Pain Management in Enhanced Recovery after Surgery (ERAS) Protocols

Reduction of postoperative pain and opioid consumption by VVZ-149, first-in-class analgesic molecule: A confirmatory phase 3 trial of laparoscopic colectomy

STUDY OBJECTIVE

VVZ-149 is a small molecule that inhibits the glycine transporter type 2 and the serotonin receptor 5-hydroxytryptamine 2 A. In this Phase 3 study, we investigated the efficacy and safety of VVZ-149 as a single-use injectable analgesic for treating moderate to severe postoperative pain after laparoscopic colectomy.

DESIGN

Randomized, parallel group, double-blind, Phase 3 clinical trial (Trial no. NCT05764525).

SETTING

5 tertiary referral centers in South Korea.

PATIENTS

284 patients undergoing laparoscopic colectomy.

INTERVENTIONS

A continuous 10-h intravenous infusion of VVZ-149 (n = 141) or placebo (n = 143) administered after emergence from anesthesia.

MEASUREMENTS

Pain intensity was assessed using a numeric rating scale (NRS) from the start of infusion for 48 h. The primary efficacy measure was the Sum of Pain Intensity Difference (SPID) for the first 12 h after the start of drug infusion. Other efficacy measures included SPID at other time points, opioid consumption via on-demand patient-controlled analgesia (PCA) and rescue medication, and proportion of patients who did not require rescue opioids for 48 h post-dose.

MAIN RESULTS

Pain relief as measured by SPID was significantly improved by 35 % in the VVZ-149 group compared to the placebo group at 6 h (p = 0.0193) and 12 h (p = 0.0047) after the start of infusion. Significantly lower pain intensity scores were observed between 4-10 h in the VVZ-149 group compared to the placebo group (p = 0.0007), reaching mild pain (mean NRS <4) at 8 h. VVZ-149 alleviated pain during the first 12 h post-dose with 30.8 % less opioid consumption and 60.2 % fewer PCA requests when compared with placebo. A higher proportion of patients receiving VVZ-149 were rescue opioid-free during 2-6 h (p = 0.0026) and 6-12 h (p = 0.0024) compared with the placebo group. VVZ-149 administration in post-colectomy patients was generally safe and well tolerated.

CONCLUSIONS

When compared to placebo, VVZ-149 infusion demonstrated a significant reduction of pain within the first 12 h after surgery with a substantial decrease in opioid use. VVZ-149 rapidly lowers the pain intensity starting at as early as 4 h post-dose, allowing subjects to experience mild pain levels from 8 h through 48 h. Therefore, the analgesic effect of VVZ-149 was shown to effectively relieve pain and reduce opioid use for treating moderate to severe pain in the early postoperative care setting.

REGISTRATION NUMBER

Trial Number NCT05764525.

Intraoperative Administration of Esketamine is Associated with Reduced Opioid Consumption After Laparoscopic Gynecological Surgery: A Randomized Controlled Trial

Purpose

To explore the postoperative opioid-sparing effect and incidence of adverse events of different dosages of intraoperative esketamine administration in patients undergoing laparoscopic gynecological surgery.

Patients and Methods

Patients undergoing elective gynecological laparoscopic operation was enrolled and randomly allocated to lower-dose esketamine group, higher-dose esketamine group, or control group. Patients in the two intervention groups received esketamine doses of 0.25 mg/Kg and 0.50 mg/Kg before wound incision. Subsequently, maintenance doses of 0.20 mg/Kg/h and 0.40 mg/Kg/h were administered throughout the procedure, respectively. The control group was given an intravenous injection and a maintenance infusion of normal saline. A patient-controlled analgesia (PCA) intravenous pump containing sufentanil was connected to control postoperative pain. Rescue analgesia was provided with injection of tramadol 100 mg.

Results

In total, 120 subjects were included in data analysis. The 24 hours and 48 hours PCA opioid consumption, 24 hours and 48 hours cumulative opioid in both lower-dose and higher-dose esketamine groups were lower than those in the control group. However, postoperative opioid consumption was comparable between the two intervention groups. No differences were found in extubation time, acute postoperative pain intensity, and incidence of adverse effects among the three groups.

Conclusion

Intraoperative esketamine administration at both low and high doses reduces opioid consumption after gynecological laparoscopic surgery, without increasing the risk of adverse events.

Reducing Postoperative Opioid Use: A Comparison of Open Versus Ultrasound-Guided Regional Anesthesia for Patients Undergoing Open Pancreatoduodenectomy

BACKGROUND

Opioid crisis is a national issue with significant economic burden and marked increase in opioid-related deaths, particularly following surgical procedures. Reducing opioid requirements while maintaining effective analgesia is critically challenging, perioperatively. Multimodal drug regimens and guided regional anesthesia (RA) have been adopted to address this issue. We aimed to assess postoperative opioid consumption in patients undergoing open pancreatoduodenectomy based on the routes of RA administration: open versus ultra-sound guided.

METHODS

This retrospective cohort study was conducted at Emory University Saint Joseph's Hospital, encompassing patients who underwent open pancreatoduodenectomy (PD) from 2020 to 2022 who received ultrasound-guided RA (U-RA) or open RA (O-RA). Patient demographics, surgical details, and postoperative outcomes, including opioid consumption measured in morphine milligram equivalents (MME) at 24, 48, and 72 h, were analyzed. Multivariable linear regression identified predictors of postoperative opioid use.

RESULTS

Of 95 patients, 47 met inclusion criteria: 27 received U-RA and 20 O-RA. Preoperative and intraoperative characteristics were similar between patients receiving O-RA and U-RA. A lower opioid requirement was noted in the O-RA group compared to the U-RA group at all time points. (24 h: 6.5 vs. 18, p = 0.004; 48 h: 18 vs. 37, p = 0.001; 72 h: 30.5 vs. 57, p = 0.002). On multivariable analysis, only route of regional anesthesia was independently associated with reduced opioid use across all time points (24 h: mean difference = -5.75, 95% CI: -11.3, -0.18; 48 h: mean difference = -16.95, 95% CI: -27.5, -6.4; 72 h: mean difference = -20.39, 95% CI: -35.4, -5.3) Patient age, gender, race, obesity, neoadjuvant chemotherapy, small pancreatic duct, and pancreatic fistula were not independently associated with opioid use.

CONCLUSIONS

O-RA may offer a better approach than U-RA in minimizing opioid consumption after open PD. These findings suggest the incorporation of O-RA for upper abdominal surgeries to decrease the necessity of postoperative opioids.

Construction of Pain Management Strategies After Hepatectomy: Evidence Summary and Delphi Study

Purpose

To develop and summarize pain management strategies after hepatectomy for liver cancer based on the best evidence summary, and to improve the strategy of the Delphi study.

Methods

According to the "6S" evidence pyramid model, the database was systematically searched, with a search deadline of December 2023. Two researchers independently conducted literature screening and quality evaluation. Relevant evidence on pain management was extracted and integrated. Relevant evidence for pain management formed a preliminary strategy through a one-day, face-to-face meeting. Subsequently, a Delphi process was performed to improve the strategy. The scientific soundness of the Delphi method was expressed by the effective response rate, authority coefficient (Cr), and coordination coefficient. The coordination of expert opinions was assessed using the coefficient of variation (CV) and Kendall's coefficient (W). Cr should be above 0.700 and the coefficient of variation (CV) should be below 0.25. Data analysis was performed using SPSS V.25.0.

Results

A total of 14 studies were included, and we summarized 13 first-level items and 48  second-level items by two rounds of Delphi. The effective response rate of the two rounds of Delphi was 100.00%, and the authority coefficient of the experts was 0.832. The coefficients of variation were 0.00-0.41 and 0.05-0.17, respectively. The Kendall's W values for the two rounds were 0.114-0.222 (p<0.05).

Conclusion

Pain management strategy after hepatectomy is scientific and applicable. We plan to translate this into a plan and confirm its feasibility in the future.

The Impact of Preoperative Combined Pectoserratus and/or Interpectoral Plane (Pectoralis Type II) Blocks on Opioid Consumption, Pain, and Overall Benefit of Analgesia in Patients Undergoing Minimally Invasive Cardiac Surgery: A Prospective, Randomized, Controlled, and Triple-blinded Trial

OBJECTIVE

Acute postoperative pain remains a major obstacle in minimally invasive cardiac surgery (MICS). Evidence of the analgesic benefit of chest wall blocks is limited. This study was designed to assess the influence of combined pectoserratus plane block plus interpectoral plane block (PSPB + IPPB) on postoperative pain and the overall benefit of analgesia compared with placebo.

DESIGN

A prospective, randomized, triple-blinded study was conducted.

SETTING

The setting was the operating room and intensive care unit of a university hospital.

PARTICIPANTS

A total of 60 patients undergoing elective right-lateral MICS were enrolled.

INTERVENTIONS

Patients were randomly assigned to preoperative PSPB + IPPB with 30 mL of ropivacaine 0.5% or saline.

MEASUREMENTS AND MAIN RESULTS

The primary endpoint was total intravenous morphine milligram equivalents administered in the first 24 hours after extubation. Secondary endpoints included the Overall Benefit of Analgesia Score (OBAS) at 24 hours after extubation and repeated Visual Analogue Scale (VAS). Values for intravenous morphine milligram equivalents administered in the first 24 hours after extubation were significantly lower (median [interquartile range]: 4.2 mg [2.1 - 7.9] v 8.3 mg [4.2 - 15.7], p = 0.025; mean difference: 6.7 mg [0.94 - 12 mg], p = 0.024, Cohen's d: 0.64 [0.09 - 1.2]). Moreover, OBAS at 24 hours and VAS after extubation were significantly lower (4.0 [3.0 - 6.0] v 7.0 [3.0 - 9.0], p = 0.043; 0.0 cm [0.0 - 2.0] v 1.5 cm [0.3 - 3.0], p = 0.030). VAS did not differ between groups at later points.

CONCLUSIONS

Preoperative PSPB + IPPB reduced 24-hour postextubation opioid consumption, pain at extubation, and OBAS. Given its low risk and expedient placement, it could be a helpful addition to MICS protocols. Future studies should evaluate these findings in multicenter settings and further elucidate the optimal timing of block placement.

