Multimodal therapy in perioperative analgesia

Peri-operative pain management in adults: a multidisciplinary consensus statement from the Association of Anaesthetists and the British Pain Society

BACKGROUND

Nearly half of adult patients undergoing surgery experience moderate or severe postoperative pain. Inadequate pain management hampers postoperative recovery and function and may be associated with adverse outcomes. This multidisciplinary consensus statement provides principles that might aid postoperative recovery, and which should be applied throughout the entire peri-operative pathway by healthcare professionals, institutions and patients.

METHODS

We conducted a directed literature review followed by a four-round modified Delphi process to formulate recommendations for organisations and individuals.

RESULTS

We make recommendations for the entire peri-operative period, covering pre-admission; admission; intra-operative; post-anaesthetic care unit; ward; intensive care unit; preparation for discharge; and post-discharge phases of care. We also provide generic principles of peri-operative pain management that clinicians should consider throughout the peri-operative pathway, including: assessing pain to facilitate function; use of multimodal analgesia, including regional anaesthesia; non-pharmacological strategies; safe use of opioids; and use of protocols and training for staff in caring for patients with postoperative pain.

CONCLUSIONS

We hope that with attention to these principles and their implementation, outcomes for adult patients having surgery might be improved.

Pudendal nerve block decreases narcotic requirements and time spent in post-anesthesia care units in patients undergoing primary inflatable penile prosthesis implantation

Efforts to minimize narcotic usage following inflatable penile prosthesis (IPP) implantation are vital, considering the current opioid epidemic in the United States. We aimed to determine whether pudendal nerve block (PNB) utilization in a multiethnic population undergoing primary IPP implantation can decrease rates of post-operative opiate usage. A single-institution, retrospective study was conducted on patients who underwent primary IPP implantation between December 2015 and June 2022. PNB usage and intra- and post-operative outcomes were analyzed using multivariate binary logistic regression. 449 patients were included, with 373 (83.1%) in the PNB group. Median time (minutes) spent in the post-anesthesia care unit (PACU) (1499 [119-198] vs. 235 [169-322], p < 0.001) was significantly lower in the PNB group. There were no significant differences in intra-operative and PACU morphine milligram equivalents or post-operative safety outcomes between groups. However, fewer patients in the PNB group called for pain medications post-operatively (10.2% vs 19.7%, p = 0.019). Multivariate analysis revealed a significantly decreased operative time (B -6.23; 95%CI -11.28, -1.17; p = 0.016) and decreased time in recovery (B: -81.62; 95%CI: -106.49, -56.76, p < 0.001) in the PNB group. PNB decreases post-operative opioid analgesic requirements and time spent in PACU in patients undergoing a primary IPP implantation and thus may represent an attractive, non-opioid adjunct.

The New Orientation of Postoperative Analgesia: Remote Ischemic Preconditioning

Purpose of Review

Postoperative analgesia is currently a significant topic in anesthesiology. Currently, the predominant approach for achieving multimodal analgesia involves the utilization of pharmacotherapy and regional anesthesia procedures. The primary objectives of this approach are to mitigate postoperative pain, enhance patient satisfaction, and diminish overall opioid usage. Nevertheless, there is a scarcity of research on the use of remote ischemia preconditioning aimed at mitigating postoperative pain.

Recent Findings

Transient stoppage of blood flow to an organ has been found to elicit remote ischemia preconditioning (RIPC), which serves as a potent intrinsic mechanism for protecting numerous organs. In addition to its established role in protecting against reperfusion injury, RIPC has recently been identified as having potential benefits in the context of postoperative analgesia.

Summary

In addition to traditional perioperative analgesia, RIPC provides perioperative analgesia and organ protection.

Investigation of Cox-2 inhibition of Laportea decumana (Roxb). Wedd extract to support its analgesic potential

ETHNOPHARMACOLOGICAL RELEVANCE

Itchy leaves Laportea decumana (Roxb). Wedd is an indigenous plant in Maluku, Indonesia, and is used traditionally to treat complaints such as fatigue and joint and muscle pains.

AIM OF THE STUDY

To provide scientific proof of the analgesic effect of L. decumana ethanolic extract tested in in vivo assays while investigating its bioactive phytochemicals using liquid chromatography tandem high-resolution mass spectrometry (LC-HRMS) profiling and Cox-2 inhibition assay.

MATERIALS AND METHODS

To investigate the analgesic activity of the ethanolic extract, assays were conducted on male mice Balb/c strain by chemical induction using acetic acid (i.p.) and heat induction (hotplate). Mice were divided into six groups consisting of six mice, i.e., the baseline group; positive control group (paracetamol 80 mg/kg BW); groups treated with extracts in dosages of 100, 200, and 400 mg/kg bodyweight (BW); and negative control group (acetic acid 0.6%, i. p.). The crude extract was partitioned with liquid-liquid fractionation to yield hexane, ethyl acetate, and water fractions. The extract and fraction were assayed for Cox-2 enzyme inhibition, and the chemical profiles were analyzed using untargeted LC-HRMS.

RESULTS

The analgesic assays revealed the dose-dependent effect of the extracts, of the effect of treatment with 400 mg/kg BW was not significantly different with that of paracetamol (p < 0.05). The ethyl acetate fraction showed IC50 of 19.25 μg/mL on Cox-2 inhibition (IC50 celexocib 18.48 μg/mL). LC-HRMS showed a distinctive profile of the ethyl acetate fraction compared with those in the extract and other fractions.

CONCLUSIONS

This study presents scientific evidence of the analgesic activity of the L. decumana ethanol extract given orally to experimental animals. Inflammatory inhibition plays a role in the overall analgesic mechanism by Cox-2 inhibition of the extract and all fractions. This finding is also supported by the phytochemical profiles of the extract and fractions, showing the presence of compounds reported elsewhere as anti-inflammatory activity.

How to Modulate Peripheral and Central Nervous System to Treat Acute Postoperative Pain and Prevent Pain Persistence

Chronic postoperative pain (CPSP) is a major issue after surgery, which may impact on patient's quality of life. Traditionally, CPSP is believed to rely on maladaptive hyperalgesia and risk factors have been identified that predispose to CPSP, including acute postoperative pain. Despite new models of prediction are emerging, acute pain is still a modifiable factor that can be challenged with perioperative analgesic strategies. In this review we present the issue of CPSP, focusing on molecular mechanism underlying the development of acute and chronic hyperalgesia. Also, we focus on how perioperative strategies can impact directly or indirectly (by reducing postoperative pain intensity) on the development of CPSP.

Improving the management of morbidly obese patients with postoperative bleeding undergoing Roux-en-Y gastric bypass

OBJECTIVE

Aim: To improve the management of morbidly obese patients who undergo gastric bypass surgery to reduce the number of postoperative complications, in particular, bleeding.

PATIENTS AND METHODS

Materials and Methods: From 2011 to 2022, a total of 348 patients with morbid obesity (MO) underwent laparoscopic gastric bypass treatment at the clinical base of the Department of General Surgery №2 of Bogomolets National Medical University. The retrospective group included 178 patients who received treatment between 2011 and 2019. 170 patients were enrolled in the prospective group for the period from 2019 to 2022.

RESULTS

Results: Retrospective group had 8 episodes of postoperative bleeding, representing a rate of 4.49%, prospective group - 3 episodes of postoperative bleeding, representing a rate of 1.76% Four factor characteristics associated with the probability of bleeding were identified: "number of comorbid conditions", "arterial hypertension", "chronic liver diseases" and "chronic obstructive pulmonary disease".

CONCLUSION

Conclusions: The factors responsible for the occurrence of postoperative bleeding in morbidly obese patients after laparoscopic gastric bypass surgery were the number of comorbid conditions, the presence of arterial hypertension, the presence of chronic liver diseases, and chronic obstructive pulmonary disease. A new strategy for the management of morbidly obese patients after laparoscopic gastric bypass was developed. This strategy involves changing cassettes to create gastroentero- and enteroenteroanastomoses, reducing the period of use of the nasogastric tube, drains, and urinary catheter from 3-4 days to 1 day, and resuming the drinking regimen 6 hours after extubation.

