Current issues in postoperative pain management:

Comparison of Pain Assessment Tools and Numeric Rating Scale Thresholds for Analgesic Administration in the Postanaesthetic Care Unit

PURPOSE

The aim of this study was to assess the correlation between the Visual Analog Scale (VAS), Numeric Rating Scale (NRS), and Verbal Rating Scale (VRS). Additionally, the study aimed to determine NRS threshold values for both mild analgesic administration (= without risk of nausea and vomiting [NV] side effects) and strong analgesic administration (= with risk of NV side effects) in the postanaesthetic care unit (PACU).

DESIGN

Prospective, observational study design.

METHODS

The study was conducted between August 2019 and April 2022. Patients scheduled for elective surgery under general anesthesia were included. The primary outcome was the correlation between the VAS, NRS, and VRS, assessed at PACU admission and discharge. Secondary outcomes included pain evolution, desire for analgesic administration with or without risk of NV side effects, and preferred tool for pain assessment.

FINDINGS

VAS, NRS, and VRS were significantly correlated (r = 0.82 to 0.94, P < .001) at both PACU admission and discharge. The median VAS scores significantly improved from 32 (interquartile range [IQR]: 9 to 22) at PACU admission to 27 (IQR: 8 to 39) at PACU discharge (P < .001), while the median NRS scores significantly improved from 3 (IQR: 1 to 6) at PACU admission to 3 (IQR: 1 to 4) at PACU discharge (P < .001). At PACU admission, receiver-operating characteristics curve analysis indicated that an optimal NRS threshold value for the administration of a mild analgesic (= without risk of NV side effects) was greater than 2, and greater than 5 for the administration of a strong analgesic (= with risk of NV side effects). At PACU discharge, patients reported a preferred median NRS score of 5 to be treated with a mild analgesic (= without risk of NV side effects), and a preferred median NRS score of 8 to be treated with a strong analgesic (= with risk of NV side effects).

CONCLUSIONS

All three pain assessment tools can be used to evaluate postoperative pain in the PACU setting during the recovery from general anesthesia.

Efficacy and safety of preoperative duloxetine in reducing post-laparoscopic surgery pain: a meta-analysis of randomized placebo-controlled trials

BACKGROUND

Recent studies suggest that duloxetine administration before non-laparoscopic surgery may reduce postoperative pain and analgesic requirement without increasing adverse event occurrence.

AIM

To perform a systematic review and meta-analysis of randomized controlled trials (RCTs) on preoperative administration of duloxetine versus placebo for postoperative pain relief in adults undergoing laparoscopic surgery, assessing efficacy- and safety-related outcomes.

METHOD

We systematically searched MEDLINE, Embase, and Cochrane Library, covering all records up to July 19, 2024. Inclusion criteria consisted of RCTs comparing preoperative administration of duloxetine versus placebo in adults undergoing laparoscopic surgery and reporting at least one outcome of interest. The random-effects model was used to estimate the mean difference (MD) and risk ratio (RR), along with their respective 95% confidence intervals (95%CIs).

RESULTS

We included four RCTs (227 patients). Compared with placebo, duloxetine provided a statistically lower pain scores at 2 (MD - 1.04; 95%CI - 1.75, - 0.33), 4 (MD - 1.28; 95%CI - 1.77, - 0.79), 8 (MD - 1.22; 95%CI - 1.72, - 0.72), 12 (MD - 1.64; 95%CI - 2.88, - 0.41), and 24 h (MD - 1.05; 95%CI - 1.72, - 0.39) after surgery. Duloxetine also granted a statistically longer time to first analgesic requirement (MD 128.38 min; 95%CI 41.31, 215.46), compared with placebo. Additionally, the duloxetine group had a significantly lower risk of nausea/vomiting (RR 0.48; 95%CI 0.25, 0.90), while there were no significant differences between both groups for the risk of dizziness, headache, and somnolence.

CONCLUSION

Compared with placebo, duloxetine administration before laparoscopic surgery significantly minimized postoperative pain intensity, delayed analgesic requirement, and reduced nausea/vomiting risk.

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.

Advances in Anesthesia Techniques for Postoperative Pain Management in Minimally Invasive Cardiac Surgery: An Expert Opinion

Minimally invasive cardiac surgery (MICS) often leads to severe postoperative pain. At present, multimodal analgesia schemes for MICS have attracted much attention, and the application of various chest wall analgesia techniques is becoming increasingly widespread. However, research on anesthesia techniques for postoperative pain management in MICS remains relatively limited at present. We searched for relevant literature and summarized recent related research in eight MICS techniques, including thoracic epidural anesthesia, spinal anesthesia, thoracic paravertebral plane block, erector spinae plane block, serratus anterior plane block, pectoral nerve block, intercostal nerve block, and parasternal block. This article provides an overview of the anatomy and procedures involved in these analgesic techniques, their mechanisms of action, and the latest clinical trial evidence. It also evaluates their progress in MICS, compares their advantages and disadvantages, and discusses practical challenges.

Efficacy of Transversus Thoracic Plane Block for Pain Management in Cardiac Surgeries

PURPOSE OF REVIEW

Effective pain management in cardiac surgery presents as a continuous challenge related to the intensity of postoperative pain and reliance on opioid therapy. The dependance of opioid-based therapies is concerning, as these therapies carry risk future addiction and potential severe side effects. The transversus thoracic plane block (TTPB) has emerged as a promising regional anesthesia technique that blocks the anterior branches of the intercostal nerves in the chest wall, potentially providing improved analgesia for cardiac surgery patients. The present investigation evaluates the efficacy of TTPB in reducing opioid consumption, decreasing postoperative pain scores, and enhancing recovery outcomes in patients undergoing cardiac surgeries.

RECENT FINDINGS

Data from randomized controlled trials revealed that TTPB significantly reduced 24-hour opioid consumption, increased the time to first rescue analgesic, and lowered Visual Analog Scale (VAS) pain scores both at rest and with movement, particularly in the first 12 h post-surgery. Additional benefits include fewer opioid-related side effects, such as nausea and pruritus, and reductions in intensive care unit (ICU) length of stay. Studies also suggested that TTPB can support earlier extubation and accelerated recovery, contributing to higher patient satisfaction and overall improved postoperative outcomes.

CONCLUSION

Despite these promising results, challenges in technique standardization and limited long-term data are still obstacles that prevent widespread adoption. Achieving consistent TTPB efficacy requires technical precision in ultrasound guidance, and there is little research on its effectiveness across diverse populations, such as pediatric and high-risk cardiac patients. Addressing these gaps through multi-center, long-term studies could help establish TTPB as a prominent pain management strategy in cardiac surgery to minimize opioid dependence and enhance patient comfort and recovery.

Efficacy of Duloxetine for Postspine Surgery Pain: A Systematic Review and Meta-Analysis

BACKGROUND

Duloxetine, a serotonin and norepinephrine reuptake inhibitor (SNRI), is used to treat various health conditions, including major depressive disorder, generalized anxiety disorder, fibromyalgia, and off-label for chemotherapy-induced pain. We conducted this systematic review and meta-analysis aiming to test the current evidence regarding effectiveness and safety of duloxetine for postspine surgeries pain.

METHODS

We searched the Cochrane Central Register of Controlled Trials, PubMed, Scopus and Web of science databases for relevant articles up to March 2024. The following search terms were Used in combination using the Boolean operators ((Duloxetine Hydrochloride) AND ((Pain, Postoperative) OR (Postoperative Period) OR (Postoperative Cognitive Complications) OR (Delayed Emergence from Anesthesia) OR (Postoperative Care) OR (spine surgery)) without time constrain for the search. Meta-analysis was performed using Review Manager (RevMan version 5.4) on the extracted outcome data that present in at least 3 of the included studies. Mean difference (MD) was used as the effect size for continuous outcomes with a 95% confidence interval (CI) or standardized mean difference (SMD) in case of different outcome reporting scales.

RESULTS

Pooled analysis showed that duloxetine significantly reduces pain intensity after 24 h from the operation compared to placebo (SMD = -1.11, 95% CI [-2.16 to -0.07], p = 0.04) with no significant difference in pain after 2 and 48 h. Meta-analysis revealed that duloxetine shows a significant reduction in the amount of analgesic consumption after 24 h postoperative; (MD = -3.33, 95% CI [-5.53 to -1.13], p = 0.003). The analysis did not show any statistically significant difference between duloxetine and placebo in patients experiencing nausea or vomiting (RR = 1.37, 95% CI [0.62 to 3.00] CONCLUSION: The findings of this study suggest that duloxetine may be effective in reducing pain 24 h after spine surgery. Furthermore, there is a promising effect of duloxetine in treating chronic postoperative pain. However, it is important to acknowledge that further research is warranted to thoroughly evaluate the efficacy and safety of duloxetine for relieving chronic postoperative pain.

