Preemptive Analgesia in Minimally Invasive Gynecologic Surgery

A Randomized Controlled Trial Assessing the Effect of Preoperative Ibuprofen Administration on Postoperative Pain Reduction Following Miniscrew Insertion

OBJECTIVE

To evaluate the impact of preoperative oral ibuprofen premedication as a preemptive analgesia protocol on postoperative pain following the insertion of a single miniscrew insert.

METHODS

A randomized, single-blind, placebo-controlled parallel-group trial design was adopted. A total of 68 patients seeking miniscrew insert placement were recruited based on inclusion and exclusion criteria. Patients were randomly assigned in a 1:1 ratio to either the ibuprofen group or the control group, with 34 patients in each group. The ibuprofen group and the control group received 300 mg of ibuprofen sustained-release capsules and a placebo, respectively, 30 min before surgery. Postoperative analgesics were administered as needed. Pain scores at 2, 4, 6, 8, 12, and 24 h postoperatively were recorded using the Numerical Rating Scale (NRS), and the postoperative analgesic consumption was documented.

RESULTS

A total of 68 patients (34 in the control group and 34 in the preemptive analgesia group) completed the trial. No adverse events such as nausea or vomiting occurred in any of the patients. The preemptive analgesia group exhibited significantly lower pain scores at 2, 4, 6, and 8 h postoperatively [2 (0,3), 0 (0,2), 0 (0,0), 0 (0,0.25), respectively] compared to the control group [3 (2,5), 3 (2,4), 2 (0.75,4), 1 (0,3), respectively] (P = 0.0396, P = 0.0067, P = 0.0111, P = 0.0299). The proportions of patients requiring additional analgesics within 2-24 h postoperatively were 17.6% (6/34) in the preemptive analgesia group and 64.7% (22/34) in the control group, with a statistically significant difference between the two groups (P = 0.013).

CONCLUSION

Preemptive analgesia with ibuprofen can effectively reduce postoperative pain following miniscrew insert placement and represents a safe and effective perioperative pain management strategy.

TRIAL REGISTRATION

The UK's Clinical Study Registry; ISRCTN68332234 (Retrospectively registered); 20/12/2024.

The Impact of Pudendal Nerve Injection in Vaginal Surgery: A Secondary Analysis

IMPORTANCE

Evidence regarding the effect of pudendal nerve blockade during vaginal surgery is conflicting. Previous studies compared pudendal nerve blockade to either normal saline placebo injection or no injection, demonstrating small or no difference in pain outcomes. Studies investigating nerve blocks at the time of vaginal surgery have not evaluated the effect of infiltration of the space around the pudendal nerve.

OBJECTIVE

The aim of the study was to determine whether intraoperative pudendal nerve injection (bupivacaine or normal saline) will result in improved pain scores and satisfaction compared with patients who receive no pudendal injection.

STUDY DESIGN

We performed a secondary analysis of 2 randomized controlled trials investigating postoperative pain after vaginal reconstructive surgery, comparing the outcomes of the following 3 groups: control (no pudendal injection), intervention (bilateral pudendal nerve blockade), and placebo (bilateral normal saline pudendal injections). The primary outcome was postoperative pain scores. Secondary outcomes were opioid use, patient satisfaction, and postoperative complications. Linear mixed effects models were applied to outcomes, and treatment effects with 95% confidence intervals were estimated at each time point from the model.

RESULTS

One hundred four patients who underwent vaginal surgery were included: 36 pudendal nerve block, 35 normal saline pudendal injection, and 33 no injection. The groups were well-matched. Linear mixed effects models demonstrated no significant differences between treatment groups for postoperative pain severity scores, opioid use, and patient-reported satisfaction at each time point.

CONCLUSIONS

Normal saline injection and no injection seem to have no clinically meaningful difference in effect, and either could reasonably serve as control for pudendal blockade during vaginal surgery.

Paracervical block before laparoscopic total hysterectomy: A randomized controlled trial

OBJECTIVE

To test the hypothesis that paracervical block with 0.5 % bupivacaine decreases postoperative pain after total laparoscopic hysterectomy (TLH).

MATERIALS AND METHOD

This randomized double-blind placebo control trial included 152 women. We injected 10 mL 0.5 % bupivacaine (study group, n = 75) or 10 mL normal saline (control group, n = 77) at the 3 and 9 o'clock positions of the uterine cervix. The primary outcome was the visual analog scale score (VAS) determined 1 h (h) postoperatively.

RESULTS

The 152 patients did not differ in their baseline demographics or perioperative characteristics. The mean VAS 1 h postoperatively was significantly lower in the study group than in controls (5.7 ± 1.2 vs. 6.8 ± 1.1, P < 0.001). The average VAS at 30 min, 3 h, and 6 h postoperatively was also significantly lower in the study group. Patients in the study group had a significantly lower analgesic requirement than did controls during the first 24 h postoperatively (6 [7.8 %] vs. 16 [21 %], P = 0.021). Total QoR-40 questionnaire scores were higher in patients who received bupivacaine.

CONCLUSION

Paracervical bloc with 0.5 % bupivacaine just before TLH is an effective and safe method to reduce pain and lower postoperative analgesic requirement. URL LINK THAT LEADS DIRECTLY TO THE TRIAL REGISTRATION: https://clinicaltrials.gov/ct2/show/NCT05341869?cond=NCT05341869&draw=2&rank=1.

Can robotic-assisted surgery support enhanced recovery programs?