Perioperative Lidocaine Infusion Reduces Opioid Use in Enhanced Recovery After Surgery Patients Undergoing Laparoscopic Colectomy

BACKGROUND

Enhanced Recovery After Surgery (ERAS) programs have become a mainstay of modern surgical care, and efforts to decrease postoperative opioid consumption have been increasingly employed. A previous study from our institution demonstrated that ERAS protocols decreased opioid use in the first 48 hours after surgery by 61%. In the present study, a lidocaine infusion was added for postoperative pain control. The aim was to analyze the differences in opioid requirements with and without this infusion in the first 48 hours after laparoscopic colectomy in ERAS patients.

METHODS

Retrospective review of patients was conducted at an academically affiliated tertiary care hospital. The population included patients undergoing elective laparoscopic colon surgery enrolled in the ERAS program with the implementation of a lidocaine drip from June 2019 to October 2019, and compared to a previous patient cohort of ERAS patients evaluated without the lidocaine drip from September 2015 to May 2018.

RESULTS

The primary endpoint was postoperative opioid use in the first 48 hours based on IV morphine milligram equivalents (MME). Secondary measures included type of surgery, age, BMI, prior abdominal surgery, and prior opioid use. Median MMEs were 6.0 in the lidocaine infusion group and 12.5 in the group without lidocaine, representing a 52% reduction (p < 0.001).

DISCUSSION

This study demonstrates a significant reduction in post-op opioid use in ERAS patients who receive a lidocaine infusion after laparoscopic colectomy. Further studies should focus on measures to limit the treatment side effects in order to maximize the opioid-sparing benefits of this intervention.

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.

Effect of Infraorbital and/or Infratrochlear Nerve Blocks on Postoperative Care in Patients with Septorhinoplasty: A Meta-Analysis

Background and Objectives: Through a comprehensive meta-analysis of the pertinent literature, this study evaluated the utility and efficacy of perioperative infraorbital and/or infratrochlear nerve blocks in reducing postoperative pain and related morbidities in patients undergoing septorhinoplasty. Materials and Methods: We reviewed studies retrieved from the PubMed, SCOPUS, Embase, Web of Science, and Cochrane databases up to August 2023. The analysis included a selection of seven articles that compared a treatment group receiving perioperative infraorbital and/or infratrochlear nerve blocks with a control group that either received a placebo or no treatment. The evaluated outcomes covered parameters such as postoperative pain, the amount and frequency of analgesic medication administration, the incidence of postoperative nausea and vomiting, as well as the manifestation of emergence agitation. Results: The treatment group displayed a significant reduction in postoperative pain (mean difference = -1.7236 [-2.6825; -0.7646], I2 = 98.8%), as well as a significant decrease in both the amount (standardized mean difference = -2.4629 [-3.8042; -1.1216], I2 = 93.0%) and frequency (odds ratio = 0.3584 [0.1383; 0.9287], I2 = 59.7%) of analgesic medication use compared to the control. The incidence of emergence agitation (odds ratio = 0.2040 [0.0907; 0.4590], I2 = 0.0%) was notably lower in the treatment group. The incidence of postoperative nausea and vomiting (odds ratio = 0.5393 [0.1309; 2.2218], I2 = 60.4%) showed a trend towards reduction, although it was not statistically significant. While no adverse effects reaching statistical significance were reported in the analyzed studies, hematoma (proportional rate = 0.2133 [0.0905; 0.4250], I2 = 76.9%) and edema (proportional rate = 0.1935 [0.1048; 0.3296], I2 = 57.2%) after blocks appeared at rates of approximately 20%. Conclusions: Infraorbital and/or infratrochlear nerve blocks for septorhinoplasty effectively reduce postoperative pain and emergence agitation without notable adverse outcomes.

Blended (Combined Spinal and General) vs. General Anesthesia for Abdominal Hysterectomy: A Retrospective Study

BACKGROUND

Adequate pain management for abdominal hysterectomy is a key factor to decrease postoperative morbidity, hospital length of stay and chronic pain. General anesthesia is still the most widely used technique for abdominal hysterectomy. The aim of this study was to assess the efficacy and safety of blended anesthesia (spinal and general anesthesia) compared to balanced general anesthesia in patients undergoing hysterectomy with or without lymphadenectomy for ovarian, endometrial or cervical cancer or for fibromatosis.

METHODS

We retrospectively collected data from adult ASA 1 to 3 patients scheduled for laparoscopic or mini-laparotomic hysterectomy with or without lymphadenectomy for ovarian, endometrial or cervical cancer or for fibromatosis. Exclusion criteria were age below 18 years, ASA > 3, previous chronic use of analgesics, psychiatric disorders, laparotomic surgery with an incision above the belly button and surgery extended to the upper abdomen for the presence of cancer localizations (e.g., liver, spleen or diaphragm surgery). The cohort of patients was retrospectively divided into three groups according to the anesthetic management: general anesthesia and spinal with morphine and local anesthetic (Group 1), general anesthesia and spinal with morphine (Group 2) and general anesthesia without spinal (Group 3).

RESULTS

NRS was lower in the spinal anesthesia groups (Groups 1 and 2) than in the general anesthesia group (Group 3) for every time point but at 48 h. The addition of local anesthetics conferred a small but significant NRS decrease (p = 0.009). A higher percentage of patients in Group 3 received intraoperative sufentanil (52.2 ± 18 mcg in Group 3 vs. Group 1 31.8 ± 16.2 mcg, Group 2 44.1 ± 15.6, p < 0.001) and additional techniques for postoperative pain control (11.4% in Group 3 vs. 2.1% in Group 1 and 0.8% in Group 2, p < 0.001). Intraoperative hypotension (MAP < 65 mmHg) lasting more than 5 min was more frequent in patients receiving spinal anesthesia, especially with local anesthetics (Group 1 25.8%, Group 2 14.6%, Group 3 11.6%, p < 0.001), with the resulting increased need for vasopressors. Recovery-room discharge criteria were met earlier in the spinal anesthesia groups than in the general anesthesia group (Group 1 102 ± 44 min, Group 2 91.9 ± 46.5 min, Group 3 126 ± 90.7 min, p < 0.05). No differences were noted in postoperative mobilization or duration of ileus.

CONCLUSIONS

Intrathecal administration of morphine with or without local anesthetic as a component of blended anesthesia is effective in improving postoperative pain control following laparoscopic or mini-laparotomic hysterectomy, in reducing intraoperative opioid consumption, in decreasing postoperative rescue analgesics consumption and the need for any additional analgesic technique. We recommend managing postoperative pain with a strategy tailored to the patient's physical status and the type of surgery, preventing and treating side effects of pain treatments.

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.

Effects of Multimodal Analgesia on Recovery From Percutaneous Spinal Cord Stimulator Implantation

OBJECTIVE

We aimed to determine the relationship between number and type of analgesic modalities utilized and postoperative pain after percutaneous spinal cord stimulator implantation. Secondary measures include opioid requirements, discharge times, and effects of specific modalities.

MATERIALS AND METHODS

This single-center retrospective cohort at Brooke Army Medical Center from April 2008 through July 2017 reviewed 70 patients undergoing stimulator implantation by a pain specialist. Data included: home opioid regimen; preoperative/postoperative medications and pain; intraoperative medications; and discharge times. Analysis utilized a Wilcoxon nonparametric mode, and chi-square testing for specific modalities. We compared outcomes based on the number of modalities administered and whether patients received specific medications.

RESULTS

Patients averaged receiving 3.8 modalities (standard deviation 1.4). Patients receiving ≥5 modalities had increased pain from preoperative to postoperative scores by two points, while those who received ≤4 had no increase (p < 0.01). Patients receiving ketamine had a median three point increase in pain scores from their baseline vs no change for others (p < 0.05). Patients receiving four modalities had shorter phase one recovery times vs ≤ 2 (median 66 vs 91.5 min; p = 0.01). Patients receiving ≥4 modalities had shorter times vs ≤3 (median 74 vs 88.5 min; p < 0.01). Patients receiving NSAIDs had shorter times than others (median 78 vs 87 min; p < 0.05).

CONCLUSIONS

Ketamine administration and use of ≥5 analgesic modalities were associated with more postoperative pain for unclear reasons. Patients receiving NSAIDs or ≥4 analgesic modalities had shorter recovery times. These data may lead to further work that could optimize ambulatory practices for stimulator implantation. More work is warranted on this subject.