The First Report on Liver Resection Using the Novel Japanese hinotori™ Surgical Robot System: First Case Series Report of 10 Cases

Background: In Japan, the hinotori™ surgical robot system (Medicaroid Corporation, Kobe, Japan) was approved for gastrointestinal surgeries in October 2022. This report details our initial experience performing liver resection using the hinotori™ system. Methods: Ten patients, who were assessed as cases that would benefit from the robot-assisted procedure, underwent liver resections using the hinotori™ system at Fujita Health University, Okazaki Medical Center, between August 2023 and October 2024. The backgrounds (patient, tumor, and liver function conditions, along with types of liver resections and previous surgical procedures) and short-term outcomes (operation time, blood loss, postoperative complications, open conversion, length of hospital stay, and mortality) of the cases were evaluated. Results: Eight cases of partial liver resection, one extended left medial sectionectomy, and one left hemi-hepatectomy were performed. Six cases of hepatocellular carcinomas, three cases of liver metastases, and one case of hepatolithiasis were included. There were seven male and three female patients with a median age of 70 years. Three physical status class III and seven class II patients were included. The median body mass index was 24. Five patients had previous upper abdominal surgical histories and five patients had liver cirrhosis. The median operation time was 419.5 min, and the median intraoperative blood loss was 276 mL. An open conversion in one hepatocellular carcinoma case was carried out due to bleeding from collateral vessels in the round ligament. The median length of hospital stay was 7.5 days. A grade IIIa complication (delayed bile leakage) was developed in one case. All patients with tumors underwent R0 resection. There were no cases of mortality. Conclusions: Liver resection using the hinotori™ system was feasibly performed. This study reports the first global use of the hinotori™ system for liver resection.

Prolonged post-operative hydrocodone usage due to psychotropic drug interaction

OBJECTIVES

To explore pain outcomes in patients prescribed hydrocodone and psychotropic medications with or without CYP2D6 inhibition activity.

METHODS

Patients hospitalized for lower/limited upper extremity injuries who were prescribed hydrocodone alongside a psychotropic medication were considered for this study (n=224). A subset of these patients (n=178) was prescribed a psychotropic medication known to inhibit CYP2D6, while the remainder (n=46) were prescribed psychotropic medications without CYP2D6 inhibition activity. Patient demographics and pain outcomes were collected by electronic health record review and interviews.

RESULTS

Patients taking a psychotropic inhibitor of CYP2D6 exhibited longer duration of opioid use post-discharge (median 33 days [IQR 10-99]) compared with patients taking a psychotropic non-inhibitor (4 days [2-20], p<0.001). No significant differences were observed with in-hospital pain outcomes, including total dose of hydrocodone administered, duration of hydrocodone use, pain index scores, and the occurrence of common mild/moderate/severe hydrocodone side effects.

CONCLUSIONS

Patients prescribed at least one psychotropic inhibitor of CYP2D6 were more likely to continue using hydrocodone for up to 3 months following surgery. Knowledge of these critical drug-drug interactions could enhance clinical practice and improve patient outcomes. This study highlights negative post-operative pain outcomes in patients prescribed hydrocodone alongside a psychotropic inhibitor of CYP2D6. The results of this study indicate that patients taking psychotropic medications that inhibit CYP2D6 are at increased risk for prolonged hydrocodone use following orthopedic surgery.

Clinical and Patient-Reported Outcome Measures of Palatal Donor Site Healing Using Polyvinylpyrrolidone-Sodium Hyaluronate Gel as a Dressing Material Following Free Gingival Graft Harvesting: A Randomized Controlled Clinical Trial

OBJECTIVES

This study evaluates the efficacy of polyvinylpyrrolidone-sodium hyaluronate (PVP-SH) gel as a dressing material in enhancing both clinical and patient-reported outcomes post-free gingival graft (FGG) harvesting from the hard palate.

MATERIAL AND METHODS

This randomized clinical trial included 18 patients and spanned from June 2022 to August 2023. Patients received an FGG procedure to manage a lack of attached gingiva. Following graft harvesting, patients were divided into two groups: the control group, which received Coe-Pak, and the test group, which was treated with PVP-SH gel. The primary outcome measured was complete epithelialization. Secondary outcomes included the Landry healing scale, post-operative pain level, and patient willingness to receive the same treatment again.

RESULTS

The test group reported significantly lower analgesic use (p < 0.001) and reduced pain severity (p < 0.001) compared to the control group. Furthermore, test group patients indicated a higher level of satisfaction regarding the prospect of retreatment. In contrast, the control group showed significantly slower progress in wound healing and epithelization (p < 0.05) compared to the test group.

CONCLUSIONS

The findings of this study suggest that PVP-SH gel is a superior dressing material post-FGG harvesting, yielding improved clinical and patient-reported outcomes relative to Coe-Pak.

Virtual Reality for Postoperative Pain Management: A Review of Current Evidence

PURPOSE OF REVIEW

With the ongoing opioid crisis, there is a continued need to develop multimodal pain management strategies inclusive of non-pharmacological treatments. Virtual reality (VR) offers a non-invasive treatment approach for the management of acute and chronic pain including postoperative pain. The aim of this review is to describe the use of VR and its effect on pain-related outcome measures compared to routine care in various types of surgical procedures.

RECENT FINDINGS

Severe postoperative pain is associated with an increased risk of medical complications and may lead to the development of chronic pain. VR-based interventions are a form of distraction therapy that attenuates pain perception and have been shown to reduce activity in central pain-processing regions. In patients undergoing cardiac surgery, VR may reduce postoperative pain and improve physiological parameters such as heart rate and blood pressure. VR technology was found to have a high satisfaction rate in patients undergoing laparoscopic abdominal surgeries. Three-dimensional (3D) VR interventions may be useful for postoperative pain control in patients undergoing head and neck surgery. VR technology has revealed mixed results for postoperative pain control following orthopedic procedures although it has beneficial effects on functional outcomes during postoperative rehabilitation. In the pediatric population, VR is notable for its applicability in postoperative pain control and anxiety. VR technology is a novel, non-pharmacologic adjunct in the management of postoperative pain. Current studies are limited regarding therapy adaptations for the elderly population. High-quality randomized controlled trials are needed to establish the clinical effectiveness of VR-based therapies in the postoperative setting.

Is the transection of the hernia sac during laparoscopic inguinal hernioplasty safe and feasible? An updated systematic review and meta-analysis

There is a debate over whether to transect or completely reduce the hernia sac during laparoscopic tension-free repair of inguinal hernia. This study endeavors to systematically assess the efficacy and safety of two approaches, namely transected sac (TS) and completely reduced sac (RS), in laparoscopic tension-free repair of inguinal hernia. Utilizing a meta-analysis methodology, we aim to provide a comprehensive analysis of these techniques. A comprehensive search was conducted across PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov databases to identify comparative studies focusing on laparoscopic tension-free repair of inguinal hernia, specifically comparing TS and RS techniques. The selected studies were subjected to meta-analysis using RevMan 5.3 software. A total of 8 studies, involving 2995 patients with inguinal hernia, were included in the analysis. The meta-analysis results revealed that the TS group had a higher incidence of seroma compared to the RS group [OR = 1.74, 95% CI (1.35, 2.25), P < 0.0001], and a prolonged time to return to normal activity postoperatively [MD = 0.99, 95% CI (0.85, 1.14), P < 0.00001]. However, no statistically significant differences were observed between the two groups in terms of operation time [MD = -1.75, 95% CI (- 8.72, 5.22), P = 0.62], incidence of postoperative pain [OR = 1.00, 95% CI (0.41, 2.44), P = 1.00], overall postoperative complication rate [OR = 0.98, 95% CI (0.43, 2.20), P = 0.95], and recurrence rate fOR = 2.53, 95% CI (0.61, 10.39), P = 0.20]. Transected sac in laparoscopic inguinal hernia repair is associated with an increased incidence of seroma and a longer recovery time for patients to return to normal activity. Clinical trial registration Registration number is INPLASY20223110070.

Comparison of short‑term outcomes and 3-year overall survival between robotic and laparoscopic gastrectomy for gastric cancer: a propensity score matching analysis

BACKGROUND

Despite the increasing use of robotic gastrectomy (RG) as an alternative to laparoscopic gastrectomy (LG) in treating gastric cancer, controversy remains over the advantages of RG compared to LG and there is a paucity of studies comparing the two techniques regarding patient survival.

METHODS

In this retrospective cohort study, 675 patients undergoing minimally invasive gastrectomy were recruited from January 2016 to January 2018 (LG: n = 567; RG: n = 108). A one-to-one propensity score matching (PSM) analysis was applied to minimize the selection bias due to confounding factors, yielding 104 patients in each of the RG and LG groups. After matching, the short-term outcomes and 3-year overall survival were compared in the two groups.

RESULTS

The PSM cohort analysis showed a similar 3-year overall survival between RG and LG groups (p = .249). Concerning the short-term outcomes, the RG compared to LG resulted in lower blood loss (p = .01), lower postoperative complications (p = .001), lower postoperative pain (p = .016), earlier initiation of soft diet (p = .011), shorter hospital stay ‌(p = .012), but higher hospitalization expenses (p = .001).

CONCLUSION

Our findings suggest that RG may offer advantages in terms of blood loss, surgical complications, recovery time, and pain management compared to LG while maintaining similar overall survival rates. However, RG is associated with higher hospital costs, potentially limiting its wider adoption. Further research, including large, multi-center randomized controlled trials with longer patient follow-up, particularly for advanced gastric cancer, is needed to confirm these findings.