Enhanced recovery after surgery (ERAS) protocols comprise a multimodal approach to optimize patient outcome and recovery. ERAS guidelines recommend minimally invasive surgery (MIS) when possible. Key components in MIS include preoperative patient education and optimization; multimodal and narcotic-sparing analgesia; prophylactic measures regarding nausea, infection, and venous thrombosis; maintenance of euvolemia; and promotion of the early activity. ERAS protocols in MIS improve outcome mainly in terms of reduced length of stay and subsequently reduced cost. In addition, ERAS protocols in MIS reduce postoperative pain and nausea, increase patient satisfaction, and might reduce the rate of postoperative complications. Robotic surgery supports ERAS through facilitating MIS in complex procedures where laparotomy is an alternative approach.

Low-dose intranasal dexmedetomidine premedication improves epidural labor analgesia onset and reduces procedural pain on epidural puncture: a prospective randomized double-blind clinical study

BACKGROUND

Epidural labor analgesia is a safe and effective method of pain management during labor with the drawbacks of delayed onset and maternal distress during epidural puncture. This study aimed to determine whether pretreatment with intranasal low-dose dexmedetomidine effectively shortens the onset of analgesia and reduces procedural pain.

METHODS

In this prospective, randomized double-blind trial, nulliparous patients were randomly assigned to either the intranasal dexmedetomidine group or the control group. The intranasal dexmedetomidine group received 0.5 μg/kg dexmedetomidine intranasally, and the control group received an equal volume of normal saline intranasally. Both groups were maintained with a programmed intermittent epidural bolus. The primary outcome was the onset time of analgesia and scores of pain related to the epidural puncture.

RESULTS

Seventy-nine patients were enrolled, and 60 completed the study and were included in the analysis. The time to achieve adequate analgesia was significantly shorter in the intranasal dexmedetomidine group than in the control group (hazard ratio = 2.069; 95% CI, 2.187 to 3.606; P = 0.010). The visual analogue scale pain scores during epidural puncture in the intranasal dexmedetomidine group were also significantly lower than those in the control group (2.0 (1.8-2.5) vs. 3.5 (3.3-4.5), P ≤ 0.001, Table 2). Pretreatment with intranasal dexmedetomidine before epidural labor analgesia was associated with improved visual analogue scale pain scores and Ramsay scores, less consumption of analgesics and higher maternal satisfaction (P < 0.05). No differences were observed for labor and neonatal outcomes or the incidence of adverse effects between the two groups.

CONCLUSIONS

Pretreatment with intranasal dexmedetomidine before epidural labor analgesia yielded a faster onset of analgesia and decreased epidural puncture pain without increasing adverse effects. Pretreatment with intranasal dexmedetomidine may be a useful adjunct for the initiation of epidural analgesia, and further investigation should be encouraged to determine its utility more fully.

TRIAL REGISTRATION

This trial was prospectively registered at Chictr.org.cn on 29/05/2020 with the registration number ChiCTR2000033356 ( http://www.chictr.org.cn/listbycreater.aspx ).

Perioperative opioid management for minimally invasive hysterectomy

Given the high volume of hysterectomies performed, the contribution of gynecologists to the opioid crisis is potentially significant. Following a hysterectomy, most patients are over-prescribed opioids, are vulnerable to developing new persistent opioid use, and can be the source of misuse, diversion, or accidental exposure. People who misuse opioids are at risk of an overdose related death, which is now one of the leading causes of death in the United States and is rising in other countries. It is the physician's responsibility to reduce opioid use by making impactful practice changes, such as 1) using pre-emptive opioid sparing strategies, 2) optimizing multimodal nonopioid pain management, 3) restricting postoperative opioid prescribing, and 4) educating patients on proper disposal of unused opioids. These changes can be implemented with an enhanced recovery after surgery protocol, shared decision-making, and patient education strategies related to opioids.

AUGS-IUGA Joint Clinical Consensus Statement on Enhanced Recovery After Urogynecologic Surgery: Developed by the Joint Writing Group of the International Urogynecological Association and the American Urogynecologic Society. Individual writing group members are noted in the Acknowledgements section

INTRODUCTION AND HYPOTHESIS

Enhanced recovery after surgery (ERAS) evidence-based protocols for perioperative care can lead to improvements in clinical outcomes and cost savings. This article aims to present consensus recommendations for the optimal perioperative management of patients undergoing urogynecological surgery.

METHODS

A review of meta-analyses, randomized clinical trials, large nonrandomized studies, and review articles was conducted via PubMed and other databases for ERAS and urogynecological surgery. ERAS protocol components were established, and then quality of the evidence was both graded and used to form consensus recommendations for each topic. These recommendations were developed and endorsed by the writing group, which is comprised of the American Urogynecologic Society and the International Urogynecological Association members.

RESULTS

All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. The components of ERAS with a high level of evidence to support their use include fasting for 6 h and taking clear fluids up to 2 h preoperatively, euvolemia, normothermia, surgical site preparation, antibiotic and antithrombotic prophylaxis, strong antiemetics and dexamethasone to reduce postoperative nausea and vomiting, multimodal analgesia and restrictive use of opiates, use of chewing gum to reduce ileus, removal of catheter as soon as feasible after surgery and avoiding systematic use of drains/vaginal packs.

CONCLUSIONS

The evidence base and recommendations for a urogynecology-relevant ERAS perioperative care pathway are presented in this consensus review. There are several elements of ERAS with strong evidence of benefit in urogynecological surgery.