Advances in the use of local anesthetic extended-release systems in pain management

Pain management remains among the most common and largely unmet clinical problems today. Local anesthetics play an indispensable role in pain management. The main limitation of traditional local anesthetics is the limited duration of a single injection. To address this problem, catheters are often placed or combined with other drugs in clinical practice to increase the time that local anesthetics act. However, this method does not meet the needs of clinical analgesics. Therefore, many researchers have worked to develop local anesthetic extended-release types that can be administered in a single dose. In recent years, drug extended-release systems have emerged dramatically due to their long duration and efficacy, providing more possibilities for the application of local anesthetics. This paper summarizes the types of local anesthetic drug delivery systems and their clinical applications, discusses them in the context of relevant studies on local anesthetics, and provides a summary and outlook on the development of local anesthetic extended-release agents.

Identifying risk factors for postoperative ileus following open abdominal aortic aneurysm repair

BACKGROUND

Postoperative ileus (POI) is a common complication following major abdominal surgery. The majority of the data available regarding POI after abdominal surgery is from the gastrointestinal and urological literature. These data have been extrapolated to vascular surgery, especially with regard to enhanced recovery programs for open abdominal aortic aneurysm (AAA) surgery. However, vascular patients are a unique patient population and extrapolation of gastrointestinal and urological data may not necessarily be appropriate. Therefore, the purpose of this study was to delineate the prevalence and risk factors of POI in patients undergoing open AAA surgery.

METHODS

This was a retrospective, single-institution study of patients who underwent open AAA surgery from January 2016 to July 2023. Patients were excluded if they had undergone nonelective repairs or had expired within 72 hours of their index operation. The primary outcome was rates of POI, which was defined as the presence of two or more of the following after the third postoperative day: nausea and/or vomiting, inability to tolerate oral food intake, absence of flatus, abdominal distension, or radiological evidence of ileus.

RESULTS

A total of 123 patients met study criteria with an overall POI rate of 8.9% (n = 11). Patients who developed a POI had a significantly lower body mass index (24.3 kg/m2 vs 27.1 kg/m2; P = .003), were more likely to undergo a transperitoneal approach (81.8% vs 42.0%; P = .022), midline laparotomy (81.8% vs 37.5%; P = .008), longer total clamp times (151.6 minutes vs 97.7 minutes; P = .018), greater amounts of intraoperative crystalloid infusion (3495 mL vs 2628 mL; P = .029), and were more likely to return to the operating room (27.3% vs 3.6%; P = .016). Proximal clamp site was not associated with POI (P=.463). Patients with POI also had higher rates of postoperative vasopressor use (100% vs 61.1%; P = .014) and greater amounts of oral morphine equivalents in the first 3 postoperative days (488.0 ± 216.0 mg vs 203.8 ± 29.6 mg; P = .016). Patients who developed POI had longer lengths of stay (12.5 days vs 7.6 days; P < .001), a longer duration of nasogastric tube decompression (5.9 days vs 2.2 days; P < .001), and a longer period of time before diet tolerance (9.1 days vs 3.7 days; P < .001). Of those who developed a POI (n = 11), four (36.4%) required total parental nutrition during the admission.

CONCLUSIONS

POI is a morbid complication among patients undergoing elective open AAA surgery that prolongs hospital stay. Patients at risk for developing a POI are those with a lower body mass index, as well as those who had an operative repair via a transperitoneal approach, midline laparotomy, longer clamp times, larger amounts of intraoperative crystalloid infusion, a return to the operating room, postoperative vasopressor use, and higher amounts of oral morphine equivalents. These data highlight important perioperative opportunities to decrease the prevalence of POI.

Evaluation of the analgesic efficacy of a low dose of intrathecal morphine in laparoscopic abdominal surgery: A randomised control trial

INTRODUCTION

Intrathecal opioid is an analgesic option in laparoscopic surgery. We assessed primarily the intraoperative opioid requirement amongst patients receiving intrathecal morphine (ITM) (Group M) versus standard care (Group C) for abdominal surgery. The secondary outcomes were intraoperative haemodynamic changes, extubation on table and pain scores in the intensive care unit (ICU) at 6 th hourly intervals for 24 h postoperatively.

PATIENTS AND METHODS

Patients undergoing laparoscopic abdominal surgery were randomised into Group M ( n = 30) that received ITM at 2 μg/kg while Group C ( n = 30) was control. A rise in mean arterial pressure > 20% from baseline was treated sequentially with 0.3 mg /kg propofol and 0.5 μg/kg fentanyl intravenously (IV). Pain management in the ICU included paracetamol 1G IV 8 th hourly for all patients, while nefopam 20 mg and fentanyl 0.5 μg/kg IV were the second and third tiers of pain management.

RESULTS

Intraoperatively, 10 patients in Group M versus 26 in Group C needed additional fentanyl ( P < 0.001) and 15 versus 26 patients needed additional propofol ( P = 0.0024). Pain scores were superior in Group M at all time points in the ICU and at ambulation and during incentive spirometry. Thirteen patients in Group C versus 3 in Group M needed nefopam at the time of shifting to the ICU ( P = 0.004) and 10 patients versus 1 at 8 h in the ICU ( P = 0.003) while pain management at 16 h and 24 h was comparable.

CONCLUSION

Pre-operative ITM at 2 μg/kg reduces intraoperative opioid requirement and improves analgesia 24 h postoperatively amongst patients undergoing major laparoscopic abdominal surgery without delay in extubation or changes in haemodynamics.

Erector spinae plane block (ESPB) enhances hemodynamic stability decreasing analgesic requirements in surgical stabilization of rib fractures (SSRFs)

OBJECTIVE

To evaluate the efficacy of erector spinae plane block (ESPB) on intraoperative hemodynamic stability, opioid and inhalation anesthetic requirements and postoperative analgesic effects in patients undergoing surgical stabilization of rib fractures (SSRFs).

METHODS

We retrospectively reviewed 173 patients who underwent surgical stabilization of rib fractures between May 2020 and December 2023. The patients were allocated into the ESPB group or the control group. Demographic data, intraoperative hemodynamic parameters, total intraoperative opioid consumption, the average minimum alveolar concentration (MAC) of inhalational anesthetics, postoperative simple analgesics and opioid consumption and the length of hospital stay were included in the analysis.

RESULTS

Compared with the control group, the ESPB group had a lower heart rate (HR) in the first 90 min after surgical incision and lower systolic blood pressure (SBP) and mean arterial pressure (MAP) at the beginning of surgery. Intraoperatively, a notable reduction in fentanyl consumption was observed in the ESPB group (p = 0.004), whereas no significant difference was observed in the average MAC of inhalational agents (p = 0.073). Postoperatively, the ESPB group required fewer doses of simple analgesics in the first 24 h (p < 0.001) and 48 h (p = 0.029). No statistically significant difference in the length of hospital stay (p = 0.608) was observed between the groups.

CONCLUSION

ESPB was shown to enhance intraoperative hemodynamic stability, reduce opioid consumption and decrease postoperative analgesic consumption in patients who underwent SSRF. These results suggest that ESPB may serve as a valuable component of multimodal analgesia protocols for SSRF. Larger prospective studies are warranted to confirm the results and evaluate long-term outcomes.

Urgent focus on enhanced recovery after surgery of AIDS patients with limb fractures

Aims

The incidence of limb fractures in patients living with HIV (PLWH) is increasing. However, due to their immunodeficiency status, the operation and rehabilitation of these patients present unique challenges. Currently, it is urgent to establish a standardized perioperative rehabilitation plan based on the concept of enhanced recovery after surgery (ERAS). This study aimed to validate the effectiveness of ERAS in the perioperative period of PLWH with limb fractures.

Methods

A total of 120 PLWH with limb fractures, between January 2015 and December 2023, were included in this study. We established a multidisciplinary team to design and implement a standardized ERAS protocol. The demographic, surgical, clinical, and follow-up information of the patients were collected and analyzed retrospectively.

Results

Compared with the control group, the ERAS group had a shorter operating time, hospital stay, preoperative waiting time, postoperative discharge time, less intraoperative blood loss, and higher albumin and haemoglobin on the first postoperative day. The time to removal of the urinary catheter/drainage tube was shortened, and the drainage volume was also significantly reduced in the ERAS group. There was no significant difference in the visual analogue scale (VAS) scores on postoperative return to the ward, but the ERAS group had lower scores on the first, second, and third postoperative days. There were no significant differences in the incidence of complications, other than 10% more nausea and vomiting in the control group. The limb function scores at one-year follow-up were similar between the two groups, but time to radiological fracture union and time to return to physical work and sports were significantly reduced in the ERAS group.

Conclusion

The implementation of a series of perioperative nursing measures based on the concept of ERAS in PLWH with limb fracture can significantly reduce the operating time and intraoperative blood loss, reduce the occurrence of postoperative pain and complications, and accelerate the improvement of the functional status of the affected limb in the early stage, which is worthy of applying in more medical institutions.

Efficacy of multimodal analgesia based on the concept of enhanced recovery after surgery in laparoscopic radical gastrectomy for gastric cancer

Objective

To explore the effect of multimodal analgesia based on the concept of enhanced recovery after surgery (ERAS) in patients undergoing laparoscopic radical gastrectomy (LRG) for gastric cancer (GC).

Methods

Clinical data of 128 patients undergoing LRG for GC, admitted to Sir Run Run Shaw Hospital, Zhejiang University School of Medicine from March 2021 to March 2022, were retrospectively analyzed. Among them, 66 patients received a multimodal analgesic management based on ERAS (ERAS group), and 62 patients were treated with conventional mode of analgesia (control group). Pain levels, rehabilitation status, as well as inflammatory factors and stress response indicators before and after surgery were compared between the two groups.

Results

There was no significant difference in baseline data between the two groups (P>0.05). The postoperative pain and recovery in the ERAS group were better than those in the control group (P<0.05). After the surgery, serum levels of tumor necrosis factor-alpha (TNF-α), Interleukin 6 (IL-6), and C-reactive protein (CRP) in both groups increased compared to before the surgery, but were significantly lower in the ERAS group compared to the control group (P<0.05). After the surgery, serum malondialdehyde (MDA) and xanthine oxidase (XOD) levels in both groups increased, while superoxide dismutase (SOD) levels decreased compared to preoperative levels. The observed postoperative levels of serum MDA and XOD were significantly lower in the ERAS group, while the postoperative SOD levels were higher compared to the control group (P<0.05).

Conclusions

Patients undergoing LRG for GC can benefit from a multimodal pain management plan based on ERAS to reduce postoperative pain, alleviate inflammation, stress responses, and shorten the postoperative recovery process.