Factors influencing postoperative urinary retention after radical hysterectomy for cervical cancer: development and validation of a predictive model in a prospective cohort study in Southwest China

OBJECTIVES

To explore influencing factors for postoperative urinary retention (POUR) in cervical cancer patients and construct and validate a POUR prediction model.

DESIGN

A prospective cohort study.

SETTING

A large tertiary hospital specialised in child and maternal healthcare in Southwest China.

PARTICIPANTS

1101 patients undergoing cervical cancer surgery at our hospital were enrolled in the analytic cohort between 1 July 2022 and 31 July 2023. Another 205 patients were enrolled in the external validation cohort between 1 August 2023 and 31 October 2023. Demographics and disease-related information were collected to construct a risk prediction model by logistic regression. Univariate analyses and a multivariate logistic regression analysis were conducted to determine possible influencing factors. The discrimination and accuracy of the model were assessed by the area under the curve (AUC) and the concordance index, respectively.

RESULTS

Univariate analysis identified duration of surgery, intraoperative bleeding, presence of diabetes, hypertension, ureteral adhesion, wound healing classification, preoperative radio/chemotherapy, category of Body Mass Index, history of urinary diseases, history of caesarean section, postoperative urinary infection and use of analgesia pumps as potential influencing factors (p<0.05). Diabetes, wound healing classification, presurgery radio/chemotherapy, postoperative urinary infection, use of analgesia pumps and pain numerical rating score were founded to be significant factors influencing the occurrence of POUR in cervical cancer patients (p<0.05). A POUR prediction model constructed using the factors demonstrated excellent prediction power, with an AUC of 0.897 (95% CI, 0.877 to 0.916, p<0.001). The sensitivity of the model at the optimal threshold was 0.591, with specificity being 0.747. The receiver operating characteristic curve indicated a good performance of the model.

CONCLUSIONS

Presence of diabetes mellitus, wound healing classification, presurgery radio/chemotherapy, postoperative urinary infection, use of analgesia pumps and pain numerical rating score are factors influencing occurrence of POUR in cervical cancer patients. The POUR prediction model developed demonstrates good predictive power and is promising for clinical utility.

Tapentadol: A Comprehensive Review of Its Role in Pain Management

Pain is a prevalent issue among patients, requiring effective management to prevent the transition of acute pain into chronic pain and to mitigate significant clinical and socioeconomic impacts, such as increased morbidity, mortality, prolonged recovery, unplanned readmissions, and diminished quality of life. Despite advancements in pain management guidelines, achieving consistent pain relief remains challenging due to individual differences in pain thresholds, the nature of surgical procedures, patient age, and existing comorbidities. Tapentadol, an opioid that acts as both a μ-opioid receptor agonist and a noradrenaline reuptake inhibitor, presents a promising option for pain management. Approved by the FDA in 2008 for immediate release and in 2011 for extended release, tapentadol effectively addresses both nociceptive and neuropathic pain, offering a more favorable efficacy-safety profile compared to traditional opioids such as tramadol. Additionally, tapentadol is gaining recognition as a preferred option for managing significant pain in cancer patients due to its effectiveness and reduced side effects. This review evaluates tapentadol's clinical and pharmacological attributes, systematically analyzing literature on its efficacy, safety, pharmacokinetics, and comparative effectiveness, suggesting that tapentadol is a viable option for effective pain management with potential for broader clinical applications.

Immune Competence and Pain: A Narrative Review

PURPOSE OF REVIEW

This review aims to summarize current knowledge on the pathophysiology of pain and the role of neuro-immune crosstalk in the development of acute and chronic pain (CP). Specifically, the review focuses on the role of immune cells involved in the innate and acquired immune response, emphasizing their bidirectional interactions with the nervous systems and discussing the implications of this crosstalk on acute and CP management.

RECENT FINDINGS

In the last two decades, multiple studies have uncovered the important role of the immune system in initiating, maintaining, and resolving pain stimuli. Furthermore, researchers discovered that the immune system interacts tightly with the nervous system, creating a bidirectional crosstalk in which immune cells influence the response of peripheral and central nerve fibers while neurotransmitters and neuropeptides released by nociceptors directly and indirectly modulate the immune response. The neuro-immune crosstalk in acute and CP is a complex and not fully understood process that comprise the interactions of multiple diverse molecules, bidirectional interferences, and numerous redundant processes. Despite the complexity, important steps have been taken in recent years toward explaining the specific roles of each immune cell type and molecule in the initiation, maintenance and resolution of pain. These findings may set the basis for innovative therapeutic options that target the immune system, overcoming the limitations of current treatments in providing pain relief and the disadvantages associated with opioid therapy.

A new long-acting analgesic formulation for postoperative pain management

Local anesthetics (LA), as part of multimodal analgesia, have garnered significant interest for their role in delaying the initiation of opioid therapy, reducing postoperative opioid usage, and mitigating both hospitalization duration and related expenses. Despite numerous endeavors to extend the duration of local anesthetic effects, achieving truly satisfactory long-acting analgesia remains elusive. Drawing upon prior investigations, vesicular phospholipid gels (VPGs) emerge as promising candidates for extended-release modalities in small-molecule drug delivery systems. Therefore, we tried to use the amphiphilicity of phospholipids to co-encapsulate levobupivacaine hydrochloride and meloxicam, two drugs with different hydrophilicity, to obtain a long-term synergistic analgesic effect. Initially, the physicochemical attributes of the formulation were characterized, followed by an examination of its in vitro release kinetics, substantiating the viability of extending the release duration of the dual drugs. Sequentially, in vivo investigations encompassing pharmacokinetic profiling and assessment of analgesic efficacy were undertaken, revealing a prolonged release duration of up to 120 h and attainment of optimal postoperative analgesia. Subsequently, inquiries into the mechanism underlying synergistic analgesic effects and safety evaluations pertinent to the delivery strategy were pursued. In summation, we successfully developed a promising formulation to achieve long-acting analgesia.

Continuous Incisional Infusion of Local Anaesthetic (CIILA) Reduces Postoperative Opioid Usage in Children

AIM

Adequate post-operative pain relief is associated with shorter recovery time and higher patient satisfaction. Universally, opioids have been the mainstay but are associated with many adverse effects. We aimed to assess the safety and effectiveness of Continuous Incisional Infusion of Local Anaesthetic (CIILA) for postoperative pain relief in the paediatric population.

METHODS

After Trust approval for the use of CIILA was obtained, data were collected prospectively from 2019 to 2022. Patients who had previously undergone laparotomy were used as historical controls. Morphine usage, pain scores and complications were documented. Median (IQR) were quoted throughout and comparison between groups performed using a Mann-Whitney U test. p < 0.05 was accepted as significant.

RESULTS

76 cases with CIILA were included (laparotomies n = 43, renal transplants n = 33), 58 children who underwent laparotomy served as control group. Age at surgery was 9.0 years (IQR: 2.3-13.1) and 6.1 years (IQR: 2.9-10.6), respectively; p = 0.23). Total morphine usage and number of bolus doses (<48 h) were significantly less in the CIILA group [23 (IQR: 2.6-261.6) vs. 460 (IQR: 265.0-566.0) mcg/kg total, and 0.4 (IQR: 0.4-10.0) vs. 10 (IQR: 10.0-10.0) mcg/kg bolus dose respectively, both p < 0001)]. Reported pain scores were similar in both groups [1.0 (IQR: 1.0-7.0) vs 0.0 (IQR: 0.0-0.5); p = 0.13)]. Length of stay was significantly shorter in the CIILA group [(4.5 days (IQR: 3.5-6.0) vs 6.0 days (IQR: 4.0-8.0); p = 0.02)]. There were no toxicity issues nor any local infection complications reported in the CIILA group.

CONCLUSION

The use of CIILA is safe, and was associated with lower morphine consumption postoperatively. We suggest that CIILA should be more widely used in the paediatric population.

The impact of surgical intervention on religious coping, psychological well-being, and pain levels in older adult patients: A quasi-experimental study

AIM

This study aimed to determine the impact of surgical intervention on religious coping, psychological well-being, and pain levels in older adult patients.

METHOD

The data of the study, which used a one-group pretest-posttest quasi-experimental design without a control group, was collected between July 1, 2023, - January 30, 2024. Data collection involved the use of a Personal Information Form, the Religious Coping Scale, the Psychological Well-Being Scale, and the Visual Analog Scale.

RESULTS

The results revealed a significant increase in psychological well-being and positive religious coping after surgical intervention compared to presurgical levels (p < 0.001). Multiple linear regression analysis revealed that male gender, younger age, enhanced psychological well-being, and positive religious coping were identified as factors contributing to a reduction in postsurgical pain levels.

CONCLUSION

The study's results indicate that surgical intervention serves as a significant variable influencing psychological well-being and religious coping among older adult patients.

Application of Integrated Medical Care "Cloud-Based Virtual Ward" Management Model on Postoperative Analgesia: Based on Zigbee Technology

PURPOSE

This study aimed to compare acute care postoperative patients monitored by standard care to those monitored through virtual ward technology by pain team to evaluate status in real-time.

DESIGN

Retrospective cohort study.