Preemptive Infiltration of Local Anesthetics During Vaginal Hysterectomy: A Systematic Review and Meta-analysis of Randomized Controlled Trials

IMPORTANCE

Vaginal hysterectomy (VH) is the preferred route of choice for women desiring hysterectomy to treat uterine pathology, including premalignant conditions and fibroids.

OBJECTIVE

The aim of this study was to evaluate the impact of the use of preemptive local analgesia (LA) on postoperative pain and perioperative outcomes for women undergoing VH.

STUDY DESIGN

A systematic search of 4 electronic databases (MEDLINE, Scopus, Cochrane CENTRAL Register of Controlled Trials, and Clinicaltrials.gov ) was performed for articles published up to January 2021. All randomized controlled trials that presented outcomes of patients who underwent VH due to pelvic floor disorders or other benign gynecological disorders and received local infiltration analgesia were finally included.

RESULTS

A total of 5 studies with 277 women (138 LA group vs 199 no-LA group) who underwent a VH were included in the present meta-analysis. Mean pain scores at both 30 minutes to 2 hours and 3 to 6 hours postoperatively were significantly lower in the LA group compared with the non-LA group (220 patients: mean difference [MD], -1.75; 95% confidence interval [CI], -2.77 to -0.74; P = 0.0007; and 220 patients: MD, -1.68; 95% CI, -2.28 to 1.09; P < 0.00001, respectively). Morphine/narcotic opioid-based consumption up to 24 hours postoperatively was significantly reduced in the LA group compared with the non-LA group (197 patients MD, -9.47 mg; 95% CI, -16.51 to -2.43; P = 0.008).

CONCLUSIONS

The use of preemptive LA during VH seems to be beneficial especially with regard to short-term postoperative pain and opioid use. However, further studies are needed to identify the optimal anesthetic regimen, the dosage, and sites of application aiming to achieve the optimal benefit in the postoperative management.

Preemptive local analgesia at vaginal hysterectomy: a systematic review

INTRODUCTION AND HYPOTHESIS

We conducted a systematic review of the effectiveness of local preemptive analgesia for postoperative pain control in women undergoing vaginal hysterectomy.

METHODS

MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews were searched systematically to identify eligible studies published through September 25, 2019. Only randomized controlled trials and systematic reviews addressing local preemptive analgesia compared to placebo at vaginal hysterectomy were considered. Data were extracted by two independent reviewers. Results were compared, and disagreement was resolved by discussion. Forty-seven studies met inclusion criteria for full-text review. Four RCTs, including a total of 197 patients, and two SRs were included in the review.

RESULTS

Preemptive local analgesia reduced postoperative pain scores up to 6 h and postoperative opioid requirements in the first 24 h after surgery.

CONCLUSION

Preemptive local analgesia at vaginal hysterectomy results in less postoperative pain and less postoperative opioid consumption.

Effect of Preventive Analgesia with Nalbuphine and Dexmedetomidine in Endoscopic Sinus Surgery

Background

The study was to assess the efficacy and safety of nalbuphine combined with dexmedetomidine for preventive analgesia in endoscopic sinus surgery.

Methods

110 patients with deviation of the nasal septum were randomized into the nalbuphine group (group N), dexmedetomidine combined with nalbuphine group (group DN), and saline group (group C). Fifteen minutes before the induction of anesthesia, patients in group N were injected nalbuphine 0.2 mg/kg intravenously; patients in group DN received intravenous infusion of dexmedetomidine 0.5 μg/kg and injection of nalbuphine 0.2 mg/kg; patients in group C received 0.9% saline. Mean arterial pressure (MAP), heart rate (HR), numerical rating scale (NRS) scores, quality of recovery-40 (QoR-40) scores, the need for remedial analgesia, the consumption of remifentanil and propofol, and the incidence of adverse reactions were recorded.

Results

MAP, HR, and NRS scores of the DN group were significantly lower and the QoR-40 scores were higher than those of groups N and C (P < 0.001). The need for remedial analgesia, the consumption of remifentanil and propofol, and the incidence of nausea in the DN group were the lowest among the three groups (P < 0.001).

Conclusion

Preventive analgesia with nalbuphine and dexmedetomidine in endoscopic sinus surgery can not only maintain hemodynamic stability but also reduce intraoperative anesthetic dosage, postoperative pain, and improve the quality of postoperative recovery without affecting the revival and extubation time.

The Effect of Low-Dose Dexmedetomidine on Pain and Inflammation in Patients Undergoing Laparoscopic Hysterectomy

Dexmedetomidine has sedative, sympatholytic, analgesic, and anti-inflammatory effects. We investigated the effects of intraoperative dexmedetomidine infusion without a loading dose in the prevention of pain and inflammation after laparoscopic hysterectomy. In this study, 100 patients undergoing laparoscopic hysterectomy under desflurane anesthesia were randomized to receive either 0.9% saline or dexmedetomidine (0.4 μg/kg/h) after induction to trocar removal. The primary endpoints were postoperative pain and inflammatory response presented by the level of tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), IL-10, and C-reactive protein (CRP). The secondary endpoints were hemodynamics during the anesthesia and surgery and postoperative nausea and vomiting. Postoperative pain was decreased in the dexmedetomidine group for every time point, and post-anesthesia care unit (PACU) rescue fentanyl doses were decreased in the dexmedetomidine group. The inflammatory response representing TNF-α, IL-6, IL-10, and CRP were similar across the two groups. Postoperative nausea and vomiting from PACU discharge to 24 h post-surgery were reduced in the dexmedetomidine group. During anesthesia and surgery, the patient's heart rate was maintained lower in the dexmedetomidine-receiving group. Dexmedetomidine of 0.4 μg/kg/h given as an intraoperative infusion significantly reduced postoperative pain but did not reduce the inflammatory responses in patients undergoing laparoscopic hysterectomy.