Role of Strong Opioids in an Effective Discharge for Lower-Limb Large Joint Arthroplasty Patients: A Patient-Based Analysis

BACKGROUND/OBJECTIVE

Adequate postoperative analgesics are an essential element in the recovery and rehabilitation of large joint lower-limb arthroplasty patients in their acute postoperative phase. In this study, we will establish that strong opioids like morphine should be included as postoperative analgesics to improve patient satisfaction.  Material: This retrospective cross-sectional study was conducted in the Arthroplasty Ward, Trauma, and Orthopaedics Department in a district general hospital of the United Kingdom. Fifty patients operated in January 2024 were enrolled in this study, out of which 25 had total hip replacement and 25 had total knee replacement. Patients were divided into two groups based on analgesics given at the time of discharge. Group A had a strong opioid and Group B had a non-steroidal anti-inflammatory drug (NSAID) plus weak opioids upon discharge. Patients with hospital stays of more than four days and patients with allergies to any analgesics were excluded.  Results: Forty percent (40%) of the patients in the total hip replacement (THR) group and fifty percent (50%) in the total knee replacement (TKR) group were discharged on adequate analgesia (NSAID + weak opioids + strong opioids) and all reported manageable postoperative pain. A significant difference in pain scores on the fifth postoperative day (POD) was observed between the two groups (p = 0.001). Patient satisfaction levels also differed notably between the groups, with significant variance (p = 0.011). Group A showed a higher rate of "very satisfied" patients (n = 3).

CONCLUSION

Adequate analgesics prescribing is an integral part of enhanced recovery after surgery (ERAS) guidelines for patients undergoing knee and hip arthroplasties. Pain has catabolic systemic consequences for patients and delays postoperative recovery. We have proposed the step ladder pattern of analgesics for such patients, in which strong opioids should be given to aid in pain relief. Apart from this, a virtual consultation should be done by an arthroplasty nurse within one week of operation for their pain assessment as the pain scale.

The efficacy of preemptive multimodal analgesia in elderly patients undergoing laparoscopic colorectal surgery: a randomized controlled trial

Objective To evaluate the effectiveness of preemptive multimodal analgesiain elderly patients undergoing laparoscopic colorectal surgery. Methods A prospective randomized controlled study was conducted in the Department of Gastrointestinal Surgery of the Second Hospital of Hebei Medical University from January 2022 to December 2022. A total of 133 patients were included according to the criteria and randomly divided into preemptive analgesia (PRA) group (test group, 67patients) and postoperative analgesia (POA) group (control group, 66patients). Results The Visual Analog Scale (VAS)scores of PRA group 24 h, 48 h, and 72 h after operation were lower than those of POA group, and the difference was statistically significant, P < 0.001.The incidences of postoperative gastrointestinal dysfunction (POGD) and postoperative delirium (POD)in PRA group were 13.43% and 8.98%, respectively, which were significantly lower than those in POA group (31.82% and 24.24%), P < 0.05. The levels of IL-6 and IL-10 in PRA group after the operation were 17.54 ± 2.13 ng/L and 15.57 ± 1.71 ng/L respectively, which were lower than those in POA group (25.45 ± 2.95 ng/L and 23.45 ± 1.88 ng/L), P < 0.05. The level of acetylcholinesterase(AchE) was 56.34 ± 5.62 nmol/L in the POA group, which was significantly higher than that in the POA group (49.59 ± 5.52 nmol/L), P < 0.001. Conclusion Preemptive multimodal analgesia can reduce the incidence of POGD and POD in elderly patients undergoing laparoscopic gastrocolic surgery, improve the recovery process of postoperative gastrointestinal function, increase the concentrations of propionic acid and butyric acid in short chain fatty acids (SCFAs) and the number of beneficial intestinal bacteria.

Clinical Trial Study Protocol: A Prospective Blinded, Randomized, Controlled Clinical Trial Protocol to Assess the Efficacy of Ultrasound-Guided Transversus Abdominis Plane Block on Postoperative Analgesia and Recovery Quality in Laparoscopic Donor Hepatectomy

Introduction

Liver transplantation is considered an effective treatment for end-stage liver disease. Laparoscopic donor hepatectomy (LDH) has become a new standard procedure. And it is important to minimize the pain of the donor. Good postoperative analgesia can reduce the occurrence of postoperative complications and promote the early recovery of the donor. Ultrasound-guided transversus abdominis plane (TAP) block can provide effective analgesia for liver donors and reduce postoperative opioid consumption. This study aims to use ultrasound-guided TAP block for LDH to improve postoperative analgesia for donors while reducing opioid consumption and improving patient rehabilitation quality.

Methods/Analysis

This study is a prospective blinded, randomized, controlled clinical trial with a concealed allocation of patients (living liver donors) scheduled to receive laparoscopic partial hepatectomy 1:1 to receive local infiltration anesthesia or TAP block. This study will recruit a total of 80 patients. The primary outcome is the dosage of opioids within 24 hours after surgery.

Ethics and Dissemination

This trial has been approved by the Institutional Review Board of Beijing Friendship Hospital of China Capital University. This trial study protocol was approved on 8 May 2023. The trial will start recruiting patients after being registered on the Chinese Clinical Trial Registry.

Trial Registration Number

ChiCTR2300071694.

Intracorporeal versus Extracorporeal Anastomosis in Laparoscopic Right Hemicolectomy: An Updated Systematic Review and Meta-Analysis of Randomized Control Trials

INTRODUCTION

Laparoscopic right hemicolectomy has become the standard surgical procedure for the treatment of right colon disease; however, the choice of anastomosis remains controversial. This study aimed to compare the safety and efficacy of intracorporeal anastomosis and extracorporeal anastomosis in laparoscopic right hemicolectomy.

METHODS

A systematic literature search was performed in PubMed, Embase, Web of Science, and Cochrane Library. Randomized controlled trials that compared intracorporeal anastomosis with extracorporeal anastomosis in patients with laparoscopic right hemicolectomy until June 4, 2023, are selected. The primary outcomes measured were incidence of anastomotic leakage within 30 days post-operation. Statistical analyses were performed using Review Manager (version 5.4.1).

RESULTS

Seven RCTs, including 720 patients, were eligible for the meta-analysis. The incidence of anastomotic leakage showed no significant difference between the intracorporeal anastomosis group and the extracorporeal anastomosis group (RR 0.93, 95% CI: 0.49, 1.76, p = 0.83, and I2 = 0%). However, the intracorporeal anastomosis group had significantly lower rates of postoperative ileus (RR 0.67, 95% CI: 0.45-0.99, p = 0.04, I2 = 46%) and surgical site infections (RR 0.34, 95% CI: 0.16-0.74, p = 0.007, I2 = 0%) compared to the extracorporeal anastomosis group. Additionally, patients in the intracorporeal anastomosis group experienced earlier postoperative passage of gas and stool (WMD -0.39, 95% CI: -0.60, -0.19, p = 0.0002, and I2 = 67%; WMD -0.53, 95% CI: -0.85, -0.21, p = 0.001, and I2 = 75%), as well as shorter hospital stays (WMD -0.46, 95% CI: -0.74, -0.18, p = 0.001, and I2 = 34%).

CONCLUSION

In laparoscopic right hemicolectomy, intracorporeal anastomosis does not increase the incidence of anastomotic leakage within 30 days post-operation compared to extracorporeal anastomosis. In addition, intracorporeal anastomosis resulted in faster recovery of bowel function. This suggests that intracorporeal anastomosis is safe and effective.

Can a Continuous Wound Infiltration System Replace Intravenous Patient-Controlled Analgesia for Postoperative Pain Management after a Single-Port Access Laparoscopy?

Background: The aim of this study was to determine whether continuous wound infiltration (CWI) can replace intravenous patient-controlled analgesia (IV PCA) and to investigate effective pain control strategies after a single-port access (SPA) laparoscopy for adnexal disease. Methods: A total of 470 patients (the CWI group [n = 109], the IV PCA group [n = 198], and the combined group [n = 163]) who underwent an SPA adnexal laparoscopy and who received CWI or IV PCA for postoperative pain management were retrospectively reviewed. The numeric rating scale (NRS) pain score at 6, 12, 24, and 48 h (h) after surgery and the total amount of fentanyl administered via IV PCA were collected. The incidence of postoperative nausea and vomiting (PONV) and the total amount of rescue antiemetic drugs administered were also evaluated. Results: The mean NRS pain scores at 6 h (combined vs. PCA vs. CWI, 3.08 vs. 3.44 vs. 3.96, p < 0.001), 12 h (2.10 vs. 2.65 vs. 2.82, p < 0.001), and 24 h (1.71 vs. 2.01 vs. 2.12, p < 0.001) after surgery were significantly lower in the combined group. CWI showed a similar pain-reduction effect after surgery compared to IV PCA, except for the acute phase (within 6 h after surgery). The incidence of PONV during the entire hospitalization period was significantly lower in the CWI group compared to the groups using IV PCA (p < 0.05). The combined group had a significantly lower incidence of PONV and use of rescue antiemetics than the IV PCA group (p < 0.05). The combined group required significantly less total PCA fentanyl compared to the IV PCA group (combined vs. PCA, 622.1 μg vs. 703.1 μg, p < 0.001). Conclusions: CWI is an effective alternative to IV PCA and has fewer side effects. Combined use of CWI and IV PCA may be an ideal pain management strategy, offering a strong pain-reduction effect and only moderate side effects.

Effectiveness of tramadol-including multimodal analgesia in spinal surgery: a single-center, retrospective cohort study

BACKGROUND

Multimodal analgesia (MMA) is recommended for postoperative pain management; however, studies evaluating the effect of tramadol-including MMA on numerical rating scale (NRS)-based postoperative pain levels and the length of stay (LOS) in the hospital are limited. Therefore, this study aimed to compare the before and after effects of tramadol-including MMA application, and assess its effect on postoperative NRS scores and LOS.

METHODS

Patients who underwent spinal surgery under general anesthesia at the Rakuwakai Marutamachi Hospital in fiscal years 2020 and 2022 were included in this study. The outcomes between the pre- and post-intervention groups were compared through propensity score matching.

RESULTS

Following propensity score matching, 249 patients were included in each group. MMA application significantly decreased the median LOS from 10 to 9 days (p < 0.001). Additionally, the median NRS scores exhibited a significant decrease from 4 to 3 on postoperative day (POD) 3 (p = 0.0109) and from 3 to 2 on POD 5 (p = 0.0087). Following MMA application, the number of patients receiving additional analgesics decreased significantly, from 38 to 6 (p < 0.001).

CONCLUSIONS

The introduction of tramadol-including MMA can effectively reduce postoperative pain and decrease the LOS for patients undergoing spinal surgery.

