Postoperative pain management in the era of ERAS: An overview

Systemic lidocaine versus erector spinae plane block for improving quality of recovery after laparoscopic cholecystectomy: A randomized controlled trial

STUDY OBJECTIVE

To compare intravenous lidocaine, ultrasound-guided erector spinae plane block (ESPB), and placebo on the quality of recovery and analgesia after laparoscopic cholecystectomy.

DESIGN

A prospective, triple-arm, double-blind, randomized, placebo-controlled non-inferiority trial.

SETTING

A single tertiary academic medical center.

PATIENTS

126 adults aged 18-65 years undergoing elective laparoscopic cholecystectomy.

INTERVENTIONS

Patients were randomly allocated to one of three groups: intravenous lidocaine infusion (1.5 mg/kg bolus followed by 2 mg/kg/h) plus bilateral ESPB with saline (25 mL per side); bilateral ESPB with 0.25% ropivacaine (25 ml per side) plus placebo infusion; or bilateral ESPB with saline (25 ml per side) plus placebo infusion.

MEASUREMENTS

The primary outcome was the 24-h postoperative Quality of Recovery-15 (QoR-15) score. The non-inferiority of lidocaine versus ESPB was assessed with a margin of -6 points and 97.5% confidence interval (CI). Secondary outcomes included 24-h area under the curve (AUC) for pain scores, morphine consumption, and adverse events.

MAIN RESULTS

124 patients completed the study. Median (IQR) 24-h QoR-15 scores were 123 (117-127) for lidocaine, 124 (119-126) for ESPB, and 112 (108-117) for placebo. Lidocaine was non-inferior to ESPB (median difference  -1, 97.5% CI: -4 to ∞). Both lidocaine (median difference 9, 95% CI: 6-12, P < 0.001) and ESPB (median difference 10, 95% CI: 7-13, P < 0.001) were superior to placebo. AUC for pain scores and morphine use were lower with lidocaine and ESPB versus placebo (P < 0.001 for all), with no significant differences between lidocaine and ESPB. One ESPB patient reported a transient metallic taste; no other block-related complications occurred.

CONCLUSIONS

For patients undergoing laparoscopic cholecystectomy, intravenous lidocaine provides a non-inferior quality of recovery compared to ESPB without requiring specialized regional anesthesia procedures. Lidocaine may offer a practical and accessible alternative within multimodal analgesia pathways.

Relationship between epidural catheter migration beneath the skin and subcutaneous fat thickness assessed using postoperative CT imaging: a retrospective cross-sectional study

PURPOSE

The causes of epidural catheter migration beneath the skin have not been previously investigated. We hypothesized that greater subcutaneous fat thickness might be associated with increased catheter migration beneath the skin.

METHODS

We conducted a retrospective cross-sectional study of patients who had undergone combined general and epidural anesthesia, selecting individuals who received thoracic and abdominal CT scans within the first 5 postoperative days. Needle depth was defined as the distance from the needle tip to the skin surface when the anesthesiologist determined that the needle tip had reached the epidural space. We measured the length of the epidural catheter from the skin surface to the epidural space (catheter length), and subcutaneous fat thickness (fat thickness) using CT imaging. Migration distance was calculated by subtracting needle depth from catheter length.

RESULTS

We analyzed 127 patients (72 males), all undergoing epidural catheter insertion in the left lateral decubitus position via a paramedian approach. The median age of the patients was 71 years. Epidural catheters were postoperatively found to substantially curve beneath the skin. Regression analysis revealed no significant influence of fat thickness on catheter length (regression coefficient 0.10, 95% confidence interval [CI]: - 0.17, 0.38). However, it indicated a positive correlation between fat thickness and needle depth (regression coefficient 0.50, 95% CI: 0.30, 0.70), and a negative correlation between fat thickness and migration distance (regression coefficient - 0.40, 95% CI: - 0.65, - 0.14).

CONCLUSION

We found a negative correlation between epidural catheter migration beneath the skin and subcutaneous fat thickness. Anesthesiologists should be aware of the possibility of substantial subcutaneous curving of the catheter, especially in patients with scant subcutaneous fat.

Society for Ambulatory Anesthesia Updated Consensus Statement on Perioperative Blood Glucose Management in Adult Patients With Diabetes Mellitus Undergoing Ambulatory Surgery

This consensus statement is a comprehensive update of the 2010 Society for Ambulatory Anesthesia (SAMBA) Consensus Statement on perioperative blood glucose management in patients with diabetes mellitus (DM) undergoing ambulatory surgery. Since the original consensus guidelines in 2010, several novel therapeutic interventions have been introduced to treat DM, including new hypoglycemic agents and increasing prevalence of insulin pumps and continuous glucose monitors. The updated recommendations were developed by an expert task force under the provision of SAMBA and are based on a comprehensive review of the literature from 1980 to 2022. The task force included SAMBA members with expertise on this topic and those contributing to the primary literature regarding the management of DM in the perioperative period. The recommendations encompass preoperative evaluation of patients with DM presenting for ambulatory surgery, management of preoperative oral hypoglycemic agents and home insulins, intraoperative testing and treatment modalities, and blood glucose management in the postanesthesia care unit and transition to home after surgery. High-quality evidence pertaining to perioperative blood glucose management in patients with DM undergoing ambulatory surgery remains sparse. Recommendations are therefore based on recent guidelines and available literature, including general glucose management in patients with DM, data from inpatient surgical populations, drug pharmacology, and emerging treatment data. Areas in need of further research are also identified. Importantly, the benefits and risks of interventions and clinical practice information were considered to ensure that the recommendations maintain patient safety and are clinically valid and useful in the ambulatory setting. What Other Guidelines Are Available on This Topic? Since the publication of the SAMBA Consensus Statement for perioperative blood glucose management in the ambulatory setting in 2010, several recent guidelines have been issued by the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists (AACE), the Endocrine Society, the Centre for Perioperative Care (CPOC), and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) on DM care in hospitalized patients; however, none are specific to ambulatory surgery. How Does This Guideline Differ From the Previous Guidelines? Previously posed clinical questions that were outdated were revised to reflect current clinical practice. Additional questions were developed relating to the perioperative management of patients with DM to include the newer therapeutic interventions.

Perioperative N-acetylcysteine: evidence and indications

Nonopioid analgesics serve to improve analgesia and limit side effects and risks of perioperative opioids. N-acetylcysteine (NAC), the primary treatment of acetaminophen toxicity, may have perioperative indications, including analgesia. NAC impacts glutathione synthesis, oxidant scavenging, glutamate receptor modulation and neuroinflammation. Potential perioperative benefits include arrhythmia prevention after cardiac surgery, decreased contrast-induced nephropathy, improved post-transplant liver function and superior pulmonary outcomes with general anesthesia. NAC may improve perioperative analgesia, with some studies displaying a reduction in postoperative opioid use. NAC is generally well tolerated with an established safety profile. NAC administration may predispose to gastrointestinal effects, while parenteral administration may carry a risk of anaphylactoid reactions, including bronchospasm. Larger randomized trials may clarify the impact of NAC on perioperative analgesic outcomes.

Development of a nomogram for predicting acute pain among patients after abdominal surgery: A prospective observational study

AIMS

To develop a nomogram to provide a screening tool for recognising patients at risk of post-operative pain undergoing abdominal operations.

BACKGROUND

Risk prediction models for acute post-operative pain can allow initiating prevention strategies, which are valuable for post-operative pain management and recovery. Despite the increasing number of studies on risk factors, there were inconsistent findings across different studies. In addition, few studies have comprehensively explored predictors of post-operative acute pain and built prediction models.

DESIGN

A prospective observational study.

METHODS

A total of 352 patients undergoing abdominal operations from June 2022 to December 2022 participated in this investigation. A nomogram was developed for predicting the probability of acute pain after abdominal surgery according to the results of binary logistic regression. The nomogram's predictive performance was assessed by discrimination and calibration. Internal validation was performed via Bootstrap with 1000 re-samplings.

RESULTS

A total of 139 patients experienced acute post-operative pain following abdominal surgery, with an incidence of 39.49%. Age <60, marital status (unmarried, divorced, or widowed), consumption of intraoperative remifentanil >2 mg, indwelling of drainage tubes, poor quality sleep, high pain catastrophizing, low pain self-efficacy, and PCIA not used were predictors of inadequate pain control in patients after abdominal surgery. Using these variables, we developed a nomogram model. All tested indicators showed that the model has reliable discrimination and calibration.

CONCLUSIONS

This study established an online dynamic predictive model that can offer an individualised risk assessment of acute pain after abdominal surgery. Our model had good differentiation and calibration and was verified internally as a useful tool for risk assessment.