Perioperative parameters to consider for enhanced recovery in surgery (ERS) in gynecology (excluding breast surgery)

The current review explores the Enhanced Rehabilitation in Surgery (ERS) approach in the specific context of gynecological surgery. Implementation of an ERS protocol in gynecological surgery reduces postoperative complications and length of stay without increasing morbidity. An ERS approach is based on maintaining an adequate diet and hydration before the operation, according to the recommended time frame, to reduce the phenomenon of insulin resistance, and to optimize patient comfort. On the other hand, the use of anxiolytic treatment as premedication is not recommended. Systematic preoperative digestive preparation, a source of patient discomfort, is not associated with an improvement in the postoperative functional outcome or with a reduction in the rate of complications. A minimally invasive surgical approach is preferrable in the context of ERS. Prevention of surgical site infection includes measures such as optimized antibiotic prophylaxis, skin disinfection with alcoholic chlorhexidine, reduction in the use of drainage of the surgical site, and prevention of hypothermia. Early removal of the bladder catheter is associated with a reduction in the risk of urinary tract infection and a reduction in the length of hospital stay. Prevention of postoperative ileus is based on early refeeding, and prevention of postoperative nausea-vomiting in a multimodal strategy to be initiated during the intraoperative period. Intraoperative hydration should be aimed at achieving euvolemia. Pain control is based on a multimodal strategy to spare morphine use and may include locoregional analgesia. Medicines should be administered orally during the postoperative period to hasten the resumption of the patient's autonomy. The prevention of thromboembolic risk is based on a strategy combining drug prophylaxis, when indicated, and mechanical restraint, as well as early mobilization. However, the eclectic nature of the implementation of these measures as reported in the literature renders their interpretation difficult. Furthermore, beyond the application of one of these measures in isolation, the best benefit on the postoperative outcome is achieved by a combination of measures which then constitutes a global strategy allowing the objectives of the ERS to be met.

Efficacy and safety between early use and late use of celecoxib in hip osteoarthritis patients who receive total hip arthroplasty: a randomized, controlled study

Celecoxib is commonly used for pain management after total hip arthroplasty (THA), while the optimal timing of analgesic celecoxib remains unclear. This randomized, controlled study aimed to investigate the pain control efficacy and safety of preoperative celecoxib versus postoperative celecoxib in osteoarthritis (OA) patients undergoing THA. Totally, 192 hip OA patients about to undergo THA were randomized into pre-treatment group (N = 96) and post-treatment group (N = 96). The former was given 400 mg celecoxib at 4 h before THA, 200 mg at 4 h after THA, and then 200 mg every 12 h until 72 h post-operation. The latter was given 400 mg celecoxib at 4 h after THA, and then 200 mg every 12 h until 72 h post-operation. Pain at rest visual analog scale (VAS) score at 6 h, and pain at flexion VAS scores at 6 h, 12 h, and on D1, D2 were decreased in pre-treatment group compared to post-treatment group (all P < 0.05). Furthermore, additional consumption of patient-controlled analgesia (PCA) (P = 0.006) and total consumption of PCA (P = 0.006) were both reduced in pre-treatment group compared to post-treatment group. Meanwhile, compared to post-treatment group, patient satisfaction in pre-treatment group was higher on D1 (P = 0.010) and D2 (P = 0.039). While, Harris hip score showed no difference between pre-treatment group and post-treatment group on M1 or M3 (both P > 0.05). In conclusion, preoperative celecoxib exhibits better analgesic efficacy and patients' satisfaction management with similar tolerance compared to postoperative celecoxib in hip OA patients undergoing THA.

Preoperative pudendal block with liposomal and plain bupivacaine reduces pain associated with posterior colporrhaphy: a double-blinded, randomized controlled trial

BACKGROUND

Pelvic reconstructive surgery may cause significant postoperative pain, especially with posterior colporrhaphy, contributing to a longer hospital stay and increased pain medication utilization. Regional blocks are being increasingly utilized in gynecologic surgery to improve postoperative pain and decrease opioid usage, yet preoperative pudendal blocks have not been used routinely during posterior colporrhaphy.

OBJECTIVE

This study aimed to compare the effect of preoperative regional pudendal nerve block using a combination of 1.3% liposomal and 0.25% plain bupivacaine vs 0.25% plain bupivacaine alone on vaginal pain after posterior colporrhaphy on postoperative days 1, 2, and 3. We hypothesized that there would be a reduction in vaginal pain scores for the study group vs the control group over the first 72 hours.

STUDY DESIGN

This was a double-blinded, randomized controlled trial that included patients undergoing a posterior colporrhaphy, either independently or in conjunction with other vaginal or abdominal reconstructive procedures. Patients were block randomized to receive 20 mL of either a combination of 1.3% liposomal and 0.25% plain bupivacaine (study) or 20 mL of 0.25% plain bupivacaine (control) in a regional pudendal block before the start of surgery. Double blinding was achieved by covering four 5-mL syringes containing the randomized local anesthetic. After induction of anesthesia, a pudendal nerve block was performed per standard technique (5 mL superiorly and 5 mL inferiorly each ischial spine) using a pudendal kit. The primary outcome was to evaluate postoperative vaginal pain using a visual analog scale on postoperative days 1, 2, and 3. Secondary outcomes included total analgesic medication usage through postoperative day 3, postoperative voiding and defecatory dysfunction, and impact of vaginal pain on quality of life factors.