Anesthesia and analgesia for experimental craniotomy in mice and rats: a systematic scoping review comparing the years 2009 and 2019

Experimental craniotomies are a common surgical procedure in neuroscience. Because inadequate analgesia appears to be a problem in animal-based research, we conducted this review and collected information on management of craniotomy-associated pain in laboratory mice and rats. A comprehensive search and screening resulted in the identification of 2235 studies, published in 2009 and 2019, describing craniotomy in mice and/or rats. While key features were extracted from all studies, detailed information was extracted from a random subset of 100 studies/year. Reporting of perioperative analgesia increased from 2009 to 2019. However, the majority of studies from both years did not report pharmacologic pain management. Moreover, reporting of multimodal treatments remained at a low level, and monotherapeutic approaches were more common. Among drug groups, reporting of pre- and postoperative administration of non-steroidal anti-inflammatory drugs, opioids, and local anesthetics in 2019 exceeded that of 2009. In summary, these results suggest that inadequate analgesia and oligoanalgesia are persistent issues associated with experimental intracranial surgery. This underscores the need for intensified training of those working with laboratory rodents subjected to craniotomies.

Systematic review registration

https://osf.io/7d4qe.

Postoperative Pain Management and Perceived Patient Outcomes following Endoscopic Pituitary Surgery

Objectives  Pain management remains a point of emphasis given the ongoing opioid crisis. There are no studies in the literature interrogating opioid prescribing and use following endoscopic pituitary surgery. This study investigates provider prescribing tendency, patient utilization of analgesics, and patient outcomes regarding pain management after endoscopic pituitary surgery. Methods  We identified 100 patients undergoing endoscopic pituitary surgery at one institution from 2016 to 2018 in the electronic medical record (EMR) and state narcotic database to determine postoperative analgesic regimens. A telephone survey was used to characterize postoperative analgesic use and satisfaction with prescribed regimen. Results  Fifty-two different pain control regimens were prescribed to the study patients. Also, 93% of study patients were prescribed an opioid postoperatively. The average quantity of opioids prescribed per patient in morphine milligram equivalents (MMEs) was 625 (equivalent 83 oxycodone 5-mg tablets) with an average MME/day of 59 (equivalent 8 oxycodone 5-mg tablets). A total of 71% survey respondents who used opioids reported using <25% of their prescription. The majority of prescription narcotic users consumed >50% of their postoperative opioid intake in the first 24 to 48 hours after discharge. There were no significant differences in pain outcome between opioid users and nonopioid users. Conclusion  Vast heterogeneity exists in narcotic prescribing by providers at our institution following endoscopic pituitary surgery. Narcotic prescribing patterns exceeded most patients' analgesic needs. Opioid analgesics were not superior to nonopioids regimens in patient-reported pain outcomes in this study population.

Overprescription of opioid analgesia is common following ambulatory Otolaryngology-Head and Neck surgery procedures: A multicenter study

Background

The rise in the use of prescription opioids for postoperative analgesia within surgery has mirrored an increased trend of opioid-related morbidity within Canada and the United States. This study prospectively studied daily pain levels and medication requirements postoperatively in patients undergoing elective Otolaryngology-Head and Neck surgery procedures.

Methods

Patients were asked to prospectively document their pain level and medication use daily for 7 days postoperatively. A final survey was used to quantify unused medication left at home and clarify each patient's disposal plan. We included patients undergoing elective outpatient or short stay surgeries from three tertiary care centers in Toronto, Ontario from September 2016 to September 2017. Previous opioids users or patients suffering from chronic pain were excluded.

Results

A final cohort of 56 eligible adult patients were included in the study. The most common procedures were thyroidectomy (n = 19), endoscopic sinus surgery (n = 10), tympanoplasty/ossiculoplasty (n = 7), and cochlear implant (n = 5). Most patients received a prescription for acetaminophen/codeine (n = 29, 51.8%) or acetaminophen/oxycodone (n = 22, 39.3%) and used on average 29% of their initial prescription. Patients most commonly opted to keep their unused narcotics at home (n = 23, 41%). A total of 710 tablets of narcotics were overprescribed in our study population, 351 of which were kept in patients' home for future use.

Conclusion

There is a clear tendency to overestimate postoperative pain resulting in significant overprescription of opioids among Otolaryngologists.

Avoid Postoperative Pain To Prevent Its Chronification: A Narrative Review

Acute postoperative pain is a normal and expected part of the patient’s postsurgical trajectory, and its intensity, severity, and duration vary with surgery-related and patient factors. In a subset of patients, postoperative pain does not resolve as the tissue heals but instead transitions to chronic postoperative pain, a challenging condition to treat and one associated with decreased quality of life, sleep and mood disorders, and neuropathy. Promptly and adequately treating acute postoperative pain can reduce the risk that it will transition into chronic postoperative pain. Numerous agents are available that may help treat postoperative pain, including nonsteroidal anti-inflammatory drugs, opioids, antidepressants, anticonvulsants, and others. In this connection, it is also important to consider patient factors, such as mental health status and comorbidities, as well as the type and duration of surgery. A multimodal approach is recommended, which uses two or more agents with complementary mechanisms of action, working at different targets. Multimodal analgesia may also reduce adverse events and lessen opioid consumption after surgery. A particularly useful fixed-dose combination product is dexketoprofen/tramadol (DEX-TRA), which is safe and effective in numerous clinical trials. This review is based on a presentation from the Roma Pain Days scientific sessions of 2021.

Implementation and outcomes of enhanced recovery protocols in pediatric surgery: a systematic review and meta-analysis

BACKGROUND

This systematic review examines the feasibility and safety of implementing Enhanced recovery after Surgery (ERAS) protocols in children.

STUDY DESIGN

A systematic search of Medline, PubMed, and the Cochrane library for papers describing ERAS implementation in children between January 2000 and January 2021. The systematic review was performed according to the PRISMA statement. The meta-analysis was done using R Software (Ver 4.0.2). p value of < 0.05 was considered statistically significant.

RESULTS

Sixteen studies, describing a total of 1723 patients, were included in the meta-analysis. An average of 15 (range 11-16) relevant components were implemented with an overall compliance close to 84%. The time to initiate feeds and reach full enteral nutrition was reduced in ERAS group with mean difference (MD) of - 21.20 h (95% CI - 22.80, - 19.59, p < 0.01), and - 2.20 days (95% CI - 2.72, - 1.71, p < 0.01), respectively. The use of opioids for postoperative analgesia was reduced with MD of -0.86 morphine equivalents mg/kg (95% CI - 1.40, - 0.32, p < 0.01). The length of hospital stay showed a significant reduction with MD of -2.54 days (95% CI - 2.94, - 2.13, p < 0.01). There was no difference in the complication and readmission rates between the groups.

CONCLUSION

ERP implementation in pediatric perioperative care is a viable option in a variety of surgical settings. There is clear evidence of a decrease in hospital stay duration with no increase in complication or readmission rates. The length of hospital stay reduced in inverse proportion to the number of ERAS elements implemented. Parental satisfaction is increased by initiating enteral feeding early, minimizing catheter and drain use, and reducing opioid use.

Is ABO Blood Group a Predictive Factor for the Amount of Opioid Consumption in the First 24 Hours After Cesarean Section?

Background

Cesarean section is the most common major surgery performed globally. Blood group O has been found as a factor affecting pain severity after cesarean section. We aimed to evaluate the predictive factors, including ABO blood group, for the amount of opioid consumption (measured as milligrams of morphine equivalent [MME]) within the first 24 hrs after cesarean section.

Methods

This retrospective study was done in 1530 pregnant women who had a cesarean section under the same regimen of spinal anesthesia (2.2 mL of 0.5% hyperbaric bupivacaine and morphine 0.2 mg). All were prescribed regular paracetamol and ibuprofen for postoperative pain control. Univariate and multinomial regression analyses were performed to identify the predictive factors for opioid consumption in the first 24 hrs postoperatively.

Results

About 2/5 of them (43.3%) received 0 mg MME, while 25.6%, 23.7% and 7.4% received 1–5, 6–10 and >10 mg MME, respectively. The majority have blood group O (40.6%), while 23.4%, 28% and 8% have blood group A, B and AB, respectively. After univariate and multinomial regression analyses, operation time, opioid consumption in PACU, maximum VNRS within the first 24 hrs and consumption of both paracetamol and ibuprofen were identified as predictive factors for postoperative opioid consumption. ABO blood group exhibited no correlation for opioid requirement postoperatively.

Conclusion

ABO blood group is not a predictive factor for opioid requirement within the first 24 hrs following cesarean section. Duration of operation, opioid given in PACU, maximum VNRS on ward and consumption of both paracetamol and ibuprofen have been found to be predictive factors for postcesarean opioid requirement.

