound pain could be considered a failure of pain management providers to devise an adequate analgesia plan. Whatever the ultimate designation, management of rebound pain should be proactive, by implementing multimodal analgesia, or tailoring the blockade to the expected trajectory of postoperative pain and managing patient expectations accordingly. Until we know more about the etiology and impact of this phenomenon, the authors suggest a more neutral designation such as "pain on block resolution."

Analgesic benefits of the quadratus lumborum block in total hip arthroplasty: a systematic review and meta-analysis

The quadratus lumborum block (QLB) is reported to reduce pain and improve function following total hip arthroplasty; however, randomised controlled trials evaluating the benefits of adding this block to general or spinal anaesthesia in this population are conflicting. We performed a systematic review seeking randomised controlled trials investigating QLB benefits for total hip arthroplasty, stratifying comparisons regarding the addition of QLB to either general or spinal anaesthesia. The primary outcome was 24-h area under the curve (AUC) pain score. Pain scores were interpreted in the context of a population-specific minimal clinically important difference of 1.86 cm on a 10-cm visual analogue scale, or an AUC pain score of 5.58 cm.h. Secondary outcomes included analgesic consumption, functional recovery and opioid-related side-effects. In all, 18 trials (1318 patients) were included. Adding QLB to general or spinal anaesthesia improved 24-h AUC rest pain scores by a mean difference (95%CI) of -3.56 cm.h (-6.70 to -0.42; p = 0.034) and - 4.19 cm.h (-7.20 to -1.18; p = 0.014), respectively. These improvements failed to reach the pre-determined minimal clinically important difference, as did the reduction in analgesic consumption. Quadratus lumborum block improved functional recovery for general, but not spinal, anaesthesia. Opioid-related side-effects were reduced with QLB regardless of anaesthetic modality. Low-to-moderate quality evidence suggests that the extent to which adding QLB to either general or spinal anaesthesia reduces postoperative pain and opioid consumption after total hip arthroplasty is statistically significant but may be clinically unimportant for most patients. However, adding QLB to general anaesthesia might enhance functional recovery. Taken together, our findings do not support the routine use of QLB as part of multimodal analgesic regimens for total hip arthroplasty.

The Intraoperative Adherence to Multimodal Analgesia of Anesthesiologists: A Retrospective Study

Introduction

Multimodal analgesia (MMA) is a critical component of enhanced recovery after surgery (ERAS). However, little research revealed its intraoperative implementation by anesthesiologists, who are on the front line defending against surgical pain. Therefore, the objective of our study is to assess the adherence of anesthesiologists to MMA comprehensively.

Methods

A retrospective study was conducted involving patients undergoing lung resection, knee arthroplasty, and radical mastectomy from pre/post-implementation year of MMA (Jan 1, 2013, to Dec 31, 2013, vs. 2019). Intraoperative analgesia regimens (analgesic mode) and hourly rated morphine milligram equivalents (MME) were compared. In addition, patient characteristics associated with continued opioid use after surgery, surgical types, and position level of anesthesiologists (attending-junior; above attending-senior) were also analyzed.

Results

After MMA initiation, the rate of multimodal analgesic regimen (mode ≥ 2) was significantly increased (post- vs. pre-implementation, 31.57 vs. 21.50%, p < 0.05). However, MME did not show significant difference (post- vs. pre-implementation, 0.402 vs. 0.456, p > 0.05). Patient-level predictors of persistent opioid use after surgery were not related to increased analgesic mode. Lung resection [coefficient, − 0.538; 95% confidence interval (CI), − 0.695 to − 0.383, p < 0.001] and knee arthroplasty (coefficient, − 1.143; 95% CI, − 1.366 to − 0.925, p < 0.001) discouraged multiple analgesic mode, while senior anesthesiologists (coefficient, 0.674; 95% CI 0.548–0.800, p < 0.001) promoted it.

Conclusions

Although anesthesiologists used more analgesics after promoting MMA, the “opioid-sparing” principle was not followed properly. The analgesic mode was not instructed by patients’ characteristics appropriately. In addition, surgeries with cumbersome preparation/process impeded the use of multiple analgesic modes, while senior anesthesiologists preferred multiple analgesic modes.

Pericapsular Nerve Group (PENG) Block versus Supra-Inguinal Fascia Iliaca Compartment Block for Total Hip Arthroplasty: A Randomized Clinical Trial

This study compared the effects of the pericapsular nerve group (PENG) block and supra-inguinal fascia iliaca compartment block (FICB) on postoperative analgesia and quadriceps strength following total hip arthroplasty under general anesthesia. A total of 58 patients were randomized to receive either PENG block (PENG group) or supra-inguinal FICB (FICB group) following anesthetic induction. The primary outcomes were the postoperative pain scores. Patients were randomized to receive either PENG block or supra-inguinal FICB following anesthetic induction. Pain scores at rest and with movement were assessed preoperatively, at the postanesthesia care unit (only at rest), and at 6, 24, 36, and 48 h postoperatively. Opioid consumption was also assessed for 48 h postoperatively. Quadriceps strength measurements were performed preoperatively, at 6, 24, and 36 h postoperatively. In total, 54 patients completed the study: 27 in the PENG group and 27 in the FICB group. Despite lower pain scores at rest in the PENG group at postoperative 6 and 24 h, there were no significant differences in the pain scores at rest and during movement between the two groups during postoperative 48 h in the linear mixed model analysis (p = 0.079 and p = 0.323, respectively). Cumulative opioid consumption up to postoperative 48 h was also similar in the two groups (p = 0.265). The changes in quadriceps strength measurements in the operative leg and the nonoperative leg were not significantly different between the groups (p = 0.513 and p = 0.523, respectively). The PENG block may have similar analgesic efficacy to the supra-inguinal FICB. No difference was detected in the quadriceps strength between the patients receiving these two blocks.

A systematic review and meta-analysis of efficacy of ultrasound-guided single-shot quadratus lumborum block for postoperative analgesia in adults following total hip arthroplasty

STUDY OBJECTIVE

To evaluate the efficacy of ultrasound-guided single-shot quadratus lumborum block (QLB) for postoperative analgesia in adults following total hip arthroplasty (THA).

DESIGN

Systematic review and meta-analysis.

SETTING

Perioperative period.

PATIENTS

Adult patients undergoing THA.

METHODS

Studies were identified by performing electronic searches in the following electronic databases, PubMed (Medline), Cochrane Central Registry of Trials (CENTRAL), and Google Scholar. We sought studies in adult patients undergoing THA, comparing QLB with a control group (no block, sham block or any other ultrasound guided regional nerve blocks). A total of 774 patients from 10 studies (7 randomized controlled, one controlled clinical and two retrospective study) were included in this meta-analysis.

MAIN RESULTS

The 24 hr opioid consumption was similar in both the groups [WMD -4.09; 95%CI (-9.00, 0.83); P = 0.10; I2 = 95%]. The pain scores at rest at 24 hr was significantly less in QLB group [WMD -0.62; 95% CI (-1.15, -0.10); P = 0.02; I2 = 75%].The difference in pain scores was not clinically significant. The pain scores on movement at 24 hours, time to first analgesic request and time to discharge from hospital were similar in both the groups.

CONCLUSIONS

QLB as part of multimodal analgesia did not result in any significant analgesic benefits in patients undergoing hip arthroplasty in terms of either postoperative opioid consumption or pain scores at rest and on movement. Overall, the level of certainty is low. Further, well-designed trials are required to verify the results.

PROSPERO REGISTRATION NO

CRD42021253425.