RESULTS

A total of 120 patients were enrolled (60 in each group). There were no significant differences in demographic data, including baseline vaginal pain (P=.88). Postoperative vaginal pain scores were significantly lower in the combined liposomal and bupivacaine group at all time points vs the plain bupivacaine group. Median pain scores for the study and control groups, respectively, were 0 (0-2) and 2 (0-4) for postoperative day 1 (P=.03), 2 (1-4) and 3 (2-5) for postoperative day 2 (P=.05), and 2 (1-4) and 3 (2-5) for postoperative day 3 (P=.02). Vaginal pain scores increased from postoperative day 1 to postoperative days 2 and 3 in both groups. There was a significant decrease in ibuprofen (P=.01) and acetaminophen (P=.03) usage in the study group; however, there was no difference between groups in total opioid consumption through postoperative day 3 (P=.82). There was no difference in successful voiding trials (study 72%, control 82%, P=.30), return of bowel function (P>.99), or quality of life factors (sleep, stress, mood, and activity).

CONCLUSION

Preoperative regional pudendal block with a combination of liposomal and plain bupivacaine provided more effective vaginal pain control than plain bupivacaine alone for reconstructive surgery that included posterior colporrhaphy. Given the statistically significant decrease in vaginal pain in the study group, this block may be considered as a potential adjunct for multimodal pain reduction in this patient population.

Auricular Point Acupressure Combined with Compound Lidocaine Cream to Manage Arteriovenous Fistula Puncture Pain: A Multicenter Randomized Controlled Trial

BACKGROUND

Arteriovenous fistula (AVF) puncture pain is an inevitable problem for maintenance hemodialysis (MHD) patients and may seriously endanger the physical and mental health of patients with MHD. Studies have shown that drug or nondrug measures can reduce AVF puncture pain, but much improvement is needed. When combined with compound lidocaine cream (CLC) in the treatment of AVF puncture pain, auricular point acupressure (APA)-a therapeutic method in which specific points on the auricle of the outer ear are stimulated to treat various disorders of the body-and the therapeutic value and synergistic effects of auriculotherapy merit further investigation.

METHODS

120 MHD patients were recruited at blood purification centers in three hospitals between January 2016 and April 2019. After completion of the baseline survey, all patients were randomly divided by the envelope method into a control group, APA group, CLC group, and APA combined with CLC, with 30 subjects per group. The numerical rating scale (NRS) of pain was used to measure the pain before intervention and 1, 4, and 8 weeks after intervention. The State-Trait Anxiety Inventory (STAI), General Comfort Questionnaire (GCQ), blood pressure, and heart rates were obtained before and after the intervention.

RESULTS

Pain, anxiety, comfort, blood pressure (BP), and heart rates (HR) of the three groups were better than those of the control group; the difference was statistically significant (P < 0.05). In addition, the APA combined with CLC group was better than the APA group and CLC group, respectively, in those outcomes (P < 0.05).

CONCLUSION

Both APA and CLC can effectively relieve AVF puncture pain, and the combined application has more outstanding effects.

Anesthetic management for robotic hysterectomy in obese women

PURPOSE OF REVIEW

Obesity is a major health epidemic, with the prevalence reaching ∼40% in the United States in recent years. It is associated with increased risk of hypertension, diabetes, heart disease, stroke, obstructive sleep apnea (OSA), and gynecologic conditions requiring surgery. Those comorbidities, in addition to the physiologic changes associated with obesity, lead to increased risk of perioperative complications. The purpose of this review is to highlight the anesthetic considerations for robotic assisted hysterectomy in obese patients.

RECENT FINDINGS

In the general gynecologic population, minimally invasive surgery is associated with less postoperative fever, pain, hospital length of stay, total cost of care and an earlier return to normal function. This also applies to robotic surgery in obese patients, which is on the rise. The physiologic changes of obesity bring different anesthetic challenges, including airway management and intraoperative ventilation. Vascular access and intraoperative blood pressure monitoring can also be challenging and require modifications. Optimizing analgesia with a focus on opioid-sparing strategies is crucial due to the increased prevalence of OSA in this patient population.

SUMMARY

Anesthesia for obese patients undergoing robotic hysterectomy is challenging and must take into consideration the anatomic and physiologic changes associated with obesity.

Preoperative Pelvic Floor Injections With Bupivacaine and Dexamethasone for Pain Control After Vaginal Prolapse Repair: A Randomized Controlled Trial

OBJECTIVE

To test the hypothesis that preoperative pelvic floor muscle injections and pudendal nerve blocks with bupivacaine and dexamethasone would decrease postoperative pain after vaginal native tissue prolapse repairs, compared with saline and bupivacaine.