A Narrative Review on Perioperative Pain Management Strategies in Enhanced Recovery Pathways-The Past, Present and Future

Effective pain management is a key component in the continuum of perioperative care to ensure optimal outcomes for surgical patients. The overutilization of opioids in the past few decades for postoperative pain control has been a major contributor to the current opioid epidemic. Multimodal analgesia (MMA) and enhanced recovery after surgery (ERAS) pathways have been repeatedly shown to significantly improve postoperative outcomes such as pain, function and satisfaction. The current review aims to examine the history of perioperative MMA strategies in ERAS and provide an update with recent evidence. Furthermore, this review details recent advancements in personalized pain medicine. We speculate that the next important step for improving perioperative pain management could be through incorporating these personalized metrics, such as clinical pharmacogenomic testing and patient-reported outcome measurements, into ERAS program.

Comparison between intravenous and intratecal clonidine for postoperative analgesia of patients submitted to laparoscopic cholecystectomy: randomized clinical trial

Introduction and objectives

Alpha2 adrenergic agonists, such as clonidine, are used as adjuvants during anesthesia due to their analgesic, sedative, and cardiovascular effects. The objective of the present study was to compare the effect of clonidine administered intravenously and intrathecally on the postoperative pain score of patients undergoing laparoscopic cholecystectomy, according to the route of administration and postoperative opioid consumption.

Methods

This randomized clinical trial, blind to patients and evaluator, assessed 60 patients, candidates for elective laparoscopic cholecystectomy under standardized general anesthesia techniques. Patients were randomly allocated into three groups (20 in each group): Control Group (CG), Intrathecal Clonidine Group (ITCG), and Intravenous Clonidine Group (IVCG). The primary outcome was the comparison of pain, Blood Pressure (BP) and Heart Rate (HR) scores among groups. The secondary outcome was report of adverse effects such as bradycardia, hypotension and sedation, and the need for rescue medication.

Results

The mean age was 37.2 ± 8.2 years, and the mean body mass was 28.3 ± 3.6 kg.m^-2. Regarding HR (p = 0.003) and pain (p = 0.027), patients in ITCG and CG showed a different profile over time, with CG showing higher consumption of morphine as rescue medication (p = 0.005).

Conclusion

The administration of intrathecal and intravenous clonidine in low doses can reduce hemodynamic parameters and decrease postoperative requirement of analgesics. Further studies should investigate the ideal dose and method.

Enhanced recovery strategies after penile implantation: a narrative review

Optimizing pain management strategies in penile implantation has historically been a challenge to urologists assuming care of patients post-operatively. In addition to the complex pathophysiology of male genital pain, the responsibility of opioid stewardship in the face of the ongoing narcotics epidemic presents its own set of challenges to experienced implanters. Recent innovations in pre- and intra-operative analgesia have provided some improvement in patient-reported pain outcomes. When used together in protocols spanning each phase of operative care, multimodal analgesia (MMA) regimens provide superior patient pain control and successfully decrease opioid usage compared to traditional opioid-based pain control. This review will systematically present literature that discusses interventions in the preoperative and intraoperative spaces aimed at optimally controlling pain. We will also highlight surgical techniques that have been demonstrated to help ameliorate post-operative pain in penile implant recipients. We will discuss the impact of MMA protocols across urology and further explore its larger impact on reducing opioid burden in the ongoing epidemic.

Postoperative Pain Treatment With Continuous Local Anesthetic Wound Infusion in Patients With Head and Neck Cancer: A Nonrandomized Clinical Trial

Importance

Up to 80% of patients with head and neck cancer undergoing ablative surgery and neck dissection develop postoperative pain with detrimental effects on quality of life that also contributes to neuropathic and chronic postoperative pain.

Objective

To investigate the association of continuous local anesthetic wound infusion with pain management after head and neck surgery.

Design, Setting, and Participants

This prospective, longitudinal, nonrandomized clinical study carried out in a single tertiary referral center (December 1, 2015, to July 1, 2017) included 2 groups of 30 patients. Patients were consecutively enrolled and presented for ablative head and neck surgery including selective neck dissection and studied from the preoperative through the fourth postoperative day.

Interventions

The control group was treated according to a standardized escalating oral treatment protocol (ibuprofen, metamizole, opioids). The intervention group was treated with an intraoperatively applied pain catheter (InfiltraLong plus FuserPump, Pajunk, ropivacaine, 0.2%, 3 mL/h) that was removed 72 hours after operating.

Main Outcomes and Measures

Average and maximum pain intensities on a numeric rating scale; quality of life using the acute version of the validated 36-Item Short Form Survey; and neuropathic pain using the validated 12-Item painDETECT questionnaire. Consumption of opioid and nonopioid analgesics and evaluation of catheter-associated complications.

Results

During postoperative days 1 through 4, patients of the intervention group (mean [SD] age, 63.2 [13.3 years; 9 [30%] women) experienced lower mean (SD) (1.6 [1.4] vs 2.7 [1.8]; η2p = 0.09 [0.01-0.21]) and maximum (2.4 [2.2] vs 4.2 [2.0]; η2p = 0.11 [0.01-0.24]) pain intensities compared with the control group (mean [SD] age, 62.5 [13.6] years; 5 [17%] women). The intervention group also reported less neuropathic pain (mean [SD], 5.4 [3.4] vs 7.6 [5.1]; η2p = 0.09 [0.004 - 0.22]) and higher quality of life regarding vitality (56.2 [21.5] vs 43.8 [20.9], r = 0.29; 95% CI, 0.01-0.52) and pain (66.8 [27.3] vs 49.5  [27.7], r = 0.31; 95% CI, 0.04-0.54). Patients from the intervention group requested nonopioid analgesics considerably less often (n = 17 [57% ]vs n = 29 [97%]; ϕ = 0.47; 95% CI, 0.30-0.67) associated with a noticeably lower need to escalate pain treatment (n = 3 [10%] vs n = 9 [30%]; mean [SD] ibuprofen dose: 500 [173] mg vs 1133 [650] mg; r = 0.64; 95% CI, 0.02-0.91). No catheter-associated complications were observed.

Conclusions and Relevance

Continuous anesthetic wound infusion is associated with reduced postoperative pain and decreased demand for analgesics. It therefore expands the treatment options for postoperative pain in head and neck cancer.

Trial Registration

German Clinical Trials Register: DRKS00009378.

Do NSAIDs Really Interfere with Healing after Surgery?

Perioperative analgesia should be multimodal to improve pain relief, reduce opioid use and thereby adverse effects impairing recovery. Non-steroidal anti-inflammatory drugs (NSAIDs) are an important non-opioid component of this approach. However, besides potential other adverse effects, there has been a longstanding discussion on the potentially harmful effects of NSAIDs on healing after surgery and trauma. This review describes current knowledge of the effects of NSAIDs on healing of bones, cartilage, soft tissue, wounds, flaps and enteral anastomoses. Overall, animal data suggest some potentially harmful effects, but are contradictory in most areas studied. Human data are limited and of poor quality; in particular, there are only very few good randomized controlled trials (RCTs), but many cohort studies with potential for significant confounding factors influencing the results. The limited human data available are not precluding the use of NSAIDs postoperatively, in particular, short-term for less than 2 weeks. However, well-designed and large RCTs are required to permit definitive answers.

Challenges and opportunities of pharmaceutical cocrystals: a focused review on non-steroidal anti-inflammatory drugs

The focus of the review is to discuss the relevant and essential aspects of pharmaceutical cocrystals in both academia and industry with an emphasis on non-steroidal anti-inflammatory drugs (NSAIDs). Although cocrystals have been prepared for a plethora of drugs, NSAID cocrystals are focused due to their humongous application in different fields of medication such as antipyretic, anti-inflammatory, analgesic, antiplatelet, antitumor, and anti-carcinogenic drugs. The highlights of the review are (a) background of cocrystals and other solid forms of an active pharmaceutical ingredient (API) based on the principles of crystal engineering, (b) why cocrystals are an excellent opportunity in the pharma industry, (c) common methods of preparation of cocrystals from the lab scale to bulk quantity, (d) some latest case studies of NSAIDs which have shown better physicochemical properties for example; mechanical properties (tabletability), hydration, solubility, bioavailability, and permeability, and (e) latest guidelines of the US FDA and EMA opening new opportunities and challenges.