Enhanced recovery after surgery in children with congenital scoliosis

To assess the impact of Enhanced Recovery After Surgery (ERAS) protocol in children undergoing corrective surgery for congenital scoliosis. A retrospective analysis was conducted on children undergoing surgical correction for congenital scoliosis, with participants categorized into either the ERAS group or the control group. Comparative evaluations were made across clinical, surgical, laboratory, and quality of life parameters. Following propensity score matching, 156 patients were analyzed. Within the initial 3 days following surgery, the ERAS cohort demonstrated lower pain intensity and exhibited higher daily oral intake compared to their counterparts in the control group. A mere 14.1% of patients in the ERAS group experienced a peak body temperature exceeding 38.5°, illustrating a significantly lower incidence compared to the 33.3% recorded in the control group. The ERAS cohort displayed expedited timeframes for the onset of initial bowel function and postoperative discharge when contrasted with the control group. Levels of IL-6 assessed on the third day post-surgery were markedly reduced in the ERAS group in comparison to the control group. Noteworthy is the similarity observed in postoperative hemoglobin and albumin levels measured on the first and third postoperative days between the two groups. Assessments of quality of life using SF-36 and SRS-22r questionnaires revealed comparable scores across all domains in the ERAS group when juxtaposed with the control cohort. ERAS protocol has demonstrated a capacity to bolster early perioperative recovery, alleviate postoperative stress responses, and uphold favorable quality of life outcomes in children undergoing corrective surgery for congenital scoliosis.

Application of multi-disciplinary team nursing model enhances recovery after surgery for total hip arthroplasty and total knee arthroplasty

AIM

To explore the effect of a multidisciplinary team (MDT) nursing model based on enhanced recovery after surgery (ERAS) in total hip arthroplasty (THA)/total knee arthroplasty (TKA) and evaluate its application in the perioperative period of patients.

METHODS

A retrospective analysis was conducted on 100 patients with THA/TKA treated at Shaoxing Second Hospital Medical Community General Hospital from January 2021 to December 2023. The patients were divided into an observation group (n = 50) and a control group (n = 50) based on the nursing method employed. The control group received traditional perioperative nursing, while the observation group received an MDT nursing model intervention based on the ERAS concept. Visual analogue scale (VAS) scores were recorded at 6, 24, and 72 hours post-surgery. Additionally, postoperative activities, hospitalization duration, and postoperative complications were documented. Differences in knee joint range of motion (ROM), hip Harris score, psychological stress response score, and quality of life score between the two groups before and one month after surgery were analyzed.

RESULTS

At 6, 24, and 72 hours post-surgery, patients in the observation group had significantly lower VAS scores compared to those in the control group (all P < 0.05). The observation group had an earlier first-time mobilization (P < 0.05). The length of hospitalization and hospitalization cost were significantly lower in the observation group than in the control group (both P < 0.05). The incidence rates of postoperative adverse reactions were 22.00% in the control group and 6.00% in the observation group (P < 0.05). One month post-surgery, the observation group showed significantly greater ROM, lower psychological stress and reaction scores, and higher Harris score and quality of life score compared to the control group (all P < 0.05).

CONCLUSION

The MDT nursing model based on ERAS concept for THA/TKA perioperative patients effectively alleviates postoperative pain, promotes early activity, shortens hospital stay, reduces hospital cost, decreases the incidence of complications, restores joint function, enhances quality of life, and reduces psychological stress.

Same-Day Discharge After a Minimally Invasive Colectomy: A Successful Approach to Patient Selection

BACKGROUND

Enhanced Recovery After Surgery (ERAS) protocols have been shown to decrease inpatient length of stay (LOS) and improve surgical outcomes in elective abdominal colorectal procedures. Discharging a patient home after a minimally invasive colectomy on the same calendar day is a multifactorial decision that takes into account the patient's decision and baseline condition, social factors, intraoperative findings, and postoperative recovery status. The aim of this study is to evaluate the outcomes of same-day discharge (SDD) following minimally invasive colectomy within an ERAS protocol in a community hospital setting in Houston, Texas.

METHODS

In this retrospective cohort study, all consecutive elective cases were performed by a single surgeon from April 2022 to April 2023. This retrospective analysis aims to report a single senior surgeon's experience of the safety, feasibility, and benefits of same-day discharge after minimally invasive colectomy in preselected patients. Same-day discharge was defined as a discharge on the same calendar day without an overnight stay. Differences between specific groups were compared using the Fisher's exact test and Mann-Whitney U test.

RESULTS

Of 86 non-emergent colectomies, 41 patients (47.7%) were successfully discharged on the same day. The median age of the patients was 63.50 years (interquartile range (IQR) 18). The cohort included 37 females (43%) and 49 males (57%). The median LOS was one day. The median operating time was 148.50 minutes (IQR 68.25). The median intraoperative fluid usage was 1500 mL (IQR 36.25), and the median estimated blood loss (EBL) was 25 mL (IQR 36.25). No readmissions among the SDD patients (0%), while three readmissions were reported in patients who stayed overnight (3.4%).  Conclusion: Same-day discharge after a minimally invasive colectomy is feasible when there is a well-established ERAS protocol and there is adequate education for patients and staff. Adequate patient selection is crucial. Patients with multiple comorbidities and a lack of a support network are not suitable candidates.

Increased Postoperative Opioid Consumption in the Presence of Coadministration of 5-Hydroxytryptamine Type 3 Antagonists with Acetaminophen: A Hospital Registry Study

BACKGROUND

Acetaminophen and 5-hydroxytryptamine type 3 (5-HT3) receptor antagonists are administered as standard prophylaxes for postoperative pain, nausea, and vomiting. Preclinical studies, however, suggest that 5-HT3 antagonists may compromise acetaminophen's analgesic effect. This hospital registry study investigates whether 5-HT3 antagonists mitigate the analgesic effect of prophylactic acetaminophen in a perioperative setting.

METHODS

This study included 55,016 adult patients undergoing general anesthesia for ambulatory procedures at a tertiary healthcare center in Massachusetts from 2015 to 2022. Using binary exposure variables and a comprehensive selection of preplanned patient- and procedure-related covariates for confounder control, the authors investigated whether intraoperative 5-HT3 antagonists affected the association between pre- or intraoperative acetaminophen and postoperative opioid consumption, gauged by opioid dose in milligram oral morphine equivalents (OME) administered in the postanesthesia care unit. A multivariable, zero-inflated negative binomial regression model was applied.

RESULTS

A total of 3,166 patients (5.8%) received only acetaminophen, 15,438 (28.1%) only 5-HT3 antagonists, 31,850 (57.9%) both drugs, and 4,562 (8.3%) neither drug. The median postanesthesia care unit opioid dose was 7.5 mg OME (interquartile range, 7.5 to 14.3 mg OME) among 16,640 of 55,016 (30.2%) patients who received opioids, and the mean opioid dose was 3.2 mg OME across all patients (maximum cumulative dose, 20.4 mg OME). Acetaminophen administration was associated with a -5.5% (95% CI, -9.6 to -1.4%; P = 0.009; adjusted absolute difference, -0.19 mg OME; 95% CI, -0.33 to -0.05; P = 0.009) reduction in opioid consumption among patients who did not receive a 5-HT3 antagonist, while there was no effect in patients who received a 5-HT3 antagonist (adjusted absolute difference, 0.00 mg OME; 95% CI, -0.06 to 0.05; P = 0.93; P for interaction = 0.013).

CONCLUSIONS

A dose-dependent association of pre- or intraoperative acetaminophen with decreased postoperative opioid consumption was not observed when 5-HT3 antagonists were coadministered, suggesting that physicians might consider reserving 5-HT3 antagonists as rescue medication for postoperative nausea or vomiting when acetaminophen is administered for pain prophylaxis.

EDITOR’S PERSPECTIVE

Ketamine intolerance in patients on enhanced recovery after surgery protocols undergoing colorectal operations

BACKGROUND

Ketamine is used in enhanced recovery after surgery (ERAS) protocols because of its beneficial antihyperalgesic and antitolerance effects. However, adverse effects such as hallucinations, sedation, and diplopia could limit ketamine's utility. The main objective of this study was to identify rates of ketamine side effects in postoperative patients after colorectal surgery and, secondarily, to compare short-term outcomes between patients receiving ketamine analgesia and controls.

METHODS

This was a retrospective observational cohort study. Subjects were adults who underwent ERAS protocol-guided colorectal surgery at a large, integrated health system. Patients were grouped into ketamine-receiving and preketamine cohorts. Patients receiving ketamine were divided into tolerant and intolerant groups. Propensity score-adjusted models tested multivariate associations of ketamine tolerance/intolerance vs control group.

RESULTS

A total of 732 patients underwent colorectal surgery within the ERAS program before ketamine's introduction (control). After ketamine's introduction, 467 patients received the medication. Intolerance was seen in 29% of ketamine recipients, and the most common side effect was diplopia. Demographics and surgical variables did not differ between cohorts. Multivariate models revealed no significant differences in hospital stays. Pain scores in the first 24 hours after surgery were slightly higher in patients receiving ketamine. Opiate consumption after surgery was lower for both ketamine tolerant and ketamine intolerant cohorts than for controls.

CONCLUSION

Rates of ketamine intolerance are high, which can limit its use and potential effectiveness. Ketamine analgesia significantly reduced opiate consumption without increasing hospital stays after colorectal surgery, regardless of whether it was tolerated.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A randomised comparative study of erector spinae plane block versus low-dose ketamine-dexmedetomidine intravenous infusion as intraoperative opioid-free analgesia for modified radical mastectomy

Background and Aims

Opioid-sparing analgesia for acute postoperative pain after breast cancer surgery is crucial due to opioid-related side effects. The utilisation of erector spinae plane block and low-dose intravenous ketamine-dexmedetomidine are widely recognised as non-opioid analgesic methodologies. The objective of this study was to conduct a randomised trial to examine the analgesic efficacy of both approaches while minimising the use of opioids.

Methods

Seventy-two female patients scheduled for unilateral modified radical mastectomy were recruited. They were allocated randomly to Group ESPB, which received ipsilateral ultrasound-guided erector spinae plane block by 20 mL bupivacaine 0.5% at the level of T5 after induction of general anaesthesia, and Group Ket-Dex, which received intravenous (IV) bolus 0.25 mg/kg of ketamine and 0.5 µg/kg of dexmedetomidine, followed by an IV infusion of 0.25 mg/kg of ketamine and 0.3 µg/kg of dexmedetomidine per hour. Total postoperative morphine consumption (24 h) was the primary outcome. The secondary outcomes were pain scores over 24 hours during rest, duration of analgesia, isoflurane consumption, time to awakening, postoperative nausea and vomiting (PONV), and postoperative serum cortisol level.