RELEVANCE TO CLINICAL PRACTICE

The constructed nomogram model could be a practical tool for predicting the risk of experiencing acute post-operative pain in patients undergoing abdominal operations, which would be helpful to realise personalised management and prevention strategies for post-operative pain.

REPORTING METHOD

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines were adopted in this study.

PATIENT OR PUBLIC CONTRIBUTION

Before the surgery, research group members visited the patients who met the inclusion criteria and explained the purpose and scope of the study to them. After informed consent, they completed the questionnaire. The patients' pain scores (VAS) were regularly assessed and documented by the bedside nurse for the first 3 days following surgery. Other information was obtained from medical records.

The impact of enhanced recovery after surgery (ERAS) on opioid consumption and postoperative pain levels in elective spine surgery

OBJECTIVE

Enhanced Recovery after Surgery (ERAS) protocols were developed to counteract the adverse effects of the surgical stress response, aiming for quicker postoperative recovery. Initially applied in abdominal surgeries, ERAS principles have extended to orthopedic spine surgery, but research in this area is still in its infancy. The current study investigated the impact of ERAS on postoperative pain and opioid consumption in elective spine surgeries.

METHODS

A single-center retrospective study of patients undergoing elective spine surgery from May 2019 to July 2020. Patients were categorized into two groups: those enrolled in the ERAS pathway and those adhering to traditional surgical protocols. Data on demographics, comorbidities, length of stay (LOS), surgical procedures, and postoperative outcomes were collected. Postoperative pain was evaluated using the Numerical Rating Scale (NRS), while opioid utilization was quantified in morphine milligram equivalents (MME). NRS and MME were averaged for each patient across all days under observation. Differences in outcomes between groups (ERAS vs. treatment as usual) were tested using the Wilcoxon rank sum test for continuous variables and Pearson's or Fisher's exact tests for categorical variables.

RESULTS

The median of patient's mean daily NRS scores for postoperative pain were not statistically significantly different between groups (median = 5.55 (ERAS) and 5.28 (non-ERAS), p=.2). Additionally, the median of patients' mean daily levels of MME were similar between groups (median = 17.24 (ERAS) and 16.44 (non-ERAS), p=.3) ERAS patients experienced notably shorter LOS (median=2 days) than their non-ERAS counterparts (median=3 days, p=.001). The effect of ERAS was moderated by whether the patient had ACDF surgery. ERAS (vs. non-ERAS) patients who had ACDF surgery had 1.64 lower average NRS (p=.006). ERAS (vs. non-ERAS) patients who had a different surgery had 0.72 higher average NRS (p=.02) but had almost half the length of stay, on average (p<.001).

CONCLUSIONS

The current study underscores the dynamic nature of ERAS protocols within the realm of spine surgery. While ERAS demonstrates advantages such as reduced LOS and improved patient-reported outcomes, it requires careful implementation and customization to address the specific demands of each surgical discipline. The potential to expedite recovery, optimize resource utilization, and enhance patient satisfaction cannot be overstated. However, the fine balance between achieving these benefits and ensuring comprehensive patient care, especially in the context of postoperative pain management, must be maintained. As ERAS continues to evolve and find its place in diverse surgical domains, it is crucial for healthcare providers to remain attentive to patient needs, adapting ERAS protocols to suit individual patient populations and surgical contexts.

Use of Muscle Relaxants for Acute Postoperative Pain: A Practical Review

Background

Skeletal muscle relaxants have emerged as a broad category of analgesic adjuncts, aiming to improve pain relief and reduce opioid reliance. These drugs induce muscle relaxation and reduce muscle spasms, and therefore, they are commonly used in surgical procedures involving muscle manipulation, such as abdominal surgery, breast surgery, and spine surgery. However, their analgesic efficacy and opioid-sparing effects are poorly explored.

Methods

A scoping review of literature was performed with several electronic databases. We used a search string with a sequence of text words and word variants related to central muscle relaxants, pain management, postoperative pain, and specific muscle relaxants.

Results

Review of literature shows significant heterogeneity among the studies in terms of surgical procedures, patient populations, choice of muscle relaxant, and timing and duration of administration, potentially limiting the generalizability of the findings and the ability for pooled analysis.

Conclusions

Given the lack of evidence, we recommend that the use of skeletal muscle relaxants be reserved for patients in whom an optimal multimodal analgesic technique is not adequate. Also, there may be a limited role for these drugs in patients at high risk of postoperative pain undergoing surgical procedures with expected high opioid requirements. Due to the concerns of potential adverse effects, the decision to use muscle relaxants in vulnerable populations should be made carefully, weighing the benefits against the risks.

Optimal Perioperative Pain Management of the Transgender Patient for Gender Affirming Surgery: A Scoping Review

INTRODUCTION

As we increasingly encounter transgender patients in the perioperative setting, it is important to be cognizant of appropriate medical management of the transgender patient. There is limited literature on the appropriate perioperative techniques to implement for adequate pain control in the transgender patient presenting for gender affirming procedures.

METHODS

In this scoping review, the authors identify publications that address perioperative pain control techniques that can be implemented by the anesthesiologist such as regional anesthesia, multimodal medications, or non-pharmacologic modalities.

RESULTS

This scoping review included two retrospective reviews, two case reports, and one letter to the editor. There are no prospective, randomized controlled trials on this topic. The limitations of this scoping review include the limited publications that are available to analyze as this is a growing area of medicine.

CONCLUSION

There are numerous variables that may play a factor in the pain experience of the transgender patient including biological factors, psychological and social factors. Techniques that are necessary for comprehensive pain management include pharmacologic, injections, physical therapy, acupuncture, massage, and more. There are limited publications on the comprehensive pain management of the transgender patient; therefore, the authors advocate that as perioperative physicians, anesthesiologists implement comprehensive preemptive analgesia techniques to avoid progression to chronic pain. Clearly more research is necessary to standardize acute pain management techniques in the transgender patient.

The effect of preemptive retrolaminar block on lumbar spinal decompression surgery

PURPOSE

Spinal decompression surgery causes severe pain. Retrolaminar block (RLB) is block, which is done by infiltration of local anesthetic to block spinal nerves between the lamina and superior costotransversospinalis muscle. The primary aim of this study is to evaluate the effectiveness of RLB on postoperative analgesia in patients undergoing spinal surgery. Secondary aims are effects on additional anesthetic and analgesic consumption.

METHODS

The sixty (60) patients who underwent lumbar spinal surgery between May 2020 and May 2021 under general anesthesia with or without applied preemptive RLB for postoperative analgesia were included in this prospective observational study. Group I received ultrasound-guided preemptive RLB. In Group II, no intervention was performed. Postoperative VAS scores were compared in groups as primary outcome, perioperative additional anesthetic and analgesic needs were compared as secondary outcome.

RESULTS

There was a significant difference between the groups in favor of the RLB group in terms of postoperative VAS scores at rest [1.33 (0.33-3.509)] and movement [2.40 (1.20-4.00)] (p < 0.001). Perioperative sevoflurane consumption was significantly low in block group (p < 0.001). Postoperative tramadol consumption was lower in Group I compared with Group II [Group 1: 200 (100-300); Group 2: 37.5 (0-200); p < 0.001].

CONCLUSION

Preemptive RLB may be used to reduce patients' pain in lumbar decompression surgery as well as to be part of a multimodal analgesia and anesthesia regimen to reduce anesthetic and analgesic drug consumption. Trial registration numberClinicalTrials.gov (No. NCT04209907).

Evaluation of the effect of intraoperative tropisetron on postoperative rebound pain after brachial plexus block: a randomized controlled trial

Introduction

Postoperative rebound pain after peripheral nerve block increases patient suffering and delays recovery after surgery.

Objectives

We tested whether the 5HT-3 receptor antagonist and α7nAChR agonist tropisetron could prevent postoperative rebound pain.

Methods

A total of 115 patients were randomized to receive 5-mg/5-mL tropisetron or the same volume of normal saline. Pain intensity was measured with the numerical rating scale of pain (NRS). Rebound pain was defined as a change from mild pain (NRS ≤ 3) measured in the postanesthesia care unit to severe pain (NRS ≥ 7) within 24 hours after peripheral nerve blockade. Logistic regression was used to identify relevant factors associated with postoperative rebound pain.

Results

Tropisetron did not affect the NRS score or the incidence of rebound pain after peripheral nerve block. Logistic regression revealed that preoperative pain, bone surgery, and length of incision were risk factors for postoperative rebound pain, and patient-controlled analgesia was protective against postoperative rebound pain.

Conclusion

Tropisetron does not affect the incidence of rebound pain after peripheral nerve block. Patients at high risk of postoperative rebound pain should be identified for appropriate management. Registration site: www.chictr.org.cn (ChiCTR2300069994).