METHODS

We included 72,240 and 68,424 postoperative patients who underwent the acute pain service model between January 2021 and April 2022 and the "cloud-based virtual ward" management model between May 2022 and September 2023, respectively. Patients were administered patient-controlled intravenous analgesia after surgery, and we collected perioperative data regarding the general condition, operation type, postoperative moderate-to-severe pain, nausea and vomiting, dizziness, hoarseness, and drowsiness of the patients.

RESULTS

The incidences of moderate-to-severe postoperative pain, postoperative nausea and vomiting, dizziness, drowsiness, hoarseness, resting pain, and activity pain were significantly reduced in the "cloud-based virtual ward" management model when compared with the acute pain service model.

CONCLUSIONS

Compared to the acute pain service model, the "cloud-based virtual ward" management model can enhance pain management satisfaction and lower the frequency of moderate-to-severe postoperative pain and adverse effects.

CLINICAL IMPLICATIONS

The "cloud-based virtual ward" management model proposed in this study may improve the care of patients with acute postoperative pain. By reviewing the two pain management models for postoperative patients, we were able to compare the incidence of postoperative adverse reactions and use the standard process of the integrated medical care "cloud-based virtual ward" management model to optimize the management of postoperative patients and promote their health outcomes.

Differences in the relationship between pain and anxiety in total knee and hip arthroplasty: a longitudinal cross-lagged analysis mediated by depression and pain catastrophizing

Acute postsurgical pain (APSP) is an important risk factor for pain chronification, with reports of being more intense after total knee arthroplasty (TKA) than after total hip arthroplasty (THA). Psychological variables have been associated with differences in postsurgical pain experience. This study aimed to analyse the longitudinal reciprocal association between pain and anxiety levels in patients undergoing TKA or THA, to investigate the moderator role of the type of surgery and to explore psychological mediators in the anxiety - pain association. Patients undergoing TKA (n = 120) or THA (n = 109) were evaluated before surgery and in the acute postsurgical period (48 h postsurgery). Presurgical assessment comprised sociodemographic, pain-related and psychological variables (anxiety, depression, pain catastrophizing, self-efficacy, optimism and satisfaction with life). Postsurgical assessment focused on pain frequency, pain intensity and anxiety. Longitudinal associations were explored using cross-lagged panel models that included the indirect effect paths through possible mediators (pain catastrophizing and depression). Multigroup analyses compared TKA and THA. In the global sample, higher APSP was predicted by higher presurgical pain and worse presurgical anxiety. Multigroup analyses revealed that worse APSP was predicted by higher presurgical anxiety in patients undergoing TKA and by higher presurgical pain in patients undergoing THA. Furthermore, there was a positive significant indirect effect of pain catastrophizing, but not depressive symptoms, in the relationship between presurgical anxiety and APSP in THA. Anxiety and APSP are differently interrelated in TKA and THA. Psychological characteristics could be managed before surgery to favour better APSP control and potentially prevent pain chronification after total joint arthroplasty.

The Effectiveness of Virtual and Augmented Reality in Surgical Pain Management: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Satisfactory management of postoperative pain remains challenging. Nonpharmacological modalities such as virtual and augmented reality (VR/AR) offer potential benefits and are becoming increasingly popular. This systematic review evaluates the effectiveness and safety of VR/AR interventions on postoperative pain and recovery.

METHODS

MEDLINE, Embase, CINAHL, Web of Science, and CENTRAL databases were searched from inception to July 27, 2023, for randomized controlled trials (RCTs), published in English, evaluating the use of VR/AR interventions for surgical pain relief. Study selection and data extraction were performed by pairs of reviewers independently and in duplicate, and potential risk of bias was determined using the Risk of Bias-version 2 (RoB 2) tool. Our outcomes included pain relief, reduction of anxiety, satisfaction, and adverse effects. Due to substantial heterogeneity, a narrative synthesis without meta-analysis was performed.

RESULTS

We included 35 trials among 2257 citations, categorized as surgery (n = 12), minor procedures (n = 15), and postoperative physiotherapy (n = 8). Surgical group included various surgeries, with 11 using immersive VR predominantly in the postoperative period, and most reporting no differences in pain, but potential for reduced anxiety and sedation requirements. In the minor procedures group, most studies reported decreased pain and anxiety during the procedural performance. Two studies reported increased heart rate, while 2 others reported better hemodynamic stability. Home-based AR physiotherapy achieved (n = 6) similar pain and functional outcomes after knee replacement, with 1 large study (n = 306) reporting reduction of mean costs by $2745 for provision of 12 weeks physiotherapy. There were some concerns around potential bias for most studies, as the nature of interventions make it challenging to blind assessors and participants. No important adverse effects were noted using VR/AR technology.

CONCLUSIONS

Evidence from RCTs indicates that the use of immersive VR during minor procedures may reduce procedural pain, decrease anxiety, and improve satisfaction. However, small studies, inconsistent effect, and variation in the application of interventions are important limitations. Evidence to support the application of AR/VR for major surgeries is limited and needs to be further investigated. Use of home-based physiotherapy with AR likely has economic advantages, and facilitates virtual care for appropriate patients who can access and use the technology safely.

Advancements in the interventional therapy and nursing care on deep vein thrombosis in the lower extremities

This review examines recent advancements in interventional treatments and nursing care for lower extremity deep vein thrombosis (DVT), highlighting significant innovations and their clinical applications. It discusses the transition to novel anticoagulants such as Direct Oral Anticoagulants, which offer a safer profile and simplified management compared to traditional therapies. Mechanical interventions, including balloon angioplasty and venous stenting, are detailed for their roles in improving immediate and long-term vascular function in acute DVT cases. Furthermore, the use of image-guided techniques is presented as essential for enhancing the accuracy and safety of DVT interventions. Additionally, this study outlines advances in nursing care strategies, emphasizing comprehensive preoperative and postoperative evaluations to optimize patient outcomes. These evaluations facilitate tailored treatment plans, crucial for managing the complex needs of DVT patients. Long-term care strategies are also discussed, with a focus on patient education to ensure adherence to treatment protocols and to prevent recurrence. The synthesis aims to inform healthcare professionals about cutting-edge practices in DVT management, promoting a deeper understanding of how these advancements can be integrated into clinical practice. It also underscores the necessity for ongoing research to address challenges such as cost-effectiveness and patient compliance, ensuring that future treatments are both accessible and effective.

The Advances in Phospholipids-Based Phase Separation Gels for the Sustained Release of Peptides, Proteins, and Chemotherapeutics

Implantable drug delivery systems formed upon injection offer a host of advantages, including localized drug administration, sustained release, minimized side effects, and enhanced patient compliance. Among the various techniques utilized for the development of in situ forming drug implants, solvent-induced phase inversion emerges as a particularly promising approach. However, synthetic polymer-based implants have been associated with undesirable effects arising from polymer degradation. In response to this challenge, a novel category of drug delivery systems, known as phospholipids-based phase separation gels (PPSGs), has emerged. These gels, characterized by their low initial viscosity, exhibit injectability and undergo rapid transformation into in situ implants when exposed to an aqueous environment. A typical PPSG formulation comprises biodegradable components, such as phospholipids, pharmaceutical oil, and a minimal amount of ethanol. The minimized organic solvents in the composition show good biocompatibility. And the relatively simple composition holds promise for industrial-scale manufacturing. This comprehensive review provides an overview of the principles and advancements in PPSG systems, with specific emphasis on their suitability as drug delivery systems for a wide range of active pharmaceutical ingredients (APIs), spanning from small molecules to peptides and proteins. Additionally, we explore the critical parameters and underlying principles governing the formulation of PPSG-based drug delivery strategies, offering valuable insights on optimization strategies.

Comparison of supraclavicular block with infraclavicular block for distal arm surgeries: A meta-analysis of randomized controlled studies

BACKGROUND

Supraclavicular and infraclavicular nerve block are commonly used for the analgesia of distal arm surgeries, and this meta-analysis aims to compare their analgesic efficacy for distal arm surgeries.

METHODS

We searched several databases including PubMed, Embase, Web of Science, EBSCO, and Cochrane library databases, and selected the randomized controlled trials exploring the analgesic efficacy of supraclavicular block versus infraclavicular block for distal arm surgeries. This meta-analysis was conducted using the random-effect or fixed-effect model based on the heterogeneity.

RESULTS

Six randomized controlled trials were included in this meta-analysis. Compared with infraclavicular nerve block for distal arm surgeries, supraclavicular nerve block was associated with substantially reduced complete sensory block (odds ratio [OR] = 0.41; 95% confidence interval [CI] = 0.19-0.88; P = .02) and block performance time (standard mean difference [SMD] = -3.06; 95% CI = -5.82--0.31; P = .03), but had no effect on duration of analgesia (SMD = -0.15; 95% CI = -0.49-0.18; P = .36), time to sensory block (SMD = -0.41; 95% CI = -2.28-1.47; P = .67), vascular puncture (OR = 1.03; 95% CI = 0.11-10.05; P = .98) or adverse events (OR = 0.70; 95% CI = 0.12-4.04; P = .69).

CONCLUSIONS

Infraclavicular nerve block may be superior to supraclavicular nerve block for the analgesia of distal arm surgeries but needs increased block performance time.