Dexmedetomidine combined with sufentanil and dezocine-based patient-controlled intravenous analgesia increases female patients' global satisfaction degree after thoracoscopic surgery

Background

There are no studies on the use of dexmedetomidine combined with sufentanil and dezocine-based patient-controlled intravenous analgesia (PCIA) in females undergoing thoracic surgery. We postulate that introducing dexmedetomidine to a combination of dezocine-based PCA drugs and sufentanil will increase female patients’ global satisfaction degree.

Methods

One hundred fifty-two female patients with physical classification type I or II according to the American Society of Anesthesiologists undergoing thoracoscopic surgery were arbitrarily classified into two categories, either receiving sufentanil and dezocine-based PCIA (group C) or incorporating dexmedetomidine with sufentanil and dezocine-based PCIA (group D). The patients’ global satisfaction degree, postoperative nausea and vomiting (PONV), PCA bolus, rescue analgesia requirements, drug-related adverse effects, rest and coughing visual analogue scale (VAS) ratings, and Ramsay sedation scores (RSS) were measured at 6, 12, 24, 36 and 48 h after surgery.

Results

Compared with the C group, the patient satisfaction degree was significantly higher; pain scores at rest and coughing were significantly different at 6, 12, 24, 36 and 48 h postoperatively; less rescue analgesia and PCA bolus were required; and a lower incidence of PONV was found in the D group. There were non-significant trends for the sedation scores and drug-related adverse effects in both groups.

Conclusions

Dexmedetomidine combined with sufentanil and dezocine increased female patients’ global satisfaction degree after thoracoscopic surgery. This effect could be linked to the improvement in postoperative analgesia and reduction in postoperative nausea and vomiting; the combined treatment did not increase drug-related adverse effects in female patients.

Trial registration

Chinese Clinical Trial Registry number, ChiCTR2000030429. Registered on March 1, 2020.

Drivers of in-hospital opioid consumption in patients undergoing lumbar fusion surgery

Background

With the current opioid crisis, as many as 38% of patients are still on opioids one year after elective spine surgery. Identifying drivers of in-hospital opioid consumption may decrease subsequent opioid dependence. We aimed to identify the drivers of in-hospital opioid consumption in patients undergoing 1-2-level instrumented lumbar fusions.

Methods

This is a retrospective cohort study. Electronic medical record analysts identified consecutive patients undergoing 1-2 level instrumented lumbar fusions for degenerative lumbar conditions from 2016 to 2018 from a single-center hospital administrative database. Oral, intravenous, and transdermal opioid dose administrations were converted to morphine milligram equivalents (MME). Linear regression analysis was used to determine associations between postoperative day (POD) 4 cumulative in-hospital MMEs and the patients' baseline characteristics including body mass index (BMI), race, American Society of Anesthesiologists (ASA) grade, smoking status, marital status, insurance type, zip code, number of fused levels, approach and preoperative opioid use.

Results

A total of 1,502 patients were included. The mean cumulative MMEs at POD 4 was 251.5. Linear regression analysis yielded four drivers including younger age, preoperative opioid use, current smokers and more levels fused. There were no associations with surgical approach, zip code, ASA grade, marital status, BMI, race or insurance type.

Conclusions

Use of preoperative opioids and smoking are modifiable risk factors for higher in-hospital opioid consumption and can be targets for intervention prior to surgery in order to decrease in-hospital opioid use.

Effective Reduction in Opioid Prescriptions for Ambulatory Lesion Excisions in Pediatric Patients

Childhood opioid consumption is potentially deleterious to cognitive development and may predispose children to later addiction. Opioids are frequently prescribed for outpatient surgery but may not be necessary for adequate pain control. We aimed to reduce opioid prescriptions for outpatient pediatric skin and soft tissue lesion excisions using quality improvement (QI) methods.

METHODS

A multidisciplinary team identified drivers for opioid prescriptions. Interventions were provider education, improving computer order set defaults, and promoting non-narcotic pain control strategies and patient-family education. Outcomes included percentage of patients receiving opioid prescriptions and patient-satisfaction scores. Data were retrospectively collected for 3 years before the QI project and prospectively tracked over the 8-month QI period and the following 18 months.

RESULTS

The percentage of patients receiving an opioid prescription after outpatient skin or soft tissue excision dropped significantly from 18% before intervention to 6% at the end of the intervention period. Patient-reported satisfaction with pain control improved following the QI intervention. Satisfaction with postoperative pain control was independent of closure size or receipt of a postoperative opioid prescription. Intraoperative use of lidocaine or bupivacaine significantly decreased the incidence of postoperative opioid prescription in both bivariate and multivariate analyses. Results were maintained at 18 months after the conclusion of the QI project.

CONCLUSION

Raising provider awareness, educating patients on expected postoperative pain management options, and prioritizing non-narcotic medications postoperatively successfully reduced opioid prescription rates in children undergoing skin and soft tissue lesion excisions and simultaneously improved patient-satisfaction scores.

Interaction Between Low-Dose Aspirin and Nonsteroidal Anti-Inflammatory Drugs Can Compromise Aspirin's Efficacy in Preventing Venous Thrombosis Following Total Joint Arthroplasty

Total joint arthroplasty is a rapid recovery procedure with patients optimized quickly in preparation for discharge. Two significant postoperative goals are effective pain management and prevention of postoperative venous thromboembolism (VTE). Low-risk patients receive aspirin 81 mg twice daily for VTE prophylaxis; this dosing regimen has been reduced over the past few years from 325 mg to 162 mg to 81 mg twice daily. Unless contraindications exist, all patients receive multimodal pain management that includes the use of celecoxib or meloxicam. Upon reduction of the aspirin dose to 81 mg twice daily, we rapidly identified 2 patients who developed a pulmonary embolus when celecoxib or meloxicam was administered concurrently with aspirin. The interaction between nonsteroidal anti-inflammatory drugs (NSAIDs) and low-dose aspirin varies among the different NSAIDs. It is also highly dependent on numerous factors, including time of administration, dose of aspirin, and both pharmacodynamics and dose of the NSAID. Real-world outcomes of concomitant administration of NSAIDs with low-dose aspirin led to increased incidence of VTE, possibly due to competitive inhibition of aspirin at platelet receptor sites. This interaction was mitigated by altering the administration times of both agents.

Multi-modal pain control regimen for anterior lumbar fusion drastically reduces in-hospital opioid consumption

Background

The opioid epidemic is at epic proportions currently in the United States. Exposure to opioids for surgery and subsequent postoperative pain management is a known risk factor for opioid dependence. In addition, opioids can have a negative impact on multiple aspects including clinical outcomes, length of hospital stay, and overall cost of care. Thus, the greatest effort to reduce perioperative opioid use is necessary and a multimodal pain control (MMPC) has been gaining popularity. However, its efficacy in spine surgery is not well known. We aimed to evaluate the efficacy of a MMPC protocol in patients undergoing lumbar single-level anterior lumbar interbody fusion (ALIF).

Methods

This is a retrospective comparative study. From a prospective, single-surgeon, surgical database, consecutive patients undergoing single-level ALIF with or without subsequent posterior fusion for degenerative lumbar conditions were identified before and after initiation of the MMPC protocol. The MMPC protocol consisted of a preoperative oral regimen of cyclobenzaprine (10 mg), gabapentin (600 mg), acetaminophen (1 g), and methadone (10 mg). Postoperatively they received a bilateral transverse abdominis plane block with 0.5% Ropivacaine prior to extubation. We compared in-hospital opioid consumption between the MMPC and non-MMPC cohorts as well as baseline demographic, the length of hospital stay, cost, and rate of postoperative ileus. Opioid consumption was calculated and normalized to the morphine milligram equivalents (MMEs).

Results

In total, 68 patients in the MMPC cohort and 39 in the non-MMPC cohort were identified. There was no difference in baseline demographics including sex, body mass index, smoking status, or preoperative opioid use between the two groups. Although there was no difference in the MMEs on the day of surgery (58.5 vs. 66.9, P=0.387), cumulative MMEs each day after surgery was significantly lower in the MMPC cohort, with final cumulative MMEs being reduced by 62% (120.2 vs. 314.8, P<0.001). There was no difference in postoperative ileus, length of stay, and hospital costs.