The effect of continuous bilateral parasternal block with lidocaine on patient-controlled analgesia opioid requirement and recovery after open heart surgery: a double-blind randomised controlled trial

Background

We hypothesised that a continuous 72-h bilateral parasternal infusion of lidocaine at 2×35 mg h-1 would decrease pain and the inflammatory response after sternotomy for open heart surgery, subsequently improving quality of recovery.

Methods

We randomly allocated 45 participants to a 72-h bilateral parasternal infusion of lidocaine or saline commencing after wound closure. The primary outcome was the cumulative patient-controlled analgesia (PCA) morphine consumption at 72 h. Secondary outcomes included total morphine requirement, pain, peak expiratory flow, and serum interleukin-6 concentration. In addition, we used an eHealth platform for a 3-month follow-up of pain, analgesic use, and Quality of Recovery-15 scores.

Results

The 72-h PCA morphine requirement was significantly lower in the lidocaine than the saline group (10 mg [inter-quartile range: 5-19 mg] and 28.2 mg [inter-quartile range: 16-42.5 mg], respectively; P=0.014). The total morphine requirement (including morphine administered before the start of PCA) was significantly lower at 24, 48, and 72 h. Pain was well controlled with no difference in pain scores between treatment groups. The peak expiratory flow was lower in the lidocaine group at 72 h. Interleukin-6 concentrations showed no difference at 24, 48, or 72 h. Quality of Recovery-15 scores did not differ between treatment groups at any time during the 3-month follow-up.

Conclusions

After sternotomy for open heart surgery, a 72-h bilateral parasternal lidocaine infusion significantly decreased PCA and total morphine requirement. However, neither signs of decreased inflammatory response nor an improvement in recovery was seen.

Clinical trial registration

EudraCT number 2018-004672-35.

Intra- and post-operative outcomes of the Enhanced Recovery after Surgery (ERAS) Program in laparoscopic hysterectomy

PURPOSE

To investigate the effect of the Enhanced Recovery After Surgery (ERAS) protocol on perioperative and post-operative outcomes in laparoscopic hysterectomies (LHs) performed for benign gynecological diseases.

METHODS

This prospective study was conducted with randomized 100 participants who underwent LH between 1 January and 31 December, 2022. A standard care protocol was applied to 50 participants (Group 1, control) and the ERAS protocol to the other 50 (Group 2, study). Length of hospitalization was compared between the groups as the primary outcome, and the duration of the operation, the amount of bleeding, post-operative nausea-vomiting, gas discharge time, visual analog scale (VAS) pain scores, and complications as the secondary outcomes.

RESULTS

No statistically significant difference was seen between the groups in terms of sociodemographic characteristics, medical history, operation indications, surgical procedures applied in addition to hysterectomy, operative time, pre-operative and post-operative hemoglobin levels, amount of bleeding, or drain use (p > 0.05). However, a statistically significant difference was observed in terms of nausea (60% vs. 26%, p = 0.001), vomiting (28% vs. 10%, p = 0.040), duration of gassing (17.74 ± 6.77 vs. 14.20 ± 7.05 h, p = 0.012), length of hospitalization (41.78 ± 12.17 vs. 34.12 ± 10.90 h, p = 0.001), analgesic requirements (4.62 ± 1.36 vs. 3.34 ± 1.27 h, p < 0.001), or VAS scores at the 1st (5.86 ± 1.21 vs. 4.58 ± 1.31, p < 0.001), 6th (5.16 ± 1.12 vs. 4.04 ± 1.08, p < 0.001), 12th (4.72 ± 1.12 vs. 3.48 ± 1.12, p < 0.001), 18th (4.48 ± 1.21 vs. 3.24 ± 1.34, p < 0.001), and 24th (4.08 ± 1.29 vs. 3.01 ± 1.30, p < 0.001) hours.

CONCLUSION

The findings of this study show that the ERAS protocol has a positive effect on peri- and post-operative outcomes in LH. Further prospective studies are now needed to confirm the validity of the results.

Short-term outcomes of an enhanced recovery after surgery pathway for children with congenital scoliosis undergoing posterior spinal fusion: a case-control study of 70 patients

Increasing evidence demonstrates the advantages of an enhanced recovery after surgery (ERAS) protocol; however, few studies have evaluated ERAS in pediatric patients. This study aimed to evaluate the effect of ERAS in pediatric patients with congenital scoliosis. Seventy pediatric patients with congenital scoliosis underwent posterior hemivertebra resection and fusion with pedicle screws and were prospectively randomly assigned to the ERAS group ( n  = 35) and control group ( n  = 35). ERAS management comprised 15 elements including a shortened fasting time, optimized anesthesia protocol, and multimodal analgesia. The control group received traditional perioperative management. Clinical outcome was evaluated by hospital stay, surgery-related indicators, diet, pain scores, laboratory tests, and complications. The surgical outcome showed a similar correction rate in the ERAS group (84.0%) and control group (89.0%; P  = 0.471). The mean fasting time was significantly shorter in the ERAS group than in the control group. Compared with the control group, the ERAS group had significantly shorter mean times to postoperative hospital stay, first anal exhaust and defecation, significantly lower mean pain scores in the first 2 days postoperatively ( P  < 0.05), and a significantly lower mean interleukin-6 concentration on postoperative day 1 ( P  < 0.001). The incidence of complications was similar in the ERAS group and control group ( P  > 0.05). The ERAS protocol is effective and safe for pediatric patients with congenital spinal deformity and may significantly improve the treatment efficacy compared with traditional perioperative management methods. Levels of Evidence: III.

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).

Management of acute postoperative pain: Conditions to guarantee the safety and effectiveness of analgesic treatments

The evidence on postoperative pain management is of low or insufficient quality. The SEDAR Acute Pain Working Group has prepared this guideline-document to apply the best available scientific evidence to clinical practice, individualizing it based on factors specific to the patient and the procedure, and encompassing different organizational options, attempting to individualize it based on specific factors of the patient and the procedure, and encompassing the different organizational options for pain control. The document updates concepts and minimum requirements necessary for optimal postoperative analgesia, a multidisciplinary approach and the management of Acute Postoperative Pain. Strategic lines and different management models are defined. A general perioperative action plan is established based on collaboration with the surgical departments involved, on the joint review of the evidence and on preparation of protocols by the procedure. Finally, a follow-up plan and a series of minimum indicators necessary for quality control of postoperative pain are presented.

Pericapsular nerve group block and lateral femoral cutaneous nerve block versus fascia iliaca block for multimodal analgesia after total hip replacement surgery: A retrospective analysis

Background

Optimal pain control with limited muscle weakness is paramount for a swift initiation of physical therapy and early discharge. Fascia iliaca compartment block (FICB) has been recommended since it offers good pain control with a low risk of motor block. Pericapsular nerve group (PENG) block with lateral femoral cutaneous block (LFCN) has been proposed as an effective alternative to FICB that offers better pain control with a considerably lower risk of motor block. We aimed to compare the aforementioned blocks and determine which one yielded the lowest numeric rating scale (NRS) score.

Methods

We designed a retrospective analysis of patients undergoing elective total hip arthroplasty. The primary outcome was the NRS score at 6, 12, and 24 hours. The secondary outcomes were total opioid consumption, time to first PRN opioid, and time to first postoperative ambulation.

Results

52 patients were recruited, (13 PENG plus LFCN, 39 FICB). PENG plus LCFN resulted in a lower NRS at all three-time points (mean difference and 95%CI at 6 h 0.378 [-0.483; 1.240], at 12 h 0.336 [-0.378; 1.050], and at 24 h 0.464 [0.013; 0.914] P = 0.02). Moreover, less PRN opioids were requested in the PENG plus LCFN vs. FICB group (0 [0;7.5] vs 60 [15;80] milligrams of morphine equivalents, P = 0.001). No delay in the first ambulation or initiation of physical rehabilitation was reported in either group.

Conclusions

PENG plus LCFN seems to offer better pain control and lead to less PRN opioids. Neither block hindered physical therapy nor ambulation. These results need to be confirmed with a larger prospective and randomized study.

Opioid reduction and enhanced recovery in orthopaedic surgery (OREOS): a protocol for a feasibility randomised controlled trial in patients undergoing total knee arthroplasty

BACKGROUND

Knee arthritis is a leading cause of limited function and long-term disability in older adults. Despite a technically successful total knee arthroplasty (TKA), around 20% of patients continue to have persisting pain with reduced function, and low quality of life. Many of them continue using opioids for pain control, which puts them at risk for potential long-term adverse effects such as dependence, overdose and risk of falls. Although persisting pain and opioid use after TKA have been recognised to be important issues, individual strategies to decrease their burden have limitations and multi-component interventions, despite their potential, have not been well studied. In this study, we propose a multi-component pathway including personalized pain management, facilitated by a pain management coordinator. The objectives of this pilot trial are to evaluate feasibility (recruitment, retention, and adherence), along with opioid-free pain control at 8 weeks after TKA.