Results

The postoperative morphine consumption over 24-hour in Group ESPB was 3.26 mg (0-6.74) versus 2.35 mg (2.08-4.88) in Group Ket-Dex (P = 0.046). Group Ket-Dex had lower pain scores at rest, longer analgesia duration, longer awakening time, and lower postoperative serum cortisol levels.

Conclusion

Intravenous low-dose ketamine-dexmedetomidine infusion intraoperatively with inhalational-based general anaesthesia provides superior opioid-sparing analgesia to that of ESPB in patients undergoing unilateral non-reconstructive modified radical mastectomy, with less postoperative opioid consumption and stress response.

Evaluation of Post-Operative Pain Management Techniques in Oral Surgery

Objective

This prospective research directed to estimate the efficacy and safety of different post-operative pain management techniques in oral surgery subjects.

Methods

Patients scheduled for various oral surgical procedures were recruited from a single oral surgery clinic between January 2022 and December 2023. Inclusion criteria encompassed adult subjects undergoing elective oral surgery under local or general anesthesia. Subjects were randomly assigned to one of three post-operative pain management protocols: Group A received standard analgesics, Group B received combination analgesics, and Group C received non-pharmacological interventions. Pain intensity scores, analgesic consumption, adverse events, and patient satisfaction were assessed at specified intervals post-operatively.

Results

Non-pharmacological interventions demonstrated lower pain intensity scores and analgesic consumption compared to standard and combination analgesics. Additionally, the incidence of adverse events was lower in the non-pharmacological intervention group. Statistical analysis revealed significant differences in pain outcomes among the three groups.

Conclusion

This prospective research suggests that non-pharmacological interventions may provide effective pain relief with fewer adverse events compared to traditional analgesics in post-operative oral surgery subjects. Implementation of multi-modal pain management approaches tailored to individual patient needs may improve overall pain control and enhance patient outcomes.

Endoscopic Endonasal Transsphenoidal Surgery for the Resection of Pituitary Adenomas: A Prime Candidate for a Shortened Length of Stay Enhanced Recovery after Surgery Protocol? A Systematic Review

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is a perioperative model of care aimed at optimizing postoperative rehabilitation and reducing hospital length of stay (LOS). Decreasing LOS avoids hospital-acquired complications, reduces cost of care, and improves patient satisfaction. Given the lack of ERAS protocols for endoscopic endonasal transsphenoidal surgery (EETS) resection of pituitary adenomas, a systematic review of EETS was performed to compile patient outcomes and analyze factors that may lead to increased LOS, reoperation, and readmission rates with the intention to contribute to the development of a successful ERAS protocol for EETS.

METHODS

The authors performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines-based systematic review of the literature. Information was extracted regarding patient LOS, surgery complications, and readmission/reoperation rates. Pearson's correlations to LOS and reoperation/readmission rates were performed with variables normalized to the number of participants. Statistical significance was set at P value <0.05.

RESULTS

Fourteen studies were included, consisting of 2083 patients. The most common complications were cerebrospinal fluid leaks (37%) and postoperative diabetes insipidus (DI) (9%). Transient DI was significantly correlated with shorter LOS. Functional pituitary adenomas were significantly correlated with lower readmission rates while nonfunctional pituitary adenomas were correlated with higher readmission rates. No other factor was found to be significantly correlated with a change in LOS or reoperation rate.

CONCLUSIONS

EETS may be an ideal candidate for the development of ERAS cranial protocols. While our data largely supports the safe implementation of shortened LOS protocols in EETS, our findings highlight the importance of transient DI and nonfunctional pituitary adenomas management when formulating ERAS protocols.

Effects of intravenous lidocaine on postoperative pain and gastrointestinal function recovery following gastrointestinal surgery: a meta-analysis

INTRODUCTION

The full extent of intravenous lidocaine's effectiveness in alleviating postoperative pain and enhancing gastrointestinal function recovery remains uncertain.

EVIDENCE ACQUISITION

We conducted an exhaustive search of databases to identify randomized controlled trials that compared intravenous lidocaine infusion's efficacy to that of a placebo or routine care in patients undergoing gastrointestinal surgery. The primary outcome measure was resting pain scores 24 h postoperatively. We utilized a random-effects model based on the intention-to-treat principle for the overall results.

EVIDENCE SYNTHESIS

This study included twenty-four trials with 1533 patients. Intravenous lidocaine significantly reduced resting pain scores 24 h after gastrointestinal surgery (twenty trials, SMD -0.67, 95% CI -1.09 to -0.24, P=0.002, I2 = 90%). This finding was consistent in subgroup analyses and sensitivity analyses. The benefit was also observed at other resting and moving time points (1, 2, 4, and 12 h) postoperatively. Intravenous lidocaine significantly decreased opioid consumption within 24 h after surgery (eleven trials, SMD: -1.19; 95% CI: -1.99 to -0.39; P=0.003). Intravenous lidocaine also shortened the time to bowel sound (MD: -8.51; 95% CI: -14.59 to -2.44; P=0.006), time to first flatus (MD: -6.00; 95% CI: -9.87 to -2.13; P=0.002), and time to first defecation (MD: -9.77; 95% CI: -17.19 to -2.36; P=0.01).

CONCLUSIONS

Perioperative intravenous lidocaine can alleviate acute pain and expedite gastrointestinal function recovery in patients undergoing gastrointestinal surgery. However, the results should be interpreted with caution due to substantial heterogeneity. Further large-scale studies are necessary to validate these findings.

New Kid on the Block: A Systematic Review of the Quadratus Lumborum Block in Plastic and Reconstructive Surgery

Background

Although the transversus abdominal plane (TAP) block is commonly used in abdominal surgery as part of enhanced recovery after surgery pathways, the quadratus lumborum (QL) block has been hypothesized as an effective alternative to the TAP block in some areas. This review evaluates the current literature, as it relates to the QL block in plastic and reconstructive surgery.

Methods

A systematic review using PubMed searched for all original, peer-reviewed articles, including the term "quadratus lumborum block." In total, 509 articles were identified for review by two independent reviewers. Original articles evaluating the use of a QL block in any plastic surgery operation were included. Articles evaluating pediatric patients, animal trials, and the use of a QL block in any nonplastic surgery operation were excluded.

Results

Three articles met inclusion criteria. One trial demonstrated decreased subjective pain scores and total opioid use, whereas the second found no statistically significant difference. A case study described the use of a QL block for unilateral breast reconstruction with minimal opiate use and reduced pain scores postoperatively. Limitations include the limited number of studies and the heterogeneity in study type and design, making analysis difficult.

Conclusions

Despite its demonstrated efficacy in other surgical subspecialties, there are limited data evaluating the use of the QL block in plastic and reconstructive surgery. Additional research is needed to evaluate the role of the QL block in plastic surgery and how it compares to the more widely utilized TAP block.

Wearable wireless continuous vital signs monitoring on the general ward

PURPOSE OF REVIEW

Wearable wireless sensors for continuous vital signs monitoring (CVSM) offer the potential for early identification of patient deterioration, especially in low-intensity care settings like general wards. This study aims to review advances in wearable CVSM - with a focus on the general ward - highlighting the technological characteristics of CVSM systems, user perspectives and impact on patient outcomes by exploring recent evidence.

RECENT FINDINGS

The accuracy of wearable sensors measuring vital signs exhibits variability, especially notable in ambulatory patients within hospital settings, and standard validation protocols are lacking. Usability of CMVS systems is critical for nurses and patients, highlighting the need for easy-to-use wearable sensors, and expansion of the number of measured vital signs. Current software systems lack integration with hospital IT infrastructures and workflow automation. Imperative enhancements involve nurse-friendly, less intrusive alarm strategies, and advanced decision support systems. Despite observed reductions in ICU admissions and Rapid Response Team calls, the impact on patient outcomes lacks robust statistical significance.

SUMMARY

Widespread implementation of CVSM systems on the general ward and potentially outside the hospital seems inevitable. Despite the theoretical benefits of CVSM systems in improving clinical outcomes, and supporting nursing care by optimizing clinical workflow efficiency, the demonstrated effects in clinical practice are mixed. This review highlights the existing challenges related to data quality, usability, implementation, integration, interpretation, and user perspectives, as well as the need for robust evidence to support their impact on patient outcomes, workflow and cost-effectiveness.

Enhanced Recovery After Surgery protocols mitigate the weekend effect on length of stay following elective colectomy

BACKGROUND

This study aimed to determine the effect of Enhanced Recovery After Surgery (ERAS) protocols on the weekend effect after elective colectomies.

METHODS

This was a retrospective study on all elective colorectal surgeries at a single institution in New York City between January 1, 2015, and December 31, 2020. The length of stay (LOS) by day of the week of surgery and the effect of ERAS using univariable and multivariable analyses were compared.

RESULTS

A total of 605 patients were included in the study. Of note, 41 cases were performed on Mondays, 197 cases were performed on Tuesdays, 45 cases were performed on Wednesdays, 187 cases were performed on Thursdays, and 135 cases were performed on Fridays. Univariate analysis showed that, for patients who did not undergo ERAS, Monday and Tuesday were significantly associated with decreased LOS (P < .001). For patients who underwent ERAS, there was no statistically significant difference in LOS (P = .06) when operated on early in the week vs later. After controlling for age, race/ethnicity, comorbidities, complications, functional health status, operation type, duration of surgery, presence of ostomy, and albumin level, adhering to the ERAS protocol was significantly associated with a shorter LOS (P < .001).

CONCLUSION

Our study demonstrated that ERAS can mitigate the weekend effect on LOS. ERAS protocols may provide more structure to the expected hospital course and allow patients to reach recovery milestones earlier, facilitating discharge even by covering teams.

Latest Advances in Regional Anaesthesia

Training and expertise in regional anaesthesia have increased significantly in tandem with increased interest over the past two decades. This review outlines the most recent advances in regional anaesthesia and focuses on novel areas of interest including fascial plane blocks. Pharmacological advances in the form of the prolongation of drug duration with liposomal bupivacaine are considered. Neuromodulation in the context of regional anaesthesia is outlined as a potential future direction. The growing use of regional anaesthesia outside of the theatre environment and current thinking on managing the rebound plane after regional block regression are also discussed. Recent relevant evidence is summarised, unanswered questions are outlined, and priorities for ongoing investigation are suggested.

