Postoperative pain control

Personal versus therapist perioperative music intervention: a randomized controlled trial

INTRODUCTION

Music interventions can alleviate patient anxiety and improve post-surgical satisfaction. However, it remains uncertain whether personal music preferences affect efficacy. The authors tested whether personal music intervention with patient-selected songs played ad libitum is more effective than standard therapist-designed treatment with classical music.

METHODS

A prospective, parallel-group, single-blinded, randomized controlled trial with 229 participants (aged 18-60 years) previously scheduled for elective surgery. Data analyses followed a modified intention-to-treat principle. The patients were randomized into three groups: Standard care without music (Control), therapist-designed classic music treatment (TT), or personal music intervention with patient-selected songs played ad libitum by the patient (PI). All patients received standard post-anaesthesia care, and music intervention was started upon arrival at the post-anaesthesia care unit. Primary outcomes were anxiety and overall satisfaction at discharge. In contrast, secondary outcomes were systolic blood pressure during music intervention, the sleep quality of the night after surgery, and the occurrence of postoperative nausea and vomiting within the first 24 h after surgery.

RESULTS

Compared with therapist-designed music treatment, personal intervention decreased systolic blood pressure (T 0 : 124.3±13.7, 95% CI:121-127.7; T 20min : 117.6±10.4, 95% CI:115-120.1; T 30min : 116.9±10.6, 95% CI:114.3-119.4), prevented postoperative nausea and vomiting (Control: 55.9%, TT: 64.6%, PI: 77.6%), including severe postoperative nausea (VAS score>4; Control: 44.1%; TT: 33.8%; PI: 20.9%) and severe emesis (Frequency≥3, Control: 13.2%; TT: 7.7%; PI: 4.5%). None of the treatments affected sleep quality at night after surgery (Median, Q1-Q3, Control: 3, 1-3; TT: 3, 1-4; PI: 3, 1-3.5). Personal, but not therapist, music intervention significantly prevented anxiety (Control: 36.4±5.9, 95% CI:35.0-37.9; TT: 36.2±7.1, 95% CI: 34.4-37.9; PI: 33.8±5.6, 95% CI: 32.4-35.2) and emesis (Control: 23.9%; TT: 23.4%; PI: 13.2%) and improved patient satisfaction (Median, Q1-Q3, C: 8, 6-8; TT: 8, 7-9; PI: 8, 7-9).

CONCLUSIONS

Personal music intervention improved postoperative systolic blood pressure, anxiety, nausea, emesis, and overall satisfaction, but not sleep quality, as compared to therapist-designed classic intervention.

Experiences and perspectives of adults on using opioids for pain management in the postoperative period: A scoping review

BACKGROUND

Opioids play an important role in peri-operative pain management. However, opioid use is challenging for healthcare practitioners and patients because of concerns related to opioid crises, addiction and side effects.

OBJECTIVE

This review aimed to identify and synthesise the existing evidence related to adults' experiences of opioid use in postoperative pain management.

DESIGN

Systematic scoping review of qualitative studies. Inductive content analysis and the Theoretical Domains Framework (TDF) were applied to analyse and report the findings and to identify unexplored gaps in the literature.

DATA SOURCES

Ovid MEDLINE, PsycInfo, Embase, CINAHL (EBSCO), Cochrane Library and Google Scholar.

ELIGIBILITY CRITERIA

All qualitative and mixed-method studies, in English, that not only used a qualitative approach that explored adults' opinions or concerns about opioids and/or opioid reduction, and adults' experience related to opioid use for postoperative pain control, including satisfaction, but also aspects of overall quality of a person's life (physical, mental and social well being).

RESULTS

Ten studies were included; nine were qualitative ( n  = 9) and one used mixed methods. The studies were primarily conducted in Europe and North America. Concerns about opioid dependence, adverse effects, stigmatisation, gender roles, trust and shared decision-making between clinicians and patients appeared repeatedly throughout the studies. The TDF analysis showed that many peri-operative factors formed people's perceptions and experiences of opioids, driven by the following eight domains: Knowledge, Emotion, Beliefs about consequences, Beliefs about capabilities, Self-confidence, Environmental Context and Resources, Social influences and Decision Processes/Goals. Adults have diverse pain management goals, which can be categorised as proactive and positive goals, such as individualised pain management care, as well as avoidance goals, aimed at sidestepping issues such as addiction and opioid-related side effects.

CONCLUSION

It is desirable to understand the complexity of adults' experiences of pain management especially with opioid use and to support adults in achieving their pain management goals by implementing an individualised approach, effective communication and patient-clinician relationships. However, there is a dearth of studies that examine patients' experiences of postoperative opioid use and their involvement in opioid usage decision-making. A summary is provided regarding adults' experiences of peri-operative opioid use, which may inform future researchers, healthcare providers and guideline development by considering these factors when improving patient care and experiences.

Harnessing artificial intelligence for predicting and managing postoperative pain: a narrative literature review

PURPOSE OF REVIEW

This review examines recent research on artificial intelligence focusing on machine learning (ML) models for predicting postoperative pain outcomes. We also identify technical, ethical, and practical hurdles that demand continued investigation and research.

RECENT FINDINGS

Current ML models leverage diverse datasets, algorithmic techniques, and validation methods to identify predictive biomarkers, risk factors, and phenotypic signatures associated with increased acute and chronic postoperative pain and persistent opioid use. ML models demonstrate satisfactory performance to predict pain outcomes and their prognostic trajectories, identify modifiable risk factors and at-risk patients who benefit from targeted pain management strategies, and show promise in pain prevention applications. However, further evidence is needed to evaluate the reliability, generalizability, effectiveness, and safety of ML-driven approaches before their integration into perioperative pain management practices.

SUMMARY

Artificial intelligence (AI) has the potential to enhance perioperative pain management by providing more accurate predictive models and personalized interventions. By leveraging ML algorithms, clinicians can better identify at-risk patients and tailor treatment strategies accordingly. However, successful implementation needs to address challenges in data quality, algorithmic complexity, and ethical and practical considerations. Future research should focus on validating AI-driven interventions in clinical practice and fostering interdisciplinary collaboration to advance perioperative care.

Gastrointestinal adverse effects associated with the use of intravenous oliceridine compared with intravenous hydromorphone or fentanyl in acute pain management utilizing adjusted indirect treatment comparison methods

Background: In the absence of head-to-head comparative data from randomized controlled trials, indirect treatment comparisons (ITCs) may be used to compare the relative effects of treatments versus a common comparator (either placebo or active treatment). For acute pain management, the effects of oliceridine have been compared in clinical trials to morphine but not to fentanyl or hydromorphone. Aim: To assess the comparative safety (specifically differences in the incidence of nausea, vomiting and opioid-induced respiratory depression [OIRD]) between oliceridine and relevant comparators (fentanyl and hydromorphone) through ITC analysis. Methods: A systematic literature review identified randomized clinical trials with oliceridine versus morphine and morphine versus fentanyl or hydromorphone. The ITC utilized the common active comparator, morphine, for the analysis. Results: A total of six randomized controlled trials (oliceridine - 2; hydromorphone - 3; fentanyl - 1) were identified for data to be used in the ITC analyses. The oliceridine data were reported in two studies (plastic surgery and orthopedic surgery) and were also reported in a pooled analysis. The ITC focused on nausea and vomiting due to limited data for OIRD. When oliceridine was compared with hydromorphone in the ITC analysis, oliceridine significantly reduced the incidence of nausea and/or vomiting requiring antiemetics compared with hydromorphone (both orthopedic surgery and pooled data), while results in plastic surgery were not statistically significant. When oliceridine was compared with hydromorphone utilizing data from Hong, the ITC only showed a trend toward reduced risk of nausea and vomiting with oliceridine that was not statistically significant across all three comparisons (orthopedic surgery, plastic surgery and combined). An ITC comparing oliceridine with a study of fentanyl utilizing the oliceridine orthopedic surgery data and combined orthopedic and plastic surgery data showed a trend toward reduced risk that was not statistically significant. Conclusion: In ITC analyses, oliceridine significantly reduced the incidence of nausea and/or vomiting or the need for antiemetics in orthopedic surgery compared with hydromorphone and a non-significant trend toward reduced risk versus fentanyl.

Mannitol Reduces Pain and Trismus After Impacted Mandibular Third Molar Surgery

BACKGROUND

The removal of the lower third molar is a routine procedure in oral surgery, yet it often leads to postoperative side effects, particularly inflammation. Despite various interventions explored in prior studies, there is still a need for effective strategies, such as anti-inflammatory substances, to address postoperative side effects.

PURPOSE

The purpose of this study is to answer the following clinical question: Does the local injection of 0.9 M mannitol reduce postoperative pain, trismus, and swelling in patients undergoing bilateral symmetrically impacted mandibular third molar extraction?

STUDY DESIGN, SETTING, SAMPLE

This prospective, single-blind, split-mouth study at Hamadan Dental School involved 30 patients with bilateral symmetrically impacted mandibular third molars. Inclusion criteria were: no current medication, no anesthesia allergies, bilateral symmetrically impacted mandibular third molars, non-smokers, and the absence of systemic diseases. Exclusion criteria were: poor oral hygiene, alcohol/cigarette use, drug consumption, diabetes, systemic/gastrointestinal disorders, infection at the surgical site, lack of patient cooperation, and mannitol/anesthetic allergy.

PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE

The predictor variable was therapeutic injection, and it was grouped into two categories, 0.9 M mannitol solution or distilled water.

MAIN OUTCOME VARIABLE

The primary outcome variable was pain. Secondary outcomes are trismus, swelling, patient satisfaction, and analgesic consumption.

COVARIATES

Covariates included demographic information and operative details.

ANALYSES

Statistical analyses included repeated measures and paired t-tests with a significance level set at P < .05.

RESULTS

The study comprised 30 participants (mean age: 22.6 ± 3.59 years; 6 men, 24 women). In the test group, pain intensity significantly decreased from 5.30 on surgery day to 0.00, with subsequent values of 2.97, 1.30, 0.40, 0.17, and 0.03. The control group also decreased from 7.68 to 0.00, with values of 4.73, 2.67, 0.97, 0.23, and 0.07. The difference was statistically significant (P < .001). No significant swelling differences at T1, T3, T5, and T7 (P > .05). The intervention group had improved maximum mouth opening at T1, T3, T5, and T7 (P = .011) compared to the control group.