METHODS

This is a protocol for a multicentre pilot randomised controlled trial using a 2-arm parallel group design. Adult participants undergoing unilateral total knee arthroplasty will be considered for inclusion and randomised to control and intervention groups. Participants in the intervention group will receive support from a pain management coordinator who will facilitate a multicomponent pain management pathway including (1) preoperative education on pain and opioid use, (2) preoperative risk identification and mitigation, (3) personalized post-discharge analgesic prescriptions and (4) continued support for pain control and recovery up to 8 weeks post-op. Participants in the control group will undergo usual care. The primary outcomes of this pilot trial are to assess the feasibility of participant recruitment, retention, and adherence to the interventions, and key secondary outcomes are persisting pain and opioid use.

DISCUSSION

The results of this trial will determine the feasibility of conducting a definitive trial for the implementation of a multicomponent pain pathway to improve pain control and reduce harms using a coordinated approach, while keeping an emphasis on patient centred care and shared decision making.

TRIAL REGISTRATION

Prospectively registered in Clinicaltrials.gov (NCT04968132).

Opioid-free versus opioid-sparing anaesthesia in ambulatory total hip arthroplasty: a randomised controlled trial

BACKGROUND

Enhanced recovery after surgery pathways are essential for ambulatory surgery. They usually recommend lower intraoperative opioid use to avoid opioid-related adverse effects. This has led to opioid-sparing anaesthesia (OSA) techniques, with the extreme approach of opioid-free anaesthesia (OFA) mostly with dexmedetomidine. As evidence is lacking in day-case primary total hip arthroplasty, this study was performed to assess the potential benefits in postoperative analgesia of OFA over OSA.

METHODS

In this single-centre, prospective, triple blind study, we randomly allocated 80 patients undergoing day-case primary THA under general anaesthesia. Patients received a total intravenous anaesthesia with a laryngeal mask and multimodal analgesic regimen with non-opioid analgesics. The OSA group received low dose of sufentanil, and the OFA group received dexmedetomidine The primary outcome was the opioid consumption in the first 24 h in oral morphine equivalents (OME).

RESULTS

There was no difference in median cumulative OME consumption at 24 h between the OSA and OFA groups (12 [0-25] mg vs 16 [0-30] mg, respectively; P=0.7). Pain scores were similar and low in both groups with comparable walking recovery time. Adverse events were sparse and equivalent in both groups except for dizziness, which was more frequent in the OSA group (P<0.05).

CONCLUSIONS

In day-case total hip arthoplasty under general anaesthesia, opioid-free anaesthesia and opioid-sparing anaesthesia both provide early recovery and effective postoperative pain relief. When compared with opioid-sparing anaesthesia, opioid-free anaesthesia does not decrease opioid consumption in the first 24 h. These findings do not suggest any significant benefit from complete intraoperative avoidance of opioids.

CLINICAL TRIAL REGISTRATION

NCT0507270.

Acute Perioperative Pain Management of the Orthopaedic Patient: Guidance for Operationalizing Evidence Into Practice

Orthopaedic surgery often results in pain, with less than half of patients reporting adequate relief. Unrelieved acute pain occurring after surgery increases the risk of negative sequelae, including delayed healing, increased morbidity, pulmonary complications, limited rehabilitation participation, anxiety, depression, increased length of stay, prolonged duration of opioid use, and the development of chronic pain. Interventions that are individualized, evidence-informed, and applied within an ethical framework improve healthcare delivery for patients, clinicians, and healthcare organizations. Recommendations for using the principles of effective pain management from preoperative assessment through discharge are detailed, including recommendations for addressing barriers and challenges in applying these principles into clinical practice.

Intrathecal Morphine for Cardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

ABSTRACT

Cardiac surgeries often result in significant postoperative pain, leading to considerable use of opioids for pain management. However, excessive opioid use can lead to undesirable side effects and chronic opioid use. This systematic review and meta-analysis aimed to evaluate whether preoperative intrathecal morphine could reduce postoperative opioid consumption in patients undergoing cardiac surgery requiring sternotomy. We conducted a systematic search of Cochrane, EMBASE, and MEDLINE databases from inception to May 2022 for randomized controlled trials that evaluated the use of intrathecal morphine in patients undergoing cardiac surgery. Studies that evaluated intrathecal administration of other opioids or combinations of medications were excluded. The primary outcome was postoperative morphine consumption at 24 h. Secondary outcomes included time to extubation and hospital length of stay. The final analysis included ten randomized controlled trials, with a total of 402 patients. The results showed that postoperative morphine consumption at 24 h was significantly lower in the intervention group (standardized mean difference -1.43 [-2.12, -0.74], 95% CI, P < 0.0001). There were no significant differences in time to extubation and hospital length of stay. Our meta-analysis concluded that preoperative intrathecal morphine is associated with lower postoperative morphine consumption at 24 h following cardiac surgeries, without prolonging the time to extubation. The use of preoperative intrathecal morphine can be considered part of a multimodal analgesic and opioid-sparing strategy in patients undergoing cardiac surgery.

Ultrasound-guided serratus anterior plane block to prevent neurocognitive impairment in elderly patients after thoracoscopic lobectomy: protocol for a single-centre, double-blind, randomised controlled trial

INTRODUCTION

Postoperative neurocognitive dysfunction (PND), including postoperative delirium (POD), is a common complication in elderly patients after major surgeries, often leading to poor postoperative recovery. Although the pathological mechanism underlying PND is still unclear, postoperative pain is strongly associated with the development of PND. The ultrasound-guided serratus anterior plane block (SAPB) has been reported to relieve postoperative pain in thoracic surgery. Therefore, this prospective trial hypothesises that SAPB may reduce the incidence of PND in the elderly undergoing thoracoscopic lobectomy.

METHODS AND ANALYSIS

This study is designed as a single-centre, double-blind, randomised controlled clinical trial. A total of 256 elderly patients scheduled to undergo thoracoscopic lobectomy at Shanghai Pulmonary Hospital will be randomly assigned to general anaesthesia group or SAPB group. The primary outcome is the incidence of PND 7 days postoperatively or before discharge from hospital. The secondary outcomes include the occurrence of POD, the postoperative pain scores, Quality of Recovery at 1-2 days postoperatively and incidence of PND at 3 months postoperatively. The levels of fasting blood glucose in peripheral blood will be examined before and 1-2 days postoperatively.

ETHICS AND DISSEMINATION

The trial has been approved by the Clinical Research Ethics Committee of Shanghai Pulmonary Hospital (identifier: K20-290). All participants will be required to provide written informed consent before any protocol-specific procedures. Findings will be disseminated in a peer-reviewed journal and in national and/or international meetings to guide future practice.

TRIAL REGISTRATION NUMBER

ChiCTR2100052633.

Factors influencing early mobilisation for patients undergoing pancreatic surgery from multiple perspectives: a qualitative descriptive study

OBJECTIVES

Despite early mobilisation as a key component of enhanced recovery after surgery pathways for pancreatic surgery, the implementation of early mobilisation remains unsatisfactory. What factors influence the implementation of early mobilisation from the lens of all stakeholders is unclear. The aim of this study was to identify the influencing factors of early mobilisation in pancreatic surgery from the perspective of patients, family members and health professionals.

DESIGN

A qualitative descriptive design using individual interviews and focus groups.

SETTING AND PARTICIPANTS

Twenty-two patients undergoing pancreatic surgery, 10 family members and 10 healthcare professionals from a large university teaching hospital in China.

METHODS

We collected data on participants' views on factors influencing early mobilisation after pancreatic surgery. Two researchers independently reviewed the transcripts and emergent coding. The data were analysed using qualitative content analysis.

RESULTS

Three main categories that influenced the implementation of early mobilisation in pancreatic surgery were identified: (1) attitude towards early postoperative mobilisation (eg, perceived advantages or disadvantages of early mobilisation), (2) subjective norm (eg, impact from health professionals, family members and fellow patients) and (3) perceived behavioural control (eg, knowledge, abilities, resources and environment).

CONCLUSION

Factors influencing early mobilisation are diverse and multidimensional. The successful implementation of early mobilisation requires the dedication of both patients and healthcare professionals.