Predictive Factors for Successful Same-Day Discharge After Minimally Invasive Colectomy and Stoma Reversal

BACKGROUND

Same-day discharge after minimally invasive colorectal surgery is a safe, effective practice in specific patients that can enhance the efficiency of enhanced recovery pathways.

OBJECTIVE

To identify predictive factors associated with success or failure of same-day discharge.

DESIGN

Prospective cohort study from January 2020 to March 2023.

SETTINGS

Tertiary colorectal center.

PATIENTS

Adult patients eligible for same-day discharge with remote postdischarge follow-up included those with minimal comorbidities, residing near the hospital, having sufficient home support, and owning a mobile device.

INTERVENTIONS

Patients were discharged on the day of surgery upon meeting specific criteria, including adequate pain control, tolerance of oral intake, independent mobility, urination, and the absence of complications. Successful same-day discharge was defined as discharge on the day of surgery without unplanned visits in the first 72 hours.

MAIN OUTCOME MEASURES

Factors associated with successful or failed same-day discharge after minimally invasive colorectal surgery.

RESULTS

A total of 175 patients (85.3%) were discharged on the day of surgery, with 14 patients (8%) having an unplanned visit within 72 hours. Overall, 161 patients (78.5%) were categorized as same-day discharge success and 44 patients (21.5%) as same-day discharge failure. The same-day discharge failure group had a higher Charlson Comorbidity Index (3.7 vs 2.8, p = 0.03). Mean length of stay (0.8 vs 3.0, p = 0.00), 30-day complications (10% vs 48%, p = 0.00), and readmissions (8% vs 27%, p = 0.00) were higher in the same-day discharge failure group. Regression analysis showed that failed same-day discharge was associated with higher comorbidities (OR 0.79; 95% CI, 0.66-0.95) and prolonged postanesthesia care unit time (OR 0.99; 95% CI, 0.99-0.99). Individuals who received a regional nerve block (OR 4.1; 95% CI, 1.2-14) and those who did not consume postoperative opioids (OR 4.6; 95% CI, 1-21) were more likely to have successful same-day discharge.

LIMITATIONS

Single-center study.

CONCLUSIONS

Our findings indicate that comorbidities and prolonged postanesthesia care unit stays were associated with same-day discharge failure, whereas regional nerve blocks and minimal postoperative opioids were related to success. These factors may inform future research aiming to enhance colorectal surgery recovery protocols. See Video Abstract .

FACTORES PREDICTIVOS PARA UN ALTA EXITOSA EL MISMO DA DESPUS DE UNA COLECTOMA MNIMAMENTE INVASIVA Y REVERSIN DEL ESTOMA

ANTECEDENTES:El alta el mismo día después de una cirugía colorrectal mínimamente invasiva es una práctica segura y eficaz en pacientes específicos que puede mejorar la eficiencia de las vías de recuperación mejoradas.OBJETIVO:Identificar factores predictivos asociados con el éxito o fracaso del alta el mismo día.DISEÑO:Estudio de cohorte prospectivo del 01/2020 al 03/2023.AJUSTES:Centro colorrectal terciario.PACIENTES:Los pacientes adultos elegibles para el alta el mismo día con seguimiento remoto posterior al alta incluyeron aquellos con comorbilidades mínimas, que residían cerca del hospital, tenían suficiente apoyo en el hogar y poseían un dispositivo móvil.INTERVENCIONES:Los pacientes fueron dados de alta el día de la cirugía al cumplir con criterios específicos, incluido un control adecuado del dolor, tolerancia a la ingesta oral, movilidad independiente, micción y ausencia de complicaciones. El alta exitosa el mismo día se definió como el alta el día de la cirugía sin visitas no planificadas en las primeras 72 horas.PRINCIPALES MEDIDAS DE RESULTADO:Factores asociados con el alta exitosa o fallida el mismo día después de una cirugía colorrectal mínimamente invasiva.RESULTADOS:Un total de 175 (85,3%) pacientes fueron dados de alta el día de la cirugía y 14 (8%) pacientes tuvieron una visita no planificada dentro de las 72 horas. En total, 161 (78,5%) pacientes se clasificaron como éxito del alta el mismo día y 44 (21,5%) pacientes como fracaso del alta el mismo día. El grupo de fracaso del alta el mismo día tuvo un índice de comorbilidad de Charlson más alto (3,7, 2,8, p = 0,03). La duración media de la estancia hospitalaria (0,8, 3,0, p = 0,00), las complicaciones a los 30 días (10%, 48%, p = 0,00) y los reingresos (8%, 27%, p = 0,00) fueron mayores en el mismo día grupo de fallo de descarga. El análisis de regresión mostró que el alta fallida el mismo día se asoció con mayores comorbilidades (OR 0,79; IC del 95 %: 0,66; 0,95) y tiempo prolongado en la unidad de cuidados postanestésicos (OR 0,99; IC del 95 %: 0,99; 0,99). Las personas que recibieron un bloqueo nervioso regional (OR 4,1; IC del 95 %: 1,2, 14) y aquellos que no consumieron opioides posoperatorios (OR 4,6, IC del 95 %: 1-21) tuvieron más probabilidades de tener éxito en el mismo día -descarga.LIMITACIONES:Estudio unicéntrico.CONCLUSIONES:Nuestros hallazgos indican que las comorbilidades y las estancias prolongadas en la unidad de cuidados postanestésicos se asociaron con el fracaso del alta el mismo día, mientras que los bloqueos nerviosos regionales y los opioides postoperatorios mínimos se relacionaron con el éxito. Estos factores pueden informar investigaciones futuras destinadas a mejorar los protocolos de recuperación de la cirugía colorrectal. (Traducción-Yesenia Rojas-Khalil ).

Morning or Afternoon Scheduling for Elective Coronary Artery Bypass Surgery: Influence of Longer Fasting Periods from Metabolic and Hemodynamic Perspectives

BACKGROUND

Prolonged preoperative fasting may worsen postoperative outcomes. Cardiac surgery has higher perioperative risk, and longer fasting periods may be not well-tolerated. We analysed the postoperative metabolic and hemodynamic variables in patients undergoing elective coronary artery bypass grafting (CABG) according to their morning or afternoon schedule.

METHODS

Single-centre retrospective study at University teaching hospital (1-year data collection from electronic medical records). Using a mixed-effects linear regression model adjusted for several covariates, we compared metabolic (lactatemia, pH, and base deficit [BD]) and haemodynamic values (patients on vasoactive support, and vasoactive inotropic score [VIS]) at 7 prespecified time-points (admission to intensive care, and 1st, 3rd, 6th, 12th, 18th, and 24th postoperative hours).

RESULTS

339 patients (n = 176 morning, n = 163 afternoon) were included. Arterial lactatemia and BD were similar (overall P = 0.11 and P = 0.84, respectively), while pH was significantly lower in the morning group (overall P < 0.05; mean difference -0.01). Postoperative urine output, fluid balance, mean arterial pressure, and central venous pressure were similar (P = 0.59, P = 0.96, P = 0.58 and P = 0.53, respectively). A subgroup analysis of patients with diabetes (n = 54 morning, n = 45 afternoon) confirmed the same findings. The VIS values and the proportion of patients on vasoactive support was higher in the morning cases at the 18th (P = 0.002 and p=0.04, respectively) and 24th postoperative hours (P = 0.003 and P = 0.04, respectively). Mean intensive care length of stay was 1.94 ± 1.36 days versus 2.48 ± 2.72 days for the afternoon and morning cases, respectively (P = 0.02).

CONCLUSIONS

Patients undergoing elective CABG showed similar or better metabolic and hemodynamic profiles when scheduled for afternoon surgery.

Analgesic efficacy of an opioid-free postoperative pain management strategy versus a conventional opioid-based strategy following laparoscopic radical gastrectomy: an open-label, randomized, controlled, non-inferiority trial

OBJECTIVE

In patients undergoing laparoscopic radical gastrectomy, the use of subcostal transversus abdominis plane block (STAPB) for completely opioid-free postoperative pain management lacks convincing clinical evidence.

METHODS

This study included 112 patients who underwent laparoscopic radical gastrectomy at the 900TH Hospital of the Joint Logistics Support Force from October 2020 to March 2022. Patients were randomly divided into (1:1) continuous opioid-free STAPB (C-STAPB) group and conventional group. In the C-STAPB group, 0.2% ropivacaine (bilateral, 20 ml per side) was injected intermittently every 12 h through a catheter placed on the transverse abdominis plane for postoperative pain management. The conventional group was treated with a conventional intravenous opioid pump (2.5 μg/kg sufentanil and 10 mg tropisetron, diluted to 100 ml with 0.9% NS). The primary outcomes were the accumulative area under the curve of the numeric rating scale (NRS) score at 24 and 48 h postoperatively at rest and during movement. The secondary outcomes were postoperative recovery outcomes, postoperative daily food intake, and postoperative complications.

RESULTS

After exclusion (n = 16), a total of 96 patients (C-STAPB group, n = 46; conventional group, n = 49) were included. We found there were no significant differences in the cumulative AUC of NRS score PACU-24 h and PACU-48 h between the C-STAPB group and conventional group at rest [(mean difference, 1.38; 95% CI, - 2.21 to 4.98, P = 0.447), (mean difference, 1.22; 95% CI, - 6.20 to 8.65, P = 0.744)] and at movement [(mean difference, 2.90; 95% CI, - 3.65 to 9.46; P = 0.382), (mean difference, 4.32; 95% CI, - 4.46 to 13.1; P = 0.331)]. The 95% CI upper bound of the difference between rest and movement in the C-STAPB group was less than the inferior margin value (9.5 and 14 points), indicating the non-inferiority of the analgesic effect of C-STPAB. The C-STAPB group had faster postoperative recovery profiles including earlier bowel movement, defecation, more volume of food intake postoperative, and lower postoperative nausea and vomiting compared to conventional groups (P < 0.001).

CONCLUSIONS

After laparoscopic radical gastrectomy, the analgesic effect of C-STAPBP is not inferior to the traditional opioid-based pain management model.

TRIAL REGISTRATION

ChiCTR2100051784.