CONCLUSION AND RELEVANCE

Mannitol infiltration significantly reduces postoperative pain and trismus in impacted third molar surgery. This finding underscores the potential for improved patient comfort and recovery in this context.

Advancing Postoperative Pain Management in Oral Cancer Patients: A Systematic Review

The goal of this review is to shed light on the management of orofacial discomfort after a cancer diagnosis in the head and neck region. A search was conducted on PubMed, Scopus, and Web of Science to identify studies on postoperative pain control in oral cancer. The review included open-access research, investigations into pain management, randomized clinical trials, retrospective studies, case-control studies, prospective studies, English-written studies, and full-text publications. Exclusion criteria included animal studies; in vitro studies; off-topic studies; reviews, case reports, letters, or comments; and non-English language. Three reviewers independently accessed databases and assigned a quality rating to the chosen articles. The review explores postoperative pain management in oral cancer patients; highlighting persistent opioid use; the efficacy of adjuvant drugs, such as gabapentin; and a multimodal approach. It emphasizes the need for personalized pain management, recognizing individual pain perception and tailoring interventions. Integrating pharmacological and non-pharmacological strategies is crucial for comprehensive pain management. The review also serves as a guide for future research, emphasizing the need for standardized methodologies and diverse participant populations.

Novel Bioresorbable Drug-Eluting Mesh Scaffold for Therapy of Muscle Injury

A novel bioresorbable drug-eluting polycaprolactone (PCL) mesh scaffold was developed, utilizing a solvent-cast additive manufacturing technique, to promote therapy of muscle injury. The degradation rate and mechanical properties strength of the PCL mesh were characterized after immersion in a buffer solution for different times. The in vitro release characteristics of vancomycin, ceftazidime, and lidocaine from the prepared mesh were evaluated using a high-performance liquid chromatography (HPLC) assay. In addition, the in vivo efficacy of PCL meshes for the repair of muscle injury was investigated on a rat model with histological examinations. It was found that the additively manufactured PCL meshes degraded by 13% after submission in buffered solution for four months. All PCL meshes with different pore sizes exhibited greater strength than rat muscle and survived through 10,000 cyclic loadings. Furthermore, the meshes could offer a sustained release of antibiotics and analgesics for more than 3 days in vitro. The results of this study suggest that drug-loaded PCL mesh exhibits superior ability to pure PCL mesh in terms of effectively promoting muscle repair in rat models. The histological assay also showed adequate biocompatibility of the resorbable meshes. The additively manufactured biodegradable drug-eluting meshes may be adopted in the future in humans for the therapy of muscle injuries.

Periarticular Infiltration Compared to Single Femoral Nerve Block in Total Knee Arthroplasty: A Prospective Randomized Study

Objective  To compare patients undergoing total knee arthroplasty (TKA) under spinal anesthesia and single femoral nerve block (FNB) with subjects undergoing TKA under spinal anesthesia and periarticular infiltration (PAI). Materials and Methods  A total of 100 patients undergoing primary TKA were randomized into two groups. Group 1 included patients undergoing surgery under FNB associated with spinal anesthesia, while group 2 included patients undergoing TKA under IPA and spinal anesthesia. The assessment of these subjects in the early postoperative period included pain, active flexion, active extension, elevation of the extended limb, and morphine use. Results  There was no significant difference in the types of analgesia concerning pain, the elevation of the extended limb, and morphine use. Active flexion and extension were better in the PAI group ( p  = 0.04 and p  = 0.02 respectively). Conclusion  We conclude that the techniques are similar regarding pain control, limb elevation, and morphine use. The use of IPA provided better active flexion and extension during the hospital stay compared to single FNB in patients undergoing TKA.

Outcomes of Pain Management Among Postoperative Patients: A Cross-sectional Study

PURPOSE

Postoperative pain management has always been a significant challenge for both hospital staff and surgical patients. Determination of pain management outcomes among surgically treated patients may help develop pain management strategies, improve health services that would yield better outcomes, and increase patient satisfaction. This study aimed to assess the outcomes of pain management among postoperative patients.

DESIGN

The study was a descriptive cross-sectional study.

METHODS

The research was performed on postoperative patients at two university hospitals in North Cyprus from July to September 2019. The study sample consisted of 90 patients from both hospitals. The Turkish Version of the revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R-TR) was used for data collection. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was used to report the present study.

FINDINGS

This study showed that the overall mean for pain severity and the worst pain experienced by patients after 24 hours was slightly higher than medium. Examination of interference of the pain with functions demonstrated that patients experienced problems with physical activities and sleeping. The most experienced side effects were nausea and drowsiness, and the most common emotions were anxiety and helplessness during the postsurgery period. The satisfaction rate of the patients with postoperative pain management was relatively high.

CONCLUSIONS

A holistic approach with evidence-based practices is crucial for adequate postoperative pain management. The recommendations include the development of individual pain outcome strategies to improve overall satisfaction with pain management among postoperative patients.

Intramedullary Kirschner Wire Fixation for Metatarsal Fractures: A Comprehensive Review of Treatment Outcomes

Metatarsal fractures pose significant challenges in orthopedic practice, necessitating effective treatment methods to ensure optimal patient outcomes. This comprehensive review focuses on intramedullary Kirschner wire fixation as a promising intervention for metatarsal fractures. Beginning with an overview of metatarsal fractures and the imperative for effective treatments, the review delves into intramedullary fixation's definition, historical background, advantages, and disadvantages. Indications for its use in metatarsal fractures are discussed, providing a foundation for understanding its application. The surgical technique section outlines critical aspects, including patient selection criteria and preoperative planning. Before presenting a detailed step-by-step procedure for intramedullary Kirschner wire fixation, anesthesia considerations are explored. Emphasizing precision, fluoroscopic guidance, and meticulous postoperative care, this section provides insights for surgeons and healthcare practitioners. Considerations for rehabilitation follow, addressing postoperative care, expected recovery timelines, and physical therapy recommendations. Early mobilization, weight-bearing guidelines, and a structured rehabilitation program play pivotal roles in recovery. In the conclusion, key findings are summarized, highlighting the efficacy of intramedullary Kirschner wire fixation, its advantages, and recommendations for clinical practice. Additionally, areas for future research are identified, guiding further exploration and refinement of this surgical approach. This review is valuable for clinicians, researchers, and healthcare practitioners involved in metatarsal fracture management, contributing to the evolution of treatment strategies and improving patient care.

Thermoresponsive Polymeric Hydromorphone Prodrug Provides Sustained Local Analgesia without Apparent Adverse Effects

The extensive use of opioids for chronic pain management has contributed significantly to the current opioid epidemic. While many alternative nonopioid analgesics are available, opioids remain the most potent analgesics for moderate to severe pain management. In addition to the implementation of multimodal analgesia, there is a pressing need for the development of more effective and safer opioids. In this study, we developed a thermoresponsive N-(2-hydroxypropyl) methacrylamide (HPMA) copolymer-based hydromorphone (HMP) prodrug (ProGel-HMP, HMP content = 16.2 wt %, in base form). The aqueous solution of ProGel-HMP was free-flowing at 4 °C but became a hydrogel when the temperature was raised to ≥37 °C, allowing sustained local retention when administered in vivo. When tested in the destabilization of the medial meniscus (DMM) mouse model of osteoarthritis (OA), ProGel-HMP was retained after intra-articular injection in the OA knee joint for at least 2 weeks postinjection, with low extra-articular distribution. ProGel-HMP was not detected in the central nervous system (CNS). A single dose of ProGel-HMP produced rapid and sustained joint pain resolution for greater than 14 days when compared to saline and dose-equivalent HMP controls, likely mediated through peripheral μ-opioid receptors in the knee joint. Systemic analgesia effect was absent in the DMM mice treated with ProGel-HMP, as evident in the lack of difference in tail flick response between the ProGel-HMP-treated mice and the controls (i.e., Healthy, Saline, and Sham). Repeated dosing of ProGel-HMP did not induce tolerance. Collectively, these data support the further development of ProGel-HMP as a potent, safe, long-acting and nonaddictive analgesic for better clinical pain management.

Enhanced recovery after surgery (ERAS) in prolapse repair: A prospective study on pre-emptive uterosacral/cervical block

OBJECTIVE

Enhanced recovery after surgery (ERAS) protocols have been introduced in gynecology. Postoperative pain management after vaginal procedures remains a relevant issue. In the present study we aimed to evaluate the effectiveness of pre-emptive uterosacral/cervical block (PUCB) for postoperative pain control in patients with uterovaginal prolapse undergoing vaginal hysterectomy and pelvic floor repair. We also evaluated the impact on the length of recovery.

METHODS

This was a pilot study analyzing 40 women who underwent pelvic organ prolapse repair through uterosacral ligament suspension. Patients who chose to undergo PUCB were considered as cases, otherwise as controls. After general or spinal anesthesia induction, the treatment group received the PUCB with ropivacaine plus clonidine injections at 2, 4, 8, and 10 o'clock of the cervix. The control group did not receive additional treatment. Pain intensity was measured at rest and after forceful cough at 1, 4, 8, 12, 24, and 48 h postoperatively.

RESULTS

We found a significant reduction in pain values at 1 h (rest and forceful cough) and 24 h (forceful cough) in the PUCB group. The incidence of moderate/severe pain was inferior in the PUCB group at 1 h (rest) and 24 h (rest and forceful cough). There were no differences in terms of the use of rescue opioids (0% vs. 5%; P = 0.311) and length of hospital stay (2.5 ± 0.6 vs. 2.3 ± 0.6; P = 0.180).

CONCLUSIONS

For the first time, we demonstrated the impact of pre-emptive uterosacral/cervical block on pain control up to 24 h after surgery. Clonidine as a sensory blockade extender appears promising in enhancing the efficacy of local anesthetics.

Harmonising IV Oxycodone with Paediatric Perioperative Medications: A Compatibility Study Through Y-Type Connectors

Purpose

Co-administering multiple intravenous (IV) agents via Y-connectors is a common practice in hospitalised and fasting surgical patients. However, there is a lack of reliable data confirming the physical compatibility of some combinations including IV oxycodone, a drug that is gaining increasing popularity in the perioperative period. Concern regarding physical drug incompatibilities precludes concurrent coadministration with other common drugs through a single lumen. This can result in the cessation of infusions to allow the administration of other medications, resulting in exacerbation of acute pain. This study aims to evaluate the physical compatibility of IV oxycodone with some commonly co-administered drugs and IV fluids.