The Effect of Implementing a Standardized Enhanced Recovery After Surgery Pain Management Pathway at an Urban Medical Center in Hawaii

Traditional use of opioids to treat postoperative pain may lead to abuse and overdose. The development of Enhanced Recovery After Surgery (ERAS) protocols has helped to shift pain management from traditional methods to evidence-based best practices involving multimodal analgesia techniques. The purpose of this quality improvement project was to implement and determine the effectiveness of a standardized, evidence-based ERAS pain management pathway for patients undergoing colorectal or gynecology procedures at a medical center in Hawaii. After the intervention, the evaluation of data associated with opioid use, patients' pain scores, time spent in the postanesthesia care unit, and inpatient length of stay showed that most results were not significant. However, the ERAS pain management pathway did reduce clinical practice variations, intraoperative opioid administration, the time that patients spent in the postanesthesia care unit, and length of stay. The ERAS pain management pathway continues to be used and updated at this facility.

Do we really know if they are in pain? A cross-sectional study in hospitalised adult patients in Spain

AIMS

To describe the prevalence and characteristics of pain in adult hospitalised patients, as well as to analyse the concordance between patient-reported and recorded pain and its impact on analgesic management.

DESIGN

A cross sectional study.

METHODS

The study was performed on a sample of 611 patients, from October to December 2017. Data were obtained from patient interviews, review of medical and nursing records and review of electronic prescribing.

RESULTS

The prevalence of pain at the time of the interview was 36.7%. The median VAS score was 4. 90% of the patients had their pain assessed within the last 24 h; however, concordance between patient-reported pain and recorded pain in the nursing record was slight.

CONCLUSION

Pain is still often documented inadequately. Despite the wide use of analgesics, half of the patients with moderate to severe pain do not have adequate pain management. A systematic assessment and recording of pain promotes appropriate analgesic prescription.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

The findings of our study provide insight into the main gaps in the correct management of pain in hospitalised patients. A systematic assessment and recording of the pain suffered by the patient facilitates its control and allows a better management of the analgesic prescription by the physician. This information could help hospital managers to develop training programmes on pain assessment and on the importance of doctor-nurse collaboration to improve pain management, increasing the quality of care and reducing hospital costs.

REPORTING METHOD

The study has adhered to the relevant EQUATOR guidelines, according to The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.

PROSPECT methodology for developing procedure-specific pain management recommendations: an update

The procedure-specific postoperative pain management (PROSPECT) working group develops evidence-based pain management recommendations. PROSPECT methodology is unique and rigorous. However, several limitations were recognised that needed to be addressed, and several new factors were identified that improved PROSPECT methodology. The aim of this article is to present updated PROSPECT methodology for development of recommendations for procedure-specific pain management, focusing on the methodological revisions we will implement. In future, included randomised clinical trials will need to be prospectively registered on a publicly accessible clinical trials database and the study design, including the primary outcome in the registration, should coincide with that in the published manuscript. Placebo-controlled studies in which the analgesic intervention of interest is solely paracetamol, non-steroidal anti-inflammatory drugs, cyclo-oxygenase-2-specific inhibitors or opioids will not be included. Studies comparing one drug in a particular class with another in the same class will also not be included. Future projects will use the Cochrane Collaboration risk of bias tool for quality of reporting of methodology and results. A modified Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach will be used for grading of level of evidence and strength of recommendations. Finally, the updated PROSPECT methodology addresses several other limitations and implements new factors that all add rigour and transparency to developing procedure-specific pain management recommendations.

A comparison of the preemptive effects of oral pregabalin and gabapentin on acute postoperative sedation and complications in patients undergoing lumbar spine surgery

BACKGROUND

Gabapentinoids are often administered preoperatively, as they have been shown to reduce postoperative opioid consumption and pain scores however sedation has always been a concern because of sedative side effect.

OBJECTIVE

This study was intended to compare oral gabapentin versus oral pregabalin sedative effects and complications in patients undergoing lumbar spine surgery under general anaesthesia.

METHODS

This study was a true experimental randomised, placebo-controlled, prospective study, conducted at Rafedia Government Surgical Hospital in Nablus, Palestine. The sample consisted of 60 male and female patients undergoing elective lumbar spine surgeries in the department of neurology and aged from 18 to 70 years. The patients were divided into three groups (20 patients each): The pregabalin 150mg group, the gabapentin group and the placebo group.

FINDINGS

Nearly 51.7% of the participants reported that they experienced a feeling of nausea or vomiting after the operation. There were statistically significant differences (p-value = 0.008) between the groups in how often complications happen after surgery.

CONCLUSIONS

Preemptive pregabalin (150mg) was established to have a more sedative effect and lowered complications than gabapentin (300mg).

Basic analgesic use in randomised trials assessing local and regional analgesic interventions for mastectomy: a critical appraisal and clinical implications

Regional analgesia is a core component of an optimal multimodal analgesia technique. Several advanced regional analgesic techniques have been evaluated for mastectomy; however, the optimal choice remains unclear. Many randomised clinical trials (RCTs) evaluating various local/regional analgesic techniques do not include basic analgesics (i.e. paracetamol, non-steroidal anti-inflammatory drugs, cyclooxygenase-2 specific inhibitors, and dexamethasone) which precludes objective evaluation of their efficacy. The aim of this scoping review was to assess the use of basic analgesics in RCTs evaluating efficacy of local and regional analgesic techniques in patients undergoing mastectomy. PubMed was searched to identify relevant articles from January 1, 2010 to May 31, 2023. The key finding of this study is that almost 90% (n=82/92) of the RCTs evaluating local/regional analgesic techniques in patients undergoing mastectomy did not administer well accepted basic analgesics in the comparator groups. Consequently, the conclusions of the RCTs assessing local/regional analgesic techniques for mastectomy should be interpreted with caution. Also, clinical guidelines based on meta-analyses of these RCTs could be inadequate or inappropriate.

Efficacy and Safety of Transdermal Buprenorphine for Acute Postoperative Pain: A Systematic Review and Meta-analysis

Transdermal buprenorphine (TBUP) may have some advantages for the management of acute postoperative pain. The aim of this systematic review and meta-analysis was to investigate the efficacy and safety of TBUP compared to other analgesics or placebo for acute postoperative pain. A systematic search was conducted using Embase, MEDLINE, and Cochrane Central Register of Controlled Trials (CENTRAL) until December 26, 2022. The search included randomized controlled trials comparing TBUP versus other analgesics or placebo for acute postoperative pain. A certainty assessment was conducted using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. The protocol for this review was registered on Prospective Register of Systematic Reviews (CRD42022318601). In total, 15 studies involving 1,205 participants were included that compared TBUP versus fentanyl (n = 2), celecoxib (n = 3), placebo (n = 2), tramadol (n = 5), diclofenac (n = 3), parecoxib (n = 1), and flurbiprofen (n = 1). Meta-analyses were conducted for 3 comparators that involved 2 studies each. There was no significant difference in pain between TBUP 10 mcg/h versus fentanyl 25 mcg/h (standardized mean difference [SMD] -.03, 95% confidence interval [CI] -.86 to .81, P = .95, I2 = 85%). TBUP 10 mcg/h was associated with less pain compared to celecoxib 200 mg twice daily (SMD -.32, 95% CI -.58 to -.05, P = .02, I2 = 0%) and placebo (SMD -2.29, 95% CI -4.32 to -.27, P = .03, I2 = 94%). The GRADE assessment showed a very low certainty of evidence for all comparisons. There is insufficient evidence that TBUP improves pain control compared to other analgesics for acute postoperative pain. PERSPECTIVE: This systematic review and meta-analysis compared the use of TBUP to other analgesics for postoperative pain. The results showed that there is insufficient evidence to recommend the use of TBUP in this setting. The findings will help clinicians select the most appropriate opioid regimens for postoperative pain.

Ultrasound-guided Transversus Abdominis Plane Block is Effective as Laparoscopic Trocar site infiltration in Postoperative Pain Management in Patients Undergoing Adrenal Surgery

BACKGROUND

Pain management in patients undergoing laparoscopy is still a matter of debate as several techniques have been proposed to reduce postoperative analgesic consumption and improve recovery. Among these, transversus abdominis plane (TAP) block is considered as safe, effective, and easy to perform under ultrasound guidance; even so, recently laparoscopically guided trocar site anesthetic infiltration has been proposed as a "surgeon-dependent alternative to TAP block." The aim of this evaluation is to compare these analgesic techniques in the setting of laparoscopic adrenalectomy.

METHODS

This is a retrospective evaluation of a prospectively maintained database. Patients were divided into two groups: Group A patients received laparoscopic-assisted trocar site infiltration of ropivacaine; Group B patients received bilateral ultrasound-guided TAP block with ropivacaine. All patients received 24 h infusion of 20 mg morphine postoperatively; pain was checked at 6, 24 and 48 h after surgery. A rescue analgesia was given if numerical rating scale (NRS) score was > 4 or on patient request.