Acupoint Stimulation for Pain Control in Enhanced Recovery After Surgery: Systematic Review and Meta-Analysis

Introduction: Postoperative pain control is a challenge in enhanced recovery after surgery (ERAS). The current study reviewed the efficacy and safety of incorporating acupoint stimulation for postoperative pain control in ERAS. Methods: Ten databases for relevant randomized controlled trials (RCTs) published in English or Mandarin Chinese were searched from 1997 to 2022. The quality of each article was appraised using the Cochrane Collaboration Risk of Bias Criteria and the modified Jadad Scale. The primary outcome was pain control, measured using the visual analog scale 24 h after surgery. Results: Eleven trials met the eligibility criteria and were included in the study. Acupoint stimulation was found more effective than control treatments in terms of pain intensity (standardized mean difference [SMD] -0.94; 95% confidence interval [CI] -1.35 to -0.53), analgesic drug consumption (SMD -1.87; 95% CI -2.98 to -0.75), postoperative nausea (PON; SMD 0.31; 95% CI 0.13 to 0.73), postoperative vomiting (POV; SMD 0.57; 95% CI 0.11 to 2.92), and PON and POV (PONV; SMD 0.29; 95% CI 0.16 to 0.53). The Zusanli (ST36) and Neiguan (PC6) were the most-used acupoints in the included trials (8/11). The reported adverse reaction was only one case of bruising. Discussion: Acupoint stimulation improved pain control in patients undergoing ERAS more than control treatments. The findings provide an evidence-based premise for incorporating acupoint stimulation into ERAS strategies. More rigorous RCTs are needed in the future.

Local anesthetic delivery systems for the management of postoperative pain

Postoperative pain (POP) is a major clinical challenge. Local anesthetics (LAs), including amide-type LAs, ester-type LAs, and other potential ion-channel blockers, are emerging as drugs for POP management because of their effectiveness and affordability. However, LAs typically exhibit short durations of action and prolonging the duration by increasing their dosage or concentration may increase the risk of motor block or systemic local anesthetic toxicity. In addition, techniques using LAs, such as intrathecal infusion, require professional operation and are prone to catheter displacement, dislodgement, infection, and nerve damage. With the development of materials science and nanotechnology, various LAs delivery systems have been developed to compensate for these disadvantages. Numerous delivery systems have been designed to continuously release a safe dose in a single administration to ensure minimal systemic toxicity and prolong pain relief. LAs delivery systems can also be designed to control the duration and intensity of analgesia according to changes in the external trigger conditions, achieve on-demand analgesia, and significantly improve pain relief and patient satisfaction. In this review, we summarize POP pathways, animal models and methods for POP testing, and highlight LAs delivery systems for POP management. STATEMENT OF SIGNIFICANCE: Postoperative pain (POP) is a major clinical challenge. Local anesthetics (LAs) are emerging as drugs for POP management because of their effectiveness and affordability. However, they exhibit short durations and toxicity. Various LAs delivery systems have been developed to compensate for these disadvantages. They have been designed to continuously release a safe dose in a single administration to ensure minimal toxicity and prolong pain relief. LAs delivery systems can also be designed to control the duration and intensity of analgesia to achieve on-demand analgesia, and significantly improve pain relief and patient satisfaction. In this paper, we summarize POP pathways, animal models, and methods for POP testing and highlight LAs delivery systems for POP management.

Factors Affecting Postoperative Pain Beliefs Among Surgical Patients in Türkiye: A Cross-Sectional Study

BACKGROUND

Frequency, ability to cope, and severity of pain; the genetic structure of the individual affects their emotional and cultural characteristics, beliefs, and personal characteristics. It is stated that pain beliefs are one of the factors affecting emotional pain control and approach to pain.

AIMS

This study, it is aimed to determine the pain beliefs of individuals experiencing postoperative pain.

METHODS

Cross-sectional descriptive study. Surgical services of a single secondary care hospital. 170 patients who were in the first week after surgery, experienced acute pain, were between the ages of 18-65, and did not have a psychiatric disorder were evaluated. Collection Tools: Postoperative pain levels of the patients were evaluated with a Visual Analog Scale. As the VAS score increases, the pain level increases. Pain beliefs were evaluated with the Pain Beliefs Scale. Pain Beliefs Scale increases in the score obtained from the sub-score of the scale indicate that the pain beliefs related to that test are high. A student T-Test was used for bivariate comparisons between groups. One-way ANOVA was used to compare trivariate groups. In addition, Spearman's Correlation analysis was performed. Statistically, a confidence interval of >95% was used. The statistical significance level was set as p < 0.05.

RESULTS

It was found that the pain levels of the patients participating in the study were low and the scores they received from the Pain Beliefs Scale subscales were moderate. It was determined that those with lower education levels had higher scale scores in the psychological beliefs sub-dimension of the Pain Beliefs Scale. In the organic beliefs sub-dimension, it was determined that those with lower income levels had higher organic beliefs. It was determined that the postoperative pain experienced did not affect pain beliefs (p > 0.05).

CONCLUSION

It was concluded that there was no relationship between the pain level and pain beliefs of patients with low pain in the postoperative period. Individuals experiencing postoperative pain believe that pain occurs due to the influence of both organic and psychological factors. For this reason, it is recommended factors that nurses who care for individuals experiencing postoperative pain provide care for both organic and psychological sources of pain.

Risk Factors for Acute Postsurgical Pain: A Narrative Review

Acute postsurgical pain (APSP) has received growing attention as a surgical outcome. When poorly controlled, APSP can affect short- and long-term outcomes in patients. Despite the steady increase in awareness about postoperative pain and standardization of pain prevention and treatment strategies, moderate-to-severe APSP is frequently reported in clinical practice. This is possibly because pain varies widely among individuals and is influenced by distinct factors, such as demographic, perioperative, psychological, and genetic factors. This review investigates the risk factors for APSP, including gender, age, obesity, smoking history, preoperative pain history, pain sensitivity, preoperative anxiety, depression, pain catastrophizing, expected postoperative pain, surgical fear, and genetic polymorphisms. By identifying patients having an increased risk of moderate-to-severe APSP at an early stage, clinicians can more effectively manage individualized analgesic treatment protocols with a combination of pharmacological and non-pharmacological interventions. This would alleviate the transition from APSP to chronic pain and reduce the severity of APSP-induced chronic physical disability and social psychological distress.

Dose safety and pharmacodynamics of subcutaneous bupivacaine in a novel extended-release microparticle formulation: A phase 1, dose-ascending study in male volunteers

A novel microparticle-based extended-release local anaesthetic containing a bupivacaine/poly-lactic-co-glycolic acid (PLGA; LIQ865A) or plain bupivacaine (LIQ865B) was examined in a first-in-human trial. The objectives were to examine the dose safety/tolerability and pharmacodynamics. Randomized subcutaneous injections of LIQ865A (n = 16) or LIQ865B (n = 12) and diluent, contralaterally, were administered in a dose-ascending manner (150- to 600-mg bupivacaine). Subjects were admitted 24 h post-injection and followed for 30 days post-injection. The risk ratios (RRs; 95% CI) of erythematous reactions for LIQ865A versus diluent was 9.00 (1.81-52.23; P = 0.006) and for LIQ865B versus diluent 2.50 (0.69-9.94; P = 0.37). The RR for the development of hematomas (LIQ865A versus diluent) were 3.25 (1.52-8.16; P = 0.004) and 4.00 (0.72-24.89; P = 0.32) (LIQ865B versus diluent). Subcutaneous indurations persisting for 4-13 weeks were seen in 6/16 subjects receiving LIQ865A. One subject receiving LIQ865A (600-mg bupivacaine) developed intermittent central nervous system (CNS) symptoms of local anaesthetic systemic toxicity (85 min to 51 h post-injection) coinciding with plasma peak bupivacaine concentrations (490-533 ng/ml). Both LIQ865 formulations demonstrated dose-dependent hypoesthesia and hypoalgesia. The duration of analgesia ranged between 37 and 86 h. The overall number of local adverse events, however, prohibits clinical application without further pharmacological modifications.

Advancements and Innovations in the Surgical Management of Sacrococcygeal Pilonidal Sinus: A Comprehensive Review

Sacrococcygeal pilonidal sinus (SPS) is a common condition characterized by the formation of a sinus tract or cavity in the sacrococcygeal region, often containing hair and debris. Surgical management plays a crucial role in its treatment due to its chronic and recurrent nature. This comprehensive review explores the advancements and innovations in the surgical management of SPS. The review begins with an overview of the historical perspective, anatomy, and pathophysiology of the condition, followed by a discussion of current surgical techniques, including conventional excision, flap procedures, and minimally invasive approaches. Recent advancements, such as laser therapy, radiological guidance techniques, and robotic-assisted surgery, are also examined. The key findings from outcomes research are summarized, including postoperative pain management, recurrence rates, and patient satisfaction. The implications for clinical practice are discussed, emphasizing the importance of staying updated on the latest surgical techniques and adopting a personalized approach to treatment. Recommendations for future research are provided, highlighting the need for prospective studies comparing different surgical techniques, as well as research focusing on minimally invasive approaches and predictive models for recurrence risk. Collaboration among researchers, clinicians, and industry partners is essential to drive innovation and improve outcomes for patients with SPS.