Methods

Mixtures of oxycodone (1mg.mL-1) and the tested drugs and IV fluids were prepared in a ratio of 1:1. The mixtures were examined at 0 and 60 minutes from mixing and assessed using the European Conference Consensus Standards. This involved visual inspection (precipitation, turbidity, colour change, gas formation), spectrophotometry, and pH change. The tested drugs included ketamine, tramadol, clonidine, vancomycin, piperacillin/tazobactam, dexmedetomidine, cefotaxime, gentamicin, and paracetamol. In addition, the commonly used IV fluids tested included glucose 5% + sodium chloride 0.9% + 60 mmol potassium chloride, plasmalyte + dextrose 5%;plasmalyte + dextrose 5% + 55 mmol potassium chloride, plasmalyte + dextrose 5% + 55mmol potassium acetate, plasmalyte + dextrose 5% + 55mmol potassium dihydrogen phosphate, Hartmann's solution, Standard pediatric Total Parenteral Nutrition (TPN) 20/100 and TPN 25/150.

Results

IV oxycodone (1 mg.mL-1) showed no visual changes; no spectrophotometric absorption variability at 350, 410, or 550nm; and no pH changes of >0.5 at 0 or 60 minutes with any of the tested drugs or fluids in the concentrations tested.

Conclusion

According to European Consensus Conference Standards, IV Oxycodone at 1 mg.mL-1 is physically compatible in a ratio of 1:1 v/v with all investigated drugs and fluids tested for at least 60 minutes.

Thoracoscopic Intercostal Nerve Block with Cocktail Analgesics for Pain Control After Video-Assisted Thoracoscopic Surgery: A Prospective Cohort Study

Objective

To evaluate whether using a cocktail of intercostal nerve blocks (TINB) during thoracoscopic surgery results in better clinical outcomes than patient-controlled analgesia (PCIA).

Methods

Patients in two medical groups undergoing video-assisted thoracoscopic surgery (VATS) for pulmonary nodules in West China Hospital of Sichuan University were collected consecutively between March 2022 and December 2022. The groups were divided into two subgroups based on their analgesic program, which were TINB group and PCIA group. The primary outcome was the visual analogue scale (VAS) of the two groups at different stage after surgery and after discharge. Any analgesic related adverse events (ARAEs) were also recorded.

Results

A total of 230 patients who underwent VATS were enrolled, in which 113 patients (49.1%) received a cocktail TINB after surgery, and 117 patients (50.9%) received a PCIA. After PSM, 62 patients in each group were selected. The difference of resting VAS (RVAS) and active VAS (AVAS) at different stage during hospitalization was only related to the change of period (p < 0.05, p < 0.05), and the two groups showed no significant differences in RVAS or AVAS during hospitalization (p = 0.271, p = 0.915). However, the rates of dizziness (4.84% vs 25.81%, p = 0.002), nausea and vomiting (0 vs 22.58%, p < 0.05), fatigue (14.52% vs 34.87%, p = 0.012), and insomnia (0 vs 58.06%, p < 0.05) in TINB group were lower than that in PCIA group. Besides, AVAS and RVAS at 7, 14, and 30 days after discharge in TINB group were both significantly lower than that in PCIA group (p < 0.05, p < 0.05).

Conclusion

Cocktail TINB provided better analgesia after discharge and reduced the incidence of ARAEs in patients undergoing VATS.

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

PURPOSE

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

DESIGN

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

METHODS

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

FINDINGS

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

CONCLUSIONS

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

Effect of Combining Dhikr and Prayer Therapy on Pain and Vital Signs in Appendectomy Patients: A Quasi-Experimental Study

Purpose: Dhikr and prayer reduce pain and improve a patient's vital signs. However, the interactions among these require further clarification in patients undergoing appendectomy. This study aimed to assess the effects of the combination of dhikr and prayer on pain, pulse rate, respiratory rate, and oxygen saturation. Study design: Quasi-experimental design. Method: Pain, pulse, respiratory rate, and oxygen saturation were measured via clinical examination immediately after leaving the recovery room at 1 and 2 hr after surgery in both the experimental and control groups. In total, 88 eligible participants were allocated to two groups: participants who received both dhikr and prayer (n  =  44), and those who received routine care without analgesic therapy (n  =  44). The chi-square test, independent t test, and general equation model were employed. Results: Respondents showed a significant interaction between group and time to decrease in pain, pulse, respiratory rate, and improved oxygen saturation, except for pain within 1 hr. The differences in all outcome scores between the groups after 1 and 2 hr were statistically significant, except for oxygen saturation after 1 hr. Conclusion: The combination of dhikr and prayer effectively decreased pain and improved vital signs. This helped nurses implement this procedure by promoting an essential culture of spiritual care for appendectomy patients.

Opioids and Immunosuppression: Clinical Evidence, Mechanisms of Action, and Potential Therapies

Background

In addition to the more well-known adverse effects of opioids, such as constipation, mounting evidence supports underlying immunosuppressive effects as well.

Methods

In this study, we provide a narrative review of preclinical and clinical evidence of opioid suppression of the immune system as well as possible considerations for therapies.

Results

In vitro and animal studies have shown clear effects of opioids on inflammatory cytokine expression, immune cell activity, and pathogen susceptibility. Observational data in humans have so far supported preclinical findings, with multiple reports of increased rates of infections in various settings of opioid use. However, the extent to which this risk is due to the impact of opioids on the immune system compared with other risk factors associated with opioid use remains uncertain. Considering the data showing immunosuppression and increased risk of infection with opioid use, measures are needed to mitigate this risk in patients who require ongoing treatment with opioids. In preclinical studies, administration of opioid receptor antagonists blocked the immunomodulatory effects of opioids.

Conclusions

As selective antagonists of peripheral opioid receptors, peripherally acting mu-opioid receptor (MOR) antagonists may be able to protect against immune impairment while still allowing for opioid analgesia. Future research is warranted to further investigate the relationship between opioids and infection risk as well as the potential application of peripherally acting MOR antagonists to counteract these risks.

Comparative effectiveness of pericapsular nerve group block versus fascia iliac compartment block on postoperative wound pain management in patients undergoing hip fracture surgery: A systematic review and meta-analysis

Hip fracture surgeries are challenging, with postoperative pain management being a critical component of patient care. This systematic review and meta-analysis aimed to compare the effectiveness of Pericapsular nerve group block (PENGB) and fascia iliac compartment block (FICB) in postoperative wound pain management for patients undergoing hip fracture surgery. The study followed the PRISMA guidelines and was structured around the PICO framework. Comprehensive searches were conducted across PubMed, Embase, Web of Science, and the Cochrane Library. Inclusion criteria were limited to RCTs comparing the effectiveness of PENGB and FICB in adult patients undergoing hip fracture surgery. Key outcomes included pain control effectiveness, safety, and complication incidence. The quality of studies was assessed using the Cochrane Collaboration's risk of bias tool. Statistical heterogeneity was evaluated using I2 statistics, and meta-analysis effect values were calculated using random-effects or fixed-effect models, depending on the degree of heterogeneity. The search identified 1095 articles, with 5 studies meeting inclusion criteria. The meta-analysis revealed that PENGB and FICB were comparable in managing postoperative pain and opioid consumption. However, PENGB significantly reduced the incidence of quadriceps muscle weakness (RR = 0.12, p < 0.05) and did not increase the risk of PONV (RR = 1.36, p = 0.51), suggesting its advantage in maintaining motor function without adding to PONV complications. No significant publication bias was detected. PENGB is comparable to FICB in pain and opioid consumption management after hip fracture surgeries. Its significant benefit lies in reducing the incidence of quadriceps muscle weakness, facilitating better postoperative mobility. Additionally, PENGB does not increase the risk of postoperative nausea and vomiting, underlining its suitability for comprehensive postoperative care in hip fracture patients.

Pharmacokinetics, metabolite profiling, safety and tolerability of YZJ-4729 tartrate, a novel G protein-biased μ-opioid receptor agonist, in healthy Chinese subjects

Objective: YZJ-4729 is a novel G protein-biased μ-opioid receptor agonist for the treatment of acute pain in adult patients who require intravenous opioid analgesic therapy. The aim of this study was to assess the pharmacokinetics, metabolite profiling, safety and tolerability of YZJ-4729 in healthy Chinese subjects following the single intravenous doses ranged from 0.2 mg to 6 mg. Methods: This single-center, randomized, double-blind, placebo-controlled clinical study was conducted in 54 healthy male and female Chinese subjects after single ascending doses of YZJ-4729 tartrate (0.2, 0.5, 1.5, 3, 4.5, and 6 mg). Subjects in each cohort were assigned randomly to receive a single intravenous dose of YZJ-4729 tartrate injection or placebo at a ratio of 4:1. Pharmacokinetic characteristics, metabolite profiling, safety and tolerability profiles of the study drug were evaluated. Results: Overall, YZJ-4729 was safe and well tolerated in healthy Chinese subjects. The study drug reached peak plasma concentrations nearly at the end of the infusion. After administration, YZJ-4729 was eliminated rapidly with a terminal elimination half-life of 0.862-2.50 h, and excreted little in human excreta. The maximum drug concentration and area under the plasma concentration-time curve increased with dose escalation across the entire dose range. YZJ-4729 experienced extensive metabolism in human body. A total of 19 metabolites were identified and the characteristic metabolic pathways involved hydroxylation, ketone formation, N-dealkylation and glucuronide conjugation. Metabolite M10 was the most abundant circulating metabolite, and represented over 10% of total drug-related systemic exposure. Further PK and safety evaluation of M10 was necessary. Conclusion: The clinical study results laid a foundation for the further clinical studies of YZJ-4729 in patients. Clinical Trial Registration: http://www.chinadrugtrials.org.cn, identifier CTR20222574.