RESULTS

One hundred and three patients were enrolled in the evaluation (57 in group A and 46 in group B). There were no differences in operative time, complications and postoperative stay, and no complications related to trocar site infiltration. There were no differences in NRS at 6, 24, and 48 hours as well as in patients requiring further analgesic administration.

CONCLUSIONS

Laparoscopic-guided trocar site ropivacaine infiltration has similar pain outcomes compared to ultrasound-guided TAP block in the management of postoperative pain in patients undergoing laparoscopic adrenalectomy. Since there is no difference among these techniques, the decision can be based on surgeon or anesthesiologist preference.

Personalized checkpoint acupuncture can reduce postoperative pain after abdominal surgery-a STRICTA-conform pilot study

BACKGROUND

Optimal pain management is one of the core elements of Enhanced Recovery After Surgery (ERAS®) protocols and remains a challenge. Acupuncture (AC) is an effective treatment for various pain conditions. Systematic and personalized allocation of acupoints may be decisive for efficacy.

METHODS

Based on the predominant pressure sensitivity of six gastrointestinal (GI) checkpoints (G1-G6), we devised a method to detect personalized patterns of pain and a corresponding set of acupoints. We performed a single AC treatment with semi-permanent needles and assessed the visual analogue scale (VAS) score, pain threshold based on pressure algometry (PA), and temperature changes on abdominal skin areas before and 5 min after AC.

RESULTS

Between April and June 2021, thirty-eight patients were prospectively included in this pilot study. The mean reduction in subjective pain sensation as assessed by VAS was 86%, paralleled by an augmentation of the pain threshold as measured by PA by 64%. A small but significant increase in the skin temperature was observed above the abdominal surface. These effects were independent of the type of surgery.

CONCLUSION

Checkpoint acupuncture may be a complementary tool for postoperative pain management. Further investigations are needed to explore this analgesic effect.

Postoperative analgesia after surgical repair of distal radius fracture: a randomized comparison between distal peripheral nerve blockade and surgical site infiltration

BACKGROUND

Pain following open reduction and internal fixation of distal radius fracture (DRF) can be significant. This study compared the intensity of pain up to 48 hours after volar plating for DRF, associated to either an ultrasound guided distal nerve block (DNB) or surgical site infiltration (SSI).

METHODS

In this prospective single blind randomized study, 72 patients scheduled for DRF surgery under 1.5% lidocaine axillary block were allocated to receive, at the end of surgery, either an ultrasound-guided median and radial nerves block with ropivacaine 0.375% (DNB) performed by the anesthesiologist or a SSI with the same drug regimen, performed by the surgeon. Primary outcome was the duration between analgesic technique (H0) and pain reappearance (Numerical Rating Scale (NRS 0-10)>3). Secondary outcomes were the quality of analgesia, the quality of sleep, the magnitude of motor blockade, and the patient satisfaction. The study was built on a statistical hypothesis of equivalence.

RESULTS

Fifty-nine patients were included in the final per-protocol analysis (DNB=30, SSI=29). Time to reach NRS>3 was (in median [95%CI]) 267 min [155;727] and 164 min [120;181] respectively after DNB and SSI (difference=103 min [-22;594] - rejection of equivalence hypothesis). Pain intensity throughout the 48 hours, quality of sleep, opiate consumption, motor blockade and patient satisfaction was not significantly different between groups.

CONCLUSIONS

Although DNB provides a longer analgesia than SSI, both techniques gave comparable level of pain control during the first 48 hours after surgery, without any difference in the incidence of side effects or patient satisfaction.

Pain management after cardiac surgery via median sternotomy: A systematic review with procedure-specific postoperative pain management (PROSPECT) recommendations

BACKGROUND

Pain after cardiac surgery via median sternotomy can be difficult to treat, and if inadequately managed can lead to respiratory complications, prolonged hospital stays and chronic pain.

OBJECTIVES

To evaluate available literature and develop recommendations for optimal pain management after cardiac surgery via median sternotomy.

DESIGN

A systematic review using PROcedure-SPECific Pain Management (PROSPECT) methodology.

ELIGIBILITY CRITERIA

Randomised controlled trials and systematic reviews published in the English language until November 2020 assessing postoperative pain after cardiac surgery via median sternotomy using analgesic, anaesthetic or surgical interventions.

DATA SOURCES

PubMed, Embase and Cochrane Databases.

RESULTS

Of 319 eligible studies, 209 randomised controlled trials and three systematic reviews were included in the final analysis. Pre-operative, intra-operative and postoperative interventions that reduced postoperative pain included paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), intravenous magnesium, intravenous dexmedetomidine and parasternal block/infiltration.

CONCLUSIONS

The analgesic regimen for cardiac surgery via sternotomy should include paracetamol and NSAIDs, unless contraindicated, administered intra-operatively and continued postoperatively. Intra-operative magnesium and dexmedetomidine infusions may be considered as adjuncts particularly when basic analgesics are not administered. It is not clear if combining dexmedetomidine and magnesium would provide superior pain relief compared with either drug alone. Parasternal block/surgical site infiltration is also recommended. However, no basic analgesics were used in the studies assessing these interventions. Opioids should be reserved for rescue analgesia. Other interventions, including cyclo-oxygenase-2 specific inhibitors, are not recommended because there was insufficient, inconsistent or no evidence to support their use and/or due to safety concerns.

Pain experience of lung cancer patients during home recovery after surgery: A qualitative descriptive study

BACKGROUND

Patients with lung cancer surgery often suffer pain after discharge. However, there is limited evidence to describe the pain experience from the qualitative investigation. This study was designed to describe the pain experience of lung cancer patients during home recovery after surgery and to provide evidence for developing pain management strategies.

METHODS

This qualitative descriptive study recruited 35 patients who had received lung resection and were discharged by purposive sampling from May to July 2022. Mobile phone interviews were conducted to collect views on patients' pain experience after discharge. The interviews were audio-recorded and converted verbatim into standard text, and the data were iteratively thematic analyzed.

RESULTS

A thematic framework was identified for three themes: perception and impact of pain, coping styles for pain, and unmet needs for pain. Whether short or long-term after discharge, patients complain that they suffer from different degrees and types of pain, causing them a "double burden" physically and mentally. The lack of knowledge about pain may lead them to adopt very different coping styles and desire professional continuous pain management.

CONCLUSIONS

This study may help clarify the status of pain problems that patients face after lung cancer surgery and provides multiple dimensions of pain assessment and management objectives for quantitative research. We call on medical staff to pay attention to patients' perspectives and related needs after discharge and formulate targeted management strategies to reduce pain and improve their quality of life.

Comment on Crettenand et al. Is Continuous Wound Infiltration a Better Option for Postoperative Pain Management after Open Nephrectomy Compared to Thoracic Epidural Analgesia? J. Clin. Med. 2023, 12, 2974

We have read with great interest the retrospective study recently published by Crettenand et al. in this journal [...].

Reply to Beilstein, C.M.; Wuethrich, P.Y. Comment on "Crettenand et al. Is Continuous Wound Infiltration a Better Option for Postoperative Pain Management after Open Nephrectomy Compared to Thoracic Epidural Analgesia? J. Clin. Med. 2023, 12, 2974"

We appreciate your comprehensive comment [...].

Day-surgery adult patients with obesity and obstructive sleep apnea: Current controversies and concerns

Obesity and obstructive sleep apnea are considered independent risk factors that can adversely affect perioperative outcomes. A combination of these two conditions in the ambulatory surgery patient can pose significant challenges for the anesthesiologist. Nevertheless, these patients should not routinely be denied access to ambulatory surgery. Instead, patients should be appropriately optimized. Anesthesiologists and surgeons must work together to implement fast-track anesthetic and surgical techniques that will ensure successful ambulatory outcomes.

The Relationship Between Fear Avoidance Belief and Threat Learning in Postoperative Patients After Lung Surgery: An Observational Study

Background

The role of fear-avoidance beliefs (FAB) in patients with chronic pain has been widely confirmed. However, few conclusions have been drawn about its role in postoperative patients.

Objective

To explore the characteristics of FAB in postoperative patients after lung surgery as well as the effect of threat learning on FAB.

Methods

Between May and September 2022, this study recruited 150 participants who had undergone thoracoscopic surgery. Variables such as age, gender, education, chronic pain, fear of pain, surgery method, pain intensity, FAB, cough, ambulation and threat learning were collected and subjected to correlation analysis and stepwise regression.