Conclusions

The use of a MMPC protocol in patients undergoing single-level ALIF for degenerative conditions reduced opioid consumption starting on the first day after surgery, resulting in a cumulative reduction of 62%.

Pain management strategies in penile implantation

The opioid epidemic continues to be a serious public health concern. Many have pointed to prescription drug misuse as a nidus for patients to become addicted to opioids and as such, urologists and other surgical subspecialists must critically define optimal pain management for the various procedures performed within their respective disciplines. Controlling pain following penile prosthesis implantation remains a unique challenge for urologists, given the increased pain patients commonly experience in the postoperative setting. Although most of the existing urological literature focuses on interventions performed in the operating room, there are many studies that examine the role of preoperative adjunctive pain medicine in diminishing postoperative narcotic requirements. There are relatively few studies looking at postoperative strategies for managing pain in prosthetic surgery with follow-up past the immediate hospitalization. This review assess the various strategies employed for managing pain following penile implantation through the lens of the current state of the opioid crisis, thus examining how urologists can responsibly treat pain without contributing to the growing threat of opioid addiction.

Transversus Abdominis Plane Block for Laparoscopic Hysterectomy Pain: A Meta-Analysis

Objective:

Review the analgesic effect of the transversus abdominis plane (TAP) block and its impact on postoperative pain scores and opioid usage for patients undergoing laparoscopic and robotic hysterectomies.

Methods:

Systematic review with meta-analysis of randomized controlled trials that compared the effect of TAP block to either placebo or no block on narcotic use (in morphine equivalent units [MEq]) and pain (per visual analog scale) within 24] h after a laparoscopic or robotic hysterectomy for benign or malignant indications. Searches were conducted in PubMed and Embase through May 31, 2019.

Results:

Nine randomized controlled trials met eligibility criteria; 7 evaluated laparoscopic hysterectomy and 2 robotic hysterectomy. A total of 688 subjects were included (559 laparoscopic hysterectomy, 129 robotic hysterectomy). Opioid consumption was similar in the first 24] h postoperative with or without TAP block (−0.8 MEq; 95% CI, −2.9, 1.3; 8 TAP arms; N] = 395). Pain scores (visual analog scale) were also similar with or without TAP block (−0.01 U; 95% CI, −0.34, 0.32; 10 TAP arms; N] = 636). Neither meta-analysis showed statistical heterogeneity across studies.

Conclusions:

The evidence does not support a benefit of TAP block to reduce pain or opioid use for patients receiving laparoscopic or robotic hysterectomies.

Neuraxial and regional anesthesia in surgical patients with osteogenesis imperfecta: a narrative review of literature

Background and objectives

Regional and neuraxial anesthesia techniques have become instrumental in the perioperative period yet have not been well described in patients with osteogenesis imperfecta (OI), a congenital connective tissue disorder characterized by skeletal dysplasia and fragility. Patients with skeletal dysplasia present unique perioperative challenges that warrant consideration of these techniques despite their relative contraindication in this population due to reports of increased bleeding with surgery, skeletal fragility concerns with positioning, and risk of spinal cord injury with continuous neuraxial catheters. The aim of this narrative review was to evaluate literature describing the use of regional and neuraxial techniques in patients with OI and any associated clinical outcomes.

Methods

All available literature from inception to July 2020 was retrieved, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, from MEDLINE, Embase, Google Scholar and The Cochrane Library. Three authors reviewed all references for eligibility, abstracted data, and appraised quality.

Results

Of 412 articles initially identified, 42 met our inclusion criteria, yielding 161 cases with regional and/or neuraxial techniques described. In 117 (72.6%) of the 161 cases, neuraxial technique was performed, including 76 (64.9%) epidural, 7 (5.9%) caudal, 5 (4.2%) combined spinal epidural, and 29 (24.7%) spinal procedures. In 44 (27.4%) of the 161 cases, the use of regional anesthesia was described. Our review was confounded by incomplete data reporting and small sample sizes, as most were case reports. There were no randomized controlled trials, and the two single-center retrospective data reviews lacked sufficient data to perform meta-analysis. While complications or negative outcomes related to these techniques were not reported in any of the cases, less than half specifically discuss outcomes beyond placement and immediate postoperative course.

Conclusions

There is insufficient evidence to validate or refute the potential risks associated with the use of regional and neuraxial techniques in patients with OI. This review did not uncover any reports of negative sequelae related to the use of these modalities to support relative contraindication in this population; however, further research is needed to adequately assess clinically relevant outcomes such as complications and opioid-sparing effect.

Pain in child patients: A review on managements

Pain has been known as one of the major universal health concerns about ill children, because of its morbidity and potential mortality. Pain suitable evaluation is a challenge in children because the verbalization is difficult. Low clinical information, few pediatric researches, and the worry of opioid side effects make difficult to provide satisfactory treatments. Many pharmacologic and non-pharmacologic strategies to manage pain exist for pediatric pain treatment. The purpose of this review article is to describe exhaustively pain mechanism, evaluation and management by review literature from January 2000 to January 2019 using PubMed, EMBASE, MEDLINE, LILACS databases. Pharmacological and integrative non-pharmacological therapies has been indicated in acute and chronic pain treatment. Opioids and opioid-sparing agents target nociceptive and neuropathic pain. With due attention to available results, an early combination of pharmacological and integrative non pharmacological treatments are indicated in children pain management.

Opioid free anesthesia: feasible?

PURPOSE OF REVIEW

The present review aims to address the feasibility of opioid free anesthesia (OFA). The use of opioids to provide adequate perioperative pain management has been a central practice of anesthesia, and only recently has been challenged. Understanding the goals and challenges of OFA is essential as the approach to intraoperative analgesia and postsurgical management of pain has shifted in response to the opioid epidemic in the United States.

RECENT FINDINGS

OFA is an opioid sparing technique, which focuses on multimodal or balanced analgesia, relying on nonopioid adjuncts and regional anesthesia. Enhanced recovery after surgery protocols, often under the auspices of a perioperative pain service, can help guide and promote opioid reduced and OFA, without negatively impacting perioperative pain management or recovery.

SUMMARY

The feasibility of OFA is evident. However, there are limitations of this approach that warrant discussion including the potential for adverse drug interactions with multimodal analgesics, the need for providers trained in regional anesthesia, and the management of pain expectations. Additionally, minimizing opioid use perioperatively also requires a change in current prescribing practices. Monitors that can reliably quantify nociception would be helpful in the titration of these analgesics and enable anesthesiologists to achieve the goal in providing personalized perioperative medicine.

Local Anaesthesia Alone Versus Regional or General Anaesthesia in Excisional Haemorrhoidectomy: A Systematic Review and Meta-Analysis

BACKGROUND

Excisional haemorrhoidectomy has been traditionally performed under general or regional anaesthesia. However, these modes are associated with complications such as nausea, urinary retention and motor blockade. Local anaesthesia (LA) alone has been proposed to reduce side effects as well as to expedite ambulatory surgery. This systematic review aims to assess LA versus regional or general anaesthesia for excisional haemorrhoidectomy.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. MEDLINE, EMBASE and CENTRAL databases were searched to 13 January 2020. All randomised controlled trials comparing LA only versus regional or general anaesthesia in patients who received excisional haemorrhoidectomy were included. The main outcomes included pain, adverse effects and length of stay.

RESULTS

Nine trials, consisting of six studies comparing local versus regional anaesthesia and three comparing LA versus general anaesthesia, were included. Meta-analysis showed a significantly lower relative risk for need of rescue analgesia (RR 0.32 [95% CI 0.16-0.62]), intra-operative hypotension (RR 0.17 [95% CI 0.04-0.76]), headache (RR 0.13 [0.02-0.67]) and urinary retention (RR 0.17 [95% CI 0.09-0.29]) for LA when compared with regional anaesthesia. There was mixed evidence for both regional and general anaesthesia in regard to post-operative pain.

CONCLUSIONS

LA alone may be considered as an alternative to regional anaesthesia for excisional haemorrhoidectomy with reduced complications and reduction in the amount of post-operative analgesia required. The evidence for LA compared to general anaesthesia for haemorrhoidectomy is low grade and mixed.