Development of prescribing indicators related to opioid-related harm in patients with chronic pain in primary care-a modified e-Delphi study

BACKGROUND

Long-term opioid use is associated with dependency, addiction, and serious adverse events. Although a framework to reduce inappropriate opioid prescribing exists, there is no consensus on prescribing indicators for preventable opioid-related problems in patients with chronic pain in primary care in the UK. This study aimed to identify opioid prescription scenarios for developing indicators for prescribing opioids to patients with chronic pain in primary care.

METHODS

Scenarios of opioid prescribing indicators were identified from a literature review, guidelines, and government reports. Twenty-one indicators were identified and presented in various opioid scenarios concerning opioid-related harm and adverse effects, drug-drug interactions, and drug-disease interactions in certain disease conditions. After receiving ethics approval, two rounds of electronic Delphi panel technique surveys were conducted with 24 expert panellists from the UK (clinicians, pharmacists, and independent prescribers) from August 2020 to February 2021. Each indicator was rated on a 1-9 scale from inappropriate to appropriate. The score's median, 30th and 70th percentiles, and disagreement index were calculated.

RESULTS

The panel unanimously agreed that 15 out of the 21 opioid prescribing scenarios were inappropriate, primarily due to their potential for causing harm to patients. This consensus was reflected in the low appropriateness scores (median ranging from 1 to 3). There were no scenarios with a high consensus that prescribing was appropriate. The indicators were considered inappropriate due to drug-disease interactions (n = 8), drug-drug interactions (n = 2), adverse effects (n = 3), and prescribed dose and duration (n = 2). Examples included prescribing opioids during pregnancy, concurrently with benzodiazepines, long-term without a laxative prescription and prescribing > 120-mg morphine milligram equivalent per day or long-term duration over 3 months after surgery.

CONCLUSIONS

The high agreement on opioid prescribing indicators indicates that these potentially hazardous consequences are relevant and concerning to healthcare practitioners. Future research is needed to evaluate the feasibility and implementation of these indicators within primary care settings. This research will provide valuable insights and evidence to support opioid prescribing and deprescribing strategies. Moreover, the findings will be crucial in informing primary care practitioners and shaping quality outcome frameworks and other initiatives to enhance the safety and quality of care in primary care settings.

Novel Targets and Drug Delivery System in the Treatment of Postoperative Pain: Recent Studies and Clinical Advancement

Pain is generated by a small number of peripheral targets. These can be made more sensitive by inflammatory mediators. The number of opioids prescribed to the patients can be reduced dramatically with better pain management. Any therapy that safely and reliably provides extended analgesia and is flexible enough to facilitate a diverse array of release profiles would be useful for improving patient comfort, quality of care, and compliance after surgical procedures. Comparisons are made between new and traditional methods, and the current state of development has been discussed; taking into account the availability of molecular and cellular level data, preclinical and clinical data, and early post-market data. There are a number of benefits associated with the use of nanotechnology in the delivery of analgesics to specific areas of the body. Nanoparticles are able to transport drugs to inaccessible bodily areas because of their small molecular size. This review focuses on targets that act specifically or primarily on sensory neurons, as well as inflammatory mediators that have been shown to have an analgesic effect as a side effect of their anti- inflammatory properties. New, regulated post-operative pain management devices that use existing polymeric systems were presented in this article, along with the areas for potential development. Analgesic treatments, both pharmacological and non-pharmacological, have also been discussed.

Novel Opioids in the Setting of Acute Postoperative Pain: A Narrative Review

Although traditional opioids such as morphine and oxycodone are commonly used in the management of acute postoperative pain, novel opioids may play a role as alternatives that provide potent pain relief while minimizing adverse effects. In this review, we discuss the mechanisms of action, findings from preclinical studies and clinical trials, and potential advantages of several novel opioids. The more established include oliceridine (biased ligand activity to activate analgesia and downregulate opioid-related adverse events), tapentadol (mu-opioid agonist and norepinephrine reuptake inhibitor), and cebranopadol (mu-opioid agonist with nociceptin opioid peptide activity)-all of which have demonstrated success in the clinical setting when compared to traditional opioids. On the other hand, dinalbuphine sebacate (DNS; semi-synthetic mu partial antagonist and kappa agonist), dual enkephalinase inhibitors (STR-324, PL37, and PL265), and endomorphin-1 analog (CYT-1010) have shown good efficacy in preclinical studies with future plans for clinical trials. Rather than relying solely on mu-opioid receptor agonism to relieve pain and risk opioid-related adverse events (ORAEs), novel opioids make use of alternative mechanisms of action to treat pain while maintaining a safer side-effect profile, such as lower incidence of nausea, vomiting, sedation, and respiratory depression as well as reduced abuse potential.

Novel Techniques for Musculoskeletal Pain Management after Orthopedic Surgical Procedures: A Systematic Review

Effective postoperative pain management is critical for recovery after orthopedic surgery, but often remains inadequate despite multimodal analgesia. This systematic review synthesizes evidence on innovative modalities for enhancing pain control following major orthopedic procedures. Fifteen randomized controlled trials and comparative studies evaluating peripheral nerve blocks, local anesthetic infiltration, cryotherapy, transcutaneous electrical stimulation, adjunct medications, and other techniques are included. Thematic analysis reveals that peripheral nerve blocks and local anesthetic infiltration consistently demonstrate reduced pain scores, opioid consumption, and side effects versus conventional analgesia alone. Oral multimodal medications also show promise as part of opioid-sparing regimens. Adjunctive approaches like cryotherapy, music, and dexmedetomidine require further research to optimize protocols. Despite promising innovations, critical knowledge gaps persist regarding comparative effectiveness, optimal interventions and dosing, combination strategies, cost-effectiveness, and implementation. High-quality randomized controlled trials using standardized protocols are essential to guide the translation of enhanced multimodal regimens into clinical practice. This review provides a framework for pursuing research priorities and advancing evidence-based postoperative pain management across orthopedic surgeries.

From Conservative Measures to Surgical Interventions, Treatment Approaches for Cubital Tunnel Syndrome: A Comprehensive Review

Cubital tunnel syndrome (CuTS) is a neuropathic condition characterized by the compression or irritation of the ulnar nerve at the elbow, resulting in a wide spectrum of symptoms ranging from pain and numbness to muscle weakness and impaired hand function. This comprehensive review delves into the diverse landscape of CuTS treatment approaches, emphasizing the importance of early intervention. The review explores how these strategies aim to alleviate symptoms and enhance patient well-being by beginning with conservative measures encompassing rest, splinting, medications, physical therapy, and lifestyle adjustments. Non-surgical medical interventions, including nerve gliding exercises, ultrasound-guided nerve injections, and orthotic devices, are considered alternative therapies for symptom relief. Surgical interventions, such as decompression procedures and emerging techniques, are discussed in detail, highlighting their indications and expected outcomes. Throughout this review, the critical role of patient-centered care is underscored, emphasizing the need for tailored treatment plans that respect individual preferences and goals. Recognizing the unique nature of each CuTS case, shared decision-making between patients and healthcare providers is advocated, ensuring that interventions align with specific patient needs. As research advances, promising developments in diagnosis, surgical techniques, and drug therapies offer hope for more effective management of CuTS, paving the way for improved symptom relief and enhanced nerve function.

Comparing Post-operative Opioid Consumption before and after a Patient-Controlled Analgesia Shortage: A Re-evaluation of Safety and Effectiveness

This retrospective cohort study aimed to compare post-surgical opioid consumption before and after a PCA (patient-controlled analgesia) shortage. The study evaluated patients who received PCA vs. nurse-administered opioid analgesia (non-PCA). Two hundred and twenty-four patients ≥18 years who were initiated on analgesia within 24 h of surgery were included. The primary outcome was opioid consumption in average daily oral morphine milliequivalents (MME). The results showed that patients in the PCA group had increased MME consumption (162 ± 100.4 vs. 70.7 ± 52.8, p < 0.01), increased length of hospital stay (4.2 vs. 3.2 days, p < 0.01), and increased frequency of nausea (33 vs. 17.9%, p < 0.01). After controlling for confounding factors, the PCA group utilized significantly more opioids (84.6 MME/day, p < 0.01) than the non-PCA group. There was no difference in pain AUC/T (0.19 ± 0.07 vs. 0.21 ± 0.08, p = 0.07) and average opioid prescribing upon discharge (150 [77.5-360] vs. 90 [77.5-400], p = 0.64) between the PCA group and non-PCA group, respectively. These results question the routine use of PCA in post-operative patients due to the increased risk of opioid consumption, longer length of hospital stay, and higher incidence of nausea.

Comparative analysis of lumbar quadratus lumborum block and epidural block for analgesia in uterine surgery at Dr. Soetomo Hospital, Surabaya

Over 80% of surgical patients experience postoperative pain, which, if inadequately managed, can lead to complications, prolonged rehabilitation, chronic pain, and decreased quality of life. Epidural block and quadratus lumborum block are techniques commonly used for postoperative pain management. This comparative analytic study aimed to analyze the differences in the analgesic effects of quadratus lumborum block and epidural block in uterine surgery at Dr. Soetomo General Hospital. The outcomes assessed were the numerical rating score (NRS) as a pain score and the administration of opioids as an adjuvant analgesic. Statistical analysis employed the Mann-Whitney test and Chi-square test. The study included 32 patients who underwent uterine surgery at Dr. Soetomo General Hospital and met the inclusion and exclusion criteria. Among the patients, 90.6% experienced mild pain, and 9.4% experienced moderate pain. Epidural blocks were performed in 50% of the patients, while quadratus lumborum blocks were performed in the other 50%. Additionally, 9.4% of the patients received opioids as adjuvant analgesics. The Mann-Whitney test revealed no significant difference in NRS between the epidural block and quadratus lumborum block groups (p-value>0.05). However, the Chi-square test indicated a significant difference in NRS between patients who received additional opioids as adjuvant analgesics and those who did not (p-value<0.00). There was no significant difference in NRS between patients who underwent epidural block and quadratus lumborum block as analgesic techniques.