Results

The correlation analysis revealed that FAB was associated with age (r = -0.183, p < 0.05), gender (r = -0.256, p < 0.01), and preoperative FOP-9 (r = 0.400, p < 0.01). Postoperative variables such as pain intensity (r = 0.574, p < 0.01), initiation day of ambulation (r = 0.648, p < 0.01), total numbers of ambulation (r = -0.665, p < 0.01), and cough performance (r = -0.688, p < 0.01) were correlated with FAB. Furthermore, FAB was highly correlated with indicators of threat learning: direct (r = 0.556, p < 0.01), observation (r = 0.655, p < 0.01), and instruction (r = 0.671, p < 0.01). The highest variance explanation model of stepwise regression which explained 52.8% of the variance including instruction (B=1.751; p<0.01), direct (B=1.245; p<0.01), observation (B=0.768; p<0.01), age (B=-0.085; p<0.01), and surgery method (B=1.321; p<0.05).

Conclusion

Patients commonly experience FAB after lung surgery, which can directly affect their recovery behaviors such as ambulation and active coughing. The formation of FAB is influenced by threat learning, which suggests that controlling threat learning is important in preventing postoperative FAB.

Assessment of Ultrasound-Guided Continuous Low Serratus Anterior Plane Block for Pain Management After Hepatectomy: A Randomized Controlled Trial

Purpose

Adequate postoperative analgesia is a key to earlier recovery from open surgery. This work investigated the pain control and quality of patient recovery after hepatectomy to evaluate the modified continuous serratus anterior plane block (called low SAPB) for postoperative analgesia.

Patients and Methods

This single-center, blinded, randomized, controlled study included 136 patients who underwent hepatectomy under general anesthesia. For postoperative analgesia, the patients in the SAPB group were given a continuous low SAPB at the 7th intercostal space in the right mid-axillary line, and the patients in the control group were given continuous intravenous opioid analgesia. The numeric pain rating scale (NPRS) was used for pain assessment. The postoperative assessment focused on the remedial drug consumption, the occurrence of adverse postoperative analgesic reactions, and the quality of patient recovery evaluated with the QoR-15 questionnaire.

Results

Compared to the controls, the SAPB patients had significantly lower NPRS scores at 12 h and 24 h at rest and 6 h, 12 h, and 24 h in motion, and a longer time to first use of remedial analgesics at 24 h, and higher overall QoR-15 scores at 24 h [124 (121, 126) vs 121 (120, 124)] and 48 h [129 (126, 147) vs 126 (125, 128)], after surgery. There was no significant difference in the incidence of analgesia-related adverse reactions between the two groups.

Conclusion

The continuous low SAPB could achieve superior pain control, especially for motor pain, to intravenous opioid analgesia during the first 24 h post-surgery. Even with no significant difference in the incidence of postoperative adverse reactions, patients with continuous low SAPB appeared to have a higher quality of recovery in the first two days post-surgery than patients with continuous intravenous analgesia.

Topical use of tranexamic acid can reduce opioid consumption compared with intravenous use for patients undergoing primary total hip arthroplasty: a prospective randomized controlled trial

BACKGROUND

The problem of opioid addiction after total hip arthroplasty (THA) has been widely concerned. Tranexamic acid (TXA) has been shown to be effective in reducing blood loss for patients undergoing THA, but few studies focus on its alleviation of postoperative local pain symptoms. The purpose of this study was to investigate whether topical TXA could reduce early postoperative hip pain for primary THA patients, thereby reducing the use of opioids, and whether local pain is related to inflammatory response.

METHODS

In this prospective randomized controlled study, we randomly divided 161 patients into a topical group (n = 79) and an intravenous group (n = 82). Hip pain was assessed using the visual analogue scale (VAS) score within three days after surgery and tramadol was used for pain relief when necessary. Inflammatory markers such as high-sensitivity C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), interleukin-6 (IL-6), total blood loss and hemoglobin drop were assessed by hematologic tests. The primary outcomes included the VAS score and dose of tramadol from the first to the third day after surgery. The secondary outcomes included the inflammatory markers level, total blood loss and complications.

RESULTS

The pain score and inflammation markers level on the first day in the topical TXA group were significantly lower than those in the intravenous TXA group (P < 0.05). The correlation analysis showed that the VAS score on the first day after surgery was positively correlated with the inflammation markers level (P < 0.05). The tramadol dose for topical group was lower than intravenous group on the first and second day after surgery. There were no differences in total blood loss between the two groups (640.60 ± 188.12 ml vs. 634.20 ± 187.85 ml, P = 0.06). There was no difference in the incidence of complications.

CONCLUSION

Topical use of TXA could relieve the local pain symptoms and reduce opioid consumption compared with intravenous use for patients undergoing primary THA by reduce the early postoperative inflammatory response.

TRIAL REGISTRATION

The trial was registered at the China Clinical Trial Registry (ChiCTR2100052396) on 10/24/2021.

Modulation of the Inflammatory Response by Pre-emptive Administration of IMT504 Reduces Postoperative Pain in Rats and has Opioid-Sparing Effects

Despite the available knowledge on underlying mechanisms and the development of several therapeutic strategies, optimal management of postoperative pain remains challenging. This preclinical study hypothesizes that, by promoting an anti-inflammatory scenario, pre-emptive administration of IMT504, a noncoding, non-CpG oligodeoxynucleotide with immune modulating properties, will reduce postincisional pain, also facilitating therapeutic opioid-sparing. Male adult Sprague-Dawley rats with unilateral hindpaw skin-muscle incision received pre-emptive (48 and 24 hours prior to surgery) or postoperative (6 hours after surgery) subcutaneous vehicle (saline) or IMT504. Various groups of rats were prepared for pain-like behavior analyses, including subgroups receiving morphine or naloxone, as well as for flow-cytometry or quantitative RT-PCR analyses of the spleen and hindpaws (for analysis of inflammatory phenotype). Compared to vehicle-treated rats, pre-emptive IMT504 significantly reduced mechanical allodynia by 6 hours after surgery, and accelerated recovery of basal responses from 72 hours after surgery and onwards. Cold allodynia was also reduced by IMT504. Postoperative administration of IMT504 resulted in similar positive effects on pain-like behavior. In IMT504-treated rats, 3 mg/kg morphine resulted in comparable blockade of mechanical allodynia as observed in vehicle-treated rats receiving 10 mg/kg morphine. IMT504 significantly increased hindpaw infiltration of mesenchymal stem cells, CD4+T and B cells, and caused upregulated or downregulated transcript expressions of interleukin-10 and interleukin-1β, respectively. Also, IMT504 treatment targeted the spleen, with upregulated or downregulated transcript expressions, 6 hours after incision, of interleukin-10 and interleukin-1β, respectively. Altogether, pre-emptive or postoperative IMT504 provides protection against postincisional pain, through participation of significant immunomodulatory actions, and exhibiting opioid-sparing effects. PERSPECTIVE: This preclinical study introduces the noncoding non-CpG oligodeoxynucleotide IMT504 as a novel modulator of postoperative pain and underlying inflammatory events. The opioid-sparing effects observed for IMT504 appear as a key feature that could contribute, in the future, to reducing opioid-related adverse events in patients undergoing surgical intervention.

Clinical application of enhanced recovery after surgery concept in laparoscopic treatment of pediatric acute appendicitis

BACKGROUND

This study assesses whether enhanced recovery after surgery (ERAS) is beneficial in treating acute appendicitis in pediatrics by laparoscopic techniques.

METHOD

The children with acute appendicitis (n = 116) were divided into the ERAS group (n = 54) and the control group (n = 62). Then the preoperative data, intraoperative observation indexes, and postoperative data were analyzed.

RESULTS

There was no significant difference in preoperative data and intraoperative observation indexes between the two groups. C-reactive protein (CRP) and white blood cell (WBC) in the ERAS group were significantly lower than those in the control group 3 days after the operation. Moreover, no significant difference in the visual analog score (VAS) between the two groups 3 days after the operation, but the other postoperative observation indexes in the ERAS group were significantly better than those in the control group. Nausea and vomiting in the ERAS group were significantly lower than those in the control group, with no significant difference in other complications between the two groups.

CONCLUSION

ERAS could improve children's comfort, reduce some postoperative complications, reduce hospitalization expenses, and speed up recovery from acute appendicitis treated by laparoscopy. Therefore, it has clinical application value.

Enhanced Recovery After Surgery Program and Opioid Consumption in Pulmonary Resection Surgery: A Retrospective Observational Study

BACKGROUND

Pulmonary resection surgery causes severe postoperative pain and usually requires opioid-based analgesia, particularly in the early postoperative period. However, the administration of large amounts of opioids is associated with various adverse events. We hypothesized that patients who underwent pulmonary resection under an enhanced recovery after surgery (ERAS) program consumed fewer opioids than patients who received conventional treatment.