Evaluating the Efficacy of Methocarbamol and Nefopam in Orthopedic Surgical Pain

Introduction Pain after orthopedic surgeries represents a special concern in patients with fractures. The use of multimodal analgesia significantly reduced the opioid need and reduced the risk of their side effects. Objectives This study compared the effectiveness and safety of methocarbamol and nefopam in the reduction of post-operative pain for patients undergoing orthopedic surgeries. Method This prospective, double-blind, randomized controlled trial took place at Al-Sader Teaching Hospital in Basrah, Iraq, from the first of February 2022 to the end of October 2023. The study aimed to assess the post-operative pain relief efficacy and safety of intramuscular nefopam (20 mg) and intravenous methocarbamol (1 g) in 110 adults (aged 18-65) undergoing elective orthopedic surgeries. Exclusions were made for allergies to the drugs, substance abuse history, and severe hepatic or renal impairment. Participants were randomized into two groups, with pain intensity measured at one hour, six hours, and 12 hours post-operation using the visual analog scale (VAS). Side effects were also evaluated. Statistical analysis was done using SPSS 27, with a significance level set at p<0.05 and a 95% confidence interval (CI). Results  In this study, we conducted a rigorous comparison between two groups, methocarbamol and nefopam, to evaluate their efficacy and safety in post-operative pain management. We started by ensuring that the groups were well-matched in terms of age, gender distribution, and body mass index (BMI). The results showed remarkable similarities in mean age, gender distribution, and BMI, supported by robust p-values, affirming the effective matching of the two groups. Moving to pain management, we observed a significant advantage in favor of methocarbamol. At all-time intervals (one hour, six hours, and 12 hours post-operation), methocarbamol consistently demonstrated lower mean VAS scores compared to nefopam. These differences were highly statistically significant, underscoring the superior pain relief efficacy of methocarbamol. Exploring side effects, we found no statistically significant disparities in the occurrence of nausea and vomiting between the two groups. However, there was a noticeable trend toward higher tachycardia incidence in the nefopam group, though it did not reach statistical significance. Conclusion The present study showed a higher efficacy of methocarbamol in post-operative pain reduction in comparison to nefopam. No serious side effects were observed with both drugs.

Population pharmacokinetic-pharmacodynamic model of subcutaneous bupivacaine in a novel extended-release microparticle formulation

The objective of this study was to develop a population pharmacokinetic-pharmacodynamic model of subcutaneously administered bupivacaine in a novel extended-release microparticle formulation for postoperative pain management. Bupivacaine was administered subcutaneously in the lower leg to 28 healthy male subjects in doses from 150 to 600 mg in a phase 1 randomized, placebo-controlled, double-blind, dose-ascending study with two different microparticle formulations, LIQ865A and LIQ865B. Warmth detection threshold was used as a surrogate pharmacodynamic endpoint. Population pharmacokinetic-pharmacodynamic models were fitted to plasma concentration-effect-time data using non-linear mixed-effects modelling. The pharmacokinetics were best described by a two-compartment model with biphasic absorption as two parallel absorption processes: a fast, zero-order process and a slower, first-order process with two transit compartments. The slow absorption process was found to be dose-dependent and rate-limiting for elimination at higher doses. Apparent bupivacaine clearance and the transit rate constant describing the slow absorption process both appeared to decrease with increasing doses following a power function with a shared covariate effect. The pharmacokinetic-pharmacodynamic relationship between plasma concentrations and effect was best described by a linear function. This model gives new insight into the pharmacokinetics and pharmacodynamics of microparticle formulations of bupivacaine and the biphasic absorption seen for several local anaesthetics.

Analgesia nociception index is an indicator of laparoscopic trocar insertion-induced transient nociceptive stimuli

Objective

This study aimed to investigate whether analgesia nociception index (ANI) could be an indicator of perioperative pain during laparoscopic trocar insertion.

Methods

A total of 280 participants of anesthesia receiving laparoscopic surgery were enrolled. Anesthesia induction and maintenance were performed using the Marsh model for target propofol and the Minto model for remifentanil. Systolic blood pressure (SBP), heart rate (HR), and ANI were recorded at skin incision, the first-, second, the last-trocar insertion, and 5 min after the last trocar insertion.

Results

ANI was significantly different among the five groups in the last four time points (all P < 0.05). Pearson's correlation showed that ANI was negatively correlated with SBP (r = -0.114, P = 0.077) and HR (r = -0.247, P < 0.001). The area under the curve of ANI was positively correlated with those of SBP (r = 0.493, P < 0.001) and HR (r = -0.420, P < 0.001). Multivariate logistic regression showed that the ANI was an independent factor associated with intraoperative hemodynamic adverse events only at 5 min after the last trocar insertion.

Conclusions

Under general anesthesia, the change in ANI was consistent with changes in the balance between analgesia and nociceptive stimuli. The ANI can reflect the extent of transient pain but had a poor predictive performance for hemodynamic adverse events.

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

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

Postoperative intravenous patient-controlled analgesia improves pain management after subcutaneous implantable defibrillator implantation

Objective

Postoperative pain is a major issue with subcutaneous implantable cardioverter defibrillators (S-ICD). In 2020, we introduced intravenous patient-controlled analgesia (IV-PCA) in addition to the conventional, request-based analgesia for postoperative pain control in S-ICD. To determine the effect and safety, we quantitatively assessed the effect of IV-PCA after S-ICD surgery over conventional methods.

Methods

During the study period, a total of 113 consecutive patients (age, 50.1 ± 15.5 years: males, 101) underwent a de novo S-ICD implantation under general anesthesia. While the postoperative pain was addressed with either request-based analgesia (by nonsteroid anti-inflammatory drugs, N = 68, dubbed as "PCA absent") or fentanyl-based IV-PCA in addition to the standard care (N = 45, dubbed as "PCA present"). The degree of postoperative pain from immediately after surgery to 1 week were retrospectively investigated by the numerical rating scale (NRS) divided into four groups at rest and during activity (0: no pain, 1-3: mild pain, 4-6: moderate pain, 7-10: severe pain).

Results

Although IV-PCA was removed on Day 1, it was associated with continued better pain control compared to PCA absent group. At rest, the proportion of patients expressing pain (mild or more) was significantly lower in the PCA present group from Day 0 to Day 4. In contrast to at rest, a better pain control continued through the entire study period of 7 days. No serious adverse events were observed. A few patients experienced nausea in both groups and the inter-group difference was not found significant.

Conclusion

IV-PCA suppresses postoperative pain in S-ICD without major safety concerns.

Perioperative pain management models in four European countries: A narrative review of differences, similarities and future directions

There is general agreement that acute pain management is an important component of perioperative medicine. However, there is no consensus on the best model of care for perioperative pain management, mainly because evidence is missing in many aspects. Comparing the similarities and differences between countries might reveal some insights into different organisational models and how they work. Here, we performed a narrative review to describe and compare the structures, processes and outcomes of perioperative pain management in the healthcare systems of four European countries using Donabedian's framework as a guide. Our comparison revealed many similarities, differences and gaps. Different structures of acute pain services in the four countries with no common definition and standards of care were found. Protocols have been implemented in all countries and guidelines in some. If outcome is assessed, it is mainly pain intensity, and many patients experiencing more intense pain than others have common risk factors (e.g. preoperative pain, preoperative opioid intake, female sex and young age). Outcome assessment beyond pain intensity (such as pain-related physical function, which is important for early rehabilitation and recovery) is currently not well implemented. Developing common quality indicators, a European guideline for perioperative pain management (e.g. for patients at high risk for experiencing severe pain and other outcome parameters) and common criteria for acute pain services might pave the way forward for improving acute pain management in Europe. Finally, the education of general and specialist staff should be aligned in Europe, for example, by using the curricula of the European Pain Federation (EFIC).

Sub-anesthetic dose of esketamine decreases postoperative opioid self-administration after spine surgery: a retrospective cohort analysis

The use of intraoperative sub-anesthetic esketamine for postoperative analgesia is controversial. In this study, the impact of sub-anesthetic esketamine on postoperative opioid self-administration was determined. Patients who underwent spinal surgery with patient-controlled analgesia (PCA) from January 2019 to December 2021 were respectively screened for analysis. Postoperative PCA was compared between patients who received a sub-anesthetic esketamine dose and patients who were not treated with esketamine (non-esketamine group) with or without propensity score matching. Negative binomial regression analysis was used to identify factors associated with postoperative PCA. Patients who received intraoperative sub-anesthetic esketamine self-administered less PCA (P = 0.001). Azasetron, esketamine, and dexamethasone lowered the self-administration of PCA (IRR with 95% confidential interval, 0.789 [0.624, 0.993]; 0.581 [0.458, 0.741]; and 0.777 [0.627, 0.959], respectively). Fixation surgery and drinking were risk factors for postoperative PCA (1.737 [1.373, 2.188] and 1.332 [1.032, 1.737] for fixation surgery and drinking, respectively). An intraoperative sub-anesthetic dose of esketamine decreases postoperative opioid self-administration. Azasetron and dexamethasone also decrease postoperative opioid consumption. The study is registered at www.chictr.org.cn (ChiCTR2300068733).