Application on perioperative ERAS concept in elderly lung cancer patients undergoing surgery

Investigating the applying effects of the enhanced recovery after surgery (ERAS) in the perioperative period of elderly lung cancer patients undergoing the surgery. We randomly selected 98 elderly patients with lung cancer who were admitted to our hospital and underwent surgery from January 2022 to September 2023 as study subjects. The control group received conventional care during the perioperative period, and the intervention group received ERAS-guided care measures. The differences in perioperative-related indices, pulmonary function, pain level, inflammatory factors, and postoperative complication rates between these 2 groups were compared. The postoperative extubation time, the activity time since getting out of bad and hospital stay were lower in the observation group than those in the control group (P  < .05). At 3 days postoperatively, the FEV1, forced vital capacity and maximum ventilation volume of these 2 groups were lower than those of their same groups before surgery, and those of the observation group were higher than those of the control group (P  < .05). At 3 days postoperatively, the numerical rating scale in both groups were lower than those of their same groups at 6 hours postoperatively, and the numerical rating scale of the observation group was lower than that of the control group (P  < .05). At 3 days postoperatively, tumor necrosis factor-α, IL-6, and CRP in both groups were higher than those in their same groups before surgery, and those of the observation group was lower than those of the control group (P  < .05). The incidence of postoperative complications in the observation group was lower than that in the control group (P  < .05). ERAS applied in the perioperative period of elderly lung cancer patients undergoing surgery can shorten the hospital stay, promote the postoperative recovery on pulmonary function, alleviate inflammation, and reduce the risk of postoperative complications.

Impact of cryoablation on operative outcomes in thoracotomy patients

OBJECTIVES

Cryoablation is increasingly being utilized as an alternative to epidurals for patients undergoing thoracotomies. Current evidence suggests cryoablation may decrease postoperative analgesia utilization, but could increase operative times. We hypothesized that the adoption of intraoperative cryoablation to manage post-thoracotomy pain would result in reduced length of stay and reduced perioperative analgesia compared to routine epidural use.

METHODS

A retrospective analysis was performed from a single, quaternary referral centre, prospective database on patients receiving thoracotomies between January 2020 and March 2022. Patients undergoing transthoracic hiatal hernia repair, lung resection or double-lung transplant were divided between epidural and cryoablation cohorts. Primary outcomes were length of stay, intraoperative procedure time, crossover pain management and oral narcotic usage the day before discharge.

RESULTS

During the study period, 186 patients underwent a transthoracic hiatal hernia repair, lung resection or double-lung transplant with 94 receiving a preoperative epidural and 92 undergoing cryoablation. Subgroup analysis demonstrated no significant differences in demographics, operative length, length of stay or perioperative narcotic use. Notably, over a third of patients in each cryoablation subgroup received a postoperative epidural (45.5% transthoracic hiatal hernia repair, 38.5% lung resection and 45.0% double-lung transplant) for further pain management during their admission.

CONCLUSIONS

Cryoablation use was not associated with an increase in procedure time, a decrease in narcotic use or length of stay. Surprisingly, many cryoablation patients received epidurals in the postoperative period for further pain control. Additional analysis is needed to fully understand the benefits and costs of epidural versus cryoablation strategies.

Efficacy of quadratus lumborum block in the treatment of acute and chronic pain after cesarean section: A systematic review and meta-analysis based on randomized controlled trials

BACKGROUND

This analysis aimed to explore the analgesic effects of quadratus lumborum block on acute and chronic postoperative pain among patients undergoing cesarean section.

METHODS

PubMed, Cochrane, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang, and VIP databases for Randomized Controlled Trials (RCTs) that focused on the use of quadratus lumborum block in cesarean section procedures were searched from the inception of the databases until December 2022. Studies were screened based on inclusion and exclusion criteria, and were then conducted for quality assessment and data extraction. Meta-analysis was performed using Stata 15.0 software. Two researchers independently screened the studies, extracted data, and evaluated the risk of bias for the included studies. In case of any disagreements, it was resolved by consultation with a third party opinion.

RESULTS

A total of 21 studies involving 1976 patients were finally included, with an overall acceptable study quality level. Compared to the control group, the administration of Quadratus Lumborum Block (QLB) resulted in significant reduction in the postoperative 24-hour visual analog scale (VAS) score (WMD = -0.69, 95% CI: -1.03 ~ -0.35, P < .001) and the consumption of opioid analgesics within 24 hours after surgery (WMD = -2.04, 95% CI: -2.15 ~ -1.92, P = .002). The incidence of chronic pain 3 months QLB (OR = 0.41, 95% CI: 0.09 ~ 1.88, P = .253) and 6 months (OR = 0.83, 95% CI: 0.33 ~ 2.07, P = .686) after surgery were observed to increase as compared with the control group.

CONCLUSIONS

The use of QLB for postoperative analgesia after cesarean section, particularly in the relief of acute postoperative pain, had been proven to significantly decrease the VAS score and morphine consumption within the first 24 hours after surgery. However, further studies are needed to determine its impact on managing chronic postoperative pain.

Effect of dexmedetomidine on postoperative nausea and vomiting in female patients undergoing radical thoracoscopic lung cancer resection

Introduction: Postoperative nausea and vomiting (PONV) is a prevalent postsurgical complication. The objective of our study was to compare the effect of different doses of dexmedetomidine on PONV in female patients undergoing radical thoracoscopic lung cancer resection. Methods: A total of 164 female patients undergoing elective thoracoscopic radical lung cancer surgery were enrolled and assigned to one of four groups. Patients received 0.2 μg/kg/h, 0.4 μg/kg/h, 0.8 μg/kg/h dexmedetomidine and normal saline in the Dex1, Dex2, Dex3 and Control groups, respectively. The primary outcome was the incidence of PONV during 48 h postoperatively. The second outcomes included the incidence of PONV and postoperative vomiting (POV) at four time points postoperatively (T1: PACU retention period; T2: PACU discharge to postoperative 12 h; T3: postoperative 12 h-postoperative 24 h; T4: postoperative 24 h-postoperative 48 h), the area under the curve of PONV grade (PONVAUC), PONV grade, POV grade and other postoperative recovery indicators. Results: The incidence of PONV differed among the four groups. The Dex2 group (29.27%) was lower than that in the Dex1 group (61.90%) and Control group (72.50%). The incidence of PONV at T2 in the Dex1 group (11.90%) and Dex2 group (9.76%) was lower than that in the Control group (42.50%). The incidence of PONV at T3 in the Dex2 group (29.27%) was lower than that in the Dex1 group (61.90%) and Control group (62.50%). The PONVAUC was lower in the Dex2 group than in the Control group. The incidence of POV at T3 in the Dex2 and Dex3 groups was lower than that in the Control group. The consumption of remifentanil, norepinephrine, PACU dwell time, VAS scores, postoperative PCA press frequency, and the time for the first postoperative oral intake were different among the four groups. The regression model shows that the Dex2 group is a protective factor for PONV. Conclusion: Dexmedetomidine can reduce the incidence of PONV and accelerate postoperative recovery in female patients undergoing radical thoracoscopic lung cancer resection. Compared with the other two dosages, 0.4 μg/kg/h dexmedetomidine is preferable. Clinical Trial Registration: chictr.org.cn, identifier ChiCTR2300071831.

Effect of intracutaneous pyonex therapy on postoperative pain management following perianal surgery: A systematic review and meta-analysis

Intracutaneous pyonex therapy (IPT), a novel acupuncture technique also known as intradermal thumbtack needle embedding therapy, has been reported to optimize postoperative pain management following perianal surgery. This meta-analysis aimed to analyze the efficacy of IPT for postoperative pain management following perianal surgery. The Cochrane Library, PubMed, EMBASE, Web of Science, CNKI, SinoMed, Wanfang, and VIP databases were systematically searched for randomized controlled trials (RCTs) on IPT as a treatment for postoperative pain management following perianal surgery from inception until June 15, 2022. The analyzed outcomes from the eleven RCTs included in this meta-analysis were as follows: postoperative visual analogue scale(VAS), analgesic duration, ineffective cases following treatment, and adverse events. Subgroup analyses were conducted according to different time points. Risk-of-bias assessment, publication bias analysis, sensitivity analysis, and trial sequential analysis were performed. Of the 895 patients, 450 and 445 were included in the IPT and control groups, respectively. The IPT group showed a better analgesic effect[standard mean difference (SMD) = -0.77, 95% CI: -1.00 to -0.53, P < 0.00001; P for heterogeneity = 0.009, I2 = 59%] and longer analgesic duration [SMD = 0.56, 95% CI: 0.31 to 0.82, P < 0.0001; P for heterogeneity = 0.6, I2 = 0%], fewer ineffective cases following treatment [risk ratio(RR) = 0.23; 95% CI: 0.13 to 0.39, P < 0.00001; P for heterogeneity = 0.76, I2 = 0%], and lower overall occurrence of postoperative complications [RR = 0.35; 95% CI: 0.17 to 0.70; P = 0.003; P for heterogeneity = 0.85, I2 = 0%] than the control group. Thus, our findings indicated that IPT can provide better pain management following perianal surgery compared to controls. This novel approach complements a reasonable modality for postoperative multimodal analgesia and is worth promoting.

Evaluating Modified Ultrasound-Guided Serratus Anterior Plane Block for Enhanced Postoperative Recovery in Thoracoscopic Lobectomy Patients

BACKGROUND Thoracoscopic lobectomy is accompanied by intense trauma and pain due to impaired chest wall integrity. We aimed to introduce a modified ultrasound-guided serratus anterior plane block (MUG-SAPB) for postoperative analgesia in patients who underwent thoracoscopic lobectomy, and to determine whether it could effectively alleviate postoperative pain and improve recovery quality. MATERIAL AND METHODS Overall, 78 patients randomly received either combined MUG-SAPB (0.25% ropivacaine, 10 mg dexamethasone, 40 mL) with patient-controlled intravenous analgesia (PCIA) or received PCIA alone. The primary outcomes were visual analog scale (VAS) scores at rest and during movement at 4, 8, 12, 20, 24, 48, and 72 h postoperatively. The secondary outcomes included use of opioids during surgery, numbers of rescue analgesics (butorphanol), frequency of patient-controlled analgesia (PCA), comfort score within 24 h postoperatively, and postoperative complications within 72 h. RESULTS Compared to the PCIA group, in the MUG-SAPB group, resting VAS scores at 4-24 h (P<0.05) and movement VAS scores at 4-12 h postoperatively (P<0.05) were lower; intraoperative use of sufentanil and frequency of PCA were less, and less rescue analgesia was used (P=0.02, P=0.04 and P=0.03, respectively). Patients in the MUG-SAPB group had faster first mobilization (P=0.04). The MUG-SAPB group had higher comfort scores than the PCIA group (P=0.03). None of the MUG-SAPB patients had any SAPB-related complications. CONCLUSIONS MUG-SAPB effectively relieved postoperative pain, reduced opioid consumption, and accelerated early ambulation in comparison with PCIA alone in patients who underwent thoracoscopic lobectomy.