Use of systemic lidocaine for postoperative acute pain management in single-lung transplantation: Case report

Introduction: Lung transplantation is associated with severe pain, which can delay recovery. Systemic lidocaine has useful analgesic properties for managing acute pain, however little is known on its use after lung transplantation. Due to pharmacological alterations during the postoperative period, the use of analgesics implies a demanding process to avoid toxicity, so lidocaine may play a role in this scenario. In this sense, the purpose of this case report is to present the use of systemic lidocaine as an option for the management of acute pain when other analgesics have failed to do so.Case presentation: The case of a male patient with acute pain in the postoperative period of single-lung transplantation is presented. Opioids and non-opioid analgesics showed limited efficacy, so the systematic administration of lidocaine was decided. Systemic lidocaine was effective for pain control, functional recovery and opioid decrease during the postoperative period.Conclusions: Systemic lidocaine was a useful drug for postoperative pain management in lung transplantation, since it allowed adequate analgesia and lung function recovery with decreased use of opioids. This drug may be a component of multimodal analgesia in selected patients when other options have failed; however its routine use is not recommended.

Emergence agitation: current knowledge and unresolved questions

Emergence agitation (EA), also referred to as emergence delirium, can have clinically significant consequences. The mechanism of EA remains unclear. The proposed risk factors of EA include age, male sex, type of surgery, emergency operation, use of inhalational anesthetics with low blood-gas partition coefficients, long duration of surgery, anticholinergics, premedication with benzodiazepines, voiding urgency, postoperative pain, and the presence of invasive devices. If preoperative or intraoperative objective monitoring could predict the occurrence of agitation during emergence, this would help to reduce its adverse consequences. Several tools are available for assessing EA. However, there are no standardized clinical research practice guidelines and its incidence varies considerably with the assessment tool or definition used. Total intravenous anesthesia, propofol, μ-opioid agonists, N-methyl-D-aspartate receptor antagonists, nefopam, α2-adrenoreceptor agonists, regional analgesia, multimodal analgesia, parent-present induction, and preoperative education for surgery may help in preventing of EA. However, it is difficult to identify patients at high risk and apply preventive measures in various clinical situations. The risk factors and outcomes of preventive strategies vary with the methodologies of studies and patients assessed.This review discusses important outcomes of research on EA and directions for future research.

Role of Ketamine in Multimodal Analgesia Protocol for Bariatric Surgery

Background and Objectives: Acute postoperative pain is one of the most undesirable experiences for a patient in the postoperative period. Many options are available for the treatment of postoperative pain. One of the methods of multimodal analgesia is a combination of opioids and adjuvant agents, such as ketamine. The aim of this study was to evaluate the effect of a pre-incisional single injection of low-dose ketamine on postoperative pain after remifentanil infusion in patients undergoing laparoscopic gastric bypass or gastric plication surgery. Materials and Methods: The prospective, randomized, double-blinded and placebo-controlled trial took place at the Hospital of the Lithuanian University of Health sciences KaunoKlinikos in 2015-2017. A total of 32 bariatric patients (9 men and 23 women) were randomly assigned to receive a single pre-incisional injection of ketamine (0.15 mg/kg (LBM)) (ketamine, K group) or saline (placebo, S group). Standardized protocol of anesthesia and postoperative pain management was followed for all patients. Postoperative pain intensity, postoperative morphine requirements, incidence of side effects and patients' satisfaction with postoperative analgesia were recorded. Results: Thirty-two patients undergoing bariatric surgery: 18 (56.25%; gastric bypass) and 14 (43.75%; gastric plication) were examined. Both groups did not differ in demographic values, duration of surgery and anesthesia and intraoperative drug consumption. Postoperative pain scores were similar in both groups (p = 0.105-0.941). Morphine consumption was 10.0 (7.0-12.5 mg) in group S and 9.0 (3.0-15.0 mg) in group K (p = 0.022). The incidence of side effects was similar in both groups (p = 0.412). Both groups demonstrated very high satisfaction with postoperative analgesia. Conclusions: Pre-incisional single dose ketamine reduces postoperative opioids consumption, but does not have an effect of postoperative pain intensity and side effects after remifentanil infusions. Very high patient satisfaction is achieved if standard multimodal analgesia protocol with an individual assessment of pain and dosage of medications is followed.

Nerve Block for Septorhinoplasty: A Retrospective Observational Study of Postoperative Complications in 24 Hours

Septorhinoplasty is a surgical procedure that provides functional improvements and esthetic adjustments to the appearance of the nose. Pain is a common postoperative complication, and pain management is known to decrease postoperative complications and total cost. Local anesthetics can cost-effectively decrease postoperative pain scores and reduce analgesic requirements.

The primary objective of this study was to assess the effect of bilateral facial nerve blocks given with general anesthesia on pain scores and the use of postoperative analgesia. The secondary objective was to compare the vital signs stability between a group given bilateral facial nerve blocks with general anesthesia and a group given general anesthesia only.

We conducted a retrospective observational study among 40 patients who were divided into two groups, each containing 20 patients. The patients in the nerve block (NB) group received general anesthesia and bilateral facial blocks of the infraorbital and infratrochlear nerves via 5 ml of 0.25% levobupivacaine with 5 ml of diluted adrenaline 1:100,000. Patients in the Control group received general anesthesia only. Both groups received the same local injection of a mixture of 5 ml of 1% lidocaine and 5 ml of 1:100,000 epinephrine at the surgical site, along with the standard general anesthesia. A numerical rating scale, the visual analog scale (VAS), was used to evaluate postoperative pain at 15, 30, and 45 minutes postoperatively, and the stability of the vital signs was also assessed.

The results showed that using bilateral infraorbital and infratrochlear nerve block injection with 0.25% levobupivacaine for patients who underwent septorhinoplasty under general anesthesia provided greater stability of vital signs but had no effect on the pain score or analgesia need. Further assessment should be performed in a larger number of patients to either confirm or refute these results. Additional studies could be conducted in several hospitals within the Kingdom to determine how broadly applicable nerve blockade is in reducing pain sensation.

Pain in child patients: A review on managements

Pain has been known as one of the major universal health concerns about ill children, because of its morbidity and potential mortality. Pain suitable evaluation is a challenge in children because the verbalization is difficult. Low clinical information, few pediatric researches, and the worry of opioid side effects make difficult to provide satisfactory treatments. Many pharmacologic and non-pharmacologic strategies to manage pain exist for pediatric pain treatment. The purpose of this review article is to describe exhaustively pain mechanism, evaluation and management by review literature from January 2000 to January 2019 using PubMed, EMBASE, MEDLINE, LILACS databases. Pharmacological and integrative non-pharmacological therapies has been indicated in acute and chronic pain treatment. Opioids and opioid-sparing agents target nociceptive and neuropathic pain. With due attention to available results, an early combination of pharmacological and integrative non pharmacological treatments are indicated in children pain management.

Acute Pain Management for Patients Receiving Medication-Assisted Therapy

Evidence-based approaches for the treatment of opioid use disorder include the use of opioid medications (methadone, buprenorphine, or naltrexone), collectively referred to as medication-assisted therapy. Patients receiving medication-assisted therapy may present in the acute care setting with pain, often related to planned surgical procedures to treat health issues that were not addressed before entering treatment. Because these medications act on the same receptors as do analgesic opioids—and, in the cases of methadone and buprenorphine, have analgesic properties — managing acute pain in these patients can be challenging. Principles of effective pain management for these patients include continuing the usual medication-assisted therapy dose; using nonpharmacological and nonopioid pain management strategies as possible and immediate-release opioids, titrating to effect and monitoring for toxicity; anticipating tolerance and hyperalgesia; and establishing a collaborative treatment relationship with the medication-assisted therapy provider. Providing effective pain treatment supports ongoing recovery in patients with opioid use disorder.

Evolving the management of acute perioperative pain towards opioid free protocols: a narrative review

Objective: Identification of pain as the fifth vital sign has resulted in over-prescription and overuse of opioids in the US, with addiction reaching epidemic proportions. In Europe, and more recently in the US, a shift has occurred with the global adoption of multimodal analgesia (MMA), which seeks to minimize perioperative opioid use. Improved functional outcomes and reduced healthcare utilization costs have been demonstrated with MMA, but wide scale use of opioids in pain management protocols continues. As a next step in the pain management evolution, opioid-free analgesia (OFA) MMA strategies have emerged as feasible in many surgical settings.Methods: Articles were limited to clinical studies and meta-analyses focusing on comparisons between opioid-intensive and opioid-free/opioid-sparing strategies published in English.Results: In this review, elimination or substantial reduction in opioid use with OFA strategies for perioperative acute pain are discussed, with an emphasis on improved pain control and patient satisfaction. Improved functional outcomes and patient recovery, as well as reduced healthcare utilization costs, are also discussed, along with challenges facing the implementation of such strategies.Conclusions: Effective MMA strategies have paved the way for OFA approaches to postoperative pain management, with goals to reduce opioid prescriptions, improve patient recovery, and reduce overall healthcare resource utilization and costs. However, institution-wide deployment and adoption of OFA is still in early stages and will require personalization and better management of patient expectations.