Combined rectus sheath block with transverse abdominis plane block by one puncture for analgesia after laparoscopic upper abdominal surgery: a randomized controlled prospective study

BACKGROUND

Rectus sheath block (RSB) and transversus abdominis plane block (TAPB) have been shown to reduce opioid consumption and decrease postoperative pain scores in abdominal surgeries. However, there are no reports about the one-puncture technique of RSB combined with TAPB for perioperative pain management during laparoscopic upper abdominal surgery.

METHODS

A total of 58 patients were randomly assigned to the control group (C), the TAP group (T), and the one-puncture technique of RSB combined with TAPB group (RT). The patients in group C did not receive any regional block. The patients in group T received ultrasound-guided subcostal TAPB with 30 mL of 0.33% ropivacaine on each side. The patients in the RT group received a combination of RSB and TAPB with 15 mL of 0.33% ropivacaine in each plane by one puncture technique. All patients received postoperative patient-controlled intravenous analgesia (PCIA) after surgeries. The range of blocks was recorded 20 min after the completion of the regional block. The postoperative opioid consumption, pain scores, and recovery data were recorded, including the incidence of emergence agitation (EA), the times of first exhaust and off-bed activity, the incidence of postoperative nausea and vomiting, dizziness.

RESULTS

The range of the one-puncture technique in group RT covered all areas of surgical incisions. The visual analogue scale (VAS) score of the RT group is significantly lower at rest and during coughing compared to groups T and C at 4, 8, 12, and 24 h after surgery, respectively (P < 0.05). The consumption of sufentanil and the number of postoperative compressions of the analgesic pumps at 24 and 48 h in the RT group are significantly lower than those in groups T and C (P < 0.05). The incidence of EA in the RT group is significantly lower than that in groups T and C (P < 0.05).

CONCLUSION

The one-puncture technique of RSB combined with TAPB provides effective postoperative analgesia for laparoscopic upper abdominal surgery, reduces the incidence of EA during PACU, and promotes early recovery.

TRIAL REGISTRATION

ChiCTR, ChiCTR2300067271. Registered 3 Jan 2023, http://www.chictr.org.cn .

Reduced side effects and improved pain management by continuous ketorolac infusion with patient-controlled fentanyl injection compared with single fentanyl administration in pelviscopic gynecologic surgery: a randomized, double-blind, controlled study

BACKGROUND

A combination of opioids and adjunctive drugs can be used for intravenous patient-controlled analgesia (PCA) to minimize opioid-related side effects. We investigated whether two different analgesics administered separately via a dual-chamber PCA have fewer side effects with adequate analgesia than a single fentanyl PCA in gynecologic pelviscopic surgery.

METHODS

This prospective, double-blind, randomized, and controlled study included 68 patients who underwent pelviscopic gynecological surgery. Patients were allocated to either the dual (ketorolac and fentanyl delivered by a dual-chamber PCA) or the single (fentanyl alone) group. Postoperative nausea and vomiting (PONV) and analgesic quality were compared between the two groups at 2, 6, 12, and 24 h postoperatively.

RESULTS

The dual group showed a significantly lower incidence of PONV during postoperative 2-6 h (P = 0.011) and 6-12 h (P = 0.009). Finally, only two patients (5.7%) in the dual group and 18 (54.5%) in the single group experienced PONV during the entire postoperative 24 h and could not maintain intravenous PCA (odds ratio: 0.056, 95% CI [0.007, 0.229], P < 0.001). Despite the administration of less fentanyl via intravenous PCA during the postoperative 24 h in the dual group than in the single group (66.0 ± 77.8 vs. 383.6 ± 70.1 μg, P < 0.001), postoperative pain had no significant intergroup difference.

CONCLUSIONS

Two different analgesics, continuous ketorolac and intermittent fentanyl bolus, administered via dual-chamber intravenous PCA, showed fewer side effects with adequate analgesia than conventional intravenous fentanyl PCA in gynecologic patients undergoing pelviscopic surgery.

Efficacy and safety of patient-controlled intravenous analgesia after APS team standardized postoperative pain management: A 6-year experience of an acute pain service in 107802 Chinese patients

There are few studies on the impact of postoperative pain management (such as Acute Pain Service, APS) on the prognosis of patients, especially the research on large samples, even less data on Chinese patients. It is reported that only 25.12 % of hospitals in China have established APS or similar teams, and less than 10 % of them are responsible for the whole process of postoperative analgesia services. Tongji Hospital affiliated to Tongji Medical College of Huazhong University of Science and Technology has established a professional APS team led by anesthesiologists (TJ-APS), and has a standardized workflow and management system. Based on the TJ-APS standardized postoperative pain management, the incidence and adverse effects of postoperative pain in different types of surgical patients were analyzed. In total, 107,802 patients receiving intravenous PCA from the Tongji Hospital affiliated to Tongji Medical College of Huazhong University of Science and Technology were selected between January 2016 and December 2021, which were under TJ-APS standardized postoperative analgesia process, postoperative analgesia strategy based on the principle of "low opioid, multimodal, specialization and individualization", as well as regular ward rounds and 24-h on call on-duty system. We assessed the incidence and adverse effects of postoperative pain in different types of surgical patients. Based on the TJ-APS standardized postoperative pain management, the incidence of poor postoperative analgesia in patients with intravenous PCA is significantly lower than that reported in the current literature (20 %), and mainly occurs in biliary-pancreatic surgery, extrahepatic surgery and gastrointestinal surgery. The overall incidence of adverse effects was 5.52 %, of which nausea and vomiting was the highest, especially among gynecological tumors and gynecological patients, which were 10.75 % and 8.68 % respectively, but both were lower than the level reported in the current literature (20 %). This APS multimodal management and analgesia process can provide reference and guidance for PCA management of postoperative acute pain.

Comparison of two methods of complementary medicine on postoperative pain and anxiety: A randomized clinical trial

BACKGROUND

Postoperative pain and anxiety are unpleasant situations that are often experienced by women undergoing cesarean section. Since the routine methods of pain relief after surgery is still inadequate, the need for complementary treatments is felt. Foot Reflexology (FR) and Auricular Acupressure (AA) are two of the most popular and safe procedures of complementary and alternative medicine therapies. So, this study aimed to determine and compare the effectiveness of reflexology and AA on postoperative pain and anxiety.

MATERIALS AND METHODS

This three-group randomized clinical trial study was performed on 101 pregnant women, admitted to Mashhad Omolbanin hospital, for a cesarean section, in 2015. In the intervention groups, 2-3 h after the operation, AA or FR was performed for 20 min. Routine care was provided for the control group. Pain and anxiety were evaluated by VAS and Spielberger anxiety questionnaire before and 1 and 2 h after the intervention.

RESULTS

The results showed that immediately after the intervention, pain intensity was significantly lower in both AA and FR groups (P < 0.001) compared with the control group. In addition, 2 h after the interventions, pain intensity was significantly lower in the AA group compared with the control group (P = 0.006). However, no significant differences were observed between the FR and the control groups (P = 0.095). In addition, 1 and 2 h after the intervention, anxiety was significantly different between the three groups (P = 0.033 and P = 0.018), respectively. The results of the Tukey test showed that this difference was only between FR and control groups (P = 0.025 and P = 0.017), respectively.

CONCLUSION

AA is more effective in reducing post-cesarean pain while FR effectively reduces post-cesarean anxiety. Therefore, these complementary medicine treatments as easy and noninvasive methods are recommended to be used during labor for improving maternal outcomes.

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

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

Effects of benidipine, paracetamol, and their combination on postoperative and normal tissue pain thresholds

Introduction: In clinical practice, inadequate pain inhibition leads to increased morbidity and mortality. Increased intracellular calcium, oxidants, and proinflammatory cytokines are known to play a role in the pathogenesis of postoperative pain. Therefore, we investigated the analgesic effects of benidipine, paracetamol, and benidipine-paracetamol combination (BPC) on postoperative and normal pain thresholds in rats. Material and methods: Sixty-four male albino Wistar rats weighing 285-295 g were used. The without-incision rats were divided into 4 subgroups: healthy control, benidipine alone, paracetamol alone, and BPC. The scalpel-incision rats were divided into 4 subgroups: scalpel incision, scalpel incision + benidipine, scalpel incision + paracetamol, and scalpel incision + BPC. Paw pain thresholds of rats were measured using a Basile algesimeter. Biochemical analyses were performed on the paw tissues of 6 rats randomly taken from the experimental groups, each containing 8 rats. Rats were sacrificed immediately after the measurements. After the pain threshold tests were finished, the paw tissues were removed and malondialdehyde (MDA), total glutathione (tGSH), cyclooxygenase (COX), and interleukin-6 (IL-6) levels were measured. Results: There was no significant difference between the groups in paw pain threshold and measured biochemical parameters in rats without incision. The decrease in the pain threshold of the incised paw was also best prevented by BPC, followed by benidipine and then paracetamol. Furthermore, increases in scalpel-incised paw tissue MDA, COX-2, and IL-6 levels and the decrease in tGSH were significantly suppressed by benidipine and BPC, while paracetamol could only significantly inhibit the increase in IL-6 production. Conclusion: The combination of the L-type Ca2+ channel blocker benidipine and paracetamol (BPC) may provide potent analgesia. Our experimental results support that BPC may be useful in the treatment of severe pain that cannot be adequately inhibited by paracetamol.