Two-stage laparoscopic transversus abdominis plane block as an equivalent alternative to thoracic epidural anaesthesia in bowel resection-an explorative cohort study

PURPOSE

We evaluated the effect of the two-stage laparoscopic transversus abdominis plane block (TS-L-TAPB) in comparison to thoracic epidural anaesthesia (TEA) and a one-stage L-TAPB (OS-L-TAPB) in patients who underwent elective laparoscopic bowel resection.

METHODS

We compared a TS-L-TAPB (266 mg bupivacaine), which was performed bilaterally at the beginning and end of surgery, with two retrospective cohorts. These were patients who had undergone a TEA (ropivacaine/sufentanil) or an OS-L-TAPB (200 mg ropivacaine) at the beginning of surgery. Oral and i.v. opiate requirements were documented over the first 3 postoperative days (POD).

RESULTS

Patients were divided into three groups TEA (n = 23), OS-L-TAPB (n = 75), and TS-L-TAPB (n = 49). By the evening of the third POD, patients with a TEA had a higher cumulative opiate requirement with a median of 45.625 mg [0; 202.5] than patients in the OS-L-TAPB group at 10 mg [0; 245.625] and the TS-L-TAPB group at 5.625 mg [0; 215.625] (p = 0.1438). One hour after arrival in the recovery room, significantly more patients in the TEA group (100%) did not need oral and i.v. opioids than in the TS-L-TAPB (78%) and OS-L-TAPB groups (68%) (p = 0.0067).This was without clinical relevance however as the median in all groups was 0 mg. On the third POD, patients in the TEA group had a significantly higher median oral and i.v. opioid dose at 40 mg [0; 80] than the TS-L-TAPB and OS-L-TAPB groups, both at 0 mg [0; 80] (p = 0.0009).

CONCLUSION

The TS-L-TAP showed statistically significant and clinically meaningful benefits over TEA and OS-L-TAP in reducing postoperative opiate requirements.

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

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

Ultrasound-guided medial branch of the superior laryngeal nerve block to reduce peri-operative opioids dosage and accelerate patient recovery

BACKGROUND

To explore whether the medial branch block of superior laryngeal nerve can reduce the stress response of patients undergoing intubation and further reduce the dosage of opioids.

METHODS

80 patients undergoing gynecological laparoscopic surgery were selected, and randomly divided into 4 groups. All patients in the experimental groups received bilateral internal branch of superior laryngeal nerve block and transversus abdominis plane block. But the dosage of sufentanil used for anesthesia induction in the group A, B, and C was 0.4, 0.2, and 0μg/kg, respectively. Group D do not underwent supralaryngeal nerve block and the dosage of sufentanil was 0.4μg/kg. The heart rate (HR) and mean arterial pressure(MAP) were recorded at the time of entering the operating room(T1), before intubation after induction(T2), immediately after intubation(T3), 5min after intubation(T4), before extubation(T5), immediately after extubation(T6), 5min after extubation(T7). We also recorded the stay time in the recovery room, the number of cases of postoperative sore throat, the number of cases of nausea and vomiting, the first intestinal exhaust time, the length of hospital stay after operation.

RESULTS

The HR of group A, C and D at T3 was significantly higher than that at T2(P < 0.01), while the HR of group B had no significant change. The HR of group A, C and D at T4 was lower than that at T3(P < 0.01), while the HR of group B had no obvious change. The HR of group C and D at T3 was significantly higher than that at T1 (P < 0.01). The MAP of group A and D at T4 was significantly lower than that at T1 (P<0.001). The first postoperative intestinal exhaust time in group A, B and C was significantly shorter than that in group D. The length of hospital stay after operation in group B and C was shorter than that in group D.

CONCLUSIONS

Ultrasound-guided superior laryngeal nerve block combined with 0.2μg/kg sufentanil can reduce the intubation reaction, have better hemodynamic stability, reduce the first postoperative intestinal exhaust time and postoperative hospital stay, thereby accelerating the postoperative recovery of patients.

Historical perspectives and recent advances in small molecule ligands of selective/biased/multi-targeted μ/δ/κ opioid receptor (2019-2022)

The opioids have been used for more than a thousand years and are not only the most widely prescribed drugs for moderate to severe pain and acute pain, but also the preferred drugs. However, their non-analgesic effects, especially respiratory depression and potential addiction, are important factors that plague the safety of clinical use and are an urgent problem for pharmacological researchers to address. Current research on analgesic drugs has evolved into different directions: de-opioidization; application of pharmacogenomics to individualize the use of opioids; development of new opioids with less adverse effects. The development of new opioid drugs remains a hot research topic, and with the in-depth study of opioid receptors and intracellular signal transduction mechanisms, new research ideas have been provided for the development of new opioid analgesics with less side effects and stronger analgesic effects. The development of novel opioid drugs in turn includes selective opioid receptor ligands, biased opioid receptor ligands, and multi-target opioid receptor ligands and positive allosteric modulators (PAMs) or antagonists and the single compound as multi-targeted agnoists/antagonists for different receptors. PAMs strategies are also getting newer and are the current research hotspots, including the BMS series of compounds and others, which are extensive and beyond the scope of this review. This review mainly focuses on the selective/biased/multi-targeted MOR/DOR/KOR (mu opioid receptor/delta opioid receptor/kappa opioid receptor) small molecule ligands and involves some cryo-electron microscopy (cryoEM) and structure-based approaches as well as the single compound as multi-targeted agnoists/antagonists for different receptors from 2019 to 2022, including discovery history, activities in vitro and vivo, and clinical studies, in an attempt to provide ideas for the development of novel opioid analgesics with fewer side effects.

Enhanced Recovery after Surgery Protocol Decreases Length of Stay and Postoperative Narcotic Use in Microvascular Breast Reconstruction

Background

Enhanced recovery after surgery (ERAS) protocols have demonstrated efficacy following microvascular breast reconstruction. This study assesses the impact of an ERAS protocol following microvascular breast reconstruction at a high-volume center.

Methods

The ERAS protocol introduced preoperative counseling, multimodal analgesia, early diet resumption, and early mobilization to our microvascular breast reconstruction procedures. Data, including length of stay, body mass index, inpatient narcotic use, outpatient narcotic prescriptions, inpatient pain scores, and complications, were prospectively collected for all patients undergoing microvascular breast reconstruction between April 2019 and July 2021. Traditional pathway patients who underwent reconstruction immediately before ERAS implementation were retrospectively reviewed as controls.

Results

The study included 200 patients, 99 in traditional versus 101 in ERAS. Groups were similar in body mass index, age (median age: traditional, 54.0 versus ERAS, 50.0) and bilateral reconstruction rates (59.6% versus 61.4%). ERAS patients had significantly shorter lengths of stay, with 96.0% being discharged by postoperative day (POD) 3, and 88.9% of the traditional cohort were discharged on POD 4 (P < 0.0001). Inpatient milligram morphine equivalents (MMEs) were smaller by 54.3% in the ERAS cohort (median MME: 154.2 versus 70.4, P < 0.0001). Additionally, ERAS patients were prescribed significantly fewer narcotics upon discharge (median MME: 337.5 versus 150.0, P < 0.0001). ERAS had a lower pain average on POD 0-3; however, this finding was not statistically significant.

Conclusion

Implementing an ERAS protocol at a high-volume microvascular breast reconstruction center reduced length of stay and postoperative narcotic usage, without increasing pain or perioperative complications.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Gabapentin May Not Decrease Opioid Use in Pediatric Enhanced Recovery After Surgery Protocols

INTRODUCTION

In adults, the use of gabapentin in Enhanced Recovery After Surgery (ERAS) protocols is associated with increased morbidity and clinically insignificant improvement in postoperative pain control. Furthermore, there are limited data supporting its use in pediatric ERAS protocols.

METHODS

A single-institution retrospective study was performed to examine the correlation of gabapentin use and postoperative outcomes among children who underwent elective general, urologic, and orthopedic surgeries. Because gabapentin was removed from our institutional ERAS protocols in August 2020, we compared eligible patients from January 2018 to September 2021 using univariate and multivariable analysis. Due to heterogeneity between the treatment groups, a propensity score-matched analysis was also performed. Significance was defined as P < 0.05.

RESULTS

In this study, 196 patients were included, with 91 (46.4%) who received gabapentin and 105 (53.6%) who did not. When used in combination with opioids, gabapentin was not associated with a reduction in the amount of opioids consumed (β = -0.4, 95% confidence interval = -1.9, 1.1). Instead, children who received gabapentin had increased odds of requiring oxygen supplementation (odds ratio = 3.1, 95% confidence interval = 1.2, 9.0), but this finding did not persist after propensity score-matched analysis.

CONCLUSIONS

The use of gabapentin in multimodal pain regimens in children following elective surgery was not associated with a decrease in postoperative narcotic use. Inclusion of gabapentin in perioperative pain medication protocols should be further evaluated with prospective studies.

Risk factors for discontinuation of intravenous patient-controlled analgesia after general surgery: a retrospective cohort study

Identifying patients at risk for developing side effects secondary to intravenous patient-controlled analgesia (IV PCA) and making the necessary adjustments in pain management are crucial. We investigated the risk factors of discontinuing IV PCA due to side effects following general surgery; adult patients who received IV PCA after general surgery (2020-2022) were included. Data on postoperative pain intensity, PCA pain relief, side effects, continuity of PCA use, and PCA pump settings were collected from the records of the acute pain management team. The primary outcome was identifying the risk factors associated with PCA discontinuation due to side effects. Of the 8745 patients included, 94.95% used opioid-containing PCA, and 5.05% used non-steroidal anti-inflammatory drug (NSAID)-only PCA; 600 patients discontinued PCA due to side effects. Female sex (adjusted odds ratio [aOR] 3.31, 95% confidence interval [CI] 2.74-4.01), hepato-pancreatic-biliary surgery (aOR 1.43, 95% CI 1.06-1.94) and background infusion of PCA (aOR 1.42, 95% CI 1.04, 1.94) were associated with an increased likelihood of PCA discontinuation. Preoperative opioid use (aOR 0.49, 95% CI 0.28-0.85) was linked with a decreased likelihood of PCA discontinuation. These findings highlight the importance of individualized pain management, considering patient characteristics and surgical procedures.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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