Pre-emptive multimodal analgesic regimen reduces post-operative epidural demand boluses in traumatic shaft of femur fracture - A randomised controlled trial

Background and Aims:

The efficacy of preemptive multimodal analgesia in post-traumatic patients has not been elucidated. Our aim was to evaluate the efficacy of preemptive MMA regimen in reducing the epidural demand boluses in the first 48 hours following the traumatic shaft of femur fractures.

Methods:

Patients scheduled for traumatic femur fracture surgery were randomised (n = 135) into two groups in this double blind, placebo controlled trial. Patients received either (Preemptive multimodal group) intravenous acetaminophen 1 gm, diclofenac 75 mg, morphine 3 mg, 75 mg Pregabalin (per oral) or a placebo 30 minutes pre-operatively. Intra-operatively, all patients were managed with spinal and epidural anaesthesia. Post-operatively, patients received patient-controlled epidural analgesia (PCEA) programmed to deliver a bolus of 5 ml of 0.2% Ropivacaine with 2 μg/ml of Fentanyl with lockout interval time of 15 min. Primary outcome was number of PCEA boluses received post-operatively over 48 h. Secondary outcomes measures were time to receive first epidural bolus, postoperative VAS scores and episodes of post-operative nausea, vomiting and sedation. Total number of PCEA bolus doses over 48 hours and VAS scores were analysed using Mann-Whitney test.

Results:

Significant reduction in median number of demand boluses were observed in preemptive multimodal group (3 [2-4]) compared to placebo group (5 [4-7]); P = 0.00. Time to first rescue epidural bolus was significantly greater in preemptive multimodal group than placebo group.

Conclusion:

The use of preemptive MMA regimen reduced the requirement of demand epidural bolus doses.

Using the principles of multimodal analgesia as a component of Fast-Track surgery in practice

Aim. To evaluate the effectiveness of reducing postoperative pain in the first days after surgery in accelerating postoperative recovery of patients and reducing the length of stay in hospital. Materials and methods. In the period from September 2011 to May 2019 we performed 569 scheduled surgeries using the Fast­track surgery principles, including MMA. Depending on the type of surgery, we defined VAS pain impulses indicators and the average stay in hospital. Results. Analyzing the impulses of pain after laparoscopic cholecystectomy in the first postoperative day (POD) VAS level was 2.87 ± 0.74, the second POD – 2.01 ± 0.50 (p < 0.001). The average hospital stay was 1.72 days. In laparoscopic hernioplasty, the results of the study of the level of pain according to VAS were as follows: the first POD – 3.44 ± 0.67, the second POD – 2.06 ± 0.51 (p < 0.001). The average hospital stay was 1.43 days after surgery. Analyzing laparoscopic bariatric interventions and interventions on the large intestine the first POD level according to VAS was 4.24 ± 0.75 and 4.39 ± 0.84 respectively; the second POD – 3.48 ± 0.57 and 3.48 ± 0.77, the third POD – 2.79 ± 0.67 and 2.84 ± 0.69. When comparing the first and second PODs after bariatric interventions, the level of pain impulsion decreased to 3.48 ± 0.57 (p < 0.001), and to the third POD – to 2.79 ± 0.67 (p < 0.001). A similar tendency was observed after laparoscopic interventions on the large intestine: the second POD – the level of pain impulsion decreased 3.48 ± 0.77 (p < 0.001), the third POD – 2.84 ± 0.69 (p < 0.001). The average hospital stay was 4.99 ± 0.45 and 4.10 ± 0.60, respectively. Conclusions. The effectiveness of reducing postoperative pain in the first days after surgery directly affects the rate of recovery of the patient and the length of stay in hospital.

The effect of hypothermia during cardiopulmonary bypass on three electro-encephalographic indices assessing analgesia and hypnosis during anesthesia: consciousness index, nociception index, and bispectral index

The depth of anesthesia is commonly assessed in clinical practice by the patient's clinical signs. However, during cardiopulmonary bypass and hypothermia, common symptoms of nociception such as tachycardia, hypertension, sweating, or movement have low sensitivity and specificity in the description of the patient nociception and hypnosis, in particular, detecting nociceptive stimuli. Better monitoring of the depth of analgesia during hypothermia under cardiopulmonary bypass will avoid underdosage or overdosage of analgesia, especially opioids. Induced hypothermia has a multifactorial effect on the level of analgesia and hypnosis. Thermoregulatory processes appear essential for the activation of analgesic mechanisms, ranging from a physiological strong negative affiliation between nerve conduction velocity and temperature, until significant repercussions on the pharmacological dynamics of the analgesic drugs, the latter decreasing the clearance rate with a subsequent increase in the effect-site concentrations. Under the hypothesis that deep hypothermia induces massive effects on the analgesia and hypnosis levels of the patient, we studied whether hypothermia effects were mirrored by several neuromonitoring indices: two hypnosis indices, consciousness index and bispectral index, and a novel nociception index designed to evaluate the analgesic depth. In this clinical trial, 39 patients were monitored during general anesthesia with coronary atherosclerosis cardiopathy who were elective for on-pump coronary artery bypass graft surgery under hypothermia. The changes and correlation between the consciousness index, bispectral index, and nociception index with respect to the temperature were compared in different timepoints at basic state, during cardiopulmonary bypass and after cardiopulmonary bypass. While the three neuromonitoring indices showed significant correlations with respect to the temperature, the nociception index and consciousness index showed the strongest sensitivities, indicating that these two indices could be an important means of intraoperative neuromonitoring during induced hypothermia under cardiopulmonary bypass.

Adjuvant analgesics in spinal surgery

Peri- and postoperative pain control can present a challenge to any doctor, particularly in the setting of spinal surgery. The use of adjuvant pain agents and multimodal analgesia is changing the face of modern anaesthesia and offering clinicians more avenues to control perioperative pain. This article discusses the use of adjuvant medications and some of the evidence surrounding their use in spinal surgery.

The Society for Pediatric Anesthesia recommendations for the use of opioids in children during the perioperative period

Opioids have long held a prominent role in the management of perioperative pain in adults and children. Published reports concerning the appropriate, and inappropriate, use of these medications in pediatric patients have appeared in various publications over the last 50 years. For this document, the Society for Pediatric Anesthesia appointed a taskforce to evaluate the available literature and formulate recommendations with respect to the most salient aspects of perioperative opioid administration in children. The recommendations are graded based on the strength of the available evidence, with consensus of the experts applied for those issues where evidence is not available. The goal of the recommendations was to address the most important issues concerning opioid administration to children after surgery, including appropriate assessment of pain, monitoring of patients on opioid therapy, opioid dosing considerations, side effects of opioid treatment, strategies for opioid delivery, and assessment of analgesic efficacy. Regular updates are planned with a re-release of guidelines every 2 years.

Safe anesthesia for office-based plastic surgery: Proceedings from the PRS Korea 2018 meeting in Seoul, Korea

There has been an exponential increase in plastic surgery cases over the last 20 years, surging from 2.8 million to 17.5 million cases per year. Seventy-two percent of these cases are being performed in the office-based or ambulatory setting. There are certain advantages to performing aesthetic procedures in the office, but several widely publicized fatalities and malpractice claims has put the spotlight on patient safety and the lack of uniform regulation of office-based practices. While 33 states currently have legislation for office-based surgery and anesthesia, 17 states have no mandate to report patient deaths or adverse outcomes. The literature on office-base surgery and anesthesia has demonstrated significant improvements in patient safety over the last 20 years. In the following review of the proceedings from the PRS Korea 2018 meeting, we discuss several key concepts regarding safe anesthesia for officebased cosmetic surgery. These include the safe delivery of oxygen, appropriate local anesthetic usage and the avoidance of local anesthetic toxicity, the implementation of Enhanced Recovery after Surgery protocols, multimodal analgesic techniques with less reliance on narcotic pain medications, the use of surgical safety checklists, and incorporating “the patient” into the surgical decision-making process through decision aids.