METHODS

We conducted a three-arm, double-blind, randomized trial of bilateral transobturator levator ani muscle injections and transvaginal pudendal nerve blocks before vaginal reconstructive and obliterative prolapse procedures (uterosacral ligament suspension, sacrospinous ligament fixation, levator myorrhaphy, or colpocleisis). Women were randomized to one of three study medication groups: 0.9% saline, 0.25% bupivacaine, or combination 0.25% bupivacaine with 4 mg dexamethasone. Our primary outcome was a numeric rating scale pain score on postoperative day 1. Using an analysis of variance evaluated at the two-sided 0.05 significance level, an assumed variance of the means of 0.67, and SD of 1.75, we calculated 21 women per arm to detect a 2-point change on the numeric rating scale (90% power), which we increased to 25 per arm to account for 20% attrition and the use of nonparametric statistical methods.

RESULTS

From June 2017 through April 2019, 281 women were screened and 75 (26.7%) were randomized with no differences in baseline demographics among study arms. There was no significant difference in median pain scores on postoperative day 1 among study groups (median [interquartile range] pain score 4.0 [2.0-7.0] for placebo vs 4.0 [2.0-5.5] for bupivacaine vs 4.0 [1.5-5.0] for bupivacaine with dexamethasone, P=.92).

CONCLUSION

Preoperative pelvic floor muscle injections and pudendal nerve blocks with bupivacaine and dexamethasone did not improve postoperative pain after vaginal native tissue prolapse procedures.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03040011.

A Randomized Observer-Blinded Controlled Trial to Compare Pre-Emptive with Postoperative Ultrasound-Guided Mandibular Nerve Block for Postoperative Analgesia in Mandibular Fracture Surgeries

Background and Aims

Ultrasound-guided (UG) mandibular nerve block is effective for providing postoperative analgesia in mandibular fracture surgeries. The pre-emptive nerve blockade prolongs the duration of postoperative analgesia and reduces the consumption of intraoperative opioids. The aim of this prospective, randomized, single-blinded study was to compare the efficacy of pre-emptive and postoperative UG mandibular nerve block for postoperative analgesia in mandibular fracture surgeries.

Methods

Sixty patients scheduled for unilateral mandibular fracture surgeries were randomly divided into two groups by computer-generated random numbers and sealed envelope method: Group A received UG mandibular nerve block before surgical incision and group B received after surgery with ropivacaine 0.5% 10mL. The second anesthesiologist, who was blinded to the group involved, monitored the patient. The patients as well as the statistician were also blinded. The patients were started on patient-controlled analgesia (PCA) morphine with bolus 1mg and a lockout interval of 10min. The morphine consumption for 24h was recorded. The pain was assessed by the VAS score. The additional intraoperative fentanyl consumption and time for a request for rescue analgesic were recorded.

Results

The total morphine consumption was reduced in group A (4.566±0.717mg) than group B (5.93±0.876mg) with a p-value of <0.0001. The time for a request for rescue analgesic was also prolonged in group A (794.08±89.561min) than group B (505.333±3.159min). In group A, only four patients required an additional dose of fentanyl as against 11 patients in group B. The heart rate was also lower in group A 30min after the administration of the block and persisted for two hours intraoperatively.

Conclusion

Pre-emptive ultrasound-guided mandibular nerve block reduces morphine consumption, prolongs the time for a request for rescue analgesic, reduces intraoperative fentanyl consumption, provides better control of intraoperative heart rate, and better pain scores postoperatively when compared to the postoperative mandibular nerve block.

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The effect of subcutaneous and intraperitoneal anesthesia on post laparoscopic pain: a randomized controlled trial

A few modes of perioperative local analgesia have been studied in order to reduce postoperative pain after laparoscopy, including preemptive local anesthetics in the trocar sites and intraperitoneal anesthetics administration at the end of the surgery. However, the evidence regarding their efficacy are conflicting. In addition, the combination of both aforementioned methods has been rarely studied. Our aim was to evaluate whether subcutaneous trocar site and/or intraperitoneal analgesia reduce pain after gynecologic operative laparoscopy. This was a single-centered, randomized, controlled, double-blinded trial. The patients were randomly assigned to one of four equally sized groups: group 1-subcutaneous and intraperitoneal analgesia; group 2-subcutaneous analgesia and intraperitoneal placebo; group 3-subcutaneous placebo and intraperitoneal analgesia; Group 4-subcutaneous and intraperitoneal placebo. The patients, the surgeons, and the pain evaluators were all blinded to the patient's allocation. Included were patients who underwent elective operative laparoscopy. Exclusion criteria were: active infection, pregnancy, known sensitivity to Bupivacaine-Hydrochloride, chronic pelvic pain, surgeries with additional vaginal procedures, conversion to laparotomy, and malignancy. A total of 9 ml of Bupivacaine-Hydrochloride (Marcaine) 0.5%, or Sodium-Chloride 0.9%, as a placebo, were injected subcutaneously to the trocar sites (3 ml to each trocar site), prior to skin incision. In addition, 10 ml of Bupivacaine-Hydrochloride 0.5%, diluted with 40 ml of Sodium-Chloride 0.9% (a total of 50 ml solution), or 50 ml of Sodium-Chloride 0.9%, as a placebo, were injected intraperitoneally at the end of the surgery. By utilizing the 10 cm Visual-analogue-scale (VAS) we assessed post-operative pain at rest at 3, 8, and 24 h, and during ambulation at 8 and 24 h. The study was approved by the local Institutional Review Board and has been registered at clinicaltrials.gov. We conformed to the CONSORT recommendations. Between December 2016 and July 2019, a total of 119 patients were included in the study. Demographic and interventional characteristics were similar among the groups. The level of postoperative pain, either at rest or with change of position, was not significantly different between the groups, at all-time points. Application of subcutaneous and/or intraperitoneal analgesia is not effective in reducing pain after gynecologic operative laparoscopy.Clinical trial identification number: NCT02976571. Date of trial registration 11/29/2016. URL of the registration site: https://clinicaltrials.gov .