The effect of anterior quadratus lumborum block on morphine consumption in minimally invasive colorectal surgery: a multicentre, double-blind, prospective randomised placebo-controlled trial

We investigated the efficacy and safety of a bilateral anterior quadratus lumborum block in patients undergoing minimally invasive colorectal surgery. This was a two-centre, double-blind, prospective, randomised, placebo-controlled trial including 150 patients undergoing laparoscopic colorectal surgery (left- or right hemicolectomy, sigmoidectomy) who were enrolled in the institutional abdominal enhanced recovery programme. Before induction of anaesthesia, patients received a bilateral anterior quadratus lumborum block in the left and right lateral decubitus position under ultrasound guidance and were allocated randomly to receive 30 ml of ropivacaine 0.375% (n = 75) or placebo (saline 0.9%) (n = 75) bilaterally. Postoperatively, all patients received multimodal intravenous analgesia including paracetamol, ketorolac and patient-controlled analgesia with morphine. The primary outcome was morphine consumption during the first 24 h after tracheal extubation. Secondary outcomes included severity of pain; presence and extent of sensory block; incidence of postoperative nausea and vomiting; and hospital duration of stay. We also investigated the need for, and dose of, rescue analgesia. Safety outcomes included the incidence of adverse events. Mean (SD) 24-hour morphine consumption was no different between patients allocated to ropivacaine and placebo (28.6 (22.3) mg vs. 28.4 (22.5) mg, p = 0.966, respectively). While a sensory block could be detected in significantly more patients allocated to the ropivacaine group, no differences were detected in pain scores or other secondary or safety endpoints. Patient satisfaction scores were high in both groups. In laparoscopic colorectal surgery, adding a bilateral anterior quadratus lumborum block to a standard multimodal analgesia regimen did not reduce opioid consumption or improve pain scores.

The incidence of post cholecystectomy pain (PCP) syndrome at 12 months following laparoscopic cholecystectomy: a prospective evaluation in 200 patients

OBJECTIVES

Post cholecystectomy pain syndrome can cause significant distress, impairs quality of life and exacerbations often result in emergency visits. Poorly controlled postoperative pain is a recognized cause of persistent postsurgical pain. Abdominal myofascial pain syndrome is an underdiagnosed cause of persistent pain in this cohort. The objective was to estimate the incidence of poorly controlled postoperative pain in the first 48 h after surgery and the likelihood of developing persistent pain at 12 months.

METHODS

The patients undergoing laparoscopic cholecystectomy at a tertiary unit were consented for participation in a prospective service evaluation. A telephone review was performed at three, six and twelve months after surgery. Incidence of poorly controlled pain in the first 48 h after surgery was assessed. Patients with persistent pain were referred to the pain clinic.

RESULTS

Over a six-month period, 200 patients were assessed. Eleven patients were excluded (5.5 %). Twelve patients were lost to follow-up (6.6 %, 12/189). Patient satisfaction with acute postoperative pain management was low in 40 % (76/189). Poorly controlled postoperative pain was reported by 36 % (68/189) of patients. Incidence of persistent pain was 29 % (54/189) at 12 months post-surgery. Over half of patients with persistent pain (63 %, 34/54) reported poorly controlled postoperative pain. A somatic source was diagnosed in 54 % (29/54) with post cholecystectomy pain syndrome.

CONCLUSIONS

Poorly controlled postoperative pain was reported by a third of patients. Persistent pain was present in 29 % at twelve months post-surgery. Abdominal myofascial pain syndrome should be considered as a differential diagnosis in post cholecystectomy pain syndrome.

Comparison of efficacy of intercostal nerve block versus peritract infiltration with 0.25% bupivacaine in percutaneous nephrolithotomy: A prospective randomized clinical trial

Introduction

Postoperative pain following percutaneous nephrolithotomy (PCNL) adds to the morbidity of patients requiring additional analgesia. Various modalities of pain control techniques, such as intercostal nerve block (ICNB) and peritract infiltration (PTI), are being studied for better pain management. This study compares the efficacy of ICNB with PTI for postoperative pain management.

Methods

A double-blinded, prospective, randomized control study was conducted, in which 0.25% bupivacaine, either ICNB or PTI, was given at the puncture site at the end of PCNL. The primary outcome was a comparison of postoperative pain score measured with resting Visual analogue Scale (r-VAS) and dynamic VAS (D-VAS) recorded at 2 h, 4 h, 8 h, 10 h, 12 h, 24 h, and at discharge. Injection ketorolac was given as rescue analgesia. Secondary outcomes include time to first rescue analgesia and total analgesic requirement (TAR).

Results

Sixty patients were randomized into two equal groups with 63.3% male and 36.6% female, with a mean age of 37.25 ± 13.09 years. In Group ICNB, 24 (40%) and 6 (10%) patients and in Group PTI, 21 (35%) and 9 (15%) patients underwent standard and mini PCNL, respectively, in each group. All cases were PCNL doen in prone position. The mean R-VAS and D-VAS scores at 2, 4, 8, 12, 24, and 48 h were similar in both groups. The mean TAR was 56.84 ± 0.33.00 mg and 55.54 ± 0.29.64 mg of injection ketorolac in Group ICNB and PTI, respectively (P < 0.894). The time to first rescue analgesic demand were 7.11 ± 4.898 h and 6.25 ± 3.354 h (P < 0.527). Both the groups were comparable in terms of length of hospital stay, stone clearance rate, and complication rate.

Conclusion

The ICNB was as efficacious as PTI for postoperative pain control with 0.25% bupivacaine following PCNL.

Intraoperative pain prediction of percutaneous kyphoplasty under local anesthesia by preoperative experimental pain assessment

BACKGROUND

Percutaneous kyphoplasty (PKP) is the preferred treatment for osteoporotic vertebral compression fractures (OVCF) Currently, the preoperative anesthesia methods for PKP are mainly local anesthesia and tracheal intubation general anesthesia.

OBJECTIVE

To assess whether patient sensitivity to pain measured preoperatively could predict the patients' pain response during PKP treatment under local anesthesia, to facilitate the development of an optimal preoperative anesthesia plan for patients.

METHODS

Fifty-five female patients diagnosed with osteoporotic single vertebral fracture who were treated with PKP under local anesthesia were selected. The patients' pain sensitivities, including pain threshold and pain tolerance threshold, were evaluated with a pain test device on the day before the operation in the ward. Heart rate (HR), mean arterial pressure (MAP), and blood oxygen saturation (SpO2) were recorded before anesthesia, post-anesthesia, after needle puncture, and after balloon dilatation. At the same time, blood was drawn at the above time points to determine the level of norepinephrine (NA) as an indicator of intraoperative pain stress response. The numerical rating scale (NRS) during surgery was recorded at the end of the surgery.

RESULTS

The preoperative pain tolerance threshold of 55 surgical patients was correlated with the intraoperative NRS score (r=-0.768, P< 0.001), as well as with the preoperative and intraoperative changes in HR (r=-0.791, P< 0.001), MAP (r=-0.819, P< 0.001), and NA (r=-0.553, P< 0.001). Thus, the lower the preoperative pain tolerance threshold, the more severe the patient's response to pain during PKP treatment under local anesthesia, and the greater the hemodynamic changes. Consequently, the intraoperative experience becomes worse. However, there was no correlation between preoperative pain threshold and NRS scores (r=-0.069, P= 0.616) nor between the preoperative and intraoperative changes in HR (r= 0.103, P= 0.453), MAP (r= 0.086, P= 0.535), and NA (r=-0.058, P= 0.674).

CONCLUSION

The results indicated that preoperative pain assessment could predict the level of pain response in OVCF patients during PKP surgery under local anesthesia.

A Randomized Control Study to Assess the Efficacy of Intrathecal Morphine in Patients on Patient-Controlled Analgesia Pump With Morphine for Postoperative Pain Relief After Elective Laparotomy

Introduction Laparotomy is associated with significant prolonged postoperative pain, which can cause an adverse neuroendocrine stress response. Intrathecal morphine (ITM) retains an important place in pain management after major laparotomy since it is easier to administer and has a relatively lesser possibility of failure and technical difficulty. Aim The study aims to compare the effect of the administration of ITM with intravenous (IV) morphine administered by a patient-controlled analgesia (PCA) pump on postoperative analgesia after elective laparotomy. The primary objective was to compare total morphine consumption while secondary objectives were to compare pain assessed by the visual analog scale (VAS) and adverse reactions to opioids. Methods Sixty patients who underwent elective laparotomy were enrolled in this study. Thirty patients were enrolled in the study group (ITM+PCA) where ITM (200 mcg) was administered before laparotomy and intravenous morphine was initiated with PCA postoperatively. In the control group, only intravenous morphine was given with PCA postoperatively for pain relief. Parameters in both groups were compared, where estimation of cumulative morphine dose was the primary outcome and pain as assessed by VAS and side effects of opioids were the secondary outcomes. Results Patients in the ITM (ITM+PCA) group required less morphine (6.6 ± 2.96 vs. 24.77 ± 6.79 mg of morphine, p < 0.001) compared to patients on PCA. There was no statistically significant difference in VAS score and adverse effects between both groups. Conclusion Preoperative ITM can be used as an effective and safe modality for alleviating immediate postoperative pain following laparotomy.