Advances in Anesthesia for Shoulder Surgery: A Comprehensive Review of Dexmedetomidine-Enhanced Interscalene Brachial Plexus Block

Surgical procedures on the shoulder pose distinctive challenges in managing pain during the perioperative period, underscoring the importance of exploring innovative anesthesia techniques. This comprehensive review article delves into integrating dexmedetomidine, an alpha-2 adrenergic agonist, within interscalene brachial plexus blocks for shoulder surgery. The review initiates by underscoring the pivotal role of effective anesthesia in shoulder surgery and elucidates the rationale behind investigating dexmedetomidine as an adjunct. It meticulously examines the anatomy and physiology of the brachial plexus, emphasizing its critical significance in shoulder surgery. Furthermore, the article expounds on dexmedetomidine's mechanisms of action and pharmacokinetics, encompassing its safety profile and potential side effects. The conventional interscalene brachial plexus block techniques, along with their limitations and challenges, are discussed, laying the foundation for the integration of dexmedetomidine. The review subsequently delves into exploring the role of dexmedetomidine in regional anesthesia, covering previous studies, mechanisms of action, and the potential advantages of incorporating it into nerve blocks. The review's core concentrates on the practical application of dexmedetomidine-enhanced interscalene brachial plexus blocks. This includes discussions on administration techniques, dosage guidelines, and compelling evidence supporting its utilization. Clinical scenarios where this approach proves most advantageous are thoroughly explored, comparing its effectiveness with traditional techniques in terms of pain control and patient outcomes. A comprehensive examination of relevant clinical trials and case studies highlights the evidence supporting its efficacy. The review also underscores safety considerations associated with dexmedetomidine. It proposes strategies for mitigating risks to ensure patient safety. Insights into future directions and research are provided, encompassing ongoing studies, areas necessitating further investigation, and potential refinements in technique. Finally, the article summarizes key findings, emphasizing the practicality of dexmedetomidine-enhanced interscalene brachial plexus blocks in shoulder surgery and its far-reaching implications for clinical practice and patient care.

Kidney Donor Perspectives on Acute Postoperative Pain Management

This study employed a qualitative descriptive approach to examine living kidney donor's experience of postoperative pain. Thirteen living kidney donors aged 46.5 (±14.4) years participated in this study. Semi-structured interviews were conducted and transcribed. Transcripts were inductively coded and reviewed for trends, patterns, and insights into donor's experience of postoperative pain. Donors experienced postoperative pain from a variety of sources that hindered recovery and created anxiety and fear in some. Donors managed pain with opioid and non-opioid medications, social support, and ambulation. Donor's past experiences with and expectations about pain, relationships with intended recipients, social support, as well as motivations for and meaning of donation informed their experience of postoperative pain. Prompt pharmacologic intervention for pain, as well as further coaching and education about pain management should be emphasized for nurses caring for living kidney donors. Further study of how donor's motivation might mediate their pain experience is needed.

How pain affect real life of children and adults with achondroplasia: A systematic review

The clinical features of achondroplasia can cause acute self-limited pain that can evolve into chronic pain. Pain causes a low quality of life, in terms of physical, emotional, social, and school functioning in both adult and children with achondroplasia. We conducted a systematic review according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement to describe prevalence, assessment tools, causes and management strategies of pain in this rare disease. We found that shoulder and knee pain is typically referred during infancy, while knee pain is generally referred around 5-6 years of age. The prevalence of general pain in adolescence can be as high as 90%. Chronic pain in the achondroplasia population increases with age, with up to 70% of adults reporting general pain and back pain. Recognizing the multiple determinants of acute and chronic pain in patients with achondroplasia may enable physicians to better understand and manage this burden, particularly with the advent of new drugs that may modify some of the striking features of achondroplasia.

Predictors of post-discharge pain and satisfaction with pain management after laparoscopic bariatric surgery: a prospective cohort study

BACKGROUND

Pain management after bariatric surgery remains challenging given the risk for analgesia-related adverse events (e.g., opioid use disorder, marginal ulcers). Identifying modifiable factors associated with patient-reported pain outcomes may improve quality of care. We evaluated the extent to which patient and procedural factors predict 7-day post-discharge pain intensity, pain interference, and satisfaction with pain management after bariatric surgery.

METHODS

This prospective cohort study included adults undergoing laparoscopic bariatric surgery at two university-affiliated hospitals and one private clinic. Preoperative assessments included demographics, Pain Catastrophizing Scale (score range 0-52), Patient Activation Measure (low [< 55.1] vs. high [≥ 55.1]), pain expectation (0-10), and Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29) anxiety and depression scales. At 7 days post-discharge, assessments included PROMIS-29 pain intensity (0-10) and pain interference scales (41.6-75.6), and satisfaction with pain management (high [10-9] vs. lower [8-0]). Linear and logistic regression were used to assess the association of pain outcomes with potential predictors.

RESULTS

Three hundred and fifty-one patients were included (mean age = 44 ± 11 years, BMI = 45 ± 8 kg/m2, 77% female, 71% sleeve gastrectomy). At 7 days post-discharge, median (IQR) patient-reported pain intensity was 2.5 (1-5), pain interference was 55.6 (52.0-61.2), and 76% of patients reported high satisfaction with pain management. Pain intensity was predicted by preoperative anxiety (β + 0.04 [95% CI + 0.01 to + 0.07]) and pain expectation (+ 0.15 [+ 0.05 to + 0.25]). Pain interference was predicted by preoperative anxiety (+ 0.22 [+ 0.11 to + 0.33]), pain expectation (+ 0.47 [+ 0.10 to + 0.84]), and age (- 0.09 [- 0.174 to - 0.003]). Lower satisfaction was predicted by low patient activation (OR 1.94 [1.05-3.58]), higher pain catastrophizing (1.03 [1.003-1.05]), 30-day complications (3.27 [1.14-9.38]), and age (0.97 [0.948-0.998]).

CONCLUSION

Patient-related factors are important predictors of post-discharge pain outcomes after bariatric surgery. Our findings highlight the value of addressing educational, psychological, and coping strategies to improve postoperative pain outcomes.

Instrument shank-assisted ovariohysterectomy: a randomized clinical trial of surgical and pain alleviation efficiency of a single-person modified technique

Objectives

To evaluate a modified ovariohysterectomy (OHE) technique performed by a single person and compare it with the conventional method based on time efficiency, trauma, and postoperative pain.

Methods

In a prospective, randomized, experimental study, 18 healthy, large, deep-chested, mixed-breed intact female dogs were randomly allocated to conventional (n = 9) and instrument shank-assisted (n = 9) groups. On the basis of video recordings, the various surgical step durations were analyzed: total surgery time (TST), pedicle intervention time (PIT), suspensory release time (SRT), shanking time (ShT), clamping time (ClpT), ligating time (LigT), and closure time (CT). The Glasgow composite pain scale short-form (GCMPS-SF), university of Melbourne pain scale (UMPS), and Visual Analogue Scales (VAS) were used to measure pain. C-reactive protein (CRP) fluctuation was also investigated. These evaluations were completed before and 6, 24, 48, and 72 h postoperatively.

Results

Instrument shank-assisted OHE was less time-consuming than conventional OHE (p = 0.005), improved PIT by 30.7% (6.44 min for both pedicles, p = 0.014), and correlated strongly with TST (ρ = 0.862, p = 0.003 and ρ = 0.955, p = 0.000, respectively). The two method's surgical step durations were also TST = 47.40 ± 9.9 vs. 34.70 ± 6.7 min, PIT = 20.96 ± 5.78 vs. 14.52 ± 3.73 min, SRT = 78.97 ± 69.10 vs. ShT = 20.39 ± 8.18 s (p = 0.035), ClpT = 50.66 ± 45.04 vs. 63.55 ± 37.15 s (p = 0.662), LigT = 12.82 ± 3.37 vs. 8.02 ± 3.11 min (p = 0.005), and CT = 16.40 ± 4.5 vs. 11.60 ± 2.5 min (p = 0.013), respectively. While both techniques inflicted pain on the animals, the novel approach resulted in a reduction of pain at T6 (GCMPS-SF, p = 0.015 and VAS, p = 0.002), T24 (UMPS, p = 0.003), and T48 (GCMPS-SF, p = 0.015 and UMPS, p = 0.050). Both methods exhibited a peak in CRP level after 24 h, which subsequently returned to baseline after 48 h. However, the shank-assisted method demonstrated a significantly lower reduction in CRP level at the 48-h compared to the other group (p = 0.032).

Conclusion

Instrument shank-assisted technique permitted ovarian removal without an assistant, less damage to animals and reducing its time when compared to a conventional technique, and resulting in an alternative that causes less surgical stress and fatigue. Further research with a larger population size is required to determine the serum CRP levels as an alternative pain biomarker.

Opioid prescribing and use in the Military Health System: a framework synthesis, FY2016-FY2021

BACKGROUND

Opioid misuse is a nationwide issue and is of particular concern with regard to military readiness. The 2017 National Defense Authorization Act charges the Military Health System with greater oversight of opioid use and mitigation of misuse.

METHODS

We synthesized published articles using secondary analysis of TRICARE claims data, a nationally representative database of 9.6 million beneficiaries. We screened 106 articles for inclusion and identified 17 studies for data abstraction. Framework analysis was conducted, which assessed prescribing practices, patient use, and optimum length of opioid prescriptions after surgery, trauma, and common procedures, as well as factors leading to sustained prescription opioid use.

RESULTS

Across the studies, sustained prescription opioid use after surgery was low overall, with <1% of opioid-naïve patients still receiving opioids more than 1 year after spinal surgery or trauma. In opioid-exposed patients who had undergone spine surgery, sustained use was slightly lower than 10%. Higher rates of sustained use were associated with more severe trauma and depression, as well as with prior use and initial opioid prescriptions for low back pain or other undefined conditions. Black patients were more likely to discontinue opioid use than were White patients.

CONCLUSIONS

Prescribing practices are well correlated with degree of injury or intensity of intervention. Sustained prescription opioid use beyond 1 year is rare and is associated with diagnoses for which opioids are not the standard of care. More efficient coding, increased attention to clinical practice guidelines, and use of tools to predict risk of sustained prescription opioid use are recommended.