Guidelines for vulvar and vaginal surgery: Enhanced Recovery After Surgery Society recommendations

This is the first collaborative Enhanced Recovery After Surgery Society guideline for optimal perioperative care for vulvar and vaginal surgeries. An Embase and PubMed database search of publications was performed. Studies on each topic within the Enhanced Recovery After Surgery vulvar and vaginal outline were selected, with emphasis on meta-analyses, randomized controlled trials, and prospective cohort studies. All studies were reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation system. All recommendations on the Enhanced Recovery After Surgery topics are based on the best available evidence. The level of evidence for each item is presented.

Enhanced Recovery and Surgical Optimization Protocol for Minimally Invasive Gynecologic Surgery: An AAGL White Paper

This is the first Enhanced Recovery After Surgery (ERAS) guideline dedicated to standardizing and optimizing perioperative care for women undergoing minimally invasive gynecologic surgery. The guideline was rigorously formulated by an American Association of Gynecologic Laparoscopists Task Force of US and Canadian gynecologic surgeons with special interest and experience in adapting ERAS practices for patients requiring minimally invasive gynecologic surgery. It builds on the 2016 ERAS Society recommendations for perioperative care in gynecologic/oncologic surgery by serving as a more comprehensive reference for minimally invasive endoscopic and vaginal surgery for both benign and malignant gynecologic conditions. For example, the section on preoperative optimization provides more specific recommendations derived from the ambulatory surgery and anesthesia literature for the management of anemia, hyperglycemia, and obstructive sleep apnea. Recommendations pertaining to multimodal analgesia account for the recent Food and Drug Administration warnings about respiratory depression from gabapentinoids. The guideline focuses on workflows important to high-value care in minimally invasive surgery, such as same-day discharge, and tackles controversial issues in minimally invasive surgery, such as thromboprophylaxis. In these ways, the guideline supports the American Association of Gynecologic Laparoscopists and our collective mission to elevate the quality and safety of healthcare for women through excellence in clinical practice.

Enhanced recovery after surgery outcomes in minimally invasive nonhysterectomy gynecologic procedures

BACKGROUND

Improved patient outcomes and satisfaction associated with enhanced recovery after surgery protocols have increasingly replaced traditional perioperative anesthesia care. Fast-track surgery pathways have been extensively validated in patients undergoing hysterectomies, yet the impact on fertility-sparing laparoscopic gynecologic operations, particularly those addressing chronic pain conditions, has not been examined.

OBJECTIVE

The objective of the study was to determine the effects of enhanced recovery after surgery pathway implementation compared with conventional perioperative care in women undergoing laparoscopic minimally invasive nonhysterectomy gynecologic procedures.

STUDY DESIGN

We conducted a retrospective cohort study of women undergoing uterine-sparing laparoscopic gynecologic procedures for benign conditions (tubal/adnexal pathology, endometriosis, or leiomyomas) during a 24 month period before and after enhanced recovery after surgery implementation at a tertiary care center. We compared immediate perioperative outcomes and 30 day complications. The primary outcome was same-day discharge rates. Factors influencing unplanned admissions, postoperative pain, sedation, nausea, and vomiting represented secondary analyses.

RESULTS

A total of 410 women (enhanced recovery after surgery, n = 196; conventional perioperative care, n = 214) met inclusion criteria. Following enhanced recovery after surgery implementation, same-day discharge rates increased by 9.4% (P = .001). Reductions in postoperative pain and nausea/vomiting represented the primary driving factor behind lower unplanned admissions. Higher preoperative antiemetic medication administration in the enhanced recovery after surgery group resulted in a 57% reduction in postanesthesia care unit antiemetics (P < .001). Total perioperative narcotic medication use was also significantly reduced by 64% (P < .001), and the enhanced recovery after surgery cohort still demonstrated significantly lower postanesthesia unit care pain scores at hours 2 and 3 (P < .001). A 19 minute shorter postanesthesia care unit stay was noted in the enhanced recovery after surgery cohort (P = .036). Increased same-day discharge did not lead to higher postoperative complications or changes in 30 day emergency department visits or readmissions in patients with enhanced recovery after surgery.

CONCLUSION

Enhanced recovery after surgery implementation resulted in increased same-day discharge rates and improved perioperative outcomes without affecting 30 day morbidity in women undergoing laparoscopic minimally invasive nonhysterectomy gynecologic procedures.

Postoperative pain management in obstetrics and gynecology

The efficiency and quality of postoperative pain management may be considered unsatisfactory in Europe, as well as in the United States. Notwithstanding our better understanding of the physiology of pain and the development of new analgesia procedures, the improvement in satisfaction of patients has not be enhanced to the same degree. Obstetrics and gynecology are no exception to this statement. In fact, obstetrics and gynecology are surgical departments in which patients experience the greatest severity of postoperative pain. Current concepts of postoperative pain management are largely based on the administration of systemic non-opioid and opioid analgesics, supplemented with regional analgesia procedures and/or peripheral nerve blockades and, in some cases, the administration of other pain-relieving pharmaceutical agents. Based on the existing body of evidence, it would be appropriate to develop procedure-related concepts of analgesia. The concepts are based on the special circumstances of the respective department, and the scheme of analgesia is aligned to the respective interventions. Generally, however, a surgeon’s individual experience in dealing with the procedures and substances could be more significant than the theoretical advantages demonstrated in preceding investigations.