METHODS

A total of 2147 patients underwent pulmonary resection surgery between August 2019 and December 2020. Two surgeons (25%) at our institution implemented the ERAS program for their patients. After screening, the patients were divided into the ERAS and conventional groups based on the treatment they received. The 2 groups were then compared after the stabilized inverse probability of treatment weighting. The primary end point was the total amount of opioid consumption from surgery to discharge. The secondary end points included daily average and highest pain intensity scores during exertion, opioid-related adverse events, and clinical outcomes, such as length of intensive care unit (ICU) stay, hospital stay, and postoperative complication grade defined by the Clavien-Dindo classification. Additionally, the number of patients discharged without opioids prescription was assessed.

RESULTS

Finally, 2120 patients were included in the analysis. The total amount of opioid consumption (median [interquartile range]) after surgery until discharge was lower in the ERAS group (n = 260) than that in the conventional group (n = 1860; morphine milligram equivalents, 44 [16-122] mg vs 208 [146-294] mg; median difference, -143 mg; 95% CI, -154 to -132; P < .001). The number of patients discharged without opioids prescription was higher in the ERAS group (156/260 [60%] vs 329/1860 [18%]; odds ratio, 7.0; 95% CI, 5.3-9.3; P < .001). On operation day, both average pain intensity score during exertion (3.0 ± 1.7 vs 3.5 ± 1.8; mean difference, -0.5; 95% CI, -0.8 to -0.3; P < .001) and the highest pain intensity score during exertion (5.5 ± 2.1 vs 6.4 ± 1.7; mean difference, -0.8; 95% CI, -1.0 to -0.5; P < .001) were lower in the ERAS group than in the conventional group. There were no significant differences in the length of ICU stay, hospital stay, or Clavien-Dindo classification grade.

CONCLUSIONS

Patients who underwent pulmonary resection under the ERAS program consumed fewer opioids than those who received conventional management while maintaining no significant differences in clinical outcomes.

The Role of the Recovery Room in Improving Adherence During an Enhanced Recovery After Surgery (ERAS) Implementation Program for Colorectal Surgery: A Single-Center Retrospective Analysis

PURPOSE

The purpose of thisstudy was to evaluate the clinical impact of the Recovery Room (RR) in an Enhanced Recovery After Surgery (ERAS) pathway in colorectal surgery.

DESIGN

Single-center retrospective study.

METHODS

From November 2019 until September 2021, a total of 149 consecutive patients that underwent to colon-rectal surgery were enrolled. The patients were divided into two study groups: RR Group if admitted to RR after surgery, and no-Recovery Room (NRR) Group if monitored directly on the ward, bypassing the RR. The postoperative ERAS items adherence was assessed in the two study groups.

FINDINGS

Final analysis included 119 patients in the RR Group and 30 patients in NRR Group. Patients that started clear liquid oral intake within two hours postoperatively were 118 in the RR group and 19 in the NRR group (99.1% vs 63.3%, P < .001). A total of 98 patients and 18 patients were mobilized on day 0 in the RR group and in NRR group, respectively (84.4% vs 15.5%, P < .05). In the RR group, postoperative adherence to the ERAS protocol components was higher in comparison with the NRR group (P < .003); adherence to the all protocol components was also higher (P < .004).

CONCLUSIONS

Among patients undergoing colorectal surgery admitted to RR after surgery, the RR nurse guaranteed effective patient assistance and ensured appropriate compliance to the postoperative ERAS items.

Pain severity scale: A methodology for classifying postoperative pain severity by surgical procedure

Background

Acute postoperative pain is common following many types of surgery, and a significant subset of patients experience severe pain, which can be difficult to manage and result in postoperative complications. Opioid agonists are commonly used to treat severe postoperative pain, but their use has been associated with adverse outcomes. This retrospective study uses data from the Veterans Administration Surgical Quality Improvement Project (VASQIP) database to develop a postoperative Pain Severity Scale (PSS) based on subjective pain reports and postoperative opioid requirements.

Methods

Postoperative pain scores and opioid prescription data were extracted from the VASQIP database for surgeries occurring between 2010 and 2020. Procedures were grouped by surgical Common Procedural Terminology (CPT) codes, and a total of 165,321 surgical procedures were examined, representing 1141 distinct CPT codes. K-means clustering analysis was used to group the surgeries based on 24-h maximum pain, 72-h average pain, and postoperative opioid prescriptions.

Results

K-means clustering analysis showed two optimal grouping strategies; one with 3 and the other with 5 groups. Both clustering strategies produced a PSS that categorized surgical procedures with generally increasing pain scores and opioid requirements. The 5-group PSS accurately captured typical postoperative pain experience across a range of procedures.

Conclusions

K-means clustering produced a Pain Severity Scale that can distinguish typical postoperative pain for a large variety of surgical procedures based on subjective and objective clinical data. The PSS will facilitate research into the optimal postoperative pain management and could be used in the development of clinical decision support tools.

Opioid consumption and non-opioid multimodal analgesic treatment in pain management trials after hip and knee arthroplasties: A meta-epidemiological study

BACKGROUND

The leading principle in peri-operative pain management is multimodal analgesia, which reduces opioid requirements and associated adverse effects. Pragmatic pain trials should optimally test interventions in addition to multimodal non-opioid analgesics and interventions to ensure clinical relevance and baseline levels of opioid consumption that reflect clinical settings. We aimed to investigate opioid consumption and use of non-opioid analgesics administered adjunct to interventions in post-operative pain trials after total hip and knee arthroplasty.

METHODS

A systematic literature search was conducted 7 January 2020 in The Cochrane Library's CENTRAL, PubMed, and EMBASE. Trials investigating analgesic interventions for post-operative pain in adults undergoing total hip or knee arthroplasty were included. The primary outcome was the aggregated median 0-24 h post-operative opioid consumption. Further, we assessed the use of paracetamol, non-steroidal anti-inflammatory drugs, gabapentinoids, high-dose glucocorticoids, local infiltration analgesia and nerve blocks administered as co-interventions equally to all participants. We assessed trends over time for all outcomes.

RESULTS

Of 14,200 records, 570 trials were included. Median 0-24 h opioid consumption was 21 and 22 mg iv morphine equivalents in hip and knee arthroplasty trials, respectively. Meta-regression showed no overall linear correlation between opioid consumption and publication year. The use of multimodal non-opioid analgesia increased over time, though only 48% of trials published from 2010 to 2020 administered two or more non-opioid analgesics. Applying more non-opioid analgesics was associated with lower opioid consumption in intervention groups.

CONCLUSION

Post-operative 0-24 h morphine consumption was median 21-22 mg. The demonstrated differences in non-opioid multimodal analgesic regimens between research and clinical settings, can potentially diminish the demonstrated opioid-sparing effects of trial interventions when such are implemented in a clinical context.

Impact of preoperative treatment with antidepressants and/or anxiolytics on outcomes after colorectal surgery with an enhanced recovery programme: a monocentric retrospective study. Acta Chir Belg 2023;123:54-61. [PMID: 34121612 DOI: 10.1080/00015458.2021.1940727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

BACKGROUND

Preoperative use of antidepressants and anxiolytics was reported to increase length of hospital stay (LOS) and worsen surgical outcomes. However, the surgical procedures studied were seldom performed with an enhanced recovery programme (ERP). This study investigated whether these medications impaired postoperative recovery after colorectal surgery with an ERP.

METHODS

The data of all patients scheduled for colorectal surgery between November 2015 and December 2019 prospectively included in our database were analysed. All the patients were managed with the same ERP. Demographic data, risk factors, incidence of postoperative complications, LOS, and adherence to the ERP were compared between patients with and without preoperative antidepressant and/or anxiolytic treatment.

RESULTS

Of the 502 patients, 157 (31.3%) were treated with antidepressants and/or anxiolytics. They were older (65.7 vs. 59.5 years, p < 0.001), sicker (higher ASA physical status score, p = 0.001), and underwent surgery more frequently for cancer (73.9 vs. 56.8%, p < 0.001). Overall adherence to ERP (p = 0.99) and adherence to the postoperative items of ERP (p = 0.29), incidence of postoperative complications (35.7 vs. 33.2%, p = 0.61), and LOS (4 [2-7] vs. 4 [2-7], p = 0.99) were similar in the two groups.

CONCLUSIONS

Our findings suggest that preoperative treatment with antidepressants and/or anxiolytics does not worsen outcome after elective colorectal surgery with an ERP, does not impact adherence to ERP, and does not prolong LOS. ERP seems efficacious in patients treated with these medications, who should therefore not be excluded from this programme.