Evaluation of Discharge Opioid Prescribing in Coronary Artery Bypass Patients Following an Opioid Stewardship Intervention for Providers

Introduction: Opioid stewardship efforts can promote safe and effective use of opioids to optimize pain control and minimize unintended consequences. The purpose of this study is to assess the difference in post-operative opioid discharge prescribing in patients undergoing coronary artery bypass graft (CABG) surgery following implementation of a tripartite opioid stewardship intervention. Methods: This was a single-center, quality improvement study at a large, quaternary academic medical center. Adult patients undergoing CABG from July 2019 to June 2020 (pre-intervention) and November 2020 to February 2021 (post-intervention) were included. The intervention included adopting hospital-wide post-surgical opioid discharge prescribing guidelines, discharge prescriber education, and electronic medical record changes. The primary outcome was the proportion of patients receiving an opioid prescription at discharge. Secondary outcomes included total morphine milligram equivalents (MME) prescribed and non-opioid analgesics prescribed at discharge. Results: A total of 200 patients were included in the study; 100 pre- and 100 post-intervention. There was no difference in opioid discharge prescribing at discharge (74% pre-intervention vs. 72% post-intervention; P = .87). There was no difference in MMEs prescribed at discharge (145.6 ± 57 pre- vs. 162.2 ± 95 post-; P = .202). No difference was seen in non-opioid analgesic prescriptions prescribed at discharge (35% pre- vs. 40% post-; P = .56). Conclusion: A multipronged opioid stewardship intervention did not lead to a reduction in opioid prescribing at discharge. Post-intervention, there was a non-statistically significant increase in the proportion of patients who received non-opioid analgesics discharge. Future studies should assess the effect of different stewardship interventions on prescribing and patient outcomes.

Enhanced Recovery After Surgery Protocols and Spinal Deformity

The authors outline a review of preoperative, intraoperative, and postoperative considerations surrounding adult spinal deformity. Preoperative management topics include imaging, hemoglobin A1c levels before spine surgery, osteoporotic management, and prehabilitation. Topics surrounding intraoperative management include the use of antibiotics, liposomal bupivacaine, and Foley catheters. The authors also discuss postoperative questions surrounding analgesia, nausea and vomiting, thromboembolic prophylaxis, and early mobilization. Throughout their discussion, the authors incorporate enhanced recovery after surgery protocols to hopefully lead to future discussions regarding optimizing complex spinal patients.

A service evaluation of the impact of parental information provision on analgesia administration at home posttonsillectomy

INTRODUCTION

Tonsillectomy and adenotonsillectomy are together the most common pediatric surgical procedure and are increasingly performed as day cases. Postoperative pain is commonly severe for 1-2 weeks, but parental analgesia concerns lead to poor analgesia prescription compliance and under administration. This service evaluation assessed parental compliance with analgesia, elicited parental concerns, and obtained parental suggestions for improving the current written advice.

METHODS

Telephone questionnaires were completed on postoperative Days 3/4 and 7 with 42 parents of pediatric (adeno)-tonsillectomy patients over a 6-month period, peri-pandemic. The questionnaire collected categorical data on: analgesia prescribed and administered, the child's symptoms, and healthcare resource use. Qualitative data on barriers to analgesia administration and suggestions for written advice improvement were grouped thematically.

RESULTS

Sore throats were reported by 93.3% parents between discharge and Day 3/4 but only 43.3% parents had 100% compliance with regular paracetamol and ibuprofen in the same time period. Parents frequently avoided morphine administration, expressing concerns about side effects, addiction, and previous experience. Parents were also concerned about using ibuprofen, discrepancies between weight-based and bottle instruction doses, and the length of the analgesia course. Parents would like further written information and reassurance on these topics as well as guidance on tapering or stopping analgesics and whether to wake their child at night.

CONCLUSION

The breadth of unmet information needs identified in this service evaluation, alongside parental suggestions, will be used to improve the current written advice with the aim to improve the postoperative pain experience at home. These include information on length of analgesic course, safety of ibuprofen and paracetamol coadministration for analgesia, and details about morphine administration, including safety, side effects, and indication.

Comparison of Mean Post-Operative Pain Score with Pre-Incisional Versus Postoperative Injection of Bupivacaine in Patients Undergoing Elective Surgery

The most important concern after the surgical intervention is pain which needs to be addressed for better compliance and early mobilization to avoid other complications. The need for a better analgesic and time of administration is the key to success.

Objective

To compare the mean post-operative pain score with pre-incisional versus post-operative injection of bupivacaine in patients undergoing elective surgery.

Study design

This Randomized controlled trial was conducted in the General surgery department, National Hospital & Medical Centre, Lahore from 24-02-20 to 24-11-20. Data was collected through Non-probability consecutive sampling. The cases of both genders with an age range of 18-60 years undergoing elective surgeries were selected. They were divided into two groups. The cases in group A were given pre-incision bupivacaine and group B with post-operative bupivacaine and were assessed 1 hour after surgery regarding pain on VAS.

Results

In the present study there were a total of 64 cases with 32 in each group. The mean age in group A was 47.56±7.51 years while in group B was 49.13±8.03 years. There were 19 (59.37%) males in group A vs 18 (56.25%) in group B. The mean post-operative pain in group A was 3.07±0.67 vs 3.59±0.91 in group B on VAS with p= 0.03. Mean post-operative pain in males was 3.12±0.65 vs 3.47±0.86 and in females, it was 3.21±0.66 vs 3.53±0.90 in groups A and B with p values of 0.21 and 0.23 respectively. Mean Post-operative pain was 3.11±0.66 vs 3.44±0.83 in the age group 18-39 years and 3.08±0.68 vs 3.47±0.88 in age group 40 to 60 years in group A and B with p values of 0.25 and 0.20 respectively. There was a significant difference in terms of postoperative pain in cases undergoing open cholecystectomy where pain was 3.21±0.78 vs 3.86±1.02 in group A and B respectively with p= 0.01. Whereas no difference was seen in the rest of the variables.

Conclusion

Mean post-operative pain is significantly better in cases treated with pre-incisional bupivacaine as compared to post-operative bupivacaine and this difference was also seen as significantly high in cases undergoing open cholecystectomy.

Preclinical characterization of the efficacy and safety of biologic N-001 as a novel pain analgesic for post-operative acute pain treatment

Inhibition of actin remodeling in nerves modulates action potential propagation and therefore could be used to treat acute pain. N-001 is a novel protein analgesic engineered from several C. Botulinum toxins. N-001 targets sensory neurons through ganglioside GT1b binding and ADP-ribosylates G-actin reducing actin remodeling. The activity and efficacy of N-001 was evaluated previously in vitro and in a mouse inflammatory pain model. To assess the relevance of N-001 for treatment of acute post-surgical pain, the current study evaluated the efficacy of N-001 in a mouse hind-paw incision model by peri-incisional and popliteal nerve block administration combined with mechanical testing. N-001 provided relief of pain-like behavior over 3 days and 2 days longer than the conventional long-acting anesthetic bupivacaine. Preclinical safety studies of N-001 indicated the drug produced no toxic or adverse immunological reactions over multiple doses in mice. These results combined with past targeting results encourage further investigation of N-001 as an analgesic for post-operative pain management with the potential to function as a differential nociceptor-specific nerve block.

Predicting postoperative pain by using preoperative pain threshold in response to electrical stimulus in women undergoing gynaecological cancer surgery - Single-arm, prospective, observational study

Background and Aims

Individual variability leading to different pain experiences makes pain prediction challenging. This study aimed to evaluate whether preoperative electrical pain threshold testing is predictive of postoperative pain.

Methods

Following ethics committee approval and registration of the trial, 40 consenting patients undergoing open laparotomy (interval debulking surgery) for ovarian cancer were included in the study. Electrical stimulus (maximum of 256 μA) was used preoperatively to determine the current perception threshold (CPT) and pain equivalent current (PEC). A numerical rating scale (NRS; 0-10, with 0 indicating no pain and 10 indicating severe pain) was used to assess pain. All patients received intravenous paracetamol in accordance to body weight, diclofenac (1 mg/kg, maximum 50 mg), and tramadol (1 mg/kg, maximum 50 mg) eight hourly for 24 hours. The preoperative PEC was compared with worst pain score (PS) at movement at the end of 24 hours. PEC was also compared with average PS at rest, at movement, and with opioid requirement (24 hours).

Results

The median values of CPT and PEC were 12.51 (45 [10.1-14.6]) μA and 94.75 (174 [48.8-94.7]) μA, respectively. A moderate correlation was observed between PEC and worst PS (P = 0.01, r = -0.402), with patients having PEC less than 60 μA being associated with moderate-to-severe PS. There was no correlation between PEC and average PS at rest (P = 0.16, r = 0.225), at movement (P = 0.46, r = 0.119), and the postoperative opioid consumption in the first 24 hours (P = 0.50, r = -0.110).

Conclusion

There is a moderate association between preoperative pain threshold in response to electrical stimulus and worst PS in the postoperative period following interval debulking surgery for ovarian cancer.

The Effect of Aromatherapy with Citrus aurantium Aroma on Pain after Orthopedic Surgery: A Randomized Clinical Trial

Introduction

Postoperative pain is one of the most common physiological and psychological stress in patients that disrupts body function and can endanger patients' health. This study aims to determine the effect of aromatherapy with Citrus aurantium essential on pain after orthopedic surgery.

Methods

This randomized clinical trial was performed on 60 candidates for orthopedic surgery. Patients were selected through convenience sampling and divided into intervention and control groups through randomized block allocation. If the visual analogue scale (VAS) score was above 3, patients in the intervention group received aromatherapy with C. aurantium essential and the patients in the control group received a placebo (almond oil). VAS was used to measure pain. Data analysis was performed using independent t test, paired t test, and analysis of variance with repeated measures using SPSS software version 13.

Results

Mean (SD) of pain intensity after intervention in experimental and control groups within 4, 8, and 12 hours after surgery was 7.30 (1.23) vs. 7.90 (0.99), 5.30 (0.98) versus 5.53 (0.68) and 2.53 (0.9) vs. 3.60 (0.77) respectively. The findings indicated that there was a significant difference in mean pain intensity between the experimental and control groups at 4 and 12 hours after surgery. Use of analysis of variance with repeated measures test with taking into account the interaction of time and group also showed a significant difference in mean pain intensity between the two experimental and control groups.

Conclusion

Aromatherapy with Citrus aurantium essential can be effective in reducing mild to moderate pain after orthopedic surgery. Further studies are recommended to confirm this finding.