The preemptive analgesia of pre-electroacupuncture in rats with formalin-induced acute inflammatory pain

Background

Electroacupuncture has been elicited to effectively alleviate the pain sensation. Preemptive analgesic effect of pre-electroacupuncture has also been suggested in recent studies, while the underlying analgesic mechanism of pre-electroacupuncture requires further investigation. This study aimed to explore the preemptive analgesia of pre-electroacupuncture in formalin-induced acute inflammatory pain model.

Methods

Forty rats were randomly divided into control, model, pre-electroacupuncture, and post-electroacupuncture group. Inflammatory pain model was induced via injecting 50 µl 5% formalin into the plantar surface of right hind paw, while the equal volume of saline injection in the control group. Rats in the pre-electroacupuncture group were treated with electroacupuncture at ipsilateral Zusanli (ST36) and Weizhong (BL40) acupoints (2 Hz, 1 mA) for 30 min before formalin injection, while received the same electroacupuncture treatment immediately after formalin injection in the post-electroacupuncture group. Flinching number and licking time were recorded during 60 min after formalin injection. Immunofluorescence and Western blot were used to detect the expression of ionized calcium binding adapter molecule 1 (Iba1) and c-fos in spinal cord. Moreover, enzyme-linked immunosorbent assay was applied to measure the secretion of IL-6, IFN-γ, IL-4, substance P, and calcitonin gene-related peptide in spinal cord.

Results

Paw flinching and licking were obviously induced by formalin injection. Iba1, c-fos, proinflammatory cytokines (IL-6 and IFN-γ), and pain neurotransmitters (substance P and calcitonin gene-related peptide) were dramatically increased in the L4-5 spinal cord after formalin injection, while anti-inflammatory cytokine IL-4 was decreased. Pre-electroacupuncture and post-electroacupuncture administration significantly attenuated formalin-induced nociceptive effects, spinal microglia and neurons activation, proinflammatory cytokines and pain neurotransmitters upregulation, and upregulated the anti-inflammatory cytokine. Furthermore, these effects of pre-electroacupuncture were more significant than that of post-electroacupuncture.

Conclusions

This study illustrates the potential therapeutic effect of pre-electroacupuncture against acute inflammatory pain and reveals the mechanism underlying pre-electroacupuncture mediated analgesia, thus providing a novel preemptive analgesic treatment.

Perioperative pain management in minimally invasive gynecologic surgery

PURPOSE OF REVIEW

The purpose of this review is to summarize the most recent evidence-based interventions for perioperative pain management in minimally invasive gynecologic surgery.

RECENT FINDINGS

With particular emphasis on preemptive interventions in recent studies, we found preoperative counseling, nutrition, exercise, psychological interventions, and a combination of acetaminophen, celecoxib, and gabapentin are highly important and effective measures to reduce postoperative pain and opioid demand. Intraoperative local anesthetics may help at incision sites, as a paracervical block, and a transversus abdominus plane block. Postoperatively, an effort should be made to utilize non-narcotic interventions such as abdominal binders, ice packs, simethicone, bowel regimens, gabapentin, and scheduled NSAIDs and acetaminophen. When prescribing narcotics, providers should be aware of recommended amounts of opioids required per procedure so as to avoid overprescribing.

SUMMARY

Our findings emphasize the evolving importance of preemptive interventions, including prehabilitation and pharmacologic agents, to improve postoperative pain after minimally invasive gynecologic surgery. Additionally, a multimodal approach to nonnarcotic intraoperative and postoperative interventions decreases narcotic requirement and improves opioid stewardship.

Final Year Nursing Students' Knowledge and Attitudes regarding Children's Pain

Pain is one of the commonest reasons why children visit the hospital. Inadequately treated pain in children can negatively affect their physical, psychological, and social well-being; it also places financial burden on families of affected children and healthcare systems in general. Considering the eventual suffering of vulnerable children and their families if nursing students are insufficiently educated and ill-prepared, the current study aimed at assessing final year nursing student's knowledge and attitudes pertaining to pediatric pain. A descriptive cross-sectional study was conducted among 100 final year undergraduate nursing students at a private university college in Ghana. In addition to their ages and gender, the students responded to the 42 individual items on the Pediatric Nurses' Knowledge and Attitudes Survey regarding pain (PNKAS) instrument. Descriptive statistical analysis was aided by the Statistical Package for Social Sciences version 25 software. The mean age of the final year nursing students was 29 years (range of 21 to 47 years); a majority of them were females (78%). Participants had an average (SD) correct answer score of 44.0% (10.6%). Good pediatric pain knowledge and attitudes were observed in items that were related to the individualized and multidimensional nature of the pain experience and its treatment, benefits of pre-emptive analgesia, pharmacodynamics, and pain assessment. Poor pediatric pain knowledge and attitudes occurred in items that focused on pain perceptions, opioid drug administration, useful pain medications, pain physiology, and nonpharmacological pain management interventions. Final year nursing students have insufficient knowledge and attitudes toward children's pain management. Areas of good and poor pediatric pain knowledge and attitudes should be considered when designing and implementing educational interventions on this subject. Curricular revisions should be made on existing nursing curriculum to lay more emphasis on children's pain management and use educational interventions that support knowledge translation for improved care.