The Role of Hypnotherapy in Postoperative Cardiac Surgical Patients, A Scoping Review of Current Literature

OBJECTIVE

Hypnotherapy has been proposed as an emerging tool that can be implemented in management of different aspects of postoperative cardiac surgical care. This technique involves hypnotic induction to redirect focus and attention away from post-surgical pain. Emerging literature has shown that hypnosis significantly improves emotional distress immediately preceding surgical procedures and these effects have been demonstrated to extend into the postoperative period. The purpose of this scoping review is to summarize current literature on the role of hypnotherapy in the management of perioperative pain, anxiety, and depression in patients undergoing cardiac surgery.

METHODS

A database search was conducted using PubMed, Embase, and Google Scholar. We included all comparative studies (randomized and non-randomized) that examined the effect of hypnotherapy on pain, anxiety, and depression in patients undergoing cardiac surgery. Included articles were restricted to adult patients and English language only.

RESULTS

Literature search yielded a total of 64 articles, of which, 14 duplicates were removed. After title and abstract screening, only 18 articles were included for full-text review. Six studies (with a total number of 420 patients) were included in the final analysis. Of these, five were randomized control trials and one was a cohort study.

CONCLUSION

Our findings suggest that there may be a potential role for the use of hypnotherapy in the management of pain, anxiety, and depressive symptoms in the perioperative period of cardiac surgery. However, more robust evidence is required to justify its incorporation in the routine perioperative management pathways in this group of patients.

Pain Self-Efficacy (PSEQ) score of <22 is associated with daily opioid use, back pain, disability, and PROMIS scores in patients presenting for spine surgery

BACKGROUND CONTEXT

Pain self-efficacy, or the belief that one can carry out activities despite pain, has been shown to be associated with back and neck pain severity. However, the literature correlating psychosocial factors to opioid use, barriers to proper opioid use, and Patient-Reported Outcome Measurement Information System (PROMIS) scores is sparse.

PURPOSE

The primary aim of this study was to determine whether pain self-efficacy is associated with daily opioid use in patients presenting for spine surgery. The secondary aim was to determine whether there exists a threshold self-efficacy score that is predictive of daily preoperative opioid use and subsequently to correlate this threshold score with opioid beliefs, disability, resilience, patient activation, and PROMIS scores.

PATIENT SAMPLE

Five hundred seventy-eight elective spine surgery patients (286 females; mean age of 55 years) from a single institution were included in this study.

STUDY DESIGN/SETTING

Retrospective review of prospectively collected data.

OUTCOME MEASURES

PROMIS scores, daily opioid use, opioid beliefs, disability, patient activation, resilience.

METHODS

Elective spine surgery patients at a single institution completed questionnaires preoperatively. Pain self-efficacy was measured by the Pain Self-Efficacy Questionnaire (PSEQ). Threshold linear regression with Bayesian information criteria was utilized to identify the optimal threshold associated with daily opioid use. Multivariable analysis controlled for age, sex, education, income, and Oswestry Disability Index (ODI) and PROMIS-29, version 2 scores.

RESULTS

Of 578 patients, 100 (17.3%) reported daily opioid use. Threshold regression identified a PSEQ cutoff score of <22 as predictive of daily opioid use. On multivariable logistic regression, patients with a PSEQ score <22 had two times greater odds of being daily opioid users than those with a score ≥22. Further, PSEQ <22 was associated with lower patient activation; increased leg and back pain; higher ODI; higher PROMIS pain, fatigue, depression, and sleep scores; and lower PROMIS physical function and social satisfaction scores (p<.05 for all).

CONCLUSIONS

In patients presenting for elective spine surgery, a PSEQ score of <22 is associated with twice the odds of reporting daily opioid use. Further, this threshold is associated with greater pain, disability, fatigue, and depression. A PSEQ score <22 can identify patients at high risk for daily opioid use and can guide targeted rehabilitation to optimize postoperative quality of life.

Bio-oriented synthesis of ibuprofen derivatives for enhancement efficacy in post-operative and chronic inflammatory pain models

The discovery of post-operative, chronic inflammatory pain and any gastroulcerogenic potential using well-established animal models in vivo with new structures, high efficiency, broad-spectrum, and low toxicity has been the focus of medicinal chemists. In the present article, we are reporting the design and synthesis of various derivatives of ibuprofen by modifying the carboxyl group of ibuprofen using three steps reactions; esterification under microwave-irradiation in 10 minutes, hydrazide formation, and finally schiff's base reaction. Microwave-assisted esterification reaction can be employed to quickly explore and increase molecular diversity in synthetic chemistry. All of the newly synthesized compounds (NS1-NS4) were characterized by ¹H-, ¹³C-NMR, and HR-ESI-MS spectroscopy and evaluated for post-operative, chronic inflammatory pain and any gastroulcerogenic potential using well-established animal models in vivo. The synthesized compounds at the tested doses of 100 and 150 mg kg^-1 significantly attenuated the incisional-injury induced post-operative pain like condition and, also inhibited the phologistic agent induced inflammatory responses in both the acute and chronic testing paradigms. The gastric histological and biochemical parameters exhibited that the synthesized compounds were devoid of any ulcerogenic potential in comparison to aspirin and ibuprofen. These findings concluded that the synthesized ibuprofen derivatives exhibited profound analgesic, anti-inflammatory properties with reduced ulcerogenic potential and might be considered as effective therapeutic agents to treat pathological conditions associated with pain and inflammation.

The Analysis of Pethidine Pharmacokinetics in Newborn Saliva, Plasma, and Brain Extracellular Fluid After Prenatal Intrauterine Exposure from Pregnant Mothers Receiving Intramuscular Dose Using PBPK Modeling

BACKGROUND AND OBJECTIVE

Pethidine (meperidine) can decrease labor pain-associated mother's hyperventilation and high cortisol-induced newborn complications. However, prenatal transplacentally acquired pethidine can cause side effects in newborns. High pethidine concentrations in the newborn brain extracellular fluid (bECF) can cause a serotonin crisis. Therapeutic drug monitoring (TDM) in newborns' blood distresses them and increases infection incidence, which can be overcome by using salivary TDM. Physiologically based pharmacokinetic (PBPK) modeling can predict drug concentrations in newborn plasma, saliva, and bECF after intrauterine pethidine exposure.

METHODS

A healthy adult PBPK model was constructed, verified, and scaled to newborn and pregnant populations after intravenous and intramuscular pethidine administration. The pregnancy PBPK model was used to predict the newborn dose received transplacentally at birth, which was used as input to the newborn PBPK model to predict newborn plasma, saliva, and bECF pethidine concentrations and set correlation equations between them.

RESULTS

Pethidine can be classified as a Salivary Excretion Classification System class II drug. The developed PBPK model predicted that, after maternal pethidine intramuscular doses of 100 mg and 150 mg, the newborn plasma and bECF concentrations were below the toxicity thresholds. Moreover, it was estimated that newborn saliva concentrations of 4.7 µM, 11.4 µM, and 57.7 µM can be used as salivary threshold concentrations for pethidine analgesic effects, side effects, and the risk for serotonin crisis, respectively, in newborns.

CONCLUSION

It was shown that saliva can be used for pethidine TDM in newborns during the first few days after delivery to mothers receiving pethidine.

Quantifying the impact of reduced opioid use in patients after emergency laparotomy

BACKGROUND

Emergency laparotomies have high rates of morbidity and mortality. The evaluation and management of pain are crucial, as poorly managed pain may contribute to postoperative complications and increase the risk of mortality. This study aims to describe the relationship between opioid use and opioid-related adverse effects and identify what constitutes appropriate dose reductions to elicit clinically relevant benefits.

METHODS

This was a retrospective, observational study of patients presenting for emergency laparotomy due to trauma from 2014 to 2018. The primary objective was to define clinical outcomes that may be significantly affected by changes in milligrams of morphine equivalent during the first 72 hours postoperatively; additionally, we sought to quantify the approximate differences in morphine equivalent that correlate with clinically meaningful outcomes such as hospital length of stay, pain scores, and time to first bowel movement. For descriptive summaries, patients were categorized into low, moderate, and high groups based on morphine equivalent requirements of 0 to 25, 25 to 50, and >50, respectively.

RESULTS

A total of 102 (35%), 84 (29%), and 105 (36%) patients were stratified into the low, moderate, and high groups, respectively. Mean pain scores for postoperative days 0 to 3 (P = .034), time to first bowel movement (P = .002), and nasogastric tube duration (P = .003) were the clinical outcomes found to be significantly associated with morphine equivalent. Estimated clinically significant reductions in morphine equivalent for these outcomes ranged from 194 to 464.

CONCLUSION

Clinical outcomes, such as pain scores, and opioid-related adverse effects, such as time to first bowel movement and nasogastric tube duration, may be linked with the amount of opioids used.

Assessment of glyceride-structured oleogels as an injectable extended-release delivery system of bupivacaine

This manuscript systematically assesses three different glycerides (tripalmitin, glyceryl monostearate, and a blend of mono-, di- and triesters of palmitic and stearic acids (Geleol™)) as potential gelator structuring agents of medium-chain triglyceride oil to form an oleogel-based injectable long-acting local anesthetic formulation for postoperative pain management. Drug release testing, oil-binding capacity, injection forces, x-ray diffraction, differential scanning calorimetry, and rheological testing were serially performed to characterize the functional properties of each oleogel. After benchtop assessment, the superior bupivacaine-loaded oleogel formulation was compared to bupivacaine HCl, liposomal bupivacaine, and bupivacaine-loaded medium-chain triglyceride oil in a rat sciatic nerve block model to assess in vivo long-acting local anesthetic performance. In vitro drug release kinetics were similar for all formulations, indicating that drug release rate is primarily dependent on the drug's affinity to the base oil. Glyceryl monostearate-based formulations had superior shelf-life and thermal stability. The glyceryl monostearate oleogel formulation was selected for in vivo evaluation. It was found to have a significantly longer duration of anesthetic effect than liposomal bupivacaine and was able to provide anesthesia twice as long as the equipotent bupivacaine-loaded medium-chain triglyceride oil, indicating that the increased viscosity of the oleogel provided enhanced controlled release over the drug-loaded oil alone.

The role of dexmedetomidine as an adjuvant for high-thoracic erector spinae plane block for analgesia in shoulder arthroscopy; a randomized controlled study

BACKGROUND

Management of postoperative pain after shoulder arthroscopy is an important issue. Dexmedetomidine, as an adjuvant, improves nerve block efficacy and decreases postoperative consumption of opioids. As a result, we designed this study to determine if adding dexmedetomidine to an erector spinae plane block (ESPB) that is guided by ultrasound (US) is beneficial for treating immediate postoperative pain following shoulder arthroscopy.

METHODS

This randomized controlled double-blind trial recruited 60 cases 18-65 years old of both sexes, American Society of Anesthesiologists (ASA) physical status I-II, scheduled for elective shoulder arthroscopy. Random allocation of 60 cases was done equally into two groups according to the solution injected in US-guided ESPB at T2 before general anesthetic induction. Group (ESPB): 20 ml 0.25% bupivacaine. Group (ESPB + DEX): 19 ml bupivacaine 0.25% + 1 mL dexmedetomidine 0.5 µg/kg. The primary outcome was The total rescue morphine consumption in the first 24 postoperative hours.

RESULTS

The mean intraoperative fentanyl consumption was significantly lower in the group (ESPB + DEX) compared to the group (ESPB) (82.86 ± 13.57 versus 100.74 ± 35.07, respectively, P = 0.015). The median (IQR) time of the 1^st rescue analgesic request was significantly delayed in the group (ESPB + DEX) compared to group (ESPB) [18.5 (18.25-18.75) versus 12 (12-15.75), P = 0.044]. The number of cases that required morphine was significantly lower in the group (ESPB + DEX) than in the group (ESPB) (P = 0.012). The median (IQR) of total postoperative morphine consumption in 1^st 24 h was significantly lower in the group (ESPB + DEX) compared to the group (ESPB) [0 (0-0) versus 0 (0-3), P = 0.021].

CONCLUSION

The dexmedetomidine as an adjuvant to bupivacaine in ESPB produced adequate analgesia by reducing the intraoperative and postoperative opioid requirements in shoulder arthroscopy.

TRIAL REGISTRATION

This study is registered on ClinicalTrials.gov (NCT05165836; principal investigator: Mohammad Fouad Algyar; registration date: 21/12/ 2021).

A Comparison of the Effects of Epidural Levobupivacaine and Morphine for Postoperative Analgesia Following Major Abdominal Surgery: A Randomized Controlled Trial

Objectives Epidural analgesia remains the cornerstone of pain management following laparotomy. Local anesthetics used in epidural analgesia provide good analgesia but may result in hypotension and/or motor blockade. Morphine, a long-acting opioid, can also be used epidurally to provide analgesia. Morphine used epidurally will cause fewer hemodynamic disturbances and no motor blockade. Hence, we compared the efficacy, hemodynamic parameters, and motor blockade between epidural levobupivacaine and morphine for postoperative analgesia following laparotomy. Materials and methods This is a prospective, double-blind, randomized controlled study registered in the Clinical Trials Registry of India (CTRI/2021/04/033102). Ninety patients undergoing elective major abdominal surgery were randomly divided into two groups: levobupivacaine (0.125%/mL) and morphine (0.032 mg/mL) group. All patients received epidural infusion at 6 mL/hour. The visual analog scale (VAS) score at rest and during cough was observed for 24 hours. Heart rate and blood pressure were monitored continuously for 24 hours postoperatively. Additional analgesic requirements, postoperative sedation score, and motor blockade were also compared between the two groups. Statistical analysis was done using the chi-square test, unpaired T-test, and Mann-Whitney test. The sample size estimation was based on a pilot study. Results The demographic data and duration of the procedure were comparable in both groups. The initial median VAS score at rest in the levobupivacaine group was high (interquartile range (IQR): 2-4) when compared to the morphine group (IQR: 1-3) at the fourth, sixth, and eighth hour with a P value of <0.05. The initial median VAS score at coughing in the levobupivacaine group was 4 (IQR: 3-5) and in the morphine group was 3 (IQR: 3-4). The VAS score at rest and at coughing was significantly higher in the levobupivacaine group. Heart rate was stable in both groups, and a significant fall in mean arterial blood pressure was observed in the levobupivacaine group. The sedation score was significantly higher in the morphine group (IQR: 2-2) when compared to the levobupivacaine group (IQR: 1-2) at the fourth hour postoperatively with a P value of <0.05. Motor blockade was found to be stronger in the levobupivacaine group (IQR: 0-2) when compared to the morphine group (IQR: 0-0) at the fourth, sixth, and eighth hour postoperatively with a P value of <0.05. An additional dose of fentanyl was required by 6.7% of the patients in the levobupivacaine group and 8.9% of the patients in the morphine group. In the levobupivacaine group, 11.1% reported headaches, 2.2% reported vomiting, and 4.4% reported hypotension, and no pruritus was reported. In the morphine group, 11.1% reported tachycardia, 6.7% reported nausea and vomiting, 6.4% reported pruritus, and 2.2% reported hypotension. Conclusion We conclude that patients receiving epidural morphine had better pain scores with better hemodynamic stability than the epidural levobupivacaine group following laparotomy. The morphine group had less motor blockade. Sedation was observed in the morphine group. Additional analgesics were required in both groups. The adverse effects observed in the epidural morphine group were tachycardia, nausea, pruritus, and itching. The epidural levobupivacaine group reported headache, vomiting and fever, and hypotension.

Allergic and other adverse reactions to drugs used in anesthesia and surgery

The list of drugs patients may be exposed to during the perioperative and postoperative periods is potentially extensive. It includes induction agents, neuromuscular blocking drugs (NMBDs), opioids, antibiotics, sugammadex, colloids, local anesthetics, polypeptides, antifibrinolytic agents, heparin and related anticoagulants, blue dyes, chlorhexidine, and a range of other agents depending on several factors related to individual patients’ clinical condition and progress in the postoperative recovery period. To avoid poor or ultrarapid metabolizers to a particular drug (for example tramadol and codeine) or possible adverse drug reactions (ADRs), some drugs may need to be avoided during or after surgery. This will be the case for patients with a history of anaphylaxis or other adverse events/intolerances to a known drug. Other drugs may be ceased for a period before surgery, e.g., anticoagulants that increase the chance of bleeding; diuretics for patients with acute renal failure; antihypertensives relative to kidney injury after major vascular surgery; and serotonergic drugs that together with some opioids may rarely induce serotonin toxicity. Studies of germline variations shown by genotyping and phenotyping to identify a predisposition of genetic factors to ADRs offer an increasingly important approach to individualize drug therapy. Studies of associations of human leukocyte antigen (HLA) genes with some serious delayed immune-mediated reactions are ongoing and variations of drug-metabolizing cytochrome CYP450 enzymes, P-glycoprotein, and catechol-O -methyltransferase show promise for the assessment of ADRs and non-responses to drugs, particularly opioids and other analgesics. Surveys of ADRs from an increasing number of institutions often cover small numbers of patients, are retrospective in nature, fail to clearly identify culprit drugs, and do not adequately distinguish immune-mediated from non-immune-mediated anaphylactoid reactions. From the many surveys undertaken, the large list of agents identified during and after anesthesia and surgery are examined for their ADR involvement. Drugs are classified into those most often involved, (NMBD and antibiotics); drugs that are becoming more frequently implicated, namely antibiotics (particularly teicoplanin), and blue dyes; those becoming less frequently involved; and drugs more rarely involved in perioperative, and postoperative adverse reactions but still important and necessary to keep in mind for the occasional potential sensitive patient. Clinicians should be aware of the similarities between drug-induced true allergic type I IgE/FcεRI- and pseudoallergic MRGPRX2-mediated ADRs, the clinical features of each, and their distinguishing characteristics. Procedures for identifying MRGPRX2 agonists and diagnosing and distinguishing pseudoallergic from allergic reaction mechanisms are discussed.

Oliceridine for the Management of Moderate to Severe Acute Postoperative Pain: A Narrative Review

Despite current advances in acute postoperative pain management, prevalence remains high. Inadequate treatment could lead to poor outcomes and even progression to chronic pain. Opioids have traditionally been the mainstay for treatment of moderate to severe acute pain. However, their use has been associated with opioid-related adverse events (ORAEs), such as respiratory depression, sedation, nausea, vomiting, pruritus, and decreased bowel motility. In addition, their liberal use has been implicated in the current opioid epidemic. As a result, there has been renewed interest in multimodal analgesia to target different mechanisms of action in order to achieve a synergistic effect and minimize opioid usage. Oliceridine is a novel mu-opioid receptor agonist that is part of a new class of biased ligands that selectively activate G-protein signaling and downregulate β-arrestin recruitment. Since G-protein signaling has been associated with analgesia while β-arrestin recruitment has been associated with ORAEs, there is potential for a wider therapeutic window. In this review, we will discuss the clinical evidence behind oliceridine and its potential role in acute postoperative pain management. We have systematically searched the PubMed database using the keywords oliceridine, olinvyk, and trv130. All articles identified were reviewed and evaluated, and all clinical trials were included.

The characteristics of opioid use in patients with proximal humerus fractures

BACKGROUND

Orthopaedic surgeons prescribe more opioid narcotics than any other surgical specialty. Proximal humerus fractures (PHF) often occur in the high-risk elderly population. The opioid epidemic has led to public policy aimed at reductions in opioid prescription. This study aimed to evaluate the impact that new legislation has had on opioid prescription patterns in patients who sustained proximal humerus fractures.

METHODS

A retrospective review of all patients who sustained PHF at a single academic institution from 1/1/2015-12/31/2019 was performed. A total of 762 proximal humerus fractures were identified and final analysis included 383 patients. Collected data included basic demographics and opioid prescriptions obtained through review of the electronic medical record. The North Carolina Strengthen Opioid Misuse Prevention act legislation that went into effect on July 1, 2017.

RESULTS

There was no difference in the number of pre- or postoperative opioid prescriptions provided with the new legislation. Our data showed a significant reduction in MeQs prescribed preoperatively pre-STOP act (188.1 MeQs) and post-STOP act (99.4 MeQs). There was also a significant difference in the amount of postoperative narcotics prescribed in the pre-STOP (972.6 MeQs) and post-STOP act (508.6 MeQs) groups (p < 0.01).

CONCLUSIONS

With the enactment of the STOP act in North Carolina, we have seen a significant reduction in the amount of narcotic prescribed after sustaining a proximal humerus fracture preoperatively and postoperatively. This data demonstrates the impact that implementation of state-wide regulatory changes in opioid prescribing policy has had for a common orthopedic condition.